(eBook PDF) Essentials of Abnormal

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 About the Authors

than 1,000 mental health professionals who participated in current research program focuses on the nature and treat-
the creation of DSM-IV, and he continued on as an Advisor ment of anxiety and related emotional disorders.
to the DSM-5 task force. He also chaired the APA task force At leisure he plays golf, skis, and retreats to his home
on Psychological Intervention Guidelines, which created a on Nantucket Island, where he loves to write, walk on the
template for the creation of clinical practice guidelines. His beach, and visit with his island friends.

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 Stefan G. Hofmann
Stefan G. Hofmann is an psychotherapy and to predict treatment outcome using
international expert on psy- neuroscience methods.
chotherapy for emotional He has won many prestigious professional awards,
disorders. He is a professor including the Aaron T. Beck Award for Significant and
of psychology at Boston Uni- Enduring Contributions to the Field of Cognitive Therapy
versity, where he directs the by the Academy of Cognitive Therapy. He is a fellow of the
Psychotherapy and Emo- American Psychological Association and the Association for
tion Research Laboratory. Psychological Science and was president of various national
He was born in a little town and international professional societies, including the Asso-
near Stuttgart in Germany, ciation for Behavioral and Cognitive Therapies and the Inter-
which may explain his thick national Association for Cognitive Psychotherapy. He was an
German accent. He studied psychology at the University of advisor to the DSM-5 Development Process and a member
Marburg, Germany, where he received his B.A., M.S., and of the DSM-5 Anxiety Disorder Sub-Work Group. As part of
Ph.D. A brief dissertation fellowship to spend some time this, he participated in the discussions about the revisions of
at Stanford University turned into a longer research career the DSM-5 criteria for various anxiety disorders, especially
in the United States. He eventually moved to the United social anxiety disorder, panic disorder, and agoraphobia.
States in 1994 to join Dr. Barlow’s team at the University at Dr. Hofmann is a Thomson Reuters’ Highly Cited Researcher.
Albany–State University of New York, and has been living Dr. Hofmann has been the editor in chief of Cognitive
in Boston since 1996. Therapy and Research and is also the Associate Editor of
Dr. Hofmann has an actively funded research program Clinical Psychological Science. He has published more than
studying various aspects of emotional disorders with a par- 300 peer-reviewed journal articles and 15 books, includ-
ticular emphasis on anxiety disorders, cognitive behavio- ing An Introduction of Modern CBT (Wiley-Blackwell) and
ral therapy, and neuroscience. More recently, he has been Emotion in Therapy (Guilford Press).
interested in mindfulness approaches, such as yoga and At leisure, he enjoys playing with his sons. He likes trav-
meditation practices, as treatment strategies of emotional eling to immerse himself into new cultures, make new
disorders. Furthermore, he has been one of the leaders in friends, and reconnect with old ones. When time permits,
translational research methods to enhance the efficacy of he occasionally gets out his flute.

vii

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 Brief Contents

1 Abnormal Behavior in Historical Context 2

2 An Integrative Approach to Psychopathology 32

3 Clinical Assessment, Diagnosis, and Research in Psychopathology 69

4 Anxiety Disorders 117

5 Somatoform and Dissociative Disorders 172

6 Mood Disorders and Suicide 200

7 Physical Disorders and Health Psychology 248

8 Eating and Sleep Disorders 282

9 Sexual and Gender Identity Disorders 326

10 Substance-Related and Impulse-Control Disorders 366

11 Personality Disorders 408

12 Schizophrenia and Other Psychotic Disorders 444

13 Developmental and Cognitive Disorders 480

14 Mental Health Services: Legal and Ethical Issues 528

ix

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 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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 Contents

Preface xix

1 Abnormal Behavior in Historical Context 2

Understanding Psychopathology 3 The 19th Century 12
J udy: The Girl Who Fainted at the Sight of
■■ ■■Discussing Diversity: Biological Explanations for Psychopathology
Blood 3 in Women: A Brief History of Hysteria 13
What Is a Psychological Disorder? 4 The Development of Biological Treatments 14
The Science of Psychopathology 6 Consequences of the Biological Tradition 14
Historical Conceptions of Abnormal Behavior 8 The Psychological Tradition 15
The Supernatural Tradition 9 Moral Therapy 15
Demons and Witches 9 Asylum Reform and the Decline of Moral Therapy 16
Stress and Melancholy 9 Psychoanalytic Theory 16
■■ Charles VI: The Mad King 10 Humanistic Theory 22
Treatments for Possession 10 The Behavioral Model 22
Mass Hysteria 10 An Integrative Approach 25
Modern Mass Hysteria 10
The Moon and the Stars 11 Summary 26
Comments 11 Key Terms 27
The Biological Tradition 11 Answers to Concept Checks 28
Hippocrates and Galen 11
Chapter Quiz 28

2 An Integrative Approach to Psychopathology 32

One-Dimensional versus The Peripheral Nervous System 45
Multidimensional Models
34 Neurotransmitters 47
What Caused Judy’s Phobia? 34 Implications for Psychopathology 51
Outcome and Comments 35 Psychosocial Influences on Brain Structure and
Function 52
Genetic Contributions to Psychopathology 36
Interactions of Psychosocial Factors and Neurotransmitter
The Nature of Genes 36
Systems 53
New Developments in the Study of Genes and
Psychosocial Effects on the Development of Brain Structure
Behavior 37
and Function 54
The Interaction of Genes and the Environment 38
Epigenetics and the Nongenomic “Inheritance” Behavioral and Cognitive Science 55
of Behavior 40 Conditioning and Cognitive Processes 55
Learned Helplessness 55
Neuroscience and Its Contributions to
Psychopathology 41 Social Learning 56
The Central Nervous System 41 Prepared Learning 57
The Structure of the Brain 44 Cognitive Science and the Unconscious 57

xi

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Emotions 58 ■■Discussing Diversity: Fear: Evolutionary and Social
The Physiology and Purpose of Fear 58 Influences 63
Emotional Phenomena 59 Global Incidence of Psychological Disorders 64
The Components of Emotion 59 Life-Span Development 64
Anger and Your Heart 60
Emotions and Psychopathology 61
Conclusions 65

