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Contents
Contributorsix
Prefacexiii
Index551
Contributors
Damla Aksen, Psychology Department, Binghamton University, State University of New York, Binghamton, New York
Michele A. Bedard-Gilligan, Department of Psychiatry and Behavioral Science, University of Washington, Seattle, Washington
Amber L. Billingsley, Department of Psychology, West Virginia University, Morgantown, West Virginia
Kara Braunstein West, Clinical Psychology Doctoral Program, University of Georgia, Athens, Georgia
Ruifeng Cui, Department of Psychology, West Virginia University, Morgantown, West Virginia
Alexandria R. Ebert, Department of Psychology, West Virginia University, Morgantown, West Virginia
Cierra B. Edwards, Department of Psychology, West Virginia University, Morgantown, West Virginia
Sarah Ehlke, Doctoral Candidate, Health Psychology Program, Old Dominion University, Norfolk, Virginia
Amy Fiske, Department of Psychology, West Virginia University, Morgantown, West Virginia
Georgette E. Fleming, School of Psychology, University of New South Wales, Sydney, Australia
Katherine A. Fowler, Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
Paul J. Frick, Department of Psychology, Louisiana State University, Baton Rouge, Louisiana
Howard N. Garb, Wilford Hall Medical Center, Lackland Airforce Base, San Antonio, Texas
Timo Giesbrecht, Forensic Psychology Section, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht,
The Netherlands
Peter J. Guarnaccia, Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New
Brunswick, New Jersey
Eva R. Kimonis, School of Psychology, University of New South Wales, Sydney, Australia
Keith Klostermann, Department of Counseling and Clinical Psychology, Medaille College, Buffalo, New York
Steven R. López, Department of Psychology, University of Southern California, Los Angeles, California
Steven J. Lynn, Department of Psychology, Binghamton University, The State University of New York, Binghamton, New York
Danielle E. MacDonald, Centre for Mental Health, University Health Network, Toronto, Ontario & Department of Psychiatry,
University of Toronto, Toronto, Ontario
James E. Maddux, Department of Psychology & Center for the Advancement of Well-Being, George Mason University, Fairfax,
Virginia
Kristian Markon, Department of Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa
Rebecca S. Martínez, Department of Counseling and Educational Psychology, Indiana University, Bloomington, Indiana
Traci McFarlane, Centre for Mental Health, University Health Network, Toronto, Ontario & Department of Psychiatry, University of
Toronto, Toronto, Ontario
Harald Merckelbach, Forensic Psychology Section, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The
Netherlands
Leah M. Nellis, Department of Communication Disorders and Counseling, School, and Educational Psychology, Indiana State
University, Kokomo, Indiana
Contributors | xi
Thomas H. Ollendick, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia
Andrea Pelletier-Baldelli, Department of Psychiatry, University of North Carolina, Chapel Hill, North Carolina
Lindsay K. Rye, Department of Educational Psychology, Ball State University, Muncie, Indiana
Janay B. Sander, Department of Educational Psychology, Ball State University, Muncie, Indiana
Mira D. Snider, Department of Psychology, West Virginia University, Morgantown, West Virginia
Shari A. Steinman, Department of Psychology, West Virginia University, Morgantown, West Virginia
Daniel Tranel, Department of Neurology & Department of Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa
Kathryn Trottier, Centre for Mental Health, University Health Network, Toronto, Ontario & Department of Psychiatry, University
of Toronto, Toronto, Ontario
Janice Zeman, Department of Psychology, College of William and Mary, Williamsburg, Virginia
We are pleased to offer the fifth edition of Psychopathology: Foundations for a Contemporary Understanding. This book was created – and revised –
with students in mind. The length, organization, and level and style of writing reflect this intention. We had – and still have – two
major goals in mind.
1. Providing up-to-date information about theory and research on the etiology and treatment of the most important psycholog-
ical disorders. Toward this end, we chose well-known researchers who would not only be aware of the cutting-edge research
on their topics but who were also contributing to this cutting-edge research. This goal also demands frequent updating of
information to reflect, as much as possible, the latest developments in the field.
