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Origins of Abnormal Behaviors [WLOs: 1, 4, 5, 7] [CLOs: 1, 4]

Prior to beginning work on this discussion forum, you must successfully complete the

Week 1 Terminology Quiz

before you will be allowed to post in this discussion forum. The Week 1 Terminology Quiz is intended to support your ability to write critically considered postings that are accurate and aligned to the prompt appropriately.

In addition, to prepare for this discussion, read

Chapter 1

of your textbook, review the articles

Freud Was Right . . . About the Origins of Abnormal Behavior

The Myth of Mental Illness

Personality Disorder Is Disease

, and

Is “Abnormal Psychology” Really All That Abnormal? (Links to an external site.)

, as well as the video

How Mental Illness Changed Human History – for the Better: David Whitley at TEDxManhattan Beach

To successfully complete this discussion,

Based on your required resources, define abnormal psychology.
Interpret why you believe it is important for clinicians to consider the three perspectives of abnormality.
Discuss the origins of mental illness and how theories throughout time have affected the metamorphosis of abnormal psychology.
Identify at least two of the theoretical foundations associated with abnormal psychology.
Discuss your understanding for the use of the DSM-5, and how it too has changed the process for diagnosis.
Based on the controversial viewpoints of Szasz (1960) and Ausubel (1961), as well as the other required resource information, evaluate your own beliefs about mental illness. Is it real? Is it common or uncommon? Is creativity supported by behaviors resembling mental illness? Support your viewpoints using citations.
Elaborate on why culture should be considered, associated with behaviors, and what might be considered normal versus abnormal.
Be sure to use your own academic voice (Links to an external site.)and apply in-text citations, according to APA: Citing Within Your Paper (Links to an external site.), appropriately throughout your post.

Post your initial response of 300 words or more by Day 3 (Thursday).

Required Resources

Text

Getzfeld, A. R. (2018).

Abnormal psychology

(2nd ed.). Retrieved from https://content.ashford.edu

· Chapter 1: Introduction to Abnormal Psychology

· Chapter 2: Stress, Trauma, and Related Disorders

Articles

Ausubel, D. P. (1961).

Personality disorder is disease

. American Psychologist, 16(2), 69–74. http://doi.org/10.1037/h0042627

· The full-text version of this article is available through the EBSCOhost database in the Ashford University Library. This article responds to Szasz’s claims that mental illness is a myth and will assist you in your Origins of Abnormal Behaviors discussion forum and Week 1 Content Review quiz this week.

Muris, P. (2006).

Freud was right . . . about the origins of abnormal behavior

. Journal of Child and Family Studies, 15(1), 1–12. https://doi.org/10.1007/s10826-005-9006-9

· The full-text version of this article is available through the EBSCOhost database in the Ashford University Library. This article provides information about the origin of abnormal behavior and will assist you in your Origins of Abnormal Behaviors discussion forum and Week 1 Content Review quiz this week.

Schaefer, J. D. (n.d.).

Is “abnormal psychology” really all that abnormal? (Links to an external site.)

[Blog post]. Retrieved from https://www.div12.org/is-abnormal-psychology-really-all-that-abnormal/

· Jonathan Schaefer, a doctoral student of clinical psychology at Duke University, discusses the suggestion that mental disorders may be more common than some believe. This article provides information about abnormal psychology and will assist you in your Origins of Abnormal Behaviors discussion forum and Week 1 Content Review quiz this week.
Accessibility Statement does not exist.

Szasz, T. S. (1960).

The myth of mental illness

. American Psychologist, 15(2), 113–118. https://doi.org/10.1037/h0046535

· The full-text version of this article is available through the EBSCOhost database in the Ashford University Library. This article questions whether mental illness exists and will assist you in your Origins of Abnormal Behaviors discussion forum and Week 1 Content Review quiz this week.

Multimedia

TEDx Talks. (2013, December 27).

How mental illness changed human history – for the better: David Whitley at TEDxManhattanBeach (Links to an external site.)

[Video file]. Retrieved from https://youtu.be/yVwfJzZdkQ0

· This video shares the history of mental illness, taking the viewer back 40,000 years, but also infuses the concepts with artistic genius attributes. This video will give you additional information that will support your postings in your Origins of Abnormal Behaviors discussion forum and Week 1 Content Review quiz this week. This video has closed captioning and a transcript.

Accessibility Statement (Links to an external site.)

1 Introduction to Abnormal Psychology

YiorgosGR/iStock/Thinkstock

Learning Objectives

After reading this chapter, you should be able to:

• Define abnormal behavior.

• Discuss the history of mental illness.

• Identify the major theorists and theoretical orientations in psychology.

• Discuss the DSM–5.

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Section 1.1 How Do We Define Abnormal Behavior?

1.1 How Do We Define Abnormal Behavior?
If you were to poll a random sample of average people, most would say that they know abnor-
mal behavior when they see it. They might assess at-a-glance someone’s behavior as strange,
odd, or sick, and they would quickly give reasons for their assessment. Let’s look at an exam-
ple of potentially odd behavior that will illustrate this point.

You are walking in your neighborhood on a gorgeous summer afternoon, listening to your
favorite songs on your smartphone. Suddenly, without warning, a man runs out from behind
the bushes across the street. This wouldn’t usually catch your eye, but you notice that this
man has no clothes on. He is running frantically while trying to cover himself with his hands,
all the while looking behind him. Before you know it, the man disappears around the corner.
Was the man’s behavior abnormal? Do you think he is likely to present a danger to himself or,
more important, to other people? Answering questions like these helps practicing psycholo-
gists to achieve one of their goals: to ascertain whether an individual’s behavior is abnormal,
and to ascertain whether their behavior presents a danger to the individual or to others.

Three Perspectives of Abnormality
Psychopathology refers to the study of the causes and development of psychiatric disorders.
Many practitioners in the mental health professions (psychologists, social workers, counsel-
ors, and psychiatrists, to name a few) agree that it is extremely difficult to arrive at a universal
definition of abnormal behavior (Gelo, Vilei, Maddux, & Gennaro, 2015). They agree in gen-
eral about what the term means, but they often use different perspectives to define it. Three
perspectives commonly used by psychologists are the statistical frequency perspective
(behavior is abnormal according to the statistics), the social norms perspective (behavior
is abnormal according to the standards set by society), and the maladaptive perspective
(behavior is abnormal because it interferes with the individual’s ability to function on a daily
basis). Each perspective has its own usefulness and limitations, as discussed in the following
sections.

The Statistical Frequency Perspective
The statistical frequency perspective labels behavior as abnormal if the behavior exists in (or
is exhibited by) only a minority of the population. This definition thus calls behaviors that
are numerically rare abnormal. The majority of the “normal” population would fall into the
middle range of a bell-shaped curve (when split in half the left side of the curve is a mirror
image of the right side). As one moves away from the middle range in either direction, the per-
son could be classified as being statistically more extreme and therefore as behaving abnor-
mally (Helzer & Hudziak, 2002). An immediate problem with this definition: A person who
falls on an extreme end of the frequency distribution would be considered abnormal based
on the statistical frequency definition (falling into about 2.2% of the population), but he or
she indeed might not be abnormal. Consider a gifted scientist or musician. Mozart, a prodigy,
would be considered abnormal based on this definition, as would Einstein.

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Section 1.1 How Do We Define Abnormal Behavior?

A few presumptions here need to be examined. First, this perspective presumes that the gen-
eral population’s behavior is considered to be normal. However, what is considered normal
today wasn’t necessarily considered normal a hundred years ago, and what’s normal in New
York City might not be considered all that normal in New Delhi. For example, consider the
following routine: Someone wakes up, eats breakfast, goes to work, has lunch, goes home,
eats dinner, spends some time with family, watches television, and then goes to bed. This is a
routine that many working adults in the United States follow on a daily basis. Therefore, the
general population would consider this to be normal behavior.

So what would you then make of the following: Instead of going to work every day and fol-
lowing the previously outlined routine, an individual goes to the beach at 8 a.m. and lies on
a blanket until the sun sets, each and every day? Or what about this possibility: A man goes
to the beach with a blanket and a guitar, sits on the boardwalk, strums away while singing
folk songs, and has a sign asking for handouts as he has lost his job due to a bad economy. Is
this considered normal behavior based on current standards in the United States? Or is this
behavior crossing over to abnormal behavior?

What about the man described earlier who ran naked from behind bushes? Do people usually
run through the streets naked anywhere in the United States? And if the statistical perspec-
tive tells us that this is extremely uncommon behavior, does that automatically mean that the
individual’s behavior must be abnormal?

The Social Norms Perspective
The social norms perspective states that behavior is abnormal if it deviates greatly from
accepted social standards, values, or norms. Norms are spoken and unspoken rules for proper
conduct. These are established by a society over time and are subject to changes over time.
Two types of norms used to assess whether behavior is abnormal are legal norms and psy-
chological norms. Legal norms tend to dictate how individuals should behave in the realm
of their civic surroundings and with regard to their friends and neighbors. In other words, a
legal norm is a mandatory rule of social behavior that is established by the state. If someone is
labeled a criminal, his or her behavior violates legal norms as determined by that society. For
example, the naked running man described earlier may be demonstrating abnormal behavior
based on legal norms, since he could be arrested for indecent exposure.

Behaviors, thoughts, and emotions are also considered to be abnormal if they violate the
norms set out by psychologists. Psychological disorders are categorized in the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DSM–5), published by the American Psy-
chiatric Association (described in more detail later in this chapter). The psychological norms
perspective would involve using diagnostic criteria in the DSM–5 to determine if the pattern of
such behaviors is likely to point to a mental disorder. For example, Michael Jackson was surely
one of the most famous individuals in the world. However, he demonstrated unusual, perhaps
odd, and maybe even abnormal behaviors at times. He often wore surgical masks when he
was out in public. Perhaps more unusual was how he dressed his children when they went
out. He would often cover his children’s faces or heads with blankets, Halloween-style masks,

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Section 1.1 How Do We Define Abnormal Behavior?

burqas, or disguises. Are these behaviors abnormal? It would likely seem so to many observ-
ers. However, what if Jackson had a phobia about germs and was afraid of being exposed to
cold viruses or other pathogens? What if he had a compromised immune system and there-
fore needed to keep his face covered? Perhaps he covered his children’s faces to protect them
from kidnappers, since he was an instantly recognizable and very wealthy pop star. Do these
latter explanations now make Jackson’s behaviors more rational and therefore not abnormal?

The Maladaptive Perspective
The statistical frequency perspective views behavior as abnormal if it occurs with statistical
infrequency relative to the general population. A person can function, and might be consid-
ered very talented, if his or her behavior is statistically infrequent, like Mozart or Michelan-
gelo. The maladaptive perspective, while seemingly similar to the statistical frequency per-
spective, views behavior as abnormal if it interferes with the individual’s ability to function
in life or in society. By this we mean the ability to work, take care of oneself, and have normal
social interactions. Do you think the naked running man is able to function in everyday life?
Can you even make these kinds of judgments without knowing much about him? If nothing
else, you can say that this naked individual appears to be somewhat unusual. However, is his
behavior abnormal or indicative of mental illness? Let’s look at another example.

There is a woman in your neighborhood whom you see often. She works a regular 9-to-5 job,
but you notice that it takes her a while to leave for work. You have noticed that she engages
in some rather “unusual” yet regular routines before she finally heads off. You notice that
it takes her a long time to leave the house. She goes back inside at least five or six times,
disappears for a few minutes, and then returns outside. She locks her door, then returns at
least four times to make sure it’s locked. When she finally gets in her car and drives off, she
returns a few minutes later to ensure the garage door is closed. You also notice that when she
finally leaves for good, the time is 10 a.m. Based on the maladaptive perspective, this woman’s
behaviors interfere with her everyday life. She is able to function, but her daily rituals make
her late for work every day. She has extreme difficulty leaving the house until she is absolutely
certain that all the doors are locked and that her gas oven and range are turned off (we will
discuss behaviors like this in more detail in Chapter 3,which covers obsessive-compulsive
and related disorders).

Other Considerations
Let’s consider several other factors used to classify abnormal behavior. First, is a person’s
behavior endangering the individual or other people? Often this is not the case. The idea that
individuals who have a mental illness are dangerous or violent people, like Adam Lanza, Omar
Mateen, or Charles Manson, is simply not true (see the accompanying Highlight). Most indi-
viduals with a mental illness are not dangerous, and of those who are, most are more likely to
pose a threat to themselves than to others.

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Section 1.1 How Do We Define Abnormal Behavior?

Highlight: How Would We Categorize Mass Shooters?

By definition, a school shooting is a form of mass shooting involving a gun attack on an
educational institution, such as a school or university. The U.S. Secret Service defines them as
shootings in which schools are “deliberately selected as the location for the attack” (Vossekuil,
Fein, Reddy, Borum, & Modzeleski, 2004, p. 4). Let’s use the Newtown, Connecticut shooting
as an example. On December 14, 2012, Adam Lanza, age 20, entered the Sandy Hook
Elementary School in Newtown, and fatally shot 20 children who were 6 or 7 years old,
as well as six adult staff members. Prior to driving to the school, Lanza shot and killed his
mother at their Newtown home. As first responders arrived at the scene, Lanza killed himself
by shooting himself in the head. This was the deadliest mass shooting at a high school or
grade school in U.S. history and at the time was the third-deadliest mass shooting by a single
person in U.S. history. What could cause a 20-year-old to murder his mother, then drive to an
elementary school and murder 20 young children? A report issued by the Connecticut State’s
Attorney’s Office (Sedensky, 2013) concluded that Lanza acted alone and planned his actions,
but none of the evidence collected provided any indication as to why he did so, or why he
targeted the school. This leads to many questions, many of which remain unanswered.
Colleagues and I are often asked how we would categorize someone like Lanza.

How about Omar Mateen? On June 12, 2016,
Mateen, a 29-year-old security guard, killed 49
people and wounded 53 others in a terrorist
attack/hate crime inside Pulse, a gay nightclub
in Orlando, Florida. Pulse was hosting Latin
Night and most of the victims were Latino.
At the time, it was both the deadliest mass
shooting by a single shooter and the deadliest
act of violence against LGBT people in U.S.
history. While not a school shooting, this
incident was somewhat easier to classify.
Regardless, what would cause someone to
enter a nightclub where people go to dance
and to have fun, and systematically murder
49 patrons? Is this someone who has a mental
illness? How about Lanza, who was previously
diagnosed with Asperger’s syndrome as well as
obsessive-compulsive disorder? Just because
we have agreed-upon models to help us define
abnormal behavior does not mean we can
always explain its causes or the reasons some
people do certain things. We also need to
exercise caution. When a clear explanation for
an individual’s behavior is lacking, does this
mean we should not provide treatment to the
individual?

Balkis Press/Sipa USA/AP Photos
On June 12, 2016, Omar Mateen killed
49 people and wounded 53 in an attack
on Pulse, a gay nightclub in Orlando,
Florida.

(continued)

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Section 1.1 How Do We Define Abnormal Behavior?

Another consideration is whether the individual’s behavior is causing him or her distress. Not
all abnormal behavior causes stress to the individual. In many cases, the individual’s family or
loved ones are more distressed than the individual is. This makes it especially important for
the family to be involved in as many aspects of treatment as possible. For example, suppose
you have a friend who finds it impossible to dispose of old newspapers. The papers are piling
up around his house, eventually making it difficult to enter certain rooms and creating a fire
hazard. You ask him about this, and he says he “needs to keep them” in case he must refer to
an article for his job as a Wikipedia editor. He appears not to be bothered by his actions, yet
he becomes uncomfortable when you start to gather up some of the papers for removal. Thus,
his behavior is not causing him stress, but trying to change his behavior does create stress.

Finally, we must consider factors such as the duration, the age of onset, and the intensity of
the behavior(s). By duration, we mean the length of time the troublesome behaviors have
existed. By age of onset, we mean the age at which the troublesome behaviors first become
noticeable. This is especially important, since some mental illnesses cannot be diagnosed
until an individual has reached a certain age, or cannot be diagnosed once an individual has
passed a certain age. By intensity, we mean how extreme the behaviors in question are.

So, where does our naked running man fit? Let’s see if more information about him helps to
clear up the picture. This man is a sophomore at a major university in the United States. He is
a psychology major and has made the dean’s list, a status granted only to the best students.

Highlight: How Would We Categorize Mass Shooters?
(continued)

According to Swanson, McGinty, Fazel, and Mays (2015), the media reports of mass shootings
by “disturbed” individuals stimulate the public’s interest. These often sensationalistic reports
reinforce the popular belief that mental illness frequently results in violence, usually gun
violence. Swanson and colleagues (2015) concluded that epidemiological studies (which
examine the incidence of disease) show that the large majority of people with serious mental
illnesses are never violent. An APA Panel of Experts report stated that people with serious
mental illness commit only a small proportion of firearm-related homicides (Webster &
Vernick, 2013). The issue of gun violence cannot be resolved solely by focusing on serious
mental illness (typically meaning disorders such as schizophrenia and bipolar I disorder)
(Webster & Vernick, 2013). In other words, there is no significant correlation between
gun violence and serious mental illness (Cornell & Guerra, 2013). However, mental illness
is strongly associated with increased risk of suicide, which accounts for over half of U.S.
firearm-related fatalities (Swanson et al., 2015).

As you read this textbook, think about the issues raised here and about how you would
react if you discovered that some mental conditions, or actions, do not have easy, if any,
explanations.

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Section 1.1 How Do We Define Abnormal Behavior?

