Psychological Disorders Perspectives on Psychological Disorders

Psychological Disorders12

Enduring Issues in Psychological Disorders Perspectives on Psychological Disorders • Historical Views of

Psychological Disorders • The Biological Model • The Psychoanalytic Model • The Cognitive–Behavioral

Model • The Diathesis–Stress Model

and Systems Theory

• The Prevalence of Psychological Disorders

• Mental Illness and the Law • Classifying Abnormal


Mood Disorders • Depression • Suicide • Mania and Bipolar Disorder • Causes of Mood Disorders

Anxiety Disorders • Specific Phobias • Panic Disorder • Other Anxiety Disorders • Causes of Anxiety Disorders Psychosomatic and Somatoform Disorders Dissociative Disorders Sexual and Gender-Identity Disorders Personality Disorders

Schizophrenic Disorders • Types of Schizophrenic

Disorders • Causes of Schizophrenia Childhood Disorders Gender and Cultural Differences in Psychological Disorders • Gender Differences • Cultural Differences



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Jack was a very successful chemical engineer known for themeticulous accuracy of his work. But Jack also had a “littlequirk.” He constantly felt compelled to double-, triple-, and even quadruple-check things to assure himself that they were done properly. For instance, when leaving his apartment in the morning, he occasionally got as far as the garage—but invariably he would go back to make certain that the door was securely locked and the stove, lights, and other appliances were all turned off. Going on a vacation was particularly difficult for him because his checking routine was so exhaustive and time-consuming. Yet Jack insisted that he would never want to give up this chronic checking. Doing so, he said, would make him “much too nervous.”

For Claudia, every day was more than just a bad-hair day. She was always in utter despair over how “hideous” her hair looked. She perceived some parts of it to be too long, and others to be too short. In her eyes, one area would look much too “poofy,” while another area would look far too flat. Claudia got up early each morning just to work on her hair. For about 2 hours she would wash it, dry it, brush it, comb it, curl it, straighten it, and snip away infinitesimal amounts with an expensive pair of hair-cutting scissors. But she was never satisfied with the


results. Not even trips to the most expensive salons could make her feel content about her hair. She declared that virtually every day was ruined because her hair looked so bad. Claudia said that she desperately wanted to stop focusing on her hair, but for some reason she just couldn’t.

Jonathan was a 22-year-old auto mechanic whom everyone described as a loner. He seldom engaged in conversation and seemed lost in his own private world. At work, the other mechanics took to whistling sharply whenever they wanted to get his attention. Jonathan also had a “strange look” on his face that could make customers feel uncomfortable. But his oddest behavior was his assertion that he sometimes had the distinct feeling his dead mother was standing next to him, watching what he did. Although Jonathan realized that his mother was not really there, he nevertheless felt reassured by the illusion of her presence. He took great care not to look or reach toward the spot where he felt his mother was, because doing so inevitably made the feeling go away.

Cases adapted from J. S. Nevis, S. A. Rathus, & B. Green (2005). Abnormal Psychol-

ogy in a Changing World (5th ed.) Upper Saddle River, NJ: Prentice Hall.

ENDURING ISSUES IN PSYCHOLOGICAL DISORDERS As we explore psychological disorders in this chapter, we will again encounter some of the enduring issues that interest psychologists. A recurring topic is the relationship between genetics, neurotransmitters, and behavior disorders (mind–body). We will also see that many psychological disorders arise because a vulnerable person encounters a particularly stressful environment (person–situation). As you read the chapter, think about how you would answer the question “What is normal?” and how the answer to that question has changed over time and differs even today across cultures (diversity–universality). Consider also whether a young person with a psychological disorder is likely to suffer from it later in life and, conversely, whether a well-adjusted young person is immune to psychological dis- orders later in life (stability–change).

PERSPECTIVES ON PSYCHOLOGICAL DISORDERS How does a mental health professional define a psychological disorder?

When is a person’s behavior abnormal? This is not always easy to determine. There is no doubt about the abnormality of a man who dresses in flowing robes and accosts pedestri- ans on the street, claiming to be Jesus Christ, or a woman who dons an aluminum-foil hel- met to prevent space aliens from “stealing” her thoughts. But other instances of abnormal behavior aren’t always so clear. What about the three people we have just described? All of them exhibit unusual behavior. But does their behavior deserve to be labeled “abnormal”? Do any of them have a genuine psychological disorder?

The answer depends in part on the perspective you take. As Table 12–1 summarizes, society, the individual, and the mental health professional all adopt different perspectives

L E A R N I N G O B J E C T I V E S • Compare the three perspectives on

what constitutes abnormal behavior. Explain what is meant by the statement “Identifying behavior as abnormal is also a matter of degree.” Distinguish between the prevalence and incidence of psychological disorders, and between mental illness and insanity.

• Describe the key features of the biological, psychoanalytic, cognitive–behavioral, diathesis–stress, and systems models of psychological disorders.

• Explain what is meant by “DSM-IV-TR” and describe the basis on which it categorizes disorders.


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when distinguishing abnormal behavior from normal behavior. Society’s main standard of abnormality is whether the behavior fails to conform to prevailing ideas about what is socially expected of people. In contrast, when individuals assess the abnormality of their own behavior, their main criterion is whether that behavior fosters a sense of unhappiness and lack of well-being. Mental health professionals take still another perspective. They assess abnormality chiefly by looking for maladaptive personality traits, psychological dis- comfort regarding a particular behavior, and evidence that the behavior is preventing the person from functioning well in life.

These three approaches to identifying abnormal behavior are not always in agree- ment. For example, of the three people previously described, only Claudia considers her own behavior to be a genuine problem that is undermining her happiness and sense of well-being. In contrast to Claudia, Jack is not really bothered by his compulsive behavior (in fact, he sees it as a way of relieving anxiety); and Jonathan is not only content with being a loner, but he also experiences great comfort from the illusion of his dead mother’s presence. But now suppose we shift our focus and adopt society’s perspective. In this case, we must include Jonathan on our list of those whose behavior is abnormal. His self-imposed isolation and talk of sensing his mother’s ghost violate social expecta- tions of how people should think and act. Society would not consider Jonathan normal. Neither would a mental health professional. In fact, from the perspective of a mental health professional, all three of these cases show evidence of a psychological disorder. The people involved may not always be distressed by their own behavior, but that behav- ior is impairing their ability to function well in everyday settings or in social relation- ships. The point is that there is no hard and fast rule as to what constitutes abnormal behavior. Distinguishing between normal and abnormal behavior always depends on the perspective taken.

