Bellack A.S., Hersen M. (Eds.) - Comprehensive Clinical Psychology Volume 1 (2000, Elsevier) PDF

Comprehensive Clinical Psychology
Copyright © 2000 Elsevier Science Ltd. All rights reserved.

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Editors-in-Chief: Alan S. Bellack and Michel Hersen
Table of Contents
Introduction
Volume 1: Foundations
Volume 2: Professional Issues
Volume 3: Research Methods
Volume 4: Assessment
Volume 5: Children & Adolescents: Clinical Formulation & Treatment
Volume 6: Adults: Clinical Formulation & Treatment
Volume 7: Clinical Geropsychology
Volume 8: Health Psychology
Volume 9: Applications in Diverse Populations
Volume 10: Sociocultural and Individual Differences
Introduction to Comprehensive Clinical Psychology

Co-Editors-in-Chief
Alan S. Bellack and Michel Hersen
Background
Clinical psychology is a relatively new field. While its roots can be traced back to at least the late nineteenth
century, its evolution as a distinct academic discipline and profession dates only to the Second World War. The first
20 years of this postwar period saw steady, albeit nonspectacular, growth. Based substantially in the United States
and Europe during this period, the study of clinical psychology developed as an alternative to medical school and
psychiatry for many students interested in clinical service careers or the scientific study of human behavior.
Postgraduate training was conducted exclusively in large university psychology departments within a strict
scientist¯practitioner model. The total number of Ph.D. candidates admitted to graduate school programs each year
was relatively small; there were fewer than 50 accredited programs in the United States during much of this period,
each admitting only 5¯10 students. The number of new Ph.D.'s produced each year was substantially less, as many
students failed to complete the rigorous scientific requirements of these elite programs. Career opportunities were
similarly delimited, due in no small part to restraints on clinical practice imposed by psychiatrists and other
physicians. The dominant form of psychotherapy was psychoanalysis, and psychologists were either excluded from
psychoanalytic institutes or trained only as lay analysts who were proscribed from clinical practice. Few
jurisdictions awarded licenses for independent practice, and psychologists generally were not reimbursed for their
activities unless they worked under the direction of a physician. A sizable minority of clinical psychologists
followed their mentors into university positions, teaching and conducting research. The majority, who were more
interested in clinical service, opted for work in large psychiatric or Veterans Administration hospitals, where the
modal activity was psychological testing; verbal psychotherapy was provided at the discretion of medical
supervisors. A gradually increasing number of psychologists elected to be in private practice, where there was a
greater professional autonomy. Medical hegemony over services for psychiatric disorders was even greater in
Europe and Latin America.
The last 30 years has witnessed a massive change in the profession, stimulated by a number of scientific,
clinical, and economic factors. Psychoanalysis gradually fell out of favor due to a dearth of data on its effectiveness
and a desire for shorter term treatments that were not the primary purview of psychiatrists. First, client-centered
therapy and then behavior therapy emerged as brief, highly effective alternatives. The former was entirely a product
of clinical psychology, and was the intellectual and technical forebear of the current mandate for empirical
evaluation of psychotherapies.
Carl Rogers, his colleagues, and students were the first to demonstrate the feasibility of careful, objective
evaluation of the therapy process as well as outcome. While behavior therapy owes much of its legacy to
psychiatrists such as Joseph Wolpe, it was substantially a product of academic psychologists searching for an
approach with a strong scientific underpinning (in this case learning theory) that could be subjected to rigorous
scientific scrutiny. Early behavior therapy emerged simultaneously in the UK and the US: in the UK psychologists
such as Hans Eysenck based their work on Pavlov and classical conditioning, while in the US researchers were
following Skinner and operant conditioning theories. The two schools merged with cognitive therapy, developed
largely by Beck and Ellis through the 1960s, when the limitations of behavior therapy in isolation became apparent,
particulary with depressed patients, and cognitive-behavior therapy is now widely practised.
Behavior therapy and cognitive-behavior therapy have not only proven themselves to be effective with a
broad array of disorders, they have since been shown to be very successful alternatives to pharmacotherapy as well.
Notably, behavior therapy was able to produce significant changes in populations that had previously been
warehoused as untreatable, including people with physical and developmental disabilities and schizophrenia. Many
of the most important contributions to the behavior therapies came from the UK, The Netherlands, South Africa,
Australia, and Scandinavia, providing a tremendous stimulus for the development of clinical psychology globally.
The availability of cost-effective, scientifically sound nonmedical treatments has decreased the medical monopoly of
psychiatric/mental health services around the world and fostered the evolution of clinical psychology as a legally
sanctioned helping profession, as well as a prestigious scientific discipline.
Scientific advances in our understanding of the brain and the role of psychosocial factors in physical health
and illness have led to the development of two other rapidly growing subspecialties of clinical psychology:
neuropsychology and health psychology. Novel assessment and treatment technologies in these two areas have
created professional opportunities for clinical psychologists in medical schools, general medical hospitals, and other
nonpsychiatric settings. Clinical psychologists can now be found conducting research and providing services in
departments of neurology and neurosurgery, medicine, cardiac surgery, pediatrics, anesthesiology, oncology, and
other medical specialty areas, as well as in the traditional psychiatric settings. They increasingly serve as directors of
governmental agencies and service facilities. They comprise a large percentage of research grant recipients in the
US, Canada, and the UK, and sit on prestigious government and foundation review boards. In fact the field has
earned sufficient public recognition that it now has the somewhat dubious distinction of having clinical
psychologists as lead characters on television shows and in cinema.
Stimulated, in part, by these exciting developments in scientific progress and clinical creativity, the field has
grown geometrically in the past two decades. Psychology is now the second leading undergraduate major in the US
and is increasingly popular elsewhere in the world as well. There are now more than 175 doctoral programs in the
United States, each admitting many more students per annum than the 5¯10 that has been typical of traditional
scientist¯practitioner Ph.D. programs over the past 25 years. Some of these schools have entering classes as large as
200 per year. Moreover, along with the professional school movement, which began in the 1970s, a new degree, the
Psy.D. (or Doctorate in Psychology), is regularly being offered as an alternative to the Ph.D. Basically a professional
rather than an academic degree, the Psy.D. is reflective of the local practitioner¯scientist model rather than the
scientist¯practitioner.
Yet another trend in the field is the proliferation of master's level psychologists, specifically trained to carry
out some of the more mundane functions formerly implemented by doctoral level psychologists. Indeed, each year
in the United States alone 10 000 new master's level psychologists graduate from university programs. The financial
and programmatic implication of such large numbers is obvious.
Statistics are not readily available about the size of the profession in all regions of the globe, but anecdotal
evidence supports the hypothesis that the field is growing worldwide. As previously indicated, behavioral and
cognitive-behavioral therapies owe a substantial debt to scientists and clinicians from Europe, Australia, and South
Africa. There are now enough cognitive-behavior therapists to support national societies in most Western European
countries, as well as Asia, Australia, and Latin America. Many of the most important developments in the
psychosocial treatment of severe and persistent mental illness in the last decade have come from the United
Kingdom, Australia, Switzerland, and Germany. Psychologists in Scandinavia, the United Kingdom, and the
Netherlands have played a central role in the development of cognitive-behavioral treatments for anxiety and
depression, and there have also been notable contributions from these regions to health psychology. As the hold of
psychoanalytic therapies on psychiatric treatment in Europe continues its inevitable decline, there will be increasing
opportunities for clinical psychologists to provide shorter term behavioral and cognitive-behavioral treatments. In
addition, exciting developments are also emerging from Japan, China, and other countries in the Pacific rim. It
seems likely that the global influence of regional approaches and thinking will lead to a more multicultural and
universal psychology than has been the case in the past.
The scientific and clinical literatures have burgeoned along with the number of clinical psychologists in the
world. This has been an era of rapid growth of knowledge and increasing specialization. General topics, such as
psychological assessment, clinical child psychology, and psychotherapy, that used to merit only one or two graduate
courses to establish expertise, have expanded and are subdivided to the extent that circumscribed specialty areas,
such as neuropsychology, geropsychology, behavioral pediatrics, or cognitive-behavior therapy for depression can
each require postdoctoral training. Consequently, hundreds of undergraduate, graduate, and professional level texts
are published each year. Specialty journals abound. Where a few key generalist journals such as the Journal of
Consulting and Clinical Psychology used to represent the entire field, each subdiscipline now has multiple journals,
and there are both national journals (e.g., the British Journal of Clinical Psychology, the British Journal of Health
Psychology, the Australian Journal of Cognitive and Behavioral Therapy) and journals representing specific
populations or disorders (e.g., Addictive Behaviors, Journal of Family Violence, Journal of Clinical
Geropsychology), or domains of practice (e.g., Journal of Clinical Psychology in Medical Setting). Specialization
has made it difficult for professionals to keep abreast of developments within their immediate areas of expertise, and
impossible for them to be conversant with the literature in other areas. Moreover, given the plethora of choices, it is
also virtually impossible for either students or professionals to know where to find the most accurate, up-to-date
information in most areas.
The combination of a large and increasing number of students and professionals, and rapidly growing
scientific and clinical literature, makes this a particularly appropriate time for Comprehensive Clinical Psychology.
This multivolume work encompasses the entire field, and represents a single source of information on the scientific
status of clinical psychology and its subspecialties, on theory, and on clinical techniques. The work covers the
history of the field, and current thinking about training, professional standards and practices, and sociocultural
factors in mental health and illness.
Genesis of Comprehensive Clinical Psychology
Following preliminary conceptual discussions between Elsevier Science and Alan S. Bellack at several
international conferences in 1994, Michel Hersen was asked to join as Co-Editor-in-Chief. The first official planning
meeting for the project took place in June 1995. In addition to Elsevier Science staff, Alan S. Bellack and Michel
Hersen invited Tom Ollendick, Nina Schooler, and Warren Tryon to serve as consultants. At that meeting, the
philosophical and international scope of the project was agreed upon and established, with the scientific
underpinnings of the field identified as the model. The objective here was to ensure that chapters reflect our core
knowledge and that the material stand the test of time.
At that meeting, we also underscored that since clinical psychology was now an international discipline, the
work should reflect contributions at the cross-cultural level, with chapters solicited from eminent psychologists
worldwide. Although it was acknowledged that the United States was in the forefront of the field, the work could not
simply represent the American perspective but to the extent possible would represent diversity at its best. Consistent
with the international perspective, at the initial planning meeting, the importance of having an Honorary
International Editorial Advisory Board comprised of international representatives was acknowledged, and the 10
specific volumes to comprise Comprehensive Clinical Psychology were identified. Preliminary outlines for each
volume were developed and volumes editors were considered.
The international perspective was to be reflected at a tripartite level. First, diversity among editors and
contributors for their respective volumes was selected as a goal. Second, chapters in each volume were designed to
reflect diversity by providing the reader with worldwide examples, not simply the Anglo-Saxon view. Of course,
where basic facts and principles were the same, there was no need to present regional diversity. Third, and related to
the first two parts, the Honorary International Editorial Advisory Board provided us with an international
perspective on overall organization and specifics for the individual volumes.
Between June and October 1995, Alan S. Bellack and Michel Hersen, in consultation with Elsevier Science,
invited the ten volume editors to assume their positions, and a meeting of the Editors-in-Chief, the ten volume
editors (C. Eugene Walker, Arthur N. Wiens, Nina R. Schooler, Cecil R. Reynolds, Thomas Ollendick, Paul
Salkovskis, Barry Edelstein, Marie Johnston and Derek W. Johnston, Nirbhay N. Singh, and Cynthia D. Belar), and
Elsevier Science staff was convened in October of that year. At that meeting, each of the volume editors presented
his or her conception of the relevant volume, and the nature of coverage and particular contributors was discussed at
length. Most of all the philosophical underpinnings of the work were stressed so as to insure intervolume
consistency.
Subsequent to the October 1995 meeting, the enormous work to bring this project to fruition began, with
potential authors invited to contribute, manuscripts reviewed, and then edited. Were it not for the wonders of
electronic communication, a project of this scope would not have been possible, especially given the international
aspects involved. A lengthy series of checks and balances was instituted to guarantee the quality and excellence of
each contribution. The volume editor first approved each contributor's chapter outline, followed by editing and
approval of the text. This process frequently required several revisions. The Co-Editor-in-Chief then reviewed each
chapter for scope, level, and overlap, but only after the volume editor had first verified the accuracy of references
cited. After the Co-Editor-in-Chief's labors, the manuscript was reviewed by Elsevier staff for format, writing style,
reference checking, and other technical issues.
Aims and Scope
The final organization and contents of the work evolved over a series of discussions between the Editors-in-
Chief, the volume editors, and Elsevier Science. It was comparatively easy to select the primary domains that
needed to be covered: history, treatment, assessment, research, training, and professional issues. It was also
comparatively easy to identify the first two-thirds, or so, of specific topics that required chapter-length coverage:
treatment of the primary DSM/ICD disorders, basic research strategies, standard assessment techniques, etc.
However, organizing the vast set of requisite topics into coherent volumes, determining which topics warranted
independent chapters, and assigning page limits to individual chapters proved to be daunting. Two broad
organizational themes immediately suggested themselves: a focus on core themes or techniques across populations
vs. integrated coverage of populations. For example, the former would have entailed volumes on treatment
modalities, such as behavior therapy, as they are applied to children and adults, while the latter would call for
separate volumes on children and adults that covered diverse approaches. To complicate matters, some topics, such
as Research Methods and Professional Issues, do not lend themselves to breakdown by population, and others, such
as Behavioral Medicine, do not lend themselves to a breakdown by themes or techniques. Volume length was also
an important factor, making some content-based solutions less practical than others. For example, we determined
that treatment should receive more attention than assessment; a strict population-based solution would have led to
separate short volumes on assessment of adults and children. Ultimately, we opted for an organizational structure
that balanced practical considerations with our collective prediction about how the individual volumes would be
used. While it was different earlier in the development of the field, we believe that the current trend is for people to
be more organized around populations than techniques. Hence, more people are likely to pick up and cross-reference
a single volume on children or the elderly than a volume on Behavior Therapy. Our strategy for identifying chapter
length topics and associated page limits is more difficult to explain. Once again, we relied on our collective
judgement, honed by negotiation. In rough order, priority was given to topics that had established empirical
literatures, that were deemed to be "important," that had broad interest, and that were likely to be at least as
important in the next decade. Page limits were determined substantially by estimates of the first two criteria. We
began with an overall target for the entire work and minimums and maximums for volumes, and then worked
backwards to divide up the allotted pages among the chapters designated for each volume. Given that no scheme
will please everyone, we are confident that the organization of the work adequately reflects the field now and in the
foreseeable future.
Under the careful aegis of the outstanding group of experts comprising the Honorary International Editorial
Advisory Board, 10 leading international scholars were selected to edit the 10 specific volumes.
Volume 1 (Foundations), edited by C. Eugene Walker, provides a complete overview of the basic foundations
of clinical psychology, with special emphasis on the relationship between clinical psychology and other fields of
science. Beginning with a brief history of clinical psychology, as well as a look at its current scientific status, this
informative volume covers such topics as the biological bases of clinical psychology, elucidating research in
genetics, psychobiology, psychopharmacology, and the use of animal models in human mental health problems;
clinical psychology in the behavioral sciences, including anthropology, epidemiology, sociology, and research
psychology; and the major systems and theories that are used in clinical psychology. The volume also describes
various techniques for library research and information retrieval in psychology.
Volume 2 (Professional Issues), edited by Arthur W. Wiens, focuses on the professional, legal, and ethical
issues that are relevant to clinical psychology. The volume addresses the various educational and training programs
available, such as doctoral study, internship training, and postdoctoral residency programs, and reviews the
accreditation of these programs. Also highlighted are the various international government guidelines for
registration, certification, and licensing, including a discussion of the advantages of specialty recognition and
practice certificates. The volume concludes with a look at ethical and legal guidelines in the management of clinical
psychology practices, national healthcare policies, and advocacy efforts for government support for practitioners.
Volume 3 (Research and Methods), edited by Nina R. Schooler, explores the function of research in clinical
psychology. The volume begins with an in-depth look at research approaches, including the use of descriptive
studies, single case designs, observational methods, and other methods of analysis. The volume goes on to explore a
broad range of topics that have been the focus of research, such as test development and validation, personality
assessment, clinical interventions, and service evaluations and outcomes. Finally, various statistical techniques are
reviewed, including descriptive and inferential statistics, factor analysis, and sampling and generalizability.
Volume 4 (Assessment), edited by Cecil R. Reynolds, provides valuable information on the development and
role of assessment in clinical practice, analyzing such topics as psychometrics; taxonomic, functional, and actuarial
approaches to diagnosis; and specific instruments, techniques, and procedures. Chapters also review the range of
assessment techniques and procedures used in clinical practice, with emphasis on intelligence, neuropsychological,
personality, projective, computer-assisted, therapeutic, and forensic assessment. The volume concludes with a
review of legal guidelines and regulations in the use of psychological testing.
Volume 5 (Children & Adolescents: Clinical Formulation & Treatment), edited by Thomas Ollendick, draws
on the experience and research of leading scientists and clinicians from Australia, Canada, Israel, the United
Kingdom, and the United States to present state-of-the-art information on all aspects of child psychology and
psychiatry, with special attention given to the psychopathology, assessment, treatment, and prevention of childhood
behavioral disorders. The volume highlights the developmental-contextual framework used in the clinical
formulation of these disorders, as well as process and outcome issues in treatment. Various theoretical perspectives
are also reviewed, including applied behavior analysis, family systems therapy, play therapy, and pharmacologic
therapy. In the final section, all of the major childhood disorders found in the DSM and ICD are described, with
information on their prevalence, etiology, assessment, and treatment. This section also analyzes the empirical status
of the various therapies used for treatment of childhood disorders.
Volume 6 (Adults: Clinical Formulation & Treatment), edited by Paul Salkovskis, provides valuable insights
into the basis of the psychological theories and interventions used for behavioral and emotional problems and
reviews how to integrate clinical skills with these theories. Various treatment approaches are addressed, such as
cognitive therapy, family therapy, and Humanistic/Rogerian/Gestalt approaches, as well as the issues related to
treatments, including stress management, arousal reduction methods, suicidal behavior, and specific issues in
working with groups. The final section details specific problem areas and disorders, ranging from such universally
recognized problems as gambling and substance abuse to more specific disorders such as post-traumatic stress,
depression, obsessive-compulsive, and the various phobias. Each chapter in the volume emphasizes approaches that
have an empirical basis.
Volume 7 (Clinical Geropsychology), edited by Barry Edelstein, addresses the emerging field of clinical
psychology in the aging population. The volume begins with a review of this area of research, presenting important
epidemiological information. The volume then offers a detailed look at issues that range from analyzing
physiological and cognitive aspects to cognitive changes and specific neurological disorders common among older
adults. Specific topics covered include sexuality, bereavement, anxiety, substance abuse, and schizophrenia. Each
chapter presents a summary of clinical research and its practical application. Voids in the knowledge base are also
noted, along with recommendations for the direction of future investigations. The volume also addresses
management problems, such as incontinence, wandering, and aggressive behavior, and reviews the various mental
healthcare systems available in different countries.
Volume 8 (Health Psychology), edited by Derek W. Johnston and Marie Johnston, provides a comprehensive
overview of the development and application of clinical health psychology. Beginning with a discussion of training,
assessment, and measurement issues, this volume analyzes the key behaviors that either affect or are related to
health. Topics covered include stress and disease, the experience of illness, and behavior that can affect the
neuroendocrine, cardiovascular, and immune systems. The volume also provides a detailed analysis of specific
clinical problems and their psychological aspects and interventions. These include cancer, diabetes, epilepsy,
disfigurement, and smoking.
Volume 9 (Applications in Diverse Populations), edited by Nirbhay N. Singh, covers the broad spectrum of
diverse issues that clinical psychologists typically face in their work. Four sections outline the various psychological
aspects found in different populations, as well as methods for assessment, diagnostic information, and interventions
useful with these different groups. Section I focuses on select child, adolescent, and adult populations, including
those with developmental disorders, learning disabilities, and mental retardation. Section II is devoted to various
types of families and their issues, including families of individuals with HIV or AIDS, families of alcoholics, and
families of children with serious emotional disturbances. Section III covers victims of violence and abuse, including
child sexual abuse. Section IV examines perpetrators of violence and abuse, including sex offenders and issues of
domestic violence.
Volume 10 (Sociocultural and Individual Differences), edited by Cynthia D. Belar, covers cross-cultural
psychopathology and interventions. Chapters examine such select topics as gender, sexual orientation,
socioeconomic status, religions, and training for clinical psychologists. The volume also provides valuable insights
into the use of clinical psychology in different parts of the world, as well as personality assessment across
international settings.
Given the scope and detail of Comprehensive Clinical Psychology, Volume 11 is devoted to: (i) a Name
Index, (ii) a Subject Index, (iii) a List of Contributors, and (iv) a list of the Contents of All Volumes. The Name
Index is an accumulation of all the authors who are cited in text in the reference sections throughout the entire work.
The Subject Index, consisting of more than 40 000 entries, is a consolidation of all the individual volume subject
indexes. It is presented in word-by-word alphabetical sequence with a maximum of three levels of heading.
Terminology in the index is based on standard internationally recognized sources. Cross-references are provided to
assist the user to locate preferred terms and terms of related interest.
Acknowledgments
To produce a tome of this magnitude requires an enormous number of individuals with unique talents
working in concert. To begin with, we applaud the herculean efforts of our driving force and friend at Elsevier
Science, Barbara Barrett. We also gratefully acknowledge the efforts of two other publishing editors at Elsevier
Science, Susan Hanscom and David Hoole, who provided guidance and encouragement along the way. We are
particularly thankful for the exceptionally hard work of Angela Greenwell and her staff in Oxford, who made sure
that all tasks were implemented reasonably on time and who orchestrated the day-to-day management of this huge
undertaking. Next, we thank our eminent volume editors, who had the difficult job of soliciting, tracking, and
editing manuscripts for their respective volumes. Similarly, we thank the Honorary International Editorial Advisory
Board for their excellent input in developing the outline for the work and suggestions as to potential international
contributors. Of course, we owe a great deal to the individual contributors who agreed to share their expertise with
us in a timely fashion. Finally, we are most appreciative of our own editorial assistants, Sonia McQuarters and Burt
G. Bolton, who repeatedly have provided us with the kind of support that makes all of this a possibility.
Editors-in-Chief
Alan S. Bellack
The University of Maryland at Baltimore, MD, USA
Michel Hersen
Pacific University, Forest Grove, OR, USA
Honorary International Editorial Advisory Board

HANS D. BRENNER DAVID M. CLARK
University Psychiatry Services Bern Wellcome Principal Research Fellow
Directorate Middle/West Department of Psychiatry
Baupenstrasse 49 University of Oxford
CH-3010 Bern Warneford Hospital
Switzerland Oxford OX3 7JX
UK
ENRIQUE ECHEBURÚA PAUL M G EMMELKAMP
Facultad de Psicología Rijkuniversitcit Hospital
Universidad del País Vasco Department of Clinical Psychology
Avenida de Tolosa 70 Ostersingel 59
20009 San Sebastián NL-9713 EZ Groningen
Spain The Netherlands
HERTA FLOR K. GUNNAR GOTTESTAM
Clinical Psychology & Behavioral Neuroscience Trondheim University
Institut für Psychologie Institute of Psychiatry
Humboldt-Universität zu Berlin Ostmarka Hospital
Hausvogteiplatz 5-7 PO Box 3008
D-10117 Berlin N-7001 Trondheim
Germany Norway
SURYA GUPTA KURT HAHLWEG
Additional Professor of Clinical Psychology Institut für Psychologie
Department of Psychiatry Technische Universität Braunschweig
All India Institute of Medical Sciences Spielmannstrasse 12 A
New Delhi - 110 029 D-38106 Braunschweig
India Germany
W. KIM HALFORD LARS-GORAN OST
School of Applied Psychology Department of Psychology
Faculty of Health and Behavioural Sciences Stockholm University
Griffith University S-10691 Stockholm
Nathan, Queensland 4111 Sweden
Australia
YUJI SAKANO BONNIE STRICKLAND
Waseda University School of Human Sciences Department of Psychology
2-579-15 Mikajima University of Massachusetts
Tokorozawa, Saitama 359 Amherst, MA 01003
Japan USA
KIKUO UCHIYAMA GARY R. VANDENBOS
2-13-21 Kashiwa-cho University of Bergen
Shiki-shi Bergen
Saitama 353 Norway
Japan
JERRY S. WIGGINS
Department of Psychology
The University of British Columbia
2136 West Mall
Vancouver, BC V6T 1Z4
Canada
Volume Editors
Professor C. Eugene Walker, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
Volume 2: Professional Issues

Professor Arthur N. Wiens, Oregon Health Sciences University, Portland, OR, USA
Volume 3: Research and Methods

Professor Nina R. Schooler, Hillside Hospital, Glen Oaks, NY, USA
Volume 4: Assessment
Professor Cecil R. Reynolds, Texas A&M University, College Station, TX, USA
Volume 5: Children & Adolescents: Clinical Formulation & Treatment

Professor Thomas Ollendick, Virginia Tech, Blacksburg, VA, USA
Volume 6: Adults: Clinical Formulation & Treatment

Professor Paul Salkovskis, University of Oxford, Warneford Hospital, UK
Volume 7: Clinical Geropsychology

Professor Barry Edelstein, West Virginia University, Morgantown, WV, USA
Volume 8: Health Psychology

Professor Derek W. Johnston and Professor Marie Johnston, University of St. Andrews, UK
Volume 9: Applications in Diverse Populations

Dr Nirbhay N. Singh, Virginia Commonwealth University, Richmond, VA, USA
Volume 10: Sociocultural and Individual Differences

Professor Cynthia D. Belar, University of Florida Health Sciences Center, Gainesville, FL, USA
Subject Index
Philip and Lesley Aslett
Marlborough, Wiltshire, UK
Every effort has been made to index as comprehensively as possible, and to standardize the terms used in the
index in line with the following standards:
- Thesaurus of Psychological Index Terms, APA, Eighth Edition, for the selection of psychological terms.
- Thesaurus of ERIC Descriptors, ERIC, Twelfth Edition, for the selection of education terms not covered by
the above.
- EMTREE Thesaurus for the selection of medical terms not covered by the above.
- IUPAC Recommendations for the nomenclature of chemical terms, with trivial names being employed
where normal usage dictates.
In general, the index follows the recommendations laid down in BS ISO 999:1996.
In view of the diverse nature of the terminology employed by the different authors, the reader is advised to
search for related entries under the appropriate headings.
The index entries are presented in word-by-word alphabetical sequence. Chemical terms are filed under
substituent prefixes, where appropriate, rather than under the parent compound name; this is in line with the
presentation given in the Thesaurus of Psychological Index Terms.
The index is arranged in set-out style, with a maximum of three levels of heading. Location references refer
to volume number (in bold) and section number (separated by a colon).
See cross-references direct the user to the preferred term; for example, character see personality.
See also cross-references provide the user with guideposts to terms of related interest, from the broader term
to the narrower term, and appear at the end of the main heading to which they refer; for example
credentialing
see also professional certification; professional licensing; recredentialing
Disclaimer
No responsibility is assumed by the Publisher for any injury and/or damage to persons or property as a matter
of products liability, negligence or otherwise, or from any use or operation of methods, products, instructions or
ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent
verification of diagnoses and drug dosages should be made.
Comprehensive Clinical Psychology. Volume 1

Editors-in-Chief: Alan S. Bellack and Michel Hersen
Table of Contents
Introduction
Open
Close
Preface
Contributors
1.01 Hippocrates Meets Democritus: A History of Psychiatry and Clinical Psychology,
Pages 1-48, Donald K. Routh
SummaryPlus | Chapter | PDF (516 K)
1.02 The Scientific Status of Clinical Psychology, Pages 49-65, Frank L. CollinsJr.
1.03 Informational Sources in Clinical Psychology, Pages 67-86, Kristi Alexander Michael
C. Roberts
1.04 Contributions of Behavioral Genetics Research to Clinical Psychology, Pages 87-

114, Thomas G. O'Connor and Kirby Deater-Deckard Robert Plomin
1.05 Psychobiology, Pages 115-172, Niels Birbaumer Herta Flor

1.06 Fundamental Psychopharmacology, Pages 173-206, Frank A. Holloway Jessica M.

Peirce
1.07 Animal Models of Psychopathology: Depression, Anxiety, Schizophrenia, Substance

Abuse, Pages 207-231, Paul Willner
1.08 Cultural Dimensions, Pages 233-260, Jan Brøgger

1.09 Life-span Developmental Theories, Pages 261-296, Gisela Labouvie-Vief Manfred

Diehl
file:///D|/1/CCP/01/00.htm (1 of 9)17.10.06 10:50:05

1.10 Social Psychological Foundations of Clinical Psychology, Pages 297-321, John H.

Harvey and Julia Omarzu
1.11 Cognitive Psychology, Pages 323-354, Richard Hoffman and Mustafa al'Absi
1.12 Epidemiology and its Rubrics, Pages 355-390, James C. Anthony and Michelle L. Van
Etten
1.13 Learning Theory, Pages 391-421, Graham C. L. Davey

1.14 Psychodynamic Theory, Pages 423-447, Peter Fonagy

1.15 Phenomenological, Existential, and Humanistic Foundations for Psychology as a

Human Science, Pages 449-472, Constance T. Fischer
1.16 Family Systems and Family Psychology, Pages 473-496, Jay L. Lebow Alan S. Gurman
Preface Volume 1
Psychology is the science of human behavior. As scientists, psychologists attempt to understand,
predict, and control human behavior. Clinical psychology is the specialty area of psychology that
deals with emotional disturbance and mental health. The field of clinical psychology draws on the
basic research data from psychology and several related areas of science in order to promote health
and effective coping with life events.
Clinical psychology is the most popular area of specialization within psychology. In 1995 nearly 44%
of the members of the American Psychological Association identified their major area of interest as
clinical or child clinical psychology. An additional 10% identified their major interest as the closely
related area, counseling psychology. This strong interest in clinical psychology no doubt stems from
the fact that training in this area provides one with a broad and generic background that may lead to a
wide variety of career options.
The majority of clinical psychologists find employment providing mental health care. This involves
diagnostic assessment, psychotherapy, and related tasks in a wide variety of settings including private
practice, outpatient clinics, hospitals, schools, and industry, to name a few. However, clinical
psychologists may be found in a wide selection of other career options.
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A significant number of clinical psychologists devote virtually all of their time to research. These
clinical psychologists may work in a research center or in a university. Their research may be funded
from federal government agencies, private foundations, or industry.
Many clinical psychologists are employed as teachers. They serve as faculty in major research
universities as well as in teaching universities and medical schools. They teach basic psychology
courses as well as service courses for other departments and professional courses for students
preparing for a career in clinical psychology. Clinical psychologists are generally employed in
departments of psychology, however, they are often found in other departments such as business,
education, and biology, to name but a few.
Because of their skills in understanding and working with people, clinical psychologists are often
selected for positions of management and leadership in many organizations. This is true whether or
not the organization's mission is related to psychology per se. Thus, many clinical psychologists are
administrators, consultants, liaisons, representatives, and program developers in a wide variety of
settings.
Since training in clinical psychology provides the necessary background for making contributions in
so many ways, most clinical psychologists combine more than one role as they pursue their career.
For example, a typical clinical psychologist might have his or her primary employment providing
mental health care but might also be involved in research and be a member of the adjunct faculty of a
nearby university. Likewise, a clinical psychologist whose primary employment is in an academic
setting, involving teaching and research, might also have a small private practice providing mental
health care and might serve as a consultant to various other agencies and organizations.
By virtue of their training, clinical psychologists are able to make several unique contributions in the
field of mental health that other professionals in this area are unable to provide. First, is their
scientific approach and research skills. Traditionally, clinical psychologists have been trained in
academic departments of psychology and have received a Ph.D. degree, which is the standard degree
for scientists and scholars. They have also generally been trained in what is known as the
"scientist¯professional" model. This model developed very early in the history of the field and is
based on the concept that a clinical psychologist should be a well-trained scientist who applies
scientific knowledge as a professional. As a result, clinical psychologists are given extensive training
in the philosophy of science, scientific method, statistics, and research design. Even though recent
years have seen the development of free-standing professional schools of clinical psychology and
professional degrees such as the Psy.D. (doctor of psychology), most clinical psychology training
programs, including the programs in professional schools and the Psy.D. programs, continue the
tradition of scientific orientation. In most clinical settings, clinical psychologists are distinguished by
their scientific skepticism about clinical practices which are not based on research data and by their
interest in conducting careful clinical research on issues related to their professional practice.
A second unique contribution of the clinical psychologist is expertise in psychological testing and
assessment. The interest of psychologists in research naturally fostered the development of
procedures for measuring human behavior since quantification is a basic necessity for scientific
investigation. When psychologists began to apply their knowledge in the clinical arena, their initial
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point of entry was their ability to provide reliable and valid information about patients based on
psychological tests. Appropriate use and interpretation of psychological testing results requires
sophistication in measurement theory and statistical prediction. Clinical psychologists received this as
part of their academic and research training.
A third unique contribution of the clinical psychologist has to do with the extensive body of research
into human behavior, personality, and the process of behavior change which has been developed in
psychological research laboratories for over 100 years. The clinical psychologist's familiarity with
this literature enables him or her to approach clinical problems with a high level of sophistication and
with a wide range of options for effective intervention.
The heavy emphasis on a scientific basis for clinical practice is appropriately the theme of Volume 1
in this series. In this volume we will survey the foundations of clinical psychology including basic
data from psychological science, biological science, social and behavioral science, and related areas.
The problem of emotional disturbance and mental illness has been with humans from the beginning.
In the first chapter of this volume, Professor Donald Routh, of the University of Miami in the United
States, traces the history of mental problems and the professions that have tried to alleviate these
problems. He also presents a brief history of research in psychopathology, citing major advances
from the earliest times to the present. This excellent chapter provides a broad perspective for
understanding all of the material presented in this volume as well as all of the other volumes in this
series.
Dr. Frank Collins of the Oklahoma State University in the United States has prepared an excellent
summary of the scientific status of clinical psychology. He begins with a brief introduction and
history of clinical psychology in America since the major events leading to the recent developments
in the field occurred on this continent. He then discusses the basis of clinical psychology in science
and contrasts this with other approaches such as philosophy and art. The current scientific status of
clinical psychology in the major areas of assessment and treatment is reviewed and summarized. This
nicely leads to a discussion of training in clinical psychology and the role of clinical psychology in
health care. Dr. Collins concludes his chapter by emphasizing the scientific basis of clinical
psychology. He forsees much more growth in the future, but believes that the current foundation
provides excellent support for such growth and development.
In any field of scholarship and inquiry, accessing information efficiently is a matter of considerable
importance. Since psychology as a field, has been concerned with human behavior including
learning, cognition, communication, and related areas, psychologists have naturally been in the
forefront of information processing and access. Dr. Kristi Alexander of the United States
International University and Dr. Michael Roberts of the University of Kansas in the United States
have prepared a comprehensive guide for the student, professional, or interested layperson who
wishes to locate information available on the wide range of topics included in clinical psychology.
Drs. Alexander and Roberts discuss access to journals and books including on-line journals which are
newly appearing through Internet services. They then describe the major abstracting and indexing
resources available, including those that are computerized. Their chapter concludes with an excellent
consumer's guide to electronic media and the Internet for those interested in pursuing topics relevant
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to clinical psychology. Computer and Internet accesses to psychological literature are a particularly
exciting development because they make the same information instantaneously available to students
and professionals as well as to the educated layperson anywhere in the world.
Human behavior results from the interaction between heredity and environment. Over the years,
students of human behavior have shifted back and forth in ascribing more weight to one side or the
other of this interactive equation. Recently, careful research has greatly added to our understanding of
the role of genetics in many areas of personality and psychopathology. Drs. Thomas G. O'Connor and
Kirby Deater-Deckard of the Institute of Psychiatry at the University of London and Robert Plomin
of PaSU, Philadelphia, United States, in their chapter on Contributions of Behavioral Genetics
Research to Clinical Psychology, provide the reader with an excellent survey of work in this
important field. They skillfully blend information about the history of the area with explanations of
key research strategies and methods as they summarize the current state of knowledge in major areas
of interest to clinical psychologists such as anxiety, depression, alcoholism, schizophrenia, attention
deficit disorder as well as several others. Much work needs yet to be done to further our
understanding of the relative contributions of genetics and environment. Thus, the debate continues.
O'Connor and his co-authors have provided us with an excellent summary of the current status in this
area and with the tools to evaluate new developments as they occur.
The mind¯body problem has been pondered by scientists and scholars for centuries. While the
average person tends to regard these as separate realms, most scientists reject this notion in favor of a
monistic view. Dr. Niels Birbaumer, University of T••gen, Germany, and his colleague Professor
Herta Flor, Humboldt-University, Berlin, reject separation of mind and body. Instead, they find it
more useful to describe human behavior in terms of three levels: verbal reports, physiological
responses, and overt or motor responses. Their chapter deals with psychobiology or biological
psychology. These two synonymous terms likewise emphasize the unity rather than separation of
mind and body. Much research in this field has contributed to our understanding of psychopathology
and therapeutic intervention. Birbaumer and Flor present necessary background scientific information
and then demonstrate the usefulness of this research information for understanding human behavior
in numerous areas of concern to the clinical psychologist. The importance of understanding human
behavior in totality including all three levels, as described in this chapter, cannot be overestimated.
Clear thinking regarding assessment and effective intervention for human problems requires a
complete view of the nature of humans.
One of the most dramatic developments in human society in the last 50¯100 years has been the major
effect that drugs play in our lives. Certainly, abuse of numerous substances by large numbers of
people throughout the world has resulted in harm and misery. On the other hand, the rapid growth of
scientific research in pharmacology has resulted in thousands of drugs that ameliorate illness and
promote human welfare. Dr. Frank Holloway of the University of Oklahoma Health Sciences Center
and Dr. Jessica Peirce of Brookline, Massachusetts, systematically review the major categories of
psychotropic drugs which are of considerable importance to the practice of clinical psychology. They
present basic scientific data and use that to discuss therapeutic benefits as well as undesirable side
effects from drugs currently available. Since there is a huge literature on the basic chemistry of these
drugs and an equally large literature on their clinical application, Holloway and Peirce can only
survey this information in their present chapter. However, they cite numerous references for the
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reader who wishes to pursue these topics in more detail. The material contained in this chapter is very
timely given the movement among clinical psychologists to obtain legal authority to write
prescriptions for medication for their patients. There is an increasing appreciation for the idea that
effective care for patients requires intervention on all three levels described in the Birbaumer and Flor
chapter. Thus, selective use of psychotropic drugs is an important part of providing total care.
The use of animals for basic research in the field of medicine is well known. There are numerous
advantages to this. Often, a less complex organism than a human being can be employed, making
experimentation easier. More rigorous experimental designs can be used than are possible with
humans. Results can often be obtained immediately and more clearly. Possible harm to humans is
avoided. What is not as well known is that animals are also often very useful in behavioral research
that ultimately may be generalized to humans. Over the years, some of the most creative ground-
breaking research on psychopathology has been based originally on animal experiments. Professor
Paul Willner of the Universtiy of Wales in the United Kingdom discusses the rationale for animal
models of psychopathology. He then describes research methods employing this approach and
reviews the major findings in the areas of depression, anxiety, schizophrenia, and substance abuse.
Professor Willner has done an excellent job of presenting the information in this area in a very
readable and exciting way.
From the preceding paragraphs it is clear that biological sciences are an important part of the
foundation of clinical psychology. However, many other areas of science also contribute significantly
to making clinical psychology a science-based profession. Professor Jan Br•¥r of the Norwegian
University of Science and Technology, Trondheim, Norway, has contributed an excellent chapter on
the contributions of anthropology to clinical psychology. He discusses the concepts of health and
illness, particularly what causes illness, within a cultural context. He draws information and examples
from a wide range including ancient and contemporaneous Western, Eastern, and African cultures.
He also discusses the development of the role of healer historically in different cultures and discusses
the development of clinical psychology in this context. Professor Br•¥r's chapter helps us see clinical
psychology within the "big picture."
Individuals have different abilities, tasks to perform, and needs at different times in their lives. All of
these are important to the clinical psychologist. Drs. Gisela Labouvie-Vief, Wayne State University,
and Manfred Diehl, Colorado State University, both in the United States, have prepared a thorough
review of the theories of life-span development along with discussion of research methods and
findings in this area. The information contained in this chapter is crucial to the clinical psychologist
interested in understanding and providing care for patients.
Mental illness is sometimes described in terms of one's inability to function effectively and cope in
interpersonal relations and psychotherapy has been described as the art of persuasion. While there is
more to it than that, it is impossible to understand psychopathology or to offer effective treatment
without taking into account the social context in which the person functions. Professor John Harvey
and Ms. Julia Omarzu of the University of Iowa in the United States have prepared an excellent
chapter reviewing areas of social psychology useful to the clinical psychologist. They deal with social
perception, attribution, influence and persuasion, interpersonal attraction, relationships, altruism, and
helping behavior.
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The field of cognition in psychology deals broadly with the process by which we acquire information,
process it, respond to it, and how it interacts with and affects feeling and behavior. Much in this area
is crucial to understanding normal as well as abnormal behavior. Drs. Richard Hoffman and Mustafa
al'Absi, University of Minnesota, Duluth School of Medicine, in the United States, have prepared an
excellent and very readable account of some of the major research in this area. They also indicate
how this information relates to psychotherapeutic intervention, notably in cognitive therapy.
A scientific discipline unique to health professions is the field of epidemiology. As Drs. James
Anthony and Michelle Van Etten of the Johns Hopkins University in the United States point out in
their chapter, the epidemiologist attempts to answer five questions, namely for a given illness how
many are affected, where are the affected cases to be found, why are some people affected while
others are not, what influences who becomes affected, and what can be done to intervene? Answers
to these questions are very useful to the health professional. The answers often lead to clues regarding
the etiology of an illness. They also alert health professionals to serious health problems and suggest
effective interventions. Epidemiologists are sometimes referred to as "medical detectives" because
their work often involves solving mysteries about the occurrence of outbreaks of illness.
Psychological theory provides the basis for decision making in clinical psychology. While there are
hundreds of psychological theories that may be employed, there are four major theoretical approaches
that provide the major rationale for most clinical psychologists. Volume 1 of Comprehensive Clinical
Psychology concludes with four excellent chapters in which these approaches are reviewed by
Professor Graham Davey, University of Sussex, United Kingdom (Learning Theory); Dr. Peter
Fonagy, University College London, United Kingdom (Psychodynamic Theory); Dr. Constance
Fischer, Duquesne University, United States (Phenomenological, Existential, and Humanistic
Foundations for Psychology as a Human Science); and Drs. Jay Lebow, Chicago Center for Family
Health, United States and Alan Gurman, Universtiy of Wisconsin Medical School, United States
(Family Systems and Family Psychology). Each of these authors provides a description of the basic
concepts of the theory under consideration along with a history of the development of the theory
followed by a review of the applications of the theoretical approach to the work of the clinical
psychologist.
The material presented in this volume, the first of 11, is intended to provide the historical, theoretical,
and scientific foundation for the material that follows in the succeeding volumes. Taken together, the
chapters in this volume provide a survey of the major ideas and approaches that serve as a basis for
the field of clinical psychology. As the wide range of topics covered will attest, clinical psychology is
a very broad field which draws support from many other fields. It is hoped that the present volume
will provide information and perspective that will illuminate the topics covered in the following 10.
Volume 1 Contributors
al’ABSI, M. (University of Minnesota, Duluth School of Medicine, Duluth, MN, USA)
*Cognitive Psychology
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ALEXANDER, K. (United States International University, San Diego, CA, USA)

*Informational Sources in Clinical Psychology
ANTHONY, J. C. (Johns Hopkins University, Baltimore, MD, USA)

*Epidemiology and its Rubrics
BIRBAUMER N. (University of T•ngen, Germany)

*Psychobiology
BR•GER, J. (Norwegian University of Science and Technology, Trondheim, Norway)

Cultural Dimensions
COLLINS, F. L. JR. (Oklahoma State University, Stillwater, OK, USA)

The Scientific Status of Clinical Psychology
DAVEY, G. C. L. (University of Sussex, UK)

Learning Theory
DEATER-DECKARD, K. (Institute of Psychiatry, University of London, UK)

*Contributions of Behavioral Genetics Research to Clinical Psychology
DIEHL, M. (Colorado State University, Colorado Springs, CO, USA)

*Life-span Developmental Theories
FISCHER, C. T. (Duquesne University, Pittsburgh, PA, USA)

Phenomenological, Existential, and Humanistic Foundations for Psychology as a Human Science
FLOR, H. (Humboldt-University, Berlin, Germany)

*Psychobiology
FONAGY, P. (University College London, UK)

Psychodynamic Theory
GURMAN, A. S. (University of Wisconsin Medical School, Madison, WI, USA)

*Family Systems and Family Psychology
HARVEY, J. H. (University of Iowa, Iowa City, IA, USA)

*Social Psychological Foundations of Clinical Psychology
HOFFMAN, R. (University of Minnesota, Duluth School of Medicine, Duluth, MN, USA)

*Cognitive Psychology
HOLLOWAY, F. A. (University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA)
*Fundamental Psychopharmacology
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LABOUVIE-VIEF, G. (Wayne State University, Detroit, MI, USA)

*Life-span Developmental Theories
LEBOW, J. L. (Chicago Center for Family Health and University of Chicago, IL, USA)
*Family Systems and Family Psychology
OMARZU, J. (University of Iowa, Iowa City, IA, USA)

*Social Psychological Foundations of Clinical Psychology
O’CONNOR, T. G. (Institute of Psychiatry, University of London, UK)

PEIRCE, J. M. (Brookline, MA, USA)

*Fundamental Psychopharmacology
PLOMIN, R. (PaSU, University Park, PA, USA)

ROBERTS, M. C. (University of Kansas, Lawrence, KS, USA)

*Informational Sources in Clinical Psychology
ROUTH, D. K. (University of Miami, Coral Gables, FL, USA)

Hippocrates Meets Democritus: A History of Psychiatry and Clinical Psychology
VAN ETTEN, M. L. (Johns Hopkins University, Baltimore, MD, USA)

*Epidemiology and its Rubrics
WILLNER, P. (University of Wales, Swansea, UK)

Animal Models of Psychopathology: Depression, Anxiety, Schizophrenia, Substance Abuse
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1.01
Hippocrates Meets Democritus: A
History of Psychiatry and Clinical
Psychology
DONALD K. ROUTH
University of Miami, Coral Gables, FL, USA
1.01.1 INTRODUCTION 2
1.01.2 THE ANCIENT GREEKS AND ROMANS 3
1.01.3 CHINA AND INDIA 4
1.01.4 THE NEAR EAST 4
1.01.5 MEDIEVAL EUROPE 5
1.01.6 FROM THE RENAISSANCE TO THE SEVENTEENTH CENTURY 5
1.01.7 THE EIGHTEENTH CENTURY, INCLUDING THE EMERGENCE OF PSYCHIATRY 6
1.01.8 THE NINETEENTH CENTURY, INCLUDING THE EMERGENCE OF CLINICAL PSYCHOLOGY 9
1.01.9 THE TWENTIETH CENTURY: GUILD-RELATED ISSUES 13
1.01.9.1 Psychiatry 13
1.01.9.2 Psychoanalysis 14
1.01.9.3 Clinical Psychology 15
1.01.9.4 Social Work 18
1.01.9.5 Religious Counseling 18
1.01.9.6 Interdisciplinary Activities and Advocacy 18
1.01.10 RESEARCH ON PSYCHOPATHOLOGY IN THE TWENTIETH CENTURY 20
1.01.10.1 General Paralysis of the Insane 20
1.01.10.2 Dementia 21
1.01.10.3 Dementia Praecox/Schizophrenia 21
1.01.10.4 Schizoaffective Disorder 22
1.01.10.5 Depression 22
1.01.10.6 Neurosis, Including Anxiety 22
1.01.10.7 Shell Shock/Post-traumatic Stress Disorder 23
1.01.10.8 Stress 23
1.01.10.9 Psychosomatic Disease 23
1.01.10.10 Anorexia Nervosa and Bulimia 23
1.01.10.11 Borderline Personality Disorder 24
1.01.10.12 Antisocial Behavior 24
1.01.10.13 Substance Abuse 24
1.01.10.14 Sexual Dysfunction 24
1.01.10.15 Mental Retardation 25
1.01.10.16 Autism 26
1.01.10.17 ªMinimal Brain Dysfunctionº (MBD)/ADHD 26
1.01.10.18 Learning Disabilities 26
1
2 Hippocrates Meets Democritus: A History of Psychiatry and Clinical Psychology
1.01.10.19 Child Abuse and Neglect 26

1.01.11 RESEARCH ON ASSESSMENT IN THE TWENTIETH CENTURY 27
1.01.11.1 Intelligence 27
1.01.11.2 Categorical Diagnosis of Mental Disorders 28
1.01.11.3 Interviews 29
1.01.11.4 Self-report Measures of Personality and Psychopathology 29
1.01.11.5 Rating Scales 30
1.01.11.6 Infant Assessment 30
1.01.11.7 The Rorschach Test 30
1.01.11.8 Human Figure Drawings 30
1.01.11.9 Thematic Assessment Methods 31
1.01.11.10 Sociometric Measures 31
1.01.11.11 Assessment of Social Competence 31
1.01.11.12 Assessment of Marital and Family Relationships 31
1.01.11.13 Neuropsychological Measures 31
1.01.11.14 Biological Assessment Procedures 31
1.01.12 RESEARCH ON TREATMENT IN THE TWENTIETH CENTURY 32
1.01.12.1 The Boston School of Psychotherapy 32
1.01.12.2 Psychoanalysis and its Derivatives 32
1.01.12.3 Play Therapy for Children 33
1.01.12.4 Japanese Therapeutic Approaches 34
1.01.12.5 Behavior Therapies 34
1.01.12.6 Behavior Analysis 35
1.01.12.7 Cognitive Therapy 35
1.01.12.8 The Interpersonal Approach 36
1.01.12.9 Research on Psychotherapy 36
1.01.12.10 The Psychotherapy Integration Movement 37
1.01.12.11 Group Therapy 37
1.01.12.12 Self-help Groups 37
1.01.12.13 Marriage and Family Therapy 37
1.01.12.14 Community Interventions and Prevention 38
1.01.12.15 Special Education 38
1.01.12.16 Rehabilitation 38
1.01.12.17 Drug Therapies 38
1.01.12.18 Psychosurgery 40
1.01.12.19 Electroconvulsive Shock Treatment 40
1.01.12.20 Other Biological Treatments and Preventive Measures 40
1.01.13 EPILOGUE 41
1.01.14 REFERENCES 42
1.01.1 INTRODUCTION many centuries before either of these specialized

fields was to emerge. Nevertheless, the principal
The story goes that Hippocrates (460±377 theme of this chapter is that even from early
BC), the famous physician, was once summoned historic times, mental disorders were the
to the Greek city of Abdera by its citizens in concern not only of physicians but also of
order to investigate the seemingly irrational philosophers and others who did not practice
behavior of the philosopher Democritus. De- medicine. This fact can serve as a sort of historic
mocritus (460±370 BC) is best known today for precedent for the existence of clinical psychol-
his view that everything consists of tiny particles ogy and related nonmedical fields concerned
called atoms. On this occasion, Democritus was with mental disorders. As Democritus once said
seated under a plane tree surrounded by the in a letter to Hippocrates:
carcasses of dogs and cats. He was experiencing
an episode of melancholy and was dissecting Wisdom is the sister of medicine: the one rescues
these animals in order to discover the source of the soul from passions, the other alleviates the
black bile, considered to be responsible for such disease of the body. The mind benefits from health,
mental disturbances (Burton, 1621/1971). The whereas ill health dampens the desire for virtue,
term ªmelancholyº literally means black bile in and illness binds the soul. (Temkin, 1991, p. 70)
Greek, and Hippocrates' theory of melancholy,
like that of Democritus, was that it was caused This history of ªclinical psychologyº is thus at
by an imbalance of the ªhumorsº of the body the same time a history of aspects of medicine,
(e.g., Jackson, 1978). Hippocrates thus consid- psychiatry, and other related fields. It is con-
ered Democritus to be rational, not insane. cerned with a broad spectrum of pathophysiol-
Hippocrates was not a psychiatrist, nor was ogy, psychopathology, assessment, and various
Democritus a clinical psychologist. It would be types of interventions for mental disorders.
The Ancient Greeks and Romans 3
The author's earlier inquiries into the history means inflammation of the mind) referred to
of clinical psychology concerned the organiza- the situation in which a person with fever begins
tions of clinical psychologists that developed in to talk nonsense; this was considered a tempor-
the USA beginning in 1917 and some of the ary condition which would clear up as soon as
practitioner pioneers in the field including the fever was over. Mania refered to a furious,
Lightner Witmer, J. E. W. Wallin, and Leta acute mental disturbance in the absence of fever.
Hollingworth (Routh, 1994, 1996, 1997). These Hysteria consisted of bodily complaints made by
writings gave relatively little recognition to women, interpreted as being due to the wander-
events before the 1890s, to the contributions ing of the uterus. Paranoia described a condition
of adjacent disciplines such as psychiatry, or to in which the person suffered from abnormal
the work of colleagues in other countries. The thinking (in the absence of fever). Dementia
request from C. Eugene Walker to write the refered to a deteriorating mental condition often
present chapter was interpreted as an invitation seen in the elderly. Plato, in the Republic, des-
to explore not just the organizational history of cribes in detail individual differences in learning
clinical psychology but its substance as well, not ability. He was also aware of the existence of
just in recent times but from its origins. In its persons with congenital mental incompetence
first 100 years, clinical psychology has become (Plato, 1933). The terminology of mental dis-
so intertwined with psychiatry (especially in the orders often changes over time, as do concepts of
domain of research) that it made more sense to psychopathology, although some of the pheno-
consider them jointly rather than separately. It mena these terms and concepts refer to may be
soon became evident that writing such a history timeless. It would thus be a mistake to identify
was nothing short of a lifetime project. How- the above concepts of the Greeks with those we
ever, the present chapter was prepared over only use today, even when they are called by the same
a two-year period and thus required the use of names.
many secondary sources and even some tertiary Hippocratic medicine emphasized the impor-
sources in order for it to be completed at all. The tance of proper diet, exercise, and moderation in
main justification for trying to carry out such a all things. It considered most illnesses to result
task is that most clinical psychologists are from an imbalance of the ªfour humorsº: blood,
remarkably ignorant about the history of their black bile, yellow bile, and phlegm. Given this
field. theory, one reasonable type of treatment tried to
The chapter begins with a brief history of reduce the excessive amount of a particular
ideas concerning mental illness in ancient, humor, by bleeding the patient, using emetics or
medieval, and early modern times. It then purgatives, or inducing sweating.
discusses the development of the specialty of Different schools of thought resembling some
psychiatry in the eighteenth century and after present controversies in the philosophy of sci-
and of clinical psychology about 100 years later. ence were already present among Hippocratic
Finally, it describes the further development of physicians, as the following quotation makes
the two fields, considered as aspects of a larger clear:
whole, during the twentieth century, with a
focus on developments in the areas of psycho- Two main sects had formed among his followers.
pathology, assessment, and treatment. Many For the so-called Dogmatists, or Logicians, Hip-
histories of psychiatry and psychology have pocrates was the founder of a scientific medicine
been written, beginning in the early nineteenth based on natural philosophy, anatomy, and
century (e.g., Marx, 1994). So far as the author physiologyÐin short, on hidden causes, as their
is aware, however, this admittedly modest effort opponents, the Empiricists contended. In the
opinion of the latter, nature could not be
is the first attempt to write a combined history fathomed; hence speculation about these hidden
of psychiatry and clinical psychology. causes, which included elements, humors, and
pneuma, was useless. They held that medicine
had to make do with a knowledge of obvious
1.01.2 THE ANCIENT GREEKS AND causes, such as hunger, cold, and sleep. The
ROMANS Empiricists thought of Hippocrates as himself
an Empiricist, their great clinical teacher of the
The Hippocratic writings of the fifth and past. (Temkin, 1991, p. 6)
fourth centuries BC and later (which have di-
verse authorship) consider mental disturbances Galen (AD 130±200), the most famous suc-
to be illnesses like any other. Besides melan- cessor of Hippocrates, was born in Greece but
choly, the Hippocratic list of mental disorders taught and practiced in Alexandria and Rome.
included phrenitis, mania, hysteria, and para- He was an early ªscientist±practitionerº in that
noia. Plato (427±347 BC) added the category of he was an expert in anatomy as well as medicine.
dementia as well. Phrenitis (which literally He carried out some of the first physiological
experiments. For example, he demonstrated years. Others follow the Unani, or Greek school,
that one could eliminate a pig's squeal by as filtered through Arabian and Persian cultures.
sectioning a particular nerve (Sarton, 1954;
Temkin, 1973). Some of the mistakes in Galen's
writings on anatomy resulted from the dissec- 1.01.4 THE NEAR EAST
tion of apes rather than human cadavers (hu- Judaism, Christianity, and Islam have been
man dissection not being allowed). competing religious and cultural forces for
millenia in the Near East and elsewhere, as they
1.01.3 CHINA AND INDIA continue to be. All of them have their own
methods for treating illness, be it physical or
The study of psychopathology did not mental. Consider, for example, Jesus' restora-
originate only in Greece but has other roots tion of the sight of a man with a missing eye and
throughout the world. A well known example raising Lazarus from the dead. As Temkin
from two centuries BC in China is the Yellow (1991) points out, secular medicine did not
Emperor's book of internal medicine (Veith, pretend to perform such feats. In Greece, Christ-
1955). This book interprets disease (according ianity eventually superseded the Asclepian
to Veith, this included the kind we would religious approach to healing. This involved
consider to be mental illness) as resulting from visiting the temples of Asclepias, consulting the
an improper balance of the powers of ªyinº and priests, and perhaps sleeping there overnight.
ªyang.º These are considered to be caused by However, these religions each managed to co-
moral transgressions of Tao, ªthe way.º Tradi- exist relatively peacefully with Hippocratic
tional Chinese medicine as described in this medicine and its descendents right up to the
book includes an elaborate description of conquest of Alexandria (the center of Hellenistic
procedures such as acupuncture, still in use in medicine) in AD 642. After that event, Islamic
China and elsewhere today. According to these physicians assimilated the medical teachings of
precepts, the person who lives properly has the Greeks and made their own independent
every reason to expect to reach age 100, in contributions to the field.
vigorous good health. It is proverbial that The most famous of the Islamic physicians
mental illness is rarely diagnosed in China, was Avicenna (AD 980±1037), whose Arabic
perhaps in part because it would involve public name was Ali al-Husayn ibn Sina. Magner
loss of ªface.º Also, children feel obliged to (1992) cites some of the work of Avicenna as an
honor their parents and to care for them even if early example of psychotherapy:
senile dementia has made them burdensome and
foolish. The identified prevalence of mental [One] challenging case involved a young man who
illness is also low among the overseas Chinese. suffered from melancholy and the delusion that he
Veith (1963) noted that while yin and yang are was a cow. The man mooed loudly, refused to eat,
implicated in the scholarly account of mental and begged to be killed and made into stew. The
illness in China, the popular view is different. patient cheered up immediately when Avicenna
Uneducated people interpret disturbed beha- sent word that the butcher would come to slaugh-
ter him. Finally, Avicenna came to the sickroom
vior as being the result of supernatural causes
with a butcher's knife and asked for the cow.
such as spirits entering into the body of the Mooing happily, the young man was bound hand
sufferer. Exorcism is thus a common treatment. and foot, but after a thorough examination,
An important nonmedical source of the Avicenna declared that the cow was too thin to
assessment component of present-day clinical be butchered. The patient ate so eagerly that he
psychology and psychiatry is the tradition of soon recovered his strength and was cured of his
formal mental tests established in China. Public delusion. (p. 143)
examinations served for almost 1000 years as
the principal way of recruiting and selecting According to Dols (1987) and Magner (1992),
ªMandarinº civil servants. In China, this system the Muslims also built hospitals including provi-
was abolished by the empress dowager only in sions for the care of the mentally ill. The largest
1905 (Hanson, 1993), which oddly enough, was of these was established in Cairo in 1286.
just when psychology's involvement in psycho- Formerly a palace, this hospital had a capacity
metrics was beginning. of 8000 patients. Other such hospitals were
In India, at least according to Sigerist's (1945) located in Baghdad and Damascus and existed
admittedly dated account, many persons receive as early as the ninth century AD. The treatments
medical care, whether for physical or mental for mental patients included baths, massage,
illness, only from indigenous practitioners. bloodletting, leeches, cautery, medication with
Some of these doctors follow the principles of purgatives, emetics, sedatives, and opium. There
the Ayurveda, the ªscience of longevity,º as was also concern for the patient's diet, oppor-
described by Brahmin texts dating back 3500 tunities to participate in pleasant conversation,
From the Renaissance to the Seventeenth Centurt 5
and diversions such as music, dance, and drama. honor St. Nymphna. The village developed the
If necessary, Dervishes performed exorcisms. pattern of boarding mentally disturbed patients
Some violent patients were in chains, and whips in the homes of the residents, and this Shrine of
were used on occasion. Gheel became an enduring legend in community
The condition we know as mental retardation care. The famous psychiatrist Esquirol visited it
was also familiar. As Dols (1987) says: in 1822.
One high point in medieval and renaissance
The village idiot, the court jester, and the wise fool thought concerning mental disturbance is the
were tolerated forms of possible derangement. The philosophical writings of the Portuguese King
archetypal wise fool in Islamic literature is Buhlul, Duarte (1391±1438) known as Leal Conselheiro
the entertaining and harmless critic of social (ªloyal counselorº). Duarte experienced mental
conditions and mores. He typically lurks undis- depression and undertook to write about it as a
turbed in the cemetary, is molested in the streets by form of self-therapy. What he had to say is well
children, or is fettered and put in chains. Having
abandoned everyday cares, he trusts in God's aid
worth quoting:
and men's charity. His intense sensitivity plays on
the ambiguity between the unholy and the holy And it seems to me . . . that sorrow generally has six
fool. (p. 13) causes: first and chiefly, fear of death, dishonor,
pain, or spiritual and bodily suffering. Second,
anger . . . Third, strong desire unfulfilled or
1.01.5 MEDIEVAL EUROPE delayed. Fourth, unhappiness which we acquire
because of dishonor, death, losses, imprisonment,
Medieval European times were not noted for illnesses, retention, and longing. Fifth, disordered
scientific advances of any kind, certainly not compression, which truly is called an illness of the
with respect to the understanding and treatment melancholy humor. Sixth, talk, conversation of
sad persons . . . By each of these means, more or
of psychopathology. The medieval era does less, we become sad, according to the feelings and
have its positive side in terms of the Christian passions which are dominant in each of us.
emphasis on the virtue of caring for the (Roberts & Sacks, 1954, p. 22)
unfortunate, including those with mental dis-
orders. Thus, in the sixth century AD, Benedict As it turned out, Duarte's melancholy abated
of Nursia proclaimed the ideal of service toward after his mother became ill, and he turned his
those living in monasteries who were ill thoughts away from himself to care for her.
(Jackson, 1972). However, such care did not An acknowledged horror story of the middle
extend very far to those in the community, as ages and renaissance (from the standpoint of the
Rosen (1964) notes: understanding and treatment of psychopathol-
ogy) is the publication of Malleus Malificarum
During the medieval period, public authorities (ªhammer of the witchesº) by two German
took only limited responsibility for the mentally Dominican monks, Heinrich Kraemer and
deranged. Mentally or emotionally disturbed Johann Sprenger (1486/1971). This was a man-
members of a community were left at liberty as
long as they caused no public disturbance. Cus-
ual for the identification, torture, and trial of
tody of the mentally ill generally rested with their witches. It was endorsed by the Pope and went
relatives and friends; only those considered too into 19 editions over the next 300 years (Leigh,
dangerous to keep at home, or who had no one to 1957). According to this book, witches, though
care for them, or who were socially disturbing, they might appear to be merely lunatics, were
were dealt with by communal authorities. (p. 377) actually in league with the devil and caused all
manner of mischief, including hailstorms, crop
The institutions for the mentally ill that devel- failure, and sexual dysfunctions such as im-
oped in that era provided at most food, lodging, potence in other persons. Most of the ªwitchesº
and basic physical care. They included general who experienced the regimen prescribed by these
hospitals such as the Hotel-Dieu in Paris, the two doctors of the church were aging women.
hospital of St. Mary of Bethlem in London (built
in 1247, later notorious as ªBedlamº), and the 1.01.6 FROM THE RENAISSANCE TO THE
madhouses that were part of the hospitals at SEVENTEENTH CENTURY
Elbing (built in 1326) and Hamburg (built in
1375). Priests offered exorcism to persons con- The answer to the ªwitches' hammerº was
sidered to be possessed by devils, and both the Johann Weyer's book, De Praestigiis Daemo-
secular and the ecclesiastical authorities some- num (ªthe slight of hand of demonsº), published
times subsidized pilgrimages by the mentally in 1583 (Mora, 1991). Weyer, an experienced
disordered to religious shrines such as Lourdes. physician, was employed by a wealthy duke and
In the twelfth century a church was built at seemed to be unafraid of the enemies he might
Gheel, a village north of Brussels, Belgium, to make by his writings. He had considerable
personal experience in examining various in- . . . in dealing with a patient who stubbornly
dividuals who were accused of witchcraft and refused to get well, Sydenham suggested a con-
usually found that they were poor, frail, ment- sultation with the wonder-working Dr. Robinson
ally unstable women who could not possibly at Inverness. The patient made a long trip on
horseback only to find that there was no such
have done the deeds of which they were accused.
doctor, but, as Sydenham expected, anticipation,
He thus disputed Kraemer and Sprenger's exercise, and anger effected a cure. (Magner, 1992,
Malleus Malificarum very thoroughly. Weyer's p. 222)
book was put on the Papal index of forbidden
writings.
Foucault's (1961) account of the classical age
Another important medical figure of the
asserts that the seventeeth century was an age of
renaissance was Paracelsus (1493±1541), the
increased ªconfinementº involving not only the
name adopted by a flamboyant Swiss man
mad but also criminals, the poor, and the
named Philippe Aureole Theophrastus Bom-
indigent ill all over Europe. On a more positive
bastus von Hohenheim. Paracelsus was of
note, Foucault credits Thomas Willis with being
modest background rather than being a member
the first to make the observation that melanch-
of the nobility (as his name might imply) and
olia and mania tended to alternate in the same
was not as well educated as many of his medical
individuals. Willis wrote about this in 1681.
peers, whom he often scandalized by commu-
Finally, some mention should be made of a
nicating in the vernacular rather than in Latin,
late-seventeenth century philosopher, John
the common language of scholars of that time.
Locke (1632±1704), and of his influential book,
His father had worked in the mines, and
An essay concerning human understanding
Paracelsus knew a lot about minerals. An
(Locke, 1689/1824). Locke is well known to
alchemist as well as a physician, he introduced
psychologists as one of the British Empiricists
chemical treatments. Temkin (1946) estimates
and as an associationist (Hoeldtke, 1967). In
that Paracelsus was as important to the history
this book, Locke argued that the mind is a blank
of medicine as Luther was to church history.
slate at birth and that its contents are acquired
The followers of Galen had always recom-
through sensory experiences and by reflection
mended herbal remedies, and now Paracelsus
upon these. One assertion of his that was
came along with chemical onesÐthe founder of
influential regarding mental disorders was that
a new school of thought known as ªiatrochem-
whereas idiots were incapable of associating
istry.º Paracelsus was also responsible for a very
ideas, madmen associate ideas incorrectly.
modern-sounding insight into the possible role
of minerals in the drinking water in the etiology
of goiter and Cretinism (a form of what we 1.01.7 THE EIGHTEENTH CENTURY,
could now call mental retardation) that was so INCLUDING THE EMERGENCE OF
prevalent in Switzerland. PSYCHIATRY
Robert Burton (1577±1640), the author of
The anatomy of melancholy (Burton, 1621/ At the beginning of the eighteenth century,
1971), lived in this era. Burton was not a Edinburgh was a major intellectual center. It
physician but a clergyman and an Oxford don. was associated with the Scottish Enlightenment
He was in a state of melancholy himself when he and with common sense philosophy and
wrote this huge universal compendium of psychology. The University of Edinburgh was
ancient knowledge partly as a way of distracting also a center of medical education, with its
himself. Burton referred to himself as ªDemo- influence reaching across the Atlantic (Carlson
critus Junior,º thereby alluding to the pre- & Simpson, 1969) and into France. Vienna was
Socratic philosopher mentioned in the title of also respected as a center of medical thought as
the present chapter. Burton evidently did not was Montpellier in France, but the German
know of King Duarte's writings, but there are states were in a rather backward condition,
interesting parallels in the lives and thinking of perhaps due to the after effects of the 30 Years
Democritus, Duarte, and Burton. Clinical War. At this time the dominant figure in
psychologists might do well to consider all of Scottish medicine was perhaps William Cullen
them as mentors. (1710±1790), who founded a school of ªneuro-
The physician Sydenham (1624±1689) wrote a pathology.º The modern sense of this word is
treatise on psychological disorders that has been somewhat misleading. It does not adequately
described as the most important one of the convey the fact that Cullen was trying to
seventeenth century. Sydenham reportedly represent the brain and the nervous system as
considered psychological disorders to be as the ªmasterº influence on the health of the body
common as physical ones. He was also some- (Riese, 1949) as an alternative to the ªhumor-
thing of a legend as a therapist, as the following alismº still lingering from the ancient days of
incident reveals: Hippocrates. Cullen's major work was a book,
The Eighteenth Century, Including the Emergence of Psychiatry 7
First principles of the practice of physic, ªalienistsº in France, and ultimately termed
published in 1776±1784. Naturally, the ªneu- ªpsychiatristsº in the German states and then
ropathologyº approach had a lot to say about all over the world. By the time of the American
mental disorders. and French revolutions, the individuals who
This was also the time when the tradition of stood out as pioneer figures in this field included
ªmad doctorsº emerged more fully in the British Benjamin Rush (1745±1873) in the United
isles (Hunter & McAlpine, 1963). The first of States, Phillipe Pinel (1745±1826) in France,
these had been John Archer, who already in the Vincenzo Chiarugi (1759±1820) in Florence,
seventeenth century became the proprietor of a and Francis Willis (1718±1807) in England.
private madhouse. The most eminent ªmad It appears that the leadership in medicine
doctorº of the eighteenth century was a man shifted from Edinburgh to Paris at about the
with the interesting name of William Battie time of the French revolution in 1789 (Ack-
(1704±1776), who published a Treatise on mad- erknecht, 1967). The French physician Philippe
ness in 1758. According to Porter (1987), Battie's Pinel, who is often considered to be the founder
book contains the key ideas of moral therapy of psychiatry, was much influenced by the
as subsequently practiced by William Tuke doctrines of William Cullen of Edinburgh. Pinel
(1732±1822). The number of private madhouses actually translated one of Cullen's books into
increased greatly during the late eighteenth and French. Cullen's writings also influenced Ben-
early nineteenth centuries. Before the advent of jamin Rush, who incidentally was a signer of the
moral therapy, many of their proprietors used American Declaration of Independence.
fear and restraint, including chains, to deal with How were mental patients treated in the
the inmates (Scull, 1993). According to Bynum eighteenth century? In some respects, the
(1974), the first act aimed at licensing private ancient ways of Hippocrates prevailed. Benja-
madhouses was passed in Britain in 1774. The min Rush was especially well known for his
law did not require the proprietors to be medic- propensity to bleed his patients, and may have
ally qualified but did require a medical certi- inadvertently hastened the death of many of
ficate for a patient to be admitted. Notably, 30 them. Many eighteenth century ªmad-doctorsº
years earlier than this, the prevailing law had in Britain emphasized coercive methods, in-
implied madness to be a condition that anyone cluding chains and fetters. The important
could recognize and that any magistrate could therapeutic innovation of this time is what
formalize; the legal recognition of special know- was known as ªmoral treatment.º This phrase
ledge about madness is part of what confirms the emphasized the attempt to use psychological
emergence of what we now call psychiatry and social influences and to treat the mentally
during the eighteenth century in Britain. As disturbed with kindness rather than physical
Ackerknecht (1986) noted, the title ªdoctorº force, chains, or medications. The asylum began
when used for the proprietor of a madhouse to be considered as a therapeutic intervention
could refer to a university-trained physician, a rather than simply a way to house and contain
surgeon, an apothecary, or simply a quack. mental patients. In retrospect, moral treatment
Although the history of psychiatry has is usually portrayed as a tremendous advance,
somewhat indistinct beginnings in various perhaps the very cornerstone of the new
European countries, the specialty was well specialty of psychiatry. Indeed, it was obvious
established on both sides of the Atlantic before from the first that many patients did not require
1800. As Porter (1987) says concerning Eng- restraint after all, and often responded well to
land: kindness and understanding. Who deserves the
most credit for the development of moral
Around 1700, the top practitioners for the dis- treatment is somewhat unclear. Philippe Pinel
turbed were all-round physicians: within a century became the focus of a legend, not only as a
they were specialists. Mad-doctoring came of age founder of psychiatry but also as the one who
on the day in 1788Ð5 December in factÐwhen the was the first to remove the chains from his
failure of the King's physicians-in-ordinary to patients at the Bicetre hospital in Paris.
master George III's delirium was acknowledged Actually, the evidence is that he was not the
by the summons to the specialist, if very much first to do this but served an apprenticeship to
despised, mad-doctor Francis Willis. (p. 175) Citizen Jean B. Pussin in this respect (Weiner,
1979). Another contender for the credit of
Some would probably not choose to honor founding moral treatment is William Tuke, who
Willis as the founder of this new professional was not a physician but a Quaker tea merchant.
specialty, since he represented the old-fashioned Tuke founded the York Retreat in 1796 as a way
coercive approach rather than the newer one of of providing a gentler approach than that
moral treatment. In any case, the specialists offered by other available institutions. Tuke's
known as ªmad doctorsº in Britain were called work was influential and was copied, for
example, by the founding of the Hartford including the role of electrical stimulation on the
Retreat in the United States. Finally, one must movement of frogs' legs (the original ªanimal
mention Vincenzo Chiarugi as one who opposed magnetismº). This was debunked as an explana-
restraints and harsh measures. Chiarugi was tion by more than one distinguished commis-
born in Florence. His patron was Pietro sion in Paris. The commissioners included such
Leopoldo, the Duke of Tuscany. Chiarugi experts on electricity as Benjamin Franklin,
directed the Hospital of Bonifacio in Florence then serving as ambassador from the United
and published three volumes on his work in States. These scientific authorities tended to
1793±1794, under the title, Della Pazzia in believe that the therapy was based merely on
Genere e in Specia (ªon madness in general and ªimagination.º At the time, the effect on
in specificº). Mesmerism was quite negative in terms of the
In any case, not all scholars view the advent of opinions of educated persons, although its
ªmoral treatmentº as an unmitigated improve- practice continued not only in France but also
ment. Foucault (1961) became famous for in the German states and elsewhere (Gauld,
noting that ªmoral treatmentº could be con- 1992). Ellenberger (1970), in his book The
sidered simply a different kind of oppression. In Discovery of the unconscious, portrays Mesmer's
making the mad responsible for their own self- work as being an important link between the
control, Tuke and Pinel may have merely sub- medieval use of priestly exorcism and the
stituted guilt for external coercion, and unduly subsequent development of psychoanalysis by
imposed demands for a certain type of bour- Freud.
geois respectability. It happened that the first cases of what was
Even with all the emphasis on the absence of subsequently identified as neurosyphilis began
chains in the era of moral treatment, Pinel and to appear in the 1780s (its prevalence rose later,
his colleagues in other countries did use restraint during the nineteenth century). This disease,
when necessary, including strait jackets and which is known to have a latent phase lasting
isolation rooms (Woods & Carlson, 1961). Pinel 10±15 years from the time of initial infection,
avoided punishment and was reluctant to use was manifested in the form of the general
the traditional Hippocratic treatments of bleed- paralysis of the insane (GPI) or paresis. Neuro-
ing, emetics, and purgatives. He observed the syphilis included dementia paralytica, progres-
progress of the patient and tried to provide a sive paralyses, terminal convulsions, and death.
humane environment, hoping that the healing Its early symptoms could include mania and
forces of nature would prevail over the illness. locomotor ataxia (tabes dorsalis). Paresis most
In Britain, the physician who became most commonly affected middle-aged men.
famous for a policy of nonrestraint was John Toward the end of the eighteenth century
Conolly, who had charge of the Hanwell there were important new developments in the
Asylum in England in the nineteenth century treatment of congenital mental handicaps. One
(Scull, 1993). innovator was Giacobbo (Jacob) Rodriguez
A countervailing force at this time was the Pereire (1715±1780). Pereire (or Pereira as his
emerging movement of romanticism, associated name is sometimes spelled), living in France at
particularly with the name of the philosopher the time, developed methods for teaching the
and social contract theorist, Jean Jacques deaf to speak. He never revealed the particulars
Rousseau (1712±1778). In his influential novel, of his methods but was obviously successful in
Emile, or education, and in his other writings, doing what he claimed, as revealed by the fact
Rousseau (1911) stressed the importance of that his deaf pupils did learn to speak. A famous
what emerged naturally in human development disciple of Pereire was the physician Jean Marc
as opposed to what is contrived by the Gaspard Itard (1775±1838), who attempted to
educational system. He emphasized the heart use some of the same approaches to train the
over head, in contrast to what he considered the Wild Boy of Aveyron. Itard considered his
overintellectual emphasis of the Enlightenment. attempts to socialize this feral child and to teach
Mesmerism emerged during the eighteenth him language to be unsuccessful, but in retro-
century, more as a treatment for medical spect they have proven to be a model for
problems than for mental disorders. This devel- educators working with children with mental
opment came from the work of Franz Anton retardation or autism. Itard's work was thus
Mesmer (1734±1815), a physician who was influential in the development of fields as
originally trained in Vienna but who later diverse as otolaryngology, child psychiatry,
flourished in Paris. Mesmer's theory about his special education, and clinical psychology.
therapy explained it in terms of magnetic forces As noted by Shorter (1997), in the late
being transmitted from the body of the doctor to eighteenth century patients with minor nervous
that of the patient, curing all kinds of ailments. complaints tended to seek out treatment at spas.
The theory was based on the study of electricity Thus, there grew up a cadre of ªspa doctorsº to
The Nineteenth Century, Including the Emergence of Clinical Psychology 9
care for them. In addition to bathing in or lerical) and to some extent replaced the previous
drinking natural mineral waters, such patients system run by the Catholic orders. Even after
might also be subjected to actual ªhydrother- the secularization of mental hospitals, many of
apy,º special diets, or to mild shocks from some the psychiatric nurses in the nineteenth century
special electric apparatus. One can see in the were supplied by Catholic religious orders such
practice of such physicians much of what was as the Sisters of St. Vincent de Paul (Santos &
more likely to be identified as clinical ªneurol- Stainbrook, 1949). The French psychiatric
ogyº for many of the years of the following journal, Annales Medico-psychologiques, began
century. publication in 1843, and in 1848 the SocieÂteÂ
medico-psychologique was founded (Dowbig-
1.01.8 THE NINETEENTH CENTURY, gin, 1989). In England, which passed a similar
INCLUDING THE EMERGENCE OF law in 1845, there had previously been founded
CLINICAL PSYCHOLOGY in 1841 an Association of Medical Officers of
Asylums and Hospitals for the Insane (Scull,
Paris continued to dominate the medical MacKenzie, & Hervey, 1996). In 1853 the
scene throughout the first half of the nineteenth Association's journal began, with Sir John C.
century, with its emphasis upon the hospital Bucknill (1817±1897) as editor. Called the
as the site of clinical investigation (Acker- Asylum Journal, it eventually became the British
knecht, 1967). It was there that treatment was Journal of Psychiatry. In the United States,
carried out and there that the correlation of Dorothea Dix (1802±1887) presented her fa-
clinical symptoms with the findings of patho- mous Memorial to the Massachusetts legisla-
logical anatomy were observed. Pinel was if ture, urging the state to take responsibility for
anything as famous in France for his work in the insane by building and staffing proper
internal medicine as in psychiatry. Pinel's most asylums for them (Gallaher, 1995). In 1844 the
famous pupil, Jean-Etienne-Dominique Esquir- forerunner of the American Psychiatric Asso-
ol (1772±1840), unlike his teacher, was able ciation was founded and began to publish the
to devote his entire professional career to American Journal of Insanity, eventually called
psychiatry. the American Journal of Psychiatry (Grob,
Berrios (1996) identifies the second decade of 1962).
the nineteenth century as a time when the In Paris, Edouard Seguin (1812±1880), a
previous global descriptions of types of mental physician who was a pupil of Itard, in 1837
disorders began to be elaborated into detailed opened an innovative training school for
symptom lists and definitions, or what is now imbeciles. Seguin later emigrated to the United
called descriptive psychopathology. This pro- States and became the most influential person in
cess was essentially complete by the time of the the founding, in 1876, of the Association of
World War I. Emil Kraepelin (1856±1926), the Medical Officers of American Institutions for
leader in this domain, published the final Idiotic and Feebleminded Persons.
volume of the eigth edition of his textbook of In Switzerland, in 1841, the physician Johann
psychiatry in 1915. J. Guggenbuhl (1816±1863) founded an institu-
The romantic movement within German tion for Cretins at the Abendberg (Kanner,
psychiatry continued to flourish in the 1820s 1959). Guggenbuhl received praise from all over
and in places perhaps until 1848. An example of the world for this innovation, but the Abend-
such a psychiatrist was Johann Heinroth (1773± berg was closed down after only a few years
1843), who was appointed to the first known because of mismanagement. Theodor Kocher
chair of psychische Heilkunde (ªpsychother- (1841±1917), a Swiss surgeon, discovered the
apyº) at the University of Leipzig in 1819. The cause of Cretinism (Schlick, 1994), despite his
type of psychotherapy favored by Heinroth lack of any intitial interest in the problem of
made considerable use of Christian precepts mental retardation. Kocher, in ablating the
such as sin, repentance, and religious conver- thyroid gland of certain of his patients with
sion. The romantics, influenced by German goiters (especially the children among them),
nature philosophy, were ªPsychikersº who noticed that he had inadvertently created a sort
battled against the ªSomatikers.º of artificial cretinism. He later made a visit to
Formal organizations of psychiatrists began the Valais and the mountains near Bern in
at about the same time in France, Britain, and Switzerland to examine some natural cases of
the United States during the 1830s and 1840s, cretinism there to compare them with his
when public mental asylums began to be surgical cases. Of 32 alleged cretins referred
constructed in these countries. In France, a to him for examination, he concluded that only
law was passed in 1838 creating a national six fit the refined criteria his surgical experience
system of asylums (Goldstein, 1987). It was led him to develop to diagnose this disease. The
supported by liberals (who tended to be antic- other patients, though mentally handicapped,
failed to meet his criteria for such a thyroid- Freud still intended to become an academic
based disorder. Later, Kocher developed tech- neuroanatomist. Meynert was the investigator
niques for transplanting thyroid glands, the first who distinguished the various layers of the
such successful organ transplant. Thus, he cerebral cortex in terms of cell types. Although
discovered a curative therapy for cretinism as he had a poor reputation as a clinican, Meynert
well as its cause. He won the Nobel prize for trained several students who themselves made
these discoveries after the turn of the century, in contributions to neuroanatomy. In 1865 the
1909. French physician Pierre P. Broca (1824±1880)
In England, physician J. Langdon Down had developed his influential hypothesis that
(1828±1896) wrote a notable paper on the expressive aphasia results from damage to the
mental retardation syndrome now associated third frontal convolution of the left hemisphere
with his name. He misinterpreted the condition of the human brain. At that time, Broca had
as representing some kind of an evolutionary only a single case with an autopsy to report. One
throw-back to ªMongolº ancestors. of Meynert's pupils, Carl Wernicke (1848±
In the late nineteenth century, let us say after 1905), later described a type of receptive aphasia
1848, the dominant role in medicine and that was quite distinct from Broca's aphasia,
psychiatry shifted to the German states (Ack- anatomically as well as functionally. The
erknect, 1967). The unified country of Germany patients Wernicke identified had lesions in the
emerged in 1871 after the Franco-Prussian war. posterior perisylvian region of the left hemi-
German medicine was dominated by laboratory sphere, were unable to understand spoken
approaches rather than by work in the clinic or words, and spoke in a fluent but incomprehen-
the hospital. As the German physician Bernard sible jargon. Julius Eduard Hitzig (1838±1907),
Naunyer (1839±1925) was reported to have said: another Meynert pupil, carried out research on
ªMedicine will be a science, or it will not exist at dogs indicating that the brain responds to local
allº (Magnus-Levy, 1944). The leaders in Ger- electrical stimulation.
man psychiatry would surely include Wilhelm Franz Joseph Gall (1759±1828), a German
Griesinger (1817±1868) and later Emil Kraepe- who received his M.D. from Vienna, also began
lin (mentioned above in relation to descriptive his career with well-respected research on the
psychopathology). Griesinger published an topic of the localization of function in neuroa-
influential book, Mental pathology and ther- natomy (Temkin, 1947). His viewpoint was
apeutics, in 1845. He was the director of opposed by Pierre Flourens (1794±1867), who
psychiatry at Berlin's Charite Hospital and held did not find evidence for such localization in his
the chair in psychiatry at the University of research on the cerebral cortex of pigeons. Gall
Berlin, beginning in 1864. Unlike other psy- and a colleague named Spurzheim went on to try
chiatrists of the time, Griesinger did not work in to establish a correlation between human
a mental hospital out in some isolated rural ªneuroanatomyº (as indexed by bumps on the
area. He tried to make psychiatry an integral skull) and psychological characteristics. Spurz-
part of a major urban university. Griesinger has heim called this field phrenology, which trans-
become infamous among the psychodynamic lates simply as the study of the mind.
psychiatrists and psychologists of our day for Phrenology went on to considerable popular
his rather dogmatic statement that mental and commercial success in England and the
diseases are brain diseases. What is not often United States and at first was supported by a
realized by such critics is that Griesinger was significant element within the medical and
quite sophisticated in the psychology of his time. psychiatric community. For example, John
He made extensive use of the concepts of the Conally (1794±1866), the prominent British
psychologist Johann F. Herbart (1776±1841) alienist and champion of the doctrine of
concerning the unconscious, the threshold of nonrestraint, was also a supporter of phrenol-
consciousness, and the ªapperceptive massº ogy. Some supporters managed to combine
used by people in interpreting their experiences. phrenology and hypnotism (Gauld, 1992).
Griesinger founded a new journal with the title Thus, they developed a professional approach
[English translation] Archives for Psychiatry and that included a sort of prototype of neuropsy-
Nervous Diseases in 1867 to focus on the type of chological assessment and psychological treat-
neurologically oriented field of psychiatry he ment. Ultimately, however, phrenology was
envisioned. However, he died the next year, with consigned to the status of a pseudoscience and
his vision still unrealized. its practice condemned as quackery.
One German psychiatrist who took the road Late nineteenth century Germany was also
laid out by Griesinger was Theodore Meynert one place where the new discipline of psychology
(1833±1892), a professor in Vienna, who was emerged. It was at first modeled upon experi-
incidentally one of the teachers of Sigmund mental physiology, for example, the work of
Freud (1856±1939). This was in the days when Ernst Weber (1795±1878) and Gustav Fechner
The Nineteenth Century, Including the Emergence of Clinical Psychology 11
(1801±1887) leading up to Fechner's 1860 book, ªfolie a deuxº for a sort of psychosis of associa-
Elements of psychophysics. The founders of tion in which an otherwise normal person
psychology as an independent academic disci- acquires symptoms from being around someone
pline in the 1870s are generally considered to with a mental disorder. Thus, a wife might adopt
have included William James (1842±1910) at her paranoid husband's view that the house is
Harvard University in the United States and surrounded by agents bent on harming them.
Wilhelm Wundt (1832±1920) at the University In England, the most influential scientific
of Leipzig, Germany. Of these founders of figure of the nineteenth century was Charles
psychology, the one who made the greatest Darwin (1809±1882), who published his book
contribution to the study of psychopathology Origin of the species in 1859. His cousin, Francis
was William James, as shown, for example, by Galton (1822±1911), was the author of a book
his 1896 Lowell lectures on exceptional mental on Hereditary genius, published in 1869 (Gal-
states (Taylor, 1982). ton, 1978), in which he developed a new field he
The American Psychological Association was called ªeugenicsº attempting to use the princi-
founded in 1892 by Granville Stanley Hall ples of genetics to improve the human species. It
(1844±1924). Hall tried his best to facilitate a was Galton's American student, James McKeen
relationship between psychology and psychia- Cattell (1860±1944), who first coined the term
try. A Ph.D., he served at one point as the ªmental testº (Cattell, 1890).
superintendent of the Bayview mental hospital French psychiatry had a lengthy involvement
in Maryland. Later he taught psychology to with a concept later considered discredited,
psychiatry trainees at Worcester State Hospital namely the theory of degeneration of Benedict
in Massachusetts. After the turn of the century, A. Morel (1809±1884). This theory was a varia-
in 1909, he was to invite Freud and Jung to tion of Lamarck's theory of the inheritance of
America, the only time Freud ever visited the acquired characteristics (Walter, 1956). It led to
US. the expectation that the offspring of disturbed
Emil Kraepelin, ultimately a professor at the or profligate persons would become worse in
University of Munich, may have been the each generation. One follower of Morel was
leading German psychiatrist of his day. He Cesare Lombroso (1835±1909) at the University
received his MD at Wurtzburg and served as of Turin in Italy. In 1876 Lombroso published a
a resident under Bernhard von Gudden (1824± book, L'uomo delinquente, concerning what he
1886) in Munich (Danek, Gudden, & Distel, described as the born criminal, with numerous
1989). He also studied psychology under Wundt ªstigmataº of degeneration. Richard von
at Leipzig. In his 1893 textbook, Kraepelin first Krafft-Ebing (1840±1902), a professor of psy-
introduced the concept of ªdementia praecox.º chiatry at the University of Vienna, also en-
This term combined a heterogeneous group of dorsed a version of degeneration theory as
symptoms including social withdrawal, hebe- applied to sexual perversions. Krafft-Ebing
phrenia (silly, childish language), paranoia published a book, Psychopathia sexualis, in
(delusions), and catatonia (paralysis with waxy 1886.
flexibility upon passive movement). The reason In the United States, George M. Beard (1839±
for combining these symptoms was Kraepelin's 1883), a New York neurologist (i.e., a specialist
hypothesis that many persons with such symp- in nervous and mental diseases), published in
toms tend to become chronic mental patients. 1880 a book about his concept of ªneurasthe-
Kraepelin considered this syndrome to be a kind nia,º meaning simply weak nerves, with a vast
of dementia in a young person that predicted the array of symptoms. Beard was interested in
individual's ultimate mental deterioration. He electrotherapy and had been involved in the
wrote extensively about the entire spectrum of scientific study of hypnosis in the 1870s.
psychopathology and divided the syndromes Neurasthenia became an extremely popular
into 13 major groups. medical diagnosis for people with chronic
In 1826 the French physician Antoine L. fatigue and vague nervous complaints (Rosen-
Bayle (1799±1858) had found an association of berg, 1962). The American Neurological Asso-
GPI with chronic inflammation of the meninges ciation had just established in 1871 its Journal of
of the brain. In 1851, two French psychiatrists Nervous and Mental Diseases. The ªneurolo-
simultaneously came up with the concept we gistsº of those days were in competition for
now term bipolar disorder, confirming the outpatients with psychiatrists, who were still for
statements of Thomas Willis in the seventeenth the most part in institutional practice. Accord-
century. Jean-Pierre Falret (1794±1870) called ing to Shorter (1997, p. 130), neurasthenia was
this condition ªfolie circulaire,º whereas Jules the ªstandard diagnosis for all functional
Baillarger (1809±1890) called it ªfolie a double nervous diseasesº up to the time of World
formeº (Bourgeois & Geraud, 1997). Inciden- War I. These were the kinds of patients for
tally, Falret was also the first to coin the term whom the Philadelphia physician Silas Weir
Mitchell (1829±1914), of the Jefferson Medical quently identified as being due to a dietary
College, prescribed his famous ªrest cure,º or as deficiency in thiamine, often found in poorly
he tended to say, ªDr. Diet and Dr. Quiet.º nourished alcoholics.
The American Neurological Association was The French physician Jean-Martin Charcot
founded in 1874. In 1894, Mitchell gave a famous (1825±1893) was a key figure in the history of
address before the 50th Annual Meeting of the several modern specialties, including neurology,
American Medico-Psychological Association psychiatry, psychoanalysis, and clinical psy-
(forerunner of the present American Psychiatric chology. Charcot, the chief physician at the
Association) in Philadelphia. As a neurologist Salpetriere hospital in Paris, was known for his
who worked mainly with outpatients, Mitchell work on clinical-neuropathological correlations
severely criticized his ªalienistº colleagues for as well as on hysteria and hypnosis. Charcot was
their lack of connection to the rest of the field of responsible for elucidating the neuropathology
medicine and their lack of research: of amyotrophic lateral sclerosis, now known
in the United States as Lou Gehrig's disease
Where, we ask, are your annual reports of scientific (in France, it is called ªCharcot's diseaseº).
study, of the psychology and pathology of your Hypnosis, meanwhile, had been rehabilitated
patients. . . . Seriously we ask you experts, what somewhat by the Englishman James Braid
have you taught us of the 91 000 insane whom you (1795±1860) under new terminology. Braid's
see and treat? (Mitchell, 1894, p. 101) 1843 book was entitled, Neurypnology, or the
rationale of nervous sleep. Charcot successfully
This talk, though harsh, facilitated the later defended hypnosis before the French Academy
integration of these two parts of present-day of Sciences on February 13, 1882 (Gauld, 1992,
psychiatry. p. 311) and used it in his ªexperimental thera-
In 1880 in New York, a rather short-lived peuticsº of hysteria. Charcot considered hyp-
organization was founded called the National notism to be an abnormal process in itself,
Association for the Protection of the Insane and characteristic only of persons with hysteria.
the Prevention of Insanity (NAPIPI). The Charcot appointed Pierre Janet as head of a
membership consisted largely of neurologists newly established psychology laboratory at the
and social workers who were critical of the Salpetriere Hospital in Paris in 1890.
asylum psychiatry of the day. In a sense this Charcot's contemporaries in Nancy, France,
organization could be regarded as a forerunner A. A. Liebault (1823±1904) and Hippolyte
of the antipsychiatry movement of the twentieth Bernheim (1840±1919), considered hypnosis to
century (Dain, 1994). apply to normal people as well as to those with
Charles Locock, a London internist, was hysteria. Sigmund Freud translated Bernheim's
responsible for initiating the common use of book on hypnosis into German. Freud also
bromides as a sedative in psychiatric practice. visited Charcot in Paris. He returned to Vienna
According to Shorter (1997, p. 200), Locock and in 1895 published a book that was the
happened to mention at a medical meeting in beginning of his development of psychoanalysis
1857 that he had given 10 grains of potassium as a treatment for hysteria that went beyond
bromide per day for two weeks to a patient with hypnosis (Breuer & Freud, 1895/1986).
ªhysterical epilepsy,º with the apparent effect of Spiritualists and mental healers throughout
suppressing the epilepsy. Otto Liebreich, a the nineteenth century had been interested in
professor of pharmacology in Berlin, discovered psychology and often identified themselves with
in 1869 that chloral hydrate could relieve psychology in their writings. One development
insomnia in patients with anxiety and depres- in the United States in the nineteenth century
sion (Shorter, pp. 198±199). This is the sub- was the emergence of Christian Science as a
stance known as ªknock-out dropsº or ªMickey religion, based on the writings of Mary Baker
Finnsº and indeed does what it is supposed to Eddy (1821±1910). She had experienced im-
do. It is considered more reliable than morphine provement in her own state of illness in the
and can be taken orally (though it has a bad hands of the healer Phineas P. Quimby
taste). It was widely used in mental hospitals (1802±1866) (Gauld, 1992).
thereafter, despite having some danger of Toward the end of the nineteenth century a
addiction. coalescence began of the traditional ªalienistsº
The Russian psychiatrist Sergei Korsakoff or psychiatrists, who worked mostly in isolated
was the first to describe the syndrome named mental hospital settings, and physicians who
after him: chronic psychosis and memory loss in were neurologists (or ªnerve specialistsº). The
patients with alcoholism. Carl Wernicke in latter had an outpatient, office clientele.
Germany had described the acute form of this Late in the nineteenth and early in the
condition in 1881Ðmental confusion and twentieth century, a field of ªabnormal psy-
staggering gait. These conditions were subse- chologyº emerged in France and was continued
The Twentieth Century: Guild-related Issues 13
in the United States. This was the result of the others rather than only studying them (McRey-
work of physicians, physiologists, philosophers, nolds, 1997; Routh, 1996). Unlike the members
and psychologists including Theodule Ribot of the Boston school, Witmer took his cues from
(1839±1916), Pierre Janet (1859±1947), William Itard, Seguin, and Montessori rather from
James (1842±1910), Granville Stanley Hall Charcot and Janet. He emphasized work with
(1844±1924), and Morton Prince (1854±1929). children rather than adults and focused on
Much of the research done by these workers can academic and cognitive problems more than
be considered to represent a nonpsychoanalytic emotional ones.
offshoot of some of Charcot's work with hypno-
tism and hysteria. Ribot, who was trained as a 1.01.9 THE TWENTIETH CENTURY:
physiologist, became chair of the department of GUILD-RELATED ISSUES
experimental psychology at the College de
France, where he specialized in abnormal psy- The twentieth century has been a time of
chology. Ribot was among those who influ- diversification in the number of professional
enced Charcot. Charcot's pupil Janet, later a groups providing services to the public in the
professor at the College de France, interpreted area of mental health. These include psychiatry,
neurotic complaints such as hysteria in terms of psychoanalysis, psychology, social work, and
his concepts of dissociation and fixed ideas. newer groups such as marriage and family
Janet wrote an influential book on the psychotherapy. It has also been a time of impressive
logical treatment of hysteria. William James, the scientific advances in the study of psychopathol-
author of the classic textbook on psychology in ogy, assessment, and treatment. The scientific
1890, also lectured on abnormal psychology advances seem to cut across these disciplines
(Taylor, 1982). and therefore can be discussed in a unified way.
Historian Eugene Taylor (personal commu- The professional developments of the century
nications, January 13±14, 1998) mentions seem to require separate treatment for each
several MD±Ph.D.s as being among those competing guild. Let us therefore discuss each
who ªdefined the interface between psychology profession separately before proceeding to an
and psychiatryº in this era and subsequently, account of scientific developments.
Boris Sidis, Hugo Munsterberg, and Pierre
Janet. According to Taylor, there were already 1.01.9.1 Psychiatry
clinics in France, Germany, the Netherlands,
and the United States by the 1890s devoted to Psychiatry began the century with most of its
ªmedico-psychologicalº treatment. Boris Sidis practitioners working in institutions. After it
did psychotherapy with adult outpatients at the began to take over work from neurologists, its
Massachusetts General Hospital beginning in outpatient practice steadily increased. Neurol-
1885. Caplan and Caplan (1969, pp. 304±305) ogy was a primary care specialty in the United
considered Boris Sidis to have been the first States up until World War II but after that
psychologist to speak to the American Medico- withdrew from such activities to become a field
Psychological Association. In this 1900 address, of consulting specialists, researchers, and tea-
his opening words were: chers (Bluestein, 1992).
Philanthropist Henry Phipps was encouraged
Medical men and especially alienists seem to by psychiatrist Adolf Meyer to endow a psy-
observe less strictly the law ªnot to admit an alien chiatric clinic at Johns Hopkins University. It
into the congregation of the Lord,º and are willing was the first university psychiatric clinic of its
to listen even to a psychologist. (Caplan, 1969, kind in the United States and opened in 1913. In
p. 305) England psychiatrist Henry Maudsley (1835±
1918) in 1907 offered funds to the London
At the time, Sidis held the position of associate Council to establish a teaching hospital.
in psychology and psychopathology at the Completed in 1915, the Maudsley Hospital
Pathological Institute of the New York State ultimately became the locale of the Institute of
Hospital. Thus, there is justice to Taylor's claim Psychiatry at the University of London. In 1917
that these developments constitute some of the Emil Kraepelin founded the German Research
roots of clinical psychology. Institute for Psychiatry in Munich. Shorter
The above developments were independent of (1997, p. 262) calls this ªthe first comprehensive
the work of Lightner Witmer, a Wundt Ph.D., center for investigating brain, mind, and their
who founded the first psychology clinic at the disorders.º Kraepelin's organization was later
University of Pennsylvania in 1896 and began to made a Kaiser Wilhelm Institute by the German
train a whole generation of Ph.D. clinical Empire. It subsequently received funds from
psychologists there in Philadelphia. He empha- the Rockefeller Foundation and today is one of
sized the role of clinical psychologists in helping the Max Planck Institutes supported by the
German government. The Rockefeller Founda- French revolution as ªthe great confinementº
tion began funding liaison psychiatry at the and tended to view this as a sort of conspiracy by
Massachusetts General Hospital and about 10 psychiatry against human freedom. Of course,
other hospitals beginning in 1925. at this time, Foucault was hardly alone in being
In 1934, the American Board of Psychiatry critical of residential treatment for psycho-
and Neurology was established and began to pathology. This type of criticism, together with
grant ªboard certificationº in psychiatry to the existing disillusionment with institutions,
those who passed its examination. This pro- and the availability of effective neuroleptic
vided to psychiatrists greater parity with their medications, hastened the general trend toward
colleagues in other medical specialties who had deinstitutionalization. By this time most psy-
long since achieved the possibility of ªboard chiatrists had established an outpatient practice
status.º in any case.
Psychiatry was especially influenced by
psychoanalysis during and after World War 1.01.9.2 Psychoanalysis
II. The first psychiatrist to attain the rank of
General in the US Army was William C. Men- Psychoanalysis virtually swamped the field of
ninger, who had a psychoanalyic orientation. psychotherapy early in the century, relying on
According to Shorter (1977, p. 307), by 1945 the treatment principles of free association and
most chairs of departments of psychiatry in US interpretation by the analyst. Freud's writings
medical schools were psychoanalysts. In 1946, attracted many disciples. Also, outpatients were
an organization called the Group for the Ad- willing to pay for this kind of treatment for
vancement of Psychiatry (GAP) was founded periods of months and years, if so advised.
within the American Psychiatric Association, Psychoanalysis soon began organizing itself in a
under the leadership of Menninger. This group formal way. The first international psycho-
favored psychoanalytic approaches. By the mid- analytic congress was held in Salzburg in 1908.
1970s, very few American departments of psy- Freud and Jung were invited to the United
chiatry selected psychoanalysts as chairs. The States in 1909 to speak at Clark University.
instruction of psychiatrists in intensive psy- Psychoanalysis also soon began a process of
chotherapy was also on the wane. According to fission, with Alfred Adler (1870±1937) breaking
some observers, an era of biological psychiatry away in 1911. Then in 1913 Carl Jung
and psychopharmacology had begun. (1875±1961) left the fold. In that same year,
Of course psychiatry is anything but a Freud and certain colleagues set up a small
monolithic field and accommodates many group called ªthe Committeeº to maintain more
viewpoints and approaches to treatment. For oversight of psychoanalytic orthodoxy. Inter-
example, psychiatrist Victor Frankl was among estingly, each of its offshoots seemed to follow
those incarcerated in a Nazi concentration camp Freud's pattern of elaborating a theory of
during World War II and believed that he had psychopathology and treatment and establish-
been able to survive the experience because he ing formal organizations that its adherents
was able to find some meaning in life (Frankl, could join.
1962). Accordingly, he developed a treatment Freud thought of psychoanalysis as an
approach he called Logotherapy aimed at independent field, separate from psychiatry
helping his patients to find meaning in their and medicine, and was willing to train analysts
own lives. (including psychologists) who lacked a medical
The ªantipsychiatryº movement is also worth background. The American Psychoanalytic
mentioning in discussing the history of twen- Association, founded in 1911, had ideas dif-
tieth century psychiatry as a profession. Psy- ferent from Freud's about the relation of
chiatrist and psychoanalyst Ronald D. Laing psychoanalysis to medical practice and after
came to voice strong criticism of both psychiatry 1938 for 50 years restricted its accredited
and of the families of persons with schizo- institutes to offering training to medical can-
phrenia (Laing, 1960). His view was that parents didates only. In 1926, on the other side of the
tended to tie their children in mental knots and Atlantic, psychologist Theodore Reik had been
threaten their identity. Laing thought of schizo- tried for practicing medicine without a license,
phrenia as being in many cases not so much a that is, for doing psychoanalysis. Reik was
breakdown as a breakthrough, a necessary stage acquitted. In fact, Freud himself came to Reik's
on the path of development. In 1967 Laing defense (S. Freud, 1927). In 1985 Bryant Welch
reviewed Michel Foucault's book, Madness and (a psychologist±attorney) and three psycholo-
civilization (Foucault, 1961) in the New States- gist colleagues filed a lawsuit against the
man and thereafter considered Foucault to be a American Psychoanalytic Association for this
sort of ally. Foucault spoke of the construction practice as a violation of federal antitrust law. In
of so many public mental hospitals after the 1988 the organization settled the suit out of
court and began allowing social workers and viable profession and as an influence on scholars
psychologists to become trainees. According to over much of the world. Its influence continues
Shorter (1997, p. 310), the number of non- to spread in Latin America and elsewhere during
medical candidates in training soon rose to the late twentieth century.
above 20%.
In France, psychoanalysis emerged as a 1.01.9.3 Clinical Psychology
highly influential approach, but a number of
years after it had done so in the United States The Boston physician Morton Prince viewed
(Roudinesco, 1990). Psychoanalysis in France abnormal psychology as a subject belonging
began with the work of Marie Bonaparte and more to philosophy or the liberal arts than to
her colleagues in the 1920s (Bertin, 1982). This medical school. He was influenced by Pierre
included the founding of an institute and a Janet and William James and published a book
professional journal as well as the translation of on ªChristine Beauchamp,º a famous case of
some of Freud's writings into French. Psychia- multiple personality disorder he had encoun-
trist and psychoanalyst Jacques Lacan (1901± tered. Prince founded the Journal of Abnormal
1981) was active on the French psychoanalytic Psychology in 1906 and later gave it to the
scene beginning in the 1930s but began his American Psychological Association. He also
influential seminars in Paris only in 1953. The founded the Harvard Psychological Clinic in
legal issue of lay vs. medical analysis also arose 1926. It was a research facility rather than one
there. After the student disturbances of 1968, for providing services to the public and later
psychoanalysis assumed a greater representa- received funding from the Rockefeller Founda-
tion in French university curricula. In 1973 tion. Another of Prince's projects was the
Lacan published a book on what he considered American Psychopathological Association,
the four fundamental concepts of psycho- open to membership for both psychiatrists
analysis. Lacan's ªdeconstructionistº approach and psychologists. If Prince had had his way,
was popularized in literary circles by Jacques the fields of psychology and psychiatry would
Derrida. Even today, if one examines the shelves probably be more unified than they have turned
of a bookstore in Paris, the section on psycho- out to be. His aims have been fulfilled much
analysis is highly visible, but there may be no more in the domain of research than that of
sections labeled psychology or psychiatry. practice.
The influence of psychoanalysis in Britain and Eleven years after his clinic had been
the United States had been evident well before established, Lightner Witmer founded a journal
that in France. The Rockefeller Foundation called the Psychological Clinic in 1907 and in its
provided some funding for the Chicago Psycho- inaugural issue elaborated on his concept of
analytic Institute in 1925. Franz Alexander what the field should involve. This was the first
(1891±1964) was appointed professor of psycho- known use of the term clinical psychology.
analysis at the University of Chicago in 1931, the Witmer's journal continued to publish about 23
first such academic recognition for the field volumes, well into the 1930s, mostly case
(Mora, 1994). The role of psychoanalysis in the histories of children treated in his own clinic
United States and Britain increased during the at the University of Pennsylvania. Witmer's
1930s, with the immigration of many analysts idea of clinical psychology focused on inter-
from continental Europe fleeing Hitler. As the vention but resembled what we now think of as
American interest in psychoanalysis cooled special education more than psychotherapy.
somewhat in the 1970s, Roy Schafer (1976) According to Eugene Taylor (personal com-
and others began to reconsider whether psycho- munication, January 13±14, 1998), the first
analysis ought to model itself after the natural official Ph.D. clinical psychologist at the Mas-
sciences. Perhaps, Schafer suggested, it would be sachusetts General Hospital was L. Eugene
more appropriate to consider psychoanalysis Emerson, who as early as 1911 was using a type
to be part of the humanities. Its use of of psychotherapy derived from the work of
hermeneutic approaches in interpreting pa- Freud and Jung. Another Ph.D. psychologist,
tients' utterances were seen as similar to those F. Lyman Wells (1884±1964), was doing psy-
of literary scholars in interpreting poems and chotherapy with inpatients at the McLean
fictional narratives. The philosopher of science Hospital at the same time. The theories of
Adolph Grunbaum (1984, 1993), an outsider to Freud, Jung, Adler, and other psychodynamic
psychoanalysis, criticized its use of a patient's views also influenced academic psychology,
subsequent behavior as a way of confirming the especially in the clinical area but also in the
correctness of psychoanalytic interpretations. areas of personality, developmental, and social
Other criticisms came from insiders, such as psychology.
psychoanalyst±historian J. M. Masson (1984). James McKeen Cattell (Ph.D. Leipzig, 1886)
Nevertheless, psychoanalysis continues as a was one of the strongest supporters of the idea
of psychology as a profession but did not have in early clinical psychology. The APA's efforts in
much interest in clinical issues. He founded the this domain did not suceed (only 25 persons were
Psychological Corporation in 1921 as a non- ever so certified) and were discontinued in 1927.
profit organization to promote applications in Psychologist Leta Hollingworth (1886±1939)
psychology, mostly psychometric testing. His published a little-cited paper in 1918 that was
interests soon turned to science at large. He the first to mention the possibility of a different
bought Science magazine from Alexander type of degree for professional psychologists,
Graham Bell, and served as its editor for many the ªdoctor of psychologyº instead of the more
years. Cattell also published American Men of usual Ph.D. (doctor of philosophy). The Psy.D.
Science (later known as American Men and was discussed as a possibility for many years but
Women of Science) and inaugurated the practice did not come into much actual use until the
of highlighting the relative merit of scientists' 1960s. One of the first programs that granted the
contributions by putting a star beside the names Psy.D. began in 1968 at the University of
of those considered the most notable. In this Illinois. In the United States, Britain, and some
way he carried forward Galton's idea of the other European countries, the Psy.D. and other
importance of individual differences. similar degrees such as the ªdoctor of clinical
In the era before World War II, clinical psychologyº (D.Clin.Psy.) are now more often
psychologists were known more as mental offered by training programs for practioners.
testers than as psychotherapists. The mainstay Research-oriented graduate programs still give
of their early activities in this area was the Binet the Ph.D. in clinical psychology.
test, first published in France in 1905, translated By the time of World War I, self-report
into English in 1908, and eventually standar- questionnaires began to be developed for the
dized in the United States. Psychologist Henry assessment of personality and psychopathology.
Goddard, who first had the Binet translated, By the 1930s, projective tests such as the
was the research director at the Vineland Rorschach inkblot test and the Thematic
Training School in New Jersey (an institution Apperception Test joined what was becoming
for persons with mental retardation). He set up the clinical psychologist's standard test battery.
the first internship program in clinical psychol- In 1937 the American Association of Applied
ogy in that same year, 1908. Internships Psychologists (AAAP) was founded. The Clin-
involving a year of full-time supervised experi- ical Section within the American Psychological
ence soon became a part of the expected training Association disbanded itself, and its members
of clinical psychologists. Goddard's research formed the Clinical Section of the AAAP. In
was supported financially by Samuel S. Fels, the 1945 Division 12 of the American Psychological
soap maker, and some friends from the Ethical Association was founded, the present Division
Culture Society of Philadelphia. Fels and of Clinical Psychology. It was based on a merger
Goddard were part of an informal group that of two groups: one of these was the psychol-
met at Vineland for some years that called itself ogists from the Clinical Section of the AAAP,
humorously, ªthe Feeble Minded Clubº (Doll, who in a sense represented the tradition
1988). established by Lightner Witmer of Philadelphia.
In 1917, the American Association of Clinical The other group briefly in 1945 carried the the
Psychologists was founded. It was the first label of the Division of Abnormal Psychology
organization in the field of clinical psychology and Psychotherapy and was to have been APA
and came about because its founder J. E. W. Division 11. This group could perhaps be seen as
Wallin (1876±1969) wished to begin to establish the descendents of the Boston school of
some professional standards. In particular, he abnormal psychology. Division 11 was never
was concerned that Binet testing was being done officially established; instead its potential
by school teachers with no background in members became part of Division 12, which
psychology on the one hand, and by academi- was initially called the Division of Abnormal
cally trained psychologists with no clinical and Clinical Psychology.
experience on the other. Only two years later, In 1945, the American Psychological Asso-
this organization disbanded itself in favor of a ciation appointed David Shakow (1901±1981)
new Clinical Section within the American to head a committee to discuss how clinical
Psychological Association. For a brief time, psychologists should be trained. The impetus
the American Psychological Association tried to for this committee's work was provided by the
develop a procedure for certifying what were at promise of massive funding of such training in
the time called ªconsulting psychologists,º all mental health fields by the Veteran's
meaning those who were adequately prepared Administration (VA) and the new National
to offer their services to the public. The person Institute of Mental Health (NIMH). James
who was in charge of this effort was F. Lyman Grier Miller who had been trained in both
Wells, already mentioned as an influential figure psychology and psychiatry was chief of the VA
Division of Clinical Psychology and Neurop- of the field. He stimulated the formation of a
sychiatry at the time. The Shakow Committee's new subgroup of persons who identified
recommendations were later endorsed by the so- themselves as clinical child psychologists.
called Boulder Conference in 1949. Shakow's Psychologist Nicholas Hobbs was one of these
model called for training clinical psychologists and was particularly effective in suggesting how
at the Ph.D. level as ªscientist-practitioners,º support and treatment could be arranged for
including a required one-year predoctoral disturbed children, coordinating work with
internship, usually obtained during the trainee's them individually, with their families, and with
third year of graduate school. As Levy (1962) the schools (Hobbs, 1966).
later pointed out, many psychologists trained as In 1962, a conference on behavior modifica-
ªscientist±practitionersº never went on to tion was held in Charlottesville, Virginia. It was
publish any research; many did not even publish instigated by psychiatrist Joseph Wolpe, beha-
their Ph.D. dissertations. Thus, this training vior therapist Andrew Salter, and psychologist
model did not seem to function as well as had Leo Reyna, who published the proceedings as a
been hoped. As time went on, more of the book (Wolpe, Salter, & Reyna, 1964). The
graduates of such programs also went into American Association of Behavior Therapies
private practice, an outcome that no doubt (AABT) was founded relatively soon after this
would have horrified David Shakow and his landmark conference, in 1966 (in 1969 the
colleagues. ªTherapiesº in the organization's name was
The first state law certifying psychologists for changed to ªTherapyº). Despite the interdisci-
independent practice was passed in Connecticut plinary origins of this field, most behavior
in 1945 (Heiser, 1945), and by 1977 all states had therapists were psychologists. Until 1972 the
such certification or licensing laws. The dis- AABT met with the American Psychological
tinction between these two types of legislation is Association; after that, it met independently.
that certification usually protects only the title Like other professional groups (including
(in this case ªpsychologyº), whereas licensing is psychoanalysts), behaviorally-oriented practi-
more likely to specify the actual content of the tioners showed some tendency toward fission.
practice. Similar legislation was passed in each Applied behavior analysis since its beginning
of the Canadian provinces. It is the goal of most tended to isolate itself from behavior therapy
national psychological associations in Eur- with separate professional organizations, jour-
opean countries to achieve full legal recognition nals, and so on (Krantz, 1971). This branch of
for professional psychology, if indeed they had behavioral psychology dates its own history
not already attained it (McPherson, 1986). from a 1947 research conference in Blooming-
In 1947, the American Board of Examiners in ton, Indiana under the aegis of B. F. Skinner.
Professional Psychology (ABEPP, later simply Unlike other behaviorists, the followers of
ABPP after the word ªExaminersº was dropped Skinner avoided using dispositional concepts,
from the Board's name) was founded. This preferred single-subject experiments to those
board soon began to grant diplomas in clinical with group designs, and emphasized the ªthree-
psychology and was modeled after boards that term contingencyº involving setting events,
were well established in various medical fields response, and environmental consequences.
including psychiatry. In 1948, Nicholas Hobbs In 1963, a new component of the National
(1915±1983) carried out a project initiated by Institutes of Health was created, called the
the American Psychological Association to National Institute of Child Health and Human
develop an explicit set of ethical standards for Development (for which the usual acronym is
psychologists. Revisions of these ethical prin- NICHD). Part of the impetus for this new
ciples continue up to the present. research institute was the interest of President
In London after World War II, psychologist John F. Kennedy and his family in the problem
Hans J. Eysenck set up a Department of of mental retardation. Research grants related
Psychology within the Institute of Psychiatry to this problem were shifted from the NIMH to
at the University of London. This department the NICHD, which also had the practical effect
became a major center for behavior therapy in of divorcing psychiatry from the medical
Britain in subsequent decades. aspects of mental retardation, which were
In his 1959 book, psychologist Alan Ross henceforth considered to be more in the domain
(1921±1993) noted the fact that after the end of of the pediatrician. The creation of this agency
World War II, clinical psychology had moved also propelled psychology into the role of being
far from some of its origins focusing on work the primary discipline concerned with psycho-
with children. This was partly because of all the pathology associated with mental retardation.
government funds that encouraged work with The California School of Professional Psy-
adults such as military veterans. Ross wished to chology was founded in 1969, with multiple
reclaim what he viewed as the original heritage campuses not affiliated with any university. The
founder was psychologist Nicholas Cummings, By 1945, an organization of social workers in

who had the backing of the state psychological the United States already had 2000 members. In
association in California. From the standpoint 1955, the National Association of Social Work-
of those who founded this and other free- ers (NASW) was established as a combination
standing schools of professional psychology of several groups. According to Shorter (1997,
that soon grew up all over the United States, the p. 293), the NASW increased to 80 000 members
existing graduate schools' programs were too by 1990, about one-quarter of whom were in
elitist and not sufficiently concerned about private practice.
producing practitioners. A conference of psy-
chologists at Vail, Colorado in 1973 urged the 1.01.9.5 Religious Counseling
acceptance of a practitioner model of training
alongside the now traditional scientist± Many mental health workers have tended to
practitioner model (Korman, 1974). The Vail distance themselves from religion, although
recommendations also endorsed the trend they might admit, if pressed, that their work
toward schools of professional psychology. was not unrelated to some of the counseling
With the growing dominance of the US done by members of the clergy or of religious
health-care system by insurance and HMOs, orders. One twentieth century exception to the
psychologists were having trouble being reim- attempt to keep mental health and religion
bursed by third parties for their professional separate was the Emmanual Movement. The
services. The insurance companies complained Rev. Elwood Worcester (1863±1940), who had a
about the fact that psychology licensing was philosophy Ph.D. from Leipzig in 1889, in 1904
usually generic and did not distinguish between became rector of the Emmanual Church in
those qualified to deliver ªhealth care servicesº Boston. In 1905, he and his colleagues
and others (such as industrial psychologists) attempted to integrate a mental health clinic
who might not have such training. For this into the activities of this church, attracting wide
reason, in 1975 psychologists established a publicity in the press. The medical community
National Register of Health Service Providers of Boston reacted somewhat adversely and
in Psychology. Each psychologist on this uncooperatively. However, historian Eugene
register had to have not only a valid state Taylor notes that the Emmanual Movement
license but also training in providing health was but ªchapter oneº of the Clinical Pastoral
services, such as a formal clinical internship. Education Movement.
In 1988 the American Psychological Society Much more recently, science-fiction writer L.
(APS), consisting mostly of research and Ron Hubbard (1950) launched ªdianeticsº as an
academic psychologists, split off from the alternative to traditional psychotherapies. In
American Psychological Association, which some respects it seems to have been modeled
was increasingly dominated by professional after psychoanalysis. Hubbard went on in 1954
practitioners. Many research and academic to establish Scientology as a church, at least in
clinical psychologists felt torn in their loyalties terms of its legal status. Shorter (1997) points out
between these two competing organizations. that Hubbard opposed ECT and that he
appointed Thomas Szasz as Scientology's ªcon-
sulting psychiatrist.º Scientologists mounted
campaigns against the use of the drug Ritalin
1.01.9.4 Social Work for children with attention deficit disorder. They
In 1917, the first National Conference on are equally against the use of Prozac.
Social Work was held in the United States. In
1917 Mary Richmond (1861±1928), a promi- 1.01.9.6 Interdisciplinary Activities and
nent figure in social work, published a book, Advocacy
Social diagnosis, which attempted to define the
nature of social case work. The existing 15 Mental health professionals cannot justify
schools of social work in the United States their existence simply as a way to make a living.
joined a new association that was established in They must demonstrate that their activites
1919. At the time, nine of them were linked to benefit their patients and society at large. One
universities and the other six to operating social of the earliest effective consumer advocates was
agencies instead, which resembled the long- Clifford Whittington Beers (1876±1943), who
standing pattern for hospital-based schools of published the book, A mind that found itself in
nursing (Leiby, 1978). Schools of social work 1908, about his own experiences as a mental
agreed among themselves in 1939 that the patient. A graduate of Yale, Beers had a mental
standard educational pattern in the field would breakdown at age 24 in which he attempted
be two years of graduate study, resulting in a suicide and was hospitalized at the Hartford
Master's degree in Social Work (MSW). Retreat. Subsequently, he experienced a manic
episode and was an inmate at the Connecticut creases in funding were also seen in Britain,
State Hospital. The book he wrote later the Scandinavian countries, and elsewhere in
described these experiences, not without some Western Europe as a part of various national
bitterness about the way he had been treated at health systems. The success of the Soviet Union
the time, and suggested the need for better in putting the satellite Sputnik in orbit in 1957
practices in this field. His advocacy was spurred the US government to even greater
endorsed by such influential figures as William efforts in funding research and training in all
James at Harvard and Adolf Meyer at Johns scientific fields.
Hopkins, and in 1909 Beers became one of the In London in 1947, the National Society for
founders of the National Committee on Mental Mentally Handicapped Children was founded.
Hygiene, an organization that still exists. The It was the first of many groups founded after
Rockefeller Brothers supplied a grant to assist World War II in various countries primarily by
the fledgling movement. parents of children with mental retardation,
A child guidance clinic, attached to the local cerebral palsy, and many other handicapping
juvenile court, was a new innovation begun in conditions. These groups proved to be quite
Chicago in 1908 by physician William Healy effective in advocating that services be provided
(1869±1963) and psychologist Grace Fernald for their children, particularly in the area of
(1879±1950). The Commonwealth Fund (estab- education. They also advocated that research be
lished by the Harkness family) in 1919 made a funded, including research on prevention. One
grant to the National Committee on Mental of the most effective of the parent-advocates for
Hygiene that supported the founding of a series persons with mental retardation was Elizabeth
of child guidance clinics around the United M. Boggs (1915±1996). Besides being the parent
States and in other countries. The Common- of a handicapped son, she was a Cambridge-
wealth Fund also provided support to several trained Ph.D. in chemistry and readily trained
child guidance clinics in England beginning in herself to follow the intricacies of government
the 1920s (Wooldridge, 1994). The typical legislation related to services and research. She
staffing of a child guidance clinic was an was therefore highly effective as a lobbyist for
interdisciplinary team consisting of a psychia- several decades.
trist, psychologist, and social worker. The usual In 1963 the Kennedy administration spon-
role of the psychiatrist was diagnostic inter- sored a bill to establish a nationwide network of
viewing and, when feasible, psychotherapy. interdisciplinary Community Mental Health
That of the psychologist was mental testing, Centers (CMHCs), which indeed came into
and that of the social worker was dealing with being and still exists. The federal government
family members and other community agencies. did not plan to continue the funding of these
As an outgrowth of the child guidance centers indefinitely and relatively quickly
movement in the United States, a new organiza- shifted their support to states and local
tion was formed in 1924 called the American communities. It is by now widely acknowledged
Orthopsychiatric Association. The Greek word that these centers were not able to provide as
ªorthoº means straight, and juvenile courts and much community support as was hoped for by
child guidance clinics were intended to help sponsors of the legislation. Many of the mental
youth ªgo straightº and avoid crime. The first patients being discharged from mental hospitals
president, not surprisingly, was William Healy. around the country were thus thrown back on
Membership was at first restricted to psychia- their own resources and those of their families.
trists but in 1926 was broadened to include all The administration of a CMHC can be in the
mental health professionals. For many years hands of persons trained in any of several
ªOrthoº has served as an interdisciplinary different mental health-related disciplines.
meeting place for practicing psychiatrists, psy- The ªantipsychiatryº movement that began
chologists, and social workers. It has also served in the 1960s was critical not only of psychiatry
as an organization advocating for the needs of proper but of the mental health establishment in
those, especially the disadvantaged, who were in general. The novel by Kesey (1962), One flew
need of mental health services. over the cuckoo's nest, criticized mental hospital
After World War II, the National Institute of treatment, focusing specifically on ECT and
Mental Health in the United States, created in lobotomy. The psychiatric nurse was portrayed
1946 and up and running in 1949, began a simply as part of an oppressive hospital team.
program of training grants for all mental health The novel was made into a movie in 1975, which
fields (Rubinstein, 1992) that lasted into the no doubt reached an even larger audience.
Reagan era of the 1980s (Benjamin, 1986). At about the same time, sociologist Erving
These funds were responsible for huge increases Goffman published his influential critique of
in the number of clinical psychologists and the mental hospital as a ªtotal institutionº in
psychiatrists who were trained. Similar in- which patients suffered numerous abasements,
degradations, humiliations, and profanations In a related US Supreme Court decision on the

(Goffman, 1961). Goffman's book was based on case of Doe v. Bolton (1973), Justice William
field work at St. Elizabeth's Hospital, a O. Douglas spoke at length about the right of
government-supported institution in Washing- an individual to be let alone, plan one's own
ton, DC at a time when about 6000 mental affairs, shape one's own life, do what one
patients were housed there. pleases, be free from bodily restraint or com-
In 1968 Bengt Nirje, director of the Swedish pulsion, and be free to work, stoll, or loaf. Such
Parents Association for Mentally Retarded words bring back memories of the Bicetre
Children, developed the concept of normaliza- Hospital in Paris in 1789.
tion, which was first applied in the field of In 1975, federal legislation was passed in the
mental retardation. The idea meant that the United States guaranteeing all children a free
goal of the service system is to assist the indi- appropriate education in the public schools,
vidual to live in as normal a way as possible, in regardless of handicapping condition. This law
spite of the presence of any handicapping con- was of tremendous importance especially to
dition: living at home, going to an ordinary parents whose handicapped children had been
school, having some kind of job or responsible excluded from the public schools or who had not
role in the household, shopping at regular stores been provided with educational accommoda-
in the community, being treated by the usual tions to their special needs. As an unanticipated
primary physicians, etc. Along with this concept side effect, this legislation fueled a tremendous
went the idea of ªself-advocacyº that indivi- amount of attention to assessing children to
duals with physical or mental disabilities should determine their eligibility for special education
themselves try to better their situation and not programs (Milofsky, 1989). Also, such special
wait for some other group such as parents or programs at times could seem very expensive to
professionals to do this for them (Shapiro, school boards, giving them reason to set up
1993). procedural barriers against such placements.
Advocacy is not just the business of parent This law was both a meal ticket and a major
groups or of those with mental problems source of frustration to clinicians working with
themselves. It is also the business of lawyers, children and to those working within the
and the mental health bar became very active in schools. These laws were revised as recently as
the latter half of the twentieth century. One 1997 under the heading of the Individuals with
important case was the suit of Wyatt v. Disabilities Education Act, which had much
Stickney, originating in Alabama in 1971. In more emphasis on mainstreaming and inclu-
this case, the court declared that mental patients sion. It is too early to see what effects and side
had a right to treatment, and that they could not effects these changes will have.
be confined in a state mental hospital without The National Alliance for the Mentally Ill
proper treatment for their condition. One side (NAMI) was founded in 1979 as a Washington-
effect of such cases was simply to speed up the based national advocacy group, consisting
course of de-institutionalization. This unfortu- largely of the parents and friends of people
nately meant that many mental patients not with major mental illness such as schizophrenia,
only did not get much treatment, they were depression, or bipolar disorder. As of 1996 it
sometimes released and had to fend for had about 130 000 members. The NAMI view
themselves as best they could, on the streets of mental illness as a type of ªno fault brain
(Isaac & Armat, 1990). disorderº successfully influenced Congress
Behaviorally-oriented token economies also and the NIMH to give greater emphasis to
sometimes ran into legal trouble. In a token biologically-oriented research in psychiatry and
economy, points are assigned to patients or psychology.
clients contingent on certain predefined appro-
priate behaviors, and these points (or tokens)
can be exchanged for preferred items or
privileges. Kazdin (1978) describes one such
1.01.10 RESEARCH ON
situation in a Missouri program sponsored by
PSYCHOPATHOLOGY IN THE
the Federal Bureau of Prisons in 1972:
TWENTIETH CENTURY
[This project] was terminated because of pending 1.01.10.1 General Paralysis of the Insane
litigation that challenged the involuntary assign-
ment of prisoners to the program without due In 1913, bacteriologist Hideo Noguchi
process, deprivation of privileges normally pro- (1876±1928), working at the Rockefeller In-
vided in prisons, aversive conditions used as part stitute, discovered Treponema pallidum (the
of treatment, and other aspects of contingencies. organism causing syphilis) in the brains of
(p. 292) paretics and patients with tabes dorsalis,
Research on Psychopathology in the Twentieth Century 21
confirming his hypothesis concerning the cause thinking, and ambivalence, with the symptom
of the disturbance (Clark, 1959). While such of loose associations being the most influential
discoveries were welcomed, they did have the concept. Psychiatrist Carl Jung was originally
effect of making the diagnosis and treatment of trained by Bleuler at the Burgholzli and early in
syphilis and of general paralysis of the insane his career participated in research on word
(GPI) the province of internal medicine rather associations in schizophrenia.
than that of psychiatry. The psychosocial as- Kurt Schneider (1887±1967), a professor of
pects of syphilis, like those of other sexually psychiatry at Heidelberg, came up with an
transmitted diseases including the AIDS virus, influential list of ªfirst rank symptomsº which
remain of interest to the behavioral sciences he considered to be characteristic of schizo-
under the new guises of behavioral medicine and phrenia. An example of such a symptom would
health psychology. be mentally hearing one's voice spoken aloud.
One of the first genetic studies of schizo-
phrenia was carried out by Hans Luxenburger
1.01.10.2 Dementia in 1928. He was a psychiatrist who worked at
Kraepelin's Institute at Munich. He searched
In 1901 the physician Alois Alzheimer, through 16 000 birth records in Bavaria and
working at a Frankfurt hospital, encountered compared them with a patient list, finding 211
a patient with a dementing condition who upon patients who were part of a twin pair. Of those
autopsy had characteristic tangles and neuritic who were monozygotic, the concordance rate
plaques in the brain. This condition is now for schizophrenia was higher than that for
known to us as Alzheimer's disease (O'Brien, dizygotic twins (Shorter, 1997, p. 241).
1996). According to Shorter (1997, p. 103), in In contrast to this approach based on
1995 a gene was discovered on chromosome 14 genetics, the German refugee psychoanalyst
and another one on chromosome 21 that were Frieda Fromm-Reichman (1899±1957) empha-
linked to Alzheimer's disease. sized the role of experiences provided the
The current focus within the behavioral developing child by the ªschizophrenogenic
sciences is probably more on the difficult mother.º Fromm-Reichman was noteworthy
situation of family caregivers of Alzheimers for her skill as a psychotherapist for patients
patients than on the dementing condition itself. with schizophrenia. She began her work at
Theirs is a high stress situation, and much Chestnut Lodge in Maryland in 1935 and was
remains to be discovered about how to offer portrayed in the novel I never promised you a
optimal support to them. rose garden as ªDr. Fried.º She was part of a
group of neo-Freudians in the United States
that included psychiatrist Harry Stack Sullivan
1.01.10.3 Dementia Praecox/Schizophrenia (1892±1949).
Psychiatrist Franz J. Kallmann (1897±1966),
The eminent German jurist Daniel Schreber who was trained at Kraepelin's Institute, fled
(1903) wrote an autobiographical account of his Hitler in 1935 to work at the New York State
nervous illness which has usually been thought Psychiatric Institute, associated with Columbia
to be schizophrenia. Schreber's story was used University. He continued his genetic research,
by Freud (1911/1959) to outline his concepts of finding higher concordance rates for schizo-
the role of homosexuality in the genesis of phrenia in monozygotic than dizygotic twins,
paranoia (with statements such as ªI love himº with the corresponding percentages being
being transformed mentally into their oppo- approximately 85% vs. 15% (Kallmann,
sites, such as ªhe hates meº). Shorter, a 1938, 1946, 1953).
biologically oriented historian of psychiatry, Seymour S. Kety and his associates were
reinterpreted the evidence to argue that Schre- involved in a Danish adoption study that was
ber may have actually suffered from neurosy- more refined in its methods than previous
philis (Shorter, 1997, p. 80). research, in part because of the quality of public
The name schizophrenia was suggested as a record keeping in Denmark. For Copenhagen
substitute for dementia praecox by Eugen adoptees with schizophrenia, this disorder was
Bleuler (1908, 1911), who was professor of found to be 10 times more common in adoptees'
psychiatry at Zurich and director of the biological relatives than in their adoptive
Burgholzli hospital there. In contrast to Krae- families (Kety et al., 1968). These findings were
pelin, Bleuler preferred to define this group of essentially replicated in the rest of Denmark
disorders in terms of their symptoms rather than (Kety, Wender, Jacpbsen, Ingraham, et al.,
relying so much on the chronic course of the 1994).
psychosis. He listed the core symptoms as Psychologist Paul Meehl (1962) presented an
including loose associations, flat affect, autistic integrative theory of how schizophrenia might
come about, under the title of ªschizotaxia, depression. Its prognosis tended to be inter-
schizotypy, and schizophrenia.º Schizotaxia mediate, that is, better than that of schizo-
refers to the hypothetical genetic predisposition phrenia but worse than that of depression.
that is considered necessary but not sufficient to
produce the disorder. Schizotypy is the beha-
vioral phenotype produced by this genotypeÐ 1.01.10.5 Depression
not necessarily abnormal, but a condition of
vulnerability to the disorder. Perhaps schizo- It was thought at first that phenothiazine
types find interpersonal relationships a bit more medications might be rather specific to schizo-
aversive than others do, or manifest some phrenia rather than depression, supporting the
subclinical cognitive slippage on occasion, but validity of the distinction between these two
nothing symptomatic. Full blown schizophrenia groups of disorders. However, it turned out that
is what is seen when a schizotype is subjected depression also responds well to such medica-
to certain stressful physical or psychological tions (Klein & Fink, 1962).
conditions. Psychiatrist A. T. Beck was one of the first to
Psychiatrist Manfred Bleuler, the son of elaborate a theory explaining how the way a
Eugen Bleuler (who had coined the term person thinks could contribute to depression,
ªschizophreniaº), was like his father a professor for example, negative thoughts about oneself,
in Zurich. M. Bleuler published a study of 208 the world, and the future, and cognitive
patients with schizophrenia whom he had distortions such as making internal, global,
followed up for over 20 years (M. Bleuler, and pervasive attributions for negative events
1972). This study confirmed the belief that the (ªthis happened because of me,º ªI am that way
disorder was quite variable in its course and about everything,º ªthat is just the way I amº)
outcome. He was not, however, able to realize (A. T. Beck, 1963).
his ambition of uncovering a Mendelian etiology Psychologist Martin Seligman linked up his
for schizophrenia, which continues to be research on experimentally produced learned
elusive. helplessness in dogs with similar phenomena
Psychologist Philip Holzman and his collea- seen in humans and moved into research on
gues showed that patients with schizophrenia helplessness and human depression (Seligman,
and their first-degree relatives were more likely 1975).
to have abnormal smooth pursuit eye move-
ments than control subjects (Holzman et al.,
1973). In this procedure, patients are simply 1.01.10.6 Neurosis, Including Anxiety
asked to try to follow a moving pendulum with
their eyes. The abnormality consists of a jagged Janet and Raymond (1903) in France wrote
pattern of eye tracking rather than a smooth one. about obsessions and psychasthenia (which
The finding has been replicated by other literally translates as ªmental weaknessº). Janet
investigators and turns out to be a ªtrait markerº considered psychasthenia to be characterized by
that does not change when an individual pathological feelings of inadequacy.
decompensates into psychosis or recovers from One interesting new development was the
schizophrenia. The research provides further discovery of the phenomenon of ªexperimental
support for some kind of genetic hypothesis neurosis.º According to Kazdin (1978), in 1912,
concerning schizophrenia. Mariya N. Yerofeyeva (1867±1925) was doing
For a time, the ªdopamine hypothesisº research in the St. Petersburg laboratory of Ivan
concerning schizophrenia was a serious scientific Pavlov (1849±1936), conditioning a dog. As
contender (see e.g., Snyder, 1976). The appeal of usual, the unconditioned stimulus was food-
this notion was that virtually all of the effective powder and the unconditioned response was
neuroleptic medications seemed to have in salivation. In this case the conditioned stimulus
common the property of blocking dopamine was a mild electric shock on the dog's skin,
receptors in the brain. When other equally which might be expected to elicit defensive
effective antipsychotic drugs such as clozapine reactions competing with salivation. Still, the
were discovered that did not block dopamine, conditioning was going well up until the point
the idea lost some of its attractiveness. when the shock was administered to one new
location after another on the animal's skin.
When this was done, conditioning broke down,
1.01.10.4 Schizoaffective Disorder and the animal developed a lasting disturbance
of its overall behavior. In 1913 another of
This term was coined by Russian psychiatrist Pavlov's co-workers made a similar discovery.
Jacob Kasanin in 1933 to describe a condition Nataliya R. Shenger-Krestikovnikova (1875±
with symptoms of both schizophrenia and 1947) was conditioning a dog to discriminate
between a circle and an ellipse. The dog was able disorder, as a condition distinct from depres-
to do so at first, but conditioning broke down sion, also did not respond to chlorpromazine
when the discrimination became too difficult (Klein, 1964; Klein & Fink, 1962).
and was replaced by enduring disturbed
behavior (Pavlov, 1927).
John Watson (1878±1958) and Rosalie Ray- 1.01.10.7 Shell Shock/Post-traumatic Stress
nor (1898±1935) published in 1920 their study of Disorder
ªlittle Albertº that is by now well known W. H. R. Rivers (1864±1922), a British
(Watson & Raynor, 1920). The child was physician, experimental psychologist, and
repeatedly presented with a furry animal in anthropologist, became involved in treating
the presence of a loud noise and evidently the war neuroses referred to as ªshell shockº
learned to fear the animal and other objects during World War I and soon developed the
similar to it as a result of this experience. The view that they were psychologically based rather
authors presented the study as a demonstration than being simply a mechanical result of combat
of how phobias might originate. Watson (1913) trauma (Ackerknecht, 1942). This view is
had presented behaviorism as a ªpurely objec- preserved in the present concept of post-
tive experimental branch of natural science. Its traumatic stress disorder (PTSD).
theoretical goal is the prediction and control of
behaviorº (Watson, 1913, p. 158).
Behaviorists were not the only ones con- 1.01.10.8 Stress
tributing to the study of the phenomena
Stress is not in itself considered a type of
underlying neurotic behavior in this era. Anna
psychopathology but is considered a risk factor
Freud (1895±1982) published a well-received
not only for psychopathology but also for
book on The ego and the mechanisms of defense
various types of physical illness. One of the
in 1937. Neurotic symptoms were interpreted as
more influential researchers in this field is
functioning as defensive maneuvers to ward off
psychologist Richard S. Lazarus (1966). His
anxiety.
writings define stress as a set of demands that
The psychoanalyst J. H. Masserman (1943)
exceed the adaptive capacity of the person. It is
did experiments with cats, putting them into
important to know not only the physical
approach-avoidance conflict situations. This
characteristics of the stressful situation but
work contributed to the thinking of subsequent
how these are appraised by the individual, and
behavioral researchers concerned with neurotic
what coping strategies are adopted to try to deal
behaviors who, however, did not necessarily
with the stress.
accept some of Masserman's psychoanalytic
speculations about his findings. Indeed, both
psychoanalysis and behaviorism remain for the 1.01.10.9 Psychosomatic Disease
most part mutually isolated systems of thought
to this day. Physician Flanders Dunbar (1902±1959)
Howard S. Lidell (1895±1962) at Cornell wrote a book on the personality factors she
University in 1956 reported research producing considered to underlie ulcers, colitis, asthma,
ªexperimental neurosisº in dogs, sheep, goats, and coronary heart disease (Dunbar, 1938). The
and rabbits. This showed that the phenomenon theory that certain ªpsychosomaticº illnesses
was not specific to dogs nor to the particular exist (e.g., the concept of ªthe ulcer person-
procedures used in Pavlov's laboratory. alityº) was subsequently rejected by many. It
After World War II, the psychoanalytic would be more accurate to say that this notion
approach to neurosis took a turn toward ªego was broadened into the idea that behavioral and
psychology,º recognizing the existence of a psychosocial factors probably have some im-
relatively conflict-free sphere of functioning portance in most medical conditions. In a later
that was little affected by neurotic disorders era, Drotar (1981) summarized some of the new
(Hartman, Kris, & Loewenstein, 1946). approaches taken by ªpediatric psychologistsº
In 1969 British psychiatrist Isaac M. Marks in studying and helping children with chronic
published an influential article suggesting that medical illness.
there might be important genetic factors in fear
and anxiety disorders including agoraphobia, 1.01.10.10 Anorexia Nervosa and Bulimia
panic disorder, and obsessive-compulsive dis-
order. In the 1960s and 1970s there seemed to be a
Psychiatrist Donald F. Klein found in his marked increase in the prevalence of self-
research on psychopharmacology that anxiety starvation and other eating disorders, particu-
patients (unlike those who were depressed) did larly among young women from socially
not get better on chlorpromazine. Panic advantaged backgrounds in the United States
and Europe. Scholars unearthed a case history behavior, and others. Also included in the
of this kind of anorexia nervosa dating back to study were subjects who had been children in
the seventeenth century, written by Richard St. Louis at the same time but were not referred
Morton (1637±1698), physician to King James to such a clinic. The follow-up was exceedingly
II. An eating disorder known as bulimia nervosa thorough and involved a personal interview
also was characterized during the 1970s, con- using standardized questions and a coding
sisting of ªbingingº episodes in which large system that later served as a model for the
quantities of food were eaten, followed by Diagnostic Interview Schedule (DIS) to be used
ªpurgingº or self-induced vomiting (Russell, with DSM-III. Also, data from the subjects'
1979). The abuse of laxatives is also sometimes a military service records, Social Security earn-
part of bulimia. ings records, the county sherriff's office, and
many other such databases were accessed. The
main finding of the study was that antisocial
1.01.10.11 Borderline Personality Disorder children tend to become antisocial adults, many
of them qualifying for classification as psycho-
In former times the phrase ªborderlineº
paths (DSM Antisocial Personality Disorder) in
referred to an individual with difficulties
adult life.
resembling schizophrenia but not being quite
The stability of aggressive behavior from
severe enough to deserve that label. Subse-
childhood to adulthood was confirmed in a
quently, borderline came to refer to a person-
prospective longitudinal study using peer-rat-
ality trait in which an individual had an
ings of third-grade school children as a means of
impaired sense of identity and problems with
selecting the subjects. This was carried out by
the boundaries of self. Suicide threats were
psychologist Leonard Eron and his colleagues
observed to be common in this condition.
(e.g., Huesmann et al., 1984).
Psychoanalyst Otto Kernberg (1967, 1975)
was one of the first influential writers on what
he called ªborderline personality organization.º
In the Diagnostic and statistical manual of 1.01.10.13 Substance Abuse
mental disorders (American Psychiatric Asso-
Some drugs have a dual history of being
ciation, 1980), the condition was labeled as
introduced as a treatment or as a means of
borderline personality disorder (BPD).
studying psychopathology, and then later to
become abused substances. Such was the fate of
1.01.10.12 Antisocial Behavior cocaine, which Freud to his lasting regret at one
time recommended to a friend as a helpful
An early example of basic research on treatment. The friend became addicted and died
aggressive behavior was that of John Dollard from an overdose (Gay, 1988). A more recent
(1900±1980), Leonard Doob, Neal E. Miller, O. example would be lysergic acid diethylamide
H. Mowrer (1907±1982), and R. R. Sears, (LSD), discovered in 1943 and once considered
reported in their 1939 book, Frustration and promising as a method of gaining insight into
aggression. the nature of psychotic hallucinations. As
On the clinical side, psychiatrist Hervey M. Shorter (1997, p. 265) comments, LSD had
Cleckley published in 1941 an influential book, ªno clinical payoffsº and became a ªstreet drug
The mask of sanity, trying to define the of abuse.º
characteristics of a psychopath. Cleckley felt
that one could not reliably diagnose this
condition on the basis of an interview because 1.01.10.14 Sexual Dysfunction
many psychopaths were so skilled at deception.
Instead, one had to look at the way the person In 1966, gynecologist W. H. Masters and
behaved in life, disregarding rules and exploit- psychologist Virginia Johnson published their
ing other people. book on human sexual experience, including
A classic study on the stability of antisocial reports of direct observation of sexual activity
behavior from childhood to adulthood was and physiological recordings during such
published in 1966 by sociologist Lee Robins events. Their work elucidated aspects of normal
under the title, Deviant children grown up. She sexual response that had previously not been so
followed up, approximately 30 years later, a well understood, for example, female vaginal
cohort of children originally seen for diagnostic lubrication during sexual arousal. It also
purposes in a St. Louis child guidance clinic. A provided new understanding and treatment
relatively crude classification was made on the recommendations for various types of sexual
basis of the presenting complaint, so that there dysfunction, for example, dyspareunia (Masters
were those who presented with antisocial & Johnson, 1966).
1.01.10.15 Mental Retardation and retardation. Skeels later published long-

term follow-up data on some of these children,
H. H. Goddard (1912) wrote a book about a which indicated that they tended to retain their
family he chose to call the Kallikaks (combining intellectual gains in adult life.
the Greek words for good and bad). The Psychiatrist George Tarjan (1912±1991) and
pedigrees of two branches of the family of his colleagues at Pacific State Hospital in
ªMartin Kallikakº were presented, one with California, an institution for persons with
considerable mental retardation among its mental retardation, collaborated with collea-
members, the other without this pattern. The gues at University of California at Los Angeles
book has been derided as an example of a lack of and the University of California at Riverside to
rigor in its attempted analysis of genetic develop a federally funded research program on
patterns (ªlook and say Mendelismº). The the social epidemiology of mental retardation.
charge was even made that some of the This work continues today well after the end of
published photographs were altered to reveal Tarjan's life.
their physical stigmata more clearly. It is also In support of the role of experience in long-
possible that the changes in the photographs term intellectual development, British psychol-
were made, in all innocence, to correct the ogists A. D. B. Clarke and Ann M. Clarke
fuzziness of some of the pictures (Fancher, published some interesting findings in their 1958
1987). book. Their work suggested that individuals
Eugenic approaches to mental retardation, from highly deprived backgrounds may be quite
considered anathema today, were widely en- retarded in their early development but have the
dorsed by professionals and the public earlier in potential for considerable gradual improvement
this century. In a famous case, Buck v. Bell when placed in more favorable surroundings
(1927), the US Supreme Court even endorsed (Clarke & Clarke, 1958).
the use of involuntary sterilization for this The publication of psychologist Norman R.
purpose. Oliver Wendell Holmes, the chief Ellis's 1963 edited book, Handbook of mental
justice, was quoted as saying ªthree generations deficiency: Psychological theory and research,
of imbeciles is enough.º catalyzed the development of new research in
Torsten Sjogren, a Swedish geneticist, estab- the behavioral sciences relevant to mental
lished in 1931 that Tay Sachs disease is a retardation. In 1968, Ellis organized the annual
Mendelian recessive condition (Sjogren, 1931). Gatlinburg Conference as a meeting place,
This disorder involves blindness, deteriorating mainly for research psychologists interested in
mental functioning, and death commonly by mental retardation and developmental disabil-
three years of age. The British geneticist Lionel ities.
S. Penrose (1898±1972) was responsible for In 1959, physician Jerome Lejeune
summarizing for his readers material on both (1926±1994) reported his discovery that Down's
biometric and molecular genetics as related to syndrome was generally characterized by an
mental retardation (Penrose, 1951). Philip extra copy of chromosome number 21 (Hecht,
Levine (1900±1987) and Alexander S. Wiener 1994). This was but the first of a long list of
(1907±1976) elucidated the mechanisms by chromosomal anomalies to be reported over the
which Rh factor incompatibilities in the blood next few years, many of which were associated
between the mother and fetus can produce fetal with mental retardation.
death or mental retardation. A team of researchers at the University of
Psychologist Edgar A. Doll and his collea- Washington in Seattle established an associa-
gues published research implicating birth in- tion between a particular syndrome of mal-
juries as being responsible for a certain formation in the offspring of alcoholic women
proportion of the cases of mental retardation (Claren & Smith, 1978; Jones, Smith, Ulleland,
(Doll, Phelps, & Melcher, 1932). & Streissguth, 1973). The syndrome, which was
In the 1930s, psychologist Harold M. Skeels dose-related in severity, is known as fetal
(1901±1970) and his colleagues published the alcohol syndrome (FAS) or (when milder) fetal
well-known ªIowa studiesº in which infants alcohol effect (FAE). FAS is associated with
from an orphanage experienced large positive mental retardation and other learning problems
changes in IQ after being transferred to an as well as behavior disorders in childhood and
environment where they received more atten- later life.
tion and stimulation. These were not controlled Anthropologist Robert Edgerton in 1967
studies and elicited strong criticism from Ter- published an ethnographic study of a cohort
man and others in the hereditarian camp. of persons released after institutionalization for
Nevertheless, the studies were the beginning diagnosed mental retardation. Virtually none of
of a long tradition of research on the effects of them accepted such a self-label. Their method of
early experience on intellectual development coping with the stigma of this diagnosis
involved drawing around themselves a protec- They were first referred to as ªbrain injuredº
tive ªcloak of competenceº and enlisting what (Strauss & Lehtinen, 1947), but later were said
Edgerton called ªbenefactorsº in the commu- to suffer from minimal brain dysfunction
nity to help them do so. (MBD).
The book, The bell curve, written by Herrn- In 1957 psychiatrist Max Laufer and pedia-
stein and Murray (1994), repeated Jensen's trician Eric Denhoff redefined a part of what had
arguments concerning the genetic basis of racial been considered to be MBD as a hyperkinetic
differences in intelligence test scores. Once behavior syndrome in children (Laufer &
more, the wrath of both professionals and Denhoff, 1957). They advocated the treatment
journalists was elicited. The general consensus of this behavior disorder with amphetamines.
in the field is that such conclusions are not An early description of such behavior problems
warranted by available data. by British physician G. F. Still (1902) was soon
rediscovered. Psychologist Virginia Douglas at
McGill University in Canada was soon to argue
1.01.10.16 Autism convincingly in the 1960s and 1970s that the
main problem for these children was one of
The child psychiatrist Leo Kanner
inattention rather than hyperactivity. Thus, it
(1894±1981) was the first to describe a syndrome
came to be that the current terminology for this
he originally called infantile autism, character-
common childhood problem is attention deficit
ized by extreme social withdrawal and impair-
hyperactivity disorder (ADHD) (Barkley, 1990).
ments in cognition and language. His basis for
doing so was a series of 11 case histories of
children he had seen in the Harriet Lane Home 1.01.10.18 Learning Disabilities
of Johns Hopkins University Medical School,
where he was a professor (Kanner, 1943). In England, physician James Hinshelwood
Kanner and Eisenberg (1956) followed up, nine (1900) published a case of a child with what he
years later, 63 children who had been diagnosed called ªcongenital word blindness,º interpreted
as having early infantile autism. They found the as a developmental variation of the adult
child's language at age five to have great neurological disorder of alexia. Psychologist
prognostic significance. Those who had no Edmund B. Huey (1908) wrote a classic
language at age five rarely improved, while monograph on the psychology and pedagogy
those who were able to speak at age five did of reading (reprinted by the MIT Press). Samuel
much better at outcome. T. Orton (1928, 1937), a psychiatrist and
Psychologist Bruno Bettelheim (1903±1990) neuropathologist at the University of Iowa,
viewed infantile autism in psychoanalytic terms reviewed similar cases he had seen of children
and tended to ªblameº the parents for causing it, with ªspecific reading disability,º which he
even comparing the autistic child's early experi- hypothesized to result from ªstrephosymbolia,º
ences to those of concentration camp victims a lack of proper lateralization in the brain that
(e.g., Bettelheim, 1950, 1967). Such views are leads the child to confuse mirror images such as
part of the explanation for his advocacy of b and d with each other. Orton also noted the
separating these children from their parents in association of reading, writing, and speech and
order to facilitate their treatment. language problems in children.
Educator Samual A. Kirk (1904±1996) was
the person who coined the term ªlearning
1.01.10.17 ªMinimal Brain Dysfunctionº disabilitiesº which served as a rallying point
(MBD)/ADHD for parent groups as well as for researchers and
practitioners since the 1960s. He was also
Neurologist Alfred A. Strauss (1897±1957),
among the first to do experimental research in
who was associated with a residential treatment
special education (Kirk, 1952).
center for children at Northville, Michigan,
carried out research in the 1930s and 1940s on
what was originally labeled as endogenous vs. 1.01.10.19 Child Abuse and Neglect
exogenous mental retardation. The term ªen-
dogenousº referred to children who functioned The problem of abuse and neglect of children,
at a delayed level but appeared to be physically including sexual abuse and psychological abuse,
normal, whereas ªexogenousº meant that there is ancient. It had long been the special concern of
was some kind of evidence suggesting neurolo- child welfare social workers, who are responsible
gical dysfunction. Subsequently, the emphasis for attending to the needs of family preservation
changed toward children without mental re- and foster home placement when abuse is
tardation but who had subtle difficulties that detected. The ªbattered babyº syndrome was
were presumed to be of neurological origin. rediscovered by the medical community in the
Research on Assessment in the Twentieth Century 27
early 1960s, and many state laws were soon recruits upon entry of the United States into
passed requiring professionals to report sus- World War I. Robert M. Yerkes (1876±1956)
pected abuse. Eventually other professionals and his colleagues developed the Army Alpha
such as psychologists and psychiatrists were and Beta tests for this purpose and tested 1.7
drawn into professional activities related to million men. After the war, the industrial and
abuse. One influential and scholarly book in this educational uses of mass testing were devel-
area was that written by sociologist David oped, and testing became big business. Reason-
Finkelhor (1984). ing that mental age scores would not be useful
for evaluating adults, Yerkes and other collea-
gues had earlier developed a ªpoint scaleº in
1.01.11 RESEARCH ON ASSESSMENT IN which each item passed was simply given unit
THE TWENTIETH CENTURY weight (Yerkes, Hardwick, & Bridges, 1915).
Lewis M. Terman (1877±1956), a psychology
1.01.11.1 Intelligence professor at Stanford University, developed a
more standardized version of the Binet±Simon
James McKeen Cattell was a key figure in the test and collected normative data with it.
early development of psychological assessment Terman's revision, known as the Stanford±
in the twentieth century. A disciple of Francis Binet (Terman, 1916), made use of ratio IQ
Galton, he originally tried to promote brief scores derived by dividing mental age by
measures of basic psychological processes: chronological age and multiplying by 100.
sensory, motor, reaction time, and the like. The use of such a mental ratio score had been
His project to demonstrate the utility of such suggested by German psychologist Wilhelm
measures in college admissions at Columbia Stern in 1912 (English translation, Stern, 1914).
University failed, however. Terman soon began his ªgenetic studies of
In trying to demonstrate the presence of a geniusº (Terman, 1925) in which he followed up
general factor (g) underlying academic and children with high Stanford±Binet scores. While
intellectual abilities, Charles E. Spearman few of them really turned out to be geniuses,
(1863±1945) originated the mathematical pro- these children indeed had high levels of
cedure that came to be known as factor analysis academic, vocational, and social accomplish-
(Spearman, 1904). Godfrey Thomson (1881± ments later in life, validating the test as a
1995) effectively critiqued Spearman's mathe- predictor of such long-term outcomes (Terman
matical procedures by showing that one could & Oden, 1947).
obtain similar evidence for a g factor based on a In England, the mathematician R. A. Fisher
matrix of random numbers (Thomson, 1919). and others working in agriculture went beyond
Although Spearman's particular approach to descriptive statistics to develop the inferential
factor analysis was soon superseded by others, approach, which eventually revolutionized
his concept of g remains somewhat influential. both psychometric testing and experimental
The psychologist Alfred Binet (1857±1911) psychology.
and his psychiatrist colleague Theodore Simon The issue of test scores and race, class, and
(1873±1961) developed an intelligence test national origin became a major one after World
(Binet & Simon, 1905) that successfully dis- War I, with IQ being interpreted by many as
tinguished children with mental retardation being more inherited than learned. The US
from others whose mental development was government restricted immigration, and many
normal. They did so by using tasks that states passed ªeugenicº sterilization laws. In
resembled what children actually do in school, 1936 the Soviet government reacted in the
rather than simple sensory-motor processes. opposite direction and put forth a decree
Binet and Simon originated the practice of banning the use of intelligence tests and all
representing a particular test score in terms of such ªpedologicalº measures. One objection to
ªmental age.º the use of such measures was that they appeared
Psychologist Henry H. Goddard to discriminate against individuals from prole-
(1866±1957), who had been appointed research tarian backgrounds as compared to children of
director at the Vineland Training School in New bourgeois parents and against members of
Jersey in 1906, learned of the Binet±Simon test various ethnic minorities within Soviet society.
on a European trip and by 1908 had it translated Oddly enough, among the researchers whose
into English (Doll, 1988). He readily confirmed writings were banned at this time was psychol-
the ability of the test to discriminate the ogist Lev S. Vygotsky (1896±1934). Vygotsky
performance of persons with mental retardation had done research on the influence of cultural
from that of others. factors on intellectual development and spoke
The use of intelligence tests on a broad scale of the ªzone of proximal developmentº as the
first began with the mass testing of military area for educational focus with a child. When
his complete writings were later published, missing or flawed. Thus, Meyer began a lifelong
Vygotsky became one of the more influential concern with developing adequate methods for
scientists arguing for environmental influences the psychiatric assessment and classification of
on intelligence (Kozulin, 1990). patients. He continued this preoccupation in
It was ultimately psychologist David Wechs- subsequent positions at the Worcester Asylum
ler (1896±1981) who developed the intelligence (now Worcester State Hospital) in Massachu-
test into the standardized form best accepted in setts and ultimately as professor of psychiatry at
the United States and other countries in the the Johns Hopkins University. Meyer's stan-
West (Wechsler, 1939). Wechsler agreed with dardized descriptions of psychiatric syndromes,
Yerkes and his associates that mental age scores or ªreactionº patterns as he called them, became
were not useful for adults. well known. Incidentally, Meyer was also
Psychologist Raymond B. Cattell (1905± interested in therapeutic methods and began
1998) (not to be confused with J. McK. Cattell) applying psychoanalysis within a New York
attempted to develop ªculture freeº intelligence state hospital as early as 1902.
tests. His theory distinguished between ªfluidº After World War II, many professionals were
and ªcrystallizedº ability. Fluid ability refers to critical of psychiatric categorical diagnoses
one's performance on relatively novel tasks such because of their low reliability (e.g., Stengel,
as the Raven's Progessive Matrices, which has 1959). Shorter (1997, p. 297) refers to Stengel's
been found to fall off more steeply with age than article as ªthe opening cannon in the campaign
crystallized ability, which refers to more to revise diagnosis.º The group of psychiatrists
practiced skills such as vocabulary. at Washington University in St. Louis were
In 1969, Arthur R. Jensen, a professor of particularly influential in advocating a more
psychology at Berkeley, published an article in rigorous approach to diagnosis. John P.
the Harvard Educational Review that was widely Feighner, the chief psychiatric resident at
reviled both by many of his professional Washington University at one point, published
colleagues and by the public (Jensen, 1969). the standardized research criteria in use in the
Essentially, Jensen argued that efforts at Department of Psychiatry there (Feighner et al.,
compensatory education had failed. He implied 1972). These ªFeighner criteriaº rapidly came
that differences in IQ scores among different into use by others, especially research psychia-
racial and ethnic groups might be hereditary in trists and psychologists. An intermediate step
nature and difficult to change. Such interpreta- between the use of Feighner criteria and the
tions of the data on IQ and race were not DSM-III was constituted by the ªresearch
uncommon in an earlier generation of beha- diagnostic criteriaº promulgated by Spitzer,
vioral scientists but certainly had become Endicott, and Gibbon (1978).
politically unacceptable by the 1960s. British child psychiatrist Michael Rutter, in
Psychologist L. J. Kamin (1974) counter- his Isle of Wight studies in 1975, demonstrated
attacked and charged psychologists of the past the applicability of rigorous epidemiological
such as Henry Goddard and L. M. Terman and methods in this field. As part of this work he
present day psychologists such as Arthur Jensen devised standardized psychiatric interviews for
and Cyril Burt with holding racist attitudes. parents and children and standardized teacher
Kamin also charged Cyril Burt with fabricating rating forms. He showed a concern with
data in his widely cited research on intelligence assessing the reliability and validity of these
in twins reared apart. Careful examination of methods and also was among the first to
Burt's data by others suggested that these advocate the use of a multiaxial classification
charges had merit. system.
Psychologist David Rosenhan published a
1.01.11.2 Categorical Diagnosis of Mental striking study using ªpseudopatientsº who
Disorders gained admission to mental hospitals on the
basis of faked auditory hallucinations (Rosen-
Adolf Meyer (1866±1950) was probably the han, 1973). They began to act in their usual way,
most influential American psychiatrist of his denying any such symptoms, immediately upon
day. Trained in Switzerland in neuropathology admission to a mental hospital. It typically took
and psychiatry, he began work in 1893 as a staff the hospital a matter of weeks to discharge
pathologist at Illinois Eastern Hospital in them, and even so the hospital psychiatric staff
Kankakee (Winters, 1966). He was frustrated tended to render discharge diagnoses such as
in his task from the beginning because of the ªschizophrenia in remission.º For many, this
poor quality of the case records. It was no use brought the credibility of the traditional
trying to establish the correlation of brain diagnostic system even more into question.
autopsy findings with clinical symptoms if the A task force of the American Psychiatric
accounts of what the patient was like in life were Association soon began work on what was to
become in 1980 a thorough revision of its used by lay interviewers, to generate DSM-III
Diagnostic and statistical manual. One issue that diagnoses. The corresponding standardized
emerged in the discussion was the question of interview for use by clinicians is called the
whether homosexuality should be included in Structured Clinical Interview for Diagnosis
the revised manual as a ªmental disorder.º Gay (SCID). These procedures have unquestionably
advocacy groups were unhappy that homo- increased the reliability of diagnosis for research
sexuality had been included in the DSM-II in purposes, though the question of validity
1968. There was evidence, for example, from the remains a perennial one.
research of psychologist Evelyn Hooker
(1907±1996) (e.g., Hooker, 1969), that homo- 1.01.11.4 Self-report Measures of Personality
sexuality was compatible with the absence of and Psychopathology
symptoms of any disorder (unless one wished to
regard sexual orientation itself as a symptom). One of the first measures of this kind was the
To make a long story short, the DSM-III Personal Data Sheet developed by psychologist
taskforce decided to delete homosexuality from Robert S. Woodworth (1869±1962), a professor
the manual, and the American Psychiatric at Columbia University, for military use during
Association affirmed this in an unprecedented World War I (Woodworth, 1917). The items
referendum in 1974. were rationally selected, mainly from psychia-
Psychologist Theodore Millon lobbied in the tric textbooks, and not initially subjected to
DSM-III taskforce to include a separate axis for empirical validation procedures. Thus, the
personality disorders, a suggestion that it content of this questionnaire was based on
ultimately implemented, though it did not descriptive psychopathology, as developed over
define many of the personality disorders pre- the entire preceding century.
cisely as Millon may have wished. The Minnesota Multiphasic Personality In-
According to Reisman (1991), the original ventory (MMPI), developed by psychologist
Diagnostic and statistical manual (DSM) of the Starke R. Hathaway (1903±1984) and psychia-
American Psychiatric Association in 1952 listed trist J. C. McKinley in the 1930s and 1940s (e.g.,
60 disorders. The DSM-II in 1968 listed 145, Hathaway & McKinley, 1940, 1943), was
and DSM-III in 1980 listed 230 of them. It innovative in several ways. For one thing, the
remains to be seen how well justified this clinical scales of the MMPI were empirically
inflation of the number of categories was. It is validated using psychiatric patients with parti-
certainly easier to diagnose the broader cate- cular diagnoses as criterion groups and visitors
gories reliably than it is the narrower ones. to the University of Minnesota hospitals as a
Considerable information has been collected on control group. Also, the MMPI contained
the reliability of the newer DSM categories, and several innovative ªvalidity scalesº that could
they do seem to be more reliable than their be used to identify subjects who might be too
counterparts in the earlier versions of the DSM. confused to give reliable answers, who could not
Although the validity of categories of descrip- read well enough to use the test properly, or who
tive psychopathology is a perennial issue, it is were trying to present themselves to the
clear that they can be made more reliable by examiner in an unduly favorable or unfavorable
standardizing the questions asked, the way the light. The MMPI quickly became one of the
answers are coded, as well as the way the most frequently used assessment procedures of
information is combined. its kind. The thousands of empirical studies
conducted with it ultimately gave it even more
1.01.11.3 Interviews credibility than it acquired from its initial
method of validation.
Informal interviewing surely goes back to the Psychiatrist A. T. Beck published the first
dawn of medicine as well as that of philosophy. article describing the Beck Depression Inven-
A Socratic dialogue is after all a type of tory (BDI) in 1961 (A. T. Beck, Ward, &
interview. This is no doubt the most common Mendelsohn, 1961). This theoretically based
ªassessmentº procedure used by mental health scale came into extremely wide use and has
professionals and is often the only one used. It recently been revised.
was only recently, however, that standardized Exploiting the conceptual distinction be-
interviews began to be developed to increase the tween ªstateº and ªtraitº measures, psycholo-
reliability and validity of clinical judgment. gist Charles Spielberger and his colleagues
Psychiatrist Max Hamilton (1960) published a devised and validated separate pencil and paper
standardized, interview-based rating scale for questionnaires to measure these two different
depression that is still in common use. Sociol- types of anxiety (Spielberger, Gorsuch, &
ogist Lee Robins and her colleagues developed Lushene, 1970). Part of the innovation in these
the Diagnostic Interview Schedule (DIS), to be questionnaires is simply in the way the items are
worded. For example, one might ask ªdo you was both a psychologist and a physician,
have butterflies in your stomach at this developed one of the earliest tests of this kind,
moment?º (state) vs. ªdo you frequently get with 195 items for infants ranging in age from 3
butterflies in your stomach?º (trait). A state to 30 months and others for babies up to age 60
anxiety measure might be more useful in months (Gesell, 1929). However, scores on these
assessing a person's response to having blood infant tests proved to have very little long-term
drawn in a medical clinic while a trait measure stability and thus were mainly of use for
would be a better choice in assessing neurotic research purposes.
anxiety. The most widely used method for assessing
infants, developed by psychologist Nancy
1.01.11.5 Rating Scales Bayley (1899±1994), is known as the Bayley
Scales of Infant Development (BSID) (Bayley,
In 1962, psychologist Lester Luborsky pub- 1955, 1969).
lished an article on his Mental Health/Sickness
Rating Scale. This work was incorporated by 1.01.11.7 The Rorschach Test
Endicott and Spitzer (a psychologist±
psychiatrist team) in their Global Assessment Swiss psychiatrist Herman Rorschach
Scale (GAS), which was developed in 1976. In (1884±1922) published the manual for his
this scale, a score of 0 would be given if the famous inkblot test in 1921, the year before
patient had died by suicide and a score of 100 if his death, and did not have a chance to follow
the individual showed superior functioning in up on his initial work. He had tried out the
every area of life. The current DSM uses a procedure with patients suffering from various
further revised version of this called a Global types of psychopathology as well as normal
Assessment of Functioning (GAF) scale, which controls. Rorschach originally had a plan of
has been shown to be quite reliable. using 15 blots but could only get the publisher
Psychologist C. Keith Conners developed a to print 10 blots, and the blots unexpectedly
teacher rating scale in the 1950s primarily for were printed including varying shades of gray.
use in research on the efficacy of stimulant Nevertheless, interpreters managed to capita-
medications with behavior disordered children. lize on every serendipitous development of this
This scale soon came into wide use for kind. Many of Rorschach's original interpre-
diagnostic purposes as well as being commonly tive hypotheses are still considered valid by
employed as a treatment outcome measure. It many present users of the procedure, most of
continues to be in use today. Conners also whom are psychologists of a psychodynamic
developed parallel scales for use with parents persuasion.
and for reports by the young persons them- Samuel J. Beck, who did his Ph.D. disserta-
selves. tion at Columbia on the Rorschach, went on to
Psychologist Thomas Achenbach and his try to objectify the scoring methods most
colleagues developed and validated an inte- frequently selected for response and collected
grated set of rating scales for assessing child norms on the frequency of different perceptions
psychopathology, including the Child Behavior of these areas. It was then possible to score
Checklist (for parent ratings), a Teacher Report ªform qualityº (perceptual accuracy, thought to
Form, and a Youth Self-report scale. Many of be lowered in schizophrenia) on the basis of
the items of these scales are parallel, and thus, these norms (e.g., S. J. Beck, 1937, 1944).
cross informant syndromes can be characterized In 1961, psychologist Wayne Holtzman and
by combining the scores from all three types of his colleagues published a new inkblot test that
informants. The development of a sizable had a more standardized procedure for admin-
database using these scales provided a new istration than the Rorschach test. The Holtz-
perspective on the classification of child psy- man test had clearer rules for scoring and
chopathology as well as its measurement provided norms for various patient groups and
(Achenbach & Edelbrock, 1978). This approach for the general population (Holtzman Thorpe,
has become widely influential, especially in the Swartz, & Herron, 1961). Despite its superior
research community concerned with child and psychometric properties, this test was not
adolescent psychopathology. frequently used in clinical evaluation. It was
considered too lengthy and cumbersome.
1.01.11.6 Infant Assessment
1.01.11.8 Human Figure Drawings
Standardized procedures were soon devel-
oped for testing infants which superficially During the 1920s, psychologist Florence L.
resembled those of intelligence tests for older Goodenough (1886±1959) at the University
children. Arnold L. Gesell (1880±1961), who of Minnesota developed and validated a
standardized way of scoring a child's drawing of judged by a knowledgable informant. Such

a man (Goodenough, 1926). This had some use information soon became a part of the way
as a brief cognitive screening procedure, for mental retardation was defined.
example, with kindergarten children and in
cross-cultural research, but is not often con-
sidered to be of much practical clinical value. 1.01.11.12 Assessment of Marital and Family
In 1948, psychologist Karen A. Machover Relationships
(1902±1996) wrote a book on the use of human Psychologist Richard Abidin developed an
figure drawings as a brief projective test. Unlike innovative measure called the Parenting Stress
Goodenough, Machover did not formally Index (PSI) (Loyd & Abidin, 1985). This work
validate her procedure but simply shared with recognized the increasing realization in the field
readers her speculations about how such that not only parents have effects on their
drawings might be interpreted. Human figure children. Children's behavior also affects their
drawings of this kind have come into very parents as well, and a difficult child can be a
common use, particularly in the assessment of major source of parental stress.
children. Psychologists Loren and Jean Chap-
man (1967, 1969) demonstrated that people
trying to interpret such human figure drawings 1.01.11.13 Neuropsychological Measures
are subject to the phenomenon of ªillusory
correlationº in which they read their biases into As neurology developed increasing sophisti-
what they see. For example, one might judge cation, there grew a need for psychological
drawings focusing on the eyes to indicate assessment procedures sensitive to the effects of
paranoid trends, when no empirical association neurological lesions. An early example of such a
between drawing eyes in this way and paranoia technique and one that continues to be used
exists. frequently is the Bender Gestalt Test, developed
by child psychiatrist Lauretta Bender (1938).
She used designs taken from the work of Gestalt
1.01.11.9 Thematic Assessment Methods psychologist Max Wertheimer. This test re-
quires the copying of these nine geometric
In 1935, Christiana Morgan and Henry A. designs with pencil and paper. A second widely
Murray (1893±1988) reported a new procedure, used neuropsychological test, the Visual Reten-
the Thematic Apperception Test, in which the tion Test (Benton, 1945), involves memory as
individual was asked to look at reproductions of well as drawing skills. The Halstead±Reitan
paintings or photographs and to tell a story battery, which developed out of the work of
about the scene portrayed in each picture. In Ward Halstead (1947), involved a combination
research in the Harvard Psychological Clinic, of many different subtests and soon came into
the diagnostic team concluded that this was the common use.
best procedure in their battery for identifying A neuropsychologist who became renowned
individuals who were seriously self-deceived in the field was the Soviet scientist, Alexander
concerning their motives (Murray et al., 1938). R. Luria (1902±1977) who often tended to use
qualitative assessment techniques rather than
1.01.11.10 Sociometric Measures standardized quantitative techniques.
The ªsociogramº based on people's choices of

others with whom they would like to share 1.01.11.14 Biological Assessment Procedures
activities or others whom they would like to A specific test for the presence of syphilitic
avoid was developed by psychiatrist Jacob Levy antibodies in the blood was developed by
Moreno (1892±1974). Moreno introduced so- August von Wasserman in 1906. About 90%
ciometric techniques in a rather unusual book, of the patients with general paralysis of the
Who shall survive? (Moreno, 1952). insane (GPI) tested positive, confirming the
syphilitic etiology of this disease.
1.01.11.11 Assessment of Social Competence The German neuropsychiatrist Hans Berger,
after 15 years of trying, succeeded in 1929 in
Psychologist Edgar A. Doll (1889±1969) once recording electrical activity from the intact
served as director of research at the Vineland human scalp. Thus, the electroencephalograph
School and maintained a lifelong interest in the (EEG) was born. By 1934 the first such
problem of mental retardation. In 1935, Doll recording in the United States had occurred,
published the Vineland Social Maturity Scale, at Harvard Medical School, and by 1939 the
which assessed what an individual character- EEG was in general use. It proved to be
istically was capable of doing in everyday life, as especially valuable in the diagnosis of seizure
disorders and presumably in distinguishing and the study of regional cerebral blood flow
hysterically-based ªepilepsyº from the (RCBF)(Andreasen, 1988).
neurologically-based kind.
Physician Murray L. Barr developed a
cytogenetic assessment procedure which an 1.01.12 RESEARCH ON TREATMENT IN
individual's cells could be examined under a THE TWENTIETH CENTURY
microscope to determine the number of X
chromosomes present in each one. This would 1.01.12.1 The Boston School of Psychotherapy
ordinarily indicate simply whether the person According to historian Eugene Taylor, the
was male or female (since males have only one X first use of different psychotherapeutic methods
chromosome, while females have two). There began at the Massachusetts General Hospital
are rarer cases of females with only a single X between 1903 and 1905 and on Ward's Island in
(Turner's syndrome), males with more than one New York after 1905. This work, which had its
X (Kleinfelter's syndrome), or other persons origins in developments in France, was subse-
with multiple supernumerary X chromosomes. quently overshadowed in the United States by
Each of these syndromes has its own profile of developments in psychoanalysis.
cognitive and behavioral characteristics (e.g.,
Money, 1963).
Physician Robert Guthrie (1916±1995) devel- 1.01.12.2 Psychoanalysis and its Derivatives
oped a blood test for detecting phenylketonuria
(PKU) in newborn babies, making possible a Psychoanalysis dominated the mental health
program of early dietary treatment to prevent scene for more than half of the century and
mental retardation and associated behavior remains of interest today. Psychoanalysis
disorders in this Mendelian recessive condition. usually involves daily or at least relatively
Geneticist Herbert A. Lubs (1969) published frequent meetings between the therapist and
his findings on a ªmarker X chromosome,º later patient, with the patient lying on a couch and
to be implicated in the discovery of the fragile-X engaging in free association (ªjust say whatever
syndrome, one of the most common genetic comes to mindº). From the first, this approach
causes of mental retardation and various to treating neurotic problems achieved good
associated disabilities (de la Cruz, 1985). It is ªconsumer acceptanceº and was sufficiently
of interest that fragile-X is a disease that remunerative that its practitioners could make a
actually does become worse in successive living. Admittedly, psychoanalysis was not only
generations as it is passed on because of the a method of treatment but a theory of
increasing number of trinucleotide repeat psychopathology and had important implica-
mutations on the X chromosome. Perhaps this tions for assessment as well. Detailed coverage
provides at least limited vindication of the of all of this is well beyond the scope of this
nineteenth century psychiatrist B. A. Morel's chapter, since there are hundreds of books on
concept of degeneration. this topic.
Endocrinologist Rosalyn S. Yalow developed Freud had broken with his colleague Josef
techniques for the radioimmunoassay of peptide Breuer before the turn of the twentieth century
hormones. Among other uses, these procedures and henceforth referred to psychoanalysis as his
allowed the diagnosis and treatment of thyroid own creation. He published books on the
disease in newborn infants before any signs of interpretation of dreams in 1900, on the
cretinism appeared. She won a Nobel prize for psychopathology of everyday life in 1904, on
this work in 1977. jokes and their connection with the uncon-
New imaging technology is one of the fastest scious, on psychosexual development, on sexu-
growing areas of assessment. Computerized ality in general in 1905, and many more in later
tomography (CT), for example, is a noninvasive years.
procedure that enables one to view the brain in Although psychoanalysis was considered
cross-section and to visualize neuronal struc- mainly as a treatment for neurotic symptoms,
tures there as well as tumors, areas of hemor- some practitioners tried it with psychotic
rhage, and so on. Johnstone et al. (1976) used CT patients. For example, psychoanalyst Marguer-
relatively soon after it became available. They ite Sechehaye did psychotherapy with schizo-
were able to document that persons with chronic phrenic patients at the Burgholzli hospital in
schizophrenia tended to have enlarged cerebral Zurich and described her experiences in a 1947
ventricles. They also examined the relation of book.
these to degree of impairment. Besides CT, the Otto Rank (1884±1939) was encouraged by
new techniques include magnetic resonance Freud to obtain a Ph.D. in psychology from the
imaging (MRI), the positron emission technique University of Vienna and was for many years a
(PET) for observing brain metabolic activities, member of the inner circle of psychoanalysis.
Research on Treatment in the Twentieth Century 33
Rank's book on the Trauma of birth was but the confidential, and the committee was disbanded
first public example of his departure from strict in 1957.
orthodoxy. Part of Rank's historical impor- One of the more recent variants of psycho-
tance is as a liaison man between psychoanalysis is psychoanalytic self-therapy, devel-
analysis, social work, and psychology. At a later oped by psychiatrist Heinz Kohut (1913±1981),
point in his career, Rank taught at the School of an emigrant from Vienna to Chicago. Kohut is
Social Work in Philadelphia and supervised the reported to have been particularly sympathetic
clinical work of Jessie Taft (Robinson, 1962), to narcissistic and borderline patients, both of
who even became his biographer (Taft, 1958). whom have notable difficulties with the ªself.º
Jessie Taft was, in turn, one of the early With the emergence of managed care in the
supervisors of clinical psychologist Carl Rogers United States, it became more and more
(1902±1987). Thus, there are indirect links difficult for psychoanalysts and others doing
between psychoanalysis and Rogers' client- long-term psychotherapy to be reimbursed for
centered or person-centered therapy. their services by third-party payers. Never-
In Germany in 1936, obituaries recorded the theless, this type of therapy maintains its appeal
death of Bertha Pappenheim (1859±1936), a to some who are willing to pay for it out of their
woman who was only three years younger than own pockets. Historian Eugene Taylor (perso-
Freud. She was a prominent social worker and nal communication, January 13, 1998) ventured
was perhaps the only one to have her likeness the following prediction:
featured on a postage stamp. It eventually
became known, via Ernest Jones' biography of psychologists opposed to the medicalization of
Freud, that Bertha Pappenheim was the actual psychotherapy and the imposition of managed
name of the patient in Freud's case history of care and its required treatment protocols will split
ªAnna O.º Breuer and Freud (1895) had off and develop autonomously, possibly launching
credited this patient with inventing the ªtalking an entirely new generation of deregulated philo-
cure.º Records subsequently unearthed have sophical psychologists whose job is to teach people
documented that Pappenheim was not cured by how to live, as psychotherapy itself becomes de-
medicalized, de-pathologized, and more oriented
psychoanalysis after all. She subsequently spent toward education for transcendence.
time as a patient in a sanatorium. Incidentally,
Pappenheim lived on to become an effective
opponent of the use of psychoanalytic methods 1.01.12.3 Play Therapy for Children
for children under her care.
The psychoanalyst Eric H. Erickson Psychoanalytic methods were first adapted
(1902±1994) was trained by Anna Freud. for use with children by Hermine von Hug-
Although he always presented himself as Hellmuth (1921). Children generally are not
orthodox in his theoretical beliefs, he never- able to lie on a couch and free associate but
theless managed to produce some of the most prefer to play with toys, and thus what became
original and influential contributions. For play therapy was a necessary modification. The
example, in Childhood and society, Erikson next developments in the psychoanalytic treat-
(1950) transformed Freud's psychosexual stages ment of children were due to Melanie Klein
into psychosocial ones that many readers found (1882±1960), who was known for her boldness
more palatable and added something all of his in making ªdeepº interpretations of children's
own about the stages beyond childhood of play activities (e.g., Klein, 1932). The principal
identity development, intimacy, generativity, historic importance of Klein's work may lie in
and integrity. His writings on identity develop- its role in the emergence of the ªobject
ment have in particular generated much relationsº school of psychoanalysis that was
research related to development and the types especially influential in Britain. One of Klein's
of psychopathology that attend failure at pupils was the pediatrician and psychoanalyst
negotiating it. In terms of treatment activities, Donald Winnicott (1896±1971). His clinical
Erickson was an acknowledged master at concepts included the idea that ªtransitional
psychoanalytic play therapy. objectsº such as blankets and teddy bears are
In the 1950s, psychoanalysts began to be used by children as mother substitutes.
concerned about the absence of research Child psychiatrist Frederick Allen
evidence concerning the efficacy of this type (1890±1964) had obtained his M.D. from Johns
of therapy. In 1953 the American Psycho- Hopkins University after previously spending
analytic Association appointed a Central Fact three years as a school psychologist. He became
Gathering Committee to address this question. Director of the Philadelphia Child Guidance
According to Shorter (1997, p. 311; see also Center and contributed to the literature on play
Knight, 1953), the discussions of this commit- therapy. His work was influenced by that of
tee were inconclusive, its report was kept Otto Rank.
1.01.12.4 Japanese Therapeutic Approaches gastroenterologist. In the 1950s a follow-up

study was published of over 4000 patients who
The Japanese psychiatrist Shoma Morita had received this type of treatment. The results
(1874±1952) developed psychotherapeutic pro- were promising though not definitive.
cedures based on Zen Buddhism that were The ªbell and padº method for treating bed-
named after him. Although such approaches are wetting in children (still in use today) was first
commonly used in Japan, they have not become popularized by Mowrer and Mowrer (1938).
widely adopted elsewhere (Moriyama, 1991). Their work was based on a method originally
There continue to be major language and developed by pediatrician M. Pfaundler in 1904.
cultural barriers between East and West in the A pad containing electronic moisture sensors
mental health field, as has been illustrated every was placed in the child's bed. If the child
time this topic has come up in the present urinated during the night, a bell rang to awaken
chapter. the child, who was then supposed to get up and
use the bathroom to finish urinating. Repeated
use of this procedure was observed to decrease
1.01.12.5 Behavior Therapies and then eliminate enuresis, although relapses
were a problem. The Mowrers explained how
In 1924, psychologist Mary Cover Jones this procedure worked in terms of a Pavlovian
published a study of the case of ªPeterº in which conditioning process. Many years later, Azrin
she showed how the child could be induced to and Foxx (1974) developed and field tested a
overcome his fear of a furry animal by gradually more elaborate version of the Mowrers' beha-
increasing exposure to it in the presence of vioral procedures that could even enable parents
competing activities such as eating. Her super- to toilet train their child in ªless than a day.º
visor in this research was psychologist John B. One of the earliest practitioners to make a
Watson, well known as one of the founders of living doing behavior therapy was Andrew
behaviorism and a strong advocate of this Salter (1914±1996), from New York City. He
theoretical position (Watson, 1913). At the time had done his undergraduate work at New York
he worked with Jones, Watson had already been University but had no graduate or professional
dismissed from his academic position at Johns degree. Salter was influenced by Clark Hull's
Hopkins University and had entered the world behaviorally oriented writings on hypnosis
of business, working for an advertising firm in (Salter, 1941) as well as Pavlov's work on
New York. As Taylor remarks (personal conditioned reflexes (Salter, 1949). His concept
communication, January 13, 1998), ªbehavior- of ªassertion trainingº influenced the work of
ism met Madison Avenue in the 1920s.º Joseph Wolpe.
The name of William H. Burnham (1855± According to Kazdin (1978), the psycho-
1941) is not well known, but Kazdin (1978) says analyst Alexander Herzberg moved to London
that he was an important pioneer in the during World War II and developed a mod-
development of behavior therapy. Burnham ification of psychoanalysis that he called
(1924) published a book on The normal mind: An ªgraduated tasksº (Herzberg, 1945). Kazdin
introduction to mental hygiene and the hygiene of notes that psychologist Hans J. Eysenck (1916±
school education. 1997) worked with Herzberg in the 1940s and
Physiologist Edmund Jacobson published an was influenced by him, thus providing part of
influential procedure for systematically teach- the context for Eysenck's later emergence as an
ing people to relax (Jacobson, 1929). This advocate for behavior therapy.
procedure was later incorporated into beha- Eysenck received his Ph.D. at the University
vioral approaches to desensitizing phobias and of London in 1940 and in his early days in the
had many applications in behavioral medicine. field viewed clinical psychology as involving
Another behavioral psychologist, Knight only research and diagnostic testing, not
Dunlap (1875±1949), a professor at Johns treatment. That he left to psychiatry. Eysenck
Hopkins University, wrote a book about the spent some time in the United States and
use of ªnegative practiceº in order to get rid of changed his mind about the role of psycholo-
unwanted habits such as stuttering or thumb gists as therapists. In 1952 he published a review
sucking (Dunlap, 1932). To get rid of such a of the effects of traditional psychotherapy
habit, the individual was encouraged to perform which had the effect of a bombshell on
it voluntarily over and over, until it became psychotherapists who read it. He concluded
unpleasant to do so. that there was no evidence that psychotherapy
In 1935, physician Walter L. Voegtlin and his was effective, because about two-thirds of the
colleagues from the Shadel Sanitarium in Seattle patients improved with or without therapy.
proposed the use of aversion therapy to help Eysenck went on to pioneer the field of behavior
alcoholics achieve abstinence. Voegtlin was a therapy in Britain.
In 1958, psychiatrist Joseph Wolpe (1915± behaviors in a child at bedtime. Such advice
1997) published an influential book about the about how to deal with tantrums is now routine
use of systematic desensitization for phobias in behavioral parent-training programs.
(Wolpe, 1958), claiming a 90% success rate with Behavior analysis also proved to be useful
this type of problem. In its most common with psychotic adult inpatients, as shown by
variant, Wolpe's treatment involved teaching Ayllon and Michael's (1959) paper on ªthe
the patient to relax (using the procedure of psychiatric nurse as a behavioral engineer.º In
Jacobson, 1929). Then the patient learned to 1962, psychologist Montrose Wolf went a step
associate this state of relaxation with a series of further to design a token economy at Ranier
imagined scenes that were arranged in a School, an institution for persons with retarda-
hierarchy of increasing anxiety related to the tion, in Washington. Ayllon and Azrin (1968)
object of the patient's phobia. The reasoning did the same thing for all types of state hospital
was that relaxation and anxiety are incompa- patients. In the 1970s Wolf designed what came
tible responses, and anxiety can be counter- to be called the Achievement Place model, a type
conditioned in this way. Wolpe had received his of family group home for youngsters considered
M.D. from Witwatersrand in South Africa. In to be at risk for delinquent outcomes. In an
1956 he came to California to spend his Achievement Place home, the live-in foster
sabbatical at the Center for Advanced Study parents used behavioral principles to encourage
in the Behavioral Sciences, and it was there that various types of prosocial behavior, everything
he wrote his 1958 book. In 1962 he took a from cleaning up the bathroom, to doing
position at the University of Virginia and then homework, to avoiding aggressive outbursts.
moved to Temple University in 1965, where he By the 1960s, psychologist O. Ivar Lovaas
spent most of his career. and his colleagues at University of California at
Systematic desensitization soon attracted the Los Angeles (e.g., Lovaas, 1987) had become
attention of behavioral psychologists who engaged in intensive treatment efforts for
began to carry out empirical research on this children with autism, using what came to be
topic (e.g., Rachman, 1959; Lang & Lazovik, called ªdiscrete trialº operant conditioning
1963). Controlled research was supportive of methods. These efforts eventually attracted
Wolpe's claim that such treatment was effective. great interest and even generated demands from
However, critics of this research (e.g., Breger & parent groups around the country for their local
McGaugh, 1965) pointed out, with good reason, school systems to fund behavior analysts to
the fact that this procedure did not seem to be work with their children.
based purely on behavioral principles. In Psychiatrist Stuart Agras and his colleagues
particular, the role of the hierarchy of imagined (Agras, Barlow, & Chapin, 1974) published
scenes in the therapy seemed very cognitive. It is data showing that anorexia nervosa could be
thus not a complete suprise that behavior treated using behavior modification. In this and
therapy, as it developed, tended toward a subsequent research it was shown that weight
greater and greater rapprochement with cogni- gain could be used as the basis for presentation
tive approaches. of contingent reinforcement such as the oppor-
tunity to watch television or to see a boyfriend.
Anorexic patients exposed to such contingen-
1.01.12.6 Behavior Analysis cies gained weight, at least while the contin-
gencies were in effect.
The basic research of psychologist B. F.
Skinner (1904±1990) on the functional analysis
of the behavior of rats and pigeons ultimately 1.01.12.7 Cognitive Therapy
created a clinical specialty of ªapplied behavior
analysisº that separated itself from other Although not labeled as such at the time, one
behavioral and certainly from cognitive-beha- can see in retrospect that the ªpersonal
vioral approaches to treatment. Skinner re- constructº therapy and the related assessment
ceived his Ph.D. from Harvard in 1931 and procedures developed by George A. Kelly
published his first book in 1938. Psychologist (1905±1966) could be considered to be an early
Sidney W. Bijou, who was once a colleague of variant of cognitive therapy (Kelly, 1955). Kelly
Skinner's at Indiana University, was one of the thought of every person as a sort of scientist
first to apply this type of behavior analysis to who developed particular ways of construing
children and individuals with mental retarda- other people and events as a result of experience.
tion or autism (Bijou, 1996). Others followed He tried to assess these personal constructs and
suit. For example, using a single subject design, to help the person modify them so reality would
Carl D. Williams (1959) illustrated the use of be representated as accurately as possible.
extinction procedures to eliminate tantrum Another early example of cognitive therapy
was the ªrational emotiveº treatment developed one is most attached and emphasized the
by psychologist Albert Ellis (1958), a prolific importance of ªconsensual validationº not only
writer on this topic. by one's therapist but by peers or ªchums.º
In terms of basic research, one could find few Thus, Sullivan thought it important to encou-
more effective advocates of the integration of rage close, confiding social relationships, espe-
cognitive and behavioral approaches than cially among youth.
Albert Bandura, a professor of psychology at
Stanford University (e.g., Bandura, 1971). Early
in his career, Bandura published research 1.01.12.9 Research on Psychotherapy
showing the effects of modeling or imitation
on children's behavior, including aggression. From the time of Hippocrates down to World
Subsequently, Bandura's research incorporated War II, one would be hard pressed to come up
the influence of cognitive variables in such with many examples of controlled experimental
processes. For example, he found that children's research on psychotherapy or even on many of
behavior would only be influenced by models if the medical approaches used to treat mental
they directed their attention toward what the disorders. It is to the credit of psychologist Carl
model was doing and engaged in mental R. Rogers that he not only developed a new
rehearsal in order to remember what they saw. approach to therapy (Rogers, 1951), he also
Seeing the model rewarded for certain behaviors began to use some of the research methods he
might not influence the child observer at the had learned about in graduate school to study
time, but would do so later if rewards became both the process and the outcome of the therapy
available to the child for demonstrating the he had developed. Rogers tape-recorded ther-
behaviors later. Bandura's theory also empha- apy sessions, had them transcribed, and used
sized the importance of ªself-efficacyº or the coding procedures to try to quantify what was
belief that one would be able to accomplish some happening. He used control groups, for exam-
goal. Even though Bandura did not do treatment ple, persons who were asked to stay on a waiting
outcome research, his theory provided a frame- list for a time with the promise of receiving the
work for cognitive-behavior therapy. same therapy at a later time. He and his
Beck's model of cognitive therapy for colleagues used standardized measures such as
depression has been influential (Beck, 1976). Q-sorts to try to get at psychotherapy outcomes.
Among other strategies, it encourages patients Of course, Rogers' therapy tapes and tran-
to become aware of their negative ªautomatic scripts could also be used by those with
thoughtsº and to learn to dispute them. theoretical views quite in contrast with his
One of the more promising new cognitive- own. Psychologist Charles Truax (1966), for
behavioral treatments to emerge is the one example, managed to demonstrate that Roger-
developed by Marsha Linehan for borderline ian therapists were not as nondirective as might
personality disorder (Linehan, 1993). It is called have been supposed. They were more likely to
ªdialectic behavior therapyº in that among pay attention, and thus presumably to reinforce,
other strategies it encourages patients to explore some types of client statements than others.
possible alternative explanations for certain Psychologist A. E. Bergin is known as both a
distressing events they describe. This treatment researcher and as a reviewer of psychotherapy
has already been shown to be effective in research. One theme he focused on was the fact
reducing the number of self-destructive acts that psychotherapy can harm as well as help
engaged in by patients with BPD. (Bergin, 1966). Researchers and clinicians
therefore need to be concerned about ªside
effectsº as well as ªeffects.º
1.01.12.8 The Interpersonal Approach One interesting twist on psychotherapy
research presented data suggesting that the
One of America's most innovative psychia- provision of psychotherapeutic services in an
trists was Harry Stack Sullivan (1882±1949). He HMO setting could actually reduce patients'
was especially known for his ability as a inappropriate utilization of nonpsychiatric
therapist working with young male schizophre- medical care (Cummings & Follette, 1967).
nic inpatients (Sullivan, 1931). On occasion he Such conclusions are rather self-serving to the
encouraged such patients to become intoxicated mental health professions, of course, and more
on alcohol for 3±10 days in order to ªopen them research is needed to confirm or disconfirm
upº to psychotherapy. Although influenced by these findings.
psychoanalysis, he defined the field as being Another innovation in psychotherapy re-
primarily concerned with interpersonal rela- search was the trend toward using meta-
tionships (Sullivan, 1953). Sullivan coined the analysis, begun by Smith and Glass (1977). In
term ªsignificant otherº for the person to whom a meta-analysis, the existing research literature
is reviewed quantitatively rather than only in the version of this approach known as psychodra-
traditional narrative fashion. Summary statis- ma and in 1942 established a Psychodramatic
tics such as ªeffect sizesº are calculated to pool Institute.
the results of many separate investigations. The According to Shorter (1997), psychiatrist
best known conclusion of the Smith and Glass Joshua Bierer (1901±1984) introduced the use
(1977) review is simply that psychotherapy of group psychotherapy at Runwell Hospital,
ªworksº as compared to various control London, and then at other London hospitals.
conditions. Scholars criticized some authors This eventually took the form of a Social Club,
of meta-analyses, for averaging in flawed which elected its own members. Bierer founded
studies with those that were well designed. In a Social Psychiatry Center in Hampstead in
the familiar language of the computer world, 1946 and set up the first day hospital in England
this amounts to ªgarbage in, garbage out.º in 1948.
Meta-analysis was soon applied to child therapy During the 1960s and 1970s, many new forms
as well (Casey & Berman, 1985; Weisz, Weiss, of group therapy were developed. Encounter
Alicke, & Klotz, 1987), with much the same groups became a fad (especially in California).
conclusions. Gestalt Therapy (not to be confused with
The neglected issue of the clinical significance Gestalt Psychology) and other approaches
of psychotherapy research was addressed by associated with the human potential movement
Jacobson and Revenstorf (1988). It is important or humanistic psychology thrived (Buhler,
in reading a research article in this domain to 1971).
look not just for ªstatistically significantº
findings, which in the case of studies with large
samples may be trivial in size. Instead, one 1.01.12.12 Self-help Groups
should ask whether the amount of change
The first and most famous of these groups,
observed would actually be important to a
Alcoholics Anonymous (AA), was founded in
therapy client. For example, did the client come
1935 by ªBillº Wilson and Bob Smith. To this
into therapy with a particular psychological
day, persons who attend AA receive social
disorder and move into the normal range as a
support for their sobriety and turn their
result of treatment?
attention away from themselves toward helping
others. AA was from the first a religiously
1.01.12.10 The Psychotherapy Integration oriented group, in a sense an offshoot of Frank
Movement Buchman's Oxford Group within charismatic,
evangelical Christianity. Participants were thus
One problem for psychotherapy researchers encouraged to confess their allegiance to a
was the sheer number of ªnewº therapies being ªhigher powerº and their inability to overcome
developed. It was widely estimated in the 1980s their difficulties without spiritual help. There is,
that there were more than 130 different types of however, a nonreligious alternative approach
psychological therapies. There was thus a need known as Rational Recovery. Treatment for
to try to specify what these diverse approaches substance abuse has been a rather separate
might have in common that could account for enterprise from that of traditional psychiatry or
their effectiveness, as well as to work toward psychology. Many of the therapists involved in
designing specific psychological therapies for such work are themselves former alcoholics,
specific disorders (Beutler, 1979). A classic work and the ideology of AA is strong among them.
on this topic was psychiatrist Jerome Frank's
(1973) book, Persuasion and healing. Frank
examined not only different types of formal 1.01.12.13 Marriage and Family Therapy
psychotherapy but also traditional religious or
One pioneer in the development of family
shamanistic approaches to healing (for an
therapy was psychologist John Elderkin Bell.
updated version of this book, see Frank &
According to Bell's own recall of events
Frank, 1991).
(personal communication, Iowa City, Iowa,
early 1980s), he read in a journal in the 1950s
1.01.12.11 Group Therapy some accounts of the work of colleagues in
England who were seeing parents and children
According to historian Eugene Taylor, group in therapy, which he mistakenly interpreted to
therapy began with the work of Joseph Hersey mean seeing them together, or what is now
Pratt in Boston in 1904, with the Class labeled ªconjointly.º Thus he began doing this
Treatment of patients with tuberculosis. The in his own practice, only to discover that he had
term ªgroup therapyº was used by psychiatrist evidently been the first in the world to do so. He
J. L. Moreno in 1932. Moreno also developed a published a book on this topic (Bell, 1961).
The field of marriage therapy grew up as one 1.01.12.15 Special Education

that was rather separate from the mainstream of
either psychiatry or psychology. Many social The physician and educator Maria Montes-
workers had a special interest in this domain. sori (1870±1952) in Italy began her work by
Gradually, psychologists began to be interested familiarizing herself deeply with the writings of
in working with married couples. Jacobson J. M. G. Itard and Edouard Seguin and
(1989) was a pioneer in carrying out controlled translating their works into Italian (Kraemer,
research on behavioral marital therapy. 1988). She developed educational techniques for
young children with delayed development living
in the slums of Rome that used structured play-
1.01.12.14 Community Interventions and like tasks to engage children's natural attention.
Prevention As things turned out, her approaches came into
Within both psychiatry and psychology after common use throughout the world in private
World War II, some were interested in moving preschools for well-to-do children with no
beyond interventions with individuals or small particular developmental delays.
groups. Their desire was to go out into the Psychiatrist Samuel T. Orton (1937) not only
neighborhoods and the cities to make larger came up with neurological hypotheses about the
changes. Psychologist Seymour B. Sarason is an origins of reading disability in children but also,
example of such an individual. He and his together with colleagues in education such as
colleagues set up a ªpsychoeducational clinicº Anna Gillingham and Bessie Stillman, devised
at Yale, not as a place for the evaluation and remedial techniques involving intensive drills on
treatment of individual school children but to analyzing words into sounds and learning
exert an impact on the whole school system and letter±sound associations.
on the city. When asked about his motives for
such activities, Sarason mentioned the facts that 1.01.12.16 Rehabilitation
he was Jewish, that he had polio as a child, and The psychologist Shepherd Ivory Franz
that as a youth he had been an adherent of (1874±1933) was presented with an honorary
Trotsky. Thus, he was disposed to view M.D. by medical colleagues at George Wa-
problems such as discrimination and economic shington University for his research contribu-
injustice as community matters rather than tions. He was also made an honorary member of
simply individual ones. the American Psychiatric Association. He was
In England, psychologist Jack Tizard an early advocate of rehabilitation for patients
(1919±1979) developed a sort of action research with neuropsychological disorders (e.g., speech
program to move adults from institutions for training for aphasics) as well as for those with
the retarded out into the community. He and his severe psychopathology.
colleague Neil O'Connor (1917±1997) demon- Psychologist Marc Gold (1939±1982) was
strated that with suitable instruction these responsible for developing innovative ap-
individuals could perform as well as other proaches to teaching specific vocational skills
workers employed in competitive jobs (O'Con- to persons with mental handicaps. For example,
nor & Tizard, 1956). In part because of research Gold carried out a task analysis specifying the
of this kind, deinstitutionalization eventually details of how to put bicycle coaster brakes
went from a trickle to a flood. The use of ªjob together and showed that adults with mental
coachesº to help handicapped persons adapt to retardation could learn to master it. For those of
competitive employment is now widespread. us who as school children had the experience of
Psychologist George Albee (1968) engaged in taking our bicycles apart and unsucessfully
extensive research on the cost effectiveness of trying to put them back together, Gold's
mental health treatments and the number of accomplishment is most impressive.
personnel required to deliver them. He came to
the conclusion that there were simply never 1.01.12.17 Drug Therapies
going to be enough therapists to do the job. To
him, prevention was the only answer. Albee In terms of developing medications for
(1970) proceeded to make himself very unpop- treating mental disorders and understanding
ular with his colleagues by speaking and writing how they work, a crucial discovery was of the
about ªthe uncertain future of clinical psychol- existence of neurotransmitters, the chemical
ogyº (he thought the same thing about the substances that mediate the synaptic transmis-
future of psychiatry). He suggested on a later sion of neural impulses. According to Shorter
occasion that since its clientele mostly consists (1997), the first neurotransmitter to be dis-
of relatively well-to-do persons, insurance covered was acetylcholine by Otto Loewi in
coverage of psychotherapy might represent a 1926. By the mid-1990s, over 40 neurotrans-
subsidy to the rich from the poor (Albee, 1979). mitters had been identified.
The use of neuroleptic drugs for psychotic though with caution due to its known adverse
patients beginning in the early 1950s greatly side effects.
reduced the census of mental hospitals world- In 1970 psychiatrist Jules Angst (director of
wide. Reisman (1991), for example, reports that the Burgholzli Hospital in Zurich) and his
the US mental hospital population went down colleagues demonstrated that lithium had
from about 600 000 in the 1940s to about similar prophylactic effects in unipolar and
150 000 in the 1970s. Shorter (1997, p. 248) gives bipolar depressed individuals (Angst, Weis,
some details of how this all happened, as Grof, Baastrup, & Schou, 1970). In other
follows: Henri Laborit, who was a surgeon in words, lithium has effects on depression as well
the French navy, in 1951 developed the drug as on mania.
chlorpromazine. The chemist who synthesized it According to Shorter (1997), meprobamate
was Paul Charpentier. At the time, Laborit was was first synthesized in 1950 by Bernie Ludwig,
looking for something to potentiate anesthetics. an organic chemist for Carter Products, with the
He noted that surgical patients given this drug consultation of physician Frank Berger. It was
became rather indifferent to the world. By 1952 tested as an anti-anxiety drug and marketed by
the drug began to be used in Paris (Delay, Wallace Labs in 1955 under the labels of
Deniker, & Harl, 1952) and by May 1953 had ªMiltownº and ªEquanil.º It became the first
transformed the disturbed wards there. The psychiatric drug to become a popular fad. The
same kind of thing then happened in Montreal, comic writer S. J. Perelman in 1957 published a
London, and Boston later the same year. book with the title, The road to Miltown.
Psychiatrist Heinz E. Lehmann, who intro- Comedian Milton Berle began referring to
duced chlorpromazine to Montreal's Verdun himself as ªMiltown Berle.º
Protestant Hospital in 1953 (Lehmann & Antidepressants were the next medications to
Hannahan 1954; Lehmann, 1989), of the first emerge, in a somewhat circuitous way. Selikoff,
to note that the drug had some side effects, some Robitzek, and Ornstein (1952) published a
known as extrapyramidal or Parkinsonian, and report that iproniazid (Marsilid), a drug used
others subsequently described by the term in the treatment of tuberculosis, seemed to have
tardive dyskinesia. The Parkinsonian side some antidepressant properties. A related drug,
effects were temporary and readily treatable named Tofranil, was then developed, tested,
with other medications, but this was not so for and marketed by Geigy (Kuhn, 1957). It was the
the dyskinesia, which were sometimes enduring first of the tricyclic antidepressants, for which
ones. 10 million prescriptions were written in 1980 in
With regard to the use of lithium in mania, the United States alone. Swiss psychiatrist
Shorter (1997) gives the following account: in Roland Kuhn, who was responsible for this
1949, John Cade, the superintendent of a mental work, had undergone a training analysis under
hospital in Australia, injected urine from manic Ludwig Binswanger but later fell away from
patients and from controls into guinea pigs. The psychoanalysis (Shorter, 1997, pp. 258±262).
guinea pigs died. To try to make the urine more The advent of the benzodiazepines in the
soluble, Cade mixed lithium with it. On a whim, 1950s and 1960s is very much a commercially
he decided to inject lithium alone into the guinea motivated story. Once more, I will depend on
pigs. To his surprise, instead of the usual frantic the account given by Shorter (pp. 316±319). In
struggling, they lay there placidly. He tried 1954, the Hoffman-LaRoche company wished
injecting himself with lithium and then injected to develop a sedative or anxiolytic drug that
several mental patients, including 10 with would be able to compete with Miltown and
mania, six with schizophrenia, and three with Equanil. The chemist involved was Leo Stern-
depression. Interestingly, the manic patients bach, and in 1955 he synthesized Librium. Then
tended to improve. It so happened that the in 1959 he came up with diazepam (Valium),
Journal of the American Medical Association which was marketed in 1963. Even though these
reported in the same year two deaths associated drugs were placed on Schedule IV by the FDA
with attempted lithium therapy, so the research because of their addictive potential, benzodia-
community understandably became very cau- zepines accounted for about half the prescrip-
tious about the topic. Nevertheless, Mogens tions written for psychiatric office patients by
Schou, a Danish psychiatrist, confirmed Cade's 1990. Later in the 1990s the hottest drug in this
results, using a double-blind crossover research group was alprazolam (Xanax). Shorter (1997,
design (Schou et al., 1954). It was not until 1970 p. 320) describes panic disorder (for which this
that the Food and Drug Administration (FDA) drug was often prescribed) as ªthe Upjohn
in the United States approved the use of lithium, illness.º
and then only in response to the threat of civil By the 1970s, drug therapy had become quite
disobedience by an Oregon psychiatrist. Now standard for many types of psychopathology. In
lithium is in common use with manic patients, 1982, Rafael Osheroff, a 42-year-old physician
who had been a patient at Chestnut Lodge in with 5-hydroxytryptophan (5HT), or serotonin,
Maryland in 1979, sued the hospital for mal- in the 1950s. In 1957 Bernard Brodie at the
practice because he had been treated only by National Institutes of Health discovered that
means of psychotherapy, not medications. The reserpine could greatly reduce bodily stores of
case was settled in his favor by an arbitration 5HT. Alec Coppen at the Medical Research
panel (Klerman, 1990). This case was note- Council in Britain in 1963 showed that drugs
worthy also because of the fact that Chestnut which were serotonin equivalents could relieve
Lodge was so well known for the use of psycho- depression. It was Ray Fuller, a senior pharma-
analytic treatment for psychosis. cologist at Eli Lilly in Indianapolis, who
In the 1950s and 1960s child psychiatrist Leon synthesized Prozac (Lilly 110140), working with
Eisenberg and psychologist C. Keith Conners biochemist David Wong. By 1980 the field
began to carry out placebo controlled double- testing of this new drug was underway, and in
blind studies of the effects of stimulant medi- 1987 it was released to the public. Shorter notes
cations on the behavior of disturbed children that by 1993 almost half of the patient visits to
(e.g., Conners & Eisenberg, 1963). This research psychiatrists were for mood disorders and typi-
supported the efficacy of such medications. The cally included a prescription for Prozac.
clinical use of Ritalin (methylphenidate) with
behavior problem children increased accord- 1.01.12.18 Psychosurgery
ingly, at least in the United States. British and
other European psychiatrists did not quickly The Portuguese physician Egas Moniz
follow suit, however. It is estimated that over (1874±1955) and a surgical colleague developed
two million children in the United States receive techniques for lobotomy, in which neural fibers
Ritalin at present (Shorter, 1997, p. 290). connecting part of the frontal lobes to the rest of
In France, Lambert (1966) carried out the brain were severed (Moniz, 1937). He won a
research demonstrating the antimanic proper- Nobel prize for his work, but this type of
ties of valproic acid, which had originally been surgery is now rarely used as a treatment for
synthesized as an organic solvent in 1882 and in psychopathology. In the peak year of 1949, over
1963 discovered, more or less by accident, to act 5000 lobotomies were performed on mental
as an anticonvulsant. patients. In the same year, however, controlled
In the 1980s, it was discovered that clomi- research found that the rate of favorable
pramine (Anafranil) caused improvement in changes did not differ between patients with
the symptoms of obsessive-compulsive disorder frontal topectomies and controls (Mettler &
(OCD) in children as well as adults (Rapaport, Columbi-Greystone Associates, 1949). The
1988). This disorder had previously proven frequency of psychosurgery declined greatly
quite refractory to treatment by any method, thereafter.
whether psychoanalytic, behavioral, or medical.
A syndrome involving motor and verbal tics, 1.01.12.19 Electroconvulsive Shock Treatment
often including curse words, was described by Electroconvulsive shock treatment (ECT)
the nineteenth century French physician Char- was developed by psychiatrists Lucio Bini and
cot and named after his colleague, Georges Ugo Cerletti (1877±1963) in the 1930s. In initial
Gilles de la Tourette (1857±1904), who had been experiments on dogs, placing the electrodes on
the first to report such a case. Tourette the animal's mouth and anus, the investigators
syndrome (as it has come to be called) was found that about half of the subjects died. Later
rediscovered by psychiatrist E. Shapiro, who they discovered that if the electrodes were
found that the tics could be controlled by the placed on the dog's temples, electric current
drug haloperidol (Haldol), a neuroleptic (Sha- could be delivered safely (Shorter, 1997,
piro et al., 1989). pp. 218±219). Next, they tried the same thing
At the time of writing, the biggest story in on pigs at a Roman slaughterhouse. Finally, on
medications for psychopathology is that of April 18, 1938, they tried ECT on the first
Prozac (fluoxetine) and the general class of human patient (Cerletti & Bini, 1938). The
drugs of which it is a part, selective serotonin clinical use of ECT spread rapidly to England,
reuptake inhibitors (SSRIs). In the 1990s, France, and the United States. This therapy is
Prozac was the drug most commonly prescribed still in use, especially for the treatment of severe
by psychiatrists. By 1992 it was the second most depression.
frequently prescribed drug in the world. It is
typically employed as an antidepressant. Once 1.01.12.20 Other Biological Treatments and
more we will depend on the account of Shorter Preventive Measures
(1997), who even included Prozac in the subtitle
of his book on the history of psychiatry. The In 1910 Paul Ehrlich developed an arsenical
development of Prozac had its origins in work compound later called Salvarsan that proved to
Epilogue 41
be an effective treatment of syphilis. This Karl Landsteiner (1868±1948) and A. S.

received a mixed reception but by about six Wiener published their first paper on the Rh
years later had been made the basis of a factor in human blood in 1940 (Wiener, 1952).
government-supported public health interven- This work ultimately led to the ability to prevent
tion in Britain (Ross & Tomkins, 1997). Surely fetal malformations and mental retardation due
the most unusual treatment for psychopathol- to Rh factor incompatibility in mother and
ogy so far developed was that of treating infant (Zimmerman, 1973).
neurosyphilis by infecting the patients with Pediatricians Harry M. Meyer, Jr., chief of
malariaÐthe fever had the requisite antibiotic the Laboratory of Viral Immunology at the
effect. This treatment was used by the psychia- National Institutes of Health (NIH) in Bethes-
trist Julius Wagner-Jauregg (1857±1940), a da, Maryland, and Paul D. Parkman developed
professor at the University of Vienna. In fact, a rubella vaccine that proved to be an effective
he won a Nobel prize for this work in 1927. Now preventive measure. It undoubtedly prevented a
there are safer antibiotics available to treat large number of fetal malformations, stillbirths,
syphilis. and cases of mental retardation, deafness, and
Interestingly, Wagner-Jauregg had also been other severe disabilities.
responsible previously for encouraging the Finally, pediatricians Porter W. Anderson,
Viennese government to attempt to prevent Jr. and David Smith, together with immunol-
cretinism and other hyperthyroid conditions by ogists John Robins and Rachel Schneerson,
requiring that salt be iodized (Wagner±Jauregg, developed a vaccine against Hemophilis influ-
1894), an effective public health measure that is enzae type b (Hib), the agent causing bacterial
now in wide use (Whitrow, 1993). meningitis and responsible for death, deafness,
One of the most curious episodes in the and mental retardation among children (Hol-
medical treatment of mental disorders was the den, 1996).
one involving extracting all the teeth of patients
with psychoses, on the theory that focal infec-
tions were maintaining their disturbed mental 1.01.13 EPILOGUE
condition. This approach was carried out by
Cotton (1922) and was endorsed for a time by This chapter was begun in search of the
prominent figures in the field, including psy- forerunners of present day psychiatry and
chiatrist Adolf Meyer. This proved to be clinical psychology. It was acknowledged in
nothing more than an unfortunate fad. Section 1.01.1 that Hippocrates could not really
Insulin coma was introduced as a treatment be considered a psychiatrist. Perhaps he is best
for schizophrenia by psychiatrist Manfred Sakel regarded as the ancestor of the many physicians
(1900±1957) in Berlin in 1933. The rationale for who have to deal not only with physical illness
this treatment was the notion, later considered but also with the emotional and behavioral
quite in error, that there was some incompat- problems that commonly present themselves in
ibility between schizophrenia and seizures. medical practice. Primary care physicians to this
Thus, the reasoning was that if one induced day provide reassurance, dispense advice, and
seizures, perhaps these could interrupt the psy- prescribe medications for many such patients
chosis. The use of insulin coma was discon- and are responsible for the care of those who are
tinued after about two decades in favor of ECT, not referred to mental health specialists. Such
which was much more reliable in its production physicians are the mainstay of the managed care
of seizures, without so many unwanted side system in the United States and of the national
effects, and even ECT was generally used in health systems of many other countries.
treating depression, not schizophrenia. Similarly, Democritus was hardly a clinical
Metrazol (Cardiazol) convulsive therapy for psychologist. In his role as a scientist trying to
schizophrenia was introduced in 1934 by investigate the fundamental causes of mental
Ladislaus von Meduna (1896±1964). The ratio- disorder, he could perhaps be most aptly viewed
nale for it was similar to that for insulin coma as the ancestor of persons such as Hideo
therapy. Meduna was trained as a neuropathol- Noguchi, the bacteriologist working at the
ogist and had done research comparing the Rockefeller Institute. There he discovered
brains of persons with epilepsy to the brains of syphilis spirochetes in the brains of paretics.
those with schizophrenia. Thus, he bore major The actual specialty of psychiatry did not
responsibility for the erroneous hypothesis develop until the late eighteenth and early
elaborated above about the incompatibility nineteenth centuries. A transition took place
between these two conditions. Meduna pub- early in the field in which the role of such
lished an article on this new treatment in 1935 physicians changed from that of simply re-
and a book on it in 1937. Metrazol therapy was straining troublesome patients to engaging in
also superceded by ECT. ªmoral treatmentº of them. Only a few of the
early psychiatrists, such as Esquirol, Griesinger, But after the 1890s, neurology tended to lose
and Kraepelin, were able to combine their its ªmarket shareº in the everyday care of
clinical activities with those of a university persons with functional nervous ailments.
professor and scientist. During the late nine- Similarly, psychiatry today remains an essential
teenth and early twentieth centuries, psychiatry discipline in terms of its knowledge about areas
expanded its scope of practice and for the most such as psychopathology and psychopharma-
part superseded neurology in the care of cology. Clinical psychology has comparable
outpatients with milder functional complaints. expertise in fields such as psychometrics and
Psychiatry was then almost taken over by behavioral approaches to treatment. One can-
psychoanalysis, especially in the United States not imagine that either of these fields will
in the era preceding and immediately following disappear, but it is likely for the moment that
World War II. Beginning in the 1950s, psy- much of the everyday clinical work will be
chiatry was revolutionized by the development carried out by professionals with more modest
of psychotropic drugs, first the neuroleptics and levels of training.
subsequently the anxiolytics, antidepressants,
and antimanic medications. It is currently
undergoing some contraction of its activities ACKNOWLEDGMENTS
due to managed care. Primary care physicians Preparation of this chapter was supported in
are taking over an increasing amount of the part by a William Evans Fellowship to the
responsibility for the medical management of author from the University of Otago, Dunedin,
mental disorders, and other mental health New Zealand. Many persons made helpful
practitioners are carrying out more of the comments on early drafts, including John M.
psychotherapy. Reisman, Marion W. Routh, Eugene Taylor,
Clinical psychology had its origins toward the and C. Eugene Walker.
end of the nineteenth century, with roots in the
work of Pierre Janet and others in France and in
Witmer's psychology clinic in Philadelphia. Its
1.01.14 REFERENCES
early development was much influenced by
Binet's intelligence test and certainly by psycho- Achenbach, T. M., & Edelbrock, C. (1978). The classifica-
analysis, although psychologists for several tion of child psychopathology: A review and analysis of
empirical efforts. Psychological Bulletin, 85, 1275±1301.
decades had many barriers to overcome if they Ackerknecht, E. H. (1942). In memory of William H. R.
wanted to become psychotherapists. By the time Rivers 1864±1922. Bulletin of the History of Medicine, 11,
of World War II, clinical psychologists were 478±481.
known primarily as mental testers, and for a Ackerknecht, E. H. (1967). Medicine at the Paris hospital
1794±1848. Baltimore: Johns Hopkins University Press.
time were well accepted into the ªclinical teamº Ackerknecht, E. H. (1986). Private institutions in the
(e.g., Menninger, 1950). Gradually in the genesis of psychiatry. Bulletin of the History of Medicine,
postwar era psychologists became more active 60, 387±395.
as psychotherapists in private practice. They Agras, W. S., Barlow, D. H., & Chapin, H. N. (1974).
were prominent in the development of beha- Behavior modification of anorexia nervosa. Archives of
General Psychiatry, 30, 279±286.
vioral therapy and behavior analysis and were Albee, G. (1968). Conceptual models and manpower
responsible for the origins of formal research on requirements in psychology. American Psychologist, 23,
psychotherapy. Along with their colleagues in 317±320.
various academic specialties within psychology, Albee, G. (1970). The uncertain future of clinical psychol-
ogy. American Psychologist, 25, 1071±1080.
clinical psychologists such as Paul Meehl and Albee, G. (1977). Does including psychotherapy in health
Hans Eysenck also contributed significantly to insurance represent a subsidy to the rich from the poor?
research on psychopathogy. Having fought American Psychologist, 32, 719±721.
their battles to become psychotherapists, clin- American Psychiatric Association (1980). Diagnostic and
ical psychologists then saw much of this role statistical manual of mental disorders (3rd ed.). Washing-
ton, DC: Author.
usurped in turn by social workers and master's- Andreasen, N. C. (1988). Brain imaging applications in
level counselors. psychiatry. Science, 239, 1381±1388.
At present, it seems that one likely scenario Angst, J., Weis, P., Grof, P., Baastrup, P. C., & Schou, M.
for both psychiatry and clinical psychology (1970). Lithium prophylaxis in recurrent affective
disorders. British Journal of Psychiatry, 116, 604±614.
might be provided by what happened to Ayllon, T., & Azrin, N. H. (1968). The token economy. New
neurology at the end of the nineteenth century. York: Appleton-Century-Crofts.
Neurology continued to be an essential specialty Ayllon, T., & Michael, J. (1959). The psychiatric nurse as a
in terms of research, teaching, and specialized behavioral engineer. Journal for the Experimental Ana-
consultation. Indeed, in this ªdecade of the lysis of Behavior, 2, 323±334.
Azrin, N. H., & Foxx, R. M. (1974). Toilet training in less
brainº the neurosciences have become a major than a day. New York: Simon & Schuster.
scientific frontier, attracting luminaries such as Bandura, A. (1971). Behavior therapy and the models of
Francis Crick. man. American Psychologist, 29, 859±869.
References 43
Barkley, R. A. (1990). Attention-deficit hyperactivity standard ediction of the complete psychological works of
disorder: A handbook for diagnosis and treatment. New Sigmund Freud. (Vol. 2). London: Hogarth Press and the
York: Guilford. Institute of Psychoanalysis (originally published, 1895).
Bayley, N. (1955). On the growth of intelligence. American Buck v. Bell (1927). 274 U.S. 200.
Psychologist, 10, 805±818. Buhler, C. (1971). Basic theoretical concepts of humanistic
Bayley, N. (1969). Manual for the Bayley Scales of Infant psychology. American Psychologist, 26, 378±386.
Development. New York: Psychological Corporation. Burnham, W. H. (1924). The normal mind: An introduction
Beard, G. (1880). A practical treatise on nervous exhaustion to mental hygiene and the hygiene of school education.
(neurasthenia). New York: Wood. New York: Appleton.
Beck, A. T. (1963). Thinking and depression. 1. Idiosyn- Burton, R. (1971). The anatomy of melancholy. Amster-
craatic content and cognitive distortion. Archives of dam, NY: De Capo Press (facsimile edition) (originally
General Psychiatry, 9, 324±344. published, 1621).
Beck, A. T. (1976). Cognitive therapy and emotional Bynum, W. F. (1974). Rationale for therapy in British
disorder. Philadelphia: University of Pennsylvania Press. psychiatry: 1780±1835. Medical History, 18, 317±334.
Beck, A. T., Ward, C. H., & Mendelsohn, M. (1961). An Caplan, R. B., & Caplan, G. (1969). Psychiatry and the
inventory for measuring depression. Archives of General community in nineteenth century America. New York:
Psychiatry, 4, 561±571. Basic Books.
Beck, S. J. (1937). Introduction to the Rorschach method Carlson, E. T., & Simpson, M. M. (1969). Models of the
(Monograph No. 1). New York: American Orthopsy- nervous system in eighteenth century psychiatry. Bulletin
chiatric Association. of the History of Medicine, 43, 101±115.
Beck, S. J. (1944). Rorschach's test: Vol. 1. Basic processes. Casey, R. J., & Berman, J. S. (1985). The outcome of
New York: Grune & Stratton. psychotherapy with children. Psychological Bulletin, 98,
Beers, C. W. (1908). A mind that found itself. New York: 388±400.
Longmans Green. Cattell, J. M. (1890). Mental tests and measurements.
Bell, J. E. (1961). Family group therapy (USPHS Mono- Mind, 15, 373±381.
graph No. 64). Washington, DC: US Government Cerletti, U., & Bini, L. (1938). L'Elettroshock. Archivio
Printing Office. generale di neurologia, 19, 266±268.
Bender, L. (1938). A visual motor gestalt test and its clinical Chapman, L. J., & Chapman, J. P. (1967). Genesis of
use. New York: American Orthopsychiatric Association. popular but erroneous psychodiagnostic observations.
Benjamin, L., Jr. (1986). Why don't they understand us? A Journal of Abnormal Psychology, 72, 193±204.
history of psychology's public image. American Psychol- Chapman, L. J., & Chapman, J. P. (1969). Illusory
ogist, 41, 941±946. correlation as an obstacle to the use of valid psycho-
Benton, A. L. (1945). A visual retention test for clinical use. diagnostic signs. Journal of Abnormal Psychology, 74,
Archives of Neurology and Psychiatry, 54, 212±216. 271±280.
Bergin, A. E. (1966). Some implications of psychotherapy Claren, S. K., & Smith, D. W. (1978). The fetal alcohol
research for therapeutic practice. Journal of Abnormal syndrome. New England Journal of Medicine, 298,
Psychology, 71, 235±246. 1063±1067.
Berrios, G. E. (1996). The history of mental symptoms: Clark, P. F. (1959). Hideyo Noguchi, 1876±1928. Bulletin
Descriptive psychopathology since the nineteenth century. of the History of Medicine, 33, 1±20.
Cambridge, UK: Cambridge University Press. Clarke, A. D. B., & Clarke, A. M. (Eds.) (1958). Mental
Bertin, C. (1982). Marie Bonaparte: A life. New York: deficiency: The changing outlook. London: Methuen.
Harcourt Brace Jovanovich. Cleckley, H. M. (1941). The mask of sanity. St. Louis, MO:
Bettelheim, B. (1950). Love is not enough. Glencoe, IL: Free Mosby.
Press. Conners, C. K., & Eisenberg, L. (1963). The effects of
Bettelheim, B. (1967). The empty fortress. New York: Free methylphenidate on symptomatoloty and learning in
Press. disturbed children. American Journal of Psychiatry, 120,
Beutler, L. E. (1979). Toward specific psychological 458±464.
therapies for specific conditions. Journal of Consulting Cotton, H. A. (1922). The etiology and treatment of the so-
and Clinical Psychology, 47, 882±897. called functional psychoses. American Journal of Psy-
Bijou, S. W. (1996). Reflections on some early events chiatry, 2, 157±210.
related to behavior analysis of child development. Cummings, N., & Fillette, W. T. (1967). Psychiatric
Behavior Analyst, 19, 49±60. services and medical utilization in a prepaid health plan
Binet, A., & Simon, T. (1905). [A new method for the setting. Medical Care, 5, 25±35.
diagnosis of intellectual level of abnormal persons.] Dain, N. (1994). Psychiatry and anti-psychiatry in the
Annee psychologique, 11, 191±244. United States. In M. S. Micale & R. Porter (Eds.),
Bleuler, E. (1908). Die Prognose der Dementia praecox Discovering the history of psychiatry (pp. 415±444). New
(Schizophrenie Gruppe). Allgemeine Zeitschrift fur Psy- York: Oxford University Press.
chiatrie, 65, 436±437. Danek, A., Gudden, W., & Distel, H. (1989). The dream
Bleuler, E. (1911). Dementia praecox oder die Gruppe der king's psychiatrist Bernard von Gudden (1824±1886): A
Schizophrenien. Tubingen: Diskord (reprinted, 1988). life committed to rationality. Archives of Neurology, 46,
Bleuler, M. (1972). Schizophrenic disorders in the light 1349±1353.
of long-term illness and family history. Stuttgart: G. de la Cruz, F. F. (1985). Fragile X syndrome. American
Thieme. Journal of Mental Deficiency, 90, 119±123.
Bluestein, B. E. (1992). Percival Bailey and neurology at Delay, J., Deniker, R., & Harl, J-M. (1952). Utilisation en
the University of Chicago, 1928±1939. Bulletin of the therapeutique psychiatrique d'un phenothiazine de'ac-
History of Medicine, 66, 90±113. tion centrale elective (4560 RP). Annales Medico-
Bourgeois, M. L., & Geraud, M. (1997). Jules Baillarger, psychologique, 110, 112±120.
1809±1891. American Journal of Psychiatry, 154, 262. Doe v. Bolton (1973). 410 U.S. 179.
Breger, L., & McGaugh, J. L. (1965). Critique and Doll, E. A. (1935). A genetic scale of social maturity.
reformulation of ªlearning-theoryº approaches to psy- American Journal of Orthopsychiatry, 5, 180±190.
chotherapy and neurosis. Psychological Bulletin, 63, Doll, E. A., Phelps, W. M., & Melcher, R.C. (1932).
338±358. Mental deficiency due to birth injuries. New York:
Breuer, J., & Freud, S. (1986). Studies in hysteria. In The Macmillan.
Doll, E. E. (1988). Before the big time: Early history of the Gesell, A. (1929). Infancy and human growth. New York:
Training School at Vineland, 1888±1949. American Macmillan.
Journal on Mental Retardation, 93, 1±15. Goddard, H. H. (1912). The Kallikak family. New York:
Dollard, J., Doob, L. W., Miller, N. E., Mowrer, O. H., & Macmillan.
Sears, R. R. (1939). Frustration and aggression. New Goffman, E. (1961). Asylums: Essays on the social situations
Haven, CT: Yale University Press. of mental patients and other inmates. New York:
Dols, M. W. (1987). Insanity and its treatment in Islamic Doubleday.
society. Medical History, 31, 1±14. Goldstein, J. (1987). Console and classify: The French
Dowbiggin, I. (1989). French psychiatry and the search for psychiatric profession in the nineteenth century. Cam-
a professional identity: The Societe medico-psychologi- bridge, UK: Cambridge University Press.
que, 1840±1870. Bulletin of the History of Medicine, 63, Goodenough, F. L. (1926). Measurement of intelligence by
331±355. drawings. Yonkers, NY: World.
Down, J. L. (1866). Observations on the ethnic classifica- Grob, G. N. (1986). Psychiatry and social activism. Bulletin
tion of idiots. London Hospital Clinic Lecture Reports, 3, of the History of Medicine, 60, 477±501.
259±262. Grunbaum, A. (1984). The foundations of psychoanalysis: A
Drotar, D. (1981). Psychological perspectives on chronic philosophical critique. Berkeley: University of California
childhood illness. Journal of Pediatric Psychology, 6, Press.
211±228. Grunbaum, A. (1993). Validation in the clinical theory of
Dunbar, H. F. (1938). Emotions and bodily changes. New psychoanalysis: A study in the philosophy of psycho-
York: Columbia University Press. analysis. Madison, CT: International Universities
Dunlap, K. (1932). Habits: Their making and unmaking. Press.
New York: Liveright. Halstead, W. C. (1947). Brain and intelligence. Chicago:
Edgerton, R. (1967). The cloak of competence. Berkeley, University of Chicago Press.
CA: University of California Press. Hamilton, M. (1960). A rating scale for depression. Journal
Ellenberger, H. (1970). The discovery of the unconscious: of Neurology, Neurosurgery and Psychiatry, 23, 56±61.
The history and evolution of dynamic psychiatry. New Hanson, F. A. (1993). Testing testing: Social consequences
York: Basic Books. of the examined life. Berkeley: University of California
Ellis, A. (1958). Rational psychotherapy. Journal of Press.
General Psychology, 59, 35±49. Hartman, H., Kris, E., & Loewenstein, R. M. (1946).
Ellis, N. R. (Ed.) (1963). Handbook of mental deficiency: Comments on the formation of psychic structure.
Psychological theory and research. New York: McGraw- Psychoanalytic Study of the Child, 2, 11±38.
Hill. Hathaway, S. R., & McKinley, J. C. (1940). A multiphasic
Erikson, E. H. (1950). Childhood and society. New York: personality inventory schedule. Journal of Psychology,
Norton. 10, 249±254.
Eysenck, H. J. (1952). The effects of psychotherapy: An Hathaway, S. R., & McKinley, J. C. (1943). The Minnesota
evaluation. Journal of Consulting Psychology, 16, Multiphasic Personality Inventory. New York: Psycholo-
319±324. gical Corporation.
Fancher, R. E. (1987). Henry Goddard and the Kallikak Hecht, F. (1994). Jerome Lejeune (1926±1994). In memor-
family photographs: ªConscious skullduggeryº or ªWhig iam. American Journal of Human Genetics, 55, 201±202.
history'? American Psychologist, 42, 585±590. Heiser, K. F. (1945). Certification of psychologists in
Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Connecticut. Psychological Bulletin, 42, 624±630.
Jr., Winokur, G., & Munoz, R. (1972). Diagnostic Hernstein, R. J., & Murray, C. (1994). The bell curve:
crtieria for use in psychiatric research. Archives of Intelligence and class structure in American life. New
General Psychiatry, 26, 57±63. York: Free Press.
Finkelhor, D. (1984). Child sexual abuse: New theory and Herzberg, A. (1945). Active psychotherapy. New York:
research. New York: Free Press. Grune & Stratton.
Foucault, M. (1961). Histoire de la Folie a l'age classique. Hinshelwood, J. (1900). Congenital word blindness. Lan-
Paris: Plon (the English translation of this book had the cet, 1, 1506.
title, Madness and civilization). Hobbs, N. (1966). Helping disturbed children: Psychologi-
Frank, J. D. (1973). Pursuasion and healing: A comparative cal and ecological strategies. American Psychologist, 21,
study of psychotherapy. Baltimore: Johns Hopkins 1105±1115.
University Press. Hoeldtke, R. (1967). The history of associationism and
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing British medical psychology. Medical History, 11, 46±65.
(Rev. ed.). Baltimore: Johns Hopkins University Press. Holden, C. (1996). Lasker awards. Science, 274, 39.
Frankl, V. (1962). Man's search for meaning. Boston: Hollingworth, L. S. (1918). Tentative suggestions for the
Beacon Press. certification of practicing psychologists. Journal of
Freud, A. (1937). The ego and the mechanisms of defense. Applied Psychology, 2, 280±284.
Vienna: International Psychoanalytic Verlag. Holtzman, W. H., Thorpe, J. S., Swartz, J. D., & Herron,
Freud, S. (1927). The problem of lay analyses. New York: E. W. (1961). Inkblot perception and personality. Austin,
Brentano's. TX: University of Texas Press.
Freud, S. (1959). Psychoanalytic notes upon an autobio- Holzman, P. S., Proctor, L. R., & Hughes, D. W. (1973).
graphical account of a case of paranoia. Collected papers Eye tracking patterns in schizophrenia. Science, 181,
(Vol. 3). New York: Basic Books (originally published, 179±181.
1911). Hooker, E. (1969). Parental relations and male homosexu-
Gallaher, D. (1995). Voice for the mad: The life of Dorothea ality in patient and non-patient samples. Journal of
Dix. New York: Free Press. Consulting and Clinical Psychology, 33, 140±142.
Galton, F. J. (1978). Hereditary genius: An inquiry into its Hubbard, L. R. (1950). Dianetics: The modern science of
laws and consequences. London: Julian Friedmann mental health. Los Angeles: American St. Hill Organiza-
(originally published, 1869). tion.
Gauld, A. (1992). A history of hypnotism. Cambridge, UK: Huesmann, L. R., Eron, L. D., Lefkowitz, M. M., &
Cambridge University Press. Walder, L. O. (1984). Stability of aggression over time
Gay, P. (1988). Freud: A life for our time. New York: and generations. Developmental Psychology, 20,
Norton. 1120±1134.
References 45
Huey, E. B. (1908). The psychology and pedagogy of Mental illness in the biological and adoptive relatives
reading. Cambridge, MA: MIT Press. of schizophrenic adoptees: Replication of the Copen-
Hunter, R., & McAlpine, I. (1963). Three hundred years of hagen study in the rest of Denmark. Archives of General
psychiatry, 1535±1860: A history presented in selected Psychiatry, 51, 442±455.
English texts. London: Oxford University Press. Kirk, S. A. (1952). Experiments in the early training of the
Isaac, R. J., & Armat, V. C. (1990). Madness in the streets. mentally retarded. American Journal of Mental Defi-
New York: Free Press. ciency, 56, 692±700.
Jackson, S. W. (1972). Unusual mental states in medieval Klein, D. F. (1964). Behavioral reaction pattents with
Europe. I. Medical syndromes of mental disorder, phenothiazines. Archives of General Psychiatry, 7,
400±1100 A.D. Journal of the History of Medicine and 397±408.
Allied Sciences, 27, 262±297. Klein, D. F., & Fink, M. (1962). Behavioral reaction
Jackson, S. W. (1978). Melancholia and the waning of the patterns with phenothiazines. Archives of General Psy-
humeral theory. Journal of the History of Medicine and chiatry, 5, 449±459.
Allied Sciences, 33, 367±376. Klein, M. (1932). The psycho-analysis of children. New
Jacobson, E. (1929). Progressive relaxation. Chicago: York: Norton.
University of Chicago Press. Klerman, G. L. (1990). The psychiatric patient's right to
Jacobson, N. (1989). The maintenance of treatment gains effective treatment: Implications of Osheroff v. Chestnut
following social learning-based marital therapy. Behavior Lodge. American Journal of Psychiatry, 147, 409±418.
Therapy, 20, 325±336. Knight, R. P. (1953). The present status of organized
Jacobson, N., & Revenstorf, D. (1988). Statistics for psychoanalysis in the United States. American Psycho-
assessing the clinical significance of psychotherapy analytic Association Journal, 1, 197±221.
techniques. Behavioral Assessment, 10, 133±145. Korman, M. (1974). National conference on levels and
Janet, P., & Raymond, F. (1903). Obsessions et al patterns of professional training in psychology: The
psychastehia. Paris: Alcan. major themes. American Psychologist, 29, 441±449.
Jensen, A. R. (1969). How much can we boost IQ and Kozulin, A. (1990). Vygotsky's psychology: A biography of
scholastic achievement? Harvard Educational Review, 39, ideas. Cambridge, MA: Harvard University Press.
1±123. Kraemer, H., & Sprenger, J. (1971). Malleus malificarum
Johnstone, E. C., Crow, T. J., Frith, C. D., Husband, J., & (M. Summers Trans.). New York: Dover (originally
Kneel, L. (1976). Cerebral ventricle size and cognitive published, 1486.).
impairment in chronic schizophrenia. Lancet, 2, Kraemer, R. (1988). Maria Montessori: A biography.
924±926. Reading, MA: Addison-Wesley.
Jones, K., Smith, D., Ulleland, C., & Streissguth, A. (1973). Krantz, D. L. (1971). The separate worlds of operant and
Patterns of malformation in offspring of chronic non-operant psychology. Journal of Applied Behavior
alcoholic mothers. Lancet, 1, 1267±1271. Analysis, 4, 61±70.
Jones, M. C. (1924). The elimination of children's fears. Kuhn, R. (1957, August 31). Uber die Behandlung
Journal of Experimental Psychology, 7, 382±390. depressiver Zustande mit einem Iminodibenzyl derivat
Kallmann, F. J. (1938). The genetics of schizophrenia: A (G22355). Schweitzerische Medicine Wochenschrift, 87,
study of heredity and reproduction in the families of 1,087 1135±1140.
schizophrenics. New York: Augustin. Laing, R. D. (1960). The divided self: A study of sanity and
Kallmann, F. J. (1946). The genetic theory of schizo- madness. London: Tavistock.
phrenia: An analsis of 691 schizophrenic twin index Lambert, P. A. (1966). Action neuropsychotropique d'un
families. American Journal of Psychiatry, 103, 309±322. nouvel anti-epileptique: Le Depamide. Annales medico-
Kallmann, F. J. (1953). Heredity in health and mental psychologique, 1, 707±710.
disorder: Principles of psychiatric genetics in the light of Lang, P. J., & Lazovik, A. D. (1963). Experimental
comparative twin studies. New York: Norton. desensitization of a phobia. Journal of Abnormal and
Kamin, L. J. (1974). The science and politics of IQ. Social Psychology, 66, 519±525.
Potomac, MD: Erlbaum. Laufer, M. W., & Denhoff, E. (1957). Hyperkinetic
Kanner, L. (1943). Autistic disturbance of affective behavior syndrome in children. Pediatrics, 50, 463±474.
contact. Nervous Child, 2, 217±250. Lazarus, R. S. (1966). Psychological stress and the coping
Kanner, L. (1959). Johann Jakob Guggenbuhl and the process. New York: McGraw-Hill.
Abendberg. Bulletin of the History of Medicine, 33, Lehmann, H. E. (1989). The introduction of chlorproma-
489±502. zine to North America. Psychiatric Journal of the
Kanner, L., & Eisenberg, L. (1956). Early infantile autism. University of Ottawa, 14, 263±265.
1944±55. American Journal of Orthopsychiatry, 26, Lehmann, H. E., & Hannahan, G. E. (1954). Chlorpro-
556±566. mazine: New inhibiting agent for psychomotor excite-
Kazdin, A. E. (1978). History of behavior modification: ment and manic states. AMA Archives of Neurology and
Experimental foundations of contemporary research. Psychiatry, 71, 227±237.
Baltimore: University Park Press. Leiby, J. (1978). A history of social welfare and social work
Kelly, G. A. (1955). The psychology of personal constructs. in the United States, 1815±1972. New York: Columbia
New York: Norton. University Press.
Kernberg, O. (1967). Borderline personality organization. Leigh, D. (1957). Recurrent themes in the history of
Journal of the American Psychoanalytic Association, 15, psychiatry. Medical History, 1, 237±248.
641±685. Levy, L. (1962). The skew in clinical psychology. American
Kernberg, O. (1975). Borderline conditions and pathological Psychologist, 17, 244±249.
narcissism. New York: Aronson. Linehan, M. M. (1993). Cognitive-behavioral therapy of
Kesey, K. (1962). One flew over the cuckoo's nest. New borderline personality disorder. New York: Guilford.
York: Viking. Locke, J. (1824). An essay concerning human understanding
Kety, S. S. et al. (1968). The types and prevalence of mental (25th ed.). London: William Baynes and Son (originally
illness in the biological and adoptive families of adopted published, 1639).
schizophrenics. Journal of Psychiatric Research, 6 Lovaas, O. I. (1987). Behavioral treatment and normal
(Suppl. 1), 345±362. educational and intellectual function in young autistic
Kety, S. S., Wender, P. H., Jacobsen, B., Ingraham, children. Journal of Consulting and Clinical Psychology,
L. J., Jansson, L., Faber, B., & Kinney, D. K. (1994). 55, 3±9.
Loyd, B. H., & Abidin, R. R. (1985). Revision of the Murray, H. A. (1959). Explorations in personality. New
Parenting Stress Index. Journal of Pediatric Psychology, York: Oxford University Press.
10, 169±177. O'Brien, C. (1996). Auguste D. and Alzheimer's disease.
Luborsky, L. (1962). Clinicians' judgments of mental Science, 275, 28.
health. Archives of General Psychiatry, 7, 404±417. O'Connor, N., & Tizard, J. (1956). The social problem of
Lubs, H. (1969). A marker X chromosome. American mental deficiency. London: Pergamon.
Journal of Human Genetics, 21, 231±244. Orton, S. T. (1928). Specific reading disability: Strepho-
Machover, K. (1948). Personality projections in the drawing symbolia. Journal of the American Medical Association,
of the human figure. Springfield, IL: Charles C. Thomas. 90, 1095.
Magner, L. N. (1992). A history of medicine. New York: Orton, S. T. (1937). Reading, writing, and speech problems
Marcel Dekker. in children. London: Chapman and Hall.
Magnus-Levy, A. (1944). The heroic age of German Pavlov, I. P. (1927). Conditioned responses: An investigation
medicine. Bulletin of the History of Medicine, 16, of the physiological activity of the cerebral cortex. G. V.
331±342. Anrep (trans.). London: Oxford University Press.
Marks, I. M. (1969). Genetics of fear and anxiety disorders. Penrose, L. S. (1951). The biology of mental defect. London:
British Journal of Psychiatry, 149, 406±418. Sidgwick and Jackson.
Marx, O. M. (1994). The beginnings of psychiatric Perelman, S. J. (1957). The road to Miltown; or, Under the
historiography in nineteenth-century Germany. In M. spreading atrophy. New York: Simon and Schuster.
S. Micale & R. Porter (Eds.), Discovering the history of Plato. (1993). Republic. R. Waterfield (trans.). Oxford, UK:
psychiatry (pp. 39±52). New York: Oxford University Oxford University Press.
Press. Porter, R. (1987). Mind-forg'd manacles: A history of
Masserman, J. H. (1943). Behavior and neurosis: An madness in England from the Restoration to the Regency.
experimental psycho-analytic approach to psychobiologic Cambridge, MA: Harvard University Press.
principles. Chicago: University of Chicago Press. Rachman, S. (1959). The treatment of anxiety and phobic
Masson, J. M. (1984). The assault on truth: Freud's reactions by systematic desensitization psychotherapy.
suppression of the seduction theory. New York: Farrar Journal of Abnormal and Social Psychology, 58, 259±263.
Straus Giroux. Rapaport, J. L. (1989). The boy who couldn't stop washing.
Masters, W. H., & Johnson, V. E. (1966). Human sexual New York: Dutton.
response. Boston: Little, Brown. Reisman, J. M. (1991). A history of clinical psychology (2nd
McPherson, F. M. (1986). The professional psychologist in ed.). New York: Hemisphere.
Europe. American Psychologist, 41, 302±305. Richmond, M. (1917). Social diagnosis. New York: Russell
McReynolds, P. (1997). Lightner Witmer: His life and times. Sage Foundation.
Washington, DC: American Psychological Association. Riese, W. (1949). An outline of a history of ideas in
Meehl, P. E. (1962). Schiztaxia, schizotypy, and schizo- neurology. Bulletin of the History of Medicine, 23,
phrenia. American Psychologist, 17, 827±838. 111±136.
Menninger, W. C. (1950). The relationship of clinical psy- Roberts, K. S., & Sacks, N. P. (1954). Dom Duarte and
chology and psychiatry. American Psychologist, 5, 3±15. Robert Burton: Two men of melancholy. Journal of the
Mettler, F. A., & Columbia-Greystone Associates (Eds.) History of Medicine, 9, 21±37.
(1949). Selective partial ablation of the frontal cortex. Robinson, V. P. (Ed.) (1962). Jessie Taft: Therapist and
New York: Hoeber. social work educator. Philadelphia: University of Penn-
Milofsky, C. (1989). Testers and testing: The sociology of sylvania Press.
school psychology. New Brunswick, NJ: Rutgers Uni- Robins, L. N. (1966). Deviant children grown up. Baltimore:
versity Press. Williams & Wilkins.
Mitchell, S. W. (1894). Address before the 50th Annual Rogers, C. R. (1951). Client centered therapy. Boston:
Meeting of the American Medico-Psychological Associa- Houghton Mifflin.
tion, held in Philadlephia, May 16, 1894. Journal of Rorschach, H. (1921). Psychodiagnostic. Bern: Huber.
Nervous and Mental Diseases, 21, 413±438. Rosen, G. (1964). The mentally ill and the community in
Money, J. (1963). Cytogenetics and psychosexual incon- western and central Europe during the late middle ages
gruities, with a note on space form blindness. American and the renaissance. Journal of the History of Medicine,
Journal of Psychiatry, 119, 820±827. 19, 377±388.
Moniz, E. (1937). Prefrontal leucotomy in the treatment of Rosenberg, C. E. (1962). The place of George M. Beard in
mental disorder. American Journal of Psychiatry, 93, nineteenth-century psychiatry. Bulletin of the History of
1379±1385. Medicine, 36, 245±259.
Mora, G. (Ed.) (1991). Witches, devils, and doctors in the Rosenhan, D. L. (1973). On being sane in insane places.
renaissance: Edition of Johann Weyer (1583), De Science, 179, 250±258.
praestigiis daemonum. Binghamton, NY: Medieval and Ross, A. O. (1959). The practice of clinical child psychology.
Renaissance Texts and Studies. New York: Grune & Stratton.
Mora, G. (1994). Early American historials of psychiatry: Ross, J. E., & Tomkins, S. M. (1997). The British reception
1910±1960. In M. S. Micale & R. Porter (Eds.), of Salvarsan. Journal of the History of Medicine and
Discovering the history of psychiatry (pp. 53±80). New Allied Sciences, 52, 398±423.
York: Oxford University Press. Roudinesco, E. (1990). Jacques Lacan & Co.: A history of
Moreno, J. L. (1952). Who shall survive? New York: Beacon psychoanalysis in France, 1925±1985. J. Mehlman (trans).
House. Chicago: University of Chicago Press.
Morgan, C. D., & Murray, H. A. (1935). A method for Rousseau, J. J. (1911). Emile, or education. New York:
investigating fantasies: The Thematic Apperception Test. Dutton (originally published, 1762).
Archives of Neurology and Psychiatry, 34, 289±306. Routh, D. K. (1994). Clinical psychology since 1917:
Moriyama, N. (1991). Shoma Morita, founder of Morita Science, practice, and organization. New York: Plenum.
therapy, and haiku poet Shiki: Origin of Morita therapy. Routh, D. K. (1996). Lightner Witmer and the first 100
Japanese Journal of Psychiatry and Neurology, 45, years of clinical psychology. American Psychologist, 51,
787±796. 244±247.
Mowrer, O. H., & Mowrer, W. M. (1938). Enuresis: A Routh, D. K. (1997). A history of Division 12 (clinical
method for its study and treatment. American Journal of psychology): Fourscore years. In D. A. Dewsbury (Ed.),
Orthopsychiatry, 8, 436±459. Unification through division: Histories of the divisions of
References 47
the American Psychological Association (Vol. 2, Strauss, A. A., & Lehtinen, L. E. (1947). Psychopathology
pp. 55±82). Washington, DC: American Psychological and education of the brain injured child. New York:
Association. Grune & Stratton.
Rubenstein, E. A. (1992). Robert H. Felix (1904±1990). Sullivan, H. S. (1931). The modified psychoanalytic
American Psychologist, 47, 589. treatment of schizophrenia. American Journal of Psy-
Russell, G. F. M. (1979). Bulimia nervosa: An ominous chiatry, 11, 519±540.
variant of anorexia nervosa. Psychological Medicine, 9, Sullivan, H. S. (1953). The interpersonal theory of psy-
429±448. chiatry. New York: Norton. (published posthumously).
Salter, A. (1941). Three techniques of autohypnosis. Taft, J. (1958). Otto Rank. New York: Julian.
Journal of General Psychology, 24, 423±438. Taylor, E. I. (1982). William James on exceptional mental
Salter, A. (1949). Conditioned reflex therapy. New York: states: Reconstruction of the 1896 Lowell lectures. New
Creative Age. York: Scribner's Sons.
Santos, E. H., & Stainbrook, E. (1949). A history of Temkin, O. (1946). An essay on the usefulness of medical
psychiatric nursing in the nineteenth century. Part I. history for medicine. Bulletin of the History of Medicine,
Journal of the History of Medicine, 4, 48±60. 19, 9±47.
Sarton, G. (1954). Galen of Pergamon. Lawrence, KS: Temkin, O. (1947). Gall and the phrenological movement.
Univeristy of Kansas Press. Bulletin of the History of Medicine, 21, 275±321.
Schlick, T. (1994). Changing disease identities: Cretinism, Temkin, O. (1973). Galenism: Rise and decline of a medical
politics, and surgery (1844±1892). Medical History, 38, philosophy. Ithaca: Cornell University Press.
421±443. Temkin, O. (1991). Hippocrates in a world of pagans and
Schou, M. et al. (1954). The treatment of manic psychoses Christians. Baltimore: Johns Hopkins University Press.
by the administration of lithium salts. Journal of Terman, L. M. (1916). The measurement of intelligence.
Neurology, Neurosurgery, and Psychiatry, 17, 250±260. Boston: Houghton Mifflin.
Schreber, D. P. (1903). Denkwurdigkeiten eines Nervenk- Terman, L. M. (1925). Genetic studies of genius (Vol. 1).
ranken. Leipzig: Mutze. Stanford, CA: Stanford University Press.
Scull, A. (1993). The most solitary of afflictions: Madness Terman, L. M., & Oden, M. H. (1947). The gifted child
and society in Britain 1700±1900. New Haven, CT: Yale grows up: Twenty-five years' follow-up of a superior
University Press. group. Stanford, CA: Stanford University Press.
Scull, A., MacKenzie, C., & Hervey, N. (1996). Masters of Thomson, G. (1919). The proof or disproof of the existence
Bedlam: The transformation of the mad-doctoring trade. of general ability. British Journal of Psychology, 9,
Princeton, NJ: Princeton University Press. 321±336.
Seligman, M. E. P. (1975). Helplessness: On depression, Truax, C. B. (1966). Reinforcement and nonreeinforcement
development, and death. San Francisco: Freeman. in Rogerian psychotherapy. Journal of Abnormal Psy-
Selikoff, I. J., Robitzek, E. H., & Ornstein, G. G. (1952). chology, 71, 1±9.
Toxicity of hydrazine derivatives of isonicotinic acid in Veith, I. (1955). Psychiatric thought in Chinese medicine.
the chemotherapy of human tuberculosis. Bulletin of the Journal of the History of Medicine, 10, 261±268.
Sea View Hospital, 13, 17. Veith, I. (1963). The supernatural in far Eastern concepts
Shapiro, E., Shapiro, A. K., Fulop, G., Hubbard, M., of mental disease. Bulletin of the History of Medicine, 37,
Mandel, J., Nordlie, J., & Phillips, R. A. (1989). 139±155.
Controlled study of haloperidol, pimozide, and placebo von Hug-Hellmuth, H. (1921). Zur Technik der Kinder-
for the treatment of Gilles de la Tourette's syndrome. analyse. Internationale Zeitschrift fur Psychoanalyse, 7.
Archives of General Psychiatry, 46, 722±730. Wagner-Jauregg, J. (1894). Thyroid basis of cretinism, use
Shapiro, J. P. (1993). No pity: People with disabilities forg- of iodized salt. Jahrbuch fur Psychiatrie, 12, 102±107.
ing a new civil rights movement. New York: Times Books. Walter, R. D. (1956). What became of the degenerate? A
Shorter, E. (1997). A history of psychiatry. New York: Wiley. brief history of the concept. Journal of the History of
Sigerist, H. E. (1945). The need for an institute of the Medicine, 11, 422±429.
history of medicine in India. Bulletin of the History of Watson, J. B. (1913). Psychology as the behaviorist views
Medicine, 17, 113±126. it. Psychological Review, 23, 158±179.
Sjogren, T. (1931). Die juvenile amaurotische Idiotie: Watson, J. B., & Raynor, R. (1920). Conditioned
klinische and erblichkeitsmedicinische Untersuchungen. emotional reactions. Journal of Experimental Psychol-
Hereditas (Lund), 14, 197±225. ogy, 3, 1±14.
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of Wechsler, D. (1939). The measurement of adult intelligence.
psychotherapy studies. American Psychologist, 32, Baltimore: Williams & Wilkins.
752±760. Weiner, D. B. (1979). The apprenticeship of Philippe Pinel:
Snyder, S. H. (1976). The dopamine hypothesis of A new document, ªObservations of Citizen Pussin on the
schizophrenia: Focus on the dopamine receptor. Amer- Insane.º American Journal of Psychiatry, 136,
ican Journal of Psychiatry, 133, 197±202. 1128±1134.
Spearman, C. E. (1904). General intelligence objectively Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L.
determined and measures. American Journal of Psychol- (1987). Effectiveness of psychotherapy with children and
ogy, 15, 201±292. adolescents: A meta-analysis for clinicians. Journal of
Spielberger, C. D., Gorsuch, R., & Lushene, R. (1970). Consulting and Clinical Psychology, 55, 542±549.
Manual for the State-Trait Anxiety Inventory. Palo Alto, Whitrow, M. (1993). Julius Wagner-Jauregg (1857±1940).
CA: Consulting Psychologists Press. London: SmithGordon.
Spitzer, R. L., Endicott, J., & Gibbon, M. (1978). Research Wiener, A. S. (1952). History of Rhesus blood types.
diagnostic criteria: Rationale and reliability. Archives of Journal of the History of Medicine, 7, 369±383.
General Psychiatry, 35, 773±782. Williams, C. D. (1959). The elimination of tantrum
Stengel, E. (1959). Classification of mental disorders. behavior by extinction procedures. Journal of Abnormal
Bulletin of the World Health Organization, 21, 601±663. and Social Psychology, 59, 269.
Stern, W. (1914). The psychological method of testing Winters, E. E. (1966). Adolf Meyer's two and a half years
intelligence. Baltimore: Warwick & Wood (originally at Kankakee. Bulletin of the History of Medicine, 40,
published, 1912). 441±458.
Still, G. F. (1902). Some abnormal physical conditions in Wolpe, J. (1958). Psychotherapy by reciprocal inhibition.
children. Lancet, 1, 1008±1012, 1077±1082, 1163±1168. Stanford, CA: Stanford University Press.
Wolpe, J., Salter, A., & Reyna, L. J. (Eds.) (1964). The Wooldridge, A. (1994). Measuring the mind: Education and
conditioning therapies: The challenge in psychotherapy. psychology in England, c. 1860-c. 1900. Cambridge, UK:
New York: Holt, Rinehart, and Winston. Cambridge University Press.
Woods, E. A., & Carlson, E. T. (1961). The psychiatry of Yerkes, R. M., Hardwick, J. W., & Bridges, R. S. (1915). A
Philippe Pinel. Bulletin of the History of Medicine, 35, point scale for measuring mental ability. Baltimore:
14±25. Warwick & York.
Woodworth, R. S. (1917). Personal data sheet. Chicago: Zimmerman, D. R. (1973). Rh: The intimate history of a
Stoelting. disease and its conquest. New York: Macmillan.
1.02
The Scientific Status of Clinical
Psychology
FRANK L. COLLINS, JR.
Oklahoma State University, Stillwater, OK, USA
1.02.2 BRIEF HISTORY OF CLINICAL PSYCHOLOGY IN THE UNITED STATES 50
1.02.3 SCIENCE: DEFINITIONS AND MODELS FOR CLINICAL PSYCHOLOGY 51
1.02.3.1 The Behavior of Scientists 51
1.02.3.2 Science vs. Art 53
1.02.3.3 Clinical Scientists and Clinical Practitioners 53
1.02.4 THE CURRENT STATUS OF SCIENCE IN CLINICAL PSYCHOLOGY 55
1.02.4.1 Diagnosis and Assessment 55
1.02.4.2 Scientific Status of Clinical Assessment 56
1.02.4.3 Clinical Interventions 57
1.02.4.4 Scientific Status of Clinical Interventions 58
1.02.5 TRAINING SCIENCE IN CLINICAL PSYCHOLOGY: THE SCIENTIST±PRACTITIONER MODEL 59
1.02.6 SCIENCE, THE CHANGING HEALTH CARE SYSTEM, AND THE DEMAND FOR PSYCHOLOGY 60
1.02.7 CONCLUSIONS 61
Psychologists work to develop a valid and reliable the applied discipline of psychology that focuses
body of scientific knowledge based on research. on the application of psychological principles to
(from the Preamble to the Ethical Principles of adjustment problems of individuals (Rotter,
Psychologists and Code of Conduct; American 1971; Shakow, 1976), the domain of clinical
Psychological Association, 1992)
psychology includes ªassessment, diagnosis,
and treatment of clinical dysfunction; issues in
1.02.1 INTRODUCTION the application of treatment to individuals or
society at large; factors that influence adjust-
Psychology grew out of the fields of philoso- ment and functioning in everyday life; develop-
phy and experimental physiology (Boring, 1950) ment across the life span; personality; the family;
and is typically described as the scientific study delivery of psychological services; training of
of behavior (Sternberg, 1995; Zimbardo & psychologists; and ethical and professional
Gerrig, 1996). This includes both animal and issuesº (Kazdin, 1994, p. 1). While science plays
human behavior with the term ªbehaviorº a role in each of these areas, this chapter will
typically so broadly defined as to include physio- focus on the scientific status of clinical psychol-
logical acts, overt behaviors, and thoughts. ogy with respect to assessment and diagnosis,
While clinical psychology can be considered as clinical interventions, and clinical training.
49
50 The Scientific Status of Clinical Psychology
From its inception, clinical psychology has terms of public policy and the science of clinical
been described both as a science and a psychology.
profession (Peterson, 1976). The flagship jour-
nal of clinical psychology, Clinical Psychology: 1.02.2 BRIEF HISTORY OF CLINICAL
Science and Practice, has chosen a name which PSYCHOLOGY IN THE UNITED
highlights the dual identity of clinical psychol- STATES
ogy. Likewise, many of the activities of clinical
psychologists do not fit our historical concep- Historically, the differentiation of psychology
tualizations of science. For example, clinical from philosophy was the emphasis which
psychologists are less likely to be engaged in psychology placed on science and the scientific
laboratory-based ªbenchº research, rather they method (Sokal, 1992). However, there was little
are more likely to serve as a consultant to an agreement as to which aspects of science were
individual or agency to evaluate and develop a most important. Specifically, two distinct types
treatment plan relevant to a problem presented of science emerged: (i) laboratory-based activ-
by an individual or group of individuals (family, ities more in line with experimental physiology,
couple, or other system). Depending on the and (ii) applied research activities which focused
results of the evaluation and plan, the clinical on individual differences and mental measure-
psychologist might also be engaged in the ment (Goodwin, 1983). This division has been
delivery of an intervention (psychotherapy) that identified as a foreshadowing of the science±
has potential for reducing the distress identified practice split in psychology through an empha-
by the individual or group being evaluated. sis of the difference between experimental and
This chapter has several goals. First, it will applied psychology (Rice, 1997).
identify the similarities, while acknowledging Clinical psychology as a specialized area of
the differences, of the science and practice roles training began with the establishment of the first
in clinical psychology. These differences will be psychology clinic by Lightner Witmer in 1986
focused on through the discussion of the (Brems, Thevenin, & Routh, 1991; Watson,
different roles of clinical psychologists (science 1953). Following World War I, many of the
and practice) with an emphasis on why training psychologists interested in the measurement of
in the science and practice of clinical psychology individual differences began to consult with
is critical for these dual roles. To accomplish this organizations outside academia. This led to the
goal, a brief review of the history of clinical first attempt to develop a professional identity
psychology is presented, followed by a discus- complete with accreditation procedures for
sion of the philosophy and definition of science. ªconsultingº psychologists. Although this
Concepts from behavioral psychology will be movement for accreditation was not supported
presented which will emphasize the role of by the American Psychological Association
different types of learning experiences and the (APA) Council (Wallin, 1960), consulting was
importance of the scientist±practitioner training viewed by the APA leadership as a form of
model on the behavior of the clinical psychol- applied research with all the components of an
ogist primarily engaged in (i) clinical researchÐ emerging professional identity (Rice, 1997).
the clinical scientist or (ii) clinical practiceÐthe By 1919 the clinical section of the APA was
clinical practitioner. These behavioral concepts formed (Edelstein & Brasted, 1983), and several
will be used to reframe the ªscientistº vs. position papers (cf., Poffenberger, 1938; Ro-
ªpractitionerº debate in terms of the need to gers, 1939; Shakow, 1938) appeared that
maintain a science-based practice of clinical delineated the distinct requirements necessary
psychology. to become a ªclinical psychologistº (Derner,
Second, by focusing on the similarities and 1965; Edelstein & Brasted, 1983; Norton-Ford,
contributions that clinical scientists and clinical 1982; Reisman, 1981).
practitioners make to the field of clinical World War II served to provide much of the
psychology, it will be shown that the important emphasis for the emergence of the profession of
question is not whether or not clinical psychol- psychology. First, the APA developed new
ogy is a science but, rather, the question is, bylaws which gave recognition to the science
ªWhat is the current status of science in clinical and profession of psychology (Capshew &
psychology?º This question will be addressed Hilgard, 1992). Second, the Veterans Adminis-
through a brief discussion of the current tration sponsored a large program to train
scientific status of diagnosis, assessment, and clinical psychologists. This program incorpo-
intervention. rated university-based training in psychological
Finally, changes in the health care system are theory with clinical practice training which
likely to influence, or be influenced by, the included therapy in addition to psychological
science-based practice of clinical psychology. assessment. This model cumulated in the
Potential issues and change will be discussed in Boulder Conference (Raimy, 1950).
Science: Definitions and Models for Clinical Psychology 51
Since that time numerous national confer- First, however, definitions and models will be
ences have been held to address these issues presented to set the foundation for a discussion
(e.g., Stanford, Strother, 1956; Miami Beach, of the critical need for a science-based practice
Roe, Custard, Moore, Ross, & Skodak, 1959; of clinical psychology.
Hoch, Ross, & Skodak, 1966; Vail, Korman,
1976; West Virginia, Foster, Berler, & Collins, 1.02.3 SCIENCE: DEFINITIONS AND
1982; Gainesville, Belar & Perry, 1992; Ann MODELS FOR CLINICAL
Arbor, Belar et al., 1993; to name but a few), PSYCHOLOGY
which resulted in the training guidelines
followed today. Defining science is not easy. One approach is
The early conferences (Boulder, Stanford, to identify activities that we can all agree are not
Miami Beach, Chicago, and Vail) focused on science (Sullivan & Collins, 1996). For example,
clinical training in general, with an emphasis on most would agree that religion, art, and mysti-
a broad-based background in psychology. cism are not scientific fields. Physics, chemistry,
Recommendations resulting from these confer- physics, and biology are easy examples of science
ences led to specific evaluation criteria and fields, and many of us would agree that sociol-
processes by which the APA accredits clinical ogy, anthropology, and psychology are scientific
training programs. Accreditation by the APA is approaches. However, scholars might well en-
presumed to be documentation that students gage in the scientific study of religion (theology),
receive certain minimum training experiences music, painting, etc. Are these individuals en-
believed necessary to ensure that they have been gaged in ªscience?º Does science provide unique
appropriately trained as clinical psychologists. perspectives to problems of behavior that are
Each of these conferences reaffirmed the need different or distinct from the perspectives pro-
for training in both the science and practice of vided by religion, art, or mysticism? Are there
clinical psychology. alternative conceptual models that can be used
The West Virginia Conference focused on the to describe how scientific behaviors develop?
essential ingredients for training psychologists in Why do scientists do what they do?
a single school of thought, behavioral psychol-
ogy. As an organizer of this meeting, I was sure 1.02.3.1 The Behavior of Scientists
that this ªworking conferenceº would specify
objective criteria that would be necessary and At the most basic level, scientists engage in
sufficient for training in clinical psychology. problem-solving activities that may include
Much to my surprise there was absolutely no observation, conceptualization, and experimen-
consensus among this group of clinical psychol- tation. Walker (1963) suggests that ªthe
ogists, all who were engaged in behavioral scientific method is a survival technique that
training. ªIndeed, after 6 hours of discussion developed during the biological evolution of
among a group of prominent clinical directors, living things. Any organism or device that
the only critical component of behavioral train- includes a suitably connected memory unit can
ing that was unanimously endorsed was training ªlearn by experience,º and this learning by
in an empirical approach to the study of beha- experience contains the basic elements of the
viorº (Collins, Foster, & Berler, 1986, p. 304). scientific methodº (p. 15). While the basic
This emphasis on the importance of science elements of the scientific method may account
training was the primary theme of the National for all learning, contemporary science is a bit
Conference on Scientist±Practitioner Education more complicated.
and Training for the Professional Practice of Kuhn (1970) offers a somewhat more com-
Psychology (Belar & Perry, 1992). Recommen- plex definition of science. For Kuhn, science
dations from this conference will be discussed in
greater detail later in this chapter; however, it is means research firmly based upon one or more
important to note that, while science plays a past scientific achievements, achievements that
major role in the field of clinical psychology, the some particular scientific community acknowl-
edges for a time as supplying the foundation for
practice of clinical psychology has not always its further practice. Today such achievements are
been integrated with science. recounted, though seldom in their original form,
However, many authors (e.g., Rice, 1997; by science textbooks, elementary and advanced.
Schneider, 1990) have expressed concern that These textbooks expound the body of accepted
the division between the science and practice of theory, illustrate many or all of its successful
psychology may lead to an irreversible division applications, and compare these applications with
in psychology. The goal of this chapter is to exemplary observations and experiments. (p. 10)
show the importance of science in clinical
psychology and the need to adhere to a Thus, science is more than merely learning
science-based practice of clinical psychology. from experience. A science must be based on
information, theory, models, and methods that she belongs to for both science in general
guide the actions of individuals engaged in (Habermas, 1975; Holton, 1973; Polanyi, 1958)
science. In addition, knowledge about the beha- and for the science of psychology (Campbell,
vior of the individual scientist can provide a more 1984; Fishman, 1988; Gergen, 1985; Howard,
complete understanding of science. Sidman 1985; Koch, 1976, 1981; Krasner & Houts, 1984;
(1994) provides an interesting example of the Scarr, 1985). At the extreme, science is seen as
importance of knowing about the scientist and nothing more than a construction of the human
the effect of his or her experiences on the devel- mind. As Scarr put it, ªFacts do not have an
opment of theories and models. In the epilogue, independent existenceº (p. 499). While total
he provides excerpts of correspondence between discussion of this issue is beyond the scope of
himself and Willard Day. This dialogue provides this chapter, some general comments are
an interesting perspective of the influence that necessary.
Day had on Sidman's approach to science. The belief that researchers are neutral, value-
The behavior of scientists can be broken free truth seekers is probably based on the
down into conceptual or decision-making philosophical principle called logical positivism.
behaviors and experimental method behaviors. Logical positivism is based on two assumptions:
The conceptual process used in science is the ª(1) there is an external world independent of
hypothetico-deductive method (Walker, 1963). human experience, and (2) objective knowledge
This method is a combination of induction, about this world can be obtained through direct
inspiration, and deduction (Walker). Using sense experienceº (Fishman, 1985, p. 5). Thus,
induction and inspiration, scientists postulate logical positivism suggests that all observations
models or theories (Ackermann, 1970). From are the ultimate forms of truth since observa-
these models or theories, he or she can then tions are objective (Staats, 1988).
deduce predictions or hypotheses which can An alternative to logical positivism has been
then be verified by further observation. labeled by Gergen (1985) as social construction-
Experimental methods include (i) identifica- ism. This model suggests that all knowledge,
tion of measures of interest, (ii) developing the including scientific knowledge, is a construction
methodology to conduct the measurements, and of the mind:
(iii) developing predictive models for analyzing
the measures. Identification of measures has Sensory data are filtered through the knowing
historically required specific definitions as to the apparatus of the human senses and made into
operations used in measuring the quantity. For perceptions and cognitions. The human mind is
example, the weight of an object is the number also constructed in a social context, and its
read from a scale when the object is placed on knowledge is in part created by the social and
the scale. The term operational definition was cultural world. Knowledge of the world is there-
fore always constructed by the human mind in the
coined by P. W. Bridgman, who felt that it was working models of reality in the sciences. If this is
the hallmark of science (Walker, 1963). While it not evident, consider for a moment the vast
has been argued that concepts which cannot be differences in our concepts of the world before
adequately defined using operations are not in Galileo, Darwin, Einstein, and Freud. (p. 499)
the realm of science (Walker), most philoso-
phers today have abandoned the doctrine of While there is no doubt that data are a
operational or explicit definition (Suppe, 1977). product of the observed and the observer,
This is an important point. Technological science can, and will, continue to make major
advances such as the invention of a more contributions to our understanding (no matter
powerful microscope can change science by how limited it may be) of behavior.
allowing for the operationalization of concepts Hayes (1995) offers an alternative definition
that were previously seen as ªnot subject to of science:
empirical validations,º or for the development of
new operationalizations of a concept that may Science is a human endeavor that has as its purpose
result in different outcomes. Concepts once the development of increasingly integrated systems
thought to be unmeasurable become measurable of verbal rules that allow us to accomplish analytic
with increased technology. Thus, the operatio- goals with precision, scope, and depth, based on
nalization of a concept is quite arbitrary. verifiable experience . . . Science is a special kind of
This historical focus on operationalization is word-producing, rule-making enterprise. (p. 52)
perhaps one factor that resulted in the percep-
tion that science is value-free or a measure of the Hayes's definition is consistent with Kuhn
ªtruth.º Today, there is general agreement that (1970) in that both see science as the accumula-
science, and the results of science, are influenced tion of information designed towards a better
by the beliefs, expectations, and values of the understanding of the world. Unlike other per-
researcher and the research community he or spectives, however, Hayes suggests that there
Science: Definitions and Models for Clinical Psychology 53
are aspects of the world that can be studied and descriptors might be quite elaborate and,
measured which are beyond the scope of rule- combined with some video clips of someone
governed science. engaged in ªbatting,º we may have the funda-
mentals for the science of baseball. However,
1.02.3.2 Science vs. Art this ªscience of baseballº will never be an exact
replica of baseball experienced by the profes-
As mentioned previously, science must be sional, unless it incorporates the contingency-
understood in terms of both the factual theories shaped skills learned through the interaction of
and method and the behavioral experiences of the ballplayer and his or her experiences at
the scientist. Facts are more likely to be learned playing ball.
from reading and studying a subject but Likewise, an understanding of the science of
experiences are a critical part of any learning clinical psychology requires an understanding of
endeavor. the known rules of clinical psychology, com-
It is widely accepted that behavior is bined with experiences that allow contingency-
influenced by rules and experiences (Hayes, shaped learning. While the study of science
1989; Haye's, Zettle, & Rosenfarb, 1989). These involves both components, it is difficult to
different influences are often labeled as ªrule- document those critical experiential aspects of
governed behaviorº (Hayes, 1989, 1995) and science training. Most often we focus on issues
ªcontingency-shaped behaviorº (Hayes, 1995). such as mentoring and directed research as a
Another way of expressing these ideas might be mechanism to acquire contingency-shaped as-
the difference between what is often thought of pects of science.
as didactic ªacademicº information vs. practical There has been a push to evaluate the critical
ªexperience.º In clinical psychology, this trans- importance of hands-on training in the labora-
lates roughly into what one learns from reading tory for teaching science. For example, Ertepi-
the literature or going to class compared with nar and Geban (1996) demonstrated that the
what one learns from supervised clinical and addition of a laboratory-based method which
research opportunities. focuses on conducting science studies resulted in
There are important differences between a greater mastery of science knowledge than
those behaviors acquired through rule-gov- merely providing students with science informa-
erned processes and behavior acquired via tion. Thus, it appears that active involvement in
contingency-shaping: behaviors relevant to science may be an
important part of science training.
Rule-governed behavior tends to be somewhat
more rigid, less modifiable by its direct conse-
quences, more precise in its initial forms, and more 1.02.3.3 Clinical Scientists and Clinical
subject to arbitrary social contingencies. Practitioners
Contingency-shaped behavior is generally more
moldable and modifiable, but it is also more As mentioned previously, clinical psycholo-
variable, and subject to chance contingencies. gists engage in many different activities with two
(Hayes, 1995, p. 52) of the most identifiable being the science and
practice roles. Psychologists who emphasize
Science focuses primarily on rule-governed clinical research can be identified as clinical
behaviors. However, as Hayes (1995) points scientists, while individuals who emphasize
out, while ªscience is the best rule-generating clinical practice are often described as clinical
institution ever invented, it is wrong to think practitioners. While it is clear that these roles are
that all behavior can be directly rule- arbitrary and that science and practice often go
governed . . . Any instance of rule-governed be- hand in hand, it is also clear that some training
havior stands ultimately on contingency-shaped programs emphasize training for clinical science
behavior, at least to a degreeº (pp. 52±53). careers and others emphasize training for
Thus, experience plays a critical role in science. clinical practice careers. Likewise, many clinical
An example might be helpful. Articulation of psychologists engage in both scientific and
rules that govern behavior is the first step in the practice careers simultaneously; however, there
development of science and critical to the is much to be gained from differentiating
understanding of the status of a scientific clinical science training from clinical practice
discipline. If we were to develop a science of training.
baseball, we might first want to articulate rules Clinical scientists and clinical practitioners
to describe how a person should swing a bat to need to be well grounded in the knowledge base
hit a ball approaching at speeds of nearly 140 of clinical psychology (this will be discussed in
kilometers per hour. The rules might include a greater detail in Section 1.02.4). Such training
discussion on stance, placement of the bat, would allow both types of trainees comparable
choice of the type of bat, etc. This verbal set of exposure to the rules of the science of clinical
psychology. In addition, basic contingency- much more variable and likely to be influenced
shaped experiences in clinical research and by chance contingencies (Hayes, 1995). How-
clinical practice are critical for both career ever, there are certain activities that will enhance
paths. To become a sound clinical researcher, training in science or practice. The development
basic training in clinical practice is critical. of contingency-shaped practice skills can be
Likewise, sound clinical practitioners must have enhanced through an emphasis on practical
basic experience in clinical research. However, training clinical service delivery with a broader
the types of contingency-shaped experiences range of clients and treatment methods. Science
and the amount of contingency-shaped experi- training can be enhanced with an emphasis on
ences may be quite different for success as a practical research training, again with a broader
researcher or practitioner. range of methods and problems. While time
The ideal method for gaining contingency- constraints in a training program will limit the
shaped experiences in research would be through amount of experiential training in both the
supervised research with an experienced mentor practice and science aspects of clinical psychol-
who can guide and direct the activity. Such ogy, the time spent engaged in an activity does
experiences would provide contingency-shaped not guarantee more or better contingency-
behaviors critical for science practice in clinical shaped behavior. It is likely that the quality
psychology that are unique from the rule- of the supervised experience (either in research
governed science behaviors. These activities or practice) will have a greater influence on
are typically formalized in academic training outcomes.
programs in terms of thesis and dissertation Given that an emphasis on training students
requirements; however, successful completion of for roles as clinical scientists or clinical practi-
a dissertation is probably minimal for both tioners may result in unique behavioral reper-
clinical scientists and clinical practitioners and toires owing to differential rule-governed and
more extensive supervised research experiences contingency-shaped behaviors, it should come
(such as one or two years of postdoctoral as no surprise that both career paths offer
experience with a senior scientist) would en- unique and important contributions to the
hance the development of contingency-shaped science of clinical psychology. A recognition
research skills critical for a career as a clinical of the different contributions may be critical to
scientist. our advancement of the science of clinical
Practice training requires extensive contact psychology, but beyond the scope of this
with clinical populations. The ideal is super- chapter. However, several papers (e.g., Clem-
vised clinical work with an experienced profes- ent, 1988, 1996; Davison & Lazarus, 1995;
sional who can guide and direct the activity. Fensterheim, 1993; Fensterheim & Raw, 1996;
Like research experience, clinical experiences Kanfer, 1990; Marten & Heimberg, 1995; Nezu,
will provide contingency-shaped behaviors 1996; Woolfolk & Lazarus, 1979) will provide
critical for the practice of clinical psychology an overview of this area for interested readers.
that are unique to the contingency-based An understanding of these unique contributions
research behaviors or the rule-governed aspects requires better identification of the rule-gov-
of clinical psychology. Academic programs erned and contingency-shaped aspects of clin-
require a minimal amount of clinical practice ical psychology.
and a-year of full-time clinical training (intern- Much of the controversy over the science
ship). However, these experiences are minimal and practice of clinical psychology comes from a
basic training. As with research training, failure to recognize the importance of con-
postdoctoral experiences in a clinical setting tingency-shaped behaviors and the unique
may be critical for the development of sophis- perspective gained from mentored research
ticated contingency-shaped practice skills. and mentored clinical training. It has been
At first glance, this may seem to be merely an suggested that if the split between the science
attempt to redefine the existing model of clinical and practice of clinical psychology is not
psychology training using new jargon. How- resolved, we may see a dissolution between
ever, this redefinition can greatly influence the the science and practice of clinical psychology
manner in which science and practice are taught (Rice, 1997). Failure to resolve this split might
and may provide a useful model for the result in clinical training being removed from
integration of science and practice. It should academic psychology departments and rele-
come as no surprise that there will be a great deal gated exclusively to professional schools. In this
of variability with respect to contingency- scenario, Rice has predicted that clinical health
shaped behaviors. By their definition, these psychology would become an allied health
experiences are somewhat unique. Unlike rules, profession, rehabilitation psychology would
where everyone can be taught the same ally itself with occupational therapy, and
concepts, contingency-shaped behavior will be counseling psychology would evolve into
The Current Status of Science in Clinical Psychology 55
ªspiritual counseling.º Academic departments empiricism and science. Categories were chan-
would see a decline in graduate students and the ged (or added) only if there were sufficient data
blending of traditional psychology departments to warrant such a change. Symptoms of dis-
with other academic units such as neuroscience, orders likewise were modified, only with con-
human development, computer science, and siderable evidence that the existing criteria were
social science departments. inadequate and that new criteria were more
Rice's (1997) dissolution scenario is by no accurate.
means the future of psychology, but a probable While there is a strong scientific emphasis in
outcome if science and practice are not the DSM system, it is not without its critics (cf.,
emphasized in clinical psychology training. Kaplan, 1983; Kirk & Kutchins, 1992; Miller,
Later in this chapter, Rice's ªscience-based Bergstrom, Cross, & Grube, 1981; Schacht,
practiceº scenario will be discussed as the ideal 1985; Singerman, 1981). As with any scientific
outcome for clinical psychology. First, however, endeavor, there are some assumptions in which
the current status of science in clinical psychol- science may have appeared to play little or no
ogy is reviewed with an emphasis on identifiable role. Spitzer (1985) identified several nonscience
rule-governed and contingency-shaped aspects aspects involved in the development of the
of the science of clinical psychology. DSM, two of which will be summarized here.
First, the DSM is based on a descriptive
approach which emphasized classification on
the basis of shared clinical features rather than
1.02.4 THE CURRENT STATUS OF presumed etiology. Science has not shown that
SCIENCE IN CLINICAL descriptive approaches are superior to other
PSYCHOLOGY approaches. In fact, there is no compelling
reason to believe that a similar disorder would
1.02.4.1 Diagnosis and Assessment not show up in different individuals as different
The publication of the third edition of the symptoms. The DSM deals with these differ-
Diagnostic and statistical manual of mental ences by identification of a list of descriptive
disorders (DSM-III; American Psychiatric As- criteria, and the clinician merely tallies the
sociation, 1980) changed the manner and number of symptoms presented by the client.
approach to diagnosis and classification used A diagnosis is given if the number of symptoms
in clinical psychology. The system was widely meets or exceeds a predetermined criteria.
adopted (although not uniformly supported, see Second, Spitzer points out that subjective
Kirk & Kutchins, 1992, for a review) by all judgments played a major role in the develop-
mental health professions. DSM-III (and its ment of the DSM-III. As noted in the
successors DSM-III-R, American Psychiatric introduction to DSM-III, ªmost of the diag-
Association, 1987; DSM-IV, American Psy- nostic criteria are based on clinical judgment,
chiatric Association, 1994) has become the and have not yet been fully validated by data.º
standard classification system for clinical psy- While the revisions have continued to search for
chology and is represented in almost every empirical support and less subjective data,
major textbook on the topic (Klerman, 1984). clinical judgment continues to play a major
The shift from DSM-II (American Psychiatric role in this diagnostic system.
Association, 1968) to DSM-III was profound. For the scientist±practitioner and the clinical
DSM-II was heavily influenced by psychody- scientist, the DSM-III and its successors
namic theory and used concepts such as neurosis provide a significant step towards the develop-
and psychosis as major classifications. DSM-III ment of a strong science. The rules are clearer
attempted to develop a more empirical, and to than other diagnostic systems; however, the
some, more scientific classification. This change system continues to utilize clinical judgments
had great influences on both the science of (contingency-shaped behaviors) necessary given
clinical psychology and psychiatry. Maxmen the existing knowledge base. As the field
(1986) described this shift as: develops and more is learned about specific
disorders, the DSM system allows for correc-
Psychoanalytic psychiatry bases truth on author- tion and changes in the diagnostic rules. It is
ity; something is true because Freud said so. anticipated that changes will occur and me-
Scientific psychiatry bases truth on scientific chanisms have been built in to facilitate and
experimentation . . . The old psychiatry derives foster change.
from theory, the new psychiatry derives from fact. The scientific status of psychological assess-
(p. 31) ment is difficult to evaluate. On the one hand,
with regard to testing and test development,
Changes in the DSM (from the third to the there are ª180 guidelines covering 16 categories
fourth edition) have continued to emphasize pertaining to the activities of test developers,
test users, and test takersº (Cone, 1995, p. 204). Managed health care may directly influence
However, there is considerable debate as to the the use of sound clinical assessment strategies
best use of tests in clinical psychology (cf., (Nelson-Gray, 1996). The current trend is to
Collins & Thompson, 1993; Cone, 1989; Hayes, develop outcome measures applicable to all
Nelson, & Jarrett, 1987, 1989; Haynes & clients (Nelson-Gray). While the development
Uchigakiuchi, 1993). of uniform measures may be useful, measures
With respect to guidelines, the majority focus unique to diagnostic categories may be far more
on (i) technical standards for test construction helpful because of the differences in success
and evaluation, such as validity, reliability, rates with different clinical problems (Nelson-
norming, etc.; (ii) professional standards for test Gray). For example, treatment of social phobia
use, such as employment testing, educational may be best evaluated using the Index of Social
testing, etc.; (iii) standards for particular Phobia Improvement (Turner, Beidel, & Wolf,
applications, such as testing of individuals for 1994); depressed individuals might best be
whom English is a second language, visual evaluated using the Beck Depression Inventory
impairments, etc.; and (iv) standards for (Beck, Ward, Mendelsohn, Mock, & Erbaugh,
administrative procedures, such as scoring 1961), and anxiety disorders might be evaluated
and reporting issues, and the rights of test- using the State-Trait Anxiety Inventory (Spiel-
takers (Cone, 1995). berger, Gorusch, & Lushene, 1970). For many
While the existing standards are important situations, however, individualized (or idio-
and useful to the science of psychology, Cone graphic) assessment methods may be needed
(1995) recommends that new standards be (Collins & Thompson, 1993; Nelson-Gray,
developed to improve the utility of psycholo- 1996).
gical assessment methods. Cone's detailed
rationale for each of these recommendations
will not be presented in this chapter; however, 1.02.4.2 Scientific Status of Clinical Assessment
the new standards should:
A great deal is known about the psychometric
(1) Recognize that different subject matters might properties of tests (Cone, 1988). Clinical
require modifications in standards. psychology has developed sophisticated mea-
(2) Make room for the concept of accuracy, and sures of intelligence (Kaufman & Harrison,
distinguish it from reliability and validity. 1991) and personality (Ben-Porath & Butcher,
(3) Distinguish between representational and ela- 1991). In general, we have a fairly sophisticated,
borative validity, and require purveyors of new sound set of rule-governed behaviors as a
measures to show the former and some evidence of foundation for the science of clinical psychol-
the latter before publishing the measure.
(4) Require psychologists to evaluate what they
ogy. The use of assessment in clinical settings
do. (contingency-shaped experiences) is less clear
(5) Develop standards dealing with the process of cut. Since the mid-1970s, there has been a
that evaluation. noticeable decline in emphasis on clinical
(6) Consider specific standards dealing with func- assessment (Garfield & Kurtz, 1973, 1976;
tional analysis. Levitt, 1973; Shemberg & Keeley, 1970).
(7) Include standards focusing on idiographic or One factor that has contributed to the
local use assessment activities. (Cone, 1995, p. 220) decreased use of clinical assessment in the field
is that clinicians have not always found these
One of the most important steps for improv- data to be useful in treatment (Adams, 1972;
ing the science in clinical assessment is to get Moore, Boblitt, & Wildman, 1968). The beha-
practicing psychologists to evaluate what they vioral alternative to traditional assessment,
do. While everyone agrees that evaluation is behavioral assessment, was developed in part
important, it is difficult to get consensus on the as a reaction to more traditional assessment
systematic application of psychological meth- approaches (Hersen, 1976). More recently, even
ods and practices to clinical assessment (Kaz- among behavioral psychologists, reliance on
din, 1996a). Clement (1996) offers a model of behavioral observations for assessment has
practice assessment which focuses on diagnosis, given way to more moderate approaches in-
treatment plans, compliance with treatment volving the use of psychometrically sound trait
plans, and assessment of treatment outcome. measures (Collins & Thompson, 1993; Gross,
While this plan may be criticized as relying 1990; Watkins, Campbell, & McGregor, 1990).
heavily on self-report measures (Nezu, 1996), Cone (1988) points out that there are two
the spirit of the plan is an important step for ªcontrasting models of behavioral assessmentº
improving the scientific status of assessment in (p. 46): a nomothetic-trait approach and an
clinical psychology (Hayes, 1996; Lambert & idiographic-behavioral approach. The nomo-
Brown, 1996). thetic approach enables the comparison of an
The Current Status of Science in Clinical Psychology 57
individual's score on an assessment measure to a Miller, 1980; VandenBos & Pino, 1980; Yates &
normative reference group. The idiographic- Newman, 1980) reached the general conclusion
behavioral approach focuses on changes over that ªPsychotherapy, as a generic treatment
time for a single individual. Idiographic assess- process, [is] demonstrably more effective than
ment provides the scientist±practitioner with no treatmentº (VandenBos, 1986, p. 111). The
useful methods for increasing the quality of the primary reason for this has to do with what has
science in his or her practice (Barlow, Hayes, & been called ªnonspecific factorsº thought to be
Nelson, 1984). common to all forms of psychotherapy (cf.,
While the integration of idiographic and Arkowitz, 1995; Beutler, 1995; Elkin, 1995;
nomothetic systems is strongly encouraged Frank, 1995; Ilardi & Craighead, 1994; Lu-
today, there is little evidence about how to borsky, 1995; Weinberger, 1995). The years
accomplish this integration. Hersen and Bellack since 1985 have focused on comparative out-
(1988) have advocated an ªidiographic ap- come research. That is, the emphasis was no
proach within the normal nomothetic systemº longer on whether or not psychotherapy works,
(p. 78). Collins and Thompson (1993) suggest but what type of psychotherapy works with
that an equally useful alternative is the use of what disorders. In the mid-1980s, VandenBos,
ªnomothetic (personality) data [integrated] in the introduction to the special issues of the
within the idiographically based behavioral American Psychologist on Psychotherapy Re-
assessmentº (p. 69). search, appeared to encourage such research:
Four broad guidelines have been recom-
mended (cf., Collins & Thompson, 1993). First, It now appears that single-focus ªoutcomeº (or
assessments must use empirically sound mea- efficacy) research should be a ªthing of the past.º
sures. There are many unsound measures, Future psychotherapy outcome research should,
frequently tied to particular theoretical con- at a minimum, be ªcomparativeº outcome
structs or part of ªclinical lore.º Not only must researchÐexploring the relative advantages and
the assessment measures used have an empirical disadvantages of alternative treatment strategies
basis, the ªmethods must be administered and for patients with different specific psychological
interpreted from an empirical data baseº (p. 65). and behavioral difficulties. (p. 111)
Second, assessments derived from specific
measures must be confirmed. Most measures In 1995, the Task Force on the Promotion
are open to multiple interpretations. Third, the and Dissemination of Psychological Procedures
behavior of interest must be differentiated from published a list which contained ªExamples of
the assessment score. Assessment data are only empirically validated treatmentsº (Table 3,
useful because of their ability to predict p. 22). The publication of this list has resulted
behavior; however, the assessment data are in immense praise and criticism and, regardless
not the behavior. Finally, assessment data must of one's perspective as to the accuracy of the list,
be collected repeatedly over time. Single the list is important for the evaluation of the
measures are rarely useful in clinical settings. scientific status of clinical intervention in psy-
chology.
Many psychotherapy researchers agree with
1.02.4.3 Clinical Interventions the general conclusions of the Task Force. For
example, Seligman (1995) states,
Our knowledge about the scientific status of
clinical interventions has grown immensely.
studies show . . . that cognitive therapy, interper-
However, the conclusions drawn from these sonal therapy, and medications all provide mod-
data are not consistent. On the one hand, there erate relief from unipolar depressive disorder; that
is a lot known about which types of therapy are exposure and clomipramine both relieve the
likely to produce the greatest benefit in some symptoms of obsessive-compulsive disorder mod-
clinical disorders (Kazdin, 1996b); on the other, erately well but that exposure has more lasting
there is continued evidence that most forms of benefits; that cognitive therapy works very well in
psychotherapy are useful with little to no panic disorder; that systematic desensitization
differences between the ªtypeº of therapy and relieves specific phobias; that ªapplied tensionº
success (Seligman, 1995). These somewhat virtually cures blood and injury phobia; that
antithetical conclusions have been derived using aversion therapy produces only marginal improve-
ment with sexual offenders; that disulfram (Anti-
different scientific methodologies and will be buse) does not provide lasting relief from
explained in some detail. alcoholism, that flooding plus medication does
By 1980, many psychotherapy researchers better in the treatment of agoraphobia than either
(e.g., Bergin & Lambert, 1978; Luborsky, alone; and that cognitive therapy provides sig-
Singer, & Luborsky, 1975; Shapiro & Shapiro, nificant relief of bulimia, outperforming medica-
1982; Smith & Glass, 1977; Smith, Glass, & tions alone. (pp. 965±966)
Barlow (1996) adds, Second, psychotherapy allows for correction.