When you looked more closely at the man, you saw that he was wearing only sneakers, which
enabled him to run faster. The sneakers had the university’s logo on the sides. Is this enough
information for you to reach a conclusion about his behavior?

Psychologists often have to make judgments based on what they see on the surface or in an
individual’s overt behaviors. These are behaviors that are open and detectable by whoever
observes them (Reber & Reber, 2001, p. 500). In other words, these are behaviors that we can
see on the surface and therefore measure. Let’s look at some other facts about the naked run-
ning man: He was running because he had been skinny-dipping in a backyard pool and was
discovered by the homeowners. He also had a camcorder set up to record his escapades. Does
this help?

Now do you think this man’s behavior is abnormal based on the aforementioned perspec-
tives? Is skinny-dipping in someone else’s pool statistically frequent? Does it conform to
social norms? Do you think it interferes with the man’s ability to function at his university?
Does the man’s skinny-dipping in a stranger’s pool present a danger to himself or to others?
Perhaps a bit more information would help. The man was skinny-dipping and recording his
feat because he was pledging a fraternity at his university. This was part of a “hazing” ritual.
The man had to prove he performed his escapade and therefore filmed it. As you learn more
about the man, you discover that he is extremely
reserved, painfully shy, and generally withdrawn in
many social situations.

Perhaps he is just what David Weeks and Jamie
James (1995) call eccentric. Those labeled as eccen-
tric have odd or unusual habits but do not have a
mental illness. Weeks and James published a work
called Eccentrics: A Study of Sanity and Strangeness,
in which they examined eccentrics throughout his-
tory. They concluded that the eccentrics’ thought
patterns are not disrupted and their behavior
doesn’t typically cause them distress; in fact, most
eccentrics may take pleasure in being an “original.”
Perhaps you yourself have some odd or unusual
habits, or perhaps you know someone who does.
Albert Einstein could be classified as eccentric. He
picked up cigarette butts off the street and smoked
them in order to circumvent his doctor’s ban on
buying tobacco for his pipe. He also would use his
sailboat on windless days because he enjoyed a
challenge. Oscar Wilde, the famous novelist, was
another famous eccentric. While studying at Oxford
University, Wilde would walk through the streets
with a lobster on a leash, in addition to engaging in
other odd behaviors.

Science and Society/SuperStock
Eccentrics exhibit odd or unusual hab-
its, yet do not have a mental illness.
Albert Einstein may be considered an
eccentric or an “original” for displaying
peculiar habits.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

1.2 A History of Theoretical Orientations
for Abnormal Behavior

Imagine this: It is a few thousand years ago, and your friend is planning to attend a regularly
occurring event that he is eagerly anticipating. Your friend talks about looking forward to the
occasion, as it is a form of socialization for him. The government sanctions the event and sup-
ports it as a way of pleasing its citizens and giving back to them. Your friend then mentions
that he would like you to come along to see how exciting the event is. You arrive and see that
the arena contains at least 80,000 screaming people. You naturally wonder why everyone is
yelling and why they seem so excited. All of the people are standing. You even see a “royal box”
where dignitaries are sitting. At the end of the event, your friend asks you, “Well, what did you
think?” You reply that you have never seen anything like it and love what you saw. You then
ask when you can attend the next performance.

Does any of this seem unusual or abnormal? What if you now knew that you were in ancient
Rome attending gladiator fights and seeing prisoners being torn to pieces by lions? These
events were considered to be a normal form of entertainment in ancient Rome, but if we tried
to stage such an event in the United States in 2017, you can imagine the consequences and
outrage. Thus, what constitutes abnormal behavior depends in part on society’s definitions
of what is normal, which can change over time. Humans have demonstrated abnormal behav-
ior for at least, by this author’s account, a few thousand years. The gladiator fights were not
considered unusual in their time, but they are now considered to be unusual and, by many
people, repulsive.

Ancient Times
The earliest explanations for mental illness seem to have been that the afflicted were pos-
sessed by evil spirits or demons (an idea that some people still believe today). Skulls dating
back to 6500 BCE have been discovered with holes bored into them (see Figure 1.1), which
are an indication of trepanning (also known as trephining). The belief seems to have been
that the holes would allow the evil spirits to leave the “possessed” person. In later medieval
societies, exorcisms were performed, usually by a specially trained priest. This was a non-
invasive way to drive the demons or evil spirits from the possessed person or a place, often
a house. These became more common in the 1600s. Exorcisms, although rare, are still per-
formed today.

The first physiology-based explanations for mental illness were provided in ancient Greece
by Hippocrates (460–377 BCE), the father of modern medicine. Hippocrates viewed abnor-
mal behavior—and physical illnesses in general—as having internal causes. Specifically, he
believed that the body contained four fluids, or humors (yellow bile, black bile, blood, and
phlegm), that must be kept in adequate balance to maintain health (it must be noted that
the theory was wrong about the cause of diseases). His prescriptions for the ill included rest,
proper diet, sobriety, and exercise, strategies that are still recommended today. Hippocrates
also believed that if you took care of your body, your mind would stay well.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

The Middle Ages and the Renaissance
The Middle Ages occurred from approximately the fifth to the fifteenth centuries. Many peo-
ple adopted the perspective that demons were causing mental illnesses in certain people.
The views held by the ancient Greeks and Romans, who saw physiological causes of mental
illnesses, lost favor. Plagues were common in the Middle Ages, and exorcisms reemerged as a
form of “treatment” for mental illnesses. An important concept emerged during these times:
the idea that evil supernatural forces were to blame for the individual’s mental illness. Oddly
enough, this in effect removed some of the responsibility of “getting sick” or of “being sick”
from the mentally ill.

During the Renaissance (around 1400–1700), the treatment of the mentally ill improved sig-
nificantly. The mentally ill were viewed as having “sick” minds; therefore, their minds needed
to be treated along with their bodies. A more significant event occurred during the early part
of the Renaissance: the creation of asylums. Even though the name asylum connotes bad feel-
ings and scenes of patient abuse today, this was not how they were run at their founding.
Their sole purpose was to treat the mentally ill in a humane fashion. They soon became over-
crowded, however, and the treatment turned to punishment and torture. One of the most
famous asylums was London’s Bethlehem Hospital, founded in 1247 as a hospital for the poor.

Figure 1.1: Trepanning

Note the holes bored into the skull.

Skull

Trephine

Hole made
by trepanning

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

In the early 1400s, it began to be used to house the
mentally ill. During the 16th century, Bethlehem
Hospital was used solely to house the criminally
insane. Did you know that the term bedlam comes
from Bethlehem Hospital? Bethlehem Hospital
was called “Bethlem” for short, and Londoners
pronounced it “bedlam.” The term bedlam even-
tually became associated with the chaotic condi-
tions within the hospital’s own walls, with mental
illness, and with a place or situation where mass
confusion reigns (New Advent, n.d.).

Two Important Mental Health
Reformers: 1700s–1800s
Philippe Pinel (1745–1826) was one of the early
reformers in the proper treatment of individu-
als with mental illnesses. Pinel, a Frenchman,
advocated that they be treated with sympathy,
compassion, and empathy and not with beatings
and torture. Dorothea Dix (1802–1887) helped
to establish many state mental hospitals in the
United States during her nationwide campaign

to reform treatments of the mentally ill. She was directly responsible for laws that aimed to
reform treatment of this population.

Psychoanalytic Theory: 1890s–1930s
Although trephination dates back thousands of years, the history of abnormal psychology
can realistically be traced to 1895, when Sigmund Freud (1856–1939), in collaboration with
Josef Breuer (1842–1925), published his first book, Studies in Hysteria. (The first book Freud
wrote alone was The Interpretation of Dreams, published in 1900.) Freud, a neurologist, was
initially a researcher who studied the reproductive systems of eels. In 1885, just before he
married, he obtained a grant to go to Paris to see the famous neurologist Jean Martin Char-
cot (1825–1893). Charcot specialized in the study of hysteria and susceptibility to hypnosis.
From his time with Charcot, Freud realized the power that the mind could have over the body,
and he returned from Paris determined to make a name for himself in the field of hypnosis.
After experimenting with hypnosis on his patients, Freud abandoned this form of treatment
as it proved ineffective for many of them. He favored treatment in which the patient talked
through his or her problems, which he termed psychoanalysis.

Breuer, a Viennese physician, treated patients who suffered from hysteria. Breuer’s patients
told him that they had physical illnesses. However, after examination, he discovered that
they had no physical symptoms. Breuer discovered that in some cases his patients’ symp-
toms eased or disappeared once they discussed the past with him in a safe environment with-
out censure and while under hypnosis. Breuer and Freud discussed their ideas, and Freud
expanded on them and created psychoanalytic theory, thus leading to an entire movement

Time Life Pictures/Contributor/Getty Images
An inmate at Bethlehem Hospital, where
the mentally ill were held in inhumane
conditions.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

that is still popular today. Freud’s basic tenet was that unconscious processes, motives, and
urges are at the core of all of our behaviors and difficulties.

How did Freud view abnormal behavior? He saw adult human behavior as resulting from
a combination of the components of what he termed the psyche, which consisted of three
parts: the id, the ego, and the superego (see Figure 1.2). The id is the primitive part of the
personality that houses our unconscious desires, wishes, and basic innate drives such as sex
and aggression. If these drives are not satisfied, or if the unconscious desires come into con-
sciousness, anxiety can result. The id is the only piece of the psyche that is present at birth.
The ego, which is partially conscious and is the second part of the psyche, does its best to
control the id by trying to “convince” it to delay gratification until a reasonable solution to
the drive reduction is found. The id does not listen, as it needs to be satisfied immediately
regardless of the consequences. The ego develops when a child is between 1½ and 3 years
old. Eventually the superego, the final part of the psyche, develops when a child is between 3
and 6 years old and enables the individual to feel guilt and have a conscience. The superego is
also partially conscious, and it helps the ego to control the id’s desires. Even if the id’s urges
are controlled by the ego and the superego, its desires still exist, driving behavior. Because
these desires are so strong, they cause anxiety if they are unmet. According to psychoanalytic
theory, this can lead to abnormal behavior.

Figure 1.2: Freud’s theory of personality

Freud compared personality to an iceberg. A small part is conscious, a somewhat larger part is
preconscious (available to conscious awareness with some mental effort), and the largest part of
personality is unconscious (unavailable to the individual without massive psychoanalytic effort).

Source: Reprinted from Steven Schwartz and James Johnson, Psychopathology of childhood: A clinical-experimental approach, p. 13,
Pergamon Press, 1985, with permission from Elsevier.

Unconscious

Preconscious

Conscious

Ego Superego

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

Freud and his followers also looked at abnormal behavior in other ways. For example, Freud
saw depression as anger turned inward. He maintained that everyone has self-destructive
tendencies, but that they usually remain repressed. Repression is an ego defense mechanism
that operates unconsciously. Repression keeps certain ideas, impulses, and memories from
reaching consciousness. If these ideas were to surface, they would produce anxiety and guilt,
among other feelings. However, when individuals are unable to express their anger appropri-
ately and turn it inward as a form of self-punishment, this can lead to depression.

Behaviorism: 1910s–1940s
Freud’s explanations for abnormal behavior varied somewhat according to an individual’s
diagnosis; however, the explanations of two American psychologists, John B. Watson (1878–
1958) and B. F. Skinner (1904–1990), stayed the same regardless of the individual or the
diagnosis. These two posited that something in the environment is always reinforcing an indi-
vidual’s aberrant behavior(s). In other words, the causal factors are outside of the individual.
Behaviorists believe that only observable and scientifically measurable behaviors are worth
studying and investigating. Some behaviorists go to more of an extreme, stating that only
physiological responses matter; consciousness and any mental states are not worth examin-
ing, as they do not exist. (They have often been called radical behaviorists.) Let’s consider an
example: A child is often disruptive in class, screaming and throwing objects. That child is
usually sent to the principal’s office for subsequent punishment. It turns out that the child
loves the attention he gets when he is removed from class, as he has no friends and is also
ignored at home by his father. His acting out is reinforced by the attention he gets in the class-
room and by getting sent to the principal’s office. Perhaps you can think of some celebrities
whose behaviors are reinforced by environmental actions (gaining more attention and noto-
riety). Effective treatment, therefore, always relies on the manipulation of the environment in
order to change the individual’s behavior. In the case of someone suffering from depression,
for example, Skinner would try to discover what environmental factors were sustaining the
depressive symptoms and then help the patient to eliminate those reinforcers, with little to
no emphasis on the person’s thoughts, unconscious desires, and so on.

Cognitive Behaviorism: 1950s–1970s
Cognitive behaviorism is a psychotherapeutic method that alters distorted attitudes by
identifying and replacing negative and inaccurate thoughts, which will therefore lead to
behavioral changes. Albert Ellis (1913–2007) took a somewhat unique approach to defin-
ing and treating abnormal behavior. He believed that people become depressed and develop
other mental illnesses because of faulty thinking. For example, Ellis said that some people set
themselves up to fail because of “musterbation.” This means that you create a series of men-
tal “musts” that are virtually impossible to satisfy, such as “I must always do well in all of my
performances and always win the praise and approval of others. If not, I’m a failure.” This is
an unrealistic expectation, and when it’s not met, the individual gets depressed and anxious
or develops other problems. Ellis defined an ABC model that refers to the three components
of how people experience and interpret events in either a faulty or a healthy manner. In this
model, A is the activating event or adversity, B is the belief that follows, and C is the conse-
quence. For example, let’s look at a woman who receives a negative work evaluation (this is
the A, activating event or adversity). She then believes that she is a failure (the B, or belief ).

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

The end result (or C, consequence) is that the woman now feels anxious and depressed. Ellis
created rational emotive behavior therapy (REBT) to treat people with problems resulting
from such faulty thinking. It works by helping patients to replace their irrational responses
to events (the B, or belief ) with a more healthy and rational interpretation (such as, in the
case of the poor job review, “I tried my best” or “I’m still learning and will get better”). REBT
works well in treating anxiety disorders and some mood disorders (such as some depressive
disorders); it does not work well with lower-functioning individuals or with those who are
not very verbal (or verbally astute).

Albert Bandura (b. 1925) created social learning theory, also known as modeling. Bandura
postulated that people could learn by observing the behavior of others—whether in real life,
on television, or in the movies—and then copying, or modeling, those behaviors. Modeling
is a powerful form of learning. How did you learn to read, ride a bicycle, or use a computer?
Likely through modeling. Therefore, abnormal behavior is easy to explain from a modeling
perspective. The individual sees a model demonstrate a behavior and either get rewarded or
get punished for it. If the model is rewarded for the behavior, the observer may think, “Hmm,
he got rewarded, maybe I should do the same.” Then the observer copies what she sees and
demonstrates the behavior. This may seem (and is, to a degree) rather simplistic, but, in addi-
tion to biological factors, it might help to explain why certain behaviors run in families. For
example, if an individual was abused as a child, he or she is more likely to be an abuser as an
adult.

Aaron Beck (b. 1921) developed the cognitive perspective theory to examine the causes
of unipolar depression, known just as depression to most people; this depression has one
“pole” or dysfunctional mood state. These individuals have no history of mania and revert to
a normal mood state when the depression lifts. Bipolar disorder has two poles and two dys-
functional mood states—a manic state and depression. The cognitive perspective attributes
abnormal behavior to faulty thinking—that is, to seeing life’s events in a negative fashion.
Having these negative thoughts will lead to negative behavior, which can lead to unipolar
depression. According to Beck, depression develops in childhood and adolescence because
of what he calls negative schemas, or the tendency to see the world pessimistically or nega-
tively. A schema is defined as the fundamental way in which people process information, typi-
cally about themselves (Dozois & Rnic, 2015). Individuals acquire these negative schemas for
a variety of reasons: for example, the death of a parent, repeated social rejection by peers, or
one tragedy after another. These schemas are activated whenever the individual experiences
a new situation that is similar to the conditions in which the negative schemas were learned.
Beck also notes that these individuals are prone to misinterpreting reality. Thus, they think
irrationally and may believe that they are responsible for all of their family’s ills, that they
are totally worthless, and so on. They may end up seeing themselves as hopeless and their
chances of future success as limited or nonexistent.

These negative schemas and their accompanying cognitive distortions support the negative
triad. Beck explained this in the following fashion: First, the person maintains a negative view
of himself or herself (“Everything I touch is ruined.”). The person also maintains a negative
view of the environment (“No one could possibly get along with these roommates.”). Finally,
the person has a negative view of the future and sees things as hopeless (“No matter what I do,
things will always turn out bad for me, so it is really hopeless to even try.”). Individuals who
follow this triad set themselves up for failure, and most likely depression, by adopting these
schemas. If they experience stress or disappointment, the likelihood of becoming depressed

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

increases. In effect, the individual’s negative thoughts lead to negative behaviors (Beck, 1976;
Beck, Rush, Shaw, & Emery, 1979).

Martin Seligman (b. 1942), a professor of psychology at the University of Pennsylvania
(where Beck also taught), was inspired by Beck’s work and developed a theory of learned
helplessness as it applies to depression. Again, keep in mind that even though we are spe-
cifically discussing depression, these theories can explain other mental illnesses, but not all.
In Seligman’s view, individuals develop depression, or perhaps anxiety disorders, because
they see themselves as helpless to control the reinforcers in their environment, and there-
fore the environment itself; they cannot make positive changes in their lives. If individuals

are consistently experiencing bad incidents (for
example, they might say that they are having a bad
month), Seligman would say that eventually the
individuals will resign themselves to the negativity
as “fate.” Avoidance and escape behaviors then dis-
appear and individuals see themselves as helpless
to escape, prisoners of their environments and of
their situations. Seligman and his colleagues later
revised this theory and renamed it the reformu-
lated helplessness theory.

