Chapter 14: Psychological Disorders (心理障碍)

14.0 Learning Objectives

After completing this chapter, you should be able to:

1. Appropriately consider the nature of what it means to be abnormal through the application of
the “four Ds” of psychological disorders.

2. Understand how the use of certain words and labels affect the lives of people who have a
mental illness and know how to use terms that are respectful and reduce stigma.

3. Briefly describe the history of the Diagnostic and Statistical Manual (DSM) of Mental Disorders,
and describe the way in which clinicians use the DSM-5 to formulate cases for patients and
diagnose psychological disorders.

4. Describe each of the major classifications of psychological disorders, as well as a highlighted

disorder for each classification.

5. Compare the prevalence rates of various major psychological disorders.

6. Explain how the biopsychosocial model helps us interpret the causes of psychological disorders.

14.1 Introduction: What Is Abnormal? (什么是变态)

The study of psychological disorders is called abnormal psychology. Even though there is a whole field of
study with that moniker, abnormal is a really hard word to define. What is abnormal? Well, it’s the
opposite of normal, right? Maybe a better question is, “What is normal?”

Look at Table 14.1; what are the opposites of these words? The first five are probably pretty easy. The
rest may be more complicated.
Normal and abnormal are subjective terms, meaning that our views are influenced by personal feelings,
opinions, and experiences. Our subjective views are also influenced by gender, race/ethnicity,
socioeconomic status, and a number of other factors. Essentially, the same behavior can be interpreted
in different ways based on context and circumstance. For example, Hector’s screams while riding a roller
coaster at the amusement park do not cause any heads to turn. However, his screams while sitting at his
desk at work will likely cause his co-workers to be concerned. What is normal in one situation can be
abnormal in another.

Society is one of the biggest influencers on our view of what is normal or abnormal. Our society
condones certain behaviors and admonishes others, and when we do not abide by the rules and laws of
our society, there are consequences. This often boils down to "normal" being a positive label and
"abnormal" being negative. There is still some ambiguity, though. Consider this Pocatello, Idaho, law: “A
person may not be seen in public without a smile on their face.” A possible interpretation of this societal
convention is that it is abnormal to frown when it starts to rain in the middle of a parade or to grimace
when walking past an overflowing garbage dumpster. But what about an individual smiling when seeing
a dog almost run over by a car? Is that a normal reaction? By the way, while this law is still on the books,
it is no longer enforced.
14.1.1 What Is a Psychological Disorder?

This chapter will focus on defining and describing abnormal behaviors, thoughts, and feelings that
constitute psychological disorders. Whether referred to as a mental disorder, mental illness,
psychological problem, or psychiatric condition, psychological disorders cause significant impairment in
an individual’s life (Stein et al., 2010). They keep people from doing the things they need to do and want
to do. Perhaps this is a more acceptable definition of abnormal.

The signs and symptoms of a psychological disorder are assessed by mental health professionals to
determine abnormal behaviors, thoughts, and feelings. Though not without limitations, the Four
Ds (deviance, distress, dysfunction, and danger) provide some guidance for these decisions.

Deviance describes a departure from what is normal or usual, and in terms of psychological disorders it
refers to behaviors, thoughts, and feelings that are not in line with generally accepted standards.
Deviance can be measured against statistical standards or cultural views. Statistically deviant behaviors
occur infrequently among members of the population, whereas culturally deviant behaviors go against
societal standards. Let’s consider underage drinking. In the United States, consumption of alcohol by
individuals under the age of 21 is illegal—a deviant behavior. However, almost 40% of youth aged 12–20
years have consumed alcohol in their lifetimes (Center for Behavioral Health Statistics and Quality,
2020). That actually makes underage drinking a pretty common occurrence—so it is definitely not
statistically deviant.

Figure 14.3: The Scream, painted by Edvard Munch, has many interpretations,
including an expression of the artist’s distress over the commitment of his sister to an asylum. [3]
Taken alone, deviance does not fully determine the presence or absence of a psychological
disorder. Distress refers to behaviors, thoughts, and feelings that are upsetting and cause pain,
suffering, or sorrow, whereas dysfunctional behaviors, thoughts, and feelings are disruptive to one’s
regular routine or interfere with day-to-day functioning. Finally, dangerous behaviors, thoughts, and
feelings may lead to harm or injury to self or others.

Another important defining factor of psychological disorders is that they tend to be consistent over a
span of time. Stealing one piece of candy or staying up all night to study for finals are deviant and
dysfunctional behaviors, but they do not merit diagnosis of a psychological disorder. Psychological
disorders are patterns of deviant and dysfunctional behaviors, thoughts, and feelings that cause
significant distress, and may even be dangerous.

Given the example of underage drinking, there are certainly plenty of teenagers who consume alcohol
without feeling bad about it, without it disrupting their routine, and without hurting themselves or
anyone else. However, the Centers for Disease Control and Prevention (2016) report that each year,
underage drinking is responsible for close to 200,000 emergency room visits and more than 4,300
deaths of young people under age 21. Even the possibility of distress, dysfunction, and danger can hint
at abnormal behavior. Mental health professionals often rely on clinical judgment (i.e., decision making
based on professional experience) when assessing psychological disorders.
14.1.2 Labels: Not to Be Taken Lightly (标签：不可掉以轻心)

Armed with information about the level of impairment, the Four Ds, and the recurrence of the behavior,
a mental health professional may consider diagnosing a psychological disorder. Assigning a diagnosis can
be helpful for a number of reasons. First, a diagnostic label may provide an explanation for abnormal
behaviors, thoughts, and feelings being experienced. This can be reassuring and can empower the
individual to seek out appropriate resources. Second, diagnostic labels provide a common language for
clinicians, researchers, and insurance companies to communicate effectively about psychological
disorders, making sure everyone is on the same page about areas of concern (First et al., 2018). Finally,
labels are an efficient means of tracking the rates of psychological disorders and utilization of services
(First, 2010). These data are vital for ensuring adequate access and availability of mental health services
for everyone who needs them.

While there are plenty of benefits to labeling psychological disorders, there are also plenty of problems
as well. Besides formal labels, there are lots of derogatory terms thrown around when referring to
psychological disorders. Words like crazy, psycho, or retard can be hurtful and counterproductive (Rose
et al., 2007). Labels can also be used to excuse unacceptable behaviors and can lead to lowered
expectations or self-fulfilling prophecies about an individual’s functioning. Additionally, labels are sticky,
meaning that diagnoses may have a long-lasting impact on self-image and other’s perceptions of the
individual.
14.1.3 Stigma (污名)

Another concern about labels is the stigma associated with them. Stigma refers to disapproval, poor
treatment, discrimination, or isolation due to being different (Link & Phelan, 2001). Mental health
stigma is widespread, and it seems to be fueled by discomfort and a lack of understanding. Beliefs that
people diagnosed with psychological disorders are dangerous or that mental illness is a conscious choice
persist in our society. This issue can be made worse by portrayals of psychological disorders in the
media. These depictions are often sensationalized, and both news and entertainment media tend to
focus on extreme and violent behaviors. In the video below, comedian John Oliver uses humor to
highlight the state of mental health stigma in the United States.

Mental Health: Last Week Tonight with John Oliver (HBO) - YouTube

Unfortunately, individuals diagnosed with psychological disorders are frequently stigmatized, and
internalization of these negative perceptions can lead to shame, embarrassment, and additional distress
(Thornicroft et al., 2016).

There is a long history of mental health stigma, and it is not likely that these negative perceptions will
just disappear. For much of history, the prevailing view was that psychological disorders were caused by
witchcraft or demonic possession. Relating these conditions to morality and spirituality lent a
considerable sense of shame to these disorders, and individuals with mental illness were often punished
as criminals. Trepanation, a surgical procedure in which a hole was drilled into the human skull to
release evil spirits, was practiced for thousands of years (see Figure 14.5), and there was even a
movement for negative eugenics, which proposed sterilization of individuals considered to be mentally
inferior.
During the nineteenth century, a schoolteacher and author named Dorothea Dix advocated for more
humane treatment of the insane, a now antiquated term for mental illness. As a result of her lobbying,
states began to fund specialized institutions to house and treat individuals with psychological disorders.

These institutions were called asylums, thus the term insane asylum. By 1890, every state had built one
or more of these mental hospitals, and these institutions quickly reached and exceeded their capacity
soon after opening (U.S. National Library of Medicine, 2013). Individuals with psychological disorders
tended to receive inhumane treatment in these cramped settings. They were often chained to the wall
and subjected to beatings, submersion in cold water, and electric shock. There was also little hope of
being released from these institutions. Conditions remained dire until medications that were effective in
treating psychological disorders were introduced in the 1950s. This prompted reform in the treatment of
psychological disorders called deinstitutionalization. The goals of deinstitutionalization were to reduce
admissions to psychiatric hospitals, shorten lengths of stay, and improve the treatment that admitted
individuals received.
Mental health stigma continues to be a formidable societal issue. However, organizations like NAMI
(National Alliance on Mental Illness) and MHA (Mental Health America) are working hard to increase
awareness and understanding of psychological disorders while combating stigma. For those interested,
these and similar organizations are great ways to get involved in mental health advocacy.
14.1.4 Word Choices

The words we use are powerful and can often unwittingly convey stigmatizing messages. The American
Psychological Association encourages the use of person-first language in verbal and written
communications when referring to individuals diagnosed with a psychological disorder (Dunn &
Andrews, 2015). This is a deliberate way of communicating and may initially appear to be unnatural or
cumbersome. For example, referring to an individual as a person with schizophrenia instead of a
schizophrenic implies that the individual is, in fact, a person and possesses attributes in addition to a
condition.