Identifying behavior as abnormal is also a matter of degree. To understand why, imag- ine that each of our three cases is slightly less extreme. Jack is still prone to double-checking, but he doesn’t check over and over again. Claudia still spends much time on her hair, but she doesn’t do so constantly and not with such chronic dissatisfaction. As for Jonathan, he only occasionally withdraws from social contact; and he has had the sense of his dead mother’s presence just twice over the last 3 years. In these less severe situations, a mental health pro- fessional would not be so ready to diagnose a mental disorder. Clearly, great care must be taken when separating mental health and mental illness into two qualitatively different cate- gories. It is often more accurate to think of mental illness as simply being quantitatively dif- ferent from normal behavior—that is, different in degree. The line between one and the other is often somewhat arbitrary. Cases are always much easier to judge when they fall at the extreme end of a dimension than when they fall near the “dividing line.”


Standards/Values Measures

Society Orderly world in which people assume responsibility for their assigned social roles (e.g., breadwinner, parent), conform to prevailing mores, and meet situational requirements.

Observations of behavior, extent to which a person fulfills society’s expectations and measures up to prevailing standards.

Individual Happiness, gratification of needs. Subjective perceptions of self-esteem, acceptance, and well-being. Mental health professional

Sound personality structure characterized by growth, development, autonomy, environmental mastery, ability to cope with stress, adaptation.

Clinical judgment, aided by behavioral observations and psychological tests of such variables as self-concept; sense of identity; balance of psychic forces; unified outlook on life; resistance to stress; self-regulation; the ability to cope with reality; the absence of mental and behavioral symptoms; adequacy in interpersonal relationships.

Source: From “A Tripartite Model of Mental Health and Therapeutic Outcomes with Special Reference to Negative Effects on Psychotherapy” by H. H. Strupp and S. W. Hadley, American Psychologist, 32 (1977), pp. 187–196. Copyright © 1977 by American Psychological Association.


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Psychological Disorders 393

Historical Views of Psychological Disorders How has the view of psychological disorders changed over time?

The place and times also contribute to how we define mental disorders. Thousands of years ago, mysterious behaviors were often attributed to supernatural powers and madness was a sign that spirits had possessed a per- son. As late as the 18th century, the emotionally dis- turbed person was thought to be a witch or to be possessed by the devil. Exorcisms, ranging from the mild to the hair raising, were performed, and many people endured horrifying tortures. Some people were even burned at the stake.

By the late Middle Ages, there was a move away from viewing the mentally ill as witches and possessed by demons, and they were increasingly confined to public and private asylums. Even though these institu- tions were founded with good intentions, most were little more than prisons. In the worst cases, inmates were chained down and deprived of food, light, or air in order to “cure” them.

Little was done to ensure humane standards in mental institutions until 1793, when Philippe Pinel (1745–1826) became director of the Bicêtre Hospital in Paris. Under his direction, patients were released from their chains and allowed to move about the hospital grounds, rooms were made more comfortable and sanitary, and questionable and violent medical treatments were abandoned (James Harris, 2003). Pinel’s reforms were soon fol- lowed by similar efforts in England and, somewhat later, in the United States where Dorothea Dix (1802–1887), a schoolteacher from Boston, led a nationwide campaign for the humane treatment of mentally ill people. Under her influence, the few existing asylums in the United States were gradually turned into hospitals.

The basic reason for the failed—and sometimes abusive—treatment of mentally dis- turbed people throughout history has been the lack of understanding of the nature and causes of psychological disorders. Although our knowledge is still inadequate, important advances in understanding abnormal behavior can be traced to the late 19th and 20th cen- turies, when three influential but conflicting models of abnormal behavior emerged: the biological model, the psychoanalytic model, and the cognitive–behavioral model.

The Biological Model How can biology influence the development of psychological disorders?

The biological model holds that psychological disorders are caused by physiological mal- functions often stemming from hereditary factors. As we shall see, support for the biologi- cal model has been growing rapidly as scientists make advances in the new interdisciplinary field of neuroscience, which directly links biology and behavior (see Chapter 2,“The Biolog- ical Basis of Behavior”).

For instance, new neuroimaging techniques have enabled researchers to pinpoint regions of the brain involved in such disorders as schizophrenia (Kumra, 2008; Ragland, 2007) and antisocial personality (Birbaumer et al., 2005; Narayan et al., 2007). By unravel- ing the complex chemical interactions that take place at the synapse, neurochemists have spawned advances in neuropharmacology leading to the development of promising new psychoactive drugs (see Chapter 13,“Therapies”). Many of these advances are also linked to the field of behavior genetics, which is continually increasing our understanding of the role

In the 17th century, French physicians tried various devices to cure their patients of “fantasy and folly.”

biological model View that psychological disorders have a biochemical or physiological basis.


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of specific genes in the development of complex disorders such as schizophrenia (Horiuchi et al., 2006; Tang et al., 2006; Ying-Chieh Wang et al., 2008) and autism (Kuehn, 2006; Losh, Sullivan, Trembath, & Piven, 2008).

Although neuroscientific breakthroughs are indeed remarkable, to date no neu- roimaging technique can clearly and definitively differentiate among various mental dis- orders (Callicott, 2003; Sarason & Sarason, 1999). And despite the availability of an increasing number of medications to alleviate the symptoms of some mental disorders, most drugs can only control—rather than cure—abnormal behavior. There is also some concern that advances in identifying the underlying neurological structures and mecha- nisms associated with mental illnesses may interfere with the recognition of equally impor- tant psychological causes of abnormal behavior (Dudai, 2004; Widiger & Sankis, 2000). Despite this concern, the integration of neuroscientific research and traditional psycholog- ical approaches to understanding behavior is taking place at an increasingly rapid pace, and will undoubtedly reshape our view of mental illness in the future (Lacy & Hughes, 2006; Westen, 2005).

The Psychoanalytic Model What did Freud and his followers believe was the underlying cause of psychological disorders?

Freud and his followers developed the psychoanalytic model during the late 19th and early 20th centuries. (See Chapter 10, “Personality.”) According to this model, behavior disorders are symbolic expressions of unconscious conflicts, which can usually be traced to childhood. The psychoanalytic model argues that in order to resolve their problems effectively, people must become aware that the source of their problems lies in their childhood and infancy.

