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Psych opathology Foundations for a Contemporary Understanding

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Edited by James E. Maddux Barbara A. Winstead

PSYCHOPATHOLOGY
FOUNDATIONS FOR A CONTEMPORARY UNDERSTANDING

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PSYCHOPATHOLOGY
FOUNDATIONS FOR A CONTEMPORARY UNDERSTANDING Edited by James E. Maddux George Mason University Barbara A. Winstead Old Dominion University LAWRENCE ERLBAUM A !C"A#E $ %UBL" &ER !!" Ma'(a'$ Ne( Jersey London

Seni#r C#ns$%tin& Edit#r' Edit#ria% Assistant' S$san Mi%(#e )risten De*+en C#,et Desi&n' Te-tb##+ Pr#d$.ti#n Mana&er' )at/tyn H#$&/ta%in& La.ey F$%%0Ser,i.e C#(*#sit#r Te-t and C#,er Printer' Pa$% S(#%ens+i Te./1##+s Ha(i%t#n Printin& C#(*any T/is b##+ 2as ty*eset in 3!43 *t. Ti(es Ne2 R#(an5 1#%d5 and Ita%i.. T/e /eads 2ere ty*eset in Sab#n 1#%d5 and 1#%d Ita%i.. C#*yri&/t O !!" by La2ren.e Er%ba$( Ass#.iates5 In.. A%% ri&/ts reser,ed. N# *art #6 t/is b##+ (ay be re*r#d$.ed in any 6#r(5 by */#t#stat5 (i.r#6#r(5 retrie,a% syste(5 #r any #t/er (eans5 2it/#$t *ri#r 2ritten *er(issi#n #6 t/e *$b%is/er. La2ren.e Er%ba$( Ass#.iates5 In..5 P$b%is/ers 3! Ind$stria% A,en$e Ma/2a/5 Ne2 7ersey !89:! 222.er%ba$(..#( Library #6 C#n&ress Cata%#&in&0in0P$b%i.ati#n Data Psy./#*at/#%#&y ' 6#$ndati#ns 6#r a .#nte(*#rary $nderstandin& 4 edited by 7a(es E. Madd$-5 1arbara A. Winstead. In.%$des bib%i#&ra*/i.a% re6eren.es and inde-. IS1N !0;O";09O880< =a%+. *a*er> 3. Psy./#%#&y5 Pat/#%#&i.a%. I. Madd$-5 7a(es E. II. Winstead5 1arbara A. RC9"9.P8;? !!9 1##+s *$b%is/ed by La2ren.e Er%ba$( Ass#.iates are *rinted #n a.id06ree *a*er5 and t/eir bindin&s are ./#sen 6#r stren&t/ and d$rabi%ity. *. .(. ?3?.;@Ad. !!9!338!: Printed in t/e United States #6 A(eri.a 3! @ ; 8 ? " 9 : 3

"To the students and clients who have inspired us and taught us so much."

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C#ntents Pre6a.e i- List #6 C#ntrib$t#rs -i PART I' THIN)ING A1OUT PSYCHOPATHOLOGY 3 3. C#n.e*ti#ns #6 Psy./#*at/#%#&y' A S#.ia% C#nstr$.ti#nist Pers*e.ti,e : ames !. Maddu"# ennifer T. Gosselin# and $arbara %. &instead . C$%t$ra% Di(ensi#ns #6 Psy./#*at/#%#&y' T/e S#.ia% W#r%dBs I(*a.t #n Menta% I%%ness 3@ 'teven (egeser )ope* and +eter . Guarnaccia :. Gender and Psy./#*at/#%#&y :@ $arbara %. &instead and anis 'anche* 9. C%assi6i.ati#n and Dia&n#sis' Hist#ri.a% De,e%#*(ent and C#nte(*#rary Iss$es ?: Thomas %. &idiger ". Psy./#%#&i.a% Assess(ent and C%ini.a% 7$d&(ent ;" ,oward -. Garb# 'cott O. )ilienfeld# and .atherine %. /owler ?. 1i#%#&i.a% 1ases #6 Psy./#*at/#%#&y 3!@ (obert ,. ,owland PART II' COMMON ADULT5 ADOLESCENT5 AND CHILD DISORDERS 3 " 8. An-iety Dis#rders 3 8 '. )loyd &illiams 8

,iii CONTENTS ;. M##d Dis#rders 3"" (ick 0ngram and )ucy Trenary @. S./iC#*/renia 38@ !laine &alker# %nnie $ollini# .aren ,ochman# and )isa .estler 3!. Pers#na%ity Dis#rders !3 )inda %nne 1oker and Thomas %. &idiger 33. Eatin& Dis#rders @ anet +olivy# 1. +eter ,erman# and Michele $oivin 3 . Se-$a% Dys6$n.ti#ns and Dis#rders "" -athaniel Mc1onaghy 3:. S#(at#6#r( Dis#rders ;3 Georg,. !ifert and Michael . 2volensky 39. S$bstan.e Use Dis#rders :!3 &illiam /als3'tewart 3". E-terna%iCin& Dis#rders #6 C/i%d/##d and Ad#%es.en.e : " +aul . /rick and !va (. .imonis 3?. Interna%iCin& Dis#rders #6 C/i%d/##d and Ad#%es.en.e :": Thomas ,. Ollendick# %lison ). 'hortt# and anay $. 'ander 38. C#&niti,e Dis#rders #6 C/i%d/##d and Ad#%es.en.e' S*e.i6i. Learnin& Disabi%ities and Menta% Retardati#n :88 ack -aglieri# 1laudia 'alter# and ohannes (o4ahn 3;. Menta% Hea%t/ and A&in&' C$rrent Trends and F$t$re Dire.ti#ns :@: .risten ,. 'orocco# )isa M. .inoshita# and Dolores Gallagher3Thompson A$t/#r Inde- S$bDe.t Inde- 9 3 9"@

Pre6a.e in)e *++,$ more t'an t'irty textboo-s for undergraduate abnorma. psy)'o.ogy )ourses 'a/e been pub.is'ed. #'is )ount does not in).ude re/ised editions of existing boo-s. #'e same period 'as seen t'e pub.i)ation of numerous 0'andboo-s0 in psy)'opat'o.ogy and psy)'iatry$ ('i)' are )on)ei/ed primari.y as referen)e boo-s for ).ini)a. pra)titioners and resear)'ers. W'at 'as been missing is a true textboo- of psy)'opat'o.ogy for first1year graduate students in ).ini)a. psy)'o.ogy$ )ounse.ing psy)'o.ogy$ and re.ated fie.ds. !ur goa. in )reating t'is boo- (as to pro/ide t'e 0missing .in-0 in t'e )ontinuum. We designed )ontent and )o/erage for a first1.e/e. graduate )ourse 2or an ad/an)ed1.e/e. undergraduate )ourse for ex)eptiona. students or t'ose ('o 'a/e a.ready ta-en an entry1.e/e. undergraduate )ourse in abnorma. psy)'o.ogy3. #'is boo(as designed and (ritten (it' students in mind. #'e .engt'$ organi4ation$ )ontent$ and .e/e. and sty.e of (riting ref.e)t t'is intention. We$ t'e editors$ are ).ini)a. psy)'o.ogists (it' a )ombined forty1fi/e years of experien)e tea)'ing do)tora. students in ).ini)a. psy)'o.ogy. #'e )'apter aut'ors are among t'e most distinguis'ed resear)'ers in t'e fie.ds of ).ini)a. psy)'o.ogy and psy)'opat'o.ogy. We 'ad t(o primary goa.s for t'e boo-5 *. To provide up3to3date information about theory and research on the etiology and treatment of the most important psychological disorders. #o(ard t'is end$ (e )'ose (e..1-no(n aut'ors ('o are not on.y fami.iar (it' t'e )utting1edge resear)' in t'eir areas of spe)ia.i4ation but are a.so a)ti/e.y )ontributing to it. 2 . To challenge students to think critically about psychopathology# not 4ust memori*e infor3 mation. We tried to a))omp.is' t'is goa. in t(o (ays. First$ (e en)ouraged aut'ors to )'a..enge traditiona. assumptions and t'eories about t'e prob.ems t'ey (ere addressing. e)ond$ and more important$ (e )ommissioned )'apters t'at dea.t dire)t.y and in dept' (it' su)' )ru)ia. and )ontro/ersia. issues as t'e definition of psy)'opat'o.ogy$ t'e inf.uen)es of )u.ture and gender$ t'e /a.idity of psy)'o.ogi)a. testing$ ).ini)a. 6udgment and de)ision ma-ing$ t'e /a.idity and uti.ity of traditiona. psy)'iatri) diagnosis$ and t'e ro.e of bio.ogi)a. fa)tors in t'e )ause of psy)'o.ogi)a. prob.ems. 10

X %REFACE We be.ie/e strong.y t'at a sop'isti)ated understanding of psy)'opat'o.ogy in genera. and of spe)ifi) psy)'o.ogi)a. prob.ems re7uires mu)' more t'an t'e memori4ation of a .ist of diagnosti) )riteria 2as in t'e 8 M3 or t'e findings of numerous studies. "nstead$ it re7uires t'e mastery of ideas and concepts and 'o( to use t'em to be )riti)a. )onsumers of resear)' and )riti)a. readers of t'e 8 M. For t'e most part$ )urrent boo-s pay too .itt.e attention to t'ese ideas$ )on)epts$ and issues. "n %art "$ (e de/ote six )'apters to t'ese issues. #'e ma6or reason for p.a)ing t'ese genera. )'apters before t'e )'apters on disorders is to gi/e students a set of )on)eptua. too.s t'at (i.. 'e.p t'em read more t'oug'tfu..y and )riti)a..y t'e materia. on spe)ifi) disorders. #'is textboo- is di/ided into t(o main parts. %art " is de/oted to dis)ussions of t'e ideas$ )on)epts$ and issues noted pre/ious.y. %art "" is de/oted to dis)ussions of t'e most )ommon prob.ems and disorders. We as-ed aut'ors to fo..o($ to t'e extent possib.e$ a )ommon format )onsisting of5 *. A definition and des)ription of t'e disorder or disorders. 9. A brief 'istory of t'e study of t'e disorder. :. #'eory and resear)' on etio.ogy. ;. Resear)' on empiri)a..y /a.idated treatments. <. A dis)ussion of t'e issues )o/ered in %art " ('ere appropriate. Editors a.(ays must ma-e )'oi)es regarding ('at s'ou.d be in).uded in a textboo- and ('at s'ou.d not. A boo- t'at de/oted a )'apter to ea)' and e/ery disorder des)ribed in t'e 8 M (ou.d be un(ie.dy and impossib.e to )o/er in a sing.e semester. !ur )'oi)es regarding ('at to in).ude and ('at to ex).ude (ere guided primari.y by our experien)es (it' t'e -inds of psy)'o.ogi)a. prob.ems ).ini)a. students typi)a..y en)ounter in t'eir training and subse7uent ).ini)a. )areers. For t'ese reasons$ (e in).uded t'ree )'apters on t'e psy)'o.ogi)a. and )ogniti/e prob.ems of )'i.dren and ado.es)ents. We 'ope t'at bot' instru)tors and students (i.. find our approa)' to psy)'opat'o.ogy )'a..enging and usefu.. We 'a/e .earned mu)' from our )ontributing aut'ors in t'e pro)ess of editing t'eir )'apters$ and (e 'ope t'at students (i.. .earn mu)' from reading ('at t'e aut'ors 'a/e produ)ed. James E. Maddux =eorge Mason Uni/ersity Fairfax$ >A Barbara A. Winstead !.d 8ominion Uni/ersity Norfo.-$ >A Apri. 9?$ 9,,;

C#ntrib$t#rs Mi./E%e 1#i,in5 Uni/ersity of #oronto Annie 1#%%ini5 Emory Uni/ersity Linda Anne C#+er5 Uni/ersity of @entu)-y Ge#r& H. Ei6ert5 C'apman Uni/ersity Wi%%ia( Fa%s0Ste2art5 Uni/ersity at Buffa.o$ #'e tate Uni/ersity of Ne( Aor- )at/erine A. F#2%er5 Emory Uni/ersity Pa$% 7. Fri.+5 Uni/ersity of Ne( !r.eans D#%#res Ga%%a&/er0T/#(*s#n5 tanford Uni/ersity )'oo. of Medi)ine H#2ard N. Garb5 Uni/ersity of %ittsburg' 7enni6er T. G#sse%in5 %epperdine Uni/ersity Peter 7. G$arna..ia5 Rutgers$ #'e tate Uni/ersity of Ne( Jersey C. Peter Her(an5 Uni/ersity of #oronto )aren H#./(an5 Emory Uni/ersity R#bert H. H#2%and5 Uni/ersity of %ittsburg' )'oo. of Medi)ine Ri.+ In&ra(5 Uni/ersity of @ansas Lisa )est%er5 Emory Uni/ersity E,a R. )i(#nis5 Uni/ersity of Ne( !r.eans Lisa M. )in#s/ita5 tanford Uni/ersity )'oo. of Medi)ine S.#tt O. Li%ien6e%d5 Emory Uni/ersity Ste,en Re&eser L#*eC5 Uni/ersity of Ca.ifornia$ Los Ange.es 7a(es E. Madd$-5 =eorge Mason Uni/ersity Nat/anie% M.C#na&/y5 Uni/ersity of Ne( out' Wa.es 7a.+ Na&%ieri5 =eorge Mason Uni/ersity T/#(as H. O%%endi.+5 >irginia %o.yte)'ni) "nstitute and tate Uni/ersity 7anet P#%i,y5 Uni/ersity of #oronto 7#/annes R#Da/n5 =eorge Mason Uni/ersity C%a$dia Sa%ter5 =eorge Mason Uni/ersity 7anis San./eC5 !.d 8ominion Uni/ersity 7anay 1. Sander5 >irginia %o.yte)'ni) "nstitute and tate Uni/ersity A%is#n L. S/#rtt5 >irginia %o.yte)'ni) "nstitute and tate Uni/ersity 12

-ii CONTRI1UTORS )risten H. S#r#..#5 Uni/ersity of !-.a'oma &ea.t' )ien)es Center L$.y Trenary5 Uni/ersity of Co.orado E%aine Wa%+er5 Emory Uni/ersity T/#(as A. Widi&er5 Uni/ersity of @entu)-y S. L%#yd Wi%%ia(s5 tuttgart$ =ermany 1arbara A. Winstead5 !.d 8ominion Uni/ersity Mi./ae% 7. F,#%ens+y5 #'e Uni/ersity of >ermont

PA RT i THIN)ING A1OUT PSYCHOPATHOLOGY 14

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CHAPTER

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C#n.e*ti#ns #6 Psy./#*at/#%#&y' A S#.ia% C#nstr$.ti#nist Pers*e.ti,e 7a(es E. Madd$George Mason University 7enni6er T. G#sse%in +epperdine University 1arbara A. Winstead Old Dominion University A textboo- about a sub6e)t s'ou.d begin (it' a ).ear definition of t'e sub6e)t. Unfortunate.y$ in t'e )ase of a textboo- on psy)'opat'o.ogy$ definition is diffi)u.t if not impossib.e. #'e definitions or )on)eptions ofpsychopathology and re.ated terms su)' as mental disorder 'a/e been t'e fo)us of 'eated debate t'roug'out t'e 'istory of psy)'o.ogy and psy)'iatry$ and t'e debate is far from o/er 2e.g$ =orenstein$ *+B;5 &or(it4$ 9,,9C Widiger$ *++D3. 8espite many /ariations$ t'e debate 'as )entered on a sing.e o/erriding 7uestionEare psy)'opat'o.ogy and re.ated terms su)' as menta. disorder and menta. i..ness s)ientifi) terms t'at )an be defined ob6e)ti/e.y and by s)ientifi) )riteria or are t'ey so)ia. )onstru)tions 2=ergen$ *+B<3 t'at are defined entire.y by so)ieta. and )u.tura. /a.uesF #'e goa. of t'is )'apter is to address t'is 7uestion. Addressing it ear.y is important be)ause readersG /ie(s of e/eryt'ing t'ey read in t'e rest of t'is boo- (i.. be inf.uen)ed by t'eir /ie(s on t'is 7uestion. A )on)eption of psy)'opat'o.ogy is not a t'eory of psy)'opat'o.ogy 2Wa-efie.d$ *++9a3. A )on)eption of psy)'opat'o.ogy pro/ides one definition of t'e termEit de.ineates ('i)' 'uman experien)es are )onsidered psy)'opat'o.ogi)a. and ('i)' are not. A )on)eption of psy)'opat'o.ogy does not try to exp.ain t'e psy)'o.ogi)a. p'enomena t'at are )onsidered pat'o.ogi)a. but instead te..s us ('at psy)'o.ogi)a. p'enomena are )onsidered pat'o.ogi)a. and t'us need to be exp.ained. A t'eory of psy)'opat'o.ogy$ 'o(e/er$ pro/ides an exp.anation of t'ose psy)'o.ogi)a. p'enomena and experien)es t'at 'a/e been identified by t'e )on)eption as pat'o.ogi)a.. #'is )'apter dea.s (it' )on)eptions of psy)'opat'o.ogy. #'eories and exp.anations )an be found in a number of ot'er )'apters$ in).uding a.. of t'ose in part "". Understanding /arious )on)eptions of psy)'opat'o.ogy is important for many reasons. As medi)a. p'i.osop'er La(rie Re4ne- 2*+BD3 said$ 0Con)epts )arry )onse7uen)esE).assifying t'ings one (ay rat'er t'an anot'er 'as important imp.i)ations for t'e (ay (e be'a/e to(ards su)' t'ings0 2p. *3. "n spea-ing of t'e importan)e of t'e )on)eption of disease$ Re4ne- (rote5 16

17 MADDU<5 GOSSELIN5 WINSTEAD The classification of a condition as a disease carries many important consequences. We inform medical scientists that they should try to discover a cure for the condition. We inform benefactors that they should support such research. We direct medical care towards the condition, making it appropriate to treat the condition by medical means such as drug therapy, surgery, and so on. We inform our courts that it is inappropriate to hold people responsible for the manifestations of the condition. We set up early warning detection services aimed at detecting the condition in its early stages when it is still amenable to successful treatment. We serve notice to health insurance companies and national health services that they are liable to pay for the treatment of such a condition. Classifying a condition as a disease is no idle matter, p. ! " "f (e substitute t'e term psy)'e1pat'o.ogy or menta. disorder for t'e (ord disease in t'is paragrap'$ Re4ne-Gs message sti.. 'o.ds true. &o( (e )on)ei/e of psy)'opat'o.ogy and re.ated terms 'as (ide1ranging imp.i)ations for indi/idua.s$ medi)a. and menta. 'ea.t' professiona.s$ go/ernment agen)ies and programs$ and so)iety at .arge. TRADITIONAL CONCEPTIONS OF PSYCHOPATHOLOGY >arious )on)eptions of psy)'opat'o.ogy 'a/e been offered o/er t'e years. Ea)' 'as its merits and its defi)ien)ies$ but none suffi)es as a tru.y s)ientifi) definition. Psy./#*at/#%#&y as Statisti.a% De,ian.e A )ommon and )ommon sense )on)eption of psy)'opat'o.ogy is t'at pat'o.ogi)a. psy)'o.ogi)a. p'enomena are t'ose t'at are abnorma. or statisti)a..y de/iant or infre7uent. %bnormal .itera..y means a(ay from t'e norm. #'e (ord norm refers to ('at is typi)a. or a/erage. #'us$ in t'is )on)eption$ psy)'opat'o.ogy is /ie(ed as de/iation from psy)'o.ogi)a. norma.ity. !ne of t'e merits of t'is )on)eption is its )ommonsense appea.. "t ma-es sense to most peop.e to use terms su)' as psy)'opat'o.ogy and menta. disorder to refer on.y to be'a/iors or experien)es t'at are infre7uent 2e.g.$ paranoid de.usions$ 'earing /oi)es3 and not to t'ose t'at are re.ati/e.y )ommon 2e.g.$ s'yness$ sadness fo..o(ing t'e deat' of a .o/ed one3. A se)ond benefit of t'is )on)eption is t'at it .ends itse.f to a))epted met'ods of measurement t'at gi/e it at .east a semb.an)e of s)ientifi) respe)tabi.ity. #'e first step in using t'is )on)eption s)ientifi)a..y is to determine ('at is statisti)a..y norma. 2typi)a.$ a/erage3. #'e se)ond step is to determine 'o( far a parti)u.ar psy)'o.ogi)a. p'enomenon or )ondition de/iates from statisti)a. norma.ity. #'is step is often a))omp.is'ed by de/e.oping an instrument or measure t'at attempts to 7uantify t'e p'enomenon and t'en assigns numbers or s)ores to peop.eGs experien)es or manifestations of t'e p'enomenon. !n)e t'e measure is de/e.oped$ norms are typi)a..y estab.is'ed so t'at an indi/idua.Gs s)ore )an be )ompared to t'e mean or a/erage s)ore of some group of peop.e. )ores t'at are suffi)ient.y far from a/erage are )onsidered to be indi)ati/e of abnorma. or pat'o.ogi)a. psy)'o.ogi)a. p'enomena. #'is pro)ess des)ribes most tests of inte..igen)e and )ogniti/e abi.ity and many )ommon.y used measures of persona.ity and emotion 2e.g.$ t'e Minnesota Mu.tip'asi) %ersona.ity "n/entory3. 8espite its )ommonsense appea. and its s)ientifi) merits$ t'is )on)eption presents prob.ems. "t sounds re.ati/e.y ob6e)ti/e and s)ientifi) be)ause it re.ies on (e..1estab.is'ed psy)'ometri) met'ods for de/e.oping measures of psy)'o.ogi)a. p'enomena and de/e.oping norms. Aet$ t'is

approa)' .ea/es mu)' room for sub6e)ti/ity. ub6e)ti/ity first )omes into p.ay in t'e )on)eptua. definition of t'e )onstru)t for ('i)' a measure is de/e.oped. A measure of any psy)'o.ogi)a. )onstru)t$ su)' as inte..igen)e$ must

*. CONCEPTIONS OF PSYCHOPATHOLOGY 19 begin (it' a )on)eptua. definition. We 'a/e to as- ourse./es$ 0W'at is inte..igen)eF0 !f )ourse$ different peop.e 2in).uding different psy)'o.ogists3 (i.. offer different ans(ers to t'is 7uestion. &o( t'en )an (e s)ientifi)a..y and ob6e)ti/e.y determine ('i)' definition or )on)eption is true or )orre)tF #'e ans(er is t'at (e )annot. A.t'oug' (e 'a/e pro/en met'ods for de/e.oping a re.iab.e and /a.id 2i.e.$ it predi)ts ('at (e (ant to predi)t3 measure of a psy)'o.ogi)a. )onstru)t on)e (e 'a/e agreed on its )on)eption or definition$ (e )annot use t'ese same met'ods to determine ('i)' )on)eption or definition is true or )orre)t. #'ere is no one true definition of inte..igen)e and no ob6e)ti/e$ s)ientifi) (ay of determining one. "nte..igen)e is not a t'ing t'at exists inside of peop.e and ma-es t'em be'a/e in )ertain (ays and t'at a(aits our dis)o/ery of its true nature. "nstead$ it is an abstra)t idea t'at is defined by peop.e as t'ey use t'e (ords intelligence and intelligent to des)ribe )ertain -inds of 'uman be'a/ior and t'e )o/ert menta. pro)esses t'at supposed.y pre)ede or are )on)urrent (it' t'e be'a/ior. We usua..y )an obser/e and des)ribe patterns in t'e (ay most peop.e use t'e (ords inte..igen)e and inte..igent to des)ribe t'eir o(n be'a/ior and t'at of ot'ers. #'e des)riptions of t'e patterns t'en )omprise t'e definitions of t'e (ords. "f (e examine t'e patterns of t'e use of inte..igen)e and inte..igent$ (e find t'at at t'e most basi) .e/e.$ t'ey des)ribe a /ariety of spe)ifi) be'a/iors and abi.ities t'at so)iety /a.ues and t'us en)ouragesC uninte..igent be'a/ior is a /ariety of be'a/iors t'at so)iety does not /a.ue and t'us dis)ourages. #'e fa)t t'at t'e definition of inte..igen)e is grounded in so)ieta. /a.ues exp.ains t'e re)ent expansion of t'e )on)ept to in).ude good interpersona. s-i..s$ se.f1regu.atory s-i..s$ artisti) and musi)a. abi.ities$ and ot'er abi.ities not measured by traditiona. tests of inte..igen)e. #'e meaning of inte..igen)e 'as broadened be)ause so)iety 'as )ome to p.a)e in)reasing /a.ue on t'ese ot'er attributes and abi.ities$ and t'at )'ange in /a.ues is t'e resu.t of a dia.ogue or dis)ourse among t'e peop.e in so)iety$ bot' professiona.s and .aypersons. !ne measure of inte..igen)e may be more re.iab.e t'an and more usefu. t'an anot'er measure in predi)ting ('at (e (ant to predi)t 2e.g.$ a)ademi) a)'ie/ement$ in)ome3$ but ('at (e (ant to predi)t ref.e)ts ('at (e /a.ue$ and /a.ues are not s)ientifi)a..y deri/ed. ub6e)ti/ity a.so inf.uen)es t'e determination of 'o( de/iant a psy)'o.ogi)a. p'enomenon must be from t'e norm to be )onsidered abnorma. or pat'o.ogi)a.. We )an use ob6e)ti/e$ s)ientifi) met'ods to )onstru)t a measure su)' as an inte..igen)e test and de/e.op norms for t'e measure$ but (e are sti.. .eft (it' t'e 7uestion of 'o( far from norma. an indi/idua.Gs s)ore must be to be )onsidered abnorma.. #'is 7uestion )annot be ans(ered by t'e s)ien)e of psy)'ometri)s be)ause t'e distan)e from t'e a/erage t'at a personGs s)ore must be to be )onsidered abnorma. is a matter of debate$ not a matter of fa)t. "t is true t'at (e often ans(er t'is 7uestion by re.ying on statisti)a. )on/entions su)' as using one or t(o standard de/iations from t'e a/erage s)ore as t'e .ine of di/ision bet(een norma. and abnorma. 2see t'e )'apter on )ogniti/e abi.ities in )'i.d'ood3. Aet t'e de)ision to use t'at )on/ention is itse.f sub6e)ti/e. W'y s'ou.d one standard de/iation from t'e norm designate abnorma.ityF W'y not t(o standard de/iationsF W'y not 'a.f a standard de/iationF W'y not use per)entagesF #'e .ines bet(een norma. and abnorma. )an be dra(n at many different points using many different strategies. Ea)' .ine of demar)ation may be more or .ess usefu. for )ertain purposes$ su)' as determining t'e )riteria for e.igibi.ity for .imited ser/i)es and resour)es. W'ere t'e .ine is set a.so determines t'e pre/a.en)e of abnorma.ity or menta. disorder among t'e genera. popu.ation 2@ut)'ens H @ir-$ *++D3$ so it 'as great pra)ti)a. signifi)an)e. But no su)' .ine is more or .ess true t'an t'e ot'ers$ e/en ('en based on statisti)a.

)on/entions. We )annot use t'e pro)edures and met'ods of s)ien)e to dra( a definiti/e .ine of demar)ation bet(een norma. and abnorma. psy)'o.ogi)a. fun)tioning$ 6ust as (e )annot use t'em to dra( .ines of demar)ation bet(een s'ort and ta.. peop.e or 'ot and )o.d on a t'ermometer. No su)' .ines exist in nature a(aiting our dis)o/ery.

21 MADDU<5 GOSSELIN5 WINSTEAD Psy./#*at/#%#&y as Ma%ada*ti,e =Dys6$n.ti#na%> 1e/a,i#r Most of us t'in- of psy)'opat'o.ogy as be'a/ior and experien)e t'at are not 6ust statisti)a..y abnorma. but a.so ma.adapti/e 2dysfun)tiona.3. -ormal and abnormal are statisti)a. terms$ but adaptive and maladaptive refer not to statisti)a. norms and de/iations but to t'e effe)ti/eness or ineffe)ti/eness of a personGs be'a/ior. "f a be'a/ior is effe)ti/e for t'e personEif t'e be'a/ior 'e.ps t'e person dea. (it' )'a..enge$ )ope (it' stress$ and a))omp.is' 'is or 'er goa.sEt'en (e say t'e be'a/ior is more or .ess adapti/e. "f t'e be'a/ior does not 'e.p in t'ese (ays$ or if t'e be'a/ior ma-es t'e prob.em or situation (orse$ (e say it is more or .ess ma.adapti/e. Li-e t'e statisti)a. de/ian)e )on)eption$ t'is )on)eption 'as )ommonsense appea. and is )onsistent (it' t'e (ay most .aypersons use (ords su)' as pat'o.ogy$ disorder$ and i..ness. Most peop.e (ou.d find it odd to use t'ese (ords to des)ribe statisti)a..y infre7uent 'ig' .e/e.s of inte..igen)e$ 'appiness$ or psy)'o.ogi)a. (e.. being. #o say t'at someone is pat'o.ogi)a..y inte..igent or pat'o.ogi)a..y (e..1ad6usted seems )ontradi)tory be)ause it f.ies in t'e fa)e of t'e )ommonsense use of t'ese (ords. #'e ma6or prob.em (it' t'e )on)eption of psy)'opat'o.ogy as ma.adapti/e be'a/ior is its in'erent sub6e)ti/ity. #'e distin)tion bet(een adapti/e and ma.adapti/e$ .i-e t'e distin)tion bet(een norma. and abnorma.$ is fu44y and often arbitrary. We 'a/e no ob6e)ti/e$ s)ientifi) (ay of ma-ing a ).ear distin)tion. >ery fe( 'uman be'a/iors are in and of t'emse./es eit'er adapti/e or ma.adapti/eC t'eir adapti/eness and ma.adapati/eness depends on t'e situations in ('i)' t'ey are ena)ted and on t'e 6udgment and /a.ues of t'e obser/er. E/en be'a/iors t'at are statisti)a..y rare and t'erefore abnorma. are more or .ess adapti/e under different )onditions and more or .ess adapti/e in t'e opinion of different obser/ers. #'e extent to ('i)' a be'a/ior or be'a/ior pattern is /ie(ed as more or .ess adapti/e or ma.adapti/e depends on a number of fa)tors$ su)' as t'e goa.s t'e person is trying to a))omp.is' and t'e so)ia. norms and expe)tations of a gi/en situation. W'at (or-s in one situation mig't not (or- in anot'er. W'at appears adapti/e to one person mig't not appear so to anot'er. W'at is usua..y adapti/e in one )u.ture mig't not be so in anot'er. E/en so1)a..ed norma. persona.ity in/o./es a good dea. of o))asiona..y ma.adapti/e be'a/ior$ for ('i)' you )an find e/iden)e in your o(n .ife and t'e .i/es of friends and re.ati/es. "n addition$ peop.e gi/en persona.ity disorder diagnoses by ).ini)a. psy)'o.ogists and psy)'iatrists often )an manage t'eir .i/es effe)ti/e.y and do not a.(ays be'a/e in disordered (ays. Anot'er prob.em (it' t'e psy)'opat'o.ogi)a.1e7ua.s1ma.adapti/e )on)eption is t'at deter1 minations of adapti/eness and ma.adapti/eness are .ogi)a..y unre.ated to measures of statisti)a. de/iation. !f )ourse$ often (e do find a strong re.ations'ip bet(een t'e statisti)a. abnorma.ity of a be'a/ior and its ma.adapti/eness. Many of t'e prob.ems des)ribed in t'e Diagnostic and 'tatistical Manual of Mental Disorders 28 MC Ameri)an %sy)'iatri) Asso)iation IA%AJ$ 9,,,3 and in t'is textboo- are bot' ma.adapti/e and statisti)a..y rare. #'ere are$ 'o(e/er$ ma6or ex)eptions to t'is re.ations'ip. First$ psy)'o.ogi)a. p'enomena t'at de/iate from norma. or a/erage are not a.. ma.adapti/e. "n fa)t$ sometimes de/iation from norma. is adapti/e and 'ea.t'y. For examp.e$ "K s)ores of *:, and D, are e7ua..y de/iant from norma.$ but abnorma..y 'ig' inte..igen)e is mu)' more adapti/e t'an abnorma..y .o( inte..igen)e. Li-e(ise$ peop.e ('o )onsistent.y s)ore abnorma..y .o( on measures of anxiety and depression are probab.y 'appier and better ad6usted t'an peop.e ('o )onsistent.y s)ore e7ua..y abnorma..y 'ig' on su)' measures.

e)ond$ ma.adapti/e psy)'o.ogi)a. p'enomena are not a.. statisti)a..y infre7uent and /i)e /ersa. For examp.e$ s'yness is /ery )ommon and t'erefore is statisti)a..y fre7uent$ but s'yness is a.most a.(ays ma.adapti/e to some extent$ be)ause it a.most a.(ays interferes (it' a personGs abi.ity to a))omp.is' ('at 'e or s'e (ants to a))omp.is' in .ife and re.ations'ips. #'is is not

3. CONCEPTIONS OF PSYCHOPATHOLOGY 23 to say t'at s'yness is pat'o.ogi)a. but on.y t'at it ma-es it diffi)u.t for some peop.e to .i/e fu.. and 'appy .i/es. #'e same is true of many of t'e prob.ems (it' sexua. fun)tioning t'at are in).uded in t'e 8 M as menta. disorders. Psy./#*at/#%#&y as Distress and Disabi%ity ome )on)eptions of psy)'opat'o.ogy in/o-e t'e notions of sub6e)ti/e distress and disabi.ity. ub6e)ti/e distress refers to unp.easant and un(anted fee.ings su)' as anxiety$ sadness$ and anger. 8isabi.ity refers to a restri)tion in abi.ity 2!ssorio$ *+B<3. %eop.e ('o see- menta. 'ea.t' treatment are not getting ('at t'ey (ant out of .ife$ and many fee. t'at t'ey are unab.e to do ('at t'ey (ou.d .i-e to do. #'ey may fee. in'ibited or restri)ted by t'eir situation$ t'eir fears or emotiona. turmoi.$ or by p'ysi)a. or ot'er .imitations. #'e indi/idua. may .a)- t'e ne)essary se.f1effi)a)y be.iefs 2be.iefs about persona. abi.ities3$ p'ysio.ogi)a. or bio.ogi)a. )omponents$ andLor situationa. opportunities to ma-e positi/e )'anges 2Bergner$ *++D3. ub6e)ti/e distress and disabi.ity are simp.y t(o different but re.ated (ays of t'in-ing about adapti/eness and ma.adapti/eness rat'er t'an a.ternati/e )on)eptions of psy)'opat'o.ogy. A.t'oug' t'e notions of sub6e)ti/e distress and disabi.ity may 'e.p refine our notion of ma.adapti/eness$ t'ey do not'ing to reso./e t'e sub6e)ti/ity prob.em. 8ifferent peop.e define persona. distress and persona. disabi.ity in /ast.y different (ays$ as do different menta. 'ea.t' professiona.s and t'ose in different )u.tures. Li-e(ise$ peop.e differ in 'o( mu)' distress or disabi.ity t'ey )an to.erate. #'us$ (e are sti.. .eft (it' t'e prob.em of 'o( to determine norma. and abnorma. .e/e.s of distress and disabi.ity. As noted pre/ious.y$ t'e 7uestion 0&o( mu)' is too mu)'F0 )annot be ans(ered using t'e ob6e)ti/e met'ods of s)ien)e. Anot'er prob.em is t'at some )onditions or patterns of be'a/ior 2e.g.$ sexua. fetis'isms$ antiso)ia. persona.ity disorder3 t'at are )onsidered psy)'opat'o.ogi)a. 2at .east offi)ia..y$ a)1 )ording to t'e 8 M3 are not )'ara)teri4ed by sub6e)ti/e distress$ ot'er t'an t'e temporary distress t'at mig't resu.t from so)ia. )ondemnation or )onf.i)ts (it' t'e .a(. Psy./#*at/#%#&y as S#.ia% De,ian.e Anot'er )on)eption /ie(s psy)'opat'o.ogy as be'a/ior t'at de/iates from so)ia. or )u.tura. norms. #'is )on)eption is simp.y a /ariation of t'e )on)eption of psy)'opat'o.ogy as abnor1 ma.ity$ ex)ept t'at in t'is )ase 6udgments about de/iations from norma.ity are made informa..y by peop.e rat'er t'an forma..y a))ording to psy)'o.ogi)a. tests or measures. #'is )on)eption a.so is )onsistent to some extent (it' )ommon sense and )ommon par.an)e. We tend to /ie( psy)'opat'o.ogi)a. or menta..y disordered peop.e as t'in-ing$ fee.ing$ and doing t'ings t'at most ot'er peop.e do not do and t'at are in)onsistent (it' so)ia..y a))epted and )u.tura..y san)tioned (ays of t'in-ing$ fee.ing$ and be'a/ing. #'e prob.em (it' t'is )on)eption$ as (it' t'e ot'ers$ is its sub6e)ti/ity. Norms for so)ia..y norma. or a))eptab.e be'a/ior are not s)ientifi)a..y deri/ed but instead are based on t'e /a.ues$ be.iefs$ and 'istori)a. pra)ti)es of t'e )u.ture$ ('i)' determine ('o is a))epted or re6e)ted by a so)iety or )u.ture. Cu.tura. /a.ues de/e.op not t'roug' t'e imp.ementation of s)ientifi) met'ods but t'roug' numerous informa. )on/ersations and negotiations among t'e peop.e and institutions of t'at )u.ture. o)ia. norms differ from one )u.ture to anot'er$ and t'erefore ('at is psy)'o.ogi)a..y abnorma. in one )u.ture may not be so in anot'er 2 ee Lope4 H =uarna))ia$ t'is boo-3. A.so$ norms of a gi/en )u.ture )'ange o/er timeC t'erefore$ )on)eptions of psy)'opat'o.ogy a.so )'ange o/er time$ often /ery dramati)a..y$ as e/iden)ed by Ameri)an so)ietyGs )'anges o/er t'e past se/era. de)ades in attitudes to(ard sex$ ra)e$ and gender. For

examp.e$ psy)'iatrists in t'e *B,,s ).assified masturbation$ espe)ia..y in )'i.dren and (omen$ as a disease$ and it (as treated in some )ases by ).itoride)tomy 2remo/a. of t'e ).itoris3$ ('i)'

25 MADDU<5 GOSSELIN5 WINSTEAD Western so)iety today (ou.d )onsider barbari) 2Re4ne-$ *+BD3. &omosexua.ity (as an offi)ia. menta. disorder in t'e 8 M unti. *+D:. "n addition$ t'e )on)eption of psy)'opat'o.ogy as so)ia. norm /io.ations is at times in )onf.i)t (it' t'e )on)eption of psy)'opat'o.ogy as ma.adapti/e be'a/ior. ometimes /io.ating so)ia. norms is 'ea.t'y and adapti/e for t'e indi/idua. and benefi)ia. to so)iety. "n t'e *+t' )entury$ (omen and Afri)an1Ameri)ans in t'e United tates ('o soug't t'e rig't to /ote (ere trying to )'ange (e..1estab.is'ed so)ia. norms. #'eir a)tions (ere un)ommon and t'erefore abnorma.$ but t'ese peop.e (ere far from psy)'o.ogi)a..y un'ea.t'y$ at .east by todayGs standards. Ear.ier in t'e *+t' )entury$ s.a/es ('o desired to es)ape from t'eir o(ners (ere said to 'a/e 0drapetomania.0 #oday s.a/ery itse.f$ a.t'oug' sti.. pra)ti)ed in some parts of t'e (or.d$ is seen as so)ia..y de/iant and pat'o.ogi)a.$ and t'e desire to es)ape ens.a/ement is )onsidered to be as norma. and 'ea.t'y as t'e desire to .i/e and breat'e. CONTEMPORARY CONCEPTIONS' PSYCHOPATHOLOGY AS HARMFUL DYSFUNCTION A more re)ent attempt at defining psy)'opat'o.ogy is Wa-efie.dGs 2*++9a$ *++9b$ *++:$ *++D$ *+++3 'armfu. dysfun)tion 2&83 )on)eption. %resumab.y grounded in e/o.utionary psy)'o.ogy 2e.g.$ Cosmides$ #ooby$ H Bar-o($ *++93$ t'e &8 )on)eption a)-no(.edges t'at t'e )on)eption of menta. disorder is inf.uen)ed strong.y by so)ia. and )u.tura. /a.ues. "t a.so proposes$ 'o(e/er$ a supposed.y s)ientifi)$ fa)tua.$ and ob6e)ti/e )ore t'at is not dependent on so)ia. and )u.tura. /a.ues. "n Wa-efie.dGs 2*++9a3 (ords5 # $mental% disorder is a harmful dysfunction &wherein 'armfu. is a value term based on social norms, and dysfun)tion is a scientific term referring to the failure of a mental mechanism to perform a natural function for which it was designed by evolution . . . a disorder e'ists when the failure ofa person(s internal mechanisms to perform theirfunction as designed by nature impinges harmfully on the person(s well&being as defined by social values and meanings, p. )*)" !ne of t'e merits of t'is approa)' is t'at it a)-no(.edges t'at t'e )on)eption of menta. disorders must in).ude a referen)e to so)ia. normsC 'o(e/er$ t'is )on)eption a.so tries to ground t'e )on)ept of menta. disorder in a s)ientifi) t'eoryEt'at is$ t'e t'eory of e/o.ution. Wa-efie.d 2*+++3 re)ent.y 'as reiterated t'is definition in (riting t'at 0a disorder attribution re7uires bot' a s)ientifi) 6udgment t'at t'ere exists a fai.ure of designed fun)tion and a /a.ue 6udgment t'at t'e design fai.ure 'arms t'e indi/idua.0 2p. :D;3. &o(e/er$ t'e ).aim t'at identifying a fai.ure of a designed fun)tion is a s)ientifi) 6udgment and not a /a.ue 6udgment is open to 7uestion. Wa-efie.dGs ).aim t'at dysfun)tion )an be defined in 0pure.y fa)tua. s)ientifi)0 2Wa-efie.d$ *++9a$ p. :B:3 terms rests on t'e assumption t'at t'e designed fun)tions of 'uman menta. me)'anisms 'a/e an ob6e)ti/e and obser/ab.e rea.ity and$ t'us$ t'at fai.ure of t'e me)'anism to exe)ute its designed fun)tion )an be ob6e)ti/e.y assessed. A basi) prob.em (it' t'is notion is t'at a.t'oug' t'e p'ysi)a. inner (or-ings of t'e body and brain )an be obser/ed and measured$ menta. me)'anisms 'a/e no ob6e)ti/e rea.ity and t'us )annot be obser/ed dire)t.y Eno more so t'an t'e un)ons)ious for)es t'at pro/ide t'e foundation for Freudian psy)'oana.ysis. E/o.utionary t'eory pro/ides a basis for exp.aining 'uman be'a/ior in terms of its )ontribution to reprodu)ti/e fitness. A be'a/ior is )onsidered more fun)tiona. if it in)reases t'e sur/i/a. of

t'ose ('o s'are your genes in t'e next generation and t'e next and .ess fun)tiona. if it does not. E/o.utionary psy)'o.ogy )annot$ 'o(e/er$ pro/ide a )ata.ogue of menta.

3. CONCEPTIONS OF PSYCHOPATHOLOGY 27 me)'anisms and t'eir natura. fun)tions. Wa-efie.d states t'at 0dis)o/ering ('at in fa)t is natura. or dysfun)tiona. may be extraordinari.y diffi)u.t0 2*++9b$ p. 9:?3. #'e prob.em (it' t'is statement is t'at$ ('en app.ied to 'uman be'a/ior$ natura. and dysfun)tiona. are not properties t'at )an be dis)o/eredC t'ey are /a.ue 6udgments. #'e 6udgment t'at a be'a/ior represents a dysfun)tion re.ies on t'e obser/ation t'at t'e be'a/ior is ex)essi/e andLor inappropriate under )ertain )onditions. Arguing t'at t'ese be'a/iors represent fai.ures of an e/o.utionari.y designed menta. me)'anisms 2itse.f an untestab.e 'ypot'esis be)ause of t'e o))u.t nature of menta. me)'anisms3 does not re.ie/e us of t'e need to ma-e /a.ue 6udgments about ('at is ex)essi/e or inappropriate in ('at )ir)umstan)es. #'ese /a.ue 6udgments are based on so)ia. norms$ not on s)ientifi) fa)ts$ an issue t'at (e (i.. exp.ore in greater detai. .ater in t'is )'apter. Anot'er prob.em (it' t'e &8 )on)eption is t'at it is a mo/ing target. Re)ent.y$ Wa-efie.d modified t'e &8 )on)eption by saying t'at it refers not to ('at a menta. disorder is but on.y to ('at most s)ientists t'in- it is. For examp.e$ 'e states t'at 0My )omments (ere intended to argue$ not t'at %# 8 Iposttraumati) stress disorderJ is a disorder$ but t'at t'e &8 ana.ysis is )apab.e of exp.aining ('y t'e symptom pi)ture in %# 8 is )ommon.y 6udged to be a disorder0 2*+++$ p. :+,3. A))ording to ad.er 2*+++3$ Wa-efie.dGs origina. goa. (as to 0define menta. disorders pres)ripti/e.y Iand toJ 'e.p us de)ide ('et'er someone is menta..y disordered or not. I&o(e/er$ 'is )urrent /ie(J a/oids ma-ing any pres)ripti/e ).aims$ instead fo)using on exp.aining t'e )on/entiona. ).ini)a. use of t'e disorder )on)ept Iand 'eJ 'as abandoned 'is origina. tas- to be pres)ripti/e and 'as no( sett.ed for being des)ripti/e on.y$ for examp.e$ te..ing us ('y a disorder is 6udged to be one0 2pp. ;::1;:;3. 8es)ribing 'o( peop.e 'a/e agreed to define a )on)ept is not t'e same as defining t'e )on)ept in s)ientifi) terms$ e/en if t'ose peop.e are s)ientists. #'us$ Wa-efie.dGs re/ised &8 )on)eption simp.y offers anot'er )riterion t'at peop.e 2).ini)ians$ s)ientists$ and .aypersons3 mig't use to 6udge ('et'er or not somet'ing is a menta. disorder. But )onsensus of opinion$ e/en among s)ientists$ is not s)ientifi) e/iden)e. #'erefore$ no matter 'o( a))urate.y t'is )riterion mig't des)ribe 'o( some or most peop.e define menta. disorder$ it is no more or no .ess s)ientifi) t'an ot'er )on)eptions t'at a.so are based on 'o( some peop.e agree to define menta. disorder. "t is no more s)ientifi) t'an t'e )on)eptions in/o./ing statisti)a. infre7uen)y$ ma.adapti/eness$ or so)ia. norm /io.ations. 2 ee a.so Widiger$ t'is boo-.3 CONTEMPORARY CONCEPTIONS' THE DSM DEFINITION OF MENTAL DISORDER Any dis)ussion of )on)eptions of psy)'opat'o.ogy 'as to in).ude a dis)ussion of t'e most inf.uentia. )on)eption of a..Et'at of t'e 8 M. #'e 8 M do)uments 0('at is )urrent.y un1 derstood by most s)ientists$ t'eorists$ resear)'ers$ and ).ini)ians to be t'e predominant forms of psy)'opat'o.ogy0 2Widiger$ t'is boo-3. First pub.is'ed in *+<9 and re/ised and expanded fi/e times sin)e$ t'e 8 M pro/ides t'e organi4ationa. stru)ture for /irtua..y e/ery textboo2in).uding t'is one3 on abnorma. psy)'o.ogy and psy)'opat'o.ogy$ as (e.. as a.most e/ery professiona. boo- on t'e assessment and treatment of psy)'o.ogi)a. prob.ems. 2 ee Widiger$ t'is boo-$ for a more detai.ed 'istory of psy)'iatri) ).assifi)ation and t'e 8 M.3 Just as a textboo- on psy)'opat'o.ogy s'ou.d begin by defining its -ey term$ so s'ou.d a taxonomy of menta. disorders. #o t'eir )redit$ t'e aut'ors of t'e 8 M attempted to do t'at. #'e diffi)u.ties in'erent in attempting to define psy)'opat'o.ogy and re.ated terms is ).ear.y

28 MADDU<5 GOSSELIN5 WINSTEAD i..ustrated by t'e definition of menta. disorder found in t'e .atest edition of t'e 8 M$ t'e 8 M1 ">1#R 2A%A$ 9,,,35 . . . a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress e.g., a painful symptom" or disability i.e., impairment in one or more important areas of functioning" or with a significantly increased risk ofsuffering death, pain, disability, or an important loss of freedom. !n addition, this syndrome or pattern must not be merely an e'pectable and culturally sanctioned response to a particular event, for e'ample, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. +either deviant behavior e.g., political, religious, or se'ual" nor conflicts that are primarily be& tween the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above, p. '''i" A.. of t'e )on)eptions of psy)'opat'o.ogy des)ribed pre/ious.y )an be found to some extent in t'is definitionEstatisti)a. de/iation 2i.e.$ not expe)tab.e3C ma.adapti/eness$ in).uding distress and disabi.ityC so)ia. norms /io.ationsC and some e.ements of t'e 'armfu. dysfun)tion )on)eption 2a dysfun)tion in t'e indi/idua.3$ a.t'oug' (it'out t'e f.a/or of e/o.utionary t'eory. For t'is reason$ it is a )ompre'ensi/e$ in).usi/e$ and sop'isti)ated )on)eption and probab.y as good as$ if not better t'an$ any proposed so far. Nonet'e.ess$ it )ontains t'e same prob.ems (it' sub6e)ti/ity as ot'er )on)eptions. For examp.e$ ('at is t'e meaning of ).ini)a..y signifi)ant and 'o( s'ou.d ).ini)a. signifi)an)e be measuredF 8oes ).ini)a. signifi)an)e refer to statisti)a. infre7uen)y$ ma.adapti/eness$ or bot'F &o( mu)' distress must peop.e experien)e or 'o( mu)' disabi.ity must peop.e ex'ibit before t'ey are said to 'a/e a menta. disorderF W'o 6udges a personGs degree of distress or disabi.ityF &o( do (e determine ('et'er a parti)u.ar response to an e/ent is expe)tab.e or )u.tura..y san)tionedF W'o determines t'isF &o( does one determine ('et'er de/iant be'a/ior or )onf.i)ts are primari.y bet(een t'e indi/idua. and so)ietyF W'at exa)t.y does t'is meanF W'at does it mean for a dysfun)tion to exist or o))ur in t'e indi/idua.F Certain.y a bio.ogi)a. dysfun)tion mig't be said to be .itera..y in t'e indi/idua.$ but does it ma-e sense to say t'e same of psy)'o.ogi)a. and be'a/iora. dysfun)tionsF "s it possib.e to say t'at a psy)'o.ogi)a. or be'a/iora. dysfun)tion )an o))ur in t'e indi/idua. apart from t'e so)io)u.tura. and interpersona. mi.ieu in ('i)' t'e person is a)tingF C.ear.y$ t'e 8 MGs )on)eption of menta. disorder raises as many 7uestions as do t'e )on)eptions it (as meant to supp.ant. CATEGORIES GERSUS DIMENSIONS #'e diffi)u.ty in'erent in t'e 8 M )on)eption of psy)'opat'o.ogy and ot'er attempts to distinguis' bet(een norma. and abnorma. or adapti/e and ma.adapti/e is t'at t'ey are )at1 egori)a. mode.s in ('i)' indi/idua.s are determined eit'er to 'a/e or not 'a/e a disorder. An a.ternati/e mode.$ o/er('e.ming.y supported by resear)'$ is t'e dimensiona. mode.. "n t'e dimensiona. mode.$ norma.ity and abnorma.ity$ as (e.. as effe)ti/e and ineffe)ti/e psy)'o.ogi)a. fun)tioning$ .ie a.ong a )ontinuumC so1)a..ed psy)'o.ogi)a. disorders are simp.y extreme /ariants of norma. psy)'o.ogi)a. p'enomena and ordinary prob.ems in .i/ing 2@eyes H Lope4$ 9,,9C

Widiger$ t'is boo-3. #'e dimensiona. mode. is )on)erned not (it' ).assifying peop.e or disorders but (it' identifying and measuring indi/idua. differen)es in psy)'o.ogi)a. p'enomena su)' as emotion$ mood$ inte..igen)e$ and persona. sty.es 2e.g.$ Lubins-i$ 9,,,3. =reat differen)es among indi/idua.s on t'e dimensions of interest are expe)ted$ su)' as t'e

3. CONCEPTIONS OF PSYCHOPATHOLOOY 30 differen)es (e find on forma. tests of inte..igen)e. As (it' inte..igen)e$ di/isions made bet(een norma.ity and abnorma.ity may be demar)ated for )on/enien)e or effi)ien)y but are not to be /ie(ed as indi)ati/e of true dis)ontinuity among types of p'enomena or types of peop.e. A.so$ statisti)a. de/iation is not /ie(ed as ne)essari.y pat'o.ogi)a.$ a.t'oug' extreme /ariants on eit'er end of a dimension 2e.g.$ intro/ersiMn1extra/ersiMn$ neuroti)ism$ inte..igen)e3 may be ma.adapti/e if t'ey .ead to inf.exibi.ity in fun)tioning. Empiri)a. e/iden)e for t'e /a.idity of a dimensiona. approa)' to psy)'o.ogi)a. ad6ustment is strongest in t'e area of persona.ity and persona.ity disorders 2Co-er H Widiger$ t'is boo-C Coste..o$ *++?C Maddux H Munde..$ 9,,<3. Fa)tor ana.yti) studies of persona.ity prob.ems among t'e genera. popu.ation and ).ini)a. popu.ations (it' persona.ity disorders demonstrate stri-ing simi.arity bet(een t'e t(o groups. "n addition$ t'ese fa)tor stru)tures are not )onsistent (it' t'e 8 MGs system of ).assifying disorders of persona.ity into )ategories 2Maddux H Munde..$ 9,,<3. #'e dimensiona. /ie( of persona.ity disorders a.so is supported by )ross1 )u.tura. resear)' 2A.ar)on$ Fou.-s$ H >a--ur$ *++B3. Resear)' on ot'er prob.ems supports t'e dimensiona. /ie(. tudies of t'e /arieties of norma. emotiona. experien)es 2e.g.$ !at.ey H Jen-ins$ *++93 indi)ates t'at ).ini)a. emotiona. disorders are not dis)rete ).asses of emotiona. experien)e t'at are dis)ontinuous from e/eryday emotiona. upsets and prob.ems. Resear)' on adu.t atta)'ment patterns in re.ations'ips strong.y suggests t'at dimensions are more usefu. des)riptions of su)' patterns t'an are )ategories 2Fra.ey H Wa..er$ *++B3. Resear)' on se.f1defeating be'a/iors 'as s'o(n t'at t'ey are extreme.y )ommon and are not by t'emse./es signs of abnorma.ity or symptoms of disorders 2Baumeister H )'er$ *+BB3. Resear)' on )'i.drenGs reading prob.ems indi)ates t'at dys.exia is not an a..1or1none )ondition t'at )'i.dren eit'er 'a/e or do not 'a/e$ but rat'er$ t'e )ondition o))urs in degrees (it'out a natura. brea- bet(een dys.exi) and nondys.exi) )'i.dren 2 'ay(it4$ Es)obar$ 'ay(it4$ F.et)'er$ H Ma-u)'$ *++93. Resear)' on attention defi)itL'ypera)ti/ity 2Bar-.ey$ *++D3 and posttraumati) stress disorder 2Ant'ony$ Lonigan$ H &e)'t$ *+++3 demonstrates t'is same dimensiona.ity. Resear)' on depression and s)'i4op'renia indi)ates t'at t'ese disorders are best /ie(ed as .oose.y re.ated ).usters of dimensions of indi/idua. differen)es$ not as disease1 .i-e syndromes 2C.aridge$ *++<C Coste..o$ *++:a$ *++:bC %ersons$ *+B?3. #'e )oiner of t'e term schi*ophrenia# Eugen B.eu.er$ /ie(ed so1)a..ed pat'o.ogi)a. )onditions as )ontinuous (it' so1 )a..ed norma. )onditions and noted t'e o))urren)e of s)'i4op'reni) symptoms among norma. indi/idua.s 2=i.man$ *+BB3. "n fa)t$ B.eu.er referred to t'e ma6or symptom of s)'i4op'renia 2t'oug't disorder3 as simp.y unge(N'n.i)'$ ('i)' in =erman means unusua.$ not bi4arre$ as it (as trans.ated in t'e first Eng.is' /ersion of B.eu.erGs ).assi) monograp' 2=i.man$ *+BB3. Essentia..y$ t'e )reation of s)'i4op'renia (as 0an artifa)t of t'e ideo.ogies imp.i)it in nineteent' )entury European and Ameri)an medi)a. noso.ogies0 2=i.man$ p. 9,;3. 2 ee a.so Wa.-er$ Bo..ini$ &o)'man$ H @est.er$ t'is boo-.3 Fina..y$ bio.ogi)a. resear)'ers )ontinue to dis)o/er )ontinuities bet(een so1)a..ed norma. and abnorma. 2or pat'o.ogi)a.3 psy)'o.ogi)a. )onditions 2C.aridge$ *++<C Li/es.ey$ Jang$ H >ernon$ *++B3. SOCIAL CONSTRUCTIONISM AND CONCEPTIONS OF PSYCHOPATHOLOGY "f (e )annot deri/e an ob6e)ti/e and s)ientifi) )on)eption of psy)'opat'o.ogy and menta. disorder$ t'en ('at (ay is .eft to us to understand t'ese termsF &o( t'en are (e to )on)ei/e of psy)'opat'o.ogyF #'e so.ution to t'is prob.em is not to de/e.op yet anot'er definition of psy)'opat'o.ogy. #'e so.ution$ instead$ is to a))ept t'e fa)t t'at t'e prob.em 'as no so.utionE at

.east not a so.ution t'at )an be arri/ed at by s)ientifi) means. We 'a/e to gi/e up t'e goa. of

32 MADDU<5 GOSSELIN5 WINSTEAD de/e.oping a s)ientifi) definition and a))ept t'e idea t'at psy)'opat'o.ogy and re.ated terms )annot be defined t'roug' t'e pro)esses t'at (e usua..y t'in- of as s)ientifi). We 'a/e to stop strugg.ing to de/e.op a s)ientifi) )on)eption of psy)'opat'o.ogy and attempt instead to try to understand t'e strugg.e itse.fE('y it o))urs and ('at it means. We need to better understand 'o( peop.e go about trying to )on)ei/e of and define psy)'opat'o.ogy and 'o( and ('y t'ese )on)eptions are t'e topi) of )ontinua. debate and undergo )ontinua. re/ision. We start by a))epting t'e idea t'at psy)'opat'o.ogy and re.ated )on)epts are abstra)t ideas t'at are not s)ientifi)a..y )onstru)ted but instead are so)ia..y )onstru)ted. #o do t'is is to engage in so)ia. )onstru)tionism$ ('i)' in/o./es 0e.u)idating t'e pro)ess by ('i)' peop.e )ome to de1 s)ribe$ exp.ain$ or ot'er(ise a))ount for t'e (or.d in ('i)' t'ey .i/e0 2=ergen$ *+B<$ pp. :1;3. o)ia. )onstru)tionism is )on)erned (it' 0examining (ays in ('i)' peop.e understand t'e (or.d$ t'e so)ia. and po.iti)a. pro)esses t'at inf.uen)e 'o( peop.e define (ords and exp.ain e/ents$ and t'e imp.i)ations of t'ese definitions and exp.anationsE('o benefits and ('o .oses be)ause of 'o( (e des)ribe and understand t'e (or.d0 2=ergen$ *+B<$ pp. :O*3. From t'is point of /ie($ (ords and )on)epts su)' as psychopathology and mental disorder 0are produ)ts of parti)u.ar 'istori)a. and )u.tura. understandings rat'er t'an... uni/ersa. and immutab.e )ategories of 'uman experien)e0 2Bo'an$ *++?$ p. x/i3. Uni/ersa. or true definitions of )on)epts do not exist be)ause t'ese definitions depend on ('o does t'e defining. #'e peop.e ('o define t'em are usua..y peop.e (it' po(er$ and so t'ese definitions ref.e)t and promote t'eir interests and /a.ues 2Mue'.en'ard H @imes$ *+++$ p. 9:;3. #'erefore$ 0W'en .ess po(erfu. peop.e attempt to )'a..enge existing po(er re.ations'ips and to promote so)ia. )'ange$ an initia. batt.eground is often t'e (ords used to dis)uss t'ese prob.ems0 2Mue'.en'ard H @imes$ *+++$ p. 9:;3. Be)ause t'e interests of peop.e and institutions are based on t'eir /a.ues$ debates o/er t'e definition of )on)epts often be)ome ).as'es bet(een deep.y and imp.i)it.y 'e.d be.iefs about t'e (ay t'e (or.d (or-s or s'ou.d (or- and about t'e differen)e bet(een rig't and (rong. u)' ).as'es are e/ident in t'e debates o/er t'e definitions of domestic violence 2Mue'.en'ard H @imes$ *+++3$ child se"ual abuse 2&o.mes H .app$ *++BC Rind$ #romo/i)'$ H Bauserman$ *++B3$ and ot'er su)' terms. #'e so)ia. )onstru)tionist perspe)ti/e )an be )ontrasted (it' t'e essentia.ist perspe)ti/e. Essentia.ism assumes t'at t'ere are natura. )ategories and t'at a.. members of a gi/en )ategory s'are important )'ara)teristi)s 2Rosenb.um H #ra/is$ *++?3. For examp.e$ t'e essentia.ist per1 spe)ti/e /ie(s our )ategories of ra)e$ sexua. orientation$ and so)ia. ).ass as ob6e)ti/e )ategories t'at are independent of so)ia. or )u.tura. pro)esses. "t /ie(s t'ese )ategories as representing 0empiri)a..y /erifiab.e simi.arities among and differen)es bet(een peop.e0 2Rosenb.um H #ra/is$ *++?$ p. 93. "n t'e so)ia. )onstru)tionist /ie($ 'o(e/er$ 0rea.ity )annot be separated from t'e (ay t'at a )u.ture ma-es sense of it0 2Rosenb.um H #ra/is$ *++?$ p. :3. "n so)ia. )onstru)tionism$ su)' )ategories represent not ('at peop.e are but rat'er t'e (ays t'at peop.e t'in- about and attempt to ma-e sense of differen)es among peop.e. o)ia. pro)esses a.so deter1 mine ('at differen)es among peop.e are more important t'an ot'er differen)es 2Rosenb.um H #ra/is$ *++?3. #'us$ from t'e essentia.ist perspe)ti/e$ psy)'opat'o.ogies and menta. disorders are natura. entities ('ose true nature )an be dis)o/ered and des)ribed. From t'e so)ia. )onstru)tionist perspe)ti/e$ 'o(e/er$ t'ey are but abstra)t ideas t'at are defined by peop.e and t'us ref.e)t t'eir /a.uesE)u.tura.$ professiona.$ and persona.. #'e meanings of t'ese and ot'er )on)epts are not

re/ea.ed by t'e met'ods of s)ien)e but are negotiated among t'e peop.e and institutions of so)iety ('o 'a/e an interest in t'eir definitions. "n fa)t$ (e typi)a..y refer to psy)'o.ogi)a. terms as )onstru)ts for t'is /ery reasonEt'at t'eir meanings are )onstru)ted and negotiated rat'er t'an dis)o/ered or re/ea.ed. #'e (ays in ('i)' )on)eptions of su)' basi) psy)'o.ogi)a. )onstru)ts as t'e se.f 2Baumeister$ *+BD3 and se.f1esteem 2&e(itt$ 9,,93 'a/e )'anged o/er

3. CONCEPTIONS OF PSYCHOPATHOLOGY 34 time and t'e different (ays t'ey are )on)ei/ed by different )u.tures 2e.g.$ Cross H Mar-us$ *+++C Cus'man$ *++<C &e(itt$ 9,,93 pro/ide an examp.e of t'is pro)ess at (or-. #'us 0a.. )ategories of disorder$ e/en p'ysi)a. disorder )ategories )on/in)ing.y exp.ored s)ientifi)a..y$ are t'e produ)t of 'uman beings )onstru)ting meaningfu. systems for understanding t'eir (or.d0 2Ras-in H Le(ando(s-i$ 9,,,$ p. 9*3. "n addition$ be)ause 0('at it means to be a person is determined by )u.tura. (ays of ta.-ing about and )on)eptua.i4ing person'ood... identity and disorder are so)ia..y )onstru)ted$ and t'ere are as many disorder )onstru)tions as t'ere are )u.tures.0 2Neimeyer H Ras-in$ 9,,,$ p. ?1D3. Fina..y$ 0if peop.e )annot rea)' t'e ob6e)ti/e trut' about ('at disorder rea..y is$ t'en /iab.e )onstru)tions of disorder must )ompete (it' one anot'er on t'e basis of t'eir use and meaningfu.ness in parti)u.ar ).ini)a. situations0 2Ras-in H Le(ando(s-i$ 9,,,$ p. 9?3. From t'e so)ia. )onstru)tionist perspe)ti/e$ so)io)u.tura.$ po.iti)a.$ professiona.$ and e)onomi) for)es inf.uen)e professiona. and .ay )on)eptions of psy)'opat'o.ogy. !ur )on)eptions of psy)'o.ogi)a. norma.ity and abnorma.ity are not fa)ts about peop.e but abstra)t ideas t'at are )onstru)ted t'roug' t'e imp.i)it and exp.i)it )o..aborations of t'eorists$ resear)'ers$ pro1 fessiona.s$ t'eir ).ients$ and t'e )u.ture in ('i)' a.. are embedded and t'at represent a s'ared /ie( of t'e (or.d and 'uman nature. For t'is reason$ menta. disorders and t'e numerous diagnosti) )ategories of t'e 8 M (ere not dis)o/ered in t'e same manner t'at an ar)'eo.o1gist dis)o/ers a buried artifa)t or a medi)a. resear)'er dis)o/ers a /irus. "nstead$ t'ey (ere in/ented 2see Ras-in H Le(ando(s-i$ 9,,,$ in Neimeyer H Ras-in3. By saying t'at menta. disorders are in/ented$ 'o(e/er$ (e do not mean t'at t'ey are myt's 2 4as4$ *+D;3 or t'at t'e distress of peop.e ('o are .abe.ed as menta..y disordered is not rea.. "nstead$ (e mean t'at t'ese disorders do not exist and 'a/e properties in t'e same manner t'at artifa)ts and /iruses do. #'erefore$ a )on)eption of psy)'opat'o.ogy 0does not simp.y des)ribe and ).assify )'ara)teristi)s of groups of indi/idua.s$ but... a)ti/e.y )onstru)ts a /ersion of bot' norma. and abnorma.... ('i)' is t'en app.ied to indi/idua.s ('o end up being ).assified as norma. or abnorma.0 2%ar-er$ =eorga)a$ &arper$ M)Laug'.in$ H to(e..1 mit'$ *++<$ p. +:3. Con)eptions of psy)'opat'o.ogy and t'e /arious )ategories of psy)'opat'o.ogy are not mappings of psy)'o.ogi)a. fa)ts about peop.e. "nstead$ t'ey are so)ia. artifa)ts t'at ser/e t'e same so)io)u.tura. goa.s as do our )on)eptions of ra)e$ gender$ so)ia. ).ass$ and sexua. orientationEt'ose of maintaining and expanding t'e po(er of )ertain indi/idua.s and insti1 tutions and maintaining so)ia. order$ as defined by t'ose in po(er 2Bea..$ *++:C %ar-er et a..$ *++<C Rosenb.um H #ra/is$ *++?3. As are t'ese ot'er so)ia. )onstru)tions$ our )on)epts of psy)'o.ogi)a. norma.ity and abnorma.ity are tied u.timate.y to so)ia. /a.uesEin parti)u.ar$ t'e /a.ues of so)ietyGs most po(erfu. indi/idua.s$ groups$ and institutionsEand t'e )ontextua. ru.es for be'a/ior deri/ed from t'ese /a.ues 2Be)-er$ *+?:C %ar-er et a..$ *++<C Rosenb.um H #ra/is$ *++?3. As M)Namee and =ergen 2*++93 state5 0#'e menta. 'ea.t' profession is not po.iti)a..y$ mora..y$ or /a.uationa..y neutra.. #'eir pra)ti)es typi)a..y operate to sustain )ertain /a.ues$ po.iti)a. arrangements$ and 'ierar)'ies of pri/i.ege0 2p. 93. #'us$ t'e debate o/er t'e definition of psy)'opat'o.ogy$ t'e strugg.e o/er ('o defines it$ and t'e )ontinua. re/isions of t'e 8 M are not aspe)ts of a sear)' for trut'. Rat'er$ t'ey are debates o/er t'e definition of so)ia..y )onstru)ted abstra)tions and strugg.es for t'e persona.$ po.iti)a.$ and e)onomi) po(er t'at deri/es from t'e aut'ority to define t'ese abstra)tions and t'us to determine ('at and ('om so)iety /ie(s as norma. and abnorma..

#'ese debates and strugg.es are des)ribed in detai. by A..an &or(it4 in 1reating Mental 0llness 29,,93. A))ording to &or(it45 The emergence and persistence of an overly e'pansive disease model of mental illness was not accidental or arbitrary. The widespread creation of distinct mental diseases developed in specific

36 MADDU<5 GOSSELIN5 WINSTEAD historical circumstances and because of the interests of specific social groups.. .,y the time the -./&!!!was developed in 0123, thinking ofmental illnesses as discrete disease entities ... offered mental health professionals many social, economic, andpolitical advantages. !n addition, applying disease frameworks to a wide variety of behaviors and to a large number of people benefited a number of specific social groups including not only clinicians but also research scientists, advocacy groups, and pharmaceutical companies, among others. The disease entities of diagnostic psychiatry arose because they were useful for the social practices of various groups, not because they provided a more accurate way of viewing mental disorders, p. 04" %sy)'iatrist Mit)'e.. Wi.son 2*++:3 'as offered a simi.ar position. &e 'as argued t'at t'e dimensiona.L)ontinuity /ie( of psy)'o.ogi)a. (e..ness and i..ness posed a basi) prob.em for psy)'iatry be)ause it 0did not demar)ate ).ear.y t'e (e.. from t'e si)-0 2p. ;,93 and t'at 0if )on)ei/ed of psy)'oso)ia.O$ psy)'iatri) i..ness is not t'e pro/in)e of medi)ine$ be)ause psy)'iatri) prob.ems are not tru.y medi)a. but so)ia.$ po.iti)a.$ and .ega.0 2p. ;,93. #'e purpose of 8M 1"""$ a))ording to Wi.son$ (as to a..o( psy)'iatry a means of mar-ing out its professiona. territory. @ir- and @ut)'ins 2*++93 rea)'ed t'e same )on).usion fo..o(ing t'eir t'oroug' re/ie( of t'e papers$ .etters$ and memos of t'e /arious 8 M (or-ing groups. #'e so)ia. )onstru)tion of psy)'opat'o.ogy (or-s somet'ing .i-e t'is. omeone obser/es a pattern of be'a/ing$ t'in-ing$ fee.ing$ or desiring t'at de/iates from some so)ia. norm or idea. or identifies a 'uman (ea-ness or imperfe)tion t'at$ as expe)ted$ is disp.ayed (it' greater fre7uen)y or se/erity by some peop.e t'an ot'ers. A group (it' inf.uen)e and po(er de)ides t'at )ontro.$ pre/ention$ or treatment of t'is prob.em is desirab.e or profitab.e. #'e pattern is t'en gi/en a s)ientifi)1sounding name$ preferab.y of =ree- or Latin origin. #'e ne( s)ientifi) name is )apita.i4ed. E/entua..y$ t'e ne( term may be redu)ed to an a)ronym$ su)' as !C8 2!bsessi/e1 Compu.si/e 8isorder3$ A8&8 2Attention18efi)itL&ypera)ti/ity 8isorder3$ and B88 2Body 8ysmorp'i) 8isorder3. #'e ne( disorder t'en ta-es on an existen)e a.. its o(n and be)omes a disease1.i-e entity. As ne(s about t'e disorder spreads$ peop.e begin t'in-ing t'ey 'a/e itC medi)a. and menta. 'ea.t' professiona.s begin diagnosing and treating itC and ).ini)ians and ).ients begin demanding t'at 'ea.t' insuran)e po.i)ies )o/er t'e treatment of it. !n)e t'e disorder 'as been so)ia..y )onstru)ted and defined$ t'e met'ods of s)ien)e )an be used to study it$ but t'e )onstru)tion itse.f is a so)ia. pro)ess$ not a s)ientifi) one. "n fa)t$ t'e more 0it0 is studied$ t'e more e/eryone be)omes )on/in)ed t'at 0it0 is a /a.id 0somet'ing.0 Medi)a. p'i.osop'er La(rie Re4ne- 2*+BD3 'as demonstrated t'at e/en our definition of p'ysi)a. disease is so)ia..y )onstru)ted. &e (rites5 5udging that some condition is a disease is to 6udge that the person with that condition is less able to lead a good or worthwhile life. #nd since this latter 6udgment is a normative one, to 6udge that some condition is a disease is to make a normative 6udgment... This normative view of the concept of disease e'plains why cultures holding different values disagree over what are diseases p. 200". . . Whether some condition is a disease depends on where we choose to

draw the line of normality, and this is not a line that we can discover, p. 202"... disease 6udgments, like moral 6udgments, are not factual ones. Li-e(ise$ edg(i)- 2*+B93 points out t'at 'uman diseases are natura. pro)esses. #'ey may 'arm 'umans$ but t'ey a)tua..y promote t'e .ife of ot'er organisms. For examp.e$ a /irusGs reprodu)ti/e strategy may in).ude spreading from 'uman to 'uman. edg(i)- (rites5 There are no illnesses or diseases in nature. The fracture of a septuagenarian(s femur has, within the world ofnature, no more significance than the snapping ofan autumn leaf from its twig7 and the

3. CONCEPTIONS OF PSYCHOPATHOLOGY 38 invasion of a human organism by cholera germs carries with it no more the stamp of 8illness 8 than does the souring of milk by other forms of bacteria. 9ut of his anthropocentric self&interest, man has chosen to consider as 8illnesses 8 or 8diseases 8 those natural circumstances which precipitate death or the failure to function according to certain values", p. )3" "f t'ese statements are true of p'ysi)a. disease$ t'ey are )ertain.y true of psy)'o.ogi)a. disease or psy)'opat'o.ogy. Li-e our )on)eption of p'ysi)a. disease$ our )on)eptions of psy1)'opat'o.ogy are so)ia. )onstru)tions t'at are grounded in so)io)u.tura. goa.s and /a.ues$ parti)u.ar.y our assumptions about 'o( peop.e s'ou.d .i/e t'eir .i/es and about ('at ma-es .ife (ort' .i/ing. 2 ee a.so Lope4 H =uarna))ia$ t'is boo-$ and Widiger$ t'is boo-.3 #'is trut' is i..ustrated ).ear.y in t'e Ameri)an %sy)'iatri) Asso)iationGs *+<9 de)ision to in).ude 'omosexua.ity in t'e first edition of t'e 8 M and its *+D: de)ision to re/o-e its disease status 2@ut)'ins H @ir-$ *++DC 'orter$ *++D3. As stated by Wi.son 2*++:3$ 0#'e 'omosexua.ity )ontro/ersy seemed to s'o( t'at psy)'iatri) diagnoses (ere ).ear.y (rapped up in so)ia. )onstru)tions of de/ian)e0 2p. ;,;3. #'is issue a.so (as in t'e forefront of t'e debates o/er posttraumati) stress disorder$ parap'i.i) rapism$ and maso)'isti) persona.ity disorder 2@ut)'ins H @ir-$ *++D3$ as (e.. as )affeine dependen)e$ sexua. )ompu.si/ity$ .o( intensity orgasm$ sib.ing ri/a.ry$ se.f1defeating persona.ity$ 6et .ag$ pat'o.ogi)a. spending$ and impaired s.eep1re.ated painfu. ere)tions$ a.. of ('i)' (ere proposed for in).usion in 8 M1"> 2Widiger H #ru..$ *++*3. !t'ers 'a/e argued )on/in)ing.y t'at s)'i4op'renia 2=i.man$ *+BB3$ addi)tion 2%ee.e$ *++<3$ persona.ity disorder 2A.ar)on et a..$ *++B3$ and disso)iati/e identity disorder 2former.y mu.tip.e persona.ity disorder3 2 panos$ *++?3 a.so are so)ia..y )onstru)ted )ategories rat'er t'an disease entities. Wit' ea)' re/ision$ our most po(erfu. professiona. )on)eption of psy)'opat'o.ogy$ t'e 8 M$ 'as 'ad more and more to say about 'o( peop.e s'ou.d .i/e t'eir .i/es and about ('at ma-es .ife (ort' .i/ing. #'e number of pages in)reased from B? in *+<9 to a.most +,, in *++;$ and t'e number of menta. disorders in)reased from *,? to 9+D. As t'e s)ope of menta. disorder 'as expanded (it' ea)' 8 M re/ision$ .ife 'as be)ome in)reasing.y pat'o.ogi4ed$ and t'e s'eer number of peop.e (it' diagnosab.e menta. disorders 'as )ontinued to gro(. Moreo/er$ menta. 'ea.t' professiona.s 'a/e not been )ontent to .abe. on.y ob/ious.y and b.atant.y dysfun)tiona. patterns of be'a/ing$ t'in-ing$ and fee.ing as menta. disorders. "nstead$ (e 'a/e denned t'e s)ope of psy)'opat'o.ogy to in).ude many )ommon prob.ems in .i/ing. Consider some of t'e menta. disorders found in t'e 8 M1"> Cigarette smo-ers 'a/e Ni)otine 8ependen)e. "f you drin- .arge 7uantities of )offee$ you may de/e.op Caffeine "ntoxi)ation or Caffeine1"ndu)ed .eep 8isorder. "f you 'a/e 0a preo))upation (it' a defe)t in appearan)e0 t'at )auses 0signifi)ant distress or impairment in... fun)tioning0 2p. ;??3$ you 'a/e a Body 8ysmorp'i) 8isorder. A )'i.d ('ose a)ademi) a)'ie/ement is 0substantia..y be.o( t'at expe)ted for age$ s)'oo.ing$ and .e/e. of inte..igen)e0 2p. ;?3 'as a Learning 8isorder. #odd.ers ('o t'ro( tantrums 'a/e !ppositiona. 8efiant 8isorder. Not (anting sex often enoug' is &ypoa)ti/e exua. 8esire 8isorder. Not (anting sex at a.. is exua. A/ersion 8isorder. &a/ing sex but not 'a/ing orgasms or 'a/ing t'em too .ate or too soon is an !rgasmi) 8isorder. Fai.ure 2for men3 to maintain 0an ade7uate ere)tion... t'at )auses mar-ed distress or interpersona. diffi)u.ty0 2p. <,;3 is Ma.e Ere)ti.e 8isorder. Fai.ure 2for (omen3 to attain or maintain 0an ade7uate .ubri)ation or s(e..ing response of sexua. ex)itement0 2p. <,93 a))ompanied by distress

is Fema.e exua. Arousa. 8isorder. #'e past fe( years 'a/e (itnessed media reports of epidemi)s of internet addi)tion$ road rage$ pat'o.ogi)a. sto)- mar-et day trading$ and 0s'opa'o.ism.0 8is)ussions of t'ese ne( disorders 'a/e turned up at s)ientifi) meetings and in )ourtrooms. #'ey are .i-e.y to find a

40 MADDU<5 GOSSELIN5 WINSTEAD 'ome in t'e next re/ision of t'e 8 M if t'e media$ menta. 'ea.t' professions$ and so)iety at .arge )ontinue to )o..aborate in t'eir )onstru)tion and if treating t'em and (riting boo-s about t'em be)ome .u)rati/e. #'ose adopting t'e so)ia. )onstru)tionist perspe)ti/e do not deny t'at 'uman beings experien)e be'a/iora. and emotiona. diffi)u.ties$ sometimes /ery serious ones. #'ey insist$ 'o(e/er$ t'at su)' experien)es are not e/iden)e for t'e existen)e of entities )a..ed menta. disorders t'at t'en exp.ain t'ose be'a/iora. and emotiona. diffi)u.ties. #'e be.ief in t'e existen)e of t'ese entities is t'e produ)t of t'e a..1too1'uman tenden)y to so)ia..y )onstru)t )ategories in an attempt to ma-e sense of a )onfusing (or.d. SUMMARY AND CONCLUSIONS #'e debate o/er t'e )on)eption or definition of psy)'opat'o.ogy and re.ated terms 'as been going on for de)ades and (i.. )ontinue$ 6ust as (e (i.. a.(ays 'a/e debates o/er t'e definitions of trut'$ beauty$ 6usti)e$ and art. !ur position is t'at psy)'opat'o.ogy and menta. disorder are not t'e -inds of terms ('ose true meanings )an be dis)o/ered or defined ob6e)ti/e.y by using t'e met'ods of s)ien)e. #'ey are so)ia. )onstru)tionsEabstra)t ideas ('ose meanings are negotiated among t'e peop.e and institutions of a )u.ture and t'at ref.e)t t'e /a.ues and po(er stru)ture of t'at )u.ture at a gi/en time. #'us$ t'e )on)eption and definition of psy)'opat'o.ogy a.(ays 'as been and a.(ays (i.. be debated and a.(ays 'as been and a.(ays (i.. be )'anging. "t is not a stati) and )on)rete t'ing ('ose true nature )an be dis)o/ered and des)ribed on)e and for a... By saying t'at )on)eptions of psy)'opat'o.ogy are so)ia..y )onstru)ted rat'er t'an s)ientifi)a..y deri/ed$ (e are not proposing$ 'o(e/er$ t'at 'uman psy)'o.ogi)a. distress and suffering are not rea. or t'at t'e patterns of t'in-ing$ fee.ing$ and be'a/ing t'at so)iety de)ides to .abe. psy)'opat'o.ogi)a. )annot be studied ob6e)ti/e.y and s)ientifi)a..y. "nstead$ (e are saying t'at it is time to a)-no(.edge t'at s)ien)e )an no more determine t'e proper or )orre)t )on)eption of psy)'opat'o.ogy and menta. disorder t'an it )an determine t'e proper and )orre)t )on)eption of ot'er so)ia. )onstru)tions su)' as beauty$ 6usti)e$ ra)e$ and so)ia. ).ass. We )an nonet'e.ess use s)ien)e to study t'e p'enomena t'at our )u.ture refers to as psy)'opat'o.ogi)a.. We )an use t'e met'ods of s)ien)e to understand a )u.tureGs )on)eption of menta. or psy)'o.ogi)a. 'ea.t' and disorder$ 'o( t'is )on)eption 'as e/o./ed$ and 'o( it affe)ts indi/idua.s and so)iety. We a.so )an use t'e met'ods of s)ien)e to understand t'e origins of t'e patterns of t'in-ing$ fee.ing$ and be'a/ing t'at a )u.ture )onsiders psy)'opat'o.ogi)a. and to de/e.op and test (ays of modifying t'ose patterns. %sy)'o.ogy and psy)'iatry (i.. not be diminis'ed by a)-no(.edging t'at t'eir basi) )on)epts are so)ia..y and not s)ientifi)a..y )onstru)tedEany more t'an medi)ine is diminis'ed by a)-no(.edging t'at t'e notions of 'ea.t' and i..ness are so)ia..y )onstru)ted 2Re4ne-$ *+BD3$ nor e)onomi)s by a)-no(.edging t'at t'e notions of po/erty and (ea.t' are so)ia..y )onstru)ted. )ien)e )annot pro/ide us (it' pure.y fa)tua. s)ientifi) definitions of t'ese )on)epts. #'ey are f.uid and negotiated matters of /a.ue$ not fixed matters of fa)t. As Li.ienfe.d and Marino 2*++<3 'a/e said5 :emoving the imprimatur of science... would simply make the value 6udgments underlying these decisions more e'plicit and open to criticism... heated disputes would almost surely arise concerning which conditions are deserving of attention from mental health professionals. .uch disputes, however, would at least be

settled on the legitimate basis of social values and e'igencies, rather than on the basis of ill&defined criteria of doubtful scientific status, pp. ;02&;01"

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CHAPTER

C$%t$ra% Di(ensi#ns #6 Psy./#*at/#%#&y' T/e S#.ia% W#r%dBs I(*a.t #n Menta% I%%ness Ste,en Re&eser L#*eC University o f 1alifornia Peter 7. G$arna..ia (utgers# The 'tate University o f -ew ersey !/er t'e past se/era. de)ades$ resear)'ers 'a/e in)reasing.y examined )u.tura. inf.uen)es in psy)'opat'o.ogy. &o(e/er$ for mu)' of t'is period$ t'e study of )u.ture and menta. disorders (as a margina. fie.d of in7uiry. As (e demonstrate in t'is )'apter$ )u.tura. issues 'a/e mo/ed to t'e fore in t'e study of psy)'opat'o.ogy. A .andmar- e/ent mar-ing t'is transition )ame in *+DD ('en @.einman 'era.ded t'e beginning of a 0ne( )ross1)u.tura. psy)'iatry$0 an interdis)ip.inary resear)' approa)' integrating ant'ropo.ogi)a. met'ods and )on)eptua.i4ations (it' traditiona. psy)'iatri) and psy)'o.ogi)a. approa)'es. Menta. 'ea.t' resear)'ers (ere en)ouraged to respe)t indigenous i..ness )ategories and to re)ogni4e t'e .imitations of traditiona. i..ness )ategories$ su)' as depression and s)'i4op'renia. A.so$ t'e ne( )ross1)u.tura. psy)'iatry distinguis'ed bet(een disease$ a 0ma.fun)tioning or ma.adaptation of bio.ogi)a. or psy)'o.ogi)a. pro)esses$0 and i..ness$ 0t'e persona.$ interpersona.$ and )u.tura. rea)tion to disease0 2p. +3. #'e perspe)ti/e t'at @.einman and ot'ers 2Fabrega$ *+D<C @.einman$ Eisenberg$ H =ood$ *+DB3 arti)u.ated in t'e se/enties ref.e)ted an important dire)tion for t'e study of )u.ture and psy)'opat'o.ogyEto understand t'e so)ia. (or.d (it'in menta. i..ness. 2 ee a.so 8raguns$ *+B,$ and Marse..a$ *+B,3. Many ad/an)es (ere made during t'e first de)ade of t'e ne( )ross1)u.tura. psy)'iatry. !ne (as t'e estab.is'ment of t'e interdis)ip.inary 6ourna. 1ulture# Medicine# and +sychiatry. #'is ne(.y founded 6ourna.$ in )on6un)tion (it' Transcultural +sychiatry in Canada 2former.y Tran3 scultural +sychiatric (esearch (eview=# pro/ided and )ontinues to pro/ide an important forum for )u.tura. resear)'. A.so$ during t'e eig'ties$ .arge1s)a.e epidemio.ogi)a. studies (ere )arried out. #'e se)ond mu.tinationa. Wor.d &ea.t' !rgani4ation 2W&!3 study of s)'i4op'renia (as .aun)'ed and pre.iminary findings (ere reported 2 artorius et a..$ *+B?3. #'e Epidemio.ogi)a. Cat)'ment Area 2ECA3 studies (ere )ondu)ted as (e.. 2Regier et a..$ *+B;3. ome may 7uestion 'o( )u.tura..y informed t'ese ).assi) studies (ere 2Edgerton H Co'en$ *++;C Fabrega$ *++,C =uarna))ia$ @.einman$ H =ood$ *++,3. &o(e/er$ most re/ie(s of )u.ture$ 46

47 LLPEF AND GUARNACCIA et'ni)ity$ and menta. disorders today refer to t'e findings from t'e W&! and ECA studies to address 'o( so)ia.$ et'ni)$ and )u.tura. fa)tors are re.ated to t'e distribution of psy)'opat'o.1 ogy. A.so during t'is time$ t'e Nationa. "nstitute of Menta. &ea.t' 2N"M&3 funded resear)' )enters (it' t'e so.e purpose of )ondu)ting resear)' on and for spe)ifi) et'ni) minority groups 2Afri)an Ameri)ans$ Ameri)an "ndians$ Latino Ameri)ans$ and Asian Ameri)ans3. ome of t'e resear)' from t'ese )enters )ontributed to t'e gro(ing )u.tura. psy)'opat'o.ogy database 2e.g.$ Cer/antes$ %adi..a$ H a.gado de nyder$ *++*C @ing$ *+DBC Manson$ 'ore$ H B.oom$ *+B<C Neig'bors$ Ja)-son$ Campbe..$ H Wi.son$ *+B+C Rog.er$ Ma.gady$ H Rodrigue4$ *+B+3. 8ia.ogues a)ross dis)ip.ines (ere a.so initiated during t'is time. For examp.e$ @.einman and =oodGs 2*+B<3 inf.uentia. boo-$ 1ulture and Depression# broug't toget'er t'e resear)' not on.y of ant'ropo.ogists$ but a.so of psy)'o.ogists and psy)'iatrists. Anot'er signifi)ant indi)ator of t'e fie.dGs de/e.opment (as and )ontinues to be its su))ess in attra)ting ne( in/estigators$ as suggested by &ar/ardGs .ong1standing )u.tura. ant'ropo.ogy and menta. 'ea.t' training grant 2for a summary see @.einman$ *+BB3. "ndeed$ t'ese first ten years )an be )'ara)teri4ed as an ex)iting and ferti.e time for t'e study of )u.tura. psy)'opat'o.ogy. 8espite t'e many ad/an)es$ t'e fie.dGs main )on)epts (ere not rea)'ing .arger audien)es. "n/estigators (ere )ommuni)ating primari.y among t'emse./es in t'eir spe)ia.ty 6ourna.s and boo-s. #'ose findings t'at (ere pub.is'ed in (ide.y distributed mainstream 6ourna.s (ere s)attered among a broad array of 6ourna.s. #'us$ from t'e perspe)ti/e of mainstream in/estigators$ t'e de/e.opments of t'e ne( )ross1)u.tura. psy)'iatry (ent .arge.y unnoti)ed. !n a rare o))asion$ one (ou.d find a spe)ia. issue on )u.tura. resear)' in a mainstream 6ourna. Be.g.# ournal of 1onsulting and 1linical +sychology# *+BD3. "n an effort to bring t'e fie.dGs )on)epts to a broader audien)e 2genera. psy)'iatry and ot'er menta. 'ea.t' fie.ds3$ @.einman 2*+BB3 pro/ided a )ompre'ensi/e re/ie( of )u.ture$ psy)'opat'o.ogy$ and re.ated resear)'. 8ra(ing on empiri)a. data and t'eory$ @.einman argued t'at )u.ture matters for t'e study and treatment of menta. disorders. #'is boo- ser/es as a signifi)ant mar-er in t'e de/e.opment of t'e ne( )ross1)u.tura. psy)'iatry$ ('i)' (e refer to 'ere as t'e study of )u.tura. psy)'opat'o.ogy. )EY DEGELOPMENTS C#n.e*t$a% C#ntrib$ti#ns Definition o f 1ulture. Centra. to t'e study of )u.tura. psy)'opat'o.ogy is t'e definition of culture. Mu)' of t'e past and e/en )urrent resear)' re.ies on a definition of )u.ture t'at is outdated. "n fa)t$ Betan)ourt and Lope4 2*++:3 (rote a )riti)a. re/ie( of )u.ture and psy)'o1 .ogi)a. resear)' in ('i)' )u.ture (as defined as t'e /a.ues$ be.iefs$ and pra)ti)es t'at pertain to a gi/en et'no)u.tura. group. #'e strengt' of t'is definition is t'at it begins to unpa)- )u.ture. "nstead of arguing t'at a gi/en expression of distress pertains to a gi/en et'no)u.tura. group$ for examp.e$ resear)'ers argue t'at t'e expression of distress is re.ated to a spe)ifi) /a.ue or be.ief orientation. We see t'is )'ange as a signifi)ant ad/an)ement. "t 'e.ps resear)'ers begin to operationa.i4e ('at about )u.ture matters in t'e spe)ifi) )ontext. Furt'ermore$ it re)ogni4es t'e 'eterogeneity (it'in spe)ifi) et'no)u.tura. groups. @no(ing t'at someone be.ongs to a spe)ifi) et'ni) group pro/ides guide.ines to potentia. )u.tura. issues in psy)'opat'o.ogy$ but it does not imp.y t'at t'at person ad'eres to a.. t'e )u.tura. /a.ues and pra)ti)es of t'at group. #'e definition of )u.ture as /a.ues$ be.iefs$ and pra)ti)es 'as important .imitations 2Le(is1 Fernande4 H @.einman$ *++<3. !ne is t'at it depi)ts )u.ture as residing .arge.y (it'in indi1

/idua.s. #'e emp'asis on /a.ues and be.iefs points out t'e psy)'o.ogi)a. nature of )u.ture.

. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 49 We argue t'at )u.ture is manifested in t'e intera)tion bet(een peop.e and is 'ig'.y so)ia. in nature. ituating pra)ti)es 2)ustoms and ritua.s3 (it' /a.ues and be.iefs gi/es t'e impression t'at t'e pra)ti)es in t'e so)ia. (or.d are a fun)tion of /a.ues and be.iefs. For examp.e$ peop.e are t'oug't to re.y on t'eir fami.y in times of )risis be)ause t'ey are 'ig' in fami.ism or fami.y orientation. "n/estigators rare.y examine ('at about t'e so)ia. (or.d fa)i.itates or fosters re.ian)e on fami.y members. %er'aps 'ars' en/ironmenta. )onditions )ontribute to fami.ies )oming toget'er to o/er)ome ad/ersity. W'en app.ying t'e /a.ues and be.iefs definition of )u.ture$ t'e so)ia. (or.d is sub6ugated to t'e psy)'o.ogi)a. (or.d of t'e indi/idua.. Contrary to t'is perspe)ti/e$ (e argue t'at it is a)tion in t'e so)ia. and p'ysi)a. (or.d t'at produ)es )u.ture as mu)' as peop.eGs ideas about t'e (or.d. "n our /ie($ t'e so)ia. (or.d intera)ts e7ua..y (it' t'e psy)'o.ogi)a. (or.d in produ)ing 'uman be'a/ior. A se)ond .imitation of t'is fre7uent.y used definition of )u.ture is t'at it depi)ts )u.ture as a stati) p'enomenon. We be.ie/e t'at )u.ture is a pro)ess. Cu.ture is a dynami) and )reati/e pro)ess 2=arro$ 9,,*C =reenfie.d$ *++D3$ some aspe)ts of ('i)' are s'ared by .arge groups of indi/idua.s resu.ting from parti)u.ar .ife )ir)umstan)es and 'istories. =i/en t'e )'anging nature of our so)ia. (or.d and gi/en t'e efforts of indi/idua.s to adapt to su)' )'anges$ )u.ture )an best be /ie(ed as an ongoing pro)ess$ a system or set of systems in f.ux. #'erefor$ attempts to free4e )u.ture into a set of genera.i4ed /a.ue orientations or be'a/iors (i.. )ontinua..y misrepresent )u.ture. A re.ated .imitation of t'e /a.ues1based definition of )u.ture is t'at it depi)ts peop.e as re)ipients of )u.ture from a genera.i4ed so)iety (it' .itt.e re)ognition of indi/idua.sG ro.es in negotiating t'eir )u.tura. (or.ds. More re)ent approa)'es to )u.ture in ant'ropo.ogy$ ('i.e not dis)arding t'e importan)e of a personGs )u.tura. in'eritan)e of ideas$ /a.ues$ and (ays of re.ating$ 'a/e fo)used e7ua..y on t'e emergen)e of )u.ture from t'e .ife experien)es of indi/idua.s and sma.. groups. %eop.e )an )'ange$ add to$ or re6e)t )u.tura. e.ements t'roug' so)ia. pro)esses su)' as migration and a))u.turation. A /iab.e definition of )u.ture a)-no(.edges t'e agen)y of indi/idua.s in estab.is'ing t'eir so)ia. (or.ds. "n sum$ )urrent /ie(s of )u.ture attend mu)' more to peop.eGs so)ia. (or.d t'an did past /ie(s of )u.ture t'at emp'asi4ed t'e indi/idua.. !f parti)u.ar interest are peop.eGs dai.y routines and 'o( su)' a)ti/ities are tied to fami.ies$ neig'bor'oods$ /i..ages$ and so)ia. net(or-s. By examining peop.eGs dai.y routines$ one )an identify ('at matters most to peop.e 2=a..imore$ =o.denberg$ H Weisner$ *++:3 or ('at is most at sta-e for peop.e 2Ware H @.einman$ *++93. Furt'ermore$ t'is perspe)ti/e )aptures t'e dynami) nature of )u.ture as a produ)t of group /a.ues$ norms$ and experien)es$ as (e.. as of indi/idua. inno/ations and .ife 'istories. #'e use of t'is broader definition of )u.ture s'ou.d 'e.p guide in/estigators a(ay from f.at$ unidimensiona. notions of )u.ture$ to dis)o/er t'e ri)'ness of a )u.tura. ana.ysis for t'e study of psy)'opat'o.ogy. An important )omponent of t'is perspe)ti/e is t'e examination of intra1)u.tura. di/ersity. "n parti)u.ar$ so)ia. ).ass$ po/erty$ and gender )ontinue to affe)t different .e/e.s of menta. 'ea.t' bot' (it'in )u.tura. groups and a)ross )u.tura. groups. Goals o f 1ultural (esearch. Cu.ture is important in a number of domains (it'in psy)'opat'o.ogy resear)'. "t is important in t'e expression and measurement of disorder and distressC a )u.tura. ana.ysis )an point out t'e /ariabi.ity in t'e manner in ('i)' menta. i..ness is manifested. o)ia. and )u.tura. fa)tors )an a.so affe)t t'e pre/a.en)e of disorder by differentia..y p.a)ing some at more ris- t'an ot'ers for de/e.oping psy)'opat'o.ogy. "n addition$ t'e )ourse of

disorder$ as ref.e)ted in t'e degree of disabi.ity or in t'e number of ).ini)a. re.apses$ is a.so re.ated to important )u.tura. fa)tors. We en)ourage a.. of t'ese .ines of in7uiry. Regard.ess of t'e spe)ifi) domain of resear)'$ t'ere are t(o metagoa.s of )u.tura. resear)'. ome (riters imp.y t'at )u.tura. resear)' s'ou.d test t'e genera.ity of gi/en t'eoreti)a. notions.

51 LLPEF AND GUARNACCIA For examp.e$ in a t'oug'tfu. ana.ysis of )u.tura. resear)'$ C.ar- 2*+BD3 noted5 0Con)eptua. progress in psy)'o.ogy re7uires a unified base for in/estigating psy)'o.ogi)a. p'enomena$ (it' )u.ture1re.e/ant /ariab.es in).uded as part of t'e matrix0 2p. ;?<3. From C.ar-Gs point of /ie($ )ross1)u.tura. (or- )an ser/e to en'an)e t'e genera.ity of gi/en )on)eptua. mode.s by adding$ ('en ne)essary$ )u.tura. /ariab.es to an existing t'eoreti)a. mode. to exp.ain bet(een group and (it'in group /arian)e. A.t'oug' C.ar- a)-no(.edges t'e possibi.ity t'at a )onstru)t de/e.oped in one )ountry may not 'a/e a )ounterpart in anot'er )ountry$ at no time does s'e dis)uss t'e /a.ue of deri/ing mode.s of distin)t ).ini)a. entities found in on.y one )ountry$ et'no)u.tura. group or one group mar-ed by spe)ifi) so)ia. or 'istori)a. fa)tors. #'is approa)' suggests t'at for C.ar-$ t'e main purpose of studying )u.ture is to en'an)e t'e /a.idity of existing psy)'o.ogi)a. mode.s by attending to )ross1)u.tura. /ariations. "n )ontrast$ bot' Fabrega 2*++,3 and Rog.er 2*+B+3 )riti)i4e resear)'ers for paying .itt.e attention to t'e )u.tura. spe)ifi)ity of menta. i..ness and menta. 'ea.t'. Fabrega examines resear)'ersG use of mainstream instruments and )on)eptua.i4ations in studying menta. disorders among Latinos and )'a..enges su)' resear)'ers to be bo.d in t'eir )riti7ues of 0estab.is'ment psy)'iatry.0 Rog.er re)ommends a frame(or- for mainstream psy)'iatri) resear)'ers t'at attends more fu..y to )u.ture. For bot' Fabrega and Rog.er$ t'e ris- of o/er.oo-ing )u.tura. /ariations is mu)' greater in )urrent psy)'opat'o.ogy resear)' t'an t'e ris- of o/er.oo-ing )u.tura. simi.arities. Fo)using on )u.ture1spe)ifi) p'enomena at t'is time is of )entra. importan)e to Fabrega and Rog.er. An important )on)eptua. ad/an)ement is t'e re)ognition of bot' positions$ t'at is$ studying )u.ture to identify genera. pro)esses and studying )u.ture to identify )u.ture1spe)ifi) pro)esses. By fo)using on.y on genera.ities$ (e o/er.oo- t'e importan)e of )u.ture1spe)ifi) p'enomena. !n t'e ot'er 'and$ by emp'asi4ing )u.ture1spe)ifi) p'enomena (e o/er.oo- t'e possibi.ity of genera.ities. #'e o/era.. purpose of )u.tura. resear)'$ t'en$ is to ad/an)e our understanding of genera. pro)esses$ )u.ture1spe)ifi) pro)esses$ and t'e manner in ('i)' t'ey intera)t in spe)ifi) )ontexts 2see a.so 8raguns$ *++,3. !ur aim is to identify )u.tureGs mar- amidst t'e ubi7uity of 'uman suffering. MaD#r Ad,an.es' DSM0IG5 t/e W#r%d Menta% Hea%t/ Re*#rt5 and t/e S$r&e#n Genera%Bs Re*#rt #n Menta% Hea%t/' C$%t$re5 Ra.e5 and Et/ni.ity We no( turn to se.e)ted re)ent de/e.opments in t'e study of )u.ture and psy)'opat'o.ogy. We begin (it' a dis)ussion of t'ree of t'e most important pro6e)ts t'at (ere )arried out sin)e *+BB5 t'e in)orporation of )u.tura. fa)tors in t'e Diagnostic and 'tatistical Manual of Mental Disorders# ;t' ed.$ 28 M1">C Ameri)an %sy)'iatri) Asso)iation$ *++;3C t'e pub.i)ation of t'e &orld Mental ,ealth (eport 28es6ar.ais$ Eisenberg$ =ood$ H @.einman$ *++?3C and t'e re.ease of t'e U.'. 'urgeon Generals (eport on Mental ,ealth5 1ulture# (ace# and !thnicity 2U. . 8epartment of &ea.t' and &uman er/i)es$ 8&& $ 9,,*3. #'e N"M& funded t'e estab.is'ment of a )u.ture and diagnosis tas- for)e to inform t'e de/e.opment of t'e 8 M1">. #'e tas- for)eGs efforts resu.ted in t'ree main )ontributions to 8 M1">5 2a3 in).usion of some dis)ussion of 'o( )u.tura. fa)tors )an inf.uen)e t'e expression$ assessment$ and pre/a.en)e of spe)ifi) disordersC 2b3 an out.ine of a )u.tura. formu.ation of ).ini)a. diagnosis to )omp.ement t'e mu.tiaxia. assessmentC and 2)3 a g.ossary of re.e/ant )u.ture1bound syndromes from around t'e (or.d. A more )omp.ete do)umentation of t'e tasfor)eGs findings is a/ai.ab.e in t'e 8 M1"> our)eboo- 2Me44i)' et a..$ *++D3 and in ot'er

pub.i)ations 2e.g.$ A.ar)on$ *++<C @irmayer$ *++BC @.einman$ Me44i)'$ Fabrega$ H %arron$

. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 53 *++?3. Wit'out a doubt t'e attention gi/en to )u.ture in 8 M1"> is a ma6or a)'ie/ement in t'e 'istory of ).assifi)ations of menta. disorders. Ne/er before 'ad ).assifi)ation s)'emas or re.ated diagnosti) inter/ie(s addressed to t'is degree t'e ro.e of )u.ture in psy)'opat'o.ogy 2Lope4 H Nune4$ *+BDC Rog.er *++?3. 2 ee @irmayer$ *++B for a dis)ussion of t'e .imitations of 'o( 8 M1"> referred to )u.ture3. A se)ond ma6or de/e.opment (it'in t'e .ast de)ade (as t'e pub.i)ation of t'e Wor.d Menta. &ea.t' Report 28es6ar.ais et a..$ *++?3. 8es6ar.ais and )o..eagues )ompi.ed resear)' from around t'e (or.d to identify t'e range of menta. 'ea.t' and be'a/iora. prob.ems 2e.g.$ menta. disorders$ /io.en)e$ sui)ide3$ parti)u.ar.y among .o(1in)ome )ountries in Afri)a$ Latin Ameri)a$ Asia$ and t'e %a)ifi). #'e aut'ors deri/ed se/era. )on).usions. %er'aps t'e most signifi)ant (as t'at menta. i..ness and re.ated prob.ems exa)t a signifi)ant to.. on t'e 'ea.t' and (e..1being of peop.e (or.d(ide and produ)e a greater burden based on a 0disabi.ity1ad6usted .ife years0 index t'an t'at from tuber)u.osis$ )an)er$ or 'eart disease 2see Murray and Lope4$ *++?3. 8epressi/e disorders a.one (ere found to produ)e t'e fift' greatest burden for (omen and se/ent' greatest burden for men a)ross a.. p'ysi)a. and menta. i..nesses. A se)ond important obser/ation (as t'at menta. i..ness and be'a/iora. prob.ems are intri)ate.y tied to t'e so)ia. (or.d. For examp.e$ t'e aut'ors identified t'e so)ia. roots of t'e poor menta. 'ea.t' of (omen. Among t'e many fa)tors in).ude 'ungerEundernouris'ment aff.i)ts more t'an ?,P of (omen in de/e.oping )ountriesC (or-E(omen are poor.y paid for dangerous$ .abor intensi/e 6obsC and domesti) /io.en)eEsur/eys in some .o(1in)ome )ommunities (or.d(ide report up to ?,P of (omen 'a/ing been beaten. #'e resear)' on (omenGs menta. 'ea.t' i..ustrates t'at psy)'opat'o.ogy is as mu)' pat'o.ogy of t'e so)ia. (or.d as pat'o.ogy of t'e mind or body. Based on t'eir findings$ 8es6ar.ais and asso)iates ma-e spe)ifi) re)ommendations to ad/an)e bot' menta. 'ea.t' po.i)y and resear)' to 'e.p redu)e t'e signifi)ant burden of menta. i..ness a)ross t'e (or.d. #'eir )onsideration of t'e so)ia. (or.d .eads easi.y to re)ommending spe)ifi) inter/entions to address not on.y t'e ).ini)a. prob.em but a.so t'e so)ia. )onditions (it' ('i)' t'ey are asso)iated. "n addressing t'e poor menta. 'ea.t' of (omen$ for examp.e$ t'ey )a.. for )oordinated efforts bot' to empo(er (omen e)onomi)a..y and to redu)e /io.en)e against (omen in a.. its forms. "n addition$ (omenGs menta. 'ea.t' is identified as one of t'e top fi/e resear)' priorities (or.d(ide. #'ey )a.. for resear)' to examine t'e so)ia. fa)tors t'at inf.uen)e (omenGs 'ea.t' in spe)ifi) )u.tura. )ontexts and to identify effe)ti/e )ommunity1based inter/entions in impro/ing t'eir 'ea.t' status. #'e most re)ent de/e.opment sin)e *+BB (as t'e urgeon =enera.Gs upp.ementa. Report on Menta. &ea.t' )on)erning )u.ture$ ra)e$ and et'ni)ity 2U. . 8epartment of &ea.t' and &uman er/i)es$ 8&& $ 9,,*3. #'e surgeon genera. first pub.is'ed a .andmar- report on t'e status of t'e nationGs menta. 'ea.t' 2U. . 8&& $ *+++3. ome obser/ers (ere )on)erned t'at insuffi)ient attention (as gi/en to t'e menta. 'ea.t' of t'e )ountryGs et'ni) and ra)ia. minority groups 2Lope4$ 9,,:3. "n response to t'is )on)ern and under t'e .eaders'ip of t'e ubstan)e Abuse and Menta. &ea.t' er/i)es Administration$ t'e surgeon genera. pub.is'ed a report on t'e menta. 'ea.t' of t'e nationGs four main minority groups5 Ameri)an "ndiansLA.as-a Nati/es$ Afri)an Ameri)ans$ Asian Ameri)ansL%a)ifi) "s.anders$ and Latino Ameri)ans. A.t'oug' t'e reportGs fo)us (as on menta. 'ea.t' )are$ )onsiderab.e attention (as gi/en to our )urrent understanding of t'e psy)'opat'o.ogy of t'ese groups$ based .arge.y on epidemio.ogi)a. and ).ini)a. resear)'.

#'e main message of t'e urgeon =enera.Gs report is t'at 0)u.ture )ounts.0 0#'e )u.tures from ('i)' peop.e 'ai. affe)t a.. aspe)ts of menta. 'ea.t' and i..ness$ in).uding t'e types of stresses t'ey )onfront$ ('et'er t'ey see- 'e.p$ ('at types of 'e.p t'ey see-$ ('at symptoms and )on)erns t'ey bring to ).ini)a. attention$ and ('at types of )oping sty.es and so)ia. supports t'ey possess0 2p. ii3. #'e urgeon =enera.Gs report )ompi.es t'e best a/ai.ab.e resear)' t'at

55 LLPEF AND GUARNACCIA )u.ture matters in t'ese domains. For examp.e$ e/iden)e is re/ie(ed regarding t'e re.ations'ip bet(een ra)ism and menta. 'ea.t' 2e.g.$ @ess.er$ Mi)-e.son$ H Wi..iams$ *+++3 and et'ni)ity and psy)'op'arma)o.ogy 2e.g.$ Lin$ %o.and$ H Anderson$ *++<3. "n addition$ t'e report out.ines future dire)tions to address t'e menta. 'ea.t' needs of t'ese underser/ed )ommunities$ in).uding expanding t'e s)ien)e base and training menta. 'ea.t' s)ientists and pra)titioners. "n a..$ t'is report 'as ser/ed t(o important fun)tions. "t 'as broug't toget'er t'e best a/ai.ab.e menta. 'ea.t' resear)' regarding t'e main U. . minority groups. A.so$ be)ause of t'e status and /isibi.ity of t'e !ffi)e of t'e urgeon =enera.$ t'e report 'as a.erted t'e nation to t'e menta. 'ea.t' needs of t'e four main et'ni) and ra)ia. minority groups. #oget'er t'e 8 M1">$ t'e Wor.d Menta. &ea.t' Report$ and t'e urgeon =enera.Gs upp.ementa. Report on Menta. &ea.t' ma-e ma6or )ontributions to t'e study of )u.ture and psy)'opat'o.ogy. Furt'ermore$ t'ey i..ustrate t'e range of )on)eptua.i4ations of )u.ture and t'e importan)e of t'e so)ia. domain. For 8 M1">$ )u.ture tends to be depi)ted as exoti)$ t'roug' its inf.uen)e on symptom expression$ t'e noted )u.ture1bound syndromes$ and its referen)e to persons from 0)u.tura..y different0 groups. #'ere is .itt.e attention to )u.ture being part of e/ery ).ini)a. en)ounter$ inf.uen)ing t'e ).ient$ pro/ider$ and t'e broader )ommunity )ontext$ regard.ess of t'e patientGs et'ni) or ra)ia. ba)-ground. #'e Wor.d Menta. &ea.t' Report$ on t'e ot'er 'and$ re)ogni4es t'e dynami)$ so)ia. pro)esses .in-ed to )u.ture. &unger$ (or-$ and edu)ation$ for examp.e$ are integra..y re.ated to 'o( peop.e adapt or fai. to adapt. C.ini)a. p'enomena are re)ogni4ed$ but so are be'a/iora. prob.ems not traditiona..y )onsidered in psy)'iatri) ).assifi)ation systems$ su)' as domesti) /io.en)e and sexua. /io.en)e. #'roug'out$ t'e aut'ors re)ogni4e )u.tura. /ariabi.ity but t'eir stan)e is not extreme )u.tura. re.ati/ism$ as t'ey re)ogni4e t'e mora. and 'ea.t' imp.i)ations for )ontro/ersia. pra)ti)es$ su)' as fema.e )ir)um)ision. #'e surgeon genera.Gs report fa..s bet(een t'e t(o perspe)ti/es. "t re)ogni4es t'e importan)e of )u.ture in spe)ifi) ).ini)a. entities 2bot' )u.ture1bound syndromes and mainstream menta. disorder )ategories3. "t a.so a)-no(.edges t'e importan)e of t'e broader so)ia. (or.d t'oug' t'e emp'asis tends to be more disorder1based and .ess )ontextua..y based t'an t'e Wor.d Menta. &ea.t' Report. 8espite t'e differen)es in t'e treatment of )u.ture$ t'ese t'ree pub.i)ations indi)ate t'at )u.ture as a sub6e)t matter is no .onger so.e.y (it'in t'e pur/ie( of )u.tura. psy)'o.ogists$ psy)'iatrists$ and ant'ropo.ogists. "t is no( t'e sub6e)t matter of a.. users of 8 M1">$ (or.d(ide po.i)y ma-ers$ nationa. 'ea.t' po.i)y ma-ers$ and menta. 'ea.t' resear)'ers. Dis#rder0Re%ated Resear./ We no( turn to t'e examination of se.e)ted psy)'opat'o.ogy resear)'. We se.e)ted t'e study of anxiety$ s)'i4op'renia$ and )'i.d'ood psy)'opat'o.ogy be)ause (it'in ea)' of t'ese areas systemati) studies examine t'e )u.tura. basis of t'e expression of t'ese disorders as (e.. as t'e so)ia. and )u.tura. pro)esses t'at under.ie t'e de/e.opment and )ourse of i..ness. %n"iety. We )'ose to fo)us our attention on one .ine of resear)'$ t'e study of ataCues de nervios. #'is is an important .ine of resear)' be)ause it fo)uses on a )u.ture1spe)ifi) p'enomenon for ('i)' t'e triangu.ation of et'nograp'y$ epidemio.ogy$ and ).ini)a. resear)' 'as made important )ontributions. #'us$ (e (i.. be ab.e to examine some (ays et'nograp'y informs mainstream resear)'. %taCue de nervios is an idiom of distress parti)u.ar.y prominent among Latinos from t'e Caribbean$ but a.so re)ogni4ed among ot'er Latino groups. ymptoms )ommon.y asso)iated

(it' ataCues de nervios in).ude tremb.ing$ atta)-s of )rying$ s)reaming un)ontro..ab.y$ and

. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 57 be)oming /erba..y or p'ysi)a..y aggressi/e. !t'er symptoms t'at are prominent in some ataCues but not ot'ers are sei4ure1.i-e or fainting episodes$ disso)iati/e experien)es$ and sui)ida. gestures. A genera. feature experien)ed by most sufferers of ataCues de nervios is fee.ing out of )ontro.. Most episodes o))ur as a dire)t resu.t of a stressfu. .ife e/ent re.ated to fami.y or signifi)ant ot'ers 2e.g.$ deat' or di/or)e3. After t'e ataCue# peop.e often experien)e amnesia of ('at o))urred$ but t'en 7ui)-.y return to t'eir usua. .e/e. of fun)tioning. =uarna))ia initiated a program of resear)' by first )arrying out open1ended$ des)ripti/e inter/ie(s (it' peop.e ('o 'ad experien)ed ataCues de nervios in ).ini)a. settings 28e La Can)e.a$ =uarna))ia$ H Cari..o$ *+B?$ =uarna))ia$ 8e La Can)e.a$ H Cari..o$ *+B+a3. 8ra(ing from t'e ri)' des)ription of ).ini)a. )ases and an understanding of t'e so)ia. 'istory of %uerto Ri)ans .i/ing in t'e United tates$ t'ese in/estigators pointed out an asso)iation bet(een so)ia. disruptions 2fami.y and immediate so)ia. net(or-s3 and t'e experien)e of ataCues. #o bui.d on t'e et'nograp'i) base$ =uarna))ia and )o..eagues turned to epidemio.ogi)a. resear)' to examine its pre/a.en)e in %uerto Ri)o. After pre.iminary epidemio.ogi)a. resear)' in ('i)' a somati) symptom s)a.e index (as used as a proxy measure of ataCues 2=uarna))ia$ Rubio1 tipe)$ H Canino$ *+B+b3$ a subse7uent study (as )arried out in ('i)' respondents (ere dire)t.y 7ueried as to ('et'er t'ey 'ad suffered an ataCue de nervios and ('at t'e experien)e (as .i-e 2=uarna))ia$ Canino$ Rubio1 tipe)$ H Bra/o$ *++:3. #'e pre/a.en)e rate (as found to be 'ig'$ from *?P to 9:P of .arge )ommunity samp.es <-s Q +*9 and *<*:3$ and ataCues de nervios (ere found to be asso)iated (it' a (ide range of menta. disorders$ parti)u.ar.y anxiety and mood disorders. #'e so)ia. )ontext )ontinued to be important. %taCues (ere found to be more pre/a.ent among (omen$ persons o.der t'an ;<$ t'ose from .o(er so)ioe)onomi) ba)-ground$ and t'ose from disrupted marita. re.ations. More re)ent.y$ =uarna))ia$ Ri/era$ Fran)o$ and Neig'bors 2*++?3 returned to t'e et'nograp'i) mode to exp.i)ate t'e experien)e of ataCues from t'ose persons ('o 'ad reported suffering an ataCue de nervios in t'e epidemio.ogi)a. study. #'roug' in1dept' inter/ie(ing$ t'e fu.. range of symptoms and t'e spe)ifi) so)ia. )ontexts (ere identified. #'is 0experien)e1near0 or et'nograp'i) resear)' approa)' enab.ed =uarna))ia and asso)iates to examine )arefu..y 'o( t'e so)ia. (or.d )an be)ome part of t'e p'ysi)a. se.f as ref.e)ted in ataCues de nervios. C.ini)a. resear)' 'as broadened t'e examination of ataCues de nervios. Liebo(it4 and )o.1 .eagues 2*++;3 )arried out ).ini)a. diagnosti) inter/ie(s of *<? Latino patients from an urban psy)'iatri) ).ini) t'at spe)ia.i4es in t'e treatment of anxiety. #'ey examined t'e re.ations'ip bet(een patients 'a/ing an ataCue de nervios and meeting )riteria for pani) disorder$ ot'er anxiety disorders$ or an affe)ti/e disorder. #'eir fine1grained ana.ysis suggests t'at t'e different expressions of ataCue de nervios are affe)ted by t'eir re.ations'ip to different )oexisitng psy)'iatri) disorders. %ersons (it' an ataCues de nervios ('o a.so suffer from pani) disorder present .arge.y pani)1.i-e symptoms. &o(e/er$ in t'ose (it' an affe)ti/e disorder$ ataCues de nervios are )'ara)teri4ed by emotiona. .abi.ity$ espe)ia..y anger 2 a.man et a..$ *++B3. #'us$ in addition to t'e so)ia. fa)tors pre/ious.y noted$ t'ese findings suggest t'at t'e ).ini)a. )ontext may a.so p.ay a ro.e in understanding ataCue de nervios. #'e study of ataCue de nervios is exemp.ary for many reasons. W'at is most stri-ing is t'e systemati) ongoing dia.ogue among et'nograp'i)$ epidemio.ogi)a.$ and no( ).ini)a. resear)'ers ('i)' ad/an)es our understanding of ataCues of nervios and 'o( t'e so)ia. (or.d intera)ts (it' psy)'o.ogi)a. and p'ysi)a. pro)esses in t'e indi/idua.. Wit' t'e mu.tip.e approa)'es$ one

obser/es t'e s'ifting of t'e resear)'ersG .enses 2@.einman H @.einman$ *++*3. "n t'e ear.y et'nograp'i) (or-$ =uarna))ia and )o..eagues dre( from a sma.. number of ).ini)a. )ases and interpreted t'eir findings (it' broad stro-es fo)using on t'e broader so)ia. )ontexts of t'e indi/idua.s$ parti)u.ar.y t'eir migration experien)e and experien)es of margina. so)ia. status. "n t'e epidemio.ogi)a. resear)'$ t'e in/estigators used .arge$ representati/e samp.es to

59 LLPEF AND GUARNACCIA identify peop.e (it' ataCues and t'e so)ia. )orre.ates of t'at experien)e. "n t'is resear)'$ t'e so)ia. )ontext is redu)ed to sing.e 7uestions )on)erning gender$ age$ edu)ationa. .e/e.$ and marita. status$ ('i)' pro/ides some basis for interpretation but )ertain.y .a)-s t'e ri)'ness of et'nograp'i) materia.. #'e ).ini)a. studies pro/ide an in1dept' profi.e of patientsG symp1 tomato.ogy and t'e symptom patterns of t'ose (it' and (it'out an ataCue# but t'ey pro/ide .ess information about t'e so)ia. (or.d of t'e sufferer. Ea)' approa)' 'as its strengt's and .imitations. W'at matters$ t'oug'$ is not t'e strengt's or .imitations of a gi/en study but t'e (ea/ing of mu.tip.e studies (it' mu.tip.e approa)'es to understand t'e gi/en p'enomenon in some dept'. "n addition to t'e ongoing dia.ogue bet(een resear)' approa)'es$ t'e resear)' is exemp.ary by p.a)ing ataCue de nervios and re.ated menta. disorders in t'eir so)ia. )ontext. "n a.most a.. studies$ ataCue de nervios is presented not as a popu.ar i..ness 2t'at is$ an i..ness defined by t'e )ommunity3 or ).ini)a. entity 2t'at is$ a psy)'o.ogi)a..y or bio.ogi)a..y defined disorder3 t'at resides (it'in indi/idua.s$ but as a popu.ar i..ness t'at ref.e)ts t'e .i/ed experien)e of (omen (it' .itt.e po(er and disrupted so)ia. re.ations. "n adopting mu.tip.e approa)'es$ t'e emp'asis gi/en to t'e so)ia. domain is .i-e.y to s'ift. Ne/ert'e.ess$ o/er t'e se/era. studies =uarna))ia and 'is )o..eagues 'a/e maintained )onsiderab.e attention to t'e so)ia. )ontext. "n so doing$ t'ey 'a/e demonstrated 'o( to in).ude t'e so)ia. in epidemio.ogi)a. 2e.g.$ =uarna))ia et a..$ *++:3$ ).ini)a. 2 a.man et a..$ *++B3$ and et'nograp'i) studies. !/era..$ t'e study of ataCue de nervios pro/ides a mode. for t'e in/estigation of )u.ture and psy)'opat'o.ogy$ parti)u.ar.y for resear)' t'at begins (it' a )u.ture1spe)ifi) form of distress. 'chi*ophrenia. #'e )u.tura. )on)eption of t'e se.f )an inf.uen)e t'e manner in ('i)' disorders are expressed and understood by ot'ers. #'is be.ief is arti)u.ated in FabregaGs 2*+B+3 t'oug'tfu. o/er/ie( of 'o( past ant'ropo.ogi)a..y informed resear)' )ontributed to t'e study of psy)'osis and 'o( future studies )an ad/an)e our understanding of t'e interre.ations of )u.ture and s)'i4op'renia. A))ording to Fabrega$ t'e effe)t of s)'i4op'renia on indi/idua.s and )ommunities depends on ('et'er t'ey )on)ei/e of t'e se.f as autonomous and separate from ot'ers or as )onne)ted and bound to ot'ers 2Mar-us H @itayama$ *++*C '(eder H Bourne$ *+B;3. #'e resear)' t'at most dire)t.y addresses t'is notion is t'at ('i)' examines t'e ro.e of so)ia. fa)tors in t'e )ourse of s)'i4op'renia. #(o prominent .ines of in7uiry in).ude t'e W&! )ross1nationa. study of s)'i4op'renia and a series of studies examining t'e re.ations'ip of fami.iesG emotiona. ).imate to t'e )ourse of i..ness. 2For an examination of )u.ture and symptom expression in s)'i4op'renia$ see Bre--e and Barrio$ *++D$ and Weisman et a..$ 9,,,3 #'e W&!Gs "nternationa. %i.ot tudy on )'i4op'renia 2"% 3 and t'e fo..o(1up study 8eterminants of !ut)omes of e/ere Menta. 8isorder 28! M83 represent t'e .argest mu.ti1 nationa. study of s)'i4op'renia to date 2"% 5 + )ountries and *9,9 patientsC 8! M85 *, )ountries and *:D+ patientsC Jab.ens-y et a..$ *++9C W&!$ *+D+3. #'ese in/estigations 'a/e made many )ontributions$ in).uding finding e/iden)e of t'e )omparabi.ity of s)'i4op'reniaGs )ore symptoms a)ross se/era. )ountries 2for a )riti7ue$ see @.einman$ *+BB3. #'e finding t'at 'as re)ei/ed t'e most attention by )u.tura. resear)'ers is t'at s)'i4op'renia in de/e.oping )ountries 'as a more fa/orab.e )ourse t'an in de/e.oped )ountries 2Weisman$ *++D3. ome in/estigators 'a/e referred to t'is basi) finding as 0arguab.y t'e sing.e most important finding of )u.tura. differen)es in )ross1)u.tura. resear)' on menta. i..ness0 2Lin H @.einman$ *+BB$ p. <?:3. !t'ers 'a/e been most )riti)a. of t'e studiesG met'ods and interpretations 2see Co'en$ *++9C Edgerton H

Co'en$ *++;C &opper$ *++*3. For examp.e$ Edgerton and Co'en point out t'at t'e distin)tion bet(een de/e.oped and de/e.oping )ountries is un).ear. Moreo/er$ t'ey argue t'at t'e )u.tura. exp.anation for t'e differen)es in )ourse is poor.y substantiated. #'ey a.so suggest t'at su)' resear)' )ou.d be more )u.tura..y informed t'roug' t'e dire)t measure

9. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 61 of spe)ifi) )u.tura. fa)tors in )on6un)tion (it' obser/ations of peop.eGs dai.y .i/es 2see a.so &opper *++*3. W'at is ).ear is t'at t'e W&! findings 'a/e pro/ided t'e basis for an important dis)ussion of met'od and t'eory in t'e )ontext of s)'i4op'renia and t'e so)ia. (or.d. Anot'er .ine of resear)' addressing )u.tureGs ro.e in t'e )ourse of s)'i4op'renia fo)uses on fami.iesG emotiona. ).imates. Based on t'e ear.y (or- of =eorge Bro(n and asso)iates 2e.g.$ Bro(n$ Bir.ey$ H Wing$ *+D93$ resear)' 'as found t'at patients ('o return to 'ouse'o.ds mar-ed by )riti)ism$ 'osti.ity$ and emotiona. in/o./ement 2toget'er t'is pattern is referred to as 'ig' expressed emotion$ EE3 are more .i-e.y to re.apse t'an t'ose ('o return to 'ouse'o.ds t'at are not so )'ara)teri4ed 2Bebbington H @uipers$ *++;C But4.aff H &oo.ey$ *++BC Leff H >aug'n$ *+B<3. #'is .ine of in/estigation is important to t'e study of )u.ture be)ause it points out t'e importan)e of t'e so)ia. (or.d. More spe)ifi)a..y$ )ross1nationa. and )ross1et'ni) studies 'a/e un)o/ered interesting differen)es in t'e .e/e. and nature of expressed emotion 2Jen-ins H @arno *++93. #'ese studies s'o( t'at )u.tura. fa)tors in t'e definitions and experien)es of s)'i4op'renia affe)t t'e emotiona. ).imate of fami.ies ('ere i.. indi/idua.s .i/e. Furt'ermore$ t'ese )u.tura. differen)es 'a/e important effe)ts on menta. 'ea.t' out)omes. #'e most systemati) )u.tura. ana.ysis of fami.iesG ro.es in s)'i4op'renia 'as been )arried out by Jen-ins and 'er )o..eagues. "n using bot' ).ini)a. resear)' met'ods based on t'e prototypi) )ontemporary study of expressed emotion 2>aug'n H Leff$ *+D?3 and et'nograp'i) met'ods based on in1dept' inter/ie(s$ Jen-ins and asso)iates extended t'is .ine of study to Mexi)an Ameri)an fami.ies in Los Ange.es. "n t'e first ma6or report$ @arno et a.. 2*+BD3 rep.i)ated t'e genera. finding t'at patients ('o return to 'ig' EE fami.ies are more .i-e.y to re.apse t'an patients ('o return to .o( EE fami.ies. Jen-ins 2*+BBa3 t'en )arried out an in1dept' examination of Mexi)an Ameri)an fami.iesG )on)eptua.i4ations of s)'i4op'renia$ spe)ifi)a..y nervios# and 'o( t'is differed from a )omparab.e samp.e of Ang.o Ameri)an fami.ies ('o /ie(ed s)'i4op'renia .arge.y as a menta. i..ness 2see a.so =uarna))ia$ %arra$ 8es)'amps$ Mi.stein$ H Argi.es$ *++93. Based on bot' 7uantitati/e 2)oded responses to open1ended 7uestions3 and 7ua.itati/e data$ Jen-ins 2*+BBb3 suggested t'at Mexi)an Ameri)ansG preferen)e for nervios is tied to t'e fami.y membersG efforts to de)rease t'e stigma asso)iated (it' t'e i..ness and a.so to promote fami.y support and )o'esi/eness. "n subse7uent papers$ Jen-ins 2*++*$*++:3 )riti7ued t'e )u.tura. basis of t'e expressed emotion )onstru)t in genera. and its )omponents$ )riti)ism and emotiona. o/erin/o./ement$ in parti)u.ar. A most important t'eoreti)a. )ontribution to t'e study of t'e )ourse of s)'i4op'renia is t'at Jen-ins situates fami.iesG expressed emotion$ not in t'e fami.y membersG attitudes$ be.iefs$ or e/en fee.ings$ ('i)' is t'e approa)' ta-en by most in/estigators$ but in t'e patient1fami.y so)ia. intera)tion. !/era..$ Jen-insG (or- 'as broug't mu)' needed attention to 'o( serious menta. i..ness is embedded in spe)ifi) so)ia. and )u.tura. )ontexts. Bui.ding on Jen-insG (or-$ Lope4 and )o..eagues 'a/e furt'er )riti7ued t'e notion of expressed emotion (it' its fo)us on negati/e fami.y fun)tioning 2Lope4$ Ne.son$ nyder$ H Mint4$ *+++3. #'ey point out t'at at an ear.y 6un)ture in t'e study of fami.ies and re.apse$ in/estigators 2i.e.$ Bro(n et a..$ *+D93 opted to fo)us on aspe)ts of fami.y )onf.i)t t'at predi)t re.apse rat'er t'an t'e proso)ia. aspe)ts of fami.y fun)tioning t'at buffer re.apse. "n a reana.1ysis and extension of t'e Mexi)an Ameri)an samp.e 2@arno et a..$ *+BD3 and a )omparab.e Ang.o Ameri)an samp.e 2>aug'n$ nyder$ Jones$ Freeman$ H Fa..oon$ *+B;3$ Lope4 et a.. 29,,;3 found t'at a .a)- of fami.y (armt' predi)ted re.apse for Mexi)an Ameri)ans ('ereas )riti)ism predi)ted re.apse for

