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“The editors have graced us with a reprise of their outstanding 4th edition of this textbook with chapters by almost all of the
previous, very distinguished, experts. Attention to older adults and clinical judgment is particularly noteworthy, as is the attention
to the current ICD and DSM diagnostic systems. It is concise, readily supplemented, and will not overwhelm students with dense
and lengthy material. The book is a gem.”
—Barry A. Edelstein, PhD, Eberly Family Distinguished Professor,
Department of Psychology, West Virginia University, USA

“As with previous editions, this volume is highly readable, well-­organized, scholarly, and comprehensive. Maddux and Winstead
have again produced an indispensable work for graduate-­level education in understanding and treating mental illness. Written by
acclaimed experts in that particular topic, each chapter follows a similar format which makes the material accessible to both students
and instructors alike. More importantly, the authors present the up-­to-­date empirical work guiding research, assessments, and
interventions. Updated to reflect both revisions to the DSM and advancements in the field, this is an essential textbook for training
future mental health professionals.”
—Stephen M. Saunders, PhD, Professor and Chairperson, Department of Psychology, Marquette University, USA

Praise for previous editions

“The challenge of not only describing, but also starting to explain, psychopathology is a daunting one, but Psychopathology does
a superb job…Students’ understanding and appreciation for the key issues in psychopathology etiology, assessment, intervention,
and research will increase tremendously by reading this text.”
—Bethany Teachman, PhD, Director, Program for Anxiety, Cognition, and Treatment;
Associate Professor of Psychology, University of Virginia, USA

“This book will be of great value to mental health professionals across career stages…For all readers, the book’s clarity and insight
on the nature of psychopathology itself, on clinical assessment, on cultural dimensions, and more will provide an invaluable
resource.”
—Thomas Joiner, PhD, Author of Lonely at the Top and Why People Die by Suicide

“This textbook will be of great value to all students and health professionals in the field of psychology and psychiatry as it gives
them access to the main issues of contemporary psychopathology and to updated data about specific disorders throughout the
life-­span.”
—Diane Purper Ouakil, Author of European Child and Adolescent Psychiatry
 Psychopathology

Psychopathology, Fifth Edition is the most up-­to-­date text about the etiology and treatment of the most important psychological disorders.

The chapters are written by leading experts in the field of psychopathology who provide up-­to-­date information on theory, research,
and clinical practice. The book is unique in its strong emphasis on critical thinking about psychopathology as represented by
chapters on such topics as culture, race, gender, class, clinical judgment and decision-­making, and alternatives to traditional
categorical approaches to understanding psychopathology. The contributors have incorporated information about and from the
World Health Organization’s International Classification of Diseases along with information about and from the DSM-­5.

As with the previous editions, this book remains a true textbook in psychopathology. Unlike the many weighty volumes that are
intended as reference books, Psychopathology, Fifth Edition has been designed specifically to serve as a textbook on psychopathology for
graduate students in clinical and counseling psychology programs and related programs such as social work. It will also serve as an
extremely useful reference source for practitioners and researchers.

James E. Maddux, PhD, is university professor emeritus in the Department of Psychology and Senior Scholar in the Center for the
Advancement of Well-­Being at George Mason University in Fairfax, Virginia.

Barbara A. Winstead, PhD, is professor of psychology in the Department of Psychology at Old Dominion University and in the
Virginia Consortium Program in Clinical Psychology, Norfolk, Virginia.
 Psychopathology
Foundations for a Contemporary Understanding
FIFTH EDITION

Edited by James E. Maddux and Barbara A. Winstead

Fifth Edition published 2020
by Routledge
52 Vanderbilt Avenue, New York, NY 10017

and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2020 Taylor & Francis

The right of James E. Maddux and Barbara A. Winstead to be identified as the authors of the editorial material, and of the
authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs
and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic,
mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.

First edition published by Routledge, 2004

Fourth edition published by Routledge, 2016

Library of Congress Cataloging-­in-­Publication Data

Names: Maddux, James E., editor. | Winstead, Barbara A., editor.
Title: Psychopathology: Foundations for a Contemporary Understanding / ­edited by James E. Maddux and
Barbara A. Winstead.
Description: 5th Edition. | New York: Routledge, 2019. | Revised edition of Psychopathology, 2016. |
Includes bibliographical references and index.
Identifiers: LCCN 2018059750 (print) | LCCN 2018061625 (ebook) | ISBN 9780429028267 (Master) |
ISBN 9780429650512 (Adobe) | ISBN 9780429645235 (Mobipocket) | ISBN 9780429647871 (ePub3) |
ISBN 9780367085803 (hbk : alk. paper) | ISBN 9780429028267 (ebk)
Subjects: LCSH: Psychology, Pathological.
Classification: LCC RC454 (ebook) | LCC RC454 .P786 2019 (print) | DDC 616.89—dc23
LC record available at https://­lccn.loc.gov/­2018059750

ISBN: 978–0-­367–08580–3 (hbk)

ISBN: 978–0-­429–02826–7 (ebk)

Typeset in Joanna MT
by Apex CoVantage, LLC

Visit the companion website: www.routledge.com/­cw/­maddux

Contents

Contributorsix
Prefacexiii

PART I: THINKING ABOUT PSYCHOPATHOLOGY 1

1 Conceptions of Psychopathology: A Social Constructionist Perspective 3
James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

2 Psychopathology: A Neurobiological Perspective 19

Daniel Tranel, Molly A. Nikolas, and Kristian Markon

3 Developmental Psychopathology: Basic Principles 57

Janice Zeman, Cynthia Suveg, and Kara Braunstein West

4 Cultural Dimensions of Psychopathology: The Social World’s Impact on Mental Disorders 67

Steven Regeser López and Peter J. Guarnaccia

5 Gender, Race, and Class and Their Role in Psychopathology 85

Barbara A. Winstead and Janis Sanchez-­Hucles

6 Classification and Diagnosis: Historical Development and Contemporary Issues 109

Thomas A. Widiger

7 Psychological Assessment and Clinical Judgment 125

Howard N. Garb, Scott O. Lilienfeld, and Katherine A. Fowler

8 Psychotherapy Research 141

Rebecca E. Stewart and Dianne L. Chambless

PART II: COMMON PROBLEMS OF ADULTHOOD 153

9 Anxiety Disorders and Obsessive-­Compulsive and Related Disorders 155
Shari A. Steinman, Amber L. Billingsley, Cierra B. Edwards, Mira D. Snider, and Lauren S. Hallion

10 Trauma-­and Stressor-­Related Disorders 173

Lori A. Zoellner, Belinda Graham, and Michele A. Bedard-­Gilligan

11 Depressive Disorders and Bipolar and Related Disorders 201

Lauren B. Alloy, Naoise Mac Giollabhui, Amber A. Graham, Allison Stumper, Corinne P. Bart, Erin E. Curley, Laura E. McLaughlin,
Daniel P. Moriarity, and Tommy H. Ng

12 Schizophrenia Spectrum and Other Psychotic Disorders 247

Matilda Azis, Ivanka Ristanovic, Andrea Pelletier-­Baldelli, Hanan Trotman, Lisa Kestler, Annie Bollini, and Vijay A. Mittal

13 Personality Disorders 281

Cristina Crego and Thomas A. Widiger

14 Sexual Dysfunctions and Paraphilic Disorders 305

Jennifer T. Gosselin and Michael Bombardier

15 Somatic Symptom and Related Disorders 341

Michael J. Zvolensky, Lorra Garey, Justin M. Shepherd, and Georg H. Eifert

16 Dissociative Disorders 355

Steven Jay Lynn, Scott O. Lilienfeld, Harald Merckelbach, Reed Maxwell, Damla Aksen, Jessica Baltman, and Timo Giesbrecht
viii | Contents

17 Substance-­Related and Addictive Disorders 377

Keith Klostermann, Michelle L. Kelley, and Sarah Ehlke

18 Mental Health and Aging 399

Amy Fiske, Ruifeng Cui, and Alexandria R. Ebert

PART III: COMMON PROBLEMS OF CHILDHOOD AND ADOLESCENCE 425

19 Externalizing Disorders of Childhood and Adolescence 427
Eva R. Kimonis, Paul J. Frick, and Georgette E. Fleming

20 Internalizing Disorders of Childhood and Adolescence 459

Janay B. Sander, Lindsay K. Rye, and Thomas H. Ollendick

21 Learning Disorders of Childhood and Adolescence 481

Rebecca S. Martínez and Leah M. Nellis

22 Eating Disorders 495

Danielle E. MacDonald, Traci McFarlane, and Kathryn Trottier

23 Gender Dysphoria 521

Jennifer T. Gosselin and Michael Bombardier

24 Autism Spectrum Disorders 537

Susan W. White and Caitlin M. Conner

Index551
Contributors

Lauren B. Alloy, Department of Psychology, Temple University, Philadelphia, Pennsylvania

Damla Aksen, Psychology Department, Binghamton University, State University of New York, Binghamton, New York

Matilda Azis, Department of Psychology, Northwestern University, Evanston, Illinois

Jessica Baltman, The Reeds Center, New York

Corinne P. Bart, Department of Psychology, Temple University, Philadelphia, Pennsylvania

Michele A. Bedard-­Gilligan, Department of Psychiatry and Behavioral Science, University of Washington, Seattle, Washington

Amber L. Billingsley, Department of Psychology, West Virginia University, Morgantown, West Virginia

Annie Bollini, Patient-­Centered Outcomes Research Institute, Washington, DC

Michael Bombardier, Private Practice, Baltimore, Maryland

Kara Braunstein West, Clinical Psychology Doctoral Program, University of Georgia, Athens, Georgia

Dianne L. Chambless, Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania

Caitlin M. Conner, Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania

Cristina Crego, Department of Psychology, University of Kentucky, Lexington, Kentucky

Ruifeng Cui, Department of Psychology, West Virginia University, Morgantown, West Virginia

Erin E. Curley, Department of Psychology, Temple University, Philadelphia, Pennsylvania

Alexandria R. Ebert, Department of Psychology, West Virginia University, Morgantown, West Virginia

Cierra B. Edwards, Department of Psychology, West Virginia University, Morgantown, West Virginia

Sarah Ehlke, Doctoral Candidate, Health Psychology Program, Old Dominion University, Norfolk, Virginia

Georg H. Eifert, Department of Psychology, Chapman University, Orange, California

Amy Fiske, Department of Psychology, West Virginia University, Morgantown, West Virginia

Georgette E. Fleming, School of Psychology, University of New South Wales, Sydney, Australia

Katherine A. Fowler, Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia

Paul J. Frick, Department of Psychology, Louisiana State University, Baton Rouge, Louisiana

Howard N. Garb, Wilford Hall Medical Center, Lackland Airforce Base, San Antonio, Texas

Lorra Garey, Department of Psychology, University of Houston, Houston, Texas

x | Contributors

Timo Giesbrecht, Forensic Psychology Section, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht,
The Netherlands

Jennifer T. Gosselin, Salt Lake City, Utah

Amber A. Graham, Department of Psychology, Temple University, Philadelphia, Pennsylvania

Belinda Graham, Department of Experimental Psychology, University of Oxford, Oxford, England

Peter J. Guarnaccia, Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New
Brunswick, New Jersey

Lauren S. Hallion, Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania

Michelle L. Kelley, Department of Psychology, Old Dominion University, Norfolk, Virginia

Lisa Kestler, Princeton, New Jersey

Eva R. Kimonis, School of Psychology, University of New South Wales, Sydney, Australia

Keith Klostermann, Department of Counseling and Clinical Psychology, Medaille College, Buffalo, New York

Scott O. Lilienfeld, Department of Psychology, Emory University, Atlanta, Georgia

Steven R. López, Department of Psychology, University of Southern California, Los Angeles, California

Steven J. Lynn, Department of Psychology, Binghamton University, The State University of New York, Binghamton, New York

Danielle E. MacDonald, Centre for Mental Health, University Health Network, Toronto, Ontario & Department of Psychiatry,
University of Toronto, Toronto, Ontario

Naoise Mac Giollabhui, Department of Psychology, Temple University, Philadelphia, Pennsylvania

James E. Maddux, Department of Psychology & Center for the Advancement of Well-­Being, George Mason University, Fairfax,
Virginia

Kristian Markon, Department of Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa

Rebecca S. Martínez, Department of Counseling and Educational Psychology, Indiana University, Bloomington, Indiana

Reed Maxwell, Cornell Weil Medical College, New York

Traci McFarlane, Centre for Mental Health, University Health Network, Toronto, Ontario & Department of Psychiatry, University of
Toronto, Toronto, Ontario

Laura E. McLaughlin, Department of Psychology, Temple University, Philadelphia, Pennsylvania

Harald Merckelbach, Forensic Psychology Section, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The
Netherlands

Vijay A. Mittal, Department of Psychology, Northwestern University, Evanston, Illinois

Daniel P. Moriarity, Department of Psychology, Temple University, Philadelphia, Pennsylvania

Leah M. Nellis, Department of Communication Disorders and Counseling, School, and Educational Psychology, Indiana State
University, Kokomo, Indiana
 Contributors | xi

Tommy H. Ng, Department of Psychology, Temple University, Philadelphia, Pennsylvania.

Molly A. Nikolas, Department of Psychology, University of Iowa, Iowa City, Iowa

Thomas H. Ollendick, Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, Virginia

Andrea Pelletier-­Baldelli, Department of Psychiatry, University of North Carolina, Chapel Hill, North Carolina

Ivanka Ristanovic, Department of Psychology, Northwestern University, Evanston, Illinois

Lindsay K. Rye, Department of Educational Psychology, Ball State University, Muncie, Indiana

Janis Sanchez-­Hucles, Department of Psychology, Old Dominion University, Norfolk, Virginia

Janay B. Sander, Department of Educational Psychology, Ball State University, Muncie, Indiana

Justin M. Shepherd, Department of Psychology, University of Houston, Houston, Texas

Mira D. Snider, Department of Psychology, West Virginia University, Morgantown, West Virginia

Shari A. Steinman, Department of Psychology, West Virginia University, Morgantown, West Virginia

Rebecca E. Stewart, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania

Allison Stumper, Department of Psychology, Temple University, Philadelphia, Pennsylvania

Cynthia Suveg, Department of Psychology, University of Georgia, Athens, Georgia

Daniel Tranel, Department of Neurology & Department of Psychological and Brain Sciences, University of Iowa, Iowa City, Iowa

Hanan Trotman, Department of Psychology, Mercer University, Macon, Georgia

Kathryn Trottier, Centre for Mental Health, University Health Network, Toronto, Ontario & Department of Psychiatry, University
of Toronto, Toronto, Ontario

Susan W. White, Department of Psychology, University of Alabama, Tuscaloosa, Alabama

Thomas A. Widiger, Department of Psychology, University of Kentucky, Lexington, Kentucky

Barbara A. Winstead, Department of Psychology, Old Dominion University, Norfolk, Virginia

Janice Zeman, Department of Psychology, College of William and Mary, Williamsburg, Virginia

Lori A. Zoellner, Department of Psychology, University of Washington, Seattle, Washington

Michael J. Zvolensky, Department of Psychology, University of Houston, Houston, Texas

Preface

We are pleased to offer the fifth edition of Psychopathology: Foundations for a Contemporary Understanding. This book was created – and revised –
with students in mind. The length, organization, and level and style of writing reflect this intention. We had – and still have – two
major goals in mind.

1. Providing up-­to-­date information about theory and research on the etiology and treatment of the most important psycholog-
ical disorders. Toward this end, we chose well-­known researchers who would not only be aware of the cutting-­edge research
on their topics but who were also contributing to this cutting-­edge research. This goal also demands frequent updating of
information to reflect, as much as possible, the latest developments in the field.
2. Challenging students to think critically about psychopathology. We tried to accomplish this goal in two ways. First, we encouraged
chapter authors to challenge traditional assumptions and theories concerning the topics about which they were writing. Sec-
ond, and more important, we have included chapters that discuss in depth crucial and controversial issues facing the field of
psychopathology, such as the definition of psychopathology, the influence of cultural and gender, the role of developmental
processes, the validity of psychological testing, and the viability and utility of traditional psychiatric diagnosis. The first eight
chapters in this book are devoted to such issues because we believe that a sophisticated understanding of psychopathology
consists of much more than memorizing a list of disorders and their symptoms or memorizing the findings of numerous
studies. It consists primarily of understanding ideas and concepts and understanding how to use those ideas and concepts to make
sense of the research on specific disorders and the information found in formal diagnostic manuals.

Part I offers in-depth discussions of a number of important ideas, concepts, and theories which provide perspective on specific
psychological disorders. The major reason for placing these general chapters in the first section before the disorders chapters is to
give students a set of conceptual tools that will help them read more thoughtfully and critically the material on specific disorders.
Parts II and III deal with specific disorders of adulthood, childhood, and adolescence. We asked contributors to follow, as much
as possible, a common format consisting of:

1. A definition and description of the disorder or disorders.

2. A brief history of the study of the disorder.
3. Theory and research on etiology.
4. Research on empirically supported interventions.