That is, if a technique or approach is not
I believe, along with many others, that the evidence working for a client, then another approach is
is incontrovertible that we have effective psycho- typically tried. This issue of self-correction is
logical interventions for a large number (but not similar to medical treatments that are discon-
all) of psychological disorders. Numerous studies tinued and/or replaced if the desired short-term
and subsequent meta-analyses have demonstrated
that any number of specific psychotherapeutic
outcome is not forthcoming. Comparative
approaches, either alone or, in some cases, in outcome studies are rarely designed with this
combination with pharmacological approaches, in mind. Blanchard and his colleagues (Blan-
are more effective and often longer lasting than chard et al., 1996) used a self-correcting design
credible alternative psychological interventions. in the study of biofeedback and hypertension.
(p. 216) Treatment failures were then randomly assigned
to an alternative therapy. However, I am not
Given these strong endorsements, it may at aware of similar designs in the psychotherapy
first seem confusing to learn that some of the literature.
more influential psychotherapy researchers Third, in the field, patients are often engaged
(e.g., Garfield, 1996; Havik & VandenBos, in ªactive shopping.º They learn about different
1996; Seligman, 1995; Shapiro, 1996) believe forms of therapy and actively seek out someone
that these research studies are of little impor- who can provide that type or modality of
tance to the scientific study of psychotherapy. therapy. In controlled outcome studies, random
One of the major criticisms of comparative assignment results in a great deal of passivity on
outcome studies is that the results have little the part of the participant (Howard, Orlinsky, &
relevance to clinical practice (Garfield, 1996; Lueger, 1994).
Havik & VandenBos, 1996; Munoz, Hollon, Fourth, patients seen in the field often have
McGrath, Rehm, & VandenBos, 1994; Selig- more than one problem, or the problems that
man, 1995). Participants seen in comparative they present with do not fit diagnostic criteria.
outcome studies give informed consent to be Many times the symptoms of their problems
randomly assigned to different treatment con- result in multiple diagnoses. See Lilienfeld,
ditions, whereas patients seen in clinical practice Waldman, and Israel (1994), Rutter (1994),
do not. Comparative outcome studies frequently Widiger and Ford-Black (1994) for a discussion
use manualized treatment protocols that place of the problems with comorbid diagnosis in
guidelines on therapist behaviors and the DSM. Comparative outcome studies, however,
number of treatment sessions provided, whereas tend to focus on individuals with fairly specific
therapists in clinical practice rarely adhere to the inclusion criteria. While this is reasonable in
type of manualized treatments used in compara- terms of the specific data analytic models used in
tive outcome studies (Persons, 1995) and almost comparative outcome studies, it still makes
never routinely limit the number of sessions. generalization to field studies more difficult.
Seligman (1995) argues that ªeffectivenessº Finally, the end goal of field studies is ªwith
psychotherapy studies, not comparative out- improvement in the general functioning of
comes studies, are the best way of ªfinding out patients, as well as amelioration of a disorder
what treatments actually work in the fieldº and relief of specific, presenting symptomsº
(p. 966). To conduct a sound effectiveness study (Seligman 1995, p. 967). Comparative outcome
requires allowing a great deal of flexibility. For studies focus on specific symptom reduction.
example, Seligman identifies five ªproperties
that . . . characterize psychotherapy as it is done
in the fieldº (p. 966). These factors will be 1.02.4.4 Scientific Status of Clinical
discussed in some detail as they are critical for Interventions
evaluation of the scientific status of clinical
psychology. Clearly there is a great deal of information
First, psychotherapy cannot be defined in available regarding rule-governed aspects of
terms of number of sessions. In the field, it psychotherapy. Elaborate manuals have been
continues until there is some improvement or developed to help therapists administer a variety
until the patient decides he or she should quit. of interventions ranging from relaxation train-
This is extremely important since the most ing (e.g., Bernstein & Borkovec, 1973) to
elaborate effectiveness study conducted to date, cognitive therapy (e.g., Beck, Rush, Shaw &
the Consumer Reports study (1995; Seligman, Emery, 1979). Therapist manuals are available
1995), found duration of therapy to be to help in the treatment of many disorders (e.g.
positively related to improvement with the Panic and anxiety, Barlow & Craske, 1994;
greatest improvement reported by individuals Craske, Meadows, & Barlow, 1994; Borderline
in therapy for two or more years. personality disorder, Linehan, 1993).
Training Science in Clinical Psychology 59
The development of manualized therapy has of efficacious training manuals. Such training
had a significant impact on the science of will enhance the scientific status of clinical
clinical psychology (Eifert, Schulte, Zvolensky, interventions by directly shaping therapist
Lejuez, & Lau, 1997). The operationalization of behavior.
specific aspects of therapy has contributed Flexibility in the use of treatment manuals is
significantly to clinical outcome research (Bar- less clear. Allowing therapists to ªfreelanceº or
low & Craske, 1994; Chambless, 1996; Selig- stray too far from the procedures outlined in the
man, 1995); however, the existence of a manual manuals may not be desired (Eifert et al., 1997).
does not guarantee that all therapists will be For example, Frank, Kupfer, Wagner, McEa-
equally effective, or that they will present the chran, and Cornes (1991) demonstrated a
material in the same manner (Chambless). strong relationship between adherence and
Likewise, manualized therapy does not guar- positive outcomes. More research is needed,
antee that the behaviors identified in the therapy and it is possible that some manualized
manual are identical to those used in the treatments need to be closely adhered to, while
practice of clinical psychology (Collins & others may allow for substantial therapist
Thompson, 1988). flexibility.
Most therapy manuals provide some caution
that successful implementation of manualized
treatment requires skilled therapists. For ex- 1.02.5 TRAINING SCIENCE IN CLINICAL
ample, Barlow and Craske (1994) state: PSYCHOLOGY: THE SCIENTIST±
PRACTITIONER MODEL
The first revolution in the development of effective
psychosocial treatments during the past decade The scientist±practitioner model was first
has been the manualization of these treatments. articulated at the Boulder Conference (Raimy,
Because these are structured programs for specific 1950) and continues to be one of the most
disorders, they can be written in sufficient detail to prominent, if not the primary, model for training
allow trained therapists to administer them in clinical psychologists. Rice (1997) sees a
roughly the same manner that they were proven ªscience-based practiceº as a likely scenario
effective. This does not imply that therapeutic skills
are no longer needed. In fact, in the training
for psychology as a profession, and in my
tapes. . .there are numerous examples of the im- opinion, the most optimistic scenario for
portance of highly trained psychotherapeutic skills psychology. The Gainesville Conference (Belar
as one proceeds with the program. (Chap. 2, p. 6, & Perry, 1992) articulated the components of
italics added) this model quite well and a brief summary
follows.
Chambless (1996) concurs but expands on the First, delegates at the Gainesville Conference
usefulness of manualized therapy: ªasserted that the scientist±practitioner model
was essential for the ever-changing discipline of
I agree that manuals do not completely mirror psychologyº (Belar & Perry, 1992, p. 71). While
clinical practice but argue that they have much to there appears to be room for alternative models
teach us if the treatment they depict is efficacious. I of training, this model is critical to the
find that students learn treatment approaches continued scientific development of clinical
much more quickly from their systematic depiction psychology.
in manuals. . .than through supervision alone. Second, the hallmark of this model is the
(p. 231) integrated training of science and practice, not
the job title or position of the graduate. This
Using the model of rule-governed/ difference is important. The usefulness of this
contingency-shaped behaviors as a guide, it is training model cannot be evaluated by counting
clear that the professional use of treatment the number of graduates who publish scholarly
manuals will foster the acquisition of rule- work or who are employed as clinical scientists.
governed behaviors. Likewise, clinical super- Rather, training in the scientist±practitioner
vised practice using efficacious treatment model should produce professionals who use
manuals sets the occasion for continued the scientific knowledge base of clinical psy-
contingency-shaped learning. Several writers chology in their practice and who approach the
(Iwamasa & Orsillo, 1997; Persons, 1995) have problems and questions of clinical practice in a
suggested that incorporating efficacious treat- scientific manner.
ment manuals into a clinical training program is Third, the conference identified the impor-
critical. Persons suggests that the main reason tance of both didactic (rule-governed) and
most psychotherapists do not conduct therapy practical (contingency-shaped) training in the
consistent with the outcome literature is that science of psychology and the strategies and
they have received little or no training in the use tactics of applied work. Didactic science
training includes competence in the major settings. A two-year specialty internship completes
scientific areas of psychology identified as the the training. A research dissertation, usually of an
biological bases of behavior, cognitive-affective applied nature, is required for all completing the
bases of behavior, social bases of behavior, and PhD. Fewer students are admitted to these pro-
grams because of the training, which is rigorous
individual differences. Didactic practice train-
and expensive due to the large number of full-time
ing emphasizes ªthe application of scientific faculty who teach these basic courses and who
thinking and behavior to problem-solving and engage in a range of applied psychology research
hypothesis-testing in practiceº (p. 73). Practical ventures.
training must focus on the integration of science Academic psychology departments continue the
and practice and should include both predis- tradition of preparing teachers and researchers.
sertation research as well as the completion of a Teaching positions are fairly abundant in both
dissertation. The doctoral dissertation should psychology departments and professional schools.
provide an opportunity for the trainee to Research positions are found outside academia in
demonstrate ªcompetence to carry out an commercial and governmental settings. The tradi-
tional psychology fields such as social, experi-
original, independent scientific investigation
mental, developmental, and I/O psychology
that furthers psychological knowledgeº (p. 74). remain, but most departments offer training in
Clearly, the scientist±practitioner training health psychology, experimental psychopathol-
model articulated by Belar and Perry (1992) is ogy, or both. (pp. 1177±1178)
consistent with the model of science discussed
throughout this chapter. Scientist±practitioner While some will cringe at the notion that
training requires contemporary didactic train- training in applied psychology should occur in a
ing in the knowledge base of clinical psychology. professional school, this scenario is more con-
Such training should strengthen the acquisition sistent with current training goals and in no way
of rule-governed behaviors critical for the minimizes the importance of science training.
science of clinical psychology. Likewise, prac- Likewise, much of the conflict between the
tical experience is needed. However, such science and practice of psychology can be
experiences should continue to integrate science minimized through this scenario.
knowledge in all aspects of practice. This
includes research and clinical work. Thus,
research training in clinical psychology must 1.02.6 SCIENCE, THE CHANGING
integrate the acquired knowledge of the science HEALTH CARE SYSTEM, AND THE
of psychology, with supervised experience DEMAND FOR PSYCHOLOGY
conducting clinical research. Likewise, clinical
practice must integrate the acquired knowledge Changes in health care appear inevitable
of the science of psychology, with supervised (VandenBos, 1993). Two factors will influence
experience in clinical assessment and psy- the final outcome of this process: (i) costÐall
chotherapy. else being equal, less expensive forms of treat-
While the scientist±practitioner model is ment will be preferred; and (ii) effectivenessÐfor
typically applied to clinical psychology, Rice problems with known effective treatment, those
(1997) sees a future where all professional treatments shown to be effective will be sup-
psychology is science based: ported (Barlow, 1994). It is critical, therefore, to
develop a strong case for scientific evaluation
and implementation of clinical psychology
In this scenario, all psychological practitioners, services.
including counseling, school, and industrial/orga-
nizational (I/O) psychologists, are trained as
Detailed guidelines are already being devel-
science-based practitioners to work in a variety oped. For example, the Agency for Health Care
of settings. Most of the persons preparing for the Policy and Research, which was commissioned
practice attend professional schools, which are by the federal government to determine the
typically attached to universities and maintain effectiveness of treatments for specific disor-
close relations with academic psychology depart- ders, has published a two-volume document
ments. These professional schools usually offer the which provides recommendations for treating
PhD rather than the PsyD degree, though there is major depressive disorders (Barlow, 1994). The
variation with respect to this. summarized findings of this evaluation was that
The professional school curriculum is rigorously medications are the first-line treatment for
and narrowly structured during the first two years;
students take course work in cognitive psychology,
almost all cases of major depressive disorder.
neuropsychology, psychometic theory, develop- Exceptions to medication are when the depres-
mental and social psychology, psychopharmacol- sion is mild or when the patient specifically asks
ogy, and research methods. During the next two for psychosocial treatments (Barlow).
years, students take more specialized courses to While clinical psychology continues to debate
prepare them for work in various organizational the usefulness of controlled outcome studies, it
References 61
is clear that these types of studies are providing are consistent with the primary training model
the major source for the analysis and ultimate of clinical psychology (the scientist±practitioner
development of public policy. Students in model) which is flexible enough to allow clinical
clinical psychology must be trained in the psychologists to focus on the science (clinical
science of clinical psychology and the methods scientists) and practice (clinical practitioners) of
that currently appear most efficacious. It is clinical psychology.
expected that the specific methods will change Clinical assessment has a strong didactic
(Iwamasa & Orsillo, 1997); however, sound knowledge base. While clinical psychologists
professional science training will allow clinical are not using clinical assessment strategies as
psychology to adapt and develop. frequently as in the past, changes in the way
One often overlooked aspect of clinical psychological assessment is conceptualized and
psychology is the extent to which practice used appear promising. However, it is likely that
activities are the exclusive domain of clinical clinical assessment and clinical intervention will
psychology, or also in the domain of other become more integrated and the need to
health care providers. Clinical psychology as a differentiate between assessment and interven-
discipline requires the doctoral degree for entry tion may no longer be critical.
into the profession; however, many of the Much is known about the most effective
professional activities historically identified treatments for some psychological problems.
with clinical psychology are today provided While the development of effective treatments is
by other professionals, often with a terminal contested by some, the proliferation of treat-
master's degree. The professionals are often ment manuals and potential changes in public
licensed by states as counselors, social workers, policy should serve to strengthen the science
marriage and family therapists, and in a few base of clinical intervention.
states as psychologists. In summary, clinical psychology retains a
Given the change in health care that strong commitment to science and science
emphasizes less expensive forms of treatment models predominate all aspects of clinical
as preferred, it is not surprising that many state psychology. There is room for growth and
agencies and health organizations frequently new developments in the field; however, the
employ master's training professionals to current status of clinical psychology will serve as
provide counseling and psychotherapy services. a strong foundation.
This change, combined with the large number of
doctoral clinical psychologists graduating each
year, has led to a concern with the current 1.02.8 REFERENCES
supply and future demand for clinical psychol-
Ackermann, R. (1970). Philosophy of science: An introduc-
ogists (cf., Pion, 1991; Robiner, 1991a, 1991b; tion. New York: Pegasus.
VandenBos, DeLeon, & Belar, 1991). While it is Adams, J. (1972). The contribution of the psychological
not clear how ªmanyº psychologists are needed, evaluation to psychiatric diagnosis. Journal of Person-
it is clear that psychology must identify those ality Assessment, 36, 561±566.
aspects of training that make psychologists American Psychiatric Association (1968). Diagnostic and
statistical manual of mental disorders (2nd ed.). Wa-
unique from master's level practitioners. Rig- shington, DC: Author.
orous training in science that includes rule- American Psychiatric Association (1980). Diagnostic and
governed and contingency-based training may statistical manual of mental disorders (3rd ed.). Wa-
prove to be the critical difference. shington, DC: Author.
American Psychiatric Association (1987). Diagnostic and
Clinical scientists will be expected to show statistical manual of mental disorders (3rd ed., Rev.).
leadership in research on effective clinical Washington, DC: Author.
assessment and intervention approaches. Clin- American Psychiatric Association (1994). Diagnostic and
ical practitioners must incorporate the knowl- statistical manual of mental disorders (4th ed.). Washing-
edge base of clinical psychology in their practice ton, DC: Author.
American Psychological Association (1992). Ethical princi-
and identify strengths and weaknesses of ples of psychologists and code of conduct. Washington,
proposed efficacious treatments. This dialog DC: Author.
between clinical scientists and clinical practi- Arkowitz, H. (1995). Common factors or processes of
tioners is critical for the continued development change in psychotherapy? Clinical Psychology: Science
and Practice, 2, 94±100.
of science in clinical psychology. Barlow, D. H. (1994). Psychological interventions in the
era of managed competition. Clinical Psychology:
Science and Practice, 1, 109±122.
Barlow, D. H., & Craske, M. G. (1994). Mastery of your
1.02.7 CONCLUSIONS anxiety and panic: II. Albany, NY: Graywind Publica-
tions.
The hallmark of clinical psychology is the Barlow, D. H. (1996). The effectiveness of psychotherapy:
emphasis on science. The scientific status of Science and policy. Clinical Psychology: Science and
clinical psychology is strong. Models of science Practice, 3, 236±240.
Barlow, D. H., Hayes, S. C., & Nelson, R. O. (1984). The Cone, J. D. (1988). Psychometric considerations and the
scientist practitioner: Research and accountability in multiple models of behavioral assessment. In A. S.
clinical and educational settings. New York: Pergamon. Bellack & M. Hersen (Eds.), Behavioral Assessment: A
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). practical handbook (3rd ed., pp. 42±66). New York:
Cognitive therapy of depression: A treatment manual. Pergamon.
New York: Guilford Press. Cone, J. D. (1989). Is there utility for treatment utility?
Beck, A. T., Ward, C. H., Mendelsohn, M., Mock, J., & American Psychologist, 44, 1241±1242.
Erbaugh, J. (1961). An inventory for measuring depres- Cone, J. D. (1995). Assessment practice standards. In S. C.
sion. Archives of General Psychiatry, 4, 561±571. Hayes, V. M. Follette, R. M. Dawes, & K. E. Grady
Belar, C. D., Bieliauskas, L. A., Klepac, R. K., Larsen, K. (Eds.), Scientific standards of psychological practice:
G., Stigall, T. T., & Zimet, C. N. (1993). National Issues and recommendations (pp. 201±224). Reno, NV:
conference on postdoctoral training in professional Context Press.
psychology. American Psychologist, 48, 1284±1289. Consumer Reports (1995, November). Mental health: Does
Belar, C. D., & Perry, N. W. (1992). National conference therapy help? Vol. 60, pp. 734±739.
on scientist±practitioner education and training for the Craske, M. G., Meadows, E. A., & Barlow, D. H. (1994).
professional practice of psychology. American Psychol- Therapist's guide for the mastery of your anxiety and
ogist, 47, 71±75. panic II: Agoraphobia supplement. Albany, NY: Gray-
Ben-Porath, Y. S., & Butcher, J. N. (1991). The historical wind Publications.
development of personality assessment. In C. E. Walker Davison, G. C., & Lazarus, A. A. (1995). The dialectics of
(Ed.), Clinical psychology: Historical and research science and practice. In S. C. Hayes, V. M. Follette, R.
foundations (pp. 121±156). New York: Plenum. M. Dawes, & K. E. Grady (Eds.), Scientific standards of
Bergin, A. E., & Lambert, M. J. (1978). The evaluation of psychological practice: Issues and recommendations
therapeutic outcomes. In S. L. Garfield & A. E. Bergin (pp. 95±120). Reno, NV: Context Press.
(Eds.), Handbook of psychotherapy and behavior change: Derner, G. F. (1965). Graduate education in clinical
An empirical analysis (2nd ed., pp. 139±190). New York: psychology. In B. B. Wolman (Ed.), Handbook of clinical
Wiley. psychology (pp. 1403±1414). New York: McGraw-Hill.
Bernstein, D. A., & Borkovec, T. D. (1973). Progressive Edelstein, B. A., & Brasted, W. (1983). Clinical training.
relaxation training: A manual for the helping professions. In M. Hersen, A. E. Kazdin, & A. S. Bellack (Eds.),
Champaign, IL: Research Press. Clinical psychology handbook (pp. 35±56). New York:
Beutler, L. E. (1995). Common factors and specific effects. Pergamon.
Clinical Psychology: Science and Practice, 2, 79±82. Eifert, G. H., Schulte, D., Zvolensky, M. J., Lejuez, C. W.,
Blanchard, E. B., Eisele, G., Vollmer, A., Payne, A., et al. & Lau, A. W. (1997). Manualized behavior therapy:
(1996). Controlled evaluation of thermal biofeedback in Merits and challenges. Behavior Therapy, 28, 499±509.
treatment of elevated blood pressure in unmedicated Elkin, I. (1995). Further differentiation of common factors.
mild hypertension. Biofeedback and Self-Regulation, 21, Clinical Psychology: Science and Practice, 2, 75±78.
167±190. Ertepinar, H., & Geban, O. (1996). Effect of instruction
Boring, E.G. (1950). A history of experimental psychology supplied with the investigative-oriented laboratory ap-
(2nd ed.). New York: Appleton-Century-Crofts. proach on achievement in a science course. Educational
Brems, C., Thevenin, D. M., & Routh, D. K. (1991). The Research, 38, 333±341.
history of clinical psychology. In C. E. Walker (Ed.), Fensterheim, H. (1993). Letter to the editor. The Behavior
Clinical psychology: Historical and research foundations Therapist, 16, 149.
(pp. 3±35). New York: Plenum. Fensterheim, H., & Raw, S. D. (1996). Psychotherapy
Campbell, D. T. (1984). Can we be scientific in applied research is not psychotherapy practice. Clinical Psychol-
science? In R. F. Conner, D. G. Altman, & C. Jackson ogy: Science and Practice, 3, 168±171.
(Eds.), Evaluation studies review annual (Vol. 9, Fishman, D. B. (1985). Where the underlying boundaries
pp. 26±48). Beverly Hills, CA: Sage. are: Organizing psychology by paradigm analysis.
Capshew, J. H., & Hilgard, E. R. (1992). The power of International Newsletter of Uninomic Psychology, 2, 4±9.
service: World War II and professional reform in the Fishman, D. B. (1988). Pragmatic behaviorism: Saving and
American Psychological Association. In R. B. Evans, V. nurturing the baby. In D. B. Fishman, F. Rotgers, & C.
Staudt-Sexton, & T. C. Cadwallader (Eds.), The Amer- M. Franks (Eds.), Paradigms in behavior therapy: Present
ican Psychological Association: A historical perspective and promise (pp. 254±293). New York: Springer.
(pp. 149±176). Washington, DC: American Psychologi- Foster, S. L., Berler, E. S., & Collins, F. L. (1982).
cal Association. Conference report: The West Virginia Working Con-
Chambless, D. L. (1996). In defense of dissemination of ference on Behavioral Training in Clinical Psychology.
empirically supported psychological interventions. Clin- The Behavior Therapist, 5, 184.
ical Psychology: Science and Practice, 3, 230±235. Frank, E., Kupfer, D. J., Wagner, E. F., McEachran, A. B.,
Clement, P. W. (1988). Professional role modeling by & Cornes, C. (1991). Efficacy of interpersonal psy-
faculty: The neglected child in doctoral training. Profes- chotherapy as a maintenance treatment of recurrent
sional Psychology: Research and Practice, 19, 253±254. depression: Contributing factors. Archives of General
Clement, P. W. (1996). Evaluation in private practice. Psychiatry, 48, 1053±1059.
Clinical Psychology: Science and Practice, 3, 146±159. Frank, J. D. (1995). Psychotherapy as rhetoric: Some
Collins, F. L., Foster, S. L., & Berler, E. S. (1986). Clinical implications. Clinical Psychology: Science and Practice,
training issues for behavioral psychology. Professional 2, 90±93.
Psychology: Research and Practice, 17, 301±307. Garfield, S. L. (1996). Some problems associated with
Collins, F. L., & Thompson, J. K. (1988). On the use of ªvalidatedº forms of psychotherapy. Clinical Psychol-
symbolic labels in psychotherapy outcome research: ogy: Science and Practice, 3, 218±229.
Comment on Wills, Faitler, and Snyder. Journal of Garfield, S. L., & Kurtz, R. (1973). Attitudes toward
Consulting and Clinical Psychology, 56, 932±933. training in diagnostic testing: A survey of directors on
Collins, F. L., & Thompson, J. K. (1993). The integration internship training. Journal of Consulting and Clinical
of empirically-derived personality assessment data into a Psychology, 40, 350±355.
behavioral conceptualization and treatment plan: Ratio- Garfield, S. L., & Kurtz, R. (1976). Clinical psychologists
nale, guidelines, and caveats. Behavior Modification, 17, in the 1970s. American Psychologist, 31, 1±9.
58±71. Gergen, K. J. (1985). The social constructionist movement
References 63
in modern psychology. American Psychologist, 40, Kazdin, A. E. (1994). Clinical psychology: Science and
266±275. practice. Clinical Psychology: Science and Practice, 1,
Goodwin, C. J. (1983). On the origins of Titchener's 1±2.
Experimentalists. Journal of the History of the Behavioral Kazdin, A. E. (1996a). Evaluation in clinical practice:
Sciences, 21, 383±389. Introduction to the series. Clinical Psychology: Science
Gross, A. M. (1990). An analysis of measures and design and Practice, 3, 146±159.
strategies in research in Behavior Therapy: Is it still Kazdin, A. E. (1996b). Validated treatments: Introduction
behavioral? The Behavior Therapist, 13, 203±209. to the series. Clinical Psychology: Science and Practice, 3,
Habermas, J. (1975). Legitimization crisis. Boston: Beacon 216±217.
Press. Kirk, S. A., & Kutchins, H. (1992). The selling of DSM:
Havik, O. E., & VandenBos, G. R. (1996). Limitations of The rhetoric of science in psychiatry. New York: Aldine
manualized psychotherapy for everyday clinical practice. de Gruyter.
Clinical Psychology: Science and Practice, 3, 264±267. Klerman, G. L. (1984). The advantages of DSM-III.
Hayes, S. C. (Ed.) (1989). Rule-governed behavior: Cogni- American Journal of Psychiatry, 141, 539±542.
tion: contingencies, and instructional control. New York: Koch, S. (1976). Language communities, search cells, and
Plenum. the psychological studies. In J. K. Cole & W. J. Arnold
Hayes, S. C. (1995). What do we want from scientific (Eds.), Nebraska symposium on motivation 1975: Con-
standards of psychological practice? In S. C. Hayes, V. ceptual foundations of psychology (pp. 477±559). Lincoln,
M. Follette, R. M. Dawes, & K. E. Grady (Eds.), NE: University of Nebraska Press.
Scientific standards of psychological practice: Issues and Koch, S. (1981). The nature and limits of psychological
recommendations (pp. 49±66). Reno, NV: Context Press. knowledge: Lessons of a century qua ªscience.º Amer-
Hayes, S. C. (1996). Creating the empirical clinician. ican Psychologist, 36, 257±269.
Clinical Psychology: Science and Practice, 3, 179±181. Korman, M. (Ed.), (1976). Levels and patterns of profes-
Hayes, S. C., Nelson, R. O., & Jarrett, R. B. (1987). The sional training in psychology. Washington, DC: American
treatment utility of assessment: A functional approach to Psychological Association.
evaluating assessment quality. American Psychologist, Krasner, L., & Houts, A. C. (1984). A study of the ªvalueº
42, 963±974. systems of behavioral scientists. American Psychologist,
Hayes, S. C., Nelson, R. O., & Jarrett, R. B. (1989). The 39, 840±850.
applicability of treatment utility. American Psychologist, Kuhn, T. S. (1970). The structure of scientific revolutions
44, 1242±1243. (2nd ed.). Chicago: University of Chicago Press.
Hayes, S. C., Zettle, R. D., & Rosenfarb, I. (1989). Rule Lambert, M. J., & Brown, G. S. (1996). Data-based
following. In S. C. Hayes (Ed.) Rule-governed behavior: management for tracking outcome in private practice.
Cognition, contingencies, and instructional control Clinical Psychology: Science and Practice, 3, 172±178.
(pp. 191±220). New York: Plenum. Levitt, E. E. (1973). Internship versus campus: 1964 and
Haynes, S. N., & Uchigakiuchi, P. (1993). Incorporating 1971. Professional Psychology, 4, 129±132.
personality trait measures in behavioral assessment: Lilienfeld, S. O., Waldman, I. D., & Israel, A. C. (1994). A
Nuts in a fruitcake or raisins in a Mai Tai? Behavior critical examination of the use of the term and concept of
Modification, 17, 72±92. comorbidity in psychopathology research. Clinical Psy-
Hersen, M. (1976). Historical perspectives in behavioral chology: Science and Practice, 1, 71±83.
assessment. In M. Hersen & A. S. Bellack (Eds.), Linehan, M. M. (1993). Skills training manual for treating
Behavioral assessment: A practical handbook (pp. 3±22). borderline personality disorder. New York: Guilford
New York: Pergamon. Press.
Hersen, M., & Bellack, A. S. (1988). DSM-III and Luborsky, L. (1995). Are common factors across different
behavioral assessment. In A. S. Bellack & M. Hersen psychotherapies the main explanation for the Dodo bird
(Eds.), Behavioral assessment: A practical handbook (3rd verdict that ªEveryone has won so all shall have prizes'?
ed., pp. 67±84). New York: Pergamon. Clinical Psychology: Science and Practice, 2, 106±109.
Hoch, E. L., Ross, A. O., & Skodak, M. (Eds.) (1966). Luborsky, L., Singer, B., & Luborsky, L. (1975). Com-
Professional preparation of clinical psychologists. Wa- parative studies of psychotherapies. Archives of General
shington, DC: American Psychological Association. Psychiatry, 3, 995±1008.
Holton, G. (1973). Thematic origins of scientific thought: Marten, P. A., & Heimberg, R. G. (1995). Toward an
Kepler to Einstein. Cambridge, MA: Harvard University integration of independent practice and clinical research.
Press. Professional Psychology: Research and Practice, 26,
Howard, G. S. (1985). The role of values in the science of 48±53.
psychology. American Psychologist, 40, 255±265. Maxmen, J. (1986). The new psychiatry. New York: New
Howard, K., Orlinsky, D., & Lueger, R. (1994). Clinically American Library.
relevant outcome research in individual psychotherapy. Miller, L. S., Bergstrom, D. A., Cross, H. J., & Grube, J.
British Journal of Psychiatry, 165, 4±8. W. (1981). Opinions and use of the DSM system by
Ilardi, S. S., & Craighead, W. E. (1994). The role of practicing psychologists. Professional Psychology, 12,
nonspecific factors in cognitive-behavior therapy for 385±390.
depression. Clinical Psychology: Science and Practice, 1, Moore, G. H., Bobitt, W. E., & Wildman, R. W. (1968).
138±156. Psychiatric impressions of psychological reports. Journal
Iwamasa, G. Y. & Orsillo, S. M. (1997). Individualizing of Clinical Psychology, 24, 373±376.
treatment manuals as a challenge for the next generation. Munoz, R. F., Hollon, S. D., McGrath, E., Rehm, L., &
Behavior Therapy, 28, 499±509. VandenBos, G. R. (1994). On the AHCPR depression in
Kanfer, F. H. (1990). The scientist±practitioner connec- primary care guidelines. American Psychologist, 49,
tion: A bridge in need of constant attention. Professional 42±61.
Psychology: Research and Practice, 21, 264±270. Nelson-Gray,R. O. (1996). Treatment outcome measures:
Kaplan, M. (1983). A woman's view of DSM-III. American Nomothetic or idiographic? Clinical Psychology: Science
Psychologist, 38, 786±792. and Practice, 3, 164±167.
Kaufman, A. S., & Harrison, P. L. (1991). Individual Nezu, A. M. (1996). What are we doing to our patients and
intellectual assessment. In C. E. Walker (Ed.), Clinical should we care if anyone else knows? Clinical Psychol-
psychology: Historical and research foundations ogy: Science and Practice, 3, 160±163.
(pp. 91±119). New York: Plenum. Norton-Ford, J. D. (1982). Therapy outcome research
methods. In P. C. Kendall & J. Butcher (Eds.), Handbook Singerman, B. (1981). DSM-III: Historical antecedents and
of research methods in clinical psychology (pp. 429±460). present significance. Journal of Clinical Psychiatry, 42,
New York: Wiley. 409±410.
Persons, J. B. (1995). Why practicing psychologists are slow Smith, M. L., & Glass, G. V. (1977). Meta-analysis of
to adopt empirically-validated treatments. In S. C. psychotherapy outcome studies. American Psychologist,
Hayes, V. M. Follette, R. M. Dawes, & K. E. Grady 32, 752±760.
(Eds.), Scientific standards of psychological practice: Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The
Issues and recommendations (pp. 141±157). Reno, NV: benefits of psychotherapy. Baltimore: Johns Hopkins
Context Press. University Press.
Peterson, D. R. (1976). Is psychology a profession? Sokal, M. M. (1992). Origins and early years of the
American Psychologist, 31, 572±581. American Psychological Association: 1890 to 1906. In R.
Pion, G. M. (1991). A national human resources agenda for B. Evans, V. Staudt-Sexton, & T. C. Cadwallader (Eds.),
psychology: The need for a broader perspective. Profes- The American Psychological Association: A historical
sional Psychology: Research and Practice, 22, 449±455. perspective (pp. 43±71). Washington, DC: American
Poffenberger, A. T. (1938). The training of a clinical Psychological Association.
psychologist. Journal of Consulting Psychology, 1, 1±6. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E.
Polanyi, M. (1958). Personal knowledge: Towards a post- (1970). Manual for the State-Trait Anxiety Inventory.
critical philosophy. Chicago: University of Chicago Press. Palo Alto, CA: Consulting Psychologist Press.
Raimy, J. C. (Ed.) (1950). Training in clinical psychology. Spitzer, R. L. (1985). DSM-III and the politics±science
Englewood Cliffs, NJ: Prentice-Hall. dichotomy syndrome: A response to Thomas E.
Reisman, J. (1981). History and current trends in clinical Schacht's ªDSM-III and the politics of truth.º American
psychology. In C. E. Walker (Ed.), Clinical practice of Psychologist, 40, 522±526.
psychology (pp. 1±32). New York: Pergamon. Staats, A.-W. (1988). Paradigmatic behaviorism, unified
Rice, C. E. (1997). Scenarios: The scientist±practitioner positivism, and paradigmatic behavior therapy. In D. B.
split and the future of psychology. American Psycholo- Fishman, F. Rotgers, & C. M. Franks (Eds.), Paradigms
gist, 52, 1173±1181. in behavior therapy: Present and promise (pp. 211±253).
Robiner, W. N. (1991a). How many psychologists are New York: Springer.
needed? A call for a national psychology human resource Sternberg, R. J. (1995). In search of the human mind. Fort
agenda. Professional Psychology: Research and Practice, Worth, TX: Harcourt Brace.
22, 427±440. Strother, C. R. (Ed.) (1956). Psychology and mental health.
Robiner, W. N. (1991b). Dialogue on a human resource Washington, DC: American Psychological Association.
agenda for psychology: A welcome and a response. Sullivan, M. A., & Collins, F. L. (1996). Instructor's
Professional Psychology: Research and Practice, 22, resource manual for Wilson, Nathan, O'Leary, & Clark,
461±463 Abnormal Psychology: Integrating perspectives. Boston:
Roe, A., Custard, J. W., Moore, B. J., Ross, S., & Skodak, Allyn & Bacon.
M. (Eds.) (1959). Graduate education in psychology. Suppe, F. (1977). The structure of scientific theories (2nd
Washington, DC: American Psychological Association. ed.) Urbana, IL: University of Illinois Press.
Rogers, C. R. (1939). Needed emphasis in the training of Task Force on the Promotion and Dissemination of
clinical psychologists. Journal of Consulting Psychology, Psychological Procedures (1995). Training in and dis-
3, 141±143. semination of empirically validated psychological treat-
Rotter, J. B. (1971). On the evaluation of methods of ments: Report and recommendations. The Clinical
intervening in other people's lives. The Clinical Psychol- Psychologist, 48, 3±23.
ogist, 24, 1±2. Turner, S. M., Beidel, D. C., & Wolff, P. L. (1994). A
Rutter, M. (1994). Comorbidity: Meanings and mechan- composite measure to determine improvement following
isms. Clinical Psychology: Science and Practice, 1, treatment for social phobia: The Index of Social Phobia
100±103. Improvement. Behaviour Research and Therapy, 32,
Scarr, S. (1985). Constructing psychology: Making facts 471±476.
and fables for our times. American Psychologist, 40, VandenBos, G. R. (1986). Psychotherapy research: A
499±512. special issue. American Psychologist, 41, 111±112.
Schacht, T. E. (1985). DSM-III and the politics of truth. VandenBos, G. R. (1993). U.S. mental health policy-
American Psychologist, 40, 513±521. Proactive evolution in the midst of health care reform.
Schneider, S. F. (1990). Psychology at a crossroads. American Psychologist, 48, 283±290.
American Psychologist, 45, 521±529. VandenBos, G. R., DeLeon, P. H., & Belar, C. D. (1991).
Seligman, M. E. P. (1995). The effectiveness of psychother- How many psychological practitioners are needed? It's
apy: The Consumer Reports study. American Psycholo- too early to know! Professional Psychology: Research and
gist, 50, 965±974. Practice, 22, 441±448.
Shakow, D. (1938). An internship year for psychologists VandenBos, G. R., & Pino, C. D. (1980). Research in the
(with special reference to psychiatric hospitals). Journal outcome of psychotherapy. In G. R. VandenBos (Ed.),
of Consulting Psychology, 2, 73±76. Psychotherapy: Practice, research, policy (pp. 23±69).
Shakow, D. (1976). What is clinical psychology? American Beverly Hills, CA: Sage.
Psychologist, 31, 553±560. Walker, M. (1963). The nature of scientific thought.
Shapiro, D. A. (1996). ªValidatedº treatments and Englewood Cliffs, NJ: Prentice-Hall.
evidence-based psychological services. Clinical Psychol- Wallin, J. E. W. (1960). History of the struggles within the
ogy: Science and Practice, 3, 256±259. American Psychological Association to attain member-
Shapiro, D. A., & Shapiro, D. (1982). Meta-analysis of ship requirements, test standardization, certification of
comparative therapy outcome studies: A replication and psychological practitioners, and professionalization.
refinement. Psychological Bulletin, 92, 581±604. Journal of General Psychology, 63, 287±308.
Shemberg, K., & Keeley, S. (1970). Psychodiagnostic Watkins, C. E., Campbell, V. L., & McGregor, P. (1990).
training in the psychiatric setting: Past and present. What types of psychological tests do behavioral (and
Journal of Consulting and Clinical Psychology, 34, other) counseling psychologists use? The Behavior
205±211. Therapist, 13, 115±117.
Sidman, M. (1994). Equivalence relations and behavior: A Watson, R. I. (1953). A brief history of clinical psychology.
research story. Boston, MA: Authors Cooperative. Psychological Bulletin, 50, 321±346.
References 65
Weinberger, J. (1995). Common factors aren't so common: Cognitive Therapy and Research, 3, 239±244.
The common factors dilemma. Clinical Psychology: Yates, B. J., & Newman, F. L. (1980). Findings of
Science and Practice, 2, 45±69. cost-effectiveness and cost±benefit analyses of psy-
Widiger, T. A., & Ford-Black, M. M. (1994). Diagnoses chotherapy. In G. R. VandenBos (Ed.), Psychotherapy:
and disorders. Clinical Psychology: Science and Practice, Practice, research, policy (pp. 163±186). Beverly Hills,
1, 84±87. CA: Sage.
Woolfolk, R. L., & Lazarus, A. A. (1979). Between Zimbardo, P. G., & Gerrig, R. J. (1996). Psychology and
laboratory and clinic: Paving the two-way street. life (14th ed.). New York: HarperCollins.
1.03
Informational Sources in Clinical
Psychology
KRISTI ALEXANDER
United States International University, San Diego, CA, USA
and
MICHAEL C. ROBERTS
University of Kansas, Lawrence, KS, USA
1.03.2 JOURNALS AND BOOKS 68
1.03.2.1 Journals 68
1.03.2.1.1 Psychopathology and abnormal psychology 69
1.03.2.1.2 General clinical psychology 70
1.03.2.1.3 Clinical psychology subspecialties and topics 70
1.03.2.1.4 Therapeutic techniques 71
1.03.2.1.5 Professional issues 71
1.03.2.1.6 On-line journals 71
1.03.2.2 Books 72
1.03.2.3 Conclusions 72
1.03.3 ABSTRACTING SERVICES 72
1.03.3.1 PsycINFO 73
1.03.3.1.1 Psychological Abstracts 74
1.03.3.1.2 PsycLIT 74
1.03.3.1.3 PsycSCANs 75
1.03.3.2 Educational Resources Information Center 75
1.03.3.3 Index Medicus 76
1.03.3.4 Focused Abstracting Services 76
1.03.3.4.1 Dissertation Abstracts International 76
1.03.3.4.2 Child Development Abstracts and Bibliography 76
1.03.3.4.3 Clinician's Research Digest 77
1.03.3.5 Indexing Systems 77
1.03.3.5.1 Social Science Citation Index 77
1.03.3.5.2 Current Contents/Social and Behavioral Sciences 77
1.03.3.5.3 UnCover 78
1.03.4 ELECTRONIC MEDIA: THE INTERNET 79
1.03.4.1 Electronic Mail 79
1.03.4.2 Listservers 79
1.03.4.3 Usenet Newsgroups 80
1.03.4.4 File Transfer Protocols 80
1.03.4.5 World Wide Web 80
1.03.4.5.1 Accessing the World Wide Web 82
1.03.4.5.2 Collections of resources on the World Wide Web 84
67
68 Informational Sources in Clinical Psychology
1.03.4.6 Limitations 84
1.03.5 EVALUATING THE RESOURCES 85
1.03.1 INTRODUCTION the library is the researcher's first stop. In this

area, the holdings of the library are cataloged
and access to the bibliographic tools is usually
Knowledge is of two kinds. We know a subject available. Depending on the size and fiscal
ourselves, or we know where we can find informa- solvency of the library, the tools may include
tion upon it. (Boswell, Life of Samuel Johnson, card catalogs, computer terminals connected to
1775)
library-specific holdings catalogs, CD-ROM
readers for systems such as PsycLIT and
A new client presents to your clinical practice Educational Resources Information Center
with pica. How do you determine the best (ERIC), and a variety of journal abstracts
course of treatment? A colleague asks you to and references. Many of the materials described
lecture to the family therapy class on innova- in the third section of this chapter will be located
tions in the treatment of marital discord. Where in this section where they are available to users.
do you find a comprehensive review of the Regardless of how this information is
recent literature? You are interested in learning obtained, call letters and numbers will be used
about the new research on post-traumatic stress to find the material in the library. The two
disorder. Is the library your only source of systems of classification, the Library of Con-
information? gress and the Dewey Decimal System, are most
The field of clinical psychology is diverse and frequently used in libraries in the United States
informational material continually becomes and psychological materials are cataloged under
available in a multitude of places. Because the a variety of call letters and numbers. The search
half-life of psychological knowledge is brief, the for books is relatively straightforward but may
need for updating and accessing resources is allow for some aerobic exercise benefits,
nearly constant for both researchers and depending upon the layout of the library.
practitioners alike. The purpose of this chapter Journals, in contrast, are often more difficult
is to indicate where sources of information and to locate. Most libraries separate, often by
the vast array of resources are available. several floors, the current periodicals from the
Understanding the variety of reference tools bound, archived volumes. Although this would
that are useful and how to employ them appear to present a minor inconvenience, the
effectively is critical to ªexploit the richness of consistency with which this procedure is
the materials contained within themº (Mendel- employed is often variable. Thus, a recent
sohn, 1987, p. 1). In this first section, we outline edition of Journal of Consulting and Clinical
where to find psychologically relevant material Psychology may be unbound and on the shelf
and some of the ªnuts and boltsº of accessing with other current issues; bound and in the
the available information. In the second section, stacks; unbound in the stacks with some or all of
we highlight the types of journals and books the other issues in that volume; or finally, off to
that may be most useful to the clinical the bindery.
psychologist. Third, we address the various In light of the declining financial resources of
systems and indexes that summarize the university libraries and the often substantial
psychological literature. Finally, we hope to increases in the cost for books and periodical
bring the reader ªon-lineº with information subscriptions, libraries are becoming more
regarding the use of the Internet for the novice selective in their holdings. In the future, the
web surfer. It is our hope that this chapter will easy and immediate access that many have
serve as a road map to the wide world of grown accustomed to may become atypical.
information available in clinical psychology. Fortunately, other resources are becoming
Although it has been speculated that these increasingly available to aid the clinical psy-
days are numbered, the search for informational chologist.
resources in clinical psychology still begins at
the library. Those fortunate to have access to a
comprehensive, research university library, with 1.03.2 JOURNALS AND BOOKS
all the advantages of interlibrary loan and on- 1.03.2.1 Journals
line search capabilities, will be in the best
position to retrieve the psychological literature. The scientific±practitioner field of clinical
As would be expected, the reference section of psychology has relied on scholarly journals as
Journals and Books 69
the prime source of professional information. Although clinical psychology as an area of

The foundations of today's general and practice and research can be divided and
specialty clinical psychology journals may be subdivided into varieties of categories, in the
found in the American Journal of Psychology following sections, we will illustrate the topical
(founded by G. Stanley Hall in 1887), the coverage of these archival and serial publica-
Journal of Abnormal Psychology (founded by tions through the following subsections: psy-
Morton Prince in 1906), the Psychological chopathology and abnormal psychology
Clinic (founded by Lightner Witmer in 1912), (Section 1.03.2.1.1), general clinical psychology
the Journal of Consulting Psychology (founded (Section 1.03.2.1.2), clinical psychology sub-
by Johnnie Symonds for the American Asso- specialties and topics (Section 1.03.2.1.3),
ciation of Applied Psychologists; later to therapeutic techniques (Section 1.03.2.1.4),
become the Journal of Consulting and Clinical and professional issues (Section 1.03.2.1.5).
Psychology), and the Journal of Clinical
Psychology (founded by Frederick C. Thorne
1.03.2.1.1 Psychopathology and abnormal
in 1945) (Routh, 1996). Clinical psychology
psychology
and related applied psychology specialties can
now boast literally hundreds of serial publica- Much of the basic research forming the
tions. Similarly, there has been a significant foundation of clinical psychology is conducted
rise over the years in the number of books under the rubric of psychopathology or abnor-
serving the field. In this section, we will describe mal psychology. The oldest journal in this
the range of journals and books with a view to area, the Journal of Abnormal Psychology,
the distinctive contributions each can make. published by APA, generally covers articles
The PsycINFO database (of the American Psy- on the etiology of psychopathology and
chological Association [APA]) abstracts around abnormal behavior. Similarly, the Journal of
1500 journals and publications each year (a list Abnormal Child Psychology publishes studies of
of these is available on the APA homepage). Of behavioral pathology in children and adoles-
course, not all of these publications contain cents, but also includes etiology, assessment,
information applicable or useful to the clinical and some treatment aspects. Psychological
psychologist, but many do. Consequently, Assessment branched from the Journal of
sorting through the information sources re- Consulting and Clinical Psychology to focus
mains a challenging task. on assessment theory and methodology em-
Many professional and scholarly organiza- ployed in clinical psychology research and
tions sponsor journals. For example, in addition practice. The Journal of Psychoeducational
to the major organizations of APA and Assessment and the Journal of Psychopathology
American Psychological Society (APS), other and Behavioral Assessment also attend to the
groups supporting journals include the Amer- theoretical and methodological aspects of
ican Orthopsychiatric Association, the Society psychological assessment.
for Research in Child Development, the Amer- Other journals are published to provide
ican Association for Applied and Preventive scholarly and clinical coverage for a particular
Psychology, the American Association on diagnostic category or psychological disorder.
Mental Deficiency, the Association for Ad- For example, Mental Retardation, American
vancement of Behavior Therapy, and the Journal of Mental Deficiency, Journal of Autism
Association for Humanistic Psychology. Many and Developmental Disorders, and Research in
of these contract with commercial publishers or Developmental Disabilities provide an arena for
self-publish their journals. research in mental retardation and develop-
In addition, numerous commercial publishers mental disabilities. The Journal of Affective
have also developed journal publications Disorders, Journal of Anxiety Disorders, and
through contracts with scholarly editors. Some Anxiety, Stress, and Coping focus on internaliz-
of the major publishers of privately developed ing disorders, while The Schizophrenia Bulletin
journals include Plenum Publishing Corpora- and Schizophrenia Research publish research
tion, Clinical Psychology Publishing Company, dealing with the etiology, diagnosis, and
Lawrence Erlbaum Associates, Sage Publica- treatment of serious emotional disorders. The
tions, Cambridge University Press, Human Journal of Substance Abuse and Journal of Drug
Sciences Press, Elsevier Science/Pergamon and Alcohol Abuse disperses scholarly literature
Press, and Guilford Publications. These pub- on addictive behaviors. Many other journals
lishers also produce journals sponsored by publish applied and basic research related to
organizations; many are noted later. All of specific psychological problems (e.g., Journal of
these journals are abstracted or indexed by the Traumatic Stress, Child Abuse and Neglect,
major services as will be described in Journal of Emotional and Behavioral Disorders,
Section 1.03.3. Journal of Family Violence).
1.03.2.1.2 General clinical psychology Research, and Practice, to begin publication in

1998.
The field of clinical psychology is diverse in
Non-APA journals in this area include
the range of problems and interventions that are
Children's Health Care, an interdisciplinary
within its domain. This diversity may not have
journal published by the Association for the
been a major problem in the early years of
Care of Children's Health, with editorial and
development; many clinical psychologists con-
article contributions by pediatric and clinical
sidered themselves generalists with the ability to
child psychologists as well as nurses, child life
research and intervene on a wide range of
specialists, and pediatricians. Another interdis-
problems and psychotherapeutic techniques.
ciplinary journal, American Journal of Orthop-
Increasingly, however, specialties have emerged
sychiatry, is published by the American
within clinical psychology. Nonetheless, some
Orthopsychiatric Association with contribu-
journals remain diverse in their topical catch-
tions by psychologists, psychiatrists, and social
ment and do not restrict their view on the types
workers. An international, interdisciplinary
of research or professional articles they publish.
journal, Clinical Child Psychology and Psychia-
For example, two empirical journals, Journal of
try, began publication in 1996. Finally, some-
Consulting and Clinical Psychology and Journal
times the child and family focus gets paired with
of Clinical Psychology, place no restrictions on
a particular theoretical approach, as in Child
subject population, theoretical, or methodolo-
and Family Behavior Therapy and Psycho-
gical approaches. Similarly, two review and
analysis of the Child. Both of these journals
conceptual journals, Clinical Psychology:
publish articles reflecting a specific orientation
Science and Practice and Clinical Psychology
and target population.
Review, are open to any relevant content.
Geropsychology, at the other end of the
Within their pages, these journals may inter-
developmental continuum, focuses attention on
mingle articles reflecting different ages or
adult development and aging, including the
populations, the types of problems studied,
development of psychological problems. As a
methodological approaches, and theoretical
primary resource, APA publishes the journal,
conceptualizations, although some special is-
Psychology and Aging. Other psychology and
sues might focus on a specific topic.
interdisciplinary publications that cover this age
group for clinical psychology interests include
The Gerontologist, Clinical Gerontologist, Jour-
1.03.2.1.3 Clinical psychology subspecialties
nal of Geropsychology, Journal of Aging and
and topics
Health, and Journal of Applied Gerontology.
Increasingly, the field has become an um- Health psychology/behavioral medicine has
brella for research and applications targeted to been a fast growing field allied with clinical
special populations and different theoretical or psychology, although it is not always concep-
methodological approaches. Thus, different tualized as a clinical subspecialty (Bernard &
ages or psychopathological conditions are some Krupat, 1994). Journals that publish articles at
of the divisions used to categorize publications. the interface of behavioral sciences, health, and
Clinical child and pediatric psychology are illness include the Journal of Pediatric Psychol-
perhaps the oldest subspecialties in clinical ogy, Health Psychology (sponsored by the APA
psychology. Clinical psychologists have con- Division of Health Psychology), Psychology and
ducted research and made therapeutic applica- Health, Journal of Health Psychology, and
tions for children and adolescents dating back to Journal of Behavioral Medicine.
the inception of the field. Two child-oriented Community psychology is often thought of as
sections within the APA Division of Clinical distinct from clinical psychology, however, some
Psychology (Section on Clinical Child Psychol- aspects of its publications bear on clinical
ogy, Society of Pediatric Psychology) sponsor psychology interests. For example, the American
scholarly journals. The Journal of Clinical Child Journal of Community Psychology (sponsored by
Psychology publishes articles on child and APA Division 27) and the Journal of Community
adolescent psychopathology research and inter- Psychology report applied and basic research as
ventions, services and programs for children well as evaluations of intervention programs
and families, and professional issues, such as employing clinically important techniques.
training and ethics. The Journal of Pediatric Neuropsychology and rehabilitation psy-
Psychology publishes empirical, review, and chology have several publications of interest
case study articles related to applications of and utility to clinical psychologists in different
psychology to pediatric problems and issues. employment settings. These range from basic
Another APA Division, Child, Youth, and research on brain and nervous system func-
Family Services, recently decided to sponsor a tioning, assessment and diagnosis, to treat-
journal, Children's Services: Social Policy, ment, rehabilitation, and prevention. Journals
Journals and Books 71
in this and related fields include: International clinical psychology interventions. Although
Journal of Clinical Neuropsychology, Psycho- several journals in the field publish articles on
social Rehabilitation Journal, Rehabilitation prevention activities, a primary focus on this
Psychology, and Journal of Applied Rehabilita- topic is provided by such journals as Applied and
tion Counseling. Preventive Psychology, Journal of Primary
Prevention, and Journal of Prevention and
Intervention in the Community.
1.03.2.1.4 Therapeutic techniques
Finally, psychopharmacological treatments
In practice, clinical psychologists use a broad represent a substantial and growing specialty
range of psychological/behavioral intervention interest within clinical psychology. Although
techniques to improve the functioning of those some treatment and/or psychopathology or-
presenting with problems. Research and prac- iented journals provide coverage of these issues,
tice publications in this area may describe the Journal of Psychopharmacology, Research
clinical analogues, controlled experiments, and Communications in Psychology, Psychiatry, and
field evaluations. Some journals take a broad Behavior, Journal of Child and Adolescent
view of psychotherapeutic techniques appro- Psychopharmacology, and Experimental and
priate for publication; others take a more Clinical Psychopharmacology focus exclusively
focused view. Psychotherapy: Theory, Research, on medication and medication-related issues.
and Practice (sponsored by the APA Division of
Psychotherapy) and the American Journal of
Psychotherapy are among the more generally 1.03.2.1.5 Professional issues
oriented journals.
Within the profession of clinical psychology,
In contrast, there are many periodicals that
issues such as (i) ethics for clinicians, research-
reflect a specific theoretical orientation. Jour-
ers, and educators, (ii) training for professional
nals that evidence psychoanalytic or psychody-
competence, and (iii) professional practice and
namic viewpoints include Psychoanalytic
functioning (including employment and reim-
Psychology (sponsored by the APA Division
bursement considerations) are important to-
of Psychoanalysis), Psychoanalytic Review
pics. Such professional issues are regularly
(sponsored by the National Psychological
covered by Professional Psychology: Research
Association for Psychoanalysis), and Contem-
and Practice, Ethics and Behavior and Psychol-
porary Psychoanalysis.
ogy, Public Policy, and Law. Practitioner
An orientation to family-based interventions
oriented publications have provided clinicians
and family and marital therapy is provided
with information on changes in public sector
through publications such as Journal of Family
and private practice concerns, insurance re-
Psychology (sponsored by the APA Division of
imbursement and managed care issues, such as
Family Psychology), Family Therapy, Family
in Journal of Mental Health Administration, The
Process, and The Family Therapy Networker.
National Psychologist, Professional Practice of
Cognitive-behavioral interventions, as an
Psychology, Journal of Clinical Psychology in
amalgamation of cognitive therapy approaches
Medical Settings, Psychotherapy in Private
and behaviorally-oriented treatments, are re-
Practice, and Behavioral Healthcare Tomorrow.
presented by such journals as Cognitive and
The range of journals for the field of clinical
Behavioral Practice, Cognitive Therapy and
psychology is extensive; this sampling cannot do
Research, and Journal of Rational-Emotive
justice to the wealth of serial publications
and Cognitive Behavior Therapy. Behavioral
archivable for the clinician and researcher.
therapy and behavior analysis publications on
Additional sources can be ascertained through
clinical interventions derived from learning
the APA publication, Journals in Psychology: A
theory are found in a number of scholarly
Resource Listing for Authors (APA, 1993) and
journals including Journal of Applied Behavior
the list of journals abstracted by PsycINFO (see
Analysis, Behavior Therapy, Behavior Modifica-
APA homepage on the World Wide Web).
tion, Journal of Behavior Therapy and Experi-
mental Psychiatry, Behavior Research and
Therapy, and the new, on-line journal, Journal
1.03.2.1.6 On-line journals
of Behavior Analysis and Therapy.
Group psychotherapy has been served by In addition to the familiar print form, some
several interdisciplinary publications, including journals have also been added to the Internet.
the International Journal of Group Psychother- The quality of these publications varies,
apy, Small Group Behavior, and Journal of Child although they provide an additional source of
and Adolescent Group Therapy. information for the clinical psychologist. Table
Prevention of mental and physical health 1 lists some of the publications currently
problems is a frequently mentioned goal of available on-line.
Table 1 On-line journals for clinical psychology.
Homepage Association
URL address
American Journal of Psychotherapy

http://www.apj.com/
Canadian Journal of Behavioural Science
http://www.cycor.ca/Psych/ac-main.html
Gestalt!
http://rdz.stjohns.edu/gestalt!/
International Journal of Psychopathology, Psychopharmacology, and Psychotherapy
http://www.psycom.net/ijpppp.html
Journal of Behavior Analysis and Therapy (jBAT)
http://sage.und.nodak.edu/org/jBAT/jbatinfo.html
PsychNews International
http://www.cmhc.com/pni/ or http://www.mhnet.org/pni/
Psychology
http://cogsci.ecs.soton. ac.uk/harnad/psyc.html
1.03.2.2 Books unfortunate as descriptions of treatments of

unproven quality may be widely disseminated
In addition to journal publications, published with potential adverse impact on clients.
volumes have been the sine qua non for the
science and clinical practice of psychology.
Authored books and edited books with indivi- 1.03.2.3 Conclusions
dually authored chapters have summarized the
The nature of journals and books is changing
knowledge and progress of this field since G.
with the rise of computer and Internet cap-
Stanley Hall.
abilities to transmit information. Although
Currently, a vast number of books, from a
many predict the ultimate demise of the printed
variety of publishing companies too many to list
paper format for journals and books, others
here, serve the field. Many book series act as
have not been so quick to accept this prediction.
collections of various titles in clinical psychol-
Given the seemingly chaotic nature of the
ogy, such as Advances in Pediatric Psychology
Internet development, the need to sort through
(Guilford), Sage Human Services Guides (Sage),
and apply some standards of accuracy and
Wiley Series in Clinical Psychology (Wiley),
utility will remain. Thus, it is likely that the
Wiley Series in Personality Processes (Wiley),
fundamental and time-tested aspects of publish-
Developmental Clinical Psychology and Psychia-
ing will hold up, that is, the tradition of the
try (Sage), Applied Clinical Psychology (Ple-
editor as gatekeeper, and the peer review
num), Clinical Child Psychology Library
process.
(Plenum), Issues in Clinical Child Psychology
(Plenum), and Stress and Coping (Plenum).
As with other forms of information, the 1.03.3 ABSTRACTING SERVICES
prodigious number of published volumes makes
it difficult to determine their utility. Decisions As was suggested in Section 1.03.2.3, the
about quality are often made by considering sheer number of individual references for any
the source, the qualifications and reputation of given topic may often be overwhelming.
the author/book editors, series editor(s), and the Fortunately, there exist several good sources
publishing company. Fortunately, there is some of abstracts, indexes, and other retrieval
additional guidance from Contemporary Psy- mechanisms to facilitate the identification of
chology. This journal is devoted to publishing relevant literature. Information systems such as
scholarly and critical reviews of new book PsycINFO (from the APA) attempt to provide
publications. Other journals also publish a few the resources to access the world's literature in
book reviews (e.g., Journal of Pediatric Psy- psychology and related disciplines. Journals,
chology, Clinical Psychology Review). Unfortu- technical reports from university and govern-
nately, the time lag for the reviews is often too ment sources, dissertation abstracts, mono-
long to be helpful to the reader. Unlike most graphic series, and similar materials are the
journals that employ peer review, books fodder for these systems. The systems do,
frequently do not undergo adequate scrutiny however, vary considerably. Some abstracting
before publication. This deficit is particularly products provide nonevaluative reports of any
Abstracting Services 73
reference while others abstract the material PsycINFO permits scholars to ªstay currentº
presented within a selected set of journals. in their field without surveying all the primary
Further, some indexes provide summaries of sources.
the literature, while others offer only biblio- The PsycINFO database, and the other
graphic information. In this section we will PsycINFO reference systems, supply three
describe the major systems and ways to access fundamental types of information: biblio-
the information they contain. Although we graphic information, an abstract (or summary),
have provided the most current (as of the late and standardized keywords. The database,
1990s) information regarding abstracting however, may only be accessed directly through
sources in psychology, because of the rapidly institutions that have an annual lease for its use
evolving technology, databases, particularly and through commercial on-line services, such
CD-ROM systems, change frequently (Reed & as Knight-Ridder (formerly DIALOG) and
Baxter, 1991). Thus, in order to minimize CompuServe.
frustration and maximize successful searches, Before using any PsycINFO products, an
the reader is advised to monitor new develop- understanding of the language and logic of the
ments in the field. search systems is necessary. As is the case with
most searchable databases, Boolean logic is
used. Boolean modifiers such as ªAND,º
1.03.3.1 PsycINFO ªOR,º and ªNOTº may be used to alter the
results of a search. By using these modifiers, a
The major source of information regarding large search can be narrowed to a more relevant
the psychological literature is PsycINFO. In topic, while restricted topics can be expanded.
addition to maintaining the comprehensive For example, a search using anxiety ªANDº
PsycINFO database, this department of the adolescents will generate fewer matches than
APA produces several other resources from anxiety ªORº adolescents. If no modifier is
their database such as Psychological Abstracts, specified, an ªORº is assumed, which may result
PsycLIT, and PsycSCAN. The PsycINFO in fewer relevant references.
electronic database includes all the biblio- Familiarity with the Thesaurus of Psycholo-
graphic references in psychology since 1967, a gical Index Terms (APA, 1997), the key to the
collection of more than one million citations of ªcontrolled vocabularyº used to index entries in
psychologically relevant material including the PsycINFO database, is essential. Because a
journal articles, book chapters and books, variety of words exist to describe psychological
dissertations, as well as technical and govern- concepts, the Thesaurus provides a standardized
mental reports (APA, 1996). References prior to wording, thereby decreasing the frustration that
1967 have been digitized and indexed, and will may result when confronted with the idiosyn-
be available as an option to institutions that crasies of the language. By using the Thesaurus
lease the database (Hayward, 1996). PsycINFO one is redirected from unused words to the
is updated monthly and all references are keywords used by PsycINFO (and the corre-
presented in English, although not all of the sponding five digit subject codes). For example,
literature abstracted is from English-language searching ªbirth parents,º an unused word,
publications. retrieved only 23 records, but by substituting the
PsycINFO is an abstracting system for keyword recommended in the Thesaurus, ªbio-
psychology and related disciplines that is not logical family,º 125 records were obtained.
bound by geographic or linguistic constraints, In addition, this reference provides related
but rather evaluates the entire body of relevant terms, both broader and narrower, that may be
psychological information. The database in- used to further define a literature search. In
cludes research reports and other scholarly general, use of the narrower descriptor is
works, literature reviews, surveys, case studies, preferred because PsycINFO records are in-
theoretical papers, dissertations, books, chap- dexed with the most specific descriptors possible
ters, conference and case law reports, and, if the (APA, 1996). Now in its eighth edition, the
original work was included in the database, Thesaurus is updated every three years to reflect
comments and replies. Excluded are editorials, changes in the vocabulary of psychology and
letters to the editors, news items, interviews, and related disciplines.
poems. Unlike some other abstracting services, Although the Thesaurus strives for complete-
PsycINFO does not maintain a core list of ness, there may be times when searching the
journals but rather evaluates the psychological ªfree-textº fields may be more fruitful. The free-
relevance of any individual entrant regardless of text fields are entries such as the title (TI),
the source (e.g., journal, book chapter, govern- abstract (AB), key phrase (KP), and author
ment monograph, etc.). By providing a com- (AU) that may be searched for a word or phrase.
pendium of the psychological literature, A complete list of the possible ªfree-textº search
fields is available in the PsycINFO User Manual Thus, to retrieve records with both American
(Walker, 1992) and through on-line ªhelp.º and British spellings, ªcolorº and ªcolour,º in
Searching the free-text fields may be necessary the title, ªcolo?r in TIº must be entered.
when a concept does not have a corresponding
descriptor. When this occurs, searching the title,
1.03.3.1.1 Psychological Abstracts
the key phrase and abstract of journal articles,
may result in a successful ªmatch.º For The ªwork horseº of the PsycINFO stable is
example, if a psychologist was interested in Psychological Abstracts, the well-used reference
finding articles that address the topic ªcorporate for nearly 70 years. This reference, published
cultureº at the FIND prompt, one would enter monthly, is available only in printed form and
ªcorporate culture in TI (title) or corporate provides abstracts of journal articles, technical
culture in KP (key phrase).º For books and reports, book chapters, and books. Each
chapters, the table of contents may also be volume contains approximately 47 000 records.
searched. By including coverage from 1927 to the present,
A free-text field search would be appropriate scholars can learn of advances in the field as well
when references with a specific word or phrase as the historical contributions to clinical
are of interest to the researcher. For example, if psychology. Because of the volume of psycho-
interested in studies evaluating the effectiveness logical literature worldwide and the cost of
of the antidepressant ªZoloft,º a search for that producing a printed publication, the inclusion
specific term in the free-text fields would be of foreign language entries in Psychological
made. Likewise, a hunt for a specific person or Abstracts was discontinued in 1988, although
assessment device may be conducted by this the PsycINFO database still retains these
method. references (Reed & Baxter, 1992).
Finally, a free-text search may be needed when For many years, Psychological Abstracts was
searching for studies prior to the development of the only system available to researchers and
a new descriptor. For example, to retrieve clinicians who wished to find literature on any
articles on ªAIDS preventionº prior to 1994 given topic in psychology. However, with the
(the year it was entered into the database as a development of PsycINFO and related re-
descriptor), a free-text search would be neces- sources, gone are the days of thumbing through
sary. The Thesaurus indicates when a particular the cumbersome subject references to find the
descriptor was added and in some cases provides page numbers of corresponding abstracts.
alternative descriptors to use when searching PsycLIT replaces, for many, the printed
the older literature. For example, it suggests that abstracts and allows the user to access the same
to access the research on post-traumatic stress material from a CD-ROM database. Never-
disorder published between 1973 and 1984, one theless, Psychological Abstracts, available only
may use ªstress reactionsº or ªtraumatic through subscription from the APA, remains a
neurosisº as the index words. staple reference in most libraries. Each issue
Two other ªtricksº that may be used to features subject, book title, and author indexes,
maximize the results of a ªfree-textº search are and at the end of the year cumulative indexes of
the use of the truncation symbol (*) and the authors and subjects are published in a separate
wildcard symbol (?). The truncation symbol volume.
may be used to retrieve variants of the specified
word or phrase. For example, entering ªsex* in
1.03.3.1.2 PsycLIT
TIº retrieved 7636 records from the journal
database (January 1990 to June 1996) with a PsycLIT is the database with which most
broad range of related words in the titles such as individuals are familiar. Although PsycLIT and
sexualized, sexual harassment, sex offenders, PsycINFO are frequently used interchangeably,
sexually abused, and sexual orientation. Con- there are significant differences between the
sequently, to obtain the most relevant informa- two. As previously described, PsycINFO is an
tion, it is important to restrict use of the on-line database; in contrast, PsycLIT is a CD-
truncation symbol by including as many of the ROM database derived from the PsycINFO
letters in a word as possible. In the above database, that contains references for journals,
example, ªhad sexu*º been used, then fewer book chapters, and books only. Contained
records would have been produced. within two compact discs, this reference,
Use of the wildcard symbol (?) in a word will updated quarterly, comprises three separate
permit a letter (or letters) to replace it. If the ª?º databases: (i) journal references from 1974
is used at the end of a word, it may be used to through 1989, (ii) journal references from
represent an ªsº for plural forms of the word. 1990 to the present, and (iii) books and book
Another use of the wildcard symbol is to obtain chapters from 1987 to the present. Each entrant
references with alternate spellings of a word. includes a bibliographic citation, an abstract,
and, for journal articles, index words. The Both the Abstracts and the PsycSCANs can
indexing is included to allow similar articles to be very useful in that they provide a manageable
be selected from the database. Book and chapter number of references to peruse. Nonetheless,
records include comparable information, with scholars interested in a wider scope of informa-
the addition of the table of contents for books. tion may be frustrated by the circumscribed
To find references on this CD-ROM version range covered by these journals. For example,
of the Psychological Abstracts, keywords are clinical psychologists interested in pediatric
entered. As previously discussed, the use of phenomena and applications would not have
Boolean modifiers is necessary. There are access to all relevant research in this area by
several support systems that make PsycLIT using the PsycSCAN: Clinical Psychology
very user-friendly including an ªon-discº The- exclusively.
saurus, a tutorial, a videotape entitled ªHow to In summary, the PsycINFO products are
Search PsycLIT on CD-ROM,º several user's excellent resources and allow the scholar to
manuals from PsycINFO, and a toll free access a wide variety of materials through
number to the PsycINFO Actionline ([800] several user-friendly mechanisms. By develop-
374-2722) (APA, 1996). ing several different kinds of products, PsycIN-
Similarly, the ClinPSYC CD-ROM database FO has provided multiple levels of access to
offers a reduced set of abstracts specifically their database that vary in terms of scope and
chosen for their relevance to practitioners and cost. Thus, while PsycLIT may be too expensive
interested others in clinical psychology, behav- for a small group practice, the lower cost of the
ioral medicine, and related fields. Because of the PsycSCANs may allow clinical psychologists
reduced volume of entries, the ClinPSYC data- entry to the research literature.
base is much less expensive and may be useful
for smaller institutions and organizations.
1.03.3.2 Educational Resources Information
1.03.3.1.3 PsycSCANs Center
Finally, PsycINFO publishes field-specific In addition to PsycINFO, another large
bibliographic and abstract journals including database that produces a variety of products
Psychoanalytic Abstracts and PsycSCANs. The that may be relevant to clinical psychologists is
increasing specificity of these publications the ERIC. This national information system,
allows individuals to keep up to date with established in 1966, provides access to the large
current literature in a circumscribed area of body of education-related resources. ERIC is
interest. The PsycINFO database of over 1300 supported and operated by the National
journals in psychology and related disciplines is Institute of Education (Gay, 1992).
searched to provide the citations and abstracts As with PsycINFO, ERIC offers a range of
for these journals. For example, PsycSCAN: services, although a primary function is the
Behavior Analysis and Therapy provides concise maintenance of a national bibliographic data-
summaries of journal articles on basic research base of over 775 periodicals in education and
and applied topics accompanied by complete related fields. This database is compiled from 16
citation to assist readers in locating the full-text subject-specific ªclearinghousesº that abstract
article. PsycSCANs, published quarterly, are and index the education literature. The majority
currently available for the following areas of of these clearinghouses, however, will not be of
interest: applied psychology, behavior analysis interest to clinical psychologists as they pri-
and therapy, clinical psychology, developmen- marily provide teaching-related materials such
tal psychology, and learning disabilities/mental as curricula and classroom resources. While
retardation. there is considerable overlap with the material
Psychoanalytic Abstracts and Neuropsychol- covered by PsycINFO, ERIC does include
ogy Abstracts are two similar PsycINFO references for unpublished research that is not
products that encompass a specific area of usually available from other sources, such as
psychology. The quarterly Psychoanalytic Ab- papers presented at professional conferences
stracts replaced the PsycSCAN: Psychoanalysis and studies conducted by school districts. The
in 1993 and features abstracts of journal ERIC database can be accessed through the
articles, as well as summaries of book chapters Internet (URL: http://ericir.syr.edu) and by
and books relevant to the speciality area of CD-ROMs purchased from vendors such as
psychoanalysis. A core set of approximately 40 Knight-Ridder, Oryx Press, and SilverPlatter
psychoanalytic journals, in addition to the 1300 Information, Inc.
general psychology journals, are abstracted. In addition to the database, two other
Neuropsychology Abstracts fulfills a similar products available in both microfiche and
function for the field of neuropsychology. printed versions are offered by ERIC: Resources
in Education and Current Index to Journals in providing coverage of medical journals not
Education. As with the Thesaurus of Psycholo- included in PsycINFO. For example, a search
gical Index Terms produced by PsycINFO, for ªpicaº resulted in the retrieval of 710
ERIC has a companion guide, Thesaurus of references, in contrast to the 50 references
ERIC Descriptors (Houston, 1990) that should obtained through the PsycLIT search.
be consulted before beginning a search. One of the major limitations of Index
Although indexed similarly, the monthly Re- Medicus, however, is the limited information
sources in Education includes educational re- provided. Because only the title is provided in
search, conference proceedings, position papers, the index, there is no indication as to the content
curriculum guides, books, and dissertations, of the article, making it difficult to identify
while the Current Index to Journals in Education critical references from this resource. In con-
covers only periodicals. trast, MEDLINE searches may include ab-
Clinical psychologists interested in references stracts when they are available, thus overcoming
for child development, education, testing and this deficiency.
evaluation research will find references within
the ERIC database. Notwithstanding, for many
1.03.3.4 Focused Abstracting Services
other clinical topics, such as psychological
disorders and treatment, PsycINFO products In addition to the three major resources
would be a preferable resource. For example, previously described, PsycINFO, ERIC, and
while the search with the keyword ªpicaº Index Medicus, a number of other resources
resulted in 50 ªhitsº from the PsycLIT CD- provide reference sources and informational
ROM database, the same search performed with services relevant to clinical psychology.
the ERIC CD-ROM generated no relevant Although most of the psychological literature
references. will be accessible through PsycINFO and the
other ªpowerhouses,º these additional resources
1.03.3.3 Index Medicus may be of interest to clinical psychologists. In
this section we will describe these products, with
Index Medicus, published by the National an eye to their unique contributions.
Institutes of Health (NIH), is an abstracting
reference for all medical journals, including
those areas of psychology related to the health 1.03.3.4.1 Dissertation Abstracts International
sciences. Approximately 62 psychology and There are two parts of the Dissertation
80+ psychiatry journals are indexed, although Abstracts International (DAI), Part A: Huma-
many of these are ªselectivelyº searched, and nities and social sciences, and Part B: Sciences
not all their references are included (NIH, 1996). and engineering. Within this resource, disserta-
Unlike PsycINFO or ERIC, this reference does tions are listed under subject headings, with
not provide abstracts or summaries of the interdisciplinary dissertations listed under more
material, only bibliographic citations organized than one category. The majority of psychology
by subject and author. dissertations will be found in Part B, although
On-line access to Index Medicus is available Part A contains educational psychology, tests
from MEDLINE, which also includes the Index and measurements, and gerontology (Reed &
to Dental Literature and International Nursing Baxter, 1991). Published monthly by the
Index. MEDLINE may be accessed through the University Microfilms International at the
World Wide Web (http://www.healthgate.com/ University of Michigan, the DAI is available
or http://www.medscape.com/), by institutional on microfilm, CD-ROM, and in print. Because
lease, and on CD-ROM, through vendors such dissertations often represent the ªcutting edgeº
as Ovid and Knight-Ridder. The Medical of research, this reference may be very useful to
Subject Headings, the thesaurus for use with individuals interested in new developments in
MEDLINE and Index Medicus, is updated and the field. In addition, this reference may be one
published annually. of the few ways to access this body of scholarly
Many topics of interest to psychologists, such works since dissertations are no longer included
as conduct disorders, ªbystander intervention,º in PsycLIT or Psychological Abstracts.
and family therapy, are found on MEDLINE.
Most MEDLINE searches, however, will ne-
1.03.3.4.2 Child Development Abstracts and
cessitate some culling to obtain the most useful
Bibliography
subset of references as both psychosocially
oriented articles and physical medicine articles This publication of the Society for Research
are retrieved. For psychologists interested in in Child Development (SRCD) provides ab-
health and pediatric psychology, Index Medicus stracts and bibliographies for books and
and MEDLINE are invaluable references, journal articles related to the growth and
development of children. Unlike the PsycINFO may be more manageable, and consequently,
products, Child Development Abstracts and useful. With regard to availability, discipline-
Bibliography maintains a list of journals specific libraries, such as those found at large
regularly searched and solicits contributions research universities, may carry the appropriate
of abstracts from journals not included in this references. Nevertheless, because of financial
list (SRCD, 1996). This database reference is exigencies, many institutions have discontinued
available in print and free through the Internet their subscriptions to these abstract services.
(http://www.journals.uchicago.edu/CDAB/).
1.03.3.5 Indexing Systems
1.03.3.4.3 Clinician's Research Digest
In contrast to abstracts, indexes provide only
Designed specifically for clinicians, the bibliographic information, yet they may be
monthly Clinician's Research Digest (CRD) is useful reference tools for some scholars. Given
published by the APA. This six-page newsletter the emergence of the ªcomputer age,º many of
covers the highlights gleaned from the review of these resources are available electronically as
over 50 clinically relevant journals. Each issue well as in print form.
includes a summary of recent research and
complete bibliographic information. The CRD
claims to be more ªuser friendlyº than similar 1.03.3.5.1 Social Science Citation Index
publications (APA, 1996), although the re- This quarterly publication from the H. W.
stricted number of articles reported and the Wilson Company provides only author and
absence of PsycINFO descriptors and keywords subject indexes from 1400 international
would appear to limit its utility. Nonetheless, English-language periodicals and selective cov-
for individuals seeking a brief, informal review erage of 3300 additional journals. The coverage
of clinical research, the CRD may be a very of the Social Science Citation Index (SSCI) is
approachable resource. very comprehensive; journal articles, review
Similar reference information for clinical articles, scholarly replies to the literature,
psychologists may be found in print publications interviews, book reviews, meeting notes, correc-
such as the Behavioral Medicine Abstracts tions, obituaries, and biographies are indexed
(published by the Society for Behavioral Med- (Garfield, 1995). In addition to a print edition,
icine), the Human Resources Abstracts (pub- the index is also available on CD-ROM and
lished by Sage), and the Social Work Research Social SCISEARCH is the corresponding on-
and Abstracts (produced by the National line database from the Institute for Scientific
Association of Social Workers). These refer- Information. While the majority of psychology
ences are limited to a specific content area and journals are covered in the SSCI, there is some
are currently not available electronically. In overlap with the companion publication, the
addition, because of their cost and redundancy Science Citation Index (SSCI). Both the SSCI
with information abstracted by the other larger and the SCI are very expensive and therefore
abstract services, they may not be carried at may not be available in smaller libraries.
many libraries. The SSCI allows the identification of re-
In contrast, there are several on-line data- search that has been cited by others. If an
bases that provide abstracts for specific content author's work has been cited by another it will
areas that are only available electronically, with be indexed here, allowing interested individuals
no corresponding print equivalents. Among to find more recent work based on older
these are Child Abuse and Neglect (produced by research. This information may be very useful
the National Center on Child Abuse and for scholars seeking to understand the historical
Neglect), DRUGINFO which provides infor- trends in research or the impact of a specific
mation regarding the psychological aspects of empirical finding. A distinct advantage of these
drug and alcohol abuse (produced by Drug indexes is the use of the Permuterm Subject
Information Services at the University of Index. This system indexes every substantive
Minnesota), the Mental Health Abstracts (pub- word in an article's title, thus overcoming some
lished by IFI/Plenum Data Company), and of the obstacles of other indexing systems that
REHABDATA (from the National Rehabilita- require the use of specific descriptors.
tion Information Center).
The utility and availability of these abstract
1.03.3.5.2 Current Contents/Social and
services varies considerably. The smaller re-
Behavioral Sciences
sources reference a much more circumscribed
range of journals and are therefore redundant This is one of the seven multidisciplinary
with the larger systems. Conversely, for some editions available from the Current Contents
psychologists, the reduced number of references database, a product of the Institute for Scientific
Information (ISI). This database is updated access to almost 17 000 journals and over seven
weekly and is available in both print and million articles, The literature available is not
electronic forms. For the Social and Behavioral just in psychology, but from the totality of
Sciences edition, 1421 journals from psychol- science, social science, and the humanities.
ogy, psychiatry, education, public health, social Journals that are related to clinical psychology
work, and education, as well as other social (as listed in this chapter) are included in the
science areas, are indexed (ISI, 1996). All forms database.
of the publication (e.g., print, disk, CD-ROM, There are several ways to access the UnCover
on-line) provide the tables of contents from all database: at libraries with an institutional lease,
the journals reviewed, along with author and by telnet (database.carl.org), by modem ([303]
publisher addresses. The provision of addresses 756±3600), and through the World Wide Web at
is particularly handy for ordering reprints. In the address provided. There is no cost to search
some formats of Current Contents, abstracts the database and individuals may search by
and keywords are also included. As with author's name, keyword, or journal title.
PsycLIT, on-line access to Current Contents/ Journal titles allow branching to tables of
Social and Behavioral Sciences is available from contents for issues published over a period of
commercial services such as Knight-Ridder and years. The results of a search are limited to
Ovid Technologies. bibliographic information. Once articles are
Although there is considerable overlap with identified in the search, UnCover can be
the PsycINFO database, Current Contents does requested to fax the article to a specified fax
provide a unique reference tool. For scholars machine. The average service charge for fax
interested in a wide range of psychology-related delivery of the article, including the copyright
materials, such as sociology, law, and social release fee, is $10.25.
work, Current Contents is unparalleled in its An UnCover topic keyword search for the
scope. The wide range of coverage is not topic of ªmanaged careº identified 2303 entries.
inexpensive, however; the price of a one-year By adding the phrase ªmental healthº to
individual subscription on disk being $895 in ªmanaged care,º the number of entries was
1997. Moreover, because it is updated weekly, reduced to 115 articles in a variety of journals.
continual review of the contents is necessary to All entries seemed relevant, although it is not
keep up with the issues, a task some individuals discernible how many potential entries were
may find difficult. missed in the search. Examination of the entries
Another drawback to Current Contents is the will eliminate some from interest; others may be
division of the database into multiple issues marked for fax delivery. An UnCover keyword
(e.g., Social and Behavioral Sciences, Life search for ªdepressionº found 7687 items and
Sciences, etc.). Thus, individuals may find that ªdepression in the elderlyº netted 247 entries.
one edition does not include all the articles in Large numbers of entries are not sorted by the
their area of interest. Finally, the index terms service. The user must scroll through the entries
included in the back of each issue are very broad to find useful references.
(e.g., ªpersonality,º ªchildº) and therefore In addition to the search capacities, another
provide only minimal guidance in searching service of this electronic data bank is UnCover
for references on specific topics. Complete which allows the ordering and faxing
of any articles in journals not indexed in the data
bank or from pre-1989 issues. Entry of the
1.03.3.5.3 UnCover
bibliographic information obtained from other
Libraries have long maintained interactive sources (e.g., PsycLIT) or reference lists of other
systems to share their resources (e.g., through articles is required.
interlibrary loan, faxes) and have developed A particularly useful service available from
computerized systems of informational retrie- the UnCover company is UnCover Reveal.
val. One particularly important and useful UnCover Reveal allows a subscriber to select up
electronic development has been the establish- to 50 journals from the database for an
ment of electronic databases for access to ªawareness serviceº where the table of contents
scholarly publications. As a result of the from the selected journals are sent to the
widespread use of these information sources, subscriber's e-mail account as the journal issues
library groups and private companies have are published. Once the desired articles are
established document notification and delivery identified, subscribers may then order them to
services. The UnCover Company (a Knight- be sent to their facsimile machine within 24
Ridder Information Company) is one hours. UnCover Reveal also permits the sub-
such service (http://www.carl.org/uncover/ scriber to identify 25 keyword and/or author
unchome.html; telephone: 1-800-787-7979; names to be searched weekly as new articles are
e-mail: uncover@ carl.org). It provides Internet entered into the database and the results
Electronic Media: The Internet 79
delivered to his or her e-mail address. This Access to the Internet, and the many services
service is particularly useful for individuals who it supports, may be made through commercial
may not have access, either personally or companies (e.g., America Online, Compuserve,
through their library, to all of the journals in Prodigy, and many local network providers) as
their area of interest or for scholars who want well as educational institutions and govern-
the most current information as soon as it mental agencies. Generally, the type of connec-
becomes available. A one-year subscription to tion to the Internet does not affect the types of
this service is $25.00. services available, but will impact the speed at
In general, UnCover appears to be a which information may be accessed.
potentially useful database service for indivi- In the last few years, consumer-oriented,
duals with limited library access. The ability to user-friendly, services and tools have developed
order articles on-line and receive them within a to make it quite easy for the novice computer
brief time period is very convenient, albeit user (a ªnewbyº in Internet lingo) to gain access
costly. The charge for this service, however, may to the multitude of informational sites (as well
be equivalent to interlibrary loan fees, with a as entertainment and other diversions) on the
more expedient delivery time. Internet. The software for sending out electro-
nic mail or searching the Internet for informa-
1.03.4 ELECTRONIC MEDIA: THE tion via the larger commercial companies are
INTERNET fairly easy to use (although the financial charges
for use and time can accumulate fairly rapidly).
The rise of the electronic media in its For those accessing the Internet through other
multitude of forms has created a vast array of means (e.g., regional or local networks, or .edu
new resources for clinical psychologists, includ- or .gov computer accounts), special e-mail
ing both researchers and practitioners. At the software and/or use of a ªweb browserº may
same time, however, the rapid rise and the be provided. Web browsers are generally point-
enormous wealth of resources have made sifting and-click tools for searching and accessing
through and evaluating the utility of those information; we have found the easiest ones to
resources more difficult. In this section, we will use are Netscape and MS Internet Explorer.
outline the types of resources available in the These programs are free for academic and
electronic media, some of the information sites research users and provide a hypertext interface
and their contents, how to access that informa- to the World Wide Web. Easily installed, they
tion, and how to evaluate their use. We want to can be quickly activated for conducting searches
emphasize that, perhaps different from other and acquiring information. These browser
referential sources of information in clinical programs generally provide a range of options
psychology heretofore, any list of materials for accessing information. We will describe
available through the Internet is, upon compila- some of the informational search options later
tion, almost immediately outdated. That is, in this section.
informational homepages, professional and
topical newsgroups, discussion networks,
Internet-based journals, newsletters, publica- 1.03.4.1 Electronic Mail
tions, and other forums are being created daily
Although directly e-mailing other profes-
(and others cease to exist). Most importantly,
sionals is a useful way of requesting, obtaining,
we emphasize that the mere availability of
and exchanging information for the clinical
abundant information does not ensure its
psychologist, we will not deal with this medium
accuracy or utility for the clinical psychologist.
in detail. Electronic mail addresses for indivi-
Before describing some useful Internet re-
duals are now frequently included in member-
sources, we want to clarify and define some of
ship directories for professional organizations
the terms. Although it is often described as a
such as the APA and the APS.
single entity, the Internet is the network of
networks, (Kehoe, 1995). Individuals who are
connected to another computer in some way, 1.03.4.2 Listservers
either through telephone lines and a modem, or
through direct wiring, are part of the Internet Collections of e-mail addresses of those
and join approximately 20 million other users in people who have actively subscribed to a central
50 countries on any given day. It is through this computer list are called listservers (or listservs).
network of computers that electronic mail (e- These groups are typically centered around a
mail), file transfer protocols (FTP), mailing lists common interest or activity such as members
(listservers), on-line discussions (bulletin boards of the Division of Clinical Psychology, or
and newsgroups), and the World Wide Web researchers and practitioners with interests in
(WWW) are possible. traumatic stress. Members of the listserver may
post inquiries for information, posit a thought, For example, many of the groups interested in
initiate dialogues and discussions over profes- psychology begin with the ªalt.psychologyº
sional issues, and provide information via e- followed by another, more specific term such as
mail to the central computer and all members of ªpersonality.º The DejaNews research service
the group receive copies of the message in their (http://www.dejanews.com) may be used to
e-mailboxes. Some listserver groups are mod- locate newsgroups addressing specific topics.
erated by a professional; others are freewheeling Some examples of Usenet newsgroups that may
and supervised only by peer pressure. be of interest to clinical psychologists include:
As an example of how a listserver group
might assist the clinical psychologist, an inquiry alt.psychology (.adlerian, .jung, .help)
to a clinical psychology network from a alt.support (.attn-deficit, .depression,
practitioner asked for valid and reliable ways .schizophrenia)
to assess a particular disorder suspected in a alt.recover (.compulsive eating, .sex-
client. Replies from the group included several ual addiction, .aa)
suggestions of how to handle the case, references sci.psychology (.theory, .psychotherapy,
to written material, and summaries or abstracts .personality)
of articles on the topic. Often the replies
illuminate and educate, although sometimes alt.sexual.abuse.recovery
the discussion turns into an argument or soc.support.loneliness
meaningless chatter. (A word of warning here:
There are those who enter a newsgroup 1.03.4.4 File Transfer Protocols
apparently to stir up trouble deliberately by
posting erroneous information or making Through file transfer protocols (FTP), pro-
statements calculated to provoke the other fessionals may obtain and exchange informa-
members of the newsgroup.) To enroll in a tion in computer files from one system to
listserver usually requires only that one sends a another. A variety of information resources
ªsubscribeº message by e-mail, although a few including journals, books, and other documents
others require checking against a master list or can be downloaded to the clinical psychologist's
review of credentials. Some listservers of computer through this mechanism. Searches for
relevance to clinical psychology are listed in information obtainable through FTP may be
Table 2. made through the ªGopherº system which
searches for documents and retrieves them or
a Wide-Area Information System (WAIS).
1.03.4.3 Usenet Newsgroups
Usenet newsgroups differ from e-mail list- 1.03.4.5 World Wide Web
servers in that messages or articles are not
transferred directly to a user, but are posted in a The collective term for the global network of
central location accessible by individualsº interlinked computers is the Web or World
computers through the Internet. Usenet news- Wide Web (WWW). The vast array of informa-
groups typically form around a topic or interest. tion contained in all those computers is
Members of the newsgroup post messages on available for access through special, easy to
the ªbulletin boardº of the group, and other use tools. The Web is both a ªtreasure troveº
members may react by posting replies or new and a ªchaos morass.º Indeed, a new user
positions/statements to the bulletin board for all accessing the WWW for the first time will be
to see or send personal replies to those who have amazed and perplexed at the variety and range
posted before. There is no Usenet organization of offerings. After initial shock and fascination
or authority, although some newsgroups are in ªsurfingº around the Net, the Internet user
ªmoderatedº by an individual who reads and will approach the Web and Internet activities
approves a message before posting it in the with a more calculated examination of what is
newsgroup board. Supportive contacts with useful to him or her.
others facing a particular problem are often All Web pages are found by their addresses
facilitated in these groups. known as uniform resource locators (URLs).
The lengthy list of the thousands of Usenet These typically start with http://www and the
newsgroups can be accessed through Net- entire address must be exactly entered. WWW
scape (http://sunsite.unc. edu/usenet-i/hier-s/ homepages often contain sound, color, and
top.html). Each newsgroup address is preceded graphics. Consequently, many pages may take
by a category prefix (e.g., sci., soc., alt., etc.) that some time to download into one's computer,
represents a broad topic area (e.g., science, thus a fast modem is recommended (2400 baud).
social, alternative, etc.). Subsequent words serve Individuals, organizations, and companies all
to add specificity to the particular newsgroup. have a presence on the Web. Many individuals
Table 2 Listservers for clinical psychology
Organization
E-mail address
Behavior Analysis
behvioraanalsys@mankato.msus.edu
behav-an@listlistserv.nodak.edu
Division 12 Net
(for members of the Division of Clinical Psychology, APA)
div12@listserv.nodak.edu
Society for a Science of Clinical Psychology
(for members of the Section III of the Division 12, APA)
sscpnet@bailey.psych.nwu.edu
Group-Psychotherapy
Majordomo@freud.apa.org
(in body of message, type: SUBSCRIBE GROUP-PSYCHOTHERAPY)
Society for Community and Research Action
(Division 27 of APA)
SCRA-L@UICVM.CC.UIC.EDU
PsyUSA: Practice-Oriented discussions
(managed by John Roraback: jmroraback@aol.com)
PsyNetUSA@aol.com
Autinet (Autism)
autinet-request@iol.ie
LISTSERV@sjuvm.STJOHNS.EDU
Behavioral Disorders in Children
LISTSERV@ASUVM.INRE.ASU.EDU
(in body of message type: Subscribe BEHAVIOR username)
Dual Diagnosis
(for professionals with interests in persons with dual diagnoses of mental disorders, drug and alcohol addiction)
MIDAA-dual-diagnosis@idealist.com
NetPsy: Internet Psychotherapy
(issues related to psychotherapy services provided via Internet)
listserv@sjuvm.stjohns.edu
PsychNews International
LISTSERV@LISTSERV.NODAK.EDU
(in body of message type: SUBSCRIBE PSYCHNEWS Firstname Lastname)
GrantsNet
listserv@list.nih.gov
(in the body of the message type: subscribe GNET-L FirstName LastName)
have set up their own homepages containing homepages with links to other sites within
information about themselves and their inter- their institution, including descriptions of
ests, businesses, productions, and professional course offerings, faculty, their expertise and
activities. Specific to topics within psychology, research, and other useful information. Other
professionals and lay people with common Web sites contain encyclopedic-type informa-
interests have established homepages with tion (e.g., ARGUS/University of Michigan
information about biopsychosocial phenomena Clearinghouse and The Electric Library). Most
(e.g., on dual diagnoses, depression, anxiety importantly, governmental agencies, scholars
disorders, aggression, drug and alcohol addic- and practitioners, and scientific and profes-
tion). Table 3 provides the Internet addresses sional organizations have created sites of
for special interest groups. information containing a great variety of
Similarly, companies offering services or resources in their homepages (and interlinked
information have also created homepages with them with others of similar topics). Table 4
book or product catalogs. (We do suggest, until provides the Internet addresses for several
better safeguards are in place, placing any organization homepages. These are some
orders for materials through the mail or illustrative samples, not a comprehensive list,
telephone for credit card number security.) of organizations related to clinical psychology
Many colleges and universities also have accessible on the Net.
Table 3 Special interest and discussion groups on the Web.
Homepage association
URL address
The Obsessive-Compulsive Foundation (Resource Center)

http://www.ocdresource.com
Society for Research in Adolescence
(special interest group in peer relations)
http://www.darling.hhdev.psy.edu/peesig.htm
Group Psychotherapy
http://freud.tau.ac.il/~haimw/group2.html
Behavior OnLine
(discussions and interviews with practitioners and researchers)
http://www.behavior.net/
Dual Diagnosis
(for professionals with interests in persons with dual diagnoses of mental disorders, drug and alcohol addiction)
http://www.erols.com/ksciacca/
The Psychoanalytic Connection
http://marge.infohouse.com/psacnct/
1.03.4.5.1 Accessing the World Wide Web ªclinical psychology.º Searches can be fine-
tuned, specified, or narrowed by the inclusion of
If the reader is not familiar with accessing the additional concepts central to the individual's
Web, we suggest consulting the variety of books desired search (e.g., add ªpsychopathologyº or
on surfing the Net, although the best way to ªelderlyº).
learn the Net resources, capabilities, and To demonstrate the wealth of information
limitations is to take some time to explore it available, we conducted a search via the bigger
for oneself. We will give here only a brief programs in Netscape on the keyword of
introduction to accessing the WWW with a ªdepressionº and to refine the concept, added
focus on clinical psychology resources. the phrase ªin the elderly.º The results of the
Most novices (and likely more experts) access various searches include:
the Internet for information using one of the
popular Web browsers (e.g., Netscape, MS Depression Depression in the elderly
Internet Explorer). There are numerous Web
indexes available providing some organization Yahoo 82 matches 0 matches
(e.g., the Yahoo index site itself lists and links to Magellan 6640 ªresultsº 12 651 ªresultsº
over 400 index sites). Programs (called crawlers, Excite over 100 over 100
robots, spiders, and search engines) allow the documents documents
user to search through the Web and collect Infoseek 5681 ªbestº 13 061 ªbestº
addresses of the information sought through a (searched through 51 191 696 unique URL
keyword search; the user can then access the sites)
identified sites through pointing-and-clicking Altavista 7000 matches 7000 matches
(e.g., through Webcrawler, Lycos). These search
programs are easily accessed through the The browser programs organize the site hits
Netscape or Mosaic programs. The newest using an algorithm, and the results are often
search vehicle is AltaVista, reported to index ranked by ªrelevanceº or confidence in the ªfit
and search over 30 million documents on the to the concept.º Given the ambiguity of the term
Web out of 225 000 Web servers around the ªdepressionº and the range of topics in ªel-
world (Heacock, 1996). derly,º these searches generated quite a few
The various sites are, thus, interlinked and unrelated information sites for such things as
permit exploration and searching. The search ªdepression era artists,º ªdepression glass,º
capacities of the programs or search engines ªThe Great Depression,º and data on a tropical
allow the user to enter a keyword or phrase for a depression off Acapulco. Fortunately, many
search through all the Internet for the concept or documents or pages were found for psycholo-
exact word/phrase. Often a large number of hits gical depression. These sites included health
on the topical term will be found. In a search via center information, on-line depression screening
Yahoo (through Netscape 2.0), we obtained 24 tests, governmental information pages, support
hits or sites with information on the topic of groups, professional organizations, consensus
Table 4 Organization homepages relevant to clinical psychology.
Homepage Association
URL address
Psychology organizations
American Psychological Association
http://www.apa.org
American Psychological Society
http://www.hanover.edu/psych/APS/aps.html
British Psychological Society
http://www.bps.org.uk/
Canadian Psychological Association
http://www.cpa.ca/
Society for a Science of Clinical Psychology
http://www.sscp.psych.ndsu.nodak.edu
Clinical child/pediatric psychology organizations
Society of Pediatric Psychology
http://129.171.43.143/SPP/index.html
University of Minnesota: Pediatric Centers, Policies, and Societies
http://www.peds.umn.edu/centers
Children's Defense Fund
http://www.tmn.com/cdf/index.html
Legal organizations
ABA Network: American Bar Association
http://www.abanet.org/home.html
LAWlink: ABA Legal Research Selected Starting Points
http://www.abanet.org/lawlink/home.html
The ABA Center on Children and the Law
http://www.abanet.org/child/
Governmental information sites
National Institute of Mental Health
gopher://gopher.nimh.nih.gov
GrantsNet: Department of Health and Human Services
gopher://gopher.os.dhhs.gov:70/1/Topics/grantsnet
FedWorld
http://www.fedworld.gov
National Institute on Drug Abuse
http://www.nida.nih.gov
conference statements on treatment, a number some search by different mechanisms or in

of testimonials (e.g., autobiographies, poetry, different sources). Going through the multitude
photos) of people describing their own depres- of sites identified in the search on ªdepressionº
sive episodes and treatment, and a large number and ªdepression in the elderlyº (or whatever
of adverts offering psychological services. Some keyword) is eye-straining, if not mind-boggling.
of the information offered treatment ap- In other keyword searches for clinical
proaches or information of questionable accu- psychology topics, we found a similar bewilder-
racy, efficacy, and taste (and relatedly, ethics). ing, yet potentially helpful, array of informa-
Once the search service (e.g., Lycos, Altavis- tion. A search on ªpanic disordersº turned up
ta) presents the results, the user points-and- the NIH consensus statement and the NIMH
clicks on each interesting entry and that site is patient information pamphlet. A search on
accessed. Because one site is usually linked to ªtraumatic stressº obtained the homepage for
several others of similar topics, one may then the VAMC in Phoenix with diagnostic and
follow from one piece of information to treatment information. ªAttention Deficit Dis-
another. Alternatively, one may return to the ordersº generated a large number of sites on
list of search results to explore the next entry. treatments, professionals offering diagnosis and
Information in the sites can be read at the time, therapy, educational and behavioral assess-
downloaded for later use, or printed into ment, and support services. It is unclear how all
hardcopy. In our search, many of the same of these reflect on the call from some profes-
sites were uncovered by the various services (but sionals in clinical psychology for validated
assessment and treatment information, but the Association (http://www.worldcorp.com/

information is all ªout thereº for public dc-online/nmha), and HandsNet (30 000 human
consumption. service and public interest organizations: http://
www.igc.apc.org/handsnet) also maintain in-
formational sites.
Governmental agencies are often a font of
1.03.4.5.2 Collections of resources on the World
information through Web homepages (URLs)
Wide Web
or Gopher sites. For example, the Center
Professional groups and individual psychol- for Substance Abuse Prevention (in the Depart-
ogists have developed a number of WWW sites ment of Health and Human Services) maintains
in which many other homepages are listed for the informational service of the National
the users to follow up. (Special icons or Clearinghouse for Alcohol and Drug
indicators are used, such as push-pins, high- Information accessible through the Web
lighting, underlining, or different colored (http://www.health.org/). Service and research
words, to note that a linkage to another set of grant information from the Federal government
information or page may be accessed by is obtainable through a Gopher search
pointing at the icon and clicking.) A central (gopher : / /gopher.os . dhhs.gov:70 /1 /Topics /
site listing homepages is a useful place to start in grantsnet). The National Technical Information
finding information related to psychology in Services, also known as FedWorld, provides
general and clinical psychology, in particular. electronic access for health-related information
Following from one site to another is the best (http://www.fedworld.gov), while information
way to explore the Web. Once the user has about US House and Senate legislation is
identified some sites as more useful than others, accessible through the Library of Congress
the URLs can be retained as bookmarks for (http://thomas.loc.gov/).
easy access. Table 5 provides the Internet
addresses for several resource links. Each of
the sites listed includes links to many other sites 1.03.4.6 Limitations
related to clinical psychology.
Using the Web browser (and various search The rapid rise of the Internet led to great
engines such as Yahoo, Lycos, Magellan, expectations and excitement over its motherlode
WebCrawler, AltaVista), one can also enter of information. Increasingly, however, the
the name of an organization or group having Internet has been criticized for a number of
related interests on a topic and find its resource limitations. A primary criticism is that there is
pages of position papers, scientific or profes- no overview or organization of the material
sional articles, and other informative docu- placed on the Web, for example, and that almost
ments. The URLs for the APA links to pages of anything can be and is out on the Net for public
its Public Policy Office and Practice Directorate, and professional access. In its very foundation
while the APS has several psychology links. and its chaotic development, ªmanagementº
Other organizations' homepages, such as the has been avoided. While this may be seen as an
American Bar Association (ABA), maintain asset, the explosion of information and the huge
interesting and useful Internet resource linkages number of sites has made it difficult to make
as well. The ABA entity, for example, links 2200 sense of it all. In contrast to scientific and
sites including the Commission on Mental and professional publications that typically have
Physical Disability Law, the Center on Children editors and editorial boards for evaluating the
and the Law, and the Commission on Domestic credibility of the information prior to publica-
Violence, as well as numerous publications and tion, most of the material on the Web is not
position papers. Similarly, the American Med- subject to any overview, except in certain
ical Association (http://www.ama-assn.org/) instances (such as for some Internet journals).
maintains links to the Journal of the AMA As an example of how bad information can be
and other medical information sites. Other disseminated widely, we have received e-mail
useful homepages include the American messages via a large listserver group with
Academy of Pediatrics (http://www.aap.org/), repeated claims that there are federal laws
the American Psychiatric Association requiring that a report of child abuse be made
(http://www.psych.org/), and the American anytime a child client presents with a change in
Academy of Child and Adolescent Psychiatry behavior. (This claim is untrue, and several
(http://www.psych.med.umich.edu/web/aacap)/). attempts to correct this information were met
Mental health and human services organ- with harsh and personal attacks from the
izations such as The National Alliance for vociferous poster of the misinformation.)
the Mentally Ill (http://www.cais.com/vikings/ Similarly, Web sites may offer psychotherapy
nami.index.html), the National Mental Health through the Internet or services and products of
References 85
Table 5 Resource links for clinical psychology.
Homepage association
URL address
Psychology resources
Psychology Web Pages
http://www-psy.ucsd.edu/otherpsy.html
Psych Web
http://www.gasou.edu/psychweb
Psyc Site
http://www.unipissing.ca/psyc/psycsite.htm
Hanover College Psychology Department
http://psych.hanover.edu
Mental Health Net
http://www.cmhc.com
PsychScapes Worldwide
http://www.mental-health.com
Informational and related resource links
Clearinghouse for subject-oriented Internet resource guides
http://www.lib.umich.edu/chhome.html
THOMAS: Legislative information on the Internet
http://www.thomas.loc.gov/
Neuroscience mailing lists
http://www.lm.com/~nab/neurolist.html
MedWeb
http://www.emory.edu/WHSCL/medweb.ejs.html
uncertain ethical or probative value. Indeed, resources available to clinical psychologists

there is no requirement that any Web site are good. The difficulty is, then, in assessing
contain truthful or useful information. Thus, in the quality of unknown information and
our view, the warning of caveat emptor (buyer locating appropriate references.
beware) extends to the free access to the Web With respect to quality, the peer-review
information sites. process provides one mechanism by which the
How does one sort through this range of caliber of research literature may be kept high.
information? As with other professional litera- ªRefereedº journals, where others knowledge-
ture, we suggest the reader consider the source able about the topic review each article prior to
and apply one's professional training of publication, are common, although not uni-
evaluation. Heacock (1996) suggests that many versal. Unfortunately, this system also results in
people ªhave been led to believe that the many potentially important research reports
Internet (and more specifically, the World Wide not being published as the average rejection rate
Web) is some kind of exhaustive library of for journals is about 75% (Salkind, 1994). In
human knowledge, that anything you want to contrast, most books do not undergo a similar
know is out there, and that there is some simple, pre-publication evaluation. Thus, it behooves
logical way to find it. Nothing could be further the scholar to keep a skeptical eye open when
from the truthº (p. 2D). Thus, Web searching evaluating the utility of any given resource, be it
may result in an overabundance of undigested journal, book, or Usenet newsgroup.
and untested information. The old saying about
the ªneed to separate the wheat from the chaffº
1.03.6 REFERENCES
is quite applicable here.
American Psychological Association (1993). Journals in
psychology: A resource listing for authors (4th ed.).
Washington, DC: Author.
1.03.5 EVALUATING THE RESOURCES American Psychological Association (1997). Thesaurus of
psychological index terms. Washington, DC: Author.
Evaluating the vast array of reference American Psychological Association (1996). PsycINFO:
materials for clinical psychology may be over- Information services in psychology. [On-line], Available:
whelming, perhaps similar to ªbeing asked to http://www.apa.org/psycinfo/psycinfo.html
Bernard, L. C., & Krupat, E. (1994). Health psychology:
climb Mount Everest without a Sherpa guideº Biopsychosocial factors in health and illness. Fort Worth,
(Rosnow & Rosnow, 1995, p. 19). It is our TX: Harcourt Brace.
conclusion that most of the informational Gay, L. R. (1992). Educational Research: Competencies for
analysis and application (4th ed.). New York: Macmillan. National Institutes of Health (1996). Index Medicus.
Garfield, E. (1984). How to search the Social Citations Bethesda, MD: Author.
Index. Current Contents, 27, 3±11. Reed, J. G., & Baxter, P. M. (1992). Library use: Handbook
Hayward, W. C. (1996, Spring). PsycINFO News, 16(1). for psychology (2nd ed.). Washington, DC: American
Washington, DC: American Psychological Association. Psychological Association.
Heacock, D. (1996, June 24). Search engines clear Web Rosnow, R. L., & Rosnow, M. (1995). Writing papers in
dumping ground. Lawrence Journal-World, 2D. psychology (3rd ed.). Pacific Grove, CA: Brooks/Cole.
Houston, J. E. (Ed.) (1990). Thesaurus of ERIC Descriptors Routh, D. K. (1996). Lightner Witmer and the first 100
(12th ed.). Phoenix, AZ: Oryx. years of clinical psychology. American Psychologist, 51,
Institute for Scientific Information (1996). Current Con- 244±247.
tents Journal Coverage. Philadelphia: Institute for Salkind, N. J. (1994). Exploring research (2nd ed.) New
Scientific Information. York: Macmillan.
Kehoe, B. P. (1995). Zen and the art of the internet (4th ed.). Society for Research in Child Development (1996). Child
Upper Saddle River, NJ: Prentice-Hall. development abstracts and bibliography, 70. Chicago:
Mendelsohn, H. N. (1987). A guide to the information University of Chicago Press.
sources for social work and the human services. Phoenix, Walker, A. (Ed.) (1992). PsycINFO user manual. Washing-
AZ: Oryx. ton, DC: American Psychological Association.
1.04
Contributions of Behavioral
Genetics Research to Clinical
Psychology
THOMAS G. O'CONNOR and KIRBY DEATER-DECKARD
Institute of Psychiatry, University of London, UK
and
ROBERT PLOMIN
PaSU, University Park, PA, USA
1.04.2 HISTORICAL CONTEXTS AND CHANGING CONCEPTUALIZATIONS OF BEHAVIORAL
GENETICS AND PSYCHOLOGY 89
1.04.2.1 The Changing Dynamics of Behavioral Genetics Research 89
1.04.2.2 Key Studies in Behavioral Genetics Research 90
1.04.2.2.1 Genetics and major mental illness 90
1.04.2.2.2 Genetics and development 90
1.04.2.2.3 Genetics and the environment: sibling differences in adjustment 90
1.04.2.2.4 Genetics and the environment: environments are not independent of genetic ªeffectsº 91
1.04.2.2.5 Progress in animal research 91
1.04.2.2.6 Psychometric developments in behavioral genetics 91
1.04.2.3 Controversies Old and New 92
1.04.2.4 Summary 92
1.04.3 A SELECTIVE OVERVIEW OF METHODOLOGICAL ISSUES IN BEHAVIORAL GENETICS
RESEARCH 92
1.04.3.1 A PreÂcis of Quantitative Genetics 93
1.04.3.2 An Overview of Research Designs to Detect Genetic and Environmental Influence 93
1.04.3.2.1 Twin studies 93
1.04.3.2.2 Adoption studies 94
1.04.3.2.3 Family history studies 94
1.04.3.3 Alternative Research Designs 94
1.04.3.4 Methodological Criticisms of Behavioral Genetics Methods 95
1.04.3.5 Methodological Recommendations 96
1.04.3.5.1 Multiple measures 96
1.04.3.5.2 Specification of individual-specific environmental risks 96
1.04.3.6 Summary 97
1.04.4 THE CONTRIBUTIONS OF BEHAVIORAL GENETICS TO RESEARCH ON CLINICAL
PHENOTYPES 97
1.04.4.1 A Selective Review of Genetic and Environmental Etiology in Psychopathology 97
1.04.4.2 Continua and Categories in Models of Psychopathology 98
1.04.4.2.1 Distinguishing between the underlying assumptions and quantitative implications of categorical
87
88 Contributions of Behavioral Genetics Research to Clinical Psychology
and dimensional models 98

1.04.4.2.2 Are shared environmental influences more salient at the extremes? 99
1.04.4.2.3 Continuum, boundaries, and spectra 99
1.04.4.3 Comorbidity of Psychopathologies 99
1.04.4.3.1 Comorbidity of psychopathologies: environmental evidence 101
1.04.4.4 Genetic Heterogeneity 101
1.04.4.4.1 Age of onset and other features 102
1.04.4.5 Genetic Influence on Change and Stability of Psychopathology 102
1.04.4.6 Summary 103
1.04.5 MODELS OF GENETIC AND ENVIRONMENTAL RISK MECHANISMS 103
1.04.5.1 Conceptualizing Genetic Influence 103
1.04.5.2 Conceptualizing the Environment 104
1.04.5.3 Genotype±Environment (G±E) Correlations 104
1.04.5.3.1 Passive genotype±environment correlation 104
1.04.5.3.2 Evocative and active genotype±environment correlations 104
1.04.5.3.3 Hypothesized age changes in genotype±environment correlations 105
1.04.5.4 Genotype±Environment Interactions 105
1.04.5.5 Summary 106
1.04.6 MOLECULAR GENETIC RESEARCH ON PERSONALITY AND PSYCHOPATHOLOGY 107
1.04.6.1 Methods and Questions in Molecular Genetics Research on Psychopathology 107
1.04.6.2 Contributions of Molecular Genetics Research to Models of Psychopathology 107
1.04.6.3 Summary and Future Directions 108
1.04.7 CLINICAL PSYCHOLOGY IMPLICATIONS OF BEHAVIORAL GENETICS RESEARCH FINDINGS 108
1.04.7.1 Clarifying Genetic Risks in Assessment 108
1.04.7.2 Genetic and Environmental Considerations for Treatment and Prevention 108
1.04.7.3 Summary 109
1.04.8 GENERAL SUMMARY AND CONCLUSION 109
1.04.1 INTRODUCTION specifies the samples and methods necessary to

answer conceptual questions. A second diffi-
There have been numerous significant ad- culty in writing this chapter is that there are
vances in our understanding of the nature of already a number of excellent texts that
mental disorder in recent years, and consider- introduce many of the key methodological and
able progress derives from the contributions conceptual issues. In particular, the third edition
made by behavioral genetic research. Research of Behavioral genetics (Plomin, DeFries,
findings from behavioral genetics have substan- McClearn, & Rutter, 1997) introduces many
tially altered how we understand: the risks for central concepts and methods in behavioral
major mental illnesses such as schizophrenia, genetics research and reviews of many of the
depression, and bipolar illness; personality dis- more challenging findings. In addition, other
orders and dimensions; disorders of childhood well-received sources focus on more specific
and adolescence; stability and change in psy- areas within behavioral genetics, such as the role
chopathology; and the nature of psychosocial of genetic factors in major mental illness
risks for psychopathology. No longer a periph- (Gottesman, 1991) and childhood psycho-
eral issue, behavioral genetics has made lasting pathology (McGuffin, Owen, O'Donovan, Tha-
contributions to the field of clinical psychology. par, & Gottesman, 1994; Rutter et al., 1990). Still
This is perhaps most obviously indicated by the other volumes provide an overview of the recent
inclusion of a chapter on behavioral genetics in and ongoing questions of behavioral genetics in
the ªFoundationsº volume. psychology (Loehlin, 1992; Plomin, 1994; Plo-
Writing a foundations chapter in behavioral min & McClearn, 1993). Technical texts on
genetics is complicated for many reasons. First statistical genetics (e.g., Neale & Cardon, 1992)
of all, the field of behavioral genetics is, by and molecular genetics are also available. In this
design, multidisciplinary and complex. At a very chapter, we incorporate lessons from each of
basic level, behavioral genetics provides a these perspectives, provide an update on more
conceptual and methodological bridge between recent findings with major implications for
the biological and the behavioral sciences. Con- research on psychopathology, and mold it in a
ceptually, behavioral genetics hypotheses test form that is pertinent to clinical psychology.
whether individual differences in a behavioral An additional major challenge for a review
phenotype can be attributed to genetic and chapter is the amazing speed with which the field
environmental influences. Methodologically, of behavioral genetics is progressing. Research
behavioral genetics is the research tool that reviews on the genetics of one area or another
Historical Contexts and Changing Conceptualizations of Behavioral Genetics/Psychology 89
published just a few years ago are already pathology in particular, are delineated. The
outdated. Nowhere is this more apparent than in penultimate section introduces the burgeoning
the field of molecular genetics and the interface field of molecular genetics and its links with
between molecular genetics and psychiatry. clinical psychology and psychiatry. Such is the
Accordingly, our primary focus is on the con- influence and momentum of molecular genetics
ceptual underpinnings of behavioral genetics. that a chapter on the foundations of behavioral
An effort is made to review key findings, but we genetics and clinical psychology would surely be
avoid an encyclopedic approach in which the incomplete without a general discussion of the
genetics of all disorders is discussed. Chapters methods and emergent findings. Finally, the last
that focus on specific disorders in this series will section discusses some of the implications of
address genetic influences. behavioral genetics methods and findings for
A further orienting remark concerns the clinical psychology.
perspectives from which we review the relevance
of behavioral genetics for clinical psychology.
We view behavioral genetics research as rele- 1.04.2 HISTORICAL CONTEXTS AND
vant not only to our understanding of genetic CHANGING
influences on development, but also to our CONCEPTUALIZATIONS OF
understanding of psychosocial factors. A theme BEHAVIORAL GENETICS AND
emphasized throughout the chapter is that PSYCHOLOGY
behavioral genetic studies provide one of the 1.04.2.1 The Changing Dynamics of Behavioral
best handles on environmental influences. A Genetics Research
second perspective is that we adopt a develop-
mental approach. The reasons for this are The current prevalence of behavioral genetics
rooted not only in our background as develop- research in a very wide array of journals is
mental psychopathologists, but also in the fact impressive. Indeed, it is difficult to avoid
that empirical studies (behavioral genetic stu- reading behavioral genetics studies in main-
dies included among them) repeatedly empha- stream clinical, personality and developmental
size that much can be learned about the psychology journals such as Journal of Abnor-
behavioral phenotype, risk and protective mal Psychology, Journal of Personality and
factors, and mechanisms underlying the devel- Social Psychology, Developmental Psychology,
opment of disorder when clinical phenomena or in journals of disciplines that have tradition-
are observed longitudinally. ally been eager to criticize and slow to adopt this
This chapter is divided into six sections. First, approach (e.g., Journal of Educational Psychol-
in order to place the current set of findings and ogy). The current state of affairs belies the
methods in context, we briefly highlight the difficult history of behavioral genetics research
history of behavioral genetics research. Classic as applied to psychology and psychiatry.
papers and exemplary studies that challenged Curiously, historical assessments of the
basic notions of child and adult development receptiveness of the general and scientific
are emphasized. The central theme in this audience to genetics research in psychology
section is that the pendulum that has swung reveal not only outright dismissal, but also over-
back and forth between nature and nurtureÐ eager acceptance. The pendulum metaphor as
the terms coined by Francis Galton over a applied to the last half-century, with different
century agoÐappears to have settled to a happy swings punctuated by key studies, has been
equilibrium. Second, we review some of the core discussed (Plomin & McClearn, 1993). In
conceptual and methodological issues in beha- addition, Kimble (1993) provides an overview
vioral genetics. Some of the central issues are of some of the key epistemological issues
included here for readers who may not have underlying the history of nature±nurture in
come across these ideas previously. In parti- psychology. In recent years a critical mass of
cular, we seek to clarify some of the popular findings has accumulated to permit a reasoned
controversies and misunderstandings and dif- debate of the conceptual and methodological
ferentiate those debates that have been largely implications of behavioral genetics research.
resolved from those that require additional Many of these debates have been published
attention. Third, we examine how behavioral (e.g., Detterman, 1996; Plomin & Bergeman,
genetics research has contributed to nosological 1991, and commentaries; Scarr, 1992). It is
debate and a number of related issues (e.g., indeed encouraging that behavioral genetics
comorbidity) and whether psychopathology is research has attracted attention and spurred
qualitatively different from the normal range. discussions from psychologists from diverse
Fourth, the ways in which behavioral genetics perspectives (Plomin & McClearn, 1993).
research has contributed to our understanding Fortunately, the most recent iteration in the
of development, and to developmental psycho- nature±nurture debate has moved beyond
discussing whether genetic influences are sig- lications dealt more extensively with how
nificant in behavioral development. Instead, development could be studied from a behavioral
questions now focus on how genetic factors exert genetic perspective (e.g., Plomin, 1986).
their influence. The question of ªhowº to inte-
grate genetic and environmental factors in devel-
1.04.2.2.3 Genetics and the environment: sibling
opmental theory is not new. Anastasi's (1958)
differences in adjustment
recently exhumed paper raised this issue most
directly, and subsequent papers also emphasized One of the most significant advances in
the need for a deÂtente or rapprochement between behavioral genetics research concerns not
competing genetic and environmental models genetics but the environment. Few findings
of development and psychopathology (e.g., illustrate this point better than the remarkable
Gottesman, 1974; Scarr & McCartney, 1983; finding that simply growing up together in the
Turkheimer & Gottesman, 1991). However, it is same home does not make siblings (very)
only relatively recently that we have been able to similar. Correlations between siblings on a
come to grips with the empirical analyses needed range of personality and other indicators in
to answer this question. Some of the important individual differences research (with the notable
inroads are discussed in Section 1.04.5. exception of cognition) are remarkably weak,
and usually less than 0.3. Leaving aside method-
1.04.2.2 Key Studies in Behavioral Genetics ological issues such as measurement error, this
Research low correlation suggests that siblings are quite
different, and this has lead to the search for
Central to the pendulum metaphor noted factors that make siblings different from one
above are key papers, conferences or books that another, that is ªnonshared environment.º A
substantially changed the way in which the target article and attached commentaries to
behavioral genetics link to clinical psychology Plomin and Daniels's (1987) paper published a
was understood. A full discussion of this issue is decade ago still provides a useful introduction to
not within the scope of this chapter, but it is this issue, and continues to be widely cited in
instructive to cite a few examples. research on family influences, sibling relations
and children's psychosocial development.
It is now accepted that nonshared environ-
1.04.2.2.1 Genetics and major mental illness
ment, and particularly differential parental
Although genetic influence on schizophrenia treatment, has provided critical insight into
(and most major mental disorders) has been the socialization influences within families.
widely accepted for many years, this was not Parents do treat their children differently,
always the case. The critical studies to demon- because of age differences, triangulated family
strate the role of genetic factors appeared in the alliances (Vogel & Bell, 1960), or other reasons.
late 1960s and early 1970s (see Gottesman, Phenotypically, this differential treatment of
1991). As Gottesman (1991) notes, researchers sibling children has been linked to problems in
studying schizophrenia were ªconvertedº by the adjustment. Not surprisingly, a child who has a
remarkable findings reported by Heston (1966) more negative relationship with his or her
and others in a ground-breaking conference in parent compared with a sibling, is more likely to
1968. have higher levels of behavioral and emotional
problems (Dunn, Stocker, & Plomin, 1991;
Plomin & Daniels, 1987; Rodgers, Rowe, & Li,
1.04.2.2.2 Genetics and development
1994). The extent to which the effects of
Several key papers ushered behavioral genet- differential treatment are moderated by siblings'
ics research into ªmainstreamº psychology and perceptions and family context has also been
psychopathology research. Behavioral genetics examined (McHale & Pawletko, 1992; Quittner
had received some attention in developmental & Opipari, 1994).
psychology up to the early 1980s, but the Although not usually explicitly tested, the
influence was largely limited to certain areas prevailing assumption in social development
such as temperament and cognitive abilities. A research was that there was no need to include
special issue of Child Development in 1983 more than one child per family. Implicitly, the
(Plomin, 1983) was devoted to a relatively wide hypothesis was that one child was an adequate
range of topics in which behavioral genetics ªproxyº for processes affecting other children in
findings offered important insights into devel- the family. For example, in research on marital
opmental processes underlying change and conflict and children's disruptive behavior only
stability and models that sought to integrate one child per family needed to be studied because
genetic and environmental factors from child- the focus was on the between-family effectsÐthe
hood through adolescence. Subsequent pub- association between individual differences in
Historical Contexts and Changing Conceptualizations of Behavioral Genetics/Psychology 91
marital conflict and individual differences in disorders and diseases such as depression,
children's disruptive behavior across families. Alzheimer's disease, alcoholism, and schizo-
However, the implication of nonshared envir- phrenia. Genetic research using animal models
onment is that simply ªsharingº parental found evidence for genetic influence in areas
conflict does not make siblings similar to one such as learning, behavioral effects of drugs,
another. In addition to encouraging a search for and social behavior, long before similar con-
familial and nonfamilial influences that would clusions were reached in human research
make siblings different from one another, the (Plomin et al., 1997; Scott, 1977). Animal
possibility was raised that siblings adjusted model research is currently leading the way
differently to the same stressor. Several studies towards the integration of molecular genetics
now support the role of nonshared environment and psychology, especially in the area of
(Plomin, 1994), and there is a suggestion that psychopharmacology (Crabbe, Belknap, &
siblings are differentially affected by family Buck, 1994; McClearn et al., 1997), but also
stresses hitherto thought to be ªsharedº in other areas such as fearfulness (Flint et al.,
(O'Connor, Hetherington, & Reiss, in press). 1995).
Accordingly, it is no longer sufficient to examine
just one child per family; assessing the impact of
1.04.2.2.6 Psychometric developments in
how siblings are similarly or differentially
behavioral genetics
affected by stresses can inform our under-
standing of how psychosocial risks operate. A final area that deserves historical attention
is the psychometric progression underlying
behavioral genetics research. A brief overview
1.04.2.2.4 Genetics and the environment:
of the key papers and iterations is provided here
environments are not independent of
because behavioral genetics is intensely quanti-
genetic ªeffectsº
tative, and improved ability to test genetic
A second major insight concerned the way in hypotheses came about only following quanti-
which genetic influences were conceptualized: tative advances.
so-called environmental influences are not Partialling variance in a phenotypic trait into
independent of genetics (Plomin & Bergeman, genetic and environmental factors, the hallmark
1991). That is, environments do not just of behavioral genetics research and an analytic
ªhappen.º Instead, the way in which individuals approach that leads to statements regarding
actively select and respond to their environment heritability, was laid out by Fisher over a half
is correlated with personality, temperamental, century ago (see Jinks & Fulker, 1970). Falconer
and intellectual abilities that are genetically (1960) compiled available evidence and distilled
influenced. In other words, environments are the basic elements of research design that
not randomly distributed but correlated with formed the basis for quantitative genetics (see
genetic factors (Rutter, 1991). Loehlin, 1992). Subsequent contributions that
The ways in which genetic influences shape had a major impact on behavioral genetics
how individuals approach their environments research were both computational and concep-
has been discussed at a conceptual level tual in origin. Most notably, Jinks and Fulker
(Plomin, DeFries, & Loehlin, 1977; Scarr & (1970) provided the quantitative foundations
McCartney, 1983), but there were relatively few for contemporary approaches to regression
empirical examples that directly assessed the analysis and model-fitting. More recently,
hypothesis (Lytten, 1977; Plomin & Rowe, DeFries and Fulker (1985) developed a way of
1979) until the 1980s (Plomin & Bergeman, examining whether genetic influences are great-
1991; Rowe, 1981). Numerous studies published er for extreme (clinical) groups than for groups
subsequently provide support for their hypoth- within the normal range.
esis (Kendler, 1995, 1996; Plomin, Reiss, Additionally, because behavioral genetics
Hetherington, & Howe, 1994). Lessons about analyses are computationally intense, the devel-
how genetic factors influence experience are opment of software packages has also had much
discussed in detail in Section 1.04.5. to do with the accessibility of behavioral gene-
tics research approaches (Joreskog & Sorbom,
1989). Moreover, criticisms of the basic assump-
1.04.2.2.5 Progress in animal research
tions of the twin and other research designs
The history of behavioral genetics research needed to be empirically assessed, such as influ-
needs also to include advances made in research ences of assortative mating, the equal environ-
using animal models, in which both genotype ments assumption in twin studies, selective
and environment can be manipulated. The placement in adoption studies, and differentiat-
development of animal models has long been ing nonshared environment from error of
considered an important step in studying measurement (McArdle & Goldsmith, 1990).
Conceptual questions regarding longitudinal research on individual differences with models

analyses, analyses of latent traits, and multi- of species-typical behavior and processes (Buss,
variate genetic analyses were also asked, and 1991).
similarly required new analytic models. For- A second but related source of confusion is
tunately, the methods to model these sources of heritability, the degree of genetic influence on
influence are now readily available in Neale and individual differences. Heritability is a popula-
Cardon's (1992) comprehensive book. tion parameter derived from a particular sample
Finally, molecular genetic research on com- at a particular time. Although estimating
plex dimensions and disorders required new heritability is often a ªbottom lineº of the
analytic paradigms from single-gene ap- majority of behavioral genetics research, there is
proaches (Plomin, Owen, & McGuffin, 1994). no ªtrueº heritability estimate, just as there is no
The essence of these methods is to identify genes ªtrueº estimate of the effects of any descriptive
in multiple-gene systems that are of modest statistic such as the correlation between life
effect size, which have been called quantitative events and depression. Like any other statistic,
trait loci (QTL) or susceptibility genes. These heritability can vary depending on sample
advances include QTL linkage approaches that characteristics, methodology, and historical
attempt to locate general regions of a chromo- context.
some where a QTL resides (Fulker & Cherny, A further fundamental aspect of understand-
1996) as well as association analyses that cor- ing heritability is that genetic influences are not
relate candidate genes with complex traits (e.g., fixed, nor is it the case that strongly heritable
Risch & Merikangas, 1996). forms of psychopathology will not respond to
environmental input. Thus, there is no necessary
relationship between genetic influence and
1.04.2.3 Controversies Old and New psychosocial susceptibility. Numerous exam-
ples of secular changes in aspects of develop-
Misunderstandings of what research findings ment and psychopathology help illustrate this
from behavioral genetics do and do not imply point (e.g., see Rutter & Smith, 1995).
have led to several controversies, some of which
continue to linger. Rutter (1991) outlines many
of the misconceptualizations of behavioral 1.04.2.4 Summary
genetics research in psychology and psychiatry.
Not surprisingly, controversy remains re-
One of the most frequent, and perhaps most
garding the conceptualization of genetic influ-
important, areas of misunderstanding concerns
ences in the development of psychopathology.
what behavior genetic research examines:
Fortunately, however, there is now good reason
individual differences. That is, why do indivi-
to suspect that the dialogue between behavioral
duals vary, for instance, in their likelihood of
geneticists, developmental psychologists, and
approaching and conversing with strangers,
clinical psychologists and psychiatrists is in-
performing well on ability tests, or experiencing
creasing and has reached a critical mass (Reiss,
depressive symptoms.
1995). The kinds of conceptual questions now
The magnitude of genetic influence on
asked in behavioral genetics research are more
individual differences does not readily translate
sophisticated than those asked a decade ago,
into a second paradigm in psychological
and there is far greater interest in combining
research: group differences, or why two groups
analytic strategies to test competing theories of
of individuals may differ in, for example, their
psychopathological processes (Rutter et al.,
susceptibility to alcoholism. Despite efforts to
1997). Moreover, there are a number of invest-
clarify the marked contrasts between these
igations currently underway that are likely to
approaches, examples of misunderstanding of
provide important clues of how genetic factors
the distinction between research on individual
are involved in the development of psycho-
differences and group differences continue to
pathology (Reiss et al., 1995). In the remainder
appear in the scientific and popular press. A
of the chapter we examine these advances and
notable misunderstanding of genetic methods is
highlight new research directions.
made in the attempts to link ethnic differences
on ability tests and the findings that scores of
ability tests are partly genetically influenced to 1.04.3 A SELECTIVE OVERVIEW OF
conclude that group differences in scores are METHODOLOGICAL ISSUES IN
genetically determined. Although our focus is BEHAVIORAL GENETICS
on an individual differences approach to RESEARCH
development and psychopathology, it is not
the only way that genetic influences operate. As in every other branch of psychological
Several authors have attempted to integrate research, behavioral genetics investigations are
A Selective Overview of Methodological Issues 93
limited by methods and design. The mechanics comparing unrelated siblings, as in the adoption
of the designs used in behavioral genetics design. The adoption design is particularly
research have been discussed widely (Loehlin, powerful because it ªcontrolsº for genetic
1992; Plomin et al., 1997; Rutter et al., 1990), similarity (i.e., adopted siblings are genetically
and will therefore receive only limited attention unrelated). Because unrelated siblings do not
here. Rather than discuss the actual methods in share genes, any similarity must be attributed to
detail, we instead emphasize the hitherto largely common environment. Finally, the magnitude
underappreciated relative strengths and weak- of nonshared environment is most easily seen in
nesses of certain designs in light of current the differences within pairs of identical twins.
models of genetic and environmental influences Because MZ twins are genetically identical, any
on psychopathology. differences must be attributed to different
experiences (and measurement error).
As a general point, it is noteworthy that
1.04.3.1 A PreÂcis of Quantitative Genetics whereas it is possible to examine the magnitude
of the three parameters assessed in behavioral
The first point to make is that genetic genetics research (genetic, shared and non-
influences, or the role of individual differences shared environment), different designs have
in genotype, are estimated based on phenotypic different strengths and weaknesses and are
or observed patterns of similarity in genetically differentially affected by, for instance, gene±
informative designs that vary genetic or envir- gene interactions (which are included in the
onmental relatedness. Given the frequent mis- similarity of MZ twins because they are
interpretation of behavioral genetics findings, genetically identical for all genes) and gene±
we briefly discuss how empirical findings allow environment correlations (which are differen-
us to make inferences regarding the role of genes tially assessed in adoption and twin studies).
and the environment. This helps explain why different results are
Behavioral genetics decomposes individual sometimes obtained from twin and adoption
differences in the variation of behavior into designs and why no design should be taken as
genetic, shared environment, and nonshared the absolute estimate of these influences.
environmental sources of influence. Genetic
influence refers to inherited genetic differences
that contribute to observed (phenotypic) differ- 1.04.3.2 An Overview of Research Designs to
ences among individuals. For identical twins, Detect Genetic and Environmental
these genetic factors contribute entirely to their Influence
phenotypic similarity, while for first-degree
1.04.3.2.1 Twin studies
relatives (parents, offspring, and siblings),
who are 50% similar genetically, additive The most frequent form of behavioral
genetic factors contribute to phenotypic simi- genetics design is the twin study. Historically,
larity and differences in equal measure. twin studies have provided critical initial
One way to determine genetic influence is to findings that have fundamentally altered de-
compare identical (monozygotic or MZ) and bates regarding genetic influence on schizo-
fraternal (dizygotic or DZ) twins. If identical phrenia (Gottesman, 1991) and autism (Folstein
twins are more similar than nonidentical twins, & Rutter, 1977), among other disorders. To
it follows that they may be more similar because date, twin studies provide data on a wide range
they are more similar genetically. The extent to of psychiatric and psychological disorders and
which genetic influences are important can be dimensions virtually across the lifespan (Bou-
quantified because we know that MZ twins chard & Propping, 1993; Eaves et al., 1997;
share all of their genes and DZ twins are, on McGuffin et al., 1994). As noted above, study-
average, 50% similar genetically. Doubling the ing twins is perhaps the best way to assess the
difference between MZ and DZ correlations role of nonshared environment independent of
estimates heritability, or h2, the proportion of genetic effects. Pike, McGuire, Reiss, Hether-
phenotypic variance that is explained by ington, and Plomin (1996) exploited this issue
genotypic variance. Comparing adopted-apart directly in their search of nonshared environ-
MZ and DZ twins (that is, pairs that were raised mental influences that underlie MZ differences
in different homes) provides a rare but even in behavioral adjustment in adolescence. They
more powerful way of estimating genetic found that differential parental negativity and
influences, that ªcontrolsº for shared family warmth could explain differences between MZ
environment. twins in rate of problem behavior.
Shared environmental influences can also be Further examples of exploiting discordant
straightforwardly assessed. The magnitude of MZ twin pairs has provided important insights
shared environment is most easily seen by into which biological substrates associated with
psychopathology might (or might not) be under genetic risk (although, of course, it also indexes
genetic control. For example, Torrey, Bowler, environmental risk), and it would then be
Taylor, and Gottesman (1994) reported that possible to assess the extent to which there is
identical twins discordant for schizophrenia overlap between genetic and environmental risk
also differed in brain structures implicated in its factors for psychopathology.
neuropathology. This finding suggests that
genetic influences on schizophrenia are unlikely
to be mediated through genetic effects on brain 1.04.3.3 Alternative Research Designs
pathology.
The designs noted above are the most
common, but no means the only way of
1.04.3.2.2 Adoption studies
assessing genetic influence. A recent addition
Adoption studies have an equally revered to the armory of behavioral genetics designs is
place in behavioral genetics research on psy- the half-sibling or stepsibling design. The
chopathology. For instance, it was the finding viability of the stepsibling model follows from
that children of schizophrenic mothers who two major demographic changes affecting
were adopted away (and living with nonschizo- families since the mid 1970s. First, the number
phrenic families) were at increased risk of of adoptions has steadily decreased, and it is
developing schizophrenia that lead to a major especially difficult to ascertain representative
shift in how the causes of schizophrenia was samples of adoptive children and adoptive
conceptualized (Heston 1966; see Gottesman, families. The second demographic trend is that
1991). Furthermore, adoption studies based on the number of divorces and remarriages and,
registries in Denmark and Sweden have proved consequently, the number of half- and unrelated
indispensable in our understanding of genetic siblings in reconstituted families has increased
influences on alcoholism and antisocial beha- dramatically (see Reiss et al., 1994). The
vior, among other disorders (Cloninger, Boh- stepsibling design therefore has the unique
man, & Sigvardsson, 1981). Adoption designs advantage of uniting the diverse perspectives
are also well suited to assess genotype± of behavioral geneticists and family researchers.
environment correlations and interactions, a From a quantitative genetic perspective, the
topic discussed below. half- and stepsibling design is as informative as a
twin or adoption design because it is possible to
estimate the degree to which sibling similarity is
1.04.3.2.3 Family history studies
explained by known genetic similarity (full
Family history designs, which also have a siblings are 50% similar genetically, half-
long history in psychiatric research, examine the siblings are 25% similar genetically). There is
extent to which family members, usually first evidence that this approach may be a reasonable
degree relatives of a proband, or the ªtargetº addition to twin and adoption studies. The most
patient, are affected by a disorder. The central encouraging evidence comes from research on
drawback of the family history method is that it intelligence. When similarity of relatives' in-
is impossible to explain why, in terms of genetic tellectual ability is assessed across numerous
and environmental influences, family members types of consanguinity, results from half-
may be similarly affected. Depression, for siblings and cousins complements and does
instance, may run in families because family not detract from the overall pattern of results
members share genes or because they share the (Bouchard & McGue, 1981). Qualified encour-
psychosocial stresses associated with depression agement for the half/unrelated sibling design
(low socioeconomic status, family conflict). comes from the Nonshared Environment and
Nonetheless, family history studies have made Adolescent Development project (NEAD) (Re-
several important contributions to our under- iss et al., 1994), the first study to combine the
standing of genetic influences on psychiatric twin and stepsiblings in the same design
conditions, for example in the area of hetero- (Neiderhiser, et al., in press). Other studies
geneity (see Coryell, 1997) and age of onset (e.g., employing the half-sibling design have endorsed
Weissman et al., 1984) among others. A final this strategy for other behaviors (e.g., Van den
advantage of the family history method is that it Oord & Rowe, 1997).
allows for the test of genetic hypothesis without The stepsibling design provides a further
requiring that investigators ascertain a sample parallel to the adoption design in that it is
of twins or adoptive families. It is therefore possible to ascertain the magnitude of genetic
possible that a genetic component could be effects by comparing biological parent±child
added to existing studies of environmental risk correlations with stepparent±child correla-
for psychopathology. Psychopathology in first- tions. In quantitative genetic terms, the
degree relatives can be used as a proxy for adoptive and stepparent±offspring correlations
A Selective Overview of Methodological Issues 95
are identical in one respect, i.e., the correlation experience perinatal complications (Rutter &
can be explained only by shared environmen- Redshaw, 1991), and these factors may have
tal influence. implications for the development of psycho-
There are, of course, a number of limitations pathology. Some studies also suggest that twins
that complicate interpretation of the stepsibling appear to be at slightly elevated risk for conduct
model results, including potential assortative or other behavioral problems compared with
mating differences in first and second mar- singletons, but other studies suggest the oppo-
riages, variation in length of time sharing a site (see Simonoff, 1992). Additionally, mothers
household, and elevated stress in stepfamilies. of twins are more likely to experience depression
However, there are clear benefits of this than parents of closely spaced children (Thorpe,
strategy, such as examining how environmental Golding, MacGilliuray, & Greenwood, 1991),
factors (e.g., family context) modify genetic and there may be twin-specific processes that
influences. increase the risk for antisocial behavior, such
The final point regarding research design is as imitation (Carey, 1992). This is an important
that studies of biological families can tell us finding given the association between maternal
surprisingly little about mechanisms and pro- depression and children's adjustment problems.
cesses in development (Scarr, 1992). The reason To be sure, the assumption that findings from
is that, as reviewed in Section 1.04.5, findings twins can be generalized to the larger popula-
from biological families cannot distinguish tion should not be accepted uncritically, and
between genetic and environmental processes, further research is warranted (Rutter, Simonoff,
nor can they identify the ways in which these & Silberg, 1993), but there are good reasons
influences correlate and interact. Thus, beha- for accepting twin study results in research on
vioral geneticists and psychosocially minded psychopathology. A more recent methodologi-
investigators need to be equally concerned cal issue in twin studies is chorionic status,
about the use of genetically informative designs as MZ twins can be either monochorionic
to answer questions of causality (Plomin, 1983). or dichorionic but DZ twins are always
dichorionic.
A number of criticisms have been raised
1.04.3.4 Methodological Criticisms of regarding adoption study design as well.
Behavioral Genetics Methods Perhaps the most important of these concerns
the association between the biological and
Criticisms have been raised, and are con- adoptive family characteristics, or selective
tinuously raised, about the methods used to placement. Selective placement in which chil-
make conclusions about the impact of genetic dren from high (or low) genetic risk are placed
factors on development. We briefly review these into families at high (or low) environmental risk
criticisms and outline the implications for confounds these sources of risk that adoption
clinical research. designs are designed to disentangle.
One criticism of the twin method concerns the Assortative mating, the correlation between
ªequal environmentsº assumption, that is MZ spouses, is an issue relevant to both twin and
twins are assumed to experience environments adoption studies. The net effect of assortative
that are no more similar than DZ twins. We now mating for genetic studies is that it will deflate
know that MZ twins do in fact receive a more heritability estimates in twin studies (because
similar familial and extrafamilial environment DZ twin correlations will be increased but MZ
than DZ twins (Plomin, 1994). In this sense, correlations will be unaffected) and increase
then, there is not equal similarity in the parent±offspring correlations between one bio-
environments experienced by MZ and DZ logical parent and offspring. Although assorta-
twins. But the issue is not whether this is the tive mating is not usually found for personality
case, but whether parental differences in (see Loehlin, 1992), it is common for educa-
treatment are the cause or the effect of twins' tional attainment. For psychopathology, there
differences in behavior (Lytton, 1977). Only if is an elevated concordance between husbands'
the former is true is the equal environments and wives' levels of psychopathology for
assumption violated. depression and antisocial behavior (e.g., Kreu-
A separate issue is whether there are features ger, Moffitt, Caspi, & Bleske, in press), but it is
about being a twin that are fundamentally important to consider that assortative mating
different from being a singleton. If so, then does not necessarily imply assortment on the
again we would be concerned about general- same form of psychopathology (see Mednick,
izing findings from twin studies. Relatively few 1978).
factors distinguish twins from nontwins. For A further methodological concern is that
example, there is a suggestion that twins may be different research designs often produce differ-
more likely to exhibit language difficulties and ent estimates for genetic and environmental
influences. Of course, there is no reason to parameter). A somewhat exaggerated example

expect that different designs would necessarily of rater effects is given by Thapar and McGuffin
produce the same results. Nonetheless, attempts (1995). They reported that the heritability of
to include data from adoption and twin studies anxiety symptoms in children was 59% accord-
are relatively rare (Bouchard & McGue, 1981; ing to parent reports but 0% according to
Miles & Carey, 1997). Where differences are children's self-reports! The low agreement
found among research designs, the general invariably found among different reporters in
pattern is for twin designs to produce the research on psychopathology in childhood is
largest genetic effects. Of course, it may be that not just an issue of rater bias, because data from
the greater genetic effects derived from twin different reporters may lead to different sub-
studies is a real finding, attributed to non- stantive findings.
additive genetic influences and epistasis that are However, even when multiple sources of data
best assessed by studying twins. That there is are simultaneously assessedÐan attempt to
variation among different genetically-informa- analyze an error-free latent construct defined
tive designs, and that this variation may be both by what is common among ratersÐthe results
substantive and methodological in nature, are not necessarily any clearer. An example of
cautions against over-reliance on a single this approach is provided by Simonoff, Pickles,
research design and the need to incorporate Hewitt, and Silberg (1995), who examined
multiple designs in the same research program. adolescent self-reports and mother and father
reports of adolescent behavioral problems. In
addition to assessing the genetic±environmental
1.04.3.5 Methodological Recommendations pattern for the common variance among
reporters (i.e., the latent trait), these investiga-
Just as behavioral genetics research findings tors also examined the genetic±environmental
provide clues to the role of both genetic and pattern specific to each rater. Thus, these
environmental factors, findings from these authors hypothesized that genetic (and environ-
studies also suggest methodological recommen- mental) influences on children's behavioral
dations for future studies of mechanisms in problems could be detected by mothers but
development and psychopathology. not by children or fathers. It is not clear,
however, how to interpret mother-specific
genetic effects on children's behavioral pro-
1.04.3.5.1 Multiple measures
blems. To date, no satisfactory way of handling
Methodological problems such as rater bias method effects has been proposed. What is clear
and other forms of measurement error in is that single-reporter designs may suggest
behavioral genetics research complicate the misleading substantive conclusions, particularly
interpretation of findings. This is particularly in research on childhood psychopathology.
true in research on children and adolescents, in Consequently, multiple-reporter designs should
which it is customary to gather information be considered and results based on different
from multiple sources. Were multiple sources of designs compared.
data routinely collected in research on adult
psychopathology, the same problems would
1.04.3.5.2 Specification of individual-specific
inevitably result. Rater effects have predictable
environmental risks
influences on the relative magnitude of genetic
and shared and nonshared environmental A wealth of research demonstrates that
estimates. Specifically, compared with child environmental risks that are shared by siblings,
self-report data, there is a general tendency for or what is termed ªshared environmentº, play
parent ratings to indicate more shared environ- little role in the development of psychopathol-
ment and less nonshared environmental effects; ogy. The one robust exception to this rule is
the differences in the magnitude of the genetic conduct disorder and aggression, for which
parameter among raters is somewhat less there is substantial evidence that simply growing
predictable. In a recent meta-analysis of up in the same home (and the concomitant
behavioral genetics studies of aggression, Miles sharing of psychosocial risks such as poverty
and Carey (1997) found that methodological and neighborhood violence) makes siblings
differences across studies was as important a similar beyond the effects of genetics (McGuffin
contributor to the overall pattern of resultsÐ et al., 1994; O'Connor, McGuire, Reiss,
almost as large as the genetic parameters! In Hetherington, & Plomin, 1998; Plomin et al.,
other words, there is almost as much variation 1997). In general, however, environmental
attributed to methods as to genetic influences influences that are salient for development
(although this was true more for the shared appear to make siblings different from one
environmental parameter than the genetic another.
The Contributions of Behavioral Genetics to Research on Clinical Phenotypes 97
A central implication of this finding for As we discuss in more detail below, the major
research is that risk needs to be conceptualized questions for genetic research in psychopathol-
as individual-specific. That is, there is a need to ogy are no longer whether or not (or how much)
assess the actual impact of the putative risk a disorder is genetic, but what features of a
factor on the individual's construction of disorder are genetic (e.g., onset and course,
events. For example, rather than define parent- heterogeneous subtypes, response to treat-
ing risk in terms of global parent attitudes, it is ment), how does genetic research inform
important to assess the parent's attitudes nosology and treatment, what is the nature of
towards the specific child, how the parent acts genetic risks (e.g., do they influence disorder,
toward the specific child, how parenting to the core symptoms, or other risks), and how do
target child differs from parenting experienced genetic and environmental risks jointly lead to
by siblings. The bottom line of much of the maladjustment. These questions shape the
research on nonshared environment is that risk discussion in this and the following section of
processes occur on an individual-by-individual this chapter.
basis and not on a family-wide level (Plomin, Rather than discuss the forms of psycho-
1995). A corollary is that it is not sufficient to pathology that show genetic influence (this
equate exposure to risk with the effect of the would take an inordinate length of space, and is
risk. covered in chapters on specific manifestations
of psychopathology), we highlight the more
recent and more challenging findings. Several
1.04.3.6 Summary texts and papers describe in detail genetic
A number of strategies are available to influences on a range of disorders in childhood
estimating the effects of genes and environment and adolescence (for depression, Tsuang &
in behavioral development. Previous behavioral Faraone, 1990; for schizophrenia, Gottesman,
genetics research has underscored the metho- 1991; Karayiorgou & Gogos, 1997; for aggres-
dological strengths and weaknesses of each sion, Bohman, 1996). General overviews are
approach and has illustrated a number of provided by Plomin et al. (1997), and more
lessons for researchers seeking to integrate specific volumes are also available (Gershon &
genetic and environmental mechanisms in the Cloninger, 1994). What follows is an overview
development of psychopathology. of the key conceptual questions for under-
standing psychopathology for which behavioral
genetics research provides unique insights.
1.04.4 THE CONTRIBUTIONS OF It may not be a surprise to learn that many
BEHAVIORAL GENETICS TO forms of psychopathology are genetically
RESEARCH ON CLINICAL influenced, but it may be surprising to learn
PHENOTYPES how early in development behavioral problems
can be attributed to genetic etiology. Several
Having discussed the historical change in studies identify relatively robust genetic influ-
behavioral genetics research and some of the ence on externalizing and internalizing symp-
central methodological issues in interpreting toms from age 2±3 (e.g., Van den Oord,
behavioral genetics findings, we now turn to an Verhulst, & Boomsma, 1996). It is not yet
overview of the ways in which behavioral known how (or if) genetic influence on
genetics research has contributed to our under- behavioral problems can be differentiated
standing of clinical phenotypes. Our review from the genetic influences on temperament
focuses on five areas: etiology, the continuity/ at this age, to what extent the results may reflect
discontinuity debate, comorbidity, heterogene- strong parental reporter effects (i.e., self-
ity, and stability and change. reported symptoms of psychopathology are
not reliable before late childhood), or the degree
1.04.4.1 A Selective Review of Genetic and to which the picture might be different if
Environmental Etiology in extreme cases were included (the above studies
Psychopathology were based on normal risk groups and included
few ªcasesº). Nonetheless, the replicated
Genetic influences appear to play an im- findings that early behavior problems show
portant role in the development of most forms genetic influence challenges the notion that
of psychopathology. For example, research early forms of problem behavior are entirely
consistently shows higher concordance of determined by family environmental factors.
schizophrenia among MZ than among DZ These reports provide a good example of how
twins and elevated rates of psychopathology research that simply shows genetic influence can
among children adopted away from disordered challenge prevailing views of the nature of
biological parents, to name just two examples. psychopathology.
Nor is it the case that genetic influences The two approaches require different statis-
disappear in older age. Perhaps the best example tical methods. A quantitative genetic analysis of
is provided by research on depression. McGue individual differences in dimensions of psycho-
and Christensen's (1997) study of Danish twins pathology, which is by far the more straightfor-
75 years or older indicated strong genetic ward of the two, is based on correlations. In the
influence on both affective and somatic symp- example of a twin design, one would hypothe-
toms. These findings are noteworthy because size that identical twins would be more similar
they challenge the notion that somatic symp- than fraternal twins. Alternatively, the diag-
toms of depression index physical impairments nostic approach is based on twin siblings'
in old age rather than depression per se. These concordance for disorder. The genetic effect
findings also contradict the hypothesis thatÐ size or heritability is not estimated from
for a variety of reasons, including the loss of concordances alone, but also takes into con-
friends and loved ones from death, increasing sideration base rates in the population. The
social isolation, and difficulty adjusting to concordance is translated into liability correla-
physical limitationsÐdepression in older age tions that assume a continuous distribution of
is more psychosocially determined. risk. This procedure assumes, paradoxically, a
continuum of liability despite the categorical
measurement. This liability-threshold model
1.04.4.2 Continua and Categories in Models of assumes that the genetic and environmental
Psychopathology contributions to the disorder are continuously
distributed, but that disorder only occurs when
Although diagnostic or categorical ap- a certain threshold of liability is exceeded.
proaches have dominated phenotypic research An additional statistical approach, referred to
on psychopathology, there is increasing interest as DF extremes analysis (from DeFries &
in comparing dimensional and categorical Fulker, 1985), integrates quantitative genetic
models of disorder. Continuous phenotypic research on dimensions and disorders. This
dimensions or syndromes have been demon- approach requires continuous measurement of
strated for a wide variety of medical disorders in behaviors that are relevant to the disorder of
addition to psychiatric forms of disorder, interest among the cotwins of selected, or
including personality disorders (Livesley, Jang, diagnosed, probands. Familial resemblance is
Jackson, & Vernon, 1993; Nigg & Goldsmith, estimated as the extent to which the mean
1994) and depression (Kendler, Neale, Kessler, cotwins' score on this quantitative measure
Heath, & Eaves, 1992a). regresses back to the population mean. If the
The debate about dimensions vs. diagnoses cotwin mean regresses all the way back to the
has attracted the attention of genetic investiga- population mean, the group correlation is 0; if
tors in recent years because at the core of this the cotwin mean is the same as the proband
debate lies a fundamental question of etiology: mean, the group correlation is 1. Group
do the same genetic and environmental factors correlations for identical and fraternal twins
that operate at the extremes also affect the entire can then be compared to estimate group
continuum in the population? Given the novel heritability, or the degree to which genetic
findings that behavioral genetics research is influences are associated with being in the
contributing to this debate and the important extreme group.
clinical implications derived from these results, There is a fundamental difference between the
we provide a detailed overview of the conceptual DF extremes method and the liability-threshold
and methodological issues in this area. method already described. In contrast to the
liability-threshold model, group heritability is
not based on the assumption that the disorder
1.04.4.2.1 Distinguishing between the underlying
is manifested only after a certain threshold is
assumptions and quantitative
reached. On the contrary, disorder-relevant
implications of categorical and
symptoms are assumed to increase continuously
dimensional models
from the normal to the abnormal ªlevelsº of
The dimensional method assesses quantita- the disorder. Group heritability assesses the
tive variation throughout a continuous distri- contribution of genetic and common environ-
bution of symptoms. By definition, individual mental factors to the average quantitative
differences one standard deviation below the difference between the selected probands and
mean are just as informative as 1, 2, or 3 stan- the population.
dard deviations above the mean. The diagnostic Although the liability-threshold and DF
approach, on the other hand, emphasizes extremes models are based on different under-
average differences between an ªextremeº lying assumptions, they do not necessarily yield
diagnosed group and a nondisordered group. different empirical results. Indeed, if the
assumption of the liability-threshold model is defined above (e.g., DF analysis), it is possible

correct (i.e., there is an underlying continuum of to assess the extent to which shared environ-
liability for the disorder), and if the quantitative mental influences are greater in extreme,
dimension measured in the DF extremes model diagnosed groups compared with nondiag-
assesses the actual continuum underlying the nosed, less impaired groups. As in the case of
disorder, then the heritability of liability in the research on genetic influences at the extremes,
liability-threshold model will be very similar to there are few studies that examine whether
the group heritability in the DF model. environmental effects differ at the extremes
Determining whether genetic influences are compared with the normal range, and available
more salient at the extreme is complex. For data suggest that the differences are minimal
instance, most approaches require extremely (Deater-Deckard et al., 1996; Eaves et al., 1993).
large samples (of mild and severe impairment)
in order that there is sufficient power to detect
even large differences. Additionally, these 1.04.4.2.3 Continuum, boundaries, and spectra
approaches determine only if the magnitude A further nosological question related to the
of genetic influence varies across different levels debate of categorical and continuous measure-
of impairment; it is not possible to determine ments concerns the boundaries around a dis-
from the quantitative methods whether different order (this also relates closely to the topic of
genes are involved in the normal and more heterogeneity, which is reviewed next). Beha-
extreme levels of impairment; molecular genetic vioral genetics research findings indicate that
studies are needed for this. even with major mental disorders, the pheno-
To date, there is only limited evidence that type extends more broadly than the traditional
directly addresses the question of whether diagnostic boundaries. For example, it is clear
genetic influence is different at the extremes; that first-degree relatives of schizophrenic
most reports do not find differences. For individuals are not only more likely to exhibit
example, using DF analyses, Deater-Deckard, schizophrenia but also schizophrenic-related
Reiss, Hetherington, and Plomin (1996) found symptoms such as neurological impairments
that genetic influence at the extremes was and schizoid symptoms (Kendler, Gruenberg, &
similar to genetic influence on normal variation Kinney, 1994). A parallel pattern is found
in parent- or adolescent-reported behavior among first-degree relatives of autistic indivi-
problems. Gjone et al. (Gjone, Stevenson, & duals, who exhibit elevated levels of pervasive
Sundet, 1996; Gjone, Stevenson, Sundet, & developmental disorder (Bailey, Phillips, &
Eilertsen, 1996) reported some evidence for Rutter, 1996; Bolton et al., 1994; Rutter, Bailey,
greater heritability on more extreme levels of Simonoff, & Pickles, in press).
behavioral problems, but this effect depended An additional example, which complicates
on how the scale scores were analyzed. Other matters even further, is that the genetically
studies have compared heritability across influenced liability to psychopathology may not
different definitions of disorder. Kendler et al. concern the disorder per se, but associated
(1992a) reported similar heritabilities across personality featuresÐas in the case of neuroti-
different definitions of depression in women, cism and depression (Kendler, Neale, Kessler,
and Slutske et al. (1997) reported identical Heath, & Eaves, 1993). In this instance, it is not
genetic and environmental influences using clear whether associated personality features
broad and more severe definitions of conduct constitute: a core, less acute condition of the
disorder in their study based on retrospective disorder; a distinct feature that increases the risk
reports from the Australian twin registry. In for the disorder; or a consequence of experien-
general, then, the genetic evidence available so cing a disorder. Genetic research findings may
far indicates that there is a continuity of genetic play an important role in nosology, but it is
influence between the normal and the abnormal equally true that confusion regarding the
(Plomin, Nitz, & Rowe, 1990). clinical phenotypes may lead to misinterpreta-
tions of behavioral genetics findings.
1.04.4.2.2 Are shared environmental influences
more salient at the extremes?
1.04.4.3 Comorbidity of Psychopathologies
A recurring theme throughout this chapter is
that genetic studies provide unique clues to One of the most robust findings in psychiatric
understanding the mechanisms through which research is that disorders covary at rates far
environmental risks operate. This is also the higher than would be expected by chance. This
case in the context of the debates on whether is illustrated by numerous epidemiological
genetic influences affect the continuum of reports, such as the National Comorbidity
psychopathology. Using the same approaches Study (NCS) (Kessler et al., 1994). It is generally
found that a minority of individuals account for however, an exception to the general rule that
the majority of disorders. The degree of overlap the genetic correlation between correlated
between and among dimensions of psycho- dimensions is usually more moderate.
pathology is found regardless of whether Research findings from psychopathology in
diagnostic or dimensional indicators are exam- childhood and adolescence lead to similar con-
ined. Several explanations have been proposed clusions. For example, the robust phenotypic
to explain remarkably±elevated rates of cooc- correlation between depressive symptoms and
curring disorders or dimensions (Caron & antisocial behavior in children and adolescents
Rutter, 1991). Higher than expected rates of is well known, and there is increasing evidence
comorbidity or symptom cooccurrence may be that both dimensions are under some genetic
explained by: diagnostic overlap of individual influences (for depression, see Silberg et al.,
symptoms (i.e., a particular symptom is in- 1994; for antisocial behavior, see Gottesman &
cluded under more than one diagnosis); the Goldsmith, 1994). A genetic correlation be-
possibility that one disorder may be a risk factor tween these dimensions was recently found in a
for developing a second disorder; different large national study of 720 families using a
disorders may be overlapping because of multi-method measurement design (O'Connor,
common psychosocial risks; diagnostic schemas McGuire et al., in press). Approximately 50%
may favor multiple diagnoses (DSM-IV) over of the phenotypic correlation between these
identifying a central diagnosis (ICD-10). Other dimensions could be explained by shared
explanation, however, are also possible. genetic influences. A follow-up study conducted
The degree to which two (or more) disorders approximately two years later found roughly
or dimensions may be correlated because of the same results (O'Connor, Neiderhiser, Reiss,
a shared genetic liability has been examined Hetherington, & Plomin, 1998). It is important
only recently. Virtually all available evidence to note that the study also found genetic
indicates that genetic influences are not influences unique to each dimension. Interest-
diagnosis- or dimension-specific. Rather, the ingly, the same pattern of genetic and environ-
nearly universal phenotypic correlations be- mental influences was found for boys and girls
tween different dimensions of psychopathology despite marked mean differences in these
can be explained, in part, by shared genetic dimensions of maladjustment. Data from a
factors, called genetic correlations. large study of juvenile twins in Virginia
A genetic correlation underlying two (or examined the genetic correlation underlying
more) syndromes is possible if each syndrome is hyperactivity and oppositional/conduct pro-
genetically influenced and the syndromes are blems (Silberg et al., 1996). Results of that study
correlated phenotypically. The quantitative indicated that the correlation between these two
basis for analyzing genetic correlations is dimensions was explained largely from the
described in Neale and Cardon (1992). In genetic influences common to both syndromes,
simple terms, genetic influence on the correla- although the pattern varied slightly by age and
tion between two disorders is based on the cross- gender. Family history data provide an addi-
twin cross-correlation. In the case of antisocial tional source of support for genetic factors
and depressive symptoms, genetic influence on underlying different disorders. In this approach,
the correlation between these two dimensions is evidence for genetic influences underlying
suggested if the correlation between twin A's cooccurring disorders is suggested if first-degree
antisocial behavior and twin B's depressive relatives of depressed probands are at elevated
symptoms is greater in MZ than in DZ pairs (or risk for depression, and for a second disorder,
other genetically informative comparison). e.g., alcoholism, compared with first-degree
In a series of studies on adult female twins in relatives of nondepressed probands. Such data
the Virginia twin registry, Kendler and collea- are taken as evidence for cosegregation of
gues reported a significant genetic correlation depression and alcoholism. Cosegregation
between depression and Generalized Anxiety among disorders is relatively common (see,
Disorder (Kendler, Neale, Kessler, Heath, & e.g., duFort, Kovess, & Boivin, 1994; Feng &
Eaves, 1992d), alcoholism (Kendler, Heath, Baker, 1994; Mednick, 1978) and has also been
Neale, Kessler, & Eaves, 1993), and smoking demonstrated in research on child probands
(Kendler, Neale, MacLean, et al., 1993). In the (Puig-Antich et al., 1989). It is important to
case of major depression and generalized note, however, that some studies that suggest
anxiety disorder, Kendler and colleagues re- cosegregation of disorders do not always
ported a genetic correlation of 1.0 between control for the fact that probands may exhibit
major depression and generalized anxiety dis- multiple disorders.
order. In other words, the same genes make one However, just as there is mounting evidence
vulnerable to depressive and anxious symptoms. of nonspecificity of genetic risks for psycho-
The finding of a genetic correlation of 1 is, pathology, there is also evidence, in some cases,
for specificity. Most of the available evidence genetics analyses to the extent that siblings who
suggesting specificity of genetic risks derives differ in their experience of environmental risks
from family history studies. Among the better also differ on both dimensions of psychopathol-
known examples is the finding that first-degree ogy. An example is provided by the study of
relatives of schizophrenic individuals are at antisocial behavior and depressive symptoms in
greater risk for schizophrenia and schizo- adolescence noted above (O'Connor, McGuire,
phrenia-related conditions but not at greater et al., 1998).
risk for bipolar disorder. This supports the
hypothesis, which is also suggested from
available molecular genetic studies (see below), 1.04.4.4 Genetic Heterogeneity
that schizophrenia and bipolar disorder are not
influenced by the same genes (see, e.g., Kendler The concept of heterogeneity of disorder is a
et al., 1994; Tsuang & Faraone, 1990). Similar focus of increasing clinical research attention.
methods also provide convincing evidence that Heterogeneity is an important topic to study
the genetic influences underlying liability to because a clear understanding of the diverse
bipolar disorder are not linked to those ways in which a disorder may manifest is central
associated with unipolar depression (see Tsuang to optimally effective treatment and prevention.
& Faraone, 1990; Weissman et al., 1984), sug- Notwithstanding the significance of the con-
gesting that the same genetic influences are not cept, there has been little progress in how it
shared by all affective disorders. should be defined. Recent papers on the topic
Unfortunately, too few studies have system- define heterogeneity in diverse ways including
atically examined cooccurrence among multiple presumed etiology, biological correlates, re-
(i.e., more than two) disorders, so it is not yet sponse to treatment, longitudinal course, and
known whether the same genetic influences may association with other disorders. These different
help explain that, among affected individuals, definitions likely lead to different conclusions
the average number of diagnoses per individual regarding heterogeneity. Moreover, there are
is greater than two (Kessler et al., 1994). few attempts to examine multiple alternative
definitions within the same study.
Some of the most important data that focuses
1.04.4.3.1 Comorbidity of psychopathologies:
on heterogeneity are based on the work of
environmental evidence
Winokur, Coryell, and colleagues. The ªIowa
There is little specificity in the relationship 500º family study has provided evidence that
between environmental risks such as interper- familial influences are associated with certain
sonal stress or absence of social support and subtypes of depressive disorder (see Coryell,
particular manifestations of psychopathology 1997 and references therein). Unfortunately,
(Wrate, Rothery, McCabe, Aspin, & Bryce, there have been few attempts to replicate these
1995). Behavioral genetic research has contrib- subtypes, and it is not known whether psycho-
uted to this line of research by also demonstrat- pharmacological treatments are differentially
ing that, controlling for genetic factors, there is effective for different subtypes (but see Sig-
evidence that two (or more) disorders or vardsson, Bohman, & Cloninger, 1996, for
dimensions may cooccur because of common the case of alcoholism). A further example of
shared and nonshared environmental risks. In using genetic data to identify subgroups of
the study examining antisocial behavior and affected individuals is provided by DiLalla &
depression noted above (O'Connor, McGuire, Gottesman (1989), who hypothesized that
et al., 1998), there was a small but significant whereas adolescence-limited and late-onset
effect of shared environment that contributed to delinquency may derive from largely psycho-
siblings' similarity in both syndromes. That is, social factors, antisocial behavior exhibited by
by virtue of sharing the same household, siblings individuals who exhibit a stable antisocial
share familial experiences that function to make trajectory may be genetically mediated (Moffitt,
them similar to each other in their levels of both 1993).
behavioral dimensions (cf. Downey & Coyne, Behavioral genetics methods can be used to
1990). Of course, studies that rely on only model- assess whether different symptom clusters of
fitting cannot identify which shared environ- the same disorder are influenced by the same
mental factors underlie the correlation between genes, and whether subgroups of disordered
behavioral dimensions, but the key advantage is individuals can be identified by degree of genetic
that they are able to identify environmental risk. In a recent study of depression in Danish
influence independent of genetics. twins 75 years or older, McGue & Christensen
Similarly, individual-specific environmental (1997) tested the hypothesis that two factors of
risk factors will contribute to the covariation depression in the elderly, somatic and affective
between disorders in multivariate behavioral symptoms, were influenced by the same genetic
factors. They found that despite being clearly 1.04.4.5 Genetic Influence on Change and
distinguishable at a phenotypic level, the two Stability of Psychopathology
factors of depression were nonetheless ex-
plained by the same genetic factors. In other A critical developmental question that awaits
words, there were no genes that were specific to firm answers is the extent to which genetic
somatic symptoms or affective symptoms. In influences mediate the marked stability of
this way, these authors provide a model for disorder from childhood through adulthood.
further research to examine whether the A related question is whether genetic influences
heterogeneous manifestations of a dimension on psychopathology change with age, pubertal
of psychopathology have different genetic and status, or other markers of development. In
environmental origins. other words, to what extent are genetic
An opposite example is provided by reports influences on psychopathology in adolescence
on aggression and delinquency, two aspects of and adulthood different from those detected in
conduct disorder. These two behavioral syn- childhood. It is not that an individuals' genes
dromes are distinct, but nonetheless are highly change, but that genes can have different effects
correlated. However, despite the considerable at different points in development.
overlap, two studies reported that aggression is Consider, for example, the finding that
strongly genetically influenced but delinquency bipolar and schizophrenic disorders are rare
is under minimal influence (Edelbrock, Rende, before puberty, and may first emerge during
Plomin, & Thompson, 1995; Eley, Lichenstein, adulthood and even into older age. These
& Stevenson, in press). disorders are known to be under genetic
influence, so it seems likely that the genetic
mechanisms are not apparent in early childhood
(although there is little research addressing this
1.04.4.4.1 Age of onset and other features
issue) but come ªon lineº only later in develop-
Behavioral genetics methods have also been ment. Further examples of genetic influences
used to examine whether certain features of a explaining discontinuity or marked change in
disorder are under genetic control. Family development include such disorders such as
history data have suggested that younger age Huntington's disease and life-course changes
of onset is a proxy for stronger genetic influence such as pubertal development. This is an
(Todd, Neuman, Geller, Fox, & Hickok, 1993; important lesson for molecular genetic studies
Weissman et al., 1984). In general, probands (see below) that seek to identify the presence of a
with an earlier age of onset tend to have more single or a set of genes associated with the
first-degree relatives with a similar disorder than presence of a disorder. The developmental
those with a late onset. However, although genetic perspective suggests that individuals
many studies have found that age of onset is may have the genetic risk but may not exhibit
correlated with genetic risk, not all studies signs of the disorder until late in development.
replicate this pattern, or they report that the The analytic models used to assess genetic
pattern holds for adolescent but not childhood influences underlying stability and change in
onset probands (cf. Harrington et al., 1993). psychopathology are similar to those used to
More convincing support implicating genetic examine genetic correlations underlying comor-
influences on the age of onset is reported by bid disorders (Plomin, 1986). However,
Kendler, Neale, Kessler, Heath and Eaves although the analytic models are straightfor-
(1992). In their large sample of adult female ward, there are few examples of longitudinal
twins, they were able to identify a large number behavioral genetics analyses of psychopathol-
of identical and fraternal twins concordant for ogy (McGue, Bacon, & Lykken, 1993).
major depression. When they examined how Two studies found that both genetic and
these concordant, affected cotwins manifested environmental factors contribute to stability in
depression, they found that depressed identical adolescent adjustment. For example, Van den
twins were no more similar in the likelihood of Oord and Rowe (1997) reported that genetic and
exhibiting particular symptoms of depression. shared environmental influences contribute to
However, concordant depressed identical twins the stability of antisocial, anxious/depressed,
were more similar than concordant fraternal and hyperactive symptoms. O'Connor, Neider-
twins in the age of onset of disorder. A hiser et al. (1998) found that genetic influences
conclusion drawn from these data is that genetic explained approximately half of the stability in
influences underlie the likelihood of experien- antisocial and depressive symptoms, shared
cing a disorder and perhaps some features such environmental factors explained stability of
as age of onset, but genetic influences appear not antisocial but not depressive symptoms, and
to directly influence the particular pattern of nonshared influences also contributed to stabi-
symptoms the disorder takes. lity for both syndromes.
Models of Genetic and Environmental Risk Mechanisms 103
Genetic influences have also been reported in These findings raise important questions re-
research on adult psychopathology. Data from garding the turning ªon and offº of genes and
the Virginia sample studied by Kendler and gene mechanisms in development.
colleagues suggests that, for example, stability In the next section we expand these lessons by
of depressive symptoms is mediated genetically examining what behavioral genetics research
(Kendler, Neale, et al., 1993). Data from a twin suggests about the processes associated with the
registry composed of individuals who served in development of psychopathology.
the military during the Vietnam War indicated
that phenotypic stability between juvenile and
adult forms of antisocial behavior was due in 1.04.5 MODELS OF GENETIC AND
roughly equal measure to genetic, shared envir- ENVIRONMENTAL RISK
onment, and nonshared environment (Lyons MECHANISMS
et al., 1995). Although the data are derived from
The range of behaviors apparently under
retrospective reports, this is one of the few
genetic control is remarkable. It is now well
studies that has examined the well-known phe-
accepted that intelligence, personality and
notypic connection between conduct problems
psychopathology are influenced by genetic
in adolescence and antisocial behavior in
factors, but recent studies also suggest genetic
adulthood from a genetic perspective.
influence on divorce (McGue & Lykken, 1992),
Family history data are also consistent with
life events (Plomin, Lichtenstein, Pedersen,
the hypothesis that genetic influences underlie
McClearn, & Nesselroade, 1990), sexual or-
stability in psychopathology. As noted, genetic
ientation in males (Bailey & Pillard, 1991) and
mediation of stability is suggested by parent±
females (Bailey, Pillard, Neale, & Agyei, 1993),
offspring concordance rather than age-to-age
social support (Bergeman, Plomin, Pederson,
genetic correlations. In one sense the family
McClearn, & Nesselroade, 1990; Kendler et al.,
history design is a strict test of genetic stability
1995), peer affiliation (Manke, McGuire, Reiss,
because it requires that the genes associated
Hetherington, & Plomin, 1995), personal devo-
with the disorder in childhood or adolescence
tion to religion (Kendler, Gardner & Prescott,
are the same as those associated with its
1997), smoking (Kendler, Neale, MacLean,
manifestation in adulthood, and that the phe-
et al., 1993), television viewing (Plomin et al.,
notypic expression of the disorder is similar.
1990), behavior in problem-solving interactions
Examples of analyses of this type for depression
(O'Connor, Hetherington, Reiss, & Plomin,
are given by Harrington et al. (1993).
1995), work behavior and a remarkably wide
range of attitudes and interests (Plomin et al.,
1997), among others. Indeed, some authors
1.04.4.6 Summary have commented that the null hypothesis of no
genetic influence is no longer justifiable (see
In this section we examined five distinct ways
commentaries on Plomin & Bergeman, 1991).
in which behavioral genetics research has
These findings lead to the inevitable conclu-
informed and challenged our notion of the
sion, already stated in the chapter, that the main
clinical phenotype. In particular, we provided
thrust of research in behavioral genetics is no
evidence that genetic etiology for psychopathol-
longer whether a behavior or trait is genetically
ogy is apparent, and in some cases pervasive,
influenced. Instead, the focus of behavioral
throughout the life-span. Second, consistent
genetics research in psychopathology is how to
with the phenotypic research findings, beha-
conceptualize the mechanisms through which
vioral genetics studies support a continuous
genetic factors impart their influence, and how
model of psychopathology. There is remarkably
genetic and psychosocial risks jointly operate to
little evidence that individuals exhibiting clinical
lead to maladjustment.
levels of disorder are qualitatively distinct from
individuals expressing milder forms, in terms of
genetic and environmental risks. Third, beha- 1.04.5.1 Conceptualizing Genetic Influence
vioral genetics findings have helped to explain
the pervasive cooccurrence of disorders in Many of the models cited for understanding
childhood through adulthood. The nosological how genes and environment operate together
implications of these findings require further have little relevance to psychopathology. An
attention. Fourth, the concepts of heterogeneity example of this is PKU, a disorder in which
and disorder spectrum have also been shaped by affected individuals are unable to synthesize
behavioral genetics findings. Finally, although phenylalanine. This condition, which leads to
the evidence is limited, there appears to be mental impairment, can be effectively treated if
growing support for the impact of genetic dietary restrictions are followed. Although
influences on the stability of psychopathology. PKU is a good example of how genetic causes
can have environmental cures, it is an inade- in that children themselves play no direct role in
quate model for understanding genes and creating the overlap of genetic and environ-
environment as applied to psychopathology. mental factors. The only way of directly
In this example, neither the genetic model estimating the influence of passive genotype±
(single gene) nor the environmental model environment correlations is to compare parents
(environmental risk exposure leads directly and their offspring in biological and adoptive
and unfailingly to the manifestation of the families.
disorder) parallel what is known about psycho- Passive genotype±environment correlations
pathology. make a number of studies of children of
psychiatric parents difficult to interpret because
these children are not only more likely to inherit
1.04.5.2 Conceptualizing the Environment genetic risks but also to be exposed to dys-
Much of the controversy regarding family functional environments that psychiatric par-
influence from behavioral genetics research ents are disproportionately likely to provide
concerns the finding that shared environmental (Rutter & Quinton, 1984). Studying the off-
parameters are usually modest or even zero. spring of parents diagnosed with depression,
Does this finding suggest that there is no effect alcoholism, or other disorders was a mainstay of
of the family environment? Absolutely not. high-risk research, but the presence of passive
Instead, what this suggests is that simply genotype±environment correlations makes in-
growing up in the same home appears to matter terpretations of the mechanisms leading to
little in shaping children's similarity in beha- behavior problems difficult to determine.
vioral traits. It is worth restating here that
estimates of shared familial environment are 1.04.5.3.2 Evocative and active
based on effects rather than measures. Accord- genotype±environment correlations
ingly, shared environmental influences arise
only to the extent to which environments have The principle that individuals are active
functionally equivalent effects on siblings. participants in and create and select their own
As noted previously, one of the most environments is widely acknowledged. Indivi-
important lessons for environmental research dual differences in relationship styles, hyper-
has been the importance of nonshared environ- activity, conduct disorder, and sociability are
ment. In order to identify environmental influ- sustained through the dynamic interchange
ences that play salient roles in development and between personal characteristics and social
psychopathology it is critical to assess risks experiences (Caspi & Moffitt, 1995; Rutter,
specific to the individual because risks shared by Champion, Quinton, Maughan, & Pickles,
family members (e.g., socioeconomic disadvan- 1995). There are many illustrations of this
tage, maternal depression) may nonetheless principle from phenotypic research, including
have nonshared effects. the finding that aggressive children evoke
negative responses from strangers (Anderson,
Lytton, & Romney, 1986) and aggressive
1.04.5.3 Genotype±Environment (G±E) individuals are more likely to select aggressive
Correlations partners (Krueger et al., in press; see Caspi &
Moffitt, 1995).
A major advance in integrating genetics and Even more striking is the finding that the way
the environment in research has been the in which individuals evoke, select, and react to
discovery of genotype±environment correla- their environments is not independent of genetic
tions. Some of the lessons learned from these influence. In this way, there is a correlation
efforts are described below. between the genetic predispositions of indivi-
duals and the environments they experience
(Plomin, 1994). Comparisons of identical and
1.04.5.3.1 Passive genotype±environment
nonidentical twins (and biological and adopted
correlation
siblings) consistently demonstrate that the
Genotype±environment correlations come in former are more similar than the latter in, for
a variety of forms (Plomin et al., 1977; Scarr & example, their selection of peer groups (Manke
McCartney, 1983). The most obvious example is et al., 1995) and manner of interacting with
passive genotype±environment correlation. Pas- others, notably parents (O'Connor et al., 1995).
sive correlations arise because related parents These findings illustrate how there may be
and children share both genes and environ- genetic influences on environmental measures
ments. That is, children share half of their (Plomin & Bergeman, 1991).
parents' genes and are exposed to environments Two recent adoption studies provide parallel
provided by them. The correlation is ªpassiveº examples of genotype±environment evocative
Models of Genetic and Environmental Risk Mechanisms 105
correlation as regards antisocial behavior. In a correlations found no sign of developmental

high-risk adoption study, Ge et al. (1996) change from late childhood through early
reported that adopted adolescents at genetic adolescence (O'Connor, Deater-Deckard et al.,
risk for antisocial behavior (by virtue of having in press).
a biological parent with diagnosed disorder) Of course, the hypothesis that there are
were more likely to evoke aggressive, hostile developmental changes in the type and magni-
parenting and less likely to evoke supportive tude of genotype±environment correlations is
parenting from their adoptive mothers and different from the more straightforward hy-
fathers compared with adoptees not at genetic pothesis that there are age-based changes in the
risk. The study also found that the more effects of genetic influences and, alternatively,
negative parenting of at-risk adoptees was shared and environmental influences. As noted,
mediated by their own disruptive, aggressive there is now considerable evidence that genetic
behavior toward the parent. influences seem to increase with age and that
A similar study based on the Colorado shared environmental influences decrease stea-
Adoption Project (CAP) also found that dily from early childhood through adulthood
individuals with a biological parent with a (McCartney, Harris & Bernier, 1990).
history of antisocial behavior were more likely One implication of genotype±environment
to evoke negative, coercive parenting from their correlations is that the psychosocial processes
adoptive parent relative to adoptees not at associated with the development of psycho-
genetic risk for antisocial behavior (O'Connor, pathology may not be entirely environmentally
Deater-Deckard, Fulker, Rutter, & Plomin, in mediated. Consider the process of coercive
press). The CAP study found that evocative parenting and child disruptive behavior out-
genotype±environment correlations were mod- lined by Patterson (1982). It is possible to view
est in magnitude from late childhood to early both sides of this transactional process as
adolescence. As in the Ge et al. (1996) study, genetically influenced. Children's aggressive
O'Connor, Deater-Deckard et al. (in press) behavior is partly genetically influenced; ag-
found that the effect was mediated by children's gressive antisocial parenting may itself be
aggressive behavior, but the mediation effect associated with genes affecting the parent's
was far less dramatic in the latter study. Both antisocial tendencies or may be evoked by
studies provide compelling evidence that genetic genetically influenced antisocial behavior in the
influences are not limited to trait-like behaviors, children.
but are equally relevant to socialization pro- Consistent with the processes suggested
cesses and family relations. above, a handful of studies demonstrate that
relations between parenting and child
adjustmentÐthe hallmark of developmental
1.04.5.3.3 Hypothesized age changes in
research on psychopathologyÐare mediated by
genotype±environment correlations
genetic influences. For example, in a twin±
Scarr and McCartney (1983) advanced the sibling study, Pike et al. (1996) attributed the
provocative hypothesis that genotype± association between mothers' and fathers'
environment correlations increase with age negative parenting and adolescent symptoms
and change in type. Specifically, they suggested of depression and antisocial behavior largely to
that passive genotype±environment correlations genetic factors. That is, the correlation be-
would predominate in infancy and early child- tween, for example, coercive, hostile parental
hood and that, with increasing age and ability to behavior and children's externalizing symp-
select one's own environments, there would be a toms arises because genetically influenced
gradual shift and evocative/active genotype± aggressive and externalizing behaviors evoke
environment correlations would predominate. negative parenting.
There is a natural developmental appeal in
this hypothesis, but few data are available to test
the idea. What data are available are not 1.04.5.4 Genotype±Environment Interactions
consistent with the proposal. For example,
rather than wane from infancy to adolescence, a It is possible to identify several types of
recent adoption study highlighted that passive genotype±environment interactions. The most
genotype±environment correlations remain common way in which genotype±environment
strong in adolescence (McGue, Sharma, & interactions are conceptualized is that there
Benson, 1996). Additionally, Lytton (1977), are genetic influences on the sensitivity to
among others, has found that evocative environmental risks (Kendler, 1995). Stated
genotype±environment correlations are robust differently, individuals at genetic risk are more
in early childhood. Moreover, one of the few likely than individuals not at genetic risk to
studies of evocative genotype±environment react maladaptively to psychosocial stresses.
This hypothesis is a simple extension of a basic relatively more vulnerable to environmental

tenet in developmental psychopathology, adversity than children not at genetic risk.
namely, that there are individual differences In a separate adoption study of antisocial
in vulnerability to psychopathology. The ex- behavior, Cadoret, Yates, Troughton, Wood-
tension is that a source of these individual worth, & Stewart (1995) reported an association
differences in vulnerability is genetics. between adverse adoptive home environment
Despite the general acknowledgement that and adoptee aggressive, antisocial outcome only
there are likely to be genotype±environment in the presence of genetic risk (see also
interactions in development, there are remark- Cloninger, Sigvardsson, Bohman, & von Knor-
ably few examples. Wahlsten (1990; see also ring, 1982). In their study of depression in adult
commentaries) suggests that the reason may be female twins, Kendler et al. (1995) found that
partly methodological. He rightly points out the difference in the likelihood of experiencing
that many human studies lack the power to depressive symptoms between those at high and
detect interaction effects after the main effects low genetic risk was substantially magnified
are removed. This is particularly relevant to following severe life events. Cadoret et al. (1996)
studies that compare correlations, such as also reported genotype±environment interac-
between MZ and DZ twins, and particularly tion for depression in females (but not males),
if comparisons are made between patterns under but in that study genetic diathesis was defined
high and low stress. Wahlsten's assumption is not by depression but by alcoholism. None-
that genotype±environment interactions are theless, the interaction is the same: environ-
common but go undetected. One reason for mental adversity is associated with increased
believing this argument is that genotype± likelihood of depression only in the presence of
environment interactions are numerous in genetic risk.
animal research in which it is relatively easy Finally, Wahlberg et al. (1997) reported a
to control and constrain both genetic factors genotype±environment interaction for
(through breeding or using identified strains) schizophrenia-related symptoms. Although
and environmental conditions (through experi- neither genetic risk (having a biological parent
mental manipulation that would not be ethical with schizophrenia) nor environmental risk
in human research). (defined as communicative deviance in the
There are several additional reasons why adoptive family) alone resulted in thought
detecting genotype±environment interactions disorder among adoptees, the joint effect of
has been difficult. First, there are few examples both variables was associated with a substantial
of behavioral genetics analyses across a wide increase in thought disorder (see also Tienari
range of stress conditions. Most authors assume et al., 1994; see True et al., 1994, for an example
that genotype±environment interactions would as applied to post-traumatic stress disorder).
be most easily detected in the context of extreme A slightly different model of genotype±
adversity because genetic effects are thought to environment interaction was reported by
be stronger in high-risk environments than in Slutske et al. (1997). These authors found that
normal and low-risk environmentsÐalthough genetic influence on conduct disorder based on
one could make the opposite argument that retrospective reports in adulthood existed only
high-risk environments might overwhelm in- if the twins had the same friends; this was true
dividual differences in vulnerability (e.g. Scarr, only for boys. In this instance, it is not genetic
1992). control over sensitivity to environmental stress,
These challenges notwithstanding, there are but rather similarity in environmental circum-
a number of illustrations of genotype± stances that accentuated genetic influences.
environment interactions for a range of psycho-
pathological conditions. The Swedish adoption
study reported by Bohman (1996) provides one 1.04.5.5 Summary
of the best examples. Bohman (1996) reported
that children with an antisocial biological parent Several developmental models need to be
who were also raised in their biological family considered in elucidating genetic influences in
(i.e., high genetic risk and environmental risk) the development of psychopathology (e.g.,
were considerably more likely to be antisocial Bronfenbrenner & Ceci, 1993; Gottesman &
than children of antisocial biological parents Goldsmith, 1994; Kendler & Eaves, 1986;
who were raised by adoptive parents (i.e., high Plomin, 1994; Reiss, 1995; Rutter et al., 1997).
genetic risk but low-risk environment), children Among the possibilities are: (i) genetic and
exposed to environmental risk in the absence of environmental effects operating in an additive
genetic risk, and children from the normal manner; (ii) genetically influenced characteris-
population. The implication of the pattern of tics altering the exposure to environmental risks,
findings is that children at biological risk are or genotype±environment correlations; (iii)
Molecular Genetic Research on Personality and Psychopathology 107
genetic influences mediating the association influences lead to psychopathology. Accord-

between putative risk and adjustment; and (iv) ingly, results from molecular genetics studies
genetic influences controlling the sensitivity to will likely heighten the need for intensive
environmental risks, or genotype±environment research on environmental processes. There
interactions. It is important to note that are, to date, few attempts to assess both genetic
additive, correlated, mediational, and interac- and psychosocial sources of risk in these studies,
tive genotype±environment models are not and this remains an important direction for
mutually exclusive. future research.
Further improvements and refinements of It is important to distinguish research that
our understanding of these mechanisms will attempts to identify genetic loci associated with
depend on future research in which genetic disorder from research that uses previously
risks, like environmental risks, are specified. identified loci (Plomin & Rutter, in press).
This, of course, requires the contributions of Although it is difficult and expensive to identify
molecular genetics research. genes associated with behavior, it is relatively
easy and inexpensive to use previously identified
genes as measured genetic risk factors in any
1.04.6 MOLECULAR GENETIC type of research on description, prediction,
RESEARCH ON PERSONALITY prevention, and intervention.
AND PSYCHOPATHOLOGY
Behavioral genetics refers to the genetic
analysis of behavior. Quantitative genetic 1.04.6.2 Contributions of Molecular Genetics
analyses such as twin and adoption studies Research to Models of
are best known, but molecular genetic analyses Psychopathology
that attempt to identify specific genes and their
Despite a decade of attempts to identify genes
functions are becoming increasingly important.
for schizophrenia and bipolar disorder (e.g.,
Although complex traits like behavior are likely
Peltonen, 1995), success in identifying genes
to be influenced by multiple genes, identifying
seems to be coming more quickly for personality
some of these genes will provide the opportunity
dimensions (Cloninger, 1997; Ebstein, Nema-
for more focused analyses of questions raised by
nov, Klotz, Gritsenko, & Belmaker, 1997) and
quantitative genetics using direct assessment of
more common disorders such as reading
measured genotypes (Plomin & Rutter, in
disability (Cardon et al., 1994; Grigorenko
press).
et al., 1996; Schulte-Korne et al., 1997), attention
deficit hyperactivity disorder (ADHD) (La-
1.04.6.1 Methods and Questions in Molecular Hoste et al., 1996; Palmer et al., 1997; Sunohara
Genetics Research on Psychopathology et al., 1997) and opioid dependence (Ebstein &
Belmaker, 1997). For schizophrenia, there have
A detailed discussion of the relative merits of been several reports suggesting genes on chro-
association and linkage studies and the statis- mosomes 3, 5, 6, 8, and 22 (see Schwab et al.,
tical methods devised to detect quantitative trait 1997).
loci, among other statistical procedures, is A further example of how molecular genetics
beyond the scope of this chapter (see Baron; has contributed to clinical psychology and
1997; Plomin et al., 1997). Suffice it to say here psychiatry is Alzheimer's disease. A familial
that just as nonbehavioral genetics investigators component of Alzheimer's disease, at least in a
are increasingly familiar with the quantitative minority of cases, had been suspected for several
models and assumptions in that field, the years, and genetic influence was implicated in
methods and assumptions of molecular genetics twin studies (Breitner et al., 1993). Molecular
will also become increasingly familiar. genetic studies indicated that late-onset Alzhei-
Although we avoid a detailed methodological mer's disease (onset after age 65) that shows a
overview, several points deserve attention. familial pattern is linked to a gene on chromo-
First, it is important to recall that molecular some 19 (apolipoprotein E4 or Apo-E4)
genetics studies of psychopathology should not (Corder et al., 1993). Apo-E4 operates as a
be equated with simplistic reductionistic mod- susceptibility gene, quadrupling risk for Alz-
els. There are a number of reasons why this is the heimer's disease, but it is neither necessary nor
case. The most obvious is that most authors sufficient for the development of the disorder.
would agree that specific genes will account for In addition, a much rarer form of Alzheimer's
a very small percentage of the total variance in disease, early onset, can be caused by a gene on
psychopathology. Moreover, simply identifying chromosome 14 (Sherrington et al., 1995); other
the genes provides no answers to the processes even rarer single genes for early-onset Alzhei-
through which genetic and environmental mer's disease have been found.
1.04.6.3 Summary and Future Directions agree, contribute to understanding the difficul-
ties experienced by the patient and the like-
The end goal of the ªgene chaseº in lihood of an individual developing a similar
behavioral science (McClearn et al., 1991) is disorder. Whether such information would alter
not simply to detect an association between a how a patient's diagnosis is conceptualized is a
specific locus (or loci) and behavior. Neither a slightly more complicated matter. Although
significant association between an allele and behavioral genetics research findings have made
disorder nor a significant heritability estimate important contributions to diagnostic debates,
indicate how genetic factors operate in devel- the translation of these findings into clinical
opment. Once genes are identified, we need to practice as applied to an individual is not direct
explore the biological and social pathways and often fraught with difficulty.
through which genetic vulnerabilities, expressed Consequently, it may be that knowledge
through specified biochemical markers, respond of genetic risks (e.g., based on family history)
to social and psychological events to produce contributes most directly not to the conceptua-
psychopathology. The identification of specific lizing diagnosis, but rather to conceptualizing
genetic vulnerability markers may lead to the sources of risk. Research on ADHD
advances such as the identification of which provides a good example. ADHD can be
individuals may be more sensitive to certain managed by psychostimulant medication
psychosocial stresses and a better understanding and parenting practices (Barkley, 1990). The
of how genetic vulnerabilities covary with finding that first-degree relatives, notably
psychosocial adversity, as well as progress in parents, of ADHD probands are also at elevated
defining genetic heterogeneity and genetic risk of ADHD (Biederman et al., 1992) suggests
correlation between disorders. that it would make good clinical sense to
assess symptoms of poor concentration and
1.04.7 CLINICAL PSYCHOLOGY inattention in the parents, even if they are not
IMPLICATIONS OF BEHAVIORAL the identified patient. Assessing ADHD symp-
GENETICS RESEARCH FINDINGS toms in the parents may lead to relief in the
parent(s) and facilitate parent-training ap-
There have already been major clinical proaches and other forms of parent±child and
implications for medical treatment, but what family treatment.
about clinical psychology? In many cases the
clinical implications of behavioral genetics
findings for psychology are not yet well under-
stood. This is partly because the field is still 1.04.7.2 Genetic and Environmental
relatively young as regards psychopathology Considerations for Treatment and
and because the mechanisms of genetic influ- Prevention
ences have not yet been clearly delineated. Perhaps the most important lesson for
A further reason why lessons from behavioral treatment is that there is no necessary connec-
genetics studies have only slowly begun to shape tion between causes and curesÐspecifically,
clinical practice in psychology is that there between genetic influence and type of interven-
continue to be misplaced biases against beha- tion. That is, psychopathology that is strongly
vioral genetics findings. This appears to be so influenced by genetic factors may nevertheless
despite excellent papers dispelling various be affected by intervention. Thus, finding
myths (Rutter & Plomin, 1997). As the section genetic effects in no way contradicts the benefits
on genotype±environment models emphasized, of, e.g., behavioral interventions to improve the
there is no ªzero-sumº relationship between the parenting of antisocial children (Patterson,
role of genetics and the role of environmental 1982; Webster-Stratton, Hollinsworth, Kolpac-
influences (which include clinical interventions). off, 1989). In this context it is also interesting to
Indeed, it is precisely because genetic influences note the high rate of schizophrenia in people
do not operate in isolation from psychosocial from the Caribbean living in the UK but not in
stresses that the finding of genetic influences those living in the Caribbean area (Van Os,
should encourage the development of effective Castle, Takei, Der, & Murray, 1996). In
prevention and intervention models. addition, it is worth remembering that the
factors influencing individual differences in
1.04.7.1 Clarifying Genetic Risks in Assessment psychopathology are not necessarily the same
as those underlying differences in the rate of
It is already common practice to collect psychopathology between groups or over time.
information on family psychiatric history. Consider, for example, the marked secular
Whether there is a history of depression or changes in crime and suicide in young people
substance use in the family may, most would over the last 50 years and the reported increase
General Summary and Conclusion 109
in rates of depression and other mental crease the likelihood of psychopathology. The
disorders (Rutter & Smith, 1995). second point which we wish to emphasize here is
Although somewhat speculative, it is possible that intervention and prevention studies are
to derive treatment and prevention implications powerful designs in which to test some of the
from research on genotype±environment corre- most critical but yet unanswered questions
lations and interactions. To take one example, concerning the mechanisms leading to psycho-
antisocial children often have a ªdoubleº risk: pathology.
inheriting genetic risk from parents and being
exposed to coercive interactions and poor
monitoring (that may be a result of the parents' 1.04.8 GENERAL SUMMARY AND
antisocial behavior). Consequently, it is possible CONCLUSION
to conceptualize parent±child interventions as
interfering with an otherwise ªnaturally occur- The remarkable progress in our understand-
ringº passive and evocative genotype± ing of genetic influences on a wide range of
environment correlation. A complementary medical conditions and behavior has been noted
explanation is also possible based on genotype± by numerous commentators in the scientific and
environment interactions, namely, intervention popular press. Fortunately, previous concep-
and prevention efforts reduce genetic risk by tions of genetic influence as immutable and
decreasing environmental risks to which these contrary to psychological interventions and
individuals might be particularly susceptible. socialization theories are now dispelled. More-
The number of studies designed to prevent the over, contemporary concerns regarding ethical
development of disorder in children of de- and moral issues for genetic research are based,
pressed parents is a second example (e.g., rather, on informed dialogue (e.g., see Gottes-
Beardslee, Wright, Salt, & Drezner, 1997). man & Bertelson, 1996). No longer a topic of
More clinical research is needed that speci- largely political weight, the so-called nature±
fically identifies genetic risk status and eluci- nurture debate has spawned a major research
dates treatment processes. In fact, clinical paradigm that has yielded some of the most
research is one of the best lines of investigation important clues to our understanding of the
to document genotype±environment interac- development, etiology, and conceptualization
tions and correlations, basic notions of how of psychopathology.
genes and environment jointly contribute to the We reiterate three general conceptual ad-
development of psychopathology. Moreover, vances derived from behavioral genetics re-
intervention research that explicitly incorpo- search. Perhaps the most important is that the
rates genetic risk status and manipulates conceptualization of genetic and environmental
psychosocial experiences may help to identify factors has advanced beyond the question of
subgroups of individuals who respond best to whether genetic influence is relevant (cf. Rutter
particular treatment approaches. This could be et al., 1997). Questions that need to be addressed
accomplished, for instance, by including genetic focus instead on how genetic vulnerabilities lead
risk status (based on presence of disorder in to maladjustment and how to incorporate gen-
first-degree relatives or perhaps even genetic etic vulnerability into the already well-estab-
markers) as a predictor of treatment response. lished models of risk and resilience. A second,
fundamental conclusion is that although
authors differ in their optimism regarding how
1.04.7.3 Summary genetic studies can shed light on environmental
mechanisms of risk, all would agree that study-
Necessarily, the clinical implications of ing psychosocial risks must cooccur with
available behavioral genetics findings are, at analyses of biological and genetic factors (Reiss,
this time, largely speculative. Although it is Plomin, & Hetherington, 1993). This is as true
possible to derive some general lessons regard- for molecular genetics as it is for twin and adop-
ing treatment and prevention from nonclinical tion designs. Finally, one of the most important
studies, there is an unfortunate absence of directions of behavioral genetics research has
research that directly fuses psychological inter- been to encourage molecular geneticists to
vention and genetic risk models. What available search for specific genes that may help answer
findings do suggest is that the mechanisms of questions about how genetic influences create
intervention may be far more complex than vulnerability to psychopathologies. Clearly,
initially proposed. Psychological interventions progress in understanding genetic and environ-
may be effective partly because they alter mental sources of risk for psychopathology thus
genetically-based susceptibility to environmen- appears to be following a path of dialectic
tal risk or eliminate otherwise pervasive integration rather than pendulum-like swings
genotype±environment correlations that in- that characterized research just a decade ago.
1.04.9 REFERENCES disorders. Archives of General Psychiatry, 52, 916±924.

Cardon, L., Smith, S. D., Fulker, D. W., Kimberling, W. J.,
Anastasi, A. (1958). Heredity, environment, and the Pennington, B. F., & DeFries, J. C. (1994). Quantitative
question ªHow?º. Psychological Review, 75, 81±95. trait locus for reading disability on chromosome 6.
Anderson, K. E., Lytton, H., & Romney, D. M. (1986). Science, 266, 276±279.
Mothers' interactions with normal and conduct dis- Carey, G. (1992). Twin imitation for antisocial behavior:
ordered boys: Who affects whom? Developmental Psy- Implications for genetic and family environment re-
chology, 22, 604±609. search. Journal of Abnormal Psychology, 101, 18±25.
Bailey, A., Phillips, W., & Rutter, M. (1996). Autism: Caron, C. & Rutter, M. (1991). Comorbidity in child
Towards an integration of clinical, genetic, neuropsy- psychopathology: Concepts, issues and research strate-
chological and neurobiological perspectives. Journal of gies. Journal of Child Psychology and Psychiatry and
Child Psychology and Psychiatry and Allied Disciplines, Allied Disciplines, 32, 1063±1080.
37, 89±126. Caspi, A., & Moffitt, T. E. (1995). The continuity of
Bailey, J. M., & Pillard, R. C. (1991). A genetic study of maladaptive behaviour: From description to under-
male sexual orientation. Archives of General Psychiatry, standing in the study of antisocial behaviour. In D.
48, 1089±1096. Cicchetti & D. Cohen (Eds.), Developmental psycho-
Bailey, J. M., Pillard, R. C., Neale, M. C., Agyei, Y. (1993). pathology (Vol. 2, pp. 472±511). New York: Wiley.
Heritable factors influence sexual orientation in women. Cloninger, C. R. (1997). Quantitative trait loci for
Archives of General Psychiatry, 50, 217±223. personality in families of alcoholics [abstract]. American
Baron, M. (1997). Genetic linkage and bipolar affective Journal of Medical Genetics (Neuropsychiatric Genetics),
disorder: Progress and pitfalls. Molecular Psychiatry, 2, 74, 579.
200±210. Cloninger, C. R., Bohman, M., Sigvardsson, S. (1981).
Barkley, R. A. (1990). Attention deficit hyperactivity Inheritance of alcohol abuse: Cross-fostering analysis of
disorder: A handbook for diagnosis and treatment. New adopted men. Archives of General Psychiatry, 38,
York: Guilford Press. 861±868.
Beardslee, W. R., Wright, E. J., Salt, P., & Drezner, K. Cloninger, C. R., Sigvardsson, M., Bohman, M., & von
(1997). Examination of children's responses to two Knorring, A. L. (1982). Predisposition to petty crimin-
preventive intervention strategies over time. Journal of ality in Swedish adoptees, II: Cross fostering analysis of
the American Academy of Child and Adolescent Psychia- gene±environment interaction. Archives of General Psy-
try, 36, 196±204. chiatry, 39, 1242±1247.
Bergeman, C. S., Plomin, R., Pederson, N. L., McClearn, Corder, E. H., Saunders, A. M., Strittmatter, W.,
G. E., & Nesselroade, J. R. (1990). Genetic and Shmechel, D. E., Gaskell, P., Small, G., Roses, A. D.,
environmental influences on social support: The Swedish Haines, J. L., & Pericak-Vance, M. A. (1993). Gene dose
Adoption/Twin Study of Aging (SATSA). Journal of of apolipoprotein and type 4 allele and the risk of
Gerontology, 45, 101±106. Alzheimer's disease in late-onset families. Science, 261,
Biederman, J., Faraone, S. V., Keenan, K., Benjamin, J., 921±923.
Krifcher, B., Moore, C., Buckminster, S., Ugaglia, K., Coryell, W. (1997). Do psychotic, minor and intermittent
Jellinek, M., Steingard, R., Spencer, T., Norman, D., depressive disorders exist on a continuum? Journal of
Kolodny, R., Kraus, I., Perrin, J., Keller, M., & Tsuang, Affective Disorders, 45, 75±83.
M. (1992). Further evidence for family-genetic risk Crabbe, J. C., Belknap, J. K., & Buck, K. J. (1994). Genetic
factors in attention deficit hyperactivity disorder. Ar- animal models of alcohol and drug use. Science, 264,
chives of General Psychiatry, 49, 728±738. 1715±1723.
Bohman, M. (1996). Predisposition to criminality: Swedish Deater-Deckard, K., Reiss, D., Hetherington, E. M., &
adoption studies in retrospect. In G. R. Bock & J. A. Plomin, R. (1996). Dimensions and disorders of adoles-
Goode (Eds.), Genetics of criminal and antisocial behavior cent adjustment: A quantitative genetic analysis of
(pp. 99±114). Chichester, UK: Wiley. unselected samples and selected extremes. Journal of
Bolton, P., MacDonald, H., Pickles, A., Rios, P., Goode, Child Psychology and Psychiatry, 38, 515±525.
S., Crowson, M., Bailey, A., & Rutter, M. (1994). A DeFries, J. C., & Fulker, D. W. (1985). Multiple regression
case-control family history study of autism. Journal of analysis of twin data. Behavior Genetics, 15, 467±473.
Child Psychology and Psychiatry and Allied Disciplines, Detterman, D. (1996). Current topics in human intelligence,
35, 877±900. Vol. 5: The environment. Norwood, NJ: Ablex.
Bouchard, T., & McGue, M. (1981). Familial studies of DiLalla, L. F., & Gottesman, I. I. (1989). Heterogeneity of
intelligence: A review. Science, 212, 1055±1059. causes for delinquency and criminality: Lifespan per-
Bouchard, T., & Propping, P. (1993). Twins as a tool of spectives. Development and Psychopathology, 1, 339±349.
behavioral genetics. Chichester, UK: Wiley. Downey, G., & Coyne, J. C. (1990). Children of depressed
Breitner, J., Gatz, M., Bergern, A., Christian, J., Mortimer, parents: An integrative review. Psychological Bulletin,
J., McClearn, G. E., Heston, L. L., Welsh, K., Anthony, 108, 50±76.
J., & Folstein, M. F. (1993). Use of twin cohorts for du Fort, G., Kovess, V., & Boivin, J. F. (1994). Spouse
research in Alzheimer's disease. Neurology, 43, 261±267. similarity for psychological distress and well-being: A
Bronfenbrenner, U., & Ceci, S. J. (1993). Heredity, population study. Psychological Medicine, 24, 431±447.
environment, and the question ªhow?ºÐa first approx- Dunn, J., Stocker, C., & Plomin, R. (1990). Nonshared
imation. In R. Plomin & G. E. McClearn (Eds.), Nature, experiences within the family: Correlates of behavioral
nurture, and psychology (pp. 313±324). Washington, DC: problems in middle childhood. Development and Psycho-
APA Books. pathology, 2, 113±126.
Buss, D. M. (1991). Evolutionary personality psychology. Eaves, L. J., Silberg, J. L., Hewitt, J. K., Rutter, M.,
Annual Review of Psychology, 42, 459±491. Meyer, J. M., Neale, M. C., & Pickles, A. (1993).
Cadoret, R. J., Winokur, G., Langbehn, D., Troughton, E., Analyzing twin resemblance in multi system data:
Yates, W. & Stewart, M. A. (1996). Depression spectrum Genetic applications of a latent class model for
disease, I: The role of gene±environment interaction. symptoms of conduct disorder in juvenile boys. Behavior
American Journal of Psychiatry, 153, 892±899. Genetics, 23, 5±19.
Cadoret, R. J., Yates, W. R., Troughton, E., Woodworth, Eaves, L. J., Silberg, J., Meyer, J., Maes, H., Simonoff, E.,
G., & Stewart, M. A. (1995). Genetic±environmental Pickles, A., Rutter, M., Neale, M., Reynolds, C.,
interactions in the genesis of aggressivity and conduct Erikson, M., Heath, A., Loeber, R., Truett, K., &
References 111
Hewitt, J. (1997). Genetics and developmental psycho- Grigorenko, E. L., Wood, F. B., Meyer, M. S., Hart, L. A.,
pathology, 2: The main effects of genes and environment Speed, W. C., Shuster, A., & Pauls, D. L. (1996).
on behavioral problems in the Virginia Twin Study of Susceptibility loci for distinct components of dyslexia on
Adolescent Behavioral Development. Journal of Child chromosome 6 and 15. American Journal of Human
Psychology and Psychiatry and Allied Disciplines, 38, Genetics, 60, 27±39.
965±980. Harrington, R. C., Fudge, H., Rutter, M. L., Bredenkamp,
Ebstein, R. P., & Belmaker, R. H. (1997). Saga of an D., Groothues, C., & Pridham, J. (1993). Childhood and
adventure: Novelty seeking, substance abuse and the adult depression: A test of continuities with data from a
dopamine D4 receptor (DRD4) exon III repeat poly- family study. British Journal of Psychiatry, 162, 627±633.
morphism. Molecular Psychiatry, 2, 381±384. Heston, L. L. (1966). Psychiatric disorders in foster home
Ebstein, R. P., Nemanov, L., Klotz, I., Gritsenko, I., & reared children of schizophrenic mothers. British Journal
Belmaker, R. H. (1997). Additional evidence for an of Psychiatry, 112, 819±825.
association between the dopamine D4 receptor (DRD4) Jinks, J. J., & Fulker, D. W. (1970). Comparison of the
exon III repeat polymorphism and the human person- biometrical genetical, MAVA, and classical approaches
ality trait of novelty seeking. Molecular Psychiatry, 2, to the analysis of human behavior. Psychological
472±477. Bulletin, 75, 311±349.
Edelbrock, C., Rende, R., Plomin, R., & Thompson, L. A. Joreskog, K. G., & Sorbom, D. (1989). LISREL VII:
(1995). A twin study of competence and problems User's guide (2nd ed.). Mooresville, IN: Scientific Soft-
behaviours in childhood and early adolescence. Journal ware.
of Child Psychology and Psychiatry and Allied Disci- Karayiorgou, M., & Gogos, J. (1997). Dissecting the
plines, 36, 775±785. genetic complexity of schizophrenia. Molecular Psychia-
Eley, T., Lichenstein, P., & Stevenson, J. (in press). Sex try, 2, 211±223.
differences in the etiology of aggressive and non- Kendler, K. S. (1995). Genetic epidemiology in psychiatry:
agressive antisocial behavior: Results from twin studies. Taking both genes and environment seriously. Archives
Child Development. of General Psychiatry, 52, 895±899.
Falconer, D. S. (1960). Introduction to quantitative genetics. Kendler, K. S. (1996). Parenting: A genetic±
New York: Ronald Press. epidemiological perspective. American Journal of Psy-
Feng, D., & Baker, L. (1994). Spouse similarity in attitudes, chiatry, 153, 11±20.
personality, and psychological well-being. Behavior Kendler, K. S., & Eaves, L. J. (1986). Models for the joint
Genetics, 24, 357±364. effect of genotype and environment on liability to
Flint, J., Corley, R., DeFries, J. C., Fulker, D. W., Gray, J. psychiatric illness. American Journal of Psychiatry, 143,
A., Miller, S., & Collins, A. C. (1995). A simple genetic 279±289.
basis for complex psychological trait in laboratory mice. Kendler, K. S., Gardner, C. O., & Prescott, C. A. (1997).
Science, 269, 1432±1435. Religion, psychopathology, and substance use and
Folstein, S., & Rutter, M. (1977). Genetic influences and abuse: A multimeasure, genetic±epidemiologic study.
infantile autism. Nature, 265, 726±728. American Journal of Psychiatry, 154, 322±329.
Fulker, D. W., & Cherny, S. S. (1996). An improved Kendler, K. S., Gruenberg, A. M., & Kinney, D. K. (1994).
multipoint sib-pair analysis of quantitative traits. Beha- Independent diagnoses of adoptees and relatives as
vior Genetic, 26, 527±532. defined by DSM-III in the provincial and national
Ge, X., Conger, R. D., Cadoret, R. J., Neiderhiser, J. M., samples of the Danish Adoption Study of schizophrenia.
Yates, W., Troughton, E., & Stewart, M. A. (1996). The Archives of General Psychiatry, 51, 456±468.
developmental interface between nature and nurture: A Kendler, K. S., Heath, A. C., Neale, M. C., Kessler, R. C.
mutual influence model of child antisocial behavior and & Eaves, L. J. (1993). Alcoholism and major depression
parent behaviors. Developmental Psychology, 32, in women: A twin study of the causes of comorbidity.
574±589. Archives of General Psychiatry, 50, 690±698.
Gershon, E. S., & Cloninger, C. R. (1994). Genetic Kendler, K. S., Kessler, R. C., Walters, E. E., MacLean,
approaches to mental disorders. Washington, DC: Amer- C., Neale, M. C., Heath, A. C., & Eaves, L. J. (1995).
ican Psychiatric Press. Stressful life events, genetic liability, and onset of an
Gjone, H., Stevenson, J., & Sundet, J. M. (1996). Genetic episode of major depression in women. American Journal
influence on parent-reported attention-related problems of Psychiatry, 152, 833±842.
in a Norwegian general population twin sample. Journal Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C.,
of the American Academy of Child and Adolescent & Eaves, L. J. (1992b). Childhood parental loss and
Psychiatry, 35, 588±596. adult psychopathology in women: A twin study perspec-
Gjone, H., Stevenson, J., Sundet, J. M., & Eilertsen, D. E. tive. Archives of General Psychiatry, 49, 109±116.
(1996). Changes in heritability across increasing levels of Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C.,
behavior problems in young twins. Behavior Genetics, 26, & Eaves, L. J. (1992d). Major depression and generalized
419±426. anxiety disorder: Same genes, (partly) different environ-
Gottesman, I. I. (1974). Developmental genetics and ments? Archives of General Psychiatry, 49, 716±722.
ontogenetic psychology: Overdue detente and proposi- Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C.,
tions from a matchmaker. In A. D. Pick (Ed.), & Eaves, L. J. (1992a). A population-based twin study of
Minnesota symposium on child psychology (pp. 55±80). major depression in women: The impact of varying
Minneapolis, MN: University of Minnesota Press. definitions of illness. Archives of General Psychiatry, 49,
Gottesman, I. I. (1991). Schizophrenia genesis: The origins 257±266.
of madness. New York: Freeman. Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C.,
Gottesman, I. I., & Bertelson, A. (1996). Legacy of German & Eaves, L. J. (1992c). Familial influences on the clinical
psychiatric genetics: Hindsight is always 20/20. American characteristics of major depression: A twin study. Acta
Journal of Medical Genetics, 67, 317±322. Psychiatrica Scandinavica, 86, 371±378.
Gottesman, I. I., & Goldsmith, H. H. (1994). Develop- Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C.,
mental psychopathology of antisocial behavior: Inserting & Eaves, L. J. (1993). A longitudinal twin study of 1-year
genes into its ontogenesis and epigenesis. In C. A. Nelson prevalence of major depression in women. Archives of
(Ed.), Threats to optimal development: Minnesota sympo- General Psychiatry, 50, 843±852.
sium on child psychology (Vol. 27, pp. 20±44). Hillsdale, Kendler, K. S., Neale, M. C., MacLean, C. J., Heath, A.
NJ: Erlbaum. C., Eaves, L. J., & Kessler, R. C. (1993). Smoking and
major depression: A causal analysis. Archives of General Miles, D. R., & Carey, G. (1997). Genetic and environ-
Psychiatry, 50, 36±43. mental architecture to human aggression. Journal of
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Personality and Social Psychology, 72, 207±217.
Hughes, M., Eshleman, S., Wittchen, H.-U., Kendler, K. Moffitt, T. (1993). Adolescence-limited and life-course-
S. (1994). Lifetime and 12-month prevalence of DSM- persistent antisocial behaviour: A developmental taxon-
III-R psychiatric disorders in the United States. Archives omy. Psychological Review, 100, 674±701.
of General Psychiatry, 51, 8±19. Neale, M. C., & Cardon, L. R. (1992). Methodology for
Kimble, G. A. (1993). Evolution of the nature±nuture issue genetic studies of twins and families. Boston: Kluwer.
in the history of psychology. In R. Plomin & G. E. Neiderhiser, J. M., O'Connor, T. G., Chipuer, H., Reiss,
McClearn (Eds.), Nature, nuture and psychology. Wa- D., Hetherington, E. M., & Plomin, R. (in press). Adding
shington, DC: American Psychological Association. stepfamilies to genetic designs. Manuscript submitted for
Krueger, R., Moffitt, T. E., Caspi, A., & Bleske, A. (in publication.
press). Assortative mating for antisocial behavior: Nigg, J. T., & Goldsmith, H. H. (1994). Genetics of
Developmental and methodological considerations. Be- personality disorders: Perspectives from personality and
havior Genetics. psychopathology research. Psychological Bulletin, 115,
Livesley, W. J., Jang, K. L., Jackson, D. N., & Vernon, P. 346±380.
A. (1993). Genetic and environmental contributions to O'Connor, T. G., Deater-Deckard, K., Fulker, D., Rutter,
dimensions of personality disorder. American Journal of M., & Plomin, R. (in press). Genotype±environment
Psychiatry, 150, 1826±1831. correlations in late childhood and early adolescence:
Loehlin, J. C. (1992). Genes and environment in personality Antisocial behavioral problems and coercive parenting.
development. Newbury Park, CA: Sage. Developmental Psychology.
Lyons, M. J., True, W. R., Eisen, S. A., Goldberg, J., O'Connor, T. G., Hetherington, E. M., & Reiss, D. (in
Meyer, J. M., Faraone, S. V., Eaves, L. J., & Tsuang, M. press). Family systems and adolescent development:
T. (1995). Differential heritability of adult and juvenile Shared and nonshared risk and protective factors in
antisocial traits. Archives of General Psychiatry, 52, nondivorced and remarried families. Development and
906±915. Psychopathology.
Lytten, H. (1977). Do parents create, or respond to, O'Connor, T. G., Hetherington, E. M., Reiss, D., &
differences in twins? Developmental Psychology, 13, Plomin, R. (1995). A twin±sibling study of observed
456±459. parent±adolescent interactions. Child Development, 66,
Manke, B., McGuire, S., Reiss, D., Hetherington, E. M., & 812±829.
Plomin, R. (1995). Genetic contributions to adolescent's O'Connor, T. G., McGuire, S., Reiss, D., Hetherington, E.
extrafamilial social interactions: Teachers, best friends, M., & Plomin, R. (1998). Co-occurrence of depressive
and peers. Social Development, 4, 238±256. symptoms and antisocial behaviour in adolescence: A
McArdle, J. J., & Goldsmith, H. H. (1990). Alternative common genetic liability. Journal of Abnormal Psychol-
common factor models for multivariate biometric ogy, 107, 27±37.
analyses. Behavior Genetics, 20, 569±608. O'Connor, T. G., Neiderhiser, J. M., Reiss, D., Hether-
McCartney, K., Harris, M. J., & Bernieri, F. (1990). ington, E. M., & Plomin, R. (1998). Genetic contribu-
Growing up and growing apart: A developmental meta- tions to continuity, change and co-occurrence of
analysis of twin studies. Psychological Bulletin, 107, antisocial and depressive symptoms in adolescence.
226±237. Journal of Child Psychology and Psychiatry, 39, 323±326.
McClearn, G. E., Plomin, R., Gora-Maslak, G., & Crabbe, Palmer, C. G., Bailey, J. N., Ramey, C., Cantwell, D.,
J. C. (1991). The gene chase in behavioral science. De'Homme, M., McGough, J., Woodward, J., Saranow,
Psychological Science, 2, 222±229. R., Asarnow, J., Smalley, S., & Nelson, S. (1997).
McClearn, G. E., Taranino, L. M., Rodriguez, L., Jones, Possible evidence of DATI gene by sex interaction in
B., Blizard, D., & Plomin, R. (1997). Genotypic selection susceptibility to dopamine transporter [abstract]. Amer-
provides experimental confirmation for an alcoholic ican Journal of Medical Genetics (Neuropsychiatric
consumption quantitative trait locus in mouse. Molecu- Genetics), 74, 630.
lar Psychiatry, 2, 486±489. Patterson, G. R. (1982). Coercive family process. Eugene,
McGue, M., Bacon, S., & Lykken, D. T. (1993). OR: Catalia.
Personality stability and change in early adulthood: A Peltonen, L. (1995). All out for chromosome six. Nature,
behavioral genetic analysis. Developmental Psychology, 378, 665±666.
29, 96±109. Pike, A., McGuire, S., Reiss, D., Hetherington, E. M., &
McGue, M., & Christensen, K. (1997). Genetic and Plomin, R. (1996). Family environment and adolescent
environmental contributions to depression symptoma- depressive symptoms and antisocial behaviour: A multi-
tology: Evidence from Danish twins 75 years of age and variate genetic analysis. Developmental Psychology, 32,
older. Journal of Abnormal Psychology, 106, 439±448. 574±589.
McGue, M., & Lykken, D. T. (1992). Genetic influence on Plomin, R. (1983). Developmental behavior genetics. Child
risk for divorce. Psychological Science, 3, 368±373. Development, 54, 253±259.
McGue, M., Sharma, A., & Benson, P. (1996). The effect of Plomin, R. (1986). Development, genetics, and psychology.
common rearing on adolescent adjustment: Evidence Hillsdale, NJ: Erlbaum.
from a US adoption cohort. Developmental Psychology, Plomin, R. (1994). Genetics and experience. Newbury Park,
32, 604±613. CA: Sage.
McGuffin, P., Owen, M. J., O'Donovan, M. C., Thapar, Plomin, R. (1995). Genetics and children's experiences in
A., & Gottesman, I. I. (1994). Seminars in psychiatric the family. Journal of Child Psychology and Psychiatry
genetics. London: Gaskell Press. and Allied Disciplines, 36, 33±68.
McHale, S. M., & Pawletko, T. M. (1992). Differential Plomin, R., & Bergeman, C. S. (1991). The nature of
treatment of siblings in two family contexts. Child nurture: Genetic influences on ªenvironmentalº mea-
Development, 63, 68±81. sures. Behavioral and Brain Sciences, 14, 373±427.
Mednick, S. A. (1978). Berkson's fallacy and high-risk Plomin, R., Corley, R. DeFries, J. C., & Fulker, D. W.
research. In L. C. Wynne, R. L. Cromwell, & S. S. (1990). Individual differences in television viewing in
Matthysse (Eds.), The nature of schizophrenia: New early childhood: Nature as well as nurture. Psychological
approaches to research and treatment (pp. 442±452). Science, 1, 371±377.
New York: Wiley. Plomin, R., & Daniels, D. (1987). Why are children in the
References 113
same family so different from one another? Behavioral Rutter, M. (1991). Nature, nurture, and psychopathology:
and Brain Sciences, 10, 1±16. A new look at an old topic. Development and Psycho-
Plomin, R., DeFries, J. C., & Loehlin, J. C. (1977). pathology, 3, 125±136.
Genotype±environment interaction and correlation in Rutter, M., Bailey, A., Simonoff, E., & Pickles, A. (in
the analysis of human behavior. Psychological Bulletin, press). Genetic influences and autism. In F. Volkmer &
84, 309±322. D. Cohen (Eds.), Handbook of autism. New York: Wiley.
Plomin, R., DeFries, J. C., McClearn, G. E., & Rutter, M. Rutter, M., Champion, L., Quinton, D., Maughan, B., &
(1997). Behavioral genetics (3rd ed.). New York: Free- Pickles, A. (1995). Understanding individual differences
man. in environmental risk exposure. In P. Moen, G. H. Elder,
Plomin, R., Lichtenstein, P., Pedersen, N. L., McClearn, & K. Luscher (Eds.), Examining lives in context: Perspec-
G. E., & Nesselroade, J. R. (1990). Genetic influences on tives on the ecology of human development (pp. 61±93).
life events during the last half of the life span. Psychology Washington, DC: American Psychological Association.
and Aging, 5, 25±30. Rutter, M., Dunn, J., Plomin, R., Simonoff, E., Pickles, A.,
Plomin, R., & McClearn, G. E. (1993). Nature, nurture, and Maughan, B., Ormel, H., Meyer, J., & Eaves, L. (1997).
psychology. Washington, DC: American Psychological Integrating nature and nurture: Implications of person±
Association. environment correlations and interactions for develop-
Plomin, R., Nitz, K., & Rowe, D. C. (1990). Behavioral mental psychopathology. Development and Psycho-
genetics and aggressive behavior in childhood. In M. pathology, 9, 335±364.
Lewis & S. M. Miller (Eds.), Handbook of developmental Rutter, M., MacDonald, H., Le Couteur, A., Harrington,
psychopathology (pp. 186±205). New York: Plenum. R., Bolton, P., & Bailey, A. (1990). Genetic factors in
Plomin, R., Owen, M. J., & McGuffin, P. (1994). The child psychiatric disorders, II: Empirical findings.
genetic basis of complex human behviors. Science, 264, Journal of Child Psychology and Psychiatry and Allied
1733±1739. Disciplines, 31, 39±83.
Plomin, R., Reiss, D., Hetherington, E. M., & Howe, G. Rutter, M., & Plomin, R. (1997). Opportunities for
(1994). Nature and nurture: Genetic contributions to psychiatry from genetic findings. British Journal of
measures of the family environment. Developmental Psychiatry, 171, 209±219.
Psychology, 30, 32±43. Rutter, M., & Quinton, D. (1984). Parental psychiatric
Plomin, R., & Rowe, D. C. (1979). Genetic and environ- disorder: Effects on children. Psychological Medicine, 14,
mental etiology of social behavior in infancy. Develop- 853±880.
mental Psychology, 15, 62±72. Rutter, M., & Redshaw, J. (1991). Annotation: Growing
Plomin, R., & Rutter, M. (in press). Child development up as a twin: Twin±singleton differences in psychological
and molecular genetics: What do we do with the genes development. Journal of Child Psychology and Psychiatry
once they are found? Child Development. and Allied Disciplines, 32, 885±895.
Puig-Antich, J., Goetz, D., Davies, M., Kaplan, T., Davies, Rutter, M., Simonoff, E., & Silberg, J. (1993). How
S., Ostrow, L., Asnis, L., Twomey, J., Iyengar, S., & informative are twin studies of child psychopathology?
Ryan, N. D. (1989). A controlled family history study of In T. J. Bouchard & P. Propping (Eds.), Twins as a tool
prepubertal major depressive disorder. Archives of of behavioural genetics (pp. 433±458). New York: Wiley.
General Psychiatry, 46, 406±418. Rutter, M., & Smith, D. J. (Eds.) (1995). Psychosocial
Quittner, A. L., & Opipari, L. C. (1994). Differential disorders in young people: Time trends and their causes.
treatment of siblings: Interview and diary analyses Chichester, UK: Wiley.
comparing two family contexts. Child Development, 65, Scarr, S. (1992). Developmental theories for the 1990s:
800±814. Development and individual differences. Child Develop-
Reiss, D. (1995). Genetic influence on family systems: ment, 63, 1±19.
Implications for development. Journal of Marriage and Scarr, S., & McCartney, K. (1983). How people make their
the Family, 57, 543±560. own environments: A theory of gene environment
Reiss, D, Hetherington, E. M., Plomin, R., Howe, G. W., effects. Child Development, 54, 424±435.
Simmens, S. J., Henderson, S. H., O'Connor, T. G., Schulte-Korne, G., Grimm, T., Nothen, M. M., Muller-
Bussell, D. A., Anderson, E. R., & Law, T. C. (1995). Myhsok, B., Propping, P., & Remschmidt, H. (1997).
Genetic questions for environmental studies: Differential Evidence for linkage of spelling disability to chromo-
parenting and psychopathology in adolescence. Archives some 15 [abstract]. American Journal of Medical Genetics
of General Psychiatry, 52, 925±936. (Neuropsychiatric Genetics), 74, 661.
Reiss, D., Plomin, R., & Hetherington, E. M. (1993). Schwab, S. G., Eckstein, G., Hallmayer, J., Lerer, B.,
Genetics and psychiatry: An unheralded window on the Albus, M., Borrman, M., Lichterman, D., Ertl, M.,
environment. American Journal of Psychiatry, 148, Maier, W., & Wildenauer, D. (1997). Evidence sugges-
283±291. tive of a locus on chromosome 5q31 contributing to
Reiss, D., Plomin, R., & Hetherington, E. M., Howe, G., susceptibility for schizophrenia in German and Israeli
Rovine, M., Tryon, A., & Stanley, M. (1994). The families by multipoint affected sibpair linkage analysis.
separate worlds of teenage siblings: An introduction to Molecular Psychiatry, 2, 156±160.
the study of the nonshared environment and adolescent Scott, J. P. (1977). Social genetics. Behavior Genetics, 7,
development. In E. M. Hetherington, D. Reiss, & R. 327±346.
Plomin (Eds.), Separate social worlds of siblings: Sherrington, R., Rogaev, E., Liang, Y., Rogaev, E. A.,
Importance of nonshared environment on development Levesque, G., Ikeda, M., Chi, H., Lin, C., Li, G., &
(pp. 63±109). Hillsdale, NJ: Erlbaum. Holman, K. (1995). Cloning a gene bearing mis-sense
Risch, N., & Merikangas, K. (1996). The future of genetic mutations in early-onset familial Alzheimer's disease.
studies of complex human diseases. Science, 273, Nature, 375, 754±760.
1516±1517. Sigvardsson, S., Bohman, M., & Cloninger, C. R. (1996).
Rodgers, J. L., Rowe, D. C., & Li, C. (1994). Beyond Replication of Stockholm adoption study of alcoholism.
nature versus nurture: DF analysis of nonshared Archives of General Psychiatry, 53, 681±687.
influences on problem behaviors. Developmental Psy- Silberg, J. L., Erickson, M. T., Meyer, J. M., Eaves, L. J.,
chology, 30, 374±384. Rutter, M. L., & Hewitt, J. K. (1994). The application of
Rowe, D. (1981). Environmental and genetic influences on structural equation modelling to maternal ratings of
perceived parenting: A twin study. Developmental twins' behavioral and emotional problems. Journal of
Psychology, 17, 203±208. Consulting and Clinical Psychology, 62, 510±521.
Silberg, J. L., Rutter, M., Meyer, J., Maes, H., Hewitt, J., Tsuang, M., & Faraone, S. D. (1990). The genetics of mood
Simonoff, E., Pickles, A., Loeber, R., & Eaves, L. (1996). disorders. Baltimore: Johns Hopkins University Press.
Genetic and environmental influences on the covariation Van den Oord, E. J., Koot, H. M., Boomsma, D., &
between hyperactivity and conduct disturbance in Verhulst, F. C. (1995). A twin±singleton comparison of
juvenile twins. Journal of Child Psychology and Psychia- problem behavior in 2±3-year-olds. Journal of Child
try, 37, 803±816. Psychology and Psychiatry and Allied Disciplines, 36,
Simonoff, E. (1992). A comparison of twins and singletons 449±458.
with child psychiatric disorders: An item sheet study. Van den Oord, E. J., & Rowe, D. C. (1997). Continuity and
Journal of Child Psychology and Psychiatry and Allied change in children's social maladjustment: A develop-
Disciplines, 33, 1319±1332. mental behavior genetic study. Developmental Psychol-
Simonoff, E., Pickles, A., Hewitt, J., Silberg, J. (1995). ogy, 33, 319±332.
Multiple raters of disruptive child behavior: Using a Van den Oord, E. J., Verhulst, F. C., & Boomsma, D.
genetic strategy to examine shared views and bias. (1996). A genetic study of maternal and paternal ratings
Behavior Genetics, 25, 311±326. of problem behaviors in 3-year-old twins. Journal of
Slutske, W., Heath, A. C., Dinwiddie, S., Madden, P., Abnormal Psychology, 105, 349±357.
Bucholz, K., Dunne, M., Statham, D., & Martin, N. G. Van Os, J., Castle, D. J., Takei, N., Der, G., & Murray, R.
(1997). Modeling genetic and environmental influences M. (1996). Psychotic illness in ethnic minorities: Clar-
in the etiology of conduct disorder: A study of 2,682 ification from the 1991 census. Psychological Medicine,
adult twin pairs. Journal of Abnormal Psychology, 106, 26, 203±208.
266±279. Vogel, E. F., & Bell, N. W. (1960). The emotionally
Sunohara, G., Bar, C. L., Jin, U., Scahcher, R., Roberts, disturbed child as the family scapegoat. In N. W. Bell &
W., Tannock, R., Malone, M., & Kennedy, J. L. (1997). E. F. Vogel (Eds.), A modern introduction to the family
Is the dopamine D4 receptor gene associated with (pp. 382±397). Glencoe, IL: Free Press.
children and adults with attention-deficit-hyperactivity Wahlberg, K. E., Wynne, L. C., Oja, H., Keskitalo, P.,
disorder? [abstract]. American Journal of Medical Genet- Pykalainen, L., Lahti, I., Moring, J., Naarala, M., Sorri,
ics (Neuropsychiatric Genetics), 74, 629. A., Seitmaa, M., Laksy, K., Kolassa, J., & Tienari, P.
Thapar, A., & McGuffin, P. (1995). Are anxiety symptoms (1997). Gene±environment interaction in vulnerability to
in childhood heritable? Journal of Child Psychology and schizophrenia: Findings from the Finnish adoptive
Psychiatry and Allied Disciplines, 36, 439±447. family study of schizophrenia. American Journal of
Tienari, P. Wynne, L. C., Moring, J., Lahti, I., Naarala, Psychiatry, 154, 355±362.
M., Sorri, A., Wahlberg, K.-E., Saarento, O., Seitmaa, Wahlsten, D. (1990). Insensitivity of the analysis of
M., Kaleva, M., & Laksy, K. (1994). The Finnish variance to heredity±environment interaction. Behavior
adoption study of schizophrenia: Implications for family and Brain Sciences, 13, 109±161.
research. British Journal of Psychiatry, 164 (Suppl. 23), Webster-Stratton, C., Hollinsworth, T., & Kolpacoff, M.
20±26. (1989). The long-term effectiveness and clinical signifi-
Todd, R. D., Neuman, R., Geller, B., Fox, L. W., & cance of three cost-effective training programs for
Hickok, J. (1993). Genetic studies of affective disorders: families with conduct-problem children. Journal of
Should we be starting with childhood onset probands? Consulting and Clinical Psychology, 57, 550±553.
Journal of the American Academy of Child and Adolescent Weissman, M. M., Wickramaratne, P., Merikangas, K. R.,
Psychiatry, 32, 1164±1171. Leckman, J. F., Prusoff, B. A., Caruso, K. A., Kidd, K.
Torrey, E. F., Bowler, A. E., Taylor, E. H., & Gottesman, K., & Gammon, G. D. (1984). Onset of major depression
I. I. (1994). Schizophrenia and manic-depressive disorder. in early adulthood: Increased familial loading and
New York: Basic Books. specificity. Archives of General Psychiatry, 41,
True, W. R., Rice, J., & Heath, A. C. (1994). Genetic and 1136±1143.
environmental influences of twins in post-traumatic Wrate, R. M., Rothery, D. J., McCabe, R. J. R., Aspin, J.,
stress. Archives of General Psychiatry, 51, 838±839. & Bryce, G. (1995). Psychosocial adversity in an
Turkheimer, E., & Gottesman, I. I. (1991). Individual adolescent psychiatry inpatient cohort: WHO ICD-10
differences and the canalization of human behavior. findings from a multicentre prospective study. Social
Developmental Psychology, 27, 18±22. Psychiatry and Psychiatric Epidemiology, 30, 5±13.
1.05
Psychobiology
NIELS BIRBAUMER
University of TuÈbingen, Germany
and
HERTA FLOR
Humboldt-University, Berlin, Germany
1.05.1 PSYCHOBIOLOGY AND CLINICAL PSYCHOLOGY 117

1.05.1.1 Terminology 117
1.05.1.2 The Three-systems Approach 117
1.05.2 GENETICS AND CLINICAL PSYCHOLOGY 118
1.05.3 PSYCHONEUROENDOCRINOLOGY AND PSYCHONEUROIMMUNOLOGY 118
1.05.3.1 Introduction and Definitions 118
1.05.3.2 Hormones, Bodily Rhythms, and Behavior 119
1.05.3.3 Hormones and Emotions 119
1.05.3.4 Relationships Between Nervous and Immune System 120
1.05.3.5 Stress and the Immune System 120
1.05.3.6 Learning and the Immune System 120
1.05.4 NEUROCHEMISTRY AND NEUROPHARMACOLOGY 121
1.05.4.1 Psychopharmacology and Clinical Psychology 121
1.05.4.2 Mechanisms of Action of Psychoactive Substances 122
1.05.4.2.1 Neuronal mechanisms 122
1.05.4.2.2 Receptors for neurochemicals 122
1.05.4.3 Transmitter Systems 123
1.05.4.3.1 Amino acids 123
1.05.4.3.2 Amines 123
1.05.4.3.3 Opioids 123
1.05.4.3.4 Neuropeptides 124
1.05.4.3.5 Acetylcholine 124
1.05.5 PSYCHOPHYSIOLOGY 124
1.05.5.1 Introduction 124
1.05.5.2 Concepts in Psychophysiology 124
1.05.5.2.1 The three-systems approach 124
1.05.5.2.2 The law of initial values 125
1.05.5.2.3 Activation, arousal, and directional fractionation 125
1.05.5.2.4 Stimulus±response specificity 125
1.05.5.2.5 Individual response stereotopies 126
1.05.5.2.6 Orienting, habituation, and defense 126
1.05.5.2.7 Social psychophysiology 126
1.05.5.3 Methods in Psychophysiology 127
1.05.5.3.1 Electroencephalography 127
1.05.5.3.2 Magnetoencephalography (MEG) 127
1.05.5.3.3 Functional magnetic resonance imaging (fMRI) 127
1.05.5.3.4 Positron emission tomography (PET) 129
1.05.5.3.5 Electromyography (EMG) 129
115
116 Psychobiology
1.05.5.3.6 Electrodermal activity (EDA) 129

1.05.5.3.7 Heart activity and blood pressure 131
1.05.5.4 Applications of Psychophysiology 131
1.05.5.4.1 Biofeedback 131
1.05.5.4.2 Biofeedback of slow cortical potentials 132
1.05.5.4.3 EMG biofeedback 132
1.05.5.4.4 Detection of deception 132
1.05.5.4.5 Clinical psychophysiology 133
1.05.6 CONSCIOUSNESS AND ATTENTION 133
1.05.6.2 Psychophysiology of Consciousness 133
1.05.6.3 The Ascending Reticular Activating System 134
1.05.6.3.1 Neurophysiology of tonic and phasic activation 134
1.05.6.3.2 Transmitter systems involved in attention 134
1.05.6.3.3 Gating of attention 135
1.05.6.4 The Psychophysiology of Selective Attention 135
1.05.6.5 Event-related Potentials as Indicators of Attentional Processes 136
1.05.6.5.1 N1/P1 136
1.05.6.5.2 N2 136
1.05.6.5.3 P3 137
1.05.7 SLEEP, DREAM, CIRCADIAN RHYTHMS, AND SLEEP DISORDERS 137
1.05.7.2 Circadian Clocks 138
1.05.7.3 Sleep and Dream 139
1.05.7.4 The Neurobiology of Sleep 140
1.05.7.5 Psychophysiology of Sleep Stages 140
1.05.7.6 Sleep Disorders 141
1.05.8 LEARNING, PLASTICITY, AND DISORDERS OF LEARNING AND MEMORY 141
1.05.8.2 Mechanisms of Plasticity 142
1.05.8.3 The Formation of Memory Traces 142
1.05.8.4 Neuropsychology of Memory 143
1.05.8.5 Cellular Mechanisms of Learning 144
1.05.8.6 Neuronal Bases of Learning and Memory 145
1.05.8.7 Neurochemistry of Memory 145
1.05.9 MOTIVATION AND MOTIVATION-RELATED DISORDERS 147
1.05.9.2 Hunger and the Eating Disorders 147
1.05.9.3 Sexual Function and the Sexual Disorders 148
1.05.9.3.1 The sexual response 148
1.05.9.3.2 Sexual differentiation and sex hormones 149
1.05.9.3.3 Hormonal basis of sexual behavior 149
1.05.9.3.4 Neuronal mechanisms of sexual behavior 150
1.05.9.3.5 Influence of sex hormones on the brain 150
1.05.9.3.6 Brain processes and homosexuality 151
1.05.9.4 Acquired Motivation and Substance-induced Disorders 151
1.05.9.4.1 The neurobiology of addiction 152
1.05.9.4.2 Learned motivation and addiction 152
1.05.10 EMOTION AND THE EMOTIONAL DISORDERS 154
1.05.10.2 Fear and Anxiety and the Anxiety Disorders 155
1.05.10.2.1 Avoidance, fear, and anxiety 155
1.05.10.2.2 Startle reflex modulation and fear 155
1.05.10.2.3 Psychopharmacology of fear and anxiety 156
1.05.10.3 Sadness, Depression, and the Affective Disorders 156
1.05.10.3.1 Sadness and depression 156
1.05.10.3.2 Neurochemistry of depression 157
1.05.10.4 Aggression and Aggression-related Disorders 158
1.05.10.4.1 Development of aggression 158
1.05.10.4.2 Neuronal basis of aggression 158
1.05.10.4.3 Hormonal basis of aggression 158
1.05.10.4.4 Psychopathy 159
1.05.10.5 The Neocortical Hemispheres and Emotion 159
1.05.10.6 Behavioral Medicine: Application of the Psychophysiology of Emotion to Disease 159
1.05.11 COGNITIVE PROCESSES AND COGNITIVE DISORDERS 160
1.05.11.2 Functions of the Cerebral Hemispheres 160
1.05.11.3 Evolution and Neurophysiology of Language 162
1.05.11.3.1 Language disorders 164
Psychobiology and Clinical Psychology 117
1.05.11.4 The Association Areas of the Neocortex 164

1.05.11.4.1 Parietal cortex 164
1.05.11.4.2 The frontal lobe 166
1.05.11.4.3 The temporal lobe 168
1.05.11.5 Thought Disorders 168
1.05.12 SUMMARY 170
1.05.1 PSYCHOBIOLOGY AND CLINICAL meaning or significance. As we shall see in