Although Freud and his followers profoundly influenced both the mental health disci- plines and Western culture, only weak and scattered scientific evidence supports their psy- choanalytic theories about the causes and effective treatment of mental disorders.

The Cognitive–Behavioral Model According to the cognitive–behavioral model, what causes abnormal behavior?

A third model of abnormal behavior grew out of 20th-century research on learning and cognition. The cognitive–behavioral model suggests that psychological disorders, like all behavior, result from learning. For example, a bright student who believes that he is acade- mically inferior to his classmates and can’t perform well on a test may not put much effort into studying. Naturally, he performs poorly, and his poor test score confirms his belief that he is academically inferior.

The cognitive–behavioral model has led to innovations in the treatment of psycholog- ical disorders, but the model has been criticized for its limited perspective, especially its emphasis on environmental causes and treatments.

The Diathesis–Stress Model and Systems Theory Why do some people with a family history of a psychological disorder develop the disorder, whereas other family members do not?

Each of the three major theories is useful in explaining the causes of certain types of disor- ders. The most exciting recent developments, however, emphasize integration of the vari- ous theoretical models to discover specific causes and specific treatments for different mental disorders.

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psychoanalytic model View that psychological disorders result from unconscious internal conflicts.

cognitive–behavioral model View that psychological disorders result from learning maladaptive ways of thinking and behaving.

The cognitive–behavioral view of mental dis- orders suggests that people can learn—and unlearn—thinking patterns that affect their lives unfavorably. For example, an athlete who is convinced she will not win may not practice as hard as she should and end up “defeating herself.”


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Psychological Disorders 395

One promising integrative approach is seen in the diathesis–stress model (McKeever & Huff, 2003; L. A. Schmidt, Polak, & Spooner, 2005). This model suggests that a biological predisposition called a diathesis must combine with a stressful circum- stance before the predisposition to a mental disorder is manifested (S. R. Jones & Ferny- hough, 2007).

The systems approach, also known as the biopsychosocial model, examines how bio- logical risks, psychological stresses, and social pressures and expectations combine to pro- duce psychological disorders (Fava & Sonino, 2007; Weston, 2005). According to this model, emotional problems are “lifestyle diseases” that, much like heart disease and many other physical illnesses, result from a combination of risk factors and stresses. Just as heart disease can result from a combination of genetic predisposition, personality styles, poor health habits (such as smoking), and stress, psychological problems result from several risk factors that influence one another. In this chapter, we follow the systems approach in exam- ining the causes and treatments of abnormal behavior.

diathesis Biological predisposition.

systems approach View that biological, psychological, and social risk factors combine to produce psychological disorders. Also known as the biopsychosocial model of psychological disorders.

Mind–Body Causes of Mental Disorders Throughout this chapter, as we discuss what is known about the causes of psychological disorders, you will see that biological and psychological factors are intimately connected. For example, there is strong evidence for a genetic component in some personality disor- ders as well as in schizophrenia. However, not everyone who inherits these factors develops a personality disorder or suffers from schizophrenia. Our current state of knowledge allows us to pinpoint certain causative factors for certain conditions, but it does not allow us to completely differentiate biological and psychological factors. ■

The Prevalence of Psychological Disorders How common are mental disorders?

Psychologists and public-health experts are concerned with both the prevalence and the incidence of mental health problems. Prevalence refers to the frequency with which a given disorder occurs at a given time. If there were 100 cases of depression in a popu- lation of 1,000, the prevalence of depression would be 10%. The incidence of a disorder refers to the number of new cases that arise in a given period. If there were 10 new cases of depression in a population of 1,000 in a single year, the incidence would be 1% per year.

In 2005, the National Institute of Mental Health conducted a survey finding that 26.2% or approximately 57.7 million Americans were suffering from a mental disorder. While only about 6% were regarded as having a serious mental illness, almost half the peo- ple (45%) suffering from one mental disorder also met the criteria for 2 or more other mental disorders (Kessler, Chiu, Demler, & Walters, 2005). Notably, mental disorders are the leading cause of disability in the United States for people between the ages of 15 and 44 (The World Health Organization, 2004). Figure 12–1 shows the prevalence for some of the more common mental disorders among adult Americans. As shown in Figure 12–1, anxi- ety disorders are the most common mental disorder followed by mood disorders. (All of these are described in detail later in this chapter.)

More recently diagnostic interviews with more than 60,000 people in 14 countries around the world showed that over a 1-year period, the prevalence of moderate or serious psychological disorders varied widely from 12% of the population in the Americas to 7% in Europe, 6% in the Middle East and Africa, and just 4% in Asia (World Health Organization [WHO] World Mental Health Survey Consortium, 2004).

diathesis–stress model View that people biologically predisposed to a mental disorder (those with a certain diathesis) will tend to exhibit that disorder when particularly affected by stress.


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Mental Illness and the Law Is there a difference between being “mentally ill” and being “insane”?

Particularly horrifying crimes have often been attributed to mental disturbance, because it seems to many people that anyone who could commit such crimes must be “crazy.” But to the legal system, this presents a problem: If a person is truly “crazy,” are we justi- fied in holding him or her responsible for criminal acts? The legal answer to this ques- tion is a qualified yes. A mentally ill person is responsible for his or her crimes unless he or she is determined to be insane. What’s the difference between being “mentally ill” and being “insane”? Insanity is a legal term, not a psychological one. It is typically applied to defendants who were so mentally disturbed when they committed their offense that they either lacked substantial capacity to appreciate the criminality of their actions (to know right from wrong) or to conform to the requirements of the law (to control their behavior).

When a defendant is suspected of being mentally disturbed or legally insane, another important question must be answered before that person is brought to trial: Is the person able to understand the charges against him or her and to participate in a defense in court? This issue is known as competency to stand trial. The person is exam- ined by a court-appointed expert and, if found to be incompetent, is sent to a mental institution, often for an indefinite period. If judged to be competent, the person is required to stand trial.

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Figure 12–1 Prevalence of selected mental disorders in the United States. A 2005 survey by the National Institute of Mental Health found that approximately 26.2%, or about 57.7 million Americans suffer from a mental disorder. The prevalence among adult Americans for a few of the more common mental disorders is shown here. Source: National Institute of Mental Health (2005).