Editors must always make choices regarding what should be included in a textbook and what should not. A textbook that devoted
a chapter to every disorder described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the mental, behavioral, and
­neurodevelopmental disorders section of the International Classification of Diseases and Related Problems (ICD) would be unwieldy and impos-
sible to cover in a single semester. Our choices regarding what to include and what to exclude were guided primarily by our expe-
riences over several decades of teaching and training clinical psychology doctoral students regarding the kinds of psychological
problems that these and students in related programs (e.g., counseling, social work) typically encounter in their training and in their
subsequent clinical careers. We also wanted to be generally consistent with the nomenclature that appear in the DSM-­5 and the
new ICD-­11.
We were pleased that the authors of 23 of the 24 chapters of the fourth edition agreed to revise their chapters for the fifth
edition. This helps to assure continuity in content and style from the fourth edition to the fifth.
We continue to hope that instructors and students will find this approach to understanding psychopathology challenging and
useful. We continue to learn much from our contributors in the process of editing their chapters, and we hope that students will
learn as much as we have from reading what these outstanding contributors have produced.
James E. Maddux
George Mason University
Fairfax,Virginia
Barbara A.Winstead
Old Dominion University
Virginia Consortium Program in Clinical Psychology
Norfolk,Virginia
May 1, 2019
PART I
Thinking About Psychopathology
Chapter 1

Conceptions of Psychopathology
A Social Constructionist Perspective

James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

Chapter contents

Conceptions of Psychopathology 4
Categories Versus Dimensions 9
Social Constructionism and Conceptions of Psychopathology 11
Summary and Conclusions 15
References15
4 | James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

A textbook about a topic should begin with a clear definition of the topic. Unfortunately, for a textbook on psychopathology, this
is a difficult if not impossible task. The definitions or conceptions of psychopathology and such related terms as mental disorder have been
the subject of heated debate throughout the history of psychology and psychiatry, and the debate is not over (e.g., Gorenstein, 1984;
Horwitz, 2002; Widiger, Chapter 6 in this volume). Despite its many variations, this debate has centered on a single overriding
question: Are psychopathology and related terms such as mental disorder and mental illness scientific terms that can be defined objectively and
by scientific criteria, or are they social constructions (Gergen, 1985) that are defined largely or entirely by societal and cultural values?
Addressing these perspectives in this opening chapter is important because the reader’s view of everything in the rest of this book
will be influenced by his or her view on this issue.
This chapter deals with conceptions of psychopathology. A conception of psychopathology is not a theory of psychopathology
(Wakefield, 1992a). A conception of psychopathology attempts to define the term – to delineate which human experiences are
considered psychopathological and which are not. A conception of psychopathology does not try to explain the psychological phe-
nomena that are considered pathological, but instead tells us which psychological phenomena are considered pathological and thus
need to be explained. A theory of psychopathology, however, is an attempt to explain those psychological phenomena and experiences
that have been identified by the conception as pathological. Theories and explanations for what is currently considered to be psy-
chopathological human experience can be found in a number of other chapters, including all of those in Part II.
Understanding various conceptions of psychopathology is important for a number of reasons. As explained by medical philos-
opher Lawrie Reznek (1987), “Concepts carry consequences – classifying things one way rather than another has important impli-
cations for the way we behave towards such things” (p. 1). In speaking of the importance of the conception of disease, Reznek wrote:

The classification of a condition as a disease carries many important consequences. We inform medical scientists that they should try to
discover a cure for the condition. We inform benefactors that they should support such research. We direct medical care towards the
condition, making it appropriate to treat the condition by medical means such as drug therapy, surgery, and so on. We inform our courts
that it is inappropriate to hold people responsible for the manifestations of the condition. We set up early warning detection services
aimed at detecting the condition in its early stages when it is still amenable to successful treatment. We serve notice to health insurance
companies and national health services that they are liable to pay for the treatment of such a condition. Classifying a condition as a disease
is no idle matter (p. 1).

If we substitute psychopathology or mental disorder for the word disease in this paragraph, its message still holds true. How we conceive of
psychopathology and related terms has wide-­ranging implications for individuals, medical and mental health professionals, gov-
ernment agencies and programs, legal proceedings, and society at large.

Conceptions of Psychopathology
A variety of conceptions of psychopathology have been offered over the years. Each has its merits and its deficiencies, but none
suffices as a truly scientific definition.

Psychopathology as Statistical Deviance

A commonly used and “common sense” conception of psychopathology is that pathological psychological phenomena are those
that are abnormal – statistically deviant or infrequent. Abnormal literally means “away from the norm.” The word “norm” refers to
what is typical or average. Thus, this conception views psychopathology as deviation from statistical psychological normality.
One of the merits of this conception is its common sense appeal. It makes sense to most people to use words such as psychopa-
thology and mental disorder to refer only to behaviors or experiences that are infrequent (e.g., paranoid delusions, hearing voices) and
not to those that are relatively common (e.g., shyness, a stressful day at work, grief following the death of a loved one).
A second merit to this conception is that it lends itself to accepted methods of measurement that give it at least a semblance of
scientific respectability. The first step in employing this conception scientifically is to determine what is statistically normal (typical,
average). The second step is to determine how far a particular psychological phenomenon or condition deviates from statistical
normality. This is often done by developing an instrument or measure that attempts to quantify the phenomenon and then assigns
numbers or scores to people’s experiences or manifestations of the phenomenon. Once the measure is developed, norms are typically
established so that an individual’s score can be compared to the mean or average score of some group of people. Scores that are
sufficiently far from average are considered to be indicative of “abnormal” or “pathological” psychological phenomena. This process
describes most tests of intelligence and cognitive ability and many commonly used measures of personality and emotion (e.g., the
Minnesota Multiphasic Personality Inventory).
Despite its common sense appeal and its scientific merits, this conception presents problems. Perhaps the most obvious issue
is that we generally consider only one “side” of the deviation to be problematic (see “Psychopathology as Maladaptive Behavior”
later in this chapter). In other words, Intellectual Disability is pathological, intellectual genius is not. Major Depressive Disorder is
 Conceptions of Psychopathology | 5

pathological, unconstrained optimism is not. Another concern is that, despite its reliance on scientific and well-­established psycho-
metric methods for developing measures of psychological phenomena and developing norms, this approach still leaves room for
subjectivity.
The first point at which subjectivity comes into play is in the conceptual definition of the construct for which a measure is developed.
A measure of any psychological construct, such as intelligence, must begin with a conceptual definition. We have to answer the
question “What is ‘intelligence’?” before we can attempt to measure or study its causes and consequences. Of course, different
people (including different psychologists) will come up with different answers to this question. How then can we scientifically and
objectively determine which definition or conception is “true” or “correct”? The answer is that we cannot. Although we have tried-­
and-­true methods for developing a reliable and valid (i.e., it consistently predicts what we want to predict) measure of a psycho-
logical construct once we have agreed on its conception or definition, we cannot use these same methods to determine which
conception or definition is true or correct. The bottom line is that there is not a “true” definition of intelligence and no objective,
scientific way of determining one. Intelligence is not a thing that exists inside of people and makes them behave in certain ways and
that awaits our discovery of its “true” nature. Instead, it is an abstract idea that is defined by people as they use the words “intelli-
gence” and “intelligent” to describe certain kinds of human behavior and the covert mental processes that supposedly precede or
are at least concurrent with the behavior.
We usually can observe and describe patterns in the way most people use the words intelligence and intelligent to describe the
behavior of themselves and others. The descriptions of the patterns then comprise the definitions of the words. If we examine the
patterns of the use of intelligence and intelligent, we find that at the most basic level, they describe a variety of specific behaviors and
abilities that society values and thus encourages; unintelligent behavior includes a variety of behaviors that society does not value
and thus discourages. The fact that the definition of intelligence is grounded in societal values explains the recent expansion of the
concept to include good interpersonal skills (e.g., social and emotional intelligence), self-­regulatory skills, artistic and musical
abilities, creativity, and other abilities not measured by traditional tests of intelligence. The meaning of intelligence has broadened
because society has come to place increasing value on these other attributes and abilities, and this change in societal values has been
the result of a dialogue or discourse among the people in society, both professionals and laypersons. One measure of intelligence
may prove more reliable than another and more useful than another measure in predicting what we want to predict (e.g., academic
achievement, income), but what we want to predict reflects what we value, and values are not derived scientifically.
Another point for the influence of subjectivity is in the determination of how deviant a psychological phenomenon must be from
the norm to be considered abnormal or pathological. We can use objective, scientific methods to construct a measure such as an
intelligence test and develop norms for the measure, but we are still left with the question of how far from normal an individual’s
score must be to be considered abnormal. This question cannot be answered by the science of psychometrics because the distance
from the average that a person’s score must be to be considered “abnormal” is a matter of debate, not a matter of fact. It is true that
we often answer this question by relying on statistical conventions such as using one or two standard deviations from the average
score as the line of division between normal and abnormal. Yet the decision to use that convention is itself subjective because a
convention (from the Latin convenire, meaning “to come together”), is an agreement or contract made by people, not a truth or fact
about the world. Why should one standard deviation from the norm designate “abnormality”? Why not two standard deviations?
Why not half a standard deviation? Why not use percentages? The lines between normal and abnormal can be drawn at many dif-
ferent points using many different strategies. Each line of demarcation may be more or less useful for certain purposes, such as
determining the criteria for eligibility for limited services and resources. Where the line is set also determines the prevalence of
“abnormality” or “mental disorder” among the general population (Kutchins & Kirk, 1997; Frances, 2013), so it has great practical
significance. But no such line is more or less “true” than the others, even when those others are based on statistical conventions.
We cannot use the procedures and methods of science to draw a definitive line of demarcation between normal and abnormal
psychological functioning, just as we cannot use them to draw definitive lines of demarcation between “short” and “tall” people or
“hot” and “cold” on a thermometer. No such lines exist in nature awaiting our discovery.

Psychopathology as Maladaptive (Dysfunctional) Behavior

Most of us think of psychopathology as behaviors and experiences that are not just statistically abnormal but also maladaptive (dys-
functional). Normal and abnormal are statistical terms, but adaptive and maladaptive refer not to statistical norms and deviations but to the
effectiveness or ineffectiveness of a person’s behavior. If a behavior “works” for the person – if the behavior helps the person deal
with challenges, cope with stress, and accomplish his or her goals – then we say the behavior is more or less effective and adaptive.
If the behavior does not “work” for the person in these ways, or if the behavior makes the problem or situation worse, we say it is
more or less ineffective and maladaptive. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-­5) incorporates this notion
in its definition of mental disorder by stating that mental disorders “are usually associated with significant distress or disability in
social, occupational, or other important activities” (American Psychiatric Association [APA], 2013, p. 20).
Like the statistical deviance conception, this conception has common sense appeal and is consistent with the way most
laypersons use words such as pathology, disorder, and illness. As we noted earlier, most people would find it odd to use these words
to describe statistically infrequent high levels of intelligence, happiness, or psychological well-­being. To say that someone is
6 | James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

“pathologically intelligent” or “pathologically well-­adjusted” seems contradictory because it flies in the face of the common
sense use of these words.
The major problem with the conception of psychopathology as maladaptive behavior is its inherent subjectivity. Like the dis-
tinction between normal and abnormal, the distinction between adaptive and maladaptive is fuzzy and arbitrary. We have no objec-
tive, scientific way of making a clear distinction. Very few human behaviors are in and of themselves either adaptive or maladaptive;
instead, their adaptiveness and maladaptiveness depend on the situations in which they are enacted and on the judgment and values
of the actor and the observers. Even behaviors that are statistically rare and therefore abnormal will be more or less adaptive under
different conditions and more or less adaptive in the opinion of different observers and relative to different cultural norms. The
extent to which a behavior or behavior pattern is viewed as more or less adaptive or maladaptive depends on a number of factors,
such as the goals the person is trying to accomplish and the social norms and expectations in a given situation. What works in one
situation might not work in another. What appears adaptive to one person might not appear so to another. What is usually adaptive
in one culture might not be so in another (see López & Guarnaccia, Chapter 4 in this volume). Even so-­called “normal” personality
involves a good deal of occasionally maladaptive behavior, which you can find evidence for in your own life and the lives of friends
and relatives. In addition, people given official “personality disorder” diagnoses by clinical psychologists and psychiatrists often can
manage their lives effectively and do not always behave in maladaptive ways.
Another problem with the “psychopathological = maladaptive” conception is that judgments of adaptiveness and maladaptive-
ness are logically unrelated to measures of statistical deviation. Of course, often we do find a strong relationship between the statis-
tical abnormality of a behavior and its maladaptiveness. Many of the problems described in the DSM-­5 and in this textbook are both
maladaptive and statistically rare. There are, however, major exceptions to this relationship.
First, not all psychological phenomena that deviate from the norm or the average are maladaptive. In fact, sometimes deviation
from the norm is adaptive and healthy. For example, IQ scores of 130 and 70 are equally deviant from norm, but abnormally high
intelligence is much more adaptive than abnormally low intelligence. Likewise, people who consistently score abnormally low on
measures of anxiety and depression are probably happier and better adjusted than people who consistently score equally abnormally
high on such measures.
Second, not all maladaptive psychological phenomena are statistically infrequent and vice versa. For example, shyness is almost
always maladaptive to some extent because it often interferes with a person’s ability to accomplish what he or she wants to accom-
plish in life and relationships, but shyness is very common and therefore is statistically frequent. The same is true of many of the
problems with sexual functioning that are included in the DSM as “mental disorders” – they are almost always maladaptive to some
extent because they create distress and problems in relationships, but they are relatively common (see Gosselin & Bombardier,
Chapter 14 in this volume).

Psychopathology as Distress and Disability

Some conceptions of psychopathology invoke the notions of subjective distress and disability. Subjective distress refers to unpleasant and
unwanted feelings, such as anxiety, sadness, and anger. Disability refers to a restriction in ability (Ossorio, 1985). People who seek
mental health treatment usually are not getting what they want out of life, and many feel that they are unable to do what they need
to do to accomplish their valued goals. They may feel inhibited or restricted by their situation, their fears or emotional turmoil, or
by physical or other limitations. Individuals may lack the necessary self-­efficacy beliefs (beliefs about personal abilities), physiolog-
ical or biological components, self-­regulatory skills, and/­or situational opportunities to make positive changes (Bergner, 1997).
As noted previously, the DSM incorporates the notions of distress and disability into its definition of mental disorder. In fact,
subjective distress and disability are simply two different but related ways of thinking about adaptiveness and maladaptiveness rather
than alternative conceptions of psychopathology. Although the notions of subjective distress and disability may help refine our
notion of maladaptiveness, they do nothing to resolve the subjectivity problem. Different people will define personal distress and
personal disability in vastly different ways, as will different mental health professionals and different cultures. Likewise, people differ
in their thresholds for how much distress or disability they can tolerate before seeking professional help. Thus, we are still left with
the problem of how to determine normal and abnormal levels of distress and disability. As noted previously, the question “How
much is too much?” cannot be answered using the objective methods of science.
Another problem is that some conditions or patterns of behavior (e.g., pedophilic disorder, antisocial personality disorder) that
are considered psychopathological (at least officially, according to the DSM) are not characterized by subjective distress, other than
the temporary distress that might result from social condemnation or conflicts with the law.

Psychopathology as Social Deviance

Psychopathology has also been conceived as behavior that deviates from social or cultural norms. This conception is simply a variation
of the conception of psychopathology as statistical abnormality, only in this case judgments about deviations from normality are
made informally by people using social and cultural rules and conventions rather than formally by psychological tests or measures.
 Conceptions of Psychopathology | 7

This conception also is consistent to some extent with common sense and common parlance. We tend to view psychopatho-
logical or mentally disordered people as thinking, feeling, and doing things that most other people do not do (or do not want to
do) and that are inconsistent with socially accepted and culturally sanctioned ways of thinking, feeling, and behaving. Several exam-
ples can be found in DSM-­5’s category of paraphilic disorders.
The problem with this conception, as with the others, is its subjectivity. Norms for socially normal or acceptable behavior
are not derived scientifically but instead are based on the values, beliefs, and historical practices of the culture, which determine
who is accepted or rejected by a society or culture. Cultural values develop not through the implementation of scientific meth-
ods, but through numerous informal conversations and negotiations among the people and institutions of that culture. Social
norms differ from one culture to another, and therefore what is psychologically abnormal in one culture may not be so in
another (see López & Guarnaccia, Chapter 4 in this volume). Also, norms of a given culture change over time; therefore, con-
ceptions of psychopathology will change over time, often very dramatically, as evidenced by American society’s changes over
the past several decades in attitudes toward sex, race, and gender. For example, psychiatrists in the 1800s classified masturbation,
especially in children and women, as a disease, and it was treated in some cases by clitoridectomy (removal of the clitoris),
which Western society today would consider barbaric (Reznek, 1987). Homosexuality was an official mental disorder in the
DSM until 1973.
In addition, the conception of psychopathology as social norm violations is at times in conflict with the conception of psy-
chopathology as maladaptive behavior. Sometimes violating social norms is healthy and adaptive for the individual and beneficial
to society. In the 19th century, women and African-­Americans in the US who sought the right to vote were trying to change
well-­established social norms. Their actions were uncommon and therefore “abnormal,” but these people were far from psycho-
logically unhealthy, at least not by today’s standards. Earlier in the 19th century, slaves who desired to escape from their owners
were said to have “drapetomania.” Although still practiced in some parts of the world, slavery is almost universally viewed as
socially deviant and pathological, and the desire to escape enslavement is considered to be as normal and healthy as the desire to
live and breathe.

Psychopathology as “Dyscontrol” or “Dysregulation”

Some have argued that we should only consider as psychopathologies or mental disorders those maladaptive patterns of behaving,
thinking, and feeling that are not within the person’s ability to effectively control or self-­regulate (e.g., Kirmayer & Young, 1999;
Widiger & Sankis, 2000). The basic notion here is that if a person voluntarily behaves in maladaptive or self-­destructive ways, then
that person’s behavior should not be viewed as in indication of or result of a mental disorder. Indeed, as does the notion of a
physical or medical disorder, the term mental disorder seems to incorporate the notion that what is happening to the person is
not within the person’s control. The basic problem with this conception is that it draws an artificial line between “within control”
(voluntary) and “out of control” (involuntary) that simply cannot be drawn. There are some behaviors that a person might engage
in that most of us would agree are completely voluntary, deliberate, and intentional and some other behaviors that a person might
engage in that most of us would agree are completely involuntary, non-­deliberate, and unintentional. Such behaviors, however, are
probably few and far between. The causes of human behavior are complex, to say the least, and environmental events can have such
a powerful influence on any behavior that saying that anything that people do is completely or even mostly voluntary and inten-
tional may be a stretch. In fact, considerable research suggests that most behaviors most of the time are automatic and therefore
involuntary (Weinberger, Siefert, & Haggerty, 2010). Determining the degree to which a behavior is voluntary and within a per-
son’s control or involuntary and beyond a person’s control is difficult, if not impossible. We also are left, once again, with the
question of who gets to make this determination. The actor? The observer? The patient? The mental health professional? Although
using theories of self-­regulation can be highly useful in understanding the etiology and maintenance of those problems that get
labeled as disorders (Sheppes, Suri, & Gross, 2015; Strauman, 2017), those theories cannot tell us which problems should be
viewed as “disorders.”