PSYCHOLOGY Section 1.05.11.3, the construction of meaning
is based on a well-described associative learning
mechanism in the CNS. The creation of mean-
When I carefully consider the curious habits of dogs ing consists of a relatively fast automatic process
I am compelled to conclude that man is the superior
animal. When I consider the curious habits of man I
(for simple stimuli it lasts up to 200 ms) which in
confess, my friend, I am puzzled. (Ezra Pound) most instances does not need conscious, con-
trolled information processing.
One of the main reasons which makes the
1.05.1.1 Terminology simultaneous observation and measurement of
all three response levels mandatory in clinical
Psychobiology describes the relationship psychology is their generally low correlation in a
between psychological and behavioral pro- given stimulus context. Exceptions, such as
cesses and the underlying physiological me- extremely intensive emotions (e.g., terror), are
chanisms. It is not only brain functions that are rare. The problem becomes particularly obvious
the scope of psychobiology but also the if we refer from a given response channel (e.g.,
interplay of all bodily activities with behavior an angry outburst) to an underlying construct
and cognition. The term biological psychology such as an emotion. The different measures of
is often used synonymously. While physiolo- the given response would be expected to be
gical psychology and behavioral neuroscience highly correlated with each other because they
deal with the CNS (central nervous system)± would be indicators of the same construct.
behavior interaction, psychobiology encom- However, as shown by OÈhman (1987), it is
passes both peripheral±physiological and CNS quite complicated to decide what a ªhigh
functions. Neuropsychology applies a compar- correlationº means in this instance. Since
able strategy but uses naturally occurring behavior, physiology, and verbal reports re-
lesions in humans. present very diverse data domains, most of the
variance in each of the measures would be
1.05.1.2 The Three-systems Approach attributable to factors that would not contri-
bute to the variance in the others. For example,
All disorders of behavior and thought have a a peripheral±physiological measure such as
physiological basis, and virtually all physical heart rate is primarily constrained by the design
disorders are strongly related to deviant beha- and demands of the cardiovascular system, and
vior. Therefore, any separation between mind the variance left for psychological factors is
and body, or brain and behavior, is unjustified. necessarily small. Similarly, verbal reports are
For each disorder, the specific psychological shaped by cultural conventions including lin-
and physical variance must be specified. Any guistic limitations which may not affect heart
principal distinction between the two levels of rate at all. Since a high correlation between two
observation compromises progress toward the measures requires that their variance is deter-
understanding of the etiology of diseases. The mined by the same sources in approximately the
psychobiology of disease is an integral part of same proportions, high correlations between,
clinical psychology; any attempt to ignore its for example, heart rate and verbal reports would
significance will lead to misleading conclusions. be unlikely. In fact, using the theorems of factor
Behavior in general can be measured in analysis for a theoretical treatment of this
humans at the level of verbal reports, often problem, OÈhman has shown that the maximal
called subjective level, the level of physiological between-response channel correlation one could
responses (including hormonal, endocrine, and realistically expect in the present case would be
immunological), and the level of overt (motor) 0.30 rather than 0.70. Indeed, even within one of
responses. The three response levels are usually the response domains, for example, within
elicited by stimuli in the environment. Their autonomic reponses, covariations between re-
impact on the three systems is defined by their sponse measures and various emotional stimuli
118 Psychobiology
often barely reach statistical significance, typi- 1.05.2 GENETICS AND CLINICAL
cally ranging between 0.2 and 0.3 (Fahrenberg, PSYCHOLOGY
Walschburger, & Foerster, 1979). Given this
limitation on the expected covariation, one The knowledge of the principles of genetics
would be likely to encounter frequent cases is critical for the clinical psychologist for sev-
where, for example, behavior and physiology eral reasons. The genetic make-up of an
would provide discordant bases for inferring an individual not only determines the limits of
emotion (for a more extended discussion of the systematic behavior modification and treat-
covariation problem see Birbaumer & OÈhman, ment but in many disorders allows the guidance
1993). of interventional strategies toward the plastic
In stressing the necessity of physiological gene-behavior chains and the investment of
definitions and measurements in clinical psy- modification efforts in already fixed and rigid
chology, particularly neurophysiological and behavioral expressions of genetic activity.
neurochemical studies, we emphasize that Modern genetics teaches us that the genetic
physiology cannot substitute for, but rather is apparatus is a highly flexible system which
dependent on, the other levels. Even with allows environmental (learning) factors to
perfect knowledge about the neurophysiologi- influence its functions at most if not all levels
cal mechanisms, the definition of a disordered of synthesis and expression. A natureÐnurture
behavior requires, in addition, the contextual± polarization, still popular among behavioral
situational, the subjective±verbal, and the beha- and molecular scientists and the public, is
vioral components in order to be complete. incompatible with our present state of knowl-
The covariation or a lack of covariation be- edge. Clinical psychology should incorporate
tween the three response levels frequently these new scientific advances to target inter-
becomes the main source of variance in the ventions according to the existing biological
etiology or maintenance of a disorder. In panic limits and possibilities. A detailed discussion of
disorder, for example, the aberrant subjective genetic foundations of clinical psychology can
perception and evaluation of cardiovascular be found in Chapter 1.04, this volume.
responses constitutes the main etiological factor
involved (lack of correlation between response 1.05.3 PSYCHONEUROENDO-
levels). On the other hand, in phobics, Lang, CRINOLOGY AND
Melamed, and Hart (1970) have convincingly PSYCHONEUROIMMUNOLOGY
demonstrated that a high correlation between 1.05.3.1 Introduction and Definitions
the physiological response (cardiovascular in
this case), expressive motor behavior (avoid- Psychoneuroendocrinology and psychoneur-
ance), and verbal response (fear) provides the oimmunology deal with the study of the
best predictor for fast extinction of the response. relationship between the hormonal and immune
In some forms of schizophrenia, the discor- system and behavior, particularly in humans.
dance and variability between some of the Behavioral endocrinology and behavioral im-
response systems is often regarded as the core of munology use mostly animals for the same
the disorder (see Section 1.05.11.5). purpose. Several excellent texts are available for
Since physiological mechanisms play such a an in-depth review of both fields (cf., Ader,
pivotal role in the etiology of most disorders of Felten, & Cohen, 1990; Becker, Breedlove, &
behavior, their assessment is necessary for Crews, 1992; Nelson, 1994). Here we provide a
planning and documenting psychological treat- short overview of the main topics of both fields
ment. Most treatment outcome studies in without a repetition of basic immunology or
clinical psychology and psychiatry are satisfied endocrinology. Both can be found in the
with the documentation of changes in a verbal textbooks on physiology and the above-men-
report or, in the more advanced publications, tioned introductions.
include systematic behavioral observations. There are intricate relationships between the
Psychophysiological measurements are more nervous system, the immune system, and the
expensive and time-consuming and require endocrine system. Behavior (on all three levels:
appropriate training. Therefore, many clinical motor, cognitive, and physiological) is not
psychologists and psychiatrists avoid their directly influenced by the two systems but
application. As will become apparent in the hormones and immune factors enter the nervous
following sections, a lack of acceptance and system and change behavior through that
credibility of psychological treatments and high system. It is important to note that there are
rates of relapse related to insufficient treatment reciprocal interactions between the nervous
outcome measures constitute the negative system and behavior: behavior is not only
consequences of neglecting the psychobiologi- affected by the hormonal and immune system
cal response system. but together with environmental stimuli and the
Psychoneuroendocrinology and Psychoneuroimmunology 119
consequences of a particular behavior, behavior be the insight into the inverse of separation,
itself affects again the two ªslowº bodily namely social attachment and love.
systems. Attachment and love certainly contain strong
Hormones or immune factors can have elements of psychological dependency and in
organizing or activating effects. An organizing the case of separation, withdrawal reactions in
effect would, for example, be the specific the form of sadness or jealousy. Therefore, the
formation of hypothalamic nuclei during in- considerations in Section 1.05.9.4 concerning
trauterine development which later in life cause drug dependency and the dopamine system are
heterosexual or homosexual behavior (see also relevant for love and attachment. All sub-
Section 1.05.9.3.6). An activating effect con- stances which stimulate the limbic dopamine
sists, for example, of the unspecific secretion of system (opiates, benzodiazepines, and alcohol)
ACTH after stressful stimuli. Hormones influ- reduce the symptoms of separation withdrawal.
ence sensory systems, the CNS, as well as the Particularly effective are direct injections of
effectors. The hormonal and the immune system opiates in the ventral tegmental dopamine sys-
are phylogenetically very old systems (from tem; injection of naloxone, an opiate antago-
insect to humans with similar structure and nist, produces cries of separation in rats and
function) and act relatively slowly on behavio- monkeys (Wise, 1988).
rally relevant structures. Slow means that the Affiliative behavior is, however, heteroge-
direct actions of the nervous system on muscles neous (pair bonding, parental care, mutual
are usually much faster (in the millisecond defense, sexual interaction, and altruistic±
range), whereas the ªwetº bloodstream-depen- helpful behavior), each behavior will correlate
dent hormones and immune structures exert with a specific neurohormonal profile (response
their effects within seconds, hours, days, or stereotopy). Situational factors such as touch,
months. Both fields become increasingly im- smell, eye contact, and temperature play a
portant for clinical psychology and behavior central role in the formation of those emotion-
modification: many clinical psychological and specific hormonal profiles (stimulus stereotopy).
psychiatric disorders are caused or at least in The lack of physical contact between many
some aspects influenced by endocrine and/or developing mammals including humans and a
immunological agents. Additionally, the tailor- caregiver prevents slow wave sleep and GH
ing of psychological intervention strategies to secretion and causes psychosocial dwarfism and
endocrine and immunological changes in pa- autistic social behavior. For example, tactile
tients is extremely important, as can be seen stimulation in rat pups causes synthesis of the
from the intricate interplay of circadian hor- enzyme ornithine decarboxylase (ODC); se-
monal rhythms and depression, sex hormones paration stops the synthesis and brush strokes
and sexual deviations, and in the modification analogous to the mother's licking restore ODC
of antisocial behavior, treatment of obesity and production. ODC is an enzyme essential for
eating disorders, and stress-related disorders. tissue growth and development.
The peptide hormone oxytocin was for a long
1.05.3.2 Hormones, Bodily Rhythms, and time known to be the central hormone in the
Behavior initiation of milk ejection and uterine contrac-
tions for viviparity. However, extrahypothala-
Nearly all hormones are synthesized and/or mic hypophyseal oxytocin plays a totally
secreted in a rhythmic manner, triggered by different role from hypothalamic and brain
endogenous oscillators in the CNS which can be stem-produced oxytocin. The latter is univer-
entrained to exogenous (mainly light) or sally important for initiation of maternal
psychological (mostly social) stimuli within behavior, sexual attraction, grooming, and
certain limits. monogamy. It seems as if a certain critical level
of oxytocin has to be present in the hypothala-
1.05.3.3 Hormones and Emotions mus in order to make social interaction reward-
ing (Schulkin, 1993). Central b-endorphin and
The hormonal reaction to separation and loss oxytocin both act in an agonistic fashion on the
constitutes the most intensively studied emo- central dopamine psychomotor reward system
tional reaction because of its obvious relevance (see Section 1.05.9.4.2). The behavioral effects
to the pharmacotherapy of depression. Disrup- of oxytocin and endorphins depend more upon
tion of the circadian rhythm of GH, ACTH, and the location of their synthesis in the brain and
cortisol is accompanied by an initial increase in less on their biochemical or physiological actions
some endogenous opioids in the periventricular on nerve cells or glands. Both are strongly
gray and a depletion of noradrenaline (NA) and influenced by the circadian rhythm and sup-
serotonin (5-HT). A productive research direc- pressed during negative emotions such as stress,
tion to understand antidepressive agents might anxiety, and depression. Soft tactile stimulation
120 Psychobiology
on nipples and genitals in social interaction humans, stress increases the probability for
increase their production. Stress, anxiety, and newly acquired infections but rarely affects
depression are discussed in Section 1.05.10. already active immune diseases.
Learned helplessness stress (see Section
1.05.3.4 Relationships Between Nervous and 1.05.10.3.2) dramatically reduces CD4+ T
Immune System helper cells through glucocorticoid increase
and leaves the organism more vulnerable to
The nervous system has various direct and new infections. This may explain why in older or
indirect (mostly) endocrine connections with already weak populations, loss of the partner
different (but not all) parts of the immune system results in a significant reduction of survival
and vice versa: immune factors regulate and because of an increased susceptibility to disease
modify several neuronal responses mainly (cf., Schedlowski & Tewes, 1996).
through endocrine effects on the CNS but also On the other hand, an increased plasma level
within the nervous system through direct activa- of glucocorticoids after physical stress, for
tion of immune cells by psychological and example, blood poisoning, protects the organ-
physical stimuli. ism. Adrenalectomized animals, who are defi-
Several substances in the nervous system (NS) cient in glucocorticoid release, die from severe
constitute signals for the immune system: these stress, whereas intact animals survive severe
are the main neurotransmitters such as NA, stress because an excessive immune reaction to
acetylcholine (Ach), and excitatory amino external toxins is prevented by the release of
acids, such as glutamate. Neuropeptides mod- glucocorticoids. In addition, some cytokines
ulate immune function through neurotransmit- stimulate the adreno±cortical±pituitary axis and
ters or directly. Most important are substance P, suppress the growth of tumor cells with reactive
VIP (vasoactive intestinal peptide), and endo- stimulation of ACTH and cortisol. Therefore,
genous opioids. Endocrine growth factors and use of the term, ªstress-induced immunosup-
cytokines (interleukines and interferons) also pressionº as an indicator of an adverse effect on
act as neuroactive messengers. health and homoeostasis is too general to be
The immune system, on the other hand, sends useful. It has to be specified which psychological
signals to the nerve cells through cytokines, variable leads to which specific immunological
neuropeptides, and neurotrophins (such as GH). change. These changes can be protective or
Immune cells possess receptors for neurotrans- harmful for the organism.
mitters and peptides, whereas nerve cells are Several studies have shown that behavioral
affected mostly indirectly through receptors for treatment and social support have a protective
neuropetides, histamine, and neurotrophins. effect on various immune parameters and
Nerve cell metabolism is, however, regulated diseases. In human immunodeficiency virus
by glia cells which contain cytokine receptors in (HIV)-infected persons, the destruction of
addition to all other types of membrane CD4+ helper cells and other lymphocytes can
receptors (cf., Schedlowski & Tewes, 1996). be significantly retarded. Survival rates of aging
populations can be prolonged for years with
1.05.3.5 Stress and the Immune System appropriate behavioral and social interventions
targeted towards improving self-control and
There is agreement that some but not all types self-efficacy. These studies document an in-
of stressors have an immunosuppressive effect crease in lymphocytes and long-term reduction
which may later contribute to initiation or of cortisol levels in the intervention groups
maintenance of illness and ªsickness behaviorº (Schedlowski & Tewes, 1996).
during infections or other immune disorders.
Depending upon the type of stress, very dif- 1.05.3.6 Learning and the Immune System
ferent and highly specific responses of immune
cells result. The main effects of stress on the Early in the twentieth century, several pub-
immune system are mediated by the ACTH- lications reported the classical conditioning of
glucocorticoid release of the anterior pituitary± immune reactions. Most, if not all, of the reports
adreno±cortical axis. Glucocorticoids have remained unnoticed until 1975, when Ader and
immunosuppressive effects on some but not Cohen published their seminal paper on classi-
all cytokines (i.e., cytotoxic T lymphocytes, cally conditioned immune suppression by using
CD8+). The immunosuppressive effect may be a conditioned taste aversion paradigm in rats
desirable or adverse for the organism. Gluco- (cf., Ader & Cohen, 1985; Ader et al., 1990). The
corticoids show their immunosuppressive effect unconditioned stimulus (US) cyclophospha-
mainly on nonactivated immune cells. If they mide (CY) causes severe gastrointestinal dis-
have already been activated by antigen pre- orders and suppression of a host of immune
sentation, their effect is negligible. Therefore, in factors. The rats in the experimental group
Neurochemistry and Neuropharmacology 121
received the neutral saccharin as a conditioned mechanisms of neurons and synapses are the
stimulus (CS) and shortly afterwards an injec- most rapid growing fields in the biobehavioral
tion of CY as US. Three days after the sciences. The enormous interest and financial
conditioning trial only the CS was given and investment is primed by the factual and
sheep erythocytes were injected as an antigen- anticipated economic benefits of drug treat-
stimulating agent. After nine days the animals ments and the relative ease and time-saving
were killed and the amount of antibodies against application for clinical problems. A representa-
the antigen was counted. A profound reduction tive overview of the rapid growth is provided by
of proliferation of T lymphocytes and natural the 2000-page volume Psychopharmacology.
killer (NK) cells was found. The same effect can The fourth generation of progress, edited by
be induced by the operant procedure of learned Bloom and Kupfer (1994). An introduction to
helplessness (see Section 1.05.10.3.2): animals in basic neurochemistry can be found in Siegel,
a yoked group that could not escape repetitive Agranuff, Albers, and Molinoff (1994).
aversive shocks showed lasting immune sup- The relationship between psychopharmacol-
pression in comparison with the escape group ogy and clinical psychology is characterized by
with the same number of shocks presented. an attitude of mutual exclusiveness on both
Adrenalectomy prevented the effect, demon- sides. At best, biological psychiatrists or psy-
strating that the pituitary±adreno±cortical axis chopharmacologists construe a psychological
is involved in the operant effect but not in the treatment as an adjunct to the ªrealº pharma-
classical conditioning effect; the latter remains cological treatment. Clinical psychologists, on
after adrenalectomy. the other hand, sometimes see the biologically
Not only immunosuppression but also acti- oriented treatments as ªunfair competitionº to
vation of immune cells can be classically their time-consuming and often nonspecific
conditioned, for example, by use of the injection socially oriented treatment approaches. This is
of the cytokine agonist ovalbumine protein as a a very unproductive state of affairs since the
US. Clinically relevant for human transplanta- potential profit of integration could be sub-
tion surgery are experiments demonstrating that stantial for both disciplines. If we conceptualize
skin transplants are much less sensitive to graft the brain±behavior±cognition relation as a uni-
vs. host reactions if the immunosuppressive CS tarian identity principle or at least as a tightly
is presented again after transplantation (cf., coupled parallelism, as most neopositivistic
Ader et al., 1990). natural scientists would prefer, some strategic
Conditioned immunosuppression and immu- consequences for the application of psycholo-
noinduction has many potential clinical applica- gical, neurochemical, and neurophysiological
tions. In autoimmune diseases such as lupus modifications are obvious. Psychobiologists
erythematodes, the weekly presentation of an should, for example, obtain the legal right to
immunosuppressive CS significantly reduced prescribe some types of medication.
mortality in rats. In humans, conditioned nausea Psychological or behavioral treatments are
during radiation therapy for cancer can be often effective for ªpurelyº physical diseases
successfully eliminated by a systematic desensi- without a psychological etiology, while physical
tization and extinction procedure (Heninger, or pharmacological therapies are frequently
1995). Moderate physical (pleasurable) exercise indicated for complex psychological problems
leads to a dramatic increase in lymphocytes and with no or less clear-cut pathophysiology.
NK cells; the antimicrobacterial activity of Behavioral medicine provides many examples
macrophages is strengthened and depressive of the physical effectiveness of behavioral
mood, which strongly exacerbates immune treatments, while psychiatrists often treat
suppression, is reduced. Since cytokines such psychological problems (i.e., marital conflict,
as interleukin-1 themselves produce changes in addictions) effectively with drugs. For example,
corticosteroid release and monoamine turnover relapse after drug abuse can be prevented by
in the brain, the immune system provides drugs chemically antagonistic to the one abused
negative and positive feedback loops on emo- (see Section 1.05.9.4, despite the conditioned
tional brain systems. origin of relapse).
The construction of psychological interven-
1.05.4 NEUROCHEMISTRY AND tion strategies can and should be modeled after
NEUROPHARMACOLOGY well-known and effective neurophysiological or
neurochemical treatment modalities while
1.05.4.1 Psychopharmacology and Clinical avoiding the inescapable negative side effects
Psychology of medical procedures. Along the same lines,
drugs or medical strategies should be matched
Neurochemistry, psychopharmacology, and to specific behavioral and psychopathological
the scientific disciplines studying the molecular mechanisms of a particular disorder.
122 Psychobiology
The biological boundaries inherent in some steps by incoming external synaptic or hormo-
disturbed behaviors or diseases can only be nal signals.
transgressed with physical approaches, while Plasticity and behavior change therefore
the social boundaries of disorders (e.g., the depend ultimately upon synaptic changes which
addictions) construct the limits of biological alter themselves to dendritic and somatic extra-
intervention. and intracellular responsivity. During the rest-
Presently we are more distant than ever from ing state the membrane receptors are inactivated
an interdisciplinary interaction and respectful and an imbalance of electrically charged ions is
understanding and incorporation of the other maintained so that the intracellular membrane is
discipline in one's own views. The widening gap more negatively charged (&70 mV) relative to its
between biological and social or psychological external part. With the arrival of an action
sciences has many reasons; since human beings potential which consists of a rapidly progressing
have only very limited information-processing wave of depolarization, the voltage gated Ca2+
capacities, the overflow of scientific information channels are opened and Ca2+ enters the
in both fields causes an increasing protective synaptic terminal. Ca2+ prompts the binding
tendency to exclude and ignore deviant and new of synaptic vesicles containing the transmitter
principles. The narrower and the more rigid the substance onto the presynaptic membrane
individual's intellect, the more readily other terminal which causes their release into the
positions are discarded. A still prevalent dicho- synaptic cleft. The transmitter molecules fuse
tomy of the mind±brain relationship, particu- (bind) with specific receptor molecules at the
larly in the psychological realm, undermines postsynaptic membrane if they match allosteri-
any fruitful interaction with the questionable cally the shape of the transmitter. In the case of a
argument of the infinite complexity and the match between receptor and transmitter, the
intellectual inaccessibility of ªsubject±objectº postsynaptic membrane channels open and
relations (cf., Lycan, 1996, for a philosophical positively charged ions (mostly Na+) are
analysis). allowed to follow their electrochemical gradient
and other forces quickly (less than milliseconds)
and depolarize the postsynaptic membrane.
1.05.4.2 Mechanisms of Action of Psychoactive Depolarization consists of a change in electrical
Substances polarization from an electrically positive
charged extracellular membrane to a negatively
1.05.4.2.1 Neuronal mechanisms
charged potential (20±100 m V). Only if many
Behavior and mental activity are represented depolarizations at multiple synaptic sites in one
in the CNS as cell assemblies which were formed cell occur simultaneously will an action potential
by associative strengthening of synapses in be created at the axon hillock and information
simultaneously activated neurons (Hebb, 1949). transmitted to other cells.
Mental processes are coded as multidimensional
vectors of excitatory electrical activity in
1.05.4.2.2 Receptors for neurochemicals
strongly coupled assemblies or so-called ªsyn-
fire chainsº (Abeles, 1991). These electrical Receptors are the constituents of a cell that
patterns of synchronous activity tend to have the ability to recognize a drug, a hormone,
oscillate in various rhythms because the plastic or a transmitter. Membrane-bound receptors
cell assemblies and brain regions all have such as those for transmitters cause rapid ion
recurrent networks forming a virtually endless flows as described above and activate the so-
reticulum of feedback and feedforward connec- called second messenger systems. This rapid
tions. The structural, physiological, and mole- mechanism of opening membrane channels for
cular processes which determine the electrical depolarization happens within one to several
activity of nerve cells and neuronal assemblies milliseconds and is called classical neurotrans-
constitute the biophysical basis of behavioral mission.
pharmacology, which attempts to influence the Steroid hormones enter the cell membrane
electrical vectors through modification of the and bind to steroid receptors which enter the
neurochemical determinants at the cellular and membrane of the nucleus and act directly on
synaptic levels. DNA±RNA transcription. The second messen-
The electrical properties of a cell depend gers, among the most important Ca2+, cylic
primarily on the structure of its membranes. adenosine monophosphate (cAMP), and inosi-
Those in turn are built by the proteins which toltriphosphate (IP3), cause a cascade of intra-
are synthesized by the genetic apparatus. cellular chemical reactions which ends with the
Transcription and translation can occur ªspon- phosphorylation of a protein by the protein
taneouslyº as part of the intracellular meta- kinases. Phosphorylation consists of the binding
bolisms or are induced and modified at various of a phosphate molecule with a protein that
Neurochemistry and Neuropharmacology 123
activates its enzymatic properties, and only locations within the brain. They consist of
through this mechanism do proteins become several families of receptor subunits, each with
functional and modify a cellular response. different functional properties. The highest
Neuromodulation is slower and uses the concentrations are found in the cortex and
binding of an agonist to a nonchannel receptor. hippocampus, which indicates their role in
Instead of involving an ion channel, these excitatory cell-assembly formation for associa-
receptors are proteins that change their cyto- tive memory.
plasmatic (intracellular) ªtailº in order to bind
with a so-called G-protein (a guanine nucleo- 1.05.4.3.2 Amines
tide). The activated G-protein remains in an
The catecholamines (adrenaline, noradrena-
activated state for a much longer period
line, dopamine, tyrosine, and others), serotonin,
(10±100 ms) than ion channels, again binding
and histamine are the most important CNS
to adenylyl cyclase which activates the second
amines. Each of them matches several receptors
messenger cAMP, repeating the above-de-
at the pre- and postsynaptic membranes. Their
scribed intracellular cascade. cAMP then enters
overall quantity in the CNS is low (approxi-
the nucleus and selectively increases the expres-
mately 3±5%); their functional role in behavior,
sion of genes. The later phosphorylated ion
however, is enormous. Dopamine of the
channel or G-protein-coupled receptor may
mesolimbic system constitutes the main trans-
change the excitability of the membrane for a
mitter system in the organization of positive
particular neurotransmitter.
reinforcement and incentive motivation. Its
overactivity, probably caused by dysregulation
of cortical and hippocampal glutamate systems,
1.05.4.3 Transmitter Systems is involved in the etiology and maintenance of
schizophrenia; the blockade of dopamine
The description of behaviorally relevant receptors through neuroleptics reduces active
transmitter and neuromodulator systems fol- hallucinatory symptoms but at the same time
lowed the discovery and isolation of four psy- causes anhedonia andÐthrough reduction of
choactive drugs in the 1950s: reserpine and dopamine in the motor nigrostriatal systemÐ
chlorpromazine in the treatment of schizophre- Parkinson's disease and tardive dyskinesia.
nia, and iproniazide and imipramine for depres- Overactivity of both the central and peripheral
sion. Binding arrays of receptors and cloning of noradrenaline system is related to anxiety states
receptors finally elucidated their distribution and underavailability of NA to depression.
and action in the CNS. The distribution of serotonin (5-hydroxytryp-
Three main classes of neurotransmitter sys- tamine, 5-HT) is also widespread in the brain.
tems and some new transmitters can be differ- Tryptamine and melatonin are chemically
entiated: amino acids, amines, and peptides. related hormones. Again, despite its small
New transmitter systems whose behavioral quantity in the CNS, the significance of
functions are less researched include arachido- serotonin for behavior, mood, and biological
nic acid, nitric oxide (NO), proto-oncogenes, rhythms is significant: eating, sleep, sexual
and purinoceptors. behavior, circadian rhythm, mood, and aggres-
sion are more or less regulated by the diverse 5-
1.05.4.3.1 Amino acids HT transmitter-receptor systems.
Excitatory amino acids, particularly L-gluta-
1.05.4.3.3 Opioids
mate, constitute the main excitatory transmit-
ters in the CNS. There is virtually no behavioral Opium has been known to humans for
function, including memory, learning, and thousands of years as an analgesic and a
higher cognitive functions, that does not involve euphoria- and obstipation-inducing substance.
glutamate. Three classes of glutamate receptors However, only during the past years has its full
have been distinguished: N-methyl-D-aspartate importance and structure been elucidated. The
(NMDA), kainic acid (KA), and a-amino-3- fact that our peripheral and central nervous
hydroxy-5-methyl-4-isoxazole propionic acid system contain receptors for plant opioid
(AMPA) receptor. The functional physiological alkaloids was one of the most significant
range of glutamate and glutamate receptors is discoveries of pharmacology. In the CNS,
extremely narrow and even slight deviations opioid receptors are found as in the periphery,
cause a host of neurological and psychological centrally, close to pain structures such as the
disorders through excitotoxicity. Excitotoxicity periaqueductal gray, thalamus, subcortically
of glutamate seems to be involved particularly near reflex centers, and in the hypothalamic±
in schizophrenia and Alzheimer's disease. The pituitary system. The main subtypes of mu,
three receptor types are distributed at different delta, and kappa receptors are differentially
124 Psychobiology
distributed in the CNS and subserve different induces sprouting in dendritic growth. In
behavioral functions: all three are involved in Alzheimer's disease, most basal forebrain
pain modulation, others are critical for salt± neurons die. Electroencephalogram (EEG)
water balance, cardiovascular functions, sexual desynchronization and negative slow brain
behavior, grooming, memory, and the immune potentials depend on an intact Ach system.
system. The addictive properties of opioids are Cholinomimetic drugs may prove useful for
probably related to their affinity with the many psychological disorders; to date their side
positive reinforcement system (see Section effects are substantial.
1.05.9.4) and with dopamine.
1.05.5 PSYCHOPHYSIOLOGY
1.05.4.3.4 Neuropeptides 1.05.5.1 Introduction
Short-chain amino acids are called peptides
and were originally believed to serve mainly The interest of humankind in body±soul or
hormonal-neuromodulatory roles. We know body±behavior relationships probably dates
today that they can function as neuromodula- back to Stone-age populations about 250 000
tors, hormones, and neurotransmitters depend- years ago, where trepanations of the skull were
ing on their location, molecular substructure, obviously performed to modify supposed head
and receptor types. For most of them their role diseases. Egyptian and Greek pre-Socratic
in behavioral functions is unknown. For some, a philosophy and medicine correctly attributed
well-defined psychological ªprofileº has been mental functions to the brain and emotional
developed such as ACTH and stress, oxytocin ones to ªhumorsº (Hippocrates) and autonomic
and the formation of social bonds, substance P functions, particularly the heart. However,
and pain, growth hormone and development, Aristotle's (384±322 BC) view of the heart as
sleep and immune function, and the above- the seat of nervous and mental control was
described opioids, enkephalins, and endorphins maintained until early Renaissance around
and their role in pain modulation. 1450. Only Arab and Chinese traditions
provided exceptions to the strict Aristotelian±
Christian rule during the early Middle Ages,
1.05.4.3.5 Acetylcholine particularly in southern Italy and Spain (e.g.,
Acetylcholine (Ach) is not only the transmit- Avicenna, whose real name was Ibn Sina).
ter of the somatic motor system and the Psychophysiology together with the rest of
parasympathetic system but also a central medicine had to wait until the mid-nineteenth
nervous system agent of great importance. Its century for its first experimental investigations,
functional effects depend on pre- and post- which were largely dependent upon the con-
synaptic receptors, nicotinic and muscarinic, struction of electrophysiological recording de-
which can be classified into several subtypes. vices after Galvani's first demonstration of
Most Ach receptors in the CNS cause excitatory bioelectricity in 1791. The first animal EEG was
activity (depolarization) at the postsynaptic recorded in 1875 by Richard Caton, and the first
membranes. human EEG in 1924 by Hans Berger (for a
Ach has a modulatory role in the CNS in that history see Clarke & O'Malley, 1995).
its fiber system lacks specific point-to-point The modern development of psychophysiol-
projection but exerts a more diffuse, unspecific ogy is tightly coupled to the construction and
function on its target cells. Therefore, Ach is availability of the polygraph, where several
usually identified as the main transmitter in physiological measures can be recorded simul-
arousal and attention. Most neurons originate taneously. The foundation of the Society for
in the basal forebrain of the nucleus basalis Psychophysiological Research in 1961, which
Meynert which projects to limbic areas (amyg- grew from a small US-only society into a large
dala) and the entire cerebral cortex. Many international organization, marked the world-
intracortical connections are cholinergic and wide establishment of relatively cheap and
depolarize large groups of assemblies as a universal recording devices.
threshold regulation mechanism in learning and
attention (Birbaumer, Elbert, Canavan, & 1.05.5.2 Concepts in Psychophysiology
Rockstroh, 1990; Mesulam, 1995). The unspe-
1.05.5.2.1 The three-systems approach
cific activation systems (ascending reticular
activating system, ARAS) of the midbrain In order to understand human behavior, in
reticular formation and the thalamus and parts most instances physiological, psychological
of the basal ganglia are all cholinergic. Learning (cognitive subjective), and motor-behavioral
increases Ach activity, leads to an enlargement variables have to be assessed in their particular
of cortical spines on plastic neurons, and environments. Origin and consequences of this
Psychophysiology 125
three-systems approach to human behavior as a ever, for some physiological variables and for
ªwholeº were extensively described earlier in some types of performance the ªlawº does not
this chapter. apply.
In order to explain those instances, Lacey and
Lacey (1970) formulated their concept of
1.05.5.2.2 The law of initial values
directional fractionation of physiological and
The law of initial values (LIV) states that the motor responses. According to this concept, the
higher the initial value of a particular physio- different physiological response systems are
logical function, the smaller the increase of this activated or simultaneously deactivated de-
physiological measure in response to a parti- pending upon the physiological and behavioral
cular stimulus or psychological event. Con- requirements of the particular situation. Direc-
versely, the higher the initial, baseline value, the tional fractionation is partially overlapping
larger the decrease to a stimulus or event which with another term coined by Lacey and Lacey,
usually produces a decrease in the particular stimulus±response (SR) specificity.
physiological system.
The LIV was found to be roughly true for
1.05.5.2.4 Stimulus±response specificity
cardiovascular variables, pupil dilation, vascu-
lar variables, but not for skin conductance or Different stimulus situations may call for
skin temperature. In cortical blood flow such as different response requirements, causing differ-
measured by PET or fMRI (position emission ent and situation-specific physiological adapta-
tomography or functional magnetic reasonance tions. Psychophysiology provided many
imaging, see below) and with electrocortical examples for the correctness of this statement,
measures, the validity of the LIV remains despite the fact that most situation-specific
uncertain. adaptations occur in body systems that are
difficult to record from the intact human
without invasive recording, such as colon
1.05.5.2.3 Activation, arousal, and directional
movements in anticipation of food.
fractionation
One of the best-studied examples of stimulus-
Every behavior, sensory experience, and specificity is heart rate slowing in nonthreaten-
physiological response varies on a continuum ing sensory information intake and heart rate
of intensity. However the relationships between increase to potentially aversive information
the intensity of a particular variable and other rejection, the first demonstration of this effect
variables are rarely linear. The term ªactiva- dating back to Lacey and Lacey (cf., Dworkin
tionº is usually applied to the more long-lasting et al., 1994). The physiological mechanism for
tonic (hours, days, months) changes in intensity, this phenomenon was elucidated and confirmed
mainly within the sleep±wakefulness conti- in a series of laboratory studies by Rau and
nuum, while ªarousalº signifies the rather Birbaumer (1993). Increase in pressure of the
short-lasting phasic (milleseconds to minutes) carotid sinus and other large arteries causes the
changes; the border between both is, however, baroreceptors to fire as a response to blood
not fixed. Arousal therefore ªridesº on top of a pressure increase. The afferent fibers to the brain
particular activation level being subject to the stem end in inhibitory centers of the reticular
LIV. formation, causing heart rate deceleration and
Early in the twentieth century, Yerkes and short-lasting cortical inhibition. The neuronal
Dodson independently discovered an inverted disfacilitation is strong enough to block the
U-shaped relationship between muscle tension impact of aversive overarousing stimulation but
(activation) and performance in various tasks; improves some form of low-intensity stimulus
later called the Yerkes±Dodson Law. After processing. Cortical slow waves, for example,
discovery of the ascending reticular activation are dramatically reduced by direct stimulation
system ARAS by Lindsley, Magoun, and of carotid baroreceptors through a neck cuff
Moruzzi (cf., Birbaumer & Schmidt, 1996), a stimulation device (Rau & Birbaumer, 1993).
neurophysiological basis of the inverted U- The stress- and pain-reducing impact of phasic
function seems to be at hand, because many blood pressure increase is ªusedº noncon-
neurons in this system showed firing rates sciously by genetically prone persons as a stress
compatible with the ªlaw.º In addition, mod- coping strategy; the rewarding consequences of
erate electrical stimulation of the ARAS this strategy increase blood pressure up to the
improves performance, but vigorous or rhyth- point of essential hypertension.
mic low-frequency electric stimulation has Another example of situation- or stimulus-
deleterious effects on behavioral output in specificity are changes in muscle tension:
animals (Andreassi, 1995). In sum, most studies electromyographic recording of facial muscles
confirmed the inverted U-shaped curve; how- or micromovements of peripheral muscles
126 Psychobiology
(Birbaumer & OÈhman, 1993; Clynes, 1989) can In higher animals and humans, an orienting
reliably differentiate between the basic emotions or defensive response depends on a short-term
(sadness, pleasure, interest, rage) even in the memory comparison process between actually
absence of visible changes in facial expressions. present and stored similar stimulus configura-
Also, imagery of emotional scenes evokes the tions. In the case of a mismatch of biologically
same peripheral but partially different CNS relevant stimuli, orienting occurs; in cases of
changes (Schupp, Lutzenberger, Birbaumer, potentially threatening stimuli, a slowly habi-
Braun, & Miltner, 1994) as actual perception tuating defensive ªreflexº is recorded. In the
of these events. These stimulus-specific physiol- CNS, the amplitude of a positive evoked brain
ogies interact and overlap with individual potential 300±500 ms after stimulus presenta-
response stereotypies. tion, the so-called P300, is a good indicator of
that mismatch process. In the periphery, heart
rate decrease is mostly related to orienting,
1.05.5.2.5 Individual response stereotopies
while heart rate increase is related to defensive
These stereotypies characterize tonic, in most responses. Very short-latency muscular re-
instances long-lasting ªpreferencesº of a person flexes, such as the startle reflex, measurable
to react and, in the case of pathology, overreact as an eye blink 40 ms after an intensive
with a preferred bodily response system in stimulus, act as an ªinterruptº to threatening
different situations. Individual response idio- stimuli and are part of a whole-body escape
syncrasies originate from genetic, constitu- response disposition (cf., Birbaumer & OÈhman,
tional, or learned causes. The concept of 1993). Modulation of the startle reflex ampli-
response specificity, as it is also called, is tude through emotionally positive or negative
extremely important for the explanation of background material is one of the most reliable
psychosomatic, psychiatric, and somatic dis- indicators of the emotional condition of the
orders. CNS state: startle inhibition through emotion-
Apart from the development of essential ally positive and startle potentiation through
hypertension, individual response stereotopies emotionally negative material is easy to
were found to be responsible for musculo- measure and provides an excellent diagnostic
skeletal chronic pain related to the lower back, tool in psychopathology (Lang, Bradley, &
face, and head (Birbaumer, Flor, Lutzenberger, Cuthbert, 1990).
& Elbert, 1995). While in healthy subjects
individual response stereotopies are unreliable
1.05.5.2.7 Social psychophysiology
and short-lasting, they cause pathology in
subjects with a high genetic risk and they are All human behavior and subjective experi-
triggered under conditions of long-lasting ence evolved out of social interaction and
(particularly instrumental or classical condi- communication. The laboratory situation
tioning) circumstances such as intensive stress in therefore creates an artificial isolation of the
vulnerable periods of ontogenetic development. individual which may produce response pat-
terns not representative of ªrealº life. The
observation and measurement of motor and
1.05.5.2.6 Orienting, habituation, and defense
verbal behavior, cognition, and emotion simul-
Pavlov was the first to examine these taneously with the physiology is the most
prepared response patterns to novel, old, or promising but methodologically difficult area
potentially harmful stimuli in dogs. The of psychophysiology. During the last 20 years, a
principles he described for their occurrence considerable amount of data has emerged
and psychophysiological meaning are as valid which has shed light on the enormous impact
today as they were 100 years ago (Pavlov, 1926). of social factors on physiological response
Habituation to repeated stimulus presentation systems (Cacioppo & Petty, 1983; Hauser,
is regarded as the most primitive form of 1996). Flor, Elbert, et al. (1995) recently
learning, learning to cease responding to demonstrated a dramatic effect of the presence
biologically irrelevant stimuli. In mollusks of a solicitous spouse on the processing of
and other simple animals, the molecular basis painful stimuli in chronic back pain patients.
of habituation involves the gradual reduction of The mere physical presence of the partner not
intracellular cascades which eventually lead to a only induced a more than threefold increase in
decreased binding of Ca2+ on to presynaptic pain sensitivity but brain electrical potentials to
terminals. The reduced release of transmitters as painful stimuli were increased at a very early
a consequence weakens the strength of synaptic stage (100 ms) of information processing in
connections between previously functionally patients and high-risk groups. Social factors
connected cells (cf., Birbaumer & Schmidt, such as reinforcement history with a spouse
1996, for a review). obviously modify CNS stimulus processing,
already at an early preconscious level not available noninvasive recordings of brain

accessible to conscious voluntary control. activity.
1.05.5.3 Methods in Psychophysiology 1.05.5.3.3 Functional magnetic resonance

imaging (fMRI)
1.05.5.3.1 Electroencephalography
One disadvantage of EEG/MEG imaging is
EEG frequency spectra, averaged evoked its low spatial resolution 5 cm or more below the
responses combined with computer-aided bio- cortical surface. In order to visualize local
electric imaging of many electrodes on the scalp, subcortical activity changes and for an anato-
are still the most inexpensive CNS measures mically correct representation of the individual
with an excellent time resolution. In addition, brain, MRI has to be applied. While structural
source localization of early evoked potentials MRI was introduced 15 years ago as a
allows in some cases a precise anatomical noninvasive technique to visualize gray and
localization of the cortical origins of these white matter of the human brain, functional
potentials. Figure 1 shows localization of MRI (fMRI) is relatively recent and in the few
electrical sources of tactile evoked primary years of its existence has become an extremely
brain potentials components with a latency of successful measure of regional changes in brain
40±70 ms at the postcentral gyrus in patients blood flow.
with phantom limb pain due to amputation of The basic physical principles of fMRI are not
one upper limb. The index finger of the intact different from structural MRI, except that with
arm and corner of the lip at both sides were the introduction of efficient power supplies,
stimulated with 1000 stimulus repetitions and superconducting magnets, and rapid analog to
EEG responses averaged in order to enhance the digital converters, MR images can be taken in
signal-to-noise ratio. The same stimulation was the range of tenths of milliseconds. In order to
repeated after local anesthesia of the stump and acquire MR images, a 1±3 tesla magnetic field is
shoulder. applied through the head. The magnetic field
The electrical sources of these potentials were forces hydrogen proton nuclei into an aligned
calculated and superimposed on each subject's direction of the magnetic field. The protons
individual magnetic resonance brain image (see exhibit the property of ªspinº: they rotate
below). It can be seen that a precise anatomical around their axis. In the magnetic field, the
localization of the finger and lip region is spins of the protons will all be oriented and
possible in accordance with the known homun- rotating in the same direction (quantization).
cular organization of the somatosensory cortex. Of these rotating protons in the magnetic
After anesthesia and pain relief, the pain-related field, more of the protons are in a lower energy
pathological reorganization of the brain repre- state which gives the proton ensemble a net
sentations of the phantom limb returns to magnetization. The time to magnetization after
normal (Birbaumer, Lutzenberger, et al., 1997). application of the magnetic field is T1 (for water,
the main constituent of brain tissue, it is 2 s). Fat
molecules magnetize much more slowly. There-
1.05.5.3.2 Magnetoencephalography (MEG)
fore, gray and white substances magnetize
The development of low-temperature super- differently. The uniform field gives the exceed-
conducting interference devices (SQUIDs) al- ingly small magnetic dipoles because of their
lows recording of the magnetic fields of neural alignment a uniform magnetization and a
structures in the brain, which are in the uniform rotating frequency (Lamor frequency).
femtotesla range (equivalent to 10715 tesla), The size of this combined magnetization of the
the earth's magnetic field being in the range of spins is the magnetic resonance signal. With
1074 T. Since magnetic fields cross all biological time the spins lose phase coherence and the
tissues not affected by electric resistance, they signal decays, depending upon tissue properties
can be recorded undistorted above the head. (as T1). This time is called T2. At the borders of
MEG has an unprecedented local resolution of tissues, a large difference of magnetization may
2 mm up to a brain depth of about 5 cm. Its time exist over small distances and the proton spins
resolution is like that of EEGÐexcellent and in at those borders will be out of phase rapidly.
the millisecond range. The limitations of MEG The macroscopic field varies as a consequence
technology are the still high costs, the necessity of this; the macroscopic decay is T2. In order to
of a mu-metal isolation chamber, and the cause the angular orientations of the protons to
biophysical fact that only horizontally located align, an electromagnetic field of about 63 MHz
dipoles can be recorded from the brain. (radio band with the Lamor frequency) is added
However, together with EEG imaging, MEG to the magnetic field, the protons' rotation is
provides the best time and space resolution of all forced away from their longitudinal axis by this
128 Psychobiology
Figure 1 Cortical representation of the digits and the lower lip before and after brachial plexus blockade in a
unilateral upper extremity amputee with phantom limb pain who experienced complete pain relief due to the
regional anesthesia. The preanesthesia location of the representation of the fifth digit (D%) of the intact hand is
indicated by the illed square, and the locations of the representations of the lip of the intact side and the
amputated side by the filled squares below. The mirror images (15,18) of the intact digit and the intact lip
projected onto the amputation-side hemisphere are marked by open squares. These locations refer to the
preanesthesia period. The location of the representation of the amputation-side lip postanesthesia is indicated
by a filled square. Note that before brachial plexus blockade, the lip in the amputated side had shifted into the
region occupied by the representation of the fingers on the intact side (mirror D5). Twenty minutes after
amputation stump anesthesia, the phantom pain was almost eliminated; at the same time there was a dramatic
shift of the amputation-side back toward the postition occupied by the lip representation on the intact side
(mirror lip, open square). The white dots are the vitamin E capsules marking the electrode positions (ªEffects of
regional anesthesia on phantom limb pain are mirrored in change in cortical reorganization,º by N. Birbaumer,
W. Lutzenberger, et al., 1997, Journal of Neuroscience, 17, pp. 5503±5508. Copyright 1997 by Oxford University
Press. Reprinted with permission).
field; however, they all now rotate in ªreso- the oldest and most useful psychophysiological
nance.º This field is large enough to be detected, assessments. DuBois-Reymond recorded for
because it induces an electric voltage at a nearby the first time the electrical activity of muscles
antenna. At tissue boundaries, the detected in 1849. Surface EMGs with electrodes at the
frequencies will be different and can be skin above a muscle group record Ach-caused
transformed into color contrasts. depolarization of the motor endplate shortly
Figure 2 shows the result of an fMRI before the actual contraction, but the correla-
experiment where phobic patients and healthy tion of muscular effort and EMG amplitude is
subjects were exposed to neutral faces and aver- very good. The spike frequency from a motor
sive odors. An increase in blood flow (because unit ranges from 20 to 1000 Hz; the amplitudes
of increased net magnetization) in the amygdala from 50 to 1000 mV. The main frequencies used
(but not in the thalamus) was observed for in psychophysiological experiments range from
phobics but not the healthy controls during 70 to 1000 Hz. Today, integration techniques
presentation of faces. This confirms animal give a measure of total EMG output over time.
experiments showing that the amygdala is the EMG recording has proven to be extremely
critical structure for the emotional valence of useful for studying mental load, muscular-
fear objects and that the thalamus does not mental tension, and emotions, particularly
participate in the emotional ªcoloringº of facial expressions: with the use of only three
stimuli, but only in their sensory processing. facial muscles, the main basic emotions (disgust,
anger, pleasure, joy, interest, sadness) can be
differentiated even in the absence of visible
1.05.5.3.4 Positron emission tomography
changes in facial expression. Biofeedback of
(PET)
EMG from the back muscles is the most
When a radioactive ligand is injected or effective treatment for chronic low back pain;
inhaled, it is taken up by the cerebral blood- the same is true for trapezius or neck muscles
stream and binds to specific cells and regions and tension headache (cf., Birbaumer & OÈh-
that are metabolically active. Collision of the man, 1993; Flor & Birbaumer, 1993).
protons of the radioactive ligand with the
electrons of the particular atom (e.g., 15O)
1.05.5.3.6 Electrodermal activity (EDA)
causes annihilation of the two particles and the
emission of a photon. Annihilation photons DuBois-Reymond also discovered in 1849
carry high energy which can be detected by a that an electric current applied between both
ring of many radiation detectors around the hands changed its voltage with psychological
head. These detectors of g-radiation count the events. Obviously, the electrical resistance
density of radiation and reconstruct their spatial between superficial tissue is modified by
sources in a color-coded brain map. neuronal outflow to the skin. The eccrine sweat
PET has a less precise spatial and temporal glands are innervated by the sympathetic
resolution than fMRI or EEG/MEG imaging. branch of the autonomic nervous system
However, its capacity to localize specific sources (ANS) and use Ach instead of noradrenaline
of increased or decreased metabolic activity of as a transmitter. The palms of the hands and the
specific transmitters and substances such as soles of the feet contain most of the body's
water, glucose, fluoride, dopamine, and GABA eccrine sweat glands. During situations of
is indispensable for understanding the link emergency, ANS activity increases and the
between molecular neurochemical processes sweat glands are filled with salt-containing
and the global systemic changes recorded with sweat which reduces the electrical resistance of
all brain imaging systems. In general, PET the skin. It is unknown which brain regions
allows the reconstruction of brain areas with contribute to this reaction. The debate whether
increased or decreased blood flow relative to a skin conductance reflects more aversive emo-
specified baseline condition. However, the tional or ªpureº arousal responses is still
target mental activity has to be present undecided. In experiments using emotional
continuously for several seconds to minutes slides, EDA varied only on the arousal dimen-
and is averaged over several trials before a clear sion and had no relationship with emotional
enough signal-to-noise ratio appears. The high valence (Birbaumer & OÈhman, 1993).
cost and its invasive nature, however, limits its EDA has been used in all areas of psychology,
value for psychophysiology. neurology, and psychiatry: its application for
the detection of deception (see below) is highly
controversial. As an indicator of the orienting
1.05.5.3.5 Electromyography (EMG)
response (OR), it shows distinct changes with
The measurement of action potentials from psychopathology: lack of OR habituation in
the motor units of the skeletal muscles is one of high-risk subjects predicts later schizophrenia, a
Figure 2 Local blood flow changes in the amygdala of healthy (left) and phobic (right) subjects during presentation of a fear conditioned stimulus (below) and an
unconditioned stimulus (an odor, above). Increasing dark dots indicates flow (from Birbaumer et al., in press).
high frequency of spontaneous fluctuations is and on a long-term basis causes essential

found in generalized anxiety, and nonresponder hypertension in genetically prone individuals.
depressives and schizophrenics exhibit a more Neither Obrist's cardiac±somatic coupling nor
chronic course of their disease (Andreassi, 1995; Lacey and Lacey's information processing
Davison & Neale, 1996). The absence of EDA hypothesis was unanimously confirmed. HR
responses to fearful stimuli is a reliable slowing clearly appears in orienting, while HR
diagnostic tool for the detection of antisocial increase after intensive or dangerous stimuli
personalities and sociopathy. constitutes part of the defensive reaction.
The interaction of stress and blood pressure
increase was also confirmed in different person-
1.05.5.3.7 Heart activity and blood pressure
ality patterns such as type A and hostility: type
Heart rate (HR) and blood pressure are the A subjects (competitive, driven, impatient) with
most frequently used psychophysiological in- hostile attitudes toward others, demonstrate
dicators. HR is used because it is easily recorded large increases in blood pressure during stressful
from any two electrodes affixed at the more right situations and exhibit a high risk for essential
or left side of the body allowing the heart to be hypertension and stroke. Early behavioral
positioned between them (i.e., both hands). intervention effectively prevents this vicious
Blood pressure has become more popular during circle of blood pressure increase, stress reduc-
recent years when noninvasive continuous tion through cortical inhibition, and aggressive
measurement was realized with pulse-wave muscular mobilization.
velocity devices. The obvious physiological role
of the cardiovascular system explains the high 1.05.5.4 Applications of Psychophysiology
correlations of HR with all kinds of behaviors:
1.05.5.4.1 Biofeedback
motor, mental, perception, attention, and
orienting; stress, emotion, and motivation; The most successful and clinically relevant
personality, social stimuli, brain interactions, application of psychophysiology became the
and conditioning (cf., Andreassi, 1995, for a instrumental conditioning of physiological
review). The dual sympathetic and parasympa- variables mostly realized through feedback of
thetic nervous control allows separation of the the relevant physiological variable on a com-
two branches of the ANS: slowing of the puter screen; subjects are instructed to change
heartbeat indicates the chronotopic parasym- the variable in a particular direction and are
pathic, speeding the increased excitability and positively reinforced for successful modifica-
contraction force of the sympathetic branch. tions or receive immediate feedback for it, which
For decades psychophysiology was obsessed also functions as a reward. The scientific and
with discussions of the psychological signifi- clinical history of biofeedback is severely
cance of HR changes: while Obrist (1981) and hampered by exaggerated claims of the clinical
his co-workers interpreted HR changes as efficacy and by a very early failure to replicate
variations of mobilization of blood supply for the pioneering animal studies of Miller (1969)
the somatic musculature (cardiac±somatic cou- and collaborators. Meanwhile, several success-
pling), Lacey and Lacey (1970)proposed a close ful clinical indications have emerged, while the
relationship with information processing in the majority of controlled clinical studies revealed
brain: HR deceleration and negative going slow that most of the early expressed hopes could not
cortical potentials should accompany informa- be confirmed. The possibility to condition
tion intake, acceleration information rejection, autonomic and brain functions instrumentally
and positive going slow cortical potentials. The without mediation of the skeletal muscles as
deceleration in a signaled foreperiod reaction postulated by Miller was clearly confirmed in
paradigm is caused by phasic blood pressure studies with totally paralyzed, artificially re-
increase which fires the baroreceptors in the spirated subjects who had no voluntary control
carotis sinus. This leads to parasympathetic of their muscles because all motor neurons had
slowing of the heart and increased cortical been destroyed (Birbaumer, Rockstroh, et al.,
activity because the nucleus of the vagus located 1994): after extensive training to self-regulate
in the reticular formation fires the ARAS. Tonic slow cortical potentials (SCP), a patient with
stimulation of the baroreceptors through a advanced amyotrophic lateral sclerosis (ALS)
specially designed neck cuff, however, produces achieved 100% control of his brain waves and
heart rate slowing and positive going cortical could use his learned ability to communicate by
slow waves which causes inhibition of cortical affecting a computer system with his brain
activity and information rejection (Rau, Pauli, waves (Birbaumer, 1998).
Brody, Elbert, & Birbaumer, 1993). The Well-established indications for biofeedback
accompanying stress reduction negatively re- treatment are chronic pain states, neuro-
inforces the preceding blood pressure increase muscular rehabilitation after CNS damage,
132 Psychobiology
epilepsy, encopresis and enuresis, Raynaud's patients watch them on a screen or listen to
disease, and scoliosis and kyphosis. Doubtful different tones reflecting the actual amplitude of
but frequent applications relate to hyperactiv- the particular muscle. Patients are instructed to
ity, asthma, essential hypertension, cardiac reduce (or increase) muscle tension in specific
arrhythmias, anxiety and depression, tics and situations (e.g., stress confrontation) and re-
stuttering, and athletic performance. No lasting ceive immediate feedback of their attempts. In
changes of biofeedback treatment were reported chronic low back pain, facial pain, and tension
in well-controlled studies for these conditions. headache, EMG biofeedback of the painful
muscle region has proven to be the most
effective treatment approach compared with
1.05.5.4.2 Biofeedback of slow cortical
traditional medical treatments and cognitive-
potentials
behavioral treatments (Flor & Birbaumer,
The most extensively researched area in 1993).
biofeedback is self-regulation of slow cortical EMG biofeedback is also extremely useful in
potentials. These EEG potentials are recorded neuromuscular rehabilitation after stroke and
with very long time constants (5 s to d.c.) and other nervous system lesions: foot drop or
reflect depolarization (negative potentials) and spastic tension is effectively removed through
disfacilitation (positivity) of the upper dendritic observation of EMG activity of extensor and
cortical layers (Birbaumer et al., 1990). Subjects flexor muscles at the paralyzed or spastic region.
watch their own SCPs on a computer screen for Insertion of EMG electrodes in the anal canal
2±10 s. The SCPs appear as a stylized rocket on and feedback of internal and external sphincter
a video monitor moving horizontally or/and contraction became the treatment of choice for
vertically. Subjects have to move the rocket to fecal incontinence and urinary incontinence
one side of the screen. If positivity of the brain is after neurological disorders such as spina bifida,
required (or right and left hemispheric negativ- partial paralysis in paraplegics, old age, and
ity), an ªAº appears on the screen; with required incontinence after surgery. Observation of
cortical negativity, a ªBº appears. If the correct external sphincter contraction increases sensi-
movement is performed, immediate reinforce- tivity and perception of anal or bladder filling
ment (e.g., points that later change into money and leads to sphincter control after only a few
or a ªgoalº with a smiling face) appears on the sessions.
screen. After 20±60 trials with feedback, sub-
jects have to produce the required SCP
1.05.5.4.4 Detection of deception
amplitude without feedback, ªout of their
mind.º No specific instructions are given Detection of deception is the most contro-
because highly individual cognitive strategies versial application of psychophysiological
are used for brain self-regulation. methods. The issue has mainly touched the
Healthy subjects are able to control their USA because in Europe the ªpolygraphº is
SCPs after 2 h training from vertex electrodes. banned from criminal investigation and per-
More localized SCP changes such as the sonnel selection. The understanding of the law-
production of cortical negativity in the left makers in Europe is that as long as the guilty
precentral region and simultaneous right-hemi- knowledge test (GKT) or the control question
spheric positivity need several sessions of test (CQT) have not proven 100% accuracy in
training (cf., Elbert, Rockstroh, Lutzenberger, detecting the innocent or the guilty, it should
& Birbaumer, 1984). After training, substantial not be used in court. The GKT informs the
effects on behavior were noted: vertex negativity suspect that several items will be named by the
improves performance on many cognitive and interrogator and the suspect has to repeat them.
motor tasks, hemispherically localized negativ- Only one of the items is true, and the other
ity improves performance on the contralateral control items are irrelevant. For example, a
hand only, positivity leads to deteriorating robber has used a gun in robbing a bank in order
performance. Several clinical applications were to (i) to buy a house, (ii) to buy a new car, (iii) to
tested in controlled studies but only two showed pay the doctor's bill, etc. In the CQT several
lasting improvements superior to other estab- questions are asked, where only one is correct:
lished treatments: epilepsy and brain/computer ªDid you use caliber X?,º ªDid you use caliber
communication in total paralysis (Birbaumer, Y?,º etc. Skin conductance (EDA), blood
1998). volume, and respiration are usually recorded.
EDA is the most valid measure, but even in
laboratory settings only 90% accuracy can be
1.05.5.4.3 EMG biofeedback
achieved. If the subjects use countermeasures
Changes of the electromyographic activity of such as distraction strategies, the accuracy falls
different body muscles are amplified and to 70% at best.
Consciousness and Attention 133
The situation may change with the introduc- consciousness is an increase in widespread
tion of event-related brain potentials (ERPs, see arousal that is mirrored in the transition from
Section 1.05.6.5) as measures to detect decep- automatic to controlled processing on a psy-
tion. However, so far only laboratory proce- chological level. Consciousness is closely tied to
dures with faked crimes and subjects playing the selective activation of certain brain regions
guilty have been published. (Here, some of them beyond a defined level of activity as well as the
reach 100% accuracy.) In a promising proce- balance between activating and inhibiting
dure of Farwell and Donchin (1991), three types neuronal mechanisms. Cognitive psychology
of items are presented: probes, targets, and has given very detailed descriptions of the
irrelevants. Probes are related to the crime various forms of attentional processes (Matlin,
scenario, targets could only be known by the 1983; NaÈaÈtaÈnen, 1990); the focus of this chapter
suspect. Only larger P300 components of the is the biological basis of attention and con-
ERP to targets are counted as evidence. Since sciousness.
ERPs are difficult to control or distort by
countermeasures and a lack of P300 compo- 1.05.6.2 Psychophysiology of Consciousness
nents in a subject is already visible in the
reactions to probes, this procedure might also Patients with commissurectomies (where the
reach 100% accuracy in field tests. two hemispheres of the brain have been
separated) and split brain experiments in
1.05.5.4.5 Clinical psychophysiology animals have shown that split brains lead to
split consciousness (Chalmers, Crawley, &
A volume by Carlson, Seifert, and Birbaumer Rose, 1971; Sperry, 1964). Contents that have
called Clinical applied psychophysiology (1994) been learned by one hemisphere must be
summarized many of the possibilities of psy- actively transported to the other hemisphere.
chophysiological measures in the clinic, work- Without the commissures, the left hand no
force, and personnel applications. Any longer participates in the experiences of the
psychological, psychiatric, or neurological dis- right hand, the visual worlds of both hemi-
order that is characterized by deficits in spheres are completely separate, the actions of
information processing causes changes in the left side of the body can no longer be
EEG/MEG recordings and, in the case of described, and verbal±syntactic tasks can only
emotional disorders, also modifications of be solved if they are presented to the left
autonomic variables and subcortical alterations hemisphere.
in PET and fMRI. Psychophysiological mea- Controlled attention is related to changes in
sures alone rarely allow diagnosis of a particular SCPs that develop on the cortical surface during
disorder but have to be used in conjunction with expectancy of a relevant stimulus. In a typical
other parameters (behavioral, cognitive, bio- experiment involving SCPs, a warning stimulus
chemical, and radiological) in order to char- (S1) precedes a required motor response that is
acterize a disease state fully. In the case of signaled by a second stimulus (imperative
psychiatric diagnosis where the definition of the stimulus, S2) several seconds after S1. The
disease itself is often unreliable, psychophysiol- ensuing cortical negativity shows two negative
ogy cannot increase the validity of the diagnosis peaks: the first peak, which is especially visible
further because validity depends on reliability. in frontal brain regions, represents the expec-
tancy and resource mobilization of the sensory
input channels and stimulus processing and is
1.05.6 CONSCIOUSNESS AND thus primarily related to working memory; the
ATTENTION second negative peak reflects primarily motor
1.05.6.1 Introduction mobilization and voluntary effort directed
towards the response (Birbaumer et al., 1990).
The problem of consciousness has been at the The provision of resources is thus proportional
center of scientific and philosophical interest for to the negativity, and the consumption of
millennia. Biological psychology and the neu- resources is proportional to the positivity of
rosciences have made major discoveries about the slow cortical potential. The amplitude of the
the processes that underlie consciousness and SCP is usually determined by both processes.
attention. This research has shown that there is The allocation of resources and thus the
no unified concept of consciousness, but rather allocation of cortical activation is, however,
there are several heterogeneous neuronal pro- site-specific: preactivation and lowering of
cesses that underlie these and related functions cortical thresholds for responses is provided
such as selective attention and short-term in the area where a present or future activity
memory. The common physiological character- originates. Sudden loss of control and help-
istic of the many heterogeneous forms of lessness lead to mobilization (negativity) of
134 Psychobiology
resources for analysis of the new situation and reticular formation (MRF). This system (also
related decisions. Not only the analysis of called the ascending reticular activating system,
sensory input, but also the preparation for ARAS) fulfills three important functions: (i)
motor acts is characterized by slow cortical generation of wakefulness, (ii) maintenance of
negativities which are low in automatic and high muscle tone, and (iii) facilitation and inhibition
in voluntary, conscious movements. Voluntary of the intake and conduction of sensory and
movements are also preceded by (nonconscious) motor impulses. EEG desynchronization and
cortical negativities that occur about 350 ms behavioral activation are initiated by ascending
before the consciousness of the action. Experi- afferent fibers from the reticular formation to
ments on the self-regulation of these cortical higher centers. The reticular formation is
negativities have shown that performance activated by collateral fibers from the specific
increases with higher negativity and decreases ascending tracts. During phasic waking re-
with increasing positivity, thus confirming the sponses the impulses of the RF interfere with the
role of these potentials as a basis of attentional thalamic pacemakers which leads to EEG
processes. desynchronization in the cortex. In addition,
In PET studies, which allow for the analysis the reticular formation maintains the tonic
of both subcortical and cortical activations, the waking level by constant maintenance of a
electric and magnetic data on slow potentials diffuse arousal of the higher brain centers above
have been confirmed. In addition, activation in a certain critical level. Sleep occurs when the RF
the basal ganglia and the anterior cingulate has is actively inhibited and the afferent input is
been described during controlled processing. reduced (see Section 1.05.7).
The cingulate gyrus and the frontal cortex seem
to be especially active when executive functions
1.05.6.3.1 Neurophysiology of tonic and phasic
of attention (such as the formation of decisions)
activation
are required, and passive attention to a stimulus
does not lead to activation of the anterior Tonic activation is primarily a function of the
cingulate (Corbetta, Miezin, Dobmeyer, Shul- MRF whereas phasic activation related to
man, & Petersen, 1991). selective attention is primarily a function of
Studies using evoked potentials have shown the nucleus reticularis of the thalamus in
that attention rather than lack of attention in a conjoint action with the MRF, the frontal
task can be differentiated in the averaged EEG and parietal cortex. The intralaminar nuclei of
trace. Obviously, the regulation of attention the thalamus can also activate the cortex
needs subcortical regulation mechanisms; the without involvement of the MRF; this activa-
regulation itself occurs, however, via thalamo- tion is, however, only phasic. Without the MRF
cortical and cortical thresholds of activation. the general waking level is disturbed (Steriade &
This cortical regulation of attention ensures that McCarley, 1990). On a cellular level, the
every stimulus is analyzed by the neocortex activating function of the MRF (there are also
(even if it never reaches consciousness) which some inhibitory actions) relies on a tonic level of
then inhibits well-known irrelevant stimuli on a depolarized readiness in thalamic and cortical
cortical level. networks which is the precondition for phasic
activation, waking, and paradoxical sleep.
1.05.6.3 The Ascending Reticular Activating Thalamocortical activation is expressed by
System elevated firing rates in neurons with long axons,
elevated excitability of the thalamocortical cells,
The regulation of attention and conscious- suppression of secondary excitation and inhibi-
ness is based on the activity of many widespread tion related to spindles and a-waves in the EEG,
brain systems. Attentive behavior and prepara- narrowing and focusing of inhibitory processes,
tory planning depend on the integrated activity and depolarization of apical dendrites in the
of multisensory and motor systems (Lindsley, neocortex.
Bowden, & Magoun, 1949). Whereas the wide-
spread activation of the neocortex and the
1.05.6.3.2 Transmitter systems involved in
maintenance of an optimal tonic level of
attention
activation are a function of the reticular
formation (RF) of the brain stem, phasic local Despite many pharmacologically activating
mobilization is related to the integrated activity substances such as the amphetamines or caf-
of the RF, the basal ganglia, the thalamus, the feine, the transmitters and neuromodulators of
cingulate gyrus, the parietal region, and the the ARAS are not well established. Although
frontal cortex. most activating substances influence the synth-
The anatomical and physiological basis of esis of noradrenaline and dopamine, the cate-
waking consciousness is the mesencephalic cholaminergic systems probably do not have a
Consciousness and Attention 135
direct influence on the MRF-thalamocortical with many collaterals to the specific thalamic
activating structures. The origin of the mono- nuclei. These long multipolar axons commu-
aminergic systems in the midbrain and their nicate with the rest of the thalamus and the
extensive branching into the superior regions midbrain but not with the neocortical struc-
turns them, however, into candidate structures tures. The nucleus reticularis thalami is orga-
for activating systems. Most attempts at an exact nized in a somatotopic and a visuotopic fashion:
categorization have, however, so far led to afferents from the various regions can be
controversial results. Electrical and chemical differentiated on the basis of their functional
activation of the origins of the noradrenergic significance. Depending on the origin of the
system in the nucleus coeruleus and the afferents, only the specific gate that corresponds
serotonergic system in the nucleus rapheÂ lead to the respective afferent (sensory modality) is
to hyperpolarization and inhibition of activa- opened by the nucleus reticularis thalami.
tion in the respective neocortical projection In addition to the nucleus reticularis, the
areas. Destruction of the noradrenergic system pulvinar, a large nucleus in the posterior
has no effect on EEG activation and tonic thalamus, plays an important role in visual
wakefulness. Only cholinergic stimulation in the attention. It is involved in the increase of
midbrain activates cortical regions. It seems, activation that occurs in the posterior parietal
however, to be clear that the monoaminergic cortex when attention is focused on an object.
systems improve the signal-to-noise ratio in The pulvinar is also closely connected with the
cortical regions by the inhibition of specific areas lateral prefrontal cortex. If visual stimuli are
and by local increases in activation. presented with other potentially distracting
Dopamine is, like noradrenaline, involved in stimuli, cells in the pulvinar active and activate
many psychological functions. Whereas dopa- the striatal and extrastriatal areas of the visual
mine is not necessary for the maintenance of cortex. In the visual cortex, a signal that has
tonic wakefulness, dopaminergic systems reg- been attended to leads to an elevated evoked
ulate the construction of goal hierarchies and potential after only 60 ms. This elevated evoked
selective motor attention. Amphetamine in potential suggests that there is a very early
small doses improves attentional performance preconscious selection by the thalamus (Posner
primarily by an increased presynaptic dopamine & Raichle, 1995). The existence of multisensory
release and the inhibition of dopamine re-uptake comparisons on a neocortical level before active
from the synaptic cleft. In high doses, this leads gating occurs is based on a series of studies. For
to motor stereotypies and psychotic behavior. example, lesions of the right parietal lobe distort
The regulation of attention is especially con- the analysis and comparison of visual and tactile
trolled by the mesolimbic dopamine system. and also partially acoustic stimuli. The con-
Destruction of this system by 6-hydroxydopa- sequence is that the contralateral side of the
mine causes irreversible disorganization of body is ignored as well as stimuli that are
attentional processes: animals do not habituate, presented in that direction in spite of intact
they are extremely irritable, and they do not perception and motor function (neglect). Atten-
learn well; similar disturbances are seen in tion remains fixated on the contralateral body
attention deficit disorders. Cholinergic systems and face. Every shift of attention leads to an
seem to have an activating influence on the increase of blood flow in the prefrontal and
cortex, whereas the direction of activation seems inferior-parietal cortex which is further indica-
to be determined by monoaminergic systems tive of the important role of this region for
and other neurotransmitters and modulators. multisensory comparisons. Cells in the lower
parietal cortex where visual, acoustic, and
tactile information enters fire only when the
1.05.6.3.3 Gating of attention
animal is attentive to the source of the stimulus;
The ability of neuroanatomical networks to axons of these attention cells lead to the frontal
select part of the incoming information and to cortex as well as the thalamus and the basal
exclude the rest from continued processing is ganglia. This further underlines the role of the
called gating. The thalamus seems to have an parietal lobe for multisensory comparison.
important role in this gating process. Within the
thalamus, the nucleus reticularis thalami seems
to be the gate to the cortex. The nucleus 1.05.6.4 The Psychophysiology of Selective
reticularis thalami surrounds the thalamus like Attention
a shell and shows an internal structure that is
ideal for the selection of incoming sensory Two important parts of the limited capacity
activation: the cells in the nucleus reticularis control system are the mesencephalic reticular
thalami are characterized by widespread den- formation as a provider of energy and the
drites within the nucleus and multipolar axons nucleus reticularis thalami as a gate for the
136 Psychobiology
distribution of activation. There is an additional closing of the gates. The frontal cortex
ªdecision makerº that opens the cortical areas modulates these neocortical±striatal inhibitory
of the thalamic (visual or acoustic) gates before circuits. Disruptions of this system are always
the actual conscious reduction of the threshold related to disturbances in consciousness and
(increase of activation) and which gates the flow attention. Destruction of the basal ganglia
of activation to the region where it is needed for leads, for example, to unconsciousness. Incom-
further stimulus analysis or preparation of plete lesions lead to reduction of the readiness
movement. This latter function is provided by potential and disturbances of attention. If the
the prefrontal cortex and the cingulate gyrus frontal cortex is lesioned, selectivity is dis-
which receive information about the incoming turbed, the person's behavior is guided from all
activity and the result of the nonconscious the stimuli that are momentarily available, and
comparison process from all areas of the too many thalamic gates are opened.
neighboring cortex, especially (right) inferior
parietal association cortex. They also receive
1.05.6.5 Event-related Potentials as Indicators
information from the limbic system about the
of Attentional Processes
motivational significance of a stimulus. The
second system involves the basal ganglia and Evoked cortical potentials indicate the time
their connection to the nucleus reticularis course (latency) and the strength (amplitude) of
thalami. This system informs the nucleus a certain level of information processing. There
reticularis thalami about the current distribu- seems to be a close correspondence between
tion of activation in the neocortex and prevents these electrophysiological substrates and the
the continued activation of already activated psychological levels of attention (Hillyard et al.,
areas (to a level of epileptic overactivation). 1995). Figure 3 shows the typical form of an
This system closes the thalamic gates by endogenous evoked cortical potential to at-
increasing inhibition when activation is intended acoustic stimuli. The more automated
creased in the respective cortical module and the attention (the more frequently the stimuli
reaches a critical level. are presented without consequence), the lower
Efferents from the frontal cortex and the the amplitude, especially of the components
mesencephalic reticular formation converge on around 20±50 ms (positive components), of
the reticular nucleus that distributes the N100 and all ensuing negative components.
thalamo-cortical activation. Stimulation of An increase of amplitudes after 50 ms which
the mesencephalic formation opens the gate in occurs during selective attention is very site-
a nonspecific manner, that is, the amplitudes of specific. The early components are only visible
the event-related potentials increase, and the in the primary projection areas. The later
EEG is desynchronized. This results in a general components (after N100), however, extend to
readiness for the uptake of information and wide areas of the cortex.
orienting. Activation of the frontal cortex closes
the thalamic gates. In contrast to mesencephalic
reticular formation, the afferents and efferents 1.05.6.5.1 N1/P1
of the prefrontal cortex are anatomically N1/P1 is first component of the endogenous
selective in that only a portion of the connec- evoked cortical potential that responds to
tions from frontal cortex to the reticular nucleus manipulations of attention and is measured
are activated, another part is silent, and thus a about 100 ms after stimulus onset. N1 is
gate (e.g., the medial geniculate for acoustic recorded over the primary sensory projection
information) is opened; all other gates remain areas. The temporal N1 component, for
closed. The cingulate gyrus may activate frontal example, is very sensitive to shifts of attention:
areas of working memory if difficult decisions if attention is shifted to the right ear, the left
have to be made. Stimulation of the caudate temporal amplitude increases and vice versa (see
nucleus leads to inhibition (positivity, lower Figure 3). Lesions of the respective projection
activation) in a prescribed cortical area. All system abolish N1. N1 increases with stimulus
neocortical regions project to the striatum, and intensity but responds primarily to changes in
stimulation of this region leads to behavioral the temporal sequence of a given sequence of
and neuronal inhibition (Birbaumer & Schmidt, stimuli.
1996). This basal system prevents an increase of
activation in the cortico±thalamic feedback
1.05.6.5.2 N2
circuits: they increase the threshold for activa-
tion when activation of the cortical modules N2 can be induced by the omission of a
exceeds a critical level. The higher the neocor- stimulus in a sequence of stimuli. It has
tical activation, the stronger the neuronal influx therefore been termed mismatch negativity. In
into the basal ganglia and the stronger the particular, the first partÐN2aÐwhich is
Sleep, Dream, Circadian Rhythms, and Sleep Disorders 137
Figure 3 Schematic of a typical event-related potential for the time up to 400 ms after the presentation of a
simple, but task-relevant stimulus. A dichotic listening task is used where tones (120±320 ms) are presented in
rapid succession to the right (5000 Hz tone) or left (3400 Hz tone) ear (see upper portion of the figure). The
crosses mark slightly deviant tones (targets), to which the subject has to respond with a key press. Below the
averaged evoked potentials to the attended (continuous line) and the unattended (dotted line) stimuli are
displayed. After 20±30 ms an elevated potential to the attended stimuli is present (based on Hillyard et al., 1995).
modality-specific seems to be involved in in short-term memory. Its location is primarily

neuronal comparison processes of the incoming central at the vertex and parietal.
stimulus in comparison to the previously stored
stimuli of the same modality. Changes of
stimulus intensity also lead to N2. N2 is not 1.05.7 SLEEP, DREAM, CIRCADIAN
sensitive to changes in voluntary focused RHYTHMS, AND SLEEP
attention and reflects, like N1/P1, automatic DISORDERS
attention.
1.05.7.1 Introduction
The rotation of the earth around its axis
1.05.6.5.3 P3
leads to an approximate 24-hour light and
P3 is not related to any sensory system but temperature rhythm in plants as well as animal
occurs in a nonspecific manner, whenever an organisms influences almost all physiological
expectancy has not been fulfilled. It occurs after and psychological expressions. These circadian
all target stimuli that are incongruent with a rhythms are based on the activity of oscillators
previously formed attention and it can last for that originate in the organism and provide
seconds, depending on the amount of deviation well-defined oscillatory periods that are in
of expectancy. P3 is a correlate of a sensory general synchronized by Zeitgeber in the
process that makes comparisons between sti- environment. In addition to this circadian
muli. The stimulus must have been identified as periodicity, there are a number of endogenous
deviant from expectancy before P300 occurs. oscillators with short periodicities, such as
Thus P300 may reflect an extinction process of EEG, respiration, and some vegetative
the content in short-term memory when an rhythms. Rhythms which are longer-lasting
expectancy has to be corrected. P300 may thus than the circadian rhythms are called infradian
be a correlate of reflectory inhibitory processes rhythms, the shorter ones are termed ultradian
138 Psychobiology
rhythms. When isolated from the Zeitgeber chiasma lead in patients to irregular sleeping
(i.e., light) of the environment, most mammals and difficulty in waking. Similar changes have
and humans continue to show a circadian been observed in the sleep±waking cycle of
rhythm. The periodicity of those freely running animals after lesions without changes in the
rhythms is, however, somewhat longer or absolute time of sleep and wakefulness.
shorter than 24 hours, in humans about 25
hours. The endogenous oscillators seem to be
innate providers of rhythm. Some adaptation 1.05.7.2 Circadian Clocks
to external Zeitgebers is possible: in humans,
the maximum time to synchronize is between In humans and other animals, sleep±wake
23 hours and 27 hours for body temperature, cycles are the most important expressions of
and for motor activity between 20 and 32 central pacemakers: the daily change of aware-
hours. Within these limits, the circadian ness to non-awareness or partially conscious
rhythm adapts to a Zeitgeber. Outside this experience dominates our life like no other
region, the rhythms are disturbed and desyn- bodily rhythm. Another important circadian
chronizations between various rhythms occur rhythm is that of ingestion of food and fluid.
(Wever, 1979). The intake of food and activity cycles are highly
In humans, bright light functions as the most synchronized in mammals. The rhythm is
important Zeitgeber. In addition, social cues are determined by anticipation of the availability
important. Circadian rhythms also determine of food and thus depends primarily on previous
motivational behavior. For example, the effec- learning. Synchronization of the rhythmicity of
tiveness of feedback signals and the ensuing other body functions, for example, the produc-
learning and memory performance also depend tion of saliva before the intake of food, depends
on the momentary phase of circadian rhythms. on an intact nucleus suprachiasmaticus. The
The provision of water as a feedback stimulus in anticipatory rhythm related to the search of
a thirsty organism is much more effective during food is, however, not dependent on the SCN but
the night than during daytime hours. The on the ventromedial nucleus of the hypothala-
closeness of the coupling of endogenous mus. Rhythms for drinking are usually corre-
oscillators and the influence of Zeitgeber lated with the rhythms for food intake; they can,
depends on the joined physiological function however, also be separated from them. The
of the oscillators. Every oscillator is correlated drinking rhythm is strongly related to exogen-
with a specific environmental cycle, that is, the ous factors as SCN lesions destroy the rhyth-
oscillators must have different sensors that micity of drinking. The rhythm of body
convey the specific Zeitgeber signal on the temperature is similar in most mammals: after
internal clock. The sensors for light±dark cycles 6 p.m. the temperature reaches a maximum
are probably located in the retina and for (Aschoff, Daan, & Groos, 1982). In a phase of
eat±fast cycles there are probably sensors in the inactivation it is continuously lowered and
hypothalamus. True oscillators are pacemakers before waking up it shows an anticipatory
which measure time independent of external increase. There are also specific endocrine
cues. The circadian pacemakers are located in rhythms: for example, plasma corticosteroids
the CNS. Peripheral pacemakers and secondary are synchronized with light±dark or sleep±wake
oscillators synchronize the respective organ rhythms. Like temperature rhythms they are
system. difficult to influence by external factors. The
The nucleus suprachiasmaticus has been rhythms of psychological variables are coupled
identified as the central circadian pacemaker to circadian oscillators. For example, pain
in mammals. Lesions of the suprachiasmatic perception, reaction time, vigilance, and arith-
nucleii of the ventral hypothalamus lead to metic speed as well as immediate memory co-
complete and long-lasting loss of rhythmicity. vary with circadian rhythms (Folkard & Monk,
Numerous control lesions in and outside the 1986).
CNS do not have any comparable effect on If circadian rhythms are disturbed, such as in
rhythmicity. The nucleus suprachiasmaticus shift-work or during ªjet-lag,º lasting conse-
forces its endogenous rhythm on other struc- quences for physiological and psychological
tures by the pulsating release of hormones and functions ensue. Additional disturbances of
the rhythmic depolarization of its neurons. In circadian periodicity are related to sleep
primates, bilateral lesions of the SCN lead to a disorders, depression, and epilepsy. The main
complete loss in activity rhythms, including the characteristic of long disturbances in rhythm is
drinking rhythm without effect on the absolute the desynchronization of usually highly corre-
amount of fluid that is ingested (no homeostatic lated physiological and psychological variables
function of circadian rhythms). Tumors in the or extreme synchronization of usually uncorre-
anterior part of the third ventricle of the lated variables. Night-work and shift-work lead
Sleep, Dream, Circadian Rhythms, and Sleep Disorders 139
to long-lasting disturbances of periodicity and 5±10 min at the beginning to 22 min in the last
the connected physiological systems. Even phase. The approximately 90 min long REM±
experienced shift-workers maintain a low in NREM phase has also been termed the basic
performance after midnight; additional con- rest±activity cycle (BRAC) since it may con-
sequences are gastrointestinal disorders, sleep tinue during wakefulness. A number of rhythms
disorders, respiratory problems, pain, and (such as eating, drinking, heart rate) seem to be
immunological effects. Jet-lag leads to similar synchronized to it (Jovanovic, 1971).
problems such as sleep disorders, gastrointest- REMS has been called paradoxical sleep
inal disorders, reduction of vigilance, feelings of because an active brain is coupled with a more
nausea, and reduced immune function. The or less ªparalyzedº body. Rapid eye movements
more time zones a flight covers, the more intense occur in groups over the period of several
are the disorders. The change of only one hour records (up to 23 s) with variable intervals
from summer-time to winter-time and vice versa (200 ms to 23 s) between them. About 20±120 ms
leads to measurable alterations, especially in before EEG desynchronization during REMS,
older persons. ponto-geniculo-occipital waves (PGOs) become
active and remain visible throughout the entire
REM phase. They have especially been studied
1.05.7.3 Sleep and Dream in the cat and nonhuman primates, but their role
in human sleep is not yet clear. They can be
Although humans spend about 30% of their recorded from widespread areas in the brain
time asleep, sleep became a topic of research including the pons, the lateral geniculate body,
only in the 1950s. The discovery of rapid eye and the occipital cortex. The PGO waves of
movement sleep (REMS) by Aserinsky and REMS can also be observed during the waking
Kleitman (1953) revealed that the brain is not state and seem to be indicators of the activation
passive during sleep (as was previously as- of neural mechanisms indicative of orienting.
sumed) but that one phase of the sleep cycle They seem to originate in the dorsal pons near
(REMS) is very similar to alert wakefulness the midbrain and are generated by cholinergic
(Hobson & Stickgold, 1995). The various stages neurons between the pons and the midbrain
of the sleep cycle are as follows: (i) transition (McCarley, 1990).
from wakefulness to sleep with grouped occur- REMS is also accompanied by brief phasic
rences of a-waves; (ii) stage 1 of the sleep cycle muscle activity (myocloni), whereas muscle tone
characterized by the loss of a, low-amplitude, ceases to exist (atonia). This atonia is related to
high-frequency b activity and low amplitude y; hyperpolarization of a-motoneurons, and the
(iii) stage 2 with low-amplitude fast activity with myocloni are related to descending excitatory
sleep spindles and K-complexes; (iv) stage 3 bursts from the brainstem. In REMS presy-
sleep with about 10±50% of d; and (v) stage 4 naptic inhibition of group I primary afferents
sleep with d (4100 mV, 53 Hz) occurring for and thus suppression of monosynaptic reflexes
more than 50% of the time. In the REM stage, is found in addition to descending inhibition of
low-amplitude EEG with low y-waves, so-called polysynaptic reflexes. Concurrent with sensory
see-saw waves, occurs, otherwise the EEG is inhibition in the periphery, there is increased
similar to an attentive waking state. K-com- sensory activity in the brain (increased neuronal
plexes might be the correlates of a strong activity in the specific thalamic nuclei) which
internal discharge of sensory systems, and seems to be relevant for perceptual stability
spindles signal the inhibition of sensorimotor during REMS and the development of sensory
areas. From stage 1 to 4, EMG activity structures in the growing organism (McCor-
decreases to a complete muscular atonia during mick & Bal, 1997). During phasic REMS the
REMS. threshold for waking up is highest, whereas in
There is considerable variability across nights phases of paradoxical low-voltage, high-fre-
and persons in the course of the sleep stages of quency sleep without REM there is slightly
an individual person. The first NREM stage improved response. The ability to respond to
usually lasts about an hour. The duration of the internal stimuli decreases continuously from
REM phases is about 104 min overall. In stage 1 to stage 4. During REMS, activity of the
mammals, slow wave sleep (SWS: stages 3 and sympathetic nervous system is increased.
4) always precedes REMS. A REM±NREM Whereas the regulatory function of the hy-
cycle lasts about 90 min, with the first cycles pothalamus continues during NREMS, it is
being shorter, and the late cycles being longer. diminished during REMS. Penile erection and
Stage 2 covers about 50% of the entire sleep and vaginal lubrication during REMS can be used to
extends in time over the course of the night, differentiate organic from psychological factors
SWS is very rare in the last cycles. The duration in erectile dysfunction and lack of vaginal
of an individual REM phase extends from lubrication.
140 Psychobiology
A look at the evolutionary aspects of sleep are active while the cholinergic influence may be
suggests that small and short-lived animals with dampened. During REMS, the aminergic
a relatively high metabolic rate and a short systems may be inhibited and the cholinergic
BRAC sleep longer than mammals who spend a systems are dominant. The state of conscious-
large part of the day searching for food. The ness depends on the reciprocal interaction of
duration of sleep seems to be inversely related to cholinergic and aminergic systems. During
the length of the sleep cycle. Large animals with dreams, the visual input no longer originates
high predator vulnerability seem, however, to in the retina but in the brain stem, which is
have less REMS. In younger people, SWS may coupled with reduced serotonergic and nora-
constitute up to 40% of total sleep time. Older drenergic activity. The ensuing disinhibition of
persons sleep less, wake up more often, show cholinergic neurons leads to PGO waves which
shorter REM phases and generally reduced create the subjective images of dreams (Hobson
SWS. Infants show maximum REM activity in & Stickgold, 1995).
the pre- and postnatal phase. REMS thus seems Endogenous sleep factors also seem to play a
to be correlated with the maturation of the role in sleep generation. They include several
CNS: the high rate of REM in babies might substances such as factor S, sleep-promoting
compensate for the lack of structured sensory substance, 8-sleep-inducing peptide, and va-
input from the not yet fully developed sensory soactive peptide. Whereas some of these sub-
system and activates the formation of synaptic stances seem to induce sleep, others are
connections. produced and released during sleep.
1.05.7.4 The Neurobiology of Sleep 1.05.7.5 Psychophysiology of Sleep Stages

Multiple brain systems are involved in sleep The sleep stages are important regulatory
regulation. Sleep-regulating structures seem to physiological processes. Sleep during the first
be located in the caudal region of the midbrain three hours of the night seems to have an
down to the medulla. SWS seems to be generated important function for endocrine and immu-
by the basal forebrain, the lateral preoptic nological responses. Long-term deprivation
region of the hypothalamus and the nucleus leads to considerable consequences for the
tractus solitarius which inhibits the activating organism: REM and SWS episodes occur
reticular formation. Whereas the nucleus rapheÂ during the day, optic and acoustic illusions
seems to be involved more in the regulation of and hallucinations occur, and after four days
NREMS, the nucleus coeruleus seems to be paranoid ideation may be reported. The meta-
important for REMS coordination. The rapheÂ bolic and behavioral changes are less severe.
nucleus synthesizes serotonin, the nucleus REM rebound usually occurs when selective
coeruleus noradrenaline, and portions of the REM deprivation is instituted; in general sleep
reticular formation acetylcholine. But SWS is deprivation REM is increased only after about
not exclusively dependent on the nucleus rapheÂ, four waking days. Barbiturates and some
nor is REMS dependent on the nucleus benzodiazepines suppress SWS and/or REM
coeruleus. The dorsal serotonergic rapheÂ nuclei sleep (both are experienced as aversive), lead to
lower their firing rate from the waking state to REM rebound in dreaming or wakefulness
SWS, and during REMS they are completely nights, and therefore have an addictive poten-
silent. Nonadrenergic synapses from the nucleus tial. Dreams occur during REM and NREM
coeruleus probably mediate the phasic activa- sleep but seem to be experienced differently.
tion of the dorsal serotonergic rapheÂ nuclei to Dream reports following REMS seem to be
external and internal stimuli which might be more vivid, more visual, and emotional than
related to waking up during SWS and REMS. those experienced in NREMS where the dreams
During immobilization in various sleep stages, seem to be more abstract. Whereas dreams in
the dorsal rapheÂ nuclei are inhibited. Immobi- the first half of the night seem to be more reality-
lization is caused by the activity of nuclei in the oriented, those of the second half are more
pontine tegmentum that activate the nucleus unusual and unreal.
magnocellularis of the reticular formation Sleep seems to have an important function in
which in turn inhibits the spinal motorneurons. the consolidation of learned material into long-
Cholinergic reticular structures (reticular term memory. REM deprivation leads to
formation, pontine and midbrain tegmentum, deficiencies in retrieval of learned material.
posterior thalamus, and hypothalamus) are This reduced consolidation seems to be related
hyperactive during REMS. In contrast, it is to reduced RNS synthesis when REM sleep is
assumed that during the very similar waking deprived. Hippocampal y, which occurs during
state, noradrenergic and serotonergic systems the transition from short- to long-term memory,
Learning, Plasticity, and Disorders of Learning and Memory 141
is also present during REMS. In addition, activating structures is reduced. Nightmares

elevated DNS concentrations in the brain have with sleep paralysis (the inability to move the
been found subsequent to learning and are also limbs) are usually REM episodes with extreme
seen subsequent to REM episodes. motor inhibition and concurrent awakening.
Borbely's (1984) theory of sleep and dream Sleep is distorted in several psychiatric condi-
regulation suggests that two processes, S (SWS tions such as depression and post-traumatic
pressure) and C (REM pressure), are active at stress disorder. In major depression, REMS often
different points in time. Process S seems to appears very early and rapid eye movements
depend on the duration of the waking state and may be more frequent. This has been related to
increases in an exponential fashion. Process C is enhanced cholinergic activity and/or a deficit in
related to the reciprocal value of the tempera- noradrenergic and serotonergic activity.
ture oscillator. The entire ªsleep pressureº is
related to the sum of S and C. This model makes
exact predictions about the effects of sleep 1.05.8 LEARNING, PLASTICITY, AND
deprivation on depression, implies the existence DISORDERS OF LEARNING AND
of active sleep substances as the basis of S, and MEMORY
views the circadian oscillator of the nucleus 1.05.8.1 Introduction
suprachiasmaticus as the neuroanatomical basis
of C. The simplest form of learning is nonassocia-
tive learning such as habituation and sensitiza-
tion. These refer to a decrease or an increase in a
1.05.7.6 Sleep Disorders behavioral response dependent on the number
and intensity of stimulus presentations. Asso-
Although psychological variables are most ciative learning such as classical and instru-
important in most sleep disorders, biological mental conditioning involves the pairing of two
factors contribute significantly to delayed stimuli or a response and a subsequent stimulus
sleep phase insomnia (DSPI), drug insom- in a time-contingent manner. Classical condi-
nia, sleep apnea, narcolepsy, somnambulism, tioning is characterized by the (usually) frequent
and sleep disorders in depression. In DSPI pairing of a neutral stimulus and a biologically
persons go to bed late, but often need an hour or relevant unconditioned stimulus (US) which
more to fall asleep and wake up very early. The elicits an unconditioned response (UR). After
cause of DSPI is probably a lack of flexibility several trials, the formerly neutral, conditioned
of the SWS oscillator to alter the circadian stimulus (CS) comes to elicit the conditioned
period forward, that is, to induce sleep before response (CR) which may be agonistic or
the beginning of the circadian period. These antagonistic to the UR. Extinction occurs when
patients can in general adapt their endogenous the CS is presented without the US: the CR
rhythm of 25 hours to a 24-hour cycle, but are slowly ceases to be. CRs may occur towards
unable to correct phase delays due to external stimuli that are similar although not identical to
factors. Chronotherapy has been used in these the CS: this phenomenon is called general-
patients: based on the assumption of a Zeitgeber ization. Modern theories of learning (Rescorla,
period of about 27 hours, the patients were 1988) emphasize that stimulus associations
instructed to delay sleep by three additional rather than stimulus±response associations are
hours per day. learned: the signal value of a stimulus deter-
Drug insomnia is related to alterations in the mines the speed of acquisition. In a latent
sleep profile by barbiturates and benzodiaze- inhibition design, for example, the CS is
pines: REM sleep and SWS are reduced, stages 1 presented several times without the US before
and 2 and b-activity are increased. Cessation of the onset of a conditioning phase. This retards
the hypnotic agents leads to REM rebound with the later acquisition of a CR to the CS.
nightmares, which are suppressed by renewed Imprinting is a special form of conditioning.
drug intake. Rebound insomnia occurs after It denotes a sensitivity for the acquisition of
three days of hypnotics intake with no effect on certain S±S or S±R connections in a certain
the original insomnia (Borbely, 1984). developmental stage.
Narcolepsy is characterized by frequent sleep Operant conditioning is characterized by the
attacks during the day that are related to loss of learning of a response which is acquired by
muscle tone and may cause sudden loss of providing positive or negative reinforcers sub-
posture of the person affected by them. They are sequent to its execution. Although operant and
characterized by the intrusion of REM episodes classical conditioning show similarities, it is
into the waking state. Narcoleptics enter questionable whether they have a common
immediately upon sleep onset into an REM physiological basis. For example, instrumental
phase which suggests that inhibition of REM- learning of autonomic responses is difficult to
142 Psychobiology
achieve, whereas classical conditioning of and motor areas is present in the adult
visceral responses is easily obtained and vice organism. Both nervous system lesions as well
versa: classical conditioning of muscular re- as behavioral training alter the architecture of
sponses needs more learning trials than operant sensorimotor maps in the cortex. The functional
conditioning. significance of these cortical changes has
recently also been demonstrated in humans.
In human amputees, reorganization of the
1.05.8.2 Mechanisms of Plasticity primary somatosensory cortex is highly posi-
tively correlated with the magnitude of phan-
Although memory and learning are closely tom limb pain. In chronic back pain patients,
related, memory research has for a long time chronicity of the pain and cortical reorganiza-
focused on the encoding of abstract materials tion show a high positive association. To what
such as numbers and words rather than on the extent these reorganizational changes cause
acquisition of skills. The specificity of a memory these pain phenomena needs to be determined
trace seems to be determined by (i) the location (Birbaumer et al., 1995; Flor, Elbert, et al.,
of the neuronal circuit underlying the memory 1995).
and (ii) the anatomical and physiological
characteristics of the cell assembly and the
subsequent synaptic modifications. Plastic 1.05.8.3 The Formation of Memory Traces
changes in the development of the organism
are based on the branching and growth of Engrams refer to the electrochemical pro-
dendrites and their dendritic spines. This cesses that underlie specific memory contents.
growth is not random but occurs along Hebb (1949) proposed that reverberating cell
ªguidingº structures with common chemical assemblies are the basis of these memories.
affinity: specific chemical growth gradients of These reverberatory circuits are characterized
the glial cells probably guide axons and dendrite by interconnected excitatory synapses that
growth (Gazzaniga, 1995). The strong increase maintain the neuronal activation. A cell
in weight of the brain in the first years of life is assembly is usually formed by several of these
related to an increase in the number of synapses, reverberatory circuits that must exceed a certain
myelinization/enlargement of the cells, the level of activation for a cell assembly to ªfire.º
dendrites, and dendritic spines, and an increase The activity in reverberatory circuits may be
in glial cells and of the capillary net of the brain. viewed as the neurophysiological basis of the
Adequate sensory and motor or emotional consolidation of memory traces. Continuing
stimulation is required for this development. reverberation leads to structural synaptic and
Sensory or motor deprivation lead to cellular changes that represent long-term mem-
reduced growth and atrophy which is more ory. A certain time of undisturbed reverbera-
severe and long lasting the more pervasive and tory activity is needed for consolidation,
earlier in development it occurred (Rosenzweig otherwise interference with memory formation
& Leimann, 1982). Enriched environmental occurs. Weak synaptic connections between
conditions compared with impoverished envir- neurons increase in strength during the con-
onmental conditions have profound effects on solidation phase if neurons are activated in close
dendritic growth and other markers of brain temporal proximity or simultaneously in an
growth which are related to the long-term ªassociativeº manner. These temporally closely
effects of behavioral learning (only active coordinated synaptic activations are the basis of
interaction with the environment causes these conditioning and learning. Once the synaptic
changes). Learning also occurs after comple- connection has been formed, activation of a part
tion of developmental processes and is prob- of the cell assembly will activate the entire cell
ably mediated by sprouting as well as assembly. High-frequency synchronous oscilla-
disinhibition of silent connection and changes tions in the g-band range seem to be an
at spines and their synaptic connections (Cot- expression of the mechanism of formation of
man & Nadler, 1978). cell assemblies (Singer & Gray, 1995).
Sprouting or reactive synaptogenesis has been A fundamental principle of neuronal plasti-
described as a consequence of nervous system city is based on the Hebb rule (1949): if the axon
lesions. It refers to the development of new of neuron A excites neuron B and causes
synaptic connections and has been related to repeatedly or constantly the firing of neuron B
recovery of function. The activation of pre- (i.e., the suprathreshold excitation of neuron B),
viously inhibited or silent synaptic connections then the efficacy of neuron A in exciting neuron
may happen within minutes after a lesion. B increases either through a growth process or a
Recent animal work (Kaas, 1995) has shown metabolic change in one or both neurons.
that neuronal plasticity of the primary sensory Realization of the Hebb rule usually depends on
two presynaptic (synapses 1 and 2) and one assembly. Slow EEG oscillations in the fre-
postsynaptic cell. Assume that synapse 1 is quency band of 0±15 Hz depend primarily on
excited by a neutral tone which by itself is not thalamocortical excitatory circuits and their
sufficient to excite the postsynaptic cell on nonspecific input from reticular subcortical
which converge synapses 1 and 2. Synapse 2 structures. They determine the excitatory
(which may, for example, be excited by a tactile thresholds of cortical tissue in the waking and
receptor in the eye) is excited together or shortly sleep state. Since most of our memories are
after synapse 1 by an air puff to the eye which cortical, cortico-cortical assemblies are neces-
elicits activation of the blink reflex in the sary for their formation. Calculation of con-
postsynaptic cell. Firing of the postsynaptic cell duction velocities in cortical assemblies suggests
(caused by synapse 2) now reinforces the activity that optimal distances (also for widely separated
of all synapses that were simultaneously active cell assemblies) of two synchronous depolariza-
at the postsynaptic cell, thus it also increases the tions are in the vicinity of 20±60 Hz. It is just the
excitability of the weak synapse 1. After several oscillatory frequency in the g-band range which
pairings of the two stimuli, the tone alone will may be detected in the EEG and MEG when
excite the postsynaptic cell sufficiently to cause gestalts, meanings and words or dreams are
it to fire and will thus elicit the blink reflex. perceived. They also appear when new concepts
Thus, classical conditioning of the blink reflex are formed during learning.
has been established.
According to Hebb's theory, the excitatory
configuration must reverberate in the same cell 1.05.8.4 Neuropsychology of Memory
assembly for some time before structural long-
term memory changes occur. The information In 1880, the Russian neurologist Korsakoff
the CNS needs for memory storage is not the first described the amnesic syndrome which is
activity of one or a few cells, but the concurrent characterized by anterograde amnesia, retro-
coherent firing pattern of an entire cell assembly. grade amnesia, and confabulation. The neuro-
Coherence is formed by the simultaneous firing physiological basis of this syndrome is a
of an excitatory pattern in the cell assembly destruction of diencephalic and limbic struc-
where structure and frequency are specific for a tures and often also the mamillary bodies and
memory content. A measure of the coherence is the dorsomedial nucleus of the thalamus (for
the amplitude of the evoked potential of the example in alcoholism, by lack of thiamine).
EEG or the evoked field of the MEG above a The main lesion in Korsakoff's syndrome is,
certain cell assembly or the cross-correlation however, located in the hippocampus. The
function of the various firing patterns between lesions in Korsakoff's syndrome are too diffuse
several cell assemblies. The higher the amplitude to allow for exact determination of the relevance
of the evoked potential, the more cells must fire of temporal structures for memory. Patients
synchronously, the more complex the learned with surgical removal of the temporal lobe (e.g.,
materials, the larger the cell assemblies involved, due to epilepsy, as in the famous case H.M.)
and the longer the time the reverberatory activity make more exact examinations possible. The
must be active in order to attain a critical shif of data from these patients suggest that the medial
metabolic activity in the cells. temporal lobe system is essential for declarative
Every cortical cell is connected to about memory.
4000±10 000 other cortical cells. If there were The medial temporal lobe system plays an
only fixed connections for the representation of important role in declarative learning. The
memories, then we would quickly run out of hippocampus receives information from all
connections to store all memory traces. Since association areas of the neocortex via the
one cell can participate in the representation of entorhinal cortex as well as from limbic areas,
many different contents, that is, participate in especially the cingulate gyrus, the orbitofrontal
many different cell assemblies, we have a nearly cortex, and various regions of the temporal
unlimited number of combinations of functional cortex. All these connections are reciprocal in
connections that build the basis of our implicit that the hippocampus also has efferent connec-
learning capabilities. This summation of syn- tions to the association cortices where the actual
chronous input to an assembly is necessary long-term changes of memory storage must take
because the convergence of only a few synapses place. The medial-temporal lobe system must be
would not reach the critical firing threshold. If active during the presentation and repetition of
information is connected its individual elements memory-related materials so that associative
appear in temporal synchrony and thus allow for connections can be formed between the various
the formation of Hebb synapses. The larger the stimuli that are present during encoding. The
assembly and the more complex the context, the hippocampus and the adjacent entorhinal
slower the reverberatory activity in the cell cortex connect the various representations of
144 Psychobiology
the entire environment that is present during (unconditioned defensive reflex). About 10
learning with respect to temporal and spatial stimulations of the siphon lead to habituation
aspects. Creation of such a context is especially of the defensive reflex. This response reduction is
necessary when new situations and new learning related to the reduction of transmitter release in
materials have to be encoded since new the sensory neuron. Every new action potential
perceptions and new thoughts that have so reduces the Ca2+ influx into the sensory
far not been associatively connected have to be synapse. Long-term habituation (weeks,
associated. As soon as these contents are months) is related to a reduction in the number
associatively learned, a small aspect or a part of vesicles that release transmitter in the synapse.
of the situation is sufficient to reproduce the When sensitization occurs, increased transmit-
entire situation. The hippocampal system thus ter release of sensory interneurons at the motor
connects the cortical representations of certain neuron occurs (Hawkins & Kandel, 1984).
situations with each other so that they build one Classical conditioning in Aplysia entails the
general memory content (ªbindingº). following processes:
Whereas declarative learning is heavily (i) Stimulation of the tail activates a group of
dependent on an intact medial-temporal lobe facilitator neurons that lead to transmitter
system, nondeclarative learning does not need release at the synapses of the sensory neuron
an intact medial-temporal lobe. General cortical (presynaptic facilitation).
processes are less important for the formation of (ii) The transmitter (serotonin) activates the
nondeclarative memories although the acquisi- enzyme adenylyl cyclase which increases cyclic
tion of habits and motor skills involves the AMP in the synapses of the sensory neurons.
motor and prefrontal cortical areas of the (iii) Increase of cAMP activates a second
cortex. Specific subcortical regions have been enzyme, a cAMP-dependent protein kinase.
identified for specific nondeclarative or implicit (iv) The protein kinase closes a specific type
learning processes. For example, the already of K+ channel in the membrane and reduces the
described classical conditioning of the nictating number of open K+ channels during the action
membrane of the eye in the rabbit is dependent potential. The protein kinase also activates the
on an intact cerebellum and the conditioned synaptic vesicles.
emotional responses to aversive stimuli in the (v) The decrease of the K+ outflow leads to a
rat are dependent on an intact amygdala. In broadening, that is, a temporal extension of the
general, the learning process takes place in the next incoming action potential, which causes
location where the two sensory informations more Ca2+ to enter the synaptic terminal and
that are to be associated meet. For example, if more transmitter release since the binding of the
the conditioned stimulus is a tone and the transmitter to Ca2+ is a prerequisite of its
unconditioned stimulus an aversive tactile release.
stimulus, the associative connection in the rat (vi) The increased Ca2+ binds partially to
is formed in the medial section of the medial calmodulin which attaches to the adenylyl
geniculate nucleus where both channels of cyclase and increases the potential for cAMP
information converge. production.
In the cortex and hippocampus where gluta-
1.05.8.5 Cellular Mechanisms of Learning mate is the excitatory transmitter, NMDA
receptors most likely initiate these processes
The cellular basis of learning has been (Linden & Connor, 1995). In hippocampal and
primarily studied in simple organisms such as cortical dendrites, long-term potentiation (LTP)
the sea snail Aplysia whose nervous system has been described as a potential physiological
consists only of 20 000 neurons, and the mechanism of the encoding and retrieval of
common fruit fly Drosophila melanogasta. information in short-term memory. Homosy-
Sensitization, habituation, and operant and naptic LTP occurs when a cell is stimulated for
respondent (Pavlovian) conditioning have been about 1 s at a 100 Hz frequency. The cell
described. increases its firing frequency and also its
Associative learning in complex organisms synaptic strength when a test stimulus is later
may follow similar principles as learning in presented. The incoming stimuli lead to depo-
simple organisms such as Aplysia. Since the larization and Ca2+ influx into the cell because
1970s it has been shown that habituation, the ensuing Mg2+ blockade opens the NMDA
sensitization, and classical conditioning are all (or AMPA) receptor.
related to specific pre- and postsynaptic mod- Associative LTP occurs when slow stimula-
ifications in neuronal systems with few cellular tion (5 Hz) of an axon is coupled with high
connections. In Aplysia, stimulation of the frequency activation of an adjacent axon. The
siphon or the mantle shelf leads to contraction connection of the slow-frequency stimulated
of the siphon, the mantle shelf, and the gill axon synapse with the postsynaptic membrane
leads to a long-lasting increase in excitation and synapses of the parallel fibers of the Purkinje
a strengthening of the synaptic connection upon cells which have AMPA receptors. Thus,
renewed stimulation. Long-term depression cerebellar cortical LTD disinhibits the nucleus
(LTD) protects the synapse from extreme interpositus (which is usually inhibited by the
(epileptoform) LTPs and facilitates the reduc- cerebellar cortex) and the CS can elicit the CR.
tion of LTP, thus increasing the possibility for This engram is thus stored in the cerebellar
renewed excitation. In its heterosynaptic form, cortex, not the afferent or efferent structures.
one synapse is stimulated tetanically while the In humans, destruction of the cerebellar
adjacent synapse is not preactivated. Associative cortex likewise leads to disruption or elimina-
LTD occurs during asynchronous (anti-Hebb) tion of classical eye lid conditioning, with intact
stimulation of two synapses. Low-frequency responses to the CS and US (Daum et al., 1993).
stimulation (1 Hz for 10 min) leads to homo- The cerebellum is, however, only involved in
synaptic LTD. motor learning. The learning of emotional
LTD is probably the mechanism responsible responses or declarative learning are unaffected
for forgetting and affects lateral inhibition in by cerebellar lesions.
LTP. Whereas LTP leads to increased intracel-
lular Ca2+, the activation of protein kinase (G- 1.05.8.7 Neurochemistry of Memory
protein), and phosphorylization of proteins in
the cell and subsequent gene expression with the The biosynthesis of proteins seems to play an
synthesis of new proteins, LTD leads to important role in transferring information from
dephosphorylization of the receptors and short-term into long-term memory. It is unlikely
reduced conductivity. that qualitative changes in the amino acid
sequences of the RNS are the underlying
1.05.8.6 Neuronal Bases of Learning and mechanism for long-term storage, since these
Memory changes only seem to reflect unspecific activa-
tion or stress (Davis & Roitblat, 1984).
Simple classical conditioning does not require Alterations in gene expression may be viewed
an intact cortex. Thompson and Krupa (1994) as the basis of learning-induced physiological
showed the development of an engram in the changes.
hippocampus and the nucleus interpositus of Learning and other environmental influences
the cerebellum during classical eyeblink con- modify the binding of proteins that activate
ditioning in the rat, rabbit, and cat. In the transcription of the genetic code via regulatory
rabbit, closure of the nictating membrane of the proteins. Every gene has three regions: a code
eye was used as UR, a tone as CS, and an air region which is transcribed by mRNS and
puff to the eye as US. Cells in the CA1 layer of translated into a specific protein, and a
the hippocampus become active in the CS±US regulatory region which consists of the promo-
interval several trials prior to the expression of ter region, and an enhancer region which
the CR nictating membrane closure to the tone. contains binding locations for regulatory pro-
The mean firing frequency of these cells exactly teins which ensure tissue-specific gene expres-
predicts the form of the later CR. A similar sion for every specific type of cell. The promoter
firing frequency was found in cells of the nucleus region consists of a brief sequence of nucleotides
interpositus of the cerebellum from which which must first be activated by a regulatory
efferents of the cerebellum to other brain protein before RNS-polymerase can transcribe
regions originate. If these cells are destroyed, the structural gene. Phosphorylation of the
the CR is abolished and a new CR (but not the regulatory proteins is essential for their function
UR) can no longer be acquired. The learning as a key in the lock of the regulatory region.
mechanism is the previously described LTD of Various antibiotics inhibit cerebral protein
Purkinje cells in the cerebellar cortex. The tone biosynthesis during the translation of tRNS into
CS is transported via the auditory tract to the the respective amino acids at the ribosome.
cerebellar cortex and the nucleus interpositus, About 80±90% of cerebral protein synthesis can
and the air puff US reaches these structures be blocked temporarily without severe deficits in
about 100±300 ms later via the nucleus trige- behaviors other than memory. Encoding and the
minus and the olive. The motor UR and CR are input of information is not disturbed if the
relayed from the nucleus interpositus (which is training time does not overlap too much with the
inhibited from the cerebellar cortex and has an time it takes for antibiotics to exert their effect.
excitatory connection to it) to the motor nuclei Even weeks after the completion of training, the
of the brainstem. Learning occurs in the plastic retrieval of memory contents is interfered with.
Purkinje cells: LTD is initiated by the shortly The strongest amnesia occurs when protein
temporally spaced firing of the parallel mossy synthesis is inhibited shortly before the begin-
fibers (CS) and the climbing fibers (US) at the ning of training, that is, if protein synthesis is
146 Psychobiology
disturbed during training. The retrieval of systems in the mammalian brain and precursors
memory contents is not influenced by protein of acetylcholine and metabolites participate in
biosynthesis inhibition because injections of the almost all behaviors directly (as transmitters) or
respective antibiotics at the time of retrieval does indirectly (as neuromodulators). It is therefore
not show an effect on learned materials. This especially difficult to show the role of choliner-
means that the protein biosynthesis is only gic systems in associative learning. Scopola-
needed for a critical phase of consolidation mine, which blocks most cholinergic receptors,
during and after training. Interestingly, short- leads to memory loss for birth incidents if it is
term memory is not affected by the inhibition of given to mothers during delivery. It has some-
protein biosynthesis. times been reported that postsynaptic choliner-
Both long-term potentiation and long-term gic stimulators improve retrieval from memory
depression lead to a modification of early and in patients with Alzheimer's disease. In patients
late gene expression. Excitation as well as with morbus Alzheimer's disease where neuro-
damage to nerve axons (e.g., after deafferenta- nal aging processes seem to occur at a very rapid
tion during amputation) leads to long-lasting rate, reduced acetylcholine is found, along with
LTP or LTD (based on the cell type). a lower density of muscarine receptors and a
Subsequent to injury, hyperexcitability, synap- lower number of cholinergic neurons. The low
tic facilitation, and growth occur in the deaf- efficacy of cholinergic stimulation alone sug-
ferented neurons. These may occur within hours gests that cholinergic and noradrenergic sys-
and explain the quick and lasting chronic pain tems have to converge in layers 1 and 2 of the
that may occur subsequent to amputation. cortex in order to make normal memory and
Although this is not an associative learning consolidation possible, although they may not
mechanism, the molecular changes are probably be involved in the encoding and storage process.
similar to those of associative learning. There is In Alzheimer patients, degeneration of nucleus
a critical time period during which the content coeruleus cells has been observed. In animal
of a memory can be moved from short-term to experiments long-lasting stimulation of the
long-term memory. This critical time period is nucleus coeruleus in aging mice led to an
determined by the duration of the change in inhibition of the forgetting of a shock avoidance
gene expression. After LTP, the so-called response, which would otherwise occur because
immediate early genes are altered and subse- of the aging process. These results suggest that
quently late genes are activated that lead to a memory processes depend on the interplay of
permanent synaptic modification by transport several transmitters in specific brain regions,
of the newly synthesized gene products from the primarily in the cortex, hippocampus, and
nucleus to the cell membrane. This could be the limbic regions.
structural basis of long-term memory. Just like the neurotransmitters, centrally as
Except for protein biosynthesis, no single well as peripherally injected peptides modulate
substance or class of substances has been shown memory functions. They all seem to have an
to have a causal influence on memory. This indirect influence; none of the peptides that
suggests that memory can be coded in a number have been examined so far are necessary
of synaptic and cellular processes that all lead to preconditions for learning and memory pro-
the same final result: long-term changes in the cesses: vasopressin, ACTH, and somatostatin
firing rate of a cell assembly. Whereas central enhance learning and encoding, endorphines
catecholamines seem to have a minor role in and oxytocine have negative influences. Angio-
learning and memory, peripheral catechola- tensin, cholecystokinin, and substance P inter-
mines seem to play an important role in the fere with encoding if they are directly injected
consolidation of memories. For example, into the central nervous system.
lesions of the medulla of the adrenal gland lead Opioid peptides and low doses of morphine-
to a severe reduction of peripheral noradrena- containing substances lead to forgetfulness;
line and concurrently to severe amnesias. The naloxone and opioid antagonists improve
activation of b-adrenergic receptors on the encoding in various tasks. This memory-
central or peripheral level by emotional stimuli enhancing effect may be related to the inhibition
seems to have a strong influence on retrieval of catecholaminergic receptors by the opioids
from long-term memory. If the b-adrenergic and the blockade of the facilitatory effect of
receptors are blocked (e.g., by propanolol), noradrenaline, dopamine, and acetylcholine.
retrieval of emotional but not neutral events Naloxone also prevents retrograde amnesia
from memory is severely disturbed at a later related to electric shock which is accompanied
point in time (Cahill, Prins, Weber, & by a massive output of beta-endorphine and
McGaugh, 1994). methionin-enkephaline.
Acetylcholine seems to play an important role The high concentration of glutamate in the
in learning. There are several cholinergic hippocampus and neocortex suggests that this
Motivation and Motivation-related Disorders 147
amino acid has an important role in consolida- ditioning, and (iii) incentive salience, objects
tion processes. It is not clear if the increase of and behaviors that were associated with
glutamate receptors and the correlating growth reinforcement become more prominent (ªsali-
of dendritic spines following long-term poten- entº) than other stimuli, capture more atten-
tiation of the hippocampus plays a causal and tion, and motivate approach or avoidance
specific role for memory processes. The use of behavior.
glutamate to increase learning and memory has
so far not shown consistent results. Although 1.05.9.2 Hunger and the Eating Disorders
Alzheimer's disease is related to a marked
reduction of CNS glutamate (60%), treatment Hunger is one of the homeostatic drives.
efforts that influence glutamate metabolism Under physiological conditions, a reduction in
have so far not shown consistent results. blood glucose concentration serves as signal for
hunger. The glucosensors are located in hy-
pothalamus, brainstem, and liver. Upon the
1.05.9 MOTIVATION AND MOTIVATION- ingestion of food, hunger ceases fairly rapidly
RELATED DISORDERS (short-term presorptive satiety), whereas the
1.05.9.1 Introduction ingestion of food is terminated only when the
blood glucose levels have again reached their
The term motivation is used to describe an predetermined level (long-term resorptive sati-
internal state of the organism that modulates the ety). Classical conditioning usually plays an
frequency and intensity of behavioral responses. important role in motivating food intake. Social
Motivational states may be based on innate and environmental stimuli such as dinner time,
drives or may be induced by acquired drives. taste and appearance of food, or persons present
Some drives follow homeostatic principles: they at dinner determine the time and the amount of
are less dependent on environmental influences food ingestion much more than physiological
and the learning history of the individual but are factors. Taste and odor cues serve an important
rather elicited by deviations from the internal function in the selection and ingestion of food
homeostasis of the body (e.g., hunger, thirst). (e.g., taste cues increase appetite despite
They show stable levels of attainment that complete reduction of hunger (Carlson, 1991;
motivate a stereotypical sequence of behaviors Legg & Booth, 1984). In addition to glucostatic
if they are exceeded or not attained. Non- factors, thermostatic (food intake proportional
homeostatic drives (such as sexuality, explora- to changes in temperature) and lipostatic
tion) show variable levels of attainment and mechanisms (food intake proportional to the
deprivation times that are highly determined by metabolism of lipoproteins) have been discussed
learning processes and other environmental (Carlson, 1991).
variables (such as availability, incentive). Be- Presorptive satiety is determined by the
havior is determined by drives as well as activation of odor, taste, and mechanoreceptors
reinforcement. Whereas drives provide the in the otolaryngeal cavity and trachea as well as
ªenergyº for a certain behavior, stimuli that by chewing. Additional factors are pressure-
increase the probability of the occurrence of a sensitive receptors in the stomach and the colon
response are termed reinforcers, and stimuli as well as chemoreceptive vagal afferents from
that reduce the probability of the occurrence of the stomach and upper colon that respond to the
a response are termed punishing stimuli. glucose and amino acid content of food.
Reinforcement is the increase in response Resorptive satiety is determined by chemor-
probability in the presence of a discriminative eceptors of the digestive system as well as all
situation by the delivery of reinforcing stimuli enteroreceptive sensory processes related to
subsequent to a response. Drives and reinforce- hunger feelings. The enhanced glucose avail-
ments are based on different neuronal sub- ability, enhanced heat production as well as
strates. changes in lipid metabolism, activate central
In addition to drive reduction, incentive receptors that signal satiety. Gastrointestinal
motivation plays an important role in the hormones are also important in the generation
instigation of goal-directed behavior: after some of long-term satiety. For example, cholecysto-
reinforcing trials not only the drive but also the kinin, a neuropeptide, leads to satiety probably
reinforcement will move the behavior in a mediated via cholecystokinin receptors in the
specific direction. Incentive motivation is deter- ventromedial hypothalamus. Based on the
mined by (i) the neuronal substrate for glucostatic model of hunger and satiety, the
reinforcement that is activated by behavioral activity of the lateral hypothalamus (LH) is
consequences, (ii) the emotion related to viewed as a signal for hunger and the
reinforcement which is associated with ventromedial hypothalamus (VMH) is viewed
reinforcement-related stimuli via classical con- as important for satiety. Both centers are
148 Psychobiology
assumed to be reciprocally inhibitory. The Appetitive behavior involves ªinvitationº to

lateral hypothalamus seems to serve the func- approach and to mount, changes in posture,
tion of a glucostat and inducer of hunger. An erection, and the emission of sounds. Appetitive
increase in glucose levels inhibits LH activity, behavior is disorganized when the cortex is
activates VMH, and initiates satiety. Destruc- removed, whereas copulatory behavior (intro-
tion of the VMH leads to overeating and mission, orgasm) does not depend on the
obesity. The VMH and its connections to the neocortex. Orgasm involves ejaculation (male)
paraventricular nuclei of the hypothalamus and and contractions of the pelvic muscles and
the efferent vagal nuclei as well as to the nucleus vagina (female) or the penis and the pelvic
tractus solitarius seem to code taste as nutri- musculature (male).
tionally adaptive and maladaptive. The limbic In humans, the sexual responses of both sexes
system and associated cortical structures as well are fairly similar. Women usually need a longer
as the motor system are also involved in the appetitive (plateau) phase to attain orgasm and
planning of food intake, probably via catecho- most men have an absolute postcopulatory
laminergic fiber systems that connect the brain (refractory) period: subsequent erection and
stem, cerebellum, basal ganglia, and cortex. The ejaculation is only possible after a certain
search for food is probably instigated by recreational phase.
neurons in the lateral hypothalamus that are The sexual response of the male is initiated by
connected to motor regions by dopaminergic erection which is caused by dilatation of arteries
fiber bundles. to and in the corpora cavernosa, the corpus
Eating disorders such as anorexia or bulimia spongiosum urethrae, and the sinusoids of the
are primarily caused by cultural and psycholo- corpora cavernosa via the activation of post-
gical variables (see Volume 6). Biological ganglionic parasympathetic neurons. These
variables are, however, important in the course neurons are activated by afferents from the
and maintenance of these disorders since dieting penis and surrounding tissue and, in addition,
is followed by serious biological sequelae. by supraspinal (cortical) structures via psycho-
Ongoing dieting leads to major disruptions of logical mechanisms. In addition to vasodilation,
the endocrine system, especially the pituitary± the venous reflex from the corpora cavernosa is
adreno±cortical axis. The regulation of sexual reduced by venous constriction; both mechan-
and reproductive functions is disturbed. Re- isms lead to vasocongestion. The sacral spinal
versible reductions of brain mass have also cord is the locus of the erectile reflex. Strong
occasionally been reported which are associated activation of afferents from the sexual organs
with negative consequences such as psycholo- leads to the activation of sympathetic afferents
gical disorders and ongoing weight problems by in the lower thoracic and lumbar spine. This
30% of patients. Biological and hereditary sympathetic activation then provokes the
factors of metabolic rate seem to be much more release of semen and fluid into the internal
important in obesity than in other eating urethra. Following this emission, ejaculation is
disorders. However, dieting also has negative initiated by afferent activation from the prostate
consequences in the case of obesity where the and the internal urethra in the pelvic nerves.
lost weight is regained and maintained at a Both sympathetic and parasympathetic neurons
higher than prediet level (Carlson, 1991), to the sexual organs show maximum activation
referred to as ªcycling.º during ejaculation. The sympathetic afferents
cause tonic±clonic contractions of the pelvic
musculature and erectile tissue, causing fluids
1.05.9.3 Sexual Function and the Sexual and semen to be expelled via the external
Disorders urethra.
The female sexual response is characterized by
1.05.9.3.1 The sexual response
a venous blood occlusion and vascular dilation
Four phases of sexual activity can be of the labia majora and minora. Glans and
differentiated: sexual attraction, appetitive corpus clitoris swell and increase in size and
behavior, copulatory behavior, and postcopu- length due to parasympathetically induced
latory behavior. They have to be synchronized vasocongestion. Just as in the male, both
during sexual activity between the involved afferents from the genital region (especially
partners and they are based on clearly differ- the clitoris) and supraspinal inputs lead to these
entiable neuronal and hormonal mechanisms. changes. Within 6±30 s after stimulation (affer-
Sexual attraction and all other phases of ent or supraspinal), lubrication of the vagina
sexual behavior are influenced by the androgen ensues in sexually mature females and formation
levels of the male and the estrogen levels of the of an ªorgiastic cuffº in the outer third of the
female in most species. Odors, posture, and vagina. The ªorgiastic cuffº contracts during
color changes contribute to sexual attraction. orgasm and this activity can be compared to
emission and ejaculation in the male. The uterus very distant from the hypothalamus or they act
changes to an erect and enlarged position and like transmitters at the synaptic cleft where they
contracts during orgasm. exert a tonic modulating influence on neuronal
Some persons with complete spinal cord excitability. All sex hormones are regulated by
lesions show erection, lubrication, and orgasm luteinizing hormone releasing hormone
when the sexual organs are stimulated but all (LHRL), also called gonadotropin releasing
sexual sensation from the genital region is hormone (GnRH), which is excreted by several
absent. These patients report, however, ªphan- hypothalamic and extrahypothalamic cell sys-
tom sensationsº that are independent of tems. LHRH stimulates the excretion of
peripheral stimulation. luteinizing hormone (LH) and follicle stimulat-
ing hormone (FSH) from the anterior pituitary.
Whereas dopamine and serotonin have an
1.05.9.3.2 Sexual differentiation and sex
inhibitory influence, noradrenaline has an
hormones
excitatory influence on the LHRL cells in
The development of a male or female hypothalamus. Estradiol and progesterone
organism is determined by the male reproductive reaching the CNS via the blood system increase
cells in sperms: if they contain a Y chromosome and testosterone decreases its release.
the organism will be male, if they contain an X LHRH is bound to the cells that release LH,
chromosome, the organism will be female (all FSH, and prolactin. Only rhythmic pulsative
ova have X chromosomes). Up to the eighth LHRH activity will lead to hormone release
week of pregnancy the organism is dimorphic; (every 3±4 h except for the first phase of the
only after this period the sex hormones deter- menstrual cycle, where women release hormones
mine if the organism will have male or female sex every 90 m). LH and FSH stimulate the growth
organs. In humans, weeks 12±22 of pregnancy and transformation of the follicle n the ovaries
and the first six weeks after birth are periods that and the production of estrogen; in the male they
are sensitive for androgens. During prenatal maintain spermatogenesis and the production of
development, the androgens also act on the CNS testosterone. In the male organism, they are
and create the gender-specific differences in the released at a constant level: testosterone inhibits
hypothalamus and the limbic system, among LHRH (negative feedback). Environmental
others. This androgen action on the brain also stimuli (e.g., anticipation of sexual activity)
seems to determine later sexual preferences influence FSH and LH release.
(hetero-homo-bisexualism). In the female organism, LH and FSH are
If an XY chromosome is present, precursors released in a cyclic pattern: increase of estrogen
of the testes form in the seventh and eighth week leads to increase of LH and FSH release in the
which produce androgens (e.g., testosterone) first phase of the menstrual cycle. When the
that are essential for the formation of a male follicle grows in the first days of the cycle,
organism. If androgens are lacking, a female estrogen and progesterone slowly increase, on
organism will develop. Secondary gender char- day 12 on average LH production steeply
acteristics (such as a beard in the male, or increases (because of a positive feedback circle
breasts in the female) develop in puberty when of estradiol on LH and FSH). This burst causes
the hypothalamus begins to produce precursors ovulation (about 24 h later). The follicle then
of the gonadotropic hormones that excite the releases the ovum and the remaining follicle cells
release of estrogens and testosterone via increase progesterone synthesis. The follicle
luteinizing and follicle stimulating hormones turns into the corpus luteum and releases more
of the pituitary gland. These secondary changes progesterone and estradiol. This positive feed-
can be partially altered in later life if sex back circle is followed by negative feedback: the
hormones are withdrawn or added. Hermaph- increase of progesterone leads to LH and FSH
roditism denotes a disorder where the internal or inhibition, estrogen and progesterone release is
external sexual organs are malformed and terminated around day 24 when LH and FSH
consequently no clear gender assignment can release decrease further. Menstruation follows
be made. when the mucosa of the uterus loses vitality
owing to progesterone reduction.
The influence of the sex hormones on
1.05.9.3.3 Hormonal basis of sexual behavior
behavior is less powerful in humans than in
Regulation of the sex hormones depends on other mammals. Appetitive and copulatory
the activity of hypothalamic cells that excrete behavior is maintained after ovarectomy and
peptides into the local circulation and through castration if prior learning of sexual behaviors
neural pathways or via the pituitary gland into has taken place. Castration after puberty has
the systemic circulation. These peptides either only delayed effects on sexual activity (slow
act as hormones and bind to receptors often decline) and is reduced if prior sexual experience
150 Psychobiology
is present. Contraceptives that suppress the drives, excitability of moto neurons, the fight±
rhythm of hypothalamic, pituitary, and ovarial flight response, reproduction, aggression, and
hormones do not influence appetitive and territoriality. The anterior hypothalamus has
copulatory behavior, whereas testosterone le- been identified as the region that integrates the
vels have a stronger influence on sexual appetite various sex-related reflexes into a goal-oriented
in the female than estrogens. behavior pattern.
Amenorrhea (cessation of menstruation) is In the male, cutaneous mechanoreceptors of
often related to psychological factors that the penis have an important role in the
suppress LH increase but may also be related induction of copulatory behavior. If both
to physical factors (e.g., lack of nourishment in destruction of olfaction and social isolation
anorexia) or diseases such as tumors of the are present, male sexual behavior is suppressed
pituitary. Intake of LHRH suppresses LH and in the rat. In the monkey, the medial preoptic
FSH release and induces reversible castration region is essential for copulatory behavior.
in the male (e.g., for treatment of tumors of the Additional important modulators of male
prostate or in sexual delinquency). In the male, sexual behavior are the frontal and somatosen-
the normal level of available testosterone is sory cortex and the basolateral nucleus of the
usually unrelated to sexual behavior. However, amygdala. The so-called KluÈver±Bucy syndrome
if a certain level of testosterone (5 350 ng/l) is in the monkey (tameness and hypersexuality)
lacking, impotence may occur and may be which occurs after removal of the temporal lobe
corrected by substituting testosterone. Help- and the amygdala is probably related to the loss
lessness and depression reduce, and anticipa- of inhibitory input of the amygdala on the
tion of sexual activity increases, testosterone medial preoptic region of the hypothalamus.
production. Female sexual behavior is likewise coordi-
PheromonesÐsubstances that are secreted by nated by hypothalamic structures in concert
an organism and influence the other organism's with lower reflexes: the medial preoptic region
behavior via the sense of smellÐhave important of the hypothalamus inhibits and the ventro-
consequences on partner selection, sexual medial nucleus facilitates the lordosis reflex in
behavior, and pregnancy in rodents. Their role the female rat. The hypothalamic efferents and
in human sexual behavior is less clear. the somatosensory afferents converge in the
central gray of the midbrain and the dorsolat-
eral reticular formation. The basic hormonal
1.05.9.3.4 Neuronal mechanisms of sexual
level (primarily estrogens) determines to a large
behavior
extent the strength of the hypothalamic influ-
Most research on neuronal mechanisms of ence. It thus has a priming function on the entire
sexual behavior is based on research in rodents. chain of behavior, whereas the individual motor
The applicability of these findings to human and vegetative elements depend on spinal
sexual behavior is questionable. Within the reflexes.
same organism two different neuronal networks
for male and female sexual behavior exist: this
1.05.9.3.5 Influence of sex hormones on the
sexual dimorphism seems to be a universal
brain
characteristic of all organisms. The apparent
behavior of the organism results from the Androgen- and estrogen-sensitive cell sys-
inhibition and/or excitation of the respective tems have been identified in the hypothalamus
networks. Thus both sexes are ªrepresentedº in and the limbic system. Their growth depends on
the brain (Swaab & Hofman, 1995). the amount of peripherally available hormone
In both sexes, the hypothalamus is the central levels. Axons and dendrites of these cells are
regulating structure controlling sexual behavior modified by androgens and this leads to
in concert with sensory and motor reflexes in the anatomical differences of these structures in
genitals, the autonomic extraspinal ganglia and men and women. This might be related to the
fibers, and spinal reflexes. Cortex and limbic often reported advantages of verbal vs. spatial
system exert a modulating influence, primarily abilities in the female vs. male sex and the
on the hypothalamus. The hypothalamus func- increased plasticity with respect to verbal
tions as both a neuronal control center and defects in the female. Creative musical talent
secretory organ. The limbic system, the hy- has been associated with profiles of sex
pothalamus, and their most important afferents hormones that resemble those of the opposite
and efferents are all structures with a high sex. Despite these prenatal sex hormone
content of sex hormones. This system has also influences on gender differences, cultural and
been referred to as the paracrine heart of the social factors are paramount.
neuraxis since it has a central function in the The interaction of hormonal influences and
regulation of homeostatic and nonhomeostatic sexual behavior in humans is best studied by the
analysis of disorders in the endocrine glands homosexuality which seems to have a preva-
that occur pre- or postnatally. The androgenital lence of about 5% in men and 2±3% in females
syndrome is based on excessive release of male across cultures.
hormones in the fetal stage of development. As a In animals (e.g., rats), sexual preference has
consequence, the external female organs be- been modified in the pre- and postnatal phase by
come male (penis but not testes develops) even if altering the action of male or female hormones.
the organism is chromosomally female, based For example, extreme stress of the mother often
on the sex chromosomes, and has internal leads to androgen suppression in the male fetus
female organs. These genetically female children (Bailey, Willerman, & Parks, 1991). Although
have been raised as males and have developed these rats develop external male sexual organs,
attraction to females in the postpubertal phase they show female copulatory behavior. If female
because of brain masculinization. In some cases rats are prenatally exposed to androgens, the
(especially if the external genitals were not well reverse behaviors occur. A genetic component
formed) these women were treated postnatally also seems to be relevant for homosexuality: the
to reduce virilization and their external genitals X chromosome of some homosexual males
were surgically corrected; their later sexual seems to have specific markers for homosexu-
orientation remained, however, ªmaleº: 48% ality in the 928 region (Le Vay et al., 1995). This
were reported to be bisexual and 17% homo- assumption is substantiated by the observation
sexual (compared with 2±5% among females in that children who are raised by homosexual
general). Prenatal masculinization of the brain couples do not show an increased prevalence of
is obviously sufficient to induce lifelong changes homosexuality, thus rendering the role of
in sexual orientation. environmental factors unlikely. Defense reac-
In the androgen-insensitivity syndrome, a tions of the maternal immune system against
genetically determined insensitivity of the androgens of the male fetus have also been
androgen receptors at the androgen effector implicated in the development of ªfemale
cells, leads to external female sexual organs in a brainsº in male bodies.
genetic male. These children are usually raised The common final path of these influences
as females and reportedly show average hetero- seems to be the hypothalamus. Male and female
sexual behaviors (i.e., they prefer males as sex brains show the most pronounced differences in
partners). In male hermaphroditism a lack of this structure. It is, however, not clear if these
androgen production in a genetic male leads to alterations are really at the basis of differences
undefined external sexual organs. These chil- in sexual orientation. Dimorphic regions of the
dren are, therefore, often raised as males or hypothalamus are not fully developed by the
females, independent of their genetic gender. If postnatal period; rather, the sexually dimorphic
raised as girls, these genetic males accept men as nucleus of the preoptic region can only be
sexual partners. differentiated between the sexes at age four and
In 5-a-reductase-deficit disorder, a genetic there are substantial anatomic and neurochem-
defect leads to lack of the enzyme 5-a-reductase ical alterations in this structure in puberty and
which transforms testosterone to dihydrotes- in later age. It is therefore likely that some
tosterone, which is responsible for development gender differences in the brain may not relate to
of the external male sexual characteristics. This different brain development but to differential
defect does not, however, influence brain cell death of brain regions in the sexes. The
development. Thus, a ªmale brainº is found vasopressin-containing subnucleus of the nu-
in a ªfemale bodyº in a chromosomally male cleus suprachiasmaticus was found to have
organism. In the first generation, the children twice the size in homosexual as compared with
were raised as female, when it became clear that heterosexual males, whereas no reduction
masculinization set in during puberty, the next (demasculinization) of the sexually dimorphic
generation of children was raised as males with nucleus of the preoptic region was observed. In
less behavior problems than the first generation transsexuals, similar deviations have been
ªmachoº and often lesbian females (Money, observed (LeVay, 1996).
1987). Thus, brain development seems to have a
more substantial influence on sexual orientation 1.05.9.4 Acquired Motivation and Substance-
than environmental influences and reinforce- induced Disorders
ments of sexual behavior.
The substance-induced disorders with their
accompanying addictive behaviors are a ªmod-
1.05.9.3.6 Brain processes and homosexuality
elº for acquired motivation which yielded
Homosexual behavior seems to be primarily important information about the neuronal
dependent on hormonal changes in the brain. mechanisms of drives and incentives. Although
This statement refers to primary (exclusive) a genetic risk has been proposed for the
152 Psychobiology
addictions, they reflect primarily learned beha- exhaustion. Stimulation of the lower structures
vior patterns that are determined by psycholo- in the midbrain (the periventricular system) had
gical and biological factors. Although an opposite effect: the animals attempted to
psychosocial factors may play the most im- prevent any kind of electrical stimulation. Olds
portant role in the development of the addic- therefore called those centers pleasure or
tions (see Volume 6), their maintenance is punishment centers. Persistent ICSS can be
strongly determined by learning and central elicited from many subcortical and cortical
nervous system variables. regions: the optimal regions in the rat are the
The positive and negative reinforcing proper- descending medial forebrain bundle, the lateral
ties of substances and the time course of their hypothalamus, and the frontal cortex. Preferred
intake are important determinants of addiction. sites of self-stimulation are those fibers of the
Whereas previous definitions of substance- medial forebrain bundle that lead from the
induced disorders focused mainly on the lateral hypothalamus to the posterior and
phenomenon of tolerance (reduction of the ventral tegmentum. Those sites coincide to
efficacy of a drug over time related to some extent with the dopamine system. The
pharmacokinetic (metabolic), pharmacody- dopaminergic fibers from which intracranial
namic (receptor-related) mechanisms, and with- self-stimulation can be elicited are mainly
drawal symptoms), current formulations ascending in the direction of the forebrain. This
(American Psychiatric Association [DSM-IV], includes the part of the medial forebrain bundle
1994) focus more on compulsive drug seeking that leads to the nucleus accumbens as well as
and craving as determinants of drug abuse the ventral tegmental bundle, the posterior
(Robinson & Berridge, 1993). medial forebrain bundle, and the capsula
interna, which have connections to the caudate
nucleus, the putamen, and the amygdala. Thus
1.05.9.4.1 The neurobiology of addiction
the dopamine system seems to be the common
The psychobiological basis of drug abuse and final path of the descending medial forebrain
drug dependence has been well established. bundle±lateral hypothalamus system and of
ImportantÐalthough not necessaryÐcharac- endogenous opiate cells. Neuroleptics block this
teristics of dependence are the development of final common path of the positive incentive
tolerance and withdrawal symptoms with re- system and lead to anhedonic behavior by
peated drug usage. Tolerance refers to the reducing incentive salience of reinforcing as-
decrease in efficacy of a drug with repeated pects of the environment.
administration and has been related to both In humans, rather than complete anhedonia,
pharmacokinetic and pharmacodynamic pro- reduction and blunting of positive affect and
cesses. Pharmacokinetic tolerance is based on reduced incentive motivation seem to be the
the increased availability and efficacy of drug- consequence of the intake of neuroleptics.
metabolizing enzymes that lead to enhanced Whereas dopaminergic neurons seem to be
absorption of the drug into the blood stream. related to the energizing incentive motivational
Pharmacokinetic tolerance is related to changes aspects of positively motivated behavior, the
at the receptor level, for example, dopamine endogenous opiates seem to be important for
receptors of limbic cells. Both tolerance and the the positive affective tone of reinforcing stimuli.
development of withdrawal symptoms are This effect of the endogenous opiate system is
related to neuroadaptive processes whose mo- probably primarily related to the inhibition of
lecular bases have been described to some extent noxious inputs. Opiate receptors are primarily
(Di Chiara, 1995; Self & Nestler, 1995). A located close to the pain-processing centers in
structure of special relevance for the develop- the central nervous system. They modulate pain
ment of addictive behaviors is the mesolimbic perception in the dorsal horn of the spinal cord
dopamine system. This system seems to be the over the periaquaductal gray (where descending
final common path of the positive reinforcement pain inhibition can be elicited) to the thalamic
system of the brain that was discovered by Olds relay stations for painful stimuli in the amyg-
and Milner (1954) in their experiments on dala, the temporal cortex, as well as the
intracranial self-stimulation. striatum, where they end in ascending dopami-
nergic neurons. The high addictive potential of
the opiates is probably based on this aversion-
1.05.9.4.2 Learned motivation and addiction
reducing effect.
In 1954, Olds and Milner first showed the The development of tolerance and the
phenomenon of intracranial self-stimulation increase of incentive motivation are based on
(ICSS) (Olds & Milner, 1954). The implantation intracellular sensitization and neuroadaptation.
of electrodes in the septum led rats to self- It is assumed that the increase of incentive
stimulate at a very high rate up to complete motivation and incentive salience after the
intake of drugs is related to a sensitization to excessive transcription and channel activa-

process of the mesolimbic dopamine system and tion. The dopaminergic system becomes over-
that tolerance and development of dependence reactive and this leads to abstinence symptoms
are related to an intracellular process of (Robinson & Berridge, 1993). In general, the
neuroadaptation. The positive reinforcing value increase of positive reinforcement (euphoria)
seems to be elicited by the binding of dopamine and incentive salience after repeated drug intake
to D2-dopamine receptors or opiate receptors and the activity of the dopaminergic system are
(especially m- and d-receptors). They activate G- parallel processes (American Psychiatric Asso-
proteins that lead to reduced adenylyl cyclase ciation, 1994). The courses of wanting and
activity, reduced cAMP, and reduced cAMP liking in the development of an addiction are
protein kinase. G-proteins directly regulate K+ not necessarily parallel. Whereas drug wanting
and Ca2+ channels. The reduced cAMP- may increase with repeated drug intake, the
dependent protein kinase activity leads to euphoria and positive effects of the drug may
reduced phosphorylization of proteins that slowly decrease. Figure 4 shows an integration
regulate neuroexcitability such as ion channels, of the most important systems and processes for
enzymes, and receptors. The infusion of sub- the development of liking and wanting, based
stances that activate protein kinase block on the theory of Robinson and Berridge).
positive reinforcing effects (Sp-cAMPS); inhibi- The contiguous pairing of CS and US leads to
tion of protein kinase increases reinforcement their associative connection (primarily in cor-
by blocking phosphorylization of the proteins tex); the strength of the associative connection
that are necessary for excitation of the nerve. also depends on comparison with similar stored
In the course of chronic drug intake, the contents. The direction of the attention towards
cAMP system is adjusted at a higher level in a a certain stimulus is guided by this memory
compensatory fashion in order to compensate process. Activation of the dopaminergic in-
for cAMP reduction by the drugs and to centive system and the positive reinforcement
guarantee normal excitability of the cells. This system is also determined by current drive
leads to systematic changes in gene expression states. Drugs can stimulate each of the two
of the proteins that are important for excit- systems, the positive reinforcement system and
ability and could explain the long-term effects of the incentive system directly and independently,
incentive motivation, while cAMP reduction is which means that wanting and liking can be
an immediate effect of the direct (with ICSS or separated. Drugs do have joint effects (cross-
amphetamin) or indirect (e.g. with food) tolerance), specific psychophysiological effects,
positive reinforcement. It is assumed that that also determine the course of the depen-
persons (or animals) who have a genetically dency. The term cross-tolerance denotes the fact
higher risk for the abuse of substances show a that the adaptation to certain substances (e.g.,
molecular structure of the dopaminergic cells morphine) also leads to tolerance towards
which is similar to that of persons who are another substances (e.g., alcohol), although
already dependent. In those persons, externally one does not have ever to have used this drug.
ingested substances have a weaker effect and Some of the endogenous opiate systems are in
have to be ingested at a higher level. Tyroxine a close functional relationship with the dopa-
hydroxilase (TH) synthesizes dopamine (DA) minergic positive reinforcement structures. The
and binds to dopamine receptors that are euphorizing (reinforcing) effect of exogenous
coupled to G-proteins and neurofilaments and endogenous opiates seems to be related to
(NF). The neurofilaments transport gene pro- the sensitivity and increased excitability of
ducts from the axon to the synapse. The cAMP- positive reinforcing structures rather than to
dependent protein kinases (PKA) modify the tolerance and withdrawal symptoms. The
ion channels and stimulate the transcription identification of neurochemical mechanisms
factors (e.g., CREB, c-fos). The nucleus ac- for reinforcement, tolerance, and withdrawal
cumbens (NAc) that projects back to the VTA is complicated by the fact that we have at least
also has connections to the basal ganglia, three endogenous opiate systems with at least
especially the ventral pallidum (VP), and the four types of receptor classes. Each of these
hippocampus (HP) and receives projections three systems and receptors could be related to
from the amygdala (AMYG), the olfactory and different behaviors that occur during addiction.
gustatory system (Olf), and the cortex. After It is, however, clear that cells show compensa-
repeated intake of cocaine or morphine in an tory intracellular processes when they bind their
animal, a dopaminergic cell is extremely easily receptors with externally added opiates. With-
conditionable to drugs: now the VTA cells and drawal leads to a sudden loss of these
its axon have shrunk, less dopamine is synthe- compensatory effects and counter-regulation
sized and released. Adenylyl cyclase and cAMP leads to an overshoot of the compensation. In
show a compensatory elevation and PKA leads alcoholism, the unconditioned dependence
154 Psychobiology
subjective
wanting
CS
incentive salience – wanting, liking
environ- incentive attraction
evaluation and assignment: dopamine
mental CS
dopamine system and cortex system
stimuli cortex intake
reinforces
associated learning and comparison physiological drive:
with past contents: cortex hypothalamus
subjective
positive
UCS positive liking
positive reinforcement system feeling
biological stimulus enjoyable
descending reinforcement system
stimuli cortex pleasant
affective
reactions
Figure 4 Comprehensive model of the development of addiction. Bottom: development of pleasure; top:
development of craving. Biologische Psychologie, by N. Birbaumer and R. F. Schmidt, 1996, New York:
Springer. Copyright 1996 by Springer. Reprinted with permission.
(neuroadaptation) seems to be at least partially that seem to be cross-culturally invariant (Ek-

mediated by opiate receptor binding: during man & Davidson, 1984). Moods are longer-
oxidation of alcohol in the liver by the enzymes lasting response tendencies towards certain
alcohol dehydrogenase and aldehyde hydro- emotional states. Emotional states or feelings
genase, aldehyde metabolites reach the central are usually short-lived, rarely exceed more than
nervous system where they create condensation a few seconds, and are characterized by specific
products together with central monoamines muscular responses of the facial muscles with a
which form alkaloids that have a morphine-like high communicative value as well as specific
structure. These products (tetrahydro-isoqui- approach±avoidance patterns. Moods, by con-
nolone, TIQ) act as ªfalseº transmitters and trast, tend to influence cognitive processes
bind to the opiate receptors. This distorts the rather than elicit motor responses.
opiate neuroadaptation that has been described Based on the work of Lange, William James
above. proposed that the conscious experience of an
Nicotine seems to stimulate nicotinic choli- emotion is dependent on the physiological
nergic receptors at low levels; at higher levels the changes we perceive from the periphery of
cholinergic receptors are blocked and relaxation our body. Thus the James±Lange theory of
occurs. Nicotine also activates the production emotion proposes that we ªfeel sorry because we
of catecholamines and serotonin in the brain cry, angry because we strike, afraid because we
which probably leads to increased attentional trembleº (James, 1890). In contrast, the
levels. The blockade of nicotinic cholinergic Cannon±Bard theory (Cannon, 1929) suggested
receptors by mecamylamine reduces smoking, that emotions were not characterized by a
but leads, however, to very significant side specific peripheral physiological response pat-
effects. These neurobiological principles should tern and could therefore not be detected based
be taken into account when addictions are solely on the peripheral response. This theory
treated. based the source of the emotion in the brain and
considered it as a result of the perception and
interpretation of emotion-inducing events in the
1.05.10 EMOTION AND THE higher nervous system. This latter view is
EMOTIONAL DISORDERS correct: the stimulation of specific brain regions
1.05.10.1 Introduction leads to the experience of specific primary
emotions. It is, however, likely that peripheral
Emotions are behavioral responses to either input also contributes to the experience of an
aversive or appetitive stimuli that are charac- emotion. The work of Ekman and Lang and
terized by responses on the verbal-subjective, their colleagues suggests that very specific
the motor-behavioral, and the physiological peripheral physiological patterns are related
level. Emotions vary along the two basic to the primary emotions (Ekman, 1984).
dimensions of valence (positive±negative) and Related to this theoretical controversy is the
arousal (arousing vs. calm). Several primary question, to what extent does cognition precede
emotions (fear, anger, surprise, disgust, emotion or to what extent emotions are primary
happiness±joy, sadness) have been identified and are only followed by cognitions? The great
Emotion and the Emotional Disorders 155
emphasis on cognitive processes in clinical is necessary for the interpretation of contextual

psychological models of emotional disorders cues, whereas the lateral nucleus of the
in the 1970s and 1980s made this question very amygdala governs the conditioned response.
pressing (Lazarus, Kanner, & Folkman, 1980; If the central nucleus is destroyed, motor,
Zajonc, 1980). Schachter and Singer (1962) autonomic, and endocrine CRs are abolished.
showed in a number of experiments that Lesions of the septum and hippocampus lead
emotional states that were artificially induced to reduced exploratory behavior in novel
(e.g., by adrenaline) and could not be explained situations, reduce orienting to expected (but
by the subjects were readily attributed to the not unexpected) aversive stimuli, facilitate
situational cues that were presented to the avoidance and escape behavior, and disturb
subjects. These results were taken as evidence passive avoidance. Both peripheral sympathetic
that cognitive variables (attributions) are pri- and central noradrenergic systems act in concert
mary and the specific peripheral activation when intense stressors have to be dealt with.
pattern is secondary in the interpretation of an Noradrenaline seems to have a nonspecific
emotion. There is, however, evidence that activating function on the neocortex and
emotions may develop irrespective of conscious increases the signal-to-noise ratio, thus leading
evaluations of the situation. For example, to increased attention to intensive stimuli
subliminal perception experiments or experi- (Cameron, 1994). The noradrenergic fibers
ments with masked stimuli suggest that emo- are organized into a dorsal bundle (periven-
tions may be evoked by these stimuli although tricular, originating in the locus coeruleus),
they are not consciously perceived (LeDoux, which runs to the cortex and hippocampus, and
1995; OÈhman & Birbaumer, 1993). Aversion to a ventral bundle (tegmental, not originating in
odors or tastes can also be conditioned in an locus coeruleus) which runs to the amygdala
anesthesized state. and the septum. Destruction of the dorsal fibers
does not affect learning but selectively prolongs
extinction in animals. In this case the filtering of
1.05.10.2 Fear and Anxiety and the Anxiety irrelevant materials is disturbed and passive
Disorders avoidance behavior is maintained. In humans,
the findings on regulatory dysfunctions of the
1.05.10.2.1 Avoidance, fear, and anxiety
noradrenergic system are much more contro-
The learning of anxiety and fear responses versial. Instead of a general hyper-reactivity of
has been well described in psychology textbooks adrenergic systems, a specific dysregulation
(Birbaumer & OÈhman, 1993) and will not be seems to be present that is specific for the
reviewed here. In accordance with modern various anxiety disorders. For example, in
theories of learning (Rescorla, 1977), it is post-traumatic stress disorder, marked increases
important to note that fear conditioning is in peripheral autonomic responses (e.g., heart
stimulus, not response, conditioning: the CS rate, startle response) have been found in
acquires the ability to drive brain systems that general, and especially during confrontation
activate a defense response that is well estab- with the traumatic event (Lang, Bradley, &
lished in cerebral networks. Animal experiments Cuthbert, 1993). In panic disorder, clonidine, a
have shown that the cortex is not needed in the noradrenergic agonist, leads to a paradoxical
learning of a conditioned emotional response: inhibition of the release of growth hormone
obviously the thalamo±amygdaloid connection (GH) from the pituitary gland, whereas in
is sufficient to establish a conditioned fear healthy controls noradrenaline leads to an
response. Destruction of the amygdala will increase in GH release. It is assumed that
eliminate the conditioned emotional response long-lasting NA release has led to excessive
(Mackintosh, 1974). levels of NA in the hypothalamus, which have
The cortex is, however, needed for differential reduced the sensitivity or number (downregula-
conditioning where higher order interpretation tion) of postsynaptic a2-adrenoreceptors. The
of the stimulus is important and for the subjective improvement of the anxiety attack
extinction of a conditioned response. Both the that follows clonidine is in accordance with the
primary sensory and the medial prefrontal hypothesis of reduced sensitivity of central
cortex, which is closely connected to the receptors.
amygdala, are needed for extinction. The
amygdala thus plays an important role in the
1.05.10.2.2 Startle reflex modulation and fear
acquisition of fear. The instrumental mainte-
nance of fear seems, however, to be mediated by The startle reflex is a fast, protective, reflex
the septo-hippocampal system which regulates response of the muscular system to loud noise or
the expectancy of safety signals and selective other intensive surprising stimuli. In humans,
motor avoidance responses. The hippocampus activation of the muscularis orbicularis oculi
156 Psychobiology
can be measured by electromyographic record- have anti-epileptic effects. Since the benzodia-
ings about 30±50 ms after a 95±110 dB loud zepines do not have a specific effect on anxiety-
noise was presented. The amplitude of the related neuronal networks, they cannot effec-
startle response is influenced by the emotional tively reduce anxiety and sleep disorders on a
valence of stimuli that are presented concur- long-term basis, although they do have bene-
rently with the startling noise: fear increases, ficial short-term effects. In addition, they show a
positive emotions decrease the response (Lang substantial addictive potential. Barbiturates,
et al., 1993). This affective modulation of the benzodiazepines, and alcohol seem to inhibit
startle response occurs independently of atten- the behavioral inhibition system selectively and
tion and activation but is related to the response may thus selectively influence conditioned but
disposition of the organism: if the organism is not unconditioned fear responses of the passive
geared toward approach, the reflex is inhibited, but not of the active avoidance type. They do not
avoidance and escape facilitate it since motor influence approach behaviors. This is in accor-
responses need to be interrupted when new dance with the finding that phobias respond well
stimuli are presented which require immediate to benzodiazepines, whereas obsessive-compul-
action. Reflexes that have an approach char- sive disorders respond badly to them. The
acter such as the closure reflex of the hand or the necessity of cortical involvement in the extinc-
foot show reverse modulation (Davis, Hitch- tion of fear suggests that pharmacological
cock, & Rosen, 1991; OÈhman & Birbaumer, reduction of fear may not be indicated when
1993). long-term reduction of fear and anxiety, for
The brain structures and neurotransmitters example by behavioral treatments such as
involved in modulation of the startle response confrontation, is desired.
have been well studied in the rat. Whereas the
amygdala is essential for the potentiation of
fear-induced startle response in rats, the nucleus 1.05.10.3 Sadness, Depression, and the Affective
accumbens, an incentive and reinforcement Disorders
structure, shows an inhibitory influence on
1.05.10.3.1 Sadness and depression
fear-potentiated startle (Koch & Bubser, 1994).
The medial prefrontal and the orbitofrontal Sadness is a basic negative feeling that
cortex primarily inhibit fear during extinction accompanies separation and the loss of attach-
and mediate delay of reinforcement based on ment that is interculturally relatively invariant.
expectancies. The medial septum and the Depression is a complex mixture of feelings that
hippocampus are activated during stimulus contains sadness, but also disgust, anger, rage,
discrimination and passive avoidance of fear hostility, fear, guilt, and shame. Thus, depres-
stimuli. sion is always related to a multitude of
Measurement of the startle response has psychological, social, and biological factors.
proven to be an important instrument in The focus of this section will be on the biological
differentiation of the emotional valence of preconditions of depression.
emotional stimuli. The valence of the condi- Sadness and depression are clearly distinct
tioned stimuli (positive, negative, neutral) from other feelings not only in subjective
determines the potentiation of the startle experience but also in electromyographic and
response, whereas the arousal of a stimulus electrodermal responses. In addition, the ex-
determines changes in skin conductance level pression of different feelings is different in
(Lang et al., 1993). healthy and depressed persons. In electroence-
phalographic recordings, the induction of
negative or depressive moods has been found
1.05.10.2.3 Psychopharmacology of fear and
to correlate with a right frontal activation, but
anxiety
PET studies suggest that the left amygdala and
Benzodiazepines such as diazepam (Valium) the left prefrontal cortex show increased
are effective inhibitors of anxiety and bind to metabolism. This increase in blood flow in
GABA (gamma amino butyric acid) receptors fronto-limbic areas could result from the lack of
prevalent in the limbic system. Benzodiazepines activity in the positive reinforcing dopaminergic
inhibit anxiety by binding to the benzodiaze- mesocortical connections that are usually
pine receptor which regulates (together with inhibitory and could have caused overactivity
the GABAa receptor) Cl7 influx into the cell. in the frontal cortex and the amygdala. If one
The Cl7 influx into the cell is enhanced when assumes that the left hemisphere and the
the benzodiazepine receptor is activated and amygdala show more dopaminergic activity
this increases the hyperpolarization of the cell. during depressed emotions and more activation,
This explains why benzodiazepines are not only this could lead to an increased inhibition on the
generally relaxing and soothing but why they left side and an elevated activity in the
electrocortical measures in the right frontal lobe hand, reduction of the number of receptors is
(Davidson, 1993). associated with a compensatory increase of
The psychological factors that are important activity of the remaining b-receptors.
in depression and bipolar disorders are reviewed Tricyclic antidepressants lead to a reduction
in Volume 6. As in other chronic disorders, of the synthesis and the metabolism of
genetic predisposition may play an important noradrenaline and serotonin by increasing their
role especially for bipolar affective disorders. availability in the synaptic cleft. The noradre-
Twin studies as well as adoption studies suggest nergic cells fire at a lower level and MHPG in
increased rates of concordance in biological blood and urine is lower. During mania,
relatives of depressed patients. Studies of however, a clear increase of noradrenergic
circadian rhythms in depressed patients suggest activity has been found that is reduced by
that the endogenous clock may be accelerated. lithium. In depressed patients, but also in
Days and weeks before a depressive episode, obsessive-compulsive patients, a lack of sensi-
desynchronizations in temperature periodicity tivity of the presynaptic a2 autoreceptors seems
are found. The circadian temperature curve is to be present. These suppress noradrenaline
flattened or completely irregular. The release of release when noradrenergic cells are active.
growth hormone is reduced. The amount of When the autoreceptors are blocked, more
REM sleep increases, the amount of slow wave transmitter is being released. If the receptors are
sleep decreases, the entire sleep period becomes underactive, less noradrenaline is released. The
shorter, frequent awakening, especially in the reduction and subsensitivity of the a2 auto-
morning, occurs. REM latency is shortened, receptors could, however, also be the conse-
probably due to a low slow wave sleep pressure quence of increased noradrenaline and
(see Section 1.05.7). Sleep deprivation tends to serotonin activity in depression.
improve depression the following day. Persistent stress seems to increase central as
well as peripheral noradrenaline. Long-lasting
stress and helplessness lead to a central loss of
noradrenaline (Peterson, Maier, & Seligman,
1.05.10.3.2 Neurochemistry of depression
1993). This would coincide with the monoamine
The effectiveness of antidepressant medica- theory of depression, but not, however, with an
tions has been based on their ability to increase overabundance of noradrenaline. Some of these
the availability of noradrenaline and/or ser- controversies could be resolved if one considers
otonin in the synaptic cleft. The monoamine the dynamic course of action of antidepressants
theory of depression has, however, not been and the dynamic course of coping with stress. In
substantiated: substances that do not directly depression and after uncontrollable stress, the
affect the noradrenergic and serotonergic activity of cells with b-adrenergic receptors in
system are also effective in treating depression the brains of animals seems to be low. If
(e.g., lithium). Post mortem analyses of depres- demands are addressed to the individual that
sive persons show no changes in noradrenaline need energy-mobilizing coping behavior, net-
or serotonin content, the precursor of nora- works that are connected to noradrenergic
drenaline synthesis, the enzyme dopamine-b- systems cannot sufficiently respond (learned
hydroxylase is unchanged, and the metabolites helplessness). In contrast, successful coping
of central noradrenaline (MHPG) and seroto- with stress (immunization) or treatment with
nin (5-HIAA) are also not reduced in depressed antidepressants leads to increased activity of
patients. Thus, either mechanisms other than postsynaptic cells with noradrenergic receptors
the increase of the aminergic transmitters in the on their postsynaptic membranes. Since b-
synaptic cleft must be assumed or neurotrans- adrenergic receptors are widely distributed in
mitters other than noradrenaline and serotonin the brain and can coexist with other receptors
cause changes in these substances as a secondary on the same neuron, the chronic intake of
effect. antidepressants or successful stress manage-
Antidepressives lead to a loss of noradrener- ment can increase the reactivity of serotonergic
gic b2 and a2 receptors. The clinical effect of and dopaminergic cell systems. The reduced
improvement in depression seems to be asso- number of b-adrenergic receptors after anti-
ciated with the speed of reduction of receptor depressant treatment or after stress manage-
binding and not with the increased availability ment with a concurrent increase in the activity
of noradrenaline and serotonin. Depressions of b-adrenergic cells is probably related to a
could, therefore, also be caused by too much desensitization process of the b-adrenergic
availability of central noradrenaline and only membrane. An initially increased noradrenergic
the destruction of postsynaptic noradrenergic activity due to stress or antidepressant intake
receptors by the drugs (this lasts usually days or leads to reduction in the number of b-receptors.
weeks) improves the depression. On the other The receptors that remain, however, increase
158 Psychobiology
their efficacy manifold, which improves the living and inanimate objects. It is assumed that
information processing and distribution of the amygdalae regulate the hypothalamic
these cells. aggression structure via the stria terminalis.
The so-called KluÈver±Bucy syndrome where the
destruction of the anterior temporal lobe leads
1.05.10.4 Aggression and Aggression-related to tameness and hypersexuality in the rhesus
Disorders monkey seems to be related to destruction of
1.05.10.4.1 Development of aggression the amygdala and loss of the temporal lobe.
The integrity of normal social interaction in
In animals, several subtypes of aggression primates and humans seems to be dependent on
such as between-male, between-female, fear- intact structures and connections of the amyg-
induced, maternal, and sexual aggression have dala, temporal lobe, and prefrontal cortex.
been identified. All subclasses of aggression can These three structures are anatomically con-
be reduced to two environmental events: (i) the nected by extra- and intrathalamic connections.
presentation of aversive, painful stimuli and (ii) The anterior cingulate gyrus seems to play a
the withdrawal of positive stimuli (frustration). central role. The amygdala, the posterior
If aggression or fear/flight are elicited by certain orbitofrontal cortex, and the anterior cingulate
stimulus configurations, this depends on eva- gyrus receive input from all higher sensory
luation of the stimulus configuration; neuronal cortex areas and project themselves again to the
structures that are involved in these emotions higher motor and premotor areas. Their con-
are overlapping. nections with the reinforcing structures there-
Aggressive behavior is not a homeostatic fore predestine them for the analysis and
drive but primarily a learned behavior whose adequate response to the social meaning of a
probability of occurrence is also influenced by situation.
constitutional and hormonal factors. The The anterior cingulate gyrus seems to be
heredity of aggressive behaviors of male mice, necessary for the generation and maintenance of
for example, is about 0.3±0.5 (with a maximum energy for attention. Its destruction leads in
of 1) based on selective breeding experiments. humans to akinetic mutism, where patients no
The variance related to environmental factors longer speak and if asked indicate that they have
varies therefore between 50 and 70%. The no energy since nothing is of any meaning to
genetic transmission for aggressive behavior in them. Lesions of the orbitofrontal cortex
humans is not known: the concordance rates of frequently cause pseudopsychopathy and a loss
mono- and dicygotic twins seems not to be of social responsibility. The effects of lesions of
different, which suggests that the hereditary the amygdala, the cingulate gyrus, and frontal
component is not important. The idea of cortex show that the associative connection of
localization of an aggression gene on the male peripheral physiological input and the evalua-
Y chromosome has not been supported, nor has tion of a situation is of central significance for
the relationship between crime and the existence emotional experience since the association is
of an XYY gene configuration in men been formed in this high-level social vegetative
substantiated (Rose, 1995). muscular regulation system. Persons with
epilepsy of the temporal lobe frequently show
emotional disturbances and psychiatric com-
1.05.10.4.2 Neuronal basis of aggression
plications especially if the right anteromedial
The localization of aggressive behavior in one temporal regions that are closely connected to
or a few brain structures is not possible owing to limbic structures are impaired.
the heterogeneity of aggressive behavior within
and between the species. Some important brain
1.05.10.4.3 Hormonal basis of aggression
areas for aggression have, however, been
identified. Stimulation of the amygdala usually Hormones can have an activating or organiz-
leads to fearful behavior in both humans and ing influence on aggressive behavior. Adult
animals, but frequently also to aggression. The animals who have already been involved in
lateral and medial hypothalamus seem to be fights no longer need testosterone to maintain
integrating structures for aggressive behavior. their rank. Without the presence of androgens
Stimulation of the lateral hypothalamus leads in the fetus and in the postnatal phase the
to prey aggression and stimulation of the neuronal connections that are needed to form
medial hypothalamus to affective aggression. aggressive behavior do not develop. In the
Stimulation of the dorsal hypothalamus leads hypothalamus and septum of certain strains of
to flight or fear aggression. Experimental mice, androgen- and estrogen-sensitive neurons
lesions in the cortico-medial part of the amyg- have been found that are correlated with various
dala can lead to extremely aggressive attacks on types of aggressive behavior.
Castration during puberty seems to inhibit sions of the right hemisphere often lead to
postpubertal increases of aggression. In general, emotional indifference or euphoric disinhibi-
testosterone seems to influence the development tion, lesions of the left hemisphere may lead to
of intermale aggression; other types of aggres- catastrophic reactions with severe depression.
sion seem to be less sensitive to variations in In the interpretation of these results it is
testosterone levels. Aggressive behavior seems important to consider that lesions of one
to be also related to cholinergic activity: hemisphere may result in a disinhibition and
anticholinergic drugs suppress aggressive at- thus overactivation of the other hemisphere.
tacks in mice almost completely. Long-lasting Emotional expression is impaired after lesions
learned helplessness leads to endorphine- in right frontal cortex, emotional recognition
mediated analgesia and immune suppression, and discrimination after right posterior lesions.
as well as inhibition of the production of In right parietal lesions the existence and
androgens. Animals that lose in fights also show consequences of disease and/or emotional
opiate-induced analgesia. contents are often denied (sensory and emo-
tional neglect), and emotional expression fades
or is inadequate. Electroconvulsive treatment
1.05.10.4.4 Psychopathy for depression is significantly more effective
Psychopaths are persons who repeatedly when applied to the right rather than the left
commit antisocial aggressive acts without being hemisphere. By contrast, a left-sided Wada test
impressed by punishment or negative conse- leads to a depressed state. For the Wada test a
quences. They seem not to show any remorse or sedative drug is injected in the right or left main
guilt following antisocial activities, however, brain artery, putting the respective hemisphere
they are usually intellectually capable of under- to sleep. The sensitivity of the right hemisphere
standing their behavior as well as its con- for negative feelings is also supported by the fact
sequences. In general, psychopaths seem to be that aversive stimuli such as pain or unpleasant
characterized by reduced autonomic respond- odors primarily activate the right and positive
ing in situations that usually elicit fear. In stimuli primarily activate the left hemisphere.
passive avoidance situations, psychopaths are In depressive disorders, increased right-
often impaired since they are unable to suppress frontal activation has been reported, and for
behaviors that have previously been punished. mania, increased left-frontal activation. Since
Rather they continue to execute punished motor activity and control of right-handers are
sequences, indicating an inhibitory behavior regulated predominantly by the left hemi-
deficit (lack of fear). Consequently, adrenaline sphere, right-hemisphere overactivation leads
and amphetamine seem to improve the behavior to difficulty in controlling verbal and motor
of sociopathic persons, and barbiturates and behaviors. This is supported by the fact that
alcohol can increase psychopathic behavior. In left-handers and ambidextrous persons often
a series of studies, Patrick (1994) has shown that show emotional, verbal, and psychosomatic
fear potentiation of the startle reflex is absent in disorders. Dyslexias and allergies as well as
psychopaths. Lesions in the orbitofrontal cortex hyperactivity and irritable bowel syndrome are
lead to a pseudopsychopathic state that is more frequent in left-handed persons who have
related to a lack of delay of reinforcement and a larger corpus callosum with more fibers and a
an inability to learn from punishment or the larger right hemisphere. This has been asso-
lack of reinforcement. Therefore, psychopathy ciated with a larger influence of testosterone
might be related to deficits in both the amygdala during development which facilitates growth of
and the orbitofrontal cortex. the right hemisphere and inhibits growth of the
thymus gland (immune competence) in animal
experiments.
1.05.10.5 The Neocortical Hemispheres and
Emotion
1.05.10.6 Behavioral Medicine: Application of
Differences between the right and the left the Psychophysiology of Emotion to
hemispheres have mostly been discovered in Disease
split-brain patients or in patients with specific
lesions of the right or the left hemisphere during Behavioral medicine is an interdisciplinary
presentation of tasks that force the unilateral field concerned with the integration of beha-
processing of information (e.g., dichotic listen- vioral and medical knowledge in the prevention
ing, fixation). Usually, there is continuous and treatment of disease with a strong focus on
exchange between the hemispheres with the left behavioral intervention methods. One of the
hemisphere playing an important role in the most important intervention methods in beha-
interpretation and attribution of causes. Le- vioral medicine is biofeedback treatment where a
160 Psychobiology
biological signal is recorded, amplified, and gyrusÐwhich caused a so-called sensory or

subsequently converted to a sound or visual receptive aphasia; patients could speak but had
signal which can be perceived by the patient. difficulty in understanding what was told them.
Thus the control over physiological processes Wernicke developed the concept of the regula-
that function normally outside our conscious tion of language that is still valid today: the
awareness becomes possible. Biofeedback treat- connections of the primary auditory area to the
ment has been used to successfully influence upper posterior temporal lobe (Wernicke's area)
chronic pain, epilepsy, scoliosis and kyphosis, and from there to the lower posterior frontal
and Raynaud's disease, among others lobe (Broca's area). He also introduced the term
(Schwartz, 1995). Biofeedback follows the ªdisconnection syndromeº by postulating spe-
principles of operant learning. It is so far not cific deficits if the connections between these
known to what extent control over autonomic three areas were interrupted. His student Hugo
function is possible without involvement of the Liepman described a right-handed patient who
muscular system which is under voluntary showed an apraxia of the left hand (inability for
control. The curarization experiments by Miller voluntary movement) subsequent to a lesion of
(1978) and his colleagues designed to address the corpus callosum. The patient also showed
this issue yielded controversial results, but agraphia on the left side (inability to write). In
supported in general the notion that operant post-mortem studies it was shown that the
conditioning of autonomic function is possible. corpus callosum had been destroyed. Liepman
The self-regulation of brain potentials without concluded from this case that (i) commands for
the alteration of peripheral physiological vari- left-sided movements had to be transferred by
ables also favors this interpretation. the corpus callosum to the right hemisphere and
(ii) the left hemisphere was not only relevant for
language but also for complex learned move-
1.05.11 COGNITIVE PROCESSES AND ment. This second postulate is supported by the
COGNITIVE DISORDERS fact that apraxias occur predominantly after
1.05.11.1 Introduction left-hemispheric lesions. Subsequent to these
lesions, complex voluntary movements cannot
Cognitive functions are all conscious and be correctly performed even after much train-
nonconscious processes that occur during the ing. These apraxias are also called ideomotor
processing of information from within or apraxias. It is, however, known today that
outside the organism, for example, encoding, planning, initiating, and execution of voluntary
comparison with stored information, distribu- movements can also be initiated in the right
tion of information, decoding, and language. hemisphere. The so-called constructive apraxias
The focus of this section will be on the occur after lesions of the right hemisphere: the
neurobiological foundations of these processes. deficits that occur here relate, for example, to
the construction of puzzles, drawings of clock-
1.05.11.2 Functions of the Cerebral faces that can no longer be performed, and
Hemispheres drawings and model buildings that can no
longer be constructed. Apraxias can, however,
The term cerebral asymmetry denotes the also occur after lesions of the basal ganglia and
finding that the functioning of both neocortical the thalamus.
hemispheres is an important prerequisite for the In the twentieth century, a counter localiza-
regulation of various behaviors and mental tion position was strongly formulated by Karl
functions. Although the right and the left Lashley who introduced the principle of
hemispheres usually have a synergistic action equipotentiality. Lashley postulated that spe-
in most higher cognitive functions, there is cific brain centers were not important for
hardly any response where one of the two learning and memory but the mass action of
hemispheres of the brain would not have a several areas of the brain was important. The
certain advantage compared with the other. larger the lesion, the stronger the defect. The
Although the idea that the two hemispheres position that is taken today is a combination of
subserve different cognitive functions origi- the two views: certain cognitive processes such
nated in antiquity, it was Paul Broca who as language or motor commands are relatively
provided empirical data to substantiate the dominant in one of the hemispheres, other
different functions of the two cortical hemi- cognitive processes are not specialized to certain
spheres. Broca found that persons with aphasias brain regions.
all had lesions in the left frontal hemisphere. Sperry's work on split-brain preparations in
Shortly after, Karl Wernicke published his cats and monkeys and later a split-brain analysis
observations on patients with left posterior in patients with complete resection of the corpus
lesionsÐespecially the superior temporal callosum have made important contributions to
Cognitive Processes and Cognitive Disorders 161
this question (Sperry, 1952, 1964). A number of nection of efferents from areas 17, 18, or 19 in
influences on sensory processing have been the corpus callosum with additional disruption
revealed in split-brain patients. If the anterior of connections to the temporal areas leads to
commissure and the corpus callosum are blindness, despite preserved optic systems. In
separated, odors from the right nasal mucosa addition to apraxia of the left side of the body,
can no longer be named since the olfactory tract agraphia of the left hand to verbal commands
is uncrossed. The right hemisphere can, how- and acopea (an inability to copy writing and
ever, use the left hand to choose between objects drawing) of the right hand, tasks that require a
of different odors. The right hemisphere is more cooperation of fine motor movements of both
strongly activated by odors from the right hands are impaired. The few-split brain patients
nostril than from the left. who have expressive language in the right
Although the auditory tract is only partially hemisphere suggest that the left hemisphere is
crossed, dichotic presentation of words leads to rather sequential, analytic, and causal, and that
a preference of the right ear. Sounds presented the right is more holistically oriented with rather
to the right ear are no longer moved to the left parallel and intuitive processing.
hemisphere in split-brain patients, but simple In new-born babies a preference of left
instructions can also be understood from the hemispheric processing of language (e.g., right
right hemisphere. Objects that are not viewed in ear) can be detected in dichotic listening tests
the right visual field cannot be described, and in elevated amplitudes for evoked poten-
although the right hemisphere can correctly tials for language on the left side. However, left
identify them (disconnection agnosia). hemispheric lesions lead to compensatory
Tactile discrimination of the hands cannot be uptake of language functions by the right
transformed from the secondary somatosensory hemisphere up to the 10th year of life. Complete
cortex of the contralateral to the ipsilateral side. compensation seems only to be possible in the
This means that learned tactile discriminations first years of an individual's life. Obviously
remain localized in the hand of the contralateral there is an innate predisposition for the
hemisphere. Separate presentations of visual localization of language on the left side. New-
contents to the right and left visual fields have born babies already have a larger left-sided
shown that the right hemisphere is dominant in planum temporale which is the region that lies
the analysis of visual spatial patterns and within the Sylvian fissure behind the auditory
manipulative spatial tasks. Although the right cortex. In adults, the left planum temporale is
hemisphere is in almost all patients expressively about 2 cm longer than that of the right side.
aphasic, drawings are only copied correctly by The better a language has been learned, the
the left hand. Geometric figures are recognized smaller the cortical area that is needed to
better when they are projected to the left visual produce a certain language performance. This
field and geometric and tactile tasks are also holds at least for cortical blood flow in PET and
solved better by the left hand. The right fMRI studies: the second less well-learned
hemisphere is dominant in face recognition, language has significantly larger increases of
but not, however, in tasks where the faces are blood flow on the right and the left hemisphere.
semantically categorized. The presentation of Women have less activation of blood flow
chimeric stimuli leads to separate completions of during language processing than men.
the entire picture in each hemisphere, although In addition to the genetically determined
all patients report seeing one unified picture. anatomical preconditions for laterality, audi-
The sequential lesion of various fiber bundles tory experience during development seems to be
including the posterior corpus callosum and the a central influencing factor for its development:
anterior commissure in monkeys showed all the language-deprived children, that is, children
brain structures that are involved in visual who had very little external stimulation to
discrimination. Visual information leaves area speak, and are therefore also impaired in
17 via areas 18 and 19 (visual memory), then speaking, show less left lateralization in dichotic
crosses to the contralateral side and runs on listening tests similar to persons who are born
both sides of the lower temporal lobe and from deaf. The perception and motor regulation of
there to the amygdala and the orbitofrontal sign language seem, however, to be primarily
cortex (emotional and motivational signifi- left-dominant which depends on the superiority
cance). Here again a transfer between both of the left hemisphere for sequential informa-
sides takes place. This tract is therefore called tion processing as well as its dominance for
the what-pathway compared with the upper complex and learned movements.
parietal connection which has been termed the The Wada test has been used as an assessment
where-pathway (Mishkin & Ungerleider, 1982). instrument for the analysis of dominance. This
Unilateral lesions of these systems have few test is used before neurosurgical operations to
consequences in the monkey; however, discon- diagnose the dominance of one hemisphere.
162 Psychobiology
Usually a narcotic agent (sodium amytal) is preferred activation of the left fetal vestibular
injected into the carotid artery. This leads some organs and thus the right hemisphere during
minutes later to ipsilateral anesthesia of the pregnancy. The hypothesis of preferred stimula-
entire hemisphere. For the left hemisphere there tion of the left vestibular organ and the right ear
is usually complete right-sided paresis and during pregnancy attempts to explain a number
global aphasia. Some 96% of right-handed of differences in lateralization: for example, that
and 70% of left-handed persons have language women have a superior ability in verbal fluency
localized on the left side and 4% of right-handed (left hemispheric function) but have on the other
persons have language localized on the right side a less well-developed ability for spatiogeo-
side; 15% of left-handed persons have a bilateral metric tasks which are solved better by men.
language localization based on the Wada test. Lesions of the left hemisphere lead equally often
The relationship between laterality and to aphasias in men and women, although within
handedness is positive but far from perfect. the hemisphere women tend to be aphasic and
The localization of language is in humans apractic rather after anterior, men rather after
usually a much better predictor of an anatomic posterior lesions. In most studies on healthy
organization than hand preference. Left-hand- persons, women were less lateralized in all tasks
edness is usually not related to an improved than men, which suggests that a strong later-
ability of the right hemisphere for expressive alization does not necessarily mean better
and receptive language; however, left-handed performance. All the differences between the
people often show less language problems after performance of the left and right hemisphere we
left hemispherical lesions. Although the causes have named could be based on a joint
for left-handedness are not clear, there seem to anatomical difference, the more variable and
be two groups of left-handers: one group with a therefore flexible intracortical communication
strong genetic component and a second group of the left hemisphere.
where left-handedness may be the consequence Lateralization of cognitive functions may
of pre- or postnatal brain damage of the left depend on anatomical differences between the
hemisphere with a subsequent compensation of two hemispheres. Left±right differences have
the right hemisphere. The first group is not not only been found in different areas of the
intellectually different from right-handers, ex- cortex, for example, Broca's and Wernicke's
cept for a certain increase of musical and artistic regions, but also in subcortical areas, for
talents among left-handers. example, in the thalamus. These differences
Tactile tasks that require the recognition of are not only on a macroscopic level, but are also
forms and figures seem to be solved better by the visible on a microscopic level in the neuroa-
left hand in right-handers if the material is natomy of individual neurons, for example, the
presented in a static manner. In the case of size of the soma of a pyramidal cell or the
sequential presentation the right hand makes structure of their dendritic branches, implying
less mistakes. The asymmetry of information that neuroanatomical differences lead to func-
processing is complemented by an asymmetry of tional differences (Kolb & Wishaw, 1995;
the planning and execution of movement: Springer & Deutsch, 1993).
although the left hemisphere is dominant in
right-handers in learned skill tests (thus aprax- 1.05.11.3 Evolution and Neurophysiology of
ias are often correlated with aphasias), we move Language
the head and the eyes more to the right side
when we solve verbal problems, when we solve For thousands of years language has been
spatial problems we move more to the left. considered as a typically human achievement
Simultaneous speaking interferes more with that separates humans from animals, especially
activities of the right hand, the humming of the primates. However, it has been shown that
melodies interferes more with the left hand. differences between human and animal lan-
There seems to be an interaction of left guage are quantitative rather than qualitative.
dominance for motor activity and preferred The increase in speed and the heightened
cognitive processing style. variability of the exchange of neuronal com-
There is some convergent opinion that the munication in the human cortex seems to be a
preference of the right hand in about 75% of precondition for the achievements of human
humans has to do with the upright gait of language as a means of communication.
humans. The preference for the right side of the Vocal language seems to have begun only
body is already present at birth. Hand preference about 60 000 years ago, and written symbols
develops later than the superior ability of the have been found from up to 30 000 years ago.
right hemisphere to process visuospatial tasks. Language could have developed out of non-
The lateralization of visuospatial functions in verbal communication: gestures as well as vocal
the right hemisphere might be caused by the sounds are generated primarily in the left
hemisphere, and both functions are lost when When a child learns that certain word forms
lesions of the left parietal cortex occur. Emo- always occur in certain contexts (at about the
tional sounds and expressions that can, for age of 2±4 years), this leads to the simultaneous
example, be observed in primates, are less likely activation of cell assemblies in many cortex
to be the beginning of language: emotional areas (e.g., with respect to a drinking glass:
sounds are difficult to be conditioned in order to visual for glass, tactile for touching the glass,
be used as signs; gestures, however, can also be gustatory for taste, etc.) Cell groups are
conditioned in primates. Emotional expression activated that are then the assembly for the
seems to be primarily a frontal and basal ganglia content word that represents an object or an
phenomenon in human as well as in primates. action (nouns, verbs, and adjectives). Depend-
Nevertheless, the development of language has ing on the associative context of the word,
begun from gestures and the increasingly perfect certain brain areas are activated in an assembly
control of the facial musculature. Gross move- that can be assessed by d-band EEG activity.
ments of the body could have been replaced by For example, verbs elicit more motor associa-
subtle movements of the lips and the tongue tion and substantives elicit more visual associa-
(Crosson, 1992). tion. This is visible in g-band oscillations that
The acquisition and use of language can be are more pronounced in the occipital cortex for
explained by associative connections of pho- the nouns and more pronounced in the frontal
neme, word, and sentence assemblies of cortical cortex for the verbs.
and subcortical neuronal assemblies. The neo- The neuronal basis of function words (how,
cortex may beÐespecially in its associative it, is, etc.) that have syntactic functions and are
areasÐviewed as a large associative storage not associated with specific environmental
area. The storage of words, sentences, and stimuli seems to be the left perisylvan region.
syntax is part of the functions of both hemi- When semantic errors occur in a sentence, an
spheres. Like the visual cortex, the auditory event-related brain potential is detectedÐ
cortex also has hierarchically built interconnec- usually a strong negativity (around 400 ms)Ð
tions of neurons that range from simple to whose location in the brain seems to vary with
hypercomplex and that respond selectively to the location of storage of the respective word.
various aspects of sound: individual cells answer During syntactic errors, late positivities in the
preferentially to certain frequencies, the begin- left perisylvic regions (around 600±800 ms) seem
ning and the end of sounds and phonetic to occur or late frontal negativity.
characteristics of syllables (ba, pa) and con- It is, however, not clear to what extent those
sonants (b, g). Many neurons that represent such event-related potentials are language specific or
simple aspects are interconnected to higher- to what extent they reflect the excitatory
order assemblies if they are frequently excited thresholds in semantic or syntactic cell assem-
together. With respect to the language lexicon, blies as has been described before. N400 and
therefore, assemblies of phonemes are built that other negativities after surprising events seem to
are characterized by different properties. These indicate a new readiness state of the brain region
coupled phonetic networks are connected dur- with new search processes for strategies to solve
ing development by further associative connec- problems. It is, however, possible to see from the
tions to syllables and word forms. For example, context of a language task based on the event-
certain cells in the upper temporal cortex show a related potential whether a word or part of a
very characteristic frequency when a word is sentence has been detected as right or wrong,
acoustically presented, since the same cell is part when this happens in the brain, and at what
of a different cell assembly based on the type of location. This can be used for lie detection: the
word that was presented. cortical lie detector is a higher positive wave
Neonates are already more sensitive to (P300) to words or objects compared with
syllables of the mother tongue than to control similar control stimuli only the perpetrator
syllables in the pre- and postnatal phase. can know. If the sequence of the crime is known
Between the sixth and the 12th month of life, and test stimuli are well presented, the event-
syllables that are heard and last about 200 ms related potentials can lead to very high lie
(auditory cortex) are frequently repeated (in- detection quota of 90±100% which are much
ferior frontal cortex) and are thus associatively higher than lie detection based on skin con-
interconnected to transcortical syllables and ductance readings.
later to phonetic assemblies. These articulations During imagery of an object, all those brain
lead, of course, also to proprioceptive stimuli areas are activated that are also active during its
from the articulatory musculature that activate perception. The sequence of the activation
an inferior parietal assembly and are thus seems, however, to be reversed: where the real
connected to an entire assembly in the perisylvic visual stimulus first activates area 17 (primary
region. visual area) and then the extrastriatal area,
164 Psychobiology
especially area 18, imagery first activates area 18 that are close to the left perisylvic regions,
and only afterwards area 17. The time course is, sometimes also lesions in the right
however, comparable to real perception: evoked hemisphereÐthis aphasia is characterized by
potential changes in area 18 are already visible minor language deficits, deficits that are char-
about 200 ms after the beginning of an image. acterized by semantic paraphrases and disor-
Blood flow changes as measured in PET and ders in naming objects;
MRI are in general in the same region as the (v) transcortical aphasias that are character-
perception occurred; however, the retrieval of ized by deficits in language production and
visual contents from memory leads to PET language understanding or both capabilities
activation, especially in the left temporal and are based on lesions in most of the left
parietal, right parietal, and bilateral frontal area perisylvic area;
cortex which occurs in addition to the activation (vi) conduction aphasias which show a
that occurs during perception (Farah, 1995). strong disorder in the ability to repeat words
The frontal activation which is also visible in with lesions in the fasciculus arcuatus;
EEG is probably related to the activation of (vii) subcortical aphasias which show an
working memory. The left perisylvic brain initial mutism and subsequent paraphasias.
region is always necessary during imagery if it An acquired inability to understand written
is language related. language is called alexia. Alexias occur with and
without agraphia, based on localization of the
lesion in the brain tissue. Alexia without
1.05.11.3.1 Language disorders
agraphia and aphasia seems to be a disconnec-
We will not describe language disorders in tion syndrome where the connections from the
detail but rather discuss their neurobiological right visual association cortex through the
basis. Aphasias are language disorders that corresponding language area in the left gyrus
occur in humans who have already learned a angularis are interrupted. Alexias with agra-
language. The cause is usually an ischemic or phias usually show an isolated lesion in the left
hemorrhage-related cerebrovascular insult, a gyrus angularis. Agraphias occur very fre-
tumor, encephalitis, or trauma. All language quently together with aphasias. They can,
modalities are usually disturbed. Although however, also be assessed independently which
lesions of the left hemisphere usually lead to points towards partially separated brain struc-
aphasias, right-hemispheric processes are also tures with regulation of both functions. Lesions
involved in language processing. Aphasias also in several, often widely different brain regions
occur in subcortical lesions of the white matter, can cause disorders of writing, which is under-
the basal ganglia, or the thalamus. These standable with respect to the complexity of
subcortical aphasias with initial mutism are writing which involves semantic, visual, spatial,
usually quickly reversible. The cortical aphasia- and motor functions.
causing lesions are usually situated in areas
close to the Sylvian fissure: Broca's region 1.05.11.4 The Association Areas of the
(Brodmann's areas 44 and 45) and Wernicke's Neocortex
region (area 22) can be differentiated.
All aphasias include disturbances in the In a simplifying manner, the three large
naming of objects, the production and under- associative areas of the cortex could be
standing of sentences, reading, and writing. The connected to the three main psychological
currently most widely used aphasia test, the so- functions: whereas the temporal lobe with its
called Token Test, examines to what extent a limbic connections seems to subserve primarily
patient is able to perform manual manipula- memory functions, the frontal cortex seems to
tions with a number of colored sheets. Almost regulate motor and motivational behaviors, and
all aphasics show deficits in this test. the parietal association cortex seems to be the
The following aphasia syndromes are clini- basis of sensory and cognitive function. The
cally significant: posterior striatum is, however, also an impor-
(i) Broca's aphasia, where language produc- tant part of parietal function because it provides
tion problems are predominant; an indirect subcortical connection specifically to
(ii) Wernicke's aphasia, where language per- prefrontal regions.
ception problems are predominant;
(iii) global aphasia, where the entire perisyl-
1.05.11.4.1 Parietal cortex
vic region is lesioned and where both language
production and language understanding are The parietal cortex with its multisensory
severely incapacitated; integration function therefore has an important
(iv) amnesic aphasia, which is usually based role as a command center for structuring
on lesions of the gyrus singularis or other areas movements that are directed towards a goal
of motivational meaning. The large number of lesions of the right parietal lobe, the disorder of
cognitive disorders related to lesions of the the recognition of known faces including one's
parietal region is based on its central anatomical own in the mirror, however, depends on
role between the three modalities of vision, bilateral occipital±parietal lesions. Contralat-
hearing, and somatic sense which provide the eral neglect occurs especially after lesions of the
parietal lobe with information. The posterior lower right parietal lobe. The person no longer
parietal lobe with the gyrus angularis, the gyrus responds to visual tactile and acoustic stimuli
supramarginalis, and the upper parietal lobe is contralateral to the lesion (usually the left side
disproportionally large on the right hemisphere of the body). The person also reports no
in humans. This seems to be related to spatial contents of this side and never orients towards
information processing and the regulation of this side if new stimuli are represented. Neglect
goal-directed movement in space. The efferents can be viewed as a spatial perceptual disorder or
of the posterior parietal cortex project to the an attention disorder. That the perception is
frontal and temporal association areas, thala- disorganized is suggested by the neglect of the
mus, striatum, midbrain, and spinal cord. In left side independent of attention. If the
addition to afferents from the three primary and patients, for example, are to view the square
secondary projection areas, the parietal lobe in front of the dome of Milano, they only report
also receives input from the lateral and posterior about the right side of the dome during
thalamus and hypothalamus. perception as well as during imagery. If a
Engrams for reafferent motor and visuoki- patient, however, changes his or her location so
netic spatial functions are localized in the that the left visual field now receives the
parietal cortex. The copying of movements previously neglected side of the dome, the
and gestures is disturbed after left parietal patient now reports in reality as well as in
lesions, and spatial activity related to drawing is imagery the previously ignored part of the
disturbed after lesions of the right hemisphere. dome. The representation of the external object
A number of lesions lead to disturbances, which is obviously lost depending on the local frame of
inhibit the initiation, planning, and execution of reference of the person.
complex and goal-directed movement sequences The parietal cortex seems to be part of a
in left-hemispheric ideomotor apraxia. The widely distributed cortical±subcortical atten-
sequential spatial functions of the left parietal tional system. The multimodal, parietal, and
region need to be separated from the perceptive superior±temporal association areas have the
functions of the right parietal region. Visual- task of comparing incoming excitatory patterns
perceptual skills are, for example, the recogni- with stored ones and to extract from them the
tion of visual objects, the synthesis and significance of the pattern. Whereas temporally
comparison of visual objects, line orientation, the ªwhatº of objects seems to be analyzed, the
drawing of lines, and recognition of weights. parietal region seems to analyze the special
Visuospatial skills are the location of objects in location ªwhere.º Motivational and activating
space, judgment of the direction and distance± structures in the limbic system, the basal
topographic orientation in space, and the ganglia, the reticular formation, thalamus,
localization of one's own body or body parts and the frontal cortex play an important role
in space. Lesions of the parietal lobe therefore in this attentional system. Unilateral lesion of
frequently lead to topographic agnosia and each of the subsystems can cause unilateral
amnesia. Objects, landmarks, and one's own neglect. The frontal and temporal regions
position with respect to them and orientation modulate the thalamic filter system of the
are disturbed or are not remembered. For nucleus reticularis by inhibitory connections.
example, the orientation of hand movements to Reticular formation activates all cortical re-
a visible goal is not possible. In parietal- gions, but inhibits the nucleus reticularis, which
occipital lesions, the cell assemblies for indivi- leads to selective gating of the thalamus for
dual characteristics of a stimulus, for example, incoming regions by its inhibitory influence on
color, form, and location, can no longer be all specific afferents. The right hemisphere is
associatively connected. The consequences of dominant in the regulation of these processes
this are completely separate experiences of during spatial attention. Neglect can therefore
individual elements of the environment and occur after every lesion in any of these regions,
the loss of orientation, for example, the color of especially, however, on the right side. The
letters can no longer be recognized and the patient can no longer learn to concentrate on the
location and size of geometric objects can no contralateral side. Lesions of the parietal lobe
longer be compared. also lead to disturbances of short-term memory
Especially remarkable are disorders of face and therefore also long-term encoding, espe-
recognition (prosopagnosia): the lack of dis- cially of visuospatial material. This does not
crimination of unknown faces occurs during mean that short-term memory is an exclusive
166 Psychobiology
function of the parietal cortex, but only that Lesions of the prefrontal and orbitofrontal
important steps in the processing of information cortex lead to disorders of the temporal
in declarative short-term memory depend on sequence of behavior and therefore to second-
multisensory integration of the parietal region. ary social disturbances. Lesions of the pre-
frontal cortex lead to typical changes in
behavior that have been described in many
1.05.11.4.2 The frontal lobe
textbooks using the example of Phineas Gage,
Even extensive lesions of the frontal cortex whose brain was damaged by an iron rod as a
which forms about 30% of the neocortex consequence of premature detonation of ex-
usually create no sensory or motor dysfunction. plosives. Lesions of the frontal cortex damage
They have, however, severe psychological the ability to plan ahead and to select the right
consequences. The frontal cortex, especially behavioral sequences, to ignore distracting
the dorsolateral frontal and prefrontal cortex, stimuli, and to continue with behavior that
has an important role in the creation of stable has begun, and to remember what has already
contingencies between responses and their been done previously. This temporal organiza-
consequences especially if those follow with tion of behavior by the prefrontal cortex needs
delay; associations between a cue, the following detailed information about sensory stimuli and
motor response, and the biological±social the context of the situation from the parietal and
consequences lead to the formation of stable temporal cortex as well as the motivational
expectancies. The frontal cortex plays an value of a specific given and stored situation. In
important role in those expectancies: if the animal experiments lesions of the dorsolateral
frontal cortex is lesioned behavior loses its frontal cortex, especially of the stria principalis,
future orientation, behavior is difficult to lead to disorders that include attention as well as
predict, is irregular and extremely stereotypical learning functions. Tasks that require delayed
and perseverative. responses are especially disturbed. Delayed
In general, three subsystems of the frontal matching to sample (DMS) tasks are also
cortex can be differentiated: (i) the motor and affected: in these tasks a visual stimulus is
premotor regions including Broca's area and the usually presented and with some delay the same
frontal eye fields (areas 4, 6, 44), (ii) the stimulus is presented together with other stimuli
dorsolateral frontal cortex with areas 8, 9, 10, and the animal must choose which stimulus has
44, 45, and 46, which is called the prefrontal previously been seen; the right choice is
cortex together with the orbitofrontal cortex, reinforced. The target stimulus is changed on
and (iii) the orbitofrontal cortex which includes a trial-to-trial basis. DMS tasks are also affected
areas 11, 12, and 47. The prefrontal cortex has after temporal lesions, since they require visual
often been called the granular frontal cortex discrimination. Table 1 gives an overview of the
because it has an especially well-developed layer various deficits after lesions of the frontal cortex
IV of stellate cells and spherically organized including its motor and premotor areas.
short dendrites. Areas 4, 6, 8, and 44 have In expectancy situations, animals as well as
primarily motor functions, the dorsolateral humans show a characteristic slow cortical
frontal cortex is related to attentional functions, potential. Between a warning stimulus and a
working memory, and the formation of ex- second imperative stimulus which requires
pectancies; the orbital system is related to motor or cognitive responses, two negativities
motivational functions. The most important or components of the EEG are formed: one after
afferents to the prefrontal cortex come from the the first stimulus and one before the second
medio-dorsal nucleus of the thalamus. In stimulus. The first negativity usually has a
addition, the anterior nucleus of the thalamus, prefrontal localization and the second one can
the hypothalamus, the amygdala, the limbic vary topographically over various cortical areas
cortex, and the cingular gyrus as well as the depending on the response that has to be
mesencephalic reticular formation and the executed. This first component is reduced over
nonprimary sensory and motor association the frontal cortex when motor acts become
areas project to the prefrontal cortex. All automatic, when stimuli habituate, and when
connections are reciprocal, the prefrontal cortex stimuli have no signal value, informative stimuli
projects especially to area 7 (somatic), area 22 increase this component. The first frontal
(auditory), and area 21 (visual). The orbito- component of the SCPs seems to be related to
frontal cortex also has olfactory connections. preparatory activation of memory contents after
The efferents of the frontal cortex go to the presentation of the first warning stimulus. The
basal ganglia, the hippocampi, and the limbic expectancy of the stimulus is the subjective
region. The connections of the basal ganglia are correlate of this preparatory activation. In
especially important in the regulation of atten- patients with bifrontal lesions this first compo-
tional behavior. nent is absent and explains the disturbance of
Table 1 Overview of the main symptoms after lesions of the frontal lobe.
Symptom Site of lesion
Disorders of movement
Loss of fine motor skills Area 4
Loss of force 4,5, dorsolateral
Faulty planning of movement Premotor, dorsolateral
Voluntary fixation of eyes Frontal eye fields
Disturbed corollary discharge Dorsolateral, premotor
Broca's aphasia 44
Loss of divergent thinking Orbital
Reduced spontaneity
Disorders in behavioral strategies Dorsolateral, orbital
Stimulus control of behavior
Deficient inhibition of responses Dorsolateral
Search for risk and loss of rules Prefrontal
Disorders of associative learning Dorsolateral
Problems in memory for time
Disturbed perception of frequency Dorsolateral
Disturbed retrieval of sequences Dorsolateral
Delayed responses Dorsolateral
Disordered social behavior Orbital, dorsolateral
Altered sexual behavior Orbital
Disordered olfactory discrimination Orbital
Source: Kolb and Whishaw (1995).
expectancy processes with longer time intervals sensory and motor mobilization is not correctly
between two stimuli as found in delayed chosen or it may be suppressed. The conse-
response tasks. The basic learning of the quence is the symptomatology of the frontal
association between a response and its con- patient, which has been described as difficult to
sequences or the association between two stimuli predict, with irregular behavior, especially in
seems to depend considerably on prefrontal waiting situations and with extreme distract-
structures. Between CS and UCS or response ibility. In lesions of the dorsolateral frontal
and reinforcement, repetitive temporal pairing cortex it has been noted that verbally formulated
results in an electrophysiological connection action programs loose their influence on
that is mirrored in surface negativity. The behavior. The disorganization of behavior plans
prefrontal cortex has an important role in the is accompanied by distractibility, the inability to
temporal regulation of information and motor give up response strategies that have once been
acts for other neocortical regions. This active chosen (perseveration). The inflexibility and
mechanism takes its energy from limbic and perseveration is especially caused by lesions of
subcortical structures. If this source of energy is left area 9, the distractibility occurs in prefrontal
absent or distributed temporally independent of regions in general. In many types of disorders
learned cues, the temporal sequence of thought (e.g., anxiety, schizophrenia, tics, obsessive
and behaviors becomes irregular and the behavior, and criminal behavior), the frontal
probability for goal-directed behavior is re- lobe used to be destroyed in order to reduce
duced. This has been confirmed for cases of symptomatology. Bilateral lesions lead to a
bilateral lesions of the prefrontal cortex. pseudopsychopathic state, especially if the right
The prefrontal cortex seems to be activated in frontal cortex is lesioned and a pseudodepressive
all situations when a stimulus requires a state occurs after left frontal lobe lesions.
temporal discrimination. This is the case with Although there is similarity in those behavioral
all warning stimuli and conditioned stimuli: the deficits to psychopathic behaviors, there is less
organism estimates the probability of occur- stability in behavior in frontal lesions: within a
rence of a certain stimulus and mobilizes the few minutes usually incompatible behaviors can
respective sensory and motor systems in a occur in a fast sequence. Self-control requires a
preparatory manner. If the temporal estimation series of cognitive operations that require intact
of future events is faulty or destroyed, the time of prefrontal regions.
168 Psychobiology
1.05.11.4.3 The temporal lobe with absolute pitch) (Schlang, Jancke, Huang,
& Steinmetz, 1995).
The temporal lobe has acoustic, visual, and
memory functions that are reflected in its
anatomical structure. Based on its anatomic 1.05.11.5 Thought Disorders
substructures, the temporal lobe has sensory
functions (primary and secondary auditory One type of thought disorder with extensive
system) and portions of the tertiary visual loss of intellectual function and memory are the
system (superior and inferior portions); the dementias. More than half of all persons with
medial and limbic portion by way of contrast dementias suffer from morbus Alzheimer. Very
has memory functions and is responsible for little is known about the causes of Alzheimer's
affective tone. Whereas the parietal cortex is disease. The early occurring severe forms of
related to the location of function, the temporal Alzheimer's might be a dominantly transmitted
cortex is related to the differentiation of objects. anomaly in cell metabolism. The mutation of a
The temporal lobe comprises neocortical re- gene (s182) on chromosome 21 may be involved.
gions 20, 21, 22, 37, 38, 41, and 42, which are This gene codes for the precursor protein of b-
also called archicortex, and the medial phylo- amyloid, which is responsible for the destruc-
genetically older, tripartite portions of paleo- tion of cells and can be found in large amounts
cortex: gyrus ambiens, parahippocampal gyrus, in the brain of these patients (Levy-Lahad,
and uncus, the entorhinal (area 28) and Wijsman, & Nemens, 1995). Other researchers
perihinal cortex (areas 35 and 36) belong to have also found mutations of chromosome 1,
the medial temporal memory systemÐthe the function of which seems to be similar to that
hippocampus and amygdala are closely asso- of chromosome 21. Typical for Alzheimer's
ciated with the paleocortex. disease is the atrophy of the gray matter,
Table 2 shows the most important functional especially of the association cortices, atrophy of
disorders after lesions of various temporal the dendritic branches, and the presence of
regions, based on Kolb and Whishaw (1995). histologically very well visible senile plaques
The role of the inferior gyrus temporalis for and neurofibrillary tangles. Senile plaques are
visual discrimination has been demonstrated in deposits of dead nerve cells with a high content
animal as well as human experiments. Bilateral of neurotransmitters and proteins. Neurofibril-
lesions of the auditory cortex do not lead to lary tangles consist of excessive multiplication
cortical deafness as is the case in the primary of normal neurofibrils that usually have
visual field. However, tone discrimination is supporting function for the cells.
impaired, especially the minimal time that has to In Parkinson's disease a loss of dopamine in
pass in order to discriminate two tones or two the nigro-striatal system has been found. The
vocal sounds. The minimal stimulus duration causes of idiopathic Parkinson's disease are
for tone discrimination is 50 ms, but after unknown; the uptake of pesticides or drugs that
lesions it can increase substantially which leads destroy dopamine cells might be one cause
to an inability to perceive language if the sounds which may, however, not be relevant for all
and words are not presented for a very long patients. Parkinson's symptoms may also occur
time. This is especially true for the left superior as a consequence of chronic intake of anti-
posterior temporal lobe. This sound discrimina- psychotic medication with antidopaminergic
tion seems to be impaired in dyslexias and in effects. Since Parkinson's disease is character-
disorders of language comprehension in chil- ized by a loss of dopaminergic cells in the
dren. Extensive training of the discrimination substantia nigra and the adjacent ventral
ability can restitute the cortical capability in tegmentum, and since the substantia nigra is
these children. In monkeys it has been shown part of a complex system with motor, cognitive,
that extensive training of acoustic discrimina- and motivational functions, motor deficits
tion in the superior temporal lobe and training alone are improbable in Parkinson's disease.
of visual discrimination in the lower temporal For example, Parkinson patients show disor-
lobe leads to an increase in frequency of action ders which are comparable to those in patients
potentials to tone sequence and visual patterns with frontal lesions.
of more than 30% compared with the time The schizophrenias are a heterogeneous group
before training. As in the somatosensory cortex of disorders of attention, perception, and
there is an expansion of complex receptive fields language. The neurobiological causes of schizo-
related to learning. Musical talent seems also to phrenia seem to be related to an overactivity of
be related to the interplay between the two the mesolimbic dopamine system and a disorder
temporal cortices, for example, musicians with of the left mediotemporal prefrontal cortex
and without absolute pitch differ in the size of region. The neurobiological basis of type I and
the left planum temporale (larger in persons type II schizophrenia seem to be different: type
Table 2 Disorders after lesions of various temporal regions.
Symptom Site of lesion
1. Disorders of acoustic perception Areas 22, 41, 42

2. Disorders of the selection of visual and acoustic stimuli Areas 20, 21, 22, 37, 38
3. Disorders of visual perception Areas 20, 21
4. Disorders of acoustic perception Areas 41, 42, 22
5. Disorders of organization and categorization Areas 21, 38 left
6. Disorders of context memory Hippocampus
7. Disorders of language perception Area 22 left
8. Disorders in long-term memory Area 21 (hippocampus and surrounding tissue)
9. Changes in personality and affect Areas 21, 38 and amygdala
10. Changes in sexual behavior Amygdala and temporal?
Source: Kolb and Whishaw (1995).
II patients show clear signs of a degeneration of inactivates the receptor. This suggests that an
the brain and have expanded ventricles corre- overactivity of the mesolimbic dopamine
lating with intellectual decay. The genetic system may be a major cause of the positive
vulnerability of type II schizophrenia for a symptoms in schizophrenia. It is assumed that
virus that might later lead to the schizophrenic the so-called D2-receptors in schizophrenics are
disorder may be larger than in type I schizo- either increased in number or overly sensitive.
phrenia. Similarities between the type II group Substances that block the D2-receptors have
and patients with multiple sclerosis suggest an the best therapeutic effect, whereas blockade of
immunological involvement of the CNS in the the D1-receptors only has small effects on the
disorder. In the cerebrospinal fluid of a symptomatology. A general overactivity of the
subgroup of schizophrenics, antibodies against dopaminergic neurons has not been shown. D2-
a viral infection similar to the herpes virus have receptors are activated by apomorphine and
been identified. are blocked by neuroleptic substances. Dopa-
However, type I schizophrenics also show mine agonists such as amphetamine and
neurophysiological changes. Blood flow in the cocaine can induce schizophrenia-like symp-
frontal hemispheres, especially the left hemi- toms in healthy persons and may increase
sphere, compared with the occipital region, schizophrenic symptoms in schizophrenics.
seems to be reduced, and the frontal glucose Whereas the mesolimbic dopamine system
uptake in PET also seems to be lower. Event- seems to be overactive, the frontal cortex seems
related brain potentials show a decrease rather to have lower metabolic activity as shown in
than an increase in negativity when attention is PET studies. This could be related either to a
directed to a stimulus which might be an compensatory dopamine suppression in meso-
indicator of the attentional deficits that have cortical dopamine fibers or to the inhibitory
been shown in schizophrenia. Structural effect of dopamine in the prefrontal cortex.
changes have also been observed in the temporal The use of dopamine antagonists leads to
hippocampal region. The hippocampus of a dyskinesias and a loss of quality of life as
schizophrenic shows a disorganized orientation important side effects. The most frequent effects
of cells. The growth of the cells in this region are Parkinson-like disorders in movement such
takes place in the second and third trimesters of as loss of facial expression and tremor. About
pregnancy and this provides an additional 10% of the patients also develop irreversible
argument for the embryonal cause of some tardive dyskinesias subsequent to long-term
types of schizophrenias. Potentially androgens medication: tics related to the face and the
have a triggering function in the brain of tongue, incomprehensible gestures, problems in
schizophrenics since schizophrenia usually oc- speaking, gross movement of the arms, etc. The
curs after puberty in men and after the age- receptors seem to develop a denervation super-
related reduction of estrogens in women. sensitivity: the ongoing inhibition of the
The dopamine hypothesis of schizophrenia receptors by the drugs causes compensatory
was based on findings that medication which irreversible supersensitivity to the blocked
influences the dopaminergic system has a clear transmitter (Wise, 1982). Blockade of the
antipsychotic effect in schizophrenic patients. overactive mesolimbic dopamine system by
A substance seems to be effective if it quickly neuroleptica not only leads to a suppression
binds to dopamine receptors in the cell of thought disorders but also to anhedonia. As
membrane of the mesolimbic system and if it previously described, the dopaminergic system
170 Psychobiology
plays an important role in intracranial self- nociception to cognition. Advances in pain research and
stimulation: its inhibition reduces the efficacy of therapy (Vol. 22, pp. 331±344). New York: Lippincott-
Raven.
positive reinforcement and therefore leads to a Birbaumer, N., Grodd, W., Diedrich, O., Schneider, F., &
general sedation that is medication-induced. Flor, H. (1997). Functional magnetic resonance imaging
The overactivity of the mesolimbic dopamine reveals substantial activation of the amygdala during the
system as an incentive system could explain processing of social stimuli in social phobics. Submitted
for publication.
some of the symptoms of schizophrenia: since Birbaumer, N. (1998). Self-regulation of slow cortical
this system creates positive reinforcement and potentials. The Neuroscientist.
incentive motivation, overactivity leads to Birbaumer, N., Lutzenberger, W., Montoya, P., Larbig,
reinforcement of a number of stimuli and W., Unertl, K., ToÈpfner, S., Grodd, W., Taub, E., &
responses. Unimportant and not connected Flor, H. (1997). Effects of regional anesthesia on
phantom limb pain are mirrored in changes in cortical
stimuli become suddenly important and rele- reorganization. Journal of Neuroscience, 17, 5503±5508.
vant for behavior. The selection of attention Birbaumer, N., Lutzenberger, W., & Schleichert, H. (1994).
breaks down. These are the most important Think to moveÐand move! Self-regulation of
symptoms of the schizophrenic disorder. movement-related brain potentials. Society for Neu-
roscience Abstracts.
Birbaumer, N., & OÈhman, A. (Eds.) (1993). The structure
of emotion: Psychophysiological, cognitive, and clinical
1.05.12 SUMMARY aspects. Seattle: Hogrefe & Huber.
Birbaumer, N., Rockstroh, B., Elbert, T., Wolf, P.,
This chapter has given an overview of the DuÈchting-RoÈth, A., Reker, M., Daum, I., Lutzenberger,
psychobiological foundations of clinical psy- W., & Dichgans, J. (1994). Biofeedback of slow cortical
chology. The basic fields of psychobiology, such potentials in epilepsy. In J. Carlson, R. Seifert, & N.
as psychophysiology, psychopharmacology, Birbaumer (Eds.), Clinical applied psychophysiology
psychoendocrinology, psychoimmunology, (pp. 29±42). New York: Plenum.
Birbaumer, N., & Schmidt, R. F. (1996). Biologische
and behavioral genetics, were defined and psychologie (3rd ed.). New York: Springer.
important principles of these fields were Bloom, F. E., & Kupfer, D. J. (Eds.) (1994). Psychophar-
described. The neurobiology of basic psycho- macology. The fourth generation of progress. New York:
logical functions such as emotion, motivation, Raven Press.
Borbely, A. A. (1984). Sleep regulation: outline of a model
memory, cognition, and language was then and its implications for depression. In A. Borbely & J. L.
described and the psychobiological basis of Valatx (Eds.), Sleep mechanisms. New York: Springer.
their dysfunction in clinical±psychological dis- Cacioppo, J. T., & Petty, R. E. (1983). Social psychophy-
orders was delineated. siology: A sourcebook. New York: Guilford Press.
Cahill, L., Prins, B., Weber, M., & McGaugh, J. (1994). b-
adrenergic activation and memory for emotional events.
1.05.13 REFERENCES Nature, 371, 702±704.
Cameron, O. G. (Ed.) (1994). Adrenergic dysfunction and
Abeles, M. (1991). Corticonics. Neural circuits of the psychobiology. Washington, DC: American Psychiatric
cerebral cortex. Cambridge, UK: Cambridge University Press.
Press. Cannon, W. B. (1929). Bodily changes in pain, hunger, fear
Ader, R., & Cohen, N. (1985) CNS±immune system and rage. New York: Appleton Century.
interactions: Conditioning phenomena. The Behavioral Carlson, J., Seifert, R., & Birbaumer, N. (Eds.) (1994).
and Brain Sciences, 8, 379±426. Clinical applied psychophysiology. New York: Plenum.
Ader, R., Felten, D., & Cohen, N. (Eds.) (1990). Carlson, N. R. (1991) Physiology of behavior (4th ed.).
Psychoneuroimmunology (2nd ed.). New York: Academic Boston: Allyn & Bacon.
Press. Chalmers, N., Crawley, R., & Rose, S. P. R. (Eds.) (1971).
American Psychiatric Association (1994). Diagnostic and The biological bases of behavior. London: Harper.
statistical manual of mental disorders (4th ed.). Washing- Clarke, E., & O'Mally, C. D. (1995). The human brain and
ton, DC: Author. spinal cord. (2nd ed.). San Francisco: Norman.
Andreassi, J. L. (1995). Psychophysiology (3rd ed.). Hills- Clynes, M. (1989). Communication and generation of
dale, NJ: Erlbaum. emotion through sentic form. In L. Levi (Ed.), Emotion.
Aschoff, J., Daan, S., & Groos, G. A. (1982). Vertebrate New York: Raven Press.
circadian systems. Structure and physiology. New York: Corbetta, M., Miezin, F. M., Dobmeyer, S., Shulman, G.
Springer. L., & Petersen, S. E. (1991). Selective attention modulates
Aserinsky, E., & Kleitman, N. (1953). Regulary occurring extrastriate visual regions in humans during visual feature
periods of eye motility, and concomitant phenomena discrimination and recognition. Exploring brain functional
during sleep. Science, 118, 273±274. anatomy with position tomography. Ciba Foundation
Bailey, J. M., Willerman, L., & Parks, C. (1991). A test of Symposium. New York: Wiley.
the maternal stress theory of human male homosexu- Cotman, W. M., & Nadler, L. G. (1978). Reactive
ality. Archives of Sexual Behavior, 20, 277±293. synaptogenesis in the hippocampus. In C. W. Cotman
Becker, J. B., Breedlove, S., & Crews, D. (Eds.) (1992). (Ed.), Neuronal plasticity. New York: Raven Press.
Behavioral endocrinology. Cambridge, MA: MIT Press. Crosson, B. (1992). Subcortical functions in language and
Birbaumer, N., Elbert, T., Canavan, A., & Rockstroh, B. memory. New York: Guilford Press.
(1990). Slow potentials of the cerebral cortex and Daum, I., Ackermann, H., Schugens, M. M., Reimold, C.,
behavior. Physiological Reviews, 70, 1±41. Dichgans, J., & Birbaumer, N. (1993). The cerebellum
Birbaumer, N., Flor, H., Lutzenberger, W., & Elbert, T. and cognitive functions in humans. Behavioral Neu-
(1995). The corticalization of chronic pain. In B. Bromm roscience, 107, 411±419.
& J. E. Desmedt (Eds.), Pain and the brain. From Davidson, R. J. (1993). Cerebral asymmetry and emotion:
References 171
Conceptual and methodological conundrums. Special James, W. (1890). The principles of psychology. New York:
Issue: Neuropsychological perspectives on emotion. Holt; reprint: Cambridge, MA: Harvard University Press
Cognition and Emotion, 7, 115±138. (1983).
Davis, H. P., & Roitblat, H. L. (1984). Cholinergic Jovanovic, U. J. (1971). Normal sleep in man. Stuttgart,
pharmacology, behavior and age-related memory de- Germany: Hippokrates.
cline. In L. Squire & N. Butters (Eds.), Neuropsychology Kaas, J. H. (1995). The reorganization of sensory and
of memory. New York: Guilford Press. motor maps in adult mammals. In M. Gazzaniga (Ed.),
Davis, M., Hitchcock, J. M., & Rosen, J. B. (1991). Neural The cognitive neurosciences. Cambridge, MA: MIT Press.
mechanisms of fear conditioning measured with the Koch, M., & Bubser, M. (1994). Deficient sensorimotor
acoustic startle reflex. In J. Madden (Ed.), Neurobiology gating after 6-hydroxydopamine lesion of the rat medial
of learning, emotion and affect. New York: Raven Press. prefrontal cortex is reversed by haloperidol. European
Davison, G., & Neale, J. M. (1996). Abnormal psychology Journal of Neurosciences, 6, 1837±1845.
(6th ed.). New York: Wiley. Kolb, B., & Whishaw, I. Q. (1995). Fundamentals of human
Di Chiara, G. (1995). The role of dopamine in drug abuse neuropsychology (4th ed.). New York: Freeman.
viewed from the perspective of its role in motivation. Lacey, J. I., & Lacey, B. C. (1970). Some autonomic-central
Drug and Alcohol Dependence, 38, 95±137. nervous system interrelationships. In P. Black (Ed.),
Dworkin, B. R., Elbert, T., Rau, H., Birbaumer, N., Pauli, Physiological correlates of emotion. New York: Aca-
P., Droste, C., & Brunia, C. H. M. (1994). Central effects demic Press.
of baroreceptor activation in humans: Attenuation of Lang, P., Melamed, B., & Hart, J. D. (1970). A
skeletal reflexes and pain perception. Proceedings of the psychophysiological analysis of fear modification using
National Academy of Science, 91, 6329±6333. an automated desensitization procedure. Journal of
Ekman, P. (1984). Expression and the nature of emotion. Abnormal Psychology, 76(2), 220±234.
In K. R. Scherer & P. Ekman (Eds.), Approaches to Lang, P., Bradley, M. M., & Cuthbert, B. N. (1990).
emotion. Hillsdale, NJ: Lawrence. Emotion, attention, and the startle reflex. Psychological
Ekman, R. & Davidson, R. A. (Eds.) (1984). The nature of Review, 97, 377±385.
emotion: Fundamental questions. Oxford, UK: Oxford Lang, P. J., Bradley, M. M., & Cuthbert, B. N. (1993).
University Press. Emotion, arousal, valence and the startle reflex. In N.
Elbert, T., Rockstroh, B., Lutzenberger, W., & Birbaumer, Birbaumer & A. OÈhman (Eds.), The structure of emotion.
N. (Eds.) (1984). Self-regulation of the brain and behavior. Toronto, Canada: Hogrefe.
New York: Springer. Lazarus, R. S., Kanner, A. D., & Folkman, S. (1980).
Fahrenberg, J., Walschburger, P., & Foerster, F. (1979). Emotions: A cognitive phenomenological analysis. In R.
Psychophysiologische Aktivierungsforschung. MuÈnchen: Plutchik & H. Kellerman (Eds.), Emotion: Theory,
Minerva. research and experience (Vol. 1). New York: Academic
Farah, M. (1995). The neural bases of mental imagery. In Press.
M. Gazzaniga (Ed.), The cognitive neurosciences. Cam- LeDoux, J. (1995). Emotion: Clues from the brain. Annual
bridge, MA: MIT Press. Review of Psychology, 46, 209±235.
Farwell, L., & Donchin, E. (1991). The truth will out: Legg, C. R., & Booth, D. A. (Eds.) (1984). Appetite: Neural
Interrogative polygraphy (ªlie detectionº) with event and behavioral bases. Oxford, UK: Oxford University
related brain potentials. Psychophysiology, 28, 531±547. Press.
Flor, H., & Birbaumer, N. (1993). Comparison of the LeVay, S. (1996). Queer science: The use and abuse of
efficacy of EMG biofeedback, cognitive±behavioral research on homosexuality. Cambridge, MA: MIT Press.
therapy, and conservative medical interventions in the LeVay, S., Pattatucci, A. M. L., Patterson, C., Lili, D. W.,
treatment of chronic musculoskeletal pain. Journal of Fulker, S. S., Cherny, S. S., Kruglyak, L., & Hamer, D.
Consulting & Clinical Psychology, 61, 653±658. H. (1995). Linkage between sexual orientation and
Flor, H., Elbert, T., Knecht, S., Wienbruch, C., Pantev, C., chromosome X928 in males but not in females. Nature
Birbaumer, N., Larbig, W., & Taub, E. (1995). Genetics, 11, 248±256.
Phantom-limb pain as a perceptual correlate of cortical Levy-Lahad, E., Wijsman, E., & Nemens, E. (1995). A
reorganization following arm amputation. Nature, 375, familial Alzheimer's disease locus on chromosome 1.
482±484. Science, 269, 970±973.
Folkard, S., & Monk, T. M. (1986). Chronopsychology: Linden, D. J., & Connor, J. A. (1995). Long-term synaptic
Circadian rhythms and human performance. In A. Gale depression. Annual Review of Neuroscience, 18, 319±357.
& J. A. Edwards (Eds.), Physiological correlates of Lindsley, D. B., Bowden, J. W., & Magoun, H. W. (1949).
human behavior (Vol. 2). London: Academic Press. Effect upon the EEG of acute injury to the brainstem
Gazzaniga, M. (Ed.) (1995). The cognitive neurosciences. activating system. Electroencephalography and Clinical
Cambridge, MA: MIT Press. Neurophysiology, 1, 475±486.
Hauser, E. (1996). The evolution of communication. Cam- Lycan, W. (1996). Consciousness and experience. Cam-
bridge, MA: MIT Press. bridge, MA: MIT Press
Hawkins, R. D., & Kandel, E. R. (1984). Is there a cell- Mackintosh, N. S. (1974). Psychology of animal learning.
biological alphabet for simple forms of learning? New York: Academic Press.
Psychological Review, 91, 375±391. Matlin, M. (1983). Cognition. New York: Harcourt Brace.
Hebb, D. O. (1949). The organization of behavior. New McCarley, R. W. (1990). Brainstem cholinergic systems
York: Wiley and models of REM sleep production. In J. Montplaisir
Heninger, G. R. (1995). Neuroimmunology of stress. In M. & R. Godbout (Eds.), Sleep and biological rhythms.
J. Friedman et al. (Eds.), Neurobiological and clinical Oxford, UK: Oxford University Press.
consequences of stress. Philadelphia: Lippincott-Raven. McCormick, D. A., & Bal, T. (1997). Sleep and arousal:
Hillyard, S., Mangun, F. R., Woldorff, M., & Luck, S. Thalamocortical mechanisms. Annual Review of Neu-
(1995). Neural systems mediating selective attention. In roscience, 20, 185±215.
M. Gazzaniga (Ed.), The cognitive neurosciences. Cam- Mesulam, M. M. (1995). Structure and function of
bridge, MA: MIT Press. cholinergic pathways. In F. Bloom & D. Kupfer (Eds.),
Hobson, A., & Stickgold, R. (1995). The conscious state Psychopharmacology. The fourth generation. New York:
paradigm: A neurocognitive approach to waking, sleep- Raven Press.
ing and dreaming. In M. Gazzaniga (Ed.), The cognitive Miller, N. E. (1969). Learning of visceral and glandular
neurosciences. Cambridge, MA: MIT Press. responses. Science, 163, 434±445.
172 Psychobiology
Miller, N. E. (1978). Biofeedback and visceral learning. physiological determinates of emotional state. Psycholo-
Annual Review of Psychology, 29, 373±404. gical Review, 69, 379±399.
Mishkin, M., & Ungerleider, L. G. (1982). Contribution of Schedlowski, M., & Tewes, U. (Eds.) (1996). Psychoneur-
striate inputs to the visuospatial functions of parieto- oimmunologie. Heidelberg, Germany: Spektrum.
preoccipital cortex in monkeys. Behavioural Brain Schlaug, G., JaÈncke, L., Huang, Y. & Steinmetz, H. (1995).
Research, 6, 57±77. In vivo evidence of structural brain asymmetry in
Money, J. (1987). Sin, sickness, or status. Homosexual musicians. Science, 267, 699±701.
gender identity and psychoneuroendocrinology. Amer- Schulkin, R. (Ed.) (1993). Hormonally induced changes in
ican Psychologist, 42, 384±399. mind and brain. New York: Academic Press.
NaÈaÈtaÈnen, R. (1990). The role of attention in auditory Schupp, H., Lutzenberger, W., Birbaumer, N., Braun, C.,
information processing as revealed by event-related & Miltner, W. (1994). Neurophysiological differences
potentials and other brain measures of cognitive func- between perception and imagery. Cognitive Brain Re-
tion. Behavioral and Brain Sciences, 13, 201±288. search, 2, 77±86.
Obrist, P. A. (1981). Cardiovascular psychophysiology: A Schwartz, M. (Ed.) (1995). Biofeedback (2nd ed.). New
perspective. New York: Plenum. York: Guilford Press.
OÈhman, A. (1987). The psychophysiology of emotion: An Self, D. W., & Nestler, E. J. (1995). Molecular mechanisms
evolutionary±cognitive perspective. In P. K. Ackles, J. R. of drug reinforcement and addiction. Annual Review of
Jennings & M. G. H. Coles (Eds.), Advances in Neuroscience, 18, 463±495.
psychophysiology (Vol. 2). Greenwich, CT:JAI Press. Siegel, G., Agranoff, B., Albers, W., & Molinoff, P. (Eds.)
OÈhman, A., & Birbaumer, N. (1993). Psychophysiological (1994). Basic neurochemistry (5th ed.). New York:
and cognitive±clinical perspectives on emotion: Intro- Lippincott-Raven.
duction and overview. In N. Birbaumer & A. OÈhman Singer, W., & Gray, C. M. (1995). Visual feature
(Eds.), The structure of emotion. Toronto, Canada: integration and the temporal correlation hypothesis.
Hogrefe & Hubert. Annual Review of Neuroscience, 18, 555±586.
Olds, J., & Milner, P. (1954). Positive reinforcement Sperry, R. W. (1952). The great cerebral commissure.
produced by electrical stimulation of septal area and American Scientist, 40, 291±312.
other regions of rat brain. Journal of Comparative and Sperry, R. W. (1964). The great cerebral commissure.
Physiological Psychology, 47, 419±427. Scientific American, January.
Patrick, C. J. (1994). Emotion and psychopathy: Startling Springer, S. P., & Deutsch, G. (1993). Left brain, right brain
new insights. Psychophysiology, 31, 319±330. (3rd ed.). New York: W. H. Freeman.
Pavlov, I. (1926). Die hoÈchste NerventaÈtigkeit (das Verhal- Steriade, M., & McCarley, R. W. (1990). Brainstem control
ten) von Tieren. Munich: J. Bergmann. of Wake±Sleep states. New York: Plenum.
Peterson, C., Maier, S. F., & Seligman, M. E. P. (1993). Swaab, D. F., & Hofman, M. A. (1995). Sexual differentia-
Learned helplessness: A theory for the age of personal tion of the human hypothalamus in relation to gender
control. New York: Oxford University Press. and sexual orientation. Trends in Neurosciences, 18,
Posner, M. I., & Raichle, M. E. (1995). Images of mind. 264±270.
New York: W. H. Freeman. Thompson, R. F., & Krupa, D. J. (1994). Organization of
Rau, H., Pauli, P., Brody, S., Elbert, T., & Birbaumer, N. memory traces in the mammalian brain. Annual Review
(1993). Baroreceptor stimulation alters cortical activity. of Neuroscience, 17, 519±549.
Psychophysiology, 30, 322±325. Watson, J. D., & Crick, F. M. C. (1953). Molecular
Rescorla, R. A. (1988). Pavlovian conditioning: It's not structure of nucleic acids. Nature, 171, 737±738.
what you think it is. American Psychologist, 43, 151±160. Wever, R. A. (1979). The circadian system of man. New
Robinson, T. E., & Berridge, K. C. (1993). The neural basis York: Springer.
of drug craying: an incentive-sensitisation theory of Wise, R. (1988). The neurobiology of craving. Journal of
addiction. Brain Research Reviews, 18, 247±291. Abnormal Psychology, 97, 118±132.
Rose, R. J. (1995). Genes and human behavior. Annual Wise, R. A. (1982). Neuroleptics and operant behavior:
Review of Psychology, 46, 625±654. The anhedonia hypothesis. Behavioral Brain Sciences, 5,
Rosenzweig, M. R., & Leimann. A. L. (1982). Physiological 39±87.
psychology. Boston: Houghton Mifflin. Zajonc, R. B. (1980). Feeling and thinking: Preferences
Schachter, S., & Singer, S. (1962). Cognitive, social and need no inferences. American Psychologist, 35, 151±175.
1.06
Fundamental
Psychopharmacology
FRANK A. HOLLOWAY
University of Oklahoma Health Sciences Center,
Oklahoma City, OK, USA
and
JESSICA M. PEIRCE
Brookline, MA, USA
1.06.1 INTRODUCTION AND SCOPE 175
1.06.2 CNS NEUROPHARMACOLOGY 175
1.06.2.1 Neuroanatomy and Neurophysiology of Neurons 175
1.06.2.2 Features of Neuronal Activity and Synaptic Neurotransmission 176
1.06.2.2.1 Membrane potentials and neural activation 176
1.06.2.2.2 Presynaptic events and modulation 176
1.06.2.2.3 Postsynaptic events and modulation 177
1.06.2.3 Neural Receptors 177
1.06.3 NEUROTRANSMITTERS AND NEUROMODULATORS 177
1.06.3.1 Acetylcholine (ACh) 178
1.06.3.1.1 Cholinergic neurotransmission and receptors 178
1.06.3.1.2 Cholinergic neuropharmacology 178
1.06.3.1.3 Cholinergic pathways 178
1.06.3.2 Norepinephrine (NE) and Epinephrine (Epi) 179
1.06.3.2.1 Catecholaminergic neurotransmission and receptors 179
1.06.3.2.2 NE neuropharmacology 179
1.06.3.2.3 Noradrenergic pathways 179
1.06.3.3 Dopamine (DA) 180
1.06.3.3.1 Dopaminergic neurotransmission 180
1.06.3.3.2 Dopamine pathways 180
1.06.3.3.3 Dopamine receptors 180
1.06.3.3.4 Dopamine neuropharmacology 181
1.06.3.4 Serotonin (5-hydroxytryptamine, 5-HT) 181
1.06.3.4.1 Serotonin neurotransmission 181
1.06.3.4.2 5-HT neuropharmacology 182
1.06.3.4.3 5-HT pathways 182
1.06.3.5 Amino Acid NTs 182
1.06.3.5.1 g-Aminobutyric acid (GABA) 182
1.06.3.5.2 Glycine 183
1.06.3.5.3 Glutamate and aspartate 183
1.06.3.6 Neuroactive Peptides and Hormones 183
1.06.3.6.1 Other neuromodulators 184
1.06.3.7 The Neuropharmacology of Normal Behavioral Functions 184
1.06.4 BASIC PHARMACOLOGY 184
1.06.4.1 Pharmacokinetics 184
173
174 Fundamental Psychopharmacology
1.06.4.1.1 Drug administration and absorption 184

1.06.4.1.2 Drug distribution 185
1.06.4.1.3 Elimination 185
1.06.4.2 Pharmacodynamics 186
1.06.4.2.1 Receptor theory 186
1.06.4.2.2 Drug receptor properties 186
1.06.4.2.3 Types of drug-receptor interactions 186
1.06.5 PRINCIPLES OF BEHAVIORAL PHARMACOLOGY AND PSYCHOPHARMACOLOGY 186
1.06.5.1 Behavioral Drug Properties 186
1.06.5.1.1 Dose±effect curves (DEC) 186
1.06.5.1.2 Drug sensitivity and effectiveness 187
1.06.5.2 Drug Tolerance 187
1.06.5.2.1 Definitions 187
1.06.5.2.2 Kinds of tolerance 187
1.06.5.3 Sensitization 188
1.06.5.4 Physical Dependence 188
1.06.5.5 Basic Psychopharmacology Principles 188
1.06.5.5.1 Drug±behavior interactions 188
1.06.5.5.2 Baseline effects/rate dependency 188
1.06.5.5.3 Discriminative and state-dependent drug effects 188
1.06.5.5.4 Reward and reinforcing effects of drugs 189
1.06.5.6 Drug Classes 189
1.06.5.7 Drug Side-effects, Interactions, and Overdose 189
1.06.5.8 Drug Regulation 189
1.06.6 THE PSYCHOPHARMACOLOGY OF MENTAL DISORDERS 189
1.06.6.1 Mood Disorders: Depressive Disorders 190
1.06.6.1.1 Characteristics of depression disorders 190
1.06.6.1.2 The catecholamine (CA) hypotheses of depression 190
1.06.6.1.3 The serotonin (5-HT) hypothesis of depression 191
1.06.6.1.4 The cortisol hypothesis of depression 191
1.06.6.1.5 Status of depression theories 191
1.06.6.1.6 Drug therapies for depression 192
1.06.6.2 Mood Disorders: Bipolar Disorder 193
1.06.6.3 Anxiety Disorders: Generalized Anxiety Disorder 193
1.06.6.4 Anxiety Disorders: Panic Disorder 194
1.06.6.4.1 Phenomenology and etiology of panic disorder 194
1.06.6.4.2 Neuropharmacology of panic disorder 194
1.06.6.4.3 Drug therapies for panic disorder 194
1.06.6.5 Anxiety Disorders: Obsessive-compulsive Disorder 194
1.06.6.6 Anxiety Disorders: Post-traumatic Stress Disorder 195
1.06.6.7 Anxiety Disorders: Social Phobia 195
1.06.6.8 Psychotic Disorders: Schizophrenia 196
1.06.6.8.1 Characteristics of psychosis 196
1.06.6.8.2 The phenomenology and biological basis of schizophrenia 196
1.06.6.8.3 The DA hypothesis of schizophrenia 196
1.06.6.8.4 Antipsychotic medications 197
1.06.6.8.5 Antipsychotic drug side-effects 197
1.06.6.8.6 Side-effect profile of newer antipsychotics 197
1.06.6.9 Substance Abuse and Dependence Disorders 198
1.06.6.9.1 Definitions and diagnostic criteria 198
1.06.6.9.2 Models of addiction 198
1.06.6.9.3 Psychopharmacology of and pharmacotherapy for drugs of abuse 198
1.06.6.9.4 Alcoholism 199
1.06.6.9.5 Cocaine and amphetamine dependence 200
1.06.6.9.6 Nicotine and caffeine dependence 200
1.06.6.9.7 Opiate (narcotic) dependence 201
1.06.6.9.8 Sedative-hypnotic and anxiolytic dependence 201
1.06.6.9.9 Marijuana abuse 202
1.06.6.9.10 Abuse of hallucinogens and related drugs 202
1.06.6.9.11 Over-the-counter and prescribed drugs 203
1.06.6.10 Eating Disorders 203
1.06.6.11 Neurological Disorders 204
1.06.6.11.1 Parkinson's disease 204
1.06.6.11.2 Alzheimer's disease and other dementias 204
1.06.6.11.3 Huntington's disease (HD) 205
1.06.6.12 Developmental Disorders Originating in Childhood 205
1.06.6.12.1 Attention-deficit hyperactivity disorder (ADHD) 205
1.06.6.12.2 Other disorders 205
CNS Neuropharmacology 175
1.06.1 INTRODUCTION AND SCOPE genous (external compounds like drugs) factors
can influence the communication between
This chapter is intended to give the well- neurons. Further, when the chemical messages
educated reader an overview of how psycho- are too strong or too weak, or when the reception
tropic drugs work to produce changes in is too sensitive or too poor, the normal neural,
behavior, mood, or perception. Psychotropic physiological, and behavioral functions may be
drugs fall into three classes, psychotomimetic disrupted. Here is where clinical psychophar-
(drugs inducing a psychosis), psychedelic (drugs macology looks for drugs that will normalize the
producing a change in one's state of conscious- disrupted function of brain chemistry.
ness or mood), and psychotherapeutic (drugs
relieving some biopsychological problem). The
major psychotherapeutic drug classes are anti- 1.06.2 CNS NEUROPHARMACOLOGY
psychotics, anxiolytics (anxiety reducing), anti- 1.06.2.1 Neuroanatomy and Neurophysiology of
depressants, and stimulants. Accordingly, we Neurons
will describe how and why health professionals
use specific drugs to treat certain neuropsychia- The CNS generally contains two types of
tric disorders. It is not our intention to give a cells: neurons and glial cells. Glial cells support
comprehensive account of all the relevant the integrity and function of neurons, which
topics. However, we will provide citations of serve the brain's sensory or input, integration,
current reference works where more technical and motor or output functions. The principal
information can be found. We will introduce targets of drugs in the CNS are the neurons,
the reader to neurophysiology, briefly describ- whose components are the cell body or soma,
ing how the targets of psychoactive drugs in dendrites, and axons. The supporting glial cells
the central nervous system (CNS) normally are found around all parts of the neuron
function. Next, we will examine the neurophar- (astrocytes among axons and dendrites, oligo-
macology of the major classes of neurotrans- dendrites near cell bodies, and Schwann cells
mitters, whose different functions specific drugs surrounding peripheral axons).
can target, and then address the applied biology Neurons have five basic features. First,
of drug action (pharmacology). Necessarily, we neuron cell bodies contain the genetic material
will discuss some principles of how psychoactive and apparatus necessary to synthesize or make
drugs affect behavior (behavioral pharmacol- new molecules (amino acids, proteins, peptides,
ogy or psychopharmacology). Finally, we will etc.). Cell bodies also play a critical role in
review the psychobiology of neuropsychiatric initiating a traveling wave of electrical signals
disorders and briefly describe what medications (the action potential). Second, neurons gener-
have been found useful in the treatment of these ally talk with each other via special extensions
disorders (clinical psychopharmacology). from the cell body, called axons and dendrites.
To understand how drugs work in the CNS, it Axons form output or efferent paths from the
is necessary first to understand something about cell body that convey rapid, spiked signals
the structure (neuroanatomy) and function called the action potentials. Dendrites (some-
(neurophysiology/neuropharmacology) of neu- times called the dendritic tree) provide multi-
rons. The reader can refer to any of three branched afferent or input paths to the cell
excellent references for more in-depth coverage body, conveying slower, graded potentials.
of topics in these areas (Cooper, Bloom, & Third, at the end or terminal of axons lies the
Roth, 1996; Feldman, Meyer, & Quenzer, 1997; synaptic junction or cleft, that is, the point
Kandel, Schwartz, & Jessell, 1991). Carlson where neurons make contact. An axon may
(1994) also provides a brief, but excellent, synapse on dendrites, the cell body, other axons,
glossary of neurobiological terminology. or itself. The presynaptic side of the junction
The later sources will introduce the reader to produces specialized molecules called neuro-
key definitions, but a brief overview may be in transmitters, packages them in vesicles, and
order here. The key target of drugs is the nervous usually releases them into the synaptic junction
system, whose basic units are cells called when the action potential of the presynaptic
neurons. As described below, neurons talk to neuron arrives at the axon terminal. Fourth, on
one another chemically. The principal chemical both the presynaptic and postsynaptic sides of
signal is the neurotransmitter (NT), a molecule the synaptic junction are receptors designed to
released by one neuron (say Cell ªAº). In the detect and bind the neurotransmitter (NT), in a
simplest scheme, another neuron (say Cell ªBº) lock and key fashion. NT receptors are proteins
has receptors (again particular types of mole- (i.e., long chains of amino acids), which may
cules) designed to detect and respond to the NT reside outside the cell, within the cell membrane,
from Cell ªA.º As described below, a host of and inside the cell. Receptor activation by an
endogenous (other brain chemicals) and exo- NT then leads to certain events or signals that
ultimately result in some change in the pre- (charged atoms, e.g., calcium, potassium,
synaptic or postsynaptic neuron, for example, chloride) can pass passively in and out of the
initiating its own action potential. Thus, cell. At resting baseline conditions, the neuron is
communication between neurons is basically polarized, that is, is more negatively charged
chemical, not electrical. The final feature is that inside the cell (low in sodium (Na+) and high in
all parts of the neuron, the cell body, axons, and potassium (K+) ions) than it is outside the cell
dendrites, have special double-layered mem- (high in Na+ and low in K+ ions). An active
branes separating the inside from the outside of transport process (the Na+ pump) maintains
the cell. In addition, the membrane is semi- this steady state by extruding Na+ from inside
permeable. That is, it contains ion channels the cell through ion channels in the membrane.
through which some ions (charged atoms, e.g., This resting state of affairs is called polarization.
calcium, potassium, chloride) can pass passively Certain neurotoxins work by altering the way
in and out of the cell. Other ions or molecules ion channels normally function, for example,
(e.g., sodium) may require an active transport tetrodotoxin can block and tetraethylammo-
process involving a chemical energy process nium can activate sodium channels.
called an ion pump. Certain events (e.g., synaptic transmission)
A neuron's structure or neuroanatomy also can produce changes in the membrane poten-
determines the ways it can communicate with tials of the postsynaptic neuron. In the discus-
other neurons. For example, monopolar neu- sions below, we arbitrarily designate Cell ªAº as
rons usually have only an axon (e.g., sensory the presynaptic neuron relative to Cell ªB,º the
dorsal root ganglion cells), while bipolar postsynaptic neuron. If events started by
neurons have both dendrites and axons with a postsynaptic NT±receptor interaction lead to
simple structure (e.g., granule cells of the retina, depolarization of the membrane of Cell ªAº
olfactory mucosa, and auditory nerve). On the (i.e., influx of sodium into the cell and a shift
other hand, multipolar neurons have large toward intracellular positivity), then excitatory
dendritic fields with one major axonal output. postsynaptic potentials (EPSPs) are produced.
The latter can be short or long and straight or If, however, the latter events lead to hyperpo-
highly branched, contacting other neurons larization of the membrane of Cell ªAº (i.e.,
(including itself). The latter arrangements mean influx of chloride ions and/or outflow of
that even single neurons may participate in at potassium ions and a further intracellular shift
least three very complex functions. For example, toward negativity), then inhibitory postsynaptic
they may receive and integrate input or potentials (IPSPs) are produced. The membrane
information from many sources. Next, they potential of the postsynaptic neuron (Cell ªAº)
may produce similar effects in many different results from the summation of EPSPs and
neuronal groups simultaneously (e.g., activation IPSPs. Once the postsynaptic membrane
functions during arousal or alerting conditions). reaches a threshold level of depolarization
Finally, they may produce an organized array of (usually at the junction of the cell body and
different effects in different neuronal groups axon), Cell ªAº will ªfireº (excitation). The
(e.g., functions related to induction of ªstates,º latter event involves the propagation of an all-
like rapid eye movement sleep). or-nothing action potential (spike) of marked
depolarization through the axon to the neuron
terminals. Ultimately, the arrival of this action
1.06.2.2 Features of Neuronal Activity and potential at the terminal could result in synaptic
Synaptic Neurotransmission transmitter release, which in turn can act on
postsynaptic receptors of Cell ªB.º Again,
Psychoactive drugs produce behavioral however, if Cell ªBº becomes hyperpolarized,
changes by altering the ways neurons normally then the generation of an action potential
function. We now turn to a brief description of requires much more excitatory input.
bioelectric features of neuronal activity and
transmission, namely, how neurons produce
and detect the electrical or chemical signals just 1.06.2.2.2 Presynaptic events and modulation
described. Small spherical vesicles and other organelles
involved in making or storing NTs are found in
the presynaptic nerve terminals. Only some
1.06.2.2.1 Membrane potentials and neural
synaptic vesicles are bound to the presynaptic
activation
membrane. The arrival of the action potential at
First, to generate neuronal activity some the presynaptic terminal, plus the copresence of
membrane potential must exist. The neural calcium ions (Ca2+), causes some vesicles to
membrane is semipermeable, meaning that it fuse with the membrane and releases packets of
contains ion channels through which some ions NT into the synaptic cleft. Generally, how much
Neurotransmitters and Neuromodulators 177
NT gets released depends on the relative size of insignificant, since thousands of neurons may
the presynaptic action potential and/or the pre- synapse on a given postsynaptic cell. On the
synaptic neuron's firing rate. The latter depend other hand, any direct modulation of the
on the presynaptic membrane's baseline poten- postsynaptic cell will alter all subsequent signal
tial and activation of presynaptic receptors. communication in that pathway. The postsy-
Two general kinds of presynaptic receptors naptic cell's responsiveness to an NT can be
exist. Autoreceptors are found on the axon changed in two principal ways. First, the
terminal, the cell body, or the dendritic region of number of postsynaptic receptors may chroni-
the same neuron that releases the NT. NTs from cally change. Down-regulation refers to a
a different neuron activate heteroreceptors. decrease in receptor sites with prolonged use
Excitatory synaptic input to the presynaptic and/or exposure to an agonist. Up-regulation
terminal produces presynaptic inhibition. In- refers to an increase in receptor sites with
hibition occurs because a depolarized presy- prolonged disuse and/or exposure to an an-
naptic membrane potential will result in a tagonist. Here, the agonist or antagonist agent
smaller amplitude action potential and less NT can be an endogenous substance or an exogen-
release. Inhibitory synaptic input to the pre- ous drug. Second, changes in how tightly an NT
synaptic terminal produces presynaptic facil- binds to the receptor (i.e., affinity) can influence
itation. Here, the hyperpolarized presynaptic the effectiveness of the NT±receptor interac-
membrane potential will result in a larger tion. NTs, neuropeptides, neuromodulators, or
amplitude action potential (and, perhaps, open- drugs can alter affinity (see Section 1.06.2.3).
ing of calcium channels) and therefore, en-
hanced NT release. Again, modulatory factors
include the presynaptic membrane's resting 1.06.2.3 Neural Receptors
potential, adequate synthesis and storage of
NT receptors, obvious targets for psychoac-
the NT, the copresence of neuromodulators
tive drugs, reside outside the cell, within the cell
(e.g., vasopressin) and CA2+, the proportion of
membrane, and inside the cell. These receptors
membrane-bound vesicles, and the active trans-
can be found anywhere on presynaptic and
port of the NT back into the neuron or into
postsynaptic neurons. A receptor is a protein
synaptic vesicles. Psychoactive drugs can act on
membrane site to which a molecule, the ligand,
any of these presynaptic processes, for example,
or the NT, binds. Proteins are long peptides (two
calcium-channel blockers can lower NT release
or more amino acids linked by peptide bonds)
by reducing the availability of this essential ion.
that serve in a structural capacity or as enzymes.
The next issue is whether the NT will
When the ligand normally activates the recep-
effectively activate the postsynaptic receptor.
tor, we call it an agonist. An antagonist refers to
The persistence of NT in the synaptic cleft
a ligand that blocks or prevents the receptor's
depends on the three ways of NT removal: its
normal activation by an agonist. Ligands
metabolism by extracellular enzymes, its reup-
described as inverse agonists have receptor
take into the presynaptic terminal (where the
effects opposite to those produced by agonists,
NT can undergo intracellular metabolism or be
for example, closing rather than opening an ion
taken up into the vesicles), and its attachment of
channel. Partial agonists and partial inverse
NT to a postsynaptic receptor. Again, drugs can
agonists have the same but weaker effects as full
produce changes in any of the latter processes.
agonists or inverse agonists. NTs may produce
depolarization (postsynaptic excitatory and
1.06.2.2.3 Postsynaptic events and modulation presynaptic inhibitory synapses) or hyperpolar-
ization (postsynaptic inhibitory or presynaptic
Events started by the interaction between Cell
excitatory synapses). Here, whether the post-
ªAº 's presynaptic NT and the postsynaptic
synaptic neuron is more or less likely to be
receptor of Cell ªBº can lead to depolarization
activated defines excitation and inhibition.
of the Cell ªBº membrane, producing excitatory
Research has identified two major receptor
postsynaptic potentials (EPSPs). However, the
classes. Iontotropic receptors are ion-gated and
latter events also may lead to hyperpolarization
rapid acting, while metabotropic receptors
of the cell membrane, producing inhibitory
depend on second-messenger processes and
postsynaptic potentials (IPSPs). The membrane
are slower acting.
potential of the postsynaptic neuron results
from the summation of EPSPs and IPSPs and
must reach a threshold of depolarization for 1.06.3 NEUROTRANSMITTERS AND
that cell to fire. NEUROMODULATORS
Sources of modulation of postsynaptic re-
ceptors are more limited. Removal of one Besides the reference works cited above, the
presynaptic input to the postsynaptic cell is interested reader can also refer to three other
resources (Bloom & Kupfert, 1995; Hardman & increased ACh levels. Two major classes of ACh
Limbird, 1996; Schatzberg & Nemeroff, 1995). receptors exist, nicotinic and muscarinic. The
The classical definition of an NT typically muscarinic receptors are metabotropic and can
involves the sequences of events described in the lead to either depolarization or hyperpolariza-
previous section. That is, the transmitter may be tion (for subtypes, see Cooper et al., 1996).
synthesized in the cell body and transported to
the axon terminal or may be synthesized in the
axon terminal; in either case, it is stored in the
1.06.3.1.2 Cholinergic neuropharmacology
terminal. Presynaptic nerve firing releases the
transmitter into the synaptic cleft, where the Pharmacological intervention can occur at
transmitter can produce some variety of most of the steps in cholinergic neurotransmis-
synaptic membrane potential change in pre- sion. The neurotoxin NVP blocks ACh synth-
synaptic or postsynaptic receptors. Finally, the esis and vesamicol, its transport into synaptic
transmitter is removed from the synaptic vesicles. Black widow spider venom promotes
junction by some mechanism. Neuromodula- ACh release, while botulinum toxin and other
tion refers to how each step in the synaptic substances inhibit its release. Rabies and curare
transmission process can be affected by en- block nicotinic receptors, and atropine and
dogenous substances or drugs. This section will pirenzepine block muscarinic receptors. Choli-
review the major classes of CNS NTs. Where nergic neurotransmission sometimes involves
relevant, we will mention the peripheral nervous negative feedback onto presynaptic muscarinic
system (PNS), which also may use a particular receptors which, when blocked with atropine,
NT that is also found in the CNS. For each results in increased release of ACh.
major NT, we briefly introduce the reader to the
NT's functions and then provide a short
description of its synthesis and metabolism,
1.06.3.1.3 Cholinergic pathways
its neuropharmacological action (i.e., depolar-
ization or hyperpolarization), the effects of ACh also serves as the NT at the neuromus-
agonist or antagonist drugs on its functioning, cular junction and at synapses in spinal cord
and the localization/function of neural path- autonomic ganglia and the parasympathetic
ways that use the NT. autonomic nervous system. Myasthenia gravis,
an autoimmune disease associated with pro-
gressive loss of muscle tone, results from
1.06.3.1 Acetylcholine (ACh) damage and antagonism of the ACh receptor.
Within the brain, cholinergic neurons may be
ACh is an NT found in brain, spinal cord, short regional interneurons (e.g., nucleus ac-
nerve endings in muscle, ganglia of the cumbens, caudate-putamen) or long projection
autonomic nervous system (ANS), and post- neurons connecting several brain areas. The
ganglionic terminals of the parasympathetic most common degenerative neurological dis-
division of the ANS. As described below, this orders involve some loss of normal cholinergic
transmitter plays a major CNS role in arousal, function, for example, Huntington's chorea
memory, and other functions. In the periphery, (striatum) and Alzheimer's disease (nucleus
besides its role in parasympathetic function, it is basalis, neocortex, and hippocampus). Unfor-
the major transmitter innervating somatic tunately, attempts to promote ACh activity
muscles. Not surprisingly, peripheral dysfunc- have not worked well (choline, anticholinester-
tion produces motor impairment and central ase, ACh-receptor agonists).
dysfunction can produce both alterations in The two main cholinergic projection path-
states of consciousness (e.g., sleep) and memory ways are the basal forebrain system and the
function (see discussion in this section and in pons-midbrain system. Cholinergic neurons
Section 1.06.6.11). with cell bodies in the basal forebrain send
axons to most of the nonstriatal telencephalon.
The important higher cognitive functions
1.06.3.1.1 Cholinergic neurotransmission and
include attention and memory. Axons of
receptors
cholinergic neurons with cell bodies in the
Cholinergic neurons release ACh from axon midbrain and pons (the reticular activating
terminals. ACh is synthesized from choline, system) bifurcate. They send projections both
which is transported into neurons. The enzyme rostral (up) and caudal (down) to affect wide
acetylcholinesterase metabolizes ACh Impor- areas of the brain. These pathways serve both
tantly, anticholinesterases, such as those found activating and integrative functions, promoting
in insecticides (e.g., physostigmine-reversible) arousal, waking, and even rapid eye movement
or nerve gases (soman-irreversible), result in sleep.
1.06.3.2 Norepinephrine (NE) and Epinephrine release), b1 (located in the brain and in the
(Epi) periphery, where activation produces cardiac
stimulation) and b2 (located in the brain and in
NE is a major NT in the brain and in the the periphery, where activation relaxes smooth
postganglionic terminal endings of the sympa- muscles). Adrenergic receptors in the periphery
thetic division of the ANS (notably the (adrenal gland, heart, blood vessels, etc.) are
cardiovascular system). NE, along with Epi, called adrenoceptors. NE and Epi are equally
also serves as a hormone (release from the effective at b1-adrenoceptors, but Epi is more
adrenal medulla) involved in a host of periph- effective than NE at b2-adrenoceptors. CA
eral ANS functions (notable cardiovascular receptors on non-CA neurons are generally
activity). In the CNS, as described below, NE is postsynaptic receptors, with presynaptic auto-
the NT for cells in the brainstem which serve receptors located in the CA neuron itself.
arousal functions involved in attention, mood, CA-NTs acting on autoreceptors regulate the
and waking. Accordingly, dysfunctions in these release of all CAs. Activation of presynaptic a2-
CNS systems have been implicated in mood and adrenergic, muscarinic, opiate and DA auto-
anxiety disorders (see Section 1.06.6). receptors produces inhibition of NE release,
while presynaptic b2-adrenergic, nicotinic, and
angiotensin II receptor activation results in
1.06.3.2.1 Catecholaminergic neurotransmission
facilitation of NE release. Further, prolonged
and receptors
exposure to any of the CA or agonist-like drugs
Three NTs make up the group called the (e.g., reuptake blockers) can lead to a sub-
catecholamines (CA)ÐNE, epinephrine (Epi), sensitivity or desensitization of the receptor and
and dopamine (DA)Ðso-called because of the even a decrease in the number of receptors
common catechol chemical structure. Adrener- (down-regulation). This reduction in respon-
gic NTs include just NE and Epi and biogenic siveness to stimuli, inputs, or agents can be
amine NTs include CA-NTs plus indole amine nonspecific (many agents) or specific (one
NTs (e.g., serotonin). The primary synthesis agent). On the other hand, prolonged reduced
pathway for all three CA-NTs starts with the exposure to any of the CA receptors to the NT
amino acid tyrosine that undergoes enzymatic can lead to a supersensitivity of the CA receptor
conversion to DOPA (3,4-dihydroxyphenylala- to agonist agents and even an increase in the
nine). From DOPA, the synthesis path leads number of receptors (up-regulation). The latter
first to DA, then to NE (via DA-b-hydroxylase), situation could arise from destruction of CA
and finally to Epi. Monoamine oxidase (MAO) neurons or from a reduced synthesis or
primarily degrades CAs inside the presynaptic increased metabolism of CA-NTs. Essentially,
terminal, while catechol-O-methyltransferase drugs acting on the CA systems can affect both
(COMT) metabolizes CAs in the synaptic cardiovascular and a host of other neural
junction. However, most of the CA-NT is taken activities.
up into the presynaptic cell and restored in
vesicles. Many factors affect the rate of CA
1.06.3.2.2 NE neuropharmacology
synthesis, including the concentration of the NT
itself (end-product inhibition). The rate and In PNS and CNS NE neurons, drugs can
pattern of CA neuron firing can increase its affect adrenergic activity in at least four general
synthesis and turnover or metabolism. A major ways. Drugs can act: (i) presynaptically to block
metabolite of central NE is 3-methoxy-4- NE synthesis (a-methyltyrosine, Fla-63), sto-
hydroxy-phenethyleneglycol (MHPG), mea- rage (reserpine, tetrabenazine), release (amphe-
sured in blood or urine as an indicator of tamine), and reuptake (amphetamine, cocaine,
central NE production. desipramine); (ii) postsynaptically to block
In mammals, NE is the major NT for the (phenoxybenzamine, phentolamine) or mimic
peripheral sympathetic nervous system (PNS) (clonidine) the action of the NT on postsynaptic
and the CNS, with lesser concentrations of Epi receptors; (iii) on autoreceptors to indirectly
found in both CNS and PNS. Noradrenergic, influence catecholamine activity (a2-agonistÐ
adrenergic, and dopaminergic neurons respec- clonidine; a2-antagonistsÐyohimbine, piperox-
tively use NE, Epi, or DA as their NT. NE and an); and (iv) to inhibit the metabolism of NE in
Epi appear to act at one or more of four kinds of the synaptic cleft (pargyline) or presynaptic
adrenergic receptors, located presynaptically terminal (tropolone).
and/or postsynaptically: a1 (a postsynaptic
receptor in the brain and in the periphery,
1.06.3.2.3 Noradrenergic pathways
where activation contracts smooth muscle), a2
(located in the brain and in the periphery, where Since late 1960s, fluorescence histochemical
it is a presynaptic receptor modulating NE and other methods have permitted a quite
detailed picture of catecholamine pathways. NE. DA release depends on the presence of