Major Depressive Disorder

5 10 15 2520 Number of American Adults (in millions)

30 35 40 45

Bipolar 2.6%

Post-Traumatic Stress Disorder 3.5%

Attention-Deficit Hyperactivity Disorder (ADHD) 4.1%


Specific Phobias 8.7%

All Mood Disorders 9.5%

All Anxiety Disorders 18.1%

Schizophrenia 1.1%

Obsessive-Compulsive Disorder 1.0%

insanity Legal term applied to defendants who do not know right from wrong or are unable to control their behavior.

Watch PTSD 911 at


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Psychological Disorders 397

Classifying Abnormal Behavior Why is it useful to have a manual of psychological disorders?

For nearly 40 years, the American Psychiatric Association (APA) has issued a manual describing and classifying the various kinds of psychological disorders. This publication, the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been revised four times. The DSM-IV-TR (American Psychiatric Association, 2000) provides a complete list of mental disorders, with each category painstakingly defined in terms of significant behavior patterns (see Table 12–2). The DSM has gained increasing acceptance because its detailed criteria for diagnosing mental disorders have made diagnosis much more reli- able. Today, it is the most widely used classification of psychological disorders. In the remainder of this chapter, we will explore some of the key categories in greater detail.


Category Example

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence

Mental retardation, learning disorders, autistic disorder, attention-deficit/hyperactivity disorder.

Delirium, Dementia, and Amnestic and Other Cognitive Disorders

Delirium, dementia of the Alzheimer’s type, amnestic disorder.

Mental Disorders Due to a General Medical Condition

Psychotic disorder due to epilepsy.

Substance-Related Disorders Alcohol dependence, cocaine dependence, nicotine dependence. Schizophrenia and Other Psychotic Disorders Schizophrenia, schizoaffective disorder, delusional disorder. Mood Disorders Major depressive disorder, dysthymic disorder, bipolar disorder. Anxiety Disorders Panic disorder with agoraphobia, social phobia, obsessive-compulsive disorder, post-

traumatic stress disorder, generalized anxiety disorder. Somatoform Disorders Somatization disorder, conversion disorder, hypochondriasis. Factitious Disorders Factitious disorder with predominantly physical signs and symptoms. Dissociative Disorders Dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization

disorder. Sexual and Gender-Identity Disorders Hypoactive sexual desire disorder, male erectile disorder, female orgasmic disorder,

vaginismus. Eating Disorders Anorexia nervosa, bulimia nervosa. Sleep Disorders Primary insomnia, narcolepsy, sleep terror disorder. Impulse-Control Disorders Kleptomania, pyromania, pathological gambling. Adjustment Disorders Adjustment disorder with depressed mood, adjustment disorder with conduct disturbance. Personality Disorders Antisocial personality disorder, borderline personality disorder, narcissistic personality

disorder, dependent personality disorder.

Answers:1. supernatural.2. genetic.3. Insanity.4. (T).5. (F).6. (F).


1. It is likely that people in early societies believed that ________ forces caused abnormal behavior. 2. There is growing evidence that ________ factors are involved in mental disorders as diverse

as schizophrenia, depression, and anxiety. 3. ________ is a legal term that is not the same thing as mental illness.

Indicate whether the following statements are true (T) or false (F): 4. The line separating normal from abnormal behavior is somewhat arbitrary. 5. About two-thirds of Americans are suffering from one or more serious mental disorders

at any given time. 6. The cognitive view of mental disorders suggests that they arise from unconscious conflicts,

often rooted in childhood.

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MOOD DISORDERS How do mood disorders differ from ordinary mood changes?

Most people have a wide emotional range; they can be happy or sad, animated or quiet, cheerful or discouraged, or overjoyed or miserable, depending on the circumstances. In some people with mood disorders, this range is greatly restricted. They seem stuck at one or the other end of the emotional spectrum—either consistently excited and euphoric or consistently sad—regardless of life circumstances. Others with mood disorders alternate between the extremes of euphoria and sadness.

Depression How does clinical depression differ from ordinary sadness?

The most common mood disorder is depression, a state in which a person feels over- whelmed with sadness. Depressed people lose interest in the things they normally enjoy. Intense feelings of worthlessness and guilt leave them unable to feel pleasure. They are tired and apathetic, sometimes to the point of being unable to make the simplest decisions. Many depressed people feel as if they have failed utterly in life, and they tend to blame themselves for their problems. Seriously depressed people often have insomnia and lose interest in food and sex. They may have trouble thinking or concentrating—even to the extent of finding it difficult to read a newspaper. In fact, difficulty in concentrating and subtle changes in short-term memory are sometimes the first signs of the onset of depres- sion (Janice Williams et al., 2000). In extreme cases, depressed people may be plagued by suicidal thoughts or may even attempt suicide (C. T. S. Kumar, Mohan, & Ranjith, 2006). The earlier the age of onset of depressive symptoms, the greater the likelihood that suicide may be attempted (A. H. Thompson, 2008).

Clinical depression is different from the “normal” kind of depression that all people experience from time to time. Only when depression is long lasting and goes well beyond the typical reaction to a stressful life event is it classified as a mood disorder (American Psy- chological Association, 2000). (See “Applying Psychology: Recognizing Depression.”)

DSM-IV-TR distinguishes between two forms of depression: Major depressive disor- der is an episode of intense sadness that may last for several months; in contrast, dysthymia involves less intense sadness (and related symptoms), but persists with little

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depression A mood disorder characterized by overwhelming feelings of sadness, lack of interest in activities, and perhaps excessive guilt or feelings of worthlessness.


1. You are talking to a friend whose behavior has you concerned. She says, “Look, I’m happy, I feel good about myself, and I think things are going well.” Which viewpoint on mental health is reflected in her statement?

a. society’s view b. the individual’s view c. the mental health professional’s view d. Both (b) and (c) are true.

2. A friend asks you, “What causes people to have psychological disorders?” You respond, “Most often, it turns out that some people are biologically prone to developing a particular disorder. When they have some kind of stressful experience, the predisposition shows up in their behavior.” What view of psychological disorders are you taking?

a. psychoanalytic model b. cognitive model c. behavioral model d. diathesis–stress model

Answers:1. b.2. d.

L E A R N I N G O B J E C T I V E S • Explain how mood disorders differ from

ordinary mood changes. List the key symptoms that are used to diagnose major depression, dysthymia, mania, and bipolar disorder. Describe the causes of mood disorders.