Psychopathology as Harmful Dysfunction

Wakefield’s (1992a, 2010, 2013) harmful dysfunction (HD) conception, presumably grounded in evolutionary psychology (e.g., Cos-
mides, Tooby, & Barkow, 1992), acknowledges that the conception of mental disorder is influenced strongly by social and cultural
values. It also proposes, however, a supposedly scientific, factual, and objective core that is not dependent on social and cultural
values (Wakefield, 2010). In Wakefield’s (1992a) words:

a [mental] disorder is a harmful dysfunction wherein harmful is a value term based on social norms, and dysfunction is a scientific term
referring to the failure of a mental mechanism to perform a natural function for which it was designed by evolution ... a disorder exists
when the failure of a person’s internal mechanisms to perform their function as designed by nature impinges harmfully on the person’s
well-­being as defined by social values and meanings (p. 373).
8 | James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

One of the merits of this conception is that it acknowledges that the conception of mental disorders must include a reference to
social norms; however, this conception also tries to anchor the concept of mental disorder in a scientific theory – the theory of
evolution.
Wakefield (2006) has reiterated this definition in writing that a mental disorder “satisfies two requirements: (1) it is negative
or harmful according to cultural values; and (2) it is caused by a dysfunction (i.e., by a failure of some psychological mechanism
to perform a natural function for which it was evolutionarily designed)” (p. 157). He and his colleagues also write, “Problematic
mismatches between designed human nature and current social desirability are not disorders ... [such as] adulterous longings, taste
for fat and sugar, and male aggressiveness” (Wakefield, Horwitz, & Schmitz, 2006, p. 317).
One problem with this definition is that “evolution is not a directed process, and so there is no design for a particular
characteristic” (Blashfield, Keeley, Flanagan, & Miles, 2014, p. 36). Another problem is that “mental functions may not be
direct adaptions to the environment [but] exaptations, or characteristics that evolved for some other purpose but currently
serve a particular function” (Blashfield et al., 2014, p. 36). In addition, the claim that identifying a failure of a “designed
function” is a scientific judgment and not a value judgment is questionable. Wakefield’s claim that dysfunction can be defined
in “purely factual scientific” (Wakefield, 1992a, p. 383, 2010) terms rests on the assumption that the “designed functions”
of human “mental mechanisms” have an objective and observable reality and, thus, that failure of the mechanism to execute
its designed function can be objectively assessed. A basic problem with this notion is that although the physical inner workings
of the body and brain can be observed and measured, “mental mechanisms” have no objective reality and thus cannot be
observed directly – no more so than the “unconscious” forces (e.g., id, ego, superego) that provide the foundation for Freud-
ian psychoanalytic theory.
Evolutionary theory provides a basis for explaining human behavior in terms of its contribution to reproductive fitness.
A behavior is considered more functional if it increases the survival of those who share your genes in the next generation and
the next and less functional if it does not. Evolutionary psychology cannot, however, provide a catalogue of “mental mecha-
nisms” and their natural functions. Wakefield states that “discovering what in fact is natural or dysfunctional may be extraordi-
narily difficult” (1992b, p. 236). The problem with this statement is that, when applied to human behavior, “natural” and
“dysfunctional” are not properties that can be “discovered”; they are value judgments. The judgment that a behavior represents
a dysfunction relies on the observation that the behavior is excessive and/­or inappropriate under certain conditions. Arguing that
these behaviors represent failures of evolutionarily designed “mental mechanisms” (itself an untestable hypothesis because of
the occult nature of “mental mechanisms”) does not absolve us of the need to make value judgments about what is excessive,
inappropriate, or harmful and under what circumstances (Leising, Rogers, & Ostner, 2009). These are value judgments based on
social norms, not scientific “facts,” an issue that we will explore in greater detail later in this chapter (see also Widiger, Chapter 6
this volume). Wakefield (2013) is correct that “the fuzziness of ‘harm’ and ‘dysfunction’ [does not] undermine the possibility
of valuably picking out clear cases on both sides of the distinction” (p. 828). Nonetheless the enumerable unclear cases of both
harmfulness and dysfunctionality leave a lot of room for human judgment, which will inevitably be influenced by social and
professional norms.
Another problem with the HD conception is that it is a moving target. For example, Wakefield modified his original HD con-
ception by saying that it is concerned not with what a mental disorder is but only with what most scientists think it is. For example,
he states that “My comments were intended to argue, not that PTSD [posttraumatic stress disorder] is a disorder, but that the HD
analysis is capable of explaining why the symptom picture in PTSD is commonly judged to be a disorder” (1999, p. 390, emphasis
added). Wakefield’s original goal was to “define mental disorders prescriptively” (Sadler, 1999, p. 433, emphasis added) and to “help
us decide whether someone is mentally disordered or not” (Sadler, 1999, p. 434). His more recent view, however, “avoids making
any prescriptive claims, instead focusing on explaining the conventional clinical use of the disorder concept” (Sadler, 1999, p. 433).
Wakefield “has abandoned his original task to be prescriptive and has now settled for being descriptive only, for example, telling us
why a disorder is judged to be one” (Sadler, 1999, p. 434, emphasis added).
Describing how people have agreed to define a concept is not the same as defining the concept in scientific terms, even if those
people are scientists. Thus, Wakefield’s HD conception simply offers a criterion that people (clinicians, scientists, and laypersons)
might use to judge whether or not something is a “mental disorder.” But consensus of opinion, even among scientists, is not sci-
entific evidence. Therefore, no matter how accurately this criterion might describe how some or most people define “mental disor-
der,” it is no more or no less scientific than other conceptions that also are based on how some people agree to define “mental
disorder.” It is no more scientific than the conceptions involving statistical infrequency, maladaptiveness, or social norm violations
(see also Widiger, Chapter 6).

The DSM and ICD Definitions of Mental Disorder

Any discussion of conceptions of psychopathology has to include a discussion of the most influential conception of all – that of the
Diagnostic and Statistical Manual of Mental Disorders (the DSM). First published in 1952 and revised and expanded five times since, the DSM
provides the organizational structure for virtually every textbook (including this one) on abnormal psychology and psychopathol-
ogy, as well as almost every professional book on the assessment and treatment of psychological problems. (See Widiger, Chapter 6,
for a more detailed history of psychiatric classification, the DSM, and the ICD.)
 Conceptions of Psychopathology | 9

Just as a textbook on psychopathology should begin by defining its key term, so should a taxonomy of mental disorders. The
difficulties inherent in attempting to define psychopathology and related terms are clearly illustrated by the definition of “mental
disorder” found in the latest edition of the DSM, the DSM-­5 (APA, 2013):

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or
behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental
disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable
or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant
behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders
unless the deviance or conflict results from a dysfunction in the individual, as described above (p. 20).

All of the conceptions of psychopathology described previously can be found to some extent in this definition – statistical deviation
(i.e., not “expectable”); maladaptiveness, including distress and disability; social norms violations; and some elements of the harm-
ful dysfunction conception (“a dysfunction in the individual”) although without the flavor of evolutionary theory. For this reason,
it is a comprehensive, inclusive, and sophisticated conception and probably as good, if not better, than any proposed so far.
Nonetheless, it falls prey to the same problems with subjectivity as other conceptions. For example, what is the meaning of
“clinically significant” and how should “clinical significance” be measured? Does clinical significance refer to statistical infrequency,
maladaptiveness, or both? How much distress must a person experience or how much disability must a person exhibit before he/­
she is said to have a mental disorder? Who gets to judge the person’s degree of distress or disability? How do we determine whether
or not a particular response to an event is “expectable” or “culturally approved”? Who gets to determine this? How does one deter-
mine whether or not socially deviant behavior or conflicts “are primarily between the individual and society”? What exactly does
this mean? What does it mean for a dysfunction to exist or occur “in the individual”? Certainly a biological dysfunction might be
said to be literally “in the individual,” but does it make sense to say the same of psychological and behavioral dysfunctions? Is it
possible to say that a psychological or behavioral dysfunction can occur “in the individual” apart from the social, cultural, and
interpersonal milieu in which the person is acting and being judged? Clearly, the DSM’s conception of mental disorder raises as many
questions as do the conceptions it was meant to supplant.
The World Health Organization’s (WHO) 11th edition of the International Classification of Diseases and Related Health Problems (ICD-­11;
WHO, 2018) includes a Classification of Mental and Behavioural Disorders that is highly similar in format and content to the DSM-­5. In fact,
the two systems have evolved in tandem over the past several decades. In the ICD-­11,

Mental, behavioural and neurodevelopmental disorders are syndromes characterized by clinically significant disturbance in an individu-
al’s cognition, emotional regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes
that underlie mental and behavioural functioning. These disturbances are usually associated with distress or impairment in personal,
family, social, educational, occupational, or other important areas of functioning (WHO, 2018).

Although less wordy than the DSM definition, the ICD definition contains the same basic ideas and the same interpretive problems.
What is missing is the statement that a mental disorder exists “in an individual” although the notion of an “underlying dysfunction”
can be interpreted as meaning the same thing.

Categories Versus Dimensions

The difficulty inherent in the DSM conception of psychopathology and other attempts to distinguish between normal and abnor-
mal or adaptive and maladaptive is that they are categorical models that attempt to describe guidelines for distinguishing between
individuals who are normal or abnormal and for determining which specific abnormality or “disorder” a person has to the
exclusion of other disorders. In other words, people either “have” a given disorder or they do not. An alternative model, over-
whelmingly supported by research, is the dimensional model. In the dimensional model, normality and abnormality, as well as
effective and ineffective psychological functioning, lie along a continuum; so-­called psychological disorders are simply extreme
variants of normal psychological phenomena and ordinary problems in living. Divisions along these continua between normal
and abnormal or adaptive and maladaptive are arbitrary and artificial. The dimensional model is concerned not with classifying
people or disorders but with identifying and measuring individual differences in psychological phenomena, such as emotion,
mood, intelligence, and personal styles. Great differences among individuals on the dimensions of interest are expected, such as
the differences we find on standardized tests of intelligence. As with intelligence, divisions between normality and abnormality
may be demarcated for convenience or efficiency but are not to be viewed as indicative of true discontinuity among “types” of
phenomena or “types” of people. Also, statistical deviation is not viewed as necessarily pathological, although extreme variants
on either end of a dimension (e.g., introversion-­extraversion, neuroticism, intelligence) may be maladaptive if they lead to
inflexibility in functioning.
10 | James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

This notion is not new. As early as 1860, Henry Maudsley commented that “there is no boundary line between sanity and
insanity; and the slightly exaggerated feeling which renders a man ‘peculiar’ in the world differs only in degree from that which
places hundreds in asylums” (Maudsley, 1860, p. 14, as cited in Millon & Simonsen, 2010, p. 33).
Empirical evidence for the validity of a dimensional approach to psychological adjustment is strongest in the area of personality
and personality disorders (Boudreaux, 2016; Krueger & Markon, 2014; Crego & Widiger, Chapter 13 in this volume; Widiger &
Mullins-­Sweatt, 2009). Factor analytic studies of personality problems among the general population and clinical populations with
“personality disorders” demonstrate striking similarity between the two groups. In addition, these factor structures are not consist-
ent with the DSM’s system of classifying disorders of personality into categories and support a dimensional view rather than a cat-
egorical view. For example, most evidence strongly suggests that psychopathic personality (or antisocial personality) and other
externalizing disorders of adulthood display a dimensional structure, not a categorical structure (Edens, Marcus, Lilienfeld, & Poy-
thress, 2006; Krueger, Markon, Patrick, & Iacono, 2005; Larsson, Andershed, & Lichtenstein, 2006). The same is true of narcissism
and narcissistic personality disorder (Brown, Budzek, & Tamborski, 2009) and borderline personality disorder (Wright, Hop-
wood, & Zanarini, 2015). In addition, the recent emotional cascade model of borderline personality disorder, which highlights the inter-
action of emotional and behavioral dysregulation, although not presented explicitly as a dimensional model, is consistent with a
dimension model (Selby & Joiner, 2009).
Research on other psychological phenomena supports the dimensional view. Studies of the varieties of normal emotional
experiences (e.g., Carver, 2001; Oatley & Jenkins, 1992; Oatley, Keltner, & Jenkins, 2006) indicate that “clinical” emotional disorders
are not discrete classes of emotional experience that are discontinuous from everyday emotional upsets and problems. Research on
adult attachment patterns in relationships strongly suggests that dimensions are more accurate descriptions of such patterns than
are categories (Fraley, Hudson, Heffernan, & Segal, 2015). Research on self-­defeating behaviors has shown that they are extremely
common and are not by themselves signs of abnormality or symptoms of “disorders” (Baumeister & Scher, 1988). Research on
children’s reading problems indicates that “dyslexia” is not an all-­or-­none condition that children either have or do not have, but
occurs in degrees without a natural break between “dyslexic” and “nondyslexic” children (Peterson, Pennington, Olson, & Wad-
sworth, 2014). Research indicates that attention deficit/­hyperactivity (Barkley, 2005), post-­traumatic stress disorder (Rosen & Lil-
ienfeld, 2008; Ruscio, Ruscio, & Keane, 2002), anxiety disorders (Steinman et al., Chapter 9 in this volume), depression (Alloy
et al., Chapter 11 in this volume), somatoform disorders (Zvolensky et al., Chapter 15 in this volume), sexual dysfunctions and
disorders (Gosselin & Bombardier, Chapter 23 in this volume), impulsivity (Griffin, Lynam, & Samuel, 2017), pathological eating
behavior (Luo, Donnellan, Burt, & Klump, 2016), and child conduct disorders (Salekin, 2015), psychosis (Kotov, Foti, Li, Bromet,
Hajcak, & Ruggero, 2016) demonstrate this same dimensionality. Research on depression and schizophrenia indicates that these
“disorders” are best viewed as loosely related clusters of dimensions of individual differences, not as disease-­like syndromes (Clar-
idge, 1995; Costello, 1993a, 1993b; Eisenberg et al., 2009; Flett, Vredenburg, & Krames, 1997). For example, a study on depressive
symptoms among children and adolescents found a dimensional structure for all of the DSM-­IV symptoms of major depression
(Hankin, Fraley, Lahey, & Waldman, 2005).
The inventor of the term “schizophrenia,” Eugene Bleuler, viewed so-­called pathological conditions as continuous with so-­
called “normal” conditions and noted the occurrence of “schizophrenic” symptoms among normal individuals (Gilman, 1988). In
fact, Bleuler referred to the major symptom of “schizophrenia” (thought disorder) as simply “ungewonlich,” which in German means
“unusual,” not “bizarre,” as it was translated in the first English version of Bleuler’s classic monograph (Gilman, 1988). Essentially,
the creation of “schizophrenia” was “an artifact of the ideologies implicit in nineteenth century European and American medical
nosologies” (Gilman, 1988, p. 204). Indeed, research indicates that the hallucinations and delusions exhibited by people diagnosed
with a schizophrenic disorder are continuous with experiences and behaviors among the general population (Johns & van Os, 2001;
Myin-­Germeys, Krabbendam, & van Os, 2003; see also Azis et al., Chapter 12 in this volume). Recent research also suggests that
dimensional measures of psychosis are better predictors of dysfunctional behavior, social adaptation, and occupational functioning
than are categorical diagnoses (Rosenman, Korten, Medway, & Evans, 2003, as cited in Simonsen, 2010). Research on neuroticism
strongly suggests that it provides the foundation for the development of anxiety and mood disorders and is best conceived as a
dimension (Barlow, Sauer-­Savala, Carl, Bullis, & Ellard, 2013). Research on general psychopathology factors (with internalizing and
externalizing subfactors) (Martel et al., 2017) and research on hierarchical conceptions of psychopathology (Kotov et al., 2017;
Lahey, Krueger, Rathouz, Waldman, & Zald, 2017) provide strong additional support for the dimensional view (Martel et al., 2017).
Research indicates that dimensional measures of psychopathology are more reliable and valid than categorical measures (Markon,
Chmielewski, & Miller, 2011). Research also strongly supports the validity and utility of structural and hierarchical conceptions of psy-
chopathology that are based on the fundamental assumption that dimensions provide a more accurate way to conceptualize psy-
chopathology than do categories (Waszczuk, Kotov, Roggero, Gamez, & Watson, 2017; Lahey et al., 2017). The National Institute of
Mental Health’s Research Domain Criteria (RDoC; REF), concerned primarily with the etiology of mental disorders, also conceive
psychopathologies and their neurobiological influences as existing along continua (Cuthbert & Insel, 2013; Lilienfeld & Treadway,
2016). Finally, neuroscience research provides growing evidence that the activity of brain circuits is continuously distributed (Lil-
ienfeld & Treadway, 2016). (See also Chapter 2 in this volume.)
Understanding the research supporting the dimensional approach is important because the vast majority of this research
undermines the illness ideology’s assumption that we can make clear, scientifically-­based distinctions between the psychologically
well or healthy and the psychological ill or disordered. Inherent in the dimensional view is the assumption that these distinctions
 Conceptions of Psychopathology | 11

are not natural demarcations that can be “discovered”; instead, they are created or constructed “by accretion and practical necessity,
not because they [meet] some independent set of abstract and operationalized definitional criteria” (Frances & Widiger, 2012,
p. 111).
Dimensional approaches, of course, are not without their limitations, including the greater difficulties they present in commu-
nication among professionals compared to categories, and the greater complexity of dimensional strategies for clinical use (Simon-
sen, 2010). In addition, researchers and clinicians have not reached a consensus on which dimensions to use (Simonsen, 2010).
Finally, dimensional approaches do not solve the “subjectivity problem” noted previously because the decision regarding how far
from the mean a person’s thoughts, feelings, or behavior must be to be considered “abnormal” remains a subjective one. Nonethe-
less, dimensional approaches have been gradually gaining great acceptance and will inevitably be integrated more and more into
the traditional categorical schemes. [An extensive discussion of the pros and cons of categorical approaches are beyond the scope
of this chapter. Detailed and informative discussions can be found in other sources (e.g., Grove & Vrieze, 2010; Simonsen, 2010;
Clark et al., 2017)].
Dimensional conceptions of psychopathology did make some small inroads in the DSM-­5, particularly in the new conception
of “autism spectrum disorder” (that encompasses autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and per-
vasive developmental disorder not otherwise specified) and an appendix that describes an “alternative DSM-­5 model for personality
disorders” based largely on dimensional research on personality. It also incorporated severity as a dimension throughout the classi-
fication system (Clark et al., 2017). ICD-­11 also includes a severity dimension for personality disorders, schizophrenia, and other
psychotic disorders (Clark et al., 2017. Yet both documents remain essentially compendiums of categories.

