1

UNDERSTANDING ABNORMALITY:
DEFINITION, CLASSIFICATION
AND ASSESSMENT

Unit Structure
1.0 Objectives
1.1 Introduction
1.2 What is Abnormal Behaviour
1.2.1 Defining Abnormality
1.2.2 Challenges Involved in Characterising Abnormal
Behaviour
1.2.3 What causes Abnormality
1.3 The Diagnostic and Statistical Manual of Mental Disorders
1.3.1 How the DSM Developed
1.3.2 Controversial Issues Pertaining to the DSM
1.3.3 Definition of Mental Disorder
1.3.4 Assumptions of the DSM-IV-TR
1.4 Psychological Assessment
1.4.1 Clinical Interview
1.4.2 Mental Status Examination
1.5 Behavioural Assessment
1.6 Multicultural Assessment
1.7 Environmental Assessment
1.8 Physiological Assessment
1.9 Summary
1.10 Questions
1.11 Suggested Readings

1.0 OBJECTIVES :

After reading this unit you will be able to:

Understand what is meant by abnormality and the difficulties in
defining it.
Discuss the factors involved in the development of abnormality.
Describe the development and use of the Diagnostic and
Statistical Manual of Mental Disorders.
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Explain how Psychological Assessment is carried out with the

help of Clinical interviews and Mental Status Examination.
Understand Behavioural, Multicultural, Environmental and
Physiological assessment.

1.1 INTRODUCTION :

Efforts to understand, explain and control problematic

behaviours can be traced back to several years. Abnormal
Psychology is the systematic study of abnormal behaviour - it is a
branch of psychology that is concerned with the etiology,
symptomatology and the process of mental illnesses. In this
chapter we will examine what is meant by deviant or abnormal
behaviour?

After defining abnormality we will discuss the challenges

involved in characterising abnormal behaviour as well as the
causes of abnormality. Following this we will discuss the
Diagnostic and Statistical Manual of Metal Disorders and related
topics.

The concept of psychological assessment, behavioural

assessment, multicultural assessment, environmental assessment
and physiological assessment would be discussed with relevant
examples.

1.2 WHAT IS ABNORMAL BEHAVIOUR?

Lets consider the following case.

Raju, 26 year old, was laughing when he was brought to the

ward by the nurse - looked like he was having a good time. Before the
nurse could introduce him to the staff, he said, Cricket, I love cricket! I
have never played cricket in my life but that is what I am going to do
while I am here. I am going to become the worlds best cricket player!
He then went on to talk about his mother and then suddenly described
what he had for dinner the previous night. Few days back, Raju had
spent all his money and that of his elderly parents and bought an
expensive professional camera. Without any formal training in
photography, he thought he could set up the best studio in the city and
make lot of money.

Does anything about Raju seem strange? How would you

feel if you were to see someone like Raju walking in your
neighborhood? You could be surprised or scared or may even
laugh. You may think there is something abnormal about this
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person. On what basis is Raju judged to be abnormal? Is it because

the way he is talking is odd? Or since he is making tall claims? Or
because one cannot anticipate how he may behave after a while?

Anything that deviates from the normal or differs from the

usual or typical is called abnormal. However there can be
exceptions and certain very unusual behaviours may also be
considered normal in the given cultural/social context.

Thus, there are certain criteria that help us define abnormality

and also distinguish between what is normal and abnormal.

1.2.1 Defining Abnormality

The current diagnostic procedures used in the mental health
community rely on four important ways in which abnormality can be
defined.

Impairment: According to this criterion, maladaptive behaviours

that prevent an individual from functioning in daily life can be
considered abnormal. Impairment refers to a reduction in a
persons ability to function at an optimal or average level. For
example, when a woman consumes psychoactive substances
(drugs), her cognitive and perceptual abilities are impaired and she
would be at risk if she drives in this state. In certain situations, the
person may report feeling great and describe oneself in positive
terms but those around may suggest that s/he is functioning
inadequately in her/his personal or work life. In the case mentioned
earlier, Raju spent all his savings to set up a studio due to impaired
judgement.

Distress: This criterion suggests that behaviours should be

considered abnormal if the individual suffers discomfort as a result
of the behaviours and wish to get rid of them. The experience of
distress - emotional or physical pain is common in life. However,
here the intensity of pain is so high that it interferes with the
persons daily living. For example, a victim of an extremely
traumatic event may experience unrelenting pain or emotional
turmoil and may not be able to cope in daily life.

Risk to Self or Other People: When an individuals actions pose a

threat to ones own life or to the life of others, the behaviour is
considered to be abnormal. A severely depressed individual is at
risk for committing suicide and therefore the condition is referred to
as abnormal. Similarly, a person suffering from Schizophrenia is out
of touch with reality and may put oneself and/ or others at risk. In
some situations, a persons thoughts and behaviours threaten the
physical or psychological wellbeing of others and are therefore,
considered abnormal such as the act of abusing children or
exploiting others.
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Socially and Culturally Unacceptable Behaviour: Behaviours

that are not in line with the social or cultural norms are considered
abnormal. Certain behaviours may be acceptable in some cultures
but considered odd in certain others. For e.g., In India, the
phenomenon of being possessed by God is a common practice
during Navratri or other festivals, but the same behaviour would be
considered abnormal in most of the other countries. Thus, the
social context needs to be taken into account while judging
behaviour as normal or abnormal.

1.2.2 Challenges Involved in Characterising Abnormal

Behaviour
Although there are clear criteria for defining abnormality,
diagnosing abnormal conditions is not as straightforward as it may
seem. In 1973, David Rosenhan conducted a classic study that
threw light on the difficulties involved in this process - 8 sane
individuals were able to trick the staff of 12 psychiatric hospitals
across the United States. Each of them was gainfully employed and
presented oneself at these hospital reporting hearing voices such
as Empty, Hollow, and Thud. These kind of psychotic
symptoms were chosen because they had never been reported in
the history of psychiatric literature.

Except their names and employment, none of their other

details were changed and thus their history and present behaviour
(except for the symptoms) could not be considered abnormal in any
way. Interestingly, all the hospitals admitted these pseudopatients
and although they stopped producing the symptoms immediately
following the admission, none of the staff members noticed it. On
the contrary, their ordinary actions were taken as additional
evidence of their abnormality.

What was most striking was the inhuman approach of the

staff - the pseudopatients felt as if nobody from the staff was
concerned about their needs. Also, the staff didnt believe them
when they tried to convince them that they were actually normal.
The pseudopatients were released in 7 to 52 days and at
discharge, each of them had received a diagnosis of schizophrenia
in remission, which meant that their symptoms were not present, at
least during that time.

Rosenhan (1973) concluded that what prevented the hospital

staff from detecting the pseudopatients normality is the general
bias to call a healthy person sick. Since this study involved
deception of the mental health professionals, it was criticised for
ethical reasons. Questions pertaining to why a control group was
not used for comparison were raised. It was also said that since the
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symptoms reported (hallucinations) were of a serious nature, most

clinicians would have done what the hospital staff did.

Scribner (2001) found that Rosenhans controversial study had

led to an extreme change in the mental health field where now
patients with diagnosable psychotic symptoms had difficulty
receiving mental health services. He reported 7 cases with
documented history of chronic Schizophrenia, 6 of which were not
treated even while they were in the active phase of symptoms.

Lauren Slater (2004) attempted to replicate Rosenhans study

- she went to several clinicians complaining hearing thud and no
other symptom. She was denied admission everywhere and at the
most, diagnosed with depression with psychotic symptoms,
prescribed some medication and sent away. She also reported that
as opposed to the pseudopatients experience in the Rosenhan
study, she was treated very kindly by every mental health staff.

Thus, inspite of the criticisms, Rosenhans study proved to

be crucial in pointing out that the attitudes towards diagnosing and
admitting individuals with psychological difficulties need to change.

1.2.3 What causes Abnormality?

There are certain assumptions about the causes of abnormality - if
one considers the biological approach, one might think that the
abnormal behaviours are caused by a biological factor such as
genetic vulnerability to a disorder, inherited from a parent.

If one takes the psychological approach, one might assume

that the early childhood experiences or the self concept are
responsible for the symptoms. Looking at it from the social
perspective, one might think that the symptoms stem from the
interpersonal relationships or the social environment in which an
individual lives.

What is often asked is whether the cause is biological or

psychological or social? This is referred to as the nature-nurture
question - is the abnormality caused by something in the nature or
biology of the person or due to nurturing factors like life
experiences.

Social scientists are of the view that there is an interaction

between these factors and have used the term biopsychosocial
to denote the same. The diathesis-stress model suggests that a
person must carry some risk to the disorder in order to develop it.
This vulnerability can be biological - inheriting disordered genes, it
may be psychological - a faulty personality trait, or social - a history
of abuse or poor interpersonal relations. In addition to this, for the
disorder to develop, one must experience some kind of stress or
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trigger. This stress could be biological - an accident or illness that

changes the neurotransmitter balance, psychological - perceived
loss of control, or social - a traumatic event.

The full-blown disorder can develop only when the

vulnerability combines with the stress. Also, a feedback loop tends
to develop, such that, changes in one system lead to changes in
the second and then the changes in the second system bring about
changes in the first. For example, an increase in a certain
neurotransmitter (biological factor) may make an individual angry
and irritable (psychological factor). This may cause the person to
react angrily towards his friends, who may begin avoiding him
(social factor) due to this behaviour. The rejection from friends
(social factor) may make the person even more agitated, which
may cause further changes in the neurotransmitters (biological
factor).

Although the theoretical approaches are discussed in detail

in topic 2, lets have a brief look at the biopsychosocial factors
involved in the development of abnormality.

Biological causes:
In understanding what causes abnormality from the biological
perspective, mental health professionals focus on the processes
in a persons body, such as genetic inheritance or physical
disturbances.
Many disorders run in the family. For example, the chances of
the son or daughter developing schizophrenia are greater if
either of their parents is suffering from it as compared to
children of parents who do not have the disorder.
Other factors such as medical conditions (thyroid), brain
damage (head trauma), exposure to certain environmental
stimuli (toxic substances, allergens), ingestion of certain
medicines, illicit drugs, etc., can cause disturbances in the
physical functioning that cause emotional or behavioural
disturbances.

Psychological causes:
Traumatic life experiences that have an impact on the
individuals personality constitute the psychological factors in
the development of abnormality. For example, an irrational fear
of the marketplace may be caused due to a childhood
experience of having been lost in the market.
Early interpersonal relationships may lead to distortions in
perception and faulty thought processes. For example, a boy
who is very upset because his girlfriend didnt call back may
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realise that his reaction stems from his history of being

disappointed by his unreliable parents, and having internalised
the idea that important people tend to disappoint.
Unrealistic expectations, learned helplessness, focussing on the
negative, blaming, dichotomous thinking (seeing things as black
or white), catastrophising (exaggerating) etc., can trigger
psychological difficulties.

Sociocultural causes:
The term sociocultural refers to the sources of social influence
in ones life. The most immediate circle that has an impact on a
person comprises of the family members and friends - troubled
relationships can make one feel depressed. Similarly, a failed
lover may become suicidal.
The next circle involves extended family, neighbours with whom
there is less interaction. Nonetheless their behaviours,
standards, attitudes and expectations do influence individuals.
The society plays a decisive role in most peoples lives. Political
turmoil, even at the local level can leave one feeling anxious or
fearful. Discrimination on the basis of gender, caste, sexual
orientation, disability can have an impact on individuals. As
seen earlier, social and cultural norms determine what would be
called abnormal, to a large extent.

1.3 THE DIAGNOSTIC AND STATISTICAL MANUAL

OF MENTAL DISORDERS :

Mental health professionals refer to the Diagnostic and

Statistical Manual of Mental Disorders (DSM) for standard terms
and definitions of various forms of abnormality. It is a
classification system that includes descriptions of all
psychological disorders, which are also known as mental
disorders.
The DSM, published by the American Psychiatric Association
(APA), is periodically revised to incorporate the latest
information related to psychological disorders. The DSM was
first published in 1952 and since then has gone through several
changes with its latest version being DSM-IV-TR (text revision).
To develop revised editions of the DSM, task forces are
appointed which comprise of clinicians and researchers with
expertise in specific disorders. On the basis of their research, a
list of several disorders ranging from mild adjustment problems
to severe disorders has been developed.
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The DSM ensures standardised interpretation of the diagnostic

labels and also provides a common language and format for
communication between clinicians and researchers.
Its multiaxial format (explained later in the chapter) also
allows thorough evaluation of cases with attention to the mental
disorders, general medical conditions, psychosocial problems
and the level of functioning, which might get ignored if the focus
were on evaluating only the presenting complaints.
The recent editions of the DSM follow an atheoretical approach,
that is, they try to present psychological disorders in a manner
that reflects observable phenomena rather than what caused it.
For example, anxiety disorders are described in terms of the
associated psychological and physical symptoms associated
with no reference to what caused these symptoms.
The DSM classification system also helps in treatment planning.
For example, a clinician would choose very different treatment
plans for individuals with anxiety disorders as compared to
those with psychotic illnesses. Also, every DSM-IV diagnosis
has specific numerical code, which helps individuals acquire
health insurance to manage the treatment cost.
The authors of the DSM have tried to develop a reliable and
scientifically and clinically sound system such that anyone
showing a specific set of symptoms receives the same
diagnosis across clinicians, irrespective of their theoretical
orientation.
Emphasis has also been on the ensuring its validity - the extent
to which the diagnostic criteria measure a specific disorder and
how well the disorders can be distinguished from each other.
For this, the experts have been required to take into account the
base rate of a disorder - that is, the frequency with which a
disorder is found among the general population. Low base rate
means fewer cases and therefore establishing the reliability of
the disorder becomes difficult.

1.3.1 How the DSM Developed

The DSM was the first official classification system that was
developed exclusively for diagnosing mental disorders. Lets look at
the history of the DSM - the initial editions of this manual were not
as precise and reliable as the recent ones.
The DSM-I, the first edition published in 1952, followed a
theoretical approach where mental disorders were seen as an
individuals emotional reactions to his problems.
The DSM-II which was published in 1968, tried to introduce
explicit definitions and diagnostic terms that would reduce
reliance on theoretical assumptions.
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In 1974, the APA appointed a team of scholars and

practitioners to develop a manual that would be based on
observable phenomena and acceptable to clinicians irrespective
of their theoretical orientation. This led to the DSM-III, published
in 1980.
Although the DSM-III was a refined edition, it had instances in
which the diagnostic criteria were not entirely clear. Due to this,
the DSM-III-R was published in 1987 as an interim manual till a
more complete edition was developed.
Around the same time, the APA once again set up a task force
that worked towards improving the reliability and validity of the
diagnoses, in stages. In stage 1, its members reviewed the
relevant research published which was then carefully analysed
in stage 2. The next stage involved field trials in which several
thousand individuals with diagnosed psychological disorders
were interviewed. Consistency in diagnosis was assessed by
having pairs of clinicians independently rate clients through
videotaped interviews. To establish the validity of the diagnosis,
clinicians evaluated individuals diagnosed with specific
psychological disorders, with the number and nature of
symptoms needed to diagnose specific conditions. These field
trials helped to empirically decide the specific kind and number
of symptoms that would make a diagnostic criteria. For
example, to diagnose Major Depressive Disorder, a person has
to have atleast five out of the nine listed symptoms which
include lack of interest, sad mood, disturbed sleep, disturbed
appetite, feelings of worthlessness, etc.
Thus, the DSM-IV was published in 1994. A major feature of this
version was that it included the symptoms cause clinically
significant distress or impairment in social, occupational or other
areas of functioning as one criterion for almost half of all the
disorders.
The DSM-IV with updated information, known as DSM-IV-TR
(text revised) was published by 2013.
Researchers have begun working on the DSM-V which may
be published in the coming years.

1.3.2 Controversial Issues Pertaining to the DSM

For many years, critics of the DSM have argued that it tends to
unfairly label people and is not a very reliable and valid tool. It is
also suggested that politics and culture have influenced the
definitions of disorders from time to time. For example,
homosexuality was included as a diagnostic category in the
DSM-II and was removed following protests from gay activists at
the APA annual conferences from 1970 to 1973. Also, pressure
from the Vietnam War veterans forced the authors of DSM-III to
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recognise that a group of symptoms experienced by survivors of

traumatic events represented a disorder and thus post-traumatic
stress disorder was introduced. This demonstrates the biased
processes involved in defining mental disorders.
In addition to this, the DSM classification system is criticised for
being prejudiced against women, in that women are more likely
to be diagnosed with personality or mood disorders because
feminine personality characteristics are perceived as being
pathological. As a result of this, the authors of the DSM-IV have
been particularly careful about basing their decisions on fair
interpretation of the research data (Kirk & Kutchins, 1992;
Kutchins & Kirk, 1997).

1.3.3 Definition of Mental Disorder

The concept of mental disorders is fundamental to the

processes of diagnoses and treatment. The authors of the DSM
define a mental disorder as a clinically significant behavioral or
psychological syndrome or pattern that occurs in an individual that
is associated with present distress (e.g., painful symptom)
or disability (i.e., impairment in one or more areas of functioning) or
with a significantly increased risk of suffering death, pain, disability,
or an important loss of freedom and it is not typical or culturally
expected.

Lets understand this definition.

A mental disorder is clinically significant - this implies that

the symptoms have to be present for a specified period of time
and should have a major effect on the persons life. Thus, an
occasional low mood or strange behaviour or a sense of
instability are common experiences and do not represent a
mental disorder.

A mental disorder is behavioral or psychological syndrome

or pattern - a syndrome is a collection of defined symptoms. A
behavioural or psychological syndrome indicates a set of
observable actions and the thoughts and feelings reported by
the individual. Accordingly a random thought or behaviour does
not constitute a mental disorder. A person has to experience a
wide range of defined thoughts, feelings and behaviours in order
to be called as having a psychological disorder.

Further, it is associated with present distress, disability,

impairment or serious risk. This means that the syndrome
sufficiently interferes with the individuals everyday functioning.
For example, a woman who compulsively washes hands may
be very disturbed by her actions and may not be able to
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overcome the behaviour. Her productivity at work and social life

may also be severely affected by this.

In certain mental disorders the person may not experience

any distress but there may be a serious risk to life. For example,
a person in a hyperexcited state of mania, having a good time,
may believe he can fly and is thus at risk.

Finally, the disorder is not a culturally expected or

sanctioned pattern. For example, a woman feeling sad, having
difficulty eating, sleeping, concentrating, etc., for few days,
following the death of her husband, will not be called as
suffering from Major Depressive Disorder because it is an
expected reaction to this event.

1.3.4 Assumptions of the DSM-IV-TR

The DSM is based on some assumptions:

1.) Medical Model: The DSM follows a medical model which

means that every physical and psychological disorder is
regarded as a disease. In this sense the DSM is similar to the
ICD, the International Classification of Diseases (ICD),
developed by the World Health Organisation, and ensures
uniformity in the usage of medical terms. Thus, according to this
view, Schizophrenia is a disease and the individual suffering
from it is referred to as patient. The use of the term mental
disorder is also in line with this view. Although the term mental
disorder implies a distinction between mental disorders and
physical disorders, it is important to recognise that there arent
any fundamental differences between mental disorders and
general medical conditions. Mental disorders tend to involve
biological factors and similarly physical disorders have
psychological components.

The term general medical conditions (Axis III) is used only as a

convenient format to refer to illnesses that are not listed under
mental disorders.

2.) Atheoretical Orientation: The authors of the DSM have tried to

develop a descriptive rather than explanatory classification
system, that is, a psychological disorder is presented as an
observable phenomenon rather than in terms of what caused it.

The DSM is neutral with respect to the theories of causality.

For example, the DSM-IV-TR classifies social phobia as an
anxiety disorder in which the person has persistent fear of social
or performance situations, without any reference to whether the
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anxiety is caused due to a childhood trauma or an unconscious

conflict or any other factor.

The early editions of the DSM were based on the

psychoanalytical tradition in which mental disorders were seen
as neurosis or an emotional reaction to ones problems and
were thought to be a result of unconscious conflicts. The term
neurosis is not a part of the DSM anymore but is still commonly
used to describe symptoms that are distressing and do not have
a physiological basis. The term is also used to refer to
excessive anxiety or worry and to distinguish the condition from
psychosis.

Psychosis involves the presence of hallucinations (false

perceptions) and delusions (false beliefs). It is a condition in
which the person is not in touch with reality and shows grossly
disturbed and bizarre behaviour. Psychosis is not a diagnostic
category but used as a descriptive term in the DSM-IV-TR.

3.) Categorical Approach: The DSM-IV-TR classifies the

disorders into separate categories. For instance, conditions
which involve excessive anxiety or worry are categorised as
anxiety disorders, those which affect the mood are referred to
as mood disorders. Although systematic, this approach has a
limitation - psychological disorders cannot be very neatly
separated from one another. For example, it is difficult to
distinguish between sad mood and clinical depression (severe
enough to receive a diagnosis of depression). Also, some cases
involve a mixed presentation such a person experiencing
anxiety and sad mood or mood symptoms with psychosis.

Due to this, a dimensional approach is being considered,

that is, instead of fitting an individuals symptoms into some
category s/he would receive a numerical rating on his symptoms
indicating the severity of each. The dimensional model is
thought to give a better picture of the individuals condition.

There are two issues related to the categorical approach.

One is comorbidity, that is, conditions in which a person has two
or more disorders that co-exist. For instance, negative
emotional states are common in anxiety disorders, mood
disorders and some personality disorders. The second is that of
boundaries - some disorders have overlapping symptoms, such
as conduct disorder, oppositional defiant disorder and attention-
deficit/hyperactivity disorder (Widiger & Samuel, 2005).
4.) Multiaxial system: This system involves assessing five areas
of an individuals functioning so that the treatment can be
planned accordingly and the course of the disorder can be
predicted. The DSM comprises of five axes:
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Axis I: Clinical Disorders and Other Conditions That May Be a

Focus of Clinical Attention
This axis is used for listing the various forms of abnormality,
that is, the clinical syndromes or disorders with the exception of the
Personality Disorders and Mental Retardation, such as
schizophrenia, the different types of anxiety disorders, such as
social phobia, specific phobia, generalised anxiety disorder,
obsessive compulsive disorder, etc., mood disorders such as major
depressive disorder, bipolar disorder, etc., adjustment disorders,
cognitive disorders like delirium, dementia, amnestic disorder, etc.
If an individual has more than one Axis I disorder, all should be
reported with the primary reason for the visit being listed first.

Axis II: Personality Disorders and Mental Retardation

All the Personality Disorders like Paranoid personality
disorder, Schizoid personality disorder, Schizotypal personality
disorder, Antisocial personality disorder, Narcissistic personality
disorder, etc., and Mental Retardation are reported on Axis II.
Maladaptive personality features or excessive use of defense
mechanisms can also be mentioned here. This axis ensures that
the unhealthy personality characteristics and mental retardation will
be taken into account while attending to the primary complaint.

Axis III: General Medical Conditions

This axis is for reporting the general medical conditions that
are important in understanding an individuals mental disorder.
General medical conditions may be related to the mental disorders
in several ways. In some cases they may play a role in the
development of an Axis I disorder, for example, Hypothyroidism
may lead to depressive symptoms in some or an individual may
develop an Adjustment disorder as a reaction to the diagnosis of
Brain tumour. In certain cases medical conditions may influence the
treatment of the Axis I disorder, for instance, a persons heart
disease may influence the clinicians choice of medicines for this
patients depression.

Axis IV: Psychosocial and Environmental Problems

The psychosocial and environmental problems that influence
the diagnosis, treatment and prognosis (future course) of mental
disorders listed on Axis I and/or II are reported on this axis. This
includes a negative life event, interpersonal stresses, lack of social
support, etc. These problems may influence the development or
treatment of mental disorders or may develop as a result of the Axis
I/II condition.
Axis V: Global Assessment of Functioning
This axis is for reporting the clinicians judgement of the
individuals overall functioning, which is useful in treatment planning
or predicting its outcome. The Global Assessment of Functioning
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(GAF) scale is used to rate the individuals psychological, social

and occupational functioning. For example, score of 100 means
superior functioning with no symptoms while a score of 50 indicates
serious symptoms.

91-100 Superior functioning in a wide range of activities, life's

problems never seem to get out of hand, is sought out by
others because of his or her many positive qualities. No
symptoms.
81-90 Absent or minimal symptoms (e.g., mild anxiety before an
exam), good functioning in all areas, interested and involved
in a wide range of activities, socially effective, generally
satisfied with life, no more than everyday problems or
concerns (e.g., an occasional argument with family
members).
71-80 If symptoms are present, they are transient and expectable
reactions to psychosocial stressors (e.g., difficulty
concentrating after family argument); no more than slight
impairment in social, occupational, or school functioning (e.g.,
temporarily falling behind in school work).
61-70 Some mild symptoms (e.g., depressed mood and mild
insomnia) OR some difficulty in social occupational,
or school functioning (e.g., occasional truancy or theft within
the household), but generally functioning pretty well, has
some meaningful interpersonal relationships.
51-60 Moderate symptoms (e.g., flat affect and circumstantial
speech, occasional panic attacks) OR moderate difficulty in
social, occupational, or school functioning (e.g., few friends,
conflicts with peers or co-workers).
41-50 Severe symptoms (e.g., suicidal ideation, severe obsessional
rituals, frequent shoplifting) OR any serious impairment in
social, occupational or school functioning (e.g., no friends,
unable to keep a job).
31-40 Some impairment in reality testing or communication (e.g.,
speech is at times illogical, obscure, or irrelevant) OR major
impairment in several areas, such as work or school, family
relations, judgment, thinking, or mood ( e.g., depressed man
avoids friends, neglects family, and is unable to work; child
frequently beats up younger children, is defiant at home, and
is failing at school).
21-30 Behavior is considerably influenced by delusions or
hallucinations OR serious impairment in communication or
judgment (e.g., sometimes incoherent, acts grossly
inappropriately, suicidal preoccupation) OR inability to
function in almost all areas (e.g., stays in bed all day, no job,
home, or friends).
11-20 Some danger of hurting self or others (e.g., suicidal attempts
without clear expectation of death; frequently violent; manic
excitement) OR occasionally fails to maintain minimal
personal hygiene (e.g., smears feces) OR gross impairment
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in communication (e.g., largely incoherent or mute).

1-10 Persistent danger of severely hurting self or others (e.g.,
recurrent violence) OR persistent inability to maintain minimal
personal hygiene OR serious suicidal act with clear
expectation of death.0 Inadequate information.

1.4 PSYCHOLOGICAL ASSESSMENT - CLINICAL

INTERVIEWS AND MENTAL STATUS
EXAMINATION :

Psychological assessment refers to gathering and

integration of psychological data for the purpose of a psychological
evaluation through the use of tests, interview, observation, etc.

This kind of an assessment is carried out in order to arrive at

a diagnosis for an individual with a mental disorder, to determine
the individuals intellectual capacity, to predict how suitable a
person is for a job and to assess if a person is competent to stand
trial.

There are various techniques used in assessment of which

we will discuss two - the clinical interview and the mental status
examination.

1.4.1 Clinical Interview:

This is the most common method used to understand the client, his
presenting problem, history and future goals. The interview involves
asking questions in a face-to-face interaction. The clinician may
audiotape or videotape the details or note them down during or
after the interview. There are two kinds of clinical interviews:

Unstructured Interview:
In this type of an interview, the client is asked open-ended
questions related to his or her presenting problem, the family
background and life history.
The term unstructured is used to indicate that the interviewer is
free to ask questions in any order and frames them in a manner
that he prefers. The clients response to the previous question
and nonverbal cues such eye-contact, posture, tone of voice,
etc., guide the interviewer in this process.
The interviewers approach is influenced by the purpose of the
interview. A clinician who wants to arrive at a diagnosis would
ask questions related to the clients symptoms, such as changes
in mood, sleep pattern, disturbance in appetite, nature of
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thoughts, etc., their onset, duration and progress, medical or

psychiatric history if any, etc.
Some clients seek help for personal issues such as disturbed
relationships and may not have a diagnosable psychological
disorder. In such cases the interviewer would try to enquire
about the reasons for the clients distress.
A significant part of an unstructured interview is history taking,
which involves asking questions related to personal history such
as major life events since childhood, academic interest and
performance, number of friends and leisure activities, work life,
marriage, habits, etc., and family history such as numbers of
family members, close relatives and relationships with them,
atmosphere at home, history of illnesses in the family, etc.
This gives the clinician a picture of the clients world and may
also help draw connections between the clients current problem
and a traumatic event in early life.

Structured and Semistructured Interviews:

The structured interview gives less freedom to the clinician as it
involves asking a set of predetermined questions in a fixed
order. The semistructured interview also has a standardised set
of questions but the interviewer can ask follow up questions to
clarify the clients responses, if needed.
The advantage of structured and semistructured interviews is
that they help make accurate diagnosis. Some of these are
designed to cover a wide range of psychological disorders while
others are meant to diagnose specific conditions such as a
Schizophrenia or Mood or Anxiety disorder.
The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)
is a commonly used structured interview while the Structured
Clinical Interview for DSM-IV-TR Axis I disorders (SCID-I) and
the Structured Clinical Interview for DSM-IV Personality
disorders (SCID-II) are examples of semistructured interviews
(despite the word structured).
The World Health Organisation (WHO) and the U.S. Alcohol,
Drug and Mental Health Administration (ADAMHA) have
developed the Composite International Diagnostic Interview
(CIDI), which is an assessment tool that has been translated in
many languages and can be used with people from different
cultures.

1.4.2 Mental Status Examination:

The mental status means what the client thinks, feels and how the
client thinks, speaks and behaves. The mental status examination
 17

or the MSE is used to assess the clients thoughts, feelings and

behaviour and identify symptoms. An example of a structured MSE
is the mini-mental status examination (MMSE) which is very useful
in assessing patients with cognitive disorders such as Alzheimers
disease. The MSE report is based on the clients responses and the
clinicians objective observations of the clients appearance, speech
and behaviour. Following are the components of the MSE:

1.) Appearance and Behaviour: The clinician carefully looks for

any peculiarities in the clients appearance and overall
behaviour as this can give an insight into her/her mental state.
Clinicians are interested in the clients motor behaviour, that is,
the movements. Anxious patients tend to fidget or pace around
while some others tend to move about in a sluggish manner.
Overactivity can be seen in the form of hyperactivity which
refers to increased physical activity and quick movements or
psychomotor agitation which is characterised by agitation and
excessive motor and cognitive activity. Some patients show
psychomotor retardation, that is, visible slowing of thoughts,
speech and movements. Strange mannerisms, stereotyped
movements and vocal or motor tics (involuntary muscular
movements) are seen in some others.

In extreme cases, motor abnormalities may manifest as

catatonia which is seen in psychotic patients. Some of these
patients constantly maintain an immobile position (catalepsy) or
assume bizarre postures or can be moulded into a position that
is then maintained (waxy flexibility).

Compulsion is a form of motor disturbance in which there is

an uncontrollable impulse to perform an act repeatedly. For
example, counting the fingers or scratching ones nose before
answering every question, chanting a particular mantra every
few minutes, etc.

2.) Orientation: This refers to ones awareness of time, place and

person. In some disorders the patients sense of themselves
and the surrounding is disturbed. This is important in diagnosing
cognitive disorders such as Delirium, Dementia, Amnesia and
also psychotic disorders like Schizophrenia.

3.) Content of Thought: Disturbances in the thought process

occurs in various forms. Some patients have an obsession,
which means an intrusive, repetitive, thought, image or impulse
which causes distress. For example, thoughts of being unclean
or contaminated, that is often accompanied by the compulsion
of washing hands.
 18

Another form of disturbance in thought content is delusions.

These are unshakable, false beliefs which cannot be corrected
through logical reasoning, for example, a man may believe that
he is a messenger of God who has been sent on Earth for a
special mission. Delusions can be of different types:

Grandeur: A persons exaggerated conception of ones

importance, power, beauty or identity.
Control: False feeling that a persons will, thoughts or feelings
are being controlled by external forces. One form of this
delusion is thought broadcasting in which the person believes
that his/her thoughts can be heard by others as if they were
being broadcast over the air. Likewise, thought insertion is a
delusional belief that others are implanting thoughts in a
persons mind.
Reference: False belief that others actions refer to oneself or
that others are talking about him/her.
Persecution: False belief that the person him/herself or a loved
one is being harassed, cheated or mistreated by someone.
Self-blame: False feeling of regret or guilt in which the person
holds him/herself responsible for some wrongdoing.
Somatic: False belief involving body functions such the belief
that the brain is rotting or melting.
Infidelity: False belief associated with pathological jealousy
about a persons lover being unfaithful.

There are overvalued ideas which refer to unusual thoughts

of a bizarre nature but they are not as rigid as delusions. For
example, a man who believes that his credit card number should
end with the digit 6 and refuses to accept a new credit card with a
different last number. Magical thinking involves seeing a
connection between two events which would seem unrelated to
most people. For example, a woman may believe that every time
she buys things from a particular shop her husband loses a
contract.

Overvalued ideas and magical thinking do not indicate that

the person has a mental disorder but suggests some psychological
decline. Violent thoughts such suicidal ideas or thoughts of harming
or killing another person also need to be assessed.

4.) Thinking Style and Language: An individuals style of thinking

is manifested through his or her speech. For example, speaking
to person with Schizophrenia or other forms of psychosis can be
 19

difficult because their language may be illogical. Examples of

thought disorder:

Incoherence: The speech is not clear and understandable.

For example, the ice-cream threw the poodle that is not here.
Loosening of associations: Ideas expressed are unrelated.
For example, Suma is nice person but there is lot of poverty in
the world and I am going to cut my hair tomorrow.
Illogical thinking: Thoughts that has wrong conclusions. For
example, a person who likes milk thinks she must be a cat.
Neologisms: New words created, often by combining syllables
of other words. For example, I saw some snarks today that
were boredomly bad.
Blocking: Sudden interruption in the train of thought before the
idea is finished.
Circumstantiality: Indirect speech that is delayed in reaching
the point by bringing in lot of irrelevant details.
Tangentiality: Going off on a different point without coming to
the original idea.
Clanging: Association of words similar in sound but not in
meaning. For example, That is Ross, there is so much moss,
the coin will toss.
Confabulation: Making up ideas to fill in gaps in memory. This
is not an attempt to lie but to give the most possible answer. For
example, when one is not very sure if he has had breakfast and
is asked what he had eaten, he may give an elaborate account
of a typical breakfast.
Echolalia: Pathological repeating of words or phrases of one
person by another.
Flight of ideas: Rapid, continuous shifting from one idea to
another in which ideas tend to be connected.
Pressure of speech: Rapid speech as if the person feels forced
to speak continuously.
Perseveration: Continuing with a response to a previous
question or stimulus after a new question or stimulus is
presented.

5.) Affect and Mood: Emotion is a complex feeling state with

somatic, cognitive and behavioural components. Affect refers to
an observed expression of emotion. While assessing the affect,
the clinician checks if it is appropriate (condition in which
 20

emotional tone is in harmony with the accompanying idea) or

inappropriate (disharmony between the feeling tone and the
thought or idea accompanying it).

The intensity of affect, that is, its strength is also noted. The
affect is described as blunted affect when there is a severe
reduction in the intensity of externalised feeling tone and as flat
affect when signs of affective expression are absent or nearly
absent, the face is immobile and voice is monotonous. On the
other hand, exaggerated or heightened or overdramatic
affect is reported when the emotional expression is very strong.
The range of affect in terms of the variety of emotional
expressions noted is also taken into account.

Mood is a pervasive and sustained state of emotion that one

feels inside. Mood may be described as dysphoric (unpleasant
feelings such as sadness or irritability), euphoric (very cheerful
with feelings of grandeur), euthymic (normal range of mood;
absence of depressed or elevated mood), angry, anxious, etc.

6.) Perceptual Experiences: Some psychological disorders are

characterised by disturbances in perception. The clinician
enquires about these by asking whether the patient hears
voices or sees things that others are unaware of. Hallucinations
are false sensory perceptions in the absence of real external
stimuli. These are different from illusions in which there is
distortion of a real stimulus such misperceiving a rope as a
snake. Hallucinations can involve any of the five senses:

Auditory hallucinations are the most common and involve

hearing sounds or voices (usually insulting comments such
as you are dumb) or conversations. Command
hallucinations are those in which one hears instruction to act
in a certain way.
Visual hallucinations involve seeing images of objects or
persons. For example, a person may claim to see God or
ones spouse who has passed away.
Olfactory hallucinations are uncommon and refer to false
perception of smells such as unpleasant odours.
Gustatory hallucinations are false perceptions of taste
usually unpleasant in nature.
Somatic hallucinations involve false sensations pertaining
to the body, usually tactile such as crawling sensation on or
under the skin.

7.) Sense of Self: Some psychological disorders affect the

persons identity or the sense of who am I. Depersonalisation
 21

is a phenomenon in which the person feels he is unreal, strange

or unfamiliar with himself. For example, one may feel that his
mind and body are not connected. One may also experience
identity confusion which involve a lack of clear sense of who
one is, what ones role is, etc.

8.) Motivation: In some psychological disorders, the patients lose

interest in all activities to the extent that even ordinary tasks
such as having a bath or dressing may seem difficult. Some
may not be willing to put in any effort to change and might find
their familiar state of distress better than the uncertainty of
facing new challenges.

9.) Cognitive Functioning: During the MSE, the clinician attempts

to judge the clients general intellectual capacity from the
answers given by the client, on questions related to attention
and concentration, memory, ability to think in an abstract
manner, etc. For instance, in case a clients memory is severely
impaired, the clinician might suspect a neurological condition
such Alzheimers disease. Here, the clinician doesnt administer
an IQ test but rather gets a general idea about the clients
cognitive abilities.

10.) Insight and Judgement: The clinician is also interested in

seeing whether the client understands ones own difficulties.
Insight refers to a persons ability to understand the true cause
and meaning of a situation. For example, a person who has
paranoid delusions may be very defensive and unable to see
things objectively, showing poor insight.

Judgment is the ability to assess a situation correctly and to

act appropriately in the situation. Clients who are severely
impaired may not be in a position to make correct decisions and
this may result in harm to self or others. Thus, checking the
clients judgment gives the clinician an idea of protective
measures that may have to be initiated.

1.5 BEHAVIOURAL ASSESSMENT :

Behavioural assessment involves systematic recording of an

individuals behaviour in order to identify problem behaviours, the
factors that help maintain these behaviours and decide techniques
to modify the undesirable behaviours. Clinicians use various
methods such as behavioral interviews, observational methods -
naturalistic observation/ controlled observation, self-monitoring,
role-playing, inventories, checklists, etc., of which behavioural self-
report and observation are most common.
Behavioural Self-Report:
 22

This is a method in which the client provides information about

how frequently certain behaviours occur, either through an
interview or by monitoring oneself and filling up checklists or
inventories developed for this purpose.
The advantage of self-report is that it helps obtain critical
information about the clients behaviours which others would not
have access to.
Behavioural interviews involve a detailed enquiry into what
happens before, during and after the behaviour in question. In
understanding the before factors, the clinician may ask
questions such as when and where does the behaviour occur,
does the behaviour occur in presence of any particular person
or stimulus, etc.
Particulars of the during phase may be found out with the help
of questions such as how many times and for how long does the
problem behaviour occur, what happens first, what follows that,
etc.
The client is also asked about the consequence of the
behaviour in terms of what effect does it have or how does it
benefit him or her. For example, in case of a client who wants to
give up smoking, the clinician may be interested in knowing how
frequently the person smokes in a day, any specific time and
place at which he smokes, does he smoke in the company of
certain people, what triggers the smoking behaviour, what the
client thinks and feels after smoking, etc.
Thus, the extensive information obtained helps set realistic
goals and devise strategies to change the undesirable
behaviour.
Another behavioural self report technique is self monitoring,
which involves keeping a record of the frequency of the problem
behaviour such as, number of cigarettes or calories consumed,
number of times the client bit her nails or had unwanted
thoughts or got angry.
The client is trained to note the time, place and relevant
information pertaining to the target behaviour. Self-monitoring is
a very useful technique because it may lead to important
insights, for example, a woman may realise that she tends to
eat more while watching the television or when she is distracted.
Behavioural checklists or inventories help to find whether certain
events or experiences have occurred. For example, the
Conners Ratings Scales-Revised uses self and observer ratings
to assess attention deficit hyperactivity disorder and determine
the number and nature of undesirable behaviours present.
 23

Checklists and inventories are quite commonly used in the

clinical set up because they are easy to use and economical.

Behavioural Observation:
In this method, the clinician observes and records the frequency
of the behaviour in question, including any other relevant
situational variables. For example, a nurse may be asked to
observe the number of times a patient washes her hands and
also her reactions when she is prevented from doing that. Or a
trained observer may record the number of times a child leaves
his place or speaks out of turn.
In observing the clients, the clinician first selects the problem
behaviour on the basis of an interview, direct observation or
using behavioural checklists or inventories. The problem
behaviour is then broken down into behavioural terms, that is, it
is defined. For example, temper tantrum would be defined in
terms of crying and shouting.
Selecting vague target behaviours is inappropriate in
behavioural observation because it makes measurement
difficult. For example, violent behaviour cannot be measured
unless specified as breaking things around or whichever is the
behaviour exhibited.
It is best to observe the target behaviour in the natural setting
and this kind of behavioural observation is known as in vivo
observation. In assessing a child with attention deficit
hyperactivity disorder, a clinician is likely to get an accurate
picture of the childs problem behaviours if he is observed in the
classroom or at home rather than in the lab or clinic.
While using this method the clinician has to be careful about the
clients reactivity - the knowledge of being observed can
influence the target behaviours. In order to avoid these
problems, the client may be observed through a one-way mirror.
In some situations, others may be included and the clients
interaction with them may be observed with focus on the target
behaviours.

1.6 MULTICULTURAL ASSESSMENT :

In the process of assessment, the clinician needs to be

sensitive to the cultural, racial and ethnic background of the client.
There is a growing emphasis on developing culture fair tests and
being careful while administering and interpreting psychological
tests as the background from which the client comes can seriously
influence the test performance. For example, while assessing a
client whose mother-tongue is not English, the clinician needs to
 24

ensure that the instructions are followed and that the clients scores
are interpreted on the basis of norms developed for that specific
group. Also, certain phrases or behaviours may have multiple
meanings and are likely to be misunderstood by the clients. Thus,
the clinicians are required to have to sufficient knowledge of the
clients cultural background and critically evaluate the tests to see if
they are designed for use with the specific group to which the client
belongs.

1.7 ENVIRONMENTAL ASSESSMENT :

As seen earlier, the environment that surrounds a person

has a tremendous impact on his/her life. Psychologist Rudolf Moos
has developed Environmental assessment scales in which
individuals provide ratings on aspects of the environment that are
thought to influence behaviour. This includes the various circles of
social influence in ones life such as the family, the neighbourhood,
the school and the society at large. For example, in the Family
Environment Scale is used to assess aspects of the clients family
such as the nature of relationships between the family members.
Nature of relations, such as cohesiveness and identification with
family members, expression of emotions, etc; the activities that the
family engages such as what do the members do for recreation or
how are responsibilities shared, attitudes / beliefs of the family
members, etc.

Another example is the Global Family Environment Scale, a

cross-cultural tool that measures factors such as the extent to
which the family provides good physical and emotional care, secure
attachments, consistency and discipline.

These scales can be used to assess the home environment

of children / adolescents with behavioural disorders, excessive
anxiety, etc., and thus help clinicians get insight into the family
dynamics of the client and understand its impact on the clients
condition.

1.8 PHYSIOLOGICAL ASSESSMENT :

It is important to understand the biological basis of behaviour

as all psychological problems are manifested in the body. Due to
this physiological assessment becomes a part of the evaluative
process.
Psychophysiological Assessment

Psychophysiological assessment involves the use of

instrumentation to monitor psychophysiological processes,
based on the idea that psychological experiences are
 25

associated with definite physiological components such as

changes in heart functioning, muscles, skin, brain, etc.
The electroencephalogram (ECG) is used to monitor whether
the heart is functioning normally. A measure of the blood
pressure gives an estimate of any excessive or damaging
pressure of the blood against the walls of the blood vessels.
This helps to assess the risk for developing any stress-related
heart conditions.
The electromyography (EMG) is an instrument which is used to
measure muscle tensing/contraction associated with stress and
to rule out conditions such as headaches.
Individuals tend to sweat excessively when they are tensed -
this leads to changes in the electrical properties of the skin and
can be measured with the help of the galvanic skin response
(GSR).

Brain Imaging Techniques

Various techniques that construct pictures of the structure

and function of the brain have been developed since the 1970s:

The Electroencephalogram (EEG):

The EEG measures the electrical activity in the brain that
indicates ones level of arousal, that is, whether one is alert,
resting, sleeping or dreaming.
The procedure involves pasting electrodes onto the scalp with
an electricity-conducting gel. The machine picks up the brain
activity and a device called the galvanometer, which has an ink
pen attached to it, writes continuously creating wave-like
patterns on moving paper strip.
The EEG shows a distinct pattern of brain waves depending on
the mental activity one engages in. Thus, the EEG recording
helps in assessing conditions such as epilepsy in which
convulsions are caused by disturbed neural activity, sleep
disorders, brain tumors, etc.
An abnormality in the EEG patterns is used as a basis for
further investigations. In recent years computerised
interpretations of the EEG have made objective evaluation
possible. The computer can convert specific EEG patterns into
colour-coded plots.
For example, low amplitude areas are shown in black or blue
while high amplitude areas are highlighted in yellow and red.
These colourful images help understand the patterns of
electrical activity throughout the surface of the brain and are
useful for diagnosis.
 26

Computerised Axial Tomography (CAT CT scans):

This is a technique in which one lies down with the head in a
large X-ray tube. Highly focused beam of X-rays is then passed
through the brain from many different angles. Differing densities
of the different brain regions result in different deflections
(bending) of the X-rays.
The deflection is greater in case of dense tissue such as bones
and it is least in case of fluid. The X-ray detectors gather the
readings taken from multiple angles and a computerised
program constructs an image of the brain in the form of slices
(tomo means slice in Greek).
This method helps obtain a cross sectional slice of the brain
from a specific angle or level. For example, CT scans can
provide images such as the fluid filled ventricles in the brain,
showing differences in the brains of people with and without
Schizophrenia.

Magnetic Resonance Imaging (MRI):

This technique uses magnetic fields and radio waves to produce
high quality two or three dimensional images, based in the water
content of the different tissues. The person undergoing an MRI
lies inside a tunnel-like structure that surrounds the person with
a strong magnetic field.
The activity of the electromagnetic energy from several angles,
through a computer program is converted into a high resolution
image of the scanned region. The MRI images are quite detailed
and can detect tiny changes of structures within the body.
Using the MRI, trauma to the brain can be seen as bleeding or
swelling. Sometimes tumours that go undetected in CT scans
can be seen in MRI. It is also used in identifying brain
dysfunction in specific disorders.
For example, one study compared the MRIs of women with
Major Depressive Disorder (MDD) and controls on a task in
which they had to learn objects paired with faces displaying six
emotions. It was seen that women with MDD had difficulty
learning the pairs and also showed larger amygdala (part of the
limbic system that is involved in emotional responsiveness).
However, when both the above factors were taken together,
only women with MDD and larger amygdala were found to do
poorly on the learning task. This suggests that the memory
deficit may have resulted from changes in the brain triggered by
MDD (Weniger, Lange & Irle, 2006).
 27

Functional Magnetic Resonance Imaging (fMRI):

This is a new technique and a specialised MRI which relies on
the idea that when an area of the brain becomes active due to
mental processing, the blood flow to that region increases.
This scan is called functional MRI because it shows the brain
as it is functioning while performing a mental task and is
therefore very useful in psychological assessment.
The fMRI produces images of the active brain regions when one
processes information. This is done by showing regions with
increased activity in different colours reflecting high and low
levels of blood flow. The advantage of this technique is that it
shows the brain in action rather than just its physical structures.

Positron Emission Tomography (PET), Singe Photon Emission

Computed Tomography (SPECT):
This is another brain imaging technique that involves injecting a
radioactively labelled compound into the persons veins which
binds itself to the oxygen in the blood.
This compound travels to the brain through the blood and emits
positively charged electrons (positrons), which are detected by
the scanner. A computer program then converts this into images
showing the structure and function of organs and tissue.
Bright colours at the red end indicate greater activity in the
brain while colours at the blue-green-violet end suggest lower
activity. Thus, any kind of mental activity will result in lighting up
a region of the brain.

Neuropsychological Assessment
Neuropsychological assessment involves assessing brain
functioning from how an individual performs on certain
psychological tests.
Two best known test batteries that are used for
neuropsychological evaluation are the Halstead-Reitan Battery
and the Luria-Nebraska Neuropsychological Battery.
The Halstead-Reitan is used to differentiate between the brain
damaged individuals and the neurologically intact and
comprises of subtests such as category test, tactual
performance test, rhythm test, speech-sounds perception test,
time sense test, aphasia screening test, finger-oscillation test,
etc. This may often be combined with the MMPI-2 to get a
measure of the individuals personality and the WAIS-III to
assess cognitive functioning.
 28

The Luria-Nebraska test assesses a wide range of cognitive

functions such as memory; motor functions; rhythm; tactile,
auditory and visual functions; receptive and expressive speech;
writing; spelling; reading and arithmetic.
This test is extremely sensitive for identifying specific types
of problems such as dyslexia and dyscalculia rather giving
global impressions of brain dysfunction. Also as compared to
the Halstead-Reitan battery, this test is administered faster and
is more standardised.
The Neuropsychological Assessment Battery (NAB) is another
instrument that can be administered within 4 hours and includes
modules on attention, language, memory, spatial functions,
executive functions, etc.
The reliability and validity of neuropsychological tests may be
affected by mood states (anxiety and depression), motivation
and also effects of medication.

1.9 SUMMARY :

In this unit we had defined abnormality and discussed the

four important ways in which abnormality can be defined. Changes
involved in characterising abnormal behaviour were also discussed.
Following this we had discussed the various causes of abnormality.
The concept of Diagnostic and Statistical Manual of Metal
Disorders was also discussed along with various controversial
issues pertaining to the DSM. The concept of psychological
assessment was discussed. The important instruments of
psychological assessment, i.e., clinical interview as well as mental
status examination were discussed. Various types of assessment
such as multicultural assessment, environmental assessment,
physiological assessment were also discussed.

1.10 QUESTIONS :

Q.1 Discuss the various ways in which abnormality can be defined.

Q.2 Discuss the Diagnostic and Statistical Manual of Mental
Disorders.
Q.3 Write short notes on
a) Definition of Mental Disorder
b) Assumptions of DSM-IV-TR
c) Five Axis of DSM
Q.4 Explain Clinical Interview and its types.
Q.5 Write a detailed note on Mental Status Examination.
 29

Q.6 Write short notes on the following.

a) Behavioural Assessment
b) Multicultural Assessment
c) Environmental Assessment
Q.7 Discuss the different types of Physiological Assessment.

1.11 SUGGESTED READINGS :

1. Barlow David H and Durand M.V. Abnormal Psychology,

(2005), New Delhi.
2. Halgin R.P. and Whitbourne S.K. (2010) Abnormal
Psychology, Clinical Perspectives on Psychological Disorders,
(6th Ed.), McGraw Hill.

 30

2
THEORETICAL PERSPECTIVES

Unit Structure
2.0 Objectives
2.1 Introduction
2.2 The Purpose of Theoretical Perspectives in Abnormal
Psychology
2.3 Psychodynamic Perspective
2.4 Humanistic Perspective
2.5 Sociocultural Perspective
2.6 Behavioural and Cognitively Based Perspectives
2.7 Biological Perspective
2.8 Biopsychosocial Perspective on Theories and Treatment :
An Integrative Approach
2.9 Summary
2.10 Questions
2.11 Suggested Readings

2.0 OBJECTIVES :

After reading this topic you will be able to:

Explain how theoretical orientation of the clinicians and

researchers determines the way they perceive abnormal
behaviour.
Critically evaluate the psychodynamic, humanistic, sociocultural,
behavioural and cognitively based and biological perspectives of
Abnormal Psychology.
Understand the integrative biopsychosocial approach to the
theories and treatment of psychological disorders.

2.1 INTRODUCTION :

Causation of abnormal behaviour is one important areas of

psychopathology. Many different theoretical perspectives have
been developed to conceptualise and explain the various causes of
 31

abnormal behavior. In this unit we will discuss the most prominent

theoretical perspectives. We will begin with the purpose of
theoretical perspectives and then discuss the psychodynamic
perspective. Some important concepts of psychodynamic
perspectives would be discussed. We will also study about post
Freudian scholars and evaluate the psychodynamic perspective.

Humanistic perspective developed in 1950s out of works of

Carl Rogers, Abraham Maslow and others. Person centered and
self actualisation theories as well as treatment based on it would be
examined. We will also evaluate the humanistic theories.

Socio-cultural factors are also taken in to consideration while

understanding and assessing abnormal behaviour. Among the
socio-cultural perspectives family perspective on psychopathology
would be discussed. Similarly, Social discrimination and Social
influences and historical events would be studied. Treatment based
on socio-cultural perspective such as family therapy, group therapy,
multicultural approach, milieu therapy would also be briefly
discussed. Following this socio-cultural perspective will be
evaluated.

Behavioral and cognitively based perspective is an important

theoretical v:ew point expressed in writings of Ivan P. Pavlov in his
classical conditioning, B.F. Skinner in his operant conditioning, etc.
Social learning and social cognition developed late in 1960s and
grew out of behavioral perspective. It was developed by Albert
Bandura. Cognitive based theory developed out of the work of
Aaron Beck and Albert Ellis. Treatment approaches based on
cognitive perspective include conditioning techniques, contingency
management techniques, modeling and self efficacy training and
cognitive therapies.

Biological perspectives include the nervous system and its

role in the development of abnormal behavior. Under this we will
discuss the role of genetics, models of genetic transmission and the
treatments based on biological perspectives such as
Psychosurgery, Electroconvulsive therapy, TMS, DBS, Medication,
etc. All these, including evaluation of biological perspective, would
be discussed.

Towards the end of this unit we will discuss the

biopsychological perspective on theories and treatment.
 32

2.2 THE PURPOSE OF THEORETICAL

PERSPECTIVES IN ABNORMAL PSYCHOLOGY :

This chapter focuses on what causes abnormality. There are

different schools of thought that vary in their beliefs and
assumptions about what leads to abnormal behaviours and how
they can be treated. In this chapter we will critically evaluate five
major theoretical perspectives that are influential in this field.

The theoretical orientation of the clinicians and researchers

determine how they perceive abnormal behaviour. In practice, most
experienced clinicians follow an eclectic approach, that is, they put
together concepts and techniques from several theoretical
perspectives.

2.3 PSYCHODYNAMIC PERSPECTIVE :

The psychodynamic view emphasises on the idea that

behaviour is primarily influenced by unconscious factors. The term
psychoanalytical is used to refer to Freuds ideas while the term
psychodynamic covers a broader perspective that focuses on
unconscious processes as well as various other factors that are
thought to influence behaviour.

Freuds Psychoanalytic theory

Freud was a neurologist from Vienna who became interested in

unconscious processes while working with Jean Charcot.
Freuds theory was controversial because he wrote extensively
about the role of sexual instincts during a period when sex was
not discussed openly.

He was of the opinion that early childhood experiences are the

most influential in determining ones personality. He believed
that events that occur in childhood deeply impact the
unconscious mind and these experiences continue to influence
an individual in his adulthood.

This idea was based on Freuds analysis of his own dreams,

thoughts and early childhood memories. He also realised that by
recollecting the memory of his traumatic train ride at the age of
4, he was relieved from some very disturbing symptoms.

Being a medical student he was convinced that disorders of the

mind could be studied scientifically and that they are caused by
physiological processes.
 33

Structure of Personality: Id, Ego and Superego

According to Freud, the psyche comprises of three

structures - the id, ego and the superego and used the term
psychodynamics to explain that our behaviour is the result of a
complex interaction between these structures.
Id: The id is the most primitive part of the unconscious mind and
contains sexual and aggressive instincts. It is based on the
pleasure principle and needs immediate satisfaction of its desires.

An unfulfilled desire or impulse creates tension and only when it

is satisfied that one experiences pleasure. The id tries to
achieve pleasure from the actual gratification of needs as well
as wishful thinking.

Freud uses the term primary process thinking to indicate ids

attempts to satisfy needs by forming wish-fulfilling mental
images of the desired objects. In other words, primary process
thinking satisfies motives in imagination rather than reality.
Fantasising about your enemy, being beaten up or having your
favourite desert is an instance of primary process thinking.

Ego: This part of the personality has conscious awareness and

enables the individual to perceive, use judgment, memory and
make decisions necessary to adapt to the environment.

It also helps to transform the wishes and fantasies of the id into

reality. It works on the reality principle which makes the
individual face the constraints and difficulties of the external
world.

The ego engages in secondary process thinking, a more logical

and rational way of solving problems. For example, suppose a
man has an argument with his wife and as a result gets delayed
and misses his bus. In this case primary process thinking would
probably make him curse wife whereas secondary process
thinking would help him look for a solution such as finding an
alternate way of reaching his destination.

