Chapter 3The Skeletal SystemStructures and Functions of

Chapter 3
The Skeletal System
Structures and Functions of the Skeletal System (1 of 2)
Bones
Act as the framework of the body
Support and protect the internal organs
Joints
Work in conjunction with muscles, ligaments, and tendons
Make possible the wide variety of body movements
Calcium
Mineral required for normal nerve and muscle function; is
stored in bones
Red bone marrow
Plays an important role in the formation of blood cells
Located within spongy bone
Schroeder/Ehrlich/Schroeder Smith/Ehrlich, Medical
Terminology for Health Professions, 9th Edition. © 2022
Cengage. All Rights Reserved. May not be scanned, copied or
duplicated, or posted to a publicly accessible website, in whole
or in part.
Learning Objective 3.01: Identify and describe the maj or
functions and structures of the skeletal system.
2
Structures and Functions of the Skeletal System (2 of 2)
The Formation of Bones
A newborn’s skeleton
Begins as fragile membranes and cartilage
Ossification

Starts turning into bone
Continues through adolescence
After growth is complete, new bone formation continues
Osteoclast cells break down old or damaged bone
Osteoblast cells help rebuild the bone
Ossification repairs minor damage from normal activity and also
repairs bones after injuries, such as fractures
or in part.
Learning Objective 3.01: Identify and describe the major
3
The Structure of Bones (1 of 4)
The Tissues of Bone
Bone is the form of connective tissue
Second hardest tissue in the human body
Capable of growth, healing, and reshaping itself
Compact bone, also known as cortical bone
Dense, hard, and very strong bone
Forms the protective outer layer of bones
Spongy bone, also known as cancellous bone
Porous (“sponge-like”), making it lighter and weaker than
compact bone; more susceptible to fractures
Commonly contains red bone marrow
Long bones include femur and humerus
Short bones include the wrist and ankle
Anatomic features of a typical long bone.

or in part.
4
The Tissues of Bone
Medullary cavity
Central cavity located in the shaft of long bones and surrounded
by compact bone
Red and yellow bone marrow stored here
Endosteum
Tissue that lines the medullary cavity
Bone Marrow
Red bone marrow is a hematopoietic tissue
Located within the spongy bone
Manufactures red blood cells, hemoglobin, white blood cells,
and thrombocytes
Yellow bone marrow functions as a fat storage area
Gradually replaces about half of red bone marrow after early
adolescence
or in part.
5

Cartilage
Smooth, rubbery, blue-white connective tissue
Acts as a shock absorber between bones
Makes up the flexible parts of the skeleton, such as the outer ear
and tip of the nose
Articular cartilage
Covers the surfaces of bones where they articulate
Makes smooth joint movement possible
Protects the bones from rubbing against each other
Meniscus
Curved, fibrous cartilage found in some joints
Examples: knee and temporomandibular joint of the jaw
A lateral view of the knee showing the structures of a synovial
joint and bursa.
or in part.
6
Anatomic Landmarks of Bones
Diaphysis: shaft of a long bone
Epiphyses: wider ends of long bones such as the femurs of the
legs
Proximal epiphysis: end of the bone located nearest to the
midline of the body
Distal epiphysis: end of the bone located farthest away from the
midline of the body

Foramen: opening through which blood vessels, nerves, and
ligaments pass
Example: foramen magnum
Process: normal projection on the surface of a bone
Most commonly serves as an attachment for a muscle or tendon
Example: mastoid process
or in part.
7
Joints (1 of 3)
Joints
Also known as articulations
Place of union between two or more bones
Classified by construction or based on the degree of movement
they allow
Fibrous Joints
Hold the bones tightly together
Consist of inflexible layers of dense connective tissue
Known as sutures in adults, allow little or no movement
Called fontanelles or soft spots in newborns and very young
children, these joints allow for passage through the birth canal
and for growth of the skull during the first year
or in part.

Learning Objective 3.02: Describe three types of joints.
8
Joints (2 of 3)
Cartilaginous Joints
Allow only slight movement
Consist of bones connected entirely by cartilage
Breastbone
Where the ribs connect to the sternum
Allow movement during breathing
Pubic symphysis
Allows some movement to facilitate childbirth
Located between the pubic bones in the anterior (front) of the
pelvis
Anterior view of the pelvis.
or in part.
9
Joints (3 of 3)
Synovial Joints
Ball-and-socket joints
Allow a wide range of movement in many directions
Examples: hips and shoulders
Hinge joints
Allow movement primarily in one direction or plane
Examples: knees and elbows
Components of Synovial Joints

Synovial capsule
Synovial membrane
Synovial fluid
Ligaments and bursa
Examples of synovial joints. (A) Ball-and-socket joint of the
hip. (B) Hinge joint of the elbow. (C) Hinge joint of the knee.
or in part.
10
The Skeleton (1 of 11)
Typical Adult Skeleton
Consists of approximately 206 bones
Divided into axial and appendicular
Axial Skeleton
Protects major organs of the nervous, respiratory, and
circulatory systems
80 bones of the head and body organized into five parts:
Bones of the skull
Ossicles (bones) of the middle ear
Hyoid bone
Rib cage
Vertebral column
Anterior and posterior views of the human skeleton.

or in part.
Learning Objective 3.03: Differentiate between the axial and
appendicular skeletons.
11
Appendicular Skeleton
Makes body movement possible
Protects the organs of digestion, excretion, and reproduction
Consists of 126 bones
Upper extremities (shoulders, arms, forearms, wrists, and
hands)
Lower extremities (hips, thighs, legs, ankles, and feet)
Appendicular means referring to an appendage
An appendage is anything that is attached to a major part of the
body
An extremity is the terminal end of a body part such as an arm
or leg
or in part.
Learning Objective 3.03: Differentiate between the axial and
appendicular skeletons.
12
Bones of the Skull
Bones of the cranium
Frontal, parietal, occipital, external auditory meatus sphenoid,

and ethmoid
Enclose and protect the brain
Auditory ossicles
Malleus, incus, and stapes
Three tiny bones located in the middle ear
Bones of the face
Nasal, zygomatic, maxillary, palatine, lacrimal, inferior
conchae, vomer, and mandible
Anterior view of the adult human skull.
duplicated, or posted to a publicly accessible website, in whol e
or in part.
13
Thoracic Cavity
Also called rib cage; consists of ribs and sternum
Bony structure that protects the heart and lungs
Ribs (12 pairs)
True ribs: first seven pairs attached anteriorly to the sternum
False ribs: Next three pairs attached anteriorly to cartilage that
connects to the sternum
Floating ribs: only attached posteriorly to the vertebrae but are
not attached anteriorly
Sternum (also known as the breast bone)
Manubrium: forms the upper portion of the sternum
Body of the sternum or gladiolus: forms the middle portions of
the sternum

Xiphoid process: cartilage that forms the lower portion of the
sternum
or in part.
14
Shoulders and Arms
Shoulders
Clavicle (collarbone)
Scapula (shoulder blade)
Acromion (extension of scapula)
Arms
Humerus (bone of upper arm)
Radius (smaller, shorter forearm bone)
Ulna (larger, longer forearm bone)
Olecranon (proximal tip of the ulna; commonly known as the
funny bone)
Anterior view of the ribs, shoulder, and arm. (Cartilaginous
structures are shown in blue.)
or in part.

