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An Integrative Approach
EIGHTH EDITION
David H. Barlow
V. Mark Durand
Stefan G. Hofmann
Copyright 2018 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. WCN 02-200-203
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Eighth Edition
Abnormal Psychology
A N I N T E G R AT I V E A P P R O A C H
David H. Barlow
Boston UnivErsity
V. Mark Durand
U n i v E r s i t y o f s o U t h f l o r i d a – s t. P E t E r s B U r g
Stefan G. Hofmann
Boston UnivErsity
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Printed in Canada
Print Number: 01 Print Year: 2016
To my mother, Doris To Wendy and Jonathan, whose To Benjamin and Lukas for
Elinor Barlow-Lanigan, patience, understanding, helping me integrate the
for her multidimensional and love provided me the many dimensions of life.
influence across my opportunity to complete such s. g. h.
life span. an ambitious project.
d. h. B. v. M. d.
About the Authors
David H. Barlow is an from the American Psychological Association “for his lifelong dedi-
internationally recognized cation and passion for advancing psychology through science, edu-
pioneer and leader in clini- cation, training, and practice.”
cal psychology. Currently He also has received career/lifetime contribution awards from
Professor Emeritus of Psy- the Massachusetts, Connecticut, and California Psychological Asso-
chology and Psychiatry at ciations, as well as the University of Mississippi Medical Center and
Boston University, Dr. Barlow the Association for Behavioral and Cognitive Therapies. In 2000, he
is Founder and Director was named Honorary Visiting Professor at the Chinese People’s Lib-
Emeritus of the Center eration Army General Hospital and Postgraduate Medical School in
for Anxiety and Related Beijing, China, and in 2015 was named Honorary President of the
Disorders, one of the largest Canadian Psychological Association. In addition, the annual Grand
research clinics of its kind Rounds in Clinical Psychology at Brown University was named
in the world. From 1996 to in his honor. During the 1997–1998 academic year, he was Fritz
2004, he directed the clini- Redlich Fellow at the Center for Advanced Study in the Behavioral
cal psychology programs at Sciences in Palo Alto, California. His research has been continually
Boston University. From 1979 funded by the National Institute of Mental Health for over 40 years.
to 1996, he was distinguished Dr. Barlow has edited several journals including Clinical Psychol-
professor at the University at ogy: Science and Practice and Behavior Therapy, has served on the
Albany–State University of New York. From 1975 to 1979, he was editorial boards of more than 20 different journals, and is current-
professor of psychiatry and psychology at Brown University, where ly Editor in Chief of the “Treatments that Work” series for Oxford
he also founded the clinical psychology internship program. From University Press. He has published more than 600 scholarly articles
1969 to 1975, he was professor of psychiatry at the University of and written or edited more than 75 books and clinical manuals,
Mississippi Medical Center, where he founded the psychology resi- including Anxiety and Its Disorders, 2nd edition, Guilford Press;
dency program. Dr. Barlow received his B.A. from the University of Clinical Handbook of Psychological Disorders: A Step-by-Step Treat-
Notre Dame, his M.A. from Boston College, and his Ph.D. from the ment Manual, 5th edition, Guilford Press; Single-Case Experimental
University of Vermont. Designs: Strategies for Studying Behavior Change, 3rd edition, Allyn
A fellow of every major psychological association, Dr. Barlow & Bacon (with Matthew Nock and Michael Hersen); The Scientist–
has received many awards in honor of his excellence in scholarship, Practitioner: Research and Accountability in the Age of Managed Care,
including the National Institute of Mental Health Merit Award for 2nd edition, Allyn & Bacon (with Steve Hayes and Rosemary Nelson-
his long-term contributions to the clinical research effort; the Dis- Gray); Mastery of Your Anxiety and Panic, Oxford University Press
tinguished Scientist Award for applications of psychology from the (with Michelle Craske); and, more recently, The Unified Protocol for
American Psychological Association; and the James McKeen Cattell Transdiagnostic Treatment of Emotional Disorders with the Unified
Fellow Award from the Association for Psychological Science hon- Team at BU. The books and manuals have been translated into more
oring individuals for their lifetime of significant intellectual achieve- than 20 languages, including Arabic, Chinese, and Russian.
ments in applied psychological research. Other awards include the Dr. Barlow was one of three psychologists on the task force that
Distinguished Scientist Award from the Society of Clinical Psychol- was responsible for reviewing the work of more than 1,000 mental
ogy of the American Psychological Association and a certificate health professionals who participated in the creation of DSM-IV,
of appreciation from the APA section on the clinical psychology and he continued on as an Advisor to the DSM-5 task force. He also
of women for “outstanding commitment to the advancement of chaired the APA task force on Psychological Intervention Guide-
women in psychology.” He was awarded an Honorary Doctorate of lines, which created a template for the creation of clinical practice
Science from the University of Vermont, an Honorary Doctorate guidelines. His current research program focuses on the nature and
of Humane Letters from William James College, as well as the C. treatment of anxiety and related emotional disorders.
Charles Burlingame Award from the Institute of Living in Hartford At leisure he plays golf, skis, and retreats to his home on Nan-
Connecticut “for his outstanding leadership in research, education, tucket Island, where he loves to write, walk on the beach, and visit
and clinical care.” In 2014 he was awarded a Presidential Citation with his island friends.
iv
V. Mark Durand is known the American Psychological Association for his body of work in
worldwide as an authority the field of autism spectrum disorder. Dr. Durand was elected to
in the area of autism spec- serve as President of the American Psychological Association’s
trum disorder. He is a pro- Division 33 (Intellectual and Developmental Disabilities/Autism
fessor of psychology at the Spectrum Disorders) for 2019. Dr. Durand is currently a mem-
University of South Florida– ber of the Professional Advisory Board for the Autism Society of
St. Petersburg, where he was America and was on the board of directors of the International
the founding Dean of Arts & Association of Positive Behavioral Support. He was co-editor of
Sciences and Vice Chancellor the Journal of Positive Behavior Interventions, serves on a num-
for Academic Affairs. Dr. ber of editorial boards, and has more than 125 publications on
Durand is a fellow of the functional communication, educational programming, and
American Psychological Asso- behavior therapy. His books include Severe Behavior Problems:
ciation. He has received more A Functional Communication Training Approach; Sleep Better! A
than $4 million in federal Guide to Improving Sleep for Children with Special Needs; Help-
funding since the beginning ing Parents with Challenging Children: Positive Family Interven-
of his career to study the tion; the multiple national award winning Optimistic Parenting:
nature, assessment, and treat- Hope and Help for You and Your Challenging Child; and most
ment of behavior problems in recently Autism Spectrum Disorder: A Clinical Guide for General
children with disabilities. Before moving to Florida, he served in a Practitioners.
variety of leadership positions at the University at Albany, including Dr. Durand developed a unique treatment for severe behav-
associate director for clinical training for the doctoral psychology ior problems that is currently mandated by states across the
program from 1987 to 1990, chair of the psychology department country and is used worldwide. He also developed an assessment
from 1995 to 1998, and interim dean of Arts and Sciences from 2001 tool that is used internationally and has been translated into
to 2002. There he established the Center for Autism and Related more than 15 languages. Most recently he developed an innova-
Disabilities at the University at Albany–SUNY. He received his B.A., tive approach to help families work with their challenging child
M.A., and Ph.D.—all in psychology—at the State University of New (Optimistic Parenting), which was validated in a 5-year clinical
York–Stony Brook. trial. He has been consulted by the departments of education
Dr. Durand was awarded the University Award for Excel- in numerous states and by the U.S. Departments of Justice and
lence in Teaching at SUNY–Albany in 1991 and was given the Education. His current research program includes the study of
Chancellor’s Award for Excellence in Research and Creative prevention models and treatments for such serious problems as
Scholarship at the University of South Florida–St. Petersburg in self-injurious behavior.
2007. He was named a 2014 Princeton Lecture Series Fellow and In his leisure time, he enjoys long-distance running and has
received the 2015 Jacobson Award for Critical Thinking from completed three marathons.
Stefan G. Hofmann emotional disorders. Furthermore, he has been one of the leaders
is an international expert in translational research methods to enhance the efficacy of psy-
on psychotherapy for emo- chotherapy and to predict treatment outcome using neuroscience
tional disorders. He is a methods.
professor of psychology at He has won many prestigious professional awards, including
Boston University, where he the Aaron T. Beck Award for Significant and Enduring Contribu-
directs the Psychotherapy tions to the Field of Cognitive Therapy by the Academy of Cognitive
and Emotion Research Therapy. He is a fellow of the American Psychological Association
Laboratory. He was born in and the Association for Psychological Science and was president of
a little town near Stuttgart in various national and international professional societies, includ-
Germany, which may explain ing the Association for Behavioral and Cognitive Therapies and
his thick German accent. the International Association for Cognitive Psychotherapy. He was
He studied psychology at an advisor to the DSM-5 Development Process and a member of
the University of Marburg, the DSM-5 Anxiety Disorder Sub-Work Group. As part of this, he
Germany, where he received participated in the discussions about the revisions of the DSM-5
his B.A., M.S., and Ph.D. criteria for various anxiety disorders, especially social anxiety dis-
A brief dissertation fellow- order, panic disorder, and agoraphobia. Dr. Hofmann is a Thomson
ship to spend some time Reuters’ Highly Cited Researcher.
at Stanford University turned into a longer research career in the Dr. Hofmann has been the editor in chief of Cognitive Therapy
United States. He eventually moved to the United States in 1994 to and Research and is also the incoming Associate Editor of Clinical
join Dr. Barlow’s team at the University at Albany–State University Psychological Science. He has published more than 300 peer-reviewed
of New York, and has been living in Boston since 1996. journal articles and 15 books, including An Introduction of Modern
Dr. Hofmann has an actively funded research program studying CBT (Wiley-Blackwell) and Emotion in Therapy (Guilford Press).
various aspects of emotional disorders with a particular emphasis on At leisure, he enjoys playing with his sons. He likes traveling to
anxiety disorders, cognitive behavioral therapy, and neuroscience. immerse himself into new cultures, make new friends, and recon-
More recently, he has been interested in mindfulness approaches, nect with old ones. When time permits, he occasionally gets out his
such as yoga and meditation practices, as treatment strategies of flute.
vi
Brief Contents
1 abnormal Behavior in historical Context 2
2 an integrative approach to Psychopathology 32
3 Clinical assessment and diagnosis 74
4 research Methods 104
5 anxiety, trauma- and stressor-related, and obsessive-Compulsive and
related disorders 126
6 somatic symptom and related disorders and dissociative disorders 184
7 Mood disorders and suicide 216
8 Eating and sleep–Wake disorders 272
9 Physical disorders and health Psychology 322
10 sexual dysfunctions, Paraphilic disorders, and gender dysphoria 360
11 substance-related, addictive, and impulse-Control disorders 404
12 Personality disorders 448
13 schizophrenia spectrum and other Psychotic disorders 484
14 neurodevelopmental disorders 520
15 neurocognitive disorders 552
16 Mental health services: legal and Ethical issues 580
vii
Contents
1 Abnormal Behavior in Historical Context 2

Understanding Psychopathology 3 Consequences of the Biological
Tradition / 16
What Is a Psychological Disorder? / 4
The Science of Psychopathology / 6 the Psychological
Historical Conceptions of Abnormal Behavior / 9 tradition 16
Moral Therapy / 16
the Supernatural tradition 9
Asylum Reform and the Decline
Demons and Witches / 10 of Moral Therapy / 17
Stress and Melancholy / 10 Psychoanalytic Theory / 18
Treatments for Possession / 11 Humanistic Theory / 23
Mass Hysteria / 11 The Behavioral Model / 24
Modern Mass Hysteria / 12
The Moon and the Stars / 12 the Present: the Scientific Method
Comments / 12 and an integrative Approach 27
the Biological tradition 13 Summary 28
Hippocrates and Galen / 13 Key terms 29
The 19th Century / 14 Answers to Concept Checks 29
The Development of Biological Treatments / 15
2 An integrative Approach to Psychopathology 32

one-Dimensional versus The Peripheral Nervous System / 47
Multidimensional Models 33 Neurotransmitters / 49
What Caused Judy’s Phobia? / 33 Implications for
Psychopathology / 53
Outcome and Comments / 35
Psychosocial Influences on Brain
Genetic Contributions to Structure and Function / 54
Psychopathology 36 Interactions of Psychosocial
Factors and Neurotransmitter Systems / 56
The Nature of Genes / 36
Psychosocial Effects on the Development of Brain
New Developments in the Study of Genes Structure and Function / 57
and Behavior / 37
Comments / 58
The Interaction of Genes and the Environment / 38
Epigenetics and the Nongenomic “Inheritance” Behavioral and Cognitive Science 58
of Behavior / 41 Conditioning and Cognitive Processes / 58
neuroscience and its Contributions to Learned Helplessness / 59
Psychopathology 42 Social Learning / 60
Prepared Learning / 60
The Central Nervous System / 43
Cognitive Science and the Unconscious / 61
The Structure of the Brain / 44
ix
emotions 62 Social Effects on Health and Behavior / 67
The Physiology and Purpose of Fear / 62 Global Incidence of Psychological Disorders / 69
Emotional Phenomena / 62 Life-Span Development 69
The Components of Emotion / 63
Anger and Your Heart / 64 Conclusions 70
Emotions and Psychopathology / 65 Summary 72
Cultural, Social, and interpersonal Key terms 73
Factors 65 Answers to Concept Checks 73
Voodoo, the Evil Eye, and Other Fears / 65
Gender / 66
3 Clinical Assessment and Diagnosis 74

Assessing Psychological Disorders 75 DSM-III and DSM-III-R / 95
Key Concepts in Assessment / 77 DSM-IV and DSM-IV-TR / 96
The Clinical Interview / 78 DSM-5 / 96
Physical Examination / 80 Creating a Diagnosis / 99
Behavioral Assessment / 80 Beyond DSM-5: Dimensions
and Spectra / 101
Psychological Testing / 84
Neuropsychological Testing / 88 Summary 103
Neuroimaging: Pictures of the Brain / 89
Key terms 103
Psychophysiological Assessment / 90
Answers to Concept Checks 103
Diagnosing Psychological Disorders 92
Classification Issues / 92
Diagnosis before 1980 / 95
4 Research Methods 104

examining Abnormal Genetics and Behavior
Behavior 105 across time and
Important Concepts / 105 Cultures 116
Basic Components of a Research Studying Genetics / 117
Study / 106 Studying Behavior over Time /
Statistical versus Clinical Significance / 108 119
The “Average” Client / 108 Studying Behavior across Cultures / 121
Power of a Program of Research / 122
types of Research Replication / 123
Methods 108 Research Ethics / 123
Studying Individual Cases / 109
Research by Correlation / 109 Summary 125
Research by Experiment / 111 Key terms 125
Single-Case Experimental Designs / 113 Answers to Concept Checks 125
x ContEnts
Anxiety, trauma- and Stressor-Related, and obsessive-
5 Compulsive and Related Disorders 126
the Complexity of Anxiety trauma- and
Disorders 127 Stressor- Related
Anxiety, Fear, and Panic: Some Definitions / 127 Disorders 160
Causes of Anxiety and Related Disorders / 129
Posttraumatic Stress
Comorbidity of Anxiety and Related Disorders / 132
Disorder (PtSD) 160
Comorbidity with Physical Disorders / 133
Clinical Description / 160
Suicide / 133
Statistics / 161
Anxiety Disorders 134 Causes / 162
Treatment / 165
Generalized Anxiety Disorder 134
Clinical Description / 135 obsessive-Compulsive and Related
Statistics / 135 Disorders 168
Causes / 136
obsessive-Compulsive Disorder 168
Treatment / 137
Panic Disorder and Agoraphobia 139 Statistics / 170
Clinical Description / 140 Causes / 170
Statistics / 140 Treatment / 171
Causes / 143
Body Dysmorphic Disorder 172
Treatment / 145
Plastic Surgery and Other Medical Treatments / 176
Specific Phobia 147 other obsessive-Compulsive and Related
Disorders 176
Statistics / 150
Hoarding Disorder / 176
Causes / 151
Trichotillomania (Hair Pulling Disorder) and
Treatment / 153 Excoriation (Skin Picking Disorder) / 177
Social Anxiety Disorder (Social Summary 180

Phobia) 154
Key terms 181
Statistics / 155
Causes / 156
Treatment / 157
6 Somatic Symptom and Related Disorders

and Dissociative Disorders 184
Somatic Symptom and Related illness Anxiety
Disorders 185 Disorder 187
Somatic Symptom Disorder 186
Statistics / 188
ContEnts xi
Causes / 189 Dissociative Amnesia 200
Treatment / 191
Dissociative identity Disorder 203
Psychological Factors Affecting Medical Clinical Description / 203
Condition 192 Characteristics / 204
Conversion Disorder (Functional Can DID Be Faked? / 204
neurological Symptom Disorder) 193 Statistics / 206
Causes / 207
Suggestibility / 207
Closely Related Disorders / 193
Biological Contributions / 208
Unconscious Mental Processes / 195
Real Memories and False / 208
Statistics / 196
Treatment / 210
Causes / 197
Treatment / 198 Summary 212
Dissociative Disorders 198 Key terms 213
Depersonalization-Derealization
Disorder 199
7 Mood Disorders and Suicide 216

Understanding and Defining Mood Social and Cultural
Dimensions / 247
Disorders 217
An Integrative Theory / 249
An Overview of Depression and Mania / 218
The Structure of Mood Disorders / 219 treatment of Mood
Depressive Disorders / 220 Disorders 251
Additional Defining Criteria for Depressive Medications / 251
Disorders / 222
Electroconvulsive Therapy and Transcranial
Other Depressive Disorders / 229 Magnetic Stimulation / 254
Bipolar Disorders / 231 Psychological Treatments for Depression / 255
Additional Defining Criteria for Bipolar Combined Treatments for Depression / 258
Disorders / 232
Preventing Relapse of Depression / 259
Prevalence of Mood Disorders 234 Psychological Treatments for Bipolar
Disorder / 260
Prevalence in Children, Adolescents, and Older
Adults / 235 Suicide 262
Life Span Developmental Influences on Mood
Statistics / 262
Disorders / 235
Causes / 263
Across Cultures / 237
Risk Factors / 263
Among Creative Individuals / 237
Is Suicide Contagious? / 265
Causes of Mood Disorders 238 Treatment / 265
Biological Dimensions / 239
Summary 268
Additional Studies of Brain Structure
and Function / 242 Key terms 269
Psychological Dimensions / 242 Answers to Concept Checks 269
xii ContEnts
8 eating and Sleep–Wake Disorders 272
Major types of eating Disorders 273 Sleep–Wake
Bulimia Nervosa / 275 Disorders: the Major
Anorexia Nervosa / 277 Dyssomnias 301
Binge-Eating Disorder / 279 An Overview of Sleep–Wake
Statistics / 280 Disorders / 301
Insomnia Disorder / 302
Causes of eating Disorders 284 Hypersomnolence Disorders / 307
Social Dimensions / 284 Narcolepsy / 308
Biological Dimensions / 287 Breathing-Related Sleep Disorders / 309
Psychological Dimensions / 288 Circadian Rhythm Sleep Disorder / 310
An Integrative Model / 289
treatment of Sleep Disorders 311
treatment of eating Disorders 289 Medical Treatments / 311
Drug Treatments / 289 Environmental Treatments / 313
Psychological Treatments / 290 Psychological Treatments / 313
Preventing Eating Disorders / 294 Preventing Sleep Disorders / 314
Parasomnias and Their Treatment / 314
obesity 295
Statistics / 295 Summary 318
Disordered Eating Patterns in Cases of Obesity / 296 Key terms 319
Causes / 297
Treatment / 298
9 Physical Disorders and Health Psychology 322