2. Challenging students to think critically about psychopathology. We tried to accomplish this goal in two ways. First, we encouraged
chapter authors to challenge traditional assumptions and theories concerning the topics about which they were writing. Sec-
ond, and more important, we have included chapters that discuss in depth crucial and controversial issues facing the field of
psychopathology, such as the definition of psychopathology, the influence of cultural and gender, the role of developmental
processes, the validity of psychological testing, and the viability and utility of traditional psychiatric diagnosis. The first eight
chapters in this book are devoted to such issues because we believe that a sophisticated understanding of psychopathology
consists of much more than memorizing a list of disorders and their symptoms or memorizing the findings of numerous
studies. It consists primarily of understanding ideas and concepts and understanding how to use those ideas and concepts to make
sense of the research on specific disorders and the information found in formal diagnostic manuals.
Part I offers in-depth discussions of a number of important ideas, concepts, and theories which provide perspective on specific
psychological disorders. The major reason for placing these general chapters in the first section before the disorders chapters is to
give students a set of conceptual tools that will help them read more thoughtfully and critically the material on specific disorders.
Parts II and III deal with specific disorders of adulthood, childhood, and adolescence. We asked contributors to follow, as much
as possible, a common format consisting of:
Editors must always make choices regarding what should be included in a textbook and what should not. A textbook that devoted
a chapter to every disorder described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the mental, behavioral, and
neurodevelopmental disorders section of the International Classification of Diseases and Related Problems (ICD) would be unwieldy and impos-
sible to cover in a single semester. Our choices regarding what to include and what to exclude were guided primarily by our expe-
riences over several decades of teaching and training clinical psychology doctoral students regarding the kinds of psychological
problems that these and students in related programs (e.g., counseling, social work) typically encounter in their training and in their
subsequent clinical careers. We also wanted to be generally consistent with the nomenclature that appear in the DSM-5 and the
new ICD-11.
We were pleased that the authors of 23 of the 24 chapters of the fourth edition agreed to revise their chapters for the fifth
edition. This helps to assure continuity in content and style from the fourth edition to the fifth.
We continue to hope that instructors and students will find this approach to understanding psychopathology challenging and
useful. We continue to learn much from our contributors in the process of editing their chapters, and we hope that students will
learn as much as we have from reading what these outstanding contributors have produced.
James E. Maddux
George Mason University
Fairfax,Virginia
Barbara A.Winstead
Old Dominion University
Virginia Consortium Program in Clinical Psychology
Norfolk,Virginia
May 1, 2019
PART I
Thinking About Psychopathology
Chapter 1
Conceptions of Psychopathology
A Social Constructionist Perspective
Chapter contents
Conceptions of Psychopathology 4
Categories Versus Dimensions 9
Social Constructionism and Conceptions of Psychopathology 11
Summary and Conclusions 15
References15
4 | James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead
A textbook about a topic should begin with a clear definition of the topic. Unfortunately, for a textbook on psychopathology, this
is a difficult if not impossible task. The definitions or conceptions of psychopathology and such related terms as mental disorder have been
the subject of heated debate throughout the history of psychology and psychiatry, and the debate is not over (e.g., Gorenstein, 1984;
Horwitz, 2002; Widiger, Chapter 6 in this volume). Despite its many variations, this debate has centered on a single overriding
question: Are psychopathology and related terms such as mental disorder and mental illness scientific terms that can be defined objectively and
by scientific criteria, or are they social constructions (Gergen, 1985) that are defined largely or entirely by societal and cultural values?
Addressing these perspectives in this opening chapter is important because the reader’s view of everything in the rest of this book
will be influenced by his or her view on this issue.
This chapter deals with conceptions of psychopathology. A conception of psychopathology is not a theory of psychopathology
(Wakefield, 1992a). A conception of psychopathology attempts to define the term – to delineate which human experiences are
considered psychopathological and which are not. A conception of psychopathology does not try to explain the psychological phe-
nomena that are considered pathological, but instead tells us which psychological phenomena are considered pathological and thus
need to be explained. A theory of psychopathology, however, is an attempt to explain those psychological phenomena and experiences
that have been identified by the conception as pathological. Theories and explanations for what is currently considered to be psy-
chopathological human experience can be found in a number of other chapters, including all of those in Part II.