The locus coeruleus (LC) comprises the main calcium ions presynaptically and on the rate and
brainstem area from which axons of NE pattern of firing in the presynaptic cell, with
neurons arise. These neurons act to inhibit cells burst-firing producing enhanced DA release.
on which they synapse by way of the slower Since DA neurons have presynaptic inhibitory
metabotropic-receptor hypopolarization pro- autoreceptors, DA agonists inhibit, while DA
cess. Cell bodies of the large LC neurons are antagonists enhance DA release. Like NE and
found in the caudal pontine central grey. LC Epi, the major way DA is removed from the
axons typically form long and extensively synaptic cleft is by reuptake into the presynaptic
branched projections over five major pathways neuron. This process involves a DA transporter.
to widely separated areas of the brain. Their We now know that several DA-specific com-
targets include all the cortices (probably b- pounds can selectively block this reuptake
adrenergic receptors) and all the specific process to enhance DA activity. Cocaine and
thalamic and hypothalamic nuclei. The projec- amphetamine are examples of nonspecific
tion patterns of central adrenergic neurons reuptake blockers.
suggest some general action on most of the
forebrain and on autonomic activity. Empirical
1.06.3.3.2 Dopamine pathways
data showing increased LC responsiveness to
novel events argues for some role in vigilance, Dopamine neuron cell bodies, largely found
while other data suggest some role in stress- in the midbrain and hypothalamus, are three to
related processes. The potential functions for four times more numerous than NE neurons.
LC adrenergic neurons are large, for example, Middle-length DA pathways connect areas of
sleep and waking, reinforcement, memory the hypothalamus with the pituitary (involved
formation, affective functions and dysfunctions, in prolactin secretion), other areas of the
and anxiety±pain interactions (see Bloom & hypothalamus, and limbic system and areas of
Kupfer, 1995). the medulla with other brainstem regions. The
long-length DA neurons arise from cell bodies
in the ventral tegmental (VTA) and substantia
1.06.3.3 Dopamine (DA) nigra (SN, nigrostriatal system) areas of the
midbrain. SN-DA neurons project to the basal
Dopamine, also a catecholamine, is an NT ganglia (neostriatum: caudate and putamen
involved in three major systems associated with areas) and serve to activate and organize motor
activation of motoric, motivational (reward), functions (damage and/or dysfunction of these
and learning processes. These systems are cells is found in Parkinson's disease). Like most
described below. Dysfunction or alteration of DA projection systems, the nigrostriatal system
any one of these systems can have profound contains interactive, reciprocal connections, so
consequences, including integrated movements that innervation of striatal neurons results in a
and cognitions, including persistent and abnor- decrease in SN-DA activity. VTA-DA neurons
mal ideations, movements, and behaviors (see form two projection systems, the mesocortical
Sections 1.06.6.8, 1.06.6.9, and 1.06.6.11. system projecting to limbic cortical areas and
the mesolimbic system projecting to deeper
limbic areas (e.g., nucleus accumbens, and the
1.06.3.3.1 Dopaminergic neurotransmission
amygdala). Generally, the mesocortical and
Neurons using DA as their NT have both mesolimbic systems serve affective and motiva-
similarities (synthesis and metabolism) and tional functions. These brain areas appear
differences (organizational complexity) relative responsive to positive and negative events or
to adrenergic neurons. It has already been stated states (stress, conditioned fear, pain and
that the synthesis or production of DA is just pleasure). Further, they modulate the conse-
like that for NE and Epi. What is different in the quences of such events (affective states like
DA neuron is the absence of dopamine b- anxiety and ªcognitiveº processes like reinfor-
hydroxylase, which would convert DA to NE. cement; see Bloom & Kupfer, 1995; Wise, 1990).
In the presynaptic cell, MAO converts DA to The DA projections largely function to inhibit
dihydroxyphenylacetic acid (DOPAC). After their targets.
release from the presynaptic terminal, COMT
converts DA to 3-MT (3-methoxytyramine) and
1.06.3.3.3 Dopamine receptors
MAO converts 3-MT to homovanillic acid
(HVA). In humans, HVA, the primary DA Postsynaptic targets use both of the two major
metabolite, provides a good indicator of DA DA receptor subtypes, D1 and D2. DA-auto-
activity when measured in cerebral spinal fluid. receptors (located on all parts of the DA neuron)
The regulation of DA levels is similar to that for typically are D2 receptors. Activation of auto-
receptors on the cell body or dendrites slow the pathways (SN), but not others (mesolimbic and
firing rate of the DA cell, while those at the axon mesocortical), tolerance to antipsychotics oc-
terminal can inhibit DA release or synthesis. Not curs. A return to baseline levels of DA activity,
surprisingly, autoreceptors located far from the release, and metabolism after long-term treat-
cell body synthesis apparatus (e.g., prefrontal or ment illustrates the latter effect.
cingulate cortices) only possess the inhibition of Various antipsychotics, such as phenothia-
release property. Both D1 and D2 receptors are zenes (e.g., chlorpromazine), thioxanthines, and
metabotropic, involving the second messenger butyrophenones act as DA antagonists. The
adenylate cyclase, but D1 activation stimulates resulting reduction of DA function produces
while D2 activation inhibits adenylate cyclase. extrapyramidal (i.e., found outside the primary
Further, D2 receptors are five to ten times more pyramidal motor system) motor side-effects and
sensitive than D1 receptors to DA (or DA the alleviation of psychotic symptoms. How-
agonists like apomorphine). Thus, low doses of ever, these antipsychotics also can increase DA
DA agonists will first affect these autoreceptors, turnover, presumably by blocking autorecep-
resulting in a net reduction in DA function. tors, which would normally decrease DA
Higher doses, of course, will override this effect function. On the other hand, several drugs
and stimulate postsynaptic receptors. Never- can enhance DA activity. Amphetamine and
theless, postsynaptically, a maximal DA effect on cocaine block DA reuptake and amphetamine
behavior or brain activity may require activation may induce the release of DA. At high doses,
of both D1 and D2 receptors. All DA receptors amphetamine and cocaine will produce a
can develop supersensitivity and desensitization psychotic state that is reversible with antipsy-
with changes in the chronic level of DA activity. chotics (this has suggested a pharmacological
So in Parkinson's disease, the loss of SN input model for schizophrenia). Nomifensine and
produces an increase in striatal D1 and D2 benztropine, an anticholinergic drug, also block
receptor density. Increases in D2 receptor density DA reuptake. Pargyline enhances DA function
also are found in the brains of postmortem by MAO inhibition (MAOI). MAO would
schizophrenics. However, the presynaptic auto- normally degrade intraneuronal DA. All anti-
receptors appear more likely to show desensiti- depressive drugs that are MAOIs will increase
zation. This means that chronic DA-mediated the amount of DA available for release.
drug therapy may fluctuate in its efficacy. Tropolone, which inhibits COMT, can block
Two other DA receptors are subtypes of the the degradation of extraneuronal DA.
D2 receptor. D3 receptors are densest in limbic
brain areas and have a much higher affinity for
specific DA agonists. In primates, the density of 1.06.3.4 Serotonin (5-hydroxytryptamine,
a D4 receptor subtype is highest in the frontal 5-HT)
cortex, midbrain, amygdala, and medulla and
lowest in the basal ganglia. Of interest, the D3 Serotonin, an indole amine like melatonin,
and D4 subtypes have a higher affinity for the functions as an NT for cells residing in the
atypical antipsychotic Clozapine, which has few brainstem. These cells project down into the
basal ganglia side-effects. spinal cord and upwards into many areas of the
brain. 5-HT also functions as an NT in the
periphery (gut and blood vessels). 5-HT, as
1.06.3.3.4 Dopamine neuropharmacology described below, apparently has sometimes
The same drugs affect NE and DA synthesis, subtle, regulatory functions for mood, sleep/
storage, release, reuptake, and metabolism. All waking, and motivated behaviors. Clinically,
CAs produce end-product inhibition of tyrosine drugs that enhance 5-HT levels have antide-
hydroxylase (TH) which converts tyrosine to pressive effect and may stabilize excessive
DOPA. Increased neuronal firing changes TH behavior patterns (see Sections 1.06.6.1 and
from a low-affinity to a high-affinity form and 1.06.6.5).
increases speed of this conversion. a-methyltyr-
osine inhibits TH, thereby reducing the produc-
1.06.3.4.1 Serotonin neurotransmission
tion of DOPA. DOPA is very rapidly
metabolized, so administering L-DOPA dra- Serotonin (5-HT) synthesis starts with the
matically increases the production of DA. DA essential amino acid tryptophan. Tryptophan is
end-product inhibition of DA synthesis and converted to 5-hydroxytryptophan, which then
release also occurs when DA binds with is converted into 5-HT. As an interesting side
presynaptic receptors. DA agonists (apomor- note, 5-HT in the pineal body is converted to
phine) can inhibit synthesis and release of DA, melatonin. MAO breaks 5-HT down into 5-
and DA antagonists (antipsychotics like halo- hydroxyindoleacetaldehyde, which is further re-
peridol) can enhance them. However, in certain duced to 5-hydroxyindoleacetic acid (5-HIAA).
Unlike the CAs, 5-HT and 5-HIAA do not spinal cord, and others project rostrally to the
inhibit the synthesis of 5-HT and its metabolites. limbic system, striatum, thalamus, and cerebral
However, blocking their catabolism results in cortex. Research has discovered two different
linear increases in both. Several avenues can types of neurons: fat beaded axons from the
regulate the production and release of serotonin, median raphe and fine axons from the dorsal
including diet. raphe. Research reveals that the fine axons are
more sensitive to MDMA, taken recreationally
under the name ªEcstasy.º MDMA produces a
1.06.3.4.2 5-HT neuropharmacology
profound loss of these axons that lasts for at
5-HT is primarily found in peripheral tissues, least months, if not forever. MDMA users have
with only 1±2% found in the brain. Like the a measurable loss of function of 5-HT metabo-
CAs, 5-HT binds to many different receptors, lism and catabolism.
but unlike the CAs, different 5-HT receptors
mediate very different functions. We know of
four 5-HT1 receptors, four 5-HT2 receptors, and 1.06.3.5 Amino Acid NTs
five 5-HT3±7 receptors. The most well-re-
searched receptor is the 5-HT1a receptor. Some Certain amino acids have also been found in
psychiatrists use buspirone, a possible selective the brain and appear to act as NTs. Strictly
antagonist for this receptor, to treat many speaking, however, many amino acid NTs have
anxiety disorders. Ondansetron and granise- not yet met all the criteria for being called NTs.
tron, treatments for chemotherapy-induced Despite this, they are the most widespread of all
nausea and vomiting, antagonize the 5-HT3 the NTs. CAs and acetylcholine NTs are better
receptor. The atypical antipsychotic Clozapine researched, but account for only a small part of
antagonizes 5-HT6 and 5-HT7 receptors, and neurotransmission in the brain. g-aminobutyric
amitryptaline, a tricyclic antidepressive, also acid (GABA) and glycine are the primary,
antagonizes the 5-HT7 receptor. 5-HT functions inhibitory NTs and glutamate and aspartate are
primarily as an inhibitory NT, causing a the excitatory NTs. Both excitatory (NMDA)
decrease in tonic firing. 5-HT activity is highest and inhibitory amino acid NT mechanisms
in states of physiological arousal, lowest in appear to function in one or more components
sleep, and completely absent in REM sleep. of learning and memory processes.
Therefore, an association between increased
motor activity and increased 5-HT may exist.
1.06.3.5.1 g-Aminobutyric acid (GABA)
This apparently paradoxical action may occur
by increased inhibition of inhibitory neurons. Of the two inhibitory amino acid NTs, GABA
The administration of p-chlorophenylalanine has been the subject of more research, possibly
hampers enzymatic conversion, competing with because of its primary location in the CNS.
tryptophan for access to the enzyme. After GABA's particular interest lies in the benzo-
synthesis, 5-HT is stored in and released from diazepine (BZD) receptor, which is part of the
presynaptic vesicles, just like the CAs. As a receptor complex. Activation of this receptor
result, reserpine will interfere with the storage produces anxiolytic (anxiety-reducing) effects
mechanism of 5-HT as well. The recreational (see Section 1.06.6 on anxiety disorders). Also of
drug lysergic acid diethylamide (LSD) is a interest is the fact that the compounds which
partial agonist on presynaptic and postsynaptic block activation of GABA or BZD receptors
5-HT receptors. It functions to reduce 5-HT can produce proconvulsant effects (i.e., in-
release. As mentioned above, buspirone is a 5- creased likelihood of seizures).
HT1a antagonist, which causes reduced binding The synthesis of GABA begins with gluta-
of 5-HT. MAO inhibitors (MAOI) slow the mine, which is then converted to glutamate (an
degradation of 5-HT in the cell, allowing more excitatory NT, also known as glutamic acid).
storage of 5-HT in vesicles. Since the 1980s, Glutamate is then converted to GABA by
fluoxetine, fluvoxamine, sertraline, and parox- glutamic acid decarboxylase (GAD). GABA-
etine have been found to act as selective transaminase (GABA-T) metabolizes GABA.
serotonin reuptake inhibitors (SSRI). They Both GAD and GABA-T require pyridoxine (a
serve to increase the amount of 5-HT in the form of vitamin B6) as a coenzyme, although in
synaptic junction. differing affinities. As a result, pyridoxine
deficiency causes an increased susceptibility to
seizures due to the reduced production of
1.06.3.4.3 5-HT pathways
GABA. Pyridoxine deficiency occurs most
5-HT-containing neurons cluster in the raphe commonly in infants with a vitamin B6
nuclei, near the midline of the upper brainstem. deficiency, and the resulting seizures can be
Some nuclei project caudally to the medulla and fatal.
Research identifies two classes of GABA in metabolic pathways, and glutamate is

receptors: GABAA and GABAB. GABAA has a involved in GABA synthesis. Thus, differentiat-
gated chloride (C17) channel, with binding sites ing between these functions and any NT activity
for GABA, BZDs, barbiturates, steroids, and the compounds may have is difficult. However,
picrotoxin. BZDs increase the frequency of research has discovered five different types of
opening of the Cl7 channel, and barbiturates excitatory amino acid receptors, the best-known
increase the duration of channel opening, thus of which is the NMDA receptor. The NMDA
potentiating GABA's inhibition of neuronal receptor has binding sites for both glutamate
activity. Both ethanol and certain neurosteroids and a particular kind of glycine molecule.
also appear to increase GABA activity. Inverse Phencyclidine (PCP) is an NMDA channel
agonists like beta-carbolines also act at the BZD blocker and a drug of abuse. NMDA receptors
receptor site but close the Cl7 channel. The appear to affect memory and developmental
latter effect is similar to that produced by plasticity, having high densities in hippocampal
proconvulsants such as pentylenetetrazol (me- and cortical areas.
trazol), which act at the picrotoxin site. GABAB
receptors are less common than GABAA
receptors in the CNS and are not linked to 1.06.3.6 Neuroactive Peptides and Hormones
Cl7 channels or affected by BZDs or barbitu-
rates. Baclofen is a well-known agonist for Neuroactive peptides are protein fragments,
GABAB receptors. cleaved from larger compounds. Peptides,
As mentioned above, BZDs and barbiturates known mostly to coexist with other NTs, enrich
potentiate the effects of GABA at postsynaptic the effect of the classical NT. For example, a
receptors, which may explain their common peptide may alter the rate of production of
anxiolytic action. Flumazenil, a benzodiazepine another NT or strengthen or prolong the effect
antagonist, can block this effect. The GABA of an NT. Hormones are substances that are
agonist muscimol will activate GABAA post- released from one location and travel to another
synaptic receptors, and bicuculline and picro- location to act on receptors there. These
toxin will block postsynaptic GABA receptors. compounds may act both on CNS and
One can also inhibit degradation of GABA with peripheral organ systems.
gabaculine, which is an inhibitor of GABA-T. Opioid peptides, also known as endorphins,
GABA travels in two long pathways and in mimic endogenous morphine-like substances
short interneurons of the cortex, hippocampus, that have antinociceptive (i.e., antipain) proper-
and spinal cord. GABA is the primary NT in ties. The class of opioid peptides includes
striatal neurons that project to the substantia proopiomelanocortin (POMC) peptides (e.g.,
nigra, which is the brain site with the highest b-endorphin, a-MSH, ACTH), proenkephalin
concentration of GABA. peptides (e.g., met- & leu-enkephalin), and
prodynorphin peptides (e.g., dynorphin A & B).
The enkephalin peptides may act as NTS
1.06.3.5.2 Glycine
(Carlson, 1994). The four major kinds of opiate
Glycine is very widespread throughout the receptors are mu, kappa, delta, and sigma.
human body, in part because it is a necessary Kappa receptors, largely located in the dorsal
component of many metabolic pathways. horn of the spinal cord, induce analgesia by
However, research has discovered evidence that depressing the initial site of pain transmission.
it also functions as an NT in inhibitory The mu receptors, primarily found in the medial
interneurons of the spinal cord, lower brain thalamus and brainstem, mediate morphine-
stem, and possibly the retina. Strychnine induced analgesia and morphine's sedative,
appears to block the inhibitory effects of respiratory depressant, miotic, euphoric, and
glycine. physical dependence properties. Delta receptors
largely overlap both mu receptor location and,
to a lesser extent, its effects. Activation of the
1.06.3.5.3 Glutamate and aspartate
opiate sigma receptors, primarily found in the
Glutamate and aspartate occur in high limbic system (hippocampus and amygdala) can
concentrations in the brain and exert powerful result in psychotomimetic, hallucinatory, and
excitation on neurons. Thus, it is likely that dysphoric responses.
these compounds act as excitatory NTs. Part of Several other neuroactive peptides are
their function may involve the establishment of equally well-researched. Two, released from
new functional connections between neurons, the posterior pituitary, vasopressin (AVP,
but dysregulation of their receptors also may antidiuretic hormone) and oxytocin, respec-
produce hyperexcitability, including seizures tively, causes the kidneys to retain more water
and even cell death. Each compound also serves and cause contractions of smooth muscles of
milk ducts and the male and female sexual and in the various sleep disorder syndromes.
systems. Substance P, a tachykinin, is thought to Further, the neuromodulator adenosine also
act as a sensory (pain) NT or modulator. may act to inhibit cholinergic activation of the
Neurotensin, colocalized in some DA and NE frontal cortex by the midbrain reticular
neurons, can intensify the actions of those NTS. formation. The latter reticular effect thought
Glucagon-related peptides, like vasoactive in- to be important in arousal functions and in the
testinal polypeptide (VIP), colocalize with ACh. present context is interesting since caffeine and
in parasympathetic systems, particularly those other xanthene compounds inhibit adenosine's
of the gut. Pancreatic-related polypeptides, like actions.
neuropeptide Y, colocalize with the NTs, NE
and Epi, affecting the action of these NTs in the
brain (e.g., limbic system) and smooth muscle in 1.06.4 BASIC PHARMACOLOGY
the periphery. Some hormones are peptides, like This section reviews three topics relevant to a
AVP, oxytocin, b-endorphin, and ACTH, but general understanding of psychopharmacology.
others are steroids (small fat soluble molecules), Pharmacokinetics refer to the principles and
like cortisol, corticotropin-releasing hormone processes governing how the body absorbs,
(CRH), and sex hormones. Neuroactive pep- distributes, and eliminates drugs. Pharmacody-
tides and hormones are occasionally, but rarely, namics define the ways in which targets of drugs
administered exogenously. These peptides may (i.e., drug receptors) behave. The subsection on
mediate psychological or neurological disorders interaction between drugs and receptors begins
or modulate CNS drug actions (see Cooper to introduce some functional ways in which
et al., 1996). drugs can affect the CNS. Pertinent reference
works for the latter two topics include those by
Smith and Darlington (1996), Hardman and
1.06.3.6.1 Other neuromodulators Limbird (1996), Dyskstra (1992), Johanson
Clearly, there are a host of other neuropep- (1992), and Julien (1997).
tides and neuromodulatory compounds not
described in the above discussion. Neuropep- 1.06.4.1 Pharmacokinetics
tides include those involved in regulatory
processes related to water balance and thirst 1.06.4.1.1 Drug administration and absorption
(e.g., angiotensin II), to nutritional balance, to
growth, and/or to gastrointestinal function Bioavailability refers to that fraction of
(e.g., somatostatin, cholecystokinin). Other unchanged drug reaching systemic circulation,
neuromodulators include adenosine (which is whatever the route of administration. Drug
found at most synapses) and a large class of absorption depends on the drug dose, the drug
second messengers. The second messenger formulation and the route of administration.
compounds (including cyclic AMP and GMP, Selection of a drug dose, usually calculated in
calcium/calmodulin, phosphoinositide, and ei- drug weight per body weight, depends on many
cosanoids) serve to mediate the initial reaction factors. The initial therapeutic window defines
produced by NT-receptor binding by activating the drug concentration in the body that
intracellular enzymes called protein kinases. produces the desired effect without intolerable
side-effects. Development of tolerance (require-
ment of a higher dose for the same effect) or
1.06.3.7 The Neuropharmacology of Normal sensitization (requirement of a lower dose for
Behavioral Functions the same effect), respectively, might call for the
upward or downward adjustment of the dose.
Many books devote considerable space to the Incomplete absorption or reabsorption of the
description of the neuropharmacology of drug from the bloodstream into the body tissue
psychological or behaviorally related physiolo- can occur before or after first-pass metabolism
gical functions (see Carlson, 1994). Chapter by the liver, thereby reducing the drug con-
1.05 also discusses some of this information. centration in the blood. The time that the drug
However, a very brief mention of one function concentration in the blood is above the
should serve to illustrate the multiple involve- minimum effective concentration determines
ment of the various NT and neuromodulatory the intensity duration of the drug effect.
systems. Reciprocal inhibitory interactions Drug formulation or preparation (i.e., cap-
among cholinergic (giant-celled, lateral reticu- sule, tablet, liquid, injection, vapor) depends on
lar area of the pons), serotonergic (raphe nuclei the route of administration and absorption. The
in brainstem), and noradrenergic (locus coer- latter include administering the drug by oral
uleus) areas of the brainstem have been intake through the mouth, by insertion into the
implicated in the regulation of sleep and waking rectum, by injection (parenterally through the
Basic Pharmacology 185
skin), by inhalation through the lungs, or by cules can passively diffuse or be transported
application and absorption through mucous across membranes. Drugs that are large water-
membranes (nose, mouth, etc.). soluble molecules require active transport
Oral drugs must be soluble and stable in the across membranes. The blood±brain barrier (a
stomach and permeable across stomach or capillary-glial cell layer) admits nonionized,
intestinal lining to enter the bloodstream lipid-soluble drugs, but excludes ionized, water-
(factors include stomach/intestinal acidity or soluble drugs. Whether the drug reaches the
pH and the drug's lipid or water-soluble CNS depends on the extent to which it stays in
properties (see below). the blood, bound to proteins and how well it
Parenteral administration requires that the passes the blood±brain barrier. Similarly, lipid-
drug (drogue, French for ªa dry powderº) be soluble drugs can readily pass the placental
dissolved or suspended in a vehicle, usually barrier. Drug risk for the fetus is greatest both
physiological or normal saline (0.9% NaCl, early (teratogenesis) and late (respiratory
table salt in water). Potential problems arising depression) in pregnancy. The circulatory
with drug injections include rapid absorption, system rapidly distributes drugs through the
the necessity of sterile technique, and lack of body, unless the drug is bound to blood-borne
ªrecallability.º Absorption is not a factor with proteins. However, not all water-soluble drugs
intravenous (IV, into the vein) injections, where are bound to plasma, for example, the lithium
the effect can be immediate. Licensed health ion.
professionals find this method useful for
emergencies, dose control, and large volumes
1.06.4.1.3 Elimination
and/or diluted irritating agents. However, the IV
route involves potential increased risks for Clearance refers to the rate of elimination of
untoward effects, requires slower injection rates, the drug in urine relative to its concentration in
and cannot be used for oily or insoluble agents. blood (or any tissue). Some maintenance
Intramuscular (IM, into the muscle) and concentrations will achieve a steady-state drug
subcutaneous (SC, under the skin) injections level when rate of drug administration equals
also can produce an immediate response with the total rate of clearance. A drug's half-life is
aqueous substances, with sustained drug blood the time required for a drug to reach 50% of
levels. IM injections can prove useful for the steady-state levels during administration or to
administration of moderate volumes and of oily decay 50% from steady-state levels after
and some irritating agents. However, they administration ceases. Time-course versus
cannot be used with anticoagulant drugs and drug-concentration curves map both absorp-
can interfere with some medical assays. SC tion and elimination processes.
injections can be useful for insoluble agents or Elimination mechanisms involve the meta-
pellets, but cannot be used for large volumes bolism (breakdown) of drugs by one of four
and can produce pain and necrosis. Intraper- major metabolic routes: oxidation, reduction,
itoneal (IP, into abdominal or peritoneal cavity) hydrolysis, and conjugation. Liver and blood-
injections are rarely used in humans. borne enzymes convert drugs into ionized and
Rectal drug administration may be expedient excretable metabolites. First-pass metabolism
but absorption is variable. Drugs absorbed (FPM) refers to the initial transport of the drug
through mucus membranes (nose, mouth, to the liver via the arterial portal system. Here,
rectum) generally enter the blood steam directly much of it is broken down by one or more of the
(e.g., nicotine gum, nasal decongestants). In- several metabolic pathways. The rate of
halation of gaseous drugs produces rapid metabolism varies with drug and route of
absorption, but little is known about inhalation administration, for example, FPM is greater
of particulates (e.g., smoke). with oral than intravenous routes of adminis-
tration. Drugs and their metabolites are
excreted though the kidney, lungs, or bile, but
1.06.4.1.2 Drug distribution
also in sweat, saliva, and breast milk. The rate of
The volume of drug distribution refers to the metabolism may depend on several factors.
quantity of the drug in the body tissue relative to Enzyme induction promotes increased enzyme
blood or plasma. This measure depends on the activity (see Section 1.06.5.2), depression of
degree to which the drug exists in an ionized or a enzymes produced by drug accumulation (e.g.,
nonionized, lipid (fat) soluble state, and binds to disulfiram blocks metabolism of the alcohol
proteins in blood limits its entry into tissue. metabolite acetaldehyde). Other metabolic
These factors determines what tissue a drug can factors include age, gender, circadian rhythms,
enter. Finally, drugs must be transported across nutrition, disease state, and genetics (including
membranes (usually in capillaries). Drugs that ethnicity). Most drug interactions also depend
are lipid-soluble or small water-soluble mole- on metabolic factors. (For a description of
metabolic pathways in the CNS, see Cooper receptor, thereby positively or negatively reg-
et al., 1996). Clearly, metabolism also affects the ulating its affinity for the primary endogenous
therapeutic window. ligand. For example, at the GABAA receptor
complex, BZD agonists enhance and inverse
agonists retard activation of GABAA receptor
1.06.4.2 Pharmacodynamics activation.
1.06.4.2.1 Receptor theory
A receptor is a binding site (a protein 1.06.4.2.3 Types of drug-receptor interactions
membrane component) to which a ligand, the These interactions determine how drugs affect
drug, can bind. This event produces an intra- cell function (see Smith & Darlington, 1996).
cellular action that results in some drug effect. Activation of extracellular receptors can open an
Yet drugs can bind to many cellular sites other ion channel, for example, the action of BZDs on
than NT receptors. For example, the D2 receptor the GABAA receptor Cl7 channel. Stimulation
is the primary target site for chlorpromazine, an of extracellular receptors coupled to an inter-
antipsychotic, and for endogenous dopamine. mediary G-protein can produce intracellular
However, the enzyme inositol-1-phosphatase enzyme changes (tetrahydrocannabinoids).
may be the receptor for lithium, and a calcium Triggering of extracellular receptors on a
channel the receptor for verapamil. transmembrane protein can effect intracellular
enzyme changes. Finally, drugs can be directly
1.06.4.2.2 Drug receptor properties transported across membranes to affect recep-
tors in the cell nucleus, for example, steroids.
Drug receptors have several distinctive prop- At least three types of receptor antagonism
erties. Generally, a limited number of receptors exist. Competitive antagonists bind to the same
exist, and the extent to which the drug molecules site as the agonist and compete with the agonist
occupy these sites varies with its concentration. for that site. Noncompetitive antagonists bind
Saturability defines the size of this effect with to a site different from that to which the agonist
maximum saturation occurring with occupation binds but block receptor activation by the
of all the sites. Receptor selectivity refers to the agonist. Finally, partial antagonists, or mixed
extent to which a receptor binds with a agonists and antagonists have agonist proper-
particular drug rather than other molecules. ties with submaximal efficacy.
Selectivity depends both on the receptor and on
the size, shape, and bioelectrical charge of the
drug molecule. Reversibility of drug/receptor 1.06.5 PRINCIPLES OF BEHAVIORAL
binding occurs, since the latter interaction is PHARMACOLOGY AND
generally not permanent. PSYCHOPHARMACOLOGY
How avidly or ªtightlyº a receptor binds a Much of the information described below
given drug molecule is described as its affinity. also applies to most nonbehavioral physiologi-
Receptors with high affinity for a drug require a cal measures of drug effects, for example, heart
lower drug concentration for full saturation. For rate and endocrine effects. Behavioral pharma-
example, agonists and antagonists could bind to cology (usually preclinical, animal studies) or
the same receptor but differ in their affinity. A psychopharmacology (usually human, clinical
high affinity agonist and low affinity antagonist studies) defines the special principles or factors
could lead to an insurmountable drug effect. one should address when considering drug
Efficacy refers to the size of the intracellular actions on behavioral or mental processes.
or drug effect when the drug and receptor Some references relevant to this topic include
interact. Zero efficacy drugs include receptor those by Bloom and Kupfer (1995), Carlton
antagonists, which generally have no effect (1983), Leonard (1992), McKim (1986), and the
other than preventing the receptor from being volumes edited by Goldberg and Stolerman
activated by an agonist drug. A full agonist drug (1986), by Grabowski and VandenBos (1992)
has high efficacy and can produce the maximum and by Thompson, Dews, and Barratt (1987).
effect on receptors at a sufficient concentration.
Partial agonist or inverse agonist drugs have a
lower efficacy and cannot produce the maximal 1.06.5.1 Behavioral Drug Properties
effect at any drug concentration level.
1.06.5.1.1 Dose±effect curves (DEC)
Allosteric regulation of receptors with multi-
ple binding sites can occur. Allosteric (ªother Plotting drug effect against drug dose or
sideº) binding sites are usually sites other than concentration conveniently illustrates a variety
that for the endogenous agonist. Activation of of drug properties, individual differences in
these sites can change the shape of the NT drug action, and changes in drug action over
Principles of Behavioral Pharmacology and Psychopharmacology 187
time. Several standard types of dose±response tably alter drug potency and/or efficacy, for
relationships have been identified. Lawful and example, age, gender, ethnicity, prior drug
constant rates of change in response with history, and current psychiatric status.
increases in the dose describe linear DECs
(rarely demonstrated across all doses). With
sigmoidal DECs, the typical dose±response 1.06.5.2 Drug Tolerance
relation signifies some threshold dose at which 1.06.5.2.1 Definitions
a change in the response begins to occur and an
asymptotic dose at which higher doses produce This phenomenon is most easily shown with
no further response changes. Inverted U-shaped sedative/hypnotic drugs. Two definitions of
dose±effect functions resemble sigmoidal tolerance differentiate drug history versus
DECs, except that at doses higher than those individual, predrug history. Baseline tolerance
producing the maximum response, the size of defines those initial individual differences in the
the response change decreases with further dose potency of a drug to produce some effect in a
increases. drug-naive subject. That is, drug-naive indivi-
duals could be hyporeactive, normoreactive, or
hyperreactive to a given drug. The source of this
1.06.5.1.2 Drug sensitivity and effectiveness potency difference could stem from pharmaco-
Potency refers to the dose or concentration of kinetic or pharmacodynamic factors or from
the drug required to produce some effect, for factors like genetics, age, gender, disease state,
example, different drugs can have different emotional state, environment, and so on.
potencies for a given effect. The ED50 (effective Acquired drug tolerance defines the situation
dose) indexes the dose that produces half the where prior exposure to a drug decreases the
maximal drug effect. For example, barbiturates potency of that drug to produce a given effect.
are more potent (require a lower dose in mg/ Stated differently, to produce the same, initial
bodyweight) in producing sedation than alco- drug effect requires a higher dose (i.e., the dose-
hol. Similarly, haloperidol produces more effects curve shifts to the right producing a
potent antipsychotic effects than chlorproma- higher ED50).
zine. Conjoint treatment with a second drug can
alter the behavioral potency of drugs (Dwoskin,
1.06.5.2.2 Kinds of tolerance
Neal, & Sparber, 1987). For example, pretreat-
ment with an antagonist will shift the agonist Physiological tolerance describes the body's
DEC to the right, resulting in a higher ED50, adaptation to repeated drug exposure. Meta-
indicating a decreased sensitivity or potency for bolic or pharmacokinetic tolerance could result
the agonist drug. Likewise, pretreatment with a from an increase in the rate of drug metabolism
similar agonist (#2) could shift the DEC for after repeated drug exposures. For example, the
agonist #1 to the left, resulting in a lower ED50 induction of metabolic enzymes for the drug
and possibly indicating some synergy between could produce metabolic tolerance. Functional
the drugs. A related DEC metric, the toxicity or pharmacodynamic tolerance results from a
index (TD50) defines the dose at which 50% of decrease in the way CNS receptors respond to
patients experience toxic effects. Finally, the the drug after repeated drug exposures. A down-
therapeutic index, defined as the ratio of the regulation of receptors (i.e., fewer) or a
median toxic dose (TD50) to the median reduction in receptor affinity or efficacy could
effective dose (ED50), provides a relative produce a functional tolerance effect. Finally,
measure of a drug's toxicity or safety. Drugs cross-tolerance may occur, where the develop-
with a very low therapeutic index, like lithium ment of tolerance to one drug conveys tolerance
and Clozapine, require monitoring of serum to drugs within the same class or acting on
drug levels. similar CNS mechanisms.
Efficacy provides a measure of the maximum Behavioral tolerance belongs to a special class
desired effect, given a sufficient drug dose. In the of functional tolerance, involving conditioned
behavioral economics of psychotropic medica- or learned changes rather than drug receptor
tions, knowing the cost/benefits of different changes (see Goudie & Demellweek, 1986). The
drugs is important. Drugs must have sufficient opponent-process theory of drug tolerance
efficacy with the fewest side-effects and lowest (Siegel, 1990) relies on the Pavlovian condition-
costs. Note that idiosyncratic drug responses can ing model. According to this theory, most drugs
occur, for example, some patients become quite appear to have immediate alpha effects (e.g., a
agitated when given BZDs such as diazepam or decrease in activity), followed by delayed-
atypical anxiolytics such as buspirone. While rebound beta effects. The latter are opposite
some individual differences in response to drugs in direction to that of the alpha effect (e.g., an
are unpredictable, certain factors may predic- increase in activity). Tolerance results from
conditioning of the beta opponent process. With opponent-process, rebound pattern of with-
repeated drug exposures in the same context, the drawal symptoms. However, both drug classes
beta effect becomes conditioned to the con- can produce subjective effects of anxiety. Acute
textual stimuli. It gradually moves forward in withdrawal after even a single drug exposure
time, reducing the initial alpha drug effect. This also can occur, for example, alcohol hangover.
kind of learned tolerance is specific to the drug
exposure context. The compensatory-response 1.06.5.5 Basic Psychopharmacology Principles
model of behavioral tolerance involves instru-
1.06.5.5.1 Drug±behavior interactions
mental or operant conditioning (Holloway &
King, 1989; Schuster, 1978). According to this The preceding Sections on tolerance and sen-
model, drug effects on behavior result in a loss of sitization clearly illustrate the importance of
reinforcement. This prompts the acquisition of drug history in understanding the current drug
some strategies to compensate for the drug's effects on behavior. However, other biobeha-
effects and restore access to reinforcements. This vioral factors related to drug history also can
kind of learned tolerance is specific to the drug's influence current drug effects. For example, ex-
behavioral effects and to the behavioral-rein- perience with a drug's subjective and/or beha-
forcement demand characteristics of the task. vioral effect probably removes novelty per se as a
determinant of drug action. Further, prior use of
related drugs may activate the same enzyme or
1.06.5.3 Sensitization brain systems as the primary drug (cross-
tolerance?). Further, one's subjective or beha-
Sensitization refers to an increased potency of
vioral history can influence the potency and/or
a drug with repeated exposures to that drug (i.e.,
efficacy of a drug's behavioral effects: For
decrease in the ED50). The principal theory for
example, prior practice on a behavioral task
sensitization points to pharmacodynamic
may reduce the size of the drug's effects on task
changes. According to this viewpoint, an
performance. Also, a drug can affect newly
increase in the way CNS receptors respond to
acquired behaviors or skills (e.g., young drivers)
the drug occurs after repeated drug exposures.
more adversely. Finally one must distinguish
The mechanism of these changes is incompletely
between behavioral antagonism versus masking
understood. Nevertheless, the obvious candi-
by drugs. Sometimes a drug may decrease
dates are an up-regulation of receptors (i.e.,
performance or behavior, not by antagonizing
more) or an increase in receptor affinity or
some endogenous receptor, but by producing
efficacy. This phenomenon is most readily
other effects that interfere with that behavior
shown with stimulant drugs like amphetamine
(Dwoskin et al., 1987).
or cocaine. Some evidence points to the
possibility of behavioral or learned sensitiza-
tion. A related phenomenon, reverse tolerance, 1.06.5.5.2 Baseline effects/rate dependency
refers to an increase in a drug's potency with
The intensity or frequency of behavior can
repeated exposure due to toxic reactions, disease
influence both the size and direction of a drug's
state, or organ damage. For example, chronic
effect on that behavior. For example, with high
alcoholics with cirrhosis may experience in-
rates of responding, even a drug like ampheta-
creased alcohol effects due to the loss of the chief
mine will reduce responding (such as methyl-
organ of alcohol metabolism.
phenidate's effects in ADHD). Similarly, with
low rates of responding, even a drug like alcohol
1.06.5.4 Physical Dependence or a benzodiazepine can increase that behavior.
In this regard, related baseline factors can
Physical dependence refers to a general modulate a drug's behavioral action. For
physiological adaptation to chronic drug ex- example, acute or chronic state variables can
posure, usually manifested during withdrawal influence the size of the drug effect. The latter
from the drug (see Henningfield, Schuh, & states include an individual's normal states (e.g,
Jarvik, 1995). The chronic withdrawal or arousal level) and any psychiatric state or trait
abstinence syndrome involves physiological, factors (e.g., anxiety or depression).
subjective, and cognitive symptoms. The char-
acter of the withdrawal syndrome depends on
1.06.5.5.3 Discriminative and state-dependent
the drug class. For example, sedative/hypnotics,
drug effects
like alcohol, BZDs, and morphine, generally
produce an excitable withdrawal profile. On the Nearly all psychotropic drugs produce
other hand, stimulants like cocaine or amphe- interoceptive stimulus cues that subjects/pa-
tamine generally produce depressive or lethargic tients can learn to discriminate or detect (see
withdrawal symptoms. These data suggest an Colpaert, 1986). These drug stimuli can become
The Psychopharmacology of Mental Disorders 189
conditioned occasion setters for other behaviors. hypertension, drowsiness, dizziness, and reflex
A related phenomenon, state-dependent retrie- tachycardia), a2-adrenergic (blockade of some
val, shows that information acquired under a antihypertensive drug effects), D2-dopaminer-
given drug state is most efficiently recalled only gic (extrapyramidal movement disorders), and
when that drug state is present again. H1-histaminergic (sedation, weight gain). Drugs
can have undesired interactions through phar-
1.06.5.5.4 Reward and reinforcing effects of macokinetic or pharmacodynamic mechanisms.
drugs These interactions can vary widely in their
potential to cause serious problems. Tricyclic
Drugs produce positive reinforcement when antidepressive drugs can produce potential
the antecedent behavior (ªself-administrationº) hazardous interactions when combined with
increases in its frequency of occurrence (see MAOIs, NE, Epi, or phenothiazines. Drug
Dworkin & Smith, 1987; Henningfield, Lukas, & overdosing could result from certain classes of
Bigelow, 1986; and Young & Herling, 1986, for drug interactions but more commonly results
descriptions of animal and human studies from the patient's deliberate attempt at suicide.
respectively). Drugs also act as negative re- See Kaplan and Sadock (1996), Hughes and
inforcers, that is, they may be self-administered Pierattini (1992), or Gelenberg and Bassuck
to alleviate some aversive condition (e.g., taking (1997) for the diagnosis and treatment guide-
aspirin for arthritis or consuming alcohol to lines for these drug effects.
avoid withdrawal or hangover). This latter
situation describes the ªself-medicationº hy-
pothesis of drug seeking. In addition, drugs can 1.06.5.8 Drug Regulation
produce reward or aversive effects (i.e., positive
or negative hedonic states), as indicated by an The federal Food and Drug Administration
attraction to or an avoidance of places asso- (FDA) in the United States was given the
ciated with such states. Strictly speaking, reward authority under the federal Food, Drug, and
and positive reinforcement are not the same, but Cosmetic Act (FDC) to approve only those new
the same neural systems may mediate both, that drugs that were both safe and effective. The sale
is, the dopaminergic mesolimbic brain areas (n. of such drugs is conditional on truthful labeling
accumbens and VTA; Wise, 1990). and all the pertinent information needed for the
drug's safe and effective use. Prescription of a
drug for unapproved use is not regulated but
1.06.5.6 Drug Classes this does not exempt the prescriber from
Multiple classification schemes for psycho- liability. The Drug Reinforcement Administra-
tropic drugs exist. Sometimes such drugs are tion classifies drugs according to various levels
grouped by their mechanism of action (see of their abuse potential, for example, Schedule I
Cooper et al., 1996), by the pattern of their drugs like heroin are deemed to have high abuse
behavioral effects (e.g., drugs of abuse; see potential and low usefulness, while Schedule V
Balfour, 1990; Smith & Darlington, 1996), by drugs like lomotil have low abuse potential and
the symptoms or disease for which they are used high usefulness. Scheduled drugs with higher
to treat (see Stahl, 1996), or by a mixed set of abuse potential require increased caution when
criteria (see Hardman & Limbird, 1996; Julien, prescribing.
1998). This chapter will not focus on such
classification schemes, but the interested reader
can refer to the references just cited. The major 1.06.6 THE PSYCHOPHARMACOLOGY
problem with such classification schemes is that OF MENTAL DISORDERS
many psychotropic drugs have profiles showing Drugs used to treat mental disorders are given
effects on multiple NTS, on multiple aspects of for a variety of reasons. Some disorders are
behavior, and on multiple types of psychiatric better understood than others, and psychophar-
symptoms. macological treatments are based on hypotheses
about the biological causes or influences of the
1.06.5.7 Drug Side-effects, Interactions, and disorder. Unfortunately, our understanding of
Overdose many more disorders is limited. Psychopharma-
cological treatments for these disorders may be
The particular array of side-effects depends based on theories about the biological systems
on which NT receptors are blocked, i.e., involved. Stahl (1996) describes at least eight
muscarinic (blurred vision, dry mouth, urinary ways that a compromised CNS could affect the
retention, constipation, sinus tachycardia, and manifestation or expression of behavior or
cognitive dysfunction), a1-adrenergic (blockade mental disease: (i) changes in molecular neuro-
of some antihypertensive drug effects, postural biology (e.g., the inheritance of an abnormal
gene); (ii) loss of synaptic plasticity (i.e., the 1.06.6.1 Mood Disorders: Depressive Disorders
branching, pruning, growing, and dying of axons
1.06.6.1.1 Characteristics of depression
and dendrites); (iii) excitotoxicity (e.g., the
disorders
overexcitation of a cell by glutamate, resulting
in cell death); (iv) no neurotransmission (e.g., the The cluster of symptoms in depression
loss of DA input to the basal ganglia in involves abnormalities of mood, its quality, its
Parkinson's disease); (v) too much neurotrans- direction of change from normal (down in-
mission (see discussion below on the DA dicates depression, up indicates mania), and its
hypothesis for schizophrenia); (vi) an imbalance frequency and duration (Stahl, 1996). However,
among NTS; (vii) the wrong rate of neurotrans- other dimensions of depression involve symp-
mission, and (viii) the wrong neuronal wiring toms that may be vegetative (reductions in sleep,
during development. The interested reader is appetite, weight, and sex drive), cognitive
encouraged to refer to any of a number of (lowered attention span, memory function,
reference works for more complete descriptions frustration tolerance, and self-esteem), impulse
of theories, models, and data on the psychobiol- control (suicide and homicide attempts), beha-
ogy of neuropsychiatric illness (Bloom & vioral (lowered motivation, pleasure, interest,
Kupfer, 1995; Kaplan & Sadock, 1996). stamina), and somatic (increased headaches,
Frequently, however, treatment drugs that stomach aches, and muscle tension). The
alleviate symptoms of a disorder are discovered possible presence of other distinguishable
both by serendipitous observations and by sys- symptom clusters such as anxiety (comorbid)
tematic screening of candidate drugs. Therefore, further complicates the symptom picture of
we will discuss the current theories about the depression. Finally, depression may result from
systems involved in many mental disorders and or accompany any number of organic condi-
the drugs used to treat the disorders separately. tions, including neurological disorders, meta-
Where research has not differentiated between bolic or endocrine disorders, infectious diseases,
the biological system involvement of disorders, tumors, drugs, medications, or poisons.
disorders will be grouped into classes (e.g.,
depressive disorders). We will not include
1.06.6.1.2 The catecholamine (CA) hypotheses
mental disorders that have no apparent psy-
of depression
chopharmacological treatments (e.g., gender
identity disorders). Further, because of space Many theories of how depressive disorders
limitations, this section will not address all (e.g., major depressive disorder, dysthymic
neuropsychiatric disorders (e.g., somatoform disorder) develop have been proposed. The most
disorders, sleep disorders, seizure disorders, and widely known is the CA hypothesis, first
personality disorders). postulated by Schildkraut (1965). That certain
Before reviewing the clinical psychopharma- drugs that alter CA function also alter depressive
cology of psychiatric disorder, a few prefatory symptoms provides the strongest evidence for
remarks must be considered. First, currently this hypothesis. For example, the effective
these disorders are defined based on symptom antidepressives, MAO inhibitors and tricyclics,
profiles with inclusionary and exclusionary work to increase CAs in the synaptic cleft.
criteria, and based on some known biological Additionally, the drug reserpine interferes with
cause (see American Psychiatric Association, the CA storage mechanism and causes massive
1994; World Health Organization, 1993). How- release of CAs, followed by lower than normal
ever, rapid progress had been made in devel- CA levels. Reserpine can induce serious depres-
oping brain chemistry models of these disorders. sion that is indistinguishable from endogenous
Improvements in the clinical psychopharmaco- depression and administering L-DOPA, the
logical study of therapeutic agents have paral- precursor to DA, reverses reserpine-induced
leled this trend (e.g., double-blind techniques, depression. A second area of evidence favoring
preclinical screening with animal models, blind the CA hypothesis is the connection between
raters, ªactive placebos,º and sophisticated depression and the norepinephrine (NE)
analyses). All of the earlier sections on basic metabolite, 3-methoxy-4-hydroxyphenylglycol
psychopharmacology are relevant here plus two (MHPG). Early studies found urinary levels of
additional concepts, those of rebound and the NE metabolite were lower in depressed
relapse. Relapse refers to the reemergence of patients compared with controls. More recently,
the original disease process after discontinua- researchers have found that unipolar patients
tion of the drug, for example, panic attacks show a wide range of MHPG levels, and we can
return after stopping benzodiazepine medica- probably identify the best treatment based on
tion. Rebound refers to the recurrence of a more this measure. Low-MHPG patients generally
severe version of the disease, for example, more respond well to NE-active antidepressants
severe and frequent panic attacks. (imipramine) or fluoxetine, and high-MHPG
patients respond poorly to NE tricyclic anti- hypothalamic-pituitary-adrenocortical (HPA)

depressants and fluoxetine. Thus, high-MHPG axis dysregulation hypothesis. This theory is
patients may have a depression not associated supported by the finding that most people with
with impaired CA function. Cushing's disease have symptoms of depression.
Some unanswered questions about the CA Cushing's disease is a disorder of the HPA axis
hypothesis persist. First, why do drugs such as characterized by excessive cortisol secretion.
cocaine (a CA reuptake inhibitor), that act to The HPA axis dysregulation hypothesis is based
increase CAs, fail to work as antidepressants? primarily on the usefulness of two endocrine
Secondly, why do other drugs, such as ipran- challenge tests, the Dexamethasone Suppression
dole, work as antidepressants yet do not affect Test (DST) and the Corticotropin Releasing
any CA system? Thirdly, why do antidepres- Hormone (CRH) Stimulation Test. Dexametha-
sants require at least two weeks before they sone is a glucocorticoid receptor agonist that
produce a measurable clinical effect, although will drive the negative feedback system for
the pharmacological action is essentially im- cortisol secretion in a person with a functional
mediate? The fourth question is why antide- HPA axis. In nondepressed people, administer-
pressants continue to work in spite of ing dexamethasone causes a precipitous drop in
postsynaptic receptor desensitization, occurring cortisol production. In approximately 50% of
after chronic antidepressant administration. It depressed patients, cortisol production drops
seems clear, then, that the CA hypothesis only a little. These individuals are known as
cannot explain all the phenomena associated nonsuppressors. Interestingly, the rate of corti-
with depressive disorders, and other or addi- sol nonsuppression increases with the severity of
tional theories are necessary. the depression (e.g., most people with depres-
sion with psychotic features are nonsuppres-
1.06.6.1.3 The serotonin (5-HT) hypothesis of sors). From these findings, it is inferred that the
depression glucocorticoid receptors in depressed people are
down-regulated or desensitized, so their cortisol
The inability of the CA hypothesis completely levels would regularly be too high.
to explain some facets of depression led to the Many people with major depression also have
development of other theories. The 5-HT high levels of CRH in their corticospinal fluid,
hypothesis was originally suggested by Eur- which is believed to come from chronic hyper-
opean researchers who were encouraged by secretion of CRH. In a functional system, CRH
findings that depressed patients with low levels is released by the hypothalamus and causes the
of the 5-HT metabolite 5-HIAA were at greater release of ACTH, which itself causes release of
risk for violent suicide attempts. More recent cortisol. Administering CRH to a healthy
research has found that low 5-HT turnover is individual induces a dramatic increase in ACTH
related to impulsive violent behavior, although and, subsequently, cortisol. This challenge is
it is not specific to depression. called the CRH stimulation test. Some de-
However, the 5-HT hypothesis led to the pressed patients fail to show as large an increase
development of the currently popular CA and 5- in ACTH and cortisol, which is thought to be
HT hypothesis. This theory relies on the fact caused by down-regulated or desensitized CRH
that NE and 5-HT systems are known to receptors. If a single depressed patient is given
interact with each other. Selective lesions of 5- the DST and the CRH stimulation test and age
HT neurons increase NE receptor density in is taken into account, the specificity of diagnosis
some regions of the brain, and NE receptors of endogenous depression is more than 90%
cannot be down-regulated without an intact 5- (Heuser, Yasouridis, & Holsboer, 1994). How-
HT system. The strongest evidence for the CA ever, it is not yet clear whether the high levels of
and 5-HT hypothesis rests on two discoveries: cortisol and CRH are a cause or result of, or
first that well-known antidepressants like the even unrelated to, development of depression.
tricyclics affect both NE and 5-HT systems, and In addition, no medication has been found to
second that the 5-HT-specific reuptake inhibi- interact specifically with the HPA axis,
tors (SSRIs) have strong antidepressive effects although traditional antidepressants will reduce
but primarily affect 5-HT systems. The sugges- levels of cortisol and CRH.
tion is that depression disrupts a delicate
balance between CA and 5-HT systems that
can be restored with medication. 1.06.6.1.5 Status of depression theories
Clearly, no single NT theory accounts for all
the data. This situation results from the fact that
1.06.6.1.4 The cortisol hypothesis of depression
depression is not one disorder and that the
The last theory to be discussed does not various NT systems interact. Also, dysfunction
involve CA or 5-HT systems at all. It is the of any of several NT systems may be sufficient to
produce depression. For example, cholinergic gain), combined depressive and anxious symp-
neurons activate muscarinic receptors on the NE toms, or personality disorder symptoms.
neurons of the locus coeruleus. Further, choli- Tricyclic and tetracyclic antidepressants, such
nergic agonists are known to induce depressive as imipramine, amitriptyline, clomimipramine,
symptoms and chronically depressed patients doxepin, and maprotiline, are named for their
are hypersensitive to cholinergic agonists. molecular structure. They were first found to
alleviate depressive symptoms in the 1950s.
Their primary mechanism of action is to block
1.06.6.1.6 Drug therapies for depression
reuptake of NE, 5-HT, and some affect DA
Clinical psychopharmacology of depression reuptake. Although the result is to increase the
is very effective. Approximately 60±70% of amount of NE and 5-HT in the synapse, the
people with depression respond to pharma- clinical effect is thought to occur through
cotherapy, and rates go up to 80% if limited to receptor changes. The prolonged presence of
mild or moderate major depressive disorder. increased, synaptic NE results in desensitization
Three types of antidepressants are currently of postsynaptic b-receptors. This state of affairs
used: MAO inhibitors, tricyclics and tetracyc- correlates with the desired clinical effect. In
lics, and SSRIs. MAO-inhibiting drugs were the addition, the increased NE also acts to desensi-
first antidepressants, and include phenylzine, tize a2-autoreceptors, which results in a further
tranylcypromine, isocarboxazid, and seligiline. increase of the amount of NE released. Increased
MAO inhibitors inhibit the action of MAO, 5HT in the synapse seems to increase the
which metabolizes CAs. The result is that more sensitivity but reduce the density of postsynaptic
CA is available in the cleft. Both MAOA and receptors. The sensitization time course is also
MAOB inhibitors are useful, as MAOA breaks correlated to clinical effect. Tricyclics also affect
down NE, 5HT, and DA, and MAOB breaks second-messenger systems and act as cholinergic
down DA. The three drugs listed inhibit the antagonists, either of which may result in a
action of MAO irreversibly, which requires that clinical effect. Tetracyclics may also antagonize
new enzymes be synthesized. European health postsynaptic 5HT and DA receptors.
professionals use reversible MAO inhibitors Side-effects of tricyclics and tetracyclics are
that are not currently available in the USA. generally due to the anticholinergic and anti-
However, potentially serious side-effects histaminergic effects. Common side-effects in-
occur with many MAO inhibitors. The most clude dry mouth, constipation, blurry vision,
famous side-effect is the ªcheese reaction.º and tachycardia, which are all caused by
Foods containing tyramine can induce hyper- peripheral anticholinergic properties. Central
tension in patients on MAO inhibitors. MAO anticholinergic effects can include memory loss,
also metabolizes tyramine, and its inhibition in confusion, and delirium. Sedation is another
the gastrointestinal tract allows tyramine to side-effect and it is due to histamine antagonism.
pass into the blood where it causes a sympatho- Some people also experience sexual dysfunction
mimetic response. Patients on MAO inhibitors and weight gain. More important, the margin of
should avoid a range of foods, including certain safety for these drugs is relatively small. Doses
cheeses, some types of alcohol, and some cured equivalent to two to three week prescriptions can
meats and sausages. Fortunately, the MAOB be lethal. Death usually occurs from cardiac
inhibitor selegiline does not produce the cheese toxicity or seizures. Consequently, tricyclics and
reaction. In addition, because MAO is involved tetracyclics are used with extreme care in
with many systems in the body, patients should individuals who are or may become suicidal.
not use multiple medications, including many Finally, patients must wait two to six weeks to see
over-the-counter cold or flu remedies. MAO any clinical effect on symptoms of depression.
inhibitors should also not be combined with The 5-HT selective reuptake inhibitors
SSRIs or tryptophan treatment. The latter (SSRIs) currently available in the USA are
combination poses a great risk of the 5-HT fluoxetine, paroxetine, and sertraline. Fluoxe-
syndrome, which can include tremor, hyperto- tine was discovered in the 1970s and was
nicity, myoclonus, autonomic symptoms, hal- introduced for clinical use in 1988. Since then,
lucinations, and fever. MAO inhibitors also it has become the most widely prescribed (and
commonly induce insomnia. In fact, the alerting widely researched) antidepressant in the USA.
properties of MAO inhibitors can be used to As one might surmise by their name, SSRIs
advantage in hypersomnic people. A related inhibit reuptake of 5-HT. Because they have little
effect is afternoon fatigue, which can be severe. to no interaction with cholinergic, histaminergic,
In part due to the serious side-effects, MAO or noradrenergic systems, they produce fewer
inhibitors are generally prescribed for treatment side-effects. Fluoxetine has a long half-life and
of refractory depression, particularly depression an active metabolite, which also has a long half-
with atypical features (hypersomnia, weight life. In clinical trials, fluoxetine has performed as
well as or better than tricyclic antidepressants in noted that lithium has a small therapeutic
relieving symptoms of depression. window, with high serum levels causing neuro-
Although fluoxetine has a better side-effect toxicity. Symptoms of lithium's neurotoxic
profile, it does produce more nervousness, sleep effects include delirium, ataxia, and seizures.
disturbances, and nausea than tricyclics. Inter- Toxicity can be fatal if not treated immediately.
estingly, it also produces weight loss, which is Lithium is also teratogenic, so should be used in
opposite from the weight gain often seen with pregnant women with extreme care.
tricyclic use and has been useful in treating Lithium is used to treat acute manic episodes,
obesity. Fluoxetine is also sedating, at rates but its effect is not fully realized for five to ten
similar to the tricyclic antidepressants. In spite days. As a result, acute episodes are often
of lay reports, large clinical trials show no treated with BZDs or neuroleptics as short-term
greater risk of suicide or suicide attempts over adjuncts to lithium. Lithium's primary useful-
that seen with other antidepressants. Some have ness, however, is in prophylaxis of manic and
suggested that the activating effects (restlessness depressive episodes. Patients who experience
and agitation) may cause some susceptible mixed episodes or rapid cycling or have
people with a history of suicidal ideation to comorbid substance abuse are less likely to
attempt suicide. Therefore, any patient who respond well to lithium. Patients with bipolar
exhibits increased activity and feelings of rest- disorder also respond well to treatment with the
lessness should be monitored carefully. In anticonvulsant drugs, valproate and carbama-
contrast to the tricyclics, higher doses of SSRIs zepine. MAO inhibitors, tricyclics, and SSRIs
do not appear to alleviate symptoms of have also been found useful, particularly to treat
depression better. In fact, some clinical trials the depressive episodes. Antidepressants are
suggest that patients may do less well on higher used most often as adjunctive treatments or with
doses. Other antidepressives include mianserin patients who have not responded well to lithium
and iprindole. Newer types of antidepressive act alone. Further, lithium can produce many side-
to alter the linkage between the adrenergic and/ effects (see Gelenberg & Bassuk, 1997).
or serotonergic NT and second-messenger
systems, for example, Rolipram, which inhibits
cAMP phosphodiesterase. 1.06.6.3 Anxiety Disorders: Generalized
Anxiety Disorder
1.06.6.2 Mood Disorders: Bipolar Disorders While depression and its treatment are
separated from anxiety and its treatment, most
Bipolar disorders (both Bipolar I and Bipolar forms of anxiety disorders used to be lumped
II) have been effectively treated with medication together under the heading of generalized
for nearly 50 years. People with bipolar disorder anxiety disorder (GAD). Anxiety was seen as
experience alternating periods of depression a normal emotion to some threatening situation
and mania. Lithium is the most common psy- (real or imagined). However, since the 1960s,
chopharmacological treatment, but other drugs research has principally focused on the anxiety
have also been found useful. Lithium is effective subtypes described below. As happens with
in approximately 70±80% of patients presenting social phobia (see below), a clear research focus
with acute mania. The mechanism by which on the biology of GAD has yet to develop. For
lithium exerts its therapeutic effect is not yet many years, GAD has been treated with BZDs,
clear, but possibly it enhances the activity of the which continue to be the first drug of choice for
5-HT system. Some evidence shows that lithium these patients. However, recent concern about
increases the release of NE but also reduces its long-term treatment with BZDs has prompted a
postsynaptic receptor sensitivity. However, search for other psychopharmacological inter-
since lithium affects most NT systems and ventions. As a result, clinicians welcomed the
signal transduction pathways, conclusions can- introduction of buspirone, a non-BZD anxio-
not yet be drawn as to its mechanism of action. lytic. Buspirone does not produce dependence
Lithium appears to block an enzyme of the and can be withdrawn with relative ease.
intracellular second-messenger system (inositol Although buspirone is effective in treating
phosphate), resulting in a reduced responsive- GAD symptoms, it has a slow onset of action
ness in those neurons that depend on such and may not be accepted by patients who want
second-messenger linkages (Kandel et al., immediate symptom relief. Some studies also
1991). show that tricyclic antidepressants and SSRIs
Lithium's side-effects include confusion and may be helpful for patients with GAD. As with
memory problems and loss of some motor co- depression, many organic conditions can cause
ordination and development of a slight tremor. anxiety states, including endocrine disorders
It can also induce hypothyroidism. It must be (e.g., hyperthyroidism), metabolic disorders
(e.g., hypoglycemia), and drugs or medications dine, which suggests a2 NE receptor down-
(e.g., caffeine or withdrawal from addictive regulation. 5-HT has also been suggested as a
drugs). possible mechanism for PD. Administration of
m-chlorophenylpiperazine (m-CPP), which is a
5-HT agonist, in low doses showed a greater rate
1.06.6.4 Anxiety Disorders: Panic Disorder of panic induction in PD patients than in
1.06.6.4.1 Phenomenology and etiology of panic nonpatients. This might suggest a postsynaptic
disorder receptor supersensitivity. When this discovery is
coupled with the suggestion that benzodiaze-
Panic disorder (PD) is the best researched pine receptor sensitivity is reduced, 5-HT is
anxiety disorder. Twin studies have found higher thought by some to be the primary route of PD
concordance in monozygotic twins than dizy- development. However, the topic clearly re-
gotic twins, suggesting that PD is heritable. In quires more research.
truth, we have only limited understanding of PD
and its biological basis. One current theory is the
respiratory hypothesis, the formulation of which 1.06.6.4.3 Drug therapies for panic disorder
stemmed from the discovery that administration
of sodium lactate could induce panic attacks that Psychopharmacological treatment of PD is
were identical or very similar to spontaneously common and often combined with psychother-
occurring panic attacks. Researchers found that apy. High-potency BZDs such as alprazolam
lactate induces panic attacks in 50±70% of and clonazepam have been used with good
people with PD, but only 10% of people without success. Although they were originally pre-
PD. Later studies have not found any direct CNS scribed simply to relieve anticipatory anxiety,
effect of lactate, which is primarily a respiratory later research has suggested that they may
stimulant. Also, a correlation exists between function to reduce the number and intensity of
hyperventilation produced by lactate and the the panic attacks themselves. BZDs generally
induction of panic attacks. produce symptom relief within a week, a benefit
Common symptoms of panic attack include not shared with other medications. Antidepres-
shortness of breath, choking feelings, and sants also used include the tricyclic imipramine,
trouble breathing. Voluntary hyperventilation the tetracyclic clomipramine, and MAO inhi-
induces panic attacks in 30±50% of people with bitors. The SSRI fluvoxamine has been found
PD, and inhalation of carbon dioxide-enriched effective, although it is not currently available in
air induces panic attacks in 50±80% of people the USA. Antidepressants are thought to exert
with PD. The respiratory hypothesis suggests their action by their 5-HT reuptake inhibition,
that PDs stem primarily from the increased although research has not yet borne this out.
sensitivity of the central CO2 receptors. Activa- In contrast to the BZDs, antidepressants must
tion of these receptors leads to a ªfalse be administered for three to six weeks to see
suffocation alarm,º and triggers the psycholo- any improvement. No psychopharmacological
gical symptoms of anxiety. This hypothesis treatment to date seems helpful in alleviating
would suggest a purely psychological interven- symptoms of agoraphobia.
tion of breathing retraining, physiological sym-
ptom exposure, and cognitive evaluation of the
1.06.6.5 Anxiety Disorders: Obsessive-
false suffocation alarm. In fact, cognitive-
compulsive Disorder
behavioral therapy reduces vulnerability to
lactate-induced panic and appears to have For many years, clinicians were frustrated by
short-term and long-term effects on the reduc- the lack of effective psychopharmacological
tion of spontaneous panic attacks. treatments for patients with obsessive-compul-
sive disorder (OCD). Then scientists discovered
that clomipramine could decrease OCD symp-
1.06.6.4.2 Neuropharmacology of panic disorder
toms, and it has become the drug of choice.
However, some NT systems have been Until then, clinicians had few clues for how
implicated in PD. Some researchers have found OCD developed or what NT systems were
that patients with PD are hyperreactive to involved. Twin and family studies have not
yohimbine (an a2 NE receptor antagonist), supported the heritability theory of OCD. With
while others have found patients to be hypo- the discovery of clomipramine's effectiveness,
reactive to clonidine (an a2 NE receptor researchers developed the 5-HT hypothesis.
agonist). These findings have led to the NE This theory is based on the positive results of
ªdysregulationº hypothesis. Researchers have 5-HT-enhancing drugs, but additional research
found reduced a2 NE receptor binding sites and has found that OCD patients have increased
a blunted growth hormone response to cloni- turnover of 5-HT and its metabolites (5-HIAA).
In addition, the 5-HT agonist m-CPP exacer- hyperresponsivity manifests itself in three ways.
bates symptoms of OCD. Some researchers First, patients respond to reminders of their
have found that pretreatment with clomipra- trauma (e.g., imagery, sounds, videos, or
mine blocks the m-CPP-induced exacerbation, pictures) with increased blood pressure, heart
although others have not always been able to rate, muscle tension, and other physiological
replicate this phenomenon. indicators of stress. Second, patients also
The 5-HT system dysregulation also supports respond to trauma reminders with increased
a second theory that suggests that patients with neuroendocrine (epinephrine and norepinephr-
OCD suffer striatal damage. Clinically, OCD ine) activity. Third, patients have demonstrable
shares certain characteristics with tic disorders HPA axis dysfunction. Acute stress increases
(i.e., uncontrollable repetitive behaviors), and cortisol release, and the chronic stress experi-
tic disorders are believed to be caused by striatal enced in PTSD appears to result in high cortisol
dysfunction. OCD has also developed in patients levels for a long period. High cortisol levels
with Huntington's, which involves lesions in the appear to damage the hippocampus, which
striatum. Interestingly, the pathway from the would suggest that PTSD patients might
striatum to the thalamus and cortex is heavily experience neuroanatomical changes. People
dependent on 5-HT, which could explain the with PTSD have increased density of glucocor-
effectiveness of 5-HT-enhancing drugs. As ticoid receptors, which results in exaggerated
mentioned above, 5-HT is primarily inhibitory negative feedback of ACTH and cortisol. PTSD
and the neurons in the striatum appear to inhibit patients also supersuppress in response to the
activity downstream after the thalamus. The DST, which further suggests an exaggerated
striatal damage hypothesis postulates that the negative feedback system. All the evidence to
loss of striatal neurons would increase activity in date points to PTSD being a disorder of
the thalamocortical pathways. In fact, positron- hyperresponsivity.
emission tomography (PET) scans show in- Unfortunately, researchers have not yet been
creased glucose utilization in the caudate and able to find a psychopharmacological treatment
orbitofrontal regions of OCD patients. Other to correct for the autonomic hyperresponsivity.
studies have shown a reduction in metabolism in As a result, clinicians continue to rely on
those areas after treatment with clomipramine, medications to treat the emotional and sub-
fluoxetine, or behavior therapy. In severe cases jective symptoms of PTSD. The most common
of OCD, psychosurgery lesioning of pathways drugs prescribed are the tricyclic antidepres-
from the thalamus to the orbitofrontal areas sants, especially amitriptyline and imipramine.
appears to alleviate symptoms. Thus, the Researchers have had mixed results with these
evidence suggests a strong influence of 5-HT drugs, but they appear to have some effect
in the genesis of OCD. beyond their antidepressive and anti-anxiety
As mentioned above, psychopharmacologi- effects. Other drugs, such as the MAO inhibitor
cal treatment of OCD relies heavily on the use of phenelzine, SSRIs, and carbamazepine have
5-HT-enhancing drugs such as clomipramine been used with varying success. Overall,
and SSRIs. Over the years, clinicians have tried research suggests that the positive symptoms
several other medications, but the 5-HT- of PTSD (e.g., increased arousal, re-experien-
enhancing drugs are the only ones currently cing) often respond to psychopharmacological
recommended for use with people who have treatment while negative symptoms (e.g.,
OCD. Doses higher than those used for avoidance) do not.
depression are usually necessary. In a few cases,
the disorder does not respond to any treatment.
For these individuals, psychosurgery may be 1.06.6.7 Anxiety Disorders: Social Phobia
recommended to alleviate their symptoms. The
most common surgery involves making lesions We know little about the biological basis of
in the cingulate cortex on both sides of the brain. social phobia (SP). Some researchers have
suggested that the sympathetic nervous system
may be dysregulated, because people with SP
1.06.6.6 Anxiety Disorders: Post-traumatic report autonomic activation symptoms, and b-
Stress Disorder blockers such as propranolol sometimes help.
In the late 1990s, however, a sustained research
Research on post-traumatic stress disorder focus in the biology of SP does not exist.
(PTSD) has primarily been with individuals Administration of phenelzine, a MAO inhibi-
who have combat-related PTSD, although tor, alleviates nervousness and fear of criticism
other traumas do induce the disorder. The for some people with SP. BZDs have also been
current theory of PTSD states that patients helpful. Nevertheless, in psychopharmacologi-
must show autonomic hyperresponsivity. This cal treatment, as in the etiology of SP, none of
the choices are clearly superior. In fact, some positive symptoms suggesting an exacerbation
research suggests that cognitive-behavioral of normal functions (delusions, hallucinations,
treatment may be the best treatment choice. disorganized speech and behaviors, agitation,
and bizarre behaviors). On the other side is
the cluster of negative features suggesting a
1.06.6.8 Psychotic Disorders: Schizophrenia loss of normal function (flattened affect, alogia
1.06.6.8.1 Characteristics of psychosis or reduced fluency of thought and speech,
anhedonia, avolition or reduced goal-directed
Psychosis is one of the oldest psychiatric behavior, and poor attention). Finally, schizo-
syndromes (mixture of symptoms) but is not a phrenia is characterized by a significant genetic
specific diagnostic category in the Diagnostic heritability. Twin studies find monozygotic
and statistical manual of mental disorders (4th concordance rates of 30±80%, the highest found
ed., DSM-IV) or International classification of in any psychiatric disorder.
diseases (10th ed., IDC-10) (Stahl, 1996). Psy- Fortunately, research on schizophrenia and
chotic symptoms include perceptual distortions theories as to its cause abound. One such theory
(delusions, hallucinations), disorganized speech proposes that schizophrenia may be related to
and behavior, severe distortions in testing neuroanatomical lesions common to people
reality, and motor disturbances (peculiar pos- with the disorder. Neuropsychological tests
tures and stereotyped movements and acts). have revealed deficits in prefrontal cortex and
Mania, depression, substance abuse, and cog- medial temporal lobe function, showing a lack
nitive disorders like Alzheimer's dementia may of ability to plan and organize. Many schizo-
present with psychotic features. Finally, psy- phrenics also have more generalized deficits,
choses can be described as paranoid (delusional including enlarged lateral and third ventricles
beliefs and projections, hostile belligerence, and deeper sulci than people without the
and/or grandiose expansiveness), disorganized disorder. The ventricular enlargement is corre-
or excited, and/or depressive (retardation, lated with greater impairment in functioning
apathy, self-blame). Finally, one should recog- and a poorer prognosis, although some have
nize that many organic conditions may produce disputed this conclusion.
or be associated with psychotic symptoms, for
example, space-occupying CNS lesions, cerebral
hypoxia, neurological disorders like temporal 1.06.6.8.3 The DA hypothesis of schizophrenia
lobe epilepsy, cerebral vascular disorders, CNS By far the most popular theory of schizo-
infections like meningitis, metabolic and endo- phrenia and selected psychotic disorders is the
crine disorders like thyroid disease, nutritional dopaminergic hypothesis. This theory states
deficiencies (thiamine in Wernicke±Korsakoff that schizophrenia is caused by excessive central
syndrome), and drug, medications or toxic DA activity. In some people with the disorder,
agents like amphetamines or corticosteroids. the striatum and nucleus accumbens, which are
Medications are generally administered to heavily dependent on DA, exhibit normal
any person who exhibits psychotic symptoms, volume and area but a reduced neuronal
including people with schizophrenia, schizo- diameter. Further, both areas show increased
phreniform disorder, schizoaffective disorder, binding of the DA antagonists haloperidol and
delusional disorder, brief psychotic disorder, spiperone. The substantia nigra does manifest
and severe depressive disorders with psychotic reduced volume, and postmortem studies reveal
symptoms. Some newer research examines increased density of D2 receptors in the caudate
etiology and treatment of nonschizophrenic and putamen, while the density of the DA
psychotic disorders, but little is known yet. transporter and D1 receptors remain normal.
Some evidence suggests the existence of some
structural abnormalities in DA receptors and an
1.06.6.8.2 The phenomenology and biological
abnormal linkage between D1 and D2 receptors,
basis of schizophrenia
but these findings are not well-replicated.
Schizophrenia was first described in the Antipsychotics block DA and reduce its
nineteenth century by Benedict-Augustin Mor- function, which supports the dopaminergic
el, who termed it demence preÂcoce (Kaplan & hypothesis, but it is not certain that this is the
Sadock, 1996). Schizophrenia is the most mechanism by which the drugs relieve symp-
common (1% of the population) and, fortu- toms. Unmedicated schizophrenics do not show
nately, the most well-understood psychotic higher levels of HVA, the major metabolite of
disorder, but studies suggest that other psycho- DA in cerebrospinal fluid, when compared with
tic disorders have similar etiologies. The nonschizophrenics. Medicated schizophrenics
symptom profile of schizophrenia really does do have higher HVA levels, which suggests that
have two faces. On the one side is the array of antipsychotics actually do work on DA neurons.
Long-term treatment with antipsychotics pro- which can result in breast development in men
duces tolerance in nigrostriatal pathways, but and milk secretion and menstrual abnormalities
not in mesocortical or mesolimbic pathways. In in women.
postmortems of schizophrenics on chronic
antipsychotics, increased HVA was found in
1.06.6.8.5 Antipsychotic drug side-effects
cingulate and frontal cortices (mesocortical and
mesolimbic areas), but not in the putamen and All typical antipsychotics also produce ex-
nucleus accumbens (nigrostriatal system). trapyramidal symptoms (EPS) as a side-effect.
Although many studies have found increased Extrapyramidal refers to the localization of the
numbers of DA receptors in postmortem motor dysfunction in the spinal tracts. EPS are
schizophrenic brains, it is not clear whether motor problems that include Parkinsonian-like
these are from the disease or the treatment. symptoms (stiffness, tremor, shuffling gait),
Some have suggested that an abnormality in the acute dystonia (abrupt spasms of head and
DA systems projecting to the nucleus accum- neck), and akathesia (physical restlessness).
bens may mediate symptoms like anhedonia, Unfortunately, the extent to which the drug
while DA systems projecting to the central works as a DA antagonist correlates with the
nucleus of the amygdala may participate in the extent of EPS. So anti-Parkinsonian drugs are
generation of paranoid ideation. often administered to help reduce these symp-
toms. Tardive dyskinesia (TD) develops in
10±20% of patients on antipsychotics for more
1.06.6.8.4 Antipsychotic medications
than one year. TD is a movement disorder
The primary psychopharmacological treat- characterized by mouth, tongue, and face
ment for schizophrenia and other psychotic movements, besides slow, writhing movements
disorders is the use of DA antagonists, of the limbs and trunk. The elderly and those
otherwise known as antipsychotics. The older with affective disorders are particularly vulner-
typical antipsychotics and the newer ªatypicalº able to developing TD. It was once thought that
antipsychotics differ based on their pharmaco- TD was progressive and irreversible, but this is
logical mechanism and on when they were no longer thought to be true.
found effective. Chlorpromazine, the first Neuroleptic malignant syndrome (NMS) is
antipsychotic, was discovered in 1952. The an uncommon, but potentially fatal reaction to
class of conventional or typical antipsychotics antipsychotics. It is characterized by severe
is butyrophenones and phenothiazines, but this muscular rigidity, autonomic instability, high
category also includes thioxanthenes, dihy- temperature, and changing levels of conscious-
droindolones, and dibenzoxazepines. Their ness. It happens more often when high-potency
DA antagonist properties were discovered antipsychotics are given in high doses and
when they were found to reduce the behaviors escalated rapidly, and is more common in males
caused by administering dopamine agonists to and younger patients.
both humans and animals. The clinical efficacy
of typical antipsychotics is directly correlated
1.06.6.8.6 Side-effect profile of newer
to the drugs' affinity for the D2 receptor. Later
antipsychotics
studies show that for an antipsychotic to work,
it must effectively bind the receptor and Clozapine is the most common atypical
produce a subsequent decrease in DA activity. antipsychotic currently used in the United
Nevertheless, both butyrophenones and phe- States. Risperidone is also approved and is
nothiazines affect NE and DA systems. Also, gaining popularity, and raclopride is still in the
both drugs increase DA turnover, presumably clinical trial phase of FDA approval. Atypical
because their blockade of both postsynaptic antipsychotics are so named because they
DA receptors and presynaptic DA autorecep- appear to involve DA receptors other than
tors produces a feedback activation of these D2. Clozapine seems to affect neurons only in
neurons. the ventral tegmental area and not in the
Antipsychotic drugs are usually administered substantia nigra, which is thought to be the
orally, but can also be given by depot (slow- source of the EPS and TD symptoms. This drug
release) injection. Medications can be given to also has an affinity for 5HT neurons, which may
treat a psychotic episode, but are more com- be involved in its function. In fact, Clozapine
monly used as maintenance therapy to prevent has a ªcocktailº of NT actions, affecting up to
relapses. Antipsychotics are strong medications nine different receptors (Stahl, 1996).
and can induce a range of side-effects. Medica- Clozapine is noted for the rarity of patients
tion effects can include sedation and a lack of developing EPS and TD while on it. NMS also
interest in one's environment (ataraxia). Anti- occurs at lower rates than with typical anti-
psychotics also increase prolactin secretion, psychotics. However, 1±2% of patients develop
agranulocytosis (a loss of a particular group of cross-tolerance and cross-dependence (substi-

white blood cells), usually within the first six tuting a second drug to substitute for or block
months of use. This can be a fatal condition and, withdrawal from the first one). The latter effects
to monitor it, white blood cell counts must be may in part account for the phenomena of
checked weekly. Seizures are another significant polysubstance abuse. The reader should take
side-effect. Because of the potentially serious note that addiction itself is not defined in the
side-effects, Clozapine is currently approved for DSM-IV. We like the following one: ªa
use in treatment-refractory schizophrenia, pa- behavioral pattern of drug abuse characterized
tients with unmanageable EPS, and patients by an overwhelming involvement with the
with TD. compulsive use of a drug, the securing of its
Other atypical agents (Julien, 1997) include supply, and a high tendency to relapse after its
molindone (Moban), which resembles 5-HT and discontinuationº (Stahl, 1996, p. 336).
appears effective for schizophrenia with only
moderate sedative and EPS profiles. Loxapine,
1.06.6.9.2 Models of addiction
structurally related to Clozaril, has antipsycho-
tic properties but moderate sedative and EPS Of all the psychiatric disorders, those in this
profiles and lowers convulsion thresholds. category are as much socially as physiologically
Carbamazapine (Tegretol) is not effective as defined. Marlatt (1992) in fact describes four
an antischizophrenia drug. The interested read- models based on whether individuals are or are
er should refer to Stahl's summary of some not responsible for developing the addiction and
current discovery strategies for new antipsycho- for changing their addictive behaviors. The
tics (Stahl, 1996). ªmedicalº or ªaddiction as a diseaseº model
most readily lends itself to a discussion of psy-
chopharmacological interventions. Most addic-
1.06.6.9 Substance Abuse and Dependence tion researchers suggest that a drug's potential
Disorders for abuse rests on its potential to act as a
reinforcer and/or to induce euphoria (see Section
1.06.6.9.1 Definitions and diagnostic criteria
1.06.5.5.4 on reinforcing and reward properties
Stahl (1996) outlines the major DSM-IV of drugs). The latter effects derive from the
criteria for substance intoxication, abuse, and drug's action on certain mesolimbic brain
dependence. Intoxication refers to a reversible systems (specifically, the DA neurons from the
pattern of behavioral or psychological changes ventral tegmental area [VTA] innervating the
produced by the drugs' action on the CNS (e.g., nucleus accumbens) that are involved in normal
mood, belligerence, impaired cognition, judg- motivational processes (see Kalivas & Samson,
ment, motor skill performance, and social 1992; Wise 1990). Proponents of this view cite the
functioning). Substance abuse refers to a multiple NT systems that participate in this brain
maladaptive pattern of using any drug in region (e.g., GABAA, nicotinic cholinergic,
ªculturally disapproved mannerº that leads to serotonergic, and opioid systems). A key concept
adverse consequences. The latter include failure in this model is that it is a psychopharmacolo-
to meet obligations, placing self and others in gical model, that is, both the drug and the drug
harmful situations, legal difficulties related to self-administration are equally important in
drug taking, and social or interpersonal pro- sustaining the larger pattern of drug-seeking
blems. Substance dependence refers to a behaviors. Some biological theories of addiction
physiological state of adaptation produced by suggest that genetic differences in sensitivity to
a prolonged maladaptive pattern of substance drugs may reflect the under- or overexpression of
use. The DSM-IV definition of substance the latter NT receptors, among others (see
dependence includes three or more of the Crabbe & Harris 1991). For example, under-
following characteristics: the development of expression of one or more of the key NTs
tolerance (the need for more drug to get the involved in the mesolimbic reward system might
same effect), a drug withdrawal syndrome promote excessive use of drugs that affect such
(usually a drug rebound state opposite to the NTs (self-medication?). This idea is the same as
general effects of the drug), inability to control Blum's ªreward deficiency syndromeº (Blum,
the amount consumed or to stop the consump- Cull, Braverman, & Comings, 1996).
tion, the subordination of other life activities to
drug taking, and/or the persistence of drug
1.06.6.9.3 Psychopharmacology of and
taking despite recurring adverse consequences
pharmacotherapy for drugs of abuse
(see Section 1.06.5.4). Relapse refers to recur-
rence of drug taking after some effective The following sections will describe some
treatment regimen. Other concepts introduced attempts to treat some kinds of drug abuse with
earlier are relevant to this topic, for example, drugs. Of course, a key to this discussion is what
is being treated and what neuropharmacological and its acute (hangover) or chronic withdrawal
systems are involved. The treatment of acute syndrome. Alcohol enhances inhibitory GA-
drug intoxication and drug withdrawal reac- BAA neurotransmission, promotes the release
tions is straightforward. The approaches to of DA in mesolimbic pathways associated with
treating the drug-seeking behavior or drug reinforcement and pleasure, decreases how
craving may be a little less obvious. A classic much 5-HT is stored in neurons of the dorsal
strategy would be to arrange for the drug-taking raphe nucleus, and appears to reduce excitatory
behavior to be punished, for example, disulfir- neurotransmission at the NMDA form of the
am or Antabuse (alcohol consumption with glutamate receptor. The liver converts alcohol
Antabuse makes one sick). Another strategy to acetaldehyde (enzyme-alcohol dehydrogen-
involves pharmacologically blocking the drug's ase), which may promote the release of and
CNS actions, for example, using naltraxone (an interaction with CAs from stores in the adrenals
opiate receptor antagonist) to counteract heroin and in the brain. Apparently acetaldehyde and
overdoses. A final strategy would be to biogenic amines chemically interact to produce
substitute another drug or another form of opiate-like substances (tetrahydroisoquino-
the abused drug, for example, methadone (a lines, TIQs, and beta-carbolines). TIQs appear
synthetic opiate agonist) maintenance for to promote DA release in the nucleus accum-
heroin addicts or nicotine gum for addicted bens (Robert Myers, personal communication)
smokers. Apart from treatment of the addiction, and the beta-carbolines may act as inverse
medications may be used to treat acute agonists at the benzodiazepine site on GABAA
intoxication or overdose, withdrawal reactions, receptors. Such an inverse agonist action would
or drug-induced psychosis. The interested read- reduce the impact of drugs that enhance
er should examine Schuckit's fine clinical guide GABAA activity, for example, BZDs, barbitu-
to the treatment of drug and alcohol abuse rates, and alcohol. The latter effect is interesting
(Schuckit, 1995) or the Practitioner's guide to since animal research suggests that the GABAA
psychoactive drugs (Gelenberg & Bassuk, 1997). system of animals more likely to self-administer
Both volumes also review the psychopharma- alcohol is less sensitive to the effects of alcohol
cological profile for all the major drugs of abuse. (Crabbe & Harris, 1991).
Given the opponent-process model of drug
rebound and the array of direct CNS effects of
1.06.6.9.4 Alcoholism
alcohol, it is not surprising that alcohol with-
About 70% of the US adult population drawal signs include excitation, anxiety, and
consumes alcohol. Problem drinkers number discomfort (note these signs are opposite from
about 10 million and half of these may be alcohol's direct sedative, calming, and euphoric
physically dependent. Risks for developing effects). Other characteristics of the prolonged
alcoholism include sociodemographic factors alcohol withdrawal syndrome in physically
(lower socioeconomic status, ethnicity, being dependent individuals include insomnia, tremu-
divorced, nationality), genetic factors (being lousness, muscle tension, facial flushing, and
male, family history of alcoholism), and sweating, followed by nausea, vomiting, ab-
individual history factors (younger age, anti- dominal cramps, hyperreflexia, and anorexia.
social personality, school and conduct pro- Later during withdrawal, tremor, seizures, and
blems). Chronic heavy drinking, of course, can hallucinations may develop, followed some-
lead to certain forms of CNS damage, including times by delirium tremens (confusion, halluci-
Wernicke's disease, Korsakoff's psychosis, and nations, disorientation, agitation, and
Wernicke±Korsakoff syndrome. Postmortem delirium). Sedative-hypnotics, like barbiturates
studies of the latter patients show lesions in and BZDs, have been traditionally used to treat
the mammillary bodies of the hypothalamus. the withdrawal syndrome, and more recently
These disorders appear to be produced by a B1 alpha- and beta-adrenergic blockers. The per-
vitamin deficiency and are treated with thia- sistent hallucinations after prolonged drinking
mine. Further, alcohol can produce profound bouts probably represent an organic condition
CNS or other organ systems during develop- that can be treated with antipsychotic drugs like
ment, for example, the fetal alcohol syndrome. the phenothiazines or butyrophenones.
Alcohol (ethyl alcohol or ethanol), when Until recently, pharmacological treatment for
absorbed, uniformly reached all tissues in the alcoholism itself has been limited to disulfiram
body, including the CNS. Besides the CNS (Antabuse). That drug blocks the metabolism of
damage, many other organ systems may be acetaldehyde, producing a buildup of acetalde-
compromised by chronic alcohol, for example, hyde and a plethora of unpleasant autonomic,
the liver and heart. While an alcohol receptor somatic, subjective and CNS effects. This treat-
may not exist, several NT systems may mediate ment is generally ineffective because of poor
some direct acute or chronic effects of alcohol compliance (about 20% remain alcohol-free for
a year). In cases of dual-diagnosed alcoholics, even low doses can induce bizarre behavioral
treatment of the psychiatric component may reactions that appear similar to those of a
improve the substance as well, for example, paranoid psychosis.
lithium in bipolar alcoholics. Newer develop- The clinical psychopharmacology of amphe-
ments include the use of naltraxone to reduce tamine and cocaine also is similar (see Schatz-
alcohol ªcraving.º The latter is thought to work berg & Nemeroff, 1995). Acute intoxication
through the endogenous opiate system interac- with either agent can be treated with DA-
tions with the mesolimbic DA reward system. blocking drugs like chlorpromazine or haloper-
Similarly, drugs that boost brain 5-HT levels idol. Both drugs continue to have legitimate
(e.g., SSRIs) have a modest effect in reducing medical uses, for example, cocaine is used in
alcohol consumption. Alcoholics receiving bus- ophthalmology and amphetamines are used to
pirone, a partial 5-HT1A agonist, show reduced treat narcolepsy, ADHD, and exogenous obe-
consumption and anxiety, but further research is sity. However, most of the clinical research on
needed. Other compounds that may be useful in agents to counteract stimulant addiction has
reducing drinking and/or craving include focused, with uneven success, on cocaine. One
(Bloom & Kupfer, 1995): acamprosate (a direct ªquasi-substitutionº strategy has been to use
GABA receptor agonist), bromocriptine (a antidepressive drugs like desipramine, which
nonspecific dopamine-2 receptor agonist), tia- also block DA reuptake. Only modest reduc-
pride (a dopamine-2 receptor antagonist), and g- tions in the cocaine relapse rates were found. A
hydroxybutyrate (an endogenous sedative that similar approach using bromocriptine, a DA
increases DA levels). agonist, looks promising, but double-blind
clinical trials are needed. Finally, carbamaze-
pine, an antiseizure medication, has been tried
1.06.6.9.5 Cocaine and amphetamine
since cocaine appeared to increase ªkindledº
dependence
seizure activity in animal studies. Unfortu-
Besides marijuana, cocaine and ampheta- nately, double-blind studies have yet to show
mines represent the most widely abused illegal any reduction in relapses back to cocaine use.
drugs in the USA. The interested reader can
consult any number of references for more
1.06.6.9.6 Nicotine and caffeine dependence
details (Gelenberg & Bassuk, 1997; Schuckit,
1995). Both are CNS and cardiovascular The nicotine delivered through cigarette
stimulants (vasoconstriction), acting in different smoking acts directly on nicotinic cholinergic
ways to promote the increase of DA levels, and, receptors in the CNS (Schuckit, 1995). The
to a lesser extent, NE and 5-HT levels. Although reinforcing and other actions of nicotine (mood
cocaine is a local anesthetic, its stimulatory elevation, enhancement of cognitions, psycho-
effects derive from its blockade of DA and NE motor stimulation, and decreased appetite) are
reuptake into the presynaptic neuron. Amphe- similar to those of cocaine and amphetamine in
tamine acts primarily to release DA or NE from that all activate mesolimbic DA neurons.
the presynaptic neuron, but also has reuptake However, the ªhighº produced by smoking is
blocking properties. Their abuse potential lies in shorter acting since nicotine apparently briefly
their activation of the brain reward system, that shuts down the nicotinic receptor shortly after
is, the DA receptors of the mesolimbic nucleus binding to it. Smokers may up-regulate their
accumbens. Both agents at low to moderate nicotine receptors to compensate for the
doses produce a positive symptom profile: frequent ªshutdowns.º Further, this latter
including euphoria; increased wakefulness, neuroadaptation may be the basis for nicotine
concentration, and alertness; and decreases in tolerance, dependence, and withdrawal (intense
fatigue and appetite. However, higher doses can craving, agitation, increased appetite) phenom-
produce a host of negative effects, including ena. Nicotine also appears to increase NE
tremor, irritability, emotional lability, anxiety, activity, but to decrease 5-HT levels and
motor tremors, paranoia, panic, and repetitive turnover. At high doses, nicotine can produce
stereotypes in movements and speech. Over- toxic effects. The best current pharmacological
dosing can result in stroke, heart failure, and treatment of smoking addiction is a ªtapering-
seizures. The withdrawal profile of these drugs offº substitution regimen using nicotine gum,
also is similar. Intense craving, agitation, and transdermal patches, and the recently developed
anxiety are followed by fatigue, by increased nasal spray (the latter is not currently available).
sleeping and eating, and by depression, then by The caffeine found in coffee, tea, cocoa, colas
listlessness, anhedonia (inability to experience and over-the-counter medication is a member of
pleasure), decreased interest, and increased drug the class of compounds called xanthines, which
craving. Longtime cocaine addicts also may also include theophylline (tea, respiratory
show sensitization or reverse tolerance where medications) and theobromine (chocolate).
Caffeine acts to produce stimulatory effects in Alpha adrenergic agonists like clonidine are
multiple organ systems, for example, cardio- sometimes used to treat the overactivation of
vascular, respiratory, kidney, and CNS. In the the sympathetic nervous system during opiate
brain, caffeine may block GABA and adenosine withdrawal. However, more commonly, an-
receptors (activation of these normally acts to other opiate agonist like methadone, Darvon,
inhibit other neurons) and may increase turn- or Demerol or a mixed agonist±antagonist like
over in CA and 5-HT systems (Shuckit, 1995). buprenorphine, is employed to attenuate the
ªCaffeinism,º produced by a daily consumption withdrawal symptoms. Pharmacological treat-
greater than 500±600 mg, presents a set of ment of the opiate addition itself employs one of
symptoms resembling panic attacks. Caffeine three strategies. First, opiate antagonists, like
dependence is evidenced by its withdrawal naloxone or naltrexone, have proven effective in
effects, which include headaches, increased the well-motivated addict but generally these
muscle tension, fatigue, irritability, anxiety, agents present problems in compliance. Sub-
and poor concentration. No specific pharma- stitution therapies involve the maintenance on
cological treatment is available other than some prescribed opiate agonists like methadone
gradually tapering-off caffeinated products. or LAAM (a long-acting agonist). The rationale
for this approach is that the regimen blunts the
addict's craving, reducing criminal and other
1.06.6.9.7 Opiate (narcotic) dependence
risky behaviors (prostitution, HIV-infected
Section 1.06.2 described the neuropharma- needles). The rate of relapse one year after
cology of opiate receptors. Different opiate heroin or methadone detoxification can run as
narcotic drugs have different profiles of agonist high as 80±90%. A newer approach has been to
and/or antagonist actions at mu, kappa, delta, use the mixed agonist±antagonist, buprenor-
and sigma receptors (see Julien, 1997). The four phine. The rationale here is that the agonist
general categories of abused opiate drugs are: (i) effects will blunt the craving and drug-seeking
natural alkaloids of opium (opium, morphine, behaviors and the antagonist effects will blunt
and codeine), (ii) semisynthetic derivatives of the heroin high produced by any relapses.
morphine (heroin, hydromorphone or Dilaudid, Clinical trials of this compound are underway.
and oxycodone or Percodan), (iii) nonmorphine-
derived synthetics (meperidine or Demerol,
1.06.6.9.8 Sedative-hypnotic and anxiolytic
methadone, and propoxyphene or Darvon,
dependence
and (iv) opioid-containing preparations (usually
with codeine or paregoric). Most of the latter These drug abuse problems involve benzodia-
compounds produce their psychotropic effects zepine (BZD) and non-BZD compounds that,
by acting on mu opiate receptors, which in turn with varying potencies, produce CNS depressant
act on other brainstem systems (e.g., the VTA effects, ranging from lethargy and sleepiness
DA reward pathway). All, to a lesser or greater to anesthesia, and to death from respiratory
extent, produce analgesia, euphoria, sedation, and heart depression (see Schuckit, 1995).
respiratory depression, cough suppression, pu- BZDs, commonly used to treat anxiety and/or
pillary constriction, nausea and vomiting, and a withdrawal from other drugs, include chlordia-
host of other gastrointestinal symptoms. zepoxide (Librium), diazepam (Valium), alpra-
Nonmedical opioid use of any kind in the zolam (Xanax), and triazolam (Halcion).
USA ranges from 9% in women to 15% in men Non-BZD CNS depressants include short-
(for trying heroin, 0.5% and 2%). The acute acting barbiturates (used as general anesthetics
effects, described as an orgasmic-like rush, last and rarely abused), longer-acting barbiturates
about a minute, followed by a tranquil state like pentobarbital (used as hypnotics to induce
lasting for several hours (drowsiness, apathy, sleep and often abused), and long-acting barbi-
motor retardation, mental clouding, depressed turates like phenobarbital (used to treat epilepsy
respiration, and mood lability). The pupillary and other seizure disorders and not usually
constriction and constipation effects of heroin abused). Other barbiturate-like drugs (e.g.,
are the most resistant to tolerance development. methaqualone or QuaÄaÄlude) were introduced
Commonly, overdosing and death result from as hypnotics that lacked the sleep disturbances
the respiratory depression (naloxone and nal- produced with barbiturate hypnotics. Unfortu-
trexone, opiate receptor antagonists, are used to nately, some, like QuaÄaÄlude, are widely abused.
treat overdosing). Of course, the opioid with- Other non-BZD CNS depressants include
drawal syndrome, peaking between 48 and 72 chloral hydrate (used as a short-acting sedative-
hours after last dose, is opposite in character, hypnotic) and meprobamate (used to treat
that is, anxiety, dilated pupils, diarrhea, insom- anxiety), and both have high abuse potential.
nia, agitation, runny nose and eyes, sweating, The specific mechanisms by which all these
and so forth. drugs exert their CNS depressive actions are not
completely clear, but most are known to dates back almost three millennia and today it is
suppress all excitable tissue. The mechanism the most frequently used illegal drug. In the
by which some of these drugs exert their 1970s and 1980s, more than 50% of high school
anxiolytic, muscle relaxant, and anticonvulsant seniors used marijuana at least once. Marijuana
actions lies in their affinity for BZD or usually has both sedative and stimulatory acute
barbiturate receptors on the GABAA receptor effects. These include euphoria (including a
complex. There they act as allosteric modulators sense of well-being, relaxation, and friendli-
of the chloride ion channel and enhanced ness), changes in one's level of consciousness
inhibitory, GABAergic transmission. Via GA- without hallucinations (loss of temporal aware-
BAergic input to the nucleus accumbens, the ness), feelings of heightened sexual arousal and
latter drug actions may produce the reinforcing hunger, mental slowing and sleepiness, and
properties of euphoria or tranquility that lead to short-term memory loss. However, at high
abuse of these compounds. Pharmacodynamic doses, it can produce panic, delirium, and
tolerance to the latter effects develops quickly sometimes psychosis. Chronic marijuana use is
with both barbiturates and BZDs, probably associated with an amotivational syndrome
through some neuroadaptation involving de- (decreased drive and ambition), impairment of
sensitization of the receptors. social and/or performance skills (i.e., poor
With continuous usage of BZDs or barbitu- communication, ineffective interpersonal inter-
rates and then abrupt cessation, a withdrawal actions, and introversion, and/or poor judg-
profile characterized as rebound hyperexcit- ment, inattention, and distractibility), and a
ability emerges (see Schuckit, 1995). Barbiturate decline in personal habits and insight (Schuckit,
withdrawal frequently produces seizure, while 1995; Stahl, 1996).
the BZD withdrawal pattern resembles that of Tolerance may develop to THC, and sudden
alcohol withdrawal. Not surprising, the treat- cessation of THC after chronic use may produce
ment of depressant withdrawal symptoms is withdrawal symptoms, including: a hyperarou-
usually a drug from the same class of drug. Of all sal profile (insomnia, anxiety, restlessness,
the drugs of abuse, depressant drugs pose the photophobia, and irritability), somatic and
most serious problems because of their many autonomic symptoms (myalgia, chills, sweating,
medical uses, their potential for abuse, and their diarrhea, yawning), and a mixed depressive
potential for overdosing or drug interactions. profile (depression, craving, anergy, and mental
CNS depressive drugs interact with each other, confusion) (Gelenberg & Bassuk, 1997).
with alcohol, and with other psychiatric drugs THC can be administered any number of
(e.g., tricyclic antidepressives) to produce seda- ways (though usually smoked). However, its
tion. Thus, these medications are frequently complete elimination may be slow (up to a week
used in suicide attempts. Fortunately, at least or more) since both THC and its metabolites are
for BZDs, a receptor blocker exists (flumazanil) sequestered in fat deposits for later release. The
and can be used for acute BZD intoxication or mechanism by which THC produces its effects is
overdose. Since no effective blocker for non- still poorly understood, but some data suggest
BZDs exits, other medical means must be activation of the septal area of the brain's limbic
considered for barbiturate overdoses (e.g., system (known for its involvement in emotion).
hemodialysis). The acute memory impairment and long-lasting
Treatment of depressant, and particularly EEG changes also suggest clear CNS actions.
BZD, addiction is complicated by the fact that Some evidence suggests that the brain contains
the drug is often prescribed for anxiety. Thus, THC receptors and perhaps endogenous THC-
besides BZD withdrawal, the possibility of like ligands. In any event, no clear medication
rebound-anxiety exists. An alternative strategy treatment has been tried for THC abuse, other
would be to taper off BZDs, slowly and in small than detoxification and long-term abstinence.
steps. However, the latter approach may be Treatment of symptoms includes anxiolytics for
problematic when other factors are present, for anxiety, panic, or flashbacks and antipsychotics
example, underlying anxiety disorder, any other for the occasional toxic delirium, psychotic
drug use (including caffeine, nicotine, and reactions, or hallucinations (Schuckit, 1995).
alcohol), premenstrual syndrome, life stressors,
or other medical conditions (Stahl, 1996).
1.06.6.9.10 Abuse of hallucinogens and related
drugs
1.06.6.9.9 Marijuana abuse
Hallucinogens include a group of drugs that
Marijuana and hashish (from the flowering produce intoxicating effects, described as
tops of the marijuana plant) derive their effects ªhighs,º characterized by enhanced sensory
from the plant's most active ingredient, THC and perceptual experiences (both exteroceptive
(delta-9-tetrahydrocannabinol). Use of THC and interoceptive) (Stahl, 1996). Sometimes,
these effects result in visual illusions and class have any current medical use. Some
hallucinations. The hallucinations may be patterns of abuse may be short-lived because
psychedelic (i.e., enhanced sensory awareness, of the unpleasant, dysphoric effects of the drugs.
ªmind expansion,º and feelings of oneness with However, some drugs, like PCP, are associated
a larger ªotherº) or psychotomimetic (i.e., with a very treatment-resistant pattern of drug
superficially resembling a psychosis). These use.
drugs produce visual hallucinations and strong
emotional reactions, whereas schizophrenia is
more typically associated with auditory hallu- 1.06.6.9.11 Over-the-counter and prescribed
cinations and flat affect (Schuckit, 1995). drugs
Initially, the latter symptoms can occur without We conclude this section by indicating that
consciousness changes or confusion. However, many legal drugs can be abused. These include
the intoxication can progress from a confu- analgesics, antihistamines, cold and cough
sional state (disorientation and agitation) to remedies, sleep medications, and caffeinated
anxiety, depression, and panic, and to toxic products. Some research shows that certain
delirium and the psychotic symptoms of delu- combinations of these products produced
sions and paranoia. The panic-like state can subjective effects similar to those produced by
include physiological and subjective effects like cocaine, amphetamine, and morphine.
anxiety and feelings of mind loss. Even after
cessation of use, flashbacks may occur.
Schuckit (1995) described four general cate- 1.06.6.10 Eating Disorders
gories of hallucinogenic agents. Indolealkla-
mines like LSD or lysergic acid diethylamide (a There are many theories to explain the
synthetic drug) and Psilocybin (an extract of a etiology of anorexia nervosa and bulimia
mushroom plant) appear to act as partial nervosa, ranging from cultural to psychological
agonists at 5-HT receptors, particularly 5- to biological, but none have emerged as
HT2. Phenylethylamine drugs, like mescaline dominant in the field. Most of the biologically
or peyote, and phenylisopropylamine drugs (so based theories hypothesize that people with
called ªdesigner drugsº), like methylene dioxy- eating disorders lack certain mechanisms re-
methamphetamine (MDMA or ªecstasyº), have lated to feeding, such as appetite, satiety, and
structures and actions more similar to biogenic desire for balanced nutritional intake. Because
amines and amphetamine. Finally, a group of depression is so often associated with eating
related drugs also can produce hallucinations; disorders, however, the first medications used
these include phencyclidine (PCP or ªangel were antidepressants.
dustº) and inhalants (e.g., amyl or butyl Antidepressants continue to be the psycho-
nitrites). PCP appears to have a specific pharmacological treatment of choice. Both the
mechanism of action, that is, it acts allosteri- traditional tricyclics, such as imipramine and
cally to block the NMDA type of glutamate desipramine, and the SSRIs, particularly fluox-
receptor by reducing calcium ion influx into the etine, have been useful. Recent studies suggest
cell. The latter action disrupts normal and that both types of antidepressants relieve
necessary excitatory neurotransmission, there- depressive symptoms and eating disorder
by producing skeletomuscular effects (besides symptoms in both anorexia and bulimia. The
other effects described above) that include primary outcome measure in people with
catatonia (excitement alternating with catalepsy anorexia is weight gain. Although tricyclics
and stupor), motor seizures, and muscle break- may cause weight gain in other patients and
down. Other commonly abused inhalants SSRIs may cause weight loss, anorectics taking
include glues, solvents, aerosols, cleaning solu- either class of drug gain weight at equivalent
tions, and gasoline. While these substances can rates. Bulimics also respond well to either drug,
produce euphoria and lightheadedness, over- although as measured by different outcomes,
dosing can produce loss of normal cardiac such as binging and purging behaviors. It is not
function, hypoxia, seizures, and death. Toler- clear how two classes of drugs so dissimilar in
ance to the effects of inhalants develops rapidly, their mechanism of action can produce such
and hallucinations can occur with abrupt similar results.
discontinuation after prolonged use. Chronic Studies of other medications are underway.
inhalant abuse is thought to produce brain Some researchers who postulate that eating
damage associated with impairment of higher disorders are similar to opiate dependence have
cognitive functions. used naltrexone with some success. Others are
Medical management of hallucinations is investigating endocrine responses in eating
generally the same as for psychosis, that is, use disordered patients, with plans to develop and
of antipsychotics. None of the drugs in this test new medications in the future.
1.06.6.11 Neurological Disorders which is thought to work not through inhibition

of DA breakdown but as an antioxidant to
Because of limitations of space, not all prevent neuronal death. Other, more experi-
neurological disorders can be covered in this mental approaches, involve the transplantation
section. However, the reader should be aware of fetal adrenal cells directly into the basal
that many disorders are age-related. Further, ganglia (see Kandel et al., 1991).
medication in elderly individuals presents a
unique set of problems and concerns. The reader
is directed to a chapter on geriatric psycho- 1.06.6.11.2 Alzheimer's disease and other
pharmacology (Gelenberg & Bassuk, 1997). dementias
Alzheimer's disease is characterized by severe
dysregulation of the acetylcholine pathways in
1.06.6.11.1 Parkinson's disease
the brain and development of neuritic plaques
Parkinson's disease, a neurodegenerative and neurofibrillary tangles. As with most other
disorder characterized by resting tremor, mus- neuropsychiatric disorders, its etiology is not
cular rigidity, and difficulty initiating motor clear. Although the plaques and tangles are
activity, is the most common movement diagnostic, the cognitive deficits may be caused
disorder, occurring in approximately 1% of by the loss of cholinergic function, particularly
the population. The best current theory for PD that generated in the nucleus basalis. This
rests on evidence of the degeneration of disease causes degeneration of cholinergic
pigmented DA cells in the substantia nigra area neurons in the nucleus basalis, which is the
of the brainstem (see Kandel et al., 1991). These primary ACh input to the cortex. People with
DA neurons normally project to the striatum of the disorder also show reduced ACh activity in
the basal ganglia (part of the extrapyramidal the hippocampus, which is thought to be the
motor control system), primarily in the nigros- cause of the memory deficits. Researchers have
triatal pathway. This loss or injury to DA also found reduced levels of somatostatin,
neurons results in an associated loss of striatal neuropeptide Y, and corticotropin-releasing
DA. In Parkinson patients, striatal DA deple- factor and reduced numbers of NMDA recep-
tion can range from 70 to more than 90% with tors and locus coeruleus neurons. However, the
lesser losses in other DA and non-DA systems. significance of these changes is not yet known.
The loss of midbrain DA is associated with the Alzheimer's is associated with Down's syn-
loss of DA transporters in the striatum. Thus, drome, as most individuals with Down's who
any DA remaining in the synapse is metabolized live to the upper reaches of the age range develop
rather than being taken back up into the Alzheimer's. The meaning of this correlation is
terminal. Persistent lowered levels of DA results also unclear. Research is also underway into the
in an increase in D1 and D2 receptor density (up- cause and meaning of the excessive amounts of
regulation) in the caudate and putamen areas of b-amyloid protein found in the neurofibrillary
unmedicated Parkinson patients. Treatment tangles of Alzheimer's patients.
with L-DOPA (see below) returns receptor Psychopharmacological treatments have fo-
densities to normal levels. Other data are cused on the ACh deficit. Researchers have tried
consistent with this DA loss account of giving choline, physostigmine (to inhibit acet-
Parkinson's disease. In 1983, heroin addicts, ylcholinesterase), and the muscarinic agonist
attempting to synthesize their own drug, arecoline, trying to boost the production or
accidentally made MPTP. This compound, effectiveness of the patient's natural ACh. In the
which selectively destroys nigrostriatal DA late 1990s, the treatment of choice is tacrine, an
neurons, produced a Parkinson-like syndrome anticholinesterase. Tacrine inhibits the break-
in the addicts and provided researchers with down of ACh that increases the amount
excellent support of the DA theory. available for use. However, this only works if
The best current pharmacotherapy for Par- enough ACh is being released. Currently, no
kinson's disease is the DA precursor L-DOPA, treatment to stop the degradation of ACh
usually coadministered with an inhibitor of neurons exists. Researchers outside the USA
enzymes that could destroy L-DOPA. Unlike have tried to transplant fetal neural tissue to
DA itself, L-DOPA can pass the blood±brain replace the ACh neurons destroyed by Alzhei-
barrier and can be converted into DA by the few mer's. Although it is not a psychopharmacolo-
remaining neurons. In particularly severe cases, gical treatment, it is mentioned here because it is
DA agonists may prove effective, most com- designed to treat the disorder directly. However,
monly, bromocriptine, a D2 agonist. Other results have been equivocal and not adequately
drugs that act to increase DA levels (MAOIs replicated. Fetal neural transplants are still very
and DA uptake inhibitors) also have been tried. controversial, despite the US government's
One novel approach uses the drug selegiline, decision to allow fetal tissue use in research.
References 205
The interested reader is referred to an excellent inattention, impulsivity/distractibility, and hy-

chapter by Stahl (1996), which summarizes peractivity. Researchers do not have a clear
strategies and data regarding cognitive enhan- theory of its etiology. The most popular current
cers and neuroprotective agents. theory is that children with ADHD have some
Vascular dementia is differentiated from deficits in right hemispheric function, particu-
other dementias by its sudden onset and larly in the prefrontal-striatal circuitry (Heil-
stepwise deterioration. Treatment is similar to man, Voeller, & Nadeau, 1991). Several
that for a single stroke. Persons with the neuropsychological and imaging studies have
disorder may be prescribed cognition enhancers supported this hypothesis.
(e.g., free-radical scavengers like vitamin E) and However, psychopharmacological treat-
anticoagulants (e.g., aspirin) to relieve symp- ments of ADHD do not address the hypothe-
toms and reduce the chance of another stroke. sized right hemisphere dysfunction directly.
Amphetamine was first used in 1937 to treat
ADHD, and it and amphetamine-like drugs
1.06.6.11.3 Huntington's disease (HD) continue to be the most popular medications.
HD, formerly known as Huntington's chor- Medications used in the late 1990s include
ea, is included here primarily because, although dextroamphetamine (Dexedrine), methylpheni-
defined as a movement disorder, it entails date (Ritalin), and pemoline (Cylert), all of
progressive degeneration of cognition and which improve attention and reduce hyperac-
emotion. In some people, the disorder may tivity in children with ADHD. Side-effects
manifest itself first as a psychiatric disorder or include decreased appetite, increased heart rate
dementia. It is a genetic disorder, transmitted by and blood pressure, insomnia, and tics. ADHD
a gene on the short arm of chromosome 4. The is often comorbid with Tourette's syndrome,
disorder causes a particular type of cholinergic and stimulants may worsen or reveal Tourette's-
interneuron in the striatum to degenerate. like vocal and motor tics. Pemoline can cause
Although researchers do not know why these liver dysfunction, and a child on pemoline
neurons die, some have suggested that they die should have liver function tests every few
of the excitotoxic effects of glutamate or one of months to rule it out. Children with ADHD
the other excitatory amino acid NTs. This who do not respond to stimulants may need a
results in the disinhibition of the DA neurons in trial of tricyclic antidepressants such as imipra-
the substantia nigra, which causes the involun- mine and desipramine. Antidepressants are also
tary movements known as chorea. recommended for children with a comorbid
Unfortunately, a curative treatment for Hun- anxiety or depressive disorder.
tington's disease is not available, but progress
should be more rapid now that the gene locus has 1.06.6.12.2 Other disorders
been identified. Psychopharmacological treat-
ments typically attempt to correct the striatal For reasons of space and lack of a clear-cut
system imbalance. Treatments include medica- psychopharmacological strategy, most other
tions such as physostigmine, which is an developmental disorders will not be addressed
acetylcholinesterase inhibitor, to enhance the in this chapter (e.g., mental retardation, autism,
ACh available for use. In addition, DA antago- Rett's disorder, childhood disintegrative dis-
nists like the typical antipsychotics can help to order, and Asperger's disorder). However, the
inhibit the overactive DA systems and partially reader should be aware that data on pediatric
relieve the symptoms. To protect the cholinergic psychopharmacology is limited relative to that
interneurons, NMDA receptor antagonists (to for adults (see Gelenberg & Bassuk, 1997, for a
block glutamate) like amantadine and calcium- review of pediatric psychopharmacology).
channel blockers like nimodipine have also been
tried, although they are still quite experimental.
As with the other movement disorders, fetal 1.06.7 REFERENCES
striatal transplants have been suggested to American Psychiatric Association. (1994). Diagnostic and
replace the neurons lost to the disorder. statistical manual of mental disorders (4th ed.) Washing-
ton, DC: Author.
Balfour, J. K. (Ed.) (1990). Psychotropic drugs of abuse.
New York: Pergamon.
1.06.6.12 Developmental Disorders Originating Bloom, F. E., & Kupfer, D. J. (Eds.) (1995). Psychophar-
in Childhood macology: The fourth generation of progress. New York:
Raven Press.
1.06.6.12.1 Attention-deficit hyperactivity Blum, K., Cull, J. G., Braverman, E. R., & Comings, D. E.
disorder (ADHD) (1996). Reward deficiency syndrome. American Scientist,
84, 132±145.
ADHD occurs in approximately 5% of the Carlson, N. R. (1994). Physiology of behavior (5th ed.)
school-age population and is characterized by Boston: Allyn and Bacon.
Carlton, P. L. (1983). A primer of behavioral pharmacology. & G. R. VandenBos (Eds.), Psychopharmacology: Basic
New York: W. H. Freeman. mechanisms and applied interventions (pp. 97±125). Wa-
Colpaert, F. C. (1986). Drug discrimination: Behavioral, shington, DC: American Psychological Association.
pharmacological, and molecular mechanisms of discri- Johanson, C.-E. (1992). Biochemical mechanisms of
minative drug effects. In S. R. Goldberg & I. P. pharmacological principles of drug action. In J. Gra-
Stollerman (Eds.), Behavioral analysis of drug dependence bowski & G. R. VandenBos (Eds.), Psychopharmacol-
(pp. 161±193). Orlando, FL: Academic Press. ogy: basic mechanisms and applied interventions
Cooper, J. R., Bloom, F. E., & Roth, R. H. (1996). The (pp. 11±58). Washington, DC: American Psychological
biochemical basis of neuropharmacology (7th ed.). New Association.
York: Oxford University Press. Julien, R. M. (1998) A Primer of Drug Action (8th ed.) New
Crabbe, J. C., & Harris, R. A. (Eds.) (1991). The genetic York: W. H. Freeman.
basis of alcohol and drug actions. New York: Plenum. Kalivas, P. W., & Samson, H. H. (1992). The neurobiology
Dworkin, S. I., & Smith, J. E. (1987). Neurobiological of drug and alcohol addiction. New York: The New York
aspects of drug-seeking behaviors. In T. Thompson, P. Academy of Sciences.
B. Dews, & J. E. Barrett (Eds.), Advances in behavioral Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (Eds.)
pharmacology: Neurobehavioral pharmacology (vol. 6, (1991). Principles of neural science (3rd ed.) New York:
pp. 1±43). Hillsdale, NJ: Erlbaum. Elsevier.
Dwoskin, L. P., Neal, B. S., & Sparber, S. B. (1987). A Kaplan, H. I., & Sadock, B. J. (1996). Comprehensive
behavioral assay for receptor action(s) of drugs. In T. textbook of psychiatry (6th ed.). Baltimore: Williams and
Thompson, P. B. Dews, & J. E. Barrett (Eds.), Advances Wilkins.
in behavioral pharmacology: Neurobehavioral pharmacol- Leonard, B. E. (1992). Fundamentals of psychopharmacol-
ogy (Vol. 6, pp. 45±81). Hillsdale, NJ: Erlbaum. ogy. New York: Wiley.
Dyskstra, L. (1992). Drug action. In J. Grabowski & G. R. Marlatt, A. G. (1992). Substance abuse: Implications of a
VandenBos (Eds.), Psychopharmacology: Basic mechan- biopsychosocial model for prevention, treatment, and
isms and applied interventions (pp. 59±96). Washington, relapse prevention. In J. Grabowski & G. R. VandenBos
DC: American Psychological Association. (Eds.), Psychopharmacology: Basic mechanisms and
Feldman, R. S., Meyer, J. S., & Quenzer, L. F. (1997). applied interventions (pp. 127±162). Washington, DC:
Principles of neuropsychopharmacology. Sunderland, American Psychological Association.
MA.: Sinauer Associates. McKim, W. A. (1986). Drugs and behavior. Englewood
Gelenberg, A. J., & Bassuck, E. L. (1997). The practicio- Cliffs, NJ: Prentice-Hall.
ner's guide to psychoactive drugs (4th ed.). New York: Schatzberg, A. F., & Nemeroff, C. B. (Eds.) (1995).
Plenum. Textbook of psychopharmacology. Washington, DC:
Goldberg, S. R., & Stolerman, I. P. (Eds.) (1986). American Psychiatric Press.
Behavioral analysis of drug dependence. Orlando, FL: Schildkraut, J. J. (1965). The catecholamine hypothesis of
Academic Press. affective disorders. American Journal Psychiatry, 122,
Goudie, A. J., & Demellweek, C. (1986). Conditioning 509±522.
factors in drug tolerance. In S. R. Goldberg & I. P. Schuckit, M. A. (1995). Drug and alcohol abuse: A clinical
Stollerman (Eds.), Behavioral analysis of drug dependence guide to diagnosis and treatment (4th ed.). New York:
(pp. 225±285). Orlando, FL: Academic Press. Plenum.
Grabowski, J., & VandenBos, G. R. (Eds.) (1992). Schuster, C. R. (1978). Theoretical basis of behavioral
Psychopharmacology: Basic mechanisms and applied tolerance: Implications for problems of drug abuse. In N.
interventions. Washington, DC: American Psychological A. Krasnegor (Ed.), Behavioral tolerance: Research and
Association. treatment implications. (NIDA Research Monograph
Hardman, J. G., & Limbird, L. E. (Eds.) (1996). Goodman No. 18). Washington DC: US Government Printing
& Gilman's the pharmacological basis of therapeutics (9th Office.
ed.) New York: McGraw-Hill. Siegel, S. (1990). Classical conditioning and opiate toler-
Heilman, K. M., Voeller, K. K. S., & Nadeau, S. E. (1991). ance and withdrawal. In J. K. Balfour (Ed.), Psycho-
A possible pathophysiologic substrate of attention deficit tropic drugs of abuse. (pp. 59±86). New York: Pergamon.
hyperactivity disorder. Journal of Child Neurology, Smith, P. F., & Darlington, C. L. (1996). Clinical
6(Suppl.), 576±581. psychopharmacology: A primer. Mahwah, NJ: Erlbaum.
Henningfield, J. E., Lukas, S. E., & Bigelow, G. E. (1986). Stahl, S. M. (1996). Essential psychopharmacology. Cam-
Human studies of drugs as reinforcers. In S. R. Goldberg bridge, UK: Cambridge University Press.
& I. P. Stollerman (Eds.), Behavioral analysis of drug Thompson, T., Dews, P. B., & Barratt, J. E. (Eds.) (1987).
dependence (pp. 69±122). Orlando, FL: Academic Press. Advances in behavioral pharmacology: Neurobehavioral
Henningfield, J. E., Schuh, L. M., & Jarvik, M. E. (1995). pharmacology (Vol. 6). Hillsdale, NJ: Erlbaum.
Pathophysiology of tobacco dependence. In F. E. Bloom Wise, R. A. (1990). The role of reward pathways in the
& D. J. Kupfer (Eds.), Psychopharmacology: The fourth development of drug dependence. In J. K. Balfour (Ed.),
generation of progress (pp. 1715±1729). New York: Psychotropic drugs of abuse (pp. 23±58). New York:
Raven Press. Pergamon.
Heuser, I., Yassouridis, A., & Holsboer, F. (1994). The World Health Organization. (1993) International classifica-
combined dexanethasone/CRH test: A refined labora- tion of diseases: Classification of mental and behavioral
tory test for psychiatric disorders. Journal of Psychiatric disorders: Clinical descriptions and diagnostic guidelines
Research, 28(4), 341±356. (10th ed.) Geneva, Switzerland: Author.
Holloway, F. A., & King, D. A. (1989). Parallel develop- Young, A. M., & Herling, S. (1986). Drugs as reinforcers:
ment of ethanol tolerance and compensatory behaviors. Studies in animals. In S. R. Goldberg & I. P. Stollerman
Pharmacology, Biochemistry & Behavior, 34, 855±861. (Eds.), Behavioral analysis of drug dependence (pp. 9±67).
Hughes, J. R., & Pierattini, R. A. (1992). In J. Grabowski Orlando, FL: Academic Press.
1.07
Animal Models of
Psychopathology: Depression,
Anxiety, Schizophrenia,
Substance Abuse
PAUL WILLNER
University of Wales, Swansea, UK

1.07.1.1 Validation of Animal Models 208
1.07.2 ANIMAL MODELS OF DEPRESSION 210
1.07.2.1 Clinical Considerations 210
1.07.2.2 Stress Models 210
1.07.2.3 Other Approaches 212
1.07.3 ANIMAL MODELS OF ANXIETY 213
1.07.3.2 Conflict Models 214
1.07.3.3 Ethological Models 215
1.07.4 ANIMAL MODELS OF SCHIZOPHRENIA 216
1.07.4.2 Dopamine Hyperactivity Models 217
1.07.4.3 Attentional Models 218
1.07.5 ANIMAL MODELS OF SUBSTANCE ABUSE 219
1.07.5.1 Drug Self-administration 219
1.07.5.2 Drugs as Positive and Negative Reinforcers 221
1.07.5.3 Limitations 222
1.07.6 OVERVIEW: VALIDITY AND UTILITY OF ANIMAL MODELS 223
1.07.7 SUMMARY 225
1.07.1 INTRODUCTION Rayner (1920) and even earlier (Abramson &

Seligman, 1977; Weiner, 1973). However, for
The concept of modeling psychopathology in many years, practical attempts to devise animal
animals is as old as the use of animals in models were sporadic, ad hoc, and unconvincing
psychological investigations; its roots may be (see Abramson & Seligman, 1977; Keehn, 1979).
found in the work of Pavlov, Watson, and As a result, animal models of psychopathology
207
208 Animal Models of Psychopathology
were until recently viewed with justified suspi- models, in which an attempt is made to simulate
cion. This situation has now changed, with the the disorder, that the above definition applies.
recognition that animal models can provide a This chapter is primarily concerned with simu-
means of investigating the neurobiological lation models, and presents an overview of
mechanisms underlying psychopathology: in- animal models in the four areas most relevant
deed, given the limitations of the investigational to clinical psychopharmacology: depression,
techniques currently available for use in human anxiety, schizophrenia, and substance abuse.
subjects, animal models represent the only First, we consider some general issues pertain-
means of asking many of the important ing to the validity of animal models.
questions. Animal models can also be of great
value in the process of psychotropic drug
development, and again, frequently represent 1.07.1.1 Validation of Animal Models
the only viable method of predicting novel
therapeutic actions. The development and The systematic validation of an animal model
acceptance of animal models may thus be seen is no different in principle from that of any other
as an adjunct to the concurrent growth of psychological device, such as a psychometric
psychopharmacology and biological psychiatry. test (Vernon, 1963) or a psychiatric diagnosis
For the purposes of this chapter, animal (Carroll, 1989), and the same general ap-
models may be defined as representing proaches to validation are applicable: predictive
validity means that performance in the test
experimental preparations developed in one spe- predicts performance in the condition being
cies for the purpose of studying phenomena modelled; face validity means that there are
occurring in another species. In the case of animal phenomenological similarities between the two;
models of human psychopathology one seeks to and construct validity means that the model has
develop syndromes in animals which resemble a sound theoretical rationale (Willner, 1986,
those in humans in certain ways, in order to study 1991). The systematic assessment of animal
selected aspects of human psychopathology. models against each of these sets of criteria
(McKinney, 1984) allows an unbiased comparison of their
strengths and weaknesses. In the paper that
However, it should be noted in passing that first considered the problem of validating
this definition presents a rather limited view of animal models, and so formed a starting point
the way in which animal models of psycho- for subsequent research, McKinney and Bunney
pathology are actually used. Although the ear- (1969) suggested that to be valid, a model should
lier animal models were developed primarily to resemble the disorder modeled in four respects:
elucidate psychological processes, animal mod- etiology, symptomatology, treatment, and phy-
els are used increasingly, and in some cases, siological basis. The first two of these domains
exclusively, within the context of psychophar- refer primarily to face validity and the third to
macology. Within this context, animal models predictive validity, while the fourth reflects
are used for three distinct purposes (Willner, aspects of construct validity. However, any of
1990). In one class of model, which may be these substantive domains could in principle
termed a behavioral bioassay, behavioral tests contribute to an evaluation of validity on each
are used as a convenient means of measuring the of the three dimensions. Before reviewing
status of an underlying brain mechanism: for animal models of psychopathology, it is appro-
example, the bizarre set of drug-induced beha- priate to discuss briefly the general principles
viors known as the serotonin syndrome may be underlying the concepts of face, predictive, and
used to measure the responsiveness of serotonin construct validity as applied to animal models.
receptors to agonist drugs. For the purposes of The simple comparison of the features of the
this chapter, we simply note the existence of model with the features of the disorder is the
behavioral biossays, but consider them no starting point for an evaluation of face validity.
further. Behavioral models are also used as Ideally, a model should resemble the disorder in
predictive screening tests within the pharma- a variety of respects, and the DSM checklist
ceutical industry. In this context, pharmacolo- approach to psychiatric diagnosis (American
gical considerations are paramount, and the Psychiatric Association, 1994) provides one
behavioral features of the model are of less useful starting point for enumerating the areas
importance. The present review will, out of of potential comparison. If several points of
necessity, make some reference to pharmacolo- similarity are demonstrable, then it is necessary
gical studies, but they will not be emphasized. to ask whether the cluster of symptoms
Finally, animal models are used as experimental identified forms a coherent grouping that might
tools to investigate or illuminate aspects of realistically be seen in a single patient, or
psychopathology. It is to this use of animal whether they are drawn from a variety of
Introduction 209
diagnostic subgroups. Frequently, animal mod- or inactive may sometimes be incorrect. Drugs
els focus on a single behavior. In that case, it is thought to be active on the basis of early open
essential to assess the importance in the total trials are frequently found to be inactive in later
clinical picture of the symptom modeled. If the well-controlled tests; conversely, a drug may
behavior in the model consists simply of a appear to be inactive because the emergence of
change in locomotor activity, for example, this side effects prevents its administration at
is likely to be of peripheral relevance. Similarly, adequate dosages, a problem that is less likely
the face validity of the model is less strongly to arise in an animal model. It follows that the
supported if the symptom modeled is common failure of an animal model to predict accurately
to several different psychiatric disorders. A will tend to weigh against the model, but may
further requirement for face validity is that the sometimes call instead for a re-evaluation of the
similarity between behavior in the model and clinical wisdom.
the clinical symptom modeled be demonstrated In order to evaluate the theoretical rationale
rather than assumed (Abramson & Seligman, of an animal model (construct validity), we
1977). As Abramson and Seligman observed, require a theoretical account of the disordered
animals subjected to uncontrollable electric behavior in the model, a theoretical account of
shocks are undoubtedly stressed, but if severe the disorder itself, and a means of bringing the
shock is the only stressor that can be shown to two theories into alignment. This can only be
generate a particular set of behavioral or done if the clinical theory occupies an appro-
neurochemical changes, then the model has priate framework, which uses terms and con-
little relevance to the concept of stress as used in cepts applicable also to subhuman species.
human contexts. The demonstration of simi- Clearly, the subjective dimension of psycho-
larity requires a thorough experimental analy- pathology cannot be central to such a theory,
sis, which, sadly, is often lacking. since subjective phenomena in animals are for
The concept of predictive validity implies that most practical purposes outside the realm of
manipulations known to influence the patho- scientific discourse (Willer, 1991). However, at
logical state should have similar effects in the the level of the cognitive processes underlying
model: thus, manipulations known to precipi- psychopathology (Brewin, 1988), and the
tate or exacerbate the disorder should precipi- physiological and biochemical mechanisms that
tate or exacerbate the abnormalities displayed underly those cognitive processes, the possibi-
in the model, while manipulations known to lity exists of constructing parallel theories
relieve the disorder should normalize behavior (Willner, 1986, 1991). It follows from this
in the model. In principle, therefore, questions analysis that the assessment of construct
of predictive validity can be addressed to a validity involves a number of relatively inde-
number of features of simulations, including pendent steps. On the one hand, the theoretical
their etiology and physiological basis. In account of behavior in the animal model
practice, the predictive validity of animal requires evaluation. For example, if an animal
models relevant to psychopathology is deter- model of depression is conceptualized as a
mined largely by their response to therapeutic decreased ability to respond to rewards, then at
drugs. In this context, a valid test should be the very least, it must be convincingly demon-
sensitive and specific, it should respond to strated that the decrease in rewarded behavior
effective therapeutic agents, and should fail to cannot be explained by, for example, nonspe-
respond to ineffective agents. Positive responses cific sedative effects. Similarly, an animal model
should occur at sensible doses, and should be of dementia must demonstrate that perfor-
demonstrable with a range of structurally mance failures result from a disorder of learning
diverse compounds, and where applicable, to or memory, rather than from nonspecific
nonpharmacological treatment modalities; it is causes, and further work should seek to
sometimes possible to demonstrate a correlation characterize the specific memory processes
between potency in the model and the clinical involved. Equally important, however, is the
dose. Negative responses should be demon- evaluation of the account offered of the clinical
strable with agents that cause behavioral disorder, both at the level of cognitive analysis
changes similar to the therapeutic effect but and at the level of the relationship between
by nonspecific actions (e.g., by changing cognitive changes and subjective experience
locomotor activity). (Brewin, 1988; Willner, 1991). It will be clear
A number of other factors that need to be that a detailed consideration of the human
considered in relation to drug effects in animal disorder forms an essential step in the evalua-
models are discussed elsewhere (Willner, 1991). tion of animal models, and that the relatively
However, one important fact that is sometimes poor state of theoretical understanding of most
overlooked, with misleading consequences, is psychopathologies places an upper limit on
that the clinical classification of drugs as active construct validity.
1.07.2 ANIMAL MODELS OF consists of paradigms based on the application

DEPRESSION of stress. In a simple and widely-used model,
sometimes known as the ªbehavioral despairº
1.07.2.1 Clinical Considerations test, rats or mice are forced to swim in a confined
space; antidepressants are found to increase the
Depression is a heterogeneous disorder, which
duration of active struggling, or conversely, to
presents with varying patterns of symptomatol-
decrease the duration of immobility which
ogy, a fact often overlooked by clinical psychol-
develops later in the test (Porsolt, 1981; Porsolt,
ogists. Perhaps the most important distinction is
LePichon, & Jalfre, 1977). This model has been
between endogenous and nonendogenous de-
used extensively in drug development, and
pressions, which differ in their responsiveness to
functions with reasonable accuracy as an
psychological intervention (not, as frequently
antidepressant screening test (Porsolt, 1981;
assumed, in the presence or absence of psycho-
Borsini & Meli, 1988). However, many workers
logical precipitants: see e.g., Lewinsohn, Zeiss,
prefer to use the theoretically-neutral term
Zeiss, & Haller, 1977; Paykel, 1979). Endogen-
ªforced swim,º rather than the theoretically-
ous depression, which corresponds to the DSM-
loaded term ªbehavioral despair.º This more
IV diagnosis of melancholia, is defined by an
restrained position is endorsed by studies
inability to experience pleasure (anhedonia), and
suggesting that immobility during forced swim-
may be conceptualized as a decrease in the
ming may be better characterized as a successful
sensitivity of brain reward systems (Klein, 1974).
energy-saving coping response (West, 1990).
Melancholia is characterized by psychomotor
The importance of proper behavioral analysis
retardation and a number of biological markers,
is nowhere more evident than in relation to the
responds well to antidepressants, and is a
original stress model of depression, learned
particular target for animal models.
helplessness. This procedure was based on the
Inevitably, animal models must focus on
observation that animals exposed to uncontrol-
behavioral and physiological symptoms. Thus,
lable stress (usually electric shocks) were
anhedonia (decreased response to rewards), loss
subsequently impaired in learning to escape
of appetite, and sex drive are readily modeled,
from shock, a deficit not seen in animals
and loss of interest may be modeled as a decrease
exposed to controllable shock (Seligman,
in motivation, but such symptoms as feelings of
1975); these learning difficulties are reversed
worthlessness and guilt, or thoughts of suicide,
with reasonable selectivity by subchronic (3±7
fall outside the scope of animal models.
days) treatment with antidepressant drugs
Although psychomotor change, which is the
(Martin, Laporte, Soubrie, El Mestikawy, &
most characteristic symptom of severe depres-
Hamon, 1989; Sherman, Saquitne, & Petty,
sion (Nelson & Charney, 1981), is typically
1982). It was proposed that exposure to
modeled as a decrease (retardation) or increase
uncontrollable (but not controllable) stress
(agitation) in locomotor activity, the clinical
provides the basis, in animals as in people, for
phenomena are actually considerably more
learning that stress is uncontrollable (help-
complex, and there must be serious doubt about
lessness), and that this learning has a number of
the face validity of models that rely exclusively
debilitating consequences, including depression
on gross changes in locomotor activity. Depres-
(Seligman, 1975). This hypothesis has been
sion is effectively treated by a wide variety of
immensely influential within clinical psychol-
chemically and functionally distinct drugs, and
ogy, probably more so than any other hypoth-
it is therefore inevitable that pharmacological
esis derived from animal models. However,
considerations also play an important role in the
interpretation of the ªlearned helplessnessº
validation of animal models of depression. In
effect has been the subject of considerable
addition to questions of generality and specifi-
controversy in both the human (Abramson,
city of drug effects in an animal model, two
Metalsky, & Alloy, 1989; Abramson, Seligman,
features of antidepressant drug action are
& Teasdale, 1978) and animal literature.
particularly important: that these drugs have a
The term ªlearned helplessnessº implies that
slow onset of action, typically requiring 2±5
the animals perform poorly because they have
weeks of treatment, and that they fail to elevate
learned that their responses are ineffective in
mood in nondepressed individuals.
controlling their environment (Seligman, 1975).
However, inescapable shock has a variety of
1.07.2.2 Stress Models other simpler effects that could also explain
many of the behavioral impairments such as
Animal models of depression have been decreased locomotor activity (Glazer & Weiss,
reviewed by Katz (1981), Jesberger and Ri- 1976) and analgesia (Lewis, Cannon, & Lie-
chardson (1985), and Willner (1984, 1990). The beskind, 1980). In order to demonstrate that
largest group of animal models of depression inescapable shock does, additionally, cause
Animal Models of Depression 211
ªcognitiveº impairments, performance accu- the symptomatology of depression, as captured,

racy was assessed using a maze task, in which for example, by the DSM-IV diagnostic system
performance would be independent of factors (American Psychiatric Association, 1994).
influencing motor speed. As predicted, accuracy However, the learning impairment is only one
was reduced in animals previously subjected to among a wide range of consequences of
unavoidable shock, confirming the presence of a uncontrollable shock, and in fact, the breadth
ªcognitiveº component to the pattern of of syptomatic parallels to severe depression has
impairment (Jackson, Maier, & Rapoport, led to the suggestion that rodents subjected to
1978). However, subsequent work showed that uncontrollable shock could meet the DSM
this ªcognitiveº impairment arose from an criteria for major depression (Weiss et al., 1982)!
increase in distractiblity rather than from a Among these behavioral abnormalities is a poor
learning disability (Minor, Jackson, & Maier performance of rewarded behavior, which, as
1984). So inescapable shock does cause ªcog- noted above, may be relevant to melancholia.
nitiveº impairment, but at the level of atten- One manifestation of this effect is a long-lasting
tional processes rather than ªhelplessness.º decrease in responding for brain stimulation
Furthermore, in the typical experimental para- reward, which is specific to certain electrode
digm, inescapable shock is not only uncontrol- placements, and therefore suggests a subsensi-
lable but also unpredictable in onset and/or tivity within part of the brain mechanism of
offset. It was demonstrated many years ago that reward, rather than, for example, a motor
simply providing a feedback signal to accom- impairment (Zacharko, Bowers, Kokkinidis, &
pany shock offset conferred protection against Anisman, 1983; Zacharko, Lalonde, Kasian, &
the ulcerogenic effect of inescapable (and Anisman, 1987). However, this subsensitivity to
therefore, uncontrollable) shock (Weiss, reward is long-lasting only if the animals are
1970). More recently, signals at the onset or tested in the immediate aftermath of stress;
offset of uncontrollable shock have been shown otherwise the effect dissipates rapidly (Zachar-
to protect against subsequent behavioral sup- ko et al., 1983). A related finding is that
pression. It was hypothesized that unpredict- following an initial exposure to severe stress
ability generates high levels of fear, which are behavioral deficits may be reinstated by mild
maintained within manageable limits by signals stressors that are without effect in normal
denoting the presence of danger or safety animals (Anisman & Zacharko, 1982). These
(Jackson & Minor, 1988). This reconceptualiza- studies suggest that it may be possible to
tion explains some hitherto puzzling observa- develop conditioning models to explain how
tions, such as the fact that inescapably shocked the risk of depression is elevated for several
animals are easily distractable (Minor et al., months in the aftermath of a stressful life event:
1984), which is exactly as would be expected in a the predisposing influence of life events in
state of fearful hypervigilance, but is difficult to depression is well established, but is less well
explain in terms of loss of control (though even understood (Brown, 1993). Another important
this is not the whole story: Maier, 1994). From observation is that uncontrollable electric shock
this perspective, learned helplessness may be has variable behavioral effects (most of which
more valid as a model of anxiety rather than are antidepressant-reversible) in different
depression. However, while stress-induced re- inbred mouse strains. To take an extreme
sponse suppression may be prevented by example, in the C57BL/67 strain, uncontrolla-
anxiolytic drugs, they fail to reverse an already- ble shock severely impaired subsequent learning
established effect (in contrast to antidepres- to escape shock, but had no effect on responding
sants, which are effective both before and after for brain stimulation reward, while the DBA/2J
stress) (Drugan, Ryan, Minor, & Maier, 1984). strain showed exactly the opposite pattern of
This suggests that the relevance of these deficits (Shanks & Anisman, 1988; Zacharko
paradigms may be to a form of anxiety that et al., 1987). These studies may provide a
does not respond to benzodiazepines. Phobia is starting point for investigation of the physio-
one possibility, particularly if the conditioned logical mechanisms underlying individual dif-
fear interpretation of learned helplessness ferences in responses to stress.
effects is correct: phobias do not respond to Subsensitivity to reward, an operational
treatment with conventional anxiolytic drugs, definition of anhedonia, the defining symptom
but there is evidence that some phobic states do of the melancholic subtype of major depression
respond to antidepressants (Liebowitz, 1992). (Klein, 1974), has been most extensively
Another problem in attempting to relate the characterized and studied in the chronic mild
learned helplessness model to depression is that stress procedure. In this model, chronic,
the ªcore symptomº of the learned helplessness sequential exposure of rats or mice to a variety
paradigmÐan impairment of shock avoidance of mild stressors causes a decrease in their
learningÐdoes not reflect in any obvious way responsiveness to rewards, which is typically
monitored as a decrease in the consumption of changes in the sleeping electroencephalogram

dilute sucrose solutions. This and related effects characteristic of depression, such as a decrease
may be maintained over a period of weeks or in the latency to enter the first period of rapid
months by continued application of the stress eye movement sleep. Indeed, all of the beha-
regime (Willner, Towell, Sampson, Muscat, & vioral symptoms of major depressive disorders
Sophokleous, 1987; Willner, Muscat, & Papp, listed in DSM-IV have now been demonstrated
1992; Willner & Papp, 1997). The chronic mild in animals exposed to chronic mild stress, along
stress paradigm has been extensively validated with most of the biological symptoms char-
as a model of anhedonia. Initial studies showed acteristic of severe depressions (Willner et al.,
that, in contrast to the decreased intake of dilute 1992; Willner & Papp, 1997). The relevance of
solutions of sucrose or saccharin, chronic mild this model to depression is further supported by
stress did not decrease intake of plain water, the evidence that the decreases in sensitivity to
food pellets, or concentrated sucrose solutions; reward are reversed by all of the major classes of
thus the effects are not simply nonspecific antidepressant drugs, and by electroconvulsive
changes in consummatory behavior (Muscat & shock, but not by a variety of nonantidepressant
Willner, 1992). Neither are the effects on drugs. Furthermore, the effects of antidepres-
consumption of sweet fluids secondary to loss sants in this paradigm resemble the clinical
of body weight, which is another consequence of situation, in two important respects: in both
chronic mild stress (and itself a symptom of cases, treatment typically requires chronic (2±5
depression): weight loss alone does not alter weeks) drug administration; and the effects are
sweet fluid consumption, and in rats or mice specific to the stressed/depressed state, since
subjected to chronic mild stress, decreases in antidepressant treatment does not increase
sweet fluid consumption are still present after hedonic behavior either in nonstressed control
ªcorrectingº for changes in body weight (Will- animals or in nondepressed human volunteers
ner, Moreau, Nielsen, Papp, & Sluzewska, (Willner et al., 1987, 1992; Willner & Papp,
1996). 1997). In view of these parallels with clinic, the
Convergent evidence to support the hypoth- chronic mild stress model has been used
esis that changes in sweet fluids reflect an extensively to study the mechanisms of action
underlying change in sensitivity to rewards of antidepressant drugs (Willner et al., 1992;
comes from studies using place conditioning to Willner & Papp, 1997).
measure rewarding effects. In this paradigm,
animals display a preference for a distinctive
environment in which they have previously 1.07.2.3 Other Approaches
received rewards (Carr, Phillips, & Fibiger,
1989). Chronic mild stress attenuated or The presumed etiological role in depression of
abolished place preferences established using a loss events, and particularly, loss of a loved one,
variety of natural or drug rewards. By contrast, has led to the development of a number of
drug-induced place aversions were unaffected animal models of depression based on separa-
by chronic mild stress, indicating that the effects tion phenomena. The most familiar of these
on place preference conditioning are unlikely to models involves nonhuman primates, either
result from a nonspecific motivational impair- infants isolated from their parents or juveniles
ment or a failure of associative learning (Willner isolated from their peer group. These studies
et al., 1992). Finally, chronic mild stress has also originated from the work of Harlow (1958).
been shown to cause an increase in the threshold Harlow's initial studies were designed to
for brain stimulation reward (Moreau, Jenck, investigate mothering, and showed that infant
Martin, Mortas, & Haefely, 1992). The con- rhesus monkeys reared with surrogate mothers
vergent evidence from all of these techniques preferred soft, cuddly surrogates to wire models
supports the hypothesis that chronic mild stress containing a feeding bottle, demonstrating the
causes anhedonia: while any one of these effects importance of sensory contact. However, pro-
is susceptible of a variety of interpretations, test responses in infant monkeys separated from
anhedonia, a generalized decrease in sensitivity real or surrogate mothers were also noted, and
to rewards, is the most parsimonious hypothesis these became the main focus of attention. The
to account for all of the data. separation response consists of an initial stage of
Like the learned helplessness procedure, ªprotest,º characterized by agitation, sleepless-
chronic mild stress causes a range of behavioral ness, and distress calls, followed by ªdespair,º
and physiological changes relevant to depres- characterized by a decrease in activity, appetite,
sion, in addition to the ªcore symptomº of the play and social interaction, and the assumption
model, in this case, anhedonia. For example, of a hunched posture and ªsadº facial expres-
chronic mild stress causes decreases in affective sion (Henn & McKinney, 1987; Suomi, 1976).
(e.g., sexual) and locomotor behaviors, and These symptoms are strikingly similar to those
Animal Models of Anxiety 213
of ªanaclitic depressionº in institutionalized depression. Delusional depression, for example,

children (Robertson & Bowlby, 1956). The is differentiated behaviorally from nondelu-
relationship to adult depression remains un- sional depression only by a greater association
certain, though recent life event research has with psychomotor agitation (Nelson & Char-
confirmed that ªloss eventsº such as bereave- ney, 1981), but is pharmacologically distinct,
ment are particularly likely to precipitate being unresponsive to tricyclic antidepressants
depression (Brown & Harris, 1989). Although but responsive to electroconvulsive therapy
the evolutionary proximity of primates has led (ECT) or to tricyclic/neuroleptic combinations
some authors to consider these models to be of (Nelson, 1987). Bipolar disorder is another well-
particular importance (e.g., Everitt & Keverne, defined diagnostic category for which there are
1979), their contribution has been rather no animal models. In this case, the depressive
modest. Because of the expense of using episodes appear to be identical to those of
primates, the size of experimental groups in unipolar endogenous depression, but episodes
most studies has been too small to provide of mania are interspersed. While there are a
reliable data, and the few pharmacological number of animal models of mania (Lyon, 1991;
studies using these models have not been Robbins & Sahakian, 1980), the alternation of
impressive (Willner, 1990). depressive-like and manic-like behaviors in an
Separation phenomena of ªprotestº followed animal model has not yet been systematically
by ªdespairº are present to some extent in many addressed. Indeed, the episodic nature of
other species, including cats, dogs, rodent, and unipolar depression (Angst et al., 1973) is itself
precocial birds (Katz, 1981; McKinney & another area that has not been explored in
Bunney, 1969), and several of these phenomena animal models.
have also been used as the basis for the
development of animal models of depression.
One of these, the reactivation of distress calling 1.07.3 ANIMAL MODELS OF ANXIETY
in one-week-old chicks appears to perform 1.07.3.1 Clinical Considerations
relatively well as an antidepressant screening
test (Lehr, 1989). Chronic (4±6 weeks) isolation Animal models of anxiety, which have been
of adult rats has been found to cause a reviewed by Gray (1982), Treit (1985), and
disruption of cooperative social behavior (Ber- Green and Hodges (1991), have a long history,
ger & Schuster, 1982) reminiscent of the poor deriving from the early work of Pavlov and
social performance of depressed people (Le- Masserman on ªexperimental neurosis.º In
winsohn, 1974), and this impairment of social these early studies, regressive, abnormal beha-
cooperation is reversed by chronic antidepres- viors were produced by exposing animals to
sant treatment (Willner et al., 1989). Thus, the conflict: in Pavlov's studies, difficult discrimi-
investigation of complex phenomena associated nation problems in a conditioning procedure,
with social isolation does not rely on the use of and in Masserman's studies, approach-avoid-
primates. ance conflict (Abramson & Seligman, 1977).
There are many other animal models of This set the stage for later work, most of which is
depression, which will not be discussed in detail based squarely on the assumption that conflict
because they have been studied largely for their procedures are, almost by definition, animal
pharmacology, and have received little psycho- models of anxiety.
logical characterization. These include a num- A second early precursor to present-day
ber of inbred rat or mouse strains that display animal models of anxiety is found in Watson's
certain depression-like behaviors (Overstreet, description of conditioned fear in the child
1993), and could in principle be used to ªLittle Albertº (Watson & Rayner, 1920). This
investigate individual differences in vulnerabil- observation, together with the formal demon-
ity to depression, if validated. There is also a stration by Miller (1960) that fear could
quite widely-used model based on the destruc- be conditioned in laboratory animals, and
tion of the olfactory bulb in rats, which differs suppressed by counterconditioning procedures,
from most other models in that the animals are led directly to the development of systematic
hyperactive (Cairncross, Cox, Forster, & Wren, desensitization procedures for phobic anxiety
1979; Van Riezen & Leonard, 1990). Thus, this (Wolpe, 1958), which for many years remained
model may reflect different aspects of depres- the jewel in the crown of behavioral psy-
sion, and may be relevant to agitated states. chotherapies (albeit that we now know that
This example highlights a significant limita- conditioning principles provide a rather incom-
tion of animal models of depression, which have plete account of the processes underlying
tended to focus either on an undifferentiated systematic desensitization: Wilkins, 1971). An-
depressive state or on melancholia, while largely other early contribution of fear conditioning
ignoring some other well-defined subtypes of research to the treatment of phobias came from
the observation that avoidance responses, once the problem that ªvirtually any test devised by
learned, are extremely long-lasting. Though experimental psychopharmacologists can in-
initially perplexing, it soon emerged that this duce mild or severe fearº (Green & Hodges,
resistance to extinction occurs because an 1991). Thus, the appeal to the construct of fear
animal that makes a successful avoidance to validate an animal model of anxiety is not
response has no opportunity to learn that the particularly persuasive.
response is no longer necessary. If the animal Furthermore, benzodiazepines are not neces-
was prevented from making the avoidance sarily the drugs of choice for anxiety. Anti-
response, and so forcibly exposed to the depressants are commonly prescribed for
information that a failure to respond did not anxietyÐthey are clearly more effective than
lead to adverse consequences, the avoidance benzodiazepines in panic disorders (Kahn,
response extinguished rapidly. The treatment of McNair, & Frankenthaler, 1986; Robinson,
phobic anxiety by flooding is based upon this Nies, Ravaris, Ives, & Bartlett, 1978), and it is
observation (Solomon, Kamin, & Wynne, unclear whether there are any conditions,
1953). Although studies of fear conditioning including generalized anxiety disorder, in which
led directly to the development of two successful benzodiazepines are demonstrably superior to
treatments, it was later realized that this antidepressants in their clinical efficacy. With
approach had some serious limitations, notably certain limited exceptions, antidepressants are
in failing to address the specificity of phobias to not effective in traditional animal models of
certain classes of objects (e.g., animal phobias anxiety, and neither are a number of recently
are common, knife phobias are not). This developed novel anxiolytics. This has led
feature is found in certain types of animal recently to a certain disillusionment with the
learning, which, it has been claimed, are traditional conflict models.
preprogrammed by evolution to be selective
and long-lastingÐone much-discussed example 1.07.3.2 Conflict Models
is the conditioned taste aversion, in which novel
foods are later avoided if their ingestion is Conflict models are based on both uncondi-
followed by illness (Seligman, 1971). However, tioned and conditioned behaviors, and vary
while conditioned taste aversions may display considerably in their behavioral sophistication.
some of the characteristics of phobic anxiety, a The simplest test is the examination of general
more recent social learning model, in which behavior in a novel arena: locomotor activity is
monkeys acquire a fear of snakes by observation usually increased by anxiolytic drugs (e.g.,
of already fearful animals (Mineka & Cook, Blumstein & Crawley, 1983). However, this test
1986; Mineka, Davidson, Cook, & Keir, 1984), is of limited value, given the multitude of factors
is perhaps more persuasive. that can influence open-field activity the
Alongside the concept of ªconflict,º the difficulty of subjecting open-field behavior to
second major principle underlying the construc- behavioral analysis. Some derivatives of the
tion of animal models of anxiety has been the open field such as the hole-board test (File &
assumption that a model of anxiety should Wardill, 1975) and the staircase test (Simiand,
respond specifically to benzodiazepines and Keane, & Morre, 1984) are more complex, but
functionally related drugs. However, while share the same limitations. Emergence tests,
benzodiazepines are effective in generalized from a presumed ªsafeº to a presumed
anxiety disorder, they are actually ineffective ªdangerousº area, are somewhat more sophis-
in most forms of anxiety, such as phobia, ticated. A simple test of this type involves
obsessive-compulsive disorder and panic (Rick- measuring crossings between the light and the
els, 1985; Rickels & Schweizer, 1987). Thus, to dark half of a two-compartment chamber
the extent that animal models of anxiety have (Crawley, Skolnick, & Paul, 1984). Again,
relied on a response to benzodiazepines, they are however, it is difficult to distinguish conflict
primarily models of generalized anxiety dis- behavior from general locomotor activity
order. Unfortunately, of all forms of anxiety, (Carey & Fry, 1988). The best known model
the symptomatology of generalized anxiety of this group is the elevated plus-maze, a plus-
disorder is the least amenable to behavioral shaped set of runways which is raised off the
modeling, as it consists primarily of autonomic ground and has two enclosed and two open and
hyperactivity and a feeling of apprehension. In exposed arms. Most, but not all, anxiolytic
many animal models of anxiety, the behavior drugs tend to increase the time spent on the open
expressed appears to have face validity, in the arms, while other classes of drugs, such as
sense that it appears reasonable that an anxious stimulants, neuroleptics, and antidepressants,
animal might behave in that way. However, the do not. The validity of this test is supported by
similarities to generalized anxiety disorder are the demonstration that levels of defaecation and
more intuitive than demonstrable. There is also freezing, as well as blood corticosterone are
Animal Models of Anxiety 215
higher in animals confined in the open arms period serve as a control for nonspecific drug
(Critchley & Handley, 1987; Pellow, 1986; influences. If necessary, the contingencies may
Pellow, Chopin, File, & Briley, 1985). A number be manipulated so as to ensure equivalent rates
of animal models of anxiety are based on social of responding in the two components; alter-
interactions of various kinds, though there natively, the response rate during the conflict
seems little reason to see any of these tests as period may be set low to maximize the chance of
being particularly relevant to social phobias. detecting an increase, or high, to allow the
The most popular is a test in which social detection of anxiogenic effects (Geller & Seifter,
interaction between pairs of male rats is 1960; Sepinwall & Cook, 1978; see also Green &
suppressed by using a novel environment and Hodges, 1991). Clearly, this model has manifest
bright lighting; anxiolytics increase interaction advantages over the unconditioned procedures
levels under these conditions. Almost alone described above in terms of the degree to which
among animal models of anxiety, the social the behavioral parameters are under experi-
interaction test requires chronic drug adminis- mental control. However, the procedure is
tration resulting in tolerance to sedative effects, extremely time-consuming, and may require
which are apparent as a decrease in locomotor parametric changes during an experiment to
activity on acute administration (File & Hyde, maintain stable response rates. The Geller±
1978). Seifter procedure appears to have reasonably
In conflict models based on conditioned good face validity. However, the situation is not
behavior, conflict is explicitly programmed into entirely straightforward. Following the pro-
the experimental paradigm by punishing the longed training necessary to establish stable
animal for performing a response that it has baselines of responding, animals may no longer
been trained to emit in order to obtain a reward. display physical signs of fear or autonomic
A simple, and rapidly learned procedure of this arousal (e.g., Stephens & Andrews, 1991). It is
kind is the Vogel water-lick conflict test where therefore possible that benzodiazepines may
thirsty animals are first trained to lick from a increase punished responding by mechanisms
drinking tube and electric shocks are then other than anxiety reduction, and in fact, there
delivered through the tube or the floor when the is evidence that they act at least in part by
animal licks, causing a suppression of drinking. reducing the animal's ability to discriminate
Nonspecific effects are assessed either by between punished and nonpunished compo-
including nonpunished drinking periods or by nents (Hodges, Baum, Taylor, & Green, 1986).
measuring drug effects on home-cage drinking It should be noted, however, that this critique of
(Vogel, Beer, & Clody, 1971). A more complex the Geller±Seifter procedure arises precisely
model involves training rats to consume a very because it is amenable to experimental analysis.
sweet (32%) sucrose solution, then switching to Other simpler procedures, in which hypotheses
a weak (4%) solution. When the switch occurs, concerning behavioral mechanisms are less
the rate of licking falls, and only gradually, over readily testable, thereby escape criticism.
the course of several days, returns to that of a rat The construct validity of conflict models, in
maintained throughout on the weaker solution. which behavior is suppressed by ªfearº and
Benzodiazepine treatment speeds the return to reinstated by anxiolytic drug treatment, derives
normal behavior (Flaherty, Grigson, Demetri- in large part from the hypothesis that anxiety
kopoulos, & Demetrikopoulos, 1987; Flaherty, results from activity in a forebrain ªbehavioral
Grigson, & Rowan, 1986; see also Green & inhibition systemº (Gray, 1982). This hypoth-
Hodges, 1991). Unlike other conflict models, esis, and with it most of the traditional anxiety
this model is based on frustration rather than models, has received a serious challenge from
fear. Its relevance to anxiety is thus less obvious, the development of nonbenzodiazepine anxio-
though there is considerable evidence for a lytics. The anxiolytic action of buspirone, and
commonality between the brain mechanisms of related compounds acting at the 1A subtype of
fear and frustration (Gray, 1982). serotonin (5HT) receptors, is now well estab-
The classic and most widely used conflict lished; however, these drugs are ineffective, or
model is the Geller±Seifter operant conflict minimally effective, in traditional anxiety
procedure. In this model, animals (rats or models (Griebel, 1995).
pigeons) respond in an operant chamber for
food rewards; interspersed into the experimen-
tal session are periods (typically signaled by a 1.07.3.3 Ethological Models
light or tone) during which responding results in
both an increased availability of food and a mild An alternative approach views anxiety as
electric shock to the feet. Anxiolytic drugs arising from threatening situations which elicit
increase responding during the conflict period, defensive behaviors. Defensive behaviors,
and response rates during the nonconflict involving characteristic submissive postures,
are seen in an intruder rat or mouse introduced chard, Rodgers, Hendrie, & Hori, 1988). Flight
into the home cage of a resident conspecific; has been proposed as a potential model of panic
these defensive behaviors are suppressed by (Deakin & Graeff, 1991), which unlike general
anxiolytic drugs (Krsiak et al. 1984; Shepherd & anxiety disorder, does not respond to benzo-
Rodgers, 1989). Another model elicits defensive diazepines. While buspirone appears to be
behavior by shocking a rat or mouse through an ineffective in panic disorder (Sheehan, Raj,
electric prod; subsequently, the animal will bury Trehan, & Knapp, 1993), positive effects of
the prod in sawdust if given the opportunity to another 5HT1A agonist, gepirone, have been
do so. Again, defensive burying is suppressed reported (Pecknold, Luthe, Scott-Fleury, &
with reasonable specificity by anxiolytics (Treit, Jenkins, 1993), and the efficacy of specific
1985). However, the basic dependent variable in serotonin uptake inhibitors is reasonably well
this model, the depth of sawdust piled up, is established (Sheehan et al., 1993). Thus,
difficult to quantify. different psychopathologies may reflect differ-
A more complex approach, derived from ent components of the defensive behavioral
studies that were initially conducted largely in repertoire. It is important to add that one of the
wild rats, is based on an ethological analysis of defining features of psychopathology is that the
behavior in the presence of, and following behaviors displayed are disproportionate, and
exposure to, a predator (a cat). These studies led this to some extent limits the validity of models
to the description of a pattern of ªrisk that relate anxiety and panic disorders to
assessmentº behaviors, including visual ªscan- defensive behaviors resulting from the recent
ningº of the area in which the predator was or actual presence of a predator. Nevertheless,
encountered and ªstretch approachº alternating these models serve as a rich source of hypotheses
with retreat (Blanchard, Rodgers, & Blanchard, concerning the nature of, and the relationship
1994; Blanchard, Yudko, Rodgers, & Blan- between, anxiety and panic.
chard, 1993). It has been argued that risk
assessment behaviors bear a striking resem-
blance to the behavioral features of general 1.07.4 ANIMAL MODELS OF
anxiety disorder: apprehensive expectation, SCHIZOPHRENIA
vigilance, hyperattentiveness, and scanning 1.07.4.1 Clinical Considerations
(Blanchard et al., 1994). A number of simpler
tests have been developed for evaluating drug As in the case of animal models of anxiety,
effects on risk assessment, including a test in models of schizophrenia are dominated by its
which rats are exposed to cat odor (Blanchard pharmacotherapy. The evidence that neurolep-
et al., 1993), and observational techniques tic drugs act by antagonizing dopamine recep-
applied to the elevated plus maze (Rodgers & tors (Creese, Burt, & Snyder, 1976) is so strong
Cole, 1993). The potentiated startle model is a as to be indisputable, and despite many attempts
very simple model of hypervigilance. In this to break out of the dopamine trap, there is as yet
procedure, the startle response to a loud noise, no clear evidence that drugs acting at other sites
which is very readily quantifiable, is increased are effective (Rifkin & Siris, 1987). Never-
by the simultaneous presentation of a light that theless, a substantial proportion of schizophre-
has previously been paired with electric shock. nic patients do not benefit from neuroleptics,
The potentiation of startle by the fear-inducing particularly, but not exclusively, those patients
signal is suppressed by anxiolytics, which do with predominantly negative symptoms, such as
not, however, affect the basal (unconditioned) poverty of speech or social withdrawal. This fact
response to the loud noise (Davis 1979). not only stimulates the continuing search for
In contrast to the traditional conflict models, other modes of treatment, but also casts doubt
in these ethologically-derived tests, both ben- on the necessity of neuroleptic responsiveness in
zodiazepines and 5HT1A agonists are anxiolytic an animal model of schizophrenia. It is
(Blanchard et al., 1993, 1994). The effects of important to note that neuroleptics cause
benzodiazepines and 5HT1A agonists on de- significant motor impairments (via their action
fensive behavior are not, however, identical. In on dopamine receptors in the caudate nucleus),
response to an approaching predator, animals and that many of the behavioral actions in
display a characteristic repertoire of defensive animals are probably related more closely to
behaviors. Benzodiazepines increase flight re- these side effects than to their therapeutic action
sponses in wild rats to contact by a human (see Iversen, 1987). The newer ªatypicalº
experimenter; however, the 5HT1A agonists neuroleptics are thought to minimize side effects
buspirone and gepirone decrease flight re- by virtue of additional actions on other
sponses to such an extent that the rats allow neurotransmitter systems (Tamminga & Ger-
themselves to be touched (Blanchard, Hori, lach, 1987) and/or specific actions within
Rodgers, Hendrie, & Blanchard, 1989; Blan- ªlimbicº areas (White & Wang, 1983). The
Animal Models of Schizophrenia 217
development of these drugs has not, however, and the psychosis that develops in people after
challenged the basic premise that neuroleptics prolonged amphetamine intoxication (Connell,
act by antagonizing dopamine transmission. 1958). Single, high doses of amphetamine can
A number of reviews have argued in principle also elicit the amphetamine psychosis (Griffith,
against animal models of schizophrenia on the Cavanaugh, Held, & Oates, 1972). In animals
grounds that the symptoms of this disorder are high doses of amphetamine cause a species-
uniquely human (e.g., Kumar, 1976). In fact, characteristic pattern of repetitive stereotyped
this problem is common to all areas of behavior (Randrup & Munkvad, 1971), and a
psychopathology, and arguably is not especially number of paradigms have been described in
more serious in this case. Most of the symptoms which amphetamine elicits a repetitive perse-
of schizophrenia could in principle have veration either of responses, or more interest-
counterparts in animals, particularly so if ingly, of complex programs of behavior, such as
attention is paid to the structure of behavior switching between two responses, which are
rather than its content (Lyon, 1991). Halluci- continued irrespective of their outcome. These
natory behavior, for example, has been defined effects are antagonized by neuroleptics (Even-
operationally as ªsequences of well defined den & Robbins, 1983; Ridley & Baker, 1983).
behaviors that could apparently only be Similar patterns of stereotyped switching have
accounted for by the reaction of the animal to been observed in schizophrenic patients (Frith
non-existent stimuliº (Nielsen, Lyon, & Ellison, & Dorie, 1983; Lyon, Mejsholm, & Lyon, 1986).
1983), though it should be added that behavior It is frequently difficult to decide whether
meeting this criterion in animals reflects visual phenomena of this kind are more relevant to
phenomena rather than the auditory hallucina- schizophrenia or to mania, which in many
tions that are far more prevalent in schizo- respects displays a superficially similar pattern
phrenia. Lyon (1991) has suggested that for the of symptoms. However, manic behavior, while
purposes of animal models, the DSM-III increased in rate, and frequently stereotyped
criteria for schizophrenia should be augmented and repetitive, usually retains a goal-directed
by two additional symptoms that featured organization, unlike the fragmentation of
prominently in Bleuler's (1950) account of behavior characteristic of schizophrenia. Beha-
dementia praecox, excessive alternation or vior on this criterion is more obviously related
switching between behaviors, and repetitive to schizophrenia, rather than mania, and is seen
stereotyped responding. With these additions, following chronic administration of dopamine
Lyon (1991) has argued that the symptoms of agonists to rats, cats, or monkeys. This has been
schizophrenia may be reduced to four classes of achieved either by repeated daily injections of
abnormal behaviors: response switching, focus- amphetamine or cocaine, typically for a period
ing, fragmentation, and stereotypy, which of many weeks (Ellinwood & Kilbey, 1977,
appear in sequence as the disorder progresses. 1980), or by the use of an implanted slow-release
These behaviors are clearly more relevant to the amphetamine pellet, which lasts for one or two
positive symptoms of schizophrenia (hallucina- weeks (Ellison & Eison, 1983; Nielsen et al.,
tions, delusions, thought disorder), rather than 1983). Repeated injection regimes cause, even-
the negative symptoms (affective flattening, tually, a wide range of behavioral abnormal-
poverty of speech, loss of drive, anhedonia), and ities, including hyper-reactivity, abortive or
this reflects the state of the field, which consists fragmented behaviors, and a large number of
largely of models of positive symptomatology. motor disorders, including dystonias, ataxia,
akithisia, and facial dyskinesias. Motor dis-
turbances are not uncommon in schizophrenics.
1.07.4.2 Dopamine Hyperactivity Models While these are often ascribed to neuroleptic
therapy, postural and oculomotor disturbances
Animal models of schizophrenia have been were described long before the neuroleptic era
reviewed by McKinney and Moran (1981), (Kraepelin, 1919), and evidence suggests that
Iversen (1987), and Lyon (1991). As expected tardive dyskinesias may also be an intrinsic part
from the predominance of dopamine in theore- of the underlying disorder (Barnes, 1988). An
tical accounts of schizophrenia, the majority of important feature of the chronic stimulant
animal models involve pharmacological treat- syndrome, particularly apparent in the contin-
ments that increase dopamine receptor stimula- uous slow-release model, is the presence of
tion, primarily by using directly acting apparent hallucinatory behavior. Nielsen et al.
dopamine agonists, such as apomorphine, or (1983), using stringent operational criteria,
by using amphetamine to release dopamine described four types of hallucinatory behavior
from presynaptic stores. This strategy is greatly in monkeys, all directed at nonexistent objects,
encouraged by the close phenomenological resulting in flight, attack, eating, or other
similarities between paranoid schizophrenia behaviors such as threat responses. These
behaviors, as well as motor stereotypies, were Prepulse inhibition refers to the ability of a
suppressed by the neuroleptic haloperidol warning signal to decrease the amplitude of the
(Lyon, 1991). startle response to a loud noise. Prepulse
The release of dopamine in subcortical inhibition is impaired in schizophrenic patients
structures is increased in rats reared in social (Braff, Stone, Callaway, Geyer, & Ball 1978),
isolation (Jones, Hernandez, Marsden, & Rob- and is also impaired by dopamine agonist drugs
bins, 1988). Thus, the pathological effects of (amphetamine or apomorphine) in animals
isolation rearing may to some extent be (Mansbach, Geyer, & Braff, 1988), and by
mediated by dopamine hyperactivity, though isolation rearing (Wilkinson et al., 1994). While
clearly, social isolation also has many other a rather simple behavior, the prepulse inhibition
effects. Goosen (1981) has described a ªsocial paradigm is of interest because the neural
deprivation syndromeº in female rhesus mon- mechanisms underlying the acoustic startle
keys, consisting of stereotyped behaviors of reflex are very well understood, and appear to
various kinds, and bizarre and/or self-directed be very similar in rats and humans (Davis,
behaviors. These abnormalities resemble some 1984). This model is used increasingly within the
of the behaviors observed following chronic pharmaceutical industry, largely on account of
stimulant drug treatment, but the more florid its simplicity. Latent inhibition is a more
hallucinatory behaviors are far less conspic- complex form of habituation, in which pre-
uous. As some of the effects of social isolation exposure to a stimulus reduces the ability to
are reversed by antidepressants, isolation rear- learn about its consequences when it is later
ing provides at best an approximation to a paired with a significant event. This ability is
model of schizophrenia. However, the demon- impaired in acute schizophrenics, though not in
stration that prolonged changes in dopamine chronic schizophrenics (Baruch, Hemsley, &
activity can be elicited environmentally is Gray, 1988). In rats, where the significant event
encouraging. is an electric shock, latent inhibition is disrupted
In addition to causing motor stereotypies that by amphetamine and potentiated by neurolep-
resemble positive symptoms of schizophrenia, a tics (Joseph & Jones, 1991). An attractive
dramatic loss of social interaction is seen feature of this procedure is that a conditioned
following chronic stimulant treatment in rats fear paradigm is used. Thus, the conditioned
(Nielsen & Lyon, 1982) or monkeys (Ridley, stimulus suppresses operant behavior, latent
Baker, & Scragg, 1979), or acute treatment with inhibition lifts the suppression, and ampheta-
high doses of amphetamine in monkeys (Ellen- mine reverses latent inhibition to reinstate the
broek & Cools, 1990). These effects in monkeys suppression. In other words, amphetamine
are seen as an increase in interindividual causes a decrease in responding, so the effect
distance, a decrease in the number of interac- on latent inhibition cannot be an artefact of
tions initiated, and an increase in the number of psychostimulation. However, the significance of
interactions terminated, all leading to an this model is uncertain, as an increased
increase in social isolation, which may represent reactivity to preexposed stimuli could reflect a
a model for negative symptoms (Ellenbroek & nonspecific state of arousal. This interpretation
Cools, 1990). is supported by a study suggesting that the effect
of amphetamine in this model results from an
increase in the perceived intensity of the electric
1.07.4.3 Attentional Models shock rather than an altered response to the
conditioned stimulus (Killcross et al., 1994).
Returning to positive symptoms, it has long While animal models of schizophrenia are
been known that schizophrenic patients suffer dominated by dopaminergic drugs, there are a
attentional disorders which have been consid- number of models based on the use of drugs
ered to underly their cognitive deficits (Frith, interacting with other neurotransmitter sys-
1987). This defect is usually characterized as a tems. The most notable of these are lysergic acid
broadening of attention, leading to an increased diethylamide (LSD) and phencyclidine (PCP).
response to irrelevant stimuli that would Jacobs, Trulson, and Stern (1977) described a
normally be filtered out; a more specific range of bizarre behaviors in LSD-treated cats
formulation has suggested that the abnormality that resemble the effects of chronic psychosti-
could be considered to represent a reduction in mulant treatment, though at low doses, limb
the influence of past regularities on current flicks, which are not seen either in the stimulant
perception (Hemsley, 1987). These considera- models or in schizophrenia, were the most
tions have led to a number of attempts to model prominent effect of LSD. Despite the popularity
attentional dysfunction; the two most widely in the 1960s of the LSD experience as a model of
used paradigms are the prepulse inhibition and schizophrenia in humans, it is clear that both
latent inhibition models. clinicians and patients perceive the effects of
Animal Models of Substance Abuse 219
LSD as different from schizophrenia (Hollister, 1995; Lipska, Jaskiw, & Weinberger, 1993).
1962), unlike amphetamine, which appears to This is the only model to capture the develop-
exacerbate existing symptomatology. PCP, on mental aspect of schizophrenia, which typically
the other hand, does appear to induce the full first appears in late adolescence.
range of positive and negative symptoms,
including thought disorder, in volunteers and
in schizophrenics (Davies & Beech, 1960; 1.07.5 ANIMAL MODELS OF SUBSTANCE
Greifenstein, Yoshitake, De Valut, & Gajewski, ABUSE
1958). In both animal and human subjects, PCP 1.07.5.1 Drug Self-administration
produces stereotyped behaviors as well as
deficits in social behavior that are comparable It is clear from the earlier discussion of
to the social withdrawal and isolation that form depression, anxiety, and schizophrenia that the
an important part of the negative symptom validity of animal models can often be difficult
complex. Both sets of effects could be reversed to determine, in part because of the considerable
in rats by clozapine which is almost alone differences in the methodologies used to study
among neuroleptic drugs in its activity against animal behavior on the one hand, and human
negative symptoms; in contrast, the typical psychopathology, on the other. However, in the
neuroleptic haloperidol suppressed PCP-in- case of animal models of addiction, at least
duced stereotypies, but failed to normalize superficially, these difficulties appear less acute:
social behavior (Sams-Dodd, 1996). It is just like humans, animals voluntarily self-
interesting that PCP also disrupts prepulse administer drugs (Bozarth, 1987; Goudie,
inhibition, and the characteristics of this 1991; Koob, 1995). Before discussing the self-
response actually resemble the schizophrenic administration model, a second parallel should
deficit more closely than the effects of amphe- be mentioned in passing: animals are also able
tamine (Mansbach & Geyer, 1989). to report on their perceptions of a drug. In drug
Finally, there have been a number of attempts discrimination procedures, animals receive food
to model schizophrenia using brain lesions. rewards for pressing one lever if they have been
Lesions of the hippocampus have been shown to administered the drug and a different lever if
impair performance in a foraging task, using a they have received saline. After training, their
holeboard in which food was located below four response to a novel agent reflects the extent to
of the 16 holes, which has been suggested to which it is perceived as similar to the training
provide a possible model of thought disorder drug. This model is used extensively in
(Oades & Isaacson, 1978). The effects of mechanistic studies of psychotropic drug action
hippocampal lesions are similar in many (Stolerman, Samele, Kamien, Mariathasan, &
respects to those of amphetamine, and may in Hague, 1995), and is considered to represent a
general be antagonized by neuroleptics (Schma- model of the subjective effects of drugs (Preston
juk, 1987), though the neuroleptic reversal of & Bigelow, 1991).
the holeboard impairment was only partial In drug self-administration experiments, the
(Oades & Isaacson, 1978). More recently, animal, typically a rat or a monkey, is implanted
hippocampal lesions have been shown to cause with a chronic in-dwelling intravenous catheter,
an increase in sensitivity to the disruptive effect which is connected through plastic tubing to a
of amphetamine in the prepulse inhibition reservoir located outside the experimental
model (Swerdlow et al., 1995). Significantly, chamber, which places minimal restraints on
neuropathological abnormalities have been the animal's freedom of movement. Provided
described postmortem in the hippocampus of suitable precautions are taken against infection
schizophrenic patients (Kovelman & Scheibel, and blood clots, catheters can remain patent
1984), suggesting that hippocampal damage for periods of up to several months, allowing
may be at least in part responsible for an for experiments involving complex and lengthy
apparent dopamine hyperactivity in schizo- training procedures and/or chronic drug ad-
phrenia. However, while the effects of hippo- ministration. Drug delivery is made contingent
campal damage do resemble those of acute on the performance of an operant response,
amphetamine treatment, the hallucinatory and typically lever pressing, but sometimes a less
bizarre behaviors that emerge following chronic motorically demanding response, such as nose
amphetamine administration are absent. A poking. If access to the drug is unlimited, a
particularly interesting variant of this model pattern of self-administration may develop,
is based on a neonatal hippocampal lesion. consisting of periods of drug intake alternating
Animals prepared in this way appear normal as with periods of abstinence, during which other
juveniles, but when adults are hyperactive, activities such as eating, drinking, and sleeping
hyper-reactive to amphetamine, and show occur. This binge pattern of drug consumption
defective prepulse inhibition (Lipska et al., has been described in animals self-administering
a wide variety of psychomotor stimulants and a higher response rate may not denote a higher
with alcohol; binges are also characteristic of efficacy. This problem has been addressed in a
problematic use of both of these drug classes number of ways, the most popular being the
in humans. Opioid self-administration is more progressive ratio schedule. In progressive ratio
constant over time, as it is in human intravenous schedules the response requirement progres-
opiate users (Brady, Griffiths, Hienz, Ator, sively increases, during the session or across
Lukas, & Lamb, 1987; Yokel, 1987). However, session, up to the point at which the subject
unlimited access to self-administered drugs can stops responding; at this ªbreakpoint,º it is
lead to fatalities, and therefore drugs are rarely assumed that the work requirement exceeds the
made available for self-administration on an reinforcing effect of the drug. Thus, different
unlimited basis (Yokel, 1987). When drug drugs can be compared directly according to the
availability is limited by scheduling daily work that animals are prepared to perform to
sessions of several hours duration, responding earn them. Studies using this procedure have
typically follows an inverted U-shaped dose± shown that cocaine supports higher breakpoints
response function. Above a minimum dose, than a variety of other agents, supporting the
responding and drug intake rise with drug dose; popular view of cocaine as a highly addictive
this ascending portion of the curve may be drug (Katz 1990; Young & Herling, 1986).
relatively steep and difficult to study. Above a Motivation to work for drug, as revealed by
certain dose, responding falls with further performance in a progressive ratio schedule, has
increases in dose, and this has the effect of also been proposed as a method of measuring
maintaining the blood concentration of the drug drug craving in animals (Markou et al., 1993).
at a relativelyÐin some cases, remarkablyÐ This approach is supported by a study of human
constant level, which remains stable over volunteers reinforced under a progressive ratio
prolonged periods of time (Koob, 1995; Yokel, schedule by puffs on a cigarette, in which
1987). breakpoints correlated significantly with a
In general there is close agreement between questionnaire measure of cigarette craving
the drugs intravenously self-administered by (Willner, Harding, & Eaton, 1995).
animals and those which are abused by people. The importance of measuring motivation,
Thus, animals readily learn to self-administer rather than simple consumption of a drug, is
opioids (e.g., morphine, heroin), psychostimul- well illustrated by studies of alcohol self-
ants (e.g., amphetamine, cocaine), barbiturates, administration. While rats or monkeys readily
dissociative anesthetics (e.g., phencyclidine), self-administer alcohol by intravenous injec-
and alcohol. Also self-administered, though less tion, the majority of animals will not drink
reliably, are nicotine, caffeine, and benzodiaze- alcohol in sufficient quantities to produce
pines. Conversely, various drugs that are not significant pharmacological effects, and cer-
abused do not typically support self-adminis- tainly insufficient to cause physical dependence.
tration; these include antidepressants, neurolep- The need to model oral alcohol consumption in
tics, and serotonin agonists (e.g., fenfluramine, animals has stimulated selective breeding pro-
buspirone). However, there are some anomalies. grams that have succeeded in producing several
The most obvious is that animals do not reliably rat strains characterized by high alcohol con-
self-administer either hallucinogens (e.g., LSD) sumption, a preference for alcohol over water in
or cannabinoids; on the other hand, they do two-bottle tests, and in some cases, the devel-
reliably self-administer certain drugs which opment of physical dependence (Crabbe & Li,
are not abused, such as kappa opioid agonists 1995). However, when alcohol-drinking rats
and local anesthetics (Yokel, 1987; Young & are required to work for alcohol, differences
Herling, 1986). Thus, the agreement between between the strains emerge. Only one strain, the
self-administered drugs and abused drugs is not P (alcohol-preferring) line, works harder under
perfect; nevertheless, drug self-administration a progressive ratio schedule than its nonprefer-
procedures are routinely used within the phar- ring (NP) control strain; other high alcohol-
maceutical industry to predict whether novel drinking strains (HAD, AA) do not (Ritz,
compounds have ªabuse liability.º Garcia, Protz, Rael, & George, 1995). While the
Self-administration procedures can also esti- greater proclivity of P rats to consume alcohol
mate the relative reinforcing efficacy (relative suggests that the P and NP rat strains may prove
abuse liability) of different agents. This issue useful in investigating possible genetic bases for
must be approached with caution, since under alcoholism, it is equally important to note that
many circumstances (e.g., cocaine self-admin- the difference between the strains is not
istration under fixed ratio schedules of reinfor- absolute. Moderate or high levels of alcohol
cement and limited daily access), an increase in intake can be induced in outbred animals by
unit dose of the drug results in a compensatory introducing alcohol in a sweetened solution and
decrease in response rates, and vice versa. Thus, gradually fading out the sucrose componentÐa
Animal Models of Substance Abuse 221
progression reminiscent of the process by which conventionally-reinforced behaviors in more

many teenagers acquire the taste for alcohol. complex settings, where both types of reinforcer
After initiation of alcohol drinking by means of are concurrently available. It is clear from
the sucrose fading technique, alcohol consump- studies using progressive ratio procedures that
tion in NP rats is comparable to that of P rats drug-reinforced responding is ªprice sensitiveº
(Samson, Tolliver, Lumeng, & Li, 1989). (i.e., drug intake is suppressed when the work
requirement is too high). This leads to varia-
tions in drug taking as a function of the relative
1.07.5.2 Drugs as Positive and Negative price and availability of drugs and alternative
Reinforcers reinforcers, which can be described with some
precision using concepts derived from econom-
The most striking feature of the early ics, such as elasticity of demand (Bickel,
literature utilizing drug self-administration Hughes, DeGrandpre, Higgins, & Rizzuto,
models is that drugs function as reinforcers, 1992; Hursh, 1980). For example, in an early
in operant procedures, in a manner highly study, two baboons were found to respond
reminiscent of conventional reinforcers. In equally to heroin and food when both were in
particular, the characteristic patterns of beha- plentiful supply, but as resources became
vior associated with different schedules of scarcer, heroin showed greater elasticity: food
reinforcement are maintained as effectively by intake was maintained but heroin intake
drugs as by conventional reinforcers, such as decreased (Elsmore, Fletcher, Conrad, & So-
food delivery or shock termination (Schuster & detz, 1980). Behavioral economics may provide
Johanson, 1981). These similarities raise the a useful framework for analyzing human drug
question of whether drug reinforcement has taking (Heyman, 1996).
unique characteristics. One potential difference The extensive parallels between drug reinfor-
is that with conventional reinforcers, increasing cement and conventional reinforcement in
the magnitude of the reinforcer leads to nondependent animals, together with the fact
increased responding, whereas with drug re- that the construct of dependence is of very
inforcers, the dose±response function has an limited value for understanding human drug
inverted U-shape, such that increases in dose taking (Sanger, 1991), has led some workers to
cause compensatory decreases in response rate argue that self-administered drugs function
(Wise, 1987). However, the same effect can, in primarily as incentives, which are sought for
fact, be observed with conventional reinforce- their rewarding properties (Stewart, de Wit, &
ment: variations in the sweetness of a food Eikelboom, 1984). The incentive properties of
reinforcer also lead to changes in responding drugs of abuse are demonstrated by the so-
that follow an inverted U-shaped function called ªprimingº effect: in animals trained to
(Willner, Phillips, & Muscat, 1991). Another self-administer a drug, and then extinguished so
question is whether drugs are more efficaceous that responding decreases substantially, a single
than conventional reinforcers. Early studies drug administration is sufficient to reinstate
suggested that cocaine might be more reinfor- responding, in a dose-related fashion, despite
cing than food, insofar as cocaine maintained the fact that responding leads to no further drug
higher response rates than food in second-order injections. Priming effects have been consis-
schedules of reinforcement (in which long tently demonstrated with intravenously self-
chains of behavior are required to achieve administered stimulants and opiates (Stewart &
delivery of a reinforcer). However, this differ- de Wit, 1987), as well as oral alcohol (Chiamu-
ence in responding is only seen when reinforcers lera, Valerio, & Tesari, 1995), and can be seen
are presented at intervals during the session: if following multiple nonreinforced extinction
the session terminates upon delivery of the first sessions (Shaham, Rodaros, & Stewart, 1994;
reinforcer, cocaine and food maintain equiva- Chiamulera et al., 1995). Priming effects are
lent rates of responding. Similarly if a session seen not only with the training drug, but are also
run under these conditions is preceded by an elicited by other drugs, which are effective in
injection of cocaine, this results in faster reinstating responding to the extent that they
responding in both cocaine and food reinforce- resemble the training drug in drug discrimina-
ment conditions. These studies suggest strongly tion assays (Stewart & de Wit, 1987).
that cocaine is not uniquely reinforcing; rather, Furthermore, priming effects can also be
the apparent differences between cocaine- and elicited by environmental stimuli previously
food-maintained behavior result from stimulant associated with drug infusions (Stewart et al.,
effects of the cocaine delivered during experi- 1984). Consistent with these findings, in human
mental sessions (Katz & Goldberg, 1987). drug users, stimuli associated with cocaine have
Studies have begun to examine the rela- been found to elicit cocaine craving in cocaine
tionship between drug-reinforced and users, but were without effect in opiate users or
in nondrug users (Ehrman, Robbins, Childress, The withdrawal of morphine led to pronounced
& O'Brien, 1992). These studies are interpreted decreases in both food deliveries and successful
as meaning that stimuli associated with abused avoidances (Thompson & Schuster, 1964). This
drugs can acquire conditioned incentive proper- phenomenon, known as behavioral dependence,
ties. For example, following conditioning ses- is a sensitive index of withdrawal, since the
sions in which neutral stimuli are paired with disruption of operant behavior maintained by
drug infusions, nondependent animals will learn conventional reinforcers can be observed fol-
a new response that is reinforced by presenta- lowing withdrawal from treatment regimes,
tion of the conditioned stimulus (Davis & with a variety of drugs, that produce few if
Smith, 1987). Conditioned reinforcing effects any overt signs of distress (Balster, 1985).
have been studied most extensively in the place- Indeed, experiments of this kind provide strong
conditioning model (Carr et al., 1989). In this evidence for a brief cocaine withdrawal syn-
paradigm, animals are typically exposed to one drome, which is still unrecognized by many
of two distinctive environments in the presence clinicians. For example, the threshold for brain-
of a drug, and to a different environment in its stimulation reward is markedly elevated, in-
absence. In a subsequent drug-free choice trial, dicating anhedonia, following withdrawal from
animals display a preference for environments as little as 12 hours exposure to cocaine self-
associated with self-administered drugs, with administration (Markou & Koob, 1991).
few exceptions (notably, alcohol), while avoid- A number of lines of evidence confirm the
ing environments paired with drugs that are aversive nature of drug-withdrawal states. The
presumed to have aversive effects, such as most direct evidence is that morphine-depen-
lithium chloride or the opiate antagonist, dent monkeys learn to respond to a conditioned
naloxone (Goudie, 1991). A major methodolo- stimulus so as to avoid or delay infusions of an
gical advantage of these conditioning proce- opiate antagonist (Goldberg, Hoffmeister,
dures is that reinforcing effects are studied in the Schlichting, & Wuttke, 1971). Indeed, stimuli
absence of the drug, which avoids problems associated with drug withdrawal in dependent
associated with motor or other nonspecific drug subjects, which, typically, have been repeatedly
effects. precipitated, in the presence of the conditioned
In contrast to this focus on the euphoric stimulus, by administration of a pharmacolo-
properties of abused drugs, the traditional view gical antagonist, can acquire a powerful control
of drug dependence has emphasized the im- over behavior. For example, stimuli or places
portance of drug tolerance, physical depen- paired with opiate antagonists can elicit signs of
dence, and the avoidance of withdrawal distress physical withdrawal in morphine-dependent
as a major fact in the maintenance of continued rats (Wikler, 1973), monkeys (Goldberg,
drug use. It is well established that the induction 1976), and humans (O'Brien, 1975), which can
of physical dependence leads to an increase be seen many weeks after drug withdrawal, and
in drug self-administration in animal and long after offset of the withdrawal period. Like
human subjects (Cappell et al., 1987; Griffiths, withdrawal itself, such stimuli are aversive, as
Bigelow, & Henningfield, 1980; Griffiths, demonstrated, for example, in place condition-
Bigelow, & Liebson, 1986). There is also some ing experiments (Hand, Koob, Stinus, &
evidence from animal models that the induction leMoal, 1988).
of physical dependence increases not only the
quantity of drug consumed, but also the 1.07.5.3 Limitations
reinforcing efficacy of drug reinforcers in self-
administration paradigms. However, the evi- It is clear from this brief review that there
dence is equivocal. For example, in studies using have been significant advances in understanding
a progressive ratio schedule to assess relative the factors that control the initiation and
reinforcing efficacy, induction of physical maintenance of drug self-administration, and
dependence increased responding maintained many of these factors are of proven relevance to
by codeine or morphine, but not by another human drug taking. However, a significant
opioid, loperamide, which has minimal abuse limitation on the face validity of animal models
potential in humans, or by alcohol (Yanagita, of addiction arises from the impoverished
1987). environments in which animals typically self-
Other effects of withdrawal can be readily administer drugs. There is evidence that drug
demonstrated within the self-administration taking is decreased by testing animals in social
paradigm. For example, in a classic study, rats groups (Alexander, Beyerstein, Hadaway, &
were maintained in a procedure in which periods Coambs, 1981), and as discussed above, it is
of morphine availability alternated with periods clear that another potential source of enrich-
in which lever pressing resulted in food ment, the availability, and conditions of avail-
availability or in avoidance of electric shock. ability, of alternative sources of reinforcement,
Overview: Validity and Utility of Animal Models 223
can markedly influence drug taking. Human ing human substance abuse, and the relevance
drug taking typically involves a substantial of the neurobiological insights arising from
element of social ritual and cultural conven- animal models of drug self-administration,
tions, and a high degree of choice (Hartnoll, remains to be confirmed
1991). These factors may be relatively unim-
portant in studies of the biological bases of drug
action, but may be crucial if the object is to 1.07.6 OVERVIEW: VALIDITY AND
understand the environmental controls on drug- UTILITY OF ANIMAL MODELS
taking behavior. It is tempting to draw the
comparison between the environmental impov- Having surveyed animal models relevant to
erishment typically imposed on experimental four areas of psychopathology, it is of interest
animals and the conditions of social deprivation now to reconsider the general issue of the
that characterize many communities in which validity of animal models in relation to the
drug-taking is rife; however, these parallels criteria outlined at the start of this chapter, and
require detailed evaluation, and should be to summarize their uses. McKinney and Bunney
viewed with caution. (1969) suggested that an animal model should
Another area that has received little attention resemble the clinical disorder in its etiology,
is the process of change in patterns of drug self- treatment, symptomatology, and physiological
administration. For good and obvious reasons, basis, and these categories provide a convenient
drug self-administration is usually studied framework within which to examine the con-
under steady-state conditions, in which drug tribution of animal models to our understand-
taking is constant over sessions, and well- ing of the clinical disorders.
regulated within sessions. Much of the literature As noted earlier, the orientation of animal
discussed above describes factors that influence models towards psychopharmacology has
drug self-administration under these condi- meant that the predictive validity of the models
tions. Much human drug taking is also is determined largely by their pharmacological
controlled and well-regulated, and one of the responsiveness, which has not been discussed in
major challenges is to understand the conditions detail in this chapter. In general, however,
in which regulation breaks down, leading to predictive validity is reasonably high for each
uncontrolled, heavy, and typically, problematic class of model, though there are exceptions to
substance use. As discussed above, uncontrolled this general rule at the level of individual
use, including a characteristic human pattern in models. Animal models of depression can
which drug or alcohol binges alternate with usually be relied upon to differentiate estab-
periods of abstinence, can also be observed in lished antidepressants from known inactive
animal models, under appropriate experimental agents, though there are some well-known
conditions, and studies carried out under these exceptions which are difficult to interpret
conditions are most encouraging (Koob, 1995). (e.g., anticholinergic drugs often appear
However, there has been little attempt to use antidepressant-like: see Willner, 1990). How-
animal models to study the evolution of ever, a multiplicity of novel agents are currently
controlled into uncontrolled use, and the factors undergoing clinical trials in depression, and it
that control those changes. will be some years before the predictive validity
As noted earlier, the evaluation of construct of animal models of depression can be assessed
validity requires a good theoretical understand- in relation to these novel agents. By contrast,
ing of both the model and the condition animal models of anxiety, traditionally the jewel
modeled (Willner, 1991). Unfortunately, both in the crown among animal models when
sides of this equation are rarely met; in the assessed by their response to benzodiazepines,
present case, drug intake by animals is now well are currently in the unfavorable position of
understood (at least under steady-state condi- coming to terms with the anxiolytic and
tions), but a coherent theoretical understanding putatively anxiolytic actions of novel seroto-
of substance abuse by people remains elusive. nergic agents and, rather belatedly, with the
The motivational framework outlined above anxiolytic actions of antidepressants.
provides an excellent, if limited, account of Animal models of schizophrenia remain for
many aspects of drug taking in animal models. the moment unchallenged as regards their
This framework is of great heuristic value in predictive validity, as all drug development in
guiding the rapid development of an under- this area has involved variations on the theme of
standing of the neurobiological substrates dopamine blockade. However, a comparison
mediating the rewarding effects of drugs and with the position of anxiety models a few short
the aversive effects of withdrawal (Altman et al., years ago suggests caution: we do not know how
1996; Koob & Goeders, 1989). However, the well the current models would cope with the
importance of these constructs for understand- discovery of novel neuroleptics acting through
mechanisms unrelated to dopamine. Animal couched in language difficult to transport into

models of substance abuse perform well in animal models, though where the possibility
discriminating abused from nonabused sub- exists (as, for example in the learned help-
stances, but less well when asked to rank lessness model of depression), the response has
different substances for their relative abuse been enthusiastic. Irrespective of the extent to
liability. which the terminology of psychological theories
Given the intrinsic limitation that animal of depression or anxiety may or may not be
models must be based on behavioral rather than applied to animals, such theories must be
subjective symptomatology, in those cases capable of explaining the efficacy of antide-
where efforts have been made to establish face pressant and anxiolytic drugs. The fact that
validity, the position is again reasonably cognitive theories of psychopathology cannot
encouraging. Core symptoms of the disorder explain drug effects is a measure of their current
are demonstrable not only in models of limitations. Biologically based theories of
depression (e.g., subsensitivity to rewards), psychopathology take the actions of therapeutic
anxiety (responses to aversive stimuli), and agents as one of their starting points, but
substance abuse (drug self-administration), but beyond this, have made relatively little progress.
also in models of schizophrenia (bizarre and Few biological abnormalities have been deter-
hallucinatory behaviors). However, a recogni- mined with any certainty in the brains of
tion of the diagnostic heterogeneity of the psychiatric patients, and as a result, biologically
clinical disorders is now becoming a high based theories of depression (Willner, 1985),
priority. In the case of schizophrenia, the need anxiety (Gray, 1982) or schizophrenia (Frith,
for an acceptable model of negative sympto- 1987) are derived in large part from research
matology has long been explicitly recognized. using animal models (an uncomfortable fact of
However, the heterogeneity of anxiety disorders life that clinicians tend to overlook). While there
has until recently had little impact on animal is an unacceptable degree of circularity in
models: in comparison to the multitude of tests appealing to these theories as support for the
addressing generalized anxiety disorder, very construct validity of animal models, it is
little thought has been given to the development certainly arguable that the construct validity
of animal models of phobic anxiety or panic, of animal models in all three areas approaches
and virtually none to obsessive-compulsive the limits set by clinical theory. Much the same
disorder. In part, this narrow view reflects the can be said of substance abuse: the animal
degree to which the field of animal modeling is literature provides a clear and powerful theore-
drug-driven: it is difficult to see any other reason tical framework for understanding drug self-
for the scarcity of work on models of phobic administration, but the human literature is
anxiety, which is not drug-responsive but lends marked by an equally striking lack of theoretical
itself superbly well to the development of consensus (e.g., Altman et al., 1996).
models for which face validity may be estab- Perhaps surprisingly, animal models have
lished. However, domination by drugs is not the little to say about the etiology of anxiety.
whole story: the pharmacological distinction Potentially important insights about the etiol-
between delusional and nondelusional depres- ogy of phobias arise from the studies of
sions is well established clinically but has been observational conditioning of fear in monkeys
overlooked in the development of animal (Mineka & Cook, 1986), but as far as general-
models of depression. Rather, the preoccupa- ized anxiety disorder and panic are concerned,
tion with generic disorders of depression and animal models of anxiety provide no insights
anxiety reflects an unwillingness to look outside into why some people respond normally in
the ordered confines of the laboratory at the situations that generate pathological anxiety in
chaotic richness of the clinical world. This others. Models of depression are more promis-
attitude is understandable, but perhaps, short- ing, and provide strong support for the view that
sighted. stress and social isolation are of etiological
Animal models are at their weakest in the area significance, as well as some pointers to the
of construct validity. However, this reflects to a mechanisms mediating these effects. It may be
considerable extent the inadequacies of current important to reflect that this research provides
clinical theorizing. Theories of psychopathol- clear evidence against the distinction between
ogy tend to be either strongly psychological or ªpsychologicalº and ªbiologicalº depressions,
strongly biological in nature, with little attempt in demonstrating that environmental precipi-
to unify the two approaches. Psychologically tants can cause profound physiological con-
based theories are well developed in relation to sequences. The major contribution of animal
aspects of depression and anxiety, though models to the etiology of schizophrenia has been
rudimentary in their account of schizophrenia the demonstration that neuropathological fea-
(see Brewin, 1988). These theories are frequently tures of the schizophrenic brain, such as
Summary 225
hippocampal abnormalities or ventricular ton, & Glautier, 1995). Nevertheless, animal

widening, could indeed be of etiological im- models do contribute in major ways to the
portance. Animal models of substance abuse treatment of psychopathology. These contribu-
have focused to a certain extent on factors tions arise from their use in drug screening
determining individual differences in suscept- programs and their role in determining the
ibility to drug or alcohol self-administration, mechanisms of action of psychotherapeutic
and have identified clear genetic influences and drugs. This does, however, represent a signifi-
hormonal variables that could be relevant to cant change of direction: animal models were
human drug taking. initially located within mainstream psychology,
It seems likely that animal models may play but now serve primarily as one of the major
an important role in the elucidation of relation- foundations of psychopharmacology.
ships between etiology and symptomatology. In In the future, animal models will have their
particular, the demonstration that stress can greatest impact in relation to the physiological
cause insensitivity to rewards may be of great mechanisms underlying psychopathology. This
significance for understanding melancholia; is a rich seam of research, which derives not
there is little in the clinical literature to predict simply from the models themselves but also
this relationship, which clearly deserves further from the ways in which research in animal
investigation. The generation of positive, but models relates to the broad spectrum of research
not negative, schizophrenic-like symptoms by in behavioral neuroscience. In effect, animal
hippocampal lesions similarly suggests that models form a critical interface between
specific etiological factors may relate to specific psychiatry and basic research in behavioral
symptom patterns. In addition to their use in the neuroscience; they are the channel through
experimental investigation of problems related which developments at the basic level are
to etiology, animal models may also be of value brought into clinical perspective. Animal mod-
in defining diagnostic boundaries. The current els serve both as theories of psychopathology
tendency to obscure the border between and as practical tools for its investigation. Their
depression and anxiety has arisen primarily development is an iterative process: the inves-
from clinical observations (for example, that tigation of an animal model provides hypoth-
antidepressants are also anxiolytic), but has eses concerning the clinical condition, and the
long been prefigured in the involvement of outcome of the clinical investigations provides
serotonin in animal models of both disorders. the basis for a more refined assessment of the
Work with animal models has led to a unifying validity of the model. Viewed in this light, the
concept that serotonergic systems function to major limitation of animal models, their
suppress the generation of impulsive behavior preoccupation with the objective aspects of
(Soubrie, 1986; Willner, 1989), which is of major psychopathology rather than the subjective,
importance for understanding a spectrum of may actually be something of an advantage; it
disorders including depression, anxiety, buli- forces the development of a linguistic frame-
mia, alcoholism, and obesity, in which seroto- work within which the psychological and
nergic transmission is abnormal and specific biological dimensions of psychopathology
serotonin reuptake inhibitors are therapeuti- may ultimately be reconciled.
cally effective.
Animal models were initially introduced,
during the behaviorist era, as a means of 1.07.7 SUMMARY
developing behavioral therapies for psycholo-
gical disorders, and this remains the arena in This chapter reviews animal models of
which animal models are best known to many depression, anxiety, schizophrenia, and sub-
clinical psychologists. However, this use of stance abuse. Although much of the review, of
animal models is very little evident in recent or necessity, deals with drug effects in animal
current work. Indeed, it is difficult to see any models, the focus throughout is on animal
contribution to behavioral psychotherapy aris- models as simulations of psychopathology,
ing out of the current models surveyed in this rather than on their utility as drug development
chapter in the areas of depression, anxiety or tools. Even in this psychological context, the
schizophrenia. The exception is in the area of models in current use relate primarily to
addiction, where the demonstration that stimuli psychopharmacology rather than to main-
conditioned by association with abused sub- stream psychology, and their principal use is
stances can acquire motivational properties in in investigations of the physiological mechan-
their own right has led to attempts to treat isms underlying psychopathology. In contrast to
addictions by cue exposure therapy, which their historical roots, animal models of psycho-
attempts to extinguish responses to drug- pathology now make relatively little contribu-
associated cues (Drummond, Tiffany, Reming- tion to the development of psychotherapies. For
each of the disorders reviewed, models, or classes K. (1988). Taming of wild rats (Rattus rattus) by 5HT1A
of model, are assessed for the extent to which agonists buspirone and gepirone. Pharmacology and
Biochemical Behavior, 31, 269±278.
they meet the criteria of predictive validity Blanchard, R. J., Yudko, E. B., Rodgers, R. J., &
(ability to predict from the model to the clinic), Blanchard, D. C. (1993). Defense system psychophar-
face validity (extent of phenomenological simi- macology: An ethological approach to the pharmacology
larity), and construct validity (theoretical ratio- of fear and anxiety. Behavioral Brain Research, 58,
155±165.
nale). In general, the results of this assessment Blanchard, R. J., Rodgers, R. J., & Blanchard, D. C. (1994).
are quite encouraging. Ethological approaches to the preclinical psychopharma-
cology of anxiety. In T. Palomo & T. Archer (Eds.),
Strategies for studying brain disorders, Vol 1: Depressive,
anxiety, and drug abuse disorders (pp. 1145±1160). Lon-
1.07.8 REFERENCES don: Farrand Press.
Abramson, L. Y., & Seligman, M. E. P. (1977). Modeling Bleuler, E. (1950). Dementia Praecox or the group of
psychopathology in the laboratory: History and ratio- schizophrenias. New York: International Universities
nale. In J. D. Maser & M. E. P. Seligman (Eds.), Press.
Psychopathology: Experimental models (pp. 1±26). San Blumstein, L. K., & Crawley, J. N. (1983). Further
Francisco: Freeman. characterization of a simple automated exploratory
Abramson, L. Y., Metalsky, G., & Alloy, L. B. (1989). model for the anxiolytic effects of benzodiazepines.
Hopelessness depression: A theory-based subtype of Pharmacology, Biochemistry and Behavior, 18, 37±40.
depression. Psychological Reviews, 96, 358±372. Borsini, F., & Meli, A. (1988). Is the forced swimming test
Abramson, L. Y., Seligman, M. E. P., & Teasdale, J. D. a suitable test for revealing antidepressant activity?
(1978). Learned helplessness in humans: Critique and Psychopharmacology, 94, 147±160.
reformulation. Journal of Abnormal Psychology, 87, Bozarth, M. A. (1987). Methods of assessing the reinforcing
49±74. properties of abused drugs. New York: Springer.
Alexander, B. K., Beyerstein, B. L., Hadaway, P. F., & Brady, J. V., Griffiths, R. R., Hienz, R. D., Ator, N. A.,
Coambs, R. B. (1981). Effect of early and later colony Lukas, S. E., & Lamb, R. J. (1987). Assessing drugs for
housing on oral ingestion of morphine in rats. Pharma- abuse liability and dependence potential in laboratory
cology, Biochemistry and Behaviour, 15, 571±576. primates. In M. A. Bozarth (Ed.), Methods of assessing
Altman, J., Everitt, B. J., Glautier, S., Markou, A., Nutt, the reinforcing properties of abused drugs (pp. 45±85).
D., Oretti, R., Phillips, G. D., & Robbins, T. W. (1996). New York: Springer.
The biological, social and clinical bases of drug addic- Braff, D. L., Stone, C., Callaway, E., Geyer, M., Glick, I.,
tion: Debate and review. Psychopharmacology, 125, & Ball, L. (1978). Prestimulus effects on human startle
285±345. reflex in normals and schizophrenics. Psychophysiology,
American Psychiatric Association (1994). Diagnostic and 15, 339±343.
statistical manual of psychiatric disorders (4th ed.). Brewin, C. R. (1988). Cognitive foundations of clinical
Washington DC: Author. psychology. Hove, UK: Erlbaum.
Angst, J., Baastrup, P., Grof, P., Hippius, H., Poldinger, Brown, G. W. (1993). The role of life events in the aetiology
W., & Weis, P. (1973). The course of monopolar of depressive and anxiety disorders. In S. C. Stanford &
depression and bipolar psychoses. Psychiatrica Neurolo- P. Salmon (Eds.), Stress: From synapse to syndrome
gica et Neurochirurgica, 76, 489±500. (pp. 23±50) London: Academic Press.
Anisman, H. A., & Zacharko, R. M. (1982). Depression: Brown, G. W., & Harris, T. O. (1989). Life events and
The predisposing influence of stress. Behavioral and illness. New York: Guilford Press.
Brain Sciences, 5, 89±137. Cairncross, K. D., Cox, B., Forster, C., & Wren, A. F.
Balster, R. L. (1985) Behavioral studies of tolerance and (1979). Olfactory projections systems, drugs and beha-
dependence. In L. S. Seiden, & R. L. Balster (Eds.), viour: A review. Psychoneuroendocrinology, 4, 253±272.
Behavioral pharmacology: The current status Cappell, H., Busto, V., Kay, G., Naranjo, C. A., Sellers, E.
(pp. 403±418) New York: A. R. Liss. M., & Sanchez-Craig, M. (1987). Drug deprivation and
Barnes, T. R. E. (1988) Tardive dyskinesia: Risk factors, reinforcement by diazepam in a dependent population.
pathophysiology and treatment. In Granville-Grossman, Psychopharmacology, 91, 154±160.
K. (Eds.), Recent advances in clinical psychiatry, No. 6 Carey, M. P., & Fry, J. P. (1988). An evaluation of light
(pp. 185±205). London: Churchill Livingstone. aversion as a measure of anxiolytic benzodiazepine
Baruch, I., Hemsley, D. R., & Gray, J. A. (1988). activity in the mouse. European Journal of Neuroscience,
Differential performance of acute and chronic schizo- (Suppl 1) 343.
phrenics in a latent inhibition task. Journal of Nervous Carr, G. D., Phillips, A. G., & Fibiger, H. C. (1989).
and Mental Disease, 176, 598±606. Conditioned place preference as a measure of drug
Berger, B. D., & Schuster, R. (1982). An animal model of reward. In S. J. Cooper & J. Liebman (Eds.), The
social interaction: Implications for the analysis of drug neuropharmacological basis of reward (pp. 264±319).
action. In M. Y. Spiegelstein & A. Levy (Eds.), Oxford, UK: Oxford University Press.
Behavioral models and the analysis of drug action Carroll, B. J. (1989). Diagnostic validity and laboratory
(pp. 415±428). Amsterdam: Elsevier. studies: Rules of the game. In L. N. Robins & J. E.
Bickel, W. K., Hughes, J. R., De-Grandpre, R. J., Higgins, Barrett (Eds.), The validity of psychiatric diagnosis
S. T., & Rizzuto, P. (1992). Behavioral economics of (pp. 229±244). New York: Raven.
drug-self-administration. IV. The effects of response Chiamulera C., Valerio, E., & Tessari, M. (1995).
requirements on the consumption of and interaction Resumption of ethanol-seeking behavior in rats. Beha-
between concurrently available coffee and cigarettes. vioural Pharmacology, 6, 32±39.
Psychopharmacology, 107, 211±216. Connell, P. H. (1958). Amphetamine psychosis. Maudsley
Blanchard, D. C., Hori, K., Rodgers, R. J., Hendrie, C. A., monograph No. 5. London: Oxford University Press.
& Blanchard, R. J. (1989). Attenuation of defensive Crabbe, J. C., & Li, T.-K. (1995). Genetic strategies in
threat and attack in wild rats (Rattus rattus) by preclinical substance abuse research. In F. E. Bloom &
benzodiazepines. Psychopharmacology, 97, 392±401. D. J. Kupfer (Eds.), Psychopharmacology: The fourth
Blanchard, D. C., Rodgers, R. J., Hendrie, C. A., & Hori, generation of progress (pp. 799±811). New York: Raven.
References 227
Crawley, J. N., Skolnick, P., & Paul, S. M. (1984). Absence Flaherty, C. F., Grigson, P. S., Demetrikopoulos, P. S., &
of intrinsic antagonistic actions of benzodiazepine Demetrikopoulos, M. K. (1987). Effect of clonidine on
antagonists on an exploratory model of anxiety in the consummatory negative contrast and on novelty-induced
mouse. Neuropharmacology, 23, 531±537 stress. Pharmacology, Biochemistry and Behavior, 27,
Creese, I. N. R., Burt, D. R., & Snyder, S. H. (1976). 659±664.
Dopamine receptor binding predicts clinical and phar- Flaherty, C. F., Grigson, P. S., & Rowan, G. A. (1986).
macological potencies of antischizophrenic drugs. Chlordiazepoxide and the determinants of negative
Science, 192, 481±483. contrast. Animal Learning and Behavior, 14, 315±321.
Critchley, M. A. E., & Handley, S. L. (1987). Effects in the Frith, C. D. (1987). The positive and negative symptoms
X-maze anxiety model of agents acting at 5-HT1 and 5- of schizophrenia reflect impairments in the perception
HT2 receptors. Psychopharmacology, 93, 502±506. and initiation of action. Psychological Medicine, 17,
Davies, B. M., & Beech, H. R. (1960). The effects of L- 631±648.
arylcyclohexylamine (sernyl) on twelve normal volun- Frith, C. D., & Done, J. (1983). Stereotyped responding by
teers. Journal of Mental Science, 106, 912±914. schizophrenic patients on a two-choice guessing task.
Davis, M. (1979). Diazepam and flurazepam: Effects on Psychological Medicine, 13, 779±786.
conditioned fear as measured with the potentiated startle Geller, I., & Seifter, J. (1960). The effects of meprobamate,
paradigm. Psychopharmacology, 62, 1±7. barbiturates, d-amphetamine and promazine on experi-
Davis, M. (1984). The mammalian startle response. In R. mentally induced conflict in the rat. Psychopharmacolo-
C. Eaton (Ed.), Neural mechanisms of startle behavior gia, 9, 482±492.
(pp. 287±351). New York: Plenum. Glazer, H. I., & Weiss, J. M. (1976). Long-term inter-
Davis, W. M., & Smith, S. G. (1987). Conditioned ference effect: an alternative to learned helplessness.
reinforcement as a measure of the rewarding properties Journal of Experimental Psychology and Behavior Pro-
of drugs. In M. A. Bozarth (Ed.), Methods of assessing cesses, 2, 202±213.
the reinforcing properties of abused drugs (pp. 199±210). Goldberg, S. R. (1976). Stimuli associated with drug
New York: Springer. injections as events that control behavior. Pharmacolo-
Deakin, J. F. W., & Graeff, F. G. (1991). 5-HT and gical Reviews, 27, 325±340.
mechanisms of defence. Journal of Psychopharmacology, Goldberg, S. R., Hoffmeister, F., Schlichting, U., &
5, 305±315. Wuttke, W. (1971). Aversive properties of nalorphine
Drugan, R., Ryan, S. M., Minor, T. R., & Maier, S. F. and naloxone in morphine-dependent rhesus monkeys.
(1984). Librium prevents the analgesia and shuttle-box Journal of Pharmacological and Experimental Therapeu-
escape deficits typically observed following inescapable tics, 179, 268±276.
shock. Pharmacology, Biochemistry and Behavior, 21, Goosen, C. (1981). Abnormal behavior patterns in rhesus
749±754. monkeys: Symptoms of mental disease? Biological
Drummond, C., Tiffany, S., Remington, R., & Glautier, S. Psychiatry, 16, 697±716.
(1995) (Eds.). Addiction: Cue exposure theory and Goudie, A. J. (1991). Animal models of drug abuse and
practice. London: Wiley. dependence. In P. Willner (Ed.), Behavioural models in
Ehrman, R. N., Robbins, S. J., Childress, A. R., & O'Brien, psychopharmacology: Theoretical, industrial and clinical
C. P. (1992). Conditioned responses to cocaine-related perspectives (pp. 453±484). Cambridge, UK: Cambridge
stimuli in cocaine abuse patients. Psychopharmacology, University Press.
107, 523±529. Gray, J. A. (1982). The neuropsychology of anxiety: An
Ellenbroek, B. A., & Cools, A. R. (1990). Animal models enquiry into the functions of the septo-hippocampal
with construct validity for schizophrenia. Behavioural system. Oxford, UK: Oxford University Press.
Pharmacology, 1, 469±490. Green, S., & Hodges, H. (1991). Animal models of anxiety.
Ellinwood, E. H. & Kilbey, M. M. (1977). Chronic In P. Willner (Ed.), Behavioural models in psychophar-
stimulant intoxication models of psychosis. In I. Hanin macology: Theoretical, industrial and clinical perspectives
& E. Usdin (Eds.), Animal models in psychiatry and (pp. 21±49). Cambridge, UK: Cambridge University
neurology (pp. 61±74) Oxford, UK: Pergamon. Press.
Ellinwood, E. H., & Kilbey, M. M. (1980). Fundamental Greifenstein, F. E., Yoshitake, J., DeValut, M., &
mechanisms underlying altered behavior following Gajewski, J. E. (1958). A study of L-arylcyclohexylamine
chronic administration of psychomotor stimulants. for anesthesia. Anesthesia and Analgesia, 37, 283±294.
Biological Psychiatry, 15, 749±757. Griebel, G. (1995). 5-Hydroxytryptamine-interacting drugs
Ellison, G., & Eison, M. S. (1983). Continuous ampheta- in animal models of anxiety disorders. More than 30
mine intoxication: An animal model of the acute years research. Pharmacology and Therapeutics, 65,
psychotic episode. Psychological Medicine, 13, 751±761. 319±395.
Elsmore, T. F., Fletcher, G. V., Conrad, D. G., & Sodetz, Griffith, J. D., Cavanaugh, J., Held, J., & Oates, J. A.
F. J. (1980). Reduction of heroin intake in baboons by (1972). Dextroamphetamine: Evaluation of psychotomi-
an economic constraint. Pharmacology, Biochemistry and metic properties in man. Archives of General Psychiatry,
Behaviour, 13, 729±731. 26, 97±100.
Evenden, J. L., & Robbins, T. W. (1983). Increased Griffiths, R. R., Bigelow, G. E., & Henningfield, J. E.
response switching, perseveration and perseverative (1980). Similarities in animal and human drug taking. In
switching following d-amphetamine in the rat. Psycho- N. K. Mello (Ed.), Advances in substance abuse (Vol. 1,
pharmacology, 80, 67±73. pp. 1±90). Greenwich, CT: JAI Press.
Everitt, B. J., & Keverne, E. B. (1979), Models of Griffiths, R. R., Bigelow, G. E., & Liebson, I. A. (1986).
depression based on behavioural observations of experi- Human coffee drinking: Reinforcing and physical
mental animals. In E. S., Paykel & A. Coppen (Eds.), dependence producing effects of caffeine. Journal of
Psychopharmacology of affective disorders (pp. 41±59). Pharmacology and Experimental Therapeutics, 239,
Oxford, UK: Oxford University Press. 416±425.
File, S. E., & Hyde, J. R. G. (1978). Can social interaction Hand, T. H., Koob, G. F., Stinus, L., & le Moal, M.
be used to measure anxiety. British Journal of Pharma- (1988). Aversive properties of opiate receptor blockade
cology, 62, 19±24. are centrally mediated and are potentiated by previous
File, S. E., & Wardill, A. G. (1975). Validity of head- exposure to opiates. Brain Research, 474, 364±368.
dipping as a measure of exploration in a modified Harlow, H. F. (1958). The nature of love. American
holeboard. Psychopharmacologia, 44, 53±59. Psychologist, 13, 673±685.
Hartnoll, R. L. (1991). The relevance of behavioural of schizophrenic attentional dysfunction. Psychopharma-

models of drug abuse and dependence liabilities to the cology, 115, 185±195.
understanding of drug misuse in humans. In P. Willner Klein, D. F. (1974). Endogenomorphic depression: A
(Ed.), Behavioural models in psychopharmacology: conceptual and terminological revision. Archives of
Theoretical, industrial and clinical perspectives General Psychiatry, 31, 447±454.
(pp. 503±519). Cambridge, UK: Cambridge University Koob, G. F. (1995). Animal models of drug addiction. In
Press. F. E. Bloom & D. J. Kupfer (Eds.), Psychopharmacol-
Hemsley, D. R. (1987). An experimental psychological ogy: The fourth generation of progress (pp. 759±772).
model for schizophrenia. In H. HaÈfne, W. F. Gattaz, & New York: Raven.
W. Janzarik (Eds.). Search for the causes of schizophrenia Koob, G. F., & Goeders, N. E. (1989). Neuroanatomical
(pp. 179±188). Berlin: Springer. substrates of drug self-administration. In J. M. Liebman
Henn, F. A., & McKinney, W. T. (1987). Animal models in & S. J. Cooper (Eds.), The neuropharmacological basis of
psychiatry. In H. Y. Meltzer (Ed.). Psychopharmacology: reward (pp. 214±263). Oxford, UK: Oxford University
the third generation of progress (pp. 687±696). New York: Press.
Raven. Kovelman, J. A., & Scheibel, A. B. (1984). A neurohisto-
Heyman, G. M. (1996). Resolving the contradictions of logical correlate of schizophrenia. Biological Psychiatry,
addiction. Behavioral and Brain Sciences, 19, 561±610. 19, 1601±1621.
Hodges, H., Baum, S., Taylor, P., & Green, S. (1986). Kraepelin, E. (1919). Dementia praecox and paraphrenia.
Behavioural and pharmacological dissociation of chlor- Edinburgh, UK: Livingstone.
diazepoxide effects on discrimination and punished Krsiak, M., Sulcova, A., Donat, P., Tomasikova, Z.,
responding. Psychopharmacology, 59, 155±161. Dlohozkova, N., Kosar, E., & Masek, K. (1984). Can
Hollister, L. E. (1962). Drug-induced psychoses and social and agonistic interactions be used to detect
schizophrenic reactions: A critical comparison. Annals anxiolytic activity of drugs? In K. A. Miczek, M. R.
of the New York Academy of Sciences, 96, 80±88. Kruk, & B. Olivier (Eds.), Ethopharmacological aggres-
Hursh, S. R. (1980). Economic concepts for the analysis of sion research (pp. 93±114). New York: Liss.
behavior. Experimental Analysis of Behavior, 34, Kumar, R. (1976). Animal models for screening new
219±238. agents: A behavioural view. British Journal of Clinical
Iversen, S. D. (1987). Is it possible to model psychotic Pharmacology, 4, (Suppl. 1), 13±17.
states in animals? Journal of Psychopharmacology, 1, Lehr, E. (1989). Distress-call reactivation in isolated chicks:
154±176. A behavioural indicator with high selectivity for
Jackson, R. L., & Minor, T. R. (1988). Effects of signaling antidepressants. Psychopharmacology, 97, 145±146.
inescapable shock on subsequent escape learning: Im- Lewinsohn, P. M., Zeiss, A. M., Zeiss, R. A., & Haller, R.
plications for theories of coping and ªlearned help- (1977), Endogenicity and reactivity as orthogonal
lessness.º Journal of Experimental Psychology: Animal dimensions in depression. Journal of Nervous and Mental
Behavior Processes, 14, 390±400. Disorders, 164, 327±332.
Jackson, R. L., Maier, S. F., & Rapoport, P. M. (1978). Lewis, J. W., Cannon, J. T., & Liebeskind, J. C. (1980).
Exposure to inescapable shock produces both activity Opioid and non-opioid mechanisms of stress-induced
and associative deficits in rats. Learning and Motivation, analgesia. Science, 208, 623±625.
9, 69±98. Liebowitz, M. R. (1992). Reversible MAO inhibitors in
Jacobs, B. L., Trulson, M. E., & Stern, W. C. (1977). social phobia, bulimia, and other disorders. Clinical
Behavioral effects of LSD in the cat: Proposal of an Neuropharmacology, 15 (Suppl. 1A), 434±435.
animal behavior model for studying the actions of Lipska, B. K., Jaskiw, G. E., & Weinberger, D. R. (1993).
hallucinogenic drugs. Brain Research, 132, 301±314. Delayed effects of neonatal excitotoxic hippocampal
Jesberger, J. A., & Richardson, J. S. (1985). Animal models damage in the rat: A potential model of schizophrenia.
of depression: Parallels and correlates to severe depres- European Neuropsychopharmacology, 3, 398.
sion in humans. Biological Psychiatry, 20, 764±784. Lipska, B. K., Swerdlow, N. R., Geyer, M. A., Jaskiw,
Jones, G. H., Hernandez, T. D., Marsden, C. A., & G. E., Braff, D. L., & Weinberger, D. R. (1995).
Robbins, T. W. (1988). Enhanced striatal response to Neonatal excitotoxic hippocampal damage in rats causes
d-amphetamine as revealed by intracerebral dialysis post-pubertal changes in prepulse inhibition of startle
following social isolation in rats. British Journal of and its disruption by apomorphine. Psychopharmacol-
Pharmacology, 94, 349P. ogy, 122, 35±43.
Joseph, M. H., & Jones, S. H. (1991). Latent inhibition and Lyon, M. (1991). Animal models of mania and schizo-
blocking: Further consideration of their construct phrenia. In P. Willner (Ed.), Behavioural models in
validity as animal models of schizophrenia. Behavioural psychopharmacology: Theoretical industrial and clinical
Pharmacology, 2, 521±526. perspectives (pp. 253±310). Cambridge, UK: Cambridge
Kahn, R. J., McNair, D. M., & Frankenthaler, L. M. University Press.
(1987). Tricyclic treatment of generalized anxiety dis- Lyon, N., Mejsholm, B., & Lyon, M. (1986). Stereotyped
order. Journal of Affective Disorders, 13, 145±151. responding in schizophrenic outpatients: Cross-cultural
Katz, R. J. (1981). Animal models and human depressive confirmation of perseverative switching on a two-choice
disorders. Neuroscience and Biobehavioral Reviews, 5, task. Journal of Psychiatric Research, 20, 137±150.
231±246. Maier, S. F. (1994). Learned helplessness: Relationships
Katz, J. L. (1990). Models of relative reinforcing efficacy of with fear and anxiety. In S. F. Stanford, & P. Salmon
drugs and their predictive validity. Behavioural Pharma- (Eds.), Stress: From synapse to syndrome (pp. 207±243).
cology, 1, 283±301. London: Academic Press.
Katz, J. L., & Goldberg, S. R. (1987). Second-order Mansbach, R., & Geyer, M., (1989). Effects of phencycli-
schedules of drug injection. In M. A. Bozarth (Ed.), dine and phencyclidine analogs on sensorimotor gating
Methods of assessing the reinforcing properties of abused in the rat. Neuropsychopharmacology, 2, 299±308.
drugs (pp. 105±115) New York: Springer. Mansbach, R., Geyer, M., & Braff, D. (1988). Dopami-
Keehn, J. D. (1979). Psychopathology in animals: Research nergic stimulation disrupts sensorimotor gating in the
and clinical implications. New York: Academic Press. rat. Psychopharmacology, 94, 507±514.
Killcross, A. S., Dickinson, A., & Robbins, T. W. (1994). Markou, A., & Koob, G. F. (1991). Postcocaine anhedo-
Amphetamine-induced disruptions of latent inhibition nia: An animal model of cocaine withdrawal. Neuropsy-
are reinforcer mediated: Implications for animal models chopharmacology, 4, 17±26.
References 229
Markou, A., Weiss, F., Gold, L. H., Caine, B., Schulteis, Pecknold, J. C., Luthe, L., Scott-Fleury, M. H., & Jenkins,
G., & Koob, G. F. (1993). Animal models of drug S. (1993). Gepirone and the treatment of panic disorder:
craving. Psychopharmacology, 112, 163±182. An open study. Journal of Clinical Psychopharmacology,
Martin, P., Laporte, A. M., Soubrie, P., El Mestikawy, S., 13, 145±149.
& Hamon, S. (1989) Reversal of helpless behaviour by Pellow, S. (1986). Anxiolytic and anxiogenic drug effects in
serotonin reuptake inhibitors. In P. Bevan, A. R. Cools, a novel test of anxiety: Are exploratory models of
& T. Archer (Eds.), Behavioural pharmacology of 5HT anxiety in rodents valid? Methods and Findings in
(pp. 231±234). New York: Erlbaum. Experimental Clinical Pharmacology, 8, 557±565.
McKinney, W. T. (1984). Animal models of depression: An Pellow, S., Chopin, P., File, S. E., & Briley, M. (1985).
overview. Psychiatric Developments, 2, 77±96. Validation of open:closed arm entries in an elevated
McKinney, W. T., & Bunney, W. E. (1969). Animal model plus-maze as a measure of anxiety in the rat. Journal of
of depression: Review of evidence and implications for Neuroscience Methods, 14, 149±167.
research. Archives of General Psychiatry, 21, 240±248. Porsolt, R. D. (1981). Behavioural despair. In S. J. Enna, J.
McKinney, W. T., & Moran, E. C. (1981). Animal models B. Malick, & E. Richelson (Eds.), Antidepressants:
of schizophrenia. American Journal of Psychiatry, 138, Neurochemical, behavioral and clinical perspectives
478±483. (pp. 121±139). New York: Raven Press.
Miller, N. E. (1960). Learning resistance to pain and fear: Porsolt, R. D., LePichon, M., & Jalfre, M. (1977).
Effects of over-learning, exposure and rewarded expo- Depression: A new animal model sensitive to antide-
sure in context. Journal of Experimental Psychology, 60, pressant treatment. Nature, 266, 731±732.
137±145. Preston, K. L., & Bigelow, G. E. (1991). Subjective and
Mineka, S., & Cook, M. (1986). Immunization against the discriminative effects of drugs. Behavioural Pharmacol-
observational conditioning of snake fear in monkeys. ogy, 2, 293±313.
Journal of Abnormal Psychology, 95, 307±318. Randrup, A., & Munkvad, I. (1971). Behavioural toxicity
Mineka, S., Davidson, M., Cook, M., & Keir, R. (1984). of amphetamines: Studies in animal experiments. In S. B.
Observational conditioning of snake fear in rhesus de Baker (Ed.). The correlation of adverse effects in man
monkeys. Journal of Abnormal Psychology, 93, 355±372. with observations in animals. (pp. 6±17). Amsterdam:
Minor, T. R., Jackson, R. L., & Maier, S. F. (1984). Effects Excerpta Medica.
of task-irrelevant cues and reinforcement delay on Rickels, K. (1985). Benzodiazepines in emotional disorders.
choice-escape learning following inescapable shock: In D. E. Smith & D. R. Wesson (Eds.), The benzodia-
Evidence for a deficit in selective attention. Journal of zepines: Current standards for medical practice
Experimental Psychology: Animal Behavior Processes, 10, (pp. 97±109). Lancaster: MTP Press.
543±556. Rickels, K., & Schweizer, E. E. (1987). Current pharma-
Moreau, J-L., Jenck, F., Martin, J. R., Mortas, P., & cotherapy of anxiety and panic. In H. Y. Meltzer (Ed.),
Haefely, W. E. (1992). Antidepressant treatment pre- Psychopharmacology: The third generation of progress
vents chronic mild stress-induced anhedonia as assessed (pp. 1193±1203). New York: Raven.
by ventral tegmentum self-stimulation behaviour in rats. Ridley, R. M., & Baker, H. F. (1983). Is there a
European Journal of Neuropsychopharmacology, 2, relationship between social isolation, cognitive flexibil-
43±49. ity, and behavioural stereotypy? An analysis of
Muscat, R., & Willner, P. (1992). Suppression of sucrose the effects of amphetamine in marmosets. In K. A.
drinking by chronic mild unpredictable stress: A Miczek (Ed.), Ethopharmacology: Primate models of
methodological analysis. Neuroscience and Biobehavioral neuropsychiatric disorders (pp. 101±135). New York:
Reviews, 16, 507±517. Liss.
Nelson, J. C. (1987). The use of antipsychotic drugs in the Ridley, R. M., Baker, H. F., & Scragg, P. R. (1979). The
treatment of depression. In J. Zohar & R. H. Belmaker time course of the behavioural effects of amphetamine
(Eds.) Treating resistant depression (pp. 131±146). New and their reversal by haloperidol in a primate species.
York: PMA. Biological Psychiatry, 14, 753±765.
Nelson, J. C., & Charney, D. S. (1981). The symptoms of Rifkin, A., & Siris, S. (1987). Drug treatment of acute
major depression illness. American Journal of Psychiatry, schizophrenia. In H. Y. Meltzer (Ed.), Psychopharma-
138, 1±13. cology: The third generation of progress (pp. 1095±1101).
Nielsen, E. B., & Lyon, M. (1982). Behavioral alterations New York: Raven.
during prolonged low level continuous amphetamine Ritz, M. C., Garcia, J. M., Protz, D., Rael, A.-M., &
administration in a monkey family group (Cercopithecus George, F. R. (1995). Ethanol-reinforced behavior in P,
aethiops). Biological Psychiatry, 17, 423±434. NP, HAD and LAD rats: Differential regulation of
Nielsen, E. B., Lyon, M., & Ellison, G. (1983). Apparent reinforcement and motivation. Behavioural Pharmacol-
hallucinations in monkeys during round-the-clock am- ogy, 5, 521±531.
phetamine for seven to fourteen days: Possible relevance Robbins, T. W., & Sahakian, B. J. (1980). Animal models
to amphetamine psychosis. Journal of Nervous and of mania. In R. H. Belmaker & H. M. van Praag (Eds.),
Mental Disease, 171, 222±233. Mania: An evolving concept (pp. 143±216). New York:
Oades, R. D., & Isaacson, R. L. (1978). The development Jamaica, Spectrum.
of food search behavior by rats: The effects of Robinson, D. S., Nies, A., Ravaris, C. L., Ives, J. O., &
hippocampal damage and haloperidol. Behavioral and Bartlett, D. (1978). Clinical pharmacology of phenelzine.
Neural Biology, 24, 327±337. Archives of General Psychiatry, 35, 629±635.
O'Brien, C. P. (1975). Experimental analysis of condition- Robertson, J., & Bowlby, J. (1956). Responses of young
ing factors in human narcotic addiction. Pharmacologi- children to separation from their mothers. Cour du
cal Reviews, 27, 533±543. Centre Internationale de L'Enfance, 2, 131±142.
Overstreet, D. H. (1993). The Flinders sensitive line rats: A Rodgers, R. J., & Cole, J. C. (1993). Anxiety enhancement
genetic animal model of depression. Neuroscience and in the murine elevated plus-maze by immediate prior
Biobehavioral Reviews, 17, 51±68. exposure to social stressors. Physiology and Behavior, 53,
Paykel, E. S. (1979). Recent life events in the development 383±388.
of the depressive disorders. In R. A. Depue (Ed.), The Sams-Dodd, F. (1996). Phencyclidine-induced stereotyped
psychobiology of depressive disorders: Implications for the behaviour and social isolation in rats: A possible animal
effects of stress (pp. 245±262). New York: Academic model of schizophrenia. Behavioural Pharmacology, 7,
Press. 3±23.
Samson, H. H., Tolliver, G. A., Lumeng, L., & Li, T.-K. (Eds.), Animal models in human psychobiology (pp. 9±26).
(1989). Ethanol reinforcement in the alcohol nonprefer- New York: Plenum.
ring rat: Initiation using behavioural techniques without Swerdlow, N. R., Lipska, B. K., Weinberger, D. R., Braff,
food restriction. Alcoholism: Clinical and Experiment D. L., Jaskiw, G. E., & Geyer, M. A. (1995). Increased
Research, 13, 378±385. sensitivity to the sensorimotor gating-disruptive effects
Sanger, D. J. (1991). Screening for abuse and dependence of apomorphine after lesions of medial prefrontal cortex
liability. In P. Willner (Ed.), Behavioural models in or ventral hippocampus in adult rats. Psychopharmacol-
psychopharmacology: Theoretical, industrial and clinical ogy, 122, 27±34.
perspectives (pp. 486±502). Cambridge, UK: Cambridge Tamminga, C. A., & Gerlach, J. (1987). New neuroleptics
University Press. and experimental antipsychotics in schizophrenia. In H.
Schmajuk, N. A. (1987). Animal models for schizophrenia: Y. Meltzer (Ed.), Psychopharmacology: The third gen-
The hippocampally lesioned animal. Schizophrenia Bul- eration of progress (pp. 1129±1140). New York: Raven
letin, 13, 317±327. Press.
Schuster, C. R., & Johanson, C. E. (1981). An analysis of Thompson, T., & Schuster, C. R. (1964). Morphine self-
drug-seeking behavior in animals. Neuroscience and administration, food-reinforced and avoidance behaviors
Biobehavioral Reviews, 5, 315±323. in rhesus monkeys. Psychopharmacologia, 5, 87±94.
Seligman, M. E. P. (1971). Phobias and preparedness. Treit, D. (1985). Animal models for the study of anti-
Behavior Therapy, 2, 307±320. anxiety agents: A review. Neuroscience and Biobehavioral
Seligman, M. E. P. (1975). Helplessness: On depression, Reviews, 9, 203±222.
development and death. San Francisco: Freeman. van Riezen, H., & Leonard, B. E. (1990). Effects of
Sepinwall, J., & Cook, L. (1978). Behavioral pharmacology psychotropic drugs on the behavior and neurochemistry
of anti-anxiety drugs. In L. L. Iversen, S. D. Iversen, & of old factory bulbectomized rats. Journal of Pharmacol-
S. H. Snyder (Eds.), Handbook of psychopharmacology ogy and Experimental Therapeutics, 47, 21±34.
(Vol. 13, pp. 345±393). New York: Plenum. Vernon, R. E. (1963). Personality assessment: A critical
Shaham, Y., Rodaros, D., & Stewart, J. (1994). Rein- survey. London: Methuen.
statement of heroin-reinforced behavior following Vogel, J. R., Beer, B., & Clody, D. E. (1971). A simple and
long-term extinction: Implications for the treatment of reliable conflict procedure for testing anti-anxiety agents.
relapse to drug taking. Behavioural Pharmacology, 5, Psychopharmacologia, 21, 1±7.
360±364. Watson, J. B., & Rayner, R. (1920). Conditioned emotional
Shanks, N., & Anisman, H. (1988). Stressor-provoked reactions. Journal of Experimental Psychology, 3, 1±14.
behavioral changes in six strains of mice. Behavioral Weiner, H. (1973). Some thoughts on behavioral ap-
Neuroscience, 102, 894±905. proaches to therapy. Psychological Record, 23, 441±450.
Sheehan, D. V., Raj, B. A., Trehan, R. R., & Knapp, E. L. Weiss, J. M. (1970). Somatic effects of predictable and
(1993). Serotonin in panic disorder and social phobia. unpredictable shock. Psychosomatic Medicine, 32,
International Clinical Psychopharmacology, 8 (Suppl. 2), 397±408.
63±77. Weiss, J. M., Bailey, W. H., Goodman, P. A., Hoffman, L.
Shepherd, J. K., & Rodgers, R. J. (1989). Acute and J., Ambrose, M. J., Salman, S., & Charry, J. M. (1982).
chronic effects of the triazolobenzodiazepine, alprazo- A model for the neurochemical study of depression. In
lam, on defeat and analgesia evoked by conspecific M. Y. Spiegelstein & A. Levy (Eds.), Behavioral models
attack in male mice. Behavioural Pharmacology, 1, 75±83. and the analysis of drug action (pp. 195±223). Amster-
Sherman, A. D., Saquitne, J. L., & Petty, F. (1982). dam: Elsevier.
Specificity of the learned helplessness model of depres- West, A. P. (1990). Neurobehavioral studies of forced
sion. Pharmacology, Biochemistry and Behavior, 16, swimming: The role of learning and memory in the
449±454. forced swim test. Progress in Neuropsychopharmacology
Simiand, J., Keane, P. E., & Morre, M. (1984). The and Biological Psychiatry, 14, 863±877.
staircase test in mice: A simple and efficient procedure White, F. J., & Wang, R. Y. (1983). Differential effects of
for primary screening of anxiolytic agents. Psychophar- classical and atypical antipsychotic drugs on A9 and A10
macology, 84, 48±53. dopamine neurons. Science, 221, 1054±1057.
Solomon, R. L., Kamin, L. J., & Wynne, L. C. (1953). Wikler, A. (1973). Dynamics of drug dependence: Implica-
Traumatic avoidance learning: The outcomes of several tions of a conditioning theory of research and treatment.
extinction procedures with dogs. Journal of Abnormal Archives of General Psychiatry, 28, 611±616.
and Social Psychology, 48, 291±302. Wilkins, W. (1971). Desensitization: Social and cognitive
Soubrie, P. (1986). Reconciling the role of central serotonin factors underlying the effectiveness of Wolpe's proce-
neurons in human and animal behaviour. Behavioral and dure. Psychological Bulletin, 76, 311±317.
Brain Sciences, 9, 319±365. Wilkinson, L. S., Killcross, S. S., Humby, T., Hall, F. S.,
Stephens, D. N., & Andrews, J. S. (1991). Screening for Geyer, M. A., & Robbins, T. W. (1994). Social isolation
anxiolytic drugs. In P. Willner (Ed.), Behavioural models in the rat produces developmentally specific deficits in
in psychopharmacology: Theoretical, industrial and clin- prepulse inhibition of the acoustic startle response
ical perspectives (pp. 50±75). Cambridge, UK: Cam- without disrupting latent inhibition. Neuropsychophar-
bridge University Press. macology, 10, 61±72.
Stewart, J., & de Wit. H. (1987). In M. A. Bozarth (Ed.), Willner, P. (1984). The validity of animal models of
Methods of assessing the reinforcing properties of abused depression. Psychophamacology, 83, 1±16.
drugs (pp. 211±227). New York: Springer. Willner, P. (1985). Depression: A psychobiological synthesis.
Stewart, J., de Wit, H., & Eikelboom, R. (1984). Role of New York: Wiley.
unconditioned and conditioned drug effects in the self- Willner, P. (1986). Validation criteria for animal models of
administration of opiates and stimulants. Psychological human mental disorders: Learned helplessness as a
Reviews, 91, 251±268. paradigm case. Progress in Neuropsychopharmacology
Stolerman, I. P., Samele, C., Kamien, J. B., Mariathasan, and Biological Psychiatry, 10, 677±690.
E. A., & Hague, D. S. (1995). A bibliography of drug Willner, P. (1989). Towards a theory of serotonergic
discrimination research, 1992±1994. Behavioural Phar- dysfunction in depression. In P. Bevan, A. R. Cools, &
macology, 7, 643±668. T. Archer (Eds.), Behavioural pharmacology of 5HT
Suomi, S. J. (1976). Factors affecting responses to social (pp. 157±178). New York: Erlbaum.
separation in rhesus monkeys. In G. Serban & A. Kling Willner, P. (1990). Animal models of depression: An
References 231
overview. Pharmacology and Therapeutics, 45, 425±455. Willner, P., Towell, A., Sampson, D., Muscat, R., &
Willner, P. (1991). Behavioural models in psychopharma- Sophokleous, S. (1987). Reduction of sucrose preference
cology. In P. Willner (Ed.), Behavioural models in by chronic mild stress and its restoration by a tricyclic
psychopharmacology: Theoretical, industrial and clinical antidepressant. Psychopharmacology, 93, 358±364.
perspectives (pp. 3±18). Cambridge: Cambridge Univer- Wise, R. (1987). Intravenous drug self-administration: A
sity Press. special case of positive reinforcement. In M. A. Bozarth
Willner, P., Harding, S., & Eaton, G. (1995). Subjective (Ed.), Methods of assessing the reinforcing properties of
and behavioural evaluation of cigarette cravings. Psy- abused drugs (pp. 117±141). New York: Springer.
chopharmacology, 118, 171±177. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition.
Willner, P., Moreau, J.-M., Nielsen, C., Papp, M., & Stanford, CA: Stanford University Press.
Sluzewska, A. (1996). Decreased hedonic responsiveness Yanagita, T. (1987). Prediction of drug abuse liability from
following chronic mild stress is not secondary to loss of animal studies. In M. A. Bozarth (Ed.), Methods of
body weight. Physiology and Behavior, 60, 129±134. assessing the reinforcing properties of abused drugs
Willner, P., Muscat, R., & Papp. M. (1992). Chronic mild (pp. 189±198). New York: Springer.
stress-induced anhedonia: A realistic animal model of Yokel, R. A. (1987). Intravenous self-administration:
depression. Neuroscience and Biobehavioural Reviews, 16, Response rates, the effects of pharmacological chal-
525±534. lenges, and drug preferences. In M. A. Bozarth (Ed.),
Willner, P. & Papp, M. (1997). Animal models to detect Methods of assessing the reinforcing properties of abused
antidepressants: Are new models necessary to detect new drugs (pp. 1±33). New York: Springer.
agents. In P. Skolnick (Ed.), Antidepressants: New Young, A. M. & Herling, S. (1986). Drugs as reinforcers:
pharmacological strategies (pp. 213±234). Totowa, NJ: Studies in laboratory animals. In S. R. Goldberg & I. P.
Humana. Stolerman (Eds.), Behavioral analysis of drug dependence
Willner, P., Phillips, G., & Muscat, R., (1991). Suppression (pp. 9±67). London: Academic Press.
of rewarded behaviour by neuroleptic drugs: Can't or Zacharko, R. M., Bowers, W. J., Kokkinidis, L., &
won't, and why? In P. Willner (Ed.), The mesolimbic Anisman, H. (1983). Region-specific reductions of
dopamine system: From motivation to action intracranial self-stimulation after uncontrollable stress:
(pp. 251±271). New York: Wiley. Possible effects on reward processes. Behavioural Brain
Willner, P., Sampson, D., Phillips, G., Fichera, R., Research, 9, 129±141.
Foxlow, P., & Muscat, R. (1989). Effects of isolated Zacharko, R. M., Lalonde, G. T., Kasian, M., & Anisman,
housing and chronic antidepressant treatment on co- H. (1987). Strain specific effects of inescapable shock on
operative social behaviour in rats. Behavioural Pharma- intracranial self-stimulation from the nucleus accum-
cology, 1, 85±90. bens. Brain Research, 426, 164±168.
1.08
Cultural Dimensions
JAN BRéGGER
Norwegian University of Science and Technology,
Trondheim, Norway

1.08.1.1 Anthropology and Psychology 234
1.08.1.2 The Birth of Clinical Psychology 234
1.08.1.3 The Construction of Social Reality 234
1.08.2 THEORIES OF ILLNESS AND DESTINY 235
1.08.2.1 Theories of Natural Causation 235
1.08.2.2 Theories of Supernatural Causation 236
1.08.2.3 Types of Mystical Causation 236
1.08.2.3.1 Fate 236
1.08.2.3.2 Ominous sensations 236
1.08.2.3.3 Contagion 236
1.08.2.3.4 Mystical retribution 237
1.08.2.4 Theories of Animistic Causation 237
1.08.2.4.1 Soul loss 237
1.08.2.4.2 Spirit aggression 238
1.08.2.4.3 Magical causation 238
1.08.2.4.4 Witchcraft 238
1.08.3 SOCIAL SYSTEMS AND TYPES OF EXPLANATION 239
1.08.3.1 Non-Western Systems of Understanding 240
1.08.3.1.1 Complex societies 240
1.08.3.1.2 Early Greek medicine 240
1.08.3.1.3 The Indian medical system 242
1.08.3.1.4 Arabic medicine 243
1.08.3.1.5 Chinese medicine 246
1.08.3.1.6 American medicine 247
1.08.3.2 Small-scaled Societies 248
1.08.3.2.1 Africa 248
1.08.3.2.2 New Guinea 250
1.08.4 THE GROWTH OF THE WESTERN SYSTEM OF UNDERSTANDING 251
1.08.4.1 The Role of the Psychiatric Hospital 251
1.08.4.2 The Cross-cultural Issue and Human Nature 251
1.08.4.3 The Interface Between Psychology and Anthropology 252
1.08.4.4 The Impact of Anthropological Fieldwork 254
1.08.4.5 Culture and Personality 254
1.08.4.6 The Paradigm of Ethnic Identity 255
1.08.4.7 The Cross-cultural Correlational Approach 256
1.08.5 SOCIAL SYSTEMS AND THE INDIVIDUAL 257
1.08.5.1 The Dominant Kinship Dyad 257
1.08.5.2 The Iatrogenic Approach 258
233
234 Cultural Dimensions
1.08.1 INTRODUCTION tion of psychologists in mental institutions and

clinical work was restricted to psychometrics
1.08.1.1 Anthropology and Psychology and mental tests in a team which, in addition to
the psychologist, consisted of a psychiatrist and
The collaboration between anthropology and a social worker. The psychologist had an
psychology is a recent chapter in the brief academic training which in the beginning did
history of the behavioral sciences. The interest not include training in psychotherapy and
of anthropologists in the problem of mental clinical methods, although the Department of
illness originated in their concern to understand Psychology at Columbia University established
the relationship between culture and person- a curriculum for clinical psychology in 1936.
ality. In the early 1930s Margaret Mead, But formal, systematic training of clinical
Edward Sapir, and Ruth Benedict were raising psychologists in the USA did not get off the
questions of how anthroplogy could inform the ground before the 1940s when the psychological
understanding of the genesis of the human damage caused by wartime experiences primar-
personality. ily among soldiers became a major social
From 1936 to 1940 the psychiatrist Abraham problem among the more than 16 million World
Kardiner with a group of anthropologists, the War II veterans which were added to the 4
most prominent of whom were Cora DuBois, million from the previous war.
Ralph Linton, Edward Sapir, and Ruth Ben-
edict, were conducting seminars in culture and
personality. A spinoff of this seminar was the 1.08.1.2 The Birth of Clinical Psychology
first comprehensive cross-cultural research
The time was ripe for clinical psychology, but
program conducted on the interface between
not yet for a closer collaboration between
anthropology and psychology.
anthropology and clinical psychology. In the
The investigation was carried out on the
landmark event in the history of clinical
Indonesian island of Alor under the leadership
psychology which took place in Boulder,
of DuBois. ªWe had talked ourselves out, and
Colorado, in the summer of 1949 where the
only field work could test the procedure,º she
ªBoulder modelº of clinical training was
wrote in her introduction to The people of Alor
formulated, neither anthropology nor cross-
(DuBois, 1944), a landmark in cross-cultural
cultural studies were mentioned in the core
psychology. The scope of this investigation was,
curriculum proposed by the conference.
in her own words, to find out if there was a
ªdemonstrableº relationship between the per-
sonalities of adults within a group and the 1.08.1.3 The Construction of Social Reality
sociocultural milieu in which they lived. If such
a relationship were found to exist, its explana- The relevance of anthropology for clinical
tion was presumed to lie in the consistency of life psychology thus has only recently been recog-
experiences ranging from the earliest child- nized by the community of scholars, and a
rearing practices and relationships to the consistent training program has yet to be
reinforcing effects of adult institutions and formulated. The most obvious potential of
social roles (DuBois, 1944). cultural understanding to the field of clinical
The interest of these pioneers in cross- knowledge is in the realm of social reality. A few
cultural anthropology, however, was not pri- epistemological comments are called for in
marily clinical. In the school of thought order to clarify this concept which is essential to
initiated by DuBois and her collaborators the postmodern understanding of culture which
which flourished from the 1930s and well into is at the cutting edge of anthropological theory
the 1950s, the question of the ªnormalº and today.
ªabnormalº and the definition of illness in There is an unresolved disagreement between
various societies was not the main issue. The proponents of the idea that all phenomena can
Holy Grail of their investigations was ªbasic be studied by the same scientific methods and
personality structureºÐa term coined by scholars who maintain that there are phenom-
Abraham Kardiner or ªmodal personalityº in ena of different orders which call for special
the language of DuBois. Yet it is these early methods. The first group subscribes to a theory
investigations that have been the main source of of unity of science and is sometimes, in
inspiration for the current interest in the colloquial discourse, referred to as positivists
relationship. or logical empiricists. In the social sciences in
Although the term ªclinical psychologyº was general and in psychology in particular the
introduced by Lightner Witmer in 1896, several positivist approach is referred to as behaviorism.
decades had to pass before the role of the clinical The second group maintains that there are
psychologist gradually emerged. The participa- certain phenomena which cannot be studied by
Theories of Illness and Destiny 235
positivistic methods but must be approached and boundaries rather than cultures. This
through a special form of understanding approach was launched with the publication
colloquially referred to as hermeneutics. Psycho- of the influential work Ethnic groups and
analysis is an example of a system of under- boundaries by Fredrik Barth (1969). The
standing based on the hermeneutic method. question of ethnic groups articulates with the
The idea of social reality is based on the problems of personal identity which is an
observation that social life is not of the same important issue in clinical psychology. One of
order as the physical universe which has an the important interfaces between anthropology
existence independent of human socializing. and clinical psychology is located in the
Social life on the other hand is created or acted symbolic space of identity management.
out in a social process. In the words of Berger
and Luckman (1969) it is ªconstructed.º Social
reality is constructed in the process of everyday 1.08.2 THEORIES OF ILLNESS AND
life through role play following an intricate DESTINY
system of rules. A pioneering study of human
Every human group that has been studied by
interaction was carried out by Goffman (1959).
anthropologists has developed its own form of
The anthropological understanding of cul-
knowledge to cope with the everpresent adver-
ture has been strongly influenced by the
saries of our existence: disease and misfortune.
constructionist approach. The concept of
Two of the pioneers of medical anthropology
culture developed by the Columbia group under
George M. Foster and Barbara Gallatin
the leadership, of among others, Margareth
Anderson classified theories of illness in
Mead and Ruth Benedict reflected taxonomic
technologically simple societies into ªpersona-
ideas developed in the study of species. These
listicº and ªnaturalisticº theories (Foster &
taxonomic ideas are based on the fact that, in
Anderson, 1978). This classification corre-
the fauna and flora, distinct species can be
sponds to the classification later suggested by
recognized as isolates with clear boundaries.
George Peter Murdock in his last comprehen-
Although the classification of cultures was not
sive cross-cultural investigation, Theories of
explicitly organized according to the taxonomic
illness. A world survey (1980). Murdock's
paradigm of species, cultures were to a certain
investigation is based on the human relations
degree, regarded as isolates with their distinct
area files at Yale University. On the basis of
and recognizable patterns.
these files Murdock surveyed theories of illness
This taxonomic thinking strongly influenced
in 186 human groups or cultures in the language
the culture and personality school of thought
of the 1980s.
which flourished in the 1940s in the study of
national character. These studies clearly de-
monstrated that the social sciences are involved 1.08.2.1 Theories of Natural Causation
in political agendas. The national character
studies started as part of the war effort and were Murdock identified four main theories of
designed to understand, and to a certain degree, natural causation:
predict the behavior of the main adversariesÐ (i) Infection. Defined as the invasion of the
the Germans and the Japanese, and later during victim's body by noxious microorganisms. It
the cold war, the Russians. In spite of the refers particularly to the germ theory of disease
political agenda, some of the studies testified to which seems to be unique to Western medicine.
a high quality of scientific craftsmanship. An But some groups have knowledge and under-
example of this is Ruth Benedict's The chry- standing of the fact that small organisms like
santhemum and the sword (1974) in which she worms and insects may cause disease.
presents a study of Japanese culture and (ii) Stress. From the point of view of clinical
personality. psychology it is interesting to observe that
Although cultures are no longer regarded as exposure of victims to psychic strain such as
species, there are definite relationships between worry, fear, and emotional distress is recog-
culture and personality. Distinct cultures can be nized as a major cause of illness in a large
recognized, but the focus is now on the nature of number of groups. Among the Javanese and the
their boundaries. The boundaries between Pawnee anxiety is recognized as the major
species are genetic, a fact which makes them threat to health.
clear isolates. The boundaries between cultures (iii) Theories of deterioration. Murdock ob-
are maintained by entirely different processes. serves, not without irony, that physical dete-
The boundaries are not natural entities, but rioration through old age is not generally
constructions maintained by complex symbolic recognized as a major cause of illness among
efforts of self-ascription, rituals, and social human beings. According to Murdock, most of
sanctions. The focus is now on ethnic groups mankind considers itself potentially immortal
and is unable to conceive of the infirmities of old sense of intellectual achievement which sustains
or middle age as being caused by the process of the interest in the follies of the recent past.
aging itself rather than the interference of some Clearly supernatural ideas also have a special
hostile agent or force. appeal to anthropological field-workers be-
(iv) Accident. The fact that accidents are cause it was a prominent theme in the heroic
rarely regarded as the causes of illness and age of discovery at a time when anthropologists
misfortune indicates that the very notion of regarded technologically simple communities as
accident is a recent philosophical idea in human primitive. Although ªprimitiveº has developed
understanding. The general tendency is to a semantic of its own, and today is regarded as a
personalize the causation of what we in the pejorative term, its lexical origin is the Latin
modern Western world term accident and to term primus, which means first. The term
attribute it to supernatural intervention. primitive indicated that the scholars in the days
when words like primitive and savages did not
1.08.2.2 Theories of Supernatural Causation raise an eyebrow even among the most
enlightened, were of the opinion that they were
Through his comparative analysis Murdock studying humankind in its pristine or original
came up with three basic groups of supernatural state of being. In a way the opinion was that
causation: theories of mystical causation, they were investigating our common past.
theories of animistic causation, and theories
of magical causation. Of the three, the theories
of mystical causation may be regarded as the 1.08.2.3 Types of Mystical Causation
most sophisticated, entailing as they do im- 1.08.2.3.1 Fate
personal agents as the culprits. In certain ways
they are closest to modern theories; particularly In the realm of mystical causation fate is of
the belief in contagion is very close to our notion particular interest. It was regarded as the major
of infection as if the mystic theories by some sort determinant of illness among the ancient Ro-
of intuition forecast the breakthrough of mans. Fate may be regarded as the precursor of
modern medicine. Since the mystical theories our modern idea of accident or chance. In
are less concerned with social forces than the Roman times fate was understood as the
other explanations, they are at first glance, of influence of astrological influence, individual
less interest to the anthropologist and have predestination, or ill luck. In our modern idea of
received much less attention and are also accident the connection to astrology and occult
comparatively rareÐbut not of less theoretical forces has been suppressed although it is still
interest as Mary Douglas has shown in her alive in many folk beliefs which can be
fascinating study Purity and danger (1966). ascertained by anyone who cares to consult
More widespread, however, are the theories the horoscopes of popular magazines. It is a
of animistic causation, which imply the ex- sophisticated idea which is primarily found in
istence of personalized supernatural entities. In comparatively complex societies such as Tur-
accordance with this kind of explanation, key, Burma, Thailand, and Java.
disease may be caused by the occasional
departure of a person's soul, as in the cases of 1.08.2.3.2 Ominous sensations
soul loss, but much more frequently through
spirit-aggression. According to Murdock's in- This type of theory is of particular interest
vestigation, this is the most frequently encoun- because it gives prominence to the impact of
tered type of explanation. potent dreams which has been recognized by
Theories of magical causation are also found modern psychoanalysis. In addition to dreams,
in a large number of different cultures and are impressive sights and sounds may cause illness.
manifest in two main forms: witchcraft and Dreaming of a recently deceased relative is an
sorcery. For several reasons, not all of them ominous sign among the Massa. Depending on
strictly professional, these twin phenomena the circumstances such dreams may be impor-
have been the favorite of anthropology. One tant events during psychoanalytic treatment
reason is possibly that witchcraft and sorcery and are another example of the intuitive wisdom
loom with sordid prominence in more recent sometimes encountered in knowledge systems of
Western history. The topic appeals to the technologically simple societies.
peculiar kind of black fascination which human
tragedy and catastrophe are singularly capable
1.08.2.3.3 Contagion
of arousing. It provides its audience with the
combined advantages of participation and The word suggests an incipient understanding
immunity, which never fails to rally the crowds of the microbiological transfer of disease. But
also in our age. It gives modern people that the mystical concept of contagion which is fairly
Theories of Illness and Destiny 237
widespread and attested to by 49 societies in the is a divine retribution for the violation of sexual
Murdock sample is of a different order taboos.
altogether. The mystical contagion refers to Food taboos are common among certain
fear of the ritually impure, like menstrual blood ethnic groups in modern Western societies. The
and corpses. Although the fear of corpses could origin of these taboos is generally not known
have a rational dimension in terms of micro- and poorly understood. Yet they are observed
biology, the same does not hold for menstrual with care by people who subscribe to these
blood. It is a question of pollution rather than taboos and great discomfort is to be expected in
infection and is cognitively related to the case of violations. It is important for therapists
purportedly polluting categories of people, such to understand the power of taboos and beliefs.
as the ªuntouchablesº of India. These beliefs and their effects clearly demon-
This widespread theory of disease is of con- strate that social reality is a construction and
siderable interest to clinical psychology because reminds us of the fact that human beings are
it testifies to a human, cognitive disposition under the spell of different constructions.
which has been explored by Douglas (1966). Verbal taboos are recognized in our rules
Douglas observes that the impure in cognitive against swearing. But, the fear of swearing has
terms is matter out of place. In the physical lost most of its mystical force and among
world order it is recognized by everything in its modern people is regarded merely as bad
proper place; in the moral order, impurity is manners whereas in some societies the breach
equal to the lack of observance and respect for of verbal taboos may be regarded as the cause of
categories. The classical example is the taboo on illness.
pigs' meat which according to Douglas has
nothing to do with an assumed archaic knowl-
edge of microbiological hazards, which is the 1.08.2.4 Theories of Animistic Causation
common folk explanation, but with the cate- 1.08.2.4.1 Soul loss
gorization of animals into ruminating and
nonruminating types. This is written quite A common idea among human beings is the
explicitly in the Old Testament where it is existence of an insubstantial double or soul
maintained that the pig is unclean because it has which inhabits the body, but is independent of
split hooves but does not ruminate. This is an the physical and territorial restrictions which
important distinction to people of archaic apply to the physical body. This soul may depart
animal husbandry. from the body during sleep and permanently at
Another example is the fear of homosexuality death to lead a separate existence in afterlife. If
in societies with rigid sex-role segregation. To the soul departs from the body on more than
regard the homosexuals as unclean is not in minor excursions during sleep, it may cause
accordance with modern rationality, but is of illness.
the same order as the impurity of untouchables. The belief in soul loss is often combined with
Although Westerners, at first sight, regard the the institution of shamanism, which has recently
contagion theories of other societies as ªsuper- attracted some attention among psychothera-
stitiousº and ªirrational,º an understanding of pists as pointed out by Strathern (1995).
the cognitive disposition revealed by Douglas Strathern points out that in recent develop-
demonstrates that some of our Western theories ments in psychotherapy altered states of
of illness are merely posing as rational. The fact consciousness have become a main topic of
that homosexuality is no longer regarded as a interest. He observes that:
disease or pathological condition in the USA
demonstrates that some of our own theories of Trance facilitates such a reframing (of experience),
illness, at least until quite recently, were based as does spirit possession. At one end we may be
on ideas of irrational impurity. dealing with a new image presented to a patient, at
the other with a whole new persona, an alter ego
juxtaposed to the self. Either a metaphor or a
historical figure may be in focus: in either case the
1.08.2.3.4 Mystical retribution result is an altered state of consciousness which
whether trance induced or not conduces towards a
The idea that disease is a retribution for the patient's recovery, a process in which health and
violation of moral injunction or taboos is fairly identity are brought into consonance with each
widespread. The most common of the taboos other. (Strathern, 1995, p. 128)
are food, sex, as in the case of incest, and verbal.
Again it is possible to observe that ideas of The term shaman is of Siberian Tungus
mystical retribution are not entirely absent in origin, but the shaman is a well-known char-
Western society. It is, for example, being acter in ªanthropologicalº societies. He or she is
maintained by some religious leaders that AIDS a curer who has a special relationship with the
spirit world. During consultations, the shamans 1.08.2.4.4 Witchcraft