Of late, there is debate over the use of person-first language vs. identity-first language. An example of
an identity-first language choice is autistic person rather than person with autism (Vivanti, 2020).
Proponents of identity-first language argue that a disorder is an important part of an individual’s
makeup, and integrating the disorder with identity can be affirming and validating. While there are
strong arguments on both sides, the important thing seems to be respect of the individual.
14.2 Diagnosing Psychological Disorders

Classification systems help us make sense of our world by arranging things according to their similar
qualities or characteristics. Let’s say you want to take a young child to see a movie. Based on the Motion
Picture Association of America film rating system, you immediately know that an R-rated movie is not
appropriate for the child. Without seeing previews or snippets, you can assume that there may be
violence, profanity, or sexual content in the movie. Of course, you would not be able to provide a review
or describe plot details of the movie based solely on the rating, but you do have some useful
information.

14.2.1 Diagnostic and Statistical Manual of Mental Disorders (DSM) 精神疾病诊断和统计手册（DSM）

The term psychological disorders encompasses a wide range of abnormal behaviors with varying yet
overlapping qualities and characteristics. A classification system is essential to making sense of these
conditions. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification system
used by mental health professionals in the United States and many other countries. Published by the
American Psychiatric Association, the DSM helps clinicians, researchers, health insurance agencies,
pharmaceutical companies, and forensic experts make consistent and objective decisions about
defining, diagnosing, and treating abnormal behaviors across a variety of clinical settings. A psychiatrist
in an inpatient hospital, a psychologist in a primary care office, and a social worker in private practice all
use the DSM. Currently in its fifth edition (DSM-5; American Psychiatric Association, 2013), this newest
volume was published in 2013 after more than 10 years of effort put in by hundreds of international
mental health experts. DSM-5 also builds upon a foundation of more than 100 years of observation and
research on psychological disorders (Blashfield et al., 2014).

14.2.2 A Brief History of the DSM

In 1840, the United States Census began to gather statistical information on mental disorders, in those
days termed idiocy and insanity, and by 1880, seven categories of mental illness were being captured by
the Census (American Psychiatric Association, n.d.). Following World War II, the U.S. Army and the
Department of Veterans Affairs collaborated to document the psychological distress seen in active
servicemen and veterans, which prompted the World Health Organization (WHO) to include a section on
mental disorders in the sixth edition of the International Classification of Diseases (ICD-6), which was
published in 1949. This edition included 10 categories for psychoses and seven categories for disorders
of intelligence, behavior, and character. The DSM was conceptualized as an attempt to develop a
classification of mental disorders specifically for use in the United States. Since its introduction in 1952,
the DSM has been in a constant state of updating and revision and has yielded seven published editions
(including revisions of the third and fourth editions; Blashfield et al., 2014).

To review a history of the development of the DSM, click through the interactive slides below:

TimelineJS Embed ([Link])

One major milestone was the publication of DSM-III in 1980. DSM-III responded to previous critiques by
including precise definitions and explicit diagnostic criteria for mental disorders (Blashfield et al., 2014).
Additionally, DSM-III introduced a multiaxial diagnostic assessment system, which provided a more
comprehensive view of mental disorders:

 Axis I: Major mental disorders (e.g., mood disorders, anxiety disorders)

 Axis II: Underlying personality or intellectual disorders that are resistant to change (e.g.,
antisocial personality disorder, borderline personality disorder, intellectual disability)

 Axis III: Medical conditions that may influence the mental disorder (e.g., obesity, type 2
diabetes, multiple sclerosis)

 Axis IV: Psychosocial stressors that may influence the mental disorder (e.g., homelessness,
interpersonal violence)

 Axis V: Global assessment of functioning (scored from 1–100)

The sexual orientation disturbance category was replaced with ego-dystonic homosexuality, suggesting
that individuals identifying as homosexual may experience anxiety and internal conflict regarding
their sexual orientation (Spitzer, 1981). However, one’s sexual orientation was no longer considered a
mental disorder.
14.2.3 Major Changes to DSM-5

DSM-5 is a different document from DSM-IV, and mental health professionals continue to acclimate to
the changes (Sanders, 2011). One major change is the organization of the manual, which reflects the
lifespan. DSM-5 begins with disorders that are typically diagnosed in childhood, proceeds to disorders
typically diagnosed in adolescence and young adulthood, and ends with those more typically diagnosed
in older adulthood. There are also significant changes to diagnostic categories, including more
streamlined categories of autism and schizophrenia spectrum disorders (McCarron, 2013). This version
also dropped the multiaxial format initially introduced in DSM-III. Now, instead of five domains of a
mental disorder, DSM-5 requires documentation of one domain “with separate notations for important
psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).” Finally, in an
attempt to be more responsive to new and evolving research findings, new editions of the DSM will be
noted by Arabic rather than Roman numerals. Incremental updates will be marked by decimals (e.g.,
DSM-5.1) and new editions will be marked by whole numbers (e.g., DSM-6).
14.2.4 How Mental Health Professionals Use the DSM

The primary purpose of DSM-5 is to help trained mental health professionals diagnose mental disorders,
which is the first step in the development of comprehensive and effective treatment plans for these
disorders. While DSM-5 may appear to be a series of checklists for determining whether or not an
individual meets the criteria for a diagnosis, clinicians are cautioned to carefully develop a case
formulation for each individual (American Psychiatric Association, 2013).

A case formulation is an explanation of an individual’s mental disorder and is informed by factors such
as developmental history, relationship status, physical health, and cultural background (Eells, 2013). This
information is typically gathered in a clinical interview, which provides a contextual understanding of a
patient. Of critical importance is the determination of clinical significance. All mental disorders exist on a
continuum of normal to abnormal, and a disorder should only be diagnosed if the symptoms are causing
significant distress or impairment in one or more aspects of an individual’s life.

Another less-acknowledged purpose of DSM-5 is to support the logistics of mental illness. Each mental
disorder in the manual is accompanied by a diagnostic and statistical code. These strings of numbers and
letters are used for data collection and billing purposes. The codes provide information about a
diagnosis as well as specifiers, such as the severity of the disorder or whether the symptoms have
occurred one time or many times.
14.3 Major Classifications of Psychological Disorders

As stated, there are more than 500 disorders described in the DSM. The section that follows presents
the major classifications of psychological disorders in DSM-5 and spotlights one particular disorder
within each category. The order of the disorders presented in this section mirrors the order of DSM-
5. The organization is intended to follow a developmental lifespan sequence, with disorders more
common to childhood/adolescence coming first and those more common to adulthood coming
after. Feel free to peruse the DSM-5 to learn more about disorders that are not specifically highlighted.

14.3.1 Neurodevelopmental Disorders

Neurodevelopmental disorders, which affect the brain and neurological systems, are typically first seen
during infancy and early childhood (Thapar et al., 2017). This group of disorders is marked by
impairments and deficits in multiple aspects of a child’s life, including academic ability, social
functioning, and behavioral problems. These children are often delayed in reaching milestones for
speech and language, motor skills, and learning. They may also exhibit problems with retention of
information. Neurodevelopmental disorders tend to co-occur, meaning it is likely that a child meets
diagnostic criteria for more than one of these conditions at a time (Dajan et al., 2016).
As a child grows older and learns to compensate for the deficits they experience, the symptoms and
behaviors associated with neurodevelopmental disorders may change or evolve. In fact, the symptoms
may fade or seem to disappear. However, many of these disorders persist, in some form, across the
lifespan. A neurodevelopmental disorder may be diagnosed based on symptoms that were observed in
the past, but the disorder must still cause significant impairment at the time of diagnosis. Table 14.2 lists
the neurodevelopmental disorders identified in DSM-5.
[Link] Diagnostic Spotlight: Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a new addition to DSM-5. Previous versions defined discrete
categories of the spectrum, including Asperger’s syndrome, autism, and pervasive developmental
disorder. Now, however, these diagnoses have been grouped together under one term and are referred
to collectively as autism spectrum disorder. Think for a moment about the impact to an individual who
has identified with a disorder that no longer exists for their entire life. Such a change can be quite
disconcerting.

This group of neurodevelopmental disorders is characterized by significant social, emotional, behavioral,

and communication impairments. Some children with ASD may not be interested in interacting with
other people and can be hypersensitive to touch. Many parents of children with these symptoms
express the heartbreak of never being able to hug or kiss their own children. These children may also
have trouble showing or talking about their feelings and have difficulty understanding social cues. In
terms of communication, some children with ASD speak quite well while others do not communicate
verbally at all.

Other key features of ASD may include repetitive movements (rocking the body back and forth),
insistence on a routine (eating the same food every day, distress when the schedule is not followed),
intense preoccupation with a particular interest (fixation on a specific topic, like dinosaurs), and hyper-
or hypo-reactivity to sensory input (adverse responses to specific sounds or smells, excessive touching of
objects). As the term spectrum implies, there is a wide range of impairment possible within this
diagnosis. One child receiving the diagnosis may exhibit mild symptoms while another may experience
severe symptoms.

The prevalence of ASD is about 1% of the population and rising, though it is not clear if increasing rates
are due to more awareness of the disorder (and therefore more diagnoses) or a true spike in frequency
(Autism and Developmental Disabilities Monitoring Network Surveillance Year 2010 Principal
Investigators, 2014). Symptoms are typically noticed during the second year of life in the form of
delayed language or social development. There are no specific causes of ASD, though twin studies show
a strong genetic link (Bailey et al., 1995; Colvert et al., 2015; Folstein & Rutter, 1977).

14.3.2 Schizophrenia Spectrum and Other Psychotic Disorders (精神分裂症谱系和其他精神障碍)

Individuals diagnosed with a disorder in the schizophrenia spectrum and other psychotic disorders
category experience severe and persistent symptoms that significantly impair their functioning. Table
14.3 lists the disorders included in this category.
Individuals with these disorders seem to have lost touch with reality and have a hard time thinking
clearly, making good judgments, and communicating effectively. Another term for disorders in this
category is serious mental illness (SMI), which reflects their chronic and debilitating nature (Insel, 2008).