15
The Wrists, Hands, and Fingers
Carpals
Eight bones that form the wrist
Form a narrow bony passage known as the carpal tunnel
Metacarpals
Five bones that form the palms of the hand
Phalanges (singular, phalanx)
14 bones of the fingers
Each finger has three: distal (outermost), middle, and proximal
(nearest the hand)
The thumb has two bones (distal and proximal phalanges)
Superior view of the bones of the lower left arm, wrist, and
hand.
or in part.
16
The Spinal Column (Vertebral Column)
Protects the spinal cord and supports the
head and body

The spinal column consists of 26 vertebrae
Each of these bony units is known as a vertebra
Structures of the vertebrae
Body of the vertebra: anterior portion
Lamina: posterior portion
Vertebral foramen: opening in the middle
Characteristics of a typical vertebra.
or in part.
17
The Spinal Column (vertebral column)
Intervertebral disks
Made of cartilage and pads of tissue
Separate and cushion the vertebrae from each other
Allow for movement of the spinal column
Types of vertebrae
Cervical: first seven vertebrae; form the neck
Thoracic: T1 through T12; have ribs attached
Lumbar: L1 through L5; form inward curve
Sacrum: triangular bone near base of spine
Coccyx: tailbone; forms the end of the spine
Lateral view of the vertebral column.

or in part.
18
The Pelvis
Bony pelvis
Protects internal organs and supports the lower extremities
Includes sacrum, coccyx, and pelvic girdle (ilium, ischium, and
pubis)
Sacroiliac
Slightly movable articulation between the sacrum and posterior
portion of the ilium
Pubic symphysis
Cartilaginous joint that unites the left and right pubic bones
Acetabulum
Also known as the hip socket
Structures of the proximal end of the femur and the acetabulum
(hip socket).
or in part.

19
The Legs and Knees
Femurs
Largest bones in the body
Knees
Patella (kneecap)
Popliteal: space behind knee
Cruciate ligaments: shaped like a cross; make possible the
movements of the knee
Lower legs
Tibia (shinbone): larger, anterior weight-bearing bone of the
lower leg
Fibula: smaller of the two bones of the lower leg
Lateral view of bones of the lower extremity.
or in part.
20
The Ankles
Joints that connect the lower leg and foot
Tarsal bones: similar to, but bigger than, the wrist
Malleolus: rounded bony projection
Talus: articulates with the tibia and fibula
Calcaneus: heel bone; largest of the tarsal bones

The Feet and Toes
Metatarsals form the part of the foot to which the toes are
attached
Phalanges are the bones of the toes
The great toe has two phalanges
Each of the other toes has three phalanges
Bones of the right ankle and foot. (A) Lateral view.
or in part.
21
Medical Specialties Related to the Skeletal System (1 of 2)
Chiropractor
Holds a Doctor of Chiropractic (DC) degree
Specializes in the manipulative treatment of disorders
originating from misalignment of the spine
Orthopedic surgeon
Also known as an orthopedist
Physician specializing in diagnosing and treating diseases and
disorders involving the bones, joints, and muscles
Osteopath
Holds a Doctor of Osteopathy (DO) degree
Uses traditional forms of medical treatment in addition to
specializing in treating health problems by spinal manipulation

or in part.
Learning Objective 3.04: Identify the medical specialists who
treat disorders of the skeletal system.
22
Medical Specialties Related to the Skeletal System (2 of 2)
Podiatrist
Holds a Doctor of Podiatry (DP) or Doctor of Podiatric
Medicine (DPM) degree
Specializes in diagnosing and treating disorders of the foot
Rheumatologist
Physician specializing in the diagnosis and treatment of arthritis
and disorders such as osteoporosis, fibromyalgia, and tendinitis
that are characterized by inflammation in the joints and
connective tissues
or in part.
Learning Objective 3.04: Identify the medical specialists who
treat disorders of the skeletal system.
23
Pathology of the Skeletal System (1 of 11)
Joints
Ankylosis: loss or absence of mobility
Adhesive capsulitis: frozen shoulder; ankylosis caused by
adhesions
Arthrosclerosis: stiffness of the joints
Baker’s cyst: popliteal cyst; fluid-filled sac behind the knee

Bursitis: inflammation of the bursa
Chondromalacia: abnormal softening of cartilage
Costochondritis: inflammation of cartilage connecting the ribs
to the sternum
or in part.
Learning Objective 3.05: Recognize, define, spell, and
pronounce the primary terms related to the pathology and the
diagnostic and treatment procedures of the skeletal system.
24
Joints
Hallux valgus: bunion; abnormal enlargement of the base joint
of the great toe
Hemarthrosis: blood within a joint
Polymyalgia rheumatica (PMR): inflammatory disorder of
muscles and joints
Sprain: ligament that connects bones to a joint is wrenched or
torn
Synovitis: inflammation of the synovial membrane
Joint Dislocation
Dislocation: luxation; total displacement of a bone from its
joint
Subluxation: partial displacement of a bone from its joint

or in part.
25
Arthritis
Osteoarthritis (OA): wear-and-tear arthritis; degenerative joint
disease
Osteophytes: formation of bone spurs
Spondylosis: spinal osteoarthritis
Gout: gouty arthritis; deposits of urate crystals in the joints
Pseudogout: buildup of calcium pyrophosphate crystals
Rheumatoid arthritis (RA): chronic autoimmune disorder
Joints and some organs of other body systems are attacked
Ankylosing spondylitis (AS): inflammation of joints between
vertebrae
Juvenile idiopathic arthritis (JIA): formerly juvenile rheumatoid
arthritis
Psoriatic arthritis (PsA): Affects about 20% of people with
psoriasis
or in part.
26

The Spinal Column
Herniated disk: slipped or ruptured disk
Lumbago: low back pain (LBP)
Spondylolisthesis: forward slipping movement of lower lumbar
vertebrae on
the vertebra or sacrum below it
Spina bifida: congenital defect; spinal canal fails to close
completely
Curvatures of the spine
Kyphosis: hunchback; outward curvature
Lordosis: swayback; forward curvature
Scoliosis: lateral curvature
Abnormal curvatures of the spine. (A) Kyphosis. (B) Lordosis.
(C) Scoliosis. (Normal curvatures are shown in shadow.)
or in part.
27
Bones
Avascular necrosis: osteonecrosis; insufficient blood flow to
bone tissue
Osteitis: inflammation of a bone
Osteomalacia: adult rickets; abnormal bone softening; vitamin

D deficiency
Osteomyelitis: inflammation of the bone marrow and adjacent
bone
Paget’s disease: chronic bone disease of unknown cause
Periostitis: inflammation of the periosteum; often associated
with shin splints
Radiculopathy: pinched nerve; compression of a nerve in the
spine
Rickets: defective bone growth resulting from vitamin D
deficiency in children
duplicated, or posted to a publicly accessible w ebsite, in whole
or in part.
28
Bones
Spinal stenosis: narrowing of the spaces within the spine
Short stature: formerly known as dwarfism
Caused by more than 200 different conditions
Some adults of short stature prefer to be referred to as little
people
Clubfoot: talipes
Congenital deformity of the foot involving the talus
Bone tumors
Primary bone cancer: relatively rare malignant tumor
originating in the bone
Secondary bone cancer: bone metastasis; cancer spreads to

bones from other organs
Multiple myeloma: cancer that occurs in blood-making plasma
cells of red bone marrow
Osteochondroma: benign bony projection covered with cartilage
or in part.
29
Osteoporosis and Osteopenia Compared
Osteoporosis (OP)
Marked loss of bone density
Increase in bone porosity frequently associated with aging
Most common in women over 50 years old; decrease in estrogen
after menopause
Osteopenia
Thinner-than-average bone density
Condition of someone who does not yet have osteoporosis
or in part.

30
Osteoporosis-Related Fractures
Compression fracture
Occurs when the bone is pressed together (compressed) on itself
Colles fracture
Broken wrist
Often occurs when a person tries to stop a fall by landing on the
hand
Osteoporotic hip fracture
Broken hip
Usually caused by weakening of the bones due to osteoporosis
Can occur either spontaneously or as the result of a fall
A Colles fracture of the left wrist.
or in part.
31
Fractures
Broken bones
Described in terms of complexity
Closed fracture

Simple fracture or a complete fracture
No open wound in the skin
Open fracture
Compound fracture
Open wound in the skin
Comminuted fracture
Bone is splintered or crushed
Types of bone fractures. (A) Incomplete. (B) Closed (simple,
complete). (C) Open (compound). (D) Comminuted.
duplicated, or posted to a publicly accessible websi te, in whole
or in part.
32
Fractures
Incomplete fracture
Bone does not break into two separate pieces
Occurs primarily in children
Greenstick fracture
One side of the bone is broken and the other side is only bent
Buckle fracture (torus fracture)
Affected side of the bone is compressed and buckles but does
not break
Oblique fracture
Occurs at an angle across the bone
Pathologic fracture