fall into trance in which they communicate with
In witchcraft beliefs it is assumed that some
their tutelary spirits in order to understand the
human beings possess an evil force that may
cause of the illness.
cause disease and misfortune. The force is
The recent interest in shamanism and trance
supposed to be activated automatically, some-
among anthropologists is caused by a major
times even without the conscious knowledge of
paradigmatic change in the field of cultural
the witch, as demonstrated by Evans-Prichard
understanding. In the classical tradition in the
in his classical monograph Witchcraft, oracles
study and interpretation of the personality, the
and magic among the Azande (1937).
personality was regarded as a reflection in
Sorcery on the other hand is a technology of
the individual mind of the society and its
evil. A sorcerer can apply an assortment of
institution, or in other words: its culture. With
procedures based on what we may refer to as
the constructionist approach the self was
irrational knowledge to harm people. A sorcerer
introduced as a concept. Whereas the person-
is a specialist and may learn his craft.
ality is imposed on the individual by society, the
Witchcraft and sorcery are often combined
self is an active agent reacting to and sometimes
and, one is tempted to say, confused with one
even rebelling against the demands of society.
another. In strict anthropological terms, the
The concept is difficult to operationalize and
witches of popular belief in Europe were really
seems rather nebulous to ardent empiricists.
sorcerers, who sometimes were supposed to
Nevertheless it has acquired some respectability
have acquired their evil powers from the Devil
in mainstream anthropology.
himself.
The belief in witchcraft is practically uni-
1.08.2.4.2 Spirit aggression versal in the Circum-Mediterranean region, but
is comparatively rare elsewhere in the world
This is the most widespread of all the theories
except Africa. The prominence of witchcraft in
of supernatural causation. The major types of
European and American history and thinking is
supernatural aggressors are nature spirits,
due to the fact that witch craze is a phenomenon
disease demons, or lesser divinities. Among
primarily of Western culture.
the aggressors are also found departed ancestors
Belief in witchcraft does not always produce
or kinsmen, ghosts and in some instances deities
witch crazes. In many African societies, witch-
or gods. The thought is not alien to Christian
craft is regarded as a normal phenomenon, as
civilization as is testified in the Bible by the book
among the Azande, and does not produce the
of Job.
kinds of moral panic which is characteristic of
early modern Europe.
1.08.2.4.3 Magical causation Although popular opinion has it that witch-
craze was a social phenomenon of the Middle
As pointed out above, witchcraft and sorcery
Ages, its heyday was in the Renaissance. As the
looms with sordid prominence among the
British historian Trevor-Roper has pointed out,
theories of illness and destiny in comparatively
belief in witchcraft and sorcery in the sixteenth
recent Western history. In the case of sorcery an
and seventeenth centuries, a period which we
active human agent uses various techniques to
imagine as the age of reason, was not
hurt another human being. The main techniques
applied by sorcerers are supposed to be verbal
spells, prayers, and curses; object intrusions; lingering ancient superstition, only waiting to
dissolve. It was a new explosive force, constant
ritual manipulation on exuvias and belongings
and fearfully expanding with the passage of time.
of the intended victim; and administration of It was forewarned by the cultivated popes of the
poisons. Renaissance, by the great Protestant reformers, by
The distinction between rational procedures the saints of the Counter-Reformation, by the
known to be effective within a scientific scholars, lawyers, and churchmen of the age of
paradigm of understanding and irrational Scalinger and Lipsius, Bacon Grotius, Beralle and
procedures is not always clearcut. This is Pascal. (Trevor-Roper, 1970, p. 121)
particularly the case with the application of
poison. Sorcery has an instrumental dimension The craze also hit the USA in Salem, Massa-
which may be reconciled with the modern world chusetts, in the seventeenth century and many
view. The difference between the biochemical completely innocent people were executed.
effects of certain medicines and the occult effect Witchcraze is of particular interest to clinical
of the medicines of sorcerers is not always psychology as an example of a collective
obvious to people with no scientific training. paranoia. Contrary to popular opinion the
Beliefs in sorcery may therefore be quite days of moral panics are not over and it is
resilient. important that psychologists are aware of the
Social Systems and Types of Explanation 239
background and dynamics of moral panics modern, bureaucratic state), political demonol-
because they are sometimes called to the ogy may develop as part of the belief-system.
assistance of victims of irrational or pseudora- Although the table does not cover all the
tional persecutions. possible explanations of illness and misfortune
Although we have not yet found an uncon- its focus on the experiential dimension in
troversial understanding of moral panics and exchange relationships adds a comparatively
the rise of the witchcraze in the Renaissance, we unexplored dimension to the role of economics
have gained some insight into the relationship in the patterning of culture and society. It
between social systems and types of explanation directs our attention to the cognitive repercus-
of disease and misfortune. sions of the rise of bureaucracy and the
introduction of money and markets.
These institutions may have been a prerequi-
site for a rational understanding in the field of
1.08.3 SOCIAL SYSTEMS AND TYPES OF human relationships and therefore the main
EXPLANATION force behind the breakthrough of scientific
Lewis has pointed out that it may sometimes thinking in general and of a rational theory of
be more illuminating to discard the culturally illness in particular.
grounded expressions ªspirit-possessionº and In systems in which the majority of transac-
ªwitchcraftº altogether and think in terms of tions are sustained within a framework of
oblique and direct mystical attacks (Lewis, clearly personal relations, the human intellect
1971). It has been demonstrated by Brogger easily jumps to the conclusion that people or
(1992) that the nature of oblique and direct clearly recognized groups of people not only
mystical attacks clearly relate to the nature of have economic power, but power over destiny in
dependency between an individual and the general and thus over diseases and indeed over
community. The crucial dimension seems to life and death. On the basis of a general
be ascribed vs. acquired relationships and experience of social life under these conditions,
statuses on the one hand and dyadic vs. ideas of witchcraft, sorcery, and even spirits do
corporate relationships on the other. Ascribed not seem far-fetched.
relationships, of course, are those an individual The general breakthrough of the scientific
acquires at birth and as a member of his or her theory of illness therefore owes as much to the
community. In small, technologically simple development of market economy and bureau-
societies, there is little scope for choice and cratic management as to knowledge itself. The
contractual relationships are few. The dominant fact that many, even when exposed to the ideas
mode of the traditional village is the ascribed of modern medicine, do not resign their beliefs
relationship, that of the urban society the in witchcraft and sorcery clearly demonstrates
acquired form. Dyadic relationships are limited that knowledge which does not articulate with
to one other person, corporate relationships to the experiences of everyday life remains esoteric
ªcorporationsº such as a lineage, an age grade in (Brogger, 1971).
technologically simple societies, or in modern Dependency on the depersonalized forces of
societies to trade unions or political parties. bureaucracy, money, and markets, however,
These dimensions are represented in Table 1. does not irreversibly guarantee rational expla-
Acquired dyadic relationship is characteristic nation of disease and misfortune. In spite of
of the modern urban situation. In societies many impressive achievements, it is as true as
where the essential necessities of life are ever that when struck by misfortunes and
acquired through ascribed, dyadic relation- disease, human beings look for someone to
ships, witchcraft beliefs will tend to prevail. blame. As in former times, one's perspective is
This does not exclude sorcery, which may be determined by the nature of one's dependencies.
found as a residual category. Where ascribed, The age of demonology thus is not behind us,
corporate relationships dominate, spirit aggres- only its vocabulary has changed.
sion seems to prevail. In cases where acquired Although the modern human being's freedom
corporate relationships dominate, (as in the of fancy with regard to health is restrained by
the insights of modern medicine, one is as free as
ever to speculate on the social causes of destiny.
In tune with the nature of one's dependency,
Table 1 Corporate and dyadic relationships
demonology does not operate on the matrix of
Dyadic Corporate face-to-face relationships, but on the level of
institutions and social categories like race and
Ascribed witchcraft spirit-aggression class. The demonological qualities of national
Contractual sorcery political demonology socialism (Nazism) are universally recognized,
but this is not the only example. Whether
modern witchhunts are based on the assumed followed in the wake of political empire
conspiracies of ªworld Jewryº or the ªbourgeois building. Medical knowledge of course is only
capitalistº the effect on its victims is the same: a special case, knowledge in general is
suppression, persecution, and often extermina- dependent upon the power and communication
tion. Although an anthropology of knowledge structures of societies.
cannot promise to free the world from the No matter how unpopular empires are in the
savagery performed in the name of irrational political thinking of everyday life in the Western
ideologies, it may provide knowledge which, world, their importance for the development
biding its time, may deprive aggressive ideolo- and management of knowledge is enormous.
gies of some of their demonic allure. The consequences of the Arab expansion
These anthropological insights have an im- after the seventh century AD is today common
portant message to clinical psychology because knowledge and therefore a convenient example.
they are a reminder of the forces of irrationality Through the medium of the Arab language and
in mental life. It is of particular importance to lines of communications created by the Arab
appreciate that modern rationality is a world rulers, the fund of knowledge accumulated in
view or Weltanschauung which has developed three of the great civilizations of the Occident
under particular social circumstances. Although and the Near EastÐThe Byzantine, the Greco-
the majority of people in the Western world Roman, and the PersianÐwere brought to-
regard the scientific world view as true in an gether. In the wake of these events was written
absolute sense, anthropology reminds us of the an important chapter in the evolution of
great variety of world views developed in Western medicine. The knowledge reached
different societies as demonstrated in the Europe primarily through Moorish Spain. At
varieties of explanations of destiny and illness. the universities in Europe the medical text,
At the same time social science demonstrates Canon of medicine, by the Persian scholar Ibn
that even scientific rationality is merely ªskin Sina (980±1037), known by his latinized name
deep.º Behind a front of rationality, human Avicenna, was part of the curriculum for several
passions often subvert the conquests of scien- hundred years and helped to set the stage for the
tific reason. It is often the task of the therapist to development of modern Western medicine.
clarify how egocentric irrationality is the cause The great medical traditions of Greek,
of psychological disturbance, and it is some- Indian, Arab, Chinese, and American societies
times the duty of social scientists to represent will be explored in the following pages.
the voice of reason in the public domain in
situations where moral panics threaten justice
and human dignity. Anthropological insights 1.08.3.1.2 Early Greek medicine
may also threaten our somewhat ethnocentric One of the basic ideas in Greek medicine is the
convictions of having found the master key to role of the bodily ªhumors.º The theory of
truth by raising the question of whether our illness based on the so-called humoral pathol-
world view is merely a belief system among ogy is known to us through the writings of
many others developed by human civilizations. Hippocrates (born around 460 BC), the father
of Western medicine. According to Hippo-
crates, health is a state of equilibrium between
1.08.3.1 Non-Western Systems of the four humors with their associated qualities:
Understanding blood (hot and moist); phlegm (cold and moist);
1.08.3.1.1 Complex societies black bile, also known as melancholy (cold and
dry), and yellow bile or choler (hot and dry).
The various theories of illness presented in the In the text attributed to Hippocrates we are
global overview of Murdock testify that all told that
human groups develop disease theories no
matter how simple. In the evolution of knowl- The human body contains blood, phlegm, yellow
edge, which in an anthropological perspective bile and black bile. These are the things that make
cannot be understood without attention to the up its constitution and cause its pains and health.
development of political systems, more complex Health is primarily the state in which these
systems of understanding have developed and constituent substances are in the correct propor-
gained acceptance and influence in wide areas. tion to each other, both in strength and in
quantity, and are well mixed. Pain occurs when
The interdependence between knowledge one of the substances presents either a deficiency
and social institutions is often overlooked as or an exess, or is separated in the body and not
if knowledge has an independent existence mixed with the others . . . The four humors have
outside the sphere of human organization. The specific and different names because there are
fact is that the crystallization of medical essential differences in their appearance. They are
knowledge into comprehensive systems has dissimilar in their qualities of heat, cold, dryness
and moisture . . . Phlegm increases in the winter the Greek humors. Kretschmer recognized three
because as the coldest humor, it is most in keeping main physical types: pyknic, athletic, and
with the winter. During the spring the quantity of asthenic (leptosome) and added a fourth
blood increases, taking charge of the body during ªmixedº type, the dysplastic. The pyknic type
the summer and autumn. The hot and cold
is round in form and has a greater quantity of
summer weather is conductive to yellow bile,
but, as the cool and dry autumn comes on the fatty tissue compared to the leptosome who
bile is cooled, and the black bile preponderates . . . tend to be relatively thin and of linear build. The
The physician must bear in mind that each disease term athletic speaks for itself. Kretschmer
is prominent during the season most in keeping identified two main types of psychotic disposi-
with its nature. (Chadwick & Mann, 1950, pp. 204, tions: the schizoid (expressed in schizophrenia)
206, 207, 208) and the cycloid (expressed in manic-depressive
psychosis). In the normal population he
Hippocrates also specifies cures. identified nonpathological dispositions which
he referred to as schizothymia, characterized by
Diseases caused by over-eating are cured by introversion, sensitivity, and seriousness; and
fasting; those caused by starvation are cured by cyclothymia with a more extrovert disposition,
feeding up. Diseases caused by exertion are cured affectivity, and a tendency towards mood
by rest; those caused by indolence are cured by swings. According to Kretschmer, pyknic
exertion. To put it briefly, the physician should
treat disease by the principle of opposition to the
individuals tend to be cyclothymic, whereas
cause of the disease according to its form its asthenic, athlethic and dysplastic individuals
seasonal and age incidence, countering tenseness tend to be schizothymic (Kretschmer, 1925).
by relaxation and vice versa. This will bring the In the USA William Sheldon developed a
patient most relief and seems to me the principle of typology according to the same paradigm,
healing. (Chadwick & Mann, 1950, p. 208) although he discarded the strict categorizations
of Kretschmer and introduced a taxonomic
The most important organs of the body system based on a systematic study of thou-
according to early Greek medicine were the sands of college students. He concluded that
heart, the brain, and the liver. These organs human beings could be classified under three
were respectively dry and hot, moist and cold, primary components of body build: endomor-
and hot and moistÐthe healthy body was phy, mesomorphy, and ectomorphy. The en-
thought to have an excess of heat and moisture. domorph is reminiscent of the pyknic type
But each person had his or her particular characterized by softness, roundness, and a
temperament according to the personal promi- large digestive system. The mesomorph has
nence of bodily humors: The ªsanguine,º cheer- strong bones and muscles, in other words is
ful and optimistic; the ªphlegmatic,º calm and athletic. The ectomorph is thin and has a large
somewhat slow and sluggish; The ªbilious,º ill- skin area and nervous system. He recognized
tempered and indeed choleric; and the ªmelan- three essential dimensions of temperament:
cholic,º sad with a tendency for depression and viscerotonic, somatotonic and cerebrotonic,
in fact melancholic. assuming that temperament was determined
The resilience of the Hippocratic medicine is by the somatic disposition (Sheldon & Stevens,
immediately obvious to us as we recognize that 1942).
the term ªtemperamentº relates to the notion of In this context we are not primarily concerned
temperature in the theory of humor pathology with the scientific merit of the theories of
and the categories of temperament are still temperament and personality but in demon-
maintained in everyday language in the West. strating the historical background of scientific
The therapies were also logically derived from thought.
the theory and were directed against a re- A crucial institution for the influence of
establisment of an humoral balance by means of Greek medicine was the library of Alexandria
diet, purging, vomiting, bleeding, and which was founded in the third century BC.
cuppingÐtherapies which are still part of folk With the manuscripts of this library at his
medicine in the Mediterranean. disposal, Galen (130±200 AD) gave the theory
The theory of humor pathology foresha- of humors its final shape. Although he mainly
dowed or may be influenced the direction of practiced his medical knowledge in Rome,
thought in Western medicine where today the Galen was an authentic Greek and through
biochemistry of the body is a promising field of his writings Greek medicine conquered oriental
investigation and therapy. Christianity and Islam.
In the field of psychiatry, the German Through the East-Roman orbit, Byzantium,
psychiatrist Ernst Kretschmer developed a the teachings of Galen reached eastern Chris-
typology of temperaments where somatic tianity and Islam. A crucial role in this
characteristics of the body take the place of transmission of knowledge was played by the
Nestorian sect of Christianity in Edessa in theory. The doshas relate to the age and the
Mesopotamia where Galen's work was trans- seasons: phlegm with youth and the growing
lated into Arabic. Near the end of the fifth season, bile with middle age and the rainy
century the Nestorians had to flee Mesopotamia season, and the wind with old age and winter.
for political reasons and settled in Gund-Shapur The ideas of temperature are also found in the
in Persia, present day Iran. A center of medical Ayurvedic circle of ideas. Many foods are
knowledge was established at Gund-Shapur thought to have heating and cooling qualities.
which strongly influenced Islamic medicine and Hot food, garam, include eggs, meat, milk,
the Greek theory of humor pathology became honey, and sugar; cold foods, tonda, include
part of the Arabic medical tradition. Of fruit juices, yogurt, rice, and water. These
particular interest is Gund-Shapur as a med- notions are reflected in the theory in which diet
iator between Greek and Indian medicine, the has an important part to play.
Ayurvedic school. It is interesting to appreciate that during the
period when Ayurvedic medicine reached its
mature state, a strict system of socio-religious
1.08.3.1.3 The Indian medical system
taboos regulating the menus of the Hindus
As one of the great civilizations India has evolved. There is no indication to the effect that
developed its own medical system which is part these taboos, which support the hierarchy of
of the health care of modern India. The roots of castes according to degrees of ritual purity, were
Indian medicine can be traced to the Vedic developed with the aim of promoting health or
writings from the latter part of the second avoiding disease. But as Basham (1976) points
millennium BC. In the Rig Veda we encounter out, it is surprising how many of the instructions
the term bhisaj a word which later became in the Atharva Veda would tend to minimize
synonymous with vaydya which still today is the the dangers of infection and food poisoning.
Indian term for the traditional curer. In the ªIndian society seems unconsciously to have
early period disease was believed to be due to found a means of remaining healthy as far as
punishing gods and evil demons. We recognize possible in a subtropical climate, in its efforts to
the interpretation of disease in Murdock's preserve its ritual purityº (Basham, 1976, p. 19).
theory of spirit aggression. The god Varuna This statement recalls the discussion of the
was associated with moral ideas and punished religious food taboos in the Western orbit. In
those who transgressed his commands. our age of reason, we tend to project our
The idea of healing is associated with the rational understanding back to the times when
divine twin gods, the Asvins. In the Atharva the taboos were codified, times when there was
Veda demons are presented as the responsible no rational understanding to sustain the dietary
agents and part of the text is in fact made up of habits. The results of the dietary and also
spells to cure disease and promote longevity. hygienic taboos sometimes appear to have had
As pointed out by Basham (1976) in the practical effects as if they were based on rational
centuries following the Atharva Veda, the last understanding of germs and infection. It is
six centuries BC, the traditional Indian medical tempting to hypothesize that there is an intuitive
system developed into something like its present wisdom in religious taboos, an intuition which
day form. What is today known as Ayurvedic antedates the reflexive understanding of mod-
medicine has come down from Sanskrit docu- ern science.
ments from the first century BC. The most The ideas of purity and danger explored by
important of these is Caraka Samitha. Caraka is Mary Douglas (1966) demonstrate that the
the supposed author of the text, and he may be dangers of pollution emerge when essential
regarded as an Indian Hippocrates. categories are insulted. The orderliness which
By the first century AD a naturalistic system these notions promote have obvious prophy-
had developed in India. Although beliefs in lactic effects, as is the case when the dead body
personalistic causation prevail until this day on and things affiliated with it are shunned. The
the sub-continent, Ayurvedic medicine is a Jewish taboos and hygienic rules definitely
system with scientific and empirical merit. The served to promote health. Although not the
term may be translated as ªthe science of living explicit intension of the taboos, they helped to
to a ripe age.º increase the hygienic standards. The Jews
According to Ayurvedic theory, the universe shunned stagnant waters, like the wells in the
is composed of four elements: earth, water, fire, medieval cities, which were sometimes infected.
and air. The human body has three fluids or The fact that the Jews made a special effort to
humors, in Indian dosha: phlegm, bile and gall, secure running water was from our point of view
and wind. In a healthy individual the three sensible enough. But it cost them dearly because
doshas are in balance or equilibrium, this notion some Christians spread the rumor that the wells
is consequently referred to as the tridosha had been poisoned by the Jews.
Although too simplistic, ideas of evolution Seven major centers are recognized. The third-
are regarded with suspicion by cosmopolitan eye center, for example, is located an inch above
anthropology. It is a historical fact that the the meeting of the eyebrows and relates to
development of the medical systems both of the insight and understanding. These centers are
Greeks and the Indians followed a trend from normally closed and it requires conscious effort
the personalistic to naturalistic types of exon the part of the meditator to open them.
planation. As we shall see, Chinese and Arabic The yogic terminology and the sometimes
medicine followed the same developmental extravagant claims made on its behalf has
trend. It is an empirical fact that naturalist made it too easy for Western science to dis-
and rational explanations emerged with the regard the knowledge as obscure. Its promotors
development of states and institutions. This in the West also sometimes have proved to be
does not in itself demonstrate a causal connec- authentic charlatans who have exploited the
tion between development of complex societies existential crises of modern men and women to
and rationality, but invites a hypothesis to that make money. This, and a tendency towards
effect. The secret is most likely hidden in the cultural arrogance, has made it too easy for
social organization of knowledge and the Western science to disregard insights from
rationalization of economy and administration. Asian psychology. But recently, mental health
The great medical systems of the Orient professionals have started an exploration of
stopped short of developing the reflexive the Asian techniques on a personal basis.
empirically based medical science of the West. Studies of altered states of consciousness have
They did, however, develop prophylactic pro- revealed the complexity of consciousness which
cedures, curing techniques, and mental training for a long time was ignored by behaviorist
programs which are now gradually being psychology in spite of the influence of, for
recognized as valuable by Western medical example, William James. He demonstrated an
science. open-minded approach:
Of particular interest is yoga which does not
strictly belong to the Ayurvedic curriculum. The Our normal waking consciousness is but one
term ªyogaº has two Sanskrit roots, the first special type of consciousness, whilst all about it,
means ªto meditate,º the second ªto joinº. By parted from it by the flimsiest of screens, there lie
joining is understood the connection of the potential forms of consciousness entirely different.
human nature with cosmic sources. The devel- We may go through life without suspecting their
existence, but apply the requisite stimulus, and at a
opment of yoga as a technique of psychological touch they are there in all their completeness. No
healing may be regarded as an evolution of early account of the universe in its totality can be final
magico-religious beliefs and practices into a which leaves these other forms of consciousness
rational system. Seen in the light of a theory of quite disregarded. How to regard them is the
knowledge this development is of the same question. At any rate they forbid a premature
nature as the development of empirical, medical closing of our accounts with reality. (James, 1914,
theories on the basis of early, personalistic ideas p. 298)
exemplified by Greek and Indian humoral
theories. Recent advances in Western science seem to
Yoga has definitely developed on the basis of facilitate a more open-minded attitude to Asian
religious ideas (Hindu and Buddhist) but is not psychology and medical practice and theory
in itself a religion and is not based on faith, (Walsh & Vaughan, 1980).
dogma, and sacred texts. Yoga represents a
system of mental training developed over
1.08.3.1.4 Arabic medicine
milennia by practicing yogis.
The yoga philosophy clearly testifies to its Arabic medicine has two main sources. One
religious parentage. It is based on a rejection of is Greek which the Arabs incorporated into
wordly life, an idea shared by Christianity. Its their rational system of knowledge during their
aim is an altered state of consciousness. In the most enlightened period from the tenth to the
West a general scepticism to yoga has prevailed twelfth century. The other source is the medical
until quite recently. But, empirical studies tradition of the bedouins which gradually
suggest that relatively subtle effects produced merged with the teachings of the prophet
by different yoga practices can be detected by Muhammed, and is crystallized under the term
brain-wave studies (Emerson, 1972). ªprophetic medicine.º
Underlying yogic practice is the idea of the The two bodies of medical knowledge have
ªsubtle body,º which consists of a series of been in conflict with each other primarily
interconnected centers called ªchacras.º The because of the prestige of the prophet and the
chacras have the ability to process energy from theocratic influence of the clergy. The Greek
the environment and refine it to a higher level. medical tradition was regarded as alien by the
rank and file of the ulama the theocratic scholars high standards and medical ethics with its roots
who, until this day, dominate much of the in Hippocratic traditions. It is probably also due
intellectual life in Islamic countries. to the influence of this academy that Arabic
Seen from the perspective of the tenth century medicine by the Hindu and Urdu speakers is
AD it is inconceivable that the great advances known as Unani. Unani is the English spelling of
in medicine should emerge in the Christian the Arabic term Yunani which means Greek,
West. After the decline of the Roman Empire that is, Ionian.
and with it the Greco-Roman civilization, elite Of particular interest is Greek and Arab
Greek medicine was rescued by the Arabs. psychiatry. The Greek physician Rufus of
During the first three or four centuries after the Ephesus wrote a treatise on melancholia which
Hijra, Arabic became the common language was translated and supplemented by Ishaq ibn
of the Islamic world and the language of science. Imran, a court physician in Kairouan, at the
Greek medicine was taken over wholesale beginning of the tenth century. Melancholy was
by the Arabs who, to the degree that scientific treated with medicine and psychotherapy which
medicine survived, stuck to it until they were included music.
subjected to the impact of European science Considerable insight in mental illness is
in the nineteenth century. The translation of testified by the treatments recommended for
the Greek medical sources was performed by fixed ideas. The main point is that the ideas were
a comparatively small group of scholars, taken seriously and not dismissed, as they
primarily in the ninth century. Hundreds of sometimes are by modern physicians. The
Greek works were translated into Arabic and treatment was based on the authority of the
became part of the scientific legacy during the physician. It seems that Rufus of Ephesus had
golden age of Arab dominion. The Hippocratic reflected on the power of authority of the
and Galenic systems were saved for world formation of cognitive states which indepen-
civilization by these early scholars. dently of the Greek tradition, was introduced in
Arab practitioners added to the body of European clinics by Franz Anton Mesmer
knowledge developed by the Greeks the subjects (1734±1815) in his so-called magnetic treatment
of pharmacology and surgery, which flourished based on the power of suggestion. Although
in Andalusia; and ophthalmology, which flour- Mesmer's method was dismissed as fraudulent,
ished in Egypt and Mesopotamia where eye he was the first to introduce a systematic
diseases for climatic and ecological reasons were application of the authority of the practitioner
the scourge of the people. as a cure of hypochondriacs and hysterics. A
This body of knowledge was, as pointed out monument of his achievement has been raised in
above, systematized in a treatise on medicine by the English lexicon in the form of the term
Ibn Sina, Avicenna, and partly through his ªmesmeric.º
famous canon of medicine (al-qanum fit- t-tibb). Profound psychosomatic understanding ap-
Greek medicine was restored in the West. It was pears between the lines in Arab medical texts.
part of the curriculum in Salerno for centuries. This is particularly the case with regard to the
The Greeks and the Arabs also made contribu- demeanor and lifestyle demanded of the
tions to psychiatry, which of course was an physician. He had to be a respectable person
unknown term before the nineteenth century. of high ethical standards and the bedside
The high standard of medical practice in the manners were an essential part of the cure.
Arab domain was to a large degree promoted by Some of the great practitioners are sur-
the medical center in Gund-Shapur. This pre- rounded by a heroic lore which has survived
Islamic center not only promoted an exchange until the present day. Of particular interest is the
between Indian and Greek medicine, but set a story of the great Razi who healed the emir of
standard for medical craftsmanship which made Rhagae (in ancient Persia). This ruler had a
the physician a respected personality in cosmo- paralyzed leg and Razi understood that the
politan Arab culture, although the school was in ailment was a hysterical condition. Razi ordered
its heyday run by Nestorian scholars and drinks and a hot bath ªto ripen the humors.º
physicians. The academy was probably founded But suddenly he drew his knife as if he was
in the first half of the sixth century after the prepared to kill the emir, who sprang to his feet,
Academy of Athens was closed in 529. cured of his hysterical ailment. Razi, of course,
It is known that when the founder of the did not use the term hysteria, but the story
Abbasid Caliphate, al-Mansur, came down with testifies to a remarkable psychological insight
a stomach disease and his regular court (BuÈrgel, 1976, p. 51).
physicians were helpless, the chief physician The great Arab scholar Ibn Khaldun
at Gund-Shapur was called to Baghdad. When (1332±1406) wrote a famous treatise on the
he succesfully cured the ruler, the prestige of decline of Arab civilization which had flour-
Gund-Shapur was established and with that its ished from the tenth to the twelfth century.
After that the development of knowledge, legitimacy to opinions and procedures not
including medicine, did not just come to a explicitly sanctioned by the Koran. According
standstill, but fell into a deplorable decline. to the tradition, the Prophet claimed that
The reason is complicated and the explanations ªHealing resides in three things: a draught of
that are offered are controversial. Some main- honey, a cut by the cuppingglass (scarification),
tain that the reasons are political, as did Ibn and the branding by fire (cauterization). But as
Khaldun; others assume that the reasons are for branding I forbid it in my peopleº (BuÈrgel,
found in the economic developments. What we 1976, p. 57).
do know, however, is that one of the effects of The belief coded in this quotation refer to
the decline was a resurgence of personalistic honey as a medicine. It is still regarded as such at
explanations in the realm of medicine. BuÈrgel the margins of Islamic culture, for example,
(1976) gives the following explanation of this among the Sidama of Ethiopia. The cupping is
turn of events: still practiced in the Mediterranean where it has
developed a special form through the applica-
If we want to know which spiritual forces were tion of glass. A cup is heated and applied to the
most potent in paralyzing the scientific impetus of surface of the skin. When it cools, a vacuum-
the golden age, we have to ask what the essentials effect sucks the skin into the cup. It may be
of science are. I think that one essential is regarded as a milder form of therapeutic inflic-
imminent to science, its very soul and and life- tion of wounds. Cauterization is still practiced
blood, and this is rational argumentation pro- as a folk remedy in the periphery of the Islamic
pelled by an insatiable curiosity. The other thing orbit. A common practice is to drill a piece of
essential to science belongs to the history of wood, as in the old technique of fire-making.
economy as well as to the history of science, and
it is the interest in, the demand for, and the
When the stick almost catches fire through the
consumption of scientific products. What forces energy of drilling, it is applied to the skin. A
were harmful to these essentials? As for the number of burns are believed to cure minor
economic element, a strong and ever-increasing sickness. Through prophetic medicine folk
influence was exercised by Islamic mysticism, remedies were given medical legitimacy, among
which turned people to the inner instead of the which was the bedouin idea that all diseases
outer world so that they restricted their natural were caused by disorders of the stomach.
demands to a minimum. As to curiosity, I have Magic healing practices became widespread,
noted the prevailing concept of science as a and indeed are still widespread in the Islamic
constant stock of knowledge. Rational thought orbit. Of particular prominence is the magical
had several renowned enemies, some of whom
could trace their origins to antiquity. I refer to
protection of talismans. Most visitors to
astrology, alchemy, magic and, finally, of Islamic Muslim countries have noticed that children
origin, the so called prophetic medicine. These four have small bundles around their necks with
were looked upon as sciences by the great majority, scriptural talismans. Words from the Koran or
and even by most of the scholars. Nevertheless, the Prophet written on small pieces of cloth or
they were hothouses of irrationalism, the rational paper are regarded as a necessary protection.
disguise making them even more harmful. (p. 54) A widespread practice in former times was to
write holy texts on a washable material, rinse it
We recognize in the resurgence of persona- and give the rinsings to the patient as a
listic theories of causation the question of medicine. In the popular lore, the Prophet is
destiny. In monotheistic Islam the basic ques- reported to have performed ritual washing at
tion with regard to illness was its religious the bedside and afterwards to have administered
meaning. Pious people regarded illness as the the water to the sick as a drug. The lore and
will of God and wondered whether rational some of the Hadith should of course be taken
cures could be regarded as an obstruction of with a grain of salt. Charlatans have always
their ordained destiny. Illness and suffering tried to exploit the reputation of prophets and
were regarded as an atonement for sin and it sages to their economic benefit.
was common opinion that people suffering The history of the decline of scientific
from, for example, blindness or epilepsy were medicine in the Islamic orbit after the twelfth
assured a position in Paradise because of their century is only one example of the vulnerability
patient suffering. of rational knowledge. Although it cannot be
Suffering in itself came to be regarded as proved, it is probable that empirical science is
meritorious sublimely expressed in a cult of dependent upon a division of labor through
martyrs. ªHe who dies on a sickbed, dies the which economic and political interests are
death of a martyr and is secure against the divorced from the management and application
inquisition of the tomb.º This saying is of knowledge. Seen from the point of view of
attributed to the Prophet according to Hadith history, the worst possible situation in
the body of lore which is used to give prophetic the management of knowledge is theocratic
monopolies. Theocracies have often been establishment of money, markets, and orderly
passionate opponents of rational knowledge government.
and have not hesitated to oppress and even The basic concepts of Chinese medicine are
execute voices of reason and knowledge. today common knowledge in the West. The two
Criticism of prophetic medicine therefore was principles of life, ªyinº and ªyang,º are
practically nonexistent. One of the few critics, operating in the human body as everywhere
like Ibn Khaldun, pointed out that it was not else in the Chinese cosmos. Health is dependent
part of the Prophet's mission to teach medicine. upon the right balance between these two
Another was the Andalucian poet Ibn al-Khatib principles. Yang represents heaven, sun, fire,
who repudiated the explanation of plagues heat, dryness, light, the male principle, the
given by prophetic medicine pointing out that exterior, the right side, life, high, noble, good,
the validity of the traditions should not be beautiful, virtue, order, joy, and wealthÐall the
questioned if they were incompatible with the positive elements of being. Yin represents the
senses (Ullmann, 1970). opposite: earth, moon, water, cold, dampness,
The Islamic world today is struggling to darkness, the female principle, the interior, the
reconcile Western science with their traditional left side, death, low, ignoble, bad, ugly, vice,
Weltanschauung and, as BuÈrgel points out, confusion, and poverty (Foster & Anderson,
1978). Excessive yang causes fever, yin produces
The Islamic world has for over a century entered chills.
upon a new period of acculturation. From its very The hot±cold dichotomy in traditional Chi-
beginning, Islam has revealed a peculiar skill in nese medicine is reminicent of the Ayurvedic
accommodating and amalgamating foreign cul- tradition, but probably developed indepen-
tural influences without losing its own identity. dently in China. It was probably developed as
It is just now proving that it has lost nothing of far back as 180 BC. But the major work on the
this marvelous faculty. But if there is no chance hot±cold dichotomy is from the fourteenth
for the Galenic system as a whole to be revived in century. In Chia Ming's work Essential knowl-
our day, one may think of reviving particular
edge for eating and drinking (Yin-shih-hsuÈ-chih).
achievementsÐfor example, certain well-tried
therapies and old drugsÐwhich are in fact now (AD 1368), he describes
being scientifically tried out and reproduced on a
large scale by Unani pharmaceutical companies 43 kinds of fire and water, 50 kinds of grains, 87
and state pharmacies in Pakistan, India and Sri kinds of vegetables, 63 kinds of fruits and nuts, 33
Lanka. (BuÈrgel, 1976, pp. 60±61) ªflavoringsº and condiments, 68 varieties of fish,
34 kinds of fowl, and 42 kinds of meat! The entry
for each of these 460 entries tells to which of the
five flavor categories it belongs, its ªcharacterº
1.08.3.1.5 Chinese medicine (specified degrees of hotness or coolness) and the
other foods that should be eaten with it. The
Chinese medicine has evolved as a system of
character of natural rainwater is cold, while that
knowledge almost completely independent of of water from a stalactite cavern which is warm;
the other great civilizationsÐthe Greco-Ro- the flavor of both is sweet. Glutinous rice is said to
man, the Arab, and the Indian. Whereas these be warm, and eaten in excess causes fever.
three systems have, as we have seen, strongly Soybeans and fragrant leeks are warm, and eaten
influenced each other, contact with China in excess causes fever. (Foster & Anderson, 1978,
before the age of discovery was negligible. Also, p. 64).
in the development of Chinese medicine we can
recognize the shift from personalistic to natur- Acupuncture is regarded as a ªcoldº operation
alistic explanation which is the sine qua non especially suited to diseases caused by an excess
(absolute necessity) of rational knowledge. The of yang.
traditional Chinese medicine is best known Diseases are classified according to causation
through the classic work Huang Ti Nei Ching Su into external and internal diseases. Diseases
Wen which is claimed to be from the third caused by external forces are yang diseases, yin
century BC. However, recent historical research diseases by internal forces. In Chinese thinking
(Veith, 1972) has demonstrated that it most yin and yang have been understood as a single
likely was compiled during the Han dynasty entity combining in any manifestation in the
(202 BC±221 AD). This proves that naturalistic cosmos both positive and negative elements.
explanations emerged in China at about the Chinese cosmology recognizes five elements:
same time as in Greece and India. It is notable water, fire, metal, wood, and earth. This idea
that this happened during a period when of basic elements which was also part of
economic and political developments had Greek cosmology developed independently in
reached a degree of maturity calculated on China. Although this idea from our position of
the basis of comparative studies as with the knowledge seems primitive and erronous, it
cannot be denied that it put the human mind part of Western medicine although its mode of
on the right track towards modern physics operation in the human body is still unknown.
and chemistry. In the great hide and seek of
knowledge, the Chinese were at the portal of
rational, empirical science, but stopped short 1.08.3.1.6 American medicine
of entering.
Manfred Porkert has pointed out that The situation in America is unique and
Chinese thinking remained in the inductive different from the other civilizations we have
mode: been discussing. The reason for this is of course
that the civilizations of America more or less
ªThe scientist who uses the inductive and synthetic disintegrated under the impact of European
mode of cognizance will observe first, and then conquest. The knowledge systems of the Aztec,
speculate on his observation; the scientist who the Inca, and the Maya have not been adequately
supplies the causal and analytic mode will first brought forward to our times because the social
speculate and act, and after that he will observe. organization which sustained them broke down
My hypothesis is that, at the dawn of systematic and no adequate writing system was developed
speculation, philosophers of all civilizations first to codify the knowledge in texts. Although Arab
adopted the inductive and synthetic mode of medicine went into a period of decline, medical
cognition because of its directness and simplicity.
Causal analytic thought apparently did not enter
centers like Gund-Shapur served as a guarantor
the scene before the 4th century BC. In China it against total decay and the traditions had been
only constituted a brief interlude in the works of safely recorded in a medical canon. The lack of a
the mohists and of HsuÈn-tzu; in the West, the opus basic canon is the main reason why pre-
of Aristotle marked the beginning of a tradition Columbian medical knowledge has only sur-
that was to continue into our days. (Porkert, 1976, vived at the so-called folk level.
p. 63) Although the terms folk medicine and folk
level may offend some egalitarian sensibilities, it
Although its concepts seem foreign to the is a meaningful term from the point of view of
Western mind, it cannot be regarded as inferior the organization of knowledge. The vast bodies
to the Hippocratic tradition, the concept and of knowledge accumulated by the complex
ideas of which were not entirely different from civilizations need specialized institutions to be
the Chinese with regard to the theory of basic stored, retrieved, and above all applied. A
elements. A respectable body of knowledge was pedagogic system of sorts is necessary to
accumulated in the Chinese tradition and the transfer knowlege from one generation to the
efficiency of some of the cures, therapies, and next. When this system breaks down, people
drugs are no longer questioned. everywhere have struggled to save some of the
The Chinese physicians never reached the knowledge through their own management.
prestige accorded to modern Western physi- Also, in the civilizations which maintained their
cians or their Arab colleagues in the golden age. political integrity, rational medical knowledge
According to Confucian philosophy, which is survived, although outside the legitimate orbit
above all concerned with social ethics and the defined by clerics as in some of the Islamic
relation of the individual to society, the top of countries, varieties of folk medicine flourished.
the social hierachy was the literatus. The tiller of When people have little access to expert
the soil was given the second rank. At the knowledge, they resort to curers and try the
bottom were the soldiers and the merchants. best they can to retrieve the necessary knowl-
Physicians were considered to be technicians edge from the lore of their families and the local
(shu-shi) and were assigned the middle ranks of community and in the case of European
society together with engineers, craftsmen, and immigrants to the USA, from books.
artists. The folk medicine of America has been
Chinese medicine confirms Benedict's ideas primarily studied by folklorists, but in recent
on patterns of culture (1934). Although her years anthropologists have joined forces with
ideas are no longer part of mainstream anthro- the folklorists in the development of ethno-
pology, Chinese culture's meticulous concern medicine.
for detail and the patient execution of crafts- In the USA a plurality of folk medicines
manship whether in cooking, art, or medicine exists. Each immigrant group has to some
demonstrates a consistent pattern which never extent developed its own folk medicine. But it
fails to impress the observer. Their belief in their is customary to recognize three distinct types:
own tradition of knowledge, also in medicine, is Euro-, Black, and Spanish-American.
demonstrated by the persistence of the hot±cold Euro-American folk medicine is unique
dichotomy in the medical traditions of modern because most of the immigrants were able to
Hong Kong. Acupuncture is about to become read and thus were not merely dependent upon
oral traditions. But in the early years of frontier to a belief in witchcraft, a theory of illness which
life, particularly in the nineteenth century, Foster and Anderson (1978) characterize as
doctors were limited and not always elite personalistic. ªNothing else in the fieldwork
experts. However, Indian experts were highly elicited so much emotional response as the
respected as ªpowwowº doctors. Pickard and question about witchcraft. Whether answers
Buley claim that ªin some western communities were negative or affirmative, the vehemence was
in the early years there were native American often startlingº (Foster & Anderson, 1978,
doctors who were held in quite as high repute as p. 274).
regular white doctorsº (Pickard & Buley, 1945, The belief in witchcraft is probably of
p. 36). European, not African, origin. African witch
A part of American culture in general is the belief has never reached the degree of hysteria as
do-it-yourself tradition which has created a in Europe and later in the USA, and witch craze
special literary genre. Richard Carter's Valuable is an authentic Euro-American phenomenon.
vegetable medical prescriptions for the cure of all The beliefs, therefore, have probably been taken
nervous and putrid disorders (1815) was widely over from the European settlers. The idea of
distributed. protecting the body against bad weather has a
The native American knowledge came to its ring of humoral pathology which suggests
right in books like S. H. Selman's The Indian Greek influences. What is of authentic African
guide to health (1836), and William Daily's The origin is the herbal lore and practical cures and
Indian doctor's practice of medicine (1848). An remedies including a most capable midwifeship.
impressive number of home remedy books in African elements are certainly also part of
the medical mainstream tradition were also voodoo rituals.
printed, the best known is possibly John Gunn's Spanish-American folk medicine represents
Domestic medicine or Poor man's friend, in the a more coherent system than the others and is
house of affliction, pain and sickness, first based on an equilibrium model of health based
published in 1830. By 1885 it had gone through on a theory of balance between hot and cold
213 editions. calidades. Illness is the result of an excess of heat
The high level of literacy among many of the or cold, and the origin of these notions is fairly
immigrant settlers gave the folk medicine a obvious. Spanish±American folk medicine is
professional touch which is unique and may be based on the Greek pattern. Since Spain,
regarded as an intermediate type of knowledge particularly in Moorish times, was the center
from the point of view of social organization. of medical knowledge in Europe, it is not
Through literacy, the line of communication surprising that the Greek±Arab articulation of
from specialist centers to the people was humoral pathology dominated the medical
shortened and knowledge was not subjected scene in the homeland of the conquistadores.
to the same kind of distortions we know from It was brought to the New World with the
oral traditions. European settlers and remained the major
The best known of the ªauthenticº folk medical paradigm well into the eighteenth
medicine of the Euro-American type is that of century. From the elite centers of medicine in
the Pennsylvania Dutch (Amish). As Gebhard Spanish-speaking America it found its way to
(1976) points out, ideas still alive among the the mestizo peasants and acculturated native
Amish, for example, in the saying ªFeed a cold American groups. To a large degree it replaced
and starve a fever,º date back to Celsus (50 AD) preconquest medicine. However, it has been
and the use of cobwebs to cure bleeding goes suggested that, for example, the hot±cold
back to Galen. dichotomy in Mexican folk medicine has its
The black folk medicine represents a purely roots in Aztec beliefs (Lopez-Austin, 1974).
oral tradition. The best known variety is the so-
called ªvoodooº or ªconjureº which developed 1.08.3.2 Small-scaled Societies
in the early nineteenth century around New
1.08.3.2.1 Africa
Orleans. Black folk medicine has three main
sources: Catholicism, seventeenth and eight- In Murdock's (1980) comparative study we
eenth century European occultism, and tradi- noticed the great variety of explanation of
tional African medicine and belief. disease and misfortune. A typical example of
Snow classifies the black explanation of spirit aggression is recorded from the Sidama
disease as ªnaturalº and ªunnaturalº: ªThe people of southwestern Ethiopia and may serve
first includes deficiency in protecting the body as an example both of theory and practice in this
against bad weather, and divine punishment for ªmedical genre.º It will also give a portrait of a
sin. The second has to do with the individual's prominent character in the medical practice in
position as a member of societyº (Snow, 1973, small-scaled societies, the shaman (Brogger,
p. 272). As ªunnaturalº Snow refers specifically 1986).
Disease among the Sidama is commonly These were the masters, but other spirits would
explained as the result of spirit-aggression. The come at the same time. These spirits can kill and
Sidamas are firmly convinced that they are make a person sick, but they can also be of help.
surrounded by an army of spirits. They gave me children, and I built a galma for
them. In the early days I had hayatas very
Some of the spirits live in large trees, others
frequently, sometimes every two months. That
near the river. They are invisible, but are cap- protected me and my family from sickness. My
able of invading the bodies of men and talking father also had spirits. But his spirits were
through the mouth of the person they choose as different. My spirits came from Dulanna, all
their host. The spirits are capable of striking spirits come from big people like Guto and
men and animals with disease and misfortune, Dulanna. (Brogger, 1986, p. 66)
but can also be of help if they are treated
properly.
The spirits rarely strike only once. They Usually the spirit will after some time de-
prefer to establish a lasting relationship with a mand its own house, galma. The galma is a
person. When such a relationship is established, smaller replica of the sidama house, but con-
the spirit demands regular attention through structed for the sole purpose of serving the
spirit sessions, hayatas, in which communica- hayata sessions. It is built close to the main hut
tion with the spirits is based on a state of as a kind of chapel for the households of the
dissociation or trance in the host. This state is compound. Guto and Dulanna are the names of
reached through drumming and singing during particularly powerful shamans who often in-
the spirit session. troduce new spirits to the sidama ªpantheon.º
When a relationship with a spirit has been The attacks of the sheitanna are in many cases
established, it cannot be dissolved and lasts until interpreted by a kalicha. But in a number of
the person dies. When a man dies, it is very often cases the presence of the spirits is so obvious
claimed that he was killed by his spirits. To get that no consultation is regarded as necessary.
some systematic knowledge of the spirit cult, a When contact has been established by a kalicha
sample of 29 cases was selected from one local and his spirit or spirits, professional assistance
curer. Although the spirits are regarded as will rarely be necessary. Most of the people who
heavy burdens, most people were afraid of served as hosts for spirits understood when the
losing them. A spirit usually heralds its choice of spirits demanded a tribute. This did not happen
host with a sickness. Of the 29 cases recorded, 20 only through sicknessÐa spirit could some-
started with some sort of sickness. The indivi- times let its demands be known through spells of
dual histories of acquisition have the same instant possession. In a number of cases the
general pattern, but with some variations of spirit would approach a future host through a
details. The following case is fairly typical, dream.
although richer in details than most. This man A 55-year-old and very active hayata orga-
was 65 years old at the time of the fieldwork, nizer with his own galma got his first sheitani in
and had entertained the relationship with the the following way: ªIt first started through a
spirits for more than 30 years. dream. I saw it like a picture of a human being
and it told me to make hayata. But I had no
disease and I refused. It then reappeared in a
I hated the sheitanna in the beginning, I was dream.º (Brogger, 1986, p. 67)
insulting them. But one day when I came from the But he still hesitated. The same dream was
market I asked my wife to make coffee for me. As repeated several times, and gradually his mental
I drank this coffee, I suddenly began to shake, state changed during the day. He could no
and I did not know what was happening to me,
and I asked my wife. She told me that I became
longer concentrate on his work and he some-
very strange. At that time I was the student of times had hallucinations. Sometimes he was
Abba (an Italian priest). I explained to him what talking to himself, and one day he pointed at an
had happened to me. Abba told me that spirits imaginary sacrifice and said: ªThese intestines
were dangerous, and he gave me a kind of paper of the sheep we must bring to the kalicha.º
with the image of Jesus Christ and told me to keep Finally, he could no longer resist, and he made
it under my pillow and to pray. This cured me for his first hayata and became completely normal.
some time. But when the Italians left Ethiopia, From then on he gave hayatas regularly.
Abba left with them, and the spirits caught me Not every Sidama had a spirit; an enlightened
again. I got pain all over my body and I asked guess is that about 10% of the adult population
people what I should do, and they told me to
make a hayata and pay gabo, gifts, to the spirits. I
has a long-standing personal relationship with
gave him a sheep and honey, but although the one or more spirits. But those who have no spirit
spirit made me shake, it did not talk. Therefore I of their own may participate in the hayatas of
brought a kalicha to the hayata, and he made the close relatives and give gifts on these occasions.
spirit talk. I had two spirits, Dillo and Warro. Thus, most of the community of grown-ups are
in one way or another affiliated with one or The cures of the shamans are efficient within
more spirit. When an ardent spirit-worshipper their context of understanding, as in cases where
dies, the spirit is often inherited by a close the illness or disturbance belongs to the moral
relative. In fact 10 of the above 29 cases inherited order and has its roots in disturbed social
their spirits from their mother, father, or spouse. relationships.
The local curer is technically in anthropolo- The healing traditions of shamans have
gical terminology, a shaman. Although he is attracted the attention of modern Western
formally concerned with healing, his main medicine and psychology recently and they
service is to articulate social conflicts in terms cannot be dismissed as charlatans, as demon-
of the local system of interpretation of disease strated by Andrew Strathern (1995).
and misfortune. As the chief administrator of the
spirit cult and its main source of authority, he is
crucial to our understanding of shamanism. 1.08.3.2.2 New Guinea
The political leaders among the Sidama are Among the Baktaman of New Guinea
the elders. The stateliness of the elders contrasts according to Barth (1975) sickness is thought
sharply with the demeanor of the shaman. If to be caused by both spirits and sorcerers, but
stateliness is the hallmark of the elders, eccen- also by breaches of taboos. But, maintains
tricity is that of the shaman. They surround Barth,
themselves with a set of symbols which give
them a certain flamboyance, particularly their Baktaman also operate with a concept that seems
jewelry and hairstyle. They will often let their close to a Western pre-scientific notion of
hair grow long and appear in robes reminiscent ªdiseaseºÐa condition, often communicated or
of Arab traders. They adorn themselves with initiated by a particular incident, causing discom-
conspicuous rings of twisted copper, bracelets, fort of recognized kinds and even death. Thus, for
and necklaces. They show little care for dignity example, one man who developed a cold chastised
but rather inspire an aura of mystery bordering another for having been spitting and blowing
on the sinister. mucus all over the place when he had been sick;
this had been eaten by the pigs, stored in their fat,
The elders are respected, shamans are feared.
and communicated to the patient when he ate the
On the basis of their functions in the local pork. Pressed to explain the nature of what was
communities the elders could rightly be called communicated an informant fell back on the idiom
priests. They bear the responsibility for com- of spirit; but it makes sense for him none the less to
munal sacrifices, they may promote fertility declare that a particular condition of being sick is
through their blessings, and they mediate the caused not by sorcerers or spirit agents, but ªjust
tribal communication with the Sky-God, Ma- sickness.º (p. 137)
gano. They are the guarantors of the respectable
and the moral order. Sickness then can be brought about by the
The shamans, on the other hand, negotiate following causes: spirit attacks, male sorcery,
the relationship with a number of capricious female sorcery, breach of taboo, menstrual
spirits which haunt the local communities in pollution, and plain sickness.
Sidama. We have seen how the spirits impose It is not unreasonable to suspect that the
themselves on ordinary people, and how com- category ªplain sicknessº has been added to the
munication with them was established through Baktaman taxonomy recently under the influ-
the spirit session, the hayata. Most of the wor- ence of Western medicine, small elements of
shippers of spirits merely attend to the problems which were brought to the attention of the tribe
of their immediate families. by anthropologists.
There is no formal process of recruitment The Baktaman have developed a ªtechniqueº
of shamans. A shaman establishes himself by of disease prevention with an interesting and
his own choice as a public practitioner in the art familiar ring: the amulet. Baktaman children,
of spirit-management. In order to project the like children in the Mediterranean, wear small
image of a shaman he has to change his way of bundles around their necks, usually a selection
dressing and general appearance. He will either from dog femurs, water-lizard mandibles, cas-
build a special hut or arrange his house in a way sowary claws, and ginger wood. The spirits from
that facilitates the accommodation of clients. the animals are supposed to guard against spirit
Among ordinary men the spirits are regarded as attacks. Grown-ups also wear talismans, but
jealous and demanding, and unnecessary con- their amulets are secret and hidden in minute
tact with them should be avoided. But when bags suspended from the neck to hang over the
someone is struck by misfortune and sickness, breastbone near the seat of one's spirit
the presence of the spirits is actively solicited so consciousness.
they can be persuaded to withdraw their Various cures are available, but none of them
influence. seem to have a rational basis. They have
The Growth of the Western System of Understanding 251
developed medicines, but their mode of action is the seventeenth century. The outcasts in Paris,
magical. For example, spice bark is chewed and London, or Philadelphia in the eighteenth
blown over sick persons with a combined century were confined respectively to La
whistling/blowing gesture normally used in Salptriere, Bedlam, and Pennsylvania Hospital.
conversations signifying ªget lost.º Infections The insane were given worse treatment than
are transferred to the taro-plant by injecting a the other inmates. Foucault (1965) give the
small specimen of pus from the sore under the following description of their situation:
skin of the taro. Bleeding of the infected area is
also practiced. If these cures fail, the ultimate when the waters of the Seine rose, those cells
remedy for sickness is pig sacrifice with an situated at the level of the sewers became not only
appeal to the ancestors with a mountain spirit as more unhealthy, but worse still, a refuge for a
an intermediary. The sacrifice is administered swarm of huge rats, which during the night
by a shaman. It is not reported that the shaman attacked the unfortunates confined there and bit
them wherever they could reach them; madwomen
induces trance in the curing process. Trance, have been found with feet, hands, and face torn by
however, is an essential prerequisite of a bites which are often dangerous and from which
shaman as among the Sidama. several have died. (pp. 70±71)
1.08.4 THE GROWTH OF THE WESTERN But by the end of the eighteenth century more
SYSTEM OF UNDERSTANDING humane treatment of the insane was gradually
introduced. It is significant that these changes
1.08.4.1 The Role of the Psychiatric Hospital followed in the wake of modernization in the
full sense of the word both within the realm of
Until the eighteen century, personalistic economics and production which, it may be
explanation of disease, and particularly mental argued, paved the way for the age of reason in
disease, was common in Europe. In the clinical Europe and the USA.
literature it is referred to as animistic explana- The first hospital to remove the chains from
tions (Brogger, 1986). In cognitive terms there the patients was St. Boniface in Florence, Italy.
is no major difference between the belief in spirit But the most famous event is Philippe Pinel's
aggression in eighteenth century Europe and removal of the chains in his capacity of the
the personalistic explanations we have encoun- newly appointed director of La Bictre in Paris
tered in the ethnographic literature. Among the during the French Revolution in 1792.
Sidama the spirits are managed by the shaman, This was not done without opposition. A
in the European tradition by the priest. famous exchange between Pinel and one of the
Although the shaman and the priest both have radical leaders, Couthon, is interesting because
the responsibility of relieving the distress caused it forecasts an understanding of certain psy-
by assumed spirits, the priest should not be chiatric symptoms which were not generally
classified with the shaman. The priest never understood before the middle of the twentieth
resorts to trance, but holds an office based on century. After having been insulted by one of
some sort of expertise and legitimacy which is the patients, Couthon turned to Pinel and said:
dependent upon specialized, bureaucratic in- ªNow citizen, are you mad yourself to seek to
stitutions. The shaman has to sustain his unchain such beasts?º Pinel replied calmly: ªI
position through his own charisma and role am convinced that these madmen are so
play. He or she is dominating in small-scaled intractable only because they have been
societies. Priesthood is an institution of complex deprived of air and liberty (Rosenhan &
societies. In the European tradition possessions Seligman, 1995, p. 40). By these words Pinel
were treated by exorcism, and the church has was ahead of his time. The iatrogenic aspect of
codified rituals of exorcism. certain psychiatric symptoms was not generally
The belief that mental distress is caused by understood before the American anthropolo-
evil spirits is surviving, to a degree, even in a gist Goffman published his work Asylums
modern industrialized society like the USA (1961).
(Goffman, 1961). But today legitimate treat-
ment is based on the scientific Weltanschauung 1.08.4.2 The Cross-cultural Issue and Human
with the psychiatric hospital as one of the core Nature
institutions. The psychiatric hospital, however,
does not have an honorable pedigree. It evolved Two systems of understanding can be recog-
from institutions that were created to house nized at our present stage of knowledge with
the poor, the uprooted, the unemployed, and regard to the cross-cultural issue. First, the
the insaneÐin other words the outcasts emer- universalist approach has as an underlying
ging in the wake of the disruption of the paradigm that one system of understanding
agrarian society at the dawn of industrialism in may cover the human family as a whole. The
second system, the particularistic, is based on Cultural psychology is the study of the way
the assumption that cultures must be under- cultural traditions and social practices regulate,
stood on their own terms and cannot be unified express, transform, and permute the human psy-
in one master theory. The Indian Wel- che, resulting less in psychic unity for humankind
than in ethnic divergences in mind self, and
tanschauung may, for example, appear as
emotion. Cultural psychology is the study of the
strange and incomprehensible to us, and there- ways subject and object, self and other, psyche and
fore in terms of Western folk belief regarded culture, person and context, figure and ground,
as ªwrong.º If we try to translate this Wel- practitioner and practice live together, require
tanschauung into the terms of our own and, for each other, and dynamically, dialectically, and
example, insist that the cows are holy simply jointly make each other up. (p. 1)
because they are economically important, we
act as universalists. A particularist will respect A comprehensive curriculum has yet to be
the Indian view and try to understand and even designed.
acquire it as a system of knowledge. It is not a
question of an absolute dichotomy, and a 1.08.4.3 The Interface Between Psychology
taxonomic scheme may be a little premature. and Anthropology
During a symposium at the University of
California, San Diego, in 1980, a group of One of the great pioneers in psychology, the
leading scholars in the field of cultural theory German Wilhelm Wundt, was one of the first to
met to discuss the state of their art. One of their use ethnographic material to inform psycholo-
objectives was to establish contact with the gical problems. He wrote in the genre which
psychological sciences, for in the words of today is referred to as culture and personality.
Shweder and LeVine (1984): But although his influence in the growth of
modern psychology is enormous, his writings on
cultures never caught the imagination of his
The symbol-and-meaning approach to culture colleagues.
seems to be an unusually well kept secret in the
It was above all Sigmund Freud who became
psychological sciences, most notable among devel-
opmental researchers working on such culture- the pioneer in the exploration of the interface
saturated phenomena as personhood and self, between psychology and anthropology. In a
morality and convention, social cognition and number of works he tried to explain how
interpersonal relationships, self regulation and psychoanalysis could be used to explain the
emotional response. It was the best bet of the origins and functioning of social institutions.
planning group that this was the right time to bring Freud assumed that his model of the structure of
recent developments in culture theory ªout of the the mind was valid cross-culturally. He assumed
closet.º that the phenomena of repression, by which
painful experiences are kept out of the con-
It is relevant at this stage to point out that sciousness by unconscious forces, was universal.
American anthropology made great contribu- He regarded rituals and taboos he studied in the
tions when a group of scholars met and estab- ethnographic literature as caused by processes
lished some sort of consensus and joined forces similar to those he studied in his consulting-
under a common paradigm of understanding. room in Vienna, that is, to ward off anxiety. His
The Columbia group of the 1930s is a case in views have been summarized by Bock (1988,
point. p. 32) in the following illuminating phrase:
The group met in San Diego in 1980 and ªCulture is to society as neuroses is to the
was following in the wake of an established individual.º
tradition of the organization and management Psychoanalytic anthropology initiated by
of knowledge in the USA, and may serve as Sigmund Freud caught the imagination of
an example of a cultural pattern in itself. several generations of psychologists and anthro-
Although no clear consensus came out of their pologists, particularly in the USA where it has
efforts, they set the agenda for cultural studies served as a major source of inspiration until the
for the next decade or so and some of their key present.
participants, Richard A. Shweder, Robert A. The pioneering work in psychoanalytic
LeVine, Roy G. D'Andrade, and others, with anthropology is Totem and taboo (Freud,
Clifford Geerz as an inspiring pioneer of 1950). In this ground-breaking work, Freud
cultural studies, have taken over the torch from approaches these two classical anthropological
the Columbia group. problems. The term taboo is today part of the
During the next decade the field of cultural language of everyday life with only a slightly
psychology was developed. Stigler, Shweder, extended semantic sphere of reference com-
and Herdt (1990) summarize its scope with the pared to its strict anthropological meaning. In
following statement: anthropology today it covers all types of
prohibitions from the incest taboo to Jewish and hidden, connected channels, and it has caves,
Indian dietary rules. In Freud's thesis, the and secret hiding-places and dungeons.º This
Polynesian taboo served as a point of departure, first rumbling of early post-modernism inspired
and the term is linguistically Polynesian. Freud to an attack on the hidden abysses in the
Freud approached his patients in Vienna not human mind by reason, which is the main
only as a doctor within the Western clinical project of psychoanalysis.
tradition, but as a natural historian. Many of his Before Sigmund Freud, Karl Marx had
neurotic patients had restricted their lives with presented his own views on the human capacity
self-imposed prohibitions almost indistinguish- for illusions in his thesis on ªfalse conscious-
able from the authentic taboos from the South ness.º He applied the term to the realm of
Seas. In his explanation, he offered a new and political consciousness and maintained that the
comprehensive understanding of social custom workers were living in a situation of false
in psychological terms. His basic assumption is conciousness as long as they did not realize that
that just as neurotic behavior is the result of a they were oppressed. The false consciousnessÐ
compromise between unconscious erotic and with religion, the opium of the people, as the
hostile impulses, taboos are expression of main culpritÐwas, however, the result of
ambivalent emotions. capitalism and therefore not an unavoidable
The taboo surrounding Polynesian rulers are situation.
cumbersome and deprive the ruler of normal Freud was of the opposite view and was
and gratifying social intercourse. In the realm of convinced of the fact that rationalization was
the conscious sphere of discourse, the taboo is part of human cognition everywhere. Ibsen,
an expression of the highest esteem. But in the who also elaborated on the great insight of the
hidden agenda of the unconscious mind it is a nineteenth century, gave the idea a literary
punishment for their exaltation, a revenge taken articulation in The wild duck where he made it
on them by their subjects. clear that human beings could not live happily
The taboo on physical contact with the dead without the lies of life, the cherished illusion
is common in preliterate societies. Freud people sustain in everyday life.
maintains that ªthe taboo has grown up on Freud's treatment of totemism also set the
the basis of an ambivalent emotional attitu- stage for an investigation of the relationship
de. . .the contrast between conscious pain and between parents and children in the human
unconscious satisfaction over the death that has family and it was part of his theory of the
occurredº (Freud, 1950, p. 61). developmental stages of early childhood. The
Although Freud's interpretation is contro- mythological core in the exploration of tote-
versial and not generally accepted today, it mism is that of King Oedipus who unknowingly
nevertheless is an expression of the psycho- killed his father and later married his mother.
analytic insight in human cognition which today Upon discovering this, he blinded himself and
is part of our cultural system of understanding went into exile.
generally. The key concept is ªrationalization,º Freud had discovered during the analysis of
a mental process through which deeper and his patients the problems caused by the fact that
hidden motives are presented to the world as children's erotic and hostile impulses are
well as to the conscious ego in an acceptable and frequently directed toward family members.
morally legitimate fashion. He was particularly interested in the relation-
Freud articulated in his theory of the human ship between mother and son and the sometimes
soul one of the most important insights from explicit wish on the part of a small boy to
nineteenth century humanism: the human eliminate the father to have the mother's
capacity to sustain illusions. Intellectuals and undivided attention. But since small boys also
philosophers have known for millennia that love their fathers, the classic ambivalent situa-
fraud is one of the great problems of human tion emerges with great psychological costs, the
existence and have developed logic to aid their psychological distress caused by the oedipus
fellow men in the search for truth. Freud, complex.
however, went beyond the syllogisms and realm In presenting his insights on these sensitive
of pure cognition into the hidden hinterland at issues Freud created his own myth inspired by
the border of consciousness and beyond. the prevailing Darwinian idea of the primal
This thinking was in the spirit of the nine- horde, the assumed prefamily groups before the
teenth century which in philosophical terms was dawn of human civilization, dominated by a
explored by Nietzsche, particularly in his work violent and jealeous father who keeps all the
Jenseits von Gut und Bose (Beyond good and evil females for himself:
[1935]). The decline in the belief in the power of
reason is heralded by Nietzsche in the following One day the brothers who had been driven out
words: ªThe German soul has corridors and came together, killed and devoured their father
and so made an end of the patriarchal societies make judgements under uncertainty.
horde. . . .The violent primal father had been the As Kahneman, Slovic, and Tversky (1982) have
feared and envied model of each one of the demonstrated, people under certain kinds of
company of brothers: and in the act of devouring stress regress into ªprimitive mentalityº which
him they accomplished their identification with
then should be regarded as a mode of thought
him . . . The totem meal would thus be a repetition
and a commemoration of this criminal deed, which depending upon circumstances and not on
was the beginning of social organization, of moral culture.
restrictions and of religion.. . .Society was now Cognitive studies of non-Euro-American
based on complicity in the common crime; religion cultures, however, may inform our understand-
was based on the sense of guilt and remorse ing of modes of thought in general as demon-
attaching to it, while morality was based partly strated by Bateson (1958) in his study of
on the exigencies of this society (fraternal society) dichotomous thinking and the reversal of
and partly on the penance demanded by the sense opposites in the Naven ritual of New Guinea.
of guilt (exogamy and attempts at atonement) Gardner, in his book on structuralism (1981),
(Freud, 1950, p. 141±146)
suggests that cognitive anthropologists like
Levi-Strauss may broaden and deepen cognitive
Although a pioneer in the application of psychology in the same way as have linguistics
ethnographic knowledge in the understanding and developmental psychology.
of the human soul, Sigmund Freud like James
Frazer relied solely on written sources and never
did any fieldwork himself. Those were the days
before professional anthropological fieldwork 1.08.4.5 Culture and Personality
brought the social life of distant cultures within The influence of anthropological fieldwork
the reach of the intellectual community. was greatly enhanced by the works of Mead
who started publishing her studies from the
1.08.4.4 The Impact of Anthropological South Seas in 1928. Her works influenced not
Fieldwork only her own field of anthropology, but also
psychology and above all public opinion. Her
The anthropologist who set the standard for books were widely read (Mead, 1935, 1949), and
anthropological fieldwork was Bronislaw Mal- she became a celebrity and a most respected
inowski. His works from the South Seas could anthropologist, although some of her conclu-
partly confirm and partly correct some of sions were met with some reserve. After her
Freud's assumptions. With regard to repression death a virulent criticism of her work and
of sexuality Malinowski could confirm Freud's methods has been raised by the Australian
opinion regarding its psychological costs (Mal- anthropologist Freeman (1983) who claimed
inowski, 1927, 1932). With regard to the that she had been misled by her informants and
universality of the oedipus complex, however, her claim that Samoan adolescence was rela-
Malinowski pointed out that among the tively free of conflict was wrong. After the
matrilineal Trobrianders in the South Seas, it professional discussion on her work had run its
was the mother's brother rather than the father course, the general agreement is that Freeman
who was the source of discipline in the life of a overstated his case, although some of his
small boy, and therefore the primary object of criticism had to be accepted.
childish aggression. When Freeman published his work, however,
Comparative research through modern the culture and personality school of thought
anthropological fieldwork not only demanded was already history. But Mead had left a lasting
a revision of Freud's theories. Also, ideas of so- impact both on American anthropology and
called primitive mentality, promoted above all public opinion.
by Levy-Bruhl (1923), which maintained that Her work grew out of the Columbia group
individuals in preliterate societies think in a under the leadership of Franz Boas. One of
manner not only quantitatively, but also Boas' main concerns was the rampant racism
qualitatively different from individuals from both in Europe and in the USA in the first
complex societies, had to be revised. Cognitive decades of the twentieth century. His main
anthropologists who have studied the system of assumption was that it is the culture not the
knowledge in preliterate societies with the genes which determine human behavior and
regard to the mastery of their environment, institutions.
have found rational systems which demonstrate The school of thought which emerged from
that no generalized primitivity of thought can be the group at Columbia University was focused
observed (Price-Williams, 1980). on the configurations of themes found in
Of particular interest in this connection are different cultures and their mode of thought
investigations of how people in complex was influenced by Gestalt psychology. The
Gestalt psychologists had pointed out that our wake of its strategic use first in World War II
perception is self-organizing and that patterns and later in the Cold War in the study of
emerge on the basis of certain principles like national character. The portraits painted by the
similarity and proximity. The insight of the scholars of the national character of an
Gestalt psychologists that wholes have proper- assortment of other nations were clearly
ties not found in the constituent parts of a influenced by political concerns and the geo-
pattern were applied to culture and reversed political mission of the USA. But even if the
the trend towards atomism in American problems of culture and personality are not in
anthropology. the focus at the present time, there is an
Distribution of traits, elements of customs, enduring interest in the relationship between the
material culture, or kinship were, at the individual person and his culture both in
beginning of the twentieth century, used to psychology and anthropology.
inform rather speculative evolutionary theories
and theories of cultural diffusion. The trait
investigations almost disrupted culture systems, 1.08.4.6 The Paradigm of Ethnic Identity
turning them into a hodgepodge of traits.
Benedict's Patterns of culture (1934) is the The problems formerly treated under the
most elegant articulation of the configuration headline of culture and personality are today
approach of the Columbia group which crystal- being addressed under the headline of ethnicity.
lized into the culture and personality episode in An ethnic group is normally considered to be a
American anthropology. This school of thought subgroup within a larger community or nation.
was strongly influenced by psychoanalysis It is of particular relevance in the USA where
which is obvious in the following words of many different cultures meet within the frame-
Benedict: ªTradition is as neurotic as any work of a judicially defined citizenship. The idea
patient, its overgrown fear of deviation from of the big melting pot gave way, particularly
its fortuitous standards conforms to all the during the 1960s, to a resurgence of interest in
usual definitions of the psychopathicº (p. 252). ethnic identity. Formerly subdued and some-
The Columbia group was also inspired by times harassed groups, who used to be ashamed
ideas of tolerance, the roots of which can be of their culture, changed their strategy and
traced to John Stuart Mill's ideas of freedom. demanded respect for their traditions and style
Through her books from her various field- of life. This was a worldwide phenomenon
works, Mead (1928, 1935, 1949) not only indicating a shift of paradigm in cultural
convinced the anthropological community, understanding. The Euro-American culture,
but people in general, that human beings in which held a hegemonic place in the cosmo-
different cultures are different, not because of politan scale of values as described by the Italian
any difference in their genetic make-up, but philosopher Gramsci was challenged by domi-
because the human personality is molded by nated ethnic groups of people all over the world:
culture into different configurations of basic The native American, the Scandinavian Lapps
human themes. In Sex and temperament in three or Saami, the Maoris of New Zealand joined
primitive societies (1935), Mead demonstrated forces in an ethnic uprising demanding respect
that ideas of masculinity and femininity are for their unique cultures.
determined by culture and not by nature, and This great movement of self-respect focuses
thus made a considerable effort to rid modern on identity and is related to nationalism as it
society of the yoke of traditional ideas of social developed in Europe in the nineteenth century
roles. Her influence was not merely scientific, with the emergence of new national languages
but also ideological. She published her major and new nations. A hegemonic culture like the
works in a period when parts of Europe were in German was challenged by a number of ethnic
the grips of a bigot and sinister racism with roots groups within the framework of the Austrian±
partly in misinformed and partly misread Hungarian Empire: the Czech, the Slovaks, the
anthropology and biology. Hungarians, and a mosaic of people in the
Through Mead, the didactic role of anthro- Balkans struggled to construct their own
pology came into focus. But this role is not national identity based primarily on shared
entirely unproblematic. When the center of the beliefs, shared language, and mythological
anthropological stage is given to great huma- origin. As Anderson (1983) has demonstrated,
nists like Mead, the cause of reason has little to the feeling of identity and togetherness on the
fear. But with the potential ideological impact basis of national ideas is based on an imagined
of anthropology in mind, it is essential that the community dependent upon modern media of
highest standard of method is observed when it communication.
comes to questions of values. The culture and Many of the ethnic groups in the USA derive
personality school suffered a set back in the from the various European nations who
brought their national identities with them Central and South American susto, soul loss,
across the ocean. For good reason, Barth's and the Chinese koro, the fear of the penis or the
work on ethnicity (1969) became the most labia withdrawing into the body, as anxiety
quoted anthropological text in the 1970s and states. The Southeast Asian amok, the symp-
1980s. toms of which are eruptive violence followed by
The psychological effect of identity problems amnesia and exhaustion is classified as a
has been explored by Erik Homburger Erikson dissociative state. He classifies these culture
and very sensitively described in Childhood and bound ailments as a subgroup of Western
society (1950). Although Erikson does not neurotic disorders. Yap (1969) on the other
present his description and analysis of the hand classifies culture bound disorders as
Sioux Indians of the Great Plains and other reactive psychoses.
groups under the label of ethnicity, he demon- The ethnocentric bias of Western psychiatry
strates how the Sioux identity, as it had is a challenge to anthropology as demonstrated
developed through history, was based on their by Marsella and White (1982) which hopefully
tradition of being mounted warriors and bison can be remedied through an open-minded
hunters. He shows in detail how their identity in exchange of ideas and rigorous cross-cultural
Sioux pedagogics is developed in intimate research.
articulation with the stages of development,
which he regards as pan-human, to establish an
ethnic self-confidence elegantly adapted to their 1.08.4.7 The Cross-cultural Correlational
ecological situation. But through military Approach
defeat, economic dependency, and other fea-
tures of reservation life, the self-confidence of A promising venture into cross-cultural
the Sioux has been broken. Some of their research is associated with another group of
psychological reactions are reminiscent of the scholars at Yale University: John Dollard,
old-prisoner-syndrome of concentration camps George Peter Murdock, and John Whiting.
with the characteristic Freudian identification Jointly they developed the cross-cultural corre-
with the aggressor. lational approach at Yale Institute of Human
The field of ethnicity is a particularly Relations. We have already taken advantage of
promising common ground for a collaboration Murdock's encyclopedic work on theories of
between anthropologists and clinical psycholo- illness. One of the most prominent studies in the
gists. The relevance of ethnic dimensions in cross-cultural correlation approach is that of
psychotherapy has been explored by Abel and Whiting and Child (1953). They criticized the
Metraux (1974). The blacks from Brazil, Africa, studies of national character and the config-
or the Caribbean represent different cultural urations school because of its lack of scientific
configurations and should not be confused with method and embarked upon an ambitious
the blacks in the USA. program of correlation studies. In his summary
The ethnic differences are not in principle of Whiting and Child, Bock (1988) selects the
different from the socioeconomic differences following statement of their method:
which have come to the attention of scholars of
the patients of Freud and Adler. As Ansbacher In the correlation testing method the supposed
(1959) points out, three-fourths of Freud's antecedent condition is looked for as it occurs or
patients were rich, while most of Adler's fails to occur in the natural course of events in a
patients were poor. For good reason Adler number of cases. Instances are collected of its
coined the term ªinferiority complexº and presence and its absence, or of its presence in
regarded the will to power as the dominant various degrees. The supposed consequent condi-
tion is also looked for in each of these cases and
theme of life, whereas Freud maintained that
determined to be present or absent in a given
the basic theme was ªeros.º The clinical picture degree. It is then possible to determine whether
of their clients was different and can only be there is a consistent relation between the two, and
understood if the relationship between culture thus whether the hypothesis is confirmed or
and personality is taken into account. negated. Statistical techniques may be applied
When cultural differences are of a greater and the evidence of connection may be based on
order than among not too distantly related objective procedures which are repeatable. (p. 108)
ethnic groups, investigators have recorded
culture bound disorders. Whether these are The hypotheses to be tested are derived from
specific to ethnocultural settings or variants psychoanalytic theory. Two kinds of customs
of disorders found under different schemes of were to be tested: childtraining practices and
classification in the West is not clear. Kiev beliefs concerning the causes of illness. Whiting
(1972) has tried to show the parallels in the and Child identified five so-called systems of
Western diagnostic system and classify the behavior based on the Freudian theories of
Social Systems and the Individual 257
child development: oral, anal, sexual, depen- Their capacity for mutual understanding is ac-
dence, and aggression. The children are as- companied by a remarkable consensus about rules
sumed to develop socialization anxiety in each of pronunciation and grammar such that linguists
of these systems depending on the degree of can discover the rules prevailing in the whole
community not from an extensive survey, but from
frustration or indulgence they experience. High
a small number of informants. This redundancy of
oral indulgence is noted when a child is nursed rules in a speech community is theoretically
whenever it pleases. Severe weaning customs significant in illustrating how language functions
will cause ªoral socialization anxiety,º and the as social communication, it is methodologically
hypothesis assumes that high oral anxiety will significant in permitting a mode of systematic
produce theories of illness based on oral inquiry distinct from the sample survey. (LeVine,
behavior: you are sick because of something 1984, p. 68)
you said or ate. This hypothesis is mentioned
because it produced the most convincing corre-
lation in the whole study. 1.08.5 SOCIAL SYSTEMS AND THE
Whiting and Child (1953) also explored the INDIVIDUAL
problem of male initiations which in many 1.08.5.1 The Dominant Kinship Dyad
societies are extravagantly painful with scar-
ification, circumcision, whipping, and hazing. The individual tends to be somewhat distant
They assumed that the cruelty of the initiators in the analysis of social systems. A set of
(i.e., the fathers), had something to do with the hypotheses with regard to the dominant kinship
sleeping arrangements in the homes and the dyad was presented by Hsu (1965). In Hsu's
postpartum sex taboos. They made the assump- work the individual does not take center stage,
tion that in societies where mother and infant but his approach is in tune with the analysis of
share the same quarters for an extended period the social process which was to change the
of time and at the same time the postpartum course of anthropology in the late 1950s and
taboo prevented the father from having sex with 1960s. According to Hsu's hypothesis, human
the mother for more than one year, cruel societies everywhere give priority to one kinship
initiation ceremonies were to be expected. dyad from the core dyad of procreation and the
Correlation analysis confirmed the hypothesis. intrinsic qualities of this relationship are
We recognize the Freudian touch of the assumed to influence several cultural para-
hypothesis in the element of rationalization in meters. From the core dyad of mother and
the staging of the ritual where the fathers under father other essential dyads can be traced:
false, but unconscious excuses, seize the occa- father±son, mother±daughter, brother±brother,
sion to give their aggression and even sadism a and so on.
free rein in the good name of pedagogics. Each dyad had intrinsic qualities. The
This Freudian insight is one of the best allies mother±father or husband±wife dyad have the
in the protracted struggle to reduce the suffering following intrinsic qualities: discontinuity,
and abuse in human life because it rips the mask equality, sexuality. The father±son dyad has
off moralists who exploit occasions to indulge the quality of continuity because a son becomes
their cruelty in the name of saintliness. The a father himself and through the links between
problem with psychoanalytic insight, however, father and son a lineage can be traced.
is that it is hard to prove by acceptable and Authority is intrinsic because of the differences
rigorous scientific methods. It is to the great in age and command of resources. Even in
merit of Whiting and Child that they brought egalitarian societies, where the fathers try to be
their Freudian hypothesis to an irrefutable test. buddies with their sons, authority cannot be
Although Whiting and Child have been denied, only under-communicated. In other
criticized for, among other things, overlooking words, the oedipal situation cannot be avoided.
the dramatization of male solidarity in puberty There is hardly an element of sexuality in the
rituals, the correlation method still holds relationship. The husband±wife dyad on the
promise although it no longer occupies center other hand is discontinous, one marriage does
stage as in the 1950s. One of the reasons is the not beget another, there are no lineages of
great cost of statistical investigation of such a marriages. The relationship is contractual even
scale. To this can be added the new look on if it lasts a lifetime, but it always comes to an
culture which tends to regard the approach of end. Since an intimate relationship cannot be
Whiting and Child, focusing on traits, as old- sustained if the authority dimension dominates,
fashioned. the relationship is intrinsically egalitarian. Its
Culture is a symbolic system which is similar very raison d'eÃtre is sexual.
to a language and calls for its own methodology According to Hsu's hypothesis, cultures
as pointed out by LeVine. In his words of a always give priority to one of the possible
speech community: dyads, and the intrinsic qualities of the dyad
which becomes dominant will be reflected in the life (1959), Goffman analysed the strategies of
cultural system. Societies where the father±son personal behavior with the theater as a
dyad is dominant will respect traditions and metaphor. He demonstrated how human beings
authority and sexual matters will not be played their roles, not in the make-believe way of
culturally dominant. If on the other hand the the stage, but with the same objective: to impress
husband±wife dyad dominates, respect for the audience. His thick description of ªimpres-
traditions will be less and authority will be sion managementº codified in language pro-
under-communicated if not resented. Sexual cesses which formerly were not part of conscious
matters will be culturally dominant. discourse. He described how social reality is
The effects of the father±son dyad have been created through role-play, how a select part of a
more or less thoroughly explored by Hsu (1971) person's role repertory is sustained in a situation
and the evidence is in favor of the hypothesis. In through strategic interaction. Life after all is
Arab and traditional Chinese culture, the composed of situations, most of them trivial.
father±son dyad is unquestionably dominant Goffman made the situation the main object of
and the respect for tradition and authority is his study and demonstrated how social reality is
obvious. Likewise sexuality is not a prominent created on the spot and thus may be regarded as
theme in the public sphere of literature, media, a kind of illusion. After Goffman it is no longer
and discourse. In the USA on the other hand, possible to regard culture as a thing, it is a
the husband±wife dyad is clearly dominant. process sustained by strategic interaction. The
Although the respect for the constitution is insights of Goffman connect with psycho-
unquestionable, the image of North Americans analysis on the inner stage of consciousness.
as progressives and egalitarian is not un- Human beings also venture to impress them-
founded. The question of sexuality is a selves, the ego is an actor who creates the person
dominant theme both in the private and the from the raw material of basic drives.
public sphere. In his study of psychiatric hospitals we recall
Hsu's hypothesis is not uncontroversial. This, the observation of Pinel during the French
however, is the fate of culture theories generally. Revolution when he pointed out that the
So far other dominant dyads, like, for example, behavior of ªlunaticsº had something to do
mother±daughter, have not been explored. with the way they were treated (Foucault,
1965). Goffman demonstrated that many of the
symptoms recorded by psychiatrists were
1.08.5.2 The Iatrogenic Approach samples of strategic interaction. One of the
strategies is situational withdrawal. A perfectly
In the Durkheimian tradition of anthropol- comprehensive reaction to an impossible situa-
ogy and sociology, the systems have dominated tion is codified by the psychiatrists as regres-
at the cost of the individual in the English sion. Goffman opened up the Pandora's box of
speaking world in the first part of the twentieth iatrogenic symptoms, symptoms created by
century. The person has more or less been the medical profession. His insight is valid
regarded as a puppet in the strings of the social beyond the psychiatric hospital, it applies to
system. In the 1950s, however, the works of Max total institutions everywhere and he raised a
Weber reached the centers of anthropological problem which remains to be explored in depth:
discourse and the person as an actor entered the how psychological disorders may be imposed
stage. on the individual by society and by the medical
At the London School of Economics, Leach and psychological professions. If these profes-
radically changed the systemic approach which sions decide that a condition is pathological,
until then had dominated British social anthro- it becomes a social reality, and a psychiatric
pology. In his analysis of political systems disorder is magically established. This is some-
(Leach, 1954), he demonstrated how human times an overlooked part of the construction
beings as decision-makers interacted with the of social reality. Anthropology may through
social system. That changed the image of small- the insights of how social systems and in-
scaled societies as timeless depositories of stitutions mold the individual, and the person as
unchangeable traditions. This image had been a category, and vice versa, cut some of the
created from lack of information. Professional strings which bind the individual to social
field descriptions before 1950 were more or less systems.
snapshots freezing moments in time.
At the University of Chicago, Erving Goff-
man demonstrated how the anthropological 1.08.6 REFERENCES
method of participant observation could be Abel, T. M., & Metraux, R. (1974). Culture and
applied to cultures beyond the small-scaled psychotherapy. New Haven, CT: College and University
societies. In The presentation of self in everyday Press.
References 259
Anderson, B. (1983). Imagined communities. Reflections medicine: A symposium. Berkeley, CA: University of
on the origin and spread of nationalism. London: California Press.
Verso. Goffman, E. (1959). The presentation of self in everyday life.
Ansbacher, H. L. (1959). The significance of the socio- New York: Doubleday.
economic status of the patients of Freud and Adler. Goffman, E. (1961). Asylums: Essays on the social situation
American Journal of Psychotherapy, 13, 376±382. of mental patients and other inmates. New York:
Barth, F. (Ed.) (1969). Ethnic groups and boundaries: The Doubleday.
social organization of cultural difference. London: Allen Hsu, F. L. K. (1965). The effect of dominant kinship
and Unwin. relationship and non-kin behavior. American Anthropol-
Barth, F. (1975). Ritual and knowledge among the Bakta- ogist, 67, 638±661.
man of New Guinea. Oslo, Norway: Universitetsforlaget/ Hsu, F. L. K. (1971). A Hypothesis on kinship and culture.
Yale University Press. In F. L. K. Hsu (Ed.), Kinship and culture (pp. 3±30).
Basham, A. L. (1976). The Practice of Medicine in Ancient Chicago: Aldine.
and Medieval India. In C. Leslie (Ed.), Asian medical James, W. (1914). The varieties of religious experience: A
systems: A comparative study. Berkeley, CA: University study in human nature. New York: Longmans, Green.
of California Press. (Original work published 1902).
Bateson, G. (1958). Naven (2nd ed.). Stanford, CA: Kahneman, D., Slovic, P., & Tversky, A. (Eds.) (1982).
Stanford University Press. Judgement under uncertainty: Heuristics and biases.
Benedict, R. (1934). Patterns of culture. New York: Cambridge, MA: Cambridge University Press
Houghton Mifflin. Kiev, A. (1972). Transcultural psychiatry. New York: Free
Benedict, R. (1974). The chrysanthemum and the sword. Press.
Patterns of Japanese culture. New York: New American Kretschmer, E. (1925). Physique and character: An
Library. investigation of the nature of constitution and of the
Berger, P., & Luckman, T. (1969). The social construction theory of temperament. London: Paul, Trench, &
of reality: A treatise in the sociology of knowledge. Trubner.
Harmondsworth, UK: Penguin. Leach, E. R. (1954). Political systems of Highland Burma.
Bock, P. K. (1988). Rethinking psychological anthropology. New York: Humanities Press.
Continuity and change in the study of human action. New LeVine, R. (1984). Properties of culture: An ethnographic
York: Freeman. view. In R. A. LeVine & R. A. Shweder (Eds.), Culture
Brogger, J. (1971). Montevarese: A study of peasant society theory. Essays on mind, self, and emotion. Cambridge,
and culture in southern Italy. Bergen, Norway: Universi- MA: Cambridge University Press.
tetsforlaget. Levy-Bruhl, L. (1923). Primitive mentality. London: Allen
Brogger, J. (1986). Belief and experience among the Sidamo. & Unwin.
A case study towards an anthropology of knowledge. Oslo, Lewis, I. M. (1971). Ecstatic religion: An anthropological
Norway: Norwegian University Press. study of spirit possession and Shamanism. Harmonds-
Brogger, J. (1992). Nazare. Women and men in a prebureu- worth, UK: Penguin.
cratic Portuguese fishing village. Orlando, FL: Harcourt Lopez-Austin, A. (1974). Sahagun's work and the medicine
Brace Jovanovich. of the ancient Nahuas: Possibilities for study. In M. S.
BuÈrgel, J. C. (1976). Secular and religious features of Edmonson (Ed.), In sixteenth century Mexico: The work
Medieval Arabic medicine. In C. Leslie (Ed.), Asian of Sahagun. Albuquerque, NM: University of New
medical systems: A comparative study. Berkeley, CA: Mexico Press.
University of California Press. Malinowski, B. (1927). Sex and repression in savage society.
Chadwick, J., & Mann, W. N. (Trans. and Eds.) (1950). New York: Harcourt Brace.
The medical works of Hippocrates: A new translation from Malinowski, B. (1932). The sexual life of savages in
the original Greek made especially for English readers. northwestern Melanesia. London: Routledge & Kegan
Oxford, UK: Blackwell. Paul.
Douglas, M. (1966). Purity and danger. London: Routledge Marsella, A. J., & White, G. (Eds.) (1982). Cultural
& Kegan Paul. conceptions of mental health and therapy. Boston:
DuBois, C. (1944). The people of Alor: A social-psycholo- Reidel.
gical study of an east Indian island (Vol. 1). New York: Mead, M. (1928). Coming of age in Samoa. New York:
Harper Torchbooks. Morrow.
Emerson, V. F. (1972). Can belief systems influence Mead, M. (1935). Sex and temperament in three primitive
neurophysiology? Some implications of research on societies. New York: Morrow.
meditation. Newsletter Review, 5. Mead, M. (1949). Male and female: A study of the sexes in a
Erikson, H. E. (1950). Childhood and society. New York: changing world. New York: Morrow.
Norton. Murdock. G. P. (1980). Theories of illness, A world survey.
Evans-Pritchard, E. E. (1937). Witchcraft, oracles and Pittsburgh, PA: University of Pittsburgh Press.
magic among the Azande. Oxford, UK: Clarendon Press. Nietzsche, F. (1935). Beyond good and evil Chicago:
Foster G. M., & Anderson, B. G. (1978). Medical Regenery (German ed. 1887).
Anthropology. New York: Wiley. Pickard, M. E. & Buley, R. C. (1945). The midwest pioneer:
Foucault, M. (1965). Madness and civilization: A history of His ills, cures, and doctors. Crawfordsville, IN: Banta.
insanity in the age of reason. New York: Pantheon. Porkert, M. (1976). The intellectual and social impulses
Freeman, D. (1983). Margaret Mead and Samoa: The behind the evolution of traditional Chinese medicine.
making and unmaking of an anthropological myth. Cam- In C. Leslie (Ed.), Asian medical systems: A comparative
bridge, MA: Harvard University Press. study. Berkeley, CA. University of California Press.
Freud, S. (1950). Totem and taboo. New York: Norton. Price-Williams, D. R. (1980). Anthropological approaches
(First German ed. 1913). to cognition and their relevance to psychology. In H. C.
Gardner, H. (1981). The quest for the mind: Piaget, Levi- Triandis & W. Lonner (Eds.), Handbook of cross-cultural
Strauss, and the structuralist movement. Chicago: Uni- psychology, Vol 3: Basic processes. Boston: Allyn &
versity of Chicago Press. Bacon.
Gebhard, B. (1976). The interrelationship of scientific Rosenhan, D. L., & Seligman, M. E. P. (1995). Abnormal
and folk medicine in the United States of America psychology. (3rd ed.). New York: Norton.
since 1850. In W. D. Hand (Ed.), American folk Sheldon, W. H., & Stevens, S. S. (1942). The varieties of
human temperament: A psychology of constitional differ- M. Marwick (Ed.), Witchcraft and society. Harmonds-
ences. New York: Harper. worth, UK: Penguin.
Shweder, R. A., & LeVine, R. A. (Eds.) (1984). Culture Ullmann, M. (1970). Die medizin in Islam. Handbuch der
theory. Essays on mind self, and emotion. Cambridge, Orientalistik. Erste Abteilung, ErgaÈzungsband VI, Erster
MA: Cambridge University Press. Abschnitt. Leiden, The Netherlands: Bill.
Snow, L. F. (1973). I was borne just exactly with the gift: Veith, I. (1972). The yellow emperor's classic of internal
An interview with a Voodoo practitioner. Journal of medicine. Berkeley, CA: University of Callifornia Press.
American Folklore, 86, 272±281. Walsh, R. N., & Vaughan, F. E. (Eds.) (1980). Beyond ego:
Stigler, J. W., Shweder, R. A., & Herdt, G. (Eds.) (1990). Transpersonal dimensions in psychology. Los Angeles:
Cultural psychology. Essays on comparative human Tarcher.
development. Cambridge, UK: Cambridge University Whiting, J. W. M., & Child, I. L. (1953). Child training and
Press. personality: A cross-cultural study. New Haven, CT: Yale
Strathern, A. (1995). Trance and the theory of healing. University Press.
Sociogenic and psychogenic components of conscious- Yap, P. M. (1969). The culture-bound reactive syndrome.
ness. In A. P. Cohen & N. Rappaport (Eds.), Questions In W. Candill & T. Lin (Eds.), Mental health research in
of consciousness. London: Routledge. Asia and the Pacific. Honolulu, HI: University Press of
Trevor-Roper, H. R. (1970). The European witch-craze. In Hawaii.
1.09
Life-span Developmental
Theories
GISELA LABOUVIE-VIEF
Wayne State University, Detroit, MI, USA
and
MANFRED DIEHL
Colorado State University, Colorado Springs, CO, USA

1.09.2 ISSUES IN LIFE-SPAN DEVELOPMENT 263
1.09.2.1 The Postmodern Turn 263
1.09.2.2 Development in the Postmodern Era 263
1.09.2.2.1 The ªend pointº of development 263
1.09.2.2.2 The role of context 264
1.09.2.2.3 Individualism vs. relatedness 264
1.09.2.2.4 Coherence of the individual 265
1.09.2.2.5 Modes of thought 265
1.09.2.2.6 Growth vs. decline 265
1.09.2.2.7 Stability vs. plasticity 266
1.09.3 COGNITIVE DEVELOPMENT 266
1.09.3.1 Psychometric Intelligence 266
1.09.3.1.1 Differential decline 267
1.09.3.1.2 The role of context 267
1.09.3.1.3 Plasticity of intelligence 269
1.09.3.2 Everyday Intelligence 270
1.09.3.3 Cognitive-developmental Theories 271
1.09.3.3.1 Piaget's legacy 271
1.09.3.3.2 Mature reasoning structures 272
1.09.3.3.3 Cognitive development and the self 273
1.09.3.3.4 Emotional development 275
1.09.3.3.5 Wisdom 277
1.09.4 PERSONALITY DEVELOPMENT 277
1.09.4.1 Developmental Level Approaches 279
1.09.4.1.1 Freud's legacy 279
1.09.4.1.2 Beyond the ego 279
1.09.4.1.3 Ego and culture 280
1.09.4.1.4 The duality of the self 281
1.09.4.2 The Trait Approach 282
1.09.4.2.1 Traits as dimensions of stability 282
1.09.4.2.2 Context as moderator of stability 284
1.09.4.3 Empirical Research on Self and Personality 284
1.09.4.3.1 Stability and change 284
1.09.4.3.2 Midlife crisis 285
261
262 Life-span Developmental Theories
1.09.5 CONTEXT IN PERSONALITY DEVELOPMENT 286

1.09.5.1 Gender, Coping, and Personality 289
1.09.1 INTRODUCTION individuals into stable adult roles defined by

cultures that were relatively homogeneous.
In her book Culture and commitment, Mar- Thus many theories described adulthood in
garet Mead (1970) proposed that modern life terms of stability, while childhood was de-
has profoundly changed our experience of the scribed in terms of change and transformation
life course. In relatively simple societies, Mead (e.g., Baltes, 1987; Baltes, Lindenberger, &
suggests, the life structure for individuals was Staudinger, 1998; Labouvie-Vief & Chandler,
clear and predictable. Children could look at the 1978). However, contemporary life highlights
lives of their grandparents, and take those lives change and transformation along the adult
as models for their own future. In such a society, portion of the life-span as well. As a result, there
ªchange is so slow and imperceptible that has been a wide-ranging re-evaluation of what
grandparents, holding newborn grandchildren constitutes ªmaturity,º as well as the pathways
in their arms, cannot conceive of any other by which maturity is reached. In fact, this new
future for the children than their own past lives. emphasis on continued growth in adulthood
The past of the adults is the future of each new could be referred to as the ªbirth of adulthood,º
generation: their lives provide the ground planº borrowing from Philippe Aries' (1962) famous
(pp. 13±14), a plan often believed to be statement that earlier historical periods brought
supported by divine and mythic processes a similar ªbirth of childhoodº as a distinct
(Labouvie-Vief, 1994). developmental period.
In contrast, suggests Mead, contemporary A second consequence of historical changes
society involves profound differences in how the has been that many cultures no longer are based
life course is experienced. An example of such a on groups of individuals homogeneous in racial
society is the USA during and after the and ethnic features, but rather represent a
beginning of the Industrial Revolution, when ªmelting potº of groups characterized by
streams of immigrants sought new opportu- diversity (see Cavanaugh, 1997). This focus
nities on this continent. Parents no longer were on diversity also has affected the way we view
the experts in how to live, and children were as adulthood. While in the past, adulthood often
likely to learn from their peers as their parents. was defined by a single outcome (such as a
Thus, the past no longer was a guide to the strong ego or abstract reasoning), now we are
future, but rather the future became shaped by realizing that outcomes can vary widely depend-
the present. Learning and developing are no ing upon the context in which individuals grow
longer so one-sided, but elders are likely to learn up. Thus, not only has development been
from the young, just as the young learn from the extended into adulthood, but the pathways of
old. development also have taken on more diversity.
Along with Mead, many authors (e.g., This ªmultilinearityº (Baltes, 1987; Fisher &
Hareven, 1978) have suggested that social Biddell, 1992; Labouvie-Vief & Chandler, 1978)
changes such as the Industrial Revolution and is another feature important in recent writings
the information revolution have altered the way about the life-span.
we experience life. No longer do we live in Finally, all of these historical changes also
communities or countries that are relatively have had profound implications for the ways in
isolated, and homogeneous, but we are becom- which we look at the process of aging. Since
ing citizens of a global community constituted aging often is defined relative to some theore-
by individuals from diverse cultural, ethnic, and tical apex of optimal functioning, redefining
racial backgrounds. Further, technological that apex has direct implications for views of
changes have produced increases in the life- aging. Often defined as a regressive deviation
span as a result of the elimination of early from some youthful standard of optimal
mortality. This ªgreyingº of the population has functioning (e.g., Labouvie-Vief, 1985), aging
dramatically increased the number of vital is now understood as a period that has its own
individuals of advanced age. developmental challenges and opportunities,
All of these unprecedented historical changes and that needs to be understood within the
have changed the way we look at development context of the total life course (see Erikson,
through life. This is true in several basic ways. 1982; Labouvie-Vief, 1980; Staudinger, Mar-
First, in the past, emphasis was on socializing siske, & Baltes, 1995).
Issues in Life-span Development 263
In this chapter, we highlight these recent re- features of reason were understood as its
evaluations in theoretical outlook. First, we will independence of the senses, the emotions, and
briefly highlight some of the general theoretical other organismic processes. Reason was
changes that have shaped current views of thought to transcend variations in context
development in general, and of life-span devel- and to refer to abstract and conscious decision-
opment and aging in particular. Second, we will making capacities located inside the individual
turn to a summary of how these changes are mind or brain. It described our mental natures
expressed in the evolution about thinking about rather than our participation in a bodily,
intellectual functioning, while in the following material universe, and it referred to an active
section we will discuss similar changes in the ªgraspingº rather than a receptivity. In short,
domain of self and personality. We will discuss what was emphasized was reason's objective
several theoretical movements that represent nature as opposed to its subjectivity.
blends of these areas that have traditionally The rationalist model has stood as an ideal of
been isolated. maturity throughout the ages, and has served as
the basis for the most important early theories of
development, including those of Freud and
1.09.2 ISSUES IN LIFE-SPAN Piaget (Labouvie-Vief, 1994). However, as the
DEVELOPMENT twentieth century began to witness broad global
Although the main concern in this chapter is transformations in the nature of health, in-
with psychological theories of life-span changes, formation, and communityÐthe kind of
it is useful to place these theories within a changes, indeed, that Mead refers toÐ
broader context of intellectual±historical dissatisfaction with the old models of mind
changes. Concepts of human nature and the and development has arisen in many disciplines.
meaning of mature adaptive competence are As this faith in the power of logos is being
embedded into broad historical patterns that cut criticized, many contemporary views of the
across many disciplines, from philosophy mind have begun to return to the dimensions of
through literature to art and religion. All of mind and self that were abandoned by the
these domains have seen pervasive changes in classical view. Emotion and intuition, time and
how the ideal human is defined, for example, process, variability and the role of context, all of
what blend of reason or faith, emotion and these elements that previously were devalued
intuition, of independence or interdependence, have come to the forefront in discussions. This
of ªmasculinityº or ªfemininity,º and of similar contemporary confrontation with the other side
polarities should characterize that ideal indivi- of rationality is often referred to as ªpostmo-
dual that crowns our theories of development, dernº attitude (Gergen, 1991; Lyotard, 1987).
and what standards, as a result, should guide The postmodern attitude asks that we transform
how to measure the resulting characteristics. In the dogma of the inseparability of reason from
this section, we will outline some of these other, traditionally less valued functions of
changes. In doing so, we will highlight their thought. Thus, a new view is emerging that holds
pervasive and general nature and merely that reason has inherent elements that are
anticipate the themes they set for future located in the domain traditionally relegated
psychological questions. to the subjective: of the discourses unique to a
culture, of conventions that have ritualized what
1.09.2.1 The Postmodern Turn we imagine of the rhetorical and practical, of the
mythic and symbolic, and of the organic and
If one were to name a single characterization emotional (see Labouvie-Vief, 1994).
that Western intellectual tradition has held up
as applying to the kind of ideal individual we 1.09.2.2 Development in the Postmodern Era
envision when we think of advanced levels of
development, probably it would be that of As far as psychological conceptions of
rational thought and conduct. Yet, while the individuals and their development are con-
basic definition of the nature of rationality has cerned, the postmodern revolution has had
remained more or less constant for many several effects on conceptions of the life course.
centuries, the last hundred years or so have
witnessed a wide-ranging transformation of the
1.09.2.2.1 The ªend pointº of development
concepts of ªreasonº and ªrationality.º Many
disciplines (from philosophy, mathematics, and A first profound change has been in the
physics to art, literature, and religion) have nature of what we call mature, ideal function-
participated in criticizing and deconstructing ing. In traditional theories, such as those of
the traditional concept of reason. Following Freud (e.g., 1925/1963) and Piaget (e.g.,
Plato (see Labouvie-Vief, 1994), the essential Inhelder & Piaget, 1975), the end point of
development usually coincides with early ado- way (see Labouvie-Vief, 1994, for discussion).
lescence and the achievement of sexual and Instead, many thinkers began to propose that
physical maturity. Along with this early apex, truth (at least as far as it concerns relatively
theories stressed such attributes as self-control complex states of affairs) is not a static and
and the ability to adopt cultural roles. However, universal thing, but that it is best understood as
in more recent theories, the notions of biological a dynamic process, something that evolves, that
and psychologic maturity or generativity have is being constructed, and that is being con-
been specifically decoupled; hence concepts of tinually redefined. Truth has, therefore, an
maturity, following Mead's (1970) suggestion, explicit historical and developmental perspec-
extend beyond the faithful, stability-guarantee- tive, and is moved out of the realm of axioms
ing adherence to societal norms and emphasize and ideals into the very context of human
continued capacity for critique, openness, and practice (see Labouvie-Vief, 1994).
transformation of individuals and society. As These contextualist assumptions have mod-
Jung (1933) stated, the emphasis becomes less ified recent theoretical attitudes regarding
on socialization and more on individuation. In psychological development and aging, as well
general, we value the individual's attempts at as the fulcrum that is to balance the two, namely
meaning making, while valuing less the pro- maturity. Early theories tended to adopt either
pensity to adopt the meanings that are given by of two dualistic views: organicism (see Reese &
conventional social roles and settings. Overton, 1970), with its emphasis on transcul-
A good example of this new emphasis is given tural and transhistoric processes, or mechanism
by Baumeister's (1986) discussions on the with views that focus on environmental con-
nature of the self. In medieval times, there tingencies that shape behavioral repertories. In
was little emphasis on inner self and its contrast, many current views combine assump-
struggles. For example, there was almost no tions of these two models. They assume that, on
autobiographical writing. Interest in portraying the one hand, sequential and fairly pervasive
life stories rather was in exemplary and ideal life, processes of growth and decline are a part of
as in the stories surrounding saints. Similarly, in life-span changes; yet on the other hand, these
painting, the focus was not on the portraits of changes are modified by historical or cultural
ordinary individuals. Rather, the emphasis was contexts, as well as by specific individual
on biblical and religious topics and images, experiences. Indeed, a widely held view in the
which were depicted in a very formal and late 1990s is that basic developmental pathways
idealized way, such as icons. Nor did the may be shared by many groups of individuals;
individual author or artist matter: for example, yet at the same time, the specific up- and
early medieval icons or manuscripts were not downturns or even the specific directions such
signed; the role of artists was not to impress their pathways may take for any one individual, are
own individuality on the work, but rather to based on the experiences they encounter along
provide a faithful copy of an original. In the the journey of their development. Thus from a
sixteenth century, in contrast, a focus on the core pattern, one may envision different path-
inner self emerged. The notion became popular ways that partially divide in fan-shaped fashion
that the ªself º is a hidden, inner space that is (see Baltes, 1987; Bronfenbrenner, 1979).
different from one's outer appearance, and
writers and artists' now attempted to character-
1.09.2.2.3 Individualism vs. relatedness
ize this new inner self.
With the rediscovery of context also came the
realization that the mind is not just an
1.09.2.2.2 The role of context
intrapersonal entity of separate selves.
One of the consequences of the new model of Although awareness of self and mind as
persons was the vindication of the role of relatively separate is essential for functioning
context (see Labouvie-Vief & Chandler, 1978). in a complex society (see Elias, 1982; Labouvie-
Thus, rather than thinking of individuals as Vief, 1994), it is also true that all individual
mere replications of the same universal law, minds or selves participate in the interrelation-
individuality and the contextual features that ships that constitute a collective. Thus, classical
give shape to it became significant as essential models of mind and self have idealized the
features of developmental theories. A new individual in terms of such characteristics and
theoretical emphasis on context was influenced values as individuality, autonomy, indepen-
by trends early in the twentieth century, when dence, achievement motivation, and identity; in
there was a flurry of philosophical and scientific contrast, such values as relatedness, compas-
writings that dealt a profound blow to the sion, and dependence were seen as less im-
notion that what is right and true could forever portant and indeed as less mature (see Bakan,
be defined in an objective, universal, timeless 1966; Gilligan, 1982; Guisinger & Blatt, 1994).
Issues in Life-span Development 265
In contrast, many theories have begun to development, while emotions, intuition, and
account for the profound ways in which humans symbolic thinking were identified with regres-
are interrelated (e.g., Bowlby, 1969, 1988; sive trends. In actuality, however, rational views
Erikson, 1982). Indeed, such interrelatedness of development are usually undergirded by a
must constitute a basic, biologically based consistent language of images and symbols. For
propensity in a species that is neotenous and example, we typically think of rational func-
has a long period of extrauterine development. tions as masculine while those related to the
Failure to be in relation to others, in turn, is emotions are stereotyped as feminine. Similarly,
associated not only with a host of psychological we tend to associate the rational with light, airy
disorders, but also biological disorders such as heights, and golden hues, while associating the
depressed immunocompetence (Bakan, 1966; nonrational with darkness, earthy and watery
Weiss, 1987). As a consequence, a number of depths, and silvery or even black shades. Such
more recent models of development have symbolism is pervasive in art, literature, and
emphasized the need for a balance between religion, but it also permeates the theoretical
autonomy and dependence of relatedness as discourse about development. Thus an emer-
attributes of mature adults (e.g., Erikson, 1982; ging way to think about the mind is to propose
Gilligan, 1982; Guisinger & Blatt, 1994; Kohut, the parallel development of two functions.
1977). Accordingly, many theorists (e.g., Bruner,
1986; Epstein, 1990; Labouvie-Vief, 1994)
now suggest that more narrative, organismic,
1.09.2.2.4 Coherence of the individual
and experiential modes of thinking form modes
The roles of context and relation also have of thought that can develop in parallel to
supported how we look at the single individual, rational thought; these modes, then, can show
not just the individual in relationship to other progressive features and occur even at very
individuals. An assumption often made in the advances levels of complexity.
pastÐin fact explicit in Plato's theory of
mindÐwas that characteristics emanate from
1.09.2.2.6 Growth vs. decline
some inner structures such as an ego or some
other central processor that gives coherence and A further shift that has occurred in our views
unity to self and experience. However, many of human nature is a deconstruction of the
recent theories also emphasize that different, notion of perfection that was basic to past views
and sometimes vastly contradictory, experi- of rationality. As Gergen (1991; see also
ences and attributes may be activated by Sampson, 1977) suggested, the traditional view
different contexts or relationships. Thus in- was that rationality assured progress and
dividuals are no longer seen as having a single success, that it ultimately had as its goal
coherent mind, self, or personality, but are seen perfection. This belief in the perfectibility of
to combine in themselves contradictions and human nature also has guided many past
conflicts in ways that define the unique theories of development. For example, in
individuality of a person. Thus concepts of Piaget's theory, development reaches its apex
the mind or self are becoming more ªmodular,º as individuals understand logical laws; thereby,
with specific modules activated in different Piaget believed, ideas of necessity and perfec-
contexts and relationships (e.g., Ashmore & tion could come to guide behavioral regulation.
Ogilvie, 1992). This ªpsychology of moreº has posed a
conceptual problem for researchers in the field
of adulthood: if youth is construed as perfec-
1.09.2.2.5 Modes of thought
tion, it is difficult to reconcile the notion of
Another aspect of the mind that been adulthood growth with some of the obvious
deconstructed is the notion that the mind can declines that are a part of adult life. Yet, as
be described by a single mode of thinking. suggested by Labouvie-Vief (1980, 1981, 1982a,
Traditional theories of development have 1982b; see also Baltes et al., 1998), losses are not
placed primary emphasis on rational thinking unique to later life. Indeed, the whole process of
and conscious decision-making. In turn, such development is interwoven with losses, and
functions of thought as are expressed in artistic, often gains in development are related to losses
literary, or religious activities were considered in a direct gain±loss relationship. Thus often
to form a less valued aspect. Indeed, they were what is called decline or regressions can result
considered to be less mature or more childlike from the operation of developmental processes
(see the discussions on Piaget and Freud below). that are usually related to progressive develop-
Labouvie-Vief (1994) recently has addressed ment, or growth.
this issue. In her view, rationality primarily has Several principles demonstrate this trade-off
been associated with progressive trends in between growth and decline. For example, as
development proceeds, old structures often advanced development. Where original con-
become displaced or function with less effi- cepts often emphasized a tightly regulated
ciency. Thus it is well demonstrated in the developmental course that primarily reflected
child development literature (for review, see biological regulation, that was culturally and
Labouvie-Vief & Schell, 1982) that as indivi- historically universal, and that had as its goal a
duals move on to more complex levels that are coherent and conscious individual, in the late
based on more abstract rules and principles, 1990s views are highlighting characteristics that
lower-order performance actually becomes less appear more appropriate to an older and
efficient. Another principle is that of selective worldwide community.
depletion, a principle widely important in
evolutionary processes. Much as evolution is
based on an oversupply of organisms out of 1.09.3 COGNITIVE DEVELOPMENT
which only the ªfittestº are selected, so a similar
It is proper to start a discussion of theories of
mechanism operates in developing systems. For
life-span development with a review of cognitive
example, the progressive maturation of the
development. As already stated, early theore-
brain during the first stages of life actually
tical views of development were very much
involves profound losses as well. Originally,
influenced by a prevalent rationalism, and
neurons are supplied in abundance, but as
academic psychology definitely saw as its
workable networks are established, many
primary task to expand on and refine early
neurons are ªweeded outº through a process
notions of the rational person, which stood as a
of selective death. Finally, development typi-
prototype of successful, adaptive development.
cally involves increasing degrees of specializa-
In fact, as Riegel (1976) noted, until the middle
tion, or the trading off of potential for realized
of the century, most life-span discussions
structure. Thus, smooth functioning at the
centered around issues of cognitive develop-
system or collective level can be traded off for
ment which virtually dominated the literature.
specialization at the individual level.
Following historical trends, we begin this
In Labouvie-Vief's work, these trade-off
section with psychometric research on intelli-
processes are proactive and progressive. In
gence, which served as a sample case in which
addition, Baltes (1987) has added to these
many questions about life-span development
progressive trade-off processes reactive ones
were raised for the first time. Thus, psycho-
that may reflect processes of aging proper. Thus,
metric research on intellectual functions formed
as in the process of growing older, psychological
the arena in which questions about life course
and social resources decline, individuals actu-
development were raised and methodologically
ally may evolve highly adaptive and resilient
elaborated. This section is followed by discuss-
compensatory strategies. In addition, indivi-
ing the more recent influence of cognitive-
duals who experience a loss of capacity may
developmental tradition, which has added to
compensate by selecting one area and focusing
these earlier discussions new ones about the
an increased amount of attention and energy on
structure and function of intelligence and
it. Such selective optimization at times is
cognitionÐconcepts which had been developed
associated with extraordinary and highly
in the context of predicting educational out-
evolved skills.
comes in the young (see Baltes & Labouvie,
1973; Labouvie-Vief, 1985)Ðat later stages of
1.09.2.2.7 Stability vs. plasticity the life-span.
The above discussion further highlights that
even in later stages of development, a consider- 1.09.3.1 Psychometric Intelligence
able capacity exists for positive change. Earlier
stability models, such as Freud's psychoanalytic As Gardner and Clark (1992) have described
theory, assumed that individuals were fairly it, the ªpsychometric approach to intellectual
fixed in later life, and indeed that interventions development seeks to define and quantify
such as psychotherapy were not to be recom- dimensions of intelligence, primarily through
mended for adults older than about 40 years of the collection of individual differences data and
age. In contrast, following the lead of Bloom through the construction of reliable and valid
(1964), more recent positions criticized this measurement scalesº (p. 16). Thus, researchers
stability position. Instead, there now is a who adopt the psychometric approach address
tendency to explore the potentials for change questions such as: How can intellectual devel-
and plasticity even in late life. opment be quantified? How can such quanti-
In sum, the twentieth century has been fications be used to predict achievements later in
witness to a dramatic revision in notions of life? How can the intelligence of individuals be
development and concepts of what constitutes meaningfully compared? What factors make up
Cognitive Development 267
intelligence, and do the factors change with age? 1.09.3.1.1 Differential decline
(Siegler & Richards, 1982).
First, the adoption of Horn and Cattell's
Early research on the life course of intelli-
(1966) theory of fluid (Gf) and crystallized (Gc)
gence was strongly guided by the stability
intelligence as an organizing theoretical frame-
assumptions of the existing theoretical frame-
work alerted researchers to the possibility of
works, which considered intelligence usually as
ability-specific age trajectories and the multi-
a basic biological endowment with a strong
directionality of intellectual development dur-
genetic base. In fact, Riegel (1976) noted that
ing the adult years (Baltes, 1987). Horn and
early research on intelligence neglected con-
Cattell's (1966) proposition that abilities which
textual differences, and cultural background
primarily reflect a person's knowledge incul-
was not even believed to affect levels of
cated through the process of acculturation (i.e.,
intelligence. In contrast, debates in intelligence
crystallized intelligence, Gc) continue to increase
research in the late 1990s focus primarily on
into the sixties and seventies, whereas abstract
issues related to the contributions of genetic/
reasoning abilities (i.e., fluid intelligence, Gf)
hereditary and sociocultural/contextual influ-
start to decline in middle adulthood, is now
ences to individuals' intellectual performance,
supported by a large body of research (Horn &
on the different developmental trajectories of
Hofer, 1992). Horn and Hofer's (1992) explana-
intellectual abilities across the life-span, and on
tion that the observed declines in Gf seem to be
secular trends in intellectual performance
primarily related to the loss of ability to
(Flynn, 1984, 1987; Schaie, 1994, 1996). In
maintain close attention and to divide attention
particular, research on the development of
is consistent with findings obtained from studies
intellectual abilities in adulthood and old age
conducted within the information-processing
has shown different patterns of aging for
paradigm. Numerous experimental studies have
different mental abilities and has documented
shown that changes in abstract reasoning
much more intra-individual plasticity, and
abilities show strong associations with changes
interindividual and intercohort differences than
in working memory and reduced speed of
was previously expected (Baltes, 1987;
processing (Salthouse, 1991). As several re-
Labouvie-Vief, 1985; Schaie, 1996). Thus, in
searchers have suggested, these age-related
the following we will review the major findings
changes in working memory and speed of
with regard to the development of intellectual
processing may reflect neurological changes in
abilities across the life-span, placing particular
the aging person and may explain that even
emphasis on intelligence development during
under most optimal training conditions, older
the adult years.
adults do not outperform younger adults on
Perhaps the most interesting research in terms
complex cognitive tasks such as a mnemonic
of psychometric intelligence since the late 1950s
skill (Baltes & Kliegl, 1992; Kliegl, Smith, &
has been conducted with adults of different
Baltes, 1989).
ages, plotting the developmental trajectories of
different mental abilities across the adult life-
span and into old age. This research has greatly
1.09.3.1.2 The role of context
enriched our knowledge about intellectual
development across the life-span and has mostly The second development that has contributed
revised the decrement model of intellectual to a revised view on intellectual development
aging that persisted in the 1940s, 1950s, and during adulthood is related to findings from a
1960s (Labouvie-Vief, 1985). Although early number of longitudinal studies of aging (see
research suggested dramatic ªdeclinesº in Schaie, 1983). Such studies tend to suggest much
intelligence beginning as early as 20 or 30 years less dramatic declines than cross-sectional
of age, more recent findings with regard to research had indicated. In particular, the work
intellectual functioning demonstrate that these of Schaie (1996), working with the Seattle
age differences are confounded with cultural- Longitudinal Study (SLS), has shown that these
historical change, and that genuine normative patterns point to very systematic and theoreti-
declines set in much later, probably in the sixth cally important differences between cross-
life decade. In addition, researchers now sectional and longitudinal research.
emphasize the potential of gains and continued The SLS is unique because it was designed as
growth along with losses (Baltes, 1987; a cohort-sequential study (Schaie, 1965, 1986;
Labouvie-Vief, 1977) as well as the capacity see Figure 1). This research design consists of a
for plasticity during all phases of adulthood coordinated series of longitudinal and cross-
(Baltes & Baltes, 1990; Dixon & BaÈckman, sectional studies and permits the joint study of
1995). In particular, three developments have individual development and the effects of
greatly influenced the research on intellectual cultural-historical change. Thus, this design
functioning in adulthood. overcomes the shortcomings of the cross-
sectional and longitudinal methods tradition- results from the SLS have also documented
ally used in developmental psychology and substantial generational (cohort) differences in
allows generalizations about the nature and psychometric abilities, that is, different genera-
dynamics of age-related change, including the tions show different patterns of intellectual
variability created by sociocultural conditions. aging. For example, more recent cohorts have
Moreover, the SLS has followed its aging been shown to perform at a higher level on the
participants over a 35-year period, thus provid- abilities of verbal meaning, inductive reasoning,
ing the most comprehensive data set on and spatial orientation, whereas older cohorts
intellectual development in adulthood (see outperform younger cohorts on number and
Schaie, 1994, 1996). word fluency.
What are the major findings from the SLS? Similar patterns of generational differences in
Although there is a plethora of findings from the intellectual functioning have also been found in
SLS (for a comprehensive review, see Schaie, other Western countries and have been termed
1996), only the major findings will be high- the ªFlynn effectº (Flynn, 1987). The Flynn
lighted here. First, Schaie and his colleagues effect, in essence, refers to the well-documented
found that there is no uniform pattern of age- rise in intelligence test performance in subse-
related changes in adulthood across all intellec- quent generations. This steady increase seems
tual abilities. Cross-sectional analyses, for to reflect the combined effect of a variety of
example, show that some primary abilities environmental influences, such as increased
(i.e., spatial orientation, inductive reasoning) complexity of life, improvements in education,
peak in young adulthood, whereas others peak health care, and nutrition and other factors
in midlife (i.e., verbal meaning and number; see more difficult to pinpoint (Flynn, 1987).
Figure 2). In contrast, longitudinal analyses The SLS also provides a great amount of
showed at least modest gains for all abilities information with regard to contextual ante-
from young adulthood to early middle age (see cedents of individual differences in age-related
Figure 3). change, thus emphasizing the sociocultural/
Second, longitudinal analyses also showed contextual dependence of patterns of intellec-
that, except for word fluency, average age tual aging. Schaie and his colleagues, for
decrements in psychometric abilities cannot be example, showed that the absence of cardio-
reliably documented prior to age 60. However, vascular and other chronic diseases (Hertzog,
reliable average decrement was indeed found for Schaie, & Gribbin, 1978), the presence of
all abilities by age 67 (Schaie, 1994). Third, favorable environmental circumstances, the
Study Waves
1956 1963 1970 1977 1984 1991
S1T1 S1T2 S1T3 S1T4 S1T5 S1T6
(N = 500) (N = 303) (N = 162) (N = 130) (N = 92) (N = 71)
S2T2 S2T3 S2T4 S2T5 S2T6
(N = 997) (N = 420) (N = 337) (N = 204) (N = 161)
S3T3 S3T4 S3T5 S3T6
(N = 705) (N = 340) (N = 225) (N = 175)
S4T4 S4T5 S4T6
(N = 612) (N = 294) (N = 201)
S5T5 S5T6
(N = 628) (N = 428)
S6T6
(N = 690)
S = Sample; T = Time of measurement
Figure 1 Design of the Seattle Longitudinal Study. ªThe course of adult intellectual development,º by K. W.
Schaie, 1994, American Psychologist, 49, p. 305. Copyright 1994 by the American Psychological Association.
Reprinted with permission.
60
55
Mean T Scores
50
45
Inductive reasoning
Spatial orientation
40 Word fluency
Verbal meaning
Number
35
25 32 39 46 53 60 67 74 81
Age
Figure 2 Cross-sectional mean T score for single markers of the primary mental abilities (1991 data). ªThe
course of adult intellectual development,º by K. W. Schaie, 1994, American Psychologist, 49, p. 306. Copyright
1994 by the American Psychological Association. Reprinted with permission.
involvement in intellectually stimulating activ- This finding, by the way, is consistent with the
ities, the maintenance of a high level of increasing research documenting the plasticity
perceptual processing speed, a flexible person- of the aging human brain (for a review, see
ality style at midlife, as well as satisfaction with Labouvie-Vief, 1985; Scheibel, 1996).
one's life's accomplishments (Schaie, 1984) all This latter finding can also be seen as part of
are important contributors to successful in- the third major development that contributed to
tellectual aging. The role of complex living a changed view on adult intellectual develop-
arrangements, including a person's work enment. In the early 1970s, Baltes and Labouvie
vironment, for the maintenance of high levels of (1973) suggested that researchers should sys-
intellectual functioning has also been documen- tematically examine the modifiability of older
ted by Kohn and Schooler (1973; Schooler, adults' intellectual abilities. During the first
1987) and has been documented in animal phase of cognitive intervention research with
models for a long time (for a review, see older adults, these suggestions resulted in a
Labouvie-Vief, 1985). number of studies showing that older adults'
performance on intelligence tests could be
improved through simple practice (Hofland,
1.09.3.1.3 Plasticity of intelligence
Willis, & Baltes, 1981) as well as through special
Finally, Schaie and Willis (1986) provided the training programs (Baltes, Dittmann-Kohli, &
most compelling evidence for the intraindivi- Kliegl, 1986; Baltes & Willis, 1982; Hayslip,
dual plasticity (i.e., intraindividual modifiabil- 1989). Later, Baltes and his colleagues (Baltes &
ity) of intellectual functioning when they Kliegl, 1992; Kliegl, Smith, & Baltes, 1989),
showed that reliable decline in the fluid abilities however, also showed that older adults' range of
of spatial orientation and inductive reasoning plasticity is more limited than younger adults'
was reversible through specific training efforts. range of plasticity. Using the ªtesting-the-limits
60
55
Mean T Scores
50
45
Inductive reasoning
Spatial orientation
40 Word fluency
Verbal meaning
Number
35
25 32 39 46 53 60 67 74 81 88
Age
Figure 3 Longitudinal estimates of mean T scores for single markers of primary mental abilities (from 7-year
within-subject data).ªThe course of adult intellectual development,º by K. W. Schaie, 1994, American
Psychologist, 49, p. 306. Copyright 1994 by the American Psychological Association. Reprinted with
permission.
paradigm,º Baltes and Kliegl (1992), for Bandura, Elliott, & Lewkowicz, 1992) or
example, trained older and younger adults in anxiety reduction (Hayslip, 1989; Hayslip,
the mnemonic strategy of the method of loci and Maloy, & Kohl, 1995) rather than on direct
showed that in no instance were the trained cognitive strategies training. These studies have
older adults able to outperform the trained provided substantial evidence for a rather
younger adults. Instead, training actually strong connection between personality and
increased the separation between younger and cognitive functioning in adulthood, an issue
older adults, providing evidence that older to be further discussed in a later section.
adults' reserve capacity seems to be more
limited compared to younger adults' reserve
capacity, an argument that had previously been 1.09.3.2 Everyday Intelligence
made by Botwinick (1977).
An interesting contribution of cognitive In recent years, researchers' interest in adults'
intervention research in adulthood is that it intellectual performance has also shifted to
also highlights the interface between cognitive some new areas of inquiry. In her 1985 review of
functioning, personality, and affect. In parti- the literature on adult intelligence and cogni-
cular, several researchers have shown that tion, Labouvie-Vief (1985), for example, argued
improvements in older adults' intellectual for a ªre-examination of the concept of
performance can even be achieved, through intelligence as an adaptive capacityº (p. 501)
interventions that focus on personality-related and presented findings with regard to the
processes such as self-efficacy beliefs (Labouvie- adaptive function of cognition in adulthood.
Vief & Gonda, 1976; Lachman, Weaver, This notion was echoed by Salthouse (1990)
when he stated that ªone of the greatest ingly incorporated in research on personality
challenges in the field of psychology and aging development and the self. Moreover, perspec-
is to account for the discrepancy between the tives on positive development in adulthood and
inferred cognitive status of older adults based aging were first explored in the context of
on their performance in psychometric testing intellectual and cognitive development and are
situations and cognitive laboratories and that now translated into other areas of human
derived from observations of their successful development.
functioning in everyday situationsº (p. 310).
Thus, in recent years older adults' perfor-
mance with regard to practical or everyday 1.09.3.3 Cognitive-developmental Theories
problems has become a major focus of cognitive
aging research (Poon, Rubin, & Wilson, 1989; As compared to the psychometric approach,
Puckett & Reese, 1993). Several researchers, for cognitive-developmental approaches are rela-
example, have examined older adults' intellec- tive latecomers to the field of life-span changes
tual performance with regard to tasks that are in cognitive functioning. Yet their origins come
designed to simulate situations of everyday life out of the same concerns about validity that
(for review see Diehl, Willis, & Schaie, 1995). gave rise to much contemporary research within
Overall, this research has shown that older the psychometric tradition, namely issues
adults do not solve everyday problems as relating to the validity of tests when applied
effectively as middle-aged individuals but that outside of the settings for which they were
they usually outperform young adults (Denney originally developed. Thus, similar to Piaget's
& Palmer, 1981; Denney & Pearce, 1989). That original criticism that quantitative differences in
older adults' practical problem solving ability is intellectual achievements reflect core differences
not completely independent of their functioning in the organization of thinking, researchers in
on psychometric tests was shown by Diehl et al. the field of adulthood wondered if thought
(1995). These authors found that older adults' structures in adulthood and later life might not
performance on a set of observed tasks of daily reflect coherent reorganizations of thinking (see
living showed substantial relations to the Labouvie-Vief, 1980, 1982a, 1982b; Riegel,
abilities of perceptual speed, memory, fluid 1973).
intelligence, and crystallized intelligence. In-
deed, fluid intelligence was found to be the
1.09.3.3.1 Piaget's legacy
strongest predictor of older adults' performance
on everyday problem-solving tasks (see also, When Piaget's cognitive developmental view
Willis & Schaie, 1986). Overall, these findings arrived on the US scene, it created no less than a
provide support in favor of a hierarchical revolution in the field of developmental psy-
perspective of everyday cognition. The main chology. His proposal that intelligence and
assumptions of this perspective have been cognition evolved in the same way that other
outlined by Willis and Schaie (1993) and can biological structures do, in terms of a series of
be summarized in three postulates. First, qualitatively different and sequentially orga-
problems encountered in everyday life require nized stages, proved an extremely powerful
the activation and application of multiple umbrella for a host of developmental changes
mental abilities and processes for their solution. from infancy to early adulthood. In the late
Second, different types of everyday problems 1990s, it is widely accepted that the evolution of
require the application of different mental structures akin to those he proposed underlies a
abilities. Third, competence with regard to large variety of cognitive competencies, from
basic cognitive abilities and processes is a those that are rather formal and concern
necessary but not sufficient condition for the themselves with scientific thinking, to those
successful solution of everyday problems; that are more focused on everyday kinds of
domain-specific knowledge is likely to be issues such as the understanding and regulation
required as well for successful everyday problem of emotions and representations of the self
solving. (Labouvie-Vief, DeVoe, & Bulka, 1989).
In summary, theory and research on the Nevertheless, the theory recently has been
development of psychometric intelligence has widely criticized. In keeping with the issues
always been at the forefront of life-span discussed in the first section of this chapter,
developmental psychology (see Baltes, 1987) Piaget's theory evolved in an intellectual
and has greatly influenced researchers' thinking context that emphasized the priority of rational
in other domains. For example, concepts such functioning, which formed the endpoint of
as multidimensionality, multidirectionality, Piaget's theory. Similarly, the theory proposed
plasticity, or sociocultural influences on devel- a single, universal pathway to this endpoint. It
opment are among those that are now increas- further emphasized coherence of functioning at
each stage of development, such that stages how these levels actually are translated into
were assumed to provide broad integrative thought and behavior. Thus issues such as
frames for all of the individual's thought and context and domains of familiarity all become
behavior. significant variables to be added to a theoretical
This objectivism in Piaget's theory emerges as account of development. Further, another
somewhat of a paradox, since we have noted significant trend has been that the levels are
that the theory was based on the basic generalized beyond the domain of scientific
assumptionÐshared in many ways with thinking to domains that are more strongly
FreudÐthat mental life could be explained as related to emotions, self, values, and relation-
a form of biological life. Thus, his work also ships (Case, 1991; Damon & Hart, 1982; Fischer
marks a watershed in a broad trend to re-embed & Ayoub, 1994).
the mind in the organismic and biological world. Another core approach has primarily focused
In the abstract, that assumption is evident in on adults, and on re-evaluating notions of
many aspects of the theory: in its empirical maturity that may be better applicable to adult-
implementation, however, Piaget's theory is hood. As argued by Labouvie-Vief (1994), the
successively slanted towards a form of mental- role integrating formal and organismic aspects
ism that becomes dissociated from its organic of thinking may become especially important in
base. adulthood, where individuals become more
Riegel (1973) has commented on this slant active participants in the construction of knowl-
and argued that in Piaget's theory, development edge. To an extent, the dynamics of early
is represented as a successive abstraction of development may require that the individual
thought from a rich organismic base. While in put aside private and inner forms of meaning,
the theory we are confronted with children who since the process of socialization requires an
are emoting, playing, symbolizing, and strug- outward turn. However, in later development
gling with issues of authority, Piaget's adoles- that outward turn must be balanced with an
cent is described almost exclusively in terms of inward orientation: a higher degree of intro-
idealized structures of mathematical and scien- spection, understanding of intrapersonal dy-
tific thinking. These structures begin, according namics, and historical and psychological
to Piaget, in cognition's close ties to sensori- analysis.
motor processes, but gradually they become
more autonomous and less dependent on
1.09.3.3.2 Mature reasoning structures
immediate sensory experience. Thus sensori-
motor intelligence moves into the symbolic Riegel's (1973) notion of the emergence of
processes of preoperational intelligence, and dialectical operations in adulthood has inspired
then begins to concern itself with more abstract several authors to describe such dialectical,
relations and operations. multilevel modes of thinking. Riegel's work has
In ªconcrete operations,º these still are remained rather abstract, but many empirical
closely tied to the concrete realities of the approaches took their impetus from Perry's
perceived world, but in ªformal operationsº (1970) influential study on how college men
they become the ability to operate on purely rediscover the relationship of reasoning to
abstract processes, relations, and thoughts. subjective and interpersonal variables. A similar
Thus, in Piaget's theory, meaning systems that study has since been done with women (Clinchy
originate in the organismic, the sensorimotor, & Zimmerman, 1982; see also Belenky, Clinchy,
the figurative, the dynamic, and the personal Goldberger, & Tarule, 1986). Both of these
gradually are displaced by ones that are studies argued that formal thinking makes the
abstract, conceptual, stable, conventional, and individual uniquely vulnerable to a dualistic
impersonal. But in general, the theory does not emphasis on product rather than process, stasis
offer an integration of the two, except in the rather than change. This rigidity was loosened
most abstract discussions of the dynamics of as the youth moved into a position of con-
development. textual relativism. Now the individual rejected
These general criticisms have led, since the the notion of any one certain truth and asserted
late 1970s, to two important expansions of a instead that truth is inherently relative to a
Piagetian view. One pathway has been to context. Eventually, this fairly radical relati-
develop neo-Piagetian theories that expand vism is integrated in a final position of ªcom-
Piaget's views to other domains and contexts mitment in relativismº: in the midst of multiple
(see Case, 1991; Fischer, 1980). In general, these logical choices, the individual now accepts the
theories hold to the notion that there is an need for an integration that is ultimately
ordered sequence of levels of complexity. Yet subjective.
they make a clearer differentiation between this The notion that a stage of contextual
logical sequence of levels of complexity, and relativism follows one of the certainty of
formal operations has influenced most subse- Kitchener, King, Wood, & Davison, 1989) have
quent work, but most authors have sided with offered a detailed account of how individuals
Kohlberg in searching for a final stage that come to coordinate such categories as objective
goes beyond a merely subjective synthesis and knowledge and subjective belief. These authors
strives for some higher order integration. Just also carry further Perry's contention that the
how to describe this most mature level of mark of mature rationality is a return of a new,
cognitive functioning has varied, however, if more educated, form of subjectivism. Rather,
from author to author. One approach is the they suggest that from this more abstract form
work of Commons and collaborators (e.g., of subjectivism, the individual again begins to
Commons, Armon, Richards, & Schrader, search for a set of ªobjectiveº criteria. However,
1989; Commons, Richards, & Kuhn, 1982). these criteria are more procedural and dynamic:
These authors suggested that, although formal even though one may not, in principle, know
thinkers are able to abstract order relations in a what is good evidence, one has a general
systematic manner, the entire system is not procedure for distinguishing solid evidence
regarded as a single entity that can be analyzed from less trustworthy evidence by examining
in terms of characteristics and relationships the process through which knowledge has been
and thus systematically compared to other gained.
systems. In contrast, more advanced thinkers This work has many implications for modern
are able to describe features of different discussions about the nature of mature reason.
systems in terms of an underlying common Beyond these implications, it may also help
language which yields transformations across highlight the cognitive roots of some major
systems. This work is echoed by that of other psychological differences between adolescents
authors who also note that the hallmark of and adults. Labouvie-Vief (1982a), for example,
mature adult thinking is the ability to move has argued that the adolescent's understanding
from intrasystem thinking to the ability to of truth as certain and computable may be a
construct co-ordinations and transformative significant factor in her or his defense structure.
relationships between abstract systems (e.g. Since that structure is based on a dualism
Labouvie-Vief, 1982a; Fisher, Hand, & Rus- between objective and subjective processes, it
sell, 1984; Sinnott, 1989). does not involve a mechanism by which such
Other authors have specifically suggested that defensive cognitive distortions can be analyzed
adulthood brings an enhanced ability to think and, therefore, corrected. In turn, the move-
dialectically (e.g., Basseches, 1984; Kramer, ment to a model of knowledge that is more
1989; Labouvie-Vief, 1982a, 1982b, 1992; historically situated may bring a more inte-
Reich, 1990; Sinnott, 1989); thus, adults are grated structure that, by analyzing its own
better able to analyze systems and concepts in subjectivity, provides a more powerful device
terms of history, context, subjective processes, for self-regulation and correction (Blanchard-
and change and movement. Kramer (1989), for Fields, 1986; Pascual-Leone, 1984; Wood,
example, proposes that thinking from adoles- 1983).
cence to mature adulthood develops from a
dualistic and absolutistic, through a relativistic,
1.09.3.3.3 Cognitive development and the self
to a dialectical level. For example, in a
comparison of young, middle-aged and elderly The research discussed above suggests that as
adults, Kramer and Woodruff (1986) found individuals move into mature adulthood, they
older adults to display the highest level of are better able to relate the process of thinking
relativistic and dialectical thinking. There also back to a set of subjective processes (intentions,
was some evidence that Piagetian formal values, historical conditions, etc). Thus not
thinking was prerequisite but not sufficient surprisingly, these lines of thinking also have
for dialectical thinking, but that relativistic been extended to individuals' thinking about
thinking actually was necessary but not suffi- self and emotions. A major influence on this
cient for formal operations. work has been Kohlberg's (1984) theory of
Much of the work above has concentrated on moral development. Kohlberg (e.g., 1984) has
relatively abstract features of the coordination addressed himself most explicitly to morality,
between systems. Just what are the kinds of but his theory has a much broader sweep and in
systems and system features that mature fact involves an implicit theory of evolving self-
individuals are able to analyze? Several studies structures around which values and emotions
have focused on how individuals can coordinate are organized. These implications have been
such abstract concepts as truth and certainty on worked out by a group of subsequent research-
the one hand, and subjectivity and interpreta- ers both in the childhood (e.g., Damon & Hart,
tion on the other. For example, Kitchener and 1982; Selman, 1980) and adulthood (see below)
King (1981; see also Kitchener & Brenner, 1990; areas. For example, Kegan (1982) has presented
a theory of self-development from adolescence ception and measure has been demonstrated in
to mature adulthood. According to Kegan, the age-related trends in both cross-sectional and
youthful and/or conventional self remains fused longitudinal samples (e.g., Cook-Greuter, in
with an interpersonal and then institutional press; Hauser, 1976; Redmore & Loevinger,
matrix, and the ability to experience distinctness 1979). Ego development is also a good index of
and an individuated self remains limited. That such dimensions of developmental complexity
capacity to maintain a more autonomous sense as moral development and empathy (see
of selfhood emerges at the final stage, when self Loevinger, 1976b) and intellectual development
and other can be understood as entities that (see below).
transcend interpersonal and institutional mean- Labouvie-Vief and collaborators (Labouvie-
ings. Thus, both a more authentic sense of Vief, Chiodo, Goguen, Diehl, & Orwoll, 1995;
selfhood and a deeper capacity for intimacy can Labouvie-Vief, Diehl, & Coyle, 1996) developed
result. a framework within which to examine such
Armon (1984) has applied Kohlberg's no- changes. In this framework, statements about
tions to conceptions of what constitutes a good self and others (in particular, parents) are
or ethical life and work. In her study, classified into five developmental levels that
preconventional thought is focused around are ordered in terms of increasing complexity
merely individual interests and desires, while (see Table 1). In this research, younger or less
conventional thinking becomes organized mature individuals framed self and others in
around such goals as socially beneficial work, terms of a conventional perspective: self and
positive interpersonal experiences, financial others were described in terms of an organized,
security, and social utility. For the postconven- codified, and abstract set of role expectations.
tional individual, the potential conflict between At a more advanced level, the institutional
social commitment and self-fulfillment is heigh- values become susceptible to doubt and criti-
tened and the individual aims at balancing cism: for example, such values can be ªcarried
responsibility to self with that to society. too far.º Instead, a dynamic perspective evolves
Fowler (1981) has also applied Kohlbergian in which descriptions of self and others convey
(as well as Eriksonian) notions to another in vivid language the unique and evolving
domain, that of faith and religious values. experience of individuals within the context of
Fowler argues that the preconventional indivi- their particular life histories. Lives now are
dual has a magical and concrete conception of understood in the context of multiple frames,
God. At the conventional level, the orientation cultural, social, and psychological, for example.
is based on acceptance of cultural values with There is keen insight into the psychological
only little critical evaluation: religion now is dynamics that are at the root of human
oriented towards maintaining dogma and diversity, yet an understanding that such
interpersonal validation. In contrast, the post- diversity appears to be regulated by a common
conventional individual becomes both critical of human heritage.
conventional religion, and evolves a perspective Just as the self becomes viewed more from the
in which conventional religious frameworks perspective of historical patterns and general
form separate though equivalent paths towards emotional transformation, so do the parents.
more universal spiritual goals. Younger individuals and those over the age of
Another theory proposing a broad reorgani- 60 primarily describe their parents in the
zation of the self in relation to the social interpersonal context of their roles as providers
collective is Loevinger's (1976; Loevinger & of emotional and financial support to the self,
Wessler, 1970) model of ego development. or, to a lesser extent, in the institutional context
Loevinger proposed that the impulsiveness of of their societal position. Few youthful indivi-
the child gives way to a conventional mode in duals represent their parents as more autono-
which one's own subjective inner life is mous individuals in their own right. In contrast,
suppressed and subordinated to social norms. around midlife there is a peak of responses that
The mature individual, however, evolves a more are appreciative of the unique individuality of
flexible language in which the conflicts between parents: Participants describe their parents not
impulse and norm, self and society, or inner and just as carriers of parental and other social roles,
outer, are first acknowledged and then inte- but show an awareness of the conditions that
grated within more self-chosen standards. shaped the parents and made them become the
Cognitive complexity thus replaces a youthful persons they are or were.
language of self-regulation preoccupied with These results are consistent with views which
physical, mental, or emotional control, good± suggest that a restructuring of representations
bad dichotomies, and little or no tolerance of of one's parents are part and parcel of the
intrapersonal or interpersonal conflict. The reorganizations in self often associated with
developmental significance of Loevinger's con- middle adulthood (Jung, 1933; Kohut, 1977;
Table 1 Levels of self- and other-differentiation.
Level Description Examplea
0 The language used is simple and concrete. I am nice.

Concrete/ Characteristics and physical traits are My dad is very nice because he buys me
presystemic seen as global. Events are detailed in cool stuff.
simple seriation. Action-oriented She is the nicest mom in the world.
behaviors describe activities. No I'm tall.
references to goals or psychological
processes occur.
1 Simple evaluations are made that reflect I like to fool around in class and make
Interpersonal/ the values of the immediate social group. my friends laugh.
protosystemic Traits described are nondifferentiated. My mom is young that is why she
Individuals are described in terms of understands when I get into trouble.
relationships (simple descriptors) and My father is very protective of me, and he
social networks. An emphasis is placed on cares about me.
features of the self or others that make for
in-group acceptance.
2 Interpersonal descriptors indicate a I am an empathic and committed friend.

Institutional/ clearer sense of the individual within the I work hard to support my children and
intrasystemic social group. Traits at this level indicate a really love them.
more self-directed and goal-directed A caring person, she will give her last
individual whose evaluations are guided dime to her children or anyone else she
by achievement-oriented and thinks is in need or something.
conventional goals, values, and roles. He was a strict disciplinarian, bit of a
Achievement of these goals and values is a drinking problem but never missed a
frequent theme. days work.
3 Descriptions are critical of convention, I am a singer, an actress and a writer and

Contextual/ involve an awareness of how traits want to use these talents more creatively
intrasystemic change, and give a sense of individuals than I do now.
with their own value system. Institutional Accumulates material things and
goals are re-examined and put into educational & professional credentials to
historical or psychological perspective. prop herself up.
Descriptions involve references to At 83 my father is slowing down quite a
processes and contrasts over time. bit and is not the same as he was most of
his life.
4 Roles and traits are described at a I work for profit now rather than for
Dynamic/ complex psychological level and reflect satisfaction, partly because of my (guilty)
intersubjective awareness of underlying, often need to continue to support my family.
unconscious, motivation and reciprocal A fine balance of stregnth &
interaction. Activities and goals are seen vulnerability in may aspects, however a
as subject to continual revision as one marked inability to discern male
gains knowledge of oneself and others. competence and motive.
Reference is to multiple dimensions of life
history, and an emphasis on process,
becoming, and emergence.
a
Errors in grammar and spelling reflect actual responses.
Labouvie-Vief, 1994; Levinson, Darrow, Klein, 1.09.3.3.4 Emotional development

Levinson, & McKee, 1978). Overall, however, it
is also notable that relatively few individuals Advances in cognitive complexity, such as the
display the higher levels of parent representa- ones discussed, also have implications for the
tions. This finding that higher levels of understanding and regulation of emotions
representation are quite rare in the population (Labouvie-Vief, DeVoe, & Bulka, 1989). Fol-
and that they tend to be concentrated in the lowing suggestions by Piaget (1980), a number
middle age period is also replicated by many of researchers have shown that as individuals re-
other studies (see Labouvie-Vief, Chiodo et al., evaluate and reinterpret aspects of reality, their
1995). understanding of the nature and causes of
emotions changes as well. For example, from sented in less dualistic and polarized ways. This
childhood to adolescence, several changes in conclusion is also supported by research of
emotional understanding and regulation are Blanchard-Fields (e.g., 1986; Blanchard-Fields,
apparent (see Fisher & Ayoub, 1994; Harter & 1996) who showed that older adults' thinking
Monsour, 1992; Labouvie-Vief, in press; about emotional conflicts is better integrated.
Labouvie-Vief, Hakim-Larson, DeVoe, & For example, older individuals are better able to
Schoeberlein, 1989). First, the emotional voca- differentiate their (emotionally influenced) in-
bulary becomes more differentiated, referring terpretations from a body of data they evaluate;
increasingly to complex blends of emotions and they also are less likely to view others' behavior
to emotions of contrasting valence. Second, the in static terms, but more likely to explain it in
standards by which emotions are regulated terms of contextual factors.
become more abstract as the need for direct Evidence such as this may suggest that older
dyadic supervision is replaced by more internal adults may become experts at dealing with
and normative controls. Third, emotions also emotionally relevant information, a conclusion
become understood as more internal processes that is congruent with research examining how
and are described in terms of thoughts, wishes, individuals of different ages interpret narratives
and rules rather than direct physical actions and such as stories that have a highly emotional
consequences. and symbolic content (Adams, 1986; Adams,
Important as these skills are in the process of Labouvie-Vief, Hobart, & Dorosz, 1990; Jepson
early socialization, they are particularly sig- & Labouvie-Vief, 1992). That research suggests
nificant in the context of development at early that adolescents and college students in reading
life stages when individuals need to define their text primarily focus on literal features, as they
emotional lives in accord with external criteria: attend to the structure of actions and events
they begin to master a set of rules that permit depicted in the text. However, for mature and
them to regulate behavior in accordance with older adults the primary interest is not in this
cultural dictates. In contrast to this outward literal action±event structure, but rather in what
movement, adulthood may bring a compensa- it reveals about underlying emotional and
tory movement inward. A focus on inner motivational patterns of the human condition.
dynamics, on private experience, and on rich To that extent, the mature adults' interest in
organismic experience and emotive content now text becomes more abstract and symbolic: A
comes to the fore, a process Gutmann (1987) narrative does not refer to the concrete here and
refers to as the ªgreeningº of the mature now of protagonists and their actions, but
individual. rather is taken as indicative of human actions in
This notion was supported in research by general (see also Jepson & Labouvie-Vief, 1992).
Labouvie-Vief and colleagues (Labouvie-Vief, It is important to note that this focus on
DeVoe, & Bulka, 1989), showing that from emotions is not always the result of genuine
adolescence to middle adulthood, emotional integration. For example, later adulthood may
understanding and regulation show systematic bring a more general bias for emotion-based
differences. The language of emotions of responses, as noted by Blanchard-Fields (1994)
younger individuals primarily emphasized their and Carstensen (1992; Carstensen & Turk-
inner and mental nature. It was static; terms Charles, 1994). In the research by Labouvie-
were used as descriptors and emphasized how Vief, and in Adams' work too, it was noted that
one should feel; external rules and standards of the psychologizing approach appeared to occur
conduct rather than the felt experience char- with high frequency in older individuals.
acterized individuals' expression of emotions. In However, it did so in styles that differed in
contrast, mature adultsÐthose around middle complexity and elaboration. Some adults would
adulthoodÐgave evidence of a significantly give summaries that involved complex back-
reorganized emotional language. Feelings were and-forth references between the text base and
described in terms of a vivid felt process, dealing some psychological process they thought the
not with static states, but with process and text symbolized; in fact, in Adams' (1986) study,
transformation. At the same time, individuals such responses peaked in middle-aged adults.
began to differentiate an inner realm of Other responses were rather global and un-
emotional experience from an outer realm of differentiated, with affectively laden responses
convention. The conflict between these realms such as ªThe trouble is that nobody believes in
was acknowledged, and the individual was God anymore,º and it was these responses that
concerned with accepting impulses and were most frequent in the older group.
thoughts that previously seemed too over- The observation that emotion-based lan-
whelming to accept. guage sometimes is rather global and undiffer-
This research suggests that in individuals who entiated suggests that even though older adults
are older/more mature, emotions are repre- may use a more emotion-based language, this
Personality Development 277
emotional language may not necessarily imply techniques may serve to maintain emotional
the ability to reason about emotions in complex equilibrium in the face of declining resources,
and coordinated ways. Thus other mechanisms they may do so at the cost of an overall picture
than emotional understanding may play a role. of more norm dependence and rigidity.
For example, BrandstaÈdter (e.g., BrandstaÈdter
& Greve, 1994) and Carstensen (1996) both
suggest that awareness of time and mortality 1.09.3.3.5 Wisdom
are a major factor by which an increasing All of the above proposals indicate that
acceptance of emotions is ushered in, even rational processes on the one hand, and
though this awareness may be stimulated by processes related to self and emotions on the
events, such as illness, that are not related to other, are profoundly interconnected. Even
age. However, although such realization may though this is true of all of the life-span, it
effect a switch in the preferred processing appears to be only at relatively advanced levels
system as implied by Carstenson's work, such a that individuals are able to represent and
simple switch must be distinguished from the understand these relationships and integrate
kinds of processes of cognitive-affective inte- them within single, nonconflicting systems. This
gration we are concerned with. Further, it is ability to bridge the tensions between the
also possible that certain cognitive restrictions, universal and the contextual, the theoretical
particularly in the domain of fluid intelligence, and the pragmatic, and the rational and
may limit some older individuals' ability to emotional is often referred to as wisdom (Baltes
modulate complex affects (see Labouvie-Vief, & Staudinger, 1993; Clayton & Birren, 1980;
Chiodo et al., 1995, Labouvie-Vief & Diehl., Labouvie-Vief, 1990; Staudinger & Baltes, 1994,
1996; Labouvie-Vief, Diehl et al, 1995). Thus 1996).
conceivably, an increase in emotion-based While all of the work discussed above related
language might reflect less complex emotion- to processes of wisdom (see Sternberg, 1990),
regulation strategies. the most detailed research project thus far has
These findings on emotion language may be attempted to provide a specific operational
related to research on coping and defense definition of ªwisdom.º According to Baltes
processes. A number of studies (for review see and his colleagues (Baltes, Smith, & Staudinger,
Aldwin, 1994; Diehl, Coyle, & Labouvie-Vief, 1992; Baltes & Staudinger, 1993), wisdom,
1996) on coping/defense processes across the defined as expert knowledge with regard to
life-span have demonstrated that older indivi- important but uncertain matters of life, can be
duals, when compared to younger age groups, characterized by several components as out-
show a pattern of more positive coping and less lined in Table 2. Individuals receive ratings on
defensive coping. This pattern continues at least each of these components, and an overall
into the sixth decade. For example, in the ªwisdom scoreº is derived. As is true of the
research by Diehl and collaborators, older studies reported in this section, Baltes and his
individuals scored lower collaborators found that although age in itself
One current tendency in the literature is to was not a sufficient condition for the develop-
propose that such findings indicate a flexible ment of wisdom, older adults were more likely
coping strategy by which older individuals to be nominated as wise, and those nominated in
adjust to the realities of later life by the fact produced the highest wisdom scores. Baltes
adoption of ªsecondaryº or ªemotion-focusedº et al. (1992) also found that personality
coping strategies (see Blanchard-Fields, 1996; measures, in addition to standard tests of
BrandtstaÈdter & Greve, 1994; Carstensen, 1996; crystallized and fluid intelligence, predicted
Schultz, 1996). However, it is not clear at this wisdom scores, underscoring the interface
time whether coping strategies actually may between personality and cognition (see also
represent a mixture of strategies. For example, Staudinger & Baltes, 1996).
data of the Diehl et al. (1996) study suggest that
secondary strategies of meaning transformation
(e.g., through the rescaling of goals and 1.09.4 PERSONALITY DEVELOPMENT
aspirations) may not invariably imply genuine
transformation of affect, but also can indicate As Riegel (1977) noted in his work on the
its denial or repression. Thus it is possible that history of life-span development, the area of
some individuals maintain positive adaptation personality and social relations was a relative
and self-organization under conditions of newcomer to the field. Early theorists such as
relatively high-level functioning; however, Freud had proposed that personality was set
others may rely on coping strategies that involve rather early, and that it was unlikely to change
denial, repression, and gating out of disturbing (except in the direction of regression) in the
affect. Even though such more fragmenting second half of life. In contrast, the post-World
Table 2 Use of the wisdom-related criteria to evaluate discourse about life matters.
Criterion Instantiations
Factual knowledge Who, when, where?

Examples of possible different situations
Multiple options (forms of love and marriage)
Procedural knowledge Strategies of information search, decision-making, and advice giving
Timing of advice
Monitoring of emotional reactions
Cost±benefit analysis: scenarios
Means±ends analysis
Life-span Age-graded contexts (e.g., issues of adolescence)
contextualism Culturally graded contexts (e.g., change in norms)
Idiosyncratic contexts across time and life domains (e.g., terminal illness)
Interrelations, tensions, priorities of life domains
Relativism Religious and personal preferences
Current vs. future values
Historical period
Cultural relativism
Uncertainty No perfect solution
Optimization of gains vs. loss
Future not fully predictable
Backup solutions
Examples of responses (abbreviated)

Low score A 15-year-old girl wants to get married? No, no way. Marrying at age 15 would be
utterly wrong. One has to tell the girl that marriage is not possible. [After further
probing] It would be irresponsible to support such an idea. No, this is just a crazy
idea.
High score Well, on the surface, this seems like an easy problem. On average, marriage for 15-
year-old girls is not a good thing. I guess many girls might think about it when they
fall in love for the first time. And, then, there are situations where the average case
does not fit. Perhaps in this instance, special life circumstances are involved, such
that the girl has a terminal illness. Or this girl may not be from this country.
Perhaps she lives in another country and historical period. Before I offer a final
evaluation I would need more information.
ªThe search for a psychology of wisdom,º by P. B. Baltes and V. M. Staudinger, 1993, Current Directions in Psychological Science, 2, p. 78.
Copyright 1993 by the American Psychological Society. Reprinted with permission.
War II era has seen a dramatic rise in inquiries set of rich and detailed hypotheses about
into change and stability in personality and self developmental stages of life, emphasizing
in adulthood and later life. qualitative changes in personality adaptation
The question about change and stability in at different life periods. The trait-theoretical
personality will be answered according to the approach, in contrast, has been much more
investigators' theoretical position (Block, methodologically oriented, and emphasized the
1995a, 1995b; Costa & McCrae, 1980; Helson, basic continuity and stability of personality
1993; McCrae & Costa, 1990) as to how across the life-span. However, both approaches
personality has been defined and measured, in recent years have begun to draw on each
and on how stability and change have been other, the psychodynamic tradition providing
assessed. To date, two major theoretical important theoretical questions, and the psy-
approaches have dominated the field of person- chometric tradition offering a strong set of
ality psychology and have influenced research methods to examine some of these questions.
on personality development. Developmental Both of these approaches, moreover, have
level approaches have been strongly influenced begun to embrace contextual propositions that
by the psychodynamic tradition. This tradition more and more explore the ways in which self
historically was the first to elaborate on and personality respond to the unique settings in
personality organization, and has proposed a which individuals develop and age.
1.09.4.1 Developmental Level Approaches This devaluation of nonrational processes

makes Freud's theory unsuited to deal with
Level approaches to adult personality are many issues important across the life-span. To
strongly influenced by psychoanalytic thinking, begin with, the theory is individualistic, since it
along with its more recent expansions into puts values of independence, good ego bound-
object relations and self theory (see Greenberg aries, and so forth at the center (see Gilligan,
& Mitchell, 1983). Psychoanalysis itself re- 1982; Labouvie-Vief, 1994). The focus is on the
flected a significant movement in redefinitions separate individual, even from the start: desires
of mind and self, pointing out that emotions and and instincts are processes first located in the
relationships with others are not derived individual and then cathected onto another
processes, but the very ground on which (Greenberg & Mitchell, 1983). That other is not
cognition is built. Psychoanalysis thus followed treated as a separate self, but merely as a
a broad trend to take the study of the mind out projection screen for one's own wishes. This
of the transcendent and to make it part of the lack of genuine relatedness is particularly
natural world. important in the area of gender relations and
gender development, since masculinity is fa-
vored sexually as a primary, more valuable
1.09.4.1.1 Freud's legacy
state. By metaphorically extending notions of
Freud's theory pioneered the proposition that the superiority of the phallic principle into the
rational processes are built on a layer of desires mental domain, ego, consciousness, moral
and needs or instincts. Yet paradoxically, even restraint are lined up with masculinity and
though he helped link back the mind with maturity, while the feminine is considered a less
natural processes, FreudÐalong with many developed state. As a result, and following
other theoreticians, such as Piaget (see previous millennia of historical tradition (Labouvie-Vief,
section)Ðretained an objectivist bias, since as in 1994), in Freud's theory women are not really
traditional philosophy, the superiority of ra- represented as being different from the self, as
tional secondary processes over the ªirrationalº having an independent existence, their own
functioning of the primary processes was desires, their own subjectivity. Rather, they are
maintained. Thus development in large part merely represented as others, beings inferior to
becomes a matter of the victory of conscious, men, thus making them objects to the male
ego-oriented thought, while thought related to action, mind and gaze (see Benjamin, 1988;
the emotion- and symbol-based secondary Labouvie-Vief, 1994).
process was considered of less value. Another important limit of Freud's theory is
This dualism is reflected in the terms Freud that it does not deal with forms of thinking more
chose to refer to the psychic structures that closely related to the primary process domain in
were primarily related to each of these thought a progressive and positive fashion. For example,
processes: the id and ego, respectively. It is religious processes, group processes, and love all
interesting here to reflect on the historical are treated as a regressive return to infantile
origin of these terms. As Bettelheim (1983) wishes for merging. Such wishes are to be
pointed out, when Freud's work was translated suspended from the rule of ego-oriented
from the original German into English, the thought. Thus, Freud's theory does not distin-
meaning of these terms were significantly guish between mature and immature forms of
changed, as well. Freud's translators chose these feelings.
such abstract, Latin, scientific sounding words Finally, Freud does not account for cultural
as ªidº and ªego,º in contrast to Freud's choice construction of this hierarchical model. He
of such simple, common language words ªIº assumes it is inherent in universal processes of
(the German Ich) for ego, and ªitº (The gender dimorphism and ego formation rather
German es) for ªid.º The word ªI,º of course, than a cultural model. Ego and superego
indicates an immediate, direct personal identi- structures thus are viewed as stable structures
fication with part of ourselves. And it is that do not require further change. Indeed,
interesting that for Freud, that direct place of further change tends to be pathologized as
self-identification is the structure that mediates ªregressiveº; and Freud believed that psy-
decision making, planning, and conscious chotherapy cannot be successful in the second
thought. Thus, the self is, in effect, equated half of life.
with logos functioning. This is where we are
assumed to feel ourselves most ªat home,º
1.09.4.1.2 Beyond the ego
where our sense of reality is most secure. The
word ªitº in contrast connotes a distanced, Some of these limitations of Freud's theory
rejecting, and critical attitude toward that were addressed by two individuals who them-
other part of ourselves. selves were intimately familiar with Freud's
ideas. The first, Carl Gustav Jung, was one of In contrast to the socializing emphasis of
Freud's collaborators and his hoped-for suc- early life, Jung (1933) suggested that around the
cessor. When he began work with Freud, Jung middle of life, development shifts to individua-
had already done important work on the nature tion. Individuals now have an opportunity to
of the unconscious. However, as he continued accept unconscious motives, to integrate con-
to work with Freud, his position gradually trasexual aspects and tendencies, and in general
changed from that of his mentor, and eventually to integrate the dualisms formed in early
he broke from Freud in a bitter confrontation development. In this way, they begin to
that has become famous. transcend a narrow self-identification with
Jung was critical of several basic tenets in ego and superego and become guided by a
Freud's theory. He believed that Freud had too more genuine dialectic relationship between ego
negative a view of the nature of the unconscious, processes and the deeper patterns of human
and that he put too much emphasis on the experience expressed by the self. Jung felt that
importance of ego control. Instead, Jung these patterns indicate deep longings and desires
believed that the basic organizing principle, that are often unconscious. Yet they are
though it included the ego, was not primarily expressed in stories and symbols worldwide,
conscious but rather unconscious. Jung termed and they express universal aspects of the human
this general organizing principle the self, experience. These midlife tasks, Jung believed,
anticipating many modern efforts to delineate often were resolved in a crisis. Jung in fact
the nature of the self. coined the term ªmidlife crisis,º and he
Jung also believed that Freud's view of the suggested that such a crisis was a necessary
unconscious was too much based on the and positive aspect of later life development. He
individual's personal experience: the uncon- thought that as a result of that crisis, individuals
scious in Freud's theory consisted mostly of were able to experience an upsurge of creativity
contents that have become repressed in the and well-being.
individual's personal experience. Jung argued
that this interpretation did not allow positive
accounts of an individual's symbolic life as it is
1.09.4.1.3 Ego and culture
expressed in religion, art, dreams, and so forth.
He believed that the unconscious also contained Like Jung, Erik Erikson (1982) felt that
many experiences that are part of our heritage as Freud's model of development was framed too
a species, and that express important emotional narrowly, resulting in an overemphasis on
experiences related to love and hate, sexuality autonomy, a failure to account for the diverse
and the generational flow. These experiences are role of culture, and a regressive view of the role
expressed in the form of story telling and myth, of religion and spirituality in the lives of
ritual and visual symbol (see Labouvie-Vief, individuals. One of the important steps Erikson
1994). took was to expand Freud's psychosexual view
Jung also argued that one result of Freud's of development to a psychosocial one. He did so
idealization of the rational was an overvalua- by first rooting the development of autonomy in
tion of the masculine and a devaluation of the the basic fact of human relatedness. Second, he
feminine. Unlike Freud's theory, which held generalized modes of relating beyond adoles-
that healthy development requires that men cence to mature adulthood and later life, where
suppress the feminine and women the mascu- individuals were better able to give up narrow
line, Jung believed that successful development self-concerns about their own survival and
requires that the person integrate the two. Thus participate in the caring for and management
he anticipated much recent research on the of culture.
nature of androgyny. One significant feature of Erikson's theory is
As a result of these conceptual shifts, Jung that it implicitly proposes a generalization of the
and some of his students suggested that Freud's Freudian notion of ªidentification.º For Freud,
view of development was more pertinent for the processes of identification took place in the
first part of life, when in the interest of cultural ªphallicº period as a result of the internalization
adaptation and socialization the individual of parental attributes and rules. In contrast,
must suppress aspects of the self, including Erikson proposes that the self defines itself
contrasexual tendencies. All of these move- through successively widening circles of rela-
ments (together with the cognitive limitations tions. Thus, at mature adult levels, the self
discussed in the previous section) encouraged becomes invested in culture and even human-
the formation of fairly rigid dualisms between kind and the human condition, in general.
mind and body, thinking and emotion, con- Another significant feature of Erikson's
scious and unconscious, outer and inner, good theory is that he assumed that each stage of
and evil, masculine and feminine, and so forth. human development was defined by a genuine
dialectical tension (he called this tension corruptionÐcan be devastating; yet moving to
ªcrisisº) between the opposing tendencies of maturity requires that we be able to do so
autonomy and relatedness. Thus, the function without exploitation or masochism.
of the first important relation, child±mother, is Many individuals retreat from that crisis.
to build a secure base of trust, a foundation Why? Erikson thinks that ultimately, this is
from which later autonomy could be built. rooted in our need to defend ourselves, our
However, each stage is defined in terms of the inability to trust. Jaques (1965) also suggests
degree to which these oppositions can be that the midlife re-examination is not necessa-
integrated, and failures to achieve complete rily resolved successfully by all. Instead, adults
integration are the norm rather than exceptions. may retreat from the crisis:
Thus, most individuals are able to develop a
core self-sector that permits the experience of the compulsive attempts, in many men and
trust and hope, yet also may retain more women reaching middle age, to remain young,
problematic self-sectors in which basic mistrust the hypochondriacal concern over health and
and withdrawal prevail. At successive later appearance, the emergence of sexual promiscuity
in order to prove youth and potency, the hollow-
levels, these core qualities evolve into broader,
ness and lack of genuine enjoyment of life . . . are
more generalized ones. familiar patterns. These are attempts at a race
One of the core crises of adulthood, that of against time. And in addition to the impoverish-
generativity vs. stagnation, revolves around the ment of emotional life contained in the foregoing
task of surrendering the youthful need for self- activities, real character deterioration is always
idealization (Gutmann, 1994). As individuals possible . . . Increase in arrogance, and ruthless-
grow older they usually are confronted with the ness concealing pangs of envyÐor self-effacing
limits of their creativity, their physical beauty, humbleness and weakness concealing fantasies of
or their sexual attractiveness. Finding these omnipotenceÐare symptomatic of such change . . .
sources of admiration and of pleasure dwind- These defensive fantasies are equally as persecut-
ing, however, as the chaotic and hopeless internal
ling, individuals may respond with an increased
situation they are meant to mitigate. (Jaques,
need for admiration and self-affirmation. Yet 1965, p. 511)
they also are able to step back from this need
for admiration and, in experiencing its painful Erikson also suggested that after the crisis of
hold on the self, let go of it and transmute it generativity vs. stagnation, the individual faces
into a broader understanding of the human a last crisis, that of integrity vs. despair. At the
situation. And, out of this experience of loss, the close of life, individuals need to accept their own
individual can recover a sense of admiring and life cycle and the people in it as something that
idealizing others. Altruistic forms of passing on had to be and that permitted of no substitu-
one's knowledge or financial resources, such as tions. Alternatively, individuals may not be able
in forms of mentoring or philanthropy, are a to reach such acceptance. Rather than accepting
good example of such admiration of others. life as their own responsibility, they may feel
Ideally, such generative support of others is no that time is too short, that alternate roads are
longer subordinated to one's own need to find blocked; they may harbor feelings of disgust,
advancement of admiration (see also McAdams, misanthropy, and a chronic displeasure with
1994). particular institutions and particular people.
While according to Erikson the experience
of generativity is necessary to ward off a
pervasive sense of stagnation in middle adult-
1.09.4.1.4 The duality of the self
hood, true generativity may not come easily
to most adults. Ultimately, the breadth and Although both Jung and Erikson pushed the
depth of generative concerns also are related to boundaries of Freud's theory, many recent
the ability to face and integrate negative criticisms suggest that one of their core
experience (Erikson, 1982). As Jung (1933; see conceptsÐthat of the basic duality of the
also Whitmont, 1969) in particular has pointed selfÐwas not sufficiently developed, and both
out, in growing up individuals usually learn maintained a bias towards autonomy, indivi-
to split off negative aspects of reality and duality, and masculinity. That concept of
idealize its positive side. Yet mature adulthood duality should be seen as the full conjoining
is the time when these neglected aspects need of two fundamental developmental lines which
to be integrated to allow a more balanced view Bakan (1966) called agency versus communion
of reality. To face warded off negative experi- and others have called an orientation to
ence, yet not be defeated by it, is a difficult separateness versus connection (e.g., Gilligan,
challenge that not all individuals face success- 1982; Miller, 1976), power and achievement
fully. Accepting destructive impulses in oneself versus intimacy and love (McAdams, 1985), or
and othersÐconfronting hate, envy, evil and individuation and attachment (Franz & White,
1985). These orientations influence experiential has been highly successful in working with this
forms of motivation, adaptation, and strategies polarity is attachment theory as developed by
of coping and defense. In mature development, Bowlby. Attachment theory also is an out-
these lines are integrated in configurations that growth of psychoanalytic theory, but was
include a consolidated self which combines reworked by Bowlby into an ethological theory
autonomy and productivity with healthy relat- including principles of control theory. Attach-
edness. ment theory is specifically built on a conjoining
One example of such a theory is Kohut's of needs for autonomy and attachment, as
theory of the self (Kohut, 1977). Development, shown in Figure 4 (Hazan & Shaver, 1994).
according to Kohut involves the dialectic of two Ideally, individuals are able to shift from
tendencies, one related to our need to be exploration and the development of autonomy
admired by others, the other the need to admire to security- and closeness-seeking behaviors.
others. The first tendency is related to narcis- However, if early relationships do not encou-
sism/grandiosity, which in their immature forms rage flexible shifting between both tendencies,
reflect a defensively inflated sense of self in individuals are likely to develop different forms
excessive need of admiration. Yet in its more of less adaptive attachment styles. Further,
positive forms, it gives rise to mature creativity. these styles are assumed to have a stable
On the other hand, the ability to renounce one's influence throughout the life course.
narcissism gives rise to the ability to mirror and
idealize others, a core ingredient of one's ability
to love. These tendencies may occur in balanced 1.09.4.2 The Trait Approach
relationship; but in less ideal cases, one may be
inflated at the expense of the other. Kohut also On the surface, the trait or individual
thinks that midlife can be crisis-like, as differences approach to personality and person-
individuals realize that early adaptations are ality development appears not ideally suited
no longer useful. for the study of change and transformation
Many scholars have noted, however, that across the life-span (Allport, 1937; Cattell, 1979;
each tendency is maladaptive when present in Costa & McCrae, 1994; Eysenck, 1982; McCrae
exaggerated or unmitigated forms (e.g., Bakan, & Costa, 1990). Trait theorists believe that an
1966). Thus when normal development is individual's personality can be defined as a
disrupted, distorted modes of adaptation occur limited number of basic behavioral tendencies
along one developmental line or another. For that the individual has and consistently displays.
example, Benjamin (1988) suggests that one These basic tendencies may be inherited or
immature form of these two lines occurs in the acquired and may or may not be malleable over
interlocking of roles of domination and sub- the course of development. Behavioral tenden-
mission, where the dominator combines self- cies and temperament traits that are usually
inflation with the contempt and maltreatment of examined by trait theorists include extraversion/
the other, while the victim or subordinate introversion, emotional lability (i.e., neuroti-
surrenders healthy narcissistic needs and devel- cism), shyness, conscientiousness, rigidity/flex-
ops excessive needs for mirroring. Specific ibility, hostility, and others. Trait theorists
psychopathologies associated with each form assume that over the course of the life-span,
have been outlined by Blatt and Shichman these basic tendencies interact with external
(1983). The self-defining, ªintrojectiveº axis influences to produce characteristic adaptations
involves a complex of affects and behaviors which show a high degree of stability (Costa &
associated with excessive concerns about iden- McCrae, 1994; McCrae & Costa, 1990). An
tity, self-control, and self-worth. The introjec- important consequence of this assumption of
tive character uses counteractive defense stability/continuity is that the structure of
mechanisms to manage aggression directed individuals' personality can be assessed using
toward the self and others, and to fend off self-report questionnaires or objective ratings
experiences of loss of individuation. The from others.
interpersonal or ªanacliticº axis involves a
constellation of issues concerned with disrupted
1.09.4.2.1 Traits as dimensions of stability
relatedness and intimacy. Avoidant defenses
(denial, repression) are used against feelings of Historically, the trait-theoretical approach
loneliness and alienation. Anaclitic pathologies has centered around three major questions:
involve issues of dependency, unity, and How many traits are there?; How many traits
belonging. are necessary to describe individuals' person-
Theoretical frameworks such as these have ality in a comprehensive manner?; and How
become extremely important in theories of stable are personality traits across the human
development. One theoretical framework that life-span? In order to provide an answer to the
Is the
attachment Yes Playful, less
Felt security,
figure sufficiently near, inhibited, smiling,
love,
attentive, responsive, exploration-
confidence
approving, orientated, sociable
etc?
No
Hierarchy of attachment
behaviors:
Maintenance of
1. Visual checking
Feer, proximity while
2. Signaling to re-establish Defensiveness
anxiety avoiding close
contact, calling, pleading
contact
3. Moving to re-establish
contact, clinging
Figure 4 The Attachment Behavioral System. ªAttachmemt as an organizational framework for research on
close relationships.º by C. Hazan, & P. R. Shaver, 1994, Psychological Inquiry, 5, p. 3. Copyright 1994 by
Lawrence Erlbaun Associates. Reprinted with permission.
first question, Allport and Odbert (1936) able evidence showing that these five person-
argued that all trait descriptions should ality factors display a great deal of stability
basically be contained in common language, across the adult life-span.
a proposition that was echoed by Cattell Recent critics of the ªBig Fiveº model of
(1943a, 1943b), and resulted in the lexical personality (see Block, 1995a, 1995b), however,
strategy to personality assessment (Allport & have pointed out several limitations of this
Odbert, 1936). Other researchers (Cattell, 1947; approach. First, Block has meticulously docu-
Goldberg, 1981; Norman, 1963; Tupes & mented inconsistencies and subjectivity in the
Christal, 1961/1992) built on Allport and use of the lexical approach by different
Odbert's (1936) initial work and derived lists researchers (Block, 1995a). Second, Block
of trait names (for a detailed description, see has also questioned the inconsistent and often
Block, 1995a) which they analyzed in a variety very subjective use of factor analysis, specific
of ways. In particular, the use of the rotation methods, and the labeling of the
mathematical technique of factor analysis derived factors to describe particular factor
resulted in various taxonomies of personality structures (Block, 1995a). Taken together,
factors, ranging from 5 to 16 factors, that were Block (1995b) has drawn two major conclu-
considered sufficient for the assessment and sions based on his review of the relevant
description of personality. These endeavors literature. First, he concluded that from the
based on the lexical approach were also beginning the trait perspective has been
paralleled by endeavors to construct question- inherently biased in its measurement approach
naires for the assessment of personality toward the stability of traits, thus neglecting
structures. Specifically, Costa and McCrae's contextual influences and age-related factors
(1992a) development of, and research with, the that may contribute to variability in person-
NEO and the NEO-PI-R has increasingly ality development. Second, he also concluded
created the impression that five general that advocates of the ªBig Fiveº factor model
personality factors (i.e., NeuroticismÐN, present conclusions in support of the five-
ExtraversionÐE, Openness to ExperienceÐO, factor approach (FFA) far stronger than seems
AgreeablenessÐA, and ConscientiousnessÐC) to be warranted (Block, 1995b). In contrast to
describe individuals' personalities in a com- the proponents of the FFA, Block (1995a,
prehensive fashion. Moreover, Costa and 1995b) has argued in favor of a perspective in
McCrae (1988, 1994) have provided consider- personality research that incorporates both the
sociocultural context in which personality 1.09.4.3 Empirical Research on Self and

development occurs and the notion of age- Personality
period specific variability across individuals'
1.09.4.3.1 Stability and change
life course (see also Caspi, 1987). Thus, Block
(1995a, 1995b) has argued in favor of a The diffrent perspectives in personality
perspective that focuses on change as well as research differ greatly in their assumptions
on stability in personality development. Block's about stability and change. Researchers who
position and concerns regarding the FFA have subscribe to a trait perspective or any other kind
been shared by other personality theorists of stability-oriented model (i.e., the attachment
(Emmons, 1995; McAdams, 1992). Winter framework; Bowlby, 1988) assume a great
(1996), for example, has come to the conclusion amount of stability, whereas researchers who
that although ªthe five-factor theory is a subscribe to a contextual perspective are more
promising development, it is hardly the final inclined to expect changes in personality. Given
word even in trait psychology' (p. 471). this controversial situation, a careful review of
the respective literatures seems to be warranted.
What do studies in the individual difference
1.09.4.2.2 Context as moderator of stability
tradition tell us about continuity or change in
The contextualist orientation to personality personality development? As Conley (1984) has
and personality development rests on several pointed out, some of the most impressive
basic assumptions. First, contextualists usually evidence with regard to the longitudinal con-
focus on subtypes of persons or personality sistency of personality comes from studies of
syndromes and compare the developmental individual differences in children's emotional
patterns of the identified subtypes over time, health. For example, ratings of children's
because they assume that personality develop- emotional health have shown moderate con-
ment is a priori characterized by interindividual sistencies over long time periods (Cox, 1970;
differences in the intra-individual continuity of Symonds, 1961; Vaillant, 1974) and have shown
personality characteristics (Block, 1981; Caspi, good predictive validity with regard to mental
1987). Second, contextualists place great em- health outcomes (Johns, Mednick, & Shul-
phasis on studying personality ªthe long wayº singer, 1982). Moreover, the temperamental
(Block, 1993) in order to examine the effects of qualities of three year olds have shown
historical events (e.g., Great Depression, World considerable predictive validity with regard to
War II, Vietnam War) and social changes (e.g., personality traits in young adulthood (Caspi &
women's liberation movement, changes in child- Silva, 1995; Kagan & Moss, 1962; Thomas &
rearing practices) as well as the effects of indi- Chess, 1986).
vidual life events (e.g., parenthood, change in These findings are complemented by research
occupation, divorce) on individuals' personality on personality development in adulthood.
development (Caspi, Bem, & Elder, 1989). Using data from the Kelly Longitudinal Study,
Third, contextualists study personality from a Conley (1984) showed for men and women
transactional perspective (Magnusson & ToÈr- moderate mean correlations for neuroticism
estad, 1993). That is, they examine how the indicators and for indicators of social
motivations, goals and resources of individuals introversion±extraversion across a 45-year per-
interact with the surrounding social world; and iod (see also Leon, Gillum, Gillum, & Gouze,
when and why the organization of motivations 1979). In a subsequent study, Conley (1985)
and resources changes as a consequence of found that individual differences on the traits
changes in the social world (Helson, 1993). In neuroticism, social extraversion, and impulse
summary, the contextual approach to person- control were rather stable over a period of 20
ality development situates individuals in their years even when measured via different meth-
social world and examines how the reciprocal ods. Other longitudinal studies that have
interactions between person and social context documented a great deal of stability in person-
affect the emergence, maintenance, and trans- ality functioning are the Duke University
formation of distinct personality characteris- Studies of Normal Aging (Siegler, George, &
tics. Thus, although contextualists are, to some Okun, 1979), the Bonn Longitudinal Study of
extent, interested in questions of stability and Aging (Schmitz-Scherzer & Thomae, 1983), and
change of personality across the life course, the Seattle Longitudinal Study (Schaie, 1996;
their primary focus concerns the issues of Schaie & Willis, 1991). Although different
differential change patterns for different per- measures of personality functioning were used
sonality types. The assumption that both in these studies, all three research programs
stability and change are part of personality showed remarkable stability (i.e., very limited
development across the life-span is central to change over time) in participants' self-reported
this perspective. personality descriptions.
The most vocal advocates of personality particular has been associated with the potential
stability across the adult life-span have been for change and transformation is midlife. The
Costa and McCrae (1980, 1988; McCrae & notion that there are major reorganizations
Costa, 1990) who have argued that after the age around midlife has been most strongly argued
of 30 individuals' personality is ªset like plasterº by theoreticians, most notably Jung (1932),
(Costa & McCrae, 1994). Based on data from the Jaques (1965), and Levinson and collaborators
Boston Normative Aging Study (NAS) and the (Levinson et al., 1978). All of these individuals
Baltimore Longitudinal Study of Aging (BLSA), have suggested that a reorganization of person-
Costa and McCrae (1988, 1994) have provided a ality is a normative phenomenon, at least in an
considerable evidence in support of their posi- ideal sense. Thus, from a Jungian perspective,
tion. For example, they have reported moderate midlife is said to bring the opportunity to re-
to high 30-year stability coefficients (Costa & examine our constructions of good and bad,
McCrae, 1994). Moreover, since the early 1980s, birth and death, dependence and independence,
Costa and McCrae (1992b, 1994) have system- or masculinity and femininity; Erikson suggests
atically elaborated the five-factor model of a broadening of our ability to invest self in
personality (John, 1990) and have devised a culture; and Jaques argues for a change in
self-report questionnaire, the NEO-PI-R (Costa creative style from detailed and polarized to
& McCrae, 1992a), that assesses the ªBig Five.º integrative and tragic. Further, Vaillant (1993)
In terms of mean level differences, Costa and has suggested that around midlife there is a
McCrae (1992a) have shown in cross-sectional maturing of strategies of emotion regulation
studies that the ªBig Fiveº show a fairly and defense (see also Labouvie-Vief, Hakim-
consistent pattern of age differences across the Larson, & Hobart, 1987; Diehl, Coyle, &
adult life-span: small declines are found for N, E, Labouvie-Vief, 1996).
and O, whereas A and C show small increases. Research related to the notion of the notion
Although cross-sectional studies cannot rule out of a midlife crisis has not been extremely
that the observed age differences reflect genera- supportive of the notion, however. For exam-
tional rather than maturational processes, ple, there is little evidence that upheavals and
findings from a six-year longitudinal study of dramatic change are related to a unique period
self-reports and spouse ratings on the NEO-PI of adulthood. Although some individuals do
(Costa & McCrae, 1988) showed a longitudinal experience a crisis, those individuals may suffer
decline in self-reported N, but also a longitudinal from general problems of psychopathology
increase in spouse-rated N. No significant time- (e.g., Rosenberg & Farrell, 1976). Thus, some
related changes were found for either E or O. The researchers in the field have tended to conclude
most consistent longitudinal change found in that the notion of a midlife reorganization has
adults over age 30 has been a decline in activity been overstated.
level (Costa & McCrae, 1988; Douglas & However, there is some fairly good evidence
Arenberg, 1978; Field & Millsap; 1991). that many individuals experience some reorga-
Although this review of the literature shows nization of self and values across the adult life-
that adult personality can be characterized by a span. Why, then, should it be difficult to find
fair amount of stability, high retest correlations clear evidence? There are two major reasons.
by no means preclude the potential for change. One is the issue raised by Block (1995a; see also
For example, it is important to note that, in Labouvie-Vief, DeVoe, & Bulka, 1989) dis-
general, the test±retest correlations account for cussed earlier, that is the general bias in many
only 35±50% of the variance, leaving half of the current assessments towards stability. For
variance unaccounted for. Moreover, this un- example, our review of cognitive theories of
accounted variability is probably only in part adulthood suggests that the meaning indivi-
due to lack of reliability of the measures, but is duals at different life-stages impart on test
most likely related to true shifts in the ranking of items may change quite profoundly with age or
people on the personality characteristic in cognitive complexity. However, to the extent
question. Thus, overall it seems to be most that tests rely on yes±no answers or simple
appropriate to think about personality as an scaling of agreement/disagreement with items,
entity with relative stability depending on the life no room is left for different constructions of
circumstances and the life experiences of each meaning.
individual. We will return to this issue below. This issue was raised by Labouvie-Vief et al.
(1989) in the context of examining coping
strategies across the life-span. While some
1.09.4.3.2 Midlife crisis
researchers (e.g., Lazarus, 1991) have argued
As suggested above, whether or not stability against generalized age differences in coping
remains high depends on the life period under strategies, others (e.g., Diehl et al., 1996) have
consideration. One of the life periods that in reported consistent patterns of strategies of
coping and defense. One reason for this matic crises may, however, be experienced by
ambiguity is that current codings of coping individuals whose early adaptations turn out to
strategies confound strategies of different levels be problematic, and who as a consequence may
of complexity and cognition±affect integration encounter a relatively sudden and dramatic need
within a single category. In earlier research on to regroup their adaptive efforts and to
self-regulation strategies, we (Labouvie-Vief et reorganize their life structures. Stewart (1996)
al., 1987, 1989; see also Block, 1995a) already recently has proposed such a contextual view.
noted that the same strategy can have very Thus she argues that for most of the women
different meanings depending upon the devel- studied, midlife may be a time of re-examination
opmental level at which it appears. For example, of their lives. If life patterns are found wanting,
turning to others may imply that individuals these women may engage in a midlife adjust-
attempt to dissipate anxiety through aligning ment, correcting their patterns by such changes
with others ªin the same boatºÐa less mature as moving from family to work orientation. This
strategyÐor that they seek out others in an group of women subsequently shows a positive
attempt to consider alternative choices and raise turn in their patterns of adjustment. However,
their level of objectivity a more mature strategy. not all women who are dissatisfied with their
Another major issue to be considered is that lives apply such an adjustment, and failure to do
the major dynamic driving changes associated so is related to negative consequences for their
with midlife may not be so much period- subsequent life course.
dependent, but rather may follow general
cognitive changes. We have already reviewed
a considerable body of neo-Piagetian research 1.09.5 CONTEXT IN PERSONALITY
that suggests that individuals around the middle DEVELOPMENT
of adulthood show the most complex under-
standing of self, emotions, motivations, in As described earlier, contextualists are more
general, attributes, that fall under the rubric inclined than trait theorists to assume changes in
of ªpersonality.º At the same time, this personality development and to examine stabi-
literature suggests that more significantly than lity and change in response to changes in context
age, independent measures of cognitive com- (see Bloom, 1964; Helson, 1993). Bloom (1964),
plexity are the strongest predictors of higher for example, reviewed a number of studies of
levels of complexity. Thus, phenomena usually personality stability and also examined the
associated with a midlife crisis may be the result stability of other variables, including physical
of general gains in cognitive complexity from characteristics and intellectual abilities. Based
early to middle adulthood. on this review, he postulated that the change
Connections between adults' personality gradient of most traits, when plotted against
organization and their cognitive complexity age, is a positively sloped function with
have increasingly been emphasized by decreasing acceleration. Specifically, he rejected
Labouvie-Vief and her colleagues (Labouvie- the idea that personality is fully developed by
Vief, 1994; Labouvie-Vief, DeVoe, & Bulka, early adulthood.
1989). Labouvie-Vief et al. (1989), for example, That stability and change are characteristic of
found in a study with adults, that age, verbal personality development during adulthood has
ability, and level of ego development were been shown by several studies. For example,
systematically related to a more reflexive using data which covered a time span of 50
understanding of emotions and to the use of years, Haan, Millsap, and Hartka (1986) found
more flexible coping strategies. Similarly, in a that consistency indexes were largest for
study on adults' self-representations, Labouvie- adjacent age periods but were considerably
Vief, Chiodo, et al. (1995a) showed that in older smaller when examined over the entire time
adults a combination of intellectual and span. In addition, consistency coefficients
personality variables were the significant pre- varied by age period, suggesting that personality
dictors of participants' complexity of self- stability may be considerably reduced during
representations, whereas younger adults' com- periods of the life course that are characterized
plexity of self-representations was predicted by by extensive transitions and role changes (e.g.,
cognitive variables only. Taken together, these the transition to parenthood in young adult-
studies are the result of a more positive hood). A similar pattern of findings has been
perspective on the aging self and represent first reported by Skolnick (1986) with regard to
attempts to address the interfaces between attachment relationships. In brief, Skolnick's
intelligence and personality in later life. study provided a modest degree of support for
While, in general, these data suggest that so- attachment theory, showing some significant
called midlife changes are the result of rather correlations between early relationship experi-
gradual transformations, somewhat more dra- ences with the mother and later social behavior.
Context in Personality Development 287
The most striking finding, however, was the projects in adulthood was related to women's
variability of individual relationship careers changes in personality. Three social clock
across the life-span, indicating the ªdevelop- projects were identified in this study: the
mental opennessº of early relationship experi- feminine social clock (FSC) for women who
ences to influences in later parts of the life had adopted traditional feminine roles; the
course. masculine occupational clock (MOC) for wo-
That both stability and change characterize men who had chosen a career; and no social
personality development even in advanced old clock (NSC) project for those women who were
age has been shown by Field and Millsap (1991) neither committed to an FSC nor an MOC.
for the Berkeley Older Generation Study. Using this typology, Helson et al. (1984)
Although Field and Millsap (1991) found showed that women who adhered to the FSC
moderate rank order stability for the traits scored significantly higher on personality vari-
Satisfaction, Extraversion, Agreeableness, and ables indicative of conformity and norm
Intellect, they also showed significant mean orientation compared to MOC and NSC.
level changes in some of these traits over a 14- During early adulthood, these women's person-
year period as study participants grew into old ality development was dominated by the
age. For example, more than one-third of the adaptation to the roles of wife and mother,
participants increased significantly over time in which was frequently accompanied by a with-
Agreeableness, and both men and women and drawal from social life, the suppression of
old-old and oldest-old participants declined impulse and spontaneity, a more negative self-
significantly in Extraversion. Field and Millsap image, and decreased feelings of competence.
(1991) concluded that these findings do not Twenty percent of the women who adhered to
support the common stereotype that personality the FSC relinquished this life structure and
ªrigidifiesº in old age. divorced between the age of 28 and 35. In
Taken together, these studies contribute in contrast, women who had chosen the MOC at
two major ways to the literature on personality age 28 were less respectful of norms and more
development. First, in combination with the rebellious toward what they experienced as
long-term findings reported by Conley (1984, constrictive pressures. Although these women
1985), these results document that the consis- did not score lower on femininity or on well-
tency coefficients tend to decline as the testing being, they were more independent and self-
interval increases, resulting in only a modest assertive than their FSC counterparts (Helson et
degree of stability in personality components al., 1984). Long-term follow-up of the MOC
when individuals are examined over long women showed that those who continued to
periods of time. Second, these studies also stay on the MOC into middle adulthood showed
suggest that periods that are characterized by greater confidence, initiative, forcefulness, and
life course transitions and changes in important intellectual independence than women who did
social roles (e.g., work and family) are accom- not continue the MOC. Finally, women who
panied by considerably less personality stability were not engaged in any social clock project
than is found elsewhere in the life-span (see also (NSC) also showed a distinct personality
Kogan, 1990). Thus, these studies provide structure. In particular, they showed lower
evidence for the hypothesis that interindividual well-being and self-acceptance, were less in-
stability in personality varies at different dependent and more norm-oriented. Virtually
portions of the life-span (Moss & Susman, all NSC women were dissatisfied with their jobs,
1980). and the single women reported being lonely. By
Bloom's (1964) argument that patterns of their early forties, some NSC women were
stability and change may reflect the influence of better adjusted than in early adulthood and
contextual factors has been addressed in an were working or had established a family. In
exemplary fashion in the context of several summary, by taking an individual differences
longitudinal studies of women's personality approach to patterns of adherence to the social
development during adulthood. Most notably, clock, this study showed for a sample of adult
Helson and her colleagues (Helson, Mitchell, & women that distinct patterns of personality
Moane, 1984; Helson & Moane, 1987; Helson, characteristics were related to different social
Stewart, & Ostrove, 1995) have adopted a clock projects and to different life outcomes
process approach and have examined the across the first 20 years of adulthood.
interplay between social context and personality In another study, Helson, Stewart, and
development for several samples of adult Ostrove (1995) examined how different ego-
women. Helson, Mitchell, and Moane (1984) identity patterns were related to women's
used data from the Mills Longitudinal Study personality characteristics and life outcomes
(Helson, 1967) to investigate the ways in which in three different longitudinal samples. In
adherence or nonadherence to social clock particular, Helson et al. (1995) distinguished
four ego-identity groups depending on whether uneasy, and reluctant to make connections with
individuals had an integrated or unintegrated others.
identity and whether they had actively searched In another study, Block, Gjerde, and Block
for an identity or had accepted a foreclosed (1991) examined the personality antecedents of
identity. Across the three samples, results were depressive tendencies in 18-year-olds (see also
consistent in showing that unintegrated accep- Gjerde, 1995). They found that as early as age
ters showed less initiative than other women, seven, boys who subsequently reported feelings
that unintegrated searchers had less impulse of depression were aggressive, self-aggrandiz-
control, and that integrated accepters scored ing, and undercontrolled, whereas girls with
higher on support of norms and traditional later depressive tendencies were shy and
values. These relations showed high consistency reserved, oversocialized, intropunitive, and
across time. Moreover, in the three cohorts, overcontrolling. Similar gender differences were
identity status showed different relations to life observed in early adolescence. At age 14, boys
outcomes such as marital status, family status, with later depressive tendencies were more likely
and work. Overall, Helson and her colleagues to use marijuana and harder drugs, whereas girls
(see also Helson & Moane, 1987; Helson & with later depressive tendencies showed no
Wink, 1992) have shown that women's person- tendency to use marijuana but did show a
ality structures changed not only in systematic marked tendency to experiment with hard
and normative ways in early and middle drugs. These girls also had a low self-esteem.
adulthood (Helson, 1993; Helson & Stewart, Interestingly, in girls, preschool IQ correlated
1994), but that the observed changes were often positively with depressive tendencies, whereas in
related to specific changes in social roles and boys preschool IQ was negatively related to
transitions in social contexts, thus creating depressive symptoms.
distinctly different life paths for individuals Finally, Block (1993) has reported data on the
with different personalities (see also York & rank order stability of ego resiliency and ego
John, 1992). control over a 20-year period. For the boys and
A great deal of work based on the contextual young men, the correlations for ego resiliency
approach has also been conducted by Block and were consistently positive throughout the years,
his research group (Block, 1971, 1993). In 1968, suggesting that individual differences in ego
Block and Block (1980) initiated a longitudinal resiliency are identifiable from an early age and
study of personality development in which they continue over the next 20 years. The ego
enrolled a heterogeneous sample of 128 children resiliency correlations for the girls, however,
from two nursery schools in Berkeley, CA, showed considerable discontinuity from child-
which has been followed into early adulthood. hood to adolescence and early adulthood. That
Block and Robins (1993), for example, exam- means that for girls, being resilient during the
ined the longitudinal consistency and change in childhood years had no implication for being
self-concept and self-esteem from early adoles- ego resilient in adolescence or beyond. With
cence to early adulthood. They found that the regard to ego control, the cross-occasion
self-esteem of girls showed a fair amount of correlations were consistently positive for both
continuity from ages 14 through 23, whereas the sexes, suggesting that from an early age on
self-esteem of boys showed marked restructur- individual differences in the level of ego control
ing from age 14 to age 18, and reasonable are recognizable and continue to distinguish
consistency from ages 18 to 23. For both sexes, individuals for at least the next 20 years and,
self-esteem was not related to intelligence or to from the evidence of other studies (see Block,
social class. Young women and young men who 1971), even beyond. Interestingly, however, the
scored high on self-esteem were independently longitudinal relations between ego resiliency
characterized by observers as resilient, assertive and ego control differed markedly again for girls
rather than submissive, undiscouraged by and boys. Block (1993) explains the sex-specific
adversity, without fluctuating moods, decisive, pattern of relationships with the differential
having a sense of personal meaning, responsive socialization of the sexes which makes girls grow
to humor, and unpreoccupied by ruminative up in a more structured and directive world than
fantasy (Block & Robins, 1993). However, there boys. In summary, Block and his colleagues
were also a variety of sex differences suggesting (Block, 1993) have provided a great deal of
that self-esteem is embedded into very different evidence for the longitudinal plasticity and
characterological contexts for the two sexes. consistency of personality from childhood to
Young women who scored high on self-esteem early adulthood. In particular, they have shown
seemed happy, warmly extraverted, and deeply that personality development proceeds differ-
concerned about interpersonal relationships, ently for men and women, that consistency and
whereas young men with high self-esteem plasticity are age-period specific and time-
seemed self-focused and defensively critical, limited, and that contextual factors, such as
Context in Personality Development 289
parental child-rearing styles (Roberts, Block, & Hobart, 1987). Perhaps as a consequence of
Block, 1984) and social class membership, these patterns, males and females evidence
influence personality development (see also different patterns of vulnerability/resilience
Caspi, Bem, & Elder, 1989; Caspi, Elder, & for psychological disorders with age. Special
Bem, 1987, 1988). interest has been directed to gender differences
Support for a contextual explanation of in aggression, which increase from childhood to
personality development across the adult life- adulthood, while female prevalence of unipolar
span has also been provided by Jones and depression persists into adulthood and is
Meredith (1996). In this study, latent curve generally twice that of males.
analysis was used to examine six major aspects With respect to depression, women of diverse
of personality for a sample of 211 individuals social roles and ethnic backgrounds appear to
across either a 30- or 40-year time span. Jones display similar risk factors associated with
and Meredith (1996) found that a systematic perceptions of personal control, power struc-
cross-time pattern existed for five of the six tures, and gender stereotyping; even in a
personality characteristics: four of the five relatively advantaged, professional group, wo-
curves indicated personality change, and one men continued to struggle with vulnerability to
curve indicated no change. However, even with depression associated with achievement and
a unifying basic shape to individuals' cross-time affiliation needs in often hostile environments
patterns, Jones and Meredith (1996) found (McGrath, Keita, Strickland, & Russo, 1990).
individual differences in the degree and direc- Nolen-Hoeksema and Girgus (1994) examined
tion of change, with some people showing the literature on sex differences in unipolar
increases, others showing decreases, and yet depression and found the most consistent
others showing little change in personality explanation regarding the depressive experience
across the time period examined. Moreover, related to people's responses, or coping strat-
changes in the personality characteristics were egy, to depressive episodes. While men tended to
in most instances time-limited and age-period favor active responses to negative moods, such
specific, suggesting that individuals responded as thinking of other things, ignoring their
to life-stage specific challenges related to problems, or participating in physical exercise,
changes in social roles or age-graded social women became more ruminative and intro-
transitions (see Caspi, 1987). spective, which matches a more passive and
In summary, studies which have examined emotionally focused feminine style.
personality development from a contextual Profound differences also exist in how men
perspective complement findings from trait- and women subjectively experience their suc-
oriented studies. Overall, these studies show cesses in the academic and intellectual domains.
that both consistency and change characterize For example, many studies have demonstrated
personality development across the life-span gender deviations in the relationship of actual
(Helson, 1993; Helson & Stewart, 1994). More- intellectual performance and one's self-concept
over, contextually oriented studies have shown about those performances. Men and boys are
that men's and women's personality develop- more likely to adopt a self-enhancing strategy in
ment often proceeds differently and is related to evaluative situations (Dweck, Davidson, Nel-
different problems of maladaptation and dif- son & Enna, 1978; Martin & Nivens, 1987;
ferent manifestations of mental health problems Roberts, 1991; Roberts & Nolen-Hoeksema,
(see Nolen-Hoeksema & Girgus, 1994). 1989). That is, men tend initially to overestimate
their performance and remain unaffected by
1.09.5.1 Gender, Coping, and Personality negative evaluations, while women underesti-
mate their performance and are more reactive to
Empirical evidence that males and females others' feedback, both positive and negative.
undergo somewhat different development was Such splits are supported by the feedback boys
provided by Cramer (1991). Throughout the and girls receive from parents and teachers
school age period, males progressively externa- (American Association of University Women
lized conflict, relying on protection and/or [AAUW], 1992; Yee & Eccles, 1988).
direct aggression as defenses, while females Contemporary research suggests that such
increasingly used defenses that internalized patterns continue into the late 1990s. Despite
conflict, directing aggression inward. Similarly, few objective differences in intellectual status
Labouvie-Vief reports that women's predomi- between males and females, women on average
nant coping strategies are based on self-doubt continue to attain lower levels of achievement
and turning against the self, while those of men than men (e.g., Kaufman & Richardson, 1982;
are more likely to use strategies of externalizing Tomlinson-Keasey & Blurton, 1992). Although
and dissociating (Diehl, Coyle, & Labouvie- in early childhood, girls equal or surpass boys
Vief, 1996; Labouvie-Vief, Hakim-Larson, & on most measures of school achievement, by
early adolescence, they show a steady decline in We have suggested that with the broad world-
self-esteem as they go through school. By high wide reorganization in population dynamics,
school, girls are found to retreat from age distributions, and information systems has
achievement-related challenges, particularly in come a new way to look at development across
math and science (AAUW, 1992; Kerr, 1985; the life-span. Not only has the concept of
Terman & Oden, 1959; Yee & Eccles, 1988). development been pushed from early adulthood
Especially in such gender-stereotyped areas as into later adult stages, but the kinds of
math, this results in girls' disclaiming a sense of characteristics supposed to indicate ªmatureº
agency, even though they may outperform boys functioning also have been broadened. In
(Byrne, Shavelson, & Marsh, 1992). general, there is a strong emphasis on complex-
The work of Gilligan (Gilligan, 1982, 1990) ity and introspection, on the integration of
and others also shows that girls who, at the emotion and cognition, and on the ability to
dawning of adolescence were self-assured and locate oneself in a complex network of
outspoken, become increasingly tentative and contextual, historical, and interpersonal regula-
silent about what they know. In part, the girls' rities. In addition, in contrast to traditional
silence mirrors the silence of adult women who views, recent developmental approaches also
act as their models. ªAt the edge of adolescence, have systematically highlighted the role of
eleven- and twelve-year old girls observe where context in shaping individualized patterns of
and when women speak and when they are development.
silentº (Gilligan, 1990, p. 25). In part, they come This shift is visible both in the area of
to doubt that what girls and women know and cognitive and of personality development. In
experience has value in the adult world, because both of these domains, research has increasingly
it too often ªbrings a message of exclusionÐ departed from old stability assumptions and
stay out; because it brings a message of pointed out the wide range to which dimensions
subordinationÐstay under; because it brings of cognition and personality change over
a message of objectificationÐbecome an object individual and historical time. We have also
of another's worship or desire, see yourself as placed emphasis on research that suggests that
you have been seen over centuries through a despite this diversity of developmental patterns,
male gaze . . . keep quiet and notice the absence there may be several relatively uniform change
of women and say nothingº (Gilligan, 1990, patterns that characterize different stages of
p. 26). adulthood. Thus, research on transitions from
As noted earlier, however, these different early to late adulthood indicates that there may
orientations may be particularly characteristic be a host of reorganizations that lend substance
of the early half of the life-span, while the second to older notions of a ªmidlife crisis,º with
half brings a relaxation of the demands for ªsex- increases in complexity of thinking about
appropriateº behaviors (Jung, 1932; Labouvie- change and psychological process in self and
Vief, 1994). As reviewed by Labouvie-Vief others.
(1994), some individuals around the middle of
adulthood do appear to experience such
ACKNOWLEDGMENT
integrative changes. Accordingly, some women
around midlife claim domains they have Preparation of this chapter was supported by
avoided thus far, moving from a stance of grant 1RO1-AG09203 to the first author.
interiority to one of openness, assertiveness, and
power. In turn, some men integrate their
ªfeminineº aspects, accepting their vulnerability 1.09.7 REFERENCES
and nurturance. However, many studies have American Association of University Women (1992). The
not carefully ruled out alternative interpreta- AAUW report: How schools shortchange girls. Washing-
tions. For example, Gutmann's discussions ton, DC: AAUW Educational Foundation.
Adams, C. (1986). Qualitative changes in text memory
suggest that some men, rather than integrating from adolescence to mature adulthood. Unpublished
notions of feminine power, become threatened doctoral dissertation, Wayne State University, Detroit,
and enfeebled by a sense of owerpowering, MI.
ªmasculineº women. Further, such postulated Adams, C., Labouvie-Vief, G., Hobart C. J., & Dorosz M.
(1990). Adult age group differences in story recall style.
midlife changes have not yet been differentiated Journal of Gerontology, 45, P17±P27.
from cultural/cohort changes that may imply a Aldwin, C. M. (1994). Stress, coping, and development: An
move towards less gender role polarization. integrative perspective. New York: Guilford Press.
Allport, G. W. (1937). Personality: A psychological inter-
pretation. New York: Holt.
1.09.6 CONCLUSIONS Allport, G. W., & Odbert, H. S. (1936). Trait names: A
psycho-lexical study. Psychological Monographs, 47 (1,
In this chapter, we have reviewed some recent Whole Issue No. 211).
trends in the domain of life-span development. Aries, P. (1962). Centuries of childhood: A social history of
References 291
family life (R. Baldick, Trans.) New York: Vintage Biddel, T. R., & Fischer, K. W. (1992). Beyond the stage
Books. debate: Action, structure, and variability in Piagetian
Armon, C. (1984). Ideals of the good life and moral theory and research. In R. J. Sternberg & C. A. Berg
judgment: Ethical reasoning. In M. L. Commons, F. A. (Eds.), Intellectual development (pp. 100±140). New
Richards, & C. Armon (Eds.), Beyond formal operations: York: Cambridge University Press.
Late adolescent and adult cognitive development Blanchard-Fields, F. (1986). Reasoning on social dilemmas
(pp. 357±380). New York: Praeger. varying in emotional saliency: An adult developmental
Ashmore, R. D., & Ogilvie, D. M. (1992). He's such a nice perspective. Psychology and Aging, 1, 325±332.
boy . . . when he's with grandma: Gender and evaluation Blanchard-Fields, F. (1996). The role of emotion in social
in self-with-other representations. In T. M. Brinthaupt & cognition across the adult life-span. In K. W. Schaie
R. P. Lipka (Eds.), The self: Definitional and methodo- (Chair), Cognitive and affective aspects of emotion.
logical issues (pp. 236±290). Albany, NY: State Uni- Symposium conducted at the 1996 Emotion and Adult
versity of New York Press. Development Conference, University Park, PA.
Bakan, D. (1966). The duality of human existence. Chicago: Blatt, S. J. & Shichman, S. (1983). Two primary config-
Rand McNally. urations of psychopathology. Psychoanalysis and Con-
Baltes, P. B. (1987). Theoretical propositions of life-span temporary Thought, 6, 187±254.
developmental psychology: On the dynamics between Block, J. (1971). Lives through time. Berkeley, CA:
growth and decline. Developmental Psychology, 23, Bancroft.
611±626. Block, J. (1981). Some enduring and consequential
Baltes, P. B., & Baltes, M. M. (1990). Psychological structures of personality. In A. I. Rabin, J. Aronoff, A.
perspectives on successful aging: The model of selective M. Barclay, & R. A. Zucker (Eds.), Further explorations
optimization with compensation. In P. B. Baltes & M. in personality (pp. 27±43). New York: Wiley.
M. Baltes (Eds.), Successful aging: Perspectives from the Block, J. (1993). Studying personality the long way. In D.
behavioral sciences (pp. 1±34). Cambridge, UK: Cam- C. Funder, R. D. Parke, C. Tomlinson-Keasey, & K.
bridge University Press. Widaman (Eds.), Studying lives through time: Personality
Baltes, P. B., Dittmann-Kohli, F., & Kliegl, R. (1986). and development (pp. 9±41). Washington, DC: American
Reserve capacity of the elderly in aging-sensitive tests of Psychological Association.
fluid intelligence: Replication and extension. Psychology Block, J. (1995a). A contrarian view of the five-factor
and Aging, 1, 172±177. approach to personality description. Psychological Bul-
Baltes, P. B., & Kliegl, R. (1992). Further testing of limits letin, 117, 187±215.
in cognitive plasticity in old age: Negative age differences Block, J. (1995b). Going beyond the five factors given:
in a mnemonic skill are robust. Developmental Psychol- Rejoinder to Costa and McCrae (1995) and Goldberg
ogy, 28, 121±125. and Saucier (1995). Psychological Bulletin, 117, 226±229.
Baltes, P. B., & Labouvie, G. V. (1973). Adult development Block, J., Gjerde, P. F., & Block, J. H. (1991). Personality
of intellectual performance: Description, explanation, antecedents of depressive tendencies in 18-year-olds: A
and modification. In C. Eisdorfer & M. P. Lawton prospective study. Journal of Personality and Social
(Eds.), The psychology of adult development and aging Psychology, 60, 726±738.
(pp. 157±219). Washington, DC: American Psychologi- Block, J., & Robins, R. W. (1993). A longitudinal study of
cal Association. consistency and change in self-esteem from early
Baltes, P. B., Lindenberger, U., & Staudinger, U. M. adolescence to early adulthood. Child Development, 64,
(1998). Life-span theory in developmental psychology. In 909±923.
W. Damon & R. M. Lerner (Eds.), Theoretical models of Block, J. H., & Block, J. (1980). The role of ego-control
human development. Handbook of child psychology (5th and ego-resiliency in the organization of behavior. In W.
ed., Vol. 1) New York: Wiley. A. Collins (Ed.), Minnesota Symposium on Child
Baltes, P. B., Smith, J., & Staudinger, U. M. (1992). Psychology: Vol. 13. Development of cognition, affect,
Wisdom and successful aging. In T. B. Sonderegger and social relations (pp. 39±101). Hillsdale, NJ: Erlbaum.
(Ed.), Nebraska Symposium on Motivation 1991: Vol. 39. Bloom, B. S. (1964). Stability and change in human
Psychology and aging (pp. 123±167). Lincoln, NE: characteristics. New York: Wiley.
University of Nebraska Press. Botwinick, J. (1977). Intellectual abilities. In J. E. Birren &
Baltes, P. B., & Staudinger, U. M. (1993). The search for a K. W. Schaie (Eds.), Handbook of the psychology of aging
psychology of wisdom. Current Directions in Psycholo- (pp. 580±605). New York: Van Nostrand Reinhold.
gical Science, 2, 75±80. Bowlby, J. (1969). Attachment and loss: Attachment (Vol.
Baltes, P. B., & Willis, S. L. (1982). Enhancement 1). New York: Basic Press.
(plasticity) of intellectual functioning in old age: Penn Bowlby, J. (1988). A secure base: Parent±child attachment
State's Adult Development and Enrichment Project and healthy human development. New York: Basic Books.
(ADEPT). In F. I. M. Craik & S. E. Trehub (Eds.), BrandstaÈdter, J. & Greve, W. (1994). The aging self:
Aging and cognitive processes (pp. 353±389). New York: Stabilizing and protective processes. Developmental Re-
Plenum. view, 14, 52±80.
Basseches, M. A. (1984). Dialectical thinking as metasyste- Bronfenbrenner, U. (1979). The ecology of human develop-
matic form of cognitive organization. In M. L. ment: Experiments by nature and design. Cambridge,
Commons, F. A. Richards, & C. Armon (Eds.), Beyond MA: Harvard University Press.
formal operations: Late adolescent and adult cognitive Bruner, J. (1986). Actual minds, possible worlds. Cam-
development (pp. 216±238). New York: Praeger. bridge, MA: Harvard University Press.
Baumeister, R. F. (1986). Cultural change and the struggle Byrne, B. M., Shavelson, R. J., & Marsh, H. W. (1992).
for self. New York: Oxford University Press. Multigroup comparisons in self-concept research: Reex-
Belenky, M. F., Clinchy, B. M., Goldberger, N. R., & amining the assumptions of equivalent structure and
Tarule, J. M. (1986). Women's ways of knowing. New measurement. In T. M. Brinhaupt & R. P. Lipka (Eds.),
York: Basic Books. The self: Definitional and methodological issues (pp.
Benjamin, J. (1988). Bonds of love: Psychoanalysis, femin- 172±203). Albany, NY: State University of New York
ism, and the problem of domination. New York: Pantheon Press.
Books. Carstensen, L. L. (1992). Social and emotional patterns in
Bettelheim, B. (1983). Freud and man's soul. New York: adulthood: Support for socioemotional selectivity theo-
Knopf. ry. Psychology and Aging, 7, 331±338.
Carstensen, L. L. (1996). Social context of emotional and spouse ratings on the NEO Personality Inventory.
experience. In M. P. Lawton (Chair), Social aspects of Journal of Personality and Social Psychology, 54,
emotion. Symposium conducted at the 1996 Emotion 853±863.
and Adult Development Conference, University Park, Costa, P. T., Jr., & McCrae, R. R. (1992a). Professional
PA. manual: Revised NEO Personality Inventory (NEO PI-R)
Carstensen, L. L. & Turk-Charles, S. (1994). The salience and NEO Five-Factor Inventory (NEO-FFI). Odessa,
of emotion across the adult life-span. Psychology and FL: Psychological Assessment Resources.
Aging, 9, 259±264. Costa, P. T., Jr., & McCrae, R. R. (1992b). Trait
Case, R. (1991). Stages in the development of the young psychology comes of age. In T. B. Sonderegger (Ed.),
child's first sense of self. Developmental Review, 11, Nebraska Symposium on Motivation 1991: Vol. 39.
210±230 Psychology and aging (pp. 169±204). Lincoln, NE:
Case, R. (1996). The role of psychological defenses in the University of Nebraska Press.
representation and regulation of close personal relation- Costa, P. T., Jr., & McCrae, R. R. (1994). Set like plaster?
ships across the life-span. In G. Noam & K. Fischer Evidence for the stability of adult personality. In T. F.
(Eds.), Development and vulnerability in close relations Heatherton & J. L. Weinberger (Eds.), Can personality
(pp. 59±88). Hillsdale, NJ: Erlbaum. change? (pp. 21±40). Washington, DC: American Psy-
Caspi, A. (1987). Personality in the life course. Journal of chological Association.
Personality and Social Psychology, 53, 1203±1213. Cox, R. D. (1970). Youth into maturity. New York: Mental
Caspi, A., Bem, D. J., & Elder, G. H., Jr. (1989). Health Materials Center.
Continuities and consequences of interactional styles Cramer, P. (1979). Defense mechanisms in adolescence.
across the life course. Journal of Personality, 57, Developmental Psychology, 15, 477±478.
375±406. Cramer, P. (1991). The development of defense mechanisms:
Caspi, A., Elder, G. H., Jr., & Bem, D. J. (1987). Moving Theory, research, and assessment. New York: Springer-
against the world: Life-course patterns of explosive Verlag.
children. Developmental Psychology, 23, 308±313. Damon, W., & Hart, D. (1982). The development of self-
Caspi, A., Elder, G. H., Jr., & Bem, D. J. (1988). Moving understanding from childhood through adolescence.
away from the world: Life-course patterns of shy Child Development, 53, 841±864.
children. Developmental Psychology, 24, 824±831. Denney, N. W., & Palmer, A. M. (1981). Adult age
Caspi, A., & Silva, P. A. (1995). Temperamental qualities at differences on traditional and practical problem-solving
age three predict personality traits in young adulthood: measures. Journal of Gerontology, 36, 323±328.
Longitudinal evidence from a birth cohort. Child Denney, N. W., & Pearce, K. A. (1989). A developmental
Development, 66, 486±498. study of practical problem solving in adults. Psychology
Cattell, R. B. (1943a). The description of personality: Basic and Aging, 4, 438±442.
traits resolved into clusters. Journal of Abnormal and Diehl, M., Coyle, N., & Labouvie-Vief, G. (1996). Age
Social Psychology, 38, 476±506. and sex differences in strategies of coping and defense
Cattell, R. B. (1943b). The description of personality: 1. across the life-span. Psychology and Aging, 11, 127±139.
Foundations of trait measurement. Psychological Re- Diehl, M., Willis, S. L., & Schaie, K. W. (1995). Everyday
view, 50, 559±594. problem solving in older adults: Observational assess-
Cattell, R. B. (1947). Confirmation and clarification of ment and cognitive correlates. Psychology and Aging, 10,
primary personality factors. Psychometrika, 12, 197±220. 478±491.
Cattell, R. B. (1979). Personality and learning theory: Vol. Dixon, R. A., & BaÈckman, L. (Eds.) (1995). Compensating
1. The structure of personality in its environment. New for psychological deficits and declines: Managing losses
York: Springer. and promoting gains. Mahwah, NJ: Erlbaum.
Cavanaugh, J. C. (1997). Adult development and aging (3rd Douglas, K., & Arenberg, D. (1978). Age changes, cohort
ed.). Pacific Grove/CA: Brooks Cole. differences, and cultural change on the Guilford±
Clayton, V. P., & Birren, J. E. (1980). The development of Zimmerman Temperament Survey. Journal of Gerontol-
wisdom across the life-span: A reexamination of an ogy, 33, 737±747.
ancient topic. In P. B. Baltes & O. G. Brim, Jr. (Eds.), Dweck, C. S., Davidson, W., Nelson, S., & Enna, B. (1978).
Life-span development and behavior (Vol. 3, pp. 103±135). Sex differences in learned helplessness: II. The contigen-
New York: Academic Press. cies of evaluation feedback in the classroom; III. An
Clinchy, B., & Zimmerman C. (1982). Epistemology and experimental analysis. Developmental Psychology, 14,
agency in the development of undergraduate women. In 268±276.
P. Perun (Ed.), The undergraduate woman (pp. 161±181). Elias, N. (1982). The civilizing process: Vol. 2: Power and
Lexington, MA: Lexington Book. civility. New York: Pantheon.
Commons, M. L., Richards, F. A. & Kuhn D. (1982). Emmons, R. A. (1995). Levels and domains in personality:
Systematic and metasystematic reasoning: A case for An introduction. Journal of Personality, 63, 341±364.
levels of reasoning beyond Piaget's stage of formal Epstein, S. (1990). Cognitive-experiential self-theory. In L.
operations. Child Development, 53, 1058±1069. A. Pervin (Ed.), Handbook of personality: Theory and
Conley, J. J. (1984). Longitudinal consistency of adult research. New York: Guilford Press.
personality: Self-reported psychological characteristics Erikson, E. H. (1982). The life cycle completed. New York:
across 45 years. Journal of Personality and Social Norton.
Psychology, 47, 1325±1333. Eysenck, H. J. (1982). Personality, genetics and behavior.
Conley, J. J. (1985). Longitudinal stability of personality New York: Praeger.
traits: A multitrait-multimethod-multioccasion analysis. Field, D., & Millsap, R. E. (1991). Personality in advanced
Journal of Personality and Social Psychology, 49, old age: Continuity or change? Journal of Gerontology:
1266±1282. Psychological Science, 46, P299±P308.
Costa, P. T., Jr., & McCrae, R. R. (1980). Still stable after Fischer, K. W. (1980). A theory of cognitive development:
all these years: Personality as a key to some issues in The control and construction of hierarchies of skills.
adulthood and old age. In P. B. Baltes & O. G. Brim, Jr. Psychological Review, 87, 477±531.
(Eds.), Life-span development and behavior (Vol. 3, Fisher, K. W., & Ayoub, C. (1994). Affective splitting and
pp. 65±102). New York: Academic Press. dissociation in normal and maltreated children: Devel-
Costa, P. T., Jr., & McCrae, R. R. (1988). Personality in opmental pathways for self in relationships. In D.
adulthood: A six-year longitudinal study of self-reports Cicchetti & S. L. Toth (Eds.), Rochester Symposium on
References 293
Developmental Psychopathology: Vol 5. Disorders and adults. Journal of Gerontology: Psychological Sciences,
dysfunctions of the self (pp. 147±222). Rochester, NY: 50B, P141±P149.
Rochester University Press. Hazan, C., & Shaver, P. (1994). Attachment as an
Fischer, K. W., Hand, H. H., & Russell, S. (1984). The organizational framework for research on close relation-
development of abstractions in adolescence and adult- ships. Psychological Inquiry, 5, 1±22.
hood. In M. L. Commons, F. A. Richards, & C. Armon Helson, R. (1967). Personality characteristics and develop-
(Eds.), Beyond formal operations: Late adolescent and mental history of creative college women. Genetic
adult cognitive development (pp. 43±72). New York: Psychology Monographs, 76, 205±256.
Praeger. Helson, R. (1993). Comparing longitudinal studies of adult
Flynn, J. R. (1984). The mean IQ of Americans: Massive development: Toward a paradigm of tension between
gains 1932 to 1978. Psychological Bulletin, 95, 29±51. stability and change. In D. C. Funder, R. D. Parke, C.
Flynn, J. R. (1987). Massive IQ gains in 14 nations: What Tomlinson-Keasey, & K. Widaman (Eds.), Studying lives
IQ tests really measure. Psychological Bulletin, 101, through time: Personality and development (pp. 93±119).
171±191. Washington, DC: American Psychological Association.
Fordham, F. (1966). An introduction to Jung's psychology. Helson, R., Mitchell, V., & Moane, G. (1984). Personality
New York: Penguin. and patterns of adherence and nonadherence to the
Fowler, J. W. (1981). Stages of faith: The psychology of social clock. Journal of Personality and Social Psychol-
human development and the quest for meaning. San ogy, 46, 1079±1096.
Francisco: Harper & Row. Helson, R., & Moane, G. (1987). Personality change in
Franz, C. E., & White, K. M. (1985). Individuation and women from college to midlife. Journal of Personality
attachment in personality development: Extending Erik- and Social Psychology, 53, 176±186.
son's theory. Journal of Personality, 53, 224±256. Helson, R., & Stewart, A. J. (1994). Personality change in
Freud, S. (1925/1963). Some psychological consequences of adulthood. In T. F. Heatherton & J. L. Weinberger
the anatomical differences between the sexes. In P. Rieff (Eds.), Can personality change? (pp. 201±225). Washing-
(Ed.), Sexuality and the psychology of love (pp. 183±193). ton, DC: American Psychological Association.
New York: Macmillan. Helson, R., Stewart, A. J., & Ostrove, J. (1995). Identity in
Gardner, M. K., & Clark, E. (1992). The psychometric three cohorts of midlife women. Journal of Personality
perspective on intellectual development in childhood and and Social Psychology, 69, 544±557.
adolescence. In J. R. Sternberg & C. A. Berg (Eds.), Helson, R., & Wink, P. (1992). Personality change in
Intellectual development (pp. 16±43). New York: Cam- women from the early 40s to the early 50s. Psychology
bridge University Press. and Aging, 7, 46±55.
Gergen, K. J. (1991). The saturated self. New York: Basic Hertzog, C., Schaie, K. W., & Gribbin, K. (1978).
Books. Cardiovascular disease and changes in intellectual
Gilligan, C. (1982). In a different voice. Cambridge, MA: functioning from middle to old age. Journal of Gerontol-
Harvard University Press. ogy, 33, 872±883.
Gilligan, C. (1990, Fall). Joining the resistance: Psychol- Hofland, B. F., Willis, S. L., & Baltes, P. B. (1981). Fluid
ogy, politics, girls and women. Michigan Quarterly intelligence performance in the elderly: Intraindividual
Review, 501±536. variability and conditions of assessment. Journal of
Gjerde, P. F. (1995). Alternative pathways to chronic Educational Psychology, 73, 573±586.
depressive symptoms in young adults: Gender differ- Horn, J. L., & Cattell, R. B. (1966). Refinement and test of
ences in developmental trajectories. Child Development, the theory of fluid and crystallized intelligence. Journal
66, 1277±1300. of Educational Psychology, 57, 253±270.
Goldberg, L. R. (1981). Language and individual differ- Horn, J. L., & Hofer, S. M. (1992). Major abilities and
ences: The search for universals in personality lexicons. development in the adult period. In R. J. Sternberg & C.
In L. Wheeler (Ed.), Review of personality and social A. Berg (Eds.), Intellectual development (pp. 44±99). New
psychology (Vol. 2, pp. 203±234). Beverly Hills, CA: York: Cambridge University Press.
Sage. Inhelder, B. & Piaget J. (1975). The growth of logical
Greenberg, J. R. & Mitchell, S. A. (1983). Object relations thinking: From childhood to adolescence. New York:
in a psychoanalytic theory. Cambridge, MA: Havard Basic Books.
University Press. Jaques, E. (1965). Death and the mid-life crisis. Interna-
Guisinger, J. S., & Blatt, S. J. (1994). Individuality and tional Journal of Psychoanalysis, 46, 502±514.
relatedness. American Psychologist, 49, 104±111. Jepson, K. & Labouvie-Vief, G. (1992). Symbolic proces-
Gutmann, D. (1987). Reclaimed powers: Toward a new sing in youth and elders. In R. West & J. Sinnott (Eds.),
psychology of men and women in later life. New York: Everyday memory and aging: Current research and
Basic Books. methodology. New York: Springer.
Haan, N., Millsap, R., & Hartka, E. (1986). As time goes John, O. P. (1990). The ªBig-Five' factor taxonomy:
by: Change and stability in personality over fifty years. Dimensions of personality in the natural language and
Psychology and Aging, 1, 220±232. in questionnaires. In L. A. Pervin (Ed.), Handbook of
Hareven, T. K. (1978). The last stage: Historical adulthood personality: Theory and research (pp. 66±100). New
and old age. In E. H. Erikson (Ed.), Adulthood York: Guilford Press.
(pp. 201±215) New York: Norton. Johns, R. S., Mednick, S. A., & Shulsinger, F. (1982).
Harter, S., & Monsour, A. (1992). Developmental analysis Teacher reports as a prediction of schizophrenia and
of conflict caused by opposing attributes in the borderline schizophrenia: A Bayesian decision analysis.
adoloescent self-portrait. Developmental Psychology, 28 Journal of Abnormal Psychology, 91, 399±413.
(2), 251±260. Jones, C. J., & Meredith, W. (1996). Patterns of personality
Hauser, S. T. (1976). Loevinger's model and measure of change across the life-span. Psychology and Aging, 11,
ego development: A critical review. Psychological Bulle- 57±65.
tin, 83, 928±955. Jung, C. G. (1933). Modern man in search of a soul (Trans.
Hayslip, B., Jr. (1989). Alternative mechanisms for W. S. Dell & C. F. Baynes). New York: Harcourt Brace
improvements in fluid ability performance among older & World.
adults. Psychology and Aging, 4, 122±124. Kagan, J., & Moss, H. A. (1962). Birth to maturity. New
Hayslip, B., Jr., Maloy, R. M., & Kohl, R. (1995). Long- York: Wiley.
term efficacy of fluid ability interventions with older Kaufman, D. R., & Richardson, B. L. (1982). Achievement
and women: Challenging the assumptions. New York: adult cognitive development. In R. L. Sternberg & C. A
Free Press. Berg (Eds.), Intellectual development (pp. 197±228). New
Kegan, R. (1982). The evolving self. Cambridge, MA: York: Cambridge University Press.
Harvard University Press. Labouvie-Vief, G. (1994). Psyche and Eros: Mind and
Kernberg, O. F. (1980). Internal world and external reality. gender in the life course. New York: Cambridge
New York: Aronson. University Press.
Kerr, B. A. (1985). Smart girls, gifted women. Columbus, Labouvie-Vief, G. (in press). Emotional integration in later
OH: Ohio Publishing. life. In P. M. Lawton & K. W. Schaie (Eds.), Emotions in
Kitchener, K. S. & Brenner, H. G. (1990). Wisdom and adult development. New York: Springer.
reflective judgement: Knowing in the face of uncertainty. Labouvie-Vief, G., & Chandler, M. J. (1978). Cognitive
In R. Sternberg (Ed.), Wisdom: Its nature, origins and development and life-span developmental theory: Idea-
development (pp. 212±229). Cambridge, UK: Cambridge listic vs. contextual perspectives. In P. B. Baltes (Ed.),
University Press. Life-span development and behavior. New York: Aca-
Kitchener, K. S., & King, P. M. (1981). Reflective demic Press.
judgment: Concepts of justification and their relation- Labouvie-Vief, G., Chiodo, L. M., Goguen, L. A., Diehl,
ship to age and education. Journal of Applied Develop- M., & Orwoll, L. (1995). Representations of self across
mental Psychology, 2, 89±116. the life-span. Psychology and Aging, 10, 404±415.
Kitchener, K. S., King, P. M., Wood, P. K., & Davison, M. Labouvie-Vief, G., DeVoe, M., & Bulka, D. (1989).
L. (1989). Sequentiality and consistency in the develop- Speaking about feelings: Conceptions of emotion across
ment of reflective judgment: A six-year longitudinal the life-span. Psychology and Aging, 4, 425±437.
study. Journal of Applied Developmental Psychology, 10, Labouvie-Vief, G, & Diehl, M. (1996). Cognitive complex-
73±95. ity and maturity of coping and defense: Two dimensions of
Kliegl, R., Smith, J., & Baltes, P. B. (1989). Testing-the- cognitive-emotional development. Manuscript submitted
limits and the study of adult age differences in cognitive for publication.
plasticity of a mnemonic skill. Developmental Psychol- Labouvie-Vief, G., Diehl, M., Chiodo, L. M., & Coyle, N.
ogy, 25, 247±256. (1995). Representations of self and parents across the
Kogan, N. (1990). Personality and aging. In J. E. Birren & life-span. Journal of Adult Development, 2, 207±222.
K. W. Schaie (Eds.), Handbook of the psychology of aging Labouvie-Vief, G., & Gonda, J. N. (1976). Cognitive
(3rd ed., pp. 330±346). San Diego, CA: Academic Press. strategy training and intellectual performance in the
Kohlberg, L. (1984). Essays on moral development: Vol. 2. elderly. Journal of Gerontology, 31, 327±332.
The psychology of moral development. San Francisco, Labouvie-Vief, G., Hakim-Larson, J., DeVoe, M., &
CA: Harper & Row. Scholeberlein, S. (1989). Emotions and self-regulation:
Kohn, M. L., & Schooler, C. (1973). Occupational A life-span view. Human Development, 32, 279±299.
experience and psychological functioning: An assessment Labouvie-Vief, G., Hakim-Larson, J., & Hobart, C. J.
of reciprocal effects. American Sociological Review, 38, (1987). Age, ego level, and the life-span development of
97±118. coping and defense processes. Psychology and Aging, 2,
Kohut, H. (1977). The restoration of the self. New York: 286±293.
International Universities Press. Labouvie-Vief, G., & Schell, D. (1982). Learning and
Kramer, D. A. (1989). Development of an awareness of memory in later life: A developmental perspective. In B.
contradiction across the life-span and the question of Wolman & G. Stricker (Eds.), Handbook of develop-
post-formal operations. In M. L. Commons, J.-D. mental psychology (pp. 829±846). Englewood Cliffs, NJ:
Sinnott, F. A. Richards, & C. Armon (Eds.), Adult Prentice-Hall.
development: Vol. 1. Comparisons and applications of Lachman, M. E., Weaver, S. L., Bandura, M., Elliott, E., &
developmental models (pp. 133±160). New York: Praeger. Lewkowicz, C. J. (1992). Improving memory and control
Kramer, D. A., & Woodruff, D. S. (1986). Relativistic and beliefs through cognitive restructuring and self-generated
dialectical thought in three adult age groups. Human strategies. Journal of Gerontology: Psychological
Development, 29, 280±290. Sciences, 47, P293±P299.
Labouvie-Vief, G. (1977). Adult cognitive development: In Lazarus, R. S. (1991). Emotion and adaptation. New York:
search of alternative interpretations. Merrill-Palmer Oxford University Press.
Quarterly, 23, 227±263. Leon, G. R., Gillum, B., Gillum, R., & Gouze, M. (1979).
Labouvie-Vief, G. (1980). Beyond formal operations: Uses Personality stability and change over a 30-year period:
and limits of pure logic in life-span development. Human Middle to old age. Journal of Consulting and Clinical
Development, 23, 141±161. Psychology, 47, 517±524.
Labouvie-Vief, G. (1981). Re-active and pro-active aspects Levinson, D. J., Darrow, C. N., Klein, E. B., Levinson, M.
of constructivism: A life-span model. In R. M. Lerner & H., & McKee, B. (1978). The seasons of a man's life. New
N. A. Busch-Rossnagel (Eds.), Individuals as producers of York: Ballantine.
their development: A life-span perspective (pp. 197±320). Loevinger, J. (1976). Ego development: Conceptions and
New York: Academic Press. theories. San Francisco, CA: Jossey-Bass.
Labouvie-Vief, G. (1982a). Dynamic development and Loevinger, J. & Wessler, R. (1970). Measuring ego
mature autonomy: A theoretical prologue. Human development. San Francisco, CA: Jossey-Bass.
Development, 25, 161±191. Lyotard, J. F. (1987). The postmodern condition. In K.
Labouvie-Vief, G. (1982b). Growth and aging in life-span Baynes, J. Bohman, & T. McCarthy (Eds.), After
perspective. Human Development, 25, 65±79. philosophy: End or transformation (pp. 73±94). Cam-
Labouvie-Vief, G. (1985). Intelligence and cognition. In J. bridge, MA: MIT Press.
E. Birren & K. W. Schaie (Eds.), Handbook of the Magnusson, D., & ToÈrestad, B. (1993). A holistic view of
psychology of aging (2nd ed., pp. 500±530). New York: personality: A model revisited. Annual Review of
Van Nostrand Reinhold. Psychology, 44, 427±452.
Labouvie-Vief, G. (1990). Wisdom as integrated thought: Martin, V., & Nivens, M. K. (1987). The attritional
Historical and developmental perspectives. In R. J. response of males and females to noncontigent feedback.
Sternberg (Ed.), Wisdom: Its nature, origins, and devel- Sex Roles, 16, 453±462.
opment (pp. 52±83). Cambridge, UK: Cambridge Uni- McAdams, D. P. (1985). Power, intimacy, and the life story:
versity Press. Personological inquiries into identity. New York: Dorsey
Labouvie-Vief, G. (1992). A neo-Piagetian perspective on Press.
References 295
McAdams, D. P. (1992). The five-factor model in Salthouse, T. A. (1990). Cognitive competence and
personality: A critical appraisal. Journal of Personality, expertise in aging. In J. E. Birren & K. W. Schaie
60, 329±361. (Eds.), Handbook of the psychology of aging (3rd ed.,
McAdams, D. P. (1994). Can personality change? Levels of pp. 310±319). San Diego, CA: Academic Press.
stability and growth in personality across the life-span. Salthouse, T. A. (1991). Theoretical perspectives on
In T. F. Heatherton & J. L. Weinberger (Eds.), Can cognitive aging. Hillsdale, NJ: Erlbaum.
personality change? (pp. 299±313). Washington, DC: Sampson, E. E. (1977). Psychology and the American ideal.
American Psychological Association. Journal of Personality and Social Psychology, 35,
McCrae, R. R., & Costa, P. T., Jr. (1990). Personality in 767±782.
adulthood. New York: Guilford Press. Schaie, K. W. (1965). A general model for the study of
McGrath, E., Keita, G. P., Strickland, B. R., & Russo, N. developmental problems. Psychological Bulletin, 64,
F. (1990). Women and depression: Risk factors and 91±107.
treatment issues. Washington, DC: American Psycholo- Schaie, K. W. (1983). What can we learn from the
gical Association. longitudinal study of adult psychological development?
Mead, M. (1970). Culture and committment. Garden City, In K. W. Schaie (Ed.), Longitudinal studies of adult
NJ: Doubleday. psychological development (pp. 1±19). New York: Guil-
Moss, H. A., & Susman, E. J. (1980). Longitudinal study of ford Press.
personality development. In O. G. Brim, Jr., & J. Kagan Schaie, K. W. (1984). Midlife influences upon intellectual
(Eds.), Constancy and change in human development functioning in old age. International Journal of Behavior-
(pp. 530±595). Cambridge, MA: Harvard University Press. al Development, 7, 463±478.
Neumann, E. (1954). The origins and history of conscious- Schaie, K. W. (1986). Beyond calendar definitions of age,
ness. Princeton, NJ: Princeton University Press. time, and cohort: The general developmental model
Nolen-Hoeksema, S., & Girgus, J. S. (1994). The emer- revisited. Developmental Review, 6, 252±277.
gence of gender differences in depression during adoles- Schaie, K. W. (1994). The course of adult intellectual
cence. Psychological Bulletin, 115, 424±443. development. American Psychologist, 49, 304±313.
Norman, W. T. (1963). Toward an adequate taxonomy of Schaie, K. W. (1996). Intellectual development in adulthood:
personality attributes: Replicated factor structure in peer The Seattle Longitudinal Study. New York: Cambridge
nomination personality rating. Journal of Abnormal and University Press.
Social Psychology, 66, 574±583. Schaie, K. W., & Willis, S. L. (1986). Can intellectual
Pascual-Leone, J. (1984). Attention, dialectic, and mental decline in the elderly be reversed? Developmental
effort: Toward an organismic theory of life stages. In M. Psychology, 22, 223±232.
L. Commons, F. A. Richards, & C. Armon (Eds.). Schaie, K. W., & Willis, S. L. (1991). Adult personality and
Beyond formal operations: Late adolescent and adult psychomotor performance: Cross-sectional and long-
cognitive development. New York: Praeger. itudinal analyses. Journal of Gerontology: Psychological
Perry, W. G. (1970). Forms of intellectual and ethical Sciences, 46, P275±P284.
development in the college years. New York: Holt, Scheibel, A. B. (1996). Structural and functional changes in
Rinehart & Winston. the aging brain. In J. E. Birren & K. W. Schaie (Eds.),
Piaget, J. (1980). Experiments in contradiction (Trans. D. Handbook of the psychology of aging (4th ed.,
Coleman). Chicago: University of Chicago Press. pp. 105±128). San Diego, CA: Academic Press.
Poon, L. W., Rubin, D. C., & Wilson, B. A. (Eds.). (1989). Schmitz-Scherzer, R., & Thomae, H. (1983). Constancy
Everyday cognition in adulthood and late life. New York: and change of behavior in old age: Findings from the
Cambridge University Press. Bonn Longitudinal Study on Aging. In K. W. Schaie
Puckett, J. M., & Reese, H. W. (Eds.). (1993). Mechanisms (Ed.), Longitudinal studies of adult psychological devel-
of everyday cognition. Hillsdale, NJ: Erlbaum. opment (pp. 191±221). New York: Guilford Press.
Redmore, C. D., & Loevinger, J. (1979). Ego development Schooler, C. (1987). Psychological effects of complex
in adolescence: Longitudinal studies. Journal of Youth environments during the life-span: A review and theory.
and Adolescence, 8, 1±20. In C. Schooler & K. W. Schaie (Eds.), Cognitive
Reese, H., & Overton, W. (1970). Models of development functioning and social structure over the life course
and theories of development. In L. R. Goulet & P. B. (pp. 24±49). Norwood, NJ: Ablex.
Baltes (Eds.), Life-span development psychology Schultz, R. (1996). Experiences of affects and emotions
(pp. 115±145). New York: Academic Press. over the life course. In K. W. Schaie (Chair), Cognitive
Reich, K. H. (1990). Commonalities and differences of and affective aspects of emotion. Symposium conducted
Piagetian operations and complementary reasoning: A at the 1996 Emotion and Adult Development Con-
conceptual model and its support by empirical data. Paper ference, University Park, PA.
presented at the meeting of the Jean Piaget Society, Selman, R. L. (1980). The growth of interpersonal under-
Philadelphia. standing: Developmental and clinical analyses. New York:
Riegel, K. F. (1973). Dialectical operations: The final Academic Press.
period of cognitive development. Human Development, Siegler, I. C., George, L. K., & Okun, M. A. (1979). Cross-
16, 346±370. sequential analysis of adult personality. Developmental
Riegel, K. F. (1976). The dialectics of human development. Psychology, 15, 350±351.
American Psychologist, 13, 689±700. Siegler, R. S., & Richards, D. D. (1982). The development
Roberts, T. (1991). Gender and influence of evaluations on of intelligence. In R. J. Sternberg (Ed.), Handbook of
self-assessments in achievement settings. Sex Roles, 32, human intelligence (pp. 897±971). New York: Cambridge
297±308. University Press.
Roberts, G., Block, J. H., & Block, J. (1984). Continuity Sinnott, J. D. (1989). Life-span relativistic postformal
and change in parents' child-rearing practices. Child thought: Methodology and data from everyday problem
Development, 55, 586±597. solving studies. In M. L. Commons, J. D. Sinnott, F. A.
Roberts, T., & Nolen-Hoeksema, S. (1989). Sex differences Richards, & C. Armon (Eds.), Adult development: Vol. 1.
in reactions to evaluative feedback. Sex Roles, 21, Comparisons and applications of developmental models
725±747. (pp. 239±278). New York: Praeger.
Rosenberg, S. D., & Farrell, M. P. (1976). Identity and Skolnick, A. (1986). Early attachment and personal
crisis in middle-aged men. International Journal of Aging relationships across the life course. In P. B. Baltes, D.
and Human Development, 7, 153±170. Featherman, & R. M. Lerner (Eds.), Life-span develop-
ment and behavior (Vol. 7, pp. 173±206). Hillsdale, NJ: tional practice: An international perspective (pp. 151±176).
Erlbaum. Greenwich, CT: JAI Press.
Staudinger, U. M., & Baltes, P. B. (1994). The psychology Tupes, E. C., & Christal, R. E. (1992). Recurrent
of wisdom. In R. J. Sternberg (Ed.), Encyclopedia of personality factors based on trait ratings. Journal of
intelligence (pp. 1143±1152). New York: Macmillan. Personality, 60, 225±251. (Reprinted from USAF ASD
Staudinger, U. M., & Baltes, P. B. (1996). Interactive Tech. Rep. 61±97, 1961, Lackland, Air Force Base, TX:
minds: A facilitative setting for wisdom-related perfor- US Air Force.)
mance? Journal of Personality and Social Psychology, 71, Vaillant, G. E. (1974). Natural history of male psycholo-
746±762. gical health: II. Some antecedents of healthy adult
Staudinger, U. M., Marsiske, M., & Baltes, P. B. (1995). adjustment. Archives of General Psychiatry, 31, 15±22.
Resilience and reserve capacity in later adulthood: Vaillant, G. E. (1993). The wisdom of the ego. Cambridge
Potentials and limits of development across the life- MA: Harvard University Press.
span. In D. Cicchetti & D. J. Cohen (Eds.), Develop- Whitmont, E. C. (1969). The symbolic quest: Basic concepts
mental psychopathology: Vol. 2. Risk, disorder, and of analytical psychology. New York: Harper & Row.
adaptation (pp. 801±847). New York: Wiley. Willis, S. L., & Schaie, K. W. (1986). Practical intelligence
Sternberg, R. J. (1990), Wisdom: Its nature, origins, and in later adulthood. In R. J. Sternberg & R. K. Wagner
development. Cambridge, UK: Cambridge University (Eds.), Practical intelligence: Nature and origins of
Press. competence in the everyday world (pp. 236±268). New
Stewart, A. J. (1996, August). Personality in middle age: York: Cambridge University Press.
Gender, history and mid-course corrections. Murray Willis, S. L., & Schaie, K. W. (1993). Everyday cognition:
Award Lecture presented at the American Psychological Taxonomic and methodological considerations. In J. M
Association, Toronto, Canada. Puckett & H. W. Reese (Eds.), Mechanisms of everyday
Symonds, P. M. (1961). From adolescent to adult. New cognition (pp. 33±53). Hillsdale, NJ: Erlbaum.
York: Columbia University Press. Winter, D. G. (1996). Personality: Analysis and interpreta-
Terman, L. M., & Oden, M. (1959). Genetic Studies of tion of lives. New York: McGraw-Hill.
Genius: Vol. 5. The gifted group at mid-life. Stanford, CA: Wood, P. K. (1983). Inquiring systems and problem
University of California Press. structure: Implications for cognitive development. Hu-
Thomas, A., & Chess, S. (1986). The New York Long- man Development, 26, 249±265.
itudinal Study: From infancy to early adult life. In R. Yee, D. K., & Eccles, J. S. (1988). Parent perceptions and
Plomin & J. Dunn (Eds.), The study of temperament: attributions for children's math achievement. Sex Roles,
Changes, continuities, and challenges (pp. 39±52). Hills- 19, 317±333.
dale, NJ: Erlbaum. York, K. L., & John, O. P. (1992). The four faces of Eve: A
Tomlinson-Keasey, C., & Blurton, E. U. (1992). Gifted typological analysis of women's personality at midlife.
women's lives: Aspirations, achievements, and personal Journal of Personality and Social Psychology, 63,
adjustment. In J. Carlson (Ed.), Cognition and educa- 494±508.
1.10
Social Psychological Foundations
of Clinical Psychology
JOHN H. HARVEY and JULIA OMARZU
University of Iowa, Iowa City, IA, USA
1.10.1 INTRODUCTION: THE HISTORY OF THE SOCIAL±CLINICAL PSYCHOLOGY INTERFACE 298

1.10.2 SOCIAL PERCEPTION AND ATTRIBUTION 298
1.10.2.1 An Essential Base 298
1.10.2.2 Basic Ideas and Theories 299
1.10.2.2.1 Heider 299
1.10.2.2.2 Jones and Davis 300
1.10.2.2.3 Actor±observer hypothesis and ªfundamental attribution errorº 300
1.10.2.2.4 Social perception and prejudice 301
1.10.2.2.5 Kelley 301
1.10.2.2.6 Bem and Schachter 301
1.10.2.3 More Recent Applications of Attribution Theory 302
1.10.2.3.1 Learned helplessness and depression 302
1.10.2.3.2 Depression and correspondent inference 302
1.10.2.3.3 ªSane in insane placesº 303
1.10.3 SOCIAL INFLUENCE AND PERSUASION 304
1.10.3.1 Theories of Social Influence 304
1.10.3.1.1 Conformity 304
1.10.3.1.2 Group influences 305
1.10.3.1.3 Reducing the effects of negative social influence 306
1.10.3.2 Theories of Persuasion 306
1.10.3.2.1 Cognitive dissonance 306
1.10.3.2.2 Elaboration likelihood 307
1.10.3.3 Resisting Persuasion 308
1.10.4 INTERPERSONAL ATTRACTION AND CLOSE RELATIONSHIPS 309
1.10.4.1 Forming Relationships 309
1.10.4.2 Maintaining Close Relationships 310
1.10.4.3 Dissolving Close Relationships 311
1.10.4.4 Grieving and Recovering from the Loss of Close Relationships 312
1.10.4.4.1 The account 312
1.10.4.4.2 Shattered assumptions 313
1.10.5 ALTRUISM AND HELPING BEHAVIOR 314
1.10.5.1 Psychology's Role in Promoting Human Selfishness 314
1.10.5.2 General Principles of Altruism and Helping Behavior 315
1.10.6 CONCLUSION: SYNTHESIS OF THE ªSOCIAL ANIMAL IN A COMPLEX WORLDº 317
297
298 Social Psychological Foundations of Clinical Psychology
1.10.1 INTRODUCTION: THE HISTORY action psychology that involved the application
OF THE SOCIAL±CLINICAL of theory to the solution of interpersonal and
PSYCHOLOGY INTERFACE group system problems. Frank (1965) wrote
about persuasion and healing. A host of
workers authored or edited books that analyzed
One achieves mental health to the extent that one and stimulated integrations of social and clinical
becomes aware of one's interpersonal relations. psychology, including: Goldstein, Heller, and
(Harry Stack Sullivan) Sechrest (1966), Brehm (1976), Weary and
Mirels (1982), Strong and Claiborn (1982),
In this chapter, we will describe areas of basic and Leary and Miller (1986).
research in social psychology that provide a This high degree of interdisciplinary activity
foundation for applications in clinical psychol- between social and clinical psychology is most
ogy. First, it is important to define social vividly displayed in the 1990s via the research
psychology. We prefer the definition provided published in many scholarly forums. Further-
by pioneering social psychologist Gordon All- more, a journal, the Journal of Social and
port who defined social psychology as ªan Clinical Psychology, explicitly representing this
attempt to understand and explain how the interface, was created in the 1980s (Harvey,
thought, feeling, and behavior of individuals are 1983).
influenced by the actual, imagined, or implied In the following sections, we will review broad
presence of othersº (Allport, 1985, p. 3). The aspects of social psychology's contributions to
breadth of this definition is readily apparent the foundations of clinical psychology. The
when one tries to imagine human situations not following topics will be considered: social
involving one or more of these elements. Even in perception and attribution, including discussion
the realm of biological phenomena, social of prejudice; persuasion and social influence;
processes have been found to interact to influ- interpersonal attraction and close relationships;
ence behavior. From the early part of the and altruism and helping behavior. We should
twentieth century, this breadth of inquiry that stress that our review will be selective. There
represents social psychology has been appealing now is a vast landscape of scholarly interaction
to clinical psychologists interested in under- between social and clinical psychology, with
standing the bases of abnormal behavior. Social work in each field influencing work in the other.
and clinical psychology have a long history of For a handbook-length treatment of this land-
interaction that we will trace very briefly here. scape, the reader is referred to Snyder and
In 1921, Morton Prince and Floyd Allport Forsyth (1991).
changed the title of the Journal of Abnormal
Psychology that Prince had begun in 1906 to the
Journal of Abnormal and Social Psychology 1.10.2 SOCIAL PERCEPTION AND
(JASP). They began this forum to reflect the key ATTRIBUTION
role of interpersonal processes in psychopathol- 1.10.2.1 An Essential Base
ogy and psychotherapy. These scholars had
observed the pivotal role of interpersonal The topics of social perception and attribu-
relations in various aspects of psychopathology tion occupy a central role in research and
observed during World War I and also believed practice in clinical psychology. As will be shown
that the study of social behavior benefited from in a later discussion of Rosenhan's famous study
research on abnormal mental processes. ªOn being sane in insane placesº (Rosenhan,
While JASP was split into the Journal of 1973), social perception, or how we perceive
Abnormal Psychology and the Journal of other people, is central to the understanding of
Personality and Social Psychology in 1965, labeling behavior as abnormal. Rosenhan
explicit work at the interface of clinical and essentially showed that even educated profes-
social psychology has been vigorous since the sionals, too quickly and without cautious
late 1920s. Many scholars deepened our under- scrutiny of the evidence, label others and then
standing of the role of social processes in clinical direct behavior toward them that corresponds
psychology during this period. Various neo- with the label. In so doing, he revealed a major
Freudians including Harry Stack Sullivan and feature of social perception, namely that it often
Karen Horney in the 1920s and 1930s empha- is biased in terms of its rational, careful
sized social processes in phenomena which consideration of available information. Beyond
psychoanalysts previously had interpreted with- Rosenhan's demonstration, it has been recog-
out much reference to interpersonal relations. In nized since the mid-twentieth century that social
the 1930s and 1940s, Kurt Lewin (see Patnoe, perception and attribution, which refers to
1988), known as the founder of experimental inferences about causality and responsibility,
social psychology, promoted his ideas about an are pivotal in determining how people interact
Social Perception and Attribution 299
with one another. These processes, hence, are players' rough play and judged the teams as
critical not only in the unfolding of a person's generally equally guilty of infractions. Thus,
social interactions in all areas of life, but also in there is historical evidence for the idea that
therapist±client interactions during therapy. people can observe the same stimuli and come to
In social psychology, social perception often different judgments based on their motivations
is treated as the general area that subsumes a or self-biasing positions. Such evidence is
number of subareas, including attribution, important both to therapists who must make
social cognition, impression formation, person judgments about the dispositions of patients/
perception, and self-perception (Weary, Stan- clients and also to therapists and clinical
ley, & Harvey, 1989). But since the late 1950s, scholars interested in analyzing the distortions
each of these subtopics has spawned a large, in people's perceptions of others in their social
specialized literature. It has been a long time environment.
since scholars such as Heider (1958) and Kelley
(1967) attempted to integrate the diverse ideas
and findings. Nevertheless, their earlier analyses 1.10.2.2 Basic Ideas and Theories
still have great reach regarding the development
of theory and research pertaining to people's In describing how social perception and
perception of others. attribution help us understand psychopathol-
The concept of self is a general topic that ogy, labeling of mental illness, and therapeutic
traditionally was considered separately from interactions, the early foundation analyses will
social perception (James, 1890). However, self- be described. Heider (1958) provided the most
perception, which refers to the inferences we general statement of social perception and
make about ourselves, was conceived by Bem attribution in describing his naive or common
(1972) as involving a process in which people sense psychology. This psychology was con-
learn about themselves and their attitudes and cerned with how the ªperson on the streetº
dispositions by engaging in an attribution systematizes information to make inferences
process not unlike what they do when they about the social world. It articulated general
make inferences about others. In addition, schemas that people seem to learn and have in
Jones (1964) built on Goffman's (1959) ideas mind in inferring how personal forces such as
about self-presentation and developed a set of traits and skills interact with environmental
penetrating analyses of how people tactically forces such as luck in determining behavior. It
present themselves to others in order to try to included analysis of how people infer: the
fulfill various goals of social interaction. For internal±external dichotomy in much social
example, people may engage in ingratiation, perception, with causal inferences focused either
self-promotion, self-martyring, and so on with on people's traits and states of mind (internal
the goal of social or material gain. attribution) or on environmental forces (ex-
Early work on social perception demon- ternal attribution); the quest to find disposi-
strated the remarkable degree to which people's tional properties behind others' actions because
own self-biases and motivations affect their such properties help the perceiver feel more
perceptions of others. A classic example of this confident about inferences than do external
tendency toward bias in perception was pro- attributions; the causes of success and failure of
vided by Hastorf and Cantril (1954). They their own or others' behavior in achievement
showed students at Dartmouth and Princeton contexts.
Universities film from a football game played in
1951 between those two teams. The game was
1.10.2.2.1 Heider
rough, with lots of penalties especially against
Dartmouth, and Princeton's star All-American Heider (1976) believed that people perceive
selection Dick Kazmaier was injured in the causal relations as part of their basic perception
rough play. Princeton won but commentary in of the environment. He discussed how when the
the local papers continued for some time about back door of his home slammed shut, he
the disgusting display of poor sportsmanship. automatically began to develop inferences,
Hastorf and Cantril's procedure involved starting first with the attribution that his wife
showing students at both schools the same had just come home from grocery shopping. In
portions of the game film and asking them to Heider's analysis, people are seen as trying to
indicate on a questionnaire the rough play develop organized, meaningful perspectives
infractions they saw. Hastorf and Cantril found about the numerous events that they observe
that Princeton students showed a very strong practically every moment of every day, for it is
tendency to judge Dartmouth players as most only ªby referring transient and variable
responsible for the rough play. On the other behavior and events to relatively unchanging
hand, Dartmouth students de-emphasized their underlying conditionsº (1958, p. 79) that
individuals can predict and control their 1.10.2.2.3 Actor±observer hypothesis and
environment. Hence, Heider's answer to why ªfundamental attribution errorº
he believed people are almost always, if only
implicitly, engaged in attributional activity is Jones and colleagues' work on attributional
to enhance their understanding, prediction, processes led to many influential ideas and
and control over their personal and social findings. Jones and Nisbett (1972) proposed the
environments. actor±observer (A±O) hypothesis, which pre-
Heider's 1958 book The psychology of inter- dicts that actors will attribute their behavior to
personal relations provided germs of insights situational forces; whereas an observer of the
that were developed in later syntheses of same action will attribute the behavior to
attribution concepts by Jones and Davis dispositions held by the actor. Jones and
(1965), Kelley (1967), Jones et al. (1972), and Nisbett's reasoning for this proposed A±O
Bem (1972). We will trace these basic ideas as difference was that observers focus on actors
they relate to the foundations of clinical science as the figure part of their figure-ground
in the 1990s. perception of the social world. Also, observers
may not have experience observing a particular
actor previously. Actors, however, do have
experience self-observing how they react differ-
1.10.2.2.2 Jones and Davis
ently according to different situations. In
Jones and Davis (1965) developed correspon- addition, actors perceive the situation as figural
dent inference theory to trace how people search vs. the situation.
for dispositional causes behind others' actions. While factors such as empathy (Regan &
According to this model, people use the Totten, 1975) have been found to reduce the
outcome and nature of actions (including divergence between actors and observers, this
whether the actions were seen as freely taken) hypothesis has had a long and prosperous life in
to infer intention and disposition on the part of the attribution literature. In fact, qualifying
the actor. For example, when members of a jury conditions for the actor-observer effect continue
are making a decision about the guilt of a driver to be studied in the 1990s (e.g., Robins, Spranca,
involved in a traffic accident, they will examine & Mendelsohn, 1996). In general, Jones and
the circumstances surrounding the accident. If colleagues' work has had a rippling effect
the defendant-driver was witnessed to be through clinical psychological research dealing
speeding, they will consider why he or she with the inference of traits by individuals and
was speeding. Freedom of action might be therapists (Harvey & Galvin, 1984). This latter
assessed in the context of the driver's perceived work cautions therapists about the possible
medical emergency. If such an emergency were mistake of interring a person's behavior in terms
perceived by the driver and deemed to be of the person's dispositions, without careful
reasonable by the jury, this may be seen as examination of the situational context of the
reducing the driver's freedom to drive more behavior.
responsibly; hence, the driver may be judged as Jones and colleagues' work also spurred
less culpable. Did the driver have a history of development of the so-called ªfundamental
speeding or receiving driving tickets (such attribution error,º which is a vital concept
evidence pertains to the driver's dispositions)? for clinical psychology and now forms the base
If the driver did have such a history, it may lead for cognitive approaches to prejudice (Ross,
to a stronger judgment that he or she is culpable. 1977). According to the ªfundamental attribu-
Thus, in accord with this type of deductive tion error,º people have a tendency to
reasoning, the jury may be construed as making emphasize dispositional attribution versus si-
a correspondent inference. A correspondent tuational attribution in viewing others' beha-
inference would be that the driver's actions were vior. Across varying types of situations, people
consistent with his or her dispositions. tend to over-attribute actions to dispositions
Factors that Jones and Davis (1965) identi- (Funder, 1987). However, does this tendency
fied as affecting correspondent inferences represent an ªerrorº in the strict sense of an
included the extremity of an outcome and the error (e.g., perceiving that a 200 pound person
social desirability of an action (with extreme weighs 175 pounds)? No, as several scholars
outcomes and low social desirability both (e.g., Harvey, Town, & Yarkin, 1981) have
implicating correspondence regarding an ac- argued, errors in social perception cannot be as
tor's intentions or traits). In the traffic accident readily established as they can in object
example above, if someone were killed because perception (when pounds or inches, for exam-
of the driver's speeding (extreme outcome), even ple, can be measured with their meaning given
the medical emergency might not ameliorate a ordinal values). Rather, what is occurring in
strong judgment against the driver. the research on the ªfundamental attribution
errorº is establishing what more accurately of hypotheses including that extreme outcomes
could be called a ªfundamental bias toward will necessitate multiple necessary causal sche-
dispositionality in attribution.º mata (i.e., when something extreme happens,
people tend quickly to embrace the idea that
there were multiple causes for the event).
1.10.2.2.4 Social perception and prejudice
Kelley's treatment also systematized many of
Jones and colleagues' work also has formed a Heider's ideas, such as the concept that
base for contemporary cognitive approaches to behavior sometimes engulfs the field, meaning
prejudice. These investigators have analyzed that people's behavior is so salient that it
correspondence in attribution mainly in situa- swamps out perception of situational impacts
tions in which people are asked to infer others' on their behavior. This idea is consistent with
attitudes based on their behavior. A ready the ªfundamental attribution errorº and with
application to prejudice is the hypothesis that Bem's (1972) integration of self-perception into
prejudiced people will make negative disposi- attribution theory. Another major contribution
tional attributions regarding a target group's by Kelley (1979) was the introduction of
behavior (e.g., ªThey are on welfare because attribution theoretical reasoning to understand-
they are lazyº). Research in this vein, however, ing close relationships. As shown, for example,
has shown more subtle prejudice effects. Hart by Orvis, Kelley, and Butler (1976), couples
and Morry (in press) found that white observers often diverge in their attributions about the
made different dispositional inferences about causes of conflict in their relationships. This
African-American speakers than they did about divergence, and whether or not it can be affected
white speakers as a function of the speaker's by therapy, may play a significant role in
nonverbal behavior, with the attributions about whether or not their relationship can be
African-American speakers being more polar- sustained over time.
ized in negative as well as positive directions.
Relatedly, in an attitude attribution paradigm
1.10.2.2.6 Bem and Schachter
in which a speaker takes a certain position,
Linville and Jones (1980) found that social Bem (1972) and Schachter (1964) were not
evaluations of outgroup members (opposite sex) explicit attribution theorists. Yet their ideas
were more extreme than evaluations of ingroup have been assimilated into the attribution
members (same sex) in the direction being taken perspective, and each has presented concepts
by the speaker. Such a finding may be readily that have had currency in clinical science. Bem
linked to the evidence of bias in social argued that people use their behavior, and the
perception demonstrated by Hastorf and Can- context in which it occurs, to infer their internal
tril (1954). states, including attitudes. He suggested that
More generally, a defining characteristic of they use the same information they would use in
findings in cognitive social applications of making inferences about others' internal states
attribution theory is the attribution of extreme, to make inferences about their own. This
less complex and varied, qualities to outgroup description of a backward-type attribution/
versus ingroup members (Linville, 1982). As perception process has been influential in
noted by Devine (1989), low prejudice indivi- showing that people do not always have clearly
duals appear to be able to replace stereotype- in mind their attitudes about social issues, nor
congruent thoughts with thoughts reflecting readily understand why they are acting as they
equality, whereas high prejudice individuals do are (Nisbett & Ross, 1980). The power of
not appear to be able to inhibit stereotype- looking back and seeing ourselves engaged in
consistent thoughts (or have the motivation to some line of action (e.g., a fight with our spouse)
do so). may be great in determining what we think, our
next emotional state, and subsequent behavior.
Although Bem's analysis is viewed as extreme in
1.10.2.2.5 Kelley
its rendition of how people make inferences
Kelley(1967, 1972) introduced the idea that about their own attitudes and feelings (Weary et
sometimes people engage in a detailed attribu- al., 1989), it has had an impact on contemporary
tional analysis not unlike the analysis of social perception work and on practitioners'
variance in statistics, and on other occasions emphasis on getting people to act first as a way
they engage in quick deliberations about of constructively changing attitudes and beha-
causality using priming cognitive sets that he vior (as in stopping smoking before a stop-
referred to as causal schemata. His analysis was smoking attitude is firmly in place).
broader than Jones and Davis's model, referring Schachter's (1964) theory of emotion has
both to social and self-perception as well as been strongly linked to clinical issues such as
attribution. His conception suggested a number phobias. This theory argues that perceptible
physiological arousal and labeling of this Teasdale (1978) took Seligman's (1975) idea
arousal in accord with situational or cognitive of learned helplessness in dogs and added
factors are necessary for the subjective experi- attributional components to suggest that people
ence of emotional stress. For example, suppose who are highly depressed are prone to helpless
a person stutters rather badly in various social behavior because of a particular attribution
interactions. In a particular situation involving style they have developed for most important
public speaking, this person may perceive that areas of action. In this depressed attributional
he or she is aroused and attribute the arousal to style, it is hypothesized that individuals do not
fear of public-speaking. If there is no plausible, attribute positive outcomes to their own actions.
outside cause of the arousal, the individual may These outcomes are perceived as external,
become even more anxious. As suggested by global, and chance-oriented factors. If out-
Schachter's students Valins and Nisbett (1972), comes are negative, however, these individuals
the person may exacerbate the stuttering in this perceive themselves as responsible for the
situation when no other source exists for the outcomes. In effect, they are showing help-
anxious arousal. However, if this person were lessness and the accompanying sense of hope-
induced to attribute the arousal to some other lessness, not unlike what Seligman showed with
source (such as a drug taken earlier in the day), it dogs who could not escape electric shock in a
is possible that the real arousal associated with shock box situation.
public-speaking could be lessened by virtue of There is general evidence to support the value
the misattribution of anxiety to the drug. of attributional style in understanding depres-
In an indirect way, this hypothesis was sion. As noted originally, however, no attempt
confirmed in a finding by Storms and Nisbett has been made to link this work to its implicit
(1970) who used placebos in a study with base in Heider's (1958) analysis of the condi-
insomniacs to induce some participants to tions of action, nor to the derivative theory and
believe that the drug would relax them, while research by Weiner (1974) that posited and
others were led to believe that the drug would showed evidence of how people attribute causes
arouse them. The investigators reasoned that for success and failure in achievement contexts.
the participants who were naturally aroused at
bedtime but who could attribute the arousal to
1.10.2.3.2 Depression and correspondent
the drug would get to sleep more quickly than
inference
would those who believed that the drug was
supposed to relax them, yet as usual were Depression is the psychopathology that
aroused. This reverse placebo effect held sway in contemporary cognitive social psychologists
research concerned with application of attribu- most often have tried to understand. Weary
tion theory until the 1980s. From that point, and colleagues' program of work is illustrative.
however, there have been few further demon- They argue that moderately depressed people
strations. The reason probably is that there is (usually college students, since severely de-
always an ethical question associated with pressed or hospitalized persons have seldom
giving people who suffer from some ailment been studied) are particularly sensitive to
false information about what a supposed drug information about others that might render
will do for them. Beyond that, the area never their worlds more understandable, predictable,
established the boundaries very well regarding and controllable. Such information has in-
when indirect versus direct placebo, or sugges- cluded social comparison feedback (Weary,
tion, effects would occur (Kellogg & Baron, Elbin, & Hill, 1987) and another's negative or
1975). unexpected behaviors (Weary, Jordan, & Hill,
1985). Weary and colleagues (1989) further
contend that moderately depressed perceivers
1.10.2.3 More Recent Applications of use a style of information processing that may
Attribution Theory be characterized as effortful, vigilant, and
complex. Accordingly, Yost and Weary (1996)
1.10.2.3.1 Learned helplessness and depression
showed that moderately depressed persons were
In a very general way, attribution theory less likely than nondepressed persons to make
continues to be one of the most frequently correspondent inferences and more likely to
applied approaches to clinical phenomena. The process the available social information when
application is ªgeneralº because unfortunately they were not preoccupied with a cognitive
the work sometimes does not involve much overload task.
bridging between early, basic theory and Going back to the extrapolations of Jones's
contemporary theory. An example is the ideas about correspondence to the ªfunda-
attributional analysis of learned helplessness mental attribution errorº and to our under-
and depression. Abramson, Seligman, and standing of prejudice, Yost and Weary's
research implies that given the opportunity, prior to this time. He also linked the data to
moderately depressed people will be less likely work of Asch (1946) in the impression forma-
to jump to correspondent inferences about tion field, which showed that people often
others. Rather, they will engage in the effortful assimilate perceptions of others around strong,
task of analyzing situations to determine how central traits (ªwarm,º ªcold,º ªcrazyº) that
they may have affected behavior. It is not clear they impute to the others. Perhaps that is what
what severely depressed persons would do in the attending physicians, nurses, and attendants
this situation. They may not even care. As for were doing with the pseudopatients: assimilat-
nondepressed persons and the negative im- ing an interpretation of who they were around
plication of this work for their ready corre- certain labels such as ªsomeone who hears
spondent inferences, the major question may be voices and who feels empty.º
whether they are motivated to be concerned Beyond the implication of the ªstickiness of
about how the situation affected another's the psychodiagnostic label,º it was clear from
behavior, or even to be empathic with another Rosenhan's study that patients are not very
regarding the outcome. carefully observed, at least not back in those
years of mental healthcare. Why? Physicians
may have been too busy. Or they may have
1.10.2.3.3 ªSane in insane placesº
simply assumed that certain behavioral patterns
This was the title of a well-known study by would be observed if, indeed, careful observa-
Rosenhan (1973). In this study, eight ªnormalº tion had been done. Yet, they did not even
persons gained entry to 12 mental hospitals, question the pseudopatients very thoroughly.
many of which were considered to be excellent ªPatient engages in writing behaviorº was the
teaching hospitals, that were located in different daily nursing comment on one of the pseudo-
states on the east and west coasts of the USA. patients, who indicated that he never was asked
The ªPatientsº ranged in age from early what he was writing or why he was writing it.
twenties to middle age and held occupations Consistent with the ªfundamental attribution
such as psychologist, pediatrician, psychiatrist, error,º behaviors that were consistent with
painter, and housewife. They had no history of diagnosis, such as nervousness, were attributed
mental illness. To be admitted, they indicated to the pseudopatient's personality. Rarely did
that they had been hearing vague voices and the analysis of patient behavior look toward the
that they felt their lives were empty and hollow. complex stimuli surrounding the patient. Con-
These symptoms were chosen because there was sistent with what has been referred to as the self-
no indication at that time in the literature of fulfilling prophecy in social perception (Darley
what might be called existential psychoses. The & Fazio, 1980), it was evident to Rosenhan that
pseudopatients also reported typical life courses the typical patient received similar treatment
involving both losses and joys and a variety of from the staff and sometimes reacted by
experiences that were fairly common for showing a sense of powerlessness and resigna-
persons at their age. They then were admitted tion. Rosenhan also suggested that the hier-
to a mental hospital with no knowledge of when archical, often frenzied, atmosphere of the
they would be released. Their behavior in the mental hospital encouraged a depersonalization
hospitals was described as cooperative and of patients by the staff.
friendly. Related to Rosenhan's study is the work of
Rosenhan found that during the public sociologists on labeling theory. Sociological
ªshowº of sanity, when pseudopatients' his- social psychologist Goffman (1959) wrote
tories were taken, there was no instance of cogently about the presentation of self in
detection by the admitting person(s). Nor was everyday life. In this seminal analysis, Goffman
their possible sane condition questioned in any posited the similarity between human social
of the admitting reports. The length of stay behavior and the production of a theatrical
ranged from seven to 52 days, with an average of work, with tactical stage presentations, en-
19 days. The pseudopatients were not carefully trances and exits, and as much going on ªbehind
observed in any instance of hospitalization. the scenesº as was apparent in the presentations
Interestingly, 35 out of 118 patients on the to the audience. Goffman (1961) also produced
admission ward did indicate suspicions about an influential work entitled Asylums that
the sanity of the pseudopatients. addressed the social organization of deviance
Rosenhan offered a number of conclusions based on his observations from playing the role
and speculations regarding this evidence. First, of an inmate in an asylum (Goffman, 1961).
he acknowledged that the tendency to call the Central to Goffman's thinking was the view that
healthy sick may be most pronounced during people readily apply labels to one another, and
the early admissions stage, since there had been even to themselves, and then their behavior
no opportunity to observe the pseudopatients often is consistent with those labels.
The sociologist Thomas Scheff (1966) went Individuals identify themselves by social groups
further than Goffman in his labeling theory as it or categories, and strive to exemplify the
is applied to psychiatric diagnoses. He argued characteristics of these categories while also
that psychiatric diagnoses were merely con- maintaining individual distinctiveness. Thus we
venient labels attached to individuals who are driven to emulate others whom we feel
violated conventional behavioral norms. He belong to our categories, and to differentiate
suggested that the stigmatizing process some- ourselves from those whom we see as outsiders.
times produced disturbed behavior. Concepts of Because social surroundings are in constant
mental illness, according to Scheff, were part of flux, so are the social influences being brought
an ideology embedded in the historical and to bear at any time. As allegiances and the
cultural present of the white middle class of saliencies of particular self-categories shift, so
Western societies. Scheff believed that the do the relative influential strengths of the
functioning of psychiatric labels was to reify individuals surrounding us.
and legitimate the existing social order. There has been a strong negative connotation
A lot of progress in diagnosis and treatment associated with the power of social influence.
has been made since the early writings on Possibly this stems from the pattern of research
labeling theory and Rosenhan's work were in this area which has studied influence primarily
published. Still, this work shows the potential by investigating how social forces can increase
insidious nature of prejudicial social perception individuals' errors in judgment or opinion. It is
processes in influencing mental health diagnosis also possible that a Western cultural emphasis
and treatment. The same type of process may be on the strength of the individual produces a
found in the education and prison systems, and distrust of any social situation which seemingly
in any institution, wherein people are expected diminishes that strength. Social influences,
to progress from one level to another, but are however, are not inherently negative. While
judged as unequally able or prepared for such they may at times make us more susceptible to
progress. The reader also is referred to destructive norms or behaviors, they also
Rosenthal & Jacobson's (1968) demonstration provide the support, affirmation, and security
of the effect of labeling students according to that we, as social animals, need.
pseudo IQ scores on their ªeducational pro-
gress,º as a related piece of evidence about the
1.10.3.1.1 Conformity
impact of labeling.
Conformity consists of changing one's beha-
1.10.3 SOCIAL INFLUENCE AND vior to match a group's social norm. Sherif
PERSUASION (1937) and Asch (1955) performed classic
experimental work demonstrating that indivi-
1.10.3.1 Theories of Social Influence duals confronted with a group norm will often
conform to that norm, even if it is obviously
Why and how are people influenced by the incorrect. Sherif's studies utilized the optical
actions of others? An understanding of how illusion of the autokinetic effect, asking parti-
social interactions affect subsequent behaviors cipants to judge the illusory movement of an
can be invaluable to any clinician. Not only does actually stationary light. The participants'
research in this area help in analyzing troubling judgments converged over time, creating a
situations clients may face, but it also adds a group norm.
depth of understanding to the social interaction Asch, convinced that Sherif's effect was due
inherent in any therapy session. to the ambiguous nature of the stimulus,
Social influence is triggered by the desire to be attempted to demonstrate this using judgments
socially accepted and to fit into a group. of line length. One naive subject was placed in a
Festinger (1954) proposed that people continu- group of confederates. Three lines of varying
ally compare their attitudes and performance to length were displayed to the group. The
those around them in order to verify their researcher then presented a fourth line which
actions and monitor their relative social stand- clearly matched one of the preceding three in
ing. Using this social comparison process, length. The task was simple and unambiguous:
people adjust accordingly in order to gain choose the matching line. Asch expected to see
approval or status. Social influence can alter Sherif's conformity effect disappear.
behavior in both ambiguous situations with no The researcher requested verbal responses,
clear objective answer, and in those where with confederates always answering prior to the
individuals are striving to be accurate or naive participant. The participant thus heard all
factually correct. of the group's answers and knew they would
Social psychologist Turner (1991) proposes a hear his. On a certain percentage of the trials,
social categorization model of social influence. the confederates all gave the same, incorrect
Social Influence and Persuasion 305
answers. Rather than defy the group, a third of People naturally categorize themselves as be-
the subjects conformed to the erring confeder- longing to one group or another, even when the
ates, also giving the incorrect responses (Asch, groups are not clearly defined or even particu-
1955). In postexperimental interviews, these larly meaningful. Assigning people to groups
subjects often reported being confused about with meaningless labels, such as ªoverestima-
the group's behavior but not wanting to ªruinº torsº and ªunderestimatorsº causes individuals
the experiment by being wrong. to align themselves as part of their ªgroupº
Asch and his colleagues conducted many (Brewer & Weber, 1994). Even when subjects are
variations of this paradigm, including changing told they are not yet part of the group, but are
the size of the confederate group and the being considered for later membership, they
magnitude of the confederate ªerror.º There respond to tasks as if they were already group
were always those who conformed. The varia- members (Mackie & Cooper, 1984).
tion that did succeed in virtually eliminating Once individuals identify themselves as
conformity was the inclusion of an ªallyº members of a group, perceptions of self vs.
among the confederates who gave a noncon- others change. ªIngroup biasº develops, such
forming response. Just one other rebel appar- that what one's own group does is seen as better,
ently gave the subjects courage to state their true more important, and preferable to other groups'
judgments. actions. Members of a majority group are
In an interesting sociological extension of the perceived to be more heterogeneous in opinion
conformity work, Jacobs and Campbell (1961) and action than members of a minority group,
used Sherif's paradigm, cycling new naive who are all perceived to be much alike (Mullen
subjects into the experiment. They provided a & Hu, 1989). As the size of the minority
convincing demonstration of how an erroneous decreases in respect to the majority, this
social norm can be ªpassed downº through perception of homogeneity increases, and vice
generations, as the new subjects conformed to versa. This appears to be true even of the
the exaggerated responses of the ªolder gen- perceptions of the minority group members;
erationº of previously influenced subjects. they themselves may perceive their group to be
These studies are especially revealing in that more alike in attitudes and behaviors than they
no overt social influence was aimed at the do the members of the majority (Mullen, 1991).
participants. There were no attempts to per- These effects of group membership may
suade subjects to ªgo alongº with the group and partially explain what we view as ªprejudicedº
no explicit threats of any kind associated with behavior, including the belief that members of
disagreement. The pressure to conform, to be an ethnic group are ªall alikeº or cannot be
part of the whole, is thus a powerful one, even ªtold apart.º This ingroup±outgroup phenom-
when a situation is straightforward. This enon may also account for some of the anger
pressure only increases when events are un- that minority group members might sometimes
certain or confusing, as most real world feel toward others of ªtheirº group who
situations are. assimilate or appear to identify more closely
Sociologist Phillips (1974) has studied imita- with the majority group.
tive suicides. Phillips's research indicates that Group membership also impacts on indivi-
the suicide rate increases significantly following dual decisions and attitudes. Group polariza-
a news story on suicide, only in the area over tion is the tendency for the average individual
which the news of the first suicide has been group member's opinions to become more
publicized. Presumably, these additional sui- extreme after exposure to the opinions of the
cides are conforming to the example of the first. group as a whole. Once thought to be a
Incidences of single-car accidents and plane unidirectional movement in favor of higher risk
crashes which result in fatalities also appear to (and thus termed ªrisky shiftº), psychologists
increase following the reporting of a suicide. now agree that polarization can occur in either
Phillips's contention is that, these, too, are direction, depending on the initial tendencies of
sometimes ªcopycatº suicides masquerading as the group. If the average member begins
accidents (Phillips, 1979). People who are somewhat in favor of an idea, polarization will
already experiencing confusion or questions occur in the direction of extreme positivity. If
about social identities or situations may be the average member begins somewhat against,
especially vulnerable to conformity pressures polarization will push the group in the direction
and react with self-destructive behavior. of extreme negativity. There is considerable
debate over whether this polarization effect is
caused by persuasive arguments of the group
1.10.3.1.2 Group influences
majority, normative influence, or the desire to
Group influences may be more important to exemplify the group norm proposed by social
individual behavior than is overtly evident. categorization theory, (Turner, 1991).
Clinicians working with groups, either in a 1969). The minority is most effective if it begins
therapeutic situation or otherwise, should be by being flexible, not rigid, and overdemanding.
aware of these group influence effects. Indivi- The minority group also needs to be perceived,
duals may behave quite differently in a group in some way, as being ªpartº of the majority; it
than in an individual counseling session. must be perceived as a new viewpoint within the
Opinions and emotions may become more majority group, rather than an outside force
extreme in a group setting. Publicly acknowl- fighting for inclusion (Turner, 1991). Finally,
edging group membership has been used quite and perhaps most importantly, minorities must
effectively in treatments for alcoholism or other be consistent and confident in their dissenting
addictions, in which admitting the problem is opinions (Moscovici et al., 1969).
considered to be an important step in therapy. The work in minority influence highlights
This strategy reminds clients dramatically of some of the difficulties in changing attitudes.
their membership. In other therapeutic contexts Persuading others to alter opinions or to comply
this may not be appropriate. Care should also be with certain behaviors is especially complex
taken in labeling groups. A ªcancer survivorsº when competing social influences are strong.
group is probably a better name than ªcancer There are facets of human social responses that
patientº or ªcancer victimº support group. can be utilized in order to facilitate the process
The effects of group membership are quite of persuasion.
powerful. A cohesive social group that pro-
motes positive norms can be a valuable source of 1.10.3.2 Theories of Persuasion
social support and strength for an individual.
1.10.3.2.1 Cognitive dissonance
An equally cohesive group which focuses on less
positive behaviors can be a destructive trap from Consistency in behavior is something humans
which it can be difficult to escape. also strive for (Festinger, 1957). In his work on
cognitive dissonance, Leon Festinger demon-
strated that when there is a conflict between
1.10.3.1.3 Reducing the effects of negative social
attitude and behavior, individuals are driven to
influence
resolve that conflict. The ªdissonanceº or
There are methods of reducing the effect of conflict between what we may believe and what
social influence which is contributing to nega- we have actually done creates great tension. Our
tive or dysfunctional behavior. Social impact behavior appears inconsistent with our beliefs.
theory, conceived by Bibb LataneÂ, attempts to When a behavior has been performed and can
predict the intensity of social influence effects. no longer be changed, we resolve any dissonance
The intensity, number, and proximity of sources by altering our belief about the behavior. Thus,
of influence predict the amount of influence a boring task is afterwards described as
directed at the target (LataneÂ, 1981). Thus, to interesting, if it was done for little reward.
reduce the amount of influence, it is necessary to We feel obligated to live up to prior
increase the distance (physical or psychological) commitments in order to preserve that feeling
from the sources, or diffuse their effect over a of consistency in our own behavior. Once we
larger number of targets by enlisting allies. Even have made a small concession to a cause or have
one partner in dissent reduced the Asch conditionally agreed with some form of beha-
conformity effect to almost nil (Asch, 1955). vior, we may feel compelled to comply with
Another strategy for combating social influ- future, more extreme, demands that are con-
ence is to make prior commitments before being sistent with this previous action. Cialdini (1993)
exposed to the sources of influence. Individuals calls this the ªfoot-in-the-doorº technique of
who write down their judgments or share them behavioral compliance.
with others prior to an influence manipulation Commitment is an important determinant
are much less likely to be influenced (Deutsch & both of cognitive dissonance and of self-
Gerard, 1955). Deciding ahead of time how to perception (see earlier discussion of Bem's
cope with social pressure gives one leverage 1972 conception). As an illustration, a friend
against it. may suggest to a person that it would be helpful
In group situations, a minority can effect if the person helps with the political campaign of
change and override some powerful norms, if a candidate in a local election. The person may
key conditions exist. A minority of one is make a commitment to engage in the campaign-
generally ineffective in changing majority ing despite having previously not liked the
opinion; it is too easy to dismiss one person. candidate that much. After engaging in the
A minority of two or more, however, can campaigning, the person may experience dis-
sometimes convince others to defect from the sonance in connection with having publicly
majority stance, beginning a ªsnowballº of supported a candidate whom he or she did not
change (Moscovici, Lage, & Naffrechoux, previous like very much and try to reduce the
Social Influence and Persuasion 307
dissonance by deciding that he or she really likes Strong (1968) argued that when a therapist
the candidate. From a self-perception position, provides opinions that are discrepant from the
the person simply ªlooks backº and sees that he client's, the client experiences dissonance. The
or she decided to do the campaigning without client may reduce this dissonance by derogating
much pressure. Hence, the person may conclude and discrediting the therapist. When the
that he or she ªmust really like the candidate.º therapist is perceived as an expert, this reduces
Each of these conceptions may be viable in the client's ability to discredit the advice given
various arenas when people take actions that are and enhances the likelihood of attitude change
counterattitudinal in nature. in direction of the therapist's message.
The formal application of cognitive disso-
nance theory to clinical intervention has been
1.10.3.2.2 Elaboration likelihood
proposed by Cooper and colleagues (Cooper &
Axsom, 1982). Dissonance was theorized by The elaboration likelihood model is one of
Festinger (1957) as an aversive motivation that the most influential approaches in the history of
will stimulate actions designed to re-establish work on attitude change and persuasion. This
homeostasis in the organism. In dissonance model was proposed by Petty and Cacioppo
theory, a person's expenditure of effort on a task (1981, 1986), and it has greatly reinvigorated
may cause dissonance, which then may be work on attitude change since the early 1980s.
reduced by enhancing cognitions supporting the As we will see, this model also has been applied
value of the effort expenditure. Cooper and to applications of clinical and counseling
Axsom (1982) suggest that effort justification is practice.
a common ingredient in psychotherapy. Their According to the elaboration likelihood
thesis is that when a person expends major effort theory, there are two distinct routes to persua-
and spends quite a bit of money on therapy, sion. One, called the central route, views
therapeutic success will be facilitated. attitude change as resulting from a person's
The reasons for this enhancement include diligent consideration of information that is
increased motivation on the part of the client central to what people feel are the true merits of
and a more positive view about the likelihood an advocated position. The second, or periph-
of therapeutic success. Feelings of personal eral route, views attitude change as occurring
choice and responsibility are at the core of these when an advocated position has been associated
reasons, and they represent essential conditions either with positive or negative cues, or when the
for dissonance to occur; people must feel that person uses a simple decision rule to evaluate a
they had choice and were responsible for the persuasive message. These cues and decision
action that led to the dissonance. Cooper and rules may shape attitudes or allow a person to
Axsom report research using experimental decide what attitudinal position to adopt with-
designs with college students interested in out the need for engaging in extensive issue-
weight control that reveal support for this relevant thinking. Petty and Cacioppo also
dissonance explanation of therapeutic out- admit that sometimes attitude change processes
come. Only participants in a condition invol- may involve a combination of central and
ving high dissonance (expenditure of effort via peripheral processing.
exercise and choice in this type of effort) This approach to attitude change helps us
showed weight improvement relative to com- understand why people may be influenced
parison conditions involving different ap- linearly by the attractiveness of the commu-
proaches to weight control. nicator, or by the communicator's status and
As noted by Cooper and Axsom, their presumed knowledge. It also helps us under-
dissonance analysis bears considerable similar- stand better why people sometimes resist
ity to other theoretical conceptions including persuasion attempts (see discussion below),
Bandura's (1977) view that psychotherapy will since some factor such as forewarning of
be successful to the extent that it enhances persuasion has activated their thoughtful ana-
people's feelings of personal efficacy. Also, this lysis of the positions being advocated. In its
dissonance perspective is similar to Frank's generality and neutrality on whether people are
(1974) proposal that the primary function of all driven by motives such as the aversive motiva-
psychotherapies is to restore a person's sense of tion presumably involved in dissonance, this
mastery. Such conceptions are integrally related approach can subsume processes such as
because of their common emphasis on the dissonance and self-perception since either
importance of perceived personal choice and may be involved in a particular activation of
responsibility in mediating thought processes central or peripheral processing.
over a variety of behavioral contexts. Since factors such as level of perceived
There have been other applications of expertise of a therapist generally are believed
dissonance to the practice of psychotherapy. to be critical variables in the outcome of
psychotherapy (Strupp, 1981), the elaboration More generally, McQuire's ideas relate to
likelihood model is quite relevant to the therapy what threatens people and their attitudes and
process. If the person's motivation and ability to values. As has been shown by Brehm (1966) in
think are very low, then increasing the ther- his theory of psychological reactance, people
apist's expertise should enhance compliance cherish their freedomsÐincluding their freedom
with the therapy by serving as a peripheral cue. to hold their attitudes and beliefsÐand will
If a person's motivation and ability to think are react against attempts to limit those freedoms.
very high, however, then expertise should not But what are some of the most enduring ways
affect attitudes or compliance since they will be that people can resist persuasion attempts?
based primarily on a careful evaluation of the In an early demonstration, McGuire and
issue-relevant arguments presented. Therapy Papageorgis (1962) showed that forewarning an
analog studies by Heesaker, Petty, and Caciop- audience of an upcoming discrepant commu-
po (1983) have provided support for this general nication on an involving topic produces
line of reasoning. resistance to persuasion by stimulating counter-
In addition, research that did not involve an arguments in anticipation of the message. In
elaboration likelihood explanation has been terms of the previously described elaboration
reinterpreted as revealing the role of this process. likelihood model, such forewarning activates
For example, in an analog research design, central processing. McGuire believed that
Heppner and Dixon (1978) exposed participants attacks on people's attitudes and beliefs for
to an expert or an inexpert counselor who which a person was not prepared would be the
attempted to change their opinions about their most debilitating to maintaining those attitudes
problem-solving abilities. The expert counselors and beliefs.
produced greater change on an immediate To test his ideas, McGuire (1964) extended his
assessment and an assessment taken one week earlier line of work on forewarning by propos-
later. In a delayed expertise finding, Strong ing a biological analogy for resistance to
and Schmidt (1970) found that although expert persuasion. Just as people can be made more
and inexpert counselors did not differ in the resistant to a disease by giving them a small dose
amount of attitude change induced immediately of the germ so that they can develop antibodies,
after the very brief influence session, one week perhaps their attitudes can be strengthened by
later the expert counselor had produced more giving them a mild form of attack of their
change than had the inexpert counselor. The position along with arguments that refute the
result suggests that participants may have been attack. Presumably, this inoculation can then
motivated to reconsider the information pro- make them more resistant to stronger attacks on
vided by the expert after the therapy session. their position. From the position of elaboration
The elaboration likelihood model has been likelihood, the attack on an important topic
extensively imported into extant work on engages the central processing mode, and
psychotherapy and counseling (e.g., Heesaker, individuals are stimulated to think of counter-
Conner, & Prichard, 1995). It is an important arguments on their own.
model for therapy considerations in part McGuire (1964) also addressed the question
because of the value it accords central proces- of whether active or passive participation in an
sing. This type of processing presumably leads inoculation treatment is more effective when
to more persistent change and to behavior preparing people to defend their attitudes or
that is more consistent with the changed beliefs. He found that passive defenses appear to
attitude. be superior when the attacking message occurs
very shortly after the defense (in which case
1.10.3.3 Resisting Persuasion people may respond in a rote fashion with the
defenses they have just learned). However,
While other scholars were studying attitude active defenses are more effective when the
change in the 1960s, William McGuire and his attack occurs at a later point in time (e.g., after
colleagues began an important research pro- one week). As time goes on, people are
gram on factors that contribute to resisting motivated to develop their own case and to
persuasion. This work is important for parents think up stronger arguments to support the
and practitioners alike, since it is critical that case.
people learn early in life to withstand pressures Overall, McGuire and his colleagues reported
to conform and/or act in ways that contradict impressive evidence to support the inoculation
their values. McGuire's interest in this topic was model of resistance to persuasion. The research
partially stimulated by the study of how some paradigm in this work involved attacking
US prisoners of war had succumbed to the cultural truisms such as: ªIt is important to
influence attempts of their North Korean brush one's teeth after every meal.º An attack
captors during the Korean War. on this truism might be that frequent brushing
Interpersonal Attraction and Close Relationships 309
causes gum irritation and eventually gum been a small amount of work comparing
disease. Individuals presumably have not had couples with different sexual orientations
practice defending cultural truisms. Hence, such (e.g., Blumstein & Schwartz's 1983 ªAmerican
an attack may cause them uncertainty about the Couplesº study) that will be noted in the
value of regular teeth brushing. A refutational discussion. What will not be covered in this
defense for an attack on teeth brushing might be discussion are the literatures on friendship and
to admit that some gum irritation may be on family relationships.
produced by poor brushing habits, but that on
the whole brushing is essential to preventing
gum disease. Unfortunately, there has been little 1.10.4.1 Forming Relationships
application of McGuire's logic to attitudes and
Three main factors have been identified as
beliefs that are very important to research
involved in contributing to the formation of
participants (e.g., regarding the merits of
interpersonal attraction and then possibly later
income taxes). This is because these topics do
close relationships between two people. These
not lend themselves to investigation in an
factors are physical proximity, physical attrac-
experimental situation. People often have given
tiveness, and similarity in attitudes and person-
such topics considerable thought and hence are ality, each of which can be described via a classic
not readily susceptible to attack. Nevertheless,
study (see Hatfield & Rapson, 1993, for a
the basic principles of inoculation theory,
review).
especially when coupled with the reasoning of
Festinger, Schachter, and Back (1950) in-
the elaboration likelihood model, appear to
vestigated proximity by studying the pattern of
represent a valuable set of tools for practitioners
how people formed friendships in a new housing
and all persons involved in the process of
development. Festinger et al. found that func-
socialization of young people. A fuller discus-
tional proximity was critical in determining the
sion of inoculation theory as it is integrated with
growth of relationships. For example, people
the elaboration likelihood model can be found
became friends with others whom they encoun-
in Eagly and Chaiken (1993).
tered doing their normal chores such as putting
out the trash. Monge and Kirste (1980)
suggested that what is most important about
1.10.4 INTERPERSONAL ATTRACTION proximity is whether or not there is an
AND CLOSE RELATIONSHIPS opportunity to communicate.
The classic study for physical attractiveness
The area of interpersonal attraction is a
was conducted by Walster (Hatfield), Aronson,
traditional one in social psychology, having
Abrahams, and Rottman (1966). They held a
been the topic of early work in the 1940s and
college computer dance and paired men and
1950s and enjoying prosperous development
women randomly. Each individual's personal-
until about the late 1970s. This research focused
ity, intelligence, social skills, and physical
on factors involved in interpersonal attraction
attractiveness were measured (coders judged
and very early dating behavior. These factors
the individuals' attractiveness when they
included physical attractiveness, similarity in showed up at the dance). Walster et al. found
attitudes and personalities, and physical proxi-
that only attractiveness mattered in terms of
mity. Interpersonal attraction as a mainline
partners liking one another. Of course, this
interest in social psychology gave way to work situation was that of strangers meeting stran-
on close relationships around the late 1970s.
gers. Still, this finding reveals the potency early
This latter focus subsumed interpersonal attrac-
on of physical attraction in the liking and dating
tion but emphasized intimate, more long-term
process.
relationships. It also included how people
Hatfield and Sprecher (1986) review a large
maintain, and why they sometimes end, close
body of work that shows how differently people
relationships and the consequences of relation-
are treated when they are perceived as attractive
ship breakdown (or divorce in the case of
than when they are perceived as unattractive.
married couples). The close relationships area is
There appears to be a beauty stereotype in
burgeoning in popularity and involves a meld-
Western societies that has changed little over
ing of fields including social and clinical time. Actress Candice Bergen said of looks:
psychology, along with such disparate addi-
tional fields as counseling psychology, family My looks grease the palm of life, but I resent that
studies, sociology, communication studies, they're so important in our society. I resent that
religion, philosophy, and traumatology. people are excluded . . . But I'm certainly not
Most of the work that will be discussed in this talking about myself, because it's clear I've gotten
section has derived from research focusing on the long end of the stick. (interview in The Kansas
heterosexual, close relationships. There has City Times, April 14, 1984, C-2)
Physical attractiveness has also been impli- comfortable than less similar backgrounds or
cated in the self-fulfilling prophecy phenomen- which tends to elicit less conflict over time.
on that was discussed in the section on social What value does the foregoing evidence have
perception. In a provocative demonstration, for the practitioner? Factors such as similarity
Snyder, Tanke, and Berscheid (1977) recruited and physical attractiveness operate pervasively
men and women for a study on ªthe acquain- in our social relations. To be ignorant of them is
tance process.º Men then were given a photo to be ignorant of part of the basis of our
and biographical information about their part- achieving or not achieving satisfying relation-
ners. The photo was a fake. It depicted either ªa ships with others. In addition, one of the most
beautifulº or ªan unattractiveº woman. Men common concerns on the part of single persons
were asked their first impressions of the woman in dealing with dilemmas in their lives is how
they saw and about whom they read. Those who they can meet others for closeness. The
believed they had been assigned a beautiful practitioner needs to be aware of these basic
partner expected her to be sociable, poised, findings, which have relevance to strategies for
humorous, and socially skilled. Those who meeting others. Increasingly, people are becom-
thought they had been assigned to an unat- ing activists in developing their own networks of
tractive partner expected her to be unsociable, single persons who are similar in age and who
awkward, serious, and socially inept. have similar interests and affiliate in order to
In the next phase of the study, men were asked extend their opportunities for interaction and
to get acquainted with their partners via the possible closeness (Harvey, 1995).
telephone, without actually seeing them. Male
expectations had a dramatic impact on the ways
they talked to their partners in the telephone 1.10.4.2 Maintaining Close Relationships
calls. That telephone approach, in turn, created
a correspondingly major impact on the response Therapists are centrally involved in how
of the women. Essentially, the women became people maintain close relationships over time.
what the men expected them to be. If the women Berscheid (1994) noted in a major review of the
had been perceived to be attractive, they indeed literature on close, personal relationships that
talked on the phone as if they were poised and so despite this burgeoning literature, we still have
on. If the women had been perceived to be little evidence about the processes that are
unattractive, their conversation showed the involved over time in determining the progres-
awkwardness with which the men already had sion of close relationships. We simply do not
labeled them. By studying the phone recordings, have strong information on questions such as:
it was found that the males had elicited these What determines how close and satisfied
divergent lines of behavior either by showing a couples will become, and what determines
warm, accepting tone (for the woman perceived whether they will maintain high levels of
to be attractive), or by a less inviting tone (for satisfaction and closeness? This gap in our
the woman perceived to be unattractive). knowledge contrasts with the extensive theore-
Newcomb (1961) studied the role of similarity tical and empirical work both on the determi-
in the development of relationships. He studied nants of interpersonal relationships and the
a group of college men who were given free determinants and effects of breakdown in such
housing in return for providing ratings of their relationships.
friendship choices and attitudes. After the men One relevant topic is that of courtship stages
had become acquainted, Newcomb found that and progression toward marriage (Cate, Hus-
liking was greatest among those who had similar ton, & Nesselroade, 1986; Huston, McHale, &
attitudes and beliefs. This emphasis on similar- Crouter, 1986). This work has involved
ity in attitudes and beliefs also was found in a following a sample of college students (who
series of laboratory studies by Byrne (1971). In were matriculating at Pennsylvania State
comparison to other kinds of similarity (e.g., in University in the mid- to late 1970s) from
personalities), similarity in attitudes and beliefs the time of becoming engaged to several years
appears to be a fairly strong ªglueº for into their marriage, or after they had divorced.
continued development of a relationship. Why? The investigators inquiried about these young
One possibility is that people like other people people's feelings of satisfaction, and factors
who are similar to them because that similarity involved in their level of satisfaction. Often
validates their own attitudes and beliefs. It feels respondents were first asked to chart their
good to encounter others who have come to progression toward marriage on graphs.
lines of logic about the world that are similar to Among the findings deriving from this pro-
our own. Further, people who have such gram are: Significant conflict in courtship is
similarity often have similar socioeconomic strongly, positively correlated with major
backgrounds, which tends to make them more conflict developing around the one to two
year mark in later marriage; for example, 1.10.4.3 Dissolving Close Relationships
major early periods of ambivalence and
conflict often were related to postmarriage Fincham and Bradbury (1991) have con-
conflict that threatened the relationship. The ducted important research on marital distress
progression and possible deterioration of that is based on attribution theory in social
relationships are affected by numerous factors psychology. According to their contextual
including chance and individual participants' model of marital interaction, when one spouse
networks of friends who either approve or behaves, the partner attends to and perceives
disapprove of the relationship. that behavior, assigns some meaning to it, and
Harvey and Omarzu (1997) have developed exhibits a response. Between the spouse's
a process-oriented theoretical analysis of behavior and the partner's response is the
relationship closeness and satisfaction that processing stage. Bradbury and Fincham (1992)
incorporates other major approaches to the argue that the processing stage involves reac-
development of these states. They refer to this tions to the stimulus, momentary or transient
analysis as ªminding the close relationshipº to thoughts, and personality factors such as mood
emphasize the integral role of each partner's state and attitudes or beliefs about relation-
mind in the flow of interaction in a close ships. They also argue that this approach
relationship. Harvey and Omarzu theorize that expands the behavioral model of marital
to achieve and maintain a high level of satis- interaction beyond its strong emphasis upon
faction and closeness, a couple must mutually behavior and satisfaction by incorporating
engage in a set of continuous activities involv- various cognitive, affective, and personality
ing: seeking knowledge about their partner and mediators.
the relationship; self-disclosure; attributions of One of the most consistent findings from
positive intentions and motivations to their Fincham and Bradbury's research program is
partners for the relationship-relevant actions that distressed couples tend to make attribu-
they observe their partner taking; acceptance tions that blame their partner and exonerate
of, and respect for, what they learn about their themselves for negative outcomes (such as
partners over time; and other forms of behavior major embarrassments regarding the state of
that are meant to be constructive in their the relationships occurring in public). On the
impact on the relationship. These last forms of other hand, nondistressed couples tend to make
behavior can include both small acts such as attributions that do not blame the other for
feet rubs and large acts such as ongoing negative outcomes, or that emphasize the joint
problem solving in parenting and coordination responsibility for such outcomes (Fincham &
of home and work activities. Critical to the Bradbury, 1993). These researchers have
minding process is the meaning imputed to showed that to the extent that spouses make
relevant acts by the partners. Within a strong, nonbenign attributions for negative outcomes
growing relationship, most acts will be con- at one point in time, their marital satisfaction is
strued to reflect positively upon the partners. lower a year later.
Further, such positivity will be based at least to This latter finding is important in making
a considerable degree upon sharing of informa- stronger a cause±effect role for attributions in
tion, perspective, and careful listening and the process of close relationship dissolution.
analysis of information. Attributions may serve as a valuable index of
One of the benefits of Harvey and Omarzu's relationship distress, but are they causal
analysis is that it integrates earlier theoretical elements in the chain of factors involved in
conceptions on social penetration which is the ultimate breakdown of relationships? Finc-
based on self-disclosure (e.g., Altman & Taylor, ham and Bradbury's (1993) results suggest that
1973; Derlega, Metts, Petronio, & Margulis, attributions at least may become contributory
1993), intimacy processes (e.g., Prager, 1995, causal factors during the period of breakdown,
Reis & Shaver, 1988), love (e.g., Hendrick & if not involved from the inception of the process.
Hendrick, 1992), the expansion of self in love Other researchers also have implicated attri-
(Aron & Aron, 1996), empathy (e.g., Ickes, butions in relationship distress and dissolution.
1993), and positivity and other illusions in close Holtzworth-Munroe and Jacobson (1985) re-
relationships (e.g., Murray, Holmes, & Griffin, ported that wome tend to make attributions
1996; Swann, 1996). We believe that this about the state of their relationships throughout
minding the close relationship approach has its course. Men, however, tend to make
considerable implications for scholars and attributions about the state of their relation-
practitioners interested in relationship progres- ships mainly when trouble has arisen. Presum-
sion issues. Nonetheless, this approach still ably, women may be more socialized to engage
must be subjected to careful study that will in relationship caretaking than men, and hence
better reveal its conceptual and applied value. women may be more alert and active in inferring
the social psychological dynamics of relation- causes and, eventually, can be seen as past, over
ship events. This argument is consistent with and external to the individual's present self.
other findings and general theorizing on gender (Weiss, 1975, p. 15).
differences in dissolution (Bernard, 1982;
Vaughan, 1986). It may be true, however, that Weiss used narrative evidence collected from
as people increasingly have learned from a group of persons attending ªParents without
therapy and social science's work on relation- Partnersº meetings to evaluate the role of the
ship problems, many men may have become account in adjustment to marital dissolution.
more active processors of their relationship He found that those persons who had well-
dynamics (Harvey, 1995). developed accounts managed the often convo-
The idea of attributional divergence has been luted and debilitating period of separation prior
prominent in the application of attribution to formal divorce much better than did those
theory to close relationship distress and dis- who did not have very well-developed accounts.
solution. Orvis et al. (1976) and Harvey, Wells, The latter took much longer to recognize that
and Alvarez (1978) reported that couples the relationship had ended and that they needed
experiencing major distress not only made to grieve and move on. Weiss said about this
different attributions about the causes of their group of persons who do not readily begin
distress, but also they could not predict their account making, ªThose who cannot construct
partners' attributions. Such findings suggest accounts sometimes feel that their perplexity
that distressed couples often have distanced keeps them from detaching themselves from the
themselves from dialogue about relationship distressing experiences. They say, `If only I
problems to the point that they are not knew what happened, if only I could understand
cognizant of each other's explanations for why'º (p. 15).
conflict events. Hill, Rubin, and Peplau (1976) Weiss' work has considerable applicability
reported a similar kind of attributional diver- for therapists concerned with helping persons in
gence among college dating couples who had the throes of separation develop their under-
terminated their relationships. These investiga- standings or stories. As Weiss suggested, an
tors found that there was disagreement about account is not necessarily an objective and
who left whom, with each respondent claiming impartial interpretation and description. In fact,
responsibility for being the leaver. Hill et al. also it may be highly biased and distorted. Never-
noted that other evidence suggested it most theless, these constructions may have powerful
often was the woman who had been the leaver (a psychological truth for the individual.
finding replicated by Vaughan, 1986). Weiss' seminal observations had consider-
able influence on the development of theory and
research about how people cope with and
1.10.4.4 Grieving and Recovering from the Loss recover from major losses including close
of Close Relationships relationship dissolution. Harvey, Weber, Gal-
vin, Huszti, and Garnick (1986) refined Weiss'
1.10.4.4.1 The account logic of the account to define account as a
mental construction containing explanations
In a book aimed at people who are grieving and descriptive material for events and states of
the ending of their close relationships, the being of self, other, and the world. In this
sociologist Weiss (1975) suggested that people conception, account making involves both
use accounts to help them cope with loss in private and public activities. Harvey and
marital separation and divorce. Although ªthe colleagues argued that there were several
accountº was only generally defined by Weiss, a dynamics of account making, including: search
definition consistent with his statement is: a for understanding and meaning associated with
storylike construction of why the relationship a loss, achieving completion regarding a loss,
breakdown occurred, who was responsible, key achieving catharsis in venting about the loss,
events, and consequences. He argued for the presenting themselves in a certain light relative
importance of the account in a time of high to responsibility for the loss, self-esteem
distress for the individual as follows: enhancement, and persuading others about
the nature of and reasons for the loss. Several
The account is of major psychological importance of these functions are inherently social activities
to the separated, not only because it settles the
issue of who was responsible for what, but also
(e.g., persuasion of others), and later work
because it imposes on the confused marital events a focused on the importance of the social
beginning, middle, and end and so organizes the interaction component of account making.
events in a conceptually manageable unity. Once This extension of account making and
understood in this way, the events can be dealt accounts logic was amplified by Weber, Harvey,
with: They can be seen as outcomes of identifiable and Stanley (1987), Harvey, Weber, and Orbuch
(1990), and Weber and Harvey (1994) into a These assumptions include that our world is
model of the role of account making and secure and benevolent. Of course, over the
accounts in people's reactions to major stressors course of living many humans discover that
and loss events in general. This model also such assumptions are not tenable. Like Frankl
represented a revision of Horowitz's (1986) (1956), Janoff-Bulman suggests that even more
stage model of how people react to stress. In this basic is people's quest for and assumption of
model, account making is the process of meaning and personal control in their lives.
working on an account, which is the product Janoff-Bulman contends that the victim's see-
of account making. It starts to occur somewhere mingly paradoxical and maladaptive response
in a sequence that often involves these phases such as self-blame for a traumatic event is in fact
(that may occur in this order, or in a less linear a strategy, possibly unconscious, to restore the
fashion): a feeling of being numbed by the loss; illusions of comprehension and control.
an outcry about the loss; denial; intrusive Janoff-Bulman also argues that the wide
imagery; eventually private work at construct- differences in how people respond to traumas
ing a story of what happened and why; public such as death of a loved one are due in part to
confiding in a close other (or others) who listens the nature of the event, and which assumptions
and possibly offers reactions; a feeling of are most threatened. Survivors of a human-
working through the account, acceptance of induced trauma, for example, are posited to
the loss, and completion of the major grieving; view themselves more negatively than are
learning from the loss; and a major element of survivors of a natural disease process. The idea
identity change associated with the loss and this is that intentional harm carried out by a human
processing (e.g., the person no longer sees perpetrator has a negative impact on the self-
herself as ªJohn Smith's wife,º but now as worth of survivors, even if this reasoning is
ªJohn Smith's widow who will go on alone and irrational. It is an amplification on the ªWhy
make a new life for herselfº). In studies based on me?º question survivors often pose, but with
this model, the empathic response of a depend- special pertinence to the human-caused trauma.
able confidant to a person's loss has been found One of the major contributions for practi-
to be vital in the recovery process (e.g., Harvey, tioners deriving from Janoff-Bulman's work is
Orbuch, Chwalisz, & Garwood, 1991). the analysis of major tasks with which survivors
Appreciation of work on the role of account are confronted in order to adapt to their loss
making in relationship conflict and dissolution and begin to heal. Like the account-making
may be beneficial to practitioners in several logic, Janoff-Bulman emphasizes the reframing
ways. It is important to know what is the of interpretations that is required in the
accounts-narrative truth to a client. While recovery process. Included is a rebuilding of a
recognizing that a client's story may represent victim's basic assumptions about the world and
only one of many interpretations of an event or self. Somehow the survivor needs to integrate
situation, a practitioner can appreciate that the the loss into new schemas of understanding that
client still may be acting on the basis of this make the loss event less frightening (which may
interpretation. Further, the interpretation may be associated with intrusive, debilitating images
need to be challenged. People may be open to and thoughts, as was suggested in the account-
challenge of their story and may learn from the making model). The integration may involve
feedback and questions posed by a therapist. A reprioritizing of values and goals in livingÐ
practitioner also can help a client recognize the lessons learned from the lossÐand trying to find
value of developing a story and the functions of redeeming value in the suffering (as in the
story development and the confiding of them to generative act of giving back to others who may
close others. As psychiatrist Robert Coles suffer similar plights).
(1989) has cogently argued, a person's narrative Beyond cognition, Janoff-Bulman contends
and willingness to share it should be respected as that victims must not be passive, but active in
a universal gift. confronting loss. Simple activity such as garden-
ing, caring for friends and pets, and work on
hobbies may help. Support groups and close,
loving friends may help people ªget out of the
1.10.4.4.2 Shattered assumptions
houseº and begin telling their story to others, or
Janoff-Bulman's (1992) work on shattered if that is too difficult, listening to others' stories.
assumptions provides an invaluable perspective Also, similar to the account-making model,
on adaptation to loss. She argues that the Janoff-Bulman emphasizes the role of close,
psychological disequilibrium that ensues from caring others in a victim's recovery. She
major losses such as divorce or death of a spouse indicates that there is considerable evidence
or loved one often stems from the shattering of that people's adaptation to loss is most often
our fundamental assumptions about the world. facilitated rather than impeded by the presence
of close others in their lives. Finally, she warns This last criterion encompasses the idea of
of others' tendencies to blame the victim. Lerner generativity that has been emphasized by many
(1980) has theorized a ªjust world hypothesisº scholars, most notably Erikson (1963), which
that suggests people believe others deserve their may involve a human's most important work
suffering and eventually get what they deserve in both on behalf of others and oneself.
life. The tendency to blame victims is central to
the phenomenon depicted by this hypothesis.
As Janoff-Bulman notes, in the stress and 1.10.5 ALTRUISM AND HELPING
trauma area the emphasis on people's inter- BEHAVIOR
pretations and assumptions devolves principally 1.10.5.1 Psychology's Role in Promoting
from Lazarus's (1966) pioneering conceptual Human Selfishness
work and research on how people's interpreta-
tions, or appraisals, mediate their reactions to Before discussing contemporary social psy-
stress. Inherent in this reasoning is that the chological work on altruism and helping
person has the capacity after a major stressor to behavior, we will consider a basic question for
reassess interpretations and assumptions. Some the field of psychology that has been raised in
losses are so profound that they severely test this this area: What role has psychology played in
capacity. promoting excessive self-absorption and egoism
Examples of losses that may be too over- as compared to concern for others in society?
whelming for any ready cognitive adaptation Personality-social psychologists Michael and
include: wartime combat veterans' experience of Lise Wallach (1983) wrote an important book
personal terror and the deaths of close friends on people's nature, that has much relevance for
(e.g., see Shay's discussion of Vietnam veterans' the area of altruism, entitled Psychology's
reactions in Achilles in Vietnam, 1994); indivi- sanction for selfishness. In this, the Wallachs
duals' reactions to the untimely and deeply, present arguments to the effect that many of the
personally devastating loss of a spouse (e.g., most influential workers in the history of
Lewis' powerful book of grieving ªnotesº in A personality, social, and clinical psychology have
grief observed, 1961); and the horrific experi- committed the ªerror of egoismº in the positions
ences of World War II concentration camp they have advocated.
survivors who lost close loved ones to brutality The Wallachs are suggesting that major
and lost self-respect in bearing degrading, schools of thought in psychology offer a
inhuman conditions (e.g., see the powerful particular view of the human that embodies
stories told in Langer's Holocaust testimonies, an egoistic concern for self and too little concern
1991). for other people. What is this selfishness and
These works help the practitioner define the ªerror of egoismº that the Wallachs describe?
boundaries of possibility for intervention by They do not offer precise definitions, but do
interpretation, story development and telling, offer suggestions and examples. Selfishness is
and reframing of assumptions. The therapeutic equated with an ªemphasis . . . on narcissism,
relevance of stories of loss and trauma also is self-concern and preoccupation with `me'º
realized in family therapy approaches that (Wallach & Wallach, 1983, p. ix), and ªwith
follow Frankl's (1956) ideas and embrace the achieving satisfaction for our needs and desiresº
empowering value of people's search for mean- (p. 18).
ing in times of great stress (e.g., Lantz, 1993). The Wallachs suggest that the basis for this
Increasingly, therapists are advocating the value portrait of the human as guided by self-centered
of people telling their own stories of loss as a motivation is found in Freud's emphasis on the
means of adaptation (e.g., Howard, 1991). importance of satisfaction of bodily needs. The
How do we know when recovery from a Wallachs point out that within Freud's position,
major loss has been achieved? Weiss (1988) direct gratification of such needs can be most
offers the following set of criteria: optimally achieved when individuals are free of
(i) ability to give energy to everyday life; prescription, restraint, and determination from
(ii) psychological comfort, as demonstrated the outside. Beyond Freud and neo-Freudians
by freedom from pain and distress; such as Sullivan and Horney, the Wallachs also
(iii) ability to experience gratification: to feel suggest that humanistic psychologists such as
pleasure when desirable, hoped-for, or enrich- Maslow and Rogers play into the selfishness
ing events occur; theme. ªWhen we reach Maslow and Rogers,
(iv) hopefulness regarding the future, being much of society and our relations with other
able to plan and care about plans; and people is seen as obstructing our growth and the
(v) ability to function with reasonable ade- development of our potentialities. Self-determi-
quacy in social roles as spouse, parent, and nation becomes a matter of overriding signifi-
member of the community. canceº (p. 152).
Altruism and Helping Behavior 315
Wallach and Wallach take on the influential Beyond such rejoinders, many of the re-
social psychological analysis of interpersonal sponding analysts indicated a belief that the
relations by Kelley and Thibaut (1978). Kelly Wallachs had performed a major service in
and Thibaut's interdependence analysis is focusing on psychological views of human
concerned with the structures of ongoing behavior and the extent to which behavior is
situations. The structures are defined in terms motivated by selfishness. Further, the Wallachs'
of patterns of positive and negative outcomes theme about cynicism regarding psychology's
controlled by the joint actions of interdependent role in modern society was seconded and
people (i.e., people such as couples in close embellished by an interdisciplinary team of
relationships whose behavior, thoughts, and scholars, Bellah, Madsen, Sullivan, Swidler,
feelings are intertwined in significant ways over and Tipton (1985), in a well-known book
time). Wallach and Wallach suggest that this entitled Habits of the heart: Individualism and
approach implicitly prescribes mainly a self- commitment in American life.
concern. They say about the Kelley and Thibaut
logic, ªLife with others is viewed as a negotia- 1.10.5.2 General Principles of Altruism and
tion process, using the carrots and sticks at one's Helping Behavior
disposal in pursuit of reciprocity . . . Commit-
ment to another person . . . becomes a gambit or There is an extensive literature on altruism
move that is tendered to induce reciprocationº and helping or prosocial behavior in social
(pp. 177±178). psychology. Among the questions of interest to
Overall, the Wallachs believe that work such this area are: What are the conditions that
as the foregoing has furthered a cynicism about stimulate and impede people's coming to the aid
the nature of humans, with little weight given to of others in distress? Is there an altruistic
the importance of people's commitment to personality, and is this personality operative
others as an end in itself, rather than as a means across diverse situations in which helping others
to a personal goal. The theoretical work on may bring great danger to oneself? We will deal
altruism by social psychologists that will be with these questions in this section.
described below would be viewed by the There are two major reasons why this
Wallachs as also embracing self-interest as the literature should be of considerable interest to
basis of most altruism, or helping of others in practicing psychologists. First, it is in the
time of need. Readers who are interested in interest of society that people be socialized to
counterarguments about the Wallachs' position help one another and to be genuinely committed
are referred to the Journal of Social and Clinical to rendering help in others' times of distress
Psychology special issue on this topic (#1, 1985). when they can be of assistance. Second, as has
A major theme by critics of the Wallachs' been cogently argued in many classical psycho-
position in that set of papers is that their logical analyses, people can gain perspective,
analysis often was too black and white and courage, and strength to face their own
simplistic in representing complex analyses by dilemmas when they extend themselves to
other scholars. Regarding the Wallachs' critique others who are in distress. Frankl (1956), for
of Kelley and Thibaut, Kelley and Thibaut example, used his own experience in a Nazi
(1985) disputed that their theory was prescrip- concentration camp to argue that people often
tive of a ªwin at all costsº rationale. They also create or find meaning in their lives to the extent
argued: that they focus on the needs of others and are
sincerely concerned about their fellow humans.
it will be apparent that we see no incompatibility
The term ªcaretakerº increasingly has been a
between deriving altruism from self-interest, on part of psychologists' vocabulary. In general, it
the one hand, and the existence of genuine or has been found that acting in this role makes
authentic altruism, on the other . . . the Wallachs people feel good (Williams & Clark, 1989). The
make the mistake of putting our theory into the general questions here concern when and how
heads of the prosocial actors . . . we view people can be effective caretakers of others,
altruism . . . as adaptations to problems of social without reducing such others' own capacity for
interdependence . . . it seems clear that the Wal- self-accomplishment or -empowerment (Steele,
lachs regard altruism and any logic or sign of self- 1990).
interest as incompatible . . . we do not . . . Histori- Altruism theory and research were given a
cally and developmentally, self-interest underlies
altruism and other interpersonal tendencies. Con-
major stimulus by the publication of LataneÂ and
temporaneously, prosocial behavior is sometimes Darley's (1970) The unresponsive bystander:
promoted by thoughts of self-interest, but it also Why doesn't he help? This book won awards for
often reflects direct responsiveness to and concern its contribution to the field of psychology and
for other persons' interests. (Kelly & Thibaut, has become a classic regarding social conditions
1985, pp. 29±31). for helping behavior. In the book LataneÂ and
Darley discussed the case of Kitty Genovese only highlight some of the major directions. One
who in 1964, while touring New York, was area of work concerns the impact of momentary
stabbed to death on a New York City sidewalk emotional states on helping behavior. Surpris-
(Rosenthal, 1964). The murder was carried out ingly, it has been found that depressed people
over a 45-minute period and was witnessed by are especially likely to help others in need if what
38 people who heard Genovese's screams, and they have to do to help is interesting or pleasant
even observed some of the struggle, from their (Cunningham, Shaffer, Barbee, Wolff, & Kel-
windows in the nearby apartments. Yet, amaz- ley, 1990). This general finding has been linked
ingly, no one tried to intervene or otherwise help to the negative state relief model (Cialdini,
Genovese. Why such indifference? Kenrick, & Bauman, 1982). This model suggests
Two principal insights were tested by LataneÂ that helping makes people feel good, and those
and Darley. One was that there was pluralistic in a negative mood are motivated to do anything
ignorance: ªNo one else is reacting; it must not to make themselves feel better. As for positive
be an emergency after all.º Two, there could emotions, it often has been found that people
have been a diffusion of responsibility: ªI'm sure who are made to feel momentarily happy are
someone else already called the police.º LataneÂ inclined to help strangers in need. The state of
and Darley tested these ideas in the lab and field happiness has been created in a variety of ways
by creating fires, accidents, thefts, fights, and such as by receiving cookies (Isen & Levin,
seizures. For example, in one procedure, they let 1972), by listening to a comedy album (Wilson,
smoke fill the room where subject participants, 1981), or even going out on a day when the sun is
either alone or with others, were completing shining (Cunningham, 1979).
irrelevant tasks. Would the participants take Batson and his colleagues have conducted
some action to notify authorities that a fire notable research on what has been referred to as
might be occurring? Or in another situation, a the empathy-altruism hypothesis (e.g., Batson,
person in a nearby room was overheard by Duncan, Ackerman, Buckley, & Birch, 1981).
participants alone or in groups apparently This hypothesis states that when people perceive
having a seizure. Would the participants go to an emergency in which they have the potential to
this person's assistance? render assistance, empathy is aroused and then
As with the work of Milgram (1974, see helping occurs. If empathy is not aroused and if
Section 1.10.6), at the present time it is not clear people can avoid the situation, helping will not
that such procedures would stand the test of occur; if it is difficult for people to avoid the
ªhuman subjects review committeesº who situation, helping may occur in the absence of
evaluate research proposals for potential harm empathy.
to participants. But the results were fascinating To test the empathy-altruism hypothesis,
and generally have met the test of time and other Batson, O'Quinn, Fultz, Vanderplas, and Isen
workers' examination of similar questions. (1983) devised an experimental procedure in
LataneÂ and Darley repeatedly found that as which they manipulated empathic concern for
the number of bystanders in a situation the victim and ease of escape from the situation.
increased, the percentage of participant subjects Participants were informed that they would
who helped the experimental accomplice de- either have to perform a task while receiving
creased. Among those who did respond, an random electric shocks while an observer
increase in the number of bystanders led to watched on closed-circuit television, or be the
increased delay in taking action. Thus, LataneÂ observer while another participant received the
and Darley concluded that the ªbystander shocks. The real subject participant always
effectº was a powerful phenomenon in influen- served as the observer. As the observation
cing helping behavior in emergency situations. began, the accomplice pretended to be in pain
These investigators and their colleagues subse- when shock was given. But she announced that
quently elaborated on what they viewed as the despite having had a traumatic experience with
cognitive/decision-making steps that bystanders electricity as a child, she could go on with the
experience in an emergency situation. These study. The experimenter then asked the subject
included: recognizing and attending to the participant if he or she was willing to take the
emergency, checking the interpretation that victim's place. Empathic concern was manipu-
an emergency exists, deciding whether person- lated by the investigator informing the subject
ally to assume responsibility, deciding whether participants that the victim had values that were
to take some line of action to help, and if so, similar to their own (high empathy) or very
deciding what line of action is feasible. dissimilar (low empathy). The investigator also
An extensive literature on conditions of manipulated the ease with which the subject
helping behavior and personality types asso- participants could escape from the situation by
ciated with helping behavior has developed in informing them either that they could leave after
social psychology since the late 1970s. We will watching only two shock trials (easy escape) or
Conclusion: Synthesis of the ªSocial Animal in a Complex Worldº 317
that they had to watch 10 such trials (difficult four years risking his life and the lives of his
escape). family to help Jews hide from the Nazis. The
Batson et al. (1983) found that when empathy moment was the sight of flies swarming over the
was low and escape was easy, subject partici- bodies of dead and dying Jewish children who
pants tended to leave rather than engage in had been killed by the Nazi's brutal treatment of
prosocial behavior by taking the place of the them.
victim. When empathy was high, subject
participants volunteered to take the victim's
place, regardless of how easy it was to escape. It 1.10.6 CONCLUSION: SYNTHESIS OF
also was found that highly empathic subject THE ªSOCIAL ANIMAL IN A
participants volunteered even when they be- COMPLEX WORLDº
lieved that neither the investigator nor the
victim would ever know that they had declined Elliot Aronson wrote a popular introductory
to help. Hence, their helping was not due to social psychology textbook entitled The social
evaluative apprehension in the situation, but animal (1995). In this book, Aronson described
rather appears to have been mainly influenced why humans may be conceived as social
by empathy for the victim. animals, and began this thesis with Aristotle's
The above genre of research on altruism and statement:
helping behavior has focused mainly on factors
affecting helping in artificial experimental Man is by nature a social animal; an individual
who is unsocial naturally and not accidentally is
contexts and in interactions among college either beneath our notice or more than human.
students who were not acquainted with one Society is something in nature that precedes the
another. In the real world, the opportunity to individual. Anyone who either cannot lead the
help others in need often occurs in situations in common life or is so self-sufficient as not to need
which people know one another. Is there a to, and therefore does not partake of society, is
personality type associated with helping? This is either a beast or a god. (Politics, c. 328 BC,
a question that has been tested via focusing on reprinted Aronson, 1995, p. xvix)
those who have engaged in helping behavior in
situations involving real emergencies or great While we may not be beasts, if we are
danger to the helpers. reclusive we still are influenced by our society.
For example, Oliner and Oliner (1988) The reclusive ªUnibomberº was an example of
obtained personality evidence on people from a person who was greatly influenced by outside
various European countries who actively in- events and who sought to influence them in his
tervened to try to rescue Jews during World War own deadly way, yet he also was extremely
II. Oliner and Oliner found considerable reclusive in his behavior. Aronson contended
similarity among the helpers. They had an that humans are more rationalizing animals
internal locus of control (i.e., they believed that than rational in their decision making (Aronson
their own actions made a difference in changing argued from a cognitive dissonance position).
their environments). They also believed in a just He cited many examples from reckless behavior
world, which meant that they believed that in driving, smoking, and use of weapons, to
people who do good deeds will be rewarded for warfare and genocide. He also argued that
them. They felt socially responsible and believed ªPeople who do crazy things are not necessarily
that people should do their best to help others crazyº (p. 9). By this, Aronson meant that social
who are in need. They felt empathy for persons conditions such as those studied by Milgram
who were in distress, and were not egocentric in (1974) in his work on obedience may exert a
general in their approach to other people. powerful influence on human behavior.
Another powerful presentation of humans' In studies that were designed to examine how
caring spirit is contained in Eva Fogelman's people might be induced to obey authority
book Conscience and courage (1994). She, too, figures, somewhat similar to what might have
interviewed persons who had rescued Jews occurred in Nazi Germany in the 1930s and
during the Holocaust. Her treatment high- 1940s, Milgram developed an experimental
lighted the small events that often shaped long- situation at Yale University that was advertised
term, complex sequences of helping. One of the as involving the study of associative learning. If
people she interviewed was a small businessman typical members of the community show up at
in Warsaw, Poland. When the Nazis conquered the Yale psychology laboratories and are told
Poland and created the Jewish ghetto, this man that the study they are volunteering to do
said that he was curious about what was concerns learning behavior, why should they
happening in the ghetto and found a way to doubt the investigator? That was the type of
visit it. He said that one transforming moment situation set up by Milgram. The researchers
in that visit motivated him to spend the next were ªofficial-sounding and -lookingº in order
to try to determine if ordinary people would 1.10.7 REFERENCES