Social Constructionism and Conceptions of Psychopathology

If we cannot come up with an objective and scientific conception of psychopathology and mental disorder, then what way is left to
us to understand these terms? How then are we to conceive of psychopathology? The solution to this problem is not to develop yet
another definition of psychopathology. The solution, instead, is to accept the fact that the problem has no solution – at least not a
solution at which we can arrive by scientific means. We have to give up the goal of developing a scientific definition and accept the
idea that psychopathology and related terms are not the kind of terms that can be defined through the processes that we usually
think of as scientific. We have to stop struggling to develop a scientific conception of psychopathology and attempt instead to try to
understand the struggle itself – why it occurs and what it means. We need to better understand how people go about trying to
conceive of and define psychopathology, what they are trying to accomplish when they do this, and how and why these conceptions
are the topic of continual debate and undergo continual revision.
We start by accepting the idea that psychopathology and related concepts are abstract ideas that are not scientifically constructed
but socially constructed. Social constructionism involves “elucidating the process by which people come to describe, explain, or otherwise
account for the world in which they live” (Gergen, 1985, pp. 3–4). Social constructionism is concerned with “examining ways in
which people understand the world, the social and political processes that influence how people define words and explain events,
and the implications of these definitions and explanations – who benefits and who loses because of how we describe and understand
the world” (Muehlenhard & Kimes, 1999, p. 234). From this point of view, words and concepts such as psychopathology and mental
disorder “are products of particular historical and cultural understandings rather than ... universal and immutable categories of human
experience” (Bohan, 1996, p. xvi).
Universal or “true” definitions of concepts do not exist because these definitions depend primarily on who gets to do the
defining. The people who define them are usually people with power, and so these definitions reflect and promote their interests
and values (Muehlenhard & Kimes, 1999). Therefore, “When less powerful people attempt to challenge existing power relationships
and to promote social change, an initial battleground is often the words used to discuss these problems” (Muehlenhard & Kimes,
1999, p. 234). Because the interests of people and institutions are based on their values, debates over the definition of concepts
often become clashes between deeply and implicitly held beliefs about the way the world works or should work and about the
difference between right and wrong. Such clashes are evident in the debates over the definitions of domestic violence (Muehlenhard &
Kimes, 1999), child sexual abuse (Holmes & Slapp, 1998; Rind, Tromovich, & Bauserman, 1998), and other such terms.
The social constructionist perspective can be contrasted with the essentialist perspective. Essentialism assumes that there are nat-
ural categories and that all members of a given category share important characteristics (Rosenblum & Travis, 1996). For example,
the essentialist perspective views our categories of race, sexual orientation, and social class as objective categories that are independ-
ent of social or cultural processes (Ho, Roberts, & Gelman, 2015). It views these categories as representing “empirically verifiable
similarities among and differences between people” (Rosenblum & Travis, 1996, p. 2) and as “depict[ing] the inherent structure of
the world in itself” (Zachar & Kendler, 2010, p. 128). In the social constructionist view, however, “reality cannot be separated from
the way that a culture makes sense of it” (Rosenblum & Travis, 1996, p. 3). In social constructionism, such categories represent not
what people are but rather the ways that people think about and attempt to make sense of differences among people. Social processes
also determine what differences among people are more important than other differences (Rosenblum & Travis, 1996).
Thus, from the essentialist perspective, psychopathologies and mental disorders are natural entities whose true nature can be
discovered and described. From the social constructionist perspective, however, they are abstract ideas that are defined by people
12 | James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

and thus reflect their values – cultural, professional, and personal. The meanings of these and other concepts are not revealed by the
methods of science but are negotiated among the people and institutions of society who have an interest in their definitions. In fact,
we typically refer to psychological terms as constructs for this very reason – that their meanings are constructed and negotiated rather
that discovered or revealed. The ways in which conceptions of so basic a psychological construct as the “self” (Baumeister, 1987)
and “self-­esteem” (Hewitt, 2002) have changed over time and the different ways they are conceived by different cultures (e.g.,
Cushman, 1995; Hewitt, 2002; Cross & Markus, 1999) provide an example of this process at work. Other examples include the
growing evidence that our conceptual categories of emotions do not reflect “distinct, dedicated neural essences [but] require a
human perceiver for existence” (Barrett, 2017, p. 13) and growing evidence for the existence of an overarching general psychopa-
thology factor (with subordinate internalizing and externalizing factors) (Martel et al., 2017). Thus “all categories of disorder, even
physical disorder categories convincingly explored scientifically, are the product of human beings constructing meaningful systems
for understanding their world” (Raskin & Lewandowski, 2000, p. 21). In addition, because “what it means to be a person is deter-
mined by cultural ways of talking about and conceptualizing personhood ... identity and disorder are socially constructed, and there
are as many disorder constructions as there are cultures” (Neimeyer & Raskin, 2000, pp. 6–7; see also López & Guarnaccia, Chapter
4 in this volume). Finally, “if people cannot reach the objective truth about what disorder really is, then viable constructions of
disorder must compete with one another on the basis of their use and meaningfulness in particular clinical situations” (Raskin &
Lewandowski, 2000, p. 26). In other words, the debate about defining mental disorders continues because people continue to
manufacture and modify the definitions they find most useful.
From the social constructionist perspective, sociocultural, political, professional, and economic forces influence professional
and lay conceptions of psychopathology. Our conceptions of psychological normality and abnormality are not facts about people
but abstract ideas that are constructed through the implicit and explicit collaborations of theorists, researchers, professionals, their
clients, and the culture in which all are embedded and that represent a shared view of the world and human nature. For this reason,
“mental disorders” and the numerous diagnostic categories of the DSM were not “discovered” in the same manner that an archeol-
ogist discovers a buried artifact or a medical researcher discovers a virus. Instead, they were invented (see Raskin & Lewandowski,
2000). By saying that mental disorders are invented, however, we do not mean that they are “myths” (Szasz, 1974) or that the
distress of people who are labeled as mentally disordered is not real. Instead, we mean that these disorders do not “exist” and “have
properties” in the same manner that artifacts and viruses do, even if they do have concomitant, complex biological processes. There-
fore, a conception of psychopathology “does not simply describe and classify characteristics of groups of individuals, but ... actively
constructs a version of both normal and abnormal . . . which is then applied to individuals who end up being classified as normal
or abnormal” (Parker, Georgaca, Harper, McLaughlin, & Stowell-­Smith, 1995, p. 93).
Conceptions of psychopathology and the various categories of psychopathology are not mappings of psychological facts about
people. Instead, they are social artifacts that serve the same sociocultural goals as do our conceptions of race, gender, social class,
and sexual orientation – those of maintaining and expanding the power of certain individuals and institutions and maintaining
social order, as defined by those in power (Beall, 1993; Parker et al., 1995; Rosenblum & Travis, 1996). As are these other social
constructions, our concepts of psychological normality and abnormality are tied ultimately to social values – in particular, the values
of society’s most powerful individuals, groups, and institutions – and the contextual rules for behavior derived from these values
(Becker, 1963; Kirmayer, 2005; Parker et al., 1995; Rosenblum & Travis, 1996). As McNamee and Gergen (1992) state: “The mental
health profession is not politically, morally, or valuationally neutral. Their practices typically operate to sustain certain values, polit-
ical arrangements, and hierarchies of privilege” (p. 2). Thus, the debate over the definition of psychopathology, the struggle over
who gets to define it, and the continual revisions of the DSM are not aspects of a search for “truth.” Rather, they are debates over the
definition of socially constructed abstractions and struggles for the personal, political, and economic power that derives from the
authority to define these abstractions and thus to determine what and whom society views as normal and abnormal.
Millon (2010) has even suggested that the development of the DSM-­IV was hampered by the reluctance of work groups to give
up their rights over certain disorders once they were assigned them, even when it became clear that some disorders fit better with
other work groups. In addition, over half of the members of the DSM-­IV work groups (including every member of the work groups
responsible for mood disorders and schizophrenia/­psychotic disorders) had received financial support from pharmaceutical com-
panies (Cosgrove, Krimsky, Vijayaraghavan, & Schneider, 2006).
As David Patrick (2005) concluded about a definition of mental disorder offered by the British government in a recent mental
health bill, “The concept of mental disorder is of dubious scientific value but it has substantial political utility for several groups
who are sane by mutual consent” (p. 435).
These debates and struggles are described in detail by Allan Horwitz (2002) in Creating Mental Illness. According to Horwitz,

The emergence and persistence of an overly expansive disease model of mental illness was not accidental or arbitrary. The widespread
creation of distinct mental diseases developed in specific historical circumstances and because of the interests of specific social groups ...
By the time the DSM-­III was developed in 1980, thinking of mental illnesses as discrete disease entities ... offered mental health profession-
als many social, economic, and political advantages. In addition, applying disease frameworks to a wide variety of behaviors and to a large
number of people benefited a number of specific social groups including not only clinicians but also research scientists, advocacy groups,
and pharmaceutical companies, among others. The disease entities of diagnostic psychiatry arose because they were useful for the social
practices of various groups, not because they provided a more accurate way of viewing mental disorders (p. 16).
 Conceptions of Psychopathology | 13

Psychiatrist Mitchell Wilson (1993) has offered a similar position. He has argued that the dimensional/­continuity view of psycho-
logical wellness and illness posed a basic problem for psychiatry because it “did not demarcate clearly the well from the sick”
(p. 402) and that “if conceived of psychosocially, psychiatric illness is not the province of medicine, because psychiatric problems
are not truly medical but social, political, and legal” (p. 402). The purpose of DSM-­III, according to Wilson, was to allow psychiatry
a means of marking out its professional territory. Kirk and Kutchins (1992) reached the same conclusion following their thorough
review of the papers, letters, and memos of the various DSM working groups.
The social construction of psychopathology works something like this. Someone observes a pattern of behaving, thinking,
feeling, or desiring that deviates from some social norm or ideal or identifies a human weakness or imperfection that, as expected,
is displayed with greater frequency or severity by some people than others. A group with influence and power decides that control,
prevention, or “treatment” of this problem is desirable or profitable. The pattern is then given a scientific-­sounding name, preferably
of Greek or Latin origin. The new scientific name is capitalized. Eventually, the new term may be reduced to an acronym, such as
OCD (Obsessive-­Compulsive Disorder), ADHD (Attention-­Deficit/­Hyperactivity Disorder), and BDD (Body Dysmorphic Disorder).
Once a condition is referred to as a “disorder” in a diagnostic manual, it becomes reified and treated as if it were a natural entity
existing apart from judgments and evaluations of human beings (Hyman, 2010). The new disorder then takes on an existence all
its own and becomes a disease-­like entity. As news about “it” spreads, people begin thinking they have “it”; medical and mental
health professionals begin diagnosing and treating “it”; and clinicians and clients begin demanding that health insurance policies
cover the “treatment” of “it.” Once the “disorder” has been socially constructed and defined, the methods of science can be
employed to study it, but the construction itself is a social process, not a scientific one. In fact, the more “it” is studied, the more
everyone becomes convinced that “it” really is “something.”
Medical philosopher Lawrie Reznek (1987) has demonstrated that even our definition of physical disease is socially con-
structed. He writes:

Judging that some condition is a disease is to judge that the person with that condition is less able to lead a good or worthwhile life. And
since this latter judgment is a normative one, to judge that some condition is a disease is to make a normative judgment . . . This normative
view of the concept of disease explains why cultures holding different values disagree over what are diseases . . . Whether some condition
is a disease depends on where we choose to draw the line of normality, and this is not a line that we can discover . . . disease judgments,
like moral judgments, are not factual ones (pp. 211–212).

Likewise, Sedgwick (1982) points out that human diseases are natural processes. They may harm humans, but they actually promote
the “life” of other organisms. For example, a virus’s reproductive strategy may include spreading from human to human. Sedgwick
writes:

There are no illnesses or diseases in nature. The fracture of a septuagenarian’s femur has, within the world of nature, no more significance
than the snapping of an autumn leaf from its twig; and the invasion of a human organism by cholera-­germs carries with it no more the
stamp of ‘illness’ than does the souring of milk by other forms of bacteria. Out of his anthropocentric self-­interest, man has chosen to
consider as “illnesses” or “diseases” those natural circumstances which precipitate death (or the failure to function according to certain
values) (p. 30).

If these statements are true of physical disease, they are certainly true of psychological “disease” or psychopathology. Like our con-
ception of physical disease, our conceptions of psychopathology are social constructions that are grounded in sociocultural goals
and values, particularly our assumptions about how people should live their lives and about what makes life worth living. This truth
is illustrated clearly in the APA’s 1952 decision to include homosexuality in the first edition of the DSM and its 1973
decision to revoke its “disease” status (Kutchins & Kirk, 1997; Shorter, 1997). As stated by Wilson (1993), “The homosexuality
controversy seemed to show that psychiatric diagnoses were clearly wrapped up in social constructions of deviance” (p. 404). This
issue also was in the forefront of the debates over post-­traumatic stress disorder, paraphilic rapism, and masochistic personality
disorder (Kutchins & Kirk, 1997), as well as caffeine dependence, sexual compulsivity, low intensity orgasm, sibling rivalry, self-­
defeating personality, jet lag, pathological spending, and impaired sleep-­related painful erections, all of which were proposed for
inclusion in DSM-­IV (Widiger & Trull, 1991). Others have argued convincingly that schizophrenia (Gilman, 1988), addiction (Peele,
1995), post-­traumatic stress disorder (Herbert & Forman, 2010), personality disorder (Alarcon, Foulks, & Vakkur, 1998), dissocia-
tive identity disorder (formerly multiple personality disorder) (Spanos, 1996), intellectual disability (Rapley, 2004) and both
conduct disorder and oppositional defiant disorder (Mallet, 2007) also are socially constructed categories rather than disease
entities.
With each revision, our most powerful professional conception of psychopathology, the DSM, has had more and more to say
about how people should live their lives. The number of official mental disorders recognized by the APA has increased from six in
the mid-­19th century to close to 300 in the DSM-­5 (Frances & Widiger, 2012). Between 1952 and 2013, the number of pages
in the DSM increased from 130 (mostly appendices) to over 900. As the scope of “mental disorder” has expanded
with each DSM revision, life has become increasingly pathologized, and the sheer number of people with diagnosable mental dis-
orders has continued to grow. Moreover, mental health professionals have not been content to label only obviously and blatantly
14 | James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead

dysfunctional patterns of behaving, thinking, and feeling as “mental disorders.” Instead, we have defined the scope of psychopathol-
ogy to include many common problems in living (Frances, 2013) leading to a growing problem of “false positives” – people
with relatively mild forms of common problems being given psychiatric diagnosis and treated with medications. As Wakefield
(2016) states:

Diagnosis has clearly become untethered from medical reality when one out of five boys nationally is diagnosed with ADHD (Visser et al.,
2014) and when antidepressant use has increased 400% in a decade, with nearly one-­quarter of all women in their 40s and 50s taking
antidepressants (Pratt, Brody, & Gu, 2011).
(Wakefield, 2016, p. 124).

Consider some of the “mental disorders” found in the DSM-­5. Cigarette smokers have tobacco use disorder. If you try to quit, you
are likely to develop the mental disorder tobacco withdrawal. If you drink large quantities of coffee, you may develop caffeine
intoxication or caffeine-­induced sleep disorder. What used to be known as simply “getting stoned” is the mental disorder cannabis
intoxication – a mental disorder that afflicts millions of people every year – if not every day. If you have “a preoccupation with one
or more perceived deflects or flaws in physical appearance that are not observable or appear slight to others” (APA, 2013, p. 242)
that causes you significant distress of dysfunction, you may have body dysmorphic disorder. A child with “difficulties learning and
using academic skills . . . that have persisted for at least six months, despite the provision of interventions that target those difficul-
ties” (APA, 2013, p. 66) may have the mental disorder specific learning disorder. (There is no mention of the possibility that the
targeted interventions may have been the wrong interventions.) Toddlers who throw tantrums may have oppositional defiant disor-
der. Women who are irritable or emotionally labile before their menstrual period may have premenstrual dysphoric disorder. People
who eat gum or ice may have pica. Adults who are not interested in sex may have female sexual interest/­arousal disorder or male
hypoactive sexual desire disorder. Women who have sex but do not have orgasms that are frequent enough or intense enough may
have a female orgasmic disorder. For men, ejaculating too early and too late are both signs of a mental disorder.
Consider also some of the new disorders that were proposed for DSM-­5: hypersexual disorder, temper dysregulation disorders
of childhood, hoarding disorder, skin picking disorder, psychosis risk syndrome, among others. Psychiatrist Allen Frances, the chair
of the DSM-­IV task force, has argued that these new “disorders” represent a further encroachment of the DSM into the realm of com-
mon problems in living (Frances, 2010). Nonetheless, hoarding disorder, disruptive mood dysregulation disorder (a renamed
temper dysregulation disorder of childhood), and excoriation (skin-­picking) disorder found their way into the DSM-­5. A recent
example of this encroachment was the decision to eliminate from DSM-­5 the “bereavement exclusion rule” (in effect beginning with
DSM-­III) that stipulated that grief following the loss of a loved one should not be diagnosed as a major depressive disorder even if
the person otherwise meets the diagnostic criteria (Zachar, First, & Kendler, 2017). By eliminating this rule, DSM-­5 now allows us
to pathologize grief. Several other conditions (e.g., Persistent Complex Bereavement Disorder, Internet Gaming Disorder) are listed
as “conditions for further study” and therefore are likely to find their way into DSM-­6. In fact, internet gaming disorder will make
its first appearance as an official mental disorder in the new ICD-­11.
In addition, “diagnostic fads” are sparked by each new edition. Frances notes four “epidemics” that were sparked by changes
from DSM-­III to DSM-­IV: autism, attention deficit/­hyperactivity disorder, childhood bipolar disorder, and paraphilia not otherwise
specified (Frances, 2013). He also warns that DSM-­5 threatens to provoke new epidemics of at least four new disorders that emerged
in DSM-­5: disruptive mood dysregulation disorder, binge-­eating disorder, mild neurocognitive disorders, and “behavioral addic-
tions” (Frances, 2013; see also Paris, 2013).
The past few years have witnessed media reports of epidemics of internet addiction, road rage, and “shopaholism.” Discussions
of these new disorders have turned up at scientific meetings and in courtrooms. They are likely to find a home in a future revision
of the DSM if the media, mental health professions, and society at large continue to collaborate in their construction and if “treating”
them and writing books about them become lucrative (Beato, 2010).
The social constructionist perspective does not deny that human beings experience behavioral and emotional difficulties –
sometimes very serious ones. It insists, however, that such experiences are not evidence for the existence of entities called “mental
disorders” that can then be invoked as causes of those behavioral and emotional difficulties. The belief in the existence of these
entities is the product of the all too human tendency to socially construct categories in an attempt to make sense of a confusing
world. A growing body of research indicates that human emotions are not natural kinds “with boundaries that are carved in nature”
(Barrett, 2006, p. 28). If this is true of emotions, then is must also be true of emotional disorders.
The socially constructed illness ideology and associated traditional psychiatric diagnostics schemes, also socially constructed,
have led to the proliferation of “mental illnesses” and to the pathologization of human existence (e.g., Frances, 2013). Given these
precursors, it comes as no surprise that a highly negative clinical psychology evolved during the 20th century. The increasing heft and
weight of the DSM, which has been accompanied by its increasing influence over clinical psychology, provides evidence for this. As
the socially constructed boundaries of “mental disorder” have expanded with each DSM revision, more relatively mundane human
behaviors have become pathologized; as a result, the number of people with diagnosable “mental disorders” has continued to grow.
This growth has occurred largely because mental health professionals have not been content to label only the obviously and blatantly
dysfunctional patterns of behaving, thinking, and feeling as “mental disorders.” Instead, they (actually “we”) have gradually pathol-
ogized almost every conceivable human problem in living. As a result of the growing dominance of the illness ideology among both
 Conceptions of Psychopathology | 15