The original theory had two major problems. First,
it did not distinguish between cases in which out-
comes are uncontrollable for all people (called
universal helplessness) and cases in which they
are uncontrollable only for some people (called
personal helplessness). Second, the theory did not
explain when helplessness is general and when it is
specific, or when it is chronic and when it is acute.
The reformulation was based on a revised concept
of attribution theory (Abramson, Seligman, & Teas-
dale, 1987; Taube-Schiff & Lau, 2008). According to
this revision, once people perceive that they lack
control over outcomes, they attribute their helpless-
ness to a cause. This cause can be stable or unstable,
global or specific, and internal or external.

Humanism: 1950s
Carl Rogers (1902–1987) created the client- or person-centered approach. Rogers believed
in the innate goodness of all people, and in the ability of all people to grow and to lead con-
structive lives. Rogers theorized that dysfunction begins in infancy. Children who receive
unconditional positive regard—when one person is completely accepting toward another
person—from their parents early in life will grow up to become constructive and productive
adults, even though they will have flaws. They will realize that they and their contributions
are valued even with these flaws. In Rogerian therapy, clients attempt to look at themselves

4X5 Collection/SuperStock
According to the reformulated help-
lessness theory, some individuals
develop depression or anxiety because
they see themselves as prisoners of
fate, unable to control their negative
situations or environment.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

as being valuable worthwhile human beings. Those who have low self-esteem may be seen as
being incongruent, or experiencing a mismatch between their idealized self-image and their
true self-image. When this occurs, anxiety and other issues result, and it is the therapist’s job,
first, to be a model of congruence and empathize with the client. Then, the therapist will help
the individual become congruent and to effectively feel better about himself or herself. See
Table 1.1 for a summary of the main theories and theorists in the history of psychology.

Table 1.1: The main theories and theorists in the history of psychology

Theorist Theory Explanation

Sigmund Freud
(1856–1939)

Psychoanalytic theory Individuals develop neuroses because of
their unresolved conflicts (repressed id
impulses surfacing and overwhelming the
ego and superego) and because of prob-
lems occurring during childhood.

Albert Bandura
(1925–)

Social learning theory Individuals learn based on what they
observe others (models) do in the world.

Albert Ellis
(1913–2007)

Rational emotive behavior therapy Individuals develop disorders because of
faulty thinking.

Aaron Beck
(1921–)

Cognitive perspective Individuals develop depression in child-
hood and adolescence because of the
tendency to see the world negatively.

Martin Seligman
(1942–)

Theory of learned helplessness Individuals develop disorders because they
see themselves as helpless to control the
environment around them. They therefore
“give up” trying to change their situation
and “grin and bear it.”

Carl Rogers
(1902–1987)

Humanism Dysfunction begins in infancy. Children
who receive unconditional positive regard—
when one person is completely accept-
ing toward another person—from their
parents early in life will grow up to become
constructive and productive adults, even
though they will have flaws.

The Diathesis-Stress Model
Next we will look at a model that straddles the two categories of cognitive and biological
theories. The diathesis-stress model contends that behaviors are a product of both genet-
ics (biology) and environmental stressors. This is an interactionist model, which means that
it views abnormal behavior as originating from a combination of genetic predisposition(s)
(the diathesis) that are set off, or “turned on” (like a light switch), by environmental stressors
(Holmes & Rahe, 1967).

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

We can examine this concept more closely by using an example. Many psychologists accept
that schizophrenia runs in families and, therefore, that it has a genetic component. However,
this does not guarantee that individuals born into a family with a history of mental illness will
have the disorder; it just means that they are more vulnerable to developing it, or perhaps
another mental illness. They are essentially born with this gene “switched off,” and stress
from the environment may or may not eventually “turn on” the gene. For example, let’s look at
a young adult with a genetic predisposition for schizophrenia who uses illicit substances such
as marijuana and heroin. Soon after the drugs’ effects have worn off, she begins to demon-
strate schizophrenic behaviors and thoughts. This demonstrates how the environment (the
stress) turns on the diathesis (the genetic predisposition). If this individual has strong sup-
port systems, the diathesis is less likely to trigger the switch, and the illness is less likely to be
expressed. This is a useful theory for the following reason: It removes some of the responsi-
bility from individuals for contracting their illnesses. It is not their fault, not a character flaw;
it is just the fact that they were born with this genetic predisposition.

Biological Models: Late 1800s–Early 1900s
Emil Kraepelin (1856–1926) was a German research scientist who was indirectly responsible
for the foundation that eventually led to the creation of the Diagnostic and Statistical Manual
series. He also posited the concept that physical factors were responsible for mental illnesses.
If this latter concept sounds familiar to you, it is. Hippocrates espoused these ideas more than
two thousand years earlier.

Another important event occurred in 1897: the sexually transmitted disease syphilis was
found to have led to general paresis, an incurable physical disorder that has both physical
and mental symptoms (Hogebrug et al., 2013). A German neurologist, Richard von Krafft-
Ebing (1840–1902), was responsible for this discovery. This was important because syphilis
sufferers demonstrated delusions of grandeur, which can be a sign of a mental illness. This
was a critical discovery because now there was medical evidence that physical illnesses could
mimic symptoms of mental illnesses and, more important, that physiological factors were,
at the least, somehow involved with some if not all the mental disorders known at that time.

Biological Models: Early 1900s–1940s
The concept that biology was somehow involved in mental illness led to biological treatment
methods, many of which were seen as unsuccessful or perhaps inhumane. Lobotomies are
a type of psychosurgery (surgery for a psychological purpose) that destroys brain tissue to
change a person’s behavior. The person’s nerves that connect the frontal lobes to the parts of
the brain that control emotions are severed, supposedly calming their behavioral outbursts.
Unfortunately, the individual often entered a vegetative state and was basically unresponsive
to stimulation and to people (Collins & Stam, 2015). For obvious reasons, lobotomies are no
longer performed.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

Electroconvulsive therapy (ECT), also known as electroshock therapy, and often referred
to as shock treatment, is a psychiatric treatment in which seizures are electrically induced in
patients to provide relief from psychiatric illnesses, mostly for unipolar depression (Krish-
nan, 2016). The procedure is typically performed in a hospital, on either an outpatient or an
inpatient basis. You will learn about ECT in Chapter 6, but for the moment note that ECT was
often used initially to quiet agitated patients, which was not its intended use.

Finally, insulin shock therapy, also known as insulin coma therapy (ICT), was a form of
psychiatric treatment in which patients were repeatedly injected with large doses of insulin
to produce daily comas over several weeks. The concept, again, was that an agitated person
would be calmed once he or she came out of the coma (Gibson, 2014). Of course, the risk here
is evident: What if the patient does not come out of the coma? ICT is also not used today.

The field of psychology reached a major milestone in the early 1950s when Henri Laborit
(1914–1955) introduced the drug chlorpromazine (known by its trade name Thorazine).
This medication was initially used to tranquilize surgical patients, but Laborit noticed that
it also managed to calm patients without putting them to sleep. Since patients with schizo-
phrenia often exhibit perpetual agitated behavior, Laborit proposed using the drug to treat
schizophrenic disorders. Many psychiatrists thought that his idea had no merit and stood by
the practices of using electroshock therapy or psy-
chotherapy to treat serious mental illnesses. How-
ever, a fellow surgeon informed his brother-in-law,
the psychiatrist Pierre Deniker, about this possible
use of Thorazine. Deniker became interested and
ordered some to try on his most agitated, uncontrol-
lable patients. The results stunned Deniker and his
colleagues, as patients who needed to be restrained
or who were uncommunicative were now open to
communication and could be left unsupervised.
The field of psychopharmacology (the study of the
effect of drugs on the mind and behavior) was unof-
ficially born, and the nature of mental illness treat-
ment was changed forever.

How do psychotropic medications (those that help
individuals to handle psychiatric problems) gen-
erally work? They increase or decrease levels of
various neurotransmitters, brain chemicals presumed to be at either subnormal or super-
normal levels in an individual with a mental illness (see Table 1.2 for a list of common neu-
rotransmitters). Most frequently, psychotropic medications are used to increase levels of the
neurotransmitters serotonin and norepinephrine, which have been implicated in a variety of
mental illnesses. For example, serotonin deficiencies have been implicated in depression as
well as in bulimia nervosa, and high dopamine levels have been tied to schizophrenia. We will
discuss these associations in more detail in Chapters 6, 7, and 8, respectively.

Peter Sickles/SuperStock
Research in the early 1950s revealed
that drugs commonly used during
medical procedures could also be used
to treat mental illness.

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Section 1.2 A History of Theoretical Orientations for Abnormal Behavior

The advent of psychotropic medications also led to other changes in treatment for the men-
tally ill. For example, some of these individuals could now be released from inpatient units
and be treated on an outpatient basis, freeing up facility beds and allowing the patients to
lead more normal lives.

Today, a number of mental illnesses are treated with a combination of talk therapy and medi-
cations. Medications work well (for some) in alleviating the symptoms of mental illnesses, but
they do not eliminate all of the concerns that bring someone in for treatment. They also can
produce side effects, some of which are quite significant, and certain classes of medications
have addictive potential. Therefore, medications should not be viewed as panaceas or be used
as the sole treatment for a mental illness; nevertheless, they should be used when advisable
in conjunction with therapy.

A Quick Look at Another Option:
Transcranial Magnetic Stimulation (TMS)
Transcranial magnetic stimulation (TMS) is a noninvasive procedure that uses magnetic
fields to stimulate nerve cells in the brain to improve symptoms of depression. TMS is typi-
cally used when other depression treatments haven’t been effective. Typically, during a TMS
session, an electromagnetic coil is placed against the scalp, near the patient’s forehead. The
electromagnet delivers a magnetic pulse that stimulates nerve cells in the region of the brain
hypothesized to be involved with mood control, specifically unipolar depression. The proce-
dure itself is painless. In addition, and more interestingly, TMS may activate regions of the
brain that have decreased activity in people with unipolar depression. Since treatment for
unipolar depression involves delivering repetitive magnetic pulses, the procedure is often
called repetitive TMS (rTMS). Even though researchers remain uncertain as to how rTMS
works, the magnetic pulses appear to affect how this part of the brain is working, which in
turn seems to ease unipolar depression symptoms and improve the patient’s mood (Taylor
et al., 2017).

Table 1.2: Common neurotransmitters

Acetylcholine (ACH) Triggers muscle contractions; involved with muscle movement, memory, anger,
and aggression.

Dopamine Involved with muscle movement, mood, motivation, and reward-seeking behav-
ior; also involved with Parkinson’s disease; hypothesized to be involved with
schizophrenia and bipolar disorder.

Gamma-amino butyric
acid (GABA)

Involved with movement and anxiety; involved with anxiety disorders (too little
causes anxiety) and seizure disorder.

Glutamate Involved with memory and learning; hypothesized to be involved with schizo-
phrenia and some substance-related disorders.

Norepinephrine Involved with stress, alertness, arousal, and reward-seeking behavior; hypoth-
esized to be involved with anxiety and mood disorders.

Serotonin Regulates mood, sex drive, appetite, body temperature, and sleep; involved with
depression, eating disorders; may be involved with schizophrenia, bipolar disor-
der, and anxiety disorders.

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Section 1.3 The DSM–5

1.3 The DSM–5
The classification system to which psychologists and other helping professionals refer when
making diagnoses concerning mental health issues is the Diagnostic and Statistical Manual of
Mental Disorders, 5th edition (DSM–5; APA, 2013). This manual has always been published by
the American Psychiatric Association and covers all defined mental illnesses in both children
and adults that were known at the time of publication. The book lists symptoms and signs
that can help categorize the various illnesses. Symptoms are the patient’s subjective descrip-
tion of the complaints that they may have, whereas signs are generally objective observations
made by the diagnostician, from either an interview or some type of test given to the patient.

The Evolution of the DSM
The DSM was first published in 1952 and has undergone several revisions since that time.
The sole purpose of the DSM was to classify and provide a descriptive explanation for all
known mental disorders. The first version was 132 pages long, listed 106 disorders, and
offered concise descriptions of major psychiatric diagnoses. This inventory was an important
advancement in the field of psychology and led to greater reliability of mental illness diagno-
ses because all researchers began to use the same criteria. The second edition was published
in 1968 and included 182 disorders, yet it was quite similar to the DSM–I. Both the DSM–I
and DSM–II emphasized the psychodynamic (Freudian) perspective, yet the DSM–II included
sociological and biological knowledge about each disorder as well.

The third edition of the DSM was published in 1980 and was 494 pages long—quite a bit
longer than the first edition. This edition included many important changes. For example, it
addressed the fact that the first two editions neglected extraneous factors, such as medical
conditions, environmental concerns, and life stressors, that may play a part in the develop-
ment of mental illnesses. The DSM–III, unlike the DSM–I and DSM–II, was based on scientific
evidence. Its reliability was improved with the addition of explicit diagnostic criteria. In short,
the third edition acknowledged that many disorders do not have a single cause but are trig-
gered by the cumulative effect of multiple factors (Mayes & Horwitz, 2005).

The third edition also introduced a new multiaxial system in which disorders were evalu-
ated on five different axes. Many of the disorders listed in the DSM–III have a high level of
co-occurrence with other disorders. This is called comorbidity (Blashfield, Keeley, Flanagan,
& Miles, 2014). However, the idea of comorbidity may not be accurate, per Meghani et al.
(2013), who feel that many disorders could be a variation of a single underlying disorder,
rather than being distinct conditions.

Because of some inconsistencies in the criteria of some disorders, the APA issued a revision of
the DSM–III in 1987 and named it the DSM–III–R. This edition increased the coverage of psy-
chopathologies. The next major revision of the DSM took place in 1994 with the publication of
the DSM–IV, which had 943 pages and covered 373 different diagnoses. Additional revisions
were published in 2000, including some corrections and updates to the content; this was
called the DSM–IV–TR (Text Revision). The latest major revision, published in 2013, is called
the DSM–5. It is about the same length as the preceding edition but fewer diagnoses are now
included (approximately 265, according to a number of articles). Table 1.3 summarizes the
DSM series up to and including the DSM–5. To give you an idea how diagnostic criteria appear
in the DSM–5, refer to Table 1.4, which shows the diagnostic criteria for bulimia nervosa.

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Section 1.3 The DSM–5

Table 1.3: Summary of the DSM series from DSM–I through DSM–5

Version
Year
Published

Length/
# of Diagnoses Description/Changes

DSM–I 1952 132 pages/
106 diagnoses

Concise descriptions of major psychiatric diagnoses.

DSM–II 1968 136 pages/
182 diagnoses

Increased attention given to problems of children and
adolescents with addition of behavior disorders of
childhood–adolescence.

DSM–III 1980 494 pages/
265 diagnoses

Addressed the role of extraneous factors that may play a
role in mental illness, such as medical conditions and life
stressors; introduced the new multiaxial system.

DSM–III–R 1987 567 pages/
292 diagnoses

Increased coverage of psychopathologies.

DSM–IV 1994 943 pages/
373 diagnoses

Included new clinically significant criteria in almost half
the categories.

DSM–IV–TR 2000 943 pages/
373 diagnoses

Some information updated.

DSM–5 2013 947/
265 diagnoses

Some significant changes. For example, Asperger’s
syndrome was dropped, and obsessive-compulsive and
related disorders have their own chapter. The multiaxial
system was removed. Moved from a categorical model,
in which symptoms are based on a checklist format, to a
dimensional model, in which symptoms are organized on
a spectrum from mild to severe.

Source: Adapted from Andreasen and Black (2006).

How Do We Use the DSM–5?
The DSM–5 describes mental disorders and their symptoms and gives statistics and gender
breakdowns for each disorder. This common diagnostic and classification system enables
psychologists and other helping professionals to communicate with each other about specific
disorders, regardless of specialty area. Communicating a diagnosis about a patient to another
mental health professional in a succinct manner is important in trying to get the patient the
help that he or she needs (Lilienfeld, Smith, & Watts, 2013). Using a standardized method of
diagnosis leads to a better understanding of disorders and, as a consequence, better treat-
ment. For issues regarding self-diagnosis, see the accompanying Highlight.

There must be a high degree of reliability when a standardized classification system is used.
Reliability refers to the consistency of the diagnostic system. Interrater reliability means that
a test will have the same or similar results when used by different people.

The validity of a classification system, that is, the measurement or accuracy of the information
in the diagnostic categories, is also clearly important. In other words, does the test measure
or predict what it is supposed to? If it does, then we can say that the assessment technique
is valid. For example, does an intelligence test really measure intelligence? It may measure
“book smarts” but not “street smarts,” which is a type of intelligence.

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Section 1.3 The DSM–5

Table 1.4: How the DSM–5 summary table appears for bulimia nervosa

DSM–5 Diagnostic Criteria for Bulimia Nervosa (307.51)

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely

larger than most people would eat during a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or

control what or how much one is eating).
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomit-

ing; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for

3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Specify if:
In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria
have been met for a sustained period of time.
In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met
for a sustained period of time.
Specify current severity:
The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below).
The level of severity may be increased to reflect other symptoms and the degree of functional disability.
Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week. Moderate: An average
of 4–7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8–13 episodes of
inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate
compensatory behaviors per week.

Source: American Psychiatric Association (APA, 2013, p. 345).

Highlight: Do I Have a Mental Illness?