According to Freud, the ego doesnt have a motivating force and

draws its energy from ids energy that is the libido. He also
believed that although the ego reflects conscious awareness,
one is unaware of certain aspects of the ego. This includes,
memories of events in which one has been self centered or
cruel or aggressive or behaved in sexually unacceptable ways.

Superego: This refers to ones conscience and is the part of the

psyche that guides the egos efforts of gratifying the impulses and
 34

desires of the id. The superego represents the dos and donts of
the society that one has internalised. Freud was of the opinion that
if it werent for the superego, man would have tried to seek
inappropriate and unacceptable forms of pleasure such as rape,
murder, etc.

Defense Mechanisms: Defenses are strategies to protect oneself

from unpleasant and disturbing emotions. For example, if one is
feeling guilty about getting poor marks in the exam, blaming the
teacher for being partial may make him feel better. Defense
mechanism can be healthy if used in moderation. The problem
arises when they are used rigidly and in excess, so much so that it
can give rise to psychological disorders.

Adaptive Defenses: These are healthy ways of coping with stress.

Some of the healthy and adaptive defenses include the following.
a.) Humor: Focusing on the funny / lighter aspects of a situation.
Example: Mohan joked about how he slipped and fell down
during the conference.

b.) Self-assertion: Dealing with distress by expressing ones

thoughts, feelings directly. Example: Asha told her husband
that she was let down when he cancelled their dinner plan at the
last moment.

c.) Suppression: A conscious attempt to avoid unpleasant or

disturbing thoughts or ideas. Example: Sheena decided to
avoid thinking about her recent break up so that she could
concentrate on her studies.

d.) Sublimation: Channelising ones energies in socially desirable

ways.
Example: Betrayed in love, Mona decided to do her PhD on the
dynamics of romantic relationships.

Mental Inhibition: These are unconscious strategies to keep

unwanted thoughts, feelings, memories, desires, out of conscious
awareness.

a.) Displacement: Transferring an unpleasant emotion onto a non-

threatening stimulus. Example: Being scolded her mom, Rita
slaps her doll.

b.) Dissociation: Withdrawing or distancing oneself from the

unpleasant memories, aspects of self or the environment.
Example: While being shouted at by the teacher, Gopal
withdrew into his fantasy world thinking about his favourite
dinner being cooked at home.
 35

c.) Intellectualisation: Excessive emphasis on external reality or

irrelevant details to avoid expression or experience of emotion.
Example: Sumit who is getting divorced talks excessively about
the validity of marriage as a social institution.

d.) Reaction formation: Changing an unacceptable feeling or

desire into the opposite. Example: Roma who feels jealous of
her younger brother showers him with lot of gifts.

e.) Repression: An unconscious attempt to push disturbing

thoughts or ideas out of awareness. Example: Jay can not
recollect the traumatic death of his friend.

Minor Image-Distorting Defenses: These are tactics in which an

individual derives his self-esteem by altering or misrepresenting the
image of self, the body or others.

a.) Devaluation: Dealing with distress by assigning negative

characteristics to oneself or others. Example: Roshan feels that
she doesnt get good marks because of low intelligence and
lack of proper guidance.

b.) Idealisation: Seeing others in unrealistically positive light.

Example: Sita ignores her husbands dominance by thinking
that he is a man of high self-belief.

c.) Omnipotence: Dealing with stress by thinking that one is

superior to others.
Example: Prakash behaves arrogantly with others especially
during exams.

Major Image-Distorting Defenses:

a.) Splitting: Disintegrating the positives and negatives feelings or

aspects of self and others. Seeing things as all or none. Example:
Mr. Ramesh was Snehas favourite uncle whom she idealised. But
ever since he spoke against her, she began viewing him as mean
and evil.

Disavowal Defenses: Here, the individual disclaims responsibility

in an attempt to keep unpleasant thoughts, feelings, desires, and
impulses out of conscious awareness.

a.) Denial: Refusing to accept disturbing aspects of reality.

Example: Reema refused to acknowledge the news of her
brothers accidental death.
 36

b.) Projection: Seeing ones own unacceptable characteristics or

thoughts, feelings, impulses as someone elses. Example:
Satish is attracted to other women and accuses his wife for
being interested in other men.

c.) Rationalisation: Giving logical but false explanations to cover

up ones real thoughts/ideas. Example: Rekha whos upset
because her friend didnt invite her to a party said that she
wasnt interested in it in the first place.

Defenses Involving Action: These are strategies in which the

individual deals with stress by acting or withdrawing.

a.) Acting out: Dealing with distress with actions instead of

thoughts or feelings. Example: Children throw temper tantrums
when they are annoyed.

b.) Passive aggression: Expressing anger, disappointment or

opposition indirectly.

Example: Nita stops talking to her husband when she is angry

about something he has done.

c.) Regression: Dealing with distress by reverting to an earlier age

level. Example: Tushar began thumb sucking after the birth of
his younger sibling.

Defenses Involving Breaks with Reality: These are coping

techniques that involve the use of bizarre thoughts or behaviour.

a.) Delusional Projection: Delusionally seeing ones own

unacceptable characteristics or thoughts, feelings, impulses as
someone elses. Example: Kiran whos attracted to other
women thinks that his wife is interested in other men and is
convinced that she is having an affair with someone.

b.) Psychotic distortion: Dealing with distress by delusional

misrepresentation of reality. Example: Geeta developed the
belief that she is an adopted child because her father scolded
her for overspending.

Psychosexual Development: Freuds theory of personality is a

developmental theory - he believed that our personality is formed
as we pass through a series of stages from infancy to adulthood
and that the events which occur during these stages are especially
significant. He put forth the idea that every stage is characterised
by a body part that is found pleasurable (erogenous zone) and how
the child learns to satisfy the sexual desire associated with each
stage is crucial in determining the personality.
 37

Freud developed this theory on the basis of the reports of his

own patients. He was convinced that their problems were caused
by repressed sexual desires of early life. He spoke of two forms of
disturbances, regression, in which a person reverts back to a
previous level, and fixation, in which the person remains, stuck or
fixed at a particular psychosexual stage.
1.) Oral stage: In this stage which lasts from birth to 18 months,
the mouth and the lips are the primary source of pleasure for the
infant. This stage is divided into the oral-passive or receptive
phase in which the child gains pleasure from nursing or eating,
and the oral-aggressive phase in which the child enjoys
chewing, spitting and tries to bite anything that is around. In
Freuds view, regression or fixation at the oral passive phase
would result in an adult who depends excessively on oral
gratification such as overeating, cigarette smoking, etc. Those
who are regressed or fixated at the oral-aggressive phase tend
to be unfriendly and critical of others.

2.) Anal stage: In this stage the toddler (18 months to 3 years)
derives pleasure from holding on to and expelling feces.
Fixation at this stage may result in an anal retentive personality,
that is, an adult who is a control freak and obsessed about
hoarding things. On the other hand, fixation at this stage may
also result in an anal expulsive character, that is, an adult who
is sloppy, disorganised and uncontrolled.

3.) Phallic stage: According to Freud, the child faces a significant

crisis in this stage of development (3 to 5 years) in which the
erogenous zone is the genitals. Here, the child develops sexual
attraction towards the opposite sex parent (Freud referred to
this as the Oedipus complex in boys and Electra complex in
girls, based on Greek mythology).

The young boy wishes to unconsciously kill his father and

sexually possess the mother. However, he fears that the father
will punish him by cutting off his genitals (castration anxiety) for
having sexual feelings for the mother. This crisis is resolved
when the child represses his feelings for his mother and
identifies with the father.

In case of the girl, she discovers that she doesnt possess a

penis and comes to blame her mother for the same. She also
hopes to share her fathers penis and becomes sexually and
emotionally attracted towards him. This crisis gets resolved
when the girl identifies with the mother and incorporates her
values.
 38

Thus, in this stage the childrens superego begins to develop

and prepares them for dealing with unacceptable sexual urges.
Freud believed that neurosis results from an inability to resolve
the Oedipus/Electra complex.
4.) Latency stage: This is the phase (5 to 12 years) in which the
sexual energies take a backstage. During this phase, children
channelise their energies into school work and play. They
interact and imitate parents and others of the same sex.
5.) Genital stage: in this stage, there is renewed interest in
deriving sexual pleasure through the genitals. Masturbation
begins and since parents are ruled out as sex objects through
the resolution of the phallic stage, one starts looking out for
opposite sex partners. Any unresolved issues from the earlier
stages interfere with ones ability to successfully pass through
this stage.

Post-Freudian Psychodynamic Views: The post-Freudian

theorists believed in the unconscious aspects of personality but
criticised Freud for overemphasising on sexual and aggressive
instincts. They considered socio-cultural influences such as
interpersonal and social needs to also play an important role in
shaping ones personality.

Carl Jung (1875-1961) felt that Freud took a one-sided view of

the human condition. Jung believed that although the
unconscious mind contained selfish and hostile forces, it also
contained positive, even spiritual motives. He put forth the
concept of archetypes, that is, certain images which are
commonly held by all human beings. For example, the good or
evil, self, hero, etc. Jung believed that characters like superman
are popular because they evoke the hero archetype.

His original and lasting contribution is the idea of introversion

extroversion. He modified Freuds view of the unconscious and
said that we have a personal unconscious that consists of our
unknown impulses, desires, thoughts, etc., and a collective
unconscious, whose contents are the same for all humans.

He also said that healthy personality development involves

harmony between the conscious and unconscious elements of
the personality and imbalance between these results in
psychological disorders.

Alfred Adler (1870-1937) and Karen Horney (1885-1952) have

both focused on the ego and self-concept. They put forth the
idea that we all wish to see ourselves in positive light and use
defenses in order to maintain this positive image.
 39

They asserted that neurosis develops in people who see

themselves as inferior and these feelings emerge in childhood.
Adler believed that as children we are small and dependent on
adults for protection, due to which we begin life with feelings of
inferiority. Healthy personality development depends on
outgrowing the inferiority of childhood and seeing ourselves as
competent adults.

Karen Horney believed that conflicts dont develop as a result of

inborn motives but because of inadequate child-rearing
experiences. If a child feels loved and secure no conflict will
develop and positive aspects of personality will dominate.

Both of them also emphasised on the role of social and

interpersonal factors in shaping the personality and believed
that close relationships are very satisfying in themselves and
are not sought to fulfill sexual or aggressive desires.

Erik Erikson (1902-1994) formulated a theory of human

development that covers the entire life span. He described eight
stages of the life cycle. At each stage individuals face some
crisis that increases their vulnerability. When they successfully
master a particular stage, they gain strength and move on to the
next stage.

Stage Approximate Positive Outcomes Negative

age Outcomes
1.Trust versus Birth 1.5 Feelings of trust Fear and concern
mistrust years. from others regarding others.
support.
2. Autonomy 1.5 3 years. Self-sufficiency if Doubts about
versus shame exploration is self; lack of
and doubt encouraged. independence.
3.Initiative 3 6 years. Discovery of ways Guilt from actions
versus guilt to initiate action. and thoughts.
4.Industry 6 12 years. Development of Feelings of
versus sense of inferiority; little
inferiority competence. sense of mastery.
5.Identity Adolescence Awareness of Inability to identify
versus identity uniqueness of self; appropriate roles
confusion knowledge of roles. in life.
6.Intimacy Early Development of Fear of
versus adulthood loving, sexual relationships with
isolation relationships and others.
close friendships.
7.Generativity Sense of Trivialisation of
versus contribution to
 40

stagnation Middle continuity of life. ones activities.

adulthood
8.Ego-integrity Late Sense of unity in Regret over lost
versus despair adulthood lifes opportunities.
accomplishments.

Object relations theorists such as Melanie Klein (1882-1960),

Margaret Mahler (1897-1985), D.W.Winnicott (1896-1971) and
Heinz Kohut (1913-1981) suggested that we create images or
representations of ourselves and others, on the basis of our
early relationships, and these are carried throughout adulthood
and influence subsequent relationships. They suggested that
self concept develops in 4 stages:

i) Undifferentiated stage: In this stage there is no sense of self

ii) Symbiosis: Here, the newborn doesnt distinguish between

self and others but has images of good self / bad self and
good others/bad others. In this stage, the child perceives
things as all good or all bad.

iii) Separation-individuation: In this stage, the child begins to

distinguish between self and others but the images of good
me-bad me and good other-bad other are not integrated. For
example, a child who is annoyed with a parent, sees only the
bad image of the parent and says I hate you with all his heart.

iv) Integration stage: By this stage the child understands

complex representations that include both good and bad
aspects of self and others. For example, the child who is
annoyed with a parent now might say I am mad at you but I
still love you.

Mary Salter Ainsworth (1913-1999) and others developed

characterisations of infants depending on the way they relate to
the caregiver. They described four attachment styles:

a.) Fearful, in which the child desires emotional closeness but

is uncomfortable becoming close due to lack of trust or the
fear of getting hurt.
b.) Preoccupied, in which the child wants to be emotionally
close and uncomfortable without close relationships. The
child is dependent and believes that others dont value him
as much as he does.
 41

c.) Dismissing, in which the child is self-sufficient and prefers

not be emotionally close to anyone or have others depend
on him.
d.) Secure, in which the child is comfortable depending on
others and letting others depend on him. The child also
doesnt worry about being left alone or rejected.

Treatment
According to Freud, the goal of psychoanalytical treatment is to
become consciously aware of the repressed material. This is
achieved through techniques like free association, in which the
client is encouraged to feel free and speak about anything that
comes to his mind, and dream analysis, in which the client
relates details of a dream and freely associates them while the
psychoanalyst gives meaning to the dreams on the basis of its
content and the associations.
The essence of psychoanalysis is the systematic analysis of
transference and resistance. Transference is the process in
which, while interacting with the therapist, the client relives
conflictual relationships shared with ones parents and transfers
them onto the therapist. Often clients resist or hold back in
therapy which blocks the process. Dealing with unconscious
fears and conflicts is painful and as a result the client might
forget (unconsciously block) important information, may not be
able to freely associate, postpone appointments or discontinue
therapy altogether.
The therapist uses interpretation, a technique in which clients
resistance is analysed and then he or she is helped to work
through the conflictual issues by resolving them in a healthy
manner as compared to what had occurred in the childhood.
The post-Freudian therapists developed new theories of
personality and methods of treatment but the reliance on
Freudian concepts to explore the unconscious continued.

Evaluation of Psychodynamic Theories

Freud is credited for developing the first extensive theory of
psychology and an organised approach to therapy. Although
the role of instincts and the unconscious continues to be
debated on, the idea that early childhood is crucial in shaping
ones personality and that the therapist plays a significant role
in facilitating the process of change, are popular among
clinicians irrespective of their theoretical orientation.
There is lot of evidence in support of the idea of the
importance of early life and that attachment styles are related
 42

to psychological disorders. For example, one study found that

adolescents with an insecure attachment style are more likely
to develop anxiety disorders as compared to those with a
secure attachment style (Warren et al., 1997). Another study
found that those with an insecure style, receive higher scores
on depression and experience depressive symptoms - it is
suggested these individuals selectively focus on the negative
information and hold themselves responsible for the negative
events (Shaver, Schachner, & Mkulincer, 2005; Reis &
Grenyer, 2004).
One study also showed that infant attachment style can
predict relationship with ones romantic partner - those with a
secure attachment style comfortably relate to others and enjoy
close relationships and interdependence; ambivalent or
preoccupied individuals want and seek emotionally close
relationships but worry that others wont value them as much;
those with fearful style experience conflicts because they feel
others will reject or be disloyal to them; while those with a
dismissive style are self-sufficient and not very interested in
close relationships.

Freuds theory did change the conceptualisation of

psychological disorders, but a major criticism in this regard is
that Freudian concepts such as the unconscious material,
repression, dreams, etc., cannot be empirically tested.
However, the concept of unconscious does find wide
acceptance in other areas of Psychology, for example, implicit
memory, where the person may not remember details of an
event but the performance clearly seems to be influenced by it
is an instance of an unconscious process.

Interestingly certain aspects of Freuds theory cannot be

adequately tested and challenged. For example, if one refutes
the idea that the defense mechanisms are used to protect
oneself from anxiety aroused by unconscious sexual impulses,
Freud would suggest that it is ones anxiety about coming to
terms with this fact that prevents him acknowledging it.

Feminist have criticised Freud for being biased against women

and emphasising on male development. Karen Horney
rejected his concept of penis envy as the central factor that
determines their personality. She suggested that women dont
envy the penis or masculinity per se but the power and
privileges they enjoy in society.

Traditional psychoanalysis is criticised for being lengthy.

However, there are newer brief forms of therapy that use
transference-based interpretations and focus on the current
problems of the client. Brief psychodynamic therapy (BPT),
 43

developed by McCullough and associates (2003) is based on

the idea that the clients problem stems from the excessive use
of dysfunctional defense mechanisms. BPT involves increasing
the clients awareness of their defenses and encouraging them
to drop the defenses and experience the unpleasant emotions.
The therapists then help the clients come to terms with these
distressing thoughts and impulses and develop healthy ways of
expressing them. Finally, the clients, especially those with
personality disorders are helped to build a positive self image
and rewarding relationships with others.

2.4 HUMANISTIC PERSPECTIVE :

The humanistic perspective emerged as the third force in

psychology to emphasise on the human behind the cognitions,
behaviours and feelings, which seemed to be largely ignored by
psychoanalysis and behaviourism. According to this psychological
view, human beings possess an innate tendency to improve and to
determine their lives by the decisions they make.

Existential views have also influenced the humanistic

perspective. Existentialists believe that human beings try to seek
the meaning of their existence and those who appreciate each
moment and live as fully as possible in each moment are mentally
healthy. The important founders of humanistic psychology include
Carl Rogers and Abraham Maslow.

Person-Centered Theory
The person-centered or client-centered theory has been
developed by Carl Rogers, who considered every human being
as unique. He believed that individuals naturally move towards
self-actualisation, that is, fulfillment of their potential for love,
creativity and meaning. The term client-centered suggests the
idea that the focus is on the client and not on the therapist or
therapeutic techniques.
The concepts of self and self-concept, ones subjective
perception of who one is and what one is like are central to
Rogerss theory. He said there is the self the person one
thinks he is and the ideal self - the person one wishes to be. For
example, I am an average student (self) but I would like to get a
distinction in my exams (ideal self).
According to Rogers, a person is said to be fully functional or
well-adjusted when there is a match between the real and ideal
self and between ones self-image and his experiences. The
term fully implies that the individual is utilising his psychological
resources effectively. Thus, a psychological disorder results
 44

from an inability to use ones full potential that leads to an

inconsistency between how one perceives oneself and reality.
Due to stress from parents and the society, individuals develop
rigid, distorted perspectives of self and lose touch with their
values and needs. Consider the case of Sohan, who believes he
is unpopular when in fact most of his classmates are fond of
him. This creates a mismatch between reality and Sohans
perception of it. Others may try to interact with him but his
ignorance would cause him to avoid them. According to Rogers,
this leads to emotional distress, unhealthy behaviours and in
extreme cases, psychosis.
Rogers viewed a fully functioning individual as steadily moving
towards his own growth. He also suggested that psychological
problems result in children who have critical and harsh parents.
Messages such as you are a good boy only if you listen to me
create conditions of worth which make the child insecure and
anxious that he might do something that would disappoint his
parents. Conditional love on part of the parents is responsible
for the childs low self-esteem and the difficulties that follow.

Self-Actualisation Theory
Abraham Maslow, best known for his hierarchy of needs
suggested that the source of motivation is certain needs. He
proposed five types of needs - at the base of the hierarchy are
the basic biological needs for hunger, thirst, etc., followed by the
safety needs, the need for belongingness, esteem needs and at
the top of the hierarchy is the need for self-actualisation.
Maslow defined self-actualisation as the inner directed drive in
human beings to reach their highest potential. He described
self-actualised people as those who are more concerned about
the welfare of others than themselves, they usually work for
some cause or task than for fame or money, they enjoy the
company of their friends but are not dependent on their
approval, they have an accurate view of life and are yet positive
about life etc.
Maslow was of the opinion that there are very few self-
actualising individuals in this world and that many are partially
actualised who get to experience self-actualisation in what he
referred to as the peak experience - intensely moving
experiences in which one is completely immersed and feels a
sense of unity with the world.
He also said that behaviour is dominated and determined by
needs that are unfulfilled. When an individual attempts to satisfy
his needs he does it very systematically by beginning with the
most basic needs and then gradually working up the hierarchy.
 45

Both Maslow and Rogers were of the view that psychological

disorders are caused by a movement away from the ideal state
and had similar ideas about the conditions that hinder self-
actualisation.

Treatment
Rogers firmly believed that the focus on therapy should be the
client and his needs. The clinicians role is to help the client
realise that he is innately good and enhance his understanding
of himself.
To deal with the difficulties caused by the conditions of worth,
Rogers suggested that the therapist provides the client with
what he called as the core conditions necessary for therapeutic
change - positive regards, empathy and genuineness. He
believed it is important for the therapist to have unconditional
positive regard for the client, that is, a non-judgmental
acceptance of what the client thinks, feels and says. He defined
empathy as the therapists ability to enter the clients
phenomenal world - to experience the clients world as if it were
your own without ever losing the as if quality. The term
genuineness refers to being honest and suggests that the
therapist behaves in ways that are congruent with his self-
concept and thus consistent across time.
Therapists following the Rogerian approach use the techniques
of reflection and clarification. Reflection involves rephrasing and
mirroring back what the client has just said. For example, a
client might say, I feel terrible about having fought with mom.
The therapists reflection of this statement could be, So you feel
very bad when you have a fight with your mom. Clarification
involves throwing light on or making clear a vague statement
made by the client about how he feels. For example, if the client
says, I am mad at my friend for not returning my call, to which
the therapist might say, And may be slightly hurt as well.
Rogers also said that the therapist needs to avoid making
suggestions to the client as this lowers the dignity of the client
and his capacity to be self-directing.
Maslow did not put forth a model of therapy to treat
psychological disorders but rather provided theoretical
guidelines for the most favourable form of human development.
In recent times, theorists have come up with techniques like
motivational interviewing (MI) which involves using the core
therapeutic conditions suggested by Rogers in an attempt to
encourage changes from within and make the client
independent.
 46

Evaluation of Humanistic Theories

One criticism against the humanistic theories is that its concepts

cannot be scientifically tested. There has been some research
on the effectiveness of this approach but the measurement was
based on self-report techniques rather than objective evaluation.
The humanistic theories are not very useful in explaining
psychological disorders. Nonetheless, Maslows principles are
very popular and widely used in industry to enhance employee
motivation.

2.5 SOCIOCULTURAL PERSPECTIVE :

This perspective focuses on how social and cultural agents

or external factors such as other people, social institutions and
events in the social context, influence the individual. The term
sociocultural refers to all the circles of social influence that surround
the individual that is the family, neighbourhood and society.

Family Perspective of Psychopathology

According to the family perspective, psychopathology or
dysfunction in an individual reflects psychopathology or dysfunction
in the family members. There are four approaches under this
perspective:
1.) Intergenerational, given by Murray Bowen, suggests that how
parents interact with their children is influenced by how they
were treated as children.
2.) Salvador Minuchin gave the Structural approach which puts
forth the idea that in normal families every individual has
specific functions and the relationship boundaries are fixed and
that troubles occur if family members are too close or too
distant.
3.) In the Strategic approach, proposed by Jay Haley, the therapist
influences the client with direct instructions about how to resolve
issues within the family, especially power relationships.
4.) In the Experiential approach, Carl Whitaker suggests that the
family dysfunctions are caused by obstacles in ones personal
development. Virginia Satirs sculpting techniques involves
making clients role-play difficulties in interaction. John Gottman
found that characteristics such as contempt, criticism,
defensiveness and stonewalling are related to difficulties in a
marriage.

Family theorists have provided insights that help explain

and treat psychological disorders. For example, Eating
 47

disorders may be found in families with disturbed relationships

and starving oneself is seen as an adolescents attempt to
demonstrate ones control over ones body and life.

Social Discrimination
Sociocultural theorists suggest that discrimination on the
grounds of gender, race, religion, social class, age, sexual
orientation, etc., can also cause psychological disorders.
Due to stressors such as poverty, unemployment, lack of
education, nutrition, access to health care systems, etc., many
psychological difficulties are commonly found among those from
the lower socio-economic strata.
In addition to this, the rates of crime and substance abuse are
high and poor physical and mental health often results in
premature death (Khaw et al., 2008). Age and gender bias can
cause tremendous frustration and emotional difficulties giving
rise to psychological symptoms, especially since these
characteristics are fixed.

Social Influences and Historical Events

Theodore Millon (1988), a personality psychologist suggested
that changing societal values has led to a rise in psychological
disorders in the West. Social instability makes children perceive
the world as threatening and unpredictable and thus increase
the risk of developing disorders later in life.
The rates of mental disorders are higher in societies that go
through significant social change. Reorganisation in the society,
such as industrialisation, changing peoples roles and
relationships to the society from a worker to an unemployed
person or in a situation like India-Pakistan partition, from a
majority culture to a minority or multicultural society.
Traumatic events of historical or political significance or natural
disasters such as the earthquakes, floods, famines also
adversely affect mental health. American psychologists,
studying the effects of war have found that it negatively affects
psychological functioning. Also, the possibility of developing
serious anxiety disorders is greater among those who have
been disturbed by terrorist attacks, harassment, imprisonment
or experienced war.

Treatment

Therapists play a significant role in helping individuals cope

with the stresses within the family, immediate environment or the
society at large, especially since the world cannot be changed.
 48

Family Therapy
Family therapy focuses on helping the family members relate to
each other and communicate in healthy ways. The therapist
often spends time talking to every family member so as to build
rapport, especially with those who seem to resist therapy.
To improve communication, the therapist may initiate a
conversation, observe the dynamics of their relationship and
then guide the two members as they proceed. Sometimes these
sessions are videotaped or held in rooms with one-way mirrors.
Family therapy is different from individual psychotherapy, that is,
here the therapist works on disturbed relationship patterns in the
family as a whole rather than the individual issues of family
members.
Also, family therapists believe that harmonious relationships
among family members are more beneficial to treatment than
the client-therapist relationship.
Various techniques are used by family therapists, for example,
an intergenerational therapist may use a genogram, which is a
diagrammatic representation of all relatives in the recent past.
This information gives the therapist an idea of the nature of
relationships shared by the family members, which is then used
to bring about desirable changes.
Strategic family therapists work on finding solutions to issues
within the family by making the members role-play conflicting
views; while an experiential family therapist focuses on helping
the family members develop a better understanding of their
relationships.

Group Therapy
In this method people having similar problems share their
experiences with each other. Irvin Yalom (1995) suggested that
this technique is effective for various reasons - it relieves the
individuals and gives them hope as they realise that their
problems are not exceptional; they receive useful information
and suggestions from others who share how they dealt with
their issues and the feeling of being of help to someone makes
them feel better about themselves.
The evidence for the effectiveness of group therapy comes from
Alcoholics Anonymous, in which individuals with alcohol-related
problems and their families share their stories and the
techniques they successfully used to stay away from it.
Group therapy also helps individuals with pedophilias, who have
sexually abused children, to drop their defenses by providing a
 49

very supportive environment to share their concerns (Berlin,

1998).
Studies have shown that group therapy is effective for
individuals with depression, especially when combined with
individual therapy or medication (Kasters et al., 2006).

Multicultural Approach
The therapists need to be sensitive to the cultural background of
the clients. When dealing with clients from different
backgrounds, treatment should incorporate three components:
awareness, knowledge and skills.
Awareness refers to the idea that the therapist needs to be
familiar with how the cultural context influences the clients
experience or the way he relates to others.
Knowledge relates to taking the responsibility of finding out
about the clients cultural background and its effect on
assessment, diagnosis and treatment.
Skills refer to expertise in the specific therapy techniques that
would work with the clients of a particular culture.

Milieu Therapy
The term milieu implies the surrounding or the environment.
This form of therapy involves scientific structuring of the
environment by the staff - therapist, nurse or the paramedical
professional, and clients as a team, to enhance the clients
functioning.
It focuses on improving social interaction, the physical structure
of the setting and scheduling activities such as group therapy
session, occupational therapy, physiotherapy, etc.
The goal of milieu therapy is to provide a supportive
environment that encourages socially desirable behaviour and
to keep as many links as possible to the clients life, beyond the
family.

Evaluation of Sociocultural Perspective

Clinicians acknowledge the role of the environment in causing
or maintaining psychological symptoms, with the understanding
that not much can be changed in the surrounding. For example,
discrimination has adverse effects on ones mental health but
putting a stop to it is difficult. Similarly, the clients family may
have a clear role in his psychological problems but the family
members may be uncooperative or unavailable.
 50

Though group therapy can be very effective, several clients are

shy or ashamed of sharing their concerns in front of others who
are seen as strangers. These issues can be dealt with in
individual therapy by focusing on how the cultural background of
the client influences the way he relates to others.
In certain cases biological theories provide better explanations
of disorders than the sociocultutral ones. For example,
Schizophrenia cannot be accounted for by dysfunctional family
patterns. However, disturbed communication within the family is
known to increase the severity of Schizophrenia or cause
relapse.
Thus, though the sociocultural perspective throws light on the
psychological disorders, they are better explained when the
biological and psychological perspectives are combined with it.

2.6 BEHAVIOURAL AND COGNITIVELY BASED

PERSPECTIVES :

According to the behavioural and cognitively based

perspectives, abnormality results from faulty ways of thinking which
are learned, and lead to maladaptive behaviours.

Classical Conditioning

Classical conditioning is a type of learning which was studied

experimentally by Ivan Pavlov. It refers to the formation of an
association between a conditioned stimulus and response through
repeated presentation of the conditioned stimulus with the
unconditioned stimulus that originally produced the response.

For example: Sharda feels sad every time she sees the sari gifted
by her husband, who passed away recently. Here, sari is initially a
neutral stimulus because it doesnt evoke any response by itself.
But after becoming associated with her husband (a naturally
evoking stimulus) seeing the sari (now, a conditioned stimulus)
evokes the emotion of sadness (conditioned response) .

Some crucial elements in classical conditioning:

The stimulus which naturally evokes a reflex-like response is
called the unconditioned stimulus.

The reflex-like response produced by the unconditioned

stimulus is called the unconditioned response.
 51

The stimulus which is neutral in the beginning and begins

evoking a response after being paired with unconditioned
stimulus is called the conditioned stimulus.

The response produced by the conditioned stimulus after pairing

it with the unconditioned stimulus is called the conditioned
response.

In stimulus generalisation, an individual responds in the same

way to different stimuli that have common properties.

In stimulus discrimination, an organism learns to differentiate

among different stimuli and restricts its responding to one
stimulus rather than the other.

The gradual reduction in the frequency of the conditioned

response and its eventual disappearance is called extinction.

Spontaneous recovery refers to the reappearance of a

previously extinguished response after sometime has gone
without exposure to the conditioned stimulus.

John Watson (1878-1958) demonstrated how conditioned

fear developed through an experiment conducted on an 11 month
old infant Little Albert. In the experiment, Albert was playing with
white rats when Watson with his associate exposed him to a loud
noise. Following this incident Albert developed a fear for rats. This
process is called aversive conditioning in which an aversive/painful
stimulus (noise) becomes associated with a neutral stimulus (rats).
Through stimulus generalisation, Albert began fearing other white
objects too. Although experiments of this sort are not conducted
anymore due to ethical restrictions, Watsons work helped explain
the development of phobias (irrational fears).

Counterconditioning, a process of eliminating the classically

conditioned response by pairing the conditioned stimulus with an
unconditioned stimulus to elicit a response that is stronger than the
conditioned response and that cannot occur at the same time as
the conditioned response, is used to treat phobias.
Operant Conditioning

Operant or Instrumental conditioning is a type of learning in

which a voluntary response is strengthened or weakened
depending on its positive or negative consequences. Skinner,
the father of operant conditioning, was influenced by
Thorndikes law of effect which states that responses that satisfy
some motive are repeated.
 52

Operant conditioning is based on the concept of reinforcement,

a process by which a stimulus increases the probability that an
earlier behaviour will be repeated. Reinforcers are of several
kinds: a primary reinforcer satisfies some biological need and
work naturally without any prior experience. For example, food
and water are primary reinforcers.

A secondary reinforcer is a stimulus that becomes reinforcing

because of its association with a primary reinforcer. Money is a
secondary reinforcer because it helps obtain primary
reinforcers. Attention, recognition and praise are secondary
reinforcers and often play a role in the maintenance of
psychological symptoms. For example, the aches and pains
reported individuals with somatoform disorders are often
reinforced due to the attention they get from family members.

Reinforcement can be positive or negative. In positive

reinforcement, behaviour is repeating because of the reward
that follows. In negative reinforcement, the behaviour is
repeated because it removes something unpleasant from the
environment.

Negative reinforcement is often confused with punishment. In

negative reinforcement the frequency of the behaviour
increases whereas punishment involves an unpleasant or
painful stimulus that decreases the probability that an earlier
behaviour will be repeated.

For example, a mischievous child may be told that he wont be

allowed to go out to play in the evening if he misbehaves. This
is an instance of negative reinforcement because withdrawing
the pleasant stimulus (play) would encourage the child to
behave (increase in frequency). On the other hand, beating the
child for misbehaving is an instance of punishment because that
is expected to reduce his disobedience (decrease in frequency).

Shaping is a technique based on the principles of reinforcement

in which every step towards the desired goal is reinforced. For
example, while teaching a child to write alphabets, they are first
encouraged to draw a standing line, a sleeping line, then a
slanting line and then finally an A.

This is a very commonly used behavioural technique. For

example, a shy person who has difficulty communicating may
be encouraged to look at others and smile, then the next step
would involve greeting them, still later speaking one line, then
holding a conversation for two minutes and so on.

Social Learning and Social Cognition

 53

The social learning view is given by Albert Bandura who argued

that people also learn by observing the behaviour of other
people. Modeling is the process in which people acquire new
behaviours by imitating the behaviour of important people in
their lives.
Social learning theorists study the influence of modeling and
ones relationships with others on the development of
psychological disorders. They are also interested in social
cognition, that is, the manner in which we interpret, analyse,
remember and use information about the social world.
Bandura said that observational learning (vicarious
reinforcement) takes place when a person observes the rewards
and punishments that another person receives for his
behaviours and behaves accordingly.
He also put forth the concept of self-efficacy, that is, the belief
that one can successfully execute behaviours necessary to
control desired outcome (I think I can). Self-efficacy is found to
be related to motivation, self-esteem, interpersonal
relationships, health behaviours, addictions, etc. (Bandura et al.,
2004).

Cognitively Based Theory

The cognitively based theories believe that cognitions, that is,
thoughts or beliefs, shape behaviours. Aaron Beck and Albert
Ellis are two well-known cognitive theorists who have
contributed to the understanding of several psychological
disorders, especially depression.
Beck spoke about automatic thoughts - ideas that are so deep-
rooted that the individual is often not aware of them, which
come to mind spontaneously and cannot be neglected. For
example, if one slips and fall one might think how stupid am I,
others must be thinking I am so dumb, etc. These automatic
thoughts are usually of a self-defeating nature and are followed
by the experience of negative emotions.
Automatic thoughts arise from faulty attitudes. These attitudes
make a person interpret situations in a biased manner as shown
below:

Dysfunctional Attitude
I need to at my best at all times.

Experience
I happen to slip and fall.

Automatic Thought
 54

I am so dumb / People must be thinking Im stupid.

Negative Emotion
I feel useless and angry.

Albert Ellis gave the A-B-C model which suggests that how one
feels is determined by the way one thinks about the events in
his life. A refers to the activating event, B to the beliefs and C
is the consequences. According to him, irrational beliefs, that
is, unrealistic and exaggerated views about self and the world
are the cause of several psychological disorders. Conforming
rigidly to these irrational beliefs using should/must/ought
makes one feel miserable and results in emotional disturbances.
David Barlow gave a model that explains the impact of a
combination of physiological, cognitive and behavioural factors
on the development of anxiety disorders. For example, a panic
attack may be triggered when a person who hyperventilates
(physiological factor) after climbing up stairs, misinterprets
(cognitive factor) the physiological signs as an indication of an
impending heart attack and forms associations between some
stimuli and the experience of panic, consequently avoiding that
situation (behavioural factor).

Treatment

The behavioural and cognitively based approach asserts that

abnormality results from faulty thought processes which are learned
and can be unlearned.

Conditioning Techniques
Using principles of classical conditioning and operant
conditioning such as positive and negative reinforcement,
counterconditioning, aversive conditioning, extinction, etc
behaviour therapists help client change faulty behavioural
patterns and substitute them with healthy behaviours.
Joseph Wolpe used counterconditioning to treat phobias or
irrational fears. For example, he taught cats who were
classically conditioned to experience anxiety in a room in which
they were administered shocks, to associate the room with
eating, which reduced their anxiety.
Counterconditioning is effective when the new stimulus used is
able to evoke a response that is stronger and cannot exist at the
same time as the conditioned response. For example, to help
little Albert get rid of his fear of white rats, one needs to pair
white rats with a stimulus such as chocolates or his favourite
toy. Fear (evoked by the rats) and joy (evoked by the
 55

chocolate/toy) being contradictory states cannot co-exist and

repeated pairing of this nature would gradually help to reduce
his fear.
Another form of counterconditioning is systematic
desensitisation in which the therapist attempts to reduce the
clients anxiety by combining relaxation techniques and
progressive or graded exposure to the phobic stimulus. For
example, to treat a client with dog phobia, the therapist may
gradually expose him to the concept of dog in a hierarchical
order. The first step would involve helping the client enter a
relaxed state following which the therapist would speak about
the feared stimulus (the dog), the next step would involve
watching pictures of a dog, next watching a live dog outside
from the window and so on till the client is comfortable with the
idea of being close to a dog without anxiety.
Also often used is the technique of flooding, which is the
opposite of systematic desensitisation and involves intensely
exposing the client to the feared object. For example, instead of
gradually desensitising a person who has bat phobia he may be
exposed to a bunch of bats in entirety.
Wolpe developed one more form of counterconditioning -
assertiveness training, which involves expressing oneself and
satisfying ones own needs and feeling good about it without
hurting others in the process. In this technique, the aim is to
learn to communicate the desired emotion (anger) effectively so
that the opposing emotion (anxiety) gets weakened. As a result
the client is able to express ones needs and deal with the
challenging situation effectively.

Contingency Management Techniques

These set of techniques are based on the idea that any
behaviour that is followed by a positive consequence (reward) is
repeated and undesirable behaviours can be unlearned by
taking away the rewards. Accordingly, contingency
management involves helping a client connect the outcome of
the behaviour with the behaviour itself. This technique is
effective in reducing disruptive behaviours such as temper
tantrums, in disciplining children, developing good habits,
reducing smoking, weight management, etc.
Token economy is a form of contingency management in which
clients earn tokens or points showing desirable behaviour which
can be later exchanged for some concrete reward. For example:
In 1970s, at a mental health centre in Illinois, researchers
designed an environment for Schizophrenia inpatients that
encouraged appropriate socialisation, participation in group
activities, self-care such as bed-making, and discouraging
 56

violent behaviours. They then set up a token economy in which

patient could earn small luxuries such as buy cigarettes with the
tokens earned for keeping the room clean or be fined (lose
tokens) for behaving inappropriately. This technique can also be
used to mange behavioural disorders in children.

Modeling and Self-Efficacy Training

Bandura believed in observational learning (vicarious
reinforcement) and used this understanding in treating phobias
by showing clients video-tapes or real-life model. For example,
a boy who has developed the fear of white rats may be shown a
video in which a boy is enjoying playing with a rat. This helps
the boys to understand that rats need not be dangerous and
dealing with them can be fun.
Another form of this technique is participant modeling, in which
the therapist first demonstrates the desired behaviour to the
client and then helps him do the same. For instance, in the
earlier example, the therapist might first play with the rat and
then support the client in doing so.
Bandura is also credited for his theory of self-efficacy. According
to this theory, peoples beliefs about their capacities are better
predictors of their accomplishments than their actual skills. He
said that fears develop because the person believes that he
doesnt have the resources needed to deal with the phobic
stimulus and thus by improving self-efficacy, the fear can be
eliminated. Bandura describes four ways of improving self-
efficacy:

1.) Performance attainment: The best way to enhance self-

efficacy is to successfully carry out the desired task.

2.) Vicarious experience: By observing someone similar

overcome a problem, one is likely to believe or have greater
confidence that one can also overcome a similar problem.

3.) Verbal persuasion: Encouragement by saying you can do it

can increase confidence and reassure a person of his
capabilities.

4.) Physiological state: one is not likely to feel confident about

doing well when one is sweating excessively. By learning to
relax and consciously changing the physiological arousal one
can reduce stress and improve self-efficacy.

Thus, self-efficacy training can be useful in overcoming

problems such as smoking, obesity, undesirable health habits,
etc.
 57

Cognitive Therapies
According to the cognitive and cognitive-behavioural therapies,
the way we think determines the way we feel. Based on this
principle is the technique of cognitive restructuring in which the
therapist helps the client change the way he thinks about
himself, others and the future. The therapist does this by
encouraging the client to identify maladaptive attitudes and
irrational beliefs, challenge them and replace them with ideas
that can be checked in real life.
Panic control therapy (PCT) is a form of cognitive-behavioural
therapy that is used to treat panic disorder which is a type of
anxiety disorder in which the person experiences recurrent and
unexpected panic attacks. PCT combines cognitive
restructuring, exposing the client to the bodily sensations
associated with panic attacks and breathing retraining. Here, the
client is taught to identify how faulty cognitive judgments are
contributing to the experience of anxiety, examine their
reactions and change them with appropriate breathing
techniques and recognise places, persons and behaviours that
make them feel safe.
Acceptance and Commitment Therapy (ACT) is also a
cognitively based form of therapy in which the client is
encouraged to acknowledge and accept all the distressing
thoughts, feelings and behaviours and thereby gain a sense of
control that helps them in their commitment to overcome them.

Evaluation of Behavioural and Cognitively Based Perspective

The cognitive - behavioural perspective is credited for its simple
approach that emphasises on the use of objective/empirical
procedures.
According to the humanists, the behavioural perspective limits
the scope of Psychology because it doesnt take into account
the active choices that individuals make (free will) in dealing
with the environment.
The Psychoanalysts have criticised the behaviourists for
ignoring the fascinating unconscious influences on behaviour.
However, the cognitive theories acknowledge that thought
processes need to be studied and that implicit ideas about the
self do influence behaviours.
Behavioural and cognitive theories have a wide application and
are useful in explaining and treating a variety of disorders
including anxiety disorders, mood disorders, eating disorders,
sexual dysfunctions, etc.
 58

2.7 BIOLOGICAL PERSPECTIVE :

The biological perspective focuses on how certain

abnormalities in the activities of the brain and the nervous system
affect behavioural, cognitive and emotional functioning.
The Nervous System and Behaviour
The nervous system is a complex structure that regulates
our thoughts, behaviours and emotions. The central nervous
systems function is to transmit messages from different parts of the
body to the higher decision making centre and then send their
messages back to body. These messages are relayed by the
neurons, which are specialised cells for receiving, moving and
processing information.
Neurons, Synapses and Neurotransmitters:
There are over 100 billion neurons in the human body which
carry messages between the brain and the body. These
neurons form an interconnected pathway and pass the
messages through neural transmission and synaptic
transmission.
In neural transmission the information within the neuron moves
in the form of an electrochemical impulse and is called an action
potential, while synaptic transmission is the process by which
information is transmitted from one neuron to another neuron.
Neurons are arranged in the form of chains but they do not
touch each other. The space between the axon of one neuron
and the dendrite of another is a gap called the synapse.
When the neuron is stimulated, the resting potential changes
and activates an action potential which travels along the axon to
its tip, that is, the synaptic knobs which have tiny vessels called
synaptic vesicles that contain neurotransmitters.
Neurotransmitters are chemical substances which carry
information across the synapse and can have two effects on the
receiving neuron - inhibitory (turn off) or excitatory (turn on).
If the effect is excitatory in nature then there is a change in the
resting potential of the receiving neuron and the process of
neural transmission occurs in this neuron. On the other hand, if
the effect of the neurotransmitter is inhibitory, no action potential
is generated in the receiving neuron and the message is not
transmitted.
For some neurotransmitters there is a reuptake the
neurotransmitters are reabsorbed by the synaptic terminals from
which they were released. Reuptake prevents the action of the
neurotransmitter and the further production of the chemical.
 59

Whether a neuron will generate an action potential and pass the

message to other neurons in its pathway depends on the
balance between the excitatory and inhibitory synapses. Thus,
the neuron integrates all the signals it receives and responds to
the stronger signal.
Scientists have found several types of neurotransmitters which
operate in the brain and carry out different functions. Synaptic
transmission in the brain can be altered through the use of
drugs that increase or decrease the effectiveness of the
neurotransmitter.
Acetylcholine (ACh) usually has an excitatory effect, is present
mainly in the hippocampus and plays an important role in the
formation of new memories. Less amount of ACh caused by the
degeneration of the neurons that produce it is associated with
Alzheimers disease.
Gamma-aminobutyric acid (GABA) is a major inhibitory
neurotransmitter. Antianxiety drugs work by activating the action
of GABA, which slows down the nervous system.
Serotonin plays a crucial role in the regulation of mood, appetite
and sleep. Low levels of serotonin are associated with
depression. Antidepressants work by inhibiting the reuptake of
serotonin that increases the amount of serotonin in the brain.
Norepinephrine is an excitatory neurotransmitter and influences
mood states. Drugs like cocaine/amphetamines have their
psychological effects by prolonging the action of norepinephrine
and slowing its reuptake. Its insufficiency causes depression.
Dopamine when released in the brain produces intense feelings
of pleasure. An excess of dopamine is thought to cause
Schizophrenia while its deficit leads to Parkinsons disease.

Genetic Influences on Behaviour

Genetics or heredity is what one gets from ones parents.

Basic concepts in Genetics

The basic unit of genetics is the genome which is the complete
set of instructions for the development of every cell in the body.
The human genome is present in the nucleus of the trillions of
cells in ones body and consists of long molecules of
deoxyribonucleic acid (DNA). Phenotype refers to the
expression of the genes as a result of their interaction with the
environment.
 60

Strands of the DNA have the information needed by the cells to

produce the protein which the primary component of all
organisms. An important function of the DNA is to replicate itself
before cell division begins so that every new cell has a copy of
the instructions required for manufacturing the protein.
There are 32000 thousand genes in the human body, which are
functional units of the DNA and carry the precise instructions for
manufacturing a specific protein. Genes are microscopic bags of
chemicals found on the chromosomes.
Human beings have 23 pairs of chromosomes, one in each set
from each of the parents. Of the 23 single chromosomes in each
cell, 22 are called autosomes and carry non-sex-related
information. The 23rd one is the X or Y sex chromosome. In
normal females the combination of chromosomes is XX while it
is XY in normal males.
The arrangement of genes on the chromosomes has no logical
reason - a gene that determines the eye colour may be next to
the gene that influences the height.
Genes go through mutations, that is, alterations or changes
caused from incorrect copying of instructions during cell
replication and this may be inherited or acquired. Inherited
mutations are caused due to mutations in the DNA of the
reproductive cells (sperm and ovum) - when these mutated cells
get passed to the child, the mutations would be found in all the
cells in the childs body. Acquired mutations are changes in the
DNA that occur throughout ones life due to sunlight or
carcinogens. Inherited mutations play a role in diseases such as
cystic fibrosis and sickle anemia and may predispose a person
to cancer, mental illnesses, etc. However, our cells have the
ability to repair many of these mutations. If the cells fail to do so,
the mutations are passed to the future copies of the affected
cell.

Models of Genetic Transmission

The chromosomes operate in pairs and each set has the same
genes on it but in different combinations called alleles. Alleles
refer to whether the combination of genes is dominant or
recessive. The hair colour, texture, eye colour, etc., are decided
by the combination of alleles inherited by the individual. A
dominant allele always shows its effect irrespective of what the
other allele in the pair is whereas a recessive allele expresses
its effect only if it paired with another allele of its own kind.

Genetic disorders have a dominant-recessive pattern

of transmission. In dominant pattern of disease inheritance, if
 61

the person has a normal allele and a disease allele, he is likely

to develop the disease because the disease allele is dominant.
Since, this person carries a normal and a disease allele, his/her
child has a 50 percent chance of inheriting the disease allele
and thus a 50 percent chance of having the disease.

In recessive pattern of disease inheritance where both

parents carry one normal allele (N) and one disease allele (D),
neither of them have the disease but both are carriers of it. The
combination of alleles that they are likely to pass on to their
children are NN, ND, DN or DD. Thus, each of their children has
1/4th chances of being normal (NN), 1/4th chances of developed
the disease (DD) and 2/4th chances of being carriers of the
disease (ND, DN).

Disease inheritance sometimes is much complex and cannot be

explained through the dominant-recessive pattern of
transmission. In such cases the pattern is likely to be polygenic,
that is, multiple genes may play a role in the expression of a
characteristic. Diabetes, coronary heart disease, epilepsy, etc.,
are a result of such polygenic processes.

It is suggested that genetic factors are involved in the

manifestation of several traits such as subjective wellbeing,
political views, job satisfaction, religiosity etc. (Plomin & Caspi,
1999).

Genes, Environment and Psychological Disorders

Researchers believe that an important aspect of genetic
transmission is that what is inherited is only the predisposition
and not the inevitability of the disorder. It is the mutual
influences of nature (biology) and the nurture (environment) on
each other that determine most psychological disorders.
For instance, the trait of extraversion is thought to be partially
inherited (Loehlin, McCrae, Costa & John, 1998).
A child born with extraversion genes may generate positive
reactions in people in her environment, which further strengthen
this personality trait. It is also suggested that people tend to
select environments that are consistent with their inherited
interests and capabilities and these environments in turn
facilitate the expression of these characteristics.
The diathesis-stress model suggests that a person must carry
some risk to the disorder in order to develop it. This vulnerability
can be biological - inheriting disordered genes, it may be
psychological - a faulty personality trait, or social - a history of
abuse or poor interpersonal relations. In addition to this, for the
disorder to develop, one must experience some kind of stress or
 62

trigger. This stress could be biological - an accident or illness

that changes the neurotransmitter balance, psychological -
perceived loss of control, or social - a traumatic event. The full-
blown disorder can develop only when the vulnerability
combines with the stress.
A large study which demonstrates the diathesis-stress model
involved biological parents with and without psychiatric
disorders and their children. They were interviewed and ratings
were obtained to determine the childs chances of developing
psychiatric disorders (Johnson et al., 2001). A significant factor
here was the presence of maladaptive parental behaviour. It
was found that children who developed psychiatric disorders
tended to come from homes with maladaptive parental
behaviours, irrespective of whether their parents had psychiatric
disorders or not. Similarly, children of parents who had
psychiatric disorders were found to develop the disorders only
when there was a history of disturbed parental behaviour. Thus,
the diathesis of parental psychiatric disorders produced a full
blown illness only when combined with the stress of living with
parents having maladaptive behaviours.
Thus, a genome may not always express itself in the phenotype.
A phenomenon called incomplete penetrance occurs when the
genotype that predisposes a person to a disorder doesnt get
manifested.
According to the multifactorial polygenic threshold several
genes of varying influence are involved in the transmission of a
disorder or characteristic. The specific combination of inherited
genes decides whether the vulnerability or risk is high, low or
moderate. The symptoms of the disorder are thought to develop
when the combined effect of genetic and environmental factors
exceeds a certain threshold (Moldin & Gottesman, 1997). This
model is more popular than the single-gene explanations of
genetic transmission.

Treatment

Biological therapies work on reducing symptoms of a

disorder by focusing on the physiological abnormalities.

Psychosurgery: This is a surgical intervention on the brain and

typically involves cutting off the frontal lobe from the rest of the
brain. This technique was developed by Egas Moniz to treat people
with severe psychosis in 1935 and won the Nobel Prize in 1949 for
the same. The negative side-effects of this technique included loss
of motivation and emotional dullness. Psychosurgery is not used
 63

anymore but yet recommended by some to manage some forms of

obsessive compulsive disorder (Woerdeman et al., 2006).

Electroconvulsive Therapy (ECT): The ECT was developed by

Ugo Cerletti in 1937 as a treatment for psychosis based on his
observation that dogs that underwent convulsions induced through
electric shocks appeared much calmer later. Although the
technique didnt work to reduce psychotic symptoms it did help
reduce severe depression.

The procedure for ECT involves giving the patients

anesthesia so that they arent conscious and muscle relaxants so
that their muscle dont jerk violently. Metal electrodes are then
taped to the head and a current of 70-130 volts is passed through
one or both sides of the brain for about half a second. As a result
the patient goes into a convulsion which lasts for about a minute.

ECTs are often given to depressive patients who havent

responded to medication. However, how the technique helps
relieve depression is not clearly known.

ECTs are controversial for several reasons. First, there were

reports about it being inappropriately used to punish patients who
seemed out of control. Second, ECT can result in memory loss and
difficulties in learning new material. Third, though it is very effective
in relieving depression, the relapse rate is 85 percent. And finally,
the idea of passing electric current through a persons body is very
frightening and seems like a very primitive form of treatment.

Transcranial Magnetic Stimulation (TMS): This method involves

placing an electromagnet on the scalp and passing electric current
through the cortex to increase or decrease the excitability of
neurons in a given region. The effect is not restricted only to the
cortex but spreads to the subcortical areas of the brain. It is
suggested that TMS is likely to replace ECT as a treatment for
depression (Couturier, 2005) and is quite effective when given in
combination with medication (Rumi et al., 2005).

Deep Brain Stimulation (DBS): In DBS an electrical conductor is

planted in the brain, which provides continuous low electrical
stimulation to a small area of the brain. The procedure involves
inserting a thin insulated wire in the brain and connecting it through
an extension of the insulated wire passed under the skin of the
head, neck and shoulder to a neurostimulator (battery) which is
placed under the skin near the collar bone. The DBS was
developed with the aim of increasing activity in certain brain
regions, for instance, the basal ganglia which is less active in
patients with Parkinsons disease. The technique is also being
 64

considered for treating obsessive compulsive disorder and

depression.

Medication: This is the most commonly used form of biological

treatment. Medications work by altering the activity and amount of
neurotransmitters.
Selective serotonin reuptake inhibitors (SSRIs) such as
fluoxetine and setraline, block the reuptake of serotonin thus
increasing the amount of this neurotransmitter in the synapse.
SSRIs are effective in treating several disorders such as
depression, obsessive compulsive disorder, eating disorders,
borderline personality disorder, etc.
Tricyclic Antidepressants such as clomipramine and
desipramine, work by blocking the reuptake of norepinephrine
and serotonin and are used in treating depression and
obsessive compulsive disorder.
Benzodiazepines like clonazepam and diazepam are antianxiety
drugs which increase the activity of GABA and thus inhibit the
brain regions that produce anxiety and panic.
Atypical Antipsychotics such as clozapine and olanzapine block
the serotonin and dopamine receptors in the limbic system and
are effective in treating Schizophrenia and Alzheimers disease.
Mood stabilisers such as lithium and valproate work by
decreasing levels of catecholamines and increasing release of
GABA to manage Mania and Bipolar disorder.
Neuroleptics like chlorpromazine and haloperidol are
antipsychotic medicines that block the dopamine receptors and
are effective in treating Schizophrenia and Alzheimers disease.

Biofeedback: Biofeedback involves the use of instrumentation to

monitor psychophysiological processes, combined with behavioural
principles to bring these functions under voluntary control. The
technique is based on the idea that autonomic functions such as
heart rate, blood pressure, galvanic skin response, etc., can be
voluntarily altered through the use of reinforcement. It is suggested
that some physiological symptoms are caused due
misinterpretation of bodily cues (Miller & Dworkin, 1977). In
biofeedback, patients are taught to identify their bodily sensations
through sophisticated instruments and then are encouraged to
change these functions by providing a reward. For instance, one
may learn to recognise muscle tension followed by techniques to
relax them. When the person is able to reduce muscle tension
through relaxation then some lights or music is put on which acts as
reinforcement. This is often combined with shaping in such a way
that the initial goals are within the persons reach and then are
gradually made difficult.
 65

Evaluation of the Biological Perspective

It is important to understand the biological basis of behaviour as
all psychological problems are manifested in the body. Also
there is a reciprocal relationship between biological and
psychological factors explained as the concept of feedback loop
in the earlier chapter. For instance, exam anxiety raises the
heart beat, sweating, etc. and these bodily sensations interfere
with the ability to concentrate. The thought that one is not able
to focus makes one even more anxious which further leads to
physical changes.
In the development of some psychological disorders such as
Schizophrenia and Depression, biological factors like genetic
involvement play a crucial role and accordingly biological
therapy, that is, medication becomes the primary treatment.
Researchers have also found that the experience of traumatic
events or chronic stress affects the brains structure and
functions. It is suggested that with each traumatic incident the
neurotransmitter systems become more easily dysregulated -
the first episode may take a strong stressor to cause the
dysregulation but later mild stressors can also initiate the
dysregulation.
Finally, the biological perspective helps understand genetic
contributions to psychological disorders and traits, and the
patterns of genetic transmission. The advancements in genetic
technology provide improved solutions for genetically based
disorders.