Schizophrenia spectrum and other psychotic disorders have several key symptoms that differentiate
them from other psychological diagnoses. These key features can be grouped as positive
symptoms and negative symptoms (National Institute of Mental Health, 2015). Think about positive and
negative here in a mathematical sense: addition and subtraction, not good and bad.

[Link] Positive Symptoms

Positive psychotic symptoms are behaviors that were not present before the onset of the disorder.
These symptoms start to appear during the course of the psychotic disorder and are not typically seen in
healthy individuals.

Delusions are strong beliefs that are not founded in reality. These beliefs do not waver, even when
confronted with compelling evidence to the contrary. A common example is persecutory delusion, in
which an individual may believe they are being followed or harassed by the government. Hallucinations,
on the other hand, are sensory experiences that do not have a source. For example, an individual may
hear voices when no one is speaking. While auditory hallucinations are most common, hallucinations
can also be visual, olfactory, gustatory, or tactile (i.e., seen, smelled, tasted, or felt).
Another positive psychotic symptom, disorganized thinking, can typically be discerned from a person's
speech and may entail switching from one topic to another in a nonsensical way or speaking in a
jumbled, incoherent fashion. Finally, abnormal motor behaviors can range from excessive and agitated
movements to complete stillness and rigidity of the body.

[Link] Negative Symptoms

Negative psychotic symptoms are behaviors typically observed in healthy individuals that an individual
experiencing psychosis does not do. These behaviors start to disappear during the course of a
schizophrenia spectrum or other psychotic disorder.

Diminished emotional expression, also known as flat affect, is reduced expression of emotions through
facial expressions, tone of voice, or body language. For example, an individual will maintain a neutral
face in response to hearing a funny joke. Other negative symptoms include avolition, a decreased
motivation to start or follow-through on activities such as school, work, or self-care, and alogia, a
reduction in speech output. In conversation, an individual will reply sparsely, if at all.

[Link] Diagnostic Spotlight: Schizophrenia

Schizophrenia is a disorder that involves a wide range of emotional, behavioral, perceptual, and
cognitive dysfunction. It affects 0.3–0.7% of the population, so it is a fairly rare disorder. While there is a
genetic link (Sullivan, 2005), most individuals diagnosed with schizophrenia have no family history of
psychosis. Recent research reveals that there are many environmental contributors to schizophrenia,
including complications during pregnancy and birth, adverse childhood experiences, and social isolation
(Stilo & Murray, 2019). Schizophrenia is diagnosed more among racial/ethnic minority groups and those
growing up or living in urban environments, and the incidence of the disorder is slightly higher among
men (Tandon et al., 2008). The psychotic features of schizophrenia tend to appear in young adulthood,
and the earlier the age of onset, the worse the prognosis tends to be. Onset prior to adolescence is rare,
but not unheard of.
Schizophrenia is a heterogeneous clinical syndrome, meaning there are many different ways the
disorder presents. For example, in a group of three people diagnosed with schizophrenia, there may be
no overlap in the primary symptoms they exhibit. Nonetheless, most individuals diagnosed with
schizophrenia have significant difficulty functioning in their daily activities.

In addition to the positive and negative symptoms described above, an individual diagnosed with
schizophrenia may also experience cognitive symptoms. Cognitive symptoms in schizophrenia can be
subtle and are often undetectable without neuropsychological testing. These symptoms affect memory
and thought processes. Executive functioning describes the mental skills we use to make decisions
based on the information we are presented with. For example, sustained attention helps us to focus and
concentrate on the task of driving and our working memory helps us to remember that we should apply
our brakes when we see a red traffic light. In schizophrenia, these skills may be impaired, which can lead
to confusion and poor decision making.

14.3.3 Bipolar and Related Disorders (双相及相关障碍)

By definition, bipolar means two opposite extremes, such as freezing and scorching or greedy and
generous. The previous name for bipolar disorder, manic-depressive disorder, reflects the characteristic
highs and lows of conditions in the bipolar and related disorder chapter of DSM-5. However, the true
defining feature of bipolar and related disorders is the experience of a manic episode. Table 14.4 lists
the disorders included in this category.
A manic episode describes a distinct period of increased energy and activity and may include psychotic
symptoms. During this time, an individual may need less sleep, talk excessively, have a hard time
focusing, and engage in impulsive behaviors. An individual may demonstrate impaired judgment by
engaging in risky or dangerous activities, such as gambling, extravagant shopping sprees, or sexual
escapades. Some individuals report feeling extremely productive during a manic episode, as another
symptom is increased goal-directed activity. For example, a college student may complete all of their
homework for the semester in a few days. However, the risk for impulsive behavior is intensified during
a manic episode (Swann et al., 2001).

The opposite of a manic episode is a depressive episode, marked by sad mood and loss of interest or
pleasure. However, the thoughts and behaviors associated with a manic episode are so extreme that
even a return to baseline functioning may be considered a depressed state. The recognition of
consequences incurred during a manic episode may also contribute to depressed mood. The bipolar and
related disorders are marked by fluctuations between varying degrees of mania and depression.

[Link] Diagnostic Spotlight: Bipolar II Disorder (诊断聚焦：双相 II 障碍)

As stated, mania is the key characteristic of bipolar and related disorders. Hypomania is a less intense
experience of mania that features the same increased energy and activity levels without the same
impairment in functioning. A hypomanic episode also cannot feature psychotic symptoms. Bipolar II
disorder is distinguished from the other diagnoses in this section of DSM-5 by the requirement that an
individual experience both hypomanic and major depressive episodes. Because of the lessened
impairment associated with hypomania, bipolar II disorder was once considered to be a milder form of
bipolar disorder. However, the instability of mood, as well as the amount of time spent in a depressed
state, have led researchers and clinicians to recognize bipolar II disorder as a seriously debilitating
condition (Malhi et al., 2016).

14.3.4 Depressive Disorders

Depression is a common feeling that we have all experienced at one time or another. We can experience
depression in reaction to loss or disappointment, or we can just wake up feeling down. Feelings of
sadness, emptiness, hopelessness, and irritability are key features of the depressive disorders category
of DSM-5. These feelings are often accompanied by physical symptoms and negative thoughts that
significantly impair an individual’s functioning. When depressed, an individual may not have the desire
to spend time with friends and family or the energy to go to school or work. The disorders represented
in this section are not the same as occasionally feeling down or blue. Rather, the symptoms are long-
lasting and affect many aspects of an individual’s life, as well as the lives of their friends and family.
Table 14.5 lists the disorders included in this category.

Suicidal behaviors often accompany depressive disorders (as well as many other psychological
conditions). Suicidal behaviors can include thoughts, plans, and attempts to end one’s life. Motivations
for suicide may include a desire to end intense emotional suffering, feeling overwhelmed with the
stressors of life, or a wish to not be a burden to others (Klonsky et al., 2016). Suicidal behaviors should
always be taken seriously. Although it is commonly stated that the biggest risk factor for a suicide
attempt is previous attempts, most completed suicides are not preceded by a previous attempt. This
means that the majority of people who try to kill themselves do so. If you or someone you know
expresses thoughts or plans for suicide, please seek the help of a mental health professional. The
National Suicide Prevention Lifeline (1-800-273-8255) is a wonderful resource that provides 24/7 free
and confidential support.

[Link] Diagnostic Spotlight: Major Depressive Disorder (诊断聚焦：重度抑郁症)

Major depressive disorder, also known as major depression, clinical depression, or just depression,
affects more than 7% of the population at any given time, and it is thought that more than 20% of adults
will experience an episode of major depression at some point in their lives. Women are two to three
times more likely than men to be diagnosed with depression, which may be explained by hormonal
changes during puberty, menstruation, pregnancy, miscarriage, and menopause, which have
pronounced effects on mood (Nolen-Hoeksema, 2001). However, some believe that societal
pressures make men less likely to report their symptoms of depression, thereby falsely inflating the
differential rates of diagnosis. Another possibility is that men are more likely to self-medicate with drugs
or alcohol (Kessler et al., 1994).
Major depressive disorder is characterized by either sad mood or loss of interest or pleasure in activities
that were once enjoyable. Other symptoms include significant increases or decreases in weight (without
trying), appetite, or sleep patterns. For example, an individual diagnosed with major depressive disorder
may exhibit diminished appetite, weight loss, or excessive sleepiness throughout the day. Physical
symptoms, such as headaches, digestive problems, agitation, and lethargy, are also common among
individuals diagnosed with major depressive disorder. An individual may also experience feelings of
worthlessness, difficulty concentrating, and recurrent thoughts of death or suicide. This disorder may
look different in children, who tend to exhibit an irritable rather than depressed mood.

14.3.5 Anxiety Disorders

Anxiety disorders are the most common psychological disorders in the United States (Kessler et al.,
2005). The common feature of conditions grouped in this section of DSM-5 is excessive fear and
anxiety. Fear is a response to current threats, while anxiety is worry about future threats. It is important
to differentiate these two states because they elicit different responses in our minds and bodies. Fear is
associated with thoughts of immediate danger and physical symptoms that facilitate escape behaviors,
such as increased heart rate, shallow breathing, and sweating. Anxiety, on the other hand, is related to
thoughts of future danger, cautious or avoidant behaviors, and muscle tension.