Have you ever felt sad or lonely and sat down in front of the television with a pint of ice
cream to make yourself feel better? Did you feel like throwing up afterward? Does this
mean that you have bulimia nervosa? Does it mean you are depressed? If you are like many
students, you may be tempted to self-diagnose your own behaviors as you learn about the
disorders described in the remainder of this book.

It may be that you are neither bulimic nor depressed, but you may have another condition:
medical student syndrome (sometimes called medical school syndrome), wherein medical
students often begin to believe that they are suffering from the disease they are studying.
Consider that everyone overeats at some point in their lives, and everyone has days, perhaps
many in a row, when they feel blue or depressed. We are all human and, like all humans, we
have good days and bad days, and the bad days may sometimes include behaviors that could
be mistaken for mental illness symptoms. However, rest assured that the diagnostic criteria
in the DSM–5 (American Psychiatric Association [APA], 2013) require, in most instances, a
duration of several months to at least two years before any diagnosis can be made. If your
behaviors are brief and occur only occasionally, you are probably acting “normally” and have
little to worry about. You will learn more about symptoms and diagnosis of disorders in later
chapters. If after reading more, you still think you may be suffering from mental illness, by
all means, we encourage you to seek help. One resource is the National Alliance on Mental
Illness (http://www.nami.org/).

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Section 1.3 The DSM–5

The number of disorders now listed in the DSM–5 may make it easier to diagnose more indi-
viduals as having disorders. Although this results in several more types of mental illnesses,
they are more distinct from each other now than they were several years ago. Nevertheless, the
problem remains: How do you diagnose someone who meets only three of the four required
symptoms of a disorder? For example, someone who is anxious also commonly suffers from
depression. That means that this particular individual will now have two different diagnostic
labels—not just a single one that may encompass both aspects of the individual’s disorder.

It is important to note that the DSM-5 is not immune from social and political influence. Some
observers in the field believe that the most recent revisions align more with what the major
drug companies want to see, thus leading to more medications being prescribed (as discussed
in Frances, 2012). For more on the DSM–5 and its contexts, see the accompanying Highlight.

Highlight: Removing Disorders From the DSM

Did you know that until the DSM–III was published in 1980, homosexuality was considered
to be a mental illness or disorder? The DSM task force decided to eliminate homosexuality
in December 1973; this took place with the seventh printing of the DSM–II in 1974.
Technically, however, homosexuality was not completely removed (that is, not mentioned
at all) until the DSM–III was published. Also, did you know that Asperger’s syndrome (a
pervasive developmental disorder that is a higher functioning form of autism) has now been
reclassified as an autism spectrum disorder? If nothing else, these changes show how our
views of what constitutes mental illness, how it is defined, and what each diagnosis entails,
have changed over the years. What are your views on this subject?

The Medical Model
All mental illnesses described in the DSM–5 are seen as having similar symptoms in common
within each diagnostic category and subcategory (APA, 2013). For example, all individuals
suffering from bulimia nervosa will demonstrate binging behaviors as well as recurrent inap-
propriate compensatory behaviors (self-induced vomiting, abuse of laxatives, fasting, and so
on). The mental illnesses listed in the DSM–5 are seen as being similar to physical diseases
(that is, all influenzas have the same general symptoms, all bronchial pneumonias have simi-
lar symptoms), hence, the term medical model. In addition, there is thought to be a physi-
ological basis or cause for the individual’s problem(s). Those who endorse the medical model
consider symptoms to be visible signs of the physical disorder. Therefore, if symptoms are
grouped together and classified into a disorder such as bulimia nervosa, the true cause can
eventually be discovered and appropriate physical treatment administered. The behaviors
that one demonstrates (hallucinations, depressed mood, fear of heights, and so on) are con-
sidered to be symptoms of a mental illness. The symptoms are clustered together to define
various mental illnesses. When psychologists attempt to diagnose a new patient, they will look
at symptoms and see into which DSM–5 category the symptoms fit. This is critical because it
allows the helping professions to have a common language in which to communicate.

Many students, when they first encounter the DSM–5, have the following reaction: “Well,
where does this book tell me how to treat this complicated disorder?” The DSM–5 does not

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Chapter Summary

include treatment information; it is only, as its title states, a diagnostic manual that describes
the disorders. Psychologists and others in the helping professions learn how to treat mental
illnesses by direct practice, classwork, and, of course, studying and reading. We will discuss
how to treat the most commonly presented mental illnesses in the remainder of this book.

What DSM–5 Disorders Are Covered in This Book?
It is impossible to address all 265 DSM–5 disorders in the space of this book. We will cover the
following main categories of mental disorders, as listed in the DSM–5:

• Trauma and stressor-related disorders (including posttraumatic stress disorder)
• Anxiety and obsessive-compulsive disorders
• Substance-related and addictive disorders
• Dissociative disorders and somatic symptom and related disorders
• Depressive and bipolar disorders
• Sleep-wake, feeding, and eating disorders
• Schizophrenia spectrum disorders
• Personality disorders
• Neurocognitive disorders
• Neurodevelopmental disorders
• Sexual dysfunctions, paraphilic disorders, and gender dysphoria disorders

Chapter Summary

How Do We Define Abnormal Behavior?
• The statistical frequency perspective labels behavior as abnormal if it occurs rarely

in relation to the behavior of the general population.
• The social norms perspective considers behavior to be abnormal if the behavior

deviates greatly from accepted social standards, values, or norms.
• The maladaptive perspective views behavior as abnormal if it interferes with the

individual’s ability to function in life or in society.

A History of Theoretical Orientations for Abnormal Behavior
• During ancient times, mental illness was explained as the presence of evil spirits

within the body of the ill person. One method for treating mental illness was trepan-
ning, in which a small instrument was used to bore holes in the skull to allow the evil
spirits to leave the “possessed” person.

• Hippocrates noted a connection between abnormal behavior and internal, physi-
ological causes.

• Sigmund Freud and Josef Breuer noticed that some of their patients presented physi-
ological symptoms while having no physiological problems. Freud realized that one
way to help these individuals was via psychoanalysis, or talk therapy.

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Chapter Summary

• Freud’s theory includes the ideas of repression and the psyche, which consists of the
id, the ego, and the superego; this theory emphasizes the importance of examining
people’s unconscious minds.

• B. F. Skinner and John Watson believed that abnormal behavior was environmentally
caused, as an individual’s behavior was reinforced in the environment, therefore
making it more likely to recur.

• Albert Ellis, Albert Bandura, Aaron Beck, and Martin Seligman believed that a per-
son’s thoughts (irrational, maladaptive, or otherwise) lead to, or cause, a person’s
aberrant or abnormal behaviors. Bandura believed that a person learns abnormal
behaviors by watching others perform them, and then the individual reproduces (or
“models”) what he or she sees.

• Carl Rogers believed that all humans are innately good and that problems arise
when an individual is incongruent, that is, experiencing a mismatch between his or
her idealized self-image and his or her true self-image.

• The diathesis-stress model posits that abnormal behavior originates from a combi-
nation of genetic factors (the diathesis) triggered or “turned on” (like a light switch)
by environmental stressors.

• Biological models view mental illness as having biological origins, specifically
neurotransmitter levels being too low or too high. In these models, medications are
often used to treat mental illnesses.

The DSM–5
• The DSM–5 describes mental disorders, their signs and symptoms, and gives statis-

tics and gender breakdowns for each disorder.
• Comorbidity means that disorders seem to “go together” or appear at the same time

in the same individual.
• The medical model views all mental illnesses described in the DSM–5 as having simi-

lar symptoms in common within each diagnostic category and subcategory.

Critical Thinking Questions
1. What criteria would you use to determine whether someone’s behavior is abnormal

or not?
2. Discuss whether social norms should be used to diagnose mental illness.
3. What are your views on the reasons people carry out mass shootings? What could

lead someone like Adam Lanza to murder more than 20 young children?
4. Behaviorists like Skinner focus on the present, not on the past or on a person’s

upbringing. How successful would this approach be in psychotherapy, and why?
5. Which of the theories mentioned in this chapter do you think best explains the ori-

gins of mental illness? Why?
6. What are your views on Rogers’s concept of innate goodness? Do you think people

are innately good or bad?
7. Give your perspectives on the use of ECT. Additionally, discuss whether TMS is a

viable treatment modality.
8. What are the pros and cons of using medications to treat mental illnesses?

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Chapter Summary

Key Terms
ABC model A model of three components
of how we experience and interpret events:
A, the activating event or adversity; B, the
belief that follows; and C, the consequence.

age of onset The age at which the trouble-
some behaviors first become noticeable.

behaviorists Psychologists who believe
that only observable and scientifically mea-
surable behaviors are worth studying and
investigating.

bipolar disorder A disorder with two
poles and two dysfunctional mood states—a
manic state and a depressed state.

cognitive behaviorism A psychotherapeu-
tic method that alters distorted attitudes by
identifying and replacing negative and inac-
curate thoughts, which will therefore lead to
behavioral changes.

cognitive perspective theory Aaron Beck’s
theory that abnormal behavior is caused by
faulty thinking such as viewing life events in
a negative fashion.

comorbidity When one or more disorders
co-occur or overlap.

diathesis-stress model A model that con-
tends behaviors are a product of both genet-
ics (biology) and environmental stressors.

duration The length of time the trouble-
some behaviors have existed for a patient.

eccentric Individuals who have odd or
unusual habits but do not have a mental
illness.

ego A partially conscious part of the psyche
(which develops when an infant is between
1½ and 3 years old) that seeks to control
the id by “convincing” it to delay gratifica-
tion until a reasonable solution to the drive
reduction is found.

electroconvulsive therapy (ECT) Also known
as electroshock therapy, and often referred to
as shock treatment; a psychiatric treatment
in which seizures are electrically induced in
patients to provide relief from psychiatric ill-
nesses, mostly for unipolar depression.

general paresis An incurable physical
disorder that has both physical and mental
symptoms.

id The primitive part of the personality,
present from birth, that houses our uncon-
scious desires, wishes, and our basic innate
drives such as sex and aggression.

insulin shock therapy (insulin coma
therapy) A form of psychiatric treatment
in which patients were repeatedly injected
with large doses of insulin to produce daily
comas over several weeks; this would pre-
sumably calm agitated patients.

intensity How extreme the behaviors in
question are.

learned helplessness Seligman’s theory
that individuals develop depression or anxi-
ety disorders because they see themselves
as helpless to control their environments.

legal norms Rules for behavior based on
society’s laws.

lobotomies A type of psychosurgery (surgery
for a psychological purpose) that destroys
brain tissue to change a person’s behavior.

maladaptive perspective Behavior is
deemed abnormal if it interferes with the
individual’s ability to function.

medical student syndrome The syndrome
in which medical students begin to believe
they are suffering from the disease they are
studying.

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Chapter Summary

modeling The idea that we can learn by
observing the behavior of others.

negative schema A view of the world that
is negative or pessimistic. Beck believed this
to be the cause of depression.

neurotransmitters Brain chemicals; they
are presumed to be at subnormal or super-
normal levels in individuals with mental
disorders.

norms Spoken and unspoken rules for
proper conduct that are established by a
society over time and are subject to change
over time.

overt behaviors Behaviors that are on the
surface or clearly visible to others.

psyche In Freudian theory, this consists
of three parts: the id, the ego, and the
superego.

psychoanalytic theory The set of con-
cepts wherein individuals develop neuro-
ses because of their unresolved conflicts,
repressed id impulses surfacing and over-
whelming the ego and the superego, and
problems that occurred during childhood.

psychological norms Rules for behavior as
codified in the DSM–5.

psychopathology The study of the causes
and development of psychiatric disorders.

psychopharmacology The study of the
treatment of mental illnesses with drugs and
medication.

reformulated helplessness theory
A revised version of the helplessness theory
that differentiates between universal and
personal helplessness, as well as between
helplessness that is general or specific.

repetitive TMS (rTMS) A treatment for
unipolar depression that involves deliver-
ing repetitive magnetic pulses to the brain’s
nerve cells.

repression An ego defense mechanism
that operates unconsciously to keep certain
ideas, impulses, and memories from reach-
ing consciousness.

social norms perspective Behavior is
deemed abnormal according to the stan-
dards set by society.

statistical frequency perspective Behav-
ior is deemed abnormal because it occurs
rarely or in only a small minority of the
population.

superego The final part of the psyche; it
develops when a child is between 3 and 6
years old and enables the individual to feel
guilt and have a conscience. The superego
is partially conscious and helps the ego to
control the id’s desires.

transcranial magnetic stimulation (TMS)
A noninvasive procedure that uses magnetic
fields to stimulate nerve cells in the brain to
improve symptoms of depression.

trepanning A process in which a small
instrument is used to bore holes into the
skull; the purpose may have been to release
evil spirits from an afflicted person.

unconditional positive regard When
one person is completely accepting toward
another person. Rogers believed that people
who receive unconditional positive regard
from their parents early in life will grow
up to become constructive and productive
adults.

unipolar depression Known just as
depression to most people; this depression
has one “pole” or dysfunctional mood state.

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2 Stress, Trauma, and Related Disorders

gpointstudio/iStock/Thinkstock

Learning Objectives

After reading this chapter, you should be able to:

• Define stress and explain where it comes from.

• Discuss both the physical and psychological sources of stress.

• Analyze the direct and indirect ways stressors affect both psychological and physical health.

• Understand the causes and treatment modalities for posttraumatic stress disorder.

• Understand acute distress disorder.

• Explain the interplay between physical and psychological illnesses.

• Explain why some people are more prone to suffer from the effects of stress than others.

• Explain methods that can be used to help people better cope with stress.

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Section 2.1 Stress: Origins, Definitions, and Theories

2.1 Stress: Origins, Definitions, and Theories
The word stress is used widely in both psychological writing and the popular press, so widely
in fact that its meaning is not always clear. Stress is used to refer to both a cause (a “stressful”
job, for example) and an effect (“I am feeling stressed”). Our understanding of what stress is
and how it affects us has changed and evolved throughout history. This chapter examines the
concept of stress from the historical, biological, social, and psychological perspectives.

Origins: 460 BCE–1600s
Hippocrates often referred to the effects of the emotions on health. For example, the ancient
Greek teachers advised doctors to maintain a calm demeanor lest their patients become
frightened. Showing fear, they believed, would exacerbate a patient’s symptoms. Aristotle
added anger as another emotion that, like fear, could cause illness. For centuries, doctors
continued to believe in a causative link between strong negative emotions and illness, but
this connection was broken in the Renaissance by the European philosopher Rene Descartes,
who argued that the body and the esprit (French for “soul” or “mind”) were separate entities
that communicated through the pineal gland found at the base of the brain. This philosophical
position has come to be known as Cartesian dualism.

Later Years: 1800s–1900s
The classical view began to reemerge in the middle of the 19th century when doctors first
began to observe an illness called neurasthenia (“nerve weakness”; Paciaroni & Bogousslavsky,
2014). The symptoms of neurasthenia included fatigue, aches and pains, sore throat, and
low-grade fever. No physiological cause for neurasthenia was uncovered; it was blamed on
hard work, striving for success, and changing sex roles. Neurasthenia is important, however,
because its attribution to psychosocial causes provided the groundwork for Sigmund Freud’s
claim that the physical symptoms of hysteria were the bodily manifestations of emotional
traumas experienced in early childhood.

According to Freud, childhood emotional traumas leave a residue of psychic energy that can
be “converted” into physical symptoms. Indeed, followers of Freud often referred to hysteria
manifested by physical symptoms as conversion hysteria. Note that hysterical symptoms
often mimic those associated with physical disorders (such as blindness, deafness, and paral-
ysis), but Freud did not consider hysterical patients to be physically sick (although prominent
neurologists such as Charcot disagreed).

Psychosomatic Medicine
The field that came to be known as psychosomatic medicine received a considerable boost in
scientific respectability from the work of the Harvard physiologist Walter Cannon. Accord-
ing to Cannon (1939), organisms (people) faced with a threatening stimulus mobilize their

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Section 2.1 Stress: Origins, Definitions, and Theories

physiological resources to combat or escape the
threat (“fight or flight”). Cannon called the physi-
ological response to threat the emergency reac-
tion (or alarm reaction) and showed that it is con-
trolled by the sympathetic nervous system (see
Figure 2.1) and by hormones secreted mainly by the
adrenal glands. Once the person has safely escaped
or defeated the cause of the threat, the emergency
reaction dissipates. However, if the threat persists,
the emergency reaction may begin to affect a per-
son’s health.

General Adaptation Syndrome
The emergency reaction described by Cannon is
the body’s way of coping with immediate threats.
However, the emergency reaction cannot persist
indefinitely. Long-term or frequently recurring
threats cause the body to gradually wear out. Dete-
rioration takes place in a series of stages described
by the medical physiologist Hans Selye as the gen-
eral adaptation syndrome, or GAS (Selye, 1950).
According to Selye (1950), stress is the body’s non-
specific response to any demand made upon it. Not
everyone reacts the same to stressful events, of
course. For a student who receives weekly allergy
shots, getting a more painful cortisone injection into
a finger might not cause them a lot of stress. But to
someone who has a fear of injections, the possibility
of getting a painful injection could cause extreme
stress, perhaps even an avoidance response.