Cultural, Social, and Interpersonal Summary 66

Factors 61 Key Terms 67
Voodoo and the Evil Eye 61
Answers to Concept Checks 68
Gender 62
Social Effects on Health and Behavior 62 Chapter Quiz 68

3  linical Assessment, Diagnosis, and Research

C
in Psychopathology 69
Assessing Psychological Disorders 70 Types of Research Methods 95
■■ Frank: Young, Serious, and Anxious 70 Studying Individual Cases 95
Key Concepts in Assessment 71 Research by Correlation 96
The Clinical Interview 72 Research by Experiment 98
Physical Examination 74 Single-Case Experimental Designs 100
Behavioral Assessment 75 Genetics and Behavior across Time and
Psychological Testing 76 Cultures 104
Neuropsychological Testing 81 Studying Genetics 104
Neuroimaging: Pictures of the Brain 81 Studying Behavior over Time 106
Psychophysiological Assessment 82 Studying Behavior across Cultures 108
Diagnosing Psychological Disorders 84 The Power of a Program of Research 109
Classification Issues 85 Replication 110
Diagnosis before 1980 87 ■■ Discussing Diversity: Do Psychological Disorders
DSM-III and DSM-III-R 87 Look the Same across Countries? 111
DSM-IV and DSM-IV-TR 88 Research Ethics 111
DSM-5 88
Beyond DSM-5: Dimensions and Spectra 90 Summary 113

Conducting Research in Psychopathology 92 Key Terms 114

Basic Components of a Research Study 92 Answers to Concept Checks 115

Statistical versus Clinical Significance 94 Chapter Quiz 115
The “Average” Client 95

4  nxiety, Trauma- and Stressor-Related, and Obsessive-Compulsive

A
and Related Disorders 117
 he Complexity of Anxiety
T Generalized Anxiety Disorder 124
Disorders 118 ■■ Irene: Ruled by Worry 124
Anxiety, Fear, and Panic: Some Definitions 118 Clinical Description 125
■■ Gretchen: Attacked by Panic 119 Statistics 125
Causes of Anxiety and Related Disorders 120 Causes 126
■■ Discussing Diversity: Cultural Influences on Anxiety 121 Treatment 127
Comorbidity of Anxiety and Related Disorders 123
Panic Disorder and Agoraphobia 128
Anxiety Disorders 124 ■■ Mrs. M: Self-Imprisoned 129

xii • Contents

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 Clinical Description 129 Other Trauma- and Stressor-Related
Statistics 130 Disorders 152
Nocturnal Panic 131 Obsessive-Compulsive and Related Disorders 153
Causes 132
Treatment 132 Obsessive-Compulsive Disorder 153
Clinical Description 154
Specific Phobia 135 ■■ Richard: Enslaved by Ritual 154
Clinical Description 135 Statistics 155
Statistics 137 Causes 156
Causes 138 Treatment 157
Treatment 140
Body Dysmorphic Disorder 158
Social Anxiety Disorder (Social Phobia) 141 ■■ Jim: Ashamed to Be Seen 158
■■ Billy: Too Shy 141
Clinical Description 159
Clinical Description 141 Statistics 159
■■ Chuck Knoblauch: Star Players? 141
Causes and Treatment 160
Statistics 142
Causes 142 Other Obsessive-Compulsive and Related
Treatment 144 Disorders 161
Selective Mutism 145 Hoarding Disorder 161
Trichotillomania (Hair Pulling Disorder) and Excoriation
Trauma and Stressor-Related Disorders 146 (Skin Picking Disorder) 164
Posttraumatic Stress Disorder (PTSD) 146 Summary 164
Clinical Description 146
■■ The Joneses: One Victim, Many Traumas 147
Key Terms 167
Statistics 148 Answers to Concept Checks 168
Causes 149 Chapter Quiz 168
Treatment 151

5 S omatic Symptom and Related Disorders and Dissociative

Disorders 172
 omatic Symptom and Related
S Dissociative Disorders 184
Disorders 174 Depersonalization-Derealization Disorder 185
Somatic Symptom Disorder 174 ■■ Bonnie: Dancing Away from Herself 185
■■ Linda: Full-Time Patient 174 Dissociative Amnesia 185
■■ The Medical Student: Temporary Pain 175 ■■ The Woman Who Lost Her Memory 186
Illness Anxiety Disorder 175 ■■ Jeffrey: A Troubled Trip 186
■■ Gail: Invisibly Ill 175 Dissociative Identity Disorder 188
■■ Discussing Diversity: Somatic Symptoms around the ■■ Jonah: Bewildering Blackouts 188
World 179 ■■ Kenneth: The Hillside Strangler 189
Psychological Factors Affecting Medical Conditions 179
Summary 196
Conversion Disorder (Functional Neurological Symptom
Disorder) 180 Key Terms 196
■■ Eloise: Unlearning Walking 180 Answers to Concept Checks 196
■■ Celia: Seeing Through Blindness 182
Chapter Quiz 197

Contents • xiii

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 6 Mood Disorders and Suicide 200
Understanding and Defining Mood Treatment of Mood Disorders 227
Disorders 201 Medications 227
■■ Katie: Weathering Depression 201 Electroconvulsive Therapy and Transcranial Magnetic
An Overview of Depression and Mania 202 Stimulation 230
The Structure of Mood Disorders 203 Psychological Treatments for Depression 230
Depressive Disorders 204 ■■ Beck and Irene: A Dialogue 231
■■ Jack: A Life Kept Down 205 Combined Treatments for Depression 233
From Grief to Depression 206 Preventing Relapse of Depression 233
Other Depressive Disorders 207 Psychological Treatments for Bipolar
Disruptive Mood Dysregulation Disorder 208 Disorder 234
Bipolar Disorders 209 ■■ Katie: The Triumph of the Self 235