Everyone worries about something at some time or another. Anxiety is a normal emotion and is
adaptive in a lot of ways. What would happen if you never worried about being on time, making good
grades, or driving safely? Anxiety disorders, however, interfere with an individual’s ability to function.
For example, excessive anxiety could prevent an individual from sleeping due to worry about being on
time. More often, anxiety disorders are disabling, preventing people from doing what they need to do.
For instance, an individual worried about driving safely may never pull their car out of the driveway.
Other manifestations of anxiety include hesitation to interact with others due to fear of their judgments
or excessive fear of specific places, situations, or objects. Table 14.6 lists the disorders in this category.
[Link] Diagnostic Spotlight: Agoraphobia (诊断聚焦：广场恐惧症)

Agoraphobia is an anxiety disorder in which an individual fears or avoids certain places or situations
(Craske & Barlow, 2014). The word is derived from Greek and translates to “fear of the marketplace.” It
occurs in about 1.7% of the population, and women are twice as likely as men to experience
agoraphobia. Diagnosis of this condition requires fear or avoidance of at least two of the following
situations: using public transportation, being in open spaces, being in enclosed places, standing in line or
being in a crowd, or being outside of the home alone. In these situations, the individual may report
feeling trapped, helpless, or embarrassed, which amplifies their anxiety. For some, this anxiety leads to
the experience of panic symptoms, such as shakiness, chest pain, nausea, dizziness, and shortness of
breath, as well as fear of “going crazy” or dying (Wittchen et al., 2010).

Individuals diagnosed with agoraphobia tend to avoid the situations they are fearful of, and it is possible
to so actively avoid these situations that, in extreme cases, the individual becomes unable to leave their
home. The following video describes the case of a woman who was so fearful of leaving the bathroom
that her body became attached to the toilet seat.

Woman Sat on Toilet for 2 Years - YouTube

14.3.6 Obsessive-Compulsive and Related Disorders

You may notice that obsessive-compulsive and related disorders immediately follows the DSM-5 section
on anxiety disorders. This purposeful placement reflects the similarities of these diagnostic categories.
While there is a strong anxious component to obsessive-compulsive and related disorders, the
conditions described in this section share characteristics that differentiate them from anxiety disorders.
Table 14.7 provides a list of disorders in this category.

Obsessive-compulsive and related disorders are characterized by preoccupations, rituals, and repetitive
behaviors. Obsessions refer to recurrent unwanted, and intrusive thoughts, fears, urges, or images,
while compulsions are behaviors that an individual feels driven to perform in response to an obsession.
Often, compulsive rituals are performed to decrease or stop obsessive thoughts or urges. However, this
relief typically lasts for a short time, and the individual is driven to perform the ritual again when the
obsessive urges return.
[Link] Diagnostic Spotlight: Hoarding Disorder

An individual diagnosed with hoarding disorder has a perceived need to save items and becomes
distressed about discarding them (Mataix-Cols et al., 2010). In fact, the condition is marked by a
persistent difficulty parting with possessions, even when they have little to no financial or practical
value. Individuals diagnosed with hoarding disorder often report a sentimental attachment to their
possessions and experience distress when faced with getting rid of things. As a result of not throwing
away, giving away, selling, or recycling things, excessive accumulation of items can occur.

Hoarding is not the same as collecting; the quantity of a hoard soon takes over spaces in the home or
workplace that render these areas unusable. For example, an individual may accumulate so much clutter
in their kitchen that they are not able to access appliances or sit at the table. Another concern is that
hoarding behavior can cause sanitation, fall, and fire hazards. Unlike other obsessive-compulsive and
related disorders, an individual who hoards is not necessarily distressed by their behavior. However,
their behavior can be distressing to other people, like family members or landlords. The most commonly
hoarded items include books, newspapers, old clothes, mail, and paperwork.
14.3.7 Trauma- and Stressor-Related Disorders (创伤和压力源相关疾病)

Trauma and stress are similar yet distinct experiences. Trauma is an emotional response to a shocking,
terrifying, dangerous, or life-threatening event. Some examples of trauma include a car accident,
physical or sexual assault, a natural disaster, or the sudden loss of a loved one. Trauma may also stem
from a series of repeated negative experiences, such as growing up in a violent home (Van der Kolk,
2005). Stress, on the other hand, is a reaction to demands in life, such as school work, impending
deadlines, and major life changes. Experiencing a traumatic event can also be stressful. As the name of
the category implies, trauma- and stressor-related disorders are caused by exposure to trauma and
stress. Table 14.8 lists the disorders included in this category.

In previous editions of the DSM, many of the disorders listed in this chapter were grouped with anxiety
disorders. However, the ways individuals respond to trauma and stress vary and can include fear, shock,
denial, social withdrawal, anger, aggression, dissociation, or a combination of these symptoms. While it
is normal to react in any of these ways, trauma- and stressor-related disorders are diagnosed when an
individual has significant difficulty recovering from their distress.

It is important to note that trauma and stress can be experienced directly and indirectly. For example,
witnessing or even hearing about a horrific accident can produce similar reactions to being involved in
an accident. As technology allows us to bear witness to traumatic events around our world through
electronic media, it will be important for researchers to learn more about the effects of vicarious trauma
and stress (May & Wisco, 2016).
Research suggests that among minoritized individuals, both direct and indirect exposure to racial
discrimination can be experienced as psychological trauma (Anderson & Stevenson, 2019). The effects of
vicarious race-based traumatic stress (Carter, 2007) truly came to light during the Spring and Summer of
2020 when the killings of Amaud Arbery, Breonna Taylor, George Floyd, and Sean Monterossa sparked a
series of uprisings decrying and denouncing racial injustice. Subsequent conversations have highlighted
the role of systemic racism in the mental health of people of color (Serchen et al., 2020).

[Link] Diagnostic Spotlight: Post-traumatic Stress Disorder (诊断聚焦：创伤后应激障碍)

Post-traumatic stress disorder (PTSD) can develop as the result of an individual experiencing or
witnessing a traumatic event. While not everyone who experiences trauma develops PTSD, the
symptoms of PTSD usually set in within three months of exposure to a traumatic event. The desire to
avoid reliving the trauma often makes it difficult for individuals with PTSD to express their thoughts and
feelings.

At any given time, 3.5% of the population experience symptoms of PTSD, and it is projected that almost
9% of individuals will experience PTSD in their lifetime. Certain jobs, such as police officers, firefighters,
and emergency medical personnel, increase the risk of exposure to trauma. Similarly, PTSD is more
common among survivors of sexual assault and veterans of military combat. This short documentary
sheds light on how combat affects many service men and women.

PTSD - The War at Home - YouTube

There are several symptoms associated with PTSD. In fact, an individual must exhibit symptoms in four
different categories to be diagnosed:

 Re-experiencing symptoms: Flashbacks (reliving the trauma over and over), nightmares, or
involuntary disturbing thoughts about the traumatic event.

 Avoidance symptoms: Staying away from people, places, situations, or objects that serve as
reminders of the traumatic event.
 Cognitive and mood symptoms: Inability to remember important features of the traumatic
event; negative thoughts about oneself, others, or the world; persistent fear, horror, anger,
guilt, or shame; inability to feel happy, satisfied, or loved.

 Arousal and reactivity symptoms: Constantly feeling tense or edgy; being easily startled; irritable
behavior and angry outbursts; difficulty sleeping.
14.3.8 Dissociative Disorders

Dissociative disorders involve disruption in an individual’s memory, identity, emotion, perception, and
behavior. Dissociation can also affect physical sensations and motor control. Everyone has experienced
some form of dissociation, whether it be spacing out while driving down the highway or getting so
wrapped up in reading a book that you lose track of time. Even daydreaming is a form of dissociation. As
with other psychological disorders, the experience of distress and impairment is what separates “getting
lost in the moment” from a dissociative disorder.

Dissociative symptoms can be experienced in multiple ways. Positive dissociative symptoms include
feelings of disconnection from one’s body (depersonalization), feelings that one’s surroundings are not
real (derealization), or fragmentation of identity. An individual may feel as if they are outside their body
or that they are separated from the rest of the world by a fog. Others experiencing positive dissociative
symptoms may describe reality as having an unfamiliar, dreamlike quality.

Negative dissociative symptoms are experienced as loss of memory or mental function. These
symptoms can be experienced as inability to recall personal information, important life events, or
significant people in one’s life. An individual may also be unable to remember where they were or what
they did for periods of time. These disorders are largely marked by unawareness of this lost time or
information. It is not until they are confronted with evidence of gaps in information or time that they
recognize their amnesia.
Dissociative disorders are often related to traumatic experiences, such as an accident, natural disaster,
or abuse (Ban der Kolk & Fisler, 1995). It is thought that dissociation can help an individual tolerate
what may otherwise be overwhelming. In such stressful situations, an individual may dissociate to
mentally escape fear, pain, or horror. This may make it difficult to later recall details of the event (Eisen
& Lynn, 2001). Table 14.9 lists the disorders included in this category.

[Link] Diagnostic Spotlight: Dissociative Identity Disorder (诊断聚焦：分离性身份障碍)

More commonly known as multiple personality disorder, dissociative identity disorder is characterized
by the presence of two or more distinct identities and extensive memory loss. Some individuals describe
this as an experience of being possessed (Parry et al., 2018). Contrary to popular belief, an individual
diagnosed with dissociative identity disorder does not possess multiple separate personalities. Rather,
the condition reflects a fragmentation or splitting of identity that results in alternate personality states
that may have distinct names, ages, genders, attitudes, outlooks, and personal preferences. Individuals
may report that, depending on the predominant identity state, their vocabulary changes, they
experience different intensities of emotions, or their body feels different in shape or size. When
alternate personality states emerge, the individuals often experience lapses in memory and suddenly
find themselves in places or situations with no idea how they came to be there. Dissociative identity
disorder is rare, occurring in less than 1% of the population, and is strongly associated with trauma
experienced in childhood.

14.3.9 Somatic Symptom and Related Disorders (躯体症状和相关疾病)

The word somatic refers to something that is specifically related to the body and not the mind. The
DSM-5 category of somatic symptom and related disorders is characterized by an intense focus on
symptoms of physical illness or pain. Specifically, an individual’s thoughts, feelings, or behaviors related
to somatic symptoms cause significant distress and impairment. Of course, being sick or in pain can lead
to distress, but a somatic symptom disorder may be diagnosed when the level of impairment the
individual reports is over and beyond what would be expected in the course of illness. Table 14.10 lists
the disorders included in this category.