2.8 BIOPSYCHOSOCIAL PERSPECTIVE ON

THEORIES AND TREATMENT: AN INTEGRATIVE
APPROACH :

There are five major schools of thought discussed in this

chapter. In actual practice, most clinicians prefer an eclectic
approach that integrates concepts and multiple perspectives.
There are three ways in which clinicians combine the different
therapeutic models (Goldfried & Norcross, 1995): technical
eclecticism, theoretical integration and the common factors
approach. Those who follow technical eclecticism acknowledge that
particular techniques across theoretical perspectives are effective
in treating a particular problem, irrespective of their own theoretical
orientation. For example, a psychoanalyst may value the use of
graded exposure in treating a patient with phobia.
 66

Theoretical integration comprises of developing ones own

theory about the patients presenting problem by incorporating
principles from different theoretical models. For instance, a
therapist may believe that maladaptive family system and faulty
cognitions have contributed to the clients condition and accordingly
develop an intervention plan by combining these two approaches.

The common factors approach involves using the core

principles shared by the different theoretical models and those
which have been proven to effective in clinical practice such as the
counselor-client relationship (OLeary & Murphy, 2006). Some
clinicians follow a mixed model of integration which combines
aspects of all the three integrative approaches.
In understanding the psychological disorders in the following
chapters it is important to take into account the various biological,
psychological and social factors that may contribute to its
development and treatment.

2.9 SUMMARY :

In this unit we have discussed the various theoretical

perspectives. The first perspective was the psychodynamic
perspective developed by Sigmund Freud. We discussed the
structure of personality and the concept of defense mechanism.
We also discussed the psychosexual stages of development. Post
Freudian Psychodynamic writers were also discussed.
Psychodynamic theory was evaluated. The next perspective that
we discussed was the Humanistic perspective. The person-
centered theory as well as self-actualisation theory was discussed.

Sociocultural perspective was the next perspective which we

discussed. We discussed the family perspective of
psychopathology, social discrimination and related concepts.
Family therapy, group theory, milieu therapy was also discussed.

Behavioural and cognitive based perspective is one of the

most dominant current perspectives. The behavioural perspective
includes classical conditioning, operant conditioning as well as
social learning. Cognitive based theories as well as treatment
based on cognitive and behavioural approaches were also
discussed. These treatment approaches include conditioning
techniques, contingency management techniques, modeling and
self-efficacy training, etc.

Following this we had discussed the biological perspective

and concepts related to it such as neurons, synapse,
neurotransmitters, basic concepts of genetics, models of genetic
 67

transmission, etc. Treatment based on biological perspectives

were also discussed.

Towards the end of the unit we had discussed the concept of

biopsychosocial perspective.

2.10 QUESTIONS :

Q.1 Discuss the concepts of Id, Ego and Superego as given by

Sigmund Freud.
Q.2 Discuss the various Adaptive Defenses.
Q.3 Explain the psychosexual stages of development as outlined
by Sigmund Freud.
Q.4 Write notes on the following
a) Person centered theory
b) Self actualisation theory
Q.5 Discuss the sociocultural perspective in detail.
Q.6 Discuss the behavioural and cognitive perspective.
Q.7 Write short notes on the following.
a) Conditioning Techniques
b) Contingency Management Techniques
Q.8 Discuss the biological treatment approaches.

2.11 SUGGESTED READINGS :

1. Halgin R. P. and Whitbourne S.K. (2010) Abnormal

Psychology : Clinical Perspectives on Psychological
Disorders, (6th Ed.), McGraw Hill.
2. Nolen Hoeksema S. (2008) Abnormal Psychology (4th Ed.),
New York McGraw Hill.

 68

3
ANXIETY DISORDERS

Unit Structure

3.0 Objectives
3.1 Introduction
3.2 Anxiety Disorders
3.3 Panic Disorder and Phobias
3.4 Generalised Anxiety Disorder
3.5 Obsessive Compulsive Disorder
3.6 Post Traumatic Stress Disorder
3.7 The Bio psychosocial Perspective of Anxiety Disorder
3.8 Summary
3.9 Glossary
3.10 Questions
3.11 Suggested Reading

3.0 OBJECTIVES :

After reading this unit you will get to know

About the nature of anxiety disorders.

About the causes and treatments of panic disorder and phobias.
About symptoms, causes and treatments of GAD and OCD.
What is the bio-psychosocial perspective of anxiety disorders.

3.1 INTRODUCTION :

Anxiety is a complex and mysterious type of disorder in

psychopathology. It is a subjective sense of unease, a set of
behaviours or a physiological response originating in the brain. It is
a mood state characterised by marked negative affect and
somantic symptoms. A panic attack represents the alarm response
of real fear but without any actual danger. Panic and anxiety
combine to create different anxiety disorders. There is no simple
one dimensional cause of excessive emotional reactions such as
anxiety or panic. Causes come from different sources. There is
strong evidence that a tendency to the tensed is inherited.
 69

Behaviorists view anxiety as a product of early classical

conditioning. Different anxiety disorders such as GAD, OCD, PTSD,
Phobias, etc., can be treated by different approaches such as
biological, psychological, cognitive therapies, counseling, etc.

3.2 ANXIETY DISORDERS :

Most of the people have grown out of our childhood fears

and our adulthood fears are mild, short-term, or reasonable. The
fears of people with anxiety disorder are severe and lower the
quality of their lives. Their fear are chronic and frequent enough to
interfere with their functioning. Their fears are out of proportion to
dangers that they truly face. Once this anxiety starts, it tends to
feed on itself so that it might not stop even if the particular life
stressor has long since passed.

Four types of symptoms determine the presence of anxiety-

1. Somatic symptoms muscle tension, heart palpitation,

stomach pain etc.
2. Emotional symptoms restlessness, fearfulness, irritability
and constant watchfulness.
3. Cognitive symptoms problems in taking decisions and
concentration, fear of dying, loosing control, etc.
4. Behavioural symptoms escapism in behaviour,
aggressiveness, avoidance, etc.

There are different types of disorders where the main cause

is anxiety and panic. Anxieties are consciously expressed or take
some maladaptive forms like phobia, GAD, PTSD, etc.

3.3 PANIC DISORDER AND PHOBIAS :

Symptoms of Panic Attacks

Panic attacks, are short but intense periods in which
individual experiences many symptoms of anxiety. Heart
palpitations, trembling, a feeling of choking, dizziness, intense
dread, and so on. Panic attacks may occur in the absence of any
environmental triggers on in some people panic attacks are
situationally predisposed. The person is more likely to have them in
certain situation but does not always have them when in those
situations. In all cases, however, the panic attack is a terrifying
experience, causing a person intense fear or discomfort. The
physiological symptoms of anxiety, the feeling of loosing control,
going crazy, or dying when panic attacks become a common
 70

occurrence. When the panic attacks are usually not provoked by

any particular situation, and when a person begins to worry about
having attacks and changes behaviours as a result of this worry, a
diagnosis of panic disorder is made. Some people with panic
disorder have many attacks in a short period of time. Less
frequently, people who have panic disorder often fear that they
have life threatening illnesses. E.g., thyroid disorders, or with a
cardiac disorder called mitral value prelate. Between 1.5 and 4
percent of people will develop panic disorder at some time in their
lives. Most people who develop panic disorder usually do so
sometime between late adolescence and their mid thirties. Many
people with panic disorder also suffer from chronic generalised
anxiety, depression, and alcohol abuse.

Bio psychosocial Perspective

One biological theory of panic disorder is that these people
have over reactive autonomic nervous systems, which put them
into a full flight-or-fight suspense with little provocation. This may be
the result of imbalances in norepinephrine or serotonin or in hyper
sensitivity to feelings of suffocation. There also is some evidence
that panic disorder may be transmitted genetically.

Psychological theories of panic suggest that people who

suffer from panic disorder pay very close attention to their bodily
sensations, misinterpret bodily sensations in a negative way, and
engage in snowballing, catastrophic thinking. This thinking then
increases physiological activation, and a full panic attack starts.

Antidepressants and benzodiazepines have been effective in

reducing panic attack and agoraphobic behaviour, but people tend
to relapse into these disorders when they discontinue these drugs.

An effective cognitive behavioural therapy has been

developed for panic disorders. Clients are taught relaxation
exercises and then learn to identify and challenge their catastrophic
styles of thinking, often while having panic attacks induced in the
therapy sessions. Systematic desensitisation techniques are used
to reduce agoraphobic behaviour.

Phobias
Agoraphobia :-

The term agoraphobia is from the Greek for fear of the

market place. People with agoraphobia fear crowded, bustling
places, such as the market place or in our times, the shopping mall.
They also fear enclosed space, such as buses, subways, or
elevators. Finally, they fear wide open spaces, such as open fields,
particularly if they are alone. In general, they fear any place that
 71

they might have trouble escaping or getting help in an emergency

i.e., panic attack. People with agoraphobia also often fear that they
will embarrass themselves if others see their symptoms of panic
attack. In most cases, agoraphobia begins within one year after a
person begins experiencing frequent anxiety symptoms. People
with agoraphobia are unable to often get to the point, where they
will not leave their own homes.

Agoraphobia strikes people in their youth. In one large study,

more than 70 percent of the people who developed agoraphobia
did so before the age of 25, and 50 percent developed the disorder
before the age of 15 (Bourden et al. 1988).

Specific Phobias :-

Most specific phobias fall into one of four categories, (APA,

2000) animal type, natural environment type, situational type, and
blood injection injury type. When people with these phobias
encounter their feared objects or situation, their anxiety is
immediate and intense, and they may even have full panic attacks.
Most phobias develop during childhood. Adults with phobias
recognise that their anxieties are illogical and unreasonable,
however children may not have his insight and just have the
anxiety. Although as many as 04 in 10 people will have a specific
phobia at some time, making it one of the most common disorders.

a) Animals type phobias are focused on specific animal or insets,

such as dogs, cats, snakes, or spiders. A snake phobia appears
to be the most common type of animal phobia in the United
States. People with phobias go to great lengths to avoid the
objects of their fears.

b) Natural environment type phobia are focused on events or

situations in the natural environment, such as storms, heights,
or water.

c) Situational type phobias usually involve fear of public

transportation, tunnels, bridges, elevators, flying, and driving.
Claustrophobia, or fear of enclosed spaces, is common
situational phobia. People with situational phobias believe they
might have panic attacks in their phobic situations.

d) The final type, blood-injection-injury type phobias, was first

recognised in DSM IV. People with this type of phobia, fear
seeing blood or an injury, receiving an injection, or experiencing
any other medical procedure.
 72

Social Phobia
People with social phobia fear being judged on
embarrassing themselves in front of other people. Social phobia
creates severe disruption in a persons daily life. People with a
social phobia may avoid eating or drinking in public, for fear they
will make noises when they eat, drop food, or otherwise embarrass,
themselves. They may avoid writing in public, including signing their
names, for fear that others see their hands tremble. Men with social
phobia will often avoid urinating in public bathrooms for fear of
embarrassing themselves. People with social phobia tend to fall
into three groups (Eng et al 2000) some people with social phobia
fear only public speaking. Others have moderate anxiety about a
variety of social situations finally, who have severe fear of many
social situations, from speaking in public to just having a
conversation with another person, are said to have a generalised
type of social phobia.

Social phobia is relatively common, with about 8 percent of

the U.S. adult population qualifying for the diagnosis in a 12 month
period and one in eight people experiencing the disorder at some
time in their lines (Kessley et. al., 1998, Schnier el. al, 1992)
Women are somewhat more likely than men to develop this
disorder.

Once it develops, social phobia tends to be a chronic

problem if untreated. Most people with a social phobia do not seek
treatment for their symptoms.

3.4 GENERALISED ANXIETY DISORDER (GAD) :

People with GAD worry about many things in their lives.

E.g., worry about their performance on the job, about how their
relationships are going, and about their own health. The focus of
their worries may shift frequently, and they tend to worry about
many different things, instead of just focusing on one issue of
concern. Their worry is accompanied by many of the physiological
symptoms of anxiety, including muscle tension, sleep disturbances,
and a chronic sense of restlessness.

GAD is a relatively common type of anxiety disorder, with

about 4 percent of the U.S. population experiencing it in any six-
month period. The majority of people with GAD also develop
another anxiety disorder, such as phobias or panic disorder and
many experience depression as well.
 73

Theories of Generalised Anxiety Disorder

1. Psychodynamic Theories :-
Freud (1917) developed the first psychological theory of
generalised anxiety. He distinguished among three kinds of
anxiety : realistic, neurotic, and moral. Realistic anxiety occurs
when we face a real danger or threat, such as an oncoming
tornado. Neurotic anxiety occurs when we are repeatedly prevented
from expressing our id impulses, it causes anxiety. Moral anxiety
occurs when we have been punished for expressing our id
impulses, and we come to associate those impulses with
punishment, causing anxiety. Generalised anxiety occurs when our
defense mechanisms can no longer contain either the id impulses
or the neurotic or moral anxiety that arises from these impulses.

More recent psychodynamic theories attribute generalised

anxiety to poor upbringing, which results in fragile and conflicted
images of the self and others. Children whose parents were not
sufficiently warm and nurturing, and many have been overly strict or
critical, may develop images of the self as vulnerable and images of
others as hostile. As adults, their lives are filled with frantic attempts
to overcome or hide their vulnerability, but stressors often
overwhelm their coping capacities, causing frequent bouts of
anxiety.

2. Humanistic and Existential Theories :-

Carl Rogers humanistic explanation of generalised anxiety
suggests that children who do not receive unconditional positive
regard from significant others become overly critical of themselves
and develop conditions of worth, harsh self-standards they feel they
must meet in order to be acceptable. Throughout their lives, these
people, then, strive to meet these conditions of worth by denying
their true selves and remaining constantly vigilant for the approval
of others. They typically fail to meet their self-standards, causing
them to feel chronically anxious or depressed.

Existential theorists attribute generalised anxiety disorder to

existential anxiety, a universal human fear of the limits and
responsibilities of ones existence. Existential anxiety arises when
we face the finality of death, the fact that we may unintentionally
hurt someone, or the prospect that our lives have has no meaning.
We can avoid existential anxiety by accepting our limits and striving
to make our lives meaningful, or we can try to silence that anxiety
by avoiding responsibility or by conforming to others rules. Failing
to confront lifes existential issues only leaves the anxiety in place,
however, and leads us to inauthentic lives.
 74

3. Cognitive Theories :-
Cognitive theories of GAD suggest that the cognitions of
people with GAD are focused on threat, at both the conscious and
non conscious levels. At the conscious level, people with GAD have
a number of maladaptive assumptions that set them up for anxiety,
such as I must be loved or approved of by everyone, Its always
best to expect the worst, People with GAD believe that worrying
can prevent bad events from happening. These beliefs are often
superstitions, but people with GAD also believe that worrying
motivates them and facilitates their problem solving, yet people with
GAD seldom get around to problem solving. Indeed, they actively
avoid visual images of what they worry about, perhaps as a way of
avoiding the negative emotion associated with those images.

Their maladaptive assumptions lead people with GAD to

responds to situations with automatic thoughts, which directly stir
up anxiety, cause them to be hyper vigilant, and lead them to
overreact to situations.

Check Your Progress:-

1. What do you mean by GAD?

2. Discuss the different theories of GAD?

3.5 OBSESSIVE COMPULSIVE DISORDER (OCD) :

OCD is a type of anxiety disorder but differs from other

anxiety disorders. The person shows either obsessions or
compulsion, which are excessive and unreasonable.

Obsessions
They are recurrent and persistent thoughts, impulses, or
images that are experienced as intrusive and inappropriate and that
cause anxiety or distress.
 75

Compulsions
They are repetitive behaviours (such as hand washing,
checking, etc.) or mental acts (such as praying, repeating words,
etc.) that the person feels driven to perform in response to an
obsession or according to rules that must be applied rigidly.

People with obsessive compulsive disorder experience

anxiety when they have obsessions and when they cannot carry out
their compulsions.

Common obsessions one focused on contamination, sex,

violence and repeated doubts.

THEORIES OF OCD

Biological theories of OCD speculate that areas of the

brain involved a in the execution of primitive patterns of behaviour,
such as washing rituals, may be impaired in people with OCD.
These areas of the brain are rich in the neurotransmitter serotonin
and drugs that regulate serotonin have proven helpful in the
treatment of OCD.

Psychodynamic theories of OCD suggest that the

obsessions and compulsions symbolises unconscious conflict or
impulses and that the proper therapy for OCD involves uncovering
these unconscious thoughts.

Cognitive behavioral theories suggest that people with

OCD are chronically distressed, think in rigid and moralistic ways,
judge negative thoughts as more acceptable than other people do,
and feel more responsible for their thoughts and behaviours. This
makes them unable to turn off the negative, intrusive thoughts that
most people have occasionally. Compulsive behaviours develop
through operant conditioning, people are reinforced for compulsive
behaviours by the fact that they reduce anxiety.

TREATEMTNS OF OCD

Drug Therapy : The most effective drug therapies for OCD are the
antidepressant known as selective serotonin reuptake inhibitors.

Cognitive Behavioural Therapies : They have also proven helpful

for OCD. These therapies expose OCD client to the content of their
obsessions while preventing compulsive behaviour, the anxiety
over the obsessions and the compulsions to do the behaviours are
extinguished.
 76

Unfortunately neither the drug therapies nor the cognitive.

behavioural therapies tend to eliminate the obsessions and
compulsions completely. The relapse rate with the drug therapies is
high once the drugs are discontinued. Cognitive behavioural
therapies help prevent relapse.

3.6 POSTTRAUMATIC STRESS DISORDER (PTSD) :

PTSD is an anxiety disorder which occurs after a person

experiences a severe trauma. It is a set of symptoms including
hyper vigilance, re-experiencing of the trauma, emotional numbing
experienced by trauma survivors.

People who experience severe and long lasting traumas,

who have lower levels of social support, who experience socially
stigmatising traumas, who were already depressed or anxious
before the trauma, or who have maladaptive coping styles may be
at increased risk for PTSD.

The three main categories of symptoms of PTSD are

1. Re experiencing of the traumatic event
Frequent nightmares, flashbacks of the event, other stimulus
remind the event, etc.
2. Emotional numbing and detachment -
Avoidance of anything which reminds of the event, restricted
emotional responses, no reaction to any kind of emotional
provocation, sometimes unable to remember certain aspects of
the event, etc.
3. Hyper vigilance and chronic arousal -
Constantly alertness for the traumatic event, panic and flight,
chronically over aroused, easily startled, quick to anger, etc.

Four types of events are seen to result in PTSD

1. Natural disasters Floods, earthquakes, fires, tornadoes, etc.

2. Abuse Physical abuse like beating, sexual abuse like rape,
emotional abuse like critical parents, etc.
3. Combat and War related traumas - War prisoners witnessing
deaths, war zone stress etc.
4. Common traumatic events - Accidents, sudden death of loved
ones, drowning, heart break, etc.
 77

CAUSES OF PTSD

1. Psychological Causes
a) Human beings live with many assumptions about
themselves and others, this keeps the persons faith and
trust intact. But if these assumptions, one shattered because
of the trauma, may result in PTSD.
b) People already suffering from depression and anxiety are
more vulnerable to develop PTSD.
c) The onset of PTSD also depends on the persons coping
styles and adjustments. People using self-destructive styles
such as taking alcohol, drugs, isolation are more vulnerable
to PTSD.

2. Biological Causes -
a) Lower level of the hormone cortisol can result in PTSD, as it
prolongs the activity of the sympathetic nervous system.
PTSD people show increased blood flow in the amygdala
area of the brain.
b) Twin and family studies shows that PTSD can be inherited, it
runs in the family.

3. Social and Cultural Causes -

People with strong social and supportive social group are less
likely to develop PTSD after a trauma.

TREATMENT OF PTSD

1. Cognitive Treatment
a) Behavioural therapy
Systematic desensitisation helps the patient to identify the
stimulus and rank the fear ascendingly. Positive imagery
training helps the victims of rape to recover from PTSD.
b) Stress management methods helps to develop skills to
overcome stressful issues.

2. Biological therapy
Selective Serotonin Reuptake Inhibitors (SSRI) and
Benzodiazepines are helpful in treating PTSD symptoms.

3. Social Cultural Help

Community level interventions helps the people with PTSD
caused by natural disasters, etc.
 78

Check Your Progress

1. What are the causes of PTSD?
2. What are the treatments of PTSD?

3.7 BIOPSYCHOSOCIAL PERSPECTIVE OF

ANXIETY DISORDERS :

Biology is clearly involved in the experience of anxiety

disorders. Evolution has prepared our bodies to respond to
threatening situations with physiological changes that make it
easier for a person to flee or fight an attacker. In few persons this
reaction leads to chronic arousal, to over actively or poorly
regulated arousal. These people are more prone to severe anxiety
reactions to threatening stimuli and to the anxiety disorders.

Social perspective focus on differences between groups in

the rates and expression of anxiety disorders. Women have higher
rates of almost all the anxiety disorders than do men. Women may
have more genetic vulnerability to anxiety disorders because of
changes in their hormonal levels.

Culture may differ in their expression of this disorder.

Psychological perspective focus on the upbringing of an individual
e.g., specific traumatic experiences that some have suffered.

3.8 SUMMARY :

Anxiety disorders are complex and most common form of

mental disorder. Anxiety is a future oriented state where a person
focuses on the possibility of experiencing danger. Panic and
anxiety creates different anxiety disorders.

In phobia, the person avoids situations that produce severe

anxiety or panic disorders. PTSD focuses on avoiding thoughts or
images of past traumatic experiences.
OCD disorder focuses on repulsive intrusive thoughts and
the use of ritualistic behaviours.
 79

Specific genetic vulnerability seem to put person at risk for

anxiety disorder. Psychological and social causes can result in
anxiety disorders.

Psychological, social and biological treatments helps a

patient with anxiety disorder.

3.9 GLOSARY :

1. Animal Phobia unreasonable fear of animals or insects.

2. Serotonin Neurotransmitter involved in processing
information and co ordination of movements as well as
inhibition.

3.10 QUESTIONS :

Q.1 Define Anxiety and Panic Disorders and discuss their

symptoms.
Q.2 Write notes on the following.
a) Agoraphobia
b) Specific Phobia
c) Social Phobia
Q.3 What is Generalised Anxiety Disorder. Discuss the various
theories of Generdised Anxiety Disorder.
Q.4 Define Obsessive Compulsive Disorder. Discuss its theories
and treatment.
Q.5 Define Post Traumatic Disorders and discuss its causes and
treatment.
Q.6 Write a note on Biopsychosocial perspective of Anxiety
Disorders.

3.11 SUGGESTED READINGS :

1. Abnormal psychology by David H. Barlow & V. Mark Durand,

1995, 2005, New Delhi.
2. Dhanda, Amrta (2000) Legal order and mental disorder, New
Delhi. Sage Publications Pvt Ltd.

 80

4
SOMATOFORM DISORDERS,
PSYCHOLOGICAL FACTORS AFFECTING
MEDICAL CONDITIONS AND
DISSOCIATIVE DISORDERS - I

Unit Structure
4.0 Objectives
4.1 Introduction
4.2 Somatoform Disorders
4.3 Psychological Factors Affecting Medical Conditions
4.4 Summary
4.5 Questions
4.6 Reference

4.0 OBJECTIVES

After studying this unit you should:

Know the concept of somatoform disorders.
Understand conversion disorder.
Comprehend somatisation disorder and related conditions.
Know body dysmorphic disorder and hypochondriasis.
Understand conditions related to somatoform disorders.
Know theories and treatment of somatoform disorders.
Understand Psychological Factors Affecting Medical
Conditions and associated topics such as coping, stress and
the immune system, etc.

4.1 INTRODUCTION

In this unit we will discuss the concept of somatoform

disorders. The concept of conversion disorder, somatisation
disorder and related conditions, dysmorphic disorder as well as
hypocondriasis will also be discussed. Following this we will
discuss the various conditions related to somatoform disorders,
such as malingering, factitious disorder and Munchausens
 81

syndrome. Theories and treatment of somatoform disorder would

also be discussed.
Many medical conditions are influenced by psychological
factors. DSM IV TR category of psychological factors affecting
medical conditions includes situations in which psychological or
behavioural factors have an adverse effect on a medical conditions.
Theories and treatment of these conditions would also be
discussed.

4.2 SOMATOFORM DISORDERS

Somatoform disorders are those disorders in which an

individual complains of bodily symptoms but for which there is no
clear-cut identifiable physical cause. Somatoform disorders include
a variety of conditions in which conflict becomes translated in to
physical problems or complaints that cause distress or impairment
in a persons life. Psychologists have known Somatoform disorders
since a long time. The term soma refers to body and somatoform
disorders are those bodily disorders for which there is no biological
basis for physical complaints and the cause is largely a result of
psychological factors. Somatoform disorders can be defined as an
anxiety based pattern in which an individual complains of bodily
symptoms that suggest the presence of a physical problem, but for
which no organic basis can be found. Health professionals find it
difficult distinguishing between a physical cause and a
psychological cause when it comes to understanding bodily
symptoms. DSM-IV has identified many different forms of
somatoform disorders. These include: Conversion disorder,
Somatisation disorder and related conditions, Body dysmorphic
disorder, Hypochondriasis, etc.

4.2.1 Conversion Disorder: Conversion disorder involves a

translation of unacceptable drives or troubling conflicts in to bodily
motor or sensory symptoms that suggest neurological or other
kinds of medical conditions. The essential feature of this disorder is
an involuntary loss or alteration of a bodily function due to
psychological conflict or need, causing the individual to feel
seriously distressed or to be impaired in social, occupational or
other important areas of life. It should be remembered that the
person is not intentionally producing the symptoms. Clinicians
cannot establish a medical basis for the symptoms and it appears
that the person is converting the psychological conflict or need in to
a physical problem.

This disorder was earlier called as hysteria and it involves a

neurotic pattern in which symptoms of some physical
malfunctioning or loss of control appear without any underlying
organic pathology. In 1850s a French physician Paul Briquet
systematically described and categorized various symptoms of
 82

hysteria based on his review of about 400 patients. Jean Martin

Charcot used the technique of hypnosis to show that psychological
factors played a role in the physical symptoms of hysteria. Pierre
Janet and Hyppolyte Marie Bernheim did considerable work on
hysteria ane enhanced our understanding about it. Sigmund Freud
developed a radically different theory of hysteria. He called it as
hysterical neurosis.

According to Barlow and Durand (2000) conversion disorder

can be defined as physical malfunctioning such as blindness or
paralysis suggesting neurological impairment but with no organic
pathology to account for it.

Conversion disorders were once relatively common in

civilian and especially in military life. In World War I, conversion
disorders were the most frequently diagnosed psychiatric syndrome
among soldiers. It was also relatively common during World War II.

Statistical details reveal that conversion disorder may occur

in conjunction with other disorder particularly Somatisation disorder.
This disorder is common among women and generally develops
during adolescence. These disorders are common among soldiers
exposed to combat.

Conversion disorders typically occurred under highly

stressful combat conditions and involved men who would ordinarily
be considered stable.

Conversion disorder is a rare phenomenon affecting about 1

to 3 % of those referred for mental health care. The disorder often
runs in families. It generally appears between the ages of 10 and
35 Years and is more frequently observed among women and in
people with less education.

The symptoms of conversion disorder are multiple. All these

symptoms of conversion disorder can be grouped into three broad
categories. These are as follows:

A) Sensory Symptoms: Some of the sensory symptoms

involved in conversion disorder are as follows:
Anesthesia: loss of sensitivity.
Analgesia: loss of sensitivity to pain.
Hypesthesia: partial loss of sensitivity.
Hyperaesthesia: excessive sensitivity.

Ironside and Bachelor (1945) found the following sensory

symptoms among conversion disorders. These are blurred vision,
photophobia, double vision, night blindness, jumping of print during
attempts to read, etc. These researchers also found that the
 83

symptoms of each airman (whom they studied) were closely related

to his performance duties. Night fliers were more subject to night
blindness, while day fliers more often developed failing day vision.

B) Motor Symptoms: Some common motor symptoms found

among conversion disorder are as follows:
i. Paralysis: Such a behavior is usually confined to only one
arm or leg and the loss of function is usually selective for
e.g. writers cramp, ticks (localized muscular twitches).
ii. Contractors: Such a behavior involves flexing a finger and
toes or rigidity of the larger joints such as elbows and
knees. Paralysis and contractors frequently lead to
walking disturbances.
iii. Aphonia: is a most common speech disturbance. In this
disorder an individual is able to talk only in whispers and
mutism.
iv. Convulsion: This is an occasional motor symptom.
However, people with hysterical convulsion show features
or the usual characteristics of true epileptics.

C) Visceral Symptoms: Visceral conversion reactions also

cover a wide range of symptoms, including headaches lump in the
throat (formerly known as globus hystericus) and choking
sensations, coughing spells, difficulty in breathing, cold and clammy
extremities, bleaching, nausea, vomiting, and so on. Occasionally,
persistent hiccoughing or sneezing occurs.
Accurate diagnosis of conversion disorder is a difficult task
because conversion disorder can stimulate every known disease.
Conversion disorder can be distinguished from organic disorder on
the basis of the following points.

1. La Belle Indifference: This means that those who have

conversion disorder are unconcerned about the long-range
effects of their disabilities. Individuals with organic disorder
are very much concerned about the long-range effect of their
symptoms.
2. Selective nature of the dysfunctioning: Individuals who
have conversion disorder are highly selective with respect to
symptom pathology. For example, in conversion blindness,
an individual does not usually bump into people or objects;
paralyzed, muscles can be used for some activities but not
others; and controlled contractors usually disappear during
sleep.
3. Under hypnosis or narcosis: The interesting fact that
under hypnosis or narcosis (a sleep like state induced by
 84

drugs) the symptoms can usually be removed, shifted, or

reinduced by the suggestion of the therapist. Similarly, if the
individual is suddenly awakened from a sound sleep, he or
she may be tricked into using a paralyzed limb.
In the development of a conversion disorder, the following
chain of events typically occurs:
a. A desire to escape from some unpleasant situation.
b. A feeling or a wish to be sick in order to avoid the
situation (this wish, however is suppressed as
unfeasible or unworthy); and under additional or
continued stress.
c. The appearance of the symptoms of some physical
ailment. The individual sees no relation between the
symptoms and the stress situation. The particular
symptoms that occur are usually those of a previous
illness or are copied from other sources, such as
symptoms observed among relatives, seen on
television, or read about in magazines.

Conversion disorders seem to stem from feelings of guilt and

the necessity for self-punishment. Those who suffer from
conversion disorder also suffer from a dissociative disorder. It is
difficult to diagnose conversion disorder. Individuals suspected of
conversion disorder must be given a thorough neurological
examination in addition to follow up to determine whether a clients
symptoms represent an underlying medical condition.

4.2.2 Somatisation Disorder and Related Conditions:

Somatisation disorder involves the expression of psychological
issues through bodily problems that cannot be explained by any
known medical condition or as being due to the effects of a
substance.

The difference between somatization disorder and

conversion disorder is that somatisation disorder involves multiple
and recurrent bodily symptoms rather than a single physical
complaint.

This condition generally, which is relatively rare, first appears

before the age of 30 years and leads to problems in the areas of
social, occupational and interpersonal functioning. Individuals
suffering from this disorder generally tend to be from lower
socioeconomic classes.

This disorder was earlier called as Briquets Syndrome, after

the famous French physician, Pierre Briquet who in 1859 described
patients who has multiple somatic complaints for which he could
 85

not find any medical cause. Somatisation disorder was known as

Briquets syndrome for more than 100 years and was called as
somatisation disorder for the first time only in 1980s in the DSM- III.
In this disorder there are repeated and multiple vague somatic
complaints for which there is no physiological cause. This is a very
rare disorder and occurs on a continuum.

Two important points with respect to somatisation disorder

are as follows:
Majority of the individuals with somatisation disorder
tend to be women, unmarried and from lower
socioeconomic groups.
In addition to a variety of somatic complaints,
individuals may also have psychological complaints,
usually anxiety or mood disorders.

Clinical Description: The common complaints in this disorder are

pseudoneurological
i. e. neurological disorder without organic neurological causes like
double vision, or headache, allergies, nausea, stomach problem,
and menstrual and sexual difficulties.

Such people experience pain and sickness in exaggerated

manner. It has been demonstrated that individuals with
somatisation disorder tend to be women, unmatured and from lower
socio economic status.

This disorder shares a number of features with Antisocial

Personality Disorder. These are as follows:
Both these disorders begin early in life.
They both run a typical chronic course.
They both predominate among lower socioeconomic
classes.
Both are difficult to treat.
Both these disorders are associated with marital
discord, drug and alcohol abuse and suicide attempts.

Causes: Some important causes of this disorder are as follows:

1. Genetic factors: Early studies of possible genetic
contributions have had shown mixed results. For e.g. Torgerson
(1986) found no increased prevalence of somatisation disorder in
monozygotic pairs. However, most recent studies have found that
this disorder run in families and may have a heritable basis. It has
also been observed that Somatisation Disorder is strongly linked in
family and genetic studies to Antisocial Personality Disorder.

2. Early Learning: Somatisation disorder is a learned disorder.

Individuals learn from significant others, and through role modeling,
 86

significant somatic symptoms that are characteristic of these

disorders.
3. Neurobiological Factors: Jeffrey Gray and his associates
(1985) have implicated neurophysiological factors in the
development of somatisation disorder. According to him
Somatisation Disorder and Antisocial Personality Disorder share a
neurobiological based disinhibition syndrome. A variety of
neurophysiological evidence suggests a dysfunction in the brain
circuit in somatisation disorder.

According to Widom (1984) and Colninger (1987) in the

occurrence of somatisation disorder, social and cultural factors too
play an important role. Gender roles encourage development of
somatisation disorder in women in many cultures.

Treatment: Treatment of somatisation disorder is exceedingly

difficult and there are no treatments with proven effectiveness that
seem to cure the syndrome. Barlow et al (1992) have pointed out
that somatisation disorder can be better managed by providing
patients with the following:
Providing reassurance.
Reducing stress.
Reducing the frequency of help-seeking behavior.

People with somatisation disorder do not voluntarily seek

psychotherapy. They seek psychotherapy only on the insistence
from their physician. The prognosis of this disorder is generally
poor.

4.2.3 Pain Disorder : It is one variant of somatisation

disorder in which instead of the multiple somatic complaints,
individual demonstrates only one symptom, i.e. pain. The pain
causes intense personal distress or impairment. The client is not
faking pain. In some cases of pain disorder there may be a
diagnosable medical condition but the reported experience of main
is more than what can be normally seen.

In pain disorder there may have been a clear physical reason

for pain at least initially, but psychological factors play a role in
maintaining it. An important feature of pain disorder is that the pain
is real and it hurts regardless of the cause. Since it is a new and a
separate category more research on it is needed to increase our
understanding of this disorder.

People with pain disorder are likely to become dependent on

substances, either illicit drugs or prescription medications, in their
effort to alleviate their discomfort.
 87

4.2.4 Body Dysmorphic Disorder: Individuals having this

disorder have distorted negative concerns about their bodies. They
are preoccupied, almost to the point of being delusional, with the
idea that a part of their body is ugly or defective. They are so
concerned with distress about their bodily problem that their work,
social life and relationships are impaired. They may be abnormally
worried about the texture of their skin, too little facial hair, or they
feel that there is deformity in the shape of their nose, mouth, jaw or
eyebrow.

This is an imaginative disorder. This disorder is also called

as imagined ugliness (Phillips, 1991). It is a somatoform disorder
in which there is an excessive preoccupation with some imagined
defect in appearance by some one who actually looks reasonably
normal.

The prevalence of this disorder is hard to estimate since by

its very nature it tends to be kept a secret. This disorder is more
commonly found among females; however, in Japan more males
experience this disorder. This disorder occurs in adolescence and
peaks at the age of 18 or 19 years.

Clinical Description: Individuals with this disorder show the

following symptoms:
People with this disorder become fixated on mirrors. They often
view themselves in a mirror to check as if any change is taking
place in them.
As a result of this disorder, individuals indulge in suicidal
ideation as well as suicidal attempt and even actual suicide.
They have ideas of reference, i.e. they think that everything
that goes on in their world is somehow related to them.
Their psychopathology lies in their reacting to a deformity that
others cannot perceive.
They are also concerned with the width of their face
Individuals having this disorder are the ones who do not
conform to the current cultural practices of their bodily features.

Causes: The etiology of this disorder is not well known. There is no

data available to indicate whether this disorder run in families or
whether there is biological or psychological predisposition to this
disorder.

The pattern of comorbidity with other disorders does give us

some indication about the etiology of this disorder. This disorder co-
occurs with hypochondriasis, however it does not co-occur with
other somatoform disorders, nor does it occur in family members of
 88

patients with other disorders. A disorder that has been frequently

found to co-occur with Body Dysmorphic Disorder is the Obsessive
Compulsive Disorder.
Body Dysmorphic Disorder has considerable degree of
similarity with Obsessive Compulsive Disorder. Some important
points are as follows:
i) Individuals with Body Dysmorphic Disorder often complain of
persistent, intrusive and horrible thoughts about their
appearances, and they engage in such compulsive
behaviours as repeatedly looking in mirrors to check their
physical features.
ii) Body Dysmorphic Disorder and Obsessive Compulsive
Disorder also have approximately the same age of onset and
run the same course.
iii) The treatment of these two disorders is also the same.
Medically the drug that block the reuptake of serotonin, such
as Clomipramine (Anafranil) and fluoxetine (Prozac) are
useful in both these disorders. Similarly, exposure and
response prevention, the type of cognitive behavior therapy
that is effective with Obsessive Compulsive Disorder, has
also been successful with Body Dysmorphic Disorder.

Treatment: Psychological treatment of this disorder consists of

bringing about a cognitive change in the individual. Among the
medical treatment Plastic surgery is the most common. Preliminary
research suggests that as many as 2% of all the patients who
request plastic surgery may have this disorder. It has also been
noted that surgery on people with Body Dysmorphic Disorder
seldom produced the desired results and these people return for
additional surgery on the same defect, or concentrate on some new
defect.

Recent research (1993) has revealed that preoccupation

with imagined ugliness actually increased in people who had plastic
surgery, dental procedures or special skin treatments for their
perceived problems.

4.2.5 Hypochondriasis: Those suffering from hypochondriasis

believe or fear that they have a serious illness, when in fact they
are merely experiencing normal bodily reations. Unlike conversion
disorder or somatisation disorder, hypochondriasis does not involve
extreme bodily dysfunction or unexplainable medical symptoms.

It is one type of somatoform disorder, which is characterized

by multiple complaints about possible physical illness where no
evidence for such illness can be found. In hypochondriasis anxiety
is a result on ones preoccupation with bodily symptoms
 89

misinterpreting them as indicative of illness or disease, etc. Since

the preliminary symptoms of this disorder are generally of health
concerns, an individual with this disorder is likely to visit a family
physician.

In hypochondriasis an individual has a severe anxiety, which

is focused on the possibility of having a serious disease.

Clinical Description: Those who suffer from hypocondriasis show

the following symptoms:
i. They have an unrealistic interpretation of relatively common
physical complaint.
ii. Their complaints are not restricted to any logical symptoms.
iii. They have trouble in giving precise description of their
symptoms.
iv. They read a lot on medical topics and feel certain that they
are suffering from every new disease they read or hear
about.
v. They believe that they are seriously ill and cannot recover.
As their symptoms have no physical causes, no treatment is
possible. Hence, they keep on changing their physician until
the physician treats the disorder, which does not exist at all.
vi. These patients are so preoccupied with their health, that
many of them keep detailed information about diet,
functioning of body, etc. Besides, they also keep
themselves well informed about the latest medical
treatments by reading popular newspaper and magazines.
vii. Usually this disorder occurs after the age of thirty.
viii. Hypochondriacal individuals show a morbid preoccupation
with digestive and excretory functions. These individuals
have an abnormal preoccupation with disease.

Hypocondriasis differs from somatisation disorder on the following

grounds.
a. It occurs after the age of 30 years.
b. The abnormal concerns of hypocondriacal individuals
are vague, general, and do not focus on particular set
of symptoms.
c. Hypocondriacal persons have a belief that they have
a serious disorder, which is unique.

Since in this disorder there is preoccupation with physical

symptoms, individuals are more likely to visit family physicians.
 90

They come to the attention of mental health experts only

when all relevant medical conditions concerned with the presenting
physical complaints are ruled out.

Research studies indicate that hypochnodriasis shares many

features with anxiety disorders, particularly panic disorders. These
two disorders are frequently comorbid i.e. individuals with a
hypochondriacal disorder have an additional diagnosis of anxiety
disorder.

In hypochondriacal disorder an individual is preoccupied with

bodily symptoms, misrepresenting them as indicative of illness or
disease. Any physical sensation, experienced by such individuals
can become a basis of concern for individuals.

Inspite of best efforts by the doctors to convince the

individual that nothing is medically wrong with him and the disorder
is more psychological in nature; the patient is not able to
understand this.

Patients having hypochondriasis are distinguished from

those having illness Phobia. Illness Phobia is future oriented, i.e.
individuals who fear developing a disease is said to have illness
Phobia. On the other hand hypochondriasis is a current anxiety
about a presumed illness. In other words, individuals who
mistakenly believe they currently have a disease are diagnosed as
having hypochondriasis.

Statistics: The prevalence of hypochondriasis in general

population is not well known. It is estimated that anywhere between
1% to 14% of the medical patients has hypochondriasis. The sex
ratio of this disorder is 50-50. Once it was believed that
hypochondriasis was most common among elderly population.
However this is not so. It is estimated that hypochondriasis can
develop at any time of life, with peak age period found in
adolescence, middle age (40s and 50s) and ages 60 years.

Hypochandriasis is a culture specific disorder. Its

manifestation is considerably influenced by sociocultural factors.
Two important culture specific syndromes are as follows:
a) Koro
b) Dhat

Koro: This syndrome is generally found among Chinese males,

though it is also found among western women to a lesser extent. In
this syndrome there is a belief accompanied by severe anxiety and
sometimes panic that genitals are retracting into the abdomen.
Koro occurs in Chinese males because of the central importance
 91

given to sexual functioning among Chinese males. In this syndrome

an individual feels guilty about excessive masturbation,
unsatisfactory intercourse or promiscuity. These events generally
predispose men to focus their attention on their sexual organs,
which generally increases anxiety and arousal leading to
hypochondrical symptoms.

Dhat: This is another culture specific syndrome, most common

among Indians. It is an anxious concern about loosing ones
semen. The loss of semen is associated with a vague mix of
physical symptoms including dizziness, weakness and fatigue that
are not so specific as in Koro.

The various somatic symptoms present in hypochondriasis

poses diagnostic problem for a clinician and hence the clinician
must remember the following points:

a) First, the clinician must be accurately aware of the specific

culture or subculture of a patient in order to understand the
cultural manifestation of this disorder.
b) A clinician must rule out the physical cause of somatic
complaints before referring the patient to a mental health
professional.
c) The mental health professional must determine the nature of
somatic complaints in order to know whether they are
associated with a somatoform or are a part of other
psychopathological syndrome such as panic attack.

Causes of Hypochondriasis: Some important causes of

hypochondriasis are as follows:
Disorder of Cognition and Perception: Hypochondriasis is a
disorder of cognition and perception with strong emotional
contributions. Individuals with hypochondriasis pay undue
attention to physical sensations that are common to all
normal individuals. They quickly focus their attention on
these sensations. The very fact of focusing attention of their
self increases their arousal and makes physical sensations
seem more intense than they actually are. For e.g. a minor
headache may be interpreted as a sign of brain tumor.
Increased Perceptual Sensitivity: Experiments using the
stroop test has revealed that individuals having
hypochondriasis show enhanced perceptual sensitivity to
illness cues. They also tend to interpret ambiguous stimuli as
threatening.
 92

Integrated Approach: It should be remembered that no single

biological or psychological cause can be implicated in this
disorder. Researchers have pointed out that the fundamental
causes of hypochondriasis are similar to those implicated in
the anxiety disorder.

According to Cote et al (1996) three important factors related to the

etiology process of this disorder are as follows:
i. Hypochondriasis seems to develop in the context of stressful
life events. Such events often involve death or illness.
ii. People who develop hypochondriasis tend to have had a
disproportionate incidence of disease in their family when
they were children.
iii. Important interpersonal and social influence also plays an
important role in the development of hypochondriasis. For
e.g. some people who come from families where illness is a
major issue seem to have learned that an ill person is often
paid increased attention. Hence, they develop illness.

Treatment: Some important points related to treatment of this

disorder are as follows:
i) Our knowledge about the treatment of this disorder is limited.
Scientifically controlled studies are very rare.
ii) Treatment of this disorder consists of identifying and
challenging illness related misinterpretation of physical
sensations and on showing the patient how to create
symptoms by focusing attention on certain body areas.
iii) Psychoanalysis has been found to be less effective with this
type of diorder. Ladee (1966) found that only four out of the
23 patients with this type of treatment improved.
iv) Kellner (1992) found that reassurance seems to be effective
in some cases, especially when it is given by a medically
trained person such as a family physician.
v) Participation in support groups (i.e. group therapy or
counselling) can also be of considerable benefit for such
patients.

4.2.6 Conditions Related to Somatoform Disorders: Some

important conditions related to somatoform disorders that we will
discuss in this section are as follows:

i. Malingering (Faking): It involves deliberately feigning the

symptoms of physical illness or psychological disorder for an
ulterior motive. A person may feign physical problem to either
 93

obtain financial gain, avoid punishment or to fulfill some other

motive. Malingering is deliberate faking of a physical or
psychological disorder motivated by gain. It is difficult to distinguish
between malingering and conversion disorder. In the former the
person is consciously aware that he is faking a disorder, whereas,
in conversion disorder the individual is not aware, it occurs
unconsciously. Three important points that can help one to
distinguish between conversion disorder and malingering are as
follows:
An individual with conversion disorder is indifferent to the
symptoms as compared to other disorders, i.e., they show la
belle indifference.
Conversion symptoms are often precipitated by marked stress.
Individuals with conversion symptoms can usually function
normally and that they seem to be really unaware either of this
ability or of sensory input.

Psychologists have developed psychological instruments to

determine whether a patient is malingering or not. One type of
scale is the validity scales found in the MMPI or EPQ. Another
instrument is the Validity Indicator Profile (Frederick, 1998) which
consists of verbal and nonverbal tasks designed to determine
whether a subject is responding legitimately or is trying to look
impaired.

ii. Factitious Disorder: This disorder falls between

malingering and conversion disorder. It refers to non-existent
physical or psychological disorder deliberately faked for no
apparent gain except possibly sympathy and attention. In factitious
disorders the symptoms are feigned and under voluntary control,
but unlike malingering there is no good reason for voluntary
producing the symptoms except, possibly to assume the sick role
and receive increased attention. In factitious disorder, people fake
symptoms or disorders, not for the purpose of any particular gain
but because of an inner need top maintain a sick role. The
symptoms may be either physical or psychological or they may be a
combination of both. In some cases, individual fabricates a
problem, such as excruciating headaches. These individuals relish
the notion of being ill and may go to great lengths either to appear
ill or to make themselves ill

iii. Munchausens Syndrome: It is a type of factitious disorder,

named after Baron von Munchausen, a retired German cavalry
officer known for his tall tales. Munchausens Syndrome involves
chronic cases in which the individuals whole life revolves with the
pursuit of medical care. Munchausen syndrome is a type of
factitious disorder, or mental illness, in which a person repeatedly
acts as if he or she has a physical or mental disorder when, in truth,
 94

he or she has caused the symptoms. People with factitious

disorders act this way because of an inner need to be seen as ill or
injured, not to achieve a concrete benefit, such as financial gain.
They are even willing to undergo painful or risky tests and
operations in order to get the sympathy and special attention given
to people who are truly ill. Some will secretively injure themselves
to cause signs like blood in the urine or cyanosis of a limb.
Munchausen syndrome is a mental illness associated with severe
emotional difficulties.

Persons with Munchausen syndrome intentionally cause

signs and symptoms of an illness or injury by inflicting medical
harm to their body, often to the point of having to be hospitalized.
These persons are sometimes eager to undergo invasive medical
interventions. They are also known to move from doctor to doctor,
hospital to hospital, or town to town to find a new audience once
they have exhausted the workup and treatment options available in
a given medical setting. Persons with Munchausen syndrome may
also make false claims about their accomplishments, credentials,
relations to famous persons, etc.

A related condition, called Munchausen by proxy syndrome,

refers to a caregiver who fakes symptoms by causing injury to
someone else, often a child, and then wants to be with that person
in a hospital or similar medical setting.

The exact cause of Munchausen syndrome is not known, but

researchers believe both biological and psychological factors play a
role in the development of this syndrome. Some theories suggest
that a history of abuse or neglect as a child, or a history of frequent
illnesses requiring hospitalization, might be factors associated with
the development of this syndrome. Researchers also are studying
the possible link with personality disorders, which are common in
individuals with Munchausen syndrome.

4.2.7 Theories and Treatment of Somatoform Disorder:

Causes and treatment of each of the somatoform disorder has
been discussed above. However it is important to understand as to
what motivates people to appear sick. Psychologists explain
motives with the help of primary gain and secondary gain. Primary
gain is avoidance of burdensome responsibilities because one is
disabled. Secondary gain is the sympathy and attention the sick
person receives from other people.

Somatoform disorders can best be explained as interplay of

biological factors, learning experiences, emotional factors and
faulty cognitions. According to this integrative approach, childhood
events set the stage for the later development of symptoms.
 95

Most contemporary approaches to treating somatoform

disorders involve exploring a persons need to play the sick role,
evaluating the contribution of stress in the persons life and
providing clients with cognitive behavioural techniques to control
their symptoms. Medication can also be used in certain cases. For
some patients with somatisation disorder, antidepressant
medications can serve an important role in treatment.

4.3 PSYCHOLOGICAL FACTORS AFFECTING MEDICAL

CONDITIONS

Bodily conditions can be adversely affected by psychological

factors. For example, intense emotional stress can increase ones
vulnerability to getting sick and can seem to slow down recovery
from an ailment. This is a special diagnostic category in DSM IV
TR.

Psychological factors can influence physical health either

indirectly, by changing behaviors that affect your health, such as
eating, sleeping and socializing, or directly, by producing changes
in your hormones and/or heart rate. Additionally, the mind can
interact with the benefits of a medicine, reducing the effectiveness
of a certain drug or worsening the negative symptoms associated
with certain medical conditions. Therefore, you should monitor your
thoughts towards your health and psychological well-being when
coping with any medical condition.

The diagnosis of Psychological Factors Affecting Medical

Conditions, is given to those individuals who suffer from a
recognised medical condition that is adversely affected by
emotional factors that influence the course of the medical condition
or interfere with treatment, create additional health risk or
aggravate its symptoms. Emotional and psychological factors can
aggravate any physical problem.

4.3.1 Theories and Treatment of Psychological Factors

Affecting Medical Conditions: Researchers who study the mind
body relationship attempt to determine why some people develop
physiological or medical problems, when their lives become busy,
complicated or filled with pleasant events. Some important factors
worth noting are as follows:

1. Stress: Stress refers to unpleasant emotional reaction a

person has when he or she perceives an event as threatening. The
emotional reaction to stress may include heightened physiological
arousal due to increased reactivity of the sympathetic nervous
system. The term stressor is used to refer to any event that leads to
stress. Holmes and Rahe (1967) developed the Social
Readjustment Rating Scale to assess life stress in terms of life
 96

change units. They identified individuals who are prone to stress

and likely to develop physical problems and illnesses as a result of
constant exposure to stress. In recent years cognitive model of
stress has been put forward which emphasizes the fact that it is not
the event itself but the ways in which it is interpreted that
determines its impact.

2. Coping: Another important factor that is related to

Psychological Factors Affecting Medical Conditions is coping
mechanisms that is used by an individual. Coping can be defined
as active efforts to master, reduce or tolerate the demands created
by stress. Coping is the process of managing taxing circumstance,
expending effort to solve personal and interpersonal problems, and
seeking to master, minimize, reduce, or tolerate stress. Coping can
be defined as facing and finding effective means of overcoming
problems and difficulties. Coping consists of efforts, both action-
oriented and intrapsychic, to manage (i.e. master, tolerate,
reduce, minimize) environmental and internal demands and
conflicts among them. Coping strategies are also defined as
actions that people take to master, tolerate, reduce or minimize
the effects of stressors and they can include both behavioural
and psychological strategies. Coping efforts can be either adaptive
or effective (healthy) or unadaptive and ineffective (unhealthy).
Effective methods of coping with stress help to remove the
source of stress or control our reactions to it. Ineffective coping
techniques are those techniques that can come in the way of our
adaptation or that can create more problems for us in the long
run.

There are two types of coping: Problem Focused Coping and

Emotion Focused Coping. Problem Focused Coping is a type of
coping that is basically concerned with alleviating the problem,
trying to change the situation so that the problem is eliminated or to
avoid the occurrence of the same or similar problem in the future.
Problem focused coping is concerned with direct efforts to deal
with, understand and overcome current causes of stress. Problem
focused coping is generally superior in reducing the adverse effects
of stress. Emotion Focused Coping is a form of coping an individual
makes attempt to manage and deal with negative emotions and
feelings that may develop with stressful situation. Emotion focused
coping also involves learning to handle one's emotions in an
appropriate manner so that we can face and adjust to situations
where we find the problem to be uncontrollable. Emotion focused
coping centers around efforts to reduce or manage the emotional
distress resulting from stress and often involves strategies such as
refusing to recognise painful realities concluding oneself that things
could be worse, masking the stress with alcohol or other drugs.
3. Stress and the Immune System: Immune system in an
important system of our body that consists of cells, organs and
 97

chemicals in the body that responds to attacks on the body from

diseases and injuries. Immune system protects us from onslaught.
Immune system is the body's means of identifying and eliminating
any foreign materials (e.g. bacteria, parasites or even transplanted
organs, etc., ) that enter our body. A new subject which studies as
to how stress influences our body's immune system is called as
Psychoneuroimmunology. It is more specifically defined as the
study of the effects of psychological factors such as stress,
emotions, thoughts and behaviour on the immune system. The field
of psychoneuroimmunology focuses on the relationship between
psychological influences (such as stress), the nervous system, and
the immune system.

Stress appears to depress immune function in two main

ways. First, when people experience stress, they more often
engage in behaviors that have adverse effects on their health:
cigarette smoking, using more alcohol or drugs, sleeping less,
exercising less, and eating poorly. In addition, stress may alter the
immune system directly through hormonal changes. Research
indicates that glucocorticoidshormones that are secreted by the
adrenal glands during the stress responseactively suppress the
bodys immune system.

Two important points with respect to immune system and

stress that are worth noting are as follows:
Stress triggers the same response in the immune system that
infection triggers.
Positive effects of stress on the immune system only seem to
work when the stress is not continuous and acchronic condition.
Prolonged stress has detrimental effect on our immune system
functioning.

A large number of research studies have revealed that

stress considerably influences the immune system's abilities to
defend the body.

A large number of studies, both laboratory as well as field,

have been carried out to demonstrate how immune system
functioning is influenced by stress and related variables.

Emotional Expression: When emotional expression is inhibited,

health problems arise. Research studies have demonstrated that
expressing emotions is beneficial to ones physical health and
mental well-being. Inability to express ones emotions appropriately
either emotional outburst or its suppression is unhealthy and can
lead to wide variety of problems both physical as well as
psychological. Research studies by James Pennebaker (1997)
have observed that actively confronting emotions that arise from an
upsetting or a traumatic event can have long-term health benefits.
 98

For example writing about a distressing experience facilitates

coping and contributes to physical health.

Personality Style: Ones personality style is also closely

associated with development of physical and mental health
problems. One type of personality style that has been extensively
studied is the Type A personality pattern. Type A people who are
impatient, irritable, and aggressive and are always in a pressure to
get something done is more prone to develop cardiovascular
disorders such as heart attacks. Type A individuals react
explosively to stressful situations. The sympathetic system of Type
A individual is always alert and at its peak. Type A individuals with
high levels of hostility, commonly engage in unhealthy behaviours,
such as smoking and consuming large amounts of alcohol.

A new personality type that has been identified by some

researchers (Sher, 2005, Pedersen and Denollet, 2003) is the
Type D (Distressed) personality. These individual are at increased
risk for heart disease due to their tendency to experience negative
emotions while inhibiting the expression of these emotions when
they are in social situations. These individual also have a reduced
quality of life and they benefit less from medical treatment.

Sociocultural factors: Sociocultural factors play an important role

in causing and aggravating stress-related disorders. Living in a
harsh social environment threatens a persons safety, interferes
with the establishment of social relationships and involves a high
level of conflict, abuse and violence. Chronic exposure to stressful
environment can lead to higher cortisol levels resulting in
disturbances in the immune system.

Treatment: Treatment of problems associated with the condition

called Psychological factoirs affecting medical conditions requires
a multidimensional approach. Medical treatment alone is
insufficient. People must be taught to change their lifestyle, develop
certain behaviours and changes in attitude that can go a long way
in altering their lifestyle and consequently gain control over their
health and problems. One interdisciplinary approach that has been
developed is called as behavioural medicine, which makes use of
behavioural techniques and learning approaches. In this approach
they are taught to learn about unhealthy bodily processes and to
take action to avoid or modify circumstances in which they are likely
to become sick. Individuals learn to monitor early signs of mounting
tension and to initiate steps to avert the further development of
pain.
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4.4 SUMMARY

In this unit we have discussed the concept of somatoform disorders

and the various types of somatoform disorders which include
conversion disorder, Somatisation disorder and related conditions,
Pain disorder, Body dysmorphic disorder and Hypochondriasis.
Clinical symptoms, causes and treatment of each of these
disorders were briefly explained.

