Introduction

• Abnormal psychology is the scientific study of atypical or unusual behavior.
• The goal is to reliably predict, explain, diagnose, identify causes of, and treat maladaptive behavior.
• It is a major sub-field in psychology, involving extensive research and applied work on mental disorders.
• The costs of mental illness are significant and far-reaching.
• This chapter introduces key concepts, definitions, and terminology in abnormal psychology.
• It reviews how to define mental disorder and discusses strengths and limitations of current diagnostic approaches.
• Cultural norms and expectations are integral to understanding abnormality.
• Mental health professionals assess individuals who may be experiencing a mental disorder.
• Key concepts for assessment include validity and reliability.
• The chapter provides an overview of tools used by professionals for assessment.
• Professionals diagnose and classify abnormal behavior based on standardized criteria.

Defining Psychopathology

What is the Cost of Mental Illness to Society?

• Mental illness has significant social and economic costs in Canada.
• People with mental illness are more likely to experience social and economic marginalization, including social isolation, inability to work, and lower educational attainment and income, compared to those without mental illness (Burczycka, 2018).
• Individuals with mental illness have a higher risk of victimization; 1 in 10 people with mental health-related disabilities in Canada report experiencing violence over the past year, double the rate found in the general population (Burczycka, 2018).
• Mental illness affects work performance, with an estimated 2 out of 9 workers experiencing mental illness that impacts their work, leading to an annual wage loss of over $6.3 billion (Smetanin et al., 2011).
• The annual economic cost of mental illness in Canada is estimated at $51 billion (Smetanin et al., 2011).
• Direct costs to the healthcare system, including hospitalizations, medical visits, and support staff, amount to about $21.3 billion annually (Smetanin et al., 2011).
• Indirect costs affect the justice system, social services, education systems, and quality of life.
• Personal and economic costs of mental illness are expected to rise due to an increasing number of Canadians impacted by mental health problems, coupled with an aging and growing population.
• By 2041, annual costs of mental illness in Canada are projected to reach $307 billion (Mental Health Commission of Canada, 2010).
• Globally, the World Economic Forum estimated $2.5 trillion in costs related to mental illness in 2010, with projected costs rising to $6 trillion by 2030.
• The costs of mental illness surpass those of cancer, diabetes, and respiratory disorders combined (Whiteford et al., 2013).
• While no single behavior defines abnormality, clinical practitioners agree that behavior deviating from cultural norms, causing dysfunction in cognition, emotion, or behavior, and resulting in distress or impairment, is considered abnormal behavior.
• With this understanding, the discussion moves to defining mental disorders.

Definition of Abnormal Psychology and Psychopathology

• Abnormal psychology refers to the scientific study of people who exhibit atypical or unusual behavior.
• The goal is to reliably predict, explain, diagnose, identify causes of, and treat maladaptive behavior.
• A less stigmatizing term for the study of psychological disorders is psychopathology.
• These definitions raise important questions: What is considered abnormal behavior? What constitutes a psychological or mental disorder?