Ang.o Ameri)ans. "n ot'er (ords$ Mexi)an Ameri)an patients ('o returned to fami.ies mar-ed by .o( (armt' (ere mu)' more .i-e.y to re.apse t'an t'ose ('o returned to fami.ies )'ara)teri4ed by 'ig' (armt'. For Ang.o Ameri)ans$ (armt' (as unre.ated to re.apse. Lope4 and )o..eagues did not attribute t'is et'ni) differen)e to a set of presumed )u.tura. be.iefs asso)iated (it' t'e Mexi)an )u.ture or a )o..e)ti/ist )u.ture. "nstead$

63 LLPEF AND GUARNACCIA t'ey noted t'at most of t'e Mexi)an origin fami.ies and patients (ere immigrants$ and t'at maintaining fami.y ties may be )ru)ia. to t'e sur/i/a. of .o(1in)ome immigrants .i/ing in a foreign and at times 'osti.e en/ironment. #'e .atter interpretation is )onsistent (it' a so)ia..y denned /ie( of )u.ture rat'er t'an a /a.ue or be.ief perspe)ti/e. #'ese findings in )on6un)tion (it' t(o ot'er internationa. studies 2"ta.y5 Bertrando et a..$ *++9C Augos.a/ia5 "/ano/i$ >u.eti$ H Bebbington$ *++;3 are )onsistent (it' t'e 'ypot'esis t'at )u.ture p.ays a ro.e in t'e manner in ('i)' fami.ies respond to re.ati/es (it' s)'i4op'renia$ ('i)' in turn re.ates to t'e )ourse of i..ness. A .imitation of t'ese findings is t'at t'ere (as no dire)t measure of )u.tura. pro)esses. Ne/ert'e.ess$ t'e importan)e of t'is study is t'at t'e exp.oration of possib.e )u.tura. /ariabi.ity .ed to t'e beginning of a .ine of in7uiry t'at examines ('at fami.ies do to pre/ent re.apse. u)' resear)' 'as t'e potentia. to add a mu)' needed ba.an)e to fami.y resear)' by fo)using on bot' positi/e and negati/e aspe)ts of fami.iesG be'a/iors 2see a.so Weisman$ =omes$ H Lope4$ 9,,:3. #'e study of )aregi/ing 2e.g.$ =uarna))ia$ *++BC Lef.ey$ *++B3 and fami.iesG day to day intera)tions (it' i.. fami.y members (i.. .i-e.y s'ed furt'er .ig't on t'e importan)e of fami.iesG proso)ia. fun)tioning. 1hildhood Disorders. #'e study of )'i.d psy)'opat'o.ogy is a ri)' fie.d of in7uiry for t'ose interested in )u.ture. As noted by Weis4$ M)Carty$ Eastman$ C'aiyasit$ H u(an.ert$ 2*++D3$ )'i.d psy)'opat'o.ogy re7uires attention to t'e be'a/ior of )'i.dren as (e.. as t'e /ie(s of adu.tsEparents$ tea)'ers$ and menta. 'ea.t' pra)titionersEfor it is t'e adu.ts ('o usua..y de)ide ('et'er a prob.em exists. #'e fa)t t'at ot'ers determine ('et'er )'i.drenGs be'a/ior is prob.emati) indi)ates t'e importan)e of t'e so)ia. (or.d in denning menta. i..ness and disorders of )'i.dren and ado.es)ents. Jo'n Weis4 and 'is )o..eagues 'a/e )arried out t'e most systemati) resear)' on )u.ture and )'i.d'ood psy)'opat'o.ogy 2for a re/ie($ see Weis4 et a..$ *++D3. "n t'e first study$ )ondu)ted in #'ai.and and t'e United tates$ Weis4$ u(an.ert$ C'aiyasit$ Weiss$ and Wa.ter 2*+BDa3 found t'at #'ai )'i.dren and ado.es)ents ('o (ere referred to menta. 'ea.t' ).ini)s reported more interna.i4ing prob.ems t'an U. . )'i.dren and ado.es)ents. "n )ontrast$ U. . )'i.dren and ado.es)ents reported more externa.i4ing prob.ems t'an #'ai )'i.dren and ado.es)ents. "n fo..o(1 up )ommunity studies$ ('ere t'e menta. 'ea.t' referra. pro)ess (as not a fa)tor in t'e identifi)ation of prob.em be'a/iors$ t'e )ross1nationa. differen)es (ere )onfirmed for interna.i4ing prob.ems but not for externa.i4ing prob.ems 2Weis4 et a..$ *+BDbC Weis4 et a..$ *++:b3. U. . and #'ai )'i.dren and ado.es)ents identified in t'eir respe)ti/e )ommunities did not differ in terms of a)ting1out prob.ems. Weis4 and )o..eagues argue t'at t'e findings (it' regard to interna.i4ing prob.ems are )onsistent (it' t'e idea t'at )u.ture s'apes t'e manner in ('i)' )'i.dren and ado.es)ents express psy)'o.ogi)a. distress. Be)ause t'ey )ome from a .arge.y Budd'ist re.igious and )u.tura. ba)-ground t'at /a.ues se.f1)ontro. and emotiona. restraint$ #'ai )'i.dren may be more .i-e.y t'an U. . )'i.dren to express psy)'o.ogi)a. distress in a manner t'at does not /io.ate )u.tura. norms. Aside from t'e intriguing findings$ t(o ot'er fa)tors stand out in Weis4 and )o..eaguesG resear)'5 t'e systemati) nature of t'e resear)'$ and t'e )are (it' ('i)' t'e resear)' 'as been )ondu)ted. Weis4 began t'is .ine of in/estigation in menta. 'ea.t' ).ini)s$ t'en (ent to a )ommunity sur/ey to ru.e out t'e possibi.ity of referra. fa)tors 2Weis4 et a..$ *+BDb3. Based on t'ese findings$ Weis4 and Weiss 2*++*3 deri/ed a referabi.ity index for spe)ifi) prob.em be'a/iors 2e.g.$ /anda.ism and poor s)'oo. (or-3 t'at indexes t'e .i-e.i'ood t'at a gi/en prob.em (i.. be referred for treatment$

ta-ing into a))ount t'e prob.emGs pre/a.en)e in a gi/en )ommunity. "n t'is study$ t'ey demonstrated 'o( gender and nationa.ity inf.uen)e ('et'er a prob.em is broug't to t'e attention of menta. 'ea.t' professiona.s. ubse7uent.y$ Weis4 and )o..eagues examined tea)'ersG reports of a)tua. )'i.dren 2Weis4 et a..$ *+B+3 and bot' parentsG and

. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 65 tea)'ersG ratings of 'ypot'eti)a. )ases 2Weis4$ u(an.ert$ C'aiyasit$ Weiss$ H Ja)-son$ *++*3. "n a more re)ent study of tea)'ersG reports of prob.em be'a/iors$ Weis4$ C'aiyasit$ Weiss$ Eastman$ H Ja)-son 2*++<3 found t'at #'ai tea)'ers report more interna.i4ing and externa.i4ing prob.em be'a/iors in #'ai )'i.dren t'an U. . tea)'ers report in U. . )'i.dren. Ea)' of Weis4 and )o..eaguesG studies systemati)a..y bui.ds on t'eir pre/ious (or- in ad/an)ing an understanding of 'o( adu.ts (it' differing so)ia. ro.es define )'i.drenGs prob.em be'a/iors. Mu.tip.e )ross1 )u.tura. studies using different met'ods (it' different resear)' parti)ipants pro/ide a ri)' net(or- of findings to ad/an)e our understanding of 'o( t'e so)ia. )ontext s'apes t'e identifi)ation of yout'sG menta. 'ea.t' prob.ems. #'e )are Weis4 and )o..eagues ta-e (it' t'eir resear)' is best i..ustrated in t'e study of tea)'ersG ratings of prob.em be'a/iors 2Weis4 et a..$ *++<3. #'ey found t'at #'ai tea)'ers rate more interna.i4ing and externa.i4ing prob.em be'a/iors for #'ai students t'an U. . tea)'ers rate for t'eir o(n students. =i/en t'at t'is finding runs )ounter to t'e pre/ious ).ini)a. and )ommunity studies$ ('i)' found differen)es on.y for interna.i4ing prob.ems$ t'ey de/ised an inno/ati/e obser/ationa. met'odo.ogy to assess ('et'er somet'ing about t'e )'i.dren or t'e tea)'ers )ontributed to t'is )ontradi)tory finding. Weis4 and asso)iates 2*++<3 used independent obser/ers of bot' )'i.drenGs s)'oo. be'a/ior and tea)'ers to rate t'e same )'i.dren ('o (ere obser/ed in #'ai.and and in t'e United tates. !ne of t'e independent raters (as a bi.ingua. #'ai psy)'o.ogist ('o 'ad re)ei/ed graduate training in t'e United tates. &is being part of bot' teams of independent obser/ers (as )riti)a. to assessing t'e re.iabi.ity of t'e #'ai and U. . obser/ers. #'e re.ations'ip bet(een 'is ratings and t'ose of t'e ot'er U. . and #'ai raters (ere e7ua..y 'ig'$ suggesting t'at t'e ratings (ere re.iab.e a)ross bot' nationa. sites. "nteresting.y$ t'e obser/ers rated #'ai )'i.dren as 'a/ing .ess t'an 'a.f as many prob.em and off1tas- be'a/iors as U. . )'i.dren$ yet #'ai tea)'ers rated t'e obser/ed students as 'a/ing many more prob.em be'a/iors t'an U. . tea)'ers rated t'eir students. #'ese data suggest t'at #'ai tea)'ers 'a/e a mu)' .o(er t'res'o.d t'an U. . tea)'ers for identifying prob.em be'a/iors in t'eir students. Findings in )ross1)u.tura. resear)' are often open to mu.tip.e interpretations. By using )arefu. met'odo.ogy a)ross mu.tip.e studies$ Wei4 and )o..aborators (ere ab.e to pin do(n t'e spe)ifi) meaning of t'eir )omp.ex set of findings. "n doing so$ t'ey 'ig'.ig't t'e importan)e of )ontextua. fa)tors in t'e assessment of )'i.d psy)'opat'o.ogy and demonstrate t'at it is untenab.e to /ie( t'e assessment of )'i.d psy)'opat'o.ogy as )u.ture1free. 8e/e.opmenta. resear)'ers are examining more ).ose.y t'e inf.uen)e of )u.ture on t'e type and degree of prob.em be'a/iors of )'i.dren and ado.es)ents. Weis4 and asso)iates extended t'eir #'ai1U . resear)' to Jamai)a and @enya 2Lambert$ Weis4$ H @nig't$ *+B+C Weis4$ igman$ Weiss$ H Mos-$ *++:a3. !t'er in/estigators 'a/e )ompared rates of interna.i4ing and externa.i4ing prob.ems in ot'er parts of t'e (or.d 2e.g.$ 8enmar-5 Arnett H Ba..e1Jensen$ *++:C and %uerto Ri)o5 A)'enba)' et a..$ *++,3. ti.. ot'er resear)'ers 'a/e examined spe)ifi)a..y interna.i4ing type prob.em be'a/iors 2=reenberger H C'en$ *++?3 or externa.i4ing type prob.em be'a/iors 2e.g.$ Weine$ %'i..ips$ H A)'enba)'$ *++<3 in )ross1nationa. or )ross1et'ni) samp.es. An important trend in t'is resear)' is t'at epidemio.ogi)a. resear)' t'at )ompares groups )ross1 nationa..y and suggests possib.e )u.tura. exp.anations is no( being )omp.emented by resear)' t'at examines t'e psy)'oso)ia. pro)esses asso)iated (it' )'i.drenGs and ado.es)entsG ad6ustment or psy)'opat'o.ogy. For examp.e$ C'en$ =reenberger$ Lester$ 8ong$ and =uo 2*++B3 examined ris- fa)tors 2parent1ado.es)ent )onf.i)t and per)ei/ed peer appro/a. of mis)ondu)t3 and

prote)ti/e fa)tors 2parenta. (armt' and parenta. monitoring3 asso)iated (it' a)ting1out prob.ems a)ross four groups of ado.es)ents5 European Ameri)ans$ C'inese Ameri)ans$ #aipei C'inese$ and Bei6ing C'inese. #'ey found t'at a.t'oug' t'ere (ere simi.ar .e/e.s of reported mis)ondu)t a)ross t'e four groups$ peer appro/a.Ldisappro/a. a))ounted for

67 LLPEF AND GUARNACCIA more of t'e mis)ondu)t for t'e t(o groups of Ameri)ans ado.es)ents t'an for t'e t(o groups of t'e C'inese ado.es)ents. #'e strengt' of t'e more re)ent studies is t'at t'ey examine pro)esses t'at may under.ie potentia. )ross1nationa. differen)es and simi.arities$ in).uding so)ia. 2fami.y and peers3 and psy)'o.ogi)a. 2/a.ues3 pro)esses. #'us$ an important step 'as been ta-en to understand ('y differen)es and simi.arities may o))ur in be'a/ior prob.ems )ross1nationa..y. A.t'oug' t'e )on)eptua. mode.s used to frame su)' resear)' are ri)'$ in).ude so)ia. pro)esses$ and 'a/e a strong empiri)a. tradition in psy)'o.ogi)a. resear)'$ t'ey are not (e.. informed by )u.tura. spe)ifi) pro)esses 2for an ex)eption see %o.o$ 9,,93. "n/estigators app.y mode.s de/e.oped .arge.y in t'e United tates. Et'nograp'i) resear)' t'at examines ('at about t'e so)ia. and )u.tura. (or.d mig't p.ay a ro.e in t'e expression of distress and disorder among )'i.dren (ou.d be espe)ia..y (e.)ome. #'is resear)' )ou.d t'en .ead to testing dire)t.y t'ose )u.ture1spe)ifi) fa)tors t'at are t'oug't to affe)t psy)'opat'o.ogy (it'in a gi/en )on)eptua. frame(or- as e/iden)ed in t'e (or- of some de/e.opmenta. resear)'ers 2e.g.$ Fu.igni$ *++B3$ and as ad/o)ated by ot'ers 2e.g.$ )'neider$ *++B3. #'e gro(ing interest of resear)'ers in studying interna.i4ing and externa.i4ing prob.em be'a/iors )ross1nationa..y and )ross1et'ni)a..y attests to t'e uti.ity of t'is approa)' for en'an)ing our understanding of )u.ture and )'i.d'ood psy)'opat'o.ogy. E(er&in& Trends 0mmigration. A number of re)ent findings 'ig'.ig't t'e importan)e of immigration in understanding menta. 'ea.t' and menta. i..ness. #'e Los Ange.es Epidemio.ogi) Cat)'ment Area study reported t'at Mexi)an1born Mexi)an Ameri)ans 'ad signifi)ant.y .o(er pre/a.en)e rates a)ross a (ide range of disorders t'an U .1born Mexi)an Ameri)ans 2Burnam$ &oug'$ @arno$ Es)obar$ H #e..es$ *+BD3. #'is finding (as rep.i)ated in a more re)ent epidemio.ogi) study )omparing t'e pre/a.en)e rates of rura. and urban Mexi)an1origin adu.ts in Fresno and nearby )ommunities 2>ega et a..$ *++B3. An important )ontribution of t'e Fresno study is t'at e/iden)e (as pro/ided from a Mexi)o City samp.e indi)ating t'at Mexi)o City residents 'ad )omparab.e rates to t'e Mexi)an immigrant samp.e$ t'us )ountering t'e 'ardy immigrant 'ypot'esis. #'ese and ot'er studies 2!rtega$ Rosen'e)-$ A.egria$ H 8esai$ 9,,,3 'a/e been interpreted as suggesting t'at a))u.turation to t'e Ameri)an )u.ture may be 'armfu. to LatinosG menta. 'ea.t'. Mars'a.. and !r.ando 29,,93 pro/ide a )ounterpoint t'at a))u.turation )an ser/e as a prote)ti/e fa)tor rat'er t'an a ris- fa)tor$ parti)u.ar.y in t'e domain of disso)iation asso)iated (it' trauma among young Latinos. #'e so)ia. and psy)'o.ogi)a. me)'anisms t'at are responsib.e for t'e differing pre/a.en)e rates for t'e immigrant groups at t'is time are un-no(n. Ne/ert'e.ess$ a/ai.ab.e studies indi)ate t'at resear)' on immigration and a))u.turation )an )ontribute mu)' to our understanding of 'o( t'e so)ia. (or.d and psy)'opat'o.ogy interre.ate 2see a.so Rog.er$ *++;3. A parti)u.ar.y (ide1open area of study is t'e examination of immigration and menta. 'ea.t' and i..ness among )'i.dren and ado.es)ents 2see =uarna))ia H Lope4$ *++BC %o.o$ 9,,93. Not on.y (i.. immigrationLa))u.turation resear)' be ab.e to address important )on)eptua. and met'odo.ogi)a. issues in t'e study of )u.ture$ but it (i.. a.so 'a/e important po.i)y imp.i)ations for t'e de.i/ery of menta. 'ea.t' ser/i)es to underser/ed )ommunities 2e.g.$ a.gado de nyder$ 8ia41%ere4$ H Bautista$ *++B3. U.'. !thnic Minority Groups. We are en)ouraged by t'e gro(ing interest in t'e study of psy)'opat'o.ogy among U. . et'ni) minority groups. Wit' regard to Afri)an Ameri)ans$ t'ere 'as been an in)rease in t'e study of anxiety disorders sin)e Nea. and #urnerGs 2*++*3 )a.. for

resear)'. #'e most re)ent studies in).ude ).ini)a. studies 2e.g.$ Friedman$ %aradis$ H &at)'$ *++;3$ epidemio.ogi) studies 2&or(at'$ Jo'nson$ H &ornig$ *++:3$ a )ombined

. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 69 et'nograp'i) and epidemio.ogi)a. study 2&eurtin1Roberts$ no(den$ H Mi..er$ *++D3$ and a study of )'i.d'ood fears 2Nea.$ Li..y$ H Ra-is$ *++:3. A.t'oug' t'ese studies are .arge.y des)ripti/e$ t'ere is some attention to t'e differentia. so)ia. (or.d of Afri)an Ameri)an and W'ite patients. For examp.e$ Friedman and asso)iates found t'at$ re.ati/e to W'ite patients (it' pani) disorder and agorap'obia$ Afri)an Ameri)an patients reported a greater .i-e.i'ood of 'a/ing been separated as )'i.dren from t'eir parents and of 'a/ing experien)ed t'eir parentGs di/or)e. A systemati) series of studies 'as examined t'e menta. 'ea.t' prob.ems of Ameri)an "ndian )'i.dren 2e.g.$ Beiser$ a)-$ Manson$ Reds'irt$ H 8ion$ *++BC 8ion$ =oto(ie)$ H Beiser$ *++B3 and adu.ts 2Maser H 8inges$ *++9L*++:3. A.t'oug' many of t'ese studies use mainstream mode.s of disorder and distress 2see !GNe..Gs *+B+ )riti7ue3$ t'ere are gro(ing efforts to )ontextua.i4e t'e menta. 'ea.t' prob.ems (it'in t'ese )ommunities. "n one study$ 8u)os and )o..eagues 2*++B3 found t'at near.y 'a.f of t'e "ndian ado.es)ents detained in t'e 6u/eni.e 6usti)e system met )riteria for menta. disorders ranging from substan)e abuseLdependen)e 2:BP3 to ma6or depression 2*,P3. #'ese rates (ere mu)' 'ig'er t'an )ommunity sur/eys of "ndian yout' and non1"ndian yout'. #'ese resear)'ers argue t'at t'e 6u/eni.e 6usti)e system 'as t'e potentia. to ser/e as an important site to treating t'ese 'ig'1ris- yout'$ many of ('om (ou.d ot'er(ise go untreated. "n anot'er study$ !GNe.. and Mit)'e.. 2*++?3 found t'at t'e .ine bet(een norma. and pat'o.ogi)a. drin-ing among ado.es)ent "ndians is )ontextua..y based. #'eir et'nograp'i) findings suggest t'at a rigid mode. of a.)o'o. abuse denned by bio.ogy 2fre7uen)y and amount of a.)o'o.3 or psy)'o.ogy 2distress3 (it'out signifi)ant attention to t'e so)io)u.tura. )ontext 2e.g.$ ('en and (it' ('om one drin-s3 is .imited in distinguis'ing bet(een normati/e and pat'o.ogi)a. drin-ing. !/era..$ (e are impressed by re)ent systemati) efforts of psy)'opat'o.ogy resear)'ers of Ameri)an "ndians to assess t'e interre.ations of distress and disorder to t'e so)ia. (or.d. #'is emp'asis is )ontinuing as ref.e)ted in pero Manson and )o..eaguesG ma6or resear)' endea/or entit.ed 0Ameri)an "ndian er/i)es Uti.i4ation$ %sy)'iatri) Epidemio.ogy$ Ris- and %rote)ti/e Fa)tors %ro6e)t.0 #'is pro6e)t is t'e .argest study of Ameri)an "ndian groups to use state1of1t'e1art measures to assess t'e .e/e. of psy)'opat'o.ogy and ser/i)e uti.i4ation patterns and gaps in ser/i)es for t'ese )ommunities. Wit' regard to Asian Ameri)an resear)'$ ue$ Fu6 ino$ &u$ #a-eu)'i$ H Rane 2*++*3 'a/e 'ad a .ong1standing interest in treatment issues. Most re)ent.y$ ue and )o..eagues 'a/e broadened t'eir interests to in).ude psy)'opat'o.ogy 2 ue$ ue$ ue$ H #a-eu)'i$ *++<3. !f parti)u.ar importan)e is t'e epidemio.ogi)a. sur/ey of depressi/e disorders among C'inese Ameri)ans residing in t'e Los Ange.es area 2#a-eu)'i et a..$ *++B3. Resear)'ers 'a/e been ab.e to examine pre/a.en)e rates of traditiona. depressi/e and re.ated disorders$ as (e.. as neurast'enia 2R'eng et a..$ *++D3$ a )on)ept t'at (as retired in t'e ).assifi)ation of menta. disorders in t'e United tates but is sti.. in use in C'ina and ot'er parts of Asia. -eurasthenia usua..y refers to (ea-ness or fatigue$ often a))ompanied by a /ariety of psy)'o.ogi)a. 2e.g.$ poor )on)entration3 and p'ysi)a. symptoms 2e.g.$ diffuse a)'es and pains3. !f parti)u.ar interest is t'e finding t'at neurast'enia 'ad t'e 'ig'est one1year pre/a.en)e rate 2?.;P3 of any disorder in t'e C'inese Ameri)an epidemio.ogi) sur/ey. #'is (as t'e )ase e/en after remo/ing t'ose persons (it' bot' neurast'enia and anot'er disorder su)' as anxiety or depression 2pure neurast'enia rate Q :.?P3. #'e study of neurast'enia is anot'er examp.e of 'o( )u.ture )an )ontribute to s'aping t'e expression of disorder.

Most of t'e resear)' (it' Latinos 'as in/o./ed adu.ts. >ega$ @'oury$ Rimmerman$ =i.$ H War'eit 2*++<3$ 'o(e/er$ )ondu)ted an important study regarding Latino ado.es)ents in Miami$ F.orida. A signifi)ant )ontribution of t'is resear)' is t'at it points out t'at t'e re.ations'ip bet(een spe)ifi) a))u.turati/e stressors 2e.g.$ .anguage )onf.i)ts$ per)ei/ed dis)rimination3 and prob.em be'a/iors /aries by immigration status. "n addition$ in t'eir pre/a.en)e study of

71 LLPEF AND GUARNACCIA ado.es)ents in t'e &ouston metropo.itan area$ Roberts$ Roberts$ H C'en 2*++D3 found t'at of nine et'ni) groups$ Mexi)an Ameri)ans reported t'e 'ig'est rates of ma6or depression. Bot' studies are )'ara)teri4ed by rigor in samp.ing s)'oo.s$ mu.tiet'ni) samp.es$ and .arge samp.e si4es. Additiona. studies are )urrent.y being )arried out by Canino and )o..eagues among )'i.dren and ado.es)ents in bot' t'e )ommunity and ser/i)e system in %uerto Ri)o$ and by Lands/er-$ &oug'$ and )o..eagues in t'e yout' ser/i)e systems in an 8iego. W'en t'ese studies are pub.is'ed$ t'ey (i.. add to t'e .imited attention addressing Latino yout'. CONCLUSIONS Cu.tura. psy)'opat'o.ogy$ t'e study of )u.ture and t'e definition$ experien)e$ distribution$ and )ourse of psy)'o.ogi)a. disorders$ is no( on t'e map. Arti).es are being pub.is'ed in )u.ture1 fo)used 6ourna.s as (e.. as mainstream 6ourna.s <e.g.# %merican ournal of +sychiatry# ournal of %bnormal +sychology# 1hild Development=. ubstanti/e areas of psy)'opat'o.ogy resear)' are being s'aped by )u.tura. resear)'. Efforts to integrate idioms of distress (it' mainstream )onstru)ts$ for examp.e$ are (e.. under(ay <ataCues de nervios and anxiety and affe)ti/e disorders$ nervios and fami.iesG )on)eptua.i4ations of serious menta. i..nessC see =uarna))ia and Rog.er$ *+++3. "n *+BB$ it (as important for @.einman to get t'e message out t'at )u.ture matters. #'e message 'as been re)ei/edC )u.tura. resear)' is pro/iding an inno/ati/e and fres' perspe)ti/e to our understanding of se/era. important aspe)ts of psy)'opat'o.ogy. For )u.tura. resear)'ers to bui.d on t'e empiri)a. and )on)eptua. foundation t'at 'as been estab.is'ed$ it is important at t'is 6un)ture for us to )ontinue to be )riti)a. of 'o( )u.ture is )on)eptua.i4ed and 'o( su)' )on)eptua.i4ations guide our resear)'. "t is ).ear from t'is re/ie( t'at )u.ture )an no .onger be treated so.e.y as an independent /ariab.e or as a fa)tor to be )ontro..ed for. Rat'er$ )u.ture infuses t'e fu.. so)ia. )ontext of menta. 'ea.t' resear)'. Cu.ture is important in a.. aspe)ts of psy)'opat'o.ogy resear)'Efrom t'e design and trans.ation of instruments$ to t'e )on)eptua. mode.s t'at guide t'e resear)'$ to t'e interpersona. intera)tion bet(een resear)'er and resear)' parti)ipants$ to t'e definition and interpretation of symptom and syndromes$ to t'e stru)ture of t'e so)ia. (or.d t'at surrounds a personGs menta. 'ea.t' prob.ems. Cu.tura. psy)'opat'o.ogy resear)' re7uires a frame(or- t'at in)orporates )u.ture in mu.tifa)eted (ays. A))ording.y$ it is most important t'at )u.tura. resear)' not obs)ure t'e importan)e of ot'er so)ia. for)es su)' as ).ass$ po/erty$ and margina.ity t'at (or- in )on6un)tion (it' )u.ture to s'ape peop.eGs e/eryday .i/es. #'e examination of bot' so)ia. and )u.tura. pro)esses is one (ay to 'e.p guard against superfi)ia. )u.tura. ana.yses t'at ignore or minimi4e t'e po(erfu. po.iti)a. e)onomi) ine7ua.ities t'at )oexist (it' )u.ture. A )oro..ary of t'e need for a broad frame(or- for resear)' is t'e need for approa)'es t'at integrate 7ua.itati/e and 7uantitati/e met'ods. Cu.tura. psy)'opat'o.ogy resear)' )an ser/e as an important site for integrating et'nograp'i)$ obser/ationa.$ ).ini)a.$ and epidemio.ogi)a. resear)' approa)'es. Menta. 'ea.t' prob.ems )annot be fu..y understood t'roug' one .ens. Et'nograp'i) resear)' pro/ides insig'ts into t'e meaning of menta. 'ea.t' prob.ems and 'o( t'ey are experien)ed in t'eir so)io)u.tura. )ontext. !bser/ationa. resear)' )aptures peop.eGs fun)tioning in t'eir dai.y .i/es. C.ini)a. resear)' )an pro/ide detai.ed p'SnomSno.ogies of psy)'opat'o.og1 i)a. pro)esses and )an )ontribute to de/e.oping treatments to a..e/iate suffering at t'e indi/idua. as (e.. as so)ia. .e/e.s. Epidemio.ogi)a. resear)' )an broaden perspe)ti/es to more genera.i4ed pro)esses and popu.ations. "t is t'e integration of t'ese perspe)ti/es$ bot' in met'odo.ogies and in t'e )omposition of resear)' teams$ t'at (i.. ma-e t'e )u.tura. agenda su))eed.

#'e u.timate goa. of )u.tura. psy)'opat'o.ogy resear)' is to a..e/iate suffering and impro/e peop.eGs .i/es. #'is re7uires attention to t'e mu.tip.e .e/e.s of indi/idua.$ fami.y$ )ommunity$ and t'e broader so)ia. system. !ur en'an)ed notion of )u.ture .eads to ana.ysis of t'e expression

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75 LLPEF AND GUARNACCIA Ed&ert#n5 R.5 H C#/en5 A. =3@@9>. C$%t$re and s./iC#*/renia' T/e DOSMD ./a%%en&e. $ritish ournal of +sychiatry# 6E;# 0 :3. Fabre&a5 H. =3@8">. T/e need 6#r an et/n#(edi.a% s.ien.e. 'cience# 68@# @?@0@8". Fabre&a5 H. =3@;@>. On t/e si&ni6i.an.e #6 an ant/r#*#%#&i.a% a**r#a./ t# s./iC#*/renia. +sychiatry# 9:# 9"0?". Fabre&a H. =3@@!>. His*ani. (enta% /ea%t/ resear./' A .ase 6#r .$%t$ra% *sy./iatry. ,ispanic ournal of $ehavioral 'cience# 6:# ::@0:?". Fried(an5 S.5 Paradis5 C. M.5 Hat./5 M. =3@@9>. C/ara.teristi.s #6 A6ri.an0A(eri.an and W/ite *atients 2it/ *ani. dis#rder and a&#ra*/#bia. ,ospital and 1ommunity +sychiatry# ;9# 8@;0;!:. F$%i&ni5 A. =3@@;>. A$t/#rity5 a$t#n#(y5 and *arent0ad#%es.ent .#n6%i.t and .#/esi#n' A st$dy #6 ad#%es.ents 6r#( Me-i.an5 C/inese5 Fi%i*in#5 and E$r#*ean ba.+&r#$nds. Developmental +sychology# ?;# 8; 08@ . Ga%%i(#re5 R.5 G#%denber&5 C. N.5 H Weisner5 T. S. =3@@:>. T/e s#.ia% .#nstr$.ti#n and s$bDe.ti,e rea%ity #6 a.ti,ity settin&s' I(*%i.ati#ns 6#r .#(($nity *sy./#%#&y. %merican ournal of 1ommunity +sychology# :6# ":80""@. Garr#5 L. = !!3>. T/e re(e(bered *ast in a .$%t$ra%%y (eanin&6$% %i6e' Re(e(berin& as .$%t$ra%5 s#.ia% and .#&niti,e *r#.ess. In C. M##re H H. Mat/e2s =Eds.>5 The +sychology of 1ultural !"perience =**. 3!"0 398>. Ca(brid&e' Ca(brid&e Uni,ersity Press. Greenber&er5 E.5 HC/en5 C. =3@@?>. Per.ei,ed 6a(i%y re%ati#ns/i*s and de*ressed (##d in ear%y and %ate ad#%es.en.e' A .#(*aris#n #6 E$r#*ean and Asian A(eri.ans. Developmental +sychology# ?:# 8!8083?. Green6ie%d5 P. M. =3@@8>. C$%t$re as *r#.ess' E(*iri.a% (et/#ds 6#r .$%t$ra% *sy./#%#&y. In 7. W. 1erry5 Y. H. P##rtin&a5 H 7. Pandey6Eds.>5 ,andbooko41ross31ultural+sychology5 Fol. 6. Theory and Method =**. :!30:9?>. Need/a( Hei&/ts5 MA' A%%yn H 1a.#n. G$arna..ia5 P. J. =3@@;>. M$%ti.$%t$ra% e-*erien.es #6 6a(i%y .are&i,in&' A st$dy #6 A6ri.an A(eri.an5 E$r#*ean A(eri.an and His*ani. A(eri.an 6a(i%ies. In H. Le6%ey =Ed.>5 /amilies coping with illness5 The cultural conte"t =**. 9"0?3>. San Fran.is.#' 7#ssey01ass. G$arna..ia5 P. 7.5 Canin#5 G.5 R$bi#0Sti*e.5 M.5 H 1ra,#5 M. =3@@:>. T/e *re,a%en.e #6 ataCues de nervios in t/e P$ert# Ri.# st$dy' T/e r#%e #6 .$%t$re in *sy./iatri. e*ide(i#%#&y. ournal of -ervous and Mental Disease# 686# 3"803?". G$arna..ia5 P J., De La Can.e%a5 G5 H Carri%%#5 E. =3@;@a>. T/e ($%ti*%e (eanin&s #6 ataJ$es de ner,i#s in t/e Latin# .#(($nity. Medical %nthropology# 66# 980? . G$arna..ia5 P. 7.5 )%ein(an5 A.5 H G##d5 1. J. =3@@!>. A .riti.a% re,ie2 #6 e*ide(i#%#&i.a% st$dies #6 P$ert# Ri.an (enta% /ea%t/. %merican ournal of +sychiatry# 6;A# 99@09"?. G$arna..ia5 P. <5 H L#*eC S. =3@@;>. T/e (enta% /ea%t/ and adD$st(ent #6 i((i&rant and re6$&ee ./i%dren. 1hild D %dolescent +sychiatric 1linics of -orth %merica# A# ":80"":. G$arna..ia5 P. J.$ Parra5 P.5 Des./a(*s5 A.5 Mi%stein5 G.5 H Ar&i%es5 N. =3@@ >. Si Di#s J$iere' His*ani. 6a(i%iesB

e-*erien.es #6 .arin& 6#r a seri#$s%y (enta%%y i%% 6a(i%y (e(ber. 1ulture# Medicine# and +sychiatry# 6E# 3;80 3". G$arna..ia5 P. 7.5 Ri,era5 M.5 Fran.#5 F5 H Nei&/b#rs5 C. =3@@?>. T/e e-*erien.es #6 ataJ$es de ner,i#s' T#2ards an ant/r#*#%#&y #6 e(#ti#ns in P$ert# Ri.#. 1ulture# Medicine# and +sychiatry# :7# :9:0:?8. G$arna..ia5 P. 7.5 H R#&%er5 L. H. =3@@@>. Resear./ #n .$%t$re0b#$nd syndr#(es' Ne2 dire.ti#ns. %merican ournal of +sychiatry# 69E# 3: 03: 8. G$arna..ia5 P. 7.5 R$bi#0Sti*e.5 M.5 H Canin#5 G. =3@;@b>. %taCues de nervios in t/e P$ert# Ri.an Dia&n#sti. Inter,ie2 S./ed$%e' T/e i(*a.t #6 .$%t$ra% .ate&#ries #n *sy./iatri. e*ide(i#%#&y. 1ulture# Medicine# and +sychiatry# 6?# 8"0 @". He$rtin0R#berts5 S.5 Sn#2den5 L.5 H Mi%%er5 L. =3@@8>. E-*ressi#ns #6 an-iety in A6ri.an A(eri.ans' Et/n#&ra*/y and t/e E*ide(i#%#&i.a% Cat./(ent Area st$dies. 1ulture# Medicine# and +sychiatry# :6# ::80:?:. H#**er5 ). =3@@3>. S#(e #%d J$esti#ns 6#r t/e ne2 .r#ss0.$%t$ra% *sy./iatry. Medical %nthropology >uarterly# 9# @@0::!. H#r2at/5 E.5 7#/ns#n5 7.5 H H#rni&5 C. D. =3@@:>. E*ide(i#%#&y #6 *ani. dis#rder in A6ri.an0A(eri.ans. %merican ournal of +sychiatry# 697#;E93;E@. I,an#,i5 M.5 G$%eti5 F.5 H 1ebbin&t#n5 P. =3@@9>. E-*ressed e(#ti#n in t/e 6a(i%ies #6 *atients 2it/ s./iC#*/renia and its in6%$en.e #n t/e .#$rse #6 i%%ness. 'ocial psychiatry and psychiatric epidemiology# :@# ?30?". 7ab%ens+y5 A.5 Sart#ri$s5 N.5 Ernber&5 GQ An+ar5 MQ H )#rten5 A.5 C##*er5 7. E.5 Day5 R.5 H 1erte%sen5 A. =3@@ >. S./iC#*/renia' Mani6estati#ns5 in.iden.e and .#$rse in di66erent .$%t$res. +sychological Medicine# !=S$**%.>5 30@8. 7en+ins5 J. H. =3@;;a>. C#n.e*ti#ns #6 s./iC#*/renia as a *r#b%e( #6 ner,es' A .r#ss0 .$%t$ra% .#(*aris#n #6 Me-i.an0A(eri.ans and An&%#0A(eri.ans. 'ocial 'cience D Medicine# :E# 3 ::03 9:. 7en+ins5 7. H. =3@;;b>. Et/n#*sy./iatri. inter*retati#ns #6 s./iC#*/reni. i%%ness' T/e *r#b%e( #6 nervios 2it/in Me-i.an0A(eri.an 6a(i%ies. 1ulture# Medicine# and +sychiatry# 6:# :!:0::3. 7en+ins5 7. H. =3@@3>. Ant/r#*#%#&y5 e-*ressed e(#ti#n5 and s./iC#*/renia. !thos# 6@# :;80 9:3. 7en+ins5 7. H. =3@@:>. T## .%#se 6#r .#(6#rt' S./iC#*/renia and e(#ti#na% #,erin,#%,e(ent a(#n& Me-i.an# 6a(i%ies. In A. D. Gaines =Ed.>5 !thnopsychiatry =**. !:0 3>. A%bany' State Uni,ersity #6 Ne2 Y#r+ Press.

. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 77 7en+ins5 7.5 H )arn#5 M. =3@@ >. T/e (eanin& #6 e-*ressed e(#ti#n' T/e#reti.a% iss$es raised by .r#ss0.$%t$ra% resear./. %merican ournal of +sychiatry# 6;@# @0 3. )arn#5 M.5 7en+ins5 7. H.5 de %a Se%,a5 A.5 Santana5 E5 Te%%es5 C5 L#*eC5 S.5 H MintC5 7. =3@;8>. E-*ressed e(#ti#n and s./iC#*/reni. #$t.#(e a(#n& Me-i.an0A(eri.an 6a(i%ies. ournal of -ervous and Mental Disease# 6A9# 39:03"3. )ess%er5 R. C5 Mi.+e%s#n5 ). D.5 H Wi%%ia(s5 D. R. =3@@@>. T/e *re,a%en.e5 distrib$ti#n5 and (enta% /ea%t/ .#rre%ates #6 *er.ei,ed dis.ri(inati#n in t/e United States. ournal of ,ealth and 'ocial $ehavior# ;7# !; :!. )in&5 L. M. =3@8;>. S#.ia% and .$%t$ra% in6%$en.es #n *sy./#*at/#%#&y. %nnual (eview of +sychology# :@#9!"09::. )ir(ayer5 L. 7. =3@@;>. Edit#ria%' T/e 6ate #6 .$%t$re in DSM0IG Transcultural +sychiatry# ?9# ::@0:9 . )%ein(an5 A. =3@;;>. (ethinking +sychiatry5 /rom cultural category to personal e"perience. Ne2 Y#r+' Free Press. )%ein(an5 A.5 Eisenber&5 L.5 H G##d5 1. =3@8;>. C$%t$re5 i%%ness5 and .are' C%ini.a% %ess#ns 6r#( ant/r#*#%#&i. and .r#ss0.$%t$ra% resear./. %nnals of 0nternal Medicine# 88# "30 ";. )%ein(an5 A.5 H G##d5 1. 7. =Eds.>. =3@;">. 1ulture and Depression. 1er+e%ey' Uni,ersity #6 Ca%i6#rnia Press. )%ein(an5 A.5 H )%ein(an5 7. =3@@3>. S$66erin& and its *r#6essi#na% trans6#r(ati#ns' T#2ard an et/n#&ra*/y #6 e-*erien.e. 1ulture# Medicine# and +sychiatry# 69# 8"0:!3. )%ein(an5 A. M. =3@88>. De*ressi#n5 s#(atiCati#n and t/e KNe2 Cr#ss0C$%t$ra% Psy./iatry.K 'ocial 'cience and Medicine# 66# :03!. La(bert5 M. C5 WeisC5 7. R.5 H )ni&/t5 F. =3@;@>. O,er0 and $nder.#ntr#%%ed .%ini. re6erra% *r#b%e(s #6 7a(ai.an and A(eri.an ./i%dren and ad#%es.ents' T/e .$%t$re0&enera% and t/e .$%t$re0s*e.i6i.. ournal of 1onsulting and 1linical +sychology# 9A# 9?8098 . Le665 7. P.5 H Ga$&/n5 C. E. =3@;">. !"pressed emotion in families. NY' G$i%6#rd. Le6%ey5 H. =Ed.>. =3@@;>. /amilies coping with illness5 The cultural conte"t. San Fran.is.#' 7#ssey01ass. Le2is0FernandeC5 R.5 H )%ein(an5 A. =3@@">. C$%t$ra% *sy./iatry' T/e#reti.a%5 .%ini.a% and resear./ iss$es. +sychiatric 1linics of -orth %merica# 68# 9::P39;. Lieb#2itC5 M. R.5 Sa%(Rn5 E.5 7$sin#5 C. M.5 Gar6in+e%5 R.5 Street5 L.5 Cardenas5 D. L.5 Si%,estre5 7.5 Fyer5 A.5 Carras.#5 7. L.5 Da,ies5 S.5 G$arna..ia5 P.5 H )%ein5 D. F. =3@@9>. AtaJ$e de ner,i#s and *ani. dis#rder. %merican ournal of +sychiatry# 696# ;830;8". Lin5 ). M.5 H )%ein(an5 A. M. =3@;;>. Psy./#*at/#%#&y and .%ini.a% .#$rse #6 s./iC#*/renia' A .r#ss0.$%t$ra% *ers*e.ti,e. 'chi*ophrenia $ulletin# 6;# """0"?8. Lin5 ). M.5 P#%and5 R. E.5 H Anders#n5 D. =3@@">. Psy./#*/ar(a.#%#&y5 et/ni.ity and .$%t$re. Transcultural +sychiatric (esearch (eview# ?:# :A9!. LS*eC5 S. R. = !!:>. Re6%e.ti#ns #n t/e S$r&e#n Genera%Bs re*#rt #n (enta% /ea%t/5 .$%t$re5 ra.e5 and et/ni.ity. 1ulture# Medicine and +sychiatry# :A# 93@A99:. LS*eC5 S. R.5 Ne%s#n5 ).5 P#%#5 A.5 7en+ins5 7. H.5 )arn#5 M.5 Ga$&/n5 C5 H Snyder5 ). = !!9>. Et/ni.ity5 e-*ressed

e(#ti#n5 attrib$ti#ns and .#$rse #6 s./iC#*/renia' Fa(i%y 2ar(t/ (atters. ournal of %bnormal +sychology# 66?. LS*eC5 S. R.5 Ne%s#n5 ).5 Snyder5 ).5 H MintC5 7. =3@@@>. Attrib$ti#ns and a66e.ti,e rea.ti#ns #6 6a(i%y (e(bers and .#$rse #6 s./iC#*/renia. ournal of %bnormal +sychology# 678<:=# :!80:39. LS*eC5 S.5 H NTUeC5 7. A. =3@;8>. T/e .#nsiderati#n #6 .$%t$ra% 6a.t#rs in se%e.ted dia&n#sti. .riteria and inter,ie2 s./ed$%es. ournal of %bnormal +sychology# @="5 8!0 8 . Mans#n5 S. M.5 S/#re5 7. H.5 H 1%##(5 7. D. =3@;">. T/e de*ressi,e e-*erien.e in A(eri.an Indian .#(($nities' A ./a%%en&e 6#r *sy./iatri. t/e#ry and dia&n#sis. In A. )%ein(an H 1. 7. G##d =Eds.>5 1ulture and depression =**. ::30:?;>. 1er+e%ey' Uni,ersity #6 Ca%i6#rnia Press. Mar+$s5 H. R.5 H )itaya(a5 S. =3@@3>. C$%t$re and t/e se%6' I(*%i.ati#ns 6#r .#&niti#n5 e(#ti#n5 and (#ti,ati#n. +sychological (eview# @8# 90 ":. Marse%%a5 A. 7. =3@;!>. De*ressi,e e-*erien.e and dis#rder a.r#ss .$%t$res. In H. Triandis H 7. Dra&$ns =Eds.>5 ,andbook of cross3cultural psychology5 Fol. E. +sychopathology =**. :80 ;@>. 1#st#n' A%%yn and 1a.#n. Mars/a%%5 G. N.5 H Or%and#5 M. = !! >. A..$%t$rati#n and*eritra$(ati. diss#.iati#n in y#$n& ad$%t Latin# s$r,i,#rs #6 .#(($nity ,i#%en.e. ournal of %bnormal +sychology# 666# 3??0389. Maser5 7. D.5 H Din&es5 N. =3@@ 4@:>. T/e .#0(#rbidity #6 de*ressi#n5 an-iety and s$bstan.e ab$se a(#n& A(eri.an Indians and A%as+a nati,es. 1ulture# Medicine# and +sychiatry# 6E# 9!@0"88. MeCCi./5 7. E5 )%ein(an5 A.5 Fabre&a5 H.5 H ParrSn5 D. L. =Eds.>. =3@@?>. 1ulture and psychiatric diagnosis5 % D'M30F perspective. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. MeCCi./5 7. E.5 )%ein(an5 A.5 Fabre&a5 H.5 ParrSn5 D. L.5 G##d5 1. 7.5 Lin5 ).5 H Mans#n5 S. M. =3@@8>. C$%t$ra% iss$es 6#r DSM0IG In T. A. Widi&er5 A. 7. Fran.es5 H. A. Pin.$s5 R. R#ss5 M. 1. First5 W. Da,is =Eds.>. D'M30F sourcebook5 G#%. :=**. ;?303!3?>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. M$rray5 C. 7. L.5 H L#*eC5 A. D. =3@@?>. The global burden of disease5 % comprehensive assessment of mortality and disability from diseases# in4uries# and risk factors in 6@@7 and pro4ected to :7:7. Ca(brid&e5 MA' Har,ard Uni,ersity Press.

79 LLPEF AND GUARNACCIA Nea%5 A. M5 Li%%y5 R. S.5 H Fa+is5 S. =3@@:>. W/at are A6ri.an A(eri.an ./i%dren a6raid #6I ournal of %n"iety Disorders# 85 3 @03:@. Nea%5 A. M5 H T$rner5 S. M. =3@@3>. An-iety dis#rders resear./ 2it/ A6ri.an A(eri.ans' C$rrent stat$s. +sychological $ulletin# 8!@59!!093!. Nei&/b#rs5 H. W.5 7a.+s#n5 7. S.5 Ca(*be%%5 L.5 H Wi%%ia(s5 D. =3@;@>. T/e in6%$en.e #6 ra.ia% 6a.t#rs #n *sy./iatri. dia&n#sis' A re,ie2 and s$&&esti#ns 6#r resear./. 1ommunity Mental ,ealth ournal# :9# :!30:3!. OBNe%%5 T. =3@;@>. Psy./iatri. in,esti&ati#ns a(#n& A(eri.an Indians and A%as+a Nati,es' A .riti.a% re,ie2. 1ulture# Medicine# and +sychiatry# 6?# "30;8. OBNe%%5 T.5 H Mit./e%%5 C. M. =3@@?>. A%.#/#% $se a(#n& A(eri.an Indian ad#%es.ents' T/e r#%e #6 .$%t$re in *at/#%#&i.a% drin+in&. 'ocial 'cience and Medicine# ;:# "?"0"8;. Orte&a5 A.5 N.5 R#sen/e.+5 R.5 A%e&ria5 M.5 H Desai5 R. A. = !!!>. A..$%t$rati#n and t/e %i6eti(e ris+ #6 *sy./iatri. and s$bstan.e $se dis#rders a(#n& His*ani.s. ournal of -ervous and Mental Disease# 688# 8 ;08:". P#%#5 A. 7. = !! >. Mental health problems among Me"ican %merican youth5 'ocio3cultural and family correlates. D#.t#ra% dissertati#n5 Uni,ersity #6 Ca%i6#rnia5 L#s An&e%es. Re&ier5 D. A.5 Myers5 7. ).5 )ra(er5 M.5 R#bins5 L. N.5 1%aCer5 D. G.5 H#$&/5 R. L.5 Eat#n5 W. W.5 H L#.+e5 1. F. =3@;9>. T/e NIMH E*ide(i#%#&i. Cat./(ent Area *r#&ra(. %rchives of General +sychiatry# ;6# @:9@93. R#berts5 R. E.5 R#berts5 C. R.5 H C/en5 Y. R. =3@@8>. Et/n#.$%t$ra% di66eren.es in *re,a%en.e #6 ad#%es.ent de*ressi#n. %merican ournal of 1ommunity +sychology# :9# @"033!. R#&%er5 L. H. =3@;@>. T/e (eanin& #6 .$%t$ra%%y sensiti,e resear./ in (enta% /ea%t/. %merican ournal of +sychiatry# 6;E# @?0:!:. R#&%er5 L. H. =3@@9>. Internati#na% (i&rati#ns' A 6ra(e2#r+ 6#r dire.tin& resear./. %merican +sychologist# ;@#8!38!;. R#&%er5 L. H. =3@@?>. Fra(in& resear./ #n .$%t$re in *sy./iatri. dia&n#sis' T/e .ase #6 t/e DSM0IG. +sychiatry5 0nterpersonal D $iological +rocesses# 9@# 39"03"". R#&%er5 L. H.5 Ma%&ady5 R. G.5 H R#dri&$eC5 O. =3@;@>. ,ispanics and mental health5 % framework for research. Ma%abar5 FL' )rie&er. Sa%&ad# de Snyder5 G N.5 DiaC0PereC5 M.5 H 1a$tista5 E. =3@@;>. Pat/2ays t# (enta% /ea%t/ ser,i.es a(#n& in/abitants #6 a Me-i.an ,i%%a&e 2it/ /i&/ (i&rat#ry traditi#n t# t/e United States. ,ealth and 'ocial &ork# :?# 9@ ?3. Sa%(an E.5 Lieb#2itC5 M.5 G$arna..ia5 P. I5 7$sin#5 C. M.5 Gar6in+e%5 R.5 L. Street5 et a%. =3@@;>. S$bty*es #6 ataJ$es de ner,i#s' T/e in6%$en.e #6 .#e-istin& *sy./iatri. dia&n#sis. 1ulture# Medicine# and +sychiatry# ::# :3099. Sart#ri$s5 N.5 7ab%ens+y5 A.5 )#rten5 A.5 Ernber&5 G.5 An+er5 M.5 C##*er5 7. E.5 H Day5 R. =3@;?>. Ear%y (ani6estati#ns and 6irst0.#nta.t in.iden.e #6 s./iC#*/renia in di66erent .$%t$res. +sychological Medicine# 6E# @!@0@ ;. S./neider5 1. H. =3@@;>. Cr#ss0.$%t$ra% .#(*aris#n as d##r+ee*er in resear./ #n s#.ia% and e(#ti#na% adD$st(ent #6 ./i%dren and ad#%es.ents. Developmental +sychology# ?;# 8@:08@8. S/2eder5 R. A.5 H 1#$rne5 E. 7. =3@;9>. D#es t/e .#n.e*t #6 t/e *ers#n ,ary .r#ss0.$%t$ra%%yI In R. A.

S/2eder H R. A. LeGine =Eds.>. 1ulture theory5 !ssays on mind# self and emotion =**. 3";03@@>. Ca(brid&e' Ca(brid&e Uni,ersity Press. S$e S.5 F$Din# D. C5 H$5 L.5 Ta+e$./i5 D.5 HFane5 N. =3@@3>. C#(($nity (enta% /ea%t/ ser,i.es 6#r et/ni. (in#rity &r#$*s' A test #6 t/e .$%t$ra% res*#nsi,eness /y*#t/esis. ournal of 1onsulting and 1linical +sychology# 9@# "::0"9!. S$e5 S.5 S$e5 D.5 S$e5 L.5 H Ta+e$./i D. =3@@".> Asian A(eri.an *sy./#*at/#%#&y. 1ultural Diversity and Mental ,ealth# 6# :@0"3. Ta+e$./i5 D. T5 C/$n&5 R. C. Y5 Lin5 ). M.5 S/en5 H.5 )$rasa+i ).5 C/$n&5 C. A.5 H S$e5 S. =3@@;>. Li6eti(e and t2e%,e0(#nt/ *re,a%en.e rates #6 (aD#r de*ressi,e e*is#des and dyst/y(ia a(#n& C/inese A(eri.ans in L#s An&e%es. %merican ournal of +sychiatry# 699# 39!803939. U.S. De*art(ent #6 Hea%t/ and H$(an Ser,i.es =3@@@>. Mental health5 % report of the 'urgeon General. R#.+,i%%e5 MD' A$t/#r. U.S. De*art(ent #6 Hea%t/ and H$(an Ser,i.es = !!3>. Mental health5 1ulture# race# and ethnicityG% supplement to mental health5 % report of the 'urgeon General. R#.+,i%%e5 MD' A$t/#r. Ga$&/n5 C. E.5 H Le665 7. P. =3@8?>. T/e in6%$en.e #6 6a(i%y and s#.ia% 6a.t#rs #n t/e .#$rse #6 *sy./iatri. i%%ness. $ritish ournal of +sychiatry# 6:@# 3 "03:8. Ga$&/n5 C. E.5 Snyder5 ). S.5 7#nes5 S.5 Free(an5 W. 1.5 H Fa%%##n5 I. R. =3@;9>. Fa(i%y 6a.t#rs in s./iC#*/reni. re%a*se' Re*%i.ati#n in Ca%i6#rnia #6 1ritis/ resear./ #n e-*ressed e(#ti#n. %rchives of General +sychiatry# ;6# 33?@03388. Ge&a5 W5 )/#$ry5 E. L.5 Fi((er(an5 R. S.5 Gi%5 A. G.5 H War/eit5 G. 7. =3@@">. C$%t$ra% .#n6%i.ts and *r#b%e( be/a,i#rs #6 Latin# ad#%es.ents in /#(e and s./##% en,ir#n(ents. ournal of 1ommunity +sychology# :?# 3?8038@.

. CULTURAL DIMENSIONS OF PSYCHOPATHOLOGY 81 Ge&a5 W. A.5 )#%#dy5 1.5 A&$i%ar0Ga-i#%a5 S.5 A%drete5 E.5 Cata%ana5 R.5 Cara,e#0And$a&a5 7. =3@@;>. Li6eti(e *re,a%en.e #6 DSM0III0R *sy./iatri. dis#rders a(#n& $rban and r$ra% Me-i.an A(eri.ans in Ca%i6#rnia. %rchives of General +sychiatry# 99# 883088;. Ware5 N.5 H )%ein(an A. =3@@ >. C$%t$re and s#(ati. e-*erien.e' T/e s#.ia% .#$rse #6 i%%ness in ne$rast/enia and ./r#ni. 6ati&$e syndr#(e. +sychosomatic Medicine# 9;# "9?0"?!. Weine5 A. M.5 P/i%%i*s5 7. S.5 H A./enba./5 T. M. =3@@">. 1e/a,i#ra% and e(#ti#na% *r#b%e(s a(#n& C/inese and A(eri.an ./i%dren' Parent and tea./er re*#rts 6#r a&es ? t# 3:. ournal of %bnormal 1hild +sychology# :?# ?3@0?:@. Weis(an5 A. =3@@8>. Understandin& .r#ss0.$%t$ra% *r#&n#sti. ,ariabi%ity 6#r s./iC#*/renia. 1ultural Diversity and Mental ,ealth# ?# :0:". Weis(an5 A. G.5 G#(es5 L.5 H L#*eC5 S. R. = !!:>. S/i6tin& b%a(e a2ay 6r#( i%% re%ati,es' Latin# 6a(i%iesB rea.ti#ns t# s./iC#*/renia. ournal of -ervous and Mental Disease# 6@6# "890";3. Weis(an5 A. G.5 L#*eC5 S. R.5 Gent$ra5 J.$ N$e./ter%ein5 ). H.5 G#%dstein5 M. 7.5 H H2an&5 S. = !!!>. A .#(*aris#n #6 *sy./iatri. sy(*t#(s bet2een An&%#0A(eri.ans and Me-i.an0A(eri.ans 2it/ s./iC#*/renia. 'chi*ophrenia $ulletin# :E# ;380; 9. WeisC5 J. R.5 C/aiyasit5 W.5 Weiss5 1.5 East(an5 ). L.5 H 7a.+s#n5 E. W. =3@@">. A($%ti(et/#d st$dy #6 *r#b%e( be/a,i#r a(#n& T/ai and A(eri.an ./i%dren in s./##%' Tea./er re*#rts ,ers$s dire.t #bser,ati#n. 1hild Development# EE#9! P33". WeisC5 7. R.5 M.Carty5 C. A.5 East(an5 ). L.5 C/aiyasit5 W5 H S$2an%ert5 S. =3@@8>. De,e%#*(enta% *sy./#*at/#%#&y and .$%t$re' Ten %ess#ns 6r#( T/ai%and. In S. S. L$t/ar5 7. A. 1$ra.+5 D. Ci../etti5 H 7. R. WeisC =Eds.>. Developmental psychopathology5 +erspectives on ad4ustment# risk# and disorder =**. "?;0"@ >. Ca(brid&e' Ca(brid&e Uni,ersity Press. WeisC5 7. R.5 Si&(an5 M.5 Weiss5 1.5 M#s+ 7. =3@@:a>. Parent re*#rts #6 be/a,i#ra% and e(#ti#na% *r#b%e(s a(#n& ./i%dren in )enya5 T/ai%and5 and t/e United States. 1hild Development# E;# @;03!@. WeisC5 J. R.5 S$2an%ert5 S.5 C/aiyasit5 W5 Weiss5 1.5 A./enba./5 T. M.5 H East(an5 ). L. =3@@:b>. 1e/a,i#ra% and e(#ti#na% *r#b%e(s a(#n& T/ai and A(eri.an ad#%es.ents' Parent re*#rts 6#r a&es 3 03?. ournal of %bnormal +sychology# 67:# :@"P3!:. WeisC5 7. R.5 S$2an%ert5 S.5 C/aiyasit5 W5 Weiss5 1.5 A./enba./5 T.M.5 H Tre,at/anD. =3@;@>. E*ide(i#%#&y be/a,i#ra% and e(#ti#na% *r#b%e(s a(#n& T/ai and A(eri.an ./i%dren' Tea./er re*#rts 6#r a&es ?033. ournal of 1hild +sychology and +sychiatry D %llied Disciplines# ?7# 98309;9. WeisC5 J. R.5 S$2an%ert5 S.5 C/aiyasit5 W5 Weiss5 1.5 A./enba./5 T. M.5 H Wa%ter5 1. R. =3@;8b>. E*ide(i#%#&y #6 be/a,i#ra% and e(#ti#na% *r#b%e(s a(#n& T/ai and A(eri.an ./i%dren' Parent re*#rts 6#r a&es ? t# 33. ournal of the %merican %cademy of 1hild D %dolescent +sychiatry# :E# ;@!0;@8. WeisC5 7. R.5 S$2an%ert5 S.5 C/aiyasit5 W5 Weiss5 1.5 H 7a.+s#n5 E. W. =3@@3>. Ad$%t attit$des t#2ard #,er0 and $nder.#ntr#%%ed ./i%d *r#b%e(s' Urban and r$ra% *arents and tea./ers 6r#( T/ai%and and t/e United States.

ournal of 1hild +sychology and +sychiatry D %llied Disciplines# ?:# ?9"0?"9. WeisC5 7. R.5 S$2an%ert5 S.5 C/aiyasit5 W.5 Weiss5 1.5 H Wa%ter5 1. =3@;8a>. O,er0and $nder.#ntr#%%ed re6erra% *r#b%e(s a(#n& ./i%dren and ad#%es.ents 6r#( T/ai%and and t/e United States' T/e wat and wai #6 .$%t$ra% di66eren.es. ournal of 1onsulting D 1linical +sychology# 99# 83@08 ?. WeisC5 7. R.5 H Weiss5 1. =3@@3>. St$dyin& t/e Kre6erabi%ityK #6 ./i%d .%ini.a% *r#b%e(s. ournal of 1onsulting D 1linical +sychology# 9@# ??0 8:. W#r%d Hea%t/ Or&aniCati#n. =3@8@>. 'chi*ophrenia5 %n international follow3up study. Ne2 Y#r+' Wi%ey. F/en&5 Y. P.5 Lin5 ). M5 Ta+e$./i5 D5 )$rasa+i5 ). S.5 Wan&5 Y5 H C/e$n&5 E =3@@8>. An e*ide(i#%#&i.a% st$dy #6 ne$rast/enia in C/inese0A(eri.ans in L#s An&e%es. 1omprehensive +sychiatry# ?8# 9@0 "@.

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CHAPTER

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Gender and Psy./#*at/#%#&y 1arbara A. Winstead and 7anis San./eC Old Dominion University W'at ro.e does gender p.ay in psy)'opat'o.ogyF 8o (omen and men$ gir.s and boys experien)e different types of psy)'o.ogi)a. disordersF 8o t'ey experien)e t'e same disorder in different (aysF Are t'ey treated different.y by t'e menta. 'ea.t' systemF 8o re)ommended treatments (or- e7ua..y (e.. for ma.es and fema.esF 'ou.d treatments ta-e t'e sex of t'e ).ient into a))ountF 8oes it matter ('et'er t'e t'erapist is fema.e or ma.eF W'at differen)e does gender ma-eF And$ if gender ma-es a differen)e$ ('yF 8o bio.ogi)a. andLor so)io)u.tura. fa)tors a))ount for t'ese differen)esF #'is )'apter ta)-.es t'ese 7uestions. "n t'e end (e (i.. dis)o/er t'at t'ese 7uestions raise more 7uestions. C.ear1)ut ans(ers are s)ar)e$ but t'e 7uestions t'emse./es s'ed .ig't on t'e pro)ess of psy)'o.ogi)a. diagnosis and treatment of psy)'o.ogi)a. disorders. Fina..y$ a.t'oug' t'is )'apter fo)uses on gender$ gender intera)ts (it' )u.ture$ ra)eLet'ni)ity$ o)ioe)onomi) tatus$ abi.ity$ age$ and ot'er /ariab.es to form uni7ue experien)es for indi/idua.s. &en)e$ gender must be understood as a potentia..y mu.tidimensiona. as opposed to a unidimensiona. /ariab.e. #'e first 'a.f of t'e )'apter dis)usses information and issues in/o./ing gender differen)es in diagnosis and treatment. "n t'e se)ond part of t'e )'apter$ t(o spe)ifi) disordersEdepression$ an adu.t disorder t'at (omen suffer more often t'an men$ and )ondu)t disorder$ a )'i.d'ood disorder diagnosed more often in boys t'an gir.sEare used to i..ustrate t'e (ays in ('i)' resear)'ers and ).ini)ians strugg.e (it' t'e issue of gender and psy)'opat'o.ogy. DIAGNOSIS #o understand and treat a psy)'o.ogi)a. disorder re7uires a))urate diagnosis. #'e pro)ess of di1 agnosis and treatment is .ess t'an perfe)t$ but t'e goa. )an be ).ear.y stated5 We (is' to identify t'e prob.em$ treat it$ and t'ereby permit t'e ).ient to .ead a more produ)ti/e and re(arding .ife. But 'o( do (e identify t'e prob.emF Wit' p'ysi)a. symptoms$ p'ysi)ians are aided by diagnos1 ti) tests t'at identify abnorma.ities in bio)'emistry$ 'isto.ogy$ or anatomy t'at signa. spe)ifi) disease pro)esses. Wit' psy)'o.ogi)a. prob.ems$ t'ere are rare.y p'ysi)a. signs su)' as an ab1 norma. )e.. )ount. We may use diagnosti) tests$ but t'ese are .i-e.y to be based on t'e se.f1 reports of ).ients$ not b.ood )'emistry or )e.. )u.tures. !ften psy)'o.ogi)a. diagnosis is a))omp.is'ed 84

85 W"N #EA8 AN8 ANC&ER t'roug' inter/ie(s in ('i)' ).ini)ians .earn about symptoms dire)t.y from t'e ).ient or t'roug' obser/ation of symptoms. W'at t'e Diagnostic and 'tatistical Manual of Mental Disorders 28 M1">1#R5 Ameri)an %sy)'iatri) Asso)iation$ 9,,,3 pro/ides is a set of agreed1on )riteria t'at 'e.p ).ini)ians ma-e diagnoses based on sets of symptoms. %sy)'o.ogi)a. diagnosis$ fo..o(ing t'e medi)a. mode.$ .eads to presentLabsent de)isions$ a.t'oug' many 'a/e argued t'at a )ontinuous rat'er t'an a )ategori)a. mode. is better for understanding psy)'o.ogi)a. disorders 2Maddux$ 9,,93. Wit' eit'er mode.$ (e (ant to be ab.e to ma-e an a))urate assessment of t'e indi/idua. and to t'is end (e assess t'e re.iabi.ity and /a.idity of ).ini)a. tests$ ).ini)a. inter/ie(s$ and systems for identifying menta. disorders 2 ee Widiger$ )'ap. ;C =arb$ Li.ienfe.d$ H Fo(.er$ )'ap. <3. Wit' a perfe)t.y re.iab.e and /a.id system (e )ou.d easi.y dis)o/er if men and (omen 'a/e simi.ar or different psy)'o.ogi)a. disorders$ if t'e etio.ogies or disease )ourses of t'ese i..nesses are simi.ar or different$ and u.timate.y if men and (omen benefit from simi.ar or different treatments. But (it' .ess t'an perfe)t diagnosti) systems our 7uestions about gender be)ome more diffi)u.t to ans(er. An offi)ia. nomen).ature for identifying menta. i..nesses (as first estab.is'ed in part to )reate a )ommon .anguage for menta. 'ea.t' professiona.s and resear)'ers 2see Widiger$ )'ap. ;3. Beginning in *+B,$ (it' 8 M1"""$ t'is goa. (as .arge.y a))omp.is'ed in t'e United tates$ and resear)'ers of psy)'o.ogi)a. disorders and treatments adopted t'is system of diagnosis. Efforts to impro/e t'e re.iabi.ity and /a.idity of t'e 8 M 'a/e .ed to re/ised and updated editions$ 8 M1 """1R 2*+BD3 and t'e )urrent 8 M1">1#R 29,,,3. #'e purpose of a )arefu..y arti)u.ated diagnosti) system is to pro/ide ).ini)ians and resear)'ers (it' an ob6e)ti/e1as1possib.e basis for ma-ing de)isions about t'e presen)e or absen)e of spe)ifi) psy)'opat'o.ogy. But t'e 7uestion of gender bias in t'e diagnosti) )ategories t'emse./es (as raised a.most immediate.y 2@ap.an$ *+B:3. Furt'ermore$ to t'e extent t'at information re.ies on t'e inter/ie(ing and interpersona. s-i..s of a diagnosti)ian 2as opposed to a standardi4ed sur/ey or inter/ie(3$ t'e gat'ering of pertinent information to ma-e t'is determination may be biased. E/en items on standardi4ed s)a.es may introdu)e gender or sex bias. Fina..y$ a.t'oug' 8 M guide.ines are in b.a)- and ('ite$ putting a.. t'e symptoms toget'er to arri/e at a diagnosis may be inf.uen)ed by ).ini)ian expe)tations and be.iefs about gender and sex differen)es in pre/a.en)e rates. A fundamenta. issue$ for examp.e$ is ('et'er or not t'e pre/a.en)e rates of disorders are different for fema.es and ma.es. &artung and Widiger 2*++B3 )on).ude t'at 0Most of t'e menta. disorders diagnosed (it' t'e 8 M1"> do appear to 'a/e signifi)ant differentia. sex pre/a.en)e rates0 2p. 9B,3. A))ording to t'eir ana.ysis$ t'e 8 M1"> pro/ides information on differentia. sex pre/a.en)e for *,* of its *9< des)ribed psy)'o.ogi)a. disorders. Ex).uding disorders t'at are$ by definition$ spe)ifi) to one sex or t'e ot'er 2e.g.$ fema.e orgasmi) disorder$ ma.e ere)ti.e disorder3$ B;P of t'e 8 M1"> disorders$ for ('i)' information on pre/a.en)e by sex is a/ai.1 ab.e$ are reported to o))ur at different rates in fema.es and ma.es. A genera. summary of t'ese differen)es indi)ates t'at ma.es are more .i-e.y to be diagnosed (it' t'e infan)y$ )'i.d'ood$ and ado.es)ent disorders and (it' substan)e1re.ated$ sexua.$ gender identity$ and impu.si/e disorders. Fema.es are more .i-e.y to be diagnosed (it' depression$ anxiety$ somati4ation$ disso)iati/e$ and eating disorders. 8iagnoses of persona.ity disorders tend to para..e. expe)ted sex differen)es in persona.ity traits or e/en gender stereotypes5 Fema.es are reported to 'a/e 'ig'er rates of border.ine$ 'istrioni)$ and dependent persona.ity disordersC ma.es are reported to 'a/e 'ig'er rates of paranoid$ s)'i4oid$ s)'i4otypa.$ antiso)ia.$ and )ompu.si/e persona.ity disorders.

#'e 8 M1">1#R 29,,,3 re.ies on t'e best a/ai.ab.e data for ma-ing its estimates of sex differen)es in pre/a.en)e ratesC but 'o( good are t'ese dataF &o( do (e -no( 'o( many indi/idua. gir.s$ boys$ (omen$ or men a)tua..y experien)e a )ertain psy)'o.ogi)a. disorderF Widiger 2*++B3 )ites six (ays in ('i)' diagnoses may ref.e)t a sex bias5 02*3 biased diagnosti)

:. GENDER AND PSYCHOPATHOLOGY 87 )onstru)ts$ 293 biased diagnosti) t'res'o.ds$ 2:3 biased app.i)ation of t'e diagnosti) )riteria$ 2;3 biased samp.ing of persons (it' t'e disorder$ 2<3 biased instruments of assessment$ andLor 2?3 biased diagnosti) )riteria0 2p. +?3. Using t'ese )ategories as a basis for understanding gender bias in diagnosis$ (e (i.. dis)uss biases in diagnosti) standards 2e.g.$ )onstru)ts$ )riteria$ and t'res'o.ds3$ biased app.i)ations of t'ese diagnosti) standards$ in).uding assessment instruments$ and biased samp.ing. 1iased Dia&n#sti. Standards Criti)s of 8 M1""" 2*+B,3 and 8 M1"""1R 2*+BD3 argued t'at t'e diagnosti) )onstru)ts t'em1 se./es (ere sexist and t'at (omen are pat'o.ogi4ed by 8 M diagnosti) )riteria 2Bro(n$ *++9C Cap.an$ *++*$ *++<C @ap.an$ *+B:C Wa.-er$ *++;3. #'is point (as argued most often in referen)e to t'e persona.ity disorders. &istrioni) persona.ity disorder and dependent persona.ity disorder 'a/e been )ited as t'e most egregious examp.es of gendered$ in t'is )ase feminine$ traits being used to estab.is' t'e presen)e of psy)'opat'o.ogy 2@ap.an$ *+B:3. @ap.an 2*+B:3 proposed 0independent persona.ity disorder0 and 0restri)ted persona.ity disorder$0 and %antony and Cap.an 2*++*3 suggested 0de.usiona. dominating persona.ity disorder0 as )omparab.e$ but mas)u.ine stereotyped$ disorders. !t'ers$ 'o(e/er$ argued t'at 8 M1""" a.ready in).udes persona.ity disorders t'at )aptured ma.adapti/e mas)u.ine traits$ spe)ifi)a..y$ antiso)ia. persona.ity disorder and )ompu.si/e persona.ity disorder 2Wi..iams H pit4er$ *+B:3. Ross$ Fran)es$ and Widiger 2*++<3 suggest5 0#'e 8 M1"""L8 M1"""1R persona.ity disorder )riteria (ere )onstru)ted$ for t'e most part$ by ma.es (it' .itt.e input from systemati) empiri)a. resear)'. "t (ou.d not be surprising to find t'at ma.e ).ini)ians (ou.d 'a/e a .o(er t'res'o.d for t'e attribution of ma.adapti/e feminine traits t'an for t'e attribution of ma.adapti/e mas)u.ine traits0 2p. 9*93. #'ey des)ribe 'o( t'e 8 M1"> %ersona.ity 8isorders Wor- =roup addressed t'is prob.em bot' by extensi/e re/ie(s of existing empiri)a. resear)' and by )reating more gender1neutra. )riteria. For examp.e$ t'e 'istrioni) persona.ity disorder item 0inappropriate.y sexua..y sedu)ti/e in appearan)e or be'a/ior0 28 M1"""1R$ *+BD3 (as )'anged to 0intera)tion (it' ot'ers is often )'ara)teri4ed by inappropriate sexua..y sedu)ti/e or pro/o)ati/e be'a/ior.0 Remo/ing t'e referen)e to 0appearan)e0 (as intended to redu)e t'e possibi.ity t'at t'e norma. fema.e response to so)ia. pressure to appear p'ysi)a..y attra)ti/e mig't be /ie(ed as 0inappropriate.y sexua..y sedu)ti/e.0 8 M1"""1R 2*+BD3 a.so introdu)ed an appendix tit.ed 0%roposed 8iagnosti) Categories Needing Furt'er tudy.0 A.. t'ree proposed )ategoriesE.ate .utea. p'ase dysp'ori) disorder$ sadisti) persona.ity disorder$ and se.f1defeating persona.ity disorderE(ere )ontro/ersia. 2Ross$ Fran)es$ H Widiger$ *++<3. Criti)s argued t'at t'e term late luteal phase disorder mig't stigmati4e (omen by ma-ing be'a/iora. rea)tions re.ated to t'e menstrua. )y).e a menta. disorder. Kuestions about t'e empiri)a. base for in).uding t'is )ategory as a 8 M disorder (ere a.so raised. Based on extensi/e re/ie(s of t'e resear)' .iterature and data reana.yses$ t'e (or- group suggested renaming t'e disorder premenstrua. dysp'ori) disorder and )ontinuing to in).ude it in an appendix t'at for 8 M1"> is tit.ed 0Criteria ets and Axes %ro/ided for Furt'er tudy.0 #'e term self3defeating personality disorder (as parti)u.ar.y disturbing to some be)ause of its potentia. for being used to pat'o.ogi4e /i)tims of abuse. #'e proposed )riteria ma-e an abusi/e en/ironment an ex).usion )riterion$ but it (as un).ear 'o( t'is approa)' mig't be used in pra)ti)e. A )on)ern (it' t'e term sadistic personality disorder (as t'at )rimina. be'a/ior 2e.g.$ assau.t$ abuse3 mig't be .abe.ed a menta. i..ness. "n t'e end neit'er se.f1defeating persona.ity

disorder nor sadisti) persona.ity disorder (as retained in 8 M1">$ based primari.y on t'eir 'a/ing been t'e fo)us of /ery .itt.e resear)' 2Ross$ Fran)es$ H Widiger$ *++<3. #'is brief des)ription of a .engt'y pro)ess indi)ates t'e (ays in ('i)' t'e estab.is'ment

89 WINSTEAD AND SANCHEF of )onstru)ts t'at )omprise a diagnosti) system su)' as t'e 8 M is a /ery 'uman pro)ess$ inf.uen)ed ine/itab.y by bot' sub6e)ti/e and ob6e)ti/e 6udgments 2as noted in )'ap. *3. !t'er diagnosti) )ategories a.so represent a )'a..enge for gender neutra.ity. omati4ation disorder is a disorder reported to range from 0,.9P to 9P among (omen and .ess t'an ,.9P in men0 28 M1">$ *++;$ p. ;;D3. A.t'oug' substantia. re/isions (ere made to ma-e )riteria .ess sex biased$ 8 M1"> retains )riteria t'at ma-e a diagnosis in men un.i-e.y. C.ients must meet a.. of t'e four )riteria$ and t'e symptoms reported must be found to be not fu..y exp.ained by a medi)a. )ondition. et : is 0one sexua. or reprodu)ti/e symptom ot'er t'an pain.0 #'e examp.es gi/en in).ude four symptoms t'at app.y ex).usi/e.y to (omen 2irregu.ar menses$ ex)essi/e menstrua. b.eeding$ /omiting t'roug'out pregnan)y3$ one t'at app.ies to men 2ere)ti.e or e6a)u.atory dysfun)tion3$ and one t'at may app.y more often to (omen 2sexua. indifferen)e3 28 M1">$ p. ;;+3. #'ese symptoms may be t'e most /a.id )riteria for somati4ation disorder$ espe)ia..y for (omen$ but t'ey a.so tend to ex).ude men. &artung and Widiger 2*++B3 ma-e t'is point and )on).ude5 0Resear)' on t'e epidemio.ogy of t'e disorder t'erefore )ontinues to use a )riteria set t'at is biased against ma-ing t'e diagnosis in ma.es$ )omp.i)ating any identifi)ation of t'e disorder in ma.es0 2p. 9?+3. #'ey furt'er point out t'at t'e Wor.d &ea.t' !rgani4ation )riteria for t'is disorder$ a.t'oug' sti.. in).uding menstrua. symptoms$ a.so .ist gastrointestina. symptoms$ abnorma. s-in sensations$ and b.ot)'iness as )ommon symptoms$ resu.ting in t'is disorder being reported more fre7uent.y in ma.es (it'in ot'er )u.tures. #'e 7uestion of )riterion bias is furt'er )omp.i)ated by t'e issue of t'e diagnosti) /a.idity of spe)ifi) symptoms for fema.es and ma.es. #'e purpose of gat'ering information about a ).ientGs fee.ings$ t'oug'ts$ and be'a/iors is to identify a psy)'o.ogi)a. disorder. "t may be t'e )ase t'at )ertain symptoms are predi)ti/e of a diagnosti) )ategory$ future symptoms$ or responsi/eness to treatment for ma.es but not for fema.es or /i)e /ersa. An examp.e from t'e arena of p'ysi)a. i..ness i..ustrates t'is prob.em. A.t'oug' 'eart disease is t'e T* -i..er of bot' (omen and men in t'e United tates and more (omen t'an men 'a/e died from 'eart disease e/ery year sin)e *+B; 2=iardina$ 9,,,3$ 'eart disease is sti.. genera..y regarded as a greater prob.em for men t'an for (omen. ymptoms of a 'eart atta)- 2e.g.$ tig'tness or dis)omfort in t'e )'est$ spreading pain in t'e arms$ ba)-$ 6a($ or stoma)'3 are (ide.y ad/ertised be)ause see-ing medi)a. treatment 7ui)-.y is )riti)a. to pre/enting or .imiting t'e damage )aused by a 'eart atta)-. "t is estimated$ 'o(e/er$ t'at :<P of 'eart atta)-s in (omen are unreported. Women 'a/ing 'eart atta)-s are as .i-e.y as men to experien)e )'est pain$ but t'ey are some('at more .i-e.y to experien)e ot'er symptoms$ su)' as breat'.essness$ perspiration$ nausea$ and a sensation of f.uttering in t'e 'eart 2=iardina$ 9,,,3. An unfami.iar )onste..ation of symptoms may pre/ent (omen or 'ea.t' professiona.s from suspe)ting t'e presen)e of 'eart disease. "n t'e )ase of 'eart atta)-s$ a.t'oug' t'e under.ying )ondition is t'e same$ t'e presenting symptoms for (omen and men are some('at different. "t is .i-e.y t'at for some psy)'o.ogi)a. disorders a simi.ar pro)ess o))urs. Being ab.e to identify a )riterion t'at is differentia..y /a.id for fema.es or ma.es re7uires a diagnosti) system t'at is independent of t'is )riterion. "n t'e )ase of 'eart disease$ ('ate/er t'e presenting symptoms$ t'e presen)e or absen)e of a myo)ardia. infar)tion )an be assessed independent.y. For psy)'o.ogi)a. disorders$ t'ere is no simi.ar )onfirmation. "n referen)e to estab.is'ing )riteria for persona.ity disorders$ Robins and =u4e 2*+D,3 ad/o)ated for /a.idation studies t'at (ou.d 0assess t'e extent to ('i)' t'e )riteria se.e)t persons ('o 'a/e a 'istory$ present$ andLor future )onsistent (it' t'e )onstru)t of a 2parti)u.ar3 persona.ity disorder0 2p. *D3.

!ne mig't a.so suggest a /a.idity test t'at )onsiders t'e effe)ti/eness of standard inter/entions for persons (it' and (it'out a parti)u.ar diagnosti) )riterion. Widiger 2)'ap. ;3 re)ogni4es t'at a )'a..enge for 8 M1>$ t'e next edition of 8 M$ (i.. be addressing t'e prob.em of ma-ing diagnosti) )riteria more gender neutra. 2i.e.$ )riteria t'at app.y e7ua..y to fema.es and ma.es3 or de/e.oping separate sets of )riteria$ at .east for some

:. GENDER AND PSYCHOPATHOLOGY 91 disorders$ for fema.es and ma.es. #'is debate 'as been parti)u.ar.y sa.ient to t'e diagnosis of )ondu)t disorder and (i.. be exp.ored furt'er in t'at se)tion. A))ording to 8 M1"> 2*++;3$ 0#'e definition of mental disorder... re7uires t'at t'ere be ).ini)a..y signifi)ant impairment or distress0 2p. D3. #'res'o.ds for diagnoses s'ou.d represent t'e point at ('i)' t'e a))umu.ation of symptoms rea)'es t'is .e/e. of impairment or distress. But ('ere is itF #'e issue of t'res'o.ds is one of t'e arguments for a )ontinuous rat'er t'an )ategori)a. /ie( of psy)'opat'o.ogy 2Maddux$ 9,,93$ but it remains t'e )ase t'at ).ini)ians and ).ini)a. resear)'ers are regu.ar.y fa)ed (it' t'e tas- of a presentLabsent de)ision in regard to t'e diagnosis of pat'o.ogy. %re/a.en)e of a disorder among (omen and men (i.. be affe)ted by t'e setting of t'is t'res'o.dC and for disorders more often diagnosed in (omen or in men t'e setting of t'is t'res'o.d (i.. affe)t o/era.. rates of psy)'opat'o.ogy for t'e sexes. "t is important to note t'at$ for t'e most part$ t'e number of )riteria needed to rea)' t'res'o.d for a 8 M1"> diagnosis is estab.is'ed by )ommittee rat'er t'an by empiri)a. resear)' t'at (ou.d 6ustify t'at parti)u.ar number. "n an effort to determine t'e re.ati/e pat'o.ogy represented by fema.e1typed and ma.e1typed persona.ity disorders$ Funto(i)4 and Widiger 2*++<3 identified )o..ege student parti)ipants at t'e t'res'o.d of t'e disorders and t'en examined t'eir .e/e.s of so)ia. and o))upationa. dysfun)tion. #'ey found .o(er .e/e.s of dysfun)tion for ma.e1typed disorders$ suggesting t'at 0it mig't be re.ati/e.y easier to obtain a ma.e1typed persona.ity disorder diagnosis t'an some fema.e1typed persona.ity disorder diagnoses0 2Funto(i)4 H Widiger$ *++<$ p. *<D3. W'et'er ma.es or fema.es are more in danger of biased diagnoses$ (it'out t'res'o.ds estab.is'ed t'roug' resear)'$ t'e 8 M is /u.nerab.e to t'e )riti)ism of gender bias in diagnosti) t'res'o.ds. 1iased A**%i.ati#n #6 t/e Dia&n#sti. Criteria 8iagnosis may a.so in/o./e ob6e)ti/e tests or stru)tured or semistru)tured inter/ie(s. A.t'oug' bias often suggests sub6e)ti/ity in 6udgment$ standardi4ed tests )an a.so )ontain sex or gender bias. Lindsay and Widiger 2*++<3 'a/e argued t'at any se.f1report or inter/ie( response t'at does not ref.e)t dysfun)tion but does app.y to one sex more t'an t'e ot'er represents a sex1 biased item. A gender1biased item is re.ated to gender 2femininity or mas)u.inity3 but not to psy)'opat'o.ogy. A biased item o))urs ('en men or (omen 2sex bias3 or mas)u.ine or feminine persons 2gender bias3 are more .i-e.y to endorse t'e item. #'e item itse.f is not a symptom$ nor is it re.ated to genera. psy)'opat'o.ogy$ but it does )ontribute to a s)a.e t'at measures a persona.ity disorder. Using )o..ege students$ Lindsay and Widiger 2*++<3 determined t'at *:P to :* P of t'e items from t'ree standardi4ed measures of persona.ity disorder s'o(ed some e/iden)e of sex or gender bias a))ording to t'ese )riteria. "n a fo..o(1up study Lindsay$ an-is$ and Widiger 29,,,3 used outpatients from menta. 'ea.t' ).ini)s and updated /ersions of t'e instruments5 Mi..Mn C.ini)a. Mu.tiaxia. "n/entory1".. 2MMC"1"""3$ Minnesota Mu.tip'asi) %ersona.ity "n/entory1"" 2MM%"1""3$ and %ersona.ity 8iagnosti) Kuestionnaire1Re/ised 2%8K1R3. Four persona.ity disorder s)a.es 2'istrioni)$ dependent$ antiso)ia.$ and nar)issisti)3 from t'ese instruments (ere ana.y4ed for sex or gender bias. None of t'e s)a.e s)ores from any of t'e in/entories (as re.ated to bio.ogi)a. sex. !n.y t'ree s)a.e items s'o(ed sex bias 2(omen or men (ere more .i-e.y to endorse t'em but t'e item (as unre.ated to a measure of psy)'opat'o.ogy$ t'e %ersona.ity Assessment "n/entory3$ ('ereas :? items suggested gender biasEt'at is$ t'e item )orre.ated (it' a measure of femininity or mas)u.inity but not (it' t'e measure of psy)'opat'o.ogy. An examp.e of an item t'at demonstrated sex bias and gender bias (as 0"tGs

/ery easy for me to ma-e many friends0 from t'e MCM"1""" &istrioni) s)a.e. #'is item is not indi)ati/e of a psy)'o.ogi)a. prob.em$ but it does )ontribute to a 'ig'er s)ore for 'istrioni) persona.ity disorder. "t is a.so more fre7uent.y endorsed by (omen t'an men and

93 WINSTEAD AND SANCHEF it )orre.ates positi/e.y (it' measures of femininity. #'is item$ t'en$ (ou.d tend to gi/e (omen and feminine indi/idua.s 'ig'er s)ores for 'istrioni) persona.ity disorder ('i.e endorsing an item t'at does not represent a ma.adapti/e trait or be'a/ior. A.t'oug' t'e fe( items 2t'ree3 demonstrating sex bias (ere a.. from t'e &istrioni) s)a.es$ more examp.es of gender bias (ere from t'e Nar)issisti) s)a.e$ suggesting t'at mas)u.ine indi/idua.s may re)ei/e a 'ig'er s)ore by endorsing items t'at ref.e)t adapti/e$ rat'er t'an pat'o.ogi)a.$ )'ara)teristi)s. Regard.ess of t'e )are ta-en to estab.is' re.iab.e and /a.id diagnosti) too.s$ t'e ).ini)ians using t'e too.s may be affe)ted by t'eir o(n gender stereotypes in app.ying t'em$ as 'as been s'o(n to o))ur in numerous ana.ogue studies. "n ana.ogue studies ).ini)ians are presented (it' )ase 'istories t'at are identi)a. ex)ept for t'e sex of t'e patient. &a.f of t'e ).ini)ians in t'e resear)' diagnose t'e 0fema.e patient$0 and 'a.f diagnose t'e 0ma.e patient.0 =i/en t'e same information$ (i.. ).ini)ians )ome to t'e same or different )on).usions about t'e presen)e of psy)'o.ogi)a. disordersF Warner 2*+DB3 ga/e ).ini)ians ambiguous patient profi.es$ (it' a mixture of 'ysteri)a. and antiso)ia. symptoms 2e.g.$ sui)ide attempts$ no ).ose re.ations'ips$ se.f1)entered$ s'op.ifting (it' no remorse for )rime$ f.irtatious3. Fema.e profi.es (ere more .i-e.y t'an ma.e profi.es to be .abe.ed 'ysteri)a. 2D?P /s. ;+P3$ and ma.e profi.es (ere more .i-e.y t'an fema.e to be .abe.ed antiso)ia. 2;* P /s. 99PU3. "t )an be argued t'at (it' ambiguous information$ ).ini)ians re.y on base rates 2(omen are more .i-e.y to be 'ysteri)a.C men are more .i-e.y to be antiso)ia.3. #'e base rates t'emse./es$ 'o(e/er$ may a.so represent a biased a))umu.ation of data on (omen and men. "f ).ini)ians use stereotyped per)eptions of (omen and men in t'eir diagnoses 2as t'ese studies indi)ate3$ t'en t'e data based on t'eir ).ini)a. 6udgments (i.. be biased. #o )ir)um/ent t'e issue of base rates$ many studies 'a/e presented ).ini)ians (it' )ases t'at meet t'e 8 M )riteria for one or more disorders. Ford and Widiger 2*+B+3 )reated )ases based on 8 M1""" )riteria for 'istrioni) and antiso)ia. persona.ity disorders5 !ne )ase met diagnosti) )riteria for antiso)ia. persona.ity disorder$ one met )riteria for 'istrioni) persona.ity disorder$ and one fai.ed to rea)' diagnosti) )riteria for eit'er. &istrioni) persona.ity disorder (as more fre7uent.y diagnosed in (omen$ e/en ('en t'e )ase )ontained more antiso)ia. t'an 'istrioni) )riteriaC and antiso)ia. persona.ity disorder (as .ess often diagnosed in (omen. Ad.er$ 8ra-e$ and #eague 2*++,3 de/e.oped one )ase 'istory t'at met t'e exp.i)it )riteria of four diagnoses5 'istrioni)$ nar)issisti)$ border.ine$ and dependent. Men (ere more .i-e.y to re)ei/e a diagnosis of nar)issisti) persona.ity disorderC (omen$ 'istrioni) persona.ity disorder. #'ere (ere no dif1 feren)es for border.ine or dependent 2('i)' (as rare.y used3 persona.ity disorder. "n resear)' using a )ase t'at met t'e )riteria of border.ine persona.ity disorder 2B%83 and posttraumati) stress disorder$ 'o(e/er$ (omen did re)ei/e 'ig'er ratings for B%8 2Be)-er H Lamb$ *++;3. Fernba)'$ Winstead$ and 8er.ega 2*+B+3 )reated separate )ases for antiso)ia. and somati4ation disorders and found t'at t'ere (ere no sex1of1/ignette differen)es for somati4ation disorderC but for antiso)ia. persona.ity disorder$ a.t'oug' most )ases (ere a))urate.y diagnosed$ men 2D:P3 (ere more .i-e.y t'an (omen 2<:P3 to re)ei/e t'e diagnosis. Loring and %o(e.. 2*+BB3 in).uded bot' persona.ity disordered 2dependent3 and psy)'oti) 2undifferentiated s)'i4op'renia3 symptoms in t'e )ases to be diagnosed and ra)e 2B.a)- /s. W'ite3 as (e.. as gender as demograp'i) )'ara)teristi)s of t'e )ase. #'ey a.so examined gender and ra)e of t'e diagnosing psy)'iatrists as inf.uen)es on t'e diagnosti) pro)ess. #'ey found t'at simi.arity in ra)e and gender bet(een ).ini)ian and ).ient produ)ed t'e most a))urate diagnoses$ t'at ma.e ).ini)ians o/erdiagnosed depression and 'istrioni) persona.ity disorder in (omen$ and t'at a.. ).ini)ians

o/erdiagnosed paranoia in B.a)- ).ients. #'is study reinfor)es t'e )on).usion t'at gender 'as a po(erfu. inf.uen)e on diagnosis$ but )omp.i)ates t'e pi)ture by indi)ating t'at ra)e a.so matters and t'at t'e demograp'i) )'ara)teristi)s of t'e diagnosing ).ini)ian may intera)t (it' ).ient )'ara)teristi)s to affe)t diagnosis.

:. GENDER AND PSYCHOPATHOLOGY 95 "f t'e diagnosti) )riteria for a disorder are bui.t into a des)ription of t'e ).ient$ t'en t'e presen)e of ).ini)ian bias represents a fai.ure to ad'ere to t'e 8 M diagnosti) )riteria. C.ini)ians are )oming up (it' t'e 0(rong0 ans(er ('en t'ey indi)ate a diagnosti) )ategory ot'er t'an t'e one intended. Ford and Widiger 2*+B+3 demonstrated t'at at t'e .e/e. of indi/idua. )riteria$ t'ere is no sex bias. pe)ifi) be'a/iors (ere rated as indi)ati/e of 'istrioni) persona.ity disorders and antiso)ia. persona.ity disorder (it' e7ua. fre7uen)y for men and (omen. But t'ey did find sex bias ('en assigning ).ients to one of t'ese diagnosti) )ategories. Ford and Widiger 2*+B+3 )on).uded t'at 'istrioni) persona.ity disorder (as o/erdiagnosed in (omen and underdiagnosed in men. B.as'fie.d and &er-o/ 2*++?3 and Morey and !)'oa 2*+B+3 .oo-ed at ).ini)iansG ratings of 8 M )riteria for t'eir o(n patients and )ompared ratings on indi/idua. )riteria (it' a)tua. diagnoses of t'ese patients. #'ey found (ea- asso)iations bet(een ).ini)iansG ratings of t'e )riteria and t'e ).ini)iansG diagnoses$ suggesting t'at gi/ing a diagnosis does not ne)essari.y in/o./e an ob6e)ti/e formu.a based on t'e presen)e or absen)e or t'e tota. number of )ertain )riteria. Morey and !)'oa 2*+B+3 found t'at ).ini)ians o/erdiagnose antiso)ia. persona.ity disorder in men and B%8 in (omen$ a.t'oug' B.as'fie.d and &er-o/ 2*++?3 did not rep.i)ate t'ese findings. #'e absen)e of sex bias for spe)ifi) )riteria in )ontrast to t'e presen)e of sex bias in assigning 8 M1based diagnosis suggests t'at dimensiona. approa)'es to diagnosis may be .ess prone to bias t'an )ategori)a. .abe.s$ as 6udgments in t'e dimensiona. approa)' remain at t'e .e/e. of be'a/iora. indi)ators rat'er t'an a summary diagnosti) de)ision. #'ese studies indi)ate t'at ).ini)ians do use sex of patient as information t'at affe)ts t'eir 6udgment about t'e diagnosis of a )ase. ome diagnoses are more prone to t'is bias t'an ot'ers$ and t'e bias may be primari.y at t'e .e/e. of )ategori4ation rat'er t'an at t'e .e/e. of 6udging if a parti)u.ar trait or be'a/ior is present. A.t'oug' ana.ogue studies a..o( t'e resear)'er to present ).ini)ians (it' identi)a. information ('i.e /arying sex of patient$ t'e responses of ).ini)ians to paper1and1pen)i. or e/en audio or /ideo /ersions of a patient )annot )omp.ete.y )apture t'e more intera)ti/e pro)ess t'at a)tua..y o))urs during diagnosis$ a pro)ess t'at may be e/en more sus)eptib.e to bias. =ender bias in t'e app.i)ation of )riteria is a rea.ity in t'e pra)ti)e of menta. 'ea.t' )are. Fur1 t'ermore$ to t'e degree t'at a))urate diagnosis .eads to more effe)ti/e treatment of disorders$ t'ese biases t'at .ead to ina))urate diagnoses are parti)u.ar.y troub.esome. 1iased Sa(*%in& #'e most )on/enient data for ana.ysis of pre/a.en)e rates are data obtained in ).ini)a. settings. W'en indi/idua.s )ome into a ).ini)a. setting 2eit'er by t'eir o(n /o.ition or by t'e a)tions of ot'ers 2e.g.$ parent$ )ourts33$ t'ey genera..y re)ei/e a diagnosis. Assuming diagnoses are a))urate.y obtained$ t'ese data (ou.d appear to be a good sour)e of information. But do a.. indi/idua.s (it' a parti)u.ar disorder s'o( up in a ).ini)a. settingF Fa)tors bringing adu.ts into a ).ini)a. setting in).ude (i..ingness to a)-no(.edge t'e symptoms$ (i..ingness to see- treatment$ or t'e persuasi/e or )oer)i/e inf.uen)e of ot'ers. Fa)tors bringing )'i.dren into a ).ini)a. setting in).ude parentsG and tea)'ersG per)eptions of t'e se/erity of t'e prob.em and of t'e possibi.ities for treatment. #'ese fa)tors are .i-e.y to be inf.uen)ed by t'e sex of t'e affe)ted indi/idua.. Women may be more .i-e.y to re)ogni4e and .ess resistant to a)-no(.edging t'at symptoms are indi)ati/e of an emotiona. prob.em t'at needs treatment 2Aoder$ 'ute$ H #ryban$ *++,3. For )'i.dren t'e diagnosti) )ategories t'at appear in t'e 8 M are .i-e.y inf.uen)ed by ('at parents and tea)'ers )onsider prob.emati). A.t'oug' interna.i4ing 2e.g.$ anxiety$ depression3 and

externa.i4ing 2e.g.$ )ondu)t disorderC attention defi)it 'ypera)ti/ity disorder$ A8&83 prob.ems are re)ogni4ed by experts in )'i.d'ood psy)'opat'o.ogy$

97 WINSTEAD AND SANCHEF externa.i4ing disorders are more .i-e.y to )ause prob.ems in t'e s)'oo. setting as (e.. as at 'ome$ )reating additiona. pressures on t'e fami.y to see- some inter/ention. #o t'e extent t'at gender ratios in ).ini)a. popu.ations are t'e resu.t of gender differen)es in 'e.p see-ing$ prob.em re)ognition$ to.eran)eLinto.eran)e for symptoms by se.f or ot'ers$ or attitude to(ard menta. 'ea.t' )are$ t'en gender differen)es in pre/a.en)e rates in ).ini)a. settings (i.. ref.e)t t'ese differen)es and not 6ust true differen)es in t'e o))urren)e of t'e psy)'o.ogi)a. disorder. #'e so.ution to t'is di.emma is epidemio.ogi)a. studies (it' )ommunity samp.es. "n t'ese studies$ inter/ie(ers )onta)t indi/idua.s in representati/e samp.es and a)7uire information about symptoms. 8iagnosis is a))omp.is'ed independent.y of t'e parti)ipantsG a)-no(.edgement or )on)ern about t'e disorder. W'ereas gender differen)es in ).ini)a. popu.ations ref.e)t gender differen)es in t'e psy)'o.ogi)a. disorders p.us gender differen)es in /arious nondisor1dered be'a/iors su)' as 'e.p see-ing$ gender differen)es in )ommunity samp.es (i.. not 'a/e t'is prob.em. For numerous disorders$ 8 M1">1#R 29,,,3 )ites dis)repan)ies in )ommunity /ersus ).ini)a. samp.es or suggests t'at ).ini)a. data may o/er1 or underrepresent fema.es or ma.es be)ause of disorder1spe)ifi) fa)tors t'at en)ourage or dis)ourage treatment see-ing. For examp.e$ tri)'oti..omania 2)ompu.si/e 'air pu..ing3 is seen more often in (omen in ).ini)a. settings$ but (omen may be more in).ined to see- treatment for su)' an appearan)e1a.tering prob.em. More men t'an (omen see- 'e.p for gamb.ing$ but fema.e gamb.ers may fee. stigma1 ti4ed and un(i..ing to see- treatment 2see &artung and Widiger$ *++B3. "dea..y$ e/ery disorder (ou.d 'a/e an ade7uate and )urrent base of epidemio.ogi)a. data from )ommunity samp.es. #'is is not t'e )ase$ and often statements about gender differen)es in pre/a.en)e rates are based on potentia..y biased ).ini)a. samp.es. TREATMENT 8uring t'e *+D,s and *+B,s t'e dis)ip.ine of ).ini)a. psy)'o.ogy$ .i-e ot'er areas of resear)' and pra)ti)e$ (as strong.y inf.uen)ed by t'e feminist mo/ement. "n t'e re/ie( of t'e impa)t of gender on diagnosis$ t'e /oi)es of fema.e 2and ma.e3 )riti)s of t'e potentia..y ma.e1biased )reators of t'e 8 M (ere 'eard again and again. #'ese )riti)s raised important 7uestions t'at .ed to resear)'$ re/ie(s of resear)'$ and )arefu. s)rutiny of t'e )riteria and diagnoses t'at ma-e up 8 M1">1#R 29,,,3. "t is un.i-e.y t'at gender bias 'as been )omp.ete.y remo/ed from t'e manua. or from t'e sub6e)ti/e pro)esses t'at .ead to diagnosti) de)isions in ).ini)s and ).ini)iansG offi)es$ but a(areness of t'ese issues is an important step in t'e rig't dire)tion. At t'e same time$ ).ini)ians and resear)'ers began to fo)us on anot'er area ('ere gender may matter$ t'at is$ t'erapeuti) out)omes. Are (omen or men$ gir.s or boys$ more .i-e.y to benefit from t'erapyF W'i.e t'e examination of sex and gender bias in diagnosis turns out to be fair.y )omp.i)ated$ t'e sear)' for t'e ans(er to t'is seeming.y simp.e 7uestion about t'erapy out)omes is e/en more )omp.ex. "n t'eir 0go.d standard0 ,andbook of +sychotherapy and $ehavior 1hange# Bergin and =arfie.d 2*++;3 in).ude .engt'y )'apters dea.ing (it' ).ient /ariab.es$ t'erapist /ariab.es$ pro)ess /ariab.es$ four different t'erapeuti) approa)'es$ and se/en )'apters on spe)ia. groups and settings. "n order to ans(er t'e 7uestion 08oes sex affe)t treatmentF$0 (e need to )onsider at minimum t'e sex of t'e t'erapist$ t'e type of t'erapy 2e.g.$ )ogniti/e$ be'a/iora.$ fami.y$ psy)'op'arma)o.ogi)a.3$ t'e .engt' of t'erapy$ t'e t'erapy setting$ and t'e type of prob.em being treated 2e.g.$ depression$ substan)e abuse3. Many studies do not 'a/e t'e met'odo.ogi)a. )ontro.s t'at a..o( for random assignment of ).ients to t'erapists and t'erapists to ).ients$ ma-ing t'erapist or ).ient sex nonexperimenta. /ariab.es. A furt'er )omp.exity is t'at sex may intera)t

(it' ot'er important /ariab.es 2e.g.$ et'ni)ity$ ).ient moti/ation$ t'erapist training or years of experien)e3.

:. GENDER AND PSYCHOPATHOLOGY 99 In6%$en.e #6 Se- #6 T/era*ist #n T/era*y O$t.#(es %er'aps in part as t'e resu.t of t'e inf.ux of (omen into t'e menta. 'ea.t' professions$ t'ere (as a strong interest in t'e D,s and B,s in t'e impa)t of t'erapist sex on t'erapeuti) out)omes. "n a substantia. re/ie( arti).e of t'e effe)ti/e ingredients in psy)'ot'erapy$ =omes1 )'(art4$ &ad.ey$ and trupp 2*+DB3 )on).uded t'at t'ere (as no e/iden)e t'at t'erapist sex per se is re.ated to t'erapist effe)ti/eness. Beut.er$ Mar)'ado$ and Neufe.dt 2*++;3 re/ie(ed se/era. studies and )on).uded t'at t'ere are 0(ea- and .arge.y negati/e )on).usions0 2p. 9::3 )on)erning t'e inf.uen)e of sex of t'erapist on out)omes. Jones and Roppe. 2*+B93$ 'o(e/er$ obtained se.f1reports from ).ients and t'erapists regarding t'e resu.ts of t'erapy. Fema.e ).ients paired (it' fema.e t'erapists (ere per)ei/ed by bot' ).ients and t'erapists as 'a/ing experien)ed t'e most positi/e out)omes$ suggesting t'at sex mat)'ing made t'e differen)e. #'is study did not random.y assign ).ients to t'erapists nor did it pro/ide any externa. or ob6e)ti/e assessment of t'erapy resu.ts. Jones$ @rupni)-$ and @erig 2*+BD3$ 'o(e/er$ in resear)' t'at did random.y assign ?, (omen to ** ma.e or *; fema.e t'erapists found greater symptomati) impro/ement at t'e end of treatment and at fo..o(1up for t'e ).ients assigned to fema.e t'erapists. Be)ause t'ere (ere no ma.e ).ients in t'is study$ t'e re.ati/e ad/antage of 'a/ing a fema.e t'erapist may be a sex1of1t'erapist effe)t or a sex1 mat)'ing effe)t. "n a re)ent study$ R.otni)-$ E.-in$ and 'ea 2*++B3 too- ad/antage of an ex)eptiona. opportunity to in/estigate sex1of1t'erapist effe)ts in a (e..1)ontro..ed study$ t'e Nationa. "nstitute of Menta. &ea.t' #reatment of 8epression Co..aborati/e Resear)' %rogram 2#8CR%3. "n t'is resear)' a.. ).ients (ere experien)ing ma6or depression and (ere assigned random.y to different treatment )onditions$ but a.so to eit'er a fema.e or ma.e t'erapist. Attrition$ treatment out)ome 2based on t'e &ami.ton Rating )a.e for 8epression3$ and ).ient1reported t'erapist empat'y (ere assessed. Ana.yses re/ea.ed t'at 0among depressed patients$ a ma.e or fema.e t'erapist$ or same1 /ersus opposite1gender pairing$ (as not signifi)ant.y re.ated to .e/e. of depression at termination$ to attrition rates$ or to t'e patientGs per)eptions of t'e t'erapistGs degree of empat'y ear.y in treatment and at termination0 2R.otni)- et a..$ *++B. p. ?<D3. C.ientsG be.iefs about ('et'er a fema.e or ma.e t'erapist (ou.d be more 'e.pfu. (ere a.so assessed before t'erapy$ but t'ese be.iefs 'ad no impa)t on out)omes ('et'er t'ey (ere assigned to t'e person t'ey be.ie/ed (ou.d be more 'e.pfu. or not. Anot'er study )onsidered sex1 and ra)e1mat)'ing fa)tors in t'e treatment of substan)e abuse. ter.ing$ =ott'ei.$ Weinstein$ and erota 29,,*3 found no effe)ts for eit'er ra)e1 or sex1mat)'ing in terms of retention or out)ome in a study of Afri)an Ameri)an )o)aine1dependent persons. #oget'er t'ese studies demonstrate no o/era.. differen)e in out)omes for ma.e or fema.e t'erapists$ but suggest t'e possibi.ity t'at fema.e t'erapist1fema.e ).ient pairs 'a/e in some )ases better t'erapeuti) resu.ts t'an ma.e t'erapist1fema.e ).ient pairs. In6%$en.e #6 Se- #6 C%ient #n T/era*y O$t.#(es =arfie.d 2*++;3 re/ie(ed studies )on)erning t'e impa)t of sex of ).ient on t'erapy out)omes and )on).uded t'at 0one )annot ma-e mu)' of a )ase for sex of ).ient as a signifi)ant /ariab.e re.ated to out)ome in psy)'ot'erapy0 2p. 9,B3. Examining /arious demograp'i) /ariab.es as predi)tors of out)ome or differentia. treatment effe)ts in t'e #8CR%$ E.-in 2*++;3 found no e/iden)e t'at sex of ).ient 'ad a signifi)ant effe)t. A re/ie( of t'e .iterature sin)e *++; s'o(s t'at 7uestions regarding t'e inf.uen)e of sex of ).ient on t'erapy 'as generated re.ati/e.y .itt.e resear)'. #'ase

et a.. 2*++;3 examined men and (omen in a study of t'e effi)a)y of )ogniti/e

101 WINSTEAD AND SANCHEF t'erapy for outpatients (it' ma6or depression. Men and (omen 'ad simi.ar out)omesC 'o(e/er$ ).ients (it' 'ig'er pretreatment depression s)ores 'ad poorer out)omes$ and among t'is subset of se/ere.y depressed ).ients$ (omen 'ad signifi)ant.y poorer out)omes t'an men. A *++9 genera. re/ie( of treatment out)omes for abusers of a.)o'o.$ drugs$ and ni)otine found t'at (omen and men most often 'ad e7ua. t'erapeuti) resu.ts$ (it' (omenGs sometimes being better t'an menGs 2#oneatto$ obe.$ H obe.$ *++93. More re)ent studies )onfirm t'ese findings. #rif&eman 29,,*3 tested t(o treatment proto)o.s on indi/idua.s (it' )oexisting substan)e dependen)e and posttraumati) stress disorder 2%# 83. A.t'oug' (omen s'o(ed signs of greater se/erity at t'e beginning of treatment$ t'ere (ere no sex differen)es at t'e end of treatment or fo..o(1up in eit'er %# 8 or substan)e abuse. imi.ar.y$ in an outpatient addi)tion treatment )enter =a.en$ Bro(er$ =i..espie$ and Ru)-er 29,,,3 found t'at (omen 'ad greater psy)'iatri) se/erity t'an did men at t'e beginning of treatment but t'at t'ere (ere no sex differen)es in out)omes. Anot'er study )ompared treatment funding 2fee1for1ser/i)e /s. managed )are3 and treatment out)omes for )o)aine1 or a.)o'o.1dependent men and (omen. Neit'er funding type nor sex of ).ient (as re.ated to treatment out)ome 2A.terman$ Randa..$ H M)Le..an$ 9,,,3. Fina..y$ a randomi4ed ).ini)a. tria. e/a.uating p'arma)ot'erapies for )o)aine abuse found more se/ere drug prob.ems for (omen at inta-e$ but no sex differen)es at tria.Gs end and more positi/e out)omes for (omen at t'e six1mont' fo..o(1up 2@osten$ =a(in$ @osten$ H Rounsa/i..e$ *++:3. A.t'oug' t'ese studies found no sex differen)es in t'erapy out)ome$ t'e 'ig'er .e/e. of prob.em se/erity for (omen at t'e beginning of t'e studies suggests t'at (omen made greater gains during t'erapy t'an did men. "ssues about (omenGs spe)ia. needs in substan)e abuse treatment 'a/e been dis)ussed 2Wi.-e$ *++;3. #reatments in).uded in t'e studies re/ie(ed pre/ious.y (ere a.. outpatient programs. Many inter/entions for substan)e abuse or addi)tion re.y$ 'o(e/er$ on inpatient treatment. ome (omen may be unab.e to parti)ipate in inpatient treatment or need to terminate treatment premature.y be)ause of )'i.d1)are issues. A.t'oug' t'e extent of t'is prob.em is not -no(n$ some (omen in need of inpatient treatment may be t'e so.e )aregi/er for t'eir )'i.dren 2Wi.-e$ *++;3. Kuestions 'a/e a.so been raised about differen)es in t'e effe)ti/eness of sing.e1sex /ersus mixed1sex treatment groups. 8a'.gren and Wi..ander 2*+B+3 found t'at (omen in a sing.e1sex group reported better so)ia. ad6ustment and .o(er a.)o'o. )onsumption at a t(o1year fo..o(1up t'an did (omen in a mixed1sex group. tudies of smo-ing inter/entions a.so 'a/e found fe( effe)ts for sex of ).ient. "n a study of *$+DB smo-ers re)ei/ing ).ini)ian ad/i)e and nurse1assisted inter/ention$ (omen and men did not differ in parti)ipation in ea)' step of t'e inter/ention nor in reported 7uit attempts and )essation at t'ree and t(e./e mont's nor in re.apse t(e./e mont's .ater. Women did$ 'o(e/er$ use a greater number and /ariety of smo-ing1)essation strategies 2W'it.o)-$ >ogt$ &o..is$ H Li)'tenstein$ *++D3. "n a study of sustained smo-ing )essation 2after t'ree years3$ men 'ad a 'ig'er rate of 7uitting t'an (omen. #'ese gender differen)es (ere$ 'o(e/er$ .arge.y exp.ained by gender differen)es in demograp'i)s and smo-ing 'istory 2B6ornson$ Rand$ Connett$ H Lindgren$ *++<3. P#ssib%e E-.e*ti#ns t# N# E66e.ts 6#r Se- #6 C%ient #r T/era*ist A.t'oug' most studies 'a/e found t'at sex of ).ient and sex of t'erapist 'a/e re.ati/e.y .itt.e impa)t on t'e out)ome of psy)'ot'erapy$ t'ere are parti)u.ar )ir)umstan)es in ('i)' differen)es may o))ur. Lidd.e 2*++?3 examined t'erapist sex and sexua. orientation as predi)tors of gay and

.esbian ).ientsG reports of t'erapist pra)ti)es. 'e found t'at gay or bisexua. ma.e t'erapists and gay$ bisexua.$ or 'eterosexua. fema.e t'erapists (ere rated as e7ua..y 'e.pfu. but more 'e.pfu. t'an 'eterosexua. ma.e t'erapists. #'e fa)t t'at men genera..y 'a/e .ess

:. =EN8ER AN8 % AC&!%A#&!L!=A 103 positi/e attitudes to(ard 'omosexua.ity t'an (omen may 'e.p exp.ain ('y 'eterosexua. ma.e t'erapists (ere per)ei/ed as .east 'e.pfu. 2Lidd.e$ *++?3. #'e t'erapistGs attitude to(ard ).ient sexua. orientation may be a better predi)tor of out)ome t'an sex or sexua. orientation per se. Certain de.eterious effe)ts of psy)'ot'erapy are a.so more .i-e.y to o))ur in some sex1of1 t'erapist1sex1of1).ient )ombinations. For examp.e$ data suggest t'at sexua. re.ations'ips o))ur bet(een t'erapist and ).ient in <P to ?P of t'erapy re.ations'ips (it' B<P of t'ese in/o./ing a ma.e t'erapist (it' a fema.e ).ient 2Lamb H Catan4aro$ *++B3. #'is parti)u.ar negati/e t'erapeuti) experien)e is ).ear.y more .i-e.y to affe)t (omen. ex differen)es in t'e presentation and )ourse of a menta. disorder )an represent a )'a..enge for a)'ie/ing sex e7ua.ity in t'erapy out)omes. For examp.e$ a.t'oug' bipo.ar disorder 2(it' depressi/e and mani) episodes3 o))urs (it' e7ua. fre7uen)y in (omen and men 28 M1">1#R$ 9,,,3$ (omen are more .i-e.y t'an men to experien)e rapid )y).ing$ more fre7uent depressi/e episodes$ and t'e type of bipo.ar disorder t'at in).udes depressi/e and 'ypomani) 2/s. mani)3 episodes 28 M1">$ *++;C Leiben.uft$ *++D3. Rapid )y).ing is parti)u.ar.y diffi)u.t to treat$ suggesting t'at (omen (i.. be o/errepresented in t'e group of ).ients ('o do not respond positi/e.y to treatment 2Leiben.uft$ *++D3. #'e assumption$ 'o(e/er$ t'at (omen mig't be .ess responsi/e to .it'ium maintenan)e is )'a..enged by a re)ent study t'at found t'at (omen s'o(ed better 2a.beit not statisti)a..y signifi)ant.y different3 responses to .it'ium treatment and a signifi)ant.y .onger median time t'an did men before a first re)urren)e of i..ness 2>iguera$ Ba.dessarini$ H #ondo$ 9,,*3. Women in t'is study$ 'o(e/er$ did not s'o( a greater episode fre7uen)y and so did not represent t'e rapid )y).ing subgroup of )on)ern to ).ini)ians. tudies 'a/e a.so found re.iab.e sex differen)es in s)'i4op'renia. A.t'oug' t'ere are no estab.is'ed sex differen)es in presenting symptoms in a)ute p'ases of t'e disorder$ men ex1 perien)e more negati/e symptoms 2e.g.$ f.at affe)t$ so)ia. (it'dra(a.3 and (omen are more .i-e.y to be diagnosed as paranoid$ to experien)e .ater onset of t'e disorder and better premorbid ad6ustment$ and to maintain a 'ig'er .e/e. of fun)tioning during t'e )ourse of t'e i..ness and be .ess aggressi/e and se.f1destru)ti/e 228 M1">1#R$ 9,,,C #amminga$ *++D3. Fema.e s)'i4op'reni)s a.so respond better and more rapid.y to p'arma)o.ogi)a. treatment and re7uire .o(er doses t'an men in bot' a)ute episodes 2 4ymans-i$ Lieberman$ A./ir$ H Mayer'off$ *++<3 and ongoing treatment 2#amminga$ *++D3. Se- Di66eren.es 6#r Psy./#*/ar(a.#%#&y "n pre/ious de)ades$ t'e ex).usion of (omen from ).ini)a. drug tria.s and t'e fai.ure to ana.y4e data for sex differen)es .ed to a .a)- of information about t'e differentia. responses of (omen and men to psy)'op'arma)o.ogi)a. treatment. "n t'e *++,s t'e federa. go/ernment issued guide.ines intended to ma-e (omenGs 'ea.t'$ menta. 'ea.t'$ and treatment issues a greater prior1 ity in federa..y funded resear)' 2B.ument'a.$ *++<3. Effe)ts of sex differen)es in drug treatment may in).ude absorption$ distribution$ metabo.ism$ and e.imination$ a.. of ('i)' affe)t t'e bioa/ai.abi.ity of t'e t'erapeuti) substan)e. Women tend to 'a/e more fat tissue t'an men$ ('i)' affe)ts t'e metabo.ism and storage of drugs. WomenGs endogenous 2e.g.$ menstrua. )y).e$ pregnan)y$ postpartum$ menopause3 and exogenous 2e.g.$ birt' )ontro. pi..sC 'ormone rep.a)ement t'erapy$ &R#3 'ormone .e/e.s a.so affe)t drug response 2Aon-ers H &ami.ton$ *++<3. Estrogens$ for examp.e$ tend to in)rease t'e effe)ti/eness of some antipsy)'oti) drugs 2 eeman$ *++<3$ meaning t'at (omen may be treated (it' .o(er dosesC but$ t'ey may a.so experien)e more side effe)ts or toxi)ity from doses t'at are safe in men 2Aon-ers

H &ami.ton$ *++<3. Resear)' suggests t'at estrogen affe)ts metabo.i) pro)esses and drug response$ and estrogen 'as been tried (it' mixed to positi/e resu.ts$ a.one and )ombined (it' antidepressants$ in treatment for (omen (it' refra)tory depression and for

105 WINSTEAD AND SANCHEF postmenopausa. (omen 2Casper$ *++BC @ornstein$ *++D3. Resear)' a.so suggests t'at (omen respond more poor.y t'an men to some medi)ations 2e.g.$ tri).y).i)s3 and better t'an men to ot'ers 2e.g.$ R"s3. Women are a.so more .i-e.y t'an men to be exposed to more t'an one psy)'oa)ti/e drug be)ause of a greater in)iden)e of )omorbidity 2see be.o(3$ and so drug intera)tion effe)ts must be )onsidered 2Casper$ *++B3. Fina..y$ psy)'o.ogi)a. disorders$ espe)ia..y depression$ fre7uent.y o))ur in (omen t(enty to forty1fi/e years of age$ years ('en (omen are .i-e.y to bear )'i.dren. #'e effe)ts of psy1 )'op'arma)o.ogi)a. agents on materna. 'ea.t'$ t'e 'ea.t' of t'e de/e.oping fetus$ and .a)tation must be understood. #o date resear)' suggests t'at ben4odia4epines 2antianxiety drugs3 .ead to )raniofa)ia. abnorma.ities and$ ('en ta-en in .ate pregnan)y$ f.oppy infant syndromeC .it'ium 2used in treating bipo.ar disorder3 'as been asso)iated (it' )ardio/as)u.ar$ )entra. ner/ous system$ and menta. and p'ysi)a. abnorma.itiesC antidepressant medi)ations 'a/e s'o(n no ad1 /erse effe)ts in some in/estigations$ but sma.. in)reased ris-s of mis)arriage or deformities in ot'ersC resear)' on t'e effe)ts of antipsy)'oti)s is a.so mixed 2Casper$ *++B3. C.ear.y resear)' ).arifying t'e effe)ts of medi)ation during /arious stages of pregnan)y and during .a)tation is )riti)a.. Gender and C#(#rbidity Anot'er issue fa)ing t'erapists in t'eir efforts to pro/ide effe)ti/e treatment to bot' (omen and men is gender differen)es in )omorbidity$ t'at is$ t'e assignment of more t'an one diagnosti) )ategory to a ).ient. C.ients presenting (it' a primary disorder fre7uent.y 'a/e ot'er symptoms t'at need treatment. Epidemio.ogi)a. studies suggest t'at )omorbidity is parti)u.ar.y e/ident in (omen 2@ess.er et a..$ *++;C Mars' H Casper$ *++B3. For examp.e$ t'e re.ati/e.y )ommon )o1 o))urren)e of anxiety and depression affe)ts (omen per'aps t(i)e as often as men 2Mars' H Casper$ *++B3. Women (it' substan)e abuse disorders are found to 'a/e more affe)ti/e disorders$ espe)ia..y ma6or depression$ t'an men (it' substan)e abuse disorders 2Benis'e-$ Bies)'-e$ toffe.mayr$ Ma/is$ H &ump'ries$ *++93. !t'er studies 'a/e found t'at (omen (it' substan)e abuse a.so report more fami.y$ so)ia.$ emp.oyment$ and ot'er psy)'iatri) prob.ems t'an men 2A.terman et a..$ 9,,,C Bro(n$ A.terman$ Rut'erford$ Ca))io.a$ H Raba.ero$ *++:3. A.so$ a.t'oug' bot' substan)e abuse and antiso)ia. persona.ity disorder o))ur at 'ig'er rates in men t'an (omen$ t'eir )omorbidity appears to be 'ig'er for (omen. "n ot'er (ords$ t'e .i-e.i'ood of a diagnosis of antiso)ia. persona.ity disorder gi/en t'e presen)e of a.)o'o. dependen)e 'as been found to be greater for (omen t'an for men 2@ess.er$ Crum$ Warner$ Ne.son$ )'u.enberg$ H Ant'ony$ *++DC Le(is H Bu)'o.4$ *++*3. Furt'ermore$ t'e presen)e of antiso)ia. persona.ity disorder may .ead to .ess positi/e )'ange during treatment 2=a.en et a..$ 9,,,3. "n addition$ (omen (it' s)'i4op'renia$ )ompared to s)'i4op'reni) men$ are more .i-e.y to 'a/e depressi/e symptoms$ in addition to psy)'oti) symptoms$ t'at a.so re7uire treatment 2 eeman$ *++<3. Fina..y$ )ertain distressing .ife e/ents .in-ed to menta. disorders$ su)' as in)est$ sexua. abuse$ and rape$ o))ur more fre7uent.y in t'e .i/es of (omen. %# 8$ .in-ed to traumati) e/ents$ o))urs more often in (omen t'an menC and a 'ig'er rate of )omorbidity is asso)iated (it' %# 8 2Wong H Ae'uda$ 9,,93. "n)reased )omorbidity genera..y .eads to a 'ig'er .e/e. of persona. distress$ disabi.ity$ and )'roni)ity 2Mars' H Casper$ *++B3. C.ients presenting (it' mu.tip.e prob.ems may be .ess responsi/e to treatment. tudies of treatment out)omes$ 'o(e/er$ often )ontro. for diagnosis by se.e)ting parti)ipants (it' 6ust one diagnosis. #o t'e extent t'at (omen are more .i-e.y t'an men to be gi/en more t'an one diagnosis$ t'ese studies (i.. be .ess

representati/e of (omen. Furt'ermore$ t'erapies )onsidered effi)a)ious based on t'is resear)' may not be effe)ti/e for (omen 2and men3 (it' mu.tip.e diagnoses.

:. GENDER AND PSYCHOPATHOLOGY 107 SPECIFIC DISORDERS' DEPRESSION E/iden)e suggests t'at some disorders are diagnosed more often in one sex t'an t'e ot'er. "f t'is is so$ ('yF =i/en t'e presen)e of a diagnosis$ (e a.so (ant to -no( if standard treatments for t'e disorders are e7ua..y effe)ti/e for bot' sexes and if sex is ta-en into a))ount ('en app.ying and assessing t'ese treatments. Se- Di66eren.es in t/e Dia&n#sis #6 De*ressi#n Women are more .i-e.y to experien)e depression t'an men 2Burt$ 9,,9C Cu.bertson$ *++DC @ornstein$ *++DC No.en1&oe-sema$ Larson$ H =rayson$ *+++C pro)- H Aoder$ *++DC Wo.- H Weissman$ *++<3. Epidemio.ogi)a. studies in t'e United tates and ot'er de/e.oped )ountries )onsistent.y find t'at (omen are more .i-e.y to experien)e ma6or depression$ and dyst'ymia$ but not bipo.ar affe)ti/e disorder$ t'an men 2Cu.bertson$ *++DC pro)- H Aoder$ *++DC Wo.- H Weissman$ *++<3. 8ata from .ess de/e.oped )ountries are in)onsistent$ sometimes finding no sex differen)e in depression 2Cu.bertson$ *++D3. "n t'e United tates$ not on.y do (omen seetreatment for depression more often t'an men$ but$ a))ording to inter/ie( studies )ondu)ted in t'e )ommunity among t'ose ('o ne/er see- treatment$ (omen are more .i-e.y to meet diagnosti) )riteria for t'ese depressi/e disorders. #'e )onsensus is t'at t'e fema.e1to1ma.e ratio for depression is 95* and for ma6or depression it may be :5* or ;5* 2Cu.bertson$ *++D3. #'is sex differen)e 'as been found a)ross et'ni) groups 2Afri)an Ameri)an$ Cau)asian$ &ispani)3. Women a.so experien)e more )'roni) and re)urring depressi/e episodes and more seasona. affe)ti/e disorder 2Burt$ 9,,9C @ornstein$ *++D3. Fina..y$ (omen experien)e more )omorbidity t'an men. 8isorders t'at may be present at t'e same time as depression in).ude anxiety$ p'obias$ eating disorders$ %# 8$ as (e.. as medi)a. )onditions su)' as migraine or )'roni) fatigue syndrome 2Burt$ 9,,93. #'ere are re.iab.e and /a.id standardi4ed assessment too.s for depressionEfor examp.e$ t'e Be)8epression "n/entory 2B8"3 and &ami.ton Rating )a.e for 8epression. "tem ana.yses for gender bias of t'e B8" (it' a .arge samp.e of depressed outpatients and nonpatients found .itt.e e/iden)e for gender item bias. #'e on.y prob.emati) item (as an item assessing distortion of body image$ an item endorsed more often by (omen 2 antor$ Ramsay$ H Ruroff$ *++;3. !n t'e ot'er 'and$ pro)- and Aoder 2*++D3 re/ie(ed studies t'at suggest t'at )ir)umstan)es and age may affe)t t'e /a.idity of t'ese instruments. W'en s)a.es (ere des)ribed as measures of depression$ items (ere endorsed .ess often by men t'an by (omenC but t'ere (as no sex differen)e ('en t'e instruments (ere des)ribed as 'ass.es s)a.es 2%age H Bennes)'$ *++:3. "n a samp.e of geriatri) patients 'ospita.i4ed for ma6or unipo.ar depression$ A..en1Burge$ torandt$ @ins)'erf$ H Rubin 2*++;3 found t'at t'e B8" and t'e =eriatri) 8epression )a.e (ere more .i-e.y to dete)t depression in e.der.y (omen t'an in e.der.y men. "n addition$ depressed (omen report more symptoms of depression t'an do depressed men$ e/en ('en ).ini)iansG 6udgments of se/erity of depression do not differ$ .eading pro)- and Aoder 2*++D3 to suggest t'at t'e number of )riteria for diagnosis of depression s'ou.d per'aps be greater for (omen t'an for men. C.ini)ian bias a.so remains a prob.em. %otts$ Burnam$ and We..s 2*++*3 )ompared ).ini)iansG 6udgments to diagnoses made (it' a standardi4ed inter/ie( assessment and found t'at t'ere (ere dis)repan)ies bet(een standardi4ed assessment and ).ini)ian 6udgments in t'at medi)a. pra)titioners (ere .ess .i-e.y to diagnose depression in men and menta. 'ea.t' pra)titioners (ere more .i-e.y to diagnose depression in (omen. C.ear.y in t'e rea. (or.d of persons intera)ting (it' 'ea.t' and menta. 'ea.t' pra)titioners$ diagnosis of depression$ as (it' ot'er disorders$ is

not free of sex bias.