Three conditions related to Somatoform Disorders were

discussed in brief. These include: Malingering (Faking), Factitious
Disorder and Munchausens Syndrome. Theories and Treatment of
somatoform disorders were also discussed in brief.

Psychological Factors Affecting Medical Conditions as well

as its theories and treatment were discussed.

4.5 QUESTIONS

Q1. What are somatoform disorders.

Q2. Write short notes on the following:

a. Conversion disorder
b. Somatisation Disorder and Related Conditions
c. Pain Disorder Body Dysmorphic Disorder:
d. Hypochondriasis:
e. Conditions Related to Somatoform Disorders
f. Theories and Treatment of Somatoform Disorder

Q3. Discuss the Theories and Treatment of Psychological

Factors Affecting Medical Conditions:

4.6 REFERENCES

1. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology:

Clinical Perspectives on Psychological Disorders. (6th ed.).
McGraw-Hill.

2. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.

(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009 by
Dorling Kindersley, New Delhi.

3. Nolen-Hoeksema, S. (2008). Abnormal Psychology. (4th ed.).

New York: McGraw-Hill.

 100

5
SOMATOFORM DISORDERS,
PSYCHOLOGICAL FACTORS AFFECTING
MEDICAL CONDITIONS AND
DISSOCIATIVE DISORDERS - II

Unit Structure
5.0 Objectives
5.1 Introduction
5.2 Dissociative Disorders
5.3 Somatoform Disorders, Psychological Factors Affecting
Medical Conditions and Dissociative Disorders: The
Biopsychosocial Perspective
5.4 Summary
5.5 Questions
5.6 Reference

5.0 OBJECTIVES

After studying this unit you should be able to:

Understand the concept of Dissociative Disorders
Know the details about Dissociative Identity Disorder
Comprehend other Dissociative Disorders
Know the biopsychsocial perspective of various Somatoform
Disorder, Psychological Factors Affecting Medical Conditions
and Dissociative Disorders.

5.1 INTRODUCTION

Dissociative disorders are an extreme form of psychological

disturbance involving anxiety and conflict in which part of an
individuals personality actually separates from the rest of his or her
conscious functioning. One type of dissociative disorder is the
Dissociative Identity Disorder. Characteristics of Dissociative
Identity Disorder as well as its theories and treatment would be
discussed in brief. Some other dissociative disorders that we would
discuss in brief include Dissociateive Amnesia and its variants,
Dissociative Fugue, Depersonalisation Disorder. Theories and
 101

treatment of these various dissociative disorders will be discussed.

Towards the end of the unit we will discuss the biopsychsocial
perspective of various Somatoform Disorder, Psychological Factors
Affecting Medical Conditions and Dissociative Disorders.

5.2 DISSOCIATIVE DISORDERS

Dissociative disorders are one of the most attractive

disorders that have received considerable media attention. Dr.
Sigmund Freud and Morton Prince carried out some pioneering
studies on this disorder. The dissociative disorder refers to a group
of related disorders in which there is certain altered states of
consciousness. The dissociative disorder are described is DSM-IV
as sudden temporary alterations in the normally integrative
functioning of consciousness, identity or motor behavior.
Dissociative disorders are characterised by alterations in
perceptions: a sense of detachment from ones self from the world
or from memories.

Dissociative disorders are an extreme form of psychological

disturbance involving anxiety and conflict in which part of an
individuals personality actually separates from the rest of his or her
conscious functioning. An individual with dissociative disorder
experiences a temporary alteration in consciousness involving a
loss of personal identity, decreased awareness of immediate
surroundings and odd bodily movements. Once the dissociation
has occurred, the content of the dissociated part becomes
inaccessible to the rest of the clients conscious mind.

Some of the most common types of dissociative disorders

include: Dissociative Indentity Disorder, Dissociative Amnesia,
Dissociative Fugue, Depersonalization Disorder, Dissociative
Trance Disorder, etc. We would discuss the different variants of
dissociative disorders.

5.2.1 Dissociative Indentity Disorder (DID):

It is the most interesting and dramatic of all the dissociative

disorder and was earlier called as multiple personality disorder. In
Dissociative Indentity Disorder a person develops more than one
self or personality. These personalities are referred to as alerts, in
contrast to the core personality, the host. In this disorder many, say
more than 100 personalities or fragments of personality coexist
within one body and mind. In some cases the identities are
complete, each with its own behavior, tone of voice and physical
gestures. In other cases, only a few characteristics are distinct,
because the identities are only partially independent.
The disorder was made famous in novels and movies, such
as Sybil and The Three Faces of Eve. In Dissociative Indentity
 102

Disorder, each alter is understood to be a consistent and enduring

pattern of perceiving, relating to and thinking about the environment
and the self.

Characteristics of Dissociative Indentity Disorder: According to

DSM-IV the major characteristics of this disorder are as follows:
i) Amnesia is the most important characteristic feature of this
disorder.
ii) The identity of this disorder is fragmented.
iii) Many personalities live inside one body. These can be
anywhere from 3 to 4 to 100.
iv) Certain important aspects of persons identity are
dissociated.

A person who comes for treatment with a DID is called as a

host personality. The host personality tends to hold many different
identities together. The transition form one personality to another is
called as a switch. During a switch physical transformation may
occur. Posture, facial expressions, pattern of facial wrinkling and
even physical disabilities may occur. One of the most important
debatable issue is whether the DID can be faked or whether it is
real. Some important points with respect to this disorder are as
follows:
Individuals with DID are very suggestible and the alternative
personalities that these individuals manifest are actually created
as a reaction to leading questions suggested by therapists
during psychotherapy or in a state of hypnosis.
Some investigators have studied the ability of individuals to fake
dissociative experiences. According to them it is possible to
stimulate dissociative disorder. Various experiments conducted
by Spanos et al (1994) have suggested that the symptoms of
DID could be faked. They found that in one experiment 80
percent of the individuals could successfully fake an alternative
personality.
Objective tests suggest that many people with fragmented
identities are not consciously and voluntarily simulating
DID is more common among females. The ratio of females to
males is as high as 9 is to 1.
The onset of this disorder is always in childhood, often as young
as 4 years of age, although it is usually identified approximately
at the age of 7 years.
The prevalence rate of this disorder has been found to be
between 3% to 6 %.
It has also been found that large percentage of DID patients
have simultaneous psychological disorders that may include
 103

substance abuse, depression, somatisation disorder, borderline

personality disorder, panic attacks and eating disorders.
It has also been noted that there is a high degree of comorbidity
of DID with other disorders. This high rate of comorbidity may
reflect the fact that certain disorders, such as Borderline
personality disorder share many features of DID.
DID is often misdiagnosed as a psychotic disorder.
DID occur in a variety of cultures across the world.
People with DID also experiences a form of amnesia, in which
they have gaps in their memory about some aspects of their
personal history.
Richard Kluft (2005) has done considerable research in this
area. Putnam et al (1986) have noted that, in the 50 years prior to
1970s, only a handful of cases had been reported, but since 1970s,
the number of reports increased astronomically, in to thousands. In
fact, more cases of this disorder were reported during one 05
year period in the 1980s than had been documented in the
preceding two centuries.

Causes of Dissociative Identity Disorder (DID): Some important

causes of DID are as follows:

i. Childhood Traumatic Events: Many surveys have reported

that DID is a result of traumatic life events. Putnam et al
(1986) examined 100 cases and found that 97 % of the
patients had experienced significant trauma, usually sexual
or physical abuse and 68 % had reported incest. Similarly,
Ross et al (1990) had reported that, of the 97 % of the
cases, 95 percent reported physical or sexual abuse. Often
the abuse is bizarre and sadistic. Traumatised individuals fail
to develop an integrated and continuous sense of self

ii. Lack of Social Support: It has also been found that a lack
of social support during or after the abuse also seems
implicated. A recent study of 428 adolescent twins has
demonstrated that in 33% to 50% of the cases dissociative
disorder could be attributed to chaotic, nonsupportive family
environment.

iii. Sociocognitive Model of DID: This model was presented

by Lilienfeld et al (1999). According to this model, clients
enact the roles that they feel (consciously or unconsciously)
are demanded by the situation. Social attention to the
condition of DID, along with unintentional prompting by
therapist, can lead to the development of this disorder in
vulnerable individuals. According to Sociocognitive Model,
 104

these individuals may in fact have suffered abuse as

children, but many other factors, socially determined,
operate to create the dissociative symptoms in adulthood

iv. Subtype of Post Traumatic Stress Disorder: DID is very

similar in etiology to Post Traumatic Stress Disorder. Both
conditions feature strong emotional reactions to experiencing
a severe trauma. There are some researchers who are of
the opinion that DID is an extreme subtype of Post
Traumatic Stress Disorder, with a much greater emphasis on
the process of dissociation than on symptoms of anxiety,
although both are present in each disorder.

v. Biological Contributions: Some researchers have

implicated biological contributions in the development of
DID. It has been reported that individuals with certain
neurological disorders, particularly seizure disorders,
experience many dissociative symptoms. Devinsky et al
(1989) reported that approximately 6 % of the patients with
temporal lobe epilepsy reported out of body experiences.
Similarly, another groups of researchers (Schenk and Bear,
1981) have found that about 50 % of the patients with
temporal lobe epilepsy displayed some kinds of dissociative
symptoms.

Treatment of Dissociative Disorder: Some important points with

respect to the treatment of this disorder are as follows:
i. Generally individuals who experience dissociative amnesia
or a fugue state usually get better on his or her own and
remember what they have forgotten.
ii. The therapy focuses on recalling what happened during the
amnesia or fugue states, often with help of friends or family
who know what happened, so patients can confront the
information and integrate it into their conscious experience.
iii. The treatment of DID is much more difficult as compared to
other dissociative disorders. Not much controlled research
has been done on the effects of treatment, though there are
many documented successes of attempts to reintegrate
identities through long-term psychotherapy.
iv. The strategies that therapist use today in treating DID are
based on accumulated clinical wisdom as well as procedures
that have been successful with posttraumatic stress
disorder.
v. The major goal in treating DID is to identify cues or triggers
that provoke memories of trauma and/or dissociation and to
neutralize them. Most important in the treatment process is
that the patient is taught to confront and relieve the early
 105

trauma and gain control over the horrible events, at least as

they recur in the patients mind
vi. In the treatment of DID hypnosis is often used to gain access
to unconscious memories and bring various alters into
awareness.
vii. Treatment of dissociative disorders involves helping the
patient re-experience the traumatic events in a controlled
therapeutic manner in order to develop better coping skills.
In the case of dissociative identity disorder, therapy is often
long term, and may include antidepressant drugs.
Particularly essential with this disorder is a sense of trust
between therapist and patient.
viii. Sopme clinicians have used cognitive-behavioural
techniques in the treatment of DID instead of or in addition to
hypnotherapy in an effort to change the clients
dysfunctional; attitudes. These attitudes arise from the
clients history of abuse and includes the following core
beliefs:
That it is wrong to show anger or defiance
That one cannot handle painful memories
That one unconsciously hates the parents or
experiences conflicting attitudes towards one or both
the parents
That one must be punished
That one cannot be trusted, etc.

According to Ross (1997) these core beliefs needs to be

changed. Kluft (1989) has used cognitive-behavioural techniques to
bolster an individuals sense of self-efficacy through a process
called temporizing, in which the client controls the way that the
alters make their appearance. This may be accomplished through
hypnosis in an effort to help the client develop coping skills that can
be used when dealing with stress.

5.2.2 Dissociative Identity Disorder and the Legal System:

Forensic psychologists and other legal experts have been
concerned with the legal aspects of DID. Legal Defendants have
used this diagnostic category as a defense for their offences.
Forensic psychologists and other members of the judicial system
are faced with the difficult task of differentiating a true dissociative
disorder from instances of malingering. Kenneth Bianchi, a serial
murdrer also known as the Hillside Strangler, faked multiple
personality disorder defense. Individuals who seek to explain their
crimes as products of alter personalities typically invoke an insanity
defense or claim that they are not competent to stand trial
(Slovenko, 1993). Accused undertake the defense that they have
committed the crime under the control of an alter personality. They
 106

may further claim that the offense was committed in a state of

dissociation and that they have no recall of what happened.
Steinberg et al (2001) developed criteria for assessing the validity
of dissociative symptoms within the context of clinical and forensic
evaluations. They recommended the use of Structued Clinical
Intervies for DSM IV Dissociative Disorders Revised (SCID D
R).

5.2.3 Other Dissociative Disorders: Many other dissociative

disorders have also received considerable research attention and
have come to the attention of the clinicians in their routine practice.
Some important dissociative disorders that we will briefly discuss
are as follows:

a. Dissociative Amnesia: Dissociative Amnesic was earlier

called as psychogenic amnesia. In this disorder an individual is
unable to remember important personal details and experiences
usually associated with traumatic or very stressful events. This
memory loss is not attributable to brain dysfunction, brain disorder
or drugs. In this disorder an individual forgets his personal
information in totality or is unable to remember some specific
personal details. Dissociative Amnesia is common during the
time of war or similar stressful events. It should be remembered
that in most cases of Dissociative Amnesia, the forgetting is very
selective for traumatic events or memories rather than generalized.
Dissociative Amnesia is found to be common during war. There are
four forms of dissociative amnesia, each associated with the nature
of a persons memory loss. The four forms of dissociative amnesia
are as follows:
i. Generalized Amnesia: In this type of amnesia an individual is
unable to remember personal information, including ones
identity. The duration of this disorder may range from being a
life long or may last for about 6 months or a year.
ii. Localized or Selective Amnesia: In this type of amnesia there
is a failure to recall specific events. These specific events, which
are difficult to remember, are related to specific period of time.
This amnesia is more common as compared to generalized
amnesia.
iii. Selective Amnesia: The individual fails to recall some, but not
all details of events that have occurred during a given period of
time. For example, the survivor of fire may remember the
ambulance ride to the hospital, but not having been rescued
from the burning house.
iv. Continuous Amnesia: It involves a failure to recall events from
a particular date up to and including the present time. For
example a soldier may remember his childhood and youth until
the time he entered the armed services, but he may have
 107

forgotten everything that took place after his first tour of combat
duty.

Dissociative Amnesia is very difficult for clinicians to

diagnose, because there are so many possible causes of memory
loss. Amnesia can also result from physical dysfunction due to
brain injury, epilepsy, substance abuse, etc. Some individuals also
fake symptoms of dissociative amnesia to gain certain benefits or
advantages. For example, a man who has committed a serious
crime may claim that he remembers nothing of the incident or even
who is.

b. Dissociative Fugue: It was formerly called as psychogenic

fugue. The term Fugue means flight and this disorder is very much
similar to amnesia. In this disorder individuals take off from one
place and move to another place without their conscious
awareness and may be further confused, on gaining awareness, as
to how they arrived at this new place. In this disorder a person is
confused about personal identity suddenly and unexpectedly
travels to another place. People in a fugue state are unable to recall
their history or identity and a few may even assume a new identity.
A fugue is rare and usually passes quickly. The disorder is more
likely to occur at certain times, such as during a war or following a
natural disaster. Personal crises or extreme stress, such as
financial problems the desire to escape punishment or the
experience of a trauma can also precipitate fugue states. Some
other important features of this disorder are as follows:
This disorder usually occurs in adulthood and never before
adolescence. It rarely occurs after the person has crossed the
age of 50.
Dissociative Fugue is such a rare disorder that virtually no
controlled research has been carried out on it.
Fugue state end rather abruptly and the individual returns home
recalling most if not all of what happened. In this disorder, the
disintegrated experience is more than memory loss, involving
atleast some disintegration of identity if not the complete
adaptation of a new role.
One type of distinct dissociative disorder not found among
western cultures is Amok, which is very similar to the term
running amok. In this state an individual is in a trance like state
and often brutally assaults and sometimes kills persons or
animals and acquires a mysterious source of energy, runs or
flees for a long time, etc. This disorder is most common among
males.
A still another type of dissociative disorder found among the
native people of Aartic which is similar to Amok is called
 108

Pivloktoq and the same disorder amongst the Navajo tribe is

called Frenzy Witchcraft.

c. Depersonalization Disorder: It is a dissociative disorder,

usually occurring in adolescence, in which individuals lose their
sense of self and feel unreal or displaced to a different location.
Depersonalization involves a sense of thing or experiences as
being unreal and a feeling of estrangement from oneself or ones
surrounding, both feelings have an unpleasant quality and are
experienced as a distinct change from ones usual mode of
functioning.

Individuals with this disorder feel that they are, all of a

sudden different, for example, that they are other people or that
their bodies have drastically changed and hence, become very
much different.

Individuals with this disorder have an out-of-body experience

in which they feel that they are, for time, floating above their
physical bodies and observing what is going on below.

The phenomenon of depersonalization includes alterations

of mind-body perception, ranging from detachment from ones
experiences to the feeling that one has stepped out of ones body.
Depersonalisation experiences also occur in normal people when
they are placed under great stress or when they use mind-altering
drugs, such as marijuana or LSD. In depersonalization disorder,
however, distortions of mind-body perceptions happen repeatedly
without provocation by drugs. Periods of extreme stress, such as
the time immediately following an accident can also precipitate an
episode of Depersonalisation in a vulnerable individual

This disorder is often precipitated by acute stress resulting

from an infectious illness, an accident, or some other traumatic
event. Individuals who experience depersonalized state are usually
able to function entirely normally between episodes.

This disorder is episodic by nature and lasts for few minutes

or hours. This is the most frequent disorder of dissociative type, so
it is thought that it must be mildest form of dissociation and must be
more easily curable. It is assumed that depersonalization must be
an attempt to escape from a stressful situation. However, the data
about the disorder is not very clear. Some important features of this
disorder are as follows:
Depersonalisation is a psychological mechanism whereby one
dissociates from reality. Depersonalisation is often a part of a
serious set of conditions where reality experience and even
ones identity seem to disintegrate.
 109

This is the most frequent disorder of dissociative type, so it is

thought that it must be the mildest form of dissociation and must
be more easily curable.
Most frequent disorder found among normal individuals.
It involves feelings that are extremely unpleasant and result in
anxiety and feeling of lack of control.
In this disorder an individual feels that he is out of his body and
the body is distorted. Sometimes, people also report that they
were dead and floating above the body.
This disorder is episodic by nature and lasts for few minutes or
hours.

5.2.4 Theories and Treatment of Dissociative Amnesia,

Dissociative Fugue and Depersonalisation Disorder: Most
experts agree that dissociative disorders are the end product of
intensely traumatic experiences during childhood, especially those
involving abuse or other forms of emotional maltreatment. Other
forms of traumatic experiences, which can be transient or long
lasting may also lead to dissociative disorders. Current views with
regard to causation of dissociative disorder is largely based on
psychological perspectives. Our knowledge of biological factors
involved in causation of these conditions is highly limited.

5.3 SOMATOFORM DISORDERS, PSYCHOLOGICAL

FACTORS AFFECTING MEDICAL CONDITIONS AND
DISSOCIATIVE DISORDERS: THE BIOPSYCHOSOCIAL
PERSPECTIVE

Hisotrically these disorders were regarded as neuorosis

rather than psychosis. People with these disorders have
experienced conflict or trauma during their lives and circumstances
have created strong emotional reactions that they could not
integrate in to their memory, personality and self-concept. The
symptoms seen in somatisation disorder and dissociative states
represent not a loss of contact with reality but a translation of
various emotions in to terms that are less painful to acknowledge
than is the original conflict or trauma.

Stressful events in many individuals trigger maladaptive

responses in physical functioning, ranging from variety of physical
conditions to sleep dysfunctions and various somatic complaints
which are often vague. Currently the most prevalent view is that
stress related factors and not repressed sexuality is central to
understanding somatoform disorders. Besides stress, learning
seems to play a strong role, especially in cases where individuals
have developed secondary gains from their symptoms.
 110

With regard to dissociative disorders, researchers believe

that, actual, rather than imagined trauma is the source of such
symptoms as amnesia, fugue and multiple identities.

Cognitive behavioural therapists have also offered their

perspective on this group of disorders. According to them low
feelings of self-efficacy, lack of assertiveness and faulty ideas
about the self can all be contributing factors to somatoform and
dissociative disorders. For example believing that one must be sick
to be worthy of attention is a dysfunctional attitude that underlie the
development of somatoform disorders. Similarly faulty beliefs about
the self and the role of the self in past experiences of trauma seem
to be important cognitive factors that may contribute to an
individuals vulnerability to developing these maladaptive thoughts
or susceptibility to trauma.

5.4 SUMMARY

In this unit we have discussed the concept of Dissociative

disorders. We have attempted to understand as to how these
group of disorders are an extreme form of psychological
disturbance involving anxiety and conflict in which part of an
individuals personality actually separates from the rest of his or her
conscious functioning. One type of dissociative that we discussed
in detail was the Dissociative Identity Disorder (DID). The various
characteristics of Dissociative Identity Disorders as well as its
theories and treatment were discussed.

Many different types of dissociative disorders that we would

discuss in brief include Dissociateive Amnesia and its variants,
Dissociative Fugue, Depersonalisation Disorder. Theories and
treatment of these various dissociative disorders were also briefly
discussed. Towards the end of the unit we have discussed the
biopsychsocial perspective of various Somatoform Disorder,
Psychological Factors Affecting Medical Conditions and
Dissociative Disorders.

5.5 QUESTIONS

Q1. What are Dissociative disorders? Discuss Dissociative

Indentity Disorder (DID), its Characteristics, Causes and
treatment.

Q2. Write a note on Dissociative Identity Disorder and the Legal

System.
 111

Q3. Discuss Dissociative Amnesia, Dissociative Fugue and

Depersonalization Disorder.

Q4. Write a note on The Biopsychosocial Perspective of

Somatoform Disorders, Psychological Factors Affecting
Medical Conditions and Dissociative Disorders.

5.6 REFERENCE

4. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology:

Clinical Perspectives on Psychological Disorders. (6th ed.).
McGraw-Hill.

5. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.

(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009 by
Dorling Kindersley, New Delhi.

6. Nolen-Hoeksema, S. (2008). Abnormal Psychology. (4th ed.).

New York: McGraw-Hill.

 112

6
SEXUAL DISORDERS

Unit Structure

6.0 Objectives
6.1 Introduction
6.2 Abnormal Sexual Behaviour
6.3 Paraphilias
6.4 Gender Identity Disorder
6.5 Sexual Dysfunctions
6.6 Sexual Disorders :The Bio psychosocial Perspective
6.7 Summary
6.8 Glossary
6.9 Questions
6.10 Suggested Readings

6.0 OBJECTIVES :

After reading this unit you will be able to know :

About abnormal sexual behaviours.
What are the different types of paraphilias, its causes and
treatment.
About gender identity disorder, its causes and treatment.
What are the types, causes of sexual dysfunctions.
The different perspectives of sexual disorders.

6.1 INTRODUCTION :

The inability to enjoy sexual relationship and experience

distress and difficulty while engaging in sexual acts is referred to as
sexual disorder. In this unit we will discuss about the concept of
sexual disorder, its types and treatments. First one is paraphilias or
sexual deviation, second is sexual dysfunction and third is gender
identity disorder. There are different theories of the causes of these
disorders. Different treatments such as biological therapies,
psychological approaches and cognitive therapies, etc., are
successful to great extent to help the people suffering from these
disorders.
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6.2 ABNORMAL SEXUAL BEHAVIOUR :

Normal sexual response cycle has five stages sexual

desire, arousal, plateau, orgasm and resolution state. But inability
to enjoy sexual relationship and experiencing difficulty at any stage
is considered sexual disorder. For example, complete lack of
sexual desire, active avoidance of sexual activity, inability to be
aroused or maintaining erections or absence of orgasm are few
sexual disorders. Paraphilias are disorders that involve non-human
objects, non-consenting adults, children, etc. Gender Identity
disorder is wrong perception of ones own gender resulting in
transsexual or transgender individuals. Sexual sadism, pedophlia,
etc., include inflicting pain to sexual partners.

6.3 PARAPHILIAS :

1. Fetishism :-

Fetishism involves the use of inanimate objects as the

preferred source of sexual arousal or gratification. There are
different types of fetishism. The most popular are womens under
garment, according to DSM IV criteria. Fetishistic arousal can be
associated with different classes of objects or activities.

a) An inanimate object.
b) A source of specific tactile stimulation such as rubber, etc.
c) Part of the body such as toe, buttocks, etc.

Soft fetishes are soft, furry, lacy or frilly panties, stocking,

etc., Hard fetishes objects are smooth, harsh objects, such as spied
shoes, gloves, etc.

An elaborate form of fetishism is Transvestism, also referred

as cross - dressing, in which hetro sexual men dress in womens
clothing as their primary means of becoming sexually aroused.
Some use only one garment such as womens panty, under their
business suits. The complete cross dresser, fully clothes himself in
womens garments, applies make up and a wig, etc. Few engage
cross dressing alone, others participate in groups.

2. Sexual Sadism and Sexual Masochism :-

Sexual sadism and sexual masochism are two separate

diagnoses, although sadistic and masochism sexual practices are
considered together as a pattern of sadomasochism. Both are
associated with either inflicting pain or humiliation (Sadism) or
being made to suffer pain or humiliation (masochism). Some people
occasionally engage in modestly sadistic or masochistic behaviours
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during sex or stimulate such behaviours without actually inflicting

pain or suffering.

They follow the rituals of practising of bondage and

domination. One partner is bound, gagged and immobilised and is
subjected to sexual acts of other partner. Apart from sexual, acts,
beating, whippings, electrical shock, burning, cutting, stabbing,
strangulation, torture or even death. Different props such as feather
garments, chains, shackles, whips, ropes, etc. are used by the
sadistic partner to inflict pain on the other partner. Few other
partners can find it exciting, many give their consent to please their
partner, few do because they are paid for it and few are
unconsenting victims. Almost all voyeurs are men who watch
women. They typically masturbate while watching or shortly after
watching women. They get excited to see fear and disgust on the
womens face if they know that they are being watched. The danger
of being caught gives them thrill and excitement.

3. Frotteurism :-

It is another paraphilia that often occurs with voyeurism and

exhibitionism. The frotteuist gains sexual pleasure by rubbing
against and fondling parts of the body of a non-consenting person.
They engage in this behaviour in public places such as on a bus,
subway, market place, etc., Most of the frotteurists are young males
between 15 and 25 years of age.

4. Pedophilia and Incest

The most tragic deviant pattern of arousal is a sexual

attraction to children called pedophilia. The DSM IV diagnostic
criteria for pedophilia are-

a) Intense sexually arousing fantasies, sexual urges with a child

or children (over a period of at least 6 months).
b) The person is alteast 16 years and at least 5 years older than
the child or children.
c) Sexual encounters between pedophilic and their child victims
are often brief but they may reoccur frequently.
d) The contact often consists of the pedophilic exposing and
touching the childs genitals or perform fellatio (oral stimulation
of the penis) or cunnilingus (oral stimulation of the female
genitals) on children.
e) Some pedophilic penetrate, childrens vagina, mouth, or anus
with their fingers, foreign objects or their penis. Pedophilics
often threaten children, harm them physically, restrain them or
tell them that they will punish them or their loved ones if the
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children do not obey the pedophilics order. But most of them

are not physically abusive because there is no harm or threats
from their victims. Children may participate in the molestation
without seeming to protest, yet, they may be scared and
unwilling without expressing it. Most Pedophilics are family
members or acquaintances of the children. Some develop
elaborate plans for gaining access to the children, such as
winning the trust of their mothers, marrying their mothers, or in
rare cases abducting children or adopting children from other
countries.

Sometimes the activities can go out of control, for example,

Autoerotic asphyxiation. In this activity, sexual arousal in gained by
oxygen deprivation caused by hanging or chest compression.

5. Voyeurism and Exhibitionism :-

Voyeurism refers to the practice of observing an

unsuspecting person undressing or naked in order to experience
sexual orousal. Exhibitionism refers to sexual arousal and
gratification associated with exposing ones genitals to
unsuspecting strangers.

A vast majority of cases, the exhibitionists are men who

bares all to surprise women at public places such as parks, roads,
etc. His behaviour is impulsive and compulsive. He experiences
excitement, fear, restlessness and sexual arousal and feels
compelled to get relief by masturbating himself. Because of the
public nature of their behavior, they get caught but they are likely to
continue their behaviour after having been caught. The danger of
being caught increases their arousal. The element of risk or thrill
seems to be important part of this sexual disorder. The fear and
disgust on victims face gives them sexual pleasure. Exhibitionisms
in same way is the mirror image of voyeurism.

Voyeurism This type of paraphilia involves secretly watching

another individuals nude, bathing in sexual positions. Most
pedophilics are hetrosexual males abusing young girls.
Homosexual pedophilics typically abuse young boys. Women can
be pedophilics but it is rare.

If the children are from pedophilics own family, such as

daughters or son, then it is called incest. Victims of insects tend to
be daughters who are begining to mature physically. Incestors
relation may have more to do with availability and other inter
personal ongoing issues in the family.
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Causes of Paraphilias
Biological Causes :-
a) Most of the paraphilics are male (over 90 percent). This may
be because paraphilic behaviour often involves hostile or
aggressive impulses, which may be more common in males
than in females.
b) Some studies have found links between endocrine
abnormalities and paraphilia.
c) Some studies suggest a relationship between testosterone
abnormalities and sexually aggressive paraphilias.
d) Alcohol and other drug abuse is common in paraphilias
because these substances, may disinhibit the paraphilic and so
he acts out his fantasy.

Psychological Causes :

a) Freud viewed paraphilias as a result of arrested psychological

development or regression to childhood forms of sexual
arousal.
b) Robert Stoller (1975) argued that the paraphilias are symbolic
re-enactments of childhood traumas in which the paraphilies is
unconsciously taking reverge on adults who inflicted harm on
him as a child.

Behavioural Causes :

a) Behavioural theories view them as the result of chance

classical conditioning. An adolescent male might be
masturbating and notice a panty kept on the chair in the room.
He thinks of the panty and becomes more aroused. Next time
he masturbates, he might be more drawn to the panty because
it aroused him a day before. If this fantasy becomes strongly
associated with sexual arousal for him, he may develop a
fetish for panties.

b) Paraphilias may be developed by social learning. Children

whose parents engaged in aggressive, sexual behaviours with
them learn to engage in impulsive, aggressive, sexualised acts
towards others.

c) Many pedophilics have poor interpersonal skills and feel

intimidated when interacting sexually with adults. Others have
strong hostility toward women and carry out this hostile
antisocial acts towards children,
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Cognitive Causes :-

a) Cognitive theories says that a number of distortions and

assumptions that paraphilics have about their behaviours and
the behaviours of their victims. These distortions may have
been learned from parents deviant messages about sexuality.

Treatment of Paraphilias

Biological Treatment

a) Drug Treatment
Certain drugs are sometimes used to treat paraphilias, the
most popular drug is an anti- androgen drug called, Medroxy
proqesterone acetate. This drug eliminates the persons sexual
desire and fantasy by reducing his testoterone levels. But
fantasies and arousal soon returns as soon as the drug is
removed. This drug is useful for dangrous sexual offenders
who do not respond to alternative treatments.

b) Drastic biological interventions for pedophilics and men who

commit rape have been tried. These includes surgery on the
centers of the brain. Castration lowers sexual rates of
paraphilias who have committed sexual crimes.

Psychosocial Treatments :-

a) Actually touching objects that arouses them.

b) De- Aversion Therapy

During this therapy paraphilics might receive painful but
harmless electric shocks while viewing photographs of what
arouse them or while Sensitisation
This therapy helps to reduce the anxiety of the paraphilics
about getting involved in normal sexual activities with other
normal adults. Relaxation exercises overcomes their faulty
association regarding sexual behaviour.

c) Cognitive Therapy :-
This therapy encourages the paraphilics to identify and
challenge thought and situations that arouses them sexually.
They are not asked to justify their behaviours.

d) Empathy training makes paraphilics to think about their victims

condition and understand their situations when they are
attacked.
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e) Role play and Group therapy -

These two therapy helps parapilic to interact, share and gain
insight about their own behaviours.

Check Your Progress

1. What are the different types of paraphilias?

2. What are the different causes and treatments of paraphilias?
_____________________________________________________

6.4 GENDER INDENTITY DISORDER (GID) :

Gender identity is the perception of a person about

themselves as male or female. It is a fundamental component of
their self-concept.

Gender identity disorder is diagnosed when a person

believes that they are born with the wrong sexs genitals and are
fundamentally person of the opposite sex. Person feels that they
are trapped in the body of the opposite gender.

Symptoms

1. Strong and persistent identification with the other sex

a) In children, this is manifested by repeatedly stated desire to be

or insistence that he or she is the other sex.
b) In boys, preference for cross dressing or stimulating female
dress. In girls, insistence on wearing only masculine clothing.
c) Strong and persistant preference for cross sex roles in play
and in fantasies.
d) Strong preference for playmates of the other sex.
e) In adolescents or adults, identification with the other sex is
seen by symptoms such as desire to be with the other sex,
desire to live or to be treated as the other sex, conviction that
he/she has the typical feeling or reactions of the other sex.
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2. Discomfort
Persistent discomfort with his/her sex and sense of in
appropriateness in the gender role of that sex.
3. Disinterest in Opposite Sex
He/she is not interested in sexual relation with opposite sex.
They experience distress or problem in sexual interaction with
the opposite sex, if forced.
4. Confusion
Adults with gender identity disorder is also referred as
transsexual or transgender individuals. They wear dress of
opposite sex. Some go for sex change operation, some of
them are asexual, some are hetrosexual and some are
homosexual.
5. Disturbed Mental State
To relieve themselves from the tension and confusion, some
go for alcohol and drugs. Because of rejection from others they
experience frustration, low self-esteem and distress.

Causes of GID
1. Biological Causes
a) Biological theories have emphasised the effects of prenatal
hormones on brain development. The excessive exposure to
unusual levels of hormones affects the hypothalamus and
other important brain structures that controls sexual identity
and sexual orientation. But these theories are not well
investigated.
b) Few studies focus on a cluster of cells in the hypothalamus
called the bed nucleus of stria terminalis. It plays an
important role in sexual behaviour. The size of this cell cluster
plays an important role in GID. This cell cluster are found to be
half of the size in transsexual as compared to non-
transsexuals.
c) Another study suggested that prenatal hormones play an
important role in GID. In an experiment, girls were exposed to
elevated levels of testosterone in utero. Most of these girls
were born with some degree of masculisation of their genitalia
and have more masculine behaviour than other girls.

2. Psychological Causes-
a) Psychological theories focuses on the prenatal nurturing
dimension. How the parents share the childs gender related
norms will decide the vulnerability of the child to develop GID
later as adult. Usually parents encourage their children to show
gender appropriate behaviour, for example, girls playing with
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dolls, boy acting as fathers, etc. Boys showing feminine

tendencies had mothers who desired girls rather than boys, so
pampering their sons with dolls, frocks, kitchen set, etc.,
Absence of father figure at home and overprotection of mother
also leads to feminine tendencies in boys.

b) Parental psychopathology also determines the development of

GID in individuals. It is seen that parents of GID individuals had
history of depression, severe anxiety and personality disorder
issues. This type of environment may create anxiety and
confusion in children. It makes the child unsure about him or
herself. A child may adopt a cross gendered identity as a way
of pleasing the parent and reducing his/her own anxiety.

Treatment of GID

a) The therapist tries to help these individuals to clarify their

gender identity and sexual orientation.

b) Some individuals undergo gender reassignment procedures by

taking hormone therapy through sex change operation. Before
surgery they are asked to groom themselves by cross dressing
and interact in society for one or two years. They are given life
time hormone therapy in which estrogen is given to a male to
develop female secondary sexual trait (breast, etc.,) and
testosterone is given to females to develop male secondary
sexual trait (beard, etc.). Artificial genitals are created, person
can get sexual pleasure but reaching orgasm is not possible.
The change and adaptation may cause stress which is
managed by the help of counselors and therapists.

Check Your Progress-

1. What are the symptoms of gender identity disorder?

2. How an individual with gender identity disorder can be helped
out?
3. What are the biological and psychological causes of gender
identity disorder?
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6.5 SEXUAL DYSFUNCTIONS :

Three stages of sexuality - desire, arousal and orgasm

each associated with specific dysfunctions. A sexual dysfunction is
an impairment is one of these stages. In addition pain can become
associated with sexual functioning, leading to additional sexual
dysfunctions.

1. Sexual Desire Disorders

a) Hypoactive Sexual Desire Disorder

The person seems to have no interest in any type of sexual
activity. The individual might have no desire what so ever
despite having frequent sex.

b) Sexual Aversion Disorder

In this situation the individual not only have no interest in sex,
but even the thought of sex or a brief touch, such as
someones taking the persons hand to assist him or her in
getting out of a car may evoke fear, panic or disgust. In some
cases of sexual aversion disorder, the principal problem might
actually be panic disorder, when the fear or alarm response
has become associated with the physical sensation of sex.

c) Sexual Arousal Disorders

Disorders of arousal refers to male erectile disorder and female
sexual arousal disorder. Individuals with arousal disorders
have frequent sexual urgers and fantasies and strong desire to
have sex. Their problem is difficulty becoming aroused, that is,
a male has difficulty achieving maintaining an erection and a
female can not achieve or maintain adequate lubrication.

Arousal disorders can be either lifelong or acquired. Lifelong

refers to a chronic condition that in present during a persons
entire sexual life. Acquired arousal disorder being at a specific
time before which sexual activity was relatively normal. In
addition arousal disorders can either be generalised, in which
case they occur every time individual attempts sex or they can
be situational, occurring only with some partners or at certain
times, but not with other partners or at other times.

2. Orgasm Disorders
a) Inhibited Orgasm
It is inability to achieve an orgasm despite adequate sexual
desire and arousal, commonly seen in women but rarely seen
in men. Five to ten percent of the females may experience
female orgasmic disorder in which they never or almost never
reach orgasm (Wincze & Carey, 1991).
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b) Premature Ejaculation
A far more common disorder of orgasm experienced by males
is premature ejaculation, which refers to ejaculation occurring
well before the partner wishes it to.

3. Sexual Pain Disorders

In sexual pain disorders marked pain in associated with sexual
intercourse. Two subtypes have been identified-
- Dyspareunia
- Vaginismus

For some males and females sexual desire is present and

arousal and orgasm are easily attained, but the pain of
intercourse in so severe that sexual behaviour is disrupted.
This disorder is named dispareunia which, in its original Greek,
means unhappily mated as bedfellows (Wince & Carey
1991).

More common than dyspareunia is vaginismus. In this

condition, occurring in women, the pelvic muscles located in
the outer third of the vagina under go involuntary spasms
where intercourse is attempted. Women report sensation of
ripping, burning or tearing during attempted intercourse.

CAUSES OF SEXUAL DYSFUNCTION

1. Biological Causes
2. Psychological Causes
3. Socio Cultural Causes

1. Biological Causes

a) Disease
Diabetes has been linked to sexual dysfunction. Diabetes can
lower the sexual drive, arousal, pleasure and satisfaction,
especially in men. Cardiovascular disease, multiple sclerosis,
renal failure, vascular disease, spinal chord injury and injury to
automatic neurons system due to surgery or radiation have
also been linked to causes of sexual dysfunction. Males are
more prone to get affected.

b) Hormones
Low level of androgen hormones in men, especially.
Testosterone, and high/level of estrogen and prolactin
hormone have been linked to cause sexual dysfunction.
Menopausal women have low sexual desire and arousal
because of no estrogen secretion in the body. Ovarian cancer,
vaginal surgery and sexual self image problem can bring
sexual dysfunction among women.
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Prescribed Drugs

Antihypertensive drugs (for high blood pressure), antipsychotic

drugs, anti depressants, tranquillisers, etc, are medical drugs
that cause sexual dysfunction.

Marijuana, cocaine, amphetamine and nicotine can impair

sexual functioning. Alcohol intake too is linked to sexual
dysfunctioning.

2. Psychological Causes

a) Psychological disorder
Depression in one such cause of sexual dysfunction. Besides
this, the individual suffering from anxiety disorder, panic
disorder, obsessive compulsive disorder, schizophrenia too
have reported no or little desire for having sex. They lack
feelings of sexual arousal and have problems in sexual
functioning.

Attitudes and cognition about sex some people have

negative attitudes about sex. They may consider it dirty, sinful
and disgusting and may avoid involving themselves in any kind
of sexual activity.

Performance anxiety is yet another blockade for people to

enjoy sex. There in so much worry and apprehension about
their sexual performance that it psychologically hinders the
pleasure of sexual acts among individuals.
3. Social and Inter personal Causes
a) Problems in Relationship
People suffering from sexual dysfunction are also seen to be
struggling with maintaining intimate relationship. Differences in
opinion about conducting sexual activities may be the main
reason for conflicts between couples. Lack of communication
about sexual preferences and arousal to each other trigger
more interpersonal conflicts. Besides this, the male arousal
pattern differs from female patterns. Non assertiveness in
communicating ones sexual desires and stimulation to the
partner can cause dissatisfaction in sexual life leading to
frustration. Behaviour conflicts also influences sexual
relationship. Disrespect towards ones partner, bitterners,
anger, frustration among couples block sexual desire and
healthy sexual functioning.

b) Trauma
Death of loved one, job loss, diagnosis of a serious disease
unemployment in men, etc., leads to lower self esteem and
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distorts the self concept. Trauma also leads to depression and

reduces desire for sex.

4. Cross Cultural Differences

Ancient Chinese and Indian medical system consider male
masturbation as unrecommendable.
Malaysians, Southeast Asian and Southern Chinese male
population has shown a depersonalisation syndrome known
as koro. This syndrome involves acute anxiety state, panic
and fear of dying, delusional feeling that the penis is shrinking
in the body and will eventually, disappear.

5. Sexual Problems across life span

As age declines, the biological changes occurring in the body
influences ones sexual functioning. Adequate level of
testosterone are essential for proper sexual arousal in both
men and women. Testosterone levels start declining around
age of fifty in men. Inadequate erections and sexual
dysfunction increases with age.

TREATMENTS SUGGESTED FOR SEXUAL DYSFUNCTIONS

1. Biological Therapy
2. Sex Therapy
3. Couple Therapy
4. Individual Psychotherapy
5. Treatment approach towards homosexual and bisexual issue

1. Biological Therapy
Certain medical conditions like diabetese, etc., automatically
leads to sexual dysfunctioning. Regulating dosage of drugs
helps in regulating/curing sexual dysfunction.

Special drugs too are available that can treat sexual

dysfunction. Viagra is one such drug.

Some drugs are also injected in the penis to gain penile

erections.
Hormone therapy too in administered among men and
women, who are suffering from sexual dysfunctions.
2. Sex Therapy
Sex therapy in recommended to couples. The major focus of
therapy is on training the couples on various sexual practices
that can be beneficial to keep them aroused and compliment
each other sexual preferences.
3. Couple Therapy
Many times couples do not give enough attention to foreplay
and seduction prior to sexual intercourse. They just rush to
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experience the sexual pleasure through the sexual act. This

can be problematic for couple later in life, when the biological
level of testosterone and estrogen starts diminishing it result in
inadequate arousal and displeasurable experience while
having sex.

4. Individual Psychotherapy
Cognitive behaviour therapy in conducted to reshape sexual
attitudes and script between couples (Rosen and Leiblum
1995). The reasoning behind sexual fears are confronted to
form fresh perspective and positive cognitions. Psychodynamic
therapies too are used to find clues from the past to the current
sexual problems.

5. Approach towards Homosexual and Bisexual Issues : Gay,

lesbians and bisexuals too experience sexual dysfunctions
similar to heterosexuals. Societal attitude towards gay,
lesbians and bisexuals is the most important factor negatively
influencing their sexual problems.

6.6 BIOPSYCHOSOCIAL PERSPECTIVE :

Patterns of sexual behaviour vary widely across different

cultures around the world. Although most individuals around the
world, especially in western cultures, practice safe sex,
approximately 20% of individuals engage in sex with multiple
partners. Studies show that no gender differences are apparent in
attitudes about sexual satisfaction, masturbation or homosexuality.
In western cultures premarital sex is common as compared to
Sweden where attitudes, are more permissive. What is normal
sexual behaviour in one culture may not necessarily be normal in
another culture. Report says that homosexuality runs in families.
The environment and experience play very powerful role in sexual
behaviour. Sometimes negative attitudes or experiences associated
with sexual interactions may contribute to sexual determination.
Cultures with very restrictive attitudes towards sex can influence
sexual behaviour. For example. Vaginismns is rare in North
America but is most common in Ireland.

6.7 SUMMARY :

Three types of sexual disorders are gender identity disorder ,

sexual dysfunction and paraphilias. GID is dissatisfactions with
ones biological sex. Sexual dysfunctions such as disorders of
sexual desire, arousal, orgasmic disorder, inadequate penile
erection, etc., are related to different stages of normal sexual cycle.
Paraphilias is sexual attractions to inappropriate people such as
children, or objects such as clothes, etc.
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The causes are socially transmitted negative attitudes

towards sex, biological and psychological causes.

Treatments for sexual disorders include biological and

psychosocial approaches. Treatments for paraphilias are highly
successful but available only in specialised clinics. Treatments for
sexual dysfunctions is successful but not readily available.

6.8 GLOSSARY :

1. Exhibitionism - sexual gratification associated with

exposing ones genitals to unsuspecting
strangers.
2. Fetishism - sexual attraction to non-living objects, such
as clothes, shoes.
3. Pedophilia - sexual attraction to children.

6.9 QUESTIONS :

Q.1 Discuss the different types of paraphilias.

Q.2 Explain the various causes and treatment of paraphilias.
Q.3 Write a note on Gender Identity Disorder.
Q.4 Discuss the different types of sexual dysfunction and its
causes.
Q.5 Discuss various treatment options for sexual dysfunctions.

6.10 SUGGESTED READINGS :

1. Oltmanns, T.F., Emery, R.E. (2010). Abnormal Psychology 6 th

ed., New Jersy : Pearson Prentice Hall
2. Nolen Hoeksema, S. (2008). Abnormal Psychology. 4th ed.
New York : McGraw Hill

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7
MOOD DISORDER

Unit Structures :

7.0 Objectives
7.1 Introduction
7.2 General Characteristics of Mood Disorder
7.3 Depressive Disorders
7.3.1 Major Depressive Disorder
7.3.2 Types of Depression
7.3.3 Dysthymic Disorder
7.4 Disorders Involving Alterations of Mood
7.4.1 Cyclothymic Disorder
7.5 Theories of Mood Disorders
7.5.1 Biological Perspectives
7.5.2 Psychological Perspectives
7.5.3 Socio Cultural And Interpersonal Perspectives
7.6 Treatment of Mood Disorders.
7.7 Suicide.
7.8 Summary
7.9 Questions
7.10 References

7.0 OBJECTIVES

After studying this unit you should-

Comprehend the general characteristics of mood disorder.

Know the various types of mood disorders.
Understand the theories and treatment of Mood disorders.
Became aware about suicide its causes, assessment and
treatment.
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7.1 INTRODUCTION

We do feel happy and energetic and sometimes sad and

depressed. These are commonly experienced mood changes. The
mood disorders explained in this unit are more serious and
disruptive in nature.

Mood disorder is one of the group of disorders involving

severe and enduring disturbances in emotionality ranging from
elation to severe depression. Mood disorder involves disturbances
in persons emotional state or mood. People can experience
extreme depression or alternate between elation and depression.

7.2 THE GENERAL CHARACTERISTICS OF MOOD

DISORDERS

1. Individual feels overwhelming sadness or dysphoria.

2. In another variety of mood disorder, individual has experiences
that are opposite of depression, feelings of happiness called as
euphoria.
3. Mood disorder has a time limit period during which specific
symptoms of disorders are seen. The time limited period of
intense symptoms of disorder is called as an episode. The
episode of disorder may be very lengthy extending up to 2 or 3
years .
4. Mood disorders are classified as mild, moderate and severe
depending on the severity of episode.
5. Every clinician documents whether the disorder is first
occurance or if there is recurrence of symptoms. If it is a
recurrent episode, clinician tries to find out if the client has fully
recovered or not.
6. Some people may display even bizarre and unusual behaviors,
such as odd bodily postures or movements or excessive
purposeless motor activity.
7. The clinician also tries to determine if there is a postpartum
disorder. A disorder that is seen in women after giving birth to
baby is called postpartum disorder.

7.3 DEPRESSIVE DISORDERS

The person experiencing depressive disorder, usually

experiences feelings that follow a tragic loss or grief. People do get
back to day-to-day affairs and come to terms with tragic loss and
grief. Individuals suffering from depression, continue to experience
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feelings of hopelessness, fatigue, and worthlessness and show

suicidal tendencies even when there is no apparent cause.

I Major Depressive Disorder

i) The following are the characteristics of major depressive

episodes:-
1. It involves an intense dysphoric mood that is much more serious
than ordinary sad moments of day-to-day life. The dysphoria
may be found in the form of excessive dejection or sudden loss
of internal in the activities that were previously pleasurable.
2. If intense depression continues after death of loved one for
more than 2 months, then it is a major depressive disorder.
3. The depressive disorders may not always have a precipitating
event. Onset may be without any known cause.
4. Persons experiences impairment at home and work due to
depression.
5. The physical signs of depressive episode are manifested as
somatic symptoms like :-
a) Lethargy and listlessness.
b) Psychomotor retardation involving slowing down of body
moments.
c) Some people may show extreme psychomotor agitation. These
behaviors may be bizarre and extreme, sometimes may be even
categorised as catatonic.
6. Eating disturbances are more common, people may not have
appetite and may even avoid food. Some others may overeat, or
overindulge in sweet and carbohydrates.
7. Dramatic changes in sleep patterns are observed. People may
show insomnia or engage in excessive sleeping. The EEG sleep
patterns show that clients show disturbances in sleep
continuity, intermittent wakefulness and early morning
awakening. Disturbances in REM sleep are evident; there are
more eye moments and increased duration of REM sleep. Such
major REM abnormalities are seen before the major depressive
episode.
8. The cognitive symptoms are :
i) Intensely negative self concept, low self-esteem followed by
a strong need to be punished.
ii) Intense guilt feelings and persistent and thinking about the
past mistakes is common.
iii) Difficulty in thinking, concentration and decision making.
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9. Loss of interest in the activities that were considered as

interesting in the past. Person is overcome by feelings of
negativity and hopelessness and thinks that death is the only
way of escaping and may actually commit suicide.
The symptoms of depression may continue from 2 weeks to
period of two months. If untreated, symptoms may continue for
another six months. The symptoms of major depressive episode
occur gradually, they are not shown over night.

II) Types of Depression

A) Depressive episodes involving melancholic features.

B) Depressive episodes involving seasonal patterns.

A) Depressive episodes involving melancholic features:-

Persons loose interest in most of the activities. They find it difficult
to react to events that require pleasurable reactions. Morning is
very difficult for these people. They may wake up early in the
morning and continue the day with sad and gloomy feelings and
other major symptoms of depression.

B) Depressive episodes involving Seasonal Patterns:-

People with seasonal patterns of depression develop
disorder almost at the same time each year or may be about 2
months during winter, but then, they come back to normal life.
During episode they lack energy, interest, may sleep excessively,
and overeat more carbohydrates. Some researchers propose that
seasonal depression is linked with changes in biological rhythms. It
is found that people with seasonal depression are found more in
states where there is less temperature.

The onset and the course of disorder:- The average age for
major depressive disorder is 30 years.(Hasin et al 2005) A study
performed Cross National Collaboration Group 1992, (Kessler at al
2003) showed that incidence of depression and consequent
suicide is steadily increasing over the years. The national
morbidity study has shown that increasing younger groups called
as cohorts have higher prevalence rates than older people.
Individuals aged 18-29 years are more likely to become depressed
at the earlier ages than the people in the age group 30-44 years. In
short, depression has started surfacing at an early age with greater
frequency.

The length of depressive episode is variable. Some episode

may last for two weeks and in more severe cases it may last for
several years. If untreated the first episode of depression may last
for 4 to 9 months (Eaton et al 1997). The diagnosis of depressive
episode becomes completed, especially when person also has a
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personality disorder. Some may attempt to reduce depression by

resorting to drug or alcohol addiction. Depressive episodes may be
found in children and adolescents. The typical age of onset has
been estimated be early 20s. D.N. Klein Taylor Dickstein and
Harding found the three characterstics of the onset of disorder
before 21.

1) It lasts longer 2) It shows relatively poor response for treatment.

3) The chances are stronger that the disorder may run in the family
of affected persons. Study done by Kersler et al (2005) show that
approximately 2.5 percent of adult population develop this disorder
in the course of their life. This disorder reaches its peaks by 45 to
59 years.

Adults usually take on the physical symptoms of dysthymia.

Finally, hospitalisation is very rarely required except in the cases
where depression leads to suicidal attempts

III) Dysthymic Disorder :

Some people experience depression involving sadness, but

sadness is not so intense to be described as major depressive
episode. But such depression is very often long lasting. This does
not refer to the mood changes that we do experience in day-to-day
life. People with dysthymic disorder show the symptoms of major
depressive disorder for at least 2 years. These symptoms may
include appetite disorder, sleep disturbances, low energy, fatigue,
low self esteem, poor concentration, difficulty in decision making
and feelings of hopelessness. Dysthymic disorder differ from major
depressive episode only on the basis of its course, i.e., chronic in
nature. People with dysthymic disorder are never symptom free for
more than two months. They may withdraw from social interactions
and react with anger and irritability towards others. Many a times
dysthymic disorder may be accompanied by other serious
psychological disorder. In some instances dysthymia may be
accompanied by personality disorder, some of them may go for
major depressive episode. Some of them may go for substances
abuse. Hence, clinicians may diagnose wrongly, and attempts may
be done to reduce feelings of hopelessness and worthlessness.
Hospitalisation may not occur in such cases except in the cases of
suicidal behaviour. Dysthymia may be diagnosed in children and
adolescents.

The Prevalence and Occurrence of the Disorder:- It is observed

that 2.5 percent of adult population will develop this disorder in the
course of life and the disorder reaches its peak from 45 to 59 years
(Kessler et al 2005). In the older patients the disorder may take
physical form rather than psychological disturbance.
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7.4 DISORDERS INVOLVING ALTERATIONS OF

MOOD

There are two types of disorder involving mood alterations.

1) Bipolar disorder 2) Cyclothymic disorder

1) Bipolar disorder :

It involves an intense and disruptive experience of elations

or euphoria alternating with major depressive episode.

Bipolar disorder may occur in two forms. Individuals may

experience manic episode or may experience mixed episode.
Cyclothymic disorder involves alteration between dysphoria
and less intense type of euphoria called hypomaniac disorder.

Manic episode ;- Any manic episode, even if it is not followed by

depressive episode is described as bipolar disorder. Previously
bipolar disorders were described as manic depressive disorder.
The term bipolar implies two poles or extremes,
mania and depression. People with bipolar disorder may not always
show symptoms of depression. It is assumed that people with
bipolar disorder will experience depression at some time in later
months or years.

Person experiencing manic episode may appear to be

outgoing, talkative, creative, witty and self confident. The
expansiveness and feelings of energy can cause serious problems
in their day-to-day functioning. Self-esteem of these individuals may
be grossly inflated. Their thinking may be grandiose and even may
have psychotic quality.
Most people in manic episode may have bizarre thoughts,
They may show unusual ideas and swings of unusual creativity.
There is a rapid change in thoughts and ideas; they may jump from
one activity to another. They are easily distracted and continually
require stimulation. They may speak rapidly to others with a such a
speed that others find it difficult to interpret. People experiencing
manic episode may seek out pleasurable activities that may be
impulsive in nature. He or she may engage in ill advised
sexual relationships or spending sprees. Often person has grand
plans and goals which he persues fanatically.
Manic episode may appear and diminish suddenly. The
depressive episode may appear gradually and diminish with same
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speed. The duration of manic episode depends on the treatment

taken by the individual.
Types of Bipolar disorder :
Bipolar disorder is of two types:- Bipolar disorder-I and Bipolar
disorder II. Bipolar I disorder is diagnosed when individuals
experience one or more manic disorder, with the possibility of
experiencing one or more depressive disorder. But it is always not
necessary that person experience one or more depressive episode.
Bipolar II is a disorder in which major depressive episode
alternates with hypomania episode i.e., individual has one or more
major depressive episode and at least one hypomanic episode.
hypomania episode are of lesser severity.

Prevalence and course of the disorder :

It is relatively very rare for someone to develop bipolar
disorder after the age of 40. But once it appears it tends to be
chronic, where manic and depression keep on recurring indefinitely.
Bipolar disorder is less commonly seen as compared with major
depressive disorder. The incidence of bipolar disorder is equally
found in both males and females (Kessler of et al 1994). There are
gender differences in the onset of the disorder.

The first episode for men is more likely to be major manic

episode, for women it is more likely to be major depressive
episode.