■■ Jane: Funny, Smart, and Desperate 209

Suicide 236
■■ Billy: The World’s Best at Everything 210
Statistics 236
Prevalence of Mood Disorders 212 Causes 237
Prevalence in Children, Adolescents, and Older ■■ Discussing Diversity: Suicide Behaviors around
Adults 212 the World 238
Life Span Developmental Influences on Mood Risk Factors 238
Disorders 213 Is Suicide Contagious? 240
Across Cultures 215 Treatment 240
Causes of Mood Disorders 215 Summary 243
Biological Dimensions 216 Key Terms 244
Psychological Dimensions 219
■■ Katie: No Easy Transitions 221 Answers to Concept Checks 244
Social and Cultural Dimensions 223 Chapter Quiz 244
An Integrative Theory 225

7 Physical Disorders and Health Psychology 248

Psychological and Social Factors that ■■ Discussing Diversity: The Influence of Culture on Individual
Influence Health 249 Health and Development: Female Reproduction around the
Health and Health-Related Behavior 250 World 267
The Nature of Stress 251 Psychosocial Treatment of Physical Disorders 270
The Physiology of Stress 251 Biofeedback 271
Contributions to the Stress Response 252 Relaxation and Meditation 272
Stress, Anxiety, Depression, and Excitement 253 A Comprehensive Stress- and Pain-Reduction Program 272
Stress and the Immune Response 254 ■■ Sally: Improving Her Perception 272
How the Immune System Works 255 Drugs and Stress-Reduction Programs 273
Psychosocial Effects on Physical Denial as a Means of Coping 274
Disorders 257 Modifying Behaviors to Promote Health 274
AIDS 257 Summary 277
Cancer 258
Cardiovascular Problems 260 Key Terms 278
■■ John: The Human Volcano 260 Answers to Concept Checks 278
Chronic Pain 264
Chapter Quiz 278

xiv • Contents

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 8 Eating and Sleep–Wake Disorders 282
Major Types of Eating Causes 304
Disorders 283 Treatment 304
Bulimia Nervosa 284
Sleep–Wake Disorders: The Major
■■ Phoebe: Apparently Perfect 284
Dyssomnias 306
Anorexia Nervosa 286 An Overview of Sleep–Wake Disorders 306
■■ Julie: The Thinner, the Better 286
Insomnia Disorder 308
Binge-Eating Disorder 288 ■■ Sonja: School on Her Mind 308
Statistics 289 Hypersomnolence Disorders 311
■■ Discussing Diversity: Cultural Influences on Eating ■■ Ann: Sleeping in Public 311
Disorders 291
Narcolepsy 312
Causes of Eating Disorders 292 Breathing-Related Sleep Disorders 312
Social Dimensions 292 Circadian Rhythm Sleep Disorder 313
■■ Phoebe: Dancing to Destruction 295
Treatment of Sleep Disorders 315
Biological Dimensions 295
Medical Treatments 315
Psychological Dimensions 296
Environmental Treatments 315
An Integrative Model 297
Psychological Treatments 316
Treatment of Eating Disorders 298 Preventing Sleep Disorders 317
Drug Treatments 298 Parasomnias and Their Treatment 317
Psychological Treatments 298
Summary 320
■■ Phoebe: Taking Control 299
Preventing Eating Disorders 301 Key Terms 321
Obesity 302 Answers to Concept Checks 322
Statistics 302 Chapter Quiz 322
Disordered Eating Patterns in Cases of Obesity 303

9 S exual Dysfunctions, Paraphilic Disorders, and Gender

Dysphoria 326
What Is Normal Sexuality? 327 Paraphilic Disorders: Clinical Descriptions 345
Gender Differences 329 Fetishistic Disorder 346
Cultural Differences 330 Voyeuristic and Exhibitionistic Disorders 346
The Development of Sexual Orientation 330 ■■ Robert: Outside the Curtains 346
Transvestic Disorder 346
An Overview of Sexual Dysfunctions 332
■■ Mr. M: Strong Man in a Dress 346
Sexual Desire Disorders 333
■■ Mr. and Mrs. C: Getting Started 334
Sexual Sadism and Sexual Masochism
Disorders 347
Sexual Arousal Disorders 334
Pedophilic Disorder and Incest 348
■■ Bill: Long Marriage, New Problem 334
■■ Tony: More and Less a Father 349
Orgasm Disorders 335
Causes of Paraphilic Disorders 349
■■ Greta and Will: Loving Disunion 336
■■ Robert: Revenge on Repression 350
■■ Gary: Running Scared 336
■■ Tony: Trained Too Young 350
Sexual Pain Disorder 337
■■ Jill: Sex and Spasms 337 Assessing and Treating Paraphilic
Assessing Sexual Behavior 338 Disorders 351
Psychological Treatment 351
Causes and Treatment of Sexual Dysfunction 339
■■ Tony: Imagining the Worst 352
Causes of Sexual Dysfunction 339
Drug Treatments 353
Treatment of Sexual Dysfunction 342
Summary 353
■■ Carl: Never Too Late 342

Contents • xv

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Gender Dysphoria 354 Treatment 358
■■ Joe: Trapped in the Wrong Body 354 Summary 360
Defining Gender Dysphoria 355
■■ Discussing Diversity: Alternative or Mixed Gender Identity 356 Key Terms 362
Causes 356 Answers to Concept Checks 362
■■ Bruce/Brenda: Gender and Biology 356
Chapter Quiz 363