professionals and the public, eventually everything that human beings think, feel, do, and desire that is not perfectly logical, adap-
tive, efficient, or “creates trouble in human life” (Paris, 2013, p. 43) will become a “mental disorder” (Frances, 2013; Paris, 2013).
This is not surprising given that Frances notes that in his more than two decades of working on three DSMs, “never once did he recall
an expert make a suggestion that would reduce the boundary of his pet disorder” (Frances & Widiger, 2012, p. 118). DSM-­5 has
made normality “an endangered species” partly because we live in a society that is “perfectionistic in its expectations and intolerant
of what were previously considered to be normal and expectable distress and individual differences” (Frances & Widiger, 2012,
p. 116), but also partly because pharmaceutical companies are constantly trying to increase the market for their drugs by encour-
aging the loosening and expanding of the boundaries of mental disorders described in the DSM (Frances, 2013; Paris, 2013).
Essentially, DSM-­5 “just continues a long-­term trend of expansion into the realm of normality” (Paris, 2013, p. 183). As it does,
“with ever-­widening criteria for diagnosis, more and more people will fall within its net [and] many will receive medications they
do not need” (Paris, 2013, p. 38).
We acknowledge that DSM-­5 is an improvement over DSM-­IV in its greater attention to alternative dimensional models for con-
ceptualizing psychological problems and its greater attention to the importance of cultural considerations in determining whether
or not a problematic pattern should be viewed as a “mental disorder.” Yet it remains steeped in the illness ideology for most of its
900 pages. For example, still included in the revised definition of mental disorder is the notion that a mental disorder is “a dysfunction
in the individual” (p. 20) – an assumption that is inconsistent with almost every psychological and sociological conception of
human functioning.

Summary and Conclusions

The debate over the conception or definition of psychopathology and related terms has been going on for decades, if not centuries, and
will continue, just as we will always have debates over the definitions of truth, beauty, justice, and art. Our position is that psychopa-
thology and mental disorder are not the kinds of terms whose “true” meanings can be discovered or defined objectively by employing
the methods of science. They are social constructions – abstract ideas whose meanings are negotiated among the people and institutions
of a culture and that reflect the values and power structure of that culture at a given time. Thus, the conception and definition of
psychopathology always has been and always will be debated and always has been and always will be changing. It is not a static and
concrete thing whose true nature can be discovered and described once and for all.
By saying that conceptions of psychopathology are socially constructed rather than scientifically derived, we are not proposing,
however, that human psychological distress and suffering are not real or that the patterns of thinking, feeling, and behaving that
society decides to label psychopathology cannot be studied objectively and scientifically. Instead, we are saying that it is time to acknowl-
edge that science can no more determine the “proper” or “correct” conception of psychopathology and mental disorder than it can deter-
mine the “proper” and “correct” conception of other social constructions such as beauty, justice, race, and social class. We can
nonetheless use science to study the phenomena that our culture refers to as psychopathological. We can use the methods of science
to understand a culture’s conception of mental or psychological health and disorder, how this conception has evolved, and how it
affects individuals and society. We also can use the methods of science to understand the origins of the patterns of thinking, feeling,
and behaving that a culture considers psychopathological and to develop and test ways of modifying those patterns.
Psychology and psychiatry will not be diminished by acknowledging that their basic concepts are socially and not scientifically
constructed – no more than medicine is diminished by acknowledging that the notions of health and illness are socially constructed
(Reznek, 1987), nor economics by acknowledging that the notions of poverty and wealth are socially constructed. Likewise, the recent
controversy in astronomy over how to define the term planet (Zachar & Kendler, 2010) does not make astronomy any less scientific.
Science cannot provide us with “purely factual, scientific” definitions of these concepts. They are fluid and negotiated constructs,
not fixed matters of fact.
As Lilienfeld and Marino (1995) have commented:

Removing the imprimatur of science . . . would simply make the value judgments underlying these decisions more explicit and open to
criticism . . . heated disputes would almost surely arise concerning which conditions are deserving of attention from mental health pro-
fessionals. Such disputes, however, would at least be settled on the legitimate basis of social values and exigencies, rather than on the
basis of ill-­defined criteria of doubtful scientific status (pp. 418–419).

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Chapter 2

Psychopathology
A Neurobiological Perspective1

Daniel Tranel, Molly A. Nikolas, and Kristian Markon

Chapter contents

Introduction20
Neurobiological Foundations 20
Methods and Approaches 29
Disorders and Conditions 38
Attention-­Deficit/­Hyperactivity Disorder 44
Concluding Comments and Emerging Trends 45
Notes47
References47
20 | Daniel Tranel, Molly A. Nikolas, and Kristian Markon

Introduction
Decades of work in psychological science and related disciplines have demonstrated that the brain is the foundation for human
behavior. Additionally, the rise of behavioral and molecular genetic methodologies over the past 50 years has demonstrated that
genetic factors play an important role in shaping brain development and, ultimately, personality and psychopathology. Advance-
ments in non-­invasive technologies have made the study of genes and brain functioning more accessible than ever, and treatments
for psychopathology have been developed based upon this accumulating knowledge of neurobiological mechanisms. A full under-
standing of psychopathology must include an understanding of its biological bases, both genetic and neurobiological. This chapter
introduces important concepts and issues regarding the biological bases of psychopathology, with a particular emphasis on genetic
and neurobiological mechanisms and how discoveries in these areas hold great promise for the refinement of comprehensive etio-
logic models and treatment paradigms. We begin our chapter with an overview of fundamental concepts and topics in biological
accounts of behavior, and then discuss methods and methodological issues that are encountered in studying those biological sub-
strates. Finally, we discuss the biological substrates of specific disorders and forms of psychopathology.

Neurobiological Foundations

An Introduction to the Human Brain and Neurotransmitters

The human brain is extremely complex. It comprises something on the order of 50 to 100 billion neurons that each forms on the
order of tens of thousands of connections to other neurons and can exert causal influences on behavior as well as changes in
response to our experiences. We provide some basic information regarding brain structure and communication in Figure 2.1 and
Box 2.1. This overview of brain structures and means of neuronal communication provides a primer of background knowledge of
the biological bases of psychopathology. Needless to say, it is impossible to cover all of the basics of neuroanatomy, genetics, and
biological psychology, along with findings specifically related to psychopathology, in this chapter. We point interested readers to
basic textbooks for more in-­depth coverage of these concepts (Blumenfeld, 2010; Breedlove & Watson, 2013; Kandel, Schwartz,
Jessell, Siegelbaum, & Hudspeth, 2012).

BOX 2.1 NEUROTRANSMITTERS AND THEIR REGULATION

Coming in many forms, neurotransmitters are chemical messengers, mediating information transmission between neurons by passing from
one neuron to act on receptors on another. Neurotransmitters are localized in different ways. Although many are found throughout the body,
within the brain they may only be produced in specific regions; also, neurotransmitters often have different types of receptors, each of which is
localized to specific brain regions. In this way, different neurotransmitters can have different patterns of behavioral associations, even as each
serves multiple functions. Drugs used to treat psychological disorders often act through neurotransmitter pathways, such as by activating
a receptor as an agonist, blocking receptors as an antagonist, inhibiting reuptake of the neurotransmitter into a neuron, affecting chemical
synthesis or degradation, or some combination or variant of mechanisms.
Acetylcholine is found throughout the brain and in muscle tissue. It mediates muscle contraction, and is involved in a number of cog-
nitive processes, such as attention and memory. Acetylcholine acts on two different types of receptors–nicotinic acetylcholine receptors and
muscarinic acetylcholine receptors. The nicotinic receptor is an ionotropic receptor; binding of acetylcholine to the receptor opens an ion
channel that allows positive ions such as sodium and potassium to pass through. The muscarinic receptor is a metabotropic receptor; binding
of acetylcholine to the receptor causes changes in associated proteins, which eventually cause other ion channels in the neural membrane to
open and allow ions to pass through.
Dopamine is involved in numerous processes, especially reward and reinforcement, motor function, and cognition and attention. It is
synthesized from the amino acid tyrosine, and is processed by enzymes (e.g., catechol-­O-­methyltransferase) to form other neurotransmitters
in its family (i.e., the catecholamines). Many drugs of abuse directly or indirectly target dopamine pathways in various ways, and classic antip-
sychotic medications act as dopamine antagonists.
Epinephrine and norepinephrine, also known as adrenaline and noradrenaline, are examples of catecholamines formed from dopa-
mine (norepinephrine from dopamine, and epinephrine from norepinephrine). They both have a wide variety of functions, and both are
involved in fight-­or-­flight and fear responses, in part due to HPA axis sympathetic nervous system activity, as well as arousal and alertness.
Norepinephrine pathways are also associated with decision-­making, and its reuptake is a mechanism of action of popular antidepressant and
other psychotropic medications.
GABA, or gamma-­aminobutyric acid, is the primary inhibitory neurotransmitter in the adult brain, in that it inhibits neural firing (note
that inhibiting an inhibitory neuron could facilitate downstream neural responses). Very early in development, however, it has excitatory
effects; it comes to act as an inhibitory neurotransmitter early during the postnatal period. Like acetylcholine, GABA binds to one of two types
of receptors, an ionotropic and a metabotropic receptor. Many depressant substances (e.g., benzodiazepines and alcohol) act at least in part
by facilitating GABA receptor activity.
 Psychopathology: A Neurobiological Perspective | 21

Glutamate is the primary excitatory neurotransmitter in the adult brain, and the precursor to GABA. Like acetylcholine and GABA, there
are ionotropic and metabotropic forms of glutamate receptors. Given its widespread distribution in the brain, glutamate functions in a wide
variety of roles and has been linked to a wide variety of mental disorders. Overexcitation of glutamate receptors, which sometimes occurs in
traumatic brain injury or neurological disease, can lead to neurodegeneration or neuron death.
Serotonin is derived from the amino acid tryptophan and also has a wide variety of roles in the brain and elsewhere. Serotonin has
long been associated with behavioral and emotional regulation, with many antidepressants acting by preventing its elimination, either by
inhibiting its reuptake or by preventing its degradation. Many hallucinogenic substances also act via serotonin receptors, such as by acting as
a serotonin agonist.

Figure 2.1 Human brain, with covering layers (skull, meninges) stripped to show cortical gyri and sulci of the cerebral hemispheres. (a) Lateral (top) and
medial (bottom) views of the cerebral hemispheres, colored according to key to show the five major lobes. Spatial axes labeled with conven-
tional terms are shown to the left and right of the lateral view. (b) Upper left is a three-­dimensional reconstruction of a normal brain (from a
structural magnetic resonance scan), showing standard orthogonal planes of section in the sagittal (red box, upper right), coronal (blue box,
lower left), and horizontal (or transverse, green box, lower right) dimensions. The idea for Figure 1b was suggested by Hanna Damasio (2000).
22 | Daniel Tranel, Molly A. Nikolas, and Kristian Markon

Neural Systems for Emotion and Feeling

At the root of many forms of psychopathology are disturbances of emotion, including defects in perception, processing, expression, and
regulation of emotion, as well as defects in the related capacity of feelings (the conscious processing and experience of emotions). Neu-
robiological systems for emotion have been elucidated by a long tradition of conventional neuropsychological studies and, more
recently, by functional imaging approaches (especially functional magnetic resonance imaging, or fMRI). This work has pointed to a
number of key structures and networks that are closely linked to emotions and feelings. Specifically, research has identified brainstem
and hypothalamic nuclei, amygdala, insula cortex, anterior cingulate cortex, ventromedial prefrontal cortex, and somatosensory corti-
ces, among others, as important for various aspects of emotion (Barrett, Mesquita, Ochsner, & Gross, 2007; Craig, 2002, 2008; Dama-
sio, 1994; Damasio et al., 2000; Damasio, Damasio, & Tranel, 2013; Davidson & Irwin, 1999; Lane, 2000; Lane et al., 1998; Tye et al.,
2011; Wager, Phan, Liberzon, & Taylor, 2003). Some studies have pointed to focal brain regions associated with specific basic emotions
(e.g., Vytal & Hamann, 2010), while others have reported a more distributed mapping between brain regions and emotions (e.g.,
Lindquist et al., 2012). Lesion and electrical stimulation studies have provided evidence for often quite specific associations between
particular brain regions and particular emotions – e.g., specific brain regions for fear, or for sadness, or for disgust (Calder, Keane,
Manes, Antoun, & Young, 2000; Dejjani et al., 1999; Feinstein, Adolphs, Damasio, & Tranel, 2011; Feinstein et al., 2013; Fried, Wilson,
MacDonald, & Behnke, 1998). Also, for many of the bilateral cortical structures, the right-­hemisphere component has been shown to
be particularly important (more so than the left-­sided counterpart). We review below some of the principal emotion-­related structures,
along with examples of relevant empirical evidence and links to psychopathology.

Right-­Hemisphere Structures
Right-­hemisphere structures have long been considered important for emotions and feelings. Studies in behavioral neurology and
neuropsychology, for example, have consistently supported the conclusion that for emotion processing, the right hemisphere leads the
way, and the left hemisphere is less important (e.g., LaBar & LeDoux, 2003).2 This may reflect some of the underlying hemispheric
specializations associated with the right hemisphere, such as preferences for holistic, configural modes of processing that could facilitate
handling of multidimensional and alogical stimuli that convey emotional tone. Facial expressions and prosody (the stress, intonation,
and rhythm of speech that help convey emotional “coloring” in verbal utterances) are two illustrative examples of such stimuli (e.g.,
Borod, Haywood, & Koff, 1997). More generally and relevant to many forms of psychopathology, the right hemisphere contains struc-
tures important for emotional processing which may have evolved to provide the neural machinery that operates aspects of social
cognition (Bowers, Bauer, & Heilman, 1993; Gainotti, 2000; Heilman, Blonder, Bowers, & Valenstein, 2003).
Much of the specific evidence supporting these conclusions comes from neuropsychological studies. For example, lesions to
right temporal and parietal cortices can impair emotional experience and arousal, as well as imagery for emotion (see Adolphs &
Tranel, 2004). Neurological patients with right temporal and parietal damage often have difficulty discerning the emotional features
of stimuli, with corresponding diminution in their emotional responsiveness, and this can occur for both visual and auditory stimuli
(Borod et al., 1998; Van Lancker & Sidtis, 1992). Functional neuroimaging studies have also shown a preferential role of right-­
hemisphere structures in emotion recognition from facial expressions and from prosody (for a review, see Cabeza & Nyberg, 2000).
There have been two basic hypotheses regarding how and the extent to which the right hemisphere participates in emotion.
The right-­hemisphere hypothesis posits that the right hemisphere is specialized for processing all emotions. The valence hypothesis posits that
the right hemisphere is specialized only for processing emotions of negative valence, whereas positive emotions are processed
preferentially by the left hemisphere (Canli, 1999; Davidson, 1992, 2004). Both hypotheses have garnered some empirical support
(e.g., Jansari, Tranel, & Adolphs, 2000), and resolution of this debate may require more precise specification of which components
of emotion are under consideration. One distinction that seems to be important is the difference between recognition versus experience.
Recognition of emotion (e.g., identifying emotions in external stimuli such as facial expressions and prosody) may accord more
with the right-­hemisphere hypothesis, while experience of emotion (e.g., arousal and feelings) may accord more with the valence
hypothesis. For example, lesions to the right somatosensory cortex have been associated with impaired visual recognition of emo-
tional facial expressions, covering most primary emotions (e.g., sadness, fear, anger, surprise, disgust; however, visual recognition
of happy facial expressions is not impaired by right somatosensory lesions), broadly consistent with the right-­hemisphere hypoth-
esis (although not inconsistent with the valence hypothesis, either) (Adolphs, Damasio, Tranel, Cooper, & Damasio, 2000). By
contrast, studies of emotional experience have shown a lateralized pattern more consistent with the valence hypothesis. A well-­
established theory by Davidson (1992, 2004) posits an approach/­withdrawal dimension, in which increased right-­hemisphere activation
correlates with increases in withdrawal behavior (including behaviors characteristic of emotions such as fear or sadness), and
increased left-­hemisphere activation correlates with increases in approach behaviors (including behaviors characteristic of emotions
such as happiness and amusement).

Amygdala
The amygdala is a key component in the so-­called “limbic system” (Figure 2.2), which has long been connected to emotion-­related
functions, going back to the seminal formulations of Papez (1937) and MacLean (1952). The term has not been without contro-
versy, and there is not even a consensus on exactly what structures do and do not belong to the limbic system (LeDoux, 2000).
 Psychopathology: A Neurobiological Perspective | 23

Figure 2.2 Drawings of the limbic system, showing major structures, mostly on and near the midline, that comprise the interconnected cortical and sub-
cortical components of the human limbic system. Major landmarks are depicted in (A); major cortical components of the “limbic lobe” are
depicted in (B); major subcortical components are depicted in (C); and major pathways between limbic system components are depicted in (D).
The idea for Figure 2.2 was suggested by Gary Van Hoesen (see Damasio, Van Hoesen, & Tranel, 1998).