obey an authority and do something that they
Abramson, L. Y., Seligman, M. E., & Teasdale, J. D.
thought might be harming another person. In (1978). Learned helplessness in humans: Critique and
the course of the experiments, these individuals reformulation. Journal of Abnormal Psychology, 87(1),
were ªrequiredº to give what they thought were 49±74.
increasingly intense shocks to another person Allport, G. W. (1985). The historical background of social
psychology. In G. Lindzey & E. Aronson (Eds.),
(actually an experimental accomplice). Many of Handbook of social psychology (3rd ed., Vol. 1,
the participants did so, even to the point of the pp. 1±46). New York: Random House.
accomplice feigning a heart attack. Milgram's Altman, I., & Taylor, D. A. (1973). Social penetration: The
methods were questionable in terms of potential development of interpersonal relationships. New York:
harm to the participants and could not be Holt, Rinehart, and Winston.
Aron, A., & Aron, E. N. (1996). Self and self-expansion in
carried out today, but they show the great power relationships. In G. J. O. Fletcher & J. Fitness (Eds.),
of social situations. Knowledge structures in close relationships: A social
Situations such as those studied in the psychological approach (pp. 325±344). Mahwah, NJ:
obedience work are only illustrative of the Erlbaum.
Aronson, E. (1995). The social animal (7th ed.). New York:
diverse social situations that people encounter Freeman.
on almost a daily basis. These situations may Asch, S. E. (1946). Forming impressions of personality.
involve close others, acquaintanceship groups, Journal of Abnormal and Social Psychology, 41, 258±290.
work associates, or strangers, but whatever their Asch, S. E. (1955). Opinions and social pressure. Scientific
nature they may totally engulf a person's field of American, 193, 31±35.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory
thought and action. People may be induced to of behavioral change. Psychological Review, 84(2),
act in a way that is opposed to their personality 191±215.
and moral position because of the nature and Batson, C. D., Duncan, B. D., Ackerman, P., Buckley, T.,
influence of the situation. & Birch, K. (1981). Is empathic emotion a source of
We believe that a broadly construed social altruistic motivation? Journal of Personality and Social
Psychology, 40, 290±302.
psychological point of view in the last part of the Batson, C. D., O'Quinn, K., Fulz, J., Vanderplas, M., &
twentieth century represents a complex view of Isen, A. M. (1983). Influence of self-reported distress
human life that is appropriate to the intricacies and empathy on egoistic versus altruistic motivation to
of human behavior, behavioral disorders, and help. Journal of Personality and Social Psychology, 45,
706±718.
psychopathology. This approach points toward Bellah, R. N., Madsen, R., Sullivan, W. M., Swidler, A., &
many of the types of social variables and Tipton, S. M. (1985). Habits of the heart: Individualism
situations that influence people's behavior. As and commitment in American life. New York: Harper and
was shown by the 1996 Olympic Park bombing Row.
deaths in Atlanta, USA, in many ways we live in a Bem, D. J. (1972). Self-perception theory. In L. Berkowitz
(Ed.), Advances in experimental social psychology (Vol. 6,
terrifying world. Terrorism and other kinds of pp. 1±62). New York: Academic Press.
daily violence show the propensity of people to Bernard, J. (1982). The future of marriage (2nd ed.). New
kill others in an instant with little guilt. Why? Haven, CT: Yale University Press.
Inevitably the best available answers to such Berscheid, E. (1994). Interpersonal relationships. Annual
Review of Psychology, 45, 79±129.
questions take us on an odyssey into work on Blumstein, P., & Schwartz, P. (1983). American couples.
social psychological findings and theories. These New York: William Mobrow.
findings and theories are insufficient, in and of Bradbury, T. N., & Fincham, F. D. (1992). Attributions
themselves, to answer such global questions. But and behavior in marital interaction. Journal of Person-
they do sensitize us to the many nuances of ality and Social Psychology, 63(4), 613±628.
Brehm, J. W. (1966). A theory of psychological reactance.
understanding that may be tenable in consider- New York: Academic Press.
ing causation. Coupled with the work from Brehm, S. S. (1976). The application of social psychology to
related fields in psychology, this body of work clinical practice. Washington, DC: Hemisphere.
frames an understanding of some of the major Brewer, M. B. & Weber, J. G. (1994). Self-evaluation
dynamics behind these seemingly inane acts. effects of interpersonal versus intergroup social compar-
ison. Journal of Personality and Social Psychology, 66,
Contemporary social psychology is well 268±275.
integrated with the fields of personality, health Byrne, D. (1971). The attraction paradigm. New York:
psychology, and research in clinical psychology, Academic Press.
all of which form an indispensable base for the Cate, R. M., Huston, T. L., & Nesselroade, J. R. (1986).
Premarital relationships: Toward the identification of
practice of clinical psychology. This melding alternative pathways to marriage. Journal of Social and
together of fields in the pursuit of knowledge Clinical Psychology, 4(1), 3±22.
and relevant application is illustrated in all of Cialdini, R. B. (1993). Influence: Science and practice (3rd
the sections of this chapter. It leads to a synergy ed.). New York: HarperCollins.
in research that is quite positive and exciting for Cialdini, R. B., Kenrick, D. T., & Bauman, D. J. (1982).
Effects of mood on prosocial behavior in children and
progress in understanding better the ªsocial adults. In N. Eisenberg (Ed.), The development of
animal.º prosocial behavior (pp. 151±188). New York: Academic
Press.
References 319
Coles, R. (1989). The call of stories: Teaching and the moral Harvey, J. H. (1995). Odyssey of the heart: The search for
imagination. Boston: Houghton Mifflin. closeness, intimacy, and love. Salt Lake City, UT:
Cooper, J., & Axsom, D. (1982). Effort justification in Freeman.
psychotherapy. In G. Weary & H. L. Mirels (Eds.), Harvey, J. H., & Galvin, K. S. (1984). Clinical implications
Integrations of clinical and social psychology of attribution theory and Research. Clinical Psychologi-
(pp. 214±230). New York: Oxford University Press. cal Review, 4(1), 15±33.
Cunningham, M. R. (1979). Weather, mood, and helping Harvey, J. H., & Omarzu, J. (1997). Minding the close
behavior: Quasi-experiments with the sunshine samar- relationship. Personality and Social Psychology Review,
itan. Journal of Personality and Social Psychology, 1, 223±239.
37(11), 1947±1956. Harvey, J. H., Orbuch, T. L., Chwalisz, K. D., &
Cunningham, M. R., Shaffer, D. R., Barbee, A. P., Wolff, Garwood, G. (1991). Coping with sexual assault: The
P. L., & Kelley, D. L. (1990). Separate processes in the role of account-making and confiding. Journal of
relation of elation and depression to helping: Social Traumatic Stress, 4(4), 515±531.
versus personal concerns. Journal of Experimental Social Harvey, J. H., Town, J. P., & Yarkin, K. L. (1981). How
Psychology, 26(1), 13±33. fundamental is ªthe fundamental attribution error?º
Darley, J. M., & Fazio, R. H. (1980). Expectancy Journal of Personality and Social Psychology, 40(2),
confirmation processes arising in the social interaction 346±349.
sequence. American Psychologist, 35(10), 867±881. Harvey, J. H., Weber, A. L., Galvin, D. S., Huszti, H. D.,
Derlega, V. J., Metts, S., Petronio, S., & Margulis, S. T. & Garnick, N. N. (1986). Attribution and the termina-
(1993). Self-disclosure. Newbury Park, CA: Sage. tion of close relationships: A special focus on the
Deutsch, M., & Gerard, H. B. (1955). A study of normative account. In R. Gilmour & S. Duck (Eds.), The emerging
and informational social influence upon individual field of personal relationships (pp. 189±201). Hillsdale,
judgment. Journal of Abnormal and Social Psychology, NJ: Erlbaum.
51, 629±636. Harvey, J. H., Weber, A. L., & Orbuch, T. L. (1990).
Devine, P. G. (1989). Stereotypes and prejudice: Their Interpersonal Accounts: A social psychological perspec-
automatic and controlled components. Journal of tive. Oxford, UK: Blackwell.
Personality and Social Psychology, 56(1), 5±18. Harvey, J. H., Wells, G. L., & Alvarez, M. D. (1978).
Eagly, A. H., & Chaiken, S. (1993). The psychology of Attribution in the context of conflict and separation in
attitudes. Fort Worth, TX: Harcourt Brace Jovanovich. close relationships. In J. H. Harvey, W. J. Ickes, & R. F.
Erikson, E. H. (1963). Childhood and society (2nd ed.). New Kidd (Eds.), New directions in attribution research (Vol.
York: Norton. 2, pp. 235±260). Hillsdale, NJ: Erlbaum.
Festinger, L. (1954). A theory of social comparison Hastorf, A. H., & Cantril, H. (1954). They saw a game: A
processes. Human Relations, 7, 117±140. case study. Journal of Abnormal and Social Psychology,
Festinger, L. (1957). A theory of cognitive dissonance. 49(1), 129±134.
Stanford, CA: Stanford University Press. Hatfield, E., & Rapson, R. L. (1993). Love, sex, and
Festinger, L., Schachter, S., & Back, K. W. (1930). Social intimacy: Their psychology, biology, and history. New
pressures in informal groups: A study of human factors in York: HarperCollins.
housing. New York: Harper. Hatfield, E., & Sprecher, S. (1986). Mirror, mirror: The
Fincham, F. D., & Bradbury, T. N. (1991). Cognition in importance of looks in everyday life. Albany, NY: SUNY
marriage: A program of research on attribution. In W. Press.
H. Jones & D. Perlman (Eds.), Advances in personal Heesacker, M., Conner, K., & Prichard, S. (1995).
relationships: A Research annual (Vol. 2, pp. 159±203). Individual counseling and psychotherapy: Applications
London: Jessica Kingsley. from the social psychology of attitude change. Counsel-
Fincham, F. D., & Bradbury, T. N. (1993). Marital ing Psychologist, 23(4), 611±632.
satisfaction, depression, and attributions: A longitudinal Heesacker, M., Petty, R. E., & Cacioppo, J. T. (1983).
analysis. Journal of Personality and Social Psychology, Field dependence and attitude change: Source credibility
64(3), 442±452. can alter persuasion by affecting message-relevant
Fogelman, E. (1994). Conscience and courage: Rescuers of thinking. Journal of Personality, 51(4), 653±666.
Jews during the Holocaust. New York: Doubleday/ Heider, F. (1958). The psychology of interpersonal relations.
Anchor. New York: Wiley (reprinted by Erlbaum).
Frank, J. (1965). Persuasion and healing. Baltimore: Johns Heider, F. (1976). A conversation with Fritz Heider. In J.
Hopkins University Press. H. Harvey, W. J. Ickes, & R. F. Kidd (Eds.), New
Frank, J. (1974). Psychotherapy: The restoration of directions in attribution theory (Vol. 1, pp. 3±18). Hills-
morale. American Journal of Psychiatry, 131, 271±274. dale, NJ: Erlbaum.
Frankl, V. E. (1956). Man's search for meaning. New York: Hendrick, S. S., & Hendrick, C. (1992). Romantic love.
Washington Square. Newbury Park, CA: Sage.
Funder, D. C. (1987). Errors and mistakes: Evaluating the Heppner, P. P., & Dixon, D. N. (1978). Effects of client
accuracy of social judgment. Psychological Bulletin, perceived need and counselor role on clients' behaviors.
101(1), 75±90. Journal of Counseling Psychology, 25(6), 514±519.
Goffman, E. (1959). The presentation of self in everyday life. Hill, C. T., Rubin, Z., & Peplau, L. A. (1976). Breakups
Garden City, NY: Doubleday. before marriage: The end of 103 affairs. Journal of Social
Goffman, E. (1961). Asylums: Essays on the social situation Issues, 32(1), 147±168.
of mental patients and other immates. Garden City, NY: Holtzworth-Munroe, A., & Jacobson, N. S. (1985). Causal
Anchor. attributions of marital couples: When do they search for
Goldstein, A. P., Heller, K., & Sechrest, L. B. (1966). causes? Journal of Personality and Social Psychology,
Psychotherapy and the psychology of behavior change. 48(6), 1398±1412.
New York: Wiley. Horowitz, M. J. (1986). Stress response syndromes (2nd
Hart, A. J., & Morry, M. M. (in press). Nonverbal ed.). Northvale, NJ: Jason Aronson.
behavior, race, and attitude attributions. Journal of Howard, G. S. (1991). Cultural tales: A narrative approach
Experimental Social Psychology. to thinking, cross-cultural psychology, and psychother-
Harvey, J. H. (1983). The founding of the Journal of Social apy. American Psychologist, 46, 187±197.
and Clinical Psychology. Journal of Social and Clinical Huston, T. L., McHale, S. M., & Crouter, A. C. (1986).
Psychology, 1, 1±3. When the honeymoon's over: Changes in the marriage
relationship over the first year. In R. Gilmour & S. W. Linville, P. W. (1982). The complexity-extremity effect and
Duck (Eds.), The emerging field of personal relationships age-based stereotyping. Journal of Personality and Social
(pp. 109±132). Hillsdale, NJ: Erlbaum. Psychology, 42, 193±211.
Ickes, W. (1993). Empathic accuracy. Special Issue: View- Linville, P. W., & Jones, E. E. (1980). Polarized appraisals
points on personality: Consensus, self±other agreement, of outgroup members. Journal of Personality and Social
and accuracy in personality judgement. Journal of Psychology, 38(5), 689±703.
Personality, 61(4), 587±610. Mackie, D., & Cooper, J. (1984). Attitude polarization:
Isen, A. M., & Levin, P. A. (1972). Effect of feeling good on Effects of group membership. Journal of Personality and
helping: Cookies and kindness. Journal of Personality Social Psychology, 46(3), 575±585.
and Social Psychology, 21, 384±388. McGuire, W. J. (1964). Inducing resistance to persuasion:
Jacobs, R. C., & Campbell, D. T. (1961). The perpetuation Some contemporary approaches. In L. Berkowitz (Ed.),
of an arbitrary norm tradition through several genera- Advances in experimental social psychology (Vol. 1). New
tions of a laboratory microculture. Journal of Abnormal York: Academic Press.
and Social Psychology, 62, 649±658. McGuire, W. J., & Papageorgis, D. (1962). Effectiveness of
James, W. (1890). The principles of psychology. New York: forewarning in developing resistance to persuasion.
Holt. Public Opinion Quarterly, 26, 24±34.
Janoff-Bulman, R. (1992). Shattered assumptions: Toward a Milgram, S. (1974). Obedience to authority: An experi-
new psychology of trauma. New York: Free Press. mental view. New York: Harper and Row.
Jones, E. E. (1964). Ingratiation: A social psychological Monge, P. R., & Kirste, K. K. (1980). Measuring proximity
analysis. New York: Appleton-Century-Crofts. in human organization. Social Psychology Quarterly,
Jones, E. E., & Davis, K. E. (1965). From acts to 43(1), 110±115.
dispositions: The attribution process in person percep- Moscovici, S., Lage, S., & Naffrechoux, M. (1969).
tion. In L. Berkowitz (Ed.), Advances in experimental Influence of a consistent minority on the responses of a
social psychology (Vol. 2, pp. 219±263). New York: majority in a color perception task. Sociometry, 32,
Academic Press. 365±380.
Jones, E. E., Kanouse, D., Kelley, H. H., Nisbett, R. E., Mullen, B. (1991). Group composition, salience and
Valins, S., & Weiner, B. (Eds.) (1972). Attribution: cognitive representations: The phenomenology of being
Perceiving the causes of behavior. Morristown, NJ: in a group. Journal of Experimental Social Psychology,
General Learning Press. 27, 297±323.
Jones, E. E., & Nisbett, R. E. (1972). The actor and the Mullen, B., & Hu, L. (1989). Perceptions of ingroup and
observer: Divergent perceptions of the causes of beha- outgroup variability: A meta-analytic integration. Basic
vior. In E. E. Jones, D. E. Kanouse, H. H. Kelley, R. E. and Applied Social Psychology, 10(3), 233±252.
Nisbett, S. Valins, & B. Weiner (Eds.), Attribution: Murray, S. L., Holmes, J. G., & Griffin, D. W. (1996). The
Perceiving the causes of behavior (pp. 79±94). Morris- benefits of positive illusions: Idealization and the
town, NJ: General Learning Press. construction of satisfaction in close relationships.
Kelley, H. H. (1967). Attribution theory in social psychol- Journal of Personality and Social Psychology, 70(1),
ogy. In D. Levine (Ed.), Nebraska symposium on 79±98.
motivation (Vol. 15, pp. 192±240). Lincoln, NE: Uni- Newcomb, T. M. (1961). The acquaintance process. New
versity of Nebraska Press. York: Holt, Rinehart and Winston.
Kelley, H. H. (1972). Causal schemata and the attribution Nisbett, R. E., & Ross, L. (1980). Human inference:
process. In E. E. Jones, D. E. Kanouse, H. H. Kelley, R. Strategies and shortcomings of social judgment. Engle-
E. Nisbett, S. Valins, & B. Weiner (Eds.), Attribution: wood Cliffs, NJ: Prentice-Hall.
Perceiving the causes of behavior (pp. 151±174). Morris- Oliner, S. P., & Oliner, P. M. (1988). The altruistic
town, NJ: General Learning Press. personality: Rescues of Jews in Nazi Europe. New York:
Kelley, H. H. (1979). Personal relationships: Their struc- Free Press.
tures and processes. Hillsdale, NJ: Erlbaum. Orvis, B. R., Kelley, H. H., & Butler, D. (1976).
Kelley, H. H., & Thibaut, J. W. (1978). Interpersonal Attributional conflict in young couples. In J. H. Harvey,
relations: A theory of interdependence. New York: Wiley. W. J. Ickes, & R. F. Kidd (Eds.), New directions in
Kelley, H. H., & Thibaut, J. W. (1985). Self-interest, attribution research (Vol. 1, pp. 353±386). Hillsdale, NJ:
science, and cynicism. Journal of Social and Clinical Erlbaum.
Psychology, 3, 26±32. Patnoe, S. (1988). A narrative history of experimental social
Kellogg, R., & Baron, R. S. (1975). Attribution theory, psychology: The Lewin tradition. New York: Springer-
insomnia, and the reverse placebo effect: A reversal of Verlag.
Storms and Nisbett's findings. Journal of Personality and Petty, R. E., & Cacioppo, J. T. (1981). Attitudes and
Social Psychology, 32(2), 231±236. persuasion: Classic and contemporary approaches. Dubu-
Langer, L. L. (1991). Holocaust testimonies: The Ruins of que, IA: Brown.
Memory. New Haven: Yale University Press. Petty, R. E., & Cacioppo, J. T. (1986). Communication and
Lantz, J. E. (1993). Existential family therapy: Using the persuasion: peripheral routes to attitude change. New
concepts of Viktor Franck. Northvale, NJ: Jason York: Springer-Verlag.
Aronson. Phillips, D. P. (1974). The influence of suggestion on
LataneÂ, B. (1981). The psychology of social impact. suicide: substantive and theoretical implications of the
American Psychologist, 36(4), 343±356. Werther effect. American Sociological Review, 39,
LataneÂ, B., & Darley, J. M. (1970). The unresponsive 340±354.
bystander: Why doesn't he help? New York: Appleton- Phillips, D. P. (1979). Suicide, motor vehicle fatalities and
Century-Crofts. the mass media: Evidence toward a theory of suggestion.
Lazarus, R. S. (1966). Psychological stress and the coping American Journal of Sociology, 84, 1150±1174.
process. New York: McGraw-Hill. Prager, K. J. (1995). The psychology of latimacy. New
Leary, M. R., & Miller, R. S. (1986). Social psychology and York: Guilford.
dysfunctional behavior: Origins, diagnosis, and treatment. Regan, D. T., & Totten, J. (1975). Empathy and attribu-
New York: Springer-Verlag. tion: Turning observers into actors. Journal of Person-
Lerner, M. J. (1980). The belief in a just world: A ality and Social Psychology, 32(5), 850±856.
fundamental delusion New York: Plenum. Reis, H. T., & Shaver, P. (1988). Intimacy as an
Lewis, C. S. (1961). A grief observed. New York: Bantam. interpersonal process. In S. W. Duck (Ed.), Handbook
References 321
of personal relationships (pp. 367±389). Chichester, UK: Swann, W. B., Jr. (1996). Self-traps: The elusive quest for
Wiley. higher self-esteem. New York: Freeman.
Robins, R. W., Spranca, M. D., & Mendelsohn, G. A. Turner, J. C. (1991). Social influence. Pacific Grove, CA:
(1996). The actor±observer effect revisited: Effects of Brooks/Cole.
individual differences and repeated social interactions on Valins, S., & Nisbett, R. E. (1972). Attribution processes in
actor and observer attributions. Journal of Personality the development and treatment of emotional disorders.
and Social Psychology, 71(2), 375±389. In E. E. Jones, D. E. Kanouse, H. H. Kelley, R. E.
Rosenhan, D. L. (1973). On being sane in insane places. Nisbett, S. Valins, & B. Weiner (Eds.), Attribution:
Science, 179, 250±258. Perceiving the causes of behavior (pp. 137±150). Morris-
Rosenthal. A. M. (1964). Thirty-eight witnesses. New York: town, NJ: General Learning Press.
McGraw-Hill. Vaughan, D. (1986). Uncoupling: Turning points in intimate
Rosenthal, R., & Jacobson, L (1968). Pygmalion in the relationships. New York: Oxford University Press.
classroom: Teacher expectation and pupils' intellectual Wallach, M. A., & Wallach, L. (1983). Psychology's
development. New York: Holt, Rinehart and Winston. sanction for selfishness The error of egoism in theory
Ross, L. (1977). The intuitive psychologist and his short- and therapy. San Francisco: Freeman.
comings: Distortions in the attribution process. In Walster (Hatfield), E., Aronson, V., Abrahams, D., &
L. Berkowitz (Ed.), Advances in experimental social Rottman, L. (1966). The importance of physical attrac-
psychology (Vol. 10, pp. 173±220). New York: Academic tiveness in dating behavior. Journal of Personality and
Press. Social Psychology, 4, 508±516.
Schachter, S. (1964). The interaction of cognitive and Weary, G., Elbin, S. D., & Hill, M. G. (1987). Attribution
physiological determinants of emotional state. In L. and social comparison processes in depression. Journal
Berkowitz (Ed.), Advances in experimental social psychol- of Personality and Social Psychology, 52, 605±610.
ogy (Vol. 1, pp. 49±80). New York: Academic Press. Weary, G., Jordan, J. S., & Hill, M. G. (1985). The
Scheff, T. J. (1966). Being mental ill: A sociological theory. attributional norm of internality and depressive sensi-
Chicago: University of Chicago Press. tivity to social information. Journal of Personality and
Seligman, M. E. P. (1975). Helplessness: On depression, Social Psychology, 49(5), 1283±1293.
development, and death. San Francisco: Freeman. Weary, G. & Mirels, H. L. (Eds.) (1982). Integrations of
Shay, J. (1994). Achilles in Vietnam: Contact trauma and the clinical and social psychology. New York: Oxford
undoing character. New York: Atheneum/Macmillan. University Press.
Sherif, M. (1937). An experimental approach to the study Weary, G., Stanley, M. A., & Harvey, J. H. (1989).
of attitudes. Sociometry, 1, 90±98. Attribution. New York: Springer-Verlag.
Snyder, C. R., & Forsyth, D. R. (Eds.) (1991). Handbook of Weber, A. L., & Harvey, J. H. (1994). Accounts in coping
Social and clinical psychology. New York: Pergamon. with relationship loss. In A. L. Weber & J. H. Harvey
Snyder, M., Tanke, E. D., & Berscheid, E. (1977). Social (Eds.), Perspectives on close relationships (pp. 285±306).
perception and interpersonal behavior: On the self- Boston: Allyn & Bacon.
fulfilling nature of social stereotypes. Journal of Person- Weber, A. L., Harvey, J. H., & Stanley, M. A. (1987). The
ality and Social Psychology, 35, 656±666. nature and motivations of accounts for failed relation-
Steele, S. (1990). The content of our character. New York: ships. In R. Burnett, P. McGhee, & D. C. Clarke (Eds.),
HarperCollins. Accounting for relationships (pp. 114±135). London:
Storms, M. D., & Nisbett, R. E. (1970). Insomnia and the Methuen.
attribution process. Journal of Personality and Social Weiner, B. (1974). Achievement motivation and attribution
Psychology, 16, 319±328. theory. Morristown, NJ: General Learning Press.
Strong, S. R. (1968). Counseling: An interpersonal Weiss, R. S. (1975). Marital separation. New York: Basic
influence process. Journal of Counseling Psychology, 15, Books.
215±224. Weiss, R. S. (1988). Loss and recovery. Journal of Social
Strong, S. R., & Claiborn, C. D. (1982). Change through Issues, 44, 37±52.
interaction: Social psychological processes of counseling Williamson, G. M., & Clark, M. S. (1989). Providing help
and psychotherapy. New York: Wiley-Interscience. and desired relationship type as determinants of changes
Strong, S. R., & Schmidt, L. D. (1970). Expertness and in moods and self-evaluations. Journal of Personality and
influence in counseling. Journal of Counseling Psychol- Social Psychology, 56(5), 722±734.
ogy, 17, 81±87. Wilson, D. W. (1981). Is helping a laughing matter?
Strupp, H. (1981). The outcome problem in psychotherapy: Psychology, 18, 6±9.
Contemporary perspectives. In J. H. Harvey & M. M. Yost, J. H., & Weary, G. (1996). Depression and the
Parks (Eds.), Psychotherapy research and behavior change correspondent inference bias: Evidence for more effort-
(pp. 41±71). Washington, DC: American Psychological ful cognitive processing. Personality and Social Psychol-
Association. ogy Bulletin, 22(2), 192±200.
1.11
Cognitive Psychology
RICHARD HOFFMAN and MUSTAFA al'ABSI
University of Minnesota, Duluth School of Medicine, Duluth,
MN, USA

1.11.1.1 Cognition and Clinical Psychology 323
1.11.1.2 Models of Cognition, Learning, and Memory 324
1.11.1.3 Conscious and Unconscious Processing 326
1.11.1.4 Neural Network Models and Classical Conditioning 329
1.11.1.5 Multiple-level Neural Network Models 330
1.11.2 MOOD AND MEMORY 331
1.11.2.1 Effects of Affective States 331
1.11.2.2 State-dependent Learning 332
1.11.2.2.1 The Network Theory of Affect 332
1.11.2.3 Depressed Mood and Cognitive Performance 333
1.11.3 COGNITION±EMOTION INTERACTIONS 335
1.11.3.1 Cognitive Factors 335
1.11.3.2 Cognitive Appraisal 336
1.11.3.3 Attribution and Affect 337
1.11.3.4 Psychobiological Substrates 337
1.11.4 COGNITIVE MODELS OF ANXIETY 338
1.11.4.1 General Cognitive Models of Anxiety 338
1.11.4.2 Specific Phobias 339
1.11.4.3 Panic Disorder and Agoraphobia 339
1.11.4.4 Social Phobias 340
1.11.4.5 Post-traumatic Stress Disorder 341
1.11.4.6 Generalized Anxiety Disorder 341
1.11.5 COGNITIVE MODELS OF DEPRESSION 342
1.11.5.1 Cognitive Distortion Models 342
1.11.5.2 Differential Activation Model 344
1.11.5.3 Cognitive Appraisal Model 345
1.11.5.4 Learned Helplessness Model 346
1.11.5.4.1 Revised helplessness model 346
1.11.5.4.2 Hopelessness theory 347
1.11.1 INTRODUCTION how knowledge is acquired, how it is internally

represented, how it interacts and modifies or is
1.11.1.1 Cognition and Clinical Psychology modified by previous experience and existing
information, and how acquired knowledge
Cognitive psychology is that specialty area of affects feelings and behavior. The subject matter
psychology concerned with the examination of encompasses not only the process of thinking
323
324 Cognitive Psychology
(attention, concentration, consciousness, mem- ranging from anxiety and depression to panic
ory), but also an examination of emotions and disorder, anger problems, obsessive-compulsive
motivation in relation to cognition. There has disorder, and suicidal behavior (Ellis & Dryden,
been a dramatic shift in the theoretical base of 1997; Freeman & Reinecke, 1993; Yankura &
clinical psychology since the 1940s from psycho- Dryden, 1997).
analytic and behavioral models to cognitive This chapter will provide an overview of some
models as the task of clinical psychology has of the current literature in cognitive psychology
changed to encompass more than simply that is particularly germane to the practice of
disturbed behavior and maladaptive habits. clinical psychology in general and the practice of
Clinical psychologists now concern themselves cognitive behavioral therapies in particular,
routinely with such aspects of human behavior with the clear understanding that this is a highly
as the emotional state of their patient, their condensed and highly selective sampling of a
patient's ability to cope with difficult situations, rapidly expanding area. A major focus will be an
their interpersonal problems, their sense of well- examination of the origin and modification of
being or self-esteem, their memory and concen- emotional states, particularly anxiety and
tration, their thoughts and thinking process, and depression, due to their central role in con-
their physiological health status (Brewin, 1988). temporary clinical psychology.
In many respects this is a golden age for
cognitive psychology. The rapid development of
noninvasive neuroimaging technologies in the 1.11.1.2 Models of Cognition, Learning, and
mid-1980s has allowed researchers the unprece- Memory
dented opportunity to confirm some hypotheses
of cognitive functioning derived from labora- Since the 1970s, a central tenet in cognitive
tory learning experiments by looking at neural psychology has been that much, if not all of
function at the time that the subject performs cognition can be conceptualized as information
the experiment. The use of positron emission processing, and a great deal of work has been
tomography (PET), functional magnetic reso- done since that time to identify component
nance imaging (fMRI), event-related potentials cognitive processes that underlie cognition.
(ERPs), electroencephalography (EEG) and Early models of cognition were mainly derived
magnetoencephalography (MEG) technologies inferentially by systematically varying stimulus
allows researchers to look at real-time ªpicturesº properties and carefully measuring reponses.
of the human brain in the process of cognition The availability of high-speed computers al-
through measurements of blood flow and brain lowed the later development of more sophisti-
electrical activity. The reader is referred to cated discrete stage linear mathematical models
Posner & Raichle (1994) for an overview of this which, at least in a very limited sense, were
fascinating area and Posner & Raichle (1995) for capable of mimicking some aspects of cognitive
further commentary and critique. Noninvasive function. The later use of more sophisticated
neuroimaging has led to increased collaboration computer systems in the 1980s dovetailed with
between cognitive psychologists, neurologists, the growing awareness that functional brain
neuropsychologists, clinical psychologists, psy- systems and complex neural cicuits rather than
chiatrists, mathematicians, physicists, and neu- linear modules were involved in higher brain
roscientists of all sorts. The point is being rapidly function. Since that time, computer simulations
reached that brain, mind, and behavior need not of cognitive processes have been built that allow
be studied in isolation, and emerging electro- hypothesis testing of complex interactive sys-
physiological technologies such as multiple tems and model the possible effect of localized
single unit recordings and ERPs will only add brain damage on subsequent brain function.
to the available tools at the disposal of future Computational models have been built which
cognitive scientists. Models of cognitive pro- examine acquired disorders of reading (Hinton
cesses, neural networks, and mathematical & Shallice, 1991; Mozer & Behrmann, 1990;
models of cognitive function have also become Patterson, Seidenberg, & McClelland, 1990;
highly developed since the late 1980s (Taylor, Plaut & Shallice, 1993) as well as disorders of
1997), there have been enormous strides in our perception, attention, memory, frontal lobe
understanding of memory functioning from function, and language (Feinberg & Farah,
lesion studies (Zeki, 1993), and hundreds of 1997).
studies have been published in the areas of Computational models of cognition have
mood, motivation, and cognitive social psychol- influenced the field of cognitive psychology
ogy. Within this same time span, cognitive since the 1970s by providing meaningful heur-
behavior therapy and rational emotive behavior istics to link environmental events and informa-
therapy have become highly refined therapeutic tion stored in memory to subsequent behaviors.
modalities that address psychological problems The earliest such models were based primarily on
Introduction 325
digital computer processing methodology. for example, and is consistent with the observa-
These models used processing algorithms based tion that functionally similar areas of the brain
upon the premise that environmental events may contain multiple memories of any specific
trigger the retrieval of symbolically coded events event based upon their specific function (color,
from a discrete physical memory location. These form, size, motion, etc.), all or some of which
events are operated upon by some central may be recalled when a memory of the event is
processor according to previously stored in- recalled (Kolb & Whishaw, 1996).
structions, and information about the subse- The process of memory recall can be divided
quent behavior is fed back to memory stores by into two broad classes or types with different
this same central processor (Newell & Simons, underlying neural structures. Explicit memory
1972). More recently, computational models of refers to the conscious recollection of previously
cognition have been developed that more closely experienced events, whereas implicit memory is
model brain function and rely upon parallel a process that is automatic, occurs at a level
distributed processing (PDP) architecture. outside of consciousness, and is typically inferred
These have provided the methodology for from the effect that experience or practice has on
artificial neural networks as cognitive proces- the performance of a particular task (Moscov-
sing analogues (Anderson, 1995; Rumelhart & itch, 1984). Implicit memory is encoded in much
McClelland, 1986). Because the human brain is a the same way that it is perceived, whereas there
functionally and anatomically distributed and is some active reorganization of data that occurs
highly interactive system, PDP modeling has in explicit memory.
provided a conceptual framework and concrete Explicit memory can be further subdivided
tools to begin to explain the effects of local into two subtypes, strategic and associative/cue-
lesions on cognitive function as well (Farah, dependent, based upon those types of tests used
1997). to elicit explicit memory. Associative/cue-de-
Briefly stated, PDP systems consist of large pendent explicit memory is a relatively auto-
numbers of neuron-like units multiply con- matic response that is elicited following a cue
nected to each other by weighted connections that is sufficient to bring that memory to mind.
that determine the amount of activation or Strategic memory is that in which cuing does not
neural transmission that flows from one unit to elicit a specific response but rather initiates a
another. Each unit or collection of units memory ªsearchº not unlike problem-solving
functions locally and in parallel with other (Moscovitch, 1992). Petri and Mishkin (1994)
units, with no true central processor governing have identified four major limbic structures
the behavior of the network. An event is involved in the explicit memory system: the
represented as a pattern of activation distrib- rhinal cortex, the amygdala, the hippocampus,
uted across units. PDP networks can accom- and the prefrontal cortex. These structures have
odate multiple types of learning depending reciprocal connections with the medial thala-
upon the computational properties of the mus, the basal forebrain and orbital frontal
network. These computational properties in cortex, and sensory areas of the neocortex.
general are a function of the activation rule of Experimental results suggest that the rhinal
that network (e.g., linear vs. nonlinear activa- cortex is involved in object memory, the
tion), the type of connectivity within the hippocampus in spatial memory, and the
network (e.g., unidirectional vs. bidirectional), amygdala in emotional memory (Kolb &
and the learning rule imposed by the architec- Whishaw, 1996). Evidence both from animal
ture of input units vs. output units. Long-term models and lesion studies in humans has
memory is represented by the encoding of a demonstrated sparing of old memories and
pattern of connection strengths distributed implicit memories following damage to medial
within a population of units or neurons. temporal structures, but severe impairments in
A basic premise of most PDP models of the formation of new explicit memories.
memory is that because every part of the brain Implicit memory can be further subdivided
or all collections of neural units possess the into two subtypes, procedural and item-specific,
ability to learn, memory cannot therefore be based upon those types of tests used to elicit
housed in a specific structure or structures of the implicit memory. Procedural memory refers to
brain as was the case in classical theories of the acquisition and retention of general skills,
memory, but rather expressed as memory procedures, or rules including learned motor
processes or circuits which are related to those tasks. Item-specific tests, in contrast, are con-
areas processing that information. This is cerned with the acquisition and retention of a
consistent with the observation that areas of particular type of information and the increased
the brain which process auditory information accuracy or speed with which a previously seen
house auditory memory and areas that process item identified on repetition is a function of the
visual information also house visual memory, repetition priming effect (Moscovitch, 1992).
Petri and Mishkin (1994) have identified the select movement. PET and ERP data with
caudate nucleus and putamen (basal ganglia) as human subjects are consistent with these
those brain structures centrally involved in the findings (Corbetta, Miezin, Dobmeyer, Shul-
implicit memory system. The basal ganglia man, & Petersen, 1991; Corbetta, Miezin,
receive projections from cells in the substantia Shulman, & Petersen, 1993; Naatanen, 1992).
nigra and all regions of the neocortex and send Regions of the frontal lobes are also activated
projections via the globus pallidus and ventral in tasks requiring response selection. For
thalamus to the premotor cortex. Animals with example, the anterior cingulate cortex is acti-
damage in basal ganglia circuits demonstrate vated in divided attention tasks as well as the
preserved recognition memory, spatial memory, dorsolateral prefrontal cortex (Corbetta et al.,
and emotional memory, but demonstrate im- 1991), and verb-generation tasks activate the
pairments in learning motor skills, learning to inferior frontal cortex (Posner & Raichle, 1994).
make appropriate responses to cues, and Posner and Petersen (1990) have proposed that
demonstrate poor performance on association the frontal lobe therefore contains a second
tasks (Petri & Mishkin, 1994). attentional system or executive attentional
Finally, fundamental to the understanding of system which plays a major role in the activation
conscious and unconscious processing is the of selective attention systems of the posterior
inter-relationship between networks of attention cortex and which is closely related to the working
and short-term memory or ªworking memory.º memory functions of the frontal lobe. In this
Working memory refers to the form of memory model, the frontal lobe is responsible for the
used to hold words, names, digits, or other items programming of mental operations, and the
in memory for a brief period of time (Baddely, content of consciousness consists of information
1986). Working memory appears to be a within working memory that is operated on by
function of the prefrontal cortex which allows the executive attentional system.
the maintenance of information in short-term Clinically, it is not always easy to separate
memory that is later used to guide action attention and working memory. Damage to
(Goldman-Rakic, 1987; Moscovitch & Umilta, prefrontal areas of the brain, if extensive
1991). Short-term or working memory has a enough, causes deficits in both attentional
different structural basis from long-term mem- circuits and working memory. Also in some
ory. The parietal-frontal spatial system, which instances, observed deficits which appear to
includes Brodmann's frontal cortex area 8 and represent functional disorders of working
projections from the parietal cortex, is involved memory may instead be residual or secondary
in short-term memory for spatial location of to damage to atentional mechanisms. An
objects and in searching for an object when a assessment model of attention has been pro-
stimulus is presented. Frontal cortex areas 9 and posed by Mateer and Mapou (1996) that at least
46, with projections from the inferior temporal partially addresses this by carefully delineating
cortex (the inferior-temporal dorsolateral fron- the boundaries of attention and separating it
tal system), are involved in the short-term mem- into two component parts, deployment and
ory for visual objects and remembering objects capacity/encoding. Deployment is the ability to
that are identified sequentially (Petrides, Alivi- channel and focus attention, which includes the
satos, Evans, & Meyer, 1993; Wilson, Scalaidhe, assessment of arousal, focused attention, and
& Goldman-Rakic, 1993). The available evi- sustained attention. Arousal is assessed by
dence suggests that working memory and long- observation, focused attention is assessed by
term memory are parallel mechanisms in which tasks that require the rapid scanning and
material is processed separately and simulta- identification of targets, and sustained attention
neously, although information can be pulled is assessed by continuous performance tests.
from long-term memory and used in working Capacity/encoding is the ability to hold in-
memory for short-term problem-solving. formation and process it even if distracted or
Electrophysiological evidence from primate required to divide attention, and includes tasks
studies suggests that there are at least three that measure span of attention, resistance to
different types of attentional mechanisms in the interference, and mental manipulation.
mammalian brain (Moran & Desimone, 1985;
Petersen, Robinson, & Morris, 1987; Spitzer, 1.11.1.3 Conscious and Unconscious Processing
Desimone, & Moran, 1988). There is evidence
for an attentional mechanism in the parietal An understanding and appreciation of the
lobe that enhances spatial attention, one in the unconscious has been one of the central themes
inferior temporal region that selects objects, and of clinical psychology historically, and certainly
one in the visual and posterior temporal cortex a key concept in psychoanalysis and psycho-
that selects object features. In addition, cells in analytic psychotherapy. A companion theme is
the frontal eye fields have been demonstrated to the emphasis placed upon gaining an awareness
Introduction 327
of the internal state of the patient, an awareness absence of any awareness on the patient's part
both on the part of the patient and on the part of that they are even responding in any meaningful
the therapist. Patients and nonpatients alike way to external events, events that they
respond to situations and other people in ways seemingly cannot discriminate or detect. For
that seem disconnected to the current situation a thorough review of this rich area and the
and have day-to-day experiences that seem to be relationship of such syndromes to conscious-
neither desired nor clearly volitional. Is this a ness, the reader is referred to the publication by
result of experiences or learning that are below Weiskrantz (1997).
the threshold of awareness or in some way One of the first well-documented cases of
processed differently than those experiences of learning in the absence of awareness was the
which we are fully aware? famous patient H.M., who was tested exten-
Early observations of symptom remission in sively over the course of several years by multiple
hysterical patients under hypnosis led Freud, investigators (Corkin, 1968). H.M. became
Breuer, and later Janet to develop a model of severely amnesic following the removal of
repressed emotions and cognitive content to structures in the medial portions of both of his
explain the seemingly miraculous disappearance temporal lobes to treat intractable epilepsy.
and reappearance of all manner of dissociative Although H.M. had severe memory difficulties
symptoms (blindness, paralysis, anesthesias) in following this neurosurgical procedure, he was
response to hypnosis and suggestion (Brewin, nonetheless subsequently able to to master
1988). It was thought that such hysterical pursuit rotor tasks and learn mirror drawing
symptoms could be the result of traumatic tasks and retain them from session to session,
experiences that could not be readily recalled by despite the fact that he had no memory of the
patients due to the protective psychological experimental sessions or memory of ever having
mechanism they labeled repression but which, seen or used the experimental apparatus. This
under special circumstances, could be reexper- same sort of motor skill learning and retention of
ienced or reexamined to the patient's benefit. training without any conscious awareness of the
Working through the patient's resistance to learning event has been documented in other
experiencing painful affect and unacceptable densely amnesic patients by multiple authors
thoughts from unconscious to preconscious to (Brooks & Baddeley, 1976; Schacter, 1994;
conscious awareness, then becomes a central Schacter, McAndrews, & Moscovitch, 1988).
tenet of the therapeutic process. It was felt that Classical conditioning has also been demon-
the content of dreams and parapraxes or slips of strated in the absence of awareness. In a series
the tongue were further ªevidenceº of uncon- of experiments reported by Weiskrantz and
scious processes. This model of repressed Warrington (1979), a severely amnesic Korsak-
traumatic emotional events leading to symp- off patient was conditioned for anticipatory eye
toms and seemingly being responsible for day- closure with a neutral light and tone preceding
to-day behavior requires some examination of a an air puff to the eye. Despite the fact that he
mechanism or mechanisms to explain informa- reported no recall between conditioning trials
tion processing that occurs out of conscious of the air puff or what the apparatus that was in
awareness. There has been a great deal of front of him was being used for, the condi-
evidence from the laboratories of both cognitive tioned stimulus reliably elicted the conditioned
psychologists and cognitive neuropsychologists, eyeblink.
particularly since the late 1980s, to confirm a Perhaps more surprising has been the ob-
central role of the automatic processing of servation that densely amnesic patients are able
information without conscious representation. to learn and retain verbal information without
Early evidence of cognitive performance explicit recognition or recall. In a series of clever
without awareness can be found in studies in experiments, severely amnesic patients were
the neuropsychological literature describing shown a series of words and tested for
patients with amnesic syndrome and so-called recognition after several minutes (Weiskrantz
ªblindsight,º reported in the 1960s and 1970s, & Warrington, 1970). If asked to respond yes or
although there are anecdotal reports dating no to whether they had seen specific words, their
back at least to the late nineteenth century. performance was at a chance level. If instead
Although it is beyond the scope of this chapter they were provided with a very fragmented
to take an exhaustive look at this fascinating drawing of a target word and asked to guess the
area, it would be remiss not to report some identity of the word, they were much more able
examples in detail which illustrate not only to identify those fragmented words to which
preserved discrete cognitive functioning with- they had been previously exposed than those to
out the awareness of the patient that this which they had not been exposed, despite
capacity remains, but also preserved discrete having no recollection whatsoever of having
cognitive functioning that occurs in the total seen any of the words.
This sort of ªprimingº effect to enhance recall processing of information can and does occur
in the absence of awareness has also been in the absence of conscious awareness, a level of
demonstrated by providing densely amnesic processing that has been referred to as uncon-
subjects with the first few letters of target words, scious cognition (Greenwald & Draine, 1997).
which increased the facilitation of retention Merickle and Joordens (1997) have used a
induced by the previous exposure, the so-called version of the Jacoby exclusion task (Debner &
stem completion task. Retention intervals as Jacoby, 1994; Jacoby, 1991) with short stimulus
long as four months have been reported onset asynchronies to determine the critical
following priming in severely amnesic patients stimulus duration at which the unconscious
such as H.M. (Milner, Corkin, & Teuber, 1968), influence of priming exceeded the conscious
demonstrating that priming is capable of influence of priming in a word stem completion
revealing implicit memory (implicit processing) task. This same sort of priming effect (very
in the absence of explicit memory. similar to the priming effect observed in amnesic
Experiments with cortically blind patients patients) has been demonstrated in the Stroop
have revealed that the phenomenon of informa- color word task (Logan, Zbrodoff, & William-
tion processing without awareness is not simply son, 1984; Merikle & Cheesman, 1987), in both
confined to memory systems. It has been visual and auditory word recognition tasks
demonstrated by several investigators that (Groeger, 1988; Marcel, 1983), and in visual
patients who have sustained damage to the search tasks (Schneider & Shiffrin, 1977).
striate cortex of the brain at Brodmann area 17 Multiple neural pathways for processing these
(the V1 projection area) and who are cortically types of information are the likely neuroanato-
blind can nonetheless demonstrate the ability to mical substrate to account for these types of
detect the presence of stimuli, to locate them in processing independent of awareness.
space, to discriminate direction of movement, to Several lines of evidence from numerous
discriminate the orientation of lines, and to investigators in cognitive psychology suggest
discriminate between different wavelengths of that there are two general types of information
light, despite having no awareness that there is processing: conscious or control processes
any stimulus present in their blind hemifield which appear to be clearly under the control
(Blythe, Kennard, & Ruddock, 1987; Cowey & of the individual and automatic processes which
Stoerig, 1991; Weiskrantz, 1986, 1995). are triggered by a stimulus and operate outside
These seemingly impossible feats of visual of awareness and are therefore not under the
perception are explainable due to multiple control of the individual (Posner & Snyder,
cortical connections to the human optic nerve 1975). Control processes by definition would be
and retina. The major input from the optic nerve limited by the attention span of the individual,
goes to the dorsal lateral geniculate nucleus and could be characterized as deliberate, effortful,
ultimately to V1, and if this circuit is intact adaptable, and to some extent highly flexible,
patients cannot only ªseeº objects in the visual but processes that could be easily disrupted by
field but also have the awareness of ªseeing.º stimuli competing for that individual's atten-
About 10±15% of the output from the optic tion. Control processes would be more likely to
nerve goes to nine other visual pathways or be elicited by novel situations which require
connections (superior colliculus, ventral lateral more effortful cognitive processing (Brewin,
geniculate nucleus, pre-tectum, nucleus of the 1988), but in highly complex or ambiguous
optic tract, dorsal terminal accessory optic situations the limitations imposed by attention
nucleus, lateral terminal accessory optic nu- and attention span may lead to decisions that
cleus, medial terminal accessory optic nucleus, are made by simple rules or a priori expectations
inferior pulvinar, and suprachiasmatic nucleus) or hypotheses. Automatic processes, in con-
which affords the possibility of retaining some trast, require minimal attention, may be
aspects of the ability to ªseeº but without the activated without intention or awareness, are
awareness of seeing (Sahraie et al., 1997; likely to be rapid and inflexible, and are more
Weiskrantz, 1997). likely to be activated in familiar situations in
If the phenomena of ªblindsightº and which the individual has had considerable
memory retention in severely amnesic patients experience. Since automatic processes run in
are to have relevance to the everyday practice of the background below the level of awareness,
clinical psychology, similar processing of in- they are subject to misattributions of causality
formation without awareness would need to be by linking two events together that occur close
documented in nonbrain injured individuals as together in time and by judging more salient
well. Although an area not without considerable stimuli as causally prior. Automatic processing
controversy, investigations in the area of has an obvious correlate in what has been
subliminal perception and subliminal semantic referred to by investigators as implicit memory
activation provide additional evidence that in which prior experience influences later
Introduction 329
processing without conscious or deliberate information is ignored. This phenomenon has a

recollection of the experience (Schacter, 1987), corollary in the laboratory in the automatic
whereas the correlative memory analogue for attention responses reported by Schneider and
conscious processing is explicit memory. There Shiffrin (1977) in which extensive experience
is at least some evidence to suggest that with a particular stimulus in a visual search task
conscious processing of information inhibits led to subjects immediately attending to that
automatic processing of that and contiguous stimulus irrespective of the complexity of the
stimuli (Posner & Snyder, 1975), suggesting target display or the memory load of previous
some inhibitory effect of conscious processing learning trials.
and inhibitory effect of explicit memory. There have been a number of cognitive
Cognitive models of conscious processing and models that have been proposed which have
explicit memory vs. automatic processing and elaborated upon or modified the simple,
implicit memory have a direct relationship to dichotomous conscious/automatic processing
psychopathology and patient behavior. The model (Schacter, 1989; Schacter et al., 1988) and
excessive rumination of depressed patients may taken into account the relationship between
be a manifestation of the inhibitory effect of phenomenal consciousness, procedural memory
conscious processing such that a patient's and procedural systems, declarative/episodic
narrow focus on perceived deficiencies or memory, and executive functions, including
perceived slights by other people inhibits models that embrace multiple levels and types
dissonant information that might be contra- of consciousness (Block, 1995). Since the late
dictory and of a more positive nature and 1980s, numerous cognitive psychologists, neu-
excludes it from subjective experience (Beck, rophysiologists, mathematicians, and computer
Rush, Shaw, & Emery, 1979; Brewin, 1988; scientists have been actively constructing and
Dixon, 1981). Negative self-talk and negative elaborating a wide variety of computational,
core assumptions can therefore be seen as not neural network models to account for the
only tied to the content of information proces- properties of consciousness, attention, memory,
sing or cognition but also the particular process and higher cognitive processes (Alavi & Taylor,
of cognition. There is likely also a companion 1993; Gray, Buhusi, & Schmajuk, 1997; Rolls,
narrowing of focus in major depressive disorder 1997; Sun, 1997; Taylor, 1997) which may
from processing external information and ultimately have a profound affect on the way
maintaining alertness to processing internally clinical psychologists conceptualize psycho-
generated thoughts and feelings. PET scan pathology.
studies of unipolar depressed patients reported
by Posner and Raichle (1995) have documented 1.11.1.4 Neural Network Models and Classical
striking increases in cerebral blood flow in the Conditioning
frontal cortex, particularly in the left frontal lobe
and left prefrontal cortex, and decreases in blood The cognitive abnormalities characteristic of
flow in the parietal and posterior temporal lobes the acute phase of schizophrenic psychosis
compared with matched control subjects. Even (hallucinations, delusions, fragmentation, loss
more striking, when normal subjects are asked to of selective attention) have been conceptua-
contemplate sad thoughts or memories to induce lized by Hemsley (1987) as reflecting a break-
a sad mood, the same left prefrontal blood flow down in the normal control of current
increases are seen. information processing by disruption of the
One central focus in the cognitive-behavioral normal ability to use stored regularities as a
treatment of depression is to understand and guide to current information processing.
uncover unarticulated core assumptions that Information that is typically processed in an
guide patients' attitudes and beliefs about automatic, nonconscious mode is then directly
themselves and act as a filter or template to experienced and processed in a controlled or
assign values to everyday experiences, core conscious mode (Gray, Feldon, Rawlins,
assumptions that typically patients are not Hemsley, & Smith, 1991; Schneider & Shiffrin,
aware or are only minimally aware of having 1977). There is a body of evidence to suggest
(Beck et al., 1979). These core assumptions may that a disruption in latent inhibition may
be formed in large part by the automatic account for this phenomenon.
processing of information, and would therefore Latent inhibition involves a classical con-
be expected to exist without the awareness of the ditioning paradigm which embraces elements o
patient. Selective attention or selective abstrac- cognitive processing (Dunn, Atwater, & Kilts,
tion is seen in depressed and anxious patients in 1993; Ellenbroek & Cools, 1990; Killcross,
which a single detail taken out of context Dickinson, & Robbins, 1994; Weiner, 1990).
becomes the conceptual frame for the entire Briefly stated, latent inhibition is the difference
experience and other sometimes more salient in efficacy of conditioning between conditioned
responses evoked by pre-exposed conditioned ulation about the relationship of awareness,

stimuli and conditioned responses evoked by attention, consciousness, memory, and mood,
nonpre-exposed conditioned stimuli (Gray et al., this model does not include true integration of
1997). Latent inhibition is decreased or blocked limbic structures, hippocampus, and related
by amphetamine treatment in animal models areas. Of great value, however, is the compat-
(Solomon & Staton, 1982; Weiner, Lubow, & ibility of this model with neural net models of
Feldon, 1984) and in human subjects (Gray, the amygdala (Monchi & Taylor, 1995, 1997), a
Pickering, Hemsley, Dawling, & Gray, 1992; cortical structure that appears to have a central
Thornton et al., 1996). This block is reversible role in depression.
by injection of haloperidol (Gray et al., 1997). PET scan studies reported by Posner and
A mathematical neural network model for Raichle (1995) have confirmed increases in
latent inhibition has been developed (Buhusi & blood flow in depressed patients in a group of
Schmajuk, 1996; Gray et al., 1997; Schmajuk, cells in the amygdala and the medial dorsal
Lam, & Gray, 1996) which explains the cog- nucleus of the thalamus and decreases in the
nitive symptoms seen in acute schizophrenia as caudate nucleus. Examination of PET data
the result of a blockade of latent inhibition, from a second study of patients with previous
which is thought to be related to disruption of episodes of severe depression now in remission
dopaminergic pathways beginning in the nu- (Drevets et al., 1992) revealed blood flow
cleus accumbens and cascading through the increases in the amygdala with normal flow in
nucleus reticularis thalami and thalamocortical the thalamus and the caudate, and depressed
sensory relay nuclei. This model mathemati- patients in remission who were also actively
cally describes elements of the neural network treated with antidepressant medication had
theory of latent inhibition reported by Schma- normal blood flow in the amygdala. One role
juk (1997), which involves interaction between of the amygdala in cognition appears to be the
trace short-term memory for conditioned sti- affective labeling or assignment of emotional
muli, attentional long-term memory for condi- significance to experiences in long-term mem-
tioned stimuli, associative long-term memory ory. Posner and Raichle (1995) have concluded
for conditioned and unconditioned stimuli, and that if the increased blood flow in the amygdala
intermediate-term memories for conditioned seen in depressed patients represents a disrup-
and unconditioned stimuli and their predictions. tion in normal amygdala function, this dysfunc-
tion could result in a negative emotional state
1.11.1.5 Multiple-level Neural Network Models assigned to all experiences resulting in depressed
mood or could result in anhedonia due to the
Taylor (1997) has modeled a two-stage neural prevention of positive emotional labels assigned
network that accounts for blindsight and to events, thus tying together neural substrate,
neglect which is very similar conceptually to memory, cognition, and mood.
previously described conscious/automatic pro- As noted earlier, left prefrontal blood flow
cessing models, and has proposed a third stage increases have been noted on PET scans during
to this model (the ACTION net) roughly bouts of depression and also during induced
corresponding to those cortical areas involved sadness (Drevets et al., 1992). If the same
in executive functioning, planning, reasoning, dysfunction hypothesis is applied to this finding,
and working memory (Brodmann areas 46 and there is again the implication that cognition,
9). This third network is of particular interest for memory, and mood are inter-related. It is well
clinical psychologists because it involves neu- known that patients with structural damage to
roanatomic structures related to affect as well as the left prefrontal area demonstrate problems
memory and executive functioning. This model with set shifting and rigidity of thinking, and
is based upon the assumption of the basal describe having difficulty shifting problem-
ganglia (striatum and globus pallidus) acting in solving strategies even when they know that a
a disinhibitory manner on thalamocortical given strategy is incorrect. Posner and Raichle
recurrent loops. The ACTION net encompasses (1995) have suggested that disruption in left
five networks (corresponding to the five frontal prefrontal blood flow in depressed patients
loops identified by Alexander, DeLong, & could lead to this same sort of difficulty in the set
Strick, 1986) involving motor, premotor, and shifting of emotions and thoughts, leading to
supplementary motor cortex (action sequences), depressive rumination. Memory and mood are
limbic (affect), orbitofrontal (social), frontal eye again intertwined in this process. Induced
fields (eye movements), and dorsolateral pre- negative mood increases in left prefrontal blood
frontal cortex (cognition and attention). flow occur coincident with the conscious
Although such a model can account for association of thoughts or emotion with
emotional tone as global activation from the information held in long-term memory. De-
limbic system and does allow for some spec- pressive rumination and the experience of
Mood and Memory 331
incessant negative thoughts also likely involve Subjects who received neutral mood induction
making conscious associations in working were able to recall more letters than subjects
memory with information retrieved from long- who received depressed mood induction. De-
term memory. There is increasing evidence from pressed mood during learning in other experi-
a number of laboratories that memory and ments led to a lower rate of recall, a lower rate of
mood are inter-related. learning of letter sequences, and lower number
of letters chunked when compared with neutral
1.11.2 MOOD AND MEMORY mood. These findings were interpreted by
Leight and Ellis as an indication of deficits in
1.11.2.1 Effects of Affective States strategy learning (Leight & Ellis, 1981).
The effect of depressed mood induction may
Cognitive models of negative mood (e.g., also be dependent on the nature of tasks being
Blaney, 1986; Carver & Scheier, 1990) assume performed, for example, difficulty levels. In a
that there is a two-way interaction in cognitive series of experiments, Ellis, Thomas, and
processing involving memory and the regula- Rodriguez (1984) found poorer performance
tion of emotions, that is, (i) the way an in free recall among subjects who received
individual reacts to an affective stimulus is depressed mood induction vs. subjects who
influenced by previously acquired memories, received neutral mood induction. A sentence
and (ii) the way we remember previous events is completion task was used. In this task subjects
influenced by affective states that prevailed were asked to complete a sentence with a suitable
when we encountered those events. word. The sentences were either easy or difficult.
Accumulated evidence suggests that memory It was found that depressed mood induction was
processes are influenced by affective states associated with worse performance relative to
during which memories were acquired. Since performance during a neutral mood condition
the 1970s interest in the study of memory when subjects were asked to recall words used
performance in the context of negative mood with difficult sentences. These authors also
and depression has been extended to laboratory found that when subjects had the opportunity
settings by both cognitive and clinical psychol- to process the information semantically using
ogists. Laboratory studies usually involve strategies such as elaboration, they were able to
experimentally inducing a depressed, elated, show better performance, supporting a
or neutral mood to observe its effect on memory resource-allocation model (Ellis et al., 1984).
performance. The model suggests that depressed mood has
The most frequent method used to induce debilitating effects when the encoding processes
depressed mood is the Velten Mood Induction required are demanding, difficult, and complex.
procedure (Velten, 1968). In this method, mood Similar conclusions were reported by Hasher,
is induced by having subjects read statements Rose, Zacks, Sauft, and Doren (1985), who
that are related to a depressed or elated mood. indicated that memory deficits in depression
Other methods, such as hypnosis, imagery, or may be attributed to the ineffective use of
music, have also been used in the experimental processes that require cognitive effort, such as
induction of mood. organization of information, imagination, re-
The effect of a depressed mood on recall has hearsal, and other mnemonic devices. Accord-
been demonstrated in experimental settings by ing to these authors, encoding operations
several researchers. Leight and Ellis (1981) require attentional capacity which could vary,
conducted two such experiments. In the first depending on whether these operations are
they investigated the effect of depressed mood automatic or effortful. Depression is one of the
on recall and transfer of training. Subjects variables thought to limit the availability of
received depressed, elated, or neutral mood attentional capacity to perform effortful opera-
induction. Then, they were trained on a letter tion. Effects of depressed mood would therefore
sequence task. Twenty-four hours after the be evidenced on memory tasks that require
training session, subjects received the same effortful processing.
training plus a transfer task in which they were Hertel and Hardin (1990) proposed that
presented with similar letters, but different memory deficit in depression may be attributed
spatial groupings. Overall, subjects' recall to the lack of cognitive initiative in depressed
improved over trials. However, subjects in the individuals, due to less initiative in using
depressed condition showed a slower improve- strategies that would help them remember.
ment rate than subjects in the elation condition. When these subjects are directed to use such
In the transfer phase, subjects who previously strategies, memory performance should im-
received depressed mood induction recalled prove. To test these hypotheses, Hertel and
significantly fewer letters than subjects who Hardin (1990) conducted three experiments.
never received depressed mood induction. They compared the performance of college
students who received depressed mood-induc- result between the mismatch of the mood state
tion with that of subjects who received neutral under which they recalled and the mood state
mood induction. The task used in these experi- under which they learned these materials.
ments involved presenting subjects with two lists
of homophones in the context of questions that 1.11.2.2 State-dependent Learning
reflected the less typical meaning of the homo-
phones, and with added questions to disguise the In this section hypotheses are discussed that
target words. Spelling and recognition lists were address the effect of mood on memory in the
constructed from the two lists of homophones. context of mood state-dependent learning (e.g.,
After receiving the mood induction procedures, Bower, 1981). One hypothesis that has been
subjects were asked to spell new and old introduced to account for poor memory perfor-
homophones to test their memory of the old mance in depression is the mood-congruence
homophones. When subjects who received hypothesis. This hypothesis has received intense
depressed mood induction were provided with attention from scientists interested in both
spelling strategies, they performed as well as cognitive processing and emotions (see Blaney,
those who were in the neutral mood condition. In 1986; Matt, Vazques, & Campbell, 1992; Singer
addition to their argument about the role of & Salovey, 1988). In its basic form, the
cognitive initiative in memory, Hertel and hypothesis states that learning and remembering
Hardin (1990) suggested that motivational stimuli will be easier when there is a match
differences between groups may exist. Subjects between affective tone of the learned materials
who received depressed mood induction may with the receiver's current mood state than when
have had an excuse not to try hard (Hertel & there is a ªmismatch.º That is, performance is
Harden, 1990). more efficient when the recall occurs in a mood
Failure to find memory deficits among state that is similar to the mood state when the
subjects who received depressed mood induc- learning process took place (Singer & Salovey,
tion was reported by other authors, however 1988), possibly due to efficiency in mnemonic
(e.g., Hasher et al., 1985; see also Ellis, 1985). processing (Blaney, 1986).
In summary, three main hypotheses have
attempted to address the effect of depressed
1.11.2.2.1 The Network Theory of Affect
mood on memory. The first is the hypothesis
that poor recall of information learned when The Network Theory of Affect, introduced by
subjects have a depressed mood can be Bower (1981), attempts to account for the
attributed to poor learning strategies and lack mood-congruency effect. One of the salient
of flexibility (Leight & Ellis, 1981). The second factors of this theory is the importance of mood
hypothesis indicates that people who are in a state during the learning process. The mood
depressed mood have less resources to process state is thought to serve as a cue when recalling
information, that is, according to the resource this information and included in associations
allocation model (Ellis et al., 1984), when the with coincident events. When this emotion unit
task requires more processing effort, depressed is activated, it is used as a cue to retrieve its
subjects show poorer performance than if the associated events.
task is easy. Third, Hertel and Hardin (1990) According to this theory, emotions may be
suggested that low level of cognitive initiative is viewed as nodes providing points of contacts
what causes poor memory performance in within a semantic network. Nodes related to a
depressed individuals. particular affective state are connected to other
Although the experimental literature seems to nodes of related moods that provide representa-
support a detrimental effect of depressed mood tions of events or connections that were formed
on memory, some questions still need to be during learning. In this manner, nodes related to
addressed. For example, how can we differ- anxious state, for example, are more likely to be
entiate between memory deficits in depression connected with anxiety-related concepts and
and state-dependent effect? Also, to what extent experiences (e.g., fear, heightened autonomic
could a state-dependent effect account for the arousal, and muscular activity, etc.) During a
effect of depressed mood on memory? These particular prevailing mood, nodes that tap these
questions seem to be important when we take mood states are activated, and they in turn
into consideration the fact that studies have activate other related nodes. Information con-
assessed memory performance in states that gruent with prevailing mood states acquires
may have been different from the state when the stronger processing than discongruent informa-
learning took place. That is, subjects who tion according to this theory. This leads to
learned materials while they were depressed elaborate processing at both encoding and
and then were tested in a neutral mood may retrieval phases, and this in turn contributes
have shown a poor memory performance as a to a better ability to recall mood-congruent than
Mood and Memory 333
mood-incongruent information (Gilligan & relying on internal rather than external re-
Bower, 1984; Singer & Salovey, 1988). Encod- sources in creating and processing cues for
ing information that is congruent with current retrieval makes memory more mood dependent.
mood state supposedly occurs through nodes Mathews and Bradley (1983) used Velten
that connect a widespread network, which leads mood induction and music to induce either a
to a dense and elaborate representation of depressed or a neutral mood. Positivity of
incoming information. In contrast, information personal memories was used as a dependent
that is incongruent with current affective state variable in that study. Subjects who received
taps a relatively less elaborate and narrower depressed-mood induction recalled more nega-
scope of network representation. A similar tive memories than subjects with a neutral
pattern of processes occurs during retrieval, mood. Similar results were found by Forgas,
where retrieval of mood-congruent information Bower, and Krantz (1984) who used hypnosis to
is facilitated by biased search of relevant induce either an elated or a depressed mood.
activated nodes, which leads to increased Subjects were asked to remember an interaction
accessibility of mood-congruent materials. In- task they had recently completed. Subjects who
congruent materials therefore are relatively less received a depressed mood induction recalled
accessible for search and retrieval (Bower, 1981; more unpleasant and stressful aspects of that
Riskind, 1989). experience than subjects who received an elated
Studies conducted to evaluate this hypothesis mood induction. On the other hand, subjects in
have observed effects of mood-congruency on the elation condition recalled more memories
retrieving learned information (cf. Riskind, related to the friendly and relaxed interaction
1989; Singer & Salovy, 1988). These studies they had during that task.
were done both in normal participants exposed Riskind, Rholes, and Eggers (1982) asked 52
to different types of mood induction procedures undergraduates to recall four pleasant and four
and in individuals who were classified as unpleasant life experiences. Then mood induc-
depressed (cf. Blaney, 1986). tion procedures were administered using the
Bower (1981) conducted a related study with Velten mood induction technique. Subjects
college students. Either a depressed or a happy received either depressed or elated mood
mood was induced using imagination guided by induction. The latencies for recalling positive
hypnosis suggestions. The main finding of this and negative experiences were compared across
study supported the mood state-dependent groups. Subjects in the elation condition were
hypothesis. Subjects who learned a word list in significantly faster in recalling positive experi-
the depressed mood were able to recall more ences than subjects in a depression condition.
words if they were tested in the same depressed While many studies have provided data to
mood than if they were tested in the happy mood. support the mood state-dependent hypothesis,
A similar pattern of effect was found with some studies failed to provide such support
subjects who learned the list in a happy mood. (e.g., Schare, Lisman, & Spear, 1984; see
Eich and Metcalfe (1989) went further to Blaney, 1986). Schare et al. (1984) conducted
suggest that mood state-dependency influences two experiments using mood-induction proce-
one's memory for internal more than external dures to induce depressed and neutral mood in a
events. Memory for external events is defined as sample of college students. They used a word list
a memory based on sensory stimuli that are learning task. Subjects were tested in either a
brought into awareness from external sources matched or mismatched mood state compared
through perception. Memory for internal to the original state in which they learned the
events, on the other hand, is defined as those lists. None of the experiments demonstrated a
events created through mental processes such as state-dependent effect.
imagination, reasoning, thoughts, etc. (Eich &
Metcalfe, 1989). They conducted an experiment 1.11.2.3 Depressed Mood and Cognitive
with college students in which they asked Performance
subjects to generate or read 16 items while in
either a happy or a sad mood. The mood- Studies conducted both in experimental
induction technique used in that experiment was settings with normal subjects and in clinical
continuous music. Subjects were tested two days settings with depressed patients have provided
later. The mood during the testing session was evidence to support a negative effect of
either matched or not matched with the mood depressed mood on memory performance.
during learning. The findings showed a sig- Several theories have attempted to explain the
nificant impairment in remembering generated cause of this effect. The main themes of these
items when the mood was shifted. The effect of theories indicate that memory deficits in
the mood shift was significantly less when depression could be attributed to the mood
recalling read items. The authors indicated that state-dependent effect and the severity of the
psychopathology of depression (Johnson & failure tasks than nondepressed subjects. Non-
Magaro, 1987). The state-dependent theory depressed subjects compared with depressed
attributes the poor performance in depressed subjects remembered more ªsuccessful tasks.º
individuals to the incongruency of the mood Another type of material used to investigate
state under which subjects recall materials that the mood-congruence hypothesis is self-refer-
may have been learned in a different mood state. ence statements or positive/negative materials.
Other theories propose that poor learning Clark and Teasdale (1982) conducted a study
strategy and lack of cognitive initiatives may with depressed patients who were tested twice
be the reason for the poor memory performance. on different occasions to tap the diurnal
The mood state-dependent effect is explained by variation in their mood. Materials with a
pointing out the importance of contextual cues depressing tone remembered while subjects
that could be provided in a particular mood were more depressed were compared with
state. These cues help in activating particular similar materials remembered while patients
memory associations that are congruent with the were in a less intense depressed mood. The
current mood state. It is also believed that the results showed that more ªunhappyº and less
depressed mood state activates a negative self- ªhappyº materials were remembered while
schema that results in selective encoding and patients were in the more depressed time. When
retrieval of materials that match the mood state. patients were in the less depressed occasion, the
Depression may affect memory through dis- results were reversed with the more happy and
rupting the ªnormalº pattern of organizing and less unhappy materials remembered by patients.
processing information, the low level of effort Why do depressed patients show memory
exerted when encoding and storing information, deficits? Weingartner, Cohen, Murphy, Mar-
or may be a product of a conservative response ello, and Gerdt (1981) investigated the strategies
style and a lack of motivation to learn and depressed individuals use to process informa-
process information efficiently. tion. In one experiment they found that
The state-dependent effect may contribute to depressed patients did not use elaborative
memory deficits in clinically diagnosed depres- strategies to encode information. Based on this
sion. Weingartner, Miller, and Murphy (1977) and other experiments, these authors concluded
used a free association task with eight manic- that depressed patients were unable to benefit
depressive patients to investigate state-depen- from encoding operations that would help them
dent memory in depressed patients. Subjects organize material and remember it. This con-
were asked to recall associations in either the clusion indicates that a processing deficit may
same or a different mood state. Patients showed exist in depressed individuals. This deficit may
better performance when they were asked to be attributed to ineffective organization in
recall the associations in a similar state to their encoding (Johnson & Magaro, 1987). This
learning state. According to these authors, conclusion is similar to the conclusion reported
mood state did not only affect the way these by researchers who have investigated this issue
associations were encoded but also provided in laboratory settings (Hasher et al., 1985).
help to determine how subjects could retrieve Some authors have argued that short-term
the relevant cues of that state. memory deficit may be the cause of overall
The mood-congruence hypothesis (discussed memory deficits in depression (e.g., see Koh &
earlier) has also been tested in studies conducted Wolpert, 1983). This argument was based on the
with depressed patients (e.g., Clark & Teasdale, finding that deficits were found in short- but not
1982; Gotlib, 1981; Matt, Vazquez, & Camp- long-term memory in depressed patients com-
bell, 1992; Tham et al., 1997). In some of these pared with nonpsychiatric patients (see Johnson
studies, depressed individuals were provided & Magaro, 1987). However, inconsistent results
with different types of feedback about their were also reported. For example, Henry,
performance. Subjects given negative feedback Weingarten, and Murphy (1973) found long-
were able to remember these tasks better than but not short-term memory deficits among a
when tasks were followed by positive feedback group of bipolar and unipolar depressed
(Calev, 1996; Channon & Baker, 1996; Singer & patients when they performed tasks while they
Salovey, 1986). Johnson, Petzel, Hartney, and were depressed compared with their perfor-
Morgan (1983) asked depressed and nonde- mance when they were not depressed.
pressed students to recall the content of tasks on Other factors not related to cognitive pro-
which they had been successful or unsuccessful. cesses were also suggested to explain memory
Both depressed and nondepressed groups had a deficits among depressed individuals. One of
similar amount of success or failure, since the these factors is the apparent lack of high
success or lack of success was under the motivation in at least some depressed individuals
experimenters' control. The authors found that (Cohen, Weingartner, Smallberg, Pickar, &
depressed subjects were more able to recall Murphy, (1982). Effort is necessary to perform
Cognition±Emotion Interactions 335
memory tasks that require elaboration and dependent theorist may argue that this indivi-
active rehearsal (Johnson & Magaro, 1987), dual may have been in a different mood when
but depressed individuals seem to lack the ability they learned about these events, and that they
to maintain a high level of persistency (Miller, would more likely to remember them if they
1975) which may affect their performance. To were in a similar mood state. All these inferences
investigate the relationship between memory still need to be directly tested.
deficit in depression and motivation, Cohen et al. In summary, to understand the effect of
(1982) conducted a study with 11 depressed depressed mood on memory, it may be useful to
patients and five normal controls. They demon- consider both the state-dependent hypothesis
strated a negative correlation between memory and theories that focus on encoding deficits. It is
performance and severity of depression and also also important to consider the severity of
between severity of depression and the tendency depressive symptoms as a contributing variable.
to exert effort to perform this task. A positive That is, while the mood state-dependent phe-
correlation was found between memory perfor- nomenon may explain some of the findings when
mance and the effort spent to perform the task. using mood induction with normal subjects,
Another factor that has been suggested to memory deficits among severely depressed
account for memory deficits among depressed individuals involve more complex mechanisms.
individuals is the tendency to be cautious in These mechanisms may include poor learning
giving responses when they are examined. strategies, less effort exerted in encoding
Johnson and Magaro (1987) argued that this information, lack of cognitive initiative to use
is not a cognitive deficit but rather a tendency to strategies, and a conservative response style, all
respond with a certain level of confidence that of which are associated with the level of severity
may make depressives conservative in their of depression.
response to testing situations. According to this
argument, memory may be intact and the
information needed may be available in the 1.11.3 COGNITION±EMOTION
memory store. The problem is instead related to INTERACTIONS
the restrictions depressed people impose on 1.11.3.1 Cognitive Factors
what they should report, and how sure they are
regarding the ªaccuracyº of the information The cognitive model of behavior emphasizes
they report (see Johnson & Magaro, 1987). the contribution of cognitive functioning to any
Theories that focus on the state-dependent emotional distress. Cognitive processes such as
effects and the mood-congruency effects assume perception, reasoning, and thinking, represent
that learned materials are available in memory. substrates for mental health. Faulty processes,
The failure to remember these materials could such as misperception of social situations,
be attributed to the lack of sufficient retrieval negative thinking, evaluation of oneself without
cues that subjects used when they encoded these sufficient data, and patterns of attributing
materials. When subjects are in a mood state failures to oneself, contribute to negative affect
that is similar to the mood state in which they and increase the risk for psychopathology.
learned materials, they may benefit from this In addressing cognitive contributions to
mood by getting better access to associations in emotional behavior, it is important to distin-
memory. Similarly, materials that are congruent guish between various terms used to describe
with a particular mood may be processed more cognition, including such terms as cognitive
effectively because of the availability of many processes, cognitive structure, cognitive con-
cues that could enhance the encoding process tent, and cognitive products (Ingram & Ken-
and retrieval. One could also infer that subjects dall, 1986). Cognitive processes are the
who learn materials which are congruent with operations performed to receive, store, trans-
their mood would tend to have a lower form, and coordinate information. Cognitive
threshold for encoding these materials and for structures are the organization of information.
chunking them in units that are easily accessible. Cognitive structures influence our perception of
Theories that emphasize the effect of poor surrounding situations and events. The cogni-
encoding strategies and low effort to process tive content is the actual information that we
information effectively assume that materials store and process, including what we tell
cannot be remembered because they were not ourselves via self-talk. Cognitive products are
learned or they are not available in memory. those outputs that result from the various
Therefore, a depressed individual who could not cognitive processes, including conclusions one
recall particular events from a previous day may may reach (Kendall & Hammen, 1995).
not have this information in their memory any Relating a certain style of processing to a
more, or may not have stored this information mood state may be better accomplished with the
in the first place. On the other hand, a state- distinction between these terms in mind. For
example, the way one explains an event (i.e., sizes perceived control over the environment as
attribution) is a cognitive product that may a critical determinant of the psychological
result from various cognitive processes. The way impact of events.
these cognitive processes are conducted would Lazarus and Folkman (1984) have described
depend on the content and the cognitive how interactions with the environment generate
structure for that person. The attribution emotions, noting the continuous evaluation
therefore may vary in persons who are anxious, process of events that people encounter. This
depressed, or in a happy mood. evaluation, termed appraisal, is classified as
This pattern of interaction between cognition familiar or unfamiliar and as threatening or
and emotion is well accepted. However, the nonthreatening. Various cognitive and beha-
question of whether cognition and emotion vioral strategies to deal with these challenges are
should be considered as separate systems is still also developed. Emotions experienced in these
strongly debated. Gray (1990) articulated a situations provide information about whether
model in which he described neurobiological these strategies are successful and motivate
systems that may underlie both cognition and additional behaviors.
emotion. He argues that the overlap between the According to Lazarus and Folkman (1984),
two systems is very strong, to the extent that it there are two stages of appraising situations.
may be impossible to distinguish between The first, called primary appraisal, involves
substrates of cognition and substrates of evaluating the threatening aspects of the
emotion. situation and is geared towards developing a
Other emotion researchers, on the other plan to deal with the situation. The second stage,
hand, argue that separate pathways can be called secondary appraisal, involves evaluation
delineated to account for cognition and emo- of the options available for dealing with the
tion, respectively (Izard, 1992; LeDoux, 1992; challenging situation. This appraisal determines
Panksepp, 1992). This school of thought also the cognitive, behavioral, emotional, and phy-
acknowledges the close interaction between siological responses to environmental events.
these two brain systems. Indeed, the separation Factors that influence primary appraisal of
between the two tends to be blurred in certain an event include one's beliefs about how the
conditions (LeDoux, 1989, 1992). One example world should work and one's own commitments
of such conditions is when rapid unconscious to given courses of action. Events that are
computations of a situation that is survival- discongruent with beliefs and commitments in
related have to take place. Such a situation, life are perceived as threatening events. When an
while it involves the emotional system, is also event is appraised as threatening, it invokes a
accepted as a type of cognition. The distinction simultaneous emotional reaction. This reaction
is more pronounced when the process involves signals alarm and motivates various behavioral
rational, analytic processing not related to basic and psychological responses along with physio-
survival efforts. logical activation to enable one to undertake
Most of the actively researched theories in planned coping behaviors (Lovallo, 1997). On
clinical psychology deal with both cognitive and the other hand, the process of secondary
emotional aspects of behavior in a complemen- appraisal focuses on efforts that might be used
tary fashion. To this end, several cognitive to ªcopeº with situations at hand. The efforts
theories of emotion have been proposed and may include coping strategies and coping
have enjoyed significant attention. These the- behaviors, and can be overt or covert.
ories generally agree that a stimulus when Lazarus and Folkman (1984) classify coping
perceived is linked or elaborated on by previous responses into two types: problem-focused and
experiences, and based on this elaboration an emotion-focused strategies. Problem-focused
emotional response ensues. An emotional strategies are directed at the source of the
response can be discrete or a mix of multiple problem itself, with efforts geared towards
emotions, with the most widely accepted gaining information, changing events, and
emotions being anger, happiness, sadness, fear, modifying beliefs and commitments. Problem-
and disgust (Ekman, 1973). focused strategies enhance one's awareness
and knowledge about the situation, and there-
1.11.3.2 Cognitive Appraisal fore enhance one's cognitive and behavioral
coping resources. These resources help in
Lazarus (1991) discussed the generation of reducing the threat value of the event. On the
emotions as a result of cognitive appraisals. other hand, emotion-focused strategies direct
Lazarus' model of emotion proposes that events efforts towards changing the psychological
we encounter are thought over, and responses to reactions to an event. This change is geared
each event are selected consciously from a range towards limiting the degree of emotional
of options. Lazarus' model of emotion empha- distress that may be caused by a stressful event.
Cognition±Emotion Interactions 337
1.11.3.3 Attribution and Affect The way cognition influences our emotion, or
emotion influences our cognition, is influenced
For a subjective emotional state to take place, by processing that takes place at multiple
both peripheral and central inputs contribute. physiological and anatomical levels. Gray
In the early 1960s Schacter and Singer (1962) (1990) discusses the prominent role of the
described how these sources of physiological hippocampal and amygdalary systems. He
change contribute to emotion. According to proposes the presence of three basic emotional
these authors, an emotional response is a systems that include a behavioral approach
product of two factors: perception of peripheral system, a fight-or-flight system, and a beha-
physiological arousal and the label given to this vioral inhibition system. Each system is influ-
arousal. The specific emotional response is then enced by a specific neuroanatomical structure.
based on the cognitive appraisal of the source of The hippocampal system (particularly the septal
arousal, whether it is attributed to external or area) is the biological substrate for behavioral
internal stimuli. inhibition, while the amygdalary system is the
In their original study, Schacter and Singer substrate of the fight-or-flight system. Both
(1962) independently manipulated epinephrine biological systems, according to Gray (1990),
and autonomic activation on the one hand and may be involved in the behavioral approach
manipulated attribution of the source of arousal emotion. Other systems, such as brainstem and
on the other. Subjects were injected with either neocortical systems, may also be involved in
epinephrine or placebo to induce physiological organizing approach behavior.
arousal. Subjects who were injected with The anatomical delineation of these hypothe-
epinephrine received no information or were sized interactions can be further appreciated by
misinformed. Subjects were not told that they reviewing the interconnections of the hippo-
would feel either happy or angry. The prediction campus, the amygdala, and other emotion-
was that subjects who were aroused but were not related brain systems. The hippocampus has
able to attribute this arousal to epinephrine various connections with cortical and brainstem
would express stronger motions. The findings structures. The hippocampus is also a primary
supported the model, although not definitively. structure involved in the conscious recollection
In the late 1970s, subsequent studies showed of past information (Squire et al., 1992), and in
that increased sympathetic arousal contributes processing spatial, contextual, and configural
to evaluating situations in a negative manner information (Eichenbaum, Otto, & Cohen,
(Marshall & Zimbardo, 1979). However, the 1992; Rudy & Sutherland, 1995). The hippo-
role of Schachter and Singer's (1962) two campus provides inputs to structures involved
factors in predicting interactions between in emotional processes, particularly the amyg-
situations and perception of autonomic state dala (LeDoux, 1993). The hippocampus inter-
has also been criticized (Erdmann, 1983). One acts extensively with the amygdala and other
area of criticism has been the supposed over- stress effectors, especially the hypothalamic±
estimation of the role of arousal in the pituitary±adrenocortical (HPA) system (Chrou-
interaction between arousal and attribution. sos & Gold, 1992). Projections from the
The role of arousal seems to be more accepted forebrain to the hippocampal formation also
when it is perceived as providing feedback indicate involvement of the latter in attention
which intensifies the experience of emotion processes.
(Reisenzein, 1983). Advancing this information to explain ab-
normal behaviors, Gray (1990) notes that
1.11.3.4 Psychobiological Substrates lesions in the septal area produce behavioral
effects that resemble those seen as a result of
The study of cognition±emotion interaction antianxiety drugs. Based on this finding, it was
may be further advanced by understanding the proposed that anxiety may be related to
biological underpinning of such interactions. functional changes in the septohippocampal
Recent efforts in cognitive neuroscience re- system (Gray, 1990). Additional cited support
search have generated excitement about the for this hypothesis includes the heightened
value of a multidisciplinary approach to study sensitivity of this system for signals predicting
emotion and cognitive processes. Indeed, most punishment and innate fear cues. This sensitiv-
of the prominent theoretical accounts of ity results in inhibition of behavior and
emotion±cognition interaction acknowledge enhancement of autonomic activity.
the importance of incorporating physiological The integration of emotion and cognition
knowledge in understanding this interaction also involves the amygdala. The amygdala is
and propose neurobiological substrates for it. viewed as the primary brain structure involved
The next section includes a brief discussion of an in emotional behavior and expression (Aggel-
account of this interaction. ton, 1992). It is a key structure in the memory of
emotionally-relevant information (LeDoux, responsible for affect-related approach beha-

1993). It plays a significant role in providing vior (Fox, 1991). This specialized dominance
emotional meaning to a stimulus. Research with seems to occur particularly in the anterior area
brain damaged humans has demonstrated the of the cortex, whereas the posterior region seems
importance of an intact connection of the to be associated with cognitive-perceptual
amygdala with other parts of the limbic system processes (Davidson, 1993). Consistent with
for the perception and expression of emotion this hypothesis, studies of right hemisphere
(Bechara et al., 1995). For example, bilateral lesions have documented a steeper decline in
lesions in the amygdala prevent conditioned sympathetic responses to stimuli compared with
autonomic responses to aversive stimuli, in spite those noted in studies of left-hemisphere
of an intact memory of declarative information damage (Tucker & Williamson, 1984).
about the presented stimuli (Bechara et al.). This line of work has implications for
Like the hippocampus, the amygdala receives understanding the association of mood states,
projections from and provides inputs to a wide cognitive performance, psychopathology, and
range of sensory and cortical structures (Der- frontal lobe activation. Intra- and interhemi-
ryberry & Tucker, 1992). The amygdala exerts a spheric differences in EEG activity have been
facilitatory influence on HPA activity (Feld- found to be related to depressed mood disposi-
man, Conforti, & Weidenfeld, 1995) and on the tion and withdrawal in clinical and nonclinical
autonomic and behavioral apparatus associated populations (Davidson, 1993; Fox, 1991).
with stress (Weiss et al., 1994). It projects output
to various brainstem structures including the
pontine reticular formation and the brainstem 1.11.4 COGNITIVE MODELS OF ANXIETY
aminergic nuclei. The pontine reticular forma- 1.11.4.1 General Cognitive Models of Anxiety
tion facilitates the behavioral and biological
response. The locus coeruleus and raphe nuclei Behavioral techniques such as desensitiza-
in the brainstem send their aminergic fibers to tion, flooding, and response prevention have
the cortex, limbic structures, and to the spinal been historically effective treatments for anxiety
cord. This influences the level of cortical disorders, but recent cognitive-behavioral ther-
activation and the interaction of descending apy methods, in combination with behavioral
cognitive output, emotional experience, and techniques, have demonstrated superior efficacy
autonomic and motor outflow. (Brewin, 1996). Purely cognitive techniques,
Cortical structures also influence both cogni- however, may not be superior to purely
tion and expression of emotion. An important behavioral methods (Rachman, 1993). There
area of research that has received increasing are some commonalities in the mechanisms
attention is the effect of cortical hemispheric underlying the effectiveness of cognitive-beha-
lateralization on emotional perception and vioral therapy for anxiety.
expression. The right hemisphere is generally Rachman (1990) noted several ways of
thought to play a more prominent role in acquiring fear, either by direct exposure to
nonverbal, spatial, and affective processes than aversive or traumatic stimuli, by observing
the left hemisphere. The latter is more prominent others displaying fear, or by hearing or reading
in verbal, sequential, and logical reasoning verbal or written information about fear and
(Borod, 1992). The dominance of the hemi- danger. Similarly, catastrophic misinterpreta-
sphere in emotional processing seems to be tion of symptoms based on ignorance or
specific to negative affect, although it has been incorrect beliefs can lead to panic disorder
suggested that this hemisphere is also involved in (Clark, 1988) and prolonged post-traumatic
emotional perception and expression, regardless stress disorder (PTSD; Ehlers & Steil, in press).
of the specific affective tone (Davidson, 1993). In these latter cases, the representations in
Relative to the left hemisphere, the right memory giving rise to feelings of fear may be
hemisphere has more direct connections with verbally accessible and can therefore be altered
subcortical structures involved in emotional by new verbal information. Many contempor-
expression (Gainotti, Caltagirone, & Zoccolotti, ary clinical approaches are based upon apprai-
1993). sal theories of emotion such as those of Lazarus
A further delineation of the role of right vs. (1991) and Weiner (1985), which emphasize the
left hemisphere assumes that the left hemisphere role played by conscious assessments of the
is more involved in the expression and experi- meaning and cause of internal and external
ence of positive affect, whereas the left hemi- stimuli and of the coping resources available to
sphere is more involved in the perception of deal with any prospective threat.
positive affect and both the perception and Verbally accessible knowledge may also be
expression of negative affect (Borod, 1992). subject to nonconscious automatic processing,
Related to this, the left hemisphere may be particularly when it is primed by a previous
Cognitive Models of Anxiety 339
stimulus. As noted by Clark (1988), cata- 1.11.4.3 Panic Disorder and Agoraphobia
strophic thoughts may come to mind so rapidly
that patients are unaware of the interpretive According to Clark (1988), panic arises from
process, which may in part explain panic attacks specific catastrophic misinterpretations of sen-
triggered in sleep. Also, almost by definition, sations such as tachycardia or dizziness. Treat-
automatic processing does not differentiate ment therefore involves a variety of techniques
between verbally and situationally accessible aimed at eliciting and challenging these mis-
knowledge (Brewin, 1996). interpretations. In contrast, Wolpe and Rowan
(1989) suggest that at least in some patients
there are no misinterpretations and that panic is
1.11.4.2 Specific Phobias instead the result of conditioning.
Panic provocation studies using CO2 inhala-
Specific phobias are among the most com- tion provide an analogue model for naturally
mon circumscribed anxiety disorders. Phobias occurring panic attacks (Gorman et al., 1988;
may be based on unconscious representations, Sanderson & Beck, 1989) and demonstrate the
independent conscious representations, or some importance of cognition in mediating the
combination of the two. The particular pattern emotional response to physiological sensations
of response to different treatment approaches secondary to hyperventilation. CO2 inhalation
depends on the nature of the memories. studies suggest that panic attacks are more than
Most cognitive-behavioral treatment ap- mere conditioned responses to a conditioned
proaches to phobia include an emphasis on stimulus. Panic disorder patients who panic in
helping individuals undermine habits of cogni- this situation experience cognitive symptoms
tive or behavioral avoidance and to achieve (e.g., fear of dying or losing control) in addition
habituation to a feared stimulus. More sophis- to somatic symptoms, whereas nonpanicking
ticated cognitive approaches emphasize the panic disorder patients and controls experience
importance of factors such as attention and only somatic symptoms (Sanderson & Beck,
memory (Dickinson, 1987) and conscious 1989). Direct manipulation of cognitive vari-
revaluation of the unconditioned stimulus ables also affects the likelihood of a CO2
(Davey, 1992, 1995). provoked panic attack. Rapee, Mattick, and
Lang (1979) proposed that the representa- Murrell (1986) found that panic disorder
tions underlying phobias, which he termed fear patients who were told which somatic symp-
memories, contain three kinds of information: toms to expect prior to the inhalation of CO2
details of the location and physical character- reported significantly less intense somatic
istics of the feared situation (stimulus elements); symptoms and catastrophic thoughts compared
details of the verbal, physiological, and beha- to those who were provided no such explana-
vioral responses that occurred in the situation tion. Sanderson, Rapee, and Barlow (1989)
(response elements); and an interpretation of found that panic disorder patients who believed
the stimulus and response elements and their they could control the flow of CO2 (although in
significance for the individual (meaning ele- reality they could not) experienced significantly
ments). Foa and Kozak (1986) propose that less anxiety and panic during the inhalation
cognitive therapy for phobias involves changing compared to those who did not believe this.
information in the fear memory by first Rachman, Levitt, and Lopatka (1987) pro-
activating the memory and then incorporating vide further evidence for the importance of
new experiences arranged by the therapist into cognition in the production of panic attacks.
that memory (such as within- and between- ªThreat-relevantº cognitions accompanied the
session habituation to the feared situation). majority (74.6%) of panic episodes reported by
Brewin's (1989) dual representation theory panic disorder patients. When combinations of
proposes that in therapy new memories are laid two or three symptoms were examined, Rach-
down as ªsituationally accessible knowledge.º man et al. (1987) found that ªno panics were
Patients in treatment are encouraged to expose reported unless there was an associated cogni-
themselves to as good an example as possible of tion.º On the other hand, when the same
what they fear and to experience the same combination of symptoms were accompanied
sensations. In therapy, however, this experience by a fearful cognition, the episode almost
culminates in mastery and the habituation of invariably resulted in panic.
fear rather than in avoidance. Patients exposed The biopsychosocial model of panic disorder
to these feared situations are subsequently more (Barlow, 1988) conceptualizes the initial panic
likely to access this new memory than they are to attack as a misfiring of the fear system under
access the original memory containing more stressful life circumstances in physiologically
fearful response elements and a more threaten- and psychologically vulnerable individuals.
ing meaning (Brewin, 1996). Physiological vulnerability is defined as an
overly reactive or labile autonomic nervous Craske and Barlow (1993) describe a 15-
system which may in part be determined session cognitive-behavioral treatment protocol
genetically, consistent with the higher concor- that is specific for panic disorder and agor-
dance rates of panic disorder seen within first- aphobia involving self-monitoring, cognitive
degree relatives (Crowe, Noyes, Pauls, & Sly- restructuring, breathing retraining, applied
men, 1983; Moran & Andrews, 1985; Torgersen, relaxation, interoceptive exposure, and in vivo
1983). Psychological vulnerability is conceptua- situational exposure.
lized as a set of danger-laden beliefs about bodily
sensations and about the world in general. The
concepts of uncontrollability (Barlow, 1988) and 1.11.4.4 Social Phobias
anxiety sensitivity (Reiss, Peterson, Gursky, &
McNally, 1986) are central in this model of panic Beck, Emery, and Greenberg (1985) describe
disorder and panic disorder with agoraphobia. a cognitive model of anxiety and phobias,
Persons who panic tend to have stronger beliefs including social phobias. The schema, the basic
and fears of physical and mental harm arising cognitive structure that guides the processing of
from specific bodily sensations (Chambless, information, serves as the core concept in this
Caputo, Bright, & Gallagher, 1984; Clark cognitive model. Schemas are sets of rules that
et al., 1988; Holt & Andrews, 1989). classify, prioritize, and interpret incoming
Barlow (1988) and Wolpe and Rowan (1989) information to the person as well as facilitate
emphasize the traumatic nature of the first panic the retrieval of relevant information from
attack and the consequent learning that takes memory. Schemas are grouped into modes that
place. The traumatic nature of initial panic create a cognitive set or processing bias that
attacks is apparent in the relatively high operates across situations. Anxiety-disordered
frequency of individuals seeking emergency individuals, according to Beck et al. (1985),
medical help due to their misappraisal of the typically function in the vulnerability mode,
panic attack as signaling impending death. that is, the individual sees the world as a
Consequently, fearful associations are likely to dangerous place in which they must constantly
develop with the situational context and the be vigilant to potential threat. As a result,
physical sensations present at the time of the neutral or mildly positive cues are misinter-
first panic. The concept of learning fearfulness preted negatively, while positive or safety cues
of bodily sensations is based on Razran's (1961) are discounted or ignored. Memories of past
account of interoceptive conditioning. This is a successes or available coping resources are also
form of conditioning that is relatively resistant underestimated or overlooked.
to extinction, and interoceptively conditioned Social phobics are hypervigilant to cues that
fear responses are not dependent on conscious denote the possibility of negative evaluation by
awareness of triggering cues. Panic attacks may others. These cues may be situational, inter-
seem to be uncued when in fact they are personal, or internal. Social phobics devote
triggered by benign and subtle fluctuations in excessive attentional resources to the detection
physical state (Barlow, 1988). For example, a of potential social cue threats (Hope, Rapee,
slight change in heart rate might cue or elicit Heimberg, & Dombeck, 1990; Mattia, Heim-
fearfulness in some patients in anticipation of berg, & Hope, 1993; Smith, Ingram, & Brehm,
experiencing a panic attack. Such internal fear 1983).
cues can trigger more abrupt, and less pre- The self-presentational model of social anxi-
dictable fear, which in turn leads to greater ety (Leary, 1988; Schlenker & Leary, 1982)
anticipatory anxiety about the recurrence of states that social anxiety occurs when an
fear (Craske, 1991). individual desires to make a particular impres-
Anxious anticipation of panic increases the sion on others but doubts they will be successful
likelihood of its occurrence, since anxious in doing so. How one might appear to others
arousal increases the availability of arousal must be of importance and there must be
sensations that have become conditioned cues apprehension about one's ability to engage in
for panic, in addition to increasing the degree of sufficient impression management. Individuals
attentional vigilance for such cues (Barlow, may be excessively motivated to create a
1988). In this manner, a cycle is established particular impression because of a high need
between panic and anxious apprehension about for approval, and several factors may affect a
panic. It is hypothesized that sex-role behaviors person's expectations about meeting impression
and expectations and associated situational management goals, including perceived or
demands influence the degree to which agor- actual deficits in social skills, low self-esteem,
aphobia emerges as a behavioral style in and low outcome expectancies.
response to panic anticipation (Craske & Hope and Heimberg (1993) describe a
Barlow, 1988). treatment protocol for cognitive-behavioral
Cognitive Models of Anxiety 341
group therapy of social phobia which consists of suggested that traumatic events create especially
simulated exposures to feared situations, cog- large and complex fear networks that are
nitive restructuring, and homework assign- activated readily because of the large number
ments for in vivo exposure. of interconnections formed through condition-
ing and generalization. Associations that were
once considered neutral or safe may now be
1.11.4.5 Post-traumatic Stress Disorder connected with fear. This leads to a sense of
unpredictability and uncontrollability that is
Creamer, Burgess, and Pattison (1992) have important in the development and maintenance
developed a cognitive processing model for of PTSD. Treatment requires activation of the
reactions to trauma that includes a feedback fear memory and incorporation of new infor-
loop among intrusions, avoidance, and symp- mation incompatible with the current fear
tom levels. The model views the successful structure, so that new memories are formed.
processing or integrating of the trauma as The PTSD victim is asked to recall the initial
central to successful recovery. This model sees trauma in detail and helped to process the
the cognitive processing mechanisms involved memory until it is no longer intensely painful.
in recovery over time as occurring in five stages. This is combined with in vivo exposure to feared
Stage 1 is objective exposure. The major fact at but objectively safe stimuli. Cognitive proces-
this stage is the severity of the traumatic sing therapy (CPT) is a therapy model devel-
stressor. Stage 2 is network formation. This is oped to treat the specific symptoms of post-
determined primarily by subjective perceptions traumatic anxiety and stress disorder in victims
and meaning attached to the experience. Stage 3 of sexual assault (Calhoun & Resick, 1993;
is labeled intrusion. During this stage, the Resick & Schnicke, 1992), which combines
memory network is activated in an attempt to cognitive restructuring with exposure-based
process and resolve the trauma-related mem- therapy.
ories. Stage 4, avoidance, is characterized by the
use of escape and avoidance as coping strategies
in response to intrusions. During stage 5, which 1.11.4.6 Generalized Anxiety Disorder
is labeled outcome, recovery is achieved
through network resolution processing. Such In generalized anxiety disorder (GAD), there
factors as pretrauma functioning and biological are often complex sets of negative beliefs about
processes are not incorporated into this model. the self or the external world that are activated
Chemtob, Roitblat, Hamada, Carlson, and in a variety of situations, and the underlying
Twentyman (1988) have developed a similar memory representations are thought to contain
information processing model of PTSD. more abstract information than the specific
The Jones and Barlow (1992) model considers memories underlying phobias. These represen-
PTSD as a variant of other anxiety disorders, tations are thought to consist of summaries of
particularly panic disorders, with anxious numerous aversive experiences produced by
apprehension modifying or amplifying a pre- complex unconscious computations that ab-
disposition to respond to stress with chronic stract common meanings from repeated experi-
autonomic overarousal or noradrenal lability. ences (Brewin, 1996). In contrast to other
Anxious apprehension involves distorted pro- anxiety disorders, evidence suggests that
cessing of information along with extremely GAD has a more characterological presenta-
negative affect. The individual perceives the tion, although fluctuations in the course of
traumatic event and subsequent reexperiencing GAD are often noted corresponding to the
as unpredictable, uncontrollable, aversive presence or absence of life stressors.
events and reacts with chronic overarousal, Patients with GAD often present with a
hypervigilance, and narrowing of attention. lifelong history of generalized anxiety. For
This sets up a feedback loop in which example, several studies have found that many
hyperarousal, hypervigilance, and narrowing patients with GAD cannot report a clear age of
of attentional focus increase intrusive thoughts onset or report an onset dating back to
and reexperiencing. childhood (Anderson, Noyes, & Crowe, 1984;
Foa, Steketee, and Rothbaum (1989) and Barlow, Blanchard, Vermilyea, Vermilyea, &
Rothbaum and Foa (1992) have articulated a Dinardo, 1986; Butler, Fennel, Robson, &
cognitive-behavioral treatment approach for Gelder, 1991; Cameron, Thyer, Nesse, & Curtis,
PTSD based on Lang's (1979) model of the 1986; Noyes, Clarkson, Crowe, Yates, &
emotional processing of fear, proposing that McChesney, 1987; Noyes et al., 1992; Rapee,
PTSD results from inadequate processing of the 1985; Sanderson & Barlow, 1990).
trauma stimuli, responses, and the meaning Two types of cognitive distortions involved in
associated with them. Foa et al. (1989) excessive anxiety and ruminative worry are
probability overestimation and catastrophic et al., 1979). When faced with stressful life
thinking (Brown, O'Leary, & Barlow, 1993). events, depression-prone individuals experience
Cognitions involving probability overestima- negative thoughts. These thoughts typically
tion are defined as those in which a person consist of negative views of the self, the world,
overestimates the likelihood of the occurrence and the future which precede the experience of
of a negative event (that is actually unlikely to depression. To such individuals, the environ-
occur). Catastrophic thinking is defined as the ment presents overwhelming obstacles that
tendency to view an event as intolerable, guarantee personal failure. These depressed
unmanageable, or beyond one's ability to cope patients view the environment as overwhelming,
with successfully. Also in the category of as presenting insuperable obstacles that cannot
catastrophic thinking are thoughts that involve be overcome, and as continually resulting in
drawing extreme conclusions or consequences failure or loss. They view the future as hopeless
to minor, unimportant events. Cognitions and they believe that their own efforts will be
reflecting a strong need for perfection or insufficient to change the unsatisfying course of
personal responsibility (and of drawing extreme their life.
negative conclusions of the consequences of not Three major concepts in this model are the
being perfect or responsible) fall under this cognitive triad, negative schemas, and cognitive
category as well. Worry has been conceptualized errors. The cognitive triad consists of three
as a negative reinforcer that serves to dampen patterns of negative ideas and attitudes about
physiological reactivity to emotional processing the self, world, and future that are said to
(Borkovec & Hu, 1990). In a sense, worry may characterize people who are depressed.
serve to hinder complete processing of more The depressive view of the self includes
disturbing thoughts or images. negative evaluations of abilities and worth as a
Two principal targets of treatment interven- person. In comparing themselves to others,
tion for GAD are excessive, uncontrollable depressed individuals are conceptualized as
worry and its accompanying persistent over- seeing themselves as defective and inadequate.
arousal and central nervous system symptoms. This negative self-view pervades virtually all
These cognitive and somatic features have been aspects of life and results in an overwhelming
addressed most frequently with cognitive ther- sense of worthlessness. Beck and his associates
apy and some form of relaxation treatment. (Beck, 1963; Beck & Hurvich, 1959; Beck &
Targeting worry directly via an exposure-based Ward, 1961) observed that clinical interviews
paradigm has emerged as a potentially effective with depressed patients were dominated by
treatment component (Craske, Barlow, & themes of failure and personal inadequacy.
O'Leary, 1992). Brown et al. (1993) outline a Hollon and Kendall (1980) have documented
12- to 15-session protocol for GAD involving the association of depression with self-reports of
self-monitoring, progressive muscle relaxation, frequent automatic thoughts of personal inade-
cognitive restructuring (including worry expo- quacy and maladjustment. In laboratory tasks,
sure), worry behavior prevention, problem- depressed individuals consistently expected their
solving, and time management. performance to be worse than average, and when
asked to provide evaluative self-ratings, people
who were depressed selected trait descriptors
1.11.5 COGNITIVE MODELS OF with significantly negative connotations.
DEPRESSION Second, Beck (1963, 1967) observed that
1.11.5.1 Cognitive Distortion Models depressed persons perceived their daily experi-
ences as permeated by themes of loss and stress.
The cognitive distortion model of depression Their view of the world appeared to be that life
is based upon the assumption that erroneous is an overwhelming burden filled with excessive
beliefs and maladaptive information processing demands and daily defeats, and consequently
play a key role in the onset and maintenance of depressed individuals experienced a pervasive
depression (Beck, 1963, 1967, 1976). Individuals sense of helplessness. Depressed patients rate
at risk for becoming depressed are said to even the most common interpersonal problems
possess a latent cognitive schema that becomes as significantly more difficult to deal with than
active under conditions of stress. Once acti- people who are not depressed (Funabiki &
vated, this schema influences the way informa- Calhoun, 1979), and individuals who have
tion is processed and affects the nature of apparently recovered from depressive episodes
specific beliefs about the self, one's experiences continue to dream about problems and losses
in the world, and one's future (Kovacs & Beck, more often than nondepressed people (Hauri,
1978). 1976).
In this model, a negatively biased cognitive set The third component of the cognitive triad is
constitutes the core process (Beck, 1976; Beck the depressive view that the future is hopeless
Cognitive Models of Depression 343
and that the current unpleasant condition will themselves than nondepressed patients or
continue without any possibility of improve- normal controls, which lends support to the
ment. Researchers have consistently found a hypothesis that depressed individuals utilize a
strong association between depression and negative schema for processing and retaining
measures of pessimism and hopelessness (Erick- personal information. Abramson, Alloy, and
son, Post, & Paige, 1975; Gottschalk, 1974; Rosoff (1981) examined the hypothesis that
Hollon & Beck, 1979). In addition, depressed negative self-schema may prevent depressed
persons tend to dwell on past failures rather persons from generating hypotheses about the
than to look toward future possibilities (Miller, contingencies between their behavior and
1975; Shaw, 1979). possible outcomes, and found that when asked
According to this model, most symptoms of to develop generalizations for exerting control,
depression may be attributed to the negative depressed subjects underestimated the potential
cognitive triad. Sad affect and depressed mood amount of control available to them.
are assumed to be a direct consequence of In this model, stressful life events activate
negative cognitions. In support of this, Velten depressive schemas. These schemas, in turn, are
(1968), Frost, Graff, and Becker (1979), and responsible for distortions in the way
Teasdale and Fogarty (1979) have demon- depression-prone individuals perceive and in-
strated that having subjects concentrate on terpret experiences. Although interpretations
depressive thoughts can induce a depressed based on depressive schemas often result in
mood. conclusions that are logically inaccurate,
Other symptoms of depression are also depression-prone individuals maintain depres-
viewed as a consequence of the depressed sive schemas even in the face of evidence
person's cognitions in this model. Decreased disproving their validity. Beck et al. (1979)
activity levels, for example, are thought to be the contend that the maintenance of depressive
direct result of the pessimism and hopelessness schemas is a consequence of a faulty system of
that characterize a depressed person's thoughts. information processing in which the individual
A major component in Beck's model of draws illogical conclusions due to basic cogni-
depression is the concept of schemas. Schemas tive distortions. According to Beck, depressed
are stable, long-standing thought patterns individuals make these errors in logic when
representing a person's generalizations about evaluating experiences. Consequently, their
past experiences. According to this model, thoughts are characterized by extreme, nega-
schemas serve to organize information from tive, categorical, absolute, and judgmental
past circumstances that appears to be relevant cognitions. Their distorted perceptions serve
to a current situation and direct attention to maintain negative views of themselves, the
selectively to particular aspects of a situation. world, and their future.
Depression-prone individuals develop schemas Beck (1967, 1976) has described a number of
consisting of stable but negative views of specific types of cognitive distortions that tend
themselves and their experience. The schemas to be present in the thoughts of individuals with
that produce depression often involve the emotional disorders. ªArbitrary inferenceº
perception of a personal loss or damage to refers to drawing a specific conclusion in the
one's self-worth. Depression-prone individuals absence of evidence to support the conclusion.
tend to respond to life circumstances in a fixed, In ªabsolutistic, dichotomous thinking,º only
negative manner, independent of what is one or both of two extreme alternatives are
occurring in their environment due to the considered. ªOvergeneralizingº refers to a single
negative nature of their internalized schemas. instance being taken as representative of a
Once learned, a schema is usually out of broader class of situations or characteristics. In
awareness until the person encounters circum- ªselective abstraction,º some aspects of a
stances reminiscent of the conditions in which situation, typically negative, are attended to
the schema was learned. At that point, the or remembered at the expense of other more
person may employ the schema to organize and positive aspects. In ªmind reading,º the atti-
process information about the situation. De- tudes or future actions of others are assumed
pressive schemas predispose the individual to without evidence. ªPersonalizingº refers to the
distort events so as to maintain a negative view assumption that an action is directed toward (or
of the self, the environment, and the future. occurs because of) oneself rather than some
Derry and Kuiper (1981) compared the other aspect of the situation. ªShould state-
memories of depressed and nondepressed mentsº refer to absolute imperatives that are
patients for adjectives that were either mean- expressed regarding an individual's or others'
ingful to them or descriptive of them. Depressed behavior. In ªcatastrophizing,º extreme nega-
patients recalled more adjectives with depressive tive outcomes are anticipated without substan-
content that they had judged descriptive of tial evidence. In ªminimizing,º the significance
of positive outcomes is downplayed, just the depression attempts instead to limit the ease
reverse of ªcatastrophizing.º with which these memories are activated by the
Recent developments in this cognitive model current environment. One common feature of
suggest that the presence of very early schemas is depression is that negative mood changes are
an important predisposing factor for many elicited by a wide range of stimuli. Patients
patients with depression (Beck et al., 1990; Stein respond to many relatively harmless situations
& Young, 1992; Young, 1990). Young identified as though these situations contained enormous
a subset of schemas which he has labeled ªearly potential for psychological or physical threat.
maladaptive schemasº (Young, Beck, & Wein- By drawing attention to the patient's appar-
berger, 1993). ªEarly Maladaptive Schemas ent assumptions and challenging these with the
refer to extremely stable and enduring themes use of logic and behavioral experimentation,
that develop during childhood and are elabo- the patient can develop new rules for discrimi-
rated upon throughout the individual's lifetimeº nating between situations that are truly threa-
(Young, 1990, p. 9). Young has identified 16 of tening and those that merely elicit the feeling of
these early maladaptive schemas in the six being threatened, similar to the process of
following domains: instability and disconnec- construct elaboration described by Kelly
tion, impaired autonomy, undesirability, re- (1955). Practice in making these discrimina-
stricted self-expression, restricted gratification, tions then changes the content of verbally
and impaired limits. accessible knowledge so that previously threa-
According to Young, children learn to tening situations are reclassified and automatic
construct reality through early experiences with activation of the unconscious representations is
the environment, especially with significant decreased (Brewin, 1989).
others. Sometimes these early experiences lead In his activation-based model of cognitive
children to accept attitudes and beliefs that will therapy for depression (Brewin, 1996), relevant
later prove maladaptive. These schemas are situationally accessible memories are not over-
usually out of awareness, and may remain written and remain available to be reactivated,
dormant until a life event stimulates the schema. which explains the high likelihood of relapse in
Once this schema is activated, the patient depression. The more varied the negative
categorizes, selects, and encodes information experiences contributing to the formation of
in such a way that the maladaptive schema is the memories, the fewer distinctive stimulus
maintained. In this way, early maladaptive features the memories contain. This promotes
schemas predispose depressed patients to distort overgeneralization and impedes the identifica-
events in a characteristic fashion. tion of relevant discriminations. According to
Early maladaptive schemas are defined as (i) a Brewin, relevant cues associated with any event
priori truths about oneself and/or the environ- may activate or deactivate memories. Negative
ment; (ii) self-perpetuating and resistent to life events are therefore strongly associated with
change; (iii) dysfunctional; (iv) often triggered the onset of depression where there is prior low
by some environmental change; (v) tied to high self-esteem (Brown, Andrews, Harris, Adler, &
levels of emotion when activated; and (vi) Bridge, 1986), and positive events are strongly
usually are the result of an initial interaction associated with recovery from depression
between the child's innate temperament and (Brown, Lemyre, & Bifulco, 1992).
dysfunctional developmental experiences with
family members or caretakers (Young, 1990). 1.11.5.2 Differential Activation Model
Cognitive-behavior therapy of depression is
based on the premise that individuals can learn The differential activation model of depres-
to recognize and modify their negative beliefs sion (Clark & Teasdale, 1985; Teasdale, 1983;
and maladaptive information-processing ten- Teasdale & Dent, 1987) attempts to account for
dencies to prevent or alleviate depression (Beck, vulnerability both to onset and persistence of
1964, 1970; Beck et al., 1979). This approach is depression. The differential activation hypoth-
typically operationalized as a structured, didac- esis assumes that in addition to any differences
tic intervention in which clients are encouraged in cognitive organization that may be apparent
to test the accuracy of their own beliefs, often by in the nondepressed state and in addition to
means of modifying their behavior in a idiosyncratic cognitive schemas that may be
systematic fashion. Treatment is usually pro- activated, vulnerability to severe and persistent
vided in a skills-training format, with the goal depression depends upon differences in patterns
being to help clients acquire a frame of reference of thinking that are activated while in the
and a set of procedures that they themselves can depressed state. It is suggested that the patterns
apply to forestall future depressions. of thinking activated in the initial depressed
Brewin (1989) suggested that rather than state will determine whether that state remains
create new memories, cognitive therapy for mild or transient, or whether it becomes more
severe (onset vulnerability). Differences in the in the framework of a comprehensive systemic

patterns activated in more severe states will model of the organization and function of
determine whether those states show remission resources underlying human cognition, the
or become persistent and chronic (persistence interacting cognitive subsystems (ICS) model.
vulnerability). Their ICS model, an extension of Barnard's
According to this hypothesis, the original original ICS model (Barnard, 1985), proposes a
source of the depression may not matter too framework of nine peripheral and central
much. The crucial factor that determines cognitive subsystems: the acoustic, morphono-
whether the initial depression will intensify lexical, articulatory, propositional, implica-
and persist is the pattern of thinking that exists tional, body state, visual, object, and limb
when the patient is depressed. The way in which subsystems. Each subsystem is hypothesized to
experiences are interpreted will be a joint contribute either directly or indirectly to the
function of the nature of the experience and production or experience of emotion.
the state of the information processing system The ICS model characterizes persistent
that interprets them. The latter will determine depression as a product of the establishment
the type of information that is selected for of self-maintaining, reverberatory patterns of
attention and the nature of the interpretative cognitive activity within the implicational
categories that are highly primed and most subsystem, with streams of negative thoughts
likely to be used to interpret experiences (Bargh, that are experienced by depressed patients as
Bond, Lombardi, & Tota, 1986). Similarly, the markers of that activity. This theory suggests
type of information from memory that is that the function of therapy is to disrupt the
processed will be a function both of what is repeated synthesis of high-level schematic
available in memory and what is most accessible representations containing generic meanings
at a given time. Interpretative biases may also prototypical of previous depressing situations
affect the interpretation of this material. (so-called depressive interlock). These represen-
Teasdale (1983) has elaborated upon Bower's tations contain idiosyncratic sensory, proprio-
associative network theory (Bower, 1981) to ceptive, and meaning information synthesized
explain the effect of mood on cognitive from past experiences of depression that cannot
processing. Teasdale (1985) has proposed that be fully captured by a verbal description.
faulty beliefs about symptoms (depression Interlock involves numerous cognitive subsys-
about depression) lead to the exacerbation of tems, which include those responsible for
depression. Depressed mood increases the processing sensory and proprioceptive data as
accessibility of representations of depressing well as those that extract meaning at proposi-
experiences and the accessibility of negative tional and higher-order (implicational) levels.
interpretative categories and constructs. In Disruption of interlock may be achieved in a
depressed mood, there will not only be an number of ways. For example, if the representa-
increased likelihood that unhappy memories tions were continually being activated by on-
will come to mind, but there will also be a going stress, problem-solving training aimed at
negative bias in the way situations are perceived resolving that stress might effectively deactivate
and interpreted, and in the way in which them. Consistent with this view, distraction
inferences and predictions are made using procedures that interrupt the flow of negative
information from the environment and from thoughts may also lead to an alleviation of
memory. As a result of these effects of mood on patientsº depression (Fennell, Teasdale, Jones,
cognitive processing, once a person is in a & Damle, 1987).
depressed state any environmental input that
can be interpreted in ways that will produce
further depression will be more likely to be 1.11.5.3 Cognitive Appraisal Model
interpreted in that way. Similarly, the memories
that come most easily to mind in the depressed As noted earlier, the work of Lazarus has long
state are those that are likely to perpetuate the been associated with cognitive appraisal pro-
depression. This reciprocal relationship be- cesses mediating emotional responses to stress-
tween depression and cognitive processing ful stimuli (Lazarus, Averill, & Opton, 1970).
creates the potential for a positive feedback This has provided a general framework for
loop. Depressed mood and cognitive processing explaining depressive reactions to personally
can act to reinforce each other and to set up a stressful events and circumstances (Coyne,
vicious cycle that will tend to intensify and Aldwin, & Lazarus, 1981; Folkman & Lazarus,
maintain depression. 1986; Lazarus, Averill, & Opton, 1970; Lazarus
Barnard and Teasdale (1991) and Teasdale & Folkman, 1984).
and Barnard (1993) have elaborated upon the The central component of the cognitive
original differential activation hypothesis with- appraisal model of depression is an emphasis
on person±environment reciprocal influences, depressive symptomatology (Kanner, Coyne,

cognitive appraisal processes, and coping. This Schaefer, & Lazarus, 1981).
transactional perspective emphasizes relational
factors that are thought to ªtranscend the 1.11.5.4 Learned Helplessness Model
separate sets of person and environment
variables of which they are comprisedº (Lazarus The learned helplessness model was first
& Launier, 1978). In Lazarus' model, both described in the 1960s by Overmier and Selig-
environmental and personal factors are seen to man (1967) and Seligman and Maier (1967).
be involved in an ongoing reciprocal relation- They reported that dogs which experienced
ship, which can be studied as person± inescapable electric shock demonstrated signif-
environment units. Transactions between per- icant motivational, learning, and emotional
son and environment are mediated by two deficits and failed to initiate behaviors to
processes: appraisals and coping. terminate the shock. Seligman suggested that
According to Lazarus and Launier (1978), these deficits were a consequence of the animals
ªcognitive appraisal can be simply understood learning that their behavior had no impact on
as the mental process of placing any event in one the outcome of whether or not they received a
of a series of evaluative categories related either shock. After experience with uncontrollable
to its significance for the person's well-being outcomes, they appeared to develop low
(primary appraisal) or to the available coping expectancies for exerting control over later
resources and options (secondary appraisal).º outcomes which could be controlled. These low
The emotional responses of sadness and expectancies appeared to produce motivational,
depression are therefore a direct outcome of affective, and behavioral deficits similar to
appraisals of the meaning of an event in relation depression observed in humans.
to that person's well-being. The emotional Seligman (1975) compared the responses of
response may be immediate and nonreflective, people experiencing feelings of helplessness as a
so that thoughts and feelings are simultaneous, result of experimental manipulations in the
but appraisal is an essential component of laboratory with the behavior of individuals
emotion (Lazarus, 1982). suffering from naturally occurring depression.
Primary appraisals may lead to judgments Both groups demonstrated similar response
that a circumstance is irrelevant, benign or patterns including passivity, slowed learning,
positive, or stressful. A stressful appraisal can lowered aggression, loss of appetite, negative
typically be classified as one of three types: expectations, and feelings of helplessness, hope-
harm/loss (the damage has already occurred), lessness, and powerlessness.
threat (anticipated harm or loss), and challenge. The original helplessness model did not
The outcome of this primary appraisal, in this specify which factors account for differences
case the experience of depression, will be in the severity and chronicity of depression,
determined by the transaction between personal however, nor did it address subtypes of clinical
experiences, predisposition, and environmental depression or explain such symptoms as guilt
factors. Coping appraisals or secondary apprai- and blame (Abramson & Sackheim, 1977). In
sals of perceived coping resources and options some instances, uncontrollability of outcome
reciprocally interact with the primary appraisal also not only failed to produce helplessness but
of the nature and magnitude of the stressor and actually facilitated subjects' subsequent perfor-
its effect on the person's well-being. mance (Wortman & Brehm, 1975).
Similar to other cognitive models of depres-
sion, the cognitive appraisal model emphasizes
1.11.5.4.1 Revised helplessness model
the central role of cognitive processes in
provoking depressive reactions to stressful In response to the need for a more complex
events. The transactional emphasis, however, model of human depression, Abramson, et al.
differs from perspectives that emphasize either (1978) reformulated the helplessness theory,
the qualities of events (Paykel, 1979; Brown & placing an emphasis on individual causal
Harris, 1978) or personal characteristics interpretation of uncontrollable events. They
(Abramson, Seligman, & Teasdale, 1978; Beck, proposed that an individual's attribution for loss
1967). The Lazarus model views the individual of control serves as a mediator between the
as someone in a continuing state of appraising absence of control and the emergence of
and negotiating stressful occurrences and every- helplessness-related deficits and depression
day circumstances. Although threatening or and that helplessness and depression are most
stressful acute events or ongoing chronic likely to occur following either the inability to
stressors are seen as important antecedents of produce a highly desired outcome or the inability
emotional reactions, everyday ªhassles,º or to prevent a highly aversive outcome. When
more minor events can also be associated with confronted by such circumstances, individuals
attempt to explain why the circumstances have 1.11.5.4.2 Hopelessness theory

occurred and these explanations determine how
they will respond to events. Abramson, Metalsky, and Alloy (1988)
In this revised model, it is assumed that present a further elaboration of the revised
attributions are the primary determinants of an theory of human helplessness and depression
individual's actions and affect. According to which is relabeled as the hopelessness theory of
Abramson et al. (1978), the cause may be depression. The hopelessness theory of depres-
attributed either to the person or to the situation sion specifies hopelessness as a proximal
(an internal vs. an external explanation). The sufficient and necessary cause of depression
cause may also be viewed as either transient or beginning with the occurrence of negative life
persistent across time (an unstable vs. a stable events and ending with the symptoms of a type
explanation), and the cause may be perceived to of depression called hopelessness depression. It
have an impact on a variety of outcomes or may has been speculated (Seligman, 1978) that
be limited just to that particular event (a global hopelessness depression may not directly corre-
vs. a specific explanation). The revised help- spond to current diagnostic categories of
lessness model proposes that particular con- depression, and may even include psychological
sequences are associated with attributions made phenomena not currently contained in psychia-
across each of these three dimensions. For tric nosologies. The hopelessness subtype of
example, an individual who attributes a nega- depression is hypothesized to be characterized
tive event to an internal cause is likely to by three primary symptoms and one secondary
experience a loss of self-esteem. The stability of symptom. The major symptoms are described as
causal beliefs is hypothesized to affect the the retarded initiation of voluntary responses (a
persistence or chronicity of depression follow- motivational symptom), a difficulty in seeing
ing negative events. If a negative event is that one's responses control outcomes related or
explainable by a persistent cause, then depres- similar to the outcome about which one feels
sive reactions are likely to be chronic. If an hopeless (a cognitive symptom), and sad affect
individual believes that a global factor has (an emotional symptom). The secondary symp-
caused the negative event, then deficits asso- tom of lowered self-esteem is hypothesized to be
ciated with helplessness and depression are related to the expectation that other people can
likely to occur in a variety of situations. attain the outcome that the patient feels
The revised helplessness model assumes that hopeless to attain.
individuals demonstrate consistency in attribu- The causal pathway hypothesized by Abram-
tion and tend to invoke the same sorts of causal son et al. (1988) which culminates in hope-
explanations for different negative events in lessness suggests that at least two distinct
their lives. An individual who typically invokes variants of hopelessness depression may exist.
internal, stable, and global causal beliefs will The first theoretical variant of hopelessness
therefore be at a high risk for developing depression is called attributional style-event
depression when faced with uncontrollable hopelessness depression. This variant of depres-
negative events. Brewin (1985) and Sweeney, sion would develop in an individual who exhibits
Anderson, and Bailey (1986) have reviewed the a depressogenic attributional style and is con-
literature examining this relationship between fronted with a negative life event which by itself
measures of attributional style and depression. may not be sufficient to trigger hopelessness in
According the revised model, when an most people, but when interpreted or explained
individual perceives negative events as beyond by an individual with this attributional style is
their control, the expectation of future uncon- sufficient to do so. A second variant of hope-
trollability is likely to occur. In such circum- lessness depression is labeled as event hope-
stances, the specific attributions that develop lessness depression. This theoretical variant of
are influenced by the reality of the particular hopelessness depression would develop in an
circumstances and the individual's explanatory individual who does not exhibit the hypothe-
style. The expectation of future uncontrollabil- sized depressogenic attributional style or other
ity is thought to be sufficient to produce most of depressogenic cognitive styles, but who is
the symptoms of depression, including a confronted with an event sufficient to engender
lowered rate of activity, cognitive deficits such hopelessness in most people. It is thought that
as impaired learning, emotional responses of event hopelessness depression may overlap with
sadness and anxiety, and a lowering of the diagnostic category of acute dysphoria
appetitive drives. In addition, the expectation (Klein, 11974) and that attributional style-event
of uncontrollability is hypothesized to bring hopelessness depression may correspond to
about physiological consequences such as chronic over-reactive dysphoria.
neurochemical changes and an increase in Hopelessness depression is conceptualized as
susceptibility to disease. the culmination of a series of events beginning
with a negative life stress and including A trend that has been noted here is of multiple
depressogenic attributional styles, situational disciplines addressing cognition-based ques-
cues, stable and global attributions for the tions. The increased volume of these interdisci-
negative life event, and other contributory plinary investigations is being nurtured by the
causal pathways such as deficits in social growth in cognitive neuroscience, psychophy-
support networks. Intervention to reverse hope- siology, and neurobiology. Methodological and
lessness depression or to reduce vulnerability to conceptual advancements in these areas are
depressive episodes and depression-proneness being brought to bear to increase understanding
can by definition occur at any point in the causal of how cognitive processing affects behavior at
chain leading to hopelessness, and possible the level of multiple systems. Some of these
intervention strategies are reviewed by Alloy, issues have been brought to the forefront in
Clements, and Kolden (1985), Beach, Abram- discussion of the interaction of cognition and
son, and Levine (1981), and Halberstadt, emotion and the viability of integrating research
Andrews, Metalsky, and Abramson (1984). in this area with research in neurobiology and
neuroanatomy.
The challenge that lies ahead is in bringing
1.11.6 CONCLUSIONS about a coherent integration of these disciplines
that is theoretically sound and empirically
In addressing the cognitive basis of clinical supported. Such a framework not only would
psychology, several developments have been allow efforts in these areas to be well focused
considered in the field of cognitive psychology, and well guided, but would also foster further
and how they may impact the development, cross-disciplinary research on constituent ques-
presentation, and treatment of psychopathol- tions within each area to address how cognitive
ogy. The focus was limited to salient topics that factors contribute with other factors in pre-
embody multifaceted influences of other scien- cipitating psychopathology.
tific endeavors, including those of information
networking research, emotion, and abnormal
1.11.7 REFERENCES
psychology. In doing so, other issues of
importance to the field of cognitive psychology Abramson, L. Y., Alloy, L. B., & Rosoff, R. (1981).
have not been addressed comprehensively. It is Depression and the generation of complex hypotheses in
the judgment of contingency. Behavior Research and
hoped that this approach, while relatively less Therapy, 19, 35±45.
inclusive, provides the reader with a flavor of Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1988).
how information processing can impact, or at The hopelessness theory of depression: Does the research
minimum interact with, other factors in the test the theory? In L. Y. Abramson (Ed.), Social
cognition and clinical psychology: A synthesis
development of psychopathology. (pp. 33±65). New York: Guilford Press.
Broadly defined, cognitive approaches to Abramson, L. Y., & Sackheim, H. A. (1977). A paradox in
emotional response focus on evaluation of depression: Uncontrollability and self-blame. Psycholo-
information processing patterns that contribute gical Bulletin, 84, 835±851.
to directing and organizing a behavioral/emo- Abramson, L., Seligman, M., & Teasdale, J. (1978).
Learned helplessness in humans: Critique and reformu-
tional response. The role of cognitive processes lation. Journal of Abnormal Psychology, 87, 49±74.
such as appraisal determine how we react at Aggleton, J. P. (Ed.) (1992). The amygdala: Neurobiological
multiple behavioral and physiological levels, aspects of emotion, memory and mental dysfunction. New
and how these reactions may contribute to York: Wiley-Liss.
Alavi, F., & Taylor, J. G. (1993). Mathematical analysis of
maladaptive behaviors. In this vein, the role of a global network for attention. In J. G. Taylor (Ed.),
cognitive distortions as important processing Mathematical approaches to neural networks. Oxford,
dispositions that may predispose an individual UK: Elsevier.
to emotional problems have been addressed. Alexander, G. E., DeLong, M. R., & Strick, P. L. (1986).
The discussion of anxiety and depression as Parallel organisation of functionally segregated circuits
linking basal ganglia and cortex. Annual Review Neu-
examples of emotional disorders directly im- roscience, 9, 357±381.
pacted by cognitive factors provides an illustra- Alloy, L. B., Clements, C., & Kolden, G. (1985). The
tion of the nature of cognitive contributions in cognitive diathesis-stress theories of depression: Ther-
the cascade of events leading to the development apeutic implications. In S. Reiss & R. Bootzin (Eds.),
Theoretical issues in behavior therapy. New York:
of psychopathology. This discussion was pre- Academic Press.
ceded by an overview of how cognition and Anderson, D. J., Noyes, R., & Crowe, R. R. (1984). A
emotion interact in a dynamic fashion. The comparison of panic disorder and generalized anxiety
approach chosen treats cognitive and emotional disorder. American Journal of Psychiatry, 141, 572±575.
change, not only as potential mediators for each Anderson, J. A. (1995). An introduction to neural networks.
Cambridge, MA: MIT Press.
other, but also as consequences of each other. Baddely, A. (1986) Working memory. London: Oxford
Such may be the case when addressing cognitive University Press.
deficits observed in depressed individuals. Bargh, J. A., Bond, R. N., Lombardi, W. J., & Tota, M. E.
References 349
(1986). The additive nature of chronic and temporary Bower, G. H., Gilligan, S. G., & Monteiro, K. P. (1981).
sources of construct accessibility. Journal of Personality Selectivity of learning caused by affective states. Journal
and Social Psychology, 50, 869±878. of Experimental Psychology: General, 110, 451±473.
Barlow, D. H. (1988). Anxiety and its disorders: The nature Brewin, C. R. (1985). Depression and causal attributions:
and treatment of anxiety and panic. New York: Guilford What is their relation? Psychological Bulletin, 98,
Press. 297±309.
Barlow, D. H., Blanchard, E. B., Vermilyea, J. A., Brewin, C. R. (1988). Cognitive foundations of clinical
Vermilyea, B. B., & DiNardo, P. A. (1986). Generalized psychology. London: Erlbaum.
anxiety and generalized anxiety disorder: Description Brewin, C. R. (1989). Cognitive change processes in
and reconceptualization. American Journal of Psychiatry, psychotherapy. Psychological Review, 96, 379±394.
143, 40±44. Brewin, C. R. (1996). Theoretical foundations of cognitive-
Barnard, P. J. (1985). Interacting cognitive subsystems: A behavioral therapy for anxiety and depression. Annual
psycholinguistic approach to short-term memory. In A. Review of Psychology, 47, 33±57.
Ellis (Ed.), Progress in the psychology of language (Vol. 2, Brooks, D. N., & Baddeley, A. D. (1976). What can
pp. 197±258). London: Erlbaum. amnesic patients learn? Neuropsychologia, 14, 111±122.
Barnard, P. J., & Teasdale, J. D. (1991). Interacting Brown, G. W., Andrews, B., Harris, T. O., Adler, Z., &
cognitive subsystems: A systematic approach to Bridge, L. (1986). Social support, self-esteem and
cognitive-affective interaction and change. Cognition depression. Psychological Medicine, 16, 813±831.
and Emotion, 5, 1±39. Brown, G. W., & Harris, T. O. (1978). Social origins of
Beach, S. R. H., Abramson, L. Y., & Levine, F. M. (1981). depression: A study of psychiatric disorders in women.
Attributional reformulation of learned helplessness and New York: Free Press.
depression: Therapeutic implications. In J. F. Clarkin & Brown, G. W., Lemyre, L., & Bifulco, A. (1992). Social
H. I. Glazer (Eds.), Depression: Behavioral and directive factors and recovery from anxiety and depressive
intervention strategies. New York: Garland. disorders: A test of specificity. British Journal of
Bechara, A., Tranel, D., Damasio, H., Adolphs, R., Psychiatry, 161, 44±54.
Rockland, C., & Damasio, A. R. (1995). Double Brown, T. A., O'Leary, T. A., & Barlow, D. H. (1993).
dissociation of conditioning and declarative knowledge Generalized anxiety disorder. In D. H. Barlow (Ed.),
relative to the amygdala and hippocampus in humans. Clinical handbook of psychological disorders: A step-by-
Science, 269, 1115±1118. step treatment manual (2nd ed., pp. 137±188). New York:
Beck, A. T. (1963). Thinking and depression. Archives of Guilford Press.
General Psychiatry, 9, 324±333. Buhusi, C., & Schmajuk, N. A. (1996). Attention,
Beck, A. T. (1964). Thinking and depression: 2. Theory and configuration and hippocampal function. Hippocampus,
therapy. Archives of General Psychiatry, 10, 561±571. 6, 621±642.
Beck, A. T. (1967). Depression: Clinical, experimental, and Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991).
theoretical aspects. New York: Harper & Row. Comparison of behavior therapy and cognitive-behavior
Beck, A. T. (1970). Cognitive therapy: Nature and relation therapy in the treatment of generalized anxiety disorder.
to behavior therapy. Behavior Therapy, 1, 184±200. Journal of Consulting Clinical Psychology, 59, 167±175.
Beck, A. T. (1976). Cognitive therapy and the emotional Calev, A. (1996). Affect and memory in depression:
disorders. New York: International Universities Press. Evidence of better delayed recall of positive than
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety negative affect words. Psychopathology, 29, 71±76.
disorders and phobias: A cognitive perspective. New York: Calhoun, K. S., & Resick, P. A. (1993). Post-traumatic
Basic Books. stress disorder. In D. H. Barlow (Ed.), Clinical handbook
Beck, A. T., Freeman, A., Pretzer, J., Davis, D. D., of psychological disorders: A step-by-step treatment
Fleming, B., Ottaviani, R., Beck, J., Simon, K. M., manual (2nd ed., pp. 48±98). New York: Guilford Press.
Padesky, C., Meyer, J., & Trexler, L. (1990). Cognitive Cameron, O. G., Thyer, B. A., Nesse, R. M., & Curtis, G.
therapy of personality disorders. New York: Guilford C. (1986). Symptom profiles of patients with DSM-III
Press. anxiety disorders. American Journal of Psychiatry, 143,
Beck, A. T., & Hurvich, M. S. (1959). Psychological 1132±1137.
correlates of depression: Frequency of ªmasochisticº Carver, C. S., & Scheier, M. F. (1990). Origins and
dream content in a private practice sample. Psychoso- functions of positive and negative affect: A control-
matic Medicine, 21, 50±55. process view. Psychological Review, 97, 19±35.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Chambless, D. L., Caputo, G., Bright, P., & Gallagher, R.
Cognitive therapy of depression. New York: Wiley. (1984). Assessment of fear in agoraphobics: The Body
Beck, A. T., & Ward, C. H. (1961). Dreams of depressed Sensations Questionnnaire and the Agoraphobic Cogni-
patients: characteristic themes in manifest content. tions Questionnnaire. Journal of Consulting and Clinical
Archives of General Psychiatry, 5, 562±571. Psychology, 52, 1090±1097.
Blaney, P. H. (1986). Affect and memory: A review. Channon, S., & Baker, J. E. (1996). Depression and
Psychological Bulletin, 99, 229±246. problem-solving performance on a fault-diagnosis task.
Block, N. (1995). On a confusion about a function of Applied Cognitive Psychology, 10, 327±336.
consciousness. Behavioral and Brain Sciences, 18, Chemtob, C., Roitblat, H., Hamada, R., Carlson, J., &
227±287. Twentyman, C. (1988). A cognitive action theory of
Blythe, I. M., Kennard, C., & Ruddock, K. H. (1987). posttraumatic stress disorder. Journal of Anxiety Dis-
Residual vision in patients with retrogeniculate lesions of orders, 2, 253±275.
the visual pathways. Brain, 110, 887±905. Chrousos, G. P., & Gold, P. W. (1992). The concepts of
Borkovec, T. D., & Hu, S. (1990). The effect of worry on stress and stress system disorders: Overview of physical
cardiovascular response to phobic imagery. Behavior and behavioral homeostasis. Journal of the American
Research and Therapy, 28, 69±73. Medical Association, 267, 1244±1252.
Borod, J. C. (1992). Interhemispheric and intrahemispheric Clark, D. M. (1988). A cognitive model of panic attacks. In
control of emotion: A focus on unilateral brain damage. S. Rachman & J. Maser (Eds.), Panic: Psychological
Journal of Consulting and Clinical Psychology, 60, perspectives (pp. 71±89). Hillsdale, NJ: Erlbaum.
339±348. Clark, D.M., Salkovskis, P., Gelder, M., Koehler, C.,
Bower, G. H. (1981). Mood and Memory. American Martin, M., Anastasiades, P., Hackmann, A., Middle-
Psychologist, 36, 129±148. ton, H., & Jeavons, A. (1988). Tests of a cognitive theory
of panic. In I. Hand & H. Wittchen (Eds.), Panic and Carmichael, S. T., & Raichle, M. E. (1992). A functional
phobias II. Berlin: Springer. anatomical study of unipolar depression. Journal of
Clark, D. M., & Teasdale, J. D. (1982). Diurnal variation in Neuroscience, 12, 3628±3641.
clinical depression and accessibility of memories of Dunn, L. A., Atwater, G. E., & Kilts, C. D. (1993). Effects
positive and negative experiences. Journal of Abnormal of anti-psychotic drugs on latent inhibition: Sensitivity
Psychology, 91, 87±95. and specificity of an animal behavioural model of clinical
Clark, D. M., & Teasdale, J. D. (1985). Constraints on the drug action. Psychopharmacology, 112, 315±323.
effects of mood on memory. Journal of Personality and Ehlers, A., & Steil, R. (in press). Maintenance of intrusive
Social Psychology, 48, 1595±1608. memories in posttraumatic stress disorder: A cognitive
Cohen, R. M., Weingartner, H., Smallberg, S. A., Pickar, approach. Behav Cognitive Psychotherapy.
D., & Murphy, D. L. (1982). Effort and cognition in Eich, E., & Metcalfe, J. (1989). Mood dependent memory
depression. Archives of General Psychiatry, 39, 593±597. for internal versus external events. Journal of Experi-
Corbetta, M., Miezin, F. M., Dobmeyer, G. L., Shulman, mental Psychology: Learning, Memory, and Cognition,
G. L., & Petersen, S. E. (1991). Selective and divided 15, 443±455.
attention during visual discrimination of shape, color, Eichenbaum, H., Otto, T., & Cohen, N. J. (1992). The
and speed: Functional anatomy by positron emission hippocampusÐwhat does it do? Behavioral and Neural
tomography. Journal of Neuroscience, 11, 2383±2402. Biology, 57, 2±36.
Corbetta, M., Miezin, F. M., Shulman, G. L., & Petersen, Ekman, P. (1973). Cross-cultural studies of facial expres-
S. E. (1993). A PET study of visuospatial attention. sion. In P. Ekman (Ed.), Darwin and facial expression: A
Journal of Neuroscience, 13, 1202±1226. century of research in review. New York: Academic Press.
Corkin, S. (1968). Acquisition of motor skill after bilateral Ellenbroek, B. A., & Cools, A. (1990). Animal models with
medial temporal lobe excision. Neuropsychologia, 6, construct validity for schizophrenia. Behavioural Phar-
255±265. macology, 1, 469±490.
Cowey, A., & Stoerig, P. (1991). The neurobiology of Ellis, A., & Dryden, W. (1997). The practice of rational
blindsight. Trends in Neuroscience, 29, 65±80. emotive therapy (2nd ed.). New York: Springer.
Coyne, J., Aldwin, C., & Lazarus, R. (1981). Depression Ellis, H. C. (1985). On the importance of mood intensity
and coping in stressful situations. Journal of Abnormal and encoding demands in memory: Commentary on
Psychology, 90, 439±441. Hasher, Rose, Zacks, Sanft, and Doren. Journal of
Craske, M. G. (1991). Phobic fear and panic attacks: The Experimental Psychology: General, 114, 392±395.
same emotional state triggered by different cues? Clinical Ellis, H. C., Thomas, R. L., & Rodriguez, I. A. (1984).
Psychological Review, 11, 599±620. Emotional mood state and memory: Elaborative encod-
Craske, M. G., & Barlow, D. H. (1988). A review of the ing, semantic processing, and cognitive effort. Journal of
relationship between panic and avoidance. Clinical Experimental Psychology: Learning, Memory, and Cogni-
Psychological Review, 8, 667±685. tion, 10, 470±482.
Craske, M. G., & Barlow, D. H. (1993). Panic disorder and Erdmann, G. (1983). Autonomic drugs as tolls in
agoraphobia. In D. H. Barlow (Ed.), Clinical handbook differentiating psychopharmacology. In W. Janke (Ed.),
of psychological disorders: A step-by-step treatment Response variability to psychotropic drugs (pp. 275±292).
manual (2nd ed., pp. 1±47). New York: Guilford Press. New York: Pergamon.
Craske, M. G., Barlow, D. H., & O'Leary, T. A. (1992). Erickson, R. C., Post, R. D., & Paige, A. B. (1975). Hope
Mastery of your anxiety and worry. Albany, NY: as a psychiatric variable. Journal of Clinical Psychology,
Graywind Publications. 31, 324±330.
Creamer, M., Burgess, P., & Pattison, P. (1992). Reaction Farah, M. J. (1997). Computational modeling in behavioral
to trauma: A cognitive processing model. Journal of neurology and neuropsychology. In T. E. Feinberg & M.
Abnormal Psychology, 101, 453±459. J. Farah (Eds.), Behavioral neurology and neuropsychol-
Crowe, R. R., Noyes, R., Pauls, D. L., & Slymen, D. J. ogy (pp. 121±130). New York: McGraw-Hill.
(1983). A family study of panic disorder. Archives of Feinberg, T. E., & Farah, M. J. (1997). The development of
General Psychiatry, 40, 1065±1069. modern behavioral neurology and neuropsychology. In
Davey, G. C. L. (1992). Classical conditioning and the T. E. Feinberg & M. J. Farah (Eds.), Behavioral
acquisition of human fears and phobias: A review and neurology and neuropsychology (pp. 3±23). New York:
synthesis of the literature. Advances in Behavior Research McGraw-Hill.
and Therapy, 14, 29±66. Feldman, S., Conforti, N., & Weidenfeld, J. (1995) Limbic
Davey, G. C. L. (1995). Preparedness and phobias: Specific pathways and hypothalamic neurotransmitters mediat-
evolved associations or a generalized expectancy bias? ing adrenocortical responses to neural stimuli. Neu-
Behavioral and Brain Sciences, 18, 289±325. roscience Biobehavioral Reviews, 19, 235±240.
Davidson, R. J. (1992). Emotion and affective style: Fennell, M. J. V., Teasdale, J. D., Jones, S., & Damle, A.
Hemispheric substrates. Psychological Science, 3, 39±43. (1987). Distraction in neurotic and endogenous depres-
Debner, J. A., & Jacoby, L. L. (1994). Unconscious sion: An investigation of negative thinking in major
perception: Attention, awareness, and control. Journal depressive disorder. Psychological Medicine, 17, 441±452.
of Experimental Psychology Learning, Memory, and Foa, E. B., & Kozak, M. J. (1986). Emotional processing of
Cognition, 20, 304±317. fear: exposure to corrective information. Psychological
Derry, P. A., & Kuiper, N. A. (1981). Schematic processing Bulletin, 99, 20±35.
and self-reference in clinical depression. Journal of Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989).
Abnormal Psychology, 90, 286±297. Behavioral/cognitive conceptualizations of post-trau-
Derryberry, D., & Tucker, D. M. (1992). Neural mechan- matic stress disorder. Behavioral Therapy, 20, 155±176.
isms of emotion. Journal of Consulting and Clinical Folkman, S., & Lazarus, R. (1986). Stress processes and
Psychology, 60, 329±338. depressive symptomatology. Journal of Abnormal Psy-
Dickinson, A. (1987). Animal conditioning and learning chology, 95, 107±113.
theory. In H. Eysenck & I. Martin (Eds.), Theoretical Forgas, J. P., Bower, G. H., & Krantz, S. E. (1984). The
foundations of behavior therapy (pp. 57±79). New York: influence of mood on perception of social interactions.
Plenum. Journal of Experimental Social Psychology, 20, 497±513.
Dixon, N. F. (1981). Preconscious processes. Chichester, Fox, N. A. (1991). If it's not left, it's right. American
UK: Wiley. Psychologist, 46, 863±872.
Drevets, W. C., Videen, T. O., Price, J. L., Preskorn, S. H., Freeman, A., & Reinecke, M. (1993). Cognitive therapy of
References 351
suicidal behavior: A manual for treatment. New York: deficits in initiative. Journal of Experimental Psychology:
Springer. General, 119, 45±59.
Frost, R. O., Graf, M., & Becker, J. (1979). Self- Hinton, G. E., & Shallice, T. (1991). Lesioning an attractor
devaluation and depressed moods. Journal of Consulting network: Investigations of acquired dyslexia. Psychology
and Clinical Psychology, 47, 958±962. Review, 98, 74±95.
Funabiki, D., & Calhoun, J. (1979). Use of a behavioral- Hollon, S. D., & Beck, A. T. (1979). Cognitive therapy of
analytic procedure in evaluating two models of depres- depression. In P. Kendall & S. D. Hollon (Eds.),
sion. Journal of Consulting and Clinical Psychology, 47, Cognitive behavioral interventions: Theory, research, and
183±185. procedures. New York: Academic Press.
Gainotti, G., Caltagirone, C., & Zoccolotti, P. (1993). Left/ Hollon, S. D., & Kendall, P. C. (1980). Cognitive self-
right and cortical/subcortical dichotomies in the neu- statements in depression: Development of an automatic
ropsychological study of human emotions. Cognition and thoughts questionnaire. Cognitive Therapy Research, 4,
Emotion, 7, 71±93. 383±395.
Gilligan, S. G., & Bower, G. H. (1984). Cognitive Holt, P., & Andrews, G. (1989). Hyperventilation and
consequences of emotional arousal. In C. E. Izard, J. anxiety in panic disorder, social phobia, generalized
Kagan, & R. Zajonc (Eds.), Emotion, Cognition, and anxiety disorder, and normal controls. Behavior Re-
Behavior (pp. 547±588). New York: Cambridge Uni- search and Therapy, 27, 453±460.
versity Press. Hope, D. A., & Heimberg, R. G. (1993). Social phobia
Goldman-Rakic, P. S. (1992). Working memory and the and social anxiety. In D. H. Barlow (Ed.), Clinical
mind. Scientific American, 267(3), 111±117. handbook of psychological disorders: A step-by-step
Gorman, J., Fyer, M., Goetz, R., Askanazi, J., Liebowitz, treatment manual (2nd ed., pp. 99±136). New York:
M., Fyer, A., Kinney, J., & Klein, D. (1988). Ventilatory Guilford Press.
physiology of patients with panic disorder. Archives of Hope, D. A., Rappe, R. M., Heimberg, R. G., & Dombeck,
General Psychiatry, 45, 31±39. M. S. (1990). Representations of the self in social phobia:
Gotlib, I. H. (1981). Self-reinforcement and recall: Differ- Vulnerability to social threat. Cognitive Therapy and
ential deficits in depressed and nondepressed psychiatric Research, 14, 177±189.
inpatients. Journal of Abnormal Psychology, 90, 521±530. Ingram, R. E., & Kendall, P. C. (1986). Cognitive clinical
Gottschalk, L. A. (1974). A hope scale applicable to verbal psychology: Implications of an information processing
samples. Archives of General Psychiatry, 30, 779±785. perspective. In R. E. Ingram (Ed.), Information proces-
Gray, J. A. (1982). The neuropsychology of anxiety. New sing approaches to clinical psychology. New York:
York: Oxford University Press. Academic Press.
Gray, J. A. (1990). Brain systems that mediate both Izard, C. E. (1992). Basic emotions, relations among
emotion and cognition. Cognition and Emotion, 4, emotions, and emotion-cognitive relations. Psychological
269±288. Review, 99, 561±565.
Gray, J. A., Buhusi, C. V., & Schmajuk, N. (1997). The Jacoby, L. L. (1991). A process disociation framework:
transition from automatic to controlled processing. Separating automatic from intentional uses of memory.
Neural Networks, 10, 1257±1268. Journal of Memory and Language, 30, 513±541.
Gray, J. A., Feldon, J., Rawlins, J. N. P., Hemsley, D. R., Johnson, J. E., Petzel, T. P., Hartney, L. M., & Morgan, L.
& Smith, A. D. (1991). The neuropsychology of M. (1983). Recall and importance ratings of completed
schizophrenia. Behavioral and Brain Sciences, 14, 1±84. and uncompleted tasks as a function of depression.
Gray, N. S., Pickering, A. D., Hemsley, D. R., Dawling, S., Cognitive Therapy and Research, 7, 51±56.
& Gray, J. A. (1992). Abolition of latent inhibition by a Johnson, M. H., & Magaro, P. A. (1987). Effects of mood
single 5 mg dose of d-amphetamine in man. Psychophar- and severity on depression and mania. Psychological
macology, 107, 425±430. Bulletin, 101, 28±40.
Greenwald, A. G., & Draine, S. C. (1997). Do subliminal Jones, J. C., & Barlow, D. H. (1992). A new model of
stimuli enter the mind unnoticed? Tests with a new posttraumatic stress disorder: Implications for the
method. In J. D. Cohen & J. W. Schooler (Eds.), future. In P. A. Saigh (Ed.), Posttraumatic stress disorder
Scientific approaches to consciousness (pp. 83±108). (pp. 147±165). New York: Macmillan.
Mahwah, NJ: Erlbaum. Kanner, A. D., Coyne, J. C., Schaefer, C., & Lazarus, R.
Groeger, J. A. (1988). Qualitatively different effects of (1981). Comparison of two modes of stress measure-
undetected and unidentified auditory primes. Quarterly ment: Daily hassles and uplifts versus major life events.
Journal of Experimental Psychology, 40, 323±329. Journal of Behavioral Medicine, 4, 1±39.
Halberstadt, L. J., Andrews, D., Metalsky, G. I., & Kelly, G. A. (1955). The psychology of personal constructs
Abramson, L. Y. (1984). Helplessness, hopelessness, (Vol. 1). New York: Norton Press.
and depression: A review of progress and future Kendall, P. C., & Hammen, C. (1995). Abnormal psychol-
directions. In N. S. Endler & J. Hunt (Eds.), Personality ogy. Boston: Houghton Mifflin.
and behavior disorders. New York: Wiley. Killcross, A. S., Dickinson, A., & Robbins, T. W. (1994).
Hasher, L., Rose, K. C., Zacks, R. T., Sanft, H., & Doren, Amphetamine-induced disruption of latent inhibition are
B. (1985). Mood, recall, and selectivity effects in normal reinforcer medicated: Implications for animal models of
college students. Journal of Experimental Psychology: schizophrenic attentional dysfunction. Psychopharmacol-
General, 114, 104±118. ogy, 115, 185±195.
Hauri, P. (1976). Dreams in patients remitted from reactive Klein, D. F. (1974). Endogenomorphic depression: Con-
depression. Journal of Abnormal Psychology, 85, 1±10. ceptual and terminological revision. Archives of General
Hemsley, D. R. (1987). An experimental psychological Psychiatry, 31, 447±454.
model for schizophrenia. In H. Hafner, W. F. Gattaz, & Koh, S. D., & Wolpert, E. A. (1983). Memory scanning
W. Janzavik (Eds.), Search for the causes of schizo- and retrieval in affective disorders. Psychiatry Research,
phrenia. Berlin: Springer. 8, 289±297.
Henry, G. M., Weingartner, H., Murphy, D. L. (1973). Kolb, B., & Whishaw, I. Q. (1996). Fundamentals of human
Influence of affective states and psychoactive drugs on neuropsychology. New York: W. H. Freeman & Com-
verbal learning and memory. American Journal of pany.
Psychiatry, 130, 966±971. Kovacs, M., & Beck, A. T. (1978). Maladaptive cognitive
Hertel, P. T., & Hardin, T. S. (1990). Remembering with structures in depression. American Journal of Psychiatry,
and without awareness in a depressed mood: Evidence of 135, 525±533.
Lang, P. J. (1979). A bio-informational theory of emotional prefrontal loop that includes the basal ganglia in solving
imagery. Psychophysiology, 16, 495±512. the recency task. Proceedings of WCNN95. Washington,
Lazarus, R. S. (1982). Thoughts on the relations between DC: INNS Press.
emotions and cognition. American Psychologist, 37, Monchi, O., & Taylor, J. G. (1997). A model of coupled
1019±1024. frontal working memories for delayed response tasks and
Lazarus, R. S. (1991). Emotion and adaptation. New York: the Wisconsin Card Sorting Task. In P. P. Wang (Ed.),
Oxford University Press. International Joint Conference in Information Sciences
Lazarus, R. S., Averill, J. R., & Opton, E. M. (1970). (2nd IICIN'97, pp. 34±37). Amsterdam: Elsevier.
Towards a cognitive theory of emotion. In M. Arnold Moran, C., & Andrews, G. (1985). The familial occurrence
(Ed.), Feelings and emotions (pp. 207±232). New York: of agoraphobia. British Journal of Psychiatry, 146,
Academic Press. 262±267.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and Moran, J., & Desimone, R. (1985). Selective attention gates
coping. New York: Springer. visual processing in the extrastriate cortex. Science, 229,
Lazarus, R. S., & Launier, R. (1978). Stress-related 782±784.
transactions between person and environment. In L. Moscovitch, M. (1984). The sufficient conditions for
Pervin & M. Lewis (Eds.), Perspectives in interactional demonstrating preserved memory in amnesia: A task
psychology. New York: Plenum. analysis. In L. R. Squire & N. Butters (Eds.), Neurop-
Leary, M. R. (1988). A comprehensive approach to the sychology of memory (1st ed., pp. 104±114). New York:
treatment of social anxieties: The self-presentational Guilford Press.
model. Phobia Practice Research Journal, 1, 48±57. Moscovitch, M. (1992). A neuropsychological model of
LeDoux, J. E. (1989). Cognitive-emotional interactions in memory and consciousness. In L. R. Squire & N. Butters
the brain. Cognition and Emotion, 3, 267±289. (Eds.), Neuropsychology of memory (2nd ed., pp. 5±22).
LeDoux, J. E. (1992). Brain mechanisms of emotion and New York: Guilford Press.
emotional learning. Current Opinion in Neurobiology, 2, Moscovitch, M., & Umilta, C. (1991). Conscious and
191±197. nonconscious aspects of memory: A neuropsychological
LeDoux, J. E. (1993). Emotional memory systems in the framework of modules and central systems. In R. G.
brain. Behavioral Brain Research, 58, 69±79. Lister & H. J. Weingartner (Eds.), Perspectives on
Leight, K. A., & Ellis, H. A. (1981). Emotional mood cognitive neuroscience. Oxford, UK: Oxford University
states, strategies, and state-dependency in memory. Press.
Journal of Verbal Learning and Verbal Behavior, 20, Mozer, M. C., & Behrmann, M. (1990). On the interaction
251±275. of selective attention and lexical knowledge: A connec-
Logan, G. D., Zbrodoff, N. J., & Williamson, J. (1984). tionist account of neglect dyslexia. Journal of Cognitive
Strategies in the color-word Stroop task. Bulletin of the Neuroscience, 5, 89±117.
Psychonomic Society, 22, 135±138. Naatanen, T. (1992). Attention and brain function. Hills-
Lovallo, W. R. (1997). Stress and health: Biological and dale, NJ: Erlbaum.
psychological interactions. Thousand Oaks, CA: Sage. Newell, A., & Simon, H. A. (1972). Human problem solving.
Marcel, A. J. (1983). Conscious and unconscious percep- Englewood Cliffs, NJ: Prentice-Hall.
tion: Experiments on visual masking and word recogni- Noyes, R., Clarkson, C., Crowe, R. R., Yates, W. R., &
tion. Cognitive Psychology, 15, 197±237. McChesney, C. M. (1987). A family study of generalized
Marshall, G. D., & Zimbardo, P. G. (1979). Affective anxiety disorder. American Journal of Psychiatry, 144,
consequences of inadequately explained physiological 1019±1024.
arousal. Journal of Personality and Social Psychology, 37, Noyes, R., Woodman, C., Garvey, M. J., Cook, B. L.,
70±88. Suelzer, M., Clancy, J., & Anderson, D. J. (1992).
Mateer, C. A., & Mapou, R. (1996). Understanding, Generalized anxiety disorder vs. panic disorder: Distin-
evaluating and managing attention disorders following guishing characteristics and patterns of co-morbidity.
traumatic brain injury. Journal of Head Trauma Reha- Journal of Nervous and Mental Disease, 180, 369±379.
bilitation, 11, 10±16. Overmier, J. B., & Seligman, M. E. P. (1967). Effects of
Mathews, A., & Bradley, B. (1983). Mood and the self- inescapable shock upon subsequent escape and avoid-
reference bias in recall. Behavior Research and Therapy, ance learning. Journal of Comparative Physiology and
21, 233±239. Psychology, 63, 23±33.
Matt, G. E., Vazquez, C., & Campbell, W. K. (1992). Panksepp, J. (1992). A critical role of ªaffective neu-
Mood-congruent recall of affectively toned stimuli: A roscienceº in resolving what is basic about basic
meta-analytic review. Clinical Psychology Review, 12, emotions. Psychological Review, 99, 554±560.
227±255. Patterson, K. E., Seidenberg, M. S., & McClelland, J. L.
Mattia, J. I., Heimberg, R. G., & Hope, D. A. (1993). The (1990). Connections and disconnections: Acquired dys-
revised Stroop color-naming task in social phobics: lexia in a computational model of reading processes. In
Diagnostic and treatment outcome implications. Beha- R. G. M. Morris (Ed.), Parallel distributed processing:
vior Research and Therapy, 31, 305±313. Implications for psychology and neuroscience. London:
Merikle, P. M., & Cheesman, J. (1987). Current status of Oxford University Press.
research on subliminal perception. In M. Wallendorf & Paykel, E. S. (1979). Recent life events in the development
P. F. Anderson (Eds.), Advances in consumer research of the depressive disorder. In R. A. Depue (Ed.), The
(Vol. XIV, pp. 298±302). Provo, UT: Association for psychobiology of the depressive disorders: Implications for
Consumer Research. the effects of stress (pp. 245±253). New York: Academic
Merikle, P. M., & Joordens, S. (1997). Measuring Press.
unconscious influences. In J. D. Cohen & J. W. Schooler Petersen, S. E., Robinson, D. L., & Morris, J. D. (1987).
(Eds.), Scientific approaches to consciousness Contributions of the pulvinar to visual spatial orienta-
(pp. 109±123). Mahwah, NJ: Erlbaum. tion. Neuropsychologia, 25, 97±106.
Miller, W. R. (1975). Psychological deficit in depression. Petri, H. L., & Mishkin, M. (1994). Behaviorism, cogniti-
Psychological Bulletin, 82, 238±260. vism and the neuropsychology of memory. American
Milner, A. D., Corkin, S., & Teuber, H. L. (1968). Further Scientist, 82, 30±37.
analysis of the hippocampal amnesic syndrome: 14-year Petrides, M., Alivisatos, B., Evans, A. C., & Meyer, E.
follow-up study of H. M. Neuropsychologia, 6, 215±235. (1993). Dissociation of human mid-dorsolateral from
Monchi, O., & Taylor, J. G. (1995). A model of the posterior dorsolateral frontal cortex in memory proces-
References 353
sing. Proceedings of the National Academy of Science conditioning model of panic disorder: Response to
USA, 90, 873±877. Wolpe and Rowan. Behavior Research and Therapy, 27,
Plaut, D. C., & Shallice, T. (1993). Deep dyslexia: A case 581±582.
study of connectionist neuropsychology. Cognitive Neu- Sanderson, W. C., Rapee, R., & Barlow, D. (1989). The
ropsychology, 10, 377±400. influence of an illusion of control on panic attacks
Posner, M. I., & Petersen, S. E. (1990). The attention induced via inhalation of 5.5% carbon dioxide enriched
system of the brain. Annual Review of Neuroscience, 13, air. Archives of General Psychiatry, 46, 157±162.
25±42. Schacter, D. L. (1987). Implicit memory: History and
Posner, M. I., & Raichle, M. E. (1994). Images of mind. current status. Journal of Experimental Psychology:
Scientific American Library, NY: Freeman. Learning, Memory, and Cognition, 13, 501±518.
Posner, M. I., & Raichle, M. E. (1995). Precis of images of Schacter, D. L. (1989). On the relation between memoy and
mind. Behavioral and Brain Sciences, 18, 327±383. consciousness: Dissociable interactions and conscious
Posner, M. I., & Snyder, C. R. R. (1975). Attention and experience. In H. Roediger & F. Craik (Eds.), Varieties
cognitive control. In R. L. Solso (Ed.), Information of memory and consciousness: Essays in honour of Endel
processing in cognition: The Loyola Symposium Tulving. Hillsdale, NJ: Erlbaum.
(pp. 55±85). Hillsdale, NJ: Erlbaum. Schacter, D. L. (1994). Priming and multiple memory
Rachman, S. (1990) The determinants and treatment of systems: Perceptual mechanisms of implicit memory. In
simple phobias. Advances in Behavior Research and D. L. Schacter & D. Tulving (Eds.), Memory systems
Therapy, 12, 1±30. 1994. Cambridge, MA: MIT Press.
Rachman, S. (1993). A critique of cognitive therapy for Schacter, D. L., McAndrews, M. P., & Moscovitch, M.
anxiety disorders. Journal of Behavioral Therapy and (1988). Access to consciousness: dissociations between
Experimental Psychiatry, 24, 279±288. implicit and explicit knowledge in neuropsychological
Rachman, S., Levitt, K., & Lopatka, C. (1987). Panic: The syndromes. In L. Weiskrantz (Ed.), Thought without
links between cognitions and bodily symptomsÐI. language (pp. 242±278). Oxford, UK: Oxford University
Behavior Research and Therapy, 25, 411±423. Press.
Rapee, R. M. (1985). The distinction between panic Schacter, S., & Singer, J. E. (1962). Cognitive, social and
disorder and generalized anxiety disorder: Clinical physiological determinants of emotional state. Psycho-
presentation. Australia and New Zealand Journal of logical Review, 69, 379±399.
Psychiatry, 19, 227±232. Schare, M. L., Lisman, S. A., & Spear, N. E. (1984). The
Rapee, R. M., Mattick, R., & Murrell, E. (1986). Cognitive effects of mood variation on state dependent retention.
mediation in the affective component of spontaneous Cognitive Therapy and Research, 8, 387±408.
panic attacks. Journal of Behavioral Therapy and Schlenker, B. R., & Leary, M. R. (1982). Social anxiety and
Experimental Psychiatry, 17, 245±253. self-presentation: A conceptualization and model. Psy-
Razran, G. (1961). The observable unconscious and the chological Bulletin, 92, 641±669.
inferable conscious in current soviet psychophysiology: Schmajuk, N. A. (1997). Animal learning and cognition.
Interoceptive conditioning, semantic conditioning, and Cambridge: Cambridge University Press.
the orienting reflex. Psychological Review, 68, 81±147. Schmajuk, N. A., Lam, Y. W., & Gray, J. A. (1996). Latent
Reisenzein, R. (1983). The Schachter theory of emotion: inhibition: a neural network approach. Journal of
Two decades later. Psychological Bulletin, 94, 239±264. Experimental Psychology (Animal Behaviour Processes),
Reiss, S., Peterson, R., Gursky, D., & McNally, R. (1986). 22, 321±349.
Anxiety sensitivity, anxiety frequency, and the prediction Schneider, W., & Shiffrin, R. M. (1977). Controlled and
of fearfulness. Behavior Research and Therapy, 24, 1±8. automatic human information processing: I. Detection,
Resick, P. A., & Schnicke, M. K. (1992). Cognitive search, and attention. Psychological Review, 84, 1±66.
processing therapy for rape victims: A treatment manual. Seligman, M. E. P. (1975). Helplessness: On depression,
Newbury Park, CA: Sage. development, and death. San Francisco: Freeman.
Riskind, J. H. (1989). The mediating mechanisms in mood Seligman, M. E. P. (1978). Comment and integration.
and memory: A cognitive-priming formulation. Journal Journal Abnormal Psychology, 87, 165±179.
of Social Behavior and Personality, 4, 173±184. Seligman, M. E. P., & Maier, S. F. (1967). Failure to escape
Riskind, J. H., Rholes, W. S., & Eggers, J. (1982). The traumatic shock. Journal Experimental Psychology, 74,
Velten mood induction procedure: Effects on mood and 1±9.
memory. Journal of Consulting and Clinical Psychology, Shaw, B. F. (1979). The theoretical and experimental
50, 146±147. foundations of a cognitive model for depression. In P.
Rolls, E. (1997). Consciousness in neural networks? Neural Pliner, K. R. Blankenstein, & I. M. Sigel (Eds.),
Networks, 10, 1227±1240. Advances in the study of communication and affect (Vol.
Rothbaum, B. O., & Foa, E. B. (1992). Exposure therapy 5, pp. 81±119). New York: Plenum.
for rape victims with post-traumatic stress disorder. Singer, J. A., & Salovey, P. (1988). Mood and memory:
Behavioral Therapist, 15, 219±222. Evaluating the Network Theory of Affect. Clinical
Rudy, J. W., & Sutherland, R. J. (1995). Configural Psychology Review, 8, 211±251.
association theory and the hippocampal formation: an Smith, T. W., Ingram, R. E., & Brehm, S. S. (1983). Social
appraisal and reconfiguration. Hippocampus, 5, 375±89. anxiety, anxious self-preoccupation, and recall of self-
Rumelhart, D. E., & McClelland, J. L. (1986). Parallel relevant information. Journal of Personality and Social
distributed processing: Explorations in the microstructure Psychology, 44, 1276±1283.
of cognition. Cambridge, MA: MIT Press. Solomon, P. R., & Staton, D. M. (1982). Differential
Sahraie, A., Weiskrantz, L., Barbur, J. L., Simmons, A., effects of microinjections of d-amphetamine into the
Williams, S. C. R., & Brammer, M. J. (1997). Pattern of nucleus accumbens or the caudate-putamen on the rat's
neuronal activity associated with conscious and uncon- ability to ignore an irrelevant stimulus. Biological
scious processing of visual signals. Proceedings of the Psychiatry, 17, 743±756.
National Academy of Science USA, 94, 9406±9411. Spitzer, H., Desimone, R., & Moran, J. (1988). Increased
Sanderson, W. C., & Barlow, D. H. (1990). A description attention enhances both behavioral and neuronal per-
of patients diagnosed with DSM-III-R generalized formance. Science, 240, 338±340.
anxiety disorder. Journal of Nervous and Mental Disease, Squire, L. R., Ojemann, J. G., Miezin, F. M., Petersen, S.
178, 588±591. E., Videen, T. O., & Raichle, M. E. (1992). Activation of
Sanderson, W. C., & Beck, A. T. (1989). Classical the hippocampus in normal humans: a functional
anatomical study of memory. Proceedings of the National The switching model. Psychological Bulletin, 108,
Academy of Science USA, 89, 1837±1841. 442±461.
Stein, D. J., & Young, J. E. (1992). Schema approach to Weiner, I., Lubow, R.E., & Feldon, J. (1984). Abolition of
personality disorders. In D. J. Stein & J. E. Young the expression but not the acquisition of latent inhibition
(Eds.), Cognitive science and clinical disorders by chronic amphetamine in rats. Psychopharmacology,
(pp. 271±288). San Diego, CA: Academic Press. 83, 194±199.
Sun, R. (1997). Learning, action and consciousness: A Weingartner, H., Cohen, R. M., Murphy, D. L., Marello,
hybrid approach toward modelling consciousness. Neur- J., & Gerdt, C. (1981). Cognitive processes in depression.
al Networks, 10, 1317±1331. Archives of General Psychiatry, 38, 42±47.
Sweeney, P. D., Anderson, K., & Bailey, S. (1986). Weingartner, H., Miller, H., & Murphy, D. L. (1977).
Attributional style in depression: A meta-analytic review. Mood-state dependent retrieval of verbal association.
Journal of Personality and Social Psychology, 50, Journal of Abnormal Psychology, 86, 276±284.
974±991. Weiskrantz, L. (1986). Blindsight. A case study and
Taylor, J. G. (1997). Neural networks for consciousness. implications. Oxford, UK: Oxford University Press.
Neural Networks, 10(7), 1207±1225. Weiskrantz, L. (1995). Blindsight: Not an island unto itself.
Teasdale, J. D. (1983). Negative thinking in depression: Current Directions in Psychological Science, 4, 146±151.
Cause, effect, or reciprocal relationship? Advances in Weiskrantz, L. (1997). Consciousness lost and found: A
Behavioral Research Therapy, 5, 3±25. neuropsychological exploration. Oxford, UK: Oxford
Teasdale, J. D. (1985). Psychological treatments for University Press.
depression: How do they work? Behavioral Research Weiskrantz, L., & Warrington, E. K. (1970). Verbal
Therapy, 23, 157±165. learning and retention by amnesic patients using partial
Teasdale, J. D., & Barnard, P. J. (1993). Cognition, affect, information. Psychonomic Science, 20, 210±211.
and change: Re-modeling depressive thought. Hove, UK:
Weiskrantz, L., & Warrington, E. K. (1979). Conditioning
Erlbaum.
in amnesic patients. Neuropsychologia, 17, 187±194.
Teasdale, J. D., & Dent, J. (1987). Cognitive vulnerability
to depression: An investigation of two hypotheses. Weiss, J. M., Stout, J. C., Aaron, M. F., Quan, N., Owens,
British Journal of Clinical Psychology, 26, 113±126. M. J., Butler, P. D., & Nemeroff, C. B. (1994).
Teasdale, J. D., & Fogarty, S. J. (1979). Differential effects Depression and anxiety: role of the locus coeruleus and
of induced mood on retrieval of pleasant and unpleasant corticotropin-releasing factor. Brain Research Bulletin,
events from episodic memory. Journal of Abnormal 35, 561±572.
Psychology, 88, 248±257. Wilson, F. A., Scalaidhe, S. P., & Goldman-Rakic, P. S.
Tham, A., Engelbrektson, K., Mathe, A. A., Johnson, L., (1993). Dissociation of object and spatial processing
Olsson, E., & AbergWistedt, A (1997). Impaired domains in primate prefrontal cortex. Science, 260,
neuropsychological performance in euthymic patients 1955±1958.
with recurring mood disorders. Journal of Clinical Wolpe, J., & Rowan, V. (1989). Panic disorder: A product
Psychiatry, 58, 26±29. of classical conditioning. Behavior Research and Therapy,
Thornton, J. C., Dawe, S., Lee, C., Capstick, C., Corr, P. 27, 583±585.
J., Cotter, P., Frangou, S., Gray, N. S., Russell, M. A., & Wortman, C. B., & Brehm, J. W. (1975). Responses to
Gray, J. A. (1996). Effects of nicotine and amphetamine uncontrollable outcomes: An integration of reactance
on latent inhibition in human subjects. Psychopharma- theory and the learned helplessness model. In L.
cology, 127, 164±173. Berkowitz (Ed.), Advances in experimental social psychol-
Torgerson, S. (1983). Genetic factors in anxiety disorders. ogy (Vol. 8, pp. 279±315). New York: Academic Press.
Archives of General Psychiatry, 40, 1085±1089. Yankura, J., & Dryden, W. (1997). Using REBT with
Tucker, D. M., & Williamson, P. A. (1984). Asymmetric common psychological problems. New York: Springer.
neural control systems in human self-regulation. Psy- Young, J. E. (1990). Cognitive therapy for personality
chological Review, 91, 185±215. disorders: A schema-focused approach. Sarasota, FL:
Velten, E. (1968). A laboratory task for induction of mood Professional Resource Exchange.
states. Behavior Therapy and Research, 6, 473±482. Young, J. E., Beck, A. T., & Weinberger, A. (1993).
Weiner, B. (1985). An attributional theory of achievement Depression. In D. H. Barlow (Ed.), Clinical handbook of
motivation and emotion. Psychological Review, 92, psychological disorders: A step-by-step treatment manual
548±573. (pp. 240±277). New York: Guilford Press.
Weiner, I. (1990). Neural substrates of latent inhibition: Zeki, S. (1993). A vision of the brain. London: Blackwell.
1.12
Epidemiology and its Rubrics
JAMES C. ANTHONY and MICHELLE L. VAN ETTEN
Johns Hopkins University, Baltimore, MD, USA
1.12.1 OVERVIEW 355

1.12.2 BACKGROUND 358
1.12.3 THE RUBRICS OF EPIDEMIOLOGY 361
1.12.3.1 Rubric 1: How Many? A Question of Quantity 361
1.12.3.2 Rubric 2: Where? A Question of Location 365
1.12.3.3 Rubric 3: Why? A Question of Causes 369
1.12.3.4 Rubric 4: How? A Question of Mechanisms 376
1.12.3.5 Rubric 5: What Can Be Done? A Question of Prevention and Intervention 381
1.12.4 CONCLUSION 385
1.12.1 OVERVIEW background of the affected cases, frequently

numerous, who never seek help or receive care.
With a heavy reliance upon quantitative Epidemiology also provides evidence about the
methods, epidemiology functions as a lens to aid especially informative background experience of
clinicians who wish to know the answers to five mentally and behaviorally healthy individuals in
important questions about what affects their the community who might have become cases
patients. The five questions are: but did not. As discussed in this chapter,
(i) In the community at large, how many are epidemiology provides a sharp focus and greater
affected? understanding with respect to any patient's
(ii) Where are the affected cases more likely clinical condition. More than any other scientific
to be found? discipline, epidemiology involves population-
(iii) What accounts for some people in the level studies of each condition of health or ill-
community becoming cases while others do not? health. Epidemiology focuses upon the nature
(iv) What linkages of states and processes and extent of the occurrence of each condition,
influence who becomes and remains a case? its distribution in the community, the causes and
(v) What can be done to prevent and inter- mechanisms of its development, and the well-
vene? established or hotly debated means for inter-
These questions form the rubrics for epidemiol- vention, especially in terms of health promotion
ogy, that is, its major headings. and disease prevention.
Using epidemiology as a lens, a clinician can Among the most remarkable accomplish-
see along dimensions that stretch beyond the ments of epidemiology has been demonstration
individual patient, and beyond the threshold of of a counterintuitive idea. Namely, effective
the office practice, clinic, and hospital, toward prevention and intervention strategies are often
the population from which the patient has devised at an early stage of hypothesis testing,
surfaced. Viewed through this lens, the experi- well before there is definitive and thorough
ence of individual patients is seen against a evidence on the specific causes and on causal or
355
356 Epidemiology and its Rubrics
protective mechanisms (Wynder, 1994). This remain specific to an object of study, in that it
chapter draws attention to numerous examples makes no more sense to speak of an ªepide-
of effective health promotion and preventive miology of all mental illnessº than it does to
interventions before causes and causal mechan- speak of an ªepidemiology of all infectious
isms were known. The chapter also provides diseasesº or an ªepidemiology of all cancerº
illustrations that effective prevention can elude (Anthony, Eaton, & Henderson, 1995). We have
us even when we have firm knowledge about an epidemiology of cholera, which has some
specific causes. similarities but is not the same as our
As a discipline, epidemiology started to epidemiology of AIDS, although both are
intersect with the content areas of clinical conditions of infectious origin. We have an
psychology and psychiatry in the early nine- epidemiology of brain infarction and hemor-
teenth century. Valuable field surveys of mental rhage (stroke), which is not the same as the
morbidity in circumscribed national and local epidemiology of neurosyphilis or the epidemiol-
populations were underway during the 1830s, as ogy of late-life dementia, even though all of
an extension of growing concern about how these conditions involve the brain. The epide-
many people in the population were mentally ill, miology of suicide attempts is not one and the
and whether the mentally ill were mistreated. same as the epidemiology of suicide (Borges,
These epidemiological field surveys on mental Anthony, & Garrison, 1995; Monk, 1987). The
health were completed a decade before the epidemiology of suicide can be distinguished
European father of epidemiology, John Snow, from the epidemiology of major depression,
launched his studies of cholera, and about 80 although many cases of major depression
years before Joseph Goldberger embarked on become suicide victims (Moscicki, 1995).
pellagra research and became the discipline's There is an epidemiology for ªmental health,º
American father. an epidemiology for individual behaviors (e.g.,
In the mid-nineteenth century, while Snow suicide attempts), and for each of the categories
was defining cholera epidemiology, his senior of mental disorders listed in psychopathology's
colleague in London's Epidemiological Society, classifications and nomenclatures. For example,
William Farr, started a range of investigations we have an epidemiology of schizophrenia,
on mental disorders as part of his general studies within which hypotheses of genetic causation
of mortality from all causes. For instance, using contend with those of prenatal infections and
numerical methods he had learned during insults, as well as hypotheses involving later
French medical training under Pierre Charles conditions of environment or gene±environment
Alexander Louis, Farr compared mental hos- interaction (Jablensky, 1995). We have an epi-
pital patients admitted to different asylums with demiology of drug dependence, also with a new
respect to their chance of being discharged in a prominence of genetic hypotheses, but with
state of recovery vs. the risk of dying in the undeniable demands for gene±environment
institution. interactions. For example, without encounter-
The transition of epidemiology from a ing an opportunity to ingest cocaine, no one can
prenumerate phase into numeracy actually become cocaine dependent. There now is
might be seen best in relation to the study of evidence that genes may determine personality
causes of mental health and disturbances of traits that, in turn, influence who seeks out novel
mental life and behavior. Some of the opportunities, such as the opportunity to use
nineteenth-century questions provoking this cocaine. Other evidence points to genetic
transition to numeracy were the following: (i) influences on who becomes cocaine dependent
which nations and systems of government once cocaine is ingested (Uhl, Blum, Noble, &
produced the mentally healthiest populations, Smith, 1993). Cocaine, in turn, can influence the
(ii) was it true that slavery actually improved the production of messenger RNA and other gene
mental health of the Africans transported to products of potential later importance to the
America, and (3) can't we reduce the number of development of cocaine dependence (Hyman &
cases of mental disorder by finding the families Nestler, 1996).
that produce these cases and doing something Given its orientation to substantive theory,
about them? epidemiology has a position in relation to
In numerate form, epidemiology has become clinical psychology and psychiatry that is
a scientific discipline with specific guiding analogous to the position of experimental
principles and concepts. It also has a unique pharmacology and therapeutics or human
methodology and associated jargon. Most genetics. There is no unifying theory to master
theories of epidemiology can be expressed in as there might be in physics or sociology, but
a generic framework of interaction between there is a benefit for the practicing clinician to
agent, host, and environment (D.E. Lilienfeld & be familiar with concepts developed or refined
Stolley, 1994). Nevertheless, these theories often within epidemiology, such as ªepidemic,º ªrisk
Overview 357
factor,º ªodds ratio,º and ªexposure opportu- subspecialization in any field is associated with
nity.º These epidemiological concepts serve a narrowing of perspective on what has been
clinicians as well as do pharmacological learned. Important threads of historical origin
concepts such as ªthe dose±response relation- can be lost. Early concepts and principles can be
ship,º ªtolerance,º and ªwithdrawal,º or con- overlooked. This is what we trade in return for
cepts from genetics such as ªheritability,º the benefits that come with the focused attention of
human genome, and genomic imprinting. In subspecialization.
addition, to be able to use or simply to interpret This chapter is intended as a partial antidote
scientific findings that emerge from epidemiol- to overfocused subspecialization, providing an
ogy, the clinician should become familiar with overview of epidemiology and its origins while
its research designs such as the epidemiologic also introducing some selected examples of the
case±control study, and the pitfalls or threats to intersection of epidemiology with clinical
validity of results in epidemiological research. psychology and psychiatry. It is not a compre-
This familiarity complements what clinicians hensive review of all progress in this domain of
must learn about placebo-controlled double- epidemiology. Instead, the chapter introduces
blind randomized trials of experimental ther- and reviews a useful selection of key organizing
apeutics, or comparisons of proband-wise vs. features, concepts, and principles in this field as
pair-wise concordance for monozygotic vs. they have been applied to the study of mental
dizygotic twin pairs in genetics research. health and to categorical disturbances of mental
There are also important opportunities for life and behavior. The history of mental
collaborations between epidemiologists, clinical morbidity surveys is covered briefly, including
psychologists, and psychiatrists, and for bor- longitudinal and prospective studies to estimate
rowing aspects of methodology from epidemiol- the incidence of mental disorders. It seems that
ogy for the purposes of clinical research. As these field studies retain a central position, and
described in this chapter, there is a long they are likely to remain central until still-
tradition for these collaborations, and also for controversial methodological issues have been
the borrowing of epidemiological methods by resolved. By sorting out these methodological
psychologists and psychiatrists, who have had issues, greater attention can be given to what
no other way to test the psychopathological should prove to be a more productive debate on
hypotheses they have framed. substantive hypotheses about causes, causal
Despite the early misgivings of some leaders and protective mechanisms, and intervention
in epidemiology (e.g., Frost, 1927; Levin, 1950), strategies.
and unhampered by psychology's internal The final section of the chapter outlines
debate about its idiographic and nomothetic future directions for research and scholarship in
traditions, there now is much traffic at the this field. It stresses the possibilities for
intersection where epidemiology meets with collaboration between clinical scientists and
psychology and psychiatry. Until about 1980, epidemiologists, with recognition that some
two years of serious library work was more than investigators will wear both hats. Whereas this
sufficient for a scholar to master the history of chapter provides an orientation to background,
work at this intersection. This could be concepts, and principles, a companion chapter
accomplished by first developing an acquain- in this collection provides a more detailed
tance with every noteworthy book and article on introduction to some specific methods of
the topic published up to that date, and then by epidemiology as applied to the study of
evaluating every new publication on this topic, psychological and psychiatric disturbances
year by year. (see Chapter 3.06, Volume 3).
This kind of comprehensive view of the field All of these topics are covered more thor-
no longer is within easy reach. Recent upward oughly in other works. There are textbooks of
trends in the number of published articles, epidemiology, including Major Greenwood's
shown in Figure 1, have placed a comprehensive early classic Epidemics and crowd-diseases: An
view outside the range of all but the most serious introduction to the study of epidemiology (Green-
full-time scholars in the history of psychiatric wood, 1935), as well as those more recently
epidemiology and epidemiological psychology. published by Morris (1957), A. M. Lilienfeld
Adapting themselves, clinicians interested in (1980), D. E. Lilienfeld & Stolley (1994), and
epidemiology now generally approach the field Gordis (1996). There are parallel developments
as subspecialists. For example, many focus on at the intersection of epidemiology, psychiatry,
one or two domains such as the epidemiology of and psychology, including useful texts (e.g.,
depression, schizophrenia, or drug dependence; Cooper & Morgan, 1973; D. Goldberg &
likewise for those who take graduate training in Huxley, 1992; Tsuang, Tohen, & Zahner,
public health and epidemiology, but are also 1995). Short review articles and useful brief
interested in psychopathology. Regrettably, monographs also exist (e.g., Bland, 1988;
400
300
# Articles
200
100 Medline
Psychinfo
0
66 68 70 72 74 76 78 80 82 84 86 88 90 92 94
Year
Figure 1 Time trend for number of journal articles published on the topic of epidemiological psychology/
psychiatry during the period 1966 through 1995: results of Medline and Pychinfo searches. (Note: Boolean
searches were used with the following text words: Epidemiolog$ and Psychiatr$ or Psycholog$ or Mental.)
Cooper, 1993; Morrison, 1959; Reid, 1960; some occupations, less common in others. For
Robins, 1978; Rutter, 1981; Shepherd, 1985; example, the phrase ªmad as a hatterº and
Shepherd & Cooper, 1964). Lewis Carroll's ªMad Hatterº reflect an
When seeking examples to illustrate the appreciation of the toxic effects of the mercury
rubrics of epidemiology, we often turned to used to prepare felt for hats, which includes an
the Annotated bibliography of psychiatric epide- intoxication characterized by prominent dis-
miology, edited and published in 1992 by turbances of mental life and behavior. As
Michele Tansella, Giovanni de Girolamo, and exemplified by this linkage between felt making
Norman Sartorius. This useful resource repre- and mercury poisoning, a common thread
sents a recent effort to compile articles and running through these early origins of epide-
books reporting achievements in this field which miology was an attempt to find understandable
44 experts from 21 countries had ranked as patterns in the occurrence of disease and death,
ªoutstanding or of special relevanceº (Tansella expressed in relation to conditions of time,
et al., 1992). place, and person.
Epidemiology's modern era and more quan-
1.12.2 BACKGROUND titative orientation emerged from seventeenth-
century advances in mathematics, including an
Epidemiology and its rubrics came to the early ªlife tableº method developed by Edward
surface during the nineteenth century, but our Halley of comet fame, as well as more basic
field has a long history in a prenumerate form. foundations of probability and statistics. While
For thousands of years, physicians and mer- Europe passed through the Age of Enlight-
chants have written about the coming and going enment and the Industrial Revolution, these
of human diseases in relation to months and advances were refined and then applied in work
seasons of the year, according to conditions of to promote the public's health and well-being.
the land (e.g., swampy vs. arid), and across The inspiration for this work was drawn in part
tribes or families of people. The most famous of from the social philosophy of French mathe-
these ancient notes on the history, medical matician Condorcet, eighteenth-century foun-
geography, and anthropology of human suffer- der of the social sciences. The momentum
ing is a collection pulled together under the carried over from mathematics and social
name of one person: Of airs, waters, and places, philosophy into medicineÐas expressed by
attributed to Hippocrates. the use of numerical methods by French
A physician of the late Renaissance, Girola- physician Pierre Charles Alexander Louis
mo Fracastoro, followed in these footsteps and and his students, in order to improve patient
observed that variations in occurrence of care and the health of the public (Farr, 1885; A.
disease might be due to invisible but identifiable M. Lilienfeld & Lilienfeld, 1979). One of
agents in air and water. In the late seventeenth Louis's students was William Farr of London,
century, Ramazzini differentiated diseases and who defined the field of ªvital statisticsº during
causes of death found to be more common in a long career of studying Great Britain's
Background 359
administrative statistics on births, deaths, and was mosquito borne. With this knowledge, the
disease. commission began an effective program of
In early nineteenth-century Great Britain, yellow fever prevention by draining puddles
waves of Asiatic cholera started to sweep and swamps, installing nets and screens, and
through London and other European commu- otherwise creating effective barriers between
nities, regularly killing thousands. Responding mosquitoes and their human hosts. Many years
to the cholera epidemics, Farr used Halley's life passed before the yellow fever virus was
table and numerical methods taught by Louis to identified and an effective preventive immuniza-
study cholera's patterned aftermath in mortality tion was created. Thus, effective yellow fever
statistics. Based on this work, Farr helped to prevention was underway well before it became
frame the majority position of London's possible to trace the causal mechanisms and
Epidemiological Society: that breathing mias- pathways by which the virus passes from
matic vapors from unclean water or soil caused mosquitoes to humans.
cholera. Anaesthesiologist John Snow thought Pellagra is known as the disease of the three
otherwise, and chose to work against common Ds: dermatitis, diarrhea, and dementia (e.g., see
opinion. Aided by Farr, Snow assembled the Macleod, 1978). Although pellagra was not
available data on cholera deaths, gathered his mentioned by the ancients, it aroused attention
own data, and used numerical methods to during the nineteenth century, especially in the
marshal evidence that cholera was due to southern United States, Latin America, and
drinking contaminated water. Snow's thesis other places where maize had become a staple
about cholera as a waterborne disease at first cereal and where other nutrients were in short
was rejected by his peers, including Farr. supply. At the dawn of the twentieth century,
Nevertheless, in time, Snow's evidence became the connection with maize was overshadowed
overwhelming; the miasma theory was over- by the fact that many of the observed patterns of
turned. England and the other industrializing pellagra occurrence resembled those of an
countries began to prevent cholera epidemics by infectious disease with respect to matters such
improving water sanitationÐyears before bac- as seasonal variation and clustering of cases
teriologist Robert Koch finally discovered the within vulnerable subgroups (e.g., the poor).
mechanism of action and identity of the cholera Based on success with cholera, rabies, and other
vibrio, which we now trace as the disease's infectious diseases, there was a bacteriological
specific cause. For this victory of research on optimism about pellagra, with hope for an early
cholera, John Snow is now known as a father of discovery of the responsible bacterium. None-
epidemiology. theless, from the perspective of Joseph Gold-
The numerical methods of Louis also crossed berger, the American father of epidemiology
the Atlantic to the Americas (Osler, 1897), (Goldberger, 1964), there was a different way to
where nineteenth-century diseases such as interpret the data. In Goldberger's mind, the
yellow fever and pellagra compromised the evidence on pellagra as an infectious disease was
public's health and prompted major investiga- just as readily interpretable as evidence favour-
tions, just as AIDS has done in our own time. ing a nutritional deficiencyÐperhaps a defi-
The history of epidemiological research on these ciency of one of the ªvitaminesº named by
diseases teaches one of the most important Casimir Fund, a pioneer in the new science of
lessons learned by Snow in his work on cholera: nutrition. Goldberger wrote:
Effective prevention does not require thorough
knowledge of specific causes nor causal me- In view of the great uncertainty that exists as to the
chanisms. Methods of prevention can be true cause of pellagra, it may not be amiss to
identified and put into place well before suggest that pending the final solution of this
definitive etiological evidence is available. problem it may be well to attempt to prevent the
disease by improving the dietary of those among
Furthermore, firm evidence about etiology whom it seems most prevalent. In this direction I
and causal mechanism does not always translate would urge the reduction in cereals, vegetables,
into effective prevention. and canned foods that enter to so large an extent
In the case of yellow fever, many nineteenth- into the dietary of the people of the South and an
century authorities believed that the disease was increase in the fresh animal food component, such
spread by inanimate particles (ªfomitesº) in the as fresh meats, eggs, and milk (Goldberger, 1914a).
clothing, bedding, and other possessions of
infected persons. In the name of prevention, A year later, illustrating how initial epide-
millions of dollars worth of these possessions miological findings about the location of ob-
were tossed away or burned, until epidemiolo- served cases can lead toward investigations into
gical and clinical experiments under the direc- prevention and causes, Goldberger explained
tion of Walter Reed's Yellow Fever Commission his reasoning (Goldberger, Waring, & Willets,
produced conclusive evidence that yellow fever 1915):
In a paper published [last year] . . . , attention was syndrome (AIDS). Well before HIV had been
called to certain epidemiological observations isolated as an infectious agent, and before
relating to pellagra which appeared inexplicable general concepts or diagnostic criteria for AIDS
on any theory of communicability. These observa- could be specified, epidemiologists and clin-
tions showed that, at certain institutions at which
icians at the Centers for Disease Control were
pellagra was either epidemic or had long been
endemic among the inmates, the nurses and able to spot an unexpected occurrence of
attendants, drawn from the class economically Pneumocystitis carinii pneumonia. They nar-
and socially identical with that most afflicted in the rowed its predominate location to young
population at large, appeared uniformly to be homosexual men, some being consumers of
immune, although living in the same environment amyl nitrite (ªpoppersº) and other drugs, but
and under the same conditions as did the inmates. also positive for exposure to a cytomegalovirus
Neither ªcontactº nor insect transmission seemed (Centers for Disease Control, 1981a, 1981b,
capable of explaining such a phenomenon. It was 1981c; Goedert et al., 1982). As the story
suggested that the explanation was to be found in a unfolded, the epidemiologists gathered enough
difference, which was believed to exist, in the diet
of the two groups of residents. . . . It was suggested,
information to shift gears from a search for
therefore, that it might be well to attempt to locations (where are cases most likely to be
prevent the disease, . . . by providing those subject found?) to a more focused search for causes
to pellagra with a diet such as that enjoyed by well- (why are some affected while others are not?). In
to-do people, who as a group are practically free this process, they were able to identify inhalant
from the disease. and other drug use as a correlated behavior or
cofactor lacking singular causal importance.
Thereafter, Goldberger conducted this very While clarifying that drug use by itself was not a
type of experiment, as well as other key studies. cause of HIV infection, these studies noted the
In so doing, he produced evidence necessary to high-risk status of unprotected receptive anal
confirm that pellagra and the pellagra psy- intercourse with multiple male sex partners,
choses are not communicable diseases, and were often in conjunction with the use of poppers and
preventable by appropriate changes in diet such other inhalant drugs, or with crack or other
as he had described in 1914. Of course, for psychostimulant drugs. Prevention campaigns
many, the evidence from his diet experiment to reduce the risk of AIDS in the homosexual
was among the most compelling evidence in community were underway before the specific
favor of his dietary hypothesis. Subsequently, viral etiology was understood, and before the
prevention of pellagra became a topic of public risk to heterosexuals was appreciated fully.
activity and public policy, well before 1926, Because the prevention campaigns target the
when the pellagra preventive factor was nar- proximal developmental antecedents of high-
rowed down to one of the B group of vitamins. risk HIV-related behaviors, these early cam-
Goldberger died in January 1929. Almost a paigns retain utility for the prevention of HIV
decade passed before a research team at the infection and AIDS even today, years after
University of Wisconsin identified niacin as the isolation of HIV infection as the necessary
specific protective factor in relation to the causal factor for AIDS (National Institute of
etiology of pellagra. Allergy and Infectious Diseases [NIAID], 1995).
In the meantime, pellagra has essentially Drawn from the history of epidemiology
disappeared from the United States, Canada, (Wynder, 1994), the lesson that effective pre-
Western Europe, and other places where either vention can precede firm knowledge of causes,
high standards of living or other mechanisms causal mechanisms, and developmental se-
promote niacin-containing diets. For the time quences is of special importance in relation to
being, it has become difficult for US-based disturbances of mental life and behavior. With
psychopathologists to observe cases of pellagra few exceptions, it is unlikely that definitive and
psychoses except when the clinical picture is thorough evidence on the causal or protective
secondary to chronic alcohol dependence. To mechanisms and developmental processes of
see primary pellagra psychoses, psychopathol- these disturbances will be available in the near
ogists typically must travel abroad to countries future. But there is no need for research on
where various constraints thwart good nutri- prevention of these disturbances to await such
tion, and with much lower standards of living definitive and thorough evidence, even though it
than can be found at home. must be acknowledged that every important
A more contemporary history lesson on our advance in understanding basic causal mechan-
capacity to start effective prevention campaigns isms and developmental processes typically
before full knowledge of causes or causal reveals new targets for prevention and inter-
mechanisms is provided by the recent epidemic vention. The value of these advances in public
of human immunodeficiency virus (HIV) infec- health terms is that each advance can lead to
tions and the acquired immunodeficiency discovery of more efficacious interventions with
The Rubrics of Epidemiology 361
fewer unwanted side effects and at less cost. In products represent yet another unexplored part
the meantime, preventive trials can move of the causal mechanisms and developmental
forward and become part of the arsenal of processes leading toward diseases for which we
scientific tools used to discover basic causal and now have at least some effective preventive
protective mechanisms (Mrazek & Haggerty, interventions.
1994). Finally, in our own time, except for a vocal
As it happens, we still do not have completely minority in the scientific world, most scientists
definitive and thorough evidence on the causes are confident that the underlying cause of AIDS
and causal mechanisms for any of the infectious is a virus, and not the inhalants, the drinking,
or nutritional diseases mentioned above, even cocaine use, or sex per se. But the person-to-
though we know how to prevent them, at least in person spread of this virus, by routes including
theory. That is, the identification of specific unsafe sex practices and drug injection prac-
etiological agents for cholera, pellagra, and tices, is determined at least in part by drug-
AIDS did not constitute final brushstrokes in taking behavior and behavioral disturbances;
the total picture of disease etiology. In Farr's by alcohol and cocaine use, as well as the sex-
day, for example, the cholera death rate was associated behaviors of inhaling poppers, or
lower for the well-to-do than for the impover- taking methamphetamine via inhalation of
ished people of London. Apparently, this in part smoke (ªiceº) or injection. These behavioral
was because wealth was protective: it coincided characteristics by which HIV infection is spread
with access to clean water supplies before there are in turn determined by a broad array of
was a complete appreciation of the link between influences that range from the domain of
water sanitation and cholera. The association genetics to that of social policies toward drug
with wealth also seems to be present in the use and treatment of drug dependence. Hence,
recent upsurge of cholera epidemics during the even though HIV is confirmed as a necessary
late twentieth century. Nonetheless, it would be cause of infections that lead to AIDS, this
imprudent to delay our efforts to prevent evidence did not complete the picture of causal
cholera until we understand all the different mechanisms for HIV infection and AIDS. In the
ways that wealth might promote access to pure present instance, knowledge of a necessary
water supplies, or until we understand the cause has not yet produced an effective means to
determinants of the distribution of wealth in block the now global epidemic spread of this
society as it might relate to health status. In infection (NIAID, 1995).
public health work, the details of these causal
mechanisms are of secondary importance when
water sanitation, vaccines, and other effective 1.12.3 THE RUBRICS OF
preventive maneuvers are already known. EPIDEMIOLOGY
In Goldberger's day, the well-to-do rarely
Whereas the search for causes, causal me-
developed pellagra, as noted in his article from
chanisms, and methods of disease prevention
1915, quoted above. Attempting to develop a
and health promotion are central to epidemiol-
more complete view of the epidemiology of
ogy, many in this field choose to concentrate on
pellagra, Goldberger used social science meth-
the other rubrics listed in Table 1. Indeed,
ods designed by a collaborator (Edgar Syden-
epidemiology's first intersection with the subject
stricker, an economist). In so doing, his research
matter of clinical psychiatry and psychology
group was able to document a socioeconomic
addressed pragmatic questions. How many
substrate which was one step back from dietary
persons suffer from mental maladies? Where
deficiency in the causal chain leading toward
in the community population are these cases to
pellagra. In later years, Sydenstricker turned his
be found? Are they being treated badly or well?
attention to medical insurance plans and other
societal-level means of promoting public health
(Sydenstricker, 1964). Needless to say, this 1.12.3.1 Rubric 1: How Many? A Question of
aspect of the causal network for diseases Quantity
associated with socioeconomic status (SES)
continues to be underinvestigated. Many clinicians in the United States are
Turning attention from the more sociological interested in the mental and behavioral dis-
aspects of causal mechanisms for disease to a turbances that affect adolescents and adults in
fundamental biological aspect, we still are many the age range 15±54 years; fewer are acquainted
years away from definitive evidence on the with epidemiologic estimates on the prevalence
chromosomal locations of those genes respon- and incidence of these disturbances (e.g.,
sible for our species' widely shared vulnerability Kessler et al., 1994; Regier et al., 1993). Many
to Cholera vibrio, or to niacin deficiency. These do not appreciate that more Americans in this
genes, combinations of genes, and their gene age range have been affected by a history of
Table 1 The five main rubrics, subject matter, and questions of epidemiology.
Main rubrics Subject matter Questions asked by epidemiologists
(i) How many? Quantity How many in the population are affected as
cases, or are becoming cases?
(ii) Where? Location Where in the population are affected cases more
likely to be found, with respect to characteristics,
conditions, and processes of person, place, and
time?
(iii) Why? Causes What accounts for some people becoming
affected while others are spared?
(iv) How? Mechanisms What sequences or linkages of states and
processes influence who becomes and remains a
case and who does not?
(v) What can be done? Prevention and intervention What can be done to prevent or delay the onset
of suffering, to shorten its duration, or otherwise
to reduce the burden of affected cases, their
families, and society in general?
dependence on psychoactive drugs than by Institute of Mental Health (NIMH) Epidemio-

other psychiatric disturbances now accorded logic Catchment Area community surveys car-
higher priority in mental health service delivery ried out during 1981±1982, the DIS method
systems, prevention, and sponsored research found 3.6% of the study population with a
programs. For example, the most recent history of recently active DSM-III alcohol use
nationally representative sample survey of disorders (i.e., with symptoms present during
15±54-year-olds in the USA, indicates that the month prior to assessment). An estimated
cannabis (marijuana) dependence has affected 1.1% had active drug use disorders involving
about 4.2% in this population. By comparison, marijuana and other internationally regulated
this survey, conducted between 1990 and 1992, substances. The DIS estimate for one-month
found only 3.5% to have had a history of panic prevalence of DSM-III Major Depression was
disorder. intermediate, at 2.3%. By comparison, the
corresponding one-month prevalence estimates
Cocaine dependence was almost as prevalent as based on standardized psychiatric examinations
antisocial personality disorder (2.7% versus 3.5%) of the study subjects were 6.9% for alcohol use
and was about 70% more common than bipolar disorders, 3.1% for drug use disorders, and
disorder (1.6% prevalence). Alcohol dependence 1.1% for major depression. The most com-
(14.1%) was somewhat more common than simple monly found mental disorder by both methods
phobia (11.3%) and social phobia (13.3%), of case assessment was phobic disorder: accord-
whereas tobacco dependence at 24.1% was more ing to the DIS method, 11.2% of the Baltimore
prevalent than major depressive disorder at study population had phobic disorder with
17.1%. (Anthony, Warner, & Kessler, 1994)
symptoms present in the month prior to assess-
ment. The corresponding estimate based upon
The prominence of alcohol and other drug the psychiatric examination was 21.3% (An-
problems in the United States can also be seen thony et al., 1985). Other one-month prevalence
when epidemiology seeks to quantify how many estimates from the Baltimore study are pre-
persons are currently active cases of mental and sented in Table 2.
behavioral disturbances. This is true whether These recent estimates from epidemiologic
the case assessment method involves computer- surveys of community populations are not
ized diagnoses based on information from definitive for all persons, places, or times;
standardized interviews conducted by lay per- variation in epidemiological estimates proves
sons (e.g., the Diagnostic Interview Schedule, or to be as important as constancy. Nevertheless,
DIS) or standardized psychiatric diagnoses point estimates from community surveys of
made by clinicians after a formal psychiatric mental and behavioral disturbances have been
assessment with opportunities for cross-check- indispensable when policy makers and planners
ing and probing freely. For example, in the have faced hard decisions about allocation of
Baltimore (Maryland) arm of the National scarce health resources, and when society has to
Table 2 One-month prevalence of selected DSM-III conditions, by two methods of ascertainment. Data from
the Eastern Baltimore Mental Health Survey conducted as part of the NIMH Epidemiologic Catchment Area
Program, 1981.
Prevalence estimate based upon Prevalence estimate based upon Diagnostic

standardized clinical diagnosis Interview Schedule administered by lay
by study psychiatrist interviewer
DSM-III category (%) (%)
Phobic disorders 21.3 (1.9) 11.2 (1.2)

Alcohol use disorders 6.9 (1.1) 3.6 (0.8)
Drug use disorders 3.1 (1.0) 1.1 (0.5)
Major depressive episode 1.1 (0.4) 2.3 (0.4)
Schizophrenia 0.5 (0.1) 0.7 (0.2)
Manic episode 0.4 (1.2) 0.4 (0.9)
Obsessive-compulsive disorder 0.3 (0.1) 1.3 (0.3)
Panic disorder 50.1 (0.07) 0.8 (0.2)
These results are based upon multistage sequenced sampling of adult household residents living in eastern Baltimore at the time of the survey.
The diagnoses were from independently conducted standardized psychiatric examinations and Diagnostic Interview Schedule assessments of
the same subjects, who were selected by probability sampling from the community and also by probability sampling for the diagnostic
assessments. These estimates take the varying probabilities of selection into account, as reported in Anthony et al., 1985, from which this table is
adapted. Numbers in parentheses are the standard errors of the observed prevalence estimates.
weigh the relative public health importance of disturbances and how they were being attended.
one health or social problem vs. another. For The method involved two stages of case
many years the allocation of resources to the assessment. In the first stage, the clergy were
mental health field has been constrained by an asked to review each roster of parishioners,
overemphasis on the study of death certificates, which included all citizens of the area served by
the causes of death, and prevailing mortality the church without respect to religious pre-
rates. During the twentieth century, there has ference, and to make notes about the mental and
been an increasing appreciation that conquest behavioral characteristics of each listed person.
of communicable diseases yields a worldwide In a second stage, these notes were compiled and
increase in the prevalence of mental and reviewed by a royal commission of alienists
behavioral disturbances that disable but do (psychiatrists of the time), who sorted the
not necessarily kill (e.g., see Gruenberg, 1977; disturbances into categories of idiotia, demen-
Kramer, 1983; Levav, Lima, Somoza, Kramer, tia, melancholia, and mania. Based on these
& Gonzales, 1989). Recent evaluations of the assignments, the survey team then produced
global burden of diseases take both prevalence estimates for the prevalence of each of these
and disability into account, drawing estimates conditions in the urban and rural areas of
of prevalence and levels of disability from Norway, and for men and women (Table 3;
epidemiologic surveys. These evaluations show Holst, 1835, translated by Massey, 1852).
major depression and alcohol use disorders to In the United States, the first formal
be at the forefront of the major disabling health epidemiologic surveys of these disturbances
conditions that face countries worldwide, now were the responsibility of the Census Bureau. In
that more humans are living into adulthood the 1840 census, the census takers were asked to
when they otherwise would have died during identify cases of insanity as they went from
infancy and childhood (Murray & Lopez, 1996). community to community, household to house-
The same process of reduced mortality with hold, and institution to institution, with case
increased survivorship has given Alzheimer's assessment either directly observed or reported
disease and the dementias of late life a much by household, community, or institutional
more prominent aspect than human society has leaders. Edward Jarvis, who was William Farr's
ever faced before (Gruenberg, 1977). American counterpart, compiled many of the
The history of epidemiologic surveys of results of the survey, with both good and bad
mental and behavioral disturbances dates back results. Jarvis, a physician, was an early leader
to the early nineteenth century. A famous in the American Statistical Association, and his
Professor Holst of Norway is cited as having name should be remembered in this context for
been responsible for the first formal community two important reasons.
survey of mental disorders. This survey was First, Jarvis studied patterns of admission to
completed in 1835 in order to assess the number mental institutions, and found that the prob-
of citizens who were suffering from mental ability of being admitted to such an institution
Table 3 Prevalence estimates from an early community survey of mental disorders in

1835 in Norway.a
Prevalence
(cases per 10 000) Mania Melancholia Dementia Idiotia
All citizens 6.05 5.31 4.35 14.21