10 S ubstance-Related, Addictive, and Impulse-Control

Disorders 366
 erspectives on Substance-Related and
P Cognitive Dimensions 390
Addictive Disorders 367 Social Dimensions 390
■■ Danny: Comorbid Substance Use Disorders 368 Cultural Dimensions 391
Levels of Involvement 368 An Integrative Model 391
Diagnostic Issues 370 ■■ Discussing Diversity: Alcohol, Drugs, and Sex 392
Depressants 371 Treatment of Substance-Related Disorders 393
Alcohol-Related Disorders 371 Biological Treatments 394
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders 375 Psychosocial Treatments 395
Stimulants 377 Prevention 397
Stimulant-Related Disorders 377 Gambling Disorder 398
Tobacco-Related Disorders 380
Impulse-Control Disorders 399
Caffeine-Related Disorders 381
Intermittent Explosive Disorder 400
Opioid-Related Disorders 382 Kleptomania 400
Cannabis-Related Disorders 383 Pyromania 400

Hallucinogen-Related Disorders 385 Summary 402

Other Drugs of Abuse 386 Key Terms 403

Causes of Substance-Related Disorders 387 Answers to Concept Checks 404

Biological Dimensions 387 Chapter Quiz 404
Psychological Dimensions 389

11 Personality Disorders 408

An Overview of Personality ■■ Mr. Z: All on His Own 416
Disorders 409 Schizotypal Personality Disorder 418
Aspects of Personality Disorders 409 ■■ Mr. S: All on His Own 418
Categorical and Dimensional Models 409
Cluster B Personality Disorders 420
Personality Disorder Clusters 410
Antisocial Personality Disorder 420
Statistics and Development 410
■■ Ryan: The Thrill Seeker 420
Gender Differences 412
Borderline Personality Disorder 426
Comorbidity 413
■■ Claire: A Stranger Among Us 426
Personality Disorders under Study 414
■■ Discussing Diversity: Gender and
Cluster A Personality Disorders 415 Personality Disorder 430
Paranoid Personality Disorder 415 Histrionic Personality Disorder 430
■■ Jake: Research Victim 415 ■■ Pat: Always Onstage 430
Schizoid Personality Disorder 416 Narcissistic Personality Disorder 432

xvi • Contents

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 ■■ Willie: It’s All About Me 432 ■■ Daniel: Getting It Exactly Right 436
Cluster C Personality Disorders 434 Summary 438
Avoidant Personality Disorder 434 Key Terms 439
■■ Jane: Not Worth Noticing 434
Dependent Personality Disorder 435 Answers to Concept Checks 439
■■ Karen: Whatever You Say 435 Chapter Quiz 440
Obsessive-Compulsive Personality Disorder 436

12 Schizophrenia Spectrum and Other Psychotic Disorders 444

Perspectives on Schizophrenia 445 Genetic Influences 458
Early Figures in Diagnosing Schizophrenia 445 Neurobiological Influences 461
Identifying Symptoms 446 Psychological and Social Influences 464
■■ Arthur: Saving the Children 446
Treatment of Schizophrenia 467
Clinical Description, Symptoms, and Subtypes 447 Biological Interventions 467
Positive Symptoms 448 Psychosocial Interventions 469
■■ David: Missing Uncle Bill 449 Treatment across Cultures 471
Negative Symptoms 450 Prevention 472
Disorganized Symptoms 451 ■■ Discussing Diversity: Treatment and Understanding of Psychosis
Historic Schizophrenia Subtypes 452 across Cultures 472
Other Psychotic Disorders 453 Summary 473
Prevalence and Causes of Schizophrenia 456 Key Terms 475
Statistics 456
Development 457 Answers to Concept Checks 475
Cultural Factors 457 Chapter Quiz 476

13 Neurodevelopmental and Neurocognitive Disorders 480

Overview of Neurodevelopmental Causes: Biological Dimensions 495
Disorders 481 Treatment of Autism Spectrum Disorder 496
Attention-Deficit/Hyperactivity Disorder 483 Psychosocial Treatments 496
■■ Danny: The Boy Who Couldn’t Sit Still 483 Intellectual Disability (Intellectual Developmental
Clinical Description 484 Disorder) 498
■■ Discussing Diversity: ADHD across Age and Gender 484 ■■ James: Up to the Challenge 498
Statistics 485 Clinical Description 499
Causes 486 Statistics 500
Treatment of ADHD 487 Causes 500
Treatment of Intellectual Disability 503
Specific Learning Disorder 488
■■ Alice: Taking a Learning Disorder to College 488 Prevention of Neurodevelopmental Disorders 504
Clinical Description 489 Overview of Neurocognitive Disorders 505
Statistics 489
Causes 490 Delirium 505
Treatment of Learning Disorders 491 ■■ Mr. J: Sudden Distress 505
Clinical Description and Statistics 506
Autism Spectrum Disorder 492 Causes 506
Clinical Description 492 Treatment 507
■■ Amy: In Her Own World 492
Prevention 507
Statistics 494
Causes: Psychological and Social Dimensions 495 Major and Mild Neurocognitive Disorders 508

Contents • xvii

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 ■■ Pat Summitt: Grit and Determination 509 Causes of Neurocognitive Disorder 515
Clinical Description and Statistics 509 Treatment 517
Neurocognitive Disorder Due to Alzheimer’s Disease 511 Prevention 520
Vascular Neurocognitive Disorder 512 Summary 521
Other Medical Conditions That Cause Neurocognitive
Disorder 512 Key Terms 522
Substance/Medication-Induced Neurocognitive Answers to Concept Checks 523
Disorder 515
Chapter Quiz 523

14 Mental Health Services: Legal and Ethical Issues 528

■■ Arthur: A Family’s Dilemma 529 Patients’ Rights and Clinical Practice
Guidelines 541
Civil Commitment 529
The Right to Treatment 541
Criteria for Civil Commitment 530
The Right to Refuse Treatment 541
Procedural Changes Affecting Civil Commitment 532
The Rights of Research Participants 542
■■ Joyce Brown: Homeless but Not Helpless 533
■■ Greg Aller: Concerned About Rights 542
■■ Discussing Diversity: Mental Illness, Homelessness,
Evidence-Based Practice and Clinical Practice
and Culture 534
Guidelines 543
An Overview of Civil Commitment 535
Summary 545
Criminal Commitment 535
The Insanity Defense 535 Key Terms 546
Reactions to the Insanity Defense 537 Answers to Concept Checks 546
Therapeutic Jurisprudence 539
Competence to Stand Trial 539 Chapter Quiz 546
Duty to Warn 539
Mental Health Professionals as Expert Witnesses 540