Psychological and Social Factors that Psychosocial
influence Health 323 treatment of Physical
Health and Health-Related Behavior / 323 Disorders 348
The Nature of Stress / 325 Biofeedback / 348
The Physiology of Stress / 325 Relaxation and
Contributions to the Stress Response / 326 Meditation / 349
Stress, Anxiety, Depression, and Excitement / 327 A Comprehensive Stress- and Pain-Reduction
Program / 349
Stress and the Immune Response / 328
Drugs and Stress-Reduction Programs / 351
Psychosocial effects on Physical Denial as a Means of Coping / 351
Disorders 331 Modifying Behaviors to Promote Health / 352
AIDS / 331
Summary 356
Cancer / 334
Cardiovascular Problems / 336 Key terms 357
Hypertension / 336 Answers to Concept Checks 357
Coronary Heart Disease / 339
Chronic Pain / 342
Chronic Fatigue Syndrome / 345
ContEnts xiii
10 Sexual Dysfunctions, Paraphilic Disorders,
and Gender Dysphoria 360
What is normal Sexuality? 361 Voyeuristic and Exhibitionistic
Disorders / 384
Gender Differences / 363
Transvestic Disorder / 384
Cultural Differences / 364
Sexual Sadism and Sexual
The Development of Sexual Orientation / 365 Masochism Disorders / 386
An overview of Sexual Pedophilic Disorder and
Incest / 387
Dysfunctions 366
Paraphilic Disorders in Women / 388
Sexual Desire Disorders / 368
Causes of Paraphilic Disorders / 389
Sexual Arousal Disorders / 369
Orgasm Disorders / 370 Assessing and treating Paraphilic
Sexual Pain Disorder / 372 Disorders 390
Psychological Treatment / 390
Assessing Sexual Behavior 373
Drug Treatments / 392
Interviews / 373
Medical Examination / 373 Gender Dysphoria 393
Psychophysiological Assessment / 374 Defining Gender Dysphoria / 393
Causes / 395
Causes and treatment of Sexual
Treatment / 396
Dysfunction 374
Causes of Sexual Dysfunction / 374 Summary 400
Treatment of Sexual Dysfunction / 379 Key terms 401
Paraphilic Disorders: Clinical Answers to Concept Checks 401
Descriptions 382
Fetishistic Disorder / 383
11 Substance-Related, Addictive, and impulse-Control

Disorders 404
Perspectives on Substance-Related opioid-Related
and Addictive Disorders 405 Disorders 422
Levels of Involvement / 406
Cannabis-Related
Diagnostic Issues / 408
Disorders 423
Depressants 409 Hallucinogen-Related Disorders 424
Alcohol-Related Disorders / 409
Sedative-, Hypnotic-, or Anxiolytic-Related
other Drugs of Abuse 427
Disorders / 414 Causes of Substance-Related
Stimulants 416 Disorders 428
Stimulant-Related Disorders / 416 Biological Dimensions / 428
Tobacco-Related Disorders / 420 Psychological Dimensions / 431
Caffeine-Related Disorders / 421 Cognitive Dimensions / 432
xiv ContEnts
Social Dimensions / 432 Gambling Disorder 441
Cultural Dimensions / 433
An Integrative Model / 434
impulse-Control Disorders 442
Intermittent Explosive Disorder / 442
treatment of Substance-Related Kleptomania / 443
Disorders 435 Pyromania / 443
Biological Treatments / 436
Psychosocial Treatments / 437 Summary 444
Prevention / 440 Key terms 445
12 Personality Disorders 448

An overview of Personality Histrionic Personality
Disorder / 472
Disorders 449
Narcissistic Personality
Aspects of Personality Disorders / 449
Disorder / 474
Categorical and Dimensional Models / 450
Personality Disorder Clusters / 451 Cluster C Personality
Statistics and Development / 451 Disorders 476
Gender Differences / 452 Avoidant Personality Disorder / 476
Comorbidity / 454 Dependent Personality Disorder / 477
Personality Disorders under Study / 455 Obsessive-Compulsive Personality Disorder / 478
Cluster A Personality Disorders 455 Summary 480

Paranoid Personality Disorder / 455 Key terms 481
Schizoid Personality Disorder / 457 Answers to Concept Checks 481
Schizotypal Personality Disorder / 459
Cluster B Personality Disorders 461

Antisocial Personality Disorder / 461
Borderline Personality Disorder / 469
13 Schizophrenia Spectrum and other Psychotic

Disorders 484
Perspectives on Schizophrenia 485 Historic Schizophrenia
Subtypes / 493
Early Figures in Diagnosing
Schizophrenia / 485 Other Psychotic Disorders / 494
Identifying Symptoms / 486 Prevalence and Causes
Clinical Description, Symptoms, of Schizophrenia 497
and Subtypes 488 Statistics / 497
Positive Symptoms / 488 Development / 498
Negative Symptoms / 491 Cultural Factors / 499
Disorganized Symptoms / 492 Genetic Influences / 499
ContEnts xv
Neurobiological Influences / 502 Treatment across Cultures / 513
Psychological and Social Influences / 506 Prevention / 514
treatment of Schizophrenia 508 Summary 516

Biological Interventions / 508 Key terms 517
Psychosocial Interventions / 510 Answers to Concept Checks 517
14 neurodevelopmental Disorders 520

overview of neurodevelopmental Prevention of
Disorders 521 neurodevelopmental
What Is Normal? What Is Abnormal? / 522 Disorders 547
Attention-Deficit/Hyperactivity Summary 549
Disorder 522 Key terms 549
Specific Learning Disorder 529 Answers to Concept
Checks 549
Autism Spectrum Disorder 534
Treatment of Autism Spectrum Disorder / 538
intellectual Disability (intellectual

Development Disorder) 540
Causes / 543
15 neurocognitive Disorders 552

Perspectives on neurocognitive Other Medical Conditions
That Cause Neurocognitive
Disorders 553 Disorder / 563
Delirium 554 Substance/Medication-
Induced Neurocognitive
Clinical Description and Statistics / 554 Disorder / 567
Treatment / 555 Causes of Neurocognitive
Prevention / 555 Disorders / 567
Treatment / 570
Major and Mild neurocognitive Prevention / 574
Disorders 556
Clinical Description and Statistics / 558 Summary 575
Neurocognitive Disorder Due to Alzheimer’s Key terms 576
Disease / 559
Vascular Neurocognitive Disorder / 562
xvi ContEnts
16 Mental Health Services: Legal and ethical issues 580
Perspectives on Mental Health Law 581 Patients’ Rights
and Clinical Practice
Civil Commitment 581 Guidelines 592
Criteria for Civil Commitment / 582 The Right to Treatment / 592
Procedural Changes Affecting Civil The Right to Refuse
Commitment / 584 Treatment / 593
An Overview of Civil Commitment / 586 The Rights of Research
Participants / 593
Criminal Commitment 587
Evidence-Based Practice and Clinical Practice
The Insanity Defense / 587 Guidelines / 594
Reactions to the Insanity Defense / 588
Therapeutic Jurisprudence / 590 Conclusions 596
Competence to Stand Trial / 590
Duty to Warn / 591
Summary 597
Mental Health Professionals as Expert Key terms 597
Witnesses / 591 Answers to Concept Checks 597
Glossary G-1
References R-1
name index i-1
Subject index i-27
ContEnts xvii
Preface
S cience is a constantly evolving field, but every now and

then something groundbreaking occurs that alters our
way of thinking. For example, evolutionary biologists,
who long assumed that the process of evolution was gradual, sud-
denly had to adjust to evidence that says evolution happens in fits
affect neurotransmitter function and even genetic expression.
Similarly, we cannot study behavioral, cognitive, or emotional
processes without appreciating the contribution of biological and
social factors to psychological and psychopathological expression.
Instead of compartmentalizing psychopathology, we use a more
and starts in response to such cataclysmic environmental events as accessible approach that accurately reflects the current state of our
meteor impacts. Similarly, geology has been revolutionized by the clinical science.
discovery of plate tectonics. As colleagues, you are aware that we understand some disor-
Until recently, the science of psychopathology had been com- ders better than others. But we hope you will share our excitement
partmentalized, with psychopathologists examining the separate in conveying to students both what we currently know about the
effects of psychological, biological, and social influences. This causes and treatments of psychopathology and how far we have
approach is still reflected in popular media accounts that describe, yet to go in understanding these complex interactions.
for example, a newly discovered gene, a biological dysfunction
(chemical imbalance), or early childhood experiences as a “cause”
of a psychological disorder. This way of thinking still dominates Integrative Approach
discussions of causality and treatment in some psychology text- As noted earlier, the first edition of Abnormal Psychology pio-
books: “The psychoanalytic views of this disorder are . . . ,” “the neered a new generation of abnormal psychology textbooks,
biological views are . . . ,” and, often in a separate chapter, “psycho- which offer an integrative and multidimensional perspective. (We
analytic treatment approaches for this disorder are . . . ,” “cognitive acknowledge such one-dimensional approaches as biological, psy-
behavioral treatment approaches are . . . ,” or “biological treatment chosocial, and supernatural as historic perspectives on our field.)
approaches are . . .” We include substantial current evidence of the reciprocal influ-
In the first edition of this text, we tried to do something very ences of biology and behavior and of psychological and social
different. We thought the field had advanced to the point that it influences on biology. Our examples hold students’ attention; for
was ready for an integrative approach in which the intricate inter- example, we discuss genetic contributions to divorce, the effects
actions of biological, psychological, and social factors are expli- of early social and behavioral experience on later brain function
cated in as clear and convincing a manner as possible. Recent and structure, new information on the relation of social networks
explosive advances in knowledge confirm this approach as the to the common cold, and new data on psychosocial treatments for
only viable way of understanding psychopathology. To take just cancer. We note that in the phenomenon of implicit memory and
two examples, Chapter 2 contains a description of a study demon- blind sight, which may have parallels in dissociative experiences,
strating that stressful life events can lead to depression but that not psychological science verifies the existence of the unconscious
everyone shows this response. Rather, stress is more likely to cause (although it does not much resemble the seething caldron of con-
depression in individuals who already carry a particular gene
flicts envisioned by Freud). We present new evidence confirming
that influences serotonin at the brain synapses. Similarly, Chap-
the effects of psychological treatments on neurotransmitter flow
ter 9 describes how the pain of social rejection activates the same
and brain function. We acknowledge the often-neglected area of
neural mechanisms in the brain as physical pain. In addition, the
emotion theory for its rich contributions to psychopathology (e.g.,
entire section on genetics has been rewritten to highlight the new
the effects of anger on cardiovascular disease). We weave scien-
emphasis on gene–environment interaction, along with recent
tific findings from the study of emotions together with behavioral,
thinking from leading behavioral geneticists that the goal of bas-
biological, cognitive, and social discoveries to create an integrated
ing the classification of psychological disorders on the firm foun-
tapestry of psychopathology.
dation of genetics is fundamentally flawed. Descriptions of the
emerging field of epigenetics, or the influence of the environment
on gene expression, is also woven into the chapter, along with new Life-Span Developmental Influences
studies on the seeming ability of extreme environments to largely No modern view of abnormal psychology can ignore the impor-
override the effects of genetic contributions. Studies elucidating tance of life-span developmental factors in the manifestation
the mechanisms of epigenetics or specifically how environmental and treatment of psychopathology. Studies highlighting devel-
events influence gene expression are described. opmental windows for the influence of the environment on gene
These results confirm the integrative approach in this book: expression are explained. Accordingly, although we include a
Psychological disorders cannot be explained by genetic or envi- Neurodevelopmental Disorders chapter (Chapter 14), we con-
ronmental factors alone but rather arise from their interaction. sider the importance of development throughout the text; we dis-
We now understand that psychological and social factors directly cuss childhood and geriatric anxiety, for example, in the context
xix
of the Anxiety, Trauma- and Stressor-Related, and Obsessive- have retained this integrative format and have improved upon
Compulsive and Related Disorders chapter (Chapter 5). This sys- it, and we include treatment procedures in the key terms and
tem of organization, which is for the most part consistent with glossary.
DSM-5, helps students appreciate the need to study each disorder
from childhood through adulthood and old age. We note findings Legal and Ethical Issues
on developmental considerations in separate sections of each dis-
In our closing chapter, we integrate many of the approaches and
order chapter and, as appropriate, discuss how specific develop-
themes that have been discussed throughout the text. We include
mental factors affect causation and treatment.
case studies of people who have been involved directly with many
legal and ethical issues and with the delivery of mental health ser-
Scientist–Practitioner Approach vices. We also provide a historical context for current perspectives
We go to some lengths to explain why the scientist–practitioner so students will understand the effects of social and cultural influ-
approach to psychopathology is both practical and ideal. Like ences on legal and ethical issues.
most of our colleagues, we view this as something more than sim-
ple awareness of how scientific findings apply to psychopathol- Diversity
ogy. We show how every clinician contributes to general scientific
Issues of culture and gender are integral to the study of psychopa-
knowledge through astute and systematic clinical observations,
thology. Throughout the text, we describe current thinking about
functional analyses of individual case studies, and systematic
which aspects of the disorders are culturally specific and which
observations of series of cases in clinical settings. For example,
are universal, and about the strong and sometimes puzzling effects
we explain how information on dissociative phenomena provided
of gender roles. For instance, we discuss the current information
by early psychoanalytic theorists remains relevant today. We also
on such topics as the gender imbalance in depression, how panic
describe the formal methods used by scientist–practitioners,
disorders are expressed differently in various Asian cultures, the
showing how abstract research designs are actually implemented
ethnic differences in eating disorders, treatment of schizophrenia
in research programs.
across cultures, and the diagnostic differences of attention deficit/
hyperactivity disorder (ADHD) in boys and girls. Clearly, our field
Clinical Cases of Real People will grow in depth and detail as these subjects and others become
We have enriched the book with authentic clinical histories to standard research topics. For example, why do some disorders
illustrate scientific findings on the causes and treatment of psy- overwhelmingly affect females and others appear predominantly
chopathology. We have run active clinics for years, so 95% of in males? And why does this apportionment sometimes change
the cases are from our own files, and they provide a fascinating from one culture to another? In answering questions like these,
frame of reference for the findings we describe. The beginnings we adhere closely to science, emphasizing that gender and cul-
of most chapters include a case description, and most of the ture are each one dimension among several that constitute
discussion of the latest theory and research is related to these psychopathology.
very human cases.
Disorders in Detail New to This Edition