• Describe the factors that are related to a person’s likelihood of committing suicide. Contrast the three myths about suicide with the actual facts about suicide.

mood disorders Disturbances in mood or prolonged emotional state.

major depressive disorder A depressive disorder characterized by an episode of intense sadness, depressed mood, or marked loss of interest or pleasure in nearly all activities.

dysthymia A depressive disorder where the symptoms are generally less severe than for major depressive disorder, but are present most days and persist for at least 2 years.


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relief for a period of 2 years or more. Depression is two to three times more prevalent in women than in men (Inaba et al., 2005; Kessler et al., 2003; Nolen-Hoeksema, 2006).

Children and adolescents can also suffer from depression. In very young children, depression is sometimes difficult to diagnose because the symptoms are usually different than those seen in adults. For instance, in infants or toddlers, depression may be manifest as a “failure to thrive” or gain weight, or as a delay in speech or motor development. In school-age children, depression may be manifested as antisocial behavior, excessive worry- ing, sleep disturbances, or unwarranted fatigue (Kaslow, Clark, & Sirian, 2008).

One of the most severe hazards of depression, as well as some of the other disorders described in this chapter, is that people may become so miserable that they no longer wish to live.

Recognizing Depression

From time to time, almost everyonegets “the blues.” Failing a major exam,breaking up with a partner, even leav- ing home and friends to attend college can all produce a temporary state of sadness. More significant life events can have an even greater impact: The loss of one’s job or the loss of a loved one can produce a sense of hopelessness about the future that feels very much like a slide into depres- sion. But in all of these instances, either the mood disorder is a normal reaction to a real problem or it passes quickly.

At what point do these normal responses evolve into clinical depression? The DSM- IV-RT provides the framework for making this distinction. First, clinical depression is characterized by depressed mood or by the loss of interest and pleasure in usual activities, or both. Clinicians also look for significant impairment or distress in social, occupational, or other important areas of functioning. People suffering from depres- sion not only feel sad or empty, but also have significant problems carrying on a normal lifestyle. Clinicians also look for other explanations. Could symptoms be due to substance abuse or medication side effects? Could they be the result of a med- ical condition such as hypothyroidism (the inability of the thyroid gland to produce an adequate amount of its hormones)? Could the symptoms be better interpreted as an intense but otherwise normal reaction to life events?

If the symptoms do not seem to be explained by the preceding causes, clini- cians make a diagnosis of major depressive disorder according to the DSM-IV-TR, which specifies that at least five of the fol- lowing symptoms—including at least one of the first two—are present:

1. Depressed mood: Does the person feel sad or empty for most of the day, most every day, or do others observe these symptoms?

2. Loss of interest in pleasure: Has the person lost interest in performing normal activities, such as working or going to social events? Does the per- son seem to be “just going through the motions” of daily life without deriving any pleasure from them?

3. Significant weight loss or gain: Has the person gained or lost more than 5% of body weight in a month? Has the per- son lost interest in eating or com- plained that food has lost its taste?

4. Sleep disturbances: Is the person hav- ing trouble sleeping? Conversely, is the person sleeping too much?

5. Disturbances in motor activities: Do others notice a change in the person’s activity level? Does the person just “sit around” or, conversely, behave in an agitated or unusually restless manner?

6. Fatigue: Does the person complain of being constantly tired and having no energy?

7. Feelings of worthlessness or excessive guilt: Does the person express feelings such as “You’d be better off without me” or “I’m evil and I ruin everything for everybody I love”?

8. Inability to concentrate: Does the per- son complain of memory problems (“I just can’t remember anything anymore”) or the inability to focus attention on simple tasks, such as reading a newspaper?

9. Recurrent thoughts of death: Does the person talk about committing suicide or express the wish that he or she were dead?

If you or someone you know well seems to have these symptoms, that per- son should consult a doctor or mental health professional. When these symp- toms are present and are not due to other medical conditions, a diagnosis of major depression is typically the result, and appropriate treatment can be prescribed. As you will learn in Chapter 13, “Thera- pies,” appropriate diagnosis is the first step in the effective treatment of psychological disorders.

Source: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Associ- ation, 2000.


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Suicide What factors are related to a person’s likelihood of committing suicide?

Each year in the United States, approximately one suicide occurs every 17 minutes, making it the 11th leading cause of death (Centers for Disease Control, 2006; Holloway, Brown, & Beck, 2008). In addition, half a million Americans receive hospital treatment each year for attempted suicide. Indeed, suicides outnumber homicides by five to three in the United States. The suicide rate is much higher among Whites than among minorities (Centers for Disease Control, 2006). Compared to other countries, the suicide rate in the United States is below average (the highest rates are found in eastern European countries) (Curtin, 2004). More women than men attempt suicide, but more men succeed, partly because men tend to choose violent and lethal means, such as guns.

Although the largest number of suicides occurs among older White males, since the 1960s suicide attempt rates have been rising among adolescents and young adults (Figure 12–2). In fact, adolescents account for 12% of all suicide attempts in the United States, and in many other countries suicide ranks as either the first, second, or third leading cause of death in that age group (Centers for Disease Control and Prevention, 1999; Zalsman & Mann, 2005). We cannot as yet explain the increase, though the stresses of leav- ing home, meeting the demands of college or a career, and surviving loneliness or broken romantic attachments seem to be particularly great at this stage of life. Although external problems such as unemployment and financial strain may also contribute to personal problems, suicidal behavior is most common among adolescents with psychological prob- lems. Several myths concerning suicide can be quite dangerous:

Myth: Someone who talks about committing suicide will never do it. Fact: Most people who kill themselves have talked about it. Such comments should

always be taken seriously.

Myth: Someone who has tried suicide and failed is not serious about it.

Fact: Any suicide attempt means that the person is deeply troubled and needs help immediately. A suicidal person will try again, picking a more deadly method the second or third time around.

Myth: Only people who are life’s losers— those who have failed in their careers and in their personal lives—commit suicide.

Fact: Many people who kill themselves have prestigious jobs, conventional families, and a good income. Physicians, for example, have a suicide rate several times higher than that for the general population; in this case, the tendency to suicide may be related to their work stresses.