Defining Psychological Disorders

• The concept of mental or psychological disorders is challenging to define.
• The American Psychiatric Association (APA) acknowledges in the DSM-5 that no definition can capture all aspects of all disorders.
• Despite difficulties in definition, psychological disorders are recognized as important, defined as psychological dysfunctions causing distress or impaired functioning, and deviating from societal or cultural standards.
• This definition involves three components, often referred to as the 3 Ds.
• Dysfunction involves a clinically significant disturbance in cognition, emotion regulation, or behavior, reflecting underlying issues in psychological, biological, or developmental processes.
• Dysfunction can manifest as breakdowns in cognition (e.g., delusions), emotion (e.g., inability to experience pleasure), or behavior (e.g., fear preventing attendance at work).
• Abnormal behavior can impede well-being and is assessed by comparing an individual’s performance to general expectations or their past functioning.
• Distress involves psychological or physical pain and refers to suffering, but it is not sufficient on its own to classify behavior as abnormal.
• Normal life events, like the loss of a loved one or a career-ending injury, cause distress without necessarily indicating a disorder.
• Some individuals displaying abnormal behavior may not experience distress but are generally positive.
• If distress is absent, impairment is typically required to consider behavior abnormal.
• Impairment occurs when an individual is unable to function normally in daily life, such as failing to maintain hygiene, pay bills, attend social events, or work.
• Typically, distress and/or impairment in functioning are required to classify behavior as abnormal and to diagnose a psychological disorder.
• Deviance refers to behavior that deviates from what is considered normal, typical, or average.
• Culture, which includes socially transmitted behaviors, customs, values, and beliefs, determines what is normal.
• A person is considered deviant when they do not follow the stated and unstated rules of society, known as social norms.
• Social norms change over time as values and expectations shift; for example, homosexuality was once considered a mental disorder in the DSM but is now widely accepted.
• Public displays of affection (PDAs) were once restricted to private settings but are now commonly accepted.
• Behavior seen as deviant may be context-dependent, such as crying being seen as weakness for males in general but understandable during tragic events like the 2017 Vegas mass shooting.
• Statistically deviant behavior is not always negative; for example, genius is deviant but considered a positive attribute.
• Some clinicians add a fourth D to the DSM-5’s list: dangerousness, referring to behavior that poses a threat to the safety of the person or others.
• Dangerousness may be exhibited by individuals with suicidal intent, those with paranoid ideation combined with aggressive impulses, or some with antisocial personality disorder.
• Mental health professionals and researchers have a duty to report to law enforcement when an individual expresses intent to harm themselves or others.
• Most individuals with mental disorders, such as depression, anxiety, or obsessive-compulsive disorder, are no more dangerous than those without such disorders.
• Having a mental disorder does not automatically make someone dangerous, and most dangerous individuals are not mentally ill.
• Studies show that only a small proportion of crimes are committed by individuals with severe mental disorders (Matthias & Angermeyer, 2002).
• Strangers are at a lower risk of being attacked by someone with a severe mental disorder than by someone who is mentally healthy.
• The risk of violent behavior is generally limited to a small number of symptom constellations.
• Dangerousness is more the exception than the rule for individuals with mental disorders (Hiday & Burns, 2010).

Cultural Expectations

What is Clinical Assessment?

• Violating cultural expectations alone is not sufficient to identify the presence of a psychological disorder.
• Behavior that is considered appropriate in one culture may not be viewed the same way in another culture.
• In the U.S., reciprocating a stranger’s smile is a social norm, and not doing so might be seen as socially awkward or disordered.
• In Japan, cultural norms emphasize reserve, restraint, and privacy, so responding to a stranger’s smile is not expected (Patterson et al., 2007).
• Eye contact is another culturally variable behavior: in the U.S. and Europe, it signifies honesty and attention, but in Latin-American, Asian, and African cultures, direct eye contact may be viewed as rude or aggressive (Pazain, 2010).
• Hallucinations, such as seeing or hearing things not physically present, are considered abnormal in Western societies and often indicate a psychological disorder.
• In other cultures, however, visions of future events may be regarded as normal and positively valued experiences (Bourguignon, 1970).
• Cultural norms evolve over time; what is typical in one era may no longer be considered acceptable in another.
• Fashion trends, like headbands, legwarmers, and big hair from the 1980s, may once have been typical but might be viewed as unusual today.

