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COUNSELLORS’ APPROACH TO MENTAL DISORDERS

Based on

Diagnostic and Statistical Manual of Mental Disorders – 5

(DSM-5)

By

D. John Antony, OFM.Cap.

GURU PUBLICATIONS

No. 100, Kurinji Nagar, Near Lions Club

Dindigul – 624 005, Tamil Nadu, India
Tel: 0451-2441140; Mobile: 99946 46046
Email: [email protected]
Website: www.indianpsychologyclinic.com

2018
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 D. John Antony, OFM.Cap. 2018

Other Books by the Author:

1. Dynamics of Counselling (1994)

Microskill Model
TA & NLP included
2. Skills of Counselling (1995, 2003)
Microskill Model
Kinesics & Focusing Included
3. Types of Counselling (1996, 2011)
Lifespan Developmental & Situational Approach
Developmental Psychology Included
4. Psychotherapies in Counselling (2003)
Includes Theories of Personality
5. Self Psychology in Counselling (2005)
A Textbook of Self Psychology
6. Family Counselling (2005)
The Classic Schools
7. Trauma Counselling (2005)
8. Emotions in Counselling (2005)
9. Mental Disorders Encountered in Counselling (2006)
A Textbook of Clinical Psychology Based on DSM-IV
10. Principles and Practice of Counselling (2009)
11. Personality Profile Through Handwriting Analysis (2009)
A Textbook of Graphology
12. The Body Never Lies (2011)
The Basics of Body Language
13. The Flute of A Broken Reed (2012)
A Journey in Vulnerability
A Series of Psychological Themes
14. The Bangle Seller (2012)
The Different Faces of Love
A Series of Psychological Themes
15. Hypnotic Counselling (2014)
A Textbook of Hypnotism
16. Counselling Made Easy (2015)
Microskill Model
A Textbook of Counselling
Body Language Included

17. Mw;Wg;gLj;Jk; fiy (1996)

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18.. Mw;Wg;gLj;Jjypd; tiffs; (1997)
tho;T Koikf;fhd tsh;epiy kw;Wk; #oy; mZFKiw
tsh;epiyf;fhd cseytpay; ,izf;fg;gl;Ls;sJ

First Edition : September 2018

Published by : Guru Publications
No. 100, Kurinji Nagar, Near Lions Club, Dindigul – 624 005, Tamil Nadu,
India
Printed at : St. Joseph’s Press, Trichy. Mobile: (91)
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DEDICATED

To

Those careseekers

who taught me the lessons of

being with vulnerable population

in their woundedness
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ACKNOWLEDGEMENTS

I would like to express my sentiments of gratitude to

Fr. Dr. A. J. Mathew, Ph.D., OFM.Cap., Provincial Minister of Amala Annai

Province of Tamil Nadu for his encouragement,

Dr. K. Soundar Rajan, Ph.D., for his efficient editing, and

Mr. S. A. Rajan, Clinical Psychologist, for his beautiful cover design and the painstaking
presswork.
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Concise Table of Contents

Preface
1. Mental Status Examination
2. Personality Disorders
3. Schizophrenia Spectrum and Other Psychotic Disorders
4. Bipolar and Related Disorders
5. Depressive Disorders
6. Anxiety Disorder
7. Obsessive-Compulsive and Related Disorders
8. Trauma- and Stressor-Related Disorders
9. Dissociative Disorders
10. Somatic Symptoms and Related Disorders
11. Feeding and Eating Disorders
12. Elimination Disorders
13. Sleep-Wake Disorders
14. Sexual Dysfunctions
15. Gender Dysphoria
16. Paraphilic Disorders
17. Disruptive, Impulse-Control, and Conduct Disorders
18. Neurodevelopmental Disorders
19. Neurocognitive Disorders
20. Substance-Related and Addictive Disorders
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Detailed Table of Contents

Preface

1. Mental Status Examination

1. Introduction
2. General Description
1) Appearance
2) Motor Behaviour
3) Speech
4) Attitude
3. Emotions
1) Mood
2) Affective Expression
3) Appropriateness
4. Perceptual Disturbances
1) Hallucinations and Illusions
2) Depersonalisation & Derealisation
5. Thought Process
1) Stream of Thought
2) Thought Content (Delusions, Obsessions, Compulsions,
Preoccupations, Phobias)
3) Abstract Thinking
4) Education and Intelligence
5) Concentration
6. Orientation (Time, Place, Person, Situation)
7. Memory
1) Remote Memory
2) Recent Past Memory
3) Recent Memory
8. Impulse Control
9. Judgement
10. Insight
11. Reliability