The general adaptation syndrome occurs in three stages: alarm, resistance, and exhaustion
(Selye, 1950). The three stages are associated with biological markers such as changes in
hormone patterns, the production of more stress hormones, and the gradual depletion of the
body’s energy resources. GAS begins with a stressor that produces an emergency reaction.
Following the emergency reaction, the person enters what is known as a resistance stage. If
the emergency reaction can be described as the mobilization of the body’s defenses, then the
resistance stage is similar to all-out war. During the resistance stage, the person uses his or
her physiological resources to minimize tissue damage. At the same time, the adrenal glands
release corticosteroids (“stress hormones”), which further increase blood sugar for energy
while reducing inflammation and pain. Body functions that are not directly related to avoiding
harm (reproduction, digestion, growth) are gradually shut down. This only works for a time,
however. If the threat persists, the body’s defenses become progressively depleted. In the final
stage, called exhaustion, illness becomes likely. Selye’s view of GAS is depicted in Figure 2.1.

Bettmann/Getty Images
According to Walter Cannon, individu-
als undergo a physiological response
when faced with a threatening
stimulus and use these physiologi-
cal resources to combat or escape the
threat. Cannon called the physiological
response the emergency reaction or
alarm reaction.

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Section 2.1 Stress: Origins, Definitions, and Theories

Figure 2.1: Selye’s general adaptation syndrome (GAS)

Long-term or frequently recurring threats will eventually cause the body to wear out. Selye’s general
adaptation syndrome, or GAS, describes these steps. This model begins with the alarm stage, which is
a short-term, immediate response to a crisis through sympathetic system activation and epinephrine
release and is often called “fight-or-flight.” In the resistance stage, long-term metabolic adjustments
occur. Next is the exhaustion stage, which includes the collapse of vital systems. These three stages
gradually lead to death.

Source: From Martini, Frederic H., Fundamentals of Anatomy and Physiology, 1st ed., ©1989. Reprinted by permission of Pearson
Education, Inc., New York, New York.

Causes may include:

Exhaustion of lipid reserves

Inability to produce glucocorticoids

Cumulative damage to vital organs

Alarm phase Sympathetic system activation and epinephrine release:

1. Mobilization of glucose reserves

2. Changes in circulation

3. Increases in heart and respiratory rates

4. Increased energy use by all cells

“Fight or flight”

Immediate, short-term
response to crisis

Resistance phase 1. Mobilization of remaining energy reserves
Adipose tissue releases lipids
Skeletal muscles release amino acids

2. Elevation of blood glucose concentrations.
Liver synthesizes glucose from amino acids and lipids.

3. Conservation of glucose.
Peripheral tissues break down lipids to obtain energy

Long-term metabolic
adjustments occur

Exhaustion phase

Collapse of
vital systems

Death

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Section 2.2 Sources of Stress

Any form of external pressure can trigger GAS. People who have particularly demanding jobs
(such as the U.S. president, emergency department doctors, or emergency medical techni-
cians) may experience the first stages of GAS every day. We can cope with moderate levels
of stress, but extreme stress causes us to break down and become ill (Alevizos, Karagkouni,
Panagiotidou, Vasiadi, & Theoharides, 2014). For example, stress can bring about and worsen
conditions such as asthma and atopic dermatitis, and may bring about coronary inflamma-
tion and worsen allergies (Alevizos et al., 2014).

What Constitutes a Stressor?
Selye preferred to use the word stressor to refer to causes, reserving the word stress for the
results produced by a stressor. Over the years, the boundaries of what constitutes a stressor
have been extended gradually. Stressors have come to include not only physical threats, but
also emotional experiences (divorce, for example), unpleasant internal states (fatigue), and
the subjective feeling of being under pressure. With such a broad definition, practically any-
thing can be a stressor, but all stressors are related in one very important way—they have the
potential to trigger a strong emotion leading to GAS.

Selye believed that the effects of stress are nonspecific. The same physiological response
can lead to widely different conditions. To explain why people develop different illnesses in
response to stress, Selye postulated that genetic weaknesses, inadequate diet, infections, and
other individual differences mediate the effects of stress. The specific mechanisms by which
stress interacts with these mediating factors to produce illness are discussed next.

2.2 Sources of Stress
To summarize our discussion of stress so far, stress and physical illness go together. This is
true not just for traditional psychosomatic conditions such as peptic ulcer but also for meta-
bolic conditions such as diabetes. In addition, catastrophes, important life events, and every-
day hassles can also cause significant stress. This section will cover these latter sources of
stress first, and then look at health issues, using diabetes to illustrate how stress affects physi-
cal health as well as mental health.

Catastrophes
When asked to imagine the psychological and social causes of stress, most people immedi-
ately think of large-scale cataclysmic events: floods, earthquakes, airplane accidents. A cata-
clysmic event is dreaded more than a common disease that affects one person at a time, even
when the common disease kills more people. This excessive fear of horrific events seems to
have negative effects on health. One reason for the extreme stress produced by cataclysmic
events is their unpredictability. Most of us go through life with optimistic attitudes. We act
as if disasters happen only to others. When we are asked about the probability of having a
car accident, going bankrupt, or dying young, most of us rate our luck as better than average
(Trumbo, Meyes, Marlatt, Peek, & Morrissey, 2014). This concept is called comparative opti-
mism, or optimistic bias: the belief that we are less likely than other people to be harmed by

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Section 2.2 Sources of Stress

bad events. We seem to share an illusion of
invulnerability (“Bad things won’t happen
to me”). Catastrophes (momentous tragic
events that can range from a moment of
very bad luck to a moment where the per-
son’s life or livelihood is ruined or ended)
shatter this protective illusion; they show
us how tenuous our good luck really is. This
is why catastrophes frighten us more than
more common killers such as diabetes. It is
also why horrific experiences that threaten
people’s lives may produce symptoms long
after the original event (see the discussion
of posttraumatic stress disorder [PTSD]
later in this chapter).

Important Life Events
Most stressors are fairly common—job loss, bereavement, divorce. These types of negative
life events can lead to what the DSM–5 calls adjustment disorders, psychological disorders
marked by anxiety, depression, withdrawal, and overall impairments in psychological func-
tioning (American Psychiatric Association [APA], 2013). These common life events also have
the power to make people physically ill, or perhaps even lead to death. Interestingly, posi-
tive life events, such as getting married, having a child, or getting a new job that you always
dreamed about, can also be considered stressors.

One of the first researchers to study the relationship between life events and illness in a sys-
tematic way was the psychiatrist Adolf Meyer (1866–1950), an early adherent of Freud. To
study the effects of stress, Meyer devised the “life-chart” technique. He would draw a time line
(a graph of dates) with a person’s illnesses on one side and significant life events on the other.
Meyer claimed that illnesses often appeared just after significant life changes (especially job
loss and separation).

Over the years, considerable evidence has been amassed to support Meyer’s claim. For exam-
ple, long-term unemployment has been found to be related to various illnesses, including
heart disease, cirrhosis of the liver (probably from overuse of alcohol), hypertension, various
psychiatric conditions, and suicide (Brand, 2015). Unemployment reduces self-esteem and
makes people dependent on others (Brand, 2015).

Meyer’s work influenced Thomas Holmes, a medical doctor who became interested in the
relationship between life events and illness (Holmes & Rahe, 1967). Holmes routinely asked
patients about their personal experiences before they had become ill. Like Meyer, he found a
relationship between life changes and illness. By studying medical charts, Holmes produced
a list of life events that seemed most often to precede illness. Holmes assumed that any life
change, positive or negative, could produce stress if it required an adjustment in the way a
person had previously lived.

AP Photo/Stuart Ramson
The possibility of horrific events engenders
immense stress or fear in many people, largely
due to their unpredictability.

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Section 2.2 Sources of Stress

Following Holmes, scientists have repeatedly demonstrated the role of stressful life events
in various physical and mental illnesses (Ezeamama et al., 2016). Despite these findings, the
relationship between life-stress and illness should be interpreted with caution. When stress-
ors such as traumas and chronic negative events are measured, their impacts on physical and
mental health are substantial (Ezeamama et al., 2016). Moreover, even strong correlations
cannot be taken as evidence that life-stress causes illness. They could just as easily mean that
illness causes life-stress.

Everyday

Hassles

The average day is full of hassles. Daily
annoyances plague all of us: spending time
in rush-hour traffic, waiting at the bank,
dealing with noisy neighbors, getting caught
in the rain or snow, losing house keys. If we
are lucky, we also have positive experiences:
visiting with friends, performing well at
school or at work, dining out.

Daily hassles can take their toll. For exam-
ple, busy urban white-collar workers, who
are exposed to many more daily annoyances
than their rural counterparts, are consider-
ably more likely to suffer from headaches,
peptic ulcers, and hypertension (De Brou-
wer et al., 2014). The inflammation that
causes so much pain to arthritis sufferers is
exacerbated by daily hassles (De Brouwer et
al., 2014). Pregnant women whose lives are full of hassles are more likely to have premature
and low-birth-weight babies than are women with more relaxed personal lives (Bussières et
al., 2015). Studies of those with diabetes have shown mixed results, with both positive and
negative associations, due to differences in the studies’ designs and methodologies (Joseph
& Golden, 2017). Other researchers have found positive associations between diabetes and
stress (Smith et al., 2013).

Chronic

Illness

A chronic illness such as diabetes may itself be a significant source of stress (Franks, Lucas,
Parris-Stephens, Rook, & Gonzalez, 2010). For those with diabetes, frequent absences from
class or work and concern about future diabetes-related medical conditions are facts of life.
Additionally, those with insulin-dependent diabetes need to be diligent about watching their
sugar intake, monitoring their blood sugar levels, and adjusting their insulin dosages. When
one adds all of these concerns to a perhaps already too busy life, stress can result.

Raquel Carbonell/age fotostock/SuperStock
Everyday hassles, like crowded intersections
and rush-hour traffic, can take their toll on the
human body. Urban workers are more likely
to experience hypertension, peptic ulcers, and
headaches, whereas rural inhabitants are less
likely to suffer from these ailments.

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Section 2.2 Sources of Stress

Chronic Pain and Headaches
Although pain is not itself an illness, it has the capacity to affect every aspect of our lives. The
acute pain that accompanies a toothache or an illness or injury can keep us from thinking
about anything else. This type of severe pain can affect immune system functioning (Hatfield
& Umberger, 2015). Fortunately, healing usually ensures that acute pain will subside over
time. In contrast, chronic pain persists indefinitely. Often, this type of pain leads to depression
(Zhu, Galatzer-Levy, & Bonanno, 2013). But not all studies see as strong a connection between
chronic pain and unipolar depression (Rayner et al., 2016). This discrepancy demonstrates
that research on some concepts has inconsistent conclusions. You will see this again in later
chapters.

More than 25% of Americans are estimated to suffer from some form of chronic pain, with
current estimates ranging from 30% to 40% of the U.S. adult population (Gatchel, McGreary,
McGreary, & Lippe, 2014). Americans spent about $2.6 billion on over-the-counter pain medi-
cations and another nearly $14 billion on outpatient analgesics in 2004 (Kingsbury, 2008).
More recent data show that the annual cost of chronic pain in the United States is between
$560 and $635 billion (Gatchel et al., 2014).

Although chronic pain often has a physiological trigger, it may be exacerbated by stress. In
severe cases, chronic pain may even be considered a psychological disorder. For example,
the DSM–IV–TR (APA, 2000) contained diagnostic criteria for pain disorder. The criteria for
this disorder included severe pain that is not feigned and that causes distress or impairment
in social, occupational, or other areas of functioning. Most important are the onset, severity,
exacerbation, or maintenance of the pain. The validity of the pain disorder diagnosis was a
controversial subject. Some authors claimed that it was too inclusive and might lead to over-
diagnosis (Fishbain, 1996). Because of the controversy, pain disorder was removed from
the DSM–5 and was replaced with somatic symptom disorder, with predominant pain (APA,
2013). Regardless, all observers agree that pain is worsened by stress.

We also know that individuals may react very differently to the same level of pain: Some may
continue work and social activities; others may drop out of life completely (Jensen, Schmidt,
Pedersen, & Dahl, 1991). Those who cope well are optimistic, have good support networks,

and feel in control of their lives (Hanssen, Vancleef,
Vlaeyen, & Peters, 2014). These characteristics also
describe people who are resistant to stress.

Approximately 42% of the world’s adult popula-
tion experiences headaches each year (Ferrante
et al., 2013; Palacois-Cena et al., 2017). Over the
years, complicated classification systems have been
developed to characterize different types of head-
aches, but the two most common are tension and
migraine. Tension headaches were traditionally
thought to result from tense muscles in the neck
and head, whereas migraines are thought to be
caused by the contraction and dilation of blood ves-
sels in the head. Migraines are more severe than
tension headaches, often requiring a day or more to

Christopher Robbins/DigitalVision/Thinkstock
Around 42% of the world’s adult
population suffers from headaches
each year.

get83787_02_c02_027-060.indd 34 2/16/18 4:37 PM

Section 2.3 Effects of Stress

resolve. Some research suggests that the differences between the two types of headaches are
not so clear-cut; both types of headaches seem to be associated with the same physiological
phenomena (Waldie, Buckley, Bull, & Poulton, 2015). Therefore, it is possible that migraines
and tension headaches have similar causes but that migraines represent a more severe form
of headache.

Psychological variables moderate pain in two ways: through inhibition of pain impulses and
by the production of chemicals called endogenous opioids (endorphins). In its simplest form,
psychological inhibition can be construed as shutting the “gate” that allows pain stimuli to be
transmitted to the brain (Melzack & Wall, 1982). According to the gate control theory, pain
stimuli are transmitted to the brain via the dorsal horns of the spinal column, which serve as
a kind of gate. Pain stimuli open the gate, but inhibitory signals sent by the brain can close
the gate and keep pain stimuli from reaching the brain. This seems to be what happens when
soldiers are injured in battle; some do not feel any pain until after the battle is over (Melzack
& Wall, 1982). Endorphins are chemicals produced by the body that, like opiates (heroin,
for instance), can serve to reduce pain. Some evidence indicates that people who cope well
with their pain produce higher levels of endorphins than do those who fail to cope (Bandura,
O’Leary, Taylor, Gauthier, & Gossard, 1987). It seems possible that, in addition to the endor-
phins, we may also have specialized chemical pain-reduction systems (Chapman, Tuckett, &
Song, 2008).

2.3 Effects of Stress
To understand the complex web of interactions between external stressors and the stress
produced by chronic illness, we need to take a closer look at the precise mechanisms by which
stress exerts its effects on physical and psychological health. Specifically, we will examine two
ways in which stress affects health: (a) the direct effects of stress on physiological functioning
and (b) the indirect effects of stress on health-relevant behaviors.

Direct Physiological Effects of Stress
As we have seen in the discussion of the general adaptation syndrome, stress has direct effects
on physiological functioning. As shown in Figure 2.2, stress causes the release of certain hor-
mones, which increases the rate of blood clotting, raises respiration and blood pressure, and
prepares the body for exertion.

The direct effects of stress on physiological functioning have also been implicated in cardiac
arrest (heart attack) and stroke (when brain damage results from ruptured or blocked blood
vessels). According to Sapolsky (1992), the corticosteroid hormones produced by GAS have
both beneficial and harmful effects. They reduce inflammation and inhibit pain, but they may
also weaken neurons, especially in the hippocampus. In the short term, the body produces
special proteins to protect neurons and other cells from hormone damage, but their effective-
ness weakens with prolonged or repeated stress (Marcuccilli & Miller, 1994). Once the hippo-
campus has been weakened, it can no longer play its moderating role, and the stress response
becomes difficult to “turn off.”

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Section 2.3 Effects of Stress

Indirect Effects of Stress on Health

Effects of Stress on Cognition
Stress exerts profound effects on memory, judgment, and other aspects of cognition (Vogel,
Fernández, Joëls, & Schwabe, 2016). Studies of airline pilots, for example, have shown that
as they become increasingly stressed, they become less alert. They have attention lapses and
become easily distracted. Stress does seem to be a factor for pilot burnout (Yang, Zhao, Wu,
& Lu, 2014).

The effects of stress are insidious because they are not immediately apparent to the indi-
vidual concerned. Even when they were slow to respond to their instrument readings, pilots
believed they were as efficient as they were when not under stress.

Figure 2.2: Corticosteroid release in response to stress

When the brain perceives a stressor, the hypothalamus releases CRF (corticotropin releasing factor) and
other hormones. The CRF triggers the release of ACTH (adrenocorticotropic hormone, or corticotrophin)
in the anterior pituitary. The ACTH travels in the bloodstream to the adrenal glands, where it triggers the
release of corticosteroids.

Source: Robert Sapolsky, Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, Stress Related Diseases, and Coping. San Francisco:
W.H. Freeman, 1998, p. 33. Reprinted by permission.

Hypothalamus

CRF
Posterior pituitary

Anterior pituitary

Glucocorticoids
(corticosteroids)

ACTH

Adrenal gland

Kidney

Stressor

get83787_02_c02_027-060.indd 36 2/16/18 4:37 PM

Section 2.3 Effects of Stress

However, stress tends to affect information-processing capacity in complex ways (Critten-
den & Heller, 2017). Stress does not always lead to poor decision making. Moderate amounts
of anxiety (such as that produced by an upcoming performance, for example) may actually
serve to focus attention on essential information. However, high levels of stress can shrink
information-processing capacity to the point where important information is ignored. Studies
of airline pilots have found them more likely to read their instruments incorrectly when flying
in bad weather. Presumably, this is because coping with a storm produces stress (Broadbent,
1973). Perhaps this a more relevant analogy: When a student procrastinates and waits until
the last minute to complete a 10-page paper, the closer the student gets to the deadline, the
more stress is induced, which makes it more likely the student will leave out the main points
required for a good paper.