We cover the major psychological disorders in 11 chapters, A Thorough Update
focusing on three broad categories: clinical description, causal
This exciting field moves at a rapid pace, and we take particular
factors, and treatment and outcomes. We pay considerable
pride in how our book reflects the most recent developments.
attention to case studies and DSM-5 criteria, and we include
Therefore, once again, every chapter has been carefully revised
statistical data, such as prevalence and incidence rates, sex
to reflect the latest research studies on psychological disorders.
ratio, age of onset, and the general course or pattern for the dis-
Hundreds of new references from 2015 to 2016 (and some still
order as a whole. Since several of us were appointed Advisors
“in press”) appear for the first time in this edition, and some of
to the DMS-5 task force, we are able to include the reasons for
the information they contain stuns the imagination. Nonessential
changes as well as the changes themselves. Throughout, we
material has been eliminated, some new headings have been
explore how biological, psychological, and social dimensions
added, and DSM-5 criteria are included in their entirety as tables
may interact to cause a particular disorder. Finally, by covering
in the appropriate disorder chapters.
treatment and outcomes within the context of specific disor-
Anxiety, Trauma- and Stressor-Related, and Obsessive-
ders, we provide a realistic sense of clinical practice.
Compulsive and Related Disorders (Chapter 5), Mood Disor-
ders and Suicide (Chapter 7), Eating and Sleep–Wake Disorders
Treatment (Chapter 8), Physical Disorders and Health Psychology (Chapter 9),
One of the best received innovations in the first seven editions was Substance-Related, Addictive, and Impulse-Control Disorders
our strategy of discussing treatments in the same chapter as the (Chapter 11), Schizophrenia Spectrum and Other Psychotic Disor-
disorders themselves instead of in a separate chapter, an approach ders (Chapter 13), and Neurodevelopmental Disorders (Chapter 14)
that is supported by the development of specific psychosocial and have been the most heavily revised to reflect new research, but all
pharmacological treatment procedures for specific disorders. We chapters have been significantly updated and freshened.
xx P r E fa C E
Chapter 1, Abnormal Behavior in Historical Context, features ● Updated generalized anxiety disorder discussion, espe-
updated nomenclature to reflect new titles in DSM-5, updated cially about newer treatment approaches;
descriptions of research on defense mechanisms, and fuller and ● Updated information on description, etiology, and treat-
deeper descriptions of the historical development of psychody- ment for specific phobia, social anxiety disorder, and
namic and psychoanalytic approaches. posttraumatic stress disorder.
Chapter 2, An Integrative Approach to Psychopathology,
includes an updated discussion of developments in the study of
The grouping of disorders in Chapter 6, now titled Somatic
genes and behavior with a focus on gene–environment interaction;
Symptom and Related Disorders and Dissociative Disorders,
new data illustrating the gene–environment correlation model; new
reflects a major overarching change, specifically for somatic
studies illustrating the psychosocial influence on the development
symptom disorder, illness anxiety disorder (formerly known as
of brain structure and function in general and on neurotransmit-
hypochondriasis), and psychological factors affecting medical
ter systems specifically; updated, revised, and refreshed sections on
conditions. The chapter discusses the differences between these
behavioral and cognitive science including new studies illustrating
overlapping disorders and provides a summary of the causes and
the influence of positive psychology on physical health and longev-
treatment approaches of these problems. In addition, Chapter 6
ity; new studies supporting the strong influence of emotions, spe-
now has an updated discussion on the false memory debate relat-
cifically anger, on cardiovascular health; new studies illustrating
ed to trauma in individuals with dissociative identity disorder.
the influence of gender on the presentation and treatment of psy-
Chapter 7, Mood Disorders and Suicide, provides an updated
chopathology; a variety of powerful new studies confirming strong
discussion on the psychopathology and treatment of the DSM-5
social effects on health and behavior; and new studies confirming
Mood Disorders, including persistent depressive disorder, sea-
the puzzling “drift” phenomenon resulting in a higher prevalence of
sonal affective disorder, disruptive mood dysregulation disorder,
schizophrenia among individuals living in urban areas.
bipolar disorder, and suicide. The chapter discusses new data on
Chapter 3, Clinical Assessment and Diagnosis, now presents
the genetic and environmental risk factors and protective factors,
references to “intellectual disability” instead of “mental retarda-
such as optimism. Also included is an update on the pharmaco-
tion” to be consistent with DSM-5 and changes within the field;
logical and psychological treatments.
(a new discussion about how information from the MMPI-2—
Thoroughly rewritten and updated, Chapter 8, Eating and
although informative—does not necessarily change how clients
Sleep–Wake Disorders, contains new information on mortality
are treated and may not improve their outcomes;) a description of
and suicide rates in anorexia nervosa; new epidemiological infor-
the organization and structure of DSM-5 along with major changes
mation on the prevalence of eating disorders in adolescents; new
from DSM-IV; a description of methods to coordinate the devel-
information on the increasing globalization of eating disorders
opment of DSM-5 with the forthcoming ICD 11; and a description
and obesity; updated information on typical patterns of comor-
of likely directions of research as we begin to head toward DSM-6.
bidity accompanying eating disorders; and new and updated
In Chapter 4, Research Methods, a new example of how behav-
research on changes in the incidence of eating disorders among
ioral scientists develop research hypotheses is presented and a
males, racial and ethnic differences on the thin-ideal body image
new example of longitudinal designs which look at how the use of
associated with eating disorders, the substantial contribution of
spanking predicts later behavior problems in children (Gershoff,
emotion dysregulation to etiology and maintenance of anorexia,
Lansford, Sexton, Davis-Kean, & Sameroff, 2012).
the role of friendship cliques in the etiology of eating disorders,
Chapter 5, entitled Anxiety, Trauma- and Stressor-Related,
mothers with eating disorders who also restrict food intake by
and Obsessive-Compulsive and Related Disorders, is organized
their children, the contribution of parents and family factors in
according to the three major groups of disorders: anxiety dis-
the etiology of eating disorders, biological and genetic contribu-
orders, trauma- and stressor-related disorders, and obsessive-
tions to causes of eating disorders including the role of ovarian
compulsive and related disorders. Two disorders new to DSM-5
hormones, transdiagnostic treatment applicable to all eating dis-
(separation anxiety disorder and selective mutism) are presented,
orders, results from a large multinational trial comparing CBT to
and the Trauma and Stressor-Related Disorders section includes
psychoanalysis in the treatment of bulimia, the effects of combin-
not only posttraumatic stress disorder and acute stress disorder
ing Prozac with CBT in the treatment of eating disorders, racial
but also adjustment disorder and attachment disorders. The final
and ethnic differences in people with binge eating disorder seek-
new grouping, Obsessive-Compulsive and Related Disorders,
ing treatment, the phenomenon of night eating syndrome and its
includes not only obsessive-compulsive disorder but also body
role in the development of obesity, and new public health policy
dysmorphic disorder, hoarding disorder, and finally trichotillo-
developments directed at the obesity epidemic.
mania (hair pulling disorder) and excoriation (skin picking dis-
Realigned coverage of Sleep–Wake Disorders, also in Chapter
order). Some of the revisions to Chapter 5 include the following:
8, with new information on sleep in women is now reported—
including risk and protective factors, an updated section on nar-
● Updated information about the neuroscience and genet-
colepsy to describe new research on the causes of this disorder,
ics of fear and anxiety;
and new research on the nature and treatment of nightmares are
● Updated information on the relationship of anxiety and now included.
related disorders to suicide; In Chapter 9, Physical Disorders and Health Psychology,
● Updated information on the influence of personality and updated data on the leading causes of death in the United States;
culture on the expression of anxiety; a review of the increasing depth of knowledge on the influence
P r E fa C E xxi
of psychological social factors on brain structures and function; with the major changes in DSM-5. In addition, Chapter 14 now
new data supporting the efficacy of stress management on cardio- describes new research to show that gene–environment interac-
vascular disease; an updated review of developments into causes tion can lead to later behavior problems in children with ADHD
and treatment of chronic pain; updated information eliminating (Thapar, Cooper, Jefferies, & Stergiakouli, 2012; Thapar, et al., 2005);
certain viruses (XMRV and pMLV) as possible causes of chron- new research on ADHD (and on other disorders) that is finding
ic fatigue syndrome; and updated review of psychological and that in many cases mutations occur that either create extra copies of
behavioral procedures for preventing injuries. a gene on one chromosome or result in the deletion of genes (called
In Chapter 10, Sexual Dysfunctions, Paraphilic Disorders, and copy number variants—CNVs) (Elia et al., 2009; Lesch et al., 2010);
Gender Dysphoria, a revised organization of sexual dysfunctions, and new research findings that show a variety of genetic mutations,
paraphilic disorders, and gender dysphoria to reflect the fact that including de novo disorders (genetic mutations occurring in the
both paraphilic disorders and gender dysphoria are separate chap- sperm or egg or after fertilization), are present in those children
ters in DSM-5, and gender dysphoria disorder, is, of course, not with intellectual disability (ID) of previously unknown origin (Rauch
a sexual disorder but a disorder reflecting incongruence between et al., 2012).
natal sex and expressed gender, in addition to other major revi- Chapter 15, now called Neurocognitive Disorders, features
sions—new data on developmental changes in sexual behavior descriptions of research assessing brain activity (fMRI) in indi-
from age of first intercourse to prevalence and frequency of sexual viduals during active episodes of delirium as well as after these
behavior in old age; new reports contrasting differing attitudes episodes; data from the Einstein Aging Study concerning the prev-
and engagement in sexual activity across cultures even within alence of a disorder new in DSM-5, mild neurocognitive disorder
North America; updated information on the development of sex- (Katz et al., 2012); and a new discussion of new neurocognitive
ual orientation; and a thoroughly updated description of gender disorders (e.g., neurocognitive disorder due to Lewy bodies or
dysphoria with an emphasis on emerging conceptualizations of prion disease).
gender expression that are on a continuum. And Chapter 16, Mental Health Services: Legal and Ethical
Chapter 10 also includes updated information on contribut- Issues, presents a brief, but new, discussion of the recent trend
ing factors to gender dysphoria as well as the latest recommenda- to provide individuals needing emergency treatment with court-
tions on treatment options, recommended treatment options (or ordered assisted outpatient treatment (AOT) to avoid commitment
the decision not to treat) for gender nonconformity in children, a in a mental health facility (Nunley, Nunley, Cutleh, Dentingeh,
full description of disorders of sex development (formerly called & McFahland, 2013); a new discussion of a major meta-analysis
intersexuality), and a thoroughly revamped description of para- showing that current risk assessment tools are best at identifying
philic disorders to reflect the updated system of classification with persons at low risk of being violent but only marginally successful
a discussion of the controversial change in the name of these dis- at accurately detecting who will be violent at a later point (Fazel,
orders from paraphilia to paraphilic disorders. Singh, Doll, & Grann, 2012); and an updated section on legal
A thoroughly revised Chapter 11, Substance-Related, Addictive, rulings on involuntary medication.
and Impulse-Control Disorders, features new discussion of how the
trend to mix caffeinated energy drinks with alcohol may increase the Additional Features
likelihood of later abuse of alcohol; new research on chronic use of In addition to the changes highlighted earlier, Abnormal Psychology
MDMA (“Ecstasy”) leading to lasting memory problems (Wagner, features other distinct features:
Becker, Koester, Gouzoulis-Mayfrank, & Daumann, 2013); and new
research on several factors predicting early alcohol use, including
● Student Learning Outcomes at the start of each chapter
when best friends have started drinking, whether family members assist instructors in accurately assessing and mapping
are at high risk for alcohol dependence, and the presence of behav- questions throughout the chapter. The outcomes are
ior problems in these children (Kuperman, et al., 2013). mapped to core American Psychological Association
Chapter 12, Personality Disorders, now features a completely goals and are integrated throughout the instructor
new section on gender differences to reflect newer, more sophis- resources and testing program.
ticated analyses of prevalence data, and a new section on crimi- ● In each disorder chapter a feature called DSM
nality and antisocial personality disorder is now revised to better Controversies, which discusses some of the contentious
reflect changes in DSM-5. and thorny decisions made in the process of creating
Chapter 13, Schizophrenia Spectrum and Other Psychotic DSM-5. Examples include the creation of new and some-
Disorders, presents a new discussion of schizophrenia spectrum times controversial disorders appearing for the first time
disorder and the dropping of subtypes of schizophrenia from in DSM-5, such as premenstrual dysphoric disorder,
DSM-5; new research on deficits in emotional prosody compre- binge eating disorder, and disruptive mood dysregulation
hension and its role in auditory hallucinations (Alba-Ferrara, disorder. Another example is removing the “grief ” exclu-
Fernyhough, Weis, Mitchell, & Hausmann, 2012); a discussion of a sion criteria for diagnosing major depressive disorder so
new proposed psychotic disorder suggested in DSM-5 for further that someone can be diagnosed with major depression
study—Attenuated Psychosis Syndrome; and a new discussion of even if the trigger was the death of a loved one. Finally,
the use of transcranial magnetic stimulation. changing the title of the “paraphilia” chapter to “para-
In Chapter 14, Neurodevelopmental Disorders are presented, philic disorders” implies that paraphilic sexual arousal
instead of Pervasive Developmental Disorders, to be consistent patterns such as pedophilia are not disorders in
xxii P r E fa C E
themselves, but only become disorders if they cause Our integrative approach is instantly evident in these diagrams,
impairment or harm to others. which show the interaction of biological, psychological, and social
factors in the etiology and treatment of disorders. The visual sum-
maries will help instructors wrap up discussions, and students will
DSM-IV, DSM-IV-TR, and DSM-5 appreciate them as study aids.
Much has been said about the mix of political and scientific con-
siderations that resulted in DSM-5, and naturally we have our Pedagogy
own opinions. (DHB had the interesting experience of sitting
on the task force for DSM-IV and was an Advisor to the DSM-5 Each chapter contains several Concept Checks, which let students
task force.) Psychologists are often concerned about “turf issues” verify their comprehension at regular intervals. Answers are listed
in what has become—for better or worse—the nosological stan- at the end of each chapter along with a more detailed Summary;
dard in our field, and with good reason: in previous DSM editions, the Key Terms are listed in the order they appear in the text and
scientific findings sometimes gave way to personal opinions. For thus form a sort of outline that students can study.
DSM-IV and DSM-5, however, most professional biases were left
at the door while the task force almost endlessly debated the data. MindTap for Barlow, Durand, and
This process produced enough new information to fill every psy-
chopathology journal for a year with integrative reviews, reanaly-
Hofmann’s Abnormal Psychology
sis of existing databases, and new data from field trials. From a MindTap is a personalized teaching experience with relevant
scholarly point of view, the process was both stimulating and assignments that guide students to analyze, apply, and improve
exhausting. This book contains highlights of various debates that thinking, allowing you to measure skills and outcomes with ease.
created the nomenclature, as well as recent updates. For example, ● Guide Students: A unique learning path of relevant
in addition to the controversies described above, we summarize readings, media, and activities that moves students up the
and update the data and discussion of premenstrual dysphoric dis- learning taxonomy from basic knowledge and compre-
order, which was designated a new disorder in DSM-5, and mixed hension to analysis and application.
anxiety depression, a disorder that did not make it into the final
criteria. Students can thus see the process of making diagnoses, as
● Personalized Teaching: Becomes yours with a Learning
well as the combination of data and inferences that are part of it. Path that is built with key student objectives. Control
We also discuss the intense continuing debate on categorical what students see and when they see it. Use it as-is or
and dimensional approaches to classification. We describe some of match to your syllabus exactly—hide, rearrange, add, and
the compromises the task force made to accommodate data, such create your own content.
as why dimensional approaches to personality disorders did not ● Promote Better Outcomes: Empower instructors and
make it into DSM-5, and why the proposal to do so was rejected motivate students with analytics and reports that provide
at the last minute and included in Section III under “Conditions a snapshot of class progress, time in course, engagement,
for Further Study” even though almost everyone agrees that these and completion rates. In addition to the benefits of the
disorders should not be categorical but rather dimensional. platform, MindTap for Barlow, Durand, and Hofmann’s
Abnormal Psychology includes:
Prevention ● Profiles in Psychopathology, an exciting new product that
Looking into the future of abnormal psychology as a field, it seems guides users through the symptoms, causes, and treat-
our ability to prevent psychological disorders may help the most. ments of individuals who live with mental disorders.
Although this has long been a goal of many, we now appear to be at ● Videos, assessment, and activities from the Continuum
the cusp of a new age in prevention research. Scientists from all over Video Project.
the globe are developing the methodologies and techniques that may ● Concept Clip Videos that visually elaborate on specific dis-
at long last provide us with the means to interrupt the debilitating orders and psychopathology in a vibrant, engaging manner.
toll of emotional distress caused by the disorders chronicled in this ● Case studies to help students humanize psychological
book. We therefore highlight these cutting-edge prevention efforts— disorders and connect content to the real world.
such as preventing eating disorders, suicide, and health problems,
including HIV and injuries—in appropriate chapters as a means to
● Aplia quizzes aid student understanding.
celebrate these important advancements, as well as to spur on the ● Master Training, powered by Cerego, for student person-
field to continue this important work. alized learning plans to help them understand and retain
key topics and discussions.
Retained Features
Visual Summaries Teaching and Learning Aids
At the end of each disorder chapter is a colorful, two-page visual Profiles in Psychopathology
overview that succinctly summarizes the causes, development, In Profiles of Psychopathology, students explore the lives of indi-
symptoms, and treatment of each disorder covered in the chapter. viduals with mental disorders to better understand the etiology,
P r E fa C E xxiii
symptoms, and treatment. Each of the ten modules focuses on one consisting of 40 articles from popular magazines and jour-
type of disorder. Students learn about six individuals—historical nals. Each article explores ongoing controversies regarding
and popular culture figures—and then match the individual to mental illness and its treatment. ISBN: 0-534-35416-5
the disorder that best explains their symptoms and causes. The ● Casebook in Abnormal Psychology, 5th edition, by
experiences of a real-life person from the population-at-large is Timothy A. Brown and David H. Barlow, is a comprehen-
also featured, with video footage of that individual discussing sive casebook fully updated to be consistent with DSM-5
their experience with psychopathology. that reflects the integrative approach, which considers the
multiple influences of genetic, biological, familial, and
Continuum Video Project environmental factors into a unified model of causality as
The Continuum Video Project provides holistic, three-dimensional well as maintenance and treatment of the disorder. The
portraits of individuals dealing with psychopathologies. Videos show casebook discusses treatment methods that are the most
clients living their daily lives, interacting with family and friends, and effective interventions developed for a particular disorder.
displaying—rather than just describing—their symptoms. Before It also presents three undiagnosed cases in order to give
each video segment, students are asked to make observations about students an appreciation for the complexity of disorders.
the individual’s symptoms, emotions, and behaviors, and then rate The cases are strictly teaching/learning exercises, simi-
them on the spectrum from normal to severe. The Continuum lar to what many instructors use on their examinations.
Video Project allows students to “see” the disorder and the person, ISBN: 9781305971714
humanly; the videos also illuminate student understanding that
abnormal behavior can be viewed along a continuum.
Acknowledgments
Instructor Resource Center Finally, this book in all of its editions would not have begun and
certainly would not have been finished without the inspiration and
Everything you need for your course in one place! This collection coordination of our senior editors at Cengage, Tim Matray, and
of book-specific lecture and class tools is available online via www Carly McJunkin, who always keep their eyes on the ball. A special
.cengage.com/login. Access and download videos, PowerPoint note of thanks to senior content developer Tangelique Williams-
presentations, images, instructor’s manual, and more. Grayer and her eye for detail and organization. The book is much
better for your efforts. We hope to work with you on many sub-
Cognero sequent editions. We appreciate the expertise of marketing man-
Cengage Learning Testing Powered by Cognero is a flexible, online agers James Findlay and Jennifer Levanduski. Kimiya Hojjat and
system that allows you to author, edit, and manage test bank con- Katie Chen were hardworking, enthusiastic, and organized from
tent from multiple Cengage Learning solutions, create multiple beginning to end.
test versions in an instant, and deliver tests from your LMS, your In the production process, many individuals worked as hard as
classroom, or wherever you want. we did to complete this project. In Boston, Hannah Boettcher, Clair
Cassiello-Robbins and Amantia Ametaj assisted enormously in inte-
grating a vast amount of new information into each chapter. Their
Instructor’s Manual
ability to find missing references and track down information was
The Online Instructor’s Manual contains chapter overviews, learn- remarkable, and Hannah and Jade Wu also took the lead in putting
ing objectives, lecture outlines with discussion points, key terms, together a remarkably useful supplement detailing all of the changes
classroom activities, demonstrations, and lecture topics, suggested in diagnostic criteria from DSM-IV to DSM-5 in an easy-to-read,
supplemental reading material, handouts, video resources, and side-by-side format. It is an understatement to say we couldn’t have
Internet resources. done it without you. In St. Petersburg, Ashley Smith’s professional-
ism and attention to detail helped smooth this process immensely.
PowerPoint At Cengage, Vernon Boes guided the design down to the last detail.
The Online PowerPoints feature lecture outlines and important Michelle Clark and Ruth Sakata-Corley coordinated all of the pro-
visuals from the text. duction details with grace under pressure. We thank Priya Subbrayal
for her commitment to finding the best photos possible.
Numerous colleagues and students provided superb feedback
Titles of Interest
on the previous editions, and to them we express our deepest grat-
● DSM-5 Supplement by Boettcher, Wu, Barlow, and Durand itude. Although not all comments were favorable, all were impor-
is a thorough comparison of the changes made in DSM-5 tant. Readers who take the time to communicate their thoughts
with the previous criteria and language in DSM-IV-TR. Also offer the greatest reward to writers and scholars.
includes discussion of major controversies resulting from the Finally, you share with us the task of communicating knowl-
proposed and realized modifications to the latest diagnostic edge and discoveries in the exciting field of psychopathology, a
manual. ISBN: 9781285848181 challenge that none of us takes lightly. In the spirit of collegiality,
● Looking into Abnormal Psychology: Contemporary Readings we would greatly appreciate your comments on the content and
by Scott O. Lilienfeld is a fascinating 234-page reader style of this book and recommendations for improving it further.
xxiv P r E fa C E
Reviewers extraordinarily perceptive critical comments, corrected errors,
pointed to relevant information, and, on occasion, offered new
Creating this book has been both stimulating and exhausting,
insights that helped us achieve a successful, integrative model
and we could not have done it without the valuable assistance
of each disorder.
of colleagues who read one or more chapters and provided
We thank the following expert reviewers and Bryan Cochran, University of Montana Ernest Keen, Bucknell University
survey participants of the eighth edition: Julie Cohen, University of Arizona Elizabeth Klonoff, San Diego State
Kanika Bell, Clark Atlanta University Dean Cruess, University of Connecticut University
Jamie S Bodenlos, Hobart and William Smith Sarah D’Elia, George Mason University Ann Kring, University of California–Berkeley
Colleges Robert Doan, University of Central Oklahoma Marvin Kumler, Bowling Green State
Lawrence Burns, Grand Valley State Juris Draguns, Pennsylvania State University University
University Melanie Duckworth, University of Thomas Kwapil, University of North
Don Evans, Simpson College Nevada–Reno Carolina–Greensboro
Susan Frankel, Lamar Community College Mitchell Earleywine, State University of George Ladd, Rhode Island College
Tammy Hanna, Albertus Magnus College New York–Albany Michael Lambert, Brigham Young
Sarah Heavin, University of Puget Sound Chris Eckhardt, Purdue University University
Stephen T. Higgins, University of Vermont Elizabeth Epstein, Rutgers University Travis Langley, Henderson State University
Fiyyaz Karim, University of Minnesota Donald Evans, University of Otago Christine Larson, University of
Maureen C. Kenny, Florida International Ronald G. Evans, Washburn University Wisconsin–Milwaukee
University Janice Farley, Brooklyn College, CUNY Elizabeth Lavertu, Burlington County
Lissa Lim, California State University–San Anthony Fazio, University of College
Marcos Wisconsin–Milwaukee Cynthia Ann Lease, VA Medical Center,
Barbara S. McCrady, University of New Diane Finley, Prince George’s Community Salem, VA
Mexico College Richard Leavy, Ohio Wesleyan University
Winfried Rief, University of Allen Frances, Duke University Karen Ledbetter, Portland State
Marburg–Germany Louis Franzini, San Diego State University University
Robert Rotunda, University of West Florida Maximillian Fuhrmann, California State Scott Lilienfeld, Emory University
Kyle Stephenson, Willamette University University–Northridge Kristi Lockhart, Yale University
Lynda Szymanski, St. Catherine University Aubyn Fulton, Pacific Union College Michael Lyons, Boston University
Noni Gaylord-Harden, Loyola Jerald Marshall, Valencia Community
We also thank the reviewers of previous University–Chicago College
editions: Trevor Gilbert, Athabasca University Janet Matthews, Loyola University–New
Amanda Sesko, University of Alaska–Southeast David Gleaves, University of Canterbury Orleans
Dale Alden, Lipscomb University Frank Goodkin, Castleton State College Dean McKay, Fordham University
Kerm Almos, Capital University Irving Gottesman, University of Minnesota Mary McNaughton-Cassill, University of
Frank Andrasik, University of Memphis Laurence Grimm, University of Texas at San Antonio
Robin Apple, Stanford University Medical Illinois–Chicago Suzanne Meeks, University of Louisville
Center Mark Grudberg, Purdue University Michelle Merwin, University of
Barbara Beaver, University of Wisconsin Marjorie Hardy, Eckerd College Tennessee–Martin
James Becker, University of Pittsburgh Keith Harris, Canyon College Thomas Miller, Murray State University
Evelyn Behar, University of Illinois–Chicago Christian Hart, Texas Women’s University Scott Monroe, University of Notre Dame
Dorothy Bianco, Rhode Island College William Hathaway, Regent University Greg Neimeyer, University of Florida
Sarah Bisconer, College of William & Mary Brian Hayden, Brown University Sumie Okazaki, New York University
Susan Blumenson, City University of Stephen Hinshaw, University of California, John Otey, South Arkansas University
New York, John Jay College of Berkeley Christopher Patrick, University of
Criminal Justice Alexandra Hye-Young Park, Humboldt State Minnesota
Robert Bornstein, Adelphi University University P. B. Poorman, University of
James Calhoun, University of Georgia William Iacono, University of Minnesota Wisconsin–Whitewater
Montie Campbell, Oklahoma Baptist Heidi Inderbitzen-Nolan, University of Katherine Presnell, Southern Methodist
University Nebraska–Lincoln University
Robin Campbell, Brevard Community Thomas Jackson, University of Arkansas Lynn Rehm, University of Houston
College Kristine Jacquin, Mississippi State University Kim Renk, University of Central Florida
Shelley Carson, Harvard University James Jordan, Lorain County Community Alan Roberts, Indiana
Richard Cavasina, California University of College University–Bloomington
Pennsylvania Boaz Kahana, Cleveland State University Melanie Rodriguez, Utah State University
Antonio Cepeda-Benito, Texas A&M Arthur Kaye, Virginia Commonwealth Carol Rothman, City University of New York,
University University Herbert H. Lehman College
Kristin Christodulu, State University of New Christopher Kearney, University of Nevada– Steve Schuetz, University of Central
York–Albany Las Vegas Oklahoma
P r E fa C E xxv
Stefan Schulenberg, University of Mississippi Lisa Terre, University of Missouri–Kansas W. Beryl West, Middle Tennessee State
Paula K. Shear, University of Cincinnati City University
Steve Saiz, State University of New Gerald Tolchin, Southern Connecticut State Michael Wierzbicki, Marquette University
York–Plattsburgh University Richard Williams, State University of New
Jerome Small, Youngstown State University Michael Vasey, Ohio State University York–College at Potsdam
Ari Solomon, Williams College Larry Ventis, College of William & Mary John Wincze, Brown University
Michael Southam-Gerow, Virginia Richard Viken, Indiana University Bradley Woldt, South Dakota State
Commonwealth University Lisa Vogelsang, University of University
John Spores, Purdue University–North Central Minnesota–Duluth Nancy Worsham, Gonzaga University
Brian Stagner, Texas A&M University Philip Watkins, Eastern Washington Ellen Zaleski, Fordham University
Irene Staik, University of Montevallo University Raymond Zurawski, St. Norbert College
Rebecca Stanard, State University of West Georgia Kim Weikel, Shippensburg University of
Chris Tate, Middle Tennessee State Pennsylvania
University Amy Wenzel, University of Pennsylvania
xxvi P r E fa C E
Abnormal Psychology
A N I N T E G R AT I V E A P P R O A C H
1 Abnormal Behavior
in Historical Context
ChaptEr OutLinE
understanding psychopathology
What Is a Psychological Disorder?
The Science of Psychopathology
Historical Conceptions of Abnormal Behavior
the Supernatural tradition
Demons and Witches
Stress and Melancholy
Treatments for Possession
Mass Hysteria
Modern Mass Hysteria
The Moon and the Stars
Comments
the Biological tradition
Hippocrates and Galen
The 19th Century
The Development of Biological Treatments
Consequences of the Biological Tradition
the psychological tradition
Moral Therapy
Asylum Reform and the Decline of Moral
Therapy
Psychoanalytic Theory
Humanistic Theory
The Behavioral Model
the present: the Scientific Method
and an Integrative Approach
Jerry Cooke/Science Source
Student learning outcomeS*
Describe key concepts, principles, and overarching • Explain why psychology is a science with the primary
themes in psychology objectives of describing, understanding, predicting,
and controlling behavior and mental processes
(APA SLO 1.1b) (see textbook pages 4–7, 25–27)
• Use basic psychological terminology, concepts, and
theories in psychology to explain behavior and mental
processes (APA SLO 1.1a) (see textbook pages 3–6,
9–14, 16–21, 23–27)
Develop a working knowledge of the content domains • Summarize important aspects of history of psychology,
of psychology including key figures, central concerns, methods used, and
theoretical conflicts (APA SLO 1.2c) (see textbook pages 9–27)
• Identify key characteristics of major content domains in
psychology (e.g., cognition and learning, developmental,
biological, and sociocultural) (APA SLO 1.2a)
(see textbook pages 4–6, 13–21, 25–27)
Use scientific reasoning to interpret behavior • See APA SLO 1.1b listed above
• Incorporate several appropriate levels of complexity
(e.g., cellular, individual, group/system, society/cultural)
to explain behavior (APA SLO 2.1c) (see textbook
pages 8–9, 12–16, 18–27)
*
Portions of this chapter cover learning outcomes suggested by the American Psychological Association
(2013) in their guidelines for the undergraduate psychology major. Chapter coverage of these outcomes
is identified above by APA Goal and APA Suggested Learning Outcome (SLO).
Understanding Psychopathology
leave her. She continued to be bothered by them and occa-
Today you may have gotten out of bed, had breakfast, gone to class, sionally felt slightly queasy. She began to avoid situations in
studied, and, at the end of the day, enjoyed the company of your which she might see blood or injury. She stopped looking
friends before dropping off to sleep. It probably did not occur to at magazines that might have gory pictures. She found it
you that many physically healthy people are not able to do some or difficult to look at raw meat, or even Band-Aids, because
any of these things. What they have in common is a psychological they brought the feared images to mind. Eventually,
disorder, a psychological dysfunction within an individual asso- anything her friends or parents said that evoked an image
ciated with distress or impairment in functioning and a response of blood or injury caused Judy to feel lightheaded. It got so
that is not typical or culturally expected. Before examining exactly bad that if one of her friends exclaimed, “Cut it out!” she
what this means, let’s look at one individual’s situation. felt faint.
Beginning about 6 months before her visit to the clinic,
Judy actually fainted when she unavoidably encountered
The Girl Who Fainted at something bloody. Her family physician could find nothing
Judy...
the Sight of Blood wrong with her, nor could several other physicians. By the
time she was referred to our clinic, she was fainting 5 to
10 times a week, often in class. Clearly, this was problematic
J udy, a 16-year-old, was referred to our anxiety disorders