Appendix A Answers to Chapter Quizzes A-1

Glossary G-1
References R-1
Name Index I-1
Subject Index I-22

xviii • Contents

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 Preface

Science is a constantly evolving field, but every now and the chapter, along with new studies on the seeming ability
then something groundbreaking occurs that alters our way of extreme environments to largely override the effects of
of thinking. For example, evolutionary biologists, who long genetic contributions. Studies elucidating the mechanisms
assumed that the process of evolution was gradual, sud- of epigenetics or specifically how environmental events
denly had to adjust to evidence that says evolution happens influence gene expression are described.
in fits and starts in response to such cataclysmic environ- These results confirm the integrative approach in this
mental events as meteor impacts. Similarly, geology has book: Psychological disorders cannot be explained by
been revolutionized by the discovery of plate tectonics. genetic or environmental factors alone but rather arise
Until recently, the science of psychopathology had been from their interaction. We now understand that psycho-
compartmentalized, with psychopathologists examining logical and social factors directly affect neurotransmitter
the separate effects of psychological, biological, and social function and even genetic expression. Similarly, we cannot
influences. This approach is still reflected in popular media study behavioral, cognitive, or emotional processes without
accounts that describe, for example, a newly discovered appreciating the contribution of biological and social fac-
gene, a biological dysfunction (chemical imbalance), or tors to psychological and psychopathological expression.
early childhood experiences as a “cause” of a psychological Instead of compartmentalizing psychopathology, we use a
disorder. This way of thinking still dominates discussions more accessible approach that accurately reflects the cur-
of causality and treatment in some psychology textbooks: rent state of our clinical science.
“The psychoanalytic views of this disorder are . . . ,” “the As colleagues, you are aware that we understand some
biological views are . . . ,” and, often in a separate chapter, disorders better than others. But we hope you will share
“psychoanalytic treatment approaches for this disorder are our excitement in conveying to students both what we cur-
. . . ,” “cognitive behavioral treatment approaches are . . . ,” rently know about the causes and treatments of psychopa-
or “biological treatment approaches are . . .” thology and how far we have yet to go in understanding
In the first edition of this text, we tried to do some- these complex interactions.
thing very different. We thought the field had advanced to
the point that it was ready for an integrative approach in
which the intricate interactions of biological, psychologi-
cal, and social factors are explicated in as clear and con-
Integrative Approach
vincing a manner as possible. Recent explosive advances in As noted earlier, the first edition of Essentials of Abnor-
knowledge confirm this approach as the only viable way of mal Psychology pioneered a new generation of abnormal
understanding psychopathology. To take just two examples, psychology textbooks, which offer an integrative and mul-
Chapter 2 contains a description of a study demonstrating tidimensional perspective. (We acknowledge such one-­
that stressful life events can lead to depression but that not dimensional approaches as biological, psychosocial, and
everyone shows this response. Rather, stress is more likely supernatural as historic perspectives on our field.) We
to cause depression in individuals who already carry a par- include substantial current evidence of the reciprocal influ-
ticular gene that influences serotonin at the brain synapses. ences of biology and behavior and of psychological and
Similarly, Chapter 7 describes how the pain of social rejec- social influences on biology. Our examples hold students’
tion activates the same neural mechanisms in the brain attention; for example, we discuss genetic contributions to
as physical pain. In addition, the entire section on genet- divorce, the effects of early social and behavioral experi-
ics has been rewritten to highlight the new emphasis on ence on later brain function and structure, new informa-
gene–environment interaction, along with recent thinking tion on the relation of social networks to the common cold,
from leading behavioral geneticists that the goal of basing and new data on psychosocial treatments for cancer. We
the classification of psychological disorders on the firm note that in the phenomenon of implicit memory and blind
foundation of genetics is fundamentally flawed. Descrip- sight, which may have parallels in dissociative experiences,
tions of the emerging field of epigenetics, or the influence psychological science verifies the existence of the uncon-
of the environment on gene expression, is also woven into scious (although it does not much resemble the seething