Males 6.20 5.19 4.46 15.12
Females 5.91 5.43 4.25 13.34
Citizens of towns
Males 9.27 5.69 5.60 7.97
Females 9.03 6.66 3.85 5.03
Rural districts
Males 5.84 5.13 4.31 15.96
Females 5.52 5.28 4.30 14.38
a
These prevalence estimates (cases per 10 000 population) are from a report written by Professor Holst of
Norway, 1835, translated by Massey, 1852. As described in the text, the clergy of each parish in the country
made notes about the mental life and behavior of each area resident. These notes were reviewed by a panel of
specialists, who sought to identify the mentally ill, and to sort their disturbances into the categories listed
above.
varied inversely with the distance of one's sorted the disturbances into discrete categories
residence from the institution (Jarvis, 1865±66). from the classification of neuropsychiatric
This relationship, now known as ªJarvis's Lawº conditions of the era, and calculated prevalence
still held when it was checked in the mid- estimates for each of the categorized distur-
twentieth century (e.g., Kramer, Goldstein, bances. Though the results of this early
Israel, & Johnson, 1955). Second, Jarvis was sophisticated community survey of mental
proud of the results of the 1840 census, and disorders were used to help plan for mental
praised them as a major advance in the health services in the county, the survey had an
understanding of insanity in the United States. unfortunate origin in the eugenics movement.
Illustrating his point, he used the census data to One of its stated goals was to identify families
calculate the prevalence of insanity among who were responsible for bearing offspring with
ªcoloredº persons living in the slave states of mental and behavioral disturbances, and doing
the South vs. the corresponding prevalence something about these families (Rosanoff,
among those living in the free states of the 1917).
North. In so doing, he found and reported that This chapter is too brief to provide a
the prevalence of insanity in this group was complete account of the history of community
lower in the South than in the North, only to surveys of mental and behavioral disturbances.
discover, after his publication of the results, that Many surveys of this type have been completed
serious errors had produced an undercounting during the twentieth century, both in the US
of mentally disordered slaves in the South. and abroad (e.g., see Cooper & Morgan, 1973;
Despite repeated retractions, and to his great Dohrenwend & Dohrenwend, 1974; Lemkau,
dismay, Jarvis was unable to stop use of this Tietze, & Cooper, 1942; Robins & Regier, 1991;
statistical evidence in the proslavery arguments Schwab & Schwab-Stone, 1978; Tansella et al.,
that ultimately led to the great Civil War 1992). For the present purposes, it might suffice
between the North and the South (Deutsch, to say that the impulse to count the number of
1944; Jarvis, 1843a, 1843b). persons affected by mental and behavioral
Another neglected classic survey was con- disturbances in the community was first
ducted during 1916 by Aaron J. Rosanoff, a expressed in scientific studies during the first
psychiatrist who worked in Nassau County, half of the nineteenth century. This impulse
New York. Rosanoff's two-stage community grew to full strength during the twentieth
survey involved a sophisticated first-stage century and continues unabated. First oriented
assessment designed to screen for mental and to counting how many persons in the popula-
behavioral disturbances via brief tests and item tion are affected by each type of mental and
sets (e.g., cognitive tests of orientation and behavioral disturbance (i.e., the prevalence of
memory, and proverb interpretation). In the each disorder), this epidemiologic research has
second stage, Rosanoff or another psychiatrist expanded to other domains. For example, via
colleague examined every one of the individuals prospective and longitudinal research designs,
suspected of having some mental or behavioral epidemiologists now seek estimates for the risk
disturbance. After this direct examination, they of becoming a case for the first time (i.e., the
incidence of each disorder), and also seek to 1.12.3.2 Rubric 2: Where? A Question of
gauge the size of an ªicebergº phenomenon Location
(i.e., the relative proportion of active cases who
have come to the attention of health authorities Either before or along with the capability to
vs. the proportion who remain without atten- estimate how many persons in a population are
tion or care). Figure 2 illustrates the iceberg dying or are falling ill, epidemiology can
phenomenon, which might help convey how it provide a means for making separate estimates
is that epidemiology helps clinicians see beyond for geographic locations or political jurisdic-
the horizons of clinical practice (Eaton et al., tions, for different chronological ages or time
1989). periods, and for shared or individual circum-
Of course, once questions about treated and stances such as social class and sex. In many
untreated cases of mental disorder are raised, it circumstances, these estimates are presented in
becomes necessary to account for why some relation to dimensions of location. For exam-
cases are recognized and treated, while others ple, one such dimension was the distance of
are not. The transition from being a case in the one's residence from a mental hospital, as
community to being a recognized case and expressed in Jarvis's Law (Jarvis, 1865±66).
receiving clinical attention has been character- Dimensions of socioeconomic status also have
ized in relation to filters that promote or impede been prominent in epidemiological studies of
these transitions. As identified by Goldberg and mental disorders. For example, in one recent
Huxley (1980, 1992), the progress of a case from study, a research group led by psychologist
the community toward psychiatric attention Bruce P. Dohrenwend presented estimates for
appears to be influenced strongly by the type the occurrence of mental disorders in relation to
and severity of the mental disorder (see Gallo, a dimension of social status defined according
Marino, Ford, & Anthony, 1995; Marino, to educational attainment. Separate estimates
Gallo, Ford, & Anthony, 1995). In this were presented for persons located at different
expanded research mission, epidemiology turns positions along that dimension (Dohrenwend,
to its second rubric. et al., 1992).
40
20
0
% of Cases
20
40
60
80
100
D
Sc
Ph
O
Su epe
ep
th
d
hi
ob
bs nd
e
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ia
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s
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ie
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Figure 2 The ªicebergº phenomenon in the epidemiology of mental disorders. Data from the National
Institute of Mental Health Epidemiologic Catchment Area (ECA) surveys, 1979±1985. The total area of each
bar represents 100% of the active cases, in each of the listed categories of DSM-III disorders, found in the ECA
surveys. The solid area above the x-axis represents the proportion of cases who had been seen by a mental health
specialist (the ªtip of the icebergº), while the hatched area below the x-axis shows the proportion of active cases
not seen by mental health specialists (Marino et al., 1995).
Often, the locational dimensions of time, connection with sexual encounters was not
chronological age, and stages of development understood at all, but the capacity to start
have been of central importance in epidemio- developing interventions directed toward ap-
logical studies. For centuries, epidemics have parently risky sexual activities was created early
been observed to come and go, either varying in in the epidemic.
relation to the season of the year (e.g., influenza) Sometimes we need to sustain basic descrip-
or with much longer between-epidemic intervals tive efforts to learn where cases are more likely to
(e.g., smallpox, cholera). Many communicable be found, even when advances are being made in
diseases such as measles, chickenpox, and tests of competing theories about causes and
mumps were discovered to affect mainly the causal mechanisms. This certainly is true in the
young and rarely the old: a manifestation of instance of the epidemiology of suicide, which
durable immunity after an initial attack. While has been studied carefully for about 160 years,
these epidemics raged among older children, starting with William Farr's discovery of
newborn infants might be spared for a few evidence both conforming with and contra-
months, due either to immunity acquired from dicting Par M. Bronc's ªsocial lawº that ªsuicide
the mother, or because of being swaddled or is most common where education is most
otherwise protected from contact with the diffused: suicides and scholars increase in the
infective agent. Those who managed to escape same ratio.º The supportive evidence was based
relatively mild disease during childhood might upon a comparison of four jurisdictions in which
be faced with much more serious medical it was possible to review marriage records in
complications once the years of puberty were order to determine the proportion of persons
reached, as is the case with the mumps. who were able to write their names at the time of
On occasion, the dimension of time serves as a being married. Based on this indication of
marker for preventive actions, and early epide- education in these four areas, it was found that
miologists discovered that studies of disease the number of suicides per 100 000 population
occurrence over time might help them to was 2.2 in the district with the lowest level of
understand the preventive value of these actions. education and 10.9 in the district with the highest
For example, decades before Farr was able to level of education. Of course, this type of
rely upon Great Britain's national vital statistics epidemiological evidence was liable to the
data for calculation of mortality rates, Robert ªecological fallacyº in that it is operating at a
Watt had studied the burial registers of unit of analysis that is more aggregate than
Glasgow, Scotland, to learn the annual numbers individual. There was no assurance that it was
of smallpox deaths during the period 1783±1812. the more educated persons in these districts who
Watt observed generally declining numbers of were committing suicide. Pursuing this line of
smallpox deaths; proportionately, smallpox reasoning, Farr found the contradictory evi-
deaths became much less prominent among all dence: namely, in a comparison of the number of
deaths, despite generally increasing population suicides per 10 000 males, Farr found a value of
size in Glasgow. Watt attributed the observed 6.7 suicides per 10 000 among servants and
decline in the occurrence of smallpox deaths to coachmen, vs. a lower value of 4.9 per 10 000
the initiation of smallpox vaccination in that among capitalists, professionals, and other
area (Watt, 1813, cited in Farr, 1885). educated men (Farr, 1838, reprinted 1885).
Nonetheless, in epidemiology, the question of Later in the nineteenth century, Durkheim
where (and when) we are more likely to find (1897) tested more complex theories of suicide
cases occurring often runs ahead of questions in relation to social structural characteristics
about causes, mechanisms, and prevention or and social constructs such as anomie, using vital
intervention, especially when there are no statistics data on suicide mortality rates. None-
strong theories to guide more probing investi- theless, we still have not come to a firm
gations. This has had some advantages, because understanding of the causes and causal mechan-
intervention and prevention-oriented services isms of suicide (Monk, 1987). Moreover, in
can be mobilized toward the locations of recent years, by plotting the age-specific suicide
incident and active cases, once there is some mortality rates over time, in the United States
firm evidence about location, and even before and in many other countries, it has been possible
there is good theory to guide causal investiga- to spot an increasing occurrence of suicide
tions. This was true in the history of the HIV deaths among young people and in late life,
and AIDS epidemics, as noted above: interven- especially among elderly men in the United
tions were directed toward the gay community, States (Moscicki, 1995). This work illustrates
and especially toward those in the gay commu- useful epidemiological efforts to identify the
nity who were engaged in high-risk sexual location of incident cases in terms of the
encounters tending to facilitate the spread of increasing trends over time and in terms of
sexually transmitted diseases. The nature of the these two age subgroups within the population.
With firm evidence that these are real and comparisons of mental morbidity statistics, as
persisting increases, and not insignificant and well as comparisons between the sexes and other
transient phenomena, we have all the more variations in the liability to mental disorders
reason to probe more deeply, to frame, and to (e.g., with reference to marital status). For
test theories about causes, causal mechanisms, example, in Tuke's Dictionary of psychological
and the means of prevention. medicine, there is a serious critique of previous
Farr maintained his interest in suicide methods of calculating the relative liability to
mortality throughout his career. Toward the insanity of different communities, with an
end of his life, he completed an international emphasis on the problem of whether the
comparison of suicide deaths and other deaths numbers of insane persons were counted in a
from violent means (e.g., homicides). In so methodologically comparable way across coun-
doing, he found substantially greater numbers tries. In addition, considering whether there
of suicides per million living persons in Switzer- might be increases in the liability to become
land (196), Prussia (134), Austria (113), and insane over time, Tuke (1892) noted:
Bavaria (103), as compared to Ireland (21),
Finland (34), Italy (37), and Scotland (37) (Farr, A moment's consideration will show that the only
1885). Farr was well aware that differences such proper test of the increase of mental disease is the
as these might be explained by variation in the proportion of first attacks to the population
death certification process (Farr, 1885). during different periods. First admissions [to
Complementing these nineteenth-century mental institutions] are clearly not identical with
analyses to investigate where suicide mortality first attacks, seeing that a patient may be admitted
was more likely to be occurring, at that time into an asylum for the first time, and yet have had
one or more previous attacks of insanity.
there also were analyses on the location of active
cases of mental disorders. We already have
mentioned Jarvis's troubles in connection with From Rosanoff's survey in 1916 onward
his analyses of the 1840 US Census data on through the twentieth century, it has been
insanity among free and enslaved African- uncommon for epidemiologists to estimate
Americans in the various states of this country. how many individuals are becoming affected
The early nineteenth-century Norwegian survey by mental disorders, or how many individuals
included prevalence estimates for specific mental have become recently active cases, without also
disorders, cross-classified for urban vs. rural analyzing the variation to the prevalence or
parts of the country, and also by sex and age incidence of these disorders in relation to
(Holst, 1852, translated by Massey), as pre- location in time, from place to place, or across
sented in Table 3. In Wine's report on the 1880 circumstances. For example, in addition to
US Census, detailed tables were presented to reporting an overall morbidity risk estimate
show both the numbers and proportions of US to age 56 for both sexes, in a nonconcurrent
residents affected by insanity and idiocy in each prospective study conducted on Bornholm
state (i.e., the state-specific prevalence values), Island (Denmark), Fremming (1951) estimated
as well as the age of onset of these conditions, the morbidity risk of alcoholism for males as
with cross-classification analyses according to 3.41%, but was unable to do so for females
the sexes, various ages, and social groups. The because only two of the women in the study
report also gave consideration to the excess population had developed alcoholism.
frequency of insanity among foreign-born In a comparison of this type, even when the
residents (3881 per million inhabitants) vs. goal simply is to locate where the cases are more
native-born inhabitants (1509 per million), likely to be occurring or more likely to be found,
and to the hypothesis that foreign nations were it is possible to take differences or to form
shipping their insane citizens to the shores of the ratios. Taking differences in Fremming's data
United States. Addressing this hypothesis, on morbid risk of alcoholism for males vs.
Wines reanalyzed the census data, showing that females, we can compute an excess morbidity
the excess was much reduced when a correction risk of 3.0% or greater, given that the morbidity
was made by subtracting persons under the age risk for males was 3.41% and that for women
of 16 from the denominators of these prevalence truly was too small to calculate. Alternatively,
values. This correction was motivated by his we can compute the ratio of the two morbidity
consideration of the age of first onset of insanity, risk estimates, which in this instance would
which was observed quite infrequently prior to prove to be far greater than a threefold excess in
age 16 (Wines, 1888). morbidity risk for males vs. females. In that the
In the nineteenth-century literature on psy- female morbidity risk value is close to zero, an
chological medicine, there also were fairly estimate based upon the actual ratio of male
sophisticated discussions of the methodological morbidity risk to female morbidity risk would
problems associated with making international tend towards infinity.
In addition to these risk difference and risk In a case±control study, the values ªob-
ratio computations that are used to quantify the servedº for the cases can be compared to the
magnitude of variation from one subgroup to ªexpected valuesº observed for the noncases,
another, from place to place, and time to time, much as a clinician might measure some
etc., we also can transform each morbidity risk characteristic of a case, and then make a
estimate into an odds estimate, and then take the comparison of this observed value to a table
ratio of the odds. The term ªodds,º by con- of reference values or ªnormsº for a reference
ventional definition, refers to a probability population. If we are interested in making
divided by the complement of that probability. comparisons about the incidence of a specific
To the extent that we can ignore the fact that condition, we see cases who have just become
incidence rates are expressed in relation to units cases (ªincident casesº) and we compare them to
of time, if these units are kept the same for the individuals who have no past history of having
groups being compared, we can convert the become a case (ªcontrolsº) or we compare them
standard form of the incidence rate (ªprobability to the reference population out of which the
of becoming a case for the first timeº) into an incident cases have surfaced (ªa sample of the
odds value by treating its numerical value as a study baseº). In this instance, the magnitude of
proportion, and by expressing the odds as that association between case status and the loca-
proportion divided by the complement of the tional characteristic of interest is typically
proportion. Thereafter, we can divide the odds estimated using the odds ratio. However, it
of becoming a case for one group (or time or can be useful to think of the odds in a special
place) by the odds of becoming a case for another way. For example, to conduct a case±control
group (or time or place). The resulting ªodds study of the association between sex (being
ratioº also serves well as a statistical measure female) and major depression, we might recruit
when studying variation in the location of oc- a sample of incident cases of major depression
rrence of cases. Indeed, under some circum- as well as noncases with no history of major
stances, the odds ratio approximates the risk depression. Among cases, we estimate the odds
ratio defined above (e.g., see Breslow & Day, that an incident case of depression is female, and
1980). among the noncases, we estimate the odds ratio
If the proportions under study are prevalence that a noncase is female. Properly designed, the
values from cross-sectional survey data, then it case±control study, with its sample based on the
has become customary to use the terms ªpre- outcome variable (major depression), yields a
valence difference,º ªprevalence ratio,º and ratio of these two odds that serves as a good
ªprevalence odds ratioº instead of ªrisk differ- approximation to the incidence odds ratio that
enceº or ªincidence difference,º ªrisk ratio,º or would be derived from a prospective study in
ªincidence ratio,º and ªodds ratio.º Indeed, if which the sample has been assembled with
the risk values are cumulative probabilities over reference to the locational grouping variable of
some specified interval of time, then there is good interest (here, ªbeing femaleº), and with sub-
reason to use the terms ªcumulative risk sequent follow-up assessments to evaluate
difference,º ªcumulative risk ratio,º and ªcu- whether one group is more likely than another
mulative odds ratioº in order to distinguish these to become a new case of major depression. This
statistical measures of variation from the is an important aspect of case±control study
corresponding measures based upon incidence design that merits reflection: the odds ratio
rates. estimate from a case±control study often serves
The same comparative statistics to identify well as an estimate for the incidence odds ratio
variation in the location of cases (e.g., estimates from a prospective study (Breslow & Day, 1980;
of prevalence odds ratios and cumulative risk Schlesselman, 1982).
ratios) can be derived from epidemiologic case± Two central advantages of a case±control
control studies, as well as from other compara- research design over a prospective study design
tive study designs related to the case±control are that the case±control study can often be
paradigm. The case±control research design can completed with less time and effort, and a
be thought of as a special case of the sequenced case±control study also allows testing of multi-
two-stage (or multistage) survey sample design: ple hypotheses with a single sample. For this
in case±control studies we always sample on the reason, the analysis of case±control study data is
outcome variable in the first stage of assessment. often organized as a test of one or more central
In a second stage of assessment, we measure hypotheses of greatest interest, followed by a
locational grouping variables of interest in the more exploratory search for associations of less
cases and also in sampled controls (noncases). central interest. That is, once key hypotheses
That is, we seek a sample of people who are have been tested, analyses of case±control data
becoming cases, and who seek a comparison can shift toward a more exploratory mode of
sample of people we have not become cases. investigation in which the aim is to screen for
new, previously unestablished patterns of order to probe the possible causal significance
associations that might serve as leads to causal of this observed association. With the human
hypothesis testing in future studies. species, these observational studies are the best
Nonetheless, the most powerful uses of the we can do: a randomized controlled trial of head
case±control study design have been observed trauma as a cause of SDAT makes for an
when there is a need for rapid detection of leads interesting thought experiment, but is out of the
for more probing causal investigations, when question.
the supply of available cases is limited (i.e.,
sample size is small), and when there is no viable
opportunity to use a prospective study design or 1.12.3.3 Rubric 3: Why? A Question of Causes
a randomized controlled trial to test alternative
hypotheses. This situation can arise when an The history of epidemiology's search for
epidemic outbreak of a disease occurs and there causes of mental and behavioral disturbances
is an urgent need for a means of prevention or dates back to the prenumerate period when
other public health action before a deliberate Ramazzini made observations about
and long-term search for causes can be under- occupation-related diseases such as the ailments
taken. In some instances, randomized trials are and premature mortality affecting hatters,
ethically impossible (e.g., to test whether fetal medical workers, and others who handled
exposure to cigarette smoke via maternal mercury incautiously. As mentioned earlier in
smoking might increase a child's risk of later this chapter, in the middle of the nineteenth
drug dependence). In other instances, the century, William Farr also turned his attention
planning of prospective or longitudinal studies to the subject matter of psychology and
requires preliminary information best gained by psychiatry when he considered links between
relatively inexpensive and rapidly conducted education and suicide, but stopped short of a
case±control study methods. probing causal analysis.
Under circumstances such as these, and until Nevertheless, by the middle of the 1800s,
effective means of public health action are well John Snow and others had taken Louis's
in hand, it makes good sense to be very numerical methods for the clinical study of
enthusiastic about the prospect of completing patients and had adapted them for causal
multiple case±control studies that show where analyses of the probabilities and rates of
the new cases are located. At a minimum, these diseases that affect populations. As practiced
studies can yield new information and expertise today, these adapted numerical methods en-
which then can be harnessed within the frame- compass study design and analysis tools such as
work of prospective studies to test causal randomization, stratification, and matching. In
hypotheses. The recent history of the interna- the main, all of these refinements of numerical
tional research program on Alzheimer's disease methods are used to create balance or compar-
provides a useful example of this linkage from ability when we search for the causes of human
informative case±control studies toward more suffering or the means to prevent or reduce this
probing prospective investigations. Specifically, suffering.
multiple case±control studies on senile dementia For example, by randomly allocating patients
of the Alzheimer's type (SDAT) were conducted to different treatment interventions, we seek to
between 1975 and the late 1980s, and virtually constrain the influence of possibly distorting
all of these studies were based on cases referred influences such as sex or age in order to allow
to specialty clinics of neurology or neuropsy- the effects of the various interventions to shine
chiatry. Estimated odds ratios from almost all through. When we are careless in our work, we
of these studies pinpointed a past history of simply assume that randomization works to
head trauma with loss of consciousness as a constrain the influence of these variables, even
locational characteristic with excess occurrence though randomization in any given trial
of SDAT (Anthony & Aboraya, 1992; Breteler, actually might fail, and often does so. When
Claus, van Duijn, Launer, & Hofman, 1992). we are careful, we check to make sure that
Given the biological plausibility that head randomization has worked to our benefit,
trauma at one stage of human development looking to see that the distributions of poten-
might cause an increased risk of SDAT at a later tially influential variables are balanced across
stage, and despite the clear possibility that our various intervention groups. Theory or
referred cases might be a biased sample of all prior evidence guides us when we choose which
cases, investigators who learned the ropes of pre-intervention variables might be distorting
SDAT research via case±control studies now are influences on treatment outcome, and the
conducting prospective and longitudinal stu- means of assessing these variables. Checking
dies, including longitudinal investigations of to see that the distributions of these variables
twins who are discordant for head trauma, in are balanced means that we look at statistical
indicators for each group in relation to the bringing into balance and holding constant an
central tendency of the variables (e.g., mean, area's elevation above sea level (unchanged
median), their dispersion (e.g., variance, stan- before and after), as well as the presence of
dard deviation, interquartile range), skewness, poverty, crowding, and other potentially causal
and kurtosis, allowing comparisons within and factors. As described in Table 4, unless taken
between the groups to be made. into account, these factors (labeled a, b, c, d, e,
When we find that the hypothesized influen- and z) might have distorted Farr's before-and-
tial variables are not in balance across the after comparison.
groups to be compared (i.e., when the groups The twentieth century has added refinements
are ªnonequivalentº), we have a number of to this application of numerical methods in
options at our disposal. For example, we can epidemiological research, but it is hard to
rerandomize until balanced distributions are improve upon the logic of Farr's original
achieved. In this fashion, group equivalence can reasoning. Included among the more recent
be achieved on all pertinent variables except for refinements are: a greater appreciation of the
the interventions to be compared. Or, when odds ratio as an indicator of how strongly one
rerandomization is not possible, we have the variable might influence another; widespread
option of conducting a stratified analysis that use of a multiple logistic regression model, that
will ªhold constantº the influential variables can be used to express the odds of disease
when we seek to know whether the intervention occurrence in relation to set of potentially
had its desired effect. For example, if we think influential variables (corresponding to Farr's a,
educational level might introduce a distorting b, c, d, e, and z in Table 4); improvements in the
influence on the trial results, and if we find out estimation of the odds ratio under conditions of
that one randomly allocated intervention group matched samples; advances in statistical meth-
has proportionately too many college-educated ods needed to estimate the odds ratio when
patients, we can stratify in our analyses, making multiple distorting influences must be kept in
sure the distribution of the education variable is check; and software programming plus compu-
balanced within strata before making a contrast tational advances which now place these
of intervention effects. Two special cases of statistical innovations within reach of each
stratification involve (i) matching, which is a individual investigator who has access to a
kind of ªfine-grainedº stratification which we personal or office computer, whereas less than
use to make sure that the matching variable has 20 years ago large mainframe computers were
the same distribution within the groups to be required.
compared, and (ii) exclusion, which amounts to In concept, the multiple regression model
stratifying and then eliminating from considera- serves a function analogous to that of stratifica-
tion any instances of a powerful distorting tion or matching in more elementary numerical
variable. For example, after completing all methods. Namely, the idea is to apply multiple
baseline assessments for a trial of a new regression models in order to hold constant or
psychotherapeutic intervention, we might find adjust for the potentially distorting influence of
that, somehow, three individuals already taking other variables. Application of this method is
a serotonin reuptake inhibitor slipped into one not unique to epidemiology as a scientific
group, and two individuals taking this same enterprise, and some investigators in psychol-
antidepressant drug slipped into another group. ogy have taken the multiple regression ap-
In this instance, we might well decide to proach far beyond anything to be seen in the
eliminate these individuals from the analytical public health branches of epidemiology (e.g., see
sample, restricting our study and our analyses to Bentler & Stein, 1992; Newcomb & Felix-Ortiz,
the stratum of individuals not taking such 1992). Nonetheless, more than most fields,
antidepressant medicines. epidemiology now makes use of the multiple
All of these numerical methods for constrain- logistic regression model, fostered mainly by
ing the influence of possibly distorting variables graduate training that teaches how to derive and
were available to early epidemiologists and were interpret the odds ratio from fourfold cross-
used by them in their efforts to search for the classification tables and to extract the same
causes of disease in populations. For example, from logistic regression (e.g, see Breslow & Day,
once Farr had come to agree with Snow's 1980; Hosmer & Lemeshow, 1989).
rejection of the miasma theory about the In its search for causes, epidemiology also has
cholera epidemics, and to focus on water benefited from twentieth-century advances in
supply, he made a before-and-after comparison the design of experiments, contributed by Sir
that sought to clarify the cause of an observed Ronald A. Fisher and others. In this respect,
drop in cholera mortality rates, namely, a epidemiology is no different from other scien-
change in water supply between 1849 and 1854. tific fields that make use of both experimental
In his reasoning, he illustrated methods of and observational research designs. However,
Table 4 Epidemiologic reasoning in the nineteenth century.
Farr's reasoning illustrated early methods of bringing into balance and holding constant
an area's elevation above sea level (unchanged before and after), the presence of poverty,
crowding, and other potentially causal factors which otherwise might have a distorting
influence on the comparison. As expressed here in a reorganized outline, and with
correction of two minor typographical errors, Farr summarized his reasoning as follows
(excerpt from Farr, 1885, pp. 375±377):
(i) The excess of mortality (x) by cholera in the Southwark and Lambeth water-fields in
1849 and 1854 was produced by one or other of all the possible causes existing in
1849, repersented by a, b, c, d, e, z.
(ii) In the second period (1854), as well as the first (1849), all the possible causes
remained unchanged, except the possible cause z, which varied.
(iii) With it varied x so as to diminish as z diminished. Therefore z was the cause of x.
(iv) If the enumeration of the possible causes is complete, and given the assumption that
the forces of a, b, c, d, and e are substantially unchanged, it is difficult to resist the
conclusion that z was the cause of x.
(v) The obvious possible causes are exposure to infection (a), bad drains (b), crowding
(c), poverty (d), imperfect medical relief (e), impure water (z).
(vi) None of these, as far as it is known, differed, as far as Lambeth is concerned, in 1849
and in 1854, except the water (z), which was very impure in 1849, and much purer in
1854.
the epidemiological case±control study design patients in October 1989, EMS was soon
has been refined by epidemiologists through discovered to be affecting more than 1500
years of usage in this century, first in applica- people in the United States alone, and with
tions involving research on lung cancer, then on more cases abroad. The main laboratory finding
other cancers, mental retardation and other on these cases was striking eosinophilia, in-
neuropsychiatric disorders of children (A. M. creased eosinophils, and eosinophil precursors
Lilienfeld, Pasamanick, & Rogers, 1955) and, in bone marrow, but the main presenting ailment
more recently, on a broad array of diseases and of affected cases was severe muscle pain, which
health conditions, including schizophrenia, generally was severe enough to constrain the
panic attacks, and major depression (Anthony, patient's usual activities and often was disabling.
Tien, & Petronis, 1989; Dohrenwend et al., A great majority of cases also complained of
1992; Link, Dohrenwend, & Skodol, 1986). headaches, feelings of numbness or muscle
Because it tends to be underappreciated outside weakness, and fatigue. As the case histories
of epidemiology, this particular research design progressed, cognitive deficits associated with
merits some special attention. EMS were identified, as well as neuropathy due
As implied in our introduction to this topic, if to axonal loss and documented by electromyo-
the epidemiological case±control study design graphy and nerve conduction studies. In some
did not already exist, we would have to invent it. cases, the neuropathy was severe and progres-
This is not mere boasting on behalf of sive to the point of quadriplegia; some cases
epidemiologists and biostatisticians, such as required mechanical ventilation to compensate
Morton Levin, Abraham Lilienfeld, Nathan for respiratory insufficiency secondary to the
Mantel, Norman Breslow, and others, who have neuropathy. Over the course of a relatively brief
labored to develop and refine case±control epidemic period from 1989 to 1990, a small
methods. The case±control research design number of deaths attributed to EMS accumu-
poses some of the most impressive challenges lated, but the epidemic was curbed and its
in epidemiology, but epidemiology could not apparent cause was identified in time to keep the
respond to pressing public health problems EMS-associated mortality to a minimum. This
without this design. An example might help rapid action is attributable to a series of very
drive home this point. The following illustration small case±control studies, all conducted within
of the value of case±control research draws one month of clinical reports on the first EMS
upon the experience of clinicians and epide- cases; that is, far more rapidly than it would have
miologists who faced a recent epidemic of taken to mount standard longitudinal, prospec-
eosinophilia-myalgia syndrome (EMS), de- tive, or experimental investigations.
scribed in detail by Kilbourne (1992) and The clinicians reporting the first three EMS
summarized here. cases thought that the appearance of this
First identified as an outgrowth of the work of syndrome had something to do with the
astute clinicians who compared notes on three patients' ingestion of oral L-tryptophan, an
amino acid precursor to serotonin, taken by relation to huge odds ratios: all of the cases
them as a dietary supplement (e.g., with the in both studies had ingested tryptophan-con-
intention of improving mood or reducing sleep taining products; fewer than 10% of the
problems). The reported syndrome brought noncases had done so. Furthermore, only one
other possibilities to the minds of epidemiolo- of the 85 cases reported to the CDC by early
gists at the US Centers for Disease Control November 1989 was found to have no prior
(CDC). For example, an epidemic form of a history of ingesting tryptophan-containing
very similar syndrome had developed in Spain products.
during the early 1980s, ultimately affecting On the basis of this evidence, because other
20 000 cases and accounting for 300 deaths. suspected causes had been ruled out, and because
Traced by case±control and clinical methods, no biases appeared to account for the observed
the Spanish epidemic ultimately had been linked EMS±tryptophan associations, the US Food
to ingestion of rapeseed oil, though the specific and Drug Administration (FDA) asked manu-
causal mechanism or contaminant still remains facturers and suppliers for a voluntary recall of
unknown. Another suspected cause was the tryptophan-containing products, effective No-
nematode Trichinella spiralis, which causes vember 17, 1989Ðless than six weeks after the
trichinosis when ingested via undercooked original report on the syndrome! Thereafter, the
and contaminated pork. Indeed, a similar number of reported EMS cases declined sharply.
syndrome might appear as a consequence of Although there were more than 1000 man-
neoplasms, and when no more than a handful of ufacturers of tryptophan at that time, it was
cases had been reported, this possibility could discovered that six Japanese companies were
not be dismissed entirely. responsible for essentially all of the dietary
Once the CDC investigators set up a system to tryptophan consumed in the United States
collect clinical reports on cases of this syn- during 1989. Furthermore, adaptations of the
drome, the known number of affected cases case±control strategy narrowed the search to a
mounted. By July 1990, confirmed reports of single Japanese manufacturer and to retail lots
EMS had been received from every state of the of dietary tryptophan that had been produced
USA, and more than 1500 cases had been from this manufacturer's supplies between mid-
reported. Prevalence, calculated as the number 1988 and mid-1989. Whereas other manufac-
of reported cases per million (cpm) population, turers might have produced tryptophan that
was greatest in New Mexico and Oregon (420 caused EMS, the risk of EMS was shown to be
cpm population), but also was high in South markedly greater among users of a single
Carolina (15.1 cpm) Minnesota (14.5 cpm), manufacturer's retail lines.
Colorado and Arizona (13 cpm), California, Securing the cooperation of the Japanese
Idaho, and Washington State (9±10 cpm). The company, the epidemiologists sorted batches or
lowest value was from Louisiana, with only 0.2 lots of tryptophan in relation to whether they
cases per million population. were found to be linked to one or more cases of
Two case±control studies, one in New Mexico EMS or to no cases of EMS. Tryptophan batches
and one in Minnesota, proved to be pivotal in linked to the EMS cases were more likely to have
establishing an empirical link between EMS and involved changes in standard fermentation and
oral L-tryptophan, despite a background of purification processes. Two of several changes
observed associations with other factors, and were implicated: less powdered activated carbon
suspected causes such as trichinosis and cancer. had been used in product purification, and in
For example, from the early case reports, a addition, a new strain of Bacillus amyloliquefa-
female excess was apparent: 84% of the ciens had been used for fermentation. Subse-
reported EMS cases in the US were women, quent chromatographic studies were used to
97% were Whites not of Hispanic origin, the identify a possible contaminant, apparently the
median age of cases was 48 years, and few cases result of using the new strain of bacterium for
were under 25 years of age. In the New Mexico fermentation, and this contaminant (EBT) is
case±control investigation, the history of inges- now regarded as a candidate for the etiologic
tion of dietary L-trytophan and 32 other agent in this epidemic of EMS. (However,
suspected etiologic factors was ascertained for subsequent to the end of the epidemic, rando-
11 identified cases, along with 22 neighbors of mized controlled trials of EBT exposure in Lewis
the cases of the same sex and age groups; in the rats showed that EBT can cause some but not all
Minnesota case±control study, the character- of the histopathological changes associated with
istics of 12 identified cases were compared with EMS.)
12 noncases matched on sex, age, and telephone Although some postepidemic cases of EMS
exchange. In both studies, the associations have been reported, and it is claimed that there
between ingestion of tryptophan-containing are other causes of EMS besides badly
nutritional supplements were expressed in manufactured dietary tryptophan (Spitzer
et al., 1995), the 1989±1990 epidemic subsided to treated cases to assess who has become sick and
negligible levels within months of the FDA who remains well, and to determine what might
regulatory action (Kilbourne, 1992). Hence, be causing this variation in the occurrence of
dramatic reductions in the incidence of EMS sickness. What makes them examples of the
following the FDA action constitute additional case±control study design is that they sample on
important evidence that the root causes of this the outcome by starting with a sample of
epidemic involved dietary tryptophan in some affected twins.
way. There now are many such twin studies of
As exemplified by the story of the mental disorders and a growing number of
eosinophilia-myalgia syndrome, there often discordant sibling studies. For many years, twin
are public health emergencies that cannot be researchers were preoccupied with establishing
addressed quickly without case±control meth- whether inheritance had anything to do with the
ods. Because they seem to be developmentally etiology of mental and behavioral disturbances,
backward and sample on the outcome, epide- and the focus of attention was on a question of
miologic case±control study methods are often genes vs. environment or on estimation of the
criticized by behavioral scientists who seem not heritability of a disorder or a trait. More
to appreciate how this tool can be used recently, the questions have looked beyond the
complementarily with other research strategies. more basic issue of whether inheritance matters.
However, case±control studies have a demon- Instead, the hypotheses are framed in terms of
strated value in public health emergencies such which genes might account for observed
as the EMS outbreak and have also helped to inheritance of mental and behavioral distur-
propel etiologic research on Alzheimer's disease bances or traits, and how genes and environ-
and other nonemergency public health pro- ment might combine in dynamic interplay to
blems in a manner that has facilitated the design influence the development of these disturbances
of subsequent prospective and longitudinal and traits. Simply by way of illustration, the
investigations. For a fraction of the cost of twin studies of Breitner et al. (1995) provide a
other investigations, the epidemiological case± starting point in relation to the epidemiology of
control study can yield invaluable information Alzheimer's disease. The work of Pickens,
needed to plan prospective and longitudinal Svikis, McGue, Lykken, and Heston (1991)
studies (e.g., estimates for the effect sizes needed and Johnson, van den Bree, Uhl, and Pickens
to determine sample size values in prospective (1996) illustrate the case±control variety of twin
studies, or empirical evidence on plausible but study research as applied to alcohol and other
possibly unimportant confounding variables). drug dependence.
Under these circumstances, it often is imprudent In a second line of case±control research,
to initiate fieldwork in expensive longitudinal or inter-related with twin studies, are recent tests of
prospective studies until after epidemiologic etiologic hypotheses about specific genetic
case±control research has been completed. polymorphisms. These experiments are espe-
Three emerging lines of case±control research cially well-served by the epidemiological case±
on mental and behavioral disturbances deserve control study design because the nature of the
special note because they are likely to appear suspected causal associations has a temporal
with increasing frequency in the research ordering that finesses some of the interpretive
literature of interest to clinicians in the profes- challenges sometimes faced in case±control
sions of psychology and psychiatry. First, in studies. Namely, it is hard to confuse the
essence, studies of discordant twin pairs are temporal sequence that leads from genes and
sometimes special cases of case±control re- gene expression toward mental and behavioral
search: in these instances, a twin who has been disturbances, even when the underlying theory
affected by a disorder is found, and subse- specifies complicated interactions between
quently there is an effort to determine whether genes and environment. Once they have been
the index twin's co-twin has also been affected. used to establish a well-replicated linkage
These twin studies hold constant inherited between specifically mapped genes or gene
characteristics (in the case of monozygotic markers and subsequent mental or behavioral
twins) or allow them to vary (in the case of disturbances, adaptations of the case±control
dizygotic twins) in order to identify aspects of design can be used to test targeted hypotheses
the environment that might modify inherited about how environmental conditions or pro-
vulnerabilities or that might affect occurrence of cesses might modify or interact with these
mental and behavioral disturbances indepen- genetic influences. This can be accomplished in
dent of inheritance. The same logic applies to the same way that case±control methods had to
studies of discordant sibling sets in general. be adapted to evaluate which manufacturing
What makes them epidemiological (if they are at processes might have changed the risk of EMS
all) is that there is a deliberate search beyond and caused that epidemic to occur.
Again, providing a starting point to under- Typically, over the span of a standard follow-
stand this line of research, the first studies to up interval in these prospective studies, very few
investigate polymorphisms associated with the candidates become incident cases during the
dopamine D2 receptor gene and their suspected follow-up interval. In consequence, within any
causal linkage with severe alcoholism and given sampled neighborhood, it is possible to
cocaine dependence represent applications of compare and contrast the candidates who
the epidemiological case±control study design remain noncases with those who become
(Blum et al., 1990; Uhl et al., 1993). The incident cases. Thus, by using the conditional
continuing debate over these studies mainly has form of the logistic regression model or other
to do with the controversial selection of their numerical methods that treat the neighborhood-
noncase series (ªcontrolsº). Applying epide- level variable as a matched characteristic, an
miological strategies within the framework of investigator is allowed to hold constant shared
family-genetic studies, and via case±control aspects of living in a particular neighborhood
analyses of the resulting study data, Strittmatter (e.g., social disorganization, disadvantage,
et al. (1993) at Duke University and Henderson street-level availability of drugs, police pre-
et al. (1995) at the Australian National Uni- sence). At the same time, it is possible to estimate
versity in Canberra have made advances in our the risk of becoming an incident case in relation
understanding of polymorphisms linked to a to a suspected causal factor that has been
gene for apolipoprotein epsilon-4 and their measured at the personal or behavioral level.
suspected causal or protective associations with This form of epidemiological case±control
Alzheimer's disease. study design has been used to test a variety of
In a third line of research with importance for hypotheses about suspected causal factors for
clinical psychology and psychiatry, the epide- mental disorders and behavioral disturbances:
miological case±control study design has been (i) Whether an individual's use of cocaine
used with increasing frequency to analyze the might increase risk of panic attacks (Anthony
evidence from large-sample epidemiological et al., 1989), hallucinatory or delusion-like
studies in a manner that holds constant shared experiences (Tiens & Anthony, 1990), and
aspects of local neighborhood environment in obsessive-compulsive behavior (Crum & An-
order to test hypotheses about how personal and thony, 1993).
individual characteristics might account for (ii) Whether failing to achieve social expec-
excess risk of mental and behavioral distur- tations for education and schooling increase the
bances. The opportunity to use the case±control risk of developing DSM-III alcohol dependence
study design in this context emerges from a or alcohol abuse in adulthood (Crum, Bucholz,
feature of the multistage area probability Helzer, & Anthony, 1992), or the risk of
sampling plans that are used to draw these developing major depression in middle age or
study samples. That is, these plans first sample later life (Gallo, Royall, & Anthony, 1993).
from lists of primary sampling units (PSUs) (iii) Whether jobs with high levels of physical
which sometimes are as large as states or large or psychological demands and low levels of
metropolitan areas. From within the PSUs, there personal control and autonomy might increase
is another stage of probability sampling from risk of drug dependence in adulthood (Munta-
blocks, block groups, census tracts, or neighbor- ner, Anthony, Crum, & Eaton, 1995).
hoods within which there are multiple house- Even the data from a cross-sectional survey
holds or dwelling units; these ªneighborhoodº- can be organized within the framework of a
level aggregations then are sampled. From case±control study and used to investigate
within the sampled ªneighborhoodsº there is questions about causation if an investigator
an additional stage of probability sampling of will take care to gather the data carefully and
listed households or dwelling units, and then analyze the results with attention to possible
from within the households, there is a listing of distorting influences. For example, one of the
all eligible study participants, and a random most informative recent studies on the issue of
sample of these is taken in order to designate a social causation of mental disorders was com-
participant for the study. Once sampling and pleted, in essence, as a cross-sectional study, but
recruitment has occurred, the study's assessment with case±control analyses of the resulting study
procedures are undertaken, either cross-section- data. The hypotheses to be tested in this study
ally or prospectively, and when mental disorders have long occupied the attention of epidemiol-
are under study, it is possible to identify those ogists, who were able to notice, even in mental
who have become cases as well as those who have hospital statistics, that individuals with mental
not. Followed prospectively over time, and disorders often seemed more socioeconomically
reassessed, those who have not become cases disadvantaged than one might expect (e.g., see
at the time of the baseline assessment are at risk Faris & Dunham, 1939). A challenging question
of becoming incident cases. has been whether it is the disadvantaged social
conditions that increase the risk of mental use disorders was higher than expected for the
disorders or whether it is more that the mental socially disadvantaged when compared to
disorders cause individuals to be held back or socially advantaged persons. Case±control ana-
even to lose social status. For example, lifelong lyses based on the multiple logistic regression
social disadvantage would tend to hold people model were completed in order to adjust for
back from acquiring prestigious social status other suspected distorting influences such as
(e.g., as reflected in years of schooling, ad- marital status, but the results from such analyses
vanced degrees, and educational attainment in did not alter these inferences from the study
general). Accordingly, any socially disadvan- (Dohrenwend et al., 1992). This important
taged person who managed to achieve high investigation serves as a good illustration of
social status such as a good education might be how a cross-sectional epidemiological study can
an especially healthy and adaptive person, with do more than estimate how many people are
life chances relatively unencumbered by mental affected, and where within the population the
disorders. Contrariwise, any socially advan- affected cases are more likely to be found. With
taged person who failed to achieve high social careful reasoning, assessment, and analyses, this
status might more likely be one whose life study shed new light on an important enduring
chances had been encumbered by mental dis- issue about the causes of mental disorders, and
orders. Evaluated at each point along a gradient identified some important new issues that can be
of social status (e.g., educational attainment), probed more thoroughly in future prospective
social causation might result in higher risk of and longitudinal studies.
mental disorders among persons with lifelong An often overlooked feature of the case±
social disadvantage due to discrimination based control study design is its capacity to make
on race or ethnicity when compared to persons efficient and rapid use of study resources. In
without such disadvantage. Social selection concrete terms, many prospective studies of
might result in higher risk of mental disorders mental disorders have involved samples of
among persons with lifelong social advantage literally thousands of participants. Upon follow
when compared to persons without such dis- up, no more than a small fraction of these
advantage (Dohrenwend et al., 1992). participants has developed into an incident case
Presenting this analysis of the selection± of any specific mental disorder. In the resulting
causation issue, Dohrenwend et al. (1992) analyses of all the study data, there are hundreds
studied Jews living in Israel, cross-classifying of noncase control participants for every
them in relation to their membership in groups incident case of mental disorder. This can
whose African family heritage, physical appear- represent an unnecessary and inefficient alloca-
ance, and ethnicity might place them at a lifelong tion of study resources in that statistical power
social disadvantage. In addition to making in case±control hypothesis testing reaches near-
standardized assessments of their lifetime his- maximum levels once the ratio of noncases to
tories of mental disorders, the research team cases is 10:1 (Schlesselman, 1982).
evaluated each study participant's social status Rather than computerizing and analyzing the
in relation to educational attainment, and also study data on the thousands of participants, it
measured other suspected influences on mental would be justifiable and efficient to apply
life and behavior (e.g., age, sex, marital status). case±control reasoning, namely to identify the
In a careful analysis of occurrence of different incident cases plus 10 noncases for comparison
types of mental disorders in groups cross- with each incident case, and to computerize and
classified by disadvantage attributed to ethnicity analyze the study data on each set of 11
and socioeconomic status, these investigators participants. If useful, the noncases could be
found patterns of association consistent with a matched to the cases on possible distorting
more prominent influence of social selection in variables such as age, sex, or neighborhood, in
relation to disorders such as schizophrenia. order to hold these characteristics constant and
However, the evidence was consistent with a focus attention on suspected causal factors at
more prominent influence of social causation in the personal or behavioral level.
relation to disorders such as the substance use The utility of this form of ªnestedº case±
disorders. That is, the evidence on schizophrenia control analysis becomes especially clear in
and related disorders indicated social selection targeted research when the hypotheses involve
mechanisms at work: socially disadvantaged laboratory work for genetic studies, biomarkers,
persons with high educational attainment actu- or other bioassays, or when each participant's
ally were less likely to have developed schizo- record includes data that must be reviewed in
phrenia than socially advantaged persons with detail and coded. For example, in large-sample
high educational attainment. In contrast, all epidemiological research, it has become quite
along the gradient of educational attainment, common to ask each of the thousands of
the estimated risk of having developed substance participants for permission to draw a blood
sample or to take a buccal swab sample of tissue, ques that can bring distorting influences into
which can be frozen and archived, and from balance, so that we might gain a clearer view of
which sufficient DNA can be extracted to test for what accounts for some individuals becoming
homozygosity or heterozygosity with respect to cases while other individuals are spared.
specific genes or genetic polymorphisms.
Although less common, there also are epide-
miological studies with large samples in which 1.12.3.4 Rubric 4: How? A Question of
videotapes of interviews or family interaction Mechanisms
patterns are made and archived, in an effort to
characterize facial expressions of each partici- Epidemiologists turn to the wishy-washy
pant, or to evaluate dynamic interactional concept of a risk factor whenever there is a
processes such as coercive interactions between constraint on our understanding about the
family members. Along the lines of case±control causes and causal mechanisms that influence the
reasoning, a case±control study can be nested risk of ill-health or disease. For example, on
within these large-sample studies. When cases occasion, the available evidence highlights
from these studies are compared with noncases, locations in space or time, or within subgroups
it is possible to obtain efficient and unbiased of populations, where cases are more likely to be
study estimates by drawing case material from found. Depending upon the focus on prevalence
the stored archives (e.g., the frozen blood or incidence, the observed associations will be
sample, or the archived videotape), along with described in terms of prevalence or incidence
material on 3±10 noncases for each case, and to correlates. With these circumstances, nothing
conduct the detailed and intensive assays only on more than a correlation is implied; causation
this subset of the thousands of participants. In clearly is not established.
studies of bioassays or videotape coding of facial As this evidence is worked up, it sometimes
expression or family interaction, this might becomes possible to point toward character-
mean no more than 100±500 assays, vs. the istics, conditions, or processes that seem to have
thousands that otherwise would be required in some influence on the risk of becoming a case,
order to obtain the assay data on all the but uncertainty remains. There is an unwilling-
participants. The ªnestedº case±control design ness to finger a specific cause or causal
and associated statistical issues have been mechanism, but the accumulated evidence
described by Checkoway and Demers (1994). implies an association that has some causal
As implied throughout this section, we have significance, at least in theory. Under these
concentrated on the epidemiological case± circumstances of still limited understanding,
control study design because its advantages epidemiologists would like to say that a cause or
for etiological research are often overlooked by a causal factor has been identified, but instead
investigators whose own graduate research they will pull the punch and say that they have
training has led them to focus on either cross- identified a ªrisk factor.º
sectional surveys, prospective and longitudinal The late lamented Abraham Lilienfeld, who
research, or experimental design. Nonetheless, served at Johns Hopkins as Professor and Chair
as shown in examples of cross-sectional survey of Epidemiology for many years, and later as
research, what distinguishes an epidemiological Professor and Chair Pro Tem of the Mental
investigation that answers questions about Hygiene Department, introduced one of the
causation is not to be found in the investigator's present authors to this idea that the term ªrisk
choice of a specific design, but rather in the factorº reflects a limited understanding of
combination of research design with numerical causation and causal mechanisms. When asked
methods used to analyze study data and to about the origins of the term, his memory led
interpret the resulting evidence. In an investiga- him back to the 1950s and the Framingham
tion oriented toward the first two rubrics of Heart Study team's original observation that
epidemiologyÐquantity and locationÐthere is the risk of heart disease was found to increase
no need for detailed attention to the issue of with increasing age as that study's participants
whether the study subgroups, or the cases and were followed forward in time. At the time, he
noncases, might be balanced with respect to said, the investigators did not wish to claim that
potentially distorting influences. There is no age caused heart disease, as if heart disease were
reason to master or apply techniques of an inevitable consequence of growing old and
randomization, stratification, matching, exclu- there was nothing to do about it. At the same
sion, or statistical adjustment that can be used time, they inferred that increasing age was an
to bring these influences into balance. What important marker of age-related causal char-
characterizes epidemiological research on the acteristics, processes, or events that might be
question of causation is attention to this issue of altered in order to reduce the risk of heart
balance, and to the appropriate use of techni- disease, and they did not wish to throw away the
idea that some modifiable aspect of the aging even years after exposure to combat-related
process might become an appropriate target for trauma. With respect to dependence upon
successful intervention and prevention. In this various drugs, there are measurable induction
respect, the term risk factor represents a periods from the initial ªexposure opportunityº
felicitous choice of words because, by etymol- until the first use of a drug, for instance, as
ogy, a ªfactorº can be taken to represent a force measured in terms of the first time a youth has a
that might turn out to make a difference: it is real opportunity to smoke a marijuana cigarette
possible that it has causal significance, either as until the very first smoking experience (An-
an independent cause, a contributing cause or thony & Helzer, 1995; Van Etten, Neumark, &
cofactor that works conjointly with other Anthony, 1997). Afterwards, there is a measur-
causes, or as an inert marker that runs along able induction period from the time of first drug
with some other important causal factor in a use until the appearance of the initial drug
complex causal chain. problem (e.g., see Anthony & Petronis, 1995) or
For present purposes, the origins and etymol- until the appearance of a fully developed clinical
ogy of risk factor are less important than the syndrome of drug dependence.
array of distinctions to be drawn between Within the set of ªincidence correlatesº we
prevalence correlates and incidence correlates have ªrisk factorsº and we have ªcausesº and
on the one hand, and between risk factor and ªcausal mechanisms.º The distinction between
ªcauseº or ªcausal mechanismº on the other. ªrisk factorº and ªcauseº or ªcausal mechan-
The distinction between prevalence correlate ismº refers to an investigator's judgment about
and incidence correlate refers to variation in the whether the available evidence is sufficient to
epidemiological indicator of disease frequency warrant to say more than ªit seems like this
or occurrence. If the observed association might be making a difference in who becomes a
involves something that is associated with being case and who does not.º When an investigator is
a case or having become a case, then it involves a willing to say no more than this, then the term
prevalence correlate. If the observed association ªrisk factorº is warranted. When the evidence is
involves something that is associated with sufficient to allow investigators to make a causal
becoming a case, then it involves an incidence inference, to point a finger at a specific
correlate. Some prevalence correlates might also characteristic, condition, event, or process,
prove to be incidence correlates, but many and to name it as a ªcause,º then there is no
prevalence correlates are neither risk factors nor need to appeal to the wishy-washy concept of a
incidence correlates. Rather, they are conse- ªrisk factorº; they might as well call it a ªcauseº
quences of having become a case, or they are or a ªcausal factor.º When they have marshaled
associated with the duration of remaining a case. suitable evidence to allow them to point out
For example, receiving clinical services from a specific sequences or linkages of states and
mental health specialist is associated with being a processes that influence who becomes and
case of a mental disorder: active cases are more remains a case and who does not, then they
likely to receive specialty services than noncases have clarified our understanding of at least some
(Marino et al., 1995). If we are to make sense of aspect of ªcausal mechanism,º which remains
the terms incidence correlate and risk factor then one of the highest and most esteemed goals of the
attention to the issue of temporal sequencing is scientific enterprise of public health work.
required: the risk factor appears first, and Epidemiology's history of conducting em-
becoming a case comes later. pirical investigations that probe causal mechan-
Within epidemiology, the ªincubation peri- isms dates back at least to the 1840s, when Peter
odº or ªinduction periodº that precedes Ludwig Panum, a Danish pathologist, studied
occurrence of a case serves as a useful heuristic an outbreak of measles on the Faroe Islands of
and reminder of the temporal sequencing the North Atlantic. Though the successive eras
between the risk-promoting characteristic, of bacteriology and virology had not yet begun,
event, or process, and the later occurrence of and no one had any idea that measles was
clinically apparent signs and symptoms. The caused by a virus, Panum recorded the details of
domains of clinical psychology and psychiatry how measles swept through the Faroe Islands,
hold some direct analogies for the incubation recording notes about the spread from person to
period of communicable diseases. For example, person, from place to place, and over time.
with respect to post-traumatic stress disorder Coupled with his close observations and careful
(PTSD), the signs and symptoms of the disorder reasoning, what allowed Panum to shed new
can be observed shortly after exposure to the light on the epidemic spread of measles was the
traumatic event, or the induction period for the fact that this was essentially a ªvirginº popula-
clinical syndrome might last for a long period, tion, in which some 65 years had passed since
as observed among wartime veterans in relation the last recorded measles epidemic and which
to ªdelayed-onsetº PTSD occurring months or therefore had no immunity to speak of. In
contrast to prior observers, who had watched perhaps because no one had a clear under-
measles epidemics where many population standing of what was contaminating the well
members already had acquired immunity from water and how it had become contaminated.
past infection and therefore did not become This aspect of causal mechanism was clarified
cases, Panum was able to see that more than later by one of Snow's colleagues, who learned
70% of a population would contract measles that the cholera epidemic had started soon after
when periods as long as 65 years passed between the death of a local baby from diarrheal disease.
outbreaks. He appreciated that measles was Helped by the residents, he located a cesspool
spread by person-to-person contact, but also less than three feet from the well, into which the
hypothesized a mechanism that now is con- baby's discharges had been thrown. Upon
sidered to be uncommon but not impossible: inspection, the cesspool and well were discov-
namely, measles is spread when noncases come ered to be constructed so poorly as to allow the
into contact with clothing worn by a case cesspool's contents to flow through the well's
(Panum, 1846, translated by Hatcher & Di- faulty brickwork into the water supply. This
mont, 1940). prompted repair of the well, but it was not until
Of course, later in the nineteenth century, the the threat of a new cholera epidemic in 1866 that
scientific contributions of Louis Pasteur and the Broad Street pump and shallow well were
Robert Koch created a bacteriological revolu- finally disabled (Chave, 1958).
tion that helped to clarify the causal mechan- Attempts to identify the more microscopic
isms by which measles and other communicable aspects of the causal mechanism of cholera
diseases might be spread, from person to person started around 1849, when Snow first articu-
or by other means. Even so, many years passed lated his theory of waterborne infection. These
from the time that specific infectious agents efforts included early experiments in which
were identified until it became possible to use rodents were fed fecal matter and other material
antibody tests in order to clarify which from cholera victims. Nonetheless, this early
individuals had come into effective contact ªanimal modelº of cholera failed, and it was not
with an infective agent (sufficient to produce an until 1876 that Koch isolated Cholera vibrio and
antibody response), but had not developed identified it as the specific microscopic causal
manifestations of disease and were clinically agent for cholera. Of course, even after this
inapparent cases. Analogously, Mendel's ad- success, aspects of the causal mechanism eluded
vances in genetics were not widely appreciated Koch, including knowledge of what might
until after the chromatids had been identified as account for some individuals being exposed to
specific mechanisms of genetic inheritance late C. vibrio without ever developing cholera, as
in the nineteenth century; once this aspect of well as the information that oral rehydration
inheritance was illuminated, additional work in therapy is sufficient to prevent many of the
genetics led to increasing advances (McKusick, deaths from cholera once it occurs.
1996), but also to efforts at social control as Several of the tools used by early epidemiol-
reflected in the eugenics movement. ogists to distinguish between common source
As described early in this chapter, it was epidemics and those spread by person-to-person
before the bacteriological revolution and later contact can be traced directly back to the
discovery of filterable viruses that John Snow numerical methods of data analysis and careful
and other epidemiologists were able to begin to study of clinical cases that had been taught to
distinguish diseases whose spread was primarily William Farr and others by Pierre Charles
person-to-person, such as smallpox, from those Alexandre Louis. One of these tools involved
emanating from a common source. The proto- plotting the epidemic curve in relation to the day-
typical common source was the infamous Broad to-day and hour-to-hour occurrence of new
Street well and pump in London, which John cases; that is, a frequency distribution of cases by
Snow identified as a source of cholera during the the time of onset. As Farr discovered, diseases
London epidemic of August 1854. Snow learned such as smallpox that are mainly spread by either
that nearly all of the deaths from cholera in direct or indirect person-to-person contact have
south London had occurred among residents an epidemic curve that grows slowly toward a
living within a short distance of that shallow peak and then gradually subsides, in accord with
well, and he had linked drinking of the well's equations that could be replicated from epidemic
water to cholera mortality as far away as period to epidemic period (Farr, 1885). In
Hampstead, where a former resident had bottled contrast, outbreaks emanating from a common
water from the pump conveyed to her each day. vehicle or source, without any elaboration via
Although the handle of the pump was removed person-to-person spread, typically rise quickly
in early September, the epidemic had already to a peak and then drop off quickly as well
started to die down, and the pump was back in because there are no secondary cases following
operation soon after the epidemic subsidedÐ exposure to each primary case. The epidemic
curve of eosinophilia-myalgia syndrome fol- groups of people. His observations led to

lowed this kind of trace, consistent with a specification of an epidemiological tool known
common source in the contaminated dietary as the ªsecondary attack rate,º which has been
tryptophan products which were quickly re- extremely useful in epidemiological studies
moved from the market, although not showing aimed at identifying familial and other group-
the more explosive rise and fall of the epidemic wise aggregations of disease, and at investigat-
curve that can be seen when there is common- ing mechanisms that might account for the
vehicle spread of disease after a single exposure observed aggregation.
at one point in time. Within the domain of In operational terms, investigating the famil-
clinical psychology and psychiatry, post-trau- ial secondary attack rate requires an attempt to
matic stress syndromes after a mass disaster such identify the first or ªindexº case that surfaces
as an earthquake often follow this ªcommon within each family, and to identify all of the
sourceº type of epidemic curve, although some remaining susceptible individuals in the family
of the occurrence of these syndromes is delayed in order to determine which of them becomes a
in onset, which tends to extend the peak of the subsequent or ªsecondaryº case (after the index
epidemic curve. case). The timing of the occurrence of the
Epidemiologists soon learned of complica- secondary cases relative to the index case and
tions to be faced when attempting to understand relative to other secondary cases is also studied.
causal mechanisms of disease spread by study- Among those who do not become cases, it is
ing epidemic curves. In some instances, these necessary to attempt a distinction between
complications now can be seen as manifesta- individuals who have a previous history of
tions of immunity and a mechanism of antibody being affected by the condition (e.g., on the
response that had been carried over from basis of past history of symptoms and signs) and
exposure to an infective agent during a previous those who have no apparent history but remain
outbreak or epidemic. In the case of measles, for susceptible to future occurrences. Once these
example, mechanisms of acquired immunity details have been investigated, the secondary
prevent individuals with past exposure from attack rate for each family can be estimated as a
developing measles, and this can lead to a lower conditional probability by dividing the number
peak and more rapid decline of the epidemic of cases who are secondary to the index case in a
curve when the between-outbreak interval was given family by the total number of susceptible
short; the susceptible individuals either were persons in that family, setting aside the
surrounded by persons with acquired immunity experience of the index case and of all persons
who were not exposing them to the virus, or with a past history of the condition. If necessary,
were becoming cases rapidly. As evidence that the time of onset of each case can be used as a
the epidemic had ªburned outº all the suscep- stratifying variable in order to express the
tibles in a community's households, the epi- probability of becoming a case in relation to
demic would end. units of time. Thus, the secondary attack rate is
In other instances, the interpretation of related to the conditional probability of becom-
epidemic curves can be complicated when the ing a case during some specified time span, given
outbreak starts from a common vector, but that an index case has occurred and that there is
subsequently there is person-to-person spread. no prior history of the condition. Especially
The result is often an epidemic curve that rises to when an infection leaves few inapparent cases
a peak but then falls slowly in conjunction with (i.e., all infected persons develop some form of
the elaboration of cases secondary to person-to- clinical expression of the infection), the sec-
person spread. For example, salmonella might ondary attack rate can be especially useful. The
be introduced into an institutional setting via magnitude of a secondary attack rate helps to
food (e.g., bulk eggs or poultry, unpasteurized clarify whether familial aggregation is occurring
milk products), and then spread among patients at all, and also can be used to narrow the search
or inmates via person-to-person contact and for specific causal mechanisms and agents of
sometimes by fomites that have come into disease.
contact with an infected person and convey the As might be surmised, years of accumulated
bacteria to another. experience with various diseases have left
Shortly after the turn of the twentieth epidemiologists in a position to recognize the
century, epidemiologists like Henry Value specific ªsignaturesº of various diseases that are
Chapin developed new tools for studying the disclosed in their epidemic curves and in
mechanisms that account for outbreaks and indicators such as incubation periods and
epidemics of disease. Chapin recognized that it secondary attack rates. These signatures allow
was important to take the temporal sequencing epidemiologists to start narrowing the search
of incident cases into account when studying the for causal agents and mechanisms, even before
spread of diseases within families or other it is possible to complete laboratory studies that
might be used to isolate factors such as bacteria, criticized by Fremming in his report on the
viruses, and contaminants of diet or poisons. Bornholm Island study, evolved into a variety of
Part of the signature consists of the clinical family-genetic research designs which work
features in the form of symptoms and signs that from an identified index case, with a backward
can be observed without aid of laboratory tests, look toward the history of mental disorders in
but in addition to these features observed by deceased forebears and other older relatives,
studying individual patients, the signature and a concurrent or even prospective assess-
includes what can be learned or inferred about ment of mental disorders in surviving relatives,
incubation periods from the time of suspected spouses, and progeny (e.g., see Merikangas,
exposure to the appearance of the first clinical Risch, & Weissman, 1994; Weissman, 1993).
manifestations, the distribution of these incu- Studies of especially informative pedigrees, and
bation periods as summarized for a group of family study designs to detect founder effects, fit
cases, the shape of the epidemic curve, and the into this tradition of family-oriented epidemio-
size of secondary attack rates. As graduate logical research, as do the nonconcurrent and
students of epidemiology learn in their first concurrent prospective designs of twin and
laboratory exercises on outbreaks of foodborne sibling research (Risch & Zhang, 1996).
illnesses, these signatures are sometimes essen- Nonconcurrent twin studies involve recruit-
tial for the discovery of causal mechanisms and ment and assessment of the past history of
can help public health officials decide, for mental disorders in twin pairs, both monozy-
instance, whether an outbreak of gastrointest- gotic and dizygotic, most often reared together
inal illness might be the result of eating egg salad but sometimes separated at birth or in later
vs. tuna salad. When laboratory evidence on years, and reared apart. The resulting study data
specific agents cannot be obtained, as often is can be analyzed within the case±control frame-
the case, the study of these clinical and work, but it is often more sensible to analyze the
epidemiological details often provides the only data as if it had been gathered prospectively,
evidence available for determining what might treating each twin pair as a homogeneous risk set
be causing the outbreak, and what are the observed from conception or birth until the time
indications for reducing or preventing the of follow-up. When the twins have been
occurrence of future cases. separated at birth or later, there are particular
As for the application of these principles of opportunities to tease apart the independent and
epidemiology to disturbances of mental life and combined effects of genes and the shared and
behavior, we have already mentioned PTSD nonshared aspects of their environments and
and drug dependence. In addition, casual experiences (e.g., see Breitner et al., 1993;
mechanisms for outbreaks of somatoform ill- DiLalla, Carey, Gottesman, & Bouchard,
ness and epidemic hysteria can be studied using 1996; Kaprio, Koskenvuo, & Langinvainio,
the concepts and principles of epidemiology 1984; Kendler, Eaves, Walters, Neale, Heath,
(e.g., E. L. Goldberg, 1973). The epidemiolo- & Kessler, 1996; Kendler, Neale, Heath, Kessler,
gical concepts of exposure opportunity, effec- & Eaves, 1994; Langinvainio, Kaprio, Kosken-
tive contact, inapparent cases, incubation vuo, & Lonnqvist, 1984; Lyons, 1996; Lyons et
periods, and secondary attack rates can also al., 1996; Lyons et al., 1995; Scherrer et al., 1996).
be used when studying normal and abnormal There is an increasing number of concurrent
responses to events such as death by suicide of a prospective studies of twin pairs who are
classmate or co-worker, and when studying recruited during fetal life or soon after birth,
possibly neurotoxic and psychotoxic responses and followed prospectively to observe their
to industrial accidents or wartime exposures disturbances of mental life and behavior.
(e.g., the destruction of nerve gases or other Closely related epidemiological research designs
biological weapons during the Persian Gulf for siblings in general have been developed, one
War). In these instances, it is often useful to of the most interesting of which is based on a
adapt the concepts and methods of epidemiol- late twentieth-century upturn in the frequency
ogy without forcing them to apply where the of sequential monogamy and an associated
adaptation makes no sense. For example, in lieu increase in prevalence of half-sibs in the general
of a focus on familial aggregation when population. That is, epidemiologists now have a
estimating secondary attack rates, it is possible greatly increased opportunity to recruit families
to substitute a focus on a classroom, a school's in which there has been a change in spouse or
student body, a military platoon, or the workers partner during the reproductive years. As
in each shift of factory work. described by Olsen et al. (1997):
The application of family study research
methods in epidemiology has occurred in Like traditional square dances, modern life offers a
parallel with developments in other fields of large selection of new partners, only some of whom
inquiry. A ªgenealogical random test method,º remain with one dance partner for more than a
limited period of time; a large number of indivi- epidemiological research on inherited traits. As
duals, therefore, have half-brothers or half-sisters, we seek to discover causal mechanisms that lead
thus providing an opportunity to study the effect toward disease, including mental and behavior-
of a change in partner on reproductive outcome. al disorders, it is possible to think of large-scale
epidemiological studies in which cases of mental
Olsen and colleagues coin the term ªcompu- disorders and samples of noncases are asked to
terized square dance designº for epidemiologi- provide biological samples and allow bioassays
cal research in which computerized population to clarify how their genes might respond to
registries are used to identify couples who specific environmental challenges.
change partners or social conditions within In a direction opposite to that of the
the reproductive time period, and to use the microscopic study of genes responding to
resulting risk sets for research on genetic and environmental challenges, epidemiology is also
environmental contributions to adverse health benefiting from an increased capacity to exam-
outcomes. Despite possible distortions from ine how characteristics of the household,
developmentally important influences such as neighborhood, and community at large can
genomic imprinting, a variety of concurrent have an influence on associations observed at the
prospective designs with twins and half-siblings level of the individual organism. For example,
can be used to clarify genetic and environmental using an adaptation of the generalized estimat-
contributions to the occurrence of disease, and ing equations developed by Scott Zeger and K.
to study the interplay of these influences (Hall, Y. Liang, Katz et al. (1993) have been able to
1992, Plomin, 1990). In their own application of study how individual-level, household-level, and
this research design, Olsen et al. (1997) have village-level characteristics work together to
studied congenital abnormalities, most recently influence rates of diarrheal disease in developing
focusing upon a cohort of men who fathered a countries. The statistical methodology has been
child with a facial cleft defect and who had at refined to allow estimation of the strength of a
least one additional child during the study possibly causal association between the hand-
period. As with the parallel concurrent pro- washing behavior of individuals and their risk of
spective studies of twins reared together and diarrheal disease, and then to tease apart how
apart, these studies of half-sibs can help tease much of that association might be influenced by
apart genetic and environmental aspects of household-level characteristics (e.g., whether
disease risk, with the advantage of prospective there is running water in the household), and
assessments from the fetal period or birth. how much might be influenced by village-level
Notwithstanding their limitations, such as characteristics (e.g., whether the village practice
incomplete control over theoretically important is to fertilize crops with night soil, that is, human
distorting influences such as genomic imprint- fecal matter). Together with related develop-
ing (Hall, 1992), these ªnatural experimentsº ments in hierarchical modeling (e.g., Bryk &
are among our most powerful opportunities for Raudenbush, 1992), these innovations can soon
epidemiological research into the mechanisms become part of epidemiological research designs
underlying the risk of mental and behavioral for inspecting causal mechanisms at various
disturbances. Harnessed with gene-mapping levels of organization: from the nation-state
and biomarking tools of molecular biology down to the community, family, and individual
and genetics, these concurrent and prospective levels, and onward to the level of tissues and cells
research designs open new doors for epidemio- (e.g., see Sampson, Raudenbush, & Earls, 1997).
logical studies of these disorders. These research As described by some observers (e.g., Susser &
designs will help to shift the focus of attention Susser, 1996a, 1996b), the results of these
away from the less fruitful study of the innovations will amount to a change in orienta-
transmission of complex ªinherited traitsº to tion for epidemiology, characterized (we think)
the more productive study of the mechanisms by by an increasing focus upon mechanisms that
which genes mapped on chromosomes are cause human suffering and the mechanisms for
transmitted from parent to offspring, the preventing human suffering, as distinct from
phenotypic effects of these genes, and the ªrisk factorsº that might or might not have
influence of environment on patterns of gene causal significance.
expression during different developmental per-
iods of human life (e.g., see Hulka & Margolin, 1.12.3.5 Rubric 5: What Can Be Done? A
1992; Hyman & Nestler, 1996; Kosofsky, Question of Prevention and
Genova, & Hyman, 1994). Intervention
In addition to these applications of family
study research designs and longitudinal re- The theme of epidemiology in the service of
search designs in the study of causal mechan- prevention and intervention runs through this
isms, there are some new developments in entire chapter and its stories of cholera and
pellagra. Indeed, sustained by both predisposi- recognized by the ancients, but is with us no
tion and training, epidemiologists aspire to more. The virus that causes smallpox was
make a difference in the world by discovering or eradicated from all but research laboratories
devising effective ways to prevent human and eliminated as a scourge of humankind in
disease and suffering. In epidemiology, this 1977. As background, partially effective means
practical goal generally is given a value even of inoculation against smallpox were intro-
greater than those of discovering causes of duced to Great Britain before 1750; Edward
disease, causal mechanisms, or effective treat- Jenner discovered a more effective vaccination
ment of active cases. method in 1796. The specific orthopoxvirus was
The degree of commitment of epidemiologists identified by the middle of the twentieth
to the goal of prevention can sometimes be century, while the vaccine and methods for its
measured in relation to personal risk, suffering cryopreservation required refinement even be-
and even death. For instance, soon after the yond that date. However, the last smallpox case
Spanish±American War, Major Jesse W. Lazear in the United States was recorded in 1949. In
joined Walter Reed's Yellow Fever Board in more tropical and developing countries, small-
Cuba, which first sought to identify the specific pox epidemics continued for an additional two
cause of yellow fever by testing the idea that decades, despite widespread mass vaccination
yellow fever was caused by the hog-cholera with a refined and stable vaccine. Finally,
Bacillus icteroides. Unable to find evidence in epidemiologists working through the World
support of the hypothesis about bacteria or any Health Organization (WHO) devised a two-
other specific causal agent, the Board decided pronged strategy, described by epidemiologist
that it might be better to investigate alternative D. A. Henderson (1980) as follows:
mechanisms by which yellow fever was spread.
They turned to a ªformiteº hypothesis, (1) a 2- to 3-year program of systematic vaccina-
according to which yellow fever was spread tion to reach at least 80 percent of the population
by contact with clothing and bedding soiled by and so diminish transmission, and (2) the devel-
the excrement of yellow fever sufferers, and also opment during this period of a reporting network
to physician Carlos Juan Finlay's theory about and surveillance system that would permit prompt
spread by mosquitoes. As the research team detection of cases so that outbreaks could be
leader responsible for breeding and tending the contained and transmission finally disrupted.
experimental mosquitoes, Lazear came to be
bitten by a mosquito, contracted yellow fever, This global epidemiological surveillance±
and died. Others tested the fomite theory by containment strategy was initiated in 1967.
sleeping on bed sheets and pillows that had been By 1976, WHO had reduced the number of
fouled by the blood and vomit of actively smallpox-affected countries to Ethiopia and
suffering yellow fever victims: none developed Somalia. Mobilizing for a final phase of the
the disease. More than 20 volunteers partici- surveillance±containment method, WHO teams
pated in life-risking experiments on yellow fever contained the last smallpox epidemic in early
in this manner before the Board accumulated 1977. The last known case developed smallpox
sufficient evidence to confirm Finlay's theory, rash on October 26, 1977 in Somalia (D. A.
and to guide Colonel William Crawford Gorgas Henderson, 1980).
toward an effective means of prevention. Complementing its attention to smallpox and
Namely, Gorgas saw that the mosquitoes other diseases of infectious origin, more than 30
generally remained near humans for a nutri- years ago the American Public Health Associa-
tional blood supply, and sought breeding tion recognized discoveries and accomplish-
places, to lay eggs, in nearby standing water. ments in the prevention and control of mental
He organized teams to drain the standing water disorders by publishing a handbook analogous
near homes; the density of mosquitoes near to its compendium on communicable diseases
human habitations became much reduced, and (American Public Health Association [APHA],
the incidence of yellow fever declined as cases 1962, 1994). Entitled Mental disorders: A guide
were prevented. (While yellow fever was being to prevention and control, this APHA handbook
prevented by Gorgas' methods, 30 years passed continues to serve as a remarkable statement of
before Max Theiler identified a specific viral what we already know about how to prevent
cause for yellow fever, from which an effective mental disorders. Now an out-of-print classic, it
yellow fever vaccine was produced.) is required reading for any serious prevention
The commitment of epidemiologists to pre- researcher in the field of alcohol, drug, or
vention can also be seen in recent episodes of the mental disorders, or epidemiologist interested in
history of smallpox, a communicable disease these disorders.
characterized by rash and fever, and with a case The introductory chapters of the APHA
fatality ratio of up to 40%. Smallpox was handbook convey the best ideas from one of the
most challenging prevention scientists of the ample, there are detailed tables of physical
twentieth century, Ernest M. Gruenberg, who agents that can give rise to mental and
has already been mentioned in this chapter for behavioral disturbances, including the intoxica-
his key article The failures of success (Gruen- tion and delirium secondary to preventable
berg, 1977). In the handbook, Gruenberg and exposures to chemicals such as mercury, carbon
his APHA colleagues first focus attention on the disulfide, and cocaine, as well as description of
prevention of a ªsocial breakdown syndrome,º the types of effects and the antidotes, if known.
which is a breakdown of social functioning There are also tables and text covering the
concurrent with anger, hostility and sometimes infections that can produce mental disorders,
social withdrawal, often observed when mental such as St. Louis encephalitis, rubella (measles),
disorders are accompanied by changes in and toxoplasmosis, which remain active as
affected individuals' social relationships after causes of mental disorders to this day. We are
the onset of mental disordersÐand often not aware of any more comprehensive catalog
aggravated when these patients remain institu- of the currently known techniques for prevent-
tionalized for overlong periods of time. ing mental and behavioral disturbances.
Tackling the problem of how to prevent this A more recent attempt to summarize the
type of syndrome, Gruenberg and his colleagues means of prevention of mental and behavioral
sought to address what is still a pressing disturbances was published by the United States
question for primary care practitioners and Institute of Medicine (IOM) in 1994, but this
specialists: namely, how can we reorganize the effort has much less focus upon the more firmly
delivery of health and mental health services so established means of prevention, for instance,
as to reduce the suffering and secondary increasing rubella immunization to reduce
disabilities faced by victims of mental disorders? measles-related neuropsychiatric diseases
Seeking to answer this question, and to reduce (IOM report; Mrazek & Haggerty, 1994).
the secondary adverse consequences of expo- Instead, the focus of the report is upon
sure to the ªtotal institutionº of a mental conditions for which the means of prevention
hospital, Gruenberg and his colleagues devised are still quite uncertain (e.g., schizophrenia,
a population-oriented and patient-centered major depression, conduct disorders).
system of linkages between family, primary The IOM report is particularly valuable for
care provider, mental hospital, and other its description of a cyclical prevention research
specialty sector resources. Focusing upon the process by which emerging evidence on the
social breakdown syndrome, his team used their suspected risk factors and causal mechanisms is
system in an effort to prevent these unintended translated into prevention program evaluations.
adverse consequences of hospitalization. It is To the present authors' knowledge, this is the
important to acknowledge that Gruenberg's most thorough review and summary of evidence
own attempt to evaluate his system of organiz- from recent experimental field trials concerned
ing mental health services was promising but with the prevention or reduced occurrence of
inconclusive (Gruenberg, 1970). Nonetheless, mental and behavioral disturbances or with the
the ideas retain pertinence, especially in the promotion of mental health.
current era of clinical care for mentally One useful illustration in the IOM report
disordered patients, during which concern involves prevention of conduct problems or
about the mental disorders and secondary misbehavior, such as breaking rules about
disabilities of sometimes angry, hostile, and underage tobacco use and drinking. Some
sometimes socially withdrawn homeless persons prevention scientists have approached these
has replaced a previous concern about the problems by means of comprehensive
adverse consequences of excessively prolonged community-based programming efforts, and
institutionalization (Gruenberg, 1977). have conducted evaluations by comparing
After introducing concepts and tasks for communities with and without a broad profile
prevention in relation to the social breakdown of political, school, and family-based interven-
syndrome, the APHA handbook turns to the tions (e.g., Pentz et al., 1989; Perry et al., 1996).
task of cataloging all of the now recognized Others have oriented their prevention efforts to
mental disorders and the techniques to prevent more focused health education initiatives within
these disorders, much as the APHA commu- schools and classrooms, relying more heavily
nicable diseases handbook does for infectious upon what can be accomplished within class-
diseases. With effectively compiled tables and rooms than upon a more broadly based
narrative text, the handbook reviews the causes approach (e.g., Botvin, Baker, Filazzola, &
of specific mental and behavioral disturbances Botvin, 1990; Ellickson & Bell, 1990).
as they were known in 1962, as well as the means A different point of departure can be seen in
of prevention when the causes and causal the work of research teams formed by J. David
mechanisms remained unclear. Thus, for ex- Hawkins and by Sheppard G. Kellam. Orienting
themselves with regard to a long tradition of Mayer, 1994; Kellam et al., 1991; O'Donnell,
clinical observations about how drug users seen Hawkins, Catalano, Abbott, & Day, 1995).
in clinical practice seemed to have an excess of Nonetheless, even if these trials end with
childhood conduct problems, Hawkins and inconclusive results, they clarify a new direction
Kellam also noted Lee Robins' observations for prevention research in relation to mental and
about the continuity of childhood conduct behavioral disturbances. Namely, analogous to
problems in relation to adult antisocial behavior. the communicable disease epidemiologists who
This was exemplified in a classic nonconcurrent sought either to identify specific causes or to
prospective study over a period of more than 25 identify causal mechanisms, we have psycholo-
years, during which childhood rule-breaking gically and psychiatrically oriented epidemiol-
and conduct problems were found to account for ogists who seek to identify specific causes or
adult drug problems (Robins, 1966). Kellam and causal mechanisms for mental and behavioral
his Woodlawn, Chicago research team (Kellam, disturbances. As these investigations yield
Brown, Rubin, & Ensminger, 1983) extended evidence of suspected associations of causal
this line of research in their own prospective significance, the observed findings can be
study of youths, who were first recruited and translated into research questions for prevention
measured at school entry in 1966 and then researchers, who must take the next step of using
followed up at age 16±17 in the mid-1970s. The experimental evaluation methods to organize
Woodlawn research group found that first- field trials that can probe more deeply into the
graders who had been rated by teachers as rule suspected causal significance of the observed
breakers were about three times more likely to associations (Mrazek & Haggerty, 1994).
have become frequent tobacco, alcohol, and Several additional preventive studies con-
marijuana users by their teen years. The long- ducted by teams led by or including epidemiol-
itudinal association was particularly strong ogists deserve mention in this chapter. One of
among boys, less so among girls. the most interesting of these involved an
Both Hawkins and Kellam were able to analysis of data that was gathered over years
perceive that inferences about the causal for the National Institute on Drug Abuse's
significance of these observed associations Monitoring the future survey of high school
depended upon completion of comparative seniors. Literally thousands of these high school
trials. That is, the available evidence was not seniors have been surveyed each year since 1976
sufficient to sort out competing explanations for in order to produce a trace of epidemiological
the observed data. On the one hand, it might be trends in the prevalence of drug use. O'Malley
said that prevention of early misbehavior could and Wagenaar (1991) took advantage of these
reduce the risk of later drug involvement. On the survey data to evaluate the impact of state-level
other hand, it could be said that the apparent restrictions on underage alcohol consumption
predictive linkage from early misbehavior to and the occurrence of fatal car crashes. This
later drug involvement was no more than a evaluation of state-level policy making was
spurious artifact of some unmeasured or possible because over a relatively short span of
unknown causal determinant of both early years the high school senior survey covered
conduct problems and later drug use. The multiple states with different drinking regula-
evidence to unravel this complex research issue tions, some allowing legal alcohol consumption
would remain incomplete without preventive at age 18, and some prohibiting it until age 21.
trials to study the impact of early childhood This is, of course, an important public health
interventions. That is, within the framework of and public policy question, and one that would
a preventive trial, there could be an attempt to be difficult to test using an experimental design
alter early childhood misbehavior. If the early at the state level or at the local level.
intervention proved to be effective, and if there Notwithstanding some difficulties in study
is a causal link between early misbehavior and implementation and interpretation (e.g., relat-
later drug involvement, then the children ing to underage drinkers' capacities to cross
exposed to the intervention program should state lines in order to become legal drinkers), the
be less likely to initiate drug use. authors' analyses provided confirmatory evi-
The trials to test these causal and preventive dence of modest but tangible beneficial effects
hypotheses were initiated in the 1980s, with of state laws to postpone legal drinking until age
recruitment of children as they entered early 21. Exploratory subanalyses indicated that the
elementary school. Early results are promising, beneficial effects might be conveyed by factors
both in the Seattle trial organized by Hawkins' such as reducing the amount of time that
research group and in the Baltimore trial underage drinkers spend in bars and taverns.
organized by Kellam's research group (Haw- Another pair of epidemiological studies
kins, Von Cleve, & Catalano, 1991; Kellam & investigated how handgun regulations might
Anthony, in press; Kellam, Rebok, Ialongo, & be influencing the rates of homicides and
Conclusion 385
suicides in North America, a topic of consider- (Bero & Rennie, 1992; Sheldon & Chalmers,
able public health and political interest. These 1994) Clive Adams in Great Britain serves as first
investigations were made possible by making a editor of a Cochrane Collaborative Review
direct comparison between the homicide and Group concerned with mental health, with a
suicide rates of Seattle, Washington, and focus on therapeutic interventions. The devel-
Vancouver, British Columbia. These two me- opment of a collaborative review group con-
tropolitan areas of the Pacific Northwest are cerned with prevention of alcohol, drug, and
comparable in many respects, but they have mental disorders was the subject of planning
substantially different handgun regulations. In meetings started by C. Hendricks Brown, Pat
Seattle, the handgun regulations are more lax, Mrazek, and James C. Anthony in 1996.
whereas in Vancouver, they are quite restrictive. Publications based on the work on this review
Studying homicide rates, and making compar- group should begin to appear in 1998±2000.
isons via analyses that were able to adjust for There are also some distinctively epidemio-
some of the apparent differences between logical research designs that have been brought
Seattle and Vancouver, the research team found into service for the evaluation of prevention
evidence of substantially lower homicide rates programs, but which have not yet been used in
in Vancouver, and drew the inference that these the domains of psychology and psychiatry. For
lower rates could be attributed to the greater example, Comstock (1994) has described how
restrictions on handguns. Though an important the epidemiologic case±control design has been
epidemiological investigation, the study lacked harnessed to evaluate the effectiveness of new
a capacity to hold constant some of the vaccines.
potentially distorting influences on homicide There are some clear advantages to using
rates, such as variation in the street drug trade in case±control methods to evaluate prevention
each city, Seattle's more prominent contrasts efforts, as well as some unusual challenges that
between wealthy and poor neighborhoods in can block proper inference. Nonetheless, the
close proximity, and the existence of a more case±control study method may be especially
comprehensive social ªsafety netº in Vancou- helpful in understanding variation in response
ver, which might reduce feelings of frustration to preventive or therapeutic efforts. Unless a
and despair, with a resulting impact on program evaluation has been pre-planned for
aggressive behavior (Sloan et al., 1988). measurement of all pertinent response-affecting
The investigation on the possible preventive variables, there might prove to be no alternative
impact of handgun regulations in relation to to case±control methods when we seek to
suicide mortality rates, in general, was negative. account for why some individuals responded
Using the same methodology used in the to the intervention while others did not.
homicide study, the research team compared
Seattle and Vancouver, and found insufficient 1.12.4 CONCLUSION
evidence to support the claim that more
restrictive handgun laws can help reduce suicide Epidemiological research continues to make
death rates. Nonetheless, in exploratory sub- exciting discoveries about the prevention of
group analyses, the research team found some human disease and suffering, not only in
evidence that certain subgroups of the popula- relation to the long-time scourges for epide-
tion might have lower suicide mortality rates miologists such as cholera, for which a new and
due to restrictive handgun legislation. Namely, more effective vaccine has just been developed,
there was a tendency for the suicide rates to be but also in relation to mental and behavioral
lower for Native American young people living disturbances (Mrazek & Haggerty, 1994).
in Vancouver when compared to counterparts Nonetheless, there still remain important areas
in Seattle (Sloan et al., 1990). As noted with for new collaborations between epidemiolo-
respect to the study of homicides, interpretation gists, clinical psychologists, and psychiatrists.
of these comparative data is complicated by Future progress depends upon a narrowing of
some between-city imbalances in possibly the gap between epidemiological psychology
distorting variables, but this takes nothing and psychiatry on one side and psychiatric or
away from an important epidemiological study psychological epidemiology on the other .
of a significant issue for prevention. As described in earlier sections of this
One of the recent innovations that can help in chapter, clinical psychologists and psychiatrists
the process of translating new scientific infor- have already harnessed tools of epidemiology
mation on causal mechanisms into prevention when studying causal hypotheses and program
efforts is the Cochrane Collaboration, which is evaluation issues. The works of Dohrenwend
an international network of individuals and et al. (1992) and Kellam already have been cited
groups who prepare, maintain, and disseminate (Kellam et al., 1983), but there are many other
systematic reviews of the effects of health care clinicians who have worked in this arena. The
cumulative epidemiological studies undertaken American Public Health Association (1994). Control of
by Michael Rutter's research group in Great communicable diseases in man. Washington, DC: Author.
Anthony, J. C., & Aboraya, A. (1992). The epidemiology
Britain serve as an especially important example of selected mental disorders in later life. In J. E. Birren,
of how to build a research program to answer R. B. Sloane, & G. D. Cohen (Eds.), Handbook of mental
questions of central importance in public health and aging (2nd ed., pp. 27±73). Orlando, FL:
mental health (e.g., see Rutter, 1989; Rutter, Academic Press.
Anthony, J. C., Eaton, W. W., & Henderson, A. S. (1995).
Tizard, Yule, Graham, & Whitmore 1976). Psychiatric epidemiology. Epidemiologic Reviews, 17(1),
In the United States, Lloyd Johnston's and 1±8.
Jerrold Bachman's Monitoring the future Anthony, J. C., Folstein, M. F., Romanoski, A. J., et al.
surveys, published each year since the mid- (1985). Comparison of the lay Diagnostic Interview
1970s, serve as an annual reminder of the power Schedule and a standardized psychiatric diagnosis:
Experience in eastern Baltimore. Archives of General
of epidemiological methods in answering ques- Psychiatry, 42, 667±675.
tions such as ªHow many high school seniors Anthony, J. C., & Helzer, J. E. (1995). Epidemiology of
are taking drugs?º The field studies of Bentler, drug dependence. In M. T. Tsuang, M. Tohen, & G. E.
Newcomb, Brook, Muthen, and others have P. Zahner (Eds.), Textbook in psychiatric epidemiology
(pp. 361±406). New York: Wiley-Liss.
drawn heavily upon epidemiological methods Anthony J. C., & Petronis, K. R. (1991). Suspected risk
and strategies while remaining psychological in factors for depression among adults 18±44 years old.
focus (e.g., see Bentler & Stein, 1992; Brook & Epidemiology, 2, 123±132.
Newcomb, 1995; Muthen, 1995, 1996; New- Anthony, J. C., & Petronis, K. R. (1995). Early-onset drug
comb & Bentler, 1988). These investigations use and risk of later drug problems. Drug and Alcohol
Dependency, 40, 9±15.
represent important progress at the interface of Anthony, J. C., Tien, A. Y., & Petronis, K. R. (1989).
epidemiology, psychology, and psychometrics. Epidemiologic evidence on cocaine use and panic
Nonetheless, there still are some areas of attacks. American Journal of Epidemiology, 129,
differences between epidemiology and the 543±549.
clinical sciences of psychology and psychiatry Anthony, J. C., Warner, L. A., & Kessler, R. C. (1994).
Comparative epidemiology of dependence on tobacco,
that can be addressed in greater detail. alcohol, controlled substances, and inhalants: Basic
Epidemiology, originating with the study of a findings from the National Comorbidity Survey. Experi-
discrete categorical event such as death or frank mental and Clinical Psychopharmacology, 2(3), 244±268.
disease, tends to emphasize the study of manifest Bentler, P. M., & Stein, J. A. (1992). Structural equation
models in medical research. Statistical Methods in
indicators of human suffering. In addition, Medical Research, 1(2), 159±181.
epidemiology's strong links to clinical medicine Bero, L., & Rennie, D. (1992). The Cochrane Collabora-
reinforce this tradition. In terms of measure- tion. Preparing, maintaining, and disseminating systema-
ment, this often means a focus on discrete tic reviews of the effects of health care. Journal of the
categories and transitions between categories. American Medical Association, 274(24), 1935±1938.
Bland, R. C. (1988). Psychiatric epidemiology. Canadian
With regard to the study of causal hypotheses, Journal of Psychiatry, 33(7), 618±625.
this emphasis often implies a reluctance to Blum, K., Noble, E. P., Sheridan, P. J., Montgomery, A.,
depend heavily upon statistical modeling when Ritchie, T., Jagadeeswaran, P., Nogami, H., Briggs, A.
basic associations cannot be perceived without H., & Cohn, J. B. (1990). Allelic association of human
the assumptions of these models. From psychol- dopamine D2 receptor gene in alcoholism. Journal of the
American Medical Association, 263(15), 2055±2060.
ogy, we often have the opposite tendencies, with Borges, G., Anthony, J. C., & Garrison, C. Z. (1995).
a much heavier focus upon latent variables, and Methodological issues relevant to epidemiologic investi-
with considerable reliance upon structural gations of suicidal behaviors of adolescents. Epidemio-
equation modeling, which is sometimes so logic Reviews, 17(1), 228±239.
Botvin, G. J., Baker, E., Filazzola, A. D., & Botvin, E. M.
complicated that the basic relationships cannot (1990). A cognitive-behavioral approach to substance
be perceived except from within the framework abuse prevention: one-year follow-up. Addictive Beha-
of these models. As epidemiologists collaborate vior, 15(1), 47±63.
with clinical psychologists and psychiatrists, Breitner, J. C., Gatz, M., Bergem, A. L., Christian, J. C.,
there is a need for greater dialog and truly Mortimer, J. A., McClearn, G. E., Heston, L. L., Welsh,
K. A., Anthony, J. C., Folstein, M. F. et al. (1993). Use
interdisciplinary interaction on important mat- of twin cohorts for research in Alzheimer's disease.
ters such as these. Through dialog and interac- Neurology, 43(2), 261±267.
tion, we can hope for continuing progress under Breitner, J. C., Welsh, K. A., Gau, B. A., McDonald, W.
each of the rubrics of epidemiology as they relate M., Steffens, D. C., Saunders, A. M., Magruder, K. M.,
Helms, M. J., Plassman, B. L., Folstein, M. F., et al.
to the disciplines of clinical psychology and (1995). Alzheimer's disease in the National Academy of
psychiatry. Sciences±National Research Council Registry of Aging
Twin Veterans. III. Detection of cases, longitudinal
results, and observations on twin concordance. Archives
1.12.5 REFERENCES of Neurology, 52(8), 763±771.
Breslow, N. E., & Day, N. E. (1980). Statistical methods in
American Public Health Association (1962). Mental cancer research. Vol. IÐThe analysis of case±control
disorders: A guide to prevention and control. Washington, studies. (IARC Scientific Publications No. 32). Lyon,
DC: Author. France: International Agency for Research on Cancer.
References 387
Breteler, M. M., Claus, J. J., van Duijn, C. M., Launer, L. infirmity in a sample of the Danish population. Occasional
J., & Hofman, A. (1992). Epidemiology of Alzheimer's papers on eugenics, no. 7. London: Cassell.
disease. Epidemiologic Review, 14, 59±82. Frost, W. H. (1927). Epidemiology. Nelson Loose-Leaf
Brook, J. S., & Newcomb, M. D. (1995). Childhood System. Public Health-Preventive Medicine. Vol. 2,
aggression and unconventionality: Impact on later Chap. 7, pp. 163±190. New York: Thomas Nelson. Also
academic achievement, drug use, and workforce involve- available in K. F. Maxcy (ed.) (1941). Papers of Wade
ment. Journal of Genetic Psychology, 156(4), 393±410. Hampton Frost, MD: Contribution to epidemiological
Bryk, A. S., & Raudenbush, S. W. (1992). Hierarchical method (pp. 439±542) New York: The Commonwealth
linear models. Newbury Park, CA: Sage. Fund.
Centers for Disease Control (1981a) Pneumocystis Gallo, J. J., Marino, S., Ford, D., & Anthony, J. C. (1995).
pneumoniaÐLos Angeles. Morbidity and Mortality Filters on the pathway to mental health care, II.
Weekly Report, 30, 250±252. Sociodemographic factors. Psychological Medicine,
Centers for Disease Control (1981b). Kaposi's sarcoma and 25(6), 1149±1160.
Pneumocystis pneumonia among homosexual menÐ Gallo, J. J., Royall, D. R., & Anthony, J. C. (1993). Risk
New York City and California. Morbidity and Mortality factors for the onset of depression in middle age and
Weekly Report, 30, 305±308. later life. Journal of the Society of Psychiatry and
Centers for Disease Control (1981c). Follow-up on Psychiatric Epidemiology. 28, 101±108.
Kaposi's sarcoma and Pneumocystis pneumonia. Mor- Goedert, J. J., Neuland, C. Y., Wallen, W. C., Greene, M.
bidity and Mortality Weekly Report, 30, 409±410. H., Mann, D. L., Murray, C., Strong, D. M., Fraumeni,
Chave, S. P. W. (1958). John Snow, the Broad Street pump J. F., Jr., & Blattner, W. A. (1982). Amyl nitrite may
and after. The Medical Officer, 99, 347±349. alter T lymphocytes in homosexual men. Lancet 1 (8269),
Checkoway, H., & Demers, P. A. (1994). Occupational 412±416.
case±control studies. Epidemiologic Review, 16(1), Goldberg, D. P., & Huxley, P. (1980). Mental illness in the
151±162. community. London: Tavistock.
Comstock, G. W. (1994). Evaluating vaccine effectiveness Goldberg, D., & Huxley, P. (1992). Common mental
and vaccine efficacy by means of case±control studies. disorders: A bio-social model. London: Tavistock/Rout-
Epidemiologic Review, 16(1), 77±89. ledge.
Cooper, B. (1993). Single spies and battalions: The clinical Goldberg, E. L. (1973). Crowd hysteria in a junior high
epidemiology of mental disorders. Psychological Medi- school. Journal of School Health, 43(6), 362±366.
cine, 23(4), 891±907. Goldberger, J. (1914a). The etiology of pellagra: The
Cooper, B., & Morgan, H. G. (1973). Epidemiological significance of certain epidemiological observations with
psychiatry. Springfield, IL: Thomas. respect thereto. Public Health Reports, 29, 1683±1686.
Crum, R. M., & Anthony, J. C. (1993). Cocaine use and Goldberger, J. (1914b). The cause and prevention of
other suspected risk factors for obsessive-compulsive pellagra. Public Health Reports, 29, 2354±2357.
disorder: A prospective study with data from the Goldberger, J. (1964). Goldberger on pellagra. Terris, M.
Epidemiologic Catchment Area surveys. Drug and (ed.). Baton Rouge, LA: Louisiana State University
Alcohol Dependency, 31, 281±295. Press.
Crum, R. M., Bucholz, K. K., Helzer, J. E., & Anthony, J. Goldberger, J., Waring, C. H., & Willets, D. G. (1915). The
C. (1992). The risk of alcohol abuse and dependence in prevention of pellagra. A test of diet among institutional
adulthood: The association with educational level. imates. Public Health Reports, 30(43), 3117±3131.
American Journal of Epidemiology, 135, 989±999. Gordis, L. (1996). Epidemiology. Philadelphia: Saunders.
Deutsch, A. (1944). The history of mental hygiene. In Greenwood, M. (1935). Epidemics and crowd diseases: An
American Psychiatric Association: One hundred years of introduction to the study of epidemiology. New York:
American psychiatry. New York: Columbia University Macmillan.
Press. Gruenberg, E. M. (1970). Mental health services can be
DiLalla, D. L., Carey, G., Gottesman, I. I., & Bouchard, T. organized to prevent chronic disability. Community
J., Jr. (1996). Heritability of MMPI personality indica- Mental Health Journal, 6(6), 431±436.
tors of psychopathology in twins reared apart. Journal of Gruenberg, E. M. (1977). The failures of success. Milbank
Abnormal Psychology, 105(4), 491±499. Mem Fund Q Health Soc. 55, 3±24.
Dohrenwend, B. P., & Dohrenwend, B. S. (1974). Social Hall, J. G. (1992). Genomic imprinting and its clinical
and cultural influences on psychopathology. Annual implications. New England Journal of Medicine, 326(12),
Review of Psychology, 25, 417±452. 827±829.
Dohrenwend, B. P., Levav, I., Shrout, P. E., Schwartz, S., Hawkins, J. D., Von Cleve, E., & Catalano, R. F., Jr.
Naveh, G., Link, B. G., Skodol, A. E., & Stueve, A. (1991). Reducing early childhood aggression: results of a
(1992). Socioeconomic status and psychiatric disorders: primary prevention program. Journal of the American
The causation±selection issue. Science, 255, 946±952. Academy of Child and Adolescent Psychiatry, 30(2),
Durkheim, E. (1897). Le suicide: Etude de sociologie. Paris: 208±217.
F. Alcan. Henderson, A. S., Easteal, S., Jorm, A. F., Mackinnon, A.
Eaton, W. W., Kramer, M., Anthony, J. C. et al. (1989). J., Korten, A. E., Christensen, H., Croft, L., & Jacomb,
The incidence of specific DIS/DSM-III mental disorders: P. A. (1995). Apolipoprotein E allele epsilon 4, dementia,
data from the NIMH Epidemiologic Catchment area and cognitive decline in a population sample. Lancet,
Program. Acta Psychiatrica Scandinavica, 79, 163±178. 346(8987), 1387±1390.
Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in Henderson, D. A. (1980). Diseases transmitted from person
junior high: a multi-site longitudinal test. Science, 247 to person. The eradication of smallpox. In J. M. Last
(4948), 1299±1305. (Ed.), Public health and preventive medicine (11th ed.,
Faris, R. E. L., & Dunham, H. W. (1939). Mental disorders pp. 95±110). New York: Appleton-Century-Crofts.
in urban areas. Chicago: University of Chicago Press. Holst (1852). On the statistics of the insane, blind, deaf and
Farr, W. (1885). Vital statistics: A memorial volume of dumb, and lepers of Norway. (Trans. Massey, A. S. O.).
selections from the reports and writings of William Farr. Royal Statistical Society of London Journal, 15, 250±256.
N. A. Humphreys (Ed.), For the Sanitary Institute of Hosmer, D. W., & Lemeshow, S. (1989). Applied logistic
Great Britain. London: The Sanitary Institute of Great regression. New York: Wiley.
Britain. Hulka, B. S., & Margolin, B. H. (1992). Methodological
Fremming, K. H. (1951). The expectation of mental issues in epidemiologic studies using biologic markers.
American Journal of Epidemiology, 135(2), 200±209. disorders: a pandemic threat. Psychiatric Quarterly,
Hyman, S. E., & Nestler, E. J. (1996). Initiation and 55(2±3), 115±143.
adaptation: a paradigm for understanding psychotropic Kramer, M., Goldstein, H., Israel, R. H., & Johnson, N. A.
drug action. American Journal of Psychiatry, 153(2), (1955). An historical study of the disposition of first
151±162. admissions to a state mental hospital. Experience of the
Jablensky, A. (1995). Schizophrenia: Recent epidemiologic Warren State Hospital during the period 1916±1950.
issues. Epidemiologic Reviews, 17(1), 10±20. Public Health Service Publication No. 445, Public Health
Jarvis, E. (1843a). Statistics of insanity in the United Monograph No. 32. Washington, DC: Government
States. Boston Medical and Surgical Journal, 27, 116±121. Printing Office.
Jarvis, E. (1843b). Statistics of insanity in the United States Langinvainio, H., Kaprio, J., Koskenvuo, M., & Lonnq-
(Part II). Boston Medical and Surgical Journal, 27, vist, J. (1984). Finnish twins reared apart. III: Person-
281±282. ality factors. Acta Genet Med Gemellol (Roma), 22(2),
Jarvis, E. P. (1865±66). Influence of distance from and 259±264.
nearness to an insane hospital on its use by the people. Lemkau, P. Tietze, C., & Cooper, M. (1942). A survey of
American Journal of Insanity, 22. statistical studies on the prevalence and incidence of
Johnson, E. O., van den Bree, M. B., Uhl, G. R., & mental disorder in sample populations. Public Health
Pickens, R. W. (1996). Indicators of genetic and Reports, 58, 1909±1921.
environmental influences in drug abusing individuals. Levav, I., Lima, B. R., Somoza, L. M., Kramer, M., &
Drug and Alcohol Dependency, 41(1), 17±23. Gonzales, R. (1989). Salud mental para todos en
Kaprio, J., Koskenvuo, M., & Langinvainio, H. (1984). America Latina y el Caribe. Bases epidemiologicas para
Finnish twins reared apart. IV: Smoking and drinking la accion. Boletin de la Oficina Sanitaria Panamericana,
habits. A preliminary analysis of the effect of heredity 107, 196±219.
and environment. Acta Genet Med Gemellol (Roma), Levin, M. L. (1950). Discussion of a paper entitled
33(3), 425±433. ªEvaluation of this material.º In Epidemiology of mental
Katz, J., Carey, V. J., Zeger, S. L., et al. (1993). Estimation disorder: papers presented at a round table at the 1949
of design effects and diarrhea clustering within house- Annual Conference of the Milbank Memorial Fund.
holds and villages. American Journal of Epidemiology, November 16±17, 1949, New York, (p. 96). New York:
138(11), 994±1006. Milbank Memorial Fund.
Kellam, S. G., & Anthony, J. C. (in press). Targeting early Lilienfeld, A. M. (1980). Foundations of epidemiology. New
antecedents to prevent tobacco smoking: Findings from York: Oxford University Press.
an epidemiologically-based randomized field trial. Lilienfeld, A. M., & Lilienfeld, D. E. (1979). A century of
Kellam, S. G., Brown, C. H., Rubin, B. R., & Ensminger, case±control studies: Progress? Journal of Chronic
M. E. (1983). Paths leading to teenage psychiatric Disease, 32(1±2), 5±13.
symptoms and substance use: Developmental epidemio- Lilienfeld, A. M., Pasamanick, B., & Rogers, M. (1955).
logic studies in Woodlawn. In S. B. Guze, F. J. Earls, & Relationship between pregnancy experience and the
J. E. Barrett (Eds.), Childhood psychopathology and development of certain neuropsychiatric disorders in
development (pp. 17±51). New York: Raven Press. childhood. American Journal of Public Health, 45,
Kellam, S. G. Rebok, G. W., Ialongo, N., & Mayer, L. S. 637±641.
(1994). The course and malleability of aggressive Lilienfeld, D. E., & Stolley, P. D. (1994). Foundations of
behavior from early first grade into middle school: epidemiology (3rd ed.). New York: Oxford University
results of a developmental epidemiologically-based pre- Press.
ventive trial. Journal of Child Psychology and Psychiatry, Link, B. G., Dohrenwend, B. P., & Skodol, A. E. (1986).
35(2), 259±291. Socio-economic status and schizophrenia: Noisome
Kellam, S. G., Werthamer-Larsson, L., Dolan, L. J., occupational characteristics as a risk factor. American
Brown, C. H., Mayer, L. S., Rebok, G. W., Anthony, J. Sociological Review, 51(2), 242±258.
C., Laudolff, J., & Edelsohn, G. (1991). Developmental Lyons, M. J. (1996). A twin study of self-reported criminal
epidemiologically based preventive trials: baseline mod- behaviour. Ciba Foundation symposium, 194, 61±70.
eling of early target behaviors and depressive symptoms. Lyons, M. J., Nong, L., Eisen, S., Goldberg, J., True, W.,
American Journal of Community Psychology, 19(4), & Tsuang, M. T. (1996). Genetic and environmental
563±584. influences on psychiatric pathology over time. Paper
Kendler, K. S., Eaves, L. J., Walters, E. E., Neale, M. C., presented at the 35th Annual Meeting of the American
Heath, A. C., & Kessler, R. C. (1996). The identification College of Neuropsychopharmacology, San Juan, Puerto
and validation of distinct depressive syndromes in a Rico.
population-based sample of female twins. Archives of Lyons, M. I., True, W. R., Eisen, S. A., Goldberg, J.,
General Psychiatry, 53(5), 391±399. Meyer, J. M., Faraone, S. V., Eaves, L. J., & Tsuang, M.
Kendler, K. S., Neale, M. C., Heath, A. C., Kessler, R. C., T. (1995). Differential heritability of adult and juvenile
& Eaves, L. J. (1994). A twin-family study of alcoholism antisocial traits. Archives of General Psychiatry, 52(11),
in women. American Journal of Psychiatry, 151(5), 906±915.
707±715. Macleod, J. (1978). Davidson's principles and practices of
Kessler, R. C., McGonagle, K. A., Shanyang, Z., Nelson, medicine (12th ed.). Edinburgh, UK: Churchill Living-
C. B., Hughes, M., Eshleman, S., Wittchen, H.-U., & stone.
Kendler, K. S. (1994). Lifetime and 12-month prevalence Marino, S., Gallo, J. I., Ford, D., & Anthony, J. C. (1995).
of DSM-III-R psychiatric disorders in the United States. Filters on the pathway to mental health care, I. Incident
Results from the National Comorbidity Survey. Archives mental disorders. Psychological Medicine, 25(6),
of General Psychiatry, 51, 8±19. 1135±1148.
Kilbourne, E. M. (1992). Eosinophilia±myalgia syndrome: McKusick, V. A. (1996). Book review: Genetics and
Coming to grips with a new illness. Epidemiologic medicine in the United States, 1800±1922 by A. R.
Reviews, 14, 16±36. Rushton. Bulletin of the History of Medicine, 70(4),
Kosofsky, B. E., Genova, L. M., & Hyman, S. E. (1994). 731±733.
Postnatal age defines specificity of immediate early gene Merikangas, K. R., Risch, N. J., Weissman, M. M. (1994).
induction by cocaine in developing rat brain. Journal of Comorbidity and co-transmission of alcoholism, anxiety
Comparative Neurology, 351(1), 27±40. and depression. Psychological Medicine, 24(1), 69±80.
Kramer, M. (1983). The increasing prevalence of mental Monk, M. (1987). Epidemiology of suicide. Epidemiologic
References 389
Reviews, 9, 51±69. Northland: Outcomes of a communitywide alcohol use

Morris, J. N. (1957). Uses of epidemiology. London: prevention program during early adolescence. American
Livingstone. Journal of Public Health, 86(7), 956±965.
Morrison, S. L. (1959). Principles and methods of Pickens, R. W., Svikis, D. S., McGue, M., Lykken, D. T.,
epidemiological research and their application to psy- Heston, L. L., & Clayton, P. J. (1991). Heterogeneity in
chiatric illness. Journal of Mental Science, 105(441), the inheritance of alcoholism: A study of male and
999±1011. female twins. Archives of General Psychiatry, 48(1),
Moscicki, E. K. (1995). Epidemiology of suicidal behavior. 19±28.
Suicide and Life Threatening Behaviour, 25(1), 22±35. Plomin, R. (1990). The role of inheritance in behavior.
Mrazek, P. J., & Haggerty, R. J. (Eds.) (1994). Reducing Science, 248(4952), 183±188.
risks for mental disorders: Frontiers for preventive Regier, D. A., Farmer, M. E., Rae, D. S., Myers, J. K.,
intervention research. Washington, DC: National Acad- Kramer, M., Robins, L. N., George, L. K., Karno, M.,
emy Press. & Locke, B. Z. (1993). One-month prevalence of mental
Muntaner, C., Anthony, J. C., Crum, R., & Eaton, W. W. disorders in the United States and sociodemographic
(1995). Psychosocial dimensions of work and the risk of characteristics: The Epidemiologic Catchment Area
drug dependence among adults. American Journal of study. Acta Psychiatrica Scandinavica 88(1), 35±47.
Epidemiology, 142(2), 183±190. Reid, D. D. (1960). Epidemiological methods in the study of
Murray, C. J. L., & Lopez, A. D., (Eds.) (1996) The global mental disorders. Public Health Paper No. 2. Geneva:
burden of disease. Geneva, Switzerland: World Health World Health Organization.
Organization. Risch, N. J., & Zhang, H. (1996). Mapping quantitative
Muthen, B. O. (1995). Factor analysis of alcohol abuse and trait loci with extreme discordant sib pairs: sampling
dependence symptom items in the 1988 National Health considerations. American Journal of Human Genetics,
Interview Survey. Addiction, 90(5), 637±645. 58(4), 836±843.
Muthen, B. O. (1996). Psychometric evaluation of diag- Robins, L. N. (1966). Deviant children grown up; A
nostic criteria: application to a two-dimensional model sociological and psychiatric study of sociopathic person-
of alcohol abuse and dependence. Drug and Alcohol ality. Baltimore: Williams and Wilkins.
Dependency, 41(2), 101±112. Robins, L. N. (1978). Psychiatric epidemiology. Archives of
National Institute of Allergy and Infectious Diseases General Psychiatry, 35(6), 697±702.
(1995). The relationship between the human immunode- Robins, L. N., & Regier, D. A. (Eds.) (1991). Psychiatric
ficiency virus and the acquired immunodeficiency disorders of America. New York: Free Press.
syndrome [on-line]. Available: http:www.niaid.nih.gov/ Rosanoff, A. J. (1917). Survey of mental disorders: In
publications/hivaids/all.htm. Bethesda, MD: Author. Nassau County, New York, July±Oct., 1916. Psychiatric
Newcomb, M. D., & Bentler, P. M. (1988). The impact of Bulletin, 2(2), 1±73.
family context, deviant attitudes, and emotional distress Rutter, M. (1981). Epidemiological/longitudinal strategies
on adolescent drug use: Longitudinal latent-variable and causal research in child psychiatry. Journal of the
analyses of mothers and their children. Journal of American Academy of Child Psychiatry, 20(3), 513±544.
Research in Personality, 22(2), 154±176. Rutter, M. (1989). Isle of Wight revisited: twenty-five years
Newcomb, M. D., & Felix-Ortiz, M. (1992). Multiple of child psychiatric epidemiology. Journal of the Amer-
protective and risk factors for drug use and abuse: Cross- ican Academy of Child and Adolescent Psychiatry, 28(5),
sectional and prospective findings. J Pers Society 633±653.
Psychology, 63(2), 280±296 . Rutter, M., Tizard, J., Yule, W., Graham, P., & Whitmore,
O'Donnell, J., Hawkins, J. D., Catalano, R. F., Abbott, R. K. (1976). Research report: Isle of Wight Studies,
D., & Day, L. E. (1995). Preventing school failure, drug 1964±1974. Psychological Medicine 6(2), 313±332.
use, and delinquency among low-income children: Long- Sampson, R. J., Raudenbush, S. W., & Earls, F. (1997).
term intervention in elementary schools. American Neighborhoods and violent crime: a multilevel study of
Journal of Orthopsychiatry, 65(1), 87±100. collective efficacy. Science, 277 (5328), 918±924.
Olsen, J., Schmidt, M. M., & Christensen, K. (1997). Scherrer, J. F., Lin, N., Eisen, S. A., Goldberg, J., True, W.
Evaluation of nature±nurture impact on reproductive R., Lyons, M. J., & Tsuang, M. T. (1996). The
health using half-siblings. Epidemiology, 8(1), 6±11. association of antisocial personality symptoms with
O'Malley, P. M., Wagenaar, A. C. (1991). Effects of marijuana abuse/dependence. A monozygotic co-twin
minimum drinking age laws on alcohol use, related control study. Journal of Nervous Mental Disorders,
behaviors and traffic crash involvement among Amer- 184(10), 611±615.
ican youth: 1976±1987. Journal of Studies on Alcohol, Schlesselman, J. (1982). Case-control studies. New York:
52(5), 478±491. Oxford University Press.
Osler, W. (1897). Influence of Louis on American Schwab, J. J., & Schwab-Stone, M. E. (1978). Sociocultural
medicine. Bulletin of the Johns Hopkins Hospital, 8, roots of mental illness: An epidemiologic survey. New
161±164. York: Plenum.
Panum, P. L. (1940). Observations made during the Sheldon, T., & Chalmers, I. (1994). The UK Cochrane
epidemic of measles on the Faroe Islands in the Year Centre and the NHS Centre for reviews and dissemina-
1846. J. A. Doull (Ed.), Trans. A. Hatcher, & J. Dimont. tion: Respective roles within the information systems
New York: Delta Omega Society. strategy of the NHS R & D programme, coordination
Pentz, M. A., Dwyer, J. H., MacKinnon, D. P., Flay, B. R., and principles underlying collaboration. Health Econom-
Hansen, W. B., Wang, E. Y., & Johnson, C. A. (1989). A ics, 3(3), 201±203.
multicommunity trial for primary prevention of adoles- Shepherd, M. (1985). Psychiatric epidemiology and epide-
cent drug abuse. Effects on drug use prevalence. Journal miological psychiatry. American Journal of Public
of the American Medical Association, 261(22), Health, 75(3), 275±276.
3259±3266. Shepherd, M., & Cooper, B. (1964). Epidemiology and
Perry, C. L. (1987). Results of prevention programs with mental disorder: A review. Journal of Neurology,
adolescents. Drug and Alcohol Dependency, 20(1), 13±19. Neurosurgery, and Psychiatry, 27, 277±1283.
Perry, C. L., Williams, C. L., Veblen-Mortenson, S., Sloan, J. H., Kellermann, A. L., Reay, D. T., Ferris, J. A.,
Toomey, T. L., Komro, K. A., Anstine, P. S., Koepsell, T., Rivara, F. P., Rice, C., Gray, L., &
McGovern, P. G., Finnegan, J. R., Forster, J. L., LoGerfo, J. (1988). Handgun regulations, crime, as-
Wagenaar, A. C., & Wolfson, M. (1996). Project saults, and homicide. A tale of two cities. New England
Journal of Medicine, 319(19), 1256±1262. London: Gaskell.

Sloan, J. H., Rivara, F. P., Reay, D. T., Ferris, J. A., & Tien, A. Y., & Anthony, J. C. (1990). Epidemiological
Kellerman, A. L. (1990). Firearm regulations and rates analysis of alcohol and drug use as risk factors for
of suicide: A comparison of two metropolitan areas. New psychotic experiences. Journal of Nervous and Mental
England Journal of Medicine, 322(6), 369±373. Diseases, 178, 473±480.
Snow, J. (1855). On the mode of communication of cholera. Tsuang, M. T., Tohen, M., & Zahner, G. E. P. (Eds.)
London: John Churchill. Reprinted in W. H. Frost (Ed.) (1995). Textbook in psychiatric epidemiology. New York:
(1936). Snow on cholera. New York: Commonwealth Wiley-Liss.
Fund. Tuke, D. H. (Ed.) (1892). A dictionary of psychological
Spitzer, W. O., Haggerty, J. L., Berkson, L., Davis, W., medicine. 2 vol. Reprinted by Arno Press, New York.
Palmer, W., Tamblyn, R., Laprise, R., Faith, J. M., Uhl, G., Blum, K., Noble, E., & Smith, S. (1993).
Elmore, J. G., & Horwitz, R. L. (1995). Continuing
Substance abuse vulnerability and DRD2 receptor genes.
occurrence of eosinophilia myalgia syndrome in Canada.
Trends in Neuroscience 16(3), 83.
British Journal of Rheumatology, 34(3), 246±251.
Van Etten, M. L., Neumark, Y. D., & Anthony, J. C.
Strittmatter, W. J., Saunders, A. M., Schemechel, D.,
Pericak-Vance, M., Enghild, J., Salvesen, G. S., & Roses, (1997). Initial opportunity to use marijuana and the
A. D. (1993). Apolipoprotein E: High-affinity binding to transition to first use: United States, 1979±1994. Drug
beta-amyloid and increased frequency of type 4 allele in and Alcohol Dependence, 49, 1±7.
late-onset familial Alzheimer disease. Proceedings of the Watt, R. (1813). Appendix to treatise on Chincough
National Academy of Sciences USA, 90(5), 1977±1981. (pp. 375±379). As cited in Farr, William (1885). Vital
Susser, M., & Adelstein, A. (1975). An introduction to the statistics: A memorial volume of selections from the
work of William Farr. American Journal of Epidemiol- reports and writings of William Farr. Edited for the
ogy, 101(6), 469±476. Sanitary Institute of Great Britain, by Noel A. Hum-
Susser, M., & Susser, E. (1996a). Choosing a future for phreys. London: The Sanitary Institute of Great britain.
epidemiology: II. From black box to Chinese boxes and Weissman, M. M. (1993). Family genetic studies of panic
eco-epidemiology. American Journal of Public Health, disorder. Journal of Psychiatric Research, 27 (Suppl. 1)
86(5), 674±677. 69±78.
Susser, M., & Susser, E. (1996b). Choosing a future for Wines, F. H. (1888). Report on the defective, dependent, and
epidemiology: I. Eras and paradigms. American Journal delinquent classes of the population of the United States as
of Public Health, 86(5), 668±673. returned at the Tenth Census (June 1, 1880). Washing-
Sydenstricker, E. (1974). The challenge of facts. R. V. ton, DC: Government Printing Office.
Kasius (Ed.). New York: Prodist. Wynder, E. L. (1994). Invited commentary: Studies in
Tansella, M., de Girolamo, G., & Sartorius, N. (1992). mechanism and prevention. Striking a proper balance.
Annotated bibliography of psychiatric epidemiology. American Journal of Epidemiology, 139(6), 547±549.
1.13
Learning Theory
GRAHAM C. L. DAVEY
University of Sussex, UK

1.13.2 BASIC DEFINITIONS, CONCEPTS, AND PROCESSES OF CONDITIONING 393
1.13.2.1 Classical Conditioning 393
1.13.2.1.1 Pavlov's prototypical conditioning procedure 393
1.13.2.1.2 The nature of the conditioned response 393
1.13.2.1.3 Control procedures 393
1.13.2.1.4 Basic phenomena of classical conditioning 394
1.13.2.1.5 Special features of human classical conditioning 396
1.13.2.2 Operant Conditioning 398
1.13.2.2.1 Basic concepts in operant conditioning 398
1.13.2.2.2 Basic phenomena of operant conditioning 399
1.13.2.2.3 Special features of operant conditioning in humans 400
1.13.3 HISTORICAL ASPECTS OF LEARNING THEORY AND CLINICAL PHENOMENA 401
1.13.3.1.1 The ªLittle Albertº study and attempts at its replication 401
1.13.3.1.2 Pavlov and experimental neuroses 402
1.13.3.1.3 Two-factor theory of neuroses 403
1.13.3.1.4 Eysenck's theory of incubation 403
1.13.3.1.5 The origins of behavior therapy 404
1.13.3.2.1 Principles of the experimental analysis of behavior and their application to psychopathology 404
1.13.3.2.2 Operant reinforcement and psychopathology 405
1.13.4 CURRENT APPLICATIONS OF LEARNING THEORY IN CLINICAL AND EXPERIMENTAL
PSYCHOPATHLOGY 406
1.13.4.1.1 Traditional criticisms of classical conditioning models of phobias 406
1.13.4.1.2 Contemporary cognitive models of human classical conditioning 407
1.13.4.1.3 How contemporary conditioning models of phobias account for the traditional criticisms 407
1.13.4.1.4 Further applications of classical conditioning to anxiety-based disorders 410
1.13.4.1.5 Classical conditioning in behavior therapy 410
1.13.4.2.1 Functional analysis 412
1.13.4.2.2 Token economy schemes 413
1.13.4.2.3 Response shaping 414
1.13.4.2.4 Multifaceted behavioral self-control programs 415
1.13.5 SUMMARY 416
1.13.1 INTRODUCTION conditioning in the early part of the twentieth

century, the study and understanding of the
Ever since the first controlled experiments processes of learning have contributed signifi-
were systematically carried out on learning and cantly to all aspects of clinical psychology. The
391
392 Learning Theory
classical conditioning paradigm established by were based on objectively derived principles of

Pavlov very soon led to the investigation of conditioning and were consistent with the kinds
psychopathology in terms of learning proof processes that conditioning theories assumed
cesses, with Pavlov's own studies of experi- were responsible for the generation of anxiety
mental neuroses in animals leading to a and emotion-based disorders. Put in its simplest
conceptualization of many aspects of psycho- form, if anxiety-based disorders were manifes-
pathology not in terms of dysfunction but in tations of inappropriately learned conditioned
terms of the animal's experience of controlled responses, then those conditioned responses
replicable environmental contingencies. This could be eliminated by adopting procedures
process began the demystification of psycho- which would extinguish those responses. This,
pathology, and enabled clinicians to remove as we shall see later, was the rationale for the
much of the stigma that had been associated development of a variety of highly successful
with psychopathologyÐpsychological disor- behavior therapies, including flooding, counter-
ders were not so much the result of dysfunc- conditioning, and systematic desensitization
tional psychological systems, but the result of (see Section 1.13.4.1.5).
learning experiences generated by perfectly Apart from the use of classical conditioning
normal learning mechanisms. procedures in both the explanation and ameli-
Pavlov's work on classical conditioning led oration of psychological disorders, the devel-
rather naturally to the use of that conditioning opment of operant conditioning paradigms
paradigm in the explanation of a variety of offered completely new and different applica-
acquired psychological disorders. The most tions to clinical psychology. While there were
famous of these was the use of the classical clearly some psychological problems whose
conditioning paradigm in the explanation of etiology could be explained by reference to
specific phobias by J. B. Watson and his co- the nature of the consequences of behavior (e.g.,
worker Rayner in the early 1920s. Their study of through conducting a functional analysis of the
the classical conditioning of a specific phobia in contingencies which were maintaining the
eight-month old ªLittle Albertº (Watson & problem), what operant conditioning also
Rayner, 1920) has entered psychological folk- offered was a valuable tool for changing
lore as the prototypical conditioning study of behavior. This has generated a wide range of
acquired fears. It is still quoted in nearly all behavior therapy and behavior modification
clinical psychology textbooks that deal with programs that not only help to maintain
anxiety, even though most texts criticize the psychologically healthy and desirable behaviors
ability of this study to explain many of the (e.g., The token economy; Ayllon & Azrin, 1968),
important features of acquired fears (see Sec- but also enable the therapist to develop new
tions 1.13.3.1.1 and 1.13.4.1.1). Even though it behavior repertoires where none existed before
has had a significant impact on contemporary (e.g., in establishing basic self-help and com-
models of acquired fears (Davey, 1992a), the munication behaviors in individuals with learn-
original Watson and Rayner study is poorly ing disabilities). What is so valuable about the
reported and frequently misdescribed in sec- paradigm offered by operant conditioning is
ondary texts (Harris, 1979). Nevertheless, this that it enables the therapist to examine the
should not underestimate the importance of the functional relationships between problem be-
conditioning paradigm in contributing to the havior and environmental contingencies, and in
understanding of a range of acquired fears, many cases allows the therapist to provide the
including specific phobias, panic disorder and, client with a treatment program that the client
more recently post-traumatic stress disorder can establish and execute on his or her own.
(PTSD). Such behavioral self-control programs have
While the studies of classical conditioning become a valuable addition to many therapeutic
processes were providing useful insights into the programs (e.g., diet control, treatment of
etiology of anxiety-based disorders, it became addictions, etc., see Section 1.13.4.2.4).
clear that if conditioning theory could provide This chapter will provide a structured over-
an explanation of these problems, then they view of the contribution of learning theory to
should also provide principles relevant to the clinical psychology and will begin with a
development of successful therapeutic proce- description and explanation of the basic
dures. This was exactly the thinking of Joseph processes of conditioning. This will be followed
Wolpe and Hans Eysenck in the 1950s. by an assessment of the seminal historical
Disillusionment with the failure of psychody- contributions from learning theorists. The
namic therapies to fit comfortably into emer- chapter will conclude with an overview of the
ging objective and scientific conceptualizations contribution of contemporary conditioning
of psychological processes led to the develop- theory to the etiology and treatment of
ment of behavior therapies. These therapies psychological disorders.
Basic Definitions, Concepts, and Processes of Conditioning 393
1.13.2 BASIC DEFINITIONS, CONCEPTS, conditioning procedure), the CR is often what

AND PROCESSES OF looks like a faithful facsimile of the UCR. In
CONDITIONING Pavlov's study the UCR is salivation and the
learned CR to the CS is also salivation.
1.13.2.1 Classical Conditioning However, the learned CR can often be rather
1.13.2.1.1 Pavlov's prototypical conditioning different from the type of response elicited by
procedure the UCS. For example, in rats an aversive UCS
such as electric shock will elicit a UCR which
In classical conditioning a conditioned sti- consists of heart-rate increases, jumping, and
mulus (CS) is paired in close temporal con- squealing, whereas the CS which is paired with
tiguity with an unconditioned stimulus (UCS). electric shock often results in the acquisition of
After a number of CS-UCS pairings, the CS ªemotionalº anticipatory responses in the
comes to elicit a conditioned response (CR) presence of the CSÐsuch responses include
relevant in some way to the UCS. This process is heart-rate decreases, freezing defecating, etc.
displayed schematically in Figure 1. The UCS is (Black, 1971; Borgealt, Donahoe, & Weinstein,
usually some biologically important event 1972). Some traditional explanations of classi-
which itself evokes an unlearned, reflexive cal conditioning have argued that what occurs
reaction known as the unconditioned response during classical conditioning is a form of ªreflex
(UCR). In Pavlov's prototypical conditioning transferº in which the CS becomes a ªsub-
experiment, a hungry dog was presented with stituteº for the UCS and thus elicits the same
pairings of a bell or metronome (the CS) and a responses as the UCS (cf. Davey, 1989b). This is
bowl of food (the UCS), after a number of clearly not the whole story. The CS does elicit a
pairings of CS and UCS, the dog began to range of responses which are relevant to the
salivate to the CS (the CR). UCS, but they are not necessarily the responses
UCSs used to generate conditioned respond- that are elicited by the UCS. This has important
ing are typically either appetitive or aversive. implications for the acquisition of specific fears
Appetitive UCSs are such things as food or in humans. The dental phobic does not wince
water to a hungry or thirsty animal. Aversive and cry out in pain while sitting in the dentist's
UCSs are stimuli which the animal finds either waiting room; what is elicited by the dentist's
painful or distressing (such as a brief mild waiting room is an anticipatory fear rather than
electric shock or a loud noise). responses that would normally be reactions to
the dentist's drill. What the reader should be
1.13.2.1.2 The nature of the conditioned aware of is that classical conditioning is not
response necessarily the nonconscious, reflexive form
of learning that is portrayed in traditional
In most traditional classical conditioning textbooks. It is a highly cognitive form of
studies (such as Pavlov's traditional salivary associative learning which permits a wide range
of conscious and nonconscious reactions to be
emitted to the CS as a result of learning about
the relationship between the CS and UCS
BELL FOOD (Davey, 1992a; see Sections 1.13.2.1.4 (vi) and
1.13.4.1.2).
UCS 1.13.2.1.3 Control procedures

CS
The important experimental manipulation in
classical conditioning is the paired relationship
between the CS and the UCS. Therefore, in
order to conclude that classical conditioning has
occurred, it is important to be able to determine
CR UCR that any responses which are elicited by the CS
are the result of the CS being paired with the
UCS. Clearly, there are other learning pro-
(SALIVATION) (SALIVATION) cesses, such as habituation and sensitization,
Figure 1 Schematic representation of the typical that could produce spurious behavior changes
classical conditioning procedure. Pairing a in a classical conditioning procedure. For
conditioned stimulus, CS (e.g., a bell), with an example, a study by Grether (1938) first made
unconditioned stimulus, UCS (e.g., food), eventually monkeys fearful by presenting a number of
evokes the conditioned response, CR, to the CS (in powder flashes. Following this, the monkeys
this case salivation). were given a series of presentations of a bell, all
394 Learning Theory
of which elicited reliable fright reactions which long as the subject was immediately aware of
they had not done prior to the powder flashes. the predictive significance of the CS (cf. Davey,
In this example, the powder flash was a UCS 1992a; Dawson & Schell, 1987;). Indeed, if
and the bell a CS, yet a fearful response to the human subjects are pre-experimentally in-
CS had been established without any pairing formed of the predictive relationship between
between CS and UCS. the CS and the UCS, a full-blown CR can be
Because the important manipulation in exhibited on the first presentation of the CS
classical conditioning is the arrangement of before any CS±UCS pairings have been
the CS and UCS in a consistent temporal or experienced (Dawson & Grings, 1968; Deane,
predictive relationship, any classical condition- 1969; Wilson, 1968).
ing experiment should possess controls which
retain all the features of the conditioning (ii) Extinction
procedure except the predictive relationship
If, after conditioning has been acquired, a CS
between CS and UCS. The most appropriate
is subsequently presented alone, the strength of
control procedure is known as the truly random
the CR to that CS subsequently declines over
control (Rescorla, 1967). In this control proce-
trials until the CS no longer elicits a CR. This is
dure, subjects are given a similar number of CS
known as extinction. This process has been used
and UCS presentations to experimental sub-
extensively in the application of conditioning
jects, but CS and UCS are programmed
models to psychopathology, largely in the
independently of each other. Thus, control
development of behavior treatments for emo-
subjects receive exactly the same number of CS
tional disorders (e.g., flooding, systematic
and UCS presentations, but not the predictive
desensitization). These therapies attempt to
relationship between them. This distinction is
ensure that the emotion-eliciting stimulus (the
important particularly in relation to the acquisi-
CS) is not presented in conjunction with an
tion of fearful or anxious responding, because
aversive UCS (such as fear), and thus the
such responding can be acquired through
learned relationship between the CS and trauma
nonassociative processes such as sensitization
is extinguished. There is some doubt about
as demonstrated in the Grether experiment
whether extinction represents the unlearning of
(above). Models of psychopathology based on
previously acquired CS±UCS associations,
classical conditioning emphasize the importance
because presenting a novel stimulus or an
of the learning of an association between the CS
additional single CS±UCS pairing can often
and UCS (e.g., Davey, 1992a, 1997), and it is
fully reinstate a previously extinguished CR
this association that generates many of the
(Pavlov, 1927). This suggests that extinction
features of psychopathological responding (see
may represent either the inhibition of a learned
Section 1.13.4.1).
CR or the learning of new CS±UCS associations
which override the original ones (cf. Davey,
1.13.2.1.4 Basic phenomena of classical
1989c). In either case, extinguished CRs do not
conditioning
have to be totally relearned in order to be
(i) Predictive value of the CS reinstated and their spontaneous recovery may
explain at least some instances of relapse
Traditionally it has been assumed that the
following treatment of emotional disorders by
important feature of classical conditioning
therapies based on extinction principles.
which generated the CR was the simple pairing
of CS and UCS. That is, it was assumed that
(iii) Latent inhibition
the number of pairings of the CS with a
temporally contiguous UCS was a prime When a CS is presented alone on a number of
determinant of the strength of the CR (e.g., occasions prior to being paired with a UCS, it
Kimble, 1961). Nevertheless, while temporal subsequently takes significantly longer to gen-
contiguity is an important contributor to erate a CR to that CS than when no pre-
learning, it is not necessarily the number of exposure has taken place. This is known as
CS±UCS pairings that is important, but the latent inhibition and has been widely demon-
predictive significance of the CS as measured strated in a variety of classical conditioning
by the correlation between the CS and UCS. preparations in both animal and human subjects
When we come to discuss the features of (Lubow, 1973; Siddle & Remington, 1987). This
classical conditioning in humans, it will become feature of classical conditioning is potentially
clear that it is not the number of pairings important in a number of conditioning theories
between CS and UCS that determines either of psychopathology because it predicts that if
the speed of acquisition of the CR or the a previously neutral CS (e.g., a car) is paired
strength of the CR. Reliable conditioning can with an aversive UCS (e.g., a traumatic car
occur after a single pairing of CS and UCS as accident), then whether the individual acquires a
conditioned fear response to cars will be the organism has learnt to associate certain
inversely proportional to the amount of prior contiguous or predictive events together and it is
nonaversive experience they have had with cars. these learned associations which mediate the
This principle, for example, can potentially help CR. However, the theoretical problem is that we
to explain why some people acquire a phobia cannot directly observe what associations have
following pairing of a stimulus or event with a been formed but have to infer them from the
traumatic UCS and some do not (cf. Davey, experimental manipulations that are carried
1989a). out. We can ask very generally what kinds of
things the organism might have learnt during
(iv) Blocking classical conditioning which led it to emit a CR
during the CS. For example, Pavlov's dog may
If a UCS is already reliably predicted by a CS
have learned that the bell (CS) predicts food;
(call it A), then subsequently signaling that UCS
that is, after some pairings of the bell (CS) with
with a compound CS consisting of the original
food (UCS), the bell comes to elicit a memory or
CS, A, plus a new component (call it B), results
internal representation of the food that is to
in little or no learning about the new component
follow, and it is this evoked representation that
B (Kamin 1968, 1969). This is known as
stimulates salivation. Alternatively, the dog
blocking, and it is a robust phenomenon in
may be much less ªcognitiveº in its learning.
animal conditioning (cf. Mackintosh, 1983).
Instead of becoming associated with food, the
Blocking is normally considered to be an
bell may have become associated with the act of
associative phenomenon in that organisms do
salivation which is also associated with food.
not appear to learn about the new component B
Thus, a direct link may have been formed
because the UCS is already reliably signaled by
between centers representing the bell and the
component A (Dickinson & Mackintosh, 1979;
reflex arc which controls salivation. In order to
Rescorla & Wagner, 1975). Although this is an
differentiate between these two possibilities,
important phenomenon for theories of associa-
animal learning theorists have developed in-
tive learning in animals (Pearce & Hall, 1980;
ferential techniques which enable them to
Rescorla & Wagner, 1972), it has rarely been
ascertain exactly what kinds of learned associa-
applied in the context of conditioning models of
tions are acquired during classical conditioning.
psychopathology. This may be because it has
One simple technique is known as postcon-
been difficult to experimentally isolate and
ditioning stimulus revaluation (Dickinson,
demonstrate examples of blocking in human
1980; Rescorla, 1980). This procedure involves
subjects (Davey, 1992a; Davey & Singh, 1988).
attempting to revalue the UCS for the subject,
and normally consists of three stages: (a)
(v) Higher-order conditioning
subjects are given pairings of CS and UCS
Once a CS has been associated with a UCS until a CR is established (b) subjects are then
and is capable of eliciting a reliable CR, that CS given off-the-baseline training with the UCS
can then be used to reinforce other potential alone in which the UCS is revalued (e.g., a food
CSs. For instance, second-order conditioning UCS may be paired with gastric poisoning to
can be demonstrated using the following make it less attractive and less palatable); and
procedure: a CS1 (e.g., a light) is paired with (c) the animal is then given test presentations of
a UCS (e.g., food); then CS2 (e.g., a tone) is the CS. The logic here is that, if the CR is
paired with CS1 (the light). This will usually mediated by a CS±UCS association, then
result in a CR relevant to the original UCS revaluation of the UCS will also affect the
(food) being evoked by CS2, even though CS2 CR because the CR is mediated via the UCS
has never been directly paired with food (e.g., representation. If, however, the CR is mediated
Rescorla, 1980; Rizley & Rescorla, 1972). This by a more reflexive association between the CS
phenomenon also has potential importance for and the UCR reflex, then the CR will not be
conditioning models of psychopathology be- affected by changes in the evaluation of the
cause it implies that emotional reactions can be UCS. Most studies which have used this
acquired through higher-order conditioning in technique have demonstrated that first-order
which the potentially phobic CS has never been classical conditioning (both appetitive and
paired directly with a traumatic UCS. aversive) appears to be mediated by CS±UCS
associations (cf. Davey, 1989c; Dickinson, 1980;
Rescorla, 1980) and not by reflexive associa-
(vi) What is learnt during classical
tions formed between the CS and the response
conditioning?
to the UCS. These findings have a number
Although we know that pairing a CS with of important implications for our conceptions
a UCS will generate a CR to the CS, we cannot of the classical conditioning process, and for
easily explain how this happens. Most probably the application of classical conditioning to
396 Learning Theory
psychopathological phenomena. First, it im- correct CS±UCS relationship in postexperimen-

plies that classical conditioning is not a simple, tal interviews exhibit differential CRs (Baer &
mechanistic or reflexive form of learning. Fuhrer, 1968, 1970); when awareness of con-
Instead, it involves (a) the learning of associa- tingencies is measured on a trial-by-trial basis,
tions between contiguous and predictive events, differential conditioning appears only after the
and (b) mediation of the CR by representations appearance of contingency awareness (Dawson
of the UCS and the knowledge of the UCS & Biferno, 1973; Dawson, Schell, & Tweddle-
contained in that representation. Thus, classical Banis, 1986), and subjects regularly fail to
conditioning is a complex cognitive process exhibit differential conditioning in studies
which involves the formation of representations which deliberately attempt to ªmaskº the
of events as well as the establishment of relationship between CS and UCS by employing
associations. Second, since CRs generally distracter tasks (Dawson, 1973; Dawson, Cat-
appear to be mediated by information about ania, Schell, & Grings, 1979). These findings
the UCS contained in a UCS representation, have led some theorists to suggest that the
then the nature or strength of the CR can be classical conditioning of autonomic responses
affected by changes in the information con- (such as those concerned with emotional
tained in the UCS representation. This has responding) is only possible when individuals
extremely important implications for condition- are consciously aware of the CS±UCS relation-
ing models of emotional disorders, and has been ship, and that this can only occur as a result of
a central feature of contemporary conditioning strategic processing of the contingencies (e.g.,
models of phobias (Davey, 1992a, 1997; see Dawson & Schell, 1987; Dawson, Catania,
Sections 1.13.4.1.2 and 1.13.4.1.3). Schell, & Grings, 1979). However, there are
other forms of human classical conditioning
that appear to occur in the absence of awareness
1.13.2.1.5 Special features of human classical of the CS±UCS contingency. There are (a) the
conditioning evaluative conditioning procedure, where a
(i) Similarities between animal and human subjectively neutral stimulus (CS) is paired with
conditioning a liked or disliked stimulus (UCS) which results
in the CS acquiring positive or negative valence
Davey (1992a) has argued that while there are depending on the valency of the UCS (Baeyens,
some important differences in classical con- Eelen, Van den Bergh, & Crombez, 1989, 1990),
ditioning between human and nonhuman and (b) human aversive conditioning studies in
animals (see below), the basic conditioning which the CS is a picture of a fear-relevant
phenomena tend to be common to both. For stimulus (e.g., a snake) which is presented
example, human subjects exhibit blocking subliminally (Esteves, Dimberg, Parra, & OÈh-
(Dickinson, Shanks, & Evenden, 1984) and man, 1994; OÈhman, 1993). Nevertheless, there is
latent inhibition (Siddle & Remington, 1987; still much theoretical argument about whether
Siddle, Remington, & Churchill, 1985). Higher- these latter two paradigms represent condition-
order conditioning can be demonstrated in ing without awareness (Davey, 1994, 1995), and
humans (Davey & Arulampalam, 1981, 1982; a definitive answer to the question of whether
Davey & McKenna, 1983), and CR strength in conscious processing of contingencies is neces-
humans can be shown to be a function of the sary for classical conditioning in humans is still
predictive significance of the CS as measured by awaited.
the correlation between the CS and UCS (Alloy
& Tabachnik, 1984; Prokasy & Kumpfer, 1969,
Prokasy & Williams, 1979). In terms of the (iii) Re-evaluation of the UCS
associations that are learned during classical Studies using the postconditioning stimulus
conditioning, human subjects also appear to reevaluation procedure (see Section 1.13.2.1.4
learn to associate CS and UCS so that the CR is (vi)) have shown that by independently manip-
mediated by the subject's internal representa- ulating the animal's evaluation of the UCS, the
tion of the UCS (Davey & McKenna, 1983; strength or nature of the CR can also be
White & Davey, 1989). changed. This implies that there is a nonasso-
ciative process that can affect the strength of the
CR which is independent of the strength of the
(ii) Conscious awareness of contingencies
association between the CS and UCS. For
A large number of studies have suggested that example, in aversive conditioning, if the ani-
human subjects only exhibit a differential CR mal's evaluation of the UCS is changed so that it
when they are able to verbalize the CS±UCS now perceives the UCS as being less aversive
contingency (see Dawson & Schell, 1987 for a than it originally was, then the next presentation
review). Only subjects who can verbalize the of the CS will evoke a significantly weaker CR.
Davey (1989c, 1992a) has argued that the CR (Davey & Matchett, 1996; Russell & Davey,
process of UCS reevaluation is significantly 1991).
more important in modulating the strength of (d) Cognitive rehearsal of the UCS. It is clear
the CR in humans than it is in nonhuman that individuals who suffer anxiety disorders
animals, and that because humans are social have a tendency to focus on and rehearse the
animals that have developed sophisticated possible aversive outcomes of phobic encoun-
communication skills, there will be many ways ters (Marks, 1987), and this ruminative ten-
in which experiences and communicated in- dency may act to inflate their aversive
formation can alter an individual's perception evaluation of the potential aversive outcome
and evaluation of a UCS. Thus, because learnt (UCS). A laboratory conditioning study by
CRs are mediated via a representation of the Davey and Matchett (1994) showed this to be
UCS, then arguably the most important con- the case, but only in subjects who were already
tributor to the strength of a CR in human anxious. When asked to experimentally re-
classical conditioning is not necessarily the hearse the UCS after conditioning had been
strength of the association between CS and completed, subsequent presentations of the CS
UCS, but how the individual perceives and elicited a greater magnitude fear CR than had
evaluates the UCS. This is critically important occurred prior to rehearsal, but this effect was
when it comes to considering conditioning found only in subjects with high levels of trait
models of psychopathology, and will be dis- anxiety or who had undergone a procedure
cussed more fully in Section 1.13.4.1.3. which induced an acute anxious state. Davey
However, it is worth listing the kinds of and Hatchett argued that this increase in the
processes that can contribute to changes in strength of the CR following rehearsal of the
evaluation of the UCS in human subjects. UCS in anxious subjects was the result of
(a) Experiences with the UCS alone. Some rehearsal inflating the aversive evaluation of
postconditioning experiences with the UCS in the UCS in these subjects.
the absence of the CS can lead the individual to (e) Coping strategies which neutralize the
revalue the UCS. For example, an individual UCS. Many individuals who have aversive-
may reassess a UCS more favorably if they conditioning experiences during their daily lives
experience a number of UCS-alone trials which (e.g., traumatic car accidents, being bitten by a
allow their fear to habituate (Davey & McKen- dog, painful or traumatic dental experiences)
na, 1983). Similarly, the perceived aversiveness subsequently fail to develop a learned anxiety or
of the UCS may be inflated by experiences with fear reaction to these stimuli. One reason for
a similar UCS of greater intensity (e.g., White & this failure may be the ability of some indivi-
Davey, 1989). Both of these processes will have duals to devalue or neutralize the trauma
a subsequent effect on the strength of the CR immediately following the experience, and they
when the CS is next presented. may do this by adopting appraisal strategies
(b) Socially/verbally transmitted information which allow them to effectively devalue the
about the UCS. In a laboratory conditioning stressful meaning of the trauma. In a recent
experiment, subjects can simply be told that on study Davey, McDonald et al. (1997) identified
future presentations the UCS will be more or seven factorially independent reappraisal stra-
less intense than before. If the subject believes tegies all of which contribute to trauma or UCS
this information, then the evaluation of the devaluation. These are downward comparison
UCS is changed, and this affects the strength of (e.g., ªother people are worse off than meº)
the CR to subsequent CS presentations (Davey (Wills, 1981), positive reappraisal (e.g., ªin
& McKenna, 1983). every problem there is something goodº) (Da-
(c) Interpretation of interoceptive cues. vey, 1993), cognitive disengagement (e.g., ªthe
Many anxious people attend to their own bodily problems involved in this situation simply
sensations and use these stimuli as a means of aren't important enough to get upset aboutº),
assessing the aversive nature of potentially optimism (e.g., ªeverything will work itself out
threatening consequences (cf. Davey, 1988; in the endº) (Scheier & Carver, 1992), faith in
Parkinson, 1985). As a result, the individual's social support (e.g., ªI have others who can help
reaction to either the CS or UCS can act as an me through thisº), denial (e.g., ªI refuse to
important source of information for evaluating believe this is happeningº) (Breznitz, 1983), and
the UCS. For example, if they believe they are life perspective (e.g., ªI can put up with these
emitting a strong fear response to a CS (even problems as long as everything else in my life is
though this may not be the case physiologi- okayº). Davey et al. (1997) found that use of
cally), then they will often attribute this to being these strategies (except for denial) was posi-
fearful of the UCS, and this inflation of the tively correlated with measures of psychological
aversive evaluation of the UCS in turn does health and inversely correlated with a variety of
produce an actual increase in the strength of the measures of psychopathology. In addition,
398 Learning Theory
Davey, Burgess, and Rashes (1995) found that circumstances also shows a significant resis-
both simple phobics and panic disorder patients tance to extinction (Hugdahl & Johnsen, 1989;
differed from normal controls by reporting OÈhman, 1979). A series of experiments by
reduced use of appraisal strategies which deva- Davey (1992b) showed that this tendency for
lue the stressful meaning of a trauma. Such fear-relevant stimuli to show stronger condi-
coping strategies may therefore play an impor- tioning effects than fear-irrelevant stimuli was
tant role in insulating individuals from the probably the result of a pre-experimental
acquisition of phobic responding following expectancy bias. In this study, Davey used a
traumatic conditioning experiences. ªthreatº conditioning procedure (where sub-
jects are warned that they might receive aversive
UCSs following some CSs, but in fact receive
(iv) UCS expectancy biases
none) and found that subjects began the
It was mentioned in Section 1.13.2.1.4 (i) that experiment with a significantly higher expec-
human subjects will emit a fear CR to the first tancy of aversive UCSs following fear-relevant
presentation of a CS if they have previously stimuli than fear-irrelevant stimuli. These
been informed that the CS is to be followed by studies indicate that individuals enter a con-
an aversive UCS. Thus, a UCS ªexpectancyº ditioning episode believing that fear-relevant
can be generated simply through verbal trans- stimuli are more likely to have aversive
mission of the contingencies. Life consists of consequences than fear-irrelevant stimuli. This
regular discussion and transmission of contin- speeds up the learning of associations between
gencies relevant to daily living, so it is not fear-relevant CSs and aversive UCSs, and also
unreasonable to suppose that individuals will makes them more resistant to extinction. There
develop beliefs and expectancies about what will has been considerable debate about how such
happen when they encounter a conditioning expectancy biases are derived, with some
episode. As a result, when they enter a arguing that they have been biologically
conditioning episode, individuals are not tabula determined as a result of evolutionary pressures
rasa but will hold beliefs and expectancies about (e.g., Cook, & Mineka 1990; OÈhman, Dimberg,
what is likely to happen. & OÈst, 1985), and others that they are the result
An example of the associative biases that of culturally transmitted information about the
influence the formation of CS±UCS associa- stimulus (e.g., Davey, 1995; Merkelbach & de
tions can be found in covariation assessment Jong, 1997). This discussion has particular
studies. Studies of covariation have pointed out relevance to the application of conditioning
that assessing whether two stimuli covary models to phobic responding, and we will return
appears to be influenced by both situational to it in Section 1.13.4.1.3.
information (i.e., current information about the
contingency) and prior expectations or beliefs
about the covariation (e.g., Alloy & Tabachnik, 1.13.2.2 Operant Conditioning
1984; Crocker, 1981). There are a variety of
1.13.2.2.1 Basic concepts in operant
circumstances in which the combination of
conditioning
situational information (e.g., the experienced
CS±UCS contingency) and prior expectancies Whereas classical conditioning involves a
(e.g., the belief that a CS is to be followed by a contingency relationship between two environ-
particular kind of UCS) give rise to what is mental stimuli (the CS and UCS), operant
called a covariation bias which generates a conditioning involves a contingency between
distorted perception of the covariationÐusually some aspect of the organism's behavior and
in the direction of the prior expectation (Alloy & some aspect of the environment. Thus, whereas
Tabachnik, 1984). classical conditioning involves stimulus±
Expectancy or covariation biases can be stimulus contingencies, operant conditioning
found quite frequently in human classical involves response±stimulus contingencies. Oper-
conditioning, especially in circumstances where ant conditioning acts to alter the frequency of
subjects will have developed a belief that a the response involved in the contingency
particular type of CS may be followed by a relationship in a predictable way, depending
particular type of UCS (even though that is not on the nature of the consequence of the
necessarily the case). For example, when response. Those consequences which increase
pictures of fear-relevant stimuli (i.e., stimuli the future probability of the response are known
that are potentially dangerous such as a snake or as reinforcers, and those that decrease the future
a gun) are used as CSs in aversive conditioning probability of the response are called punishers.
studies, subjects acquire the CR more rapidly A common example of a reinforcer is food for a
than if the CS were a picture of a fear-irrelevant hungry animal, and a frequently used punisher
stimulus (e.g., a flower). The CR in such in experimental studies of operant conditioning
is mild electric shock (cf. Davey, 1989b). contingencies that are maintaining behaviors is
Reinforcers and punishers can be either positive know as functional analysis, and functional
or negative, depending on the kind of change the analysis is a process that has been regularly
response exerts on the environment. Positive utilized in clinical psychology to discover the
means that the response adds something to the environmental contingencies that might be
situation (e.g., it delivers a food pellet or electric maintaining problematic or dysfunctional
shock), and negative means that the response behavior.
removes or avoids some environmental con-
sequence (e.g., it terminates or avoids an electric
shock). Thus, reinforcer/punisher refers to the 1.13.2.2.2 Basic phenomena of operant
effect of the consequence on the frequency of the conditioning
response, and the adjective positive/negative
refers to the nature of the response consequence. (i) Superstitious reinforcement
This terminology is illustrated in Figure 2. It is unclear what aspect of the relationship
A further term that is used frequently in between response and reinforcer is important
operant conditioning is discriminative stimulus. for the operant conditioning process. It could
When a particular response is reinforced only in be that a causal relationship between response
the presence of a specific stimulus (e.g., a light), and reinforcer is necessary for operant re-
the organism will come to make that response inforcement to occur; alternatively, it could
only in the presence of that stimulus and not merely be temporal contiguity between a
when the stimulus is absent. In this case the light response and a reinforcer that is necessary.
is known as a discriminative stimulus because it Skinner (1948) argued that organisms are
ªsets the occasionº for the organism to respond sensitive to contiguity between response and
and for the response to be reinforced. The reinforcer in such a way that mere accidental
process of learning to respond in the presence of correlation between response and reinforcer
a discriminative stimulus is called discrimination will result in the organism learning about the
learning. relationship and modifying its behavior accord-
In an organism's normal environment many ingly. For example, winning money on a fruit
responses are maintained by reinforcement machine may accidentally coincide with a
contingencies. Analyzing an organism's inter- sequence of behaviors emitted by the player
actions with its environment in order to discover (e.g., pressing buttons in a particular sequence
the nature and frequency of the reinforcement with a particular speed, etc.). This sequence of
REINFORCER PUNISHER
RECEIVING A FOOD RECEIVING AN

POSITIVE PELLET FOR PRESSING ELECTRIC SHOCK FOR
A LEVER PRESSING A LEVER
PRESSING A LEVER PRESSING A LEVER

SERVES TO AVOID OR DELAYS OR PREVENTS
POSITIVE
ESCAPE ELECTRIC THE DELIVERY OF
SHOCK FOOD
Figure 2 Reinforcement and punishment as procedures in operant conditioning. Each cell contains an example
of positive and negative reinforcement and punishment.
400 Learning Theory
behaviors has no causal relationship to winning food, and food delivery is accompanied by a
money, but may be perceived as doing so by the brief tone stimulus, that tone stimulus is likely to
player. Hence the player emits these sequences acquire reinforcing properties. This can be
more frequently, and they are then more likely demonstrated by showing that rats which have
to be accidentally associated with winning in received such training will continue to press the
the future, thus strengthening the ritual. This lever merely to deliver the tone (e.g., Pierrel &
process is known as superstitious reinforcement, Sherman, 1963). Conditioned reinforcement is a
and is a common feature of operant condition- valuable contributor to many behavior mod-
ing. In clinical contexts, superstitious reinforce- ification programs in that it enables clinicians to
ment may be responsible for a variety of develop reinforcers which are convenient to
phenomena, including inappropriate rituals deliver, will reinforce all members of a group,
and the accidental reinforcement of disruptive and which can be exchanged for a variety of
or dysfunctional behaviors. biologically important stimuli. The most well-
known of these procedures is the Token
Economy (see Section 1.13.4.2.2).
(ii) Response shaping
From the basic principles of operant con-
(iv) Schedules of reinforcement
ditioning, it is obvious that a particular behavior
must first occur for some unspecified reason One of the important features of operant
before it can be reinforced. When a behavior is conditioning is that not every instance of a
commonplace in an organism's repertoire the response needs to be reinforced in order to
problem of this initial occurrence is not an increase the frequency of the response. Inter-
important one. However, when one wishes to mittent reinforcement of this kind can be
reinforce a behavior pattern which occurs either programmed on what are known as schedules
very rarely or is particularly complex, the of reinforcement, with responses being rein-
problem of the first occurrence of the behavior forced on the basis of time (e.g., time since the
is a salient one. Instead of waiting indefinitely last reinforcement) or number (e.g., every nth
for the first occurrence of a rare behavior, the response is reinforced). Basic schedules of
way around this is to reinforce successive reinforcement generate characteristic patterns
approximations to the desired behavior. For of behavior which it is not necessary to elaborate
instance, in order to speed up the acquisition of on here (see Davey, 1989b; Ferster & Skinner,
lever-pressing in a rat, approximations to this 1957).
behavior can be successively reinforced. The However, intermittent reinforcement of the
experimenter may first choose to reinforce going kind used in schedules of reinforcement does
to the side of the apparatus where the lever is have one important quality±±it produces robust
situated (a response that is likely to occur quite responding that is significantly more resistant to
frequently). When this is well-established, the extinction than when continuous reinforcement
response requirement is made stricter by is used (cf. Ferster & Skinner, 1957). This is an
reinforcing the animal only when it touches important consideration when behavior modi-
the lever, and so on. This process of response fiers are attempting to develop patterns and
shaping is an important one in behavior repertoires of behavior that will survive beyond
modification programs based on operant con- the therapeutic conditions in which they are
ditioning, because it allows new and complex initially reinforced.
behavior repertoires to be constructed where
none had existed before (e.g., in building up self-
1.13.2.2.3 Special features of operant
help and communication skills in individuals
conditioning in humans
with learning disabilities) (see Section
1.13.4.2.3). While it is clear that human subjects do learn
about the relationship between their behavior
and its consequences in simple operant con-
(iii) Conditioned reinforcement
ditioning procedures (e.g., Alloy & Tabachnik,
Some operant reinforcers are considered to 1984; Dickinson, Shanks, & Evenden, 1984),
have intrinsic and immediate biological impor- the variables that influence human operant
tance (e.g., food to a hungry animal). However, performance appear to be more involved than
effective reinforcers can be established which do those already implicated in the performance of
not have this intrinsic biological value. Condi- nonhuman animals. For example, human
tioned reinforcers are those which acquire their operant performance is often rigid and in-
reinforcing properties by being paired with sensitive to changes in the reinforcement
biologically important stimuli. If, for instance, a contingencies. Some experimenters have en-
hungry rat is trained to press a lever to obtain countered great difficulty in extinguishing a
Historical Aspects of Learning Theory and Clinical Phenomena 401
simple learned response in human subjects Yet while it appeared to constitute a demon-
under experimental conditions (Bijou & Baer, stration of a learned fear, Watson never
1966; Buchwald, 1959). Others have reported attempted to formulate a theory of phobias
that human responding on schedules of based on classical conditioning (cf. Eysenck,
reinforcement frequently entails erratic rates 1979)Ðmainly because at the time there was
often interspersed with long and unpredictable nothing available to him that resembled a
pauses (Davey, 1989b; Lowe, 1979; Weiner, cohesive body of knowledge on classical con-
1969). Lowe (1983) has argued that these ditioning itself. When critics subsequently came
apparently maladaptive aspects of human to analyse conditioning accounts of acquired
operant performance can to a large extent be fears, the Watson±Rayner approach could only
explained by the fact that, unlike nonhuman be judged by evaluating the adequacy of the
animal performance, much human operant procedure, and this±±not surprisingly±±was
performance becomes rule-governed rather nearly always found wanting.
than contingency-governed. That is, when Less well publicized than the Little Albert
faced with any learning situation, human study are the subsequent attempts to replicate it.
subjects will attempt to formulate hypotheses These studies almost invariably failed to
about the relationships between behavior and reproduce the straightforward learning re-
reinforcement. Very often, these initial hypoth- ported by Watson and Rayner and often
eses are wrong, especially in the artificial and reported other curious side effects.
simplistic environment of the operant condi- English (1929) reported attempting to con-
tioning laboratory. Lowe (1983) suggests that dition a fear in a 14-month-old girl. A wooden
ªit is the human subject's capacity to formulate toy duck was used as the CS which was paired
their own descriptions of reinforcement con- with a hammer blow to a large metal bar (UCS).
tingencies and to use these descriptions to Even after 50 pairings, English reported no
formulate rules to govern their behavior which evidence of a CR to the wooden duck. However,
results in human operant behavior being so these negative results might be attributed to a
different from that of lower animalsº (p. 77). weak UCS: English found that the UCS itself
The conclusion, therefore, is that while humans failed to evoke fear in the girl. In another
are clearly able to learn about the relationship childÐwho was reported to be frightened of the
between their behavior and its consequences, noise UCSÐEnglish does report conditioned
the factors which translate this learning into fear to a stuffed black cat.
performance are complex, and frequently In another study, Bregman, a student of
involve processes not obviously observed in Thorndike (1935), paired a variety of objects
nonhuman performance. (wooden shapes and colored clothes) with an
electric bell (UCS). None of the objects used as
CSs became a focus of fear, although the electric
1.13.3 HISTORICAL ASPECTS OF bell UCS was genuinely frightening to the
LEARNING THEORY AND infants used as subjects.
CLINICAL PHENOMENA During these attempts to replicate the
original Watson and Rayner study, Valentine
1.13.3.1 Classical Conditioning (1930) observed that it seemed to be easier to
condition fears to furry or leathery objects
1.13.3.1.1 The ªLittle Albertº study and
rather than more common household objects.
attempts at its replication
English had reported that the child in his
Attempts to explain human psychopathology original studyÐalthough not showing fear to a
in terms of classical conditioning processes date wooden duckÐdid subsequently learn through
back to the ªLittle Albertº study reported by conditioning to fear a pair of patent leather
Watson and Rayner (1920). Watson and boots she had never seen before.
Rayner attempted to condition in 11-month- More recently, writers have revived these
old Albert a fear of his pet white rat. They did attempted replications as evidence against
this by pairing the pet rat (the CS) with a loud simple contiguity-based conditioning accounts
noise produced by striking an iron bar (the of specific fears (e.g., Emmelkamp, 1982;
UCS). After several pairings of CS and UCS, Eysenck, 1979; Marks, 1987). Even the original
Little Albert would begin to cry when the rat Little Albert study has not gone uncriticized.
was introduced into the room (the CR) (see Some reports suggest that Little Albert only
Figure 3). In the subsequent 80 years this study showed fear to the rat when his comforting
has drifted into psychological folklore, being thumb was pulled out of his mouth, while others
quoted in most psychology textbooks (fre- imply that Watson and Rayner never reported a
quently with inaccurate details) as the proto- replication although they must undoubtedly
typical example of a learned fear (Harris, 1979). have attempted one.
402 Learning Theory
EXPECTANCY EVALUATION
• Situational Contingency
Information
• Verbally and Culturally
Transmitted Information
About Contingency
• Emotions Elicited By The CS
OUTCOME COGNITIVE
CS EXPECTANCY REPRESENTATION
OF THE
UCS
UCS REVALUATION
PROCESSES
• Eperience With The UCS Alone

• Socially/Verbally Transmitted EVALUATION
Information About The UCS OF THE
• Interpretation of Interoceptive UCS
Cues
• Cognitive Rehearsal of UCS
• Coping Strategies Which
Neutralize The UCS
CONDITIONED
RESPONSE
Figure 3 A schematic representation of a contemporary model of human classical conditioning (see text for
further explanation) (Phobias: Handbood of theory, research and treatment, by G. C. L. Davey, 1997, Chichester,
UK: Wiley. Copyright 1997 by Wiley. Reprinted with permission).
Nevertheless, despite criticisms of the Watson 1.13.3.1.2 Pavlov and experimental neuroses
and Rayner study, it was a ground-breaking
attempt to apply principles derived from experi- One of the most single important premises of
mental psychology to psychopathology. Many the learning theory approach to psychopathol-
of the failures to replicate this seminal study ogy and therapy is that much of psychopathol-
have themselves been criticized on methodolo- ogy can be considered as resulting from perfectly
gical grounds (e.g., Delprato, 1980), and the normal learning processes: that is, if an organ-
Watson and Rayner study is still the influential ism encounters a specific set of environmental
forerunner of contemporary conditioning mod- contingencies then this will result in the learning
els of fears and phobias (cf. Davey, 1997). of emotional reactions or dysfunctional re-
sponses. Thus, psychopathology was to be by Mowrer (1947). This was based on Mowrer's
explained, not in terms of the dysfunction of two-factor theory of learning, and attempted to
any psychological or physiological process, but combine both classical and operant condition-
in the interaction between perfectly normally ing into a single model. Mowrer hypothesized
functioning learning processes and particular that on encountering pairings between a CS and
environmental contingencies. an aversive UCS, fear or anxiety became
Perhaps the oldest application of this view conditioned to the CS. Subsequent escape from,
derives from Pavlov's own studies on experi- or avoidance of, the CS acted to reduce this
mental neuroses. In studies of discrimination anxiety or fear, and this process of fear
learning he and his colleagues found that certain reduction acted to operantly reinforce the
types of experimental procedures induced signs avoidance or escape response and maintain
of anxiety and irritability in previously friendly the phobia. This model was particularly
and cooperative dogs (Pavlov, 1927, p. 29). In attractive because it appealed to specific
fact, the symptoms resembled those of behavior accreditable learning principles, and also helped
labeled as ªneuroticº in humans. One particular to explain what was known as the ªneurotic
procedure involved training the dog to salivate paradoxºÐthat is, why phobic avoidance was
when a circle was presented on a screen. so persistent even in the absence of continued
Following this, the subject was taught a CS±UCS pairings.
discrimination between the circle (CS+) and While Mowrer's account was influential as
an ellipse (CS7), with an initial ratio between the first integrated conditioning model of
the semi-axes of 2:1. The discrimination was acquired fears (Eysenck & Rachman, 1965), it
learnt quite quickly and as training progressed has generally failed to stand up to a number of
the shape of the ellipse was changed until it was theoretical and practical considerations. First, it
almost circle-like (a ratio between the semi-axes does not explain why fear evoked by the CS does
of 9:8). Kimble (1961) describes the subsequent not extinguish rapidly with continued avoid-
change in the dog's behavior: ªThe hitherto quiet ance of the UCS. Second, there is little evidence
dog began to squeal in its stand, kept wriggling for the hypothetical state of fear postulated to
about, tore off with its teeth the apparatus for occur during the CS presentation and which is
mechanical stimulation of the skin and bit reduced as a result of avoidance. ªFearº does
through the tubes leading from the animal's not appear to bear any simple relationship to its
room to the observer's . . . On being taken into measures (McAllister & McAllister, 1971) and,
the experimental room the dog now barked indeed, both nonhuman animals and humans
violently . . . In short, it presented symptoms of a frequently show no physiological signs of fear
condition which, in human beings, we would call during the presentation of an aversively condi-
neurosisº (p. 441). tioned CS (Brady, Kelly, & Plumlee, 1969;
Numerous other studies have described Davey & Arulampalam, 1982)Ðespecially
similar behavioral effects under conditions when an avoidance response is available (cf.
which require a very difficult discrimination Seligman, 1976). Nevertheless, attempts to
(Masserman, 1943, 1950; Schneiderman et al., understand phobic responding have still needed
1971). The effects are usually quite predictable to explain what had been known as the
and the phenomenon extremely persistent ªneurotic paradox,º and more recent cognitive-
(Anderson & Parmenter, 1941). based models of anxiety-based disorders have
This type of experiment served as a fore- used Mowrer's two-factor theory as a basis for
runner of animal conditioning studies which evolving more sophisticated models of both
attempted to discover the environmental con- phobias (cf. Davey, 1997) and panic disorder
ditions underlying psychopathological phenom- (e.g., Salkovskis, 1991).
ena. Influential others included the approach-
avoidance conflict paradigm reported by Mas-
1.13.3.1.4 Eysenck's theory of incubation
serman (1943), and the learned helplessness
procedure reported by Seligman (1976). Both Over a number of years Eysenck has devel-
described the systematic nature of environmen- oped a conditioning model of neuroses designed
tal contingencies which generated behavior specifically to account for the fact that phobic
resembling human psychopathology, and both reactions are often observed to increase in
were influential in determining theoretical intensity with nonreinforced presentations of
conceptions of neurosis and depression. the CS (Eysenck, 1976, 1979; Eysenck & Kelley,
1987). This phenomenon is known as incuba-
tion, and while it is a common clinical
1.13.3.1.3 Two-factor theory of neuroses
phenomenon, it is clearly inconsistent with
The first attempt to construct a genuine the conditioning principle of extinction which
conditioning theory of acquired fears was made predicts a reduction in the intensity of the CR
404 Learning Theory
with successive nonreinforced presentations of (vi) the development of behavioral and social
the CS. learning alternatives to the traditional medical
Eysenck attempted to resolve this paradox model of psychopathology; and
by suggesting that the CS comes to act as a (vii) the failure of psychodynamic and psy-
partial substitute for the UCS. That is, once choanalytic psychotherapies as indicated by
paired with an aversive UCS, the CS comes to internal dissatisfaction and widespread external
evoke fear; on subsequent occasions when critique.
the CS is presented alone, the fear evoked by In effect, these historical influences can be
the CS can act as a potent reinforcer, thus distilled to form just three good reasons why
generating an increasingly stronger CR over a learning theory was to provide a basis for new
series of CS-only presentations. Eventually, psychotherapies. First, the writings of beha-
because of this process, the CR can become viorists J. B. Watson and later B. F. Skinner
even stronger and more intense than the (1953) were to stress a belief in the continuity of
original UCR. psychological mechanisms between nonhuman
At the time, Eysenck's model was an attempt animals and humans. If conditioning principles
to explain one of the features of phobic had been established with animals thenÐsince
responding which clearly did not fit comfortably humans were only quantitatively rather than
into existing models of classical conditioning, qualitatively different from animals in learning
and during the 1960s and 1970s represented a abilitiesÐthese principles should also apply to
series of ad hoc models designed to explain humans. Second, there was a growing dissatis-
individual anomalies in conditioning accounts faction in the late 1940s and 1950s with the
of psychopathology. These individual ad hoc medical or disease model of psychopathology.
accounts have not proved to be enduring, but This was gradually being replaced by a ªfaulty
have been superseded by integrated condition- learningº account which stressed the need to
ing models which account for a whole range of treat symptoms as bona fide behavioral pro-
traditional criticisms leveled at conditioning blems rather than mere symptoms of underlying
models (cf. Davey, 1992, 1997; see Section causes. Third, the growing belief in the greater
1.13.4.1.2). efficiency and usefulness of concepts derived
from experimental psychology. In particular,
that branch of experimental psychology which
rested on the rubric of behaviorism was most
1.13.3.1.5 The origins of behavior therapy
favored, primarily because the principles of
Behavior therapies based on conditioning behavior derived from behavioristic analyses
principles have been shown to provide some of readily suggested therapeutic action and had
the most effective forms of treatment for a whole greater predictive power than their contempor-
range of psychological problems (cf. Rachman ary psychodynamic counterparts.
& Wilson, 1980), but this begs the question of
why conditioning principles were chosen to
form the basis of an approach to applied human 1.13.3.2 Operant Conditioning
psychology. In this respect, it is instructive to
1.13.3.2.1 Principles of the experimental
trace the origins of behavior therapy and to
analysis of behavior and their
pinpoint some of the events from which it
application to psychopathology
developed. Krasner (1971) has outlined a
number of these historical factors: From its beginnings as the study of learning
(i) the early conditioning studies of J. B. processes in animals (Ferster & Skinner, 1957;
Watson and his subsequent influence on experi- Skinner, 1938), operant conditioning developed
mental psychology; as the basis for an entire philosophy of the
(ii) the field of operant conditioning, and in understanding of human behavior. Pioneered
particular a seminal report by Lindsley, Skin- by B.F. Skinner, operant reinforcement princi-
ner, and Solomon (1953) on conditioned bar- ples provided the basis for an entire analysis of
pulling in psychotics; human behavior, covering aspects of human
(iii) Wolpe's development of reciprocal in- behavior such as social behavior and human
hibition techniques based on the classical con- achievement, problem-solving, language devel-
ditioning research of Pavlov and Hull; opment (Skinner, 1953, 1957, 1969, 1974), and
(iv) the work of Eysenck and colleagues at eventually being touted as a form of behavioral
the Maudsley Hospital, UK, working within a technology which could shape and determine
Hullian framework; the nature of whole cultures (Skinner, 1971).
(v) Dollard and Miller's (1950) attempts to This form of behaviorism has come to be known
interpret psychoanalysis into learning theory alternatively as radical behaviorism, the experi-
terms; mental analysis of behavior or simply behavior
analysis, and the principles surrounding this between (a) the variables involved in an in-
approach to the explanation of human behavior dividual's behavior history, and (b) those de-
are clearly ones which would have relevance to terminants currently impinging upon the
understanding and treating human psycho- organism. With the knowledge of the former
pathology. we can better predict how the latter will
The radical behaviorist approach to psycho- influence behaviorº (Sandler & Davidson,
pathology which gave rise to the treatments 1973, pp. 63±64).
called behavior modification techniques (see Since behavior analysts assume that psycho-
Section 1.13.4.2) is based on a number of inter logical problems are acquired via normal
related assumptions: learning processes, there is thus nothing
(i) that human behavior is governed by the pathological about them, and the removal of
principles of learning which are embodied in the problematic behavior thus removes the
operant and classical conditioning principles; problem. This aspect of the traditional beha-
(ii) many human behaviors (including many viorist approach has been controversial since it
of those which are diagnosable as psychological assumes that hypothetical underlying causes
disorders) are acquired, maintained, and mod- either do not exist or are irrelevant to successful
ified by these principles of learning; therapy. Opponents to this view have argued
(iii) since this approach emphasizes that the that simply dealing with behavioral symptoms
causes of behavior are located in the environ- without addressing the basic underlying cause
ment (in the form of reinforcement contingen- of the problem will result in ªsymptom
cies) and not ªwithinº the individual (in the substitutionº (i.e., that the successfully treated
form of ªmotives,º ªintentions,º etc.), these symptom will simply be replaced by another).
causes can be readily accessed and manipulated; However, the evidence on this is equivocal.
(iv) if the causes of behavior can be manipu- Some studies have found little evidence for
lated, then the behavior of the individual can symptom substitution following therapies based
also be manipulated in a controlled and pre- on learning principles (e.g., Kazdin, 1975;
dictable fashion. Rachman & Wilson, 1980), while some others
In these assumptions were the beginnings have (e.g., Willems, 1974).
of a technology of behavior, and this technol-
ogy was first applied in the late 1950s and early
1960s to behavioral problems in the clinical
1.13.3.2.2 Operant reinforcement and
setting (e.g., Ayllon & Azrin, 1968). From these
psychopathology
beginnings developed the broader field of
behavior modification and techniques then Of all the applications of learning principles
evolved from single-client therapies based on to psychopathology, perhaps the most obvious
classical conditioning principles to group ther- one is to suggest that some features of
apy and management procedures based on psychopathological behavior are developed
operant conditioning. The introduction of op- and maintained because they have reinforcing
erant principles into the field of therapy was an consequences. They may either reduce anxiety
important step because operant psychology (as in phobic avoidance), or they may help the
offered a wider range of therapeutic possibili- individual to acquire certain things which are
ties. First, it provided a method for changing valuable or important to them (such as attention
complex and integrated behavior patterns in a or approval).
way that classical conditioning procedures The way in which attention, for example, can
could not. Second, it allowed the introduction act as a reinforcer is well illustrated in a study
of group management procedures where ther- reported by Williams (1959). This study
apy could be conducted in large groups and in reported the modification of tantrum behavior
settings which resembled those found in every- in a 21-month-old infant. The child had been
day life (e.g., Token Economy procedures, seriously ill in very early life and one parent had
Kazdin, 1975, 1981; see Section 1.13.4.2.2). always spent time at the child's bedside waiting
Third, it provided a framework in which those for him to fall asleep. When a parent was not
variables controlling behavior could be ana- present the child cried. This crying behavior was
lyzed, and as a consequence of this analysis, virtually extinguished by allowing the child to
more appropriate therapy could be devised. cry without reinforcing it with attention. To
Sandler and Davidson (1973) emphasize the underline the fact that this crying behavior was
importance of a functional analysis of this kind: controlled by attentive consequences, Williams
ªThe views expressed by Skinner and other also reports that crying was reinstated by an
operant theorists suggest that a better under- aunt who unwittingly reinforced the behavior
standing of pathological conditioning can be by re-entering the bedroom when the child
accomplished by analysing the interactions cried.
406 Learning Theory
A further study by Ayllon, Haughton, and Rayner never explicitly articulated the princi-
Hughes (1965) compared explanations of bi- ples of this conditioning model, although the
zarre psychotic behavior patterns given by implication was that it was a model based on
learning and psychodynamic theories of psy- findings from animal learning studies, and in
chopatholgy. They reinforced a female schizo- particular the acquisition of conditioned fear to
phrenic resident in a psychiatric hospital for a CS based on the contiguous pairing of that CS
carrying a broom. Whenever she was observed with an aversive UCS. In the subsequent 60
holding the broom a nurse would approach her, years there have been many criticisms of the
offer her a cigarette, or give her a token which classical conditioning model of phobias, and
could be exchanged for a cigarette. Eventually, they are ones which primarily address a
when this behavior was established, it was contiguity-based model of classical condition-
transferred from a continuous to an intermittent ing (e.g., Emmelkamp, 1982; Rachman, 1977).
reinforcement schedule until the patient was It is worth detailing these criticisms, so that they
carrying the broom around for a considerable can be assessed in the context of more recently
part of the day. It was at this point that Ayllon developed contemporary conditioning models
et al. called in two psychodynamic therapists of fears and phobias.
(who were unaware of the reinforcement First, many phobics appear unable to recall
schedule) to give their opinions on the nature any trauma or aversive conditioning experiences
of this behavior. One of them gave the following at the time of the onset of their phobia
reply: ªHer constant and compulsive pacing, (Emmelkamp, 1982; Rachman, 1977). This
holding a broom in the manner she does, could appears to be particularly true of some animal
be seen as a ritualistic procedure, a magical phobics such as snake or spider phobics (Davey,
action . . . Her broom would be then: (1) a child 1992c; Murray & Foote, 1979), and also height
that gives her love and she gives him in return phobics and water phobics (Menzies & Clarke,
her devotion, (2) a phallic symbol, (3) the sceptre 1993a, 1993b).
of an omnipotent queen . . . this is a magical Second, not all people who experience pain or
procedure in which the patient carries out her trauma (UCS) paired with a situation (CS)
wishes, expressed in a way that is far beyond our develop a phobia. For example, not everyone
solid, rational and conventional way of thinking who has a traumatic experience undergoing
and actingº (Ayllon et al., 1965, p. 3). dental treatment acquires a dental phobia
There are two points to be made here. First, (Lautch, 1971), not everyone who experiences
the description given by the psychodynamic a violent thunderstorm acquires a thunderstorm
therapist may well represent what goes on in the phobia (Liddell & Lyons, 1978), and not all
patient's headÐwe do not know for sureÐbut it fliers who experience a traumatic flying accident
does not in any way reflect the process by which express a subsequent anxiety of flying (Aitken,
the behavior was acquired. Second, although Lister, & Main, 1981; Goorney, 1970). A simple
Ayllon et al. have systematized the acquisition contiguity-based conditioning model does not
process in this example, it seems reasonable to appear to have the power to predict when an
suppose that contingencies of this kind could be individual will acquire a phobia and when they
unwittingly set up quite frequently. Although will not.
this study does caricature the process of Third, a simple incremental±decremental
acquisition, it certainly implies that operant model of conditioning (where pairing a CS with
reinforcement can play a powerful role in an aversive UCS produces an increment in fear
establishing maladaptive, inappropriate, or to the CS, and an unreinforced presentation of
bizarre behavior patterns. the CS produces a decrement in fear) does not
appear to account for the common clinical
phenomenon of incubation of fear (see Section
1.13.4 CURRENT APPLICATIONS OF
1.13.3.1.4). While incubation is a common
LEARNING THEORY IN CLINICAL
clinical phenomenon (Eysenck, 1979), it is
AND EXPERIMENTAL
rarely found in laboratory analogue studies
PSYCHOPATHLOGY
(cf. Richards & Martin, 1990). Incremental±
1.13.4.1 Classical Conditioning decremental models of phobias would predict a
successive decrease in fear with successive
1.13.4.1.1 Traditional criticisms of classical
nonreinforced CS presentations (extinction),
conditioning models of phobias
not an increase in fear as found with incubation.
The discussion of the Little Albert experiment Fourth, simple conditioning models treat all
of Watson and Rayner (1920) described in stimuli as equally likely to enter into association
Section 1.13.3.1.1 provides a basic framework with aversive consequences, yet fears and
for a possible model of fears and phobias based phobias are not evenly distributed across stimuli
on classical conditioning processes. Watson and and experiences. People appear to develop
Current Applications of Learning Theory in Clinical and Experimental Psychopathology 407
phobias of animals (snakes, spiders), heights, the way in which the individual evaluates the
water, death, thunder, and fire more readily UCS (Davey, 1989c, 1992a). In humans, there
than fear of hammers, electricity outlets, knives, are a variety of processes that can influence the
guns, and so on, even though the latter group of evaluation of the UCS and some of these have
stimuli seem to have a high likelihood of being been described in Section 1.13.2.1.5 (iii).
associated with trauma (Agras, Sylvester, & Figure 3 provides a schematic representation
Oliveau, 1969; Kirkpatrick, 1984; Seligman, of a contemporary cognitive model of human
1971). This uneven distribution of fears appears classical conditioning. This illustrates the kinds
to violate the Pavlovian principle of equipo- of factors that may influence the strength of an
tentiality, which states that all stimuli should be association between CS and UCS (Expectancy
equally capable of entering into associative Evaluations), and also how the UCS represen-
relationships with a consequential UCS. tation's evocation of a fear CR will be
Fifth, many surveys suggest that a substantial influenced by how the UCS has been evaluated
percentage of phobics appear to acquire their or revalued (UCS Revaluation Processes).
fear through observational learning rather than
direct experience with trauma (Menzies &
Clarke, 1993a, 1993b; OÈst & Hugdahl, 1981; 1.13.4.1.3 How contemporary conditioning
Rachman, 1977). This has generally been models of phobias account for the
conceived of as a route to phobias that is an traditional criticisms
alternative to direct conditioning.
(i) Inability to recall trauma at the onset of
The next section argues that while these
the phobia
criticisms are valid in terms of traditional
contiguity-based classical conditioning models, Many phobics appear unable to recall any
they are significantly less damaging for more trauma at the time of the first appearance of
recently developed contemporary cognitive their phobia. Nevertheless, the contemporary
conditioning models of phobias. conditioning view conceives of acquisition of
the CS±UCS association and modulation of the
aversiveness of the UCS as relatively indepen-
1.13.4.1.2 Contemporary cognitive models of
dent processes (Figure 3). Thus, it is quite
human classical conditioning
conceivable for an individual to learn an
Contemporary models of human classical association between a CS and UCS when the
conditioning differ from their contiguity-based UCS is relatively nonaversive, and then subse-
predecessors in a number of important ways. quently (through the process of UCS inflationÐ
First, unlike their behaviorist forerunners, see Section 1.13.2.1.5 (iii)) to have the aversive-
modern learning theories are happy to incor- ness of the UCS inflated. This process would
porate cognitive conceptualizations of the eventually generate a fear response to the CS
conditioning process. Examples of such kinds without that CS ever having been explicitly
of incorporations include the willingness to paired with an aversive UCS.
attempt to discover the exact nature of the White and Davey (1989) demonstrated this
associations that are formed during process in a laboratory analogue, and then
conditioningÐeven though they cannot be described a putative ªreal-worldº analogue of
directly observed (see Section 1.13.2.1.4 (vi)). the following kind. An individual may witness
Second, it is now well accepted that many an unknown person die of a heart attack on a
factors other than the experienced pairing of bus or a train; on future occasions, riding on
the CS and UCS can affect the strength of the public transport may evoke memories of this
association between the CS and UCS. In the incident, but no anxiety. Subsequently, how-
case of humans, these include verbally and ever, that individual may be present when a
culturally transmitted information about the close friend or relative dies of a heart attack,
CS±UCS contingency (e.g., Dawson & Grings, thus inflating the aversive properties of heart
1968; Wilson, 1968), existing beliefs and attacks. This may then give rise to acute anxiety
expectancies about the possible consequences when riding on public transport. Davey, De
associated with a particular CS (Davey, 1992; Jong, and Tallis (1993) report a number of
Honeybourne, Matchett, & Davey, 1993), and actual case histories in which this type of
emotional reactions currently associated with scenario fits the etiology of a variety of anxiety
the CS (e.g., Davey & Dixon, 1996) (see disorders, including phobias, panic disorder,
Section 1.13.2.1.5 (iv)). and obsessive-compulsive disorder. What these
Third, and arguably of most importance in findings suggest is that a conditioning account
this context, is the finding that the strength of a of anxiety disorders is no longer bound by the
CR can be radically influenced, not just by the need to discover contiguous stimulus-trauma
strength of the CS±UCS association, but also by experiences in the etiologies of individual cases.
408 Learning Theory
(ii) Not all people who experience pain or and prior to a series of extinction CS-alone
trauma develop a phobia trials, subjects who were either high in trait
anxiety levels or who had an induced anxious
There are a number of processes by which
mood subsequently showed increased fear CRs
contemporary conditioning theory would pre-
to CS presentations during extinction. Davey
dict that encounters with traumatic stimuli
and Matchett argued that this effect was the
would not generate acquired fears.
result of UCS rehearsal in anxious individuals
First, the process of latent inhibition (see
inflating the aversive evaluation of the UCS,
Section 1.13.2.1.4 (iii)) allows for the failure to
and thus causing an increased strength CR on
develop a CR following pairings of a CS and
future CS presentations. This process is analo-
UCS. Davey (1989a) tested this possibility by
gous to the rumination about the consequences
investigating the role of latent inhibition in the
of contact with phobic stimuli that is often
acquisition of dental phobias. He found that
reported in individuals with anxiety disorders,
individuals who reported having a painful
and may provide at least a partial explanation of
dental experience but did not acquire a dental
clinical incubation effects.
phobia reported having their first painful
experience significantly later in the dental
treatment careers than individuals who did (iv) Fears and phobias are not evenly distributed
acquire a dental phobia. Thus, consistent with across stimuli and experiences
the operation of latent inhibition, individuals
There appears to be an uneven distribution of
who did not acquire a phobia had the equivalent
fears, with some stimuli being very common foci
of a series of CS alone trials prior to the first
for phobias (e.g., snakes, spiders, heights,
pairing of the CS with a traumatic UCS.
water), and otherÐequally potentially danger-
Second, the process of UCS revaluation
ous stimuliÐonly rarely being reported as
permits the aversiveness of any experienced
phobic stimuli (e.g., guns, hammers, electricity
UCS to be devalued following an aversive
outlets).
conditioning episode. There are a number of
The traditional explanation of this uneven
processes that have been identified as contribut-
distribution of fears has been a variant of
ing to UCS reevaluation (see Section
conditioning theory called preparedness theory
1.13.2.1.5 (iii)), and effective devaluation of
(Seligman, 1971). This account hypothesizes
the UCS will result in the failure of the CS to
that stimuli which tend to become the focus for
evoke a substantial fear CR. Some empirical
fears and phobias are those which have been
support is lent to this hypothesis by the fact that
hazardous for our pretechnological ancestors
individuals with clinically diagnosed specific
(e.g., poisonous snakes and spiders, dangerous
phobias and panic disorder are significantly less
heights, etc.). This has resulted in the evolution
likely to report using trauma devaluation
of phylogenetically-based predispositions to
strategies (see Section 1.13.2.1.5 (iii)) than a
associate biologically ªpreparedº stimuli with
sample of normal control subjects (Davey,
aversive outcomes.
Burgess, & Rashes, 1995).
Support for the preparedness hypothesis has
come from:
(iii) Conditioning models do not appear to
(a) Laboratory conditioning studies which
account for the clinical phenomenon of
have paired ªpreparedº CSs (such as pictures of
incubation
snakes and spiders) with aversive UCSs such as
When a CS is presented alone on several electric shock (e.g., OÈhman, Dimberg, & OÈst,
occasions following conditioning, extinction 1985; OÈhman, Frederickson, & Hugdahl, 1978).
should occur (see Section 1.13.2.1.4 (ii)). These studies have demonstrated a greater
However, in many phobic circumstances, pre- resistance to extinction in ªpreparedº stimuli
sentation of the CS alone leads paradoxically to than ªunpreparedº stimuli (McNally, 1987).
incubation of the fear (Eysenck, 1979). Never- (b) Studies of the observational learning of
theless, contemporary conditioning theories are fear of snakes in primates. These studies have
able to describe some circumstances in which indicated that monkeys who are not initially
CS-alone presentations following conditioning afraid of snakes will rapidly acquire an intense
may lead to increases rather than decreases in fear when they have watched a wild-reared
the strength of the CR. This has again been monkey behaving fearfully in response to a
linked to the operation of UCS revaluation toy snake, but will regularly fail to acquire fear
processes (Davey, 1997; Davey & Matchett, towards artificial flowers or a toy rabbit using
1993). Davey and Matchett found that when the same paradigm (Cook & Mineka, 1987,
subjects in a conditioning experiment were 1989, 1990; Cook, Mineka, Wolkenstein, &
asked to cognitively rehearse the aversive Laitsch, 1985; Mineka, Davidson, Cook, &
UCS for a period following acquisition trials Weir, 1984).
However, Davey (1995) has critically re- heightened expectancy of aversive outcomes
viewed much of the evidence that is often used following such stimuli, and hence such stimuli
to support the biological preparedness hypoth- readily enter into association with aversive
esis. Among the problems identified with this outcomes (Davey, 1995).
evidence are:
(a) that the evidence from clinical studies
(v) Indirect associative routes to phobias
largely fails to support predictions from pre-
paredness theory (de Silva, 1988; de Silva, Some writers have suggested that, rather than
Rachman, & Seligman, 1977); clinical phobias being caused by specific direct conditioning
identified as ªpreparedº rarely exhibit the experiences, the majority of phobias are caused
resistance to extinction expected of such fears, by vicarious learning in the form of either
(b) the failure of the primate studies of observational learning (watching someone else
Mineka and colleagues to use a balanced design; being frightened in the presence of the phobic
as a result these studies are open to explanations stimulus) or verbally transmitted information
other than biological preparedness, and about the phobic stimulus and its potentially
(c) the finding that ontogenetic fear-relevant threatening consequences (OÈst & Hugdahl,
stimuli (such as guns, electricity outlets, etc.) 1981; cf. Rachman, 1977). However, contem-
often display similar conditioning characteris- porary conditioning models make it clear that
tics to so-called ªbiologically preparedº stimuli associations can be formed between a stimulus
(such as snakes and spiders) (Davey & Dixon, (CS) and its outcome (UCS) in a variety of
1996; Honeybourne, Matchett, & Davey, 1993; waysÐnot just by direct conditioning experi-
McNally & Heatherton, 1993). ences (see Section 1.13.2.1.5 (iv)). An implica-
As an alternative to biological preparedness, tion of this is that an association between a CS
Davey (1992b, 1995) has argued that in labora- and UCS can be learned as a result of
tory preparedness experiments, human subjects information about the contingency, or through
begin the conditioning procedure with an observing someone else experiencing the con-
inflated estimate of the probability of fear- tingency. In terms of contemporary condition-
relevant stimuli being followed by aversive ing models, this is still conditioning.
UCSs (Davey, 1992b). Details of some of the Admittedly, there is very little information at
evidence supporting this view are presented in present on the strength and persistence of
Section 1.13.2.1.5 (iv). Subsequent studies have associations that are learned in these vicarious
identified some of the factors that give rise to manners. They may be weaker and less resistant
this UCS expectancy bias. These include esti- to extinction than associations acquired
mates of the ªdangerousnessº of the CS (Davey through direct experience, but they do appear
& Craigie, 1997; Davey & Dixon, 1996), judge- to be mediated by the same associative
ments about the semiotic similarity of the CS to mechanism that mediates conditioning through
the potential aversive UCS (Davey & Dixon, direct experience (Mineka & Cook, 1993).
1996; Hamm, Viatl, & Lang, 1989), and existing However, evidence that is available does suggest
prior fear to the CS (Diamond, Matchett, & that direct conditioning experiences are more
Davey, 1995; Davey, & Dixon 1996). Interest- memorable than vicarious learning experiences,
ingly, nearly all of these studies have failed to and that a majority of strong fears are attributed
find any significant differences between phylo- by individuals to direct conditioning rather than
genetic and ontogenetic fear-relevant stimuli in vicarious learning (Merckelbach, de Ruiter, van
the determinants of UCS expectancy bias. This den Hout, & Hoekstra, 1989; Withers & Deane,
suggests that the same underlying process may 1995).
mediate expectancy bias to both types of
stimuli.
(vi) Summary
To summarize, there are at least two
contrasting conditioning-based theories which Section 1.13.4.1.3 has described how con-
attempt to explain the uneven distribution of temporary models of conditioning have con-
fears. Preparedness theory is essentially an tributed to our understanding of anxiety-based
evolutionary-based account which argues that clinical disorders. Contemporary conditioning
many phylogenetic fear-relevant stimuli are models differ from their more traditional
biologically ªpreparedº to enter into associa- counterparts in that they explicitly contain
tions with aversive outcomes (Seligman, 1971). both an associative element and an element
Alternatively, the UCS expectancy bias account which allows the anxiety or fear CR to be
says that the selective conditioning of certain modulated through revaluation of the UCS.
stimuli results from biases in the way that Such conditioning models provide a systematic
individuals process information concerning framework for the understanding of many
fear-relevant stimuli; these biases create a features of anxiety-based responding.
410 Learning Theory
1.13.4.1.4 Further applications of classical There has been a tendency to assume that
conditioning to anxiety-based such techniques are applicable only to the
disorders treatment of anxiety and phobic disorders (e.g.,
Bandura, 1969; Paul & Bernstein, 1973), but
While classical conditioning models have
they have in fact been applied successfully to a
primarily been applied to the understanding
wider range of disorders including sexual
of phobic responding, conditioning models are
dysfunction (e.g., Kockott, Dittmar, & Nusselt,
increasingly being applied to an understanding
1975; Mathews et al., 1976), marital conflict
of the etiology of other anxiety disorders, and,
(e.g., Jacobson & Weiss, 1978), and addictive
indeed, are being integrated into broader
disorders (e.g., Lichtenstein & Danaher, 1976;
cognitive accounts of psychological disorders.
O'Leary & Wilson, 1975).
At a specific level, classical conditioning models
Such techniques have, over the years, been
have been postulated to account for some of the
subjected to rigorous tests of their internal and
important features of panic disorder (Goldstein
external validity (cf. Rachman & Wilson, 1980),
& Chambers, 1978; Wolpe & Rowan, 1988) and
with results convincingly demonstrating that
post-traumatic stress disorder (PTSD) (Fair-
such techniques are successful because of the
bank & Brown, 1987; Keane, Zimering, &
principles on which they are based, and superior
Caddell, 1985; Kilpatrick, Veronen, & Best,
in outcome to many other differing types of
1985). However, aspects of associative learning
psychotherapy.
are becoming increasingly integrated into
broader cognitive models of psychopathologyÐ
especially those models that postulate the (i) Flooding
existence of associative networks underlying
Flooding is an extinction-based therapy
the expression and maintenance of fear and
procedure involving therapist-directed pro-
anxiety (e.g., Brewin, 1988, 1989; Foa & Kozak,
longed exposure to the anxiety-eliciting stimulus
1986), and the revaluation of information
or situation. Flooding can be conducted in vivo
related to threat (e.g., Brewin, Dalgleish, &
or in vitro, the latter by asking the client to
Joseph, 1996). Thus, while conditioning models
imagine extended contact with their phobic
continue to be valuable at the level of specific
stimulus. It is not necessary for high levels of
phenomena, the processes contained in con-
fear to be elicited during the flooding experi-
temporary models of conditioning are them-
ence, and mere exposure appears to be the
selves having increasing influence on the
sufficient condition (Hafner & Marks, 1976;
conceptualizations of broader-based cognitive
Mathews, 1978). This would be consistent with
models of psychopathology.
the extinction rationale on which the method is
based, and inconsistent with more
psychoanalytically-oriented versions of expo-
1.13.4.1.5 Classical conditioning in behavior
sure therapy (such as implosion therapy) which
therapy
demand that high levels of fear are elicited
Ever since Wolpe (1958) published what was during exposure in order for treatment to be
arguably the seminal text on behavior therapy, a effective.
variety of therapeutic techniques have been Studies have demonstrated that flooding is
developed which have their origins in classical significantly more effective than placebo treat-
conditioning principles. Many of these methods ments, indicating that its success is not simply
have since been modified and supplemented, but the result of client expectations (Gelder et al.,
almost all owe their origins to the Pavlovian 1973).
principle of extinction. The assumption was that
if emotional disorders were learned through a
(ii) Counterconditioning
process of classical conditioning, then those
disordered responses could be eliminated Counterconditioning is also a procedure
through applying procedures which effectively based on Pavlovian extinction principles, but
disrupted the learned CS±UCS association and as well as extinguishing the emotional CR it
extinguished the learned emotional response. develops an acceptable alternative CR. The
The most famous of such techniques are procedure is illustrated well in an animal
flooding, counterconditioning, and systematic analogue study by Klein (1969). Initially rats
desensitization. Wolpe's main contribution was were trained on a discriminated avoidance task
to introduce the notion of reciprocal inhibition, to run between two compartments in a shuttle-
by which the emotional response is eliminated box. This response was subsequently extin-
not just by extinction, but also by attaching a guished, but during the extinction procedure the
response to the emotion-eliciting stimulus which rats were divided into three groups: one group
is incompatible with the pathological emotion. was confined to the compartment where shock
had been delivered and was also given food in Rachman & Teasdale, 1969; Wilson, 1978).
this compartment (the counterconditioning Some original studies by Voegtlin and Lemere
group); animals in the second group were (1942) and Lemere and Voegtlin (1950) serve as
simply confined in the compartment without examples of this method with alcoholics. In
food (flooding); and members of the third group their procedure alcoholic patients were given
were not confined at all (extinction). The results injections of emetine or apomorphine, which
suggested that the counterconditioning proce- quickly elicit both nausea and vomiting (UCS).
dure was the most effective in eliminating the Immediately prior to vomiting the patient is
conditioned response. given a drink of their favorite alcoholic beverage
A variation of the counterconditioning (CS). The success of this procedure depends on
procedure is known as systematic desensitiza- whether the CS (alcohol) comes to elicit a CR of
tion by reciprocal inhibition (Wolpe, 1958). nausea. Some early studies of this type of
conditioning therapy report relatively success-
ful treatment of addictive disorders such as
(iii) Systematic desensitization
alcoholism. For example, Wiens, Montague,
In this variant of counterconditioning, the Manaugh, and English (1976) reported that 12
therapist constructs a ranked list of events or months after receiving aversion therapy, 63% of
stimuli to which the client reacts with increasing 261 treated patients were still abstaining.
fear or anxiety (the fear hierarchy). The client is Nevertheless, treatment programs such as
then trained to relax while at the same time aversion therapy do appear to rely for their
being exposed to the stimulus condition at the long-term success on related support programs
bottom of the fear hierarchy. When the client such as community reinforcement (e.g., Azrin,
feels quite relaxed in this situation, they then 1976), and there has been little success in
progress on to the next most fear-inducing event demonstrating that aversion therapy using
on the hierarchy (Wolpe & Lazarus, 1966). This electric shock UCSs is any more effective than
technique involves extinction of the anxiety placebo control conditions (Hedberg & Camp-
response through graduated exposure to the bell, 1974; Wilson, 1978; Wilson, Leaf, &
anxiety-eliciting stimuli, and countercondition- Nathan, 1975). However, certain types of
ing of a response incompatible with anxiety aversion therapy do have a role in the treatment
(relaxation) to these stimuli (the principle of of specific disorders, especially addictive dis-
reciprocal inhibition). orders, but it is a role that is best embedded in a
Systematic desensitization has arguably been multifaceted approach to therapy.
one of the most durable and successful of all the
behavior therapy procedures. Studies have
(v) Recent developments in the treatment of
shown that there is no methodologically
anxiety-based disorders
acceptable evidence to prove that the therapeu-
tic benefits derived from systematic desensitiza- While classical conditioning principles have
tion can be attributed to nonspecific treatment contributed substantially to the development of
effects such as placebo influences and expecta- exposure-based therapies, the last 10±15 years
tions of therapeutic improvement (Gelder et al., have seen rapid and important changes in the
1973; Kazdin & Wilcoxon, 1976; Wilson, 1973), nature of therapies for anxiety-based disorders.
and in comparative outcome studies systematic Arguably the two most important aspects of
desensitization has generally been shown to be change have been (a) the emergence of cognitive
more effective than both no treatment condi- therapies, and (b) the development of treatment
tions and almost every other psychotherapy packages addressed to specific disorders. These
variant with which it has been compared (cf. changes have meant that while incorporating
Leitenberg, 1976; Rachman & Wilson, 1980). some elements of traditional conditioning
principles in their procedures, contemporary
treatment packages are considerably more
(iv) Aversion therapy
multifaceted than their behavior therapy pre-
A rather different use of classical condition- decessors, and their primary objective is to
ing principles is found in aversion therapy. change aspects of the cognitions maintaining
This is where the conditioning paradigm is the disorder (e.g., Beck, 1976; OÈst, 1997).
used to condition an aversive response to a Nevertheless, many of these contemporary
formally attractive stimulus. Aversion therapy procedures retain exposure as the central
is most widely used in the treatment of element in the treatment (e.g., Booth &
addictive behaviors such as alcoholism, and Rachman, 1992; OÈst, 1989), although what
aversive UCSs that have been used include may have changed is the rationale for retaining
electric shock and drugs (such as emetine) that exposure. Traditional behavior therapies such
induce unpleasant physiological reactions (cf. as flooding and systematic desensitization
412 Learning Theory
included exposure because of its role in theoretically neutral definition would be one
facilitating extinction of any associative link that emphasizes the functional relationships
between the phobic stimulus (CS) and fearful between behavior and environment. Haynes
outcomes (UCS). However, the perceived role and O'Brien (1990), for instance, define func-
of exposure appears to have changed somewhat tional analysis as ªThe identification of im-
to one that either disconfirms dysfunctional portant, controllable, causal functional
beliefs about the phobic stimulus (e.g., OÈst, relationships applicable to a specified set of
1997; Salkovskis, 1981) or facilitates the target behaviors for an individual clientº
acquisition of behaviors designed to help the (p. 654). This definition emphasizes that the
individual cope with contact with the phobic relationships identified should be
stimulus or situation (e.g., ªguided mastery,º controllable±±otherwise they cannot be ma-
Williams, Turner, & Peer, 1985). nipulated during the course of treatment, and
Thus, while traditional classical conditioning that functional analysis is idiographic (addres-
principles can be seen as the seminal influence in sing causal relationships for behavior problems
the development of the basic behavior therapy of individual clients) rather than nomothetic
treatments for emotional disorders, their direct (addressing causal relationships for a behavior
influence in contemporary therapies is limited. problem across clients).
However, what has yet to be exploited is the Functional analysis has two specific roles in
therapeutic value of contemporary conditioning the treatment process. First, it allows the
models (see Section 1.13.4.1.2). These recent therapist to identify reinforcers that may be
models have cognitive components (such as maintaining aberrant behavior. As a result the
UCS revaluation processes) which are compa- therapist may then be able to manipulate those
tible with modern cognitive conceptions of reinforcement contingencies in such a way that
therapy and which seem highly suited to will eradicate the aberrant behavior. For
therapeutic application; however, this potential example, self-injurious behaviors or challenging
has yet to be explored. behaviors may be maintained by any number of
reinforcing consequences such as seeking atten-
tion, being left alone, or sensory stimulation.
1.13.4.2 Operant Conditioning Identifying exactly the type of consequence that
reinforces such behavior allows the therapist to
Operant conditioning has contributed exten- disrupt the contingency and reduce the fre-
sively to modern-day clinical psychology, both quency of the behavior through extinction (e.g.,
at the level of behavioral assessment and specific Mazaleski, Iwata, Vollmer, Zarcone, & Smith,
techniques. This section covers some of the 1993; Wacker et al., 1990), or even through
more influential of these applications. presenting reinforcers noncontingently (e.g.,
Hagopian, Fisher, & Legacy, 1994; Vollmer,
Iwata, Zarcone, Smith, & Mazaleski, 1993).
1.13.4.2.1 Functional analysis
Second, a functional analysis is important
One of the important by-products of the because it improves the therapist's ability to
study of operant conditioning was the discovery develop an effective behavioral intervention.
that behavior could be understood in terms of For example, attempting to eradicate aberrant
the consistent relationships between behavior behaviors by reinforcing appropriate ones is less
and the environment. For example, rats in a likely to be successful if the reinforcement
Skinner box would learn to press a lever because contingencies maintaining the aberrant beha-
that act had a consistent relationship with the viors have not been identified and are still
consequential delivery of food. This identifica- operating (Vollmer & Smith, 1996). This
tion of consistent relationships between beha- effectively means that existing reinforcement
vior and environmental events led to the contingencies are competing with the reinforce-
development of the behavioral assessment ment contingencies used to develop the appro-
technique known as functional analysis. This priate new responses.
is currently an assessment technique that is Functional analysis has been adopted across
widely used in clinical psychology to understand a range of clinical settings as an aid to effective
aberrant behavior and also to facilitate effective treatment. These applications include aggres-
therapy. sive/challenging behavior (O'Reilly, 1995; Sam-
While functional analysis has its roots in son & McDonnell, 1990), tantrums (Darby et al.,
operant conditioning, it has now developed into 1992), pica (Mace & Knight, 1986), stereotypy
an assessment technique that is considered to be (Mace, Browder, & Lyn, 1987), attention deficit
theoretically neutral (Owens & Ashcroft, 1982). hyperactivity disorder (Northrup, Broussard,
As a result there is often dispute about how Jones, George, Vollmer, & Herring, 1995),
functional analysis should be defined. A depression (Ferster, 1985), anorexia nervosa
(Slade, 1982), and self-injurious behavior and Paulson (1977) found that patients in a
(Iwata, Dorsey, Slifer, Bauman, & Richman, token economy scheme were better groomed,
1985). spent more time in activities and less time in
bed, and made fewer disturbing comments than
patients on a traditional ward. Patients on
1.13.4.2.2 Token economy schemes
token economy schemes also earn discharge
One great advantage of operant conditioning significantly sooner than patients who are not
principles is that they are more readily adap- on such a scheme (Hofmeister, Scheckenbach,
table to group therapy and group management & Clayton, 1979). A large-scale study by Paul
situations than principles derived from classical and Lentz (1977) compared token economy
conditioning, and perhaps the first group programs with milieu therapy and traditional
management procedure of this kind was the custodial care approaches. The results of this
token economy (Ayllon & Azrin, 1968). In this comprehensive four-and-a-half year study
type of program the participants receive tokens showed that participation in both the token
(a generalized reinforcer) when they have economy and milieu therapy groups was
engaged in appropriate behavior and they followed by major improvements at the end
can, at some later time, exchange these tokens of treatment. However, the token economy
for a variety of desired items. In the psychiatric group produced significantly greater reductions
setting, these might include access to the in bizarre behavior and increases in adaptive
hospital grounds, preferred consumables, etc. behavior such as self-care and interpersonal
The token acts as a generalized conditioned social skills than the milieu therapy. Assess-
reinforcer and can be delivered with the ment of overall functioning on a number of
minimum of delay after the required response standardized scales showed that the token
is emitted. Its primary use in clinical psychology economy program resulted in significantly
is as a therapeutic program with psychiatric greater improvement than the milieu therapy
patients (usually inpatients, but it has increas- at every six-month evaluation.
ingly been used in community programs, cf. Nevertheless, despite these positive findings,
Corrigan, 1991). Behaviors normally fostered in recent surveys indicate that the use of token
these programs are prosocial or self-care ones economies in clinical settings is in serious
(e.g., combing hair, bathing, brushing teeth, decline (Boudewyns, Fry, & Nightengale,
etc.) (Ayllon & Azrin, 1965). With more 1986; Corrigan, 1995; Hall & Baker, 1973).
withdrawn patients, tokens can be administered The reasons for this are not entirely clear given
simply to encourage socialization. Such pro- the demonstrated efficacy of the technique as a
grams help to increase the sociability of therapeutic process. However, a number of
institutionalized individuals, strengthen beha- reasons have been put forward for this decline.
viors that are likely to be needed in life outside First, there are legal and ethical issues which
the institution, and help to keep the individual need to be considered. This is especially so when
receptive to other, more specialized, therapies. decisions have to be made about who will
As a technique for behavior modification, the participate in token economies, for how long,
token economy has a number of advantages: (i) and what will be made available as positive
it does not necessarily need professionally reinforcers. Legislation over the past 25 years
trained therapists to appropriately dispense has sought to protect patientsº rights, and
tokens; (ii) such programs prevent the dete- treatment staff are severely constrained with
rioration of normal social and self-care beha- regard to the use of more basic items as
viors on admission to an institution such as a reinforcers (Glynn, 1990)±±especially when
psychiatric hospital (Dickerson, Ringel, & patients now have a legal right to their own
Parente, 1994; Kazdin & Bootzin, 1972; Lipp- personal property, humane treatment including
man & Motta, 1993); and (iii) they can be used comfortable bed, chair, bedside table, nutritious
in any group situation, either as a therapeutic or meals, cheerful furnishings, and so on.
a management program (Kazdin, 1975, 1981). Second, one of the major challenges for token
A number of studies have demonstrated that economies has been maintenance and general-
token economies can have significant thera- ization of therapeutic effects. To the extent that
peutic gains. For example, Gripp and Magro patients can obtain reinforcers outside the
(1971) showed that schizophrenic patients in a program and avoid punishment by exiting from
token economy ward improved significantly the program, the therapeutic benefit of token
more than patients in a traditional ward. economies becomes less useful (Glynn, 1990). It
Herson, Eisler, Alford, and Agras (1973) is true that some studies have shown that
found that depressed patients exhibited less behaviors targeted for improvement in a token
depressive behavior while participating in a economy scheme return to low baseline levels
token economy. Gershone, Errickson, Mitchell outside of the program (e.g., Ayllon & Azrin,
414 Learning Theory
1968; Walker & Buckley, 1968). However, there by the end of week 3, these behaviors were
are other studies that have shown positive relatively frequent.
effects of maintenance and generalization (iii) The experimenters then withheld gum
(Banzett, Liberman, & Moore, 1984). Never- until the patient made vocalizations of some
theless, it should be pointed out that general- sort; by the end of the fourth week the patient
ization is not a passive process, and clinicians was moving his eyes and lips and making
must actively build into the program strategies audible ªcroakingº noises.
that transfer positive effects to settings outside (iv) During weeks 4 and 5, the experimenter
the treatment scheme (Stokes & Baer, 1977; asked the patient to ªsay gum,º repeating this
Stokes & Osnes, 1988). each time the patient vocalized. At the end of
Third, some other proponents of the token week 6, the patient spontaneously said ªgum
economy have argued that its decline has been please.º
the result of unfounded misconceptions about (v) In later sessions the patient verbally
the nature and efficacy of such programs (e.g., responded to questions from the experimenters,
Corrigan, 1995). These include such misconcep- but only in the therapeutic situation.
tions as token economies not being therapeu- (vi) To enable verbal behavior to generalize
tically effective, their benefits do not generalize, beyond the experimental setting, the patient was
they do not provide individualized treatment, placed back on the ward and the nursing staff
they are abusive and cohersive, and they are not were asked to attend to his needsÐbut only if he
practical to implement in the context of present- verbalized them.
day attempts to treat patients in the community. This example demonstrates a number of
Corrigan (1995) argues that these are all features of the response shaping procedure in
unfounded, and that the token economy clinical settings. First, it provides an example of
remains an important and valuable tool for how response shaping can be a powerful and
the management of patients and staff in effective means of establishing complex re-
treatment settings. sponse repertoires relatively quickly. Second,
it also illustrates the distinction between ªarbi-
traryº and ªnaturalº reinforcers in behavior
1.13.4.2.3 Response shaping
modification. In this case, chewing gum was an
As noted in Section 1.13.2.2.2 (ii), response effective reinforcer for the behaviors being
shaping is a useful procedure for strengthening shapedÐbut it is an ªarbitraryº one in that
rarely-occurring behaviors or building up com- it is not a normal reinforcer for verbal behavior.
plex response repertoires, and this method is Thus, while chewing gum may have acted as an
utilized regularly in behavior modification effective reinforcer during the shaping process,
programs. An early study by Isaacs, Thomas, in order to be maintained in any way, verba-
and Goldiamond (1960) serves to illustrate this lizations need to be transferred to a more
method. They attempted to reinstate verbal ªnaturalº reinforcer for those behaviors. This
behavior in a psychiatric inpatient who had been was the aim of stage (vi) in the study where the
mute for over 19 years. In this example, the patient's needs were met only if he verbalized
target behavior occurs relatively infrequently, them.
and thus has to be approached via the Finally, there was no apparent follow-up
reinforcement of successive approximations to analysis of the gains achieved in this study, and
the behavior. They discovered that although the one suspects that, once back in the unstructured
patient was withdrawn, he did appear to setting of the ward, the patient in the Isaacs et al.
respond to chewing gum, which they considered (1960) study would have reverted to his previous
would act as an effective reinforcer. They then mute state. However, this study does still
broke down the target behavior so that it could emphasize two things. First, as is the case with
be reached by reinforcing a series of approx- token economy studies, behavior change has to
imations to verbal behavior. The first responses be subsequently supported by stable and
to be reinforced were fairly simple, discrete structured changes to the individual's environ-
responses whose baseline levels were high ment which will maintain the therapeutic gains
enough for them to occur spontaneously within achieved in the behavior modification program.
a training session. The shaping program went as Second, whether the patient in this study did
follows. revert to a mute state still does not deny the
(i) When the patient moved his eyes towards usefulness of response shaping procedures in
the chewing gum, he was reinforced by being swiftly developing relatively complex behavior
given the gum; after 2 weeks the probability of repertoiresÐthe problem of response mainte-
this response was relatively high. nance, however, usually requires other con-
(ii) The experimenters then only gave the siderations (cf. Glynn, 1990; Stokes & Baer,
patient gum when he moved his mouth and lips; 1977; Stokes & Osnes, 1988).
1.13.4.2.4 Multifaceted behavioral self-control of behavior in this way has frequently been used
programs in weight loss programs. Typical reinforcers
include refunding of portions of a deposit or fee
Operant conditioning offers a wide range of
for meeting behavioral goals (e.g., Harris &
principles that the clinician can utilize for
Bruner, 1971; Harris & Hallbauer, 1973), and
therapeutic purposes, but so far we have
the return or loss of prewritten cheques (perhaps
discussed those that center on individual
sent to some organization that the individual
principles and which are administered in
particularly dislikes) or valuables (Mann, 1972).
relatively traditional therapist±client settings.
While such contingencies have proven relatively
However, operant conditioning principles can
effective in helping clients to meet behavioral
be used as the basis for devising behavior change
targets, they are often inadequate in maintain-
programs that individuals can apply themselves
ing any therapeutic gains. One solution to this is
in a way which structures and controls the
to facilitate generalization of gains by using
interactions between their behavior and their
contingency contracting procedures which fos-
environment. These were traditionally known
ter mutual reinforcement of desirable behaviors
as behavioral self-control programs (e.g., Thor-
between family members (e.g., J. R. Lutzker &
esen & Mahoney, 1974), but have since been
S. Z. Lutzker, 1977).
adapted into multifaceted behavioral programs
to deal with a variety of personal problems
which include addictions, habits, obsessions, (iii) Response shaping and the setting of
and other behavioral problems (e.g., Lutzker & attainable therapeutic targets
Martin, 1981; Stuart & Davies, 1972). The
All behavioral programs set attainment
resulting program is one that the individual can
targets of some kind, and it is extremely
manage and assess without the need for
important that any subgoals in the programs
constant, external therapeutic supervision.
are attainable. For example, in weight-loss
Operant principles that have been incorpo-
programs it is critical that weekly targets are
rated into behavioral self-control programs
attainable: if they are not met because they are
include stimulus control (environmental plan-
overambitious, then this is tantamount to
ning), reinforcement/punishment, the principle
punishing the effort that was expended in
of response-reinforcement contiguity, response
attempting to meet the goal. The reinforcement
shaping and response discrimination (response
of modest gains on a regular basis is advisable,
feedback), among others.
and is consistent with the principles inherent in
response shaping (see Section 1.13.4.2.3).
(i) Stimulus control (environmental planning)
This essentially involves fading out or (iv) Response discrimination/feedback
extinguishing undesirable responses by decreas- Many habitual or addictive behaviors are
ing the number of stimuli which will elicit them. characterized by the fact that the individual is
For example, in the treatment of obesity, eating not always aware of their occurrence, has poor
responses will occur in the presence of very recall of the frequency of the behavior, or, has
many environmental cues that all gain control little structured knowledge of the circumstances
over the response. To regulate overeating, in which the behavior is emitted. This being the
therefore, it is important to begin by reducing case, it is perhaps not surprising that such
the number of these cues. This can be achieved individuals have difficulty controlling these
by eating only in specific environments (such as behaviors. One way in which this can be
a kitchen), or even eating from one particular, overcome is by including in the program a
distinctively patterned plate, and by never period of self-observation, where the individual
engaging in reinforcing activities while eating records or charts information relevant to
(for example, watching TV or reading an controlling the response.
interesting magazine) (Ferster, Nurnberger, & This may take the form of a diary in which the
Levitt, 1962; Stuart, 1967). person notes the time of occurrence of the target
behavior, the circumstances in which the
behavior is emitted, and any potentially re-
(ii) Reinforcement/punishment
inforcing or punishing consequences of the
In contrast to controlling the stimuli that behavior (Mahoney, 1974; Stuart, 1971). While
elicit target behaviors, the individual can also this form of self-observation may be beneficial
control the consequences of these behaviors by in enabling the individual to identify the
ensuring that desirable behaviors are reinforced frequency of target behaviors and to make re-
and undesirable behaviors go unreinforced or adjustments to existing contingencies (i.e, it is a
are punished. The control of the consequences form of functional analysis, see Section
416 Learning Theory
1.13.4.2.1), it is normally the case that self- attempt to put psychotherapy on a more
monitoring alone is not sufficient to maintain scientific footing, it was learning theory that
any therapeutic gains, but it is best utilized in the provided the basis for a new experimental
context of more multifaceted programs (Bel- analysis of psychopathology and a radical
lack, Schwartz, & Rosensky, 1974; Mahoney, alternative to contemporary psychodynamic
1974). interpretations. Learning theory is still
evolvingÐespecially that area of learning
theory that is concerned with human
(v) Response-reinforcer contiguity/contingency conditioningÐand as a result, it still has much
While many people claim to be aware of the to offer clinical psychology in terms of its
principle of operant reinforcement, most rarely contribution to the understanding of psycho-
apply it consistently. For instance, a student pathology and to the development of new and
may decide to spend two hours in the library effective therapies.
writing a paper and then reward oneself for this
effort by going and having a coffee and a chat
with friends. However, after two hours the 1.13.6 REFERENCES
student finds that he or she is working so well Agras, S., Sylvester, D., & Oliveau, D. (1969). The
that he or she continues writing until concen- epidemiology of common fears and phobias. Compre-
tration and motivation begins to wane, and then hensive Psychiatry, 10, 151±156.
Aitken, R. C. B., Lister, J. A., & Main, C. J. (1981).
goes for coffee. With all the good intentions in Identification of features associated with flying phobias
the world, what has happened is that the student in aircrew. British Journal of Psychiatry, 139, 38±42.
has inadvertently reinforced behaviors consis- Alloy, L. B., & Tabachnik, N. (1984). Assessment of
tent with falling levels of concentration and variation by humans and animals: The joint influence of
prior expectations and current situational information.
motivation rather than the two hours focused Psychological Review, 91, 441±485.
work that preceded this. Thus, the essence of Anderson, D. O., & Parmenter, R. (1941). A long-term
behavioral programming in self-control proce- study of the experimental neurosis in sheep and in the
dures is to ensure that the correct behaviors are dog. Psychosomatic Medicine Monographs, 2, Nos. 3 & 4.
reinforced, and that sloppy management of Ayllon, T., & Azrin, N. (1965). The measurement and
reinforcement of behavior of psychotics. Journal of the
contingencies does not inadvertently reinforce Experimental Analysis of Behavior, 8, 357±383.
inappropriate behaviors. Ayllon, T., & Azrin, N. H. (1968). The token economy: A
A good example of a multifaceted behavioral motivational system for therapy and rehabilitation. New
self-control program based on these rules is a York: Appleton-Century-Crofts.
Ayllon, T., Haughton, E., & Hughes, H. B. (1965).
behavioral control program aimed at weight Interpretation of symptoms: Fact or fiction. Behaviour
loss devised by Stuart (1967). The main elements Research & Therapy, 3, 1±7.
of this program were: (a) recording of time and Azrin, N. H. (1976). Improvements in the community-
quantity of food consumption (self-observa- reinforcement approach to alcoholism. Behaviour Re-
tion), (b) weighing in before each meal and search & Therapy, 14, 339±348.
Baer, P. E., & Fuhrer, M. J. (1968). Cognitive processes
before bedtime (aiding discrimination of the during differential trace and delayed conditioning of the
consequences of eating), (c) removal of food GSR. Journal of Experimental Psychology, 78, 81±88.
from all places in the house except the kitchen Baeyens, F., Eelen, P., Van den Bergh, O., & Crombez, G.
(environmental planning), (d) pairing eating (1989). Acquired affective evaluative value: Conservative
but not unchangeable. Behaviour Research & Therapy,
with no other activity that might be reinforcing 27, 279±287.
(such as watching TV) (behavioral program- Baeyens, F., Eelen, P, & Van den Bergh, O. (1990).
ming), (e) setting a weight-loss goal of 1±2 Contingency awareness in evaluative conditioning: A
pounds per week (setting attainable goals), (f) case for unaware affective-evaluative learning. Cognition
slowing down the pace of eating (defining & Emotion, 4, 3±18.
Bandura, A. (1969). Principles of behavior modification.
appropriate responses), and (g) substituting New York: Holt.
other activities for between-meal eating (pro- Banzett, L. K., Liberman, R. P., & Moore, J. W. (1984).
gramming acceptable competing responses). Long-term follow-up of the effects of behavior therapy.
Hospital & Community Psychiatry, 35, 277±279.
Beck, A. T. (1976). Cognitive therapy and the emotional
disorders. New York: New American Library.
1.13.5 SUMMARY Bellack, A. S., Schwartz, J., & Rozensky, R. H. (1974). The
contribution of external control to self-control in a
This chapter has traced the history of the weight reduction program. Journal of Behavior Therapy
influence of learning theory on clinical theory & Experimental Psychiatry, 5, 245±249.
and practice. It is clear that the principles of Bijou, S. W., & Baer, D. M. (1966). Operant methods in
both classical and operant conditioning have child behavior and development. In W. K. Honig (Ed.),
Operant behavior: Areas of research and application
played prominent roles in the development of (pp. 718±789). New York: Appleton-Century-Crofts.
therapeutic techniques and understanding the Black, A. H. (1971). Autonomic aversive conditioning in
etiology of psychopathology. Originally, in an infrahuman subjects. In F. R. Brush (Ed.), Aversive
References 417
conditioning and learning. New York: Academic Press. Davey, G. C. L. (1993). A comparison of three cognitive
Borgealt, A. J., Donahoe, J. W., & Weinstein, A. (1972). appraisal strategies: The role of threat devaluation in
Effects of delayed and trace components of a compound problem-focused coping. Personality & Individual Differ-
CS on conditioned suppression and heart rate. Psycho- ences, 14, 535±546.
nomic Science, 26, 13±15. Davey, G. C. L. (1994). Is evaluative conditioning a
Booth, R., & Rachman, S. (1992). The reduction of qualitatively distinct form of classical conditioning?
claustrophobiaÐI. Behaviour, Research & Therapy, 30, Behaviour Research & Therapy, 32, 291±299.
207±221. Davey, G. C. L. (1995). Preparedness and phobias: Specific
Boudewyns, P. A., Fry, T. J., & Nightengale, E. (1986). evolved associations or a generalized expectancy bias.
Token economy programs in VA medical centers: Where Behavioral & Brain Sciences, 18, 289±325.
are they today? Behavior Therapist, 9, 126±127. Davey, G. C. L. (1997). A conditioning model of phobias.
Brady, J. V., Kelly, D., & Plumlee, L. (1969). Autonomic In G. C. L. Davey (Ed.), Phobias: Handbook of theory,
and behavioral responses of the rhesus monkey to research and treatment. Chichester, UK: Wiley.
emotional conditioning. Annals of the New York Davey, G. C. L., & Arulampalam, T. (1981). Second-order
Academy of Science, 159, 959±975. electrodermal conditioning in humans. IRCS Medical
Brewin, C. R., (1988). Cognitive foundations of clinical Science, 9, 567±568.
psychology. London: Erlbaum. Davey, G. C. L., & Arulampalam, T. (1982). Second-order
Brewin, C. R. (1989). Cognitive change processes in ªfearº conditioning in humans: Persistence of CR2
psychotherapy. Psychological Review, 96, 379±394. following extinction of CR1. Behaviour Research &
Brewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual Therapy, 20, 391±396.
representation theory of post-traumatic stress disorder. Davey, G. C. L., Burgess I., & Rashes, R. (1995). Coping
Psychological Review, 103, 670±686. strategies and phobias: The relationship between fears,
Breznitz, S. (Ed.) (1983). The denial of stress. New York: phobias and methods of coping with stressors. British
International Universities Press. Journal of Clinical Psychology, 34, 423±434.
Buchwald, A. M. (1959). Extinction after acquisition under Davey, G. C. L., & Craigie, P. (1997). Manipulation of
different verbal reinforcement combinations. Journal of dangerousness judgements to fear relevant stimuli:
Experimental Psychology, 57, 43±48. Effects on a priori UCS expectancy and a posteriori
Cook, M., & Mineka, S. (1987). Second order conditioning covariation assessment. Behaviour Research & Therapy,
and overshadowing in the observational conditioning of 35, 607±617.
fear in monkeys. Behaviour Research & Therapy, 25, Davey, G. C. L., De Jong, P. J., & Tallis, F. (1993). UCS
349±364. inflation in the aetiology of a variety of anxiety
Cook, M., & Mineka, S. (1989). Observational condition- disorders: Some case histories. Behaviour Research &
ing of fear to fear-relevant versus fear-irrelevant stimuli Therapy, 31, 495±498.
in rhesus monkeys. Journal of Abnormal Psychology, 98, Davey, G. C. L., & Dixon, A. (1996). The expectancy bias
448±459. model of selective associations: The relationship of
Cook, M., & Mineka, S. (1990). Selective associations in judgements of CS dangerousness, CS±UCS similarity
the observational conditioning of fear in rhesus mon- and prior fear to a priori and a posteriori covariation
keys. Journal of Experimental Psychology: Animal assessments. Behaviour Research & Therapy, 34, 235±252.
Behavior Processes, 16, 372±389. Davey, G. C. L., & Matchett, G. (1993). UCS rehearsal
Cook, M., Mineka, S., Wolkenstein, B., & Laitsch, K. and the retention and enhancement of differential ªfearº
(1985). Observational conditioning of snake fear in conditioning: Effects of trait and state anxiety. Journal of
unrelated rhesus monkeys. Journal of Abnormal Psychol- Abnormal Psychology, 103, 708±718.
ogy, 94, 591±610. Davey, G. C. L., & Matchett, G. (1996). The effects of
Corrigan, P. W. (1991). Strategies that overcome barriers response feedback on conditioned responding during
to token economies in community programs for severely extinction: Implications for the role of interoception in
mentally ill adults. Community Mental Health Journal, anxiety-based disorders. Journal of Psychophysiology, 10,
27, 7±30. 291±302.
Corrigan, P. W. (1995). Use of a token economy with Davey, G. C. L., McDonald, A. S., Ferguson, C. E.,
seriously mentally ill patients: Criticisms and misconcep- O'Neill, A.-M., Shepherd, J., & Band, D. (1997).
tions. Psychiatric Services, 46, 1258±1263. Cognitive neutralising strategies, coping and psycholo-
Crocker, J. (1981). Judgements of covariation by social gical health. Manuscript submitted for publication.
perceivers. Psychological Bulletin, 90, 272±292. Davey, G. C. L., & McKenna, I. (1983). The effects of
Davey, G. C. L. (1988). Pavlovian conditioning in humans: postconditioning revaluation of CS1 and UCS following
UCS revaluation and self-observation of conditioned Pavlovian second-order electrodermal conditioning in
responding. Medical Science Research, 16, 957±961. humans. Quarterly Journal of Experimental Psychology,
Davey, G. C. L. (1989a). Dental phobias and anxieties: 35B, 125±133.
Evidence for conditioning processes in the acquisition Davey, G. C. L., & Singh, J. (1988). The Kamin ªblockingº
and modulation of a learned fear. Behaviour Research & effect and electrodermal conditioning in humans. Journal
Therapy, 27, 51±58. of Psychophysiology, 2, 17±25.
Davey, G. C. L. (1989b). Ecological learning theory. Dawson, M. E. (1973). Can classical conditioning occur
London: Routledge. without contingency learning? A review and evaluation
Davey, G. C. L. (1989c). UCS revaluation and condition- of the evidence. Psychophysiology, 10, 82±86.
ing models of acquired fears. Behaviour Research & Dawson, M. E., & Biferno, M. A. (1973). Concurrent
Therapy, 27, 521±528. measurement of awareness and electrodermal classical
Davey, G. C. L. (1992a). Classical conditioning and the conditioning. Journal of Experimental Psychology, 101,
acquisition of human fears and phobias: A review and 55±62.
synthesis of the literature. Advances in Behaviour Dawson, M. E., Catania, J. J., Schell, A. M., & Grings, W.
Research & Therapy, 14, 29±66. W. (1979). Autonomic classical conditioning as a
Davey, G. C. L. (1992b). An expectancy model of function of awareness of stimulus contingencies. Biolo-
laboratory preparedness effects. Journal of Experimental gical Psychology, 9, 23±40.
Psychology: General, 121, 24±40. Dawson, M. E., & Grings, W. W. (1968). Comparison of
Davey, G. C. L. (1992c). Characteristics of individuals with classical conditioning and relational learning. Journal of
fear of spiders. Anxiety Research, 4, 299±314. Experimental Psychology, 76, 227±231.
418 Learning Theory
Dawson, M. E., & Schell, A. M. (1987). The role of Ferster, C. B., & Skinner, B. F. (1957). Schedules of
ªcontrolledº and ªautomaticº cognitive processes in reinforcement. New York: Appleton-Century-Crofts.
human autonomic classical conditioning. In G. C. L. Foa, E. B., & Kozak, M. J. (1986). Emotional processing of
Davey (Ed.), Cognitive processes and Pavlovian condition- fear: Exposure to corrective information. Psychological
ing in humans. Chichester, UK: Wiley. Bulletin, 99, 20±35.
Dawson, M. E., Schell, A. M., & Tweddle-Banis, H. T. Gelder, M., Bancroft, J. H. J., Gath, D., Johnston, D. W.,
(1986). Greater resistance to extinction of electrodermal Mathews A. M., & Shaw P. M. (1973). Specific and non-
responses conditioned to potentially phobic CSs: A specific factors in behaviour therapy. British Journal of
noncognitive process? Psychophysiology, 23, 552±561. Psychiatry, 123, 445±462.
de Silva, P. (1988). Phobias and preparedness: Replication Gershone, J. R., Errickson, E. A., Mitchell, J. E., &
and extension. Behaviour Research & Therapy, 26, 97±98. Paulson, D. A. (1977). Behavioral comparison of a token
de Silva, P., Rachman, S. J., & Seligman, M. E. P. (1977). economy and a standard psychiatric treatment ward.
Prepared phobias and obsessions: Therapeutic outcome. Journal of Behavior Therapy & Experimental Psychiatry,
Behaviour Research & Therapy, 15, 65±77. 8, 381±385.
Deane, G. E. (1969). Cardiac activity during experimentally Glynn, S. M. (1990). Token economy approaches for
induced anxiety. Psychophysiology, 6, 17±30. psychiatric patients: Progress and pitfalls over 25 years.
Delprato, D. J. (1980). Hereditary determinants of fears Behavior Modification, 14, 383±407.
and phobias: A critical review. Behavior Therapy, 11, Goldstein, A. J., & Chambers, D. L. (1978). A reanalysis of
79±103. agoraphobia. Behavior Therapy, 9, 47±59.
Derby, K. M., Wacker, D., Sasso, G., Steege, M., Goorney, A. B. (1970). Treatment of aviation phobias by
Northrup, J., Cigrand, K., & Asmus, J. (1992). Brief behaviour therapy. British Journal of Psychiatry, 117,
functional assessment techniques to evaluate aberrant 535±544.
behavior in an outpatient setting: A summary of 79 Grether, W. F. (1938). Pseudo-conditioning without paired
cases. Journal of Applied Behavior Analysis, 25, 713±721. stimulation encountered in attempted backward con-
Diamond, D., Matchett, G., & Davey, G. C. L. (1995). The ditioning. Journal of Comparative Psychology, 25, 91±96.
effect of prior fear levels on UCS-expectancy ratings to a Gripp, R. F., & Magaro, P. A. (1971). A token economy
fear-relevant stimulus. Quarterly Journal of Experimental program evaluated with untreated control ward compar-
Psychology, 48A, 237±247. isons. Behaviour Research & Therapy, 9, 137±149.
Dickerson, F., Ringel, N., & Parente, F. (1994). Seclusion Hafner, J., & Marks, I. (1976). Exposure in vivo of
and restraint, assaultiveness, and patient performance in agoraphobics: Contributions of diazipam, group expo-
a token economy. Hospital & Community Psychiatry, 45, sure and anxiety evocation. Psychological Medicine, 6,
168±170. 71±88.
Dickinson, A. (1980). Contemporary animal learning theory. Hagopian, L. P., Fisher, W. W., & Legacy, S. M. (1994).
Cambridge, UK: Cambridge University Press. Schedule effects of noncontingent reinforcement on
Dickinson, A., & Mackintosh, N. J. (1979). Reinforcer attention-maintained destructive behavior in identical
specificity in the enhancement of conditioning by post- quadruplets. Journal of Applied Behavior Analysis, 27,
trial surprise. Journal of Experimental Psychology: 317±325.
Animal Behavior Processes, 5, 162±177. Hall, J., & Baker, R. (1973). Token economy systems:
Dickinson, A., Shanks, D., & Evenden, J. (1984). Judge- Breakdown and control. Behaviour Research & Therapy,
ment of act-outcome contingency: The role of selective 11, 253±263.
attribution. Quarterly Journal of Experimental Psychol- Hamm, A. O., Viatl, D., & Lang, P. J. (1989). Fear
ogy, 36A, 29±50. conditioning, meaning and belongingness: A selective
Dollard, J., & Miller, N. E. (1950). Personality and analysis. Journal of Abnormal Psychology, 98, 395±406.
psychotherapy: An analysis in terms of learning, thinking Harris, B. (1979). Whatever happened to Little Albert?
and culture. New York: McGraw-Hill. American Psychologist, 34, 151±160.
Emmelkamp, P. M. G. (1982). Phobic and obsessive- Harris, M. B., & Bruner, C. G. (1971). A comparison of a
compulsive disorders: Theory, research and practice. self-control and a contract procedure for weight control.
New York: Plenum. Behaviour Research & Therapy, 9, 347±354.
English, H. B. (1929). Three cases of the ªconditioned fear Harris, M. B., & Hallbauer, E. S. (1973). Self-directed
response.º Journal of Abnormal & Social Psychology, 34, weight control through eating and exercise. Behaviour
221±225. Research & Therapy, 11, 523±529.
Esteves, F., Dimberg, U., Parra, C., & OÈhman, A. (1994). Haynes, S. N., & O'Brien, W. H. (1990). Functional
Nonconscious associative learning: Pavlovian condition- analysis in behavior therapy. Clinical Psychology Review,
ing of skin conductance responses to masked fear- 10, 649±668.
relevant facial stimuli. Psychophysiology, 31, 375±385. Hedberg, A. G., & Campbell L., III (1974). A comparison
Eysenck, H. J. (1976). The learning theory model of of four behavioral treatments of alcoholism. Journal of
neurosisÐa new approach. Behaviour Research & Behavior Therapy and Experimental Psychiatry, 5,
Therapy, 14, 251±268. 251±256.
Eysenck, H. J., & Kelley, M. J. (1987). The interaction of Hersen, M., Eisler, R. M., Alford, G., & Agras, S. (1973).
neurohormones with Pavlovian A and Pavlovian B Effects of token economy on neurotic depression: An
conditioning in the causation of neurosis, extinction, experimental analysis. Behavior Therapy, 4, 392±397.
and incubation of anxiety. In G. C. L. Davey (Ed.), Hofmeister, J. F., Schneckenbach, A. F., & Clayton, S. H.
Cognitive processes and Pavlovian conditioning in humans (1979). A behavioral program for the treatment of
(pp. 251±286). Chichester, UK: Wiley. chronic patients. American Journal of Psychiatry, 136,
Eysenck, H. J., & Rachman, S. J. (1965). Causes and cures 396±400.
of neuroses. London: Routledge. Honeybourne, C., Matchett, G., & Davey, G. C. L. (1993).
Eysenck, H. J. (1979). The conditioning model of neurosis. Expectancy models of laboratory preparedness effects: A
Behavioral & Brain Sciences, 2, 155±199. UCS-expectancy bias in phylogenetic and ontogenetic
Fairbank, J. A., & Brown, T. A. (1987). Current behavioral fear-relevant stimuli. Behavior Therapy, 24, 253±264.
approaches to the treatment of post-traumatic stress Hugdahl, K., & Johnsen, B. H. (1989). Preparedness
disorder. The Behavior Therapist, 3, 57±64. and electrodermal fear conditioning: Ontogenetic vs.
Ferster, C. B., Nurnberger, J. I., & Levitt, E. B. (1962). The phylogenetic explanations. Behaviour Research &
control of eating. Journal of Mathetics, 1, 87±109. Therapy, 27, 269±278.
References 419
Isaacs, W., Thomas, J., & Goldiamond, I. (1960). behavior. In M. D. Zeiler & P. Harzem (Eds.), Advances
Application of operant conditioning to reinstate verbal in analysis of behavior (Vol 1, pp. 159±192). Chichester,
behavior in psychotics. Journal of Speech & Hearing UK: Wiley.
Disorders, 25, 8±12. Lowe, C. F. (1983). Radical behaviorism and human
Iwata, B. A, Dorsey, M. F., Slifer, K. J., Bauman K. E., & psychology. In G. C. L. Davey (Ed.), Animal models of
Richman, G. S. (1985). Toward a functional analysis of human behavior. Chichester, UK: Wiley.
self-injury. In G. Murphy & B. Wilson (Eds.), Self- Lubow, R. E. (1973). Latent inhibition. Psychological
injurious behavior. Kidderminster, UK: BIHM. Bulletin, 79, 398±407.
Jacobson, N., & Weiss, R. L. (1978). Behavioral marriage Lutzker, J. R., & Lutzker, S. Z. (1977). A two-dimensional
therapy III. The contents of Gurman et al. may be contract: Weight loss and household responsibility
hazardous to our health. Family Process, 17, 149±163. performance. In E. E. Abramson (Ed.), Behavioral
Kamin, L. J. (1968). ªAttention-likeº processes in classical approaches to weight control (pp. 114±122). New York:
conditioning. In M. R. Jones (Eds.), Miami symposium Springer.
on the prediction of behavior: Aversive stimulation. Lutzker, J. R., & Martin, J. A. (1981). Behavior change.
Miami, FL: University of Miami Press. Monterey, CA: Brooks.
Kamin, L. J. (1969). Predictability, surprise, attention and Mace, F. C., Browder, D., & Lyn, Y. (1987). Analysis of
conditioning. In B. A. Campbell & R. M. Church (Eds.), demand conditions associated with stereotypy. Journal of
Punishment and aversive behavior. New York: Appleton- Behavior Therapy & Experimental Psychiatry, 18, 25±31.
Century-Crofts. Mace, F. C., & Knight, D. (1986). Functional analysis and
Kazdin, A. E. (1975). Behavior modification in applied treatment of severe pica. Journal of Applied Behavior
settings. Homewood, IL: Dorsey Press. Analysis, 19, 411±416.
Kazdin, A. E., & Bootzin, R. R. (1972). The token Mackintosh, N. J. (1983). Conditioning and associative
economy: An evaluative review. Journal of Applied learning. Oxford, UK: Oxford University Press.
Behavior Analysis, 5, 343±372. Mahoney, M. J. (1974). Self-reward and self-monitoring
Kazdin, A. E., & Wilcoxon, L. A. (1976). Systematic techniques for weight control. Behavior Therapy, 5,
desensitization and non-specific treatment effects: A 48±57.
methodological evaluation. Psychological Bulletin, 83, Mann, R. A. (1972). The behavior-therapeutic use of
729±758. contingency contracting to control an adult weight
Kazdin, A. E. (1981). The token economy. In G.C.L.Davey problem: Weight control. Journal of Applied Behavior
(Eds.), Applications of conditioning theory. London: Analysis, 5, 99±109.
Methuen. Marks, I. M. (1987). Fears, phobias and rituals. New York:
Keane, T. M., Zimering, R. T., & Caddell, J. M. (1985). A Oxford University Press.
behavioral formulation of post-traumatic stress disorder Masserman, J. H. (1943). Behavior and neurosis. Chicago:
in Vietnam veterans. The Behavior Therapist, 8, 9±12. University of Chicago Press.
Kilpatrick, D. G., Veronen L. J., & Best C. L. (1985). Masserman, J. H. (1950). Experimental neurosis. Scientific
Factors predicting psychological distress among rape American, 182, 38±50.
victims. In C. R. Figley (Ed.), Trauma and its wake Mathews, A. (1978). Fear-reduction research and clinical
(pp. 113±141). New York: Brunner/Mazel. phobias. Psychological Bulletin, 85, 390±406.
Kimble, G. A. (1961). Hilgard and Marquisº Conditioning Mathews, A. M., Bancroft, J., Whitehead, A., Hackmann,
and learning. London: Methuen. A., Julier, D., Bancroft, J., Gath, D., & Shaw, P. (1976).
Kirkpatrick, D. R. (1984). Age, gender and patterns of The behavioral treatment of sexual inadequacy: A
common intense fears among adults. Behavior Research comparative study. Behaviour Research & Therapy, 14,
& Therapy, 22, 141±150. 427±436.
Klein, S. B. (1969). Counterconditioning and fear reduc- Mazaleski, J. L., Iwata, B. A., Vollmer, T. R., Zarcone, J.
tion in the rat. Psychonomic Science, 77, 150±151. R., & Smith, R. G. (1993). Analysis of the reinforcement
Kockott, G., Dittmar, F., & Nusselt, L. (1975). Systematic and extinction components in DRO contingencies with
desensitization of erectile impotence: A controlled study. self-injury. Journal of Applied Behavior Analysis, 26,
Archives of Sexual Behavior, 4, 493±500. 143±156.
Krasner, L. (1971). Behavior therapy. Annual Review of McAllister, W. R., & McAllister, D. E. (1971). Behavioral
Psychology, 22, 483±532. measurement of conditioned fear. In F. R. Brush (Ed.),
Lautch, H. (1971). Dental phobia. British Journal of Aversive conditioning and learning. New York: Academic
Psychiatry, 119, 151±158. Press.
Leitenberg, H. (1976). Handbook of behavior modification McNally, R. J. (1987). Preparedness and phobias: A
and behavior therapy. Englewood Cliffs, NJ: Prentice- review. Psychological Bulletin, 101, 283±303.
Hall. McNally, R. J., & Heatherton, T. F. (1993). Are covaria-
Lemere, F., & Voegtlin, W. L. (1950). An evaluation of tion biases attributable to a priori expectancy biases.
aversive treatment of alcoholism. Quarterly Journal of Behaviour Research & Therapy, 31, 653±658.
the Study of Alcoholism, 11, 199±204. Menzies, R. G., & Clarke, J. C. (1993a). The aetiology of
Lichtenstein, E., & Danaher, B. (1976). Modification of childhood water phobia. Behaviour Research & Therapy,
smoking behavior: A critical analysis of theory, research 31, 499±501.
and practice. In M. Hersen, R. M. Eisler, & P. M. Miller Menzies, R. G., & Clarke, J. C. (1993b). The etiolology of
(Eds.), Progress in behavior modification (Vol. 3). New fear of heights and its relationship to severity and
York: Academic Press. individual response patterns. Behaviour Research &
Liddell, A., & Lyons, M. (1978). Thunderstorm phobias. Therapy, 31, 355±365.
Behavior Research & Therapy, 16, 306±308. Merckelbach, H., & de Jong, P. J. (1997). Evolutionary
Lindsley, O. R., Skinner, B. F., & Solomon, H. C. (1953). models of phobias. In G. C. L. Davey (Ed.), Phobias:
Studies in behavior therapy: Status report I. Waltham, Handbook of theory, research and treatment. Chichester,
MA: Metropolitan State Hospital. UK: Wiley.
Lippman, M. R., & Motta, R. W. (1993). Effects of Merckelbach, H., de Ruiter, C., van den Hout, M. A., &
positive and negative reinforcement on daily living skills Hoekstra, R. (1989). Conditioning experiences and
in chronic psychiatric patients in community residences. phobias. Behaviour Research & Therapy, 27, 657±662.
Journal of Clinical Psychology, 49, 654±662. Mineka, S., & Cook, M. (1993). Mechanisms involved in
Lowe, C. F. (1979). Determinants of human operant the observational conditioning of fear. Journal of
420 Learning Theory
Experimental Psychology: General, 122, 23±38. Rachman, S. (1977). The conditioning theory of fear
Mineka, S., Davidson, M., Cook, M., & Weir, R. (1984). acquisition: A critical examination. Behaviour Research
Observational conditioning of snake fear in rhesus & Therapy, 15, 375±387.
monkeys. Journal of Abnormal Psychology, 93, 355±372. Rachman, S. J., & Teasdale J. (1969). Aversion therapy and
Mowrer, O. H. (1947). On the dual nature of learningÐa behavior disorders: An analysis. Coral Gables, FL:
reinterpretation of ªconditioningº and ªproblem-sol- University of Miami Press.
ving.º Harvard Educational Review, 17, 102±148. Rachman, S. J., & Wilson, G. T. (1980). The effects of
Murray, E., & Foote, F. (1979). The origins of fear of psychological therapy. London: Pergamon.
snakes. Behaviour Research & Therapy, 17, 489±493. Rescorla, R. A. (1967). Pavlovian conditioning and its
Northup, J., Broussard, C., Jones, K., George, T., Vollmer, proper control procedures. Psychological Review, 74,
T. R., & Herring, M. (1995). The differential effects of 71±80.
teacher and peer attention on the disruptive classroom Rescorla, R. A. (1980). Pavlovian second-order conditioning:
behavior of three children with a diagnosis of attention Studies in associative learning. Hillsdale, NJ: Erlbaum.
deficit hyperactivity disorder. Journal of Applied Beha- Rescorla, R. A., & Wagner, A. R. (1972). A theory of
vior Analysis, 28, 277±288. Pavlovian conditioning: Variations in the effectiveness of
O'Leary, K. D., & Wilson, G. T. (1975). Behavior therapy: reinforcement and non-reinforcement. In A. H. Black &
Application and outcome. Englewood Cliffs, NJ: Prentice- W. F. Prokasy (Eds.), Classical conditioning II: Current
Hall. research and theory. New York: Appleton-Century-
O'Reilly, M. F. (1995). Functional analysis and treatment Crofts.
of escape-maintained aggression correlated with sleep Richards, M., & Martin, I. (1990). Eysenck's incubation of
deprivation. Journal of Applied Behavior Analysis, 28, fear hypothesis: An experimental test. Behaviour Re-
225±226. search & Therapy, 28, 373±384.
OÈhman, A. (1979). Fear relevance, autonomic conditioning Rizley, R. C., & Rescorla, R. A. (1972). Associations in
and phobias: A laboratory model. In P. O. Sjoden, S. second-order conditioning and sensory preconditioning.
Bates, & W. S. Dockens III (Eds.), Trends in behaviour Journal of Comparative & Physiological Psychology, 81,
therapy. New York: Academic Press. 1±11.
OÈhman, A. (1993). Fear and anxiety as emotional Russell, C., & Davey, G. C. L. (1991). The effects of false
phenomena: Clinical phenomenology, evolutionary per- response feedback on human ªfearº conditioning.
spectives, and information processing mechanisms. In Behaviour Research & Therapy, 29, 19±196.
M. Lewis & J. M. Haviland (Eds.), Handbook of Salkovskis, P. M. (1991). The importance of behaviour in
emotions. New York: Guilford Press. the maintenance of anxiety and panic: A cognitive
OÈhman, A., Dimberg, U., & OÈst, L-G (1985). Animal and account. Behavioural Psychotherapy, 19, 6±19.
social phobias: Biological constraints on learned fear Samson, D. M., & McDonnell, A. A. (1990). Functional
responses. In S. Reiss & R. R. Bootzin (Eds.), Theoretical analysis and challenging behaviours. Behavioural Psy-
issues in behavior therapy. New York: Academic Press. chotherapy, 18, 259±271.
OÈhman, A., Fredrikson, M. L., & Hugdahl, K. (1978). Sandler, S., & Davidson, R. S. (1973). Psychopathology:
Towards an experimental model of simple phobic reac- Learning theory, research and applications. New York:
tions. Behavioural Analysis & Modification, 2, 97±114. Harper Row.
OÈst, L-G. (1989). A one-session group treatment for Scheier, M. F., & Carver, C. S. (1992). Effects of optimism
specific phobias. Behaviour Research & Therapy, 27, 1±7. on psychological and physical well-being: Theoretical
OÈst, L-G. (1997). Rapid treatment of specific phobias. In overview and empirical update. Cognitive Therapy &
G. C. L. Davey (Ed.), Phobias: Handbook of theory, Research, 16, 201±228.
research and treatment. Chichester, UK: Wiley. Schneiderman, N. E., Pearl, L., Wilson, W., Metcalf, F.,
OÈst, L-G., & Hugdahl, K. (1981). Acquisition of phobias Moore, J. W., & Swadlow, H. A. (1971). Stimulus
and anxiety response patterns in clinical patients. control in rabbits (Oryctolagus cuniculus) as a function of
Behaviour Research & Therapy, 19, 439±447. different intensities of intracranial stimulation. Journal of
Owens, R. G., & Ashcroft, J. E. (1982). Functional analysis Comparative & Physiological Psychology, 76, 175±186.
in applied psychology. British Journal of Clinical Seligman, M. E. P. (1971). Phobias and preparedness.
Psychology, 21, 181±189. Behavior Therapy, 2, 307±320.
Parkinson, B. (1985). Emotional effects of false autonomic Seligman, M. E. P. (1976). Helplessness. San Francisco:
feedback. Psychological Bulletin, 98, 471±494. Freeman.
Paul, G. L., & Bernstein, D. (1973). Anxiety and clinical Siddle, D. A. T., & Remington, B. (1987). Latent inhibition
problems: Systematic desensitization and related techni- and human Pavlovian conditioning: Research and
ques. Morristown, NJ: General Learning Press. relevance. In G. C. L. Davey (Ed.), Cognitive processes
Paul, G. L., & Lentz, R. J. (1977). Psychological treatment and Pavlovian conditioning in humans (pp. 115±146).
of chronic mental patients: Milieu versus social-learning Chichester, UK: Wiley.
programs. Cambridge, MA: Harvard University Press. Siddle, D. A. T., Remington, B., & Churchill, M. (1985).
Pavlov, I. P. (1927). Conditioned reflexes. Oxford, UK: Effects of conditioned stimulus pre-exposure on human
Oxford University Press. electrodermal conditioning. Biological Psychology, 20,
Pearce, J. M., & Hall, G. (1980). A model for Pavlovian 113±127.
learning: Variations in the effectiveness of conditioned Skinner, B. F. (1938). The behavior of organisms. New
but not of unconditioned stimuli. Psychological Review, York: Appleton-Century-Crofts.
87, 532-552. Skinner, B. F. (1948). ªSuperstitionº in the pigeon. Journal
Pierrel, R., & Sherman, J. G. (1963). Barnabus, the rat with of Experimental Psychology, 38, 168±172.
the college training. Brown Alumni Monthly, February. Skinner, B. F. (1953). Science and human behavior. New
Prokasy, W. F., & Kumpfer, K. L. (1969). Conditioning, York: MacMillan.
probability of reinforcement and sequential behavior in Skinner, B. F. (1957). Verbal behavior. New York:
human conditioning with intermittent schedules. Psy- Appleton-Century-Crofts.
chonomic Science, 14, 49±50. Skinner, B. F. (1969). Contigencies of reinforcement: A
Prokasy, W. F., & Williams, W. C. (1979). Information theoretical analysis. New York: Appleton-Century-
processing and the decremental effect of intermittent Crofts.
reinforcement schedules in human conditioning. Bulletin Skinner, B. F. (1971). Beyond freedom and dignity. New
of the Psychonomic Society, 14, 57±60. York: Alfred A. Knopf.
References 421
Skinner, B. F. (1974). About behaviorism. London: Jona- reactions. Journal of Experimental Psychology, 3, 1±14.
thon Cape. Weiner, H. (1969). Controlling human fixed-interval
Slade, P. (1982). Towards a functional analysis of Anorexia performance. Journal of the Experimental Analysis of
Nervosa and Bulimia Nervosa. British Journal of Clinical Behavior, 12, 349±373.
Psychology, 21, 167±179. White, K., & Davey, G. C. L. (1989). Sensory precondi-
Stokes, T. F., & Baer, D. M. (1977). An implicit technology tioning and UCS inflation in human ªfearº conditioning.
of generalization. Journal of Applied Behavior Analysis, Behaviour Research & Therapy, 27, 161±166.
10, 349±369. Wiens, A. N., Montage, J. R., Manaugh, T. S., & English,
Stokes, T. F., & Osnes, P. G. (1988). The developing C. J. (1976). Pharmacological aversive countercondition-
applied technology of generalization and maintenance. ing to alcohol in a private hospital: One year follow-up.
In R. H. Homer, G. Dunlap, & R. L. Koegel (Eds.), Journal of Studies on Alcohol, 37, 1320±1324.
Generalization and maintenance: Life style changes in Willems, E. P. (1974). Behavioral technology and beha-
applied settings. Baltimore: Brookes. vioral ecology. Journal of Applied Behavior Analysis, 7,
Stuart, R. B. (1967). Behavioral control of overeating. 151±165.
Behaviour Research & Therapy, 5, 357±365. Williams, C. D. (1959). The elimination of tantrum
Stuart, R. B. (1971). A three-dimensional program for the behaviors by extinction procedures. Journal of Abnormal
treatment of obesity. Behaviour Research & Therapy, 9, and Social Psychology, 59, 269.
177±186. Williams, S. L., Turner, S. M., & Peer, D. F. (1985).
Stuart, R. B., & Davis, B. (1972). Slim chance in a fat Guided mastery and performance desensitization treat-
world: Behavioral control of obesity. Champaign, IL.: ments for severe acrophobia. Journal of Consulting &
Research Press. Clinical Psychology, 53, 237±247.
Thoresen, C. E., & Mahoney, M. J. (1974). Behavioral self-
Wills, T. A. (1981). Downward comparison principles in
control. New York: Holt, Rinehart & Winston.
social psychology. Psychological Bulletin, 90, 245±271.
Thorndike, E. L. (1935). The psychology of wants, interests
Wilson, G. T. (1968). Reversal of differential GSR
and attitudes. London: Appleton-Century-Crofts.
conditioning by instructions. Journal of Experimental
Valentine, C. W. (1930). The innate bases of fear. Journal
Psychology, 76, 491±493.
of Genetical Psychology, 37, 394±420.
Voegtlin, W. L., & Lemere, F. (1942). The treatment of Wilson, G. T. (1973). Effects of false feedback of avoidance
alcohol addiction: A review of the literature. Quarterly behavior: ªCognitiveº desensitization revisited. Journal
Journal of the Study of Alcohol, 2, 717±803. of Personality & Social Psychology, 28, 115±123.
Vollmer, T. R., Iwata, B. A., Zarcone, J. R., Smith, R. G., Wilson, G. T. (1978). Aversion therapy for alcoholism:
& Mazaleski, J. L. (1993). The role of attention in the Issues, ethics, and evidence. In G. A. Marlatt & P. E.
treatment of attention-maintained self-injurious beha- Nathan (Eds.), Behavioral approaches to alcoholism. New
vior: Noncontingent reinforcement (NCR) and differ- Brunswick, NJ: Center for Alcohol Studies.
ential reinforcement of other behavior (DRO). Journal of Wilson, G. T., Leaf, R. C., & Nathan, P. E. (1975). The
Applied Behavior Analysis, 26, 9±21. aversive control of excessive alcohol consumption by
Vollmer, T. R., & Smith, R. G. (1996). Some current chronic alcoholics in the laboratory setting. Journal of
themes in functional analysis research. Research in Applied Behaviour Analysis, 8, 13±26.
Development Disabilities, 17, 229±249. Withers, R. D. & Deane, F. P. (1995). Origins of common
Wacker, D. P., Steege, M. W., Northup, J., Sasso, G., Berg, fears: Effects of severity, anxiety responses and memories
W., Reimers, T., Cooper, L., Cigrand, K., & Donn, L. of onset. Behaviour Research & Therapy, 33, 903±915.
(1990). A component analysis of functional communica- Wolpe, J. (1958). Psychotherapy by reciprocal inhibition.
tion training across three topographies of severe Stanford, CA: Stanford University Press.
behavior problems. Journal of Applied Behavior Analysis, Wolpe, J., & Lazarus, A. A. (1966). Behavior therapy
23, 417±429. techniques: A guide to the treatment of neuroses. New
Walker, H., & Buckley, N. (1968). The use of positive York: Pergamon.
reinforcement in conditioning attending behavior. Jour- Wolpe. J., & Rowan, V. C. (1988). Panic disorder: A
nal of Applied Behavior Analysis, 1, 242±250. product of classical conditioning. Behavior Research &
Watson, J. B., & Rayner, R. (1920). Conditioned emotional Therapy, 26, 441±450.
1.14
Psychodynamic Theory
PETER FONAGY
University College London, UK

1.14.1.1 The Basic Psychodynamic Model 424
1.14.1.2 The Plurality of Psychodynamic Theories and the Homogeneity of Psychodynamic Frames of Reference 424
1.14.1.3 Problems of Validity of Psychodynamic Theories 425
1.14.1.4 Psychic Reality, Physical Reality, Fantasy, and Reconstruction 425
1.14.1.5 Further Controversial Issues 426
1.14.2 FREUD'S MULTIPLE MODELS OF THE MIND 426
1.14.2.1 The Affect-trauma and Topographic Frames of Reference 426
1.14.2.2 The Structural Frame of Reference 427
1.14.2.3 Some Limitations of Freud's Models 427
1.14.3 THE STRUCTURAL APPROACH 427
1.14.3.1 American Ego Psychology 427
1.14.3.1.1 Hartmann's classical model 427
1.14.3.1.2 Modern structural theory 428
1.14.3.1.3 Extensions of the ego psychology model 428
1.14.3.1.4 The classical model of the neurosis 429
1.14.3.1.5 The classical model of severe psychopathology 429
1.14.3.2 The Structural Developmental Tradition 430
1.14.3.2.1 Anna Freud 430
1.14.3.2.2 Margaret Mahler 431
1.14.3.2.3 Sandler's reframing of the structural model 432
1.14.3.3 Strengths and Weaknesses of the Model 432
1.14.4 THE OBJECT RELATIONS APPROACH 432
1.14.4.1 Introduction to the Object Relations Approach 432
1.14.4.2 The Klein±Bion Model 433
1.14.4.2.1 Some essential Kleinian concepts 433
1.14.4.2.2 Kleinian approach to neurosis 435
1.14.4.2.3 Rosenfeld's developmental model of narcissism 435
1.14.4.2.4 Kleinian approach to severe psychopathology 435
1.14.4.2.5 Strengths and weaknesses of the Klein±Bion model 435
1.14.4.3 The Fairbairn±Winnicott Model 436
1.14.4.3.1 Major innovations of the ªIndependentº tradition 436
1.14.4.3.2 The Independent view of neurotic processes and severe psychopathology 437
1.14.4.3.3 Strengths and weaknesses of the approach 437
1.14.4.4 Kohut's Self-psychology 438
1.14.4.4.1 Innovative aspects of Kohut's theory 438
1.14.4.4.2 Self-psychological model of mental disorder 438
1.14.4.4.3 Strengths and weaknesses of Kohut's model 438
1.14.4.5 Kernberg's Integrated Theory 439
1.14.4.5.1 Internalization and the construction of self, object, and affect triads 439
1.14.4.5.2 Levels of pathology within Kernberg's system 439
1.14.4.5.3 Borderline personality disorder 439
1.14.4.5.4 Strengths and weaknesses of Kernberg's model 440
1.14.4.6 Bowlby's Attachment Theory Model 440
1.14.4.6.1 Innovative aspects of Bowlby's approach 440
423
424 Psychodynamic Theory
1.14.4.6.2 Attachment and psychopathology 441

1.14.4.6.3 Strengths and weaknesses of Bowlby's theory 441
1.14.5 EVIDENCE FOR PSYCHODYNAMIC THEORIES 441
1.14.1 INTRODUCTION a constant state of change since its inception.