2. Personality Disorders

1. Introduction
2. General Personality Disorder
1) Diagnostic Criteria
2) Usefulness of Treatment
3) Treatment

Cluster “A” Personality Disorders:

Odd or Eccentric
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1. Paranoid Personality Disorder

1) Diagnostic Criteria
2) Treatment
2. Schizoid Personality Disorder
1) Diagnostic Criteria
2) Treatment
3. Schizotypal Personality Disorder
1) Diagnostic Criteria
2) Treatment

Cluster “B” Personality Disorders:

Dramatic, Emotional, or Erratic

1. Antisocial Personality Disorder

1) Diagnostic Criteria
2) Treatment
2. Borderline Personality Disorder (BPD)
1) Diagnostic Criteria
2) Treatment
(1) Dialectical Behaviour Therapy (DBT)
a. Dialectics as a World View
b. Stages of Dialectical Behaviour Therapy
c. Dialectical Strategies
(a) Dialectics of the Relationship: Balancing Treatment
Strategies
(b) Teaching Dialectical Behaviour
(c) Specific Dialectical Strategies
d. Behavioural Analysis
(a) Problem-Solving Procedures
(b) Cognitive Modification
(c) Exposure
3. Histrionic Personality Disorder
1) Diagnostic Criteria
2) Treatment
4. Narcissistic Personality Disorder
1) Diagnostic Criteria
2) Treatment

Cluster “C” Personality Disorders:

Anxious or Fearful

1. Avoidant Personality Disorder

1) Diagnostic Criteria
2) Treatment
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2. Dependent Personality Disorder

1) Diagnostic Criteria
2) Treatment
3. Obsessive-Compulsive Personality Disorder (OCPD)
1) Diagnostic Criteria
2) Treatment

Other Personality Disorders

1. Personality Change due to Another Medical Condition

1) Diagnostic Criteria

2. Conclusion

3. Schizophrenia Spectrum and Other Psychotic Disorders

1. Introduction
2. Schizophrenia Symptoms and Diagnosis
1) “Positive” Symptoms
(1) Delusions
(2) Hallucinations
(3) Disorganized Thinking
(4) Grossly Disorganized Motor Behaviour Disorders
(5) Confused Thoughts and Speech
(6) Trouble Concentrating
(7) Different Movements
2) “Negative” Symptoms
3) “Cognitive” Symptoms
Part I
Schizophrenia
1. Schizophrenia
1) Diagnostic Criteria
2. Schizophreniform Disorder
1) Diagnostic Criteria
3. Schizoaffective Disorder
1) Diagnostic Criteria
4. Brief Psychotic Disorder
1) Diagnostic Criteria
5. Delusional Disorder
1) Diagnostic Criteria
6. Substance/Medication-Induced Psychotic Disorder
1) Diagnostic Criteria
7. Psychotic Disorder due to Another Medical Condition
1) Diagnostic Criteria
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Part II
Catatonia

1. Catatonia Associated with Another Mental Disorder (Catatonia

Specifier)
1) Diagnostic Criteria
2. Catatonic Disorder due to Another Medical Condition
1) Diagnostic Criteria
Part III
1. Course of Schizophrenia
2. Outcome of Schizophrenia
3. Treatment
1) Clinical Management
2) Physical Treatment
(1) Electroconvulsive Therapy (ECT)
3) Psychosocial and Programmatic Intervention
4) Psychotherapies
(1) Cognitive Therapy Techniques
a. Cognitive Rehabilitation
b. Cognitive Content
c. Social Skills Training
5) Psychosocial Treatment and Rehabilitation
6) Rehabilitation Centre
7) Treatment for Other Psychotic Disorders
4. Conclusion

4. Bipolar and Related Disorders

1. Introduction
1) Bipolar I Disorder
2) Bipolar II Disorder
3) Cyclothymia
4) Symptoms
5) Is It Bipolar Disorder or Depression?
6) Indication that One’s Depression is Bipolar Disorder
2. Bipolar I Disorder
1) Diagnostic Criteria
3. Bipolar II Disorder
1) Diagnostic Criteria
4. Cyclothymic Disorder
1) Diagnostic Criteria
5. Substance/Medication-Induced Bipolar and Related Disorder
1) Diagnostic Criteria
6. Bipolar and Related Disorder due to Another Medical Condition
1) Diagnostic Criteria
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7. Treatment
1) Medication Treatment for Bipolar Disorder
2) Psychotherapy
(1) Cognitive Therapy (CT)
(2) Cognitive-Behaviour Therapy (CBT)
(3) Behaviour Therapy
(4) Interpersonal Therapy (IPT)
(5) Interpersonal and Social Rhythm Therapy
(6) Family-Focused/Family Therapy
(7) Psychodynamic Psychotherapy
(8) Jungian Therapy
(9) Lifestyle Changes
(10) Complementary Treatments for Bipolar Disorder
(11) Other Therapies
3) Combining Medications and Psychotherapy
4) Comprehensive Treatment for Bipolar Disorder
8. Conclusion