Bipolar disorder has been reported in psychiatric literature, it

has been found in children as young as 3 years. There is lack of
consistency in the diagnostic criteria and methods of assessment
for young children. Psychologically disturbed children display wide
range of symptoms.

II) Cyclothymic disorder :

It is similar in many ways to dysthymic disorder. Like

dysthymic disorder, cyclothymic disorder is chronic alteration of
mood elevation and depression. People with cyclothymic disorder
display unusually dramatic and recurrent mood shifts. The
symptoms may not be as severe as with people with bipolar
disorder. The elation may not be severe enough to be diagnosed as
manic episode, depression is never severe enough to be diagnosed
as depressive episode. It is the effects of the disorder that disrupts
the life of an individual.

Persons with cyclothymic disorder tend to be in one mood

state or other with relatively few periods of neutral mood. This
pattern must last for 2 years (1 year for children and adolescent).
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People with cyclothymic disorder alternate between the kinds of

mild depressive symptoms. The behaviour is not severe enough to
require hospitalisation or immediate intervention. In many cases
such people are only regarded as moody. Sometimes, individual
with this disorder is actually more likely to experience some
impairment in interpersonal dealings as people may consider them
unreliable because of their mood changes.

The problem of diagnosis becomes complicated among

children because the symptoms of bipolar disorder may co-exist
with already present disorders like conduct disorder, hyperactivity,
attention deficit disorder (Shapiro 2005). Lot of research needs to
be done in area of diagnostics for judging bipolar disorder in
children.

Kindling is a phenomena indicating that individuals who have

experienced manic episode are at greater risks of experiencing
another episode, even if they are taking medicines for controlling it.
Manic depressive episode may occur just before or so on after
major depressive episode. The frequency of manic depressive
episode is on an average 4 episodes within a span of decade, for
those who do not under go any treatment or medication. Not more
than 15% people experience four to eight episodes of mood
disorder. These individuals are described as rapid cyclers. Majority
of women are likely to become rapid cyclers, Hyperthyroidism, use
of antidepressant drugs increase the chances of reducing the time
gap between episodes.

Most individuals with bipolar disorder feel normal between

the episodes. But one forth of them may continue to feel depressed
and have difficulty in dealing with people at home or at work,
problems are especially likely for individuals who struggle with
unpredictable mood changes that occur in rapid cycles because
other people consider them to be moody and unreliable.

Onset and duration :- The average onset of this disorder in

between 19 to 22 years. This disorder begins with minor mood
changes or minor cyclothymic mood swings.

7.5 THEORIES OF MOOD DISORDERS:

There are different perspectives towards mood disorders.

They explain the causes of mood disorders. Researchers have
identified biological, psychological and social factors that seem to
play an important role in the etiology of mood disorders.
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7.5.1 Biological Perspectives:

The Twin studies and family studies indicate the role of

biological factors in mood disorders.
Genetics:-

Studies on genetics suggest that bipolar disorder is seen in

families. Research has shown that the first degree relatives of
people with major depression are twice likely to develop disorder
as compared with individuals from general population (Sullivan,
Neak & Kender 2006) The risk in higher for the first degree relatives
of children of depressed individuals (Lieb et al 2002) The studies of
three generation of children, parents and grandparents, show that
this disorder tend to run in families. If major depressive disorder is
present in parents and grandparents, children are more likely to
show symptoms of psychopathology. This psychopathology takes
the form of a disorder. A child with anxiety disorder who comes
from family with major depressive disorder in more likely to suffer
from depressive disorder later in life.

The five large scale studies observed inheritance patterns in

families. They found that the heritability of 31 to 42 percent,
meaning among 100 individuals who have close relative who has
disorder out of them approximately 30 to 40 of them have a major
likelihood of having major depression (Sullivan, Neals & Kendler
2009).

NIMH carried out a major study or bipolar disorder at 5 major

research centers, They carried our genetic linkage analysis of 500
individuals diagnosed with bipolar disorder.(Faraone, Glatt, Su &
Tsuang, 2004) This is a largest study that offered evidence for
genetic linkage. The available evidence does not clearly indicate
the role of specific genes (De Paule 2004).

In the development of mood disorders, gender also plays an

important role. In a study of over 1000 pairs of opposite sex twins
who were interviewed 2 years apart, to study the effect of receiving
social support on the development of depressive symptoms. It was
found that both men and women of twin pairs had more chances of
developing major depression when social support is very low, as
compared with men and women who had more social support.
The study indicated that even powerful genetic risk factors can be
influenced by environmental conditions.

Biochemical factors The biological theories emphasise the

altered neurotransmitter functioning as a cause of mood disorder.
It is not possible to observe neurotransmitter substances in human
brain.
 136

Following are two explanations given that suggest the role of

deficiency of neurotransmitter substances.
1) Catecholamine hypothesis, suggests that, the shortage of
norepinephrine (a catecholamine) causes depression and
excess causes mania.
2) Indolemine hypothesis (Glassman, 1969) suggests that
deficiency of serotonin produces behavioural symptoms of
depression.

The above two hypothesis regarding the role of deficient

neurotransmitter substances in mood disorder, is called as
Monoamine Depletion Model. All the antidepressants currently
used attempt to increase the availability of these neurotransmitter
substances. Studies have pointed out the relationship between
hormonal activity and depression. Researchers are focusing on the
role of Cortisol. It is a hormone that mobilises bodys resources
during stress.

The research findings in the area of genetics imply the role

of biological factors in the causation and symptomatology of mood
disorder.

7.5.2 Psychological Perspectives :

The review of genetic contribution to the causes of

depression could be attributed to psychological factors.

7.5.3 Psychodynamics Theories :

1) The earlier theories emphasised upon the loss and feelings

of rejection as a cause of mood disorders. The later psychodynamic
theories emphasised the inner psychic processes as the basis of
mood disorders.

2) British psychoanalyst, John Bowlby proposed that people

can become depressed as adults, if they were raised by parents
who failed to provide them with secure and stable relationship.

Similar theory was proposed by Jules Bempoard (1985). He

emphasised the role of deficient parenting in mood disorders.
Children of such parents become preoccupied by being loved by
others. As adults they form relationship where they overvalue the
support of their partners. End of such relationship may make
depressed person experience feelings of inadequacy and loss.

3) Psychoanalytic theory of personality suggests that mania is

a defensive response adopted by an individual to deal with feelings
 137

of inadequacy and loss. People become hyperenergetic as a

defense against becoming gloomy and depressed.

7.5.4 Behavioural and Cognitive Perspective :

1) Lazarus and Skinner (1968, 1953) proposed that depression

is the consequence of reduction of positive reinforcement.
Depressed people withdraw from life because they do not
have an incentive to remain active.

2) The contemporary perspective on depression is (Kanter et al

2004), based on Lewinshons theory, maintaining that low
rate of response contingent positive reinforcement is the
cause of depression.

Behavioural approaches have been integrated into cognitive

approaches. Cognitive approaches propose that serious mood
changes can result from events in our lives or from our perception
of events.

Cognitive perspectives suggest that people experience

depression as their earlier experiences sensitise, them to react in
certain ways to stressful events. People react to stressful events,
with a set of thoughts involving negative view of self, world and
future. Beck in 1967, described this negative view of self world and
future as cognitive triad, he further proposed that if this view is
activated once, it continues further in a cyclical manner.

Cyclical thinking is maintained by cognitive distortions. They

are the errors that depressed people make while drawing
conclusions. The cognitive distortions include applying illogical
rules, jumping to conclusions, over generalising and taking detail
out of context. As a consequence of this, depressed people give
negative meaning to past and future events. They may have
pessimistic expectations from future. Such persons may not be
even aware of such negativity in their thinking.

Beck proposes that depressed people feel sad because they

are deprived of something that threatens their self esteem. It
represents an individuals misguided attempts to adapt to
psychological environment.

Harry Stack Sullivan proposed that abnormal behaviour is a

consequence of impaired interpersonal relationships, including
deficiencies in communication.

Bowlby proposed that, a disturbed attachment pattern in the

childhood in the cause of depression is later years.
 138

Interpersonal theory of depression connects this ideas and

gives behavioural and cognitively oriented theory of depression. It
explains the steps in the development of depression.
i) Failure to develop social skills in childhood. The skills required
for developing relationship.

ii) This leads to sense of despair and solution resulting in

depression.

iii) Once depression in established it is further enhanced by poor

social skills and communication. This invites rejection from others.
The depression that develops in adulthood may arise when person
experiences a event like a death or loss of loved one. Depression
continues because of a vicious cycle.
Poor communications skills keep people away; poor
interactions make person experience feelings of loneliness and
worthlessness still more intensely, Women are more exposed to
stressful events as compared to men. As a consequences women
are more likely to experience depression.
These individuals are convinced of facture in their efforts.
The positive experience also may be distorted to fit in their negative
framework. The cognitive distortions make depressed individuals to
experience low feelings of well being, energy and desire to be with
others and lack of interest in the environment. For e.g., one may
find them making statements like . If a person like me contests
for election, no one will really vote for me because I know people
do not like me.

7.5.5 Socio Cultural and Interpersonal Perspectives :

Interpersonal model of mood disorder: (Myrna Werssman,

Gerald Klerman & associates) This model emphasises disturbed
social functioning. The interpersonal therapy (IPT) follows from this
model. It is a time limited form of therapy for treating depressed
persons. This therapy assumes that individuals are genetically
vulnerable to interpersonal stress and hence they are more likely to
experience depressive episode. The interpersonal therapy focuses
on both poor social skills and origin of depressed persons problem.

Adolph Meyer (1957), An interpersonal theorist with

psychobiological approach to abnormal behaviour emphasised that,
psychological problems are diagnosed with depression. (Hammen
2005).
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7.6 TREATMENT OF MOOD DISORDERS

A) Biological Treatment :

The most common treatment for mood disorder is

antidepressants. People with bipolar disorder are treated with
lithium carbonate. The most common medication used to treat
depressions are:

i) Tricyclic Antidepressants. (TCAS)

ii) Monoamine Oxidase Inhibitor (MAOIS).
iii) Selective Serotonin Reputake Inhibitors (SSRIS).

Tricyclic antidepressants (TCAS) these chemicals have three

ring structures. They are available in the market with trade names
like Elavit, Endep, Norpramin, Tofranil, Aventyl and Pamelor. These
medications are effective with people who have disturbed appetite
and sleep. These tricyclic antidepressant increase the excitatory
effect of postsynaptic neurons.

Monoamine Oxidase Inhibitions (MAOIS)These drugs are

available with trade names Nardil and tranlcypromine (Parnate) It
is effective in treatment of chronic depression.These chemicals
function by prolonging the effects of neurotransmitter substances.
MAOIS are not frequently prescribed as they can lead to serious
complications. People taking MAOIS are not able to take allergy
medications or not able to ingest food containing tyramine, e.g.,
beer, Cheese and Chocolate. The combination of this with MAOIS
can rise blood pressure dramatically.

Selective Serotonin Reputake Inhibitors (SSRIS) It is

generally used as an alternative to tricylic and MAIOS. They block
the uptake of serotonin, so that more of serotonin in made available
to action at receptor sites. SSRIS are different from other
antidepressants as they do not block many receptor sites at a
moment; that can cause sedation, weight gain, constipation and
rise in the blood pressure and dry mouth. The new SSRI
medications also have side effects such as feelings of nausea,
agitation and sexual dysfunction.

Studies during past two decades suggest the effectiveness

of SSRIS. The result of these studies should be viewed with
caution. These studies fail to indicate the effectiveness of
medication. Most studies done in this area have not been
published.
 140

There are reports of higher suicide risk with SSRI

medication. But the investigation during 1996 to 1998 showed that
the rate of suicide is much lower among people treated with SSRI
as compared with other antidepressants.

The higher suicide rate among SSRIS prescribed persons

made clinicians to focus attention on the number of related
variables such as comorbid psychological disorder, gender and
geographic location and role of psychotherapy. Antidepressants,
are frequently prescribed to patients with severe symptoms by
nature. They are at the higher risk of suicide (Rosack 2005).
Therefore, precaution has to be exercised by administering to
children and adolescents. Several studies have shown a link
between suicidal behaviour and antidepressants.

Antidepressants medications have are commonly used for

relieving symptoms. But many people are not eligible for this
medication, especially women of child bearing age.

Lithium carbonate in a common salt found in the natural

environment. It is used as an antidepressant, Dosage has to be
carefully monitored to prevent toxicity, and low thyroid functioning,
which might intensify lack of energy associated with depression.
Lithium carbonate has side effects such as mild central nervous
system disturbances, gastrointestinal upsets or even cardiac
effects.

Lithium interferes with the high associated with the bipolar

disorder. Persons with bipolar disorder actually enjoy the
pleasurable feelings associated with mania. By the time full blown
mania is developed, individuals may not accept that they have any
problem. If side effects are considered, then person is at risk of
developing another episode. Therefore, therapists encourage the
clients to remain on the maintance dose of lithium.

The variable nature of bipolar disorder makes it necessary to

have an additional antidepressant along with lithium. Persons prone
to mania may develop mania after medication. Persons with
psychotic symptoms, may benefit from antipsychotic medications.
Clinicians may also prescribe ECT., for clients with mood disorders
for whom medication may be ineffective or slow in alleviating the
symptoms. People have negative attitude towards ECT, as it is
more likely to be misused. This method has been used for
punishment in the past rather than for treatment.

ECT - (Electro Convulsive Therapy) Lisanby (2007) has

demonstrated that ECT is life saving treatment for severely
depressed people. Clients are usually given anasthesia to reduce
discomfort, and are given muscle relaxing drugs to prevent
 141

breaking of bones from convulsions during seizures. Electric shock

is directly administered through the brain for less than a second.
This produces seizures and brief convulsions. In current practice
ECT is administered 6 to 8 times, once every other day, until the
persons mood returns to normal. The side effects are few. Person
has short term memory loss and confusion that disappears within
one or two weeks. Some clients may show long term memory
problems. It is not clear as to why ECT works. One explanation is
that induces changes in neurotransmitter receptors and bodys
neural opiates.
TMS - Transcranial Magnetic Stimulation (TMS) in an alternative to
traditional ECT. TMS combined with medications have been found
to be more effective with persons who do not respond to
medications.
Light therapy is another treatment offered for seasonal
depression. Depressed individuals are especially exposed to
special light during winter season. Another less well known method
of the treatment is sleep deprivation. Both the methods are effective
when combined with medication.

B) Psychological Treatment
Cognitive Behavioural approach and interpersonal
psychotherapy are the most commonly adopted approaches for
treatment of depression.

Behavioural Approach :
The major features of this approach in dealing with
depression are :

1. Careful assessment of frequency, quality and range of activities

and social interactions in clients life.
2. Helping client change his or her social environment along with
teaching of social skills.
3. Encouraging clients to seek activities that restore mood
balance, helping clients to seek reinforcement in activities.
4. Educating client in settling realistic goals because depressed
clients often set unrealistic goals for themselves. Therapist may
give homework to clients in this area.
5. Therapist focuses on self-reinforcement procedures such as self
congratulations like rewarding one self with some pleasurable
activity.
6. If these procedures do not succeed then therapist may engage
in more extensive programme like instructions. Modeling and
coaching, role playing, rehearsals at real world trials, etc.
 142

Cognitive based approach :

Short time structured approach- It focuses our negative thoughts

and it includes activities that will improve clients daily life.

1. Clients are taught to examine carefully their thought processes

while they are depressed. They are made to recognise
depressive errors in thinking.
2. Client in taught that errors in thinking can directly cause
depression.
3. It involves correcting cognitive errors and substituting more
realistic thoughts and appraisals.
4. Later in therapy underlying negative cognitive schemes
(characteristic ways of viewing the world) that trigger the
cognitive errors are targeted.
5. Therapist makes it clear to the client that both of them together
will be working as a team to uncover faulty thinking patterns.
To summarise, cognitive approach incorporates didactic
work, i.e., cognitive restructuring and behavioural techniques. It
involves explaining theory to client, teaching the client how
depression results from faulty thinking and cognitive restructuring.
Clients are instructed to monitor their thought processes carefully,
especially in situations where client might feel depressed. Client is
required to plan activity for a week, it may involve graded task
assignment. It may involve pleasure prediction experiments like
how much pleasure will be produced by a given activity and how
much pleasure is produced in reality. This pleasure production
experiments help therapist in demonstrating to client how gloomy
predictions are inaccurate. Client is asked to rate the pleasure of
each activity. If patient is inactive, then activities are planned on
the hour by hour basis. Thus, helping clients to experience success
of accomplishing something.

Cognitive behavioural therapy is a short term method. It

requires generally 10 to 12 sessions. People with chronic major
depressive disorder may require long term cognitive behaviour
therapy.

Psychodynamic approaches involve short terms focused

treatment combined with medication. Clinicians treating bipolar
disorder, begin with medication, incorporated by psychological
intervention.
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Interpersonal Psychotherapy :

It is observed that problems in personal relationships,

absence of relationship, etc is a major stressful event, and it can
lead to relapse of the bipolar disorder.

Interpersonal and social rhythm therapy (IPSRT) According to

this model mood, episodes are likely to emerge from:

a) Non adherence to medication

b) Stressful life events
c) Disruption in social rhythms.

Clinicians, who follow IPSRT model, focus on educating

clients, about medication adherence, helping them to understand
their feelings about the disorder and how it has changed their lives.

Clinicians emphasise the reduction of interpersonal stress in

clients life, especially one who is suffering from bipolar disorder for
following reasons.

1. Stressful life events affect circadian rhythm, i.e., sleep wake

cycles, appetite energy levels.
2. Stressful life events change the daily routine.
3. This may affect persons mood and may bring about changes in
social, rhythms. (Frank 2007).

Researchers have found this programme to be very effective

in improving relationships.

Socio cultural and interpersonal therapy The family members

of the client are involved in treatment. They can understand the
experiences of the person with mood disorder and help him or her
in dealing with the symptoms. Interpersonal therapy may last from
12 to 16 weeks. This theory is divided into three broad phases.

1) Assessing the nature of depression by using quantities

measurement.
Interviews are carried and to determine exactly what triggered
the present episode.
2) Therapist and patient together formulate a treatment plan
focusing on primary problems like grief, interpersonal disputes
and problems faced due to inadequate social sketch.
3) Third phase treatment plans are carried out depending on the
nature of clients problem.
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7.7 SUICIDE

Suicide is one of the most common causes of death among

youngsters and elderly members of society. Suicide in often
associated with depression, it is a way a escaping from hard
realities of life. Suicide attempts are usually desperate efforts at
getting attention from concerned people. These are the people who
communicate about their suicide intentions rather than actually
doing it.

American studies and statistics shows that men are likely to

commit suicide than women. Women may attempt suicide but their
attempts may not be completed as compared to men. Generally
90% adults who commit suicide have some diagnosable
psychological disorder. Disorders like alcohol abuse, dependence
or Schizophrenia are associated with suicide. (Duberstein &
Conwell 2000). Similarly, people with borderline personality
disorder also make suicide attempts.

The statistics of suicide in India in different. According to

WHO, India has a highest suicide rates in the world. The countrys
health ministry estimates that 1,20,000 people kill themselves every
year and among these 40% of them are below 30 years.

South India in considered as worlds suicide capital. Kerala,

has highest suicide rate, 32 people commit suicide almost every
day. In India it is observed that women are more likely to commit
suicide then men.

The study found that suicide rate for women in the age group
of 19-29 years in 148 per 1,00,000 and for men it is 58 per
1,00,000.

There are international variations in suicide rates. The

highest rates of suicide are found in Eastern Europe and lowest in
Latin America. (WHO 2004).

1) Causes of Suicide

i) Biological perspective

In one the largest investigations of family patterns of suicide,

250 relatives of 25 people who committed suicide were compared
with 171 relatives of men who did not commit or attempt suicide.
The results of the study showed that relatives of suicide completers
had 10 times more chances of committing suicide.
 145

Baud (2005) showed that tendency to commit suicide is

associated with genetic vulnerability involving serotonin related
genes. Thus, vulnerability leads to certain personality traits which
interact with life events, thus making a person more prone to
committing suicide. Similarly, low alcohol tolerance combined with
genetic vulnerability increases the risks of committing suicide
(Marusie 2005).

ii) Psychological perspective

If one of the family member commits suicide then there is an

increased risks that someone else in the family will also follow.
Brent and colleagues observed a six fold increased risk of suicide
attempts in the offspring of the family members who had attempted
suicide compared to the offspring of persons who had not
attempted suicide. If sibling was a suicide attempter then the risk
increased even more (Brent et al 2003). The question is people
who kill themselves, do they simply adopt a solution that in familiar
to them? or is it impulsivity that is inherited as a family trait that is
responsible?

Studies show that early onset of mood disorder, as well as

aggressive and impulsive traits, make such persons succeptible to
suicidal behaviour (Mann et al 2005).

Existing psychological disorders such as mood disorder may

become a precipitating cause of suicidal behaviour. Many people
who commit suicide do have mood disorders.

Similarly, alcohol use and abuse in also associated with

suicides, particularly in adolescent suicides. Combination of
disorders such as substance abuse and mood disorder in adults
and mood disorder and conduct disorder in children seem to create
a stronger vulnerability, then any one disorder alone. Hawton &
Colleagues (2003) found that prevalence of previous attempts and
repeated attempts doubled if a combination of disorder in present.
Esposito and Clum (2003) also noted that presence of anxiety and
mood disorder predicated suicide attempts in adolescents. J.
Cooper and Colleagues (2005) followed almost 8,000 individuals
who were treated in emergency room for deliberate self harm for 4
years. Sixty of these people killed themselves, a 30 fold increase in
risk compared to population statistics.

The important risks factor in suicidal behaviour is stressful

life event which are experienced as shameful or humiliating, such
as failure that may be real or imagined. The stress and disruption of
national disasters increase the likelihood of suicide.
 146

The psychological factors that predispose individuals to

committing suicide are explained by Edwin Shneidman (1984). He
suggests that act of taking ones life is an attempt of interpersonal
communication. Through suicidal attempts people try to
communicate frustrated psychological needs to significant people in
life.

Beck explains suicide from cognitive perspective. He

suggests that suicide is an expression of feelings of hopelessness
triggered by preception that stress is beyond control. Beck (1996)
has used the concept of suicidal mode to describe the frame of
mind of person who has made multiple suicidal attempts.

Impaired decision making and altered Serotonin pathways in

the parts of the brain involved in making complex choices also
predisposes an individual towards suicidal behaviour.

Socio cultural perspective :

Emile Durkheim, a French sociologist, suggest that a feeling

of alienation from society can become a cause of suicidal
behaviour, Media also plays an important role in propogating
suicide, especially among teenagers. Media accounts often
describe in detail the methods used for suicide, thus they provide
guidelines to potential victims.

There are racial and age related differences in suicide.

Whites are more likely to commit suicide followed by African
Americans. The age at which a member of a given race will commit
suicide also varies e.g., for blacks suicide may occur at an average
age of 32 whereas for whites it may be 44 years.

iii) Assessment and Treatment :

Clinicians can assess suicidal intent in the client. The

suicidal intent refers to how person in committed to dying.
Secondly, the suicidal lethality in also judged. The suicidal lethality
refers to the dangerousness of the method adopted for dying.
Suicidal intent and lethality are always connected.

Many people are willing to discuss their suicidal intentions.

Many people may prefer avoiding warning signs of suicide, by
thinking that asking about intention may provoke a person. Even a
trained clinician may find it difficult to judge the suicidal intentions of
person. Client may deny the suicidal thought, but his behaviour
may give clue about the suicidal intention, Changes in mood,
declining grades, recklessness, substance abuse, giving up of
former interests, stormy relationships are considered as suicidal
 147

signs. The potential factors involved in suicide may differ from

individual to individual.

Suicidability is assessed through hotlines, hospital

emergency rooms, mental health clinic and inpatient psychiatric
departments.

Professionals help the person with suicidal intention, by

providing support and by regaining sense of control in the life of the
individual.

The clinician can have a two way agreement, where client

promises to contact clinician when he experiences such ideas and
clinician promises client that he will be available whenever the crisis
is experienced.

Therapist may use cognitive techniques and help an

individual to get control over the suicidal intentions by thinking
about alternative ways of dealing with the problem.

Brent (2001) suggested a comprehensive model of treatment

for adolescence that include :

1) Treatment of psychopathology.
2) Reduction of cognitive distortion.
3) Work improvement of social skills.
4) Encouragement of problem solving.
5) Regulation of affect and family intervention.

7.8 SUMMARY :

In this unit we had discussed the general characteristics of

mood disorder. Following this we had discussed the different types
of mood disorders. The characteristics of major depressive episode
and various types of depression were discussed. One of the most
common types of depression is Dysthymic disorder, which was
briefy explained. Two types of disorder involving mood alteration
was also discussed, which included bipolar disorder and
cyclothymc disorder. Types of bipolar disorder, its prevalence and
course was also discussed.

There are various causes of mood disorders such as

biological perspective, psychological perspective, psychodynamic
theories, behavioral and cognitive perspective, etc.
 148

Various treatments of mood disorder was also discussed.

Towards the end of the unit the concept of suicide, its cause,
assessment and treatment were discussed.

7.9 QUESTIONS :

Q. 1. Discuss the general characteristics of mood disorders.

Q.2. Explain the various characteristics of major depressive
episodes.
Q.3. Discuss :
a) Depressive episodes involving melancholic features.
b) Depressive episodes involving seasonal patterns.
c) Dysthmic Disorder

Q.4. Discuss Bipolar and Cyclothymic disorder.

Q.5. Discuss the various theories of mood disorders.
Q.6. Explain the various treatments of mood disorder.
Q.7. Explain Suicide its causes, assessment and treatment.

7.10 REFERENCES :

1. Richard P. Halgin and Susan Krauss Whitbourne, (2010)

Abnormal Psychology, Clinical Perspectives or Psychological
disorders. (6th Ed).

2. V. Mark Durand and David-H-Barlow (2010, 2006, Essentials of

Abnormal Psychology. Wadsworth, Cengage learning.

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8
SCHIZOPHRENIA AND RELATED
DISORDERS I

Unit Structure

8.0 Objectives
8.1 Introduction
8.2 Characteristics of Schizophrenia positive, negative and
other Symptoms
8.3 Other Psychotic Disorders
8.4 Summary
8.5 Glossary
8.6 Questions
8.7 Suggested readings

8.0 OBJECTIVES :

After reading this unit, you will the able to know

About major psychosis, schizophrenia.

About the positive, negative and other symptoms of
schizophrenia.
The other psychotic disorders related to schizophrenia
schizophreni form disorder, schizoaffective disorder, delusional
disorder and grandiose delusion.

8.1 INTRODUCTION :

One of the common psychotic disorders is schizophrenia,

more common in men than women. It is a puzzling disorder where
sometimes patient think and communicate clearly and is related
with reality. Sometimes thinking and speech are disorganised and
there is no touch of reality. It is more common in men than women
and their is a strong evidence for a genetic transmission of this
disorder. Structure of brain, prenatal environment and birth
complications may result in this disorder. DSM-IV recognises two
main symptoms of schizophrenia- positive and negative. Type I
 150

symptoms (positive) include unusual perceptions, thoughts and

behaviours. Type II symptoms (negative) represent loss or absence
of behaviours. As this disorder is a complex one, psychologist
believe that there are different types of schizophrenias. Five major
types of Schizophernia include are paranoid schizophrenia,
disorganised schizophrenia, catatonic schizophrenia,
undifferentiated schizophrenia and residual schizophrenia.

8.2 CHARACTERISTICS OF SCHIZOPHRENIA :

The term psychotic has been used to characterise many

unusual behaviours, although in its strictest sense it usually
involves delusions (which involve irrational beliefs) and / or
hallucination (experiencing things through the scenes in the
absence of any external events such as hearing voices.
Schizophrenia in just one of the disorders that involve psychotic
behaviour .

Process disrupted by schizophrenia include those that

involve thought, our perception of the world, our emotions and even
how we move.

DMS- IV has a multiple part process for determining whether

some one does or does not have schizophrenia.

Psychologists in this field typically distinguish between what

are called positive and negative symptoms of schizophrenia.
Positive symptoms refer to more active manifestations of abnormal
behaviour or an excess of distortion of normal bahaviours, these
include delusions, hallucinations and disorganised speech.
Negative symptoms involve deficit in normal behaviour or such
dimensions as affect speech and motivation. A diagnosis of
schizophrenia requires that two or more of these positive and/or
negative symptoms are present for at least one month.

POSITIVE SYMPTOMS OF SCHIZOPHRENIA

(a) Delusions
A belief that would be seen by most of members of a society
as a misrepresentation of reality is called a disorder of thought,
content as a delusion. Because of its importance in schizophrenia
delusions has been called as basic characteristic of madness. If for
example, you belief that squirrels really are aliens sent to earth on a
reconnaissance mission, this belief would be considered a
delusion.
 151

Delusions are difficult to believe (like house will fall resulting

in death of person). Individual experiencing it are preoccupied with
them.
Common types of delusions are
i) Persecutory delusions
ii) Delusions of reference
iii) Grandiose delusions
iv) Delusions of thought insertions

i) Persecutory Delusions :- Individual suffering from these

delusions constantly feel that they are being watched or tormented
by people whom they know such as professors (in case of
students), CBI who are involved in hard core crime or any other
authoritative figure.

ii) Delusions Reference :- Individual suffering from this type of

delusion believe that random events, comments passed by others
are aimed at them. People with delusion of reference may feel that
a politician is trying to harm him personally through speech.

iii) Grandiose Delusions :- Individual suffering from this

delusion feel that they are special person and have magic powers.
They may consider them selves as the most intelligent, insightful
and creative person on planet earth. They may think that they are
great historical characters and think they have discovered the cure
of an incurable disease.

iv) Delusion of Thought Insertions :- Individual suffering from

this delusion feel that their thoughts are being controlled by out side
forces (e.g., serial killers or terrorists).

An intriguing view of delusion in that they may serve a

purpose for people with schizophrenia, who are otherwise quite
upset by the changes, talking place within themselves. The
delusions may serve as adaptive function for delusional individuals
is at present just a theory with little support, but it may help us
understand this phenomenon and the reactions to it expressed by
those experiencing the delusions.

b) Hallucinations
The experience of sensory events without any input from
surrounding environment is called hallucination. Hallucination can
involve any of the senses, although hearing things that are not
there or auditory hallucination in the most common form
experienced by person with schizophrenia.

Types of Hallucinations :-
i) Auditory Hallucinations
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ii) Visual Hallucinations

iii) Tactile Hallucinations
iv) Somatic Hallucinations
i) Auditory Hallucinations :-
In auditory hallucinations individuals hear heavy voices,
music, different type of noises, which are imaginary and not
existing. Women are more prone to it than men. The schizophrenic
answer the voice back even when in the middle of conversations
with a real person.

ii) Visual Hallucinations :-

An individual suffering from this may see a ghost coming out
of T.V. and talking to him.

iii) Tactile Hallucinations :-

It involves a feeling that some weird thing in happening to
ones body . E.g., insects are crawling allover his body.

iv) Somatic Hallucinations :- It involves feeling that some

thing in happening inside ones body and they are tickling him from
within.

Research on hallucinations suggests that people tend to

experience hallucination more frequently when they are unoccupied
or restricted from sensory input . By studying cerebral blood flow
using single photon emission computed tomographty (SPECT).
scientists of London have discovered that the part of the brain most
active during hallucinations was the area called Brocas area.
Brocas area is involved in speech production.

If hallucinations involves understanding the speech of

others, you might expect more activity in the area of the brain that
involves language comprehension, on area called Wernicks area.
Research establishes that during hallucination Brocas is more
active than Wernicks area. This observation of brain activity during
hallucinations supports a theory that the people who are
hallucinating are in fact not hearing the voices of others but instead
are listening to their own thoughts or voice and can not recognise
the difference.

c) Disorganised speech :-

People with schizophrenia often lack insight that they have

disease. They experience associative splitting and cognitive
slippage. DSM IV has used the term disorganised speech to
describe these problems with communications.

The most commonly found disorganised tendency in to slip

from one topic to a totally unrelated topic. There in no association
 153

between topics discussed by them. This is also known as

derailment of thought. When questioned the schizophrenic person
may give a totally unrelated reply. At times schizophrenic quote
words that have some meaning only to them. Such words are
known as neologisms. They also associate the words on the basis
of its sounds rather than meaning. Such associations are known as
clangs. e.g., dog may be called spog and cat as meaw.

Sometimes the person may repeat the same word again and
again by stressing on particular word.

Men with schizophrenia show greater tendency of language

deficit as compared to women. Men have limited linguistic
resources to overcome their problems.

Grossly Disorganised or Catatonic Behaviour :-

People with schizophrenia engage in a number of other

active behaviours that might be considered positive symptoms. For
example, catatonia in one of the symptoms present in some
individual with schizophrenia. It involves a spectrum of motor
dysfunctions from wild agitation to immobility.

Schizophrenic are unpredictable, suddenly react in an

agitated manner. They may suddenly shout, swear and wander
about up and down the street alone. They may tend to engage in
an embarrassing behaviour by acting in a socially disapproved
manner, like publicly masturbating. Their daily routines are
disturbed, where they do not care for themselves, showing
carelerneres in eating, dressing, oral hygiene, etc.

Catatonic behaviour too in seen in patients of schizophrenia.

Catatonia in referred to as a group of disorganised behaviours that
reflect an extreme lack of responsiveness to the out side world.
Catatonic excitement involves extreme uncontrollable agitation
expressing a number of delusions and hallucinations.

NEGATIVE SYMPTOMS OF SCHIZOPHRENIA

In contrast to the active presentations that characterise the

positive sysptoms of schizophrenia, the negative symptoms usually
refer to the absence or insufficiency of normal behaviour and
include emotional and social withdrawal, blunted effect, apathy, and
poverty of thought or speech.

(a) Flat Affect :- Approximately two thirds of the people with

schizophrenia exhibit what in called flat affect. They do not show
emotions. They may stare at you with vacant eyes, speak in a flat
and toneless manner and seems to be unaffected by things going
 154

an around them. This condition in also known as blunted affect. The

person remains in a freezed condition most of the time. They are
extremely unresponsive to the events around them. The flat affect
in schizophrenia may represent the persons difficulty with
expressing emotion and an inability to feel the emotion.

(b) Avolition :-
Derived from the prefix a meaning Without and volitions
which mean am act of willing, choosing or deciding. Avolition is an
inability to initiate and persist in many important activities. It is also
referred to as apathy, people with this symptom show little interest
in even the most basic day-to-day activities, including personal
hygiene. Avolition in an inability to be committed to a common goal
directed activity. Schizophrenic are unmotivated, disorganised and
careless in the task that they undertake.

(C) Alogia :-
It refers to the relative absence in either the amount or the
content of speech. The word derives from the combination of a
(without) and logos (word). A person suffering with alogia may
respond the question with very brief replies that have little content
and many appear disinterested in the conversation.

This deficiency in communication by some people with

schizophrenia in believed to reflect a negative thought disorder
rather than an in adequacy in communication skills. Some times
alogia takes the form a delayed comments or slow response to the
questions. Trying to talk to people suffering with alogia is very
frustrating.

OTHER SYMPTOMS OF SCHIZOTHRENIA

Some symptoms of schizophrenia are not prominently seen

in all cases but they do frequently occur in schizophrenic as
follows-

(a) Inappropriate Affect :- The schizophrenic patients may

react with an inappropriate emotion to a particular action, e.g.,
individual may cry when it is time to laugh and vice-versa.

(b) Anhedonia:- It is derived from the word bedonic, pertaining

to pleasure. It refers to the presumed lack of pleasure experienced
by some people with schizophrenia. Individuals with anhedonia
report loss of enjoyment for activities that would typically be
considered, pleasurable, including eating, social relations, sexual
interactions, etc. Anhedonia in the inability to experience emotions.
They lack feeling of both happy and sad emotions.
 155

(c) Impaired Social Skills :- Most of the schizophrenic

patients show poor social skills, such as difficulty in maintaning
conversation, job and relationship.

CHECK YOUR PROGRESS -

1. Discuss the positive symptoms of schizophrenia.

2. Explain the negative symptoms of schizophrenia.
3. What are the other symptoms of schizophrenia.

8.3 OTHER PSYCHOTIC DISORDERS (THE

SCHIZOPHRENIA SRECTRUM DISORDERS)

(a) Schizophreniform Disorder- Some people experience the

symptoms of schizophrenia, but for only a few months. These
symptoms disappear quickly, often for unknown reasons, and the
person can usually resume his or her life as before. Such
symptoms would the classified under the lable Schizophreniform
disorder. There are few studies on this disorder, therefore, data on
important aspects of it are sparse. It appear, however, that the
lifetime prevalence is approximately 0.2% (American Psychiatric
Association, DSM IV, 1994).

(b) Schizoaffective Disorder The symptoms of schizophrenia

coincides with symptoms of depression or mania, but there is at
least a two week period when only symptoms of schizophrenia are
present. The person exhibits symptoms of both schizophrenia and
mood disorders and this mixed bag of symptoms is now diagnosed
as schizoaffective disorder. These individuals tend not to get better
on their own and are likely to continue experiencing major life
difficulties for many years.

(c) Delusional Disorder - The major feature of delusional

disorder is a persistent delusion or belief that is contrary to reality.
These persistent delusion is not the result of an organic factor such
as brain seizures or any severe psychotic disorder. Individual with
these delusions tend not to have most of the other problems
associated with schizophrenia. They may become socially isolated
 156

because of their suspicion of others. DSM IV divides the

delusions in different types

i) Persecutory Delusion - False belief that oneself or ones loved

ones are being persecuted watched, or conspired against by
others.

ii) Grandiose Delusion - False belief that one has great power,
knowledge, or talent or that one is a famous and powerful person.

iii) Delusion of Reference - Belief that random events are directed

at oneself.

iv) Delusions of being Controlled Belief that ones thoughts,

feelings, or behaviours are being imposed or controlled by an
external force.

v) Thought Broadcasting Belief that ones thoughts are being

broadcast from ones mind for others to learn.

vi) Thought Insertion Belief that another person or object is

inserting thoughts into ones head.

vii) Thought Withdawal Belief that thoughts are being removed

from ones head by another person or an object.

viii) Delusion of Guilt or Sin False belief that one has

committed a terrible act or is responsible for a terrible event.

ix) Somatic Delusion False belief that ones appearance or part

of ones body is diseased or altered.

(d) Brief Psychotic Disorder - This disorder shows the

presence of one or more positive symptoms such as delusions,
hallucinations, or disorganised speech or behaviour over the course
of less than a month. This disorder is precipitated by extremely
stressful situations.

(c) Shared Psychotic Disorder It is a name given to a

condition in which an individual develops delusions simply as a
result of a close relationship with a delusional individual. The
content and nature of the delusion depends on the delusion of the
partner and can range from the relatively bizarre, such as believing
that enemies are sending gamma rays through your house to less
bizarre, such as believing that you are about to receive a major
promotion.
 157

CHECK YOUR PROGRSS

1. Explain any two other Psychotic Disorders.

2. Discuss Schizophreniform Disorders.
3. Explain different types of delusions found in delusional disorder.

8.4 SUMMARY

Schizophrenia is a type of psychosis which is very common.

It is more common in men than in women.

There are mainly two types of clinical symptoms of this

disorder negative and positive symptoms.

Positive symptoms include delusions, hallucinations,

disorganised thought and speech, disorganised or catatonic
behaviour.

Delusions are ideas that an individual believes are true but

are highly unlikely and often simply impossible. There are different
types of delusions Persecutory delusions, delusions of reference,
grandiose delusions and delusions of thought insertion. People with
persecutory delusion may believe they are being watched or
tormented by people they know. People with delusion of reference
believe that random events or comments by others are directed at
them. people with delusions of thought believe that their thought
are controlled by others. People with grandiose delusions believe
that they are special person with special powers. Negative
symptoms of schizophrenia are affect flattening alogia and
avolition. Affect flattening is a severe reduction or absence of
affective responses to the environment. Alogia is reduction in
speaking. Avolition is an inability to persist at common, goal
directed activities.

Other symptoms are inappropriate affect, anhedonia and

impaired social skills. Other types of schizophrenia are paranoid
schizophrenia, disorganised schizophrenia, catatonic
schizophrenia, undiffentiated schizophrenia, residual schizophrenia.
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8.5 GLOSSARY

1. Affect subjective aspect of an emotion that accompanies an

action at a given time.
2. Anhedonia inability to experience pleasure.
3. Catatonia immobility or excited agitation.
4. Paranoia persons belief that he/she is especially important or
other people are seeking to harm him/her.

8.6 QUESTIONS

Q.1. Discuss the various characteristics, positive and negative

symptoms of schizophrerina.
Q.2. Discuss the different types of psychotic disorders.
Q.3. Write notes on the following
a) Hallucinations and its types.
b) Types of Delusions.

8.7 SUGGESTED READINGS

1. Oltmanns, T.F. & Emery, R. E. (2010). Abnormal Psychology,

6th ed., New Jersery : Pearson Prentice Hall.
2. Bennet, P. (2003). Abnormal and Clinical Psychology : An
Introductory Textbook Open University Press.

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9
SCHIZOPHRENIA AND RELATED
DISORDERS- II

UNIT STRUCTURE

9.0 Objectives
9.1 Introduction
9.2 Theories of Schizophrenia
9.3 Treatments of Schizophrenia
9.4 The Bio psychosocial perspective
9.5 Summary
9.6 Glossary
9.7 Suggested Readings

9.0 OBJECTIVES

After reading this unit you will know

About different theories or causes of schizophrenia.
About the various treatments available for schizophrenia.
About the bio psychosocial perspective of schizophrenia

9.1 INTRODUCTION

Schizophrenia is characterised by a broad specturm of

cognitive and emotional dysfunctions that include symptoms of
delusions, hallucinations, disorganised speech and behaviour and
inappropriate emotions. A number of causative factors have been
implicated for schizophrenia including genetic, neurotransmitters
imbalances, structural damage to the brain and psychological
stressors.

Different biological theories such as Dopamine theory,

structural abnormality, etc, proves the genetic causes of this
disorder Psychological theories such as psychodynamic, expressed
emotions, etc, gives the causes of this disorder. Social and cross
cultural theories proves the social factors as the causes of
schizophrenia. Two approaches to treatments biological and
psychosocial are recommended for this disorder. But these
 160

treatments have limited effects as schizophrenia is a chronic

disorder.
9.2 THEORIES OF SCHIZOPHRENIA

Many people studied this disorder and have given their

analysis and interpretation. All these theories are classified into
two broad categories

1. Biological Theories
2. Psycho social Theories

Biological theories are sub divided into several categories

1. Genetic Influences on Schizophrenia.

2. Neurotransmitters
3. Structural Brain Abnormality
4. Birth complications
5. Prenatal Viral Exposure

1) Genetic Influences on Schizophrenia

Genes are responsible for making some persons vulnerable
to schizophrenia. To examine the evidence of genetic vulnerability
many studies on family, twin, adoption, linkages has been done.

a) Family Studies
Franz Kallmann (1938) in his research showed that severity
of the parents disorder influenced the likelihood of the childs
having schizophrenia. All forms of schizophrenia (for example,
catatonic paranoid) were seen within the families. A person may
inherit a general predisposition for schizophrenia that may be same
or different from that of his parent.

The risk of having this disorder varies according to how

many genes a preson shares with some one who has the disorder.
For example a person will have the greatest chance ((approx 48%)
of having this disorder if he has an identical twin who has
schizophrenia. The risk drops to about 17% in case of fraternal
twins.

b) Twin Studies
Gottesman (1991) has reported that monozygotic twins have
higher possibility of suffering from schizophrenia as compared to
dizygotic twins. 46% of monozygotic twins have concordance rate
where as 14% was found for dizygotic twins.

c) Adoption Studies
A study carried out by Leonard Heston (1966) on adoption,
found that 17% of the adopted children of parents with
 161

schizophrenia developed the disorder in their adulthood. Kety

(1994) found that biological relative of adoptees were 10 times
more likely to have a diagnosis of schizophrenia as compared to
biological relatives of adoptees who did not have this disorder.

2) Neurotransmitters
Various theories has studied the interlink between
schizophrenia and the neurotransmitter dopamine. Davis, Kahn,
Ko, and Davidson (1991) found that there is a strong relatation
between dopamine and schizophrenia. The dopamine system is too
active in person with this disorder. The drug phenothiazines or
neuroleoptics reduces the dopamine levels and calms down the
symptoms accordingly. High number of neuronal receptors for
dopamine in certain brain areas and high level of a by product of
dopamine named homovamilic (HVA) in the blood and
cerebrospinal fluld is reported to be the cause of schizophrenia.

But recent studies suggest that neurotransmitters other than

dopamine are instrumental in causing this disorder. New theories
suggest that excess dopamine activity in the mesolimbic system,
the area which controls human cognition and emotions, has a
major, role in determining schizophrenia. Other studies suggest that
deficiencies in neurotransmitters named Gluamate and GABA,
widely spread in the nervous system are suspected to cause
schizophrenia, thus leading to severe cognitive and emotional
malfunctioning.

3) Structural Brain Abnormality

There are some structural brain abnormalities which lead to
schizophrenia. Modern medical equipments like PET, CAT scans,
MRI scans, etc, shows that structural abnormalities of brain can
result in this disorder.

Enlarged Ventricles
The ventricles are fluid-filled space in the brain. When the
ventricles are enlarged the blood tissues starts detoriating. It has
been seen that schizophrenics having enlarged ventricles also
show deterioration of the whole matter, i.e., prefrontal areas of the
brain and abnormal link between the pre-frontal cortex and the
amygdala and hippocampus. The patients having enlarged
ventricles show poor tendencies of social, emotional and other
behavioural issues even before the full ouset of schizophrenia.

Brain areas such as frontal cortex, temporal lobe, basal

ganglia, limbic system, thalamus, amygdala are vital in determining
schizophrenia. Studies shows that if the volume, density and
metabolic rate in the neurons of these areas follow an abnormal
pattern then the person may suffer from this disorder.
 162

Lower level of frontal cortex activity is mostly found in

schizophrenics with negative symptoms.

3) Birth Complications -
Prenatal development and complications during birth also
influences the possibilities of schizophrenia due to neurological
damage and dysfunction. Delivery complications and oxygen
deprivation to the baby, during labour and delivery, can give rise to
neurological vulnerability, thus further leading to schizophrenic
tendencies. Study show that 39% of people with schizophrenia
reported to have a history of prenatal hypoxia. (deprivation of
oxygen at birth).

4) Prenatal Viral Exposure

There are evidences that a virus like disease may account
for some cases of this disorder (Kirch, 1993). Studies have shown
that persons whose mothers were exposed to influenza during the
time of pregnancy were much likely to have schizophrenia than
others (Cannon, Barr & Mednick, 1991). Influenza affects the fetal
brains in this way that this damage causes the behaviours that
characterize people with schizophrenia. Disruption of brain cells
and malformation of central nervous system of the unborn baby
may result in major structural deficits that are similar to the brains of
people with schizophrenia.

2) Psycho- Social Theories

There are many perspectives which throws light on the
psychosocial aspects in the development of schizophrenia. Few of
them are-
a) Psychodynamic Perspective
b) Communication Patterns
c) Expressed Emotions
d) Stress and Relapse
e) Behavioural and Cognitive Perspective
f) Cross Cultural Perspective
a) Psychodynamic Perspective
Sigmund Freud (1924) in his psychodynamic theory
suggested that negative childhood experiences may result in
schizophrenia in a person. Poor parenting may place additional
strain on a vulnerable person already at risk for schizophrenia.
Freud said that when mothers behave extremely harsh towards
their child and when they do not express love to their child then the
child regresses and shows infantile tendencies while carrying out
the daily functioning. This becomes unhealthy for the Ego to
discriminate between reality and unreality. Freida Formm
Reichmann (1948) pointed out that poor parenting can affect the
mental state of a child. Two contrasting situation were a mother is
over protective on one side and at the same time questioning the
 163

child about his well-worth. This leads the child in state of confusion,
worthlessness and despair. It may lead to disturbed and illogical
ego that may result in tendencies of schizophrenia.
b) Communication Patterns
Bateson (1959) introduced the term double bind which
portrays a type of communication style that produces conflicting
messages, which in turn, causes schizophrenia to develop. If the
parent communicates messages that have two conflicting meanings
(for example, a mother responding coolly to her childs embrace,
but saying Dont you love me anymore? when the child withdraws.
Such children get sensitive to the contrasting remarks and distrust
their own feelings and perceptions of the world. It may result in
developing fake views of themselves, of others and of the
environment, which may contribute to schizophrenia.

A higher level of communication deviance was found in

families with schizophrenia. If children having a family history of
schizophrenia are exposed to communication deviance patterns
they face more risk to develop schizophrenia (Goldstein 1987).

c) Expressed Emotions
One area researchers have focused on a particular
emotional communication style of few families which is referred to
as Expressed Emotions (E E). This concept was given by George
W. Brow and his colleagues in London. The researchers studied a
sample of people discharged from the hospital after an episode of
schizophrenia. They found that former patients with less family
contact did better than the patients who spent long periods of time
with their families (Brown,1959). The cause was that the level of
criticism (expressing disapproval), hostility (expressing animosity),
and emotional overinvolvement (being intrusive) by the families was
high, patients tended to relapse (Brown Monck & Wing 1962). Jill
Hooley (1985) have found that ratings of high expressed emotion in
a family are a good predictor of relapse among people with
schizophrenia (almost 3.7 times more likely to relapse). An analysis
of 27 Studies reveals the fact that the relapse rate of schizophrenia
in high expressed emotion families were 70% as compared to
31% of relapse cases in patients from low expressed emotion
families.

d) Social Circumstances
According to Dohrenmed et al (1987), people suffering from
this disorder are more likely to be exposed to chronically stressful
circumstances. They may live in low income and low status
occupations neighborhood.

The social selection explanation states that schizophrenic

people are unable to continue education or job and so automatically
slides down the economic ladder. Lewis et. al (1992) stated that
 164

there is a link between Urban lifestyle and this disorder.

Schizophrenia and other psychosis are seen to be prevailing largely
in big cities than small towns.
e) Stress and Relapse
Researchers have studied the effects of a variety of
stressors on schizophrenia. Dohrenwend and Egri (1981) observed
that otherwise healthy people who engage in combat during a war
(an extremely stressful situation) often display temporary symptoms
resembling schizophrenia. Brown and Birley (1968, 1970) found
that people showing early symptoms of this disorder tended to have
a high number of stressful life events in the 3 weeks just before
they started showing the signs of the disorder.

Ventura, Lukoff and Hardesty (1989) studied 30 people who

has onsets of schizophrenia. 11 of the 30 people had significant
relapse in which the symptoms returned or worsened. It was found
that people who had relapsed experienced an increase in stressful
life events in the month before their relapse. Social withdrawal is
one of the prominent causes of schizophrenic relapse. Job loss,
relationship problems, etc; are caused because of this disorder.
These things may lead to social withdrawal, which can result in
relapse.

f) Behavioural and Cognitive Causes

Belcher (1988) studied that schizophrenia can develop
through operant conditioning under normal circumstances. In case
of people with schizophrenia, the basic training for operating over
environment is missing. Because of inadequate parenting or due to
some unfortunate circumstance they learn irrelevant, inappropriate
and socially unacceptable responses towards others around them.

According to Belcher (1988) if the family members ignore

reacting to illogical and inappropriate behaviour that the
schizophrenic people show, then he develops operant conditioning.
Cognitive theorists considered that schizophrenia in caused
because of lack of basic perceptual and intentional skills. Delusions
are formed due to irrelevant misinterpretation of the information
attended and perceived in a distorted manner. For example, if a
schizophrenic person report his hallucination to which his family
members may neglect or reject. This in turn can, be misinterpreted
by the patient that his family members have teamed up with
invisible force to harm him. This may give rise to paranoid beliefs in
the person with schizophrenia.
g) Cross Cultural causes
Different cultures and societies have different viewpoint
related to this disorder. Most cultures explain this disorder as a
biological issue, a disorder which runs in the families. Sometimes
lack of spiritual inclination and family interactions can also cause
 165

the symptoms of this disorder. Living in more critical and hostile

cultures may provide additional stressors that can in turn lead to
more relapses.
Check Your Progress-

1. Explain the different causes of schizophrenia?

2. What are the biological causes of schizophrenia?
3. How the socio cultural environment affects the symptoms of
schizophrenia?

9.3 TREATMENT OF SCHIZOPHRENIA

1. BIOLOGICAL TREATMENT :

DRUG THERAPY

Over the centuries, many treatments for this disorder have

been developed, based on the scientific theories of the time.

During the 1930s, one approach used massive doses of

insulin the drug used to treat diabetes to induce coma
deliberately in people suffering from schizophrenia. It was called
Insulin coma therapy, which has great risk of serious illness and
death. During this time, Psychosurgery, including prefrontal
lobotomies, was introduced, and in the late 1930s,
electroconvulsive therapy (ECT) was used as a treatment for this
disorder. A break through in this field came in 1950 with the
introduction of many drugs called neuroleptics. It helped the
patient to think clearly, reduce or eliminate the hallucinations and
delusions and was effective on the positive symptoms. Because of
the side effects of this drug such as grogginess, blurred vision,
dryness of the mouth, slow motor activities, etc., most of the
patients refuse to take it. New medicines, such as, Clozapine is
widely used and results in fewer negative side effects.
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2. PSYCHO SOCIAL TREATMENTS OF SCHIZOPHRENIA

Psychological and social interventions helps them to cope

more effectively with their families, job and medical aspects.

1. Behavioural Cognitive and Social interventions -

Behavioural interventions includes social learning theory,

operant conditioning and modeling. It teaches the patients essential
skills such as initiating and maintaining conversations with others,
asking for help or information from the doctor, etc . The therapist
and family members can reinforce socially appropriate behaviour
by giving attention and positive emotional responses. Sometimes
token economy is used in hospitals, based on the principles of
operant conditioning. Patients earn tokens, which they can
exchange for privileges, such as time for watching television, walks,
etc.

Cognitive interventions includes helping the patients to

recognise demoralising attitudes and change them. This helps the
patients to mix in society and learn new life skills for healthy
functioning and adaptations in ones environment.

Social interventions include increasing the social interaction

between patients and supportive others or self-help support groups.
These groups meet to discuss the impact of the disorder on their
lives, frustration, fears of relapse, experiences and other concerns
of daily life. They help each other by giving feedback, solving
problems, etc.

2. Family therapy -

Family members are trained to deal with the patient in the

family. They are made aware of the causes of this disorder,
symptoms and the side effect of the drug therapy. This helps the
family members to reduce self blame and tolerate while adjusting
with the patient. Rash, unhealthy and rude interactions are reduced
and good communication skills are taught.

3. Assertive Community Treatment Programs

Many people with schizophrenia do not have families who

can care for them. Even those who do have families have such a
wide array of needs for the monitoring and adjustment of their
medications, occupational training, assistance in getting financial
resources (such as social security and medications), social skills
training, emotional support, and some times basic housing that
 167

comprehensive community based treatment programs are

necessary. Assertive community treatment programs provide
comprehensive services to people with schizophrenia, using the
expertise of medical professionals, psychologists to meet the
variety of patients needs 24 hours a day.

Other comprehensive treatment programs provide skills

training, vocational rehabilitation and social support to people with
schizophrenia who are living at home. Studies of these prograoms
find that they reduce the amount of time spent in the hospital by
people with schizophrenia and as a result, can be cost effective.
(Bastille et al, 2001). In a model program established in Madison,
Wisconsin, by founders of the assertive community program
movement (Test & Stein, 1980), mental health professionals
worked with chronically disabled schizophrenics.

1. To help them gain material resources for food shelter,

clothing and medical care.
2 To help them gain coping skills to meet the demands of
community life, such as using public transportation,
preparing simple but nutritious meals and budgeting money.
3. To lessen their dependency on family members.
4. To educate family and community members about the kind
of support they need.

4. Cross Cultural treatments -

Traditional Healers

The symptoms of schizophrenia are sometimes treated by

folk or religious healers, according to the cultural beliefs about the
meaning and causes of these symptoms.

Anthropologists and cultural psychiatrists have described

four models that traditional healers tend to follow in treating
schizophrenic symptoms.

1. According to the structural model, there are interrelated

levels of experience, such as the body, emotion cognition, as
well as the person, society and culture. Symptoms arise
when the integration of these levels is lost. Healing thus
involves reintegrating these levels, through changes in the
client, or environment, or both and / or the prescription of
herbal medicines, or rituals.
2. The social support model holds that symptoms arise form
conflictual social relationships and that healing involve
mobilising a patients kin to support him or her through this
 168

crisis and reintegrating the patient into a positive social

support network.
3. The persuasive model suggests that rituals can transform
the meaning of symptoms for the patient, diminishing the
pain of the symptoms.
4. Clinical model, it is simply the faith that the patients puts in
the traditional healer to provide a cure for the symptoms.