The Stress-Illness Cycle
As already noted, illness can be a source of stress. It can interfere with cognitive and emo-
tional functioning and exacerbate the effect of external stressors. Illness can also produce
stress through its effects on social functioning. Some illnesses produce stress because they
are perceived as a sign of weakness. For example, people with liver disease resulting from the
overuse of alcohol and people with AIDS resulting from intravenous drug use are often stig-
matized and shunned because their illness is perceived as self-inflicted (Weiner, 1993), and
this stigmatization can cause stress.

Clinical psychologists need to be sensitive to the many ways in which physical, social, and psy-
chological factors interact. Helping people requires that we somehow prevent the tendency
for stress and illness to feed off one another. However, before we examine how this might
be accomplished, we need first to examine why some people seem better able to withstand
stress than others. Specifically, we need to understand differences in coping skills.

Let’s examine the case study of William Cole.

The Case of William Cole: Part 1

University Hospital Psychology Service

CONFIDENTIAL

Consultation Note

Psychologist: Dr. Stewart Berg

Referral: Dr. M. Jankowitz

Reason for Referral: The client was brought to the Emergency Room in a diabetic coma. He
responded well to medical treatment, but he seemed withdrawn and complained of chronic
headaches. Dr. Jankowitz requested advice about the patient’s state of mind and about the
potential for his mental state to affect his illness.

(continued)

get83787_02_c02_027-060.indd 37 2/16/18 4:37 PM

Section 2.4 Posttraumatic Stress Disorder (PTSD)

Stress can have a profound psychological effect on the individual, as we will see in the next
section, in which we examine posttraumatic stress disorder (PTSD).

2.4 Posttraumatic Stress Disorder (PTSD)
Posttraumatic stress disorder (PTSD) existed long before the Vietnam War, but it had not
been formally identified as a diagnosable condition. PTSD was previously known as “shell
shock,” initially identified by Myers (1915), or “battle fatigue.” In 1980, the newly published
DSM–III gave the disorder a name. PTSD was defined as an extreme anxiety response to trau-
matic, life-threatening events that were “outside the range of normal human experience.” By

The Case of William Cole: Part 1 (continued)

Behavioral Observations: William Cole is an 18-year-old African American male. He is of
average height but rather thin. He was neatly dressed and clean shaven. He entered my office
slowly and hesitantly. Although he cooperated by answering questions, he volunteered little
and seemed withdrawn. He avoided making eye contact, and his facial expression was tense.
He frequently held his forehead in his hand.

History: William is a first-year student and the first member of his family to attend college.
He is assisted by a student loan and has a job working in the library. His father works in
an automobile factory, and his mother is a telephone company employee. They live in Los
Angeles and see their son on holidays. He calls home every Sunday.

William reports being an athletic child with a close group of same-sex friends. He first
learned that he had diabetes at age 13. His mother took him to the family doctor because
he was always tired and thirsty and he urinated frequently. A blood test at the time
confirmed the diagnosis. William’s illness could not be controlled by diet. He required daily
insulin injections. At first, William would not believe he was sick and resisted treatment.
He continued to “hang out” with his friends and to play football and baseball. Eventually,
however, he says he “accepted” his illness.

William reports that his mother became his nurse. She made sure that he followed a proper
diet, checked his urine for sugar (several times each day), and administered his injections.
She posted a chart of glucose test results on the bathroom door. William gradually lost
contact with his friends. He says this was because his mother urged him to avoid sports or
any other activity where he could get physically hurt.

A combination of diet and insulin kept William’s condition stable for 5 years. The only
exceptional incident occurred toward the end of his junior year in high school. He was
preparing for his examinations and was feeling left out because he did not have a date for
the junior prom. He felt weak but kept going to school. He fainted in class and, although he
quickly revived, was taken to the hospital, where he spent one day.

Since William entered college, he has had no serious diabetic episodes until the current one,
although he has had trouble sleeping and has experienced loss of appetite. He claims not to
have told any of the other students of his illness.

See appendix for full case study.

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Section 2.4 Posttraumatic Stress Disorder (PTSD)

giving Vietnam veterans’ symptoms a name, and by
making PTSD a recognized mental condition, the
DSM–III legitimized the claims for help from veter-
ans (and others who experience extreme trauma).

The main symptoms of PTSD are anxiety, the
avoidance of stimuli associated with the trauma,
flashbacks in which the traumatic event is relived
mentally, and a “numbing” of emotional responses
(Bisson, Roberts, Andrew, Cooper, & Lewis, 2013).
Additional symptoms include hyperarousal such as
sleep disturbance, increased irritability, and hyper-
vigilance. You might also see negative beliefs and
expectations about oneself, persistent distorted
blame on oneself or others, and feelings of detach-
ment and constricted affect (APA, 2013; Sareen, 2014). Not surprisingly, PTSD has been found
to affect practically every aspect of everyday life and is among the disorders most strongly
associated with suicidal behavior, including attempts (Sareen, 2014). People with PTSD also
typically have interpersonal, relationship, and parenting struggles, and a reduction in house-
hold income as they have difficulty maintaining a job or perhaps even going to work (Sareen,
2014).

PTSD is not limited to veterans who survive a war. PTSD also affects victims of violence, espe-
cially rape (Sareen, 2014), as well as those who witness acts of extreme violence such as the
September 11, 2001 terror attacks on the World Trade Center in New York City and most likely
those who witnessed the Las Vegas shooting in October 2017. Recognizing that the symptoms
of PTSD appear differently in children younger than 6 years old, the DSM–5 includes a sepa-
rate subcategory: posttraumatic stress disorder for children 6 years and younger (APA, 2013).
Within the subcategory posttraumatic stress disorder, notes within specific criteria differenti-
ate how children older than age 6 might manifest symptoms. For example, a child’s dreams
may be frightening, but the content of the dreams might be unrecognizable (APA, 2013). Chil-
dren who have been abused, for example, often exhibit behavioral changes (an outgoing child
may become reclusive; a quiet child may start acting aggressively). Young children who have
been toilet trained may go back to soiling themselves and bed-wetting. Left untreated, PTSD
symptoms can last a lifetime (APA, 2013; Potts, 1994).

A summary checklist of major diagnostic criteria for PTSD, adapted from the DSM–5 (APA,
2013), appears below:

• The individual is exposed, directly or indirectly, to a threatening or traumatic event:
death or threatened death, severe injury, sexual violence, and so on.

• Presence of one or more of the following intrusive symptoms:
• Recurrent, involuntary distressing memories
• Recurrent distressing dreams where the content(s) is/are related to the traumatic

event
• Dissociative features such as flashbacks, where the individual feels as though the

trauma is reoccurring
• Intense distress when exposed to cues related to the experienced trauma
• Marked physiological reactions when reminded of the trauma(s)

Ingemar Edfalk/Blend Images/SuperStock
Many soldiers are affected by posttrau-
matic stress disorder long after the
danger of combat is over.

get83787_02_c02_027-060.indd 39 2/16/18 4:38 PM

Section 2.4 Posttraumatic Stress Disorder (PTSD)

• The person continually avoids trauma-like stimuli.
• The person is unable to recall key features of the event(s).
• The individual displays changes in arousal and reactivity, such as excessive alertness,

extreme startle responses, or sleep disturbances.
• These symptoms and stress last at least one month.

The DSM–5 moved PTSD out of the chapter titled “Anxiety Disorders” and into the “Trauma
and Stressor-Related Disorders” chapter. Although commonalities remain, this demonstrates
that PTSD has unique features that separate it from anxiety disorders.

Etiology of PTSD
Approximately 7.8% of the population has PTSD (Bisson et al., 2013). For someone to qualify
for diagnosis, PTSD symptoms must be present for at least one month (most of the DSM–5
disorders require that symptoms be present at least six months). In addition, if the diagnostic
criteria are not met until, minimally, six months after the event’s occurrence (though some
symptoms may be present), the specifier “with delayed expression” is used (APA, 2013).

Unlike most psychological disorders, the etiology of PTSD is defined in its diagnostic crite-
ria—it is caused by experiencing, either directly or indirectly, an extraordinarily stressful,
traumatic event (see Figure 2.3). (Etiology refers to the study of the causes or origins of dis-
ease, in this case mental illnesses.) The 9/11 attacks provide an excellent example. Direct
exposure would refer to individuals who were at the Twin Towers when the planes struck or
when the towers collapsed. Indirect exposure would refer to watching the second plane strike
on television, or hearing or reading about the attacks.

Given a severe enough trauma, even well-adjusted people may develop PTSD (Clark, Watson,
& Mineka, 1994). Yet, most people manage to escape even the most terrifying events with
no signs of disorder (Bolton, Jordan, Lubin, Litz, & Gold, 2017). What protects such people?
What makes others succumb? The usual answer to these questions is that some people are
more vulnerable than others. They may have preexisting psychological disorders or a family
history of psychological disorder, especially depressive disorders, anxiety disorders, and con-
duct disorder (Sareen, 2014). Vulnerable people may inherit a disposition to develop PTSD
(Andreasen, 1995; Koenen et al., 2003; True, Rice, Eisen, & Heath, 1993). There is evidence
that people with PTSD have higher levels of stress hormones than others (Burijon, 2007),
although the evidence is vague (Bachmann et al., 2005). Certainly, people who develop PTSD
seem to have strong emotional reactions to life’s problems (Burijon, 2007).

We should not discount the important role played by a person’s social environment. Consider,
for example, the finding that PTSD is more common among African American and Hispanic
Vietnam War veterans than among white veterans, especially white officers. Does this mean
that, compared with white officers, African American and Hispanic enlisted men are less able
to respond to challenging situations, or more prone to ignore problems? Not necessarily.
Forces outside the individual, such as poor social support, may also play an etiological role in
PTSD (Sareen, 2014). Seeking treatment for post-combat-related issues often carries social
stigma that may prevent an individual from obtaining the needed help.

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Section 2.4 Posttraumatic Stress Disorder (PTSD)

Figure 2.3: Posttraumatic stress disorder

A model of the causes of PTSD.

Source: From “Posttrumatic Stress Disorder” by T. M. Keane & D. H. Barlow (2002), in Anxiety and Its Disorder: The Nature and
Treatment of Anxiety and Panic, by D. H. Barlow, 2nd ed. New York: Guilford Press. Copyright © 2004 by Guilford Press. Reprinted by
permission.

(or alternative intense basic
emotions, such as anger, distress)

True alarm

(or strong, mixed emotions)

Learned alarm

Focused on reexperienced emotions

Anxious apprehension Avoidance or numbing
of emotional response

Experience of trauma

Moderated by social support and ability to cope

Post-traumatic stress disorder

Generalized
psychological vulnerability

Generalized
biological vulnerability

get83787_02_c02_027-060.indd 41 2/16/18 4:38 PM

Section 2.4 Posttraumatic Stress Disorder (PTSD)

Therapeutic Treatment for PTSD
With the publication of the DSM–III (APA, 1980), mental health professionals began to devote
increasing attention to PTSD. With increased research, it has been determined that early
intervention is of paramount importance to make treatment success more likely. In therapy,
trauma victims were encouraged to discuss their troubles in groups made up of victims of
similar traumas. It is generally accepted that the social support provided by these groups is
an important ingredient of successful therapy (Sareen, 2014). However, group discussions
alone may not always be sufficient. Other therapeutic interventions may also be needed.
The most common behavioral intervention is exposure (Koch & Haring, 2008). Victims are
helped to confront their memories of the traumatic event so that their anxiety can be extin-
guished. Flooding, cognitive restructuring (discussed in Chapter 3), desensitization, and
stress- management training are also used to help clients overcome their anxiety and to teach
them how to cope with anxiety-provoking situations that may arise in the future (Bisson et
al., 2013).

Some research has reported successful treatment of PTSD using a technique called eye move-
ment desensitization and reprocessing (EMDR), in which people are asked to visualize images
of the traumatic event (Bisson et al., 2013). Once the images are clear, clients are required to
follow the movements of the clinician’s finger (or a pencil) with their eyes while holding their
head still. Because it is a relatively new type of intervention, the effectiveness of EMDR has
been controversial, and early research results are inconclusive. Some researchers believe the
exposure itself and not the eye movement may be responsible for the success with this treat-
ment method (McGuire, Lee, & Drummond, 2014). A growing body of research aims to deter-
mine the legitimacy and efficacy of this approach. Some research suggests that EMDR results
in more rapid symptom reductions than other, comparable treatment modalities (McGuire et
al., 2014).

Drug Treatment for PTSD
The U.S. Food and Drug Administration has approved only two medications for PTSD treat-
ment: the selective serotonin reuptake inhibitors (SSRIs) paroxetine (Paxil) and sertraline
(Zoloft). They seem to help alleviate anxiety and panic attacks, making other PTSD symp-
toms more manageable (Golier, Legge, & Yehuda, 2007). Antidepressants alone are not usu-
ally effective in treating the insomnia and nightmares that often accompany PTSD. Options
include using atypical antipsychotics such as risperidone (Risperdal), as well as zopiclone
(Zimovane), a sedative-hypnotic (sleeping aid).

An experimental form of drug treatment involves using 3,4-methylenedioxymethamphet-
amine, more commonly known as MDMA. This is not ecstasy or Molly, designer drugs sold
on the street that contain MDMA as well as other, perhaps lethal, substances. The Multidisci-
plinary Association for Psychedelic Studies (MAPS) is currently researching the use of MDMA
with PTSD victims. Preliminary studies have shown that MDMA in conjunction with psy-
chotherapy can help people overcome PTSD, and possibly other disorders as well. MDMA is
known for increasing feelings of trust and compassion toward others, which could make it an
ideal adjunct to psychotherapy for PTSD (MAPS, n.d.). The primary method of treating PTSD
remains psychotherapy.

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Section 2.6 Illness of the Mind or the Body: A Dubious Distinction

Early Intervention and Prevention of PTSD
The prevention of PTSD works best with early intervention. For soldiers, this means institut-
ing treatment at the first sign of stress (Samter et al., 1993). Many victims of trauma never
get treatment. For example, rape victims rarely seek psychological help in the period imme-
diately following the rape. Of those who seek treatment at all, only between 19% to 39% seek
treatment right away (Price, Davidson, Ruggiero, Acierno, & Resnick, 2014). They do not see
themselves as psychologically disturbed but as victims of a crime that they would rather for-
get. Unfortunately, sometimes the police, lawyers, and the press make sure that the attack is
never far from the victim’s mind. Some victims may even find themselves being blamed for
the attack. The stress can build up until it produces a stress disorder (Falsetti, Resnick, Dan-
sky, Lydiard, & Kilpatrick, 1995). Police reactions often seem to influence how rape victims
feel, possibly affecting the severity of PTSD, since arrest and sentencing of the perpetrator
often do not occur (Venema, 2014). It is at this point that victims seek assistance.

2.5 Acute Stress Disorder
The DSM–5 recognizes another disorder associated with trauma: acute stress disorder. Simi-
lar to PTSD, this disorder occurs in response to traumas, but acute stress disorder is diag-
nosed when the symptoms typically occur immediately after the trauma. The symptoms must
last for at least three days and no longer than a month after the trauma to qualify for this
diagnosis (APA, 2013). The symptoms of acute distress disorder are similar to those for PTSD:
persistent reexperiencing of the trauma through flashbacks, intrusive thoughts, and night-
mares. A person experiencing acute stress disorder may avoid reminders of the trauma and
may feel numb or detached, or report feeling as if he or she is in a dreamlike state. Although
it is a short-term response to trauma, people with acute distress disorder are at risk for con-
tinuing to experience posttraumatic stress symptoms for many additional months.

2.6 Illness of the Mind or the Body: A Dubious Distinction
Diabetes may not seem particularly relevant to abnormal psychology because it is a physical
disease. Traditionally, abnormal psychologists have limited their interest in physical diseases
to the so-called psychophysiological or psychosomatic disorders (psycho = mind, somatic
= body)—disorders in which psychological factors produce “real” physical diseases, such as
peptic ulcer, asthma, hypertension, and headaches. Psychosomatic conditions were thought
to differ from other physical illnesses because psychological factors played a significant role
in their etiology. Asthma, for example, was attributed to loss or separation, ulcers to stress-
producing jobs, headaches to helplessness, and hypertension was supposedly the result of
repressed anger. In recent years, it has become increasingly clear that this approach to physi-
cal illness is too simplistic. For example, we now know that many peptic ulcers are the result
of a bacterial infection that thrives on stress, which results in a physical condition (peptic
ulcer). This is a perfect example of the diathesis-stress model of psychopathology discussed
in Chapter 1.

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Section 2.6 Illness of the Mind or the Body: A Dubious Distinction

Because of the interplay between physiological and psychological factors, distinguishing
between pure physical illnesses and those with psychological components is now widely rec-
ognized as artificial and futile. Social and psychological factors affect all illnesses, from the
common cold to cancer, from hernia to heart disease, from skin rashes to diabetes. Those
studying behavioral medicine examine the interaction between psychology and physiology,
seeking to learn how psychological factors (a) make people susceptible (or resistant) to ill-
ness, (b) alter the course of an illness, (c) influence compliance with medical treatment, and
(d) affect health-related behavior. Today’s serious illnesses tend more and more to be the
result of behavioral choices—smoking, using drugs, and drinking alcohol to excess (Oyama
& Andrasik, 1992). Understanding and preventing illness-causing behaviors such as smoking
have the potential to do more to improve public health than building any number of new hos-
pitals. The disciplines contributing to behavioral medicine are depicted in Figure 2.4.

Figure 2.4: Disciplines contributing to behavioral medicine

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000,
Figure 5.1, p. 196.