clinic after increasing episodes of fainting. About 2 years
earlier, in Judy’s first biology class, the teacher had shown a
for her and disruptive in school; each time Judy fainted, the
other students flocked around her, trying to help, and class
was interrupted. Because no one could find anything wrong
movie of a frog dissection to illustrate various points about with her, the principal finally concluded that she was being
anatomy. manipulative and suspended her from school, even though
This was a particularly graphic film, with vivid images of she was an honor student.
blood, tissue, and muscle. About halfway through, Judy felt
a bit lightheaded and left the room. But the images did not (Continued next page)
U n d E r s ta n d i n g P s y C h o Pat h o l o g y 3
for the disorder, so knowing where to draw the line between
Judy was suffering from what we now call blood– injection– normal and abnormal dysfunction is often difficult. For this rea-
injury phobia. Her reaction was quite severe, thereby meeting son, these problems are often considered to be on a continuum or
the criteria for phobia, a psychological disorder character- a dimension rather than to be categories that are either present or
ized by marked and persistent fear of an object or situation. absent (McNally, 2011; Stein, Phillips, Bolton, Fulford, Sadler, &
But many people have similar reactions that are not as severe Kendler, 2010; Widiger & Crego, 2013). This, too, is a reason why
when they receive an injection or see someone who is injured, just having a dysfunction is not enough to meet the criteria for a
whether blood is visible or not. For people who react as severely psychological disorder.
as Judy, this phobia can be disabling. They may avoid certain
careers, such as medicine or nursing, and, if they are so afraid
of needles and injections that they avoid them even when they distress or impairment
need them, they put their health at risk. • That the behavior must be associated with distress to be classi-
fied as a disorder adds an important component and seems clear:
The criterion is satisfied if the individual is extremely upset. We
can certainly say that Judy was distressed and even suffered with
What Is a Psychological Disorder? her phobia. But remember, by itself this criterion does not define
Keeping in mind the real-life problems faced by Judy, let’s look problematic abnormal behavior. It is often quite normal to be dis-
more closely at the definition of psychological disorder: or prob- tressed—for example, if someone close to you dies. The human
lematic abnormal behavior: It is a psychological dysfunction condition is such that suffering and distress are very much part of
within an individual that is associated with distress or impair- life. This is not likely to change. Furthermore, for some disorders,
ment in functioning and a response that is not typical or culturally by definition, suffering and distress are absent. Consider the per-
expected (see E Figure 1.1). On the surface, these three criteria son who feels extremely elated and may act impulsively as part of
may seem obvious, but they were not easily arrived at and it is a manic episode. As you will see in Chapter 7, one of the major
worth a moment to explore what they mean. You will see, impor- difficulties with this problem is that some people enjoy the manic
tantly, that no one criterion has yet been developed that fully state so much they are reluctant to begin treatment or stay long in
defines a psychological disorder.
Psychological dysfunction
Psychological dysfunction refers to a breakdown in cognitive, emo-
tional, or behavioral functioning. For example, if you are out on a
date, it should be fun. But if you experience severe fear all evening
and just want to go home, even though there is nothing to be afraid
of, and the severe fear happens on every date, your emotions are
not functioning properly. However, if all your friends agree that
the person who asked you out is unpredictable and dangerous in
some way, then it would not be dysfunctional for you to be fearful
and avoid the date.
A dysfunction was present for Judy: She fainted at the sight of
blood. But many people experience a mild version of this reaction
(feeling queasy at the sight of blood) without meeting the criteria
Psychological
disorder
Enigma/Alamy Stock Photo
Psychological dysfunction
Distress or impairment
Atypical response
E FIGURE 1.1 Distress and suffering are a natural part of life and do not in them-
The criteria defining a psychological disorder. selves constitute a psychological disorder.
4 CHAPTER 1 a B n o r M a l B E h av i o r i n h i s t o r i C a l C o n t E x t
treatment. Thus, defining psychological disorder by distress alone more of the Masai’s view of psychological disorders, Sapolsky had
doesn’t work, although the concept of distress contributes to a the following discussion:
good definition.
“So, Rhoda,” I began laconically, “what do you suppose was
The concept of impairment is useful, although not entirely
wrong with that woman?”
satisfactory. For example, many people consider themselves shy
She looked at me as if I was mad.
or lazy. This doesn’t mean that they’re abnormal. But if you are so
“She is crazy.”
shy that you find it impossible to date or even interact with people
“But how can you tell?”
and you make every attempt to avoid interactions even though
“She’s crazy. Can’t you just see from how she acts?”
you would like to have friends, then your social functioning is
“But how do you decide that she is crazy? What did
impaired.
she do?”
Judy was clearly impaired by her phobia, but many people with
“She killed that goat.”
similar, less severe reactions are not impaired. This difference again
“Oh,” I said with anthropological detachment, “but
illustrates the important point that most psychological disorders
Masai kill goats all the time.”
are simply extreme expressions of otherwise normal emotions,
She looked at me as if I were an idiot. “Only the men
behaviors, and cognitive processes.
kill goats,” she said.
“Well, how else do you know that she is crazy?”
atypical or not culturally expected “She hears voices.”
Again, I made a pain of myself. “Oh, but the Masai
Finally, the criterion that the response be atypical or not culturally
hear voices sometimes.” (At ceremonies before long cattle
expected is important but also insufficient to determine if a
drives, the Masai trance-dance and claim to hear voices.)
disorder is present by itself. At times, something is considered
And in one sentence, Rhoda summed up half of what any-
abnormal because it occurs infrequently; it deviates from the
one needs to know about cross-cultural psychiatry.
average. The greater the deviation, the more abnormal it is. You
“But she hears voices at the wrong time.” (p. 138)
might say that someone is abnormally short or abnormally tall,
meaning that the person’s height deviates substantially from
average, but this obviously isn’t a definition of disorder. Many
people are far from the average in their behavior, but few would
be considered disordered. We might call them talented or eccen-
tric. Many artists, movie stars, and athletes fall in this category.
For example, it’s not normal to wear a dress made entirely out
of meat, but when Lady Gaga wore this to an awards show, it
only enhanced her celebrity. The late novelist J. D. Salinger, who
wrote The Catcher in the Rye, retreated to a small town in New
Hampshire and refused to see any outsiders for years, but he
continued to write. Some male rock singers wear heavy makeup
on stage. These people are well paid and seem to enjoy their
careers. In most cases, the more productive you are in the eyes of
society, the more eccentricities society will tolerate. Therefore,
“deviating from the average” doesn’t work well as a definition
for problematic abnormal behavior.
Another view is that your behavior is disordered if you are vio-
lating social norms, even if a number of people are sympathetic to
your point of view. This definition is useful in considering impor-
tant cultural differences in psychological disorders. For example,
to enter a trance state and believe you are possessed reflects a
psychological disorder in most Western cultures but not in many
other societies, where the behavior is accepted and expected (see
Chapter 6). (A cultural perspective is an important point of refer-
ence throughout this book.) An informative example of this view is
provided by Robert Sapolsky (2002), the prominent neuroscientist
Steve Granitz/Getty Images
who, during his studies, worked closely with the Masai people in
East Africa. One day, Sapolsky’s Masai friend Rhoda asked him to
bring his vehicle as quickly as possible to the Masai village where a
woman had been acting aggressively and had been hearing voices.
The woman had actually killed a goat with her own hands. Sapolsky
and several Masai were able to subdue her and transport her to a We accept extreme behaviors by entertainers, such as Lady Gaga,
local health center. Realizing that this was an opportunity to learn that would not be tolerated in other members of our society.
A social standard of normal has been misused, however. Con-
sider, for example, the practice of committing political dissidents
to mental institutions because they protest the policies of their
government, which was common in Iraq before the fall of Saddam
Hussein and now occurs in Iran. Although such dissident behav-
ior clearly violated social norms, it should not alone be cause for
commitment.
Jerome Wakefield (1999, 2009), in a thoughtful analysis of
the matter, uses the shorthand definition of harmful dysfunction.
A related concept that is also useful is to determine whether the
behavior is out of the individual’s control (something the person
ake1150/Fotolia LLC
doesn’t want to do) (Widiger & Crego, 2013; Widiger & Sankis,
2000). Variants of these approaches are most often used in current
diagnostic practice, as outlined in the fifth edition of the Diag-
nostic and Statistical Manual (American Psychiatric Association,
2013), which contains the current listing of criteria for psycho- Some religious behaviors may seem unusual to us but are culturally
logical disorders (Stein et al., 2010). These approaches guide our or individually appropriate.
thinking in this book.
a rating of 4 would indicate continual and severe symptoms