5. Depressive Disorders

1. Introduction
2. Disruptive Mood Dysregulation Disorder
1) Diagnostic Criteria
3. Major Depressive Disorder
1) Diagnostic Criteria
4. Persistent Depressive Disorder (Dysthymia)
1) Diagnostic Criteria
5. Premenstrual Dysphoric Disorder
1) Premenstrual Syndrome
2) Diagnostic Criteria
3) Treatment
6. Substance/Medication-Induced Depressive Disorder
1) Diagnostic Criteria
7. Depressive Disorder due to Another Medical Condition
1) Diagnostic Criteria
8. Psychotherapies
1) Cognitive Therapy
(1) Theory of Cognitive Therapy
(2) Assumption of Cognitive Model
(3) Cognitive Triad of Depression
(4) Cognitive Techniques
a. Eliciting Automatic Thoughts
b. Testing Automatic Thoughts
c. Reattribution
d. Schemas
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(a) Maladaptive Schemas

(b) Characteristics of Maladaptive Schema
2) Behaviour Techniques
3) Psychosocial Techniques
9. Conclusion

6. Anxiety Disorders
1. Introduction
2. Separation Anxiety Disorder
1) Diagnostic Criteria
2) Treatment
3. Selective Mutism
1) Diagnostic Criteria
2) Treatment
4. Specific Phobia
1) Diagnostic Criteria
2) Treatment
5. Social Anxiety Disorder (Social Phobia)
1) Diagnostic Criteria
2) Treatmrny
3) Psychotherapies
(1) Overview of Cognitive-Behaviour Group Therapy (CBGT)
a. Treatment Orientation Interview
b. Treatment Preview
c. SUDs Training
d. Fear and Avoidance Hierarchy
e. Treatment Contract
(2) Psychodynamic Therapy
(3) Visual-Kinaesthetic Dissociation (VKD)
(4) Pharmacology
(5) Multifaceted Treatment
6. Panic Disorder
1) Diagnostic Criteria
7. Panic Attack Specifier
1) Overview of Treatment
(1) Cognitive Restructuring
(2) Breathing Retraining
(3) Relaxation
(4) Interoceptive Exposure
8. Agoraphobia
1) Diagnostic Criteria
2) Treatment
(1) Cognitive-Behaviour Therapy
(2) Situational Exposure
(3) Massed Exposure
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(4) Graduated Intense Exposure

(5) Controlled Escape
(6) No Distraction
(7) Pharmacotherapy
9. Generalized Anxiety Disorder
1) Diagnostic Criteria
2) Overview of Treatment
3) Process of Treatment
(1) Relaxation Training and Techniques
(2) Cognitive Therapy
(3) Worry Exposure
(4) Worry Behaviour Prevention
(5) Problem Solving
(6) Time Management
(7) Psychodynamic Psychotherapy
(8) Other Behaviour Therapies
10. Substance/Medication-Induced Anxiety Disorder
1) Diagnostic Criteria
11. Anxiety Disorder due to Another Medical Condition
1) Diagnostic Criteria
12. Treatment
13. Conclusion

7. Obsessive-Compulsive and Related Disorders

1. Introduction
2. Obsessive-Compulsive Disorder (OCD)
1) Diagnostic Criteria
3. Body Dysmorphic Disorder (BDD)
1) Diagnostic Criteria
2) Treatment
4. Hording Disorder
1) Diagnostic Criteria
5. Trichotillomania (Hair-Pulling Disorder)
1) Diagnostic Criteria
2) Treatment
6. Excoriation (Skin-Picking) Disorder
1) Diagnostic Criteria
7. Substance/Medication-Induced Obsessive-Compulsive and Related
Disorder
1) Diagnostic Criteria
8. Obsessive-Compulsive and Related Disorder due to Another Medical
Condition
1) Diagnostic Criteria
9. Treatment
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1) Psychotherapies
(1) Cognitive-Behaviour Therapy (CBT)
(2) Associative Splitting
(3) Behaviour Therapy (BT)
2) Medication
3) Combination
4) Other Therapies
(1) Psychoanalytic Psychotherapy
(2) Supportive Psychotherapy
(3) Thought-Stopping
(4) Systematic Desensitization
(5) Modelling
(6) Hypnotic Counselling
(7) Swish
10. Conclusion