The Myth of Mental Illness

• In the 1950s and 1960s, the concept of mental illness faced widespread criticism.
• Critics argued that mental illness was a “myth” used to justify psychiatric intervention in socially disapproved behavior (Wakefield, 1992).
• Thomas Szasz, a prominent psychiatrist, was a major proponent of this view.
• Szasz contended that mental illness was invented by society and the mental health establishment to stigmatize and subjugate people who violate social and legal norms.
• He suggested that symptoms of mental illness were better characterized as “problems in living” rather than actual illnesses (Szasz, 1960).
• In his 1961 book The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, Szasz expressed disdain for the concept of mental illness and psychiatry.
• Szasz argued that genuine illness or disease must involve detectable abnormalities in bodily structures or functions, such as infections or organ damage.
• Since symptoms of mental illness are not accompanied by such detectable abnormalities, Szasz claimed psychological disorders are not true disorders (Szasz, 1961/2010).
• Szasz proclaimed that “disease or illness can only affect the body; hence, there can be no mental illness” (p. 267).
• Today, the reality of mental illness is widely recognized, given the extreme psychological suffering, disordered behavior, distress, and impairment experienced by those with psychological disorders.
• Despite the controversy surrounding Szasz’s views, they influenced the mental health community and society in several ways.
• Terms like “mental health problems” are now commonly used, reflecting Szasz’s “problems in living” perspective (Buchanan-Barker & Barker, 2009).
• Szasz was one of the first psychiatrists to challenge the notion that homosexuality represented a mental illness or disease (Szasz, 1965).
• His challenge helped pave the way for the social and civil rights of gay and lesbian people (Barker, 2010).
• Szasz’s work also inspired legal changes that protect the rights of individuals in psychiatric institutions, giving them more influence and responsibility over their lives (Buchanan-Barker & Barker, 2009).

Clinical Assessment

What is Clinical Assessment?

• Mental health professionals must engage in clinical assessment to effectively treat clients and determine if treatments are working.
• Clinical assessment involves collecting information through observation, psychological tests, neurological tests, and interviews.
• The goal of clinical assessment is to understand the client’s symptoms, skills, abilities, personality characteristics, cognitive and emotional functioning, social context, and cultural factors (e.g., language, ethnicity).
• Clinical assessment is conducted throughout the treatment process, not just at the beginning.
• The first reason for assessment is to determine if treatment is needed by evaluating the client’s symptoms and their impact on daily functioning.
• If treatment is deemed necessary, the second reason for assessment is to identify which treatment approach will be most effective for the specific client.
• Common treatment approaches include Behavior Therapy, Cognitive Therapy, Cognitive-Behavioral Therapy (CBT), Humanistic-Experiential Therapies, Psychodynamic Therapies, Couples and Family Therapy, and biological treatments (e.g., psychopharmacology).
• Clinical assessment helps in determining which therapy will work best for a particular client, as some therapies have greater efficacy for specific mental disorders.
• Assessment also allows for measuring symptoms and behavior before, during, and after treatment to monitor improvement and ensure the treatment is effective.
• Baseline measurements taken at the beginning of the assessment process help track progress and confirm when improvement occurs.
• Clinical assessment is an ongoing process that continues throughout the treatment plan, including the implementation and post-treatment phases, to ensure desired outcomes.

Key Concepts in Assessment

• Three critical concepts are important in the assessment process: reliability, validity, and standardization.
• Reliability ensures that assessment is consistent. For example, if two mechanics give the same diagnosis for a car issue, their assessment tools are reliable; the same applies to mental health assessments.
• Interrater reliability occurs when two different mental health professionals give consistent diagnoses using the same assessment tool.
• Test-retest reliability refers to the consistency of a person’s test results over time. For instance, if someone takes the MMPI twice within a few days, the results should be nearly identical unless something significant has changed in their life.
• High test-retest reliability is indicated by a strong positive correlation between the scores of both tests.
• Validity ensures that the test measures what it claims to measure. For example, a new test for depression should produce results that are highly correlated with an established and proven test, like the Beck Depression Inventory (BDI).
• Concurrent or descriptive validity refers to the correlation of a new test with an existing valid test, ensuring they measure the same concept.
• Face validity is when a test appears to measure what it is supposed to, based on a general impression, though this does not rely on statistical evidence.
• Predictive validity is when a test accurately predicts future outcomes, such as the SAT predicting college success or the GRE predicting graduate school performance.
• Standardization ensures that the testing experience is consistent for all patients, regardless of the day, tester, or other variables.
• Standardization involves clear rules, norms, and procedures to guarantee uniform test administration and consistent interpretation of results across different patients.