xix

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caldron of conflicts envisioned by Freud). We present new Disorders in Detail
evidence confirming the effects of psychological treatments
We cover the major psychological disorders in 10 chap-
on neurotransmitter flow and brain function. We acknowl-
ters, focusing on three broad categories: clinical descrip-
edge the often-neglected area of emotion theory for its rich
tion, causal factors, and treatment and outcomes. We pay
contributions to psychopathology (e.g., the effects of anger
considerable attention to case studies and DSM-5 criteria,
on cardiovascular disease). We weave scientific findings
and we include statistical data, such as prevalence and
from the study of emotions together with behavioral, bio-
incidence rates, sex ratio, age of onset, and the general
logical, cognitive, and social discoveries to create an inte-
course or pattern for the disorder as a whole. Since several
grated tapestry of psychopathology.
of us were appointed Advisors to the DSM-5 task force, we
are able to include the reasons for changes as well as the
Life-Span Developmental Influences
changes themselves. Throughout, we explore how biolog-
No modern view of abnormal psychology can ignore the ical, psychological, and social dimensions may interact to
importance of life-span developmental factors in the man- cause a particular disorder. Finally, by covering treatment
ifestation and treatment of psychopathology. Studies high- and outcomes within the context of specific disorders, we
lighting developmental windows for the influence of the provide a realistic sense of clinical practice.
environment on gene expression are explained. Accord-
ingly, although we include a chapter describing Neurode- Treatment
velopmental Disorders (Chapter 13), we consider the
importance of development throughout the text; we dis- One of the best-received innovations in the first seven edi-
cuss childhood and geriatric anxiety, for example, in the tions was our strategy of discussing treatments in the same
context of the Anxiety, Trauma- and Stressor-Related, and chapter as the disorders themselves instead of in a separate
­Obsessive-Compulsive and Related Disorders (Chapter 4). chapter, an approach that is supported by the development
This system of organization, which is for the most part con- of specific psychosocial and pharmacological treatment
sistent with DSM-5, helps students appreciate the need to procedures for specific disorders. We have retained this
study each disorder from childhood through adulthood and integrative format and have improved upon it, and we
old age. We note findings on developmental considerations include treatment procedures in the key terms and glossary.
in separate sections of each disorder chapter and, as appro-
priate, discuss how specific developmental factors affect Legal and Ethical Issues
causation and treatment. In our closing chapter, we integrate many of the approaches
and themes that have been discussed throughout the text.
Scientist–Practitioner Approach We include case studies of people who have been involved
We go to some lengths to explain why the scientist–­ directly with many legal and ethical issues and with the
practitioner approach to psychopathology is both prac- delivery of mental health services. We also provide a histor-
tical and ideal. Like most of our colleagues, we view this ical context for current perspectives so students will under-
as something more than simple awareness of how sci- stand the effects of social and cultural influences on legal
entific findings apply to psychopathology. We show how and ethical issues.
every c­ linician contributes to general scientific knowledge
through astute and systematic clinical observations, func- Diversity
tional analyses of individual case studies, and systematic Issues of culture and gender are integral to the study of
observations of series of cases in clinical settings. For psychopathology. Throughout the text, we describe current
example, we explain how information on dissociative phe- thinking about which aspects of the disorders are culturally
nomena provided by early psychoanalytic theorists remains specific and which are universal, and about the strong and
relevant today. We also describe the formal methods used sometimes puzzling effects of gender roles. This is accom-
by scientist–practitioners, showing how abstract research plished both in the narrative and in “Discussing Diversity”
designs are actually implemented in research programs. boxes throughout the disorders chapters. For instance,
we discuss the current information on such topics as the
Clinical Cases of Real People gender imbalance in depression, how panic disorders are
We have enriched the book with authentic clinical histories expressed differently in various Asian cultures, the ethnic
to illustrate scientific findings on the causes and treatment differences in eating disorders, treatment of schizophrenia
of psychopathology. We have run active clinics for years, so across cultures, and the diagnostic differences of attention
95% of the cases are from our own files, and they provide a deficit/hyperactivity disorder (ADHD) in boys and girls.
fascinating frame of reference for the findings we describe. Clearly, our field will grow in depth and detail as these
The beginnings of most chapters include a case description, subjects and others become standard research topics. For
and most of the discussion of the latest theory and research example, why do some disorders overwhelmingly affect
is related to these very human cases. females and others appear predominantly in males? And

xx • Preface

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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
why does this apportionment sometimes change from one Chapter 3, Clinical Assessment, Diagnosis, and Research
culture to another? In answering questions like these, we in Psychopathology now presents references to “intellectual
adhere closely to science, emphasizing that gender and cul- disability” instead of “mental retardation” to be consistent
ture are each one dimension among several that constitute with DSM-5 and changes within the field; (a new discus-
psychopathology. sion about how information from the MMPI-2—although
informative—does not necessarily change how clients are
treated and may not improve their outcomes;) a descrip-
New to This Edition tion of the organization and structure of DSM-5 along with
major changes from DSM-IV; a description of methods
A Thorough Update to coordinate the development of DSM-5 with the forth-
This exciting field moves at a rapid pace, and we take coming ICD 11; and a description of likely directions of
particular pride in how our book reflects the most recent research as we begin to head toward DSM-6. In addition, a
developments. Therefore, once again, every chapter has new example of how behavioral scientists develop research
been carefully revised to reflect the latest research studies hypotheses is presented and a new example of longitudi-
on psychological disorders. Hundreds of new references nal designs which look at how the use of spanking predicts
from 2015 to 2017 (and some still “in press”) appear for the later behavior problems in children (Gershoff, Lansford,
first time in this edition, and some of the information they Sexton, Davis-Kean, & Sameroff, 2012).
contain stuns the imagination. Non-essential material has Chapter 4, entitled Anxiety, Trauma- and Stressor-­
been eliminated, some new headings have been added, and Related, and Obsessive-Compulsive and Related Disor-
DSM-5 criteria are included in their entirety as tables in the ders, is organized according to the three major groups of
appropriate disorder chapters. disorders: anxiety disorders, trauma- and stressor-related
A n x i e t y, Tr a u m a - a n d S t r e s s o r- R e l a t e d , a n d disorders, and obsessive-compulsive and related disorders.
­Obsessive-Compulsive and Related Disorders (Chapter 4), Two disorders new to DSM-5 (separation anxiety disorder
Mood Disorders and Suicide (Chapter 6), Physical Disor- and selective mutism) are presented, and the Trauma- and
ders and Health Psychology (Chapter 7), Eating and Sleep– Stressor-Related Disorders section includes not only post-
Wake Disorders (Chapter 8), Substance-Related, Addictive, traumatic stress disorder and acute stress disorder but also
and Impulse-Control Disorders (Chapter 10), Schizophre- adjustment disorder and attachment disorders. The final
nia Spectrum and Other Psychotic Disorders (Chapter 12), new grouping, Obsessive-Compulsive and Related Disor-
and Neurodevelopmental Neurocognitive Disorders (Chap- ders, includes not only obsessive-compulsive disorder but
ter 13) have been the most heavily revised to reflect new also body dysmorphic disorder, hoarding disorder, and
research, but all chapters have been significantly updated finally trichotillomania (hair pulling disorder) and excoria-
and freshened. tion (skin picking disorder). Some of the revisions to Chap-
Chapter 1, Abnormal Behavior in Historical Context, fea- ter 4 include the following:
tures updated nomenclature to reflect new titles in DSM-5,
■■ Updated information about the neuroscience and genet-
updated descriptions of research on defense mechanisms,
ics of fear and anxiety;
and fuller and deeper descriptions of the historical devel-
■■ Updated information on the relationship of anxiety and
opment of psychodynamic and psychoanalytic approaches.
related disorders to suicide;
Chapter 2, An Integrative Approach to Psychopa-
■■ Updated information on the influence of personality and
thology, includes an updated discussion of develop-
culture on the expression of anxiety;
ments in the study of genes and behavior with a focus on
■■ Updated generalized anxiety disorder discussion, espe-
­gene–­environment interaction; new data illustrating the
cially about newer treatment approaches;
gene–environment correlation model; new studies illus-
■■ Updated information on description, etiology, and
trating the psychosocial influence on the development of
treatment for specific phobia, social anxiety disorder,
brain structure and function in general and on neurotrans-
and posttraumatic stress disorder.
mitter systems specifically; updated, revised, and refreshed
sections on behavioral and cognitive science including new The grouping of disorders in Chapter 5, titled Somatic
studies illustrating the influence of positive psychology on Symptom and Related Disorders and Dissociative Disor-
physical health and longevity; new studies supporting the ders, reflects a major overarching change, specifically for
strong influence of emotions, specifically anger, on cardi- somatic symptom disorder, illness anxiety disorder (for-
ovascular health; new studies illustrating the influence of merly known as hypochondriasis), and psychological fac-
gender on the presentation and treatment of psychopathol- tors affecting medical conditions. The chapter discusses the
ogy; a variety of powerful new studies confirming strong differences between these overlapping disorders and pro-
social effects on health and behavior; and new studies vides a summary of the causes and treatment approaches of
confirming the puzzling “drift” phenomenon resulting in a these problems. In addition, Chapter 5 now has an updated
higher prevalence of schizophrenia among individuals liv- discussion on the false memory debate related to trauma in
ing in urban areas. individuals with dissociative identity disorder.