Bone weakened by osteoporosis or cancer breaks under normal
strain
or in part.
33
Fractures
Spiral fracture
Complete fracture in which the bone has been twisted apart
Occurs as the result of a severe twisting motion
Stress fracture (overuse injury)
Small crack in bone that develops from chronic, excessive
impact
Transverse fracture
Occurs straight across, perpendicular to the shaft of the bone
Additional terms associated with fractures
Fat embolus: fat cells from yellow bone marrow are released
into the blood
Crepitation (crepitus): grating sound heard when ends of a
broken bone move together
Callus: bulging deposit around the area of the break that forms
as bone heals

or in part.
34
Diagnostic Procedures of the Skeletal System (1 of 2)
X-ray imaging (radiography)
Uses a form of electromagnetic radiation to create x-rays
Arthroscopy
Visual examination of the internal structure of a joint using an
arthroscope
Bone marrow biopsy
Necessary after abnormal types or numbers of red or white
blood cells are found in a complete blood count test
Bone marrow aspiration
Use of a syringe to withdraw tissue from the red bone marrow
Magnetic resonance imaging (MRI)
Used to image soft tissue structures such as the interior of
complex joints
or in part.
35

Diagnostic Procedures of the Skeletal System (2 of 2)
Bone Density Testing
Determine losses or changes in bone density
Used to diagnose osteoporosis, osteomalacia, osteopenia, and
Paget’s disease
Measures the amount of mineral in the bones
Ultrasonic bone density testing
Screening test for osteoporosis or other conditions that cause a
loss of bone mass
Sound waves are used to take measurements of the calcaneus
(heel) bone
Dual x-ray absorptiometry (DXA)
Low-exposure radiographic measurement of the spine and hips
Produces more accurate results than ultrasonic bone density
testing
or in part.
36
Treatment Procedures of the Skeletal System (1 of 11)
Medications
Bisphosphonates
Class of drugs used to slow the loss of bone density due to
osteoporosis
Reduces the risk of broken bones
Low-dose hormone replacement therapy
Sometimes used in the short term to maintain bone density in

women at high risk for bone loss after menopause
or in part.
37
Bone Marrow Transplants (BMT)
Stem cell transplant used to treat certain types of cancers, such
as leukemia and lymphomas
Initially both the cancer cells and the patient’s bone marrow are
destroyed with high-intensity radiation and chemotherapy
Next, healthy bone marrow stem cells are infused into the
recipient’s blood
Cells migrate to the spongy bone, where they multiply to form
cancer-free red bone marrow
Stem cells produced by the bone marrow eventually develop
into blood cells
or in part.

38
Types of Bone Marrow Transplants
Allogenic bone marrow transplant (allogenic stem cell
transplant)
Uses healthy bone marrow cells from a compatible donor, often
a sibling
Unless donor is a perfect match, recipient’s body could reject
the transplant
Autologous bone marrow transplant (autologous stem cell
transplant)
Patient receives his or her own bone marrow cells
Harvested (usually from the hip), cleansed, treated, and stored
before the remaining bone marrow in the patient’s body
undergoes treatment
Peripheral blood stem cell transplant
Utilizes blood-forming stem cells from the bloodstream of the
patient or donor
or in part.
39
Medical Devices
Orthotic

Mechanical appliance, such as a shoe insert, leg brace, or a
splint
Specially designed to support, control, correct, or compensate
for impaired limb function
Prosthesis
Substitute for a diseased or missing body part, such as a leg that
has been amputated
Joints
ACL reconstruction
Surgery to replace a torn anterior cruciate ligament (ACL) in
the knee
Arthrodesis (surgical ankylosis)
Surgical fusion (joining together) of two bones to stiffen a joint
or in part.
40
Joints
Arthroscopic surgery
Minimally invasive procedure for the treatment of the interior
of a joint
Example: torn cartilage removed using an arthroscope and
instruments inserted through small incisions
Bone grafting
Transplanting bone to rebuild bones damaged by injury or
disease

Uses synthetic material, allograft (donor tissue), or autograft
(patient’s tissue)
Synovectomy
Removal of a synovial membrane from a joint
During arthroscopic surgery, the physician is able to view the
interior of the knee on a monitor.
or in part.
41
Joint Replacements
Arthroplasty
Surgical repair of a damaged joint
Now usually refers to resurfacing of bones, or surgical
placement of an artificial joint (implant)
Total knee replacement (TKR)
All parts of the knee are replaced
Also known as a total knee arthroplasty
Usually necessitated by damage to the joint from arthritis
X-ray (radiograph) of a total knee replacement. On the film the
metallic components appear lighter than the bone.

or in part.
42
Joint Replacements
Total hip replacement (THR)
Total hip arthroplasty
Restores a damaged hip to full function
Hip resurfacing arthroplasty
Alternative to removing the head of the femur
Shoulder replacement surgery
Replaces top of the humerus with a metal ball, and damaged
portion of the socket with a plastic prosthesis
Revision surgery
Replaces a worn or failed implant
Total hip replacement (THR).
or in part.
43

Spinal Column
Phantom limb pain
Post-amputation phenomenon; sensation of pain from a body
part that is no longer there
Percutaneous diskectomy
Removal of a fragment of the disk that is compressing a nerve
Percutaneous vertebroplasty
Bone cement injected to stabilize osteoporosis-related
compression fractures
Laminectomy (decompression surgery)
Surgical removal of lamina; relieves pressure on spinal cord by
enlarging spinal column
Spinal fusion
Immobilizes part of the spine by joining together (fusing) two
or more vertebrae
or in part.
44
Bones
Decompressive craniectomy
Surgical removal of a portion of the skull
Relieves increased intracranial pressure due to swelling from a
traumatic brain injury

Craniotomy
Surgical incision or opening into the skull
Performed to gain access to the brain to remove a tumor, relieve
intracranial pressure, or obtain access for other surgical
procedures
Osteotomy
Surgical cutting and reshaping of a bone
Used to repair damaged joints, realign dental occlusions, correct
congenital defects, and reshape arthritic knees and hips
or in part.
45
Treatment of Fractures
Closed reduction (manipulation)
Attempted non-surgical realignment of a fracture or joint
dislocation
Open reduction (surgical procedure) performed when closed
reduction is not practical
Immobilization (stabilization)
Holding, suturing, or fastening bone in a fixed position with
strapping or a cast
Traction
Pulling force exerted on a limb to return the bone or joint to
normal alignment
External fixation

Fracture treatment with external appliance
External fixation of the femur stabilizes the bone and is
removed after the bone has healed.
or in part.
46
Treatment of Fractures
Internal fixation
Also known as open reduction internal fixation (ORIF)
Plate or pins placed directly into the bone to hold pieces in
place
This form of fixation is not
usually removed after the
fracture has healed
Internal fixation of fractured hip. (A) Fracture of the femoral
neck. (B) Internal fixation pins are placed to stabilize the bone.
These pins are not removed after the bone has healed.
or in part.

47
Abbreviations Related to the Skeletal System
Refer to Table 3.1 in the text for an overview of the
abbreviations related to the terms introduced in this chapter
Examples:
Bone density testing = BDT
Osteoarthritis = OA
Partial knee replacement = PKR
Rheumatoid arthritis = RA
Total hip arthroplasty = THA
or in part.
48
Abnormal Psychology

nol00187_fm_i-xix.indd 1 11/28/18 9:41 AM
This page intentionally left blank
Abnormal Psychology
Eighth Edition
Susan Nolen-Hoeksema
ABNORMAL PSYCHOLOGY, EIGHTH EDITION
Published by McGraw-Hill Education, 2 Penn Plaza, New York,
NY 10121. Copyright © 2020 by McGraw-Hill Education. All
rights
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Some ancillaries, including electronic and print components,
may not be available to customers outside the United States.