It is important to note that diagnoses in this category do not imply that physical symptoms are not real.
However, it is possible for an individual to experience symptoms that do not have a medical explanation.
Somatic symptoms and related disorders are typically uncovered in a medical setting, as individuals tend
to seek out medical care when they experience illness or injury. Diagnoses in this category tend to be
considered when medical workups and treatments do not eventually produce symptom relief (Murray
et al., 2016).
There are many psychological disorders that can produce physical symptoms. For example, increased
heart rate may be a symptom of an anxiety disorder and fatigue may be a symptom of a depressive
disorder. It is therefore important that other psychological disorders be ruled out before a somatic
symptom disorder is diagnosed.

[Link] Diagnostic Spotlight: Factitious Disorder (诊断焦点：人为障碍)

Previously known as Munchausen syndrome, factitious disorder describes a condition in which

individuals knowingly and deliberately cause themselves to be physically ill or injured. An individual may
purposely expose themselves to illness or injury, exaggerate their symptoms to appear sicker than they
actually are, or even tamper with medical tests or results (Yates & Feldman, 2016). It is hard to know for
sure the prevalence of factitious disorder because of the role of deception in this population. Onset
tends to be during early adulthood and often follows hospitalization for a physical or mental condition.

Factitious disorder can be imposed on oneself or imposed on another. In the latter, the individual
presents another individual to others as sick, impaired, or injured. For example, a mother may insist that
her child has a rare medical condition and go to great lengths (e.g., giving the child substances that will
induce abnormal lab results) to convince medical providers to diagnose and treat the condition.
Individuals diagnosed with factitious disorder do not tend to fake medical problems for financial gain.
While they are aware of their deceit, they are often unable to pinpoint the reasons why (Jafferany et al.,
2018).
14.3.10 Feeding and Eating Disorders

The feeding and eating disorders category of the DSM-5 is a group of disorders that have significant
diagnostic overlap but differ in many important ways. Both feeding and eating disorders are
characterized by problems with consuming food and absorbing nutrients, which can lead to physical and
emotional health problems. In fact, it is often difficult to distinguish between feeding and eating
disorders.

One of the major differences is that feeding disorders tend to be seen in infants and children,
while eating disorders usually have onset in adolescence and adulthood (Uher & Rutter, 2012). Another
important difference is the motivation behind the disordered eating patterns. Feeding disorders tend to
be the result of food preferences and perceived intolerances, while eating disorders are related to an
emotional response to food. Diagnostic criteria for avoidant/restrictive food intake disorder (ARFID) and
anorexia nervosa are similar in that restriction of food intake and low body weight are key features of
both disorders. However, the distinguishing factors are that anorexia nervosa requires an intense fear of
weight gain or becoming fat as well as extreme discomfort in the individual’s perception of his or her
own body weight and shape. ARFID, on the other hand, is often defined by selective or picky
eating(Zimmerman & Fisher, 2017).

The majority of disorders in the feeding and eating disorders category have mutually exclusive
diagnostic criteria, meaning that an individual cannot be diagnosed with more than one feeding and
eating disorder at the same time. The exception is pica (eating of non-food substances, like dirt, hair, or
soap, on a regular basis; Rose et al., 2000), which can be diagnosed along with another condition in this
category. Table 14.11 lists the disorders included in this category.

[Link] Diagnostic Spotlight: Binge Eating Disorder (诊断聚焦：暴食症)

Although newly introduced as a formal diagnosis in DSM-5, binge eating disorder (BED) is the most
common of the eating disorders. While the prevalence rates are higher among women, close to 2% of
men also engage in these behaviors. Joey Julius, a college football player, shares his struggles with binge
eating disorder in the following video.

College Football Star Opens Up About Binge-Eating Disorder - YouTube

Binge eating disorder is most prevalent among individuals seeking to lose weight and is characterized by
eating an abnormally large amount of food in a short period of time (Grucza et al., 2007). Many people
may binge at Thanksgiving or when eating at a buffet, but binge eating disorder is different. Individuals
report loss of control, a sense that they cannot stop eating, even when they want to. In order to be
diagnosed with BED, a person must engage in frequent binge eating, at least once a week over a period
of three months. Unlike the bingeing behaviors that occur in bulimia nervosa, a person with BED will not
engage in compensatory behaviors such as purging, exercising, or taking a laxative. However, a key
feature of the disorder is a feeling of distress, disgust, depression, or guilt following a binge eating
episode (Wilfley et al., 2016).
14.3.11 Elimination Disorders

Elimination disorders are typically diagnosed in childhood or adolescence and is characterized by a lack
of bladder or bowel control that is not consistent with the individual’s current level of development.
While we all have to go sometime, elimination disorders involve the inappropriate elimination of urine
(enuresis) and feces (encopresis). This means any place other than the toilet, such as in underwear, in
the bed, or on the floor. Of course, it is common for children to have occasional accidents. However,
elimination disorders are diagnosed when the improper elimination is recurrent in potty-trained children
over 5 years of age. A diagnosis of enuresis should specify whether wetting occurs during sleeping hours
(nocturnal), waking hours (diurnal), or both night and day (nocturnal and diurnal), whereas a diagnosis
of encopresis should specify whether soiling occurs with constipation and overflow incontinence or
without constipation and overflow incontinence. Elimination disorders can be voluntary or involuntary.
Table 14.12 lists the disorders included in this category.

[Link] Diagnostic Spotlight: Encopresis (诊断聚焦：大便失禁)

Encopresis is defined as repeated defecation in inappropriate places when it is developmentally

expected that an individual would use a toilet (DeVries, 2017). The majority of children diagnosed with
encopresis have experienced chronic constipation earlier in life. Involuntary stool withholding, as with
constipation, may result in large, hard, and difficult-to-pass stools and can lead to fear of pain associated
with defecation. Children may also exhibit more generalized anxiety about toileting, such as fear of using
public bathrooms. Voluntary encopresis, which is much less common, may be associated with willful,
defiant, or rule-breaking behaviors.
14.3.12 Sleep–Wake Disorders

As humans, we spend about a third of our lives sleeping. Good quality sleep is necessary for optimal
physical and mental health. Learn more about the importance of sleep in the video clip below.

The benefits of a good night's sleep - Shai Marcu - YouTube

Sleep can be disturbed in a number of ways, including teeth grinding, breathing problems, involuntary
limb movement, and inability to fall or stay asleep. The sleep–wake category of DSM-5 is concerned with
disturbances that entail dissatisfaction with the quality, timing, or duration of sleep. As a result of these
disturbances, individuals experience daytime distress and impairment, including fatigue, difficulty with
cognitive focus, and declines in mood. Table 14.13 lists the disorders included in this category.

While sleep disturbances may cause adverse health outcomes, they can also be signs and symptoms of
medical problems like cardiovascular disease, osteoarthritis, and Alzheimer’s disease. Sleep–wake
disorders are often comorbid with depression, anxiety, and cognitive changes, and recurring sleep
disturbances are, themselves, risk factors for the manifestation of mental illness and substance-use
disorders (Baglioni et al., 2016; Zhang et al., 2017) .
[Link] Diagnostic Spotlight: Narcolepsy (诊断聚焦：嗜睡症)

Narcolepsy is a sleep–wake disorder that involves excessive daytime sleepiness due to the inability to
maintain good sleep at night (Scammell, 2015). This excessive sleepiness results in recurrent, sudden
lapses into sleep, typically lasting from a few seconds to several minutes. These daytime naps may occur
at any time without warning, and although the naps may be experienced as refreshing in the short term,
the overall poor quality of sleep associated with narcolepsy leaves the individual in a constant state of
fatigue. Other symptoms of narcolepsy include sudden loss of muscle tone, paralysis, vivid dreaming
(even during brief periods of sleep), and hallucinations.

14.3.13 Sexual Dysfunctions (性功能障碍)

The sexual dysfunctions chapter of DSM-5 is an umbrella category for disorders associated with clinically
significant difficulty in sexual response or the ability to experience sexual pleasure. Table 14.14 lists the
disorders included in this category.

When making a diagnosis, it is important to rule out inadequate sexual stimulation; in some
circumstances, an individual may benefit from education about effective stimulation to achieve sexual
arousal or orgasm. Such a situation would not merit a sexual dysfunction diagnosis.

Sexual dysfunction is a sensitive topic, and it is thought to be more prevalent than current estimates
because of underreporting. Sexual problems affect both men and women and can occur across the
lifespan, though rates of dysfunction tend to increase with age. This is likely associated with general
declines in health associated with aging. There are a number of other factors that also contribute to
sexual dysfunction:

 Partner factors: A partner’s own sexual dysfunction or poor health

 Relationship factors: Poor communication or incongruent sexual interests

 Cultural or religious factors: Socialized negative attitudes toward sexuality

 Medical factors: Medication side effects or a medical condition (in these cases, a diagnosis of
sexual dysfunction would not be made)

 Individual factors: Vulnerability because of poor body image or history of emotional or sexual
abuse; psychological difficulties such as depression or anxiety; or stressors such as increased
workload or loss of a loved one

It is important to specify whether a sexual dysfunction is lifelong (present since the individual’s first
sexual encounter) or acquired (onset occurred after a period of normal sexual function). Lifelong sexual
dysfunction often has psychological origins, while acquired sexual dysfunction tends to have both
psychological and physiological explanations. For example, erectile failure on the first sexual encounter
has been found to be related to having sex with a previously unknown partner, drug or alcohol use, and
peer pressure. This negative experience can lead to long-term difficulty with erectile function. Acquired
erectile disorder, on the other hand, may be the result of medical conditions such as diabetes or
cardiovascular disease.

It is also important to specify whether the sexual dysfunction is generalized (not limited to specific types
of stimulation, partners, or situations) or situational (only occurs with specific types of stimulation,
partners, or situations; Hatzichristou et al., 2016). In the case of female orgasmic disorder, for instance,
generalized dysfunction may be attributable to a variety of factors, including anxiety, religious views, or
medical condition such as vulvovaginal atrophy, which is characterized by vaginal pain, itching, and
dryness. Situational female orgasmic disorder may be due to discomfort in a certain physical location or
lack of attraction to a sexual partner. Additionally, women are more likely to experience orgasm during
masturbation than during sexual activity with a partner.