Historically, it has evolved from an early
1.14.1.1 The Basic Psychodynamic Model concentration on the role of instincts (sexual
and aggressive) in psychopathology via a focus
This chapter provides a review of psychody- on the functions of the ego, to the current
namic theories, including classical and contem- interest in the early mother±infant dyad and its
porary structural theories, developments of ego long-term effect upon interpersonal relation-
psychological models, and British and US ships and their internal representation (object
object relational approaches. The discussion relations). In the meantime a psychology of the
of each of these psychoanalytical schools is self has become part of most psychoanalytic
organized in terms of illustrating the contribu- theories, and the move away from a physical
tions each may be seen to provide to clinical science metaphor for psychopathology has
psychology in terms of etiological treatment and resulted in a clinical theory where both
empirical considerations. pathology and its treatment are viewed in terms
Psychodynamic psychology, Freud's discov- of mental representations.
ery and invention (Cooper, 1985), has enjoyed Psychodynamic theory has changed literally
considerable success as an explanatory frame- out of all recognition over the past 30 years. Yet
work for understanding psychopathology and mental health scientists, if they think about
clinical work because its few basic assumptions psychodynamic theories at all, are still likely to
and propositions are open to endless elabora- think of these as some parody of the libidinal
tion, revision, and refinement. Most specific developmental phases of oral, anal, phallic, and
psychodynamic propositions are data depen- genital sexuality: excessive indulgence of any of
dent, that is, they may be revised or discarded these pleasures, as well as their unreasonable
without fundamentally affecting the integrity of frustration, causes fixations which psychoana-
the psychoanalytic approach. There may be lysts are supposed to regard as the roots of
some assumptions which are essential to the adverse developmental consequences.
theory (Sandler & Joffe, 1969). These include: Although now clearly outdated, there was a
(i) psychic determinism, namely that cogni- remarkably prescient aspect to Freud's (1905b)
tive, emotional and behavioral aspects of psychosexual theory. His general approach,
pathology may be most conveniently studied seeing adult pathology as the outcome of
in terms of psychological causes (rather then deviations from normal developmental pro-
physical causality or random biological events); cesses, set a developmental frame of reference
(ii) the pleasure±unpleasure principle, namely for psychoanalytic thought which has remained
that behavior may be seen as an adaptive effort important to the present day and currently links
at minimizing psychic pain and maximizing psychodynamic thought to the vibrant disci-
psychic pleasure and a sense of intrapsychic pline of developmental psychopathology (Cic-
safety; chetti & Cohen, 1995). The continuity of
(iii) the biological nature of the organism personality from childhood through adoles-
drives its psychological adaptation; cence to adulthood, and the role of childhood
(iv) the dynamic unconscious, namely that experience in setting these trajectories, lies at the
mental forces contend for control over access heart of the psychodynamic approach and
to consciousness and to actions; and serves to unify it.
(v) the genetic±developmental proposition Early theories, however, continue to exist
which states that behavior is explicable in terms side-by-side with more recent formulations.
of earlier (or even earliest infantile) events. Some writers even suggest that a number of
frameworks are necessary to provide a com-
prehensive theory of psychopathology and
1.14.1.2 The Plurality of Psychodynamic
therapy (Pine, 1985). In practice, each theory
Theories and the Homogeneity of
has its ªrange of convenience,º particular
Psychodynamic Frames of Reference
clinical phenomena which it addresses in a
Psychodynamic theories are diverse in terms particularly helpful way. For example, dreams
of focus but share a common frame of reference. are still best explained in the context of Freud's
Undoubtedly because of the flexibility of its topographical frame of reference (Freud, 1900).
assumptions, psychodynamic theory has been in By contrast, neurotic disorders are most easily
Introduction 425
explained psychodynamically as part of a First, 1990). The behavior-based, descriptive

psychology of conflict (Brenner, 1982). Axis approach of DSM minimizes clinical inference,
II disorders, particularly personality disorders is rooted in logical positivism and thus favors
in the Dramatic Cluster, are most productively behavioral and biological orientations (M. A.
explored in the context of theories which have Schwartz, 1991) over dynamic and other
evolved as repudiations of the conflict-based potentially useful orientations to psychopathol-
models (Kohut, 1971). ogy (M. A. Schwartz & Wiggins, 1988).
Psychodynamic accounts have a further
pervasive limitation: that of gender bias. Since
1.14.1.3 Problems of Validity of Psychodynamic the work of Freud (1900), masculine develop-
Theories ment has invariably been more coherently
described than its feminine counterpart (Hor-
A major shortcoming of psychodynamic ney, 1939). In contrast, psychodynamic models
models lies in the fact that hypotheses about far more often implicate the mother in patho-
the nature of development, psychopathology, or logical processes than they do the father, with
treatment techniques are rarely based on direct remarkably few exceptions (e.g., Limentani,
evidence. To accept clinical accounts as validat- 1989).
ing psychodynamic hypotheses runs into justifi-
able opposition from philosophers of science
who regard them as irretrievably confounded by 1.14.1.4 Psychic Reality, Physical Reality,
suggestion (e.g., GruÈnbaum, 1984). Psycho- Fantasy, and Reconstruction
analytic metapsychology is at best loosely
coupled to clinical observations (Fonagy, A specific issue concerning the status of
1982; Holzman, 1985; G. S. Klein, 1976b; clinical evidence has emerged recently and
Ricoeur, 1977; Schafer, 1976) and clinical acquired the status of a major pseudoscientific
reports cannot therefore provide an indepen- debate: that of the validity of reconstructions of
dent confirmation for psychodynamic theory. childhood traumatic experiences in therapy
Their clinical roots explain why psycho- (Allen, 1995; Sandler & Fonagy, 1997). The
analytic ideas tend to reflect the population of classical psychoanalytic view emphasized the
patients which preoccupied particular theoreti- intrapsychic experience of the individual and
cians. For example, Winnicott (1965c) con- was relatively uninterested in the ªrealº world.
ceived of inauthenticity and the false self as a There was a silent assumption that the matura-
core problem and focused on its cause as the tional stages of drives were of greater impor-
failure of good enough mothering and the tance than so-called ªaccidentsº of the
inadequate provision of a holding environment. environment. In, contrast many more recent
Kohut's (1971, 1977) central clinical puzzle was theories, based on the study of adult pathology,
the question of how one develops an enfeebled posit that the actual behaviors of the caregivers
self, and he oriented his interests towards the towards the young child, as recovered in
mother's capacity for empathic responsiveness. therapy, are of crucial significance to pathogen-
It is rarely clear whether each psychodynamic esis (e.g., Bowlby, 1958; Kohut, 1971; Sullivan,
approach is associated with a particular 1953; Winnicott, 1965a). Do such reconstruc-
category of clinical cases or, as is more likely tions have a truth value?
the case, theoreticians reconstruct their patients There is controversy in psychoanalysis (re-
in ways that fit the theory. flecting a culture-wide debate) concerning the
There is a further reason why psychodynamic ªknowabilityº of early experience. Shengold
ideas are hard to integrate into the network of (1989) links the controversy to the eighteenth-
behavioral science knowledge even at the level century debate initiated by George Berkley
of clinical description. Psychodynamic diag- concerning the knowability of reality beyond
nostic descriptions map poorly onto current the mind and its ideas. Masson (1984) fueled the
psychiatric nomenclature (Jacobson & Cooper, current debate by his oversimplified Assault on
1993; Shapiro, 1989). Many psychodynamically truth in which he chastised Freud for having
oriented clinicians claim that the phenomen- defensively abandoned and deliberately with-
ological approach of modern psychiatry is held evidence supporting the seduction theory
inherently alien to the etiological models of of neurosis. Fredrick Crews (1995), in a series of
psychoanalysis (A. Freud, 1965), and the vicious attacks, laid the blame on false
intention of the framers of the Diagnostic and memories of childhood sexual abuse at the
statistical manual of mental disorders, 4th door of psychodynamic approaches.
edition (DSM-IV), is to exclude all psychody- Faced with the unpleasant choice between
namic data and inference as basic to clinical risks of fabrication and denial, many psycho-
assessment (Frances, Pincus, Widiger, Davis, & dynamic clinicians adopted a hermeneutic
approach to psychodynamic theory (e.g., Ri- with the external world provided that the latter
coeur, 1977; Spence, 1982). They repudiate a does not thwart its desire for self-actualization,
therapeutic search for the ªrealº past and through malevolence and unresponsiveness
embrace the criterion of internal coherence as (Winnicott, 1965b)?
the sole appropriate test of ªtruth.º For (iv) Can stage theory used to describe child
example, Spence (1987) insists that psycho- development be extended to the adult, as for
analysis cannot claim to have a privileged example Erikson (1950a) suggests, or is devel-
position with regard to what was (Freud's opment better seen as the repetition of char-
archaeological past), and encountering the past acteristic positions throughout an individual's
in the therapeutic context is an act of creation of life course (Klein, 1952)?
a ªplausibleº coherent narrative of our patient's (v) If development continues throughout life,
life. Spence (1982) gives a critical warning: is such development merely a shift of concerns
ªOnce stated, it (the narrative truth) becomes (e.g., Tyson & Tyson, 1990), or does the
partially true, as it is repeated and extended, it structure of the mind remain flexible, open to
becomes familiar; and as its familiarity adds to drastic alteration and the generation of new
its plausibility, it becomes completely trueº structures, more or less, throughout the life-
(p. 177). span (e.g., Emde, 1985)?
There is no adequate resolution to this debate.
In most of the cases the quality of the patient's
recall leaves little room for doubt as to whether 1.14.2 FREUD'S MULTIPLE MODELS OF
abuse actually happened. In others, there is THE MIND
room for doubt, and while the search for 1.14.2.1 The Affect-trauma and Topographic
meaning is a ubiquitous aspect of human Frames of Reference
personality, the therapist must resist the
temptation to give false meaning to current His work with hypnosis led Freud (Freud &
misery, anguish, and dejection by ªdiscoveringº Breuer, 1895) to believe that he had discovered
a spurious historical account of early depriva- the etiology of neurosis in the actual event of
tion. There is no special expertise concerning the childhood seduction. In this conception the
client's past which the therapist has access to interpersonal event of the early trauma was
beyond that which emerges as part of the represented in a distorted form in the neurotic
relationship that the client creates with him or symptom. For example, a child of eight with
her in the therapeutic situation. This experience hysterical blindness may have achieved relative
is unique, but whether it is an enactment of an internal safety by ªshutting his eyesº to the
actual past experience or the product of a memory of having witnessed his mother's rape.
defensively distorted representation of a self± In this model he assumed little by way of a
other relationship, fantasized or real, is, at the mental apparatus, simply the physical conver-
current state of knowledge, impossible to sion of emotional energy generated and damned
determine. up by trauma. The therapeutic intervention was
appropriately principally cathartic.
The discovery of free association and dream
1.14.1.5 Further Controversial Issues interpretation as clinical-research tools
prompted Freud to seek a more elaborate
The integration of psychodynamic theories psychological model of mental disorder. The
into a coherent singular model has been three-layered topography of the mindÐthe
undermined by a number of unresolved issues systems unconscious, preconscious, and
which include the following. consciousÐmotivated by sexual (and later
(i) The relative importance for pathogenesis aggressive) instincts gave adequate accounts
of early childhood (infantile) experiences in of the therapeutic value of the recovery of
contrast to later oedipal (age 4) and middle- repressed, unconscious sexual fantasies of early
childhood events (see Cooper, 1983). childhood. The turning away from his seduction
(ii) The interpersonal vs. intrapsychic nature hypothesis in favor of his second model,
of human development: is the self an individual however, discredited psychoanalytic theory as
construction as conceived by Freud or is it an a social theory of psychopathology and therapy.
intersubjective unit derived from the interaction It led Freud (1905b) to attempt to explain all
of mother and infant (Winnicott, 1956) or infant actions in terms of the failure of the child's
and his or her self-objects (Kohut, 1971)? mental apparatus to deal adequately with the
(iii) Is the basic constitution of human nature pressures of a maturationally predetermined
in conflict with its environment which must sequence of drive states. Adult psychopathol-
tame and inhibit it as Freud (1930) and Klein ogies, as well as dreaming, jokes, and para-
(1957) conceive, or is it potentially consonant praxes, were seen as the revisiting of unresolved
The Structural Approach 427
childhood conflicts over sexuality (Freud, 1900, development of a theory of the self throughout
1901, 1905a). He now saw anxiety as arising the life-cycle (Jung, 1916, 1923). Other impor-
from the failure of repression of unacceptable tant omissions were:
sexual wishes (Freud, 1905b, p. 224). (i) the cultural and social context, including
interpersonal aspects of development;
(ii) the significance of the experiences of
1.14.2.2 The Structural Frame of Reference infancy;
(iii) the developmental significance of the
The fundamental influence of the social
real behavior of the real parents, including
environment again found a preeminent place
transactional processes;
with the third major shift in Freud's thinking
(iv) the role of attachment and safety in
(Freud, 1920, 1923, 1926). Freud's model now
development alongside the role of instinctual
recognized three mental structures: the id
drives;
(sexual and aggressive instincts), the ego (the
(v) the synthesizing function of the self;
self as agent) and the superego (a personalized
(vi) the importance of the nonconflictual
source of internal and social moral injunction).
aspects of development;
This new structural theory was to survive long
(vii) the role of the experiences of adoles-
after Freud because of the compelling fit with
cence and adulthood in shaping normal and
clinical observational data. In his dual instinct
pathological development.
theory, he describes the child's struggle with
innate destructive and self-destructive forces as
well as sexual conflicts (Freud, 1920). Freud 1.14.3 THE STRUCTURAL APPROACH
(1926) also revised his theory of anxiety from
1.14.3.1 American Ego Psychology
one caused by inhibited biological drives, to a
psychological state linked to the perception of 1.14.3.1.1 Hartmann's classical model
internal (instinctual or moral) or external
Freud's third, structural, model was refined
danger. The danger situation was specified as
and advanced in the ego psychology of Heinz
the fear of helplessness resulting from loss (loss
Hartmann and his colleagues. Hartmann et al.
of the mother, her esteem, loss of a body-part, or
(1946) postulated an initial undifferentiated
loss of self-regard).
matrix which contains the individual's endow-
This revision achieved two goals: (i) it
ment and from which both the id and the ego
restored adaptation to the external world as
originate. They also introduced the concept of
an essential part of the psychoanalytic account,
an ªaverage expectable environment,º which
and (ii) it recast the theory into cognitive terms,
affirmed the importance of the parental con-
making way for a representational account of
tribution to development, and outlined a
the mind (see below). Freud's theory of
scheme for the phase-specific maturation of
pathology was now of inadequately resolved
autonomous, conflict-free ego functions, ac-
conflict (Freud, 1938). The hypothesis that
commodating both environmental and matura-
conflicts within the human mind are essentially
tional influences upon personality development.
of three kinds (wish vs. moral injunction, wish
Development of the ego is driven by a
vs. reality, and internal reality vs. external
maturational pull, whereby independently emer-
reality) has had extraordinary explanatory
ging components and functions come to be
power. In particular, the ego's capacity to
linked, forming a coherently functioning orga-
create defenses which organize characterologi-
nization (the ego) which is more complex than
cal and symptomatic constructions as part of an
the sum of its parts (Hartmann, 1958, 1964c).
adaptive process, became the cornerstone of
Stages of ego development represent nodal
psychodynamic theorization and clinical work
points at which ªfixationº may occur and to
in the USA (Hartmann, Kris, & Loewenstein,
which, under the stress of conflict, the individual
1946) and Britain (A. Freud, 1946) for 30±40
may return. For example, obsessive-compulsive
years.
disorder is seen by structural theorists (Arlow &
Brenner, 1964) as a regression to the phase of ego
1.14.2.3 Some Limitations of Freud's Models functioning characteristic of the two-year-old
(magical phenomenalism, repetitive, ritualistic
The limitations of Freud's models are mani- behaviors).
fold, and many of these were pointed out by Hartmann (1958) accurately claimed that
Freud's contemporaries who moved away from psychoanalysts frequently used the develop-
organized psychoanalysis. For example, Jung's mental point of view in a reductionist way. His
controversial rejection of libido theory drew concept of the ªchange of functionº (Hartmann,
attention away from the undoubted advances he 1958, p. 25) and secondary autonomy (Hart-
made in the understanding of narcissism and his mann, 1964a) pointed to how the same behavior
in the adult may serve quite different functions that major developmental shifts in psychologi-
and is likely to be functionally independent from cal organization, marked by the emergence of
the childhood wish from which it may have new behaviors and new forms of affective
originated. The persistence of dependent beha- expression (e.g., social smiling), occurred when
vior in adulthood cannot be treated as if it were functions are brought into new relation with one
a simple repetition of the individual's early another and are linked into a coherent unit. He
relationship with the mother. Adult behaviors drew attention to the meaning of new forms of
should be seen as having multiple functions emotional expression (ªpsychic organizersº)
(Brenner, 1979). The failure to recognize this has such as the smiling response (2±3 months),
been termed the ªgenetic fallacyº (Hartmann, marking the initial differentiation of self and
1964b, p. 221). It is not uncommon for primitive object, eight month anxiety which indicates
modes of mental functioning (e.g., splitting or differentiation amongst objects, especially of
identity diffusion) in severe personality-disor- the ªlibidinal object properº and the assertion of
dered individuals to be treated as evidence for self in the ªnoº gesture between 10 and 18
the persistence or regressive recurrence of early months. The way in which these organizers
pathogenic developmental experiences. Yet, herald dramatic changes in interpersonal inter-
their reemergence in adult mental functioning actions was elaborated in a highly influential
may be linked to later or persistent trauma (see series of papers by Robert Emde (1980a, 1980b,
Tyson & Tyson, 1990). 1980c).
Spitz (1965) was also a pioneer in seeing the
infant's and child's human partner as ªquick-
1.14.3.1.2 Modern structural theory eningº the development of the child's innate
Partly in response to the challenge of object abilities and mediating all perception, beha-
relations theories (see below), there has been a vior, and knowledge. Spitz (1957) saw self-
revival of the structural theory in psycho- regulation as arising out of the mother±infant
analysis. Modern structural theory (see, e.g., relationship. Psychoanalytic observational stu-
Boesky, 1988) retains the tripartite model of id, dies repeatedly showed the ways in which
ego, and superego, but dispenses with concepts constitutional, early environmental, and inter-
of psychic energy and other problematic actional factors contribute to the structuring of
notions. The theory takes as its central premise the self-regulatory process leading to adapta-
the ubiquitous nature of internal psychic tion or maladaptation (Spitz, 1959). The
conflict (see Brenner, 1982). Brenner suggests mother's emotional expression at first serves
that all mental contents (thoughts, actions, a ªsoothingº or ªcontainingº function which
plans, fantasies, and symptoms) are compro- facilitates the restoration of homeostasis and
mise formations which are best conceived of as emotional equilibrium. Later, the infant uses
multiply determined by components of conflict: the mother's emotional response as a signaling
(i) a drive derivative, conceived of in this device to indicate safety. Later still, the infant
context as an intense, personal childhood wish internalizes the affective response and uses his
for gratification; or her own emotional reaction as a signal of
(ii) unpleasure in the form of anxiety, or safety or danger (Emde, 1981). These concepts
depressive affect, and their ideational contents were to become a core part of attachment
of object loss, loss of love, or castration, theory (see below).
associated with the drive derivative;
(iii) defense, which functions to minimize (ii) The work of Erikson
unpleasure; and
(iv) manifestations of superego functioning An important extension to the classical model
such as guilt, self-punishment, remorse, and was proposed by Erik Erikson (1950b). His
atonement. concern was the interaction of social norms and
Self and object representations, in this biological drives in generating self and identity.
scheme, are the result of compromise formation He described eight developmental stages span-
which in their turn effect further compromises ning the whole of life (e.g., the ªidentity crisisº
between the tendencies above. of adolescence) determined by biologically
caused life events that were thought to disturb
the equilibrium between drives and social
1.14.3.1.3 Extensions of the ego psychology adjustment. Personality would be arrested if
model the developmental challenge was not mastered
through the evolution of new skills and
(i) Contribution of ReneÂ Spitz
attitudes, compromising later developmental
Spitz (1959) was one of the first ªempiricistsº stages. Erikson was remarkable among psycho-
of the psychoanalytic tradition. He proposed analysts for his attention to cultural and family
factors and his extension of the developmental Specific neurotic reactions are thought to
model to the entire life-cycle. His theory reflect regression to particular developmental
introduced plasticity to the psychoanalytical fixations and characteristic modes of compro-
model, as well as attributing critical importance mise formation. Regression occurs because the
to the need for a coherent self concept fulfilled in compromise formations established to resolve
a coherent, supportive social milieu. the oedipal dilemma (the so-called ubiquitous
infantile neurosis) was challenged by internal or
external stressors. In conversion hysteria, the
(iii) The work of Edith Jacobson
compromise achieves dramatic representation
Edith Jacobson (1964) advanced the idea that in somatic form and reflects an oral or phallic
the infant acquires self and object images with fixation. In obsessional neurosis, it is assumed
good (libidinal) or bad (aggressive) valences, that the ego binds anal sadistic and aggressive
depending on experiences of gratification or drive derivatives into forms of secondary
frustration with the caretaker. In order to clarify process thinking (e.g., ruminations, obsessional
and distinguish the concepts of ego, self, and doubts, etc.), but it is developmentally unable to
self-representation, she used the term ªself- neutralize these drive derivatives and therefore
representationº to stress the notion of the self aggression and anal concerns will be transpar-
and object as they were experienced, as ent and arouse massive anxieties (see e.g.,
distinguished from external objects. She stated Fenichel 1945; Glover 1949). In phobias, the
that the ego was a structure in contrast to the fear is externalized and is wholly psychological
self, which is the totality of the bodily and in its presentation, but in unconscious content,
psychic person, and defined self-representation may reflect quite similar developmental con-
as ªthe unconscious, preconscious, conscious, cerns. The process remains largely an internal
intra psychic representation of the bodily and one; the neurotic compromise that results in
mental self in the system egoº (p. 19). She obsessions is located in the thought processes
assumed that introjections and identificatory themselves.
processes replaced the state of primitive fusion, Psychoanalytic writers have noted problems
and, through these, traits and actions of objects with this concept of neurosis. As the focus
became internalized parts of self-images. She shifted in the psychoanalytic literature to pre-
was particularly concerned with superego oedipal developmentÐwhich had been the
formation, which she saw as initially polarized primary focus for the Kleinian groupÐ
between pleasure and unpleasure, then by issues questions were raised about the obligatory link
of strength and weakness, and finally as the between adult neurosis and oedipal issues.
internalization of ethical considerations which Outside of psychoanalysis, the concept of
regulated self-esteem as well as behavior. neurosis has been assaulted with much greater
ferocity. The concept of neurosis has been
discredited as the trend toward descriptive
1.14.3.1.4 The classical model of the neurosis
clarity and reliability in diagnosis gains the
The classical model of the neurosis is well upper hand, together with the push toward
known and will not be elaborated in detail here. atheoretical, operational definitions of psychia-
Childhood sexual wishes are presumed to tric disorders and biological explanations of
arouse conscious repugnance when experienced pathogenesis. Derided as vague, unreliable,
in adulthood because of their aggressive or impossible to verify empirically, overinclusive,
incestuous content. They can reach awareness and tied to an obsolete theory, neurosis has been
only when disguised. The neurotic compromise excluded from psychiatry's official diagnostic
represents a disguised (id) derivative of child- classifications. Despite this slight, neurosis
hood sexuality, the ego's defense, and signal refused to disappear.
anxiety marking the ego's experience of internal
danger. It unifies the wish and the reaction
1.14.3.1.5 The classical model of severe
against it in a part of the personality that is
psychopathology
experienced as separate (ego dystonic). This is
characterized by a subjective experience of Whereas notions of neurotic pathology have,
punishment, suffering, and irritation which on the whole, evolved little since the structural
originates from, and is designed to placate, theory of Freud, models of personality disorder
the superego. The sequence of events associated have become ªparadigmaticº of various psycho-
with neurotic reaction are: (i) frustration, (ii) analytic models. As subsequent sections will
regression, (iii) internal incompatibility, (iv) illustrate, extremes of personality types, now
signal anxiety, (v) defense by regression, (vi) embodied in the psychiatric diagnostic schemes
return of the repressed, (vii) compromise as the second axis of psychiatric diagnosis
formation and symptomatic disorders. (American Psychiatric Association, 1994), are
formulated radically differently across different suggested that the ego kept the superego at a
theoretical models. distance, causing it to be isolated and therefore
Structural theory distinguishes those char- unable to prevent the individual from yielding to
acter disorders which resemble neurosis in terms an impulse.
of dynamic considerations and those which Johnson and Szurek (1952) suggested that
reflect a non-neurotic pattern based on struc- superego lacunae (lack of superego in certain
tural deficit (see Waelder, 1960). The so-called circumscribed areas) was the nature of the
character neurosis (a concept introduced by superego pathology. Such gaps in the superego
Alexander (1930)) of the former category is (which is regarded as an internalization of
assumed to be dynamically similar to neurosis parental morality) were thought to occur
with the exception that compromise formations because of the parentsº unconscious wish to
are not split off from the ego and thus the act out forbidden impulses; the child is
symptoms are not experienced as ego alien or unconsciously encouraged by the parents to
ego dystonic. More severe personality act in amoral ways, but is consciously discour-
disordersÐfor example, narcissistic personality aged from doing this. Lampl-de-Groot (1949)
disorderÐare regarded as a consequence of a suggested that the balance of the superego and
developmental arrest, deviation, or dishar- the ego ideal explained why certain individuals
mony. The structural view of such cases tends became neurotically depressed, whilst others
to be in terms of faulty ego development (see became antisocial. The former corresponds to a
Gitelson, 1955; Rangell, 1955). Important ego severe superego and strong ego ideal, whereas
functions such as reality testing, anxiety the latter is a consequence of a menacing
tolerance, and stable defenses are impaired, superego and a weak ego ideal.
while others appear to retain their integrity, thus These ideas exemplify the strengths and
giving the patient a semblance of normality. weaknesses of structural theory. While the
suggestions fit well with clinical observation
and phenomenology, their explanatory value is
(i) Structural model of borderline personality
sustained by the assumption of the actuality
disorder
(concrete existence) of the psychic structures
Knight (1953) was the first to propose a proposed by Freud, yet Freud was clear that his
comprehensive model of personality disorder in metapsychology was, in essence, metaphoric
terms of ego functions impaired by traumatic (Schafer, 1976).
development. Among the ego functions he
considered were: ªintegration, concept forma-
tion, judgment, realistic planning, and defend- 1.14.3.2 The Structural Developmental
ing against eruption into conscious thinking of Tradition
id impulses and their fantasy elaborationsº
1.14.3.2.1 Anna Freud
(p. 6). Erikson (1959a, 1959b) in his epigenetic
sequence of identity formation described the Anna Freud represented, and to some degree
syndrome of identity diffusion, which he saw as continues to represent, the structural psycho-
reflecting deficiencies in a sustained sense of dynamic model, although her work embodies a
self-sameness, temporal continuity of self ex- unique psychodynamic approach to both psy-
perience, and a feeling of affiliation with a social chopathology and clinical work. Anna Freud
group of reference. Jacobson (1964) drew (1965) was one of the first coherently to adopt a
attention to how these individuals, at times, developmental perspective on psychopathol-
experience their mental functions and bodily ogy. She provided a comprehensive develop-
organs not as belonging to them, but as objects mental theory using the metaphor of
which they wish to expel. They may also attach developmental lines to stress the continuity
their mental and body self to external objects. and cumulative character and transactional
She saw them as retaining an ªadolescent nature of childhood development. For example,
fluidity of moodsº (Jacobson, 1964, p. 159). aspects of the child's relationship to the mother
may be described as a line moving from
ªdependency to emotional self-reliance to adult
(ii) Structural theory of antisocial personality
object relationships,º ªfrom irresponsibility to
disorder
responsibility in body management.º Uneven-
Aichhorn (1935) was the first psychoanalyst ness of development may be regarded as a risk
to seriously work with delinquent individuals. factor for psychiatric disturbance, and thus
In his influential formulation he posited a developmental lines have etiological signifi-
failure of progression from the pleasure prin- cance. A child's problem may be understood
ciple to the reality principle in conjunction with in terms of an arrest or regression in terms of a
a malformation of the superego. Reich (1933) particular line of development (A. Freud, 1965).
The clinical implication of her formulation is process by which objects (representations of

that in addressing disturbance the psychody- people) are invested with instinctual energy. The
namic clinician should focus not only on the individual attempts to identify with the frus-
determinants of symptomatic aspects of the trating and disappointing object, providing a
disorder, but also on offering ªdevelopmental focus for libidinal cathexis that heightens
helpº to the child and restore him/her to the narcissism and cathexis of the self (ego-
ªpath of normal developmentº (A. Freud, centrism).
1981).
1.14.3.2.2 Margaret Mahler
(i) Developmental approach to anxiety
Margaret Mahler (Mahler, 1968; Mahler,
The developmental approach is helpful to Pine, & Bergman, 1975), using a naturalistic
distinguish emotional experiences at different observational strategy of infants and young
levels of maturity. Yorke, Wiseberg, and Free- children, evolved an influential psychodynamic
man (1989), following in Anna Freud's tradi- model. Of particular relevance was her descrip-
tion, differentiate a nameless terror, a tion of the separation±individuation process
principally somatic experience developmentally beginning at 4±5 months and ending in the third
rooted within the undifferentiated mother±baby year of life. Overall, the process is one of moving
unit, psychic panic dating back to a time when away from a symbiotic unity with the caregiver
the infant is capable of mental experience but to a consolidation of individuality. A critical
not yet capable of affect regulation, pervasive subphase is the 6±10 month period commencing
anxiety where there is fear of helplessness but in the latter half of the second year of life when
already some capacity to control affect and a the child's greater awareness of separateness
signal anxiety which functions to circumvent intensifies separation anxiety at the same time as
over-arousal by activating defenses. While this promoting a greater need to be separate from
theory is compelling, there is surprisingly little her. The caregiver's handling of this subphase
observational data to support the notion that (ªrapprochementº) is thought to be critical, as
early stages of development are associated with the mother must combine emotional availability
more pervasive and intense emotional experi- with a gentle push towards independence. If the
ence (Harris, 1994; Stern, 1985). balance of availability and push toward in-
dependence is weighted too much on either side,
the infant may become desperately dependent
(ii) Anna Freud's approach to severe
and clingy, experience great difficulty in
psychopathology
investing his or her environment with sufficient
Anna Freud agrees with structural theorists interest, and his or her pleasure and confidence
in regarding severe personality disorders as in his or her own functioning will be impaired
reflecting structural deficits such as defects in (Settlage, 1977).
reality testing, the dominance of primitive Masterson (1972, 1976) believes that border-
defenses, limited capacities for anxiety toler- line patients experience a deep conflict between
ance, poor superego development, etc. She the wish for independence and the threat of loss
explains these as developmental disturbances of love and thus search for a clinging tie with a
(deviations or disharmonies). For example, mother substitute. Such a tie will temporarily
Yorke et al. (1989) suggested that the inade- ensure a feeling of safety, but any wish for self-
quate response by the mother to an infant's assertiveness will present him with the terror of
instinctual needs creates dangers and external abandonment. A lifelong and vicious cycle of
conflict. Such disharmony of need and external brief blissful unions, ruptures and emptiness
environment will be most intensely felt when and depression will ensue.
structuralization is not yet ready to sustain the He discusses ªabandonment depressionº as
pressures caused by the internal and external the consequence of the borderline child's quest
stresses thus created. Ego development will for separation from the withdrawing or ag-
suffer because the internalizing and identifica- gressive maternal object who in turn, for
tory processes will be specifically threatened. A pathological reasons of her own, wishes to
constant representation of the other, for keep the child in a symbiotic relationship with
example, may not develop if the early relation- her. The patient develops a fear that ªhis very
ship with the mother is disrupted by trauma. existence is dependent ultimately upon the
The failure to achieve structured compromise presence of need gratifying and life sustaining
produces the labile character of borderline and othersº (R. Klein, 1989, p. 36). The withdrawing
other personality disturbances. Narcissistic and rewarding object representations are kept
character disorder is seen as rooted in early rigidly separate to maintain the possibility of
emotional deprivation which compromises the symbiotic union with the rewarding object and
to ward off abandonment depression. The scious (Sandler & Sandler, 1987). According to
borderline individual's dramatic response to Sandler, the etiological and appropriate ther-
actual separation is thus explained by his apeutic focus of psychodynamic approaches is
incomplete separation from his objects, with not early childhood experience and primitive
the psychological experience of separation fantasy, but rather the current derivatives of
becoming equivalent to a loss of a part of the these experiencesÐthe ways in which uncon-
self. Borderline patientsº common vigorous scious wishes and fantasies of the past create
pursuing of their therapists at home, in their dynamic conflicts and elicit defensive maneu-
holidays, or in other professional activity can be vers in the present.
understood in this way. The direct influence of one individual on
There is strong evidence, particularly from another within Sandler's scheme (Sandler, 1976)
retrospective studies, that borderline patients is accounted for by the evocation of particular
appear to have parents with mental illness, roles in the mind of the other person who is
personality disorder, and drug abuse (e.g., being influenced. The behavioral role of the
Ogata, Silk, & Goodrich, 1990a) and frequently influencing person is seen as crucial in eliciting a
report having experienced family violence, complementary response from the other parti-
physical and sexual abuse and other trauma cipant. In this way, within the individual's
(Ogata et al., 1990b; Paris, 1992; Paris & Zweig- present unconscious, infantile or childhood
Frank, 1992). Evidence is only indirectly patterns of relationships may be enacted or
supportive of Masterson's view because data actualized in adult interpersonal interaction.
are retrospective and because experiences of
maltreatment usually pertain to teenage years
rather than early development. More recent 1.14.3.3 Strengths and Weaknesses of the Model
developmental evidence tends to disconfirm The quasiphysiological character of the
Mahler's assumption of an early self-object original model has been the subject of intense
merger postulated by Mahler for the first half of criticism (e.g., G. Klein, 1976a). Many of the
the first year of life (see Gergely, 1991). classical explanations of psychopathology ap-
Nevertheless, Mahler's emphasis on the second pear to reify the hypothetical constructs of ego,
year of life has been helpful in identifying what superego, and id in order to produce credible
may be a critical period for the emergence of explanations. To talk of lacunae in the superego
awareness of mental states in both self and as a cause of antisocial behavior is only plausible
others, in other words an appreciation of human if we assume that such a structure actually exists
individuality (Dunn, 1996; Fonagy et al., in the mind rather than conceiving of it as a
1995a). metaphor evocatively summarizing a certain
range of behaviors. Stripped of reification,
1.14.3.2.3 Sandler's reframing of the structural many structural accounts are revealed as
model circular. For example, an absence of the ego
function of anxiety tolerance, stripped of
Bringing a unique blend of developmental metapsychological jargon, means no more than
and psychological sophistication to the classical such an individual gets very upset in situations
structural model, Joseph Sandler can be said to that induce anxiety.
have achieved the most coherent integration This is not to say that either the clinical or the
between object relations theory and the struc- metapsychological observations are without
tural model. Of greatest clinical relevance is value. In reading many of these classical papers,
Sandler's meticulously systematic work to move even with the sophistication freely provided by
psychoanalysis to the level of representations hindsight, it is hard not to be impressed by
and affects (Sandler & Rosenblatt, 1962). clinical sensitivity and the remarkable integra-
Sandler reframed the psychodynamic theory tive abilities of many of these pioneers who, in
of motivation, highlighting the role of affects many instances, decades before other profes-
rather than drive state (Sandler, 1985). A key sionals had highlighted key characteristics of
concept is that of safety, an aspect of phenom- important disorders.
enal experience which is intensely sought
throughout development (Sandler, 1987). Past
patterns of relationships and associated emo- 1.14.4 THE OBJECT RELATIONS
tional states are thought to be actively recreated APPROACH
by the individual because of the associated sense 1.14.4.1 Introduction to the Object Relations
of safety, even when these patterns appear Approach
maladaptive (Sandler & Sandler, 1987). An
important aspect of this formulation is the Greenberg and Mitchell (1983), in their
distinction between past and present uncon- definitive review of theoretical work on object
The Object Relations Approach 433
relations theory to date, use the term to denote theories. Hard theorists, in which he includes
theories ªconcerned with exploring the relation- Melanie Klein, Fairbairn, and Kernberg, see
ship between real, external people and the much hate, anger, and destruction, and dwell on
internal images and residues of relations with obstacles, illness, and confrontation, whereas
them and the significance of these residues for soft object relations theorists (Balint, Winni-
psychic functioningº (p. 14). cott, and Kohut) deal with love, innocence,
The rise of object relations theories signaled a growth needs, fulfillment, and progressive un-
change of focus in psychodynamic theories. folding.
Intrapsychic conflict, particularly conflicts
relating to the sexual and aggressive drives,
and the central organization of oedipal com- 1.14.4.2 The Klein±Bion Model
promises and the complementary influences of Melanie Klein's (1964, 1975a, 1975c) model
biological and experiential forces in develop- combines the structural model with an inter-
ment are no longer the cornerstones of personal, object-relations model of develop-
psychodynamic theory, a change which has ment. It was with the contributions of Bion
been regretted by some (see, e.g., Spruiell, 1988). (1962) that the theory became a fully relational
Regardless of particular theoretical models, object relations model. Until 1935 Klein was
psychodynamic thinking seems to have moved basically working with the theoretical frame-
in the 1980s towards a phenomenologically work of Freud and Karl Abraham. The 1935
based perspective which emphasizes the indivi- (1975a) and 1940 (1984) papers on the depres-
dual's experience of being with others and with sive position, the 1946 (1952) paper on the
the therapist during clinical work (see, e.g., paranoid-schizoid position, and the 1957 book
Loewald, 1986). The clinical emphasis upon Envy and gratitude established her as the leader
experience inevitably drives theory away from a of an original psychoanalytic tradition.
structural mechanistic model towards what
Mitchell (1988) broadly terms ªrelational
theory.º Patients in treatment express them- 1.14.4.2.1 Some essential Kleinian concepts
selves in terms of relationships (Modell, 1990),
(i) The two basic positions
and the move towards object-relations-based
psychodynamic theories may thus be seen as led In the Kleinian model the human psyche has
by an increasing demand on clinicians to two basic positions: the ªparanoid-schizoidº
explore clinical phenomena from the point of and the ªdepressiveº (Klein, 1952). In the
view of the patient. paranoid-schizoid position, the relationship to
There are several assumptions which object the object (the caregiver) is to a part object, split
relations theories share (see Fonagy, Target, into a persecutory and idealized relationship,
Steele, & Gerber, 1995b). These include: and similarly the ego (the self) is split. In the
(i) that severe pathology has pre-oedipal depressive position, the relation is to an
origins (i.e., the first three years of life); integrated image, both loved and hated, and
(ii) that the pattern of relationships with the ego is more integrated. The paranoid-
objects becomes increasingly complex with schizoid superego is split between the exces-
development; sively idealized ego ideal characterized by the
(iii) that the stages of this development experience of narcissistic omnipotence and the
represent a maturational sequence which exists extremely persecutory superego of paranoid
across cultures but which nevertheless may be states. In the depressive position the superego is
distorted by pathological personal experiences; a hurt love object with human features.
(iv) that early patterns of object relations are The paranoid-schizoid position is the infant's
repeated, are in some sense fixed and repro- earliest relationship with the external world and
duced throughout life; is dominated by innate internal representations
(v) that the developmental continuum of (Klein, 1975c, p. 248). The infant's initial
these relationships is isomorphic with the con- attempt at organizing internal and external
tinuum of pathology; perceptions is dominated by splitting. In this
(vi) that patientsº clinical reactions to their way he attributes all goodness, love, and
therapist provide a window for examining pleasure to an ideal object, and all pain, distress,
healthy and pathological aspects of early re- and badness to a persecutory one. All good
lationship patterns. feelings of affection and desire are aimed at the
There exist, however, considerable differ- idealized good object which the infant wishes to
ences between psychoanalytic theories in terms possess, take inside (introject) and experience as
of the rigor with which the problem of object himself (identify with). Negative affect (hatred,
relationships is tackled. Friedman (1988) differ- disgust, etc.) is directed to the persecutory
entiates between hard and soft object relations object and projected (externalized) onto it since
the infant wishes to rid himself of everything to have the feelings appropriate to the projec-
that is experienced as bad and disruptive. The tor's phantasy.
infant's mental life is envisaged as extremely Bion (1959) pointed to the general necessity
labile; good rapidly turns into bad, the bad gets for projective identification in infancy, a time
worse, and the good gets increasingly idealized. when the individual is ill-equipped to absorb its
Each external object has at least one good and impressions of the world. By projecting these
one bad representation, but both representa- elements into another human mind (a container)
tions are partial and not the whole person. that has the capability to accept, absorb and
The depressive position is marked by the transform them into meanings, his mental
infant's capacity to perceive the mother as the survival was ensured. The absence of a suitable
whole person who accounts for both his good container makes projective identification a
and bad experiences and is seen by Klein (1975a, pathogenic process of evacuation. Bion (1962)
p. 310) as the central achievement or process in discussed the significance of the mother's
the child's development. At this moment the capacity mentally to ªcontainº the baby and
infant becomes aware of his or her own capacity respond to the infant emotionally and in terms
to love and hate the parent. The discovery of this of physical care in a manner that modulates
ambivalence and the growing capacity to unmanageable feelings. Capable caregivers are
recognize absence and potential loss of the likely to experience and transform these feelings
attacked object, opens the child to the experi- into a tolerable form which probably combines
ence of guilt over hostility to a loved object. This mirroring of intolerable affect in combination
is what Klein calls ªdepressive anxietyº as with emotional signals, indicating that the affect
distinct from the persecutory anxieties of the is ªcontained,º that is, under control (Bion's
earlier paranoid-schizoid position. Working ªalpha functionº). The infant can cope with,
through the characteristic experiences of the accept and re-internalize what was projected,
depressive position brings with it reparative thus creating a representation of these emo-
feelings. The psychic pain associated with the tional moments of interaction with the caregiver
integration is so great that it can lead to defenses which is tolerable, in place of his original
characteristic of this position, including manic experience which was not. In time he inter-
or obsessional reparation, total denial of nalizes the function of transformation and will
damage or contempt. Segal (1957) links the have the capacity to contain or regulate his own
capacities for symbolization and sublimation to negative affective states. The nonverbal nature
depressive reparation. Once the object is of this process implies that physical proximity of
perceived as a mentally independent entity, it the caregiver is essential.
is seen as having desires, wishes, loyalties and
attachments of his/her own, and oedipal
(iii) Envy and gratitude
concerns about the feeling about the ªthirdº
may arise (Britton, 1989). Klein (1957) suggests that early, primitive
envy represents a particularly malignant form of
innate aggression. This is because, unlike other
(ii) Projective identification
forms which are turned against bad objects,
For Melanie Klein (1957), projective identi- already seen as persecutory, envy is hatred
fication is an unconscious infantile phantasy by directed to the good object and arouses a
which the infant is able to relocate his premature expression of depressive anxiety
persecutory experiences by separating (splitting) about damage to the good object. The child
them from his self representation and making may resent the inevitable limitations of maternal
them part of his image of a particular object. care, cannot tolerate the mother's control over it
Disowned unconscious feelings of rage or shame and would prefer to destroy it rather than
are firmly believed by the infant to exist within experience the frustration. This interferes with
the mother. By acting in subtle but influential the primal differentiation of ªgoodº and ªbad.º
ways, he may achieve a confirming reaction of Excessive envy is seen as interfering with
criticism or even persecution. The phantasy of a working through the paranoid-schizoid posi-
magical control over an object may be achieved tion, and ultimately it becomes the develop-
in this way. Projective identification is not a mental precursor of many forms of confusional
truly internal process and involves the object states (Rosenfeld, 1950).
who may experience it as manipulation, seduc-
tion or a myriad of other forms of psychic
(iv) Primitive transferences
influence. Spillius (1992) suggests the use of the
term ªevocatory projective identificationº to In therapy, Kleinians prefer to work exclu-
designate instances where the recipient of sively with interpretations, primary transference
projective identification is put under pressure interpretations aimed at the patient's current
anxieties. They work psychodynamically with inadequacies in others whom he can then
relatively severe disorders, and stress early denigrate and devalue. To deal with their envy,
interpretation of negative transferences derived narcissists devalue their objects (their therapists,
from the paranoid-schizoid position. Kleinians their spouses). Denigration serves the function
have contributed enormously to our under- of avoiding recognizing goodness in others,
standing and use of projective and introjective which the person finds threatening to his or her
aspects of the countertransference (e.g., Racker, own delusional state of self-idealization as in
1968, chap. 6.5). A pioneer in this respect was possession of the ªgood breast.º
Bion (v1962), for whom transference and
countertransference are about the transfer of
1.14.4.2.4 Kleinian approach to severe
intolerable mental pain by projective identifica-
psychopathology
tion, originally from infant to mother, and in the
treatment situation from patient to therapist. Klein's (1975b) formulations were vital to the
understanding of borderline personality condi-
tions. The paranoid-schizoid condition is the
1.14.4.2.2 Kleinian approach to neurosis
template for borderline personality functioning:
Psychological illness reflects the predomi- (i) In object relationships, splitting predomi-
nance of the paranoid-schizoid position nates over repression, and others are seen as
whereas health implies the stabilization of the either idealized or denigrated. There is no real
depressive framework, promoting development knowledge of the other and the inner world is
and maturity. In neurotic states, the transition populated by parts (or caricatures) of the
between schizo-paranoid and depressive posi- object.
tions is perceived as partial; the superego (ii) Since the depressive position is avoided
contains both paranoid and depressive features, and all badness is pushed into the object, there
manifesting as persecutory guilt. The most can be no genuine sadness, mourning, or guilt.
common anxiety is the fear of guilt and the (iii) Projective identification predominates;
possibility of the loss of the loved object. If communication cannot be meaningful, and the
the depressive position is not approached, the object is manipulated by being forced to
anxiety will be about fragmentation, annihila- experience unacceptable aspects of the border-
tion, and persecution, and the reality sense will line individual's personality.
be grossly distorted by projections. This picture Splitting is both a cause and a consequence of
is more fitting of patients with severe person- the borderline person's difficulty in maintaining
ality disorders, such as borderline or narcissistic an ambivalent, balanced view of both self and
personalities. object, which in Kleinian theory would require
Bion (1962) outlined the processes that can the acknowledgment of his experientially over-
lead to pathology in the paranoid-schizoid whelming destructive potential. With more than
position. He names two factors: (i) deficiencies one object at their disposal, borderline indivi-
in the mother's capacity for receiving the child's duals may externalize their incapacity to inte-
communications through projective identifica- grate good and bad objects, by polarizing
tion (ªreverieº) (see also the formulation of people working with them and constantly
primary maternal preoccupation by Winnicott, attacking the links between them (Main, 1957).
1962), and (ii) overwhelming envy in the infant.
1.14.4.2.5 Strengths and weaknesses of the
1.14.4.2.3 Rosenfeld's developmental model of Klein±Bion model
narcissism
Critics of Kleinian formulations focused on
Rosenfeld (1964, 1988) views narcissistic the unwarranted assumption of the early
states as characterized by omnipotent object development of higher-order cognitive and
relations and defenses which deny the separate- perceptual capacities (see Hayman, 1989;
ness and identity of the object. He stresses the Yorke, 1971). For example, the mechanism of
destructiveness of the narcissist's relationship projection in the paranoid-schizoid position
with others, his ruthless use of people, his denial assumes a differentiated sense of self and other,
of their value to him and yet need for them. To since were there not yet a differentiation of inner
recognize the object would mean recognizing and outer, self and other, it would seem
the object's control over ªgoodnessº and his impossible to displace the experienced source
vulnerability to separation from it. By intro- of negative affect from the self onto an external
jective identification the narcissistic individual object. By now there is detailed documentation
lays claim to the good part of the object and in of remarkably abstract and complex cognitive
fantasy owns it. Projective identificatory pro- capacities of the human infant. In particular
cesses help him deposit his own perceived there exists compelling evidence that the infant
differentiates between the self and other; for Winnicott (1958a) described the powerful desire
example, at five months a baby differentiates a to develop a sense of self and an equally strong
video image of his or her own legs moving from impulse to hide or falsify it. The loss of optimal
those of another baby's legs (Bahrick & Watson, intimacy with the primary object will give rise to
1985). ªsplittingº in the self (the ego). Conflicting
Kleinian assumptions concerning infantile multiple ego±object systems are seen as the
mental capacities extend beyond the representa- developmental roots of psychopathology.
tion of self and other and assume causal Winnicott (1965b) saw the child as evolving
reasoning on the part of the infant. Studies of from a unity of infant and mother. The mother
the perception of causality in infancy (Bower, holds the infant, both actually and figuratively,
1989) and causal reasoning (Golinkoff, Hardig, and so gives cohesion to his or her sensorimotor
Carlson, & Sexton, 1984) suggest that the elements. Holding is based on ªcomprehen-
human mind is innately predisposed to impose sion,º holding in mind, of the infant's mental
a causal structure on perceptual experience. If state. Her primary maternal preoccupation (a
the Kleinian model of development is inaccu- partial withdrawal from activities other than the
rate, it is so because it under- rather than over- baby and a state of heightened sensitivity to her
estimates the child's cognitive capacities. own self, her body, and the baby) helps the
More pertinent current criticisms address the mother achieve a state whereby the baby is
ªfuzzinessº (Greenberg & Mitchell, 1983, provided with the ªillusionº that the mother
pp. 148±149) of Klein's descriptions of the responds accurately to his or her gesture because
development of mental structure. The emphasis she is his/her own creation (a part of him/her).
upon ªphantasyº as the building block of Winnicott (1971a) saw object relating as
mental structure confounds the experiential arising from the experience of magical omni-
and nonexperiential aspects of mental function- potence. The breast in phantasy is the infant's
ing (see Sandler & Joffe, 1969). Klein and post- creation. When self±object differentiation is
Kleinians have moved mental structuralization incomplete, object representations are best
into the experiential realm, which carries with it designated self-objects. The infant's muscular
the advantage of experience-nearness for clin- ªattacksº on the mother, and her survival of
icians, and rids theory of much reified pseu- them, facilitate the development of the self and
doscientific terminology. However, it bypasses the mother's release from omnipotent control.
essential questions concerning the nature of the The infant can perceive her as a real or separate
mechanisms underpinning the organizations of other who can be used properly and not just
mental functions. omnipotently. Winnicott (1956) suggests that
optimal development of self-esteem depends on
the mother's capacity for affective ªmirroringº
1.14.4.3 The Fairbairn±Winnicott Model of the infant. Inevitable failures and frustration
are essential for ultimate adaptation in that they
1.14.4.3.1 Major innovations of the
facilitate the breakaway from infantile omni-
ªIndependentº tradition
potence and give an opportunity to the mother
The term ªIndependentº is not a misnomer; to repair the inevitable hurt by permitting
unlike other psychoanalytic schools, this tradi- regression to complete fusion.
tion is the work of a number of analysts working The idea of ªtransitional phenomenaº shows
independently, without a single leader or how the infant uses the mother to facilitate
reference point. Not surprisingly, the approach independent functioning (Winnicott, 1971b). A
lacks the internal coherence of a more unified favorite blanket may help to soothe the infant
group. Fairbairn (1954) was the systematic because it is grasped in the moment when the
theory builder, but major contributions came infant fantasizes about the breast-feeding
from Winnicott (1958a) and Balint (1959, 1968). situation, and it is associated with calling the
The focus of the Independents on early mother (and the breast) to mind in her absence.
development led them away from a libidinally The physical object is both the infant (the ªmeº
driven structural model to develop a ªself± aspect) and the mother (the ªnot-meº aspect); it
objectº theory. Parts of the self are seen as in is transitional in facilitating the move from the
dynamic interaction with each other and with omnipotence that must occur in relating to a
complementary internal and external objects. subjectively created object, to relating to the
Fairbairn (1954, 1963) envisages the self as a ªrealº mother who is seen as part of external
crucial agent of motivation; there is no emotion reality.
without the self and no self without emotion The mother has to be ªgood-enough,º but her
(Rayner, 1991). Fairbairn (1952) wrote ªThe failure is expectable and is the motivator of
libido is primarily object-seeking (rather than growth. Winnicott (1958b) stresses that the
pleasure seeking as in classical theory)º (p. 82). baby must not be challenged too soon about the
mother's ªrealnessº (her independent existence) hateful, giving themselves over to the pleasures
and asked to negotiate the ªme and the not-me.º of hating and destruction.
The baby's omnipotence gives rise to the ego
nuclei which will in time become integrated in (iii) The false self
the real experience of the I (the true self). Serious
If trauma occurs at the stage of absolute
trauma at the developmental level prior to the
dependency, an adaptation in the form of a
stable differentiation of self and objects, creates
ªcaretaker selfº may develop (Winnicott, 1965a,
a basic fault in the structure of the psyche, which
1971a). If the mother is unable to provide
Balint (1968) envisages not as a split or fracture,
comprehension of the infant through her
but as a profound misordering. A person man-
gestures, the infant will be forced into a
ifesting a basic fault has an underlying feeling
situation of compliance, which has mimicry
that something is not right about him or her; he
but which is alien to his or her true self. The
or she is not resentful about this but invariably
infant, and then child, will have the capacity to
seeks a solution in the environment. The basic
ªgo through the motionsº of interpersonal
fault is seen as the developmental root of
relationships, but these encounters will be with
personality disorder.
the false self which will serve to hide the true self
(Winnicott, 1965b). At the extreme, it is only
1.14.4.3.2 The Independent view of neurotic functional outside of intimate relationships, and
processes and severe psychopathology when called upon within such relationships (by,
(i) Splitting of the self for example, an intensive psychotherapeutic
encounter) it may ªbreak downº and leave
The key contribution by Fairbairn (1944) is unprotected an infantile and poorly developed
the proposition that early trauma of great sense of ªtrue self.º
severity is stored in memories which are
ªfrozenº or dissociated from a person's central 1.14.4.3.3 Strengths and weaknesses of the
ego or functional self. This conception steps approach
beyond the classical psychoanalytic notion of
repression in developmental accounts of psy- Post-war British psychoanalysis, particularly
chopathology. The classical model of pathogen- as exemplified in the work of Winnicott, has
esis (conflict ? repression ? reactivation of been immensely influential in bringing about
conflict ? neurotic compromise) is still seen to the sea change in psychodynamic thinking
apply to conflicts which reach the oedipal (3±4 which we have witnessed over the last 20 years.
year) level. The Independent model concerns Winnicott, and other Independent object-rela-
disorders of the self, thought to arise out of tions theorists, became a source of inspiration to
traumatic events before that age. Anxiety, as all US object-relations theorists such as Modell
pathological states, is regarded as rooted in the (1984) and Ogden (1986). At the same time they
conflicts over infantile dependence. The regres- have influenced the work of major French
sive wish to be dependent carries with it the psychoanalytic thinkers such as Andre Green
threat of loss of identity. The progressive goal of (1975). In addition, its impact on Kohutian
separation generates anxiety over feeling iso- thinking was considerable although not often
lated, alone, and unsupported. Whilst a retreat acknowledged.
to the home base might offer short-term relief, The major weakness of the British object-
eventually it creates anxiety over engulfment relations school is its naive reconstruction of
and loss of identity, thus reinitiating the infancy in the adult mind. Although infant
conflict. research confirms some speculations and in-
formal observations, it cannot sustain the
developmental argument of a linear evolution
(ii) Schizoid personality
from infancy to adulthood. Human develop-
Schizoid personality (Fairbairn, 1952) arises ment is far too complex for infantile experiences
out of the infantile experience that love is to have direct links to adult pathology. In fact,
destructive for the mother and therefore has to to the extent that such research is available,
be inhibited along with all intimacy. In schizoid longitudinal studies of infancy suggest that
states the ego is so split that the individual may personality organization is subject to reorgani-
be mystified about himself and is transiently zation throughout development, based on
disturbed about reality (finding the familiar in significant positive and negative influences
the unfamiliar and vice versa). These individuals (Block, Block, & Gjerde, 1988; Emde, 1988a,
resist perceiving others as whole persons; they 1988b). The infantile experiences described by
hide their love, and, to protect themselves from Winnicott and others are thus no less metapho-
othersº love, they erect defenses designed to rical and reductionistic than the ego psycholo-
distance others, seeming indifferent, or even gical formulations they aimed to replace.
1.14.4.4 Kohut's Self-psychology taking a playful or humorous stance towards the

self, hypomanic states of exaltation, and over-
1.14.4.4.1 Innovative aspects of Kohut's theory concern with the bodily self. There is a defect in
Kohut (1971, 1977, 1984) proposed that the the self, predisposing the individual to experi-
main developmental attainment for any indivi- ences of threatened fragmentation and empty
dual is the achievement of a cohesive self. Self- depression. These experiences are disguised by
cohesion is the primary motivational property defensive and compensatory behavior such as
guiding human behavior, and is derived from the seeking of adulation and intense excitement.
inevitable disappointments of grandiosity and The grandiose self persists in an unneutralized
exhibitionistic needs (Kohut, 1971). way because the child is not met with appro-
Self-development is the internalization of the priate mirroring responses. The idealized par-
self-object. A self-object is defined as a person in ental imago will remain, and the child will be left
the environment who performs particular func- with an unattainable, unrealistic, or partial
tions for the self; these functions evoke the system of values and ideas. Patients in Kohutian
experience of selfhood (Wolf, 1988). To begin treatment are allowed to express both their
with, a mirroring selfobject (assumed to be the idealization of the therapist and their own
mother) allows the unfolding of exhibitionism grandiosity without being met by confrontation
and grandiosity. Frustration, when phase or interpretation. The empathic stance taken by
appropriate and optimal in degree, permits a the therapist is believed to reactivate the
gradual modulation of infantile omnipotence developmental process, and, through the in-
through ªa transmuting internalizationº of this evitable and gradual disappointment of the
mirroring function. Empathic responses from patient, the neutralization of both the grandiose
the mirroring selfobject facilitate the unfolding self and the idealization of the caregiving figures
of the infant's grandiosity, exhibitionism, feel- will be resumed.
ings of perfection and omnipotence, and this
enables him or her to build an idealized image of
the parent with whom he or she wishes to merge. 1.14.4.4.3 Strengths and weaknesses of Kohut's
The idealization of self-objects, also through model
internalization, leads to the development of
ideals. The internalizing of the mirroring Kohut's clinical approach has strong follow-
function and idealized self-object leads to the ing amongst psychologists. This is principally
emergence of a ªbipolar selfº with its ambitions because of the clinical relevance of his ideas and
and ideals and the natural talents available to it. their usefulness in psychotherapeutic work.
ªTransmuting internalizationº of the self-object There are clear and readily implementable
leads gradually to consolidation of the nuclear technical recommendations arising out of
self (Kohut & Wolf, 1978, p. 83). Kohut (1977) Kohut's approach based around the need to
suggested that it is the ªenfeebled self º which ªrestore the self º using therapeutic methods
turns defensively towards pleasure aims which perform the developmental task of
(drives). Drives are breakdown products of transmuting internalization.
disappointments to the self, usually involving There are numerous critical reviews of
failures in emotional attunement of selfobjects. Kohut's theory from within structural psycho-
analytic models (see, e.g., Slap & Trunnel,
1987). Schwartz (1978), for example, finds
Kohut's descriptions suffer from overinclusive-
1.14.4.4.2 Self-psychological model of mental
ness. Fragmentations of the self are believed to
disorder
include depressions, depersonalizations, and
When parents consistently fail to provide for disorganizing anxieties, as well as temporary
the child's narcissistic needs, Kohut suggests or encapsulated psychotic states.
that the archaic grandiose self and the idealized A major problem in Kohut's more recent
parent imago may become hardened and fail to formulations is the implicit confusion between
be integrated into later structures. Akhtar and self and self-representation. The self is presented
Anderson, however, (1982) summarize some of by Kohut in representational terms, yet Kohut
the behavioral features of narcissistic person- ascribes to it motivational properties and
ality disorder included in Kohut's writing (see tendencies such as goals, plans, and self-esteem
Kohut, 1971): rage as a reaction to threats to motivation (see Kohut, 1971). In this way, the
self-esteem, the need for revenge to deal with self comes to denote most, if not all, of the
narcissistic injury, a lack of capacity to form and personality and therefore becomes a super-
maintain relationships, perverse sexuality or a fluous term, much as the concept of ego was
lack of sexual interest, lack of empathy with overextended by ego psychologists (see, e.g.,
others, pathological lying, a limited capacity for Schafer, 1976).
1.14.4.5 Kernberg's Integrated Theory complex presentation containing both loving

and hostile elements evolved.
1.14.4.5.1 Internalization and the construction Even such relatively integrated internal
of self, object, and affect triads representations, however, contain dyadic units
In Otto Kernberg's model, affects serve as the which reflect either a defensive or an impulsive
primary motivational system (Kernberg, 1983). aspect of psychic conflict. An individual is
He suggests that combinations of a self- highly susceptible to anxiety when configura-
representation, an object-representation, and tions of self- and object-representations are
an affect state linking them are the essential highly charged affectively, and are poorly
units of psychic structure. He terms these differentiated. For example, a representation
self±object±affect triads. His model is based of the self as being weak and vulnerable may be
on reconstructions from the treatment of coupled with an object representation of
severely disturbed adults, which are strongly ruthless domination with a violent affective
influenced by Kleinian theory. It is less tone. When this configuration is activated in
concerned with the child's real experience and therapy or elsewhere, the individual may
focuses on the force of introjects and fantasies. become highly anxious.
Kernberg (1976) described self-image as a In more severe psychopathology, identifica-
product of the process of internalization. For tion with self- or object-representations may
Kernberg (1976) internalization entails three rapidly alternate. For example, an individual
processes: may feel criticized, but very quickly the criticism
(i) Introjection, the most basic, involves the can shift from the self onto the other; and the
reproduction of an interaction with the envir- critic is now seen as the self who is hurt and
onment by means of the clustering of memory mistreated, and the individual identifies with the
traces attached to the self- or object-image and critical stance. This oscillation of self and other
the interactions of the two in their affective accounts for many instances where impulses
context. appear to change into their opposite (active into
(ii) Identification presumes the child's cogni- passive, good into bad). Very severe levels of
tive ability to recognize the variety of role character pathology are typified by primitive
dimensions that exist in interactions with dissociation or splitting of internalized object
others, and involves the capacity of the self to relations which entail a lack of integration of
model itself after the object influenced by self- and object-representations, projections of
fantasy and affect. The individual's experiences primitive superego nuclei, splitting, impulsivity,
of gratification and frustration influence affec- lack of empathy, and the unmodulated expres-
tive states and determine the degree to which sion of libido and aggression (Kernberg, 1984).
self-representation is flexible, true, and com- Splitting is a key feature of borderline person-
plex. ality organization, antisocial personalities, ªas
(iii) Ego identity, borrowed from Erikson if º characters, patients with multiple sexual
(1959b), as the overall organization of introjec- deviations in narcissistic personalities, addic-
tions and identifications under the synthesizing tions, and even in analytically approachable
influence of the ego. psychosis. The highly unrealistic, sharply idea-
lized or (through aggression) highly persecutory
self- and object-representations characteristic of
this group do not correspond to any real
1.14.4.5.2 Levels of pathology within Kernberg's
relationship. As object relations are poorly
system
integrated, the reversals of the enactment of self-
Kernberg suggested that all levels of dis- and other-representations may be particularly
turbance are more complex in severe personality rapid. This can make relationships with such
disturbance but exist across the entire spectrum individuals confusing and even chaotic. For
of psychopathology. Kernberg (1984) sees example, love and hate may exist in a
neurotic pathology as regression to a relatively dissociated way side by side; several object
integrated, although repressed, infantile self, relations may be condensed into single images.
connected to relatively integrated although also
unconscious representations of the parental
1.14.4.5.3 Borderline personality disorder
object. Patients with a neurotic, rather than
borderline, level of personality organization are It should be noted that, for Kernberg,
able to integrate positive and negative repre- borderline is a level of psychic organization
sentations of self and others. They have passed rather than a nosological entity. His criteria for
through developmental phases where good and the disorder include: (i) nonspecific manifesta-
bad representations of self and others were tions of ego weakness (poor affect tolerance,
combined across affective valances and a impulse control and sublimatory capacity), (ii)
primitive defenses, (iii) identity diffusion, (iv) pathology have characteristics in common with
intact reality testing but a propensity to shift children's thinking that the functions served in
towards dream-like thinking. There is some the adult mind are identical in the two contexts.
empirical evidence in support of Kernberg's Thus the developmental metaphor cannot be
criteria (see Clarkin, Foelsch, & Kernberg, used for explanatory purposes.
1996; Kernberg, Goldstein, & Carr, 1981). (ii) A related weakness is the emphasis on
For Kernberg (1977), the root cause of early development as the root of severe psy-
borderline states is the intensity of destructive chological disturbance. Many significant envir-
and aggressive impulses, and the relative onmental influences do not make themselves
weakness of ego structures available to handle felt until late childhood, adolescence, or even
them. Kernberg sees the borderline individual as adulthood.
using the developmentally early defenses (e.g., (iii) There is a lack of specificity in Kern-
splitting) in an attempt to separate contra- berg's model which is apparent perhaps only
dictory images of self and others to protect because he, more than other writers, attempts
positive images from being overwhelmed by actively to distinguish between subtypes of
negative and hostile ones. Primitive idealiza- disorders. Yet it is not clear from his theory
tion, also a consequence of splitting, protects the why, for example, borderline personality dis-
individual from the ªall badº objects through ordered individuals spontaneously improve
creating an omnipotent object in fantasy which with time (McGlashan, 1986; Stone, 1990).
is the container of grandiose identifications.
Splitting also results in a ªdiffuse sense of
identityº which is characterized by a confused 1.14.4.6 Bowlby's Attachment Theory Model
internal representation of the ªrealº object, and
1.14.4.6.1 Innovative aspects of Bowlby's
an unintegrated primitive superego which sets
approach
unattainable ideals and internalized persecutory
images. The infant comes into the world predisposed
Kernberg (1987) illustrates how the self- to participate in social interactions. The British
destructiveness, self-mutilating behavior, and psychoanalyst, John Bowlby (1969, 1973, 1980)
suicidal gestures tend to coincide with intense was the first to give central place to the child's
attacks of rage towards the object. They can biological proclivity to form attachments, to
serve to re-establish control over the environ- initiate, maintain, and terminate interactions
ment by evoking guilt feelings, or express with the caregiver and use him/her as a ªsecure
unconscious guilt over the success of a deepen- baseº for exploration and self-enhancement.
ing relationship. In some patients self-destruc- Bowlby's (1969) critical contribution was his
tiveness occurs because their self-image focus on the infant's need for unbroken (secure)
becomes ªinfiltratedº with aggression, so that early attachment to the mother. The child who
they experience increased self-esteem and a does not have such provision is likely to show
confirmation of their grandiosity in self-mutila- signs of partial deprivation: excessive need for
tion or masochistic sexual perversions. The love or for revenge, gross guilt and depression;
caring professions can respond only with or complete deprivation: listlessness, quiet
despair to these patientsº obvious sense of unresponsiveness, and retardation of develop-
triumph in their victory over pain and death. ment. Later there are signs of superficiality,
Their efforts seem futile to the patient, who at an want of real feeling, lack of concentration,
unconscious level experiences a sense of being in deceit and compulsive thieving. Later Bowlby
control over death. Self-mutilation, such as (1973) placed these reactions into a framework
cutting, may also protect from the identity of reactions to separation: protest ? despair ?
diffusion (derealization) which is a constant detachment.
threat to the fragmented internal world of the Bowlby's attachment theory is unlike most
borderline individual. other psychoanalytic formulations in that it is,
for the most part, prospective (Bowlby, 1969).
Laboratory investigations such as those of
1.14.4.5.4 Strengths and weaknesses of
Brazleton and colleagues provided important
Kernberg's model
support for Bowlby in demonstrating the innate
Kernberg's is perhaps the most systematically social disposition of the infant, and the adverse
elaborated of all the psychodynamic models, yet consequences if expectations of social respon-
it shares many weaknesses with all the other siveness from the caretaker are not met (see
models we have considered. These can be briefly Tronick, Als, Adamson, Wise, & Brazelton,
summarized as follows. 1978). He is also most bold in claiming that the
(i) It is logically erroneous to assume that infantile roots of pathology lie in actual
just because some features of severe psycho- realistically based fears.
Evidence for Psychodynamic Theories 441
Following Bowlby (1973), the attachment of as physical support, leading to positive self-
infants to their parents is recognized across the concept and confidence in the availability and
social science disciplines as a fundamental responsiveness of the other. Insensitive parent-
psychological process affecting human devel- ing will give rise to insecure models of relation-
opment across the lifespan (see Goldberg, Muir, ships, characterized by lack of trust in the other
& Kerr, 1995). Secure (safe and stable) vs. and a self-representation as unworthy and
insecure (anxious or ambivalent) attachment of undeserving of love and affection.
the child to its parents has been identified as a Broadly speaking, Bowlby's prediction that
primary influence upon the child's evolving insecure attachments are associated with var-
adaptation to the environment. Quality of ious later difficulties has been borne out by
attachment can be successfully assessed in empirical research. Insecurely attached children
infancy using a simple laboratory separation appear to be more likely to experience fluctuat-
between a 12±18 months-old child and the ing and unpredictable affective states, including
caregiver, developed by John Bowlby's closest intensely negative emotions such as excessive
colleague, Mary Ainsworth (Ainsworth, Blehar, sadness and anger (Cassidy, 1994). Insecure
Waters, & Wall, 1978). Upon reunion, secure attachments are associated with maladaptive
infants actively seek contact with and are functioning in other contexts, with problems of
soothed by the caregiver. Insecurely attached emotional disregulation, heightened sensitivity
infants either avoid the caregiver or resist the to stress, pervasive anxiety and distress pro-
caregiver's attempt to comfort them. The blems in interpersonal relationships, internaliz-
pervasive influence of the quality of infant± ing and externalizing disorders (Carlson &
parent bonds upon subsequent social, cognitive, Sroufe, 1995).
and emotional development has been inten-
sively studied (Carlson & Sroufe, 1995). A 1.14.4.6.3 Strengths and weaknesses of
number of longitudinal studies show that Bowlby's theory
attachment in infancy strongly influences many
aspects of psychological adaptation, including Bowlby's approach is a general systems
social behavior (Skolnick, 1986), affect regula- theory and, as such, has many strong features.
tion (Erickson, Sroufe, & Egeland, 1985), It has close ties to empirical data. His approach
cognitive resourcefulness (Grossmann & Gross- is also consistent with the current interpersonal
mann, 1991), and psychological disturbance or relational emphasis in psychodynamic ther-
(Sroufe, 1989). apy (Greenberg, 1991). The notion of internal
Infant patterns of attachment, however, do working model is a useful, if somewhat vague,
not invariably determine subsequent attach- metaphor (Dunn, 1996) which encompasses the
ment relationships (Lamb, 1987), and this three components of human goal-oriented
variability is probably due to qualities of the interpersonal behavior: the self, an object,
internal representation of attachment patterns. and an interactional field within which the
two establish a specific pattern of relationship
(Greenberg, 1991). Bowlby's theory is strong
1.14.4.6.2 Attachment and psychopathology with regard to identifying ªmaintaining factorsº
Bowlby (1969, 1973) suggests that disruption in pathological transactions without placing an
in the functioning of the attachment system will unduly strong emphasis on past experience.
interfere with the child's developing capacities The weakness of his theory is in failing to
for regulating his behavior, emotions, and specify how change may be most readily
arousal. He argues that since children have achieved, or indeed what might constitute
many of their first experiences of emotional change. For interpersonalists, change is often
states (intense anger and anxiety, as well as love seen as deriving from the development of a new
and happiness) in the context of their early relationship with the attachment figure of the
attachment relationships, the quality of these therapist (Holmes, 1993). Traditional psycho-
relationships will determine their capacity for dynamic notions of aggression and conflict also
self-regulation at times of high stress. Insecurely are difficult to integrate with Bowlby's ideas.
attached children should therefore be more
vulnerable to emotional and behavioral dis- 1.14.5 EVIDENCE FOR
regulation, and have fewer opportunities to PSYCHODYNAMIC THEORIES
elaborate the capacity to regulate emotional
experiences, than secure ones (see also Ains- We have already touched on the speculative
worth et al., 1978). Further, Bowlby (1973, 1980) nature of many psychodynamic constructs. The
maintained that secure attachment will generate tendency for psychodynamic theorists to iden-
internal working models of relationships char- tify evidence from their clinical work consistent
acterized by an expectation of emotional as well with their theories is overwhelming and is most
likely responsible for the numerous overlapping As we have seen, one of the core assumptions
formulations offered to fit comparable data sets. of modern psychodynamic approaches concerns
In this section we shall consider some of the the representational processes which are as-
areas of active research in which such interplay sumed to underpin maladaptive behavior.
could have taken place more intensively given Object relations approaches to psychopathol-
interest from either the research or the psycho- ogy (Greenberg & Mitchell, 1983) assume that
dynamic clinical community. disorders are rooted in cognitive structures
As has been emphasized throughout this which bias the representation of interpersonal
chapter, the framework perhaps most consis- relationships. Object relations formulations of
tently made use of is the developmental one. The psychodynamic theory have much in common
psychodynamic assumption that childhood with approaches rooted in social cognition, as
experience has complex causal relationships has been shown by Western (1991). Distortions
with the characteristics of adult adaptation has or pervasive biases of social cognition are
been supported by evidence from a number of generally accepted as central to understanding
fields of study. manifestations of severe psychopathology,
There are numerous longitudinal studies whatever the causes of such cognitive distor-
which demonstrate that problems of adaptation tions may be (e.g., Mineka & Sutton, 1992).
are predictable on the basis of childhood Blatt and his colleagues (e.g., Blatt et al. 1994)
characteristics. The longitudinal study of Block demonstrated cognitive distortions in the nar-
and Block (1980) demonstrated that both drug ratives of depressed patients, particularly
abuse (Shedler & Block, 1990) and depression marked deficits in the description of the self.
(Block, Gjerde, & Block, 1991) can be predicted Those patients whose experience of depression
from childhood characteristics. Such findings was one of emptiness, loneliness, and labile,
are naturally equally consistent with genetic diffuse negative affectivity are more likely to be
predispositions; however, many findings con- diagnosed with borderline personality disorder.
tain subtle specific associations which are more Such associations may be relatively easy to
readily accounted for in psychodynamic terms account for in terms of differences in self and
than in terms of behavior genetics. For object representations in borderline and non-
example, in the Block et al. (1991) report, borderline individuals. The quality of depressive
men with depressive features were observed to experience reflects the sparsity of the internal
have been impulse-ridden in childhood, whereas world of the borderline individual.
women with the same diagnosis had been Modern cognitive science has increasingly
overcontrolled. drawn on notions of unconscious cognitive
Research using a wide range of methodolo- processes to account for performance in the
gies uniformly reports that poor parenting areas of memory (e.g., Schacter, 1992), thought
practices are a major contributing factor to (e.g., Jacoby & Kelly, 1992), and emotion (e.g.,
the development of psychiatric disorders. The Murphy & Zajonc, 1993). That much cognitive
balance of evidence now favors the case for the processing occurs outside of awareness is an
pervasive and apparently irreversible impact of inevitable conclusion given our enhanced un-
inadequate early social relationships (e.g., derstanding of the complexity of these pro-
Hodges & Tizard, 1989a, 1989b). It is also cesses. Somewhat more controversial, but
recognized that, in particular during early equally unassailable, is the idea that conscious
months, when growth and maturation are most and unconscious processing of the same theme
rapid, the degree and quality of caregiver may produce qualitatively different outputs. A
assistance may be critical for the long-term study by Fazio and his colleagues (Fazio,
biological organization of the child (e.g., Jackson, Dunton, & Williams, 1995) illustrates
Greenough & Black, 1992). The accessibility this point. They administered a measure of
of attachment patterns to empirical research conscious racial attitudes to subjects at the same
(Ainsworth et al., 1978) has prompted numer- time as assessing unconscious or implicit
ous longitudinal studies. These have demon- attitudes by seeing the extent to which subjectsº
strated that particularly secure mother±infant responses to adjectives was slowed down or
attachment predicts predominantly good long- speeded up by the presentation of black or white
term outcome (Carlson & Sroufe, 1995) and faces. The subjectsº task was simply to
disorganized patterns of attachment are most categorize adjectives as good or bad. An implicit
likely to be associated with pathological negative attitude was indicated by the face of a
patterns of adaptation (Lyons-Ruth, 1996). In black person speeding up responses to negative
particular, there is unassailable evidence to words, and a white person's face speeding up
suggest that, at the extreme end, childhood responses to positive adjectives. The subjects
maltreatment is a powerful cause of maladap- then engaged in conversation with a black
tive behavior (Cicchetti & Toth, 1995). confederate who rated them in terms of their
References 443
friendliness as she discussed racial issues with 13, pp. 39±101). Hillsdale, NJ: Erlbaum.
them. Interestingly the priming task, but not the Block, J., Block, J. H., & Gjerde, P. F. (1988). Parental
functioning and the home environment in families of
conscious attitude ratings, predicted the blind divorce: Prospective and concurrent analyses. Journal of
independent ratings of the confederate. the American Academy of Child and Adolescent Psychia-
This necessarily brief survey has illustrated try, 27, 207±213.
that psychodynamic notions are not ªoutland- Block, J. H., Gjerde, P., & Block, J. (1991). Personality
antecedents of depressive tendencies in 18-year-olds: A
ishº from the point of view of empirical prospective study. Journal of Personality and Social
psychology. None of these studies can ªproveº Psychology, 60, 726±738.
psychodynamic ideas, as the two pertain to Boesky, D. (1988). A discussion of evidential criteria for
independent realms of human functioning: the therapeutic change. In A. Rothstein (Ed.), How does
laboratory and the consulting room. However, treatment help? On the modes of therapeutic action of
psychoanalytic therapy (pp. 171±180). Madison, CT:
taken as a whole, they point to the validity of International Universities Press.
underlying psychological processes implicitly Bower, T. R. (1989). The rational infant: Learning in
posited by psychodynamic theoreticians when infancy. New York: Freeman.
offering their model of human development and Bowlby, J. (1958). The nature of the child's tie to his
mother. International Journal of Psycho-Analysis, 39,
the pathological outcomes that may arise from 350±373.
it. Psychodynamic theory is unlikely ever to be Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment.
comprehensively validated in empirical studies. London: Hogarth Press and the Institute of Psycho-
All that we can hope for is that the general Analysis.
model of a person, painstakingly assembled on Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation:
Anxiety and anger. London: Hogarth Press and Institute
the basis of neuropsychological, social and of Psycho-Analysis.
cognitive-psychological investigations, will not Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss:
be too dissimilar from the vision of human Sadness and depression. London: Hogarth Press and
functioning which has emerged from the clinical Institute of Psycho-Analysis.
endeavors of psychodynamically oriented prac- Brenner, C. (1979). The components of psychic conflict and
its consequences in mental life. Psychoanalytic Quarterly,
titioners. 48, 547±567.
Brenner, C. (1982). The mind in conflict. New York:
International Universities Press.
1.14.6 REFERENCES Britton, R. (1989). The missing link: Parental sexuality in
the Oedipus complex. In J. Steiner (Ed.), The Oedipus
Aichhorn, A. (1935). Wayward youth. New York: Viking. complex today (pp. 83±102). London: Karnac Books.
(Original work published 1925). Carlson, E., & Sroufe, L. A. (1995). Contribution of
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. attachment theory to developmental psychopathology.
(1978). Patterns of attachment: A psychological study of In D. Cicchetti & D. J. Cohen (Eds.), Developmental
the Strange Situation. Hillsdale, NJ: Erlbaum. psychopathology: Vol. 1. Theory and methods
Akhtar, S., & Anderson, T. J. (1982). Overview: Narcissis- (pp. 581±617). New York: Wiley.
tic personality disorder. American Journal of Psychiatry, Cassidy, J. (1994). Emotion regulation: influences of
139, 12±20. attachment relationships. In N. A. Fox (Ed.), The
Alexander, F. (1930). The neurotic character. International development of emotion regulation. Monograph of the
Journal of Psycho-Analysis, 11, 292±311. society for research in child development (Serial No. 240)
Allen, J. (1995). The spectrum of accuracy in memories of (pp. 228±249). Chicago: University of Chicago Press.
childhood trauma. Harvard Review of Psychiatry, 3, Cicchetti, D., & Cohen, D. J. (1995). Perspectives on
84±95. developmental psychopathology. In D. Cicchetti & D. J.
American Psychiatric Association. (1994). DSM-IV draft Cohen (Eds.), Manual of developmental psychopathology
criteriaÐTask force on DSM-IV. Washington, DC: (pp. 3±23). New York: Wiley.
Author. Cicchetti, D., & Toth, S. L. (1995). A developmental
Arlow, J. A., & Brenner, C. (1964). Psychoanalytic concepts psychopathology perspective on child abuse and neglect.
and the structural theory. New York: International Journal of the American Academy of Child and Adolescent
Universities Press. Psychiatry, 34, 541±565.
Bahrick, L. R., & Watson, J. S. (1985). Detection of Clarkin, J., Foelsch, P. A., & Kernberg, O. F. (1996).
intermodal proprioceptive-visual contingency as a po- Manual for the Inventory of Personality Organization
tential basis of self-perception in infancy. Developmental (IPO). New York: Cornell University Medical College.
Psychology, 21, 963±973. Cooper, A. M. (1983). Psychoanalytic inquiry and new
Balint, M. (1959). Thrills and regressions. London: knowledge. In J. D. Lichtenberg & S. Kaplan (Eds.),
Hogarth. Reflections on self psychology (pp. 19±34). Hillsdale, NJ:
Balint, M. (1968). The basic fault. London: Tavistock. Analytic Press.
Bion, W. R. (1959). Attacks on linking. International Cooper, A. M. (1985). A historical review of psycho-
Journal of Psycho-Analysis, 40, 308±315. analytic paradigms. In A. Rothstein (Ed.), Models of the
Bion, W. R. (1962). Learning from experience. London: mind: Their relationships to clinical work (pp. 5±20). New
Heinemann. York: International Universities Press.
Blatt, S., Ford, R. Q., Berman, W. H., Cook, B., Cramer, Crews, F. (1995). The memory wars: Freud's legacy in
P., & Robins, C. E. (1994). Therapeutic change: An object dispute. London: Granta Books.
relations approach. New York: Plenum. Dunn, J. (1996). The Emanuel Miller Memorial Lecture
Block, J., & Block, J. (1980). The role of ego-control and 1995: Children's relationships: Bridging the divide
ego-resiliency in the organization of behavior. In W. A. between cognitive and social development. Journal of
Collins (Ed.), Minnesota symposium on child psychology: Child Psychology and Psychiatry and Allied Disciplines,
Development of cognitive affect and social relations (Vol. 37, 507±518.
Emde, R. N. (1980a). Emotional availability: A reciprocal Fonagy, P., Target, M., Steele, M., & Gerber, A. (1995b).
reward system for infants and parents with implications Psychoanalytic perspectives on developmental psycho-
for prevention of psychosocial disorders. In P. M. Taylor pathology. In D. Cicchetti & D. J. Cohen (Eds.),
& F. Orlando (Eds.), Parent±infant relationships Developmental psychopathology: Vol. 1. Theory and
(pp. 87±115). New York: Grune & Stratton. methods (pp. 504±554). New York: Wiley.
Emde, R. N. (1980b). Toward a psychoanalytic theory of Frances, A., Pincus, H., Widiger, T., Davis, W., & First, M.
affect: Part 1. The organizational model and its (1990). DSM-IV: Work in progress. American Journal of
propositions. In S. I. Greenspan & G. H. Pollock Psychiatry, 147, 1439±1448.
(Eds.), The course of life: Vol. 1. infancy and early Freud, A. (1946). The ego and the mechanisms of defence.
childhood (pp. 63±83). Washington, DC: DHSS. New York: International Universities Press. (Original
Emde, R. N. (1980c). Toward a psychoanalytic theory of work published 1936.)
affect: Part II. Emerging models of emotional develop- Freud, A. (1965). Normality and pathology in childhood.
ment in infancy. In S. I. Greenspan & G. H. Pollock Harmondsworth, UK: Penguin.
(Eds.), The course of life: Vol. 1. Infancy and early Freud, A. (1981). Changes in psychoanalytic practice and
childhood (pp. 85±112). Washington, DC: DHSS. experience. New York: International Universities Press.
Emde, R. N. (1981). Changing models of infancy and the Freud, S. (1900). The interpretation of dreams. In J.
nature of early development: Remodelling the founda- Strachey (Ed. and Trans.), The standard edition of the
tion. Journal of the American Psychoanalytic Association, complete psychological works of Sigmund Freud (Vols. 4,
29, 179±219. 5, pp. 1±715). London: Hogarth.
Emde, R. N. (1985). From adolescence to midlife: Freud, S. (1901). The psychopathology of everyday life. In
Remodeling the structure of adult development. Journal J. Strachey (Ed. and Trans.), The standard edition of the
of the American Psychoanalytic Association, 33, 165±192. complete psychological works of Sigmund Freud (Vol. 6,
Emde, R. N. (1988a). Development terminable and inter- pp. 1±190). London: Hogarth.
minable. I. Innate and motivational factors from infancy. Freud, S. (1905a). Jokes and their relation to the
International Journal of Psycho-Analysis, 69, 23±42. unconscious. In J. Strachey (Ed. and Trans.), The
Emde, R. N. (1988b). Development terminable and standard edition of the complete psychological works of
interminable. II. Recent psychoanalytic theory and Sigmund Freud (Vol. 8, pp. 1±236). London: Hogarth.
therapeutic considerations. International Journal of Freud, S. (1905b). Three essays on the theory of sexuality.
Psycho-Analysis, 69, 283±296. In J. Strachey (Ed. and Trans.), The standard edition of
Erickson, M. F., Sroufe, L. A., & Egeland, B. (1985). The the complete psychological works of Sigmund Freud (Vol.
relationship between quality of attachment and behavior 7, pp. 123±230). London: Hogarth.
problems in preschool in a high-risk sample. Monographs Freud, S. (1920). Beyond the pleasure principle. In J.
of the Society for Research in Child Development, 50, Strachey (Ed. and Trans.), The standard edition of the
147±166. complete psychological works of Sigmund Freud (Vol. 18,
Erikson, E. H. (1950a). Childhood and society. New York: pp. 1±64). London: Hogarth.
Norton. Freud, S. (1923). The ego and the id. In J. Strachey (Ed.
Erikson, E. H. (1950b). Growth and crises of the ªhealthy and Trans.), The standard edition of the complete
personality.º The healthy personality. Caldwell, NJ: psychological works of Sigmund Freud (Vol. 19,
Progress Associates. pp. 1±59). London: Hogarth.
Erikson, E. H. (1959a). Identity and the life cycle. New Freud, S. (1926). Inhibitions, symptoms and anxiety. In J.
York: International Universities Press. Strachey (Ed. and Trans.), The standard edition of the
Erikson, E. H. (1959b). The problem of ego identity. In complete psychological works of Sigmund Freud (Vol. 20,
Identity and the life cycle (pp. 104±164). New York: pp. 77±172). London: Hogarth.
International Universities Press. (Original work pub- Freud, S. (1930). Civilization and its discontents. In J.
lished 1956.) Strachey (Ed. and Trans.), The standard edition of the
Fairbairn, W. R. D. (1944). Endopspychic structure complete psychological works of Sigmund Freud (Vol. 21,
considered in terms of object-relationships. International pp. 57±146). London: Hogarth.
Journal of Psycho-Analysis, 25, 60±93. Freud, S. (1938). An outline of psychoanalysis. In J.
Fairbairn, W. R. D. (1952). An object-relations theory of the Strachey (Ed. and Trans.), The standard edition of the
personality. New York: Basic Books. complete psychological works of Sigmund Freud (Vol. 23,
Fairbairn, W. R. D. (1954). Observations on the nature of pp. 139±208). London: Hogarth.
hysterical states. British Journal of Medical Psychology, Freud, S., & Breuer, J. (1895). Studies on hysteria. In J.
29, 112±127. Strachey (Ed. and Trans.), The standard edition of the
Fairbairn, W. R. D. (1963). Synopsis of an object-relations complete psychological works of Sigmund Freud (Vol. 2,
theory of the personality. International Journal of pp. 1±305). London: Hogarth.
Psycho-Analysis, 44, 224±225. Friedman, L. (1988). The clinical popularity of object
Fazio, R., Jackson, J. R., Dunton, B., & Williams, C. J. relations concepts. Psychoanalytic Quarterly, LVII,
(1995). Variability in automatic activation as an unob- 667±691.
trusive measure of racial attitudes: A bona fide pipeline? Gergely, G. (1991). Developmental reconstructions: In-
Journal of Personality and Social Psychology, 69, fancy from the point of view of psychoanalysis and
1013±1027. developmental psychology. Psychoanalysis and Contem-
Fenichel, O. (1945). The psychoanalytic theory of neurosis. porary Thought, 14, 3±55.
New York: Norton and Routledge. Gitelson, M. (1955). Contribution to scientific proceedings,
Fonagy, P. (1982). Psychoanalysis and empirical science. reported by L. Rangell. Journal of the American Psycho-
International Review of Psychoanalysis, 9, 125±145. analytic Association, 3, 294±295.
Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Glover, E. (1949). Psycho-Analysis. New York: Staples.
Mattoon, G., & Target, M. (1995a). Attachment, the Goldberg, S., Muir, R., & Kerr, J. (1995). Attachment
reflective self, and borderline states: The predictive theory: Social, developmental and clinical perspectives.
specificity of the Adult Attachment Interview and Hillsdale, NJ: Analytic Press.
pathological emotional development. In S. Goldberg, Golinkoff, R. M., Hardig, C. B., Carlson, V., & Sexton, M.
R. Muir, & J. Kerr (Eds.), Attachment theory: Social E. (1984). The infant's perception of causal events: The
developmental and clinical perspectives (pp. 233±278). distinction between animate and inanimate objects. In L.
Hillsdale, NJ: Analytic Press. P. Lipsitt & C. Rovee-Collier (Eds.), Advances in infancy
References 445
research (pp. 125±165). Norwood, NJ: Ablex. Johnson, A. M., & Szurek, S. A. (1952). The genesis of
Green, A. (1975). The analyst, symbolization and absence antisocial acting out in children and adults. Psycho-
in the analytic setting: On changes in analytic practice analytic Quarterly, 21, 323±343.
and analytic experience. International Journal of Psycho- Jung, C. G. (1916). Psychology of the unconscious. London:
Analysis, 56, 1±22. Routledge & Kegan Paul.
Greenberg, J. (1991). Oedipus and beyond. Cambridge, MA: Jung, C. G. (1923). Psychological types. London: Routle-
Harvard University Press. dge & Kegan Paul.
Greenberg, J. R., & Mitchell, S. A. (1983). Object relations Kernberg, O. F. (1976). Object relations theory and clinical
in psychoanalytic theory. Cambridge, MA: Harvard psychoanalysis. New York: Aronson.
University Press. Kernberg, O. F. (1977). The structural diagnosis of
Greenough, W., & Black, J. (1992). Induction of brain borderline personality organization. In P. Hartocollis
structure by experience: Substrates for cognitive devel- (Ed.), Borderline personality disorders: The concept, the
opment. In M. R. Gunnar & C. A. Nelson (Eds.), syndrome, the patient (pp. 87±121). New York: Interna-
Minnesota symposia on child psychology (Vol. 24, tional Universities Press.
pp. 155±200). Hillsdale, NJ: Erlbaum. Kernberg, O. F. (1983). Object relations theory and
Grossmann, K. E., & Grossmann, K. (1991). Attachment character analysis. Journal of the American Psycho-
quality as an organizer of emotional and behavioural analytic Association, 31, 247±271.
responses in a longitudinal perspective. In C. M. Parkes, Kernberg, O. F. (1984). Severe personality disorders:
J. Stevenson-Hinde, & J. Marris (Eds.), Attachment Psychotherapeutic strategies. New Haven, CT: Yale
across the life cycle (pp. 93±114). London: Routledge. University Press.
GruÈnbaum, A. (1984). The foundations of psychoanalysis: A Kernberg, O. F. (1987). Borderline personality disorder: A
philosophical critique. Berkeley, CA: University of psychodynamic approach. Journal of Personality Dis-
California Press. orders, 1, 344±346.
Harris, P. L. (1994). The child's understanding of emotion: Kernberg, O. F., Goldstein, E., & Carr, A. (1981).
Developmental change and the family environment. Diagnosing borderline personality. Journal of Nervous
Journal of Child Psychology and Psychiatry, 35, 3±28. and Mental Disease, 169, 225±231.
Hartmann, H. (1958). Ego psychology and the problem of Klein, G. (1976a). Psychoanalytic theory: An exploration of
adaptation. New York: International Universities Press: essentials. New York: International Universities Press.
(Original work published in 1939.) Klein, G. S. (1976b). Freud's two theories of sexuality.
Hartmann, H. (1964a). Comments on the psychoanalytic Psychological Issues, Monograph, 36, 14±70.
theory of the ego. New York: International Universities Klein, M. (1952). Notes on some schizoid mechanisms. In
Press. (Original work published 1950.) M. Klein, P. Heimann, S. Issacs, & J. Riviere (Eds.),
Hartmann, H. (1964b). Notes on the theory of sublimation. Developments in psychoanalysis (pp. 292±320). London:
In Essays on ego psychology (pp. 215±240). New York: Hogarth.
International Universities Press. (Original work pub- Klein, M. (1957). Envy and gratitude. New York: Basic
lished in 1955.) Books.
Hartmann, H. (1964c). The mutual influences in the Klein, M. (1964). Contributions to psychoanalysis,
development of ego and id. In Essays on ego psychology 1921±1945. New York: McGraw-Hill. (Original work
(pp. 155±182). New York: International Universities published 1934.)
Press. (Original work published in 1952.) Klein, M. (1975a). A contribution to the psychogenesis of
Hartmann, H., Kris, E., & Loewenstein, R. (1946). manic-depressive states. In The writings of Melanie Klein
Comments on the formation of psychic structure. The (pp. 236±289). London: Hogarth (Original work pub-
Psychoanalytic Study of the Child, 2, 11±38. lished 1935.)
Hayman, A. (1989). What do we mean by ªphantasyº? Klein, M. (1975b). On the theory of anxiety and guilt. In
International Journal of Psycho-Analysis, 70, 105±114. Envy and gratitude and other works, 1946±1963. New
Hodges, J., & Tizard, B. (1989a). IQ and behavioral York: Delacorte Press. (Original work published 1948.)
adjustment of ex-institutional adolescents. Journal of Klein, M. (1975c). Our adult world and its roots in infancy.
Child Psychology and Psychiatry and Allied Disciplines, In Envy and gratitude and other works, 1946±1963. New
30, 53±75. York: Delacorte Press. (Original work published 1959.)
Hodges, J., & Tizard, B. (1989b). Social and family Klein, M. (1984). Mourning and its relation to manic-
relationships of ex-institutional adolescents. Journal of depressive states. In Love, guilt and reparation and other
Child Psychology and Psychiatry and Allied Disciplines, works 1921±1945 (pp. 344±369). New York: Macmillan.
30, 77±97. (Original work published 1940.)
Holmes, J. (1993). John Bowlby and attachment theory. Klein, R. (1989). Introduction to the disorders of the self.
London: Routledge. In J. F. Masterson & R. Klein (Eds.), Psychotherapy of
Holzman, P. S. (1985). Psychoanalysis: Is the therapy the disorders of the self (pp. 30±46). New York: Brunner/
destroying the science? Journal of the American Psycho- Mazel.
analytic Association, 33, 725±770. Knight, R. P. (1953). Borderline states. Bulletin of the
Horney, K. (1939). New ways in psychoanalysis. New York: Menninger Clinic, 17, 1±12.
Norton. Kohut, H. (1971). The analysis of the self. New York:
Jacobson, E. (1964). The self and the object world. New International Universities Press.
York: International Universities Press. Kohut, H. (1977). The restoration of the self. New York:
Jacobson, W., & Cooper, A. M. (1993). Psychodynamic International Universities Press.
diagnosis in the era of the current DSM's. In N. E. Kohut, H. (1984). How does analysis cure? Chicago:
Miller, L. Luborsky, J. P. Barber, & J. P. Docherty University of Chicago Press.
(Eds.), Psychodynamic treatment research: A handbook Kohut, H., & Wolf, E. S. (1978). The disorders of the self
for clinical practice (pp. 109±126). New York: Basic and their treatment: An outline. International Journal of
Books. Psychoanalysis, 59, 413±425.
Jacoby, L., & Kelley, C. M. (1992). A process-dissociation Lamb, M. (1987). Predictive implications of individual
framework for investigating unconscious influences: differences in attachment. Journal of Consulting Clinical
Freudian slips, projective tests, subliminal perception, Psychology, 55, 817±824.
and signal detection theory. Current Directions in Lampl-de-Groot, J. (1949). Neurotics, delinquents and
Psychological Science, 1, 174±179. ideal formation. In K. R. Eissler (Ed.), Searchlights on
delinquency (pp. 225±245). New York: International analytic Association, 25, 835±871.
Universities Press. Rosenfeld, H. (1950). Notes on the psychopathology of
Limentani, A. (1989). Between Freud and Klein. London: confusional states in chronic schizophrenias. Interna-
Free Association. tional Journal of Psycho-Analysis, 31, 132±137.
Loewald, H. (1986). Transference±countertransference. Rosenfeld, H. (1964). On the psychopathology of narcis-
Journal of the American Psychoanalytic Association, 34, sism: A clinical approach. International Journal of
275±288. Psycho-Analysis, 45, 332±337.
Lyons-Ruth, K. (1996). Attachment relationships among Rosenfeld, H. (1988). Contribution to the psychopathology
children with aggressive behavior problems: The role of of psychotic states: The importance of projective
disorganized early attachment patterns. Journal of identificatioin in the ego structure and object relations
Consulting and Clinical Psychology, 64, 32±40. of the psychotic patient. In E. B. Spillius (Ed.), Melanie
Mahler, M. (1968). On human symbiosis and the vicissitudes Klein today (pp. 117±137). London: Routledge. (Original
of individuation. New York: International Universities work published 1971.)
Press. Sandler, J. (1976). Countertransference and role-respon-
Mahler, M. S., Pine, F., & Bergman, A. (1975). The siveness. International Review of Psycho-Analysis, 3,
psychological birth of the human infant: Symbiosis and 43±47.
individuation. New York: Basic Books. Sandler, J. (1987). The background of safety. In From
Main, T. (1957). The ailment. British Journal of Medical safety to superego: Selected papers of Joseph Sandler
Psychology, 30, 129±145. (pp. 1±8). London: Karnac. (Original work published
Masson, J. (1984). The assault on truth: Freud's suppression 1960).
of the seduction theory. New York: Farrar, Straus & Sandler, J. (1985). Towards a reconsideration of the
Giroux. psychoanalytic theory of motivation. Bulletin of the
Masterson, J. F. (1972). Treatment of the borderline Anna Freud Centre, 8, 223±243.
adolescent: A developmental approach. New York: Wiley. Sandler, J., & Fonagy, P. (Eds.) (1997). Recovered
Masterson, J. F. (1976). Psychotherapy of the borderline memories of abuse: True or false? London: Karnac
adult: A developmental approach. New York: Brunner/ Books.
Mazel. Sandler, J., & Joffe, W. G. (1969). Towards a basic
McGlashan, T. (1986). Long-term outcome of borderline psychoanalytic model. International Journal of Psycho-
patients. Archives of General Psychiatry, 40, 20±30. Analysis, 50, 79±90.
Mineka, S., & Sutton, S. K. (1992). Cognitive biases and Sandler, J., & Rosenblatt, B. (1962). The concept of the
the emotional disorders. Psychological Science, 3, 65±69. representational world. The Psychoanalytic Study of the
Mitchell, S. A. (1988). Relational concepts in psycho- Child, 17, 128±145.
analysis: An integration. Cambridge, MA: Harvard Sandler, J., & Sandler, A.-M. (1987). The past unconscious,
University Press. the present unconscious and the vicissitudes of guilt.
Modell, A. (1984). Psychoanalysis in a new context. New International Journal of Psycho-Analysis, 68, 331±341.
York: International Universities Press. Schacter, D. L. (1992). Understanding implicit memory: A
Modell, A. (1990). Other times, other realities. Cambridge, cognitive neuroscience approach. American Psychologist,
MA: Harvard University Press. 47, 559±569.
Murphy, S. T., & Zajonc, R. (1993). Affect, cognition, and Schafer, R. (1976). A new language for psychoanalysis. New
awareness: Affective priming with optimal and subopti- Haven, CT: Yale University Press.
mal stimulus exposures. Journal of Personality and Social Schwartz, L. (1978). Review of ªThe Restoration of the
Psychology, 64, 723±739. Selfº by Heinz Kohut. Psychoanalytic Quarterly, XLVII,
Ogata, S. N., Silk, K. R., & Goodrich, S. (1990a). The 436±443.
childhood experience of the borderline patient. In P. Schwartz, M. A. (1991). The nature and classification of
Links (Ed.), Family environment and borderline person- the personality disorders: A reexamination of basic
ality disorder (pp. 87±103). Washington, DC: American premises. Journal of Personality Disorders, 5, 25±30.
Psychiatric Press. Schwartz, M. A., & Wiggins, O. P. (1988). Perspectivism
Ogata, S. N., Silk, K. R., Goodrich, S., Lohr, N. E., and the methods of psychiatry. Comprehensive Psychia-
Westen, D., & Hill, E. (1990b). Childhood sexual and try, 29, 237±251.
physical abuse in adult patients with borderline person- Segal, H. (1957). Notes on symbol formation. International
ality disorder. American Journal of Psychiatry, 147, Journal of Psycho-Analysis, 38, 391±397.
1008±1013. Settlage, C. F. (1977). The psychoanalytic understanding of
Ogden, T. (1986). The matrix of the mind: Object relations narcissistic and borderline personality disorders: Ad-
and the psychoanalytic dialogue. New York: Aronson. vances in developmental theory. Journal of the American
Paris, J. (1992). Social risk factors for borderline person- Psychoanalytic Association, 25, 805±833.
ality disorder: A review and hypothesis. Canadian Shapiro, T. (1989). Psychoanalytic classification and
Journal of Psychiatry, 37, 510±515. empiricism with borderline personality disorder as a
Paris, J., & Zweig-Frank, H. (1992). A critical review of the model. Journal of Consulting and Clinical Psychology, 57,
role of childhood sexual abuse in the etiology of 187±194.
borderline personality disorder. Canadian Journal of Shedler, J., & Block, J. (1990). Adolescent drug use and
Psychiatry, 37, 125±128. psychological health: A longitudinal inquiry. American
Pine, F. (1985). Developmental theory and clinical process. Psychologist, 45, 612±630.
New Haven, CT: Yale University Press. Shengold, L. (1989). Soul murder: The effects of childhood
Racker, H. (1968). Transference and countertransference. abuse and deprivation. New York: Ballantine Books.
New York: International Universities Press. Skolnick, A. (1986). Early attachment and personal
Rangell, L. (1955). The borderline case. Journal of the relationships across the life course. In D. F. P. Baltes,
American Psychoanalytic Association, 3, 285±298. D. L. Featherman, & R. Lerner (Eds.), Lifespan
Rayner, E. (1991). The independent mind in British psycho- development and behaviour (Vol. 7, pp. 173±206). Hills-
analysis. London: Free Association Books. dale, NJ: Erlbaum.
Reich, W. (1933). Character analysis (3rd ed.) (V. R. Slap, J., & Trunnel, E. E. (1987). Reflections on the self
Carfagno, Trans.). New York: Farrar, Straus & Giroux. state dream. Psychoanalytic Quarterly, 61, 251±262.
Ricoeur, P. (1977). The question of proof in Freud's Spence, D. (1987). The Freudian metaphor. New York:
psychoanalytic writings. Journal of the American Psycho- Norton.
References 447
Spence, D. P. (1982). Narrative truth and historical truth: Westen, D. (1991). Social cognition and object relations.
Meaning and interpretation in psychoanalysis. New York: Psychological Bulletin, 109, 429±455.
Norton. Winnicott, D. W. (1956). Mirror role of mother and family
Spillius, E. B. (1992). Clinical experiences of projective in child development. In D. W. Winnicott (Ed.), Playing
identification. In R. Anderson (Ed.), Clinical lectures on and reality (pp. 111±118). London: Tavistock.
Klein and Bion (pp. 59±73). London: Routledge. Winnicott, D. W. (1958a). Collected papers: Through
Spitz, R. (1965). The first year of life. New York: paediatrics to psycho-analysis. London: Tavistock.
International Universities Press. Winnicott, D. W. (1958b). Primary maternal preoccupa-
Spitz, R. A. (1957). No and yes: On the genesis of human tion. In D. W. Winnicott (Ed.), Collected papers:
communication. New York: International Universities Through paediatrics to psycho-analysis (pp. 300±305).
Press. London: Tavistock. (Original work published 1954.)
Spitz, R. A. (1959). A genetic field theory of ego formation: Winnicott, D. W. (1962). The theory of the parent±infant
Its implications for pathology. New York: International relationshipÐfurther remarks. International Journal of
Universities Press. Psycho-Analysis, 43, 238±245.
Spruiell, V. (1988). The indivisibility of Freudian object Winnicott, D. W. (1965a). Ego distortion in terms of true
relations and drive theories. Psychoanalytic Quarterly, and false. In The maturational process and the facilitating
LVII, 597±625. environment (pp. 140±152). New York: International
Sroufe, L. A. (1989). Pathways to adaptation and Universities Press. (Original work published 1960.)
maladaptation: Psychopathology as a developmental
Winnicott, D. W. (1965b). The maturational process and the
deviation. In D. Cicchetti (Ed.), Rochester symposium
facilitating environment. London: Hogarth.
on developmental psychopathology: The emergence of a
discipline (pp. 13±40). Hillsdale, NJ: Erlbaum. Winnicott, D. W. (1965c). The theory of the parent±infant
Stern, D. N. (1985). The interpersonal world of the infant: A relationship. In The maturational process and the
view from psychoanalysis and developmental psychology. facilitating environment (pp. 37±55). New York: Interna-
New York: Basic Books. tional Universities Press. (Original work published
Stone, M. H. (1990). The fate of borderline patients: 1960.)
Successful outcome and psychiatric practice. New York: Winnicott, D. W. (1971a). Playing and reality. London:
Guilford Press. Tavistock.
Sullivan, H. S. (1953). The interpersonal theory of Winnicott, D. W. (1971b). Transitional objects and
psychiatry. New York: Norton. transitional phenomena. In D. W. Winnicott (Ed.),
Tronick, E., Als, H., Adamson, L., Wise, S., & Brazelton, Playing and reality (pp. 1±25). London: Tavistock.
T. (1978). The infant's response to entrapment between Wolf, E. S. (1988). Case discussion and position statement.
contradictory messages in face-to-face interaction. Jour- Psychoanalytic Inquiry, 8, 546±551.
nal of Child Psychiatry, 17, 1±13. Yorke, C. (1971). Some suggestions for a critique of
Tyson, P., & Tyson, R. L. (1990). Psychoanalytic theories of Kleinian psychology. The Psychoanalytic Study of the
development: An integration. New Haven, CT: Yale Child, 26, 129±155.
University Press. Yorke, C., Wiseberg, S., & Freeman, T. (1989). Develop-
Waelder, R. (1960). Basic theory of psychoanalysis. New ment and psychopathology: Studies in psychoanalytic
York: International Universities Press. psychiatry. New Haven, CT: Yale University Press.
1.15
Phenomenological, Existential,
and Humanistic Foundations for
Psychology as a Human Science
CONSTANCE T. FISCHER
Duquesne University, Pittsburgh, PA, USA

1.15.2 PHENOMENOLOGY 451
1.15.3 EXISTENTIALISM 453
1.15.4 PHENOMENOLOGICAL±EXISTENTIAL PSYCHIATRY 455
1.15.5 HUMANISTIC PSYCHOLOGY 457
1.15.6 HUMAN SCIENCE PSYCHOLOGY 458
1.15.7 EMPIRICAL PHENOMENOLOGICAL RESEARCH METHOD 460
1.15.7.1 Procedures 461
1.15.7.1.1 Collecting instances 462
1.15.7.1.2 Organizing the data 462
1.15.7.1.3 Data analysis and forms of results 462
1.15.7.2 Clarifications 463
1.15.7.3 Example: Being in Privacy 464
1.15.7.4 Example: Being Impatient 464
1.15.7.5 Comments 464
1.15.8 HUMAN SCIENCE PSYCHOLOGICAL ASSESSMENT 465
1.15.8.1 Developing and Contextualizing Issues for the Assessment 465
1.15.8.2 Using Tests 466
1.15.8.3 Collaborating and Intervening 467
1.15.8.4 Writing Reports 468
1.15.8.5 Judging Validity 469
1.15.8.6 Comments 469
1.15.9 CONCLUDING REMARKS 469
1.15.1 INTRODUCTION into account human characteristics that include

but go beyond those of the objects, materials,
This chapter highlights the historical founda- and processes that are addressed by the natural
tions of psychology as a human science, a sciences. These human characteristics include
rigorous, empirically-based study of humans as our experiencing and acting in accordance with
humans. That is, its approach to humans takes meanings, such as anticipated futures, pasts that
449
450 Phenomenological, Existential, and Humanistic Foundations for Psychology
are alive in the present, and the world that we repeatedly to make personal decisions and sense
relate to personally. of his or her existence, with no guarantees except
In contrast, for the most part psychology that everything human carries co-authored
has achieved its rightful status as a science by meanings and that life ends. Human science
adopting the assumptions and methods of early psychologists hold that when studying human
twentieth century natural sciences, particularly situations as such, at some point researchers
physics and physiology. As this Comprehensive ought to attend to whatever existential themes
Clinical Psychology series attests, that adoption become apparent, rather than ªcontrollingº
has been beneficial for clinical psychology as them out for the sake of ªobjective science.º
well as for our discipline's other specialties. The founding phenomenological and existen-
However, there has been a cost: the content tial authors were European, primarily German
of traditional scientific psychology has been and French. Humanistic psychology is a un-
limited to subject matter that is amenable to the iquely North American movement, arising in the
experimental and statistical methods of natural 1960s both as a popular protest against de-
science: ªIf we can't count it, it doesn't count as humanizing trends in the culture at large, and as
psychology.º As practicing clinicians we often a course championed by certain psychologists.
have to figure out how to integrate the science In its early years, it was characterized as the
we were taught with what was left outÐhuman ªhuman potential movement,º reflecting its
striving, hope, moral sensitivity, and the likeÐ insistence that society in general and psychology
which are not reducible to biology and inde- in particular ought to address not only dysfunc-
pendent determinants. Although contemporary tions, limits, deficits, and their supposed causes,
cognitive psychology allows much more of life but individuals' potential for growth and for
into psychology, it both explains away some of positive experiences such as joy, love, creativity,
it and does not quite address how uniquely and community. Contemporary humanistic psy-
human content is to be accounted for scienti- chology continues to remind us that research,
fically. Even as researchers and theoreticians, theories, and practices bring consequences to
we find that we often have relied on aspects of society and to individuals, and that we ought to
life not addressed by our science in order to be mindful of values as we practice psychology.
develop hypotheses and links among theoretical Applied human science psychology occurs
themes. within an existential±phenomenological or re-
Phenomenological and existential movements lated hermeneutic frame. ªHermeneuticº here
have contributed philosophical foundations for implies an approach which acknowledges that
a human science psychology. Humanistic psy- understandings necessarily are developed
chology has promoted positive values in theory through perspectival meaningsÐinterpreta-
and practice. Briefly, phenomenological philo- tions. Human science practitioners are devel-
sophy notes that the starting point of any science oping clinical and research methods, and bodies
is the direct appearance (phenomenon) of sub- of understanding, appropriate to humans as
ject matter to human observation. Analysis of beings who are always in relation to their
appearances allows us to discover how humans world(s). In that these beings are always in-
construe meaningsÐthe basis of all knowing, volved in interpersonal and societal, and hence,
including that of the natural sciences. From a moral undertakings, humanistic psychology's
human science perspective, when we study bio- concerns are ever present. Although a human
logical (including neurological and physiologi- science approach to psychology respects, and
cal) aspects of being human, it is appropriate to indeed in some instances counts on, the work of
use the procedures developed by those disci- natural science psychology, it understands that
plines; but we should be mindful that these work within a broader frame.
procedures, observations, and sense-making are This chapter will now go on to address
all human undertakings and construals. More- phenomenological, existential, and humanistic
over, the studied biological aspects are always of movements in more detail. Each section is
a person; each implies and influences the other. written for readers not particularly familiar with
Hence, we ought not automatically impose its approach rather than for psychologists al-
experimental designs and explanations based ready working within this orientation. Intra-
on theories and methods developed for studying orientation disputes are bypassed. The chapter
nonhumans. Again, from a human science per- will then turn to human science psychology,
spective, when we study humans as such, we which draws on the above traditions. The
ought to be faithful to human reality, and to connections of human science psychology with
develop research methods explicitly suited to hermeneutics, the ªpostsº (postmodernism, pos-
that purpose. tenlightenment, postpositivism), and construc-
Existential philosophy addresses the univer- tionism will be mentioned. Finally, because most
sal human condition of each individual having readers are not familiar with the implications for
Phenomenology 451
the practice of a human science psychology, Husserl earned his doctorate in mathematics,
separate sections are devoted to its mainstay and attempted in his first book, Philsophie der
research method, empirical phenomenological Arithmatik, published in 1891, to demonstrate
investigation, and to human science psycholo- that the basis of logic and mathematics was
gical assessment. These sections describe prac- psychological, that is, that they were based only
tical differences that flow from this alternative on the brain's operations. He later retracted and
philosophy of science. Psychotherapy is not refuted this position, known as ªpsychologism,º
addressed in a separate section because it which was in large part an effort to establish
appears earlier in Section 1.15.4, and because absolute foundations for knowledge. In his
a chapter on existential psychotherapy appears critique, Husserl noted that psychological laws
in a later volume of this series. are generalizations from empirical observations;
What follows is written in the United States, that is, logic is used by psychologists to gather
to psychologists, in the last couple of years of data and validate findings. Logic thus turns out
the twentieth century. This rendition is colored to be more reasonably viewed as a human means
by my long affiliation with the Psychology of checking on thinking, rather than being
Department of Duquesne University, which reducible to brain functions. Biology is neces-
began to develop its existential±phenomenolo- sary for thought, but not sufficient to account
gical approach to psychology as a human for human reasoning and self-reflection.
science some 30 years ago. Other routes to a Three centuries earlier Descartes, too, had
human science psychology also could be sought to establish a foundation for absolute
written. Certainly hundreds of additional truth. His approach was to systematically doubt
references could have been included. all assertions until he reached the indubitable: ªI
think, therefore I am.º The cost of this proof,
1.15.2 PHENOMENOLOGY however, was a radical separation of mind and
matter, a separation with which psychology still
The phenomenology addressed in this chap- contends. Husserl initiated phenomenology's
ter is only remotely related to two common uses resolution to that artificial distinction. In a very
of the term in North America. The first refers significant sense, Husserl unseparated mind and
simply to taking experience seriously, in its own material. In contrast to Descartes' method of
right, as Carl Rogers did, or as a journalist does systematically doubting the existence of objects
when summarizing reported experiences. In the until ultimate certainty was discovered in the
present context these practices would be char- ªI who thinks and doubts,º Husserl's method
acterized as phenomenal rather than as phenom- was to return respectfully to things in the
enological. That is, they refer to experience, but world, considering them in their own right. By
not to the further analysis of that experience ªthingsº he meant any things of which we are
which would develop its structure and implica- consciousÐphenomena. Experience thereby was
tions for understanding the human construction expanded beyond sense perception, another
of situations. ªPhenomenologyº in this chapter shift of importance for psychology. Moreover,
refers to just such study of (ªologyº) how an Husserl contended that consciousness is not
event or object appears (ªphenomenonº). The isolated, separate from the world; consciousness
second usage common in North America is a is always of something, and that ªsomethingº is
medical one, in which ªphenomenologyº refers necessarily laden with meaning. The term
to similar outward appearances despite diverse ªintentionalityº in philosophy often refers not
etiologies. For example, we might encounter an to purposiveness but to this inevitable attending
article on the phenomenology of schizophrenia, to, intending toward of consciousness. Although
only to find that it dealt with common externally we of course can distinguish our thought pro-
identifiable symptoms rather than with schizo- cesses or perception (a ªnoeticº focus) from
phrenic experience. what we are conscious of (a ªnoematicº focus),
So-called beginnings always have their pre- the two imply each other.
decessors. Still, as we look back from con- Husserl referred to the everyday ways in which
temporary phenomenology, its foundational people are attuned to the world as the ªnatural
philosopher is Edmund Husserl (1859±1938). attitude,º a prephilosophical attitude. When we
Martin Heidegger (1889±1976), who addressed are being scientific, we adopt a much narrower
existential themes in his own phenomenology, stance. Within that specialized frame, we can
has been more influential in contemporary accomplish positive advances in conceptions
applied psychology. Their critiques of psycho- and technology. However, Husserl's critique
logy's philosophy of science continue to chal- remains salient for today's Western psychology:
lenge our assumptions about humans, about as we go about our lives as striving, hoping,
ways of knowing, and about the nature of creative, disciplined scientists, we have forgotten
science and of psychology. that we are more fully human than the
specialized attitude takes into account. Simi- In part responding to criticism of his abstract,
larly, we are quick to explain and treat de- detached concern with essences, Husserl in his
pression in terms of serotonin levels, while being later years expanded his earlier view of the
forgetful that even in instances of biological importance of the LebensweltÐthe lived world.
predisposition, a person's struggles, losses, and The lived world is just that, the world as we live
defeats are also essential for the development of it prior to theorizing. The hyphens in expres-
depression. In other words, we too readily sions such as ªbeing-in-the-worldº are intended
explain all human activity in terms of behavior, to convey that humans are not in the world in
sensation, neurology, or cognition, thereby the same manner as coffee is in a cup, but rather
ignoring or explaining away the perceiving, that humans are always in a unitary relation
striving person. Working in terms of restrictive with the world. That relation is the (necessary)
concepts can be decidedly useful for particular context or horizon within or against which we
purposes, but our findings too are restricted perceive. In turn, as we study our perceptions of
when we fail to return to the experiencing person. objects we also draw out themes of, and better
Husserl's philosophical method avoids sever- understand, that lived background, world.
ing the world (e.g., in the form of scientific Husserl's most influential books on this con-
categories and measurements) from the person tinent have been Ideas: General introduction to
who is in relation to that world. The phenom- pure phenomenology (1913/1962) and The crisis
enological epocheÂ involves questioning and for of European sciences and transcendental phe-
the moment putting aside (bracketing) one's nomenology (1935±37/1970).
presuppositions related to both theory and the Heidegger studied with Husserl, was his
natural attitude. As we then examine a pheno- assistant, and later was awarded what had been
menon in its full variety, we become aware of Husserl's chair at Freiburg University. How-
surprises and of instances that do not fit our ever, Heidegger developed phenomenology in a
anticipations; we discover our assumptions, decidedly existential direction. That is, he left
which we bracket to look anew. Husserl ack- behind Husserl's rather sterile focus on con-
nowledged, however, that although we can sciousness and its objects, and instead centered
bracket even the question of whether the world his study on being-in-the-world. Heidegger's
is real, we cannot bracket our own conscious- academic background and the cultural context
ness which is an integral aspect of whatever we of his early adult years differed significantly from
examine. those of Husserl. Heidegger's basic graduate
Husserl intended that phenomenology be- training was not in mathematics or science, but in
come a science of essencesÐof what was essen- philosophy and the history of theology. His
tial for any phenomenon to be that particular historical context was a Europe coping with
phenomenon. The eidos (essence) was known World War I, concerned about the effects of the
through remaining actively present to the object industrial revolution, questioning society and its
of consciousness and its variations, through notions of ªprogress,º and seeing both nation-
forming language about what appeared, and alism and finished philosophical systems as
through comparing these appearances to related stultifying and dangerous. Soren Kierkegaard's
phenomena. ªConsciousnessº thus is our active (1813±1855) anguished and earnest writings,
presence to whatever we are attending to. which came to be known as Christian existential
Husserl anticipated that various disciplines works, were republished in this era. The edu-
would pursue different phenomena and es- cated public consumed Dostoyevsky's novels,
sences. He meant for this project to retain the with their vivid accounts of complex motiva-
unity of consciousness and world, in particular tions, people caught in circumstances, introspec-
to bypass both subjectivism and empiricism. tion about responsibility, and life's uncertainties
However, many of his contemporaries and many and agonies.
of today's philosophers and psychologists have Within that context, Heidegger turned his
regarded this eidetic phenomenology as moving attention to questions of human existence be-
into idealism, that is, as emphasizing thought at yond Husserl's concern with consciousness.
the expense of the world. Heidegger explicitly eschewed metaphysical
Nevertheless, Husserl's spelling out that con- philosophy with its various claims of ultimate
sciousness is necessary for any experience, and knowledge of the nature and organization of
that it is necessary for unifying our fleeting matter and causes. Unfortunately, his ontologi-
impressions into coherent ones, has had an en- cal philosophy is not as accessible to most
during positive impact. In particular, in human readers as are the writings of phenomenological
science contexts, consciousness is regarded as an and existential psychologists and psychiatrists.
active contribution to our experience; never- In addition, Heidegger's penchant for relying on
more is consciousness only a passive recipient of arcane etymological derivations for his distinc-
input. tive use of German words has made his works
Existentialism 453
difficult to read even for Germans. Moreover, mainstream psychology. In addressing Being
translators, faced with the dilemma of having no beyond consciousness, Heidegger established a
comparable terms in English, often have hermeneutics (ªinterpretationº) of existence; his
retained his original German. Heidegger's philosophical hermeneutics also addressed the
major, most influential, text is Being and time assumptions of social sciences' methods.
(1927/1962). While Heidegger focused on interpretation of
Heidegger set himself the task of developing Being, other philosophers with similar interests
an ontologyÐan explication of the meaning of have focused on particular topics such as lan-
Being. The capitalization indicates concern with guage (e.g., Gadamer) and symbolism in psy-
the nature of existence and being, in contra- choanalysis and religious experience (Ricouer).
distinction to concern with actual beings. Psychologists have employed the hermeneutic
Heidegger's term for human Being, ªDaseinº philosophical tradition (see Hoy, 1978) both to
(ªdaº = there; ªseinº = being), emphasizes that examine individuals' ways of taking up their
human reality is always situated, always in lives, and to research phenomenaÐto explore a
relation to a surrounding ªthere,º never without particular experience and its lived-world ground
environment. However, Dasein does not refer to across instances. The experiences as reported by
individual humans, as has sometimes been individuals are referred to as phenomenal in-
misassumed (understandably, and usually pro- stances, instances of unexamined living of a
ductively). Rather, for Heidegger Dasein refers phenomenon (such as being anxious, or bored,
to the character of existence as being both open or whatever). A phenomenological comprehen-
to the world's possibilities and as always finding sion is yielded by (hermeneutically) examining
itself already in the world. We do, however, instances, asking what becomes evident about
explore human Being through examining actual how phenomenal appearances reveal and instan-
individuals' basic modes of being-in-the-world tiate general human foundations of meaning-
(existenitiala). making, such as caring and temporality, in the
Care is one such mode. We find that events case of a particular phenomenon. See Packer
and things matter to us; we cannot help but to and Addison (1989) for a broader range of
care. But we care in authentic and in inauthentic hermeneutic psychological studies, where ªher-
ways. When we are open to the depth, newness, meneuticº refers to the interpretive (meaning-
and possibilities of what we are attending to, and making) character of the research, and where
when we heed our responsibility for choosing researchers acknowledge perspective, ambigu-
that openness, we are living authentically. When ity, and the always unfinished aspect of under-
we turn other beings into fixed objects or adopt a standing. That understanding begins in the life
closed, unreflectively technological, or judg- world, where the researcher reflects on possible
mental attitude, we are living inauthentically. Of understandings of the subject matter, then has a
course it is impossible to go about life being dialog with his or her own and others' prior
continuously or fully authentic. We are stuck understandings, and circles back to the life-
with always being at least partially inauthentic; world phenomenon to deepen and revise the
the challenge is to strive for authenticity. Our earlier understanding. Hermeneutic interpreta-
finitude, our always being-toward-death, is an- tion does not explain the phenomenon in terms
other of the basic modes of being-in-the world. of external or underlying, or any other, vari-
Our finitude reminds us of our responsibility to ables; it remains with what the researcher is
make our choices within our limited time. We are present to in the life world. This interpretation is
always caught within temporal moments, com- not a translation into established systems of
ing from and going toward. Heidegger's distin- knowledge.
guishing clock time from temporality is a Readings in regard to Husserl, Heidegger,
particularly influential theme for psychology. and other phenomenological philosophers in-
As human-science researchers and clinicians we clude: Edie (1987), Kockelmans (1985), Natan-
are keenly aware that lived time differs mean- son (1966), and Spiegelberg (1965). Also see The
ingfully from measured time (see Slife, 1993). encyclopedia of phenomenology (Embree et al.,
Heidegger extended his analysis of finitude 1997).
and temporality to include our being inevitably
historicalÐcaught in historical times and mo- 1.15.3 EXISTENTIALISM
ments. Our language and understandings are
historically formed, hence we cannot arrive at Jean-Paul Sartre (1905±1980), probably the
an absolute or final interpretation of Being. name North Americans associate most readily
However, Dasein is openness to future as well as with existential philosophy, wrote in close dialog
to past. This basic human way of being (toward with the works of Husserl and Heidegger. In his
the future) has been ignored both by Husserl's own way, he appropriated consciousness as a
eidetic phenomenology and by contemporary constituting, construing character of being
human. He took up the notions of humans being demned to,º an existential dilemma, rather than
temporal and situatedÐalways in relation. His with ªhaving a depression.º (As will be seen in
Being and nothingness (1943/1956) addresses the following brief discussion of Merleau-
consciousness, Being, and their relation. For Ponty's work, the body's chemistry can be seen
Sartre, consciousness is forever striving either to as participating in the depressed state, rather
be at one with Being or to become a concrete than as originating it.) Even a person caught in a
something. Sartre's famous sentence, ªExistence brain-damaged body, or living out a genetic
precedes essenceº refers to this necessity of predisposition to schizophrenia, nevertheless
constructing one's meanings, because they are still participates in forming the meanings of his
not given in our merely existing. Hence also we or her circumstance, in making continuing
are ªcondemned to freedomº to perpetually choices, and in shaping his or her brain-
choose our meanings, especially through our damaged or schizophrenic life.
actions. Sartre's (1948) analysis of emotion as a ªbad
In much of his work, Sartre emphasized the faithº attempt to magically escape from the
emptiness of our future being a ªnot yetº and of meaning of one's situation has been useful in
our past being a ªno longer.º For him, the basic ordinary life and in clinical practice. The
character of consciousness is a perpetual dia- author's own empirical phenomenological re-
lectic between Being and Nothingness. Sartre search on becoming angry, for example, echoes
certainly is not a philosopher of joy! Not all Sartre in finding that the angry person's
existential writers stress the anguish of dealing seemingly powerful protest against whatever
with the possibility of the void, but all do, in one is blocking his or her way is a self-deceptive
way or another, emphasize the bad faith of not effort not to attend to a sense of being made
acknowledging both our situatedness and the helpless or of feeling demeaned (Fischer, 1998).
availability of at least some degree of choice. Maurice Merleau-Ponty (1908±1961) was a
Most existentially oriented philosophers and contemporary of Sartre's, but from his position
psychologists are sympathetic with Sartre's in psychology at the Sorbonne he addressed
amplification of Heidegger's concerns about different issues, in particular those of then
our falling into a technological attitude, char- contemporary psychology: perceptual theory,
acterizing others as ªthey,º and living as though behaviorism, and neuropsychology. In The
we too are objectsÐalready complete, determi- phenomenology of perception (1945/1962),
nate. Sartre wrote primarily of such failures in Merleau-Ponty bypassed the old mind±body
our efforts to be open to our own and others' split by describing persons as being embodied
subjectivity, freedom, humanity. Others, espe- consciousness. We are our bodies even as we
cially Martin Buber in his I and thou (1958), have transcend their physicality. Our bodily being is
emphasized that it is through recognizing an opening onto things; our body and things
another person's humanity that we discover imply each other, for example, as one reaches for
our own. Our social context renders us radically a cup of coffee. Moreover, we perceive only
intersubjective. Authentic community is possible against horizons, against physical settings and
only through the efforts to affirm our own and biographical contexts. As horizons shift in
others' openness to perspective and possibility. accordance with our movement and our efforts
This standpoint was at odds with psycho- toward clarity, perception too shifts. In this
analysis, of which Sartre was a serious reader sense what we know through perception is
and critic. He developed an alternative existen- always ambiguous, never once-and-for-all; like-
tial psychoanalysis, not as a system of treatment wise knowledge. This state of affairs is not to be
but as a study of motivation, conflict, and of lamented, but rather to be acknowledged against
what others identified as neurosis. He deci- claims of fixed meanings and of absolute
phered the dynamics of behavior in terms of a knowledge.
person's earlier fundamental choices and of his In the above work, and in his The structure of
or her continuing existential projects. He pub- behavior (1942/1963), Merleau-Ponty described
lished compelling existential analyses of Genet, three interpenetrating orders of being. As bodily
Flaubert, and Baudelaire. beings, we are part of the physical order, just like
Sartre's impact on psychiatry and clinical rocks, and other objects that ªobey the laws of
psychology, as well as on the educated public, nature.º We also participate in the biological
has been significant. Existential±phenomeno- order, just like other organic, animate beings.
logical clinicians have emphasized that often Finally, we participate in the human order, which
what we diagnose as pathological depression is is grounded in and limited by the other orders
the state of a person struggling with choices that but also surpasses them. The human order
he or she sees as determining who he or she will affects the others: a strained life can occasion a
be. In seeming paradox, it can be liberating to heart attack or clinical depression. Reciprocally,
acknowledge that one is struggling with, ªcon- meditation or a human-made pill can alleviate
Phenomenological±Existential Psychiatry 455
biological strain. By now, as we enter the twenty- actual beings rather than understanding his
first century, these ideas do not seem the least bit characterizations as being about the nature of
controversial, but mainstream psychology has human Being. It was indeed productive.
not adopted a philosophy of science that can Binswanger's early training was with Bleuler
accommodate such observations. and Jung at a clinic in Zurich. He opted out of
Let me mention a few other major existential an academic appointment, and instead served as
authors before moving on to address existential director of a Swiss sanatorium (Bellevue), where
psychiatry and psychology. Victor Frankl's over the years he hosted such foundational
(1905±1997) short, readable Man's search for scholars as Husserl, Heidegger, Freud, Pfander,
meaning: From death camp to existentialism Scheler, Cassirer, and Buber.
(1946/1962) has been widely read. Its compel- Binswanger remained steadfast in his concern
ling account of the psychiatrist's survival in a that psychiatry should be properly, rigorously,
Nazi concentration camp gave credence to the scientific; that is, it should be open to person-in-
importance of actively creating personal mean- world rather than arbitrarily narrow its focus to
ing. Rollo May, as first editor of Existence: A presumed internal states and historical causes.
new dimension in psychiatry and psychology His applied phenomenological method included
(1958), although writing for a professional ªbracketing,º putting aside theory and philo-
audience, opened the way for English-speaking sophy while allowing more and more of a
readers to explore what was happening in con- person's being-in-the-world to become appar-
tinental philosophy and psychiatry. Although in ent through a respectful, caring presence to that
later years, May wrote from a more humanistic person. He collated his findings across instances
concern to wider audiences, the introduction he of those ways of being-in-the-world we call
wrote for this book served as a solid introduc- schizophrenia, mania, and melancholia. Per-
tion to existentialism and phenomenology for haps his best known individual analyses are
many North Americans. Adrian van Kaam's ªThe Case of Ellen West,º found in May et al.'s
(1966) Existential foundations of psychology is a (1958) Existence, and ªThe Case of Lola Voss,º
classic text. In more recent times, Irving Yalom found in Needleman's (1963) edited volume,
(1980) has written a widely read version of Being-in-the-world. Binswanger never regarded
Existential psychotherapy that presents as its his efforts as settled accomplishments nor even
guiding existential themes the necessity of as building toward a complete system, but
dealing with death, freedom, isolation, and rather as explorations beyond the artificial
meaninglessness. The author's own, extended, constraints of a mechanistic psychiatry. Many
version of existential themes includes finitude of his adaptations of Heidegger's notions,
(limitation), choice and meaning, intersubjec- however, have provided readers with an alter-
tivity, and lived body (see Leder, 1990, in native access to ordinary living as well as to
addition to Merleau-Ponty, in regard to the restricted or disordered existence.
latter; see Fischer, 1991, for an overview of Binswanger emphasized the we-relationship,
phenomenological±existential psychotherapy). a we-hood, between the clinician and the other
person, and he studied not ªpersonalityº but
1.15.4 PHENOMENOLOGICAL± rather the patient's worldsÐhis or her multiple
EXISTENTIAL PSYCHIATRY relationships. Broadly, those worlds may be
addressed in terms of an umweltÐone's relation
From the 1920s to the 1960s, while North to his or her nonpersonal environment, an
American psychiatry imported psychoanalytic eigenweltÐone's private world or relations with
theory and method, and North American psy- self, and a mitweltÐone's social relations.
chology developed behaviorism and diagnostic Always he attended to temporal and spatial
assessment instruments, a significant segment of unfoldings of personal topographies, such as
European psychiatry created an approach that Ellen West's ethereal, tomb, and action worlds.
addressed the work of both Freud and Binswanger described various ªfailures of
Heidegger (see Spiegelberg's (1972) Phenomen- Dasein,º notably those of losing one's way,
ology in psychology and psychiatry: A historical finding one's meanings mixed up, and settling
introduction). The two major figures were Swiss. for a life of mannerisms.
Ludwig Binswanger (1881±1966) and Me- Binswanger did not attempt to develop a
dard Boss (1903±1990) both described their system of therapy, but he did agree that his
work as daseins-analysis in contrast to psycho- Daseinsanalyse carried implications for helping
analysis. In both cases Heidegger's DaseinÐ persons whose ways of being in the world had
humans' always being in relationÐwas taken up become problematic. He advised allowing the
at an existential rather than at an ontological patient to explore how he or she had lost his or
level. Binswanger later wrote of his productive her way, and he encouraged the patient's re-
error in applying Heidegger's notions directly to exploring our shared world, both in and beyond
therapy sessions. He regarded therapy as an emerging possibilities. For example, a clinician

interpersonal encounter, and transference as a might inquire, ªSo might this dream be an
present encounter between the participants. He instance of your already relating to your family
regarded dreams as reflecting one's relations, as possibly becoming accepting of you?º The
that is, one's lived worlds, and as indicating clinician also guides the patient by noting
openings to future choices. resistance to his or own desires. Note that the
Medard Boss's work is more systematic and goals are other than symptom removal or
more widely published in English than that of conflict resolution.
Binswanger (see Boss, 1949, 1958, 1963; Moss, Consonantly, Boss distinguishes between
1978). He respectfully bridged Freud's psycho- neurotic guilt which originates in childhood
analytic method into phenomenological psy- transgressions and existential guilt which is a
chiatry. He received his medical education at the failure to remain open to one's possibilities. Both
University of Zurich, worked with Bleuler, can be terribly constraining, as one avoids
received Freudian psychoanalytic training, and looking at continuing choice, lives in a past, and
continued his psychoanalytic studies in London dreads the future. Remaining open, as Heideg-
and Berlin with Ernest Jones, Horney, and ger wrote, is not an achievement, but rather is a
Fenichel. After a long collaboration with Jung, feature of being human; we are less fully human
Boss ultimately found himself dissatisfied with to the extent that we turn away from possibility
the deterministic assumptions of both Freud's amidst the conditions in which we find ourselves.
and Jung's theories. During World War II Boss Both attempting to override the limits of our
studied Binswanger's work, delved into Hei- situations and settling for closed objectifications
degger's writing, and then consulted with of self or others are inauthentic. Patients are not
Heidegger directly. Boss held seminars in Zurich so much encouraged to form relationships with
at which Heidegger spoke to psychiatrists and others or to self-disclose, but rather are en-
other physicians. couraged to allow fundamental ªworld open-
Boss noted common references in Freud and nessº to occur. Boss replaced the psychoanalytic
Heidegger to openness and freedom. He ªwhy?º (does the patient behave in self-defeating
regarded his own phenomenologically inspired ways, recapitulate earlier trauma, etc.) with an
Daseinsanalysis as remaining truer to Freud's existential ªwhy not?º (take your longings
insights than was Freud himself when Freud seriously, move on from stultifying stances,
converted these insignts into the language of the relate to others more intimately).
prevailing natural sciences. However, Boss The above understandings contrast markedly
found psychoanalytic technique to be highly with psychoanalytic notions of conflicts occur-
compatible with Heidegger's writings. For ring internally. Rather than seeking internal
example, following the rule of free association resolution, Boss encourages revised and opened
returns the patient to an openness to experience relationships (with self, other people, things,
and meanings, through which he or she loosens places, the past and future). Boss regards
self-imposed constrictions. ªacting outº not as resistance but rather as
Free association and dream analysis uncover trying out possibilities in a new setting. Like-
not just the past, but previously resisted futures, wise, he regards ªtransferenceº as the patient's
which now become newly possible in the context bringing old ways and old perceptions to the
of an authentic, caring relationship. Freud's relationship going on in therapy now. For a
injunction to maintain ªevenly hovering atten- clinician to deny his or her additional part in the
tionº is affirmed, but is accompanied by an therapy encounter is inauthentic and contrary
injunction against translating the patient's to the project of the client trying out revised
reports into reductive psychoanalytic concepts. ways of relating. Boss, regards Daseins analysis
Reductive interpretations too often transfer the as especially demanding of the clinician, who
patient out of his or her restricted under- makes use of his or her experience with the
standings into the restrictive understandings of patient to encourage greater openness. He re-
the therapist. gards therapy as a genuine encounter in which
Like Binswanger, Boss consistently attends to the clinician is relatively selfless and restrained
the patient's matrices of meaning, or lived and especially respectful of the patient's
worlds, as the place where the patient can individuality.
experience invitations for new possibilities. He There are, of course, many other contributors
adopted Heidegger's distinction between ªinter- from this period in which Europeans sought to
vening careº and ªanticipatory care,º that is, a develop psychological approaches that respected
distinction between intervening by making deci- humans' relational meaning-making. Among
sions, providing interpretations, giving advice, these are Johannes Buytendijk, Henri Ey, Karl
or administering medical treatment, and inter- Jaspers, Eugen Minkowski, Paul Schilder, Erwin
vening by alerting the patient to his or her Straus, J. H. Van den Berg, and Victor von
Humanistic Psychology 457
Gebsattel. Their work has been of interest to like- attended by sandal-footed, knap-sacked,
minded psychiatrists and psychologists around openly breast-feeding members of the Associa-
the world. However, historically there has been tion of Humanistic Psychology (AHP), whose
little communication between these authors and meeting overlapped with the APA conference.
mainstream psychiatry and psychology, al- The establishment types were dismayed as some
though the former group generally has been members of the other organization interrupted
traditionally trained and makes use of a range symposium speakers from the audience with
of theory and data. Indeed, my characterization proclamations such as, ªI just have to tell you
of my own orientation is probably accurate that I love your soul!º One psychologist who
for most phenomenological±existential practi- earlier had published in staid journals pro-
tioners: our philosophical orientation is pheno- pounded nude group therapy in swimming
menological±existential; we make pluralistic use pools.
of developmental theories (such as those of Unfortunately, for those psychologists who
Erikson, Sullivan, Kohut, etc.); we integrate have not kept up with the literature of
research studies into our ongoing understand- humanistic psychology, those earlier dramatic
ings and questions; and within this frame we times still color the movement. To the contrary,
make eclectic use of a range of techniques. the AHP's journal, The Journal of Humanistic
Unlike other major approaches, no basic Psychology, has consistently been a major
therapeutic method is identified with pheno- source for well-considered work that explores
menological±existential clinical practice, as the and supports central human phenomena that
case is for psychoanalysis, behaviorism, and are still underaddressed by mainstream educa-
cognitive psychology. Several psychotherapists tion and psychology: our spiritual, creative,
have developed particular techniques, useful spontaneous, caring, transcendent, and trans-
within many frameworks; examples are personal moments (see Bynum, 1994, in regard
Frankl's (1946/1962) paradoxical intentionism to transpersonal psychology). Even while
and Bugental's (1965) ªWhat's stopping you?º acknowledging the painful and darker sides of
In closing this section, I offer several correc- existence, the AHP continues to champion
tions of common misunderstandings. As re- human potential for positivity and to promote
flected in the preceding sections, existential responsibility for self and to others. Other
philosophy and practice do not posit unfettered positive legacies of the mixed beginnings of
free will. Nor do they emphasize dread and humanistic psychology have been its contribu-
anguish. A second point: Europe is no longer a tions to the growth of self-help organizations,
fountainhead of phenomenological±existential and to education and psychology at least
psychology and psychiatry. North American nodding to notions of the ªwhole personºÐthe
behaviorism and research design were quickly experiencing, thinking, valuing, emotional,
imported by academicians in Europe, Great bodily, spiritual, choosing, interpersonal, be-
Britain, and Scandanavia. Now, interest in having person.
human science alternatives for psychology is Indeed, dissatisfactions with the 1950s parti-
developing in all continents just as it is in North tive, deductive, and reductive experimental
America. research model, with sterile and deterministic
behaviorism, and with pathology-oriented psy-
choanalytic theory, led Abraham Maslow to
1.15.5 HUMANISTIC PSYCHOLOGY form a mailing group of kindred professionals.
He referred to their efforts as the ªthird forceº in
Humanistic psychology emerged as a full- psychology's evolution, following psychoana-
blown professional movement in the 1960s. The lysis and behaviorism. Their exchange of
California-centered countercultural ªhappen- writings eventually grew into the Journal of
ing,º which protested society's suppressions, is Humanistic Psychology (founded in 1961).
similarly named and is sometimes conflated Among the first board of editors for the journal
with a reflectively planned movement within were Andras Angyal, Charlotte Buhler, Kurt
psychology (cf. Smith, 1990). The happening, Goldstein, Dorothy Lee, Rollo May, Lewis
in which assorted citizens, professionals, and Mumford, and David Riesman. In 1963 the
many psychologists participated, also stressed founding meeting of the AHP took place in
the importance of aspects of life neglected by Philadelphia, where nearly 100 like-minded
education and the social sciences: joy, creativ- professionals confirmed the importance of
ity, love, self-affirmation, and spontaneous inserting the place of values into psychology's
expression of affect and belief. Overlap between subject matter and activities. Gordon Allport,
the popular and professional movements did Jacques Barzun, George Kelly, Clark Mousta-
occur. American Psychological Association kas, Gardner Murphy, Henry Murray, and Carl
(APA) annual conferences in those days were Rogers were among nationally known figures
who attended the Old Saybrook (CT) follow-up This brief overview is concluded with a
conference in 1964. International meetings backward- and a forward-looking note. By
followed. The first psychology departments de- now, the humanism of earlier centuries has been
dicated to a humanistic approach were Sonoma a touch point for humanistic psychology, but in
State College (CA) in 1966, West Georgia fact it was not explicitly raised as a source of
College in 1969, and the Humanistic Psychology inspiration in the founding years of the latter
Institute, HPI (San Francisco) in 1970. The HPI movement. The phrase ªhumanistic psychol-
has since become Saybrook Institute (see ogyº was adopted for the AHP's journal only
deCarvalho, 1994, for an organizational history after rejection of options such as ªperson
of this period). psychology,º ªself psychology,º and ªorthop-
In the 1950s and 1960s, as psychology moved sychologyº (Greening, 1985; Sutich, 1962);
increasingly out of academia and into practice, Gordon Allport had first used the term with
Carl Rogers' Client-centered counseling (1951) its present meaning in 1930 (deCarvalho,
and On being a person (1961) were welcomed. 1991a). From the Renaissance onward, ªhu-
He emphasized persons' capacity for growth manismº has referred to humans' unique values,
through self-understanding, enhanced through creativity, and reason, which exceed both
the empathic, authentic presence of the counse- Church doctrine and our material nature (see
lor. He referred to ªcounselingº rather than to Bullock, 1985). Humanistic psychology has
psychotherapy or analysis in large part because helped to put psychology in touch with both
those terms belonged to the legally protected historical humanism and contemporary arts.
domain of medicine. Rogers' work was in Humanistically informed psychologists con-
striking contrast with psychiatry's emphasis tinue to remind us both of the place of values
on psychoanalytic theory and psychopathology, in our personal and work worlds, and of the
and with psychology's emphasis on learning importance of examining the assumptions and
theory and behavior modification. In academia, implications of our scientific practices.
determinism dominated psychology, which
identified itself as a science that could ªpredict
and controlº behavior. Maslow's Toward a psy- 1.15.6 HUMAN SCIENCE PSYCHOLOGY
chology of being (1962) and his I-thou knowledge
in a psychology of science (1966) were welcomed Human science psychology is an approach to
as alternative frameworks for thinking about psychology's subject matter. It is not a philo-
ourselves and our clients, see also Bugental sophy or a theory. The approach is intended to
(1963). respect humans as a subject matter that differs
In 1971, Division 32 (Humanistic Psychol- from nonhuman material. A thorough human
ogy) of the APA was established, largely science approach would encourage study of, and
through the efforts of AHP members. Its work with, humans' physical, biological, and
purpose was to bring the concepts, theories, meaning-making character all at once. Many
and philosophy of humanistic psychology to the clinicians attempt to practice in just that way,
research, education, and professional applica- but when they are not familiar with an explicit
tions of scientific psychology. Among its foundational framework, their efforts are not as
nationally known first board members were consistent as they could be.
David Bakan, Leonard Blank, Albert Ellis, Many researchers could work within a human
Carman Harari, James Klee, and Everett science frame while continuing to pursue their
Shostrom. Among the presidents of the APA psychological studies through experimental and
who have also been leaders within humanistic other statistical designs, which are efficient for
psychology are Carl Rogers, Abraham Maslow, dealing with large samples and with the biolo-
and Brewster Smith. The Division's journal, The gical (and chemical, neurological, etc.) aspects of
Humanistic Psychologist, publishes articles on being human. However, these studies would take
theoretical and philosophical issues, and on into account that variables do not explain
methodological advances in human science behavior or experience, but rather are super-
research. Many members are also actively imposed grids for organizing the orderliness of
involved in the APA's Division of Theoretical psychological matters. An analogy is the field of
and Philosophical Psychology. economics, where explanations and predictions
Accounts of the founders of this movement, are made in terms of unemployment rates, gross
their writings, and the issues they dealt with can national product, and so on, although the human
be found in deCarvalho (1991b), Royce and Mos order underlies those created and imposed
(1981), and Welch, Tate, and Richards (1978). measures. Ultimately the measures reflect the
Division 32's contribution to APA's centennial actions of individuals living within various
publications on the divisions' histories and circumstances and working, enjoying, compet-
contributions may be found in Wertz (1994). ing, making decisions, spending, investing,
Human Science Psychology 459
striving, risking, and so on. In both psychology up by the new discipline. Their philosophical
and economics, the imposed grids are definitely essays and books were ignored in favor of
useful, but they are most useful when we take into hands-on, technically-oriented practice. Never-
account that we made them up, and that we theless, a sampling of books and essays in
understand and serve people best when we return developmental, clinical, and social psychology
from our constructions to reflect on individuals through the 1940s shows that most authors were
going about their lives. These reflections allow us more holistic, and more historically and
to revise our constructions. philosophically minded, than is the case today.
At this point human science psychology is a Although North American psychology has
critique and a call. It is a critique of mainstream always housed a broad mix of theorists and
assumptions and practices for their being practitioners, by the 1950s ªscientificº psychol-
forgetful of the fuller human context, and it is ogy was equated with experimental psychology.
a call to develop a thorough alternative. By the 1960s, many of us who were not satisfied
Adopting a human science framework for with that situation discovered the translations of
psychology's ongoing work would eventually existential phenomenology that were finding
obviate the need for the term. Of course by then their way from Europe. Within this country,
other critiques would emerge, and psychology many critiques and calls for returning persons as
would accordingly advance in new directions. such to our studies were published, for example,
Positivism similarly was adopted as a corrective those by Gordon Allport, David Bakan, Roger
to nineteenth and early twentieth century arm- Barker, Joseph Lyons, Robert McLeod, and
chair philosophizing, and much of the achieve- Nevitt Sanford. In 1970 Amedeo Giorgi pub-
ments of North American psychology are the lished Psychology as a human science: A pheno-
product of that adoption. By now newer menologically based approach. Trained in
generations of psychologists ask ªWhat's experimental psychology, he had encountered
positivism?,º not because it is no longer around, its limitations as a natural science, and turned to
but because it is not being taught as such. Even Dilthey and phenomenological writers for
though many theorists say that positivism foundations appropriate to studying humans
served its purpose, and now has few strict as humans. His book has been a touch point for
adherents, in the absence of widespread alter- diverse readers who have looked for support and
native views, implicit positivism determines the inspiration for their own kindred reflections.
research designs that are supported by grants, Institutionally, Duquesne University's Psy-
publications, and so on. Positivism has become chology Department, shaped in the 1960s by
the invisible approach of mainstream academic Adrian van Kaam and Giorgi, has been a center
psychology. Because psychology no longer has for the systematic development of psychology as
to develop and prove itself as a science, a human science. Its work, however, has been
philosophy of science courses are rarely taught. foundational and corrective and has not yet
Slife and Williams (1997) have called for embodied a full human science research pro-
specialty training in philosophical/theoretical gram, which would include our cultural,
psychology so that departments will have such biological, etc., dimensions. Nevertheless, at
expertise available and, once again even within Duquesne alone, nearly 200 empirical phenom-
experimental programs, will engage in discus- enological research dissertations have been
sions of assumptions and their implications. completed; gradually substantive content area
Toward that end, let me briefly rehash the comprehensions are taking shape. Moreover, as
historically-based approach of a human science qualitative research methods are increasingly
psychology, and some contemporary trends practiced across disciplines and continents, their
with which it is joined. William Dilthey practitioners are increasingly identifying them-
(1833±1911) urged that psychology become a selves with a human science tradition.
rigorous and systematic science, a model for all Saybrook Institute, which also offers a
the Geisteswissenschaften (the disciplines of doctorate, stressing humanistic psychology,
mind, spirituality, and human affairs). He offers substantive work in a human science
argued against the new discipline modeling tradition. The masters degree psychology pro-
itself on the highly successful disciplines of time, grams at West Georgia College and Seattle
mathematics, and the natural sciences (see University are dedicated to humanistic/human
Dilthey, 1894/1977; Hodges, 1944). Neverthe- science psychology. Other institutions include
less, even though Wilhelm Wundt also wrote a clusters of colleagues pursuing this approach,
social psychology that was closer to Dilthey's and of course there are hundreds of individual
proposed human science, and William James faculty members doing likewise along with
wrote extensively on consciousness, it was their thousands of nonacademics. Many individuals
fledgling laboratories in Germany and the do not use the ªhuman scienceº title, and many
United States, respectively, that were taken are working within overlapping interest areas. A
small but representative sampling would include and to the social world, and as inevitably par-
constructivist psychotherapists, who have ad- ticipating in making meaning and choices no
vanced George Kelley's (1955) analysis of how matter how constrained. The mind±matter split
we construct our worlds and can be encouraged is undone. The moral dimension of human
to construct them differently; narrative thera- matters is more clearly proper to psychology.
pists, who help clients to see how they have The old goals of predict and control become
storied their lives and might co-author them those of describe, understand, and influence.
differently; and action researchers, who not only Data developed using natural science methods,
acknowledge but plan and track their influence including neurological and biochemical data,
on their field subjects. Related areas of scholar- are comprehended within this frame. To the
ship include social constructionism, which extent that a body participates in the human
explores how science as well as society and order, its biological order is part of that
individuals are inevitably shaped by our ideas structure; even sciences of the body are human
and interactions, and which finds that we have constructions. Description of human percep-
no access to truth aside from these constructions; tion, experience, and action is narrative rather
linguistic studies, which explore the inherent role than reductive, and it respects ambiguity as
of language in our sense of reality and possibility sometimes inherent to the subject matter rather
for action; and feminist studies, which in a than as a deficient account. Accounts are
variety of ways highlight the culturally situated structuralÐretaining the mutuality of differ-
social construction of gendered possibility. entiated aspects of whatever is described.
(Leading sources on social constructionism Understanding and influencing require respect-
include Berger & Luckmann, 1967, and Gergen, ing persons as choosing in accordance with both
1985, 1994; sources on personal construct contingencies and personal meanings. Validity
therapy include Epting, 1984 and Leitner, and objectivity become matters of specifying
1985; linguistic and discourse studies include means and perspectives, and of sharing data,
Barnard, 1998, and Gavey, 1997; feminist works comprehensions, and practical outcomes, to-
include Harding, 1987; and Hawkensworth, ward consensual agreement. Progress evolves as
1989.) new perspectives are continually brought to
Many other approaches and practices that bear.
nowadays carry one of the ªpostº labels also Below are concrete illustrations of approaches
dovetail with human science psychology. ªPost- to research and to psychological assessment that
enlightenmentº refers to orientations that flow from a human science orientation. Repre-
emerged in response to disenchantment with sentative psychotherapeutic practices have been
the enlightenment era's assumption that God described in Section 1.15.4 on existential
had created a mathematically ordered world psychiatry and psychology. I have drawn on
which mortals could uncover through empiri- work with which I have been intimately
cism and logic. ªPostmodernº refers similarly to connected, and which has been developed within
contemporary movements across the arts and the Duquesne community for over 30 years, in
sciences that have ceased to look for absolute order to provide examples of what the foregoing
Truth. Reality is always known only from discussion might come down to. A wide range of
perspectives, which are necessarily local (not nonphenomenological substantive work can be
universal). Contrary to some protests, this characterized as human scientific. Human
position is not one of ªanything goesº relati- science psychology will develop and contribute
vism, but rather one that respects subgroup to the extent that variations and innovations are
realities, and calls for accountability through undertaken and discussed.
specifying the motives and history through Further examples of human science, broadly
which particular understandings emerge (see conceived, can be found in the Duquesne Studies
Aanstoos, 1990). Finally, ªpostpositivismº series edited by Giorgi and colleagues (1971,
refers to having superseded the notions that 1975, 1979, 1983) and in the series edited by
science requires that its knowledge be based on Valle and colleagues (1978, 1989, 1997).
sense data that have been processed through
mathematics based on Aristotelian logic.
To review, human science psychology differ- 1.15.7 EMPIRICAL
entiates itself from positivistic traditions by PHENOMENOLOGICAL
drawing on broad hermeneutic traditions and/ RESEARCH METHOD
or phenomenological descriptions of persons as
always being in relation to the world, always The term ªempiricalº in ªempirical phenom-
temporally on the way from and toward, and on enological researchº refers to directly observed,
existential extensions of those descriptions of pretheoretical experience (one's own or an-
persons as always being in relation to lived body other's) in contrast to data derived from the
Empirical Phenomenological Research Method 461
use of predetermined categories and through are qualitative studies. At last count, five
measurement. ªEmpiricalº also refers to the nursing journals publish significant qualitative
availability to other researchers of data and research. About a third of the research
analytic steps, so that they can check the extent to presentations at the Society for Psychotherapy
which they come to similar findings. The basic Research conferences is qualitative. Well over
method, developed and elaborated for over 30 half of the research papers presented at the
years at Duquesne University, is a systematic Association for Women in Psychology Con-
means of addressing psychological phenomena ferences use qualitative methods.
in their own terms, that is, in terms of how they Many variations on the EP (empirical
were lived. Empirical phenomenological ana- phenomenological) research procedures de-
lyses of ªbeing in privacyº and ªbeing impatientº scribed here have been, and could be, under-
will be reported below. ªPhenomenologicalº taken. Guy Kashgarian (1997) employed a
here refers both to the more immediately variety of linguistic analysis as part of his
accessible ªwhat it's likeº for individuals (to be phenomenological analysis of instances of
impatient, etc.) and also to what researchers ªbeing criticizedº reported by persons diag-
learn when they ask what else these phenomenal nosed as narcissistic personality disorder and
descriptions can reveal about the process of being those not diagnosed. Martin Packer (e.g.,
human in that situation. In the latter regard Packer & Scott, 1992) encourages EP analyses
researchers repeatedly rediscover their subjects based in part on ethnographic data.
as being temporal, always in relation and on the A thorough human science research program
way, restricted and choosing, and so on. At would accommodate biological, cultural, and
Duquesne we have referred to a cohesive psychological dimensions of any studied cir-
representation of these themes as they appear cumstance. It is to be hoped that before long
in, and shape, the phenomenon as its phenom- psychologists will undertake studies of the
enological structure. mutuality of biological and psychological
Empirical phenomenological research is ex- depression, for example. In the meantime, this
istential in that psychologists have departed chapter focuses on Duquesne's EP research
from a purer phenomenological philosophy, to method because it offers a crucial approach to
address people in their necessarily existential understanding human phenomena otherwise
situations. ªThe method,º moreover, is a great missing from psychology's efforts. EP research
variety of variations and innovations, as von is the appropriate method when the question is
Eckartsberg (1986) helpfully described in Life± ªWhat is such-and-such a phenomenon?,º as in
world experience: Existential±phenomenological ªWhat is privacy?º or ªWhat is being impa-
research approaches in psychology. For other tient?º When our questions have to do with
examples and discussions of variations of the absolute amounts and with amounts of change,
method, see Aanstoos, 1987; Colaizzi, 1973, traditional measurement and experimental
1978; Giorgi, 1985; Richer, 1978; Walsh, 1995; methods are appropriate. Unfortunately, his-
and Wertz, 1983. torically psychology typically has not asked the
Qualitative research in general addresses the What question, and has instead resorted to
experience and action of persons as they engage operational definitions (defining something in
in particular situations. Findings are in terms terms of measurement criteria, as in hunger =
of the life world rather than transformations percentage of body weight loss, or of food
into categories and measurements. Traditional reduction).
quantitative findings of course provide ground
for reflection in concert with qualitative des-
cription. Many nonphenomenological qualita- 1.15.7.1 Procedures
tive research methods are also appropriate for a
human science psychology. These include Long before beginning a formal study, one
ethnography, linguistic and conversation ana- has noted instances of the phenomenon in one's
lysis, case studies, ethnomethodology, and some own life, talked with colleagues and friends
forms of grounded theory. Psychology has been about instances in their lives, and noted
slow to become involved with qualitative occurrences in newspapers, novels, and so on.
research methods in that they do not fit our Research and theoretical literatures have been
received, rather narrow, notions of science. In consulted for their accounts. As in all research,
contrast, sociology, education, gender studies, formal participants for the study are chosen on
human development, nursing, and counseling the combined grounds of practicality/availabil-
all have established or are building major ity and of being appropriate for the issues and
qualitative research traditions. About a third literatures one hopes to address. Because EP
of the papers presented at the American analyses are so arduous and time-intensive, a
Educational Research Association conferences dissertation study might involve only five or six
formal participants. One funded project with relevant text. At this point the researcher
multiple researchers included 50 formal subjects decides on a system for breaking the text into
(Fischer & Wertz, 1979). Regardless of the workable form. Usually this involves number-
number of formal participants, the study's ing ªmeaning unitsºÐsegments of text that
preliminary findings are compared with other seem to be cohesive and that are followed by a
instances, both to reconsider one's work, and to shift in the reporter's account. Some researchers
make comparisons with regard to differences number phrases, some entire paragraphs. The
among participants in different situations. point is both to have a way to check that one has
included all the text in the analysis, and to later
be able to cite sections in every report to
1.15.7.1.1 Collecting instances
illustrate each finding.
Although EP research need not be con-
strained to analysis of verbal reports, which is
1.15.7.1.3 Data analysis and forms of results
the tradition that developed at Duquesne,
through faculty members' projects, more than Some researchers have met regularly as a
200 doctoral dissertations, the work of gradu- group, exchanging their own descriptions, or
ates, and the work of others who have based those that they have collected, working together
their research on the Duquesne tradition. to formulate their findings. Others have met
Requests for descriptions from pilot partici- regularly with the providers of accounts, to
pants result in a refined formulation of the collaboratively revise their findings in discus-
research request that is presented to the formal sion with the providers. Most researchers
participants. An example: ªPlease recall a working on dissertations have worked singly,
situation in which you became angry. Please in consultation with a faculty committee. Of
write out what was going on before that course one can combine these approaches.
situation, what happened as the situation Although variously formulated, most of the
evolved, and what happened then. Include work at Duquesne includes the following
details that will help us to understand what it processes. One immerses oneself in the descrip-
was like to be you throughout the situation. tions, ªdwellingº in them, as we say, becoming
Thank you.º Participants have agreed in familiar with their internal cohesion and their
advance to provide a description, and hence nuances at a prearticulate level. Of course at the
have been recalling long before they sit down to same time, one is noting recurrent themes, and
write. Some researchers have recorded inter- jotting down phrases and metaphors that hint at
views rather than requesting written accounts; what seems to be present in all the accounts. The
usually those accounts are briefer on the one method section of the research report itemizes
hand or rambling on the other. Written reports the formal steps that were conducted and
allow participants to organize and elaborate documented, and that a reader may follow
their recollections. along to see whether the reported findings are
The researcher types any recorded or hand- evident, and whether the procedures seem to
written accounts, and reads and rereads them have been followed. However, the formal steps
before returning to the participant for a follow- do not characterize all that goes on as one
up interview, which is taped and later tran- becomes more deeply immersed in apprehend-
scribed. Typically, the researcher asks if there ing and giving expression to the phenomenon
are additions to the account that the participant under study. For example, while supervising a
might have thought of since providing the student psychotherapist, I realize that a phrase
description. Then he or she is given a copy of the she has just uttered is perfectly suited to
transcript, from which the researcher reads characterize an aspect of what my research
aloud any sections that seem to require clari- participants have reported. While doing my
fication. Open-ended requests for elaboration morning physical exercises, a just-right meta-
are made, in the form of, ªCould you tell me phor seems to come out of nowhere. Upon
more about that?º Only at the end of the rereading a transcription for the umpteenth
interview might the researcher ask direct time, I realize this person's wording fits all my
questions such as ªDid that occur on the same participants' instances. While reviewing my
day?º or ªWould you say that this instance of notes for a lecture on object relations, I
being impatient is typical for you?º somehow realize that I have been forcing a
distinction on my data.
One is not discovering external, independent,
1.15.7.1.2 Organizing the data
features of an object, but rather is making a
The researcher typically recasts each account phenomenon visible and differentiable from
into chronological order, inserting interview related phenomena. The process requires four
elaborations (in a contrasting font) into the kinds of rigor: diligence in describing and
Empirical Phenomenological Research Method 463
following formal procedures, faithful presence to example, my own societal and clinical concerns
data, disciplined and systematic reflection on become evident to me at some point as I reflect
what is appearing in instances of the topic, and further on my findings. Levels of abstraction
finally, creativity in expressingÐrepresentingÐ vary among research authors, as does style of
making visibleÐthe unity and differentiations of representation. Some writers put greater stress
the phenomenon. We struggle with the limita- on evoking readers' lived sense of a phenomen-
tions and possibilities posed by language and by on, and others place greater emphasis on
our being historically and culturally situated. highlighting themes that lend themselves to
The formal steps usually include uncluttering dialog with philosophy. In any case, the findings
each participant's report by dropping out must be demonstrable in every instance of
information not essential to that person's formal data, and in all instances encountered
experience for it to be an example of the outside of the study. No settling for probability
particular phenomenon. For example, in Ms. levels here! Quotations from the participants'
Smith's account of being criminally victimized, original accounts document and illustrate the
we might drop out the names of her children and findings.
the color of her handbag. We might condense
references to having done three loads of 1.15.7.2 Clarifications
washing, made all the beds, and vacuumed to
ªafter a morning of heavy housework . . . º The When undertaking a study, researchers first
resulting condensation might be referred to as put aside theoretical positions and what they
an individual or situated description, and can already know about their biases, and then
serve as one form of the study's results. specify what they know about their guiding
Next, each condensation is analyzed by asking interests (e.g., making a rape victim's experience
what is being said about where this person was available to law enforcement, medical, and
going in his or her life, how he or she was in court personnel). However, throughout these
relation to self, others, and the world, and how steps and in the findings, the researcher
he or she was living a past and the future. The repeatedly discovers his or her preconceptions
researcher might then attempt to represent this (for example, that being impatient is a negative
understanding by writing a narrative version stance, or that privacy is privacy-from). He or
that stays close to the participant's own words she makes formal note of the discovery for later
but draws out experienced meanings more discussion, and in the meantime tries to hold the
explicitly and in relation to the research question assumptions in abeyance. We recognize that we
(e.g., ªWhat is the experience of being criminally cannot thoroughly separate ourselves from our
victimized?º). Here, the researcher might say, in historical, cultural, biographical contexts nor
part, ªHaving completed her planned morning from motives for undertaking a study, but we
of heavy housework, Ms Smith gathered her hold ourselves accountable for bracketing all
children into the family car, anticipating a that we can, and specifying all that we identify
successful shopping trip.º This level of analysis about the perspectives from which we have
can be presented to the participant as a check on viewed our data.
having rendered her explicit and unarticulated Researchers follow different steps and dif-
experience faithfully. This version of the findings ferent exercises within those steps depending on
again is both one form of findings and a step the subject matter, their own route into
toward further analysis. This step, which might phenomenology, and so on. In one way or
be a half-page to two or three pages in length, is another, all follow what can be called a
referred to as an individual phenomenological ªdwelling and hermeneutic presenceº to their
description or structure. By ªstructureº we mean data. Analysis does not occur in a finished step
that the descriptive account is cohesive in its by finished step fashion. Rather, the researcher
explication of differentiable but essential as- repeatedly immerses him- or herself in the
pects, and that none is made more basic than any original descriptions and in the forms of
other; each aspect implies the others. findings developed so far. Sometimes this
Finally, the researcher examines each indivi- delving is a roaming around, noticing nuances.
dual phenomenological structure, identifies the Other times it is a reading of one account with
themes that are shared by all, and formulates a another account in mind, allowing synergistic
single phenomenological structure that ex- meanings to emerge. When a new insight or
presses what was necessary and essential for understanding emerges, the researcher returns
all the accounts to be instances of the phenom- to the earlier understandings, and reworks them
enon under study. This level of finding is of in the light of the newer perspective. This
course more abstract than the preceding ones. systematic circling back to revise one's inter-
The researcher's implicit and explicit questions pretation, the hermeneutic movement, is diffi-
to the data are evident in the findings. For cult to represent in a procedures section.
1.15.7.3 Example: Being in Privacy future will unfold as P anticipates, is no longer

certain. P's sense of time feels distorted. An earlier
The following structure of being in privacy absence of concern about the future gives way to
has been useful in distinguishing privacy from intensifying affect in the face of waiting. In spite of
secrecy. It also makes a case for the importance obstacles in the way, P is poised to move forward,
of solitude, even in public settings, for the resisting the temptation to become emotional.
development of wonder, reflection, and so on. As P's focus narrows, the complexities of the
Instances from which the analysis was situation go unnoticed, particularly as P becomes
tired and frustrated. P tries to force the situation to
developed included being immersed in a novel
evolve as planned and cannot imagine alternative
until interrupted by telephone solicitor, con- courses of action. The situation is one that
sidering a painting in an art gallery until a tour demands something new of P who nevertheless
group came through, working on a math grasps at the familiar in the face of the unknown. P
problem until the teacher looked over one's overlooks evidence that would help in navigating
shoulder, enjoying a flower garden until chimes the situation more efficiently. In attempting to
reminded one of obligations. avoid waiting, P creates further delays and finds
These characterizations are paraphrased him- or herself frustrated or defeated.
from Fischer (1971) (pp. 153±154): In denying limitations of a habitual style, P is
confronted with the annihilation of previously
unchallenged assumptions about him- or herself.
As we look back, it seems that in privacy one's P becomes vigilantly focused on preserving a shred
sense of self falls away, and one flows with of his or her identity in failing to meet his or her
whatever is being attended to. One seems nearly, own expectations. P admonishes self and others
but not quite, merged with that something. This while waiting. Innocent delays are experienced as
attending is recalled as including an aura of moral affronts. P casts about for targets of blame,
familiarity, at-homeness, of things fitting even alternatively believing delays to be purposive on
when they do so unpleasantly or newly. In privacy the part of others or reflecting inadequacies in P's
one's relation to subject matter may occur through own participation.
reflection, action, imagination, whatever. The In spite of the awareness that being impatient
relation includes relative openness to and wonder worsens the situation, any attempts to relax are
at the object's possibilities, facets, realities, even defeated by P's rigid alertness. P tries to hurry in
when the person is in a problem-solving mode or is order to feel less vulnerable, but remains tense or
reflecting on an unfortunate aspect of one's life. becomes angry. Although P has restrained him- or
One's attention eventually turns, seemingly in its herself from becoming emotional, when looking
own course, to other matters, usually things to be back on the situation, P identifies his or her
done. However, when privacy is disrupted prema- responses as disproportionate to the demands of
turely, attention is torn from its prior focus, and the situation.
shifts repeatedly among intruder, self as caught by Having failed, P reflects on the situation and
the intrusion, the peripheral world, and the lost becomes open to its particular meanings and
focus. One now contends with contingenciesÐ possibilities. Now the present and each small step
time, space, demands. Affect varies with desire and P takes become more figural, while larger, future
felt capacity to deal with the intrusion, and to oriented goals become horizonal. Nevertheless, P
recapture the disrupted presence to the previously arrives at destination too deflated or exhausted to
evolving subject. enjoy any sense of accomplishment except for the
modest satisfaction of having modified his or her
initial plan.
1.15.7.4 Example: Being Impatient In contrast, when patient, P experiences open-
ness to unexpected events. Anticipation is tolerable,
The following Condensed General Structure even pleasurable, and P responds imaginatively
is taken from Donna Coufal's (1997) disserta- when action is not yet possible, appreciating the
tion. Among other themes, the dissertation limitations imposed by the situation, but not
discusses the surprising discovery of a moral assuming a catastrophic outcome.
dimension, and compares being impatient with
phenomenological analyses of being angry,
frustrated, and anxious. Instances provided by 1.15.7.5 Comments
her participants (Ps) included being stuck in an
automobile bank teller line, coping with a client Another researcher or reader may suggest a
who seemed not to be hearing the counselor, and more evocative, accurate, felicitous, or other-
being lost on a country road while trying to get wise preferable word or phrase, may identify
to a social event. additional assumptions on the researcher's part,
may point out relations to other phenomena,
The awareness of time as protracted but immi- and so on. That is how bodies of understanding
nently fleeting is central to the experience of being evolve. Note that I have referred throughout to
impatient. What was initially taken for granted, ªunderstandingsº rather than to ªknowledgeº
that time is sufficient to meet P's goals and that the in order to emphasize that what we know, even
Human Science Psychological Assessment 465
though through our natural science or human Assessment in Austin and Leonard Handler at
science methods it is always an interpretation. the University of Tennessee have developed
What is phenomenological research good for? similar approaches from orientations that
It provides a means of addressing experience as overlap mine. Finn and others have published
such. It enhances consideration of the human research reports on the effectiveness of, and
order of events and how we participate in them. client satisfaction with, assessment collabora-
Within such descriptions, we discover choice tion and feedback. Slowly, my textbook
points; we are freer than our psychology's (Fischer, 1994), Individualizing psychological
literature on determinants would lead us to assessment, originally published in 1985, is
believe. Phenomenological research also helps increasingly referenced or adopted in graduate
us to see the relations among phenomena, and courses. It seems to me and my colleagues that
how one can turn into another, which again our work in collaborative assessment validates
helps to guide our choices. This type of the private inclinations of practitioners, whose
descriptive psychology puts us in touch with university training, in contrast, had followed the
the humanities, art, literature, and drama, laboratory traditionÐin which one gathers data
making them available to our psychological and draws inferences, without consulting with
theories. the subject. Availability of an explicit human
Adrian van Kaam's dissertation (1958) at the science framework encourages efforts to involve
University of Chicago, on the experience of clients as co-investigators.
feeling really understood in psychotherapy, was
a forerunner of the research method developed
at Duquesne, where van Kaam brought to- 1.15.8.1 Developing and Contextualizing Issues
gether the group who initially began the for the Assessment
department. Amedeo Giorgi took the lead in
developing conceptual and procedural founda- If an assessment referral has been made by a
tions for existential±phenomenological re- third party, I ask that person to tell me more
search. Other faculty members and graduates concretely what the issues are. Often the referral
have contributed to and furthered their devel- remains abstract until I ask what decisions
opment, for example, C. Aanstoos, S. Churchill, might be influenced by the assessment. For
P. Collaizzi, C. Fischer, W. Fischer, S. Halling, example, in one instance, a director of an
and P. Richer. Among phenomenologically adolescent program requested an assessment of
oriented researchers who developed their re- a youngster's ªpersonality structure.º Upon
search approaches independently of Duquesne discussion he initially revised his request to be
are Howard Pollio at the University of ªevaluate Axis II diagnoses,º and then after
Tennessee and Joseph deRivera at Clark further discussion, to ªassess capacity for
University. Further illustrations of EP research empathic relations.º When asked about what
and writings on method can be found in the decisions he was faced with in regard to the
Duquesne studies in phenomenological psychol- young woman, he said that an immediate one
ogy series (Giorgi et al., 1971, 1975, 1979, 1983), was whether she could be placed in a therapy
in the Journal of Phenomenological Psychology, group that required mutual support among the
and in the journal Methods: A Journal for members and an ability to introspect. He agreed
Human Science. with the assessor that he also was trying to
determine how psychologically developed the
client was so as to anticipate her level of
1.15.8 HUMAN SCIENCE involvement with the overall program and to
PSYCHOLOGICAL ASSESSMENT determine whether several months of participa-
tion might or might not make a difference. The
The author developed the following approach assessor then asked for information and
and practices while teaching psychological observations that had been gathered on both
assessment within the human science psychol- sides of the issues. It turned out that the client's
ogy program at Duquesne University. One does family had been unstable in many ways all her
not have to adopt the orientation of this chapter life, and that she had been truant from school
to incorporate the practices into assessment. I regularly (and was failing most classes), had a
do think that accommodating this chapter to reputation for defending herself from insults
one's own assumptions about the nature of through physical retaliation, was suspected of
being human can allow one to engage a client being responsible for items missing from the
more fully and consistently as a co-assessor, and school lunch room, and was seen as a loner at
to participate in developing tailored, viable school. On the other hand, she had earned a
changes in his or her life. Stephen Finn (1996) ªB+º from an English teacher she seemed to
and his colleagues at the Center for Therapeutic like, had taught a younger brother to read, and
had impressed the Program's social worker as efficient and conscientious. But she has backed
being sad rather than as defiant and as having a away from projects that seemed to require
definite, albeit dry, sense of humor. ªjumping in and taking the ballº into ªunknown
Often, this ªgetting down to earthº process territory.º A when-not, however, had occurred
suggests next steps that enable bypassing formal when she decided to have an addition built on
assessment. On the other hand, just a few her home. She had written numerous notes and
consultations, such as that above, with referring questions in a binder, consulted several con-
staff members, results in assessment requests tractors, then consulted friends who had built
that are already accompanied by concrete events additions, and checked in regularly with the
from a client's life and by a clear notion of how contractor and subcontractors. We agreed that
the assessment might address the client's with the freedom to consult she had indeed
situation. The assessor encourages the referring taken the ball into previously unknown terri-
parties to discuss their dilemmas directly with tory.
the client, and to ask for experiences that might Fran offered another issue for assessment,
weigh on one side or the other. Inevitably, staff namely whether she was a ªdependent person-
members discover that clients are more capable ality.º We deªconstructºed that notion and
of entering these discussions than was assumed. wound up discussing times that she had and had
In addition, explaining and discussing issues not deferred to others' judgments when in fact
with clients, without professional jargon, clari- she could have acted on her own. From there we
fies staff notions while revealing the clients' went on to the Minnesota Multiphasic Person-
understandings and concerns. This process is ality Inventory (MMPI) and Rorschach to see
constructive in itself. what else we might find in regard to her
When a formal assessment is arranged, questions. I reminded Fran that I would
whether on referral or from a direct request summarize our findings after our next meeting,
from the individual, I continue the above and then would send a copy of my written report
procedure. I ask the client for his or her to both her and her therapist. The beginning of
understanding of the referral, and I clarify the assessment process has already been
whatever I know about it. Later, after we have collaborative, individualized, and oriented to-
developed ways of working together, I may ask ward the life world.
for the above clarifications again. At that point I
am sometimes told that a psychiatrist or
therapist wants to know whether the client is 1.15.8.2 Using Tests
really crazy, suicidal, or hopeless. Almost
needless to say, it is imperative that I have Any assessor should be knowledgeable in the
previously obtained the referring party's per- realms of test selection, profiles, and norms, and
mission to discuss the presented issues with the in their relations to theories of, and research on,
client, so that I can be honest, reassuring, and personality patterns, psychopathology diagnos-
exploratory, as called for. tic systems, styles of coping and thinking, and
I ask what the client would like to learn from levels of effectiveness. This expertise allows the
the assessment, and I ask what the client already assessor to form impressions, be surprised, and
understands about his or her, and others', form alternative understandings. To be most
concerns. As we talk, I try to use his or her terms useful, however, the assessor must also know
in order to keep us both grounded in the client's how to use this expertise to gain access to a
life rather than in abstractions. I help the client client's life. Within a human-science approach,
to ªdeconstructº any personality constructs, our primary data are life events. As above, after
and to provide examples of the ªwhen-notsº as locating referral issues in life situations, we then
well as the ªwhensº of problematic reactions turn to assessment tools, to theories, and to
and actions. For example, a woman tells me that research to gain access to and to explore those
she shares her therapist's concern that she might life events. If written assessments end instead
be pushing beyond her ªnatural ability,º that with scores, categories, and diagnoses, I would
she might not have ªenough intelligenceº to say that they are unfinished, that they have
pursue a promotion to a managerial position. reported our tools rather than findings pertinent
We discussed what the managerial job require- to an individual's life. The life world should be
ments would be, and agreed that we would look our point of return from testing, as well as our
into her styles of approaching problems and point of departure into testing.
would relate our observations to the managerial Test scores do not reveal anything more basic
position. or explanatory than we could find by following a
Before we began testing, we had discovered person around through various contexts and
that Fran has gotten along well with co-workers observing his or her reactions and actions. Of
and subordinates, and has been regarded as course the latter ªoptionº is not efficient or
Human Science Psychological Assessment 467
usually even feasible. At any rate, the assessor's nonconscious sense of his circumstances, and
explorations with the client culminate in a that unburdened him a bit.
description of how the client has contributed Individual tests and techniques allow both
to his or her successes and failings, and how the client and assessor to observe the person going
client might recognize alternative routes to about an activity. Similar past situations
revised goals. Our understandings weave a story, become available to the client in ways that talk
a narrative account, in contrast to assessments alone would not have afforded. For example,
that explain in terms of ªunderlying variables.º Ms. Rose had wanted to know if we might
Examples of using test patterns in discussion, discover how it was that her boss gave her low
and then of using individual tests intervention- performance ratings for efficiency, although she
ally, follow. I had been asked to conduct an gets more done than anyone else in the office by
assessment of an electrical engineer whose the end of the day. As I watched her copy the
MMPI-2 had been too defensive to allow Bender designs, I wondered if my reaction was
immediate clearance into restricted areas of a similar to that of her boss. Ms. Rose looked at
nuclear plant. He and I agreed that he had tried each design for a good while, stretched, then
to look as unproblematic as possible in order to held her pencil lightly with one hand and
obtain clearance, but also that he has always anchored the paper with just two fingers of the
seen himself as ªa good citizen,º that he does not other. She drew parallel lines for the square,
look very deeply into personal matters, and that then half the circle, then finished the box, then
a retest would probably result again in what the circle. She continued in her unorthodox
would look defensive to others. I remarked that manner through the nine designs. She never
although he had not flagged in filling out several looked at me, and never looked back at the
pages of background forms I had given him, he stimulus card after first observing it. When she
struck me as being tired. He said no, that it had had finished the designs, I was astounded to see
just been a long day. ªWell,º I asked, ªhow that they were geometrically precise and neat,
about this possibility?: Although you aren't and that she had finished in considerably less
depressed [he nods], this asterisk here [I point to than the average time. We laughed together as
the subtle depression score on a computer print- she realized that she similarly has created her
out] often happens when a person has been kind own world in the busy office, where others
of down, not as alert or enthusiastic as usual, cannot see what she is up to as she does things
even though people at work and at home out of order, stretches, seems oblivious to the
haven't noticed.º Mr. Kern looked up at me clock, and so on; others had not noticed the
with surprise, nodded quizzically, but said he nicely completed projects among the part
did not know much more about it. I then projects arranged on her desk. Through our
mentioned that on the Rorschach he had been work, Ms. Rose was already finding that she
attuned to a lot of things ªjust happeningº could make sense of her circumstance; she had
[inanimate m], like a leaf that was being blown discovered how she had been contributing to
in the wind, and a lit candle melting. I reported others' perceptions of her. We then role-played
to him that when people are able to see that kind doing the Bender again with her making
of ªjust happening,º that their lives are often in comments that allowed me to know what she
a holding pattern, that they know where they was doing and that she was indeed following
would like to be going, but it is as though they directions. She remarked later that she was now
just have to tread water. To this, Mr. Kern ªliberatedº both to be herself and to win the
nodded decisively, and when I suggested that approval of her boss.
most people know what that holding pattern is
all about, and that they also find themselves
tossing in their sleep about it, he explained to me 1.15.8.3 Collaborating and Intervening
that his entire work unit had been waiting for
eight months to hear whether the corporation Finn has pointed out that this approach to
was going to close them out of existence. He assessment can be undertaken as a therapeutic
volunteered that during the same time he and his activity in its own right. Note the therapeutic
wife were waiting to see whether they would be process in the following examples of intervening
able send their son to the college he preferred. into the client's usual course. On the Rorschach,
Mr. Kern explained then that perhaps he was Harrietthadhesitatinglyreportedafightbetween
feeling ªworn downº but that he was not two bears who were both injured. On the next
ªtired,º which meant to him beginning to lose card, instead of the usual humans cooperating on
hope or not being able to pay attention. ordinary tasks, she reported ªwarriors from
Although Mr. Kern had not wanted to examine another planet; they make me laughÐthey're too
his current life at all, he found that he had done stupid to know that they're hermaphrodites.º I
so in a way that affirmed his previously pointed out a similar sequence with other cards,
and asked her what she already knew about a readers of the client's agencyÐhis or her power
pattern of running from being afraid or from to initiate shifts in course. Constructs are
being in touch with the danger of being injured, eschewed as implying that external factors
and then trying to hide through being silly, account for the person's actions. Any necessary
voicing put-downs, and so on. Harriett readily jargon is explained in everyday terms. When
provided examples within her family and her psychologists cannot write their findings in
personal relationships. We used life instances and terms of everyday events, they literally do not
the Rorschach instances to help her to recognize know ªwhat in the worldº they are talking
landmarks which could indicate that she had about. Reports are written in first or third
entered frightening territory. She could then look person (Mr. Jones, I, we) rather than referring to
for turn-off points in order to change course if she ªthe examinerº or to ªthis patient.º We write
found herself veering into silliness or offensive- with verbs rather than nouns whenever possible,
ness. One landmark she identified was an in order to move from abstractions to actual
inclination to convert her fearfully tightened lips behavior. For example, instead of ªJohn's low
into a sneer. We agreed that she might then self-esteem keeps him from entering the con-
purposively transform the coming sneer into an test,º we might write, ªFearing that he would be
expression of determination to stay her course made fun of, John has not entered the contest.º
while checking out whether she was indeed in Yes, it does take extra effort to locate and
dangerous territory. contextualize the actual instances of what has
On other occasions an assessor might inter- been abstracted into nouns, and it usually takes
vene during a client's telling of a Thematic more writing to describe them than to name
Apperception Test (TAT) story. For example: constructs. But the worthwhile outcome is
ªGeez, John, is this going to end dismally like all understandings of actual events shared by all
the rest? Can you tell it so the fellow figures out a participants (client, family, teachers therapists,
plan?º This was John's first recognition that he etc.). We also write in the past tense rather than
had been co-authoring his own dreary circum- in the present tense, to indicate situatedness and
stances outside the assessment. the possibility of change. For example, instead
Note that this collaborative, interventional of ªJanine sees authority figures as demeaning,º
approach affirms the client as an active agent, we might say, ªJanine has seen her bosses and
sometimes self-defeating, but also capable of teachers as likely to demean her.º We try to own
changing course. It focuses on actual situations, our perceptions rather than attributing all
whether during assessment or the client's larger conclusions to test data. For example: ªAs
life, rather than on drives, traits, cognitions, Ms Gertz glared at me when I asked personal
determinants, and so on. The client is seen as questions, I thought of the MMPI's references
always in relation to goals, to pasts, to obstacles, to `nondisclosive' and `hostile,' which I see as a
to invitations. We characterize the person in defensive stance on her part.º
terms of his or her construing situations and of Some impressions are only implied or evoked
being formed through choices in those situa- rather than spelled out, not reflecting deficient
tions. Although not illustrated in this chapter, understanding so much as respect for the
assessor and client often agree to disagree, or ambiguity inherent to the life world. A report
agree that they cannot spell out what it is they that is faithfully descriptive does not attempt
are in touch with. In that process, they become false clarity. For example: ªSomething about
at least peripherally aware of both the necessity the contrast between Mr. Hersh's stiff upper
for, and the inadequacy of, language. Shared body and his causally stretched out legs struck
humanity and understandings between the me as being as disjunctive as was his account of
participants move the assessment along, despite how he had been arrested.º
personal differences. The client knows he or she We may add a technical appendix to reports,
has been met by someone attempting to deal with commentary on assorted test features, for
authentically with limits and possibilities, even psychologist readers. This information is re-
when the assessor comes to conclusions not in garded as a tool, data for further reflection, not
the client's favor, such as findings of neurolo- as findings. Again, ªfindingsº are clarifications
gical impairment, or of unsuitability for un- of life events. We explain any diagnoses con-
supervised visits with a child. tained in the report, in the client's language. We
often provide the appropriate pages of the DSM
1.15.8.4 Writing Reports (Diagnostic and statistical manual of mental
disorders) for the client to read and then discuss.
In human science assessment reports, ªfind- The report is regarded by all as a progress
ingsº are both clarifications of past life events report, a report of progress to date in under-
and identification of personally viable options standing the client's situations, and in develop-
for the client. So reports are crafted to remind ing concrete suggestions. After addressing any
Concluding Remarks 469
referring party's concerns, the report ends with does not explain the person. Although various
a section itemizing suggestions that client and knowledge domains do provide information
assessor developed. For example, ª(2) When about a person's present restrictions and
you've arrived at a solution instantly, remember possibilities, we still must explore that person's
to slow down to show others how you got there, ways of going about life, so we can locate when-
or how they might get there. You'll recall that nots, help that person to develop personally
we talked about this in regard to my not seeing viable pivot points, and so on.
your ªbattlefieldº on the Rorschach until you Even when intending to work within a human
guided me through it. We then related that to science orientation, we find ourselves falling into
times your co-workers and supervisor have our culture's and our discipline's reductive
thought that you were just shooting from the attitude all too easily. Hence, in my assessment
hip, until you helped them to find their way to courses I include numerous exercises to remind
your insight.º us of the primacy of the life world, and that test
We include a section for the client to write data are always about a life that we are re-
commentary about the report. Often we find sponsible for getting back to. On the blackboard
that the client has developed further under- I draw the first Bender design, but with the circle
standings since our last meeting (usually two and square overlapping instead of adjacent. The
meetings occur prior to reading the written class offers ideas about how an overlapping
report). Even when the client does not want to rendition might occur. The ensuing range re-
write much on the report, the invitation affirms minds us not to rush to interpretation from
the client as a collaborator in the process. manuals, but rather to be open to a range of
Knowing that the client is going to read the possibilities: being in a rush, attending to just
formal report also encourages the author to find getting through the task rather than trying to
expressions that are true to the client's life. be precise, resenting having to go through an
assessment, leaning on others for comfort or
support or to avoid the possibility of not
1.15.8.5 Judging Validity connecting, being unmindful of boundaries.
In another exercise, Rorschach students write
In that the report deals with direct observa-
descriptions of their own situations in
tions and reports of actual events, we are not
ªRorschacheseº: ªThere I was, Maing toward
faced with the task of justifying inferences.
Fd, when a large H AG'd into the line in front of
Instead, the criterion is that client and readers
me; I found myself Hxing (H) images, and
must recognize in the report's descriptions
imagining him MOR.º To further ground
touch points with their interpretations or
Rorschach ratios in life, we act out introversive
experiences of this client or similar clients,
and extratensive styles of entering the classroom
and therein a consensual validity is formed.
late. In still another exercise, we observe slides
Ambiguity of the life world is respected when
of the American painter Andrew Wyeth's
certain findings are implied or evoked rather
representational art, and talk about how we
than spelled out. Differences in perspective are
too re-present our subjects. We do so without
respected as inevitable, and it is understood that
ªartist's licenseº to change features, but with
further observation and reflection will result in
awareness that we too are creating a portrait,
continuing clarifications and revisions. No
from our perspectives and with our lives as
portrait, description, or other interpretation
points of access.
can be final. In the meantime, the practical
utility of the concrete, individualized, sugges-
tions is a strong form of validity.
1.15.9 CONCLUDING REMARKS
1.15.8.6 Comments Through emulation of the natural sciences,

psychology rightly has achieved status as a
Working within a human science frame does rigorous discipline. From that secure place,
not bypass the critical contributions of neu- however, we now note that the experimental
ropsychology, medicine, cognitive psychology, method, when based on a residual positivistic
object relations theory, diagnostic systems, and philosophy of science, is not fully adequate for
so on. We take these contributions most studying human affairs. An approach that
seriously but do not adopt the reductive studies humans in terms of their being subjects
philosophies within which many of them were (agents) as well as objects is human science
developed and/or frequently are practiced. For psychology. This approach respects data
example, although it is definitely helpful to formed through natural science methods, but
know that a person matches criteria for looks more broadly to lived-world contexts to
borderline personality disorder, that match reflect on their significance.
As fewer psychologists identify with radical existential±analytic approach to psychotherpy. New York:
behaviorism or a strict logical positivism, and Holt, Rinehart, & Winston.
Bullock, A. (1985). The humanist tradition in the West. New
more hope for psychology to do greater justice York: Norton.
to human phenomena, psychologists increas- Bynum, E. B. (1994). Brief overview of transpersonal
ingly are adopting the term ªhuman scienceº to psychology. In F. J. Wertz (Ed.), The humanistic move-
characterize their own leanings. Simulta- ment: Recovering the person in psychology, pp. 186±191.
Lake Worth, FL: Gardner Press.
neously, qualitative research methods are find- Colaizzi, P. (1973). Reflection and research in psychology: A
ing their way from other disciplines into phenomenological study of learning. Dubuque, IA:
psychology. Through our national organiza- Kendall Hunt.
tion, psychology advocates respect for cultural Colaizzi, P. (1978). Psychological research as the phenom-
and individual differences, and urges that we enologist views it. In R. Valle & M. King (Eds.),
Existential±phenomenological alternatives for psychology.
become familiar with what it is like to be in other New York: Oxford University Press.
people's situations. In these and many other Coufal, D. (1997). Being impatient: An existential phenom-
ways we find ourselves increasingly heeding enological study. Unpublished doctoral dissertation.
persons' unitary relations with their worlds. I Pittsburgh: Duquesne University.
deCarvalho, R. J. (1991a). Gordon Allport and humanistic
have written this chapter as an invitation to psychology. Journal of Humanistic Psychology, 31, 8±13.
revisit the human science literature, which deCarvalho, R. J. (1991b). The founders of humanistic
affords promising possibilities of unifying our psychology. New York: Praeger.
discipline. Although human science psychology deCarvalho, R. J. (1994). The institutionalization of
has been outside the mainstream, its history is as humanistic psychology. In F. J. Wertz (Ed.), The
humanistic movement: Recovering the person in psychol-
long as that of prevailing psychology, and its ogy. Lake Worth, FL: Gardner Press.
grounding philosophy is at least as formidable. Dilthey, W. (1977). Descriptive psychology and historical
Studies exploring the mutuality of biology understanding (R. Zaner & K. Heigas Trans.). The
and psychology, integrative research methods, Hague; The Netherlands Nijhoff. (Original work pub-
and transdiscipline cooperation are all still in lished 1894).
Edie, J. M. (1987). Edmund Husserl's phenomenology: A
their beginning stages. However, their emer- critical commentary. Bloomington: Indiana University
gence is now accelerating through the work of Press.
diverse communities of scholars and practi- Embree, L., Behne, E. A., Carr, D., Evan, J. C., Huertas-
tioners. The second edition of Comprehensive Jourda, J., Kockelmans, J. J., McKenna, W., Mickunas,
A., Mohanty, J. N., Seebohm, T. M., & Zaner, R. M.
Clinical Psychology will probably include in its (Eds.) (1997), Encyclopedia of phenomenology. Boston:
foundations volume the growing literatures of Kluwer.
hermeneutics, linguistics, feminist studies, con- Epting, F. R. (1984). Personal construct counseling and
structionism, and other endeavors that ac- psychotherapy. New York: Wiley.
knowledge human participation in what we Finn, S. E. (1996). A manual for using the MMPI-2 as a
therapeutic intervention. Minneapolis, MN: University of
take to be reality. Indeed, perhaps the second Minnesota Press.
edition will explicitly summarize work exploring Fischer, C. T. (1971). Toward the structure of privacy:
how it is that our clinical practices necessarily Implications for psychological assessment. In A. Giorgi,
draw on our life worlds. These are exciting, W. F. Fischer, & R. von Eckartsberg (Eds.), Duquesne
studies in phenomenological psychology (Vol. 1). Pitts-
promising times. burg, PA: Duquesne University Press.
Fischer, C. T. (1991). Phenomenological-existential psy-
chotherapy. In M. Hersen, A. E. Kazdin, & A. S. Bellack
1.15.10 REFERENCES (Eds.). The clinical psychology handbook (2nd ed.
pp. 534±550). New York: Pergamon.
Aanstoos, C. M. (1987). A comparative survey of human Fischer, C. T. (1994). Individualizing psychological assess-
science psychologies. Methods, 1, 1±36. ment. Hillsdale, NJ: Erlbaum. (Original work published
Aanstoos, C. M. (Ed.) (1990). Psychology and postmoder- 1985.)
nity. The Humanistic Psychologist, 18(1), 1±132. Fischer, C. T. & Wertz, F. J. (1979). Phenomenological
Barnard, S. (1998). Socializing psycholinguistic discourse: analyses of the experience of being criminally victimized.
Language as praxis in Lacan. In K. Malone & S. In A, Giorgi, R. Knowles, & D. Smith (Eds.). Duquesne
Friedlander (Eds.), Looking at Lacan: A Lacanian reader studies in phenomenological psychology (Vol. 3
for psychologists. Albany, NY: State University of New pp. 135±158). Pittsburgh: Duquesne University Press.
York Press. Fischer, C. T. (1998). Being angry revealed as self-
Berger, P., & Luckmann, T. (1967). The social construction deceptive protest: An empirical phenomenological ana-
of reality. London: Penguin. lysis. In R. Valle (Ed.), Phenomenological inquiry in
Boss, M. (1949). Meaning and content of sexual perversions. psychology: Existential and transpersonal dimensions (pp.
New York: Grune & Stratton. 111±122). New York: Plenum.
Boss, M. (1958). The analysis of dreams. New York: Frankl, V. (1946/1962). Man's search for meaning: From
Philosophical Library. death camp to existentialism (I. Lasch, Trans.) Boston:
Boss, M. (1963). Psychoanalysis and daseinsanalysis (L. B. Beacon Press. (Original work published 1946.)
Lefebre, Trans.). New York: Basic Books. Frankl, V. (1986). The doctor and the soul: From
Buber, M. (1958). I and thou. New York: Scribner's. psychotherapy to logotherapy (2nd ed.) (R. & C. Winston,
Bugental, J. F. T. (1963). Humanistic psychology: A new Trans.). New York: Vintage Books. (Original work
break-through. American Psychologist, 18, 563±567. published 1946.)
Bugental, J. F. T. (1965). The search for authenticity: An Gavey, N. (1997). Feminist poststructuralism and discourse
References 471
analysis. In M. Gergen & S. Davis (Eds.), Toward a new tion (C. Smith, Trans.). New York: Humanities Press.
psychology of gender. New York: Routledge. (Original work published 1945.)
Gergen, K. J. (1985). The social constructionist movement Merleau-Ponty, M. (1963). The structure of behavior. (A. L.
in modern psychology. American Psychologist, 40, Fisher, Trans.). Boston: Beacon Press. (Original work
266±275. published 1942.)
Gergen, K. J. (1994). Realities and relationships. Cam- Moss, D. (1978). Medard Boss. In R. S. Valle & M. King
bridge, MA: Harvard University Press. (Eds.), Existential±Phenomenological alternatives for
Giorgi, A. (1970). Psychology as a human science: A psychology (pp. 308±322). New York: Oxford University
phenomenologically based approach. New York: Harper Press.
& Row. Natanson, M. (1966). Essays in phenomenology. The
Giorgi, A. (Ed.) (1985). Phenomenology and psychological Hague, The Netherlands: Martinus Nijhoff.
research. Pittsburgh: Duquesne University Press. Needleman, J. (Ed.) (1963). Being-in-the-world: Selected
Giorgi, A., Fischer, W. F., & von Eckartsberg, R. (Eds.) papers of Ludwig Binswanger. New York: Basic Books.
(1971). Duquesne studies in phenomenological psychology. Packer, M. J., & Addison, R. B. (Eds.) (1989). Entering the
Pittsburgh: Duquesne University Press. circle: Hermeneutic investigation in psychology. Albany
Giorgi, A., Fischer, C. T., & Murray, E. L. (Eds.) (1975). NY: State University of New York Press.
Duquesne studies in phenomenological psychology (Vol. Packer, M. J., & Scott, B. (1992). The hermeneutic
2). Pittsburgh: Duquesne University Press. investigation of peer relations. In T. Winegar & J.
Giorgi, A., Knowles, R., & Smith, D. L. (Eds.). (1979). Valsinar (Eds.), Children's development within social
Duquesne studies in phenomenological psychology (Vol. contexts: Research and methodology (Vol. 2,
3). Pittsburgh: Duquesne University Press. pp. 75±111). Hillsdale: NJ: Erlbaum.
Giorgi, A., Barton, T., & Maes, C. (Eds.). (1983). Duquesne Richer, P. (1978). A phenomenological analysis of the
studies in phenomenological psychology (Vol. 4). Pitts- perception of geometric illusions. Journal of Phenomen-
burgh: Duquesne University Press. ological Psychology, 8, 123±135.
Greening, T. (1985). The origins of the Journal of Rogers, C. R. (1951). Client-centered counseling: Its current
Humanistic Psychology and the Association of Huma- practice, implications, and theory. Boston: Houghton-
nistic Psychology. Journal of Humanistic Psychology, 25, Mifflin.
7±11. Rogers, C. R. (1961). On becoming a person: A therapist's
Harding, S. (1987). Introduction: Is there a feminist view of psychotherapy. Boston: Houghton-Mifflin.
method? In S. Arding (Ed.), Feminism and methodology: Royce, J., & Mos, L. (Eds.) (1981). Humanistic psychology:
social sciences issues (pp. 1±13). Bloomington, IN: Concepts and criticisms. New York: Plenum.
Indiana University Press. Sartre, J. P. (1948). The emotions: Outline of a theory (B.
Hawkesworth, M. (1989). Knowers, knowing, known: Frechtman, Trans.). New York: Philosophical Library.
Feminist theory and claims of truth. Signs: Journal of (Original work published 1939.)
Women in Culture and Society, 14, 533±557. Sartre, J. P. (1956). Being and nothingness: An essay on
Heidegger, M. (1962). Being and time (J. Macquarrie & E. phenomenological ontology (H. Barnes, Trans.). New
Robinson, Trans.). London: SMC Press. (Original work York: Philosophical Library. (Original work published
published 1927.) 1943.)
Hodges, H. A. (Ed.) (1944). Wilhelm Dilthey: An introduc- Slife, B. D. (1993). Time and psychological explanation.
tion. London: Routledge. Albany, NY: State University of New York Press.
Hoy, D. C. (1978). The critical circle: Literature, history, Slife, B. D., & Williams, R. N. (1997). Toward a theoretical
and philosophical hermeneutics. Berkeley: University of psychology: Should a subdiscipline be formally recog-
California Press. nized? American Psychologist, 52, 117±129.
Husserl, E. (1962). Ideas: General introduction to pure Smith, M. B. (1990). Humanistic psychology. Journal of
phenomenology (W. R. Boyce Gibson, Trans.). New Humanistic Psychology, 30, 6±21.
York: CollierÐMacMillan. (Original work published Spiegelberg, H. (1965). The phenomenological movement: A
1913.) historical introduction (2nd ed., Vols. 1 and 2). The
Husserl, E. (1970). The crisis of European sciences and Hague, The Netherlands: Nijhoff.
transcendental phenomenology (D. Carr, Trans.). Evan- Spiegelberg, H. (1972) Phenomenology in psychology and
ston, IL: Northwestern University Press. (Original work psychiatry: A historical introduction. Evanston, IL:
published 1935±37). Northwestern University Press.
Kashgarian, G. T. (1997). Narcissitic injury: A Sutich, A. (1962). American Association of Humanistic
phenomenological±linguistic study of the experience of Psychology: Articles of the Association. Journal of
feeling criticized. Unpublished doctoral dissertation. Humanistic Psychology, 2, 96±97.
Pittsburgh: Duquesne University. Valle, R. S. (Ed.) (1997). Phenomenological inquiry in
Kelley, G. A. (1955). The psychology of personal constructs. psychology: Existential and transpersonal dimensions.
New York: Routledge. New York: Plenum.
Kockelmans, J. J. (1985). Heidegger and science. Washing- Valle, R. S., & Halling, S. (Eds.) (1989). Existential±
ton, DC: University Press of America. phenomenological perspectives in psychology: Exploring
Leder, D. (1990). The absent body. Chicago: University of the breadth of human experience. New York: Plenum.
Chicago Press. Valle, R. S., & King, M. (Eds.) (1978). Existential±
Leitner, L. M. (1985). The terrors of cognition: On the phenomenological alternatives for psychology. New York:
experiential validity of personal construct theory. In D. Oxford University Press.
Bannister (Ed.), Issues and approaches in personal Van Kaam, A. (1958). The experience of feeling really
construct theory (pp. 83±103). London: Academic Press. understood by a person. Unpublished doctoral disserta-
Maslow, A. H. (1962). Toward a psychology of being. tion, Western Reserve University.
Princeton, NJ: Van Nostrand. Van Kaam, A. (1966). Existential foundations of psychol-
Maslow, A. H. (1966). I-Thou knowledge in a psychology of ogy. Pittsburgh, PA: Duquesne University Press.
science. New York: Harper & Row. Von Eckartsberg, R. (1986). Life±world experience:
May, R., Angel, E., & Ellenberger, H. F. (Eds.) (1958). Existential±phenomenological research approaches in psy-
Existence: A new dimension in psychiatry and psychology. chology. Washington, DC: Center for Advanced Re-
New York: Basic Books. search in Phenomenology & University Press of
Merleau-Ponty, M. (1962) The phenomenology of percep- America.
Walsh, R. (1995). The study of values in psychotherapy: A tion. Journal of Phenomenological Psychology, 14,
critique and call for an alternative method. Psychother- 97±241.
apy Research, 5, 313±326. Wertz, F. J. (Ed.) (1994). The humanistic movement:
Welch, I. D., Tate, G., & Richards, F. (Eds.) (1978). Recovering the person in psychology. Lake Worth, FL:
Humanistic psychology: A source book. Buffalo: Pro- Gardner Press.
metheus Books. Yalom, I. (1980). Existential psychotherapy. New York:
Wertz, F. (1983). From everyday to psychological descrip- Basic Books.
1.16
Family Systems and Family
Psychology
JAY L. LEBOW
Chicago Center for Family Health and University of Chicago, IL, USA
and
ALAN S. GURMAN
University of Wisconsin Medical School, Madison, WI, USA

1.16.2 DEFINING THE PURVIEW OF FAMILY THERAPY 474
1.16.3 THE VARIETY OF FAMILY THERAPIES 475
1.16.4 A BRIEF HISTORY OF COUPLE, FAMILY, AND SYSTEMS THERAPIES 475
1.16.5 CORE SYSTEMIC CONCEPTS 477
1.16.6 MODELS OF FAMILY THERAPY 478
1.16.6.1 Structural Family Therapy 479
1.16.6.2 Strategic Approaches 479
1.16.6.2.1 The Mental Research Institute 480
1.16.6.2.2 Haley's problem-solving therapy 480
1.16.6.2.3 Milan systemic therapy 481
1.16.6.2.4 Solution-focused therapy 482
1.16.6.3 Cognitive-behavioral Approaches 482
1.16.6.4 Psychoeducation 484
1.16.6.5 Bowen Therapy and Other Intergenerational Approaches 485
1.16.6.6 Psychodynamic Approaches 486
1.16.6.7 Experiential Approaches 487
1.16.6.8 Narrative Approaches 488
1.16.6.9 Integrative Approaches 488
1.16.7 THE EFFICACY OF COUPLE AND FAMILY THERAPY 489
1.16.8 TRENDS IN COUPLE AND FAMILY THERAPY 490
1.16.9 THE DEVELOPMENT OF FAMILY PSYCHOLOGY 491
1.16.10 SUMMARY 492
473
474 Family Systems and Family Psychology
1.16.1 INTRODUCTION and the field of family therapy, highlighting

both the common threads underlying these
The place of family systems theories and methods and the differences that have emerged
couples and family therapies within psychology across the schools of practice.
has vastly expanded in recent years. Once seen
as a radical departure from the more traditional
focus on the individual that has typified the
1.16.2 DEFINING THE PURVIEW OF
mental health disciplines, family systems view-
FAMILY THERAPY
points have now been with us for over 40 years
and gained wide acceptance. Many systemic Delineating what is meant by family therapy
theories and therapies have been developed, and is far more complex than might be thought. The
couple and family therapies are now among the simplest way of labeling a therapy as a ªfamilyº
most widely practiced. Several prominent guild therapy is to look at who is seen in treatment.
organizations supporting the practice of family From this vantage point, family therapy occurs
therapy have blossomed, including The Amer- when more than one member of a family are
ican Association for Marriage and Family seen together in psychotherapy. This definition
Therapy, the American Family Therapy Acad- has considerable advantage in its parsimony.
emy, and the Division of Family Psychology of Accepting this definition, it is clear when family
the American Psychological Association, as therapy is occurring and when it is not, an
have a number of prominent journals including appraisal that can be made through a simple
Family Process, Journal of Marital and Family head count. From this viewpoint, the meeting of
Therapy, and Family Therapy Networker. The a couple, a parent and son, or a multigenera-
Division of Family Psychology within the tional family with a therapist, all constitute
American Psychological Association now has family therapy, whereas meetings of therapists
over 6000 members, while the American with one individual or with unrelated indivi-
Association for Marriage and Family Therapy duals in groups do not. In most such usage, the
has over 25 000 members. term ªfamily therapyº is restricted to instances
The essence of what has driven all this when family members are seen together at one
attention lies in the emergence of a broad time (also more specifically termed conjoint
recognition of the importance of the family in family therapy), although at times the definition
the life of the individuals within it and the has been expanded to include therapies in which
society made up of families. Whether we various members of the family are seen in
consider the impact of a depressed parent on different sessions, termed concurrent treatment
a child, the role of poor parenting practices as a (e.g., when a child is seen in some meetings and
risk factor for conduct disorder in children, or parents in another).
the impact spouses have on one another, both Despite the attractiveness of such a simple
clinical experience and much research point to straightforward definition, most family thera-
the enormous influence of the family. Gurin, pists have not found this way of conceptualizing
Veroff, and Feld (1960) found that 42% of all family therapy either satisfying or sufficient.
people who had sought professional help for Instead, most family therapists view the essence
psychological problems viewed their problems of family therapy as centered on maintaining a
as related to a marital problem, and another focus on the system rather than who is seen in
17% viewed their problems as pertaining to treatment. They point to therapies in which
family relationships. multiple members of families are seen but in
However, family therapy is truly unified only which the focus remains on an individual (e.g.,
in the shared belief that relationships are of at as when the focus is exclusively on changing the
least as much importance in the behavior and symptomatic client) as failing to meet the
experience of people as are internal processes criterion for family therapy, and to other
within individuals or broader social forces. As therapies that directly involve only one client
Gurman, Kniskern, and Pinsof (1986) have but focus on the social system (e.g., Bowen
suggested, family therapy includes therapists Therapy) as family therapies. It has been the
from many professions, has no unified theory, presence or absence of a systemic focus of
and few techniques that are specific to it. There treatment that has emerged as most important
are many distinct systemic therapies, which to the majority of those who practice family
differ enormously from one another. Some are therapy. Based on such a notion, Gurman et al.
directed to the treatment of families, some to (1986) offered the following classic definition of
subsystems within the family (e.g., couples), and family therapy: ªFamily therapy may be defined
others abandon the specific focus on the family as any psychotherapeutic endeavor that expli-
entirely, aiming at the broader social nexus. In citly focuses on altering the interactions between
this chapter, we overview basic systems concepts or among family members and seeks to improve
A Brief History of Couple, Family, and Systems Therapies 475
the functioning of the family as a unit, or its in a broader dimension of relational life, for
subsystems, and/or the functioning of indivi- example, marital satisfaction. In examining
dual members of the family.º This definition family therapy, we must maintain a focus on
best fits with the zeitgeist of family therapy, but the impact on both family process and other
leaves some room for debate about whether a treatment goals.
particular treatment is ªfamily therapy.º
A related issue in demarcating the territory of
family therapy concerns the place of couple 1.16.4 A BRIEF HISTORY OF COUPLE,
therapy, specifically whether couple therapy FAMILY, AND SYSTEMS
represents a subset of family therapy or a THERAPIES
separate endeavor. Some have argued that
because couples therapy calls for a distinct set To understand the enormous variation
of skills, it should be considered separately among family therapies, it is important to grasp
(Alexander, Holtzworth-Monroe, & Jameson, the diverse origins of the field. The earliest
1994). More typically, couples therapy has been couple and family therapy was framed as a
regarded as a subset of family therapy (Lebow & direct extension of existent models of individual
Gurman, 1995). Most prominently, those who therapy. Although much of this work was
emphasize the importance of a systemic view- conjoint, the essence of these methods consisted
point as the essence of family therapy view the of helping to uncover individual patterns to be
treatment of couples as simply work with one altered. In these therapies, some of the core
family subsystem. techniques for working with more than one
It also should be mentioned that in the late client in the room were developed (e.g., early
1990s ªmarital and family therapyº has become variants of communication training), but these
ªcouple and family therapy.º Respect for the therapies were largely considered adjunctive to
diverse forms of family in our society (Walsh, what was viewed as the more important work of
1993) has led to this fundamental change in individual therapy.
nomenclature. Family therapy leapt to prominence through
the work in the 1950s and 1960s of such figures
as Nathan Ackerman, John Bell, Ivan
1.16.3 THE VARIETY OF FAMILY Boszormenyi-Nagy, Murray Bowen, James
THERAPIES Framo, Jay Haley, Donald Jackson, Salvador
Minuchin, Virginia Satir, Carl Whitaker, and
Family therapy is actually a number of Lyman Wynne, who shared a common belief in
different activities linked by a few common the core importance of the family system as well
understandings. Systemic concepts merely set a as a great deal of personal charisma. In contrast
frame for possibilities. They do not limit the to earlier couple and family therapies, this work
range of intervention. Both the mediating and actively questioned and argued against the
ultimate goals of treatment may vary, as may traditional individual oriented view of problem
the theoretical frame, the treatment strategies, development and treatment. The early work of
and the specific interventions employed (Gur- these pioneers included a wide range of family-
man, 1978). Therefore, it makes conceptual focused intervention, crossing the boundaries of
sense to subdivide family therapies into ones schools of family therapy that have subse-
that share common characteristics. quently emerged. Each developed theories and
Family therapies can be classified best along methods of intervention, and several ultimately
two axes: the first consisting of who is seen in shaped their methods into the foundation of a
treatment (e.g., individual, couple, nuclear school of treatment. Each incorporated aspects
family, extended family), and the second, the of systems theory into their work, most
theoretical perspective on which the therapy prominently the view that causality is best
centers (e.g., structural, strategic, object rela- conceived of as a circular process in which
tions, or a type of integration). Both who is seen behavior is seen as interdependent and subject
and the theory of the approach contribute to the to mutual influence. Within the zeitgeist of the
differences between therapies at the level of time, the behavior of ªidentifiedº patients (i.e.,
operations. those with symptoms who were labeled as
It is also crucial in examining this literature to having the problems) were seen as a reflection of
keep in focus the importance of treatment goals underlying family process, that is, the family
(Gurman, 1978). In couple and family therapy, was viewed as the principal locus of the
change in family process is always both a problem, central in its development, and the
mediating and an ultimate goal. Most couple most appropriate context for treatment. The
and family therapy also has an additional goal, first generation of family therapists emphasized
be it a change in the behavior of an individual or systemic concepts with the kind of fervor that
goes with those who have discovered an as yet major executive position in the family). Fem-
undiscovered truth, and were highly critical of inists called for a more egalitarian family
traditional methods of mental health interven- therapy (Goldner, 1985; Hare-Mustin & Mar-
tion in which individuals were seen out of their ecek, 1988). Other criticisms focused on the
natural context in the social system. basically homeostatic vision of family life in
The influences on this generation of pioneers family therapy, in which families were seen as
themselves were enormously diverse. Some had highly resistant to change and readily relapsing
backgrounds in psychoanalysis (e.g., Acker- into dysfunctional patterns. Alternative visions
man, Framo) that they brought to bear. Some developed emphasizing family resilience and the
had backgrounds in fields other than the mental natural tendency in families toward change
health professions, such as anthropology (e.g., (Walsh, 1982, 1993).
Bateson, Weakland) and communication (e.g., Other questions were raised about whether
Haley). In general, new and exciting ideas were the therapist needed to be the powerful enactor
welcome and sought out. Thus, for example, of change depicted in many of the earlier models
Haley became quite interested in the work of of treatment. Theoretical precepts of second-
Milton Erikson, bringing core techniques of his order cybernetics were advanced (Hoffman,
variant of hypnotherapy, emphasizing para- 1981) that emphasized the view that there were
doxical intervention, into the mainstream of no ªobjectiveº observers (Von Glaserfeld,
methods of practice in family therapy. Observa- 1984), and that therapists, like all others,
tion of the importance of difficulties in com- become part of the system, being influenced
munication in troubled families, based on the by it as well as influencing it. Following Gergen
work of the double bind project (Bateson, (1981), social constructivism further argued that
Jackson, Haley, & Weakland, 1954) and the knowing and knowledge are socially con-
parallel work of Wynne, Ryckoff, Day, and structed through language and discourse.
Hirsch (1958) and Lidz, Cornelison, Fleck, and Models of family therapy developed that
Terry (1957), also exerted an enormous impact, emphasized collaboration (Anderson & Goo-
focusing emphasis on changing these deviant lishian, 1988) and the personal construction of
communication patterns. narrative (White & Epston, 1990).
Through the 1970s and 1980s, the field of Still others became critical of the exclusive
family therapy passed from the shared excite- focus on the family as the locus of change in
ment about the core importance of the family systemic models. Movement has clearly been
system to emphasizing differences across the away from the earlier simplistic notion that the
many distinct schools that emerged. Some of family was the sole etiologic agent in the
these schools accepted or transmuted a range of development of difficulties, and that family
concepts from individual therapy, creating therapy was the sole preferred method of
schools that are psychoanalytic (Ackerman, intervention across all difficulties. An integra-
1958; Scharff & Scharff, 1987), experiential tive viewpoint is emerging that includes not only
(Greenberg & Johnson, 1988; Whitaker & the concepts from various family methods of
Keith, 1981), and behavioral (Patterson, intervention, but also interventions at the level
1982). Other schools rejected virtually all of the individual (Lebow, 1984, 1987a) and
aspects of individual models of treatment, larger system (Breunlin, Schwartz, & Karrer,
remaining exclusively focused on aspects of 1992). Some have even called for a basic
the social system such as structure (Minuchin, redefinition of systemic therapy, moving from
1974) overcoming family homeostasis (Watzla- a specific focus on the family to a broader vision
wick, Beavin, & Fisch, 1974), or intergenera- of consultation with social systems, including
tional process (Bowen, 1978). Across these but not limited to families (Wynne, McDaniel,
schools, a vision developed of a powerful & Weber, 1986).
therapist (sometimes literally referred to as a Family therapy has also been examined
wizard), jousting or performing some version through the lens of several other pertinent
verbal judo to free up the family from its and powerful vantage points including culture
patterns. Through this time, family therapy (Boyd-Franklin, 1989; McGoldrick, Pierce, &
grew enormously in popularity and began to Giordano, 1988), life cycle development (Carter
enter into the mainstream of practice. & McGoldrick, 1988), and postmodernism
In the 1980s, voices began to emerge within (Hare-Mustin & Maracek, 1988). This has been
family therapy that were highly critical of a field boiling over with ideas and concepts, and
aspects of the schools of practice that had ways of examining the family and how to have
developed. Most prominently, the feminist an impact on it. It has been a continually
critique pointed to the numerous male assump- developing field, in which treatments have
tions that were endemic to most models in emerged and been refined, theory has under-
family therapy (e.g., that fathers should hold the gone considerable revision, and assumptions
Core Systemic Concepts 477
have been continually examined within the Without that piece of information, the behavior
emerging vantage points about family within looks eccentric or psychotic, but sense can be
the broader society. made of this behavior in the appropriate
context. Early in the history of family therapy,
1.16.5 CORE SYSTEMIC CONCEPTS a focus on context became the cornerstone of
the belief that the behavior of all family
A few core assumptions underlie all family members would make sense if only the meaning
therapy, the most central being the core of the behavior in the appropriate context could
importance assigned to the social system in be deciphered. In particular, severe mental
influencing individual behavior. Families are illness was seen as the product of behavior that
seen as having a powerful effect in shaping and made sense in a particular context (e.g, within
maintaining individual patterns of behavior. the family process), although it appeared to
There have been a range of ways of conceptua- make little sense when seen outside of that
lizing this influence represented in the various context.
models of family therapy. A common extension of these concepts early
One set of core concepts that have been in the history of family therapy was to label the
prominent within a wide range of models behavior of the family members displaying
derives from general systems theory, developed psychopathology or other problematic behavior
by Von Bertalanffy (1969) as a way of under- as ªidentified patients.º These ªidentified
standing all systems, animate and inanimate. patientsº were typically seen as the victims of
The central tenet of general systems theory is labeling of their behavior when considered out
that the whole is more than the sum of its parts. of the appropriate family context. Within this
Therefore, to understand any part (e.g., an viewpoint, the real patient and bearer of the
individual), one must grasp its relation to the problem is the family, and therefore, family
whole of which it is a part (e.g., the family). therapy is the most appropriate method of
Within general systems theory, humans are bringing about change. A frequently encoun-
viewed as part of what is termed an ªopenº tered correlate of this set of beliefs was dismissal
system, one in which there is ongoing exchange of the biological basis for severe mental disorder
with those outside, be they other individuals, (e.g., Haley, 1963).
families, or other systems. Open systems remain General systems theory also emphasizes
subject to influences from outside. Systems (e.g., circular paths of causality. Rather than focusing
families) are also made up of subsystems (e.g., a on linear pathways of actions followed by
couple, children), which affect one another, and reaction, attention centers on recursive patterns
sum to more than their parts. General systems of mutual interaction and influence. If the
theory focuses on the most global principles of behavior of one person affects that of another
how systems evolve, be they particles in space or (e.g., a father punishes his child), attention still
human families. must focus on how the response of the second
A principle that assumes great importance in person affects the first (e.g., the child's
general systems theory is equifinality. Equifin- aggressive behavior leads to the parent's
ality suggests that there are many ways of punishment, the parent's punishment leads to
reaching particular configurations within the the child temporarily stopping the behavior,
system and that the particular pathway by followed by further aggressive behavior). From
which a configuration has been reached does the perspective of general systems theory, the
not matter. End states reached through different system, not a single person, is responsible for the
pathways are equivalent. Applied to family behavior that is maintained through such
systems, an emphasis on equifinality focuses circular pathways.
concern on the state the family is presently in Some of the critiques and reappraisals of
and not how the family reached that state. To systems theory have been directed at these
the extent equifinality is stressed, history and concepts. One line of criticism has centered on
individual motivation assumes lesser impor- the notion of ªidentified patients.º Much
tance, while the topography of how the system is research has shown very real disabilities in
presently organized assumes more. those with mental illness. Many now question
In general systems theory, how behavior is the use of this term when applied to situations in
understood is viewed as a function of the which there is psychopathology. In particular,
context in which it is conceived. In a classic the psychoeducational movement has called
example cited by Watzlawick, Beavin, and attention to some of the costs of this approach
Jackson (1967), the meaning of seeing a man in alienating families from the treatment they
quacking at ducks is significantly altered by the need, because of the sense of shared family
knowledge that this man is Konrad Lorenz, causation that accompanies usage of the term
engaged in experiments about imprinting. ªidentified patient.º
Others have argued the limits of circular Another important emphasis in systemic
notions of causality (Dell, 1986), pointing to the theory has been on communication processes.
dangers inherent in the argument that all parties The point of entry for these ideas in family
are equally responsible for sequences of beha- therapy was the double bind theory of schizo-
vior. In particular, the example of family phrenia developed by Bateson et al. (1954),
violence has been cited as an instance where which suggested that the psychotic process was
individual responsibility and lineal arcs of the product of disturbed communication. In the
causality need to be highlighted, lest the double bind, two or more parties are involved in
observer be left with an inappropriate sense an important relationship that is ongoing. A
that batterer and victim are coequal in respon- primary injunction is given, such as ªshow me
sibility for violent behavior (Dell, 1986, Gold- your feelings.º A second injunction is given that
ner, Penn, Sheinberg, & Walter, 1990). There is conflicts with the first, such as ªThe feelings you
considerable agreement among family thera- have are unacceptable and should not be
pists that both lineal and circular pathways of verbalized.º Given that the recipient of the
causality and problem maintenance need to be communication cannot leave the field, he or she
considered in assessing family systems. is in a double bind that induces anxiety. The
Cybernetics, the science of communication double bind theory suggested that the repeated
and control in man and machine, developed by exposure to such binds results in responses that
Wiener (1961) and others, added to the under- break out of the bind through psychotic
standings developed through general systems processes.
theory among family therapists. In cybernetics, Although empirical research never was able
systems are viewed as self-correcting, influenced to demonstrate high frequencies of such double
in an ongoing way by feedback. Feedback is the binding on the part of parents of schizophre-
process by which a system gains information to nics (indeed, in the research, the presence of
self-correct to maintain a steady state or move double bind communication could not even be
toward a goal. Positive feedback describes input reliably rated as present by observers), this
that increases deviations from the steady state, work has remained highly influential in family
negative feedback describes input that reduces therapy in focusing interest on deviant com-
such deviations. Homeostasis is the powerful munication processes in families. Beginning
force moving the system toward a steady state. with the premise that ªyou can't not commu-
Early family therapy was profoundly influenced nicateº (Watzlawick et al., 1967), this work
by the idea that human systems were homeo- sought to understand the communication
static, that is, moving toward the reduction of which was occurring, and alter patterns of
change. As a result, most first-generation family communication so that the system could use
therapies were based in the notion that power- this communication to reorganize in a more
ful interventions needed to be created to functional manner.
reorganize the family, overcoming the homeo-
static forces. 1.16.6 MODELS OF FAMILY THERAPY
Systemic thinking has given more weight to
morphogenesis, the natural force moving the Many specific couple and family therapies
system toward change. A systemic emphasis on have been developed. Some of these models
morphogenesis creates very different implica- have been directed to specific difficulties (e.g.,
tions for psychotherapy than a homeostatic Kaplan's treatment for sexual disorders), but
emphasis. Models emphasizing morphogenesis the majority have been directed toward a broad
suggest that initiating the process of change is range of problems. Some family therapies are
likely to kick off a positive chain reaction, very aimed at resolving difficulties that are explicitly
unlike the minimization of change thought to be labeled as being about family relationships
active in a perspective emphasizing home- (e.g., couple therapy aimed at marital dis-
ostasis. Thus, in morphogenetic models, launch- satisfaction; family therapy aimed at over-
ing small changes is seen as likely to be coming differences between parents and their
productive in creating movement within the grown children), whereas other family thera-
system, while in homeostatic models, only the pies utilize a family systems perspective for
most powerful of interventions are seen as likely intervention with problems that manifest
to produce change. In a similar vein, Maturana themselves in the behavior of an individual,
and Verela (1980) highlight the process they and which from another perspective might be
termed autopoesis, whereby the internal struc- seen as ªindividualº problems (e.g., depres-
ture of the living system determines its behavior. sion). The numerous couple and family
Following the notion of autopoesis, the thera- therapies can be divided into a few distinct
pist can only perturb the system to make categories on the basis of emphasis. These
changes that the client system itself produces. are structural, strategic, cognitive-behavioral,
Models of Family Therapy 479
psychoeducational, intergenerational, psycho- static vision of systems at the base of structural

dynamic, experiential, narrative, and integra- therapy, therapists seek to create powerful in-
tive schools of family therapy. session experiences to work to alter the family's
organization. Frequently, a transaction is
1.16.6.1 Structural Family Therapy created by the therapist that promotes in-
session family membersº habitual patterns of
Structural family therapy, developed by relating (called enactment). There is much
Salvador Minuchin, is an example of a family emphasis on joining with the family through
therapy largely drawn purely from systemic such interventions as tracking (adopting the
concepts. Structural family therapy emphasizes symbols of the family's life), accommodation
the power of the social system, as manifested (relating to the family in congruence with the
through family structure. Health and dysfunc- family's patterns), and mimesis (joining with the
tion are directly viewed as products of the family by becoming like the family in manner or
effectiveness of the family structure. By family content). Ultimately, interventions are directed
structure, Minuchin means the regulating codes to fully restructuring the system. Symptomatic
as manifested in the operational patterns change in ªidentifiedº patients is assigned a
through which people relate to one another in much less important role than change in
order to carry out functions. The three primary structure of the system.
dimensions of structure are boundary, alliance, The structural approach remains the most
and power. influential school within family therapy. Some
Boundaries are the rules defining who of its ideas, such as the importance of boundary,
participates and how, who is in and who is alliance, and power in family systems have come
out of an operation, regulating contact. The to be broadly accepted by most family thera-
strength of boundaries vary, ranging from rigid, pists. However, there has also been considerable
resulting in disengagement, to very permeable, criticism of some of the assumptions of
resulting in enmeshment. At the disengaged end structural therapy. Most emphatically, the
of the spectrum, families act like they have little highly gender-based nature of some of the
to do with each other, leaving the individuals assumptions about the roles of men and women
substantially disconnected. At the enmeshed and boys and girls within structural family
end, there are violations of function boundaries, therapy has resulted in considerable criticism,
in which family members intrude into functions particularly from feminists. The emphasis of
that are the domain of other family members. this approach on equifinality and, thus limited
Structural family therapy aims to move families concern with history or the internal process of
away from the extremes of enmeshment and individuals, has also been attacked. Minuchin
disengagement. (1996) has recently moved to a more gender
Alliances are the joining or opposition of one aware version of the structural approach, and
member of a system to another in carrying out acknowledged a greater appreciation for the
an operation. Alignments are inevitable. They importance of history.
become dysfunctional when they become fixed
and unchanging (stable coalitions) or when they 1.16.6.2 Strategic Approaches
are primarily cross-generation. Triangulation
describes the process of two people demanding Strategic approaches are the most purely
that a third join with them against the other. systemic of the family therapies. These models
Structural family therapy aims to create simply ask, ªWhat is the most expeditious route
alliances that are functional (e.g., parents with to promote systemic change?º Strategic ap-
one another), while at the same time not proaches also share an orientation toward brief
becoming rigid. focused intervention. From a strategic view-
Power describes the relative influence of each point, change is a discontinuous process. The
family member on the outcome of an activity. goal is to intervene, find a new way of
Power can be functionally distributed with the functioning that works better, and promptly
primary locus in the older generation or can end the treatment.
become rigidly held by one individual or Strategic models have also been closely
coalition, or there can be insufficient executive identified with several specific methods. One
authority (weak executive function). Power is common thread is the use of ªparadoxicalº
seen as best held in the hands of an executive interventions, in which directives are offered
(e.g., a parental coalition), but in such a fashion which if acted on would move the family in the
to leave everyone with some degree of power. opposite direction from that which is desired.
Treatment in structural family therapy pri- Although direct interventions are also common
marily consists of efforts to change these in strategic methods, the rapier-like effort to
elements of family structure. Given the homeo- find the simplest and most expedient pathway to
change is best represented by the use of paradox. Paradoxical directives capitalize on the force
Strategic methods have also been closely in social systems to move against the direction
associated with the use of team approaches, toward which it is directed. For example, the
utilizing observers behind one-way mirrors as therapist may list reasons why change is not
part of the intervention process, typically likely to be productive or even harmful.
offering commentary or directives to the Although much more controversial than re-
therapist and family. Strategic methods have framing, paradox has become common within
been further associated with cool detached family therapies, especially strategic ones.
stances on the part of the therapist (e.g., the Treatment within the MRI model always
MRI model), although there have been sig- remains brief and focused. The therapist's cool
nificant exceptions to this trend. Strategic detached stance is not designed to make for
therapies center on altering feedback cycles long-term attachment, and termination is en-
within the family, but do not seek to enable couraged by the therapist as soon as problem
insight within the family about such cycles. resolution has been substantially initiated.
Change, not learning about the change process, The MRI model stands as the exemplar of a
is clearly the center of attention. The strategies strategic family therapy, and has been highly
of change invoked vary significantly with the influential among all other strategic therapies.
specific strategic model. Several of its core concepts (reframing, ªmore of
the same,º first- and second-order change) have
been adopted within a broad range of family
1.16.6.2.1 The Mental Research Institute
approaches. Nonetheless, although highly in-
The first systems-based strategic model with- fluential, this approach today is rarely seen in
in family therapy was the ªMental Research practice in its pure form. The paradoxical bent
Instituteº (MRI) or ªPalo Altoº model devel- of the intervention strategy and the detached
oped by Jackson, Watzlawick, and Weakland, stance of the therapist have caused this
and their colleagues (actually the first MRI approach to receive a great deal of attention,
model, as there have been subsequent other but have also led many who have tried this
MRI models). The MRI model derived from a approach to move on to other models that
mix of systems theory, cybernetics, and the emphasize a more collaborative approach
study of communication processes. between clients and therapist. In addition, little
In the original MRI model, problems are empirical support is available for this approach.
viewed as a natural part of family life that
families regularly deal with on their own. The
1.16.6.2.2 Haley's problem-solving therapy
need for intervention is seen as stemming not
from the problem itself, but from how family Haley's (1976, 1980) problem-solving therapy
members treat the problem. When families and the closely related work of his colleague
become stuck in systemic patterns and in efforts Madanes (1981) combines a strategic use of
to solve problems (ªmore of the sameº), changes paradoxical techniques with goals that typify
in behavior, termed ªfirst-order change,º are structural family therapy. Problem-solving
seen as unlikely to resolve the problem, and therapy strongly emphasizes grasping and
possibly making the problem even worse. working with the function that behaviors serve
Therefore, therapy focuses on the creation of within the system. Most often, this function is
ªsecond-order change,º an alteration in the conceptualized as a struggle for power and
rules of the system that govern interactions. control.
Treatment consists of identifying the ways An initial stage of the therapist and client
problems are maintained by the behavior within becoming acquainted is followed by a stage in
the system, examining the rules that lie beneath which each person's perspective about the
these behaviors, and then changing the rules. problems which exist is elicited. Specific
Reframing and paradoxical interventions are observation by the therapist focuses on triangles
viewed as the most powerful tools for initiating (who supports whom in interaction) and
second-order change. Reframing consists of hierarchy (who has what power), but these
active efforts by the therapist to create a new ideas are not directly shared with the clients.
and different understanding of old events that Directives to the family follow from a con-
has a more benign meaning. For example, in sideration of solutions that have been at-
recasting behavior that has been seen as bad as tempted, and aim to engage the family in new
being out of the control of the individual, a and different behaviors. Many of the techniques
different reality is created. Reframing has utilized by Haley and Madanes derive from the
become perhaps the most common intervention hypnotic work of Milton Erickson, aimed at
in couple and family therapy, employed by increasing suggestibility and openness to
therapists regardless of their orientation. change. One example is the pretend technique
(Madanes, 1981), in which the family is directed The rituals prescribed in Milan systemic
to have children pretend to have symptoms and therapy move to exaggerate or move against
parents pretend to help them, a paradoxical rigid patterns in the family. Most of the rituals
technique that suggests the possibility of overt have an ironic quality and engender confusion,
control over patterns thought to be out of although some (e.g., one called ªodd and even
conscious control. Other commonly employed days,º in which control is given to each parent
techniques more directly aim at establishing a on alternating days) merely serve to call
coalition between parents to help adult children attention to patterns in the family, and thereby
leave home. move the family to see their ability to impact on
Haley remains highly controversial in his the situation and resolve their difficulties. The
adherence to some of the earliest systemic early Milan approach strongly stressed the
conceptualizations of family therapists, for importance of therapist neutrality in delivering
example, the view that ªidentified patientsº these interventions.
carry symptoms entirely due to the function In the most influential variant of the Milan
these symptoms serve within the family and a methods, Boscolo and Cecchin (Cecchin, 1987)
denial of the existence of mental illness. For moved away from directives toward the use of
Haley, psychopathology is always the product what they termed ªcircular questions.º Circular
of a dysfunctional social system, not due to questions are questions used to learn about
biology or individual psychology. These ideas, differences in the family that might provide
once a welcome contrast to the determinism of clues to recursive family patterns. Circular
biological and psychoanalytic formulation, now questions include ones about differences in
appear rigid and stale in the wake of the the perception of relationships (who is closer?),
development of the considerable literature differences between before and after something
delineating the biological and psychological else happened (were you more depressed before
basis for severe disorder, and the emergence of or after the birth of the baby?), and hypothetical
highly effective psychoeducational treatments differences (if you had not married, how would
that demonstrate how an approach can be your life be different?). Curiosity is the essential
family based and yet consistent with the best ingredient in circular questioning. The aim is
data about schizophrenia and other mental not to move the family toward a specific goal,
illness. but to initiate thought and conversation in order
to create greater understanding of how the
present situation and the family's behavior in it
came about, what the systemic patterns are that
1.16.6.2.3 Milan systemic therapy
help keep the family from resolving their
A number of strategic therapeutic approaches difficulties, and what are the most productive
have been developed in Milan, Italy, by Selvini- pathways toward change. Work in this model
Palazzoli, Boscolo, Cecchin, Prata and their becomes much more collaborative than in the
colleagues in various combinations. Versions of earlier version of Milan therapy.
these models have varied enormously, although Selvini-Palazzoli (1986) added another var-
all have maintained a strategic focus. iant of the Milan model. Selvini-Palazzoli came
In the classic Milan therapy that brought to believe that disturbed patients were inevi-
worldwide recognition to this group (Selvini- tably caught up in what she termed the ªdirty
Palazzoli, Boscolo, Cecchin, & Prata, 1978), game,º a power struggle between parents in
sessions are held approximately once per which patient's symptoms help support one
month, almost always involving a team situated parent. Her response was what she called ªthe
behind a one-way mirror. The team forms a invariant prescription,º applied to all families.
hypothesis about the family, to be modified over In the invariant prescription, the therapist
the course of treatment. During a break in each suggests to parents that they tell family
session, the team formulates an intervention. members that they have a secret and go out
The therapist then brings the intervention to the together mysteriously without warning other
family, most often through positive connotation family members, and that they then observe the
or the prescription of a ritual. family's reaction. The ªinvariant prescriptionº
Positive connotation consists of reframing aims to help strengthen the alliance between the
behavior in a positive light, most frequently parents and enable understanding of dysfunc-
through suggesting how the behavior serves the tional patterns in the family. Although rooted in
goals of the system. Positive connotation aims some of the same observations about triangula-
to change the family view of dysfunctional tion in disturbed families as those made by
behavior, while also decreasing resistance by Haley, Bowen, and Minuchin, this approach
allowing each family member to emerge with a has acquired little support because of its highly
positive view of their own behavior. pathological view of family processes, its
ignoring of the mounting evidence demonstrat- question. Unfortunately, given their promise,
ing the importance of expressed emotion to solution-focused approaches remain among the
recidivism, and its failure to respond to least studied of the family therapies.
differences among families.
More generally, the Milan approaches have
proven to be highly influential. Although only 1.16.6.3 Cognitive-behavioral Approaches
a small number of family therapists practice
any of the variants of Milan therapy, the Cognitive-behavioral models extend beha-
attitude of curiosity and prompting of circular vioral principles to the treatment of family
questions have come to serve as the base of systems. These models have primarily been
investigation for many family therapists. There utilized in work with child behavior problems
has been very little empirical testing of the (especially conduct disorder and delinquency)
Milan approaches. and with difficulties encountered by couples
(especially marital dissatisfaction). Cognitive-
behavioral methods begin with the assumption
that thoughts and behavior are central to all
1.16.6.2.4 Solution-focused therapy
aspects of functioning and that the most
Emerging into prominence since the mid- efficacious pathways to change directly address
1980s have been a number of approaches that dysfunctional thoughts and behavioral patterns.
take positive connotation and reframing a step Classical and operant conditioning are the
further, attempting to move discussion fully to central mechanisms for shaping behavior within
thinking in terms of solutions rather than a behavioral paradigm. In behavioral family
problems. Among the best known of this therapy, operant conditioning has assumed
solution-focused set of approaches is the work particularly great importance.
of DeShazer (1985, 1988), Berg (1993), and Central to operant conditioning is reinforce-
O'Hanlon and Weiner-Davis (1989). The ment: presenting some event or behavior that
solution-focused approaches assume that clients increases the rate of a particular response.
want to change and reject the notion of deeply Humans are seen as inevitably affected by the
ingrained pathology. Instead, these approaches reinforcements they receive. However, beha-
seek to introduce ways of thinking about and vioral family therapy is not fully the product of
facing difficulties that are different, and can classical learning theory, but instead its applica-
kindle the family's own process of resolving tion in the social context, called social learning
their difficulties. One favorite technique is to theory. Here, learning is not simply the product
look for exceptions, times when problems have of primary reinforcers such as food, but of social
not been present or overcome. Another has been reinforcers, such as approval. Social learning
to nurture and help clients notice small changes also occurs both directly from experiences that
from which they can build larger ones. For reinforce or punish, and indirectly through
example, De Shazer asks clients to observe what processes such as modeling, in which learning
happens in their lives that they want to continue. occurs through observation of contingencies.
DeShazer and colleagues also employ the This array of processes shape social behavior.
ªmiracle questionº: ªSuppose one night, while Social exchange theory (Thibaut & Kelley,
you were asleep there was a miracle and this 1959) also has had a prominent place in
problem was solved. How would you know? cognitive-behavioral approaches. Social ex-
What would be different?º All these techniques change theory suggests that individuals strive
are designed to help clients begin to think in to maximize their outcomes, to increase the
terms of solutions and the ability to resolve rewards they receive, and decrease the costs.
difficulties rather than in terms of problems and Behavior from one person is viewed as likely to
one's difficulty in resolving them. be met with reciprocity to behavior from
Solution-focused approaches have been another, so that positive behavior will lead to
among the most widely influential in the positive behavior, and punishment to punish-
1990s, especially in the context of the mandate ment on the part of the other. In particular,
of managed care for brief therapy. The positive couples are regarded as likely to develop social
focus and optimistic frame of these models has exchanges that can become mutually supportive
proven most welcome to families and therapists (each emitting positives to the other) or coersive
alike. Criticism has focused on the repetitive use (each emitting punishing behaviors). Problem
of the same few interventions (e.g., the miracle behavior is viewed as primarily the product
question), and on vary simplistic notion of of either skill deficits that stem from a lack
problem development and resolution implicit in of knowledge, or from the establishment of
the model. Ultimately, whether such parsimony coersive exchange. Skill training is aimed at
and positive ideas are sufficient is an empirical providing the knowledge and experience needed
to engage in appropriate social behaviors, be one another, as are treatments for children and
they as a spouse or a parent. Positive exchange is adolescent problems.
altered directly by helping clients become more Weiss (1978), Jacobson and Margolin (1979),
aware of patterns of exchange, and by negotia- and Stuart (1980) have all articulated similar
tion of a more satisfying quid pro quo. approaches to couples therapy. Each approach
The cognitive theories that make up the begins with a behavioral assessment that
cognitive part of cognitive-behavioral empha- includes the use of instruments to assess general
size the development and maintenance of levels of relationship satisfaction such as the
dysfunctional or ªirrationalº thought processes, dyadic adjustment scale. However, the primary
and direct efforts to alter these cognitions focus of the assessment is on delineating
through learning in therapy. Cognitive inter- problematic exchanges, specific target beha-
ventions examine the ideas that lie behind viors, and themes in the relationship that
behavior and emotion for the presence of core require change, evaluated through client re-
distortions. The emphasis lies in being able to cording of these behaviors between sessions,
understand the importance of the thought that therapist observation of typical interactions,
lies between an experience and the resultant and clients completing self-report forms. The
feeling. Cognitive interventions principally help results of the assessment are directly shared with
clients to understand and alter the tendency to the couple, highlighting the areas in their
overgeneralize, personalize, or be overly nega- relationship that require attention, leading to
tive about events that are occurring. Homework the development of a blueprint for change.
is essential in tracking and assessing beliefs, just Much of couple dissatisfaction is viewed as the
as it is essential in accomplishing behavioral product of the low level of positive reinforce-
goals. ment and high level of coersive exchange within
Early in the history of behavioral couple and the relationship, an often replicated finding in
family therapy, there was little that was systemic maritally distressed couples.
in the approach. Systems theory was not part of Many interventions are brought to bear to
the theoretical base. Instead, the emphasis was change these interactions. The monitoring of
on ways of promoting individual learning to behavior, through tracking and sometimes
change family patterns. It was not unusual for including the use of videotape feedback, help
behavioral family therapists to meet exclusively couples to objectify their behavior, to see it from
with parents to train them in better parent the perspective of an outsider. Where specific
practices to shape the behavior of children. skills are lacking, skills training is employed to
Indeed, much of this work was called behavioral develop competencies. Typical skills training
parent training rather than family therapy. includes the development of communication
More recent work by cognitive-behavioral skills such as attending, reflecting, listening, and
therapists has been much more systemic. For speaking, and of problem-solving skills such as
example, Patterson and Chamberlain (1992) the abilities to define problems, generate
clearly explicate the reciprocal influence of child alternative solutions, and reach naturally
and parent in conduct disorder, and emphasize satisfying outcomes. Behavior exchange is
how therapists if they do not remain sensitive to specifically addressed through the development
client needs can engage in too frequent teaching of contracts between the parties about these
behaviors that promote noncompliance with exchanges, most based in a quid pro quo, in
therapeutic tasks. Alexander and Parsons which the behavior of one party is directly
(1982) have added the systemic notion of exchanged for the behavior of the other.
function to behavior analysis. In their func- Behavioral couples treatments have a parti-
tional family therapy, attention centers on cularly strong record of demonstrating success
identifying the function of behavior, much in in empirical studies, at least in short-term
the manner of the Haley or MRI models. Once effectiveness (Lebow & Gurman, 1995). The
identified, behavioral interventions are intro- great conundrum for behavioral couples ther-
duced to accomplish this function in a less apy lies in addressing the aspects of the
damaging way. relationship that are not simply about behavior,
Cognitive-behavioral therapies are more those that involve feeling states, particularly
similar to one another than other groupings love and caring. Behavioral couple therapists
of family therapies, such as strategic or have therefore stretched the model to accom-
intergenerational. It is a strength of these modate the obvious importance of this aspect of
models that the work of each investigator the relationship. In early formulations, some
builds on that of others. Even if models have form of noncontingent loving behavior was
different names and slightly different compo- prescribed, called ªcaring daysº or ªlove days.º
nents, they are essentially similar in how to treat Jacobson and Christenson (1996) have empha-
specific problems. Couples therapies are like sized the importance of developing accepting
behaviors in addition to other skills. Other veloped. Home token economies and point
criticisms of behavioral couples approaches systems provide ways for credit to accrue for
have more recently emphasized the lack of positive behavior and debits for problematic
attention to history, meaning, and internal behaviors, with rewards dispensed for overall
dynamics in the approach (Gurman & Knud- performance. In all programs, the preference for
son, 1978). The addition of cognitive theory and positive reward over punishment in shaping
interventions have mitigated some of this behavior is emphasized.
criticism, but not all. Although behavioral parenting programs
In sex therapy, a range of specific techniques have been very successful in helping parents
for dealing with sexual problems are added to to deal with a wide range of problems, they have
couple therapy. At times, interventions other not been sufficient to deal with more difficult
than behavioral ones are included, as in problems. Here, the developers of these treat-
Kaplan's (1979) widely circulated integrative ments have refocused their attention on the need
model, but sex therapy always retains what to find ways to overcome resistance. Patterson
primarily is a behavioral core. Much of this and his colleagues (Patterson & Chamberlain,
core, developed by Masters and Johnson (1970), 1992) have highlighted situations in which
derives from the well-demonstrated insight that therapist directives merely increase resistance,
anxiety is antithetical to sexual response and, and sought ways to intervene that respond to
that through classical conditioning, relaxation client reactance. In a similar vein, Alexander
can replace anxiety. Sex therapy invariably and Parsons (1982) have directed functional
includes the use of what are termed ªsensate family therapy for adolescent delinquent beha-
focusº techniques to induce relaxation. Other vior toward ways of examining function and
specific techniques are added which are speci- using that knowledge to enable engagement and
fically tailored to each sexual dysfunction. Sex cooperation in treatment. Further, in the work
therapy numbers among the most effective of groups led by Patterson, Alexander, and
therapies in outcome studies, although the rates Henggeler, the behavior of the child or
of success reported by LoPiccolo and LoPiccolo adolescent and the impact of peer groups and
in 1978 are considerably lower than those other relevant systems is accorded equal footing
reported by Masters and Johnson. with the intervention with parents. These
Much of the treatment of child problems in models assume a systemic perspective and
behavioral family therapy has exclusively resemble typical family therapy far more than
focused on the parents in behavioral parent parent training.
training. Given the theoretical orientation Behavioral family approaches to child and
emphasizing reinforcement as crucial in beha- adolescent problems are among the most
vior, and the large body of data available researched and validated of psychotherapies.
suggesting that the parents of problematic Although the early variants of these approaches
children help shape their dysfunctional behavior could readily be criticized for their simplistic
and respond poorly to it, many behavior analysis and failure to consider a range of
therapists have concluded that time in therapy important variables (e.g., history and meaning),
is best spent with the parents who control the recent work has been auspicious, leaving these
reinforcers rather than with the children, among the most sophisticated as well as
especially when children are small. As in validated psychotherapies.
behavioral couple therapy, parent training
begins with an assessment phase in which
patterns of thought and behavior are recorded 1.16.6.4 Psychoeducation
and connected to the target behavior of concern.
This leads to a functional analysis of the Psychoeducational approaches to the treat-
problematic behavior, from which a plan is ment of disorders are based on the notion that
formed specifying the skills that need to be syndromes that seriously impair functioning
mastered and changes in contingencies that need have a biopsychosocial basis, and that illness
to occur for the problem to be eradicated. Focus models of these disorders are to be taken
may center on caring behaviors as well as on seriously. Sometimes illness models are fully
establishing control. If the problematic beha- incorporated as part of the approach, while in
vior on the part of the child is restricted to a other variants they are examined with families
single area of concern, specific contingencies as possible explanations for the disorder.
may be created in response to that behavior. For Flowing directly from these ideas is the
example, a program may be constructed of corollary that affected individuals and their
reward for school work. When problems are families can gain a great deal from developing
encountered in a number of areas, more their understanding of the relevant problem and
comprehensive contingency programs are de- acquiring the requisite skills that best fit with
that particular problem. The goal is to establish which have been followed up with replication.
a collaborative partnership with families who With both methods, expressed emotion has
suffer from mental disorders, providing them been decreased in these families, compliance
with the kind of information and skills most with procedures increased, and recidivism and
needed. Information is viewed as a major route symptoms decreased in the index patient. As
to coping. Beyond this constant, psychoeduca- such, this research suggests these treatments
tional treatments include an eclectic mix of offer the most consistent cost-effective treat-
interventions derived from individual and ment for schizophrenia. This work has been
family therapy that have particular relevance followed up with similar procedures for families
to the particular syndrome, as well as psycho- dealing with manic depression (Miklowitz &
pharmacological interventions. Goldstein, 1990).
Psychoeducational family treatments were One striking aspect of these models has been
developed in the context of schizophrenia, the inclusion of family in treatment in a way that
where the treatments have been most exten- has proved highly acceptable to these families,
sively refined and tested, and extended to other in contrast to earlier methods of dealing with
disorders, most notably manic-depressive dis- these families that left many families blamed
order. In the context of schizophrenia, a group and highly dissatisfied. Much of this earlier
at Western Psychiatric Institute in Pittsburgh work questioned the very existence of mental
(Anderson, Reiss, & Hogerty, 1986) and illness or even of disturbed internal processes in
another at UCLA (Falloon, Boyd, & McGill, the schizophrenic. Some (e.g., Haley, 1976) even
1984) developed related, although somewhat suggested that medication for the schizophrenic
different, psychoeducational methods. Each is harmful since it further establishes the patient
featured medication for the person with schizo- in the sick role, and obscures what were
phrenia, along with education for the family. regarded as the inevitable systemic issues. The
Each approach centered substantially around strong evidence for the efficacy of psychoeduca-
the notion that expressed emotion in families tion, coupled with the lack of evidence that
must be reduced. These approaches followed family therapy works in these samples without
the extensive studies by Leff and Vaughn (1985), the use of medication, suggests that the
among others, demonstrating that when schizo- psychoeducational form of family therapy is
phrenics are exposed to much expressed emo- clearly superior to the earlier variety. Indeed, it
tion in families, consisting of criticism and high appears clear that the highly stimulating family
negative affect, high rates of recidivism and therapies of old frequently seen in the tapes of
symptomology ensue. many masters of family therapy in treating
Anderson et al.'s unique contribution lies in schizophrenia provide exactly what is not
what they termed ªsurvival skillsº workshops, needed: a highly stimulating environment likely
which over a full day, present the current state of to be difficult for the patient and an environ-
knowledge about schizophrenia to families. ment in which families are likely to feel blamed
These workshops seek to impart information, for the problem. All told, for schizophrenia and
increase the sense of social support, and reverse other severe mental disorders, psychoeduca-
the negative interaction families of disturbed tional treatments number among the most
individuals often have with mental health successful family therapies, and are becoming
providers. Families are regarded as full colla- widely disseminated as the standard for care.
borators and taught in these workshops both
what is known and what is speculative about
schizophrenia. The Anderson et al. (1986) 1.16.6.5 Bowen Therapy and Other
family model also accented work in therapy Intergenerational Approaches
designed to alter dysfunctional aspects of family
structure, and a minimalist approach to inter- Bowen (1978) developed a prominent form of
vention in sessions that included the schizo- family therapy, now called Bowen family
phrenic, with one constant goal being to keep systems therapy, that incorporates systems
expressed emotion to a minimum. theory, along with a unique language for
The methods of Falloon, Boyd, and McGill considering the relationship of the individual
(1984) also seek to involve family and reduce with family. The crux of the Bowen approach
expressed emotion, but place greater emphasis lies in the concept of differentiation of self,
on behavioral skills training. There also is a which essentially amounts to the ability to
greater emphasis in this model on crisis distinguish thoughts and feelings. For Bowen,
management when the inevitable crises develop psychological and systemic health is a direct
in the lives of these families. Both the UCLA function of level of differentiation. When
and the Pittsburgh groups reported remarkable individuals differentiate themselves from family
levels of outcome in sophisticated clinical trials, processes, they are viewed as less susceptible to
the pathology-inducing aspects of the system. suggests that this is a highly satisfying and
Differentiation is clearly distinguished from effective treatment for clients, there has un-
cutoff, the establishment of rigid boundaries fortunately been a paucity of research investiga-
that minimize contact with family, which is tion of this approach.
viewed in this system as innately problematic. There have been numerous other approaches
In Bowen's theory, individual development is that have centered on the kind of examination of
largely shaped by the family system. Bowen intergenerational process developed by Bowen.
envisioned what he termed an ªundifferentiated Most prominent are approaches that create
family ego mass,º of beliefs and feelings within family rituals that serve as cathartic events for
families that are transmitted through what he negotiating the emotional turmoil resulting
termed a ªfamily projection processº across from multi-generational legacies (Imber-Black
generations. The position of the individual in & Roberts, 1993). Others have focused on
the family, in part determined by birth order and explicating and adapting the family myths that
in part by other factors, is also viewed as of key have evolved.
importance in shaping the individual. A key
element of family processes lies in the creation of 1.16.6.6 Psychodynamic Approaches
triangles, in which the interaction between two
individuals are affected by the presence of a Although psychoanalytic formulations have
third. Triangles are viewed as inevitable but also often served as the foil in expositions of several
treacherous for individual development. family therapies against which the value of
In Bowen family systems therapy, each focused systemic therapies could be highlighted,
member of the family involved is helped to there has also been a long standing tradition of
increase their ability to manage their own family therapies that have incorporated psy-
anxiety. In individual differentiation lies the chodynamic concepts (Reiner, 1997). Early in
basis for better family relationships. Therefore, the history of family therapy, Ackerman,
much of the work focuses on the relationships Boszormenyi-Nagy, Framo, Sager, Steirlin,
adult clients have with their families and, most and others created treatments that blended
specifically, their families of origin. Family of systems concepts with specific psychodynamic
origin is typically not seen directly in treatment, theories. More recently, the refinement of object
but examined through forays outside sessions in relations concepts within psychoanalysis has led
which the client learns about family processes, to the emergence of several family therapies that
experiences them, and finds new ways to cope take object relations one step further, to
with them. In this part of the therapy, termed consider those dynamics directly in the context
coaching, the therapist helps the client develop a of the family in treatment (e.g., D. Scharff &
plan for investigation and examine the thoughts J. S. Scharff, 1987; Slipp, 1993).
and feelings that emerge. Exploration involves Psychodynamic family approaches share a
both direct contacts with living relatives and number of common characteristics, despite
efforts to learn about and experience feelings in there being considerable variation with the
relation to deceased family. Genograms, dia- particular psychodynamic formulation in-
grams of the multigenerational family systems cluded. These approaches have roots in psycho-
of participants, are employed to help in this analytic concepts, but in all cases there is a
examination, to shape exploration and set goals. significant transformation in the family context.
Because this is the essential process of treat- Most basic to psychodynamic formulations in
ment, much of Bowen family systems therapy is couple and family therapy is the notion of an
conducted with only a single client in the office, active dynamic internal process within indivi-
although the work is principally centered on duals. Psychodynamic approaches share the
their family relationships. belief that unconscious mental processes are
Bowen family systems therapy represents a extremely important and that early experience
bridge between individual and family therapy. has a crucial influence on later behavior and
Although couched in systemic terms, many of experience. Psychodynamic family therapy has
Bowen's ideas about differentiation resonate retained from its individual therapy counterpart
with the concepts of object relations and an emphasis on the processes that occur within
cognitive models of therapy. Although much individuals.
of the unique terminology developed by Bowen Psychodynamic therapists also emphasize
adds little (with a few clear highly salient maintaining the frame of treatment, the formal
exceptions such as ªcoachingº), Bowen devel- arrangements such as frequency, time, and
oped a method that has enabled an exciting and length of sessions. Creating an appropriate
moving voyage of exploration of family pro- frame is viewed as leading to the development of
cesses by innumerable clients. Although the a holding environment (D. Scharff & J. S.
clinical experience of many family therapists Scharff, 1987), in which the therapist tolerates
clientsº anxieties and tensions while remaining The stance of the therapist toward the family,
empathic with their emotional experiences. The termed by Boszormenyi-Nagy and Spark ªmul-
creation of a holding environment also allows tidirected partiality,º is also much like the
for observations of deviations that arise from hovering attention basic in more recent forms of
the frame. Another important route into psychoanalytic approaches, but carried over to
unconscious process is the understanding of the family context with new language and
transference: the client's displacement or pro- intervention strategies.
jections onto others of feelings, impulses, The work of Framo (1981) also draws heavily
defenses, and fantasies from important past on the psychodynamic tradition, but adapted to
relationships or conflicts. These projections the context of the family therapy. Framo
help recapitulate important aspects of clientsº developed what he termed family-of-origin
earlier relationships in therapy or in the family sessions as part of couple or family therapy,
relationships. In psychodynamic family ther- in which the adults in the therapy would meet
apy, transferences are observed as much in for a few sessions with members of their own
relation to other family members, particularly family of origin, in order to understand better
spouses, as in relation to the therapist. and resolve the outstanding issues that derive
Psychodynamic couple and family therapies from that experience.
also accent the therapist's awareness of their Although pure-form psychoanalytic thera-
own feelings in the therapy process. Counter- pies are relatively infrequently encountered in
transference, the therapist's reactions to the couple and family therapy, psychodynamic
client based on client transferences or on the principles are central in the practice of many
therapist's own personal experience, are viewed family therapists. These concepts have been
as important sources of information about highly influential, especially in their important
client process. Most importantly, in projective place in a variety of integrative therapies.
identification, the therapist may be induced to Many of the intergenerational and experiential
feel or behave as the client has in the past or as family therapies also include a number of
others have behaved and felt toward the client. psychodynamic concepts. Psychodynamic
In most psychodynamic couple and family therapies have rarely been evaluated through
therapy, the understanding and owning of research. The demonstrated effects of a variant
projective identification on the part of the client of pychodynamic therapy, insight-oriented
assumes an especially important place in the couples therapy (Snyder & Wills, 1989),
process. suggests the likelihood of a promising future
Therapists offer interpretations that provide for these treatments in research, should this
meaning to behavior by explicating unconscious research ever be carried out.
processes. Change is seen as the product of
working through one's issues over time, often as
the product of these interpretations. Under- 1.16.6.7 Experiential Approaches
standing resistance, the process, often rooted in
anxiety, that moves against therapeutic goals, is Prominent experiential couple and family
also important in enabling change. therapies have been developed by Whitaker
In many instances, the language and inter- (Whitaker & Keith, 1981), Satir (1983), and
ventions of psychodynamic family therapy Greenberg and Johnson (1988). Each of these
merely extends those of individual psychody- approaches places the emphasis on felt experi-
namic therapy and, most especially, object ence, that is, in the therapy restoring liveliness
relations theory (e.g. D. Scharff & J. S. Scharff, and connection. In each, the primary instru-
1987). Other family therapies begin with similar ment is the therapist, who uses self as an
concepts, but draw on quite different methods, instrument toward change.
and language. For example, Boszormenyi-Nagy Each experiential family therapy employs
and Spark (1973) examine much of the same different intervention strategies. Whitaker
territory as an existential psychodynamic utilized a wide array of techniques, ranging
psychotherapy, but look at relationships in from direct commentary to physically wrestling
terms of what they term ªinvisible loyaltiesº with clients, all aimed to fight emotional
rather than using traditional language in their deadness. Satir employed exercises from the
contextual therapy. Their work aims at explor- human potential movement with which she was
ing multi-generational processes in families with so long associated, and Greenberg and John-
an eye to what they term ªledgers,º the balance son utilize methods of focused interaction
of what has been given and received by each between couples derived from Gestalt therapy.
individual. The central tenet of the therapy lies Although there are relatively few family
in helping clients deal with and balance the therapists trained in these specific methods,
ledger they bring from their families of origin. this work remains enormously influential in
highlighting the importance of the person of 1.16.6.9 Integrative Approaches

the therapist, and the need to maintain
liveliness and authenticity in the work of Integrative methods have become common-
couple and family therapy. place in couple and family therapy. Not only has
a considerable literature emerged concerned
with integration (Lebow 1984, 1987a, 1987b;
1.16.6.8 Narrative Approaches Liddle, 1984; Grunebaum, 1988; Moultrop,
1981, 1989), and numerous integrative models
At the time of the publication of this volume, have been developed and widely disseminated
narrative concepts have captured the greatest (e.g. Feldman, 1985, 1990; Gurman, 1981;
recent attention among family therapies. Mi- L'Abate, 1986; Pinsof, 1995), but the move to
chael White (White & Epston, 1990) has integration has become so much part of the
emerged as the major figure in the narrative fabric of our work that it largely goes
movement. Other prominent figures include unrecognized.
Anderson and Goolishian (1988), Combs and Integrative models merge the raw material of
Freedman (1990), and Hare-Mustin (Hare- the various approaches. This merger occurs at
Mustin & Marecek, 1988). Their approaches three distinct levels: theory, strategy, and
vary in specifics, but all have roots in social intervention. Because there are numerous
constructivism (Gergen, 1981, 1991), the notion therapies to merge, and several levels along
that knowing is socially constructed through which to merge them, integrative models vary
language and discourse, and depends on the enormously in content. Some integrative ap-
context of the observer. Each places a strong proaches accent each therapist's building of a
emphasis on thought processes and beliefs, and personal method, while others offer highly
in each difficulties are envisioned as the product prescriptive delineations of therapeutic ingre-
of stories that have been socially created and can dients and a specific map for when to do what.
be reconstructed. Problem-oriented descrip- Moultrop's work (1981, 1989), describing the
tions are replaced by stories of accomplishment. therapist's personal odyssey, and Lebow's
White emphasizes externalizing problems, (1987a), suggesting guidelines for each ther-
that is, seeing them as separate entities from apist's model development, offer examples of
the individuals involved. Much like solution- conceptions focused on the therapist as an agent
oriented and MRI therapists, White also of integration. Jacobson's (1992) couple therapy
emphasizes the outcomes that occur when and Liddle, Dakof, and Diamond's (1992)
individuals have been successful in overcoming treatment for adolescent drug abusers and their
problems. Anderson and Goolishian (1988) families offer examples of highly specific
offer the ultimate extension of this type of prescribed routes to intervention, which can
approach, fully replacing the notion of the be specified in treatment manuals. Other
expert therapist with the idea of therapist and models, such as Pinsof's (1983) problem
clients as equal partners in conversation. centered therapy or Gurman's (1981) integra-
Rather than merely opening discourse, these tive marital therapy, bridge this chasm through
approaches also accent the freeing of repressed prescribing ingredients, but allowing varying
voices. For White, following Foucoult, the levels of room for improvisation, especially for
dialogue needs to be as much about overcoming more advanced practitioners.
societal oppression as about family processes. Most integrative efforts combine behavioral
Although sometimes these therapies do notions of learning, with a systemic under-
involve seeing families together, these therapies standing of the family process, and the
move far from the family emphasis of early individual psychodynamics that are brought
family therapy. Much of the work is done with to bear in these patterns (Feldman, 1985, 1990;
individuals, with only passing references to the Gurman, 1981; Kirschner & Kirschner, 1986;
family system. As yet, we also have little in the Nichols, 1987, 1995; Pinsof, 1983, 1995;
way of outcome research testing the effective- Sander, 1979; Wachtel, 1992, 1995; Wachtel
ness of these models. However, narrative & Wachtel, 1985). Pinsof's (1983) ªProblem
models have already gained many proponents, centered therapyº offers a highly refined
and have influenced many more family thera- version of this type of model, in which self-
pists, in creating a frame for treatment that psychology is the internal system. Gurman
emphasizes a co-equal collaborative conversa- (1981, 1992) has developed a combination of
tional style that de-emphasizes the therapist's object relations, behavioral, and systemic
role as expert, in emphasizing the importance of procedures for working with couples. Feldman
the client's voice, and in directly working with (1990) adds an integration of similar ingredi-
client stories about their lives to help create ents envisioned as linked in a multilevel circular
more workable realities. process.
The Efficacy of Couple and Family Therapy 489
Much of the creative edge in integration has As yet, research has only assessed a small
been concerned with the development of specific number of these integrative treatment models.
treatments for specific populations. Goldner Nonetheless, the results of the existent research
et al. (1990) have merged feminist, narrative, are very promising. The integrative methods
systemic, and psychodynamic concepts in the studied have proven highly effective at dealing
treatment of abuse within couples. Liddle et al. with a wide range of problems.
(1992) and Piercy and Frankel (1989) have
brought structural, systems, and behavioral
principles together along with a developmental 1.16.7 THE EFFICACY OF COUPLE AND
perspective in the treatment of adolescent FAMILY THERAPY
chemical dependency. Similarly, Kaplan
(1974) has brought an integrative approach to Three decades of research have confirmed
sex therapy; Addis and Jacobson (1991) to adult and reconfirmed the effectiveness of couple and
depression, Rolland (1994), Wright and Leahy family therapy. Reviews of the literature
(1994) and Wood (1994) to families with physical conclude that the outcomes achieved by treat-
illness; Wachtel (1995) to families with young ment groups have exceeded those of control
children; Steinglass (1992) to alcoholism; Alex- groups (Gurman & Kniskern, 1978, 1981;
ander and Parsons (1982) to adolescent acting Gurman et al., 1986; Alexander et al., 1994;
out; Markman (1979) to premarital couples; Jacobson & Addis, 1993; Baucom & Hoffman,
Trepper and Barrett (1989) to sexual abuse, and 1986). With more and better research emerging
Harkaway (1989) to eating disorders. Each of the evidence for overall effectiveness has
these methods provides a hearty integration, become unequivocal (e.g., Jacobson, Dobson,
that includes theory, methods of intervention, Fruzzetti, Schmaling, & Salusky, 1991; Snyder
and particular values that guide treatment. & Wills, 1989). Although the majority of studies
Feminists (Goldner, 1985; Hare-Mustin & have focused on behavioral treatments, there is
Marecek, 1988, 1990) and those who offer now also a considerable base of nonbehavioral
treatment in diverse cultures (Aponte, 1985; treatment studies that point to treatment
Boyd-Franklin, 1989, McGoldrick et al., 1988) efficacy. Further, the earlier stated concerns
have focused attention on the obvious impor- about possible confounds of treatment method
tance of race, class, and gender, and on the value that might mitigate this conclusion (Beach &
of therapistsº shaping treatment in relation to O'Leary, 1985; Gurman & Kniskern 1978;
these factors. This has resulted in the develop- Bednar, Burlingame, & Masters, 1988; Lebow,
ment of several integrative treatments, specifi- 1981) can now be put to rest. A range of
cally designed for particular cultural groups or excellent methodological studies confirms the
gender-related issues (Boyd-Franklin, 1989; general findings of efficacy found in less
Goldner, 1985; Szapocznik & Kurtines, 1989; rigorous research.
Watts-Jones, 1992). These models move beyond Nonetheless, there is clearly a differential
the notion of one method for all to a better amount of evidence supporting the efficacy of
understanding of which methods work best in the various couple and family therapies (Lebow
what combination with various populations. & Gurman, 1995). Behavioral approaches
Culture and gender have also been incorporated largely have extensive bodies of research
as anchors in some broader efforts at integra- support, particularly in treating childhood
tion (Breunlin et al., 1992). The feminist and and adolescent conduct disorder, marital dis-
cultural perspectives have also helped elucidate satisfaction, and adolescent acting out. Struc-
the underlying assumptions about gender and tural approaches also have considerable
culture within treatment models, leading to a support, particularly in child and adolescent
more informed discussion of what is being conduct disorder. An experiential approach to
integrated. couple therapy, emotionally focused therapy
It should be noted here that even though (Greenberg, Ford, Alden, & Johnson, 1993),
feminist family therapy presumes an integration and a psychodynamic approach, insight-or-
of feminist ideas and methods of family therapy, iented (Snyder & Wills, 1989), also have
feminist work has seldom been labeled as garnered research support. A considerable body
integrative. Nevertheless, feminists have proof research evidence points to the efficacy of
vided some of the richest integrative frame- treatments that integrate individual and con-
works; many models include a wide range of joint treatments, including psychoeducational
precepts and interventions. Similarly, the in- treatments of schizophrenia (Hogarty, Ander-
tegrative nature of the models of those working son, Reiss, Knornblith, & Greenwald, 1986),
with specific cultural groups often goes over- cognitive-behavioral treatment of depression
looked in considerations of integrative treat- (O'Leary & Beach, 1990), multisystemic treat-
ment models. ment (Henggeler, 1993), and functional family
therapy for adolescent delinquent behavior of process can focus on a few cases, particularly
(Alexander & Parsons, 1982), and multidimen- when the cases are selected by outcome status
sional family therapy for adolescent drug abuse and the methods for assessing process clearly
(Liddle, Dakof, & Diamond, 1992). There exists focus on change events rather than engaging in a
very little research support for a variety of hunting expedition (Greenberg, 1991). We also
widely practiced couple and family therapies are beginning to see a great deal of research on
including Bowen, narrative, humanistic, strate- treatments that transcend the labels ªindivi-
gic, and solution-focused approaches. Differ- dual,º ªcouple,º or ªfamilyº therapy, just as
ences in knowledge about models are even more clinical methods are moving to transcend these
pronounced than earlier (Gurman et al., 1986). boundaries (Lebow, 1987a, 1987b). We are also
Looked at from the perspective of the seeing more efforts to be conscious of gender
presenting problem, couple and family therapies and culture in research. No longer is the
have been demonstrated to have considerable assumption made that findings are necessarily
value in treating depression, anxiety disorder, generalizable across gender or culture. Perhaps
panic disorder, schizophrenia, alcoholism and most promising, family therapists and family
marital maladjustment in adults, conduct dis- researchers have begun to engage in dialogue,
order, autism, and drug abuse in children and suggesting that the notable gap between
adolescents (Lebow & Gurman, 1995; Pinsof & research and practice may narrow.
Wynne, 1995). Most of these demonstrations of
effectiveness include a combination of couple
and family therapy with other interventions. 1.16.8 TRENDS IN COUPLE AND FAMILY
Offered alone, couple and family therapies THERAPY
emerge as the only demonstrated effective
means for impacting on couple and family A number of trends are clearly emerging in
issues (e.g., couple conflict and marital mal- family therapy. These include:
adjustment). Frequently it appears that even a (i) Most family therapies have moved away
small amount of family involvement adds from radical systemic positions, which focused
immeasurably to treatment effectiveness and solely on interpersonal processes and viewed the
increases acceptability and participation in etiology of disorder, treatment, and the assess-
treatment (Lebow & Gurman, 1995). There ment of change exclusively in terms of the
are indications that treatments diminish in their properties of systems (e.g., circular causality
effectiveness over time. Although outcomes are and homeostasis). These radical systemic view-
quite impressive in the short term, effects often points showed little respect for any linear
dissipate (Lebow & Gurman, 1995). epistemology, including the traditional methods
An outstanding body of research is now also of empirical research, and focused attention on
available associated with family process and a complex set of variables that were extremely
family development (Cox & Paley, 1997). This difficult to measure. A shift has occurred in
work implies many hypotheses for treatment which interpersonal processes, feedback loops,
research. For example, Gottman and associates and the system's role in problem generation and
have carried out several studies that have added resolution are still emphasized; but attention
immeasurably to our knowledge of patterns and broadens to include individual functioning, the
sequences of dysfunction in marriage (Buehl- larger social system, and other levels of analysis.
man, Goldman, & Katz, 1992; Gottman, 1991, (ii) The boundaries among individual, cou-
1992, 1993; Gottman & Krofkoff, 1989), such as ple, and family therapy and between schools of
showing particular patterns in couples conflict family therapy are blurring. There are more and
that directly lead to decreasing levels of marital more integrative therapies that include couple
satisfaction and ultimately to divorce. Similarly, and family treatment. Many therapies that
powerful bodies of research concerned with include significant aspects of systems theory
such issues as patterns in divorcing and and interventions with couples and family do
remarried families (Bray & Hetherington, not label themselves ªfamily therapyº (Pinsof &
1993), family transitions around the birth of Wynne, 1995).
children (Cowan & Cowan, 1992), and patterns (iii) Methods of practice in family therapy are
in the alcoholic family (Steinglass, Bennett, becoming more generic. Therapists practice in
Wolin, & Reiss 1987) have clear clinical ways that are more integrative, and utilize
implications. strategies and interventions that cross a range
A few other trends in the research that have of schools of practice. Concepts like therapeutic
emerged are particularly noteworthy. We are alliance (Pinsof & Catherall, 1986), loss (McGol-
seeing a trend toward more clinical trials drick & Walsh, 1983), life cycle (Carter &
research comparing treatments. Paradoxically, McGoldrick, 1988), cohesion (Olson, 1986),
research also shows the impact the intense study isomorphism (Liddle, 1984); macrosystem
The Development of Family Psychology 491
(Imber-Black, 1988), and differentiation (Bo- vary and generalizations about family process
wen, 1978); interventions such as enactment must always be viewed through the lenses of
(Minuchin & Fishman, 1981), ritual (Imber- gender and culture.
Black & Roberts, 1993), and genogram (McGol- This focus on gender and culture has taken
drick & Gerson, 1985); and tactics for dealing two forms. Some have offered critiques of the
with such processes as engagement (Minuchin & concepts of family therapy, explicating the
Fishman, 1981), resistance (Anderson & Stew- ethnocentric and gendered aspects of the most
art, 1983), and termination (Lebow, 1995) are widely taught models of treatment. For exam-
used by a wide range of family therapists, ple, Green and Werner (1996) have focused on
transcending the approach in which they were the tendency to view closely connected families,
first utilized. We have also seen the development frequently found in many minority cultures as
of a common language that transcends approach pathologically enmeshed. Green and Werner
(Simon, Stierlin, & Wynne, 1985), and the argue that closeness can be and often is a
beginnings of catalogs of interventions that positive value. Similarly, Goldner (1985) has
transcend orientation (Figley & Nelson, 1989; described the gender assumptions implicit in
Minuchin & Fishman, 1981). most schools of family therapy. The second tact
(iv) Biology is clearly emerging in the litera- has been to explicate specific methods that fit
ture as an important variable in family life, in with the culture of particular groups of
such disparate contexts as conflict in marriage individuals (McGoldrick et al., 1988) or power-
(Gottman & Levenson, 1992) and processes ful gendered issues (Carter, 1996; Goldner et al.,
around schizophrenia in the family (Leff & 1990).
Vaughn, 1985). Family reactions to crises in (ix) Others have become increasingly con-
health (Rolland, 1994) and, more broadly, the cerned with the impact and relationship of
field of family systems medicine have come to systems larger than the family. Early family
occupy much attention. therapy focused on the family and its dynamics.
(v) Many models now feature a very strong More recent thinking has viewed the family as
cognitive emphasis on intervention strategy. only one of multiple systems impinging on the
Behavioral models have added cognitive theory individual. The family system is viewed in
and intervention, strategic models a heavy relation to a number of other influences, such
emphasis on reframing, and narrative models as schools, the legal system, poverty, and peer
fully focus on the creation of new stories about groups. Multisystemic treatments targeting mul-
events. tiple systems are beginning to emerge (e.g.,
(vi) There is a growing tendency to develop Henggeler, 1993; Liddle et al., 1992). Some
specific variants of treatment to respond to the family therapists (Wynne et al., 1986) now even
specific issues in particular kinds of cases, refer to themselves as system consultants.
especially different diagnostic groups. Such (x) An increasing emphasis in family therapy
treatments as psychoeducational intervention has been on a life cycle perspective (Carter &
for schizophrenia (Hogarty et al., 1986), McGoldrick, 1988). It has become typical to
cognitive-behavioral couple treatment of de- consider a family in relation to where they are
pression (O'Leary & Beach, 1990), multisyste- within the developmental process, and shape
mic treatment (Henggeler, 1993) and functional interventions accordingly.
family therapy for adolescent delinquent beha- (xi) There is much more emphasis than ear-
vior (Alexander & Parsons, 1982), and multi- lier in family therapy on health, normality, and
dimensional family therapy for adolescent drug resilience, as opposed to homeostasis, resis-
abuse (Liddle et al., 1992); all are fully struc- tance, and pathology (Walsh, 1993). Not only
tured and adapted to the specific population in do the specific approaches that have captured
focus. the most recent attention feature these assump-
(vii) Much attention has been focused on the tions (e.g., solution focused and narrative), but
meaning and methods for intervening in family most family therapy now emphasizes resilience
violence (Avis, 1992; Goldner et al., 1990). In and coping.
attempting to deal with family violence, many
assumptions of systems theory have required
modification, for example, the absolute cen- 1.16.9 THE DEVELOPMENT OF FAMILY
trality of circular causal explanations. PSYCHOLOGY
(viii) As previously noted, gender and cul-
ture have emerged as vital considerations in From its beginning, couple and family
shaping practice. No longer is the assumption therapy has been a multidisciplinary endeavor.
made that the same treatment will be appro- Perhaps more than in the development of any
priate across varying groups (McGoldrick et al., other psychotherapy, psychologists, psychia-
1988). Patterns of behavior and expectations trists, social workers, psychiatric nurses, and
others (even including anthropologists and therapies, and as couple and family intervention
sociologists) have worked together in harmony. has come to be seen as essential in the treatment
Indeed, many of the central developments in the of a wide array of problems.
field have been carried out in family institute
settings, away from the organized centers of
training in specific disciplines. 1.16.10 SUMMARY
The downside of this pattern of development Systems formulations of family process and
has been that it has taken considerable time for family systems orientations to psychotherapy
family therapy to occupy a central place within have been prominent methods of conceptuali-
the specific disciplines, including psychology. zation and intervention since the early 1960s. A
Well after the emergence of family therapy as a variety of distinct forms of couple and family
much practiced endeavor, few training pro- therapy have developed and become widely
grams within the mental health disciplines practiced, including structural, strategic, ex-
offered training in systems therapy. For exam- periential, inter-generational, cognitive-beha-
ple, Stanton (1976) reported that as late as the vioral, and pyscho-educational methods.
mid-1970s, only 10 psychology programs of- Approaches to couple and family therapy are
fered family therapy training. However, since increasingly integrative, incorporating a range
the mid-1970s, this pattern has substantially of concepts and intervention strategies, and
changed, as structures have evolved in training including a focus on the individuals within the
and practice that recognize the importance of family as well as on the broader social system in
the family system in psychology. which the family resides. In the future, we are
Foremost has been the creation of a sub- likely to see the further development of such
discipline, family psychology. The American therapies that feature a systemic orientation, but
Psychological Association has recognized the which are less distinctly ªfamilyº therapies, in
importance of family psychology in creating the which therapists move their focus across levels
Division of Family Psychology (Division 43) of social system: from family, to couple, to
and a journal to represent scholarship in this individual, to the larger system.
discipline, Journal of Family Psychology. In Knowledge derived from research about the
surveys, 63% of psychology programs with family system and family therapy also is
special treatment services had family therapy growing. Much of this research supports the
clinics (Sayette & Mayne, 1990), 19% of all tenets of systems theory as an explanatory set
faculty had systemic theoretical orientation of concepts (Cox & Paley, 1997). This research
(Mayne, Norcross, & Sayette, 1994), and family is also helping to build a base of greater
research was the second most represented area understanding of family processes. Research
of research across departments (Sayette & assessing the efficacy of couple and family
Mayne, 1990). Eighty-five percent of psychol- therapy has consistently demonstrated its
ogy internships reported some marital and efficacy. Specifically, couple and family therapy
family training (Soloman, Ott, & Roach, appears to have a unique impact in alleviating
1986). In many departments, a specific specia- relationship difficulties, to contribute in im-
lization in family psychology has been created portant ways in the multimodal treatment of
(Green, 1996). In addition, many psychologists psychopathology, and to help engage many
continue to receive training in postdegree clients who cannot be engaged in other forms of
programs in family institute settings. treatment.
As this is being written, discussion is under- Family psychology is emerging as a promi-
way about whether family psychology should be nent field within psychology. In the twenty-first
regarded as a specialization on a par with century, we are likely to see it occupy an even
clinical and counseling psychology or whether it more central place within the discipline, with
should be regarded as a proficiency lying within greater formal recognition of the specific skill
clinical psychology. Green (1996) has argued base needed to work with couples and families.
cogently for the former, suggesting that ªthere is
nothing about clinical or counseling psychology
that makes them inherently more generalist than 1.16.11 REFERENCES
a family psychology program would be.º Green Ackerman, N. W. (1958). The psychodynamics of family
further suggests the creation of a full predoctor- life. New York: Basic Book.
al specialization in family psychology as well as Alexander, J. F. Holzworth-Monroe, A., & Jameson
a postdegree specialization. Whatever the out- (1994). The process and outcome of marital and family
come of this debate, it is clear that family therapy. In A. E. Bergin & S. L. Garfield (Eds.),
Handbook of psychotherapy and behavior change (4th
psychology has moved to a central place within ed.). New York: Wiley
psychology, just as systemic therapies have Addis, M. A., & Jacobson, N. S. (1991). Integration of
become among the most widely practiced cognitive therapy and behavioral marital therapy for
References 493
depression. Journal of Psychotherapy Integration, 1, Dell, P. (1986). In defense of lineal causality. Family
249±264. Process, 25, 515±524.
Alexander J. F., & Parsons, B. (1982). Functional family De Shazer, S. (1985). Keys to solution in brief therapy. New
therapy: Principles and procedures. Carmel, CA: Brooks/ York: Norton.
Cole. De Shazer S. 1988. Clues: Investigating solutions in brief
Anderson, H., & Goolishian, H. (1988). Human systems as therapy. New York: Norton.
linguistic systems. Family Process, 27, 371±393. Falloon I, Boyd J., & McGill C. (1984). Family care of
Anderson, C. M., Reiss, D., & Hogarty, B. (1986). schizophrenia: A problem-solving approach to the treat-
Schizophrenia and the family. New York: Guilford Press. ment of the mentally ill. New York: Guilford Press.
Anderson, C. M., & Stewart, S. (1983). Mastering Falloon I. R. H., Boyd J. L., McGill C. W., Williamson M.,
resistance: A practical guide to family therapy. New & Razani J., (1985). Family management in the
York: Guilford Press. prevention of morbidity of schizophrenia: Clinical out-
Aponte, H. (1985), The negotiation of values in therapy. come of a two year longitudinal study. Archives of
Family Process, 24, 323±338. General Psychiatry, 42, 887±896.
Avis, J. M. (1992). Where are all the family therapists? Feldman, L. B. (1985). Integrative multi-level therapy: A
Abuse and violence within families and family therapy's comprehensive interpersonal and intrapsychic approach.
response. Journal of Marital Family Therapy, 18, Journal of Marital and Family Therapy, 11, 357±372.
223±230. Feldman, L. B. (1990). Multi-dimensional family therapy.
Barton C., & Alexander J. F. (1981). Functional family New York: Guilford Press.
therapy. In A. S. Gurman & D. P. Kniskern Feldman, L. B., & Pinsof, W. M. (1982). Problem
(Eds.), Handbook of family therapy. New York: Brun- maintenance in family systems: An integrative model.
ner/Mazel. Journal of Marriage and Family Therapy, 8, 295±308.
Bateson, G., Jackson, D., Haley, J., and Weakland, J. Figley, C., & Nelson, T. S. (1989). Basic family therapy
(1954). Toward a theory of schizophrenia. Behavioral skills 1: Conceptualization and initial findings. Journal of
Science, 1, 251±264. Marital and Family Therapy, 15, 349±365.
Baucom D. H., & Epstein N. (1990) Cognitive-behavioral Framo, J. L. (1981). The integration of marital therapy
marital therapy. New York: Brunner/Mazel. with sessions with family of origin. In A. S. Gurman &
Baucom, D. H., & Hoffman, J. A. (1986). The effectiveness D. P. Kniskern (Eds.), Handbook of family therapy. New
of marital therapy: Current status and application to the York: Brunner/Mazel.
clinical setting. In N. Jacobson & A. Gurman (Eds.), Gergen, K. J. (1981). The social constructionist movement
Clinical handbook of marital therapy (pp. 597±620). New in modern psychology. American Psychologist, 40,
York: Guilford Press. 266±275.
Beach, S. R. H., & O'Leary, K. D. (1992). Treating Gergen, K. (1991). The saturated self. New York: Basic
depression in the context of marital discord: Outcome Books.
and predictors of response of marital therapy versus Glaserfeld, E. Von. (1984). An introduction to radical
cognitive therapy. Behavior Therapy, 23, 507±528. constructivism. In P. Watzlawick (Ed.), The invented
Bednar, R. L., Burlingame, G. M., & Masters, K. S. (1988). reality. How do we know what we believe we know?
Sysems of family treatment: Substance or semantics? (pp. 17±40). New York: Norton.
Annual Review of Psychology, 39, 401±434. Goldner, V. (1985). Feminism and family therapy. Family
Berg, I. K. (1993). Family based services. New York: Process, 24, 31±48.
Norton. Goldner, V., Penn, P., Sheinberg, M., & Walter, G. (1990).
Boscolo L., Cecchin G., Hoffman L., & Penn P. (1987). Love and violence: Gender paradoxes in volatile attach-
Milan systemic therapy. New York: Basic Books. ments. Family Process, 29, 343±364.
Boszormenyi-Nagy, I., & Spark, G. (1973). Invisible Gottman, J. M. (1991). Predicting the longitudinal course
loyalties. Hagerstown, MD: Harper and Row. of marriages. Journal of Marital and Family Therapy,
Bowen, M. (1978). Family therapy in clinical practice. 17(1), 3±7.
Northvale, NY: Jason Aronson. Gottman, J. (1992). The roles of conflict engagement,
Boyd-Franklin, N. (1989). Black families in family therapy: escalation, and avoidance in marital interaction: A
A multi-systems approach. New York: Guilford Press. longitudinal view of five types of couples. Journal of
Buehlman, K. T., Gottman, J. M., & Katz, L. F. (1992). Consulting and Clinical Psychology, 61, 6±15.
How a couple views their past predicts their future: Gottman, J. (1993). A theory of marital dissolution and
Predicting divorce from an oral history interview. stability. Journal of Family Psychology, 7, 57±75.
Journal of Family Psychology, 5(3, 4), 295±318. Gottman, J. M., & Krokoff, L. (1989). Marital interaction
Bray, J., & Hetherington, E. M. (1993). Families in and marital satisfaction. A longitudinal view. Journal of
transition: Introduction and overview. Journal of Family Consulting and Clinical Psychology, 57, 47±52.
Psychology, 7, 3±8. Gottman, J. M., & Levenson, R. W. (1992). Marital
Breunlin D., Schwartz, R., & Karrer, B. (1992). Meta- processes predictive of later dissolution: Behavior,
frameworks: Transcending the models of family therapy. physiology, and health. Journal of Personality and Social
San Francisco: Jossey-Bass. Psychology, 63(2), 221±233.
Carter, B. (1996). Love, honor, & negotiate. New York: Gottman, J., Markman, H., & Notarius, C. (1977). The
Pocket Books. topography of marital conflict: A sequential analysis of
Carter, B., and McGoldrick, M. (1988). The changing verbal and nonverbal behavior. Journal of Marriage and
family life cycle: A framework for family therapy (2nd the Family, 39, 461±477.
ed.) Boston: Allyn & Bacon. Green, R. J. (1986). Education in family psychology.
Cecchin, G. (1987). Hypothesizing, circularity and neu- Family Psychologist, Winter, 10±15.
trality revisited: An invitation to curiosity. Family Green, R. J., & Werner, R. (1996). Enmeshment and
Process, 26, 405±413. disengagement. Family Process, 35, 112±132.
Combs, G., & Freedman, J. (1990). Symbol, story, and Greenberg, L. S. (1991). Research on the process of change.
ceremony. New York: Norton. Psychotherapy Research, 1(1), 3±16.
Cowan, C. P., & Cowan, P. A. (1992). When partners Greenberg, L. S., Ford, C. O., Alden, L. S., & Johnson, S.
become parents. New York: Basic Books. M. (1993). In-session change in emotionally focused
Cox, M. J., & Paley, B. (1997). Families as systems. Annual therapy. Journal of Consulting and Clinical Psychology,
review of psychology, 48, 243±267. 61, 78±84.
Greenberg, L. S., & Johnson, S. M. (1988). Emotionally Guilford Press.

focused therapy for couples. New York: Guilford Imber-Black, E., & Roberts, J. (1993). Rituals from our
Press. times: Celebrating, healing, and changing our lives and our
Grunebaum, H. (1988). The relationship of family theory relationships. New York: Harper Collins.
to family therapy. Journal of Marital & Family Therapy, Jacobson, N. S. (1992). Behavioral couple therapy: A new
14, 1±14. beginning. Behavior Therapy, 23, 493±505.
Guerney, B. G. (1977). Relationship enhancement: Skill Jacobson, N. S., & Addis, M. E. (1993). Research on
training programs for therapy, problem prevention and couple therapy: What do we know? where are we going?
enrichment. San Francisco: Jossey-Bass. Journal of Consulting and Clinical Psychology, 61(1),
Gurin, E., Veroff, J., & Feld, S. (1960). Americans view 85±93.
their mental health. New York, Basic Books. Jacobson, N. S., & Christenson A. (1996). Acceptance and
Gurman, A. S. (1978). Contemporary marital therapies. In change in couple therapy. New York: Norton.
T. Paolino & B. McCrady, Marriage and marital therapy: Jacobson, N. S., Dobson, K., Fruzzetti, A., Schmaling, K.
Psychoanalytic, behavioral, and system theory perspec- B., & Salusky, S. (1991). Marital therapy as a treatment
tives. New York: Brunner-Mazel, for depression. Journal of Consulting and Clinical
Gurman, A. S. (1981). Integrative marital therapy: Toward Psychology, 59(4), 547±557.
the development of an interpersonal approach. In S. Jacobson, N. S., & Margolin, G. (1979). Marital therapy:
Budman (Ed.) Forms of brief therapy. New York: Strategies based on social learning and behavior exchange
Guilford Press. principles. New York: Brunner/Mazel.
Gurman, A. S., & Kniskern, D. P. (1978). Research on Kaplan, H. S. (1979). The new sex therapy: active treatment
marital and family therapy: progress, perspective, and of sexual dysfunctions. New York: Brunner/Mazel.
prospect. In S. L. Garfield & A. E. Bergin (Eds.), Kirschner, D., & Kirschner, S. (1986). Comprehensive
Handbook of psychotherapy and behavior change: An family therapy: An integration of systemic and psychody-
empirical analysis (2nd ed., pp. 817±901). New York: namic treatment models. New York: Brunner/Mazel.
Wiley. L'Abate, L. (1986). Systemic family therapy. New York:
Gurman, A. S., & Kniskern, D. P. (1978). Technolatry, Brunnel-Mazel.
methodolatry, and the results of family therapy. Family Lebow, J. (1981). Issues in the assessment of outcome in
Process, 17, 275±281. family therapy. Family Process, 20, 167±188.
Gurman, A. S., & Kniskern, D. P. (1981). Handbook of Lebow, J. L. (1987a). Developing a personal integration in
family therapy. New York: Brunner/Mazel. family therapy: Principles for model construction and
Gurman, A. S., Kniskern, D. P., & Pinsof W. M. (1986). practice. Journal of Marital and Family Therapy, 13,
Research on marital and family therapies. In S. L. 1±14.
Garfield & A. E. Bergin (Eds.), Handbook of psychother- Lebow, J. L. (1987b). Integrative family therapy: An
apy and behavior change (3rd ed., pp. 565±624). New overview of major issues. Psychotherapy, 40, 584±594.
York: Wiley. Lebow, J. L. (1984). On the value of integrating approaches
Gurman, A. S. & Knudson, R (1978). Behavioral marriage to family therapy. Journal of Marital and Family
therapy: A psychodynamic-systems analysis and critique. Therapy, 10, 127±138.
Family Process, 17, 121±138. Lebow, J. L. (1995). Termination in marital and family
Haley, J. (1963). Strategies of psychotherapy. New York: therapy. In R. H. Mikesell, D. D. Lusterman, &
Grune & Stratton. S. H. McDaniel (Eds.), Integrating family therapy
Haley, J. (1976). Problem-solving therapy. San Francisco: handbook of family psychology and systems theory (1st
Jossey-Bass. ed.). Washington, DC: American Psychological Associa-
Haley, J. (1980). Leaving home. New York: McGraw-Hill. tion.
Hare-Mustin, R. T., & Marecek, J. (1988). The meaning of Lebow, J., & Gurman, A. S. (1995). Research assessing
difference: Gender theory, postmodernism and psychol- couple and family therapy. Annual Review of Psychology,
ogy. American Psychologist, 43, 455±464. 46, 27±57.
Harkaway, J. E. (1989). Family intervention in the Leff, J., & Vaughn, C. (1985). Expressed emotion in
treatment of childhood and adolescent obesity. In J. E. families: Its significance for mental illness. New York:
Harkaway (Ed.), Eating disorders. Rockville, MD: Guilford Press.
Aspen. Liddle, H. A. (1984). Towards a dialectical-contextual-
Henggeler S. W. (1993). Multi-systemic treatment of coevolutionarey translation of structural-strategic family
serious juvenile offenders: implications for the treatment therapy. Journal of Strategic and Systemic Therapies, 3,
of substance-abusing youths. In L. S. Onkine, J. D. 57±66.
Blaine, & J. J. Borne (Eds.), Behavioral treatments for Liddle, H. A., Dakof, G. A., & Diamond, G. (1992).
drug abuse and dependence (pp. 181±199). Rockville, Adolescent substance abuse: Multidimensional family
MD: National Institute on Drug Abuse Research therapy in action. In E. Kaufman & P. Kaufmann (Eds.),
Monograph 137. Family therapy of drug and alcohol abuse (2nd ed.)
Henggeler, S. W., Melton, G. B., & Smith, L. A. (1992). Boston: Allyn & Bacon.
Family preservation using multisystemic therapy: An Lidz T., Cornelison, A., Fleck, S., & Terry, D. (1957).
effective alternative to incarcerating serious juvenile Intrafamilial environment of the schizophrenic patient.
offenders. Journal of Consulting and Clinical Psychology, Psychiatry, 20 329±342.
60(6), 953±961. LoPiccolo, J., & LoPiccolo, L. (1978). Handbook of sex
Hoffman, L. (1981). Foundations of family therapy: A therapy. New York: Plenum.
conceptual framework for system change. New York: Madanes, C. (1981). Strategic family therapy. New York:
Basic Books. Jossey-Bass.
Hogarty, G., Anderson, C. M., Reiss, D. J., Knornblith, S. Markman, H. J. (1979). Application of a behavioral model
J., & Greenwald, D. P., (1986). Family psychoeducation, of marriage in predicting relationship satisfaction of
social skills training and maintenance chemotherapy in couples planning marriage. Journal of Consulting and
the aftercare treatment of schizophrenia: I. One-year Clinical Psychology, 47, 743±749.
effects of a controlled study on relapse and expressed Markman, H. J., Floyd, F. J., Stanley, S. W. & Lewis, H.
emotion. Archives of General Psychiatry, 43, 633±642. C. (1986). Prevention. In N. S. Jacobson & A. S.
Imber-Black, E. (1988). Families and larger systems: A Gurman (Eds.), Clinical handbook of marital therapy.
family therapist's guide through the labyrinth. New York: New York: Guilford Press.
References 495
Masters, W. H., & Johnson, V. S. (1970). Human sexual Sander, F. (1979). Individual and family therapy. New
inadequacy. Boston: Little-Brown. York: Jason Aronson.
Maturana, H. R., & Varela, F. J. (1980). Autopoesis and Satir, V. (1983). Conjoint family therapy. Palo Alto, CA:
cognition. Boston: D. Riedel Science and Behavior Books.
Maturana, H. R., & Varela, F. J. (1987). The tree of Sayette, M. A., & Mayne, T. J. (1990). Survey of current
knowledge: The biological roots of human understanding. clinical and research trends in clinical psychology.
Boston: New Science Library. American Psychologist, 45, 1263±1266.
Mayne, T. J., Norcross, J. C., & Sayette, M. A. (1994). Scharff, D., & Scharff, J. S. (1987). Object relations family
Admission requirements, acceptance rates, and financial therapy. New York: Jason Aronson.
assistance in clinical psychology programs. American Selvini-Palazzoli, M. (1986). Toward a general model of
Psychologist, 49, 806±811. psychotic games. Journal of Marital and Family Therapy,
McGoldrick, M., & Gerson, R. (1985). Genograms in 12, 339±349.
family assessment. New York: Norton. Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G.
McGoldrick, M., Pierce, C., & Giordano, J. (1988). (1978). Paradox and counterparadox. New York: Jason
Ethnicity and family therapy. New York: Guilford Aronson
Press. Simon, F., Stierlin, H., & Wynne, L. (1985). The language
McGoldrick, M., & Walsh, F. (1983). A systemic view of of family therapy: A systemic vocabulary and source book.
family history and loss. In L. R. Wolberg & M. L. New York: Family Process Press.
Aronson (Eds.), Group and family therapy. New York: Slipp, S. (1993). Object relations: A dynamic bridge between
Brunner-Mazel. individual and family treatment. New York: Jason
Miklowitz, D. J., & Goldstein, M. J. (1990). Behavioral Aronson.
family treatment for patients with bipolar affective Snyder, D. K. & Wills, R. M. (1989). Behavioral versus
disorder. Behavior Modification, 14, 457±489. insight-oriented marital therapy: Effects on individual
Minuchin, S. (1974). Families and family therapy. Cam- and interspousal functioning. Journal of Consulting and
bridge, MA: Harvard University Press. Clinical Psychology, 57, 39±46.
Minuchin, S. (1996). Interview. Family Therapy Networker, Soloman, J., Ott, J., & Roach, A. (1986). A survey of
20(November/December), 50±57. predoctoral psychology interns in marriage and family
Minuchin, S. & Fishman, C. (1981). Family therapy therapy. Journal of Marital and Family Therapy, 12,
techniques. Cambridge, MA: Harvard University Press. 269±280.
Moultrop, D. (1981). Towards an integrated model Stanton, M. D. (1975). Family therapy training: Academic
of family therapy. Clinical Social Work Journal, 9, and internship opportunities for psychologists. Family
111±125. Process, 14, 433±439.
Moultrop, D. J. (1989). Integration: A coming of age. Steinglass, P. (1992). Treatment of alcoholism. American
Contemporary Family Therapy, 8, 159±167. Association of Marital and Family Therapy Annual
Nichols, M. P. (1987). The self in the system: Expanding the Meeting, Miami, FL.
limits of psychotherapy. New York: Brunner-Mazel. Steinglass, P., Bennett, L. A., Wolin, S. J., & Reiss, D.
Nichols, W. C. (1995). Treating people in families. New (1987). The alcoholic family. New York: Basic Books.
York: Guilford Press. Stuart, R. (1980). Helping couples change. New York:
O'Hanlon W., & Weiner-Davis, M. (1989). In search of Guilford Press.
solutions. New York: Norton. Szapocznik, J., & Kurtines, W. M. (1989). Breakthroughs in
O'Leary, K. D., & Beach, R. H. (1990). Marital therapy: A family treatment. New York: Springer
viable treatment for depression and marital discord. Thibaut, J., & Kelley, H. H. (1959). The social psychology
American Journal of Psychiatry, 147, 183±186. of groups. New York: Wiley
Olson, D. H. (1986). Circumplex model VII: Validation Trepper, T. S., & Barrett, M. J. (1989). Systemic treatment
studies and FACES III. Family Process, 25, 337±351. of incest: A therapeutic handbook. New York: Brunner/
Patterson G. R. (1982). Coercive family process. Eugene, Mazel.
OR: Castalia. Von Bertalanffy, L. (1969). General systems theory: Essays
Patterson, G. R., & Chamberlain, P. (1992). A functional on its foundation and development. New York: George
analysis of resistance (A neobehavioral perspective). In Braziller.
H. Arkowitz (Ed.), Why don't people change? New Wachtel, E. (1992). An integrative approach to working
perspectives on resistance and noncomplicance. New with troubled children and their families. Journal of
York: Guilford Press. Psychotherapy Integration, 2, 207±224.
Piercy, F. P., & Frankel, B. R. (1989). The evolution of an Wachtel, E. F. (1995). Treating troubled children and their
integrative family therapy for substance abusing adoles- families. New York: Guilford Press.
cents. Journal of Family Psychology, 3, 5±21. Wachtel E. F., & Wachtel, P. L. (1995). Family dynamics in
Pinsof, W. M. (1983). Integrative problem-centered ther- individual psychotherapy. New York: Guilford Press.
apy: Toward the synthesis of family and individual Walsh, F. (Ed.) (1982). Normal Family Processes; A guide
psychotherapies. Journal of Marital and Family Therapy, to clinical strategies. New York: Guilford Press.
9, 19±35. Walsh, F. (Ed.) (1993) Normal family processes (2nd ed.).
Pinsof, W. & Catherall, D. (1986). The integrative New York: Guilford Press.
psychotherapy alliance. Journal of Marital and Family Watts-Jones, D. (1992). Cultural and integraive therapy
Therapy, 12, 137±152. issues in the treatment of a Jamaican woman with panic
Pinsof, W. (1995). Integrative problem centered therapy. disorder. Family Process, 31, 105±113.
New York: Basic Books. Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change:
Pinsof, W., & Wynne, L. (1995). Special Issue: The Principles of problem formation and problem resolution.
effectiveness of marital and family therapy. Journal of New York: Norton.
Marital and Family Therapy, 21, 339±610. Watzlawick, P., Beavin, P. and Jackson, D. (1967).
Reiner, P. (1997). Psychoanalytic approaches to super- Pragmatics of human communication. New York: Nor-
vising marriage and family therapy. In C. Storm & T. ton.
Todd (Eds.), The complete systemic supervisor. Boston: Whitaker, C. A. & Keith, D. V. (1981) Symbolic-
Allyn & Bacon. experiential family therapy. In A. S. Gurman & D. P.
Rolland, J. S. (1994). Families, illness and disability: An Kniskern (Eds.), Handbook of family therapy. New York:
integrative treatment model. New York: Basic Books. Brunner/Mazel.
Wiener, N. (1991). Cybernetics or control and communica- behavioral model of pediatric illness. Family Process, 32,
tion in the animal and in the machine. Cambridge, MA: 261±278.
MIT Press. Wright, L. M., & Leahey, M. (1994). Calgary family
Weiss, R. (1978). The conceptualization of marriage from a intervention model: One way to think about change.
behavioral perspective. In T. Paolino & B. McCrady. Journal of Marital and Family Therapy, 20, 381±396.
(Eds.), Marriage and marital therapy: Psychoanalytic, Wynne, L., McDaniel, S., & Weber T. (1986). Systems
behavioral, and systems theory perspectives. New York: consultation: A new perspective for family therapy. New
Brunner/Mazel. York: Guilford Press.
White, M., & Epston, D. (1990). Narrative means to Wynne, L. C., Ryckoff, I., Day, J., & Hirsch, S. I. (1958).
therapeutic ends. New York: Norton. Pseudomutuality in the family relationships of schizo-
Wood, B. L. Beyond the psychosomatic family: A bio- phrenics. Psychiatry, 20, 205±220.

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Comprehensive Clinical Psychology

Copyright © 2000 Elsevier Science Ltd. All rights reserved.

Comprehensive Clinical Psychology

Editors-in-Chief: Alan S. Bellack and Michel Hersen

Volume 2: Professional Issues

Volume 3: Research Methods

Volume 5: Children & Adolescents: Clinical Formulation & Treatment

Volume 6: Adults: Clinical Formulation & Treatment

Volume 7: Clinical Geropsychology

Volume 8: Health Psychology

Volume 9: Applications in Diverse Populations

Volume 10: Sociocultural and Individual Differences

Introduction to Comprehensive Clinical Psychology

Honorary International Editorial Advisory Board

Volume 2: Professional Issues

Volume 3: Research and Methods

Volume 5: Children & Adolescents: Clinical Formulation & Treatment

Volume 6: Adults: Clinical Formulation & Treatment

Volume 7: Clinical Geropsychology

Volume 8: Health Psychology

Volume 9: Applications in Diverse Populations

Volume 10: Sociocultural and Individual Differences

Comprehensive Clinical Psychology. Volume 1

Copyright © 2000 Elsevier Science Ltd. All rights reserved.

1.04 Contributions of Behavioral Genetics Research to Clinical Psychology, Pages 87-

1.05 Psychobiology, Pages 115-172, Niels Birbaumer Herta Flor

1.06 Fundamental Psychopharmacology, Pages 173-206, Frank A. Holloway Jessica M.

1.07 Animal Models of Psychopathology: Depression, Anxiety, Schizophrenia, Substance

1.08 Cultural Dimensions, Pages 233-260, Jan Br&#xf8;gger

1.09 Life-span Developmental Theories, Pages 261-296, Gisela Labouvie-Vief Manfred

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1.10 Social Psychological Foundations of Clinical Psychology, Pages 297-321, John H.

1.13 Learning Theory, Pages 391-421, Graham C. L. Davey

1.14 Psychodynamic Theory, Pages 423-447, Peter Fonagy

1.15 Phenomenological, Existential, and Humanistic Foundations for Psychology as a

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ALEXANDER, K. (United States International University, San Diego, CA, USA)

ANTHONY, J. C. (Johns Hopkins University, Baltimore, MD, USA)

BIRBAUMER N. (University of T•ngen, Germany)

BR•GER, J. (Norwegian University of Science and Technology, Trondheim, Norway)

COLLINS, F. L. JR. (Oklahoma State University, Stillwater, OK, USA)

DAVEY, G. C. L. (University of Sussex, UK)

DEATER-DECKARD, K. (Institute of Psychiatry, University of London, UK)

DIEHL, M. (Colorado State University, Colorado Springs, CO, USA)

FISCHER, C. T. (Duquesne University, Pittsburgh, PA, USA)

FLOR, H. (Humboldt-University, Berlin, Germany)

FONAGY, P. (University College London, UK)

GURMAN, A. S. (University of Wisconsin Medical School, Madison, WI, USA)

HARVEY, J. H. (University of Iowa, Iowa City, IA, USA)

HOFFMAN, R. (University of Minnesota, Duluth School of Medicine, Duluth, MN, USA)

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LABOUVIE-VIEF, G. (Wayne State University, Detroit, MI, USA)

OMARZU, J. (University of Iowa, Iowa City, IA, USA)

1.08 Cultural Dimensions, Pages 233-260, Jan Brøgger