Nonetheless, the concept has remained useful, at least as a heuristic (see Feinstein et al., 2010), and the amygdala is very much at
the center of the action insofar as emotional functions are concerned. In fact, the past couple of decades of work in cognitive neu-
roscience have propelled the amygdala to a place of notable importance in the neuroanatomy of emotion.
The amygdala is a bilateral structure composed of a collection of nuclei deep in the anterior temporal lobe. It receives highly
processed input from most sensory modalities, and in turn has extensive, reciprocal connections with many brain structures that
are important for various aspects of emotion-­related processing (Amaral, Price, Pitkanen, & Carmichael, 1992). Of particular impor-
tance, the amygdala has extensive bidirectional connections with the orbitofrontal cortices, known to be important for emotion and
decision-making (Bechara, Damasio, Tranel, & Damasio, 1997; Gläscher et al., 2012). The amygdala is also extensively and bidirec-
tionally connected with the hippocampus, basal ganglia, and basal forebrain, key structures for memory and attention. The amygdala
24 | Daniel Tranel, Molly A. Nikolas, and Kristian Markon

projects to the hypothalamus and other structures that are involved in controlling homeostasis, as well as visceral and neuroendo-
crine output. The amygdala is thus well-­situated to link information about external stimuli conveyed from sensory cortices with
modulation of decision-making, memory, and attention, as well as somatic, visceral, and endocrine processes (see Adolphs &
Tranel, 2004).
The amygdala makes critical contributions to a diverse array of emotional and social behaviors. Adolphs and Tranel (2004; see
also Damasio, 1999) outlined three general principles:

1. The amygdala links perception of stimuli to an emotional response, using afferents from sensory cortices and efferents to
emotion control structures such as hypothalamus, brainstem nuclei, and periaqueductal gray matter.3
2. The amygdala links perception of stimuli to modulation of cognition, based on bidirectional connections with structures
involved in decision-making, memory, and attention.
3. The amygdala links early perceptual processing of stimuli with modulation of such perception via direct feedback (e.g., Galle-
gos & Tranel, 2005). These various mechanisms allow the amygdala to contribute critically to emotion processing by modulat-
ing multiple processes simultaneously.

A number of psychopathological processes and psychiatric illnesses have been linked to pathology in the amygdala, including
autism, post-­traumatic stress disorder, generalized anxiety disorders, phobias, and schizophrenia (e.g., Aggleton, 2000). There is
also evidence of amygdala dysfunction in mood disorders (Drevets, 2000; Davidson & Irwin, 1999). Histological (e.g., analyses of
cell densities and neuronal arrangements) and volumetric (e.g., analyses of the volumes of grey and white matter structures) mag-
netic resonance imaging (MRI) studies have found abnormal amygdala cell density throughout development in individuals with
autism and autism-­spectrum disorders, and functional MRI (fMRI) work has shown abnormal amygdala activation in persons with
autism, especially during emotion-­related tasks (Baron-­Cohen et al., 2000). Although surrounded by lively scientific debate, an
“amygdala theory of autism” has remained a popular and largely valid heuristic for understanding the neurobiology of autism and
related disorders in which emotional and social processing are notably disturbed.
Studies using neuropsychological and functional neuroimaging approaches have provided compelling evidence that the
amygdala is involved in processing emotion via all principal sensory modalities, including visual, auditory, somatosensory,
olfactory, and gustatory. Extensive work in animals has shown that the amygdala is important for fear conditioning (e.g., Davis,
Walker, & Lee, 1997; LeDoux, 1996), and in humans, lesions to the amygdala impair the ability to acquire conditioned auto-
nomic responses to stimuli that have been paired with unconditioned aversive stimuli (Bechara et al., 1995). In parallel, the
acquisition of conditioned fear responses activates the amygdala in functional imaging studies (Buechel, Morris, Dolan, &
Friston, 1998).
Many neuropsychological investigations have pointed to a key role for the amygdala in the recognition of emotion from various
types of stimuli (e.g., facial emotional expressions), as well as the experience of emotion triggered by emotional stimuli or emotional
memories. For example, patients with focal, bilateral amygdala damage have been shown to be specifically and severely impaired in
recognizing fear in facial expressions (Adolphs & Tranel, 2000). A similar impairment has been shown for anger and other highly
arousing emotions similar to fear, which is consistent with the notion of a more general impairment in recognition of negative
emotions in patients with bilateral amygdala damage (Adolphs et al., 1999). Functional neuroimaging studies have corroborated
much of the lesion work, showing, for example, that the amygdala is strongly activated by tasks that require the recognition of
signals of unpleasant and arousing emotions (Morris et al., 1996). In fact, visual, auditory, olfactory, and gustatory stimuli all activate
the amygdala during processing of unpleasant and arousing emotions (Royet et al., 2000). Data such as these have led to the sug-
gestion that the amygdala may play a role in recognizing highly arousing, unpleasant emotions (emotions that signal potential
harm), and in the rapid triggering of appropriate physiological states related to these stimuli (Adolphs & Tranel, 2004). This mech-
anism may operate in a bottom-­up, automatic fashion that can be below the level of conscious awareness. For example, Whalen
et al., (1998) reported amygdala activation in participants who were shown facial expressions of fear that were presented so briefly
the expressions could not be consciously recognized.
More generally, the amygdala appears to participate in the allocation of processing resources and the triggering of responses
to stimuli that signal threat or are otherwise of particular and immediate importance or relevance to the organism (LeDoux,
1996). For example, Bechara (2004) has suggested that pleasant or aversive stimuli, such as encountering a fear object (e.g., a
snake), trigger quick, automatic, and obligatory affective/­emotional responses via the amygdala. In addition, there is physiolog-
ical evidence that responses triggered through the amygdala are short-lived and habituate quickly (Buchel et al., 1998). The
amygdala provides a mechanism to link the features of external stimuli to emotional responses, which are evoked via visceral
motor structures, such as the hypothalamus and autonomic brainstem nuclei that produce changes in internal milieu and visceral
structures, as well as behavior-­related structures such as the striatum, periaqueductal gray (PAG), and other brainstem nuclei. The
powerful and seemingly automatic nature of emotional responses triggered by the amygdala has important implications for
psychopathology, including common psychiatric conditions such as post-­traumatic stress disorder, phobias, and generalized
anxiety disorders. The role of the amygdala in different facets of personality (e.g., disinhibition) has also begun to be clarified
(e.g., Lilienfeld et al., 2016).
 Psychopathology: A Neurobiological Perspective | 25

Ventromedial Prefrontal Cortex

Given the extensive interconnections between the amygdala and orbitofrontal (or ventromedial prefrontal, more generally)4 cortex,
it is not surprising that lesions to the orbitofrontal cortex can produce emotion processing defects that are reminiscent of those
associated with amygdala damage. Moreover, neuronal responses in the orbitofrontal cortex appear to be modulated by the emo-
tional significance of stimuli (e.g., reward or punishment contingencies) in much the same way as such responses are modulated
in the amygdala (e.g., Kawasaki et al., 2001; Rolls, 2000). Disconnecting the amygdala and orbitofrontal cortex from each other can
produce emotional impairments similar to those following lesions of either structure. In sum, there is considerable evidence that
these two structures function as key components of a richly connected emotion processing network.
The medial part of the orbitofrontal cortex is part of a more extensive functional neuroanatomical system that has been termed
the ventromedial prefrontal cortex (vmPFC; see note 3 at the end of this chapter), and there is extensive evidence that the vmPFC plays a
critical role in many aspects of higher-­order emotional processing (Figure 2.3). For example, numerous neuropsychological and
functional imaging investigations have documented that the vmPFC is crucial for moral reasoning, social conduct, and decision-­
making, especially decision-­making that involves emotional and social situations (see Tranel, Bechara, & Damasio, 2000, for review).
Damage to the vmPFC leads to poor judgment, poor decision-­making, and impaired emotions and feelings. Some of the most
prominent defects are in the social realm, including social perception and social emotions (e.g., empathy, regret; see Damasio,
Anderson, & Tranel, 2012; Beadle, Paradiso, & Tranel, in press). Patients with damage to the vmPFC cannot represent choice bias in
the form of an emotional “hunch” (Bechara et al., 1997), and cannot trigger normal emotional responses to emotionally charged
and socially relevant stimuli (Damasio, Tranel, & Damasio, 1990).

Basal Ganglia
The basal ganglia, especially on the right, also play an important role in emotion. Damage to the basal ganglia can produce impaired
recognition of emotion from a variety of stimuli (Cancelliere & Kertesz, 1990). The right basal ganglia are activated by tasks requir-
ing the processing of facial emotional expressions (Morris et al., 1996). Also, diseases that preferentially damage certain sectors of
the basal ganglia, including obsessive-­compulsive disorder, Parkinson’s disease, and Huntington’s disease, are marked by distur-
bances of emotions and feelings. For example, it has been shown that patients with obsessive-­compulsive disorder have abnormally

Figure 2.3 Ventromedial prefrontal cortex (vmPFC). The region of the prefrontal lobes that is termed the “ventromedial prefrontal cortex,” is marked in
green on mid-­sagittal right hemisphere (a), mid-­sagittal left hemisphere (b), ventral (c), and frontal (d) views. The vmPFC encompasses the
medial part of the orbitofrontal cortex and the ventral sector of the mesial prefrontal cortex.
26 | Daniel Tranel, Molly A. Nikolas, and Kristian Markon

strong feelings of disgust and are impaired in the recognition of facial expressions of disgust (Bhikram, Abi-­Jaoude, & Sandor, 2017;
Sprengelmeyer et al., 1997). A hallmark sign in Parkinson’s disease is impaired emotional expression, and patients with Parkinson’s
disease often have impaired feelings of emotions and impaired recognition of emotion. Studies have shown that patients with Hun-
tington’s disease have a selective impairment in recognizing disgust from facial expressions – that is, the patients have more diffi-
culty recognizing disgust, compared with other facial emotions (Jacobs, Shuren, & Heilman, 1995; Sprengelmeyer et al., 1996).

Other Structures
Several other structures are especially important to link stimulus perception to emotional response. The bed nucleus of the stria
terminalis appears to have a role in anxiety, via the neuropeptide corticotropin-­releasing factor. The substantia innominata and nuclei
in the septum are important for emotional processing, and may mediate their effects through the neurotransmitter acetylcholine.
A collection of nuclei in the brainstem (especially the locus ceruleus and Raphe nuclei) provides neuromodulatory functions that
are critical for emotions and feelings. The ventral striatum is another important region. For example, the nucleus accumbens appears
to be important for processing rewarding stimuli and for causing behaviors that prompt an organism to seek stimuli that predict
reward. The periaqueductal gray in the midbrain is also important, and stimulation in this area can produce panic-­like behavioral
and autonomic changes, as well as reports of panic-­like feelings (Panksepp, 1998).

Genes and Behavior

Enormous strides have been made over the past two decades regarding our understanding of the role of genetic processes in psy-
chopathology. Reaction to reports regarding potential genetic impacts on complex behaviors (for example, findings of genetic
influence on divorce reported by McGue & Lykken, 1992), however, have somewhat altered (or perhaps simplified) general under-
standing regarding the role of genes in the development of psychopathology. While there is clear evidence that genetic factors play
important roles in the development of nearly every psychological disorder (Burt, 2009; Krueger et al., 2002), genes do not directly
code for specific types of behavior – especially the complex behavior that is disordered in psychopathology (i.e., there is no “gene
for schizophrenia”). Rather, genes encode proteins, and genetic variation likely impacts the development of psychopathology via
its “upstream” consequences on protein formation and expression, which then have cascading effects on neurodevelopment and
neurotransmission. Alterations or dysfunction in neurodevelopment may then be exhibited behaviorally via the manifestation of
symptoms of psychopathology.

A Primer on Genetics
What are genes and how might they impact psychopathology? At the most basic level, genes are long molecules of deoxyribonucleic
acid (DNA), which are located at various positions within paired chromosomes. Humans have 23 paired chromosomes (46 total),
which are contained within the cell nucleus; individuals inherit one pair of chromosomes from each of their parents. Chromosomes
are numbered from 1 to 22 (with 1 being the longest and 22 being the shortest, referred to as autosomal); genes on these chro-
mosomes encode proteins involved in the development of the body and brain. The 23rd pair of chromosomes determines an indi-
vidual’s sex; individuals with two copies of the X chromosome are genetically female; those with one X and one Y chromosome are
genetically male.
Abnormalities in chromosomal division and inheritance have been linked to numerous disorders of health and development –
perhaps the most notable example is Down syndrome. Also referred to as trisomy 22, Down syndrome occurs as the result of prob-
lematic division of the chromosomes during meiosis in the egg of the mother (termed chromosomal non-­disjunction), such that
an additional copy (or portion) of chromosome 22 is passed on to the child. The presence of this additional portion of the chro-
mosome then results in changes in facial characteristics (e.g., flattened nasal bridge, small eyes) and intellectual impairments. Several
chromosomal abnormalities have been linked to behavioral disorders; for example, William’s syndrome is the result of deletion of
approximately 26 genes in chromosome 7 and results in both physical changes (heart defects, flattened nasal bridge), as well as
anxiety, attention problems, and intellectual disability (although individuals with William’s syndrome may be highly verbal relative
to their overall IQ – see Lashkari, Smith, & Graham, 1999). Similarly, 22q deletion syndrome, which involves a deletion of genes from
the long arm of chromosome 22, has also been associated with numerous cognitive delays during childhood, as well as the devel-
opment of psychosis during adolescence (Bassett & Chow, 2008). Importantly, however, the majority of psychological disorders are
not the result of dysfunction or alteration of a single chromosome (or even a single gene). Rather, psychopathology likely results,
in part, from numerous contributions from multiple genes. The term polygenic is used to describe most psychological disorders,
which reflects the notion that many different genes likely each contribute a small portion to their etiology.
The total length of the human genome (all human DNA) is around three billion base pairs, which are estimated to contain
approximately 20,000 different genes (U.S. Department of Energy Office of Science, 2009). An individual’s DNA is contained with
the cell nucleus of every cell in the human body, although not all base pairs are different across people; in fact, over 99% of base
pairs do not vary across people at all, and likely code for proteins involved in the basic “construction” of a human being (i.e., proteins
that create heart, skin, hair cells, or that provide information for cells to combine to create nose, hands, feet, etc.). Only a small
 Psychopathology: A Neurobiological Perspective | 27

proportion of the DNA code is polymorphic; that is, only certain regions actually vary from person to person. This variation occurs
because an individual inherits one set of code from the mother and the other set from the father, resulting in two alleles at each
genetic locus. These alternate forms of the gene can be associated with phenotypic (or observable) differences. Classic Mendelian
inheritance specified that each individual allele at a particular locus corresponded with a particular phenotype, or observable trait.
Further, alleles could be dominant or recessive, such that dominant alleles would always be expressed over recessive alleles. Much
of this theory was based on Mendel’s experiments with peapod phenotypes, including pod color, shape, and height, among other
physical characteristics, (see Fisher, 1936 for a discussion of Mendel’s work), which may not apply to the inheritance of complex
traits in humans. For decades, scientists applied the concepts of Mendelian inheritance to human phenotypes, such as eye color,
positing that the allele for brown eyes was dominant over the alleles for blue eyes and green eyes. However, genetic investigations
of eye color over the last several decades have indicated that it does not likely follow Mendelian patterns of inheritance and that
approximately 16 different genes contribute to human eye color (White & Rabago-­Smith, 2011).
While Mendelian models of inheritance are no doubt important for understanding genetic recombination and variation
throughout the genome, it does not appear that psychopathology is inherited in this classical Mendelian sense. Rather, it appears
that most psychological disorders are polygenic, meaning that many polymorphic variations at different regions across the genome
each contribute a small portion to the etiology of psychopathology. The notion that behavioral traits and disorders have a genetic
contribution has long been recognized and established by the field of behavior genetics. While work is currently underway to specify
the exact nature of the genetic differences that may increase liability for psychopathology (see Methods of Gene Discovery, in this
chapter, page 36), the magnitude of genetic influence on psychological disorders has been consistently established via the use of
twin and family studies, which we turn to next.