[Link] Diagnostic Spotlight: Erectile Disorder

Also known as impotence, erectile disorder is a sexual dysfunction characterized by recurrent failure to
get or keep an erection during sexual activity with a partner. Another manifestation of erectile disorder
is a significant decrease in the rigidity or hardness of erection. Erectile disorder can lead to low self-
esteem or a decreased sense of masculinity. This dysfunction can also affect the individual’s partner,
contributing to decreased sexual satisfaction and lessened sexual desire (Li et al., 2016).
14.3.14 Gender Dysphoria (性别焦虑)

While often used interchangeably, there are important distinctions between sex and gender. Sex refers
to the biological indicators of male and female as they relate to sex chromosomes and internal and
external genitalia. Gender, on the other hand, refers to societal indicators of roles ascribed to boys, girls,
men, and women. Gender assignment typically occurs at birth, following inspection of the infant’s
genitalia. Gender identity, however, is one’s personal experience of being a girl, boy, woman, man, or
other gender. Gender dysphoria is the experience of dissatisfaction, anxiety, and distress associated
with a gender assignment that does not match an individual’s gender identity (Zucker et al., 2016).

An individual with gender dysphoria may express the wish to be another gender, insist that they are
another gender, or in the case of children, assert that they will grow up to be another gender. For
example, a child assigned male at birth may strongly identify as and desire to be a girl. This child may
prefer to dress in traditional girls’ clothing, show strong interest in feminine role models, and play with
dolls and kitchen sets while avoiding cars, trucks, and rough-and-tumble sports. When signs of puberty
appear, the young person may shave their legs, bind their genitals to make bulges and erections less
visible, or seek hormone-suppressing medications. Individuals may also seek sex reassignment surgery.
Watch the video interview below with Jazz Jennings, a young girl diagnosed with gender dysphoria at
age five.

Transgender at 11: Listening to Jazz Jennings | 20/20 | ABC News - YouTube

Jazz’s experience may not be typical. She was able to articulate her dysphoria at a very young age and
had parents and medical professionals who listened and supported her. It is also important to note that
a diagnosis of gender dysphoria focuses on distress or discomfort as the clinical condition rather than
the identity. Adolescents and adults with gender dysphoria are at increased risk for anxiety, depression,
and suicidal behaviors (Olsen et al., 2015).

[Link] Diagnostic Spotlight: Gender Dysphoria (诊断聚焦：性别焦虑)

This category of DSM-5 includes one overarching diagnosis, though there are separate criteria for
children and for adolescents and adults (Ristori & Steensma, 2016; Zucker et al., 2016). Table 14.15 lists
the separate classifications of this disorder in the DSM-5.

Gender dysphoria is rare, with prevalence rates ranging from 0.002% to 0.014%. Since these data tend
to be captured in specialty clinics, these rates may be modest underestimates.

Gender dysphoria replaces the gender identity disorder diagnosis from DSM-IV. A diagnosis is necessary
to access medical treatments and get insurance coverage for counseling, hormone replacement therapy,
and gender reassignment surgery. However, changing the name of the diagnosis is an attempt to
diminish stigma associated with the condition and may help with attaining more accurate prevalence
estimates.

14.3.15 Disruptive, Impulse-Control, and Conduct Disorders (破坏性、冲动控制和品行障碍)

The common feature of disruptive, impulse-control, and conduct disorders is a problem controlling
one’s emotions and behaviors. While many other psychological disorders involve emotional and
behavioral dysregulation, these conditions also involve behaviors that disregard the rights of others,
social norms, or authority figures. For example, an individual may be verbally or physically aggressive
toward others, destroy property, or intentionally break rules or laws. Symptoms of disruptive, impulse-
control, and conduct disorders are typically first seen during childhood and adolescence, and they are
often associated with difficult adjustment during adulthood. These disorders are also more common
among males. Table 14.16 lists the disorders included in this category.

The disruptive, impulse-control, and conduct disorders have been described as disorders of self-control.
For instance, poor control of one’s aggressive behaviors may result in hurting other people or physical
damage to property. Poor control of one’s emotions, such as anger, can lead to loss of temper or angry
outbursts that may be perceived by others as out of proportion to the situation. Finally, poor control of
impulses and compulsions can lead to harmful or illegal activities, such as stealing or setting fires
(American Academy of Pediatrics, 2015).
[Link] Diagnostic Spotlight: Kleptomania (诊断聚焦：盗窃癖)

Kleptomania is the repeated failure to resist urges to steal items, even though the individual does not
need the items for personal use or their monetary value. In fact, individuals with kleptomania can often
afford to pay for the items and may discard or give them away after stealing them. The act of stealing is
also not an expression of anger or retaliation, and there tends to be considerable fear, guilt, and
remorse associated with the act. An individual with kleptomania may experience recurring thoughts
about stealing or a sense of tension that is relieved only following the theft (Grant & Chamberlain,
2018). Although the general prevalence of kleptomania is low, around 0.5%, the prevalence among
individuals arrested for shoplifting is 4–24%. Onset tends to be in adolescence, though there are cases of
young children reporting strong urges to steal. This brief video clip introduces a woman whose
kleptomania contributes to her hoarding disorder.

Hoarders: Ellen Comes Clean About Her Kleptomania (Season 8,Episode 9) | A&E - YouTube

14.3.16 Substance-Related and Addictive Disorders

The substance-related and addictive disorders category of DSM-5 encompasses activities that stimulate
the brain-reward system. This system is critical to our survival, as food, water, and sex activate the
reward center and release dopamine. Because of the pleasurable sensations associated with the release
of dopamine, we are more likely to repeat these behaviors and associate them with pleasant memories
(Nestler, 2004). Ingestion of certain drugs may also activate the brain-reward system, resulting in
intense feelings of pleasure (often referred to as a high). Addiction is a disorder of the brain-reward
system characterized by compulsive and repetitive engagement in activities associated with immediate
pleasure, even when the long-term outcomes are negative.

In the late 1990's, based on reassurance from pharmaceutical companies that patients would not
become addicted to opioid pain relievers such as OxyContin (oxycodone), medical providers began to
prescribe these drugs at much higher rates. It quickly became clear, however, that the opioid
medications could be highly addictive - and deadly (Murthy, 2016). In addition to pain relief, these drugs
can also produce euphoria, which has led to many individuals taking opioids in larger quantities or for a
longer time than prescribed. The widespread misuse of prescription (e.g., codeine, morphine, fentanyl)
and illicit non-prescription (e.g., heroin) opioids has been termed the Opioid Epidemic, and is associated
with tens of thousands of deaths by overdose each year (Hedegaard et al., 2020).

It is important to note that addictions can be substance related or non-substance related (i.e.,
behavioral), as is the case with gambling disorder. Substance-related disorders are further divided into
substance-use disorders and substance-induced disorders. Substance-use disorders refer to negative
consequences associated with frequent and persistent use of substances; these consequences often
accumulate after prolonged use. For instance, individuals often neglect their family, home, school, or
work obligations and may engage in detrimental, dangerous, or illegal activities to satisfy their addiction
(Chavarria et al., 2015). The same pattern of consequences may be seen in non-substance-related
addictions as well. Other hallmarks of addiction include preoccupation with the substance or behavior
and denial that there is a problem. In contrast, substance-induced disorders are characterized by
immediate effects of substance use, such as intoxication. In both substance-induced and non-substance-
related addictive disorders, the individual tends to experience distress, restlessness, and irritability when
attempting to reduce or discontinue use of the addictive substance or behavior. This is known
as withdrawal.
DSM-5 specifies nine substances and one behavior that are classified as distinct disorders (see Table
14.17).

Two important common factors of all substance-related disorders are physiological dependence (a
change in brain circuitry related to repeated ingestion of a substance) and tolerance (requiring more
and more of a substance to achieve the original effects).

While non-substance-related addictive disorders do not involve ingestion of substances, the rewards,
symptoms, and consequences are similar (Yau & Potenza, 2015). Currently, gambling disorder is the sole
diagnosis in this category. However, with additional research, we may see the inclusion of internet
gaming, sex, exercise, and shopping addictions in future versions of the DSM.

[Link] Diagnostic Spotlight: Gambling Disorder

Gambling involves risking something of value on the chance of gaining something of even greater value.
Compulsive gambling, an uncontrollable urge to continue gambling despite the consequences, is known
as gambling disorder (Nautiyal et al., 2017). These consequences can revolve around money or time
spent on gambling, and they can affect the individual’s relationships, job or education, and financial
well-being. The individual may establish a pattern of chasing losses, in which larger risks are taken to
compensate for previous losses. For example, a person may wager something of greater value, such as
their car, in hopes of making up for all the money lost over the previous month. Individuals may also lie
about their gambling or resort to theft or fraud to support their addiction.

Previous editions of the DSM listed gambling disorder as an impulse-control disorder, though DSM-5
classifies the condition as a behavioral addiction. The prevalence of gambling disorder is about 0.3% and
is more commonly diagnosed in men.

14.3.17 Neurocognitive Disorders

The neurocognitive disorders category of DSM-5 represents a broad range of disorders that affect how
the brain processes information. While many other psychological disorders lead to a decline in cognitive
ability, the key factor that differentiates neurocognitive disorders is that the condition is acquired. This
means that the cognitive deficit was not present at birth or during early childhood. Furthermore,
diagnosis of a neurocognitive disorder indicates evidence that cognitive ability is considerably different
from what was attained over the lifespan. Table 14.18 lists the disorders included in this category.
Neurocognitive disorders affect memory, attention, language, perception, and learning and are
attributable to brain injury, disease, or substance/medication use. For example, impact to the head
while playing football or during an automobile accident can result in loss of consciousness, amnesia, or
disorientation and confusion. Traumatic brain injuries account for 2.5 million emergency room visits,
282,000 hospitalizations, and 50,000 deaths annually (Taylor et al., 2017). While many of these
neurocognitive disorders are mild, 2% of the population report disability associated with a major
traumatic brain injury. Prolonged substance use and genetic mutation in brain cells can also lead to
neurocognitive disorders.