Methods of Assessment

The Clinical Interview

• A clinical interview is a face-to-face meeting between a mental health professional and a patient where the clinician gathers data on the patient’s behavior, attitudes, personality, current situation, and life history.
• Interviews can be unstructured, where open-ended questions are asked; structured, where a specific set of questions is followed; or semi-structured, which includes a pre-set list of questions but allows for follow-up on noteworthy topics.
• A mental status examination is used to organize information gathered during the interview by systematically evaluating the client through observations and questions.
• Key areas assessed in the mental status examination include appearance and behavior (e.g., grooming, body language), thought processes and content (e.g., disorganized speech, false beliefs), mood and affect (e.g., hopelessness, elation), intellectual functioning (e.g., speech, memory), and awareness of surroundings (e.g., knowledge of where they are, who they are, and the current time).
• The mental status exam helps identify areas not typically covered during the interview and highlights which areas may need further examination.
• A limitation of the interview process is the lack of reliability, especially in unstructured interviews where consistency may be compromised.

Psychological Tests and Inventories

• Psychological tests assess various aspects of a client, including personality, social skills, cognitive abilities, emotions, behavioral responses, and interests, and can be administered individually or in groups.
• Projective tests use ambiguous stimuli to elicit a wide range of responses, providing insights into the client’s worries, needs, emotions, and conflicts.
  • Examples include the Rorschach inkblot test and the Thematic Apperception Test, which involves writing stories based on cards depicting different scenes.
  • The sentence completion test requires individuals to finish incomplete sentences like “My mother…” or “I hope…”
• Personality inventories involve clients indicating whether statements apply to them, covering aspects like feelings, behaviors, or beliefs.
  • Examples include the Minnesota Multiphasic Personality Inventory (MMPI) and the NEO-PI-R, which measures the five major domains of personality: Neuroticism, Extroversion, Openness, Agreeableness, and Conscientiousness.
  • The NEO-PI-R assesses six facets within each domain, evaluating emotional, interpersonal, experimental, attitudinal, and motivational styles.
• These inventories are advantageous due to their ease of administration, standardization, objective scoring, and availability in computer or paper-and-pencil formats.
• Despite their utility, personality inventories cannot directly assess personality, meaning they cannot fully capture the individual’s complexity.

Neurological Tests

• Neurological tests diagnose cognitive impairments due to brain damage from tumors, infections, head injuries, or changes in brain activity.
• Positron Emission Tomography (PET) involves injecting a radionuclide into the patient, which accumulates in the brain. The patient then lies on a scanning table while a ring-shaped machine captures images, providing information about brain function.
• Magnetic Resonance Imaging (MRI) uses magnetic fields and computers to produce 3D images of the brain and other body structures. It helps detect structural abnormalities like brain and spinal cord tumors and nervous system disorders such as multiple sclerosis.
• Computed Tomography (CT) scans take X-rays of the brain from different angles, which are combined to create images. This method detects structural abnormalities like brain tumors and damage from head injuries.

Physical Examination

• Many mental health professionals recommend that patients see their family physician for a physical examination.
• Organic conditions like hyperthyroidism or hormonal irregularities can produce behavioral symptoms similar to mental disorders.
• Ruling out these conditions through a physical exam can prevent unnecessary and costly therapy or surgery.

Behavioral Assessment

• Within behavior modification and applied behavior analysis, behavioral assessment involves measuring a target behavior.
• The target behavior can be either excessive (requiring reduction) or deficient (requiring increase).
• Behavioral assessment examines the ABCs of behavior:
  • Antecedents: Environmental events or stimuli that trigger the behavior.
  • Behaviors: What the person does, says, thinks, or feels.
  • Consequences: The outcomes of the behavior that influence whether it will be repeated or not.
• Self-monitoring involves measuring and recording one’s own ABCs to change personal behavior.
• Behavior modification can be applied in treating phobias, reducing habit disorders, and addressing maladaptive cognitions.
• A limitation of behavioral assessment is reactivity, where the process of observing or recording a behavior causes the behavior to change.
  • Example: Noticing someone staring at you while eating may lead you to change your behavior or become self-conscious.
• Another limitation is cross-sectional validity, where behavior observed in one situation may not generalize to other situations (e.g., a person acting out only at a football game and not at home).