People considering suicide are overwhelmed with hopelessness. They feel that things cannot get better and see no way out of their difficulties. This perception is depression in the extreme, and it is not easy to talk someone out of this state of mind. Telling a suicidal person that things aren’t really so

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Figure 12–2 Gender and race differences in the suicide rate across the life span. The suicide rate for White males, who commit the largest number of suicides at all ages, shows a sharp rise beyond the age of 65. In contrast, the suicide rate for African American females, which is the lowest for any group, remains relatively stable throughout the life span. Source: From Suicide and Life-Threatening Behavior by E. K. Moscicki. Copyright © 1995 by Guilford Publi- cations, Inc. Reprinted by permission of Copyright Clearance Center on behalf of the publisher.

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Psychological Disorders 401

bad does no good; in fact, the person may only view this as further evidence that no one understands his or her suffering. But most suicidal people do want help, however much they may despair of obtaining it. If a friend or family member seems at all suicidal, getting professional help is urgent. A community mental health center is a good starting place, as are the national suicide hotlines.

Mania and Bipolar Disorder What is mania, and how is it involved in bipolar disorder?

Another mood disorder, which is less common than depression, is mania, a state in which the person becomes euphoric or “high,” extremely active, excessively talkative, and easily distracted. People suffering from mania may become grandiose—that is, their self-esteem is greatly inflated. They typically have unlimited hopes and schemes, but little interest in realistically carrying them out. People in a manic state sometimes become aggressive and hostile toward others as their self-confidence grows more and more exaggerated. At the extreme, people going through a manic episode may become wild, incomprehensible, or violent until they collapse from exhaustion.

The mood disorder in which both mania and depression are present is known as bipolar disorder. In people with bipolar disorder, periods of mania and depression alternate (each lasting from a few days to a few months), sometimes with periods of normal mood in between. Occasionally, bipolar disorder occurs in a mild form, with moods of unrealistically high spirits followed by moderate depression. Research sug- gests that bipolar disorder is much less common than depression and, unlike depres- sion, occurs equally in men and women. Bipolar disorder also seems to have a stronger biological component than depression: It is more strongly linked to heredity and is most often treated with drugs (Hayden & Nurnberger, 2006; Konradi et al., 2004; Serretti & Mandelli, 2008).

Causes of Mood Disorders What causes some people to experience extreme mood changes?

Mood disorders result from a combination of risk factors although researchers do not yet know exactly how these elements interact to cause a mood disorder (Moffitt, Caspi, & Rutter, 2006).

Biological Factors Genetic factors can play an important role in the development of depression (Haghighi et al., 2008; Zubenko et al., 2003) and bipolar disorder (Badner, 2003; Serretti & Mandelli, 2008). Strong evidence comes from studies of twins. (See Chapter 2, “The Biological Basis of Behavior.”) If one identical twin is clinically depressed, the other twin (with identical genes) is likely to become clinically depressed also. Among fraternal twins (who share only about half their genes), if one twin is clinically depressed, the risk for the second twin is much lower (McGuffin, Katz, Watkins, & Rutherford, 1996). In addition, genetic researchers have recently identified a specific variation on the 22 chro- mosome that appears to increase an individual’s susceptibility to bipolar disorder by influ- encing the balance of certain neurotransmitters in the brain (Hashimoto et al., 2005; Kuratomi et al., 2008).

A new and particularly intriguing line of research aimed at understanding the cause of mood disorders stems from the diathesis–stress model. Recent research shows that a diathesis (biological predisposition) leaves some people particularly vulnerable to certain stress hormones. Adverse or traumatic experiences early in life can result in high levels of those stress hormones, which in turn increases the likelihood of a mood disorder later in life (Bradley et al., 2008; Gillespie & Nemeroff, 2007).

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mania A mood disorder characterized by euphoric states, extreme physical activity, excessive talkativeness, distractedness, and sometimes grandiosity.

bipolar disorder A mood disorder in which periods of mania and depression alternate, sometimes with periods of normal mood intervening.

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Psychological Factors Although a number of psychological factors are thought to play a role in causing severe depression, in recent years, researchers have focused on the contribution of maladaptive cognitive distortions. According to Aaron Beck (1967, 1976, 1984), during childhood and adolescence, some people undergo wrenching experiences such as the loss of a parent, severe difficulties in gaining parental or social approval, or humiliating criticism from teachers and other adults. One response to such experience is to develop a negative self-concept—a feeling of incompetence or unworthiness that has little to do with reality, but that is maintained by a distorted and illogical interpretation of real events. When a new situation arises that resembles the situation under which the self- concept was learned, these same feelings of worthlessness and incompetence may be acti- vated, resulting in depression. Considerable research supports Beck’s view of depression (Alloy, Abramson, & Francis, 1999; Alloy, Abramson, Whitehouse, et al., 1999; Kwon & Oei, 2003). Therapy based on Beck’s theories has proven quite successful in treating depression. (See Chapter 13, “Therapies.”)

Social Factors Many social factors have been linked with mood disorders, particularly difficulties in interpersonal relationships. In fact, some theorists have suggested that the link between depression and troubled relationships explains the fact that depression is two to three times more prevalent in women than in men (National Alliance on Mental Illness, 2003), because women tend to be more relationship oriented than men are in our society (Ali, 2008; Pinhas, Weaver, Bryden, Ghabbour, & Toner, 2002). Yet, not every person who experiences a troubled relationship becomes depressed. As the systems approach would predict, it appears that a genetic predisposition or cognitive distortion is necessary before a distressing close relationship or other significant life stressor will result in a mood disorder (Wichers et al., 2007).

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Person–Situation The Chicken or the Egg? It is sometimes difficult to tease apart the relative contribution of the person’s biological or cognitive tendencies and the social situation. People with certain depression-prone genetic or cognitive tendencies may be more likely than others to encounter stressful life events by virtue of their personality and behavior. For example, studies show that depressed people tend to evoke anxiety and even hostility in others, partly because they require more emo- tional support than people feel comfortable giving. As a result, people tend to avoid those who are depressed, and this shunning can intensify the depression. In short, depression- prone and depressed people may become trapped in a vicious circle that is at least partly of their own creation (Coyne & Whiffen, 1995; Pettit & Joiner, 2006). ■

cognitive distortions An illogical and maladaptive response to early negative life events that leads to feelings of incompetence and unworthiness that are reactivated whenever a new situation arises that resembles the original events.


Indicate whether the following statements are true (T) or false (F):

1. ________ People with a mood disorder always alternate between the extremes of euphoria and sadness.