109 W"N #EA8 AN8 ANC&ER E-*%ainin& t/e Se- Di66eren.e in De*ressi#n #'e repeated )onfirmation of t'e finding t'at (omen are t(i)e as .i-e.y as men to suffer from depression 'as .ed to studies t'at attempt to exp.ain t'is sex differen)e in depression. Most exp.anations of sex differen)es are bio.ogi)a.$ so)io)u.tura.$ or some )ombination of ea)'. 0Women 'a/e a parti)u.ar.y in)reased /u.nerabi.ity to depressi/e disorders during t'e )'i.dbearing years I('enJ... (omen s'ou.der myriad ro.e responsibi.ities$ are more .i-e.y to experien)e sexua. and domesti) /io.en)e$ and are fre7uent.y disad/antaged in terms of bot' so)ia. and finan)ia. status. A.so$ during t'ese years$ many (omen experien)e bot' pregnan)y and t'e postpartum0 2Burt$ 9,,9$ pp. *,*1*,93. #'at t'ese reprodu)ti/e years in).ude bot' en/ironmenta. and bio.ogi)a. stressors ma-es identifying )ausa. fa)tors diffi)u.t. Bio.ogi)a. exp.anations of sex differen)es in depression 'a/e been soug't primari.y in 'ormona. and neurop'ysio.ogi)a. differen)es bet(een (omen and men. ome mar-ers t'at distinguis' t'e depressed from t'e nondepressedEgreater g.oba. and regiona. )erebra. metabo.i) rate of g.u)ose uti.i4ation$ response to t'e dexamet'asone suppression test$ .o(er .e/e.s of natura. -i..er )e..sE a.so demonstrate sex differen)es$ (it' (omen responding more .i-e depressed persons 2 pro)H Aoder$ *++D3. #'e inf.uen)e of 'ormones on (omenGs depression is suggested by t'e fa)t t'at rates of depression are simi.ar in gir.s and boys before puberty 2see )'ap. *?$ 0"nterna.i4ing 8isorders03 and t'at t'e sex differen)e is .ess pronoun)ed in t'e e.der.y 2 pro)- H AoderC *++DC Wo.- H Weissman$ *++<3. A dire)t )onne)tion bet(een 'ormone .e/e.s and depression$ 'o(e/er$ 'as not been demonstrated. Nor 'as an asso)iation bet(een menopause and depression been supported by empiri)a. resear)' 2Wo.- H Weissman$ *++<3. !n t'e ot'er 'and$ (omen are at in)reased ris- for psy)'iatri) i..ness immediate.y fo..o(ing )'i.dbirt'. Le/e.s of estrogen and progesterone drop dramati)a..y (it' t'e expu.sion of t'e p.a)enta fo..o(ing )'i.dbirt'. &o(e/er$ dire)t )orre.ations bet(een 'ormone .e/e.s and postpartum b.ues$ postpartum depression$ or postpartum psy)'osis 'a/e not been found. "t is true t'at a 'istory of depression or psy)'iatri) i..ness is a ris- fa)tor in postpartum psy)'osis or depressionC and a 'istory of one postpartum i..ness predi)ts subse7uent ones 2:,P to <,P for postpartum depressionC 9,P to ::P for postpartum psy)'osis3 2@ornstein$ *++DC Wo.- H Weissman$ *++<3. o)io)u.tura. exp.anations of depression are )on)erned (it' .ife e/ents$ so)ia. ro.es$ and )ogniti/e and )oping sty.es. For examp.e$ stressfu. .ife e/ents and marita. prob.ems are risfa)tors for postpartum depression 2Wo.- H Weissman$ *++<3. Women are a.so more .i-e.y t'an men to )ite a stressfu. .ife e/ent in t'e six mont's before t'e onset of a ma6or depressi/e episode$ and t'ey are not on.y more rea)ti/e to stress in t'eir o(n .i/es but a.so in t'e .i/es of t'ose (it' ('om t'ey 'a/e re.ations'ips 2@ornstein$ *++D3. E/en 'a/ing supporti/e fami.y net(or-s )an be .ess rat'er t'an more 'e.pfu. for some (omen. >eie. 2*++:3 found t'at (omen ('o (ere 'omema-ers and reported 'a/ing a supporti/e fami.y (ere .ess .i-e.y t'an men or (or-ing (omen to re)o/er from ma6or depression. For t'ese (omen t'e demands of fami.y re.ations'ips may 'a/e done more 'arm t'an t'e support a fami.y )an pro/ide. ome psy)'o.ogists 'a/e proposed t'at gender so)ia.i4ation of (omen .eads t'em to 'a/e an experien)e of .earned 'e.p.essness ('i)' predisposes t'em to depression$ a.t'oug' dire)t .in-s bet(een .earned 'e.p.essness and 'ig'er rates of depression 'a/e not been demonstrated 2Wo.H Weissman$ *++<3. "n many )ases t'e asso)iation bet(een re.ations'ip or )ogniti/e /ariab.es and depression may not ref.e)t a )ausa. inf.uen)e of t'e former /ariab.es$ but rat'er an effe)t of depression on 'o( peop.e t'in- or intera)t (it' ot'ers. "n a .ongitudina. study 2one year3 of

adu.ts a)ross t'e age span$ No.en1&oe-sema et a.. 2*+++3 (ere ab.e to demonstrate t'at (omen experien)e more )'roni) strain$ .o(er sense of mastery$ and more rumination t'an men and t'at t'ese fa)tors mediated t'e sex differen)es in depressionC t'at is$ sex (as no .onger

:. GENDER AND PSYCHOPATHOLOGY 111 a signifi)ant predi)tor of depression at time t(o 2one year .ater3 ('en t'e inf.uen)e of t'ese /ariab.es (as remo/ed. C'roni) strain$ .o( mastery$ and rumination intera)ted in )omp.ex (ays to predi)t depression$ and depressi/e symptoms a.so )ontributed to more rumination and .ess mastery. "n t'is study$ rumination and .o( sense of mastery (ere parti)u.ar.y strong predi)tors of depression and$ assuming t'ey a.so )ontribute to t'e sex differen)e in depression$ (e are ne/ert'e.ess .eft (it' t'e 7uestion of 'o( sex differen)es in rumination and sense of mastery )ome about. Se- Di66eren.es in t/e Treat(ent #6 De*ressi#n As reported pre/ious.y$ out)ome studies of treatment for depression suggest t'at (omen and men bot' benefit from t'e standard t'erapies. Components of t'e psy)'ot'erapeuti) pro)ess t'at ma-e it effe)ti/e$ 'o(e/er$ 'a/e rare.y been studied. =ender differen)es in persona.ity$ re.ations'ips$ and )oping sty.es suggest t'at a finer tuned .oo- at t'e )omponents of t'erapy may find sex differen)es in t'e re.ati/e effe)ti/eness of different t'erapy )omponents or t'erapist sty.es. A ma6or re/ie( of treatments for depression fai.ed to address t'e 7uestion of sex differen)e at a..$ ex)ept to a)-no(.edge t'at be)ause (omen are prone to depression in t'e )'i.dbearing years$ t'e re.ati/e su))ess of psy)'ot'erapy (it'out medi)ation is en)ouraging 2&o..on$ #'ase$ H Mar-o(it4$ 9,,93. Resear)' on t'e effe)ti/eness of antidepressant medi1 )ation$ 'o(e/er$ suggests t'at (omen respond more poor.y t'an men to tri)y).i)s and better t'an men to serotonin reupta-e in'ibitors 2 R"s3 and monoamine oxidase in'ibitors 2@ornstein$ *++D3. Women may respond more s.o(.y to p'arma)ot'erapy and 'ormona. state (i.. affe)t optima. doses. Redu)ing doses of tri)y).i)s for (omen ta-ing ora. )ontra)epti/es and in)reasing doses in t'e se)ond 'a.f of pregnan)y may be benefi)ia. 2 rame- H Fra)-ie(i)4$ 9,,93. S$((ary #'e )'a..enge posed by in).uding gender in understanding and treating depression is at .east t'reefo.d. First$ (e must be )ertain t'at (e are not underdiagnosing depression in men. Men may be .ess (i..ing t'an (omen to identify negati/e emotiona. states or to admit t'at t'ey are symptoms of depression. C.ini)ians 'earing about negati/e emotions from men may be .ess .i-e.y to see t'em as signs of depression. e)ond$ (e must be )arefu. not to o/erdiagnose depression in (omen. "n see-ing )ausa. fa)tors and dis)o/ering t'at )ertain psy)'o.ogi)a. )'ara)teristi)s or experien)es t'at differ for (omen and men )ontribute to depression$ (e need to .oo- furt'er to understand ('y (omen and men differ in t'ese )'ara)teristi)s or experien)es. #'ird$ a.t'oug' moderate su))ess for psy)'o.ogi)a. and psy)'op'arma)o.ogi)a. treatments for depression are (e.. do)umented and seem to pro/ide (omen and men (it' )omparab.e re.ief$ t'e data indi)ate t'at t'ere are sex differen)es in some drug responses and )ertain )onditions$ su)' as se/erity of symptoms or )omorbidity. #'e impa)t of t'ese differen)es on t'e effe)t of sex on t'erapy out)omes deser/es furt'er in/estigation. SPECIFIC DISORDERS' CONDUCT DISORDER Anot'er disorder t'at 'as a signifi)ant sex differen)e in diagnosis is )ondu)t disorder$ des)ribed in 8 M1"> 2*++;3 as 0a repetiti/e and persistent pattern of be'a/ior in ('i)' t'e basi) rig'ts of ot'ers or ma6or age1appropriate so)ieta. norms or ru.es are /io.ated0 2p. B<3. A.t'oug' t'is is a disorder of )'i.d'ood or ado.es)en)e$ it )an be used for persons o/er *B if t'ey do not

112 WINSTEAD AND SANCHEF meet t'e )riteria for antiso)ia. persona.ity disorder. We are not surprised to .earn t'at it is more often diagnosed in boys 2t(o to t'ree times more often3 t'an in gir.s 28 M1">$ *++;C @ann H &anna$ 9,,,3. Se- Di66eren.es in t/e Dia&n#sis #6 C#nd$.t Dis#rder A .oo- at t'e 'istory of )ondu)t disorder in t'e 8 M re/ea.s t'at t'e basi) definition as 7uoted in t'e pre/ious paragrap' appears (it' /ery minor differen)es in a.. t'ree /ersions under re/ie( 28 M1"""$ 8 M1"""1R$ 8 M1">3C but ot'er diagnosti) )riteria )'ange. tarting (it' 8 M1"""$ )ondu)t disorder must be diagnosed by meeting )riteria to one of four subtypes5 underso)ia.i4ed$ aggressi/eC underso)ia.i4ed$ nonaggressi/eC so)ia.i4ed$ aggressi/eC or so)ia.i4ed$ nonaggressi/e. #'e underso)ia.i4ed /ersus so)ia.i4ed portion of t'is diagnosis (as made based on t'e )'i.dGs degree of affe)tion$ empat'y$ or bond (it' ot'ers. #'e essentia. )'ara)teristi) of )ondu)t disorder$ 'o(e/er$ is eit'er one of t'e nonaggressi/e )riteriaE)'roni) /io.ations of important 'ome or s)'oo. ru.es$ repeated running a(ay o/ernig't$ persistent serious .ying$ or stea.ing (it'out )onfrontationEor one of t'e aggressi/e )riteriaEp'ysi)a. /io.en)e against persons or property 2not in se.f1defense3 or t'efts outside t'e 'ome in/o./ing )onfrontation. A))ording to 8 M1""" )ondu)t disorder is more )ommon among boys (it' sex ratios of ;5* to *95*$ ex)ept t'e underso)ia.i4ed$ nonaggressi/e type 0('i)' may be e7ua..y )ommon in bot' sexes0 2p. ;D3. #'e four subtypes (ere dropped in 8 M1"""1R in fa/or of diagnoses in/o./ing antiso)ia. be'a/ior perpetrated by a )'i.d a.one 2so.itary aggressi/e type3 /ersus antiso)ia. be'a/ior perpetrated by a )'i.d in a group and an undifferentiated type for )'i.dren t'at do not fit t'e so.itary /ersus gang distin)tion. But t'ese are types$ not different diagnoses$ and t'e basi) diagnosis rests on t'e presen)e$ .asting at .east six mont's$ of t'ree of a .ist of t'irteen be'a/iors5 sto.e (it'out )onfrontationC ran a(ay o/ernig't at .east t(i)eC often .iesC set firesC often truantC bro-e into 'ouse$ bui.ding$ )arC destroyed property 2ot'er t'an by fire3C p'ysi)a..y )rue. to anima.sC for)ed someone into sexua. a)ti/ityC used a (eapon in more t'an one fig'tC often initiates p'ysi)a. fig'tsC sto.e (it' )onfrontationC p'ysi)a..y )rue. to peop.e. #'ese )'anges made t'e diagnosis diffi)u.t to ma-e un.ess t'e )'i.d or ado.es)ent engaged in p'ysi)a..y /io.ent be'a/ior$ a )'ange t'at (ou.d tend to ma-e t'e diagnosis 0rarer and more restri)ted to ma.es0 2Ro))o.i..o$ #remb.ay$ H >itaro$ *++?$ p. ;?93. Estimates of pre/a.en)e (ere stated as +P for ma.es and 9P for fema.es. 8 M1"> 2*++;3 in).udes a 0modifi)ation It'atJ is based on t'e fie.d1tria. resu.ts and pro/ides a definition t'at in).udes be'a/iors )'ara)teristi) of fema.es (it' Condu)t 8isorder0 2p. DD<3. "tems from t'e 8 M1"""1R .ist are in).uded. #(o items are added5 0often bu..ies$ t'reatens$ or intimidates ot'ers0 and 0often stays out at nig't despite parenta. pro'ibitions$ beginning before age *: years0 2p. +,3. Estimates of pre/a.en)e are some('at 'ig'er t'an in 8 M1"""1R$ but t'e sex ratio is .ess extreme5 0for ma.es ... rates range from ?P to *?PC for fema.es$ rates range from 9P to +P0 2p. BB3. #'e .ist of )riteria sti.. fa/ors aggression and destru)tion of property 2nine of t'e fifteen )riteria3$ a.t'oug' it is possib.e to meet t'e t'res'o.d for diagnosis 2t'ree of t'e fifteen3 based on de)eitfu.ness$ t'eft (it'out )onfrontation$ or serious ru.es /io.ations. 8 M1"> emp'asi4es gender differen)es in t'e pattern of symptoms5 0Ma.es... ex'ibit fig'ting$ stea.ing$ /anda.ism$ and s)'oo. dis)ip.ine prob.ems. Fema.es. . . are more .i-e.y to ex'ibit .ying$ truan)y$ running a(ay$ substan)e use$ and prostitution0 28 M1">$ p. BB3. Curious.y$ t'e be'a/iors )'ara)teristi) of ma.es are a.. )riteria for diagnosis of )ondu)t disorder$ but some be'a/iors )ited as )'ara)teristi) of fema.es$ substan)e use and prostitution$ are not in).uded.

Based on 'is )on)erns about 8 M1"""1R$ Ro))o.i..o 2*++:3 re)ommended t'at separate )riteria be used for diagnosing )ondu)t disorder in gir.s be)ause of ).ear sex differen)es in

:. =EN8ER AN8 % AC&!%A#&!L!=A 114 be'a/iora. prob.ems. &e and ot'ers 2Robins$ *+B?3 find t'at 0Ado.es)ent gir.s (it' )ondu)t disorder 'a/e a poor out)ome in).uding ear.y and /io.ent deat'$ arrest$ substan)e abuse and dependen)e$ antiso)ia. persona.ity disorder$ fai.ing to finis' 'ig' s)'oo.$ and teenage pregnan)y0 2Ro))o.i..o et a..$ *++?$ p. ;?93. Ear.y identifi)ation and inter/ention for t'ese gir.s )ou.d per'aps ame.iorate t'ese negati/e out)omes 2Webster1 tratton$ *++?3. !n t'e ot'er 'and$ Ra'n1 Wax.er 2*++:3 'as pointed out t'at different )riteria for gir.s and boys )ou.d .ead to pat'o.ogi4ing a be'a/ior$ su)' as substan)e use or ru.es /io.ations$ in gir.s t'at mig't be )onsidered more a))eptab.e in boys. A))ording.y$ t'is perspe)ti/e 'o.ds t'at$ if boys are more .i-e.y to be diagnosed (it' )ondu)t disorder$ it is be)ause t'ey do in fa)t engage in t'e ag1 gressi/e and /io.ent be'a/ior )'ara)teristi) of t'is disorder more often t'an gir.s do. Missing from t'ese arguments is t'e possibi.ity t'at parti)u.ar be'a/iors are differentia..y predi)ti/e for (omen and men of t'e dire out)omes )ited by Ro))o.i..o et a.. 2*++?3. Resear)' examining t'e predi)ti/e po(er of aggressi/e or destru)ti/e be'a/ior /ersus .ying or ru.es /io.ations /ersus prostitution or substan)e abuse in )'i.d'ood or ear.y ado.es)en)e on /arious negati/e out)omes 2)rimina. )ondu)t$ ear.y parent'ood$ interrupted edu)ation$ )'roni) substan)e abuse$ deat'3 for (omen and men (ou.d be more instru)ti/e per'aps t'an debates on t'e )riteria for 8 M diagnoses. Anot'er issue for diagnosis of )ondu)t disorder in gir.s and boys is t'at it re.ies on be'a/iors t'at are )onsidered prob.emati) by ot'ers$ t'at is$ parents$ tea)'ers$ peers$ but genera..y not by t'e )'i.d 'erse.f or 'imse.f. #'us$ t'e symptomati) be'a/iors must )ome to t'e attention of t'ese ot'ers 2espe)ia..y adu.ts3. Be)ause gir.sG be'a/iors are .ess often o/ert.y aggressi/e and may$ in fa)t$ be )o/ert$ t'ey are .ess .i-e.y to )ome to t'e attention of )areta-ers. A.so non)omp.ian)e and /erba. aggression may be .ess .i-e.y t'an p'ysi)a. aggression to )ause tea)'ers to re)ommend or parents to see- treatment 2@ann H &anna$ 9,,,C Webster1 tratton$ *++?3. #o t'e extent t'at gir.s engage in be'a/iors not noti)ed by or su))essfu..y 'idden from parents and tea)'ers$ t'ey may not re)ei/e a diagnosis and inter/ention. #o t'e extent t'at ear.y inter/ention yie.ds positi/e out)omes$ fai.ure to identify t'e prob.em is troub.esome. Fina..y$ as (it' ot'er psy)'o.ogi)a. disorders$ gir.s (it' )ondu)t disorder are more .i-e.y t'an boys to be gi/en anot'er diagnosis$ in).uding attention defi)it disorder$ substan)e abuse$ and .earning disorders 2M)Ma'on H We..s$ *++B3. E-*%ainin& t/e Se- Di66eren.e in C#nd$.t Dis#rder W'i)'e/er diagnosti) system is used$ 'o(e/er$ and despite t'ese )a/eats$ it is .i-e.y t'at boys engage in disrupti/e and aggressi/e be'a/iors )'ara)teristi) of )ondu)t disorder more often t'an gir.s. "n an attempt to understand more about t'is sex differen)e$ Cote$ #remb.ay$ Nagin$ Ro))o.i..o$ and >itaro 29,,93 examined t'e ris- tra6e)tories of a .arge samp.e of gir.s and boys from -indergarten to grade six. #'ey fo)used on t'ree be'a/iora. dimensions5 'ypera)ti/e$ fearfu.$ and un'e.pfu.. #'e on.y profi.e t'at predi)ted )ondu)t disorder 2using 8 M1"""1R )riteria3 for gir.s (as 'ypera)ti/e p.us un'e.pfu.. #'ree profi.es predi)ted for boys5 'ypera)ti/e 2on.y3$ 'ypera)ti/e p.us un'e.pfu.$ and 'ypera)ti/e p.us fear.ess p.us un'e.pfu.. #'e .ast profi.e$ a )ombination of a.. t'ree predi)ti/e dimensions$ did not o))ur in t'e fema.e samp.e. A.most eig't times more boys t'an gir.s 'ad a ris- profi.e in -indergarten and a.most t'ree times more boys 'ad a )ondu)t disorder diagnosis in ado.es)en)e. 0#'us a 'ig'er proportion of boys (ere on 'ig'.y stab.e ris- tra6e)tories from -indergarten on0 2Cote et a..$ 9,,9$ p. *,+93. @eenan and 'a( 2*++D3 'a/e a.so examined ear.y )'i.d'ood inf.uen)es on prob.em be'a/iors.

#'ey found t'at beginning around age four$ gir.s s'o( a de).ine in diffi)u.t temperament$ ('ereas boys s'o( an in)rease or a sma..er de).ine. #'us$ boys persist in prob.em be'a/iors$ ('ereas gir.s s'o( impro/ement. #'ey suggest t(o 'ypot'eses t'at mig't exp.ain t'is sex

116 W"N #EA8 AN8 ANC&ER differen)e5 so)ia.i4ation t'at )'anne.s gir.s into interna.i4ing be'a/iors and gir.sG de/e.opment of adapti/e s-i..s. A re/ie( of so)ia.i4ing inf.uen)es re/ea.s se/era. t'at may )ontribute to t'e sex differen)e. =ir.s may re)ei/e .ess p'ysi)a. punis'ment t'an boys 2Lytton H Romney$ *++*3. BoysG aggressi/e be'a/ior$ rat'er t'an being extinguis'ed by p'ysi)a. punis'ment$ may be mode.ed on it 2@ami H &anna$ 9,,,3. Wit' /ery young )'i.dren 2one year3$ mot'ers ma-e a )ontinued effort to tea)' diffi)u.t gir.s but tend to (it'dra( from diffi)u.t boys 2Ma))oby$ no($ H Ja)-.in$ *+B;3. "n a samp.e of :B4 1year1o.ds$ gir.sG assertions (ere more often ignored by parents t'an boysG assertions$ ('ereas gir.sG )omp.iant be'a/iors re)ei/ed more positi/e responses from fat'ers t'an did boysG )omp.iant be'a/iors 2@erig$ Co(an$ H Co(an$ *++:3. Mot'ers of t(o1year1o.d daug'ters (ere more .i-e.y to point out t'e )onse7uen)es of ru.e brea-ing on ot'ers t'an mot'ers of sons 2 metana$ *+B+3. %arents super/ising t'eir todd.ersG p.ay (it' a same1sex peer tend to en)ourage re.in7uis'ing a toy to t'e peer$ but t'ey do so more (it' daug'ters t'an (it' sons 2Ross$ #es.a$ @enyon$ H Lo..is$ *++,3. %eers a.so treat gir.s and boys different.y. Fagot and &agan 2*+B<3 found t'at among todd.ers$ gir.sG aggression (as more .i-e.y to be ignored by peers and t'at t'is (as effe)ti/e in ending t'e aggression. #oget'er t'ese studies indi)ate t'at gir.s are being taug't to be )omp.iant$ perspe)ti/e ta-ing$ and proso)ia.$ a.. be'a/iors t'at may ser/e to redu)e t'e be'a/iors asso)iated (it' )ondu)t disorder. !ne (onders ('at t'e impa)t (ou.d be if t'ese be'a/iors (ere stressed for boys as (e... @eenan and 'a( 2*++D3 a.so )onsider sex differen)es in rate of maturation as a possib.e exp.anation for sex differen)es in prob.em be'a/iors. Resear)' genera..y finds t'at gir.s de/e.op .anguage more rapid.y t'an boys. Language )an pro/ide )'i.dren (it' nonp'ysi)a. means for reso./ing disputes and getting t'eir (ay (it'out aggression. An ear.y de/e.opment of t'ese abi.ities may fa)i.itate de).ines in )ondu)t prob.ems in )'i.d'ood. =ir.s a.so de/e.op empat'i) responding and proso)ia. be'a/iors ear.ier t'an boys 2@ennan H 'a($ *++D3. #o t'e extent t'at any of t'ese abi.ities are a resu.t of faster neuro.ogi)a. de/e.opment$ t'is differen)e pro/ides a more bio.ogi)a. exp.anation for t'e sex differen)e in )ondu)t disorder. &astings$ Ra'n1Waxier$ Robinson$ Us'er$ and Bridges 29,,,3 in/estigated t'e de/e.opment of )on)ern for ot'ers in a .ongitudina. study of )'i.dren fi/e to ten. #'ey )on).uded t'at 0!ne of t'e most sa.ient resu.ts of t'is in/estigation (as t'e demonstration of t'e prote)ti/e ro.e t'at )on)ern for ot'ers may p.ay in t'e de/e.opment of )'i.drenGs externa.i4ing be'a/ior prob.ems0 2p. <;93. C'i.dren disp.aying )on)ern at fi/e years s'o(ed a de).ine in externa.i4ing prob.ems from fi/e to se/en years. Mot'ersG so)ia.i4ation be'a/iors a.so p.ayed a ro.e. #'ey found t'at stri)t$ 'ars'.y puniti/e mot'ers ('o disp.ay anger or disappointment and fai. to reason (it' t'eir )'i.dren or estab.is' )onsistent ru.es interfere (it' t'eir )'i.drenGs proso)ia. de/e.opment. "n t'is study gir.s at a.. ages s'o(ed more )on)ern for ot'ers t'an boys. W'et'er a)7uired t'roug' so)ia.i4ation or maturation or bot'$ t'e emergen)e of proso)ia. or 'e.pfu. be'a/iors in gir.s at an ear.ier age t'an in boys may exp.ain t'e .ater sex differen)e in t'e pre/a.en)e of )ondu)t disorder. #'e data from Cote et a.. 29,,93 indi)ate t'at ris- profi.es in).uding 0un'e.pfu.0 2/s. 0'e.pfu.03 are more predi)ti/e of )ondu)t disorder 2C83 for boys 2P (it' C85 *9.*: /s. +.+D3 but espe)ia..y for gir.s 2P (it' C85 D.<D /s. :.BD3$ suggesting t'at 'e.pfu.ness is prote)ti/e against de/e.oping C8. Se- Di66eren.es in Treat(ent #6 C#nd$.t Dis#rder Re)ommended inter/entions for )'i.dren and ado.es)ents (it' C8 in).ude parent management training$ prob.em1so./ing s-i..s training$ and mu.tisystemi) t'erapy 2@a4din$ 9,,:3. Unfor1

tunate.y$ many studies of t'erapy effe)ti/eness do not in).ude gir.s or do not examine sex differen)es ('en bot' gir.s and boys are in).uded 2@ann H &anna$ 9,,,C Webster1 tratton$ *++?3. Webster1 tratton 2*++?3 did examine sex differen)es in t'e effe)ts of parent training on

:. GENDER AND PSYCHOPATHOLOGY 118 four1 to se/en1year1o.ds (it' )ondu)t prob.ems. At base.ine$ mot'ers reported more externa.1 i4ing prob.ems for boys t'an for gir.s ('ereas fat'ers reported more interna.i4ing prob.ems for gir.s t'an for boys. #ea)'ers reported more be'a/ior prob.ems$ 'osti.e1aggressi/e prob.ems and 'ypera)ti/e be'a/iors for boys t'an for gir.s. Mot'ers$ fat'ers$ and tea)'ers reported signifi)ant redu)tions in externa.i4ing be'a/ior prob.ems from pre1 to postinter/ention$ but no )'ange from postinter/ention to fo..o(1up for boys and gir.s. #'e effe)ts (ere t'e same for bot' boys and gir.s. E/en fo..o(ing t'e inter/ention$ tea)'ers per)ei/ed boys as more 'osti.e1aggressi/e and 'ypera)ti/e t'an gir.s. Webster1 tratton 2*++?3 a.so in/estigated )'i.d$ parenting$ and fami.y /ariab.es as predi)tors of out)omes. =ir.s and boys did not initia..y differ on t'e parenting and fami.y /ariab.es$ ex)ept mot'ers used more p'ysi)a..y negati/e be'a/ior (it' boys. At fo..o(1up boysG externa.i4ing prob.ems (ere predi)ted primari.y by prior externa.i4ing be'a/ior and not'ing e.se ex)ept fat'er negati/ity. !n t'e ot'er 'and$ gir.sG externa.i4ing prob.ems 'ad more signifi)ant parenting predi)tors 2mot'er inappropriate dis)ip.ine$ mot'er and fat'er negati/ity$ mot'er depression$ fat'er .ife stress3 suggesting t'at gir.sG )ondu)t prob.ems are more inf.uen)ed by parent /ariab.es t'an boysG. #'is finding furt'er suggests t'at additiona. t'erapeuti) fo)us on parenting and fami.y /ariab.es may be differentia..y benefi)ia. to gir.s. We )an a.so spe)u.ate t'at t'e different symptom profi.es presented by gir.s and boys 2e.g.$ boys engaging in more 'osti.e1aggressi/e be'a/iors3 mig't .ead to sex differen)es in t'e effi)a)y of different t'erapies or different )omponents of a t'erapy. =ir.s$ be)ause of t'eir 'ig'er rate of )omorbidity$ may a.so pose more )'a..enging and )omp.ex prob.ems for t'e t'erapist. S$((ary 8iagnosti) )riteria for )ondu)t disorder raise t'e issue of t'e re.ati/e /a.idity of using t'e same$ preferab.y gender neutra.$ symptoms for bot' boys and gir.s /ersus different sets of )riteria for t'e t(o sexes. "dentifying )'i.d and ado.es)ent be'a/iors t'at predi)t adu.t prob.ems for fema.es and for ma.es appears to be t'e dire)tion resear)' in t'is area s'ou.d ta-e. #'e fo)us on boys to t'e ex).usion of gir.s in understanding t'is disorder or e/a.uating t'erapy out)omes needs to )'ange. tudies t'at in).ude bot' sexes and )ompare predi)tors of ado.es)ent C8 and predi)tors of t'erapy out)ome suggest t'at t'e de/e.opmenta. tra6e)tory for C8s and t'e impa)t of inter/entions may differ for gir.s and boys and are in need of furt'er in/estigation. SUMMARY AND CONCLUSIONS "dentifying and exp.aining t'e ro.e p.ayed by sex or gender in psy)'opat'o.ogy and its treatment are ongoing )'a..enges for ).ini)a. s)ientists. A diffi)u.t issue for diagnosis of psy)'o.ogi)a. disorders is 'o( to ma-e diagnosti) )riteria e7ua..y /a.id for (omen and men$ gir.s and boys. E/en ('en )riteria are made as ob6e)ti/e as possib.e$ ).ini)ians may app.y t'em differentia..y based on t'e sex of t'e ).ient and$ as 'as been demonstrated$ may more readi.y assign diagnosti) .abe.s t'at )onform to gender stereotypes. 8imensiona. des)riptions rat'er t'an )ategori)a. .abe.s may a..e/iate some of t'ese prob.ems. But standardi4ed tests designed to measure diagnosti) )ategories are not a.(ays free of sex or gender bias. Efforts to use t'e diagnosti) system to determine pre/a.en)e rates are furt'er biased by using ).ini)a. samp.es rat'er t'an )ommunity samp.es. A )'a..enge for 8 M1> (i.. be determining if t'e same )riteria oug't to be used for ma.es and fema.es or if some psy)'o.ogi)a. disorders (i.. re7uire different sets of )riteria to be optima..y a))urate. Resear)' on t'e effe)ts of sex on t'erapy out)omes 'as produ)ed mixed resu.ts$ but mu)' data suggest t'at neit'er sex of t'erapist nor sex of ).ient 'as a predi)tab.e or

si4ab.e effe)t on t'erapy out)ome. ex of ).ient or t'erapist may p.ay

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=3@@8>. Li6eti(e .##..$rren.e #6 DSM0III0R a%.#/#% Ab$se and de*enden.e 2it/ #t/er *sy./iatri. dis#rders in t/e Nati#na% C#(#rbidity S$r,ey. %rchives of General +sychiatry# 9;# :3:0: 3. )ess%er5 R. C5 M.G#na&%e5 ). A.5 F/a#5 S.5 Ne%s#n5 C. 1.5 H$&/es5 MQ Es/%e(an5 S.5 Witt./en5 H. G5 H )end%er5 ). S. =3@@9>. Li6eti(e and 3 0(#nt/ *re,a%en.e #6 DSM0III0R *sy./iatri. dis#rders in t/e United States' Res$%ts 6r#( t/e Nati#na% C#(#rbidity S$r,ey. %rchives of General +sychiatry# 96# ;03@. )#rnstein5 S. G. =3@@8>. Gender di66eren.es in de*ressi#n' I(*%i.ati#ns 6#r treat(ent. ournal of 1linical +sychiatry# "S=S$**%. 3">5 3 03;. )#sten5 T. A.5 Ga2in5 F. H.5 )#sten5 T. R.5 H R#$nsa,i%%e5 1. 7. =3@@:>. Gender di66eren.es in .#.aine $se and treat(ent res*#nse. ournal of 'ubstance %buse Treatment# 67# ?:0??. La(b5 D. H.5 H CatanCar#5 S. 7. =3@@;>. Se-$a% and n#nse-$a% b#$ndary ,i#%ati#ns in,#%,in& *sy./#%#&ists5 .%ients5 s$*er,isees5 and st$dents' I(*%i.ati#n 6#r *r#6essi#na% *ra.ti.e. +rofessional +sychology5 (esearch and +ractice# :@# 9@;0"!:. Leiben%$6t5 E. =3@@8>. Iss$es in t/e treat(ent #6 2#(en 2it/ bi*#%ar i%%ness. ournal of 1linical +sychiatry# "VS=S$**%. 3">5 "033. Le2is5 C5 H 1$./#%C5 ). =3@@3>. A%.#/#%is(5 antis#.ia% be/a,i#r and 6a(i%y /ist#ry. $ritish ournal of %ddiction# 8E# 38803@9. Lidd%e5 1. 7. =3@@?>.T/era*ist se-$a% #rientati#n5 &ender5 and .#$nse%in& *ra.ti.es as t/ey re%ated t# ratin&s #6 /e%*6$%ness by &ay and %esbian .%ients. ournal of 1ounseling +sychology# ;?# :@909! . Lindsay5 ). A.5 San+is5 L. M.5 H Widi&er5 T. A. = !!!>. Gender bias in se%60re*#rt *ers#na%ity dis#rder in,ent#ries. ournal of +ersonality Disorders# 6;# 3;0 : . Lindsay5 ). A.5 H Widi&er5 T. A. =3@@">. Se- and &ender bias in se%60re*#rt *ers#na%ity dis#rder in,ent#ries' Ite(s ana%yses #6 t/e MCMI0II5 MMPI5 and PDN0R. ournal of +ersonality %ssessment# E9# 30 !.

124 W"N #EA8 AN8 ANC&ER L#rin&5 M.5 H P#2e%%5 1. =3@;;>. Gender5 ra.e and DSM0III' A st$dy #6 t/e #bDe.ti,ity #6 *sy./iatri. dia&n#sti. be/a,i#r. ournal of,ealth and 'ocial $ehavior# :@# 30 . Lytt#n5 H.5 H R#(ney5 D. M. =3@@3>. ParentsB di66erentia% s#.ia%iCati#n #6 b#ys and &ir%s' A (eta0ana%ysis. +sychological $ulletin# 67@# ?80 @?. Ma..#by5 E. E.5 Sn#25 M. E.5 H 7a.+%in5 C. N. =3@;9>. C/i%drenBs dis*#siti#ns and (#t/er0 ./i%d intera.ti#n at 3 and 3; (#nt/s' A s/#rt0ter( %#n&it$dina% st$dy. Developmental +sychology# :7# 9"@098 . Madd$-5 7. E. = !! >. St#**in& t/e K(adnessK' P#siti,e *sy./#%#&y and t/e de.#nstr$.ti#n #6 t/e i%%ness ide#%#&y and t/e D'M. In C. R. Snyder H S. 7. L#*eC =Eds.>5 ,andbook of positive psychology =**. 3:0 ">. NY' O-6#rd. Mars/5 L.5 H Cas*er5 R. =3@@;>. Gender di66eren.es in brain (#r*/#%#&y and in *sy./iatri. dis#rders. In R. C. Cas*er =Ed.>5 &omenHs health5 ,ormones# emotions and behavior =**. ":0; >. Ca(brid&e' Ca(brid&e Uni,ersity Press. M.Ma/#n5 R. <5 H We%%s5 ). C. =3@@;>. C#nd$.t *r#b%e(s. In E. 7. Mas/ H R. A. 1ar+%ey =Eds.>5 Treatment of childhood disorders =**. 3330 !8>. NY' G$i%6#rd. M#rey5 L. C5 H O./#a5 E. =3@;@>. An in,esti&ati#n #6 ad/eren.e t# dia&n#sti. .riteria' C%ini.a% dia&n#sis #6 t/e DSM0III *ers#na%ity dis#rders. ournal of +ersonality Disorders# ?# 3;!03@ . N#%en0 H#e+se(a5 S.5 Lars#n5 <5 H Grays#n5 C. =3@@@>. E-*%ainin& t/e &ender di66eren.e in de*ressi,e sy(*t#(s. ournal of +ersonality and 'ocial +sychology# AA# 3!?303!8 . Pa&e5 S.5 H 1ennes./5 S. =3@@:>. Gender and re*#rtin& di66eren.es in (eas$res #6 de*ressi#n. 1anadian ournal of $ehavioural 'cience# :9# "8@0";@. Pant#ny5 ). L.5 H Ca*%an5 P. 7. =3@@3>. De%$si#na% d#(inatin& *ers#na%ity dis#rder' A (#dest *r#*#sa% 6#r identi6yin& s#(e .#nseJ$en.es #6 ri&id (as.$%ine s#.ia%iCati#n. 1anadian +sychology# ?:# 3 !03::. P#tts5 M. ).5 1$rna(5 M. A.5 H We%%s5 ). 1. =3@@3>. Gender di66eren.es in de*ressi#n dete.ti#n' A .#(*aris#n #6 .%ini.ian dia&n#sis and standardiCed assess(ent. +sychological %ssessment# ?# ?!@0?3". R#bins5 E.5 H G$Ce5 S. 1. =3@8!>. Estab%is/(ent #6 dia&n#sti. ,a%idity #6 *sy./iatri. i%%ness' Its a**%i.ati#n t# s./iC#*/renia. %merican ournal of +sychiatry# 6:E# @;:0@;?. R#bins5 L. N. =3@;?>. T/e .#nseJ$en.es #6 .#nd$.t dis#rder in &ir%s. In D. O%2e$s5 7. 1%#.+5 H M. Rad+e0Yarr#2 =Eds.>5 Development of antisocial and prosocial behavior. Or%and#5 FL' A.ade(i. Press. R#ss5 H.5 Tes%a5 C5 )eny#n5 1.5 H L#%%is5 S. =3@@!>. Materna% inter,enti#n in t#dd%er *eer .#n6%i.t' T/e s#.ia%iCati#n #6 *rin.i*%es #6 D$sti.e. Developmental +sychology# :E# @@903!!:. R#ss5 R.5 Fran.es5 A. <5 H Widi&er5 T. A. =3@@">. Gender iss$es in DSM0IG In < M. O%d/a( H M. 1. Riba =Eds.>5 (eview of psychiatry =G#%. 395 **. !"0 ?>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. Sant#r5 D. A.5 Ra(say5 7. O5 H F$r#665 D. C. =3@@9>. N#n*ara(etri. ite( ana%yses #6 t/e 1e.+ De*ressi#n In,ent#ry' E,a%$atin& &ender ite( bias and res*#nse #*ti#n 2ei&/ts. +sychological %ssessment# E# ""0 8!. See(an5 M. G =3@@">. Gender di66eren.es in treat(ent res*#nse in s./iC#*/renia. In M. G See(an =Ed.>5 Gender and psychopathology. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. S(etana5 < G. =3@;@>.

T#dd%ersB s#.ia% intera.ti#ns in t/e .#nte-t #6 (#ra% and .#n,enti#na% trans&ressi#ns in t/e /#(e. Developmental +sychology# :9# 9@@0"!;. S*r#.+5 <5 H Y#der5 C. Y. =3@@8>. W#(en and de*ressi#n' An $*date #n t/e re*#rt #6 t/e APA tas+ 6#r.e. 'e" (oles# ?E# ?@0:!:. Sra(e+5 < <5 H Fra.+ie2i.C5 E. < = !! >. E66e.t #6 se- #n *sy./#*/ar(a.#%#&y #6 antide*ressants. In F. Le2is0Ha%%5 T. S. Wi%%ia(s5 < A.5 Panetta5 H 7. M. Herrera =Eds.>5 +sychiatric illness in women =**. 33:0 3:3>. Was/in&t#n5 DC' A(eri.an Psy./iatri. P$b%is/in&. Ster%in&5 R. C5 G#tt/ei%5 E.5 Weinstein5 S. P.5 H Ser#ta5 R. = !!3>. T/e e66e.t #6 t/era*ist4*atient ra.e0 and se-0(at./in& in indi,id$a% treat(ent. %ddiction# @E#3!3"03! . SCy(ans+i5 S.5 Lieber(an5 < A.5 A%,ir5 < M.5 Mayer/#665 D.5 =3@@">. Gender di66eren.es in #nset #6 i%%ness5 treat(ent res*#nse5 .#$rse and bi#%#&i. inde-es in 6irst0e*is#de s./iC#*/reni. *atients5 %merican ournal of +sychiatry# 69:# ?@;08!:. Ta((in&a5 C. A. =3@@8>. Gender and s./iC#*/renia5 ournal of 1linical +sychiatry# 7"=S$**%. 3">5 ::0:8. T/ase5 M. E.5 Reyn#%ds5 C. F.5 Fran+5 E.5 Si(#ns5 A. D.5 M.Geary5 7.5 Fasi.C+a5 A. L.5 Gara(#ni.G. G.5 7ennin&s5 R.5 H )$*6er5 D. < =3@@9>. D# de*ressed (en and 2#(en res*#nd si(i%ar%y t# .#&niti,e be/a,i#r t/era*yI %merican ournal of +sychiatry# 696# "!!0"!". T#neatt#5 A.5 S#be%%5 L. C5 H S#be%%5 M. 1. =3@@ >. Gender iss$es in t/e treat(ent #6 ab$sers #6 a%.#/#%5 ni.#tine5 and #t/er dr$&s. ournal of 'ubstance %buse# ;# !@0 3;. Tri66%e(an5 E. = !!3>. Gender di66eren.es in a .#ntr#%%ed *i%#t st$dy #6 *sy./#s#.ia% treat(ents in s$bstan.e de*endent *atients 2it/ *#st0tra$(ati. stress dis#rder' Desi&n .#nsiderati#ns and #$t.#(es. %lcoholism Treatment >uarterly# 68# 33:03 ?. Geie%5 H. O. F. =3@@:>. Detri(enta% e66e.ts #6 +in s$**#rt net2#r+s #n t/e .#$rse #6 de*ressi#n. ournal of %bnormal +sychology# 67:# 93@09 @.

:. GENDER AND PSYCHOPATHOLOGY 126 Gi&$era5 A. D.5 1a%dessarini5 R. 7.5 T#nd#5 L. = !!3>. Res*#nse t# %it/i$( (aintenan.e treat(ent in bi*#%ar dis#rders' C#(*aris#n #6 2#(en and (en. $ipolar Disorders# ?# 9"0 " . Wa%+er. L. E. A. =3@@9>. Are *ers#na%ity dis#rders &ender biasedI In S. A. )ir+H S. D. Einbinder =Eds.>5 1ontroversial issues in mental health =**. 0 @>. Ne2 Y#r+' A%%yn H 1a.#n. Warner5 R. =3@8;>. T/e dia&n#sis #6 antis#.ia% and /ysteri.a% *ers#na%ity dis#rders. ournal of -ervous and Mental Disease# 6EE# ;:@0;9". Webster0Stratt#n5 C. =3@@?>. Ear%y0#nset .#nd$.t *r#b%e(s' D#es &ender (a+e a di66eren.eI ournal of 1onsulting and 1linical +sychology# E;# "9!0""3. W/it%#.+5 E. R5 G#&t5 T. M.5 H#%%is5 7. R.5 H Li./tenstein5 E. =3@@8>. D#es &ender a66e.t res*#nse t# a brie6 .%ini.0based s(#+in& inter,enti#nI %merican ournal of +reventive Medicine# 6?# 3"@03??. Widi&er5 T. A. =3@@;>. In,ited essay' Se- biases in t/e dia&n#ses #6 *ers#na%ity dis#rders. ournal of +ersonality Disorders# 6:# @"033;. Wi%+e5 D. =3@@9>. W#(en and a%.#/#%is(' H#2 a (a%e0as0n#r( bias a66e.ts resear./5 assess(ent5 and treat(ent. ,ealth and 'ocial &ork# 6@# @0:". Wi%%ia(s5 7. 1. W5 H S*itCer5 R. L. =3@;:>. T/e iss$e #6 se- bias in DSM0III. CritiJ$e #6 KA 2#(anBs ,ie2 #6 DSM0IIIK by Mar.ie )a*%an. %merican +sychologist# ?8# 8@:08@;. W#%+5 S. I.5 H Weiss(an5 M. M. =3@@">. W#(en and de*ressi#n' An $*date. (eview of +sychiatry# 6;# 80 "@. W#n&5 C. M.5 H Ye/$da5 R. = !! >. Se- di66eren.es in *#sttra$(ati. stress dis#rder. In F. Le2is0Ha%% H T. S. Wi%%ia(s5 =Eds.>5 +sychiatric illness in women5 !merging treatments and research =**. "80@?>. Y#der5 C. Y.5 S/$te5 G. E.5 H Tryban5 G. M. =3@@!>. C#(($nity re.#&niti#n #6 #bDe.ti,e and s$bDe.ti,e ./ara.teristi.s #6 de*ressi#n. %merican ournal of 1ommunity +sychology# 68# "980"??. Y#n+ers5 ). A.5 H Ha(i%t#n5 J. A. =3@@">. Psy./#tr#*i. (edi.ati#ns. In 7. M. O%d/a( H M. 1. Riba =Eds.>5 (eview of psychiatry =G#%. 395 **. :!80:: >. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. Fa/n0 Wa-%er5 C. =3@@:>. Warri#rs and 2#rriers' Gender and *sy./#*at/#%#&y. Development and+sychopathology# 9# 8@0;@. F%#tni.+5 C.5 E%+in5 I.5 H S/ea M. T. =3@@;>. D#es t/e &ender #6 a *atient #r t/e &ender #6 a t/era*ist a66e.t t/e treat(ent #6 *atients 2it/ (aD#r de*ressi#nI ournal of 1onsulting and 1linical +sychology# EE# ?""0?"@. F#..#%i%%#5 M. =3@@:>. Gender and t/e de,e%#*(ent #6 .#nd$.t dis#rder. Development and +sychopathology# 9#?"08;. F#..#%i%%#5 M.5 Tre(b%ay5 R.5 H Gitar#5 F. =3@@?>. DSM0III0R and DSM0III .riteria 6#r .#nd$.t dis#rder in *read#%es.ent &ir%s' S*e.i6i. b$t insensiti,e. ournal of the %merican %cademy of 1hild and %dolescent +sychiatry# ?9#9?3P98!.

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CHAPTER

4
C%assi6i.ati#n and Dia&n#sis' Hist#ri.a% De,e%#*(ent and C#nte(*#rary Iss$es T/#(as A. Widi&er University o f .entucky Aberrant$ dysfun)tiona.$ and ma.adapti/e t'in-ing$ fee.ing$ be'a/ing$ and re.ating are of sub1 stantia. )on)ern to many different professions$ t'e members of ('i)' (i.. 'o.d an e7ua..y di/erse array of be.iefs regarding etio.ogy$ pat'o.ogy$ and inter/ention. "t is imperati/e t'at t'ese persons be ab.e to )ommuni)ate meaningfu..y (it' one anot'er. #'e primary purpose of an offi)ia. diagnosti) nomen).ature is to pro/ide t'is )ommon .anguage of )ommuni)ation 2@ende..$ *+D<C artorius et a..$ *++:3. !ffi)ia. diagnosti) nomen).atures$ 'o(e/er$ )an be ex)eeding.y po(erfu.$ impa)ting sig1 nifi)ant.y many important so)ia.$ forensi)$ ).ini)a.$ and ot'er professiona. de)isions 2 )'(art4 H Wiggins$ 9,,93. %ersons t'in- in terms of t'eir .anguage$ and t'e predominant .anguages of psy)'opat'o.ogy are t'e fourt' edition of t'e Ameri)an %sy)'iatri) Asso)iationGs 2*++;$ 9,,,3 Diagnostic and 'tatistical Manual of Mental Disorders 28 M1">3 and t'e tent' edition of t'e Wor.d &ea.t' !rgani4ationGs 0nternational 1lassification of Diseases 2"C81*,C *++93. As su)'$ t'ese nomen).atures 'a/e a substantia. impa)t on 'o( ).ini)ians$ so)ia. agen)ies$ and t'e genera. pub.i) )on)eptua.i4e psy)'opat'o.ogy. #'ese t(o .anguages$ 'o(e/er$ are not t'e fina. (ord. "nterpreting 8 M1"> or "C81*, as )on).usi/e.y /a.idated nomen).atures exaggerates t'e extent of t'eir empiri)a. support 2Fran)es$ %in)us$ Widiger$ 8a/is$ H First$ *++,3. !n t'e ot'er 'and$ 8 M1"> and "C81*, are not .a)-ing in )redib.e or )ompe..ing empiri)a. support. 8 M1"> and "C81*, )ontain many f.a(s but t'ey are a.so (e..1reasoned$ s)ientifi)a..y resear)'ed$ and (e..1do)umented nomen).atures t'at des)ribe ('at is )urrent.y understood by most s)ientists$ t'eorists$ resear)'ers$ and ).ini)ians to be t'e predominant /ariants of psy)'opat'o.ogy 2Nat'an H Langenbu)'er$ *+++C Widiger H #ru..$ *++:3. #'is )'apter (i.. o/er/ie( t'e 8 M1"> diagnosti) nomen).ature$ beginning (it' 'istori)a. ba)-ground$ fo..o(ed by a dis)ussion of ma6or issues fa)ing future re/isions. 128

129 WIDIGER HISTORICAL 1AC)GROUND #'e impetus for t'e de/e.opment of an offi)ia. diagnosti) nomen).ature (as t'e )ripp.ing )onfusion generated by its absen)e 2Widiger$ 9,,*3. 0For a .ong time )onfusion reigned. E/ery se.f1respe)ting a.ienist It'e *+t' )entury term for a psy)'iatristJ$ and )ertain.y e/ery professor$ 'ad 'is o(n ).assifi)ation0 2@ende..$ *+D<$ p. BD3. #'e produ)tion of a ne( system for ).assifying psy)'opat'o.ogy be)ame a rig't of passage in t'e nineteent' )entury for t'e young$ aspiring professor. To produce a well&ordered classification almost seems to have become the unspoken ambition of every psychiatrist of industry and promise, as it is the ambition of a good tenor to strike a high C. This classificatory ambition was so conspicuous that the composer ,erlio< was prompted to remark that after their studies have been completed a rhetorician writes a tragedy and a psychiatrist a classification. =ilboorg, 01;0, p. ;>3" "n *+,B t'e Ameri)an Bureau of t'e Census as-ed t'e Ameri)an Medi)o1%sy)'o.ogi)a. Asso)iation 2('i)' subse7uent.y a.tered its tit.e in *+9* to t'e Ameri)an %sy)'iatri) Asso)i1 ation3 to de/e.op a standard noso.ogy to fa)i.itate t'e obtainment of nationa. statisti)s. #'is )ommittee affirmed t'e need for a uniform system. The present condition with respect to the classification of mental diseases is chaotic. .ome states use no well&defined classification. !n others the classifications used are similar in many respects but differ enough to prevent accurate comparisons. .ome states have adopted a uniform system, while others leave the matter entirely to the individual hospitals. This condition of affairs discredits the science. .almon, Copp, /ay, #bbot, ? Cotton, 010*, pp. 2>>& 2>4" #'e Ameri)an Medi)o1%sy)'o.ogi)a. Asso)iation$ in )o..aboration (it' t'e Nationa. Committee for Menta. &ygiene$ issued a noso.ogy in *+*B$ tit.ed 'tatistical Manual for the Use of 0nstitutions for the 0nsane 2=rob$ *++*C Menninger$ *+?:3. #'is nomen).ature$ 'o(e/er$ fai.ed to gain (ide a))eptan)e. "t in).uded on.y 99 diagnoses$ ('i)' (ere )onfined .arge.y to psy)'oses (it' a presumab.y neuro)'emi)a. pat'o.ogy. 0"n t'e .ate t(enties$ ea)' .arge tea)'ing )enter emp.oyed a system of its o(n origination$ no one of ('i)' met more t'an t'e immediate needs of t'e .o)a. institution0 2Ameri)an %sy)'iatri) Asso)iation IA%AJ$ *+<9$ p. /3. A )onferen)e (as 'e.d at t'e Ne( Aor- A)ademy of Medi)ine in *+9B to de/e.op a more aut'oritati/e and uniform.y a))epted manua.. #'e resu.ting nomen).ature (as mode.ed after t'e 'tatistical Manual but it (as distributed to 'ospita.s (it'in t'e Ameri)an Medi)a. Asso)iationGs 'tandard 1lassified -omenclature of Disease. Many 'ospita.s used t'is system$ but it e/entua..y pro/ed to be inade7uate ('en t'e attention of t'e profession expanded (e.. beyond psy)'oti) disorders during Wor.d War "". ICD0? and DSM0I #'e Na/y$ Army$ and >eterans Administration de/e.oped t'eir o(n$ .arge.y independent nomen).atures during Wor.d War "" main.y be)ause of t'e inade7ua)ies of t'e 'tandard 1las3 sified. 0Mi.itary psy)'iatrists$ indu)tion station psy)'iatrists$ and >eterans Administration psy)'iatrists$ found t'emse./es operating (it'in t'e .imits of a nomen).ature spe)ifi)a..y not

designed for +,P of t'e )ases 'and.ed0 2A%A$ *+<9$ p. /i3. #'e Wor.d &ea.t' !rgani4ation 2W&!3 a))epted t'e aut'ority in *+;B to produ)e t'e ?t' edition of t'e 0nternational 'tatistical 1lassification of Diseases# 0n4uries# and 1auses of Death 2"C83. "C81? (as t'e first to in).ude

9. CLASSIFICATION AND DIAGNOSIS 131 a se)tion de/oted to menta. disorders 2@ende..$ *+D<C @ramer$ artorius$ Jab.ens-y$ H =u.binat$ *+D+3$ per'aps in re)ognition of t'e many psy)'o.ogi)a. )asua.ties of Wor.d War "" and t'e in)reasing impa)t of menta. 'ea.t' professions. #'e United tates %ub.i) &ea.t' er/i)e )om1 missioned a )ommittee$ )'aired by =eorge Raines 2(it' representations from a /ariety of professions and pub.i) 'ea.t' agen)ies3$ to de/e.op a /ariant of t'e menta. disorders se)tion of "C81? for use (it'in t'e United tates. #'e United tates$ as a member of t'e W&!$ (as ob.iged to use "C81?$ but modifi)ations )ou.d be made to maximi4e its a))eptan)e and uti.ity for use (it'in t'e United tates. #'e resu.ting nomen).ature resemb.ed ).ose.y t'e >eterans Administration system de/e.oped by Brigadier =enera. Wi..iam Menninger 2brot'er to @ar. Menninger$ *+?:3. Responsibi.ity for pub.is'ing and distributing t'is noso.ogy (as gi/en to t'e Ameri)an %sy)'iatri) Asso)iation 2*+<93 under t'e tit.e Diagnostic and 'tatistical Manual. Mental Disorders 2'ereafter referred to as 8 M1"3. 8 M1" (as genera..y su))essfu. in obtaining a))eptan)e$ main.y be)ause of its expanded )o/erage$ in).uding somatoform disorders$ stress rea)tions$ and persona.ity disorders. &o(e/er$ t'e Ne( Aor- tate 8epartment of Menta. &ygiene$ ('i)' 'ad been inf.uentia. in t'e de/e.opment of t'e .tandard +omenclature, )ontinued for some time to use its o(n ).assifi)ation. 8 M1" a.so in).uded narrati/e des)riptions of ea)' disorder to fa)i.itate understanding and more )onsistent app.i)ations. Ne/ert'e.ess$ fundamenta. )riti)isms regarding t'e re.iabi.ity and /a.idity of psy)'iatri) diagnoses (ere a.so raised 2e.g.$ Rig.er H %'i..ips$ *+?*3. For examp.e$ a (ide.y )ited re.iabi.ity study by Ward$ Be)-$ Mende.son$ Mo)-$ and Erbaug' 2*+?93 )on).uded t'at most of t'e poor agreement among psy)'iatristsG diagnoses (as due .arge.y to inade7ua)ies of 8 M1". "C81? (as .ess su))essfu.. #'e 0menta. disorders se)tion Iof "C81?J fai.ed to gain Iinternationa.J a))eptan)e and e.e/en years .ater (as found to be in offi)ia. use on.y in Fin.and$ Ne( Rea.and$ %eru$ #'ai.and$ and t'e United @ingdom0 2@ende..$ *+D<$ p. +*3. #'e W&! t'erefore )ommissioned a re/ie( by t'e Eng.is' psy)'iatrist Er(in tenge.. tenge. 2*+<+3 reiterated t'e importan)e of estab.is'ing an offi)ia. nomen).ature5 # . . . serious obstacle to progress in psychiatry is difficulty of communication. @verybody who has followed the literature and listened to discussions concerning mental illness soon discovers that psychiatrists, even those apparently sharing the same basic orientation, often do not speak the same language. They either use different terms for the same concepts, or the same term for different concepts, usually without being aware of it. !t is sometimes argued that this is inevitable in the present state of psychiatric knowledge, but it is doubtful whether this is a valid e'cuse. .tengel, 01>1, p. 430" tenge. attributed t'e fai.ure of ).ini)ians to a))ept t'e menta. disorders se)tion of "C81? to t'e presen)e of t'eoreti)a. biases$ )yni)ism regarding any psy)'iatri) diagnoses 2some t'eoreti)a. perspe)ti/es opposed t'e use of any diagnosti) terms3$ and t'e presen)e of abstra)t$ 'ig'.y inferentia. diagnosti) )riteria t'at 'indered )onsistent$ uniform app.i)ations by different ).ini)ians. ICD0; and DSM0II Wor- began on "C81B soon after tenge.Gs 2*+<+3 report 2"C81? 'ad been re/ised to "C81D in *+<<$ but t'ere (ere no re/isions to t'e menta. disorders3. Considerab.e effort (as made to

de/e.op a system t'at (ou.d be used by a.. of t'e member )ountries of t'e W&!. #'e fina. edition of "C81B (as appro/ed by t'e W&! in *+?? and be)ame effe)ti/e in *+?B. A )ompanion g.ossary$ in t'e spirit of tenge.Gs 2*+<+3 re)ommendations$ (as to be pub.is'ed

133 W"8"=ER )on6oint.y$ but (or- did not begin on t'e g.ossary unti. *+?D and it (as not )omp.eted unti. *+D9. 0#'is de.ay great.y redu)ed IitsJ usefu.ness$ and a.so IitsJ aut'ority0 2@ende..$ *+D<$ p. +<3. "n *+?<$ t'e Ameri)an %sy)'iatri) Asso)iation appointed a )ommittee$ )'aired by Ernest M. =ruenberg$ to re/ise 8 M1" to be )ompatib.e (it' "C81B and yet a.so be suitab.e for use (it'in t'e United tates. #'e fina. /ersion (as appro/ed in *+?D$ (it' pub.i)ation in *+?B. #'e diagnosis of menta. disorders$ 'o(e/er$ (as re)ei/ing substantia. )riti)ism during t'is time 2e.g.$ Rosen'an$ *+D:C 4as4$ *+?*3. A fundamenta. prob.em )ontinued to be t'e absen)e of empiri)a. support for t'e re.iabi.ity$ .et a.one t'e /a.idity$ of its diagnoses 2e.g.$ B.as'fie.d H 8raguns$ *+D?3. Resear)'ers$ 'o(e/er$ too- to 'eart t'e re)ommendations of tenge. 2*+<+3 by de/e.oping more spe)ifi) and exp.i)it )riterion sets 2B.as'fie.d$ *+B;3. #'e most inf.uentia. of t'ese efforts (as produ)ed by a group of neurobio.ogi)a..y oriented psy)'iatrists at Was'ington Uni/ersity in t. Louis. #'eir )riterion sets generated so mu)' interest t'at t'ey (ere pub.is'ed separate.y in ('at 'as be)ome one of t'e most (ide.y )ited papers in psy)'iatry 2i.e.$ Feig'ner et a..$ *+D93. Resear)' 'as sin)e indi)ated t'at menta. disorders )an be diagnosed re.iab.y and do pro/ide /a.id information regarding etio.ogy$ pat'o.ogy$ )ourse$ and treatment 2Nat'an H Langenbu)'er$ *+++3. ICD0@ and DSM0III By t'e time Feig'ner et a.. 2*+D93 (as pub.is'ed$ (or- (as nearing )omp.etion on t'e nint' edition of t'e "C8. #'e aut'ors of "C81+ 'ad de)ided to in).ude a g.ossary t'at (ou.d pro/ide more pre)ise des)riptions of ea)' disorder$ but it (as apparent t'at "C81+ (ou.d not in).ude t'e more spe)ifi) and exp.i)it )riterion sets used in resear)' 2@ende..$ *+D<3. "n *+D;$ t'e Ameri)an %sy)'iatri) Asso)iation appointed a tas- for)e$ )'aired by Robert pit4er$ to re/ise 8 M1"" in a manner t'at (ou.d be )ompatib.e (it' "C81+ but (ou.d a.so in)orporate many of t'e )urrent inno/ations in diagnosis. 8 M1""" (as pub.is'ed in *+B, and (as remar-ab.y inno/ati/e$ in).uding 2a3 a mu.tiaxia. diagnosti) system 2most menta. disorders (ere diagnosed on Axis "$ persona.ity and spe)ifi) de/e.opmenta. disorders (ere diagnosed on Axis ""$ medi)a. disorders on Axis """$ psy)'oso)ia. stressors on Axis "V and .e/e. of fun)tioning on Axis >3$ 2b3 spe)ifi) and exp.i)it )riterion sets for a.. but one of t'e disorders 2s)'i4oaffe)ti/e3$ 2)3 a substantia..y expanded text dis)ussion of ea)' disorder to fa)i.itate diagnosis 2e.g.$ age at onset$ )ourse$ )omp.i)ations$ sex ratio$ and fami.ia. pattern3$ and 2d3 remo/a. of terms 2e.g.$ neurosis3 t'at appeared to fa/or a parti)u.ar t'eoreti)a. mode. for t'e disorderGs etio.ogy or pat'o.ogy 2 pit4er$ Wi..iams$ H -odo.$ *+B,3. DSM0in0R A disad/antage of 8 M1""" (as t'at errors in )riterion sets (ere as spe)ifi) and exp.i)it as t'e diagnosti) )riterion sets$ and a number of su)' errors (ere soon apparent 2e.g.$ pani) disorder )ou.d not be diagnosed in t'e presen)e of a ma6or depression3. 0Criteria (ere not entire.y ).ear$ (ere in)onsistent a)ross )ategories$ or (ere e/en )ontradi)tory0 2A%A$ *+BD$ p. x/ii3. #'e Ameri)an %sy)'iatri) Asso)iation t'erefore aut'ori4ed t'e de/e.opment of a re/ision to 8 M1""" to )orre)t t'ese errors. Fundamenta. re/isions (ere to be tab.ed unti. (or- began on "C81*,. &o(e/er$ it mig't 'a/e been unrea.isti) to expe)t t'e aut'ors of 8 M1"""1R to )onfine t'eir efforts to refinement and ).arifi)ation$ gi/en t'e impa)t$ su))ess$ and importan)e of 8 M1""". The impact of -./&!!! has been remarkable. .oon after its publication, it became widely accepted in the Anited .tates as the common language of mental health clinicians and researchers for

9. CLASSIFICATION AND DIAGNOSIS 134 communicating about the disorders for which they have professional responsibility. :ecent ma6or te'tbooks of psychiatry and other te'tbooks that discusspsychopathology have either made e'tensive reference to -./&!!! or largely adopted its terminology and concepts. #P#, 012*, p. 'viii" "t (as not diffi)u.t to find persons ('o (anted to be in/o./ed in t'e de/e.opment of 8 M1"""1R$ and most persons ('o (ere 2or (ere not3 in/o./ed (anted to 'a/e a signifi)ant impa)t. More persons (ere in/o./ed in ma-ing )orre)tions to 8 M1""" t'an (ere used in its origina. )onstru)tion$ and$ not surprising.y$ t'ere (ere many proposa.s for additions$ re/isions$ and de.etions. Four of t'e diagnoses appro/ed for in).usion by t'e aut'ors of 8 M1"""1R 2i.e.$ sadisti) persona.ity disorder$ se.f1defeating persona.ity disorder$ .ate .utea. p'ase dysp'ori) disorder$ and parap'i.ia) rapism3 generated so mu)' )ontro/ersy t'at a spe)ia. ad 'o) )ommittee (as appointed by t'e Board of #rustees of t'e Ameri)an %sy)'iatri) Asso)iation to re)onsider t'eir in).usion. A )on)ern )ommon to a.. four (as t'at t'eir in).usion mig't resu.t in 'arm to (omen. For examp.e$ parap'i.ia) rapism mig't be used to mitigate )rimina. responsibi.ity for rape and se.f1defeating persona.ity disorder mig't be used to b.ame fema.e /i)tims for 'a/ing been abused. Anot'er )on)ern (as t'e .a)- of suffi)ient empiri)a. support to address or offset t'ese )on)erns. A )ompromise (as e/entua..y rea)'ed in ('i)' t'e t(o persona.ity disorders and .ate .utea. p'ase dysp'ori) disorder (ere in).uded in an appendix 2Endi)ott$ 9,,,C Widiger$ *++<3C parap'i.ia) rapism (as de.eted entire.y. ICD-10 and DSM0IG By t'e time (or- (as )omp.eted on 8 M1"""1R$ (or- 'ad a.ready begun on "C81*,. #'e de)ision of t'e aut'ors of 8 M1""" to de/e.op an a.ternati/e to "C81+ (as instrumenta. in de/e.oping a 'ig'.y inno/ati/e manua. 2@ende..$ *++*C pit4er et a..$ *+B,3. &o(e/er$ its inno/ations (ere a.so at t'e )ost of de)reasing )ompatibi.ity (it' t'e "C81+ nomen).ature t'at (as used t'roug'out t'e rest of t'e (or.d$ ('i)' is prob.emati) to t'e stated purpose of pro/iding a )ommon .anguage of )ommuni)ation. "n May of *+BB t'e Ameri)an %sy)'iatri) Asso)iation appointed a 8 M1"> tas- for)e$ )'aired by A..en Fran)es 2Fran)es$ Widiger$ H %in)us$ *+B+3. Mandates for 8 M1"> in).uded better )oordination (it' "C81*, and impro/ed do)umentation of empiri)a. support. #'e 8 M1"> )ommittee aspired to use a more )onser/ati/e t'res'o.d for t'e in).usion of ne( diagnoses and to 'a/e de)isions t'at (ere guided more exp.i)it.y by t'e s)ientifi) .iterature 2Nat'an H Langenbu)'er$ *+++3. Fran)es et a.. 2*+B+3 suggested t'at 0t'e ma6or inno/ation of 8 M1"> (i.. not be in its 'a/ing surprising ne( )ontent but rat'er (i.. reside in t'e systemati) and exp.i)it met'od by ('i)' 8 M1"> (i.. be )onstru)ted and do)umented0 2p. :D<3. %roposa.s for additions$ de.etions$ or re/isions (ere guided by *D< .iterature re/ie(s t'at used a spe)ifi) format t'at maximi4ed t'e potentia. for )riti)a. re/ie($ )ontaining 2for examp.e3 a met'od se)tion t'at do)umented exp.i)it.y t'e )riteria for in).uding and ex).uding studies and t'e pro)ess by ('i)' t'e .iterature 'ad been re/ie(ed. Ea)' of t'ese re/ie(s 'as sin)e been pub.is'ed in t'ree /o.umes of a 8 M1"> our)eboo- 2Widiger et a..$ *++;$ *++?$ *++D3. #estab.e 7uestions t'at )ou.d be addressed (it' existing data sets (ere a.so exp.ored in t'irty1six studies$ ('i)' emp'asi4ed t'e aggregation of mu.tip.e data sets from independent resear)'ers$ and t(e./e fie.d tria.s (ere )ondu)ted to pro/ide re.iabi.ity and /a.idity data on proposed re/isions. #'e resu.ts of t'e t'irty1six studies and t(e./e fie.d tria.s (ere pub.is'ed in t'e fourt'

/o.ume of t'e 8 M1"> our)eboo- 2Widiger et a..$ *++B3. Criti)a. re/ie(s of t'ese 99: pro6e)ts (ere obtained by sending initia. drafts to ad/isors or )onsu.tants to a respe)ti/e (or- group$ by presenting drafts at re.e/ant )onferen)es$ and by submitting drafts to peer1re/ie(ed 6ourna.s 2Widiger$ Fran)es$ %in)us$ 8a/is$ H First$ *++*3.

136 W"8"=ER DSM0IG0TR !ne of t'e inno/ations of 8 M1""" (as t'e in).usion of a re.ati/e.y detai.ed text dis)ussion of ea)' disorder$ in).uding information on age of onset$ gender$ )ourse$ and fami.ia. pattern 2 pit4er et a..$ *+B,3. #'is text (as expanded in 8 M1"> to in).ude )u.tura. and et'ni) group /ariation$ /ariation a)ross age$ and .aboratory and p'ysi)a. exam findings 2Fran)es$ First$ H %in)us$ *++<3. Large.y ex).uded from t'e text is information )on)erning etio.ogy$ pat'o.ogy$ and treatment as t'is materia. (as )onsidered to be too t'eoreti)a..y spe)ifi) and more suitab.e for a)ademi) texts. Ne/ert'e.ess$ it 'ad a.so be)ome apparent t'at 8 M1"> (as being used as a textboo-$ and t'e materia. on age$ )ourse$ pre/a.en)e$ and fami.y 'istory (as 7ui)-.y be)oming outdated as ne( information (as being gat'ered. #'erefore$ in *++D$ t'e Ameri)an %sy)'iatri) Asso)iation appointed a 8 M1"> #ext Re/ision (or- group$ )'aired by Mi)'ae. First 2editor of t'e text and )riterion sets for 8 M1">3 and &aro.d %in)us 2>i)e1C'air for 8 M1">3 to update t'e text materia.. No substanti/e )'anges in t'e )riterion sets (ere )onsidered$ nor (ere any ne( additions$ subtypes$ de.etions$ or ot'er )'anges in t'e status of any diagnoses imp.emented. "n addition$ ea)' of t'e proposed re/isions to t'e text 'ad to be supported by a systemati) .iterature re/ie( t'at (as )riti7ued by a )onsiderab.e number of ad/isors. #'e 8 M1"> #ext Re/ision 28 M1">1#R3 (as pub.is'ed in 9,,, 2A%A$ 9,,,3. ICD-11 and DSM0G 8 M1"$ 8 M1""$ 8 M1"""$ and 8 M1"> (ere ea)' )oordinated$ at .east in timing$ (it' an edition of t'e "C8 2"C81?$ "C81B$ "C81+$ and "C81*,$ respe)ti/e.y3. "f t'is )oordination (ere to )ontinue$ 8 M1> (ou.d begin in tandem (it' t'e de/e.opment of "C81**. &o(e/er$ t'e W&! experien)ed substantia. diffi)u.ty )omp.eting a.. of t'e se)tions of t'e "C8 2@ende..$ *++*3. #'e menta. disorders se)tion of "C81*, (as pub.is'ed in *++9$ but to t'is day 'as sti.. not been imp.emented offi)ia..y (it'in t'e United tates. #'e W&! is un.i-e.y to attempt again to re/ise t'e entire "C8. Future re/isions (i.. be )onfined to indi/idua. se)tions of t'e manua.$ ea)' being re/ised on its o(n s)'edu.e. Re/isions to t'e menta. disorders se)tion of t'e "C8 may in fa)t be )oordinated (it' t'e de/e.opment of 8 M1> 2rat'er t'an /i)e /ersa3 part.y be)ause of t'e re)ogni4ed su))ess of t'e re)ent editions of t'e 8 M. "n *+++$ a )onferen)e 6oint.y sponsored by t'e Nationa. "nstitute of Menta. &ea.t' 2N"M&3 and t'e Ameri)an %sy)'iatri) Asso)iation (as 'e.d to identify t'e resear)' t'at (ou.d most .i-e.y be informati/e for t'e aut'ors of 8 M1> 2M)Kueen$ 9,,,3. ubstanti/e issues emp'asi4ed by resear)' p.anning (or- groups de/e.oped from t'is )onferen)e in).uded 2but (ere not .imited to3 )ross1)u.tura. issues$ gender differen)es$ de/e.opmenta. differen)es$ t'e distin)tion bet(een Axis " and Axis ""$ t'e definition of menta. disorder$ t'e t'res'o.d for diagnosis$ t'e use of .aboratory findings in diagnosis$ t'e impa)t of neuros)ien)e$ and dimensiona. mode.s of psy)'opat'o.ogy 2e.g.$ A.ar)on et a..$ 9,,9C First et a..$ 9,,9C Le'man et a..$ 9,,9$ Rounsa/i..e et a..$ 9,,93. A series of more spe)ifi) internationa. )onferen)es are .i-e.y to fo..o($ .eading up to a 8 M1> tasfor)e t'at may not be formed unti. approximate.y 9,,<$ (it' an anti)ipated pub.i)ation of 8 M1 > in approximate.y 9,*,. CONTINUING ISSUES FOR DSM0G #'e issues )onsidered by t'e 8 M1> resear)' p.anning (or- groups 2M)Kueen$ 9,,93 (i.. not ne)essari.y be ne( or uni7ue to 8 M1> "n fa)t$ some of t'em )on)ern fundamenta. issues

;. CLASSIFICATION AND DIAGNOSIS 137 t'at 'a/e been raised t'roug'out t'e 'istory of t'e diagnosis of menta. disorders 2B.as'fie.d$ *+B;C @ende..$ *+D<C Ri.boorg$ *+;*3. ix issues (ort' 'ig'.ig'ting in parti)u.ar are 2*3 t'e definition of menta. disorder and t'res'o.d for diagnosis$ 293 mu.tip.e diagnoses 2i.e.$ ex)essi/e diagnosti) )o1o))urren)e3$ 2:3 )ategori)a. /ersus dimensiona. mode.s of ).assifi)ation$ 2;3 )u.ture and /a.ues$ 2<3 gender$ and 2?3 t'e in).usion of .aboratory tests (it'in diagnosti) )riterion sets. Ea)' of t'ese issues (i.. be dis)ussed brief.y in turn. De6initi#n #6 Menta% Dis#rder and T/res/#%d 6#r Dia&n#sis #'e boundaries of t'e diagnosti) manua. 'a/e been in)reasing (it' ea)' edition$ and t'ere 'as been /o)a. )on)ern t'at mu)' of t'is expansion represents an en)roa)'ment into norma. prob.ems of .i/ing 2Cap.an$ *++<C Fo.ette H &outs$ *++?3. 8iagnoses proposed for 8 M1"> (ere u.timate.y in).uded (it'in an appendix primari.y be)ause t'ey mig't be be.o( an appropriate t'res'o.d for diagnosis$ su)' as mixed anxiety1depressi/e disorder$ age1re.ated )ogniti/e de).ine$ and minor depressi/e disorder 2Widiger H Co-er$ 9,,:3. A diffi)u.t tas- fa)ing t'e aut'ors of 8 M1> (i.. be estab.is'ing a meaningfu. boundary bet(een abnorma. and norma. psy)'o.ogi)a. fun)tioning. 2 ee Maddux$ =osse.in$ H Winstead$ t'is boo-$ for a more detai.ed dis)ussion of t'is issue.3 #'e extra)t t'at fo..o(s pro/ides t'e definition of menta. disorder presented in 8 M1">1#R 2A%A$ 9,,,3. !n -./&W each of the mental disorders is conceptuali<ed as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress e.g., a painful symptom" or disability i.e., impairment in one or more important areas offunctioning" or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. !n addition, this syndrome or pattern must not be merely an e'pectable and culturally sanctioned response to a particular event, for e'ample, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. +either deviant behavior e.g., political, religious, or se'ual" nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above. #merican Psychiatric #ssociation, 2333, p. '''i" #'is definition (as t'e resu.t of an effort by t'e aut'ors of 8 M1""" to de/e.op spe)ifi) and exp.i)it )riteria for de)iding ('et'er a be'a/ior pattern 2'omosexua.ity in parti)u.ar3 s'ou.d be ).assified as a menta. disorder 2 pit4er H Wi..iams$ *+B93. #'e intense )ontro/ersy o/er 'omosexua.ity 'as .arge.y abated$ but t'e issues raised in t'is 'istori)a. debate )ontinue to app.y. For examp.e$ in order to be diagnosed (it' pedop'i.ia$ 8 M1"""1R 2A%A$ *+BD3 re7uired on.y t'at an adu.t 'a/e re)urrent intense urges and fantasies in/o./ing sexua. a)ti/ity (it' a prepubes)ent )'i.d o/er a period of at .east six mont's and 'a/e a)ted on t'em 2or be mar-ed.y distressed by t'em3. E/ery adu.t ('o engaged in a sexua. a)ti/ity (it' a )'i.d for .onger t'an six mont's (ou.d meet t'ese diagnosti) )riteria. #'e aut'ors of 8 M1"> (ere t'erefore )on)erned t'at 8 M1"""1R (as not pro/iding ade7uate guidan)e for determining ('en de/iant sexua.

be'a/ior is t'e resu.t of a menta. disorder. 8e/iant be'a/ior a.one 'as not traditiona..y been )onsidered suffi)ient for a diagnosis 2=orenstein$ *+B;3. %resumab.y$ some persons )an engage in de/iant$ aberrant$ and e/en 'einous a)ti/ities (it'out being )ompe..ed to do so by t'e presen)e of psy)'opat'o.ogy. #'e aut'ors of 8 M1iy t'erefore$ added t'e re7uirement t'at 0t'e be'a/ior$ sexua. urges$ or fantasies )ause ).ini)a..y signifi)ant distress or impairment in so)ia.$ o))upationa.$ or ot'er important areas of fun)tioning0 2A%A$ *++;$ p. <9:3.

139 WIDIGER (eCuire +resence o f +athologyI pit4er and Wa-efie.d 2*+++3$ 'o(e/er$ 'a/e argued t'at t'e impairment )riteria in).uded in 8 M1"> are inade7uate. #'ey )on)urred (it' a )on)ern raised by t'e Nationa. La( Center for C'i.dren and Fami.ies t'at 8 M1"> mig't )ontribute to a norma.i4ation of pedop'i.i) and ot'er parap'i.i) be'a/ior by a..o(ing t'e diagnoses not to be app.ied if t'e persons ('o 'a/e engaged in t'ese a)ts are not t'emse./es distressed by t'eir be'a/ior or do not ot'er(ise experien)e impairment. "n response$ Fran)es et a.. 2*++<3 'ad argued t'at pedop'i.i) sexua. 0be'a/iors are in'erent.y prob.emati) be)ause t'ey in/o./e a non)onsenting person 2ex'ibitionism$ /oyeurism$ frotteurism3 or a )'i.d 2pedop'i.ia3 and may .ead to arrest and in)ar)eration0 2p. :*+3. #'erefore$ any person ('o engaged in an i..ega. sexua. a)t 2for .onger t'an six mont's3 (ou.d be ex'ibiting a ).ini)a..y signifi)ant so)ia. impairment and (ou.d t'erefore meet t'e 8 M1"> t'res'o.d for diagnosis. &o(e/er$ using t'e i..ega.ity of an a)t as a diagnosti) )riterion presents t'ree prob.ems. First$ it undermines t'e origina. rationa.e for t'e in).usion of t'e impairment )riterion 2i.e.$ to distinguis' immora. or i..ega. a)ts from abnorma. or disordered a)ts3. e)ond$ it pro/ides no meaningfu. basis for determining ('en de/iant sexua. a)ts or fantasies are or are not due to a menta. disorder. #'ird$ it is in)onsistent (it' t'e stated definition of a menta. disorder t'at indi)ates t'at neit'er de/ian)e nor )onf.i)ts (it' t'e .a( are suffi)ient to (arrant a diagnosis 2see pre/ious A%A definition3. pit4er and Wa-efie.d argued t'at t'e distin)tion bet(een disordered and nondisordered abuse of )'i.dren re7uires an assessment for t'e presen)e an under.ying$ interna. pat'o.ogy 2e.g.$ irrationa. )ogniti/e s)'ema or neuro)'emi)a. dysregu.ation3. Wa-efie.d 2*++D3 'as pro/ided examp.es of ot'er )riterion sets from 8 M1"> .ess po.iti)a..y or so)ia..y )ontro/ersia. t'an pedop'i.ia$ ('i)' 'e 'as argued 'a/e a.so fai.ed to ma-e a ne)essary distin)tion bet(een ma.adapti/e prob.ems in .i/ing and true psy)'opat'o.ogy due to t'e re.ian)e (it'in t'e )riterion sets on indi)ators of distress or impairment rat'er t'an referen)es to pat'o.ogy. For examp.e$ t'e 8 M1"> )riterion set for ma6or depressi/e disorder )urrent.y ex).udes most instan)es of depressi/e rea)tions to t'e .oss of a .o/ed one 2i.e.$ un)omp.i)ated berea/ement3. 8epression after t'e .oss of a .o/ed one )an be )onsidered a menta. disorder$ t'oug'$ if 0t'e symptoms persist for .onger t'an t(o mont's0 2A%A$ *++;$ p. :9D3. A..o(ing t(o mont's to grie/e before one is diagnosed (it' a menta. disorder mig't be as arbitrary and meaning.ess as a..o(ing a person to engage in a sexua..y de/iant a)t on.y for six mont's before t'e be'a/ior is diagnosed as a parap'i.ia. imi.ar )on)erns 'a/e been raised by Regier et a.. 2*++B3 regarding t'e diagnosis of )ommon anxiety and mood disorders. #'ey suggested t'at t'e pre/a.en)e rates for many of t'e anxiety$ mood$ and ot'er menta. disorders obtained by t'e N"M& Epidemio.ogi) Cat)'ment Area program 2ECA3 and t'e Nationa. Comorbidity ur/ey 2NC 3 (ere ex)essi/e. 0Based on t'e 'ig' pre/a.en)e rates identified in bot' t'e ECA and NC $ it is reasonab.e to 'ypot'esi4e t'at some syndromes in t'e )ommunity represent transient 'omeostati) responses to interna. or externa. stimu.i t'at do not represent true psy)'opat'o.ogi) disorders0 2Regier et a..$ *++B$ p. **;3. #'e in).usion of pat'o.ogy (it'in diagnosti) )riterion sets 2e.g.$ irrationa. )ogniti/e s)'emas$ un)ons)ious defense me)'anisms$ or neuro)'emi)a. dysregu.ations3 (ou.d be )onsistent (it' t'e definition of menta. disorder pro/ided in 8 M1">$ ('i)' states t'at t'e syndrome 0must )urrent.y be )onsidered a manifestation of a be'a/iora.$ psy)'o.ogi)a.$ or bio.ogi)a. dysfun)tion in t'e indi/idua.0 2A%A$ 9,,,$ p. xxxiC see pre/ious A%A definition3. &o(e/er$ a .imitation of t'is proposa. is t'at t'ere is )urrent.y .itt.e agreement o/er t'e spe)ifi) pat'o.ogy t'at s'ou.d be

re7uired for any parti)u.ar disorder. #'ere is insuffi)ient empiri)a. support to gi/e preferen)e to one parti)u.ar )ogniti/e$ interpersona.$ neuro)'emi)a.$ psy)'odynami)$ or ot'er t'eoreti)a. mode. of pat'o.ogy. #'e pre)ise nature of t'is pat'o.ogy )ou.d be .eft undefined or )'ara)teri4ed simp.y as an 0interna. dysfun)tion0 2Wa-efie.d$ %otti)-$ H @ir-$ 9,,93$ but an assessment of an unspe)ified pat'o.ogy is un.i-e.y to be re.iab.e. C.ini)ians (i.. 'a/e

9. CLASSIFICATION AND DIAGNOSIS 141 /ery different opinions )on)erning t'e nature of t'e interna. dysfun)tion and 7uite different t'res'o.ds for its attribution. #'e assumption t'at t'e expansion of t'e nomen).ature is subsuming norma. prob.ems in .i/ing is itse.f 7uestionab.e. %ersons )riti)a. of t'e nomen).ature 'a/e de)ried t'e substantia. expansion of t'e diagnosti) manua. o/er t'e past <, years 2e.g.$ Cap.an$ *++<C Fo..ette H &outs$ *++?C @ut)'ins H @ir-$ *++D3. "t (ou.d 'a/e been more surprising$ 'o(e/er$ to find t'at s)ientifi) resear)' and in)reased -no(.edge 'a/e fai.ed to .ead to t'e re)ognition of more instan)es of psy)'opat'o.ogy 2Wa-efie.d$ *++B3. "n fa)t$ t'e )urrent manua. mig't sti.. be inade7uate in its )o/erage despite t'e expansion. Kuite often$ t'e most )ommon diagnosis in genera. ).ini)a. pra)ti)e is not1ot'er(ise1spe)ified 2N! C C.ar-$ Watson$ H Reyno.ds$ *++<3. #'e N! diagnosis is pro/ided ('en a ).ini)ian 'as determined t'at psy)'opat'o.ogy is present but t'e symptomato.ogy fai.s to meet )riteria for any one of t'e existing disorders. C.ini)ians pro/iding t'e diagnosis of N! for anxiety$ mood$ persona.ity$ and ot'er disorders is a testament to t'e inade7uate )o/erage )urrent.y pro/ided 2a.t'oug' per'aps one )ou.d argue as (e.. t'at t'is is a testament to a tenden)y of ).ini)ians to diagnose norma. prob.ems in .i/ing as being instan)es of menta. disorder3. #'e in).usion of pat'o.ogy (it'in diagnosti) )riterion sets may e/en fai. to resu.t in a more )onser/ati/e t'res'o.d for diagnosis. "rrationa. )ogniti/e s)'emas and neuro)'emi)a. dysregu.ations 2%rigerson et a..$ *+++3 mig't be found in t'e ostensib.y norma. )ases of be1 rea/ement des)ribed by Regier et a.. 2*++B3 and Wa-efie.d 2*++D3. %at'o.ogy mig't a.so be present in t'e absen)e of any impairment or distress 2Le'man et a..$ 9,,93. !ptima. psy)'o1 .ogi)a. fun)tioning$ as in t'e )ase of optima. p'ysi)a. fun)tioning$ mig't represent an idea. t'at is a)'ie/ed by on.y a sma.. minority of t'e popu.ation. #'e re6e)tion of a 'ig' pre/a.en)e rate of psy)'opat'o.ogy may ref.e)t t'e best of intentions$ su)' as )on)erns regarding t'e stigmati4ation of menta. disorder diagnoses 2@ut)'ins H @ir-$ *++D3 or t'e potentia. impa)t on funding for treatment 2Regier et a..$ *++B3. #'ese so)ia. and po.iti)a. )on)erns$ 'o(e/er$ )ou.d a.so 'inder a more dispassionate and a))urate re)ognition of t'e true rate of a broad range of psy)'opat'o.ogy (it'in t'e popu.ation 2Widiger H an-is$ 9,,,3. ,armful Dysfunction or Dyscontrolled Maladaptivityf Wa-efie.d 2*++93 'as de/e.oped an a.ternati/e 'armfu. dysfun)tion definition of menta. disorder ('ere dysfun)tion is a fai.ure of an interna. me)'anism to perform a natura..y se.e)ted fun)tion 2e.g.$ t'e )apa)ity to experien)e fee.ings of gui.t in a person (it' antiso)ia. persona.ity disorder3 and 'arm is a /a.ue 6udgment t'at t'e design fai.ure is 'armfu. to t'e indi/idua. 2e.g.$ fai.ure to .earn from mista-es resu.ts in repeated punis'ments$ arrests$ .oss of emp.oyment$ and e/entua. impo/eris'ment3. Wa-efie.dGs mode. 'as re)ei/ed substantia. attention and is being )onsidered for in).usion in 8 M1> 2Rounsa/i..e et a..$ 9,,93. &o(e/er$ t'e mode. 'as a.so re)ei/ed )ompe..ing )riti)ism 2e.g.$ Bergner$ *++DC @irmayerHAoung$ *+++C Li.ienfie.dHMarino$ *+++3. A fundamenta. .imitation is its girding (it'in e/o.utionary t'eory$ t'ereby .imiting its re.e/an)e and usefu.ness to a.ternati/e mode.s of etio.ogy and pat'o.ogy 2Bergner$ *++D3. Wa-efie.dGs mode. mig't e/en be in)onsistent (it' some so)iobio.ogi)a. mode.s of psy)'opat'o.ogy. Cu.tura. e/o.ution may at times outstrip t'e pa)e of bio.ogi)a. e/o.ution$ rendering some designed fun)tions t'at (ere origina..y adapti/e (it'in ear.ier time periods ma.adapti/e in many )urrent en/ironments 2Li.ienfe.d H Marino$ *+++C Widiger H an-is$ 9,,,3. For examp.e$ 0t'e existen)e in 'umans of a preparedness me)'anism for de/e.oping a fear of sna-es may be a re.i) not (e.. designed to dea. (it' urban

.i/ing$ ('i)' )urrent.y )ontains 'osti.e for)es far more dangerous to 'uman sur/i/a. 2e.g.$ )ars$ e.e)tri)a. out.ets3 but for ('i)' 'umans .a)- e/o./ed me)'anisms of fear preparedness0 2Buss$ &ase.ton$ 'a)-e.ford$ B.es-e$ H Wa-efie.d$ *++B$ p. <:B3.

143 W"8"=ER Missing from Wa-efie.dGs 2*++93 definition of menta. disorder is any referen)e to dys)ontro.. &arm (it'in Wa-efie.dGs )on)eptua.i4ation of menta. disorder is )on)erned (it' t'e presen)e of impairment$ dysfun)tion (it' t'e presen)e of pat'o.ogy. Menta. disorders$ 'o(e/er$ are per'aps better understood as dys)ontro..ed impairments in psy)'o.ogi)a. fun)tioning 2@irmayer H Aoung$ *+++C @.ein$ *+++C Widiger H #ru..$ *++*3. 0"n/o.untary impairment remains t'e -ey inferen)e0 2@.ein$ *+++$ p. ;9;3. 8ys)ontro. is one of t'e fundamenta. features of menta. disorder emp'asi4ed in BergnerGs 2*++D3 signifi)ant restri)tion and Widiger and an-isG 29,,,3 dys)ontro..ed ma.adapti/ity definitions of menta. disorder. Fundamenta. to t'e )on)ept of a menta. disorder is t'e presen)e of impairments to fee.ings$ t'oug'ts$ or be'a/iors o/er ('i)' a norma. 2'ea.t'y3 person is be.ie/ed to 'a/e ade7uate )ontro.. #o t'e extent t'at a person (i..fu..y$ intentiona..y$ free.y$ or /o.untari.y engages in 'armfu. sexua. a)ts$ drug usage$ gamb.ing$ or )'i.d abuse$ t'e person is not )onsidered to 'a/e a menta. disorder. %ersons see- professiona. inter/ention in .arge part to obtain t'e insig'ts$ te)'ni7ues$ s-i..s$ or ot'er too.s 2e.g.$ medi)ations3 t'at in)rease t'eir abi.ity to better )ontro. t'eir mood$ t'oug'ts$ or be'a/ior. "n sum$ impairment and dys)ontro. mig't pro/ide t'e optima. means (it' ('i)' to identify a meaningfu. boundary bet(een$ or an important parameter for 7uantifying$ norma. and abnorma. psy)'o.ogi)a. fun)tioning$ if t'ese )onstru)ts are more pre)ise.y defined$ )a.ibrated$ and assessed. 2 ee a.so Maddux$ =osse.in$ H Winstead$ t'is boo-.3 M$%ti*%e Dia&n#ses #'e diffi)u.ty in de.ineating a point of demar)ation bet(een norma. and abnorma. psy)'o.ogi)a. fun)tioning is para..e.ed by an e7ua..y fundamenta. prob.em of differentiating indi/idua. menta. disorders from one anot'er. 08 M1"> is a )ategori)a. ).assifi)ation t'at di/ides menta. disorders into types based on )riterion sets (it' defining features0 2A%A$ 9,,,$ p. xxxi3. #'e intention of t'e diagnosti) manua. is to 'e.p t'e ).ini)ian determine ('i)' parti)u.ar disorder is present$ t'e diagnosis of ('i)' (ou.d purported.y indi)ate t'e presen)e of a spe)ifi) pat'o.ogy t'at (ou.d exp.ain t'e o))urren)e of t'e symptoms and suggest a spe)ifi) treatment t'at (ou.d ame.iorate t'e patientGs suffering 2@ende..$ *+D<C Fran)es et a..$ *++<3. "t is e/ident$ 'o(e/er$ t'at 8 M1"> routine.y fai.s in t'e goa. of guiding t'e ).ini)ian to t'e presen)e of one spe)ifi) disorder. 8espite t'e best efforts of t'ose ('o 'a/e been t'e primary aut'ors of ea)' re/ision$ mu.tip.e diagnoses are t'e norm 2C.ar- et a..$ *++<3. "t is rare for a patient to meet t'e 8 M1">1#R diagnosti) )riteria for 6ust one menta. disorder. #'e number of mu.tip.e diagnoses is e/en 'ig'er ('en one in).udes .ifetime as (e.. as )urrent fun)tioning and it mig't be remar-ab.y 'ig' if a.. of t'e disorders (it'in 8 M1">1#R are in fa)t )onsidered. Ex).uded from prior epidemio.ogi) studies 'a/e been many disorders 2e.g.$ persona.ity disorders and spe)ifi) substan)e abuse disorders3 t'at mig't in)rease e/en furt'er t'e o))urren)e of mu.tip.e diagnoses 2Widiger H an-is$ 9,,,3. "n genera. medi)ine$ t'e presen)e of mu.tip.e diagnoses (ou.d .ogi)a..y suggest t'e presen)e of mu.tip.e disorders 2i.e.$ )omorbidity3. &o(e/er$ t'e fre7uen)y (it' ('i)' psy)'iatri) patients routine.y meet diagnosti) )riteria for t'ree$ four$ fi/e$ and e/en more menta. disorders 'as raised 7uestions )on)erning t'e /a.idity of t'is straig'tfor(ard understanding. 0#'e greatest )'a..enge t'at t'e extensi/e )omorbidity data pose to t'e )urrent noso.ogi)a. system )on)erns t'e /a.idity of t'e diagnosti) )ategories t'emse./esEdo t'ese disorders )onstitute distin)t ).ini)a. entitiesF0 2Mine-a$ Watson$ H C.ar-$ *++B$ p. :B,3. 8iagnosti) )omorbidity 'as be)ome so pre/a.ent t'at some argue for an abandonment of t'e term comorbidity in fa/or of a term 2e.g.$ )o1

o))urren)e3 t'at does not imp.y t'e presen)e of distin)t ).ini)a. entities 2Li.ienfe.d$ Wa.dman$ H "srae.$ *++;3. #'ere are instan)es in ('i)' t'e presen)e of mu.tip.e

9. CLASSIFICATION AND DIAGNOSIS 145 diagnoses do suggest t'e presen)e of distin)t yet )omorbid psy)'opat'o.ogies$ but in many instan)es t'e presen)e of )o1o))urring diagnoses does appear to suggest t'e presen)e of an eti1 o.ogy or pat'o.ogy t'at is s'ared by t'e purported.y distin)t disorders 2Widiger H C.ar-$ 9,,,3. Cate&#ri.a% and Di(ensi#na% M#de%s #6 C%assi6i.ati#n #'ere 'as been substantia. interest in identifying a spe)ifi) gene 2or ot'er form of spe)ifi) etio.ogy3 for ea)' menta. disorder$ mode.ed after t'e su))ess obtained (it' some p'ysi)a. disorders. 0As t'e rare Mende.ian disorders su)' as )ysti) fibrosis and &untingtonGs disease are so./ed$ t'e entire geneti)s )ommunity is$ (it' great ex)itement$ turning its attention to )omp.ex disorders... IandJ psy)'iatri) i..nesses are fu..y and un7uestionab.y /ie(ed as part of t'e next )'a..enge in mainstream geneti)s0 2&yman$ *++B$ p. :B3. &o(e/er$ t'e )omp.ex disorders of psy)'opat'o.ogy appear un.i-e.y to 'a/e spe)ifi) etio.ogies or e/en spe)ifi) geneti) etio.ogies 2M)=ue H Bou)'ard$ *++B3$ and initia. su))esses in identifying spe)ifi) genes 'a/e typi)a..y fai.ed to rep.i)ate 2%ortin H A.anen$ *++D3. For examp.e$ up to B<P of t'e sus)eptibi.ity to s)'i4op'renia appears to be attributab.e to geneti) )ontributions$ but t'e extensi/e genome s)an studies of s)'i4op'renia )urrent.y 0do not support t'e 'ypot'esis t'at a sing.e gene )auses a .arge in)rease in t'e ris- of s)'i4op'renia0 2Le/inson et a..$ *++B$ p. D;*3. 0Categori)a. disease mode.s are being )'a..enged. . . by t'e re)ent data indi)ating t'at indi/idua.s may )arry a geneti) ris- fa)tor to de/e.op a disorder t'at )an be measured premor1bid.y... and t'at may or may not u.timate.y be expressed as t'e fu.. form of t'e disorder$ depending on t'e o))urren)e of a /ariety of fa)tors0 2Andreasen$ *++D$ p. *<BD3. #'ere )ontinues to be a 'ope of demar)ating 0a ).ear1)ut$ natura.$ 7ua.itati/e subgroup0 of psy)'opat'o.ogy 2Len4en(eger$ *+++$ p. *B?3$ but it mig't be unrea.isti) to expe)t ma.adapti/e )ognitions$ affe)ts$ and be'a/iors$ or any parti)u.ar )onste..ation of symptoms$ to 'a/e a spe)ifi) etio.ogy. Not on.y (ou.d t'is etio.ogy 'a/e to 'a/e pro/ided a uni7ue.y and spe)ifi)a..y important )ontribution to t'eir de/e.opment 2Mee'.$ *+DD3$ but t'e p'enomeno.ogy of t'e disorder (ou.d a.so 'a/e to 'a/e been .arge.y resi.ient to t'e potentia. impa)t of ot'er geneti) and en/ironmenta. inf.uen)es. #'e symptomato.ogy of most menta. disorders appears to be$ in )ontrast$ responsi/e to a (ide /ariety of neuro)'emi)a.$ interpersona.$ )ogniti/e$ and ot'er mediating /ariab.es. Menta. disorders are most .i-e.y t'e resu.t of po.ygeneti) dispositions and mu.tip.e$ intera)ting etio.ogies 2Rutter$ *++D3. Many resear)'ers are no( turning t'eir attention to t'e identifi)ation of under.ying spe)tra of dysfun)tion t'at )ut a)ross t'e existing diagnosti) )ategories. For examp.e$ Bro(n$ C'orpita$ and Bar.o( 2*++B3 )ondu)ted a series of )onfirmatory fa)tor ana.yses of t'e symptomato.ogy e/ident among :<, anxiety and mood disorder patients. #'eir resu.ts )onfirmed t'e presen)e of .atent dimensions of pat'o.ogy 2e.g.$ abnorma. .e/e.s of positi/e affe)ti/ity and arousa.3$ some of ('i)' )ut a)ross t'e mood and anxiety disorders 2e.g.$ negati/e affe)ti/ity or neuroti)ism3. "n an extensi/e .ongitudina. epidemio.ogi)a. study$ @rueger$ Caspi$ Moffitt$ and i./a 2*++B3 assessed a range of symptomato.ogy in a .arge$ unse.e)ted birt' )o'ort in Ne( Rea.and at ages *B and 9*. Using stru)tura. e7uation mode.ing to examine )ross1se)tiona. and .ongitudina. )o1o))urren)e patterns$ t'ey identified t'e presen)e of 0stab.e$ under.ying G)ore psy)'opat'o1.ogi)a. pro)essesG 0 2@rueger et a..$ *++B$ p. 9*?3. More spe)ifi)a..y$ @rueger et a.. suggested t'at a broad domain of interna.i4ation 2neuroti)ism or negati/e affe)ti/ity3 under.ies t'e mood and anxiety disorder diagnosti) )ategories and a )omp.ementary fa)tor of externa.i4ation 2.o( )onstraint$ disin'ibition3 under.ies t'e disrupti/e be'a/ior and substan)e use disorder diagnosti) )ategories.

@rueger 2*+++3 obtained simi.ar resu.ts in a )onfirmatory fa)tor ana.ysis of t'e patterns of )o1 o))urren)e among t'e diagnoses in).uded (it'in t'e NC and )on).uded t'at 0)omorbidity resu.ts from )ommon$ under.ying )ore psy)'opat'o.ogi)a. pro)esses0 2p. +9*3.

147 WIDIGER Lynam and Widiger 29,,*3 aggregated t'e diagnosti) )o1o))urren)e among t'e persona.ity disorder diagnoses obtained in fifteen pre/ious studies. 0A.t'oug' 'ig' )omorbidity presents a fundamenta. )'a..enge to t'e /a.idity of t'e )ategori)a. approa)'$ it is easi.y a))ommodated (it'in a dimensiona. mode. t'at /ie(s t'e )ategories as )onfigurations of basi) dimensions of persona.ity0 2Lynam H Widiger$ 9,,*$ p. ;,:3. #'ey indi)ated t'at ('en persona.ity disorders are understood in terms of t'e domains and fa)ets of t'e dimensiona. Fi/e1Fa)tor Mode. of genera. persona.ity fun)tioning$ t'e apparent )omorbidity is readi.y exp.ained. A Fi/e1Fa)tor Mode. understanding of t'e persona.ity disorders is presented in Co-er and Widiger 2t'is boo-3. A mode. for t'e future diagnosis of a.. menta. disorders mig't be pro/ided by one of t'e o.dest and best /a.idated diagnoses$ menta. retardation$ a disorder for ('i)' mu)' is -no(n of its etio.ogy$ pat'o.ogy$ and ).assifi)ation. #'e point of demar)ation for its diagnosis is an arbitrary$ 7uantitati/e distin)tion a.ong t'e norma..y distributed .e/e.s of t'e mu.ti/ariate domain of inte..igen)e. Menta. retardation is diagnosed primari.y on t'e basis of 'a/ing an inte..igen)e 7uotient 2"K3 of D, or be.o( 2A%A$ 9,,,3. #'ere are persons (it' an "K .ess t'an D, for ('om a 7ua.itati/e.y distin)t disorder is e/ident. &o(e/er$ t'is disorder is not menta. retardation$ it is a p'ysi)a. disorder 2e.g.$ 8o(n syndrome3 t'at )an be tra)ed to a spe)ifi) bio.ogi)a. e/ent 2i.e.$ trisomy 9*3. "nte..igen)e is itse.f distributed as a )ontinuous /ariab.e. "n addition$ 0in approximate.y :,P1;,P of indi/idua.s seen in ).ini)a. settings$ no ).ear etio.ogy for t'e Menta. Retardation )an be determined despite extensi/e e/a.uation efforts0 2A%A$ 9,,,$ p. ;<3. "nte..igen)e is t'e resu.t of a )omp.ex array of mu.tip.e geneti)$ feta. and infant de/e.opment$ and en/ironmenta. inf.uen)es 2Neisser et a..$ *++?3. #'ere are no dis)rete brea-s in t'e distribution of inte..igen)e t'at (ou.d pro/ide an abso.ute distin)tion bet(een norma. inte..igen)e and abnorma. inte..igen)e. C$%t$re and Ga%$es "t is t'e intention of t'e aut'ors of "C81*, to pro/ide a uni/ersa. diagnosti) system$ but diagnosti) )riteria and )onstru)ts )an 'a/e 7uite different imp.i)ations and meanings a)ross different )u.tures. 8 M1"> addresses )u.tura. issues in t'ree (ays. First$ t'e text of 8 M1"> pro/ides a dis)ussion of 'o( ea)' disorder is -no(n to /ary in its presentation a)ross different )u.tures. e)ond$ an appendix of )u.ture1bound syndromes des)ribes disorders t'at are )urrent.y t'oug't to be spe)ifi) to a parti)u.ar )u.ture. #'ird$ an additiona. appendix pro/ides a )u.tura..y informed diagnosti) formu.ation t'at )onsiders t'e )u.tura. identity of t'e indi/idua. and t'e )u.ture1spe)ifi) exp.anations of t'e personGs presenting )omp.aints 2Me44i)' et a..$ *++D3. #'ere is bot' a strong and a (ea- )ross1)u.tura. )riti7ue of )urrent s)ientifi) understanding of psy)'opat'o.ogy. #'e (ea- )riti7ue does not 7uestion t'e /a.idity of a )on)ept of menta. disorder but does argue t'at so)ia. and )u.tura. pro)esses affe)t and potentia..y bias t'e 0s)ien)e of psy)'opat'o.ogy and diagnosis5 a3 by determining t'e se.e)tion of persons and be'a/iors as suitab.e materia. for ana.ysisC b3 by emp'asi4ing ('at aspe)ts of t'is materia. (i.. be 'and.ed as re.e/ant from a I).ini)a.J standpointC )3 by s'aping t'e .anguage of diagnosis$ in).uding t'at of des)ripti/e psy)'opat'o.ogyC d3 by mas-ing t'e symptoms of any putati/e Guni/ersa.G disorderC e3 by biasing t'e obser/er and (ou.d1be diagnosti)ianC and f3 by determining t'e goa.s and endpoints of treatment0 2Fabrega$ *++;$ p. 9?93. #'ese )on)erns are not (ea- in t'e sense t'at t'ey are tri/ia. or in)onse7uentia. but t'ey are re.ati/e.y (ea- in t'at t'ey do not ne)essari.y dispute t'e fundamenta. /a.idity of a )on)ept of a menta. disorder or t'e s)ien)e of psy)'opat'o.ogy. #'e strong )riti7ue$ in )ontrast$ is t'at t'e )onstru)t of menta. disorder is itse.f

a )u.ture1bound be.ief t'at ref.e)ts t'e .o)a. biases of (estern so)iety$ and t'at t'e s)ien)e of psy)'opat'o.ogy is /a.id on.y in t'e sense t'at it is an a))epted be.ief system of a parti)u.ar )u.ture 2Le(is1Fernande4 H @.einman$ *++<3.

9. CLASSIFICATION AND DIAGNOSIS 149 #'e )on)ept of menta. disorder does in).ude a /a.ue 6udgment t'at t'ere s'ou.d be ne)essary$ ade7uate$ or optima. psy)'o.ogi)a. fun)tioning 2Wa-efie.d$ *++93. &o(e/er$ t'is /a.ue 6udgment is a.so a fundamenta. )omponent of t'e )onstru)t of p'ysi)a. disorder 2Widiger$ 9,,93. "n a (or.d in ('i)' t'ere (ere no impairments or t'reats to p'ysi)a. fun)tioning$ t'e )onstru)t of a p'ysi)a. disorder (ou.d 'a/e no meaning ex)ept as an interesting t'oug't experiment. Meaningfu. and /a.id s)ientifi) resear)' on t'e etio.ogy$ pat'o.ogy$ and treatment of p'ysi)a. disorders o))urs be)ause in t'e (or.d as it )urrent.y exists t'ere are impairments and t'reats to p'ysi)a. fun)tioning. "t is pro/o)ati/e and intriguing to )on)ei/e of a (or.d in ('i)' p'ysi)a. 'ea.t' and sur/i/a. (ou.d or s'ou.d not be /a.ued or preferred o/er i..ness$ suffering$ and deat'$ but t'is form of existen)e is un.i-e.y to emerge anytime in t'e near future. %.a)ing a /a.ue on ade7uate or optima. p'ysi)a. fun)tioning mig't be a natura. resu.t of e/o.ution (it'in a (or.d in ('i)' t'ere are t'reats to fun)tioning and sur/i/a.. Li-e(ise$ in t'e (or.d as it )urrent.y exists$ t'ere are impairments and t'reats to ade7uate psy)'o.ogi)a. fun)tioning. "t is pro/o)ati/e and intriguing to )on)ei/e of a so)iety 2or (or.d3 in ('i)' psy)'o.ogi)a. 'ea.t' (ou.d or s'ou.d not be /a.ued or preferred$ but t'is form of existen)e is a.so un.i-e.y to emerge anytime in t'e near future. %.a)ing a /a.ue on ade7uate$ ne)essary$ or optima. psy)'o.ogi)a. fun)tioning mig't be in'erent to and a natura. resu.t of existing in t'is (or.d. Any parti)u.ar definition of ('at (ou.d )onstitute ade7uate$ ne)essary$ or optima. psy)'o.ogi)a. fun)tioning (ou.d .i-e.y be biased to some extent by .o)a. )u.tura. /a.ues$ but t'is situation is per'aps best understood as on.y t'e fai.ing of one parti)u.ar )on)eptua.i4ation of menta. disorder 2i.e.$ a (ea- rat'er t'an a strong )riti7ue3. >a.uing ade7uate$ ne)essary$ or optima. psy)'o.ogi)a. fun)tioning )ou.d itse.f sti.. be a .ogi)a. and natura. resu.t of existing in a (or.d in ('i)' t'ere are t'reats to psy)'o.ogi)a. fun)tioning$ 6ust as p.a)ing a /a.ue on ade7uate$ ne)essary$ or optima. p'ysi)a. fun)tioning (ou.d be a .ogi)a. and natura. resu.t of existing in a (or.d in ('i)' t'ere are t'reats to p'ysi)a. fun)tioning 2Widiger$ 9,,93. 8ifferent so)ieties$ )u.tures$ and e/en persons (it'in a parti)u.ar )u.ture (i.. disagree as to ('at )onstitutes optima. or pat'o.ogi)a. bio.ogi)a. and psy)'o.ogi)a. fun)tioning 2Lope4 H =uarna))ia$ 9,,,C t'is boo-3. An important and diffi)u.t issue is 'o( best to understand t'e dif1 feren)es bet(een )u.tures (it' respe)t to ('at )onstitutes dysfun)tion and pat'o.ogy 2A.ar)on et a..$ 9,,93. For examp.e$ simp.y be)ause diagnosti) )riterion sets are app.ied re.iab.y a)ross different )u.tures does not ne)essari.y indi)ate t'at t'e )onstru)ts t'emse./es are /a.id or meaningfu. (it'in t'ese )u.tures 2Le(is1Fernande4 H @.einman$ *++<3. A re.iab.y diagnosed )riterion set )an be de/e.oped for an entire.y i..usory diagnosti) )onstru)t. !n t'e ot'er 'and$ it is per'aps e7ua..y un).ear ('y it (ou.d be ne)essary for t'e estab.is'ment of a disorderGs )onstru)t /a.idity to obtain )ross1)u.tura. 2i.e.$ uni/ersa.3 a))eptan)e. Le(is1Fernande4 and @.einman argue t'at it is ne)essary 0to produ)e a )ompre'ensi/e noso.ogy t'at is bot' inter1 nationa..y and .o)a..y /a.id0 2p. ;:<3. A uni/ersa..y a))epted diagnosti) system (i.. 'a/e an internationa. so)ia. uti.ity and )onsensus /a.idity 2@ess.er$ *+++3$ but it is a.so apparent t'at be.ief systems /ary in t'eir /eridi)a.ity. Re)ognition of and appre)iation for a.ternati/e be.ief systems is important for ade7uate fun)tioning (it'in an internationa. )ommunity$ but respe)t for a.ternati/e be.ief systems does not ne)essari.y imp.y t'at a.. be.ief systems are e7ua..y /a.id 2Widiger$ 9,,93. @irmayer$ Aoung$ and &ayton 2*++<3 i..ustrate (e.. many of t'e )omp.exities of )ross1)u.tura. resear)'. For examp.e$ a (omanGs 'ousebound be'a/ior mig't be diagnosed as agorap'obi)

(it'in (estern )u.tures but )onsidered normati/e 2or e/en /irtuous3 (it'in a Mus.im )u.tureC submissi/e be'a/ior t'at is diagnosed as pat'o.ogi) dependen)y (it'in (estern so)ieties mig't be )onsidered normati/e (it'in t'e Japanese )u.ture. &o(e/er$ simp.y be)ause a be'a/ior pattern is /a.ued$ a))epted$ en)ouraged$ or e/en statisti)a..y normati/e (it'in a parti)u.ar )u.ture does not ne)essari.y mean it is )ondu)i/e to 'ea.t'y psy)'o.ogi)a. fun)tioning.

151 WIDIGER 0"n so)ieties ('ere ritua. p.ays an important ro.e in re.igious .ife... su)' so)ieties may predispose indi/idua.s to obsessi/e1)ompu.si/e symptoms and mas- t'e disorder ('en present0 2@irmayer et a..$ *++<$ p. <,D3. 0#'e )ongruen)e bet(een re.igious be.ief and pra)ti)e and obsessi/e1 )ompu.si/e symptoms a.so probab.y )ontributes to re.ati/e.y .o( rates of insig't into t'e irrationa.ity of t'e symptoms0 2@irmayer et a..$ p. <,B3. Be'a/iors diagnosed as disordered (it'in one )u.ture mig't be normati/e (it'in anot'er$ but ('at is a))epted$ a..o(ed$ en)ouraged$ or e/en statisti)a..y normati/e (it'in a )u.ture mig't sti.. be pat'o.ogi)a.. !n t'e ot'er 'and$ it is e7ua..y important not to assume t'at ('at is be.ie/ed to be asso)iated (it' ma.adapti/e 2or adapti/e3 fun)tioning in one )u.ture s'ou.d a.so be )onsidered to be ma.adapti/e 2or adapti/e3 (it'in a.. ot'er )u.tures 2A.ar)on et a..$ 9,,93. 0#'is possib.e tension bet(een )u.tura. sty.es and 'ea.t' )onse7uen)es is in urgent need of furt'er resear)'0 2@irmayer et a..$ p. <*D3$ and it is important for t'is resear)' to go beyond simp.y identifying differen)es in be'a/iors$ be.ief systems$ and /a.ues a)ross different )u.tures. #'is resear)' a.so needs to address t'e fundamenta. 7uestion of ('et'er differen)es in be.iefs a)tua..y 7uestion t'e /a.idity of any uni/ersa. )on)eptua.i4ation of psy)'opat'o.ogy or suggest instead simp.y different perspe)ti/es on a )ommon$ uni/ersa. issue. 2 ee Lope4 H =uarna))ia$ t'is boo-$ for a more detai.ed dis)ussion of )u.ture and psy)'opat'o.ogy.3 Gender 8ifferentia. sex pre/a.en)e rates )an be 'ig'.y )ontro/ersia. as gender differen)es )an ref.e)t (ider so)ia.$ po.iti)a. )ontro/ersies 2Eag.y$ *++<3. #'e diagnoses t'at generated t'e most )ontro/ersy in t'e de/e.opment of t'e re)ent editions of t'e 8 M (ere prob.emati) .arge.y be)ause of t'eir 7uestionab.e app.i)ation to (omen 2Ross$ Fran)es$ H Widiger$ *++<3. #'e basi) )'arge (as t'at t'e 8 M is fundamenta..y f.a(ed t'roug' its imposition of patriar)'a. or mas)u.ine biases of ('at does or s'ou.d )onstitute psy)'opat'o.ogy 2e.g.$ Cap.an$ *++*$ *++<3. "n per'aps one of t'e more (ide.y )ited )riti7ues$ @ap.an 2*+B:3 argued t'at 0our diagnosti) system$ .i-e t'e so)iety it ser/es$ is ma.e )entered0 2p. D+*3 and t'at 0mas)u.ine1biased assumptions about ('at be'a/iors are 'ea.t'y and ('at be'a/iors are )ra4y are )odified in diagnosti) )riteria0 2p. DB?3. %antony and Cap.an 2*++*3 )'ara)teri4ed 8 M1"> as 0sex dis)rimination in one of its most damaging and dangerous forms0 2p. *9,3. #'e premenstrua. dysp'ori) disorder diagnosis 'as been parti)u.ar.y )ontro/ersia. 2Cap.an$ *++*C Ross et a..$ *++<3. A ma6ority of (omen may suffer from some form of premenstrua. dysp'oria. !n.y :P to <P of (omen (ou.d meet t'e 8 M1"> diagnosti) )riteria for premen1 strua. dysp'ori) disorder$ but t'e re.iabi.ity of t'e distin)tion bet(een norma. premenstrua. dysp'oria and premenstrua. dysp'ori) disorder in genera. ).ini)a. pra)ti)e is 7uestionab.e. 8 M1 "> re7uires dai.y ratings of mood for at .east t(o mont's before t'e diagnosis is made$ and it is un.i-e.y t'at pra)ti)ing ).ini)ians or patients (ou.d a)tua..y ad'ere to t'is re7uirement. #'e p'arma)euti)a. industry mig't a.so mar-et treatments to (omen ('o are (e.. be.o( t'e t'res'o.d for t'e diagnosis$ and attributions )on)erning t'e 'arm$ pat'o.ogy$ and impairments of premenstrua. dysp'oria are often exaggerated and )an be 'ig'.y stigmati4ing. &istrioni) persona.ity disorder 'as been )riti)i4ed for being too ).ose.y asso)iated (it' stereotypi) traits of femininity 2@ap.an$ *+B:3. @ap.an 2*+B:3 (ent so far as to argue t'at by /irtue of being feminine 0a 'ea.t'y (oman automati)a..y earns t'e diagnosis of &istrioni) %ersona.ity 8isorder0 2p. DB+3. #'ere is no resear)' to support t'e ).aim t'at norma.$ 'ea.t'y (omen meet diagnosti) )riteria for 'istrioni) persona.ity disorder. tudies 'a/e indi)ated t'at t'e

diagnosti) )riteria for t'is disorder in).ude ma.adapti/e /ariants of stereotypi) feminine traits$ but it is un).ear ('et'er t'is asso)iation is inappropriate for a persona.ity disorder diagnosis. #'e in).usion of gender1re.ated traits$ 'o(e/er$ does appear to )ontribute to t'e

9. CLA "F"CA#"!N AN8 8"A=N! " 153 o))urren)e of gender1biased app.i)ations of t'e diagnosti) )riteria and gender1biased assessment instruments 2Widiger$ *++B3. #'ere may not be a disorder in 8 M1"> for ('i)' gender differen)es 'a/e not been prob.emati) and e/en )ontro/ersia. 2@ap.an$ *+B:3. Con)erns about gender bias 'a/e been raised for a.most e/ery diagnosis$ eit'er (it' respe)t to t'e diagnosti) )riteria$ t'e app.i)ations of t'ese diagnosti) )riteria by ).ini)ians$ t'e assessment instruments used in resear)' and ).ini)a. pra)ti)e$ or t'e popu.ations t'at 'a/e been samp.ed 2&artung H Widiger$ *++B3. An issue for t'e aut'ors of 8 M1> is ('et'er to re/ise diagnosti) )riteria to impro/e t'eir gender neutra.ity or to de/e.op different )riterion sets for ma.es and fema.es. Current.y$ t'e same diagnosti) )riteria are used for ma.es and fema.es for a.. but a fe( of t'e disorders 2t'e ex)eptions being gender1identity disorder and sexua. dysfun)tions3$ but t'e text of 8 M1"> indi)ates 'o( ea)' respe)ti/e disorder appears different.y in ma.es and fema.es 2Fran)es et a..$ *++<3. A)'ie/ing gender1 neutra. diagnosti) )riteria for many of t'ese disorders mig't be diffi)u.t 2 pro)-$ Crosby$ H Nie.sen$ 9,,*3. !n t'e ot'er 'and$ separate diagnosti) )riteria )ou.d resu.t in t'e )reation of different disorders for ea)' sex t'at mig't 'a/e e/en more prob.emati) imp.i)ations of gender bias 2Wa-efie.d$ *+BDC Ra'n1Waxier$ *++:3. For examp.e$ Ro))o.i..o 2*++:3 suggested t'at t'e diagnosti) )riteria for )ondu)t disorder (ere gender biased be)ause t'ey des)ribed a mas)u.ine (ay in ('i)' t'e disorder is expressed. 'e suggested p.a)ing re.ati/e.y more emp'asis for gir.s on ru.e /io.ations$ substan)e abuse$ prostitution$ )'roni) .ying$ running a(ay from 'ome$ and poor s)'oo. performan)e and .ess emp'asis on /anda.ism$ fire setting$ burg.ary$ use of a (eapon in fig'ts$ and rape. &o(e/er$ p.a)ing more emp'asis on ru.e /io.ations$ rebe..iousness$ and de)eitfu.ness for gir.s$ and /io.ent and aggressi/e be'a/ior for boys$ )ou.d 'a/e t'e effe)t of diagnosing 2and stigmati4ing3 gir.s at a .e/e. of dysfun)tion t'at is mu)' .o(er t'an is used to diagnose t'e disorder in boys 2Ra'n1Waxier$ *++:3. Ra'n1Waxier suggested a.ternati/e.y t'at t'e )riterion set appropriate.y in).udes gender1re.ated be'a/iors 2e.g.$ rape3 be)ause t'e disorder is itse.f re.ated to gender in its etio.ogy and pat'o.ogy. 2 ee Winstead H an)'e4$ t'is boo-$ for a more detai.ed dis)uss of gender and psy)'opat'o.ogy.3 Lab#rat#ry Meas$res5 Dia&n#sti. Criteria5 and C%ini.a% Dia&n#sis 08iagnoses in t'e rest of medi)ine are often 'ea/i.y inf.uen)ed by .aboratory tests0 2Fran)es et a..$ *++<$ p. 993. Laboratory tests (it'in medi)a. pra)ti)e go beyond t'e assessment of symptoms. #'ey pro/ide a more dire)t and ob6e)ti/e assessment of an under.ying p'ysi)a. pat'o.ogy. A 'ope is t'at .aboratory tests )ou.d do t'e same for psy)'iatry as t'ey 'a/e done for ot'er domains of medi)ine 2Nemeroff$ @i.ts$ H Berns$ *+++C Rounsa/i..e et a..$ 9,,93. 0#'e in)reasing use of .aboratory tests in psy)'iatri) resear)' raises t'e 7uestion of ('et'er and ('en t'ese tests s'ou.d be in).uded (it'in t'e diagnosti) )riteria sets0 2Fran)es et a..$ *++<$ p. 993. ubstantia. attention is being gi/en to stru)tura. and fun)tiona. brain imaging (it' t'e expe)tation t'at t'ese instruments )ou.d be used e/entua..y to diagnose neurop'ysio.ogi)a. pat'o.ogy 28re/ets$ 9,,9C Epstein$ "senberg$ tern$ H i.bers(eig$ 9,,93. &o(e/er$ ).ear.y .imiting t'ese and ot'er neurop'ysio.ogi)a. measuresG potentia. for in)orporation (it'in di1 agnosti) )riterion sets is t'e /irtua. absen)e of resear)' indi)ating t'eir abi.ity to pro/ide independent$ b.ind diagnoses. 8espite t'e ent'usiasm for t'eir potentia. diagnosti) /a.ue$ t'ere are )urrent.y no studies t'at 'a/e assessed t'e sensiti/ity and spe)ifi)ity of neuroimaging te)'ni7ues for t'e diagnosis or differentia. diagnosis of spe)ifi) menta. disorders 2Rounsa/i..e et a..$ 9,,9C teffens H @ris'nan$ *++B3.