an accepted definition (Beesdo-Baum, et al., 2012; LeBeau, Bogels, Moller, & Craske,
In conclusion, it is difficult to define what constitutes a psycholog- 2015; LeBeau et al., 2012). These concepts are described more
ical disorder (Lilienfeld & Marino, 1995, 1999)—and the debate fully in Chapter 3, where the diagnosis of psychological disor-
continues (Blashfield, Keeley, Flanagan, & Miles, 2014; McNally, ders is discussed.
2011; Stein et al., 2010; Spitzer, 1999; Wakefield, 2003, 2009; For a final challenge, take the problem of defining a psycho-
Zachar & Kendler, 2014). The most widely accepted definition logical disorder a step further and consider this: What if Judy
used in the Diagnostic and Statistical Manual of Mental Disorders passed out so often that after a while neither her classmates nor
(5th ed.; DSM-5; American Psychiatric Association, 2013) her teachers even noticed because she regained consciousness
describes behavioral, psychological, or biological dysfunctions quickly? Furthermore, what if Judy continued to get good grades?
that are unexpected in their cultural context and associated with Would fainting all the time at the mere thought of blood be a dis-
present distress and impairment in functioning, or increased order? Would it be impairing? Dysfunctional? Distressing? What
risk of suffering, death, pain, or impairment. This definition can do you think?
be useful across cultures and subcultures if we pay careful atten-
tion to what is functional or dysfunctional (or out of control)
in a given society. But it is never easy to decide what represents The Science of Psychopathology
dysfunction, and some scholars have argued persuasively that Psychopathology is the scientific study of psychological disorders.
the health professions will never be able to satisfactorily define Within this field are specially trained professionals, including clin-
disease or disorder (see, for example, Lilienfeld & Marino, 1995, ical and counseling psychologists, psychiatrists, psychiatric social
1999; McNally, 2011; Stein et al., 2010; Zachar & Kendler, 2014). workers, and psychiatric nurses, as well as marriage and family
The best we may be able to do is to consider how the apparent therapists and mental health counselors. Clinical psychologists and
disease or disorder matches a “typical” profile of a disorder—for counseling psychologists receive the Ph.D., doctor of philosophy,
example, major depression or schizophrenia—when most or all degree (or sometimes an Ed.D., doctor of education, or Psy.D.,
symptoms that experts would agree are part of the disorder are doctor of psychology) and follow a course of graduate-level study
present. We call this typical profile a prototype, and, as described lasting approximately 5 years, which prepares them to conduct
in Chapter 3, the diagnostic criteria from DSM-5 found through- research into the causes and treatment of psychological disorders
out this book are all prototypes. This means that the patient may and to diagnose, assess, and treat these disorders. Although there
have only some features or symptoms of the disorder (a mini- is a great deal of overlap, counseling psychologists tend to study
mum number) and still meet criteria for the disorder because and treat adjustment and vocational issues encountered by rela-
his or her set of symptoms is close to the prototype. But one tively healthy individuals, and clinical psychologists usually con-
of the differences between DSM-5 and its predecessor, DSM-IV, centrate on more severe psychological disorders. Also, programs
is the addition of dimensional estimates of the severity of spe- in professional schools of psychology, where the degree is often
cific disorders in DSM-5 (American Psychiatric Association, a Psy.D., focus on clinical training and de-emphasize or elimi-
2013; Regier, Narrow, Kuhl, & Kupfer, 2009; Helzer, Wittchen, nate research training. In contrast, Ph.D. programs in universities
Krueger, & Kraemer, 2008). Thus, for the anxiety disorders, for integrate clinical and research training. Psychologists with other
example, the intensity and frequency of anxiety within a given specialty training, such as experimental and social psychologists,
disorder such as panic disorder is rated on a 0 to 4 scale where concentrate on investigating the basic determinants of behavior
a rating of 1 would indicate mild or occasional symptoms and but do not assess or treat psychological disorders.
Psychiatrists first earn an M.D. degree in medical school Focus
and then specialize in psychiatry during residency training that Clinical description
lasts 3 to 4 years. Psychiatrists also investigate the nature and Studying
causes of psychological disorders, often from a biological point of psychological Causation (etiology)
view; make diagnoses; and offer treatments. Many psychiatrists disorders
emphasize drugs or other biological treatments, although most Treatment and outcome
use psychosocial treatments as well.
Psychiatric social workers typically earn a master’s degree in
E FIGURE 1.3
social work as they develop expertise in collecting information
relevant to the social and family situation of the individual with a Three major categories make up the study and discussion of
psychological disorders.
psychological disorder. Social workers also treat disorders, often
concentrating on family problems associated with them. Psychi-
atric nurses have advanced degrees, such as a master’s or even a see whether they work. They are accountable not only to their
Ph.D., and specialize in the care and treatment of patients with patients but also to the government agencies and insurance
psychological disorders, usually in hospitals as part of a treat- companies that pay for the treatments, so they must demon-
ment team. strate clearly whether their treatments are effective or not.
Finally, marriage and family therapists and mental health Third, scientist-practitioners might conduct research, often
counselors typically spend 1 to 2 years earning a master’s degree in clinics or hospitals, that produces new information about
and are employed to provide clinical services by hospitals or clin- disorders or their treatment, thus becoming immune to the
ics, usually under the supervision of a doctoral-level clinician. fads that plague our field, often at the expense of patients
and their families. For example, new “miracle cures” for psy-
chological disorders that are reported several times a year in
the Scientist-Practitioner popular media would not be used by a scientist-practitioner
The most important development in the recent history of psy- if there were no sound scientific data showing that they work.
chopathology is the adoption of scientific methods to learn Such data flow from research that attempts three basic things:
more about the nature of psychological disorders, their causes, to describe psychological disorders, to determine their causes,
and their treatment. Many mental health professionals take and to treat them (see E Figure 1.3). These three categories
a scientific approach to their clinical work and therefore are compose an organizational structure that recurs throughout
called scientist-practitioners (Barlow, Hayes, & Nelson, 1984; this book and that is formally evident in the discussions of
Hayes, Barlow, & Nelson-Gray, 1999). Mental health practitio- specific disorders beginning in Chapter 5. A general overview
ners may function as scientist-practitioners in one or more of of them now will give you a clearer perspective on our efforts
three ways (see E Figure 1.2). First, they may keep up with the to understand abnormality.
latest scientific developments in their field and therefore use
the most current diagnostic and treatment procedures. In this
sense, they are consumers of the science of psychopathology to clinical description
the advantage of their patients. Second, scientist-practitioners In hospitals and clinics, we often say that a patient “presents”
evaluate their own assessments or treatment procedures to with a specific problem or set of problems or we discuss the
presenting problem. Presents is a traditional shorthand way of
indicating why the person came to the clinic. Describing Judy’s
presenting problem is the first step in determining her clinical
description, which represents the unique combination of behav-
Mental iors, thoughts, and feelings that make up a specific disorder. The
health word clinical refers both to the types of problems or disorders
professional that you would find in a clinic or hospital and to the activities
Consumer of science
connected with assessment and treatment. Throughout this text
• Enhancing the practice are excerpts from many more individual cases, most of them
from our personal files.
Evaluator of science
Kevin Peterson/Photodisc/Getty Images
• Determining the
Clearly, one important function of the clinical description is
effectiveness of the to specify what makes the disorder different from normal behav-
practice ior or from other disorders. Statistical data may also be relevant.
Creator of science
For example, how many people in the population as a whole
• Conducting research have the disorder? This figure is called the prevalence of the dis-
that leads to new order. Statistics on how many new cases occur during a given
procedures useful
in practice
period, such as a year, represent the incidence of the disorder.
Other statistics include the sex ratio—that is, what percentage of
E FIGURE 1.2 males and females have the disorder—and the typical age of onset,
Functioning as a scientist-practitioner. which often differs from one disorder to another.
In addition to having different symptoms, age of onset, and
possibly a different sex ratio and prevalence, most disorders
follow a somewhat individual pattern, or course. For example,
some disorders, such as schizophrenia (see Chapter 13), follow
a chronic course, meaning that they tend to last a long time,
sometimes a lifetime. Other disorders, like mood disorders
(see Chapter 7), follow an episodic course, in that the individual
is likely to recover within a few months only to suffer a recur-
rence of the disorder at a later time. This pattern may repeat
throughout a person’s life. Still other disorders may have a
time-limited course, meaning the disorder will improve without
treatment in a relatively short period with little or no risk of
recurrence.
Closely related to differences in course of disorders are dif-
ferences in onset. Some disorders have an acute onset, mean-
ing that they begin suddenly; others develop gradually over
an extended period, which is sometimes called an insidious
onset. It is important to know the typical course of a disorder
so that we can know what to expect in the future and how best
to deal with the problem. This is an important part of the clini-
cal description. For example, if someone is suffering from a
mild disorder with acute onset that we know is time limited,
© Hung Chung Chih /Shutterstock.com

we might advise the individual not to bother with expensive
treatment because the problem will be over soon enough, like
a common cold. If the disorder is likely to last a long time
(become chronic), however, the individual might want to seek
treatment and take other appropriate steps. The anticipated
course of a disorder is called the prognosis. So we might say,
“the prognosis is good,” meaning the individual will probably
recover, or “the prognosis is guarded,” meaning the probable Children experience panic and anxiety differently from adults, so
outcome doesn’t look good. their reactions may be mistaken for symptoms of physical illness.
The patient’s age may be an important part of the clini-
cal description. A specific psychological disorder occurring
in childhood may present differently from the same disorder
in adulthood or old age. Children experiencing severe anxiety disorders is so important to this field, we devote an entire chapter
and panic often assume that they are physically ill because (Chapter 2) to it.
they have difficulty understanding that there is nothing phys- Treatment, also, is often important to the study of psy-
ically wrong. Because their thoughts and feelings are differ- chological disorders. If a new drug or psychosocial treatment
ent from those experienced by adults with anxiety and panic, is successful in treating a disorder, it may give us some hints
children are often misdiagnosed and treated for a medical about the nature of the disorder and its causes. For example, if
disorder. a drug with a specific known effect within the nervous system
We call the study of changes in behavior over time develop- alleviates a certain psychological disorder, we know that some-
mental psychology, and we refer to the study of changes in abnor- thing in that part of the nervous system might either be causing
mal behavior as developmental psychopathology. When you think the disorder or helping maintain it. Similarly, if a psychologi-
of developmental psychology, you probably picture researchers cal treatment designed to help clients regain a sense of control
studying the behavior of children. We change throughout our over their lives is effective with a certain disorder, a diminished
lives, however, and so researchers also study development in sense of control may be an important psychological component
adolescents, adults, and older adults. Study of abnormal behav- of the disorder itself.
ior across the entire age span is referred to as life-span develop- As you will see in the next chapter, psychopathology is rarely
mental psychopathology. The field is relatively new but expanding simple. This is because the effect does not necessarily imply the
rapidly. cause. To use a common example, you might take an aspirin
to relieve a tension headache you developed during a grueling
day of taking exams. If you then feel better, that does not mean
causation, treatment, and etiology outcomes that the headache was caused by a lack of aspirin. Nevertheless,
Etiology, or the study of origins, has to do with why a disorder many people seek treatment for psychological disorders, and
begins (what causes it) and includes biological, psychological, treatment can provide interesting hints about the nature of the
and social dimensions. Because the etiology of psychological disorder.
In the past, textbooks emphasized treatment approaches
in a general sense, with little attention to the disorder being Concept Check 1.1
treated. For example, a mental health professional might be
thoroughly trained in a single theoretical approach, such as Part A
psychoanalysis or behavior therapy (both described later in the Write the letter for any or all of the following definitions
chapter), and then use that approach on every disorder. More of abnormality in the blanks: (a) societal norm violation,
recently, as our science has advanced, we have developed spe- (b) impairment in functioning, (c) dysfunction, and (d) distress.
cific effective treatments that do not always adhere neatly to
one theoretical approach or another but that have grown out 1. Miguel recently began feeling sad and lonely. Although
of a deeper understanding of the disorder in question. For this still able to function at work and fulfill other responsi-
reason, there are no separate chapters in this book on such bilities, he finds himself feeling down much of the time
types of treatment approaches as psychodynamic, cognitive and he worries about what is happening to him. Which
behavioral, or humanistic. Rather, the latest and most effec- of the definitions of abnormality apply to Miguel’s
tive drug and psychosocial treatments (nonmedical treatments situation? _____________
that focus on psychological, social, and cultural factors) are
described in the context of specific disorders in keeping with 2. Three weeks ago, Jane, a 35-year-old business
our integrative multidimensional perspective. executive, stopped showering, refused to leave her
We now survey many early attempts to describe and treat apartment, and started watching television talk
abnormal behavior and to comprehend its causes, which shows. Threats of being fired have failed to bring
will give you a better perspective on current approaches. Jane back to reality, and she continues to spend her
In Chapter 2, we examine exciting contemporary views of days staring blankly at the television screen. Which
causation and treatment. In Chapter 3, we discuss efforts to of the definitions seems to describe Jane’s behavior?
describe, or classify, abnormal behavior. In Chapter 4, we ______________
review research methods—our systematic efforts to discover
the truths underlying description, cause, and treatment that Part B
allow us to function as scientist-practitioners. In Chapters 5 Match the following words that are used in clinical descriptions
through 15, we examine specific disorders; our discussion is with their corresponding examples: (a) presenting problem,
organized in each case in the now familiar triad of description, (b) prevalence, (c) incidence, (d) prognosis, (e) course, and
cause, and treatment. Finally, in Chapter 16 we examine legal, (f) etiology.
professional, and ethical issues relevant to psychological dis-
orders and their treatment today. With that overview in mind, 3. Maria should recover quickly with no intervention
let us turn to the past. necessary. Without treatment, John will deteriorate
rapidly. ________________
4. Three new cases of bulimia have been reported in this
Historical Conceptions of Abnormal Behavior county during the past month and only one in the next
For thousands of years, humans have tried to explain and con- county. ______________
trol problematic behavior. But our efforts always derive from the
theories or models of behavior popular at the time. The purpose of 5. Elizabeth visited the campus mental health center
these models is to explain why someone is “acting like that.” Three because of her increasing feelings of guilt and anxiety.
major models that have guided us date back to the beginnings of _________________
civilization. 6. Biological, psychological, and social influences all
Humans have always supposed that agents outside our
contribute to a variety of disorders. ______________
bodies and environment influence our behavior, think-
ing, and emotions. These agents—which might be divini- 7. The pattern a disorder follows can be chronic, time-
ties, demons, spirits, or other phenomena such as magnetic limited, or episodic. _________
fields or the moon or the stars—are the driving forces behind 8. How many people in the population as a whole suffer
the supernatural model. In addition, since the era of ancient
from obsessive-compulsive disorder? ____________
Greece, the mind has often been called the soul or the psyche
and considered separate from the body. Although many have
thought that the mind can influence the body and, in turn,
the body can influence the mind, most philosophers looked
for causes of abnormal behavior in one or the other. This split
gave rise to two traditions of thought about abnormal behav- The Supernatural Tradition
ior, summarized as the biological model and the psychological For much of our recorded history, deviant behavior has been
model. These three models—the supernatural, the biological, considered a reflection of the battle between good and evil. When
and the psychological—are very old but continue to be used confronted with unexplainable, irrational behavior and by suffering
today. and upheaval, people have perceived evil. In fact, in the Great Persian
t h E s U P E r n at U r a l t r a d i t i o n 9
Empire from 900 to 600 b.c., all physical and mental disorders were
considered the work of the devil (Millon, 2004). Barbara Tuchman,
a noted historian, chronicled the second half of the 14th century, a
particularly difficult time for humanity, in A Distant Mirror (1978).
She ably captures the conflicting tides of opinion on the origins and
treatment of insanity during that bleak and tumultuous period.
Demons and Witches

One strong current of opinion put the causes and treatment of
psychological disorders squarely in the realm of the supernatu-
ral. During the last quarter of the 14th century, religious and lay
authorities supported these popular superstitions, and society as a
whole began to believe more strongly in the existence and power
of demons and witches. The Catholic Church had split, and a sec-
ond center, complete with a pope, emerged in the south of France
to compete with Rome. In reaction to this schism, the Roman
Church fought back against the evil in the world that it believed
must have been behind this heresy.
People increasingly turned to magic and sorcery to solve their
problems. During these turbulent times, the bizarre behavior of
people afflicted with psychological disorders was seen as the work
of the devil and witches. It followed that individuals possessed by
evil spirits were probably responsible for any misfortune experi-
enced by people in the local community, which inspired drastic
action against the possessed. Treatments included exorcism, in
which various religious rituals were performed in an effort to rid
DEA PICTURE LIBRARY/Getty Images