2. ________ More men attempt suicide, but more women actually kill themselves. 3. ________ Most psychologists now believe that mood disorders result from a combination

of risk factors. 4. ________ Mania is the most common mood disorder.

Answers:1. (F).2. (F).3. (T).4. (F). ISB N


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Psychological Disorders 403

ANXIETY DISORDERS How does an anxiety disorder differ from ordinary anxiety?

All of us are afraid from time to time, but we usually know why we are fearful, our fear is caused by something appropriate and identifiable, and it passes with time. In the case of anxiety disorders, however, either the person does not know why he or she is afraid, or the anxiety is inappropriate to the circumstances. In either case, the person’s fear and anxiety just don’t seem to make sense.

As shown in Figure 12–1, anxiety disorders are more common than any other form of mental disorder. Anxiety disorders can be subdivided into several diagnostic categories, including specific phobias, panic disorder, and other anxiety disorders, such as generalized anxiety disorder, obsessive–compulsive disorder, and disorders caused by specific trau- matic events.

Specific Phobias Into what three categories are phobias usually grouped?

A specific phobia is an intense, paralyzing fear of something that perhaps should be feared, but the fear is excessive and unreasonable. In fact, the fear in a specific phobia is so great that it leads the person to avoid routine or adaptive activities and thus interferes with life functioning. For example, it is appropriate to be a bit fearful as an airplane takes off or lands, but people with a phobia about flying refuse to get on or even go near an airplane. Other common phobias focus on animals, heights, closed places, blood, needles, and injury. Almost 10% of people in the United States suffer from at least one specific phobia.

Most people feel some mild fear or uncertainty in many social situations, but when these fears interfere significantly with life functioning, they are considered to be social pho- bias. Intense fear of public speaking is a common form of social phobia. In other cases, simply talking with people or eating in public causes such severe anxiety that the phobic person will go to great lengths to avoid these situations.

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anxiety disorders Disorders in which anxiety is a characteristic feature or the avoidance of anxiety seems to motivate abnormal behavior.


1. Bob is “down in the dumps” most of the time. He is having a difficult time dealing with any criticism he receives at work or at home. Most days he feels that he is a failure, despite the fact that he is successful in his job and his family is happy. Although he participates in various activities outside the home, he finds no joy in anything. He says he is constantly tired, but he has trouble sleeping. It is most likely that Bob is suffering from

a. clinical depression. b. generalized anxiety disorder. c. depersonalization disorder. d. somatoform disorder.

2. Mary almost seems to be two different people. At times, she is hyperactive and talks nonstop (sometimes so fast that nobody can understand her). At those times, her friends say she is “bouncing off the walls.” But then she changes: She becomes terribly sad, loses interest in eating, spends much of her time in bed, and rarely says a word. It is most likely that Mary is suffering from

a. dissociative identity disorder. b. depression. c. bipolar disorder. d. schizophrenia.

Answers:1. a.2. c.

L E A R N I N G O B J E C T I V E S • Explain how anxiety disorders differ from

ordinary anxiety. Briefly describe the key features of phobias, panic disorders, generalized anxiety disorder, and obsessive–compulsive disorder.

• Describe the causes of anxiety disorders.

specific phobia Anxiety disorder characterized by an intense, paralyzing fear of something.

social phobias Anxiety disorders characterized by excessive, inappropriate fears connected with social situations or performances in front of other people.

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Agoraphobia is much more debilitating than social phobia. This term comes from Greek and Latin words that literally mean “fear of the marketplace,” but the disorder typi- cally involves multiple, intense fears, such as the fear of being alone, of being in public places from which escape might be difficult, of being in crowds, of traveling in an automo- bile, or of going through tunnels or over bridges. The common element in all of these situ- ations seems to be a great dread of being separated from sources of security. Some sufferers are so fearful that they will venture only a few miles from home; others will not leave their homes at all.

For example, consider the accomplished author, composer, pianist, and educator Allen Shawn, who wrote in his memoir:

I don’t like heights, I don’t like being on the water. I am upset by walking across parking lots or open parks or fields where there are no buildings. I tend to avoid bridges, unless they are on a small scale. I respond poorly to stretches of vastness but do equally badly when I am closed in, as I am severely claustrophobic. When I go to a theater, I sit on the aisle. I am pet- rified of tunnels, making most train travel as well as many drives difficult. I don’t take sub- ways. I avoid elevators as much as possible. I experience glassed-in spaces as toxic, and I find it very difficult to adjust to being in buildings in which the windows don’t open. I don’t like to go to enclosed malls; and if I do, I don’t venture very far into them . . . . In short, I am afraid both of closed and of open spaces, and I am afraid, in a sense, of any form of isolation. (Shawn, 2007, p. xviii)

Panic Disorder How does a panic attack differ from fear?

Another type of anxiety disorder is panic disorder, characterized by recurring episodes of a sudden, unpredictable, and overwhelming fear or terror. Panic attacks occur without any reasonable cause and are accompanied by feelings of impending doom, chest pain, dizzi- ness or fainting, sweating, difficulty breathing, and fear of losing control or dying. Panic attacks usually last only a few minutes, but they may recur for no apparent reason. For example, consider the following description:

Minday Markowitz is an attractive, stylishly dressed 25-year-old art director for a trade mag- azine who comes to an anxiety clinic after reading about the clinic program in the newspa- per. She is seeking treatment for “panic attacks” that have occurred with increasing frequency over the past year, often 2 or 3 times a day. These attacks begin with a sudden intense wave of “horrible fear” that seems to come out of nowhere, sometimes during the day, sometimes waking her from sleep. She begins to tremble, is nauseated, feels as though she is choking, and fears that she will lose control and do something crazy, like run screaming into the street. (Spitzer, Gibbon, Skodol, Williams, & First, 2002, p. 202)

Panic attacks not only cause tremendous fear while they are happening, but also leave a dread of having another panic attack, which can persist for days or even weeks after the original episode. In some cases, this dread is so overwhelming that it can lead to the development of agoraphobia: To prevent a recurrence, people may avoid any circum- stance that might cause anxiety, clinging to people or situations that help keep them calm.

Other Anxiety Disorders How do generalized anxiety disorder and obsessive–compulsive disorder differ from specific phobias?