154 WIDIGER #'e in).usion of .aboratory data in t'e diagnosis of a disorder 'as been parti)u.ar.y )ontro/ersia. for t'e s.eep disorders. Most s.eep disorder spe)ia.ists use t'e "nternationa. C.assifi)ation of .eep 8isorders 2"C 83 de/e.oped by t'e Ameri)an .eep 8isorders Asso)iation 2*++,3. #'e t(e./e 8 M1"> s.eep disorder diagnoses are )oordinated (it' t'e "C 8$ but differ signifi)ant.y in fai.ing to in).ude po.ysomnograp'i) diagnosti) )riteria 2e.g.$ time of onset of rapid1eye1 mo/ement s.eep3. 8etai.ed referen)es are made to po.ysomnograp'i) findings (it'in t'e text of 8 M1">$ and it (as a)-no(.edged by its aut'ors t'at 0for s.eep disorders ot'er t'an insomnia$ su)' as nar)o.epsy and s.eep apnea$ t'e uti.ity of s.eep .aboratory testing is (ide.y a))epted0 2Buysse$ Reyno.ds$ H @upfer$ *++B$ pp. **,;1**,<3. Ne/ert'e.ess$ po.ysomogra1p'y findings (ere not re7uired be)ause of t'e extensi/e )ost of t'e te)'no.ogy and t'eir .a)- of a/ai.abi.ity (it'in many ).ini)a. settings 2Buysse et a..$ *++BC Fran)es et a.$ *++<3. #'ere is$ 'o(e/er$ a pre)edent in 8 M1"> for t'e re7uirement of .aboratory test findings obtained by a spe)ia.ist. Laboratory tests are fundamenta. )omponents of t'e diagnosti) )riteria for .earning disorders and menta. retardation. For examp.e$ 0t'e essentia. feature of Menta. Retardation is signifi)ant.y suba/erage genera. inte..e)tua. fun)tioning... IandJ genera. in1 te..e)tua. fun)tioning is defined by t'e inte..igen)e 7uotient 2"K or "K1e7ui/a.ent3 obtained by assessment (it' one or more of t'e standardi4ed$ indi/idua..y administered inte..igen)e tests 2e.g.$ We)'s.er "nte..igen)e )a.es for C'i.dren$ :rd EditionC tanford1Binet$ ;t' EditionC @aufman Assessment Battery for C'i.dren30 2A%A$ 9,,,$ p. ;*3. %sy)'o.ogi)a. tests admin1 istered by a trained spe)ia.ist using standardi4ed e7uipment are essentia..y e7ui/a.ent to t'e pro/ision of .aboratory testing. #'ere are )ompe..ing )on)erns regarding t'e pre)ise a))ura)y of "K tests 2Neisser et a..$ *++?3$ but routine diagnoses of menta. retardation by pra)ti)ing ).ini)ians (it'out t'e input of indi/idua..y administered "K tests (ou.d be substantia..y more prob.emati) and )ontro/ersia.. #'e pre)edent estab.is'ed by menta. retardation and .earning disorders s'ou.d per'aps be extended to ot'er disorders 2Widiger H C.ar-$ 9,,,3. 0A.t'oug' diagnosti) )riteria are t'e frame(or- for any ).ini)a. or epidemio.ogi)a. assessment$ no assessment of ).ini)a. status is independent of t'e re.iabi.ity and /a.idity of t'e met'ods used to determine t'e presen)e of a diagnosis0 2Regier et a..$ *++B$ p. **;3. #'e 8 M1""" inno/ation of pro/iding re.ati/e.y spe)ifi) and exp.i)it diagnosti) )riteria is not rea.i4ed if ).ini)ians do not in fa)t ad'ere to t'e )riterion sets and assess t'em in a )ompre'ensi/e$ systemati)$ and )onsistent fas'ion 2Rogers$ 9,,*3. Resear)'ers (ou.d be 'ard pressed to get t'eir findings pub.is'ed if t'ey fai.ed to do)ument t'at t'eir diagnoses (ere based on a systemati)$ rep.i)ab.e$ and ob6e)ti/e met'od$ yet no su)' re7uirements are pro/ided for ).ini)a. diagnoses$ (it' t'e ex)eption of menta. retardation and .earning disorders. C.ini)ians genera..y prefer to re.y on t'eir o(n experien)e$ expertise$ and sub6e)ti/e impressions obtained t'roug' unstru)tured inter/ie(s 2Westen$ *++D3$ but it is pre1 )ise.y t'is re.ian)e on sub6e)ti/e and idiosyn)rati) ).ini)a. inter/ie(ing t'at often undermines t'e re.iabi.ity and u.timate.y t'e /a.idity of ).ini)a. diagnoses 2=arb$ *++BC Rogers$ 9,,*3. !ne of t'e ne( additions to t'e text of 8 M1"> (as a se)tion de/oted to .aboratory and p'ysi)a. exam findings. #'is materia. (as intended to pro/ide t'e initia. step to(ard t'e e/entua. in).usion of .aboratory tests (it'in diagnosti) )riterion sets 2Fran)es et a..$ *++<3. A note(ort'y ex).usion from t'is text are referen)es to psy)'o.ogi)a. tests and instruments 2Rounsa/i..e et a..$ 9,,9C Widiger H C.ar-$ 9,,,3. "t is ironi) t'at psy)'o.ogi)a. tests are in).uded a.ready (it'in t'e )riterion sets for menta. retardation and .earning disorders$ yet /irtua..y no referen)e is made to

any psy)'o.ogi)a. tests (it'in t'e se)tions de/oted to .aboratory test findings. #'e dis)ussion of .aboratory instruments is )onfined in 8 M1"> to measures of neurop'ysio.ogy 2e.g.$ fun)tiona. brain imaging and t'e dexamet'asone suppression test3. emistru)tured inter/ie(s and se.f1report in/entories t'at assess )ogniti/e$ be'a/iora.$ affe)ti/e$ or ot'er )om1 ponents of psy)'o.ogi)a. fun)tioning t'at )omprise exp.i)it.y t'e diagnosti) )riterion sets for t'ese disorders$ and for ('i)' substantia. resear)' a.ready pro/ides spe)ifi)ity and sensiti/ity

9. CLASSIFICATION AND DIAGNOSIS 156 rates not obtained by t'e neurop'ysio.ogi)a. instruments$ s'ou.d at .east be a)-no(.edged a.ong (it' t'e neurop'ysio.ogi)a. measures. #'e in).usion of additiona. psy)'o.ogi)a. tests (it'in diagnosti) )riterion sets mig't 'a/e professiona. imp.i)ations for t'e ne)essary 7ua.ifi)ations to render a ).ini)a. diagnosis. For examp.e$ it is un).ear ('et'er many psy)'iatrists and e/en some psy)'o.ogists are suffi)ient.y trained in t'e administration and interpretation of t'e most informati/e and /a.id psy)'o.ogi)a. tests. "n any )ase$ t'e Ameri)an %sy)'iatri) Asso)iation 'as a.ready de/e.oped an aut'oritati/e manua. for t'e best 0psy)'iatri)0 instruments for t'e assessment of ea)' disorder in).uded (it'in 8 M1"> 2Rus' et a..$ 9,,,3. CONCLUSIONS Nobody is fu..y satisfied (it'$ or .a)-s /a.id )riti)isms of$ 8 M1"> and "C81*,. Ri.boorgGs 2*+;*3 suggestion t'at budding *+t' )entury t'eorists and resear)'ers )ut t'eir first teet' by pro/iding a ne( ).assifi)ation of menta. disorders sti.. app.ies$ a.t'oug' per'aps t'e rig't of passage today is to pro/ide a )riti7ue of t'e "C8 andLor 8 M. None$ 'o(e/er$ appear to be suggesting t'at a.. offi)ia. diagnosti) nomen).atures be abandoned. #'e benefits do appear to out(eig' t'e )osts 2 a.mon et a..$ *+*DC tenge.$ *+<+C Regier et a..$ *++B3. E/erybody finds fau.t (it' t'is .anguage$ but t'ere is at .east t'e abi.ity to )ommuni)ate disagreement. Communi)ation among resear)'ers$ t'eorists$ and ).ini)ians (ou.d be mu)' (orse in t'e absen)e of a )ommon .anguage. C.ini)ians$ t'eorists$ and resear)'ers (i.. at times experien)e t'e frustration of being re7uired to use t'e 8 M or t'e "C8. "t )an be diffi)u.t to obtain a grant$ pub.is' a study$ or re)ei/e insuran)e reimbursement (it'out referen)e to a 8 M1"> diagnosis. &o(e/er$ 8 M1"> a.so pro/ides a usefu. point of )omparison t'at u.timate.y fa)i.itates t'e de/e.opment and understanding of a ne( (ay of )on)eptua.i4ing psy)'opat'o.ogy. >iab.e a.ternati/es to parti)u.ar se)tions of 8 M1 "> are being de/e.oped$ some of ('i)' (i.. e/entua..y be in)orporated (it'in future re/isions of t'e diagnosti) manua.. #'eir effe)ti/e de/e.opment (i.. 'a/e been due in part to t'e existen)e of and empiri)a. support for 8 M1"> 8 M1"> and "C81*, are t'e offi)ia. diagnosti) systems be)ause of t'eir substantia. empiri)a. support$ t'eoreti)a. )ogen)y$ and ).ini)a. uti.ity. #'ey pro/ide a )ommon .anguage of )ommuni)ation and a (e..1/a.idated foi. for future )ontenders to o/er)ome. REFERENCES A%ar.#n5 R. D.5 1e%%5 C. C5 )ir(ayer5 L.5 Lin5 )0H5 Ust$n5 1.5 H Wisner5 ). = !! >. 1ey#nd t/e 6$n0/#$se (irr#rs' Resear./ a&enda #n .$%t$re and *sy./iatri. dia&n#sis. In D. 7. )$*6er5 M. 1. First5 H D. A. Re&ier =Eds.>5 A resear./ a&enda 6#r DSM0G =**. 3@0 ;3>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. A(eri.an Psy./iatri. Ass#.iati#n. =3@" >. Diagnostic and statistical manual. Mental Disorders. Was/in&t#n5 DC' A$t/#r. A(eri.an Psy./iatri. Ass#.iati#n. =3@?;>. Diagnostic and statistical manual of mental disorders = nd ed.>. Was/in&t#n5 DC' A$t/#r. A(eri.an Psy./iatri. Ass#.iati#n. =3@;!>. Diagnostic and statistical manual of mental disorders =:rd ed.>. Was/in&t#n5 DC' A$t/#r. A(eri.an Psy./iatri. Ass#.iati#n. =3@;8>. Diagnostic and statistical manual of mental disorders =:rd ed.5 re,.>. Was/in&t#n5 DC' A$t/#r. A(eri.an Psy./iatri. Ass#.iati#n. = 3@@9>. Diagnostic and statistical manual ofmental disorders =9t/ ed.>. Was/in&t#n5 DC' A$t/#r.

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158 W"8"=ER Andreasen5 N. C. =3@@8>. Lin+in& (ind and brain in t/e st$dy #6 (enta% i%%nesses' A *r#De.t 6#r a s.ienti6i. *sy0 ./#*at/#%#&y. 'cience# :A9# 3";?03"@:. 1er&ner5 R. M. =3@@8>. W/at is *sy./#*at/#%#&yI And s# 2/atI 1linical +sychology5 'cience and +ractice# ;# :"0 9;. 1%as/6ie%d5 R. ). =3@;9>. The classification of psychopathology. -eo3.raepelinian and Cuantitative approaches. NY' P%en$(. 1%as/6ie%d5 R. )5 H Dra&$ns5 7. G. =3@8?>. E,a%$ati,e .riteria 6#r *sy./iatri. .%assi6i.ati#n. ournal of %bnormal +sychology# 89# 39!03"!. 1r#2n5 T. A.5 C/#r*ita5 1. F.5 H 1ar%#25 1. F. =3@@;>. Str$.t$ra% re%ati#ns/i*s a(#n& di(ensi#ns #6 t/e DSM03G an-iety and (##d dis#rders and di(ensi#ns #6 ne&ati,e a66e.t5 *#siti,e a66e.t5 and a$t#n#(i. ar#$sa%. ournal of %bnormal +sychology# 67A# 38@03@ . 1$ss5 D. M.5 Hase%t#n5 M. G.5 S/a.+e%6#rd T. )Q 1%es+e5 A. L.5 H Wa+e6ie%d5 < C. =3@@;>. Ada*tati#ns5 e-a*tati#ns5 and s*andre%s. %merican +sychologist# 9?# "::0"9;. 1$ysse5 D. 7.5 Reyn#%ds5 C. F.5 H )$*6er5 D. 7. =3@@;>. DSM0IG s%ee* dis#rders' Fina% #,er,ie2. In T. A. Widi&er5 A. 7. Fran.es5 H. A. Pin.$s5 R. R#ss5 M. 1. First5 W. Da,is5 H M. )%ine =Eds.>5 D'M30F sourcebook =G#%. 95 **. 33!:033 >. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. Ca*%an5 P. < =3@@3>. H#2 d# t/ey de.ide 2/# is n#r(a%I T/e biCarre5 b$t tr$e5 ta%e #6 t/e DSM *r#.ess. 1anadian +sychology# ?:# 3? 038!. Ca*%an5 P. < =3@@">. They say you Hre cra*y. ,ow the worldHs most powerful psychiatrists decide who s normal. Readin&5 MA' Addis#n0Wes%ey. C%ar+5 L. A.5 Wats#n5 D.5 H Reyn#%ds5 S. =3@@">. Dia&n#sis and .%assi6i.ati#n #6 *sy./#*at/#%#&y' ./a%%en&es t# t/e .$rrent syste( and 6$t$re dire.ti#ns. %nnual (eview of +sychology# ;E# 3 303":. Dre,ets5 W. C. = !! >. Ne$r#i(a&in& st$dies #6 (##d dis#rders. In < E. He%Cer H 7. < H$dCia+ =Eds.>5 Defining psychopathology in the :6st century =**. 8303!">. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. Ea&%y5 A. H. =3@@">. T/e s.ien.e and *#%iti.s #6 .#(*arin& 2#(en and (en. %merican +sychologist# 97# 39"03";. Endi.#tt5 < = !!!>. Hist#ry5 e,#%$ti#n5 and dia&n#sis #6 *re(enstr$a% dys*/#ri. dis#rder. ournal of 1linical +sychiatry# E:# =S$**%. 9>5 "0;. E*stein5 <5 Isenber&5 N.5 Stern5 E.5 H Si%bers2ei&5 D. = !! >. T#2ard a ne$r#anat#(i.a% $nderstandin& #6 *sy./iatri. i%%ness' T/e r#%e #6 6$n.ti#na% i(a&in&. In < E. He%Cer H < < H$dCia+ =Eds.>5 Defining psychopathology in the :6stcentury =**. "80?@>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. Fabre&a5 H. =3@@9>. Internati#na% syste(s #6 dia&n#sis in *sy./iatry. ournal of -ervous and Mental Disease# 68:# "?0 ?:. Fei&/ner5 < P.5 R#bins5 E.5 G$Ce5 S. 1.5 W##dr$665 R. A.5 Win#+$r5 G.5 H M$n#C5 R. =3@8 >. Dia&n#sti. .riteria 6#r $se in *sy./iatri. resear./. %rchives of General +sychiatry# :E# "80?:. First5 M. 1.5 1e%%5 C.

1.5 )rysta%5 < H.5 Reiss5 D.5 S/ea5 M. T5 Widi&er5 T. A.5 H Wisner5 ). L. = !! >. Ga*s in t/e .$rrent syste(' Re.#((endati#ns. In D. < )$*6er5 M. 1. First5 H D. A. Re&ier =Eds.>5 % research agenda for D'M3F<pp. 3 :03@@>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. F#%ette5 W. C5 H H#$ts5 A. C. =3@@?>. M#de%s #6 s.ienti6i. *r#&ress and t/e r#%e #6 t/e#ry in ta-#n#(y de,e%#*(ent' A .ase st$dy #6 t/e DSM. ournal of 1onsulting and 1linical +sychology# E;# 33 !033: . Fran.es5 A. <5 First5 M. 1.5 H Pin.$s5 H. A. =3@@">. D'M30F guidebook. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. Fran.es5 A. 7.5 Pin.$s5 H. A.5 Widi&er5 T. A.5 Da,is5 W. W.5 H First5 M. 1. =3@@!>. DSM0IG' W#r+ in *r#&ress. %merican ournal of +sychiatry# 6;A# 39:@0399;. Fran.es5 A. <5 Widi&er5 T. A.5 H Pin.$s5 H. A. =3@;@>. T/e de,e%#*(ent #6 DSM0IG %rchives of General +sychiatry# ;E# :8:0:8". Garb5 H. N. =3@@;>. 'tudying the clinician. udgment research and psychological assessment. Was/in&t#n5 DC' A(eri.an Psy./#%#&i.a% Ass#.iati#n. G#renstein5 E. =3@;9>. Debatin& (enta% i%%ness. %merican +sychologist# ?@# "!0"?. Gr#b5 G.N. =3@@3>. Ori&ins #6 DSM0I' A st$dy in a**earan.e and rea%ity. %merican ournal of +sychiatry# 6;8# 9 309:3. Hart$n&5 C. M.5 H Widi&er5 T. A. =3@@;>. Gender di66eren.es in t/e dia&n#sis #6 (enta% dis#rders' C#n.%$si#ns and .#ntr#,ersies #6 DSM0IG +sychological $ulletin# 6:?# ?!0 8;. Hy(an5 S. E. =3@@;>. NIMH d$rin& t/e ten$re #6 Dire.t#r Ste,en E. Hy(an5 M.D. =3@@?0*resent>' t/e n#2 and 6$t$re #6 NIMH. %merican ournal of +sychiatry# 699 =S$**%.>5 :?09!. )a*%an5 M. =3@;:>. A 2#(anBs ,ie2 #6 DSM0III. %merican +sychologist# ?8# 8;?08@ . )ende%%5 R. E. =3@8">. The role of diagnosis in psychiatry. L#nd#n' 1%a.+2e%% S.ienti6i. P$b%i.ati#ns. )ende%%5 R. E. =3@@3>. Re%ati#ns/i* bet2een t/e DSM0IG and t/e ICD03!. ournal of %bnormal +sychology# 677# @80:!3.

;. CLASSIFICATION AND DIAGNOSIS 160 )ess%er5 R. C. =3@@@>. T/e W#r%d Hea%t/ Or&aniCati#n Internati#na% C#ns#rti$( in Psy./iatri. E*ide(i#%#&y' Initia% 2#r+ and 6$t$re dire.ti#ns 0 t/e NAPE %e.t$re. %cta +sychiatrica 'candinavica# @@# 0@. )ir(ayer5 L. 7.5 H Y#$n&5 A. =3@@@>. C$%t$re and .#nte-t in t/e e,#%$ti#nary .#n.e*t #6 (enta% dis#rder. ournal of %bnormal +sychology# 678# 99?09" . )ir(ayer5 L. 7.5 Y#$n&5 A.5 H Hayt#n5 1. C. =3@@">. T/e .$%t$ra% .#nte-t #6 an-iety dis#rders. +sychiatric 1linics of -orth %merica# 68# "!:0" 3. )%ein5 D. F. =3@@@>. Har(6$% dys6$n.ti#n5 dis#rder5 disease5 i%%ness5 and e,#%$ti#n. ournal of %bnormal +sychology# 678# 9 3P9 @. )ra(er5 M.5 Sart#ri$s5 N.5 7ab%ens+y5 A.5 H G$%binat5 W. =3@8@>. T/e ICD0@ .%assi6i.ati#n #6 (enta% dis#rders. A re,ie2 #6 its de,e%#*(ent and .#ntents. %cta +sychiatrica 'candinavika# 9@# 930 ? . )r$e&er5 R. F. =3@@@>. T/e str$.t$re #6 .#((#n (enta% dis#rders. %rchives of General +sychiatry# 9E# @ 3@ ?. )r$e&er5 R. F.5 Cas*i5 A.5 M#66itt5 T. E.5 H Si%,a5 P. A. =3@@;>. T/e str$.t$re and stabi%ity #6 .#((#n (enta% dis#rders =DSM0III0R>' A %#n&it$dina%0e*ide(i#%#&i.a% st$dy. ournal of %bnormal +sychology# 3!85 3?0 8. )$t./ins5 H.5 H)ir+5 S. A. =3@@8>. Making us cra*y. D'M5 the psychiatric bible and the creation of mental disorders. Ne2 Y#r+' T/e Free Press. Le/(an5 A. E5 A%e-#*#$%#s5 G. S.5 G#%d(an5 H. HQ 7este5 D. G5 O66#rd5 D.5 H Usr$n5 T. 1. = !! >. Disabi%ity and i(*air(ent re.#((endati#ns. In D. 7. )$*6er5 M. 1. First5 H D. A. Re&ier =Eds.>5 % research agenda for D'M3F =**. !30 3;>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. LenCen2e&er5 M. F. =3@@@>. Dee*er int# t/e s./iC#ty*y ta-#n' On t/e r#b$st nat$re #6 (a-i($( .#,arian.e ana%ysis. ournal of %bnormal +sychology# 678# 3; 03;8. Le,ins#n5 D. F.5 Ma/tani5 M. M.5 Nan.arr#25 D. 7.5 1r#2n5 D. M.5 )r$&%ya+ L5 )irby5 A.5 Hay2ard N. ).5 Cr#2e5 R. R.5 Andreasen5 N. C5 1%a.+5 D. W5 Si%,er(an5 7. M.5 Endi.#tt5 7.5 S/ar*e5 L.5 M#/s5 R. C5 Sie,er5 L. <5 Wa%ters5 M. ).5 Lenn#n5 D. P.5 7#nes5 H. L.5 Nertney5 D. A.5 Da%y5 M. <5 G%adis5 M5 H M#2ry5 1. 7. =3@@;>. Gen#(e s.an #6 s./iC#*/renia. %merican ournal of +sychiatry# 699# 89308"!. Le2is0FernandeC5 R.5 H )%ein(an5 A. =3@@">. C$%t$ra% *sy./iatry. T/e#reti.a%5 .%ini.a%5 and resear./ iss$es. +sychi3 atric 1linics of -orth %merica# 68# 9::A99?. Li%ien6e%d5 S. O.5 H Marin#5 L. =3@@@>. Essentia%is( re,isited' E,#%$ti#nary t/e#ry and t/e .#n.e*t #6 (enta% dis#rder. ournal of %bnormal +sychology# 678# 9!!0933. Li%ien6e%d5 S. O.5 Wa%d(an5 I. D.5 H Israe%5 A. C. =3@@9>. A .riti.a% e-a(inati#n #6 t/e $se #6 t/e ter( K.#(#rbidityK in *sy./#*at/#%#&y resear./. 1linical +sychology5 'cience and +ractice# 6# 830;:. L#*eC5 S. R.5 H G$arna..ia5 < < = !!!>. C$%t$ra% *sy./#*at/#%#&y' Un.#,erin& t/e s#.ia% 2#r%d #6 (enta% i%%ness. %nnual (eview of +sychology# 96# "830"@;. Lyna(5 D. R.5 H Widi&er5 T. A. = !!3>. Usin& t/e 6i,e 6a.t#r (#de% t# re*resent t/e DSM0IG *ers#na%ity dis#rders' An e-*ert .#nsens$s a**r#a./. ournal of %bnormal +sychology# 667#9!3093 . M.G$e5 M.5

H 1#$./ard5 T. < =3@@;>. Geneti. and en,ir#n(enta% in6%$en.es #n /$(an be/a,i#ra% di66eren.es. %nnual (eview of -euroscience# :6# 30 9. M.N$een5 L. = !!!>. C#((ittee #n Psy./iatri. Dia&n#sis and Assess(ent $*date #n *$b%i.ati#ns and a.ti,ities. +sychiatric (esearch (eport# 6E<:=# :. Mee/%5 P. E. =3@88>. S*e.i6i. eti#%#&y and #t/er 6#r(s #6 str#n& in6%$en.e. S#(e J$antitati,e (eanin&s. ournal of Medicine and +hilosophy# :# ::0":. Mennin&er5 ). =3@?:>. The vital balance. NY' Gi+in&. MeCCi./5 < E.5 )%ein(an5 A.5 Fabre&a5 H.5 Parr#n5 D. L.5 G##d5 1. <5 Lin5 )0H.5 H Mans#n5 S. M. =3@@8>. C$%t$ra% iss$es 6#r DSM0IG In T. A. Widi&er5 A. < Fran.es5 H. A. Pin.$s5 R. R#ss5 M. 1. First5 H W. Da,is =Eds.>5 D'M30F sourcebook =G#%. :5 **. ;?30;??>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. Mine+a5 S.5 Wats#n5 D.5 H C%ar+5 L. A. =3@@;>. C#(#rbidity #6 an-iety and $ni*#%ar (##d dis#rders. %nnual (eview of +sychology# ;@# :88P33 . Nat/an5 P.5 H Lan&enb$./er5 < W. =3@@@>. Psy./#*at/#%#&y' Des.ri*ti#n and .%assi6i.ati#n. %nnual (eview of +sychology# 97# 8@03!8. Neisser5 U5 1##d##5 G.5 1#$./ard5 T. <5 1#y+in5 A. W.5 1r#dy5 N.5 Ce.i5 S. <5 Ha%*ern5 D. E5 L#e/%in5 < C5 Per%#665 R.5 Sternber&5 R. <5 H Urbina5 S. =3@@?>. Inte%%i&en.e' )n#2ns and $n+n#2ns. %merican +sychologist# 96# 8803!3. Ne(er#6T5 C. 1.5 )i%ts5 C. D.5 H 1e(s5 G. S. =3@@@>. F$n.ti#na% brain i(a&in&' T2enty06irst .ent$ry */ren#%#&y #r *sy./#bi#%#&i.a% ad,an.e 6#r t/e (i%%enni$(I %merican ournal of +sychiatry# 69E# ?830?8:. Pant#ny5 )0L.5 H Ca*%an5 P. < =3@@3>. De%$si#na% d#(inatin& *ers#na%ity dis#rder' A (#dest *r#*#sa% 6#r identi6yin& s#(e .#nseJ$en.es #6 ri&id (as.$%ine s#.ia%iCati#n. 1anadian +sychology# ?:# 3 !03::. P#rtin5 P.5 H A%anen5 Y. O. =3@@8>. A .riti.a% re,ie2 #6 &eneti. st$dies #6 s./iC#*/renia. II. M#%e.$%ar &eneti. st$dies. %cta +sychiatrica 'candinavica# @9# 8:0;!.

162 WIDIGER Pri&ers#n5 H. G.5 S/ear5 M. ).5 7a.#bs5 S. C5 Reyn#%ds5 C. E5 Ma.ieDe2s+i5 P. ).5 Da,ids#n5 7. R. T.5 R#sen/e.+5 R. A.5 Pi%+#nis5 P. A.5 W#rt(an5 C. 1.5 Wi%%ia(s5 7. 1. W5 Widi&er5 T. A.5 Fran+5 E.5 )$*6er5 D. 75 H Fis##+5 S. =3@@@>. C#nsens$s .riteria 6#r tra$(ati. &rie6' A *re%i(inary e(*iri.a% test. $ritish ournal of +sychiatry# 6A;# ?808:. Re&ier5 D. A.5 )ae%ber5 C. T.5 Rae5 D. SQ Far(er5 M E.5 )na$*er5 1.5 )ess%er5 R. C5 H N#rJ$ist5 G. S. =3@@;>. Li(itati#ns #6 dia&n#sti. .riteria and assess(ent instr$(ents 6#r (enta% dis#rders. I(*%i.ati#ns 6#r resear./ and *#%i.y. %rchives of General +sychiatry# 99# 3!@03". R#&ers5 R. = !!3>. ,andbook of diagnostic and structured interviewing. NY' G$i%6#rd. R#sen/an5 D. L. =3@8:>. On bein& sane in insane *%a.es. 'cience# 6A@# "!0 ";. R#ss5 R.5 Fran.es5 A. 7.5 H Widi&er5 T. A. =3@@">. Gender iss$es in DSM0IG In 7. M. O%d/a( H M. 1. Riba =Eds >5 (eview of psychiatry =G#%. 395 **. !"0 ?>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. R#$nsa,i%%e5 1. 75 A%ar.#n5 R. D.5 Andre2s5 G.5 7a.+s#n5 7. S.5 )ende%%5 R. E.5 )end%er5 ). S.5 H )ir(ayer5 L. 7. = !! >. T#2ard DSM0G' 1asi. n#(en.%at$re iss$es. In D. 7. )$*6er5 M. 1. First5 H D. A. Re&ier =Eds.>5 % research agenda for D'M3F <pp. 30 @>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. R$s/5 A. 7.5 Pin.$s5 H. A.5 First5 M. 1.5 1%a.+er5 D.5 Endi.#tt5 75 )eit/5 S. I5 P/i%%i*s5 ). A.5 Ryan5 N. D.5 S(it/5 G. R.5 Ts$an&5 M. <5 Widi&er5 T. A.5 H Farin5 D. A. =Eds.>. = !!!>. ,andbook of psychiatric measures. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. R$tter5 M. L. =3@@8>. Nat$re0n$rt$re inte&rati#n. T/e e-a(*%e #6 antis#.ia% be/a,i#r. %merican +sychologist# 9:# :@!0:@;. Sa%(#n5 T. W5 C#**5 O.5 May5 7. G5 Abb#t5 E. S.5 H C#tt#n5 H. A. =3@38>. Re*#rt #6 t/e .#((ittee #n statisti.s #6 t/e A(eri.an Medi.#0Psy./#%#&i.a% Ass#.iati#n. %merican ournal of 0nsanity# A;# ""0 ?!. Sart#ri$s5 N.5 )ae%ber5 C. T5 C##*er5 7. E.5 R#*er5 M.5 Rae5 D. S.5 G$%binat5 W5 Ust$n5 T. 1.5 H Re&ier5 D. A. =3@@:>. Pr#&ress t#2ard a./ie,in& a .#((#n %an&$a&e in *sy./iatry. %rchives of General +sychiatry# 97# 33"03 9. S./2artC5 M. A.5 H Wi&&ins5 O. P. = !! >. T/e /e&e(#ny #6 t/e DSMs. In 7. Sad%er =Ed.>5 Descriptions and prescriptions5 Falues# mental disorders# and the D'M <pp. 3@@0 !@>. 1a%ti(#re' 7#/ns H#*+ins Uni,ersity Press. S*itCer5 R. L.5H Wa+e6ie%d5 7. C. =3@@@>. DSM0IG dia&n#sti. .riteri#n 6#r .%ini.a% si&ni6i.an.e' D#es it /e%* s#%,e t/e 6a%se *#siti,es *r#b%e(I %merican ournal of +sychiatry# 69E# 3;"?03;?9. S*itCer5 R. L.5 H Wi%%ia(s5 7. 1. W. =3@; >. T/e de6initi#n and dia&n#sis #6 (enta% dis#rder. In W R. G#,e =Ed.>5 Deviance and mental illness =**. 3"0: >. 1e,er%y Hi%%s5 CA' Sa&e. S*itCer5 R. L.5 Wi%%ia(s5 7. 1. W.5 H S+#d#%5 A. E. =3@;!>. DSM0III' T/e (aD#r a./ie,e(ents and an #,er,ie2. %merican ournal of +sychiatry# 6?A# 3"303?9. S*r#.+5 7.5 Cr#sby5 7. P.5 H Nie%sen5 1. A. = !!3>. E66e.ts #6 se- and se- r#%es #n t/e

*er.ei,ed (a%ada*ti,eness #6 DSM0IG *ers#na%ity dis#rder sy(*t#(s. ournal of +ersonality Disorders# 69# 930"@. Ste66ens5 D. C5 H )ris/nan5 ). R. R. =3@@;>. Str$.t$ra% ne$r#i(a&in& and (##d dis#rders' re.ent 6indin&s5 i(*%i.ati#ns 6#r .%assi6i.ati#n5 and 6$t$re dire.ti#ns. $iological +sychiatry# ;?# 8!"083 . Sten&e%5 E. =3@"@>. C%assi6i.ati#n #6 (enta% dis#rders. $ulletin of the &orld ,ealth Organi*ation# :6# ?!30??:. SCasC5 T. S. =3@?3>. The myth of mental illness. NY' H#eber0Har*er. Wa+e6ie%d5 7. C. =3@;8>. Se- bias in t/e dia&n#sis #6 *ri(ary #r&as(i. dys6$n.ti#n. %merican +sychologist# ;:# Wa+e6ie%d5 7. C. =3@@ >. T/e .#n.e*t #6 (enta% dis#rder' On t/e b#$ndary bet2een bi#%#&i.a% 6a.ts and s#.ia% ,a%$es. %merican +sychologist# ;A# :8:0;;. Wa+e6ie%d5 7. C. =3@@8>. Dia&n#sin& DSM0IG0Part I' DSM0IG and t/e .#n.e*t #6 dis#rder. $ehavioral (esearch and Therapy# ?9# ?::0?9@. Wa+e6ie%d5 7. C. =3@@;>. T/e DSMBs t/e#ry0ne$tra% n#s#%#&y is s.ienti6i.a%%y *r#&ressi,e' Res*#nse t# F#%%ette and H#$ts =3@@?>. ournal of 1onsulting and 1linical +sychology# EE# ;9?0;" . Wa+e6ie%d5 7. C5 P#tti.+5 ). 7Q H )ir+5 S. A. = !! >. S/#$%d t/e DSM0IG dia&n#sti. .riteria 6#r .#nd$.t dis#rder .#nsider s#.ia% .#nte-tI %merican ournal of +sychiatry# 69@# :;!0:;?. Ward5 C. H.5 1e.+5 A. T5 Mende%s#n5 M.5 M#.+5 7. E.5 H Erba$&/5 7. ). =3@? >. T/e *sy./iatri. n#(en.%at$re. Reas#ns 6#r dia&n#sti. disa&ree(ent. %rchives of General +sychiatry# A# 3@;0 !". Westen5 D. =3@@8>. Di,er&en.es bet2een .%ini.a% and resear./ (et/#ds 6#r assessin& *ers#na%ity dis#rders' I(*%i.ati#ns 6#r resear./ and t/e e,#%$ti#n #6 A-is II. %merican ournal of +sychiatry# 69;# ;@"0@!:. Widi&er5 T. A. =3@@">. De%eti#n #6 t/e se%60de6eatin& and sadisti. *ers#na%ity dis#rder dia&n#ses. In W. 7. Li,es%ey =Ed.>5 The D'M30F personality disorders =**. :"@0:8:>. Ne2 Y#r+' G$i%6#rd. Widi&er5 T. A. =3@@;>. Se- biases in t/e dia&n#sis #6 *ers#na%ity dis#rders. ournal of +ersonality Disorders# 6:# @"033;. Widi&er5 T. A. = !!3>. O66i.ia% .%assi6i.ati#n syste(s. In W. 7. Li,es%ey =Ed.>5 ,andbook of personality disorders =**. ?!0;:>. NY' G$i%6#rd. Widi&er5 T. A. = !! >. Ga%$es5 *#%iti.s5 and s.ien.e in t/e .#nstr$.ti#n #6 t/e DSM. In 7. Sad%er =Ed.>5 Descriptions and prescriptions5 Falues# mental disorders# and the D'M <pp. "0 93>. 1a%ti(#re' 7#/ns H#*+ins Uni,ersity Press.

9. CLA "F"CA#"!N AN8 8"A=N! " 164 Widi&er5 T. A.5 H C%ar+5 L. A. = !!!>. T#2ard DSM0G and t/e .%assi6i.ati#n #6 *sy./#*at/#%#&y. +sychological $ulletin# 6:E# @9?0@?:. Widi&er5 T. A.5 H C#+er5 L. A. = !!:>. Menta% dis#rders as dis.rete .%ini.a% .#nditi#ns' Di(ensi#na% ,ers$s .ate&#ri.a% .%assi6i.ati#n. In S. M. T$rner H M. Hersen =Eds.>5 %dult psychopathology and diagnosis =9t/ ed. **. :0:">. NY' 7#/n Wi%ey. Widi&er5 T5 Fran.es5 A.5 Pin.$s5 H.5 Da,is5 W.5 H First5 M. =3@@3>. T#2ard an e(*iri.a% .%assi6i.ati#n 6#r DSM0IG ournal of %bnormal +sychology# 677# ;!0 ;;. Widi&er5 T. A. Fran.es5 A. 7.5 Pin.$s5 H. A.5 First5 M. 1.5 R#ss5 R. R.5 H Da,is5 W. W. =Eds.> =3@@9>. D'M30F sourcebook =G#%. 3>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. Widi&er T. A.5 Fran.es5 A. 7.5 Pin.$s5 H. A.5 First5 M. 1.5 R#ss5 R. R.5 H Da,is5 W. W. =Eds.>. =3@@?>. D'M30F sourcebook =G#%. >. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. Widi&er5 T. AQ Fran.es5 A. 7.5 Pin.$s5 H. A.5 R#ss5 R. R.5 First5 M. 1.5 H Da,is5 W. W. =Eds.>. =3@@8>. D'M30F sourcebook =G#%. :>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. Widi&er5 T. A.5 Fran.es5 A. 7.5 Pin.$s5 H. A.5 R#ss5 R.5 First5 M. 1.5 Da,is5 W. W5 H )%ine5 M. =Eds.>. =3@@;>. D'M30F 'ourcebook =G#%. 9>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Ass#.iati#n. Widi&er5 T. A.5 H San+is5 L. M. = !!!>. Ad$%t *sy./#*at/#%#&y ' Iss$es and .#ntr#,ersies. %nnual (eview of+sychology# 96# :88P3!9. Widi&er5 T. A.5 H Tr$%%5 T. 7. =3@@3>. Dia&n#sis and .%ini.a% assess(ent. %nnual (eview of+sychology# ;:# 3!@03::. Widi&er5 T. A.5 H Tr$%%5 T. 7. =3@@:>. T/e s./#%ar%y de,e%#*(ent #6 DSM0IG In 7. A. C#sta e Si%,a H C. C. Nade%s#n =Eds.>5 0nternational review of psychiatry =G#%. 35 **. "@08;>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. W#r%d Hea%t/ Or&aniCati#n. =3@@ >. The 01D367 classification of mental and behavioural disorders. 1linical descriptions and diagnostic guidelines. Gene,a5 S2itCer%and' A$t/#r. Fa/n0Wa-ier5 C. =3@@:>. Warri#rs and 2#rriers' &ender and *sy./#*at/#%#&y. Development and +sychopathology# 9# 8@0;@. Fi&%er5 E.5 H P/i%%i*s5 L. =3@?3>. Psy./iatri. dia&n#sis' A .ritiJ$e. ournal of %bnormal and 'ocial +sychology# E?# ?!80?3;. Fi%b##r&5 G. =3@93>. % history of medical psychology. NY' N#rt#n. F#..#%i%%#5 M. =3@@:>. Gender and t/e de,e%#*(ent #6 .#nd$.t dis#rder. Development and +sychopathology# 9#?"08;.

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CHAPTER

5
Psy./#%#&i.a% Assess(ent and C%ini.a% 7$d&(ent H#2ard N. Garb University o f +ittsburgh S.#tt O. Li%ien6e%d and )at/erine A. F#2%er !mory University W'at ma6or ad/an)es 'a/e o))urred in t'e assessment of psy)'opat'o.ogy o/er t'e past 9< yearsF Many psy)'o.ogists (ou.d argue t'at t'e most important brea-t'roug's in).ude t'e de/e.opment of exp.i)it diagnosti) )riteria$ t'e gro(ing popu.arity of stru)tured inter/ie(s$ and t'e pro.iferation of brief measures tai.ored for use by menta. 'ea.t' professiona.s )ondu)ting empiri)a..y supported treatments 2e.g.$ Antony H Bar.o($ 9,,93. !t'ers (ou.d disagree. E/en an ad/an)e t'at most menta. 'ea.t' professiona.s 'a/e embra)ed$ t'e use of exp.i)it )riteria for ma-ing psy)'iatri) diagnoses$ 'as been )'a..enged 2Beut.er H Ma.i-$ 9,,93. For examp.e$ Weiner 29,,,3 referred to t'e )urrent Diagnostic and 'tatistical Manual of Mental Disorders 28 M1">$ Ameri)an %sy)'iatri) Asso)iation$ *++;3 as 0a psy)'ometri)a..y s'a-y$ inferentia. noso.ogi)a. s)'eme in/o./ing )riteria and definitions t'at )'ange from one re/ision to t'e next0 2p. ;:?3. 2 ee a.so Widiger$ t'is boo-.3 Contro/ersies abound in t'e domain of assessment$ and most beginning readers of t'is .iterature are .eft (it' .itt.e guidan)e regarding 'o( to na/igate t'e mur-y s)ientifi) (aters. "n t'is )'apter$ (e intend to pro/ide su)' guidan)e. pe)ifi)a..y$ (e dis)uss fundamenta. )on)eptua. and met'odo.ogi)a. issues in t'e assessment of psy)'opat'o.ogy$ (it' a parti)u.ar fo)us on re)ent de/e.opments and ad/an)es. We )ompare different types of assessment instruments$ in).uding stru)tured inter/ie(s$ brief se.f1rated and ).ini)ian1rated measures$ pro6e)ti/e te)'ni7ues$ se.f1report persona.ity in/entories$ and be'a/iora. assessment and psy1 )'op'ysio.ogi)a. met'ods. We a.so re/ie( resear)' on t'e /a.idity of assessment instruments and resear)' on ).ini)a. 6udgment and de)ision ma-ing. !ur prin)ipa. goa. in t'is )'apter is to assist readers (it' t'e tas- of be)oming (e..1informed and dis)erning )onsumers of t'e ).ini)a. assessment .iterature. "n parti)u.ar$ (e intend to pro/ide readers (it' t'e too.s ne)essary to distinguis' s)ientifi)a..y supported from unsupported assessment instruments and to ma-e /a.id 6udgments on t'e basis of t'e former instruments. 166

167 GAR15 LILIENFELD5 FOWLER PSYCHOMETRIC PRINCIPLES Before des)ribing t'e /a.idity of assessment instruments and resear)' on ).ini)a. 6udgment and de)ision ma-ing$ (e must first ).arify t'e meaning of se/era. -ey terms. pe)ifi)a..y$ (e (i.. define and dis)uss re.iabi.ity$ /a.idity$ and treatment uti.ity Isee a.so t'e .tandards for @d& ucational and Psychological Testing, Ameri)an Edu)ationa. Resear)' Asso)iation$ Ameri)an %sy)'o.ogi)a. Asso)iation$ H Nationa. Coun)i. on Measurement in Edu)ation 2AERA$ A%A$ HNCME3$ *+++J. :eliability refers to )onsisten)y of measurement. "t is e/a.uated in se/era. (ays. "f a.. of t'e items of a test are be.ie/ed to measure t'e same trait$ (e (ant t'e test to possess good interna. )onsisten)y5 #est items s'ou.d be positi/e.y inter)orre.ated. "f a test is be.ie/ed to measure a stab.e trait$ t'en t'e test s'ou.d possess test1retest re.iabi.ity5 on separate administrations of t'e test$ ).ients s'ou.d obtain simi.ar s)ores. Fina..y$ ('en t(o or more psy)'o.ogists ma-e diagnoses or ot'er 6udgments for t'e same ).ients$ interrater re.iabi.ity s'ou.d be 'ig'5 #'eir ratings s'ou.d tend to agree. #raditiona..y$ interrater re.iabi.ity (as e/a.uated by )a.)u.ating t'e per)entage of )ases on ('i)' raters agree. For examp.e$ t(o psy)'o.ogists mig't agree on diagnoses for B,P of t'e patients on a unit. &o(e/er$ per)entage agreement is undu.y affe)ted by base rates. "n t'is )ontext$ a base rate refers to t'e pre/a.en)e of a disorder. W'en t'e base rates of a disorder are 'ig'$ raters may agree on a .arge number of )ases be)ause of )'an)e. For examp.e$ if B,P of t'e patients on a )'roni) psy)'iatri) inpatient unit suffer from s)'i4op'renia$ t'en t(o ).ini)ians ('o random.y ma-e diagnoses of s)'i4op'renia for B,P of t'e patients (i.. agree on t'e diagnosis of s)'i4op'renia for about ?;P of t'e )ases 2.B x .B Q .?;3. #'us$ a moderate.y 'ig' .e/e. of agreement is obtained e/en t'oug' diagnoses are made arbitrari.y. By )a.)u.ating -appa or an intra).ass )orre.ation )oeffi)ient 2"CC3$ one )an )a.)u.ate t'e .e/e. of agreement beyond t'e )'an)e .e/e. of agreement. #'is )a.)u.ation is a))omp.is'ed by ta-ing into a))ount t'e base rates of t'e disorder being rated. W'en interpreting -appa and "CC$ one genera..y uses t'e fo..o(ing )riteria5 "nterrater re.iabi.ity is poor for /a.ues be.o( .;,$ fair for /a.ues bet(een .;, and .<+$ good for /a.ues bet(een .?, and .D;$ and ex)e..ent for /a.ues abo/e .D< 2F.eiss$ *+B*$ p. 9*B3. &o(e/er$ t'ese )riteria are typi)a..y used for ma-ing 6udgments 2e.g.$ diagnoses or predi)tions of be'a/ior3$ not for s)oring test proto)o.s. For s)oring proto)o.s$ a re.iabi.ity )oeffi)ient of at .east .+, is desirab.e 2Nunna..y$ *+DB$ pp. 9;<19;?3. Re.iabi.ity s'ou.d be 'ig'er for s)oring tests t'an for ma-ing ).ini)a. 6udgments be)ause if a test )annot be s)ored re.iab.y$ 6udgments based on t'ose test s)ores (i.. ne)essari.y 'a/e poor re.iabi.ity. A))ording to t'e .tandards for @ducational and Psychological Testing 2AERA et a..$ *+++3$ validity refers to 0t'e degree to ('i)' e/iden)e and t'eory support t'e interpretations of test s)ores0 2p. +3. %ut anot'er (ay$ /a.idity is good if t'e use of a test a..o(s us to dra( a))urate inferen)es about ).ients 2e.g.$ if t'e use of test s)ores 'e.ps us to pro/ide )orre)t des)riptions of traits$ psy)'opat'o.ogy$ and diagnoses3. Re.iabi.ity and /a.idity differ in important (ays. Re.iabi.ity refers to t'e )onsisten)y of test s)ores and 6udgmentsC /a.idity refers to t'e a))ura)y of interpretations and 6udgments. W'en re.iabi.ity is good$ /a.idity )an be good or poor. For examp.e$ t(o psy)'o.ogists )an agree on a ).ientGs diagnosis$ yet bot' )an be (rong. !r a ).ient )an obtain t'e same s)ores on t(o

administrations of a test$ yet inferen)es made using t'e test s)ores may be in/a.id. "n )ontrast$ ('en re.iabi.ity is poor$ /a.idity is ne)essari.y a.so poor. For examp.e$ if t(o psy)'o.ogists )annot agree on a ).ientGs diagnosis$ at .east one of t'em is not ma-ing a /a.id diagnosis. 8ifferent types of e/iden)e )an be obtained to e/a.uate /a.idity. First$ e/iden)e )an be based on test )ontent Bcontent validity". For examp.e$ a measure of a spe)ifi) anxiety disorder$ su)'

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 169 as obsessi/e1)ompu.si/e disorder$ s'ou.d in).ude an ade7uate representation of items to assess t'e prin)ipa. features of t'is disorder$ in t'is )ase obsessions and )ompu.sions. #o ensure )ontent /a.idity$ many stru)tured inter/ie(s )ontain 7uestions t'at in7uire )ompre'ensi/e.y about t'e 8 M )riteria for anxiety disorders and ot'er )onditions 2e.g.$ Anxiety 8isorders "nter/ie( )'edu.e1iy A8" 1">C Bro(n$ 8i Nardo$ H Bar.o($ *++;3. e)ond$ e/iden)e )an be based on t'e re.ation bet(een test s)ores 2or inferen)es based on test s)ores3 and ot'er /ariab.es conver& gent validity". For examp.e$ test s)ores )an be used to predi)t be'a/iora. out)omes 2e.g.$ sui1 )ide3$ or t'ey )an be re.ated to independent ratings of a trait 2e.g.$ anxiety3. W'en test s)ores are used to fore)ast future out)omes$ psy)'o.ogists refer to predictive validity7 ('en t'ese s)ores are )orre.ated (it' indi)es measured at approximate.y t'e same time$ psy)'o.ogists refer to con& current validity. #'e /a.idity of an assessment instrument )an a.so be e/a.uated by examining its interna. stru)ture structural validity7 see Loe/inger$ *+<D3. "f a test generates many s)ores t'at do not inter)orre.ate as expe)ted$ t'is resu.t may suggest t'at inferen)es based on t'ose test s)ores are (rong. For examp.e$ one prob.em (it' t'e Rors)'a)' "n-b.ot #est is t'at s)ores t'at are purported to ref.e)t psy)'opat'o.ogy are 'ig'.y )orre.ated (it' t'e number of responses produ)ed by ).ients 2Li.ienfe.d$ Wood$ H =arb$ 9,,,$ p. :;3. #'at is$ t'e more responses a ).ient produ)es on t'e Rors)'a)'$ t'e greater t'e .i-e.i'ood t'e ).ient (i.. generate responses t'at ostensib.y indi)ate t'e presen)e of psy)'opat'o.ogy. For examp.e$ a sing.e Rors)'a)' food response is purported.y indi)ati/e of dependent persona.ity traits$ but t'e more o/era.. responses a ).ient produ)es$ t'e greater t'e .i-e.i'ood of t'e ).ient ma-ing a food response. W'en (e des)ribe t'e )ontent /a.idity$ )on/ergent /a.idity$ or stru)tura. /a.idity of an assessment instrument$ (e are a.so des)ribing its )onstru)t /a.idity. A )onstru)t is a t'eoreti)a. /ariab.e t'at )annot be measured perfe)t.y. More spe)ifi)a..y$ )onstru)ts are 'ypot'esi4ed attributes of indi/idua.s t'at )annot be obser/ed dire)t.y$ su)' as extra/ersiMn or s)'i4op'renia 2Cronba)' H Mee'.$ *+<<3. Constru)t /a.idity is abroad )on)ept t'at subsumes )ontent /a.idity$ )on/ergent /a.idity$ and stru)tura. /a.idity. A number of statisti)s )an be used to e/a.uate t'e /a.idity of assessment instruments. Re1 sear)'ers )ommon.y )a.)u.ate )orre.ations bet(een a test and ot'er measures$ in).uding s)ores on re.ated tests. !t'er statisti)s )an yie.d e/en more usefu. information. For examp.e$ resu.ts on sensiti/ity and spe)ifi)ity are presented routine.y in t'e medi)a. .iterature$ but on.y infre7uent.y in t'e .iterature on psy)'o.ogi)a. assessment 2Antony H Bar.o($ 9,,93. .ensitivity is t'e .i-e.i'ood t'at one (i.. test positi/e gi/en t'at one 'as a spe)ified menta. disorder. .pecificity is t'e .i-e.i'ood one (i.. test negati/e gi/en t'at one does not 'a/e t'e spe)ified disorder. "dea..y$ one attempts to maximi4e bot' sensiti/ity and spe)ifi)ity$ a.t'oug' t'ere may be )ases in ('i)' one e.e)ts to emp'asi4e one statisti) o/er t'e ot'er. For examp.e$ if one (ere attempting to predi)t sui)ide in a .arge group of patients$ one (ou.d presumab.y be more )on)erned (it' sensiti/ity t'an spe)ifi)ity. !t'er important statisti)s are positi/e and negati/e predi)ti/e po(er. Positive predictive power des)ribes t'e .i-e.i'ood of a disorder gi/en t'e presen)e of a parti)u.ar resu.t on an assessment instrument. +egative predictive power des)ribes t'e .i-e.i'ood of t'e absen)e of a disorder gi/en t'e absen)e of t'e parti)u.ar resu.t on t'e assessment instrument. #'e )on)epts of sensiti/ity$ spe)ifi)ity$ positi/e predi)ti/e po(er$ and negati/e predi)ti/e po(er

are i..ustrated in #ab.e <.*. "n t'is s)enario$ pro/isiona. diagnoses of a mood disorder are made ('en t'e #1s)ore for )a.e 9 28epression3 of t'e MM%"19 is W ?< 2t'e standard )utoff for psy)'opat'o.ogy on t'e MM%"193*. "n t'e samp.e (it' a base rate of <,P 2<,P of t'e ).ients are depressed3$ <,, ).ients are depressed and <,, ).ients are not depressed. For t'e <,, ).ients ('o are depressed$ ;9< 'a/e a #1s)ore W?<. #'us$ sensiti/ity is e7ua. to ;9<L<,, Q B<.,P. BWe $se t/e ter( K*r#,isi#na% dia&n#sesK be.a$se 6#r(a% dia&n#ses #6 *sy./iatri. dis#rders s/#$%d n#t be (ade #n t/e basis #6 t/e MMPI0 a%#ne.

171 GAR15 LILIENFELD5 FOWLER TA1LE ".3 E66e.t #6 1ase Rate #n P#siti,e Predi.ti,e P#2er =PPP>5 Ne&ati,e Predi.ti,e P#2er =NPP>5 Sensiti,ity5 and S*e.i6i.ity 1ase "! Rate W X -epressed = .cale Ce +o Tot PPP ;2>D> = *). 2 -" TF4 > TG ?" T#ta% 1ase Rate W .cale 2 -" TF4 > T V ?" X -epressed Ce s 38 : +o @9 ?;? Tot al :33 ?;@ PPP NPP = 0*D)0 0 ?;?4?; @ >.3 E @@.? X s 9 " 8" "!! 3"! :"! "!! al "8" 9 " 3!!! NPP Sensiti,i ty S*e.i6i.i ty = W = *> :"!49 " 9 "4"! ! :"!4"! ! = = 1E ; .9 X ;".! X 8!.! X

Sensiti,i 384 ! = ;".! ty X T#ta% ! @;! 3!!! S*e.i6i.i 1 ?;?4@; 8!.! ty ! X Computations for spe)ifi)ity$ positi/e predi)ti/e po(er$ and negati/e predi)ti/e po(er are a.so presented in t'e tab.e. 8epending on t'e statisti) used to e/a.uate /a.idity$ a))ura)y )an /ary (it' t'e base rate of t'e be'a/ior being predi)ted 2Mee'. H Rosen$ *+<<C a.so see =reene$ 9,,,$ pp. :?<1:??3. As )an be seen from #ab.e *$ ('en per)entage )orre)t$ positi/e predi)ti/e po(er$ and negati/e predi)ti/e po(er are used to des)ribe /a.idity$ a))ura)y /aries (it' t'e base rate. For examp.e$ per)entage )orre)t is ;9< X :<, di/ided by *,,, Q **.>E ('en t'e base rate is <,P$ and *D ;1 ?B? di/ided by *,,, Q D,.:P ('en t'e base rate is 9P. "n )ontrast$ ('en sensiti/ity and spe)ifi)ity are used to des)ribe /a.idity$ a))ura)y does not /ary (it' t'e base rate. %ut anot'er (ay$ ('en per)entage )orre)t$ positi/e predi)ti/e po(er$ and negati/e predi)ti/e po(er are used to des)ribe a))ura)y$ t'e same test (i.. be des)ribed as 'a/ing /arying .e/e.s of a))ura)y depending on t'e base rates in different samp.es. "n genera.$ positi/e predi)ti/e po(er tends to de)rease ('en base rates de)rease$ ('ereas negati/e predi)ti/e po(er tends to in)rease ('en base rates de)rease. #'us$ statisti)a..y rare e/ents 2e.g.$ sui)ide3 are diffi)u.t to predi)t$ ('ereas )ommon e/ents 2e.g.$ no sui)ide3 are re.ati/e.y easy to predi)t. W'en reading about positi/e findings for a test s)ore$ psy)'o.ogists s'ou.d be a(are t'at t'e

s)ore may not (or- (e.. in t'eir (or- setting if t'e base rate in t'eir (or- setting differs (ide.y from t'e base rate in t'e study. "f t'e base rate for a disorder is .< in a study but .,* in a ).ini)$ one )an expe)t resu.ts for positi/e predi)ti/e po(er to be mu)' .ess fa/orab.e in t'e ).ini). Ne/ert'e.ess$ a .arge body of psy)'o.ogi)a. resear)' indi)ates t'at psy)'o.ogists tend to 2a3 neg.e)t or great.y underuse base rates ('en ma-ing 6udgments and predi)tions and 2b3 fo)us too 'ea/i.y on ('et'er a ).ient fa..s abo/e or be.o( a testGs )utoff s)ore 2Finn H @amp'uis$ *++<3. As a )onse7uen)e$ ).ini)iansG 6udgments )an sometimes be gross.y ina))urate ('en t'e base rates of t'e p'enomenon in 7uestion are extreme 2e.g.$ /ery .o(3. igna. dete)tion t'eory 2 8#3 often pro/ides t'e most usefu. information regarding t'e /a.idity of an assessment instrument. 8# is a statisti)a. approa)' t'at is used ('en t'e tas- is to dete)t a signa.$ su)' as t'e presen)e of ma6or depression in a ).ient. By using 8#$ (e )an des)ribe t'e /a.idity of an assessment instrument a)ross a.. base rates and a)ross a.. )utoff

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 173 s)ores 2t'e signa. is said to be present ('en a ).ientGs s)ore ex)eeds t'e )utoff s)ore3. 8ifferent ).ini)ians may set different )utoff s)ores for t'e same testC it is important t'at our estimate of t'e /a.idity of a test not be inf.uen)ed by t'e p.a)ement of t'e )utoff s)ore. As obser/ed by M)Fa.. and #reat 2*+++35 0#'ere is no .onger any ex)use for )ontinuing to )ondu)t business as usua.$ no( t'at 8#1based indi)es represent a ).ear and signifi)ant ad/an)e o/er traditiona. a))ura)y indi)es su)' as sensiti/ity$ spe)ifi)ity$ and predi)ti/e po(er0 2p. 99D3. A.t'oug' su)' indi)es as sensiti/ity$ spe)ifi)ity$ and predi)ti/e po(er are informati/e$ (e agree (it' M)Fa.. and #reat t'at in many )ases t'e use of 8# is more appropriate and )ompre'ensi/e. !t'er important psy)'ometri) )on)epts are norms$ in)rementa. /a.idity$ and treatment uti.ity. -orms are s)ores t'at pro/ide a frame of referen)e for interpreting a ).ientGs resu.ts. For t'e assessment of psy)'opat'o.ogy$ normati/e data )an be )o..e)ted by administering a test to a representati/e samp.e of indi/idua.s in t'e )ommunity. "f a ).ientGs responses are simi.ar to t'e normati/e data$ psy)'o.ogists s'ou.d be /ery )autious about inferring t'e presen)e of psy)'opat'o.ogy. 0ncremental validity des)ribes t'e extent to ('i)' an instrument )ontributes information abo/e and beyond a.ready a/ai.ab.e information 2e.g.$ ot'er measures3. For examp.e$ t'e use of a psy)'o.ogi)a. test may a..o( ).ini)ians to ma-e 6udgments at a .e/e. better t'an )'an)e$ but 6udgments made using inter/ie( and test information may not be more a))urate t'an 6udgments based on inter/ie( information on.y. !ne ma6or )riti)ism of t'e Rors)'a)' "n-b.ot #est 'as been t'e pau)ity of e/iden)e for its in)rementa. /a.idity beyond more easi.y administered instruments$ su)' as 7uestionnaires 2Li.ienfe.d et a..$ 9,,,3. Treatment utility des)ribes t'e extent to ('i)' an assessment instrument )ontributes to en'an)ed treatment out)ome. An assessment instrument )ou.d 'a/e good /a.idity and good in)rementa. /a.idity$ yet not .ead to impro/ed treatment out)ome. urprising.y$ fe( resear)'ers 'a/e examined t'e treatment uti.ity of assessment instruments 2&ar-ness H Li.ienfe.d$ *++D3. ASSESSMENT INSTRUMENTS Inter,ie2s Unstru)tured inter/ie(s are used predominant.y in ).ini)a. pra)ti)e$ ('ereas stru)tured and semistru)tured inter/ie(s are used predominant.y in resear)'. !ne ex)eption is t'at stru)tured and semistru)tured inter/ie(s are used for ).ini)a. )are in a gro(ing number of uni/ersity1based ).ini)s. W'en )ondu)ting an unstructured interview# a psy)'o.ogist is responsib.e for de)iding ('at 7uestions to as-. "n )ontrast$ ('en )ondu)ting a structured interview# 7uestions are standardi4ed. As one mig't surmise$ semistructured interviews represent a ba.an)e bet(een stru)tured and unstru)tured inter/ie(s$ pro/iding guidan)e for inter/ie(ers but affording t'em some f.exibi.ity. (eliability. "nterrater re.iabi.ity 'as genera..y been good ('en ).ini)ians )ondu)t unstru)tured inter/ie(s as .ong as t'ey attend to diagnosti) )riteria 2=arb$ *++B$ pp. ;*E;93. For examp.e$ a))eptab.e .e/e.s of interrater re.iabi.ity (ere obtained for many$ but not a..$ diagnosti) )ategories in t'e 8 M1""" fie.d tria.s and in t'e fie.d tria.s for t'e tent' re/ision of t'e 0nterna3 tional 1lassification of Diseases 2"C81*,C Ameri)an %sy)'iatri) Asso)iation$ *+B,$ pp. ;D,;D*C artorius et a..$ *++:3. &o(e/er$ ).ini)ians ('o parti)ipated in t'e 8 M1""" and "C81*, fie.d tria.s (ere fami.iar (it'$ and presumab.y ad'ered to$ t'e diagnosti) )riteria. !t'er studies indi)ate t'at many menta. 'ea.t' professiona.s do not attend to )riteria ('en ma-ing diagnoses$ but instead ma-e diagnoses by )omparing patients (it' t'eir )on)ept of t'e typi)a. person (it' a gi/en menta. disorder 2e.g.$ B.as'fie.d H &er-o/$ *++?C =arb$ *++?C Morey H !)'oa$ *+B+3. W'en psy)'o.ogists do not ad'ere to diagnosti) )riteria$ interrater re.iabi.ity is often poor.

174 GAR15 LILIENFELD5 FOWLER #'e use of semistru)tured and stru)tured inter/ie(s tends to .ead to good 2a3 ad'eren)e to diagnosti) )riteria and 2b3 interrater re.iabi.ity 2Antony H Bar.o($ 9,,9C Rogers$ *++<3. For examp.e$ t'e A8" 1"> 2Bro(n et a..$ *++;3 re7uires inter/ie(ers to in7uire about t'e 8 M1"> )riteria for anxiety disorders. Fa/orab.e re.iabi.ity resu.ts 'a/e been found for t'is instrument5 -appa /a.ues 'a/e ranged from .?D to .B? for diagnoses of t'e 8 M1"> anxiety disorders 2Bro(n$ 8i Nardo$ Le'man$ H Campbe..$ 9,,*3. Falidity. ome psy)'o.ogists 'a/e argued t'at diagnoses s'ou.d not be made using t'e 8 M )riteria. For examp.e$ as a.ready noted$ Weiner 29,,,3 argued t'at t'e 8 M )riteria are 7uestionab.e$ in part be)ause t'ey are in)onsistent a)ross editions of t'e manua.. &o(e/er$ /irtua..y a.. menta. disorders are open )on)epts. As noted by Mee'. 2*+B?3$ open concepts are mar-ed by 2a3 intrinsi)a..y fu44y boundaries$ 2b3 an indi)ator .ist t'at is potentia..y infinite$ and 2)3 an un).ear inner nature. !ne )an expe)t t'e (or-ing definition of a menta. disorder to )'ange as more is .earned about t'at disorder. For examp.e$ (e may e/entua..y .earn t'at )ertain indi/idua.s ('o meet t'e 8 M1"> )riteria for s)'i4op'renia a)tua..y 'a/e disorders t'at 'a/e not yet been identified. ti..$ t'e )onstru)t of s)'i4op'renia )an be usefu. e/en t'oug' (e are a(are t'at t'e meaning of t'e term is some('at impre)ise and (i.. )'ange as more resear)' is )ondu)ted. 8 M diagnoses )an be /a.id and usefu. e/en ('en (e possess an in)omp.ete understanding of t'eir nature$ etio.ogy$ )ourse$ and treatment. As a.ready noted$ stru)tured and semistru)tured inter/ie(s are used routine.y in resear)' studies. W'en important dis)o/eries are made about t'e nature$ etio.ogy$ )ourse$ andLor treatment of a disorder$ t'ey support t'e /a.idity of t'e instruments used in t'e studies. For examp.e$ if a stru)tured inter/ie( is used to se.e)t parti)ipants for a study on treatment out)ome and t'e treatment inter/ention is found to be effe)ti/e$ one )an infer t'at a ).ient ('o obtains a spe)ifi) diagnosis on t'e stru)tured inter/ie( is .i-e.y to respond to t'e treatment. #'us$ t'e bu.- of t'e e/iden)e on /a.idity t'at supports stru)tured and semistru)tured inter/ie(s deri/es from studies on psy)'opat'o.ogy and treatment out)ome. imi.ar.y$ e/iden)e t'at supports t'e /a.idity of t'e 8 M )riteria supports t'e /a.idity of assessment instruments t'at 'e.p to determine if a parti)ipant satisfies t'ose )riteria. Be)ause t'ere is no 0go.d standard0 for e/a.uating t'e /a.idity of stru)tured inter/ie(s 2Faraone H #suang$ *++;3 or ot'er assessment measures in psy)'opat'o.ogy resear)'$ /a.idity is estab.is'ed by e/a.uating 0t'e degree to ('i)' e/iden)e and t'eory support t'e interpretations of test s)ores0 2AERA et a..$ *+++$ p. +3. #'ere are se/era. reasons to be.ie/e t'at stru)tured inter/ie(s are more /a.id t'an unstru)tured inter/ie(s$ at .east ('en ).ini)ians )ondu)ting unstru)tured inter/ie(s do not ad'ere to diagnosti) )riteria. First$ interrater re.iabi.ity tends to be better for stru)tured and semistru)tured inter/ie(s$ so a.. t'ings being e7ua. t'ey are more .i-e.y to be /a.id. e)ond$ many stru)tured inter/ie(s are designed to in7uire )ompre'ensi/e.y about t'e 8 M )riteria. #o t'e extent t'at t'e 8 M )riteria 'a/e been /a.idated$ t'e /a.idity of t'ese stru)tured and semistru)tured inter/ie(s (i.. be supported. #'ird$ ('en inter/ie(s and se.f1report instruments are used to diagnose persona.ity disorders$ ).ini)ians using unstru)tured inter/ie(s typi)a..y s'o( t'e .o(est agreement (it' ot'er assessment instruments. "n 'is re/ie( of t'e .iterature$ Widiger 29,,93 noted t'at 0t'e (orst median )on/ergent /a.idity )oeffi)ient (as obtained in t'e on.y study to 'a/e used unstru)tured inter/ie(s by pra)ti)ing ).ini)ians0 2p. ;?:3. Additiona. e/iden)e raises 7uestions about t'e /a.idity of diagnoses made by many pra)ti)ing ).ini)ians. Agreement bet(een stru)tured inter/ie( diagnoses and diagnoses made in ).ini)a.

pra)ti)e is genera..y poor 2e.g.$ Bro)-ington$ @ende..$ H Leff$ *+DBC Mo.inari$ Ames$ H Essa$ *++;C teiner$ #ebes$ .edge$ H Wa.-er$ *++<3. For examp.e$ in one study 2 teiner et a..$ *++<3$ ).ini)a. diagnoses made for *,, patients (ere )ompared (it' diagnoses made

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 176 by resear)' in/estigators using a stru)tured inter/ie(. An o/era.. (eig'ted -appa )oeffi)ient indi)ated t'at agreement bet(een t'e t(o inter/ie( met'ods (as poor 2-appa Q .9<3. >a.ues for -appa are typi)a..y 'ig'er ('en one stru)tured inter/ie( is )ompared (it' anot'er$ a.t'oug' to a surprising degree t'is issue 'as not been studied for some (ide.y used inter/ie(s 2Rogers$ *++<3. #'us$ based on t'e a/ai.ab.e e/iden)e$ one )annot argue t'at it ma-es .itt.e differen)e ('et'er one )ondu)ts an unstru)tured or stru)tured inter/ie(. A.t'oug' stru)tured inter/ie(s genera..y appear to be more /a.id t'an unstru)tured inter/ie(s$ t'eir .imitations need to be re)ogni4ed. Be)ause t'ese .imitations are s'ared (it' unstru)tured inter/ie(s$ t'ey do not indi)ate t'at unstru)tured inter/ie(s possess ad/antages o/er stru)tured inter/ie(s. First$ it is re.ati/e.y easy for respondents to )ons)ious.y underreport or o/erreport psy)'opat'o.ogy on stru)tured inter/ie(s 2A.terman et a..$ *++?3. e)ond$ be)ause memory is fa..ib.e$ reports in inter/ie(s are often ina))urate or in)omp.ete$ e/en ('en ).ients are not intentiona..y trying to appear 'ea.t'ier or si)-er t'an t'ey rea..y are 2&enry$ Moffitt$ Caspi$ Lang.ey$ H i./a$ *++;3. #'ird$ ('en ).ini)ians are instru)ted to ma-e use of medi)a. re)ords and ot'er information in addition to stru)tured inter/ie(s$ )onsiderab.e ).ini)a. 6udgment is re7uired be)ause information from different sour)es may )onf.i)t. #'is re7uirement is a potentia. .imitation be)ause ).ini)a. 6udgment is fa..ib.e. Fina..y$ an important met'odo.ogi)a. ad/an)e in e/a.uating t'e /a.idity of inter/ie(s is t'e LEA8 standard. LEA8 is an a)ronym for longitudinal, e'pert, and all data. W'en using t'e LEA8 standard 2 pit4er$ *+B:3$ diagnoses made by using inter/ie(s are )ompared (it' diagnoses made by )o..e)ting .ongitudina. data. Using t'is approa)'$ ).ients are fo..o(ed o/er time to pro/ide .ongitudina. data for ma-ing diagnoses$ and diagnoses are made by expert ).ini)ians using a.. re.e/ant data. A.t'oug' t'e LEA8 standard )an 'e.p us .earn about t'e /a.idity of diagnoses$ it 'as rare.y been used. Using t'is approa)'$ one )an more a))urate.y e/a.uate t'e /a.idity of unstru)tured$ stru)tured$ and semistru)tured inter/ie(s. 1rie6 Se%60Rated and C%ini.ian0Rated Meas$res Brief se.f1rated and ).ini)ian1rated measures 'a/e been )onstru)ted to pro/ide information ne)essary to de.i/er standardi4ed$ e/iden)e1based inter/entions. For examp.e$ t'e Be)- 8e1 pression "n/entory1""$ t'e Be)- Anxiety )a.e$ and ot'er s)a.es are fre7uent.y used to assess depression and anxiety 2Be)- H teer$ *++,C Be)-$ teer$ H Bro(n$ *++?3. As anot'er examp.e$ psy)'o.ogists ('o use )ogniti/e be'a/iora. te)'ni7ues to treat pani) disorder fre7uent.y use se.f1 rated and ).ini)ian1rated measures to des)ribe 2a3 t'e se/erity and fre7uen)y of pani)1re.ated symptoms$ 2b3 )ognitions or be.iefs t'at are fre7uent.y asso)iated (it' pani) disorder$ 2)3 ).ientsG per)eptions of t'eir )ontro. o/er t'reatening interna. situations$ and 2d3 pani)1re.ated a/oidan)e be'a/iors 2e.g.$ Ba-er$ %atterson$ H Bar.o($ 9,,93. Be)ause psy)'o.ogists ('o use )ogniti/e be'a/iora. te)'ni7ues are not usua..y )on)erned (it' measuring broad areas of psy)'opat'o.ogy and persona.ity$ brief se.f1rated and ).ini)ian1rated measures are typi)a..y best suited for t'eir needs. #'e re.iabi.ity and /a.idity of many of t'ese measures appears to be ade7uate. For examp.e$ t'e %ani) 8isorder e/erity )a.e 2%8 C 'ear et a..$ *++D3 is a se/en1item s)a.e t'at )an be )omp.eted by eit'er ).ients or ).ini)ians to des)ribe -ey features of pani) disorder (it' agorap'obia. W'en )omp.eted by a ).ini)ian$ t'e ratings are based on information t'at 'as been gat'ered in inter/ie( and t'erapy sessions. Ratings are made for fre7uen)y of pani)$ anxiety about future pani) atta)-s$ magnitude of distress during pani)$ interferen)e in so)ia. fun)tioning$

interferen)e in (or- fun)tioning$ and a/oidan)e be'a/iors. #'e %8 possesses ex)e..ent interrater re.iabi.ity 2-appa Q .BDC 'ear et a..$ *++D3. "n addition$ %8 ratings are )orre.ated signifi)ant.y (it' ot'er measures of features of pani) disorder. For examp.e$ 'ear

178 GAR15 LILLENFELD5 FOWLER et a.. 2*++D3 obtained a )orre.ation of r H .>> for t'e re.ation bet(een tota. s)ores on t'e %8 and se/erity ratings for pani) disorder on t'e A8" 1"> E7ua..y important is e/iden)e re.ated to t'e )ontent of t'e s)a.e items5 #'e %8 (as designed to assess prob.ems t'at are important for treatment p.anning. "n fa)t$ a reason t'at brief se.f1rated and ).ini)ian1rated measures are popu.ar is t'at t'ey e/a.uate dimensions be.ie/ed to be important for treatment p.anning. #'at is$ t'ey are designed to 2a3 e/a.uate prob.ems t'at need to be addressed in treatment and 2b3 pro/ide information t'at is re7uired to imp.ement empiri)a..y1based treatment inter/entions. Fina..y$ t'e %8 )an be used to tra)- a ).ientGs progress. #'is use bears important imp.i)ations for treatment use. For examp.e$ if t'e measure is administered during t'e )ourse of treatment and indi)ates t'at a ).ient is not impro/ing$ one s'ou.d )onsider trying a different inter/ention. "n one study 2 'ear et a..$ *++D3$ ).ients (ere ).assified as treatment responders and nonresponders on t'e basis of ratings made by independent e/a.uators. A different group of e/a.uators made %8 ratings for a.. ).ients before and after treatment. "n )ontrast to nonresponders$ responders s'o(ed statisti)a..y signifi)ant impro/ement on t'e %8 . "n genera.$ t'e in)rementa. /a.idity of brief se.f1rated and ).ini)ian1rated measures 'as not been in/estigated. For examp.e$ t'e %8 )an be used to dete)t ).ients ('o are not responding to treatment for pani) disorder$ but a ).ini)ian may a.ready be ab.e to ma-e t'is 6udgment (it'out using t'is measure. Resear)' needs to be )ondu)ted to demonstrate t'e in)rementa. /a.idity of se.f1rated and ).ini)ian1rated measures. A.t'oug' re.iabi.ity and /a.idity appear to be fair for many se.f1rated and ).ini)ian1rated measures$ t'e e/a.uation of t'eir /a.idity 'as been .imited. Rat'er t'an )ompare t'e resu.ts from one of t'ese measures (it' t'e resu.ts of a stru)tured inter/ie( or (it' anot'er se.f1rated or ).ini)ian1rated measure$ it (ou.d be 'e.pfu. to use be'a/iora. assessment met'ods to e/a.uate /a.idity. #'is approa)' 'as rare.y been used$ but t'e resu.ts from one study are pro/o)ati/e. W'en be'a/iora. assessment met'ods (ere used to e/a.uate t'e /a.idity of ).ientsG statements$ ).ients (ere found to o/erestimate t'e fre7uen)y and intensity of t'eir pani) atta)-s on a stru)tured inter/ie( and on a brief se.f1rated test 2Margraf$ #ay.or$ E'.ers$ Rot'$ H Agras$ *+BD3. 1e/a,i#ra% Assess(ent Met/#ds and Psy./#*/ysi#%#&i.a% Assess(ent Be'a/iora. assessment met'ods and psy)'op'ysio.ogi)a. assessment )an pro/ide /a.uab.e information. For examp.e$ by using diary measures$ one )an as- a ).ient to re)ord and rate t'e fre7uen)y and intensity of pani) atta)-s s'ort.y after symptoms o))ur. !r one )an monitor a ).ientGs eating or smo-ing 'abits. By ma-ing ratings s'ort.y after symptoms or be'a/iors o))ur$ t'e resu.ts are more .i-e.y to be a))urate t'an ('en based on retrospe)ti/e reports. #'e in)reased a))essibi.ity of pa.m1si4ed )omputers may e/entua..y render it easier to )o..e)t and ana.y4e se.f1 monitoring data 2data des)ribing ).ientsG ongoing be'a/ior re)orded by t'e ).ients t'emse./es3. Be'a/iora. assessment tests and ot'er be'a/iora. obser/ation te)'ni7ues )an a.so pro/ide /a.uab.e information. Be'a/iora. assessment tests 2a.so -no(n as be'a/iora. approa)' tests and be'a/iora. a/oidan)e tests3 in/o./e as-ing ).ients to enter situations t'at typi)a..y ma-e t'em anxious$ t'at t'ey a/oid$ or bot'. For examp.e$ a ).ient (it' a p'obia )an be instru)ted to approa)' a feared ob6e)t 2e.g.$ a spider3 and a ).ient (it' an obsessi/e1)ompu.si/e disorder )an be instru)ted to s(it)' off an e.e)tri)a. app.ian)e and .ea/e t'e room (it'out )'e)-ing it. 8uring and after be'a/iora. assessment tests$ ).ients rate t'eir .e/e. of anxiety. !t'er te)'ni7ues in).ude obser/ing ).ients in ro.e1p.ay situations and in natura. settings 2(it'out t'eir being instru)ted to )onfront feared situations3. For examp.e$ obser/ations )an be made of )'i.dren in ).assrooms or

of patients on psy)'iatri) units.

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 180 %sy)'op'ysio.ogi)a. te)'ni7ues )an a.so pro/ide /a.uab.e information. For examp.e$ a po.ysomnograp'i) e/a.uation$ ('i)' is )ondu)ted in a s.eep .ab$ )an pro/ide /a.uab.e in1 formation about 'o( (e.. a ).ient is s.eeping 2 a/ard H Morin$ 9,,93. imi.ar.y$ measures of psy)'op'ysio.ogi)a. arousa. )an pro/ide important information in t'e assessment of posttrau1 mati) stress disorder$ espe)ia..y (it' respe)t to treatment pro)ess and out)ome 2Lit4$ Mi..er$ Ruef$ H M)#eague$ 9,,93. !ne team of in/estigators found t'at by p.aying a tape of )ombat sounds and measuring parti)ipantsG 'eart rates$ systo.i) b.ood pressure$ and mus).e tension (it' a fore'ead e.e)tromyogram$ )ombat /eterans (it' posttraumati) stress disorder )ou.d be dis)riminated from ot'er /eterans (it' +<.<P a))ura)y 2B.an)'ard$ @o.b$ %a..meyer$ H =erardi$ *+B93. Ne/ert'e.ess$ it (i.. be important to )ross1/a.idate t'ese findings in an independent samp.e. Be)ause t'e psy)'op'ysio.ogi)a. assessment of ot'er disorders 'as been )onfined .arge.y to t'e .aboratory$ t'e extent to ('i)' t'ese findings genera.i4e to natura.isti) settings remains un).ear. G%#ba% Meas$res #6 Pers#na%ity and Psy./#*at/#%#&y %ro6e)ti/e te)'ni7ues and se.f1report persona.ity in/entories are designed to measure broad aspe)ts of persona.ity and psy)'opat'o.ogy. %ro6e)ti/e te)'ni7ues in).ude t'e Rors)'a)'$ #'e1 mati) Apper)eption #est 2#A#3$ and 'uman figure dra(ings. e.f1report persona.ity in/entories in).ude t'e Minnesota Mu.tip'asi) %ersona.ity "n/entory19 2MM%"19C But)'er$ 8a'.strom$ =ra'am$ #e..egen$ H @aemmer$ *+B+3$ t'e %ersona.ity Assessment "n/entory 2%A"C Morey$ *++*3$ and t'e Mi..on C.ini)a. Mu.tiaxia. "n/entory1".. 2MCM"1"""C Mi..on$ *++;3. %ro6e)ti/e te)'ni7ues are re.ati/e.y unstru)tured5 timu.i are fre7uent.y ambiguous 2e.g.$ in-b.ots$ as in t'e )ase of t'e Rors)'a)'3 and response formats are typi)a..y open1ended 2e.g.$ te..ing a story in response to a dra(ing of indi/idua.s intera)ting$ as in t'e )ase of t'e #A#3. "n )ontrast$ se.f1 report persona.ity in/entories are re.ati/e.y stru)tured5 timu.i are fair.y ).ear1)ut 2e.g.$ statements (it' ('i)' a ).ient agrees or disagrees3 and response formats are )onstrained 2e.g.$ on t'e MM%"19$ one )an ma-e a response of 0true0 or 0fa.se03. "n genera.$ /a.idity findings are more en)ouraging for se.f1report persona.ity in/entories t'an for pro6e)ti/e te)'ni7ues$ a.t'oug' ex)eptions 'a/e been found 2see Li.ienfe.d et a..$ 9,,,C Wood$ Ne4(ors-i$ Li.ienfe.d$ H =arb$ 9,,:3. +ro4ective TechniCues A )ommon argument for using pro6e)ti/e te)'ni7ues is t'at t'ey )an )ir)um/ent a ).ientGs purported defenses. A))ording to t'is argument$ t'ey )an be used to e/a.uate )ons)ious and un)ons)ious pro)esses e/en ('en ).ients try to appear 'ea.t'ier or si)-er t'an t'ey rea..y are. For examp.e$ some psy)'o.ogists be.ie/e t'at ('en ).ients .oo- at Rors)'a)' in-b.ots and report ('at t'ey see$ t'ey )annot in/ent fa-ed responses be)ause t'ey do not -no( t'e true meaning of t'eir Rors)'a)' responses. &o(e/er$ resear)' demonstrates t'at pro6e)ti/e te)'ni7ues are /u.nerab.e to fa-ing. For examp.e$ in one study 2A.bert$ Fox$ H @a'n$ *+B,3$ norma. parti)ipants (ere instru)ted to fa-e paranoid s)'i4op'renia. %resumed experts in t'e use of t'e Rors)'a)' 2Fe..o(s of t'e o)iety for %ersona.ity Assessment3 (ere unab.e to dete)t fa-ing of psy)'osis. 8iagnoses of ma.ingering (ere made for ;P of t'e psy)'oti) parti)ipants$ +P of t'e informed fa-ers 2t'ey (ere informed about t'e nature of disturbed t'oug't pro)esses and paranoid s)'i4op'renia$ but not about t'e Rors)'a)'3$ DP of uninformed fa-ers$ and 9P of norma. parti)ipants ('o (ere not instru)ted to fa-e. 8iagnoses of psy)'osis (ere made for ;BP of t'e psy)'oti) parti)ipants$ D9P of t'e informed fa-ers$ ;?P of t'e uninformed fa-ers$ and 9;P of

t'e norma. parti)ipants ('o (ere not instru)ted to fa-e.

182 =ARB$ L"L"ENFEL8$ F!WLER A prob.em (it' many pro6e)ti/e te)'ni7ues is t'at t'ey are diffi)u.t to s)ore.9 For examp.e$ t'e Compre'ensi/e ystem 2C C Exner$ *++:3 is t'e most popu.ar system for s)oring t'e Rors)'a)'. Exner 2*++:$ p. 9:3$ t'e de/e.oper of t'e C $ ).aimed t'at interrater re.iabi.ity is better t'an .B< for a.. C s)ores. &o(e/er$ resu.ts from re)ent studies indi)ate t'at t'is resu.t is true for on.y about 'a.f of t'e C s)ores 2A)-.in$ M)8o(e..$ >ers)'e..$ H C'an$ 9,,,C Na-ata$ *+++C 'affer$ Erdberg$ H &aroian$ *+++C but see Meyer et a..$ 9,,93. Furt'ermore$ in one study 2=uarna))ia$ 8i..$ abatino$ H out'(i)-$ 9,,*3$ a/erage s)oring a))ura)y (as on.y about ?<P. "n )omparison$ s)oring is typi)a..y ex)e..ent for ot'er types of tests 2e.g.$ inte..igen)e tests and persona.ity in/entories3. For examp.e$ interrater re.iabi.ity )oeffi)ients for t'e s)oring of t'e We)'s.er Adu.t "nte..igen)e )a.e$ #'ird Edition 2WA" 1"""3 'a/e a median /a.ue of .+< and a minimum /a.ue of .+,. Re.iabi.ity for s)oring t'e MM%"E9 is oftentimes e/en better5 "t is near.y perfe)t ('en responses are s)ored by a )omputer. Anot'er prob.em (it' pro6e)ti/e te)'ni7ues )on)erns t'e use of norms. %sy)'o.ogists rare.y use normati/e data ('en interpreting #A# proto)o.s and 'uman figure dra(ings$ e/en t'oug' t'e a/ai.abi.ity of normati/e data )an 'e.p to pre/ent t'e o/erper)eption of psy)'opat'o.ogy. Furt'ermore$ serious prob.ems 'a/e surfa)ed regarding t'e normati/e data for t'e Rors)'a)'. Exner 29,,*b3 re)ent.y reported t'at 'is *++: C adu.t normati/e samp.e )ontained an error of enormous magnitude5 #'e samp.e (as des)ribed as being )omposed of D,, distin)t proto)o.s but it a)tua..y )ontained ;D+ distin)t proto)o.s (it' 99* proto)o.s )ounted t(i)e. ubse7uent.y$ t'e C adu.t normati/e samp.e 'as been re/ised 2Exner$ 9,,*b3$ but e/en t'is samp.e 'as been reported to )ontain errors 2Meyer H Ri)'ardson$ 9,,*3. Moreo/er$ Exner 2persona. )ommuni)ation$ 8e)ember B$ 9,,,3 'as refused to ma-e t'e )urrent C adu.t normati/e samp.e a/ai.ab.e for examination$ e/en t'oug' J. M. Wood$ a prominent )riti) of t'e C $ offered to pay for any expenses t'at t'is (ou.d in)ur 2J. M. Wood$ persona. )ommuni)ation$ August <$ 9,,,3.: Fina..y$ and most important$ t'e use of t'e C norms is .i-e.y to .ead to t'e o/erper)eption of psy)'opat'o.ogy 2&ame.$ 'affer$ H Erdberg$ 9,,,C 'affer et a.$ *+++C Wood$ Ne4(ors-i$ =arb$ H Li.ienfe.d$ 9,,*bC a.so see Arono($ 9,,*C Exner$ 9,,*aC &uns.ey H 8i =iu.io$ 9,,*C Meyer$ 9,,*C Widiger$ 9,,*C Wood$ Ne4(ors-i$ =arb$ H Li.ienfe.d$ 9,,*a3. For examp.e$ in one study 2&ame. et a..$ 9,,,3$ t'e Rors)'a)' (as administered to a group of *,, re.ati/e.y norma. s)'oo. )'i.dren. C'i.dren (ere ex).uded from t'e study if t'ey 'ad a 'istory of menta. disorder. E/en t'oug' an independent measure 2t'e Conners %arent Rating )a.e1+9C Conners$ *+B+3 re/ea.ed t'at t'e )'i.dren (ere 'ea.t'ier t'an a/erage$ t'e resu.ts for t'e Rors)'a)' indi)ated t'at t'e typi)a. )'i.d in t'e samp.e suffered from 0a distortion of rea.ity and fau.ty reasoning approa)'ing psy)'osis0 and 0an affe)ti/e disorder t'at in).udes many of t'e mar-ers found in ).ini)a. depression0 2p. 9+*3. #'e e/iden)e for t'e )onstru)t /a.idity of most pro6e)ti/e te)'ni7ues is at best mixed. "n se/era. meta1ana.yses$ effe)t si4es for t'e Rors)'a)' 'a/e ranged from r Q .9< to .:<$ indi)ating t'at some positi/e findings 'a/e been reported 2e.g.$ =arb$ F.orio$ H =ro/e$ *++BC &i..er$ Rosent'a.$ Bornstein$ Berry$ H Brune..1Neu.eib$ *+++C Meyer H Ar)'er$ 9,,*C %ar-er$ &anson$ H &uns.ey$ *+BB3. &o(e/er$ positi/e /a.idity findings for t'e Rors)'a)'$ #A#$ and 'uman figure dra(ings 'a/e rare.y been independent.y rep.i)ated 2Li.ienfe.d et a..$ 9,,,3. In 6a.t5 t/e TAT is rare%y s.#red in .%ini.a% *ra.ti.e =see Li%ien6e%d et a%.5 !!!>. : T/ere /as a%s# been a /eated ar&$(ent #,er t/e a..essibi%ity #6 st$dies t/at /a,e been .ited t# s$**#rt t/e CS. Un*$b%is/ed st$dies s*#ns#red by R#rs./a./ W#r+s/#*s are

6reJ$ent%y .ited as e,iden.e s$**#rtin& t/e CS5 b$t atte(*ts t# #btain .#*ies #6 *a*ers des.ribin& t/e st$dies /a,e 6reJ$ent%y been $ns$..ess6$% =NeC2#rs+i H W##d5 3@@"Y W##d5 NeC2#rs+i5 H SteDs+a%5 3@@?a5 3@@?bY b$t a%s# see E-ner5 3@@"5 3@@?>. C#*ies #6 a%% .#rres*#nden.e 2i%% be *r#,ided #n reJ$est.

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 184 #'e fo..o(ing )riteria for e/a.uating )onstru)t /a.idity (ere proposed by Wood$ Ne4(ors-i$ and te6s-a. 2*++?b35 2a3 test s)ores s'ou.d demonstrate a )onsistent re.ation to a parti)u.ar symptom$ trait$ or disorderC 2b3 resu.ts must be obtained in met'odo.ogi)a..y rigorous studiesC and 2)3 resu.ts must be rep.i)ated by independent in/estigators. Fe( s)ores for t'e Rors)'a)'$ #A#$ and 'uman figure dra(ings satisfy t'ese )riteria. For t'e Rors)'a)'$ t'e )riteria 'a/e been satisfied for s)ores intended to dete)t t'oug't disorder and psy)'oti) )onditions mar-ed by t'oug't disorder 2e.g.$ s)'i4op'renia3$ predi)t psy)'ot'erapy out)ome$ and assess be'a/iors re.ated to dependen)y 2e.g.$ A)-.in$ *+++C Bornstein$ *+++C Jorgensen$ Andersen$ H 8am$ 9,,,C Meyer H &and.er$ *++D3. For t'e #A#$ t'e )riteria 'a/e been satisfied for t'e assessment of a)'ie/ement moti/es$ t'e identifi)ation of )'i.d sexua. abuse 'istory$ and t'e dete)tion of border.ine persona.ity disorder 2 pang.er$ *++9C Westen$ Lo'r$ i.-$ =o.d$ H @erber$ *++,C Westen$ Ludo.p'$ B.o)-$ Wixom$ H Wiss$ *++,3. For 'uman figure dra(ings$ t'e )riteria 'a/e been satisfied on.y for distinguis'ing g.oba. psy)'opat'o.ogy from norma.ity 2Nag.ieri H %feiffer$ *++93. "roni)a..y$ o/er 'a.f of t'e indexes t'at 'a/e been empiri)a..y supported are rare.y used by psy)'o.ogists in ).ini)a. pra)ti)e. ome of t'ese indexes are diffi)u.t to s)ore$ ('i.e ot'ers (ere not in)orporated into ExnerGs Compre'ensi/e ystemEt'e Rors)'a)' s)oring system t'at most ).ini)ians use. Most pro6e)ti/e indexes$ in).uding t'ose used (ide.y in ).ini)a. pra)ti)e$ 'a/e re)ei/ed re.ati/e.y .itt.e empiri)a. support. "n )ommenting on t'e C $ Meyer and Ar)'er 29,,*3 offered a re.ated obser/ation5 Cet many variables given fairly substantial interpretive emphasis have received little or no attention Weiner, 2330". These include the Coping -eficit !nde', 9bsessive .tyle !nde', Iypervigilance !nde', active&to&passive movement ratio, -&score,food content, anatomy and J&ray content, !ntel&lectuali<ation !nde', and !solation !nde', p. ;14" Moreo/er$ in a )ompre'ensi/e re/ie( of resear)' on t'e re.ation bet(een Rors)'a)' s)ores and psy)'iatri) diagnoses 2Wood$ Li.ienfe.d$ =arb$ Ne4(ors-i$ 9,,,3$ Rors)'a)' s)ores did not s'o( a (e..1demonstrated re.ations'ip to ma6or depressi/e disorder$ posttraumati) stress disorder 2%# 83$ anxiety disorders ot'er t'an %# 8$ disso)iati/e identity disorder$ )ondu)t disorder$ psy)'opat'y$ or persona.ity disorders. 8espite t'ese negati/e findings$ Rors)'a)' resu.ts )ontinue to be used by psy)'o.ogists for t'e diagnosis of t'ese disorders. imi.ar.y$ a.t'oug' Rors)'a)' resu.ts and 'uman figure dra(ings are sometimes used by menta. 'ea.t' professiona.s to 'e.p de)ide ('et'er a )'i.d 'as been sexua..y abused 2!ber.ander$ *++<3$ none of t'ese indexes 'as been )onsistent.y supported 2e.g.$ =arb$ Wood$ H Ne4(ors-i$ 9,,,C #ro(bridge$ *++<3. +ersonality 0nventories Li-e t'e se.f1rated brief tests des)ribed ear.ier 2e.g.$ measures of t'e se/erity of pani) symptoms3$ se.f1report persona.ity in/entories re7uire ).ients to indi)ate ('et'er a statement des)ribes t'em. &o(e/er$ )ontrary to (idespread ).aims$ se.f1report persona.ity in/entories do not re7uire ).ients to be ab.e to a))urate.y des)ribe t'eir symptoms and persona.ity traits. #'e 0dynami)s0 of se.f1report persona.ity in/entories (ere des)ribed by Mee'. 2*+;<35 # self&rating constitutes an intrinsically interesting and significant bit of verbal behavior, the non&test correlates of which must be discovered by empirical

means. $The approach is free% from the restriction that the sub6ect must be able to describe his own behavior accurately, . . . . The selection of items is done on a thoroughly empirical basis using carefully selected criterion groups, p. 21*"

186 GAR15 LILIENFELD5 FOWLER #'us$ ('ereas t'e /a.idity of brief se.f1rated tests rests on t'e )ontent of items$ t'e /a.idity of se.f1report persona.ity in/entories rests on empiri)a. resear)' t'at re.ates test items 2and test s)a.es3 to ).ient )'ara)teristi)s. #'is approa)' 'as met (it' some su))ess. For examp.e$ resu.ts from a meta1ana.ysis indi)ate t'at t'e MM%" )an be usefu. for dete)ting o/erreporting and underreporting of psy)'opat'o.ogy 2Berry$ Baer$ H &arris$ *++*3. )ientifi) support for persona.ity in/entories 'as been mixed. #'e primary s)a.es of some tests 2e.g.$ t'e MM%"19$ t'e %ersona.ity Assessment "n/entory3 'a/e genera..y been supported$ ('ereas t'e /a.idity e/iden)e for t'e s)a.es of ot'er (ide.y used tests 2e.g.$ t'e Mi..Mn C.ini)a. Mu.tiaxia. "n/entory1".. or MCM"1"""3 is (ea-er and .ess )onsistent. For examp.e$ Rogers$ a.e-in$ and e(e.. 2*+++3 re/ie(ed t'e resear)' on t'e MCM"1""" and )on).uded t'at it s'ou.d not be used in forensi) settings 2a.so see 8yer H M)Cann$ 9,,,C Rogers$ a.e-in$ H e(e..$ 9,,,3. E/en for t'e MM%"19$ 'a.f of t'e supp.ementary s)a.es 'a/e not been )onsistent.y supported 2e.g.$ =reene$ 9,,,$ pp. 9*B19?+3. 8espite t'ese negati/e findings$ positi/e resu.ts 'a/e been )onsistent.y rep.i)ated by independent in/estigators for a .arge number of MM%"19 s)ores. For examp.e$ resear)' 'as demonstrated t'at )a.e ; 2psy)'opat'i) de/iate3 is )orre.ated positi/e.y (it' )rimina. be'a/iors and re)idi/ism ris- 2see =reene$ 9,,,$ p. *;B3$ ('ereas )a.e + 2'ypomania3 is )orre.ated (it' su)' )'ara)teristi)s as impu.si/eness$ extra/ersion$ and superfi)ia.ity in so)ia. re.ations'ips 2e.g.$ =ra'am$ Ben1%orat'$ H M)Nu.ty$ *++D3. "n ).ini)a. 6udgment studies$ 6udgments 'a/e been more /a.id ('en psy)'o.ogists 'a/e been gi/en resu.ts from persona.ity in/entories t'an ('en gi/en resu.ts from pro6e)ti/e te)'ni7ues 2e.g.$ =arb$ *+B+$*++B$9,,:3. "n fa)t$ in se/era. studies$ /a.idity a)tua..y de)reased$ at .east s.ig't.y$ ('en Rors)'a)' resu.ts (ere made a/ai.ab.e in addition to brief biograp'i)a. andLor 7uestionnaire resu.ts 2e.g.$ W'ite'ead$ *+B<3. "n )ontrast to psy)'o.ogists ('o use pro6e)ti/e te)'ni7ues$ psy)'o.ogists using se.f1report persona.ity in/entories a.most a.(ays use norms. #'ere is no e/iden)e t'at t'e norms of ma6or se.f1report persona.ity in/entories$ su)' as t'e MM%"19$ are unrepresentati/e of Ameri)an adu.ts or ado.es)ents in t'e )ommunity. Nor is t'ere e/iden)e t'at t'ese norms ma-e re.ati/e.y norma. indi/idua.s appear pat'o.ogi)a.. CLINICAL 7UDGMENT AND DECISION0MA)ING E-*erien.e5 Trainin&5 and C%ini.a% 7$d&(ent W'en )onfronted (it' negati/e e/iden)e regarding t'e /a.idity of spe)ifi) assessment in1 struments$ su)' as pro6e)ti/e te)'ni7ues$ some ).ini)ians retort t'at t'eir extensi/e ).ini)a. experien)e permits t'em to extra)t usefu. inferen)es from t'ese instruments. "n ot'er (ords$ t'e argument goes$ /a.idation studies fai. to )apture t'e ri)' and subt.e information t'at 'ig'.y seasoned pra)titioners )an obtain from )ertain assessment measures. For examp.e$ in response to re/ie( arti).es demonstrating t'at a mere 'andfu. of Rors)'a)' /ariab.es are empiri)a..y sup1 ported 2e.g.$ Li.ienfe.d et a..$ 9,,,$9,,*3$ se/era. pra)titioners on messages to t'e Rors)'a)' 8is)ussion and "nformation =roup re)ent.y maintained t'at t'e negati/e resear)' e/iden)e (as .arge.y irre.e/ant be)ause t'eir numerous years of ).ini)a. experien)e (it' t'e Rors)'a)' endo(ed t'em (it' spe)ia. 6udgmenta. and predi)ti/e po(ers. Ne/ert'e.ess$ t'ese superfi)ia..y p.ausib.e arguments do not (it'stand )arefu. s)rutiny$ be)ause t'e re.ation bet(een ).ini)a. experien)e and 6udgmenta. a))ura)y 'as been (ea- in most studies of persona.ity and psy)'opat'o.ogy assessment 28a(es$ *++;3. For examp.e$ ('en gi/en MM%" 2e.g.$ =ra'am$ *+?D3 or Rors)'a)' 2e.g.$ #urner$ *+??3 proto)o.s$ ).ini)ians did not produ)e

more /a.id ratings of psy)'opat'o.ogy or persona.ity t'an did psy)'o.ogy graduate

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 188 students 2see =arb$ *+B+$ *++B$ for re/ie(s3. Nor is t'ere e/iden)e t'at presumed experts on )ertain persona.ity measures outperform ot'er ).ini)ians. "n one stri-ing examp.e$ Le/enberg 2*+D<3 as-ed ).ini)ians to identify )'i.dren as eit'er norma. or abnorma. on t'e basis of t'eir proto)o.s on t'e @ineti) Fami.y 8ra(ing test$ a )ommon.y used 'uman figure dra(ing measure. W'ereas a group of do)tora.1.e/e. psy)'o.ogists (as )orre)t for D9P of )ases$ t'e aut'or of t(o boo-s on t'e @ineti) Fami.y 8ra(ing test (as )orre)t for on.y ;DP of )ases 2see a.so #urner$ *+??$ for simi.ar findings on t'e Rors)'a)'3. !ne potentia. ex)eption to t'e .iterature on t'e neg.igib.e re.ation bet(een experien)e and a))ura)y deri/es from a study by Brammer 29,,93$ ('o )ompared psy)'o.ogists and psy)'o.ogy students on a tas- in/o./ing an artifi)ia. inte..igen)e program t'at simu.ated a psy)'iatri) inter/ie( (it' a ).ient. #'e number of years of ).ini)ian experien)e (as signifi)ant.y asso)iated 2r Q .::3 (it' t'e number of )orre)t diagnoses made$ as (e.. as (it' t'e number of diagnosti)a..y spe)ifi) 7uestions as-ed r J .<*3. BrammerGs findings raise t'e intriguing possibi.ity t'at experien)e is re.ated to /a.idity on tas-s t'at re7uire ).ini)ians to stru)ture )omp.ex tas-s$ su)' as formu.ating a psy)'iatri) diagnosis by 'oning in on potentia. prob.em areas and t'en as-ing progressi/e.y more spe)ifi) 7uestions 2see a.so C.a/e..e H #urner$ *+B,3. ome ).ini)ians )ou.d )ontend t'at a.t'oug' t'e o/era.. re.ation bet(een experien)e and a))ura)y tends to be (ea-$ many ).ini)ians in rea. (or.d settings -no( ('i)' of t'eir 6udgments are .i-e.y to be a))urate. Ne/ert'e.ess$ for t'e use of pro6e)ti/e te)'ni7ues and some ot'er assessment instruments$ t'e re.ation bet(een t'e /a.idity of ).ini)iansG 6udgments and t'eir )onfiden)e in t'ese 6udgments is genera..y poor. For examp.e$ A.bert et a.. 2*+B,3 found no signifi)ant re.ation bet(een /a.idity and )onfiden)e ('en pra)titioners (ere as-ed to use Rors)'a)' proto)o.s to dete)t ma.ingering. For t'e MM%"$ t'ere is some e/iden)e t'at )on1 fiden)e is positi/e.y re.ated to t'e /a.idity of ).ini)iansG 6udgments$ but on.y ('en t'ese 6udgments are reasonab.y /a.id 2e.g.$ =o.dberg$ *+?<3. #'at is$ ('en psy)'o.ogists use t'e MM%" to assist in ma-ing diagnoses$ t'ey tend to be ab.e to say ('i)' of t'eir diagnosti) 6udgments are most .i-e.y to be )orre)t. "n )ontrast to t'e dispiriting findings )on)erning t'e /a.ue of ).ini)a. experien)e for persona.ity assessment 6udgments$ t'e resear)' .iterature supports t'e /a.ue of training on )ertain assessment instruments. For examp.e$ in se/era. studies psy)'o.ogists using MM%" proto)o.s made more /a.id persona.ity 6udgments t'an did .ay 6udges 2e.g.$ Aronson H A-amatsu$ *+B*C see =arb$ *++B$ for a re/ie(3. Ne/ert'e.ess$ resear)' does not support t'e /a.ue of training in t'e interpretation of pro6e)ti/e proto)o.s. For examp.e$ in one study 2=ado.$ *+?+3$ ).ini)a. psy)'o.ogists and undergraduates (ere e7ua..y a))urate ('en as-ed to ma-e persona.ity ratings of psy)'iatri) patients on t'e basis of Rors)'a)' proto)o.s. imi.ar findings emerged ('en psy)'o.ogists (ere )ompared (it' .ay 6udges in t'eir abi.ity to distinguis' psy)'opat'o.ogy from norma.ity on t'e basis of 'uman figure dra(ings or senten)e )omp.etion tests 2see =arb$ *++B$ for a re/ie(3. W/y C%ini.ians O6ten D# N#t 1ene6it Fr#( E-*erien.e W'y are pra)titioners often unab.e to benefit from ).ini)a. experien)eF A.t'oug' t'e reasons are manifo.d 2see Ar-es$ *+B*C 8a(es$ Faust$ H Mee'.$ *+B+C =arb$ *+B+3$ (e fo)us on fi/e 'ere. #'e first t'ree )on)ern t'e nature of t'e feedba)- a/ai.ab.e to ).ini)ians$ and t'e se)ond t(o )on)ern )ogniti/e pro)esses t'at inf.uen)e t'e se.e)tion and interpretation of t'is feedba)-. -ature o f /eedback. First$ in )ontrast to p'ysi)ians in most domains of organi) medi)ine$

psy)'o.ogists rare.y re)ei/e ).ear1)ut feedba)- )on)erning t'eir 6udgments and predi)tions 2Mee'.$ *+D:3. "nstead$ t'e feedba)- ).ini)ians re)ei/e is often /ague$ ambiguous$ and

190 =ARB$ L"L"ENFEL8$ F!WLER open to mu.tip.e interpretations. For examp.e$ if a ).ini)ian )on).udes t'at an adu.t ).ient (as sexua..y abused in )'i.d'ood on t'e basis of an unstru)tured inter/ie( and Rors)'a)' proto)o.$ t'is 6udgment is diffi)u.t to fa.sify. "f t'e ).ient (ere to deny a past abuse 'istory or express un)ertainty about it$ t'e ).ini)ian )ou.d readi.y maintain t'at t'e abuse (as repressed 2a.t'oug' t'e s)ientifi) e/iden)e for repression is )ontro/ersia.C see &o.mes$ *++,3 or ot'er(ise forgotten. Moreo/er$ ('en ).ini)ians re)ei/e feedba)- regarding t'eir predi)tions 2e.g.$ fore)asts of /io.en)e3$ it is often substantia..y de.ayed$ t'ereby introdu)ing t'e potentia. distorting effe)ts of memory. e)ond$ ).ini)ians typi)a..y 'a/e a))ess to on.y a subset of t'e data needed for a))urate 6udgments$ a 7uandary referred to by =i.o/i)' 2*++*3 as t'e 0missing data0 prob.em. For ex1 amp.e$ ).ini)ians may per)ei/e )ertain psy)'o.ogi)a. )onditions 2e.g.$ ni)otine dependen)e3 to be more )'roni) and umemitting t'an t'ey are 2see )'a)ter$ *+B93 be)ause t'ey are se.e)ti/e.y exposed to indi/idua.s ('o remain in treatment. Co'en and Co'en 2*+B;3 referred to t'is effe)t as t'e 0).ini)ianGs i..usion.0 Moreo/er$ one .i-e.y reason ('y many ).ini)ians 'a/e not re)ogni4ed t'at t'e Rors)'a)' o/erpat'o.ogi4es ).ients is t'at ).ini)ians rare.y administer t'is measure to norma. indi/idua.s 2Wood et a..$ 9,,,3. #'ird$ some feedba)- t'at ).ini)ians re)ei/e from ).ients is mis.eading. For examp.e$ some of t'e persona.ity interpretations made by purported experts in persona.ity assessment sound suspi)ious.y .i-e t'ose of astro.ogers and pa.m readers 2see Wood$ Ne4(ors-i$ Li.ienfe.d$ H =arb$ 9,,:3. Mee'. 2*+<?3 referred to an indi/idua.Gs tenden)y to a))ept 'ig'.y genera.i4ed but nonob/ious persona.ity des)riptions as t'e P. T. ,arnum effect, after t'e )ir)us entrepreneur ('o 7uipped t'at 0" .i-e to gi/e a .itt.e somet'ing to e/erybody0 and 0A su)-er is born e/ery minute.0 Numerous studies demonstrate t'at most indi/idua.s presented (it' Barnum des)riptions 2e.g.$ 0Aou 'a/e a great dea. of unused potentia.$0 0At times you 'a/e diffi)u.ty ma-ing up your mind03 find su)' des)riptions to be 'ig'.y )ompe..ing$ parti)u.ar.y ('en t'ey be.ie/e t'at t'ese des)riptions (ere tai.ored for t'em 2Logue$ 'er$ H Frens)'$ *++9C nyder H Larson$ *+D93. #'e R #. Barnum effe)t demonstrates t'at persona. /a.idation$ t'e informa. met'od of /a.idating test feedba)- by re.ying on respondentsG a))eptan)e of t'is feedba)-$ is a 'ig'.y fa..ib.e barometer of a)tua. /a.idity. "n addition$ be)ause ).ients are often impressed by Barnum feedba)-$ su)' feedba)- )an foo. ).ini)ians into be.ie/ing t'at t'eir interpretations are more /a.id t'an t'ey rea..y are. 1ognitive +rocesses. Fourt'$ a substantia. body of .iterature do)uments t'at indi/idua.s are prone to confirmatory bias, t'e tenden)y to se.e)ti/e.y see- out and re)a.. information )onsistent (it' oneGs 'ypot'eses and to neg.e)t information in)onsistent (it' t'ese 'ypot'eses. e/era. in/estigators 'a/e found t'at ).ini)ians fa.. prey to )onfirmatory bias ('en as-ed to re)a.. information regarding ).ients. For examp.e$ tro'mer$ 'i/y$ and C'iodo 2*++,3 as-ed )ounse.ors to read t'ree /ersions of a )ase 'istory of a ).ient$ one )ontaining an e7ua. number of des)riptors indi)ating good se.f1)ontro. and poor se.f1)ontro.$ one )ontaining more des)riptors indi)ating good )ontro. t'an poor se.f1)ontro.$ and one )ontaining more des)riptors indi)ating poor t'an good se.f1)ontro.. !ne (ee- after reading t'is )ase 'istory$ psy)'ot'erapists (ere as-ed to offer as many fa)tors t'ey )ou.d remember t'at 0(ou.d be 'e.pfu. in determining ('et'er or not It'e ).ientJ .a)-ed se.f1)ontro.0 2p. ;?D3. #'erapists offered more information t'at (ou.d be 'e.pfu. for )onfirming t'an dis)onfirming t'e 'ypot'esis t'at t'e ).ient .a)-ed se.f1 )ontro.$ e/en in t'e )ondition in ('i)' t'e ).ient (as des)ribed as )'ara)teri4ed primari.y by

good se.f1)ontro. des)riptors. "n a re.ated /ein$ t'ere is e/iden)e t'at ).ini)ians are sometimes prone to premature closure in diagnosti) de)ision ma-ing5 t'ey may tend to rea)' )on).usions too 7ui)-.y 2=arb$ *++B3. For examp.e$ =auron and 8i)-inson 2*+?+3 reported t'at psy)'iatrists ('o obser/ed a /ideotaped

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 192 inter/ie( fre7uent.y formed diagnosti) impressions (it'in :, to ?, se)onds. %remature ).osure may bot' ref.e)t and produ)e )onfirmatory bias. "t may ref.e)t )onfirmatory bias be)ause ).ini)ians may rea)' rapid )on).usions by sear)'ing on.y for data t'at )onfirm preexisting 'ypot'eses. "t may produ)e )onfirmatory bias by effe)ti/e.y 'a.ting t'e sear)' for data t'at )ou.d dis)onfirm su)' 'ypot'eses. Fift'$ in/estigators 'a/e s'o(n t'at ).ini)ians$ .i-e a.. indi/idua.s$ are prone to illusory correlation, ('i)' 'as genera..y been defined as t'e per)eption of 2a3 a statisti)a. asso)iation t'at does not a)tua..y exist or 2b3 a stronger statisti)a. asso)iation t'an is a)tua..y present. "..usory )orre.ations are .i-e.y to arise ('en indi/idua.s 'o.d po(erfu. a priori expe)tations regarding t'e )o/ariation bet(een )ertain e/ents or stimu.i. For examp.e$ many indi/idua.s are )on/in)ed t'at a strong )orre.ation exists bet(een t'e fu.. moon and psy)'iatri) 'ospita. admissions$ e/en t'oug' studies 'a/e demonstrated repeated.y t'at no su)' asso)iation exists 2Rotton H @e..y$ *+B<3. "n a ).assi) study of i..usory )orre.ation$ C'apman and C'apman 2*+?D3 examined ('y psy)'o.ogists per)ei/e ).ini)a..y meaningfu. asso)iations bet(een signs 2e.g.$ .arge eyes3 on t'e 8ra(1A1%erson 28A%3 test 2a )ommon.y used 'uman figure dra(ing tas-3 and psy)'iatri) symptoms 2e.g.$ suspi)iousness3 e/en t'oug' resear)' 'as demonstrated t'at t'ese asso)iations do not exist 2@a'i.i$ *+B;3. #'ey presented undergraduate parti)ipants (it' 8A% proto)o.s t'at (ere purported.y produ)ed by psy)'iatri) patients (it' )ertain psy)'iatri) symptoms 2e.g.$ suspi)iousness3. Ea)' dra(ing (as paired random.y (it' t(o of t'ese symptoms$ ('i)' (ere .isted on t'e bottom of ea)' dra(ing. Undergraduates (ere as-ed to inspe)t t'ese dra(ings and estimate t'e extent to ('i)' )ertain 8A% signs )o1o))urred (it' t'ese symptoms. C'apman and C'apman found t'at parti)ipants 0dis)o/ered0 t'at )ertain 8A% signs tended to )onsistent.y )o1 o))ur (it' )ertain psy)'iatri) symptoms$ e/en t'oug' t'e 8A% signs and symptoms 'ad been random.y paired. For examp.e$ parti)ipants per)ei/ed .arge eyes in dra(ings as )o1o))urring (it' suspi)iousness and broad s'ou.ders in dra(ings as )o1o))urring (it' doubts about man.iness. "nteresting.y$ t'ese are t'e same asso)iations t'at tend to be per)ei/ed by ).ini)ians ('o use t'e 8A% 2C'apman H C'apman$ *+?D3. "..usory )orre.ation 'as been demonstrated (it' ot'er assessment instruments$ in).uding t'e Rors)'a)' 2C'apman H C'apman$ *+?+3 and senten)e )omp.etion tests 2 tarr H @at-in$ *+?+3. )ientifi)a..y minded pra)titioners need to be a(are of t'e p'enomenon of i..usory )orre.ation$ ('i)' suggests t'at ).ini)ians )an be )on/in)ed of t'e /a.idity of assessment indi)ators in t'e absen)e of /a.idity. Group $iases in udgment. # .arge number of studies 'a/e examined ra)e$ sex$ and so)ioe)onomi) status 2 E 3 biases in ).ini)a. 6udgment 2=arb$ *++D3. ,ias o))urs ('en t'e /a.idity of a ).ini)a. 6udgment or test differs by ).ient ra)e$ sex$ or E . #'e most fre7uent type of bias dis)ussed by psy)'o.ogists is s.ope bias$ ('i)' in/o./es differen)es in /a.idity )oeffi)ients a)ross groups. W'en a test or ).ini)a. 6udgment yie.ds a signifi)ant.y 'ig'er /a.idity )oeffi)ient in one group t'an anot'er 2s.ope bias3$ t'e test or 6udgment ex'ibits 0differentia. /a.idity0 2Anastasi H Urbina$ *++D3. Note t'at t'e mere presen)e of group differen)es on a test is not suffi)ient to infer biasC bias re7uires t'at t'e ).ini)a. 6udgment or test be .ess /a.id for one group t'an anot'er. 'e" $ias. ex ro.e1stereotypes are a )ause for )on)ern in t'e diagnosis of psy)'opat'o.1ogy$ espe)ia..y persona.ity disorders. &istrioni) persona.ity disorder is more .i-e.y to be diagnosed in (omen and antiso)ia. persona.ity disorder is more .i-e.y to be diagnosed in men$ e/en ('en

).ient symptoms 2e.g.$ sedu)ti/eness$ manipu.ati/eness3 are identi)a. in bot' groups. W'en gi/en )ase 'istories t'at differed on.y by ).ient gender$ bot' ma.e and fema.e ).ini)ians ex'ibit t'is bias 2e.g.$ Ad.er$ 8ra-e$ H #eague$ *++,C Ford H Widiger$ *+B+3. Ford and Widiger

194 =ARB$ L"L"ENFEL8$ F!WLER found t'at an ana.ysis of t'e indi/idua. )riteria for t'ese diagnoses did not ex'ibit ).ini)ian bias$ but t'at t'e fu.. diagnoses did. #'is finding suggests t'at t'e bias is .in-ed to ).ini)iansG per)eptions of t'e diagnoses t'emse./es$ not (it' t'e 8 M )riteria for t'ese disorders. (ace $ias. "n a number of studies )ondu)ted in ).ini)a. settings$ ra)e bias 'as been s'o(n to o))ur in psy)'iatri) diagnosis$ t'e pres)ription of psy)'iatri) medi)ations$ /io.en)e predi)tion$ and )'i.d abuse reporting 2=arb$ *++D$ *++B3. W'en t'e effe)t of so)ia. ).ass (as )ontro..ed$ ra)e sti.. emerged as an important predi)tor. Afri)an Ameri)an and &ispani) patients (ere .ess .i-e.y to be diagnosed (it' a psy)'oti) mood disorder and more .i-e.y to be diagnosed (it' s)'i4op'renia )ompared (it' W'ite patients ex'ibiting simi.ar symptoms 2e.g.$ Mu-'er6ee$ 'u-.a$ Wood.e$ Rosen$ H !.arte$ *+B:C imon$ F.eiss$ =ur.and$ ti..er$ H 'arpe$ *+D:3. #'is o))urred e/en ('en a diagnosis of s)'i4op'renia (as inappropriate. Additiona..y$ Afri)an Ameri)an patients re)ei/ed a .arger number of antipsy)'oti) medi)ations$ in6e)tions of antipsy)'oti) medi)ations$ and psy)'iatri) medi)ations o/era... Moreo/er$ ).ini)ians 'a/e ex'ibited ra)e bias ('en predi)ting t'e o))urren)e of /io.en)e in institutiona. settings$ in).uding psy)'iatri) (ards and prisons. "n t'ese studies$ t'ey 'a/e o/erestimated t'e ris- of /io.en)e for B.a)- inpatients and inmates. &o(e/er$ for ).ients residing in t'e )ommunity$ ra)e bias (as not found for t'e predi)tion of /io.en)e. Ra)e (as a potent predi)tor of fai.ure to report )'i.d abuse5 Cases of )'i.d abuse (ere .ess .i-e.y to be reported if t'e )'i.d (as W'ite t'an B.a)- 2&ampton H Ne(berger$ *+B<3. 'ocial 1lass $ias. o)ia. ).ass bias 'as been demonstrated on.y sparse.y in psy)'iatri) diagnosis and treatment 2=arb$ *++D$ *++B3. !ne finding t'at 'as emerged is t'e re.ation of so)ia. ).ass to psy)'ot'erapy de)isions. C.ini)ians (ere more .i-e.y to re)ommend midd.e1).ass indi/idua.s t'an .o(er1).ass indi/idua.s for psy)'ot'erapy and expe)ted t'em to do better in t'erapy ('en bot' groups (ere re)ommended. Additiona..y$ midd.e1).ass ).ients (ere more .i-e.y to be re)ommended for insig't1fo)used t'erapy$ ('ereas .o(er1).ass ).ients re)ei/ed more re)ommendations for supporti/e t'erapy 2see =arb$ *++D$ for a re/ie(3. METHODOLOGICAL RECOMMENDATIONS e/era. met'odo.ogi)a. steps )an be ta-en to impro/e t'e 7ua.ity of psy)'o.ogi)a. assessment and t'e 6udgments deri/ed from psy)'o.ogi)a. tests. First$ more sop'isti)ated pro)edures )an be used to e/a.uate /a.idity. For examp.e$ to e/a.uate t'e /a.idity of diagnoses$ one )an use t'e LEA8 standard 2 pit4er$ *+B:C a.so see =arb$ *++B$ pp. ;<1<:3. Use of t'e LEA8 standard$ ('i)' (as des)ribed ear.ier$ a..o(s resear)'ers to as)ertain t'e /a.idity of stru)tured inter/ie(s and ot'er assessment instruments. e)ond$ t'e )riteria proposed by Wood et a.. 2*++?b3 s'ou.d be used to determine if an assessment instrument is /a.id for its intended purpose. For examp.e$ if positi/e /a.idity findings 'a/e been obtained in t(o studies but not in t(o ot'ers$ one (ou.d )on).ude t'at t'e assessment instrument does not meet t'e Wood et a.. 2*++?b3 )riteria be)ause t'e resu.ts (ere not )onsistent.y rep.i)ated. A t'ird re)ommendation is t'at item response t'eory 2"R#3 be used to )onstru)t and e/a.uate tests. "R# is an a.ternati/e to traditiona. 2).assi)a.3 test t'eory. "t )an be used as a met'odo.ogi)a. and statisti)a. too. for a number of purposes in).uding test )onstru)tion$ e/a.uating a test$ and us1 ing person1fit indexes to assess 'o( (e.. a trait 2or )onstru)t3 des)ribes an indi/idua.. For exam1 p.e$ using person1fit indexes$ one may )on).ude t'at a trait is not re.e/ant to a person if t'e person responds in an idiosyn)rati) manner 2e.g.$ endorses se/ere but not moderate symptoms of depression3. "R# a.so permits test )onstru)tors to determine ('i)' items are most dis)riminating

at different .e/e.s of t'e trait in 7uestion. For examp.e$ "R# ana.yses )ou.d re/ea. t'at a measure

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 196 of depression ade7uate.y distinguis'es nondepressed from moderate.y depressed indi/idua.s$ but not moderate.y from se/ere.y depressed indi/idua.s. A.t'oug' (e.. estab.is'ed in a)'ie/ement and aptitude testing$ "R# 'as been app.ied infre7uent.y to persona.ity assessment. #'is is part.y be)ause )ogniti/e )onstru)ts are better understood t'an persona.ity )onstru)ts. %ut anot'er (ay$ )onstru)t /a.idity issues 'a/e been more formidab.e for persona.ity measurement. &o(e/er$ in re)ent years$ "R# 'as been app.ied su))essfu..y to persona.ity assessment. For examp.e$ 'istori)a..y$ .inear fa)tor ana.yses 'a/e been used to des)ribe t'e stru)ture of t'e MM%" and MM%"19. Be)ause MM%" and MM%"19 items are di)'otomous 2true1fa.se3$ and be)ause .inear fa)tor ana.ysis assumes t'at ratings are norma..y distributed and not di)'otomous$ it is more appropriate to use non.inear fa)tor ana.ysis or mu.tidimensiona. "R# met'ods. Using "R# to un)o/er t'e fa)tor stru)ture of t'e MM%"19$ Wa..er 2*++B3 found important differen)es bet(een 'is resu.ts and t'ose of pre/ious fa)tor ana.yses. Fourt'$ t'e use of )omputers for ma-ing 6udgments and de)isions is be)oming in)reasing.y important in t'e assessment of psy)'opat'o.ogy. Findings from a re)ent meta1ana.ysis 2=ro/e$ Ra.d$ Lebo($ nit4$ H Ne.son$ 9,,,3 suggest t'at )omputer programs )an be su))essfu..y de1 /e.oped for t'is purpose. #'e uti.ity of t'ese programs deri/es from (e..1estab.is'ed 2a.t'oug' sti.. .arge.y neg.e)ted3 findings t'at a)tuaria. 2statisti)a.3 formu.as based on empiri)a..y es1 tab.is'ed re.ations bet(een predi)tors and )riteria are a.most a.(ays superior or at .east e7ua. to ).ini)a. 6udgment 28a(es et a..$ *+B+C =ro/e H Mee'.$ *++?3. &o(e/er$ re.ati/e.y fe( (e..1 /a.idated )omputer programs are a/ai.ab.e for ).ini)a. tas-s 2=arb$ 9,,,3. As obser/ed by Wood$ =arb$ Li.ienfe.d$ and Ne4(ors-i 29,,935 .ubstantial progress has been made in developing computeri<ed algorithms to predict violence, child abuse and neglect, and recidivism among 6uvenile offendersKKKKIowever, there are still no well&validated algorithms for making diagnoses, predicting behavior, describing personality traits and psychopathology, or making treatment decisions, p. >);" imi.ar.y$ nyder 29,,,3 )on).uded t'at popu.ar )omputer programs t'at 'a/e been used for years to interpret test resu.ts 2e.g.$ for t'e MM%"19 and t'e Rors)'a)'3 are inade7uate.y /a.idated. Resear)' is needed to de/e.op and /a.idate ne( )omputer programs t'at pro/ide /a.id des)riptions of a ).ientGs persona.ity and psy)'opat'o.ogy. CONCLUSIONS Judging and assessing psy)'opat'o.ogy is an a)ti/ity fraug't (it' potentia. error and bias. &o(e/er$ by attending to resear)' findings$ psy)'o.ogists )an a/oid using test s)ores t'at are in/a.id$ and t'ey )an be)ome fami.iar (it' t'e strengt's and (ea-nesses of ).ini)a. 6udgment. "n t'is (ay$ errors t'at are potentia..y detrimenta. to ).ients )an be a/oided. For examp.e$ t'e use of t'e C norms for interpreting Rors)'a)' proto)o.s )an .ead to fa.se positi/es in t'e assessment of psy)'opat'o.ogy. By not using t'e C norms$ or by using t'em (it' extreme )aution$ one )an a/oid ma-ing 'armfu. 6udgments su)' as misdiagnosing norma. ).ients as pat'o.ogi)a..; ome psy)'o.ogists argue t'at a.t'oug' s)ientifi) resear)' is important$ (e s'ou.d a.so re.y on ).ini)a. experien)e to determine if an assessment instrument is /a.uab.e. "ndeed$ some e/en argue t'at ('en resear)' and ).ini)a. experien)e )onf.i)t$ (e s'ou.d p.a)e a 'ig'er premium on t'e .atter. %sy)'o.ogists are fre7uent.y en)ouraged to use t'e Rors)'a)' and ot'er pro6e)ti/e

9F#r a .ase /ist#ry des.ribin& a .%ient 2/# 2as a**arent%y /ar(ed by inter*retati#ns #6 t/e R#rs./a./5 see Garb5 W##d Li%ien6e%d5 and NeC2#rs+i = !! >.

198 GAR15 LILIENFELD5 FOWLER te)'ni7ues be)ause t'ey seem to pro/ide ri)' ).ini)a. data 2e.g.$ @aron$ 9,,,3. &o(e/er$ ).ini)a. experien)e )an be fa..ib.e for a 'ost of reasons in).uding biased feedba)-$ i..usory )orre.ation$ and )onfirmatory bias 28a(es et a..$ *+B+C =arb$ *++B3. #'e s)ientifi) met'od$ not ).ini)a. experien)e$ is t'e best met'od for minimi4ing error and reso./ing )ontro/ersies. )ientifi) te)'ni7ues$ su)' as doub.e1b.ind designs and )ontro. groups$ are too.s t'at resear)'ers 'a/e de/e.oped to prote)t t'emse./es from being mis.ed 2Li.ienfe.d$ 9,,93. As M)Fa.. 2*++*3 noted5 $There is a% commonly offered rationali<ation that science doesn(t have all the answers yet, and until it does, we must do the best we can to muddle along, relying on our clinical e'perience, 6udgment, creativity, and intuition cf., /atara<<o, 0113". 9f course, this argument reflects the mistaken notion that science is a set of answers, rather than a set of processes or methods by which to arrive at answers. Where there are lots of unknownsJand clinical psychology certainly has more than its shareJit is all the more imperative to adhere as strictly as possible to the scientific approach. -oes anyone seriously believe that a reliance on intuition and other unscientific methods is going to hasten advances in knowledgeL pp. *4&**" Fina..y$ as noted by M)Fa.. 2)ited in #ru.. H %'ares$ 9,,*$ p. ?93$ one feature t'at s'ou.d distinguis' ).ini)a. and )ounse.ing psy)'o.ogists from most ot'er menta. 'ea.t' professiona.s is t'eir s)ientifi) training. #o ignore resear)' findings be)ause t'ey ma-e us fee. un)omfortab.e is to neg.e)t our most distin)ti/e and positi/e attribute5 our training in$ and our (i..ingness to be guided by$ s)ien)e. REFERENCES A.+%in5 M. W. =3@@@>. 1e/a,i#ra% s.ien.e 6#$ndati#ns #6 t/e R#rs./a./ test' Resear./ and .%ini.a% a**%i.ati#ns. %ssessment# E# :3@0: ?. A.+%in5 M. W.5 M.D#2e%%5 C. 7.5 Gers./e%%5 M. S.5 H C/an5 D. = !!!>. Inter#bser,er a&ree(ent5 intra#bser,er re%iabi%ity5 and t/e R#rs./a./ C#(*re/ensi,e Syste(. ournal of +ersonality %ssessment# A;# 3"098. Ad%er5 D. A.5 Dra+e5 R. E.5 H Tea&$e5 G. 1. =3@@!>. C%ini.iansB *ra.ti.es in *ers#na%ity assess(ent' D#es &ender in6%$en.e t/e $se #6 DSM0III A-is III 1omprehensive +sychiatry# ?6# 3 "03:3. A%bert5 S.5 F#-5 H. M.5 H )a/n5 M. W. =3@;!>. Fa+in& *sy./#sis #n t/e R#rs./a./' Can e-*ert D$d&es dete.t (a%in&erin&I ournal of +ersonality %ssessment# ;;# 33"033@. A%ter(an5 A. I.5 Snider5 E. C5 Ca..i#%a5 7. S.5 1r#2n5 L. S.5 7r.5 Faba%%er#5 A.5 H SiddiJ$i5 N. =3@@?>. E,iden.e #6 res*#nse set e66e.ts in str$.t$red resear./ inter,ie2s. ournal of -ervous and Mental Disease# 68;# 9!:093!. A(eri.an Ed$.ati#na% Resear./ Ass#.iati#n5 A(eri.an Psy./#%#&i.a% Ass#.iati#n5 H Nati#na% C#$n.i% #n Meas$re(ent in Ed$.ati#n =3@@@>. 'tandards for educational and psychological testing. Was/in&t#n5 DC' A(eri.an Ed$.ati#na% Resear./ Ass#.iati#n. A(eri.an Psy./iatri. Ass#.iati#n =3@;!>. Diagnostic and statistical manual of mental disorders>rd ed.>. Was/in&t#n5 DC' A$t/#r. A(eri.an Psy./iatri. Ass#.iati#n =3@@9>. Diagnostic and statistical manual ofmental disorders =9t/ ed.>. Was/in&t#n5 DC' A$t/#r.

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E-ner5 7. E. =3@@">. C#((ent #n KNar.issis( in t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./.K 1linical +sychology5 'cience and +ractice# :# !!0 !?. E-ner5 < E. =3@@?>. C#((ent #n KT/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./' A Criti.a% E-a(inati#n.K +sychological 'cience# A# 3303:. E-ner5 7. E. = !!3a>. A .#((ent #n KT/e Mis*er.e*ti#n #6 Psy./#*at/#%#&y' Pr#b%e(s 2it/ t/e N#r(s #6 t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./.K 1linical +sychology5 'cience and +ractice# 8# :;?0:;;. E-ner5 < E. = !!3b>. % (orschach workbook for the 1omprehensive 'ystem ="t/ ed.>. As/e,i%%e5 NC' R#rs./a./ W#r+s/#*s. Fara#ne5 S. G5 H Ts$an&5 M. T. =3@@9>. Meas$rin& dia&n#sti. a..$ra.y in t/e absen.e #6 a K&#%d standard.K %merican ournal of +sychiatry# 696# ?"!0?"8. Finn5 S. E.5 H )a(*/$is5 < H. =3@@">. W/at a .%ini.ian needs t# +n#2 ab#$t base rates. In < 1$t./er =Ed.>5 1linical personality assessment5 +ractical approaches =**. 90 :">. Ne2 Y#r+' O-6#rd Uni,ersity Press. F%eiss5 < =3@;3>. 'tatistical methods for rates and proportions = nd ed.>. Ne2 Y#r+' Wi%ey. F#rd5 M.5 H Widi&er5 T. =3@;@>. Se- bias in t/e dia&n#sis #6 /istri#ni. and antis#.ia% *ers#na%ity dis#rders. ournal of 1onsulting and 1linical +sychology# 9A# :!30:!". Gad#%5 I. =3@?@>. T/e in.re(enta% and *redi.ti,e ,a%idity #6 t/e R#rs./a./ test in *ers#na%ity assess(ents #6 n#r(a%5 ne$r#ti.5 and *sy./#ti. s$bDe.ts. Dissertation %bstracts# :@# :9; 1. =UMI N#. ?@099?@>. Garb5 H. N. =3@;@>. C%ini.a% D$d&(ent5 .%ini.a% trainin&5 and *r#6essi#na% e-*erien.e. +sychological $ulletin# 679# :;80:@?. Garb5 H. N. =3@@?>. T/e re*resentati,eness and *ast0be/a,i#r /e$risti.s in .%ini.a% D$d&(ent. +rofessional +sychology5 (esearch and +ractice# :A# 8 0 88.