This book is printed on acid-free paper.
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MHID 1-260-08046-3 (loose-leaf edition)
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Library of Congress Cataloging-in-Publication Data
Names: Nolen-Hoeksema, Susan, 1959-2013, author.
Title: Abnormal psychology / Susan Nolen-Hoeksema, Yale
University.
Description: Eighth edition. | New York, NY : MHE, [2020] |
Includes
bibliographical references and indexes.
Identifiers: LCCN 2018044989| ISBN 9781260500189 (alk.
paper) | ISBN
9781260080469 (loose-leaf edition)
Subjects: LCSH: Psychology, Pathological—Textbooks. |

Mental
illness—Textbooks.
Classification: LCC RC454.N64 2020 | DDC 616.89—dc23
LC record available at https://lccn.loc.gov/2018044989
The Internet addresses listed in the text were accurate at the
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McGraw-Hill Education does not guarantee the accuracy of the
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mheducation.com/highered
v
ABOUT THE AUTHOR
Susan Nolen-Hoeksema (1959–2013) In January 2013
we lost our esteemed author and friend, Susan Nolen-Hoeksema.
Susan was a renowned scholar, teacher, mentor, and academic
leader.
She was recognized internationally for her work on how people
reg-
ulate their feelings and emotions and how particular patterns of
thinking can make people vulnerable to and recover slowly from
emotional problems, especially depression. Her research shaped
the
field’s perspective on depression in women and girls, and
countless
empirical studies and theoretical contributions followed as she

developed her groundbreaking theory of rumination and
depression.
In her words: “My career has focused on two parallel goals. The
first is to use empirical methods to address important social and
mental health problems (depression, rumination, women’s
mental
health). The second goal is to disseminate psychological
science. I
also believe in taking science to the public, through my
textbook on
Abnormal Psychology and books for the general public on
women’s mental health.”
Susan taught at Stanford University, the University of
Michigan, and Yale University. Susan’s work focused
on depression, mood regulation, and gender, for which she was
recognized and received the David Shakow
Early Career Award from Division 12, the Distinguished
Leadership Award from the Committee on Women
of American Psychological Association, the James McKeen
Cattell Fellow Award from the Association for
Psychological Science, a Research Career Award, and mul tiple
grants from the National Institute of Mental
Health. In addition, she was the founding editor of the Annual
Review of Clinical Psychology, now the most
highly cited journal in the field of clinical psychology.
In addition to being an accomplished professor, scholar,
teacher, and writer, Susan was a loving and
devoted mother, wife, daughter, sister, friend, and mentor.
Susan touched and inspired the lives of many
people both professionally and personally, and she will be
dearly missed.

ABOUT THE CONTRIBUTOR
Brett Marroquín is an assistant professor of psychology at
Loyola
Marymount University in Los Angeles, California. He received
his
Ph.D. in clinical psychology from Yale University under the
mentor-
ship of Susan Nolen-Hoeksema, and completed a National
Institute
of Mental Health (NIMH) postdoctoral fellowship in
biobehavioral
issues in physical and mental health at the University of
California,
Los Angeles. His research examines interpersonal influences on
emo-
tion, emotion regulation, and cognitive processing in healthy
function-
ing and mood disorders. His current work focuses on the roles
of
social contexts and romantic relationships in emotional
adjustment to
negative events, including cancer diagnosis and treatment, and
how
effective or ineffective support from partners affects couples’
physical
and mental health.
Courtesy of Susan Nolen-Hoeksema
Courtesy of Brett Marroquín
vi

BRIEF CONTENTS
About the Author, About the Contributor v
Preface xiv
1 Looking at Abnormality 2
2 Theories and Treatment of Abnormality 22
3 Assessing and Diagnosing Abnormality 58
4 The Research Endeavor 80
5 Trauma, Anxiety, Obsessive-Compulsive, and Related
Disorders 102
6 Somatic Symptom and Dissociative Disorders 146
7 Mood Disorders and Suicide 168
8 Schizophrenia Spectrum and Other Psychotic
Disorders 210
9 Personality Disorders 242
10 Neurodevelopmental and Neurocognitive Disorders 274
11 Disruptive, Impulse-Control, and Conduct Disorders 310
12 Eating Disorders 328
13 Sexual Disorders and Gender Diversity 354
14 Substance Use and Gambling Disorders 384

15 Health Psychology 420
16 Mental Health and the Law 452
McGraw-Hill Education Psychology’s APA
Documentation Style Guide
Glossary G-1
References R-1
Name Index NI-1
Subject Index SI-1
vii
About the Author, About the Contributor v
Preface xiv
1 Looking at Abnormality 2
Abnormality Along the Continuum 3
Extraordinary People 4
Defining Abnormality 4
Mental Illness 4
Cultural Norms 5

The Four Ds of Abnormality 6
Shades of Gray 6
Historical Perspectives on Abnormality 7
Ancient Theories 7
Medieval Views 9
The Spread of Asylums 11
Moral Treatment in the Eighteenth and
Nineteenth Centuries 12
The Emergence of Modern
Perspectives 13
The Beginnings of Modern Biological
Perspectives 13
The Psychoanalytic Perspective 14
The Roots of Behaviorism 14
The Cognitive Revolution 15
Modern Mental Health Care 15
Deinstitutionalization 16
Managed Care 17
Professions Within Abnormal
Psychology 18

Chapter Integration 19
Shades of Gray Discussion 19
Chapter Summary 20
Key Terms 21
2 Theories and Treatment of
Abnormality 22
Approaches Along the Continuum 23
Extraordinary People—Steven Hayes 24
Biological Approaches 26
Brain Dysfunction 27
Biochemical Imbalances 29
Genetic Abnormalities 31
Drug Therapies 33
Electroconvulsive Therapy and Newer Brain
Stimulation Techniques 34
Psychosurgery 35
Assessing Biological Approaches 35
Psychological Approaches 36
Behavioral Approaches 36

Cognitive Approaches 39
Psychodynamic Approaches 41
Humanistic Approaches 45
Shades of Gray 46
Family Systems Approaches 46
Third-Wave Approaches 47
Using New Technology to Deliver Treatment 48
Sociocultural Approaches 49
Cross-Cultural Issues in Treatment 50
Culturally Specific Therapies 52
Assessing Sociocultural Approaches 52
Prevention Programs 53
Common Elements in Effective Treatments 53
Chapter Summary 55
Key Terms 56
CONTENTS

viii Contents
3 Assessing and Diagnosing
Abnormality 58
Assessment and Diagnosis Along the
Continuum 59
Extraordinary People—Marya
Hornbacher 60
Assessment Tools 60
Validity 60
Reliability 61
Standardization 62
Clinical Interview 62
Symptom Questionnaires 62
Personality Inventories 63
Behavioral Observation and
Self-Monitoring 64
Intelligence Tests 65
Neuropsychological Tests 66

Brain-Imaging Techniques 66
Psychophysiological Tests 67
Projective Tests 67
Challenges in Assessment 68
Resistance to Providing
Information 68
Evaluating Children 68
Evaluating Individuals Across
Cultures 69
Diagnosis 70
Diagnostic and Statistical Manual of Mental
Disorders (DSM) 71
Shades of Gray 73
The Social-Psychological Dangers of
Diagnosis 76
Chapter Summary 78
Key Terms 79
4 The Research Endeavor 80
Research Along the Continuum 81

Extraordinary People—The Old Order Amish of
Pennsylvania 82
The Scientific Method 82
Defining the Problem and Stating
a Hypothesis 83
Choosing and Implementing a Method 83
Shades of Gray 84
Ethical Issues in Research 84
Case Studies 85
Evaluating Case Studies 85
Correlational Studies 86
Measuring the Relationship Between
Variables 86
Selecting a Sample 88
Evaluating Correlational Studies 88
Epidemiological Studies 89
Evaluating Epidemiological Studies 90
Experimental Studies 90
Human Laboratory Studies 90

Therapy Outcome Studies 92
Single-Case Experimental Designs 93
Animal Studies 94
Genetic Studies 95
Family History Studies 95
Twin Studies 96
Adoption Studies 96
Molecular Genetic Studies and Linkage
Analyses 96
Cross-Cultural Research 97
Meta-Analysis 98
Evaluating Meta-Analysis 98
Chapter Summary 99
Key Terms 101
Contents ix