Twin and Family Studies

The first evidence of a genetic contribution to psychopathology came largely from family studies. In these studies, the families of
individuals with various types of disorders were studied to determine if the disorder or symptoms “ran in families.” Family studies
of psychopathology were conducted as early as the latter half of the 19th century (although some were motivated by eugenic ide-
ology, which is not a current motivator of contemporary twin and family work). In general, family studies have shown that rates of
psychological disorders (e.g., schizophrenia, mood disorders, attention-­deficit hyperactivity disorder, ADHD) among family mem-
bers of affected individuals tend to be higher than the prevalence rates in the general population (Biederman et al., 1992; Kendler,
Karkowski-­Shuman, & Walsh, 1996; Tienari, 1991). However, these family studies do not point specifically toward a genetic contri-
bution to psychopathology, as environmental influences can also be shared within families. The advent of the classical twin design
has since provided researchers with tools to quantify the magnitude of genetic influence on traits and behaviors and, most impor-
tantly, to differentiate the impact of genes and environments on complex traits.
The classical twin design uses samples of monozygotic (MZ) and dizygotic (DZ) twins to infer genetic influence, owing to
some very basic differences regarding the degree of genetic relatedness among twins. MZ twins are the result of a single fertilized
embryo that splits into two (for reasons still unknown); thus, MZ twins share 100% of their genes. In contrast, DZ twins are the
result of two fertilized embryos and share, on average, 50% of their genes (as do all full biological siblings). Both MZ and DZ twins
(unlike full biological siblings) also share a common prenatal environment. Similarities in a particular behavior, trait, or disorder
among MZ twin pairs can then be compared with similarities among DZ twin pairs, in order to gauge whether or not there may be
a potential role of genetic influences. This work began by examining concordance rates (described briefly below), but now uses
biometric model fitting to quantify the proportion of variability due to genetic factors, (see Plomin, DeFries, McClearn, & McGuffin,
2008 for a review).
Initial twin studies quantified the genetic influence on psychological disorders via examination of twin concordance rates (i.e.,
how similar are twins 1 and 2 on a particular trait). That is, the relative difference in concordance rates between MZ and DZ twins
is informative when inferring a genetic influence on a disorder or trait (e.g., depression). Higher concordance rates for MZ relative
to DZ twins would suggest higher genetic influences, given that MZ twins share 100% of their genes, whereas DZ twins share 50%
on average. Inherent in this framework is the equal environments assumption, which posits that twins reared together in the same
family experience common shared environmental factors (i.e., influences that are shared among reared-­together siblings and serve to
increase sibling similarity) at 100%, regardless of twin zygosity. Furthermore, non-­shared or unique environmental factors (those that are not
common among twins in the same family and serve to decrease twin/­sibling similarity) are by definition, shared at 0% for all twins,
regardless of zygosity. Using this framework, twin concordance rates have been found to be substantially higher for MZ versus DZ
twins for a variety of disorders, including schizophrenia (Picchioni et al., 2010), mood disorders (Edvardsen et al., 2009; Kieseppa,
Partonen, Haukka, Kaprio, & Lonngvist, 2004), ADHD (Sherman, McGue, & Iacono, 1997), anxiety disorders (Skre, Onstad, Torg-
ersen, Lygren, & Kringlen, 1993), and autism spectrum disorders (Rosenberg et al., 2009).
However, these studies of overall twin concordance rates can be problematic, given that genes likely influence an underlying
continuous liability for developing a psychological disorder and may vary dramatically depending on sample source (Walker,
Downey, & Caspi, 1991). For example, concordance rates appear to vary when examining twins drawn from clinical settings versus
twins selected to represent the larger population, with the former considered to generate potential overestimates of genetic effects.
Thus, twin methodology that can quantify the magnitude of genetic (and environmental) influences on psychopathology-­relevant
28 | Daniel Tranel, Molly A. Nikolas, and Kristian Markon

dimensions in the population can then provide more precise (and potentially less biased) estimates of the magnitude of genetic
influence. This has been achieved via development of the biometric twin model (Plomin et al., 2008). Biometric twin models also make
use of the difference in the proportion of genes shared between reared-­together MZ and DZ twins. Using these differences, the
variance within observed behaviors is partitioned into three components: additive genetic, shared environment, and non-­shared
environment plus measurement error. The additive genetic component (A) includes the effect of individual genes at different loca-
tions on the chromosome (or loci) summed together. The shared environment (C) is that part of the environment common to
siblings that serves to increase sibling similarity regardless of the proportion of genes shared. The non-­shared environment (E)
encompasses environmental factors (and measurement error) differentiating twins within a pair (i.e., those effects that decrease
twin correlations regardless of genetic relatedness). Non-­additive genetic effects can also be estimated in biometric twin models.
These effects represent the multiplicative effects of genes at different loci.
The proportion of the variability in psychological symptoms or traits that can be attributed to genetic variability is referred to
as heritability. Ranging from 0 to 100%, this term provides an estimate of the magnitude of genetic influence on population-­level
individual differences in psychopathology. Multiple meta-­analyses and reviews on heritability for psychological disorders have been
conducted, and the results are summarized in Figure 2.4. As can be seen there, the relative impact of genetic influences is high for
several disorders and traits, including psychosis, mania, autism spectrum traits (i.e., social communication deficits), and inattention
and hyperactivity–impulsivity (Cardno & Gottesman, 2000; Edvardsen et al., 2008; Nikolas & Burt, 2010; Ronald & Hoekstra,
2011). Moderate heritability (estimates of around 50%) has been found for several disorders (eating disorders, conduct disorders,
substance-­related disorders, personality disorders), as well as for measures of IQ and personality traits (Bouchard, 2013; Bulik et al.,
2006; Gelhorn et al., 2005; Kendler, Maes, Sundquist, Ohlsson, & Sundquist, 2014; Pincombe, Luciano, Martin, & Wright, 2007;
Wray, Birley, Sullivan, Visscher, & Martin, 2007). Somewhat lower, albeit sizable and significant, heritabilities have been reported for
both anxiety and depression symptoms (Mosing et al., 2009).
Overall, twin studies have been critical in determining the overall magnitude of genetic influence on behavior. However, herita-
bility is a population statistic that is sensitive to time, age, and context, and does not tell us anything about what specific genetic variants
may be implicated in the causal processes underlying the development of psychopathology for a given individual. Nonetheless, future
twin work remains important for understanding factors that may cause alterations in genetic influence both within and across time.
For example, Turkheimer and colleagues (2003) found that genetic influences on IQ appeared to change at different levels of socioec-
onomic status, such that genetic influences on IQ were higher for children in higher socioeconomic status groups. That is, genes may be
less influential on IQ in the presence of greater adversity. Thus, twin and family studies will likely remain integral to future work exam-
ining the complex interplay between genetic and environmental factors in the etiology of psychopathology.
Building from this background on neuroanatomy, neurotransmission, and genetics, we turn next to more specific discussion
regarding the methods and approaches used to elucidate these biological contributors to psychopathology.

Figure 2.4 H
 eritability of Physical Traits and Psychopathology: Heritability estimates for physical traits, dimensions of psychopathology, IQ, and person-
ality traits are depicted in Figure 2.4, in descending order. These percentages refer to the proportion of variation in these traits in the popu-
lation (e.g., height, eye color, IQ, schizophrenia) that is due to genetic factors. Genetic influences are variable, but importantly, are sizeable
and significant for nearly all forms of psychopathology and are equal to, and in some cases, greater than genetic contributions to common
physical traits.
 Psychopathology: A Neurobiological Perspective | 29

Methods and Approaches

Lesion Method

Background
Neuropsychological approaches to the study of personality and psychopathology have long been a mainstay of the field. The logic
is simple and straightforward, and entails observing systematic changes in personality that develop reliably after damage to specific
brain structures (Calamia, Markon, Sutterer, & Tranel, in press). This approach – also called the lesion method – remains a fundamental
and indispensable scientific approach to the study of brain–behavior relationships and psychopathology (e.g., Chatterjee, 2005;
Fellows et al., 2005; Koenigs, Tranel, & Damasio, 2007; Rorden & Karnath, 2004; Sutterer & Tranel, 2017). Counter to the normal
association of “lesion” with “deficit,” the lesion approach has also uncovered intriguing associations whereby persons show improve-
ments in aspects of personality and well-­being following focal brain damage (King et al., in press). Historically, lesion studies pro-
vided the first sources of evidence for specific brain–behavior relationships regarding personality and psychopathology (e.g., the
famous case of Phineas Gage; Harlow, 1868), and many of these early lessons have since been validated with converging evidence
from other methods.
Using the lesion method, researchers can explore the association between focal damage to a particular brain region and impair-
ment in a clearly defined psychological function. If damage to a particular brain region results in impairment to a particular psy-
chological function, it is concluded that the brain region is necessary (albeit not necessarily sufficient) for that function (Damasio &
Damasio, 2003). The lesion method is used in human participants who have incurred focal brain damage due to specific kinds of
disease or injury (e.g., cerebrovascular disease, surgical treatment of epilepsy, tumor resection, focal trauma or infection). Such
“naturally occurring” lesions do not affect all brain regions equally, as different types of brain insults tend to produce damage pref-
erentially in certain areas of the brain. For example, herpes simplex encephalitis tends to affect limbic system structures; surgical
treatment of epilepsy typically involves the anterior-­mesial temporal lobes; and cerebrovascular events (strokes) more commonly
affect the perisylvian regions fed by the middle cerebral artery.

Limitations of the Lesion Method

There are limitations to the lesion method, deriving from both issues of practicality as well as functional resolution. One practical
limitation concerns access to relevant patients. The lesion method is frequently conducted within a medical center, because scientists
need access to neurological patients, and this often requires collaborations with medical specialists including neurologists and neu-
rosurgeons. Assembling reasonably sized groups of patients requires reliable referral pipelines of suitable patients, and scientists
depend on medical specialists for such referrals. The lesion method also has limited functional resolution, owing, in turn, to limita-
tions in both spatial and temporal resolution (see Huettel, Song, & McCarthy, 2004). Even relatively small, focal lesions may not affect
a single functional unit of the brain – and in many instances, lesions affect brain tissue that is involved in multiple functions. Another
challenge arises from the fact that higher-­order functions typically depend on more than one brain area – and this is likely even more
true of functions in the domain of “personality.” Accordingly, damage to a single brain area may not completely impair a function,
because the patient can compensate using other brain structures in the functional system. Another limitation is that researchers obvi-
ously do not make lesions experimentally in humans (different from the case in nonhuman animal research, where lesions can be
made experimentally and true “experimental control” conditions can be achieved). Thus, researchers are dependent on naturally
occurring lesions (stroke, medically indicated resections, etc., as outlined earlier). Such lesions do not occur in all areas of the brain
with equal frequency, and they vary considerably in size and involve different proportions of gray and white matter (Figure 2.5).
Some of these limitations can be overcome with lesion overlap and subtraction approaches, or voxel-­wise lesion symptom
mapping approaches, which yield more precision in mapping lesion-­deficit relationships (Rorden & Karnath, 2004; Rudrauf et al.,
2008; Pustina et al., 2017).
Connectivity among brain areas creates additional challenges. Higher functions, perhaps especially functions such as “person-
ality,” depend on brain networks and not just isolated brain regions, and the networks include both gray matter and the white matter
fiber tracts that connect various cortical regions (Friston, 2000). Specific brain regions reside in a larger, highly interconnected
context, and coordinated processing among distributed networks of brain regions is required for complex functions such as cog-
nition and personality. This appears to be particularly true as the target functions become more intricate and multifaceted, such as
personality, problem solving, and so on – for example, “moving your thumb” can be performed with a small bit of motor cortex,
whereas “feeling happy” requires a more complex network of structures. Within the last few years, investigators have arrived at
broadly similar descriptions of the spatial layout of functional systems of brain regions across the entire human cortex (Figure 2.6)
using correlations of resting state fMRI blood oxygen level dependent (BOLD) signal (Power, Schlaggar, Lessov-­Schlaggar, & Petersen,
2013; Warren et al., 2014).
Despite these limitations, the lesion method has remained the “gold standard” approach to understanding brain–behavior
relationships, especially in regard to complex functions such as personality. The relationship of behavior and cognition to brain
Figure 2.5 Lesion coverage map, showing overlaps of lesions that are represented in the Iowa Neurological Patient Registry. The color key denotes numbers
of lesions overlapping in different brain regions. The map is derived from several hundred patients, and shows that certain areas of the brain
(e.g., temporal poles, middle cerebral artery territory) are more highly sampled by lesions than are other areas (e.g., high midline structures,
occipital cortices).

Figure 2.6 Various brain “networks” that have been derived from resting state functional magnetic resonance imaging studies. The color key denotes 15
various networks, named for known or presumed functional and/­or structural correlates, and also “small systems.” (A) shows the networks
plotted on lateral (upper) and medial (lower) hemispheric views; (B) shows the nature of interconnectivity of the networks. The idea for Fig-
ure 2.6 was inspired by Warren et al., 2014.
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Author: Bernard Bosanquet

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Most recently updated: October 18, 2024

Language: English

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*** START OF THE PROJECT GUTENBERG EBOOK THE

PHILOSOPHICAL THEORY OF THE STATE ***
 Transcriber’s Note: The text is that of the first edition, with the

errata incorporated. Because there are no page breaks, footnotes

are placed under the paragraphs or quotations to which they relate,
and renumbered accordingly. Page numbers have been inserted into
the text in braces.

THE PHILOSOPHICAL THEORY OF THE STATE

BY

BERNARD BOSANQUET

C’est le peuple qui compose le genre humain; ce qui n’est pas

peuple est si peu de chose que ce n’est pas la peine de le compter.
(Émile, livre 4.)

LONDON MACMILLAN AND CO., LIMITED

NEW YORK THE MACMILLAN COMPANY

1899

All rights reserved

GLASGOW: PRINTED AT THE UNIVERSITY PRESS BY ROBERT

MACLEHOSE AND CO.

To: CHARLES STEWART LOCH

 {vii}

PREFACE.

The present work is an attempt to express what I take to be the

fundamental ideas of a true social philosophy. I have criticised and
interpreted the doctrines of certain well-known thinkers only with
the view of setting these ideas in the clearest light. This is the whole
purpose of the book; and I have intentionally abstained from
practical applications, except by way of illustration. It is my
conviction, indeed, that a better understanding of fundamental
principles would very greatly contribute to the more rational
handling of practical problems. But this better understanding is only
to be attained, as it seems to me, by a thorough examination of
ideas, apart from the associations of practical issues about which a
fierce party spirit has been aroused. And, moreover, it is my belief
that the influence of the ideas here maintained upon practical
discussion, would be, in a certain sense, to detach it from
philosophical theory. The principles which I advocate would destroy
so many party prejudices, would put the mind in possession of so
many clues to fact, that practical “social” issues would in
consequence be considered as problems of life and mind, to be
treated only with intimate experience, and by methods adequate to
their subtlety. The {viii} result would be that such discussions would
be regarded, if one may use the expression, more respectfully, and
would acquire an independence and completeness worthy of their
importance. The work of the social reformer should no more be
regarded as a mere appendix to social theory than that of the doctor
is regarded as a mere appendix to physiology. Such a division of
labour is, of course, no hindrance to the interchange of facts and
ideas between theory and practice. On the contrary, it tends to
promote such an interchange, by increasing the supply on either
side, and improving the intellectual communication between them.

It will occur to philosophical readers that the essence of the

theory here presented is to be found not merely in Plato and in
Aristotle, but in very many modern writers, more especially in Hegel,
T.H. Green, Bradley, [1] and Wallace. [2] And they may be inclined
to doubt the justification for a further work on the same lines by one
who can hardly expect to improve upon the writings of such
predecessors.

[1] See especially the chapter in Ethical Studies entitled “My

Station and its Duties.”

[2] See Lectures and Essays by the late Professor Wallace,

especially p. 213, “Our Natural Rights,” and p. 427, “The Relation of
Fichte and Hegel to Socialism.”

On this point I should like to make a brief explanation. To begin

with, it is a truism that every generation needs to be addressed in its
own language; and I might even plead that the greatness of a
tradition justifies some urgency in calling attention to it. But further,
as regards T.H. Green in particular, whom in many points I follow
very closely, I had two special reasons for desiring {ix} to express
myself independently. One of these is to be found in my attempt to
apply the conceptions of recent psychology to the theory of State
coercion and of the Real or General Will, and to explain the relation
of Social Philosophy to Sociological Psychology. For a short
discussion of the Imitation Theory, which the purpose of the present
work would not permit me to include in it, I may refer to a paper
which will shortly appear in Mind.
 My other reason lay in the conviction that the time has gone by for
the scrupulous caution which Green displayed in estimating the value
of the State to its members. I have referred to this subject in the
body of my work (ch. x.); but I desire to emphasise my belief that
our growing experience of all social “classes” proves the essentials of
happiness and character to be the same throughout the social
whole. Scepticism on this point is the product, I am convinced, of
defective social experience. Indeed, it seems worth while to observe
that the attention which is now rightly paid to such disadvantages,
affecting the poorer classes of citizens, as it may be possible to
remedy, has given rise to a serious confusion. The zeal of the
advocate has led him to slander his client. In proving that under
such and such conditions it would be no wonder if “the poor” were
bad, he forgets to observe that in fact they are generally just as
good as other people. The all-important distinction between a poor
home and a bad home is neglected. And yet it seems probable that,
omitting the definitely criminal quarters, there is no larger proportion
of bad homes among the poor than among the rich. Such terms as
“den” and “slum” {x} are too freely used, with an affectation of
intimacy, for homes in which thousands of respectable citizens
reside. Our democratic age will be remarkable to posterity for having
dimmed the time-honoured belief in the virtues of the poor. There
was cant, no doubt, in the older doctrine, but it was not so far from
the fact as the opposite cant of today, and it is time that the truth in
it should be revived.

I must repeat that these remarks are not intended to be

controversial. There is nothing in them which serious men of all
schools may not accept. They are meant to defend my attitude in
treating the Real Will, and Freedom in the greater Self, as matters of
universal concern, and not merely as hopes and fancies cherished by
“educated” persons. Indeed, although it would be churlish for a
student to disparage literary education, it must never be forgotten
that, as things are today, the citizens who live by handicraft possess
a valuable element of brain-culture, which is on the whole denied to
the literary class. Whatever, therefore, may be wanting in the
following pages, it is not, I think, the relation of their subject-matter
to the general life of peoples.

The social student should shun mere optimism; but he should not
be afraid to make the most of that which he studies. It is an
unfortunate result of the semi-practical aims which naturally
influence social philosophers, that they are apt throughout to take
up an indifferent, if not a hostile, attitude to their given object. They
hardly believe in actual society as a botanist believes in plants, or a
biologist believes in vital processes. And hence, social theory comes
off badly. No student can really appreciate an object for which he is
always apologising. There is a {xi} touch of this attitude in all the
principal writers, except Hegel and Bradley, and therefore, as I
venture to think, they partly fail to seize the greatness and ideality of
life in its commonest actual phases. It is in no spirit of obscurantism,
and with no thought of resisting the march of a true social logic, that
some take up a different position. They are convinced that an actual
living society is an infinitely higher creature than a steam-engine, a
plant or an animal; and that the best of their ideas are not too good
to be employed in analysing it. Those who cannot be enthusiastic in
the study of society as it is, would not be so in the study of a better
society if they had it. “Here or nowhere is your America.”

Bernard Bosanquet
Caterham, March, 1899.
 {xiii}

CONTENTS.