the victim of evil spirits. Other approaches included shaving the
pattern of a cross in the hair of the victim’s head and securing suf-
ferers to a wall near the front of a church so that they might benefit
from hearing Mass.
The conviction that sorcery and witches are causes of madness
and other evils continued into the 15th century, and evil contin-
ued to be blamed for unexplainable behavior, even after the found-
ing of the United States, as evidenced by the Salem, Massachusetts, During the Middle Ages, individuals with psychological disorders were
witch trials in the late 17th century, which resulted in the hanging sometimes thought to be possessed by evil spirits and exorcisms
deaths of 20 women. were attempted through rituals.
Stress and Melancholy In the 14th century, one of the chief advisers to the king of
An equally strong opinion, even during this period, reflected the France, a bishop and philosopher named Nicholas Oresme, also
enlightened view that insanity was a natural phenomenon, caused suggested that the disease of melancholy (depression) was the
by mental or emotional stress, and that it was curable (Alexander source of some bizarre behavior, rather than demons. Oresme
& Selesnick, 1966; Maher & Maher, 1985a). Mental depression and pointed out that much of the evidence for the existence of sorcery
anxiety were recognized as illnesses (Kemp, 1990; Schoeneman, and witchcraft, particularly among those considered insane, was
1977), although symptoms such as despair and lethargy were often obtained from people who were tortured and who, quite under-
identified by the church with the sin of acedia, or sloth (Tuchman, standably, confessed to anything.
1978). Common treatments were rest, sleep, and a healthy and These conflicting crosscurrents of natural and supernatural
happy environment. Other treatments included baths, ointments, explanations for mental disorders are represented more or less
and various potions. Indeed, during the 14th and 15th centuries, strongly in various historical works, depending on the sources
people with insanity, along with those with physical deformities consulted by historians. Some assumed that demonic influences
or disabilities, were often moved from house to house in medieval were the predominant explanations of abnormal behavior during
villages as neighbors took turns caring for them. We now know the Middle Ages (for example, Zilboorg & Henry, 1941); others
that this medieval practice of keeping people who have psycho- believed that the supernatural had little or no influence. As we see
logical disturbances in their own community is beneficial (see in the handling of the severe psychological disorder experienced by
Chapter 13). We return to this subject when we discuss biological late-14th-century King Charles VI of France, both influences were
and psychological models later in this chapter. strong, sometimes alternating in the treatment of the same case.
Charles VI... The Mad King from powdered pearls, proposed to cut incisions in the
King’s head. When this was not allowed by the King’s
n the summer of 1392, King Charles VI of France was
I under a great deal of stress, partly because of the divi-
sion of the Catholic Church. As he rode with his army to the
council, the friars accused those who opposed their
recommendation of sorcery” (Tuchman, 1978, p. 514).
Even the King himself, during his lucid moments, came
province of Brittany, a nearby aide dropped his lance with to believe that the source of madness was evil and sor-
a loud clatter and the king, thinking he was under attack, cery. “In the name of Jesus Christ,” he cried, weeping in
turned on his own army, killing several prominent knights his agony, “if there is any one of you who is an accom-
before being subdued from behind. The army immediately plice to this evil I suffer, I beg him to torture me no
marched back to Paris. The King’s lieutenants and advisers longer but let me die!” (Tuchman, 1978, p. 515). •
concluded that he was mad.
During the following years, at his worst the King hid in a
corner of his castle believing he was made of glass or roamed
the corridors howling like a wolf. At other times, he couldn’t Treatments for Possession
remember who or what he was. He became fearful and With a perceived connection between evil deeds and sin on the
enraged whenever he saw his own royal coat of arms and one hand and psychological disorders on the other, it is logical
would try to destroy it if it was brought near him. to conclude that the sufferer is largely responsible for the disor-
The people of Paris were devastated by their leader’s der, which might well be a punishment for evil deeds. Does this
apparent madness. Some thought it reflected God’s anger, sound familiar? The acquired immune deficiency syndrome
because the King failed to take up arms to end the schism in (AIDS) epidemic was associated with a similar belief among some
the Catholic Church; others thought it was God’s warning people, particularly in the late 1980s and early 1990s. Because the
against taking up arms; and still others thought it was divine human immunodeficiency virus (HIV) is, in Western societies,
punishment for heavy taxes (a conclusion some people most prevalent among individuals with homosexual orientation,
might make today). But most thought the King’s mad- many people believed it was a divine punishment for what they
ness was caused by sorcery, a belief strengthened by a great considered immoral behavior. This view became less common as
drought that dried up the ponds and rivers, causing cattle the AIDS virus spread to other segments of the population, yet it
to die of thirst. Merchants claimed their worst losses in persists.
20 years. Possession, however, is not always connected with sin but may
Naturally, the King was given the best care available be seen as involuntary and the possessed individual as blameless.
at the time. The most famous healer in the land was a Furthermore, exorcisms at least have the virtue of being relatively
92-year-old physician whose treatment program included painless. Interestingly, they sometimes work, as do other forms of
moving the King to one of his residences in the country faith healing, for reasons we explore in subsequent chapters. But
where the air was thought to be the cleanest in the land. what if they did not? In the Middle Ages, if exorcism failed, some
The physician prescribed rest, relaxation, and recreation. authorities thought that steps were necessary to make the body
After some time, the King seemed to recover. The physi- uninhabitable by evil spirits, and many people were subjected to
cian recommended that the King not be burdened with the confinement, beatings, and other forms of torture (Kemp, 1990).
responsibilities of running the kingdom, claiming that if Somewhere along the way, a creative “therapist” decided
he had few worries or irritations, his mind would gradually that hanging people over a pit full of poisonous snakes might
strengthen and further improve. scare the evil spirits right out of their bodies (to say nothing
Unfortunately, the physician died and the insanity of King of terrifying the people themselves). Strangely, this approach
Charles VI returned more seriously than before. This time, sometimes worked; that is, the most disturbed, oddly behaving
however, he came under the influence of the conflicting individuals would suddenly come to their senses and experi-
crosscurrent of supernatural causation. “An unkempt evil- ence relief from their symptoms, if only temporarily. Naturally,
eyed charlatan and pseudo-mystic named Arnaut Guilhem this was reinforcing to the therapist, so snake pits were built in
was allowed to treat Charles on his claim of possessing many institutions. Many other treatments based on the hypoth-
a book given by God to Adam by means of which man esized therapeutic element of shock were developed, including
could overcome all affliction resulting from original sin” dunkings in ice-cold water.
(Tuchman, 1978, p. 514). Guilhem insisted that the King’s
malady was caused by sorcery, but his treatments failed to
bring about a cure. Mass Hysteria
A variety of remedies and rituals of all kinds were tried, Another fascinating phenomenon is characterized by large-scale
but none worked. High-ranking officials and doctors of the outbreaks of bizarre behavior. To this day, these episodes puzzle
university called for the “sorcerers” to be discovered and historians and mental health practitioners. During the Middle
punished. “On one occasion, two Augustinian friars, after Ages, they lent support to the notion of possession by the devil.
getting no results from magic incantations and a liquid made In Europe, whole groups of people were simultaneously com-
pelled to run out in the streets, dance, shout, rave, and jump
t h E s U P E r n at U r a l t r a d i t i o n 11
to spread to those around us (Hatfield, Cacioppo, & Rapson, 1994;
Ntika, Sakellariou, Kefalas, & Stamatpoulou, 2014; Wang, 2006).
If someone nearby becomes frightened or sad, chances are that,
for the moment, you also will feel fear or sadness. When this kind
of experience escalates into full-blown panic, whole communities
are affected (Barlow, 2002). People are also suggestible when they
are in states of high emotion. Therefore, if one person identifies
a “cause” of the problem, others will probably assume that their
own reactions have the same source. In popular language, this
shared response is sometimes referred to as mob psychology. Until
recently, it was assumed that victims had to be in contact with
each other for the contagion to occur, as were the girls described
above in the adjacent classrooms. But lately there are document-
ed cases of emotion contagion occurring across social networks,
raising the possibility that episodes of mass hysteria may increase
(Bartholomew, Wessely, & Rubin, 2012; Dimon, 2013)
In hydrotherapy, patients were shocked back to their senses by appli-

cations of ice-cold water.
The Moon and the Stars
Source: U.S. National Library of Medicine Paracelsus, a Swiss physician who lived from 1493 to 1541,
rejected notions of possession by the devil, suggesting instead that
the movements of the moon and stars had profound effects on
around in patterns as if they were at a particularly wild party late people’s psychological functioning. Echoing similar thinking in
at night (still called a rave today, but with music). This behavior ancient Greece, Paracelsus speculated that the gravitational effects
was known by several names, including Saint Vitus’s Dance and of the moon on bodily fluids might be a possible cause of mental
tarantism. It is most interesting that many people behaved in this disorders (Rotton & Kelly, 1985). This influential theory inspired
strange way at once. In an attempt to explain the inexplicable, the word lunatic, which is derived from the Latin word luna, mean-
several reasons were offered in addition to possession. One rea- ing “moon.” You might hear some of your friends explain some-
sonable guess was reaction to insect bites. Another possibility thing crazy they did one night by saying, “It must have been the
was what we now call mass hysteria (Veith, 1965). Consider the full moon.” The belief that heavenly bodies affect human behavior
following example. still exists, although there is no scientific evidence to support it
(Raison, Klein, & Steckler, 1999; Rotton & Kelly, 1985). Despite
much ridicule, millions of people around the world are convinced
Modern Mass Hysteria that their behavior is influenced by the stages of the moon or
One Friday afternoon, an alarm sounded over the public address the positions of the stars. This belief is most noticeable today in
system of a community hospital, calling all physicians to the emer- followers of astrology, who hold that their behavior and the major
gency room immediately. Arriving from a local school in a fleet of events in their lives can be predicted by their day-to-day relation-
ambulances were 17 students and 4 teachers who reported dizzi- ship to the position of the planets. No serious evidence has ever
ness, headache, nausea, and stomach pains. Some were vomiting; confirmed such a connection, however.
most were hyperventilating.
All the students and teachers had been in four classrooms,
two on each side of the hallway. The incident began when a Comments
14-year-old girl reported a funny smell that seemed to be com- The supernatural tradition in psychopathology is alive and well,
ing from a vent. She fell to the floor, crying and complaining although it is relegated, for the most part, to small religious sects
that her stomach hurt and her eyes stung. Soon, many of the in this country and to primitive cultures elsewhere. Members of
students and most of the teachers in the four adjoining class- organized religions in most parts of the world look to psychology
rooms, who could see and hear what was happening, experi- and medical science for help with major psychological disorders;
enced similar symptoms. Of 86 susceptible people (82 students in fact, the Roman Catholic Church requires that all health-
and 4 teachers in the four classrooms), 21 patients (17 students care resources be exhausted before spiritual solutions such as
and 4 teachers) experienced symptoms severe enough to be exorcism can be considered. Nonetheless, miraculous cures are
evaluated at the hospital. Inspection of the school building by sometimes achieved by exorcism, magic potions and rituals, and
public health authorities revealed no apparent cause for the reac- other methods that seem to have little connection with modern
tions, and physical examinations by teams of physicians revealed science. It is fascinating to explore them when they do occur, and
no physical abnormalities. All the patients were sent home and we return to this topic in subsequent chapters. But such cases are
quickly recovered (Rockney & Lemke, 1992). relatively rare, and almost no one would advocate supernatural
Mass hysteria may simply demonstrate the phenomenon of treatment for severe psychological disorders except, perhaps, as
emotion contagion, in which the experience of an emotion seems a last resort.
humoral theory of disorders. Hippocrates assumed that normal
The Biological Tradition brain functioning was related to four bodily fluids or humors:
Physical causes of mental disorders have been sought since blood, black bile, yellow bile, and phlegm. Blood came from the
early in history. Important to the biological tradition are a man, heart, black bile from the spleen, phlegm from the brain, and
Hippocrates; a disease, syphilis; and the early consequences of choler or yellow bile from the liver. Physicians believed that dis-
believing that psychological disorders are biologically caused. ease resulted from too much or too little of one of the humors;
for example, too much black bile was thought to cause melan-
cholia (depression). In fact, the term melancholer, which means
Hippocrates and Galen “black bile,” is still used today in its derivative form melancholy to
The Greek physician Hippocrates (460–377 b.c.) is considered refer to aspects of depression. The humoral theory was, perhaps,
to be the father of modern Western medicine. He and his asso- the first example of associating psychological disorders with a
ciates left a body of work called the Hippocratic Corpus, writ- “chemical imbalance,” an approach that is widespread today.
ten between 450 and 350 b.c. (Maher & Maher, 1985a), in The four humors were related to the Greeks’ conception of
which they suggested that psychological disorders could be the four basic qualities: heat, dryness, moisture, and cold. Each
treated like any other disease. They did not limit their search humor was associated with one of these qualities. Terms derived
for the causes of psychopathology to the general area of “dis- from the four humors are still sometimes applied to personality
ease,” because they believed that psychological disorders might traits. For example, sanguine (literal meaning “red, like blood”)
also be caused by brain pathology or head trauma and could be describes someone who is ruddy in complexion, presumably
influenced by heredity (genetics). These are remarkably astute from copious blood flowing through the body, and cheerful and
deductions for the time, and they have been supported in recent optimistic, although insomnia and delirium were thought to be
years. Hippocrates considered the brain to be the seat of wisdom, caused by excessive blood in the brain. Melancholic means depres-
consciousness, intelligence, and emotion. Therefore, disorders sive (depression was thought to be caused by black bile flooding
involving these functions would logically be located in the brain. the brain). A phlegmatic personality (from the humor phlegm)
Hippocrates also recognized the importance of psychological indicates apathy and sluggishness but can also mean being calm
and interpersonal contributions to psychopathology, such as the under stress. A choleric person (from yellow bile or choler) is hot
sometimes-negative effects of family stress; on some occasions, tempered (Maher & Maher, 1985a).
he removed patients from their families. Excesses of one or more humors were treated by regulating the
The Roman physician Galen (approximately a.d. 129–198) environment to increase or decrease heat, dryness, moisture, or
later adopted the ideas of Hippocrates and his associates and cold, depending on which humor was out of balance. One reason
developed them further, creating a powerful and influential King Charles VI’s physician moved him to the less stressful coun-
school of thought within the biological tradition that extended tryside was to restore the balance in his humors (Kemp, 1990). In
well into the 19th century. One of the more interesting and addition to rest, good nutrition, and exercise, two treatments were
influential legacies of the Hippocratic-Galenic approach is the developed. In one, bleeding or bloodletting, a carefully measured
amount of blood was removed from the body,
often with leeches. The other was to induce
vomiting; indeed, in a well-known treatise
on depression published in 1621, Anatomy
of Melancholy, Robert Burton recommended
eating tobacco and a half-boiled cabbage to
induce vomiting (Burton, 1621/1977). If Judy
had lived 300 years ago, she might have been
diagnosed with an illness, a brain disorder,
or some other physical problem, perhaps
related to excessive humors, and been given
the proper medical treatments of the day:
bed rest, a healthful diet, exercise, and other
ministrations as indicated.
In ancient China and throughout Asia,
a similar idea existed. But rather than
“humors,” the Chinese focused on the move-
ment of air or “wind” throughout the body.
AP Images/Hatem Moussa
Unexplained mental disorders were caused

by blockages of wind or the presence of cold,
dark wind (yin) as opposed to warm, life-
sustaining wind (yang). Treatment involved
restoring proper flow of wind through vari-
Emotions are contagious and can escalate into mass hysteria. ous methods, including acupuncture.
thE BiologiCal tradition 13
Syphilis
Behavioral and cognitive symptoms of what we now know as
advanced syphilis, a sexually transmitted disease caused by a bac-
terial microorganism entering the brain, include believing that
everyone is plotting against you (delusion of persecution) or that
you are God (delusion of grandeur), as well as other bizarre behav-
iors. Although these symptoms are similar to those of psychosis—
psychological disorders characterized in part by beliefs that are
not based in reality (delusions), perceptions that are not based
in reality (hallucinations), or both—researchers recognized that
a subgroup of apparently psychotic patients deteriorated steadily,
becoming paralyzed and dying within 5 years of onset. This course
of events contrasted with that of most psychotic patients, who
remained fairly stable. In 1825, the condition was designated a
disease, general paresis, because it had consistent symptoms (pre-
National Library of Medicine
sentation) and a consistent course that resulted in death. The rela-

tionship between general paresis and syphilis was only gradually
established. Louis Pasteur’s germ theory of disease, developed in
about 1870, facilitated the identification of the specific bacterial
microorganism that caused syphilis.
Bloodletting, the extraction of blood from patients, was intended to Of equal importance was the discovery of a cure for general
restore the balance of humors in the body. paresis. Physicians observed a surprising recovery in patients with
general paresis who had contracted malaria, so they deliberately
injected other patients with blood from a soldier who was ill with
malaria. Many recovered because the high fever “burned out” the
Hippocrates also coined the word hysteria to describe a syphilis bacteria. Obviously, this type of experiment would not
concept he learned about from the Egyptians, who had identi- be ethically possible today. Ultimately, clinical investigators dis-
fied what we now call the somatic symptom disorders. In these covered that penicillin cures syphilis, but with the malaria cure,
disorders, the physical symptoms appear to be the result of a “madness” and associated behavioral and cognitive symptoms for
medical problem for which no physical cause can be found, the first time were traced directly to a curable infection. Many
such as paralysis and some kinds of blindness. Because these mental health professionals then assumed that comparable causes
disorders occurred primarily in women, the Egyptians (and and cures might be discovered for all psychological disorders.
Hippocrates) mistakenly assumed that they were restricted to
women. They also presumed a cause: The empty uterus wan-
dered to various parts of the body in search of conception John P. grey
(the Greek word for “uterus” is hysteron). Numerous physical The champion of the biological tradition in the United States
symptoms reflected the location of the wandering uterus. The was the most influential American psychiatrist of the time,
prescribed cure might be marriage or, occasionally, fumiga- John P. Grey (Bockoven, 1963). In 1854, Grey was appointed
tion of the vagina to lure the uterus back to its natural loca- superintendent of the Utica State Hospital in New York, the larg-
tion (Alexander & Selesnick, 1966). Knowledge of physiology est in the country. He also became editor of the American Journal
eventually disproved the wandering uterus theory; however, of Insanity, the precursor of the current American Journal of
the tendency to stigmatize dramatic women as hysterical Psychiatry, the flagship publication of the American Psychiatric
continued unabated well into the 1970s, when mental health Association (APA). Grey’s position was that the causes of insanity
professionals became sensitive to the prejudicial stereotype were always physical. Therefore, the mentally ill patient should
the term implied. As you will learn in Chapter 6, somatic be treated as physically ill. The emphasis was again on rest,
symptom disorders (and the traits associated with them) are diet, and proper room temperature and ventilation, approaches
not limited to one sex or the other. used for centuries by previous therapists in the biological
tradition. Grey even invented the rotary fan to ventilate his large
hospital.
The 19th Century Under Grey’s leadership, the conditions in hospitals greatly
The biological tradition waxed and waned during the centu- improved and they became more humane, livable institutions. But
ries after Hippocrates and Galen but was reinvigorated in the in subsequent years they also became so large and impersonal that
19th century because of two factors: the discovery of the nature individual attention was not possible.
and cause of syphilis and strong support from the well-respected In fact, leaders in psychiatry at the end of the 19th century
American psychiatrist John P. Grey. were alarmed at the increasing size and impersonality of
that the shock also made him “strangely elated” and wondered
if it might be a useful treatment for depression (Finger &
Zaromb, 2006, p. 245).
Independently in the 1920s, Hungarian psychiatrist Joseph
von Meduna observed that schizophrenia was rarely found in
individuals with epilepsy (which ultimately did not prove to
be true). Some of his followers concluded that induced brain
seizures might cure schizophrenia. Following suggestions on
Old Paper Studios / Alamy Stock Photo
the possible benefits of applying electric shock directly to the