Check Your Progress-

1. Discuss the Assertive Training Programs to help a patient?

2. What are the psycho social treatment of schizophrenia?

9.4 THE BIOPSYCHOSOCIAL PERSPECTIVE

The biological theories believes that there are genetic basis

of this disorder. Family, twin, adoption studies shows the genetic
cause of this disorder. Brain abnormality, prenatal environment and
neurotransmitters, etc., also play an importent role. Psychodynamic
perspective stresses on negative childhood experiences and faulty
parenting. Faulty communication patterns, over expressed
emotions, stress and relapse can result in schizophrenia. Age,
gender and cross cultural or social factors plays an influencing role.
Poor neighborhood, lower socioeconomic status, social widrawal,
etc., can be the causes of this psychosis. Cross-cultural
perespective explains that in majority of the cultures, this disorder is
considered biological or genetic. This perspective also emphasises
on spiritual indignation and family interaction.

9.5 SUMMARY

Schizophrenia is characterized by a broad spectrum of

cognitive and emotional functions, that include delusions,
hallucinations, disorganised speech and behaviour and
inappropriate emotions.

The symptoms are divided into three categories positive,

negative and others. DSM IV divides this disorder into five
 169

subtypes paranoid type, disorganised type, catatonic type,

undifferentiated type and residual type of schizophrenia. Genetic
influences, neurotransmitter imbalances, structural damage, viral
infections can be the biological causes of the disorder. Relapse
appears as a result of hostile and critical family environment .

Treatment includes drug therapy, family therapy, community

help and social interventions.
9.6 GLOSSARY

1. Alogia Deficiency in the amount or content of speech.

2. Anheedonia inability to experience pleasure.
3. Delusion disorder of thought content and presence of strong
belief that one misrepresentations of reality.

9.7 SUGGESTED READINGS

1. Balow, D. H. & Durand, V. M. (2005) Abnormal Psychology An

integrative approach, New Delhi.
2. Bennet, P. (2003). Abnormal and Clinical Psychology An
Introduction Textbook. Open university Press.

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10
PERSONALITY DISORDERS I

Unit Structure :

10.0 Objectives
10.1 Introduction
10.2 Nature of Personality Disorder
10.3 Antisocial Personality Disorder
10.4 Borderline Personality Disorder
10.5 Histrionic Personality Disorder
10.6 Narcissistic Personality Disorder
10.7 Summary
10.8 Questions
10.9 References

10.0 OBJECTIVES

After studying this unit you should be able to:

a) Understand the nature, definition and features of Personality

disorders.
b) Know the classification of Personality Disorders.
c) Comprehend the characteristics of Antisocial Personality
Disorder as well as Theories and Treatment of Antisocial
Personality Disorder.
d) Know the Characteristics of Borderline Personality Disorder
as well as Theories and Treatment of Borderline Personality
Disorder.
e) Explain histrionic and narcissistic personality disorders.

10.1 INTRODUCTION

In this unit we will first define personality disorder and

discuss its nature, characteristics as well as classification of
personality disorders. Personality Disorder, initially called as
character disorders, is defined as "those characteristics that are
inflexible and maladaptive and cause either significant functional
 171

impairment or subjective distress. Personality disorders are

classified in to 10 different types. In this unit we will discuss cluster
B disorders. The two most important of these disorders include the
Antisocial Personality Disorder and the Borderline Personality
Disorder. We will also discus its characteristic features, theories as
well as treatment. Following this we will discuss the histrionic
personality disorder as well as narcissistic personality disorder.

10.2 NATURE OF PERSONALITY DISORDERS

Personality disorders are a separate group of disorders

which are completely different from major disorders, anxiety
disorders and other related disorders. Individuals who have
maladaptive personality traits are said to possess personality
disorders. A personality trait can be defined as an enduring
pattern of perceiving, relating to and thinking about the environment
and others, a pattern that is ingrained in the matrix of the
individuals psychological makeup.

Personality Disorders: Personality Disorders are patterns of

behavior that are deeply ingrained and are manifested primarily as
exaggerations. The category of Personality Disorder is relatively
new. It was introduced by the American Psychiatric Association's
Classification in its first Diagnostic and Statistical Manual (DSM-I)
(1952). Before the publication of this manual, personality disorders
were largely termed as "Character Disorders".

DSM-IV- has defined Personality Disorder as "those

characteristics that are inflexible and maladaptive and cause either
significant functional impairment or subjective distress. Generally
these are life long patterns often recognizable by the time of
adolescence or earlier. Personality Disorders were classified on a
separate Axis. i. e., Axis II for the first time in DSM-III. Personality
Disorders are a heterogeneous group of deeply ingrained, usually
life-long, maladaptive patterns of behavior in which there was an
absence of true neurotic or psychotic symptoms. Although these
persons cause themselves and others much unhappiness, their
behavior is usually Egosyntonic and there is little motivation for
change (Arkem 1981).

In conclusion, we can say that Personality Disorders are

learned life-long consistent patterns of characteristic behavior
which impair an individual's occupational, interpersonal and social
functioning, and which lead to problematic behavior both for the
individual and for those around him.
 172

Personality disorders involves a long-lasting maladaptive

pattern of inner experience and behaviour dating back to
adolescence or young adulthood that is manifested in atleast two of
the following areas: (i) Cognition, (ii) Affectivity, (iii) Interpersonal
functioning, (iv) Impulse control. Some important features of
personality disorders are as follows:

1. The have an inflexible pattern of interaction with others that

causes considerable distress and impairment either to
themselves or to others.
2. Their problems involve excessive dependency,
overwhelming fear of intimacy, intense worry, exploitative
behaviour or uncontrollable rage. These individuals are
usually unhappy and maladjusted.
3. It is the most challenging of the psychological disorders to
treat.
4. The lifetime prevalence of personality disorders in the
population ranges from 1-3 Percent, with higher prevalence
seen in people with clinical settings. Estimates of prevalence
vary according to age and socio-demographic factors.
5. Personality disorders are most commonly diagnosed among
younger individuals, students and unemployed homemakers.
6. The prevalence of personality disorders is higher among
individuals who have alcohol and drug abuse disorders.
7. Diagnosis of personality disorders is difficult because many
personality disorders have similar features.

10.2.1 Classification of Personality Disorders: DSM IV TR

has classified personality disorders in to three categories covering
a total of 10 personality disorders which are listed in the following
table.
Cluster B Disorders
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Cluster A Disorders
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Cluster C Disorders
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive Compulsive Personality Disorder
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In this unit we will discuss Cluster B disorders. Individuals

having this cluster of disorders have in common a tendency to be
dramatic, emotional and erratic. Their impulsive behavior often
involving antisocial activities is more colorful, more forceful and
more likely to get them into contact with mental health or legal
authorities than the behavior characterizing disorders in either
Cluster A or Cluster C disorders.

10.3 ANTISOCIAL PERSONALITY DISORDER

This disorder has been known since a long time but different
labels were used to refer to this disorder. This is relatively one of
the most studied and researched disorders. In this disorder the
rights of others are violated. Individuals with this disorder find
themselves in confrontation with the laws and norms of society.
This disorder was earlier called as Sociopath or Psychopath.

10.3.1 Characteristics of Antisocial Personality Disorder:

This disorder was first recognized by Philippe Pinel as a

form of madness in which individuals exhibited impulsiveness and
destructive behaviour disorder while maintaining rational thought.
Some important characteristic of this disorder are as follows:

1. People with this disorder wreck havoc in society and for this
reason they have been the focus of great deal of research.
2. The life time prevalence of this disorder is 4.5 percent of the
adult males and 0.8 percent of the adult females (Robins and
Regier, 1991).
3. Hervey Cleckley (1941) in his work The Mask of Sanity, made
the first scientific attempt to list and categorise the behaviour of
psychopathic personality. Cleckley developed a set of criteria
for Psychopathy (which is today called as antisocial personality
disoreder). He identified more than a dozen criteria which
constitutes the core of antisocial personality disorder. Harvey
Cleckly identified 16 traits that he found was common in these
individuals. These are as follows:

i. Superficial charm of good intelligence

ii. Absence of delusions and other signs of irrational
thinking.
iii. Absence of. Nervousness or psychoneurotic
manifestations.
iv. Unreliability.
v. Untruthfulness and insincerity.
vi. Lack of remorse or shame.
 174

vii. Inadequate motivated antisocial behavior.

viii. Poor judgment and failure to learn from experiences.
ix. Pathological egocentricity and incapacity for love.
x. General poverty in major effective reactions.
xi. Specific loss of insight.
xii. Unresponsiveness in general interpersonal relations.
xiii. Fanatic and uninviting behavior with drink and some
times without.
xiv.Suicide rarely carried out.
xv. Sex life impersonal, trivial and poorly integrated.
xvi.Failure to follow any life plan.

4. Cleckley used the term Semantic Dementia to capture the

psychopaths inability to react appropriately to expressions of
emotionality. Cleckleys notion of psychopathy remains a key
concept in descriptions of antisocial personality disorder.
5. Building on Cleckleys work Canadian psychologist Robert D
Hare (1997) developed an assessment instrument known as the
Psychopathy Checklist Revised (PCL R) which has two
factors: a) Core Psychopathic Personality Traits and b)
Antisocial Lifestyle. The core personality traits include glibness
and superficial charm, a grandiose sense of self-wroth, a
tendency towards pathological lying, a lack of empathy for
others, a lack of remorse and unwillingness to accept
responsibility for ones action. The antisocial lifestyle traits
revolve around impulsivity, a characteristics that can lead to
behaviours expressed in an unstable lifestyle, juvenile
delinquency, early behavioural problems, lack of realistic long-
term goals and a need for constant stimulation. Robert Hare et
al (1989), elaborated on the work of Cleckly and developed a
20-item checklist that serves as an assessment tool. Six of the
criteria that Hare (1991) included in his Revised Psychopathy
checklist are as follows:
Grandiose sense of self-worth
Lack of remorse
Glibness/superficial charm
Proneness to boredom/need for stimulation
Pathological lying
Conning/manipulative

6. The DSM IV TR diagnostic criteria for this disorder also

includes behavioural aspects of the disorder such as
disreputable or manipulative behaviours. There is a difference
between the DSM-IV criteria of Antisocial Personality Disorder
and the Cleckley/Hare criteria. While the former focuses on
observable behavior the latter focuses primarily on the
underlying personality traits.
 175

7. Individual having antisocial personality disorder show a

pervasive disregard for the rights of others as shown by such
behaviours as lawlessness, deceitfulness and impulsivity. They
do not show any signs of remorse when they behave
impulsively, recklessly and aggressively. Occasionally they may
demonstrate feign remorse with the intention of coming out of
the difficult situation.
8. These individuals are smooth talkers who are able to get what
they want by presenting themselves in a favourable light.
9. It should be remembered that not all individuals having
antisocial personality disorder are criminals. The term criminal is
a legal connotation. Many qualities of the antisocial personality
disorder are reflected in acts that would not be considered as
violations of the law, such as job problem, promiscuity and
aggressiveness.
10. Research studies have shown that under controlled young
children i.e., children who are impulsive, restless and distractible
are more likely to meet the diagnostic criteria for antisocial
personality disorder and to be involved in crime as adults.
11. Though, today we have a good understanding of the
predisposing factors that lead to antisocial personality disorder,
we have less knowledge about the long-term prospects of
individuals having antisocial personality disorder.
12. Personality disorder, especially antisocial personality disorder
reduces as one reaches middle adulthood years and beyond.
This is called a maturation hypothesis, which means that
individuals having this disorder are better able to manage their
behaivours as they age.

10.3.2 Theories and Treatment of Antisocial Personality

Disorder: Wide varieties of theories have been developed to
explain the causation of Antisocial Personality Disorder. Some of
the most important theories are discussed below.

Biological Perspectives: Biological perspectives emphasis on the

role of brain pathology, genetic factors and related cause. Brief
descriptions of biological causes are as follows:

Brain abnormalities: Individuals having antisocial personality

disorder have certain brain abnormalities. MRI studies have
revealed that they have difficulty processing conceptually abstract
verbal information (Kiehl et al 2004).They also show deficits in
emotional processing during juvenile years. It has also been
observed (Goethals et al 2005) that individuals having antisocial
personality disorder have deficits in prefrontal lobes of the cerebral
 176

cortex an area of the brain involved in planning future activities

and in considering the moral implications of ones actions.

Individuals having antisocial personality disorder also show

amygdala dysfunction as well as have dysfunction in the
hippocampus regions.

Genetic Causes: Genetic influences have been found to play an

important role in the development of this disorder. Family, twin, and
adoption studies all suggest a genetic influence on both Antisocial
Personality Disorder and criminality. A comparison of the adopted
children of Felons along with the adoptive children of normal
parents, carried out by Crowe (1974) revealed that adopted off
spring of felons had significantly higher rates of arrests, conviction
and Antisocial Personality than did the adoptive offspring of normal
mothers. This suggests that in the development of Antisocial
Personality Disorder and criminality genetic influences play a
dominant role. Crowe (1974) also pointed out that genetic influence
is more likely to act when certain type of environment is available.
Though genetic factors provide vulnerability, actual development of
criminality will depend upon a particular type of environment.

In a similar study Cadoret et al (1995) found that if the

childrens biological parents had a history of Antisocial Personality
Disorder and their adoptive families exposed them to chronic stress
through marital, legal or psychiatric problems, the children were at
greater risk for conduct problems.

Twin studies also strongly support the view that genetic

influence plays an important role in the development of criminality.
Eysenck and Eysenck (1978) found that the average concordance
rate for criminality among Monozygotic (MZ) twins was 55%,
whereas, among Dizygotic it was only 13 %.

Strong evidence in favour of inheritance of antisocial

personality disorder comes from a study of more than 3200 male
twin pairs (Lyons et al, 1995). Recently Button et al (2005) have
pointed out that those individuals who are genetically predisposed
to antisocial personality disorder may be particularly vulnerable to
family dysfunction, supporting the noriton of gene-environment
interaction.

Psychological Perspectives: According to this perspective

Antisocial personality disorder is a result of neuropsychological
deficits reflected in abnormal patterns of learning and attention.
According to David Lykken (1957), psychopathic individuals failed
to show the normal response of anxiety whey they are subjected to
aversive stimuli. Psychopathic individuals are unable to feel fear or
anxiety.
 177

Deficient emotional arousal: Research evidence indicates

that a primary reaction tendency typically found in antisocial
individuals is a deficient emotional arousal; this condition
presumably renders them less prone to fear and anxiety in stressful
situations and less prone to normal conscience development and
socialization. In an early study, for example, Lykken (1957)
concluded that anti-social individuals have fewer inhibitions about
committing antisocial acts because they suffer little anxiety.

Response Modulation Hypothesis: This hypothesis proposes

that psychopaths are not able to process any information that is nor
relevant to their primary goals. Individuals having antisocial
personality are unable to think about someone elses needs when
focused on ones personal needs. The "response modulation"
hypothesis, postulates that psychopaths have difficulty shifting their
attention from the performance of a behavior to an evaluation of its
consequences

Social Cognitive theory is another psychological perspective

which emphasizes that low self esteem is a causal factor in
antisocial personality disorder.

Socio-cultural Perspectives: Social cultural factors emphasizes

on the role of family, early environment and socialization
experiences that lead individuals to develop psychopathic lifestyle.
Anti-social personality is thought to be more common in lower
socioeconomic groups. Lee Robins (1966) found that children of
divorce generally develop antisocial personality disorder. Research
studies have revealed that disharmony between parents lead to
development of antisocial personality disorder. Poor child rearing
practices and inconsistent discipline also contribute to development
of antisocial personality disorder. Luntz and Wisdom (1994) found
that abused and neglected children often develop antisocial
personality disorder when they grow up. These individuals have 50
% more arrests for violent crimes as compared to control group
individuals. Strangely research studies have also found that
malnutrition in early life may serve as another risk factor for the
development of antisocial personality disorder. Children who
between the ages of 03 years and 17 years experienced poor
nutrition showed more aggressiveness and motor activity as they
grew up.

10.3.3 Treatment of Antisocial Personality Disorder: Antisocial

behavior is difficult to treat. People with this disorder do not change
easily. They are unlikely to seek professional help voluntarily,
because they see no reason to change. If they do see a clinician, it
is often because treatment is mandated by a court order.The
prognosis of this disorder is highly poor. This disorder can be
 178

prevented during childhood if certain steps are taken. One such

step is Parent Training. In this type of training parents are taught to
recognize behavior problems early and how to use praise and
privileges to reduce problem behavior and encourage prosocial
behavior. A good parenting skill is one of the prerequisites for
effectively retarding the development of antisocial personality
disorder. The client should be taught to feel remorse and guild for
their behaviour, when they learn these, they start showing change
in behaviour. Psychotherapy for people with Antisocial Personality
Disorder should focus on helping the individual understand the
nature and consequences of his disorder so he can be helped to
control his behavior. Exploratory or insight-oriented forms of
psychotherapy are generally not helpful to people with Antisocial
Personality Disorder

10.4 BORDERLINE PERSONALITY DISORDER

Borderline personality disorder is characterized by a

pervasive pattern of instability, most evident in relationships, mood
and sense of identity. The term borderline has been in use in the
psychiatric literature since a long time, but it was only with the DSM
III that this term received official recognition for the first time. Stern
(1938) used it as a catchall term to refer to treatment-resistant
clients. Knight (1953) regarded such individuals to be functioning
somewhere between border of neurosis and psychosis, on the
edge of schizophrenia. Many scholars regard it as a variant of
schizophrenia or mood disorder or possibly a hybrid.

10.4.1 Characteristics of Borderline Personality Disorder:

Some important characteristic features of Borderline Personality
Disorder are as follows:

i. Individuals with this disorder often experience a distinct kind of

depression that is characterized by feeling of emptiness. They
often vacillate between extreme emotional states, one day
feeling on the top of the world and the next moment feeling
depressed, anxious or irritable.
ii. People with this disorder suddenly form intense demanding
relationships with others and to perceive other people as being
all good or all bad a phenomenon called as splitting.
iii. The inappropriate intensity of their relationship results in
recurrent experiences of distress and rage. People with this
disorder experience anger and hostility.
iv. Their interpersonal relationships are always disturbed
v. They also experience identity problems. They are often
confused about their identity as to who they are. They are
unsure of what they want out of life and lack a firm grasp of
 179

their sense of self. Their uncertainty about who they are may
be expressed in sudden shifts in life choices such as career
plans, values, goals and types of friends.
vi. They experience chronic feelings of boredom, which make
them seek stimulation. In order to overcome boredom they
may indulge in impulsive behaviour such as promiscuity,
careless spending, reckless driving, binge eating, substance
abuse, shoplifting, etc.
vii. They often indulge in suicidal thinking and self-injurious
behaviour. They indulge in suicide behaviour only to get
attention from others a phenomenon called parasuicide.
viii. They often explode in rage when they experience neglect and
abandonment by their lover or some important person in their
life.
ix. They are highly sensitive to stress and often break down
displaying brief psychotic reactions in the presence of intense
stressful situations.
x. Individuals with borderline personality disorder show a pattern
of behaviour that resembles features of both the personality
disorder and some of the more severe psychological disorder,
particularly the affective disorders and schizophrenia.
xi. People with borderline personality disorder suddenly move
from anger to deep depression. They are also characterized
by impulsivity, which can be seen in their drug abuse and self
mutilitation.
xii. Mood disorder is common among individuals having borderline
personality disorder, about 24% to 74 % of the individual
having this disorder also has major depression and about 4 %
to 20 % have bipolar disorder. About 25% of the bulimics also
has this disorder.
xiii. Although they are usually aware of their circumstances, and
surroundings, borderline personalities may have short
episodes in which they appear to be out of contact with reality
and experience delusions or other psychotic-like symptoms,
such as recurrent illusions, magical thinking, and paranoid
beliefs (O'Connell et al, 1989).\
xiv. Individuals with borderline personalities are frequently
impulsive and unpredictable, angry, empty, and unstable.
xv. They typically display intense anger outbursts with little
provocation, and they may show disturbance in basic identity
that preoccupy them and produce a basically negative outlook.
xvi. They have chronic feeling of boredom and a low tolerance for
frustration. Their extreme instability is reflected in drastic
mood shifts and erratic self- destructive behaviours, such as
 180

binges of gambling, sex, alcohol use, eating, or shoplifting.

They commonly have a history of intense but stormy
relationship, typically involving over idealisation of friends or
lovers that later end in bitter disillusionment and
disappointment (Gunderson & Singer, 1986).
xvii. Feeling slighted, they might, for example, become verbally
abusive towards loved ones or might threaten suicide over
minor setbacks.
xviii. Suicide attempts, often are often manipulative, are frequently
part of the clinical picture (Fine & Sansone, 1990), and self-
mutilation is one of the most discriminating signs for borderline
personality (Widiger et al, 1986).
xix. Clinical observation of people whose behaviour meets the
criteria of borderline personality disorder points strongly to a
problern of achieving a coherent sense of self as a key
predisposing causal factor.
xx. These people somehow fail to complete the process of
achieving an articulated self-identity and hence do not really
become individual. This lack of individualisation leads to
complication in interpersonal relationships.

10.4.2 Theories and Treatment of Borderline Personality

Disorder: This is one of the most challenging disorders as
individuals suffering from it create chaos in their lives as well as
those of others with whom they interact. This disorder evolves as a
result of combination of vulnerable temperament, traumatic early
experiences in early childhood and certain triggering events in early
adulthood

Biologic al Perspectives: Most theories regarding causation of

this disorder is psychological in nature, though psychologists have
attempted to identify biological correlates of psychological factors
thought to be involved in the development of this disorder. One set
of biological factors involved in the causation of this disorder is
neurotransmitter dysregulation. For Example sexual abuse in the
childhood influences the noradrenergic (sympathetic nervous
system \) pathways and makes them hypersensitive, so that an
individual is primed to overreact to experiences of any kind later in
childhood. This altered sympathetic system functioning predisposes
an individual towards impulsivity, due to abnormalities in the
serotonergic receptors in the brain.

MRI studies (Driessen at al 2000) comparing the brains of

women having Borderline Personality Disorder with control
subjects have revealed that the hippocampus was 16 percent
smaller and amygdala was 08 percent smaller among women
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suffering from Borderline Personality Disorder as compared to

normal healthy control subjects.

Psychological Perspectives: Most adults with Borderline

Personality Disorder show a family history of extreme negative
experiences within the family. Three important factors that have
emerged as important in the development of Borderline Personality
Disorder are as follows:

a) Disturbed childhood family environment

b) Parental psychopathology
c) Child abuse

It has been observed that child sexual abuse is the most

important significant predictor of Borderline symptomatology. Early
child abuse experiences cause children to expect that others will
harm them. Zanarini et al (1997) found that people with Borderline
Personality Disorder reported that their caretakers withdrew from
them emotionally, treated them inconsistently, denied the validity of
their thoughts and feelings and did not carry out their roles as
parents in terms of providing them with protection from abuse. It
has also been found that individuals with Borderline Personality
Disorder experience:

a. Deficits in the formation of self

b. Have a mother who is uninvolved with her child and
inconsistent in her emotional responsiveness.
c. Parents do not bolster the childs independent sense of
self.
d. As children such individual perceive other people in a
distorted way and builds a false self that is fused with
distorted perceptions of the self.

Beck and other cognitive theorists have observed that

people having Borderline Personality Disorder have a tendency to
dictomise their thinking about themselves and other people, they
think in terms of all or nothing. Such type of thinking leads to shift
in moods. For example, individuals with Borderline Personality
Disorder display splitting, which means that if individuals with this
disorder originally perceive someone as all good, and that person
fails to follow through on a promise, the person immediately is
perceived as all bad.
People with Borderline Personality Disorder are not realistic
while evaluating themselves. Even on minor ground their entire
self-evaluation becomes negative. A low sense of self-efficacy
related to their weak identity causes a lack of confidence in their
decisions, low motivation and an inability to seek long-term goals.
 182

Socio-cultural Perspectives: According to Millon and Davis

(1996) pressures of the contemporary society have placed a strain
on families and individuals which in turn has exacerbated the
deficient parenting that has given rise to this disorder.
Individuals with Borderline Personality Disorder are highly
vulnerable to reduced cohesion in society that is a result of
urbanization and modernization in the contemporary society. Their
lack of psychic cohesion is a reflection of instability within society
and lack of clearly defined cultural norms and cohesion. According
to Goldman et al, 1993, family difficulties, including depression,
substance abuse and antisocial behaviour lead to development of
this disorder. According to Stone (1990) an adult with Borderline
Personality Disorder who was abused as a child, passes on this
pattern of parenting to the next generation, who then become
vulnerable to developing this disorder.

10.4.3 Treatment of Borderline Personality Disorder: Treatment

of Borderline Personality Disorder poses number of challenges to
the clinicians. Some of the important points to be noted with respect
to the treatment of this disorder are as follows:

1. The treatment of this disorder is highly difficult as, according to

Million, (2000) these individuals often appear to be more
healthy at first glance than they really are.
2. These individuals do not remain in therapy for a long time and
they often drop out of therapy due to their volatility,
inconsistency and intensity.
3. Individuals with this disorder commonly become pathologically
dependent upon their therapist, as a result they may feel
uncontrollably enraged when the therapist fails to live up to their
idealization.
4. According to Goin (2001) in the treatment of the clients with this
disorder it is important to establish clear treatment framework by
discussing and clarifying treatment goals as well as the roles
that the clients and therapists are expected to play.
5. Therapist must also determine the extent to which these
patients need support and confrontation
6. One of the most systematically developed therapeutic approach
to treat individuals having this disorder is the Dialectical
Behaviour Therapy developed by Marsha Linehan. This
approach integrates supportive and cognitive behavioural
treatments to reduce the frequency of self-destructive acts and
to improve the clients ability to handle disturbing emotions,
such as anger and dependency. The term dialectical refers to
systematically combining opposed ideas with the goal of
reconciling them. The therapists strategy is to alternate
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between accepting clients as they are and confronting their

disturbing behaviour to help them to change. Some specific aim
of this therapy includes:

i. Regulating emotions
ii. Developing interpersonal effectiveness
iii. Learning to tolerate emotional distress
iv. Developing self-management skills

One technique used by therapists practicing Dialectical

Behaviour Therapy is called as core mindfulness in which the
clients are taught to balance emotions, reason and intuition in their
approach to lifes problems.

vii. Another approach to treat individuals having Borderline

Personality Disorder is called as Transference Focused
Psychotherapy. In this approach the therapist deals with
dominant affect laden themes that emerge in relationship
between the client and therapist. In this approach the therapist
uses techniques of clarification, confrontation and
interpretations of the transference in the here and now of the
therapeutic relationship
viii. Medication is often used as an adjunct to therapy. Some
medication has been found to be effective in treating specific
symptoms. Wide ranges of medications have been used and
these include: antidepressants, antipsychotics, anticonvulsants,
lithium and minor tranquilizers. When ever these medications
are used, they should be prescribed with careful assessment of
specific symptoms.
ix. In severe cases of Borderline Personality Disorder, effective
treatment can only be given in an inpatient or partial
hospitalization setting. This approach is more appropriate when
the patient displays: sucidial behaviour, attempts or threats,
psychotic like episodes, threat or harm to others, etc.

10.5 HISTRIONIC PERSONALITY DISORDER

The term histrionic is derived from the latin word meaning

actor. People with this disorder display theatrical qualities in their
everyday behaviour. One important characteristic that differentiates
individuals with this disorder from those who show appropriate
emotionality is the fleeting nature of their emotional states and their
use of excessive emotions to manipulate others rather than to
express their genuine feelings.
 184

This disorder is more commonly diagnosed among women.

Some important characteristics of this disorder are as follows:
1. Individuals with this disorder enjoy being the centre of attention
and behave in whatever way necessary to ensure that this
happens.
2. They are very much concerned with their physical appearances,
often trying to draw attention to themselves in extreme ways.
3. These individuals are likely to be seen as flirtatious and
seductive, demanding the reassurance, praise and approval of
others and they become furious if they do not get it.
4. These individuals seek immediate gratification of their wishes
and overreact to minor provocations, usually in exaggerated
ways, such as weeping or fainting.
5. Their relationships are superficial. They are easily influenced by
others, lack analytical ability and often see the world in broad
impressionistic ways.
6. People who are in relationships with individuals having this
disorder often feel frustrated and unsatisfied.
7. Individuals having this disorder have an insecure attachment
type style.
8. These individuals often exhibit dependence and helplessness
and are quite gullible. Their sexual adjustment is usually poor
and interpersonal relationships are stormy. In their interpersonal
relationships they are over concerned about approval from
others. Their cognitive style is impressionistic. They view
situations in a very global, black and white term.
9. Not much research has been done with respect to causes or
treatment of histrionic personality disorder. This disorder co-
occurs with antisocial personality disorder. This association has
led to the suggestion that Histrionic Personality Disorder and
Antisocial Personality Disorder may be sex typed alternative
expressions of the same unidentified underlying conditions.
10. Not much work has been done with respect to the treatment of
this disorder. It has been pointed out that modifying attention-
seeking behavior will help to reduce this disorder. A large part of
therapy for these individuals usually focuses on the problematic
interpersonal relationships. These individuals need to be taught
how the short term gains derived from their faulty interaction can
create problems for them.
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10.6 NARCISSISTIC PERSONALITY DISORDER

Sigmund Freud described narcissistic Individuals as one

who shows an exaggerated sense of self- importance and a
preoccupation with receiving attention. It has been pointed out that
grandiosity was the most stable and generalizable orientation for
diagnosing narcissistic patterns. The narcissistic personality
disorder is more frequently observed in men than in women.

People with this disorder expect others to compliment them

and gratify all their wishes and demands. They lack sensitivity to
the needs of others. They are preoccupied with and driven to
achieve their own goals, even to the extent of exploiting others.
These individuals often experience self-doubt inspite of grandiosity.
Million and his colleagues (2000) identified four subtypes of this
disorder:

Elitist Narcissistic: These individuals feel privileged and

empowered and tend to flaunt their status and achievements.
They are upwardly mobile, they engage in self-promotion and
tries to cultivate special status and any opportunity to be
recognized.
Amorous Narcissistic: These individuals are sexually seductive,
but they avoid real intimacy. Such individuals are especially
drawn to tempting, nave and emotionally needy people.
Unprincipled Narcissistic: These individuals are very much like
antisocial individuals. They are unscrupulous, deceptive,
arrogant and exploitative.
Compensatory Narcissistic: These individuals tend to be
negativistic. They often create an illusions of being superior and
exceptional.
The traditional psychoanalytic approach regards narcissism
as failure to progress beyond the early stages of psychosexual
development. Object relations approach views this disorder to be a
result of disturbances in parent-child relationships. Disturbed
parent-child relationship leads to faulty development of sense of
self. Every child needs parents to provide reassurance and positive
response to accomplishments. In the absence of these, the child
becomes insecure and this insecurity is expressed, paradoxically
as an inflated sense of self-importance that can be understood as
an individuals attempt to makeup for what was missing early in life.
Narcissistic personality disorder is viewed as the adults expression
of childhood insecurity and the need for attention.

10.7 SUMMARY
 186

Personality disorder is a separate group of disorders. In

DSM IV these disorders are coded on a separate Axis II. They are
regarded as being different enough from the standard psychiatric
syndromes to warrant separate classification. Personality Disorders
are learned life-long consistent patterns of characteristic behavior
which impair an individual's occupational, interpersonal and social
functioning, and which lead to problematic behavior both for the
individual and for those around him. After defining personality
disorders, some important features of this group of disorders were
discussed in brief.
DSM IV TR has classified personality disorders in to three
categories covering a total of 10 personality disorders. In this unit
we had briefly discussed Cluster B Disorders, which included
Antisocial Personality Disorder, Borderline Personality Disorder,
Histrionic Personality Disorder and Narcissistic Personality
Disorder.

Theories and Treatment of Antisocial Personality Disorder as

well as Theories and Treatment of Borderline Personality Disorder
were discussed in detail.

10.8 QUESTIONS

1. Define Personality Disorders and discuss the various features of

Personality Disorders.
2. Discuss the Classification of Personality Disorders.
3. Explain the Characteristic features of Antisocial Personality
Disorder
4. Discuss the various Theories and Treatment of Antisocial
Personality Disorder
5. Discuss the characteristic features of Borderline Personality
Disorder
6. Discuss the various Theories and Treatment of Borderline
Personality Disorder
7. Write short notes on the following:
a. Histrionic Personality Disorder
b. Narcissistic Personality Disorder
 187

10.9 REFERENCES

1. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology:

Clinical Perspectives on Psychological Disorders. (6th ed.).
McGraw-Hill.

2. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.

(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009 by
Dorling Kindersley, New Delhi.

3. Nolen-Hoeksema, S. (2008). Abnormal Psychology. (4th ed.).

New York: McGraw-Hill.

 188

11

PERSONALITY DISORDERS II

Unit Structure:

11.0 Objectives
11.1 Introduction
11.2 Paranoid Personality Disorder
11.3 Schizoid Personality Disorder
11.4 Schizotypal Personality Disorder
11.5 Avoidant Personality Disorder
11.6 Dependent Personality Disorder
11.7 Obsessive-Compulsive Personality Disorder
11.8 Personality Disorder: The Biopsychosocial Perspective
11.9 Summary
11.10 Questions
11.11 References

11.0 OBJECTIVES

After studying this unit you should be able to:

understand the various personality disorders such as
Paranoid Personality Disorder, Schizoid Personality
Disorder, Schizotypal Personality Disorder, Avoidant
Personality Disorder, Dependent Personality Disorder and
Obsessive-Compulsive Personality Disorder
Comprehend the biopsychosocial perspective of personality
disorder.

11.1 INTRODUCTION

In this unit we will discuss the paranoid personality disorder.

Individuals with this disorder are extremely suspicious of others and
are always on the guard against potential danger or harm.
 189

Following this we will discuss the Schizoid Personality Disorder as

well as the Schizotypal Personality Disorder. These two disorders
involve disturbances in personality that have schizophrenia-like
qualities but do not take on the psychotic form seen in
schizophrenia. It is a part of the schizophrenia spectrum disorders
implying that these two disorders are related to schizophrenia.

The next disorder that we would discuss includes the

Avoidant Personality Disorder as well as the Dependent Personality
Disorder. People having avoidant personality disorder are shy and
are often worried about committing some social blunder and
appearing foolish n front of others. They are also terrified by the
prospect of being publicly embrrassed. On the other hand
individuals with dependent personality disorder are strongly drawn
to others. They have a strong need that others should take
responsibility for them and are unable to decide for themselves.

Lastly, we would discuss obsessive compulsive personality

disorder. Individuals having this disorder are overwhelmingly
concerned about neatness and the minor details of everyday life.

Towards the end of this unit we will discuss the

biopsychosocial perspective. This perspective, as discussed in an
earlier chapter, takes in to account the biological, psychological and
social factors in the development of a given disorder. According to
this perspective any disorder is a combination of and integration of
many causes and no one cause can explain the causation of a
given disorder.

11.2 PARANOID PERSONALITY DISORDER

Individuals with paranoid personality disorder are extremely

suspicious of others and are always on the guard against potential
danger or harm. Their world view is very narrow and they are
always on the look for confirmation that others are taking
advantage of them. They may accuse a partner or spouse of being
unfaithful, even when there is no evidence for the same. They are
hostile to those who criticize them. They misconstrue innocent
comments and minor events as having threatening contents. They
draw wrong inferences. Their emotional life is constrained and
isolated. Individuals having this disorder have problematic
relationships. They generally keep other people at a distance
because of irrational fears that others will harm them. They are
particularly sensitive to people in position of power. They have a
fearful attachment style. They think and behave in ways that are
unrelated to their environment. They refuse to seek professional
help as they dont acknowledge the nature of their problems.
 190

According to Psychodynamic theorists, individuals having

paranoid personality disorder heavily uses defense mechanisms of
projection. They consider that other people rather than they
themselves have negative or damaging motives.

According to Cognitive Behavioural theorists, such as Beck

(2004) individuals with paranoid personality disorder suffers from
mistaken assumptions about the world. They attribute personal
problems and mistakes to others. According to Cognitive
Behavioural theorists three basic mistaken assumptions that
individuals with this disorder have are as follows:

People are malevolent and deceptive

They will attack you if they get the chance
You can be OK only if you stay on your toes

The treatment of Paranoid Personality Disorder is the most

difficult one. These individuals are highly resistant to change, as
they cannot form any trusting relationship even with a therapist.
The dropout rate, for such disorder, in treatment is very high and
the prognosis for this disorder is poor. Some recent research has
suggested that cognitive therapy to overcome an individuals
mistaken assumptions is of considerable help. The cognitive
behavioural therapist attempts to increase the clients feelings of
self-efficacy, so that the client feels able to handle situations
without resorting to a defensive and vigilant stance. It should be
remembered that direct confrontation with the paranoid client
usually backfires, because the client is likely to construe this as yet
another attack.

11.3 SCHIZOID PERSONALITY DISORDER

Schizoid personality disorder is characterized by an

indifference to social and sexual relationships, as well as a very
limited range of emotional experience and expressions. Individuals
with this disorder prefer to be with themselves rather than with
others. They lack desire to be accepted or loved even by their
family members. They are not interested in sex. They are basically
insensitive to feelings and thoughts of others. They are cold,
reserved, withdrawn and seclusive. They seek out situations in
which there is minimal interaction with others. They have problems
in employment and they do not retain jobs for a long period of time.
They generally do not seek psychotherapy.

According to some experts nutritional deficiency during the

prenatal period is one of the risk factors leading to development of
schizoid personality disorder by age 18 years.
 191

Treating people with schizoid personality disorder is

extremely difficult because they lack the normal patterns of
emotional responsiveness that play a role in human
communication. Individuals with this disorder do not on their own
seek treatment except when they are facing a crisis situation.
Therapeutic efforts, with this disorder consist in teaching them the
following skills:

i) Importance of social relationship as well as

developing and or maintaining good social
relationships.
ii) Teaching them certain skills of empathy.
iii) Developing social skills in them.
iv) Therapist should teach certain skills to these
individuals through role-playing.

The prognosis of this disorder is not good.

11.4 SCHIZOTYPAL PERSONALITY DISORDER

Individuals having schizotypal personality disorder are

peculiar eccentric and oddly bizarre in the way they think, behave
and relate to others, even in how they dress. Their peculiar ideas
include magical thinking and belief in psychic phenomenon such as
clairvoyance and telepathy. They have unusual perceptual
experiences in the form of illusions. Their speech is coherent, but
the contents of speech are strange to others. Their affect is
constricted and inappropriate. They are often suspicious of other
people and may have ideas of reference. They are unable to
experience pleasure and their lives are characterized by blandness
that robs them of the capacity for enthusiasm. These individuals
find it difficult to form close relationships with others.

The most important characteristics of these individuals

include social isolation, eccentricity, peculiar communication and
poor social adaptation. The symptoms of schizotypal personality
disorder represent a latent form of schizophrenia. People with
schizotypal personality disorder are vulnerable to developing a full
blown psychosis .if exposed to difficult circumstances that
challenge their ability to maintain contact with reality

Medical treatment of this disorder is very similar to that of

schizophrenia. The most commonly used drug in the treatment of
this disorder is Haloperidol. Individuals, when put on this drug
show improvement with ideas of reference, odd communication and
social isolation.
 192

The psychosocial treatment consists of teaching these

individuals social skills to help them and reduce their isolation from
others.

Very few controlled studies concerning the treatment of this

disorder is available.

Individuals with this disorder tend not to improve over time

and some move on to develop schizophrenia.

11.5 AVOIDANT PERSONALITY DISORDER

Individuals having avoidant personality disorder refrain form

social encounters, especially avoiding situations in which there is a
potential for personal harm or embarrassment. Individuals with this
disorder are extremely sensitive to the opinion of others and
therefore avoid them. Some important characteristic features of
individuals having this disorder are as follows:

These individuals are hypersensitive to rejection and

apprehension of any sign of social derogation. Their sensitivity
to rejection causes them to misinterpret even neutral and
positive remarks in a different manner.
Individuals having this disorder readily see ridicule or
disparagement where none was intended.
These individuals are too fearful of criticism. They view even a
slight remark or personal comment as a form of extreme
criticism.
Their self-esteem is very low and their fear of social rejection
makes them less friendly to others.

This disorder shares some characteristics with schizoid

personality disorder. In both disorders, the person tends to stay
away from intimate relationships. However persons with avoidant
personality disorder truly desires closeness and feels a great deal
of emotional pain about the seeming inability to make connections
with others. According to some scholars avoidant personality
disorder is a more severe form of social phobia

Causes: Millon (1981) has pointed out one psychosocial theory of

the development of this disorder. According to him individuals with
this disorder may be born with a difficult temperament or
personality characteristic, as a result their parents may reject them
or at least not provide them with enough early uncritical love. This
rejection in turn, may result in low self-esteem and social alienation.
Another group of researcher found that individuals having this
 193

disorder had parents who were more rejecting, more, more guilt
engendering and less affectionate than the control group.
According to psychodynamic writers individuals having this disorder
have a fear of attachment in relationships. Cognitive behavioural
approaches regard this disorder as hypersensitive to rejection due
to childhood experiences of extreme parental criticism. These
individuals have dysfunctional attitudes that they are unworthy of
other peoples regard. As a result of this attitude they view
themselves as unworthy and they expect that other people will not
like them and as a result they avoid getting close to other people.

Treatment: As compared to other personality disorders, there are a

number of well-controlled studies on approaches to therapy for
people with this disorder. Behavioral intervention techniques for
anxiety and social skills problems have had some success. Since
the problems experienced by people with avoidant personality
disorder resemble those of people with social Phobia, many of the
same treatments are used for both the groups. It has also been
found that systematic desensitization as well as behavioral
rehearsal works better with this group of individuals. The prognosis
for this disorder is generally poor. Therapist treating this personality
disorder must have considerable patience and attempt to build a
strong therapeutic relationship.

11.6 DEPENDENT PERSONALITY DISORDER

These individuals are highly dependent on others even for

making ordinary day-to-day decisions. Individuals having this
disorder are perceived to be clingy
Some important characteristic features of this disorder are as
follows:

These individuals show extreme dependence on other people

and acute discomfort on being alone. Without others near them
they feel abandoned and despondent. They often have the fear
that close ones will leave them.
In their interpersonal relationship they are timid, submissive and
passive.
These individuals usually build their lives around other people
and subordinate their own needs to keep these people involved
with them.
They lack self-confidence and feel helpless even when they
have actually developed good work or other competencies.
These individuals typically appear selfless and bland, since they
usually feel they have no rights to express even mild
individuality.
 194

Individuals with this disorder are very much similar to those

having avoidant personality disorder with respect to their
feelings of inadequacy, sensitivity to criticism and need for
reassurance.
Their extreme dependence upon others causes them to urgently
seek another relationship, when one breaks, to fill the void.

Causes and Treatment: Early socializing experiences and child

rearing practices contribute towards the development of this
disorder. According to psychodynamic writers individuals with this
personality disorder have regressed to or have become fixated at
oral stage of development because of parental overindulgence or
neglect of dependency needs. According to Object Relations
theorists such individuals are insecurely attached and constantly
fear abandonment. According to them, individuals having this
personality disorder have low self esteem and rely on others for
guidance and support.

The treatment literature on this disorder is largely

descriptive. Very little research is available as to whether a
particular treatment is effective or not. A therapist should take care
to see to it that the patient does not become overly dependent on
him or her. Unlike most other personality disorder, the prognosis of
this disorder is more optimistic and hopeful. Most people with this
condition are motivated to change. Structured approach and
guidance to become more independent has been found to be
beneficial. Clients must be taught to identify skill deficits and work
on improving those skills.

11.7 OBSESSIVE-COMPULSIVE PERSONALITY

DISORDER

This is the most common personality disorder, commonly

found among men than women. Individuals with obsessive-
compulsive personality disorder are too preoccupied with concern
about neatness. They are unable to take decisions. These
individuals show the following other features:
They are intensely perfectionists and inflexible
They have an inordinate concern with neatness and detail, often
to the point of losing perspective on what is important and what
is not.
People with this disorder have a poor ability to express
emotions and they have few intimate emotions.
People with this disorder are unproductive and their pursuit of
perfection becomes self -defeating rather than constructive.
 195

These individuals have a fixation on things being done the

right way. They have a preoccupation with details and perfection
that very often interferes with their normal functioning. Individuals
with obsessive-compulsive personality disorder show excessive
concern for rules, orders, efficiency and work, coupled with an
insistence that everyone do things their ways.

Individuals having this disorder are unable to, express warm

feelings. Such individuals tend to be over inhibited, over conscious,
over dutiful and rigid and to have difficulty relaxing or doing
anything just for fun. They are usually preoccupied with trivial
details and poor allocation of time.

Obsessive-compulsive personalities have whole lifestyles

characterized by obstinacy and compulsive orderliness. Although
they may be anxious about getting all their work done in keeping
with their exacting standards, they are not anxious about their
compulsive self.

Causes and Treatment: Some researchers have pointed out that

there may be a weak genetic contribution to this disorder. Freud
believed that the obsessive-compulsive style represented fixation at
or regression to the anal stage of psychosexual development.
According to cognitive behavioural therapy people with this disorder
have unrealistic expectations about being perfect and avoiding
mistakes. Their feelings of self worth depend on their behaving in
ways that conform to an abstract ideal of perfectionism. If they fail
to achieve that ideal they regard themselves as worthless.

Not much information is available with respect to the

treatment of this disorder. Behavioral techniques including
systematic desensitization and behavioral rehearsal and some
conditioning reinforcement techniques work better with them.
Therapists must help these individuals to relax or use distraction
techniques to redirect their compulsive thoughts. Some therapists
use more traditional behavioural techniques, such as thought
stopping instructing the client to reduce the amount of time spent
in ruminative worry.

11.8 PERSONALITY DISORDER:

THE BIOPSYCHOSOCIAL PERSPECTIVE

This perspective views a given disorder to be a combination

of biological, psychological and social perspective. People who
have a borderline personality disorder require a combination of
treatment approaches which includes biological, psychological and
social interventions. Biopsychosocial perspective views personality
disorder to evolve over a period of adulthood and tend to remain
 196

challenging for clinicians and researchers. In the understanding and

treatment of personality disorders integrative view combining the
various perspectives must be taken in to consideration.

11.9 SUMMARY

In this unit we have discussed the various types of

personality disorders listed in cluster A as well as cluster C
Disorders. Some of these disorders include Paranoid Personality
Disorder, Schizoid Personality Disorder, Schizotypal Personality
Disorder, Avoidant Personality Disorder, Dependent Personality
Disorder and Obsessive-Compulsive Personality Disorder. Towards
the end of the unit we have made a mention of Biopsychosocial
perspective. The prognosis of most of these disorders is difficult.

11.10 QUESTIONS

Q.1 Write short notes on the following:

a. Paranoid Personality Disorder
b.. Schizoid Personality Disorder
c. Schizotypal Personality Disorder
d. Avoidant Personality Disorder
e. Dependent Personality Disorder
f. Obsessive-Compulsive Personality Disorder

11.11 REFERENCES

1. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology:

Clinical Perspectives on Psychological Disorders. (6th ed.).
McGraw-Hill.
2. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.
(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009 by
Dorling Kindersley, New Delhi.
3. Nolen-Hoeksema, S. (2008). Abnormal Psychology. (4th ed.).
New York: McGraw-Hill.

 197

12

DEVELOPMENT-RELATED,
AGING-RELATED AND COGNITIVE
DISORDERS - I

Unit Structure
12.0 Objectives
12.1 Introduction
12.2 Introductory Issues
12.3 Mental Retardation
12.4 Pervasive Developmental Disorders
12.5 Attention Deficit and Disruptive Behavior Disorders
12.6 Learning, Communication and Motor Skills Disorder
12.7 Summary
12.8 Questions
12.9 References

12.0 OBJECTIVES

After studying this unit you should be able to understand:

The concept of mental retardation its types, characteristics
and treatment.
Know the pervasive developmental disorders, such as
autistic disorders, Retts disorder, aspergers disorders, etc.
Understand Attention Deficit and Disruptive Behavior
Disorders, its theories and treatment
Comprehend Learning, Communication and Motor Skills
Disorder as well as its theories and treatment

12.1 INTRODUCTION

In this unit we will begin with some introductory issues and

then discuss the concept of mental retardation and the various
types of mental retardation. We will also discuss the characteristics
of mental retardation, its theories and treatment.
 198

Pervasive developmental disorders are another group of

disorders that leads to severe disorder in the area of development.
It influences the social interaction or communication patterns and
leads to odd behaviour, interests and activities. The most common
pervasive developmental disorder is the autistic disorder. We will
discuss the characteristics, theories and treatment of this disorder.
Another group of disorder that has attracted the attention of
psychologists as well as educationists and parents is the Attention-
Deficit and Disruptive Behaviour Disorders. This group of disorders
includes Attention-Deficit and Hyperactivity Disorder, conduct
disorder and oppositional defiant disorder. We would discuss the
theories and treatment of these groups of disorders. Towards the
end of this unit we will discuss the motor skills disorders.

12.2 INTRODUCTORY ISSUES

In this unit we will be discussing some conditions that would

surprise you as to why they are considered as psychological
disorders. Some of you will contend that it is not appropriate to
classify these disorders in the category of psychological disorders.
Some of these disorders that we will discuss in these units actually
represent developmental abberrations rather than psychiatric
abnormalities. For example oppositional defiant disorder that we
will be discussing towards the end of this unit, is often questioned
for being included in the category of psychiatric diagnosis. Since
many of these conditions lead to maladjustment or experiences of
stress it is included in DSM IV as a diagnostic category.

12.3 MENTAL RETARDATION

Mental retardation is one of the common problems of

development. It has not received much attention in India. It is a
condition present from childhood and is characterized by
significantly below average general intellectual functioning (an IQ of
70 and below). Mental retardation is considered to be a specific
disorder, but it may occur in combination with other disorders. In
fact, other psychiatric disorders, especially psychoses (Jacobson,
1990), occur at a markedly higher rate among retarded individuals
than in the general population. It is estimated that approximately 1
% of the population has mental retardation and it is more common
in males. The American Association on Mental Deficiency
(AAMD) has defined mental retardation as significantly sub
average general intellectual functioning existing concurrently with
deficits in adaptive behavior, and manifested during the
developmental period.(AAMD, 1973, p.11).

The incidence of mental retardation seems to increase

markedly at ages 5 to 6, to peak at age 15, and to drop off sharply
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after that. According to DSM-IV there are three groups of criteria for
defining mental retardation:

1. An individual must have significantly sub average intellectual

functioning. On any standard Intelligence test their IQ must be
below 70. It is estimated that roughly about 3% of the population
have low I.Q.

2. Along with low intelligence there must be deficits or impairments

in adaptive functioning.

3. The third most important criteria is the age of onset. That is low
IQ and deficits in adaptive behavior must occur before the age
of 18 years in order to call it mental retardation.

Individuals with mental retardation differ significantly among

themselves. Four different levels of mental retardation have been
identified.

12.3.1 Classification of Mental Retardation by IQ Scores and

Behavioural Competencies: These are four levels of mental
retardation. These are as follows:
1. Mild Mental Retardation
2. Moderate Mental Retardation.
3. Severe Mental Retardation.
4. Profound Mental Retardation.
We would discuss each of them in detail:

1. Mild Mental Retardation:

Large numbers of individuals who suffer from mental
retardation fall into this group.
Mildly retarded individuals have an IQ between 50-70.
They are educable and they can learn academic skills or
study up to 6th or 7th standard.
These individuals can develop social and communication
skills. They have minimal retardation in sensory-motor areas,
often not distinguished until later areas
Their intellectual levels as adults are comparable with those
of average 8 to 11 year old children.
Social adjustment of such people often approximates that of
adolescents. However, they tend to lack normal
adolescents imagination inventiveness and judgment.
Such individuals can be guided towards social conformity.
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Such individuals have no brain pathology or other physical

anomalies. Their retardation is largely due to cultural-familial
factors.
Occupationally, they are independent. They can work and
be financially independent to a limited extent. But in some
cases especially under stress, they require supervised
guidance.
With early diagnosis, parental assistance and special
educational programs, the great majority of borderline and
mildly retarded individuals can adjust socially, master simple
academic tasks and occupational skills and become self-
supporting citizens.

2. Moderate Mental Retardation:

Individuals having Moderate Mental retardation have an IQ
between 35-50
3 to 4 percent of individuals suffering from mental retardation
fall in this group.
Individuals belonging to this group are likely to fall in the
educational category of trainable. They are likely to study
only up to 2nd or 3rd standard.
They can talk or learn to communicate. They have poor
social awareness, fair motor skills. They often benefit from
self-help skills training and require some supervision.
In adult life, individuals classified as moderately retarded
attain intellectual levels similar to those of average 4 to 7
year old children.
Physically such individuals appear clumsy and ungainly and
they suffer from bodily deformities and poor motor
coordination.
Some of these individuals are aggressive and hostile.
These individuals are semi-independent in their occupational
life. With great deal of practice they can be taught
semiskilled manual work like tailoring, carpentry, etc.
Such retardation is also due to cultural familial factors.

3. Severe Mental Retardation:

These individuals are also called as dependent retarded.
Their IQ is within the range of 20-35.
They cannot study at all. They have to be sent to special
schools or given specialised coaching even to learn self-help
skills.
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Among these individuals, motor and speech development is

severely retarded. They have sensory defects and motor
handicaps. Thus, they have poor motor development and
minimal language skills. They learn little communication
skills. They can learn only to talk or communicated using
bare language.
They have limited levels of personal hygiene and self-help
skills. They can profit from systematic habit skills.
Such individuals generally require institutionalisation.
Such individuals can perform simple occupational tasks
under supervision.

4. Profound Mental Retardation:

This is the most severely retarded group.
1% of all the retarded individuals belong to this group.
These individuals have an IQ below 20.
The term life support retarded is sometimes used to refer to
profoundly retarded individuals.
Most of these people are severely deficient in adaptive
behaviour and unable to master any but the simple tasks.
Their speech is rudimentary. They have mionimal capacity
for functioning in sensory-motor areas.
These individuals have physical deformities and Central Nervous System pathology. They
also have convulsive seizures, mutism, etc.
These category of individuals may respond to very limited range of training in self-help.

Such individuals require permanent custodial care.

They have low life expectancy due to low resistance to
disease and poor physical health.

12.3.2 Theories and Treatment of Mental Retardation: Mental

retardation results form inherited conditions or an event or an
illness. Some of the important causes of mental retardation are as
follows:

Inherited Causes: Many inherited factors contribute to

development of mental retardation, some of which are as follows:

i. Phenylketonuria: This is another disorder that leads to mental

retardation. It is a rare genetically related metabolic disorder
that occurs in about 1 in 20,000 births. Dr. Asbjorn Folling
identified PKU in 1934. PKU occurs due to recessive gene. As
a result of this genetic abnormality liver does not produce an
enzyme, which is required to decompose Phenylalanine, an
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amino acid found in many foods. As a result the amount of

Phenylalanime increases in blood and leads to brain damage.

ii. Tay-Sachs disease: It is a metabolic disorder caused by the

absence of a vital enzyme (hexosamindase A or Hex A),
which lead to accumulation of lipid in the nerve cells, leading to
neural degeneration and early death, usually before the age of
05. This disorder is most commonly found among the
descendants of Eastern European Jews.

iii. Fragile X Syndrome: It is another common chromosomal

related cause of mental retardation, especially among the
males. This disorder is caused by an abnormality on the X
chromosome.

iv. Downs Syndrome: It is a chromosomal disorder, which was

first described by Langdan Down in 1866; Down syndrome is
the most common of the clinical conditions associated with
moderate and several mental retardation. A person with the
Downs syndrome has the following characteristics:
Severe to moderate mental retardation (I.Q. is within the
range of 20 to 69 where 100 is the normal)
Obliquely slanted eyes with an extra fold of skin over the
eyelids (hence the name Mongolism)
A round face and short stature
Abnormalities of the skull bones and the jaw and
Short little fingers and other abnormalities of hand and
feet.

Downs Babies are usually quiet and placid and their

mortality rate during infancy is high because so many of them
succumb to respiratory infection and heart malformation.
Chromosomal analysis of individuals with Downs syndrome has
shown that many of them have an extra chromosome in the 21st
pair of the chromosome, i.e. in the twenty first pair instead of two;
there are three chromosomes (thus it is also called as Trisomy-21).
More than 50 percent of people with Downs syndrome have
cataracts, which are not congenital but tend to make their
appearance when a child is about 7 or 8 (Fall, 1970).

Occurrence of Downs syndrome is correlated with

mothers age. It is one birth in 2000 among 25 years old mothers
and one in 40 for women over 45. It has been found that the risk
also rises with fathers age, especially among men over 50 (Abroms
and Benneerr, 1981). DNA analysis has revealed that the extra
chromosome seems to come from the mothers ovum in 95 percent
of the cases (Antonarakis 1991).
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Children suffering from Downs syndrome are usually

able to learn self-help skills, acceptable social behaviour, and
routine manual skills that enable them to be of assistance in a
family or institutional setting. Many individuals with Downs
syndrome are able to support themselves and do well in structured
job situations. Down Syndrome babies, today, can live up to 60
years also.

Downs Syndrome children show their greatest deficit in

verbal and language related skills. Their ability in spatial
relationship and visual motor co-ordination is relatively unimpaired.
They are at special risk of developing Alzheimers disease.