202 GAR15 LILIENFELD5 FOWLER Garb5 H. N. =3@@8>. Ra.e bias5 s#.ia% .%ass bias5 and &ender bias in .%ini.a% D$d&(ent. 1linical +sychology5 'cience and +ractice# ;# @@03 !. Garb5 H. N. =3@@;>. 'tudying the clinician5 udgment research and psychological assessment. Was/in&t#n5 DC' A(eri.an Psy./#%#&i.a% Ass#.iati#n. Garb5 H. N. = !!!>. C#(*$ters 2i%% be.#(e in.reasin&%y i(*#rtant 6#r *sy./#%#&i.a% assess(ent' N#t t/at t/ereBs anyt/in& 2r#n& 2it/ t/atZ +sychological %ssessment# 6:# :30:@. Garb5 H. N. = !!:>. In.re(enta% ,a%idity and t/e assess(ent #6 *sy./#*at/#%#&y in ad$%ts. +sychological %ssessment# 69# "!;0" !. Garb5 H. N.5 F%#ri#5 C. M.5 H Gr#,e5 W. M. =3@@;>. T/e ,a%idity #6 t/e R#rs./a./ and t/e Minnes#ta M$%ti*/asi. Pers#na%ity In,ent#ry' Res$%ts 6r#( (eta0ana%yses. +sychological 'cience# @# 9! 09!9. Garb5 H. N.5 W##d5 7. M.5 Li%ien6e%d5 S. O.5 H NeC2#rs+i5 M. T. = !! >. E66e.ti,e $se #6 *r#De.ti,e te./niJ$es in .%ini.a% *ra.ti.e' Let t/e data /e%* 2it/ se%e.ti#n and inter*retati#n. +rofessional +sychology5 (esearch and +ractice# ??# 9"909?:. Garb5 H. N.5 W##d5 7. M.5 H NeC2#rs+i5 M. T. = !!!>. Pr#De.ti,e te./niJ$es and t/e dete.ti#n #6 ./i%d se-$a% ab$se. 1hild Maltreatment# "5 3?303?;. Ga$r#n5 E. E5 H Di.+ins#n5 7. ). =3@?@>. T/e in6%$en.e #6 seein& t/e *atient 6irst #n dia&n#sti. de.isi#n0(a+in& in *sy./iatry. %merican ournal of +sychiatry# 6:E# 3@@0 !". Ga2ande5 A. = !!!>. W/en d#.t#rs (a+e (ista+es. In 7. C#/en =Series Ed.> H J. G%ei.+ =G#%. Ed.>5 $est %merican science writing :777 =**. 30 >. Ne2 Y#r+' Har*er C#%%ins. =Re*rinted 6r#( The -ew Korker# 3@@@>. Gi%#,i./5 T. =3@@3>. ,ow we know what isnHt so. Ne2 Y#r+' Free Press. G#%dber&5 L. R. =3@?">. Dia&n#sti.ians ,ers$s dia&n#sti. si&ns' T/e dia&n#sis #6 *sy./#sis ,ers$s ne$r#sis 6r#( t/e MMPI. +sychological Monographs# A@ =@5 W/#%e N#. ?! >. Gra/a(5 7. R. =3@?8>. A N0s#rt st$dy #6 t/e a..$ra.y #6 .%ini.a% des.ri*ti#ns based #n t/e MMPI. ournal of+sychiatric (esearch# 9# @80:!". Gra/a(5 7. R.5 1en0P#rat/5 Y. S.5 H M.N$%ty5 7. L. =3@@8>. E(*iri.a% .#rre%ates #6 %#2 s.#res #n t/e MMPI0 s.a%es in an #$t*atient (enta% /ea%t/ settin&. +sychological %ssessment# @# :;?0:@3. Greene5 R. L. = !!!>. The MM+03:5 %n interpretive manual. Need/a( Hei&/ts5 MA' A%%yn H 1a.#n. Gr#,e5 W. M.5 H Mee/%5 P. E. =3@@?>. C#(*arati,e e66i.ien.y #6 in6#r(a% =s$bDe.ti,e5 i(*ressi#nisti.> and 6#r(a% =(e./ani.a%5 a%&#rit/(i.> *redi.ti#n *r#.ed$res' T/e .%ini.a%0statisti.a% .#ntr#,ersy. +sychology5 +ublic +olicy and )aw# :# @:0: :. Gr#,e5 W. M.5 Fa%d5 D. H.5 Leb#25 1. S.5 SnitC5 1. E.5 H Ne%s#n5 C. = !!!>. C%ini.a% ,ers$s (e./ani.a% *redi.ti#n' A (eta0ana%ysis. +sychological %ssessment# 6:# 3@0:!. G$arna..ia5 G5 Di%%5 C. A.5 Sabatin#5 S.5 H S#$t/2i.+5 S. = !!3>. S.#rin& a..$ra.y $sin& t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./. ournal of +ersonality %ssessment# AA# %<%3;6%. Ha(e%5 M.5 S/a66er5 T. W5 H Erdber&5 P. = !!!>. A st$dy #6 n#n*atient *read#%es.ent R#rs./a./ *r#t#.#%s. ournal

of +ersonality %ssessment# A9# ;!0 @9. Ha(*t#n5 R. L.5 H Ne2ber&er5 E. H. =3@;">. C/i%d ab$se in.iden.e and re*#rtin& by /#s*ita%s' Si&ni6i.an.e #6 se,erity5 .%ass and ra.e. %merican ournal of +ublic ,ealth# A9# "?0?!. Har+ness5 A. R.5 H Li%ien6e%d5 S. O. =3@@8>. Indi,id$a% di66eren.es s.ien.e 6#r treat(ent *%annin&' Pers#na%ity traits. +sychological %ssessment# @# :9@A:?!. Henry5 1.5 M#66itt5 T. E.5 Cas*i5 A.5 Lan&%ey5 7.5 H Si%,a5 P. A. =3@@9>. On t/e KRe(e(bran.e #6 T/in&s PastK' A %#n&it$dina% e,a%$ati#n #6 t/e retr#s*e.ti,e (et/#d. +sychological %ssessment# E# @ 03!3. H#%(es5 D. S. =3@@!>. T/e e,iden.e 6#r re*ressi#n' An e-a(inati#n #6 si-ty years #6 resear./. In 7. L. Sin&er =Ed.>5 Re*ressi#n and diss#.iati#n' I(*%i.ati#ns 6#r *ers#na%ity t/e#ry5 *sy./#*at/#%#&y5 and /ea%t/ =**. ;"03! >. C/i.a&#' Uni,ersity #6 C/i.a&# Press. Hi%%er5 7. 1.5 R#sent/a%5 R.5 1#rnstein5 R. F.5 1erry5 D. T. R.5 H 1r$ne%%0Ne$%eib5 S. =3@@@>. A .#(*arati,e (eta0ana%ysis #6 R#rs./a./ and MMPI ,a%idity. +sychological %ssessment# 66# 8;0 @?. H$ns%ey5 7.5 H Di Gi$%i#5 G. = !!3>. N#r(s5 n#r(in&5 and .%ini.a% assess(ent. 1linical +sychology5 'cience and +ractice# 8# :8;0:; . 7#r&ensen5 ).5 Andersen5 T. 7.5 H Da(5 H. = !!!>. T/e dia&n#sti. e66i.ien.y #6 t/e R#rs./a./ De*ressi#n Inde- and t/e S./iC#*/renia Inde-' A re,ie2. %ssessment# A# "@0 ;!. )a/i%i5 S. =3@;9>. H$(an 6i&$re dra2in& in ad$%ts' An $*date #6 t/e e(*iri.a% e,iden.e5 3@?803@; . 1anadian +sychology# :9# ?@0 @ . )ar#n5 1. P. = !!!>. T/e .%ini.a% inter*retati#n #6 t/e T/e(ati. A**er.e*ti#n Test5 R#rs./a./5 and #t/er .%ini.a% data' A ree-a(inati#n #6 statisti.a% ,ers$s .%ini.a% *redi.ti#n. +rofessional +sychology5 (esearch and +ractice# ?6# :!0 ::. Le,enber&5 S. 1. =3@8">. Pr#6essi#na% trainin&5 *sy./#dia&n#sti. s+i%%5 and )ineti. Fa(i%y Dra2in&s. ournal of +ersonality %ssessment# ?@# :;@0:@:.

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 204 Li%ien6e%d5 S. O. = !! >. W/en 2#r%ds .#%%ide' S#.ia% s.ien.e5 *#%iti.s5 and t/e Rind et a%. =3@@;> ./i%d se-$a% ab$se (eta0ana%ysis. %merican +sychologist# 9A# 38?03;;. Li%ien6e%d5 S. O.5 W##d5 7. M.5 H Garb5 H. N. = !!!>. T/e s.ienti6i. stat$s #6 *r#De.ti,e te./niJ$es. +sychological 'cience in the +ublic 0nterest# 6# 80??. Li%ien6e%d5 S. O.5 W##d 70 M.5 H Garb5 H. N. = !!35 May>. W/atBs 2r#n& 2it/ t/is *i.t$reI 'cientific %merican# :8;# ;!0;8. LitC5 1. T5 Mi%%er5 M. W5 R$e65 A. M.5 H M.Tea&$e5 L. M. = !! >. E-*#s$re t# tra$(a in ad$%ts. In M. M. Ant#ny H D. H. 1ar%#2 =Eds.>5 ,andbook of assessment and treatment planning for psychological disorders =**. 3"0 ";>. Ne2 Y#r+' G$i%6#rd. L#e,in&er5 7. =3@"8>. ObDe.ti,e tests as instr$(ents #6 *sy./#%#&i.a% t/e#ry. +sychological (eports# ?# ?:"0?@9. L#&$e5 M. 1.5 S/er5 ). 7.5 H Frens./5 P. A. =3@@ >. P$r*#rted ./ara.teristi.s #6 ad$%t ./i%dren #6 a%.#/#%i.s' A *#ssib%e K1arn$( e66e.t.K +rofessional +sychology5 (esearch and +ractice# :?# ?0 : . Mar&ra65 7.5 Tay%#r5 C. 1.5 E/%ers5 A.5 R#t/5 W. T5 H A&ras5 W S. =3@;8>. Pani. atta.+s in t/e nat$ra% en,ir#n(ent. ournal of -ervous and Mental Disease# 6A9# "";0"?". MataraCC#5 7. D. =3@@!>. Psy./#%#&i.a% assess(ent ,ers$s *sy./#%#&i.a% testin&' Ga%idati#n 6r#( 1inet t# t/e s./##%5 .%ini.5 and .#$rtr##(. %merican +sychologist# ;9# @@@03!38. M.Fa%%5 R. M. =3@@3>. Mani6est# 6#r a s.ien.e #6 .%ini.a% *sy./#%#&y. 1linical +sychologist# ;;# 8"0;;. M.Fa%%5 R. M.5 H Treat5 T. A. =3@@@>. N$anti6yin& t/e in6#r(ati#n ,a%$e #6 .%ini.a% assess(ents 2it/ si&na% dete.ti#n t/e#ry. %nnual (eview of +sychology# 97# :3"0 93. Mee/%5 P. E. =3@9">. T/e dyna(i.s #6 Kstr$.t$redK *ers#na%ity tests. ournal of 1linical +sychology# 6# @?0:!:. Mee/%5 P. E. =3@"?>. Wanted0A &##d .##+b##+. %merican +sychologist# 66# ?:0 8 . Mee/%5 P. E. =3@8:>. W/y I d# n#t attend .ase .#n6eren.es. In P. E. Mee/%5 +sychodiagnosis5 'elected papers =**. "0:! >. Minnea*#%is' Uni,ersity #6 Minnes#ta Press. Mee/%5 P. E. =3@;?>. Dia&n#sti. ta-a as #*en .#n.e*ts' Metat/e#reti.a% and statisti.a% J$esti#ns ab#$t re%iabi%ity and .#nstr$.t ,a%idity in t/e &rand strate&y #6 n#s#%#&i.a% re,isi#n. In T. Mi%%#n H G. )%er(an =Eds.>5 1ontemporary directions inpsychopathology =**. 3"0 :3>. Ne2 Y#r+' G$i%6#rd. Mee/%5 P. E.5 H R#sen5 A. =3@"">. Ante.edent *r#babi%ity and t/e e66i.ien.y #6 *sy./#(etri. si&ns5 *atterns5 #r .$ttin& s.#res. +sychological $ulletin# 9:# 3@90 3?. Meyer5 G. 7. = !!3>. E,iden.e t# .#rre.t (is*er.e*ti#ns ab#$t R#rs./a./ n#r(s. 1linical +sychology5 'cience and +ractice# 8# :;@0:@?. Meyer5 G. 7.5 H Ar./er5 R. P. = !!3>. T/e /ard s.ien.e #6 R#rs./a./ resear./' W/at d# 2e +n#2 and 2/ere d# 2e &#I +sychological %ssessment# 6?#9;?0"! . Meyer5 G. 7.5 H Hand%er5 L. =3@@8>. T/e abi%ity #6 t/e R#rs./a./ t# *redi.t s$bseJ$ent #$t.#(e' A (eta0ana%ysis #6 t/e R#rs./a./ Pr#&n#sti. Ratin& S.a%e. ournal of +ersonality %ssessment# E@# 30:;. Meyer5 G. <5 Hi%senr#t/5 M. <5 1a-ter5 D.5 E-ner5 < E.5 F#2%er5 < C5 Piers5 C. C5 H Resni.+5 < = !! >. An e-a(inati#n #6 interrater re%iabi%ity 6#r s.#rin& t/e R#rs./a./ C#(*re/ensi,e Syste( in ei&/t data sets.

ournal of +ersonality %ssessment# A8# 3@0 89. Meyer5 G. <5 H Ri./ards#n5 C. = !!35 Mar./>. %n e"amination of changes in /orm >uality codes in the (orschach 1omprehensive 'ystem from 6@A; to 6@@9. Presented at t/e (id2inter (eetin& #6 t/e S#.iety 6#r Pers#na%ity Assess(ent5 P/i%ade%*/ia. Mi%%#n5 T. =3@@9>. The Millon 1linical Multia"ial 0nventory30ll manual. Minnea*#%is5 MN' Nati#na% C#(*$ter Syste(s. M#%inari5 G5 A(es5 A.5 H Essa5 M. =3@@9>. Pre,a%en.e #6 *ers#na%ity dis#rders in t2# &er#*sy./iatri. in*atient $nits. ournal of Geriatric +sychiatry and -eurology# A# !@0 3". M#rey5 L. C. =3@@3>. +ersonality %ssessment 0nventory5 +rofessional manual. Ta(*a' Psy./#%#&i.a% Assess(ent Res#$r.es. M#rey5 L. C5 H O./#a5 E. S. =3@;@>. An in,esti&ati#n #6 ad/eren.e t# dia&n#sti. .riteria' C%ini.a% dia&n#sis #6 t/e DSM0III *ers#na%ity dis#rders. ournal of +ersonality Disorders# ?# 3;!03@ . M$+/erDee5 S.5 S/$+%a5 S.5 W##d%e5 <5 R#sen5 A. M.5 H O%arte5 S. =3@;:>. Misdia&n#sis #6 s./iC#*/renia in bi*#%ar *atients' A ($%tiet/ni. .#(*aris#n. %merican ournal of +sychiatry# 6;7# 3"8303"89. Na&%ieri5 < A.5 H P6ei66er5 S. I. =3@@ >. Per6#r(an.e #6 disr$*ti,e be/a,i#r0dis#rdered and n#r(a% sa(*%es #n t/e Dra20A0Pers#n' S.reenin& Pr#.ed$re 6#r E(#ti#na% Dist$rban.e. +sychological %ssessment# ;# 3"?03"@. Na+ata5 L. M. =3@@@>. Interrater re%iabi%ity and t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./' C%ini.a% and n#n.%ini.a% *r#t#.#%s =D#.t#ra% dissertati#n5 Pa.i6i. Grad$ate S./##% #6 Psy./#%#&y5 3@@@>. Dissertation %bstracts 0nternational# E7# 9 @?1. NeC2#rs+i5 M. <5 H W##d5 < M. =3@@">. Nar.issis( in t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./. 1linical +sychology5 'cience and +ractice# :# 38@03@@. N$nna%%y5 < =3@8;>. +sychometric theory = nd ed.>. Ne2 Y#r+' M.Gra20Hi%%.

206 =ARB$ L"L"ENFEL8$ F!WLER Ober%ander5 L. 1. =3@@">. Psy./#%e&a% iss$es in ./i%d se-$a% ab$se e,a%$ati#ns' A s$r,ey #6 6#rensi. (enta% /ea%t/ *r#6essi#na%s. 1hild %buse D -eglect# 6@#98"09@!. Par+er5 ). C. H.5 Hans#n5 R.5 H H$ns%ey5 7. =3@;;>. MMPI5 R#rs./a./5 and WAIS' A (eta0ana%yti. .#(*aris#n #6 re%iabi%ity5 stabi%ity5 and ,a%idity. +sychological $ulletin# 67?# :?80:8:. R#&ers5 R. =3@@">. Diagnostic and structured interviewing5 % handbookfor psychologists. Odessa5 FL' Psy./#%#&i.a% Assess(ent Res#$r.es. R#&ers5 R.5 Sa%e+in5 R. TQ H Se2e%%5 ). W. =3@@@>. Ga%idati#n #6 t/e Mi%%#n C%ini.a% M$%tia-ia% In,ent#ry 6#r A-is II dis#rders' D#es it (eet t/e Daubert standardI )aw and ,uman $ehavior# :?#9 "099:. R#&ers5 R.5 Sa%e+in5 R. <5 H Se2e%%5 ). W. = !!!>. T/e MCMI0III and t/e Daubert standard' Se*aratin& r/et#ri. 6r#( rea%ity. )aw and ,uman $ehavior# :;# "!30"!?. R#tt#n5 7.5 H )e%%y5 I. W. =3@;">. M$./ ad# ab#$t t/e 6$%% (##n' A (eta0ana%ysis #6 %$nar0 %$na.y resear./. +sychological $ulletin# @A# ;?0:!?. Sart#ri$s5 N.5 )ae%ber5 C. <5 C##*er5 7. E.5 R#*er5 M. T5 Rae5 D. S.5 G$%binat5 W.5 Ust$n5 T. 1.5 H Re&ier5 D. A. =3@@:>. Pr#&ress t#2ard a./ie,in& a .#((#n %an&$a&e in *sy./iatry' Res$%ts 6r#( t/e 6ie%d tria% #6 t/e .%ini.a% &$ide%ines a..#(*anyin& t/e WHO .%assi6i.ati#n #6 (enta% and be/a,i#ra% dis#rders in 01D367. %rchives of General +sychiatry# 97# 33"03 9. Sa,ard5 7.5 H M#rin5 C. M. = !! >. Ins#(nia. In M. M. Ant#ny H D. H. 1ar%#2 =Eds.>5 ,andbook of assessment and treatment planning for psychological disorders =**. " :0""">. Ne2 Y#r+' G$i%6#rd. S./a.ter5 S. =3@; >. Re.idi,is( and se%60.$re #6 s(#+in& and #besity. %merican +sychologist# ?A#9:?0 999. S/a66er5 T. W5 Erdber&5 P.5 H Har#ian5 7. =3@@@>. C$rrent n#n*atient data 6#r t/e R#rs./a./5 WAIS0R5 and MMPI0 . ournal of +ersonality %ssessment# A?# :!"0:3?. S/ear5 M. ).5 1r#2n5 T. A.5 1ar%#25 D. H.5 M#ney5 R.5 S/#%#(s+as5 D. E.5 W##ds5 S. W5 G#r(an5 7. M.5 H Pa**5 L. A. =3@@8>. M$%ti.enter .#%%ab#rati,e Pani. Dis#rder Se,erity S.a%e. %merican ournal of +sychiatry# 69;#3"8303"8". Si(#n5 R. 7.5 F%eiss5 7. L.5 G$r%and5 1. 7.5 Sti%%er5 P. R.5 H S/ar*e5 L. =3@8:>. De*ressi#n and s./iC#*/renia in /#s*ita%iCed b%a.+ and 2/ite (enta% *atients. %rchives of General +sychiatry# :8# "!@0"3 . Snyder5 C. R.5 H Lars#n5 G. R. =3@8 >. A 6$rt/er %##+ at st$dent a..e*tan.e #6 &enera% *ers#na%ity inter*retati#ns. ournal of 1onsulting and 1linical +sychology# ?8# :;90:;;. Snyder5 D. ). = !!!>. C#(*$ter0assisted D$d&(ent' De6inin& stren&t/s and %iabi%ities. +sychological %ssessment# 6:# " 0?!. S*an&%er5 W. D. =3@@ >. Ga%idity #6 J$esti#nnaire and TAT (eas$res #6 need 6#r a./ie,e(ent' T2# (eta0ana%yses. +sychological $ulletin# 66:# 39!03"9. S*itCer5 R. L. =3@;:>. Psy./iatri. dia&n#sis' Are .%ini.ians sti%% ne.essaryI 1omprehensive +sychiatry# :;# :@@0933. Starr5 1. 7.5 H )at+in5 E. S. =3@?@>. T/e .%ini.ian as an aberrant a.t$ary' I%%$s#ry .#rre%ati#n and t/e In.#(*%ete

Senten.es 1%an+. ournal of %bnormal +sychology# A;# ?8!0?8". Steiner5 7. L.5 Tebes5 7. ).5 S%ed&e5 W. H.5 H Wa%+er5 M. L. =3@@">. A .#(*aris#n #6 t/e Str$.t$red C%ini.a% Inter,ie2 6#r DSM0III0R and .%ini.a% dia&n#ses. ournal of -ervous and Mental Disease# 68?# :?"0:?@. Str#/(er5 D. C5 S/i,y5 G. A.5 H C/i#d#5 A. L. =3@@!>. In6#r(ati#n *r#.essin& strate&ies in .#$nse%#r /y*#t/esis testin&' T/e r#%e #6 se%e.ti,e (e(#ry and e-*e.tan.y. ournal of 1ounseling +sychology# ?A# 9?"098 . Tr#2brid&e5 M. M. =3@@">. Gra*/i. indi.at#rs #6 se-$a% ab$se in ./i%drenBs dra2in&s' A re,ie2 #6 t/e %iterat$re. The %rts in +sychotherapy# ::# 9;"09@:. Tr$%%5 < 7.5 H P/ares5 E. 7. = !!3>. 1linical +sychology =?t/ ed.>. 1e%(#nt5 CA' Wads2#rt/. <$rner5 D. R. =3@??>. Predi.ti,e e66i.ien.y as a 6$n.ti#n #6 a(#$nt #6 in6#r(ati#n and %e,e% #6 *r#6essi#na% e-*erien.e. ournal of +ro4ective TechniCues and +ersonality %ssessment# ?7# 9033. Wa%%er5 N. G. =3@@;>. Sear./in& 6#r str$.t$re in t/e MMPI. In S. E. E(brets#n H S. L. Hers/ber&er =Eds.>5 The new rules of measurement =**. 3;"0 38>. Ma/2a/5 N7' La2ren.e Er%ba$( Ass#.iates. Weiner5 I. 1. = !!!>. Usin& t/e R#rs./a./ *r#*er%y in *ra.ti.e and resear./. ournal of 1linical +sychology# 9E# 9:"P3:;. Weiner5 I. 1. = !!3>. Ad,an.in& t/e s.ien.e #6 *sy./#%#&i.a% assess(ent' T/e R#rs./a./ In+b%#t Met/#d as e-e(*%ar. +sychological %ssessment# 6?# 9 :09: . Westen5 D.5 L#/r5 N.5 Si%+5 ). R.5 G#%d5 L.5 H )erber5 ). =3@@!>. ObDe.t re%ati#ns and s#.ia% .#&niti#n in b#rder%ines5 (aD#r de*ressi,es5 and n#r(a%s' A T/e(ati. A**er.e*ti#n Test ana%ysis. +sychological %ssessment# :# :""0:?9. Westen5 D.5 L$d#%*/5 P.5 1%#.+5 M. 7.5 Wi-#(5 7.5 H Wiss5 F. C. =3@@!>. De,e%#*(enta% /ist#ry and #bDe.t re%ati#ns in *sy./iatri.a%%y dist$rbed ad#%es.ent &ir%s. %merican ournal of +sychiatry# 6;A# 3!?303!?;. W/ite/ead5 W. C. =3@;">. C%ini.a% de.isi#n (a+in& #n t/e basis #6 R#rs./a./5 MMPI5 and a$t#(ated MMPI re*#rt data =D#.t#ra% dissertati#n5 Uni,ersity #6 Te-as S#$t/2estern Medi.a% Center at Da%%as5 3@;">. Dissertation %bstracts 0nternational# ;E# ; ;. Widi&er5 T. A. = !!3>. T/e best and t/e 2#rst #6 $sI 1lincial +sychology5 'cience and +ractice# 8# :890:88.

". PSYCHOLOGICAL ASSESSMENT AND CLINICAL 7UDGMENT 208 Widi&er5 T. A. = !! >. Pers#na%ity dis#rders. In M. M. Ant#ny H D. H. 1ar%#2 =Eds.>5 ,andbook of assessment and treatment planning for psychological disorders =**. 9":P3;!>. Ne2 Y#r+' G$i%6#rd. W##d5 7. M.5 Garb5 H. N.5 Li%ien6e%d5 S. O.5 H NeC2#rs+i5 M. T. = !! >. C%ini.a% assess(ent. %nnual (eview of +sychology# 9?# "3@0"9:. W##d5 7. M.5 Li%ien6e%d5 S. O.5 Garb5 H. N.5 H NeC2#rs+i5 M. T. = !!!>. T/e R#rs./a./ test in .%ini.a% dia&n#sis' A .riti.a% re,ie25 2it/ a ba.+2ard %##+ at Gar6ie%d =3@98>. ournal of 1linical +sychology# 9E# :@"09:!. W##d5 7. M.5 NeC2#rs+i5 M. T5 Garb5 H. N.5 H Li%ien6e%d5 S. O. = !!3a>. Pr#b%e(s 2it/ t/e n#r(s #6 t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./' Met/#d#%#&i.a% and .#n.e*t$a% .#nsiderati#ns. 1linical +sychology5 'cience and +ractice# 8# :@8P3! . W##d5 7. M.5 NeC2#rs+i5 M. T5 Garb5 H. N.5 H Li%ien6e%d5 S. O. = !!3b>. T/e (is*er.e*ti#n #6 *sy./#*at/#%#&y' Pr#b%e(s 2it/ t/e n#r(s #6 t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./. 1linical +sychology5 'cience and +ractice# 8# :"!0:8:. W##d5 7. M.5 NeC2#rs+i5 M. T5 Li%ien6e%d5 S. O.5 H Garb5 H. N. = !!:>. &hatHs wrong with the (orschachI 'cience confronts the controversial inkblot test. San Fran.is.#5 CA' 7#ssey01ass. W##d5 7. M.5 NeC2#rs+i5 M. T5 H SteDs+a%5 W. 7. =3@@?a>. T/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./' A .riti.a% e-a(inati#n. +sychological 'cience# A# :03!. W##d5 7. M.5 NeC2#rs+i5 M. T5 H SteDs+a%5 W. 7. =3@@?b>. T/in+in& .riti.a%%y ab#$t t/e C#(*re/ensi,e Syste( 6#r t/e R#rs./a./' A re*%y t# E-ner. +sychological 'cience# A# 39038.

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CHAPTER 1i#%#&i.a% 1ases #6 Psy./#*at/#%#&y R#bert H. H#2%and University o f +ittsburgh 'chool o f Medicine #'e bio.ogi)a. basis of psy)'o.ogi)a. disorders 'as been t'e sub6e)t of extensi/e study and pas1 sionate debate 2=u4e$ *+B+3. A.. formu.ations of psy)'opat'o.ogy must in)orporate bio.ogi)a. fa)tors$ be)ause bio.ogy is t'e study of .ife pro)esses. %sy)'opat'o.ogy is t'e manifestation of disordered pro)esses in /arious brain systems t'at mediate psy)'o.ogi)a. fun)tions. #'us$ dis1 turban)es in su)' brain fun)tions as per)eption$ .earning$ t'oug't$ memory$ emotions$ )ommu1 ni)ations$ and .anguage 'a/e bio.ogi)a. underpinnings 2Bu)-$ *+++3. Contemporary resear)' 'as tended to fo)us on t'e study of parti)u.ar disorders. &o(e/er$ t'ere is a de/e.oping a(areness t'at /arious psy)'opat'o.ogi)a. states are not .imited to spe)ifi) disorders 2C.oninger$ *+++3. "n t'is )'apter$ " (i.. re/ie( some aspe)ts of t'e neurobio.ogy and geneti)s of depression$ anxiety$ mania$ psy)'osis$ and persona.ity$ ('i)' (i.. support a genera. )on)eptua. mode. of psy)'opat'o.ogy as a )omp.ex intera)tion among geneti)a..y inf.uen)ed neurobio.ogi)a. be1 'a/iora. traits$ dysregu.ation of /arious brain systems$ and t'e )entra. ner/ous system 2CN 3 response to en/ironmenta. inf.uen)es and stress 2Cooper$ 9,,*C 8enenberg$ 9,,,3. A1NORMALITIES OF NEURO1IOLOGICAL RESPONSE SYSTEMS #'e ear.iest t'eories of t'e bio.ogi)a. basis of /arious psy)'o.ogi)a. disorders suggested dys1 fun)tion of CN systems subser/ed by -ey neurotransmitters5 norepinep'rine 2NE3$ serotonin 2<1 'ydroxytryptamine or <1&#3$ and dopamine 28A3. #'ese neurotransmitters (ere found to regu.ate /ita. bodi.y fun)tions t'at often are disturbed in patients (it' psy)'o.ogi)a. disorders 2e.g.$ energy$ s.eep$ appetite$ .ibido$ and psy)'omotor be'a/ior3. 8ysregu.ation of NE$ <1&#$ and 8A systems$ indi/idua..y or in )ombination$ a.so (as be.ie/ed to be more broad.y asso)iated (it' psy)'opat'o.ogi)a. states of depression$ anxiety$ mania$ and psy)'osis 2@a'n H 8a/is$ *++<C Maes H Me.t4er$ *++<C Ninan H Cummins$ 9,,:C )'at4berg H )'i.d-raut$ *++<C Wi..ner$ *++<3. Moreo/er$ t'e first effe)ti/e p'arma)o.ogi)a. treatments for depression and anxiety 2tri)y).i) and monoamine oxidase in'ibitor antidepressant drugs3 (ere s'o(n to 'a/e effe)ts t'at en'an)ed NE andLor <1&# neurotransmission$ and t'e first effe)ti/e p'arma)o.ogi)a. treatments for mania and psy)'osis 2antipsy)'oti) drugs su)' as )'.orproma4ine3 (ere s'o(n to b.o)- 8A neurotransmission. ubse7uent resear)' 'as dis)onfirmed t'e most 210

211 HOWLAND simp.isti) mode.s of a.tered neurotransmitter .e/e.s in t'e pat'op'ysio.ogy of psy)'o.ogi)a. disorders$ but 'as yie.ded substantia. e/iden)e of disturbed neurotransmitter fun)tion in different brain regions of subgroups of peop.e (it' depression$ /arious forms of anxiety$ mania$ and psy)'osis. "n addition$ t'is resear)' 'as re/ea.ed t'e staggering )omp.exity of integrated CN response systems. Examp.es of su)' )omp.exity in).ude t'e identifi)ation of do4ens of additiona. peptide and amino a)id neurotransmitters$ re)ognition t'at neurons )an express re)eptors for se/era. different types of neurotransmitters 2enab.ing dire)t 0)ross1ta.-0 bet(een /arious neurona. systems3$ and e.u)idation of intra)e..u.ar me)'anisms of gene transdu)tion 28uman$ &eninger$ H Nest.er$ *++DC Nemeroff$ *++B3. N#radrener&i. Syste(s A.most a.. of t'e NE )e.. bodies in t'e brain are .o)ated in t'e .o)us )eru.eus 2LC3$ .o)ated in t'e rostra. pons of t'e brain stem. Noradrenergi) neurons pro6e)t (ide.y from t'e LC to t'e t'a.amus$ 'ypot'a.amus$ .imbi) system$ basa. gang.ia$ and )erebra. )ortex 2@ande.$ )'(art4$ H Jesse..$ *++*C @ings.ey$ 9,,,3. u)' diffuse distribution ref.e)ts t'e broad ro.e of NE in initiating and maintaining .imbi) and )orti)a. arousa.$ as (e.. as modu.ation of ot'er neura. systems. For examp.e$ noradrenergi) pro6e)tions to t'e amygda.a and 'ippo)ampus 'a/e been imp.i)ated in be'a/iora. sensiti4ation to stress 2Ferry$ Roo4endaa.$ H M)=aug'$ *+++3$ ('i)' is re.e/ant to understanding some aspe)ts of t'e pat'op'ysio.ogy of depression and anxiety 2Ninan H Cummins$ 9,,:3. timu.ation of t'e media. forebrain bund.e$ anot'er ma6or NE pat'(ay in t'e brain$ en'an)es attention and in)reases .e/e.s of goa.1dire)ted or re(ard1see-ing be'a/ior 2Aston1Jones$ Ra6-o(s-i$ H Co'en$ *+++3$ suggesting a ro.e for NE in t'e pat'op'ysio.ogy of 'ypomani) and mani) states 28epue H "a)ono$ *+B+3. "n support of t'is re.ations'ip$ .ongitudina. studies of bipo.ar disorder s'o( in)reased urinary NE metabo.ite .e/e.s fo..o(ing s'ifts from depression into mania$ and .it'ium treatment de)reases NE turno/er in mani) patients 2 )'at4berg H )'i.d-raut$ *++<3. #'ese findings support t'e 'ypot'esis t'at NE modu.ates t'e s(it)' pro)ess in bipo.ar disorder 2Bunney$ =ood(in$ Murp'y$ &ouse$ H =ordon$ *+D93. %er)eption of no/e. or t'reatening stimu.i is re.ayed from t'e )erebra. )ortex to t'e LC /ia t'e t'a.amus and 'ypot'a.amus. #'is input )an pro/o-e an a.most immediate in)rease in NE a)ti/ity from t'e LC. "n addition$ pat'(ays from t'e )erebra. )ortex a.so )an stimu.ate re.ease of t'e 'ypot'a.ami) neuropeptide )orti)otrop'in re.easing 'ormone 2CR&3$ ('i)' )an 0turn on0 t'e LC and synergisti)a..y mediate t'e response to externa. stimu.i or stress 2Nest.er$ A.re6a$ H Ag'a6anian$ *+++3. Cogniti/e pro)esses affe)ting per)eption t'us )an amp.ify or dampen NE )e..u.ar responses to interna. or externa. stimu.i$ ('i)' is )onsistent (it' t'e possibi.ity t'at dysregu.ation of t'ese NE systems mig't )ontribute to pat'o.ogi)a. states of anxiety$ su)' as pani) atta)-s$ so)ia. anxiety$ and p'obias 2Mat'e($ Cop.an$ H =orman$ 9,,*3. #'e perip'era. ner/ous system response to stress is triggered by t'e LC$ ('i)' stimu.ates t'e re.ease of NE and t'e g.u)o)orti)oid 'ormone Cortisol from t'e adrena. g.ands. #'e a)ti/ity of NE neurons is regu.ated in part by t'e autoin'ibitory effe)ts of noradrenergi) autore)eptors. #'us$ neurona. re.ease of NE immediate.y begins to de)rease t'e sensiti/ity of LC neurons to repeated firing. Noradrenergi) re)eptors a.so are .o)ated on serotonergi) )e.. bodies$ and stimu.ation of t'ese 'etero)eptors a)ti/ates in'ibitory <1&# neurons. A sustained in)rease in LC firing 2e.g.$ in response to persistent stress3 a.so )auses t'e number of noradrenergi) re)eptors to de)rease$ a pro)ess -no(n as do(n1regu.ation or desensiti4ation. #oget'er$ noradrenergi) autoin'ibition$ noradrenergi) re)eptor do(n1regu.ation$ and a)ti/ation of )o.o)a.i4ed in'ibitory

<1&# tra)ts )onstitute t'e )ounterregu.atory for)es t'at promote 'omeostasis in t'e fa)e of sustained stress 2i.e.$ NE1mediated arousa.3. Wit' )'roni) stress$

?. 1IOLOGICAL 1ASES OF PSYCHOPATHOLOGY 213 'o(e/er$ NE stores (i.. be)ome dep.eted be)ause demand or turno/er e/entua..y (i.. ex)eed synt'eti) )apa)ity. W'en t'is o))urs$ t'ere (i.. be diminis'ed autoin'ibitory noradrenergi) and <1&# input to t'e LC$ resu.ting in dysregu.ated NE neurotransmission and in)reased firing of t'e LC. !/er time$ t'e net effe)t is t'at CN NE neurotransmission (i.. de)rease$ but perip'era. ner/ous system output of NE and Cortisol from t'e adrena. g.ands may remain 'ig'. #'e be'a/iora. )onse7uen)es of a)ute stress on NE systems in).ude 'eig'tened anxiety 2in).uding pani) symptoms3$ fearfu.ness$ and psy)'omotor agitation. For t'is reason$ dysregu1 .ation of NE systems 'a/e been imp.i)ated in t'e pat'op'ysio.ogy of /arious anxiety disorders$ ('i)' often are responsi/e to antidepressant drug treatment. #'ere a.so is some e/iden)e t'at in)reased NE a)ti/ity may )ontribute to t'e genesis of psy)'oti) symptoms. "n addition to b.o)-ing t'e effe)ts of 8A$ some antipsy)'oti) drugs a.so b.o)- noradrenergi) re)eptors$ ('i)' mig't )ontribute to t'eir ).ini)a. effe)ts in t'e treatment of psy)'osis. By )ontrast$ )'roni) stress on NE systems .eads to de)reased exp.oratory and )onsummatory be'a/ior$ a state des)ribed in anima. mode.s of depression as .earned 'e.p.essness 2Maier H e.igman$ *+D?3. A.t'oug' not synonymous (it' depression in 'umans$ .earned 'e.p.essness in anima.s )an be /ie(ed as an ana.ogous state of CN 0ex'austion0 asso)iated (it' redu)tions of NE .e/e.s in t'e CN and e.e/ated C#rtis#% a)ti/ity 2Weiss H @i.ts$ *++B3. Not surprising.y$ antidepressant drugs$ ('i)' de)rease t'e turno/er of NE and de)rease t'e firing rate of LC neurons 2Ress.er H Nemeroff$ *+++3$ )an norma.i4e t'e be'a/iors asso)iated (it' .earned 'e.p.essness in anima.s. Ser#t#ner&i. Syste(s Most of t'e <1&# in t'e brain is synt'esi4ed in dorsa. rap'S nu).ei of t'e brain stem. #'ese <1&# neurons pro6e)t to t'e )erebra. )ortex$ 'ypot'a.amus$ t'a.amus$ basa. gang.ia$ septum$ and 'ippo)ampus 2@ande. et a..$ *++*C @ings.ey$ 9,,,3. erotonin pat'(ays are .arge.y )o.o1)a.i4ed (it' NE pat'(ays and genera..y 'a/e toni) and in'ibitory effe)ts t'at )ounterba.an)e NE a)ti/ity. erotonergi) input to t'e t'a.amus fa)i.itates appetite and input to t'e anterior 'y1 pot'a.amus 'e.ps to regu.ate su)' )ir)adian r'yt'ms as s.eep1(a-e )y).es$ body temperature$ and 'ypot'a.ami)1pituitary1adrena. axis fun)tion 2Bunney H Bunney$ 9,,,C 8un)an$ *++?3. #oni) <1&# neurotransmission is ne)essary for affi.iati/e be'a/ior 2"nse. H Wins.o($ *++B3 and for t'e expression of goa.1dire)ted motor and )onsummatory be'a/iors t'at are primari.y mediated by NE and 8A. Anima.s (it' .o(er basa. <1&# .e/e.s genera..y 'a/e .o(er ran-ings on so)ia. dominan)e 'ierar)'ies t'an do anima.s (it' 'ig'er .e/e.s 2&ig.ey$ Me'.man$ H &ig.ey et a..$ *++?C &ig.ey$ Me'.man$ H %o.and et a..$ *++?3. Con/erse.y$ a rise in so)ia. dominan)e is a))ompanied by an in)rease in <1&# .e/e.s 2Me'.man et a..$ *++<3. #'e basa. .e/e. of <1&# neurotransmission in primates is part.y under geneti) )ontro. 2&ig.ey$ Me'.man$ H &ig.ey et a..$ *++?3. "n 'umans$ t'e 'eritabi.ity of <1&# neurotransmission )ou.d be mediated by genes for t'e <1&# transporter$ t'e en4ymes in/o./ed in <1&# synt'esis or degradation$ or <1&# re)eptor subtypes 2Mann$ Brent$ H Arango$ 9,,*3. tudies in/estigating spe)ifi) genes are under(ay t'roug'out t'e (or.d. For examp.e$ geneti) po.ymorp'isms of t'e <1&# transporter gene$ ('i)' is in/o./ed in t'e reupta-e of <1&# at brain synapses and is t'e site of a)tion of serotonin reupta-e in'ibitor antidepressant drugs$ 'a/e been asso)iated (it' depression$ anxiety$ and some persona.ity temperaments and traits 2e.g.$ neuroti)ism and negati/e emotiona.ity3 2Murp'y et a..$ 9,,*3. C'roni) stress (i.. do(n1regu.ate <1&#1*A re)eptors$ .eading e/entua..y to dep.etion of <1&# stores 2LMpe4$ Liber4on$ >Y47ue4$ Aoung$ H Watson$ *+++C Weiss H @i.ts$ *++B3. "n anima.

mode.s of depression$ t'is state is asso)iated (it' (eig't .oss$ de)reased s.eep$ and de)reased exp.oratory be'a/ior. "n 'umans$ brain imaging studies 'a/e found dysfun)tion

215 HOWLAND of <1&#1*A re)eptors in depression 28re/ets et a..$ *+++C ta.ey Ma.ison$ H "nnis$ *++B3. "nteresting.y$ t'e experimenta. e.imination of tryptop'an 2a <1&# pre)ursor3 from food in unaffe)ted re.ati/es of peop.e (it' depression or mania )an indu)e depression symptoms 2Kuintin et a..$ 9,,*3. 8e)reased <1&# neurotransmission is not spe)ifi) to any parti)u.ar psy)'o.ogi)a. disorder$ but 'as been )onsistent.y .in-ed to an in)reased ris- of )omp.eted sui)ide$ potentia..y .et'a. sui)ide attempts$ and ot'er /io.ent$ .ife1t'reatening be'a/iors 2Maes H Me.t4er$ *++<C Mann$ Brent$ H Arango$ 9,,*3. Anima.s (it' .o(er basa. <1&# .e/e.s are more impu.si/e and aggressi/e$ mi)e .a)-ing <1&#1"B re)eptors are more aggressi/e$ and treatment (it' serotonergi) antidepressant drugs de)reases impu.si/e aggression 2Fairban-s$ Me.ega$ Jorgensen$ @ap.an$ H M)guire$ 9,,*3. &en)e$ de)reased <1&# a)ti/ity may be a more enduring$ trait.i-e p'enomenon t'at is asso)iated (it' impu.si/ity and aggression. 8e)reased in'ibitory <1&# a)ti/ity )an .ead to in)reased re.ease of NE$ 8A$ CR&$ and t'e ex)itatory amino a)id neurotransmitter g.utamate 2 asa-i1Adams H @e..ey$ 9,,*C Weiss H @i.ts$ *++B3. #'is effe)t may part.y exp.ain t'e asso)iation bet(een .o( .e/e.s of <1&# and t'e de/e.opment of mani) symptoms$ psy)'osis$ and anxiety states. For examp.e$ t'ere is indire)t e/iden)e t'at .o( .e/e.s of <1&# are asso)iated (it' a /u.nerabi.ity to de/e.op mani) episodes 2C'ouinard$ Aoung$ Brad(e6n$ H Annab.e$ *+B:3$ ref.e)ting t'e fai.ure of in'ibitory )ontro. o/er t'e in)reases in NE and 8A t'at are asso)iated (it' s(it)'es into mania 2Bunney et a..$ *+D9C )'at4berg$ Rot's)'i.d$ Lang.ais$ Bird$ H Co.e$ *+B<3. A.so$ 'a..u)inogeni) drugs t'at affe)t <1 &# systems$ su)' as .ysergi) a)id diet'y.amide 2L 83$ )ause psy)'oti) symptoms$ and antipsy)'oti) drugs t'at b.o)- <1&# in addition to 8A are effe)ti/e in treating psy)'oti) symptoms. #'ese obser/ations 'a/e .ed to t'e /ie( t'at intera)tions bet(een <1&# and 8A may be in/o./ed in t'e pat'op'ysio.ogy of psy)'osis 2Rot' H Me.t4er$ *++<3. Fina..y$ in anima. studies$ mi)e .a)-ing <1&#1*A re)eptors s'o( in)reased anxiety1.i-e be'a/ior 2Fairban-s et a..$ 9,,*3$ and /arious serotonergi) drugs are effe)ti/e in t'e treatment of anxiety. A.t'oug' dysregu.ation of <1&# 'as been imp.i)ated in t'e etio.ogy of obsessi/e1)ompu.si/e disorder in parti)u.ar$ based on t'e distin)t t'erapeuti) benefits of potent serotonergi) antidepressant drugs$ it is more .i-e.y t'at <1&# modu.ates t'e a)ti/ity of brain )ir)uits in/o./ing t'e orbitofronta. )ortex and basa. gang.ia in t'is disorder 28e.gado H Moreno$ *++B3. A.toget'er$ t'ese findings are )onsistent (it' t'e broader ro.e of <1&# neurotransmission as a modu.ator of CN stress response systems. D#*a(iner&i. Syste(s #'ere are four prin)ipa. 8A pat'(ays in t'e brain 2@ande. et a..$ *++*C @ings.ey$ 9,,,3. #'e tuberoinfundibu.ar system pro6e)ts from t'e 'ypot'a.amus to t'e pituitary g.and and in'ibits se)retion of t'e 'ormone pro.a)tin. #'e nigrostriatra. system$ ('i)' 'e.ps to regu.ate psy)'omotor a)ti/ity$ originates from t'e substantia nigra and pro6e)ts to t'e basa. gang.ia. #'e meso.imbi) pat'(ay begins in t'e /entra. tegmentum and pro6e)ts to t'e nu).eus a))umbens$ amygda.a$ 'ippo)ampus$ media. dorsa. nu).eus of t'e t'a.amus$ and )ingu.ate gyrus. #'e meso.imbi) 8A pat'(ay modu.ates emotiona. expression and goa.1dire)ted or )onsummate.y be'a/ior. #'e meso)orti)a. 8A pat'(ay$ ('i)' pro6e)ts from t'e /entra. tegmentum orbitofronta. and prefronta. )erebra. )ortex$ subser/es moti/ation$ initiation of goa.1dire)ted tas-s$ )ogniti/e pro)esses$ and so)ia. be'a/ior. C'roni) stress redu)es 8A .e/e.s and resu.ts in be'a/iora. )'anges suggesti/e of depression 2Wi..ner$ *++<3. For examp.e$ de)reased 8A a)ti/ity 'as been imp.i)ated in t'e de/e.opment of

psy)'omotor retardation$ an'edonia$ and impaired )ognition seen in depression. tudies of antidepressant drugs 'a/e found t'at treatment )an re/erse or pre/ent t'e 8A dysfun)tion )aused by )'roni) stress 2Cuadra$ Rurita$ =ioino$ H Mo.ina$ 9,,*C Wi..ner$ *++D3. imi.ar.y$

?. 1IOLOGICAL 1ASES OF PSYCHOPATHOLOGY 217 negati/e symptoms of psy)'osis 2i.e.$ po/erty of spee)' and t'oug't$ affe)ti/e f.attening$ an'edonia$ so)ia. (it'dra(a.$ inattention$ anergia$ and )ogniti/e impairment3 may resu.t from de)reased fun)tioning of meso)orti)a. 8A neurons in t'e prefronta. )ortex 2@a'n and 8a/is$ *++<3. Negati/e symptoms may impro/e (it' drugs t'at se.e)ti/e.y en'an)e prefronta. 8A neurotransmission. By )ontrast$ in)reased meso.imbi) 8A a)ti/ity may .ead to positi/e symptoms of psy)'osis 2i.e.$ 'a..u)inations and de.usions3 in patients (it' se/ere depression$ s)'i4op'renia$ and se/ere mania. E.e/ated Cortisol .e/e.s )an in)rease 8A a)ti/ity$ ('i)' may )ontribute to t'e de/e.opment of psy)'oti) symptoms in t'ese patients as (e.. as in patients ('o ta-e 'ig' doses of g.u)o)orti)oid drugs su)' as prednisone 2 )'at4berg H Rot's)'i.d$ *++93. A.so$ in)reased meso)orti)a. and meso.imbi) 8A a)ti/ity may be re.ated to su)' mani) symptoms as eup'oria$ grandiosity$ 'ypera)ti/ity$ 'ypersexua.ity$ and disin'ibited be'a/iors 28epue H "a)ono$ *+B+C )'at4berg et a..$ *+B<C (erd.o( H @oob$ *+BD3. Brain imaging studies 'a/e found t'at 8A19 re)eptors are up1regu.ated in mania )ompared to depression and t'at 8A19 re)eptor up1 regu.ation is greater in psy)'oti) mania t'an in nonpsy)'oti) mania 2%ear.son et a..$ *++<3. C'roni) or 'ig'1dose treatment (it' stimu.ant drugs$ ('i)' en'an)e 8A fun)tion$ )an a.so )ause a syndrome indistinguis'ab.e from mania 2Wi..ner$ *++<3. %atients (it' bipo.ar disorder are more sus)eptib.e t'an ot'er depressed patients to t'e mood1e.e/ating effe)ts of drugs affe)ting 8A 2in).uding antidepressants3$ ('i)' )an often pre)ipitate 'ypomani) or mani) episodes 2Bunney et a..$ *+D9C Wi..ner$ *++<3. Lit'ium and antipsy)'oti) drugs )an attenuate some of t'e 8A stimu.ated be'a/iors in anima.s 2 (erd.o( H @oob$ *+BD3 and are ).ini)a..y effe)ti/e in t'e treatment of mania and psy)'osis. "nteresting.y$ 8A b.o)-ing drugs may be effe)ti/e in treating some patients (it' se/ere anxiety$ suggesting a possib.e ro.e for 8A systems in t'e pat'op'ysio.ogy of some anxiety states. =amma amino butyri) a)id 2=ABA3 'as in'ibitory effe)ts on NE and 8A pat'(ays. =ABA re)eptors are dense.y .o)a.i4ed in t'e t'a.amus and as)ending meso)orti)a. and meso.imbi) systems 2@ings.ey$ 9,,,C %au.$ *++<3. C'roni) stress )an redu)e or dep.ete =ABA .e/e.s in t'ese regions of t'e brain 2Weiss H @i.ts$ *++B3. 8e)reased =ABA fun)tion )ou.d .ead to in)reased 8A a)ti/ity$ )ontributing to t'e de/e.opment of psy)'omotor agitation$ anxiety$ mania$ and psy)'osis. Ben4odia4epine drugs atta)' to =ABA re)eptors$ ('i)' mig't dampen 8A a)ti/ity and exp.ain t'eir t'erapeuti) benefits in t'e treatment of anxiety$ mania$ and psy)'osis 2%au.$ *++<3. STRESS AND THE HYPOTHALAMIC0PITUITARY0ADRENAL =HPA> A<IS #'e per)eption of stress is .in-ed to adrena. g.and a)ti/ity by pat'(ays extending from t'e )erebra. )ortex and 'ypot'a.amus to t'e pituitary g.and. #'e stress1responsi/e g.u)o)orti)oid 'ormone C#rtis#% is re.eased by t'e adrena. g.and in response to a (ide /ariety of p'ysi)a. and psy)'oso)ia. stresses. #'e &%A axis is part.y under t'e )ontro. of p'asi) NE 2a)ti/ating3 and toni) <1&# 2in'ibitory3 neurotransmission. "n t'e 'ypot'a.amus$ t'e neuropeptide CR& is re.eased in response to stimu.ation from NE and g.utamate inputs$ typi)a..y in response to t'e per)eption of stress or t'reat. CR& t'en triggers re.ease of adreno)orti)otrop'i) 'ormone 2AC#&3$ ('i)' tra/e.s from t'e pituitary g.and to t'e adrena. g.and$ ('ere g.u)o)orti)oid 'ormones are synt'esi4ed and re.eased. Cortiso. binds to g.u)o)orti)oid re)eptors on /arious )e..s t'roug'out t'e body$ ('i)' regu.ate t'e immune system$ g.u)ose and .ipid metabo.ism$ and ot'er )e..u.ar fun)tions t'at fa)i.itate s'ort1term sur/i/a. in response to o/er('e.ming or .ife1

t'reatening stress 2&o.sboer$ 9,,,3. !rdinari.y$ t'e &%A axis is tig't.y regu.ated by

219 HOWLAND a redundant$ mu.ti.e/e. system of negati/e feedba)- in'ibitory )ontro. at t'e .e/e. of t'e 'y1 pot'a.amus$ pituitary g.and$ adrena. g.and$ and 'ippo)ampus. As a)ute stresses pass or reso./e$ e.e/ated p.asma C#rtis#% .e/e.s in 'ea.t'y 'umans (i.. norma.i4e (it'in minutes or 'ours. ustained 'yper)ortiso.ism )an resu.t from in)reased CR& dri/e 2from t'e 'ypot'a.amus or 'ig'er )erebra. )orti)a. areas of t'e brain3$ in)reased se)retion of AC#& 2e.g.$ from a pituitary tumor3$ diminis'ed in'ibitory feedba)- from dysfun)tiona. 'ippo)ampa. g.u)o)orti)oid re)eptors$ unrestrained noradrenergi) stimu.ation from t'e .o)us )eru.eus$ diminis'ed seroton1 ergi) in'ibition$ or t'e fai.ure of one or more me)'anisms of feedba)- in'ibition 2&o.sboer$ *++<C &o(.and H #'ase$ *+++3. Neurons )ontaining CR& are diffuse.y .o)ated t'roug'out t'e )erebra. )ortex$ espe)ia..y (it'in t'e t'a.amus$ amygda.a$ and ot'er )omponents of t'e .imbi) system. tudies measuring CR& synt'esis demonstrate t'at t'ese brain regions 0.ig't up0 immediate.y fo..o(ing exposure to stress 2&o.sboer$ *++<3. Be)ause CR& a)ti/ates t'e LC$ ('i)' in turn furt'er stimu.ates t'e t'a.amus$ 'ypot'a.amus$ and amygda.a$ sustained stress )an pro/o-e a 0re/erberating )ir)uit0 or a positi/e feedba)- .oop$ resu.ting in destabi.i4ation of t'e &%A axis 2&o.sboer$ 9,,,C Nemeroff$ *++B3. ustained 'yper)ortiso.ism )an impair &%A axis feedba)- in'ibition 2Bremner$ *+++3. For examp.e$ pro.onged AC#& stimu.ation )an )ause adrena. 'ypertrop'y$ resu.ting in in)reased synt'esis and re.ease of Cortisol. #'e )e..s expressing g.u)o)orti)oid re)eptors in t'e 'ippo)am1 pus are sensiti/e to /ery 'ig' )on)entrations of Cortisol and (i.. e/entua..y die 2 apo.s-y$ 9,,,3. &ippo)ampa. )e.. deat' due to sustained 'yper)ortiso.ism is most .i-e.y to o))ur ear.y in de/e.opment and .ater in o.d age. For examp.e$ exposure to stress ear.y in .ife )an permanent.y impair norma. regu.ation of &%A axis a)ti/ity 2@aufman$ %.ots-y$ Nemeroff$ H C'arney$ 9,,,C M)E(en$ 9,,,3. "n anima. mode.s of ear.y trauma$ brief periods of materna. separation )an resu.t in .ong1standing )'anges in stress responses$ ('i)' )an be part.y )ompensated for by )ompetent materna. be'a/ior 2Cop.an et a..$ 9,,*3. tress in .ater .ife a))e.erates t'e s.o( de).ine in t'e integrity of &%A axis regu.ation t'at o))urs norma..y (it' aging. #'e age1 dependent )'ange in &%A axis regu.ation is due to t'e deat' of 'ippo)ampa. g.u)o)orti)oid re)eptor )e..s. E/iden)e of 'yper)ortiso.ism and dysregu.ation of &%A axis a)ti/ity is typi)a..y found in ;,P to ?,P of depressed peop.e$ but is more )ommon.y asso)iated (it' o.der age$ psy)'oti) symptoms$ se/ere depression and anxiety$ psy)'omotor agitation$ (eig't .oss$ insomnia$ and sui)ida.ity 2&o(.and H #'ase$ *+++3. #'e types of &%A axis abnorma.ities seen in depression are a.so found in mania$ a.t'oug' usua..y to a .ess se/ere degree t'an in depression 2Coo-son$ *+B<C Lin-o(s-i et a..$ *++;C )'mider et a..$ *++<3. "nteresting.y$ t'e &%A axis may be re.ati/e.y 7uies)ent in depression )'ara)teri4ed by .o( energy$ su)' as bipo.ar depression 2=era)ioti$ Loosen$ H !rt'$ *++D3$ but may be)ome o/era)ti/e in psy)'oti) mania 2Coo-son$ *+B<C Lin-o(s-i et a..$ *++;C )'mider et a..$ *++<3$ possib.y re.ated to de)reased and in)reased a)ti/ation$ respe)ti/e.y$ of t'e dopaminergi) meso)orti)o.imbi) system. "n addition$ a signifi)ant minority of peop.e (it' a)ute s)'i4op'renia$ posttraumati) stress disorder$ and ot'er anxiety disorders 'a/e abnorma. &%A axis a)ti/ity. &yper)ortiso.ism a.so is asso)iated (it' memory and ot'er )ogniti/e impairments$ ('i)' may ref.e)t neurona. atrop'y and )e.. deat' in t'e prefronta. )ortex and 'ippo)ampus 2Be.anoff$ =ross$ Aager$ H )'at4berg$ 9,,*3. Be)ause 'yper)ortiso.ism tends to )oaggregate (it' /arious measures of NE$ <1&#$ and 8A dysfun)tion$ drugs (it' dire)t or indire)t effe)ts on t'ese neurotransmitter systems tend to

norma.i4e dysregu.ation of t'e &%A axis 2&o.sboer$ *++<C Maes H Me.t4er$ *++<C )'at4berg H )'i.d-raut$ *++<3. For examp.e$ antidepressant drugs initiate an effe)t at <1&# orNE re)eptors$ and t'ese re)eptors a)ti/ate membrane1bound = proteins and /arious en4ymes 28uman et a..$ *++DC 'e.ton$ 9,,,3. #'ese en4ymes )ata.y4e t'e formation of 0se)ond messengers$0 su)' as )y).i) adenomonop'osp'ate 2)AM%3 and dia)y.g.y)ero.. #'e se)ond messengers$ in

?. 1IOLOGICAL 1ASES OF PSYCHOPATHOLOGY 221 turn$ a)ti/ate intra)e..u.ar en4ymes t'at p'osp'ory.ate t'e gene trans)ription fa)tor CREB 2)AM% response e.ement binding protein3. CREB appears to be t'e first )ommon step s'ared by antidepressants t'at se.e)ti/e.y modu.ate NE or <1&# neurotransmission 2 'e.ton$ 9,,,3. %'osp'ory.ated CREB regu.ates t'e a)ti/ity of /arious gene produ)ts re.ated to stress responses$ in).uding CR&$ g.u)o)orti)oid re)eptors$ brain deri/ed neurotrop'i) fa)tor 2B8NF3$ and t'e B8NF re)eptor 28uman et a..$ *++DC 'e.ton$ 9,,,3. B8NF is parti)u.ar.y important be)ause it 'as been s'o(n to stimu.ate neurogenesis 2t'e gro(t' of neurona. )e..s3. Lit'ium$ antidepressants$ and ot'er psy)'otropi) drugs 'a/e been s'o(n to in)rease B8NF .e/e.s and redu)e 'yper)ortiso.ism$ ('i)' re/erse neurona. atrop'y and )e.. deat' in t'e prefronta. )ortex and 'ippo)ampus 28uman$ Ma.berg$ H #'ome$ *+++C Man6i$ Moore$ H C'en$ 9,,,3. #'e ex)itatory amino a)id g.utamate is one of t'e most (ide.y distributed neurotransmitters in t'e CN $ modu.ating t'e effe)t of ot'er neurotransmitters 2@ings.ey$ 9,,,3. =.utamate binds to t'e N1met'y.181aspartate 2NM8A3 re)eptor and$ in ex)ess$ )an 'a/e neurotoxi) effe)ts simi.ar to 'yper)ortiso.ism. =.utamate )an )ause degeneration of )e..s in t'e 'ippo)ampus and amygda.a$ ('i)' 'a/e 'ig' )on)entrations of NM8A re)eptors 2Mat'e($ Cop.an$ mit' et a..$ 9,,*3$ and t'is effe)t mig't )ontribute to t'e neurotoxi) effe)ts of in)reased C#rtis#%5 furt'er de)reasing negati/e feedba)- t'at a)ti/ates t'e &%A axis 2M)E(en et a..$ *++93. #'us$ g.utamate .i-e.y )ontributes to t'e progressi/e$ de.eterious neuro)ogniti/e effe)ts of )'roni) stress in patients (it' depression$ anxiety$ mania$ and psy)'osis 2Mat'e($ Cop.an$ mit' et a..$ 9,,*3. #'ere is de/e.oping e/iden)e t'at /arious psy)'otropi) drugs mig't (or- in part /ia dire)t or indire)t effe)ts on NM8A re)eptor systems 2Anand et a..$ 9,,,3. 1RAIN CIRCUITS AND PSYCHOPATHOLOGY Computed axia. tomograp'y 2CA#3 and magneti) resonan)e imaging <M'0= s)ans pro/ide sensiti/e and nonin/asi/e met'ods to /isua.i4e different brain stru)tures. tudies in patients (it' mood disorders 'a/e found /entri)u.ar en.argement$ )orti)a. atrop'y$ su.)a. (idening$ and abnorma. .esions 2espe)ia..y t'e peri/entri)u.ar area$ basa. gang.ia$ and t'a.amus3 2E.-is$ Friedman$ Wise$ H Me.t4er$ *++<C 'e.ine$ 9,,,C oares H Mann$ *++DC tra-o(s-i et a..$ *++:3. #'ese abnorma.ities are asso)iated (it' ad/an)ed age$ i..ness se/erity$ symptom )'roni)ity$ and in)reased C#rtis#% .e/e.s 2Coffey$ Wi.-inson$ Weiner$ Rit)'ie$ H A7ue$ *++:3. Mood disorder patients a.so 'a/e brain )'anges in t'e 'ippo)ampus$ amygda.a$ )audate nu).eus$ putamen$ and prefronta. )ortex$ ('i)' are important stru)tures in t'e meso)orti)o.imbi) system 2Coffey et a..$ *++:C @ris'nan$ &ays$ H B.a4er$ *++D3. #'ese )'anges may ref.e)t t'e neurodegenerati/e effe)ts of re)urrent episodes of depression and mania. ome of t'ese abnor1 ma.ities are surprising.y simi.ar to t'e brain )'anges found in patients (it' s)'i4op'renia$ ('o typi)a..y 'a/e de)reased gray matter$ en.arged /entri).es$ and abnorma.ities in t'e 'ippo)ampus$ prefronta. )ortex$ )audate nu).eus$ t'a.amus$ and )orpus )a..osum 2Weinberger$ *++<3. tudies of patients (it' different anxiety disorders 'a/e found brain )'anges in t'e tempora. .obes$ amygda.a$ 'ippo)ampus$ orbitofronta. )ortex$ )audate nu).eus$ and t'a.amus 2#a.bot$ Mat'e($ H Larue..e$ 9,,:3. "n )ontrast to t'ese studies$ ('i)' /isua.i4e brain stru)tures$ ot'er brain imaging te)'no.ogies are used to /isua.i4e and measure brain fun)tion 2i.e.$ )erebra. b.ood f.o( and )erebra. metabo.ism3. #'ese te)'no.ogies in).ude fun)tiona. magneti) resonan)e imaging 2fMR"3$ magneti) resonan)e spe)tros)opy 2MR 3$ and positron emission tomograp'y 2%E#3 2W'a.en et a..$ *++B3. Experimenta..y pro/o-ed emotions 2e.g.$ arousa. and sadness3 'a/e been s'o(n to in)rease

)erebra. b.ood f.o( to t'e t'a.amus$ media. prefronta. )ortex$ and .eft amygda.a in 'ea.t'y persons 2Lane$ Reiman$ A'ern$ )'(art4$ H 8a/idson$ *++DC Liotti et a..$ 9,,,C

223 &!WLAN8 Mayberg et a..$ *++DC Mayberg et a.$ *+++3. #'ese studies of 'ea.t'y persons suggest t'e potentia. in/o./ement and re.e/an)e of t'ese .imbi)1)orti)a. regions in pat'o.ogi)a. states of depression. "ndeed$ in /arious studies of depressed patients$ fun)tiona. brain )'anges 'a/e been found in t'e orbita. and media. prefronta. )ortex$ t'a.amus$ amygda.a$ 'ippo)ampus$ and striatum 2)audate$ putamen$ and nu).eus a))umbens3. #'is (or- 'as .ead to t'e de/e.opment of a mode. of depression )omprised of a .imbi)1)orti)a.1striata.1pa..ida.1t'a.ami) neuroanatomi) )ir)uit$ in/o./ing pat'o.ogi)a. in)reased a)ti/ity in t'e amygda.a$ de)reased 'ippo)ampa. /o.1 ume$ and abnorma. prefronta. )orti)a. fun)tion 28re/ets$ 9,,,aC 'e.ine$ 9,,,3. Abnorma. and asymmetri)a. p'osp'orus metabo.ism 'as been found in t'e fronta. .obes of patients (it' bipo.ar disorder )ompared to norma. )ontro.s 28ei)-en$ Fein$ H Weiner$ *++<C @ato et a..$ *++<3 and in t'e .eft fronta. .obe and basa. gang.ia of patients (it' unipo.ar de1 pression 2Moore$ C'ristensen$ Lafer$ Fa/a$ H Rens'a($ *++D3. Rig't /ersus .eft 'emisp'eri) differen)es in )erebra. b.ood f.o( or metabo.ism may distinguis' depressed and mani) patients$ (it' greater .eft 'emisp'ere de)reases in depression )ompared to greater rig't 'emisp'ere )'anges in mania 2@etter et a..$ *++;C Mayberg$ *++;3. "nteresting.y$ de)reased )erebra. b.ood f.o( and g.u)ose metabo.ism in t'e prefronta. )ortex of patients (it' unipo.ar and bipo.ar depressions is re/ersed fo..o(ing s'ifts from depression into mania 2Baxter et a..$ *+B<C @etter et a..C Mayberg$ *++;3. #'ese findings suggest t'at neuroanatomi) )ir)uits in/o./ing dysregu1.ation of fronta. .obe fun)tioning are a spe)ifi) abnorma.ity in mood disorders 2=eorge$ @etter$ H %ost$ *++;C %o(e.. H Mi-.o(it4$ *++;C 'e.ine$ 9,,:3. #'ere is de/e.oping e/iden)e t'at antidepressants$ .it'ium$ and anti)on/u.sant drugs may partia..y norma.i4e some of t'e fun)tiona. brain )'anges in mood disorders 2Brody et a..$ 9,,*C 8re/ets$ 9,,,bC Martin$ Martin$ Rai$ Ri)'ardson$ H Roya..$ 9,,*3 and a.so mig't en'an)e )ompensatory neura. )ir)uits 2Mayberg et a..$ 9,,,C %ost$ peer$ &oug'$ H Ving$ 9,,:C 'e.ine et a..$ 9,,*3. Limbi) 'ypermetabo.ism is suppressed by effe)ti/e antidepressant drug t'erapy$ but reemerges ('en patients are ta-en off medi)ation 28re/ets$ 9,,,b3. Bremner et a.. 2*++D3 found t'at tryptop'an dep.etion of re)ent.y remitted$ antidepressant1treated sub6e)ts pro/o-ed in)reased a)ti/ity in t'e amygda.a. &en)e$ t'e amygda.a )ou.d represent a -ey 6un)ture in t'e .imbi)1 )orti)a.1striata.1pa..ida.1t'a.ami) neuroanatomi) emotiona. )ir)uit t'at mediates t'e per)eption and transdu)tion of stress into mood symptoms and episodes 2 'e.ine$ 9,,:3. #'e experimenta. indu)tion of anxiety in norma. persons .eads to )'anges in t'e media. prefronta. )ortex$ anterior )ingu.ate )ortex$ orbitofronta. )ortex$ anterior tempora. )ortex$ para1 'ippo)ampa. gyrus$ and amygda.a$ suggesting t'e potentia. re.e/an)e of t'ese regions in pat'o1 .ogi)a. states of anxiety 2#a.bot$ Mat'e($ H Larue..e$ 9,,:3. Brain imaging studies in pat'o1 .ogi)a. anxiety states 'a/e suggested some o/er.ap (it' t'e brain )ir)uits and neura. pat'(ays in/o./ed in depression 2#a.bot et a..$ 9,,:3$ ('i)' is )onsistent (it' t'e -no(n ).ini)a. and geneti) re.ations'ip bet(een depression and anxiety 2Ninan H Cummins$ 9,,:3. For examp.e$ in patients (it' pani) disorder$ redu)ed a)ti/ity 'as been obser/ed in 'ippo)ampa.$ para'ip1 po)ampa.$ and inferior fronta. regions of t'e brain 2=orman$ @ent$ u..i/an$ H Cop.an$ 9,,,3. "n posttraumati) stress disorder$ redu)tions in 'ippo)ampa. /o.ume are a )onsistent finding$ a.ong (it' de)reased a)ti/ity of t'e anterior )ingu.ate gyrus and in)reased a)ti/ity in t'e amygda.a 2#a.bot et a.$ 9,,:3. Fina..y$ in obsessi/e1)ompu.si/e disorder$ t'ere is a 'ig'.y )onsistent pattern of in)reased a)ti/ity in )orti)o1striata.1t'a.ami)1)orti)a. )orti)a. )ir)uits in/o./ing t'e orbitofronta. )ortex and anterior )ortex$ (it' espe)ia..y important )ontributions from basa.

gang.ia stru)tures 2i.e.$ )audate$ putamen$ and nu).eus a))umbens3 2Mi)a..ef H B.in$ 9,,*3. #o some extent$ t'e brain stru)tures and )ir)uits imp.i)ated in t'e pat'op'ysio.ogy of anxiety disorders 'a/e a.so been identified as being an important part of t'e neurobio.ogi)a. systems in/o./ed in .earning and )onditioning. #'is finding is re.e/ant to .earning t'eory perspe)ti/es on t'e etio.ogy of anxiety disorders as (e.. as )ogniti/e and be'a/iora. treatment

?. 1IOLOGICAL 1ASES OF PSYCHOPATHOLOGY 225 approa)'es for anxiety disorders 2Bouton$ Mine-a$ H Bar.o($ 9,,*C C'orpita H Bar.o($ *++B3. For examp.e$ )onditioning t'eories suggest t'at ('en stimu.i 2e.g.$ e/ents or situations3 are paired (it' anxiety 2e.g.$ pani) atta)-s3$ t'e .earning t'at may o))ur )an a..o( t'e stimu.i to trigger anxiety ('en t'ey are en)ountered again. &en)e$ )ogniti/e psy)'ot'erapy 2('i)' fo)uses on t'oug'ts and per)eptions3 and be'a/iora. t'erapies 2('i)' fo)us on exposure and re.axation3 may be effe)ti/e in t'e treatment of anxiety disorders be)ause t'ey target t'ese aspe)ts of .earning and )onditioning. imi.ar to studies in mood disorders$ drug and psy)'ot'erapy treatments may partia..y norma.i4e some of t'e fun)tiona. brain )'anges seen in anxiety dis1 orders 2Baxter et a..$ 9,,,3. "n patients (it' s)'i4op'renia$ fun)tiona. brain imaging studies 'a/e demonstrated profound redu)tions in prefronta. )ortex fun)tion$ ('i)' is )orre.ated ).ini)a..y (it' t'e presen)e of negati/e symptoms of psy)'osis and signifi)ant )ogniti/e impairment 2=ur$ *++<3. By )ontrast$ fun)tiona. )'anges in t'e 'ippo)ampus$ para'ippo)ampa. gyrus$ amygda.a$ and tempora. )ortex 2(it' greater .eft t'an rig't 'emisp'eri) dysfun)tion3 'a/e been obser/ed$ and t'ese appear to be )orre.ated (it' t'e presen)e of t'oug't disorder$ auditory 'a..u)inations$ and .anguage disturban)es 2=ur H =ur$ 9,,,3. Fina..y$ some studies suggest dysfun)tion in t'e basa. gang.ia$ ('i)' 'a/e been asso)iated (it' su)' ).ini)a. symptoms as emotiona. (it'dra(a.$ b.unted affe)t$ and psy)'omotor retardation in s)'i4op'renia 2=ur H =ur$ 9,,,3. GENETICS Fami.y$ t(in$ and adoption studies 'a/e ).ear.y s'o(n t'at mood disorders aggregate (it'in fami.ies$ but t'ere is some degree of geneti) spe)ifi)ity t'at distinguis'es ma6or depression and bipo.ar disorder 2Meri-angas H @upfer$ *++<3. Moreo/er$ t'ese studies a.so suggest t'at bipo.ar disorder may 'a/e a greater geneti) .iabi.ity t'an ma6or depression$ but t'at nongeneti) en/ironmenta. fa)tors are substantia..y important in t'e etio.ogy of mood disorders. imi.ar fami.y$ t(in$ and adoption studies a.so 'a/e found t'at anxiety disorders are strong.y fami.ia. and under geneti) )ontro. 2&ettema$ Nea.e$ H @end.er$ 9,,*3$ but t'at t'ere is some degree of geneti) o/er.ap among some of t'e anxiety disorders and bet(een depression and anxiety$ and t'at t'ere is a signifi)ant nongeneti) en/ironmenta. )omponent as (e.. 2Maier$ 9,,:3. Fami.y$ t(in$ and adoption studies strong.y indi)ate t'at s)'i4op'renia aggregates in fami.ies and t'at a substantia. proportion of t'at aggregation resu.ts from geneti) fa)tors 2Bai.er et a..$ 9,,9C &arrison H !(en$ 9,,:3. &o(e/er$ t'ere is some e/iden)e t'at s)'i4op'renia and ma6or mood disorders may be geneti)a..y re.ated$ per'aps ref.e)ting a )ommon geneti) .iabi.ity for t'e de/e.opment of psy)'osis$ ('i)' )an o))ur in s)'i4op'renia$ se/ere depression$ and mania 2Bai.er et a..$ 9,,93. Many t(in and adoption studies )onfirm t'at 'ereditary fa)tors inf.uen)e t'e de/e.opment of /arious persona.ity traits and temperaments$ su)' as t'ose proposed by Eysen)- 2i.e.$ neuroti1 )ism$ psy)'oti)ism$ and extro/ersion3 or by C.oninger 2i.e.$ no/e.ty see-ing$ 'arm a/oidan)e$ re(ard dependen)e$ and persisten)e3 2As)'auer H )'.oge.'ofer$ 9,,:3. #'e 'eritabi.ity of persona.ity traits is )onsistent (it' t'e idea t'at bio.ogi)a. fa)tors under.ie /arious dimensions of persona.ity 2C.oninger$ /ra-i)$ H %r4ybe)-$ *++:C %.omin H Caspi$ *++B3. For examp.e$ different persona.ity traits may )orrespond to t'e be'a/iora. expression of spe)ifi) neurotrans1 mitter systems in t'e brain 2e.g.$ NE$ <1&#$ and 8A3. #'is t'eory pro/ides some rationa.e for t'e use of psy)'otropi) drugs 2e.g.$ antidepressants and antipsy)'oti)s3 in t'e treatment of some persona.ity disorders 2Bond$ 9,,*C As)'auer H )'.oge.'ofer$ 9,,:3. For examp.e$ serotonergi)

antidepressant drugs$ ('i)' are effe)ti/e in t'e treatment of /arious anxiety disorders$ are used ).ini)a..y to treat patients ('o 'a/e anxiety1re.ated persona.ity disorders 2e.g.$ a/oidant

227 &!WLAN8 or obsessi/e1)ompu.si/e persona.ities3 or traits 2e.g.$ neuroti)ism3. imi.ar.y$ antipsy)'oti) drugs$ ('i)' b.o)- t'e effe)ts of dopamine and are used to treat psy)'oti) disorders$ are used ).ini)a..y to treat psy)'oti)1.i-e persona.ity disorders 2e.g.$ paranoid persona.ity3. &ereditary and bio.ogi)a. fa)tors may 'e.p exp.ain t'e re.ations'ip bet(een persona.ity and /arious psy1 )'o.ogi)a. disorders. For examp.e$ s)'i4otypa. persona.ity and s)'i4op'renia may represent t(o aspe)ts of a psy)'oti)1.i-e spe)trum 2Berenbaum$ #ay.or$ H C.oninger$ *++;3. "n adoption studies$ bio.ogi)a. re.ati/es of persons (it' s)'i4op'renia tend to 'a/e a 'ig'er pre/a.en)e of s)'i4op'renia and s)'i4otypa. persona.ity disorder. #'erefore$ ('at is geneti)a..y transmitted may not be a spe)ifi) .iabi.ity for s)'i4op'renia a.one$ but rat'er some type of genera. .iabi.ity for oddness$ poor psy)'oso)ia. fun)tioning$ andLor psy)'osis. &ereditary and bio.ogi)a. fa)tors under.ying persona.ity traits a.so mig't be a (ay to understand t'e )on)ept of /u.nerabi.ity in t'e de/e.opment of psy)'opat'o.ogy$ su)' as a geneti) p'enotype expressing i..ness or a geneti) sus)eptibi.ity to en/ironmenta. stress )ontributing to i..ness 2M)=ue H Bou)'ard$ *++B3. For examp.e$ some (or- 'as suggested t'at anxiety and depression are /ariab.e expressions of a 'eritab.e trait of neuroti)ism 2E.ey H %.omin$ *++D3. &en)e$ bot' )onditions s'are t'e same geneti) /u.nerabi.ity$ but t'e differentia. a.ternati/e expression as anxiety or as depression must be due to distin)t nongeneti) en/ironmenta. fa)tors. #'e use of /arious mo.e)u.ar geneti)s te)'ni7ues is a /ery a)ti/e area of resear)' in psy1 )'opat'o.ogy. For examp.e$ a /u.nerabi.ity to de/e.op ear.y1onset re)urrent ma6or depression 'as been .in-ed to a geneti) region )ontaining t'e CREB gene$ ('i)' regu.ates t'e a)ti/ity of /arious gene produ)ts re.ated to stress responses 2Ruben-o et a..$ 9,,:3. Extensi/e (or- a.so 'as fo)used on ot'er p.ausib.e )andidate genes in mood disorders$ su)' as t'ose re.ated to NE$ <1&#$ and 8A re)eptors$ transporters$ and metabo.i) en4ymes as (e.. as = proteins and ot'er )omponents of se)ond messenger )e..u.ar signa.ing neurona. pat'(ays. Many re)ent studies 'a/e examined geneti) po.ymorp'isms of t'e <1&# transporter gene$ ('i)' is in/o./ed in t'e reupta-e of <1&# at brain synapses and is t'e site of a)tion of serotonin reupta-e in'ibitor antidepressant drugs 2Murp'y et a..$ 9,,*3. #'ese studies 'a/e found t'at )ertain po.ymorp'isms of t'e <1&# transporter gene are asso)iated (it' neuroti)ism and negati/e emotiona.ity 2persona.ity traits asso)iated (it' depression and anxiety3. !f parti)u.ar interest$ a re)ent study found t'at peop.e (it' s'ort )opies of t'e <1&# transporter gene ex'ibited more depressi/e symptoms$ diagnosab.e depression$ and sui)ida.ity in re.ation to stressfu. .ife e/ents t'an peop.e ('o 'ad .ong )opies of t'e gene 2Caspi et a..$ 9,,:3. "n ot'er (ords$ a fun)tiona. po.ymorp'ism of t'e <1&# transporter gene (as found to moderate t'e inf.uen)e of en/ironmenta. stress on depression rat'er t'an )ausing depression. #'is finding is one examp.e of 'o( genes and en/ironment intera)t to )ause psy)'opat'o.ogy. !t'er studies a.so 'a/e pro/ided e/iden)e of geneti)1en/ironmenta. intera)tions in depression and anxiety 2Cadoret et a..$ *++?C i.berg$ Rutter$ Nea.e$ H Ea/es$ 9,,*3. 8e/e.oping (or- 'as found substantia. e/iden)e t'at geneti)1 en/ironmenta. intera)tions inf.uen)e t'e expression of persona.ity traits 2Les)'$ =reenberg$ &ig.ey$ Bennett$ H Murp'y$ 9,,9C !4-arago4 H Nob.e$ 9,,,3 and t'at t'e 'eritabi.ity of many be'a/iora. traits may be greater in permissi/e t'an in restri)ti/e en/ironments 2@end.er$ 9,,*3. Fina..y$ in s)'i4op'renia$ re)ent studies 'a/e found an asso)iation (it' t'e gene for )ate)'o.1!1 met'y.transferase 2C!M#3$ ('i)' metabo.i4es neurotransmitters$ inf.uen)es fronta. .obe fun)tion$ and regu.ates )orti)a. 8A a)ti/ity 2&arrison H !(en$ 9,,:3$ but geneti)1en/ironmenta. intera)tions are a.so ).ear.y important in t'e de/e.opment of psy)'osis 2Cannon$ @ende..$ usser$

H Jones$ 9,,:C >an !s$ &anssen$ Ba-$ Bi6.$ H >o..eberg'$ 9,,:3. >arious psy)'opat'o.ogi)a. states are ).ear.y asso)iated (it' a (ide range of neurobio.ogi)a. disturban)es$ some o/er.apping and ot'ers more distin)t or spe)ifi). "n addition to ob/ious /egetati/e re7uirements for sur/i/a.$ t'e bio.ogi)a. aspe)ts of CN fun)tion must be rooted

?. 1IOLOGICAL 1ASES OF PSYCHOPATHOLOGY 229 in e/o.utionary pro)esses t'at resu.ted in t'e de/e.opment of per)eption$ .earning$ t'oug't$ memory$ emotions$ )ommuni)ation$ and .anguage 2=i.bert$ *++BC mit'$ *++:3. #'ese fun)tions are )riti)a. for intera)ting (it' and adapting to t'e so)ia. and p'ysi)a. en/ironment and (ou.d ne)essitate t'e de/e.opment of a (e..1regu.ated set of CN responses to en/ironmenta. stresses. #'e geneti) and bio.ogi)a. )orre.ates of ('at are )on)eptua.i4ed as persona.ity traits and temperaments a.so must be rooted in e/o.utionary pro)esses 2Bou)'ard H Loe'.in$ 9,,*3$ per'aps re.e/ant to t'e de/e.opment of a be'a/iora. repertoire and an information pro)essing system t'at mediates intera)tion (it' and adaptation to t'e so)ia. and p'ysi)a. en/ironment$ ana.ogous to t'e ro.e of be'a/iora. traits in anima.s 2=os.ing$ 9,,*C Weiss$ @ing$ H Figuerdo$ 9,,,3. W'y )ertain forms of psy)'opat'o.ogy persist e/o.utionari.y may part.y ref.e)t t'e adapti/e fun)tion of under.ying traits and temperaments t'at be)ome ma.adapti/e in response to so)ia.$ )u.tura.$ or en/ironmenta. stress 2Brody$ 9,,*C &aens.y H Reyno.ds$ *++:C Le)-man H Mayes$ *++BC Wi.son$ *++B3. More f.orid psy)'opat'o.ogy may a.so o))ur as a resu.t of neurode/e.opmenta. aberrations or t'e dysregu.ation of neurobio.ogi)a. systems 2Cro($ *++<C tein H Bou(er$ *++D3. >arious forms of psy)'opat'o.ogy may t'en be /ie(ed as t'e resu.t of uni7ue intera)tions among geneti)a..y determined bio.ogi)a. fun)tions andLor be'a/iora. traits$ sporadi) andLor spontaneous neurobio.ogi)a. anoma.ies$ and en/ironmenta. stressors or insu.ts$ ea)' of ('i)' may operate on a parti)u.ar region of t'e CN andLor affe)t t'e CN at a parti)u.ar time of neurode/e.opment. From t'is perspe)ti/e$ t'en$ t'e natureEnurture approa)' to psy)'opat'o.ogy is a fa.se di)'otomy t'at s'ou.d be rep.a)ed by a deeper appre)iation of t'e profound and )omp.ex dynami)a. intera)tions among genes$ bio.ogy$ and t'e en/ironment 2@end.er$ 9,,*C Rose$ 9,,*3. REFERENCES Anand5 A.5 C/arney5 D. S.5 Oren5 D. A.5 1er(an5 R. M.5 H$5 <. S.5 Ca**ie%%#5 A.5 H )rysta%5 7. H. = !!!>. Atten$ati#n #6 t/e ne$r#*sy./iatri. e66e.ts #6 +eta(ine 2it/ %a(#tri&ine. S$**#rt 6#r /y*er&%$ta(ater&i. e66e.ts #6 N0(et/y%0 D0as*artate re.e*t#r anta&#nists. %rchives of General +sychiatry# 9A# 8!0 8?. As./a$er5 H. N.5 H S./%#&e%/#6er5 M. = !!:>. An-iety5 de*ressi#n5 and *ers#na%ity. In S. )as*er5 7. A. den 1#er5 H 7. M. Ad Sitsen =Eds.>5 ,andbook of Depression and %n"iety = nded.5 **. @3033!>. Ne2 Y#r+' Mar.e% De++er. Ast#n07#nes5 G.5 RaD+#2s+i5 7.5 H C#/en5 7. =3@@@>. R#%e #6 %#.$s .#er$%e$s in attenti#n and be/a,i#ra% 6%e-ibi%ity. $iological +sychiatry# ;E<@=# 3:!@03: !. 1ai%er5 U5 Leis./5 E5 MesCar#s5 ).5 LenCin&er5 E.5 Wi%%in&er5 U.5 Str#b%5 R.5 Heiden5 A.5 Geb/ardt5 C5 D#&e5 E.5 F$./s5 ).5 Sie&/art5 W5 )as*er5 S.5 H#rni+5 ).5 H As./a$er5 H. N. = !! >. Gen#(e s.an 6#r s$s.e*tibi%ity %#.i 6#r s./iC#*/renia and bi*#%ar dis#rder. $iological +sychiatry# 9:# 9!0" . 1a-ter5 L. R.5 A.+er(ann5 R. E5 S2end%#25 N. R.5 1r#dy5 A.5 Sa-ena5 S.5 S./2artC5 J. M.5 Gre&#rti./5 7. M.5 St#esse%5 P.5 H P/e%*s5 M. E. = !!!>. S*e.i6i. brain syste( (ediati#n #6 #bsessi,e0.#(*$%si,e dis#rder res*#nsi,e t# eit/er (edi.ati#n #r be/a,i#r t/era*y. In W. ). G##d(an5 H M. G R$d#r6er =Eds.>5 Obsessive3 1ompulsive Disorder5

1ontemporary 0ssues 0n Treatment =**. "8:0?!@>. Ma/2a/5 N7' Er%ba$( Ass#.iates. 1a-ter5 L. R.5 P/e%*s5 M. E.5 MaCCi#tta5 7. C5 S./2artC5 7. M.5 Gerner5 R. H.5 Se%in5 C. E.5 H S$(ida5 R. M. =3@;">. Cerebra% (etab#%i. rates 6#r &%$.#se in (##d dis#rders' St$dies 2it/ *#sitr#n e(issi#n t#(#&ra*/y and 6%$#0 r#de#-y&$%.#se F3;. %rchives of General +sychiatry# ;:#9930998. 1e%an#665 7. ).5 Gr#ss5 ).5 Ya&er5 A.5 H S./atCber&5 A. F. = !!3>. C#rti.#ster#ids and .#&niti#n. ournal of +sychiatric (esearch# ?9# 3 8039". 1erenba$(5 S. A.5 Tay%#r5 M. A.5 H C%#nin&er5 C. R. =3@@9>. Fa(i%y st$dy #6 s./iC#*/renia and *ers#na%ity. ournal of %bnormal +sychiatry# 67?<?=# 98"P[;9. 1#nd5 A. J. = !!3>. Ne$r#trans(itters5 te(*era(ent and s#.ia% 6$n.ti#nin&. !uropean -europsychopharmacology# 66# ?30 89. 1#$./ard5 T. <5 H L#e/%in5 7. C. = !!3>. Genes5 e,#%$ti#n5 and *ers#na%ity. $ehavior Genetics# ?6<?=# 9:0 8:. 1#$t#n5 M. E.5 Mine+a5 S.5 H 1ar%#25 D. H. = !!3>. A (#dern %earnin& t/e#ry *ers*e.ti,e #n t/e eti#%#&y #6 *ani. dis#rder. +sychological (eview# 678<6=# 90: . 1re(ner5 < D. =3@@@>. D#es stress da(a&e t/e brainI $iological +sychiatry# ;9<6=# 8@80;!".

231 HOWLAND 1re(ner5 7. D.5 Innis5 R. 1.5 Sa%#(#n5 R. MQ Staib5 L. H.5 N&5 C. ).5 Mi%%er5 H. L.5 1r#nen5 R. A.5 )rysta%5 7. H.5 D$n.an5 I5 Ri./5 D.5 Pri.e5 L. H.5 Ma%is#n5 R.5 Dey5 H.5 S#$6er5 R.5 H C/arney5 D. S. =3@@8>. P#sitr#n e(issi#n t#(#&ra*/y (eas$re(ent #6 .erebra% (etab#%i. .#rre%ates #6 try*t#*/an de*%eti#n0ind$.ed de*ressi,e re%a*se. %rchives of General +sychiatry# 9;# :?90:89. 1r#dy5 7. F. = !!3>. E,#%$ti#nary re.astin&' ADHD5 (ania and its ,ariants. ournal of %ffective Disorders# E9#3@80 3". 1r#dy5 A. L.5 Sa-ena5 S.5 St#esse%5 P.5 Gi%%ies5 L. A.5 Fairban+s5 L. A.5 A%b#rCian5 S.5 P/e%*s5 M. E.5 H$an&5 S. C5 W$5 H. M.5 H#5 M. L.5 H#5 M. ).5 A$5 S. C5 Maid(ent5 ).5 H 1a-ter5 7. R.5 7r. = !!3>. Re&i#na% brain (etab#%i. ./an&es in *atients 2it/ (aD#r de*ressi#n treated 2it/ eit/er *ar#-etine #r inter*ers#na% t/era*y' Pre%i(inary 6indin&s. %rchives of General +sychiatry# 98# ?:30?9!. 1$.+5 R. =3@@@>. T/e bi#%#&i.a% a66e.ts' A ty*#%#&y. +sychological (eview# 67E<:=# :!30::?. 1$nney5 W. E.5 H 1$nney5 1. G. = !!!>. M#%e.$%ar .%#.+ &enes in (an and %#2er ani(a%s' P#ssib%e i(*%i.ati#ns 6#r .ir.adian abn#r(a%ities in de*ressi#n. -eurospychopharmacology# ::<;=# ::"0:9". 1$nney5 W. E. 7.5 G##d2in5 F. ).5 M$r*/y5 D. L.5 H#$se5 ). M.5 H G#rd#n5 E. ). =3@8 >. T/e Ks2it./ *r#.essK in (ani.0de*ressi,e i%%ness' II' Re%ati#ns/i* t# .ate./#%a(ines5 REM s%ee*5 and dr$&s. %rchives of General +sychiatry# :A# :!90:!@. Cad#ret5 R. 7.5 Win#+$r5 G.5 Lan&be/n5 D.5 Tr#$&/t#n5 E.5 Yates5 W. R.5 H Ste2art5 M. A. =3@@?>. De*ressi#n s*e.tr$( disease5 I' T/e r#%e #6 &ene0en,ir#n(ent intera.ti#n. %merican ournal of +sychiatry# 9?<A=# ;@ 0;@@. Cann#n5 M.5 )ende%%5 R.5 S$sser5 E.5 H 7#nes5 P. = !!:>. Prenata% and *erinata% ris+ 6a.t#rs 6#r s./iC#*/renia. In R. M. M$rray H P. 1. 7#nes =Eds.>5 The !pidemiology of 'chi*ophrenia =**. 890@@>. Ne2 Y#r+' Ca(brid&e Uni,ersity Press. Cas*i5 A.5 S$&den5 ).5 M#66itt5 T. E.5 Tay%#r5 A.5 Crai&5 I. W.5 Harrin&t#n5 H.5 M.C%ay5 7.5 Mi%%5 7.5 Martin5 7.5 1rait/2aite5 A.5 H P#$%t#n5 R. = !!:>. In6%$en.e #6 %i6e stress #n de*ressi#n' M#derati#n by a *#%y(#r*/is( in t/e "0HTT &ene. 'cience# ?76# :;?0:;@. C/#r*ita5 1. F.5 1ar%#25 D. H. =3@@;>. T/e de,e%#*(ent #6 an-iety' T/e r#%e #6 .#ntr#% in t/e ear%y en,ir#n(ent. +sychological $ulletin# 6:;<L=# :0 3. C/#$inard5 G.5 Y#$n&5 S. N.5 1rad2eDn5 7.5 H Annab%e5 L. =3@;:>. Try*t#*/an in t/e treat(ent #6 de*ressi#n and (ania. %dvanced $iological +sychiatry# 67# 980??. C%#nin&er5 C. R. =3@@@>. A ne2 .#n.e*t$a% *aradi&( 6r#( &eneti.s and *sy./#bi#%#&y 6#r t/e s.ien.e #6 (enta% /ea%t/. %ustralian -ew 2ealand ournal of +sychiatry# ??<:=# 38903;?. C%#nin&er5 C. R.5 S,ra+i.5 D. M.5 H PrCybe.+5 T. R. =3@@:>. A *sy./#bi#%#&i.a% (#de% #6 te(*era(ent and ./ara.ter. %rchives of General +sychiatry# "!=3 >5 @8"0@@!. C#66ey5 C. E.5 Wi%+ins#n5 W. E.5 Weiner5 R. D.5 Rit./ie5 7. C5 H AJ$e5 M. =3@@:>. T/e de-a(et/as#ne s$**ressi#n test and J$antitati,e .erebra% anat#(y in de*ressi#n. $iological +sychiatry# ??# 99 099@. C##+s#n5 7. C. =3@;">. T/e ne$r#end#.rin#%#&y #6 (ania. ournal of %ffective Disorders# 8# ::0 93. C##*er5 1. = !!3>. Nat$re5 n$rt$re and (enta% dis#rder' O%d .#n.e*ts in t/e ne2 (i%%enni$(. $ritish ournal of

+sychiatry# i8\=S$**%. 9!>5 s@30s%! . C#*%an5 7. D.5 S(it/5 E. L. P5 A%te($s5 M.5 S./ar65 1. A.5 O2ens5 M. 75 Ne(er#665 C. 1.5 G#r(an5 7. M.5 H R#senb%$(5 L. A. = !!3>. Gariab%e 6#ra&in& de(and rearin&' S$stained e%e,ati#ns in .isterna% .erebr#s*ina% 6%$id .#rti.#tr#*in0 re%easin& 6a.t#r .#n.entrati#ns in ad$%t *ri(ates. $iological +sychiatry# 97<?=# !!0 !9. Cr#25 T. 7. =3@@">. A Dar2inian a**r#a./ t# t/e #ri&ins #6 *sy./#sis. $ritish ournal of +sychiatry# 6EA<6=# 3 0 ". C$adra5 G.5 F$rita5 A.5 Gi#in#5 G.5 H M#%ina5 G = !!3>. In6%$en.e #6 di66erent antide*ressant dr$&s #n t/e e66e.t #6 ./r#ni. ,ariab%e stress #n restraint0ind$.ed d#*a(ine re%ease in 6r#nta% .#rte-. -europsychopharmacology# :9<?=# :;90:@9. Dei.+en5 R. E5 Fein5 G.5 H Weiner.5 M. W. =3@@">. Abn#r(a% 6r#nta% %#be */#s*/#r#$s (etab#%is( in bi*#%ar dis#rder. %merican ournal of +sychiatry# 69:<E=# @3"0@3;. De%&ad#5 P. L.5 H M#ren#5 F. A. =3@@;>. Di66erent r#%es 6#r ser#t#nin in anti0#bsessi#na% dr$& a.ti#n and *at/#*/ysi#%#&y #6 #bsessi,e0.#(*$%si,e dis#rder. $ritish ournal of +sychiatry# 88:=S$**%. :"S>5 30 ". Denenber&5 G H. = !!!>. E,#%$ti#n *r#*#ses and #nt#&eny dis*#ses. $rain D )anguage# A?<:=# 890 @?. De*$e5 R. A.5 H Ia.#n#5 W G. =3@;@>. Ne$r#be/a,i#ra% as*e.ts #6 a66e.ti,e dis#rders. %nnual (eview of +sychology# ;7#9"809@ . Dre,ets5 W. C. = !!!a>. Ne$r#i(a&in& st$dies #6 (##d dis#rders. $iological +sychiatry# ;8# ;3:0; @. Dre,ets5 W. C. = !!!b>. F$n.ti#na% anat#(i.a% abn#r(a%ities in %i(bi. and *re6r#nta% .#rti.a% str$.t$res in (aD#r de*ressi#n. +rogress in $rain (esearch# 6:E# 93:P:3. Dre,ets5 W. C5 Fran+5 E.5 Pri.e5 7. C5 )$*6er5 D. 7.5 H#%t5 D.5 Greer5 P. 7.5 H$an&5 Y5 Ga$tier5 C5 H Mat/is5 C. =3@@@>. PET i(a&in& #6 ser#t#nin 3A re.e*t#r bindin& in de*ressi#n. $iological +sychiatry# ;E<67=# 3:8"03:;8. D$(an5 R. S.5 Ma%ber&5 7.5 H T/#(e5 7. =3@@@>. Ne$ra% *%asti.ity t# stress and antide*ressant treat(ent. $iological +sychiatry# ;E# 33;3033@3. D$(an5 S.5 Henin&er5 G. R.5 H Nest%er5 E. 7. =3@@8>. A (#%e.$%ar and .e%%$%ar t/e#ry #6 de*ressi#n. %rchives of General +sychiatry# 9;# "@80?!?.

?. 1IOLOGICAL 1ASES OF PSYCHOPATHOLOGY 233 D$n.an5 W. C5 7r. =3@@?>. Cir.adian r/yt/(s and t/e */ar(a.#%#&y #6 a66e.ti,e i%%ness. +harmacology Therapy# A6<?=# ":0:3 . E%ey5 T. C5 H P%#(in5 R. =3@@8>. Geneti. ana%yses #6 e(#ti#na%ity. 1urrent Opinion 0n -eurobiology# A# 8@0 ;9. E%+is5 H.5 Fried(an5 L.5 Wise5 A.5 H Me%tCer5 H. Y. =3@@">. Meta0 ana%yses #6 st$dies #6 ,entri.$%ar en%ar&e(ent and .#rti.a% s$%.a% *r#(inen.e in (##d dis#rders. C#(*aris#ns 2it/ .#ntr#%s #r *atients 2it/ s./iC#*/renia. %rchives of General +sychiatry# 9:# 8:"089?. Fairban+s5 L. A.5 Me%e&a5 W. P.5 7#r&ensen5 M. <5 )a*%an5 < R.5 H M.&$ire5 M. T. = !!3>. S#.ia% i(*$%si,ity in,erse%y ass#.iated 2it/ CSF "0HIAA and 6%$#-etine e-*#s$re in ,er,et (#n+eys. -europsychopharmacology# :;<%=# :8!0:8;. Ferry5 1.5 R##Cendaa%5 1.5 H M.Ga$&/5 7. L. =3@@@>. R#%e #6 n#re*ine*/rine in (ediatin& stress /#r(#ne re&$%ati#n #6 %#n&0ter( (e(#ry st#ra&e' A .riti.a% in,#%,e(ent #6 t/e a(y&da%a. $iological +sychiatry# ;E<@=# 339!033" . Ge#r&e5 M. S.5 )etter5 T. A.5 H P#st5 R. M. =3@@9>. Pre6r#nta% .#rte- dys6$n.ti#n in .%ini.a% de*ressi#n. Depression# :# "@08 . Gera.i#ti5 T. D.5 L##sen5 P. <5 H Ort/5 D. N. =3@@8>. L#2 .erebr#s*ina% 6%$id .#rti.#tr#*in0 re%easin& /#r(#ne .#n.entrati#ns in e$.#rtis#%e(i. de*ressi#n. $iological +sychiatry# ;:# 3??0389. Gi%bert5 P. =3@@;>. E,#%$ti#nary *sy./#*at/#%#&y' W/y isnBt t/e (ind desi&ned better t/an it isI $ritish ournal of Medical +sychology# A6<;=# :":0:8:. G#r(an5 < M.5 )ent5 < M.5 S$%%i,an5 G. M.5 H C#*%an5 < D. = !!!>. Ne$r#anat#(i.a% /y*#t/esis #6 *ani. dis#rder5 re,ised. %merican ournal of +sychiatry# 69A<;=# 9@:0"!". G#s%in&5 S. D. = !!3>. Fr#( (i.e t# (en' W/at .an 2e %earn ab#$t *ers#na%ity 6r#( ani(a% resear./I +sychological $ulletin# 6:A<6=# 9"0;?. G$r5 R. =3@@">. F$n.ti#na% brain0i(a&in& st$dies in s./iC#*/renia. In F. E. 1%##( H D. < )$*6er =Eds.>5 +sychophar3 macology5 The fourth generation ofprogress =**. 33;"033@ >. Ne2 Y#r+' Ra,en. G$r5 R. E.5 H G$r5 R. C. = !!!>. S./iC#*/renia' 1rain str$.t$re and 6$n.ti#n. In 1. < Sad#.+ and G A. Sad#.+ =Eds.>5 1omprehensive Te"tbook of +sychiatry =8t/ ed.5 **. 3338033 @>. P/i%ade%*/ia5 PA' Li**in.#tt Wi%%ia(s and Wi%+ins. G$Ce5 S. 1. =3@;@>. 1i#%#&i.a% *sy./iatry' Is t/ere any #t/er +indI +sychological Medicine# 6@<:=# :3"0: :. Haens%y5 P. A.5 H Reyn#%ds5 C. R. =3@@:>. W/it/er &#es DNAAan inte%%i&ent .reati,e *r#.essI Or5 .reati,ity e(anatin& 6r#( *sy./#ti. traitsI +sychological 0nCuiry# ;<?=# !!0 !9. Harris#n5 P. <5 H O2en5 M. < = !!:>. Genes 6#r s./iC#*/reniaI Re.ent 6indin&s and t/eir *at/#*/ysi#%#&i.a% i(*%i.ati#ns. )ancet# ?E6# 938093@. Hette(a5 < M.5 Nea%e5 M. C5 H )end%er5 ). S. = !!3>. A re,ie2 and (eta0ana%ysis #6 t/e &eneti. e*ide(i#%#&y #6 an-iety dis#rders. %merican ournal of +sychiatry# 698<67=# 3"?;0

3"8;. Hi&%ey5 < D.5 Me/%(an5 P. <5 Hi&%ey5 S. 1.5 Ferna%d 1.5 Gi.+ers5 <5 Linde%%5 S. G.5 <a$b5 D. M.5 S$#(i5 S. <5 H Linn#i%a5 M. =3@@?>. E-.essi,e (#rta%ity in y#$n& 6ree0ran&in& (a%e n#n/$(an *ri(ates 2it/ %#2 .erebr#s*ina% 6%$id "0/ydr#-yind#%ea.eti. a.id .#n.entrati#ns. %rchives of General +sychiatry# 9?#":80"9:. Hi&%ey5 < D.5 Me/%(an5 P. <5 P#%and5 R. E.5 Ta$b5 D. M.5 Gi.+ers5 75 S$#(i5 S. <5 H Linn#i%a5 M. =3@@?>. CSF test#ster#ne and "0HIAA .#rre%ate 2it/ di66erent ty*es #6 a&&ressi,e be/a,i#rs. $iological +sychiatry# 9!=33>5 3!?803!; . H#%sb#er5 F. =3@@">. Ne$r#end#.rin#%#&y #6 (##d dis#rders. In F. E. 1%##( H D. < )$*6er =Eds.>5 +sychopharma3 cology5 The fourth generation ofprogress =**. @"80@?@>. Ne2 Y#r+' Ra,en. H#%sb#er5 F. = !!!>. </e .#rti.#ster#id re.e*t#r /y*#t/esis #6 de*ressi#n. -europsychopharmacology# :?<9=# 9880"!3. H#2%and R. H.5 H </ase5 M. E. =3@@@>. A66e.ti,e dis#rders. 1i#%#&i.a% as*e.ts. In < Mi%%#n5 P. 1%aney5 H R. Da,is =Eds.>5 O"ford te"tbook of psychopathology =**. 3??0 ! >. O-6#rd' O-6#rd Uni,ersity Press. Inse%5 < R.5 H Wins%#25 < < =3@@;>. Ser#t#nin and ne$r#*e*tides in a66i%iati,e be/a,i#rs. $iological +sychiatry# ;;<?=# !80 3@. )a/n5 R. S.5 H Da,is5 ). L. =3@@">. Ne2 de,e%#*(ents in d#*a(ine and s./iC#*/renia. In F. E. 1%##( H D. < )$*6er =Eds.>5 +sychopharmacology5 The fourth generation ofprogress =**. 33@:03 !:>. Ne2 Y#r+' Ra,en. )ande%5 E. R.5 S./2artC5 < H.5 H 7esse%%5 <. M. =3@@3>. +rinciples of neural science =:rd ed.>. Ne2 Y#r+' E%se,ier. )at#5 <5 S/i#iri5 <5 M$ras/ita5 <5 Ha(a+a2a5 H.5 Ta+a/as/i5 Y5 In$b$s/i5 <5 H <a+a/as/i5 S. =3@@">. Latera%iCed abn#r(a%ity #6 /i&/ ener&y */#s*/ate (etab#%is( in t/e 6r#nta% %#bes #6 *atients 2it/ bi*#%ar dis#rder dete.ted by */ase0en.#ded :3P0MRS. +sychological Medicine# :9# ""80"??. )a$6(an5 <5 P%#ts+y5 P. M.5 Ne(er#665 C. 1.5 H C/arney5 D. S. = !!!>. E66e.ts #6 ear%y ad,erse e-*erien.es #n brain str$.t$re and 6$n.ti#n' C%ini.a% i(*%i.ati#ns. $iological +sychiatry# ;8# 88;08@!. )end%er5 ). S. = !!3>. T2in st$dies #6 *sy./iatri. i%%ness' An $*date. %rchives of General +sychiatry# 98# 3!!"3!39. )etter5 < A.5 Ge#r&e5 M. S.5 Rin&5 H. A.5 PaCCa&%ia5 P.5 Maran&e%%5 L.5 )i(bre%%5 <. A.5 H P#st5 R. M. =3@@9>. Pri(ary (##d dis#rders' Str$.t$ra% and restin& 6$n.ti#na% st$dies. +sychiatric %nnals# 9=3 >5 ?:80 ?9 . )in&s%ey5 R. E. = !!!>. 1oncise te"t of neuroscience = nd ed.>. P/i%ade%*/ia' Li**in.#tt Wi%%ia(s H Wi%+ins.

235 HOWLAND Rris/nan5 ). R. R.5 Hays5 7. C5 H 1%aCer5 D. G. =3@@8>. MRI0De6ined ,as.$%ar de*ressi#n. %merican ournal of +sychiatry# 69;<%=# 9@80"!3. Lane5 R. D.5 Rei(an5 E. M.5 A/ern5 G. L.5 S./2artC5 G. E.5 H Da,ids#n5 R. 7. =3@@8>. Ne$r#anat#(i.a% .#rre%ates #6 /a**iness5 sadness5 and dis&$st. %merican ournal of +sychiatry# 69;<6=# @ ?0@::. Le.+(an5 7. F.5 H Mayes5 L. C. =3@@;>. Understandin& de,e%#*(enta% *sy./#*at/#%#&y' H#2 $se6$% are e,#%$ti#nary a..#$ntsI ournal of the %merican %cademy of 1hild %dolescent +sychiatry# :8=3!>5 3!330 3! 3. Les./5 ). P.5 Greenber&5 1. D.5 Hi&%ey5 7. D.5 1ennett5 A.5 H M$r*/y5 D. L. = !! >. Ser#t#nin trans*#rter5 *ers#na%ity5 and be/a,i#r' T#2ard a disse.ti#n #6 &ene0&ene and &ene0en,ir#n(ent intera.ti#n. In 7. 1enDa(in H R. P. Ebstein =Eds.>5 Molecular Genetics and the ,uman +ersonality =**. 3!@03:">. Was/in&t#n5 DC' A(eri.an Psy./iatri. P$b%is/in&. Lin+#2s+i5 P.5 )er/#6s5 M.5 Gan Onderber&en5 A.5 H$bain5 P.5 C#*ins./i5 G.5 LBHer(ite0 1a%eria$-. M.5 Le.%er.J5 R.5 1rasse$r5 M.5 Mend%e2i.C5 7.5 H Gan .a$ter5 E. =3@@9>. T/e 90/#$r *r#6i%es #6 C#rtis#%5 *r#%a.tin5 and &r#2t/ /#r(#ne se.reti#n in (ania. %rchives of General +sychiatry# 96# ?3?0? 9. Li#tti5 M.5 Mayber&5 H. S.5 1rannan5 S. ).5 M.Ginnis5 S.5 7erabe+5 P.5 H F#-5 P. T. = !!!>. Di66erentia% %i(bi.0.#rti.a% .#rre%ates #6 sadness and an-iety in /ea%t/y s$bDe.ts' I(*%i.ati#ns 6#r a66e.ti,e dis#rders. $iological +sychiatry# ;8# ?73;:. LS*eC5 7. E5 LiberC#n5 I.5 GRCJ$eC5 D. M.5 Y#$n&5 E. A.5 H Wats#n5 S. 7. =3@@@>. Ser#t#nin 3A re.e*t#r (essen&er RNA re&$%ati#n in t/e /i**#.a(*$s a6ter a.$te stress. $iological +sychiatry# ;9<6=# @:90@:8. Maes5 M.5 H Me%tCer5 H. Y. =3@@">. T/e ser#t#nin /y*#t/esis #6 (aD#r de*ressi#n. In F. E. 1%##( H D. 7. )$*6er =Eds.>5 +sychopharmacology5 The fourth generation of progress =**. @::0@99>. Ne2 Y#r+' Ra,en. Maier5 S. E5 H Se%i&(an5 M. E. P. =3@8?>. Learned /e%*%essness' T/e#ry and e,iden.e. ournal of !"perimental +sychology# 679# ?3;E. Maier5 W. = !!:>. Geneti.s #6 an-iety. In S. )as*er5 7. A. den 1#er5 7. M. Ad Sitsen =Eds.>5 ,andbook of Depression and %n"iety = nd ed.5 **. 3;@0 !">. Ne2 Y#r+' Mar.e% De++er. ManDi5 H. ).5 M##re5 G. 7.5 H C/en5 G. = !!!>. C%ini.a% and *re.%ini.a% e,iden.e 6#r t/e ne$r#tr#*/i. e66e.ts #6 (##d stabi%iCers' I(*%i.ati#ns 6#r t/e *at/#*/ysi#%#&y and treat(ent #6 (ani.0de*ressi,e i%%ness. $iological +sychiatry# ;8# 89!08"9. Mann5 7. 7.5 1rent5 D. A.5 H Aran&#5 G. = !!3>. T/e ne$r#bi#%#&y and &eneti.s #6 s$i.ide and atte(*ted s$i.ide' A 6#.$s #n t/e ser#t#ner&i. syste(. -eurospychopharmacology# :;<9=# 9?80988. Martin5 S. D.5 Martin5 E.5 Rai5 S. S.5 Ri./ards#n5 M. A.5 H R#ya%%5 R. = !!3>. 1rain b%##d 6%#2 ./an&es in

de*ressed *atients treated 2it/ inter*ers#na% *sy./#t/era*y #r ,en%a6a-ine /ydr#./%#ride. Pre%i(inary 6indin&s. %rchives of General +sychiatry# 98# ?930?9;. Mat/e25 S. <5 C#*ian5 < D.5 G#r(an5 < M. = !!3>. Ne$r#bi#%#&i.a% (e./anis(s #6 s#.ia% an-iety dis#rder. %merican ournal of +sychiatry# 698<67=# 3"";03"?8. Mat/e25 S. <5 C#*ian5 < D.5 S(it/5 E. L. P.5 S./%#e**5 D. D.5 R#senb%$(5 L. A.5 H G#r(an5 < M. = !!3>. G%$ta(ate0 /y*#t/a%a(i.0*it$itary0adrena% a-is intera.ti#ns' I(*%i.ati#ns 6#r (##d and an-iety dis#rders. 1-' 'pectrums# E<6=# """0"?9. Mayber&5 H. S. =3@@9>. F$n.ti#na% i(a&in& st$dies in se.#ndary de*ressi#n. +sychiatric %nnals# :;# ?9:0?98. Mayber&5 H. S.5 1rannan5 S. ).5 Ma/$rin5 R. ).5 7erabe+5 P. A.5 1ri.+(an5 < S.5 Te+e%%5 < L.5 Si%,a5 < A.5 M.Ginnis5 S.5 G%ass5 T. G.5 Martin5 C. C5 HF#-5 P. T. =3@@8>. Cin&$%ate 6$n.ti#n in de*ressi#n' A *#tentia% *redi.t#r #6 treat(ent res*#nse. 1linical -euroscience and -europathology# 8<;=# 3!"803!?3. Mayber&5 H. S.5 1rannan5 S. ).5 Te+e%%5 < L.5 Si%,a5 < A.5 Ma/$rin5 R. ).5 M.Ginnis5 S.5 H 7erabe+5 P. A. = !!!>. Re&i#na% (etab#%i. e66e.ts #6 6%$#-etine in (aD#r de*ressi#n' Seria% ./an&es and re%ati#ns/i* t# .%ini.a% res*#nse. $iological +sychiatry# ;8<8=# ;:!0;9:. Mayber&5 H. S.5 Li#tti5 M.5 1rannan5 S. ).5 M.Ginnis5 S.5 Ma/$rin5 R. ).5 7erabe+5 P. A.5 Si%,a5 <A.5 Te+e%%5 7. L.5 Martin5 C. C5 Lan.aster5 < L.5 H F#-5 P. T. =3@@@>. Re.i*r#.a% %i(bi.0.#rti.a% 6$n.ti#n and ne&ati,e (##d' C#n,er&in& PET 6indin&s in de*ressi#n and n#r(a% sadness. %merican ournal of +sychiatry# 69E<9=# ?8"0?; . M.E2en5 1. S. = !!!>. E66e.ts #6 ad,erse e-*erien.es 6#r brain str$.t$re and 6$n.ti#n. $iological +sychiatry# ;8# 8 308:3. M.E2en5 1. S.5 An&$%#5 <5 Ca(er#n5 H.5 C/a#5 H. M.5 Danie%s5 D.5 Gann#n5 M. N.5 G#$%d5 E.5 Mende%s#n5 S.5 Sa+ai5 R.5 S*en.er5 R.5 H W##%%ey5 C. =3@@ >. Parad#-i.a% e66e.ts #6 adrena% ster#ids #n t/e brain' Pr#te.ti#n ,ers$s de&enerati#n. $iological +sychiatry# ?6# 38803@@. M.G$e5 M.5 H 1#$./ard5 T.7. =3@@;>. Geneti. and en,ir#n(enta% in6%$en.es #n /$(an be/a,i#ra% di66eren.es. %nnual (eview of -euroscience# :6# 30 9. Me/%(an5 P. T5 Hi&%ey5 7. D.5 Fa$./er5 I.5 Li%%y5 A. A.5 Ta$b5 D. M.5 Gi.+ers5 <5 S$#(i5 S. <5 H Linn#i%a5 M. =3@@">. C#rre%ati#n #6 CSF "0HIAA .#n.entrati#n 2it/ s#.ia%ity and t/e ti(in& #6 e(i&rati#n in 6ree0ran&in& *ri(ates. %merican ournal of +sychiatry# 69:<E=# @!80 @3:. Meri+an&as5 ). R.5 H )$*6er5 D. 7. =3@@">. M##d dis#rders' &eneti. as*e.ts. In H. I. )a*%an H 1. < Sad#.+ =Eds >5 1omprehensive Te"tbook of +sychiatry =?t/ ed.5 **. 33! 0 333?>. 1a%ti(#re' Wa%+ins.

?. 1IOLOGICAL 1ASES OF PSYCHOPATHOLOGY 237 Mi.a%%e65 7.5 H 1%in5 O. = !!3>. Ne$r#bi#%#&y and .%ini.a% */ar(a.#%#&y #6 #bsessi,e0 .#(*$%si,e dis#rder. 1linical -europharmacology# :;<;=# 3@30 !8. M##re5 C. M.5 C/ristensen5 7. D.5 La6er5 1.5 Fa,a5 M.5 H Rens/a25 P. F. =3@@8>. L#2er %e,e%s #6 n$.%e#side tri*/#s*/ate in t/e basa% &an&%ia #6 de*ressed s$bDe.ts' A */#s*/#r#$s0:3 (a&neti. res#nan.e s*e.tr#s.#*y st$dy. %merican ournal of +sychiatry# 69;# 33?033;. M$r*/y5 D. L.5 Li5 N.5 En&e%5 S.5 Wi./e(s5 C5 Andre2s5 A.5 Les./5 ). P.5 H U/%5 G. = !!3>. Geneti. *ers*e.ti,es #n t/e ser#t#nin trans*#rter. $rain (esearch $ulletin# 9E<9=# 9;809@9. Ne(er#665 C. 1. =3@@;>. Psy./#*/ar(a.#%#&y #6 a66e.ti,e dis#rders in t/e 3st .ent$ry. $iological +sychiatry# ;;<A=# "380" ". Nest%er5 E. 7.5 A%reDa5 M.5 H A&/aDanian5 G. ). =3@@@>. M#%e.$%ar .#ntr#% #6 %#.$s .#er$%e$s ne$r#trans(issi#n. $iological +sychiatry# ;E<@=# 33:3033:@. Ninan5 P. T.5 H C$((ins5 T. ). = !!:>. Ne$r#bi#%#&y #6 an-iety and de*ressi#n. In S. )as*er5 7. A. den 1#er5 H 7. M. Ad Sitsen =Eds.>5 ,andbook of Depression and %n"iety = nd ed.5 **. ::30:98>5 Ne2 Y#r+' Mar.e% De++er. OC+ara&#C5 T.5 H N#b%e5 E. P. = !!!>. E-tra,ersiSn' Intera.ti#n bet2een D d#*a(ine re.e*t#r *#%y(#r*/is(s and *arenta% a%.#/#%is(. %lcohol# ::<?=# 3:@039?. Pa$%5 S. M. =3@@">. GA1A and &%y.ine. In F. E. 1%##( H D. 7. )$*6er =Eds.>5 +sychopharmacology5 The fourth generation of progress =**. ;80@9>. Ne2 Y#r+' Ra,en. Pear%s#n5 G. D.5 W#n&5 D. E5 T$ne5 L. E.5 R#ss5 C. A.5 C/ase5 G. A.5 Lin+s5 7. M.5 Danna%s5 R. E5 Wi%s#n5 A. A.5 Ra,ert5 H. T5 H Wa&/er5 H. N.5 H DePa$%#5 R. =3@@">. In Gi,# D d#*a(ine re.e*t#r density in *sy./#ti. and n#n*sy./#ti. *atients 2it/ bi*#%ar dis#rder. %rchives of General +sychiatry# 9:#9830988. P%#(in5 R.5 H Cas*i5 A. =3@@;>. DNA and *ers#na%ity. !uropean ournal of +ersonality# 6:# :;8A9!8. P#st5 R. M.5 S*eer5 A. M.5 H#$&/5 C. 7.5 H <in&5 G. = !!:>. Ne$r#bi#%#&y #6 bi*#%ar i%%ness' I(*%i.ati#ns 6#r 6$t$re st$dy and t/era*e$ti.s. %nnals of 1linical +sychiatry# 69<:=# ;"0@9. P#2e%%5 ). 1.5 H Mi+%#2itC5 D. 7. =3@@9>. Fr#nta% %#be dys6$n.ti#n in t/e a66e.ti,e dis#rders. 1linical +sychology (eview# 6;# " "0"9?. N$int]n5 P.5 1en+e%6at5 C5 La$nay5 7. M.5 Arn$%65 I.5 P#interea$01e%%en&er5 A.5 1arba$%t5 S.5 A%,areC5 7. C5 Gar#J$a$-5 O.5 PereC0DiaC5 E5 7#$,ent5 R.5 H Leb#yer5 M. = !!3>. C%ini.a% and ne$r#./e(i.a% e66e.t #6 a.$te try*t#*/an de*%eti#n in $na66e.ted re%ati,es #6 *atients 2it/ bi*#%ar a66e.ti,e dis#rder. $iological +sychiatry# 97<?=# 3;903@!. Ress%er5 ). 7.5 H Ne(er#665 C. 1. =3@@@>. R#%e #6 n#re*ine*/rine in t/e *at/#*/ysi#%#&y and treat(ent #6 (##d dis#rders. $iological +sychiatry# ;E<@=# 3 3@03 ::. R#se5 S. = !!3>. M#,in& #n 6r#( #%d di./#t#(ies' 1ey#nd nat$re0n$rt$re t#2ards a %i6e%ine *ers*e.ti,e. $ritish ournal of +sychiatry# 88S=S$**%. 9!>5 s:0s8. R#t/5 1. LQ H Me%tCer5 H. Y. =3@@">. T/e r#%e #6 ser#t#nin in s./iC#*/renia. In F. E. 1%##( H D. 7. )$*6er =Eds.>5 +sychopharmacology5 The fourth generation of progress =**. 3 3"0 3 8>. Ne2 Y#r+' Ra,en. Sa*#%s+y5 R. M. = !!!>. T/e *#ssibi%ity #6 ne$r#t#-i.ity in t/e /i**#.a(*$s in (aD#r

de*ressi#n' A *ri(er #n ne$r#n deat/. $iological +sychiatry# ;8# 8""08?". Sasa+i0Ada(s5 D. M.5 H )e%%ey5 A. E. = !!3>. Ser#t#nin0d#*a(ine intera.ti#ns in t/e .#ntr#% #6 .#nditi#ned rein6#r.e(ent and (#t#r be/a,i#r. -europsychopharmacology# :9<?=# 99!09" . S./atCber&5 A. F.5 H R#t/s./i%d5 A. 7. =3@@ >. Psy./#ti. =de%$si#na%> (aD#r de*ressi#n' S/#$%d it be in.%$ded as a distin.t syndr#(e in DSM0IGI %merican ournal of +sychiatry# 6;@<E=# 8::089". S./atCber&5 A. E5 R#t/s./i%d5 A. 7.5 Lan&%ais5 P. 7.5 1ird5 E. D.5 H C#%e5 7. O. =3@;">. A .#rti.#ster#id4d#*a(ine /y*#t/esis 6#r *sy./#ti. de*ressi#n and re%ated states. ournal of +sychiatry (esearch# 6@# "80?9. S./atCber&5 A. F.5 H S./i%d+ra$t5 7. 7. =3@@">. Re.ent st$dies #n n#re*ine*/rine syste(s in (##d dis#rders. In F. E. 1%##( H D. 7. )$*6er =Eds.>5 +sychopharmacology5 The fourth generation ofprogress =**. @330@ !>. Ne2 Y#r+' Ra,en. S./(ider5 7.5 La((ers5 C. H.5 G#tt/ardt5 U5 Dett%in&5 M.5 H#%sb#er5 E5 H He$ser5 7. E.5 =3@@">. C#(bined de-a(et/as#ne4.#rti.#tr#*in0re%easin& /#r(#ne test in a.$te and re(itted (ani. *atients5 in a.$te de*ressi#n5 and in n#r(a% .#ntr#%s' 3. $iological +sychiatry# ?8# 8@80;! . S/e%ine5 Y. I. = !!!>. :D MRI st$dies #6 ne$r#anat#(i. ./an&es in $ni*#%ar (aD#r de*ressi#n' T/e r#%e #6 stress and (edi.a% .#(#rbidity. $iological +sychiatry# ;8<2=# 8@:0;!!. S/e%ine5 Y. I. = !!:>. Ne$r#i(a&in& st$dies #6 (##d dis#rder e66e.ts #n t/e brain. $iological +sychiatry# 9;#::;0 :" . S/e%ine5 Y. I.5 1ar./5 D. M.5 D#nne%%y5 7. M.5 O%%in&er5 7. M.5 Snyder5 A. F.5 H Mint$n5 M. A. = !!3>. In.reased a(y&da%a res*#nse t# (as+ed e(#ti#na% 6a.es in de*ressed s$bDe.ts res#%,es 2it/ antide*ressant treat(ent' An 6MRI st$dy. $iological +sychiatry# 97<@=# ?"30?";. S/e%t#n5 R. C. = !!!>. Ce%%$%ar (e./anis(s in t/e ,$%nerabi%ity t# de*ressi#n and res*#nse t# antide*ressants. +sychiatric 1linics of -orth %merica# :?# 83:08 @. Si%ber&5 7.5 R$tter5 M.5 Nea%e5 M.5 H Ea,es5 L. = !!3>. Geneti. (#derati#n #6 en,ir#n(enta% ris+ 6#r de*ressi#n and an-iety in ad#%es.ent &ir%s. $ritish ournal of +sychiatry# 6A@# 33?03 3. S(it/5 C. U. =3@@:>. E,#%$ti#nary bi#%#&y and *sy./iatry. $ritish ournal of +sychiatry# 6E:# 39@03":.

239 HOWL AND S#ares5 7. C5 H Mann5 7. 7. =3@@8>. T/e anat#(y #6 (##d dis#rders0re,ie2 #6 str$.t$ra% ne$r#i(a&in& st$dies. $iological +sychiatry# ;6<6=# ;?03!?. Sta%ey5 7. ).5 Ma%is#n5 R. T.5HInnis5 R. 1. =3@@;>. I(a&in& #6 t/e ser#t#ner&i. syste(' Intera.ti#ns #6 ne$r#anat#(i.a% and 6$n.ti#na% abn#r(a%ities #6 de*ressi#n. $iological +sychiatry# ;;<6=# ":90"9@. Stein D. 7.5 H 1#$2er5 C. =3@@8>. A ne$r#0e,#%$ti#nary a**r#a./ t# t/e an-iety dis#rders. ournal of %n"iety Disorders# 66<;=# 9!@P3 @. Stra+#2s+i5 S. M.5 Wi%s#n5 D. R.5 T#/en5 M5 W##ds5 1. T5 D#$&%ass5 A. W.5 H St#%%5 A. L. =3@@:>. Str$.t$ra% brain abn#r(a%ities in 6irst0e*is#de (ania. $iological +sychiatry# ??# ?! 0?!@. S2erd%#25 N. R.5H)##b5 G. F. =3@;8>. D#*a(ine5 s./iC#*/renia5 (ania5 and de*ressi#n' T#2ard a $ni6ied /y*#t/esis #6 .#rti.#0strait#0*a%%id#0t/a%a(i. 6$n.ti#n. $ehavioral and $rain 'ciences# 67# 3@80 9". Ta%b#t5 R S.5 Mat/e25 S. 7.5 H Lar$e%%e5 M. = !!:>. 1rain i(a&in& in de*ressi#n and an-iety. In S. )as*er5 7. A. den 1#er5 H 7. M. Ad Sitsen =Eds.>5 ,andbook of Depression and %n"iety = nd ed.5 **. ;@0: @>5 Ne2 Y#r+5 Mar.e% De++er. Gan Os5 7.5 Hanssen5 M.5 1a+5 M.5 1iD%5 R. G5 H G#%%eber&/5 W. = !!:>. D# $rbani.ity and 6a(i%ia% %iabi%ity .#*arti.i*ate in .a$sin& *sy./#sisI %merican ournal of +sychiatry# 6E7# 98809; . Weinber&er5 D. R. =3@@">. Ne$r#de,e%#*(enta% *ers*e.ti,es #n s./iC#*/renia. In F. E. 1%##( H D. 7. )$*6er =Eds.>5 +sychopharmacology5 The fourth generation ofprogress =**. 3383033;:>. Ne2 Y#r+' Ra,en. Weiss5 A.5 )in&5 7. E.5 H Fi&$erd#5 A. 7. = !!!>. T/e /eritabi%ity #6 *ers#na%ity 6a.t#rs in ./i(*anCees =Pan tr#&%#dytes> = !!!>. $ehavior Genetics# ?7<?=# 3:0 3. Weiss5 7. M.5 H )i%ts5 C. D. =3@@;>. Ani(a% (#de%s #6 de*ressi#n and s./iC#*/renia. In A. F. S./atCber& H C. 1. Ne(er#66 =Eds.>5 Te"tbook of +sychopharmacology = nd ed.5 **. ;@03:3>. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. W/a%en5 P. 7.5 Ra$./5 S. L.5 Et.#665 N. L.5 M.%nerney5 S. C5 Lee5 M. 1.5 H 7eni+e5 M. A. =3@@;>. Mas+ed *resentati#ns #6 e(#ti#na% 6a.ia% e-*ressi#ns (#d$%ate a(y&da%a a.ti,ity 2it/#$t e-*%i.it +n#2%ed&e. ournal of-euroscience# 68<L=# 933A93;. Wi%%ner5 P. =3@@8>. T/e (es#%i(bi. d#*a(ine syste( as a tar&et 6#r ra*id antide*ressant a.ti#n5 international 1linical +sychopharmacology# 8 =S$**%. :>5 S80S39. Wi%%ner5 P. =3@@">. D#*a(iner&i. (e./anis(s in de*ressi#n and (ania. In F. E. 1%##( H D. 7. )$*6er =Eds.>5 +sychopharmacology5 The fourth generation ofprogress =**. @ 30@:3>. Ne2 Y#r+' Ra,en. Wi%s#n5 D. R. =3@@;>. E,#%$ti#nary e*ide(i#%#&y and (ani. de*ressi#n. $ritish ournal of Medical +sychology# A6<;=# :8"0:@". F$ben+#5 G. S.5 Ma/er5 1.5 H$&/es5 H. 1.5 F$ben+#5 W. N.5 Sti66%er5 7. S.5 )a*%an5 1. 1.5 H

MaraCita5 M. L. = !!:>. Gen#(e02ide %in+a&e s$r,ey 6#r &eneti. %#.i t/at in6%$en.e t/e de,e%#*(ent #6 de*ressi,e dis#rders in 6a(i%ies 2it/ re.$rrent5 ear%y0#nset5 (aD#r de*ressi#n. %merican of ournal of Medical Genetics +art $ <-europsychiatric Genetics=# 6:?$# 303;.