Preface • xxi

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
 Chapter 6, Mood Disorders and Suicide, provides an to reflect the fact that both paraphilic disorders and gen-
updated discussion on the psychopathology and treatment der dysphoria are separate chapters in DSM-5, and gender
of the DSM-5 Mood Disorders, including persistent depres- dysphoria disorder, is, of course, not a sexual disorder but
sive disorder, seasonal affective disorder, disruptive mood a disorder reflecting incongruence between natal sex and
dysregulation disorder, bipolar disorder, and suicide. The expressed gender, in addition to other major revisions—
chapter discusses new data on the genetic and environmen- new data on developmental changes in sexual behavior
tal risk factors and protective factors, such as optimism. from age of first intercourse to prevalence and frequency
Also included is an update on the pharmacological and psy- of sexual behavior in old age; new reports contrasting dif-
chological treatments. fering attitudes and engagement in sexual activity across
Chapter 7, Physical Disorders and Health Psychology, cultures even within North America; updated information
includes updated data on the leading causes of death in the on the development of sexual orientation; and a thoroughly
United States; a review of the increasing depth of knowl- updated description of gender dysphoria with an emphasis
edge on the influence of psychological social factors on on emerging conceptualizations of gender expression that
brain structures and function; new data supporting the effi- are on a continuum.
cacy of stress management on cardiovascular disease; an Chapter 9 also includes updated information on con-
updated review of developments into causes and treatment tributing factors to gender dysphoria as well as the latest
of chronic pain; updated information eliminating certain recommendations on treatment options, recommended
viruses (XMRV and pMLV) as possible causes of chronic treatment options (or the decision not to treat) for gender
fatigue syndrome; and updated review of psychological and non-conformity in children, a full description of disorders
behavioral procedures for preventing injuries. of sex development (formerly called intersexuality), and a
Thoroughly rewritten and updated, Chapter 8, Eating thoroughly revamped description of paraphilic disorders to
and Sleep–Wake Disorders, contains new information on reflect the updated system of classification with a discus-
mortality and suicide rates in anorexia nervosa; new epi- sion of the controversial change in the name of these disor-
demiological information on the prevalence of eating dis- ders from paraphilia to paraphilic disorders.
orders in adolescents; new information on the increasing A thoroughly revised Chapter 10, Substance-Related,
globalization of eating disorders and obesity; updated Addictive, and Impulse-Control Disorders, features new dis-
information on typical patterns of comorbidity accompa- cussion of how the trend to mix caffeinated energy drinks
nying eating disorders; and new and updated research on with alcohol may increase the likelihood of later abuse of
changes in the incidence of eating disorders among males, alcohol; new research on chronic use of MDMA (“Ecstasy”)
racial and ethnic differences on the thin-ideal body image leading to lasting memory problems (Wagner, Becker,
associated with eating disorders, the substantial contribu- Koester, Gouzoulis-Mayfrank, & Daumann, 2013); and new
tion of emotion dysregulation to etiology and maintenance research on several factors predicting early alcohol use,
of anorexia, the role of friendship cliques in the etiology of including when best friends have started drinking, whether
eating disorders, mothers with eating disorders who also family members are at high risk for alcohol dependence,
restrict food intake by their children, the contribution of and the presence of behavior problems in these children
parents and family factors in the etiology of eating dis- (Kuperman et al., 2013).
orders, biological and genetic contributions to causes of Chapter 11, Personality Disorders, now features a com-
eating disorders including the role of ovarian hormones, pletely new section on gender differences to reflect newer,
transdiagnostic treatment applicable to all eating disorders, more sophisticated analyses of prevalence data, and a new
results from a large multinational trial comparing CBT section on criminality and antisocial personality disorder is
to psychoanalysis in the treatment of bulimia, the effects now revised to better reflect changes in DSM-5.
of combining Prozac with CBT in the treatment of eat- Chapter 12, Schizophrenia Spectrum and Other Psy-
ing disorders, racial and ethnic differences in people with chotic Disorders, presents a new discussion of schizo-
binge eating disorder seeking treatment, the phenomenon phrenia spectrum disorder and the dropping of subtypes
of night eating syndrome and its role in the development of schizophrenia from DSM-5; new research on deficits in
of obesity, and new public health policy developments emotional prosody comprehension and its role in auditory
directed at the obesity epidemic. hallucinations (Alba-Ferrara, Fernyhough, Weis, ­Mitchell,
Realigned coverage of Sleep–Wake Disorders, also in & Hausmann, 2012); a discussion of a new proposed psy-
Chapter 8, with new information on sleep in women is now chotic disorder suggested in DSM-5 for further study—
reported—including risk and protective factors, an updated Attenuated Psychosis Syndrome; and a new discussion of
section on narcolepsy to describe new research on the the use of transcranial magnetic stimulation.
causes of this disorder, and new research on the nature and In Chapter 13 (Neurodevelopmental and Neurocogni-
treatment of nightmares are now included. tive Disorders), the neurodevelopmental disorders are pre-
In Chapter 9, Sexual Dysfunctions, Paraphilic Disorders, sented, instead of Pervasive Developmental Disorders, to
and Gender Dysphoria, a revised organization of sexual be consistent with the major changes in DSM-5. In addi-
dysfunctions, paraphilic disorders, and gender dysphoria tion, Chapter 13 now describes new research to show that­