brain—notably, by two Italian physicians, Ugo Cerletti and Lucio
Bini, in 1938—a surgeon in London treated a depressed patient
by sending six small shocks directly through his brain, produc-
ing convulsions (Hunt, 1980). The patient recovered. Although
greatly modified, shock treatment is still with us today. The con-
troversial modern uses of electroconvulsive therapy are described
In the 19th century, psychological disorders were attributed to mental in Chapter 7. It is interesting that even now we have little knowl-
or emotional stress, so patients were often treated sympathetically edge of how it works.
in a restful and hygienic environment. During the 1950s, the first effective drugs for severe psychotic
disorders were developed in a systematic way. Before that time,
a number of medicinal substances, including opium (derived
mental hospitals and recommended that they be downsized. from poppies), had been used as sedatives, along with countless
It was almost 100 years before the community mental health herbs and folk remedies (Alexander & Selesnick, 1966). With the
movement was successful in reducing the population of discovery of Rauwolfia serpentine (later renamed reserpine) and
mental hospitals with the controversial policy of deinstitu- another class of drugs called neuroleptics (major tranquilizers),
tionalization, in which patients were released into their com- for the first time hallucinatory and delusional thought pro-
munities. Unfortunately, this practice has as many negative cesses could be diminished in some patients; these drugs also
consequences as positive ones, including a large increase in controlled agitation and aggressiveness. Other discoveries
the number of chronically disabled patients homeless on the included benzodiazepines (minor tranquilizers), which seemed
streets of our cities. to reduce anxiety. By the 1970s, the benzodiazepines (known
by such brand names as Valium and Librium) were among
the most widely prescribed drugs in the world. As drawbacks
The Development of Biological Treatments and side effects of tranquilizers became apparent, along with
On the positive side, renewed interest in the biological origin of their limited effectiveness, prescriptions decreased somewhat
psychological disorders led, ultimately, to greatly increased under- (we discuss the benzodiazepines in more detail in Chapters 5
standing of biological contributions to psychopathology and and 11).
to the development of new treatments. In the 1930s, the physi- Throughout the centuries, as Alexander and Selesnick point
cal interventions of electric shock and brain surgery were often out, “The general pattern of drug therapy for mental illness has
used. Their effects, and the effects of new drugs, were discovered been one of initial enthusiasm followed by disappointment”
quite by accident. For example, insulin was occasionally given to (1966, p. 287). For example, bromides, a class of sedating drugs,
stimulate appetite in psychotic patients who were not eating, but were used at the end of the 19th century and beginning of the
it also seemed to calm them down. In 1927, a Viennese physician, 20th century to treat anxiety and other psychological disorders. By
Manfred Sakel, began using increasingly higher dosages until, the 1920s, they were reported as being effective for many serious
finally, patients convulsed and became temporarily comatose psychological and emotional symptoms. By 1928, one of every five
(Sakel, 1958). Some actually recovered their mental health, much prescriptions in the United States was for bromides. When their
to the surprise of everybody, and their recovery was attributed to side effects, including various undesirable physical symptoms,
the convulsions. The procedure became known as insulin shock became widely known, and experience began to show that their
therapy, but it was abandoned because it was too dangerous, often overall effectiveness was relatively modest, bromides largely disap-
resulting in prolonged coma or even death. Other methods of peared from the scene.
producing convulsions had to be found. Neuroleptics have also been used less as attention has focused
Benjamin Franklin made numerous discoveries during his on their many side effects, such as chronic tremors and shaking.
life with which we are familiar, but most people don’t know that However, the positive effects of these drugs on some patients’
he discovered accidentally, and then confirmed experimentally psychotic symptoms of hallucinations, delusions, and agitation
in the 1750s, that a mild and modest electric shock to the head revitalized both the search for biological contributions to psy-
produced a brief convulsion and memory loss (amnesia) but chological disorders and the search for new and more powerful
otherwise did little harm. A Dutch physician who was a friend drugs, a search that has paid many dividends, as documented in
and colleague of Franklin tried it on himself and discovered later chapters.
thE BiologiCal tradition 15
Consequences of the Biological Tradition The Psychological Tradition
In the late 19th century, Grey and his colleagues ironically reduced It is a long leap from evil spirits to brain pathology as the cause of
or eliminated interest in treating mental patients, because they psychological disorders. In the intervening centuries, where was
thought that mental disorders were the result of some as-yet- the body of thought that put psychological development, both
undiscovered brain pathology and were therefore incurable. The normal and abnormal, in an interpersonal and social context? In
only available course of action was to hospitalize these patients. fact, this approach has a long and distinguished tradition. Plato,
Around the turn of the century, some nurses documented clini- for example, thought that the two causes of maladaptive behavior
cal success in treating mental patients but were prevented from were the social and cultural influences in one’s life and the learn-
treating others for fear of raising hopes of a cure among family ing that took place in that environment. If something was wrong
members. In place of treatment, interest centered on diagnosis, in the environment, such as abusive parents, one’s impulses and
legal questions concerning the responsibility of patients for their emotions would overcome reason. The best treatment was to reed-
actions during periods of insanity, and the study of brain pathol- ucate the individual through rational discussion so that the power
ogy itself. of reason would predominate (Maher & Maher, 1985a). This
Emil Kraepelin (1856–1926) was the dominant figure dur- was very much a precursor to modern psychosocial treatment
ing this period and one of the founding fathers of modern psy- approaches to the causation of psychopathology, which focus not
chiatry. He was extremely influential in advocating the major only on psychological factors but also on social and cultural ones.
ideas of the biological tradition, but he was little involved in Other well-known early philosophers, including Aristotle, also
treatment. His lasting contribution was in the area of diagno- emphasized the influence of social environment and early learn-
sis and classification, which we discuss in detail in Chapter 3. ing on later psychopathology. These philosophers wrote about
Kraepelin (1913) was one of the first to distinguish among the importance of fantasies, dreams, and cognitions and thus
various psychological disorders, seeing that each may have a anticipated, to some extent, later developments in psychoanalytic
different age of onset and time course, with somewhat differ- thought and cognitive science. They also advocated humane and
ent clusters of presenting symptoms, and probably a different responsible care for individuals with psychological disturbances.
cause. Many of his descriptions of schizophrenic disorders are
still useful today.
By the end of the 1800s, a scientific approach to psychological Moral Therapy
disorders and their classification had begun with the search for During the first half of the 19th century, a strong psychosocial
biological causes. Furthermore, treatment was based on humane approach to mental disorders called moral therapy became influ-
principles. There were many drawbacks, however, the most unfor- ential. The term moral actually referred more to emotional or psy-
tunate being that active intervention and treatment were all but chological factors rather than to a code of conduct. Its basic tenets
eliminated in some settings, despite the availability of some effec- included treating institutionalized patients as normally as possible
tive approaches. It is to these that we now turn. in a setting that encouraged and reinforced normal social interac-
tion (Bockoven, 1963), thus providing them with many opportuni-
ties for appropriate social and interpersonal contact. Relationships
were carefully nurtured. Individual attention clearly emphasized
positive consequences for appropriate interactions and behavior,
Concept Check 1.2 and restraint and seclusion were eliminated.
As with the biological tradition, the principles of moral
For thousands of years, humans have tried to understand
therapy date back to Plato and beyond. For example, the Greek
and control abnormal behavior. Check your understanding Asclepiad Temples of the 6th century b.c. housed the chronically
of these historical theories and match them to the treatments ill, including those with psychological disorders. Here, patients
used to “cure” abnormal behavior: (a) bloodletting; induced were well cared for, massaged, and provided with soothing music.
vomiting; (b) patient placed in socially facilitative environ- Similar enlightened practices were evident in Muslim countries
ments; and (c) exorcism; burning at the stake. in the Middle East (Millon, 2004). But moral therapy as a sys-
tem originated with the well-known French psychiatrist Philippe
1. Supernatural causes; evil demons took over the
Pinel (1745–1826) and his close associate Jean-Baptiste Pussin
victims’ bodies and controlled their behaviors. (1746–1811), who was the superintendent of the Parisian hospital
_____________ La Bicêtre (Gerard, 1997; Zilboorg & Henry, 1941).
2. The humoral theory reflected the belief that normal When Pinel arrived in 1791, Pussin had already instituted remark-
functioning of the brain required a balance of four able reforms by removing all chains used to restrain patients and
bodily fluids or humors. ______________ instituting humane and positive psychological interventions. Pussin
persuaded Pinel to go along with the changes. Much to Pinel’s credit,
3. Maladaptive behavior was caused by poor social he did, first at La Bicêtre and then at the women’s hospital Salpétrière,
and cultural influences within the environment. where he invited Pussin to join him (Gerard, 1997; Maher & Maher,
______________ 1985b; Weiner, 1979). Here again, they instituted a humane and
socially facilitative atmosphere that produced “miraculous” results.
After William Tuke (1732–1822) followed Pinel’s lead in recognized that moral therapy worked best when the number of
England, Benjamin Rush (1745–1813), often considered the patients in an institution was 200 or fewer, allowing for a great deal
founder of U.S. psychiatry, introduced moral therapy in his early of individual attention. After the Civil War, enormous waves of
work at Pennsylvania Hospital. It then became the treatment immigrants arrived in the United States, yielding their own popu-
of choice in the leading hospitals. Asylums had appeared in the lations of mentally ill. Patient loads in existing hospitals increased
16th century, but they were more like prisons than hospitals. It to 1,000 or 2,000, and even more. Because immigrant groups were
was the rise of moral therapy in Europe and the United States that thought not to deserve the same privileges as “native” Americans
made asylums habitable and even therapeutic. (whose ancestors had immigrated perhaps only 50 or 100 years
In 1833, Horace Mann, chairman of the board of trustees of earlier!), they were not given moral treatments even when there
the Worcester State Hospital, reported on 32 patients who had were sufficient hospital personnel.
been given up as incurable. These patients were treated with moral A second reason for the decline of moral therapy has an
therapy, cured, and released to their families. Of 100 patients unlikely source. The great crusader Dorothea Dix (1802–1887)
who were viciously assaultive before treatment, no more than campaigned endlessly for reform in the treatment of insanity. A
12 continued to be violent a year after beginning treatment. schoolteacher who had worked in various institutions, she had
Before treatment, 40 patients had routinely torn off any new firsthand knowledge of the deplorable conditions imposed on
clothes provided by attendants; only 8 continued this behavior patients with insanity, and she made it her life’s work to inform
after a period of treatment. These were remarkable statistics then the American public and their leaders of these abuses. Her work
and would be remarkable even today (Bockoven, 1963). became known as the mental hygiene movement.
In addition to improving the standards of care, Dix worked
hard to make sure that everyone who needed care received it,
Asylum Reform and the Decline including the homeless. Through her efforts, humane treatment
of Moral Therapy became more widely available in U.S. institutions. As her career
Unfortunately, after the mid-19th century, humane treatment drew to a close, she was rightly acknowledged as a hero of the
declined because of a convergence of factors. First, it was widely 19th century.
Asylums And Poor FArms in rurAl AmericA
I n 1822 at an annual town meeting, the town of Nantucket,

a small island 30 miles off the coast of Massachusetts,
voted to build a permanent town poor farm and asylum
that a majority of the inmates might recover under the bene-
fits of this healthy and restorative atmosphere. And the poor
farm was well run and profitable for the town!
(Gavin, 2003). After the War of 1812, Nantucket had pros- After building the asylum, town officials appointed a Board
pered from trade as well as from the beginning of the great of Overseers, responsible leaders of Nantucket, who immedi-
whaling era and the citizens wanted to take care of the less ately became concerned about the number of people visiting
fortunate. Inspired by more modern beliefs at the time about the asylum and poor farm presumably to gawk at the insane.
the treatment of insanity, it was decided to place the asylum In a further effort to protect the residents, the town passed an
away from town in an area where residents could work pro- ordinance restricting visits only to those who applied in writ-
ductively in a pleasant and restful rural setting with fresh ing and offered a good reason for visiting. Unfortunately, in the
air, individual attention, and the availability of productive winter of February 1844, the structure burned to the ground.
activities. As was characteristic of those days, asylums also Despite heroic efforts of many townspeople, ten inmates were
cared for the poor and the elderly. Since misuse of alcohol killed and the structure was destroyed.
was considered the principal cause of poverty, moving the Eventually a new asylum was built, but by this time it
asylums as far away from taverns as possible seemed logical housed only the sick and elderly who could no longer care
and was another reason for locating the asylum in the coun- for themselves. By that time, the new state asylum for the
try. But more importantly, both alcohol abuse and insanity insane had opened far from the island and the removal of
were considered curable after word reached the island of the people suffering from insanity to this large (and impersonal)
very positive results from moral therapy at McLean Asylum state institution was seen as desirable. New policies were
near Boston. Thus, it was arranged for residents of the asy- adopted for cases of poverty (presumably those not suffering
lum to engage principally in agricultural labor, producing from addiction of some kind) that included maintaining the
vegetables, eggs, and dairy products or working outside in poor in their dwellings and providing them with sufficient
the wheat and rye fields or with the livestock. The elderly (but minimal) materials and resources to see them through.
or those unable to work outside of the asylum were pro- A new town “poor department” was created for this purpose.
vided with productive work in their room such as weaving. Thus did moral therapy rise and fall in a small rural town in
Consistent with the tenets of moral therapy, it was thought New England, reflecting the tenor of the time (Gavin, 2003).
thE PsyChologiCal tradition 17
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also, yet in its absence it is not likely that it kept either valuables
or money at Westminster. But side by side with the state office
was the household office of finance, the Wardrobe, and, though
the wardrobe office was itinerating with the king, it still kept a
“treasury” or storehouse at Westminster, and this, for the sake of
greater safety, had been placed for some years at least within
the precincts of the abbey. From the monastic point of view, it
was doubtless an inconvenience that nearness to the royal
dwelling compelled them to offer their premises for the royal
service. Accordingly, kings not infrequently made demands upon
the abbey to use its buildings. Thus the chapter house became a
frequent place for meetings of parliament, and at a later time it
was used and continued to be used till the nineteenth century, for
the storage of official records. In the same way Edward secured
the crypt underneath the chapter house as one of the
storehouses of his Wardrobe. When the crypt was first used for
this purpose I do not know, but records show us that it was
already in use in 1291, at which date it was newly paved. It was
not the only storehouse of the Wardrobe. There was another
“treasury of the wardrobe” in the Tower of London, but this was
mainly used for bulky articles, arms and armour, cloth, furs,
furniture, and the like. Most of what we should call treasure was
deposited in the Westminster crypt, and we are fortunate in
having still extant a list of the jewels preserved there in 1298, the
time when the court began to establish itself for its five years’
sojourn in the north. In 1303 jewels and plate were still the chief
treasures preserved there. Some money was there also, notably
a store of “gold florins of Florence,” the only gold coins currently
used in England at a time when the national mints limited
themselves to the coinage of silver. But I do not think there could
have been much money, for Edward’s needs were too pressing,
his financial policy too much from hand to mouth, for the crypt at
Westminster to be a hoard of coined money, like the famous
Prussian Kriegsschatz at Spandau, which, we now rejoice to
learn, is becoming rapidly depleted. Whatever its contents,
Edward estimated that their value was £100,000, a sum
equivalent to a year’s revenue of the English state in ordinary
times. Unluckily mediaeval statistics are largely mere guess-work.
But the amount of the guess at least suggests the feeling that
the value of the treasures stored in the crypt was very
considerable.
The crypt under the chapter house is one of the most
interesting portions of the abbey buildings at Westminster. It is
little known because it is not, I think, generally shown to visitors.
I am indebted to the kindness of my friend, Bishop Ryle, the
present dean, for an opportunity of making a special inspection of
it. It is delightfully complete, and delightfully unrestored. The chief
new thing about it seems the pavement, but the dean’s well-
informed verger told me that it was within living memory that this
pavement had replaced the flooring of 1291. Numerous windows
give a fair amount of light to the apartment; though the enormous
thickness of the walls, some thirteen feet, it was said, prevent the
light being very abundant, even on a bright day. The central
column, the lower part of the great pillar from which radiates the
high soaring vaults of the chapter house above, alone breaks the
present emptiness of the crypt. Considerable portions of the
column are cut away to form a series of neatly made recesses,
and there are recesses within these recesses, which suggest in
themselves careful devices for secreting valuables, for it would be
easy to conceal them by the simple expedient of inserting a
stone here and there where the masonry had been cut away, and
so suggesting to the unwary an unbroken column. I should not
like to say that these curious store-places already existed in
1303; but there is no reason why they should not. Certainly they
fit in admirably with the use of the crypt as a treasury.
One other point we must also remember about the
dispositions of this crypt. There is only one access to it, and that
is neither from the chapter house above nor from the adjacent
cloister, but from the church itself. A low, vaulted passage is
entered by a door at the south-east corner of the south transept
of the abbey, now for many centuries the special burial place for
poets, eminent and otherwise. This passage descends by a flight
of steep steps to the crypt itself, and the flight originally seems, I
am told—doubtless as another precaution against robbery—to
have been a broken one suggesting that a steep drop,
presumably spanned by a short ladder, further barred access to
the crypt. We must remember, too, that this sole access to the
treasury was within a few feet of the sacristy of the abbey. The
sacristy was the chapel to the south of the south transept, and
communicating with it where the sacrist kept the precious vessels
appropriated to the service of the altar. Altogether it looks as if
the crypt were originally intended as a storehouse for such
church treasure as the sacrist did not need for his immediate
purposes. From this use it was diverted, as we have seen, to the
keeping of the royal treasures. Nowadays the sacristy is called
the chapel of St. Faith and is used for purposes of private
devotion. We must not forget the close connexion in our period of
the sacristy and the crypt. The connexion becomes significant
when we remember that among Pudlicott’s monastic boon
companions at the palace-keeper’s lodge was the sacrist of the
abbey, Adam of Warfield.
Pudlicott had made up his mind to steal the king’s treasure.
The practical problem was how to get access to it. If we examine
the evidence collected at the enquiry, we find that there are two
discrepant accounts as to how the robber effected his purpose.
The one is warranted by the testimony of a large number of
sworn juries of reputable citizens of every ward in the city of
London, of burgesses of Westminster, and of the good men of
every hundred in the adjacent shires of Middlesex and Surrey. It
is—like much truthful evidence—rather vague, but its general
tendency is, while recognizing that Pudlicott is the prime offender,
to make various monks and palace officers his accomplices. Of
the latter category William of the Palace seems to have been the
most active, while of the many monks Adam Warfield the sacrist
was the most generally denounced. But the proved share of both
Adam and William was based largely on the discovery of stolen
property in their possession. The evidence of the juries suggests
theories as to how the crime may have been perpetrated; it does
not make the methods of the culprits clear and palpable. But it
suggests that masons and carpenters were called in, so that
some breaking in of the structure was attempted, and in particular
it suggests that the churchyard was the thoroughfare through
which the robbers removed their booty.
Let us turn next to Pudlicott’s own confession, that remarkable

document from which I have already borrowed many details,
though seldom without a word of warning. According to his
confession, Pudlicott, having resolved to rob the treasury, came to
the conclusion that the best way to tackle the business was to
pierce a hole through the wall of thirteen feet of stone that
supported the lower story of the chapter house. For so colossal a
task time was clearly needed. Richard accordingly devoted
himself during the dark nights of winter and early spring to drilling
through the solid masonry. He attacked the building from the
churchyard or eastern side, having access thereto from the
palace. But the churchyard was open to the parish and the thrifty
churchwardens of St. Margaret’s had let to a neighbouring
butcher the right of grazing his sheep in it. Now the butcher was
told that his privilege was withdrawn, and passers-by were sent
round by another path. This was a precaution against the casual
wayfarer seeing the hole which was daily growing larger. To hide
from the casual observer the great gash in the stonework,
Richard tells us that he sowed hempseed in the churchyard near
the hole, and that this grew so rapidly that the tender hemp
plants not only hid the gap in the wall, but provided cover for him
to hide the spoils he hoped to steal from the treasury. When the
hole was complete on 24 April, Pudlicott went through and found
to his delight that the chamber was full of baskets, chests, and
other vessels for holding valuables, plate, relics, jewels, and gold
florins of Florence. Richard remained in the crypt gloating over
the treasure surrounding him from the evening of 24 April to the
morning of 26 April. Perhaps he found it impossible to tear
himself away from so much wealth; or perhaps the intervening
day, being the feast of St. Mark, there were too many people
about, and too many services in the abbey to make his retreat
secure. However, he managed on the morning of 26 April to get
away, taking with him as much as he could carry. He seems to
have dropped, or to have left lying about, a good deal that he
was unable to carry, possibly for his friends to pick up.
Such is Pudlicott’s story. It is the tale of a bold ruffian who