CHAPTER I

RISE AND CONDITIONS OF THE PHILOSOPHICAL THEORY OF THE STATE

1-16

1. Meaning of “Philosophical Theory” 1

2. Philosophy and the “State,” 3 a. The Greek City-State 4 b. Type

of mind implied in it 5 c. Type of political philosophy suggested by it
5

3. Transition from City-State to Nation-State. Law of Nature 9

4. Rise of Nation-States and of modern political philosophy.

Rousseau 11

CHAPTER II

SOCIOLOGICAL COMPARED WITH PHILOSOPHICAL THEORY 17-52

1. Problems of Social Physics and of Idealism 17

2. Social Theory as influenced by special sciences 19

(i) Mathematics 19
(ii) Biology 21
(iii) Economics 27
(iv) Jurisprudence and the theory of Right 34
(a) Law as “ideal fact” 34
(b) Sociological analysis of Law 36
 (v) Idea of the “spirit of laws” or mind of peoples;
Anthropology in widest sense 39
(vi) Psychology 42
(vii) Connection of points of view and kinds of fact 47

3. Comparison of Psychological Sociology and Social Philosophy 48

CHAPTER III

THE PARADOX OF POLITICAL OBLIGATION; SELF-GOVERNMENT 53-78

1. The conception of self-government 53

2. Law and Liberty in Bentham 56

3. Examination of Mill’s “Liberty” 60

(i) Mill’s idea of Individuality 60
(ii) His view of the authority of Society over the Individual 61
(iii) His applications of his principle 66

4. Views of Herbert Spencer 69

(i) Spencer and Bentham on Natural Right 70
(ii) Liberty and restraint in Spencer and Huxley 71

5. Mill’s criticism of Self-Government 73

CHAPTER IV

THE PROBLEM OF POLITICAL OBLIGATION MORE RADICALLY TREATED

79-102

1. Nature of above theories not expressed by term Individualism.

“Theories of the first look” 79
 2. Rousseau’s earlier Essays 84

3. Problem of the Contrat Social 87

4. Conflict of ideas in Rousseau’s statement 89

5. Nature of his solution 91

6. Reality of the “Moral Person” and conception of Civil Liberty 94

CHAPTER V.

THE CONCEPTION OF A “REAL” WILL 103-123

1. The Supreme Will in Hobbes and Locke 103

2. Meaning of the General Will for Rousseau 107

3- The General Will contrasted with the Will of All 111

4- The General Will and the work of the Legislator 117

CHAPTER VI

THE CONCEPTION OF LIBERTY AS ILLUSTRATED BY THE FOREGOING

SUGGESTIONS 118-154

1. Liberty as the condition of our being ourselves 118

2. Illustrated by the idea of Nature and Natural 128

3. Phases of idea of Liberty 133

(a) Juristic phase = “absence of restraint” 134
(b) Political phase = “rights of citizenship” 135
 (c) Positive connection of (a) and (b) 136
(d) Philosophical phase = “being oneself in
fullest sense” 137
(e) Danger and justification of using same term
for (a) and (d) 142

4. Liberty as attribute of the will that wills itself 146

5. This “real” will identified with State 149 (a) State in this sense is
social life as a whole 150 (b) How State is force as extension of
“individual” mind 152

CHAPTER VII

PSYCHOLOGICAL ILLUSTRATION OF THE IDEA OF A REAL OR GENERAL

WILL 155-179

1. Object of the Chapter 155

2. Connection between social and mental groupings 156

(1) Analogy between them 156
(i) Associations of persons and of ideas 156
(ii) Organisation of social groups and of ideas 159
(2) Identity of social and mental groupings 170
(i) Social groups as an aspect of mental systems 170
(ii) Individual minds as structures of
appercipient systems 173
(iii) Social whole as a system of mental systems 175

CHAPTER VIII

NATURE OF THE END OF THE STATE AND CONSEQUENT LIMIT OF STATE

ACTION 180-234
 1. Distinction between Individual and Society irrelevant to question
of Social Means and End 180

2. True contrast: Automatism and Consciousness 181

3. End of State, and Means at its disposal qua State 184

4. State can only secure “external” actions 186

5. Principle of the hindrance of hindrances 190

6. State action as the maintenance of rights 201

(a) System of rights from standpoint of community 203
(b) From standpoint of individuals. “Position” 204
(i) As Rights or recognised claims 206
(ii) As Obligations or recognised debts 206
(c) Rights as implying Duties 208
(i) When Duty = Obligation 208
(ii) When Duty = Purpose, which is source of Right 209
(d) Rights, why recognised claims? 210
(i) A “Position” involves recognition 210
(ii) No right based on individual caprice 212

7. State action as punishment 216

(i) Punishment as reformatory 221
(ii) Punishment as retributory 223
(iii) Punishment as deterrent 228

Conclusion. State Action as exercise of a General Will 232

CHAPTER IX
ROUSSEAU’S THEORY AS APPLIED TO THE MODERN STATE: KANT,
FICHTE, HEGEL 235-255

1. Rousseau’s literary influence in Germany 235

2. Freedom and Social Contract in Kant 238

3. Freedom and Social Contract in Fichte 244

4. Freedom in Hegel’s Philosophy of Right 247 (a) Supposed

reactionary tendency in Hegel 248 (b) Relation of analysis and
idealisation 290

5. The Philosophy of Right as a chapter in the Philosophy of Mind

252

CHAPTER X

THE ANALYSIS OF A MODERN STATE. HEGEL’S “PHILOSOPHY OF RIGHT”

256-295

1. Logic of Society as an ideal fact 256

2. Sphere of Right or Law and its sub-divisions 258

3. The Letter of the Law 260

4. The Morality of Conscience 262

5. Social Ethics 266

(i) Social Ethics as an actual world 266
(ii) Social Ethics as the nature of self-consciousness 267
 6. Sub-divisions of Social Ethics. The Family 269 (a) Depends on
natural fact 269 (b) Is factor in the State 270 (c) Ethical and
Monogamous Household 271 (d) Relation to Property 272

7. Bourgeois Society. Justice, State Regulation, and Trade Societies

272

8. The State proper, or Political Constitution 280

9. Public discussion and public opinion 285

10. Criticism of such an analysis of the Modern State 287

CHAPTER XI

INSTITUTIONS CONSIDERED AS ETHICAL IDEAS 296-334

1. The individual soul and the social mind 296

2. Institutions as common substance of minds 297

3. The Family and Property as elements of mind 299

4. The District or Neighbourhood as an element of mind 304

5. Class as an element of mind. “The Poor” as an ethical idea 310

6. The Nation-State as an element of mind 320

7. Morality of public and private action 322

8. Humanity as an element of mind 328 (a) Humanity not

predicable of mankind as a whole 328 (b) Humanity does not =
mankind as a true community 329 (c) Dichotomous expressions for
humanity and mankind 330 (d) The self beyond any actual society;
Art, Philosophy, Religion 332

INDEX 335

{1}

CHAPTER I.

RISE AND CONDITIONS OF THE PHILOSOPHICAL THEORY OF THE STATE

1. First, it will be well to indicate, in a very few words, what is

implied in a “philosophical theory,” as distinguished from theories
which make no claim to be philosophical. The primary difference is,
that a philosophical treatment is the study of some thing as a whole
and for its own sake. In a certain sense it may be compared to the
gaze of a child or of an artist. It deals, that is, with the total and
unbroken effect of its object. It desires to ascertain what a thing is,
what is its full characteristic and being, its achievement in the
general act of the world. History, explanation, analysis into cause
and conditions, have value for it only in so far as they contribute to
the intelligent estimation of the fullest nature and capabilities of the
real individual whole which is under investigation. We all know that a
flower is one thing for the geometrician, another for the chemist,
another for {2} the botanist, and another, again, for the artist. Now,
philosophy can of course make no pretension to cope with any one
of the specialists on his own ground. But the general nature of the
task imposed upon it is this: aiding itself, so far as possible, by the
trained vision of all specialists, to make some attempt to see the full
significance of the flower as a word or letter in the great book of the
world. And this we call studying it, as it is, and for its own sake,
without reservation or presupposition. It is assumed, then, for the
purpose of a philosophical treatment, that everything, and more
particularly in this case the political life of man, has a nature of its
own, which is worthy of investigation on its own merits and for its
own sake. How its phases come into being, or what causes or
conditions have played a part in its growth, are other questions well
worthy of investigation. But the philosophical problem is rather to
see our object as it is and to learn what it is, to estimate, so to
speak, its kind and degree of self-maintenance in the world, than to
trace its history or to analyse its causation.

Yet such phrases as “what it is” and “for its own sake” must not
mislead us. They do not mean that the nature of any reality which
we experience can be appreciated in isolation from the general world
of life and knowledge. On the contrary, they imply that when fully
and fairly considered from the most thoroughly adequate point of
view, our subject matter will reveal its true position and relations
with reference to all else that man can do and can know. This
position and these relations constitute its rank or significance in the
totality {3} of experience, and this value or significance—in the
present case, what the form of life in question enables man to do
and to become—is just what we mean by its nature “in itself,” or its
full and complete nature, or its significance when thoroughly studied
“for its own sake” from an adequate point of view. Further
illustrations of the distinction between an adequate point of view
and partial or limited modes of consideration, and of the relations
between the former and the latter, will be found in the following
chapter.
 2. In a certain sense it would be true to say that wherever men
have lived, there has always been a “State.” That is to say, there has
been some association or corporation, larger than the family, and
acknowledging no power superior to itself. But it is obvious that the
experience of a State in this general sense of the word is not co-
extensive with true political experience, and that something much
more definite than this is necessary to awaken curiosity as to the
nature and value of the community in which man finds himself to be
a member.

Such curiosity has been awakened and sustained principally if not

exclusively by two kindred types of associated life—the City-state of
ancient Greece, and the Nation-state of the modern world. It will
throw light on the nature of our subject if we glance rapidly at the
characteristics to which it is due that political philosophy began in
connection with the former, and revived in connection with the latter.

In considering the Greek city-states in connection with the birth of

political philosophy, there are three points which press upon our
attention:{4}
a. the type of experience which they presented;
b. the type of mind which that experience implied; and
c. the type of interpretation which such a mind elicited from
such an experience.

a. A Greek city-state presented a marked contrast to the modes of

human association which prevailed in the non-Greek world. It
differed from them above all things by its distinct individuality. No
doubt there was a recognisable character in the life and conduct of
Egypt or of Assyria, of Phoenicia or of Israel. But the community
which has a youth, a maturity, and a decadence, as distinct as those
of a single human being, and very nearly as self-conscious; which
has a tone and spirit as recognisable in the words and bearing of its
members as those of a character in a play; and which expresses its
mind in the various regions of human action and endurance much as
an artist expresses his individuality in the creations of his genius—
such a community had existed, before the beginnings of the modern
world, in the Greek city-state, and in the Greek city-state alone. A
political consciousness in the strict sense was a necessary factor in
the experience of such a commonwealth. The demand for
“autonomy”—government by one’s own law,—and for “isonomy”—
government according to equal law—though far from being always
satisfied, was inherent in the Greek nature; and its strenuousness
was evinced by the throes of revolution and the labours of legislation
which were shaking the world of Greece at the dawn of history. The
very instrument of all political action was invented, so far as we can
see, by the Greeks. The simple device by which an orderly vote is
{5} taken, and the minority acquiesce in the will of the majority as if
it had been their own—an invention no less definite than that of the
lever or the wheel—is found for the first time as an everyday method
of decision in Greek political life.

b. Such a type of experience implies a corresponding type of

mind. It is not surprising that science and philosophy should owe
their birth to the genius from which politics sprang. For politics is the
expression of reason in the relations that bind man to man, as
science and philosophy are the expression of it in the relations which
link together man’s whole experience. The mind which can recognise
itself practically in the order of the commonwealth, can recognise
itself theoretically in the order of nature. And ultimately, though not
at first (for curiosity is awakened by objects perceived in space and
time, before attention is turned to the very hinge and centre of
man’s own being), science passes into philosophy; and mind, and
conduct, and the political consciousness, are themselves made
objects of speculation. It has become a commonplace that this
transference of curiosity from the outer to the inner—really, that is,
from the partial to the total world—took shape in the work of
Socrates, who invested with the greatness of his own intelligence
and character a movement which the needs of the age had rendered
inevitable. And thus there arose the ethical and political philosophy
of Plato and Aristotle, the successors of Socrates, just at the time
when the distinctive political life of Greece was beginning to decay.

c. This philosophy, like all genuine philosophy, {6} was an

interpretation of the experience presented to it; and in this case the
interpretation was due to minds which were themselves a part of the
phenomena on which they reflected. Such minds, hostile as they
may feel themselves to the spirit of the age, and however
passionately they may cry out for reform or for revolution, are none
the less its representatives; and their interpretation, though it may
modify and even mutilate the phenomena, will nevertheless be
found to throw the central forces and principles of the time into the
clearest light. So Plato’s negative treatment of the family, and of
other elements which seem essential to Greek civilisation, was no
bar to his grasping, and representing with unequalled force, the
central principle of the life around him. The fundamental idea of
Greek political philosophy, as we find it in Plato and Aristotle, is that
the human mind can only attain its full and proper life in a
community of minds, or more strictly in a community pervaded by a
single mind, uttering itself consistently though differently in the life
and action of every member of the community. This conception is
otherwise expressed by such phrases as “the State is natural,” i.e. is
a growth or evolution, apart from which the end implied in man’s
origin cannot be attained; “the State is prior to the individual,” i.e.
there is a principle or condition underlying the life of the human
individual, which will not admit of that life becoming what it has in it
to be, unless the full sphere or arena which is constituted by the life
of the State is realised in fact. The whole is summed up in the
famous expression of Aristotle, “Man is a creature formed for the life
of the City-state.” The {7} working out of this idea, as we find it in
Plato’s commonwealth, is bizarre to our minds; but its difficulty really
lies in its simplicity and directness; and there is no sound political
philosophy which is not an embodiment of Plato’s conception. The
central idea is this: that every class of persons in the community—
the statesman, the soldier, the workman—has a certain distinctive
type of mind which fits its members for their functions, and that the
community essentially consists in the working of these types of mind
in their connection with one another, which connection constitutes
their subordination to the common good. This working or adjustment
obviously depends in the last resort on the qualities present in the
innermost souls of the members of the community; and thus the
outward organisation of society is really as it were a body which at
every point and in every movement expresses the characteristics of
a mind. We must not pause here to follow up the consequences of
such a conception; but it will be seen at once, by those who reflect
upon it, to imply that every individual mind must have its qualities
drawn out in various ways to answer to—in fact, to constitute—the
relations and functions which make up the community; and that in
this sense every mind is a mirror or impression of the whole
community from its own peculiar point of view. The ethical
assumption or principle of Plato’s conception is, that a healthy
organisation of the commonwealth will involve, by a necessary
connection, a healthy balance and adjustment of qualities in the
individual soul, and vice versa. An attempt will be made to illustrate
this principle further in the latter portion {8} of the present work.
The general nature of Plato’s conception—the characteristic
conception of Greek political philosophy—is all that concerns us here.

It is important to observe that during the very genesis of this

philosophical conception of society, an antagonistic view was
powerfully represented. The individual could not freely find himself
in the community unless he was capable of repudiating it; the
possibility of negation, as a logician might express it, is necessary to
a really significant affirmation. Thus we find in the very age of Plato
and Aristotle the most startling anticipations of those modern ideas
which seem diametrically opposed to theirs. We find the idea of
nature identified not with the mature fulness, but with the empty
starting point of life; we meet with the phenomena of vegetarianism,
water-drinking, the reduction of dress to its minimum, in short, the
familiar symptoms of the longing for the “return to nature,” with all
that it implies; we find law and political unity treated as a tissue of
artifice and convention, and the individual disdaining to identify
himself with the citizenship of a single state, but claiming to be a
stranger in the city and a citizen of the world. To prove that these
ideas were not without their justification, it is enough to point out
that in some instances they were accompanied by a polemic against
slavery, which, as a form of solidarity, was upheld in a qualified
sense at least by Aristotle. The existence of this negative criticism is
enough to show how distinctly the Greek intellect set before itself
the fundamental problem of the relation between the individual and
society, and of how high a quality was the bond of union which {9}
maintained this relation in such intimacy among minds of a temper
so analytic.
 3. Many writers have told the story of the change which came
over the mind of Greece when the independent sovereignty of its
City-states became a thing of the past. For our purpose it is enough
to draw attention to the fact that with this change the political or
social philosophy of the great Greek time not only lost its supremacy,
but almost ceased to be understood. From this period forward, till
the rise of the modern Nation-states, men’s thoughts about life and
conduct were cast in the mould of moral theory, of religious
mysticism and theology, or of jurisprudence. The individual
demanded in the sphere of ethics and religion to be shown a life
sufficing to himself apart from any determinate human society—a
problem which Plato and Aristotle had assumed to be insoluble.
Stoicism and Epicureanism, the earliest non-national creeds of the
western world, triumphantly developed the ideas which at first, as
we saw, were little more than a rebellion against the central Socratic
philosophy. Cosmopolitanism, the conception of humanity, the ideal
of a “Society of Friends”—the Epicurean league—from which women
were not excluded, and the precept of “not expecting from life more
than it has to give,” take the place of the highly individualised
commonwealth, with its strenuous masculine life of war and politics,
and its passionate temper which felt that nothing had been
accomplished so long as anything remained undone.

With this change of temper in the civilised world there is brought

into prominence a great deal of {10} human nature which had not
found expression through the immediate successors of Socrates. In
the period between Aristotle and Cicero there is more than a whisper
of the sound which meets us like a trumpet blast in the New
Testament, “neither Jew nor Greek, barbarian nor Scythian, bond
nor free.” But the unworldliness which took final shape in Christianity
was destined to undergo a long transmigration through shapes of
other-worldliness before it should return in modern thought to the
unity from which it started; and the history of ethics and religion has
little bearing upon true political theory between the death of
Aristotle and the awakening of the modern consciousness in the
Reformation.

In so far as the political ideas of antiquity were preserved to

modern times otherwise than in the manuscripts of Plato and
Aristotle, the influence which preserved them was that of Roman
Jurisprudence. The Roman rule, though it stereotyped the state of
things in which genuine political function and the spur of freedom
were unknown, had one peculiar gift by which it handed to posterity
the germs of a great conception of human life. This is not the place
to describe at length the origin of that vast practical induction from
the working of the “foreigners’ court” at Rome which obtained for
itself the name of the Law of Nations, and which, as tinged with
ideal theory, was known as the Law of Nature. Whatever fallacies
may be near at hand when “natural right” is named, the conception
that there is in man, as such, something which must be respected, a
law of life which is his “nature,” being indeed another name {11} for
his reason, and in some sense or other a “freedom” and an
“equality” which are his birthright—this conception was not merely a
legacy from Stoic ideas, which had almost a religious inspiration, but
was solidly founded on the judicial experience of the most practical
race that the world has ever seen.

4. In order that the forces which lay hidden in the conception of

Natural Right and Freedom, like the powers of vegetation in a seed,
might unfold themselves in the modern world, it was necessary that
conditions should recur analogous to those which had first elicited
them. And these earlier conditions were those of the Greek City-
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