xxii • Preface

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
gene–environment interaction can lead to later behavior arousal patterns such as pedophilia are not disorders
problems in children with ADHD (Thapar, Cooper, Jefferies, in themselves, but only become disorders if they cause
& Stergiakouli, 2012; Thapar et al., 2005); new research on impairment or harm to others.
ADHD (and on other disorders) that is finding that in many
cases mutations occur that either create extra copies of a
gene on one chromosome or result in the deletion of genes DSM-IV, DSM-IV-TR, and DSM-5
(called copy number variants—CNVs) (Elia et al., 2009;
Lesch et al., 2010); and new research findings that show a Much has been said about the mix of political and scientific
variety of genetic mutations, including de novo disorders considerations that resulted in DSM-5, and naturally there
(genetic mutations occurring in the sperm or egg or after are controversial views on this. Psychologists and psychi-
fertilization), are present in those children with intellectual atrists are often concerned about their own specific areas
disability (ID) of previously unknown origin (Rauch et al., of interest in what has become—for better or worse—the
2012). Chapter 13 also features descriptions of research nosological standard in our field, and with good reason: in
assessing brain activity (fMRI) in individuals during active previous DSM editions, scientific findings sometimes gave
episodes of delirium as well as after these episodes; data way to personal opinions. For DSM-IV and DSM-5, how-
from the Einstein Aging Study concerning the prevalence ever, most professional biases were left at the door while
of a disorder new in DSM-5, mild neurocognitive disorder the task force almost endlessly debated the data. This pro-
(Katz et al., 2012); and a discussion of new neurocognitive cess produced enough new information to fill every psy-
disorders (e.g., neurocognitive disorder due to Lewy bodies chopathology journal for a year with integrative reviews,
or prion disease). reanalysis of existing databases, and new data from field
And Chapter 14, Mental Health Services: Legal and trials. From a scholarly point of view, the process was both
Ethical Issues, presents a brief, but new, discussion of the stimulating and exhausting. This book contains highlights
recent trend to provide individuals needing emergency of various debates that created the nomenclature, as well
treatment with court-ordered assisted outpatient treatment as recent updates. For example, in addition to the contro-
(AOT) to avoid commitment in a mental health facility versies described above, we summarize and update the data
(Nunley, Nunley, Cutleh, Dentingeh, & McFahland, 2013); a and discussion of premenstrual dysphoric disorder, which
new discussion of a major meta-analysis showing that cur- was designated a new disorder in DSM-5, and mixed anxi-
rent risk assessment tools are best at identifying persons ety depression, a disorder that did not make it into the final
at low risk of being violent but only marginally successful criteria. Students can thus see the process of making diag-
at accurately detecting who will be violent at a later point noses, as well as the combination of data and inferences
(Fazel, Singh, Doll, & Grann, 2012); and an updated section that are part of it.
on legal rulings on involuntary medication. We also discuss the intense continuing debate on cate-
gorical and dimensional approaches to classification. We
Additional Features describe some of the compromises the task force made to
accommodate data, such as why dimensional approaches
In addition to the changes highlighted earlier, Essentials of
to personality disorders did not make it into DSM-5, and
Abnormal Psychology features other distinct features:
why the proposal to do so was rejected at the last minute
■■ Student Learning Outcomes at the start of each chap- and included in Section III under “Conditions for Further
ter assist instructors in accurately assessing and map- Study” even though almost everyone agrees that these dis-
ping questions throughout the chapter. The outcomes orders should not be categorical but rather dimensional.
are mapped to core American Psychological Associa-
tion goals and are integrated throughout the instructor Prevention
resources and testing program. Looking into the future of abnormal psychology as a field,
■■ In each disorder chapter a feature called DSM Contro- it seems our ability to prevent psychological disorders may
versies, which discusses some of the contentious and help the most. Although this has long been a goal of many,
thorny decisions made in the process of creating DSM-5. we now appear to be at the cusp of a new age in prevention
Examples include the creation of new and sometimes research. Scientists from all over the globe are developing
controversial disorders appearing for the first time in the methodologies and techniques that may at long last
DSM-5, such as premenstrual dysphoric disorder, binge provide us with the means to interrupt the debilitating toll
eating disorder, and disruptive mood dysregulation dis- of emotional distress caused by the disorders chronicled in
order. Another example is removing the “grief” exclu- this book. We therefore highlight these cutting-edge pre-
sion criteria for diagnosing major depressive disorder vention efforts—such as preventing eating disorders, sui-
so that someone can be diagnosed with major depres- cide, and health problems, including HIV and injuries—in
sion even if the trigger was the death of a loved one. appropriate chapters as a means to celebrate these impor-
Finally, changing the title of the “paraphilia” chapter tant advancements, as well as to spur on the field to con-
to “paraphilic disorders” implies that paraphilic sexual tinue this important work.

Preface • xxiii

Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
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