5 Trauma, Anxiety, Obsessive-
Compulsive, and Related
Disorders 102
Fear and Anxiety Along the Continuum 103
Extraordinary People—David Beckham, Perfection
On and Off the Field 104
Posttraumatic Stress Disorder and Acute Stress
Disorder 106
Traumas Leading to PTSD 109
Theories of PTSD 111
Treatments for PTSD 113
Specific Phobias and Agoraphobia 115
Specific Phobias 115
Shades of Gray 116
Agoraphobia 116
Theories of Phobias 117
Treatments for Phobias 119
Social Anxiety Disorder 120
Theories of Social Anxiety Disorder 122
Treatments for Social Anxiety Disorder 122

Panic Disorder 123
Theories of Panic Disorder 125
Treatments for Panic Disorder 126
Generalized Anxiety Disorder 128
Theories of Generalized Anxiety Disorder 129
Treatments for Generalized Anxiety Disorder 130
Separation Anxiety Disorder 132
Theories of Separation Anxiety Disorder 133
Treatments for Separation Anxiety Disorder 134
Obsessive-Compulsive Disorder 135
Theories of OCD and Related Disorders 138
Treatment of OCD and Related Disorders 140
Anxiety Disorders in Older Adults 141
Chapter Summary 143
Key Terms 145
6 Somatic Symptom and Dissociative

Disorders 146
Somatic Symptom and Dissociative Disorders
Along the Continuum 147
Extraordinary People—Anna O., The Talking
Cure 148
Somatic Symptom Disorders 148
Somatic Symptom Disorder and Illness Anxiety
Disorder 149
Shades of Gray 151
Conversion Disorder (Functional Neurological
Symptom Disorder) 153
Factitious Disorder 154
Dissociative Disorders 155
Dissociative Identity Disorder 156
Dissociative Amnesia 160
Depersonalization/Derealization Disorder 162
Controversies Around the Dissociative
Disorders 163
Chapter Summary 166

Key Terms 167
7 Mood Disorders and Suicide 168
Mood Disorders Along the Continuum 169
Extraordinary People—Kay Redfield Jamison,
An Unquiet Mind 170
Characteristics of Depressive Disorders 170
Symptoms of Depression 170
Diagnosing Depressive Disorders 171
Prevalence and Course of Depressive
Disorders 173
Shades of Gray 174
Characteristics of Bipolar Disorder 175
Symptoms of Mania 175
Prevalence and Course of Bipolar Disorder 177
x Contents
Creativity and the Mood Disorders 178
Theories of Depression 179

Biological Theories of Depression 179
Psychological Theories of Depression 182
Theories of Bipolar Disorder 186
Biological Theories of Bipolar Disorder 186
Psychosocial Contributors to Bipolar
Disorder 187
Treatment of Mood Disorders 188
Biological Treatments for Mood
Disorders 188
Psychological Treatments for Mood
Disorders 192
Interpersonal and Social Rhythm Therapy and
Family-Focused Therapy 195
Comparison of Treatments 196
Suicide 197
Defining and Measuring Suicide 197
Understanding Suicide 201
Treatment and Prevention 203

Chapter Summary 207
Key Terms 209
8 Schizophrenia Spectrum and Other
Psychotic Disorders 210
Schizophrenia Spectrum and Other Psychotic
Disorders Along the Continuum 211
Extraordinary People—John Nash, A Beautiful
Mind 212
Symptoms, Diagnosis, and Course 213
Positive Symptoms 213
Negative Symptoms 218
Cognitive Deficits 218
Diagnosis 219
Prognosis 221
Other Psychotic Disorders 222
Shades of Gray 226
Biological Theories 226
Genetic Contributors to Schizophrenia 226
Structural and Functional Brain
Abnormalities 228

Neurotransmitters 230
Psychosocial Perspectives 231
Social Drift and Urban Birth 231
Stress and Relapse 231
Schizophrenia and the Family 232
Cognitive Perspectives 233
Cross-Cultural Perspectives 233
Treatment 234
Biological Treatments 234
Psychological and Social Treatments 236
Chapter Summary 240
Key Terms 241
9 Personality Disorders 242
Personality Disorders Along the
Continuum 243
Extraordinary People—Susanna Kaysen, Girl,
Interrupted 244
General Definition of Personality Disorder 246

Cluster A: Odd-Eccentric Personality
Disorders 247
Paranoid Personality Disorder 248
Schizoid Personality Disorder 250
Schizotypal Personality Disorder 251
Cluster B: Dramatic-Emotional Personality
Disorders 253
Borderline Personality Disorder 254
Histrionic Personality Disorder 258
Narcissistic Personality Disorder 259
Cluster C: Anxious-Fearful Personality
Disorders 261
Contents xi
Avoidant Personality Disorder 262
Dependent Personality Disorder 263
Shades of Gray 265
Obsessive-Compulsive Personality
Disorder 265

Alternative DSM-5 Model for Personality
Disorders 267
Chapter Summary 270
Key Terms 272
10 Neurodevelopmental and
Neurocognitive Disorders 274
Neurodevelopmental and Neurocognitive
Disorders Along the Continuum 275
Extraordinary People—Temple Grandin, Thinking in
Pictures 276
Attention-Deficit/Hyperactivity Disorder 276
Biological Factors 279
Psychological and Social Factors 280
Treatments for ADHD 280
Shades of Gray 281
Autism Spectrum Disorder 282
Contributors to Autism Spectrum Disorder 285
Treatments for Autism Spectrum Disorder 286

Intellectual Disability 286
Biological Causes of Intellectual Disability 288
Sociocultural Factors 290
Treatments for Intellectual Disability 290
Learning, Communication, and Motor
Disorders 291
Specific Learning Disorder 292
Communication Disorders 293
Causes and Treatment of Learning and
Communication Disorders 294
Motor Disorders 295
Major and Mild Neurocognitive Disorders 296
Symptoms of Major Neurocognitive
Disorder 297
Types of Major and Mild Neurocognitive
Disorder 298
The Impact of Gender, Culture, and Education on
Neurocognitive Disorder 303
Treatments for and Prevention of Neurocognitive
Disorder 303
Delirium 304

Causes of Delirium 305
Treatments for Delirium 306
Chapter Summary 307
Key Terms 309
11 Disruptive, Impulse-Control, and
Conduct Disorders 310
Disorders of Conduct and Impulse Control Along
the Continuum 311
Extraordinary People—Ted Bundy, Portrait of a
Serial Killer 312
Conduct Disorder and Oppositional Defiant
Disorder 313
Contributors to Conduct Disorder and
Oppositional Defiant Disorder 316
Shades of Gray 317
Treatments for Conduct Disorder and
Oppositional Defiant Disorder 320
Antisocial Personality Disorder 321
Contributors to Antisocial Personality

Disorder 323
Treatments for Antisocial Personality
Disorder 324
Intermittent Explosive Disorder 324
Chapter Summary 326
Key Terms 327
xii Contents
12 Eating Disorders 328
Eating Disorders Along the Continuum 329
Extraordinary People—Fashion Models, Dying to
Be Thin 330
Characteristics of Eating Disorders 331
Anorexia Nervosa 331
Bulimia Nervosa 335
Binge-Eating Disorder 337
Other Specified Feeding or Eating

Disorder 338
Obesity 339
Understanding Eating Disorders 341
Shades of Gray 342
Sociocultural and Psychological Factors 343
Treatments for Eating Disorders 348
Psychotherapy for Anorexia Nervosa 348
Psychotherapy for Bulimia Nervosa and Binge-
Eating Disorder 349
Biological Therapies 350
Chapter Summary 352
Key Terms 353
13 Sexual Disorders and Gender
Diversity 354
Sexuality and Gender Along the
Continuum 355
Extraordinary People—David Reimer, The Boy Who

Was Raised as a Girl 356
Sexual Dysfunctions 357
Disorders of Sexual Interest/Desire and
Arousal 358
Disorders of Orgasm or Sexual Pain 360
Causes of Sexual Dysfunctions 361
Treatments for Sexual Dysfunctions 365
Considerations for Gay, Lesbian, and Bisexual
People 370
Paraphilic Disorders 371
Fetishistic Disorder and Transvestic Disorder 372
Sexual Sadism and Sexual Masochism
Disorders 373
Voyeuristic, Exhibitionistic, and Frotteuristic
Disorders 374
Pedophilic Disorder 374
Causes of Paraphilias 375
Treatments for the Paraphilic Disorders 376
Gender Dysphoria 377
Contributors to Gender Dysphoria 380