In the various phobias and in panic attacks, there is a specific source of anxiety. In contrast, generalized anxiety disorder is defined by prolonged vague but intense fears that are not attached to any particular object or circumstance. Generalized anxiety disorder perhaps

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agoraphobia An anxiety disorder that involves multiple, intense fears of crowds, public places, and other situations that require separation from a source of security such as the home.

panic disorder An anxiety disorder characterized by recurrent panic attacks in which the person suddenly experiences intense fear or terror without any reasonable cause.

generalized anxiety disorder An anxiety disorder characterized by prolonged vague but intense fears that are not attached to any particular object or circumstance.


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Psychological Disorders 405

comes closest to the everyday meaning attached to the term neurotic. Its symptoms include the inability to relax, muscle tension, rapid heartbeat or pounding heart, apprehensiveness about the future, constant alertness to potential threats, and sleeping difficulties (Hazlett- Stevens, Pruitt, & Collins, 2009).

A very different form of anxiety disorder is obsessive–compulsive disorder (OCD). Obsessions are involuntary thoughts or ideas that keep recurring despite the person’s attempts to stop them, whereas compulsions are repetitive, ritualistic behaviors that a per- son feels compelled to perform (Shader, 2003). Obsessive thoughts are often horrible and frightening. One patient, for example, reported that “when she thought of her boyfriend, she wished he were dead”; when her sister spoke of going to the beach with her infant daughter, she “hoped that they would both drown” (Carson & Butcher, 1992, p. 190). Compulsive behaviors may be equally disruptive to the person who feels driven to perform them. Recall Jack, the engineer described at the beginning of the chapter, who couldn’t leave his house without double- and triple-checking to be sure the doors were locked and all the lights and appliances were turned off.

People who experience obsessions and compulsions often do not seem particularly anxious, so why is this disorder considered an anxiety disorder? The answer is that if such people try to stop their irrational behavior—or if someone else tries to stop them—they experience severe anxiety. In other words, the obsessive–compulsive behavior seems to have developed to keep anxiety under control.

Finally, two types of anxiety disorder are clearly caused by some specific highly stress- ful event. Some people who have lived through fires, floods, tornadoes, or disasters such as an airplane crash experience repeated episodes of fear and terror after the event itself is over. If the anxious reaction occurs soon after the event, the diagnosis is acute stress disorder. If it takes place long after the event is over, particularly in cases of military combat or rape, the diagnosis is likely to be posttraumatic stress disorder, discussed in Chapter 11, “Stress and Health Psychology” (Oltmanns & Emery, 2006).

Causes of Anxiety Disorders What causes anxiety disorders?

Like all behaviors, phobias can be learned. Consider a young boy who is savagely attacked by a large dog. Because of this experience, he is now terribly afraid of all dogs. In this case, a realistic fear has become transformed into a phobia. However, other phobias are harder to understand. As we saw in Chapter 5,“Learning,” many people get shocks from electric sock- ets, but almost no one develops a socket phobia. Yet snake and spider phobias are common. The reason seems to be that through evolution we have become biologically predisposed to associate certain potentially dangerous objects with intense fears (Hofmann, Moscovitch, & Heinrichs, 2004; Nesse, 2000; Seligman, 1971).

Psychologists working from the biological perspective point to heredity, arguing that we can inherit a predisposition to anxiety disorders (Bolton et al., 2006; Gelernter & Stein, 2009; Leonardo & Hen, 2006). In fact, anxiety disorders tend to run in families. Researchers have located some specific genetic sites that may generally predispose people toward anxiety disorders (Goddard et al., 2004; Hamilton et al., 2004). In some cases, spe- cific genes have even been linked to specific anxiety disorders, such as obsessive hoarding (Alonso et al., 2008).

Finally, we need to consider the role that internal psychological conflicts may play in producing feelings of anxiety. The very fact that people suffering from anxiety disorders often have no idea why they are anxious suggests that the explanation may be found in unconscious conflicts that trigger anxiety. According to this view, phobias are the result of displacement, in which people redirect their anxiety from the unconscious conflicts toward objects or settings in the real world. (See Chapter 11, “Stress and Health Psychology,” for a discussion of displacement.)

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obsessive–compulsive disorder (OCD) An anxiety disorder in which a person feels driven to think disturbing thoughts or to perform senseless rituals.

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PSYCHOSOMATIC AND SOMATOFORM DISORDERS What is the difference between psychosomatic disorders and somatoform disorders?

The term psychosomatic perfectly captures the interplay of psyche (mind) and soma (body), which characterizes these disorders. A psychosomatic disorder is a real, physical disorder, but one that has, at least in part, a psychological cause. As we saw in Chapter 11 (“Stress and Health Psychology”), stress, anxiety, and prolonged emotional arousal alter body chem- istry, the functioning of bodily organs, and the body’s immune system (which is vital in fighting infections). Thus, modern medicine leans toward the idea that all physical ailments are to some extent “psychosomatic.”

Psychosomatic disorders involve genuine physical illnesses. In contrast, people suffering from somatoform disorders believe that they are physically ill and describe symptoms that sound like physical illnesses, but medical examinations reveal no organic problems. Never- theless, the symptoms are real to them and are not under voluntary control (American Psychological Association, 2000). For example, in one kind of somatoform disorder, somatization disorder, the person experiences vague, recurring physical symptoms for which medical attention has been sought repeatedly but no organic cause found. Common complaints are back pain, dizziness, abdominal pain, and sometimes anxiety and depression.

One of the more dramatic forms of somatoform disorder involves complaints of paralysis, blindness, deafness, seizures, loss of feeling, or pregnancy. In these conversion

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L E A R N I N G O B J E C T I V E • Distinguish between psychosomatic

and somatoform disorders, somatization disorder, conversion disorders, hypochondriasis, and body dysmorphic disorder. Explain what is meant by the statement that “all physical ailments are to some extent psychosomatic.”

psychosomatic disorder A disorder in which there is real physical illness that is largely caused by psychological factors such as stress and anxiety.


1. According to the psychoanalytic view, anxiety results from ________ ________. 2. The belief that we inherit the tendency to develop some phobias more easily than others

argues that these phobias are ________ ________. Indicate whether the following statements are true (T) or false (F):

3. ________ The fear in a specific phobia often interferes with life functions. 4. ________ People who experience obsessions and compulsions appear highly anxious. 5. ________ Research indicates that people who feel that they are not in control of stressful

events in their lives are more likely to experience anxiety than those who believe that they have control over such events.

Answers:1. unconscious conflicts.2. prepared responses.3. (T).4. (F).5. (T).