Environmental Causes: Many environmental causes lead to

mental retardation. Some of these causes include:
Exposure to certain drugs
Toxic chemicals
Maternal malnutrition
Infections in the mother during critical phases of fetal
development ( For example it has been observed that
mothers who developed rubella (German Measles) during
the first three months of pregnancy are likely to have child
with mental retardation.
Problems (such ass infections, anoxia lack of oxygen, and
injury to the brain) during babys delivery can cause mental
retardation.
Premature birth
After birth and during childhood mental retardation can be
due to diseases, head injuries caused by accident/s or child
abuse and exposure to toxic substance such as carbon
monoxide, lead, etc.

Fetal Alcohol Syndrome: It is one type of diorder that occurs

when a pregnant women consumes alcohol. About one in 750
individual suffers from FAS. Individuals having this defect have the
following characteristics.
Slowed prenatal and postnatal growth.
Facial and bodily malformations.
Their IQ is in the mildly retarded range.
Disorders of central nervous system such as poor sucking
response, brain-wave abnormalities and sleep disturbance in
infancy, slow information processing, short attention span,
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irritability, hyperactivity, motor impairments, learning disabilities,

etc.
It has also been found that individuals in some cases show fetal
alcohol effects. It is a milder form of FAS in which individual
shows mental retardation, retardation of uterine growth and
minor congenital abnormalities.
They show motor and Cognitive deficits as mentioned above.
Their internal organs may also be affected, particularly the
cardiovascular system.
There appears to be a direct connection between the amount of
alcohol ingested by the mother and the degree of physical and
behavioural problems in the child.
Heavy alcohol intake during pregnancy can also cause a wide
range of neuropsychological deficits, including dysfunction in
visuospatial processing, verbal and non-verbal learning,
attention and executive control proceses.

Treatment: There is no cure for mental retardation. Early

intervention can enrich the intellectual and physical development of
the child. Some individuals with mental retardation can be taught
necessary skills which are required to live as a productive member
of society. With educative intervention early in life children can be
taught to develop better motor abilities, coordination, language
usuage and social skills.

Mainstreaming: It refers to an approach in which individuals with

cognitive and physical disabilities are integrated with nondisabled
individuals. Such individuals participate in ordinary schools and
ordinary environment, but provided with assistance to cope with
any difficulties.

Behavioural Interventions: Behavioural interventions are used to

bring about changes in motor, language, social and cognitive skills.
Parents are taught as to when and how to reward the child if he
displays appropriate and crucial behaviours.

Family Based Interventions: In this approach family issues

related to mental retardation are sorted out. Such interventions
provide support to family members who have to deal with issues of
mental retardation

Public Awareness: Public awareness is required to deal with

mental retardation. One aspect of such awareness is early
detection and guidance to the parents and care givers. For example
early detection of PKU can help to overcome the damaging effects
of mental retardation and in few cases to completely avoid mental
retardation. Early prevention and public awareness also includes
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improving the conditions of prenatal development and making the

birth process safer and simpler. Similarly, community education
programs within specific populations can be influential in changing
alcohol-related behaviours among pregnant women in high risk
groups. Counseling pregnant women who abuse or are dependent
on alcohol or other substances can also help limit the damage to
the developing fetus. Parents should also be made aware as to
how head injuries, high fever during childhood, ingestion of certain
poisonous or toxic substance such as lead, carbon monoxide,
mercury, etc., can lead to mental retardation among children.

12.4 PERVASIVE DEVELOPMENTAL DISORDERS

Pervasive developmental disorders are another group of

disorders that leads to severe disorder in the area of development.
It influences the social interaction or communication patterns and
leads to odd behaviour, interests and activities. The term "pervasive
development disorders," also called PDDs, refers to a group of
conditions that involve delays in the development of many basic
skills, most notably the ability to socialize with others, to
communicate, and to use imagination. Children with these
conditions often are confused in their thinking and generally have
problems understanding the world around them. Because these
conditions typically are identified in children around 3 years of age -
- a critical period in a child's development -- they are called
development disorders. Although the condition begins far earlier
than 3 years of age, parents often do not notice a problem until the
child is a toddler who is not walking, talking, or developing as well
as other children of the same age. One important category of
pervasive development disorders is Autism which we would
discuss.

12.4.1 Autism and Characteristics of Autistic Disorder: Children

with Autism have problems with social interaction, pretend play,
and communication. They also have a limited range of activities
and interests. Many (nearly 75%) of children with autism also have
some degree of mental retardation. It has been found that in 20 %
of the cases autistic disturbance is not evident during the first or
even second year of life. Some important characteristics of Autistic
disorders are as follows:

1. Impairment in Social Interaction: Individuals having

autistic disorder show impaired social interaction in many ways.
Their non-verbal behaviour reveals emotional distancing. They

Avoid eye contact,

Make odd facial expressions, postures, etc.
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Use gestures as a way of controlling interactions

Refrain form peer relationships
They lack the ability to share thoughts feeling and interests
with others.
Their world is characterized by preference for isolation. They
lack an wareness of others, including, even their parents and
siblings.
As infants they resist the cuddling and tickling of a parent.
Autistic children do not smile or response to adults laughter.
They remain aloof and unresponsive. They lack emotion and
sensitivity in their interactions with others.

2. Impairment in Communication: The communication

patterns of individuals having this disorder is abnormal. These
individuals either are unable to speak or show serious delay in
language acquisition. Those who are able to speak generally do not
initiate a conversation or remain involved in one. Their language
and style of speech is strange. Their tone, pitch, rate and rhythm
are unusual. They may speak in a monotone voice and end
sentences with a questionable rise. They often repeat word and
phrases and their use of grammar is very poor. They may confuse
pronouns such as I and you. Their speech is characterized by
echolalia or the repetition of words or phrases that they hear.

3. Oddities of Behaviour, Interests and Activities:

Individuals having autistic disorder display several behavioural
oddities:

They may be particularly interested in the parts of the

objects, such as buttons on sweaters, moving objects, such
as rotating blades of an electric fan, etc.
Many adhere to rituals and rigid daily routines and they may
become very distracted at the slightest change.
Their bodily movements are often bizarre and include
repetitive mannerism.
People with autism may shake their arms, spin around
repetitively, rock back and forth or engage in harmful, self-
damaging behaviour such as head-banging.
Regressive behaviours are very common, such as temper
tantrums, childish expression of anger and the soiling of
clothes by defecating or urinating.
An unusual variant of this disorder is what is called as
Autistic Savant Syndrome, which occurs in people with autism
who possess an extraordinary skill, such as the ability to perform
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extremely complicated numerical operations for example

correctly naming the day of the week on which a date thousands of
years away would fall. The autistic savant syndrome typically
appears at an early age, when the young child with autistic disorder
appears to have exceptional musical skill or artistic talent or the
ability to solve extremely challenging puzzle.

12.4.2 Theories of Autistic Disorder:

Biological Factors: Autistic Disorder is attributed to biological

factors, especially familial inheritance. Heritability of autistic
disorder is estimated to be approximately 90 %. It is estimated that
this disorder is due to genetic abnormality especially on
chromosome No. 7, 2 and 15.

There is no clear evidence regarding the involvement of

deficit brain structures. However, researchers have focused their
studies on the following four factors:
Cerebellum
Frontal Cortex,
Hippocampus and amygdale

There is some research evidence pointing to the fact that

overall brain size is increased in some individuals with autistic
disorders.

Research studies have also revealed that there exists

abnormalities in the neural circuitry of people with this disorder.

Psychological Factors: Earliest psychological explanations of

causation of this disorder focused on psychodynamic processes.
Autisitc disorder was attributed to disturbances in the childs
attachment patterns to the parents. Mother of such children were
found to be cold and detached and were referred to as refrigerated
mother. In recent years cognitive explanation of this disorder is
emphasized which regards this disorder to be a result of problems
in the areas of language, attention and perception.

12.4.3 Treatment of Autistic Disorder: Treatment picture of this

disorder is not so good. Medication and behavioural treatment
programs are used to help children deal with severe and broad
range of deficits. Teaching children with these disorders will help to
reduce disruptive and self-stimulatory behaviours. It has been
observed that when children with autistic disorder are given
reinforcement for appropriate behaviours, such as asking for help
or feedback, then they are less likely to engage in self-injurious or
aggressive behaviours. Autistic children can also be taught:
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New learning skills that help them in problem solving

behaviours.
To communicate more effectively.
To regulate and initiate behaviours on their own.
Adaptive skills
Interactive skills

Self control procedures such as self-monitoring of language,

relaxation training and covert conditioning have been found to be
useful.

Ivar Lovaas (2003) developed behavioural treatment to

eliminate all odd behaviours such as self-harm. Clinicians teach
children with autistic disorder appropriate eye contact and
responsiveness to instructions as necessary preconditions for other
therapeutic and educational interventions. This program targets
undesirable behaviours and then reduces them through operant
conditioning methods of positive reinforcement, extinction, negative
reinforcement and in some cases punishment. It has been
observed that the principles and techniques of Lovaas method can
be applied in a variety of settings in addition to the laboratory,
including the home and the school.

Behavioural program to be successful must be carried out

over a long period of time, beginning early in the childs life.

Treatment of autistic children involve comprehensive

program of intervention and requires therapist who is experienced,
dedicated and perseverant and has considerable patience.

12.4.4 Other Pervasive Developmental Disorders: Some other

pervasive development disorders are as follows:

1. Retts Disorder: It is also called as Rett syndrome, which is

a brain disorder that occurs almost exclusively in girls. The child
develops normally through the first 05 months of life. However,
between 05 months and 04 years, some changes indicative of
neurological and cognitive impairments occur. They tend to grow
more slowly than other children and have a small head size
(microcephaly). There is loss of hand skills, followed by odd hand
movements (hand-wringing), poorly co-ordinated walking and bodily
movements, psychomotor retardation and severely impaired
language.

2. Aspergers Disorder: Asperger's Disorder is the term for a

specific type of pervasive developmental disorder which is
characterized by problems in development of social skills and
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behavior. In the past, many children with Asperger's Disorder were

diagnosed as having autism.

While autism and Asperger's have certain similarities, there

are also important differences. For this reason, children suspected
of having these conditions require careful evaluation.

In general, a child with Asperger's Disorder functions at a

higher level than the typical child with autism. For example, many
children with Asperger's Disorder have normal intelligence. While
most children with autism fail to develop language or have
language delays, children with Asperger's Disorder are usually
using words by the age of two, although their speech patterns may
be somewhat odd.

Most children with Asperger's Disorder have difficulty

interacting with their peers. They tend to be loners and may display
eccentric behaviors. A child with Asperger's, for example, may
spend hours each day preoccupied with counting cars passing on
the street or watching only the weather channel on television.
Coordination difficulties are also common with this disorder. These
children often have special educational needs.

Although the cause of Asperger's Disorder is not yet known,

current research suggests that a tendency toward the condition
may run in families. Children with Asperger's Disorder are also at
risk for other psychiatric problems including depression, attention
deficit disorder, schizophrenia, and obsessive-compulsive disorder.

The outcome for children with Asperger's Disorder is

generally more promising than for those with autism. Due to their
higher level of intellectual functioning, many of these children
successfully finish high school and attend college. Although
problems with social interaction and awareness persist, they can
also develop lasting relationships with family and friends.

12.5 ATTENTION DEFICIT AND DISRUPTIVE

BEHAVIOR DISORDERS

Attention deficit and disruptive behaviour disorder has

received increasing attention in recent years. Children with these
disorders commonly act in ways that are so disruptive and
provocative that caretakers and peers respond with anger,
impatience, punishment and avoidance.

12.5.1 Attention-Deficit / Hyperactivity Disorder (ADHD): It is a

disorder involving inattentiveness and hyperactivity-impulsivity.
Inattentiveness is characterized by such behaviours as:
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Carelessness
Forgetfulness in daily activities. Inattentive children
commonly loose their belongings.
Easily distracted
Cannot follow through on instructions
Difficulty organsing tasks

Hyperactivity is characterized by fidgeting, restlessness,

running about inappropriately, difficulty in playing quietly and talking
excessively. Impulsivity is seen in individuals who blurt out
answers, cannot wait their turn, interrupt or intrude on others, etc.

It can be detected early in the childs life as to whether

he/she is hyperactive or not. Children with ADHD are regarded as
difficult by their parents, relatives and friends. In primary classes
children with ADHD show deficits in educational performance, have
repeated discipline problems and are commonly held back and
require tutoring and placement in special classes.

The view that ADHD subsides by adolescence has been

discarded. It is now held that ADHD is also seen in adolescence
and adulthood. As ADHD children grow, they display problems in
executive functions, which include tasks involving self-reflection,
self-control, planning, forethought, delay of gratification, affect
regulation and resistance to distraction. Adults with ADHD are more
likely to have deficits in working memory, sustained attention,
verbal fluency and processing speed.

Teenagers with ADHD have wide range of behavioural,

academic and interpersonal problems that create emotional havoc
for them and serious difficulties in their relationships with family,
friends and educators. They tend to be especially immature, likely
to engage in conflict with their parents, have poor social skills and
engage in more high-risk activities such as substance abuse,
unprotected sex and reckless driving (Resnick, 2005). In the case
of young girls the diagnosis of ADHD is likely to be ignored or
missed because their symptoms tend to be less overt than those
seen among boys. Their symptoms take the form of forgetfulness,
disorganization, low self-esteem and demoralization. Their
tendency to internalize symptoms may cause them to become
anxious, depressed and socially withdrawn. Some teenage girls are
hyper talkative and emotionally over reactive.

12.5.2 ADHD in Adults: Considerable amount of research has

been conducted to assess the specific ways in which ADHD is
manifested in adulthood. ADHD does not emerge in adulthood, but
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there are cases where it is first diagnosed in adulthood because in

few cases childhood symptoms of this disorder were overlooked or
misdiagnosed. It is estimated that about 4 % of the American adults
meet the diagnostic criteria for his disorder. Adults with ADHD tend
to be:
Chronic procrastinators who repeatedly forget things
They are grossly disorganized regardless of the task, even
for activities that they enjoy.
They tend to be intolerant of stress, emotionally volatile and
almost incapable of meeting deadlines.
Adults with ADHD has tremendous difficulties with routines,
they are haphazard with management of time and money
and have a very hard time completing academic work or
holding down jobs.
They miss appointments, even dates with their own partners
and they forget to pay bills or follow throught on
commitments.
They crave for adventure and excitement and hence are
likely to indulge in risk-taking behaviour.
Some ADHD adults are able to manage their excessive
energy and restlessness in to creative endevaours, such as
entrepreneurial ventures.
Adult women with ADHD are more likely to experience
dysphoria, organization problems, impulsivity and
inattention.
When ADHD adults have interpersonal problems either with
their partner or colleague, it is likely to be severe as such
individuals are seeking stimulation. They may provoke
conflict in their interactions with others by starting an
argument, refusing to end arguments or insisting that they
have the last word. They are high-strung as they tend to be
hypersensitive and impulsive. They may hear only parts of
the conversation and are prone to interpreting resulting in
conflicts during arguments/conversations.

12.5.3 Conduct Disorders: It is a condition characterised by the

repetitive and persistent violation of the rights of others. Conduct
disorder is defined as a repetitive and persistent pattern of behavior
in which the basic rights of others and major-age appropriate
societal norms are violated. It is chronic pattern of behavior that
causes harm to others. It is a chronic pattern of behavior that
violates societal rules. It was previously called as Juvenile
Delinquency. Their delinquent behaviour includes:
Stealing
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Truancy
Running away from home,
Lying
Fire setting
Breaking
Physical cruelty to people and animals,
Sexual assault and
mugging

These individuals, many of whom abuse drugs or alcohol,

may act alone or in groups. When caught, they deny their guilt, shift
blame onto others and lack remorse about the consequences of
their actions. Some important symptoms of conduct disorders are
as follows:

(A) Aggression towards people & animals

- Bullies or threatens others or often gets into physical fights
- Uses weapons that can cause serious harm to others
- Physical cruelty towards people and animals
- Has forced another into sexual activity
- Stealing after threatening (e.g., mugging, etc)
(B) Destruction of property
- Deliberate fire setting or destroying others property
(C) Deceitfulness or theft
- Stealing or breaking into others house or car
- Lying or conning others
(D) Serious violation of rules
- Staying out at night repeatedly despite parental prohibition
- Running away from home
- Truancy from school

Conduct disorders are of two types: a) Conduct disorder with

childhood onset (prior to age 10), b) Conduct disorder with
adolescent onset. It is one of the most frequently diagnosed
disorders in both outpatient and inpatient treatment programs. It is
prevalent among males and estimated to range between 1% to
10% of the general population.

Causes of Conduct focuses on Gene-environment

interaction. Conduct disorder is generally associated with the
persons environment:
1. Poverty / disorganized neighborhood.
2. Violence within the home / neighborhood.
3. Abuse / neglect / inadequate supervision.
4. poor quality schools.
Treatment of Conduct Disorder: The following important points
with regard to treatment of this disorder are worth noting:
Treatment is difficult.
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Poor prognosis for children with many symptoms or those

who develop symptoms at an early age.
Medications to control aggression, mood disorders,
hyperactivity, drug abuse, impulse control problems,
psychotic behaviors, or if there is associated epilepsy.
Behavior modification techniques with structured
environment and consistent rules.
Psychiatric evaluation of parents with counseling.
Individual psychotherapy aimed at improving problem
solving skills.

12.5.4 Oppositional Defiant Disorder: Individuals having this

disorder show a pattern of negative, hostile and defiant behaviour
that results in significant family or school problems. This disorder is
much more extreme than the typical childhood or adolescent
rebelliousness. Youths with this disorder repeatedly loose temper,
refuse to do what they are told to do, argue and deliberately annoy
others. They are touchy, resentful, belligerent, spiteful and self-
rightousness. Rather than seeing themselves as the cause of
problems, they blame other people or insist that hey are a victim of
circumstances. Some young people who behave in this way are
more oppositional with their parents than with outsiders. This
disorder typically becomes evident between the ages of 08 years
and 12 years. Preadolescent boys are more likely to develop this
disorder than are girls of the same age.

12.5.5 Theories and Treatment of ADHD and Disruptive

Behaviour Disorders: The understanding of causation of this
disorder and its treatment is not so simple.
1. This disorder is caused by abnormality in brain functioning.
Family, twin and molecular genetic studies indicate the role of
genetic factors in the causation of this disorder. The heritability
of this disorder is approximately 70 % and is among the highest
rates of all psychiatric disorders. It has been observed that
interrelated brain areas is involved in impairment of attentional-
executive functions of these individuals.

2. Neuroimaging studies have found structural brain abnormalities

such as smaller volumes in the frontal cortex, the cerebellum
and subcortical structures. Functional imaging studies have
pointed out that this disorder is a result of abnormal functioning
in the circuits that provide feedback ot the cortex for regulation
of behaviour.
3. Researchers are uncertain about the causal factors other than
genetics. Researchers continue to focus on other biological
factors such as birth complications, acquired brain damage,
exposure to toxic substances and infectious diseases.
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4. psychological factors also play an important role in the

causation of this disorder. Barkley (1998) focuses on impaired
self-control. The impairment is evidenced in four realms:
non-verbal working memory
the internalization of self-directed speech
the self-regualtion of mood and level of arousal
reconstitution the ability to break down observed
behaviours in to component parts that can be recombined in
to new behaviours directed towards a goal.

5. Sociological factors also play an important role in the causation

of this disorder. Many children with this disorder have grown up
in a disturbed family environment and have had failure
experiences in school.

Treatment of this disorder typically includes medications which

are effective in helping a large proportion of people with ADHD.
Most medication is based on methylphenidate (Ritalin). Besides
this, antidepressant medications are sometimes prescribed ,
some of which includes:
i) Buproprion (Wellbutrin SR)
ii) Pemoline (Cylert)
iii) Atomoxetine (Strattera) and
iv) Imipramine

The above medications are used to treat mild to moderate ADHD.

Most of these medications are not without any sideeffects.
6. Besides medication, Murphy has emphasized multi
prolonged approach to psychosocial treatment. Some of
these include as follows:
a. Psychoeducation is used frequently. It instills hope and
optimism
b. Psychological therapies such as individual therapy provides
a context in which treatment goals can be set and co-
existing problems such as depression and anxiety can be
solved.
c. Cognitive behaviour therapy helps the client change
maladaptive behaviour and thought patterns that interfere
with daily functioning.
d. Compensatory behavioural and self management training
provides the opportunity to build skills by incorporating more
structure and routine in to ones life.
e. Marital counseling, family therapy, career counseling, group
therapy and other similar techniques are of considerable
benefit.
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f. Coaching, that involves consulting with a professional helps

in assisting the individual with ADHD to focus on practical
implementation of goals. The coach helps the person find
ways to get things done through a pragmatic, behavioural,
result oriented approach.
g. Technology can be used to help individuals with ADHD
access tools and devices that helps them to communicate
effectively, remember and organize ones ones activities in a
much better manner.
h. School and workplace accommodation can be sought that
facilitate productivity and minimize distraction. Students and
employees with ADHD work better in a quiet non-distracting
environment.
i. Advocacy. Meaning advocating oneself and ones limitations
to other can help improve situation and help others to
understand the individual better.
j. Self reinforcement can be used to encourage the child to
regulate behaviours such as settling into a task, delaying
gratification, maintaining self-motivation and monitoring
progress towards a goal
k. A combination of behavioural, cognitiveand social learning
approaches appears to be the most useful strategy in
working with youths with disruptive behaviour disorders.

12.6 LEARNING, COMMUNICATION AND MOTOR

SKILLS DISORDER

Disorders in the areas of learning, communication and motor

skills are considered as specific developmental disorder. They
cause delay or deficit in a specific area of functioning, such as
academic skills, language and speech or motor coordination. Many
scholars object to the use of learning difficulties in a classification
system designed for the diagnosis of psychological disorders. One
reason as to why these difficulties are included in the diagnostic
classification is because they are often associated with emotional
distress and may seriously interfere with persons everyday life and
social relationships.

12.6.1 Learning Disorders: A learning disorder is a delay or deficit

in an academic skill that is evident when an individuals
achievement or standardized tests is substantially below what could
be expected for others of comparable age, education and level of
intelligence. These disorders cause significant impairment in
functioning and are estimated to affect about 2 to 10 percent of the
population. Learning disorders are evident in three areas:
 216

i. Mathematics called as mathematics disorder: Individuals

having difficulty in this area has difficulties with mathematical
tasks and concepts. Impairment may be evident in linguistic
skills, such as understanding mathematical terms, symbols or
concepts, perceptual skills such as reading arithmetic signs,
attention skills such as copying numbers correctly and
mathematical skills such as learning multiplication tables.

ii. Writing Disorder of Written Expression: Disturbances in

these areas are expressed in the form of poor spelling,
grammatical or punctuation errors and disorganization of
paragraphs which creates serious problems for children in many
academic subjects.

iv. Reading Reading disorder commonly called as dyslexia: It

is a learning disorder in which the individual omits, distorts or
substitutes words when reading and reads in a slow, halting
fashion. This inability to read inhibits the childs progress in a
variety of school subjects. Individuals with learning disorders
have low self-esteem and feelings of incompetence and shame.
It is well known fact that some of the great scientists had
learning disorders. Some of these include Isaac Newton,
Albert Einstein, Thomas Edison, Charles Darwin, etc.

12.6.2 Communication Disorders: Communication disorders refer

to conditions characterised by impairment in the expression and
understanding of language. Some common types of
Communication disorders are discussed below:

i. Expressive Language Disorder: It is a developmental

disorder characterized by obvious problems of verbal expression.
Children with this disorder do not have the ability to express
themselves in ways appropriate to their age group. Their language
style consists of the following:

Faulty vocabulary, Speaking in short sentences with

simplified grammatical structures, Omitting critical words or phrases
and Putting words together in a peculiar order

For some children expressive language disorders are

developmental conditions in which speaking abilities occur at a later
age than average and progress more slowly than the average.
Others acquire this disorder as a result of medical illness or a
neurological problem resulting from a head trauma.

ii. Mixed Receptive-Expressive Language Disorder:

Children with this disorder have difficulty in both expressing and
understanding certain kinds of words or phrases, such as directions
 217

or even in more severe form basic vocabulary or entire sentences.

An individual with this disorder gets confused even with simple
directions. While speaking children with this disorder show some of
the same communication problems as children with expressive
language disorder. This disorder can be developmental or acquired.

iii. Phonological Disorder: This disorder results in difficulties

which are specific to speech. A person with phonological disorder
substitutes, omits, or incorrectly articulates speech sounds.
Mispronounciation among children may appear cute, but if it
persists for a long time it can create academic difficulties and a
child can become a target of ridicule.

iv. Stuttering: It involves a disturbance in the normal fluency

and patterning of speech that is characterized by verbalizations
such as sound repetitions and prolongations, broken words, the
blocking out of sounds, word substitutions to avoid problematic
words and words expressed with an excess of tension.

12.6.3 Motor Skills Disorders: Motor skills disorder is primarily a

developmental coordination disorder which is characterized by
marked impairment in the development of motor coordination.
Children with this disorder encounter problems in academic
achievement and daily living because of their sever lack of
coordination, unassociated with another developmental disability. In
the earlier stages of this disorder children have trouble crawling,
walking and sitting. Many children acquire age related tasks below
their average age level. These individuals may be unable to tie their
shoelace, play ball, complete a puzzle or even write legibly. Six
percent of the children between the ages of 5 years and 11 years
experience this disorder.

12.6.4 Theories and Treatment of Learning, Communication

and Motor Skills Disorders: Learning, communication and motor
skills disorders are generally a result of neurological abnormalities.
These can occur either during the stage of fetal development,
during the birth process or as a result of neurological condition
caused by physical trauma or a medical disorder.

One explanation for this disorder is that the brain areas

involved in vision, speech and language comprehension cannot
integrate information. For example a child whose ability to
remember a sequence of letters or words is impaired may have
difficulty in comprehending speech.

These disorders can best be treated in school or atleast

treatment can start from school. A treatment plan should be
designed that would take a holistic and integrated approach. School
psychologists, school counselors, a speech therapist, special
 218

education teacher, neurologist, a general physician and a class

teacher is all required to treat the child in an integrated and
coordinated manner. Parental awareness, education and their
cooperation is required.

12.7 SUMMARY:

In this unit after a brief mention of introductory issues we have

discussed the concept of mental retardation and have classified
Mental Retardation by IQ Scores and Behavioural Competencies.
We discussed the four types of mental retardation mild,
moderate, severe and profound. We then discussed the various
theories and treatment of mental retardation including some genetic
disorders such as Downs Syndrome and Fetal Alcohol Syndrome.
Various treatment options and preventive aspects of mental
retardation were also discussed.

Pervasive Developmental Disorders were discussed,

which refers to group of disorders that leads to severe
disturbances in the different areas of development, especially,
social interaction, communication patterns and odd behaviour,
interests and activities. Some important pervasive developmental
disorders that were discussed were Autism, Retts Disorder and
Aspergers Disorder. The concept of autism and its characteristic
features as well as its theories and treatment were discussed.

Following this we discussed the Attention Deficit and

Disruptive Behavior Disorders. It is a disorder involving
inattentiveness and hyperactivity-impulsivity. This disorder is most
commonly found among school going children and adolescents. In
recent years this disorder has been diagnosed among adults also.
ADHD in adults has been discussed in brief. Related to ADHD are
two disorders called as conduct disorder and Oppositional Defiant
Disorder. We would discuss their symptomatology and treatment.
Theories and Treatment of ADHD and Disruptive Behaviour
Disorders has also been discussed at length.

Another category of disorders is in the area of learning,

communication and motor skills. These groups of disorders are
considered as specific developmental disorders. They cause delay
or deficit in a specific area of functioning, such as academic skills,
language and speech or motor coordination. Different types of
learning and communication disorders were discussed. Theories
and Treatment of Learning, Communication and Motor Skills
Disorders were also briefly discussed towards the end of the unit.
 219

12.8 QUESTIONS:

Q1. Define Mental Retardation and discuss the classification of

mental disorders
Q2. Discuss the different theories and treatment of mental
disorders.
Q3. Write a note on Pervasive developmental disorders.
Q4. Explain Autism and discuss the Characteristics of Autistic
Disorder.
Q5. Discuss the Theories and Treatment of Autistic Disorder.
Q6. Write short notes on the following:
Retts Disorder
Aspergers Disorder
ADHD in Adults
Oppositional Defiant Disorder
Q7. Discuss Attention-Deficit / Hyperactivity Disorder (ADHD)
Q8. Discuss Conduct Disorders and its treatment.
Q9. Write a note on Theories and Treatment of ADHD and
Disruptive Behaviour Disorders.
Q10. Discuss learning, communication and motor skills disorders.

12.9 REFERENCES:

1. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology:

Clinical Perspectives on Psychological Disorders. (6th ed.).
McGraw-Hill
2. Barlow, D.H., & Durand, V.M. (2005). Abnormal Psychology: An
Integrative Approach. (4th ed.). New Delhi: Wadsworth Cengage
Learning
3. Bennet, P. (2003). Abnormal and Clinical Psychology: An
Introductory Textbook. Open University Press
4. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.
(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009 by
Dorling Kindersley, New Delhi.

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13

DEVELOPMENT-RELATED,
AGING-RELATED AND COGNITIVE
DISORDERS II

Unit Structure
13.0 Objectives
13.1 Introduction
13.2 Separation Anxiety Disorder
13.3 Other Disorders that Originate in Childhood
13.4 Development - Related Disorders: The Biopsychosocial
Perspective
13.5 The Nature of Cognitive Disorders
13.6 Delirium, Amnestic Disorders, Traumatic Brain Injury,
Dementia
13.7 Cognitive Disorders: The Biopsychosocial Perspective
13.8 Summary
13.9 Questions
13.10 References

13.0 OBJECTIVES

After studying this unit you should be able to:

Understand the concept of Separation Anxiety Disorder
Explain Other Disorders that Originate in Childhood
Comprehend the Biopsychosocial Perspective of
Development - Related Disorders.
Know the Nature of Cognitive Disorders
Understand the different types of cognitive disorders such as
Delirium, Amnestic Disorders, Traumatic Brain Injury and
Dementia
Comprehend the The Biopsychosocial Perspective of
Cognitive Disorders.
 221

13.1 INTRODUCTION

In this we would discuss the concept of Separation Anxiety

Disorder and its characteristics features as well as its theories and
treatment. Following this we would discuss Other Disorders that
Originate in Childhood. Some of these disorders that we would
briefly discuss under this category includes: Childhood Eating
Disorders, Tic Disorders, Elimination Disorders, Reactive
Attachment Disorder, Stereotypic Movement Disorder, Selective
Mutism, etc.

The biopsychosocial perspective of development-related

disorders as well as, towards the end of the chapter, cognitive
disorders, would be discussed.

We would also discuss the nature of cognitive disorders and

different types of cognitive disorders, such as, delirium; amnestic
disorders; traumatic brain injury and dementia. The characteristics
of Dementia as well as the concept of Alzheimers Disease, its
Alzheimers Disease, Theories and Treatment of Alzheimers
Disease would also be discussed in this unit.

13.2 SEPARATION ANXIETY DISORDER

Separation anxiety disorder can be defined as a condition

involving excessive, prolonged anxiety, concerning separation from
home or from people to whom a child is attached. Children with
separation anxiety disorder have intense and inappropriate anxiety
concerning separation from home or caregivers. Separation
anxiety disorder is a psychological condition in which an individual
experiences excessive anxiety regarding separation from home or
from people to whom the individual has a strong emotional
attachment (like a father, mother, grandparents, and brothers or
sisters). Separation Anxiety Disorder (SAD), is characterized by
significant and recurrent amounts of worry upon (or anticipation of)
separation from a child or adolescent's home or from those to
whom the child or adolescent is attached.

Characteristics of Separation Anxiety Disorder: Some important

characteristics of separation anxiety disorder are as follows:
They experience severe reactions when confronted with the
prospect of being apart form their parents.
They become upset and often physically ill when facing a
normal separation, such as when parent leaves for work or
when they go to a relatives house for a visit. Some may
 222

refuse to sleep overnight at a friends house or go to camp or

school.
They fear that something terrible will happen to them or to
their parents or themselves.
When separated from their caretakers they are likely to
complain of physical complaints such as headache or
stomach aches. They may insist that apparent stays with
them till they fall asleep.
When not with an attachment figure, they become panicky,
miserable, homesick, socially withdrawn and sad.
They are also intrusive, demanding and in need of constant
attention.

Theories and Treatment of Separation Anxiety Disorder:

Anxiety evolves as a result of Psychological and physiological
factors. Among the biological factors involved in anxiety, the study
of familial patterns and to determine the genetic basis has been
more useful.

Some children with separation anxiety disorder have found

to have a family history of anxiety. A large study by Cronk et al
(2004) found strong evidence for heritability. It was observed that
temperamental differences rooted in biology causes some children
to respond with heightened anxiety to certain environmental factors
discussed below.

They also found that along with strong heritability there are also
environmental factors that contribute to development of this
disorder. Some important environmental factors that result in
anxiety disorder include:
Loss of threat
Loss of father from the home
Natural or man made disasters

According to psychodynamic writers separation anxiety

disorders in children results from failing to learn how to negotiate
the normal developmental tasks of separating from parents.

Large number of children diagnosed with this disorder

experience remession and are completely free from this disorder in
a period of about 18 months or so. The clinicians main task while
treating these children is to help them to gain control over anxiety-
provoking situations. Behavioural treatment has been found to be
highly effective for this disorder. Some important behavioural
techniques for treating this disorder include:
Systematic desensitization,
 223

Prolonged exposure to a certain situation so as to develop

immunity
Modeling
Relaxation techniques and cognitive strategies are highly
useful.
Contingency Management and self management are useful
in teaching the child to react more positively and
competently to a fear provoking situation.

Behavioural techniques can be applied either individually or

in groups.

Medications are also used to treat separation anxiety

disorder among children. SSRIs, such as fluoxetine is the most
commonly used drug to treat this disorder. These medications
should be used cautiously as they lead to extreme impulsive
reactions in the children including suicidal attempts.

13.3 OTHER DISORDERS THAT ORIGINATE IN

CHILDHOOD

A few rare and unusual disorders are limited to childhood

years. These disorders include the following:

1. Childhood Eating Disorders: One type of childhood

disorder is called as Pica, commonly found among mentally
retarded children. In this disorder children eat inedible substances,
such as paint, string, hair, animal droppings, paper, etc. Another
eating disorder of childhood is Feeding disorder of infancy or early
childhood. In this disorder the child fails to eat leading to loss of
weight/failure to gain weight. Still another type of eating disorder is
rumination disorder in which infant or child regurgitates and
rechews food after it has been swallowed. Each of these disorders
lasts for a month and is not associated with transient stomach
distress.

2. Tic Disorders: Tic is defined as a rapid, recurring

involuntary movement or vocalization. Some important tics include
motor ticks such as eye blinking, facial twitches and shoulder
shrugging. Besides motor movements, tics can also involve vocal
tics such as coughing, grunting, snorting, coprolalia (uttering of
obscenities) and tongue clicking. One type of tic disorder is
Tourettes Disorder, a combination of movement and vocal tics,
commonly found among males. People with Tourettes Disorder
usually make uncontrollable movements of the head and
sometimes parts of the upper body. In some cases individuals
engage in complex bodily movements involving touching, squatting,
twirling or retracing steps. At the same time they utter vocalizations
 224

that sound very odd to others. Individuals with this disorder also
have obsessive-compulsive symptoms, speech difficulties and
atentional prblems. According to some experts Tourettes Disorder
is a result of deficits in brain inhibitory mechanisms in the prefrontal
cortex.

3. Elimination Disorders: In this disorder children have

difficulties in gaining control over their toilet. There are two types of
elimination disorder.

a) Encopresis: Repeated bowel movements either in clothes or at

inappropriate places.

b) Enuresis: Children with this disorder urinate in clothes or in bed

after their age when they are expected to be in control of urination.

4. Reactive Attachment Disorder: It is a sever disturbance in

the childs ability to relate to others. Some children with this
disorder do not initiate social interactions or respond when it is
inappropriate. They may act extremely inhibited or avoidant. Some
children show inappropriate familiarity with strangers. This disorder
is a result of pathological care giving or child rearing practices
adopted by the parent in which, the childs physical or emotional
needs are not satisfied. Frequent changes in the caregiver, such as
frequent parental divorce followed by remarriages or change in the
care giver, etc., can also lead to lack of formation of a stable
identity which may result in this disorder.

5. Stereotypic Movement Disorder: Children with this

disorder engage in repetitive behaviours such as waving, body
rocking, head banging, self-biting, etc. These behaviours interfere
with normal functioning and cause bodily injury.

6. Selective Mutism: In selective mutism, the child consciously

refuses to talk in certain situations, usually when there is an
expectation for interaction such as at school.

13.4 DEVELOPMENT-RELATED DISORDERS: THE

BIOPSYCHOSOCIAL PERSPECTIVE

Diagnosing and treating individuals with this disorder is not

an easy task. It requires considerable skills and a multiple
approaches which takes in to account, biological, psychological and
social factors.

There is considerable debate among researchers and

clinicians as to whether separate diagnostic categories should exist
for children for development-related disorders or other disorders.
 225

Another issue that has been debated is, are there overlap between
childhood and adult disorders? Is there continuity between them or
are they different disorders?
Another question that is raised is that of origin of childs
referral for psychological evaluation or treatment. A parent may
report childs symptoms as a cry for help from an overburdened
parent of a normal but difficult child or it may be the reflection of a
disturbance that lies outside the child but within the parent, the
family, school or a larger social milieu.

The biopsychosocial perspective takes in to consideration

the totality of the childs environment and multiple causes that can
result in to and sustain the various development-related disorders
discussed above.

13.5 THE NATURE OF COGNITIVE DISORDERS

Cognition has received considerable attention in psychology

during the last two decades. Cognitive functions include processing
of thought, memory capacity and ability to pay attention. The
cognitive disorders that we will discuss in the following pages have
following three central characteristics:
It involves impairment of thoughts
Loss of or problems in memory
Difficulties in attention

Impairment can result due to brain trauma, disease or

exposure to toxic substances (including drugs). DSM IV TR uses
the term delirium, dementia, amnestic and other cognitive
disorders to refer to cognitive disorders. Cognitive disorders is a
comprehensive term.

Impairment of cognitions can be assessed through

neurophysiological testing and through development of new
neuroimaging technologies. However inspite of advancements in
sophisticated diagnostic tools, neuropsychological assessment has
assumed greater importance to determine as to whether cognitive
disorder is a result of organic impairment or whether it is a result of
psychological factors.

13.6 DELIRIUM; AMNESTIC DISORDERS;

TRAUMATIC BRAIN INJURY; DEMENTIA

13.6.1 Delirium: It is a temporary state in which individual

experiences a clouding of consciousness, in which they are
unaware of what is happening around them and are unable to focus
or pay attention. In delirium individual experiences cognitive
 226

changes in which their memory is foggy and they are disoriented. A

person in a state of delirium may forget what he or she had eaten
for lunch only an hour earlier or be unaware of the day of the week
or even the season of the year. The speech of the individual
experiencing delirium may be rambling or incoherent as they shift
from one topic to another. Some other major characteristics of
delirium are as follows:
Individuals having delirium may experience delusion,
hallucinations or illusions as well as emotional disturbances
such as anxiety, euphoria or irritability.
Delirious individuals may do things that are physically
dangerous, such as walking in to traffic or falling down the
stairs.
Delirium is caused by changes in the brains metabolism and
usually reflects something that is happening in the brain.
Delirium can be caused by substance intoxication or
withdrawal, head injury, high fever, vitamin deficiency, etc.
Delirium can occur at any age but it is more common among
medically or psychiatrically hospitalized older adult patients,
particularly among surgical patients with pre-existing
cognitive impairment and depressive symptoms.
Certain medications and/or drugs can also give rise to
delirium.
Psychomotor disturbances related to delirium can be either
hyperactive or hypoactive. Hyperactive individuals are
restless and agitated. Hypoactive individuals are slowed
down, acting in ways that reflect their feelings of lethargy
and stupor. Hallucinations, delusions and agitation are more
likely to occur in the hyperactive phase.

Multi dimensional approach can be of help in treating

delirium. Patients and their relatives must be educated about its
symptomatology, early prevention and diagnosis. Awareness about
delirium and early intervention can help the patients to overcome
many negative consequences.

13.6.2 Amnestic Disorders: Amnestic disorders refer to loss of

memory. People with amnestic disorders are unable to recall
previously learned information or to register new memories. The
inability to incorporaterecent events into memory or to recall
important information can be very disturbing, because an individual
loses a sense of personal identity. In amnestic disorder an
individual may try to cover up social problems caused by memory
loss through denial or confabulation, the fabrication of facts or
events to fill a memory void. According to DSM IV TR there are
two major categories of amnestic disorders:
 227

a) One due to medical conditions.

b) Those that are a result of substance- induced.

Wide variety of medical conditions such as head trauma,

loss of oxygen, or herpes simplex or environmental toxins like lead,
mercury, pesticides, industrial toxins, etc. The most common cause
of amnestic disorder is chronic alcohol use. Memory loss, due to
any reason in this disorder can result from damage to subcortical
regions of the brain responsible for consolidating and retrieving
memory

13.6.3 Traumatic Brain Injury: Traumatic Brain Injury results from

exposure to trauma resulting in damage to the brain. Intense
pressure to head as a result of fall, automobile accident sports
injury, combat, etc., may lead to brain injury. It is estimated that in
war, such as Afghanistan War and Iran War about 22 % of the
soldiers suffered from brain injury. Some important brain injuries
that result due to brain trauma include:
Concussions - It is caused by a blow to the head.
Contusions
Cereberal infarcations (cutting off of blood )
Intrusion in to brain by fragments of bullets, instruments, iron
rods,e tc.

Some important symptoms of Traumatic Brain Injury include:

headaches, sleep disturbances, sensitivity to light and noise and
diminished cognitive performance on tests of attention, memory,
language and reaction time. Symptoms also include depression,
anxiety, emotional outbursts, mood changes or inappropriate affect.

Individuals suffering from Traumatic Brain Injury often

experience subtle changes that are note easily observable to
themselves or to others.

Post-Concussion Syndrome: It is a disorder arising out of

concussions in which a constellation of physical, cognitive or
emotional symptoms persists from weeks to years. These
symptoms are summarised in the following table.

Physical Cognitive Symptoms Emotional

Symptoms Symptoms
Headaches Confusion Irritability
Dizziness Concentration Mood
Sleep difficulties swings
disturbance Impaired Depression
Sensitivity to judgment
light and Amnesia
noise
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13.6.4 Characteristics of Dementia: Dementia is a form of

cognitive impairment involving generalised progressive deficits in a
persons memory and learning of new information, ability to
communicate, judgment and motor coordination. Besides cognitive
changes people with dementia experience changes in personality
and emotional state. The main cause of dementia is profuse and
progressive brain damage. Other physical conditions that can
cause dementia include vascular (circulatory) diseases, AIDS, head
trauma, psychoactive substances and various neurological
disorders. Dementia is found among people of all ages including
children. Dementia is generally found among people who have
Alzheimers Disease. Some important characteristics of dementia
are as follows:
Initially in the earlier stages the disorder may begin with mild
forgetfulness that is only slightly noticeable and annoying.
Gradually their symptoms become increasingly obvious and
severe
As their condition worsens, they gradually loose their
capacity to care for themselves.

Memory Loss: Initially there is slight memory impairment. The

person is incapable of retaining any new information. Gradually the
symptoms worsen between one to ten years. As their conditions
worsen they are unable to remember even the basic facts about
themselves and their lives.

Aphasia, Apraxia and Agnosia: Aphasia is the loss of ability to

use language. It is caused by the damage to the brains speech and
language area and this damage influences the production and
understanding of a language. There are two types of aphasia.
a) Wernikes aphasia: In this an individual is able to produce
words but has lost the ability to comprehend it so that these
verbalizations have no meanings.
b) Brocas aphasi: They have disturbance in the area of
language production, but comprehension abilities are intact.
The individual knows the rules of sentence construction and
can grasp the meaning of language, but he/she is unable to
produce complete sentences

In Apraxia a person has lost the ability carry out coordinated

bodily movements that he or she could previously perform without
difficulty. This is not due to physical weakness or decreased muscle
tone, but due to brain deterioration.
 229

Agnosia is the inability to recognize familiar objects or

experiences, despite the ability to perceive their basic elements.

Disturbances in Executive Functioning: Dementia also leads to

disturbances in executive functioning, which includes cognitive
abilities, such as abstract thinking, planning, organizing or carrying
out behaviours. Executive dysfunction is seen in many everyday
activities

13.6.5 Alzheimers Disease: Dementia seen among individuals

with Alzheimers disease is called as Dementia of the Alzheimers
type. The term senile is sometime, mistakenly, used to refer to this
disorder, or more generally to the process of growing old.
Alzheimers disease is a brain disorder named for German
physician Alois Alzheimer who first described it in 1906. It is
estimated that about 3.5 to 4 million Indians suffer from this
disorder. In Mumbai alone there are an estimated of about 40,000
individuals having this disorder.

Alzheimer's destroys brain cells, causing problems with

memory, thinking and behavior severe enough to affect work,
lifelong hobbies or social life. Alzheimers gets worse over time, and
it is fatal. Currently there is no cure for Alzheimers disease though
with love and care the suffering that the patient undergoes can be
considerably reduced.

Alois Alzheimer
At a scientific meeting in November 1906, German physician
Alois Alzheimer presented the case of Frau Auguste D., a 51-
year-old woman brought to see him in 1901 by her family. Auguste
had developed problems with memory, unfounded suspicions that
her husband was unfaithful, and difficulty speaking and
understanding what was said to her. Her symptoms rapidly grew
worse, and within a few years she was bedridden. She died in
1906, of overwhelming infections from bedsores and pneumonia.

Dr. Alzheimer had never before seen anyone like Auguste

D., and he gained the familys permission to perform an autopsy. In
Augustes brain, he saw dramatic shrinkage, especially of the
cortex, the outer layer involved in memory, thinking, judgment and
 230

speech. Under the microscope, he also saw widespread fatty

deposits in small blood vessels, dead and dying brain cells, and
abnormal deposits in and around cells.

The condition entered the medical literature in 1907, when

Alzheimer published his observations about Auguste D. In 1910,
Emil Kraepelin, a psychiatrist noted for his work in naming and
classifying brain disorders, proposed that the disease be named
after Alzheimer.

13.6.6 Symptoms of the Alzheimers disease: People with

Alzheimers experience difficulties communicating, learning,
thinking and reasoning. Alzheimers disease is a progressive fatal
illness that causes areas of the brain to shrink. The resulting
symptoms start with memory loss and other cognitive deficits,
advancing to major personality changes and eventual loss of
control over bodily functions. Some common symptoms of
Alzheimers disease are as follows:
General confusion, disorientation to date, time or place
Apathy, irritability, depression, anxiety
Problems with language, math, abstract thinking, and
judgment
Personality changes with strange quirks or inappropriate
behaviors
Wandering, hiding objects, problems with eating and
sleeping
Late in the disease, paranoia and delusions may occur
Toward the end, total loss of self, and inability to control
bodily functions

Some of the most common warning signs of Alzheimers

disease are as follows:
1. Memory loss. Forgetting recently learned information is one of
the most common early signs of dementia. A person begins to
forget more often and is unable to recall the information later.

2. Difficulty performing familiar tasks. People with dementia

often find it hard to plan or complete everyday tasks. Individuals
may lose track of the steps involved in preparing a meal, placing a
telephone call or playing a game.

3. Problems with language. People with Alzheimers disease

often forget simple words or substitute unusual words, making their
speech or writing hard to understand. They may be unable to find
the toothbrush, for example, and instead ask for "that thing for my
mouth.
 231

4. Disorientation to time and place. People with Alzheimers

disease can become lost in their own neighborhood, forget where
they are and how they got there, and not know how to get back
home.

5. Poor or decreased judgment. Those with Alzheimers may

dress inappropriately, wearing several layers on a warm day or little
clothing in the cold. They may show poor judgment, like giving
away large sums of money to telemarketers.

6. Problems with abstract thinking. Someone with Alzheimers

disease may have unusual difficulty performing complex mental
tasks, like forgetting what numbers are for and how they should be
used.

7. Misplacing things. A person with Alzheimers disease may put

things in unusual places: an iron in the freezer or a wristwatch in
the sugar bowl.

8. Changes in mood or behavior. Someone with Alzheimers

disease may show rapid mood swings from calm to tears to anger
for no apparent reason.

9. Changes in personality. The personalities of people with

dementia can change dramatically. They may become extremely
confused, suspicious, fearful or dependent on a family member.

10. Loss of initiative. A person with Alzheimers disease may

become very passive, sitting in front of the TV for hours, sleeping
more than usual or not wanting to do usual activities.

13.6.7 Dementia Caused by other Conditions: Many different

conditions can also result in dementia. Physical conditions such as
infectious diseases such as neurosyphilis, encephalitis,
tuberculosis, meningitis or localized infections in the brain can
result in dementia. People who experience kidney failure may have
symptoms of dementia as a result of toxic accumulation of
substances that the kidneys cannot cleanse from the blood. People
with certain types of brain tumors also experience cognitive
impairments and symptoms of dementia. Environmental toxins or
ingestion of substances such as drugs can also lead to dementia,
such dementia is called as Substance-induced persisting dementia.
Dementia can also result from severe nutritional deficiencies.
People who are severely undernourished are prone to develop a
deficiency of folate, a critical nutrient, which can lead to progressive
cerebral atrophy. Dementia can also result from the following
diseases:
 232

i. Picks Disease: It is a relatively rare progressive

degenerative disease that affects the frontal and temporal lobes of
the cerebral cortex. It is caused by the accumulation in neurons of
unusual proteins deposits called pick bodies. Individuals with this
disease are socially inhibited, have memory loss, they act
impulsively or inappropriately. They also appear unmotivated or
apathetic.

ii. Parkinsons Disease: It involves neuronal degeneration of

the basal ganglia, the sub-cortical structures that control motor
movements. Not all individuals with parkinsons disease experience
dementia. About 60 % of the individuals who are older and are in
the advanced stage of the disease experience dementia. This is
basically a disease involving disorder of motor disturbances. The
persons muscle becomes rigid and it is difficult for him to initiate
movement, a symptom called as akinesia. They also have general
slowing of motor activity, known as bradykinesia. Besides motor
disturbances, individuals having parkinsons disease show
cognitive deterioration such as slowed scanning on visual
recognition task, diminished conceptual flexibility and slowing of
motor response tests. The individuals face appears expressionless
and speech becomes stilted, loosing its normal rhythmic quality.
They also have difficulty producing words on tests that demand
word fluency. Individuals with this disorder have Lewy body
Dementia

Lewy body Dementia: It is similar to Alzheimers Disease resulting

in progressive loss of memory, language, calculation, reasoning as
well as other higher mental functions. The progress of illness is
more rapid than what is seen in Alzheimers Disease. Lewy bodies
are tiny spherical structures consisting of deposits of protein in
dying nerve cells found in damaged regions deep with in the brains
of people, especially having parkinsons disease. Lewy body
Dementia is diagnosed when lewy bodies are found more diffusely
dispersed throughout the brain. It is not clear whether Lewy body
Dementia is a variant of either Alzheimers Disease or Parkinsons
Disease.

Frontal-Temporal Dementia: This form of dementia is

commonly found among individuals having Alzheimers Disease or
Parkinsons Disease. The onset of this dementia is slow and
insidious.

iii. Hutingtons Disease: It is a degenerative neurological

disorder that can also affect personality and cognitive functioning. It
is a result of abnormality on chromosome 4 that causes a protein,
known as huntingtin, to accumulate and reach toxic levels. The
symptoms first appear in adult hood between 30 years to 50 years.
The disease results in the death of neurons in sub-cortical
 233

structures that control motor behaviour. The disease is associated

with following:
Mood disturbances
Changes in personality
Irritability and Explosiveness
Suicidal behaviour
Changes in sexuality and
Cognitive deficits

iv Creutzfeldt-Jacob Disease: It is a rare neurological

disorder caused by an infectious agent that results in abnormal
protein accumulations in the brain. Initial symptoms of this disease
includes:
Fatigue
Appetite disturbances
Sleep problems and concentration difficulties

As the disease progresses individual shows increasing signs of

dementia and eventually dies.

Underlying these symptoms is widespread damage known

as spongiform encephalopathy, meaning that large holes develop in
brain tissues.

v. Cardiovascular Disease: Cardiovasular disease affecting

the supply of blood to the brain is another cause of dementia.
Dementia arising from this condition is called as vascular dementia.
The damage to the artery deprives the surrounding neurons of
blood and oxygen which causes the neurons to die. Vascular
dementia resembles the dementia due to Alzheimers disease.
People with vascular dementia experiences:
Memory impairment
They may also experience any one of the following: apraxia,
agnosia or disturbance in executive functioning.
People with vascular dementia also show a particular set of
physical abnormalities such as walking difficulties and
weakness in the arms and legs.

The cognitive impairment in this disease is slightly different

from that occurring in Alzheimers disease. In a typical vascular
dementia certain cognitive functions remain intact and others show
significant loss, a pattern called patchy deterioration. Individuals
with vascular dementia also show a stepwise deterioration in
cognitive functioning, for e.g., a function that was relatively
unimpaired is suddenly lost or severely deteriorates.

13.6.8 Pseudodementia: It is also called as false dementia. It is

generally found among people who are severely depressed. People
 234

with Pseudodementia generally have a history of prior depressive

episodes that may have been undiagnosed. Their memory
problems and opther cognitive complaints have a very abrupt
onset, compared with those of people with dementia, who
experience a slowly developing downward course. Some important
points of difference between depression and Alzheimers disease
are as follows:

Depression Alzheimers Disease

Depressed individuals are Individuals with Alzheimers
more keenly aware of their Disease usually try to hide or
impaired cognition and minimize the extent of
frequently complain of their impairment or to explain it away
faulty memory. when the loss cannot be
concealed.
In depressed elderly people, Opposite is the case in
mood changes precede, Alzheimers Disease.
memory loss
Individuals with depression Individuals with dementia, in
are generally anxious, have contrast experience unsociability,
difficulty sleeping, show uncooperativeness, hostility,
disturbed appetite patterns, emotional instability, confusion,
experience suicidal thoughts, disorientation and reduced
low self-esteem, guilt and alertness.
lack of motivation

13.6.9 Diagnosis of Alzheimers Disease: It is very important to

diagnose Alzheimers Disease in its earlier stages so that
appropriate management strategies can be applied to deal with it
as well as to rule out treatable dementia. Brain imaging techniques
are being increasingly used to diagnose Alzheimers Disease. The
clinical tool used to diagnose Alzheimers Disease is a specialized
form of mental status examination known as Mini-Mental State
Examination (MMSE). People with Alzheimers Disease respond in
particular ways to several of the items on this instruments. They
tend to be circumstantial, repeat themselves and lack richness of
detail when describing people, objects and events.

13.6.10 Theories and Treatment of Alzheimers Disease:

Treatment of Alzheimers disease requires a multidisciplinary
approach that involves a comprehensive evaluation of the patient's
disease and associated symptoms. The specialists who treat
Alzheimers disease include neurologists, neuropsychologists,
neuroradiologists, psychiatrists, sleep medicine, and physical
medicine specialists.
 235

The first step in treating Alzheimer's is an accurate

diagnosis. It's important to rule out other causes of dementia,
particularly conditions that can be treated and potentially reversed.
If Alzheimer's is diagnosed early, medications and other care may
improve the patient's daily functioning and quality of life, as well as
potentially slow disease progression. The second step in treating
Alzheimer's is for the patient, and family, to prepare for and
manage the disease as it progresses.

There is no cure for Alzheimer's Disease but prospects for

management have improved. New drugs are being developed
which seek to slow down the rate of mental decline. These are
promising in the early stages of the disease, although it is unclear
for how long they can help and they are not yet widely available. In
April 1997, donepezil (Aricept) became the first drug to be licensed
for Alzheimer'' in Britain.

Affected people should live as normal a life for as long as

they can. Memory aids and familiar routines are helpful. As the
disease progresses, people need more support and may be need
close supervision and eventually nursing care. In India
Rivastigmine (Exelon) is being marketed by Novartis since 1999.

13.7 COGNITIVE DISORDERS: THE

BIOPSYCHOSOCIAL PERSPECTIVE

Cognitive impairments associated with various disorders discussed

in this unit generally result from biological causes. However,
medical experts have still not developed biological treatment for
successfully treating or managing these groups of disorders.
Individuals suffering from dementia are generally treated with a
combination of various approaches to alleviate their sufferings.
Experts have also given due attention to manage caregivers who
experience considerable stress and strain when dealing with
individuals having dementia especially Alzheimers Disease.
Emphasis is laid on improving the quality of life of these individual.
Traditional as well as technology based approaches have been
used to deal with various aspects of the problems encountered
while dealing with these individuals.

13.8 SUMMARY

In this unit we have discussed the Separation anxiety

disorder which is a psychological condition in which an individual
experiences excessive anxiety regarding separation from home or
from people to whom the individual has a strong emotional
attachment. The various Characteristics of Separation Anxiety
 236

Disorder were also discussed followed by Theories and Treatment

of Separation Anxiety Disorder.
Some disorders that specifically originate in childhood were
discussed. These included, Childhood Eating Disorders, Tic
Disorders, such as Tourettes Disorder, Elimination Disorders, such
as Encopresis and Enuresi, Reactive Attachment Disorder,
Stereotypic Movement Disorders and Selective Mutism.