Treatments for Gender Dysphoria 380
Chapter Summary 382
Key Terms 383
14 Substance Use and Gambling
Disorders 384
Substance Use Along the Continuum 385
Extraordinary People—Celebrity Drug
Abusers 386
Defining Substance Use Disorders 387
Depressants 390
Alcohol 390
Shades of Gray 393
Benzodiazepines and Barbiturates 394
Stimulants 395
Cocaine 396
Amphetamines 397
Nicotine 398
Caffeine 399

Opioids 400
Hallucinogens and PCP 401
Cannabis 403
Inhalants 404
Contents xiii
Other Drugs of Abuse 404
Theories of Substance Use Disorders 405
Psychological Factors 406
Sociocultural Factors 407
Gender Differences 408
Treatments for Substance Use Disorders 408
Biological Treatments 408
Psychosocial Treatments 409
Substance Use Treatment for Older Adults 413
Comparing Treatments 413

Prevention Programs 414
Gambling Disorder 414
Chapter Summary 417
Key Terms 419
15 Health Psychology 420
Stress Along the Continuum 421
Extraordinary People—Norman Cousins, Healing
with Laughter 422
Psychological Factors and General Health 424
Appraisals and Pessimism 424
Coping Strategies 424
Shades of Gray 426
Psychological Disorders and Physical Health 426
Psychosocial Factors in Specific Diseases 427
The Immune System 427
Coronary Heart Disease and Hypertension 430
Interventions to Improve Health-Related
Behaviors 435

Guided Mastery Techniques 435
Internet-Based Health Interventions 435
Sleep and Health 436
Assessing Sleep 437
Sleep Disorders 438
Chapter Summary 450
Key Terms 451
16 Mental Health and the Law 452
Mental Health Law Along the Continuum 453
Extraordinary People—Greg Bottoms,
Angelhead 454
Civil Commitment 454
Criteria for Civil Commitment 455
Violence by People with Mental Disorders 457
Prevalence of Involuntary Commitment 459
Patients’ Rights 459
Right to Treatment 459

Right to Refuse Treatment 460
Competence to Stand Trial 460
The Insanity Defense 461
Insanity Defense Rules 463
Problems with the Insanity Defense 466
Shades of Gray 466
Guilty but Mentally Ill 467
Mental Health Care in the Justice System 467
Chapter Summary 469
Key Terms 470
McGraw-Hill Education Psychology’s
APA Documentation Style Guide
Glossary G-1
References R-1
Name Index NI-1
Subject Index SI-1

xiv
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PREFACE
Preface xv
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xvi Preface
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CHAPTER-BY-CHAPTER
CHANGES
Revisions based on the student heat map are reflected primarily
in Chapters 2, 5, 7, 9, and 15. Other content changes include the
following:
CHAPTER 1
• Updated coverage on the dimensions of abnormality on a
continuum
• Revised coverage of the cognitive revolution
• Increased attention to disadvantages of
deinstitutionalization
• Revised coverage on the role of correctional facilities
• Updated coverage of the Affordable Care Act and mental
health
CHAPTER 2
• New statistics on benzodiazepines and overdoses

• Updated coverage of electroconvulsive therapy effects
• Updated research on brain stimulation
• Revised coverage on the difference between modeling and
observational learning
• Revised coverage on the distinction between the pleasure
principle and the reality principle
• Revised coverage of Freudian concepts
• Updated coverage of Dialectical Behavioral Therapy
(DBT) adaptations and Acceptance and Commitment
Therapy (ACT)
• Added coverage of Unified Protocol (UP)
• Added content on cultural competence
• New content on cultural adaptations of treatment
CHAPTER 3
• New coverage on computerized assessment
• Revised coverage of key DSM topics
• Revised coverage concept of DSM axes
• Updated research on DSM-5 reliability
CHAPTER 4
• Revised presentation of correlation
• Strengthened coverage (with new examples) of the
difference between correlation and causation
• Revised presentation of demand characteristics
• New example for placebo control group for
therapy
• Strengthened coverage on the limitations of laboratory
studies

• Revised coverage of the types of genetic studies
• Revised presentation of adoption studies
• Strengthened coverage of meta-analysis
• Added coverage of Research Domain Criteria (RDoC)
CHAPTER 5
• Revised coverage with new example of dissociation in
trauma
• Clarified distinction between nervios and ataque
de nervios
• Revised presentation of neuroimaging findings related to
trauma
Preface xvii
• Strengthened presentation (with examples) of exposure
therapy in cognitive-behavioral therapy (CBT)
• Revised coverage of prolonged exposure and cognitive
processing therapy
• Strengthened coverage of exposure treatment for
phobia
• Revised coverage of social anxiety disorder
• Revised coverage of panic disorder diagnosis
• New coverage of the cognitive aspect of panic
• Integrated coverage of cognitive factors of posttraumatic

stress disorder (PTSD)
• Revised coverage of benzodiazepines in treating PTSD
• Improved coverage of general anxiety disorder definition
(GAD)
• Added coverage of emotion regulation therapy (ERT) for
GAD
• Revised presentation of obsessive compulsive disorder
(OCD) diagnosis
• New example of compulsions
• Revised coverage of body dysmorphic disorder
CHAPTER 6
• Revised coverage of the reliability and controversies of
DSM-5
• Updated treatment coverage
• Revised presentation of research on stress and
maltreatment
• Updated coverage of prognosis relating to conversion
disorders
• Updated coverage of the science on theories of dissociative
identity disorder (DID)
• New coverage of treatment outcome research
• Revised coverage of dissociative fugue
CHAPTER 7
• Clarified definition and organization of subtypes of

depression
• Revised coverage relating to the different bipolar
disorders
• Strengthened coverage of bipolar episodes and diagnoses
• Revised presentation of cyclothymia
• New material on the distinction between episodes and
general reactivity in bipolar disorder
• Improved coverage, with examples, of creativity in mood
disorders
• Strengthened coverage of hopelessness in depression
• New material on the different bipolar disorders
• Revised coverage of cohort effects
• Revised coverage of gender differences in depression
• New material on puberty and gender differences in
depression
• New material on racial and ethnic differences
• Updated material on genetic and brain findings relating to
depression
• Added coverage of psychosocial contributors to bipolar
disorders
• Added example of reward sensitivity
• Updated findings on selective serotonin reuptake inhibitors
(SSRIs) and suicide
• Revised coverage of selective serotonin-norepinephrine
reuptake inhibitors (SNRI)
• Revised coverage of the pros and cons of lithium

• Added lamotrigine to medical treatments for bipolar
disorders
• Updated coverage of suicide epidemiology and
demographics
• Added coverage of African American suicide rates and
updated all coverage of ethnicity rates
• Added coverage of anxiety and suicide
• Added content on new media and suicide
• Updated research on impulsivity
• Added content on the interpersonal theory of suicide
• Added definitions of treatment vs. prevention
• Updated coverage of nonsuicidal self-injury
CHAPTER 8
• Added historical factors in discussion of delusions
• Updated research on hallucinations in general population
• Added research on anticipatory emotion
• Updated research on prognoses for psychotic disorders,
including for suicide
• Integration of cognitive and biosocial theories of
schizophrenia
• Added material on schizophrenia and bipolar family
comorbidity
• Updated status of social drift research
• Updated status of stressful events research
• Updated evidence on treatment efficacy
CHAPTER 9

• New material on cognitive treatment for schizotypal
personality disorder
• Added example of splitting
• Updated status of pharmacological treatment for
borderline personality disorder
• Clarified coverage of therapy for histrionic personality
disorder
• Revised coverage of narcissism subtypes
• Clarified difference between avoidant and schizoid
personality disorders
• Clarified distinction between obsessive-compulsive
personality disorder and obsessive-compulsive disorder
• Clarified and updated coverage of alternative dimensional
models for personality disorders
xviii Preface
CHAPTER 10
• Updated coverage of attention-deficit/hyperactivity
disorder (ADHD)
• Updated status of psychosocial factors
• Update on cognitive-behavioral therapy for adult
ADHD
• New material on genetic research