Intelligence Tests

• Intelligence testing is used to assess the client’s level of cognitive functioning through a series of verbal and nonverbal tasks.
• An example of such a test is the Stanford-Binet Intelligence test, which measures:
  • Fluid reasoning
  • Knowledge
  • Quantitative reasoning
  • Visual-spatial processing
  • Working memory
• These tests are time-consuming and require specialized training for administration.
• They are typically used when there is a suspected cognitive disorder or intellectual disability.
• Criticisms of intelligence tests include:
  • Poor prediction of future behaviors such as achievement.
  • Reflection of social or cultural biases rather than actual intelligence.

Diagnosing and Classifying Abnormal Behavior

Clinical Diagnosis and Classification

Systems

• Clinical diagnosis involves using assessment data to determine if a pattern of symptoms aligns with diagnostic criteria for a specific mental disorder, utilizing classification systems such as DSM-5 or ICD-10. A diagnosis should have clinical utility to aid in prognosis, treatment planning, and predicting treatment outcomes. However, receiving a diagnosis does not always necessitate treatment; decisions depend on factors like symptom severity, distress level, risks, and benefits.

• A syndrome refers to a cluster of symptoms that occur together regularly and follow a predictable course, characteristic of a specific disorder.

• Classification systems provide distinct categories of disorders with clear descriptions and criteria, helping to distinguish between different types of disorders (e.g., schizophrenia spectrum disorders vs. neurocognitive disorders). They also facilitate the collection of statistics on incidence and prevalence, support research, and meet insurance requirements.

• The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is widely used in the United States and Canada, published by the American Psychiatric Association (APA).

• The International Statistical Classification of Diseases and Related Health Problems (ICD) is produced by the World Health Organization (WHO), with the current edition being ICD-10 and an 11th edition expected.

• The discussion will proceed by examining the DSM-5 in detail and then moving on to the ICD-10 and its updates.

The DSM Classification System

A Brief History of the DSM

• The DSM-5, published in 2013, replaced the DSM-IV-TR, which was a revision of the DSM-IV published in 2000. The origins of the DSM trace back to 1844, when the American Psychiatric Association published a statistical classification aimed at improving communication about institutionalized mental patients.

• The first official DSM was published in 1952. Since then, the DSM has evolved through four editions after World War II, expanding its use among psychiatrists, physicians, and other mental health professionals.

• The revision process for DSM-IV-TR began in 1999, involving an evaluation of its strengths and weaknesses with input from the World Health Organization (WHO), the World Psychiatric Association, and the National Institute of Mental Health (NIMH). This led to the 2002 publication of a monograph titled A Research Agenda for DSM-V.

• From 2003 to 2008, multiple international research planning conferences were held to review literature and prepare for revisions of DSM-5 and ICD-11.

• The DSM-5 Task Force was established in 2006, with task force members and workgroup members approved in 2007 and 2008, respectively. This led to an extensive process involving literature reviews, research publications, draft criteria development, public comments, professional presentations, field trials, and revisions.

• The DSM-5 aimed to provide a common language for diagnosing disorders, reflecting current research, and accommodating updates as new evidence emerges. Some disorders were not included in the main DSM-5 text due to insufficient scientific evidence but were placed in Section III under “Conditions for Further Study” to encourage further research and highlight evolving scientific advances.

Elements of a Diagnosis

• Diagnostic criteria are guidelines for making a diagnosis. When all criteria are met, severity and course specifiers can be added to describe the patient’s presentation. If criteria are not fully met, terms like “other specified” or “unspecified” can be used. Severity can be categorized as mild, moderate, severe, or extreme, and course can include partial or full remission, or recurrent patterns. The final diagnosis relies on clinical interview, text descriptions, criteria, and clinical judgment.

• Subtypes represent mutually exclusive and jointly exhaustive subgroupings within a diagnosis, reflecting different manifestations of the same disorder. For example, non-rapid eye movement sleep arousal disorders can be classified as either sleepwalking or sleep terror. Specifiers are not mutually exclusive or jointly exhaustive, meaning multiple specifiers can be applied. For instance, binge eating disorder includes remission and severity specifiers, while major depressive disorder can have various specifiers to indicate severity, course, or symptom clusters. The main difference is that only one subtype can be assigned, but multiple specifiers may be used.