The ability to trace their cause makes neurocognitive disorders a unique category in DSM-5. Evidence of
a neurocognitive disorder can come from the individual or a person close to them reporting a significant
decline in cognitive functioning. Neuropsychological testing documenting substantial impairment in
cognitive functioning is another important factor in diagnosis. The decline in cognitive functioning may
or may not interfere with tasks of everyday life, and DSM-5 differentiates
between major neurocognitive disorder and minor neurocognitive disorder according to severity of
impairment (Jeste & Palmer, 2016).
[Link] Diagnostic Spotlight: Major or Minor Neurocognitive Disorder Due to Alzheimer’s Disease

Alzheimer’s disease is a neurocognitive disorder characterized by memory loss, disorientation,

confusion, impaired judgment, and behavioral changes. It is a fairly common disorder, with prevalence
rates ranging from 5–10% of the population (Alzheimer's Association, 2018). The condition tends to be
progressive, meaning that it starts slowly and gets worse over time. The risk for developing Alzheimer’s
disease increases with age (in fact, risk increases exponentially after an individual reaches the age of 65),
though it is not considered a normal part of the aging process. Rather, it is thought to be attributable to
genetic mutations in brain cells. Early signs of Alzheimer’s disease may include forgetfulness, difficulty
making decisions, and mood swings. As the disease progresses, physical damage occurs in the brain,
including plaque deposits and tangles that lead to death of neurons and overall shrinkage of brain
tissues. The video below explains how these plaques and tangles affect the brain.

What is Alzheimer's disease? - Ivan Seah Yu Jun - YouTube

14.3.18 Personality Disorders (人格障碍)

Personality is the combination of characteristics, beliefs, and behaviors that make us unique. Personality
traits tend to be consistent and stable over time and situations, meaning that people act and react the
same way over and over. A personality disorder, therefore, indicates an enduring pattern of
characteristics, beliefs, and behaviors that are drastically different from the expectations of the
individual’s society and lead to distress and impairment.
The patterns of personality disorders are usually first seen during adolescence or early adulthood and,
by definition, do not change over time. In fact, previous editions of the DSM considered personality
disorders to be a different domain of mental disorder because of their chronic and persistent nature as
well as resistance to treatment (Bateman et al., 2015; Sheehan et al., 2016).

An individual with a personality disorder has difficulty in social relationships and with social
expectations, though the blame for the discord is rarely accepted by the individual. Daily stressors may
seem insurmountable, and frustration is intensified by the feeling that others do not understand or
appreciate their situation. Due to the strong perception that their thoughts and beliefs are the norm, the
individual may exhibit distress, anxiety, depression, and acting out behaviors when experiencing push-
back from society. Personality disorders are most likely to receive attention when the distress manifests
as self-harm, harm to others, or other illegal activities.

There are 10 specific types of personality disorder that are grouped into three categories or clusters
based on similar descriptions of behaviors. Table 14.19 lists the disorders included in this category,
broken down by cluster.

[Link] Cluster A: Odd and Eccentric Behaviors (古怪和古怪的行为)

These personality disorders are characterized by social awkwardness, social withdrawal, and distorted
thinking. Disorders in this cluster are diagnostically similar to schizophrenia spectrum disorders.

[Link] Cluster B: Dramatic, Emotional, and Erratic Behaviors (戏剧性、情绪化和反复无常的行为)

This cluster of personality disorders is marked by problems with impulse control, moral reasoning, and
the ability to regulate emotions (Turner et al., 2017). Individuals have difficulty relating to others,
following social conventions, and may disregard rules, laws, and the feelings of others.

[Link] Cluster C: Anxious and Fearful Behaviors (焦虑和恐惧行为)

Personality disorders in this cluster are typified by shy, nervous, insecure, and overly cautious behaviors.
These disorders are thought to be less impairing than Cluster A or B personality disorders.
[Link] Diagnostic Spotlight: Borderline Personality Disorder (诊断焦点：边缘性人格障碍)

The central feature of borderline personality disorder is instability in interpersonal relationships, self-
image, and emotion (Gunderson et al., 2018). This Cluster B personality disorder is characterized by
intense emotions and moods that can change quickly. In fact, a key characteristic of borderline
personality disorder is black-and-white thinking, in which people and situations are perceived as all
good or all bad. The individual is not able to appreciate the grays of life, in which there is a mix of
positive and negatives.

Individuals with this personality disorder often have trouble calming themselves once emotions are high,
and they often attempt to soothe themselves by engaging in impulsive and harmful behaviors like
substance use, risky sexual encounters, excessive spending, self-injury (e.g., cutting), and suicidal
behaviors (Videler et al., 2019). They may frequently and quickly enter and leave social and romantic
relationships, careers, and places of residence. These changes often occur without warning, advance
preparation, or consideration of consequences. This short film describes a young woman’s experience
with borderline personality disorder.

Warning: This video discusses content that some may find upsetting including brief mentions of suicide
and depictions of self-harm.

I AM BORDERLINE: Self-Regulation Project *Award winning short film (Possible Trigger) - YouTube

14.3.19 Paraphilic Disorders (性欲障碍)

A paraphilia describes a strong and persistent sexual interest in objects, situations, or behaviors that are
not considered typical by society (Beech et al., 2016). The term is actually an attempt at
describing unusual sexual interests, sexual perversion, or sexual deviance in a non-stigmatizing way.
These interests can be focused on erotic activities, such as inflicting pain or humiliation on oneself or
another, or focused on erotic targets, such as children or non-human objects. The defining factor of a
paraphilia is that the sexual urges are equal to or greater than more typical sexual interests, such as
intercourse. In other words, the person becomes so preoccupied with the target behavior or object that
they become dependent on that behavior or object for sexual satisfaction.
As you can imagine, paraphilic disorders are quite controversial. While the urges may seem strange to
some, a paraphilia alone does not necessarily indicate a need for clinical treatment (Konrad et al., 2015).
A paraphilic disorder is diagnosed when a paraphilia causes distress or impairment in functioning,
whether to the individual or to another person. Sexual preferences tend to be a private matter, but
paraphilic disorders may lead to harm or risk of harm to others, especially when involving non-
consenting adults or children, regardless of consent. There are innumerable distinct paraphilias.
However, the DSM-5 lists the most common paraphilic disorders as well as those that are illegal (see
Table 14.20).

[Link] Diagnostic Spotlight: Fetishistic Disorder (诊断聚焦：恋物癖)

Fetishistic disorder is a paraphilic disorder in which sexual arousal and gratification depend on non-living
objects or a specific body part (Martin, 2016). Some common objects of fetishism include lingerie, shoes
and boots, and leather clothing. Fetishes focusing on body parts do not typically include genitals, but
rather fixate on hair, feet, and toes as sources of eroticism. Fetishes can also include both
objects and body parts, such as gloves and hands. Although the mere sight of the fetish object may lead
to sexual arousal, the individual typically holds, rubs, smells, or tastes the object while masturbating.
Alternatively, the individual may prefer that a sexual partner wear or use the fetish object during sexual
encounters.

14.4 The Prevalence of Psychological Disorders

Epidemiologists study the rates, causes, and effects of health conditions in specified
populations. Prevalence rate is a measure epidemiologists use to determine how many individuals are
affected by a health condition in a given time period, and these data provide information about the
impact of health conditions on overall public health.

Epidemiologists at the Substance Abuse and Mental Health Services Administration (SAMHSA, 2020)
investigate prevalence rates of psychological disorders, and results from their 2019 National Survey on
Drug Use and Health reveal that 20% of adults in the United Stated aged 18 or older had a mental illness
in the past year. That equates to 51.5 million individuals with psychological disorders. This same survey
reported that 15.7% of adolescents (3.8 million) aged 12 to 17 had a major depressive episode during
that same period of time. It is important to note that the rates of psychological disorders are
disproportionately high among certain populations. Women report higher rates, as do persons of color
and individuals from low-income environments.

These figures indicate that lots of people in the United States are affected by psychological disorders—
maybe even more than we acknowledge. How do these rates compare with the rest of the world?
According to the World Health Organization (2001), almost 450 million individuals across the world are
affected by mental illness. A more specific look reveals that 4.4% of the global population exhibits
symptoms consistent with a depressive disorder and 3.6% with an anxiety disorder. This places
psychological disorders among the leading causes of disability worldwide.

Few events have affected day-to-day life on a global level like Coronavirus 2019 (COVID-19). Pandemic is
another term used by epidemiologists to describe a disease that has spread to affect people worldwide.
On March 11, 2020, the World Health Organization declared COVID-19 a pandemic (WHO, 2020). An
examination of the prevalence of anxiety and depression among adults in the United States during April
and May, 2020 revealed rates were three times higher than during the same time period in 2019
(Twenge & Joiner, 2020). As discussed below, there are multiple causes of psychological disorders.
Researchers hypothesize that some of the factors contributing to higher prevalence of psychological
disorders during the pandemic include social isolation due to lockdowns and social distancing, greater
financial stress due to job loss, and frequent exposure to news and media reports (Ettman et al., 2020).

14.5 Investigating the Causes of Psychological Disorders: The Biopsychosocial Model

What causes psychological disorders? There have been multiple attempts to explain why certain people
are more likely to experience symptoms of mental illness while others are less susceptible.
The biopsychosocial model (Engel, 1980) suggests that there is not one single factor or event that
precipitates a psychological disorder. Rather, it is the complex interactions of a
person’s biological makeup, psychological experiences, and social environment that determine their risk
for a psychological disorder.