PA RT

II
COMMON ADULT5 ADOLESCENT5 AND CHILD DISORDERS 241

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CHAPTER

7
An-iety Dis#rders S. L%#yd Wi%%ia(s 'tuttgart# Germany %eop.e are anxious about many different t'ings$ and to many different degrees$ but near.y e/eryone -no(s about anxiety from first'and experien)e. We spea- about ourse./es and ot'ers using a /o)abu.ary ri)' (it' (ords about fee.ing anxious$ tense$ ner/ous$ afraid$ (orried$ s)ared$ and t'e .i-e. We use su)' terms not on.y to des)ribe fee.ings$ but to exp.ain be'a/iors. We say t'at someone did 2or did not do3 somet'ing be)ause s'e (as afraid or be)ause 'e (as ner/ous. )ientists too 'a/e 'e.d t'at fear and anxiety 2terms t'is paper (i.. treat as synonyms3 )ause many be'a/iors$ norma. and abnorma.$ adapti/e and ma.adapti/e. #'is anxiety t'eory of be'a/ior is (ide.y a))epted by t'ose ('o 'e.p peop.e (it' psy)'o.ogi)a. prob.ems. But t'e meaning of anxiety$ and its po(er to strong.y inf.uen)e be'a/ior$ are far from ).ear. THE CONCEPT OF AN<IETY DISORDER Anxiety a.so denotes sets of proposed menta. i..nesses )a..ed an"iety disorders# as in t'e tit.e of t'is )'apter. #'e t'eory t'at some psy)'o.ogi)a. prob.ems are anxiety disorders$ or are )aused by anxiety disorders$ deri/es from t'e medi)a. mode. t'at /ie(s peop.eGs psy)'o.ogi)a. prob.ems as psy)'opat'o.ogy$ symptoms$ psy)'iatri) syndromes$ menta. i..nesses$ menta. disorders$ and re.ated disease1.i-e )onditions. Anxiety disorder t'eory is embodied in detai. in .eading psy)'iatri) organi4ationsG offi)ia. manua.s of menta. disorders 2Ameri)an %sy)'iatri) Asso)iation$ *++;$ 8 M1">C *+B,$ 8 M1"""C *+BD$ 8 M1"""1RC Wor.d &ea.t' !rgani4ation$ *++9$ "C81*,3. From t'e aut'orGs so)ia. )ogniti/e perspe)ti/e 2Wi..iams H Cer/one$ *++BC )f. Bandura$ *+?+$ *+DB$ *+B?3$ menta. disorders$ in).uding anxiety disorders$ do not exist. Rat'er$ psy)'o.ogi)a. prob.ems exist. %sy)'o.ogi)a. prob.ems differ from menta. disorders in fundamenta. (ays t'at great.y affe)t 'o( (e study prob.ems and 'e.p peop.e so./e t'em. #'is )'apter (i.. fo)us on a number of prob.em dimensions$ in).uding ma.adapti/e a/oidan)e be'a/ior and )ompu.si/e ritua.s$ sub6e)ti/e fee.ings of fear and pani)$ disturbing t'oug'ts$ and autonomi) 'yperarousa.. #'ese are )ompe..ing psy)'o.ogi)a. rea.ities$ prob.ems in t'eir o(n rig't$ ('ereas anxiety disorders are abstra)tions de/ised by )ommittees. #'e e.usi/e re.ations'ip bet(een menta. disorders and psy)'o.ogi)a. response dimensions is e/ident in t'e (ay 8 M1"> and "C81*, )a.. prob.em responses symptoms of disorder$ but do not exp.ain 'o( 243

244 W"LL"AM a response )an define a disorder yet be a symptom of t'e disorder at t'e same time. Abstra)t disorders )on)rete.y inf.uen)e resear)' on a/oidan)e and fear$ in).uding t'e se.e)tion of par1 ti)ipants$ t'e measurement of t'eir prob.ems$ and t'e )'oi)e of experimenta. and )orre.ationa. 2i.e.$ independent3 /ariab.es and treatment inter/entions. #'ese pra)ti)es 'a/e many negati/e imp.i)ations be)ause anxiety disorders do not )orrespond ).ose.y to psy)'o.ogi)a. rea.ity. Dis#rders Dist#rt Psy./#%#&i.a% Rea%ity Menta. i..nessLdisorder as a s)ientifi) )on)ept distorts our /ie( of psy)'o.ogi)a. responses in many (ays$ a fe( of ('i)' " (i.. )on/ey 'ere so readers (i.. -no( ('y t'e )'apter does not run t'roug' t'e usua. proposed anxiety disorders$ but presents instead a psy)'o.ogi)a. /ie( of prob.ems t'at re6e)ts t'e )on)ept of menta. disorder a.toget'er 2see Wi..iams$ in preparation$ for a fu..er exposition3. -o 1ohesive Distinctive %n"iety Disorder Grouping !"ists #'e term anxiety disorders imp.ies fa.se.y t'at t'e di/erse prob.ems so .abe.ed a)tua..y be.ong toget'er in a spe)ia. distin)ti/e (ay. "n rea.ity$ no su)' )o'esi/e distin)ti/e grouping exists$ as (e (i.. see in )onsidering t'e re.ated issue of )onstru)t /a.idity of anxiety disorder. #'e burden of proof .ies 'ea/i.y on ad/o)ates of anxiety disorder t'eory. A/oidant and )ompu.si/e be'a/iors$ frig'tened fee.ings$ disturbing t'oug'ts$ p'ysio.ogi)a. 'yperarousa.$ and a.. t'e ot'er responses emp.oyed to define anxiety disorders o))ur (ide.y in psy)'o.ogi)a. .ife$ far beyond t'e narro( )onfines of proposed anxiety disorders. #'e )on)ept of anxiety disorder t'us )aptures remar-ab.y .itt.e of t'e psy)'o.ogi)a. p'enomena (it' ('i)' it )on)erns itse.f. And far from s'o(ing order.y ).ustering of t'eir prob.ems$ peop.e said to 'a/e a gi/en anxiety disorder tend to s'o( idiosyn)rati) )ombinations of prob.ems and as a group are 'ig'.y 'eterogeneous (it' respe)t to t'e a)tua. indi/idua. prob.ems t'ey disp.ay. "ndeed$ 'a/ing a.most any prob.em great.y in)reases t'e .i-e.i'ood of 'a/ing a.most any ot'er prob.em 2Boyd et a..$ *+BD3$ ('i)' dire)t.y )'a..enges t'e medi)a. mode.Gs idea. of distin)t neat ).usterings of parti)u.ar responses in disorders$ and of t'ese disorders into groupings su)' as anxiety disorders. "%n"iety Disorder" 0s /ormally 0nvalid #'e anxiety disorder )on)ept forma..y .a)-s )onstru)t /a.idity$ as it .a)-s bot' )on/ergent /a.idity and dis)riminant /a.idity 2Campbe.. H Fis-e$ *+<+3 be)ause t'e di/erse a..eged anxiety disorder prob.em dimensionsLresponses tend to be on.y modest.y )orre.ated (it' one anot'er 2Lang$ *+B<C Ra)'man$ *+D?3$ and yet )an be 'ig'.y )orre.ated (it' a..eged.y distin)t p'enomena su)' as depressed mood and ot'er prob.ems 2C.ar-$ Watson$ H Reyno.ds$ *++<3. #'is )'apter (i.. return to t'e prob.em of )onstru)t /a.idity again after it dis)usses in more detai. t'e meaning of anxiety in .ater se)tions. Note t'at unidimensiona.$ unitary )onstru)ts$ su)' as )urrent anxiety as rated on a simp.e intensity s)a.e 2Wa.-$ *+<?3$ are not burdened (it' )onstru)t /a.idation re7uirements. But mu.tidimensiona. )onstru)ts t'at .a)- )onstru)t /a.idity suffer from a fata. f.a( t'at (e ignore at our s)ientifi) and t'erapeuti) peri.. ,uman +roblems %re Dimensional# -ot Dichotomous %sy)'o.ogi)a. prob.ems su)' as a/oidan)e$ fear$ and intrusi/e t'in-ing are p.ain.y dimensiona. and graduated$ not di)'otomous. Ea)' /aries in intensity and fre7uen)y in degrees$ from being .itt.e or no prob.em to being a se/ere.y distressing andLor in)apa)itating prob.em$ (it' many important.y different .e/e.s of prob.em intensity in bet(een. "n )ontrast$ an anxiety

8. ANV"E#A 8" !R8ER 245 disorder is a.. or none5 a person eit'er 'as it or does not 'a/e it. 8iagnosing anxiety disorder t'us means gat'ering dimensiona. information 2e.g.$ number of pani)-y sensations$ amount of time spent in a/oidan)e ritua.s$ extent of p'obi) disabi.ity$ et).3$ t'en gi/ing up t'at information in ex)'ange for a di)'otomous i..ness 6udgment5 disordered or not disordered. #'is is a /ery bad trade. #ransforming a graduated dimensiona. /ariab.e into a di)'otomous )ategory is 0(i..fu. dis)arding of information. "t 'as been s'o(n t'at ('en you so muti.ate a /ariab.e$ you typi)a..y redu)e its s7uared )orre.ation (it' be'a/ior about :?P 2Co'en$ *+B:3. 8onGt do it0 2Co'en$ *++,$ p. *:,D3. #'e so)ia. )ogniti/e /ie( sees psy)'o.ogi)a. )ontinuity bet(een prob.em and nonprob.em responses 2Bandura$ *+DB$ *+B?C Wi..iams H Cer/one$ *++B3$ 'o.ding t'at t'e same -inds of psy)'obio.ogi)a. fa)tors inf.uen)e bot'. #'is fundamenta. )ontinuity .ea/es no ro.e for menta. disorders in t'e exp.anation of be'a/ior. "Disorder" !"cludes (eal +roblems Many prob.ems of a/oidan)e$ ritua.s$ fear$ and bot'ersome s)ary t'oug'ts$ bot' mi.d and se/ere$ are systemati)a..y ex).uded from t'e s)ope of menta. disorders eit'er outrig't or by p.a)ement in a nonspe)ifi) disorder )ategory 2e.g.$ Bien/enu$ Nestadt$ HEaton$ *++BC Mars'a..$ !.fson$ &e..man$ B.an)o$ =uardino$ H truening$ 9,,*3$ eit'er (ay denying peop.e t'e a..eged benefits of t'e disorder1based exp.anatory s)'eme. ome )a.. t'e prob.ems ex).uded from disorder'ood 0subt'res'o.d disorders$0 a de.ig'tfu..y nonsensi)a. term t'at seems to mean disorders t'at are not disorders. ubt'res'o.d ('ate/er1t'ey1ares resu.t in part from arbitrari.y 'ig' and ot'er(ise psy)'o.ogi)a..y 7uestionab.e )utoff s)ores t'at define disorder. For examp.e$ to )ount an anxiety atta)- as a pani) atta)- for diagnosing pani) disorder$ 8 M1"> re7uires t'at some atta)-s be a))ompanied by at .east four responses from a .onger .ist$ a.t'oug' an atta)- (it' on.y one or t(o su)' responses 2for examp.e$ a smot'ering sensation and a fee.ing of imminent deat'3 )an be intense and 'a/e serious psy)'o.ogi)a. se7ue.ae 2@aternda'. H Rea.ini$ *++:C Margraf$ #ay.or$ E'.ers$ Rot'$ H Agras$ *+BD3. #'e psy)'o.ogi)a. dimensiona. approa)' measures prob.ems a)ross t'eir fu.. intensity range$ from none to extreme$ (it'out any )utoffs or ex).usion ru.es arbitrari.y fixed in ad/an)e. Disorders %re Disconnected /rom (esponses At t'e 'eart of t'e distorting effe)ts of menta. disorder is t'at a disorder is dis)onne)ted from t'e under.ying psy)'o.ogi)a. responses it )onsists of. #'e diffi)u.ty is .ess ('en a menta. disorder is based on a sing.e under.ying psy)'o.ogi)a. dimension$ but an anxiety disorder usua..y is )onstru)ted of mu.tip.e dissimi.ar prob.em dimensions simu.taneous.y$ and t'ese dimensions )an be .itt.e )orre.ated (it' one anot'er. Be)ause on.y some of t'e prob.ems need be present for a positi/e diagnosis$ saying someone 'as a )ertain anxiety disorder )an )on/ey .itt.e definite information about 'is or 'er a)tua. prob.ems. Consider t'e dis)repan)ies bet(een pani) attack 2t'e psy)'o.ogi)a. p'enomenonLdimensionLresponse3 and pani) disorder 2t'e proposed menta. i..ness3$ and bet(een agorap'obi) avoidance 2t'e response3 and agorap'obi) disorder 2t'e proposed i..ness3. Brief.y$ a pani) atta)- is a sudden surge of intense fear$ and agorap'obi) a/oidan)e is a/oidan)e of )ertain a)ti/itiesLsettings in t'e )ommunity 2Mar-s$ *+BDC Mat'e(s$ =e.der$ H Jo'nston$ *+B*C Wi..iams$ *+B<C (e (i.. )onsider bot' pani) and agorap'obia in more detai. in .ater se)tions3. Bro(n and Bar.o( 29,,93 obser/ed$ 0a 8 M1"> diagnosis of pani) disorder (it' agorap'obia )on/eys no information about fre7uen)y and intensity of pani) atta)-s and t'e se/erity of agorap'obi) a/oidan)e0 2p. :9<3. A person a..eged to 'a/e t'is menta. disorder )an suffer from

any .e/e. of pani) atta)-s in).uding none$ and any .e/e. of agorap'obi) a/oidan)e

247 WILLIAMS in).uding none$ and indeed )an 'a/e none of eit'er. "n 8 M1">$ peop.e ('o eit'er a/oid or fear agorap'obi) a)ti/ities 'a/e pani) disorder ('et'er t'ey 'a/e pani) atta)-s or not$ as .ong as t'ey (ere at .east brief.y bot'ered by pani) at any past time$ 'o(e/er remote. Moreo/er$ 8 M1"> agorap'obi) disorders 2i.e.$ pani) disorder (it' agorap'obia and agorap'obia (it'out 'istory of pani) disorder3 re7uire on.y t'at t'e person need a )ompanion or fee. anxious in agorap'obi) settings$ not t'at 'e or s'e a/oid t'em 2"C81*, re7uires a/oidan)e be'a/ior3. o a person )an suffer from 8 M1"> pani) disorder (it' agorap'obia despite 'a/ing neit'er pani) atta)-s nor agorap'obi) a/oidan)e. u)' a diagnosis )on/eys .itt.e about someoneGs prob.ems. Anot'er sour)e of dis)ordan)e bet(een pani) as response and pani) as disorder arises be)ause pani) disorder )auses 2or )onsists of3 some -inds of pani) atta)-s but not ot'ers. For examp.e$ pani) atta)-s are not 8 M1"> pani) disorder 2or its symptoms3 if t'ey o))ur in re.ation to /arious p'obias$ obsessions$ )ompu.sions$ and stress$ as pani) atta)-s /ery often do 2Bar.o($ *+BD3. E/en more restri)ti/e.y$ "C81*, pani) atta)-s are not pani) disorder if t'e peop.e ('o suffer from t'em are depressed$ p'obi) of a.most anyt'ing 2in).uding agorap'obi)3$ or experien)e 'ig' anxiety bet(een pani) atta)-s$ a.. of ('i)' pani)-y peop.e /ery often do 2Bar.o($ 9,,93. #'e )omp.ex and ).as'ing diagnosti) ex).usion ru.es point p.ain.y to great arbitrariness in t'e )on)epts of pani) disorder and agorap'obi) disorder$ as (e.. as to t'e fai.ure of disorders to )'ara)teri4e t'eir o(n under.ying psy)'o.ogi)a. dimensions. %ani) atta)-s and agorap'obi) a/oidan)e )an )o1o))ur$ but t'ey are .arge.y un)orre.ated 2Cras-e H Bar.o($ *+BD3$ and t'ey are remedied by some('at different approa)'es 2Cras-e$ *+++3. Ea)' dimension is separate and important in its o(n rig't$ and is better /ie(ed t'at (ay. 1#di%y Ca$ses #6 1e/a,i#r Are N#t Menta% I%%nesses Bodi.y pro)esses 'a/e a bearing on a/oidan)e$ fear$ and s)ary t'oug'ts 2Bar.o($ 9,,93$ as t'ey do on near.y e/ery fa)et of 'uman fun)tioning. #'e re.ations'ip bet(een bodi.y )auses and menta. i..nesses is a point of (idespread )onfusion. A bodi.y pro)ess and a menta. i..ness are 7uite different t'ings. For examp.e$ bodi.y pro)esses are p'ysi)a. 2i.e.$ t'ey )onsist of interna. bio)'emi)a. e/ents$ anatomi)a. stru)tures$ and t'e .i-e$ measured on.y p'ysi)a..y and ob6e)ti/e.y3 ('ereas menta. i..nesses are menta. 2i.e.$ t'ey are denned .arge.y by sub6e)ti/e t'oug'ts and fee.ings$ so)ia. be'a/iors$ et).3. "n 6ust about any psy)'o.ogi)a. t'eory bodi.y pro)esses p.ay a ro.e in near.y e/ery 'uman response$ so bodi.y inf.uen)e says not'ing about disease. A bodi.y organ being affe)ted by a bodi.y pro)ess does not mean t'e organ is diseased$ and .i-e(ise a menta. state being affe)ted by a bodi.y pro)ess does not mean t'e menta. state is diseased. Nor does it mean t'at menta. states or be'a/ior )an be redu)ed to bodi.y pro)esses. Menta. states in t'eir o(n rig't )an exp.ain be'a/ior$ and t'ey must be understood on t'eir o(n terms 2Bandura$ *+B?$ *++DC a.-o/s-is$ *++?bC Wi..iams H Cer/one$ *++B3. #'is )'apter .ater re/ie(s findings t'at peop.eGs )ons)iousness )an predi)t t'eir future anxious fee.ings and a/oidant be'a/iors a))urate.y$ indeed far more a))urate.y t'an )an any measure of biop'ysio.ogy. But e/en if p'ysio.ogi)a. measures strong.y predi)ted a/oidan)e$ a/oidant be'a/ior sti.. (ou.d be neit'er a menta. i..ness nor menta. disorder. PRO1LEMS DESCRI1ED A,#idan.e 1e/a,i#r' P/#bi. A,#idan.e #'e so)ia. )ogniti/e perspe)ti/e on t'e importan)e of be'a/iora. fun)tioning is t'at a.t'oug' it is not t'e on.y important dimension of psy)'oso)ia. adaptation$ for many purposes it is t'e

8. AN<IETY DISORDERS 248 most important one 2Wi..iams H Cer/one$ *++B3. %eop.eGs pat's t'roug' .ife$ and t'eir in(ard fu.fi..ments and sufferings a.ong t'e (ay$ 'a/e a .ot to do (it' ('at t'ey do$ and do not do$ out(ard.y. !ut(ard be'a/ior is fundamenta. to meeting oneGs responsibi.ities$ to maintaining so)ia. re.ations'ips$ and to a)'ie/ing most /a.ued persona. goa.s. #o suffer anxiety in s'ops and so)ia. gat'erings is bad indeed$ but to be unab.e to go into t'em is (orse$ undermining peop.eGs /ery abi.ity to p'ysi)a..y sustain t'emse./es and fore).osing any )'an)e of a near1norma. .ife. Need.ess a/oidan)e in at .east mi.d and transitory forms is (idespread in psy)'o.ogi)a. .ife$ but ('en a/oidan)e is .imiting and persistent one spea-s of p'obia. %'obias i..ustrate prototypi)a..y t'e 0neuroti) paradox0 of se.f1defeating be'a/ior in ('i)' a person is unab.e to do a /ery ordinary a)tion a.t'oug' s'e 2or 'e3 is ot'er(ise 7uite )ompetent$ (is'es to fun)tion norma..y$ possesses t'e ne)essary )ogniti/e1motori) s-i..s$ and is (e.. a(are t'at 'er disabi.ity is sense.ess. Be'a/iora. disabi.ity is fundamenta..y important in its o(n rig't as .imiting a personGs abi.ity to .i/e a norma. .ife$ but a.so be)ause ('at peop.e do out(ard.y 2and )annot do3 po(erfu..y affe)ts for better or (orse 'o( t'ey t'in- and fee. in(ard.y 2Bandura$ *++DC Wi..iams$ *++<$ *++?a3. %'obi) a/oidan)e and )ompu.si/e ritua.s torture peop.e by robbing t'em of so)ia. and re)reationa. possibi.ities and e/en of t'eir .i/e.i'oods$ by 'umi.iating and depressing t'em$ and by .o(ering t'eir se.f1esteem and 7ua.ity of .ife 2Bandura$ *+DBC te-etee H Bar.o($ 9,,9C Mar-s$ *+BD3. A/oidan)e of a)ti/itiesLstimu.i must be distinguis'ed from fearfu. fee.ings to(ard a)ti/itiesL stimu.i$ as t'e t(o are not 'ig'.y )orre.ated 2Carr$ *+D+C Lang$ *+B<C Mine-a$ *+D+C Ra)'man$ *+D?3. #'e term phobia )an app.y to eit'er patternEfor examp.e$ diagnosing p'obi) disorder re7uires a/oidan)e be'a/ior in "C81*,$ but 8 M1"> a))epts anxiety about parti)u.ar t'ings (it'out a/oidan)e of t'em as p'obi) disorder. #'is se)tion emp'asi4es p'obi) a/oidan)e be'a/ior$ ('ereas .ater se)tions address sub6e)ti/e anxiety and s)ary t'oug'ts. %'obias /ary (ide.y in ob6e)t$ se/erity$ and genera.ity. ome p'obias are of 'ig'.y spe)ifi) ob6e)ts or a)ti/ities 2e.g.$ riding e.e/ators or en)ountering )ats or .oud peop.e3$ ('ereas genera.i4ed p'obi) patterns )an en)ompass a (ide range of seeming.y dissimi.ar a)ti/ities. Any spe)ifi) p'obia )an be a genera.i4ed prob.em ('en it is se/ere enoug' or ('en t'e feared ob6e)tLa)ti/ity is found in di/erse p.a)es 2e.g.$ spiders or strangersC Bandura$ *+DBC Mar-s$ *+BD3. pe)ifi) p'obias tend to o))ur (it' ot'er spe)ifi) p'obias$ so t'e distin)tion bet(een spe)ifi) and genera.i4ed p'obias )an be diffi)u.t to ma-e in any )ase 2&offman$ Le'man$ H Bar.o($ *++DC Lipsit4$ Bar.o($ Mannu44a$ &offman$ H Fyer$ 9,,93. A spe)ifi) p'obia )an be 'eterogeneousC for examp.e$ a denta.1p'obi) person mig't dread t'e )onfinement$ t'e need.e$ t'e dri..ing$ t'e s)ents$ a..ergi) rea)tions$ pani) atta)-s$ or /arious s)ary so)ia. possibi.ities 2e.g.$ Moore$ Brodsgaard$ H Birn$ *++*3$ so 0denta. p'obia0 )on/eys on.y a .imited amount about an indi/idua.Gs prob.ems. Mu.tip'obi) )onditions )an o))ur in )onste..ations su)' as agoraphobia# in ('i)' a person is simu.taneous.y p'obi) of at .east a fe( and possib.y many or a.. of about *< or so distin)t )ommunity a)ti/ities su)' as .ea/ing 'ome a.one$ using pub.i) transportation$ s'opping$ to.1 erating 'eig'ts$ )rossing bridges$ riding e.e/ators or es)a.ators$ dri/ing a )ar$ and being in an audien)e 2Mar-s$ *+BDC Wi..iams$ *+B<3. %'obias of so)ia. s)rutiny or of being embarassed or of )ausing embarassment to ot'ers )an a))ompany agorap'obia or o))ur separate.y from it. o)ia. p'obias are )ommon. =reat 'eterogeneity exists bet(een indi/idua.s and a)ross different )u.tura. )ontexts in t'e number$ -inds$ and patterning of mu.tip'obi) and agorap'obi) indi/idua.sG fears

and in t'eir )on)omitant prob.ems su)' as pani) atta)-s$ mood prob.ems$ (orry$ and many ot'er psy)'o.ogi)a. diffi)u.ties 2Bro(n H Bar.o($ 9,,9C &offman H Bar.o($ 9,,9C Wi..iams$ *+B<3. As mentioned ear.ier$ ex)essi/e a/oidan)e andLor fearfu. fee.ings about parti)u.ar t'ings are )ommon far beyond t'e prob.ems t'at diagnosti) manua.s deem offi)ia. p'obi) disorders.

250 WILLIAMS A.. of t'e 8 M1"> and "C81*, proposed anxiety disorders$ in).uding obsessi/e1)ompu.si/e disorder$ genera.i4ed anxiety disorder$ and /arious stress disorders$ are defined in signifi)ant part by ma.adapti/e be'a/iora. a/oidan)e of$ andLor fearfu. fee.ings about$ spe)ifiab.e a)ti/ities or ob6e)ts$ in ot'er (ords$ by p'obias. ome sexua. p'obias are )a..ed sexua. dysfun)tionsC some p'obias of 'a/ing a bodi.y deformity$ body dysmorp'i) disorderC some disease p'obias$ 'ypo)'ondriasisC some p'obias of gaining (eig't$ anorexia ner/osaC and so on. A/oidan)e be'a/iors and frig'tened fee.ings to(ard parti)u.ar a)ti/itiesLob6e)ts )ertain.y )an 'a/e indi1 /idua. distin)ti/e psy)'o.ogi)a. features and t'emati) )on)erns not s'ared among a.. p'obias. But t'ey are p'obias nonet'e.ess. A,#idan.e 1e/a,i#r' C#(*$%si,e Rit$a%s An important /ariant of dysfun)tiona. a/oidan)e be'a/ior is )ompu.si/e be'a/iora. ritua.s$ su)' as ex)essi/e ).eaning$ repeating$ )'e)-ing$ )ounting$ arranging$ 'oarding$ or ot'er a)tion t'at t'e person fee.s )ompe..ed to do. "t is diffi)u.t to exaggerate t'e 'eartbrea-ing extent of fun)tiona. impairment and strangeness of be'a/ior t'at )an be found in peop.e (it' se/ere )ompu.sions 2Ra)'man H &odgson$ *+B,C te-etee H Bar.o($ 9,,93. Less extreme but nonet'e.ess troub.ing )ompu.sions appear to be 7uite )ommon 2Muris$ Mer)-e.ba)'$ H C.a/an$ *++D3. And di/erse prob.em be'a/iors ot'er t'an t'ose defined by 8 M or "C8 as obsessi/e1)ompu.si/e disorder$ su)' as ti)s$ 'air pu..ing$ ritua.s )onne)ted (it' se.f1star/ation$ dysmorp'op'obia$ and ot'er prob.ems )an be )ompu.si/e in nature 2Aaryura1#obias H M)@ay$ 9,,93. Compu.sions are usua..y a))ompanied by obsessi/e intrusi/e t'oug'ts$ by a sense t'at t'ey pre/ent 'arm or danger$ by a sub6e)ti/e fee.ing of fear or dis)omfort t'at de).ines (it' t'e )ompu.si/e a)t$ and by rationa. re)ognition t'at t'e be'a/ior is ex)essi/e$ but none of t'ese four is in/ariab.y present e/en in se/ere )ases 2Ra)'man H &odgson$ *+B,C te-etee H Bar.o($ 9,,93. %'obia and )ompu.sion )an be /ie(ed as different points a.ong a passi/e1a/oidan)e /ersus a)ti/e1a/oidan)e )ontinuum. At one end$ a person passi/e.y refrains from a)ti/ities$ as a restaurant1p'obi) person simp.y stays a(ay from restaurants. "n t'e )ontinuumGs midd.e are a)ti/e maneu/ers to a/oid or manage p'obi) t'reats$ su)' as a bridge1p'obi) man dri/ing far out 'is (ay to (or- e/ery day to a/oid a .arge bridge. At t'e most a)ti/e end are effortfu. ritua.s performed at .engt' to a/oid a dreaded possibi.ity. %'obi) and )ompu.si/e be'a/iors often )o1 o))ur and o/er.ap 2Ra)'man H &odgson$ *+B,3. For examp.e$ a (oman ('o dreaded being burg.ari4ed remained fu..y dressed in bed e/ery nig't atop t'e bed)o/ers 2p'obia3$ and spent mu)' time before bed )'e)-ing and re)'e)-ing 'er (indo( and door .o)-s 2)ompu.sion3. A.t'oug' most peop.e (it' p'obias do not 'a/e mar-ed )ompu.sions$ t'ey often engage in subt.e se.f1prote)ti/e ritua.s in )oping (it' p'obia1re.ated a)ti/ities 2 a.-o/s-is$ *++*C Wi..iams$ *+B<3$ and most peop.e (it' mar-ed )ompu.sions are p'obi) about )ompu.sion1pro/o-ing )ir)umstan)es$ su)' as )ompu.si/e 'and(as'ers ('o p'obi)a..y a/oid )onta)t (it' )ontaminating ob6e)ts .i-e door 'and.es. Cogniti/e )ompu.sions a.so exist$ in ('i)' peop.e perform t'oug't ritua.s$ su)' as menta..y )'e)-ing$ )ounting$ re)iting$ or arranging. Compu.sions may o))ur in response to externa. stimu.i or in response to obsessions$ intrusi/e un(anted t'oug'ts$ images$ or impu.ses often experien)ed as a.ien$ a/ersi/e$ or frig'tening. At times t'e pro/o-ing a)ti/itiesLstimu.i and obsessi/e t'oug'ts operate in )on)ert. For examp.e$ ('en one man stepped off a )urb 'e 'ad not to t'in- 08amn =odZ0 e.se 'e (ou.d be eterna..y damnedC usua..y unsure if 'e 'ad done it rig't$ 'e 'ad to step ba)- and repeat it o/er and o/er. !bsessi/e t'oug'ts and )ompu.si/e be'a/iors are

part.y independent dimensions. ome indi/idua.s 'a/e obsessions but not )ompu.sions$ ot'ers 'a/e )ompu.sions but not obsessions$ and ot'ers 2per'aps B,P3 'a/e some -ind of mixture of bot'. Eit'er )an predominate$ and t'eories and treatments )on)erning ea)' are important.y

8. AN<IETY DISORDERS 252 different 2Ra)'man$ *++BC a.-o/s-is$ *++?aC te-etee H Bar.o($ 9,,93. #'erefore$ t'e genera. se/erity of a personGs )ompu.sions and obsessions (ou.d be )'ara)teri4ed far better by t(o separate dimensiona. s)ores t'an by a diagnosis 2or not3 as obsessi/e1)ompu.si/e disorder. We (i.. dis)uss obsessions in more detai. .ater ('en (e )onsider bot'ersome t'oug'ts. An-iety Unimodal# Multimodal# and +olymodal %n"iety )ientists 'a/e .ong )on)ei/ed anxiety in di/erse (ays. Anxiety )an be defined unimoda..y by a sing.e -ind of response su)' as t'e sub6e)ti/e intensity of fear 2Wa.-$ *+<?3 or ob6e)ti/e p'ysio.ogi)a. arousa. 2Mo(rer$ *+?,3. More )ommon.y anxiety is defined mu.timoda..y by bot' sub6e)ti/e anxiety and p'ysio.ogi)a. responses$ and sometimes by )ertain t'oug't patterns as (e... #'e extreme of mu.timoda. definitions " )a.. po.ymoda. anxiety in).udes expansi/e )ontents 2Lang$ *+B<3 to be dis)ussed .ater. #'e so)ia. )ogniti/e /ie( is t'at for most purposes t'e dissimi.ar responses are better -ept separate$ )on)eptua..y and termino.ogi)a..y$ rat'er t'an .umped into an a..1purpose but not /ery meaningfu. anxiety )ategory$ so so)ia. )ogniti/e t'eory )a..s t'e /arious responses by t'eir indi/idua. names. 'ub4ective %n"iety Being afraid means abo/e a.. fee.ing afraid$ )ons)ious.y$ (it'out ('i)' anxiety 'as no meaning. Fear in )ons)iousness is to some extent ineffab.e$ indes)ribab.e in (ords$ but peop.e )an meaningfu..y indi)ate 'o( intense.y afraid t'ey fee. by rating a s)a.e$ for examp.e$ from , 2not anxious or afraid3 to *, 2extreme.y anxious and afraid3. Fear intensity s)a.es from , to *,,$ or , to B$ (it' /ariant instru)tion sets and an)'or /a.ues$ are (ide.y used. #'is sort of definition 'as t'e .arge ad/antage of not imposing meanings on anxiety ot'er t'at ('at peop.e t'emse./es mean by simp.e an)'oring terms su)' as anxious$ afraid$ and t'e .i-e. ub6e)ti/e anxiety 'as meaning in re.ation to t'e psy)'o.ogi)a. )ontext in ('i)' peop.e experien)e it$ and anxiety intensity ratings indi)ate straig'tfor(ard.y 'o( mu)' parti)u.ar a)ti/ities$ ob6e)ts$ or images frig'ten peop.e 2&ersen$ *+D:C Wa.-$ *+<?C Wo.pe$ *+<B3. +hysiological %n"iety Anxiety is (ide.y )onsidered to be in part p'ysio.ogi)a. response$ main.y autonomi) arousa. and its asso)iated neuro)'emi)a. me)'anisms. %eop.e )ommon.y report s)ary experien)es and fee.ings in part by des)ribing 'o( t'eir 'eart ra)ed$ t'ey bro-e out in a s(eat$ and so on. Be)ause autonomi) arousa. per se )an be measured p'ysi)a..y$ (it'out referen)e to peop.eGs )ons)iousness$ it is a fa/ored index of fear among in/estigators ('o 6udge sub6e)ti/e fee.ings to be pri/ate e/ents ina))essab.e to s)ien)e. 8efining anxiety as p'ysio.ogi)a. arousa. gets peop.eGs uns)ientifi) inner fee.ings out of t'e (ay$ but at a 'ig' s)ientifi) pri)e. A.t'oug' peop.e are more p'ysi)a..y aroused ('en fee.ing strong emotions genera..y$ autonomi) arousa. patterns do not )orrespond to parti)u.ar sub6e)ti/e fee.ing states 2&oe'n1 ari)$ *++BC La)ey$ *+?DC Ra6on) H M)intos'$ *++93$ and frig'tened and pani)-y peop.e s'o( many patterns of p'ysio.ogi)a. arousa.$ in).uding none 2Carr$ *+D+C E'.ers$ *++:C Margraf et a..$ *+BDC Morro( H Labrum$ *+DBC #ay.or et a..$ *+B?3. %'ysio.ogi)a. arousa. (it'out sub6e)ti/e fear is )ommon$ as ('en peop.e exer)ise$ fee. sexua. interest$ or mere.y 'ear a fami.iar /oi)e 2Lang$ *+B<3. Ca..ing autonomi) arousa. anxiety )reates )onfusion about 'o( anxious someone is be)ause different autonomi) responses )orre.ate .itt.e (it' one anot'er and )an e/en )'ange in different dire)tions in an indi/idua. during treatment 2Bandura$ *+?+C Ra)'man H &odgson$ *+D;3. #'e

253 W"LL"AM .arge gap bet(een p'ysio.ogy and sub6e)ti/e fee.ing means t'at bodi.y responses per se )annot be anxiety$ but must be )onsidered on t'eir o(n terms 2Wi..iams$ *+BD3. +erception o f +hysiological %rousal "n so)ia. )ogniti/e t'eory$ p'ysio.ogi)a. arousa. per se 'as .ess impa)t on be'a/ior t'an does t'e personGs per)eption and interpretation of p'ysio.ogi)a. arousa. 2Cioffi$ *++*C C.ar-$ *+B?C a.-o/s-is H War(i)-$ *+B?3. Bodi.y per)eptions )an be)ome a fo)us of obsessi/e (orrying and )an gi/e rise to defensi/e a)tions$ su)' as see-ing medi)a. 'e.p for a ra)ing 'eart or ritua..y )arrying a bott.e of (ater against a possib.e dry mout'. Bodi.y per)eptions are imp.i)ated too in pani) atta)-s and i..ness p'obias 2C.ar-$ *+B?C a.-o/s-is H War(i)-$ *+B?3. Aet peop.e$ in).uding t'ose (it' a/oidan)e and fear1re.ated prob.ems$ are remar-ab.y ina))urate at per)ei/ing 'o( mu)' t'ey are s(eating or t'eir 'eart is beating 2E'.ers$ *++:C Mand.er$ *+?9C %enneba-er$ *+B93. #'e ina))ura)y of bodi.y per)eptions is )urious.y ignored by 8 M1"> and "C81*,$ ('i)' a..o( diagnosti)ians to measure a))e.erated 'eart rate eit'er by a biometri) apparatus or by t'e diagnosed personGs sub6e)ti/e impressions$ t(o .itt.e1re.ated indi)ants. Trait %n"iety #'eorists 'a/e )on)ei/ed anxiety not on.y as a transitory fee.ing state$ but an enduring persona.ity trait$ a disposition to genera..y see )ir)umstan)es as t'reatening and to rea)t (it' fear 2e.g.$ Catte.. H )'eier$ *+?*C pie.berger$ *+B:3. #rait anxiety is usua..y measured by as-ing peop.e to rate t'e se.f1des)ripti/eness of /arious brief genera. statements. >ariant trait )on)eptions and trait.i-e in/entories abound t'at measure anxiety in genera.$ (it'out respe)t to )ontext. %eop.e )ertain.y do differ from one anot'er in 'o( mu)' t'ey are genera..y distressed 2or disab.ed$ or bede/i.ed by bot'ersome t'oug'ts3$ but in e/ery )ase t'ey are troub.ed by )ertain definite t'ings and not by ot'ers 2e.g.$ C'amb.ess$ Be)-$ =ra)e.y$ H =ris'am$ 9,,,3. o)ia. )ogniti/e t'eory predi)ts mar-ed s'ifts in be'a/ior$ t'oug't$ and fee.ing depending on )ontext 2Bandura$ *+?+C Be)-$ *+D?C Wi..iams$ *+B<3. >ariation in an indi/idua.Gs trait1re.e/ant be'a/ior a)ross situations is simp.y ignored by genera.i4ed traits$ as is t'e idiosyn)rati) )onfiguration of parti)u.ar prob.em responses from one person to anot'er. u)' /ariation )annot in prin)ip.e be exp.ained by differen)es in genera.i4ed tenden)ies to be anxious or neuroti)$ or to t'in)atastrop'i) t'oug'ts$ fee. negati/e affe)t$ or be frig'tened by per)ei/ed bodi.y arousa.. #rait s)ores 'a/e some predi)ti/e abi.ity$ but rare.y )an t'ey re.iab.y exp.ain e/en *<P of t'e /arian)e in be'a/ior$ often far .ess 2Bandura$ *+B?C Mis)'e.$ *++,C Wi..iams H Cer/one$ *++B3. Be)ause psy)'o.ogi)a. treatments in/o./e t'e person 'a/ing dire)t menta. and p'ysi)a. )ommer)e (it' t'e spe)ifi) t'ings 'e or s'e fears$ a/oids$ ritua.i4es o/er$ or intrusi/e.y t'in-s about 2Bar.o($ 9,,9C Cras-e$ *+++3$ -no(ing someoneGs a/erage tenden)y to be anxious gi/es t'erapists .itt.e usefu. information for 'e.ping peop.e )'ange. 8i/erging from t'e trait approa)'$ t'e so)ia. )ogniti/e approa)' measures parti)u.ar prob.em responses in dire)t re.ation to parti)u.ar prob.em )ir)umstan)es$ in t'e natura. en/ironment if possib.e$ and ot'er(ise in a parti)u.ar.y defined psy)'o.ogi)a. )ontext 2Wi..iams$ *+B<3. Context1sensiti/e so)ia. )ognitions a))urate.y predi)t and exp.ain prob.em be'a/iors$ as (e (i.. see .ater. +sychiatric %n"iety Manua.s of menta. disorders re.y on anxiety as a des)ription$ a )ause$ and an effe)t of di/erse menta. i..nesses$ but are un).ear and interna..y in)onsistent in 'o( t'ey define and ta.- about anxiety. %sy)'iatri) anxiety is mu.timoda. anxiety and )omes in t'ree rat'er different forms5

8. ANV"E#A 8" !R8ER 254 t'e p'enomenon of anxiety$ t'e proposed symptoms of anxiety disorder$ and pani) atta)-s$ ea)' of ('i)' differs bet(een "C81*, and 8 M1"> +sychiatric %n"iety as a +roposed Multimodal +henomenon. "n 8 M1">Gs g.ossary$ anxiety is 0t'e appre'ensi/e anti)ipation of future danger or misfortune a))ompanied by a fee.ing of dysp'oria or somati) symptoms of tension0 2p. D?;3. "C81*,Gs definition of anxiety is .ooser 2note t'e term 0usua..y0 in ('at fo..o(s3 yet more e.aborate5 0%rimary symptoms of anxiety... usua..y in/o./e e.ements of 2a3 appre'ension 2(orries about future misfortunes$ fee.ing Gon edgeG$ diffi)u.ty in )on)entrating$ et).3C 2b3 motor tension 2rest.ess fidgeting$ tension 'eada)'es$ tremb.ing$ inabi.ity to re.ax3C and 2)3 autonomi) o/era)ti/ity 2.ig't'eadedness$ s(eating$ ta)'y)ardia.. .di44iness$ dry mout'$ et).30 2p. *;,3. Note t'at neit'er definition in)orporates a/oidan)e be'a/ior. 2Curious.y$ 8 M1"> pani) does not ne)essari.y in/o./e appre'ension of danger or 'arm$ but t'en it does not ne)essari.y in/o./e fee.ing afraid eit'er3. #'e re7uirement for danger t'oug'ts in 8 M1"> anxiety$ and t'eir optiona. in).usion in "C81*, anxiety$ transform danger t'oug'ts from anxietyGs )ause into its /ery definition$ t'ereby rendering Be)-Gs 2*+D?3 danger t'eory of anxiety nu.. and /oid be)ause a )ause )annot dire)t.y )ause itse.f. For )on)eptua. and resear)' ).arity$ it seems better to -eep danger t'oug'ts out of t'e definition of fee.ing afraid to enab.e exp.oring t'e ro.e of danger t'oug'ts in ma-ing peop.e fee. afraid. +sychiatric %n"iety as a 'ymptom o f %n"iety Disorder. 8 M1"> and "C81*, ea)' propose t'at /aried )ogniti/e$ emotiona.$ be'a/iora.$ p'ysio.ogi)a.$ and per)eptua. responses 2some('at different bet(een t'e t(o manua.s3 are anxiety disorder symptoms. ome proposed anxiety symptoms are anxiety 2e.g.$ fearfu. sub6e)ti/e fee.ings$ p'ysio.ogi)a. 'yperarousa.3$ ('ereas ot'er anxiety symptoms are not anxiety 2e.g.$ obsessi/e t'oug'ts$ p'obi) be'a/iors3$ a))ording to ea)' manua.Gs definition of anxiety 2see t'e pre)eding paragrap'3. Be)ause t'e terms anxiety$ anxiety symptoms$ and anxiety disorder symptoms are (ide.y used as inter)'angeab.e$ it seems t'at t'e diagnosti) manua.sG efforts to set t'ings straig't 'a/e if anyt'ing furt'er be).ouded anxietyGs a.ready foggy meaning. +sychiatric %n"iety as +anic %ttack. %sy)'iatri) manua.s a.so emp'asi4e pani) atta)-s$ a /ariant form of anxiety. %ani) atta)-s are sudden rus'es of intense fear 2or in 8 M1">$ dis)omfort3 t'at )an be disturbing and )an .ea/e a .asting residue of dread and disabi.ity 2Bar.o($ 9,,9C Cras-e$ *+++C Ra)'man H Maser$ *+BB3. Aet peop.e 'a/e pani) atta)-s ('o do not 'a/e or de/e.op serious prob.ems in )onne)tion (it' t'em 2Norton$ Cox$ H Ma.an$ *++9C Wi.son$ and.er$ Asmundson$ Ediger$ Larsen$ H Wa.-er$ *++93. %ani) atta)-s )an /ary (ide.y in intensity$ duration$ fre7uen)y$ number and -ind of a))ompanying sensationsLrea)tions$ and ot'er graduated dimensions 2Cras-e$ *+++3. #'e 8 M1"> definition of pani) atta)-$ (ide.y used in resear)'$ is a dis)rete period of rapid.y mounting intense fear or dis)omfort a))ompanied by at .east a sma.. subset of about t(enty1fi/e .isted t'oug'ts$ fee.ings$ per)eptions$ and p'ysio.ogi)a. or ot'er sensations. #'e t(enty1fi/e responses are sorted into t'irteen )ategories$ (it' responses in at .east four of t'e t'irteen )ategories needed for t'e atta)- to be an offi)ia. 8 M1"> pani) atta)-$ as mentioned ear.ier. Notab.y$ a/oidan)e be'a/ior is not part of t'is definition. 8 M1"> )a..s t'e t(enty1fi/e responses symptoms of pani)$ but of )ourse t'ey are pani) per se rat'er t'an its symptoms. #erms su)' as pani) responses or pani) features ser/e better be)ause t'e term pani) symptoms absurd.y imp.ies t'at pani) atta)-s )ause or produ)e t'eir o(n defining )'ara)teristi)s. Contro/ersy exists as to ('et'er pani) differs from simp.y rapid.y mounting anxiety 2Bar.o($

9,,93. #'e simi.arities seem mu)' .arger t'an t'e differen)es 2Cras-e$ *+++3. >irtua..y

256 W"LL"AM e/ery one of t'e t(enty1fi/e pani) responses .isted in 8 M1"> is )ommon.y in).uded in defini1 tions of p.ain o.d anxiety. For examp.e$ of t'e t(enty1one items in t'e Be)- Anxiety "n/entory 2Be)-$ Epstein$ Bro(n$ H teer$ *+BB3$ fifteen are 8 M1"> pani) responses. A.t'oug' pani)$ .i-e anxiety$ is )on/entiona..y defined and )on)ei/ed in part as bodi.y arousa.$ t'e a)tua. re1 .ations'ip bet(een bodi.y arousa. and pani)$ .i-e t'at bet(een bodi.y arousa. and sub6e)ti/e anxiety$ is not /ery strong$ (it' many reported pani) atta)-s 'a/ing no e/ident a))ompanying autonomi) arousa.$ and (it' 'ig' rapid autonomi) arousa. often not being experien)ed as s)ary or pani)-y by an indi/idua. 2Cras-e$ *+++C E'.ers$ *++:C #ay.or et a..$ *+B?3. As t'e essen)e and sine 7ua non of anxiety is t'e sub6e)ti/e fee.ing of anxiety$ t'e essen)e and sine 7ua non of pani) is t'e sub6e)ti/e fee.ing of pani). #'e )on)ept of spontaneous 2or un)ued or unexpe)ted3 pani) (as proposed by @.ein 2*+B,3 as being important.y different from ordinary p'obi) anxiety be)ause it (as un.in-ed to parti)u.ar stimu.i$ and ear.y t'eories )onsidered pani) to be a bio.ogi)a..y triggered e/ent 2Bar.o($ 9,,9C @.ein$ *+B,3. %ani) atta)-s /ary dimensiona..y in t'eir apparent re.ation to spe)ifi) en/ironmenta. )ir)umstan)es$ (it' some seeming to )ome unexpe)ted.y and ot'ers being per1 )ei/ed as more .i-e.y or .ess .i-e.y in gi/en )ir)umstan)es. Apart from peop.eGs per)eption of a )ue$ )ued and un)ued pani) atta)-s are simi.ar 2Cras-e$ *++*$ *+++3. #'e so)ia. )ogniti/e /ie( is t'at e/en unexpe)ted anxiety and pani) often o))ur in re.ation to dis)rete psy)'o.ogi)a. e/ents$ but t'ese )an be )ogniti/e e/ents su)' as )atastrop'i) interpretations of per)ei/ed bodi.y states 2e.g.$ C.ar-$ *+B?C C.ar- et a..$ *++DC Cras-e$ *++*3 and .oss of se.f1effi)a)y for maintaining )ogniti/e )ontro. 2Wi..iams H LaBerge$ *++;3. %ani) )an be 'ig'.y responsi/e to en/ironmenta. and psy)'o.ogi)a. manipu.ations and inter/entions 2C.ar-$ *++:C Cras-e$ *+++C Rapee$ *++:$ *++<C Wi..iams H Fa.bo$ *++?3. Multimodal %n"iety +lus5 The Three3'ystems %nalysis Most -inds of anxiety are defined by nonbe'a/iora. responses. #'e t'ree1systems ana.ysis 2Lang$ *+B<3 goes furt'er and t'ro(s in ma.adapti/e be'a/ior itse.f$ t'e /ery p'enomenon anxiety (as supposed to exp.ain. Lang 2*+B<3 states$ 0t'e data of anxiety... are measurab.e responses ('i)' fa.. into t'ree genera. )ategories of be'a/ior0 )onsisting of 0/erba. reports of distress$ fear re.ated be'a/iora. a)ts$0 and 0patterns of /is)era. and somati) a)ti/ation0 2Lang$ *+B<$ p. *::1 *:;3. #'e /erba. report )ategory 'as )ome to in).ude near.y e/eryt'ing peop.e )an say about t'eir mu.timoda. fear responses 2Cras-e$ *+++3. %eop.e no doubt t'in-$ fee.$ a)t$ and respond p'ysio.ogi)a..y$ a.. at on)e$ in near.y e/ery fa)et of t'eir .i/es. But as a t'eory of a/oidant be'a/ior t'e t'ree systems ana.ysis is sti..born. #'e emotion of anxiety (as to be t'e )ause of prob.em be'a/ior. Asserting t'at t'e emotion and t'e be'a/ior are one and t'e same$ name.y anxiety$ robs bot' of meaning. #'e t'ree1systems ana.ysis does not spe)ify psy)'o.ogi)a. )auses ex)ept to re6e)t )ons)ious t'oug't and fee.ing as )auses of anyt'ing. #'e /erba. report )ategory is sometimes )a..ed t'e )ogniti/e system$ yet it )onsists not of )ons)ious )ognitions or )ons)ious emotions but of 0/erba. reports of distress$ i.e.$ reports of anxiety$ fear$ dread$ pani)$ and asso)iated )omp.aints of (orry$ obsessions$ inabi.ity to )on)entrate$ inse)urity$ and t'e .i-e0 2Lang$ *+B<$ p. *::3. Lang 2*+B<3 states p.ain.y t'at t'ese reports 'a/e .itt.e rea. meaning5 0Fee.ing states are )omp.ete.y pri/ate and represent a poor data resour)e for t'e ).ini)ian preparing to underta-e treatment$0 and 0t'eir una/ai.abi.ity to... obser/ers appears to deny any possibi.ity of s)ientifi) in/estigation0 2p. *:*3. Fortunate.y$ 0pe)u.iarities of be'a/ior0 and 0a /ariety of Ip'ysio.ogi)a.J symptoms . . . are more

yie.ding to ob6e)ti/e ana.ysis0 2Lang$ *+B<$ p. *:*3. #'is re6e)tion of pri/ate experien)e is profound.y anti)ogniti/e. urprising.y$ t'is 0.anguage be'a/ior0 )on)ept$ despite its simi.arity to B. F. -innerGs 2*+<D3 0/erba. be'a/ior0 )on)ept$ 'as been )redited

8. AN<IETY DISORDERS 258 (it' 'a/ing .aid t'e foundation for a))eptan)e of )ognition in ).ini)a. psy)'o.ogy 2&a(ton$ a.-o/s-is$ @ir-$ H C.ar-$ *+B+$ p. *,3. "t is not ).ear 'o( )ogniti/e approa)'es benefited from a t'eory t'at pri/ate experien)e is a poor data sour)e for t'erapists$ is una/ai.ab.e to obser/ers$ and .ies beyond any possibi.ity of s)ientifi) in/estigation. Nobody e/er doubted t'at peop.e report 'a/ing t'oug'ts and fee.ings. #'e )ogniti/e re/o.ution in psy)'o.ogy (as about fina..y a))epting t'at t'ese reports of t'oug'ts and fee.ings 'a/e dire)t psy)'o.ogi)a. meaning and need to be ta-en serious.y on t'eir o(n terms 2see$ e.g.$ Bandura$ *+?+3. +olytnodal %n"iety5 $ioinformational Theory #'e t'ree1systems /ie( (as not a )ausa. t'eory so mu)' as a proposed .ist of anxiety responses. Bioinformationa. t'eory 2Coo-$ Me.amed$ Cut'bert$ M)Nei. H Lang$ *+BBC Lang$ *+B<C Lang$ Cut'bert$ H Brad.ey$ *++B3 tries to unify t'e dis)ordant proposed anxiety systems by means of a fear stru)ture 2a.so )a..ed a fear program or emotion prototype3$ a .arge.y un)ons)ious asso)iati/e net(or- of memory nodes )ontaining di/erse intera)ting e.ements$ in).uding propositions about stimu.i$ responses$ and t'eir /erba.Lsemanti) meanings$ as (e.. as efferent )odes$ motor programs$ )on)rete a)tion imagery$ )ogniti/e s)'emas$ a)tion subprograms$ and do4ens of ot'er des)ripti/e )ontents .in-ed to di/erse neurop'ysio.ogi)a. substrates. #'e fear stru)ture t'us expands anxiety to en)ompass near.y e/eryt'ing. "ts meaning net(or- seems to tou)' t'e entire 'uman menta. fa)u.ty and its biop'ysio.ogi)a. me)'anisms t'e entire 'uman body. "ndeed$ bioinformationa. t'eory .ea/es t'e reader (ondering ('ere anxiety ends and t'e rest of t'e 'uman being$ if any$ begins. "n t'is t'eory 0emotions. . . are fundamenta..y to be understood as be'a/iora. a)ts0 2Lang$ *+B<$ p. *;,3$ insofar as t'e deep emotiona. prototype initia..y produ)es a fear rea)tion unified a)ross response modes$ but in'ibitory neura. pat'(ays se.e)ti/e.y abort some fear responses before t'ey are rea.i4ed in expression 2Lang$ *+B<C Lang et a..$ *++B3. #ransmuting fearfu. emotion into a/oidant be'a/ior is 7uite a feat of psy)'i) a.)'emy gi/en t'eir (e..1-no(n empiri)a. disasso)iation 2Bar.o($ 9,,9C Carr$ *+D+C Lang$ *+B<C Mine-a$ *+D+C Ra)'man$ *+D?C )'(art4$ *+B+C e.igman H Jo'nston$ *+D:3. W'y t'e prototype (ou.d abort its o(n efferent signa.s and ('y e/o.ution (ou.d )onstru)t spe)ia. neura. pat'(ays to a)'ie/e t'is se.f1)an)e..ing ob6e)ti/e are not ).ear. #'e t'eoryGs testab.e ).aims$ for examp.e$ t'at fear arousa. is ne)essary or si4ab.y ad/antageous for treatment benefit 2Foa H M)Na..y$ *++?3$ ).as' (it' .ong1sett.ed findings 2Mat'e(s et a..$ *+B*C Ra)'man H &odgson$ *+D;$*+B,C W'ite H Bar.o($ 9,,9C Wi..iams$ *+BD3. !t'er(ise$ t'e t'eory is 'ard to e/a.uate be)ause it pro/ides no ).ear measures of its many distin)ti/e e.ements 2Wi..iams$ *++?b3. Bioinformationa. resear)' 2e.g.$ Coo- et a..$ *+BBC Lang et a..$ *++BC Lang$ Le/in$ Mi..er$ H @o4a-$ *+B:3 'as fai.ed to measure bioinformationa. pro)esses per se$ and 'as fo)used on predi)tions t'at do not seem re.e/ant to t'e prototype1 mat)'ing 'ypot'esis$ for examp.e$ t'at sna-e1p'obi) peop.e differ from pub.i) spea-ing1p'obi) peop.e in t'eir mu.timoda. anxiety rea)tions to(ard sna-es and pub.i) spea-ing 2Lang et a..$ *+B:3. Bar.o( 29,,93 (rote (e.. t'at a))epting bioinformationa. t'eoryGs deep psy)'i) unity of fear and a/oidan)e 0demands a .eap of fait'0 2p. <D3. Bioinformationa. t'eory in)orporates t'e .atest termino.ogy from neuros)ien)e$ )ogniti/e s)ien)e$ and )ybers)ien)e$ but it is a big step ba)-(ard. %rogress in so./ing 'uman prob.ems re7uires t'eories t'at sta-e ).aims t'at are meaningfu. 2reasonab.y operationa.i4ed3 and be.ie/ab.e 2not a.ready dis)onfirmed3. Mo(rerGs 2*+?,3 t(o1fa)tor autonomi) arousa. t'eory$ Be)-Gs 2*+D?3 danger )ognitions t'eory$ and BanduraGs 2*++D3 se.f1effi)a)y t'eory ea)' state

p.ain.y in operationa. terms ('at )auses a/oidant be'a/ior$ .et t'e e/iden)e s'o( ('at it (i... Bioinformationa. t'eoryGs po.yform p'enomena go/erned by myriad intera)ting un)ons)ious and neurobio.ogi)a. me)'anisms )an te.. us .itt.e about peop.eGs prob.ems. %er'aps (orse$ t'e

260 WILLIAMS t'eory ma-es peop.e into (a.-ing a/oidan)e ma)'ines$ emotion prototypes un)ons)ious.y bio1 )omputing prepositiona. data and outputting fear expressions t'at reprogram (it' prototype1 mismat)'ing input. o)ia. )ogniti/e peop.e$ in )ontrast$ fee. emotions and t'in- t'oug'ts in )ons)iousness$ t'ey a)t in a))ordan)e (it' t'eir appraisa. of t'eir )ir)umstan)es and t'emse./es$ and t'ey exer)ise )ons)ious persona. agen)y as t'ey a)ti/e.y master t'eir prob.ems in t'oug't and deed 2Bandura$ *++DC Wi..iams H Cer/one$ *++B3. 1onstruct 0nvalidity o f Multimodal %n"iety and %n"iety Disorders #'e )onstru)t /a.idity of )omp.ex persona.ity entities su)' as mu.timoda. anxiety or anxiety disorders re7uires at a minimum t'at t'e parts of t'e proposed entity must disp.ay interna. )o'eren)e or )on/ergent /a.idity by )orre.ating 'ig'.y (it' one anot'er$ and externa. dis1 tin)ti/eness or dis)riminant /a.idity by t'e parts )orre.ating .itt.e (it' ostensib.y dissimi.ar entities 2Campbe.. H Fis-e$ *+<+3$ as mentioned ear.ier. "n ot'er (ords$ sub6e)ti/e fear and e.e/ated 'eart rate s'ou.d )orre.ate (e.. (it' one anot'er be)ause bot' are anxiety 2or anxiety disorder3$ ('ereas anxious fee.ings and depressed fee.ings s'ou.d be .itt.e )orre.ated be)ause t'ey are a..eged.y distin)t entities. !f )ourse$ 6ust t'e opposite is empiri)a..y true. #'e )'apter 'as re/ie(ed t'e .o( )orre.ations among t'e proposed indi)es of mu.timoda. anxiety$ and of anxiety disorder$ a pattern sometimes )a..ed desyn)'rony but per'aps better )a..ed )on/ergent in/a.idity. #'e mu.timoda. anxiety )onstru)ts a.so .a)- dis)riminant /a.idity$ as mentioned ear.ier$ in t'at anxiety and depression in/entories tend to )orre.ate o/er .D, (it' one anot'er 2C.ar- et a..$ *++<3 and anxiety disorder diagnoses )orre.ate (it' many ot'er diagnoses 2Boyd et a..$ *+BDC Bro(n H Bar.o($ 9,,93. #'e .a)- of )onstru)t /a.idity refutes t'e /ery existen)e$ as meaningfu. psy)'o.ogi)a. entities$ of mu.timoda. anxiety and of anxiety disorders. Note t'at )onstru)t /a.idity is not at issue for unitary so)ia. )ogniti/e response )onstru)ts su)' as per)eptions of danger 2Be)-$ *+D?3$ per)eptions of se.f1effi)a)y 2Bandura$ *++D3$ or sub6e)ti/e fee.ings of anxiety intensity 2Wa.-$ *+<?C Wi..iams$ *+B<3$ be)ause t'ese )onstru)ts do not try to in)orporate dissimi.ar psy)'o.ogi)a. responses into a sing.e mu.timoda. psy)'i) entity. %arti)u.ar 'uman prob.em dimensions )ertain.y do exist$ and sub6e)ti/e fee.ings of anxiety )ertain.y do exist$ but mu.timoda. anxiety entities do not. 1#t/ers#(e T/#$&/ts %eop.e (it' mar-ed fear andLor dysfun)tiona. a/oidan)e s'o( distin)ti/e prob.em1re.ated )'anges in t'eir )ons)ious t'in-ing. ome )'ara)teristi) t'oug'ts are a.so proposed )ogniti/e me)'anisms of fear and a/oidan)e 2e.g.$ Bandura$ *++DC Be)-$ *+D?3$ ('i)' (e (i.. )onsider in t'e .ater se)tion on )ausa. t'eories. #'is se)tion )onsiders )ognitions t'at are prob.ems in t'eir o(n rig't. #roub.esome intrusi/e t'oug'ts$ diffi)u.t to )ontro. or dismiss$ )an )ome as obsessi/e preo))upations$ ex)essi/e (orries$ s)ary images$ mad impu.ses$ )atastrop'i) expe)tations$ or 'orrifying re)o..e)tions 2e.g.$ Bor-o/e)$ 'adi)-$ H &op-ins$ *++*C Frost H te-etee$ 9,,9C Rapee H Bar.o($ *++*3. ome bot'ersome t'oug'ts are neit'er fear1pro/o-ing nor resisted but simp.y )onsume too mu)' time and t'ereby interfere (it' t'e personGs .ife$ ('ereas ot'ers )an be a.ien frig'tening ideas t'at t'e person a/oids by p'obi) maneu/ers or by neutra.i4ing ritua.s or t'oug'ts 2 te-etee H Bar.o($ 9,,93. A.. of t'e /arious prob.emati) )ognitions tend to o))ur espe)ia..y often in peop.e (it' any pattern of notab.e a/oidan)e or fear. %eop.e (it' p'obias$ for examp.e$ often per)ei/e danger$ (orry$ obsess$ and 'a/e intrusi/e disturbing re)o..e)tions$ anti)ipations$ and nig'tmares about ('at t'ey a/oid 2Bandura$ *+DBC Mar-s$ *+BD3. "ndeed$ bot'ersome t'oug'ts of many -inds$ in).uding obsessions$ (orries$ intrusions$ and e/en

'a..u)inations and de.usions$ are )ommon in psy)'o.ogi)a. .ife genera..y 2Jo'ns H >an

8. AN<IETY DISORDERS 262 !s$ 9,,*C Norton et a..$ *++9C te-etee H Bar.o($ 9,,93. %eop.e ('o see- 'e.p for obsessions or (orries or identify t'emse./es as (orriers appear to 'a/e some('at more fre7uent and frig'tening t'oug'ts on t'e a/erage t'an t'ose ('o do not$ but t'e t(o groupsG prob.em t'oug'ts great.y o/er.ap and are sometimes not ).ear.y distinguis'ab.e in )ontent$ duration$ 'o( mu)' t'e person resists t'em$ of e/en in t'e anxiety$ a/oidan)e$ or )ompu.si/e ritua.s t'ey o))asion 2Bor-o/e) et a..$ *++*C Cras-e$ Rapee$ Ja)-e.$ H Bar.o($ *+B+C Ra)'man H de i./a$ *+DBC a.-o/s-is H &arrison$ *+B;3. A dimension of ma6or importan)e distinguis'ing ('et'er intrusi/e t'oug'ts are prob.emati) appears to be t'eir per)ei/ed )ontro..abi.ity 2Bor-o/e) et a..$ *++*C Cras-e et a..$ *+B+3 and ('et'er peop.e beset by intrusions )on).ude t'at t'ey )annot effe)ti/e.y manage t'e (orrisome future possibi.ities 2Ai-ins H Cras-e$ 9,,*3. !ne )an examine many different dimensions of t'oug't for different purposes$ but t'e boundaries bet(een t'e intrusi/e$ t'e (orrisome$ t'e persistent$ and t'e obsessi/e are not 'ard and fast. Worries and obsessions are simi.ar in being repetiti/e and time1)onsuming$ 'a/ing re)urrent t'emes$ and often being experien)ed as un)ontro..ab.e. 8ifferentiating (orry from obsession is per'aps possib.e in prin)ip.e 2#urner$ Beide.$ H tan.ey$ *++93$ but t'e t(o are substantia..y )orre.ated and in pra)ti)e )an be 'ard to te.. apart 2Freeston$ Ladou)eur$ R'eaume$ Letarte$ =agnon$ H #'ibodeau$ *++;C We..s H %apageorgiou$ *++B3. Ma.adapti/e (orry is a.so not a.(ays ).ear.y distin)t from )onstru)ti/e preparatory prob.em so./ing$ as bot' in/o./e )onsidering possib.e dangers and 'o( to dea. (it' t'em 2Cras-e$ *+++3. Nor are t'e boundaries bet(een t'e ex)essi/e$ t'e unreasonab.e$ and t'e de.usiona. entire.y s'arp. %eop.e (it' a/oidan)e$ pani)$ or s)ary t'oug'ts often re)ogni4e t'at t'ese are out of proportion to ob6e)ti/e fa)ts$ but su)' 0insig't0 is 'ig'.y /ariab.e a)ross situations and bet(een indi/idua.s$ and is t'us eminent.y dimensiona. in )'ara)ter 2e.g.$ Wi..iams H Watson$ *+B<C Wi..iams$ #urner$ H %eer$ *+B<3. W'y 8 M1"> re7uires insig't into t'e unreasonab.eness of fear in spe)ifi) and so)ia. p'obi) disorders$ but not in agorap'obi) or ot'er proposed anxiety disorders$ is not ).ear. %eop.e (it' obsessions and )ompu.sions$ as (e.. as t'oug'ts of danger and dysfun)tiona. a/oidan)e$ may or may not a))ept t'at t'eir t'oug'ts and a)tions are sense.ess$ and some obsessions are p.ain.y de.usiona. 2!G8(yer H Mar-s$ 9,,,C te-etee H Bar.o($ 9,,9C Aaryura1#obias H M)@ay$ 9,,93. %eop.e (it' psy)'oti) prob.ems fre7uent.y disp.ay obsessions$ )ompu.sions$ p'obias$ and traumati) stress rea)tions 2Cassano$ %ini$ aettoni$ H 8e..G!sso$ *+++C Cosoff H &afner$ *++BC Neria$ Bromet$ ie/ers$ La/e..e$ H Fo)'tmann$ 9,,93$ and (orry and anxiety appear to )ontribute to de.usiona. distress 2Freeman H =arety$ *+++C @rabbendam$ Janssen$ Ba-$ Bi6.$ de =raaf$ H /an !s$ 9,,93. "n /arious (ays 8 M1"> distorts t'e study of intrusions$ (orry$ obsessions$ danger per)eptions$ and de.usions 2)f. %ersons$ *+B?3 as psy)'o.ogi)a. dimensions by de).aring arbitarari.y$ for examp.e$ t'at ex)essi/e (orries about e/eryday t'ings )annot be obsessions$ and t'at t'e (orries in genera.i4ed anxiety disorder )annot )on)ern being a(ay from fami.y$ gaining (eig't$ being /ery i..$ pub.i) embarassment$ and ot'er t'ings peop.e (orry about a .ot$ and t'at t'e danger be.iefs in some p'obias )annot be de.usiona.. #'e so)ia. )ogniti/e approa)' studies (orry$ obsessions$ danger be.iefs$ and de.usions as graduated psy)'o.ogi)a. dimensions$ un)on)erned about trespassing on diagnosti) turf$ and indeed expe)ting ea)' prob.em response to )o/ary (it' ot'er prob.ems. #'is is neit'er to deny t'at for parti)u.ar purposes one )an ma-e meaningfu. distin)tions bet(een -inds of intrusi/e upsetting t'oug'ts$ nor to deny t'at )ertain patterns of )o1 o))urring prob.em t'oug'ts and be'a/iors mig't be of distin)ti/e interest$ but t'at t'ere is .itt.e

sa)red about any parti)u.ar (ay of denning prob.em t'in-ing$ and arbitrary ru.es about ('at )ontents (orries 2for examp.e3 s'a.. 'a/e 2and may not 'a/e3 ma-e for a se.f1'indered start of a resear)' program to understand t'e nature of ex)essi/e (orrying.

264 W"LL"AM CAUSES OF AGOIDANCE5 AN<IETY5 AND 1OTHERSOME THOUGHTS Ca$ses #6 A,#idan.e 1e/a,i#r #'is re/ie( fo)uses on )urrent psy)'o.ogi)a. )auses of prob.ems$ a.t'oug' 'istori)a. fa)tors$ in).uding de/e.opmenta.$ geneti)$ bio.ogi)a.$ and so)ia. .earning inf.uen)es$ 'a/e been studied extensi/e.y 2Bar.o($ 9,,9C Cras-e$ *+++$ Ra)'man$ *+DD3. ometimes p'obias de/e.op straig'tfor(ard.y$ for examp.e$ instated by brief so)ia. mode.ing experien)es a.one in mon-eys 2Mine-a$ 8a/idson$ Coo-$ H @eir$ *+B;3 or emerging fu..1b.o(n in peop.e from a sing.e brief traumati) experien)e. Most p'obias 'a/e un).ear or ambiguous de/e.opmenta. 'istories$ in ('i)' mu.tip.e bio.ogi)a.$ so)ia.$ psy)'o.ogi)a.$ and en/ironmenta. fa)tors appear to intera)t 2Ra)'man$ *+DD3. "n t'e so)ia. )ogniti/e approa)'$ 'istori)a. inf.uen)es operate in t'e present primari.y /ia )ons)ious )ogniti/e pro)ess t'at sustain a/oidan)e and t'at )an be easi.y measured 'ere and no( in )on6un)tion (it' a/oidan)e. A/oidan)e and ritua.s are )orre.ated to some extent (it' )ount.ess spe)ifi) inner states$ in).uding fee.ings$ )ognitions$ sensations$ and per)eptions 2Bar.o($ 9,,9C te-etee H Frost$ 9,,93$ any of ('i)' )ou.d in prin)ip.e p.ay a ro.e in )ausing t'e a/oidant be'a/ior. "so.ating inner psy)'o.ogi)a. )auses of a/oidan)e re7uires at a minimum identifying t'e inner states t'at )orre.ate most strong.y (it' a/oidan)e be'a/ior. !n.y t'e re.ati/e.y strong inner predi)tors of be'a/ior are .i-e.y to emerge as distin)ti/e independent )auses of be'a/ior. Finding strong psy)'o.ogi)a. predi)tors of a/oidan)e be'a/ior too- a /ery .ong time be)ause for de)ades anxious fee.ings$ not prob.emati) t'oug'ts$ dominated t'e resear)' agenda. %n"iety Theory o f %voidance $ehavior Ma.adapti/e a/oidan)e be'a/ior (as a prin)ipa. psy)'o.ogi)a. p'enomenon t'at t'e )on)ept of anxiety (as origina..y intended to exp.ain. Anxiety (as t'e 'ypot'eti)a. )ause and a/oidant be'a/ior (as t'e exp.ained effe)t. #'e psy)'oana.yti) )on)eption t'at an anxiety dri/e arising from un)ons)ious t'reats found symbo.i) expression in parti)u.ar neuroti) se.f1defeating be'a/iors (as reformu.ated in .earning terms by t(o1fa)tor t'eory 2Mo(rer$ *+?,3$ ('i)' 'e.d t'at anxiety )omes to )ontro. a/oidant be'a/ior in a t(o1part 2).assi)a. p.us operant )onditioning3 pro)ess. First t'e person .earns to be afraid of a pre/ious.y neutra. stimu.us after experien)ing it paired (it' an a/ersi/e stimu.us. #'en t'e anxiety pro/o-ed by t'e no(1 )onditioned stimu.us moti/ates t'e person to a/oid t'at )onditioned stimu.us$ and t'e de).ine in anxiety resu.ting from a/oidan)e re(ards t'e a/oidan)e 2Mo(rer$ *+?,C Wo.pe$ *+<B3. #(o1 fa)tor t'eory dominated t'e study of a/oidan)e for de)ades and )ontinues to 'a/e .oya. ad'erents$ a.t'oug' a series of re/ie(s in t'e .ate *+?,s and *+D,s 2Bandura$ *+?+C Bo..es$ *+D<C Carr$ *+D+CMine-a$ *+D+CRa)'man$ *+D?C Ra)'man H &odgson$ *+D;C )'(art4$ *+DB$ *+B+C e.igman H Jo'nston$ *+D:3 re/ea.ed fundamenta. prob.ems t'at t(o1fa)tor t'eory 'as ne/er so./ed 2Wi..iams$ *+BD3. Attempts 'a/e been made to resurre)t anxiety )onditioning t'eories by importing so)ia. )ogniti/e )on)epts and refraining t'em in anxiety )onditioning terms 2e.g.$ Foa H M)Na..y$ *++?C 8a/ey$ *++93. " 'a/e 7uestioned e.se('ere t'e (isdom of putting ne( )ogniti/e (ine in o.d )onditioning bott.es 2Wi..iams$ *++?b3. W'y ).ing to t'e a(-(ard o.d )onditioning termino.ogy and )on)epts ('en t'e more straig'tfor(ard and parsimonious 2)ogniti/e.y simp.e3 .anguage of so)ia. )ognition is a/ai.ab.eF 8ire)t.y fata. to anxiety t'eories of be'a/ior in genera.$ in).uding t(o1fa)tor )onditioning t'eory$ is t'e )onsistent .a)- of strong asso)iation bet(een anxiety and a/oidan)e be'a/ior$ ('i)' no amount of refraining )an )'ange.

8. ANV"E#A 8" !R8ER 265 A.t'oug' Mo(rer 2*+?,3 (as )on)erned (it' sub6e)ti/e fee.ings of anxiety$ 'e operationa..y denned anxiety as autonomi) arousa.. But perip'era. p'ysio.ogy is as .itt.e re.ated to p'obi) or )ompu.si/e be'a/iors as it is to fee.ings of sub6e)ti/e fear 2Bandura$ *+?+C Lang$ *+B<C Mine-a$ *+D+C )'(art4$ *+B+C e.igman H Jo'nston$ *+D:C Wi..iams$ *+BD3. "ndeed$ autonomi) rea)tions are 'ig'.y unstab.e in response to a gi/en stimu.us 2&o.den H Bar.o($ *+B?3 and t'us .a)- t'e statisti)a. re.iabi.ity needed to strong.y )ause mu)' of anyt'ing$ espe)ia..y 'ig'.y stab.e responses .i-e )ompu.sions and p'obias. ub6e)ti/e fee.ings of anxiety are some('at better )orre.ated (it' a/oidant be'a/ior 2e.g.$ Wi..iams$ 8ooseman$ H @.eifie.d$ *+B;C Wi..iams et a..$ *+B<3$ but often a))ount for .ess t'an *,P of t'e /arian)e in a/oidan)e 2Lang$ *+B<3. Fee.ing /ery afraid (it'out a/oiding is )ommon$ as in many pani) /i)tims ('o do not 'a/e mar-ed p'obias$ and in terrified but fre7uent f.iers. e/ere p'obi) a/oidan)e or )ompu.sion (it' .itt.e or no fear is a.so (e.. do)umented 2Carr$ *+D+C pit4er H Wi..iams$ *+B<3 and is noted by bot' 8 M1"> and "C81*,. Bridge1p'obi) )ommuters fear.ess.y .ea/e 'ome 'ours ear.y ea)' day and )a.m.y dri/e far around .arge bridges 2Wi..iams$ *+B<3. "ndeed$ most 'uman a/oidan)e be'a/ior is fear.ess5 peop.e usua..y fi.. fue. tan-s and .o)- doors in emotiona. tran7ui.ity 2Carr$ *+D+3. Easi.y exe)uted apparent.y effe)ti/e a/oidan)e maneu/ers$ e/en 7uite ma.adapti/e ones$ .ea/e not'ing to be afraid of. #'e main dri/er of p'obi) and )ompu.si/e be'a/ior ).ear.y is not sub6e)ti/e fear. +anic Theory o f %voidance A /ariation on anxiety t'eory$ embodied in 8 M1"> but not in "C81*,$ 'o.ds t'at agorap'obi) be'a/ior is )aused by pani) or pani)1.i-e rea)tions. As pani) is 'ig'.y simi.ar to anxiety$ so pani) t'eory founders on t'e same ro)- t'at san- t(o1fa)tor anxiety t'eory5 %ani) does not )orre.ate mu)' (it' agorap'obi) be'a/ior 2Cras-e H Bar.o($ *+BB3. %ani) )an be a))ompanied by extensi/e p'obias$ but often it is not$ and agorap'obia is )ommon (it'out )urrent pani) and (it'out 'istory of pani) atta)-s 2e.g$ Magee$ Eaton$ Witt)'en$ M)=onagne$ H @ess.er$ *++?3. %ani) is a.so )ommon (it' many prob.ems ot'er t'an agorap'obia 2Bar.o($ *+BDC Cosoff H &afner$ *++B3 and o))urs in peop.e ('o 'a/e no parti)u.ar prob.ems at a.. 2Norton et a..$ *++93. #'erefore$ pani) does not 'a/e e/en a distin)ti/e re.ations'ip to agorap'obia$ ne/er mind a strong )ausa. re.ations'ip to it. 'ocial 1ognitive Theory o f %voidance o)ia. )ogniti/e t'eory and a fami.y of re.ated )ogniti/e t'eories exp.ain a/oidant be'a/ior$ anxiety$ and disturbing t'oug'ts in terms of predominant.y )ons)ious )ogniti/e pro)esses 2e.g.$ Bandura$ *++DC Be)-$ *+D?C Be)-$ Emery$ H =reenberg$ *+B<C C.ar-$ 9,,*C Leary H @o(a.s-i$ *++<C Maddux$ *++<aC Ra)'man$ *++BC a.-o/s-is$ *++?a$ *++BC Wi..iams$ *++<$ *++?aC Wi..iams H Cer/one$ *++B3. " )a.. t'ese )o..e)ti/e.y so)ia. )ogniti/e t'eories 2a.t'oug' t'ey do not a.. identify t'emse./es t'at (ay3 be)ause t'ey exp.ain prob.ems by peop.eGs parti)u.ar be.iefs$ expe)tations$ and 6udgments about parti)u.ar t'ings$ as representab.e /i/id.y to t'emse./es in a(areness$ and about ('i)' t'ey )an )ommuni)ate dire)t.y and meaningfu..y. #'e so)ia. )ogniti/e /ie( is t'at non)ons)ious fa)tors exert t'eir effe)ts on a)tion .arge.y t'roug' t'e fina. )ommon pat'(ays of )ons)ious t'oug't 2Bandura$ *++DC Be)-$ *+D?C Be)- et a..$ *+B<C a.-o/s-is$ *++?b3. o)ia. )ognitions are not genera.i4ed trait.i-e )ogniti/e or information1 pro)essing sty.es$ but spe)ifi) t'oug'ts about se.f and )ir)umstan)es. u)' spe)ifi)ity enab.es$ in prin)ip.e and in pra)ti)e as (e (i.. see$ predi)ting t'e idiosyn)rati) patterning of indi/idua.sG responding a)ross situations and time.

o)ia. )ogniti/e t'eories emp'asi4e /arious -inds of )ons)ious t'oug't$ of ('i)' out)ome expe)tations and se.f1efn)a)y6udgments are espe)ia..y important 2Bandura$ *+B?C Be)-$ *+D?C

267 WILLIAMS Wi..iams H Cer/one$ *++B3. !ut)ome expe)tations refer to peop.eGs be.iefs about t'e possib.e out)omes of t'eir o(n a)tions$ su)' as en)ountering possib.e dangers or fa)ing 'ig' .i-e.i'ood of being 'armed 2e.g.$ 0if " try to pet t'e dog$ it (i.. sure.y bite me03$ anti)ipated anxiety 2e.g.$ 0if " (a.- by it$ " (i.. get /ery s)ared03$ and anti)ipated pani) 20probab.y " (ou.d pani)03. 8anger t'oug'ts are )entra. e.ements in a fami.y of )ogniti/e t'eories deri/ed from t'e pioneering (orof Be)- 2*+D?3 and addressing p'enomena su)' as p'obia$ pani)$ anxiety$ obsession$ )ompu.sion$ and traumati) stress 2e.g.$ Be)- et a..$ *+B<C C.ar-$ *+B?$*+++$9,,*C a.-o/s-is$ *++B3 in terms of /arious danger1re.ated t'oug't patterns. Anot'er fami.y of )ogniti/e t'eories emp'asi4es anti)ipated anxiety or anti)ipated pani)$ 'o.ding t'at a/oidan)e )an be moti/ated by a fear of fear$ or a/ersion to be)oming afraid$ pani)-y$ or p'ysio.ogi)a..y aroused 2e.g.$ C'amb.ess H =ra)e.y$ *+B+C @irs)'$ *++,3. e.f1effi)a)y 6udgments )onstitute anot'er ).ass of )ognitions$ peop.eGs 6udgments about t'eir abi.ity to exe)ute )ourses of a)tion irrespe)ti/e of anti)ipated out)omes 2e.g.$ 0" donGt t'in- " )ou.d tou)' t'e dog if " tried03. e.f1effi)a)y t'eory 2Bandura$ *+BB$ *++D3 'o.ds t'at a/oidan)e$ fear$ and s)ary t'oug'ts arise .arge.y be)ause peop.e 'a/e .ost t'eir be.ief t'at t'ey )an a)t effe)ti/e.y and exer)ise )ontro. in t'e )ir)umstan)es 2Leary H @o(a.s-i$ *++<C Maddux$ *++<aC Maddux$ Norton$ H Leary$ *+BBC )'(ar4er$ *++9C Wi..iams$ *++<$*++?a3. %er)ei/ed )ontro. is intimate.y re.ated to se.f1effi)a)y be)ause fee.ing in )ontro. re7uires fee.ing ab.e to ena)t )ontro..ing responses. %ersona. )ontro. 'as ma6or imp.i)ations for .o(ering anxiety 2Bar.o($ 9,,9C Bor-o/e) et a..$ *++*C Cras-e et a..$ *++*C Mine-a H @e..y$ *+B+3. Wi..iams 2*++<$ *++?a3 re/ie(ed a number of studies by different in/estigators t'at examined t'e po(er of peop.eGs se.f1effi)a)y 6udgments to predi)t t'eir approa)' be'a/ior to(ard rea. p'obi) t'reats$ and )ompared it to t'e po(er of per)ei/ed danger$ anti)ipated anxiety$ andLor anti)ipated pani) to predi)t approa)' be'a/ior 2see a.so ?st$ Ferebee$ H Furmar-$ *++D3. e.f1 effi)a)y (as )onsistent.y t'e most a))urate sing.e predi)tor of approa)' be'a/ior$ usua..y a))ounting for more t'an 'a.f t'e /arian)e$ (it' r s usua..y in t'e range of .D, to .B,$ fo..o(ed by anti)ipated anxiety and anti)ipated pani)$ ('i)' (ere a.so strong.y predi)ti/e of be'a/ior. %er)ei/ed danger (as genera..y a (ea- predi)tor of be'a/ior. "mportant.y$ se.f1effi)a)y )onsistent.y remained a strong predi)tor of be'a/ior ('en t'e a.ternati/e )ogniti/e fa)tors su)' as anti)ipated anxiety (ere 'e.d )onstant$ ('ereas t'e a.ternati/e fa)tors )onsistent.y .ost po(er to signifi)ant.y predi)t be'a/ior (it' se.f1effi)a)y 'e.d )onstant 2!st et a..$ *++DC Wi..iams$ *++<$ *++?aC Wi..iams et a..$ *+B;$ *+B<C Wi..iams$ @inney$ H Fa.bo$ *+B+3. e.f effi)a)y a.so remains an a))urate predi)tor of future approa)' be'a/ior ('en indi)es of pre/ious be'a/ior are )ontro..ed statisti)a..y or are una/ai.ab.e and ('en ot'er non)ausa. interpretations are imp.ausib.e 2Bandura$ *++DC Wi..iams$ *++<$ *++?a3. For examp.e$ Wi..iams et a.. 2*+B+3 found t'at ('en agorap'obi)s (ere gi/en performan)e exposure treatment for on.y some of t'eir p'obi) areas 2e.g.$ s'opping$ 'eig'ts3$ t'e genera.i4ed be'a/iora. impro/ements in t'eir untreated p'obias 2e.g.$ dri/ing3 (ere best predi)ted by )'anges in se.f1effi)a)y to(ard t'e genera.i4ed t'reats. #'ese data ma-e ).ear t'at peop.eGs be.iefs about t'eir abi.ities 'a/e a strong )ausa. bearing on t'eir p'obi) a/oidan)e and disabi.ity. Ca$ses #6 An-iety 1auses o f 'ub4ective %n"iety #'e pre)eding se)tion )ompared possib.e )ogniti/e )auses of be'a/ior. !ne )an a.so )ompare possib.e )ogniti/e )auses of sub6e)ti/e fear. "n t'e studies summari4ed by Wi..iams 2*++<$ *++?a3$ anti)ipated anxiety and anti)ipated pani) )orre.ated about r M .D< (it' .ater anxiety rated

during t'e be'a/iora. test$ ('ereas se.f1effi)a)y )orre.ated on.y about r Q .<, (it' .ater

8. AN<IETY DISORDERS 269 sub6e)ti/e anxiety ratings. Anti)ipated anxiety and anti)ipated pani) ea)' )ontinued to strong.y predi)t performan)e anxiety ('en eit'er se.f1effi)a)y or per)ei/ed danger (as 'e.d )onstant$ ('ereas t'e .atter t(o fa)tors .ost a.. signifi)ant predi)ti/eness of anxiety (it' anti)ipated pani) 'e.d )onstant. #'e superiority of anti)ipated anxietyLpani) o/er se.f1effi)a)y in predi)ting .ater sub6e)ti/e anxiety )orresponds to an oft1obser/ed p'enomenon5 a p'obi) person expressing simu.taneous.y 'ig' se.f1effi)a)y and 'ig' anti)ipated anxietyLpani) for a tas- and t'en doing t'e tas- (it'out diffi)u.ty but experien)ing 'ig' anxiety 2Wi..iams$ *+B<$ *+B?$ *++?a3. Bandura 2*+BB3 proposed t'at se.f1effi)a)y for )ontro..ing s)ary t'oug'ts 2)f. @ent H =ibbons$ *+B;C a.-o/s-is H &arrison$ *+B;3 a.so p.ays a ro.e in anxiety$ and t'is t'oug't )ontro. se.f1effi)a)y fa)tor does 'a/e predi)ti/e po(er beyond t'at of )on/entiona. se.f1effi)a)y measures$ but anti)ipated anxiety and anti)ipated pani) remain t'e o/erriding so)ia. )ogniti/e predi)tors of anxiety arousa. 2Rane H Wi..iams$ *++:3. #'e data suggest strong.y t'at seeing onese.f as being /u.nerab.e to anxiety or pani) is in some (ay )ausa..y )onne)ted to a)tua..y experien)ing anxiety 2@irs)'$ *++,C Wi..iams$ *+B?3$ a.t'oug' ('y and 'o( t'is )onne)tion )omes about is un).ear 2Bandura$ *++<C Maddux$ *++<b3. 8anger per)eptions are (ea- predi)tors of sub6e)ti/e anxiety 2Wi..iams et a..$ *+B<$ *+B+C Wi..iams H Watson$ *+B<3. And stri-ing.y$ danger ideas are absent from agorap'obi) peop.eGs t'oug'ts ('en t'ey are trying to do t'e t'ings t'ey most dread 2Wi..iams$ @inney$ &arap$ H Liebmann$ *++D3. 0nformation +rocessing in Trait %n"iety and %n"iety Disorders Most resear)' on t'e ro.e of )ognition in anxiety 'as been guided by one of t(o broad t'eoreti)a. approa)'es5 t'e social cognition model and t'e information&processing model. o)ia. )ogniti/e approa)'es emp'asi4e peop.eGs )ons)ious )on).usions$ su)' as t'eir be.iefs$ expe)tations$ 6udgments$ and simi.ar -inds of t'oug'ts$ in re.ation to t'emse./es and t'eir )ir)umstan)es$ ('i)' )an potentia..y be expressed open.y in an inter/ie( or on a se.f1report 7uestionnaire. o)ia. )ogniti/ists t'en re.ate t'ose t'oug'ts dire)t.y to peop.eGs psy)'o.ogi)a. fun)tioning in a)tua. )ommunity en/ironments. "n )ontrast$ t'e information1pro)essing approa)' see-s biases$ bot' )ons)ious and un)ons)ious$ in anxious indi/idua.sG attention to$ per)eption of$ interpretation of$ and memory for anxiety1promoting information 2Mat'e(s H M)Leod$ *++;$9,,9C M)Na..y$ *+++3. "nformation1pro)essing resear)' 'as re.ated pro)essing biases most.y to genera. psy)'o.ogi)a. states su)' as trait anxiety .e/e. or diagnosti) status rat'er t'an to )oping be'a/ior in t'e )ommunity per se. "nformation1pro)essing experiments often infer )ogniti/e operations indire)t.y rat'er t'an as-ing peop.e about t'em. "n typi)a. attention experiments$ for examp.e$ peop.e se.e)ted for 'a/ing 2or not 'a/ing3 a )ertain prob.em respond to brief /erba. stimu.i re.ated to /arious anxietyLdanger t'emes or to benign t'emes$ and t'eir responses 2often rea)tion times on subtas-s ostensib.y unre.ated to t'e (ordsG meanings3 are examined for a/erage intergroup differen)es in 'o( t'e (ords are pro)essed as a fun)tion of t'eir meanings. #'is resear)' 'as found t'at indi/idua.s suffering from a gi/en prob.em differ from nonprob.em indi/idua.s in 'o( t'ey pro)ess some information$ for examp.e being genera..y more attenti/e to negati/e information re.ated to t'eir prob.em 2Mat'e(s H M)Leod$ *++;$9,,9C M)Na..y$ *+++3. Less ).ear is ('et'er su)' biases te.. us mu)' distin)ti/e about trait anxiety and diagnosti) status$ or simp.y t'at peop.e are biased to attend to persona..y1re.e/ant information of any -ind$ positi/e or negati/e. Not a.. -inds of )ogniti/e operations are e7ui/a.ent.y biased in anxious indi/idua.s. For examp.e$ on exp.i)it

memory tas-s$ anxious indi/idua.s tend not to s'o( e/iden)e of information1pro)essing biases 2Mat'e(s H M)Leod$ *++;$ 9,,9C M)Leod$ *+++C M)Na..y$ *+++3.

271 WILLIAMS o)ia. )ogniti/e t'eories )on)ur t'at 'o( peop.e pro)ess prob.em1re.ated information )on1 tributes to prob.em responses. For examp.e$ peop.eGs interpretations of ('y t'ey su))eeded in doing s)ary tas-s during p'obia treatment affe)t 'o( mu)' benefi)ia. information t'ey gain from t'ose su))esses 2Wi..iams H @inney$ *++D3. #'e more t'ey attribute su))ess to t'e t'erapist rat'er t'an to t'emse./es$ t'e .ess t'ey gain in se.f1effi)a)y and be'a/iora. abi.ity. Attributions exp.ain signifi)ant /ariation in benefit beyond t'at exp.ained by t'e .e/e. of past be'a/iora. su))esses 2Wi..iams H @inney$ *++D3. Laboratory information1pro)essing resear)' often uses attenuated prob.em1re.e/ant stimu.i )onsisting of /erba. materia. presented to parti)ipants in a safe )ontext$ and it measures experimenta. responses$ su)' as .aten)y to dete)t a probe or to name a )o.or appearing on a )omputer s)reen$ rat'er t'an prob.em responses per se. Mu)' information1pro)essing resear)' addresses psy)'o.ogi)a. )onstru)ts (it' un).ear be'a/iora. referents$ su)' as trait anxiety .e/e. or diagnosti) status. #'e artifi)ia.ity of t'e experimenta. stimu.i and responses$ and t'e indef1 initeness of t'e psy)'o.ogi)a. )onditions being exp.ained$ .ea/e in'erent.y un).ear 'o( any obser/ed biases re.ate to peop.eGs a)tua. fears$ t'oug'ts$ and a/oidan)e be'a/iors in t'e natura. en/ironment. %ro)essing biases$ .i-e ot'er proposed inner )auses$ need to estab.is' t'at t'ey are not simp.y more of )ount.ess psy)'o.ogi)a. measures t'at modest.y but signifi)ant.y predi)t trait anxiety s)ores or menta. disorder diagnoses. #rait1.i-e genera. biases for seeing broad ).asses of information as t'reatening$ .i-e persona.ity traits of a.. -inds$ 'a/e .itt.e abi.ity to exp.ain t'e idiosyn)rati) patterning of peop.eGs prob.ems a)ross situations$ ('ereas spe)ifi) so)ia. )ognitions en)ounter no su)' exp.anatory .imit. %ro)essing of )omp.ex meaning information (it' a(areness is po(erfu.$ but pro)essing information (it'out any a(areness is 'ard to )on/in)ing.y demonstrate 2e.g.$ @ouider H 8epoux$ 9,,;3. Many .aboratory information1pro)essing bias effe)ts are .ess t'an robust$ being e.iminated or e/en re/ersed in dire)tion by t'eoreti)a..y minor /ariations in experimenta. stimu.i$ sub6e)ts$ or responses 2Mat'e(s H M)Leod$ *++;$ 9,,9C M)Na..y$ *+++3. And .itt.e e/iden)e exists t'at any proposed un)ons)ious pro)essing bias strong.y predi)ts a)tua. a/oidan)e be'a/ior and sub6e)ti/e fear remote.y as a))urate.y as do t'e )ons)ious so)ia. )ognitions t'at t'is )'apter 'as a.ready re/ie(ed 2Wi..iams$ *++?a3. "ntriguing re)ent (or- 'as s'o(n effe)ts of indu)ed information1pro)essing biases on ex1 perien)ed anxious fee.ings 2Mat'e(s H M)Leod$ 9,,93$ suggesting a dire)t .in- to 'uman dis)omfort. #'e so)ia. )ogniti/e /ie( is t'at anxious peop.e are biased in t'eir pro)essing of not on.y t'reat information per se$ but of e/iden)e of inabi.ity$ of persona. responsibi.ity$ of /u.nerabi.ity to anxious fee.ings$ and ot'er se.f1undermining )ognitions$ ('i)' fun)tion not as genera.i4ed traits$ but in attunement (it' spe)ifi) psy)'o.ogi)a. and p'ysi)a. )ontexts. +anic Mu)' (or- 'as been done on so)ia. )ogniti/e fa)tors in pani) atta)-s 2e.g.$ C.ar-$ *+B?C Rapee$ *++:3. Most ear.y (or- on pani) fo)used on p'ysio.ogi)a. )auses 2re/ie(ed in detai. by Bar.o($ 9,,93$ and indeed a /ariety of p'ysi)a. inf.uen)es$ in).uding sodium .a)tate$ )arbon dioxide$ )affeine$ /igorous exer)ise$ rapid breat'ing$ and ot'ers )an indu)e pani) in /u.nerab.e indi/idua.s. #'e s'eer /ariety of bodi.y inf.uen)es on pani) suggests t'e possibi.ity of a )ommon psy)'o.ogi)a. me)'anism 2C.ar-$ *+B?3. %sy)'o.ogi)a. mode.s of pani) genera..y )on)ei/e it as resu.ting from per)eption of t'reat 2Be)- et a..$ *+B<3$ in parti)u.ar$ a /i)ious )y).e of per)ei/ing bodi.y sensations$ interpreting t'em )atastrop'i)a..y$ t'erefore fee.ing afraid and appre'ensi/e$

('i)' pro/o-es more bodi.y sensations to be interpreted )atastrop'i)a..y$ and so on 2C.ar-$ *+B?C Ra)'man H Maser$ *+BBC Rapee$ *++:3. A se.f1effi)a)y ana.ysis p.a)es emp'asis a.so on t'e be.ief t'at one )an pre/ent$ .imit$ or )ontro. pani) or t'e t'oug'ts t'at gi/e rise to it$ or fun)tion effe)ti/e.y despite pani) 2Wi..iams H LaBerge$ *++;3. E/iden)e

8. AN<IETY DISORDERS 273 supports a ro.e for )ognition in pani)$ in).uding a mediating inf.uen)e of psy)'o.ogi)a. and en/ironmenta. manipu.ations on bio.ogi)a. pani) indu)tion 2C.ar-$ *++:C Rapee$ *++:3$ as (e.. as for )ogniti/e inter/entions in treatment 2dis)ussed .ater3. Ca$ses #6 1#t/ers#(e T/#$&/ts o)ia. )ogniti/e t'eories 'o.d t'at bot'ersome t'oug'ts o))ur in t'e norma. stream of )on1 s)iousness 2Ra)'man H de i./a$ *+DB3 but be)ome prob.emati) as peop.e appraise$ interpret$ and respond to t'em ma.adapti/e.y. "t is .ess t'e o))urren)e of danger t'oug'ts t'an t'e be.ief t'at one )annot manage potentia. dangers t'at gi/es danger t'oug'ts po(er to s)are 2Bandura$ *+BB3. Re)ent t'eori4ing on obsessions 'as emp'asi4ed an ex)essi/e sense of responsibi.ity for potentia. 'armfu. effe)ts and a )orresponding impu.se to ta-e pre/entati/e a)tions. W'en peop.e try to a/oid or suppress bot'ersome intrusions by neutra.i4ing ritua.s$ t'ese )an ser/e mere.y to in)rease t'e t'oug'tGs fre7uen)y and to undermine t'e sense of )ontro.$ produ)ing bot' anxiety and greater efforts to exert )ontro.$ and so on in a /i)ious )y).e 2Ra)'man$ *++BC a.-o/s-is$ *++?aC te-etee H Bar.o($ 9,,93. =enera. )ogniti/e defi)it t'eories of obsession fai. be)ause$ .i-e traits$ t'ey are unab.e to a))ount for t'e pronoun)ed situationa. spe)ifi)ity of obsessions 2 a.-o/s-is$ *++?a3. #'eories of (orry /ie( it as reinfor)ed by anxiety redu)tion$ by a sense of )ontro.$ or by per)ei/ed ris- redu)tion 2Bor-o/e)$ et a..$ *++*C Cras-e$ *+++3. A sense of )ontro. o/er s)ary t'oug'ts and se.f1effi)a)y for exer)ising su)' )ontro. appear important 2Bandura$ *+BBC @ent H =ibbons$ *+BD3 and .a)- of se.f1effi)a)y for so./ing prob.ems is imp.i)ated in genera.i4ed anxiety and (orry 2Ai-ins H Cras-e$ 9,,*3. TREATMENT %sy)'o.ogi)a. approa)'es to 'e.ping peop.e o/er)ome a/oidan)e and ritua.s$ sub6e)ti/e fear and pani) atta)-s$ and (orries$ obsessions$ and intrusi/e bot'ersome t'oug'ts 'a/e a)'ie/ed notab.e su))esses in re)ent de)ades$ a.t'oug' mu)' room for impro/ement remains 2Bar.o($ 9,,9C C'amb.ess H %eterman$ 9,,;C Cras-e$ *+++3. Ne/ert'e.ess$ t'e findings ma-e amp.y ).ear t'at be'a/iora.$ so)ia.$ and )ogniti/e met'ods )an great.y impro/e t'ese prob.ems in many )ases. Treat(ent #6 A,#idan.e and Rit$a%s &e.ping peop.e o/er)ome be'a/iora. disabi.ities is important in its o(n rig't$ of )ourse$ but a.so be)ause redu)ing a/oidan)e be'a/iors robust.y redu)es t'e sub6e)ti/e fear$ pani)$ obsessions$ intrusi/e t'oug'ts$ and depressed mood t'at tend to go (it' t'em. +erformance3$ased !"posure Treatments &istori)a..y pi/ota. to p'obia treatment (as t'e de/e.opment of systemati) desensiti4ation 2Wo.pe$ *+<B3 and re.ated met'ods t'at guide peop.e to imagine doing a/oided a)ti/ities$ and /i)arious met'ods 2e.g.$ Bandura$ B.an)'ard$ H Ritter$ *+?+3 in ('i)' peop.e (at)' ot'ers doing t'e a)ti/ities. #'e next ma6or ad/an)e (as performan)e1based treatments$ in ('i)' peop.e dire)t.y perform t'eir a/oided a)ti/ities 2e.g.$ Agras$ Leitenberg$ H Bar.o($ *+?BC Bandura et a..$ *+?+3. "n performan)e1based treatment of ritua.s t'e person engages in ritua.1pro/o-ing a)ti/ities 2e.g.$ tou)'es t'e door 'and.e$ or t'in-s 08amn =od03 but t'en refrains from t'e ritua.s 2Ra)'man H &odgson$ *+B,3$ a met'od -no(n (ide.y as exposure p.us response pre/ention. %erforman)e1based met'ods are re.iab.y more effe)ti/e t'an met'ods based on t'e person on.y imagining or /ie(ing t'e a)ti/ities 2Bandura et a..$ *+?+C Emme.-amp H Wesse.s$ *+D<C te-etee H Bar.o($ 9,,93.

274 W"LL"AM =uided mastery treatment fo)used entire.y on redu)ing a/oidan)e be'a/ior (it'out exp.i)it.y addressing$ t'in-ing and fee.ing )an )omp.ete.y e.iminate spe)ifi) p'obias and t'eir )ogniti/e and emotiona. a))ompaniments (it'in a fe( 'ours in t'e ma6ority of )ases 2Bandura$ *++DC !st$ *++?3. #'e benefits of performan)e1fo)used exposure treatment for )omp.ex p'obias and )ompu.sions are many 2Cras-e$ *+++C Ra)'man H &odgson$ *+B,C W'ite H Bar.o($ 9,,93. "ndeed$ p'obia treatment is a ma6or ingredient in t'e treatment of anxiety$ pani)$ stress rea)tions$ and bot'ersome intrusi/e t'oug'ts$ a.. of ('i)' may be sustained in .arge part by subt.e or gross a/oidan)e be'a/iors t'at insu.ate peop.e from )orre)ti/e .earning experien)es 2C.ar-$ *+++C @eane H Bar.o($ 9,,9C a.-o/s-is$ *++*C Wi..iams$ *+B<3. Guided Mastery "magery1based$ /i)arious$ and performan)e1based treatments are sometimes )a..ed )o..e)ti/e.y exposure treatments$ fo..o(ing t'e )on)eption t'at treatment is .i-e a ).assi)a. extin)tion pro)edure in ('i)' unreinfor)ed exposure to t'e )onditioned stimu.us de)onditions fear and a/oidan)e 2e.g.$ Foa H M)Na..y$ *++?C Mar-s$ *+DB3. Commer)e (it' re.e/ant stimu.i is re1 7uired for .earning 6ust about anyt'ing$ but identi)a. durations of exposure to p'obi) stimu.i routine.y resu.t in 'ig'.y disparate degrees of )'ange in p'obi) be'a/ior$ bet(een indi/idua.s and bet(een groups 2e.g.$ Bandura et a..$ *+?+C Bandura$ Jeffrey$ H Wrig't$ *+D;C Wi..iams et a..$ *+B;$*+B<3. #'e exposure )on)eption points to outer stimu.i instead of inner psy)'o.ogi)a. pro)esses$ and portrays treatment and be'a/ior )'ange in passi/e me)'anisti) de)ondition1ing terms. #'e so)ia. )ogniti/e approa)' 'o.ds t'at peop.e o/er)ome p'obias and )ompu.sions a)ti/e.y in t'oug't and deed 2Wi..iams$ *++,3. By t'is interpretation$ an agorap'obi) (oman is not exposed to stores$ s'e s'ops in t'emC and store stimu.i do not extinguis' 'er p'obia$ s'e masters it. "n treatment based on se.f1effi)a)y t'eory or guided mastery treatment 2Wi..iams$ *++,3 t'e t'erapist see-s to bui.d a strong sense of se.f1effi)a)y by fostering peop.eGs performan)e a)1 )omp.is'ments. A.t'oug' t'e proposed se.f1effi)a)y me)'anism is )ogniti/e$ t'e re)ommended pro)edure is performan)e$ be)ause first'and be'a/iora. su))ess )on/eys t'e most dependab.e information t'at one rea..y )an do somet'ing. #'e t'erapist assists peop.e to su))eed at tas-s t'at ot'er(ise (ou.d be too diffi)u.t$ and guides t'em to do tas-s profi)ient.y$ free of embedded ritua.s and restri)tions t'at .imit t'eir fee.ing of su))ess. Assisting peop.e to ta)-.e p'obi) and )ompu.si/e prob.ems usua..y produ)es better resu.ts t'an does simp.y en)ouraging t'em to ex1 pose t'emse./es to s)ary stimu.i and refrain from ritua.i4ing (it'out mu)' 'e.p 2Abramo(it4$ *++?C Bandura et a..$ *+D;C Fes-e H C'amb.ess$ *++<C !st$ a.-o/s-is$ H &e..strom$ *++*C Wi..iams et a..$ *+B;C *+B<C Wi..iams H Rane$ *+B+3. Cogniti/e t'erapies designed to 'e.p peop.e .o(er t'eir o/erestimates of danger and to adopt more 'e.pfu. (ays of t'in-ing are (ide.y used to treat be'a/iora. a/oidan)e and ritua.s$ but t'ese do not seem to 'a/e a re.iab.e impa)t beyond t'at a)'ie/ed by performan)e met'ods a.one 2Fes-e H C'amb.ess$ *++<C &ope$ &eimberg$ H Bru)'$ *++<C M)Lean$ W'itta.$ #'ordarson$ #ay.or$ o)'ting$ @o)'$ %aterson$ H Anderson$ 9,,*C te-etee H Bar.o($ 9,,9C Wi..iams H Rappoport$ *+B:3. Treat(ent #6 An-iety 'ub4ective %n"iety %eop.e usua..y fee. anxious about somet'ing in parti)u.ar$ and often a/oid it as (e... As mentioned ear.ier$ mastering t'e a/oidan)e be'a/ior a.one often e.iminates any a))ompanying sub6e)ti/e anxiety as a by1produ)t 2e.g.$ Bandura et a..$ *+?+C ?st et a..$ *++*C Wi..iams et a..$ *+B;3. W'en peop.e )an do an a)ti/ity but fee. anxious doing it$ so)ia. )ogniti/e ana.yses

suggest )ountera)ting subt.e a/oidan)e maneu/ers$ defensi/e a)ti/ities$

D. ANV"E#A 8" !R8ER 276 and se.f1prote)ti/e ritua.s t'at )ir)ums)ribe t'eir sense of mastery and t'erefore promote )ontinued anxious fee.ings 2Wi..iams$ *+B<C Wi..iams H Rane$ *+B+C Rane H Wi..iams$ *++:3. #'is p'enomenon is sometimes interpreted in .ig't of safety signa.s 2C.ar-$ 9,,*C a.-o/s-is$ *++*3. W'en peop.e stop t'e defensi/e a)ti/ities and perform in a profi)ient /aried manner$ t'e anxiety usua..y goes a(ay 7ui)-.y 2 a.-o/s-is$ *++*C Wi..iams H Rane$ *+B+3. !f )ourse sub6e)ti/e anxiety )an be treated by guiding peop.e to imagine t'emse./es en)ountering stressors and )oping effe)ti/e.y (it' t'em$ and by a /ariety of re.axation and )ogniti/e reappraisa. met'ods 2Be)-$ *+D?C Rapee H Bar.o($ *++*C Wo.pe$ *+<B3. +anic %ttacks Most peop.e (it' pani) atta)-s disp.ay some a/oidan)e be'a/ior$ gross or subt.e 2 a.-o/s-is$ *++*3$ and performan)e1based t'erapies for agorap'obi) a/oidan)e )an 'a/e a notab.e impa)t on pani) atta)-s 2Bar.o($ 9,,9C Wi..iams H Fa.bo$ *++?C Mi)'e.son$ Ma/issa-a.ian$ H Mar)'ione$ *+BB3. e/era. treatment met'ods spe)ifi)a..y fo)used on pani) in).ude so)ia. )ogniti/e t'erapies designed to in)rease rationa. appraisa. and to de)atastrop'i4e t'in-ing$ somati) inter/entions to indu)e autonomi) arousa. or ot'er bodi.y responses asso)iated (it' pani) 2sometimes )a..ed intero)epti/e exposure3$ and breat'ing and re.axation te)'ni7ues designed to norma.i4e and )a.m p'ysio.ogi)a. arousa. 2Cras-e$ *+++C Ra)'man H Maser$ *+BBC W'ite H Bar.o($ 9,,93. Ear.y studies of t'e pani)1fo)used met'ods app.ied in )ombination found t'em to 'a/e stri-ing.y positi/e effe)ts$ enduring.y e.iminating pani) atta)-s in B<P or more of pani)-y indi/idua.s 2Cras-e$ *+++C Ra)'man H Maser$ *+BB3. "n apparent )ontrast$ performan)e1based t'erapies initia..y appeared to redu)e pani) atta)-s on.y moderate.y. "t no( appears t'at t'e ad/antage of pani)1fo)used t'erapies (as .arge.y an artifa)t of sub6e)t se.e)tion differen)es. Most studies of pani)1fo)used treatments for pani) ex).uded pani)-y peop.e ('o 'ad signifi)ant p'obias$ ('ereas studies of performan)e exposure treatments for pani) in).uded or e/en se.e)ted for se/ere agorap'obi) disabi.ity 2Wi..iams H Fa.bo$ *++?3. W'en pani)-y peop.e ('o /aried (ide.y in agorap'obi) disabi.ity (ere gi/en psy)'o.ogi)a. treatments$ irrespe)ti/e of treatment )ondition signifi)ant.y more of t'ose (it' fe( p'obias 2+?P3 be)ame pani)1free t'an did t'ose (it' many p'obias 2<9PC Wi..iams and Fa.bo$ *++?3. A meta1ana.ysis of *: re)ent studies of pani) treatment by )ogniti/e1be'a/iora. t'erapies$ (it' di/erse se.e)tion )riteria$ found rates of pani)1free parti)ipants after treatment ranging from <:P to B<P$ (it' a mean of D*P 2C'amb.ess H %eterson$ in press3. E/en so$ pani)1fo)used met'ods sti.. 'a/e been forma..y tested most.y on t'e easier pani)-ers to 'e.p and (i.. need to be e/a.uated furt'er for re.ie/ing pani) in peop.e ('o are 'ig'.y p'obi)$ )ompu.si/e$ and ot'er(ise disab.ed. #'e strong.y positi/e effe)ts of se/era. different psy)'o.ogi)a. inter/entions$ in).uding performan)e exposure$ (it' many disab.ed pani)-y indi/idua.s estab.is'es psy)'o.ogi)a. met'ods as potent treatments for pani). Treat(ent #6 1#t/ers#(e T/#$&/ts &e.ping peop.e (it' bot'ersome t'oug'ts often in/o./es a )ombination of e.ements administered toget'er. %er'aps t'e most (ide.y used te)'ni7ue$ regard.ess of ('et'er t'e t'oug'ts are (orries$ obsessions$ f.as'ba)-s$ or /isua.i4ed future )a.amities$ is (it' p'obia exposure te)'ni7ues 2i.e.$ ena)ti/e or imagina. performan)e3. Worries and obsessions are often a))ompanied by menta. or be'a/iora. a/oidan)e rea)tions or neutra.i4ing ritua.s$ reassuran)e1see-ing$ and ot'er responses t'at paradoxi)a..y maintain and in)rease intrusions 2Cras-e$ *+++C @eane H Bar.o($ 9,,9C Ra)'man$ *++BC a.-o/s-is$ *++?a3. "n a menta. e7ui/a.ent of )ompu.sion treatment$ t'e person

de.iberate.y t'in-s t'e intrusi/e t'oug't t'en pra)ti)es not menta..y rea)ting

278 W"LL"AM to it. ometimes t'is -ind of t'oug't pra)ti)e is )ast as a be'a/iora. experiment to test and dis)onfirm prob.emati) be.iefs. Cogniti/e treatments 2C.ar-$ *+++C Cras-e$ *+++3 in/o./e di1 a.ogue aimed at )on/eying t'at obsessions are norma.$ )'a..enging ex)essi/e responsibi.ity be.iefs and )atastrop'i) meanings$ in)reasing to.eran)e of un)ertainty$ and a.tering prob.em imagery$ but (it'out trying to de)rease t'e number of intrusi/e t'oug'ts dire)t.y 2C.ar-$ *+++C a.-o/s-is$ *++?a3. P/ar(a.#%#&i.a% Treat(ents #'is )'apter 'as fo)used on non1bio.ogi)a. )auses and treatments$ but drugs appear a.so to 'a/e a ro.e to p.ay$ so a fe( genera. )omments on drug treatment are in order. %sy)'o.ogi)a. treatments are more effe)ti/e t'an any -no(n drug for some prob.ems su)' as spe)ifi) p'obias$ and appear superior to drugs for pani) atta)-s as (e.. 2Bar.o($ 9,,93. =enera.i4ed p'obias$ pani)$ obsessions$ and )ompu.sions impro/e from )ertain drugs more t'an from p.a)ebo pi..s 2Bar.o($ 9,,93$ and it appears t'at some indi/idua.s benefit from drugs more t'an from t'e psy)'o.ogi)a. treatments t'ey 'a/e 'ad. But drug treatments are beset by distin)t t'erapeuti) diffi)u.ties$ in).uding t'e tenden)y for prob.ems to return ('en t'e drug is (it'dra(n$ ('ereas psy)'o.ogi)a. treatment benefits tend to be more enduring. %eop.e often )annot p'ysi)a..y to.erate a drug$ may not be a..o(ed to ta-e it 2e.g.$ pregnant (omen3$ or may re6e)t t'e idea of drugs of t'eir o(n a))ord. C'emi)a. dependen)y and drug to.eran)eL(it'dra(a. rea)tions in).uding strong rebound and exa)erbating effe)ts are )ommon. #'ere is a re.ati/e pau)ity of resear)' )omparing p'arma)o.ogi)a. treatment (it' psy)'o.ogi)a. treatment and )ombined treatment a.t'oug' many indi/idua.s re)ei/e bot' in pra)ti)e 2Cras-e$ *+++3$ and of drug resear)' for some -inds of prob.ems su)' as traumati) stress rea)tions. 8rug treatment resear)' en)ounters distin)ti/e met'odo.ogi)a. prob.ems su)' as 'ig' positi/e response rates among p.a)ebo )ontro. sub6e)ts$ diffi)u.ty maintaining b.indness in drug dispensers and out)ome assessors be)ause of /isib.e )ommon side effe)ts$ sub6e)t attrition due to drug into.eran)e$ and ot'er t'orny resear)' prob.ems t'at .imit understanding of drug benefits. Be)ause psy)'o.ogi)a. treatments for most of t'e prob.ems (e 'a/e dis)ussed are substantia..y benefi)ia. to t'e a/erage indi/idua.$ and drugs ('i.e sometimes benefi)ia. 'a/e serious potentia. s'ort)omings$ it seems genera..y ad/isab.e for t'erapists to use psy)'o.ogi)a. met'ods first but be prepared to use p'arma)o.ogi)a. agents ('en psy)'o.ogi)a. treatments a.one are insuffi)ient. PREGALENCE OF DISORDER OR DISTRI1UTION OF DIMENSIONAL SCORESI #'e rates at ('i)' psy)'o.ogi)a. prob.ems o))ur in t'e )ommunity 'a/e been measured for t'e most part indire)t.y as pre/a.en)e rates of )ategori)a. menta. disorders rat'er t'an dire)t.y as fre7uen)y distributions of dimensiona. s)ores. %robab.y 6ust about e/erybody 'as experien)ed need.ess a/oidan)e$ fears$ and unp.easant t'oug'ts no( and again$ so t'eir pre/a.en)e as menta. disorders is .arge.y in t'e eye of t'e be'o.der$ dependent on ('i)' responses and )utoff )riteria one )'ooses to define disorder and on 'o( assessors a)tua..y operationa.i4e t'e definitions 2Wi..iams$ in preparation3. For examp.e$ in one ana.ysis t'e pre/a.en)e of 8 M1""" genera.i4ed anxiety disorder dropped from ;<P to +P of t'e popu.ation ('en t'e re7uired duration of anxiety in)reased from one mont' to six mont's and t'e minimum number of anxiety1defining responses in)reased from t'ree to six 2Bres.au H 8a/is$ *+B<3. %re/a.en)e of so)ia. p'obi) disorder ranges from about 9P to *+P of t'e popu.ation$ depending on )utoff s)ores and on 'o( diagnosti) inter/ie(ers pose t'eir 7uestions 2 tein$

8. AN<IETY DISORDERS 279 Wa.-er$ H Forde$ *++;3. Mar-ed.y /arying pre/a.en)e rates are found for posttraumati) stress disorder main.y be)ause of 8 MGs impre)ise nonoperationa. definitions 2e.g.$ @ess.er$ onnega$ Bromet$ &ug'es$ H Ne.son$ *++<3. #'e impa)t of ambiguous de)ision ru.es is e/ident in a re)ent reana.ysis of epidemio.ogi)a. findings app.ying t'e 8 M1"> ).ini)a. signifi)an)e )riterion$ ('i)' )'anged t'e United tates nationa. pre/a.en)e of menta. i..nesses by *+.9 mi..ion peop.e at a sing.e stro-e 2Narro($ Rae$ Robins$ H Regier$ 9,,93. "t is ).ear t'at t'e pre/a.en)e of prob.ems in t'e popu.ation (ou.d be far better )'ara)teri4ed by distributions of prob.em dimension s)ores t'an by fre7uen)y )ounts of t'e presen)e or absen)e of proposed menta. disorders. Ne/ert'e.ess$ estimated pre/a.en)es of menta. i..nesses 2e.g.$ @end.er$ *++;3 s'o( beyond any doubt t'at serious psy)'o.ogi)a. prob.ems of t'e -inds (e 'a/e been )onsidering are (idespread. " 'a/e approa)'ed anxiety disorders by en)ouraging readers to 7uestion bot' anxiety and disor1 ders. Ca..ing psy)'o.ogi)a. p'enomena by t'eir o(n proper names (it'out a pseudo1unifying anxiety .abe. remo/es a )omforting i..usion of understanding$ but 'e.ps us see prob.em p'e1 nomena more ).ear.y on t'eir o(n terms. %er'aps more important is to deep.y 7uestion disorder t'eory. Most )riti)s of psy)'iatri) diagnosis odd.y )on).ude (it' a (is' to use psy)'o.ogi)a. dimensions to de/e.op a better system of )ategori4ing menta. disorders. " disagree funda1 menta..y. &ere and no( dimensions do e/eryt'ing good t'at disorders do$ on.y mu)' better$ and (it'out a.. t'e distortions. Far from subordinating psy)'o.ogi)a. s)ien)e to t'e medi)a. mode.$ ('i)' (ou.d be .i-e t'e /i)torious =enera. =rant surrendering 'is army to t'e defeated =enera. Lee in Mar- #(ainGs ta.. ta.e$ psy)'o.ogi)a. s)ientists )an )e.ebrate t'e demise of t'e medi)a. mode. and ne/er .oo- ba)-. Needed is not a better understanding of psy)'opat'o.ogy and menta. i..ness$ but of peop.eGs psy)'o.ogi)a. prob.ems. o)ia. )ogniti/e t'eories a)'ie/e notab.e su))esses in exp.aining and ame.iorating diffi)u.t prob.ems (it'out t'e need of embra)ing dis6ointed mu.timoda. psy)'i) states$ in).uding anxiety disorders. We a)t not be)ause of mu.timoda. anxiety or anxiety disorders$ but abo/e a.. be)ause of our )ons)ious t'oug'ts about our )ir)umstan)es and ourse./es. #uthor +oteM " t'an- 8ianne C'amb.ess for 'er 'e.pfu. )omments on a draft of t'is paper. REFERENCES Abra(#2itC5 7. S. =3@@?>. Gariants #6 e-*#s$re and res*#nse *re,enti#n in t/e treat(ent #6 #bsessi,e0.#(*$%si,e dis#rder' A (eta0ana%ysis. $ehavior Therapy# :A# ";:0?!!. A&ras5 W. S.5 Leitenber&5 H.5 H 1ar%#25 D. H. =3@?;>. S#.ia% rein6#r.e(ent in t/e (#di6i.ati#n #6 a&#ra*/#bia. %rchives of General +sychiatry# 6@# ;:?3;:6. Ai+ins5 D. E.5 H Cras+e5 M. G. = !!3>. C#&niti,e t/e#ries #6 &enera%iCed an-iety dis#rder. +sychiatric 1linics of -orth %merica# :;# "8089. A(eri.an Psy./iatri. Ass#.iati#n =3@@9>. Diagnostic and statistical manual of mental disorders =9t/ ed.5 DSM0IGY :rd ed5 DSM0III5 3@;!Y :rd re,. ed5 DSM0III0R5 3@;8>. Was/in&t#n5 DC' A$t/#r. 1and$ra5 A. =3@?@>. +rinciples of behavior modification. Ne2 Y#r+' H#%t5 Rine/art5 H Winst#n. 1and$ra5 A. =3@8;>. On *aradi&(s and re.y.%ed ide#%#&ies. 1ognitive Therapy and (esearch# :# 8@03!:. 1and$ra5 A. =3@;?>. 'ocial foundations of thought and action5 % social cognitive theory. En&%e2##d C%i66s5 N7' Prenti.e0Ha%%.

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285 W"LL"AM La.ey5 7. I. =3@?8>. S#(ati. res*#nse *atternin& and stress' S#(e re,isi#ns #6 a.ti,ati#n t/e#ry. In M. H. A**%ey H R. Tr$(b$%% =Eds.>5 +sychological stress5 0ssues in research =**. 3909 >. Ne2 Y#r+' A**%et#n Cent$ry Cr#6ts. Lan&5 P. 7. =3@;">. T/e .#&niti,e *sy./#*/ysi#%#&y #6 e(#ti#n' Fear and an-iety. In A. H. T$(a H 7. D. Maser =Eds.>5 %n"iety and the an"iety disorders =**. 3:3038!>. Hi%%sda%e5 N7' La2ren.e Er%ba$( Ass#.iates. Lan&5 P. 75 C$t/bert5 1. N5 H 1rad%ey5 M. M. =3@@;>. Meas$rin& e(#ti#n in t/era*y' I(a&ery5 a.ti,ati#n5 and 6ee%in&. $ehavior Therapy# :@# ?""0?89. Lan&5 P. 75 Le,in5 D. N5 Mi%%er5 G. A5 H )#Ca+5 M. 7. =3@;:>. Fear be/a,i#r5 6ear i(a&ery5 and t/e *sy./#*/ysi#%#&y #6 e(#ti#n' T/e *r#b%e( #6 a66e.ti,e res*#nse intre&rati#n. ournal of%bnormal +sychology# @:# 8"0:!?. Leary5 M. R5 H )#2a%s+i5 R. M. =3@@">. T/e se%60*resentati#na% (#de% #6 s#.ia% */#bia. In R. G. Hei(ber&5 M. R. Lieb#2itC5 D. A. H#*e5 H F. R. S./neier =Eds.>5 'ocial phobia5 diagnosis# assessment# treatment =**. @9033 >. Ne2 Y#r+' G$i%6#rd. Li*sitC5 7. DQ 1ar%#25 D. HQ Mann$CCa5 S5 H#66(an5 S. G5 H Fyer5 A. 7. = !! >. C%ini.a% 6eat$res #6 6#$r DSM0IG0 s*e.i6i. */#bia s$bty*es. ournal of -ervous and Mental Disease# 6@7# 983098;. Madd$-5 7. E. =Ed.> =3@@"a>. 'elf3efficacy# adaptation# and ad4ustment5 theory# research# application. Ne2 Y#r+' P%en$(. Madd$-5 7. E. =3@@"b>. L##+in& 6#r .#((#n &r#$nd' A .#((ent #n )irs./ and 1and$ra. In 7. Madd$- =Ed.>5 'elf3efficacy# adaptation# and ad4ustment5 Theory# research# application =**. :880:;">. Ne2 Y#r+' P%en$(. Madd$-5 7. E5 N#rt#n5 L. W5 H Leary5 M. R. =3@;;>. C#&niti,e .#(*#nents #6 s#.ia% an-iety' An in,esti&ati#n #6 t/e inte&rati#n #6 se%60*resentati#na% t/e#ry and se%60e66i.a.y t/e#ry. ournal of 'ocial and 1linical +sychology# E# 3;!03@!. Ma&ee5 W. 75 Eat#n5 W. W5 Witt./en5 H.0U5 M.G#na&ne5 ). A5 H )ess%er5 R. C. =3@@?>. A&#ra*/#bia5 si(*%e */#bia5 and s#.ia% */#bia in t/e Nati#na% C#(#rbidity S$r,ey. %rchives of General +sychiatry# 9?# 3"@03?;. Mand%er5 G. =3@? >. E(#ti#n. In R. 1r#2n5 E. Ga%anter5 E. Hess5 H G. Mand%er =Eds.>5 -ew directions in psychology5 Fol. 0. =**. ?@0:9:>. Ne2 Y#r+' H#%t5 Rine/art5 H Winst#n. Mar&ra65 75 Tay%#r5 C. 15 E/%ers5 A5 R#t/5 W. T5 H A&ras5 W. S. =3@;8>. Pani. atta.+s in t/e nat$ra% en,ir#n(ent. ournal of -ervous and Mental Disease# 6A9# "";0"?". Mar+s5 I. M. =3@8;>. 1e/a,i#ra% *sy./#t/era*y #6 ad$%t ne$r#sis. In S. L. Gar6ie%d H A. E. 1er&in =Eds.>5 ,andbook of psychotherapy and behavior change =**. 9@:0"98>. Ne2 Y#r+' Wi%ey. Mar+s5 I. M. =3@;8>. /ears# phobias# and rituals. Ne2 Y#r+' O-6#rd. Mars/a%%5 R. D5 O%6s#n5 M5 He%%(an5 F5 1%an.#5 C5 G$ardin#5 M5 H Str$enin&5 E. L. = !!3>. C#(#rbidity5 i(*air(ent5 and s$i.ida%ity in s$bt/res/#%d PTSD. %merican ournal of +sychiatry# 698# 39?80398:. Mat/e2s5 A. M5 Ge%der5 M. G5 H 7#/nst#n5 D. W. =3@;3>. %goraphobia5 -ature and treatment. Ne2 Y#r+' G$i%6#rd.