Biological
sciences

(biochemistry,
immunology)

Professional
studies

(nursing,
physical therapy)

Social
sciences

(anthropology,
sociology)

Psychological
and

behavioral
sciences

Medical
sciences

(pathology,
radiology)

Behavioral
Medicine

Early versions of the DSM included a variety of “psychosomatic disorders.” These no longer
appear in the DSM–5, which refers instead to “psychological factors affecting other medical
conditions.” This diagnosis is applied when psychological factors appear to cause, exacer-
bate, or delay recovery from a medical condition or when psychological factors interfere with

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Section 2.7 Factors That Modify the Effects of Stress

treatment. The DSM–5 also acknowledges that causality can go both ways. In other words,
medical conditions can produce or exacerbate psychological problems.

The DSM–5 includes several diagnoses that recognize the interaction between psychologi-
cal variables and physical illness (for example, “sexual dysfunction due to a general medical
condition”). However, these diagnoses hardly do justice to the complex interactions that take
place between psychological factors and health.

Psychological interventions, such as the provision of social support, are often aimed at help-
ing clients to comply with their treatment regimen, thereby limiting complications. Thus,
interventions designed to address psychological factors such as social isolation not only have
direct psychological effects but also help to reduce the severity of the physiological disease.
Improved physical health, in turn, affects psychological well-being by reducing depression
and social isolation. This is a typical pattern. Psychological and physiological variables inter-
act continuously, with one set of variables affecting and being affected by the other. The aim of
this chapter is to illustrate the role of psychology in understanding and treating psychological
disorders as well as in fostering health. (See Part 2 of William Cole’s case in the appendix.)

2.7 Factors That Modify the Effects of Stress
Coping means finding effective ways to adapt to the problems and difficulties presented by
stress. In general, successful coping is marked by compliance with the treatment regimen,
by acceptance of the limitations and challenges of the illness, and by attempting to lead as
“normal” a life as possible. Unsuccessful coping is evidenced by poor treatment compliance,
shame, and social isolation.

Poor compliance is not surprising in chronic conditions, especially those in which the treat-
ment regimen is complicated. However, noncompliance also occurs when treatment is simple.
For example, among women who have had breast cancer, fewer than half follow their doctors’
recommendations for simple breast self-examinations (Taylor et al., 1984). Because compli-
ance is essential to long-term health, considerable research has been devoted to clarifying
why patients fail to comply with the recommended treatment. This research has identified
several important factors (for example, people comply better with clear instructions; warm
doctor-patient relationships facilitate compliance), but the most important factor seems to
be the way in which people appraise the stress produced by illness (Miller, Shoda, & Hurley,
1996). Some people deny being sick; others make a hobby out of it. Denial reduces compli-
ance, whereas obsessive attention to one’s health increases compliance. In this section, we
will see that treatment compliance depends on learning to cope with stress.

Appraisals
The effects of a stressor depend to a large extent on how the stressor is perceived. Thus, the
first step in coping is to appraise the stress-producing situation (Taylor & Aspinwall, 1996).
The appraisal of life events results in emotional, physiological, and behavioral responses that
interact with one another in complex ways to determine how people cope with illness (see
Figure 2.5).

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Section 2.7 Factors That Modify the Effects of Stress

Figure 2.5:

Life events

The effects of life events depend on how they are appraised.

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000,
Figure 5.9, p. 217.

Life events
Hassles

Catastrophies

Illness

Appraisal
of event

Emotional responses

Physiological responses

Behavioral responses

According to Richard Lazarus (1993), there are two types of appraisal: primary and second-
ary. In primary appraisal, the individual assesses the personal implications of an event. Events
may be appraised as irrelevant, beneficial, or stress-inducing. Secondary appraisal is con-
cerned with what, if anything, should be done. If an event is appraised as stress-inducing, the
individual may then appraise the harm done and decide how to prevent a future recurrence.
If the harm has not yet been done, appraisal may take the form of how to avoid or minimize
harm. Appraisals often include a comparison of costs and benefits. Cognitive appraisals need
not be so calculated or rational; they do not even have to be conscious. However, at some level,
our response to stress is always based on our personal perception of external events.

Denial is a primitive form of coping, but it can sometimes be useful. If an illness is untreat-
able, denying the facts may help the ill person make the most of what life remains. However,
if a condition can be helped by a change in behavior, denial may make matters worse. A less
extreme form of denial is to admit that one has an illness but to minimize its seriousness.
Again, if treating life-threatening illnesses as minor annoyances allows a person to lead a
fuller life than would otherwise be the case, a little denial is probably a good thing. However,
if carried too far, denial can lead people to ignore the limitations imposed by illness—and
possibly to take unwise health risks.

In contrast to those who minimize their illness, some people cope by becoming obsessed
with their condition. They devote a lot of their energy to managing their disease. If their
obsessiveness increases their quality of life, then it is a reasonable way of coping. However,
if their extreme concern with their health causes other activities and relationships to suf-
fer, then it is not a successful way of coping. Instead of controlling their illness, obsessive
people may wind up achieving the opposite; they may find that their illness controls them.
What is required is a happy medium between minimization and obsessive attention that pro-
vides a balance between controlling illness and not letting it take over one’s life. Lazarus
and his colleagues (Folkman & Lazarus, 1990; Lazarus, 1993) call denial and obsessiveness

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Section 2.7 Factors That Modify the Effects of Stress

emotion-focused coping. The goal of emotion-focused coping is to manage feelings to make
ourselves feel better (Doron, Stephan, Maiano, & Le Scanff, 2011). Problem-focused coping,
by contrast, involves making a plan of action and dealing directly with the stressor (Doron et
al., 2011). For example, when faced with a difficult final exam, emotion-based coping could
take the form of avoiding thinking about the exam in order to reduce anxiety. In contrast,
problem-focused coping would involve formulating a schedule for studying and a procedure
for self-assessment.

It is important to know when to apply different types of coping. Relying on emotion-focused
coping when problem-focused coping could result in a better outcome leads to negative
results. Consider the final exam example. Problem-focused coping could lead to a better grade.
But emotion-focused coping likely would not. However, problem-focused coping works only
when a person has the ability to remedy the situation by taking some action. When events are
not in a person’s control, problem-focused coping may lead to frustration and more stress.
When action is futile, it makes more sense to rely on emotion-focused coping. An example of
using the wrong type of coping would be to rely on alcohol instead of dealing with the stressor
or managing feelings. While alcohol does make one feel relaxed and perhaps better for a short
while, eventually it wears off and the problems resurface, as they were avoided and not prop-
erly handled.

Why do some people manage to cope successfully with their illness, whereas others never
seem to be able to adjust? At least part of the answer lies in the coping resources available to
the individual.

Social Support
Coping is not simply a matter for the person who is ill. It involves family members and friends
as well. Some family members try to distance themselves from the ill relative (perhaps to
avoid the pain of a loved one’s suffering). Others derive enhanced self-esteem from helping
the individual cope (Kovacs & Feinberg, 1982). Provided that it does not lead to overprotec-
tiveness and dependency, the latter attitude is more helpful to someone attempting to come
to grips with a chronic illness.

Given that all family members are affected by one member’s chronic illness, it is not sur-
prising that family conflict affects how well chronically ill people cope (Leeman et al., 2016).
People with diabetes who live in harmonious families seem to have better control of their
blood sugar than do those who live in distressed or unhappy families. It should be noted, how-
ever, that some studies have failed to find a strong relationship between family harmony and
diabetic control (Gowers, Jones, Kiana, North, & Price, 1995; Kovacs, Kass, Schnell, Goldston,
& Marsh, 1989). One possible reason for the discrepant results is the reliance on self-report.
Members of dysfunctional families may be reluctant to admit that disharmony exists.

To be effective, however, social support must be appropriate for a person’s stage of develop-
ment. For example, daily questioning (“Have you had your insulin this morning?”) improves
treatment compliance in young children but actually makes it worse in adolescents, who
resent this intrusion on their autonomy and independence (Idalski-Carcone, Ellis, Weisz, &
Naar-King, 2011).

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Section 2.7 Factors That Modify the Effects of Stress

Social support contributes to health in several ways. First, by providing acceptance, social
ties may help maintain self-esteem. Second, friends provide help in times of trouble and sym-
pathetic ears for the expression of painful feelings. Third, members of self-help groups are
important sources of new information about the disease and its control.

Of course, it is always possible that people
who are sick withdraw from social con-
tact. In such cases, illness has affected their
social life rather than the other way around.
We should not expect miracles from strong
social support, however. Social support
does not act in a vacuum. As described in
the next section, individual differences and
external social events can moderate the
effects of social support. There may even be
times when social support is not beneficial,
as explained in the accompanying Highlight.

Rawpixel/iStock/Thinkstock
During times of illness, friends may offer a
sympathetic ear or help maintain self-esteem.

Highlight: When Social Support Increases Stress

To be of value, social support must work to facilitate positive goals. Friends who want to take
you out for a pizza the night before an important exam may think they are being supportive,
but the outcome of their behavior may be that you fail the exam.

A compelling demonstration of the potential costs of social support may be found in a
study by Baumeister and Steinhilber (1984). These researchers examined baseball World
Series records from 1924 to 1982 and basketball semifinal and championship series for
the years 1967 to 1982. They were particularly interested in the success of the home team.
Teams playing at their home field or stadium have an audience of supporters to cheer them
on. This is a form of “social support” that is
usually interpreted as giving the home team
an advantage over the visitors. Overall, the
statistics confirmed this advantage. Both
baseball and basketball teams are more
successful in front of their fans. However,
this advantage was evident only early in the
season. End-of-season championships, such as
the World Series, produced quite the opposite
results. Home teams were more likely to lose.

The pressure of playing in front of fans, of not
wanting to lose at home, may cause a team
to “choke.” Teams actually performed better
without the social support provided by their
hometown crowds. See Baumeister (1995) and
Wallace, Baumeister, and Vohs (2005) for more
support of these findings.

Bill Cobb/SuperStock
The stress of playing at their home
field in a stadium crowded with fans
can have a negative effect on baseball
teams when stakes are high, such as
during the World Series.

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Section 2.7 Factors That Modify the Effects of Stress

Individual Characteristics
Stress affects people in markedly different ways; an event that has a devastating effect on
one person may hardly affect another. This section looks at some of the reasons for these
individual differences: knowledge, hardiness, self-esteem, locus of control, and attributions.

Knowledge
At first glance, coping with treatment for a chronic illness may appear to be simply a matter of
knowledge. We reason that once the patient knows what needs to be done and why, compli-
ance should follow. Knowing what to do (and why) does not guarantee healthy behavior. One
reason that knowledge does not guarantee healthy behavior is that the illusion of invulner-
ability discussed earlier leads most of us to minimize the probability of bad outcomes. Medi-
cal students and students of clinical psychology are exceptions. They tend to err in the oppo-
site direction, exaggerating their susceptibility to illness. They may even develop the signs
and symptoms of the diseases they study (known as a psychosomatic reaction or a somatic
symptom disorder). Called medical student syndrome, this reaction was discussed in Chapter
1. Overestimating one’s susceptibility to illness is just as misleading and maladaptive as is
minimizing it. In both cases, knowledge does not guarantee appropriate behavior.

Hardiness
People who withstand stress when their coworkers, friends, and relatives break down may
possess certain protective personality traits. Optimists, for example, tend to withstand stress
better than pessimists. Around examination time, optimistic students report less fatigue and
fewer colds, aches, and pains than their pessimistic peers. Hardiness can be defined as a
stress-resistant personality characteristic that is made up of control, commitment, and chal-
lenge (Vealey & Perritt, 2015). These individuals believe that they are in control of their lives
and that they have the power to influence people and events around them. They welcome
challenge by seeing it as a necessary means for personal growth. Finally, they usually respond
to difficult situations rationally and productively (Vealey & Perritt, 2015). There is also some
evidence that hardiness and optimism are inherited dispositions (Caprara, Steca, Alessandri,
Abela, & McWhinnie, 2009). These findings are certainly worth further investigation, but we
should be careful not to overemphasize them. Most of all, we should avoid characterizing
people who fall ill as lacking healthy personality traits.

Self-Esteem
Being different, not being able to do the same things as others, takes its toll on self-esteem.
Low self-esteem, in turn, leads to a discrepancy between a person’s real and ideal self. Human-
ists attribute many psychological problems to such a discrepancy. Not every ill person has low
self-esteem, of course. However, it is all too common among individuals who seek therapy,
and at the least, low self-esteem can create more stress in one’s life. For example, although
some people might think that an intellectually gifted child has a huge advantage over many
other children in her class, many do not understand that it is often difficult for these children
to “fit in,” as they are seen as different by their peers. This can lower their self-esteem and may
lead these children to feel out of place or ostracized.

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Section 2.7 Factors That Modify the Effects of Stress

Locus of Control
The concept of locus of control is quite interesting. Its definition is simple: the extent to which
people believe they have power over events in their lives (Rotter, 1966). One way to look at
this concept is to ask yourself: Do I control my life or does something else (like a God, demon,
the moon, sun, weather) control it? This concept, brilliant in its simplicity, has a significant
impact on our daily lives. Adults are usually considered responsible enough to comply with
treatment. However, not all people accept this responsibility. In theory, at least, people who
have an external locus of control—who believe that external forces are more likely to deter-
mine what happens to them than their own actions—should be less likely to adhere to a treat-
ment regimen than those who have an internal locus of control (Lefcourt, 1992). People who
have an internal locus of control believe that their life’s outcomes are under their control
and occur because of their actions, not because of external factors out of their control.

Studies of locus of control have produced a mixed picture (May, 1991; Wertlieb, Jacobson, &
Hauser, 1990). Some report an external locus of control among chronically ill people; some do
not. Internal locus of control has also been found not to be related to treatment adherence and
follow through (Carbone, Zebrack, Plegue, Joshi, & Shellhaas, 2013; Gibson, Held, Khawnekar,
& Rutherford, 2016). One possible reason for the discrepant results is the reciprocal effect of
health status on locus of control.

Despite uncertainties about the precise relationship between locus of control and illness,
ample evidence indicates that feeling in control helps reduce stress. Feelings of control come
from three factors: familiarity, predictability, and controllability. Familiarity reduces stress
by making us more aware of what to expect. This is why your first job interview is likely to
elicit a greater alarm reaction than your second or third. Predictability exerts an effect on
stress independent from familiarity. In a demonstration of the effects of predictability, labora-
tory rats produced a more intense autonomic reaction to unpredictable electric shock than to
shocks of exactly the same voltage occurring on a predictable schedule (Weiss, 1977). Indeed,
animals who received unpredictable shocks developed peptic ulcers at a much greater rate
than did rats who received predictable shocks. Providing the animals with a way of avoiding
or shutting off the shock reduces the stress response even further. This last finding suggests
that controllability also determines a stressor’s effect (Henderson, Snyder, Gupta, & Banich,
2012). Similar effects have been found among older people placed in nursing homes without
their consent (Rodin, 1986). They decline rapidly and die sooner than people who are allowed
to choose for themselves where they will live and to determine their own daily activities. See
the accompanying Highlight for additional discussion of locus of control and its impact on our
daily lives.

Health Beliefs and Attributions
Instead of focusing on a global belief such as internal or external locus of control, some
researchers have studied the relationship between more specific beliefs and treatment com-
pliance. For example, among those with diabetes, adherence to the treatment regimen may
be related to specific beliefs about themselves and their illness (Gonzalez, Shreck, Psarors, &
Safren, 2015). Some of these beliefs include the following:

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Section 2.7 Factors That Modify the Effects of Stress

• Susceptibility (“I will not develop complications.”)
• Severity (“Diabetes is not really all that serious.”)
• The benefits of compliance (“If I don’t stick to the regimen all of the time, it won’t

hurt me in the long run.”)
• The costs of compliance (“My injections keep me from going out at night.”)

It is not surprising that health beliefs were better predictors of adherence than of blood sugar
levels. Even when adherence is perfect, blood sugar levels may vary depending on numerous
physiological and emotional factors (Brownlee-Duffeck et al., 1987).

One unusual result of the study by Martha Brownlee-Duffeck and her colleagues was their
finding that, among adolescents, those who perceived their illness as severe (and their sus-
ceptibility to complications as high) had poorer adherence to treatment than did those who
minimized their illness. This relationship was exactly the opposite of the one the researchers
expected to find. One explanation is that people who do not adhere to treatment are just being
realistic. They know that with their severe illness they are more likely to develop complica-
tions, so why waste their effort? This explanation implies that health beliefs may both affect
behavior and be affected by behavior (May, 1991).

Highlight: Locus of Control

Do you like to play Powerball or Mega Millions? Do you say a prayer before you buy your
tickets? Do you believe that your path in life is predetermined, out of your hands? When
things are in a dark place in your life, do you attribute this to demons and wait it out, or do
you take charge and say that you will turn things around? How about a professional athlete
who says that his team won the Super Bowl because he prayed and his prayers came true?
These are all examples of locus of control. Some are examples of external locus of control,
where the player, you, or another person believes that external forces are more likely than
not to determine life’s outcomes. Here’s a question to ask: Is this a psychologically healthy
perspective? After all, the person is saying, “Let come what may. I really am not important
in determining the outcome.” Yes, sometimes things happen over which we have little to no
control, but if a person consistently believes this, he or she may just sit back and not even
try. Could this lead to anxiety or unipolar depression?