The biopsychosocial perspective of development-related

disorders as well as Nature of Cognitive Disorders were discussed.
Following this concepts such as Delirium, Amnestic Disorders,
Traumatic Brain Injury were discussed.

Characteristics of Dementia as well as Alzheimers Disease

were discussed in detail. Many different types of dementia caused
by other conditions were discussed. Some of these
disorders/disease include: Picks Disease, Parkinsons Disease,
Hutingtons Disease, Creutzfeldt-Jacob Disease, Cardiovascular
Disease etc. Towards the end of this unit we have discussed the
Biopsychosocial Perspective of Cognitive Disorders.

13.9 QUESTIONS

1. Define Separation Anxiety Disorder and discuss its

characteristics.
2. Explain the Theories and Treatment of Separation Anxiety
Disorder.
3. Discuss some Disorders that Originate in Childhood.
4. Write short notes on the following:
Biopsychosocial perspective of development-related
disorders
Nature of Cognitive Disorders
Delirium
Amnestic Disorders
Traumatic Brain Injury
Characteristics of Dementia
Alzheimers Disease
5. Discuss the different types of Dementia Caused by other
Conditions
6. Explain Biopsychosocial Perspective of Cognitive Disorders.
 237

13.10 REFERENCES

5. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology:

Clinical Perspectives on Psychological Disorders. (6th ed.).
McGraw-Hill
6. Barlow, D.H., & Durand, V.M. (2005). Abnormal Psychology: An
Integrative Approach. (4th ed.). New Delhi: Wadsworth Cengage
Learning
7. Bennet, P. (2003). Abnormal and Clinical Psychology: An
Introductory Textbook. Open University Press
8. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.
(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009 by
Dorling Kindersley, New Delhi.

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14

EATING DISORDERS AND IMPULSE

CONTROL DISORDERS I

Unit Structure
14.0 Objectives
14.1 Introduction
14.2 Anorexia Nervosa
14.3 Bulimia Nervosa
14.4 Theories and Treatment of Eating Disorders
14.5 Summary
14.6 Questions
14.7 Reference

14.0 OBJECTIVES

After studying this unit you should be able to:

Understand as to what eating disorders are.
Know the characteristics of Anorexia Nervosa
Comprehend Bulimia Nervosa
Appreciate the theories and treatment of eating disorders

14.1 INTRODUCTION

Eating disorders refer to a group of conditions defined by

abnormal eating habits that may involve either insufficient or
excessive food intake to the detriment of an individual's physical
and mental health. Eating disorders are serious behavior problems.
They include
Anorexia nervosa, in which you become too thin, but you
don't eat enough because you think you are fat
Bulimia nervosa, involving periods of overeating followed by
purging, sometimes through self-induced vomiting or using
laxatives
Binge-eating, which is out-of-control eating
 239

Women are more likely than men to have eating disorders.

They usually start in the teenage years and often occur along with
depression, anxiety disorders and substance abuse.

Eating disorders can cause heart and kidney problems and

even death. Getting help early is important. Treatment involves
monitoring, mental health therapy, nutritional counseling and
sometimes medicines.

In this unit we will discuss Anorexia Nervosa, Bulimia

Nervosa and the Theories and Treatment of Eating Disorders

14.2 ANOREXIA NERVOSA

The term anorexia literally means without appetite and is a

misleading term as far as this disorder is concerned. Anorexia
nervosa is an eating disorder affecting mainly girls or women,
although boys or men can also suffer from it. It usually starts in the
teenage years. Anorexia Nervosa is an eating disorder, which is
characterized by extreme, self, imposed weight loss. In anorexia
nervosa an individual loses at least 15% of his weight from the
normally required weight as per his weight and body constitution. It
is also defined as an eating disorder diagnosed when an otherwise
healthy person refuses to maintain a normal weight level because
of an intense fear of being overweight. Individuals who have
anorexia nervosa also have a distorted body image. Some other
important characteristics of this disorder are as follows:
It is relatively a rare disorder beginning typically in teenage
years.
About 20 times more females than males have anorexia
nervosa.
Most anorexics are adult females from well-educated middle
and upper income families that are competitive and high
achieving.
They are highly obsessed with food and weight gain.

Individuals having anorexia nervosa has the following

characteristics:
They are unwilling or unable to maintain minimally normal
weight, which is about 85 percent of the weight that is
expected of a person of given height and body frame.
These individuals have an intense fear of gaining weight or
becoming fat, even if they are grossly underweight
They have a distorted perception of the weight or shape of
their body, possibly denying the seriousness of abnormally
low body weight
 240

Postpubescent females with anorexia nervosa experience

amenorrhea, the absence of at least three consecutive
menstrual cycles.
Anorexic individuals also display the following
characteristics:
Some individuals engage in various behaviours geared
towards weight loss such as abusing laxatives, taking diet
pills or indulging in compulsive exercises. These individuals
are also called as restricting type
There are another group of individuals who are called as
Binge eating or purging type. These individuals first overeat
and then force themselves to purge or get rid of whatever
they have eaten by inducing vomiting
Anorexia nervosa is associated with many physical
complaints and problems such as: menstrual disturbance,
dry and cracking skin, slowed heart beat, gastrointestinal
disturbance, etc.
Those who induce vomiting commonly experience
abnormalities of the salivary glands, erosion of dental
enamel and scarring of hand skin from contact with the
teeth.
Extreme starvation among anorexics can lead to anemia,
impaired kidney functioning, heart problems and bone
deterioration.
It has been observed that people with this disorder generally
have normal appetite and are interested in eating, however
they have difficulty reading their hunger cues.

Psychological and Behavioural Symptomatology: Some

important psychological and behavioural symptoms found among
anorexia nervosa individuals are as follows
The individual can become seriously underweight, which can
lead to depression and social withdrawal.
The individual can become irritable and easily upset and have
difficulty interacting with others.
Sleep can become disrupted and lead to fatigue during the day.
Attention and concentration can decrease.
Most individuals with anorexia become obsessed with food and
thoughts of food. They think about it constantly and become
compulsive about eating rituals. They may collect recipes, cut
their food into tiny pieces, prepare elaborate calorie-laden meals
for other people, or hoard food. Additionally, they may exhibit
other obsessions and/or compulsions related to food, weight, or
body shape that meet the diagnostic criteria for an obsessive
compulsive disorder.
 241

Other psychiatric problems are also common in people with

anorexia nervosa, including affective (mood) disorders, anxiety
disorders, and personality disorders.
Generally, individuals with anorexia are compliant in every other
aspect of their life except for their relationship with food.
Sometimes, they are overly compliant, to the extent that they
lack adequate self-perception. They are eager to please and
strive for perfection. They usually do well in school and may
often overextend themselves in a variety of activities. The
families of anorexics often appear to be "perfect." Physical
appearances are important to the anorexia sufferer.
Performance in other areas is stressed as well, and they are
often high achievers in many areas.
While control and perfection are critical issues for individuals
with anorexia, aspects of their life other than their eating habits
are often found to be out of control as well. Many have, or have
had at some point in their lives, addictions to alcohol, drugs, or
gambling. Compulsions involving sex, exercising, housework,
and shopping are not uncommon. In particular, people with
anorexia often exercise compulsively to speed the weight-loss
process.
Body image disturbance is one of the core features of anorexia
nervosa. Individuals having anorexia often feel that they are
gaining weight and are obsessed with weight reduction and
staying slim.

Prevalence of Anorexia Nervosa: Prevalence of this disorder

range between 1 and 4 percent among women. Approximately 95%
of those affected by anorexia are female, most often teenage girls,
but males can develop the disorder as well. While anorexia typically
begins to manifest itself during early adolescence, it is also seen in
young children and adults. In the U.S. and other countries with high
economic status, it is estimated that about one out of every 100
adolescent girls has the disorder. Caucasians are more often
affected than people of other racial backgrounds, and anorexia is
more common in middle and upper socioeconomic groups.
According to the U.S. National Institute of Mental Health (NIMH),
other statistics about this disorder include the fact that an estimated
0.5%-3.7% of women will suffer from this disorder at some point in
their lives. About 0.3% of men are thought to develop anorexia in
their lifetimes.

Diagnosis of Anorexia Nervosa: Anorexia nervosa can be a

difficult disorder to diagnose, since individuals with anorexia often
attempt to hide the disorder. Denial and secrecy frequently
accompany other symptoms. It is unusual for an individual with
anorexia to seek professional help because the individual typically
does not accept that she or he has a problem (denial). In many
 242

cases, the actual diagnosis is not made until medical complications

have developed. The individual is often brought to the attention of a
professional by family members only after marked weight loss has
occurred. When anorexics finally come to the attention of the
health-care professional, they often lack insight into their problem
despite being severely malnourished and may be unreliable in
terms of providing accurate information. Therefore, it is often
necessary to obtain information from parents, a spouse, or other
family members in order to evaluate the degree of weight loss and
extent of the disorder. Health professionals will sometimes
administer questionnaires for anorexia as part of screening for the
disorder.

One instrument that has been used extensively in research

to study eating disorder is The Eating Attitudes Test, which
provides a measure of preoccupation with dieting and food, bulimic
behaviour and the ability to control eating.

The actual criteria for anorexia nervosa are found in the

American Psychiatric Association's Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-
IV-TR).

There are four basic criteria for the diagnosis of anorexia nervosa
that are characteristic:
1. The refusal to maintain body weight at or above a minimally
normal weight for age and height (maintaining a body weight
less than 85% of the expected weight)
2. An intense fear of gaining weight or becoming fat, even
though the person is underweight
3. Self-perception that is grossly distorted, excessive emphasis
on body weight in self-assessment, and weight loss that is
either minimized or not acknowledged completely
4. In women who have already begun their menstrual cycle, at
least three consecutive periods are missed (amenorrhea), or
menstrual periods occur only after a hormone is
administered.

The DSM-IV-TR further identifies two subtypes of anorexia

nervosa. In the binge-eating/purging type, the individual regularly
engages in binge eating or purging behavior which involves self-
induced vomiting or the misuse of laxatives, diuretics, or enemas
during the current episode of anorexia. In the restricting type, the
individual severely restricts food intake but does not regularly
engage in the behaviors seen in the binge-eating type.
The cause of anorexia nervosa is unknown, although it is
likely that both inherent biological factors and factors in the patient's
 243

social environment play a part. The disease is mainly encountered

in the western world and is more common among women in certain
professions, such as models and ballet dancers. One reason
younger women are particularly vulnerable to eating disorders is
their tendency to go on strict diets to achieve an "ideal" figure. This
obsessive dieting behavior reflects today's societal pressure to be
thin, which is seen in advertising and the media. Others especially
at risk for eating disorders include athletes, actors, dancers,
models, and TV personalities for whom thinness has become a
professional requirement. The causes of anorexia are multiple
some of them are as follows:-
a. One of the chief causes is the growing concern with
beauty. Adolescent girls want to look attractive and
beautiful. Excessive concern with their body makes them
obsessive about weight gain and diet. Hence, anorexia
nervosa is a reaction towards slimness.
b. Anorexia nervosa may also be a result of psychological
disturbances related to the fear of growing up and a fear of
one's own sexuality.
c. One's family also contributes towards the development of
anorexia nervosa. Anorexic girls describe their mothers as
excessively dominant, intrusive, over bearing and markedly
ambivalent.
d. According to some researchers, anorexia may result due to
physical disorder caused by deficiency of a crucial
chemical in the brain or by disturbance of the
hypothalamus.

14.3 BULIMIA NERVOSA

Bulimia nervosa is an eating disorder characterised by

frequent episodes of binge eating, followed by frantic efforts to
avoid gaining weight. The person may eat a lot of food at once and
then try to get rid of the food by vomiting, using laxatives, or
sometimes over-exercising. People with bulimia are preoccupied
with their weight and body image. Bulimia is associated with
depression and other psychiatric disorders. It shares some
symptoms with anorexia nervosa, another major eating disorder.
Because many people with bulimia can maintain a normal weight,
they may be able to keep their condition a secret for years. If not
treated, bulimia can lead to nutritional deficiencies and even fatal
complications.

Bulimia is characterised by overeating also known as

binges. They may over eat more than 2000 calories in a two hour
period. They display lack of control over eating. They then indulge
in inappropriate behaviours that are intended to prevent weight
gain. They then indulge in what is called as purging, i.e. indulge in
 244

induced vomiting to get rid of what they have eaten. They may do
this in any one of the following ways:
Induced vomiting
Administer an enema
Take laxatives or diuretics

Bulimia can also be of non-purging type in which an individual

try to compensate for what they have eaten by fasting or engaging
in excessive exercise.

Symptomatology: People with bulimia may have the following

signs and symptoms:
Binge eating of high-carbohydrate foods, usually in secret
Exercising for hours
Eating until painfully full
Going to the bathroom during meals
Loss of control over eating, with guilt and shame
Body weight that goes up and down
Constipation, diarrhea, nausea, gas, abdominal pain
Dehydration
Missed periods or lack of menstrual periods
Damaged tooth enamel
Bad breath
Sore throat or mouth sores
Depression

Binge eating signs and symptoms

Lack of control over eating Inability to stop eating. Eating
until the point of physical discomfort and pain.
Secrecy surrounding eating Going to the kitchen after
everyone else has gone to bed. Going out alone on
unexpected food runs. Wanting to eat in privacy.
Eating unusually large amounts of food with no obvious
change in weight.
Disappearance of food, numerous empty wrappers or food
containers in the garbage, or hidden stashes of junk food.
Alternating between overeating and fasting Rarely eats
normal meals. Its all-or-nothing when it comes to food.

Purging signs and symptoms

Going to the bathroom after meals Frequently
disappears after meals or takes a trip to the bathroom to
throw up. May run the water to disguise sounds of vomiting.
Using laxatives, diuretics, or enemas after eating. May
also take diet pills to curb appetite or use the sauna to
sweat out water weight.
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Smell of vomit The bathroom or the person may smell like

vomit. They may try to cover up the smell with mouthwash,
perfume, air freshener, gum, or mints.
Excessive exercising Works out strenuously, especially
after eating. Typical activities include high-intensity calorie
burners such as running or aerobics.

Physical signs and symptoms of bulimia

Calluses or scars on the knuckles or hands from sticking
fingers down the throat to induce vomiting.
Puffy chipmunk cheeks caused by repeated vomiting.
Discolored teeth from exposure to stomach acid when
throwing up. May look yellow, ragged, or clear.
Not underweight Men and women with bulimia are
usually normal weight or slightly overweight. Being
underweight while purging might indicate a purging type of
anorexia.
Frequent fluctuations in weight Weight may fluctuate by
10 pounds or more due to alternating episodes of bingeing
and purging.

Distinction between Anorexia Nervosa and Bulimia Nervosa:

Some people have both Anorexia Nervosa and Bulimia Nervosa.
Clinicians often have to distinguish between the two disorders. The
following table will help you to distinguish between the two:

Criteria of
difference Anorexia Nervosa Bulimia Nervosa
between the two

People with Anorexia Nervosa Individuals with

have distorted perceptions of bulimia nervosa have
Body Image their body image/size. Even an accurate body
when close to a chronic stage perception about but
of starvation, anorexics still worry about
perceive them selves as weight gain
overweight

Perception People with Anorexia Nervosa Many Individuals with

concerning the weigh significantly below the bulimia nervosa have
amount of weight norm for height and body build. weight that is average
lost or above average.

Medical Complications: Individuals having Bulimia Nervosa

experience many medical complications. Most of these are life
threatening complications associated with purging.
 246

i. Ipecac syrup, the medication that is used to induce vomiting

in people who have consumed poisonous substances, has
severe toxic effects when taken regularly and in large doses
by people who have eating disorders.
ii. Dental decay which results from frequent vomiting is
common as cavities develop and teeth take on ragged
appearance.
iii. The salivary gland becomes enlarged.
iv. Skin calluses develop on hands that brush against teeth in
the vomiting process.
v. Menstrual irregularity among women.
vi. Toxic effects can also occur from the laxatives, diuretics and
diet pills that bulimics use to induce weight loss.
vii. Some individuals with bulimia nervosa engage in harmful
behaviours such as using enemas, regurgitating and then re-
chewing the food or overusing saunas in efforts to lose
weight.
viii. These individuals develop problems of the gastrointestinal,
cardiovascular and nervous systems. In addition to the
effects of dehydration caused by binging and purging, the
bulimic individual runs the risk of permanent gastrointestinal
damage. Fluid retention in the hands and feet and
destruction of the heart muscles or collapse of the heart
valves.

Prevalence: This disorder is more prevalent among girls,

especially those who are between the ages of 16 to 18. The onset
of bulimia nervosa is often during adolescence, between 13 and 20
years of age, and many cases have previously suffered obesity,
with many sufferers relapsing in adulthood into episodic binging
and purging even after initially successful treatment and remission.
There is little data on the prevalence of bulimia nervosa in-the-
large, on general populations. Most studies conducted thus far
have been on convenience samples from hospital patients, high
school or university students. These have yielded a wide range of
results: between 0.1% and 1.4% of males, and between 0.3% and
9.4% of females. The lifetime prevalence of Bulimia Nervosa
among women is approximately 1%-3%; the rate of occurrence of
this disorder in males is approximately one-tenth of that in females.
Bulimia Nervosa has been reported to occur with roughly similar
frequencies in most industrialized countries, including the United
States, Canada, Europe, Australia, Japan, New Zealand, and South
Africa. Few studies have examined the prevalence of Bulimia
Nervosa in other cultures. In clinical studies of Bulimia Nervosa in
the United States, individuals presenting with this disorder are
 247

primarily white, but the disorder has also been reported among
other ethnic groups.

14.4 Theories and Treatment of Eating Disorders: Many varied

perspectives on causation and treatment of eating disorders have
been developed.

People with eating disorder have altered dopamine and

serotonin neurotransmitter substances. People with eating disorder
have abnormalities in the dopamine receptors reflecting inherited
vulnerability. It is also suggested that deficiency of serotonin is
related to feelings of hunger (leading to binging) and an excess is
related to feelings of fullness.

Psychological perspective holds the view that eating disorder

develop in young people who suffer a great deal of inner turmoil
and pain and become obsessed with bodily issues, often turning to
food for feelings of comfort and nurturance. Individuals suffering
from eating disorder tend to have difficulty understanding and
labeling their emotions and over time they learn that eating can
provide a means of dealing with unpleasant and unclear emotional
states. Some women with eating disorder, especially bulimia
nervosa have a history of sexual abuse during childhood. According
to cognitive behavioural perspective, people with eating disorders
become trapped in their pathological patterns because of a
resistance to change that commonly characterizes their thought
process. They avoid problems rather than resolve them, they resort
to wishful thinking rather than realistic appraisal;, they do not seek
social support even when they are in serious trouble.

Sociocultural perspective views societys attitude as primarily

responsible for the development of eating disorders. Societys
idealization of thinness leads adolescent girls to equate beauty with
a slim figure. As she matures, she reads magazines, hears other
people, views television and films which all depict and glamorize
thinness and equates it with beauty.

Some experts also hold the view that these eating disorders
develop as a result of complex interaction among biological,
psychological and sociological factors. IN the case of anorexia
nervosa biological factors, dieting and psychosocial influences
come together and set the stage for development of this disorder.
Once the stage is set the individual becomes trapped in a cycle of
physiological changes that leads to disorder.

Since multiple causes are responsible for the development

of eating disorder, its treatment also requires a combination of
approaches. Psychotherapy is very essential for trating people with
eating disorder. Fairburn (1997) observed that cognitive
 248

behavioural therapy and interpersonal therapy were found to be

highly effective in the treatment of eating disorders. Therapeutic
alliance is an important factor that helps to bring about therapeutic
change. Fairburn (1997) found that following factors associated
with cognitive behavioural therapy plays an important role in the
treatment of eating disorders:

Building of a good therapeutic relationship

Teaching the client Self monitoring techniques
Helping the clients to develop an understanding of the
cognitive model, the importnace of weekly weighing and
regular eating patterns and other techniques designed to
bring about healthy eating habits.
Interpersonal therapy uses techniques similar to those used
for treating depression, with a focus on helping client cope with
stress in interpersonal situations and with feelings of low self-
esteem. The clients learn to recognize emotions as triggers of
disordered eating, particularly binge eating.
Group therapy may also be helpful in the treatment of eating
disorders. However, the success rate with group therapy is far
below than what it is for individual therapy. Multifamily therapy
group is much better than ordinary group therapy.
Treatment plans often are tailored to individual needs and
may include one or more of the following:

Individual, group, and/or family psychotherapy

Medical care and monitoring
Nutritional counseling
Medications.
Some patients may also need to be hospitalized to treat
problems caused by malnutrition or to ensure they eat enough if
they are very underweight.

Treating Anorexia Nervosa: Treating anorexia nervosa involves

three components:

Restoring the person to a healthy weight

Treating the psychological issues related to the eating
disorder
Reducing or eliminating behaviors or thoughts that lead to
insufficient eating and preventing relapse.

Some research suggests that the use of medications, such

as antidepressants, antipsychotics, or mood stabilizers, may be
modestly effective in treating patients with anorexia nervosa. These
medications may help resolve mood and anxiety symptoms that
 249

often occur along with anorexia nervosa. It is not clear whether

antidepressants can prevent some weight-restored patients with
anorexia nervosa from relapsing.

Treating Bulimia Nervosa: As with anorexia nervosa, treatment

for bulimia nervosa often involves a combination of options and
depends upon the needs of the individual. To reduce or eliminate
binge-eating and purging behaviors, a patient may undergo
nutritional counseling and psychotherapy, especially cognitive
behavioral therapy (CBT), or be prescribed medication. CBT helps
a person focus on his or her current problems and how to solve
them. The therapist helps the patient learn how to identify distorted
or unhelpful thinking patterns, recognize, and change inaccurate
beliefs, relate to others in more positive ways, and change
behaviors accordingly.

CBT that is tailored to treat bulimia nervosa is effective in

changing binge-eating and purging behaviors and eating attitudes.
Therapy may be individual or group-based.

Some antidepressants, such as fluoxetine (Prozac), which is

the only medication approved by the U.S. Food and Drug
Administration (FDA) for treating bulimia nervosa, may help
patients who also have depression or anxiety. Fluoxetine also
appears to help reduce binge-eating and purging behaviors, reduce
the chance of relapse, and improve eating attitudes.

14.5 SUMMARY

In this unit we have first defined eating disorders as a

group of conditions involving abnormal eating habits that includes
either insufficient or excessive food intake to the detriment of an
individual's physical and mental health. Eating disorders lead to
serious behavior problems. Symptoms of various eating disorders
were discussed. We defined anorexia nervosa and discussed its
various symptoms including Psychological and Behavioural
Symptomatology. Following this we discussed the Prevalence of
Anorexia Nervosa and the Diagnosis of Anorexia Nervosa.

Bulimia Nervosa was the next eating disorder discussed in

detail. Bulimia nervosa was defined as an eating disorder
characterised by frequent episodes of binge eating, followed by
frantic efforts to avoid gaining weight. Symptomatology of Bulimia
Nervosa was discussed. We also distinguished between Anorexia
Nervosa and Bulimia Nervosa, especially with respect to Body
Image and Perception concerning the amount of weight lost.
 250

Various medical complications arising as a result of Bulimia

Nervosa was discussed. Following this we discussed the
prevalence of this disorder.

Towards the end of this unit we discussed the Theories and

Treatment of Eating Disorders, especially with reference to
Anorexia Nervosa and Bulimia Nervosa.

14.6 QUESTIONS

Q1. What are eating disorders. Discuss the sympotomatology of

Anorexia Nervosa.

Q2. Discuss Bulimia Nervosa as an eating disorder.

Q3. Discuss the Theories and Treatment of Eating Disorders.

14.7 REFERENCE

1. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal

Psychology: Clinical Perspectives on Psychological
Disorders. (6th ed.). McGraw-Hill.

2. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.

(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009
by Dorling Kindersley, New Delhi.

3. Oltmanns, T. F., & Emery, R. E. (2010). Abnormal

Psychology. 6th ed., New Jersey: Pearson Prentice Hall.

4. Barlow, D.H., & Durand, V.M. (2005). Abnormal Psychology:

An Integrative Approach. (4th ed.). New Delhi: Wadsworth
Cengage Learning.

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15
EATING DISORDERS AND IMPULSE
CONTROL DISORDERS II

Unit Structure
15.0 Objectives
15.1 Introduction
15.2 Definition of Impulse Control Disorders
15.3 Kleptomania
15.4 Pathological Gambling
15.5 Pyromania
15.6 Sexual Impulsivity
15.7 Trichotillomania
15.8 Intermittent Explosive Disorder
15.9 Internet Addiction
15.10 Self-injurious Behaviour
15.11 Summary
15.12 Questions
15.13 Reference

15.0 OBJECTIVES

After studying this unit you should be able to:

Understand the concept of impulse control disorders
Know what is Kleptomania, its characteristics, theories and
treatment?
Comprehend Pathological Gambling and know its
characteristics, theories and treatment.
Know the concept of Pyromania as well as its
characteristics, theories and treatment.
Understand Sexual Impulsivity and Trichotillomania.
vi Know what is Intermittent Explosive Disorder and
Internet Addiction?
Understand Self-injurious Behaviour
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15.1 INTRODUCTION

In this unit we will first discuss the concept of impulse control

disorder, which refers to urges to act in ways that are destructive or
detrimental to their well-being. Some of the impulse control
behaviours are not problematic when indulged in moderation. Some
of the most important impulse control disorders that we will discuss
in this unit along with their characteristics, theories and treatment
include the following: Kleptomania, Pathological Gambling,
Pyromania, Sexual Impulsivity, Trichotillomania, Intermittent
Explosive Disorder, Internet Addiction and Self-injurious Behaviour.

15.2 DEFINITION OF IMPULSE CONTROL DISORDERS

Impulse Control Disorders are a specific group of impulsive

behaviours that have been accepted as psychiatric disorders under
the DSM IV - TR . Although they have been grouped together in
this diagnostic category, there are striking differences as well as
similarities between these disorders.

An Impulse Control Disorder can be loosely defined as the

failure to resist an impulsive act or behaviour that may be harmful
to self or others. For purposes of this definition, an impulsive
behaviour or act is considered to be one that is not premeditated or
not considered in advance and one over which the individual has
little or no control.

While anyone can be capable of impulsive behaviours and/or

actions at any given point, this particular diagnosis is used when
there is a mental health issue present. In many cases, the
individual may have more than one formal psychiatric diagnosis.

The impulsive behaviours or actions refer to violent behavior,

sexual behavior, gambling behaviour, fire starting, stealing, and
self-abusive behaviors.
Impulse-control disorders are psychological disorders
characterized by the repeated inability to refrain from performing a
particular action that is harmful either to oneself or others. Impulse-
control disorders are thought to have both neurological and
environmental causes and are known to be exacerbated by stress.
Some mental health professionals regard several of these
disorders, such as compulsive gambling or shopping, as addictions.
In impulse-control disorder, the impulse action is typically preceded
by feelings of tension and excitement and followed by a sense of
relief and gratification, oftenbut not always accompanied by
guilt or remorse.

15.3 KLEPTOMANIA
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Kleptomania is one form of impulse control disorder in which

an individual is driven by a persistent urge to steal, although their
theft is not motivated by a wish to own the object or by the
monetary value of the item they have stolen.

Characteristics of Kleptomania: Some important characteristics

of kleptomania are as follows:
It is wrongly believed that they are driven by the wish to
acquire possessions, infact that is not the case.
They are more influenced by the excitement of engaging in
the act of stealing the object. In the process of stealing, they
experience a release of tension that is gratifying as they
experience a temporary thrill.
People with Kleptomania steal just anything, though the
most common objects are food, clothes, jewellery,
cosmetics, compact disc, toys, pens, paper, money, etc.
Most people with Kleptomania steal from a store or
workplace. In few cases, stealing is limited only to certain
particular person.
It is not the intrinsic value of these objects that motivates the
person with Kleptomania to steal, but, rather the urge to
release tension
Most people with Kleptomania are perplexed about what to
do with their acquired items. Some hoard the objects; others
give away or throw the objects. This lack of interest in the
stolen items is the main feature that distinguishes between a
typical shoplifter or the thief from a person with Kleptomania.

Theories and Treatment of Kleptomania: Very few cases of

Kleptomania come to the attention of clinicians, but only when they
are directed by the court. Clinician usually becomes aware that a
person has Kleptomania only when he or she is in treatment for
another psychological problem, such as an anxiety, psychoactive
substance abuse, eating or mood disorder. One important question
is that is Kleptomania a symptom of some underlying disorder.
Some researchers are of the view that Kleptomania constitutes a
variant of obsessive-compulsive disorder.
Biological and pharmacological treatment approaches for
Kleptomania has been developed. It has been observed that
Kleptomania responds to SSRIs. Besides pharmacological
interventions clinicians also employ behavioural treatments to help
individuals control their urge to steal.
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15.4 PATHOLOGICAL GAMBLING

Individuals with pathological gambling have an urge to

gamble that is much stronger than that of the average person, and
they often end up spending their entire lives in pursuit of big wins
People with pathological gambling often feel ashamed and try to
avoid letting others know of their problem. A person may be
diagnosed with a pathological gambling habit if they fit more than
five of the following criteria; the criteria were published in the fourth
edition of the Diagnostic and Statistical Manual of Mental Disorders:
Preoccupation: the individual constantly thinks about
gambling.
Tolerance: the individual becomes increasingly tolerant to
gambling and starts to spend more money and take more
risks to get the same rush; this is similar to someone with
alcohol dependency.
Withdrawal: the individual suffers withdrawal symptoms if
they go for a while without gambling; commonly, people with
gambling problems get irritable and restless when they dont
gamble on a regular basis.
Escape: the individual uses gambling as a means of
escaping the real world.
Chasing: the individual will continue to gamble if they have
lost money to try and win it back.
Lying: the individual lies about the gravity of their gambling
habit to loved ones and tries to disguise their addiction.
Loss of control: the individual cannot cut down on gambling,
even if they want to.
Illegal acts: the individual breaks the law to get money to
gamble or make money back following a loss; these acts
may include theft and fraud.
Risked significant relationship: the individual continues to
gamble even though they know a significant relationship is at
risk.
Bailout: an individual asks friends, family or a third party for
help with repaying gambling debts.
Pathological gambling is currently the only behavioural
addiction included in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV), and is classified as an "Impulse Control
Disorder," where the essential feature is the failure to resist an
impulse, drive or temptation to perform an act that is harmful to the
person or to others (p. 609, DSM-IV, American Psychiatric
Association, 1994).
 255

Characteristics of Pathological Gambling: Some important

characteristics of pathological gambling are as follows:
It is estimated that lifetime prevalence of this disorder is
slightly less than 01 percent. Pathological gamblers are likely
to be males, non-white and unmarried. They are likely to
have co-morbid disorders, including mood, alcohol abuse
and substance abuse disorders. Those with middle income
levels and low education levels are also at risk for
pathological gambling. Pathological gambling usually begins
in early adolescence in men, and between ages 20 and 40 in
women.
Pathological gamblers are preoccupied with gambling to
such an extent that it is difficult for them to get the idea of
being out of their mind. Repeated efforts to control their
gambling are usually unsuccessful.
Gambling progresses through a series of stages. In the first
stage the individual is simply a recreational gambler who
enjoys gambling as a social activity. The next stage is the
beginning of pathological gambling pattern, it occurs when
the individual begins to win. At this point of time individual
gains the identity as a winner and now he/she strives to
achieve more and more wins, most probably a big win.

Theories and Treatment of Pathological Gambling: Pathological

gambling is an addiction which is similar to drug or alcohol
addiction. From a biological perspective, the gamblers perceptual
pursuit of the big win can be seen as similar to the alcohol-
dependent persons search for stimulation and pleasurable feelings
through alcohol use. Some researchers have opined that people
with pathological gambling have abnormalities in the brain that lead
them to seek excess stimulation, be it through drugs, food or
gambling. Few researchers have pointed out that those who
indulge in pathological gambling have abnormalities affecting
neurotransmitters including dopamine, serotonin and MAO.
Researchers believe that dopamine abnormalities, in particular,
affect the reward system of the brain that leads pathological
gamblers to seek excessive stimulation.

Cognitive factors may also play a role in transmission of

pathological gambling. Another factor that contributes to a persons
likelihood of becoming a pathological gambler is the experience of
gambling during childhood and adolescence. Some individuals
suggest that individuals with certain personality characteristics may
have a predisposition to developing the disorder.

Socio-cultural factors are also involved in the acquisition and

maintenance of pathological gambling. Exposure to a culture of
 256

gambling, in which parents and peers are heavily engaged in

gambling activities themselves, can also increase the individuals
chances of developing this disorder.

It has been observed that treatment methods that combine

elements of the various perspectives seem to have the greatest
chance of success. Serotonin reuptake inhibitors such as
Clomipramine and fluvoxamine are effective in treatment of this
disorder. Cognitive behavioural methods such as correcting the
gamblers inaccurate perceptions of gambling, providing training in
problem solving and social skills and incorporating elements of
motivational interviewing techniques are highly useful in the
treatment of this disorder.

Treatment for people with pathological gambling begins with

recognizing the problem. Pathological gambling is often associated
with denial. People with the illness often refuse to accept that they
are ill or need treatment. Most people with pathological gambling
enter treatment under pressure from others, rather than voluntarily
accepting the need for treatment. Treatment options include:
Cognitive behavioral therapy has been found to be effective.
Self-help support groups, such as Gamblers Anonymous.
Gamblers Anonymous is a 12-step program similar to
Alcoholics Anonymous. Principles related to stopping the
habit (abstinence) for other types of addiction, such as
substance abuse and alcohol dependence, can also be
helpful in the treatment of pathological gambling.
A few studies have been done on medications for the
treatment of pathological gambling. Early results suggest
that antidepressants and opioid antagonists (Naltrexone)
may help treat the symptoms of pathological gambling.
However, it is not yet clear which people will respond to
medications.

15.5 PYROMANIA

Pyromania is an impulse control disorder in which an

individual indulges in setting fire and gets fascinated by fire. People
with this condition show evidence of the following characteristics:
They deliberately and repeatedly set fires
They experience a sense of tension or affective arousal
before the fire setting.
They are fascinated with, interested in, curious about or
attracted to fire and things associated with fire.
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They feel pleasure, gratification or relief when setting fires or

when watching or participating in the events following a fire.
Their fire setting is not done for ulterior motives, such as
monetary gain, an expression of political ideology, the
concealment of criminal activity or an expression of anger or
vengeance.

Those individuals who suffer from pyromania have a history

of childhood problems. These individuals have learned the curiosity
and attraction for fire through observation and modeling of adult fire
setting behaviour. Parents of such children are found to be
uninterested and ineffective in disciplining them. These individuals
tend to be highly aggressive and have higher levels of
psychopathology. They also show evidence of antisocial and other
pathological behaviours. As adults those who indulge in pyromania
have other coexisting disorder such as schizophrenia, bipolar
disorder or substance abuse disorder.

Individuals with this disorder have a low level of education.

Among the biological factors low level of serotonin have been
identified in individuals who indulge in pyromania

15.6 SEXUAL IMPULSIVITY

Individuals who suffer from sexual impulsivity are unable to

control their sexual beahviour and they feel driven to engage in
frequent and indiscriminate sexual activity. Although this condition
is not a DSM IV TR diagnosis, the symptoms and behaviours of
people with sexual impulsivity are very much similar to those
generally associated with impulse control disorders. Terms such as
sexual addiction, sexual compulsivity, and sexual dependency
are often used to refer to this disorder.

Characteristics of sexual impulsivity: Some important

characteristic features of sexual impulsivity are as follows:
These individuals are preoccupied with sex, feeling
uncontrollably driven to seek out sexual encounters, which
they later regret.
People with sexual impulsivity feel that they cannot control
either the number of their sexual encounters or the contexts
in which they are likely to initiate sexual behaviour.
The uncontrollable behaviour of people with sexual
impulsivity interferes with their ability to carry out normal
social and occupational responsibilities and can place their
social status in jeopardy.
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They feel a great deal of distress about their behaviour after

the sexual encounter. They also are likely to feel dejected,
hopeless and ashamed.
People with this condition are unable to control their sexual
behaviour, and they feel driven to engage in frequent and
indiscriminate sexual activity.
They experience an increasing sense of tension prior to
engaging in a sexual act.
They feel a great deal of distress about their behaviour and
following sexual encounters, are likely to feel depressed.
Their compulsive pursuit of sexual encounters interferes
with their ability to carry out normal social and occupational
responsibilities
This disorder is generally more common in men but its
manifestation in women tends to be more passive.
Individuals with sexual impulsivity commonly have a co-
existing condition, such as depression, substance abuse or
anxiety. It has been observed that episodes of strong sexual
interest seem to occur when these individuals are feeling
depressed or anxious.
Some individuals with sexual impulsivity experience
dissociative symptoms.
Theories and Treatment of sexual impulsivity: Comprehensive
approach to understanding and treatment is required for sexual
impulsivity. Biopsychosocial perspective provides an excellent
starting point for an integrated approach for management and
treatment of sexual impulsivity. Experts have suggested that sexual
impulsivity is comparable to other additions with a similar
biochemical basis.

Psychodynamic theorists view sexually addictive behaviour

as intimacy disorder rooted in early attachment experiences.
According to this view impaired bonding between infant and
caregiver can cause some individuals to experience difficulties
regulating their affect as adults. Consequently, they get caught in
compulsive cycle in which they try to soothe themselves and
regulate internal struggles by engaging in sexual behaviours.
Exposure to abusive family environment is one of the key
factors thought to predispose an individual toward this behaviour.

It has been observed that sexual impulsivity responds to

SSRIs. Besides, treatment for sexual impulsivity involves a
combination of insight oriented, behavioural and family systems
approach.
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Insight oriented therapy focuses on bringing to the surface

the individuals underlying conflicts that motivate the behaviour.
These conflicts include resolving nonsexual problems through
sexual means, needing reassurance and feeling insecure about
ones sex role. The therapist also helps the client to learn how to
regulate affect and establish adaptive sexual boundaries.

Behavioural techniques include aversive covert conditioning,

imaginable desensitization and behavioural contracting.

Where sexual impulsivity is associated with other disorder

such as mood disorder or obsessive compulsive disorder, the
treatment of these conditions also require administration of
medicines.

Family and couples therapy is also an important component

of therapy for clients whose excessive sexual behaviour occur in
the context of long term close relationship.

15.7 TRICHOTILLOMANIA

It is one type of impulse control disorder in which there is an

urge to pull out ones hair becomes a compulsion. It is estimated
that this disorder is prevalent in about 1 to 2 % of the population.
This disorder is common among female adolescent and young
adults. In some cases the condition is transient where as in some
other cases it can last for even a decade.

Characteristics of Trichotillomania: Some important

characteristics of this disorder are as follows:
Like other impulse control disorder, persons with
Trichotillomania experience an increasing sense of tension
immediately prior to pulling out the hair or when trying to
resist the urge to pull.
The experience of hair-pulling results in feelings of relief,
pleasure or gratification.
The disturbance is not accounted for by another mental
disorder and is not due to a general medical condition (i.e.,
dermatological condition)
The disturbance causes significant distress or impairment in
social, occupational, or other important areas of functioning.
In extreme cases, some individuals swallow the hair after
they have pulled it out, risking the danger that it will solidify
in the stomach or intestine (a condition referred to as a
Trichobezoar or Rapunzel syndrome).
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People with this disorder are secretive about what they are
doing and tend to engage in hair pulling only when they are
alone. For some the interest goes beyond their hair and may
involve pulling the hair from another person, or even pets,
dolls and materials such as carpets and sweaters. People
with this disorder deny that they are pulling the hair.
This disorder often coexists with other disorders including
depression, obsessive compulsive disorder, substance
abuse or an eating disorder.

Theories and Treatment of Trichotillomania: This is not a well

understood disorder. There is no certain cause of trichotillomania,
but the current way of looking at trichotillomania is as a medical
illness. One theory on a biological level is that there is some
disruption in the system involving one of the chemical messengers
between the nerve cells in parts of the brain. There may be also a
combination of factors such as a genetic predisposition and an
aggravating stress or circumstance; as with many other illnesses.
Further, trichotillomania could be a symptom caused by different
factors in different individuals just as a cough can be produced by a
multitude of different medical problems. Finding the cause(s) will
take more research.

From a biological perspective Trichotillomania is seen as

sharing the characteristics of obsessive-compulsive disorder
because people with both these disorders respond well to
medication. Some important medications that are used in the
treatment of this disorder include paroxetine (Paxil), Venlaflaxine
(Effexor), Fluvoxamine (Luvox) and Olanzapine, which is an
atypical antipsychotic.

Behavioural theorists regard this disorder as a complex

interaction among environmental cues, hair pulling and
consequences of pulling. Individuals with this disorder learn to
associate hair-pulling behaviour with relief from tension. Thus, a
young girl who becomes anxious while studying may experience
transient relief when she tugs on her hair. Overtime, she may return
to the hair-pulling behaviour in an effort to gain the sense of relief
she experienced before. In behavioral therapy, people learn a
structured method of keeping track of the symptoms and
associated behaviors, increasing awareness of pulling, substituting
incompatible behaviors and several other techniques aimed at
reversing the habit of pulling.

Sociocultural perspective states that Trichotillomania affects

an individuals social relationship. The disorder is associated with
feelings of shame andunattractiveness and in disturbed interactions
with others.
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15.8 INTERMITTENT EXPLOSIVE DISORDER

People with Intermittent explosive disorder feel a recurrent

inability to resist assaultive or destructive acts of aggression.
Intermittent explosive disorder is characterized by repeated
episodes of aggressive, violent behavior in which you react grossly
out of proportion to the situation. Road rage, domestic abuse, and
angry outbursts or temper tantrums that involve throwing or
breaking objects may be signs of intermittent explosive disorder
(IED).

People with intermittent explosive disorder may attack others

and their possessions, causing bodily injury and property damage.
Later, people with intermittent explosive disorder may feel remorse,
regret or embarrassment. People with this condition show evidence
of the following characteristics:
During several separate episodes, they are unable to resist
aggressive impulses, which result in serious acts of assault
or destruction
Their level of aggressiveness during these episodes is
grossly out of proportion to any precipitating stressors.
Their aggressive episodes are not associated with another
mental or physical disorder.

Characteristics of Intermittent Explosive Disorder: Some

important characteristics of this disorder are as follows:
Individuals with intermittent explosive disorder display
occasional bouts of extreme rage, in which they become
assaultive or destructive without serious provocation or
verbally threaten to physically assault another individual.
During these episodes these individuals can cause serious
physical harm to themselves, other people and property that
suggest that it is like a seizure state.
In some individuals the aggressive episodes are often
preceded or accompanied by symptoms such as tingling,
tremor, heart palpitations, head pressure or even hearing
echoes.
The disorder is most commonly found among men.
This disorder is also commonly associated with clinical
disorders such as mood disorders, substance abuse
disorder and anxiety disorders
Explosive eruptions, usually lasting 10 to 20 minutes, often
result in injuries and the deliberate destruction of property.
These episodes may occur in clusters or be separated by
 262

weeks or months of nonaggression. Aggressive episodes

may be preceded or accompanied by:
a. Irritability
b. Increased energy
c. Rage
d. Tingling
e. Tremors
f. Palpitations
g. Chest tightness
h. Headache or a feeling of pressure in the head

Theories and Treatment of Intermittent Explosive Disorder:

The exact cause of intermittent explosive disorder is unknown, but
the disorder is probably caused by a number of environmental and
biological factors.

Most people with this disorder grew up in families where

explosive behavior and verbal and physical abuse were common.
Being exposed to this type of violence at an early age makes it
more likely for these children to exhibit these same traits as they
mature.

There may also be a genetic component, causing the

disorder to be passed down from parents to children.

Additionally, there may be differences in the way serotonin,

an important chemical messenger in the brain, works in people with
intermittent explosive disorder. Higher levels of the hormone
testosterone have been associated with intermittent explosive
disorder.

Researchers have observed that abnormalities in brain

circuits are involved in impulsive aggressiveness.

Learning theorists have pointed out that concepts of operant

conditioning are involved in the causation of this disorder.

15.9 INTERNET ADDICTION

Internet addiction is an impulse-control condition in which an

individual feels an irresistible need to be involved in internet-based
activities. Internet addiction is not included in DSM IV TR, but
shares many of the characteristics of the impulse-control disorders
and creates substantial intrapsychic and interpersonal turmoil for
people with this uncontrollable condition.
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Characteristics of Internet Addiction: Internet addiction is

described as an impulse control disorder, which does not involve
use of an intoxicating drug and is very similar to pathological
gambling. Similar to other addictions, those suffering from Internet
addiction use the virtual fantasy world to connect with real people
through the Internet, as a substitution for real-life human
connection, which they are unable to achieve normally. Some
important symptoms of internet addiction are as follows
Preoccupation with the Internet. (Thoughts about previous
on-line activity or anticipation of the next on-line session.)
Use of the Internet in increasing amounts of time in order to
achieve satisfaction.
Repeated, unsuccessful efforts to control, cut back or stop
Internet use.
Feelings of restlessness, moodiness, depression, or
irritability when attempting to cut down use of the Internet.
On-line longer than originally intended.
Jeopardized or risked loss of significant relationships, job,
educational or career opportunities because of Internet use.
Lies to family members, therapists, or others to conceal the
extent of involvement with the Internet.
Use of the Internet is a way to escape from problems or to
relieve a dysphoric mood. (e.g. Feelings of hopelessness,
guilt, anxiety, depression.).
The term cyber-disorder is also used to refer to internet
addiction.
Some important variants of internet addiction are as follows:
a) Cyber-sexual addiction, involving the compulsive use of
sexually oriented websites, b) cyber-relationship addiction,
characterized by over involvement in online relationships, c)
net compulsions such as online gambling, shopping or
trading, 4) information overload which involves compulsive
web-surfing or database searches and 5) computer addiction
which consists of compulsive addiction in online game
playing.

Internet addiction results in personal, family, academic,

financial, and occupational problems that are characteristic of other
addictions. Impairments of real life relationships are disrupted as a
result of excessive use of the Internet. Individuals suffering from
Internet addiction spend more time in solitary seclusion, spend less
time with real people in their lives, and are often viewed as socially
awkward. Arguments may result due to the volume of time spent
on-line. Those suffering from Internet addiction may attempt to
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conceal the amount of time spent on-line, which results in distrust

and the disturbance of quality in once stable relationships.

Theories and Treatment of Internet Addiction: Biopsychosocial

model is used to conceptualise internet addiction. Internet addiction
is explained on the basis of classical conditioning and operant
conditioning. Sociocultural perspective emphasizes on the familial,
social and cultural dynamics. Many people turn to the Internet in
order to manage unpleasant feelings such as stress, loneliness,
depression, and anxiety. When you have a bad day and are looking
for a way to escape your problems or to quickly relieve stress or
self-soothe, the Internet can be an easily accessible outlet.

People who are addicted to internet usually resist treatment.

It is only at the insistence of the loved one that they seek
assistance. Therapy can give you a tremendous boost in controlling
Internet use. Cognitive-behavioral therapy provides step-by-step
ways to stop compulsive Internet behaviors and change your
perceptions regarding Internet and computer use. Therapy can also
help you learn healthier ways of coping with uncomfortable
emotions, such as stress, anxiety, or depression.

15.10 SELF-INJURIOUS BEHAVIOUR

Self injurious behaviours are acts that are not socially

sanctioned involving deliberate self-harm, self-injury, self-mutilation
and cutting. Self injurious behaviours are not included in DSM - IV
TR but often are the basis of clinical attention and share many of
the characteristics of impulse-control disorders. Self-injurious
behaviour (SIB) has been defined as: Any behaviour, initiated by
the individual, which directly results in physical harm to that
individual. Physical harm will be considered to include bruising,
laceration, bleeding, bone fractures and breakages and other tissue
damage (Murphy and Wilson, 1985). The behavior is defined as
the deliberate, repetitive, impulsive, non-lethal harming of oneself.
Self-injury includes:
Cutting
Scratching
Picking scabs or interfering with wound healing
Burning
Punching self or objects
Infecting oneself
Inserting objects in body opening
Bruising or breaking bones
Some forms of hair pulling
Other various forms of bodily harm
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Experts estimate the incidence of habitual self-injurers is

nearly 1% of the population with a higher proportion of females than
males. The typical onset of self-harming acts is at puberty The
behaviors often last 5-10 years but can persist much longer without
appropriate treatment.

Theories and Treatment of Self-injurious behaviour: Many

factors are associated in the causation of these behaviours.
Childhood maltreatment and emotional in expressivity is the main
cause of these behaviours. Many individuals who display such
behaviour may also have some forms of organic pathology, brain
disorders, concurrent psychiatric diagnosis such as borderline
personality disorder or antisocial personality disorder,
schizophrenia, etc. Self-injury treatment options include:
Outpatient therapy, partial (6-12 hours a day)
Inpatient hospitalization

When the behaviors interfere with daily living, such as

employment and relationships, and are health or life threatening, a
specialized self-injury hospital program with an experienced staff is
recommended. The effective treatment of self-injury is most often: a
combination of medication, cognitive/behavioral therapy, and
interpersonal therapy, supplemented by other treatment services as
needed.

Medication is often useful in the management of depression,

anxiety, obsessive-compulsive behaviors, and the racing thoughts
that may accompany self-injury.

Cognitive/behavioral therapy helps individuals understand

and manage their destructive thoughts and behaviors. Contracts,
journals, and behavior logs are useful tools for regaining self-
control. Interpersonal therapy assists individuals in gaining insight
and skills for the development and maintenance of relationships.
Services for eating disorders, alcohol/substance abuse, trauma
abuse, and family therapy should be readily available and
integrated into treatment, depending on individual needs.

15.11 SUMMARY

We began this unit by discussing the concept of impulse

control disorder, which refers to urges to act in ways that are
destructive or detrimental to their well-being. Some of the impulse
control behaviours are not problematic when indulged in
moderation. Some of the most important impulse control disorders
that we discussed in this unit along with their characteristics,
theories and treatment include the following: Kleptomania,
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Pathological Gambling, Pyromania, Sexual Impulsivity,

Trichotillomania, Intermittent Explosive Disorder, Internet Addiction
and Self-injurious Behaviour.

15.12 QUESTIONS

Q1. What is Kleptomania? Discuss its characteristics, theories and

treatment?
Q2. Define Pathological Gambling and explain its characteristics,
theories and treatment.
Q3. Explain the concept of Pyromania as well as its
characteristics, theories and treatment.
Q4. Write notes on the following:
a. Sexual Impulsivity
b. Trichotillomania.
c. Intermittent Explosive Disorder
d. Internet Addiction?
e. Self-injurious Behaviour

15.13 REFERENCE

1. Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal

Psychology: Clinical Perspectives on Psychological
Disorders. (6th ed.). McGraw-Hill.

2. Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M.

(2007). Abnormal Psychology. (13th ed.). Indian reprint 2009
by Dorling Kindersley, New Delhi.

3. Oltmanns, T. F., & Emery, R. E. (2010). Abnormal

Psychology. 6th ed., New Jersey: Pearson Prentice Hall.

4. Barlow, D.H., & Durand, V.M. (2005). Abnormal Psychology:

An Integrative Approach. (4th ed.). New Delhi: Wadsworth
Cengage Learning.




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T.Y.B.A. Paper V

Abnormal Psychology
Objectives :

1) To impart knowledge and understanding of the basic concepts

in Abnormal Psychology and the theories about Abnormality.
2) To impart knowledge and understanding of the different
Psychological Disorders their symptoms, diagnosis, causes
and treatment.
3) To create awareness about Mental Health problems in society.
4) To create a foundation for higher education and a professional
career in Clinical Psychology.

(4 lectures per week; 48 lectures per tem; 9 lectures per topic

and 6 lectures for Orientation to the Paper)

Topic I : Understanding Abnormality; Definition, Classification,

and Assessment
a) What is Abnormal Behaviour?
b) The Diagnostic and Statistical Manual of Mental Disorders
c) Psychological Assessment Clinical Interviews and Mental
Status Examination
d) Behavioural, Multicultural, Environmental, and Physiological
Assessment

Topic II : Theoretical Perspectives

a) The purpose of Theoretical Perspectives in Abnormal
Psychology
b) Psychodynamic Perspective
c) Humanistic Perspective
d) Socio cultural Perspective
e) Behavioral and Cognitively based Perspectives
f) Biological Perspective
g) Bio-psychosocial Perspectives on theories and treatments: An
Integrative Approach
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Topic III : Anxiety Disorders

a) The Nature of Anxiety Disorders
b) Panic Disorder and Agoraphobia
c) Specific Phobias
d) Social Phobia
e) Generalized Anxiety Disorder
f) Obsessive Compulsive Disorder
g) Acute Stress Disorder and Post Traumatic Stress Disorder
h) Anxiety Disorders : The Bio-psychosocial Perspective

Topic IV : Somatoform Disorders, Psychological Factors

Affecting Medical Conditions and Dissociative Disorders
a) Somatoform Disorders
b) Psychological Factors Affecting Medical Conditions
c) Dissociative disorders
d) Somatoform disorders, Psychological Factors affecting medical
conditions and Dissocaitive disorders : The Bio-psychosocial
perspective

Topic V : Sexual Disorders

a) What is Abnormal Sexual Behaviour?
b) Paraphilias
c) Gender Identity Disorder
d) Sexual Dysfunctions
e) Sexual Disorders : The Bio-psychosocial Perspective

Topic VI : Mood Disorders

a) General Characteristics of Mood Disorders
b) Depressive Disorders
c) Disorders involving alterations in Mood
d) Theories and Treatments of Mood Disorders
e) Suicide who and why
f) Mood Disorders : The Bio-psychosocial Perspective
 269

Topic VII : Schizophrenia and Related Disorders

a) Characteristics of Schizophrenia
b) Other Psychotic Disorders
c) Theories and Treatment of Schizophrenia
d) Schizophrenia : The Bio-psychosocial Perspective

Topic VIII : Personality Disorders

a) The Nature of Personality Disorders
b) Antisocial Personality Disorder
c) Borderline Personality Disorder
d) Histrionic, Narcissistic, Paranoid, Schizoid, Schizotypal,
Avoidant, Dependant, and Obsessive Compulsive Personality
Disorders
e) Personality Disorders : The Bio-psychosocial Perspective.

Topic IX : Development Related, Aging-Related and

Cognitive Disorders
a) Introductory Issues
b) Mental Retardation
c) Pervasive Development Disorders
d) Attention Deficit and Disruptive Behaviour Disorders
e) Learning, Communication and Motor Skills Disorder
f) Separation Anxiety Disorder
g) Other Disorders that Originate in Childhood
h) Development Related Disorders : The Bio-psychosocial
Perspective
i) The Nature of Cognitive Disorders
j) Delirium, Amnestic Disorders, Traumatic Brain Inury, Dementia
k) Cognitive Disorders: The Bio-psychosocial Perspective

Topic X : Eating Disorders and Impulse Control Disorders

a) Eating Disorders
b) Impulse Control Disorders
c) Internet Addiction
d) Self Injurious Behaviors
e) Eating Disorders and Impulse Control Disorders: The Bio-
Psychosocial Perspective
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Note : As an Orientation to this paper, the following sub-topics

should be taught in brief (questions will not be set on these sub-
topics)

a) Abnormal Psychology throughout History; Research Methods in

Abnormal Psychology; Impact of Psychological Disorders on the
individual, family, community and society; Reducing stigma.
b) Experiences of client and clinician; The diagnostic process;
Treatment Planning and Implementation.
c) Some Ethical and Legal Issues relevant in India.

Book for study

Halgin, R. P., Whitbourne, S. K. (2010). Abnormal Psychology:
Clinical Perspectives on Psychological disorders. (6th ed.) McGraw-
Hill

Book for Reference :

1. Barlow, D. H., & Durand, V. M. (2005). Abnormal Psychology:
An Integrative Approach. (4th ed.). New Delhi: Wadsworth
Cengage Learning.
2. Beidel, D. C., Bulik, C. M., & Stanley, M. A. (2010). Abnormal
Psychology. New Jersey : Pearson Prentice Hall
3. Bennet, P. (2003). Abnormal and Clinical Psychology: An
Introductory Textbook. Open University Press.
4. Carson, R. C., Butcher, J. N. Mineka, S., & Hooley, J. M. (2007).
Abnormal Psychology. (13th ed.). Indian reprint 2009 by Dorling
Kindersley, New Delhi
5. Compas, B. E, & Gotlib, I. H. (2002). Introduction to Clinical
Psychology: Science and Practice. McGraw-Hill.
6. Dhanda, Amita. (2000) Legal Order and Mental Disorder. New
Delhi, Sage publications pvt. Ltd.
7. Nolen-Hoeksema, S. (2008). Abnormal Psychology. (4th ed.)
New York: MrGraw-Hill.
8. Mash, E. J., & Wolfe, D. A. (2005). Abnormal Child Psychology.
(3rd ed.). Wadsworth / Thomson Learning
9. Oltmanns, T. F., & Emery, R. E. (2010). Abnormal Psychology.
6th ed., New Jersey: Pearson Prentice Hall.