8. Trauma- and Stressor-Related Disorders

1. Introduction
2. Acute Stress Disorder (ASD)
1) Diagnostic Criteria
2) Description of ASD
3) Commonality of ASD
4) Vulnerability to ASD resulting from Trauma
5) Difference between ASP and PTSD
6) ASD’s Predictive Validity for PTSD
7) Diagnosis of ASD
8) Treatment for ASD
(1) Cognitive Behavioural Interventions
(2) Cognitive Behavioural Therapy
(3) Psychological Debriefing
(4) Visual-Kinaesthetic Dissociation (VKD)
(5) Counselling
3. Posttraumatic Stress Disorder (PTSD)
1) Diagnostic Criteria for Adults
2) Diagnostic Criteria for Children
3) Treatment
(1) Psychotherapy
a. Visual-Kinaesthetic Dissociation (VKD)
b. Eye Movement Desensitization and Reprocessing (EMDR)
c. Psychodynamic Psychotherapy
d. Psychoeducation and Support
e. Reframing
f. Cognitive and Behaviour Therapies (CBT)
g. Behaviour Therapies
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h. Stress Inoculation Training (SIT)

i. Prolonged Exposure
j. Cognitive Processing Therapy (CPT)
k. Prolonged Exposure Therapy
l. Cognitive Processing Therapy
m. Anxiety Management Therapy(AMT)
n. Hypnosis
(2) Pharmacotherapy
4. Reactive Attachment Disorder (RAD)
1) Diagnostic Criteria
2) Treatment
3) Alternative Treatment
5. Disinhibited Social Engagement Disorder
1) Diagnostic Criteria
2) Treatment
6. Adjustment Disorders
1) Diagnostic Criteria
2) Treatment
(1) Psychosocial Treatment
(2) Supportive Psychotherapy
(3) Individual Psychotherapy
(4) Family Therapy
(5) Behaviour Therapy
(6) Group Therapy
(7) Self-Help
3) Medications
7. Conclusion

9. Dissociative Disorders

1. Introduction
2. Dissociative Identity Disorder (DID)
1) Diagnostic Criteria
2) Treatment
(1) Psychotherapy
a. Therapeutic Direction (Integration of Disparate Elements)
b. Hypnosis
c. Memory Retrieval
d. The “Rule of Thirds”
e. Traumatic Transference
f. Integration
(2) Psychopharmacology
3. Dissociative Amnesia
1) Diagnostic Criteria
2) Treatment
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(1) Psychotherapy
a. Clinical Hypnosis
b. Screen Technique
c. Cognitive Therapy
d. Family Therapy
e. Creative Therapies
(2) Medication
4. Depersonalization/Derealisation Disorder
1) Diagnostic Criteria
2) Treatment
5. Dissociative Fugue Disorder
1) Treatment
6. Dissociative Trance Disorder
1) Treatment
7. Treatments and Drugs for Dissociative Disorders
1) Psychotherapy
(1) Self-Help
(2) Encouraging Healthy Coping Behaviours
(3) Logging and Monitoring Emotions
(4) Developing a Crisis Plan
(5) Behaviour Therapy
(6) Hypnosis
(7) Abreaction
(8) Supportive Psychotherapy
(9) Psychoanalysis
2) Medications
8. Conclusion

10. Somatic Symptom and Related Disorders

1. Introduction
2. Somatic Symptom Disorder
1) Diagnostic Criteria
2) Treatment
(1) Doctor-Patient Relationship
(2) Psychosocial Interventions (Primary Care Management)
(3) Cognitive-Behaviour Therapy
(4) Supportive Psychotherapy
(5) Behaviour Modification
(6) Relaxation Therapy with Graded Physical Exercises
3. Illness Anxiety Disorder (Formerly Called Hypochondriasis)
1) Diagnostic Criteria
2) Treatment
(1) Relaxation Techniques
(2) Teaching Relaxed Breathing Techniques
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(3) Treating Underlying Anxiety