The biological aspect of the model accounts for the roles of illness, injury, physiology, and genetics. For
example, a construction worker may experience a fall that results in a traumatic brain injury, or a baby
can contract an infection that causes swelling of the brain. There are also theories that implicate
neurotransmitters like dopamine, serotonin, and norepinephrine in psychological disorders, and these
theories have credence since many psychiatric medications act on these neurotransmitter pathways.
Finally, genetics seem to play a substantial role, as psychological disorders tend to run in families, and
new genetic techniques have indicated that variability in certain genes is often associated with
psychological disorders.
The psychological piece of the biopsychosocial model factors in the roles of individual characteristics,
such as temperament, personality, mood, and behavior. These intrinsic traits elicit reactions from the
environment that can have a long-term impact on mental health. For example, a child who is fussy and
difficult to calm may be treated differently by caregivers and will be likely to have more negative
interactions than a child who is quiet and compliant. Other individual characteristics like irritability and
impulsivity also influence how an individual perceives their environment and how the environment
responds to them.

The social component of the model includes influences from factors like family, culture, socioeconomic
status, and religion. These factors make up the environment in which an individual functions or
experiences dysfunction. For example, an individual who is homeless and has no friends or family to turn
to will likely experience significant stress. As discussed, the abnormal patterns that ultimately define
psychological disorders are socially determined.

The biopsychosocial model reminds us that we cannot point to one incident or experience to explain
mental health outcomes—our life experiences do not exist in a vacuum (Ahn et al., 2009). Let’s consider
Sheridan, a 34-year-old woman. Her mother and grandmother were both treated for depression, which
implies that Sheridan has a genetic predisposition for depression. Since her mother and grandmother
were her primary caregivers growing up, Sheridan was also exposed to an environment of depression;
she remembers days when her mother would just lie in bed all day, not engaging at all with Sheridan.
She also remembers visiting her grandmother in the hospital after she took pills to try to end her life.
Sheridan has always been impulsive, acting first and thinking about the consequences later. In school,
she would shout out her thoughts in class, and as an adult, she has damaged her credit because of her
tendency to shop without paying attention to her account balances. Today, Sheridan was terminated
from her job because of company downsizing. Taken alone, these factors may or may not cause distress.
Taken together, however, these factors may increase the risk for suicidal behavior. Our body, mind, and
social environment all affect each other and interactively affect our mental health (see Figure 14.32).

Although our understanding of psychological disorders has grown tremendously over the years, there is
still plenty to learn. Understanding encompasses much more than knowledge about diagnostic
characteristics, prevalence rates, or effective treatments. Rather, true understanding also means
respect, compassion, and embracing what is different, strange, weird, or abnormal . . . even when we
may not actually understand it.

14.6 Summary

In this chapter, you learned:

 The “Four Ds” (deviance, distress, dysfunction, and danger) help guide psychologists when
determining whether a pattern of behavior should be considered abnormal.

 Psychological disorders are patterns of deviant and dysfunctional behaviors, thoughts, and
feelings that cause significant distress, and may even be dangerous.

 Diagnostic labels help provide explanations for abnormal behaviors, thoughts, and feelings, as
well as give researchers and clinicians a common language for discussing abnormal psychology.

 Mental health stigma has roots in misunderstandings of psychological disorders, including

supernatural explanations; labels can perpetuate stigma, are long-lasting, and influence how the
person sees themselves and their world.

 Dorothea Dix was one of the first advocates for the humane treatment of the mentally ill in the
United States, which resulted in the construction of insane asylums. Ironically, overcrowding in
these institutions typically resulted in inhumane treatment.

 Person-first and identity-first language can be used to respect the individuality of people with
psychological disorders.
 The DSM is published by the American Psychiatric Association and helps people make more
consistent and objective decisions about psychological disorders.

 The DSM-5 has done away with the multiaxial approach adopted by the DSM-III, has taken a
developmental approach to psychological disorders, and has significantly streamlined and
changed many of the diagnostic categories.

 Clinicians use the case formulation process to develop a detailed assessment of a person’s
psychological disorder(s) as informed by factors like developmental history, physical health, and
social factors.

 Psychological disorders are studied by epidemiologists to discover their prevalence rates; a 2014
survey estimated that almost 20% of adults in the United States had a mental illness in the past
year.

 Prevalence rates for certain psychological disorders are often disproportionately high among
certain groups, such as women, people of color, and people from low-income environments.

 Neurodevelopmental disorders affect the brain and neurological systems, leading to

developmental delays and difficulties in many aspects of a child’s life. These disorders include
autism spectrum disorder, intellectual and communication disorders, and others such as ADHD.

 Autism spectrum disorders (ASD) are a class of disorders of varying levels of impairments to
social, emotional, and behavioral processes and communication.

 The schizophrenia spectrum and other psychotic disorders are a category of psychological
disorders in which patients often have severe and persistent symptoms that significantly impair
their ability to maintain contact with reality, think clearly, make good decisions, and
communicate effectively. These manifest with positive, negative, or cognitive symptoms.

 Bipolar and related disorders are characterized by mood shifts in two directions, but more
importantly, by the presence of a manic episode in which impulsiveness or productive behavior
increase to abnormally high levels.

 Depressive disorders are characterized by physical symptoms and negative thoughts that
significantly impair an individual’s daily functioning. Suicidal thoughts and behaviors are
frequently associated with depressive disorders, and any and all suicidal comments should be
taken seriously.

 Anxiety disorders are a group of psychological disorders marked by excessive fear and anxiety;
this group of disorders includes phobias, social anxiety, agoraphobia, panic disorder, and
generalized anxiety disorder, among others.

 Obsessive-compulsive and related disorders are characterized by obsessions (unwanted and

intrusive thoughts, fears, urges, or images) and compulsions (behaviors a person feels driven to
perform in response to an obsession); rituals are frequent in these disorders to reduce anxiety
related to the obsessions and compulsions.

 Trauma and stressor-related disorders are psychological disorders that occur in response to
experiencing or witnessing a traumatic event or in response to chronic stress (such as an abusive
 childhood). Post-traumatic stress disorder (PTSD) is the most well-known of trauma and
stressor-related disorders.

 Dissociative disorders are marked by a disruption in a person’s memory, identity, emotion,

perception, or behavior. Positive dissociative symptoms include depersonalization and
derealization, as well as identity fragmentation, while negative symptoms include memory loss
or impaired mental functioning.

 Somatic symptoms and related disorders are psychological disorders related to the body, such
as an intense preoccupation with symptoms related to physical illness or pain. Physical
symptoms caused by somatic disorders are real but have no traditional medical explanation.

 Factitious disorder (formerly known as Munchausen syndrome) is a condition in which a person

knowingly and deliberately causes themselves or another person (usually a dependent such as a
child) to be physically ill or injured.

 Feeding disorders typically develop during early childhood and are a result of food preferences
and intolerances, while eating disorders such as anorexia nervosa and bulimia develop later and
are motivated by emotional responses to food.

 Elimination disorders are a class of psychological disorders that typically develop in childhood or
adolescence and are related to a lack of bladder or bowel control when a person should be
developmentally capable of controlling it; an example is encopresis.

 As discussed in Chapter 6, sleep-wake disorders are characterized by problems with the sleep-
wake cycle in some way; narcolepsy is a specific example.

 Sexual dysfunctions are a class of disorders related to clinically significant difficulty in sexual
response or the ability to experience sexual pleasure. Importantly, these disorders are not a
result of inadequate or ineffective sexual stimulation and may be lifelong or acquired, as well as
generalized or situational.

 Gender dysphoria is a clinically significant amount of dissatisfaction, anxiety, and distress related
to a gender assignment at birth that does not match a person’s gender identity; the disorder is
importantly not related to the identity itself, but to the distress caused by the mismatch
between gender assignment and identity.

 Disruptive, impulse-control, and conduct disorders are a class of disorders in which the defining
feature is a problem controlling your own emotions and behavior in a way that disregards the
rights of others, social norms, or respect for authority; kleptomania is an example.

 The substance-related and addictive disorders category is a class of psychological disorders

related to behaviors that stimulate the brain’s reward system to release dopamine and cause
addiction; these disorders can be related to substances (such as drugs) or behaviors (such as
gambling).

 Physiological dependence and tolerance are two common factors of all substance-related
disorders, and substance-related disorders can be further broken down into substance-use
disorders and substance-induced disorders.
 Neurocognitive disorders belong to a broad class of psychological disorders related to problems
with how the brain processes information due to underlying neurological conditions and can be
either major or minor in nature, depending on the severity of the deficits.

 Alzheimer’s disease is characterized by memory loss, disorientation, confusion, impaired

judgment, and behavioral issues caused by genetic abnormalities in brain cells; its prevalence
rate is 5–10% of the population and is especially likely over the age of 65.

 Personality disorders are a pervasive and enduring pattern of traits, beliefs, and behaviors due
to one’s personality that cause distress because they are drastically different from societal
expectations. Personality disorders are arranged into three clusters: (A) odd and eccentric
behaviors;(B) dramatic, emotional, and erratic behaviors; and (C) anxious and fearful behaviors.

 The central feature of borderline personality disorder (BPD) is instability in interpersonal

relationships, self-image, and emotion; an individual with BPD typically has intense emotions
and moods that can change quickly, tends toward black-and-white thinking, and engages in
impulsive behavior to calm themselves down.

 Paraphilic disorders are a class of psychological disorders related to a strong and persistent
sexual interest in a specific object, situation, or behavior that is atypical of the society that the
individual belongs. Importantly, the interest must crowd out other, more typical sexual interests
(such as sexual intercourse); fetishistic disorder is an example.

 It is important to note that psychological disorders are rarely attributable to any single event or
cause; the biopsychosocial model helps us understand that each class of factors (biological,
psychological, and social) can contribute to causing psychological disorders and that these
factors interact.