glories in his crime, and is proud to declare “I alone did it”. But
there was a touch of heroism and of devotion in our hero thus
taking on himself the whole blame. He voluntarily made himself
the scapegoat of an offence for which scores were charged, and
in particular he took on his own shoulders the heavy share of
responsibility which belonged to the negligent monks of
Westminster. Now as to the credibility of Pudlicott’s story, we
must admit that some of the juries accepted evidence that
corroborated some parts of it. Sworn men declared their belief
that the crypt was approached from the outside; that masons and
carpenters were employed on the business; that the churchyard
was closely guarded, and access refused, even to the butcher
who rented the grazing. It is clear too that the booty was got rid
of through the churchyard, and that piecemeal. There is evidence
even that hemp was sown, though the verdict of a jury cannot
alter the conditions of vegetable growth in an English winter. We
must allow too that it is pretty certain that Warfield had not the
custody of the keys of the crypt; though he was doubtless able to
give facilities for tampering with the door or forcing the lock. Yet
Pudlicott’s general story remains absolutely incredible. It was
surely impossible to break through the solid wall, and no
incuriousness or corruption would account for wall-piercing
operations being unnoticed, when carried on in the midst of a
considerable population for three months on end. Some of
Pudlicott’s lies were inconceivable in their crudity. Is it likely that
hemp, sown at Christmas-time, would, before the end of April,
afford sufficient green cover to hide the hole in the wall, and to
secrete gleaming articles of silver within its thick recesses? And
how are we to believe that there was a great gaping hole in the
wall of the crypt when nothing was heard of the crime for several
weeks after its perpetration, and no details of the king’s losses
were known until two months after the burglary, when the keeper
of the Wardrobe unlocked the door of the treasury and examined
its contents? A more artistic liar would have made his confession
more convincing.
What really happened seems to me to have been something
like this. I have no doubt that Pudlicott got into the treasury by
the simple process of his friend, Adam of Warfield, giving him
facilities for forcing the door or perhaps breaking a window. He
remained in the crypt a long time so that he might hand out its
contents to confederates who, as we learn from the depositions,
ate, drank, and revelled till midnight for two nights running in a
house within the precincts of the Fleet prison, and then went
armed and horsed to Westminster, returning towards daybreak
loaded with booty. But not only the revellers in Shenche’s
headquarters, but many monks, many abbey servants, the
custodians of the palace, the leading goldsmiths of the city, and
half the neighbours must have been cognisant of, if not
participating in, the crime. It speaks well for honour among
thieves, that it was not until deplorable indiscretions were made
in the disposal of the booty that any news of the misdeed
reached the ears of any of the official custodians of the treasure.
Suspicion of the crime was first excited by the discovery of
fragments of the spoil in all sorts of unexpected places. A
fisherman, plying his craft in the then silver Thames, netted a
silver goblet which had evidently been the property of the king.
Passers-by found cups, dishes, and similar precious things hidden
behind tombstones and other rough hiding-places in
St. Margaret’s Churchyard. Boys playing in the neighbouring fields
found pieces of plate concealed under hedgerows. Such
discoveries were made as far from Westminster as Kentish Town.
Moreover, many other people lighted upon similar pieces of
treasure trove. Foreign money found its way into the hands of the
money-changers at London, York, and Lymm, and other remote
parts. The city goldsmiths were the happy receivers of large
amounts of silver plate, among them, I regret to say, being
William Torel, the artist-goldsmith, whose skill in metal work has
left such an abiding mark in the decorations of the abbey church.
There were, too, scandalous stories whispered abroad. One of
them was that a woman of loose life explained her possession of
a precious ring by relating that it was given her by Dom Adam
the sacrist “so that she should become his friend”.
Such tales soon made the story of the robbery common

property. At last it came to the ears of the king and his ministers,
then encamped at Linlithgow for the Scottish war. Thereupon, on
6 June, the king appointed a special commission of judges to
investigate the matter. On 20 June, John Droxford, the keeper of
the wardrobe, came to Westminster with the keys of the crypt,
and then and only then did any official examination of the
treasury take place. An entry was made into the crypt and the
damage which had been done was inspected. The result is still to
be read in an inventory of the treasures lost and the treasures
found which Droxford drew up, and which may now be studied in
print.
It is pleasant to say that by the time Droxford went to work
much of the treasure, which had been scattered broadcast, was
being brought back and that more was soon to follow. The first
investigations as to where the treasure had been carried led to
fruitful results. A good deal of it was found hidden beneath the
beds of the keeper of the palace and of his assistant. Still more
was found in the lodgings of Richard Pudlicott and his mistress.
Adam the sacrist, and some of his brother monks and their
servants, were discovered to be in possession of other missing
articles. Altogether, when Droxford had finished his inventory, a
large proportion of the articles which had been lost were
reclaimed. Ultimately it seems that the losses were not very
severe.
Wholesale arrests were now made. Richard Pudlicott was
apprehended on 25 June, and William of the Palace soon
experienced the same fate. Before long the connexion which the
monks had had with the business seemed so well established
that the whole convent, including the abbot and forty-eight monks,
were indicted and sent to the Tower, where they were soon
joined by thirty-two other persons. This time the king’s net had
spread rather too widely, and the indiscriminate arrest of guilty
and innocent excited some measure of sympathy, even for the
guilty. The majority of the clerical prisoners were released on bail,
but some half-dozen laymen and ten monks were still kept in
custody. Both the released and the imprisoned culprits raised a
great outcry, sending petitions to the king demanding a further
enquiry into the whole matter.
The first commission meanwhile had been empanelling juries

and collecting evidence. But the matter was so serious that in
November a second royal commission was appointed to hear and
determine the matter. The members of this second commission
were chosen from among the most eminent of the king’s judges,
including the chief justice of the king’s bench, Sir Roger
Brabazon and the shrewdest judge of the time, William Bereford,
afterwards chief justice of common pleas.
I have already indicated in outline the result of the
investigations of the two judicial commissions. I have told you
how juries were empanelled from every hundred in the counties
of Middlesex and Surrey, and from the wards of the city of
London and from Westminster. The details of the evidence are
worthy of more special treatment than I can give them here,
because they afford a wonderful picture of the loose-living, easy-
going, slack, negligent, casual, and criminal doings of mediaeval
men and women. I must, however, be content to restate the
general result of the trials. Richard of Pudlicott was found guilty.
Various other people, including William of the Palace, and certain
monks, were declared accomplices, while Adam Warfield was
shrewdly suspected to be at the bottom of the whole business.
More than a year was spent in investigations, and it was not until
March, 1304, eleven months after the burglary, that William of the
Palace and five other lay culprits were comfortably hanged.
The great problem was how to deal with the clerical offenders
without adding to the king’s difficulties by rousing the sleeping
dogs of the church, always ready to bark when the state
meditated any infringement of the claim of all clerks to be subject
solely to the ecclesiastical tribunals. Accordingly Richard of
Pudlicott, and ten monks were reserved for further treatment.
Pudlicott, as we have seen, had been a tonsured person in his
youth, and he probably claimed, as did the monks, benefit of
clergy. It was probably now that Pudlicott nobly tried to shield his
monastic allies by his extraordinary confession. His heroism,
however, availed him nothing. But whatever his zeal for the
church, Edward I was upon adequate occasion ready to ride
rough-shod over clerical privileges, and he always bitterly
resented any attempt of a culprit, who had lived as a layman,
trying to shield himself on the pretext that he had been a clerk in
his youth. His corrupt chief justice, Thomas Weyland, had sought
to evade condemnation by resuming the tonsure and clerical garb
which he had worn before he abandoned his orders to become a
knight, a country squire, and the founder of a family of landed
gentry. But Weyland’s subdiaconate did not save him from exile
and loss of land and goods. Pudlicott’s sometime clerical
character had even less power to preserve him. He also paid
tardily the capital penalty for his misdeed. But it was surely his
clergy that kept him alive in prison for more than two years after
the date of the commission of his crime.
The Outrage at Westminster.
The fate of the incriminated clerks still hung in the balance
when in the spring of 1305 Edward came back in triumph to
London, rejoicing that at last he had effected the thorough
conquest of Scotland. His cheerful frame of mind made him listen
readily to the demands of the monks of Westminster to have pity
on their unfortunate brethren, and to comply with the more
general clerical desire that ecclesiastical privilege should be
respected. Only a few months after the burglary, the news of the
outrage on pope Boniface VIII at Anagni had filled all
Christendom with horror. At the instance of Philip the Fair, king of
France, and his agents in Italy the pope was seized, maltreated,
and insulted. In the indignant words of Dante, “Christ was again
crucified in the person of his vicar”. The universal feeling of
resentment against so wanton a violation of ecclesiastical
privilege was ingeniously used in favour of the monks of
Westminster. Among the monks, arrested at first, but soon
released with the majority of their brethren, were two men who
had some reputation as historians. One of these was
magnanimous enough to write, two or three years afterwards, a
sort of funeral eulogy of Edward, but the other, Robert of
Reading, who, in my opinion, kept the official chronicle of the
abbey from 1302 to 1326, set forth the Westminster point of view
very effectively in the well-known version of the chronicle called
Flores Historiarum, the original manuscript of which is now in the
Chetham Library. In this is given what may be regarded as the
official account of Richard’s burglary. The robbery of the king of
England was a crime only comparable to the robbery of the
treasure of Boniface VIII, six months later at Anagni. The
chronicler is most indignant at the suggestion that the monks had
anything to do with the matter, and laments passionately their
long imprisonment and their unmerited sufferings. He relies in
substance on the story as told in Pudlicott’s confession. The
burglary was effected by a single robber.
So lacking in humour was the Westminster annalist that he
did not scruple to borrow the phraseology and the copious
Scriptural citations of a certain “Passion of the monks of
Westminster according to John,” the whole text of which is
unfortunately not extant. I may say, however, that the species of
composition called a “Passion” was particularly in vogue at the
turn of the thirteenth and fourteenth centuries, and is mainly
characterised by its extraordinary skill in parodying the words of
the Scripture in order to describe in mock heroic vein some
incident of more or less undeserved suffering. For profanity, grim
humour, and misapplied knowledge of the Vulgate the “passions”
of this period have no equal. They are a curious illustration of the
profane humour of the mediaeval ecclesiastic in his lighter
moments.
The Westminster annalist did not stand alone. Other monastic
chroniclers took up and accepted his story. It became the
accepted monastic doctrine that one robber only had stolen the
king’s treasure, and that therefore the monks of Westminster
were unwarrantably accused. One writer added to his text a
crude illustration of how, it was imagined, Pudlicott effected his
purpose. You may see opposite this page his rude pictorial
representation of the “one robber” kneeling on the grass in the
churchyard, and picking up by a hand and arm extended through
the broken window the precious stores within. But Pudlicott’s arm
must have been longer than the arm of justice to effect this
operation, and must have been twice or thrice the length of a tall
man. This same chronicler was not contented with repeating the
parallel now recognised between the sufferings of the monks of
Westminster, under their unjust accusations, and the passion of
pope Boniface, five months later, at the hands of the robbers
hired by the ruthless king of France. He must give a picture of
the Anagni outrage as well as of the orthodox version of the
Westminster burglary. How far he has succeeded, you may
gather from the rude sketch figured on the opposite page. Not
only does he give us so vivid a picture of pope Boniface’s
sufferings from the rude soldiery that the drawing might well be
used as a representation of a martyrdom, like that of St. Thomas
of Canterbury. His sketch of three other sacrilegious warriors,
rifling the huge chest that contained the papal treasures, skilfully
suggests that robbery was the common motive that united the
outrage at Anagni to the outrage at Westminster. He leaves us to
draw the deeper moral that the sinful desire of unhallowed
laymen to bring holy church and her ministers into discredit was
the ultimate root of both these scandals.
Edward was satisfied with his Scottish campaign; he was

becoming old and tired; he was pleased to know that a great
deal of the lost treasure had been recovered; and he was always
anxious to avoid scandal, and to minimise any disagreement with
the monks of his father’s foundation. He, therefore, condoned
what he could not remedy. He soon released all the monks from
prison. He even restored Shenche to his hereditary office of the
keepership of the palace. Richard of Pudlicott alone was offered
up to vengeance. In October, 1305, Richard was hanged,
regardless of his clergy.
The Outrage at Anagni.
Affairs at the monastery of Westminster were not improved
after these events. There was much quarrelling among the
monks. Walter of Wenlock died. There were disputes as to his
succession; an unsatisfactory appointment was made, and there
was a considerable amount of strife for a generation. The feeling
against the king was shown equally against his son, and is
reflected in the bitter Westminster chronicle of the reign of
Edward II. One result of the demonstration of the futility of storing
valuables within the precincts of the abbey was that the chief
treasury of the wardrobe was bodily transferred to the Tower of
London.
Some obvious morals might be drawn from this slight but not
unpicturesque story; but I will forbear from printing them. One
generalisation I will, however, venture to make by way of
conclusion. The strongest impression left by the records of the
trial is one of the slackness and the easy-going ways of the
mediaeval man. The middle ages do not often receive fair
treatment. Some are, perhaps, too apt to idealise them, as an
age of heroic piety, with its statesmen, saints, heroes, artists, and
thinkers; but such people are in all ages the brilliant exceptions.
The age of St. Francis of Assisi, of Dante, of Edward I, of
St. Louis of France, of St. Thomas Aquinas, the age in which the
greatest buildings of the world were made, was a great time and
had its great men. But the middle ages were a period of strange
contrasts. Shining virtues and gross vices stood side by side. The
contrasts between the clearly cut black and white of the thirteenth
century are attractive to us immersed in the continuous grey of
our own times. But we find our best analogies to mediaeval
conditions in those which are nowadays stigmatised as Oriental.
Conspicuous among them was a deep pervading shiftlessness
and casualness. Mediaeval man was never up to time. He
seldom kept his promise, not through malice, but because he
never did to-day what could be put off till to-morrow or the next
day.
Pudlicott then is a typical mediaeval criminal. He was

doubtless a scamp, but most of the people with whom he had
dealings were loose-thinking, easy-going folk like himself. Of
course there are always the exceptions. But Edward I, with his
gift of persistence, was a peculiarly exceptional type in the middle
ages, and even Edward I found it convenient to let things slide in
small matters. Thus on this occasion Edward began his
investigation with great show of care and determination to sift the
whole matter; but when he found that thorny problems were
being stirred up, he determined—not for the first time—to let
sleeping dogs lie, and avoid further scandal.
We must not, however, build up too large a superstructure of
theory on this petty story of the police courts, plus a mild
ecclesiastical scandal. Nor must we emphasize too much or
generalise too largely from the signs of slackness and negligence
shown in mediaeval trials. I become more and more averse to
facile generalisation about the middle ages or mediaeval man.
They may, moreover, be made in both directions. On the one
side we have the doctrine of our greatest of recent scholars,
bishop Stubbs, that the thirteenth century was the greatest
century of the middle ages, the flowering type of mediaeval
christianity and so on. But on the other hand there is the
contradictory generalisation of students, like my friend
Mr. Coulton, who surveys the time from St. Francis to Dante with
the conviction that the so-called great days of faith were the days
of unrestrained criminality and violence. Both these views can be
argued; but neither are really convincing. They seem to me to be
obtained by looking at one side of the question only. A more
fruitful doctrine is surely the view that ordinary mediaeval men
were not so very unlike ourselves, and that their virtues and
vices were not those of saints or ruffians, but were not wholly out
of relation to the ordinary humdrum virtues and vices that are
found to-day.
1 A lecture delivered in the John Rylands Library on 20 January, 1915.

Return to text
NOTES.
I. Note on Authorities.
The accounts of the robbery of the king’s treasury in the

Chronicles are vitiated by the obvious desire of the writers, who
were mainly monks, to minimise the scandal to “religion” involved
in the suspected complicity of the Westminster monks. This is
seen even in the moderate account originating at St. Alban’s
Abbey, and contained in William Rishanger’s Chronicle (Rolls
Series), pp. 222 and 225, and also in the other St. Alban’s
version in Gesta Edwardi Primi, published in the same volume,
pp. 420–1. The bias is naturally at its worst in the Westminster
Abbey Chronicle, printed in Flores Historiarum, iii. 115, 117, 121,
and 131 (Rolls Series), which is more valuable perhaps as an
index of Westminster opinion than as a dispassionate statement
of the facts. The chief manuscript of this chronicle is preserved in
the Chetham Library, Manchester [MS. Chetham No. 6712]. It
was certainly written by a Westminster monk, and, perhaps after
1302, by Robert of Reading, who undoubtedly was the author of
the account of the reign of Edward II. If Robert wrote the story of
the robbery, it should be remembered that he was one of the
forty-nine monks indicted and sent to the Tower on a charge of
complicity in it. There are useful and more impartial notices in the
non-monastic Annales Londonienses in Stubbs’ Chronicles of
Edward I and Edward II, i. 130, 131, 132, and 134 (Rolls Series).
These date the robbery on 2 May.

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1 abnormal Behavior in historical Context 2

2 an integrative approach to Psychopathology 32

3 Clinical assessment and diagnosis 74

4 research Methods 104

5 anxiety, trauma- and stressor-related, and obsessive-Compulsive and

related disorders 126

6 somatic symptom and related disorders and dissociative disorders 184

7 Mood disorders and suicide 216

8 Eating and sleep–Wake disorders 272

9 Physical disorders and health Psychology 322

10 sexual dysfunctions, Paraphilic disorders, and gender dysphoria 360

11 substance-related, addictive, and impulse-Control disorders 404

12 Personality disorders 448

13 schizophrenia spectrum and other Psychotic disorders 484

14 neurodevelopmental disorders 520

15 neurocognitive disorders 552

16 Mental health services: legal and Ethical issues 580

1 Abnormal Behavior in Historical Context 2

2 An integrative Approach to Psychopathology 32

3 Clinical Assessment and Diagnosis 74

4 Research Methods 104

Social Anxiety Disorder (Social Summary 180

6 Somatic Symptom and Related Disorders

7 Mood Disorders and Suicide 216

9 Physical Disorders and Health Psychology 322

11 Substance-Related, Addictive, and impulse-Control

12 Personality Disorders 448

Cluster A Personality Disorders 455 Summary 480

Cluster B Personality Disorders 461

13 Schizophrenia Spectrum and other Psychotic

treatment of Schizophrenia 508 Summary 516

14 neurodevelopmental Disorders 520

intellectual Disability (intellectual

15 neurocognitive Disorders 552

S cience is a constantly evolving field, but every now and

Disorders in Detail New to This Edition

J udy, a 16-year-old, was referred to our anxiety disorders

a rating of 4 would indicate continual and severe symptoms

© Hung Chung Chih /Shutterstock.com

Demons and Witches

DEA PICTURE LIBRARY/Getty Images

In hydrotherapy, patients were shocked back to their senses by appli-

Unexplained mental disorders were caused

thE BiologiCal tradition 13

sentation) and a consistent course that resulted in death. The rela-

the possible benefits of applying electric shock directly to the

thE BiologiCal tradition 15

Asylums And Poor FArms in rurAl AmericA

I n 1822 at an annual town meeting, the town of Nantucket,

thE PsyChologiCal tradition 17

Let us turn next to Pudlicott’s own confession, that remarkable

Such is Pudlicott’s story. It is the tale of a bold ruffian who

Such tales soon made the story of the robbery common

The first commission meanwhile had been empanelling juries

Edward was satisfied with his Scottish campaign; he was