• Added research on name processing
• Updated status of autism spectrum disorder (ASD)
medications
• Updated statistics on sports traumatic brain injury
• Added research on early identification
• Updated coverage of delirium research and treatment
CHAPTER 11
• Updated contradictory findings on physiological reactivity
in conduct disorders
• Updated findings on Fast Track and conduct disorders
• Updated coverage on drugs are not first-line treatments for
conduct disorder and oppositional defiant disorder
• New coverage of genetic and epigenetic findings in
antisocial personality disorder
• Updated findings on amygdala and striatum
CHAPTER 12
• Updated with DSM-5 prevalence of anorexia nervosa
• Updated with DSM-5 prevalence of bulimia nervosa
• New research on leveling-out of prevalence of bulimia
nervosa since 2000s
• Updated DSM-5 and international prevalence of binge-
eating disorder
• Revised coverage of DSM-5 categories eating disorders not
otherwise specified (EDNOS) and other specified feeding
or eating disorder

• Updated coverage of obesity drugs
• Added coverage of male eating disorders and muscularity
ideal
• Updated research on thinness ideal
• Revised coverage of the treatment of eating disorders
• New coverage of treatment access, Internet-based
intervention, and prevention of eating disorders
CHAPTER 13
• New title: Sexual Disorders and Gender Diversity
• Updated coverage of sexual desire prevalence
• Added material on cognitions to include men
• New material on culture and gender roles
• Updated research on testosterone
• Updated research on biological treatments for women
• Revised heterosexual-specific language for early ejaculation
treatment
• Revised heading of LGB section to separate sexual
orientation from disorders
• Added unique considerations for LGB sexual
dysfunction
• Revised coverage of nonpathological consensus and
position on conversion therapy
• Emphasized continuum aspect of sadism/masochism
• Added evidence regarding sadism disorder in offenders
• Revised heading for treatment of paraphilic disorders to
emphasize the disorders rather than the interests and
behaviors
• Updated coverage of cognitive-behavioral therapy for

paraphilias
• Significant revision of the gender dysphoria (GD) section
to emphasize distress and impairment criteria
• Updated research on GD prevalence, associated
psychopathology, and risk factors for HIV
• Added new coverage of gender diversity and transgender
along the continuum
• Updated findings on brain in GD
• New coverage of GD in childhood and persistence into
adulthood
• Added coverage of biological treatment of GD in
children
CHAPTER 14
• Updated U.S. and world statistics throughout (prevalence
of use, abuse, ER visits, and deaths)
• Increased emphasis on recent increases in use/abuse of
methamphetamine and opioids
• Updated coverage of e-cigarettes
• Added coverage of opioid epidemic
• Updates on laws regarding medical and recreational uses
of marijuana
• Updated coverage of gambling diagnosis and treatment
• Added coverage of Internet gaming disorder and other
behavioral addictions
CHAPTER 15

• Updated epidemiology and statistics throughout
• Revised coverage of link between psychological diagnosis
and physical health
• Updated cancer intervention research
• Updated status of research on psychosocial treatment and
coronary heart disease (CHD)
• Streamlined coverage of depression and CHD
• Added discussion of culturally sensitive interventions
• New coverage of mobile health interventions (along with
updates to Internet intervention)
• Clarified sleep brain-wave language
• Added examples for sleep study
• Updated research on narcolepsy as autoimmune problem
• Revised definition of hypoventilation
Preface xix
• Updated prevalence of sleep apnea
• Revised coverage of circadian rhythm disorders
• Revised coverage of arousal
• Increased coverage of confusional arousals
• Added examples for REM sleep disorder
• Added coverage of medications for nightmare disorder
CHAPTER 16
• Updated research on violence
• Added prevalence of incompetence to stand trial

• Revised coverage of states’ use of insanity rules
• New introduction to section on justice system
• Updated rates of mental illness in prisons
ACKNOWLEDGMENTS
We are grateful to Brett Marroquín, Loyola Marymount
University,
for his invaluable contributions to this edition.
2
©travelview/Shutterstock
Shades of Gray Discussion
Chapter Summary
Key Terms
Abnormality Along the Continuum
Extraordinary People
Defining Abnormality
Shades of Gray
Historical Perspectives on Abnormality
The Emergence of Modern Perspectives

Modern Mental Health Care
Chapter Integration
C H A P T E R O U T L I N E
Looking at Abnormality
1Chapter
nol00187_ch01_002-021.indd 2 11/28/18 9:28 AM
Abnormality Along the Continuum 3
think there is a clear dividing line between normal variations in
thoughts, emotions, and behaviors and what we would label
“abnormal.” Once an individual’s behaviors or feelings crossed
that line, we would be justified in saying that there is something
wrong with that person or that he or she has a disorder. As we
discuss in this chapter and throughout this book, however, there
is increasing evidence that no such dividing line exists, perhaps
for any of the mental health problems that are currently recog-
nized. As you can see above, it can be hard to determine when
behaviors, thoughts, and feelings become unusual, distressing,
functionally impairing, or dangerous — key determinants of
abnor-
mality. We make decisions about where to draw the line that
indicates a sufficient amount of abnormality to warrant a
diagno-
sis or treatment. You will see that this continuum model of
abnormality applies to all the disorders we discuss in this book.
In this chapter, we discuss some of the factors that influence
how
thoughts, emotions, and behaviors are labeled abnormal.

As humans, we think, we feel, we behave. Most of the time, our
thoughts, feelings, and behaviors help us function in everyday
life and are in the service of important goals or values we hold.
Sometimes, however, we all have thoughts that upset us, expe-
rience feelings we’d rather not have, and act in ways that are
self- defeating or detrimental to others. We may find ourselves
in
situations in which we can’t think, feel, or behave as others
would— as when, for example, we can’t let go of a failed
relation-
ship. We may become upset over a situation that others don’t
find distressing, such as getting an average grade on an exam.
Our thoughts, feelings, or behaviors may be interfering with our
functioning in everyday life— for example, if we become afraid
to
walk alone after being mugged. Or we may be acting in ways
that are dangerous to ourselves or others, such as driving a car
when intoxicated.
Problems in thoughts, feelings, and behavior vary from nor -
mal to abnormal, as illustrated in the diagram above. We’d like
to
Abnormality Along the Continuum
Abnormal
Behaviors, thoughts, and feelings are one
or more of the following:
• Highly unusual for the social context
• The source of significant individual distress
• Significantly interfering with social or
occupational functioning

• Highly dangerous to the individual or others
(Example: College students who are hopeless about
the future, are self-loathing, chronically abuse drugs,
fail courses, and have alienated all their friends)
Behaviors, thoughts, and feelings are one
or more of the following:
• Somewhat unusual for the social context
• Distressing to the individual
• Interfering with social or occupational
functioning
• Dangerous
(Example: College students who are often unsure
and self-critical, occasionally abuse prescription
drugs, fail some courses, and avoid friends who
disapprove of their drug use)
Socially established
division between
normal and abnormal
Normal
Behaviors, thoughts, and feelings are
the following:
• Typical for the social context
• Not distressing to the individual
• Not interfering with social life or work/school
• Not dangerous
(Example: College students who are self-confident

and happy, perform to their capacity in school,
and have good friends)
nol00187_ch01_002-021.indd 3 11/28/18 9:29 AM
4 Chapter 1 Looking at Abnormality
People talk as if they have an intuitive sense of what
abnormal behavior is. Let’s explore some of the ways
abnormality has been defined.
Mental Illness
A common belief is that behaviors, thoughts, or feel-
ings can be viewed as pathological or abnormal if they
are symptoms of a mental illness. This implies that
a disease process, much like hypertension or diabetes,
is present. For example, when many people say that
an individual “has schizophrenia” (which is character-
ized by unreal perceptions and severely irrational
thinking), they imply that he or she has a disease that
should show up on some sort of biological test, just as
hypertension shows up when a person’s blood pres-
sure is taken.
To date, however, no biological test is available to
diagnose any of the types of abnormality we discuss in
this book (Hyman, 2010). This is not just because we
do not yet have the right biological tests. In modern
conceptualizations, mental disorders are not viewed as
singular diseases with a common pathology that can
be identified in all people with the disorder. Instead,
mental health experts view mental disorders as collec-
tions of problems in thinking or cognition, in emo-
tional responding or regulation, and in social behavior