Understanding various conceptions of psychopathology is important for a number of reasons. As explained by medical philos-
opher Lawrie Reznek (1987), “Concepts carry consequences – classifying things one way rather than another has important impli-
cations for the way we behave towards such things” (p. 1). In speaking of the importance of the conception of disease, Reznek wrote:
The classification of a condition as a disease carries many important consequences. We inform medical scientists that they should try to
discover a cure for the condition. We inform benefactors that they should support such research. We direct medical care towards the
condition, making it appropriate to treat the condition by medical means such as drug therapy, surgery, and so on. We inform our courts
that it is inappropriate to hold people responsible for the manifestations of the condition. We set up early warning detection services
aimed at detecting the condition in its early stages when it is still amenable to successful treatment. We serve notice to health insurance
companies and national health services that they are liable to pay for the treatment of such a condition. Classifying a condition as a disease
is no idle matter (p. 1).
If we substitute psychopathology or mental disorder for the word disease in this paragraph, its message still holds true. How we conceive of
psychopathology and related terms has wide-ranging implications for individuals, medical and mental health professionals, gov-
ernment agencies and programs, legal proceedings, and society at large.
Conceptions of Psychopathology
A variety of conceptions of psychopathology have been offered over the years. Each has its merits and its deficiencies, but none
suffices as a truly scientific definition.
pathological, unconstrained optimism is not. Another concern is that, despite its reliance on scientific and well-established psycho-
metric methods for developing measures of psychological phenomena and developing norms, this approach still leaves room for
subjectivity.
The first point at which subjectivity comes into play is in the conceptual definition of the construct for which a measure is developed.
A measure of any psychological construct, such as intelligence, must begin with a conceptual definition. We have to answer the
question “What is ‘intelligence’?” before we can attempt to measure or study its causes and consequences. Of course, different
people (including different psychologists) will come up with different answers to this question. How then can we scientifically and
objectively determine which definition or conception is “true” or “correct”? The answer is that we cannot. Although we have tried-
and-true methods for developing a reliable and valid (i.e., it consistently predicts what we want to predict) measure of a psycho-
logical construct once we have agreed on its conception or definition, we cannot use these same methods to determine which
conception or definition is true or correct. The bottom line is that there is not a “true” definition of intelligence and no objective,
scientific way of determining one. Intelligence is not a thing that exists inside of people and makes them behave in certain ways and
that awaits our discovery of its “true” nature. Instead, it is an abstract idea that is defined by people as they use the words “intelli-
gence” and “intelligent” to describe certain kinds of human behavior and the covert mental processes that supposedly precede or
are at least concurrent with the behavior.
We usually can observe and describe patterns in the way most people use the words intelligence and intelligent to describe the
behavior of themselves and others. The descriptions of the patterns then comprise the definitions of the words. If we examine the
patterns of the use of intelligence and intelligent, we find that at the most basic level, they describe a variety of specific behaviors and
abilities that society values and thus encourages; unintelligent behavior includes a variety of behaviors that society does not value
and thus discourages. The fact that the definition of intelligence is grounded in societal values explains the recent expansion of the
concept to include good interpersonal skills (e.g., social and emotional intelligence), self-regulatory skills, artistic and musical
abilities, creativity, and other abilities not measured by traditional tests of intelligence. The meaning of intelligence has broadened
because society has come to place increasing value on these other attributes and abilities, and this change in societal values has been
the result of a dialogue or discourse among the people in society, both professionals and laypersons. One measure of intelligence
may prove more reliable than another and more useful than another measure in predicting what we want to predict (e.g., academic
achievement, income), but what we want to predict reflects what we value, and values are not derived scientifically.
Another point for the influence of subjectivity is in the determination of how deviant a psychological phenomenon must be from
the norm to be considered abnormal or pathological. We can use objective, scientific methods to construct a measure such as an
intelligence test and develop norms for the measure, but we are still left with the question of how far from normal an individual’s
score must be to be considered abnormal. This question cannot be answered by the science of psychometrics because the distance
from the average that a person’s score must be to be considered “abnormal” is a matter of debate, not a matter of fact. It is true that
we often answer this question by relying on statistical conventions such as using one or two standard deviations from the average
score as the line of division between normal and abnormal. Yet the decision to use that convention is itself subjective because a
convention (from the Latin convenire, meaning “to come together”), is an agreement or contract made by people, not a truth or fact
about the world. Why should one standard deviation from the norm designate “abnormality”? Why not two standard deviations?