What about internal locus of control? Do you control what occurs in your life? Does the
athlete, as skilled as she is, control whether the ball goes in the net? Do you have control
over your course grades? Is this a psychologically healthy outlook? Some research has found
that people with a more internal locus of control seem to be better off; for example, they
tend to be more achievement oriented and to get better-paying jobs. But there is a caution.
Do financial or other privileges cause the locus-of-control perspectives, or do the beliefs
regarding control cause the situation (Hans, 2000)? Regardless, it is important to realize
that no matter what, some things are beyond our control, while other things are very much
in our control. If you are happy with who you are, one perspective is not necessarily better
than the other.

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Section 2.8 Helping People Cope

2.8 Helping People Cope
Practically every type of psychological treatment has been applied to helping people cope
with stress, chronic pain, and the management of illnesses such as diabetes (Bradley, 1994;
Rubin & Peyrot, 1992; Shillitoe & Christie, 1990). The main aim is to reduce stress, thereby
reducing pain and preventing illness or exacerbations of illness. The general term stress
management has come to be applied to the various approaches to reducing stress (Lehrer
& Woolfolk, 1993). Some treatments take a direct approach, teaching relaxation and other
stress-reduction skills. Others take an indirect approach. They attempt to change cognitions
and behaviors, which may in turn lead to better health through better diabetic management.
Every coping process and every coping resource is a potential candidate for intervention.
Thus, psychologists may try to build a person’s self-esteem, provide social support, or even
reorient a person’s locus of control from external to internal. (See Figure 2.6.)

Stress Reduction Through Relaxation
One popular and effective method of stress reduction is Edmund Jacobson’s (1938) progres-
sive muscle relaxation technique. Individuals are instructed to alternately tense and relax
different groups of muscles. For example, focusing on the muscles of the lower arm, the indi-
vidual would make a fist and then relax it. The person then continues to move throughout
the rest of the body, focusing on different muscle groups until the entire body is relaxed. The
goal is to make individuals aware of muscle tension and to give them practice in relaxing dif-
ferent muscle groups. When muscle tension is not a prominent symptom, therapists may use
other relaxation techniques, such as transcendental meditation, in which the person focuses
attention on quietly repeating a specific syllable (the mantra), or hypnosis. In each case, the
underlying rationale is that relaxation is incompatible with stress. Individuals who learn to
relax in stressful situations should have fewer and less-intense alarm reactions. Fewer alarm
reactions mean less strain on the heart, the nervous system, and the immune system.

In one now-classic demonstration of the power of relaxation, middle-aged heart attack survi-
vors were randomly assigned to one of two conditions (Friedman & Ulmer, 1984). One group
received advice from cardiologists about exercise, medications, and diet. The second group
received the same advice plus continuing counseling on how to relax (eat slowly, smile at oth-
ers and laugh at yourself, admit mistakes, and take time to enjoy life). The two groups were
followed for three years. During that period, members of the relaxation group had only half
the number of heart attacks as the first group. Friedman and Ulmer note that “no drug, food,
or exercise program ever devised, not even a coronary bypass surgical program, could match
the protection against recurrent heart attacks” of simply learning to relax (p. 141).

Evidence shows that relaxation training given to patients undergoing treatment for various
diseases, including cancer, made them less fatigued and depressed and more likely to finish
the treatment course (Demiralp, Oflaz, & Komurcu, 2010). The benefits of relaxation train-
ing are not limited to people being treated for an illness. Employers have found that offering
training in relaxation and other aspects of stress management at the workplace can improve
employee performance (Quick, Murphy, & Hurrell, 1992).

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Section 2.8 Helping People Cope

Biofeedback
Biofeedback has been used as an adjunct to stress-management programs (Kotazaki et al.,
2014). Biofeedback is a technique that trains people to improve their health by controlling
certain bodily processes that normally happen involuntarily, such as heart rate, blood pres-
sure, and muscle tension. Electrodes are attached to the person’s skin and the results are
displayed on a monitor. For example, biofeedback has been used to try to reduce the muscle
tension that seems to accompany some headaches, and to lower blood pressure. However, ini-
tial claims for biofeedback—that it might be a cure for migraines, hypertension, peptic ulcers,
and many other conditions—are now clearly seen to have been exaggerated (Miller, 1974).
Biofeedback has beneficial effects in some conditions for some people, but, when used alone,
the benefit of biofeedback for relieving stress and reducing symptoms is probably no greater
than that provided by relaxation training.

Figure 2.6: Stress relief

What do people do to relieve stress? According to one large survey, most watch television or listen to
music.

Source: Adapted from R. J. Corner, Abnormal Psychology, 6th ed. New York: Worth Publishers, 2007.

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get83787_02_c02_027-060.indd 53 2/16/18 4:39 PM

Section 2.8 Helping People Cope

Exercise
Research has indicated that exercise, both
aerobic and resistance training, reduces the
anxiety and depression often associated with
stress (Martinsen, 1990; Martinsen, Hoffart,
& Solberg, 1989; Rethorst, & Trivedi, 2013;
Singh, Clements, & Fiatarone, 1997) and
can be as effective as conventional pharma-
cotherapy (Blumenthal et al., 2007). As you
might expect, some studies do not support
these findings (Bartley, Hay, & Bloch, 2013).
Numerous studies show that those who exer-
cise live longer and spend fewer days in the
hospital than those who do not (Wen, Wai,
Tsai, & Chen, 2014). Of course, it is always

possible that people who are sick do not feel like exercising. As we have seen frequently, it is
difficult to separate cause and effect when dealing with correlational data.

Behavioral and Cognitive-Behavioral Treatment
All aspects of behaviorism, including modeling, rational emotive behavior therapy, and con-
ditioning, may be used to help people develop new coping skills. For example, people with
diabetes who fear needles are likely to miss injections. Helping them to overcome this fear
through desensitization (any decrease in reactions or sensitivity to a stimulus or stimuli),
for instance, would benefit them by helping them comply with treatment. Reward-based pro-
grams, in which those with diabetes are rewarded for keeping to their diets or their schedules
for monitoring blood sugar, can have a similar effect.

Given the evidence from human and animal studies suggesting that immune functioning
is decreased by stress, psychological interventions have also targeted the immune system.
Using a wide variety of therapeutic techniques, including relaxation, hypnosis, exercise, con-
ditioning, and cognitive therapy, psychologists have been able to increase the level of immune
functioning (Kiecolt-Glaser & Glaser, 1992; Zakowski, Hall, & Baum, 1992). Of course, the
problem of clinical significance that affects the field in general also applies to treatment stud-
ies. Specifically, it has still not been demonstrated that increasing immune system function
has a direct beneficial effect on health. (Keep in mind that, apart from AIDS, most infections
increase immune function, yet this increased production of white blood cells is hardly an
indicator of good health.)

Family Interventions
Stress and illness have profound effects not just on physical functioning but also on psycho-
logical and social identity (Kaplan, 1996; Morse & Johnson, 1991). Suffering affects a person’s
self-concept, and it subjects other family members to a burden that may require different
family members to take on different caregiver roles. The spouse of someone receiving painful

Demkat/iStock/Thinkstock
Both aerobic exercise and resistance training
can reduce anxiety and depression commonly
associated with stress.

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Section 2.8 Helping People Cope

chemotherapy, for example, must cope not only with caring for the patient but also with other
family matters, and with fears for the patient’s future. Sometimes, family therapy is required
to help families deal with the burden of one member’s illness. Self-help groups for patients
and their families are often useful sources of social support.

Environmental and Community Interventions
Because trauma and stressor-related disorders often result from threatening environments,
community interventions can sometimes be as effective as individual treatment. For example,
increased police patrols reduce the stress that comes from living in high-crime areas, antipov-
erty programs reduce the stress that comes from poverty, and employment programs help to
reduce the stress created by job loss. Combinations of behavioral and cognitive interventions
have also been used to modify a community’s health-relevant behaviors. For example, people
at high risk for illness may be taught strategies to minimize the risks while learning how to
avoid dangerous behaviors (Bennett, Wallace, Carroll, & Smith, 1991). See the accompanying
Highlight for some ways to cope with your own stress.

Highlight: Self-Help in Coping With Stress

Even without psychological interventions, there are some things you can do to help yourself
cope with stress:

• Appraise the situation. Isolate the problem. Find out as much as you can about the
stressor, its causes, and its correlates. Consider alternative actions.

• Examine your appraisal. Is it realistic? Avoid catastrophizing. If you have failed an
examination, is it really the end of the world? Perhaps you can try again. A study
plan may help. Even if you cannot erase the failure, you may find you are better at
something else. Catastrophizing leads to stress. Realistic appraisals lead to calm but
hopeful acceptance.

• Be aware of your defenses. Are you denying reality? Are you rationalizing?
• Reduce stress and practice coping skills. Learn to relax. Talk to friends. Exercise. Eat

and sleep well. Join self-help groups where appropriate.
• Take the necessary actions, but do not be impulsive. Consider possible actions,

and list the pros and cons of each. Do not be impulsive. Do not take an action just
because of the need to do something. However, once you have decided what to do,
then do it. Procrastination just produces more stress.

• Remain flexible. Adaptive behavior means not being locked into any course of action.
You must be willing to change direction when the situation warrants it.

No matter which psychological intervention is used, sociocultural factors must be taken into
account (Radley, 1993). We cannot begin to help people cope with stress and illness until
we first understand how they perceive stress and illness (Dasen, Berry, & Sartorius, 1988).
Special efforts must be made to target these groups and their beliefs if prevention is to be
successful.

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Chapter Summary

Stress: Origins, Definitions, and Theories
• Early theories in the field of psychosomatic medicine postulated a specific connec-

tion between certain personalities and certain diseases. These theories claimed that
specific unconscious conflicts produced specific diseases.

• It is difficult to prove that a personality type or psychological conflict actually causes
a disease.

• Selye’s general adaptation syndrome, or GAS, was an elaboration of Cannon’s emer-
gency reaction. There are three stages: emergency (or alarm), resistance (during
which the person uses all of his or her physiological resources to minimize tissue
damage), and, finally, the exhaustion stage (in which illness and injury become likely).

• Selye used the word stressor to refer to external threats to well-being that could trig-
ger GAS. Strong or repeated stress causes the body’s defenses to crumble, making
illness likely.

Sources of Stress
• Stress can arise from catastrophes, important life events, everyday hassles, chronic

illness, and chronic pain and headaches.

Effects of Stress
• Stress has been shown to weaken the nervous system, making it more prone to

injury from incidents such as stroke.
• Stress also reduces the effectiveness of the immune system.
• The effects of stressors may be mediated by individual differences.
• In addition to its direct physiological effects, stress affects health indirectly by inter-

fering with health-relevant behaviors. Stress affects memory, judgment, and other
aspects of cognition.

Posttraumatic Stress Disorder (PTSD)
• The main symptoms of PTSD are anxiety, avoidance of stimuli associated with the

trauma, flashbacks, and a “numbing” of emotional responses. The DSM–5 recognizes
that the symptoms of PTSD may be different in children and has different diagnostic
criteria for children under age 6.

• PTSD is caused by exposure to an extraordinarily stressful, traumatic

event.

• The most common behavioral intervention for PTSD is exposure. Other methods of

treating PTSD include flooding, desensitization, cognitive restructuring, and stress-
management training.

• Eye movement desensitization and reprocessing (EMDR) has been used to treat
PTSD.

• Antidepressant medication may help reduce some of the symptoms of PTSD.
• The prevention of PTSD occurs best with early intervention following a traumatic

event.

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Chapter Summary

Acute Stress Disorder
• Acute stress disorder is diagnosed when the symptoms occur immediately after the

exposure to the trauma and must last at least three days to a month after the expo-
sure to the trauma.

Illness of the Mind or the Body: A Dubious Distinction
• In the past, a small number of conditions were labeled psychosomatic or psycho-

physiological (peptic ulcer, asthma, headaches, hypertension). Today, this distinction
between illnesses with and without psychological components is considered artifi-
cial. Psychological factors play a role in all illnesses.

• The opposite is also true: All illnesses have psychological effects. The reciprocal
effects of stress and illness are best understood using a “stress and coping” model.
That is, the effects of various stressors on health are mediated by coping, which, in
turn, depends on an individual’s coping resources.

Factors That Modify the Effects of Stress
• Primary appraisal involves an assessment of the implications of an event for the

individual. Events may be appraised as irrelevant, beneficial, or stress-inducing.
• Secondary appraisals are concerned with what, if anything, should be done. Cogni-

tive appraisals need not be rational or even conscious.
• Response to stress is always based on our appraisal (conscious or unconscious) of

the threat and our perception of how to deal with it.
• Emotion-focused coping is aimed at managing feelings.
• Problem-focused coping attempts to challenge stressors directly by making a plan of

action and dealing with the source of stress.
• Problem-focused coping works best when a person has the ability to remedy the

situation by taking some action.
• Some people manage to cope successfully with stress or their illness, whereas others

never seem to be able to adjust. Part of the answer lies in the coping resources avail-
able to the individual.

• Social support provides a source of help in times of trouble and gives people a way
of expressing their painful feelings to one another.

• Other factors that affect coping include knowledge (about health practices), hardi-
ness, high self-esteem, locus of control, and health beliefs.

Helping People Cope
• The most widely applied intervention strategy for helping people cope with stress is

relaxation. The underlying rationale is that teaching people how to use relaxation to
reduce the intensity and frequency of emergency reactions and GAS will reduce their
stress.

• Fewer episodes of alarm reactions mean less strain on the heart, the nervous system,
and the immune system.

• Exercise, biofeedback, behavior modification, self-help groups, and many other
interventions have all been found useful in helping people cope with stress.

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Chapter Summary

Critical Thinking Questions

1. What are your views on the theory that psychological processes can cause physical
symptoms?

2. Discuss how you best cope with stress. Do you think that these techniques would
work well for your friends? Why or why not?

3. Discuss how, in your view, denial can help or hinder people coping with serious ill-
ness and stress.

4. Give your views on why we cannot make a diagnosis of PTSD until the symptoms
have been present for at least one month. Is this really enough time to recover from a
traumatic event?

5. Why are social support systems important in helping people cope with stress and
stressful situations?

6. We discussed locus of control in this chapter. Discuss whether yours is internal or
external, and how you feel about that.

7. One issue mentioned in this chapter is that some people with insulin-dependent
diabetes are afraid of injections. Let’s presume you had a good friend in this exact
situation. What techniques would you use to help him or her overcome this fear?

8. Discuss whether or not stress is increasing in today’s society, the reasons this might
be the case, and whether or not stress disorders are becoming more common.

Key Terms
acute stress disorder A short-term
response to a traumatic event with symp-
toms like posttraumatic stress disorder. The
onset of symptoms occurs immediately after
the trauma and lasts at least three days to no
longer than one month after the trauma.

adjustment disorders Psychological
disorders marked by anxiety, depression,
withdrawal, and overall impairments in
psychological functioning. The core feature
is the presence of emotional or behavioral
symptoms in response to an identifiable
stressor. The stressor may be a single event,
or there may be multiple stressful events.
These disorders can have the power to make
people physically ill, or perhaps even lead to
death.

behavioral medicine The study of the
interaction between psychology and
physiology.

biofeedback A technique that trains people
to improve their health by controlling cer-
tain bodily processes that normally happen
involuntarily, such as heart rate, blood pres-
sure, and muscle tension.

comparative optimism Also called opti-
mistic bias: when we believe that we are less
likely than other people to be harmed by bad
events.

conversion hysteria What Freudians often
referred to as hysteria manifested by physi-
cal symptoms.

coping Finding effective ways to adapt to
the problems and difficulties presented by
stress.

desensitization Any decrease in reactions
or sensitivity to a stimulus or stimuli.

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Chapter Summary

emergency (alarm) reaction The body’s
physiological response to threat.

emotion-focused coping A coping tech-
nique, such as denial or obsessiveness, that
involves managing feelings to make our-
selves feel better.

etiology The study of the causes or origins
of disease, in this case mental illnesses.

external locus of control An individual’s
belief that their problems are caused by
external events (such as demons, the moon,
stars, and so on) and thus cannot be con-
trolled by their own behaviors.

general adaptation syndrome
(GAS) When long-term or frequently
recurring threats cause the body to gradu-
ally wear out. Deterioration takes place in
a series of three stages: alarm, resistance,
exhaustion.

hardiness A stress-resistant personality
characteristic that is made up of control,
commitment, and challenge. Hardy individu-
als believe that they are in control of their
lives and that they have the power to influ-
ence people and events around them.

internal locus of control The belief that an
individual’s life’s outcomes are under their
control and occur because of their actions,
not because of external factors out of their
control.

migraines Neuralgia thought to be caused
by the contraction and dilation of blood ves-
sels in the head.

posttraumatic stress disorder (PTSD) A
disorder that typically occurs after being
exposed to a traumatic event such as war
or violence; symptoms include anxiety, the
avoidance of stimuli associated with the
trauma, flashbacks in which the traumatic
event is relived mentally, and a “numbing” of
emotional responses. Additional symptoms
include physiological arousal or hyper-
arousal such as sleep disturbance, increased
irritability, and hypervigilance.

problem-focused coping A coping tech-
nique that involves making a plan of action
and dealing directly with the stressor.

psychophysiological or psychosomatic
disorders Disorders in which psychological
factors produce “real” physical diseases.

stress Usually refers to both a cause (a
“stressful” job, for example) and an effect
(for example, “I am feeling stressed”).

stress management Refers to the various
approaches to reducing stress.

stressor Cause(s) of stress.

tension headaches Neuralgia traditionally
thought to result from tense muscles in the
neck and head.

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get83787_02_c02_027-060.indd 60 2/16/18 4:39 PM

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