Mat/e2s5 A. M5 H Ma.Le#d5 C. =3@@9>. C#&niti,e a**r#a./es t# e(#ti#n and e(#ti#n dis#rders. %nnual (eview of +sychology# ;9# "0"!. Mat/e2s5 A5 H Ma.Le#d5 C. = !! >. Ind$.ed *r#.essin& biases /a,e .a$sa% e66e.ts #n an-iety. 1ognition and !motion# 8?5::30:"9. M.Lean5 P. D5 W/itta%5 M. LQ T/#rdars#n5 D. S. Tay%#r5 S5 S#./tin&5 I5 )#./5 W. 75 Paters#n5 R5 H Anders#n5 ). W. = !!3>. C#&niti,e ,ers$s be/a,i#ra% t/era*y in t/e &r#$* treat(ent #6 #bsessi,e .#(*$%si,e dis#rder. ournal of 1onsulting and 1linical +sychology# E@# !"0 39. Mi./e%s#n5 L5 Ma,issa+a%ian5 M5 HMar./i#ne5 M. =3@;;>. C#&niti,e5 be/a,i#ra%5 and *sy./#*/ysi#%#&i.a% treat(ents #6 a&#ra*/#bia' A .#(*arati,e #$t.#(e in,esti&ati#n. $ehavior Therapy# 6@# @803 !. Mine+a5 S. =3@8@>. T/e r#%e #6 6ear in t/e#ries #6 a,#idan.e %earnin&5 6%##din&5 and e-tin.ti#n. +sychological $ulletin# 8E# @;"03!3!. Mine+a5 S5 Da,ids#n5 M5 C##+5 M5 H )eir5 R. =3@;9>. Obser,ati#na% .#nditi#nin& #6 sna+e 6ear in r/es$s (#n+eys. ournal of %bnormal +sychology# @?# :990:8 . Mine+a5 S5 H )e%%y5 ). A. =3@;@>. T/e re%ati#ns/i* bet2een an-iety5 %a.+ #6 .#ntr#% and %#ss #6 .#ntr#%. In A. Ste*t#e and A. A**e%s =Eds.>5 'tress# personal control and health =**. 3?:03@3>. Ne2 Y#r+' Wi%ey. Mis./e%5 W. =3@@!>. Pers#na%ity dis*#siti#ns re,isited and re,ised' A ,ie2 a6ter t/ree de.ades. In L. A. Per,in =Ed.>5 ,andbook of personality5 Theory and research =**. 33303?9>. Ne2 Y#r+' G$i%6#rd. M##re5 R5 1r#ds&aard5 I5 H 1irn5 H. =3@@3>. Mani6estati#ns5 a.J$isiti#n and dia&n#sti. .ate&#ries #6 denta% 6ear in a se%60re6erred *#*$%ati#n. $ehaviour (esearch and Therapy# :@# "30?!. M#rr#25 G. R5 H Labr$(5 A. H. =3@8;>. T/e re%ati#ns/i* bet2een *sy./#%#&i.a% and */ysi#%#&i.a% (eas$res #6 an-iety. +sychological Medicine# 8# @"03!3. M#2rer5 O. H. =3@?!>. )earning theory and behavior. Ne2 Y#r+' Wi%ey. M$ris5 P5 Mer.+e%ba./5 H5 H C%a,an5 M. =3@@8>. Abn#r(a% and n#r(a% .#(*$%si#ns. $ehaviour (esearch and Therapy# ?9# 9@0 " . Narr#25 W. E5 Rae5 D. S5 R#bins5 L. N5 Re&ier5 D. A. = !! >. Re,ised *re,a%en.e esti(ates #6 (enta% dis#rders in t/e United States. %rchives of General +sychiatry# 9@# 33"03 :. Neria5 Y5 1r#(et5 E. 75 Sie,ers5 S5 LaGe%%e5 75 H F#./t(ann5 L. 7. = !! >. Tra$(a e-*#s$re and *#st0tra$(ati. stress

8. AN<IETY DISORDERS 287 dis#rder in *sy./#sis' Findin&s 6r#( a 6irst0ad(issi#n .#/#rt. ournal of 1onsulting and 1linical +sychology# A7# 9?0 "3. N#rt#n5 G. R5 C#-5 1. 75 H Ma%an5 7. =3@@ >. N#n.%ini.a% *ani.+ers' A .riti.a% re,ie2. 1linical +sychology (eview# 6:# 3 303:@. OBD2yer5 A5 H Mar+s5 I. M. = !!!>. Obsessi,e0.#(*$%si,e dis#rder and de%$si#ns re,isited. $ritish ournal of +sychiatry# 6AE# ;30 ;9. ?st5 L.0G. =3@@?>. L#n& ter( e66e.ts #6 be/a,i#r t/era*y 6#r s*e.i6i. */#bias. In M. R. Ma,issa+a%ian H R. F. Prien =Eds.>5 )ong term treatments of the an"iety disorders. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. Ost5 L.0G5 Ferebee5 I5 H F$r(ar+ T. =3@@8>. One0sessi#n &r#$* t/era*y #6 s*ider */#bia' Dire.t ,ers$s indire.t treat(ents. $ehaviour (esearch and Therapy# ?9# 8 308: . Ost5 L.0G5 Sa%+#,s+is5 P5 H He%%str#(5 ). =3@@3>. One0sessi#n t/era*ist0dire.ted e-*#s$re ,s. se%60e-*#s$re in t/e treat(ent #6 s*ider */#bia. $ehavior Therapy# ::# 9!809 . Penneba+er5 7. W. =3@; >. The psychology of physical symptoms. Ne2 Y#r+' S*rin&er0Ger%a&. Pers#ns5 7. =3@;?>. T/e ad,anta&es #6 st$dyin& *sy./#%#&i.a% */en#(ena rat/er t/an *sy./iatri. dia&n#ses. %merican +sychologist# 66# 3 " 03 ?!. Ra./(an5 S. =3@8?>. T/e *assin& #6 t/e t2#0sta&e t/e#ry #6 6ear and a,#idan.e' Fres/ *#ssibi%ities. $ehaviour (esearch and Therapy# 6;# 3 "03:3. Ra./(an5 S. =3@88>. T/e .#nditi#nin& t/e#ry #6 6ear a.J$isiti#n' A .riti.a% e-a(inati#n' $ehaviour (esearch and Therapy# 69# :8"0:;8. Ra./(an5 S. =3@@;>. A .#&niti,e t/e#ry #6 #bsessi#ns' E%ab#rati#ns. $ehaviour (esearch and Therapy# ?E#:;"09!3. Ra./(an5 S5 H de Si%,a5 P. =3@8;>. Abn#r(a% and n#r(a% #bsessi#ns. $ehavior (esearch and Therapy# 6E# ::0 9;. Ra./(an5 S5 H H#d&s#n5 R. =3@89>. I. Syn./r#ny and desyn./r#ny in 6ear and a,#idan.e. $ehaviour (esearch and Therapy# 6:# :330:3;. Ra./(an5 S5 H H#d&s#n5 R. =3@;!>. Obsessions and compulsions. En&%e2##d C%i66s5 N7' Prenti.e0Ha%%. Ra./(an5 S5 H Maser5 7. D. =Eds.> =3@;;>. +anic5 psychological perspectives. Hi%%sda%e5 N7' La2ren.e Er%ba$(. Ra*ee5 R. M. =3@@:>. Psy./#%#&i.a% 6a.t#rs in *ani. dis#rder. %dvances in $ehavior (esearch and Therapy# 69#;"03! . Ra*ee5 R. M. =3@@">. Psy./#%#&i.a% 6a.t#rs in6%$en.in& t/e a66e.ti,e res*#nse t# bi#%#&i.a% ./a%%en&e *r#.ed$res in *ani. dis#rder. ournal of %n"iety Disorders# @# "@089. Ra*ee5 R. M5 H 1ar%#25 D. H. =Eds.> =3@@3>. 1hronic an"iety. Ne2 Y#r+' G$i%6#rd. Sa%+#,s+is5 P. M. =3@@3>. T/e i(*#rtan.e #6 be/a,i#r in t/e (aintenan.e #6 an-iety and *ani.' A .#&niti,e a..#$nt. $ehavioural +sychotherapy# 6@# ?03@. Sa%+#,s+is5 P. M. =3@@?a>. C#&niti,e0be/a,i#ra% a**r#a./es t# t/e $nderstandin& #6 #bsessi#na% *r#b%e(s. In R. M. Ra*ee =Ed.>5 1urrent controversies in the an"iety disorders =**. 3!:03::>. Ne2 Y#r+' G$i%6#rd. Sa%+#,s+is5 P. M. =3@@?b>. Understandin& #6 #bsessi,e0.#(*$%si,e dis#rder is n#t i(*r#,ed by rede6inin& it as s#(et/in& e%se. In R. M. Ra*ee =Ed.>5 1urrent controversies in the an"iety disorders =**. 3@30 !!>. Ne2 Y#r+' G$i%6#rd. Sa%+#,s+is5 P. M. =3@@;>. Psy./#%#&i.a% a**r#a./es t# t/e $nderstandin& #6 #bsessi#na%

*r#b%e(s. In R. P. S2ins#n5 M. M. Ant/#ny5 S. Ra./(an5 H M. A. Ri./ter =Eds.>5 Obsessive3compulsive disorder5 Theory# research.and treatment =**. ::0"!>. Ne2 Y#r+' G$i%6#rd. Sa%+#,s+is5 P. M5 H Harris#n5 7. =3@;9>. Abn#r(a% and n#r(a% #bsessi#ns' A re*%i.ati#n. $ehaviour (esearch and Therapy# ::# "9@0"" . Sa%+#,s+is5 P. M5 H War2i.+5 H. M. C. =3@;?>. M#rbid *re#..$*ati#ns5 /ea%t/ an-iety and reass$ran.e' A .#&niti,e0be/a,i#$ra% a**r#a./ t# /y*#./#ndriasis. $ehaviour (esearch and Therapy# :;# "@80?! . S./2artC5 1. =3@8;>. +sychology of learning and behavior. Ne2 Y#r+' N#rt#n. S./2artC5 1. =3@;@>. +sychology of learning and behavior =:rd ed.>. Ne2 Y#r+' N#rt#n. S./2arCer5 R. =Ed.>=3@@ >. 'elf3efficacy5 Thought control of action. Was/in&t#n DC' He(is*/ere. Se%i&(an5 M. E. P5 H 7#/nst#n5 7. C. =3@8:>. A .#&niti,e t/e#ry #6 a,#idan.e %earnin&. In F. 7. M.G$i&an H D. 1. L$(sden =Eds.>5 1ontemporary approaches to conditioning and learning =**. ?@033!>. Was/in&t#n5 DC' Winst#n H S#ns. S+inner5 1. F. =3@"8>. Ferbal behavior. Ne2 Y#r+' A**%et#n0Cent$ry0Cr#6ts. S*ie%ber&er5 C. D. =3@;:>. Manual for the 'tate3Trait %n"iety 0nventory. Pa%# A%t#5 CA' C#ns$%tin& Psy./#%#&ists. S*itCer5 R. L5 H Wi%%ia(s5 7. 1. W. =3@;">. Pr#*#sed re,isi#ns in t/e DSM0HI .%assi6i.ati#n #6 an-iety dis#rders based #n resear./ and .%ini.a% e-*erien.e. In A. H. T$(a H 7. D. Maser =Eds.>5 %n"iety and the an"iety disorders =**. 8"@088:>. Hi%%sda%e5 N7' La2ren.e Er%ba$( Ass#.iates. Stein5 M. 15 Wa%+er5 7. R5 H F#rde5 D. R5 =3@@9>. Settin& dia&n#sti. t/res/#%ds 6#r s#.ia% */#bia' C#nsiderati#ns 6r#( a .#(($nity st$dy #6 s#.ia% an-iety. %merican ournal of +sychiatry# 69:#9!;093 . Ste+etee5 G5 H 1ar%#25 D. H. = !! >. Obsessi,e0.#(*$%si,e dis#rder. In D. H. 1ar%#25 %n"iety and its disorders =**. "3?0""!>. Ne2 Y#r+' G$i%6#rd. Tay%#r5 C. 15 S/ei+/5 75 A&ras5 W S5 R#t/5 W. T5 Mar&ra65 75 E/%ers5 A5 Madd#.+5 R. 75 H G#ssard5 D. =3@;?>. A(b$%at#ry /eart rate ./an&es in *atients 2it/ *ani. atta.+s. %merican ournal of +sychiatry# 6;?# 98;09; .

289 W"LL"AM T$rner5 S. M5 1eide%5 D5 H Stan%ey5 M. A. =3@@ >. Are #bsessi#na% t/#$&/ts and 2#rry di66erent .#&niti,e */en#(enaI 1linical +sychology (eview# 6:# "80 8!. Wa%+5 R. D5 =3@"?>. Se%6 ratin&s #6 6ear in a 6ear0 in,#+in& sit$ati#n. ournal of %bnormal and 'ocial +sychology# 9:# 383038;. We%%s5 A5 H Pa*a&e#r&i#$5 C. =3@@;>. Re%ati#ns/i*s bet2een 2#rry5 #bsessi,e0.#(*$%si,e sy(*t#(s and (eta0 .#&niti,e be%ie6s. $ehaviour (esearch and Therapy# ?E# ;@@0@3:. W/ite5 ). S5 H 1ar%#25 D. H. = !! >. Pani. dis#rder and a&#ra*/#bia. In D. H. 1ar%#25 %n"iety and its disorders =**. : ;0:8@>. Ne2 Y#r+' G$i%6#rd. Wi%%ia(s5 S. L. =in *re*arati#n>. The case against an"iety disorders. Wi%%ia(s5 S. L. =3@;">. On t/e nat$re and (eas$re(ent #6 a&#ra*/#bia. +rogress in $ehavior Modification# 6@# 3!@0399. Wi%%ia(s5 S. L. =3@;?5 A$&$st>. Se%60a**raisa% deter(inants #6 de6ensi,e be/a,i#r and e(#ti#na% ar#$sa%. In R. Gane%%en =C/air>5 %goraphobia5 1ognitive contributions. Sy(*#si$( .#nd$.ted at t/e (eetin& #6 t/e A(eri.an Psy./#%#&i.a% Ass#.iati#n5 Was/in&t#n5 DC. Wi%%ia(s5 S. L. =3@;8>. On an-iety and */#bia. ournal of %n"iety Disorders# 6# 3?303;!. Wi%%ia(s5 S. L. =3@@!>. G$ided (astery treat(ent #6 a&#ra*/#bia' 1ey#nd sti($%$s e-*#s$re. +rogress in $ehavior Modification# :E# ;@03 3. Wi%%ia(s5 S. L. =3@@">. Se%60e66i.a.y5 an-iety5 and */#bi. dis#rders. In 7. Madd$- =Ed.>5 'elf3efficacy# adaptation# and ad4ustment5 Theory# research# and application =**. ?@03!8>. Ne2 Y#r+' P%en$(. Wi%%ia(s5 S. L. =3@@?a>. T/era*e$ti. ./an&es in */#bi. be/a,i#r are (ediated by ./an&es in *er.ei,ed se%60e66i.a.y. In R. Ra*ee =Ed.>5 1urrent controversies in the an"iety disorders =**. :990:?;>. Ne2 Y#r+' G$i%6#rd. Wi%%ia(s5 S. L. =3@@?b>. O,er.#(in& */#bia' Un.#ns.i#$s bi#in6#r(ati#na% de.#nditi#nin& #r .#ns.i#$s .#&niti,e rea**raisa%I In R. Ra*ee =Ed.>5 1urrent controversies in the an"iety disorders =**. :8:0:8?>. Ne2 Y#r+' G$i%6#rd. Wi%%ia(s5 S. L5 H Cer,#ne5 D. =3@@;>. S#.ia% .#&niti,e t/e#ries #6 *ers#na%ity. In D. E 1ar#ne5 M. Hersen5 H G 1. Gan Hasse%t =Eds.>5 %dvanced personality =**. 38:0 !8>. Ne2 Y#r+' P%en$(. Wi%%ia(s5 S. L5 D##se(an5 G5 H )%ei6ie%d5 E. =3@;9>. C#(*arati,e e66e.ti,eness #6 &$ided (astery and e-*#s$re treat(ents 6#r intra.tab%e */#bias. ournal of 1onsulting and 1linical +sychology# 9:# "!"0 "3;. Wi%%ia(s5 S. L5 H Fa%b#5 7. =3@@?>. C#&niti,e and *er6#r(an.e0based treat(ents 6#r *ani. atta.+s in *e#*%e 2it/ ,aryin& de&rees #6 a&#ra*/#bi. disabi%ity. $ehaviour (esearch and Therapy# ?;# ":0 ?9. Wi%%ia(s5 S. L5 H )inney5 P. 7. =3@@85 N#,e(ber>. Gariati#n in res*#nse t# a&#ra*/#bia treat(ent as a 6$n.ti#n #6 .a$sa% attrib$ti#ns 6#r *er6#r(an.e s$..ess. In S. 1#$./ard =C/air>5 /actors associated with failure in the treatment of panic disorder with agoraphobia. Sy(*#si$( at t/e (eetin& #6 t/e Ass#.iati#n 6#r Ad,an.e(ent #6

1e/a,i#r T/era*y5 Mia(i5 FL. Wi%%ia(s5 S. L5 )inney5 P. 75 H Fa%b#5 7. =3@;@>. Genera%iCati#n #6 t/era*e$ti. ./an&es in a&#ra*/#bia' T/e r#%e #6 *er.ei,ed se%60e66i.a.y. ournal of 1onsulting and 1linical +sychology# 9A# 9:?099 . Wi%%ia(s5 S. L5 )inney5 P. 75 Hara*5 S5 H Lieb(ann5 M. =3@@8>. T/#$&/ts #6 a&#ra*/#bi. *e#*%e d$rin& s.ary tas+s. ournal of %bnormal +sychology# 67E#9630" !. Wi%%ia(s5 S. L5 H La1er&e5 1. =3@@9>. Pani. dis#rder 2it/ a&#ra*/#bia. In C. G. Last H M. Hersen =Eds.>5 %dult behavior therapy casebook =**. 3!803 :>. Ne2 Y#r+' P%en$(. Wi%%ia(s5 S. L5 H Ra**#*#rt5 A. =3@;:>. C#&niti,e treat(ent in t/e nat$ra% en,ir#n(ent 6#r a&#ra*/#bi.s. $ehavior Therapy# 6;# @@0:3:. Wi%%ia(s5 S. L5 T$rner5 S. M5 H Peer5 D. F. =3@;">. G$ided (astery and *er6#r(an.e desensitiCati#n treat(ents 6#r se,ere a.r#*/#bia. ournal of 1onsulting and 1linical +sychology# 9?# :80 98. Wi%%ia(s5 S. L5 H Wats#n5 N. =3@;">. Per.ei,ed dan&er and *er.ei,ed se%60e66i.a.y as .#&niti,e deter(inants #6 a.r#*/#bi. be/a,i#r. $ehavior Therapy# 6E# :80 98. Wi%%ia(s5 S. L5 H Fane5 G. =3@;@>. G$ided (astery and sti($%$s e-*#s$re treat(ents 6#r se,ere *er6#r(an.e an-iety in a&#ra*/#bi.s. $ehaviour (esearch and Therapy# :A# :80 98. Wi%s#n5 ). G5 Sand%er5 L. S5 As($nds#n5 G. 7. G5 Edi&er5 7. M5 Larsen5 D. )5 H Wa%+er5 7. R. =3@@ >. Pani. atta.+s in t/e n#n.%ini.a% *#*$%ati#n' an e(*iri.a% a**r#a./ t# .ase identi6i.ati#n. ournal of %bnormal +sychology# 676# 9?!09?;. W#%*e5 7. =3@";>. +sychotherapy by reciprocal inhibition. Stan6#rd5 CA' Stan6#rd Uni,ersity Press. W#r%d Hea%t/ Or&aniCati#n =3@@ >. The 01D367 classification of mental and behavioural disorders5 1linical description and diagnostic guidelines. Gene,a' A$t/#r. Yar$ra0T#bias5 7. A5 H M.)ay5 D. = !! >. Obsessi,e .#(*$%si,e dis#rder and s./iC#*/renia' a .#&niti,e *ers*e.ti,e #6 s/ared *at/#%#&y. In R. O. Fr#st H G. Ste+etee =Eds.>5 1ognitive approaches to obsessions and compulsions5 Theory# assessment# and treatment <pp. "30 ?8>. O-6#rd' Per&a(#n. FaD#n.5 R. 15 H M.int#s/5 D. N. =3@@ >. E(#ti#ns resear./' s#(e *r#(isin& J$esti#ns and s#(e J$esti#nab%e *r#(ises. +sychological 'cience# ?# 8!089. Fane5 G5 H Wi%%ia(s5 S. L. =3@@:>. Per6#r(an.e0re%ated an-iety in a&#ra*/#bia' Treat(ent *r#.ed$res and .#&niti,e (e./anis(s #6 ./an&e. $ehavior Therapy# :;# ? "0?9:.

CHAPTER

8
M##d Dis#rders Ri.+ In&ra( University o f .ansas L$.y Trenary University o f 1olorado 8epression is not a re)ent p'enomenon. A.t'oug' des)riptions of )onditions resemb.ing de1 pression )an be found in t'e !.d #estament of t'e Bib.e$ it (as &ippo)rates in t'e fourt' )entury B.C. ('o 'ypot'esi4ed t'at me.an)'o.ia stemmed from an imba.an)e of b.a)- bi.e. E/en more modern )on)eptions of depression (ere suggested by Aretaeus of Cappado)ia around *9, A.8.$ ('o des)ribed me.an)'o.ia as being )'ara)teri4ed by sadness$ a tenden)y to(ard sui)ide$ fee.1 ings of indifferen)e$ and psy)'omotor agitation. "t (as not unti. t'e ear.y 9,t' )entury t'at t'eorists su)' as Abra'am 2*+**1*+?,3 and Freud 2*B<?1*+:+3 began to re)ogni4e t'e im1 portan)e of psy)'o.ogi)a. and emotiona. fa)tors in t'e de/e.opment of depression. #oday depression is not on.y (ide.y re)ogni4ed as a signifi)ant pub.i) 'ea.t' )on)ern$ but its pre/a.en)e rates are in)reasing so mu)' t'at some resear)'ers 'a/e argued t'at t'e pub.i) fa)es a depression epidemi) 2 e.igman$ *++,3. 8epression is asso)iated (it' a (ide /ariety of prob.ems in).uding so)ia. (it'dra(a.$ o))upationa. disabi.ity$ and interpersona. turmoi.. Furt'ermore$ depression is fre7uent.y a )'roni) )onditionC re.apse and re)urren)e rates are 7uite 'ig' 2&ammen$ *++* aC "ngram$ Miranda$ H ega.$ *++B3$ and indi/idua.s ('o experien)e re)urrent depression are a.so at )onsiderab.e ris- for de/e.oping dyst'ymia as (e.. as ot'er psy)'iatri) )onditions. Apart from t'e emotiona. misery t'at is .in-ed to depression$ sui)ide and sui)ide attempts are not un)ommon during depressi/e episodes. E/en o/er and abo/e sui)ide rates$ data a.so s'o( t'at depression is re.ated to ear.ier morta.ity 2 a4 H 8e(ey$ 9,,*3. "n t'is )'apter (e examine a number of fa)ets of mood disorders. A.t'oug' mood disorders in).ude bot' unipo.ar depression and bipo.ar disorder$ t'e ma6ority of our fo)us is on unipo.ar depression. We start by brief.y des)ribing t'e /arious mood disorders presented in t'e fourt' edition of t'e -iagnostic and .tatistical /anual of /ental -isorders 2Ameri)an %sy)'iatri) Asso)iation$ 9,,,3$ noting t'e approa)' ta-en by t'e 8 M as (e.. as dis)ussing some .imitations. We next mo/e to a dis)ussion of t'e epidemio.ogy of depression and t'en pro/ide some perspe)ti/es on gender differen)es and )u.tura. issues in depression. Fo..o(ing t'is$ (e examine t'eory and resear)' on depression. "n parti)u.ar$ (e dis)uss t'e ro.e of stress in depression (it' spe)ifi) referen)e to diat'esis1stress 'ypot'eses$ and t'en examine bio.ogi)a..y based mode.s 291

292 "N=RAM AN8 #RENARA of depression and psy)'o.ogi)a..y based mode.s. We )on).ude (it' an examination of data on t'e pre/ention of depression and data on bio.ogi)a. and psy)'o.ogi)a. approa)'es to treatment. DEFINITIONS AND DESCRIPTIONS OF MOOD DISORDERS Iss$es in De6inin& M##d Dis#rders %sy)'opat'o.ogi)a. )onstru)ts su)' as depression )an be /ie(ed in a /ariety of (ays. For instan)e$ Nur)ombe 2*++93 'as argued t'at t'e term depression )an be used to indi)ate a mood state$ a symptom or sign$ a syndrome )onsisting of a )onste..ation of symptoms$ a disorder t'at a..o(s for t'e identifi)ation of a group of indi/idua.s$ or a disease t'at is asso)iated (it' bio)'emi)a. or geneti) abnorma.ities. imi.ar.y$ @enda..$ &o..on$ Be)-$ &ammen$ and "ngram 2*+BD3 note t'at depression )an be a symptom 2e.g.$ being sad3$ a syndrome 2e.g.$ a )onste..ation of signs and symptoms t'at ).uster toget'er3$ or a menta. disorder. A.t'oug' ea)' use of t'ese definitions is a .egitimate des)riptor of a state or )ondition$ t'ey )an be t'e sour)e of )onfusion ('en used inter)'angeab.y. Adding to possib.e )onfusion$ a number of spe)ifi) subtypes of depression 'a/e been proposed. For instan)e$ a re.ati/e.y ear.y distin)tion differentiated bet(een rea)ti/e depressions$ ('i)' (ere t'oug't spe)ifi)a..y to be asso)iated (it' stressfu. e/ents$ and endogenous depression$ ('i)' (as .ess re.ated to stress and more asso)iated (it' internai dysregu.ation. Wit' fe( ex)eptions t'ere 'as been .itt.e agreement on t'e nature of spe)ifi) subtypes. #'is is not to suggest$ 'o(e/er$ t'at subtypes do not exist$ but rat'er t'at t'ese subtypes are diffi)u.t to pin do(n )on)eptua..y and empiri)a..y. "ndeed$ t'ere is (ide )onsensus t'at t'ere may be a number of types of depression$ and t'at depression itse.f is a .abe. for a 'eterogeneous group of )onditions t'at resu.t in a simi.ar symptom )onste..ation$ but t'at may 'a/e /ery different )auses and )ourses. 8espite t'is un)ertainty o/er t'e nature of t'e /arious types of depression$ t'e most (ide.y used set of definitions of depression is in)orporated in t'e Diagnostic 'tatistical Manual# fourt' edition 28 M1">1#R3$ of t'e Ameri)an %sy)'iatri) Asso)iation. #'e 8 M is a taxonomi) system of be'a/ior )ategori4ation. pe)ifi)a..y$ diagnosti) )ategories in t'e 8 M ref.e)t an attempt to de/e.op a taxonomy t'at differentiates and t'en ).assifies dysfun)tiona. be'a/ior. "t is important to note$ 'o(e/er$ t'at su)' taxonomi) systems are not fixed$ but rat'er$ e/o./e as )on)epts and paradigms s'ift and$ )orresponding.y$ be)ome more )omp.ex (it' a deeper appre)iation of natura. p'enomena. "ndeed$ psy)'iatri) taxonomy i..ustrates 6ust su)' an e/o.utionary pro)essC sin)e its introdu)tion in *+<9$ t'e 8 M 'as undergone four extensi/e re/isions (it' depression being defined in some('at different (ays in ea)' edition. DSM0De6ined Dia&n#ses Mood disorders )an be )on)eptua.i4ed as fa..ing into t(o main )ategories5 unipo.ar and bipo.ar disorders. #'e fo..o(ing represents t'e )ategori4ations of mood disorders as des)ribed by t'e Diagnostic 'tatistical Manual# fourt' edition 28 M1">1#R3. "n brief$ 8 M1"> in).udes diag1 noses for unipo.ar depression$ dyst'ymi) disorder$ bipo.ar disorder$ and )y).ot'ymi) disorder$ as (e.. as more minor )ategories$ ('i)' in).ude depressi/e disorder not ot'er(ise spe)ified$ bipo.ar disorder not ot'er(ise spe)ified$ mood disorder due to a genera. medi)a. )ondition$ substan)e1indu)ed mood disorder$ and mood disorder not ot'er(ise spe)ified. We fo)us 'ere on a brief des)ription of t'e ma6or )ategories of mood disorders.

;. MOOD DISORDERS 293 Unipolar Depression. "n unipo.ar depression$ an indi/idua. suffers from one or more ma6or depressi/e episodes. A ma6or depressi/e episode is denned as persisting for a period of at .east t(o (ee-s$ (it' t'e experien)e of at .east one of t(o )ardina. features. #'ese t(o )ardina. features are depressed mood and an'edonia$ ('i)' is denned as a .oss of p.easure in a)ti/ities t'at are usua..y en6oyab.e. "n tota.$ indi/idua.s must endorse fi/e of t'e fo..o(ing nine symptoms5 depressed mood$ an'edonia$ appetite or (eig't )'anges$ insomnia or 'ypersomnia$ psy)'omotor agitation or retardation$ .oss of energy$ fee.ings of (ort'.essness or gui.t$ diminis'ed abi.ity to )on)entrate or inde)ision$ or sui)ide ideation. "t is important to note t'at t'e depressed mood exemp.ifies a )'ange from t'e personGs norma. fun)tioning. "n addition$ symptoms and a.tered fun)tioning must be asso)iated (it' signifi)ant distress or impairment. Dysthymic Disorder. 8yst'ymi) disorder )an best be t'oug't of as a )'roni)$ .o(1grade depression t'at .asts for at .east t(o years. #'e same symptoms as in a ma6or depressi/e episode are present$ but in t'is )ase fe(er and .ess se/ere symptoms are needed for a diagnosis. Be)ause of t'e )'roni)ity of dyst'ymi) disorder$ t'e depressed mood and asso)iated symptoms often be)ome integrated into a personGs norma. fun)tioning 2Ameri)an %sy)'iatri) Asso)iation$ 9,,,3. A))ording to 8 M1">1#R$ after t'e first t(o years of depressed mood$ if a ma6or depressi/e episode a.so o))urs$ t'e )ombination is referred to as doub.e depression. $ipolar Disorder. Bipo.ar " and Bipo.ar "" are t(o main types of bipo.ar disorders. #'e presen)e of a mani) or mixed episode defines Bipo.ar ". A depressi/e episode does not 'a/e to o))ur to fa.. into t'is )ategory. A mani) episode is defined as a period of at .east one (ee- ('ere mood is abnorma..y expansi/e$ e.e/ated$ or irritab.e. #'ree 2or four if mood is irritab.e on.y3 out of se/en symptoms must a.so be endorsed5 inf.ated se.f1esteem or grandiosity$ de)reased need for s.eep$ more ta.-ati/e t'an usua.$ f.ig't of ideas$ distra)tibi.ity$ in)rease in goa.1dire)ted a)ti/ity$ and ex)essi/e in/o./ement in p.easurab.e a)ti/ities t'at are .i-e.y to 'a/e ad/erse )onse7uen)es. "ndi/idua.s (it' Bipo.ar " disorder may engage in a number of ris-y a)ti/ities and often ex'ibit poor 6udgment. Besides a mani) episode$ one may a.so 'a/e a mixed episode to 7ua.ify for Bipo.ar " disorder. A mixed episode .asts at .east a (ee-$ during ('i)' t'e )riteria are met for bot' a ma6or depressi/e episode and a mani) episode on a dai.y basis (it' t'e indi/idua.Gs mood state a.ternating bet(een t'ese extremes. Bipo.ar "" disorder is )'ara)teri4ed by one or more ma6or depressi/e episodes a))ompanied by at .east one 'ypomani) episode. #'oug' simi.ar to a mani) episode$ 'ypomani) symptoms .ast for a minimum of four days$ as opposed to t'e se/en re7uired for mania. "ndi/idua.s endorse t'e same number and types of symptoms as (it' mania. Fun)tioning is not as great.y impaired$ and psy)'oti) features are not present. 1yclothymic Disorder. Li-e dyst'ymia$ )y).ot'ymia is a )'roni) disorder 2.asting at .east t(o years3 during ('i)' an indi/idua. f.u)tuates bet(een depressi/e and 'ypomani) symptoms. Bot' ).asses of symptoms are of insuffi)ient number$ se/erity$ and duration to (arrant a diagnosis of a ma6or depressi/e episode or 'ypomania. No ma6or depressi/e$ mani)$ or mixed episode )an o))ur during t'e first t(o years$ t'oug' t'ey may )o1o))ur (it' t'e )y).ot'ymia on)e t'is initia. period 'as passed. P#tentia% Pr#b%e(s Wit/ t/e DSM C%assi6i.ati#n Syste( #'e 8 M represents one important (ay of )on)eptua.i4ing depression. "ndeed$ it 'as be)ome t'e 0go.d standard0 in psy)'opat'o.ogy resear)' and pra)ti)eEresear)'ers design t'eir studies

294 INGRAM AND TRENARY based on 8 M )riteria$ and ).ini)ians gi/e t'eir patients a diagnosis a.igned (it' t'e )riteria in t'is manua.. But it is important to understand t'at t'e ).assifi)ation system of t'e 8 M is on.y one of many potentia. (ays to )on)eptua.i4e t'e )onstru)t of depression. #'e t(o ma6or (ays to /ie( depression are )ategori)a..y and dimensiona..y. #'e 8 M uses a )ategori)a. perspe)ti/e$ de.ineating distin)t ).asses of mood disorders (it' definiti/e boundaries among t'em. Categori)a. /ie(s )an be /ie(ed as eit'er1or )onstru)tsEeit'er an indi/idua. is depressed or is not$ (it' .itt.e in bet(een. Moreo/er$ ).ini)a. depression is seen as 7ua.itati/e.y distin)t from t'e mi.d.y depressed mood states t'at many peop.e experien)e. Con/erse.y$ t'e dimensiona. approa)' /ie(s t'ese disorders as existing on a )ontinuum$ ranging from .ess to more se/ere$ (it'out any ).ear and definiti/e boundaries or )ategories. Li-e any ).assifi)ation system$ t'e )ategori)a. met'od 'as bot' ad/antages and disad/antages. "n t'e (ay of ad/antages$ distin)t )ategories fa)i.itate ).ear )ommuni)ation about a parti)u.ar disorder. For examp.e$ t'e se/erity and genera. ).ini)a. pi)ture are fair.y ).ear based on t'e .anguage t'at t'e 8 M pro/ides$ ('i)' pro/ides a )ommon .anguage bet(een and among ).ini)ians and resear)'ers. &en)e$ t'e )ategori)a. perspe)ti/e simp.ifies t'e )on)eptua.i4ation of psy)'opat'o.ogy and expedites ).ini)a. and resear)' de)ision ma-ing 2#ru..$ Widiger$ H =ut'rie$ *++,3. !n t'e ot'er 'and$ prob.ems in'erent in su)' a system dea. (it' t'e fa)t t'at )ategories for)e a /ague and un).ear p'enomenon into spe)ifi) and fixed )ompartments. Mood states are seen as 7ua.itati/e.y different from one anot'er$ ('en in fa)t t'ey$ or at .east /arying )omponents of t'em$ mig't exist on a )ontinuum. imi.ar.y$ 8 M uses some('at arbitrary )utoffs and diagnosti) symptoms. For examp.e$ ('y must someone 'a/e at .east fi/e out of nine possib.e symptoms 2('y not four or sixF3$ and ('y are ot'er features of t'e disorder 2e.g.$ so)ia. (it'dra(a.3 not among t'e possib.e symptomsF A re.ated point 'inges on t'e apparent simp.i)ity of a basi) diagnosis. A.t'oug' a )ategori)a. system ma-es )ommuni)ation easier$ it may a.so disguise important differen)es. #(o diagnoses of ma6or depressi/e episode )ou.d manifest in /ery different manners$ 'a/ing )omp.ete.y distin)t etio.ogies$ symptom patterns$ ).ini)a. )ourses$ and treatment out)omes. C#$rse #6 M##d Dis#rders Ma6or depressi/e episode symptoms often de/e.op o/er days to (ee-s$ often beginning (it' a mi.d form t'at .ater es)a.ates into a fu..1b.o(n episode. #'e .engt' of ea)' indi/idua. episode )an /ary great.y from person to person$ but untreated depressi/e disorders )an .ast as .ong as six mont's to a year$ and in some )ases indi/idua.s may experien)e signifi)ant symptoms for up to t(o years 2see =ood(in H Jamison$ *++,3. Many indi/idua.s )omp.ete.y re)o/er from t'eir symptoms$ entering a period of fu.. remission. Approximate.y 9,P to :,P of indi/idua.s experien)ing a ma6or depressi/e disorder remit on.y partia..y from t'e episode and remain in a .o(1grade depressi/e state. Unipolar Depression. Unipo.ar depression 'as an a/erage age of onset in t'e ear.y1to mid19,s. #ypi)a..y$ t'e number of pre/ious episodes is a good predi)tor of t'e probabi.ity of future episodes. imi.ar.y$ periods of remission tend to s'orten (it' ea)' passing episode. More t'an B,P of indi/idua.s ('o experien)e a ma6or depressi/e episode (i.. experien)e re)urrent episodes 2@ess.er$ 9,,93. "ndi/idua.s (it' on.y partia. remission are more .i-e.y to de/e.op anot'er episode$ as (e.. as being more .i-e.y to remit on.y partia..y in bet(een future episodes. #'e 8 M1">1#R notes t'at natura.isti) studies 'a/e s'o(n t'at one year after being diagnosed

(it' a ma6or depressi/e episode$ ;,P of indi/idua.s sti.. met )riteria for t'e ma6or depressi/e episode$ 9,P of indi/idua.s (ere in partia. remission$ and t'e remaining ;,PW e/iden)ed no symptoms of depression 2Ameri)an %sy)'iatri) Asso)iation$ 9,,,3.

;. MOOD DISORDERS 296 $ipolar Disorder. Among indi/idua.s diagnosed (it' Bipo.ar " disorder$ approximate.y +,P 'a/e more t'an one mani) episode. E/en t'oug' Bipo.ar " does not ne)essari.y in).ude a ma6or depressi/e episode$ ?,P to D,P of mani) 2or 'ypomani) in Bipo.ar ""3 episodes o))ur immediate.y before or after a ma6or depressi/e episode. #ypi)a..y$ indi/idua.s (it' bipo.ar disorders 'a/e more tota. episodes 2in).uding bot' depressi/e and mani) or 'ypomani)3 in t'eir .i/es t'an t'ose (it' unipo.ar depression. #'e time bet(een episodes tends to de)rease (it' in)reasing age. "n addition$ t'e presen)e of psy)'oti) features indi)ates a greater .i-e.i'ood of in)omp.ete re)o/ery bet(een episodes$ as (e.. as indi)ating a greater propensity to(ard psy)'oti) features in subse7uent mani) episodes. E*ide(i#%#&y5 Gender5 and C$%t$re !pidemiology. %oint pre/a.en)e rates of )urrent ma6or depression are found to be 2E to ;P for adu.ts 2@ess.er$ 9,,93 2point pre/a.en)e rates estimate t'e number of peop.e at a parti)u.ar point in time ('o are experien)ing t'e disorder3. From anot'er perspe)ti/e$ .ifetime pre/a.en)e rates for ma6or depression 'a/e been found to range any('ere from ?P to 9<P 2@ess.er$ 9,,93. Resear)'ers spe)u.ate t'ree reasons for t'is (ide /ariation in .ifetime pre/a.en)e estimates. #'e first is a true in)rease in t'e in)iden)e of depression in more re)ent )o'orts. e)ond$ t'ese more re)ent )o'orts are a.so more (i..ing to admit t'eir depressi/e symptoms$ t'ereby .eading to an in)rease in pre/a.en)e findings. Last$ met'odo.ogi)a. differen)es bet(een diagnosti) inter/ie(s may a))ount for t'e dis)repan)y5 More re)ent studies use more refined diagnosti) inter/ie(s t'at are better ab.e to dete)t mood disorders 2@ess.er$ 9,,93. Epidemio.ogi)a. studies 'a/e a.so found substantia. )omorbidity bet(een depression and ot'er disorders. #'e Epidemio.ogi) Cat)'ment Area tudy 2EC 3 and t'e Nationa. Comorbidity ur/ey 2NC 3 are t(o .arge epidemio.ogi)a. studies t'at des)ribe depression. Bot' use diagnosti) inter/ie(s in assessing t'e popu.ation$ and bot' s'o( )omorbidity rates of approx1 imate.y D<P 2@ess.er$ 9,,93. #'e most fre7uent Axis " )omorbid 2or )o1o))urring3 )onditions (it' depression are anxiety disorders$ parti)u.ar.y genera.i4ed anxiety disorder$ pani) disorder$ and posttraumati) stress disorder. Gender Differences. Mood disorders$ parti)u.ar.y unipo.ar depression$ are )'ara)teri4ed by substantia. gender differen)es. About t(i)e as many (omen as men suffer from ma6or depression or dyst'ymia. Moreo/er$ t'is gender differen)e persists a)ross demograp'i) and )u.tura. groups as (e.. as in different )ountries 2No.en1&oe-sema$ 9,,93. =ender differen)es seem to arise around t'e age of *9 or *: years 2possib.y )oin)iding (it' t'e onset of puberty3C before t'is time depression is un)ommon$ but boys and gir.s are e7ua..y affe)ted. Additiona..y$ data from epidemio.ogi)a. studies s'o( t'at adu.t gender differen)es are due to a greater number of initia. onsets of depression in (omen$ as opposed to a differen)e in .engt' or fre7uen)y of depressi/e episodes 2No.en1&oe-sema$ 9,,93. "nteresting.y$ fe( gender differen)es in in)iden)e of bipo.ar disorders are found. ome differen)es$ 'o(e/er$ 'a/e been found in t'e type of bipo.ar disorder experien)ed. For examp.e$ (omen are typi)a..y diagnosed first (it' a ma6or depressi/e episode and men (it' a mani) episode. Corresponding.y$ (omen typi)a..y 'a/e more ma6or depressi/e episodes ('ereas men typi)a..y 'a/e more mani) episodes 2Ameri)an %sy)'iatri) Asso)iation$ 9,,,3. 1ultural /actors. Cu.ture )an affe)t bot' t'e )on)eptua.i4ation and manifestation of depression. #'ere are t(o main approa)'es t'at resear)'ers ta-e to understand t'ese )u.tura..y based manifestations5 et'nograp'i) and biomedi)a.. #'e et'nograp'i) approa)'$ typi)a..y ta-en by

ant'ropo.ogists$ argues t'at persons in non1Western )u.tures may indeed experien)e

298 INGRAM AND TRENARY t'e same symptoms t'at are denned as depressi/e in Western )u.tures$ but t'at t'ese symptoms may 'a/e different meanings. "n )ontrast$ t'e biomedi)a. approa)' assumes t'at if t'e parti)u.ar symptoms are present$ t'en t'e disorder exists. For examp.e$ numerous studies of depressi/e symptomato.ogy in non1Western )u.tures 'a/e do)umented 'ig' rates of depressi/e disorders as t'ey are denned by t'e )onste..ation of depressi/e symptoms arti)u.ated in t'e 8 M. A.t'oug' t'e biomedi)a. approa)' does not entire.y dis)ount t'e ro.e of )u.ture$ )u.tura. meanings of symptoms are de1emp'asi4ed. %sy)'o.ogists and psy)'iatrists typi)a..y use t'e biomedi)a. approa)'. #'ere are signifi)ant.y /aried meanings of depression a)ross )u.tures. Western )u.ture 'as inf.uen)ed t'e definition of depression in t'ree (ays 2#sai H C'entso/a18utton$ 9,,93. First$ Western )u.ture /a.ues positi/e emotions and fee.ing good about onese.f$ and definitions and diagnoses of depression 'inge on t'e absen)e of su)' positi/e fee.ings. e)ond$ Western )u.tures tend to /ie( a 'ea.t'y indi/idua. as independent and autonomous$ t'ereby exp.aining depression as an interna. disturban)e. "n non1Western )u.tures$ ('ere )onne)tedness among peop.e is apt to be more 'ig'.y /a.ued t'an indi/iduation$ depressi/e symptoms are more .i-e.y to be seen as t'e resu.t of interpersona. diffi)u.ties. #'is is not to say t'at depression in Western so)ieties does not in/o./e interpersona. diffi)u.ties$ but rat'er t'at )ompared to t'e non1Western (or.d$ autonomy is .i-e.y to be /a.ued more t'an inter)onne)tedness. Last.y$ Western )u.ture /ie(s depression as t'e resu.t of disturban)e in eit'er t'e mind or t'e bodyC in )ontrast$ non1Western )u.tures 'a/e a more 'o.isti) perspe)ti/e in ('i)' mind and body are inextri)ab.y )onne)ted. #'ese differen)es )ou.d .ead to different symptom presentations. For examp.e$ indi/idua.s in non1Western )u.tures typi)a..y present more somati4ation t'an do indi/idua.s in Western )u.tures. #'us$ ('i.e )ross1 )u.tura. resear)' 'as identified a )ore expression of depressi/e disorders t'at exist in /arying degrees a)ross )u.tures$ it appears t'at symptomato.ogy is more 0psy)'o.ogi)a.0 in Western so)ieties and more 0somati4ed0 in non1Western so)ieties. Numerous fa)tors )an be responsib.e for /ariations in pre/a.en)e rates and fre7uen)y of symptoms a)ross )u.tures$ et'ni) groups$ and e/en geograp'i) .o)ations 2e.g.$ a)tua. differen)es in depression ratesC /arying degrees of po/ertyC different (ays of t'in-ing about depressionC depressi/e symptoms in).uded in and defined as anot'er i..nessC met'odo.ogi)a. differen)es in t'e assessment of depression$ et).3 2#sai H C'entso/a18utton$ 9,,93. "t is t'us important to -eep in mind t'at depression goes beyond 8 MGs definition and its manner of operationa.i4ing t'e )onstru)t and may 'a/e /ery different meanings in different )u.tura. groups. THEORY AND RESEARCH IN DEPRESSION =enes$ bio)'emistry$ so)ia. s-i..s$ negati/e .ife e/ents$ interpersona. intera)tions$ and )ogniti/e and affe)ti/e pro)esses are a.. in/o./ed in /arying (ays and degrees in t'e de/e.opment and )ourse of depression. &o(e/er$ distin)tions among t'ese /arying approa)'es to depression 'a/e be)ome in)reasing.y b.urred. For examp.e$ .ife e/ents are re)ogni4ed as t'e )ornerstone in many episodes of depression$ but /arious .ife e/ent mode.s no( attempt exp.i)it.y to integrate notions of /u.nerabi.ity$ )ogniti/e mediation$ interpersona. be'a/ior$ and brain fun)tion. &o(e/er$ a.t'oug' some progress 'as been made to(ard an integration of t'e /arious aspe)ts of depression$ fe( integrati/e mode.s of depression exist. #'us$ in t'is )'apter (e (i.. examine )ontemporary approa)'es a))ording to t'eir sing.e1/ariab.e points of origin$ but it is important to bear in mind t'at e/en t'oug' (e indi/idua..y des)ribe t'ese /arious origins$ t'ey in fa)t intera)t to /arying degrees in different )ases of depression.

;. M!!8 8" !R8ER 299 T/e R#%e #6 Stress in De*ressi#n #'e .in- bet(een an ad/erse so)ia. en/ironment and depression 'as been re)ogni4ed for )enturies. A.t'oug' t'ere are a number of different aspe)ts of so)ia. ad/ersity 2e.g.$ po/erty3$ stressfu. .ife e/ents are typi)a..y )onsidered to be a )ore )orre.ate of depression. #'e ma6ority of resear)' )onsistent.y finds a strong re.ations'ip bet(een t'e experien)e of stressfu. .ife e/ents and t'e onset of depression 2Monroe H &ad6iyanna-is$ 9,,93. E/en t'oug' t'e .in- bet(een stress and depression is (e.. do)umented$ t'e nature of t'is .in- is )omp.ex and far from )omp.ete.y understood. tress is anyt'ing but a simp.e )on)ept$ and it defies )ompre'ensi/e exposition in a sing.e )'apter. Aet$ (e (i.. dis)uss se/era. important t'emes and 7uestions t'at are important to re)ogni4e in understanding t'e re.ations'ip bet(een stress and depression. A.t'oug' most mode.s emp'asi4e t'e ro.e of stress in t'e etio.ogy of depression$ (e a.so need to as- about t'e ro.e stress p.ays in different subtypes of depression and in t'e )ourse of depression 2e.g.$ degree and duration of symptoms$ remission and re)o/ery$ re.apse or re)urren)e3. 2Monroe H &ad6iyanna-is$ 9,,93. E/en t'is dis)ussion$ 'o(e/er$ bare.y tou)'es on t'e )omp.exities of stress. For examp.e$ )an depression on.y be triggered by ma6or .ife e/ents$ or is a series of )'roni) minor .ife e/ents suffi)ientF tress may )onsist of e/ents t'at independent.y 'appen to peop.e$ but depressed indi/idua.s a.so may p.ay a ro.e in generating stress t'at pro.ongs depression 2&ammen$ *++*b3. 8ata 'a/e suggested t'at approximate.y <,P of depressed indi/idua.s experien)ed se/ere stress before onset 2Ma4ure$ *++B3. u)' data s'o( t'at stress p.ays a ro.e in depression$ but t'ey a.so s'o( t'at ot'er fa)tors are important. For examp.e$ not a.. indi/idua.s ('o experien)e signifi)ant stress de/e.op depression$ nor do a.. indi/idua.s ('o de/e.op depression experien)e signifi)ant stress. #o a))ount for t'is differen)e$ most modern t'eories of depression re.y on diat'esis1stress perspe)ti/es. 8iat'esis refers to a predisposition$ or /u.nerabi.ity$ to an i..ness$ and a.t'oug' not a.. mode.s of depression emp'asi4e a diat'esis$ most )ontemporary t'eories do ma-e use of t'e idea to some degree. #'ere is a.so genera. agreement t'at e/ents per)ei/ed as stressfu. trigger /u.nerabi.ity pro)esses t'at bring about depression 2"ngram et a..$ *++B3. #'e nature of t'e diat'esis1stress re.ations'ip is )omp.ex. ome mode.s$ for examp.e$ suggest an in/erse re.ations'ip bet(een stress and diat'eses$ su)' t'at as t'e degree or se/erity of t'e diat'esis in)reases$ .ess stress is ne)essary to initiate a depressi/e episode 2"ngram et a..$ *++B3. A.ternati/e.y$ some perspe)ti/es argue t'at bot' se/ere stress and a strong diat'esis are ne)essary to e.i)it depression 2Monroe H &ad6iyanna-is$ 9,,93. W'ate/er its nature$ t'e diat'esis1stress idea is one t'at (e (i.. )ome ba)- to fre7uent.y as (e dis)uss t'eory and resear)' in depression. De*ressi#n M#de%s and A**r#a./es #'eory and resear)' on depression is bot' remar-ab.y abundant and remar-ab.y di/erse. Nu1 merous t'eories of depression 'a/e been proposed and .itera..y t'ousands of empiri)a. reports examining /arious aspe)ts of depression 'a/e been pub.is'ed in psy)'o.ogi)a. and psy)'iatri) 6ourna.s. #'ese t'eories and resear)' span a /ariety of different mode.s of depression ranging from bio.ogi)a. to psy)'o.ogi)a. to so)ia.Len/ironmenta.. We re/ie( 'ere t'e ma6or mode.s$ t'eories$ and important findings t'at may be informati/e about su)' )ausa. fa)tors. 1i#(edi.a% M#de%s Biomedi)a. mode.s en)ompass se/era. different areas of assumption and in7uiry. #'ree re.ated approa)'es are geneti)$ bio.ogi)a.$ and neuros)ien)e perspe)ti/es.

300 INGRAM AND TRENARY Genetic %pproaches. =eneti) mode.s argue t'at at .east some of t'e /arian)e in t'e de/e.opment of depression is .in-ed to geneti) fa)tors 2Wa..a)e$ )'neider H M)=uffin$ 9,,93. 8ata t'at inform geneti) mode.s )ome from one of t'ree different sour)es5 fami.y studies$ t(in studies$ and adoption studies. Fami.y study met'ods are based on t'e obser/ation t'at depression runs in fami.ies 2&ammen$ *++*a3 and t'at to t'e extent t'at depression /u.nerabi.ity is in'erited$ mood1 disorders s'ou.d ).uster (it'in a fami.y. #'e most dire)t approa)' to e/a.uating t'is ).ustering is to inter/ie( fami.y members using a standardi4ed diagnosti) inter/ie( to determine t'e number and type of mood1re.ated disorders t'at o))ur among re.ati/es 2Faraone$ #suang$ H #suang$ *+++3. #'e more fami.ia. 'istory t'ere is of mood disorders$ t'e more e/iden)e t'ere is t'at t'e disorder$ or t'e propensity to t'e disorder$ is in'erited. &o(e/er$ be)ause fami.ies s'are not on.y genes but a.so s'are en/ironments$ fami.y studies 'a/e diffi)u.ty disentang.ing geneti) fa)tors from en/ironmenta. fa)tors. #(in studies are in some respe)ts an extension of fami.y studies$ but )ompare )on)ordan)e rates for mono4ygoti) 2identi)a.3 t(ins$ ('o are geneti)a..y identi)a. 2*,,P s'ared genes3$ to di4ygoti) 2fraterna.3 t(ins ('ose genes are simi.ar 2about <,P on a/erage3 but not identi)a.. Con)ordan)e rates refer to t'e .i-e.i'ood t'at bot' t(ins (i.. be diagnosed (it' t'e disorderC to t'e extent t'at geneti)a..y identi)a. mono4ygoti) t(ins 'a/e 'ig'er )on)ordan)e rates t'an geneti)a..y simi.ar di4ygoti) t(ins$ geneti) fa)tors are t'oug't to p.ay a signifi)ant ro.e in t'e disorder. For examp.e$ M)=uffin$ @at4$ and Rut'erford 2*++*3 found )on)ordan)e rates of < BP in mono4ygoti) t(ins as )ompared to 9BP in di4ygoti) t(ins. Li-e(ise$ @end.erNea.e$ @ess.er$ &eat'$ and Ea/es 2*++93 found rates of ;;P in mono4ygoti) t(ins and *+P in di4ygoti) t(ins. "n bot' )ases t'e degree of )on)ordan)e (as about t(i)e as 'ig' for mono4ygoti) t(ins and t'us strong.y suggests a geneti) )omponent to depression. A.t'oug' superior to fami.y studies$ t(in studies are not (it'out .imitations. For examp.e$ t(in studies re.y on t'e assumption t'at en/ironments are identi)a. for t(ins$ but t'is may not a.(ays be t'e )ase if t(ins ('o are identi)a. in appearan)e are treated more simi.ar.y t'an t(ins ('o .oo- .i-e same1aged sib.ings. &en)e$ en/ironment )annot be )omp.ete.y ru.ed out as a )ontributing fa)tor in )on)ordan)e rates$ a.t'oug' en/ironmenta. inf.uen)es are in most )ases probab.y reasonab.y simi.ar 2@end.er H =ardner$ *++B3. !t'er met'odo.ogi)a. issues 2e.g.$ sma.. samp.es in many studies$ 7uestions about genera.i4ibi.ity to nont(ins3 may a.so .imit t'e /a.idity of t(in studies 2Wa..a)e et a..$ 9,,93. #'e most po(erfu. geneti) met'od is t'e adoption study. Adopted )'i.dren are geneti)a..y simi.ar to t'eir bio.ogi)a. parents but 'a/e not'ing geneti)a..y in )ommon (it' t'eir adopti/e parents. #'ey s'are$ 'o(e/er$ a psy)'oso)ia. en/ironment (it' t'e adopted fami.ies. E/iden)e for a geneti) ro.e in depression is t'us found ('en adopted )'i.dren (it' a bio.ogi)a. fami.y 'istory of depression are a.so more .i-e.y t'an adopted )'i.dren (it'out a bio.ogi)a. fami.y 'istory of depression to experien)e a mood disorder. #'is finding is parti)u.ar.y true if )'i.dren are adopted at a young age and 'a/e 'ad .ess opportunity to be exposed to t'e psy)'oso)ia. en/ironment of t'e bio.ogi)a. fami.y$ ('i)' may be )onfounded (it' pure.y geneti) inf.uen)es. #'e ma6or disad/antage of t'ese studies is pragmati) in t'at t'ey are )ost.y and diffi)u.t to )ondu)t. As a resu.t$ re.ati/e.y fe( adoption studies on geneti) fa)tors in depression 'a/e been pub.is'ed$ and t'ose t'at 'a/e been pub.is'ed suffer from t'e types of prob.ems t'at often resu.t from .ogisti)a..y diffi)u.t1to1)ondu)t studies 2e.g.$ sma.. samp.e si4es3. A.t'oug' ea)' of t'ese met'ods 'as .imitations$ ('en ta-en toget'er$ t'ese data 'a/e pro/ided

some estimates of t'e degree to ('i)' depression is inf.uen)ed by genes. @end.er et a.. 2*++93 'a/e suggested t'at t'e 'eritab.y of mi.der forms of depression ranges any('ere from 9,P to ;<P$ (it' estimates for more se/ere )ases of depression 2e.g.$ t'ose re7uiring 'ospita.i4ation3 ranging as 'ig' as D,P 2Ma.'i$ Moore$ H M)=uffin$ 9,,,3. =eneti) )ontributions for re)urrent or )'roni) )ases of depression may a.so be 'ig'er t'an t'ose for sing.e episodes.

;. M!!8 8" !R8ER 302 #'us$ depending on type and se/erity of t'e disorder$ data suggest t'at t'e 'eritabi.ity of de1 pression is any('ere from moderate to 'ig'. E/en t'is range$ 'o(e/er$ is mitigated by ot'er fa)tors$ su)' as gender differen)esC for examp.e$ 'eritabi.ity appears to be stronger in (omen t'an in men. =i/en t'e )omp.exity of depression and its re)ogni4ed subtypes$ it is un.i-e.y t'at a sing.e gene (i.. e/er be found t'at is .in-ed to depression. Moreo/er$ it is important to )onsider ('at is being in'erited. As (e 'a/e noted$ t'ere is a reasonab.y broad )onsensus t'at depression is not in'erited$ but t'at a predisposition or /u.nerabi.ity to depression is. As (e a.so noted$ ot'er fa)tors su)' as stress determine ('et'er t'is sus)eptibi.ity e/er be)omes rea.i4ed in a diagnosab.e depressi/e disorder. #'us$ e/en t'oug' 'eritabi.ity does p.ay a potentia..y .arge ro.e in at .east some types of depression$ en/ironmenta. features a.so ).ear.y 'a/e a )onsiderab.e part in t'e etio.ogy of depression. =enes may set t'e stage more or .ess for depression and its /arious forms$ but )onsistent (it' diat'esis1stress )on)epts$ a /ariety of ot'er fa)tors are .i-e.y to determine ('et'er depression o))urs. $iological $ases o f Depression. Bio.ogi)a. fun)tioning in depression is e/ery bit as )omp.ex as t'e geneti) /ariab.es t'at inf.uen)e t'e disorder. #'is is part.y be)ause genes and bio.ogy are ).ose.y intert(ined but a.so be)ause bio.ogi)a. systems t'emse./es are )onne)ted in mu.tifa)eted and intera)ti/e (ays. Moreo/er$ bot' bio.ogi)a. fun)tion and geneti)s are intri)ate.y tied to brain stru)ture and fun)tioning$ ('i)' (e (i.. examine in t'e next se)tion. #'e ear.iest bio.ogi)a. /ie(s (ere re.ati/e.y straig'tfor(ard and suggested t'at defi)its in )ate)'o.amine norepinep'rine 2NE3 and indo.eamine serotonin 2<1&#3 (ere )ausa..y re.ated to depression 2 )'i.d-raut$ *+?<3. #'ese neurotransmitters (ere first suspe)ted to p.ay a ro.e in depression be)ause t'ey 'ad been found to )ontro. se/era. areas of p'ysi)a. fun)tioning 2e.g.$ s.eep and appetite3 t'at are sometimes disrupted in depression. 8efi)its in dopamine (ere suggested some('at .ater a.so to )ontribute to depressi/e disorders 2@orf H /an %raag$ *+D*3. &o(e/er$ a.t'oug' dysfun)tion in t'ese systems does appear to p.ay a ro.e in at .east in some forms of depression 2#'ase$ Jinda.$ H &o(.and$ 9,,93$ t'e re.ations'ip bet(een t'ese monoamines and ot'er bio.ogi)a. disturban)es no( appears to be mu)' more )omp.i)ated t'an t'e ear.y t'eories suggested. E/en t'oug' resear)' on bio.ogi)a. aspe)ts of depression is rapid.y e/o./ing$ )urrent t'in-ing )enters on se/era. possib.e areas of pat'op'ysio.ogi)a. pro)esses 2#'ase et a..$ 9,,93. For examp.e$ a subgroup of depressed indi/idua.s appears to ex)rete .o( .e/e.s of a metabo.ite for NE 2:1met'oxy1;'ydroxyp'eny.g.y)o.$ or M&%=3$ t'us suggesting t'at a redu)tion in NE may be in/o./ed in some depressions 2Ress.er H Nemeroff$ *+++3. !t'er studies 'a/e s'o(n t'at .o( .e/e.s of a metabo.ite for <1&# are found in some subgroups of depressed indi/idua.s 2Maes H Me.t4er$ *++<3. "nteresting.y$ diminis'ed <1&# fun)tion may be re.ated to be'a/iors t'at are )'ara)teristi) of some )ases of depression 2e.g.$ sui)ida.ity3$ a.t'oug' t'ese be'a/iors may )'ara)teri4e ot'er disorders as (e... For t'is reason$ <1&# disruption may be a more genera. defi)it in psy)'opat'o.ogy rat'er t'an one spe)ifi)a..y .in-ed to depression. #'ird$ 'ig' .e/e.s of C#rtis#% 2a 'ormone3 'a/e been found in some groups of depressed indi1 /idua.s. Cortiso. is regu.ated by t'e adrena. )ortex and is ex)reted in times of stress. &o(e/er$ C#rtis#% a.so returns to norma. .e/e.s ('en t'e indi/idua. is no .onger depressed. "nteresting.y$ ('en a synt'eti) C#rtis#% -no(n as dexamet'asone is administered$ nondepressed peop.e s'o( a suppression of natura..y o))urring Cortisol, a pro)edure -no(n as a dexamet'asone suppres1

sion test 28 #3. &o(e/er$ t'is suppression is not obser/ed in a subset of depressed peop.e. For t'ese parti)u.ar depressed indi/idua.s$ 'yper)ortiso. se)retion may ref.e)t an exaggerated stress response t'at is not seen in indi/idua.s ('o experien)e stress (it'out be)oming depressed. A.t'oug' t'e 8 # (as origina..y t'oug't to 'a/e great potentia. as a diagnosti) indi)ator of

304 "N=RAM AN8 #RENARA depression$ t'e fa)t t'at on.y some$ but not a..$ depressed peop.e fai. to suppress C#rtis#% 'as diminis'ed t'is ent'usiasm. Ne/ert'e.ess$ t'ese data do suggest t'at sustained or ex)essi/e C#rtis#% se)retion may ref.e)t an important bio.ogi)a. pro)ess in some forms of depression. ome e/iden)e suggests t'at s.eep neurop'ysio.ogy and )ir)adian r'yt'ms may be disturbed in depression. !t'er e/iden)e suggests t'at de)reased s.o( (a/e s.eep and t'e intensifi)ation of rapid eye mo/ement 2REM3 s.eep o))ur among depressed indi/idua.s. REM s.eep o))urs se/era. times t'roug'out t'e nig't at approximate.y +,1minute inter/a.s. ome resear)' suggests t'at t'e first REM s.eep inter/a. for some depressed peop.e o))urs ear.ier t'an t'e norma. +, minutes. Moreo/er$ some depressed peop.e s'o( e/iden)e of a.. t'ree s.eep abnorma.ities. u)' s.eep disturban)es$ a.ong (it' ot'er fa)tors su)' as 'yper)ortiso. ex)retion$ may ref.e)t a disruption in )ir)adian r'yt'ms$ a.t'oug' it is un).ear if t'is disruption p.ays an etio.ogi)a. ro.e in depression or if it is t'e resu.t of a more primary dysregu.ation in bio.ogi)a. fun)tioning. u)' data ).ear.y s'o( e/iden)e of bio.ogi)a. dysregu.ation in depression. &o(e/er$ se/era. 7ua.ifi)ations are in order. A.t'oug' data 'a/e s'o(n a /ariety of bio.ogi)a. pro)esses t'at appear to be disturbed in depression$ t'ese pro)esses do not )'ara)teri4e a.. )ases of depression$ nor are t'ey ne)essari.y spe)ifi) to depression. ome bio.ogi)a. pro)esses appear to be stab.e in some depressions$ su)' as de)reased <1&# and some s.eep disturban)es su)' as de)reased s.o( (a/e s.eep. !t'er pro)esses$ 'o(e/er$ appear to be more )'ara)teristi) of t'e depressed state 2e.g.$ 'yper)ortiso.3$ and tend to norma.i4e as indi/idua.s re)o/er. "n many )ases$ indi/idua.s ('o s'o( e/iden)e of t'ese diffuse bio.ogi)a. disturban)es typi)a..y are o.der$ more se/ere.y depressed$ 'a/e more /egetati/e symptoms$ and experien)e re)urrent episodes of depression. Moreo/er$ many of t'ese pro)esses may ref.e)t t'e effe)t of stress t'at is se/ere andLor sustained. #'ese studies do not suggest t'at some forms of depression 'a/e pure.y bio.ogi)a. )auses and t'at ot'ers 'a/e pure.y psy)'oso)ia. )auses. #'ey do suggest$ 'o(e/er 2a.ong (it' resu.ts s'o(ing t'at many of t'ese abnorma.ities run in fami.ies and t'us appear to 'a/e a geneti) )omponent3$ t'at some forms of depression 2parti)u.ar.y /ery se/ere forms3 may 'a/e a mu)' stronger bio.ogi)a. )omponent t'at ot'ers. %ffective -euroscience. Affe)ti/e neuros)ien)e fo)uses on t'e neura. pro)esses t'at are .in-ed to emotion. Resear)' in affe)ti/e neuros)ien)e uses a /ariety of met'ods su)' as examining t'e .in- bet(een brain damage and impaired fun)tioning. &o(e/er$ t'e use of imaging te)'ni7ues su)' as fun)tiona. magneti) resonan)e imaging 2fMR"3 'as be)ome in)reasing.y )ommon in re)ent years. fMR" )reates images of t'e oxygen in t'e b.ood f.o( to brain areas t'at are a)ti/e and )an t'us be used to assess t'e ro.e and fun)tion of brain stru)tures and regions during /arious tas-s. Mapping t'is a)ti/ation pro/ides a (indo( into 'o( t'e brain fun)tions in depressed 2and nondepressed3 states and )an t'us 'e.p to )'art t'e brain )ir)uitry t'at may be in/o./ed in depression. @no(.edge of t'is )ir)uitry may 'a/e imp.i)ations for understanding /arious patterns of )ogniti/e and be'a/iora. defi)its in depression and idea..y mig't a.so pro/ide insig't into t'e onset$ maintenan)e$ and remission of depression. Affe)ti/e neuros)ien)e approa)'es to depression usua..y 'a/e fo)used most attention on t'e prefronta. )ortex$ anterior )ingu.ate )ortex$ 'ippo)ampus$ and amygda.a 28a/idson$ %i414aga..i$ H Nits)'-e$ 9,,93. A.t'oug' t'ese stru)tures ser/e numerous fun)tions$ in genera.$ t'e prefronta. )ortex is t'at part of t'e )ortex t'at is most e/o./ed in primates and t'at p.ays a substantia. ro.e in goa.1dire)ted a)ti/ities su)' as p.anning and formu.ating strategies. #o a))omp.is' desired goa.s$ t'e prefronta. )ortex sends signa.s to ot'er parts of t'e brain$ in'ibiting some areas and

disin'ibiting ot'ers. #'e anterior )ingu.ate )ortex is typi)a..y in/o./ed in se.e)ti/e attention and emotion and t'us appears to be in/o./ed in t'e per)eption of emotiona..y re.e/ant information. #'e 'ippo)ampus is a part of t'e .imbi) system and is in/o./ed in t'e

B. M!!8 8" !R8ER 306 )onso.idation of memoryC it is .in-ed to t'e representation of emotion1e/o-ing e/ents$ ('i)' may be parti)u.ar.y important in understanding t'e neura. )ir)uitry under.ying an emotiona. state su)' as depression. #'e amygda.a is a.so part of t'e .imbi) system. #'is stru)ture is a.so in/o./ed in t'e memory for emotiona..y signifi)ant e/ents and is a.so )onne)ted to ot'er brain regions and ser/es to signa. to t'ese areas ('en stimu.i important to t'e person re7uire additiona. pro)essing 28a/idson$ %i44aga..i$ H Nits)'-e$ 9,,93. A.t'oug' -no(.edge of t'e brain )ir)uitry of depression is far from )omp.ete$ se/era. promising findings 'a/e emerged. For examp.e$ some depressed indi/idua.s ex'ibit de)reased a)ti/ation in t'e prefronta. )ortex 28re/ets$ *++B3$ parti)u.ar.y on t'e .eft side 28a/idson$ *++:3. #'is de)reased a)ti/ation may be responsib.e for t'e disruption of goa.1dire)ted a)ti/ities t'at fre7uent.y )'ara)teri4e depression 28 M1">3. "nteresting.y$ some studies 'a/e found t'at t'e young )'i.dren of depressed mot'ers ex'ibit a simi.ar pattern of .eft1side 'ypoa)ti/ation 2&ammen$ 9,,*3$ suggesting a geneti) .in- to t'is brain abnorma.ity. 8re/ets et a.. 2*++D3 reported t'at t'e prefronta. )orti)es of depressed indi/idua.s (it' a fami.y 'istory of depression (ere signifi)ant.y sma..er t'an t'e prefronta. )ortexes of nondepressed )ontro.s. No su)' differen)es (ere found in )omparisons bet(een depressed indi/idua.s (it'out a fami.y 'istory and norma. )ontro.s. #'ese findings offer more e/iden)e for a geneti) .in- in at .east in some forms of depression. 8e)reases in t'e a)ti/ation of t'e anterior )ingu.ate )ortex 'a/e a.so been found in depressed indi/idua.s and may be .in-ed to t'e so)ia. (it'dra(a.$ poor )oping$ and an'edonia t'at is sometimes seen in depression 28a/idson et a..$ 9,,93. ome data 'a/e a.so s'o(n redu)ed 'ippo)ampa. /o.ume in depressed patients. !ne 'ypot'esis )on)erning t'is redu)ed /o.ume is t'at t'e 'ippo)ampus may atrop'y be)ause it )ontains 'ig' .e/e.s of C#rtis#% 2a g.u)o)orti)oid3 re)eptorsC g.u)o)orti)oids$ ('i)' are -no(n to be neurotoxi)$ .ead to )e.. .oss. Be)ause t'e 'ippo)ampus is in/o./ed in en)oding en/ironmenta. )ontext$ one resu.t of t'is atrop'y may be defi)its in t'e abi.ity to pro)ess so)ia. information$ .eading to t'e preser/ation of depressed mood in situations t'at s'ou.d pro/o-e positi/e or neutra. affe)t 28a/idson et a..$ 9,,93. #'e 'ippo)ampus is strong.y )onne)ted to t'e amygda.a$ anot'er brain region ).ose.y .in-ed to depression 28re/ets$ 9,,*3. "n parti)u.ar$ t'e amygda.a 'as been s'o(n to be 'ypera)ti/ated in depressed indi/idua.s and may be responsib.e for t'e maintenan)e of t'e sad mood t'at is a 'a..mar- of depression 28oug'erty H Rau)'$ *++D3. Not on.y is t'e amygda.a .in-ed to t'e perse/ation of a sad mood$ amygda.a 'ypera)ti/ation may resu.t from t'e fai.ure of t'e prefronta. )ortex to in'ibit t'is region. 2 ieg.e$ tein'auer$ #'ase$ tenger$ H Carter$ 9,,93. Re)a.. t'at one fun)tion of t'e %FC$ ('i)' may be)ome 'ypoa)ti/e in depression$ is to regu.ate ot'er areas of t'e brain to initiate t'e attainment of goa.s. #'us fai.ure of t'e prefronta. )ortex to in'ibit t'e amygda.a may pre)ipitate t'e maintenan)e of emotiona. information pro)essing in depression t'at not on.y perpetuates a sad mood$ but a.so interferes (it' adapti/e fun)tioning. Moreo/er$ ieg.e et a.. 29,,93 'a/e s'o(n e/iden)e of sustained a)ti/ity of t'e amygda.a in depressed peop.e in a manner t'at is )onsistent (it' obser/ations of t'e rumination of negati/e information. Rumination 'as .ong been t'eori4ed to be an important pro)ess in depression 2Be)-$ *+?DC "ngram$ *+B;3. #'e prefronta. )ortex$ anterior )ingu.ate )ortex$ 'ippo)ampus$ and amygda.a form a )ir)uit t'at is extensi/e.y inter)onne)ted. Certain.y ot'er areas of t'e brain are in/o./ed in depression$ but t'is )ir)uit appears to p.ay a -ey ro.e in at .east some forms of depression and may 'a/e a

geneti) .in-. Mu)' remains to be .earned$ 'o(e/er$ about t'e neura. )ir)uitry of depression. For examp.e$ a.t'oug' some data 'a/e suggested t'at neura. defi)its )ontinue after depression 'as remitted$ it is sti.. un).ear if t'ese defi)its are .in-ed to t'e )ause of depression$ mig't )o1o))ur (it' depression$ or mig't arise as a resu.t of depression. Moreo/er$ be)ause t'ese brain regions

308 "N=RAM AN8 #RENARA are dense.y )onne)ted$ it is diffi)u.t to determine ('et'er one region is primari.y .in-ed to depression 2('ereas ot'er )onne)ted regions are of a more se)ondary nature3 and t'is primary region in turn affe)ts t'e ot'er )onne)ted areas of t'e brain. Li-e(ise$ t'e abnorma.ities .in-ed to depression may reside in t'e )onne)tions bet(een stru)tures rat'er t'an in t'e stru)tures t'emse./es. 8espite numerous 7uestions and t'e )omp.exity of t'e issues t'at are in'erent in affe)ti/e neuros)ien)e$ signifi)ant strides 'a/e been made in gaining some insig't into 'o( t'e brain fun)tions in depression. Psy./#s#.ia% A**r#a./es t# De*ressi#n' C#&niti,e M#de%s Cogniti/e approa)'es to t'e )on)eptua.i4ation$ assessment$ and treatment of depression 'a/e expanded rapid.y o/er t'e past se/era. de)ades and are probab.y t'e predominant psy)'oso)ia. approa)' to depression today. E/en t'oug' t'ere are se/era. spe)ifi) )ogniti/e mode.s of depression$ t'e primary assumption t'at under.ies a.. )ogniti/e mode.s is t'at )ertain )ogniti/e negati/e pro)esses are re.ated in some fas'ion to /u.nerabi.ity$ onset$ )ourse$ andLor a..e/iation of t'e disorder. 0rrational $elief Models. Ear.y t'eories emp'asi4ed a re.ati/e.y simp.e .inear asso)iation bet(een t'in-ing errors and t'e onset of emotiona..y troub.esome states. #'ese t'eories )an be tra)ed to t'e de/e.opment of t'e pioneering )ogniti/e1be'a/iora. inter/entions t'at fo)used on t'e treatment of psy)'o.ogi)a. dysfun)tion t'roug' pro)edures designed to )orre)t errors in t'in-ing. A.bert E..isG approa)' is probab.y t'e first of t'ese mode.s. "n t'e most re)ent re/ision of E..isG t'eory 2E..is$ *++?3$ 'e argues t'at depression1prone peop.e tend to 'o.d o/er.y rigid standards t'at are app.ied to oneGs o(n performan)e$ t'e performan)e of ot'ers$ and .ife e/ents. Be)ause t'ese standards are too rigid$ t'ey are )onsidered to be irrationa.. Conse7uent.y$ t'e person ('o 2irrationa..y3 expe)ts too mu)' of 'imse.f or 'erse.f$ ot'er peop.e$ or .ife in genera.$ is .i-e.y to be disappointed and$ u.timate.y$ be)ome depressed. )earned ,elplessness and ,opelessness Theory. #'e 'e.p.essness t'eory of depression e/o./ed from an ear.ier emp'asis on .earned 'e.p.essness in depression. #'is (or- began (it' e.igman$ ('o obser/ed t'at anima.s ('o (ere unab.e to )ontro. negati/e e/ents often de/e.oped be'a/ior t'at 0.oo-ed .i-e0 depressi/e symptoms. Based on t'ese obser/ations$ e.igman de/e.oped a t'eory of 'uman depression t'at fo)used on depressed indi/idua.sG expe)tations t'at t'ey (ere 'e.p.ess to )ontro. a/ersi/e out)omes 2see e.igman$ *+D<3. %er'aps be)ause of its intuiti/e appea. and apparent simp.i)ity$ .earned 'e.p.essness t'eory generated an enormous amount of resear)' 2Abramson$ e.igman$ H #easda.e$ *+DB3. E/en t'oug' mu)' of t'e resear)' on .earned 'e.p.essness (as supporti/e of t'e basi) tenants of t'e t'eory 2e.g.$ t'at depressed peop.e tended to disp.ay more features of 'e.p.essness t'an nondepressed peop.e3$ ot'er resear)' 'ig'.ig'ted some substantia. s'ort)omings. "n response to t'ese s'ort)omings$ t'e t'eory (as reformu.ated in *+DB as an attributiona. t'eory t'at fo)used on 'o( attributions about t'e )auses of e/ents (ere .in-ed to depression 2Abramson et a..$ *+DB3. "n parti)u.ar$ t'e t'eory proposed t'at ma-ing g.oba.$ stab.e$ and interna. attributions for negati/e e/ents and ma-ing spe)ifi)$ unstab.e$ externa. attributions for positi/e e/ents .eads to depression. "n *+B+$ Abramson$ Meta.s-y$ and A..oy 2*+B+3 refined t'is t'eory into t'e 'ope.essness t'eory of depression and suggested t'at 'ope.essness depression represented a spe)ifi) subtype of depression t'at is )aused by t'e expe)tation t'at 'ig'.y desired out)omes (i.. not o))ur$ or t'at 'ig'.y a/ersi/e out)omes (i.. o))ur and t'at no response a/ai.ab.e to t'e indi/idua. (i.. )'ange t'e .i-e.i'ood of t'ese out)omes.

B. M!!8 8" !R8ER 309 Dysfunctional 1ognitive 'chema Theories. #'e most (ide.y -no(n )ogniti/e mode. t'at fo)uses on dysfun)tiona. stru)tures (as proposed by Be)- 2*+?D3. #'e mode. 'as been e.aborated and refined se/era. times 2e.g.$ Be)-$ 9,,93$ but t'e basi) e.ements 'a/e remained t'e same. "n parti)u.ar$ t'e mode. argues t'at dysfun)tiona. )ogniti/e se.f1stru)tures$ or s)'emas$ are t'e )entra. e.ements in t'e onset and maintenan)e of depression. A s)'ema is a stored body of -no(.edge t'at intera)ts (it' in)oming information to inf.uen)e se.e)ti/e attention and memory sear)'. e.f1s)'emas organi4e t'e persona. meaning t'at indi/idua.s assign to information. "n t'e )ase of depression$ t'ese s)'emas in)orporate a signifi)ant amount of negati/e se.f1re.e/ant information and guide 'o( information is abstra)ted from so)ia. settings and pro)essed. #'at is$ t'e information to ('i)' attention is dra(n be)omes in)reasing.y )ongruent (it' t'e s)'emati) -no(.edge stru)tures dire)ting t'e sear)' 2 ega.$ *+BB3. As a resu.t$ t'ese dysfun)tiona. s)'emas be)ome se.f1perpetuating and in)reasing.y biased o/er time be)ause input t'at may ms)onfirm or )ontradi)t t'e information en)oded in a s)'ema re)ei/es insuffi)ient pro)essing. )'emas are a.so ).ose.y .in-ed (it' affe)ti/e stru)tures$ and in t'e )ase of depression$ are 'ypot'esi4ed to form t'e genesis of t'e disorder be)ause t'ey )ause and perpetuate negati/e )ogniti/e tenden)ies 2"ngram et a..$ *++B3. E/en t'oug' t'e fo)us of Be)-Gs t'eory is on s)'emas and negati/e t'in-ing in genera.$ 'e a.so 'ypot'esi4ed t(o spe)ifi) types of )on)epts represented (it'in )ogniti/e stru)tures t'at ref.e)t different subtypes of depression. "n parti)u.ar$ so)iotropi) indi/idua.s /a.ue positi/e inter)'ange (it' ot'ers and fo)us on a))eptan)e$ support$ and guidan)e from ot'ers. Moreo/er$ t'ese indi/idua.s a.so tend to be 'ig'.y se.f1)riti)a. 2B.att H &omann$ *++93. Autonomous indi/idua.s$ on t'e ot'er 'and$ /a.ue independen)e$ mobi.ity$ and a)'ie/ement. B.att 2*+D;3 'as suggested some('at simi.ar ideas and 'as argued t'at depressed indi/idua.s )an be eit'er ana).iti) or intro6e)ti/e. Ana).iti) depression is )'ara)teri4ed by fee.ings of 'e.p.essness$ (ea-ness$ dep.etion$ and being un.o/ed ('ereas intro6e)ti/e depression is )'ara)teri4ed by fee.ings of being un(ort'y$ un.o/ab.e$ gui.ty$ and 'a/ing fai.ed to .i/e up to expe)tations and standards. "n a.. )ases$ ('en stressors )ongruent (it' t'ese t'emes are experien)ed 2e.g.$ t'e disso.ution of a re.ations'ip for ana).iti) or so)iotropi) indi/idua.s or a per)ei/ed fai.ure at (or- or s)'oo. for autonomousLintro6e)ti/e indi/idua.s3$ dysfun)tiona. )ogniti/e stru)tures be)ome a)ti/e and depression resu.ts. Resear)' 'as tended to support a .in- bet(een t'ese dimensions and depression$ a.t'oug' t'ere is a )onsensus t'at t'e so)iotropi)Lana).iti) dimensions are more strong.y re.ated to depression t'an t'e autonomousLintro6e)ti/e dimensions 2Enns H Cox$ *++D3. &o(e/er$ some met'odo.ogi)a. prob.ems 'a/e been s'o(n to exist (it'in t'is .iterature$ ('i)' (ere under1 s)ored in a re)ent re/ie( by Coyne and W'iffen 2*++<3. #'ey noted$ for examp.e$ t'at many indi/idua.s s)ore 'ig' on bot' subtypes$ somet'ing )ounter to t'e predi)tion of t'e t'eory. C.ear.y t'is area is promising but in need of sounder met'odo.ogy. -etwork Theories. ome )on)eptua.i4ations of depression 'a/e fo)used on t'eoreti)a. assumptions deri/ed spe)ifi)a..y from )ogniti/e psy)'o.ogy. A.t'oug' 7uite simi.ar to )on)eptua.i4ations t'at fo)us on )ogniti/e s)'emas$ )ogniti/e net(or- approa)'es emp'asi4e some('at different stru)tura. assumptions about t'e nature of s)'emas and a))entuate infor1 mation pro)essing as t'e -ey fa)tor in depression. For examp.e$ net(or- t'eories suggest t'at t'e initia. experien)e of depression resu.ts from t'e a)ti/ation of affe)ti/e stru)tures t'at are responsib.e for a sad or depressed mood and t'at ('en t'ese stru)tures are a)ti/ated$ negati/e

)ognitions be)ome simi.ar.y a)ti/ated 2"ngram$ *+B;3. Moreo/er$ on)e a)ti/ated t'ese stru)tures pro/ide a))ess to more extensi/e and e.aborate pro)essing of depressi/e information. #'is spreading a)ti/ation feeds ba)- to affe)ti/e stru)tures t'at 'a/e pre/ious.y be)ome asso)iated (it' sadness and depression and t'us resu.ts in t'e spira.ing from t'e normati/e

311 INGRAM AND TRENARY depressi/e mood experien)ed by most peop.e into more signifi)ant and debi.itating depression. After be)oming fu..y a)ti/ated$ t'ese net(or-s ser/e to perpetuate depression unti. t'e affe)ti/eL)ogniti/e a)ti/ity .e/e. e/entua..y de)ays or is a.tered 2e.g.$ by treatment3. 0nteracting 1ognitive 'ubsystems. #easda.e and )o..eagues 2#easda.e H Barnard$ *++:C #easda.e$ *+++3 'a/e proposed a )ompre'ensi/e information pro)essing mode. of depression )a..ed t'e intera)ting )ogniti/e subsystems 2"C 3 frame(or-. #'is frame(or- attempts to a))ount for /irtua..y a.. aspe)ts of information pro)essing 2 ieg.e H "ngram$ *++?3 and suggests t'at different aspe)ts of experien)e are represented by patterns of different -inds of information$ or menta. )odes. For examp.e$ at a superfi)ia. .e/e.$ experien)e is )oded in /isua.$ auditory$ and proprio)epti/e inputs$ but at deeper .e/e.s$ patterns of sensory )odes are represented by intermediate )odes 2e.g.$ sensory data t'at form .etters are represented by )ombinations of .etters into (ords and senten)es3. At deeper .e/e.s of en)oding$ menta. )odes are formed t'at )reate meaning 2e.g.$ a senten)e )on/eys bot' information and meaning3 t'at )an be .in-ed to emotions. "n t'e "C frame(or-$ emotiona. rea)tions are produ)ed ('en patterns of .o(1.e/e. meanings and patterns of sensory1deri/ed input produ)e emotion1.aden representations of t'e se.f. %rodu)tion of a depressed state o))urs ('en t'ese depressogeni) s)'emati) mode.s are )reated and is maintained be)ause t'ese mode.s are )ontinua..y reprodu)ed in day1to1day experien)e. W'en t'e produ)tion of t'ese mode.s stops$ t'e depression abates. !valuation o f 1ognitive Models. An enormous body of empiri)a. resear)' 'as in/estigated t'e /arious ).aims of /arious )ogniti/e mode.s. upport for )ertain aspe)ts of t'ese mode.s is 7uite strong. For examp.e$ t'ere is .itt.e doubt t'at ('en depressed$ indi/idua.s do in fa)t experien)e t'e types of negati/e )ognition t'at are 'ypot'esi4ed to resu.t from depressi/e s)'emas or to emanate from dysfun)tiona. attributiona. sty.es 2"ngram et a..$ *++B3. Moreo/er$ studies 'a/e found t'ese resu.ts regard.ess of ('et'er t'ese )ogniti/e )onstru)ts are assessed using se.f1report met'ods or performan)e1based information1pro)essing tas-s. Re.ated .ines of resear)' 'a/e a.so suggested t'at ad/erse ear.y experien)es may )reate some of t'e )ogniti/e )onditions t'at seem to be re.ated to t'e experien)e of depression 2"ngram$ 9,,*C "ngram eta..$ *++B3. 8espite t'is body of resear)'$ se/era. signifi)ant aspe)ts of )ogniti/e mode.s 'a/e yet to be )onsistent.y /erified empiri)a..y. Re)a.. t'at )ogniti/e mode.s are typi)a..y )ausa. mode.s and not simp.y mode.s of t'e )ogniti/e )orre.ates of depressed states. Aet$ a number of studies 'a/e s'o(n t'at many of t'e negati/e )ogniti/e features of depressed states seem to disappear ('en depression remits. #'e inabi.ity to dete)t su)' )ogniti/e fun)tioning in remitted states pro/ides some suggestion t'at t'ese )ognitions (ere mere.y )orre.ates of or )onse7uen)es of t'e depressed state$ not )auses of it. At first$ t'ese findings seemed to undermine t'e most )riti)a. assumptions of t'ese )ogniti/e ideasEt'at negati/e t'oug'ts )ause depression. &o(e/er$ be)ause )ogniti/e mode.s of depression are in/ariab.y diat'esis1stress mode.s$ studies t'at fai.ed to in)orporate t'is re.ations'ip did not pro/ide )riti)a. tests of t'e mode. 2 ega. H "ngram$ *++;3. More appropriate tests 'a/e genera..y been supporti/e of t'e diat'esisEstress idea. "n parti)u.ar$ studies t'at attempt to mode. stress in t'e .aboratory typi)a..y find t'at depressi/e )ognition returns under t'ese stressfu. )onditions 2"ngram et a..$ *++B3. !ne of t'e more )ompre'ensi/e studies designed to assess t'e ro.e of )ognition in depression is t'e #emp.e1Wis)onsin Cogniti/e >u.nerabi.ity to 8epression pro6e)t 2A..oy H Abramson$ *+++3. #'is .ongitudina. study examined t'e proposa.s of bot' t'e 'ope.essness mode. and )ogniti/e s)'ema t'eory as represented by Be)-Gs mode. 2*+?D3. pe)ifi)a..y$ a group of indi/idua.s (ere

assessed ('o$ on entry into )o..ege$ (ere identified as possessing negati/e inferentia. sty.es or negati/e se.f1s)'emas. Among t'e resear)'ersG findings$ t'ose identified

;. M!!8 8" !R8ER 313 as being at 'ig' )ogniti/e ris- (ere in fa)t more .i-e.y to experien)e depression at some point in t'e future 2A..oy H Abramson et a..$ *+++3. &en)e$ data from t'is pro6e)t suggest t'at )ogniti/e fa)tors do in fa)t predi)t t'e e/entua. onset of depression. Psy./#s#.ia% A**r#a./es t# De*ressi#n' Inter*ers#na% A**r#a./es A.t'oug' t'e )ogniti/e approa)' fo)uses on t'e interna. pro)esses in/o./ed in depression$ ot'er approa)'es suggest t'at peop.e get depressed be)ause of prob.emati) intera)tions (it' ot'ers. "n parti)u.ar$ interpersona. approa)'es fo)us on t'e be'a/iors$ espe)ia..y t'e so)ia. be'a/iors$ of t'e depressed indi/idua. and suggest t'at t'ese be'a/iors )ontribute to t'e )ause and maintenan)e of depression. Before dis)ussing t'is approa)'$ 'o(e/er$ it is important to ).arify t'at perspe)ti/es on t'e so)ia. origins and nature of depression do not ne)essari.y represent a spe)ifi) mode. of depression. As &ammen 2*+++3 'as apt.y noted$ t'is approa)' is not suffi)ient.y arti)u.ated t'eoreti)a..y to be )onsidered a psy)'oso)ia. mode.. #'ere is .itt.e doubt t'at t'e interpersona. fun)tioning of depressed indi/idua.s )an be signifi)ant.y disrupted. A .arge body of resear)' s'o(s t'at depressed indi/idua.s are prone to marita. and re.ations'ip diffi)u.ties 2W'isman$ 9,,*3$ o))upationa. prob.ems 2#ennant$ 9,,*3$ impaired parenting 2=arber H F.ynn$ 9,,*3$ and diffi)u.ties in dai.y interpersona. fun)tioning 28i.. H Anderson$ *+++3. "t is easy to see 'o( t'e features of t'e depressed state may be .in-ed to some of t'ese interpersona. prob.ems. For examp.e$ not on.y is so)ia. (it'dra(a. )onsidered a per/asi/e feature of depression$ some spe)ifi) symptoms of depression$ su)' as )on)entration diffi)u.ties$ may pa/e t'e (ay for prob.ems in re.ating to ot'ers. A .arge and gro(ing body of resear)' 'as soug't to examine t'e interpersona. )ontext in ('i)' depression o))urs. #'e first ideas on t'e interpersona. nature of depression (ere proposed by Coyne$ ('o assigned a )entra. ro.e to t'e manner in ('i)' t'e so)ia. en/ironment responds to t'e interpersona. be'a/ior of t'e depressed indi/idua.. A))ording to CoyneGs proposa.s 2*+++3$ t'e o))urren)e of stressfu. .ife e/ents .eads to a disp.ay of depressi/e symptoms by t'e depressed indi/idua.. #'ese symptoms in).ude (it'dra(a. from intera)tions$ expressions of 'e.p.essness and 'ope.essness$ and irritabi.ity and agitation. #'e goa. of t'e depressed person is to gain reassuran)e regarding 'is or 'er se.f1(ort' and a))eptan)e by ot'ers. "nitia..y$ indi/idua.s respond (it' genuine )on)ern and support for t'e person. #'e effe)ts of t'is reassuran)e$ 'o(e/er$ are s'ort1.i/ed$ and t'e depressed person )ontinues to see- reassuran)e of 'is or 'er se.f1(ort'. #'e persisten)e of a depressi/e disp.ay$ 'o(e/er$ e/entua..y be)omes a/ersi/e to ot'ers$ and some peop.e in t'e depressed personGs so)ia. net(or- may express anger and irritation at t'e depressed person ('ereas ot'ers start to find suitab.e ex)uses to a/oid furt'er intera)tions. #'e depressed person a))urate.y interprets t'ese be'a/iors as re6e)tion$ .eading to intensified efforts by t'e depressed person to see- reassuran)e. #'us$ a )y).e based on t'e per)ei/ed or a)tua. re6e)tion by ot'ers is generated t'at is unp.easant to bot' t'e depressed person and to ot'ers ('o )ontinue to remain in t'e depressed personGs so)ia. en/ironment. "nterpersona. perspe)ti/es t'us argue t'at depression is fundamenta..y interpersona. in nature 2see Joiner H Coyne$ *+++3. "nterpersona. approa)'es 'a/e a.so been refined and extended sin)e CoyneGs origina. (or-. For examp.e$ in/estigators 'a/e fo)used on interpersona. topi)s in depression ranging from .ife stress and )oping$ to t'e ro.e of se.f1esteem$ and to t'e re.ations'ips bet(een )ogniti/e mode.s and interpersona. approa)'es 2=ot.ib H &ammen$ *++93. 1ausal /actors in the 0nterpersonal %pproach. Joiner 29,,93 'as proposed t'ree possib.e (ays t'at interpersona. fa)tors may )reate ris- for depression. First$ impaired so)ia. s-i..s may )ause

t'e intera)tiona. disruptions t'at .ead to depression. A.t'oug' many

315 INGRAM AND TRENARY indi/idua.s ('o are depressed do disp.ay .imited so)ia. s-i..s$ and a.t'oug' t'e idea t'at so)ia. s-i.. defi)its )'ara)teri4e depression1prone peop.e 'as been around for a ('i.e 2e.g.$ Le(inso'n$ *+B<3$ fe( studies s'o( t'at t'ese defi)its pre)ede depression. u)' tempora. ante)eden)e is a ne)essary )ondition for demonstrating t'at a fa)tor p.ays a )ausa. ro.e in depression 2=arber H &o..on$ *++*3. A re.ated but se)ond possibi.ity is t'at depression1prone indi/idua.s disp.ay genera. interpersona. in'ibition$ ('i)' )reates ris- for depression. u)' in'ibition suggests t'at depressed indi/idua.s tend to be so)ia..y a/oidant or s'y and t'at t'ese in'ibitions .ead to disrupted so)ia. fun)tioning and depression. A.t'oug' data re.iab.y s'o( t'at t'ese in'ibitions o))ur in t'e depressed state 2Joiner$ 9,,93$ .itt.e resear)' 'as addressed t'e possibi.ity t'at t'ese pro)esses .ead to depression. A t'ird possibi.ity$ and one t'at is asso)iated (it' )ogniti/e mode.s$ is t'at an ex)essi/e amount of interpersona. dependen)y )reates ris- for depression. A number of studies 'a/e s'o(n a .inbet(een depressi/e symptoms and dependen)y 2Ruroff H Fit4patri)-$ *++<3$ ma-ing it a reasonab.e )andidate for )reating ris-. ome resear)''as supported t'is proposition. For instan)e$ tader and &o-anson 2*++B3 demonstrated t'at fee.ings of dependen)y pre)eded e.e/ations in depressi/e symptoms$ a.t'oug' t'ese fee.ings remained e/en after t'e depressi/e symptoms diminis'ed. A.t'oug' data su)' as t'ese are suggesti/e$ more extensi/e .ongitudina. resear)' (i.. be ne)essary to determine 'o( mu)' of a ro.e dependen)y p.ays in t'e onset of depressi/e episodes. #'e onset of depression is on.y one e.ement of t'e )ausa. )y).e in depression 2"ngram et a..$ *++B3. 8epression )an .ast for mont's or years$ sometimes e/en (it' treatment$ and interpersona. pro)esses may p.ay a )riti)a. ro.e in maintaining t'e depressed state. #'e ex)essi/e reassuran)e see-ing t'at is t'e )ornerstone of interpersona. mode.s suggests pat'(ays ('ereby depression may be maintained. #'e interferen)e (it' so)ia. bonds t'at t'is pro)ess may .ead to indi)ates t'at so)ia. support (i.. be diminis'ed and interpersona. re6e)tion (i.. be in)reased. A number of studies 'a/e re/ea.ed t'is pro)ess in depressed indi/idua.s 2Joiner$ 9,,93. Moreo/er$ t'ese be'a/iors may a.so be re.ated to in)reases in stress 2&ammen$ *++*b3$ t'us ma-ing depression more diffi)u.t to es)ape. Regard.ess of ('et'er t'ese prob.emati) intera)tions are in/o./ed in t'e onset of depression or in t'e maintenan)e of depression$ t'e interpersona. approa)' is an important perspe)ti/e in understanding depression. TREATMENT AND PREGENTION Pre,enti#n #reating )ases of depression (i.. a.(ays be an important fo)us of t'erapists. &o(e/er$ some resear)'ers 'a/e argued t'at a better approa)' to treatment is pre/ention of t'e disorder before it 'as o))urred 2A.bee$ 9,,,3. #'ere is .itt.e argument t'at pre/enting depression (ou.d pro/ide )onsiderab.y greater benefits to so)iety and to indi/idua.s t'an does t'e treatment of one depressed indi/idua. at a time. #'oug' promising$ 'o(e/er$ resear)' on t'e pre/ention of depression is a young fie.d. For instan)e$ t'ere are fe( reports of pre/ention efforts t'at o))urred before t'e *++,s. %re/ention resear)'ers typi)a..y adapt and app.y treatments t'at 'a/e been s'o(n to be effe)ti/e for treating depression to indi/idua.s ('o are not yet depressed but ('o are at ris- for depression. For t'e most part$ pre/ention tria.s to date 'a/e pro/en some('at su))essfu. in redu)ing t'e in)iden)e of depression 2Muno4$ Le$ C.ar-e$ H Jay)ox$ 9,,93. Moreo/er$ t'e data tend to s'o( t'at t'ose ('o are most 'e.ped by pre/ention programs are )'i.dren and ado.es)ents 2"ngram$

!dom$ H Mit)'usson$ 9,,;3. #'e ma6ority of pre/ention resear)' 'as fo)used on

;. MOOD DISORDERS 317 psy)'oso)ia. treatment met'ods$ fre7uent.y (it' an emp'asis on modifying )ogniti/e fa)tors. Resear)' s'o(s t'e promise of t'ese met'ods and offers indi/idua.s t'e possibi.ity of ne( .earning and of modifying )ogniti/e and be'a/iora. fun)tioning t'at may 'a/e .asting effe)ts. 1i#%#&i.a% A**r#a./es t# Treat(ent %'arma)ot'erapy for depression 'as be)ome in)reasing.y )ommon. "ndeed$ be)ause of t'eir demonstrated effe)ti/eness$ t'e use of antidepressants as t'e front1.ine treatment against de1 pression 'as soared. Antidepressant medi)ations fa.. into t'e )ategories of monoamine oxidi4e 2MA!3 in'ibitors$ tri)y).i) antidepressants$ and se.e)ti/e serotonin reupta-e in'ibitors 2 R"s3. A.. of t'ese drugs (or- by in)reasing t'e .e/e.s of norepinep'rine andLor serotonin. Resear)'ers$ 'o(e/er$ are sti.. unsure as to t'e exa)t me)'anisms by ('i)' t'ese medi)ations a)'ie/e t'eir effe)ts. Monoamine O"idi*e 0nhibitors. Monoamine oxidi4e 2MA!3 in'ibitors (ere t'e first antidepressant medi)ations$ a))identa..y dis)o/ered in t'e *+<,s ('en one su)' drug 2ipronia4id3 fai.ed to )ure tuber)u.osis but inad/ertent.y ame.iorated t'e patientGs depressi/e symptoms 2%ine.$ 9,,,3. #'is ).ass of drugs in)reases t'e .e/e. of monoamines 2e.g.$ serotonin and norepinep'rine3 by in'ibiting t'e en4ymes t'at (ou.d ot'er(ise brea- do(n t'ese neurotransmitters. Current.y$ MA! in'ibitors 'a/e been re.egated to t'ird1 or fourt'1.ine an1 tidepressants$ most.y be)ause of dietary restri)tions t'at are re7uired (it' t'eir use 2=it.in$ 9,,93. u)' dietary restri)tions 'a/e been termed t'e 0)'eese effe)t0 be)ause )ertain foods t'at )ontain an amine )a..ed tyramine )annot be eaten be)ause t'ey )an raise b.ood pressure dangerous.y 'ig' 2(ine and )'eese are t(o su)' restri)ted foods3. "n addition$ MA! in'ibitors 'a/e potentia..y peri.ous drug1to1drug intera)tions t'at )an .ead to 'ypertension or deat' 2t'ese ot'er medi)ations in).ude o/er1t'e1)ounter )o.d remedies$ as (e.. as R"s3. !t'er .ess serious side effe)ts in).ude anxiety$ nausea$ di44iness$ insomnia$ (eig't gain$ and sexua. dysfun)tion. Tricylcic %ntidepressants. o named be)ause of t'eir t'ree1ringed stru)ture$ tri)y).i) antidepressants (ere a.so de/e.oped in t'e *+<,s. imi.ar to t'e MA! in'ibitors$ t'ese drugs (ere dis)o/ered ('en imipramine pro/ed unsu))essfu. in treating s)'i4op'renia 2%ine.$ 9,,,3. #ri)y).i)s fun)tion by b.o)-ing t'e reupta-e of serotonin and norepinep'rine$ t'ereby )ausing an in)rease in t'ese neurotransmitters. #'ese antidepressants )onsistent.y s'o( good effi)a)y and are t'erefore fre7uent.y used as t'e referen)e drugs in e/a.uating ne( treatments 2=it.in$ 9,,93. 8isad/antages of tri)y).i)s in).ude t'e need to in)rease t'e dosage s.o(.y to fu.. effe)t as (e.. as se/era. de.eterious side effe)ts su)' as 'eart arr'yt'mias$ ta)'y)ardia$ )onstipation$ urinary prob.ems$ sedation$ (eig't gain$ b.urry /ision$ and dry mout' 2=it.in$ 9,,93. 'elective 'erotonin (euptake 0nhibitors. 8e/e.oped in t'e *++,s$ se.e)ti/e serotonin reupta-e in'ibitors 2 R"s3 are )urrent.y t'e most )ommon.y pres)ribed antidepressants and in).ude brand names su)' as %ro4a)$ %axi.$ and Ro.oft. As t'e name imp.ies$ R"s in'ibit t'e reupta-e of serotonin$ t'ereby in)reasing t'e .e/e. of serotonin in t'e brain. #'eir (idespread use is due to t'e fa)t t'at t'ey re7uire on.y one dose dai.y$ as (e.. as to t'eir .imited side effe)ts$ su)' as nausea$ insomnia$ ner/ousness$ sedation$ and sexua. side effe)ts 2=it.in$ 9,,93. Kuite often$ t'e nausea$ insomnia$ and ner/ousness diminis' after t'e first fe( (ee-s of treatment. R"s are roug'.y e7ua. in effe)ti/eness to tri)y).i)s$ a.t'oug' some data 'a/e re)ent.y emerged t'at suggest t'at R"s are not mu)' superior to p.a)ebo effe)ts 2@irs)' H apirstein$ *++B3. Exa)t.y ('at ro.es /ariab.es su)' as be.iefs 'a/e in t'e effe)ti/eness of R"s must a(ait furt'er resear)'.

318 INGRAM AND TRENARY Psy./#s#.ia% Treat(ent A**r#a./es 8ating from FreudGs area$ depression 'as been treated (it' a /ariety of psy)'oso)ia. met'ods. Current.y t'e dominant psy)'oso)ia. approa)'es for t'e treatment of depression are )ogniti/e1 be'a/iora. t'erapy and interpersona. t'erapy. Bot' 'a/e demonstrated )onsiderab.e effi)a)y in t'e treatment of t'e disorder$ but ot'er more spe)ia.i4ed met'ods 'a/e a.so been used (it' some su))ess. For instan)e$ marita. t'erapy 'as been used in )ases ('ere marita. fun)tioning and depression appear to be entang.ed. ome ot'er approa)'es$ for examp.e$ brief dynami) t'erapy and be'a/iora. t'erapy$ 'a/e a.so s'o(n some e/iden)e of effi)a)y 28epression =uide.ine %ane.$ *++:3. &o(e/er$ be)ause of spa)e .imitations$ (e fo)us on )ogniti/e t'erapy and interpersona. t'erapy. 1ognitive Therapy. Before dis)ussing )ogniti/e t'erapy$ se/era. )a/eats are in order. First$ t'ere are a number of different approa)'es to modifying dysfun)tion t'at fa.. (it'in t'e domain of )ogniti/e t'erapy. !ur fo)us is on )ogniti/e t'erapy as de/e.oped by Be)- 2e.g.$ Be)-$ Rus'$ 'a( H Emery$ *+D+3$ .arge.y be)ause t'is parti)u.ar /ersion of )ogniti/e t'erapy 'as been empiri)a..y e/a.uated t'e most extensi/e.y and be)ause it (as t'e first psy)'ot'erapy approa)' to fo)us exp.i)it.y on t'e modifi)ation of )ogniti/e fa)tors. e)ond$ ('i.e at initia. g.an)e it mig't appear t'at t'e de/e.opment of )ogniti/e treatment met'ods (ou.d fo..o( from t'eory and resear)' on t'e )ogniti/e fa)tors in depression$ it (as in fa)t t'e ear.y su))ess of )ogniti/e t'erapy t'at stimu.ated mu)' of t'e t'eory and resear)' on )ogniti/e pro)esses. Last$ e/en t'oug' t'e goa. of t'ese approa)'es is t'e modifi)ation of )ogniti/e fa)tors t'at are presumed to p.ay an important ro.e in bot' t'e onset and maintenan)e of depressed states$ most )ogniti/e approa)'es a.so ma-e )onsiderab.e use of be'a/iora. met'ods to 'e.p a)'ie/e t'ese ends. &en)e$ )ogniti/e and )ogniti/e1be'a/iora. are terms t'at )an be used inter)'angeab.y. #'e goa. of )ogniti/e t'erapy in t'e treatment of depression 2and in ot'er disordered states3 is to tea)' indi/idua.s to re)ogni4e and modify dysfun)tiona. be.iefs and )ognitions 2Be)- et a..$ *+D+3. #o do so$ )ogniti/e t'erapists ma-e use of )o..aborati/e empiri)ism$ ('i)' entai.s (or-ing toget'er (it' t'e patient to test t'e /a.idity of negati/e t'in-ing pro)esses t'at are embedded in t'e patientGs meaning system and$ ('ere possib.e$ modify t'em. #'us$ t'e goa. is first to 'e.p patients re)ogni4e t'e t'oug'ts t'at may be maintaining depression$ and t'en to test t'e /a.idity of t'ese t'oug'ts. Cogniti/e t'erapists use a /ariety of met'ods$ but tend to re.y 'ea/i.y on o)rati) 7uestioning and be'a/iora. experiments to a)'ie/e t'ese goa.s. o)rati) 7uestioning ta-es t'e form of as-ing 7uestions su)' as 0W'at is t'e e/iden)e for t'is be.iefF0 and 0Are t'ere ot'er (ays to /ie( t'e situationF0C and if t'e be.ief is a))urate$ 0W'at is t'e meaning of t'isF0 "nitia..y t'ese met'ods s'ou.d 'e.p t'e patient minimi4e distress in a parti)u.ar situation$ but )an a.so be used in ot'er situations and after t'erapy 'as ended to dea. (it' future stressfu. situations. Be'a/iora. experiments are exer)ises designed to 'e.p t'e patient test t'e /a.idity of t'e be.ief. W'at is t'e empiri)a. e/iden)e for t'e effi)a)y of )ogniti/e t'erapyF Cogniti/e t'erapy is among t'e most extensi/e.y tested treatments for depression and is (ide.y re)ogni4ed as one of t'e most effe)ti/e psy)'oso)ia. treatments a/ai.ab.e 2&o..on$ &aman$ H Bro(n$ 9,,93. We..1)ontro..ed studies 'a/e suggested t'at )ogniti/e t'erapy produ)es out)omes t'at are roug'.y e7ui/a.ent to psy)'op'arma)o.ogi)a. inter/entions 2&o..on et a..$ 9,,93. "n addition$ )ogniti/e t'erapy may substantia..y redu)e t'e rate of re.apse 2t'e return of t'e treated episode3 2e.g.$ E/ans et a..$ *++93 and re)urren)e 2t'e appearan)e of ane( episode3 2e.g.$ Fa/a$ Rafane..i$ =randi$ Conti$ H

Be..uardo$ *++B3.

;. MOOD DISORDERS 320 Combining )ogniti/e t'erapy (it' medi)ation may modest.y en'an)e positi/e response rates 2Conti$ %.ut)'i-$ Wi.d$ H @arasu$ *+B?3$ but su)' )on).usions are not (it'out 7ua.ifi)ation. For examp.e$ superior effi)a)y for )ombined approa)'es may be obtained on.y for )ases of depression t'at are more se/ere or )omp.ex or t'at 'a/e a 'ig' degree of )omorbidity. A.ternati/e.y$ )ombined t'erapy and medi)ation may en'an)e responsi/eness for t'ose indi1 /idua.s ('o are not responsi/e to eit'er treatment a.one. %ra)ti)e guide.ines typi)a..y )a.. for t'e addition of a different approa)' if symptoms are not redu)ed (it'in six to eig't (ee-s 2Ameri)an %sy)'iatri) Asso)iation$ 9,,,3. #'us$ it appears t'at in some )ases medi)ation may en'an)e t'e effe)ts of )ogniti/e t'erapy. 0nterpersonal +sychotherapy. "nterpersona. approa)'es )an tra)e t'eir origin to t'e more psy)'oana.yti) approa)'es of Ado.p' Meyer and &arry ta)- u..i/an and exp.i)it.y re.y on t'e interpersona. t'eories of persona.ity proposed by t'ese ear.y t'eories. #'ese approa)'es /ie( interpersona. diffi)u.ties )on)erning grief$ ro.e disputes$ ro.e transitions$ or interpersona. defi)its as t'e )ore prob.ems in depression. "nterpersona. t'erapy a.so assigns a 0si)- ro.e0 to t'e patient to remo/e gui.t about t'e diagnosis of depression. W'ereas )ogniti/e t'erapy pro/ides a fair.y stru)tured set of t'erapeuti) met'ods$ interpersona. t'erapy is typi)a..y unstru)tured. After an assessment of depressi/e symptoms$ patients are as-ed to des)ribe in detai. t'e nature of t'eir interpersona. re.ations'ips and diffi)u.ties$ ('i)' pro/ides a basis for t'e t'erapist to fo)us on one or t(o of t'e ma6or areas of interpersona. fun)tioning 2e.g.$ grief$ ro.e disputes$ ro.e transitions$ or interpersona. defi)its3. "f grief is t'e fo)us$ t'e t'erapist attempts to 'e.p t'e patient mourn in a 'ea.t'y (ay and$ ('en appropriate$ to de/e.op ne( re.ations'ips. Ro.e transitions 2e.g.$ t'e .oss of a 6ob3 are dea.t (it' by 'e.ping t'e patient to a)7uire ne( s-i..s t'at (i.. fa)i.itate a positi/e transition. W'en a ro.e dispute is t'e fo)us of treatment 2e.g.$ diffi)u.ties in a ).ose re.ations'ip su)' as marriage3$ t'e t'erapist (or-s (it' t'e patient to try to reso./e t'e dispute. u)' reso.utions )an ta-e t'e form of renegotiating t'e nature of t'e re.ations'ip or mig't ta-e t'e form of disso.ution of t'e re.ations'ip. "n t'is .atter )ase$ grief at t'e .oss of t'e re.ations'ip may a.so be)ome a fo)us of t'erapy. Fina..y$ if interpersona. defi)its are t'e fo)a. point of treatment$ t'e t'erapist 'e.ps t'e patient de/e.op more effe)ti/e so)ia. s-i..s t'roug' ro.e p.aying and re.ated met'ods. Considerab.e resear)' supports t'e effi)a)y of interpersona. t'erapy for depression. An initia. study reported by Weissman et a.. 2*+D+3 found t'at interpersona. t'erapy (as e7ui/a.ent in effi)a)y to medi)ation 2amitripty.ine3. tudies 'a/e a.so suggested t'at t'e )ombination of psy)'op'arma)o.ogi)a. approa)'es and interpersona. t'erapy is effe)ti/e$ (it' some e/iden)e to suggest t'at t'e )ombination is better t'an eit'er treatment a.one 28iMasi)o et a..$ *+D+3. UMMARA #'is )'apter began (it' a basi) o/er/ie( of t'e ma6or ).asses of mood disorders$ (it' a primary fo)us on unipo.ar depression. #'e dis)ussion of t'e 8 M1">1#R noted re7uired symptoms for mood disorders$ t'e genera. )ourse of mood disorders$ and issues in defining t'e idea of depression. Epidemio.ogi)a. data$ gender differen)es$ and )u.tura. issues (ere exp.ored. ome epidemio.ogi)a. studies estimate .ifetime pre/a.en)e rates of depression to be as 'ig' as 9<P$ a.t'oug' t'ese figures may depend on t'e (ay depression is defined and in ('at )u.ture depression is assessed. About t(i)e as many (omen suffer from unipo.ar depression as men$ t'oug' t'ere are fe( gender differen)es in bipo.ar disorders. Cu.tura. issues exp.ore 'o( depression )an be manifested and )on)eptua.i4ed different.y in /arious )u.tures$ and

321 INGRAM AND TRENARY a.t'oug' 8 M1inspired notions of depression re.y 'ea/i.y on Western so)iety$ depression may be t'oug't of /ery different.y in ot'er )u.tures. #'ere are a number of mode.s of depression$ as (e.. as )orresponding resear)' findings. 8iat'esis1stress )on)eptua.i4ations fo)us on t'e intera)tion bet(een interna. and externa. sour)es in t'e de/e.opment of depression$ and a.t'oug' not uni/ersa..y t'e )ase$ most t'eories of depression ref.e)t su)' perspe)ti/es to some degree. Biomedi)a. mode.s fo)us on geneti)s$ bio.ogi)a. e/iden)e$ and affe)ti/e neuros)ien)e perspe)ti/es. =eneti) perspe)ti/es .oo- to fami.y studies$ t(in studies$ and adoption studies$ ('i)' s'o( fami.ia. ).usters of mood disorders as e/iden)e for geneti) )ontributions to depression. "n t'e area of bio.ogi)a. approa)'es to depression$ se/era. pat'op'ysio.ogi)a. pro)esses 'a/e been noted$ su)' as serotonin and norepinep'rine dysregu.ation$ 'ig' .e/e.s of C#rtis#%5 and s.eep disturban)es. Affe)ti/e neuro1 s)ien)e$ ('i)' fo)uses on neura. pro)esses .in-ed to emotion$ 'as suggested abnorma.ities of t'e prefronta. )ortex$ t'e anterior )ingu.ate )ortex$ t'e 'ippo)ampus$ and t'e amygda.a. Ea)' of t'ese perspe)ti/es 'as pro/ided important insig'ts into t'e nature of depression$ but our understanding of biomedi)a. pro)esses is sti.. far from )omp.ete. #'e ot'er ma6or approa)'es to depression are psy)'oso)ia. approa)'es. #'e )ommon t'eme among )ogniti/e mode.s is t'at negati/e )ogniti/e pro)esses p.ay an important ro.e in t'e )ause and )ourse of depression. Empiri)a. studies affirm a number of aspe)ts of t'ese )ogniti/e mod1 e.s. A.t'oug' some resear)' points to t'e )ausa. /a.idity of t'ese mode.s$ -ey )ausa. )ontribu1 tions 'a/e not yet been demonstrated. "nterpersona. approa)'es a.so represent a psy)'oso)ia. /ie( of depression$ but fo)us on intera)tiona. patterns as -ey features in depression. As (it' )ogniti/e mode.s$ interpersona. approa)'es /ary$ but tend to )on/erge on t'e idea t'at troub.ed intera)tion patterns may bot' )ause and maintain depression. A.so$ as (it' )ogniti/e mode.s$ ('i.e some resear)' 'as been supporti/e$ t'e ma6or /ariab.es in t'is approa)' 'a/e yet to be definiti/e.y s'o(n to p.ay a -ey ro.e in t'e )ause and )ourse of depression. Last.y (e examined /arious forms of treatment and pre/ention for mood disorders. %ara..e.ing t'e t(o ma6 or areas of depression t'eory and resear)'$ t'e t(o main approa)'es to treatment are bio.ogi)a. and psy)'oso)ia.. Bio.ogi)a. treatment entai.s t'e use of p'arma)ot'erapy$ (it' t'e t'ree main types of antidepressant medi)ations )onsisting of MA! in'ibitors$ tri)y).i)s$ and R"s. A.. of t'ese )an be effe)ti/e for )ertain groups of peop.e$ a.t'oug' R"s are pres)ribed most often be)ause t'eir effi)a)y is at .east e7ua. to ot'er drugs and be)ause of t'eir .imited side effe)ts. Ma6or psy)'oso)ia. inter/entions in).ude )ogniti/e t'erapy and interpersona. psy)'ot'erapy. Cogniti/e t'erapy aims to 'e.p indi/idua.s re)ogni4e and modify t'eir dysfun)tiona. be.iefs. o)rati) 7uestioning and be'a/iora. experiments are t(o te)'ni7ues t'at )ogniti/e t'erapists use. 8ata 'a/e repeated.y s'o(n t'e effi)a)y of su)' approa)'es. "nterpersona. psy)'ot'erapy fo)uses on t'e areas of grief$ ro.e disputes$ ro.e transitions$ or interpersona. defi)its as t'e )ore issues t'at are addressed in t'erapy. As (it' )ogniti/e t'erapy$ a )onsiderab.e body of resear)' supports t'e effi)a)y of t'is psy)'oso)ia. inter/ention. ignifi)ant strides 'a/e been made in understanding t'e )ore fa)tors in/o./ed in depression$ as (e.. as me)'anisms t'at may be in/o./ed in its onset and )ourse. As signifi)ant as t'ese strides 'a/e been$ 'o(e/er$ mu)' is sti.. un-no(n about t'e essentia. features of depression. Most depression t'eorists be.ie/e t'at t'ere are different subtypes of depression$ and a.t'oug' t'ese a.. resu.t in simi.ar symptom )onste..ations$ t'ey may 'a/e different )auses$ )ourses$ and )orre.ates. #'is 'eterogeneity 'as imp.i)ations not on.y for t'eory and resear)' on depression$ but a.so for

pre/ention and treatment effortsC pre/ention programs and treatment spe)ifi)a..y tai.ored to t'e )ausa. fa)tors in different -inds of depressi/e disorders may dramati)a..y impro/e positi/e out)omes. From a more genera. perspe)ti/e$ t'is 'eterogeneity i..ustrates a )on)ept t'at is important to -eep in mind in any exp.oration of depression. Mood disorders are dynami) )onstru)ts ('ose understanding 'inges on definitions and )u.tura. )ontexts. #'e -ey to

;. MOOD DISORDERS 323 $n%#.+in& t/e se.rets #6 de*ressi#n (ay t/ere6#re %ie in .ata%#&in& t/e di66erent s$bty*es #6 t/e dis#rders t/at 2e .a%% de*ressi#n5 and t/en e-a(inin& t/e bi#%#&i.a% and *sy./#%#&i.a% 6a.t#rs t/at .#ntrib$te t# t/eir ,ari#$s .a$ses and .#$rses. T/is &#a% is $n%i+e%y t# be attainab%e in t/e 6#reseeab%e 6$t$re5 b$t it is a 2#rt/y as*irati#n 6#r .%ini.ians5 t/e#rists5 and resear./ers 2/# 2is/ t# $nderstand t/e nat$re #6 de*ressi#n. REFERENCES Abra(s#n5 L. Y5 Meta%s+y5 G. I5 H A%%#y5 L. 1. =3@;@>. H#*e%essness de*ressi#n' A t/e#ry0 based s$bty*e #6 de*ressi#n. +sychological (eview# @E# :";0:8 . Abra(s#n5 L. Y5 Se%i&(an5 M. E. P5 H Teasda%e5 7. =3@8;>. Learned /e%*%essness in /$(ans' CritiJ$e and re6#r($%ati#n. ournal of %bnormal +sychology# 8A# 9@08B9. A%bee5 G. W. = !!!>. CritiJ$e #6 *sy./#t/era*y in A(eri.an S#.iety. In C. R. Snyder H R. E. In&ra( =Eds.>5 ,andbook ofpsychological change5 +sychotherapy processes and practices for the :6st century. Ne2 Y#r+' Wi%ey. A%%#y5 L. 15 H Abra(s#n5 L. Y. =3@@@>. T/e Te(*%e0Wis.#nsin C#&niti,e G$%nerabi%ity t# De*ressi#n *r#De.t' C#n.e*t$a% ba.+&r#$nd5 desi&n5 and (et/#ds. ournal of 1ognitive +sychotherapy# 6?# 80 ? . A(eri.an Psy./iatri. Ass#.iati#n. = !!!>. Diagnostic and statistical manual of mental disorders =9t/ ed. te-t re,isi#n>. Was/in&t#n D.C.' A$t/#r. 1e.+5 A. T. =3@?8>. Depression5 1auses and treatment. P/i%ade%*/ia' Uni,ersity #6 Pennsy%,ania Press. 1e.+5 A. T. = !! >. C#&niti,e (#de%s #6 de*ressi#n. In R. L. Lea/y H T. E. D#2d =Eds.>5 1linical advances in cognitive psychotherapy5 Theory and application =**. @0?3>. Ne2 Y#r+' S*rin&er. 1e.+5 A. T5 R$s/5 A. 75 S/a25 1. F5 H E(ery5 G. =3@8@>. 1ognitive therapy of depression. Ne2 Y#r+' G$i%6#rd. 1%att5 S. 7. =3@89>. Le,e% #6 #bDe.t re*resentati#n in ana.%iti. and intr#De.ti,e de*ressi#n. +sychoanalytic 'tudy of the 1hild# :@# 3!803"8. 1%att5 S. 75 H H#(ann5 E. =3@@ >. Parent0./i%d intera.ti#n in t/e eti#%#&y #6 de*endent and se%60.riti.a% de*ressi#n. 1linical +sychology (eview# 6:#980@3. C#nti5 H. R5 P%$t./i+5 R5 Wi%d5 ). G5 H )aras$5 T. 1. =3@;?>. C#(bined *sy./#t/era*y and */ar(a.#t/era*y 6#r de*ressi#n. %rchives of General +sychiatry# ;?# 983098@. C#yne5 7. C. =3@@@>. T/in+in& intera.ti#na%%y ab#$t de*ressi#n' A radi.a% restate(ent. In T. E. 7#iner H 7. C. C#yne =Eds.>5 The interactional nature of depression =**. :?"0:@ >. Was/in&t#n5 DC' A(eri.an Psy./#%#&i.a% Ass#.iati#n. C#yne5 7. C5 H W/i66en5 G E. =3@@">. Iss$es in *ers#na%ity as diat/esis 6#r de*ressi#n' T/e .ase #6 s#.i#tr#*y de*enden.y and a$t#n#(y se%6 .riti.is(. +sychological $ulletin# 668# :";0:8;. Da,ids#n5 R. 7. =3@@:>. Cerebra% asy((etry and e(#ti#n' C#n.e*t$a% and (et/#d#%#&i.a% .#n$ndr$(s. 1ognition and !motion# A# 33"03:;. Da,ids#n5 R. 75 PiCCa&a%%i5 D5 H Nits./+e5 7. 1. = !! >. T/e re*resentati#n and re&$%ati#n #6 e(#ti#n in de*ressi#n' Pers*e.ti,es 6r#( a66e.ti,e ne$r#s.ien.e. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook ofdepression =:rd ed.>

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T. E. = !! >. De*ressi#n in its inter*ers#na% .#nte-t. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of depression =:rd ed.> =**. @"0:3:>. Ne2 Y#r+' G$i%6#rd. 7#iner5 T. E5 H C#yne5 7. C. =3@@@> =Eds.>. The interactional nature of depression. Was/in&t#n5 DC' A(eri.an Psy./#%#&i.a% Ass#.iati#n. )enda%%5 P. C5 H#%%#n5 S. D5 1e.+5 A. T5 Ha((en5 C. L5 H In&ra(5 R. E. =3@;8>. Iss$es and re.#((endati#ns re&ardin& $se #6 t/e 1e.+ De*ressi#n In,ent#ry. 1ognitive Therapy and (esearch# 66# ;@0 @@. )end%er )5 H Gardner5 C. O. =3@@;>. T2ins st$dies #6 ad$%t *sy./iatri. and s$bstan.e de*enden.e dis#rders. +sychological Medicine# :8# ? "0?::. )end%er5 )5 Nea%e5 M5 )ess%er5 R5 Heat/5 A5 H Ea,es5 L. =3@@ >. MaD#r de*ressi#n and &enera%iCed an-iety dis#rder. %rchives of General +sychiatry# ;@# 83?08 . )ess%er5 R. C. = !! >. E*ide(i#%#&y #6 de*ressi#n. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of depression =:rd ed.> =**. :P9 >. Ne2 Y#r+' G$i%6#rd. )irs./5 I5 H Sa*irstein5 G. =3@@;>. Listenin& t# Pr#Ca. b$t /earin& *%a.eb#' A (eta ana%ysis #6 antide*ressant (edi.ati#n. +revention D Treatment# 6# Arti.%e !!! a. )#r65 75 H ,an Praa&5 H. H. =3@83>. Retarded de*ressi#ns and t/e d#*a(ine /y*#t/esis. +sychopharmacologia# 6@# 3@@0 !:. Le2ins#/n5 P. =3@;">. A be/a,i#ra% a**r#a./ t# de*ressi#n. In 7. C. C#yne =Ed.>5 !ssential papers in depression. Ne2 Y#r+' NYU Press. Maes5 M5 H Me%tCer5 H. Y. =3@@">. T/e ser#t#nin /y*#t/esis #6 (aD#r de*ressi#n. In F. E. 1%##( H D. 7. )$*6er =Eds.>5 +sychopharmacology5 The fourth generation ofprogress =**. @::0@99>. Ne2 Y#r+' Ra,en. Ma%/i5 G. S5 M##re5 75 H M.G$66in5 P. = !!!>. T/e &eneti.s #6 (aD#r de*ressi#n. 1urrent +sychiatry (eports# :# 3?"03?@.

;. M!!8 8" !R8ER 327 MaC$re5 C. M. =3@@;>. Li6e stress#rs as ris+ 6a.t#rs in de*ressi#n. 1linical +sychology5 'cience and +ractice# 9# @30:3:. M.G$66in5 P5 )atC5 R5 H R$t/er6#rd5 7. =3@@3>. Nat$re5 n$rt$re5 and de*ressi#n' A t2in st$dy. +sychological Medicine# :6# : @0::". M#nr#e5 S. M5 H HadDiyanna+is5 ).. = !! >. T/e s#.ia% en,ir#n(ent and de*ressi#n' F#.$sin& #n se,ere %i6e stress. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of depression =:rd ed.> =**. :390:93>. Ne2 Y#r+' G$i%6#rd. M$U#C5 R5 Le5 H5 C%ar+e5 G5 H 7ay.#-5 L. = !! >. Pre,entin& t/e #nset #6 (aD#r de*ressi#n. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of depression =:rd ed.> =**. :9:0:"@>. Ne2 Y#r+' G$i%6#rd. N#%en0 H#e+se(a5 S. = !! >. Gender di66eren.es in de*ressi#n. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of depression =:rd ed.> =**. 9@ 0"!@>. Ne2 Y#r+' G$i%6#rd. N$r.#(be5 1. =3@@ >. T/e e,#%$ti#n and ,a%idity #6 t/e dia&n#sis #6 (aD#r de*ressi#n in ./i%d/##d and ad#%es.en.e. In D. Ci../etti H S. L. T#t/ =Eds.>5 Developmental perspectives on depression. R#./ester5 NY' Uni,ersity #6 R#./ester Press. Pine%5 7. P. 7. = !!!>. $iopsychology. Need(an Hei&/ts5 MA' Pears#n Ed$.ati#n. Ress%er5 ). 75 H Ne(er#665 C. 1. =3@@@>. R#%e #6 n#re*ine*/rine in t/e *at/#*/ysi#%#&y and treat(ent #6 (##d dis#rders. $iological +sychiatry# ;E# 3 3@03 ::. SaC5 P5 H De2ey5 M. = !!3>. De*ressi#n5 de*ressi,e sy(*t#(s and (#rta%ity in *ers#ns a&ed ?" and #,er %i,in& in t/e .#(($nity' A syste(ati. re,ie2 #6 t/e %iterat$re. 0nternational ournal of Geriatric +sychiatry# 6E#? 0?:!. S./i%d+ra$t5 7. 7. =3@?">. T/e .ate./#%a(ine /y*#t/esis #6 a66e.ti,e dis#rders' A re,ie2 #6 s$**#rtin& e,iden.e. %merican ournal of +sychiatry# 6::# "!@0" . Se&a%5 F. G5 =3@;;>. A**raisa% #6 t/e se%60 s./e(a .#nstr$.t in .#&niti,e (#de%s #6 de*ressi#n. +sychological $ulletin# 67?# 39803? . Se&a%5 F. G H In&ra(5 R. E. =3@@9>. M##d *ri(in& and .#nstr$.t a.ti,ati#n in tests #6 .#&niti,e ,$%nerabi%ity t# $ni*#%ar de*ressi#n. 1linical +sychology (eview# 6;# ??:0?@". Se%i&(an5 M. E. P. =3@8">. ,elplessness5 On depression# development# and death. San Fran.is.#' Free(an. Sie&%e5 G. 75 H In&ra(5 R. E. =3@@?>. T/e bi& *i.t$re. 1ontemporary +sychology# ;6# 3?:03?9. Sie&%e5 G. 75 Stein/a$er5 S. R.5 T/ase5 M. E5 Sten&er5 A.5 H Carter5 C. S. = !! >. CanBt s/a+e t/at 6ee%in&' E,ent0re%ated 6MRI assess(ent #6 s$stained a(y&da%a a.ti,ity in res*#nse t# e(#ti#na% in6#r(ati#n in de*ressed indi,id$a%s. $iological +sychiatry# 96# ?@:08!8. Se%i&(an5 M. E. P. =3@@!>. W/y is t/ere s# ($./ de*ressi#n t#day' T/e 2a-in& #6 t/e indi,id$a% and t/e 2anin& #6 t/e .#((#ns. In R. E. In&ra(5 =Ed.>5 1ontemporary psychological approches to depression5 Theory# research# and treatment =30@>. Ne2 Y#r+5 P%en$( Press. Stader5 S. R5 H H#+ans#n5 7. E. =3@@;>. Psy./#s#.ia% ante.edents #6 de*ressi,e sy(*t#(s' An e,a%$ati#n $sin& dai%y e-*erien.es (et/#d#%#&y. ournal of %bnormal +sychology# 67A# 380 ?. Teasda%e5 7. D.