• When multiple diagnoses are present, the principal diagnosis is the primary reason for the individual’s admission in an inpatient setting or the main reason for a visit in outpatient settings. It is typically the focus of treatment.

• When there is insufficient information for a definitive diagnosis but a strong likelihood that the criteria will be met with more data or time, a provisional diagnosis can be used.

DSM-5 Disorder Categories

The ICD-11

• In 1893, the International Statistical Institute adopted the International List of Causes of Death, the first edition of the ICD.
• The World Health Organization (WHO) was entrusted with the development of the ICD in 1948 and published the 6th version (ICD-6), which was the first version to include mental disorders.
• The ICD-11 was published in June 2018 and adopted by WHO member states in June 2019.
• The WHO states that the ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions.
• The ICD is the diagnostic classification standard for all clinical and research purposes.
• The ICD defines the universe of diseases, disorders, injuries, and other related health conditions, listed in a comprehensive, hierarchical fashion.
• This allows for the easy storage, retrieval, and analysis of health information for evidence-based decision-making.
• The ICD facilitates the sharing and comparing of health information between hospitals, regions, settings, and countries.
• It also enables data comparisons in the same location across different time periods
• The ICD lists many types of diseases and disorders and includes Chapter V: Mental and Behavioral Disorders
• The list of mental disorders is broken down as follows:
• • Organic, including symptomatic, mental disorders
  • Mental and behavioral disorders due to psychoactive substance use
  • Schizophrenia, schizotypal, and delusional disorders
  • Mood (affective) disorders
  • Neurotic, stress-related, and somatoform disorders
  • Behavioral syndromes associated with physiological disturbances and physical factors
  • Disorders of adult personality and behavior
  • Mental retardation
  • Disorders of psychological development
  • Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
  • Unspecified mental disorder

Harmonization of DSM-5 and ICD-11

• According to the DSM-5, there is an effort to harmonize the two classification systems.
• The goal is to enable a more accurate collection of national health statistics and the design of clinical trials.
• Another aim is to increase the ability to replicate scientific findings across national boundaries.
• Harmonization also seeks to rectify the lack of agreement between DSM-IV and ICD-10 diagnoses (APA, 2013).
• As of the time of publication, this harmonization had not yet occurred.

Summary

• Mental illness has significant social and economic costs on society, both directly and indirectly.
• These costs include victimization, lost ability to work, burnout, hospitalizations, and medical visits.
• Abnormal psychology is a field that studies atypical or unusual individuals.
• The goal is to predict, explain, diagnose, identify causes of, and treat mental disorders.
• Mental disorders are difficult to define and often include the “3 Ds”: dysfunction, distress (or impairment), and deviance.
• Disorders disturb cognition, emotion regulation, or behavior, causing distress and deviance from cultural norms.
• Cultural context is important when evaluating abnormal behavior.
• Violating cultural expectations alone is not sufficient to identify a psychological disorder.
• Behavior expectations vary between cultures, so what is acceptable in one culture may not be in another.
• Effective treatment requires a mental health professional to understand the client’s presenting problem.
• Clinical assessment involves gathering information through observation, psychological and neurological tests, and interviews.
• Reliability, validity, and standardization are key concepts in the assessment process.
• After assessment, a diagnosis can be made if the pattern of symptoms aligns with diagnostic criteria.
• Diagnosis uses assessment data to identify specific mental health disorders based on systems like DSM-5 or ICD-10.
• Symptoms that consistently cluster together are called a syndrome.
• Classification systems provide health professionals with agreed-upon lists of disorders, clear descriptions, and criteria for diagnosis.
• The DSM-5 is the most widely used classification system in North America, published by the American Psychiatric Association.
• The DSM-5’s first edition was published in 1952, and the current edition in 2013, after nearly 14 years of research.
• The World Health Organization (WHO) publishes the International Classification of Diseases (ICD), an alternative system.
• The DSM outlines key elements of diagnosis, including diagnostic criteria and descriptors to guide the diagnostic process.
• Subtypes and specifiers help to characterize individual differences in the manifestation of the same disorder.
• Principal diagnoses are given when multiple diagnoses apply to an individual, while provisional diagnoses are made when insufficient information is available for a definitive diagnosis.