Why not half a standard deviation? Why not use percentages? The lines between normal and abnormal can be drawn at many dif-
ferent points using many different strategies. Each line of demarcation may be more or less useful for certain purposes, such as
determining the criteria for eligibility for limited services and resources. Where the line is set also determines the prevalence of
“abnormality” or “mental disorder” among the general population (Kutchins & Kirk, 1997; Frances, 2013), so it has great practical
significance. But no such line is more or less “true” than the others, even when those others are based on statistical conventions.
We cannot use the procedures and methods of science to draw a definitive line of demarcation between normal and abnormal
psychological functioning, just as we cannot use them to draw definitive lines of demarcation between “short” and “tall” people or
“hot” and “cold” on a thermometer. No such lines exist in nature awaiting our discovery.
“pathologically intelligent” or “pathologically well-adjusted” seems contradictory because it flies in the face of the common
sense use of these words.
The major problem with the conception of psychopathology as maladaptive behavior is its inherent subjectivity. Like the dis-
tinction between normal and abnormal, the distinction between adaptive and maladaptive is fuzzy and arbitrary. We have no objec-
tive, scientific way of making a clear distinction. Very few human behaviors are in and of themselves either adaptive or maladaptive;
instead, their adaptiveness and maladaptiveness depend on the situations in which they are enacted and on the judgment and values
of the actor and the observers. Even behaviors that are statistically rare and therefore abnormal will be more or less adaptive under
different conditions and more or less adaptive in the opinion of different observers and relative to different cultural norms. The
extent to which a behavior or behavior pattern is viewed as more or less adaptive or maladaptive depends on a number of factors,
such as the goals the person is trying to accomplish and the social norms and expectations in a given situation. What works in one
situation might not work in another. What appears adaptive to one person might not appear so to another. What is usually adaptive
in one culture might not be so in another (see López & Guarnaccia, Chapter 4 in this volume). Even so-called “normal” personality
involves a good deal of occasionally maladaptive behavior, which you can find evidence for in your own life and the lives of friends
and relatives. In addition, people given official “personality disorder” diagnoses by clinical psychologists and psychiatrists often can
manage their lives effectively and do not always behave in maladaptive ways.
Another problem with the “psychopathological = maladaptive” conception is that judgments of adaptiveness and maladaptive-
ness are logically unrelated to measures of statistical deviation. Of course, often we do find a strong relationship between the statis-
tical abnormality of a behavior and its maladaptiveness. Many of the problems described in the DSM-5 and in this textbook are both
maladaptive and statistically rare. There are, however, major exceptions to this relationship.
First, not all psychological phenomena that deviate from the norm or the average are maladaptive. In fact, sometimes deviation
from the norm is adaptive and healthy. For example, IQ scores of 130 and 70 are equally deviant from norm, but abnormally high
intelligence is much more adaptive than abnormally low intelligence. Likewise, people who consistently score abnormally low on
measures of anxiety and depression are probably happier and better adjusted than people who consistently score equally abnormally
high on such measures.
Second, not all maladaptive psychological phenomena are statistically infrequent and vice versa. For example, shyness is almost
always maladaptive to some extent because it often interferes with a person’s ability to accomplish what he or she wants to accom-
plish in life and relationships, but shyness is very common and therefore is statistically frequent. The same is true of many of the
problems with sexual functioning that are included in the DSM as “mental disorders” – they are almost always maladaptive to some
extent because they create distress and problems in relationships, but they are relatively common (see Gosselin & Bombardier,
Chapter 14 in this volume).
Fig. 114.—A, staff pegs of sawn timber, 1/8 scale; B, nail, full size.
Larger image
319.—In Fig. 120 the arrow upon the vernier scale is shown
reading at a position beyond 23°, which we then know must be 23°
n′. Now, if we look along the vernier, the lines of this and the scale
appear coincident at the twelfth division of the vernier; consequently,
the n′ is 12′, and the reading is altogether 23° 12′.
320.—Learning the reading of the vernier is very similar to that of
the clock, wherein a child at first gets confused by the difference of
value of the minute hand and the hour hand. In the case of the
vernier we have only to get clearly in our minds that the degree
reading and the vernier reading are quite distinct processes, in which
the vernier reads minutes only, and this by coincidence of lines only,
and that it has nothing to do with degrees, which are indicated by
the arrow only. The arrow may be assumed to be placed on the
vernier scale to save an unnecessary line of division; but this
practically might just as well be placed quite outside of it, as it has
nothing whatever to do with the vernier reading.
Fig. 123.
Larger image
Fig. 125.
Larger image