=3@@@>. M$%ti0%e,e% t/e#ries #6 .#&niti#n0e(#ti#n re%ati#ns. In T. Da%&%eis/ H M. P#2er =Eds.>5 ,andbook of cognition and emotion =**. ??"0?;3>. C/i./ester5 En&%and' Wi%ey. Teasda%e5 7. D5 H 1arnard5 P. 7. =3@@:>. %ffect# cognition# and change. Hi%%sda%e5 N7' La2ren.e Er%ba$( Ass#.iates. Tennant5 C. = !!3>. W#r+0re%ated stress and de*ressi,e dis#rders. ournal of +sychosomatic (esearch# 96# ?@808!9. T/ase5 M E5 7inda%5 R5 H H#2%and5 R. H. = !! >. 1i#%#&i.a% as*e.ts #6 de*ressi#n. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of depression =:rd ed.> =**. 3@ 0 3;>. Ne2 Y#r+' G$i%6#rd. Tr$%%5 T. 75 Widi&er5 T. A.5 H G$t/rie5 P. =3@@!>. Cate&#ri.a% ,ers$s di(ensi#na% stat$s #6 b#rder%ine *ers#na%ity dis#rder. ournal of %bnormal +sychology# @@# 9!09;. Tsai5 7. L5 H C/ents#,a0D$tt#n5 Y. = !! >. Understandin& de*ressi#n a.r#ss .$%t$res. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of Depression =:rd ed.> =**. 9?8P9@3>. Ne2 Y#r+' G$i%6#rd. Wa%%a.e5 75 S./neider5 T5 H M.G$66in5 P. = !! >. In I. H. G#t%ib H C. L. Ha((en =Eds.>5 ,andbook of depression =:r6 ed.> =**. 3?@03@3>. Ne2 Y#r+' G$i%6#rd. Weiss(an5 M5 Pr$s#665 1. A5 DiMas.i#5 A5 Ne$5 C5 G#+%aney5 M5 H )%er(an5 G. =3@8@>. T/e e66i.a.y #6 dr$&s and *sy./#t/era*y in t/e treat(ent #6 a.$te de*ressi,e e*is#des. %merican ournal of +sychiatry# 6?E#"""0"";. W/is(an5 M. A. = !!3>. T/e ass#.iati#n bet2een de*ressi#n and (arita% dissatis6a.ti#n. In S. R. H. 1ea./ =Ed>5 Marital and family processes in depression5 % scientific foundation for clinical practice =**. : A 9>. Was/in&t#n5 DC' A(eri.an Psy./#%#&i.a% Ass#.iati#n. F$r#665 D. C5 H FitC*atri.+5 D. ).. =3@@">. De*ressi,e *ers#na%ity sty%es' I(*%i.ati#ns 6#r ad$%t atta./(ent. +ersonality and 0ndividual Differences# 68# ":0:?".

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CHAPTER

9
S./iC#*/renia E%aine Wa%+er Annie 1#%%ini )aren H#./(an Lisa )est%er !mory University )'i4op'renia is among t'e most debi.itating of menta. i..nesses. "t is typi)a..y diagnosed bet(een 9, and 9< years of age$ a stage of .ife ('en most peop.e gain independen)e from parents$ de/e.op intimate romanti) re.ations'ips$ p.an edu)ationa. pursuits$ and begin (or- or )areer endea/ors 28eLisi$ *++93. Be)ause t'e ).ini)a. onset usua..y o))urs during t'is pi/ota. time$ t'e i..ness )an 'a/e a profound negati/e impa)t on t'e indi/idua.Gs opportunities for attaining so)ia. and o))upationa. su))ess$ and t'e )onse7uen)es )an be de/astating for t'e adu.t .ife )ourse. Furt'ermore$ a.t'oug' treatment approa)'es and t'e prognosis for s)'i4op'renia may differ among nations and et'ni) groups$ t'e i..ness -no(s no nationa. boundaries. A)ross )u.tures$ estimates of t'e .ifetime pre/a.en)e of s)'i4op'renia range around *P$ or one out of *,, 2@eit'$ Regier$ H Rae$ *++*C @u.'ara$ H C'a-rabarti$ 9,,*C #orrey$ *+BD3$ a.t'oug' t'e prognosis may differ among )ountries 2@u.'ara H C'a-rabarti$ 9,,*3. #'e origins of t'is de/astating menta. disorder 'a/e )ontinued to e.ude resear)'ers$ despite many de)ades of s)ientifi) resear)'. #o date$ no sing.e fa)tor 'as been found to )'ara)teri4e a.. patients (it' t'e i..ness. #'is 'o.ds for potentia. etio.ogi)a. fa)tors$ as (e.. as ).ini)a. p'enomena. )'i4op'renia patients /ary in symptom profi.es$ de/e.opmenta. 'istories$ fami.y ba)-grounds$ )ogniti/e fun)tions$ and e/en brain morp'o.ogy and neuro)'emistry. A.t'oug' t'is /ariation 'as .ed some to express dismay at our )'an)es of e/er finding t'e )ause of s)'i4op'renia$ t'ere is reason to be optimisti). Resear)' efforts 'a/e su))eeded in re/ea.ing numerous pie)es of ('at is no( re)ogni4ed as a )omp.ex pu44.e of etio.ogi)a. pro)esses. #'e )onsensus in t'e fie.d$ based on findings from /arious .ines of resear)'$ is t'at 2a3 s)'i4op'renia is a brain disease$ 2b3 its etio.ogy in/o./es t'e interp.ay bet(een geneti) and en/ironmenta. fa)tors$ 2)3 mu.tip.e de/e.opmenta. pat'(ays e/entua..y .ead to disease onset$ and 2d3 brain maturationa. pro)esses p.ay a ro.e in t'e etio.ogi)a. pro)ess. "n t'is )'apter$ (e pro/ide an o/er/ie( of t'e )urrent state of our -no(.edge about s)'i4op'renia. We (i.. begin (it' a dis)ussion of 'istory and p'enomeno.ogy$ t'en pro)eed to a des)ription of some of t'e -ey findings t'at 'a/e s'ed .ig't on t'e i..ness. 330

331 WAL)ER ETAL. &" #!RA AN8 %&EN!MEN!L!=A Written des)riptions of patients experien)ing psy)'oti) symptoms 'a/e been re)orded sin)e an1 ti7uity. &o(e/er$ be)ause psy)'oti) symptoms )an be a manifestation of a /ariety of disorders$ it is un).ear ('et'er s)'i4op'renia$ as su)'$ is an an)ient or re.ati/e.y ne( p'enomenon. "n t'e mid1to1.ate nineteent' )entury$ European psy)'iatrists (ere in/estigating t'e etio.ogy$ ).assi1 fi)ation$ and prognoses of t'e /arious types of psy)'osis. At t'at time$ t'e most )ommon )ause of psy)'osis (as tertiary syphilis# a.t'oug' resear)'ers (ere una(are t'at t'ere (as any .inbet(een psy)'osis and syp'i.is. #'e psy)'o.ogi)a. symptoms of tertiary syp'i.is fre7uent.y o/er.ap (it' symptoms of ('at (e no( )a.. s)'i4op'renia. #'e )ause of syp'i.is (as e/entua..y tra)ed to an infe)tion (it' t'e spiro)'ete$ Treponema pallidum# and antibioti)s (ere found to be effe)ti/e for pre/ention and treatment of t'e disorder. #'is important dis)o/ery ser/ed to i..ustrate 'o( a psy)'o.ogi)a. syndrome )an be produ)ed by an infe)tious agent. "t a.so sensiti4ed resear)'ers to t'e fa)t t'at simi.ar syndromes mig't be t'e resu.t of different )auses. Emi. @raepe.in 2*B<?1*+9?3 (as t'e medi)a. dire)tor of t'e famous &eide.berg C.ini). &e (as t'e first to differentiate s)'i4op'renia$ ('i)' 'e referred to as Hdementia praeco"H 2or dementia of t'e young3 from mani)1depressi/e psy)'osis 2@raepe.in$ *+*:3. &e a.so .umped toget'er 'ebep'renia$ paranoia$ and )atatonia 2pre/ious.y t'oug't to be distin)t disorders3$ and ).assified a.. of t'em as /ariants of dementia prae)ox. &e based t'is ).assifi)ation on simi.arities in age of onset and t'e tenden)y for a.. to in/o./e poor prognosis. @raepe.in did not be.ie/e t'at any one symptom (as diagnosti) of dementia prae)ox$ but instead based t'e diagnosis on t'e tota. ).ini)a. pi)ture and obser/ation of t'e e/o.ution of symptoms. "f a psy)'oti) patient deteriorated o/er an extended period of time 2mont'sLyears3$ t'e )ondition (as assumed to be dementia prae)ox. #'e expe)tation of negati/e out)ome (it' t'e diagnosis of s)'i4op'renia 'as )ontinued to per/ade t'e t'in-ing of psy)'iatry. A.t'oug' it is true t'at t'e ma6ority of patients manifest a )'roni) )ourse t'at entai.s .ife.ong disabi.ity$ t'is is not a.(ays t'e )ase 2Carpenter H Bu)'anan$ *++;3. #'e story of 8r. Jo'n Nas'$ professor and mat'emati)ian at %rin)eton$ as to.d in t'e mo/ie$ % $eautiful Mind# i..ustrates t'is 7uite (e... Aet$ e/en today$ t'e expe)tation of negati/e out)ome infuses t'e menta. 'ea.t' profession (it' an unfortunate sense of t'erapeuti) ni'i.ism. #'e term schi*ophrenia (as introdu)ed at t'e beginning of t'e 9,t' )entury by Eugen B.eu.er 2*B<D1*+:+3$ a (iss psy)'iatrist and t'e medi)a. dire)tor of a menta. 'ospita. in Ruri)' 2&o(e..s$ *++*$ pp. xii$ +<3. #'e (ord is deri/ed from t(o =ree- (ords5 schi*o# ('i)' means to tear or to sp.it$ andphren# ('i)' 'as se/era. meanings5 "n an)ient times$ t'e (ord phren meant t'e inte..e)t or t'e mind. +hren a.so referred to t'e .ungs and t'e diap'ragm$ ('i)' (ere be.ie/ed to be t'e seat of emotions. #'us$ t'e (ord s)'i4op'renia .itera..y means t'e sp.itting or tearing of t'e mind and emotiona. stabi.ity of t'e patient. B.eu.er ).assified t'e symptoms of s)'i4op'renia into fundamenta. and a))essory symptoms. #'e fundamenta. symptoms of s)'i4op'renia are often reported in textboo-s as t'e four As$ a.t'oug'$ in fa)t$ t'ere are six As and one 8 2B.eu.er$ *+**L*+<,3. #'e fundamenta. symptoms are .isted in #ab.e +.*. A))ording to B.eu.er$ t'ese symptoms are present in a.. patients$ at a.. stages of t'e i..ness$ and are diagnostic of s)'i4op'renia. B.eu.erGs a))essory symptoms of s)'i4op'renia in).uded de.usions$ 'a..u)inations$ mo/ement disturban)es$ somati) symptoms$ and mani) and me.an)'o.i) states. &e be.ie/ed t'at t'ese symptoms (ere not present in a.. s)'i4op'renia patients and often o))urred in ot'er i..nesses.

For t'ese reasons$ t'e a))essory symptoms (ere not assumed to be diagnosti) of s)'i4op'renia. Furt'er refinements in t'e diagnosti) )riteria for s)'i4op'renia (ere proposed by @urt )'neider in t'e mid *+,,s. Li-e B.eu.er$ @urt )'neider t'oug't t'at )ertain -ey symptoms

@. SCHIFOPHRENIA 333 TA1LE @.3 1%e$%erBs F$nda(enta% Sy(*t#(s #6 S./iC#*/renia Dist$rban.es #6 ass#.iati#n =%##se5 i%%#&i.a% t/#$&/t *r#.esses> Dist$rban.es #6 a66e.t =indi66eren.e5 a*at/y5 #r ina**r#*riateness> Dist$rban.es #6 attenti#n A(bi,a%en.e =.#n6%i.tin& t/#$&/ts5 e(#ti#ns5 #r i(*$%ses t/at are *resent si($%tane#$s%y #r in ra*id s$..essi#n> A$tis( =deta./(ent 6r#( s#.ia% %i6e 2it/ inner *re#..$*ati#n> Ab$%ia =%a.+ #6 dri,e #r (#ti,ati#n> De(entia =irre,ersib%e ./an&e in *ers#na%ity> TA1LE @. T/e S./neiderian First Ran+ Sy(*t#(s T/#$&/t e./#in& #r a$dib%e t/#$&/ts =*atients /ear t/eir t/#$&/ts #$t %#$d> T/#$&/t br#ad.astin& =*atients be%ie,e t/at #t/ers .an /ear t/eir t/#$&/ts #$t %#$d> T/#$&/t intr$si#n =*atients 6ee% t/at s#(e #6 t/eir t/#$&/ts are 6r#( #$tsideY t/at is5 n#t #ri&inatin& in t/eir #2n (inds> T/#$&/t 2it/dra2a% =*atients be%ie,e t/at t/e .a$se #6 /a,in& %#st tra.+ #6 a t/#$&/t is t/at s#(e#ne is ta+in& t/eir t/#$&/ts a2ay> S#(ati. /a%%$.inati#ns =$n$s$a%5 $ne-*%ained sensati#ns in #neBs b#dy> Passi,ity 6ee%in&s =*atients be%ie,e t/at t/eir t/#$&/ts5 6ee%in&s5 #r a.ti#ns are .#ntr#%%ed by an#t/er #r #t/ers> De%$si#na% *er.e*ti#n =a s$dden5 6i-ed5 6a%se be%ie6 ab#$t a *arti.$%ar e,eryday #..$rren.e #r *er.e*ti#n (ere diagnosti) of s)'i4op'renia 2 )'neider$ *+<+3. "n 'is ).assifi)ation$ 'e referred to t'ese diagnosti) symptoms as first ran- symptoms 2see #ab.e +.93. &e be.ie/ed t'at$ after )ertain medi)a. )auses of psy)'osis (ere ru.ed out$ one )ou.d ma-e t'e diagnosis of s)'i4op'renia if one or more first ran- symptom (as present. )'neiderGs des)riptions of t'e symptoms (ere more detai.ed and spe)ifi) t'an (ere B.eu.erGs fundamenta. symptoms. ubse7uent diagnosti) )riteria for s)'i4op'renia 'a/e been 'ea/i.y inf.uen)ed by )'neiderGs approa)'. "n subse7uent years$ in/estigators began to ma-e a distin)tion bet(een positi/e and negati/e symptoms of s)'i4op'renia 2&ar/ey H Wa.-er$ *+BD3. #'e positi/e symptoms are t'ose t'at in/o./e an ex)ess of ideas$ sensory experien)es$ or be'a/ior. &a..u)inations$ de.usions$ and bi4arre be'a/iors fa.. in t'is )ategory. Most of t'e first ran- symptoms des)ribed by )'neider are a.so )onsidered to be positi/e symptoms. Negati/e symptoms$ in )ontrast$ in/o./e a de)rease in be'a/ior$ su)' as b.unted or f.at affe)t$ an'edonia 2.a)- of en6 oyment in p.easurab.e a)ti/ities$ and .a)- of moti/ation3. #'ese symptoms (ere emp'asi4ed by B.eu.er. 8uring t'e midd.e of t'e t(entiet' )entury$ different diagnosti) )riteria for s)'i4op'renia be)ame popu.ar in different parts of t'e (or.d. #'e @raepe.inian tradition$ (it' its .ongitudina. re7uirements for diagnosis$ identified patients (it' poorer .ong1term prognosis. "n )ontrast$ t'e B.eu.erian and )'neiderian diagnosti) systems a..o(ed for a (ider range of psy)'oti) patients to be diagnosed (it' s)'i4op'renia. #'us t'e patients diagnosed (it' t'ese t(o systems tended to 'a/e a better prognosis t'an t'ose diagnosed in t'e more stringent @raepe.inian tradition. #'e use of mu.tip.e diagnosti) systems 'ad a detrimenta. effe)t on resear)' progress. Resear)' findings from )ountries using different diagnosti) )riteria (ere not )omparab.e$ t'us .imiting t'e genera.i4abi.ity of t'e resu.ts.

334 WAL)ER ET AL. #'e next generation of diagnosti) systems e/o./ed (it' t'e intent of a)'ie/ing uniformity in diagnosti) )riteria and impro/ing diagnosti) re.iabi.ity. Among t'ese (ere t'e Feig'ner or t. Louis diagnosti) )riteria 2Feig'ner$ Robins$ H =u4e$ *+D93$ and t'e Resear)' 8iagnosti) Criteria de/e.oped by Robert pit4er and 'is )o..eagues 2 pit4er$ Endi)ott$ H Robins$ *+DB3. #'ese t(o approa)'es to t'e diagnosis of s)'i4op'renia 'ad a ma6or impa)t on t'e )riteria for s)'i4op'renia )ontained in )ontemporary diagnosti) systems$ most notab.y$ t'e -iagnostic and .tatistical /anual of /ental -isorders 28 M3. #'e 8 M is no( t'e most (ide.y used system for diagnosing s)'i4op'renia and ot'er menta. disorders. #'e most re)ent /ersion of t'e 8 M is t'e 8 M1">1#R 2A%A$ 9,,,3. Using 8 M1">1 #R )riteria$ s)'i4op'renia )an be diagnosed ('en signs and symptoms of t'e disorder 'a/e been present for ? mont's or more 2in).uding prodroma. and residua. p'ases3. #'e )'ara)teristi) symptom )riteria for s)'i4op'renia in).ude t'e fo..o(ingC 2a3 'a..u)inations$ 2b3 de.usions$ 2)3 disorgani4ed spee)' 2e.g.$ fre7uent derai.ment or in)o'eren)e3$ 2d3 gross.y disorgani4ed or )atatoni) be'a/ior$ and 2e3 negati/e symptoms$ t'at is$ affe)ti/e f.attening$ a.ogia or a/o.ition. At .east t(o or more of t'ese psy)'oti) symptoms must be present for at .east * mont' 2or .ess if su))essfu..y treated3. !n.y one of t'ese symptoms is ne)essary if t'e de.usions are bi4arre or t'e 'a..u)inated /oi)es )onsist of a running )ommentary or of t(o /oi)es )on/ersing 2bot' of t'ese are deri/ed from )'neiderGs first ran- symptoms in #ab.e +193. "n addition to t'e ).ini)a. symptoms$ t'ere must be so)ia.Lo))upationa. dysfun)tion. Furt'ermore$ signifi)ant mood disorder$ su)' as depression or mani) symptoms$ must not be present. 2#'is re7uirement (ou.d ex).ude indi/idua.s ('o meet )riteria for ma6or depressi/e disorder (it' psy)'oti) symptoms and bipo.ar disorder (it' psy)'oti) symptoms3. Fina..y$ genera. medi)a. )onditions or substan)e abuse t'at mig't .ead to psy)'oti) symptoms must be ru.ed out. #'e four subtypes of s)'i4op'renia des)ribed in 8 M1"> are paranoid, disorgani<ed, catatonic, and undifferentiated. #'e paranoid type is )'ara)teri4ed by a preo))upation (it' de.usions or 'a..u)inations$ but t'ere is no disorgani4ed spee)'$ disorgani4ed or )atatoni) be'a/ior$ or f.at or inappropriate affe)t. #'is is t'e subtype (it' t'e best prognosis. "n t'e disorgani<ed type$ a.. of t'e fo..o(ing are prominent5 disorgani4ed spee)'$ disorgani4ed be1 'a/ior$ and f.at or inappropriate affe)t$ but t'e )riteria for t'e )atatoni) subtype are not met. #'is is t'e subtype (it' t'e (orst prognosis. #'e catatonic type in/o./es a ).ini)a. syndrome t'at is dominated by at .east t(o of t'e fo..o(ing5 motori) immobi.ity$ ex)essi/e purpose.ess motor a)ti/ity 2)atatoni) ex)itement3$ extreme negati/ism 2purpose.ess resistan)e to mo/ement andLor a.. instru)tions3$ mutism 2absen)e of spee)'3$ pe)u.iar /o.untary mo/ements 2/o.untary assumption of bi4arre or unusua. postures3$ stereotyped mo/ements 2repetiti/e$ nonfun)tiona.$ yet /o.untary3$ prominent mannerisms 2repetiti/e gestures or expressions3 or prominent fa)ia. grima)ing$ or e)'o.a.ia 2repetition of anot'er personGs (ords or p'rases3 or e)'opraxia 2repetition of anot'er personGs a)tions3. Fina..y$ t'e undifferentiated subtype is diagnosed ('en t'e patient does not meet )riteria for t'e pre/ious subtypes$ yet does meet t'e genera. )riteria for s)'i4op'renia. #'e in).usion of t'is subtype in t'e 8 M1"> s'ou.d remind us t'at t'ese are artifi)ia..y )onstru)ted )ategories$ not distin)t diagnosti) entities (it' uni7ue )auses. #(o ot'er diagnosti) )ategories in t'e s)'i4op'renia spe)trum are (ort' noting. !ne is a )ategory for indi/idua.s ('o 'a/e met )riteria for s)'i4op'renia in t'e past$ but no .onger do. #'is )ategory is referred to as t'e residual type. #'is diagnosis is app.ied ('en t'ere is a

prominen)e of negati/e symptoms$ or t(o or more attenuated )'ara)teristi) symptoms$ but no prominent de.usions$ 'a..u)inations$ )atatoni) symptoms$ or disorgani4ed be'a/ior or spee)'. #'e ot'er )ategory$ schi<ophreniform disorder, is for indi/idua.s ('ose symptoms do not meet t'e six1mont' )riterion. #'is diagnosis is fre7uent.y made as a pre.ude to t'e diagnosis of s)'i4op'renia$ ('en t'e patient presents for treatment ear.y in t'e )ourse of t'e disorder.

@. SCHIFOPHRENIA 336 ome indi/idua.s (it' t'is disorder$ 'o(e/er$ (i.. re)o/er )omp.ete.y and not suffer furt'er episodes of psy)'osis. "t is important to emp'asi4e t'at$ despite ad/an)es in diagnosis$ (e sti.. do not -no( t'e diagnosti) boundaries of s)'i4op'renia. Moreo/er$ t'e boundaries bet(een s)'i4op'renia and mood disorders are obs)ure. Many indi/idua.s ('o meet )riteria for s)'i4op'renia s'o( mar-ed signs of depression or mani) tenden)ies. #'ese symptoms are sometimes present before t'e onset of s)'i4op'renia$ and fre7uent.y o))ur in )ombination (it' mar-ed psy)'oti) symptoms. As a resu.t$ t'e 8 M1"> in).udes a diagnosti) )ategory )a..ed schi<oaffective disorder. #'is disorder )an be t'oug't of as a 'ybrid bet(een t'e mood disorders 2bipo.ar disorder or ma6or depression (it' psy)'oti) features3 and s)'i4op'renia. #'e t(o subtypes are t'e depressive subtype 2if t'e mood disturban)e in).udes on.y depressi/e episodes3 and t'e bipolar subtype 2('ere t'e symptoms of t'e disorder 'a/e in).uded eit'er a mani) or a mixed episode3. "nteresting.y$ t'e prognosis for patients (it' s)'i4oaffe)ti/e disorder is$ on a/erage$ some('ere bet(een t'at of s)'i4op'renia and t'e mood disorders. COGNITIGE AND EMOTIONAL ASPECTS OF SCHIFOPHRENIA Among t'e most (e..1estab.is'ed aspe)ts of s)'i4op'renia are t'e )ogniti/e defi)its t'at a)1 )ompany t'e i..ness. )'i4op'renia patients manifest performan)e defi)its on a broad range of )ogniti/e tas-s$ from simp.e to )omp.ex 2=reen$ @ern$ Braff$ H Mint4$ 9,,,3. !ne of t'e most basi) is t'e defi)it in t'e /ery ear.iest stages of /isua. information pro)essing. Using a .aboratory pro)edure )a..ed ba)-(ard mas-ing$ resear)'ers 'a/e s'o(n t'at s)'i4op'renia patients are s.o(er in t'e initia. pro)essing of stimu.i 2=reen$ Nue)'ter.ein$ Breitmeyer$ H Mint4$ *+++3. Among t'e 'ig'er1.e/e. )ogniti/e fun)tions$ s)'i4op'renia patients s'o( defi)its in /erba. and spatia. memory$ abstra)t reasoning$ psy)'omotor speed$ and p.anning 2@uperberg H &e)-ers$ 9,,,3. #'ere are a.so defi)its in t'in-ing about so)ia. p'enomena. tudies of so)ia. )ogniti/e abi.ities in s)'i4op'renia patients 'a/e )onsistent.y s'o(n t'at patients are impaired in t'eir abi.ity to )ompre'end and so./e so)ia. prob.ems 2%enn$ Corrigan$ Benta..$ Ra)enstein$ H Ne(man$ *++D3. 8efi)its in so)ia. )ognition may be partia..y due to .imitations in more basi) )ogniti/e pro)esses$ su)' as memory and reasoning. &o(e/er$ basi) )ogniti/e impairments do not a))ount )omp.ete.y for t'e more per/asi/e and persistent so)ia. )ogniti/e defi)its obser/ed in s)'i4op'renia. !ne of t'e diagnosti) )riteria for s)'i4op'renia is b.unted or inappropriate affe)t. "t is$ t'erefore$ not surprising t'at patients s'o( abnorma.ities in t'e expression of emotion in bot' t'eir fa)es and /erba. )ommuni)ationsC spe)ifi)a..y$ .ess positi/e and more negati/e emotion 2Bro4go.d et a.$ *++B3. Furt'er$ t'ey are .ess a))urate t'an norma. )omparison sub6e)ts in t'eir abi.ity to .abe. fa)ia. expressions of emotion 2%enn$ Combs$ Rit)'ie$ Fran)is$ Cassisi$ Morris$ H #o(nsend$ 9,,,C Wa.-er et a..$ *+B*3. %atients (it' more se/ere impairments in t'eir abi.ities to re)ogni4e and express emotion a.so 'a/e more prob.ems in so)ia. ad6ustment. THE ORIGINS OF SCHIFOPHRENIA Psy./#%#&i.a% T/e#ries "n t'e ear.y part of t'e 9,t' )entury$ psy)'oso)ia. t'eories of s)'i4op'renia dominated t'e .it1 erature. For examp.e$ igmund Freud$ t'e fat'er of psy)'oana.ysis$ be.ie/ed t'at psy)'o.ogi)a. pro)esses resu.ted in t'e de/e.opment of psy)'oti) symptoms 2&o(e..s$ *++*3. "n *+;B$ Frieda

337 WAL@ER E# AL. Fromm1Rei)'mann proposed a psy)'o.ogi)a. t'eory of s)'i4op'renia t'at postu.ated t'at t'e disorder arose in response to rearing by a s)'i4op'renogeni) mot'er 2Fromm1Rei)'mann$ *+;B3. A.t'oug' t'is 'ypot'esis 'as fa..en in disfa/or be)ause of .a)- of support from empiri)a. resear)'$ it )aused )onsiderab.e suffering for fami.ies. #'e t'eory added to t'e stigma and burden of fami.y members see-ing treatment for t'eir i.. fami.y members. ubse7uent.y$ fami.y intera)tion mode.s of t'e etio.ogy of s)'i4op'renia (ere offered by /arious t'eorists 2&o(e..s$ *++*3. Again$ t'ese )ontributed re.ati/e.y .itt.e to our understanding of t'e etio.ogy of s)'i4op'renia$ a.t'oug' t'ey did e/entua..y ser/e to 'ig'.ig't t'e importan)e of )onsidering t'e ro.e of t'e fami.y in pro/iding support for t'e re)o/ering patient. 1i#%#&i.a% T/e#ries @raepe.in$ B.eu.er$ and ot'er ear.y (riters on s)'i4op'renia did not offer spe)ifi) t'eories about t'e origins of s)'i4op'renia. #'ey did$ 'o(e/er$ suggest t'at t'ere mig't be a bio.ogi)a. basis for at .east some )ases of t'e i..ness. Li-e(ise$ )ontemporary ideas about t'e origins of s)'i4op'renia fo)us on bio.ogi)a. /u.nerabi.ities t'at are assumed to be present at birt'. Resear)'ers 'a/e identified t(o sour)es of )onstitutiona. /u.nerabi.ity5 geneti) fa)tors and prenata. or obstetri) fa)tors. Bot' appear to 'a/e imp.i)ations for feta. brain de/e.opment. The Genetics o f 'chi*ophrenia. !ne of t'e most (e.. estab.is'ed findings in s)'i4op'renia resear)' is t'at a /u.nerabi.ity to t'e i..ness )an be in'erited 2=ottesman$ *++*3. Be'a/ior geneti) studies uti.i4ing t(in$ adoption$ and fami.y 'istory met'ods 'a/e a.. yie.ded e/iden)e t'at t'e ris- for s)'i4op'renia is e.e/ated in indi/idua.s ('o 'a/e a bio.ogi)a. re.ati/e (it' t'e disorderC t'e ).oser t'e .e/e. of geneti) re.atedness$ t'e greater t'e .i-e.i'ood t'e re.ati/e (i.. a.so suffer from s)'i4op'renia. "n a re/ie( of fami.y$ t(in$ and adoption studies )ondu)ted from *+*? to *+B+$ "r/ing =ottesman 2*++*3 out.ined t'e )ompe..ing e/iden)e for t'e ro.e of geneti) fa)tors in s)'i4op'renia. Mono4ygoti) 2MR3 t(ins$ ('o s'are near.y *,,P of t'eir genes$ 'a/e t'e 'ig'est )on)ordan)e rate for s)'i4op'renia. Among MR )ot(ins of patients (it' s)'i4op'renia$ 9<P to <,P (i.. de/e.op t'e i..ness. 8i4ygoti) 28R3 t(ins and ot'er sib.ings s'are$ on a/erage$ on.y about 'a.f of t'eir genes. About *,P to *<P of t'e 8R )ot(ins of patients are a.so diagnosed (it' t'e i..ness. Furt'ermore$ as geneti) re.atedness of t'e re.ati/e to t'e patient be)omes more distant$ su)' as from first degree 2parents$ sib.ings3 to se)ond degree re.ati/es 2grandparents$ 'a.f1sib.ings$ aunts$ and un).es3$ t'e re.ati/eGs .ifetime ris- for s)'i4op'renia is redu)ed. Adoption studies 'a/e pro/ided e/iden)e t'at t'e tenden)y for s)'i4op'renia to run in fami.ies is primari.y due to geneti) fa)tors rat'er t'an t'e en/ironmenta. inf.uen)e of being exposed to a menta..y i.. fami.y member. "n a semina. adoption study$ &eston 2*+??3 examined t'e rates of s)'i4op'renia in adoptees (it' and (it'out a bio.ogi)a. parent ('o (as diagnosed (it' t'e i..ness. &e found 'ig'er rates of s)'i4op'renia$ and ot'er menta. i..nesses$ in t'e bio.ogi)a. offspring of parents (it' s)'i4op'renia$ ('en )ompared to adoptees (it' no menta. i..ness in bio.ogi)a. parents. imi.ar.y$ in a 8anis' samp.e$ @ety 2*+BB3 examined t'e rates of menta. i..ness in t'e re.ati/es of adoptees (it' and (it'out s)'i4op'renia. &e found t'at t'e bio.ogi)a. re.ati/es of adoptees ('o suffered from s)'i4op'renia 'ad a signifi)ant.y 'ig'er rate of s)'i4op'renia t'an t'e adopti/e re.ati/es ('o reared t'em. A.so$ t'e rate of s)'i4op'renia in t'e bio.ogi)a. re.ati/es of adoptees (it' s)'i4op'renia (as 'ig'er t'an in t'e re.ati/es 2bio.ogi)a. or adopti/e3 of 'ea.t'y adoptees. #'ese adoption studies pro/ide amp.e e/iden)e for a signifi)ant geneti) )omponent in t'e etio.ogy of s)'i4op'renia.

!f )ourse$ adoption studies assume a geneti) inf.uen)e ('en adopted indi/idua.s are more simi.ar to t'eir bio.ogi)a. parents t'an t'eir adopti/e parents. &o(e/er$ an en/ironmenta.

@. SCHIFOPHRENIA 339 )onfound t'at )annot be ru.ed out is t'e intrauterine en/ironment. As des)ribed .ater$ t'ere is an e.e/ated rate of substan)e abuse among s)'i4op'renia patients$ so it is possib.e t'at t'e offspring of (omen (it' s)'i4op'renia are exposed to more prenata. ris- fa)tors. #o determine ('et'er adoption findings are partia..y attributab.e to intrauterine fa)tors$ @ety 2*+BB3 examined paterna. 'a.f1sib.ings 2)'i.dren (it' t'e same fat'er and different mot'ers3 ('o (ere adopted a(ay and eit'er de/e.oped s)'i4op'renia or 'ad 'ea.t'y adu.t out)omes. "f t'e intrauterine en/ironment is in)reasing ris- for s)'i4op'renia in t'e bio.ogi)a. offspring of (omen (it' t'e disorder$ t'en paterna. 'a.f1sib.ings s'ou.d 'a/e .o(er )on)ordan)e for s)'i4op'renia. @ety found t'at t'e rate of s)'i4op'renia in paterna. 'a.f1sib.ings of s)'i4op'reni) adoptees 2*:P3 (as mu)' greater t'an t'e rate of s)'i4op'renia in 'a.f1sib.ings of norma. adoptees 2*.?P3$ suggesting t'at t'e e.e/ated ris- is attributab.e to geneti) fa)tors. But more re)ent findings from an adoption study indi)ate t'at t'e geneti) inf.uen)es often a)t in )on)ert (it' en/ironmenta. fa)tors. #ienari$ Wynne$ Moring$ and La'ti 2*++;3 )ondu)ted an adoption study in Fin.and$ and found t'at t'e rate of psy)'oses and ot'er se/ere disorders (as signifi)ant.y 'ig'er t'an in t'e mat)'ed )ontro. adoptees. &o(e/er$ t'e differen)e bet(een t'e groups (as dete)ted on.y in adopti/e fami.ies t'at (ere rated as dysfun)tiona.. #'e geneti) /u.nerabi.ity (as main.y expressed in asso)iation (it' a disrupti/e adopti/e en/ironment and (as not dete)ted in adoptees reared in a 'ea.t'y$ possib.y prote)ti/e$ fami.y en/ironment. #'ese findings are )onsistent (it' t'e pre/ai.ing diat'esis1stress mode.s of etio.ogy. #a-en toget'er$ t'e findings from be'a/iora. geneti) studies of s)'i4op'renia .ead to t'e )on1 ).usion t'at t'e disorder in/o./es mu.tip.e genes rat'er t'an a sing.e gene 2=ottesman$ *++*3. #'is )on).usion is based on se/era. obser/ations$ most notab.y t'e fa)t t'at t'e pattern of fami.1 ia. transmission does not )onform to ('at (ou.d be expe)ted form a sing.e geneti) .o)us or e/en a sma.. number of genes. Consistent (it' t'is assumption$ attempts to identify a geneti) .o)us t'at a))ounts for a signifi)ant proportion of )ases of s)'i4op'renia 'a/e not met (it' su))ess. "nstead$ resear)'ers using mo.e)u.ar geneti) te)'ni7ues 'a/e identified se/era. genes t'at may a))ount for a /ery sma.. proportion of )ases. Candidate gene ana.yses and .in-age studies 'a/e pro/ided some e/iden)e for t'e in/o./ement of se/era. spe)ifi) genes$ su)' as t'e serotonin type 9a re)eptor 2<1&#9a3 gene$ t'e dopamine 8: re)eptor gene$ and se/era. )'romosoma. regions 2i.e.$ regions on )'romosomes ?$ B$ *:$ and 993 2Mo(ry H Nan)arro($ 9,,*3. !ne of t'e most note(ort'y geneti) dis)o/eries to date is 2'e asso)iation bet(een s)'i4op'renia and )'romosoma. mi)rode.etions in t'e 7 . . band of )'romosome 99$ usua..y referred to as t'e 997. * de.etion. #'e 997. * de.etion o))urs in about .,9<P of t'e genera. popu.ation and is often a))ompanied by a p'ysi)a. syndrome t'at in).udes stru)tura. anoma.ies of t'e fa)e$ 'ead$ and 'eart. About 9<P of indi/idua.s (it' t'e 997. * de.etion syndrome 28 3 meet diagnosti) )riteria for s)'i4op'renia$ and approximate.y 9P of s)'i4op'renia patients 'a/e t'e 997. * de.etion genotype$ a.t'oug' t'e rate of 997. * de.etion maybe 'ig'er inpatients (it' an ear.ier onset 2Bassett et a..$ *++BC @arayiorgou$ Morris$ H Morro($ *++<3. But beyond t'e (e..1estab.is'ed findings des)ribed 'ere$ t'ere are some ongoing )ontro/ersies surrounding t'e geneti)s of s)'i4op'renia. !ne of t'ese )ontro/ersies )on)erns t'e spe)ifi)ity of t'e geneti) .iabi.ity for s)'i4op'renia. Ear.y be'a/iora. geneti) studies .ed to t'e )on).usion t'at t'ere (ere separab.e geneti) .iabi.ities for s)'i4op'renia and t'e ma6or affe)ti/e disorders$ name.y$ bipo.ar disorder and psy)'oti) depression. But more re)ent e/iden)e indi)ates t'at t'is is not t'e )ase. Using 7uantitati/e geneti) te)'ni7ues (it' .arge t(in samp.es$ resear)'ers 'a/e

s'o(n t'at t'ere is signifi)ant o/er.ap in t'e genes t'at )ontribute to s)'i4op'renia$ s)'i4oaffe)ti/e disorder$ and mani) syndromes 2Cardno$ Ri6sdi6-$ 'am$ Murray$ H M)=uffin$ 9,,93. !t'er studies 'a/e yie.ded simi.ar resu.ts$ .eading many in t'e fie.d to )on).ude t'at t'e geneti) /u.nerabi.ity does not )onform to t'e diagnosti) boundaries .isted in 8 M and ot'er taxonomies 2e.g.$ %otas' et a..$ 9,,*3. Rat'er$ it appears t'at t'ere

341 WAL)ER ET AL. is a geneti) /u.nerabi.ity to psy)'osis in genera.$ and t'at t'e expression of t'is /u.nerabi.ity )an ta-e t'e form of s)'i4op'renia or an affe)ti/e psy)'osis$ depending on ot'er geneti) and a)7uired ris- fa)tors. #'e se)ond ma6or )ontro/ersy in t'e fie.d )on)erns t'e magnitude and extent of t'e geneti) /u.nerabi.ity for s)'i4op'renia. "n ot'er (ords$ ('at is t'e re.ati/e importan)e of in'erited /u.nerabi.ity versus externa. fa)tors t'at impinge on t'e de/e.oping indi/idua.. As mentioned ear.ier$ (e no( -no( t'at t'e en/ironment begins to 'a/e an impa)t before birt'C prenata. e/ents are .in-ed (it' ris- for s)'i4op'renia$ and some of t'ese prenata. fa)tors are dis)ussed .ater. #'us$ in order to index en/ironmenta. e/ents t'at )ontribute to a)7uired )onstitutiona. /u.nerabi.ity$ (e must in).ude bot' t'e prenata. and postnata. periods. At t'is point$ 'o(e/er$ resear)'ers are not in a position to estimate t'e re.ati/e magnitude of t'e in'erited and en/iron1 menta. )ontributors to t'e etio.ogy of s)'i4op'renia. Moreo/er$ (e do not yet -no( ('et'er geneti) /u.nerabi.ity is present in a.. )ases of s)'i4op'renia. "t is possib.e t'at some )ases of t'e i..ness are so.e.y attributab.e to en/ironmenta. ris- fa)tors. Furt'ermore$ (e do not -no( ('et'er t'e geneti) predisposition to s)'i4op'renia is a.(ays expressed$ a.t'oug' t'ere is substanti/e e/iden)e to indi)ate t'at it is not. We -no( t'at t'e )on)ordan)e rate for s)'i4op'renia in MR t(ins is no('ere near *,,P$ ('i)' suggests t'at some geneti)a..y /u.nerab.e indi/idua.s do not de/e.op t'e i..ness. "t is possib.e$ 'o(e/er$ t'at t'e geneti) .iabi.ity for s)'i4op'renia sometimes resu.ts from a mutation t'at o))urs in on.y t'e affe)ted member of dis)ordant MR pairs. But findings from studies of dis)ordant MR t(ins indi)ate t'at t'e rate of s)'i4op'renia is simi.ar$ and e.e/ated$ in t'e offspring of bot' t'e affe)ted and nonaffe)ted )ot(ins 2=ottesman H Berte.sen$ *+B+C @ring.en H Cramer$ *+B+3. "n ot'er (ords$ t'e offspring of t'e norma. MR t(in 'a/e a rate of s)'i4op'renia simi.ar to t'e offspring of t'e i.. )ot(in$ e/en t'oug' t'ey (ere not raised by a s)'i4op'reni) parent. #'is finding pro/ides support for t'e notion t'at some indi/idua.s possess a geneti) /u.nerabi.ity for s)'i4op'renia t'at t'ey pass on to t'eir offspring$ despite t'e fa)t t'at t'ey are ne/er diagnosed (it' t'e i..ness. #'us$ unexpressed geneti) /u.nerabi.ities for s)'i4op'renia may be )ommon in t'e genera. popu.ation. #'e presen)e of indi/idua.s ('o 'a/e an unexpressed geneti) /u.1 nerabi.ity to s)'i4op'renia ma-es t'e (or- of geneti) resear)'ers mu)' more diffi)u.t. At t'e same time$ t'e e/iden)e of unexpressed genotypes for s)'i4op'renia .eads us to in7uire about fa)tors t'at trigger t'e expression of i..ness in /u.nerab.e indi/idua.s and to 'ope t'at t'is -no(.edge may$ some day$ .ead to effe)ti/e pre/entati/e inter/entions. +renatal and +erinatal /actors. "n addition to t'e support it pro/ides for 'ereditary inf.uen)es on s)'i4op'renia$ t'e be'a/ior geneti) .iterature ).ear.y i..ustrates t'e re.e/an)e of en/ironmenta. fa)tors. "dentifying t'ese fa)tors is a primary fo)us of many in/estigators$ and t'e prenata. period 'as re)ei/ed greater attention in re)ent years. #'ere is extensi/e e/iden)e t'at obstetri)a. )omp.i)ations 2!Cs3 'a/e an ad/erse impa)t on t'e de/e.oping feta. brain and may )ontribute to /u.nerabi.ity for s)'i4op'renia. Birt' )o'ort studies 'a/e s'o(n t'at s)'i4op'renia patients are more .i-e.y to 'a/e a 'istory of !Cs 2Bu-a$ #suang$ H Lipsitt$ *++:C M)Nei.$ *+BBC 8a.man$ A..ebe)-$ Cu..berg$ =rune(a.d$ H @oester$ *+++3. "n).uded among t'ese are pregnan)y prob.ems$ su)' as toxemia and pree).ampsia$ and .abor and de.i/ery )omp.i)ations. A re/ie( of t'e !C .iterature by Cannon 2*++D3 )on).uded t'at$ among t'e different types of !Cs$ .abor and de.i/ery )omp.i)ations$ ('i)' are often asso)iated (it' 'ypoxia 2feta. oxygen depri/ation3$ (ere t'e most strong.y .in-ed (it' .ater s)'i4op'renia. "n t'e Nationa. Co..aborati/e %erinata. %ro6e)t$

('i)' in/o./ed o/er +$,,, )'i.dren fo..o(ed from birt' t'roug' adu.t'ood$ t'e odds of adu.t'ood s)'i4op'renia in)reased .inear.y (it' an in)reasing number of 'ypoxia1re.ated !Cs 2Cannon$ &o..ister$ Bearden$ H &ad.ey$ *++DC Cannon$ *++B3. Anot'er prenata. e/ent t'at 'as been .in-ed (it' in)reased ris- for s)'i4op'renia is materna. /ira. infe)tion. Resear)'ers 'a/e found t'at t'e ris- rate for s)'i4op'renia is e.e/ated for

@. SCHIFOPHRENIA 343 indi/idua.s born s'ort.y after a f.u epidemi) 2Barr$ Medni)-$ H Mun-1Jorgensen$ *++,C Murray$ Jones$ !GCa..ag'an$ H #a-ei$ *++93 or after being prenata..y exposed to rube..a 2Bro(n$ Co'en$ &ar-a/y1Friedman$ H Babu.as$ 9,,*3. #'e )riti)a. period appears to be bet(een t'e fourt' and sixt' mont's of pregnan)y. #'e findings from resear)' on /ira. infe)tion are )onsistent (it' reports on t'e season1of1birt' effe)t in s)'i4op'renia. e/era. studies 'a/e found t'at a disproportionate number of s)'i4op'reni) patients are born during t'e .ate (inter mont's 2Bradbury H Mi..er$ *+B<C #orrey$ Mi..er$ Ra(.ings$ H Ao.-en$ *++D3. #'is timing may ref.e)t seasona. exposure to /ira. infe)tions$ ('i)' are most )ommon in .ate fa.. and ear.y (inter. #'us t'e fetus )ou.d 'a/e been exposed to t'e infe)tion during t'e se)ond trimester. #'e se)ond trimester is an important time for brain de/e.opment$ and disruptions during t'is stage may .ead to de/e.opmenta. abnorma.ities. tudies of rodents and non'uman primates 'a/e s'o(n t'at prenata. materna. stress )an interfere (it' feta. brain de/e.opment and is asso)iated (it' e.e/ated g.u)o)orti)oid re.ease and 'ippo)ampa. abnorma.ities in t'e offspring 2 myt'e$ M)Cormi)-$ Ro)'ford$ H Meaney$ *++;C Weinsto)-$ *++?3. A.ong t'e same .ines$ in 'umans$ t'ere is e/iden)e t'at stressfu. e/ents during pregnan)y are asso)iated (it' greater ris- for s)'i4op'renia and ot'er psy)'iatri) disorders in adu.t offspring. Resear)'ers 'a/e found 'ig'er rates of s)'i4op'renia in t'e offspring of (omen ('ose spouses 'ad died during t'eir pregnan)ies 2&uttunen$ *+B+3 and in (omen ('o (ere exposed to a mi.itary in/asion during t'eir pregnan)ies 2/an !s H e.ten$ *++B3. "t is .i-e.y t'at prenata. stress triggers t'e re.ease of materna. stress 'ormones$ ('i)' 'a/e been found to disturb feta. neurode/e.opment and subse7uent fun)tioning of t'e 'ypot'a.ami)1pituitary1adrena. axis$ ('i)'$ in turn inf.uen)es be'a/ior and )ognition 2We.berg H e)-.$ 9,,*3. !ne of t'e )'ief 7uestions )onfronting resear)'ers is ('et'er !Cs a)t independent.y to in)rease ris- for s)'i4op'renia or$ rat'er$ 'a/e t'eir effe)t in )on6un)tion (it' a geneti) /u.nerabi.ity. !ne possibi.ity is t'at t'e geneti) /u.nerabi.ity for s)'i4op'renia in/o./es an in)reased sensiti/ity to prenata. fa)tors t'at interfere (it' feta. neurode/e.opment 2Cannon$ *++DC *++B3. "t is a.so p.ausib.e t'at obstetri)a. e/ents a)t independent.y of geneti) /u.nerabi.ities$ a.t'oug' su)' effe)ts (ou.d .i-e.y entai. )omp.ex intera)tions among fa)tors 2 usser H Bro(n$ *+++3. For examp.e$ in order to produ)e t'e neurode/e.opmenta. abnorma.ities t'at )onfer ris- for s)'i4op'renia$ it may be ne)essary for a spe)ifi) !C to o))ur during a )riti)a. period of )e..u.ar migration andLor in )on6un)tion (it' ot'er fa)tors su)' as materna. fe/er or immune response. #'ese possibi.ities are )urrent.y t'e fo)us of resear)'. 1IOLOGICAL INDICATORS OF GULNERA1ILITY &a/ing identified t(o .i-e.y sour)es of /u.nerabi.ity for s)'i4op'renia$ geneti) and obstetri)a. fa)tors$ (e no( turn to t'e nature of /u.nerabi.ity. W'ere does t'e (ea-ness .ieF in)e t'e turn of t'e )entury$ (riters in t'e fie.d of psy)'opat'o.ogy 'ad suspe)ted t'at s)'i4op'renia in/o./ed some bio.ogi)a. abnorma.ity in t'e brain 2B.eu.er$ *+?<3. #'is assumption (as based$ in part$ on t'e se/erity of t'e symptoms and t'e deteriorating ).ini)a. )ourse. &o(e/er$ it (as not unti. t'e ad/ent of neuroimaging te)'ni7ues t'at so.id$ empiri)a. data (ere gat'ered to support t'is assumption. Abn#r(a%ities in 1rain Str$.t$re #'e first reports on brain abnorma.ities in s)'i4op'renia patients (ere based on )omputeri4ed axia. tomograp'y 2CA#3 s)ans$ and s'o(ed t'at t'ey 'ad en.arged brain /entri).es$ espe)ia..y in)reased /o.ume of t'e .atera. /entri).es 28ennert H Andreasen$ *+B:3. As ne( te)'ni7ues for

brain s)anning (ere de/e.oped$ t'ese findings (ere rep.i)ated and additiona. abnorma.ities

345 WAL)ER ET AL. (ere dete)ted 2&enn H Braus$ *+++3. Magneti) resonan)e imaging 2MR"3 re/ea.ed de)reased fronta.$ tempora.$ and ('o.e brain /o.ume among peop.e (it' s)'i4op'renia 2La(rie H Abu-1 mei.$ *++B3. More fine1grained ana.yses demonstrated redu)tions in t'e si4e of stru)tures su)' as t'e t'a.amus and 'ippo)ampus. "n fa)t$ of a.. t'e regions studied$ t'e 'ippo)ampus is one t'at 'as most )onsistent.y been identified as distinguis'ing peop.e (it' s)'i4op'renia from 'ea.t'y )ontro.s 2 )'ma6u-$ 9,,*3. A .andmar- study of MR t(ins dis)ordant for s)'i4op'renia (as t'e first to demonstrate t'at t'ese brain abnorma.ities (ere not so.e.y attributab.e to geneti) fa)tors 2 uddat'$ C'ristison$ #orrey$ Casano/a$ H Weinberger$ *++,3. W'en )ompared to t'eir 'ea.t'y identi)a. )ot(ins$ t(ins (it' s)'i4op'renia (ere found to 'a/e sma..er tempora. .obe /o.umes$ (it' t'e 'ip1po)ampa. region s'o(ing t'e most dramati) differen)e bet(een t'e affe)ted and nonaffe)ted )ot(ins. ubse7uent studies 'a/e )onfirmed sma..er brain /o.umes among affe)ted t(ins t'an among t'eir 'ea.t'y identi)a. )ot(ins 2Baare$ /an !e.$ %o.$ )'na)-$ 8urston$ its-oorn$ H @a'n$ 9,,*3. #'ese studies .end support to t'e 'ypot'esis t'at t'e brain abnorma.ities obser/ed in s)'i4op'renia are at .east partia..y due to fa)tors t'at interfere (it' prenata. brain de/e.opment. 8espite t'e p.et'ora of resear)' findings indi)ating t'e presen)e of abnorma.ities in t'e brains of patients (it' s)'i4op'renia$ 'o(e/er$ no spe)ifi) abnorma.ity 'as yet been s'o(n to be pat'ognomoni). "n ot'er (ords$ t'ere is no e/iden)e t'at a spe)ifi) morp'o.ogi)a. abnorma.ity is uni7ue to s)'i4op'renia or )'ara)teri4es a.. s)'i4op'renia patients. #'e stru)tura. brain abnorma.ities obser/ed in s)'i4op'renia are$ t'erefore$ gross manifestations of t'e o))urren)e of a de/iation in neurode/e.opment t'at 'as imp.i)ations for neuro)ir)uitry fun)tion. Ne$r#trans(itters #'e idea t'at s)'i4op'renia in/o./es an abnorma.ity in neurotransmission 'as a .ong 'istory. "nitia. neurotransmitter t'eories fo)used on epinep'rine and norepinep'rine. ubse7uent approa)'es 'a/e 'ypot'esi4ed t'at serotonin$ g.utamate andLor gamma1amino butyri) a)id 2=ABA3 abnorma.ities are in/o./ed in s)'i4op'renia. But$ )ompared to ot'er neurotransmitters$ dopamine 'as p.ayed a more enduring ro.e in t'eori4ing about t'e bio)'emi)a. basis of s)'i4op'renia. "n t'is se)tion (e (i.. re/ie( t'e ma6or neurotransmitter t'eories of s)'i4op're1 nia$ (it' an emp'asis on dopamine. "n t'e ear.y *+<,s$ in/estigators began to suspe)t t'at dopamine mig't be p.aying a )entra. ro.e in s)'i4op'renia. 8opamine is (ide.y distributed in t'e brain and is one of t'e neurotransmitters t'at enab.es )ommuni)ation in t'e )ir)uits t'at .in- sub)orti)a. (it' )orti)a. brain regions 2Jents)'$ Rot'$ H #ay.or$ 9,,,3. in)e t'e *+<,s$ support for t'is idea 'as (axed and (aned. "n t'e past de)ade$ 'o(e/er$ t'ere 'as been a resurgen)e of interest in dopamine$ .arge.y be)ause resear)' findings 'a/e offered a ne( perspe)ti/e. #'e initia. support for t'e ro.e of dopamine in s)'i4op'renia (as based on t(o indire)t pie)es of e/iden)e 2Car.sson$ *+BB3C 2a3 drugs t'at redu)e dopamine a)ti/ity a.so ser/e to diminis' psy)'oti) symptoms$ and 2b3 drugs t'at 'eig'ten dopamine a)ti/ity exa)erbate or trigger psy)'oti) episodes. "t (as e/entua..y dis)o/ered t'at antipsy)'oti) drugs 'ad t'eir effe)t by b.o)-ing dopamine re)eptors$ espe)ia..y t'e 89 subtype t'at is pre/a.ent in sub)orti)a. regions of t'e brain. #'e ne(er antipsy)'oti) drugs$ or atypi)a. antipsy)'oti)s$ 'a/e t'e ad/antage of )ausing fe(er motor side effe)ts. Nonet'e.ess$ t'ey a.so a)t on t'e dopamine system by b.o)-ing /arious subtypes of dopamine re)eptors 2Jents)'$ Rot'$ H #ay.or$ 9,,,3. Ear.y studies of dopamine in s)'i4op'renia soug't to determine ('et'er t'ere (as e/iden)e of

ex)ess neurotransmitter in s)'i4op'renia patients. But )on)entrations of dopamine and its metabo.ites (ere genera..y not found to be e.e/ated in f.uids from s)'i4op'renia patients 2Car.sson$ &ansson$ Waters$ H Car.sson$ *+++3. W'en in/estigators examined dopamine

@. SCHIFOPHRENIA 347 re)eptors$ 'o(e/er$ t'ere (as some e/iden)e of in)reased densities. Bot' postmortem and fun)tiona. MR" studies of patientsG brains yie.ded e/iden)e t'at t'e number of dopamine 89 re)eptors tends to be greater in patients t'an norma. )ontro.s 2@est.er$ Wa.-er$ H >ega$ 9,,*3. Contro/ersy 'as surrounded t'is .iterature$ be)ause antipsy)'oti) drugs )an )'ange dopamine re)eptor density. Nonet'e.ess$ e/en studies of ne/er1medi)ated patients (it' s)'i4op'renia 'a/e s'o(n e.e/ations in dopamine re)eptors 2@est.er et a..$ 9,,*3. !t'er abnorma.ities in dopamine transmission 'a/e a.so been found. "t appears$ for examp.e$ t'at dopamine synt'esis and re.ease may be more pronoun)ed in t'e brains of peop.e (it' s)'i4op'renia t'an among norma.s 2Lindstrom et a..$ *+++3. W'en s)'i4op'renia patients and norma. )ontro.s are gi/en amp'etamine$ a drug t'at en'an)es dopamine re.ease$ t'e patients s'o( more augmented dopamine re.ease 2Abi18arg'am et a..$ *++BC oares H "nnis$ *+++3. =.utamate is an ex)itatory neurotransmitter. =.utamatergi) neurons are part of t'e pat'(ays t'at )onne)t t'e 'ippo)ampus$ prefronta. )ortex$ and t'a.amus$ a.. regions t'at 'a/e been imp.i)ated in s)'i4op'renia. #'ere is e/iden)e of diminis'ed a)ti/ity at g.utamatergi) re)eptors among s)'i4op'renia patients in t'ese brain regions 2Car.sson$ &ansson$ Waters$ H Car.sson$ *+++C =off H Coy.e$ 9,,*C #sai H Coy.e$ 9,,93. !ne of t'e )'ief re)eptors for g.utamate in t'e brain is t'e N1met'y.181asparti) a)id 2NM8A3 subtype of re)eptor. "t 'as been suggested t'at t'ese re)eptors may be abnorma. in s)'i4op'renia. B.o)-ade of NM8A re)eptors produ)es t'e symptomati) manifestations of s)'i4op'renia in norma. sub6e)ts$ in).uding negati/e symptoms and )ogniti/e impairments. For examp.e$ administration of NM8A re)eptor antagonists$ su)' as p'en)y).idine 2%C%3 and -etamine$ indu)es a broad range of s)'i4op'reni)1.i-e symptomato.ogy in 'umans$ and t'ese findings 'a/e )ontributed to a 'ypog.utamatergi) 'ypot'esis of s)'i4op'renia. Con/erse.y$ drugs t'at indire)t.y en'an)e NM8A re)eptor fun)tion )an redu)e negati/e symptoms and impro/e )ogniti/e fun)tioning in s)'i4op'renia patients. "t is important to note t'at t'e idea of dysfun)tion of g.utamatergi) transmission is not in)onsistent (it' t'e dopamine 'ypot'esis of s)'i4op'renia$ be)ause t'ere are re)ipro)a. )onne)tions bet(een forebrain dopamine pro6e)tions and systems t'at use g.utamate. #'us dysregu.ation of one system (ou.d be expe)ted to a.ter neurotransmission in t'e ot'er. =ABA is an in'ibitory neurotransmitter. ome 'a/e suggested t'at its in'ibitory effe)ts may be in)reased in psy)'oti) disorders 2 7uires H aederup$ *++*3. !n t'e ot'er 'and$ t'e upta-e and t'e re.ease of =ABA 'as been s'o(n to be redu)ed in some studies of postmortem brain tissue from s)'i4op'renia patients 2Le(is$ %ierri$ >o.-$ Me.)'it4-y$ H Woo$ *+++3$ and t'ere are abnorma.ities in t'e inter)onne)tions among =ABA neurons 2Benes H Berretta$ 9,,*3. More spe)ifi)a..y$ t'ere is e/iden)e of a .oss of )orti)a. =ABA interneurons. Current t'eories about t'e ro.e of =ABA in s)'i4op'renia assume t'at it is important be)ause )orti)a. pro)esses re7uire an optima. ba.an)e bet(een =ABA in'ibition and g.utamatergi) ex)itation. #'e true pi)ture of t'e neuro)'emi)a. abnorma.ities in s)'i4op'renia may be more )omp.ex t'an (e (ou.d .i-e to assume. A.. neurotransmitter systems intera)t in intri)ate (ays at mu.tip.e .e/e.s in t'e brainGs )ir)uitry 2Car.sson et a..$ 9,,*3. Conse7uent.y$ an a.teration in t'e synt'esis$ reupta-e$ or re)eptor density affinity for any one of t'e neurotransmitter systems (ou.d be expe)ted to 'a/e imp.i)ations for one or more of t'e ot'er neurotransmitter systems. Furt'er$ be)ause neura. )ir)uits in/o./e mu.tip.e segments t'at re.y on different transmitters$ it is easy to imagine 'o( an abnorma.ity in e/en one spe)ifi) subgroup of re)eptors )ou.d resu.t in t'e dysfun)tion of a.. t'e brain regions .in-ed by a parti)u.ar brain )ir)uit.

COURSE AND PROGNOSIS Assuming t'at geneti) and obstetri)a. fa)tors )onfer t'e /u.nerabi.ity for s)'i4op'renia$ t'e diat'esis must be present at birt'. Aet$ s)'i4op'renia is typi)a..y diagnosed in .ate ado.es)en)e

349 WAL)ERET AL. or ear.y adu.t'ood$ (it' t'e a/erage age of diagnosis in ma.es about four years ear.ier t'an for fema.es 2Rie)'er1Ross.er H &afner$ 9,,,3. #'is fa)t raises intriguing 7uestions about t'e de/e.opmenta. )ourse before t'e ).ini)a. onset. Pre(#rbid De,e%#*(ent #'ere is )ompe..ing e/iden)e t'at t'ere are signs of s)'i4op'renia .ong before t'e i..ness is diagnosed. Most of t'ese signs are subt.e and do not rea)' t'e se/erity of ).ini)a. disorder. Nonet'e.ess$ ('en )ompared to )'i.dren (it' 'ea.t'y adu.t out)omes$ )'i.dren ('o .ater de/e.op s)'i4op'renia manifest defi)its in mu.tip.e domains. "n some of t'ese domains$ t'e defi)its are apparent as ear.y as infan)y. "n t'e area of )ogniti/e fun)tioning$ )'i.dren ('o .ater de/e.op s)'i4op'renia tend to perform be.o( t'eir 'ea.t'y sib.ings and ).assmates. #'is is ref.e)ted in .o(er s)ores on measures of inte..igen)e and a)'ie/ement and poorer grades in s)'oo. 2Ay.(ard$ Wa.-er$ H Bettes$ *+B;C Jones$ Rodgers$ Murray$ H Marmot$ *++;3. %res)'i4op'reni) )'i.dren a.so s'o( abnorma.ities in so)ia. be'a/ior. #'ey are .ess responsi/e in so)ia. situations$ s'o( .ess positi/e emotion 2Wa.-er H Le(ine$ *++,C Wa.-er$ =rimes$ 8a/is$ H mit'$ *++:3$ and 'a/e poorer so)ia. ad6ustment t'an )'i.dren (it' 'ea.t'y adu.t out)omes 28one$ Cro($ Jo'nstone$ H a)-er$ *++;C Neumann$ Wa.-er$ Le(ine$ H Baum$ *++?3. "n our studies of t'e )'i.d'ood 'ome mo/ies of s)'i4op'renia patients$ (e found t'at t'e pres)'i4op'reni) )'i.dren s'o(ed more negati/e fa)ia. expression of emotion t'an did t'eir sib.ings as ear.y as t'e first year of .ife$ indi)ating t'at t'e /u.nerabi.ity for s)'i4op'renia is subt.y manifested in t'e ear.iest interpersona. intera)tions 2Wa.-er et a..$ *++:3. >u.nerabi.ity to s)'i4op'renia is a.so apparent in motor fun)tions. W'en )ompared to t'eir sib.ings (it' 'ea.t'y adu.t out)omes$ pres)'i4op'reni) )'i.dren s'o( more de.ays and abnor1 ma.ities in motor de/e.opment$ in).uding defi)its in t'e a)7uisition of ear.y motor mi.estones su)' as bimanua. manipu.ation and (a.-ing 2Wa.-er$ a/oi$ H 8a/is$ *++;3. 8efi)its in motor fun)tion extend t'roug'out t'e premorbid period and persist after t'e onset of t'e ).ini)a. i..ness 2M)Nei.$ Cantor1=raae$ H Weinberger 9,,,3. "t is important to note t'at neuromotor abnorma.ities are not pat'ognomoni) for s)'i4op'renia$ in t'at t'ey are obser/ed in )'i.dren at ris- for a /ariety of disorders$ in).uding .earning disabi.ities and )ondu)t and mood disorders. But t'ey are one of se/era. important ).ues pointing to t'e in/o./ement of brain dysfun)tion in s)'i4op'renia. 8espite t'e subt.e signs of abnorma.ity t'at 'a/e been identified in )'i.dren at ris- for s)'i4op'renia$ most do not manifest diagnosab.e menta. disorders in )'i.d'ood. #'us$ ('i.e t'eir parents may re)a.. some irregu.arities in t'eir de/e.opment$ most pres)'i4op'reni) )'i.dren (ere not /ie(ed as ).ini)a..y disturbed. But t'e pi)ture often )'anges in ado.es)en)e. Many ado.es)ents ('o go on to de/e.op s)'i4op'renia s'o( a pattern of es)a.ating ad6ustment prob.ems 2Wa.-er H Baum$ *++B3. #'ey s'o( a gradua. in)rease in ad6ustment prob.ems$ in).uding fee.ings of depression$ so)ia. (it'dra(a.$ irritabi.ity$ and non)omp.ian)e. But t'is de/e.opmenta. pattern is not uni7ue to s)'i4op'reniaC ado.es)en)e is a.so t'e )riti)a. period for t'e expression of t'e first signs of mood disorders$ substan)e abuse$ and some ot'er be'a/iora. disorders. As a resu.t$ resear)'ers /ie( ado.es)en)e as a )riti)a. period for t'e emergen)e of /arious -inds of be'a/iora. dysfun)tion 2Wa.-er$ 9,,93. Among t'e be'a/iora. ris- indi)ators sometimes obser/ed in pres)'i4op'reni) ado.es)ents are sub).ini)a. signs of psy)'oti) symptoms. #'ese signs are a.so t'e defining features of a 8 M

Axis "" disorder$ name.y$ schi*otypal personality disorder 2 %83. #'e diagnosti) )riteria for %8 in).ude so)ia. anxiety or (it'dra(a.$ affe)ti/e abnorma.ities$ e))entri) be'a/ior$ unusua. ideas 2e.g.$ persistent be.ief in extrasensory per)eption IE %J$ a.iens$ extrasensory

@. SCHIFOPHRENIA 351 p'enomena$ et).3$ and unusua. sensory experien)es 2e.g.$ repeated experien)es (it' )onfusing noises (it' peop.esG /oi)es$ seeing ob6e)ts mo/e$ et).3. A.t'oug' t'e indi/idua.Gs unusua. ideas and per)eptions are not se/ere or persistent enoug' to meet )riteria for de.usions or 'a..u)i1 nations$ t'ey are re)urring and atypi)a. of t'e personGs )u.tura. )ontext. An extensi/e body of resear)' demonstrates geneti) and de/e.opmenta. .in-s bet(een s)'i4op'renia and %8. #'e geneti) .in- bet(een %8 and s)'i4op'renia 'as been do)umented in t(in and fami.y 'istory studies 2@end.er$ M)=uire$ =ruenberg$ H Wa.s'$ *++<C @end.er$ Nea.e$ H Wa.s'$ *++<C Raine H Medni)-$ *++<3. #'e de/e.opmenta. transition from s)'i4otypa. signs to s)'i4op'renia in young adu.t'ood 'as been fo..o(ed in se/era. re)ent .ongitudina. studies$ (it' resear)'ers reporting t'at 9,P to ;,P of s)'i4otypa. yout' e/entua..y s'o( an Axis " s)'i4op'renia spe)trum disorder 2Mi..er et a..$ 9,,9C Aung et a..$ *++B3. #'e remainder eit'er s'o( ot'er ad6ustment prob.ems or a )omp.ete remission of symptoms in young adu.t'ood. =i/en t'e 'ig' rate of progression to s)'i4op'renia$ resear)'ers are no( attempting to determine ('et'er s)'i4otypa. yout' ('o (i.. e/entua..y manifest s)'i4op'renia )an be identified before t'e onset of t'e i..ness. #'is step is )onsidered to be pi/ota. in efforts to de/e.op se)ondary pre/ention programs. Re)ent in/estigations 'a/e re/ea.ed t'at ado.es)ents (it' %8 manifest some of t'e same fun)tiona. abnorma.ities obser/ed in patients (it' s)'i4op'renia. For examp.e$ %8 yout' s'o( motor abnorma.ities 2Wa.-er$ Le(is$ Loe(y$ H %ay.o$ *+++3$ )ogniti/e defi)its 28iforio$ @est.er$ H Wa.-er$ 9,,,3$ and an in)rease in C#rtis#%5 a stress 'ormone t'at is e.e/ated in se/era. psy)'iatri) disorders 2Weinstein$ 8iforio$ )'iffman$ Wa.-er$ H Bonsa..$ *+++3. #'ese ne( findings may e/entua..y aid in t'e identifi)ation of %8 ado.es)ents ('o are at greatest ris- for de/e.oping s)'i4op'renia. T/e I%%ness Onset #'e onset of t'e first episode of s)'i4op'renia may be sudden or gradua.. As mentioned ear.ier$ it is usua..y pre)eded by es)a.ating ad6ustment prob.ems$ a period referred to as t'e prodromal p'ase 2Liebermaneta..$ 9,,*3. #'ere is some e/iden)e t'at .onger untreated psy)'oti) episodes may be 'armfu. for s)'i4op'renia patients and may resu.t in a (orse )ourse of i..ness 28a/idson H M)=.as'an$ *++D3. &o(e/er$ t'is )on).usion is )ontro/ersia.$ and some resear)'ers suggest t'at t'e re.ation bet(een .onger duration of untreated psy)'osis and (orse prognosis may be a produ)t of poorer premorbid fun)tioning and an insidious onset 2Larsen et a..$ 9,,*3. %eop.e (it' s)'i4op'renia /ary in t'eir )ourse of i..ness and prognosis. Being ma.e$ gradua. onset$ ear.y age of onset$ poor premorbid fun)tioning$ and fami.y 'istory of s)'i4op'renia are a.. asso)iated (it' poorer prognosis 2=ottesman$ *++*3. "n addition$ some en/ironmenta. fa)tors 'a/e been found to )ontribute to a (orse out)ome. For examp.e$ s)'i4op'renia patients ('o .i/e in 'omes ('ere fami.y members express greater negati/e emotion are more .i-e.y t'an t'ose from (arm$ supporti/e fami.ies to 'a/e re.apses 2But4.aff H &oo.ey$ *++B3. A.so$ exposure to stress 'as been found to exa)erbate s)'i4op'renia symptoms. Resear)'ers 'a/e found an in)rease in t'e number of stressfu. e/ents in t'e mont's immediate.y pre)eding a s)'i4op'renia re.apse 2>entura$ Neu)'ter.ein$ &ardesty$ H =it.in$ *++93. As out.ined$ t'e prognosis for many s)'i4op'renia patients is poor. !n.y 9,P to :,P are ab.e to .ead some('at norma. .i/es$ meaning t'ey )an .i/e independent.y andLor maintain a 6ob 2=rebb H Can)ro$ *+B+3. #'e ma6ority experien)e a more debi.itating )ourse$ (it' 9,P to :,P manifesting )ontinued moderate symptoms and o/er 'a.f experien)ing signifi)ant impairment t'e rest of t'eir .i/es. Furt'ermore$ patients (it' s)'i4op'renia often suffer from ot'er )omorbid 2i.

e.$ )o1o))urring3 )onditions. For examp.e$ t'e rate of substan)e abuse among s)'i4op'renia patients is /ery 'ig'$ (it' as many as ;DP in t'e )ommunity and +,P in prison settings meeting .ifetime 8 M1"> )riteria for substan)e abuse or dependen)e 2Regier et a..$ *++,3.

353 WAL)ER ET AL. ui)ide is t'e .eading )ause of deat' among peop.e (it' s)'i4op'renia. "t 'as been estimated t'at 9<P to <,P of s)'i4op'renia patients attempt sui)ide and ;P to *:P su))essfu..y )ommit sui)ide 2Me.t4er$ 9,,*3. Ris- fa)tors asso)iated (it' sui)ide in t'is popu.ation in).ude more se/ere a))ompanying depressi/e symptoms$ being ma.e$ ear.ier onset$ and re)ent traumati) e/ents 2 )'(art4 H Co'en$ 9,,*3. THE TREATMENT OF SCHIFOPHRENIA Resear)'ers 'a/e not yet identified any psy)'o.ogi)a. or bio.ogi)a. )ures for s)'i4op'renia. &o(e/er$ signifi)ant progress 'as been made in t'e de/e.opment of treatments t'at great.y impro/e t'e prognosis for t'e i..ness. #'us t'e 7ua.ity of .ife for patients is no( mu)' better t'an it (as at t'e turn of t'e )entury. #'e first issue to be addressed in t'e e/a.uation and treatment of s)'i4op'renia is safety. #'e risof se.f1'arm and potentia. for /io.en)e must be assessed. #'is is of parti)u.ar importan)e be)ause of t'e ris- of sui)ide in patients (it' s)'i4op'renia 2 iris$ 9,,*3. Furt'ermore$ a medi)a. examination is typi)a..y administered in order to ru.e out ot'er i..nesses t'at )an )ause psy)'oti) symptoms. #'is examination in).udes a re/ie( of t'e medi)a. 'istory$ a p'ysi)a. examination$ and .aboratory tests. Many patients (it' s)'i4op'renia 'a/e untreated medi)a. )onditions$ su)' as nutritiona. defi)ien)ies and infe)tions$ t'at are a resu.t of t'eir psy)'o.ogi)a. andLor so)ioe)onomi) .imitations 2=off$ &e)-ers$ H Freudenrei)'$ 9,,*3. "f a patient is not at a)ute ris- to se.f or ot'ers$ t'e next )onsideration be)omes t'e type of treatment t'at (ou.d be most benefi)ia.. #'ere are se/era. fa)tors to )onsider. #'ese in).ude t'e personGs .i/ing situation 2many patients (it' s)'i4op'renia are 'ome.ess3$ finan)ia. resour)es in).uding 'ea.t' insuran)e$ fami.y and ot'er a/ai.ab.e so)ia. support$ t'e personGs .e/e. of insig't and (i..ingness to a))ept treatment$ past treatment 'istory$ and t'e personGs preferen)e. #'e treatment of s)'i4op'renia )an be di/ided into t'ree p'ases5 t'e a)ute$ stabi.i4ation$ and maintenan)e p'ases 2@ap.an H ado)-$ *++B3. "n t'e a)ute p'ase$ t'e goa. of treatment is to redu)e t'e se/erity of symptoms. #'is p'ase is usua..y of ; to B (ee-s in duration. "n t'e stabi.i4ation p'ase$ t'e goa. is to )onso.idate treatment gains. #'is usua..y ta-es about ? mont's. Fina..y$ during t'e maintenan)e p'ase$ t'e symptoms are in remission 2partia. or )omp.ete3. At t'is point$ t'e goa. of treatment is to pre/ent re.apse and impro/e fun)tioning. Anti*sy./#ti. Medi.ati#n #'e mainstay of t'e bio.ogi)a. treatment of s)'i4op'renia is antipsy)'oti) medi)ation. #'e first effe)ti/e bio.ogi)a. treatment for s)'i4op'renia$ )'.orproma4ine 2#'ora4ine3$ (as de/e.oped in t'e *+<,s. "t (as t'e first in a .ine of medi)ations no( referred to as t'e typi)a. antipsy)'oti)s or neuro.epti)s. A.. of t'ese medi)ations a)t by b.o)-ing a)ti/ity in t'e dopamine systems. #'e typi)a. antipsy)'oti) medi)ations are ).assified as 'ig'$ medium$ and .o( poten)y and differ from ea)' ot'er in side1effe)t profi.es 2see #ab.e +.:3. ,igh potency neuro.epti)s tend to )arry a 'ig'er ris- of motor side effe)ts$ and are pres)ribed in .o( dosages. ome examp.es of 'ig' poten)y agents are %ro.ixin 2fiup'ena4ine3$ te.a4ine 2trif.uopera4ine3$ and &a.do. 2'a.operido.3. )ow potency neuro.epti)s are pres)ribed in 'ig'er doses and 'a/e .o(er ris- of motor side effe)ts$ but a 'ig'er ris- of indu)ing sei4ures$ anti'istamini) effe)ts 2in).uding sedation and (eig't gain3$ anti)'o.inergi) effe)ts 2in).uding )ogniti/e du..ing$ dry mout'$ b.urry /ision$ urinary 'esitan)y$ and )onstipation3$ and antiadrenergi) effe)ts 2in).uding postura. 'ypotension and sexua. dysfun)tion3. Examp.es of .o( poten)y neuro.epti)s in).ude #'ora4ine 2)'.orproma4ine3$ and Me..ari. 2t'iorida4ine3. Medium potency agents tend to 'a/e side effe)ts

@. SCHIFOPHRENIA 354 TA1LE @.: Se%e.ted Anti*sy./#ti. Dr$&s -rug :oute of Asual .edati #utono @'trapyr -aily on mic amidal #dministr 9ral #dverse ation -ose @ffects -H-+ C/%#r*r# Ora%5 IM !!0?!! XXX XX (aCine F%$*/enaC Ora%5 IM5 0 ! X X XXX ine de*#t Tri6%$#*er Ora%5 IM "0:! ^^ ^ XXX aCine Per*/enaC Ora%5 IM ;0?9 ^^ ^ XXX ine Ha%#*erid Ora%5 IM5 "0 ! ^ X XXX #% de*#t L#-a*ine Ora%5 IM !03!! XX X XX O%anCa*in Ora% 8."0 " X XX !I e N$etia*ine Ora% 3"!08"! XX ^^ !I Ris*erid#n Ora% 03? X XX X e C%#Ca*ine Ora% 3"!0@!! ^^^ ^^^ !I Fr#( Sad#.+ H Sad#.+5 !!!. intermediate bet(een t'e .o( and 'ig' poten)y drugs. Examp.es of t'ese are #ri.afon 2per1 p'ena4ine3 and Loxapa) 2.oxapine3. "n t'e *++,s a ne( generation of antipsy)'oti) medi)ations be)ame a/ai.ab.e for t'erapeuti) use in Europe and Nort' Ameri)a. #'e ne( ).ass of medi)ation is referred to as t'e atypi1)a.s. Medi)ations in t'is ).ass s'are (it' ea)' ot'er a .o(er ris- of bot' t'e ear.y o))urring and t'e .ate emerging 2or tardi/e3 mo/ement disorders. #'e atypi)a. antipsy)'oti)s in).ude t'e fo..o(ing5 Risperda. 2risperidone3$ Ryprexa 2o.an4apine3$ ero7ue. 27uetiapine3$ =eodon 24ipra4adone3$ and C.o4ari. 2).o4apine3. #'ey differ signifi)ant.y from one anot'er in terms of t'e neurotransmitter re)eptors t'at t'ey o))upy. A.t'oug' a.. b.o)- dopamine neurotransmission to some extent$ t'ey /ary in t'e extent to ('i)' t'ey affe)t serotonin$ g.utamate$ and ot'er neurotransmitters. #'ese atypi)a. antipsy)'oti)s 'a/e be)ome first .ine in t'e treatment of s)'i4op'renia. #'e effi)a)y of t'e atypi)a. antipsy)'oti)s for t'e treatment of positi/e symptoms is at .east e7ui/a.ent to t'at of t'e typi)a. antipsy)'oti)s$ and some studies suggest t'at t'ey are more effe)ti/e for negati/e symptoms and t'e )ogniti/e impairment asso)iated (it' t'e disorder. 2Forster$ Bu)-.ey$ H %'e.ps$ *+++3. Antipsy)'oti) medi)ations are usua..y administered ora..y. For patients ('o are not )omp.iant (it' ora. medi)ation$ in6e)tib.e$ .ong1.asting antipsy)'oti) medi)ation 2referred to as depot medi)ation3 may be administered e/ery fe( (ee-s. #(o depot neuro.epti)s are )ommer)ia..y a/ai.ab.e in t'e United tates5 %ro.ixin 2f.up'ena4ine de)anoate3$ and &a.do. 2'a.operido. de1

)anoate3. Benefits of depot neuro.epti)s in).ude t'e ease of use for t'e patient and t'e fa)t t'at )omp.ian)e is easi.y monitored by t'e ).ini)ian. #'e ris-s are simi.ar to t'e ris-s of a.. of t'e typi)a. antipsy)'oti)s. #'e on.y additiona. ris- is t'at of .o)a.i4ed pain or s(e..ing at t'e in6e)tion site. 8rug1indu)ed mo/ement disorders )an be di/ided into ear.y and .ate emerging syndromes 2from ado)- H ado)-$ 9,,,$ tab.e *9.B1: p. *9,D3. Ear.y emerging motor syndromes in).ude pseudopar-insonism$ brady-inesia 2de)reased mo/ement3$ rigidity$ and dystoni) rea)tions 2sudden onset of sustained intense$ un)ontro..ab.e mus).e )ontra)tion )ommon.y o))urring in t'e fa)ia. and ne)- mus).es3. #ardi/e dys-inesia is a .ate emerging syndrome t'at in).udes irregu.ar )'oreiform 2t(isting or (orm.i-e3 mo/ements t'at usua..y in/o./e t'e fa)ia. mus).es$ but )an in/o./e any /o.untary mus).e group. "t is fortunate t'at t'e rate of tardi/e dys-inesia 'as de).ined sin)e t'e introdu)tion of atypi)a. neuro.epti)s.

356 WAL)ER ET AL. Mention s'ou.d a.so be made of t'e neuro.epti) ma.ignant syndrome 2NM 3. #'is is a rare$ idiopat'i)$ .ife1t'reatening )omp.i)ation of neuro.epti) medi)ation. "t is )'ara)teri4ed by menta. status )'anges 2de.irium3$ immobi.ity$ rigidity$ tremu.ousness$ staring$ fe/er$ s(eating$ and autonomi) instabi.ity 2.abi.e b.ood pressure and ta)'y)ardia3. Laboratory in/estigations often re/ea. an e.e/ated ('ite b.ood )e.. )ount 2in t'e absen)e of infe)tion3$ as (e.. as ot'er ab1 norma.ities. #reatment in/o./es dis)ontinuation of neuro.epti) medi)ation$ supporti/e medi)a. treatment$ a perip'era. mus).e re.axant$ and bromo)riptine 2a 89 re)eptor agonist3 2Rosebus'$ HMa4ure-$ 9,,*3. Psy./#s#.ia% Treat(ents #6 S./iC#*/renia A.t'oug' antipsy)'oti) medi)ation is t'e )ru)ia. first step in t'e treatment of s)'i4op'renia$ t'ere is substantia. e/iden)e t'at psy)'oso)ia. inter/entions )an a.so be benefi)ia. for bot' t'e patient and t'e fami.y 2%enn H Mueser$ *++?3. "t is unfortunate t'at su)' treatments are not a.(ays a/ai.ab.e be)ause of .imited menta. 'ea.t' resour)es. Nonet'e.ess$ it is genera..y agreed t'at t'e optima. treatment approa)' is one t'at integrates p'arma)o.ogi) and psy)'oso)ia. inter/entions. A .arge body of resear)' supports t'e use of fami.y t'erapy$ ('i)' in).udes psy)'oedu)a1tiona. and be'a/iora. )omponents$ in treatment programs for s)'i4op'renia 2Busti..o$ Laurie..o$ &oran$ H @eit'$ 9,,*3. Fami.y t'erapy 'as been s'o(n to redu)e t'e ris- of re.apse$ redu)e fami.y burden$ and impro/e fami.y membersG understanding of and )oping (it' s)'i4op'renia. Compre'ensi/e programs for supporting t'e patientGs transition ba)- into t'e )ommunity 'a/e been effe)ti/e in en'an)ing re)o/ery and redu)ing re.apse. !ne su)' program$ )a..ed Asserti/e Community #reatment 2AC#3$ (as origina..y de/e.oped in t'e *+D,s by resear)'ers in Madison$ Wis)onsin 2Busti..o et a..$ 9,,*C ado)- H ado)-$ 9,,,3. AC# is a )ompre'ensi/e treatment approa)' for t'e serious.y menta..y i.. .i/ing in t'e )ommunity. %atients are assigned to a mu.tidis)ip.inary team 2nurse$ )ase manager$ genera. p'ysi)ian$ psy)'iatrist3 t'at 'as a fixed )ase.oad and a 'ig' staffLpatient ratio 2*5*93. #'e team de.i/ers a.. ser/i)es to t'e patient ('en and ('ere 'e or s'e needs t'em and is a/ai.ab.e to t'e patient at a.. times. er/i)es in).ude 'ome de.i/ery of medi)ation$ monitoring of p'ysi)a. and menta. 'ea.t' status$ in vivo so)ia. s-i..s training$ and fre7uent )onta)t (it' fami.y members. tudies suggest t'at AC# )an redu)e time spent in 'ospita.$ impro/e 'ousing stabi.ity$ and in)rease patient and fami.y satisfa)tion. o)ia. s-i..s training see-s to impro/e t'e o/era.. fun)tioning of patients by tea)'ing t'e s-i..s ne)essary to impro/e performan)e of a)ti/ities of dai.y .i/ing$ emp.oyment1re.ated s-i..s$ and intera)tion (it' ot'ers 2Busti..o et a..$ 9,,*C %enn H Mueser$ *++?3. ome so)ia. s-i..s programs emp'asi4e .earning ne( s-i..s t'roug' mode.ing. !t'ers fo)us more on tea)'ing patients better strategies for so./ing interpersona. prob.ems or training t'em to read non/erba. )ues of emotion in ot'er peop.e. Resear)' indi)ates t'at a.. of t'ese approa)'es to so)ia. s-i..s training )an impro/e so)ia. )ompeten)e in t'e .aboratory and in t'e ).ini) 2Busti..o$ 9,,*3. &o(e/er$ it remains un).ear to ('at extent t'is impro/ement in so)ia. )ompeten)e trans.ates into better fun)tioning in t'e )ommunity. #'e rate of )ompetiti/e emp.oyment for t'e se/ere.y menta..y i.. 'as been estimated at .ess t'an 9,P 2Le'man$ *++<3C t'us /o)ationa. re'abi.itation 'as been a ma6or fo)us of many treatment programs. >o)ationa. re'abi.itation programs 'a/e a positi/e inf.uen)e on (or-1re.ated a)ti/ities$ a.t'oug' t'ey 'a/e not yet been s'o(n to 'a/e a substantia. impa)t on patientsG abi.ities to obtain emp.oyment in t'e )ommunity 2Le'man$ *++<3. ome e/iden)e suggests t'at

supported emp.oyment programs t'at pro/ide assistan)e in maintaining good (or- 'abits produ)e better resu.ts t'an traditiona. /o)ationa. re'abi.itation programs. Nonet'e.ess$ 6ob retention remains a signifi)ant prob.em 2Le'man et a..$ 9,,93$ and .itt.e e/iden)e supports

@. SCHIFOPHRENIA 358 tress

Neuromaturationa. pro)esses "n'erited )onstitutiona. fa)tors

i . Constitutiona. $ /u.nerabi.ity

%renata. e/ents

A)7uired )onstitutiona. fa)tors %ostnata. stressors FIG. @.3. A diat/esis0stress (#de% #6 t/e eti#%#&y #6 s./iC#*/renia. t'e )ontention t'at emp.oyment impro/es se.f1esteem or 7ua.ity of .ife 2Busti..o et a..$ 9,,*3. !f )ourse$ emp.oyment 'as finan)ia. benefits for patients and may offer a))ess to 'ea.t' )are t'at (ou.d ot'er(ise not be a/ai.ab.e. Fina..y$ )ogniti/e be'a/ior t'erapy for s)'i4op'renia dra(s on t'e tenets of )ogniti/e t'erapy t'at (ere origina..y de/e.oped by Be)- and E..is 2Be)-$ *+D?C E..is$ *+B?3. #'e t'eory is t'at norma. psy)'o.ogi)a. pro)esses )an p.ay a ro.e in spe)ifi) psy)'oti) symptoms. Cogniti/e be'a/ior t'erapy 2CB#3 for psy)'osis )'a..enges t'e notion of a dis)ontinuity bet(een psy)'oti) and norma. t'in-ing. #'e norma. )ogniti/e me)'anisms t'at are a.ready being used in t'e nonpsy)'oti) aspe)ts of t'e patientGs t'in-ing )an be used to 'e.p t'e psy)'oti) indi/idua.s dea. dire)t.y (it' t'eir symptoms. "ndi/idua. CB# emp'asi4es a )o..aborati/e re.ations'ip bet(een patient and t'erapist. #'e t'erapist and patient 6oint.y examine t'e patientGs spe)ifi) symptoms. #'e )'oi)e of target symptoms is based on t'e patientGs preferen)e andLor se/erity of t'e prob.ems )reated by t'e psy)'oti) symptom in 7uestion. %sy)'oti) be.iefs are ne/er dire)t.y )onfronted$ a.t'oug' spe)ifi) psy)'oti) symptoms su)' as 'a..u)inations$ de.usions$ and re.ated prob.ems are targeted for inter/ention 28i)-erson$ 9,,,3. #'e fe( pub.is'ed randomi4ed )ontro..ed tria.s a/ai.ab.e for re/ie( suggest t'at CB# is at .east some('at effe)ti/e in redu)ing 'a..u)inations and de.usions in medi)ation1resistant patients and as a )omp.ement to p'arma)ot'erapy in a)ute psy)'osis 2Busti..o et a..$ 9,,*3. #'is )'apter 'as re/ie(ed a broad range of s)ientifi) resear)' on t'e nature and origins of

s)'i4op'renia. panning o/er a )entury$ t'e efforts of in/estigators 'a/e yie.ded$ pie)e by pie)e$ a ).earer /ie( of t'e i..ness. #'e pu44.e is not so./ed$ but (e )an )ertain.y ).aim progress to(ard a so.ution. #'e pi)ture t'at 'as emerged is best des)ribed in t'e frame(or- of t'e diathesis& stress mode. t'at 'as dominated t'e fie.d for se/era. de)ades. Figure +.* i..ustrates a )ontemporary /ersion of t'e diat'esis1stress mode.. #'is parti)u.ar mode. postu.ates t'at )onstitutiona. /u.nerabi.ity 2i.e.$ t'e diathesis" emanates from bot' in'erited and a)7uired )onstitutiona. fa)tors. #'e in'erited fa)tors are geneti)a..y determined )'ara)teristi)s of t'e brain t'at inf.uen)e its stru)ture and fun)tion. A)7uired /u.nerabi.ities arise main.y from prenata. e/ents t'at )ompromise feta. neurode/e.opment. W'et'er t'e )onstitutiona. /u.nerabi.ity is a )onse7uen)e of geneti) fa)tors$ en/ironmenta. fa)tors$ or a )ombination of bot'$ t'e mode. assumes t'at /u.nerabi.ity is$ in most )ases$ )ongenita.. But t'e assumption t'at /u.nerabi.ity is present at birt' does not imp.y t'at it (i.. be

360 WAL)ER ET AL. ).ini)a..y expressed at any point in t'e .ife span. Rat'er$ t'e mode. posits t'at t(o sets of fa)tors determine t'e postnata. )ourse of t'e /u.nerab.e indi/idua.. First$ externa. stress inf.uen)es t'e expression of t'e /u.nerabi.ity. A.t'oug' t'is is a .ong1standing assumption among t'eorists$ it is important to 7ua.ify t'is notion. Empiri)a. resear)' 'as pro/ided e/iden)e t'at episodes of s)'i4op'renia fo..o( periods of in)reased .ife stress 2Wa.-er H 8iforio$ *++D3. Nonet'e.ess$ t'ere is no e/iden)e t'at s)'i4op'renia patients experien)e more stress t'an 'ea.t'y indi/idua.s$ but rat'er t'at t'ey are more sensiti/e to stress ('en it o))urs. #'is assumption is t'e essen)e of t'e mode.Et'e intera)tion bet(een /u.nerabi.ity and stress is )riti)a.. "n addition$ t'e mode. assumes t'at neuromaturation is a -ey e.ement. "n parti)u.ar$ ado.es)en)eLear.y adu.t'ood appears to be a )riti)a. period for t'e expression of t'e /u.nerabi.ity for s)'i4op'renia. #'us some aspe)ts2s3 of brain maturationa. pro)esses during t'e postpuberta. period are .i-e.y p.aying an important ro.e in triggering t'e ).ini)a. expression of .atent /u.nerabi.ities 2Wa.-er$ *++;C Wa.-er$ Wa.der$ H Reyno.ds$ 9,,*3. "n summary$ a.t'oug' (e 'a/e not found a.. t'e pie)es of t'e pu44.e$ (e 'a/e made signifi)ant progress in mo/ing to(ard a )ompre'ensi/e a))ount of t'e etio.ogy of s)'i4op'renia. "n t'e )oming years$ (e )an expe)t resear)' to yie.d important information about t'e pre)ise nature of t'e brain /u.nerabi.ities asso)iated (it' s)'i4op'renia and t'e me)'anisms in/o./ed in t'e intera)tion of )ongenita. /u.nerabi.ity (it' subse7uent .ife stress and neuromaturation. REFERENCES Abi0Dar&/a(5 A5 Gi%5 R5 )rysta%5 75 1a%d2in5 R. MQ Seiby%5 7. R5 1#2ers5 M5 ,an Dy.+5 C. H5 C/arney5 D. SQ Innis5 R. 15 H Lar$e%%e5 M. =3@@;>. In.reased striata% d#*a(ine trans(issi#n in s./iC#*/renia' C#n6ir(ati#n in a se.#nd .#/#rt. %merican ournal of +sychiatry# 699# 8?308?8. A(eri.an Psy./iatri. Ass#.iati#n. = !!!>. Diagnostic and statistical manual of mental disorders =9t/ ed5 te-t re,.>. Was/in&t#n5 DC' A$t/#r. Ay%2ard E5 Wa%+er5 E5 H 1ettes5 1. =3@;9>. Inte%%i&en.e in s./iC#*/renia' Meta0ana%ysis #6 t/e resear./. 'chi*ophrenia $ulletin# 67# 9:!P3"@. 1aare5 W. F5 ,an Oe%5 C. 7.5 P#% H. EQ S./na.+5 H. G.5 D$rst#n5 S5 Sits+##rn5 M. MQ H )a/n5 R. S. = !!3>. G#%$(es #6 brain str$.t$res in t2ins dis.#rdant 6#r s./iC#*/renia. %rchives of General +sychiatry# 98<6=# ::09!. 1arr5 C. E5 Medni.+5 S. A5 H M$n+07#r&ensen5 P. =3@@!>. E-*#s$re t# in6%$enCa e*ide(i.s d$rin& &estati#n and ad$%t s./iC#*/renia' A 9!0year st$dy. %rchives of General +sychiatry# ;A# ;?@0;89. 1assett5 A. S5 H#d&+ins#n5 )5 C/#25 E. W5 C#rreia5 S5 S.$tt5 L. E5 We+sber&5 R. =3@@;>. J% 3 de%eti#n syndr#(e in ad$%ts 2it/ s./iC#*/renia. %merican ournal of Medical Genetics# 86# : ;0::8. 1e.+5 A. T. =3@8?>. C#&niti,e t/era*y and t/e e(#ti#na% dis#rders. :"?**. 1enes5 F. M5 H 1erretta5 S. = !!3>. GA1A er&i. interne$r#ns' I(*%i.ati#ns 6#r $nderstandin& s./iC#*/renia and bi*#%ar dis#rder. -europsychopharmacology# :9<6=# 30 8. 1%e$%er5 E. =3@"!>. Group of schi*ophrenias =7. Fin+in5 Trans.>. =3@"!>5 Ne2 Y#r+' Internati#na% Uni,ersities Press. =Ori&ina% 2#r+ *$b%is/ed 3@33> 1%e$%er5 M. =3@?">. C#n.e*ti#n #6 s./iC#*/renia 2it/in t/e %ast 6i6ty years and t#day. 0nternational ournal of +sychiatry# 8=9>5 "!30" :. 1radb$ry5 T. N5 H Mi%%er5 G. A. =3@;">. Seas#n #6 birt/ in s./iC#*/renia' A re,ie2 #6

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S*rin&er. Fei&/ner5 7. P5 R#bins5 E5 H G$Ce5 S. 1. =3@8 >. Dia&n#sti. .riteria 6#r $se in *sy./iatri. resear./. %rchives of General +sychiatry# :E# "80?:. F#rster5 P. L5 1$.+%ey5 R5 H P/e%*s5 M. A. =3@@@>. P/en#(en#%#&y and treat(ent #6 *sy./#ti. dis#rders in t/e *sy./iatri. e(er&en.y ser,i.e. +sychiatric 1linics of -orth %merica# ::# 8:"08"9. Fr#((0 Rei./(ann5 F. =3@9;>. N#tes #n t/e treat(ent #6 s./iC#*/renia by *sy./#ana%yti. *sy./#t/era*y. +sychiatry# 885 ?:. G#665 D. C5 HC#y%e5 7. T. = !!3>. T/e e(er&in& r#%e #6 &%$ta(ate in t/e *at/#*/ysi#%#&y and treat(ent #6 s./iC#*/renia. %merican ournal of +sychiatry# 698# 3:?8A3:88. G#665 D. C5 He.+ers5 S5 H Fre$denrei./5 O. = !!3>. Ad,an.es in t/e *at/#*/ysi#%#&y and treat(ent #6 *sy./iatri. dis#rders' I(*%i.ati#ns 6#r interna% (edi.ine. Medical 1linics of -orth %merica# 89# ??:0?;@. G#ttes(an5 3.3. =3@@3>. +sychiatric genesis5 The origins of madness. Ne2 Y#r+' W. H. Free(an. G#ttes(an5 I. I5 H 1erte%sen5 A. =3@;@>. C#n6ir(in& $ne-*ressed &en#ty*es 6#r s./iC#*/renia' Ris+s in t/e #66s*rin& #6 Fis./erBs Danis/ identi.a% and 6raterna% dis.#rdant t2ins. %rchives of General +sychiatry# ;E# ;?80;8 . Grebb5 7. A5 H Can.r#5 R. =3@;@>. S./iC#*/renia' C%ini.a% 6eat$res. In 7. I. )a*%ian H 1. 7. Sad#.+ =Eds.>5 'ynopsis of psychiatry5 behavioral sciences# clinical psychiatry ="t/ ed5 **. 8"80888>. 1a%ti(#re' Wi%%ia(s H Wi%+ins. Green5 M. F5 )ern5 R. S5 1ra665 D. L5 H MintC5 7. = !!!>. Ne$r#.#&niti,e de6i.its and 6$n.ti#na% #$t.#(e in s./iC#*/renia' Are 2e (eas$rin& t/e Kri&/t st$66KI 'chi*ophrenia $ulletin# :E<6=# 33@03:?. Green5 M. F5 N$e./ter%ein5 ). H5 1reit(eyer5 15 H MintC5 7. =3@@@>. 1a.+2ard (as+in& in $n(edi.ated s./iC#*/reni. *atients in *sy./#ti. re(issi#n' P#ssib%e re6%e.ti#n #6 aberrant .#rti.a% #s.i%%ati#n. %merican ournal of +sychiatry# 69E# 3:?803:8:. Har,ey5 P. D5 H Wa%+er5 E. F. =Eds.>. =3@;8>. +ositive and negative symptoms of psychosis5 Description# research# and future directions. Hi%%sda%e5 N7' La2ren.e Er%ba$( Ass#.iates.

364 WAL)ER ET AL. Henn5 F. A5 H 1ra$s5 D. F. =3@@@>. Str$.t$ra% ne$r#i(a&in& in s./iC#*/renia. An inte&rati,e ,ie2 #6 ne$r#(#r*/#%#&y. !uropean %rchives of +sychiatry D 1linical -euroscience# 0_`=S$**%. 9>5 9;0"?. Hest#n5 L. L. =3@??>. Psy./iatri. dis#rders in 6#ster /#(e reared ./i%dren #6 s./iC#*/reni. (#t/ers. $ritish ournal of +sychiatry# 66:# ;3@0; ". H#2e%%s5 7. G. =3@@3>. The concept of schi*ophrenia5 ,istorical perspectives. Was/in&t#n DC' A(eri.an Psy./iatri. Press. H$tt$nen5 M. =3@;@>. Materna% stress d$rin& *re&nan.y and t/e be/a,i#r #6 t/e #66s*rin&. In S. D#-iadis H S. Ste2art =Eds.>5 !arly influences shaping the individual. -%TO %dvanced 'cience 0nstitute 'eries5 Fol. 6E7. )ife sciences. Ne2 Y#r+' P%en$(. 7ents./5 7. D5 R#t/5 R. H5 H Tay%#r5 7. R. = !!!>. R#%e 6#r d#*a(ine in t/e be/a,i#ra% 6$n.ti#ns #6 t/e *re6r#nta% .#rti.#striata% syste(' I(*%i.ati#ns 6#r (enta% dis#rders and *sy./#tr#*i. dr$& a.ti#n. +rogress in $rain (esearch# 6:E# 9::09":. 7#nes5 P5 R#d&ers5 15 M$rray5 R5 H Mar(#t5 M. =3@@9>. C/i%d de,e%#*(enta% ris+ 6a.t#rs 6#r ad$%t s./iC#*/renia in t/e 1ritis/ 3@9? birt/ .#/#rt. )ancet# ?;;# 3:@;039! . )a*%an5 H. I5 H Sad#.+5 1. 7. =3@@;>. )a*%an and Sad#.+Bs syn#*sis #6 *sy./iatry' 1e/a,i#ra% s.ien.es4.%ini.a% *sy./iatry =;t/ ed.>. 1a%ti(#re5 MD5 US' Wi%%ia(s H Wi%+ins C#.5 39!3 **. )arayi#r&#$5 M5 M#rris5 M. A5 H M#rr#25 1. =3@@">. S./iC#*/renia s$s.e*tibi%ity ass#.iated 2it/ interstitia% de%eti#ns #6 ./r#(#s#(e J%%. +roceedings of the -ational %cademy of 'cience @:# 8?3 08?3?. )eit/5 S. 7Q Re&ier5 D. A5 H Rae5 D. S. =3@@3>. S./iC#*/reni. dis#rders. In L. N. R#bins H D. A. Re&ier =Eds.>5 +sychiatric disorders in %merica5 The !pidemiologic 1atchment %rea study =**. ::0" >. Ne2 Y#r+' Free Press. )end%er5 ). S5 M.G$ire5 M5 Gr$enber&5 A. M5 H Wa%s/5 D. =3@@"b>. S./iC#ty*a% sy(*t#(s and si&ns in t/e R#s.#((#n Fa(i%y St$dy' T/eir 6a.t#r str$.t$re and 6a(i%ia% re%ati#ns/i* 2it/ *sy./#ti. and a66e.ti,e dis#rders. %rchives of General +sychiatry# 9:# @?0:!:. )end%er5 ). S5 Nea%e5 M. C5 H Wa%s/5 D. =3@@">. E,a%$atin& t/e s*e.tr$( .#n.e*t #6 s./iC#*/renia in t/e R#s.#((#n Fa(i%y St$dy. %merican ournal of +sychiatry# 69:# 89@08"9. )est%er5 L. P5 Wa%+er5 E5 H Ge&a5 E. M. = !!3>. D#*a(ine re.e*t#rs in t/e brains #6 s./iC#*/renia *atients' a (eta0ana%ysis #6 t/e 6$idin&s. $ehavioural +harmacology# 6:# :""0:83. )ety5 S. S. =3@;;>. S./iC#*/reni. i%%ness in t/e 6a(i%ies #6 s./iC#*/reni. ad#*tees' Findin&s 6r#( t/e Danis/ nati#na% sa(*%e. 'chi*ophrenia $ulletin# 6;# 380 . )rae*e%in5 E. =3@3:>. Psy./iatrie =;t/ ed.>. Trans%ated by R. M. 1ar.%ay =3@3@> 6r#( G#%. :5Pt. 5 as Dementiapraeco" and paraphrenia. Edinb$r&/5 Li,in&st#ne. )rin&%en5 E5 H Cra(er5 G. =3@;@>. O66s*rin& #6 (#n#Cy&#ti. t2ins dis.#rdant 6#r s./iC#*/renia. %rchives of General +sychiatry# ;E# ;8:0;88. )$%/ara5 P5 C/a+rabarti5 S. = !!3>. C$%t$re and s./iC#*/renia and #t/er *sy./#ti. dis#rders. +sychiatric 1linics of -orth %merica# :;# 99@09?9. )$*erber&5 G5 H He.+ers5 S. = !!!>. S./iC#*/renia and .#&niti,e 6$n.ti#n. 1urrent Opinion in -eurobiology# 67#

!"0 3!. Larsen5 T. )5 Friis5 S5 Haa/r5 U5 7#a5 I5 7#/annessen5 7. O5 Me%%e5 I5 O*D#rds(#en5 S5 Si(#nsen5 E5 H Ga&%$(5 P. = !!3>. Ear%y dete.ti#n and inter,enti#n in 6irst0e*is#de s./iC#*/renia' A .riti.a% re,ie2. %cta +sychiatrica 'candinavic# 67?# : :0::9. La2rie5 S. M5 H Ab$+(ei%5 S. S. =3@@;>. 1rain abn#r(a%ity in s./iC#*/renia' A syste(ati. and J$antitati,e re,ie2 #6 ,#%$(etri. (a&neti. res#nan.e i(a&in& st$dies. $ritish ournal of +sychiatry# 6A:# 33!0 3 !. Le/(an5 A. F. =3@@">. G#.ati#na% re/abi%itati#n in s./iC#*/renia. 'chi*ophrenia $ulletin# :6<;=# ?9A"?. Le/(an5 A. F5 G#%dber&5 R5 Di-#n5 L5 M.Nary5 S5 P#strad#5 L5 Ha.+(an5 A5 H M.D#nne%%5 ). = !! >. i(*r#,in& e(*%#y(ent #$t.#(es 6#r *ers#ns 2it/ se,ere (enta% i%%nesses. %rchives of General +sychiatry# 9@# 3?"038 . Le2is5 D. A5 Pierri5 7. NQ G#%+5 D. W5 Me%./itC+y5 D. S.5 W##5 T. U. =3@@@>. A%tered GA1A ne$r#trans(issi#n and *re6r#nta% .#rti.a% dys6$n.ti#n in s./iC#*/renia. $iological +sychiatry# ;E# ?3?0? ?. Lieber(an5 7. A5 Per+ins5 D5 1e%&er5 A.5 C/a+#s5 M5 7ars+#&5 F5 1#te,a5 )5 H Gi%(#re5 7. = !!3>. T/e ear%y sta&es #6 s./iC#*/renia' S*e.$%ati#ns #n *at/#&enesis5 *at/#*/ysi#%#&y5 and t/era*e$ti. a**r#a./es. $iological +sychiatry# 97# ;;90;@8. Lindstr#(5 L. H5 Ge6Gert5 O5 Ha&ber&5 G5 L$ndber&5 T5 1er&str#(5 M.5 Hart,i&5 P5 H Lan&str#(5 1. =3@@@>. In.reased d#*a(ine synt/esis rate in (edia% *re6r#nta% .#rte- and striat$( in s./iC#*/renia indi.ated by L0=/eta033C> DORA and PET. $iological +sychiatry# ;E# ?;30?;;. M.Nei%5 T. F. =3@;;>. Obstetri. 6a.t#rs and *rerinata% inD$ries. In M. T. Ts$an& H 7. C. Si(*s#n =Eds >5 ,andbook of schi*ophrenia5 -osology# epidemiology and genetics =G#%. :5 **. :3@0:9:>. A(sterda(' E%se,ier S.ien.e. M.Nei%5 T F5 Cant#r0Graae5 E5 H Weinber&er5 D. R. = !!!>. Re%ati#ns/i* #6 #bstetri. .#(*%i.ati#ns and di66eren.es in siCe #6 brain str$.t$res in (#n#Cy&#ti. t2in *airs dis.#rdant 6#r s./iC#*/renia. %merican ournal of+sychiatry# 8"85 !:0 3 .

@. SCHIFOPHRENIA 366 Me%tCer5 H. 7. = !!3>. Treat(ent #6 s$i.ida%ity in s./iC#*/renia. In H. Hendin H 7. 7. Mann =Eds.>5 The clinical science of suicide prevention. %nnals of the -ew Kork %cademy of 'ciences =G#%. @: 5 **. 990?!>. Ne2 Y#r+' Ne2 Y#r+ A.ade(y #6 S.ien.es. Mi%%er5 T. 75 M.G%as/an5 T. H.5 R#sen5 7. L5 S#(Dee5 L5 Mar+#,i./5 P. 7.5 Stein5 )5 H W##ds5 S. W. = !! >. Pr#s*e.ti,e dia&n#sis #6 t/e initia% *r#dr#(e 6#r s./iC#*/renia based #n t/e Str$.t$red Inter,ie2 6#r Pr#dr#(a% Syndr#(es' Pre%i(inary e,iden.e #6 interrater re%iabi%ity and *redi.ti,e ,a%idity. %merican ournal of +sychiatry# 69@#;?:0;?". M#2ry5 1. 75 H Nan.arr#25 D. 7. = !!3>. M#%e.$%ar &eneti.s #6 s./iC#*/renia. 1linical D !"perimental +harmacology D +hysiology# :8# ??0?@. M$rray5 R. M5 7#nes5 P. 15 OBCa%%a&/an5 E5 H Ta+ei5 N. =3@@ >. Genes5 ,ir$ses andne$r#de,e%#*(enta% s./iC#*/renia ournal of +sychiatric (esearch# :E# "0 :". Ne$(ann5 C5 Wa%+er5 E. Le2ine5 R5 H 1a$(5 ). =3@@?>. C/i%d/##d be/a,i#r and ad$%t ne$r#*sy./#%#&i.a% dys6$n.ti#n in s./iC#*/renia. -europsychiatry# -europsychology and $ehavioral -eurolog# @# 30 @. Per(5 D. L5 C#rri&an5 P. W5 1enta%%5 R. P5 Ra.enstein5 7. M5 H Ne2(an5 L. =3@@8>. S#.ia% .#&niti#n in s./iC#*/re0nia.+sychological $ulletin# 6:6<6=# 33903: . Per(5 D. L5 H M$eser5 ). T. =3@@?>. Resear./ $*date #n t/e *sy./#s#.ia% treat(ent #6 s./iC#*/renia. %merican ournal of +sychiatry# 69?# ?!80?38. Per(5 D. L5 C#(bs5 D. R5 Rit./ie5 M5 Fran.is5 75 Cassisi5 75 M#rris5 S5 H T#2nsend5 M. = !!!>. E(#ti#n re.#&niti#n in s./iC#*/renia' F$rt/er in,esti&ati#n #6 &enera%iCed ,ers$s s*e.i6i. de6i.it (#de%s. ournal of %bnormal +sychology. 3!@=:>5 "3 0"3? P#tas/5 7. 1Q Wi%%#$r5 G L5 C/i$5 Y. F5 Si(*s#n5 S. G.5 Ma.)inn#n5 D. F5 Pear%s#n5 G. D5 DePa$%#5 7. R5 7r.5 H M.%nnis5 M. G. = !!3>. T/e 6a(i%ia% a&&re&ati#n #6 *sy./#ti. sy(*t#(s in bi*#%ar dis#rder *edi&rees. %merican ournal of +sychiatry# 698# 3 ";03 ?9. Raine5 A5 8c Medni.+5 S. =Eds.>. =3@@">. 'chi*otypal personality disorder. L#nd#n' Ca(brid&e Uni,ersity *ress. Re&ier5 D. A5 Far(er5 M. E5 Rae5 D. S.5 L#.+e5 1. F5 )eit/5 S. 75 7$dd5 L. L5 H G##d2in5 F. ). =3@@!>. C#(#rbidity #6 (enta% dis#rders 2it/ a%.#/#% and #t/er dr$& ab$se. Res$%ts 6r#( t/e E*ide(i#%#&i. Cat./(ent Area =ECA> St$dy. ournal of the %merican Medical %ssociation# :E;# "330 "3;. Rie./er0R#ss%er5 A5 H Ha6/er5 H. = !!!>. Gender as*e.ts in s./iC#*/renia' 1rid&in& t/e b#rder bet2een s#.ia% and bi#%#&i.a% *sy./iatry. %cta +sychiatrica 'candinavica# 8! =S$**%.>5 ";0? . R#seb$s/5 P. I5 H MaC$re+5 M. F. = !!3>. Identi6i.ati#n and treat(ent #6 ne$r#%e*ti. (a%i&nant syndr#(e. 1hild and %dolescent +sychopharmacology -ews# E<?=# *. 9. Sad#.+5 1. 75 H Sad#.+5 G A. =Eds.>. = !!!>. .aplan D 'adock s comprehensive te"tbook of psychiatry =8t/5 ed. G#%. 3>. Ne2 Y#r+' Li**in.#tt Wi%%ia(s H Wi%+ins. S./(aD$+5 N. A. = !!3>. Hi**#.a(*a% dys6$n.ti#n in s./iC#*/renia. ,ippocampus# 66# "@@0?3:. S./neider5 ). =3@"@>. 1linical +sychopathology. Ne2 Y#r+' Gr$ne and Stratt#n. S./2artC5 R. C5 H C#/en5 1. N. = !!3>. Ris+ 6a.t#rs 6#r s$i.ida%ity a(#n& .%ients 2it/ s./iC#*/renia. ournal of 1ounseling D Development# A@# :39A:3@. Siris5 S. G. = !!3>. S$i.ide and s./iC#*/renia.

ournal of +sychopharmacology# 6<:=# 3 80:". S(yt/e5 7. W5 M.C#r(i.+5 C. M5 R#./6#rd5 75 H Meaney5 M. 7. =3@@9>. T/e intera.ti#n bet2een *renata% stress and ne#nata% /and%in& #n n#.i.e*ti,e res*#nse %aten.ies in (a%e and 6e(a%e rats. +hysiology and $ehavior# 99# @830@89. S#ares5 7. C5 H Innis5 R. 1. =3@@@>. Ne$r#./e(i.a% brain i(a&in& in,esti&ati#ns #6 s./iC#*/renia. $iological +sychiatry# ;E# ?!!0?3". S*itCer5 R. L5 Endi.#tt5 75 H R#bins5 E. =3@8;>. (esearch diagnostic criteria <(D1= for a selected group of functional disorders. Ne2 Y#r+' 1i#(etri.s Resear./. SJ$ires5 R. F5 H Saeder$*5 E. =3@@3>. A re,ie2 #6 e,iden.e 6#r GA1er&i. red#(inan.e4&%$ta(ater&i. de6i.it as a .#((#n eti#%#&i.a% 6a.t#r in b#t/ s./iC#*/renia and a66e.ti,e *sy./#ses' M#re s$**#rt 6#r a .#ntin$$( /y*#t/esis #6 K6$n.ti#na%K *sy./#sis. -eurochemical (esearch# 6E# 3!@@03333. S$ddat/5 R. L5 C/ristis#n5 G. W5 T#rrey5 E. F5 Casan#,a5 M. F5 H Weinber&er5 D. R. =3@@!>. Anat#(i.a% abn#r(a%ities in t/e brains #6 (#n#Cy&#ti. t2ins dis.#rdant 6#r s./iC#*/renia. -ew !ngland ournal ofMedicine# ?::#8;@08@9. S$sser5 E. S5 H 1r#2n5 A. S. =Eds.>. =3@@@>. +renatal e"posures in schi*ophrenia. +rogress in psychiatry. Was/in&t#n5 DC' A(eri.an Psy./iatri. Press. Tienari5 P5 Wynne5 L. C5 M#rin&5 7. H La/ti5 3.=3@@9>. T/e Finnis/ ad#*ti,e 6a(i%y st$dy #6 s./iC#*/renia' I(*%i.ati#ns 6#r 6a(i%y resear./. $ritish ournal of +sychiatry# 6E;<'uppl. :>5 !0 ?. T#rrey5 E. F. =3@;8>. Pre,a%en.e st$dies in s./iC#*/renia. $ritish ournal of +sychiatry# 697# "@;0?!;. T#rrey5 E. F5 1#2%er5 A. E5 H Tay%#r5 E. H. =3@@9>. 'chi*ophrenia and manic3depressive disorder5 The biological roots of mental illness as revealed by the landmark study of identical twins. Ne2 Y#r+' 1asi. 1##+s. T#rrey5 E. F5 Mi%%er5 75 Ra2%in&s5 R5 H Y#%+en5 R. H. =3@@8>. Seas#na%ity #6 birt/s in s./iC#*/renia and bi*#%ar dis#rder' A re,ie2 #6 t/e %iterat$re. 'chi*ophrenia (esearch# :8# 30:;.

368 WAL)ER ET AL. Tsai5 G5 H C#y%e5 7. T. = !! >. G%$ta(ater&i. (e./anis(s in s./iC#*/renia. %nnual (eview of +harmacology D To"icology# ;:# 3?"038@. ,an Os5 75 H Se%ten5 7. =3@@;>. Prenata% e-*#s$re t# (aterna% stress and s$bseJ$ent s./iC#*/renia' T/e May 3@9! in,asi#n #6 T/e Net/er%ands. $ritish ournal of +sychiatry# 6A:# : 90: ?. Gent$ra5 75 N$e./ter%ein5 ). H5 Hardesty5 7. P5 H Git%in5 M. =3@@ >. Li6e e,ents and s./iC#*/reni. re%a*se a6ter 2it/dra2a% #6 (edi.ati#n. $ritish ournal of +sychiatry# 6E6# ?3"0? !. Wa%+er5 E. =3@@9>. De,e%#*(enta%P (#derated e-*ressi#ns #6 t/e ne$r#*at/#%#&y $nder%yin& s./iC#*/renia. 'chi*ophrenia $ulletin# :7# 9":P3;!. Wa%+er5 E. = !! >. Ad#%es.ent ne$r#de,e%#*(ent and *sy./#*at/#%#&y. 1urrent Directions in +sychological 'cience# 66# 90 ;. Wa%+er5 E5 H 1a$(5 ). =3@@;>. De,e%#*(enta% ./an&es in t/e be/a,i#ra% e-*ressi#n #6 t/e ,$%nerabi%ity 6#r s./iC#*/renia. In M. LenCen2e&er H R. D2#r+in =Eds.>5 Origins and development of schi*ophrenia5 %dvances in e"perimental psychopathology =**. 9?@A3@3>. Was/in&t#n5 DC' A(eri.an Psy./#%#&i.a% Ass#.iati#n. Wa%+er E5 H Di6#ri#5 D. =3@@8>. S./iC#*/renia' A ne$ra% diat/esis0stress (#de%. +sychological (eview# 67;# 303@. Wa%+er5 E5 Gri(es5 )5 Da,is5 D5 H S(it/5 A. =3@@:>. C/i%d/##d *re.$rs#rs #6 s./iC#*/reniaY Fa.ia% e-*ressi#ns #6 e(#ti#n. %merican ournal of +sychiatry# 0'O# 3?"90 3??!. Wa%+er5 E5 H Le2ine5 R. 7. =3@@!>. Predi.ti#n #6 ad$%t0#nset s./iC#*/renia 6r#( ./i%d/##d /#(e (#,ies #6 t/e *atients. %merican ournal ofH+sychiatry# 6;A# 3!" 03!"?. Wa%+er5 E5 Le2is5 N5 L#e2y5 R5 Pay%#5 S. =3@@@> M#t#r 6$n.ti#ns and *sy./#*at/#%#&y aS*e.ia% iss$eb. Development and +sychopathology 66# "!@0" :. Wa%+er5 E5 Mar2it5 S5 H E(#ry5 E. =3@;!>. A .r#ss0se.ti#na% st$dy #6 e(#ti#n re.#&niti#n in s./iC#*/reni.s. ournal of %bnormal +sychology. ;@=:>5 9 ;09:?. Wa%+er5 E5 Sa,#ie5 T5 H Da,is5 D. =3@@9>. Ne$r#(#t#r *re.$rs#rs #6 s./iC#*/renia. 'chi*ophrenia $ulletin# :7# 993P3" . Wa%+er5 E5 Wa%der5 D5 H Reyn#%ds5 F. = !!3>. De,e%#*(enta% ./an&es in C#rtis#% se.reti#n in n#r(a% and at0ris+ y#$t/. Development and +sychopathology# 6?# 83@08:!. Weinstein5 D5 Di6#ri#5 D.5 S./i66(an5 75 Wa%+er5 E5 H 1#nsa%%5 1. =3@@@>. Min#r */ysi.a% an#(a%ies5 der(at#0 &%y*/i. asy((etries and C#rtis#% %e,e%s in ad#%es.ents 2it/ s./iC#ty*a% *ers#na%ity dis#rder. %merican ournal of +sychiatry# 69E# ?380? :. Weinst#.+5 M. =3@@?>. D#es *renata% stress i(*air .#*in& and re&$%ati#n #6 /y*#t/a%a(i.0 *it$itary0adrena% a-isI -euroscience and $iobehavioral (eviews# :6# 303!. We%ber&5 L. A5 H Se.+%5 7. R. = !!3>. Prenata% stress5 &%$.#.#rti.#ids and t/e *r#&ra((in& #6 t/e brain. ournal of -euroendocrinology# :# 33:0 ;. Y$n&5 A. R5 P/i%%i*s5 L. 75 M.G#rry5 P. D5 Ha%%&ren5 M. A5 M.Far%ane5 C. A5 7a.+s#n5 H. 75 Fran.ey5 S5 Harri&an5 S5 Patt#n5 G. C5 H 7a.+s#n5 H. 7. =3@@;>. Predi.ti#n #6 *sy./#sis' A ste* t#2ards indi.ated *re,enti#n #6

s./iC#*/renia. $ritish ournal of +sychiatry# i8 =S$**%. ::>5 390 !.

CHAPTER

3!
Pers#na%ity Dis#rders Linda Anne C#+er and T/#(as A. Widi&er University o f .entucky "n *+B,$ t'e Ameri)an %sy)'iatri) Asso)iation 2A%A3 pub.is'ed t'e t'ird edition of t'e 8i1 agnosti) and tatisti)a. Manua. of Menta. 8isorders 28 M1"""C A%A$ *+B,3$ introdu)ing a mu.tiaxia. ).assifi)ation system. Axis "" of t'is ne( manua. (as de/oted primari.y to persona.ity dysfun)tion$ be)ause of t'e )onsiderab.e pre/a.en)e of ma.adapti/e persona.ity traits in genera. ).ini)a. pra)ti)e and t'e substantia. impa)t of t'ese traits on t'e )ourse and treatment of ot'er menta. disorders 2Fran)es$ *+B,3. "n t'is )'apter$ (e begin by dis)ussing issues in t'e diagnosis of persona.ity disorders as defined by 8 M1">1#R 2A%A$ 9,,,3. We a.so in).ude an a.ternati/e mode. for t'e diagnosis and ).assifi)ation of ma.adapti/e persona.ity fun)tioning$ t'e fi/e1fa)tor mode. 2FFMC Costa H M)Crae$ *++93. 8 M1">1#R in).udes ten indi/idua. persona.ity disorders$ organi4ed into t'ree ).usters5 2a3 paranoid$ s)'i4oid$ and s)'i4otypa. 2t'e odd1e))entri) ).uster3C 2b3 antiso)ia.$ border.ine$ 'istrioni)$ and nar)issisti) 2dramati)1emotiona.1errati) ).uster3C and 2)3 a/oidant$ dependent$ and obsessi/e1)ompu.si/e 2anxious1fearfu. ).uster3 2A%A$ 9,,,3. We present ('at is )urrent.y -no(n about fi/e of t'e more 'ea/i.y resear)'ed persona.ity disorders 2i.e.$ antiso)ia.$ border.ine$ a/oidant$ s)'i4oid$ and dependent3 and indi)ate 'o( t'e FFM )on)eptua.i4ation of ea)' of t'em extends our understanding of t'eir diagnosis$ epidemio.ogy$ etio.ogy$ and pat'o.ogy. pa)e .imitations pro'ibit detai.ed )o/erage of a.. of t'e 8 M1">1#R persona.ity disorders$ but information )on)erning t'ese additiona. persona.ity disorders is pro/ided in t'e genera. dis)ussion. PERSONALITY DISORDER >irtua..y a.. adu.ts (it' psy)'o.ogi)a. prob.ems 'a/e a )'ara)teristi) manner of t'in-ing$ fee.ing$ be'a/ing$ and re.ating to ot'ers t'at (as present before t'e onset of an Axis " disorder$ and$ for many of t'ese persons$ t'ese persona.ity traits are so ma.adapti/e t'at t'ey )onstitute a persona.ity disorder. A personality disorder is defined in 8 M1">1#R as 0an enduring pattern of inner experien)e and be'a/ior t'at de/iates mar-ed.y from t'e expe)tations of t'e 370

371 CO)ER AND WIDIGER indi/idua.Gs )u.ture$ is per/asi/e and inf.exib.e$ 'as an onset in ado.es)en)e or ear.y adu.t'ood$ is stab.e o/er time$ and .eads to distress or impairment0 2A%A$ 9,,,$ p. ?B?3. #'e pre/a.en)e of persona.ity disorders (it'in ).ini)a. settings is estimated to be abo/e <,P 2Mattia H Rimmerman$ 9,,*3. %er'aps ?,P of inpatients (it'in some ).ini)a. settings are diagnosed (it' border.ine persona.ity disorder 2A%A$ 9,,,C =underson$ 9,,*3. Antiso)ia. persona.ity disorder may be diagnosed in up to <,P of inmates (it'in a )orre)tiona. setting 2Widiger H Corbitt$ *++<3. #'e )ourse and treatment of most ot'er disorders is substantia..y a.tered by t'e presen)e of a )omorbid persona.ity disorder 28o.an1 e(e..$ @rueger$ H 'ea$ 9,,*3$ yet t'e pre/a.en)e of persona.ity disorder is genera..y underestimated in ).ini)a. pra)ti)e 2Rimmerman H Mattia$ *+++3. #'is situation may be due to a .a)- of time to pro/ide systemati) or )ompre'ensi/e e/a.uations of persona.ity fun)tioning 2Widiger H Co-er$ 9,,*3$ or per'aps to a re.u)tan)e to diagnose t'em be)ause insuran)e )ompanies may )onsider persona.ity disorders untreatab.e 2Rimmerman H Mattia$ *+++3. "t is estimated t'at *,P to *<P of t'e genera. popu.ation (ou.d meet )riteria for one of t'e ten 8 M1"> persona.ity disorders 2Mattia H Rimmerman$ 9,,*C #orgesen$ @ring.en$ H Cramer$ 9,,*3. #ab.e *,.* pro/ides pre/a.en)e data reported by t'e best a/ai.ab.e studies to date for estimating t'e pre/a.en)e of indi/idua. persona.ity disorders (it'in t'e )ommunity. #'ese pre/a.en)e estimates are genera..y ).ose to t'ose pro/ided in 8 M1">1#R$ a.t'oug' t'ere is /ariation a)ross studies due to differen)es in setting and assessment instruments. A )ommon mis)on)eption )on)erning persona.ity disorders is t'at t'ey are untreatab.e. #'is is not t'e )ase. %ersona.ity dysfun)tion )an be t'e fo)us of treatment 2Be)- et a..$ *++,C =abbard$ *++;C Mar-o/it4$ 9,,*3. %ersona.ity disorders are among t'e most diffi)u.t disorders to treat$ 'o(e/er$ be)ause t'ey in/o./e (e..1estab.is'ed be'a/iors t'at may be integra. to a ).ientGs se.f1 image 2 tone$ *++:3. Ne/ert'e.ess$ psy)'oso)ia. and p'arma.ogi) treatments )an produ)e ).ini)a..y and so)ia..y meaningfu. )'anges$ 2%erry$ Banon$ H "anni$ *+++C anis.o( H M)=.as'an$ *++B3$ a.t'o