(Cuthbert & Insel, 2013; Hyman, 2010). Thus, for
example, a person diagnosed with schizophrenia has a
collection of problems in rational thinking and in
responding emotionally and behaviorally in everyday
life, and it is this collection of problems that we label
schizophrenia. It is still possible, and in the case of
schizophrenia likely, that biological factors are associ -
ated with these problems in thinking, feeling, and
behaving. But it is unlikely that a singular disease pro-
cess underlies the symptoms we call schizophrenia.
The study of abnormal psychology is the study of
people, like the young woman in the Extraordinary
People feature, who suffer mental, emotional, and often
physical pain, often referred to as psychopathology.
Sometimes the experiences of people with psychopa-
thology are as unusual as those this young woman
describes. Sometimes, however, people with psychopa-
thology have experiences that are familiar to many of us
but more extreme, as when everyday sadness trans-
forms into life- altering depression.
In this book we explore the lives of people with
troubling psychological symptoms to understand how
they think, what they feel, and how they behave. We
investigate what is known about the causes of these
symptoms and the appropriate treatments for them.
The purpose of this book is not only to provide you
with information, facts and figures, theories, and
research but also to help you understand the experi-
ence of people with psychological symptoms. The
good news is that, thanks to an explosion of research
in the past few decades, effective biological and psy-
chological treatments are available for many of the
mental health problems we discuss.

DEFINING ABNORMALITY
In popular culture, there are a lot of words for people
and behaviors that seem abnormal: around the bend,
bananas, barmy, batty, berserk, bonkers, cracked,
crazy, cuckoo, daft, delirious, demented, deranged,
dingy, erratic, flaky, flipped out, freaked out, fruity,
insane, kooky, lunatic, mad, mad as a March hare,
mad as a hatter, maniacal, mental, moonstruck, nuts,
nutty, nutty as a fruitcake, of unsound mind, out of
one’s mind, out of one’s tree, out to lunch, potty, psy-
cho, screw loose, screwball, screwy, silly, touched,
unbalanced, unglued, unhinged, unzipped, wacky.
My illness began slowly, gradually, when I was between
the ages of 15 and 17. During that time reality became
distant and I began to wander around in a sort of haze,
foreshadowing the delusional world that was to come
later. I also began to have visual hallucinations in which
people changed into different characters, the change
indicating to me their moral value. For example, the
mother of a good friend always changed into a witch,
and I believed this to be indicative of her evil nature.
Another type of visual hallucination I had at this time is
exemplified by an occurrence during a family trip through
Utah: The cliffs along the side of the road took on a
human appearance, and I perceived them as women,
bedraggled and weeping. At the time I didn’t know what
to make of these changes in my perceptions. On the one
hand, I thought they came as a gift from God, but on the
other hand, I feared that something was dreadfully
wrong. However, I didn’t tell anyone what was happen-
ing; I was afraid of being called insane. I also feared, per -
haps incredibly, that someone would take it lightly and
tell me nothing was wrong, that I was just having a rough
adolescence, which was what I was telling myself.

Source: Anonymous, 1992.
Extraordinary People
nol00187_ch01_002-021.indd 4 11/28/18 9:29 AM
Defining Abnormality 5
judgments of abnormality. Yet opponents of cultural
relativism argue that dangers arise when cultural
norms are allowed to dictate what is normal or abnor-
mal. In particular, psychiatrist Thomas Szasz (1961,
2011) noted that throughout history, societies have
labeled individuals and groups abnormal in order to
justify controlling or silencing them. Hitler branded
Jews abnormal and used this label as one justification
for the Holocaust. The former Soviet Union some-
times branded political dissidents mentally ill and
confined them in mental hospitals. When the slave
trade was active in the United States, slaves who tried
to escape their masters could be diagnosed with
a mental disease that was said to cause them to desire
freedom; the prescribed treatment for this disease was
whipping and hard labor.
Most mental health professionals these days do
not hold an extreme relativist view on abnormality,
recognizing the dangers of basing definitions of
abnormality solely on cultural norms. Yet even those
who reject an extreme cultural- relativist position rec-
ognize that culture and gender have a number of influ-
ences on the expression of abnormal behaviors and
on the way those behaviors are treated. First, culture

and gender can influence the ways people express
symptoms. People who lose touch with reality often
believe that they have divine powers, but whether they
believe they are Jesus or Mohammed depends on their
religious background.
Second, culture and gender can influence peo-
ple’s willingness to admit to certain types of behaviors
or feelings (Snowden & Yamada, 2005). People in
Eskimo and Tahitian cultures may be reluctant to
admit to feeling anger because of strong cultural
norms against the expression of anger. The Kaluli of
Cultural Norms
Consider these behaviors:
1. A man driving a nail through his hand
2. A woman refusing to eat for several days
3. A man barking like a dog and crawling on the
floor on his hands and knees
4. A woman building a shrine to her dead husband
in her living room and leaving food and gifts for
him at the altar
Do you think these behaviors are abnormal? You
might reply, “It depends.” Several of these behaviors
are accepted in certain circumstances. In many reli-
gious traditions, for example, refusing to eat for
a period of time, or fasting, is a common ritual of
cleansing and penitence. You might expect that some
of the other behaviors listed, such as driving a nail
through one’s hand or barking like a dog, are abnor-
mal in all circumstances, yet even these behaviors are
accepted in certain situations. In Mexico, some

Christians have themselves nailed to crosses on Good
Friday to commemorate the crucifixion of Jesus.
Among the Yoruba of Africa, traditional healers
act like dogs during healing rituals (Murphy, 1976).
Thus, the context, or circumstances surrounding a
behavior, influences whether the behavior is viewed as
abnormal.
Cultural norms play a large role in defining abnor-
mality. A good example is the behaviors people are
expected to display when someone they love dies
(Rosenblatt, 2008). In cultures dominated by Shinto
and Buddhist religions, it is customary to build altars
to honor dead loved ones, to offer them food and gifts,
and to speak with them as if they were in the room. In
cultures dominated by Christian and Jewish religions,
such practices would potentially be considered quite
abnormal.
Cultures have strong norms for what is consid-
ered acceptable behavior for men versus women, and
these gender- role expectations also influence the
labeling of behaviors as normal or abnormal (Addis,
2008). In many cultures, men who display sadness or
anxiety or who choose to stay home to raise their chil-
dren while their wives work are at risk of being labeled
abnormal, while women who are aggressive or who
don’t want to have children are at risk of being labeled
abnormal.
Cultural relativism is the view that there are no
universal standards or rules for labeling a behavior
abnormal; instead, behaviors can be labeled abnormal
only relative to cultural norms (Snowden & Yamada,
2005). The advantage of this perspective is that it hon-
ors the norms and traditions of different cultures,

rather than imposing the standards of one culture on
In Mexico, some Christians have themselves nailed to a cross to
commemorate the
crucifixion of Jesus. ©AARON FAVILA/AP Images
nol00187_ch01_002-021.indd 5 11/28/18 9:29 AM
6 Chapter 1 Looking at Abnormality
The Four Ds of Abnormality
If we do not want to define abnormality only on the
basis of cultural norms, and if we cannot define abnor-
mality as the presence of a mental illness because no
singular, identifiable disease process underlies most
psychological problems, how do we define abnormal-
ity? Modern judgments of abnormality are influenced
by the interplay of four dimensions, often called “the
four Ds”: dysfunction, distress, deviance, and danger-
ousness. Behaviors, thoughts, and feelings are dysfunc-
tional when they interfere with the person’s ability to
function in daily life, to hold a job, or to form close
relationships. The more dysfunctional behaviors and
feelings are, the more likely they are to be considered
abnormal by mental health professionals. For exam-
ple, thinking that is out of touch with reality (such as
believing you are Satan and should be punished)
makes it difficult to function in everyday life and so is
considered dysfunctional.
Behaviors and feelings that cause distress to the
individual or to others around him or her are also
likely to be considered abnormal. Many of the prob-
lems we discuss in this book cause individuals tremen-

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