(4) Breathing-in-Bag Techniques
4. Conversion Disorder (Also Called Functional Neurological Symptom
Disorder)
1) Diagnostic Criteria
2) Treatment
5. Psychological Factors Affecting Other Medical Conditions
1) Diagnostic Criteria
6. Factitious Disorder
1) Diagnostic Criteria
(1) Factitious Disorder Imposed on Self
(2) Factitious Disorder Imposed on Another
7. Irritable Bowel Syndrome (IBS)
1) Treatment

8. Conclusion

11. Feeding and Eating Disorders

1. Introduction
2. Anorexia Nervosa (AN)
1) Diagnostic Criteria
2) Treatment
(1) Behaviour Therapy (BT)
(2) Individual Psychotherapy
(3) Hospitalization
(4) Group Therapy and Family Therapy
3. Bulimia Nervosa (BN)
1) Diagnostic Criteria
2) Treatment
(1) Cognitive-Behaviour Therapy (CBT)
(2) Behaviour Therapy
(3) Individual Psychotherapy
(4) Group Therapy and Family Therapy
4. Binge-Eating Disorder (BED)
1) Diagnostic Criteria
2) Treatment
5. Pica
1) Diagnostic Criteria
2) Treatment
6. Rumination Disorder
1) Diagnostic Criteria
2) Treatment
7. Avoidant/Restrictive Food Intake Disorder (ARFID)
1) Diagnostic Criteria
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2) Treatment
8. Obesity
1) Conceptual Model for Treatment
(1) Focus on Lifestyle Change
(2) Multidisciplinary Approach
(3) Cognitive-Behaviour Therapy
(4) Dialectical Behaviour Therapy
(5) Manualized Treatment
(6) Hospitalization
9. Treatment for Feeding Disorder
(1) Psychotherapy
(2) Family Counselling
(3) Dietary Consultation
(4) Peer Support Groups
(5) Residential Treatment Centres
(6) Outpatient Treatment Programmes
(7) Inpatient Hospitalization
(8) Medication

10. Conclusion

12. Elimination Disorders

1. Introduction
2. Enuresis
1) Diagnostic Criteria
2) Treatment
3. Encopresis
1) Diagnostic Criteria
2) Treatment
4. Treatment and Prognosis
5. Conclusion

13. Sleep-Wake Disorders

1. Introduction
2. Insomnia Disorder
1) Diagnostic Criteria
2) Treatment
3. Hypersomnolence Disorder
1) Diagnostic Criteria
2) Treatment
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4. Narcolepsy
1) Diagnostic Criteria
2) Treatment
5. Breathing-Related Sleep Disorders
1) Obstructive Sleep Apnoea Hypopnoea
(1) Diagnostic Criteria
2) Central Sleep Apnoea
(1) Diagnostic Criteria
3) Sleep-Related Hypoventilation
(1) Diagnostic Criteria
4) Treatment for Breathing-Related Sleep Disorders
(1) Conservative Treatments
(2) Mechanical Therapy
(3) CPAP
(4) Bi-Level PAP
(5) Auto CPAP
(6) Adaptive Servo-Ventilation (ASV)
(7) Mandibular Advancement Devices
(8) Nasal Expiratory Positive Airway Pressure
(9) Oral Pressure Therapy
(10) Hypoglossal Nerve Stimulator
(11) Surgery
6. Circadian Rhythm Sleep-Wake Disorders
1) Diagnostic Criteria
2) Treatment
7. Parasomnias
1) Non-Rapid Eye Movement Sleep Arousal Disorders
(1) Diagnostic Criteria
(2) Treatment
2) Rapid Eye Movement Sleep Behaviour Disorder
(1) Diagnostic Criteria
(2) Treatment
3) Nightmare Disorder
(1) Diagnostic Criteria
(2) Treatment
4) Restless Legs Syndrome
(1) Diagnostic Criteria
(2) Treatment
5) Substance/Medication-Induced Sleep Disorder
(1) Diagnostic Criteria
(2) Treatment
8. Treatment for Sleep Disorders
9. Conclusion

14. Sexual Dysfunctions

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1. Introduction
2. Normal Human Sexual Response Cycle
3. Male Hypoactive Sexual Desire Disorder
1) Diagnostic Criteria
2) Treatment
4. Erectile Disorder
1) Diagnostic Criteria
2) Treatment
(1) Psychological Treatment
(2) Psychosexual Counselling
(3) Cognitive Behaviour Therapy
(4) Sensate Focus/Sexual Skill Training
(5) Hurry, Worry, Fear, and Anxiety
(6) Education
(7) Stimulus Control
(8) Cognitive Restructuring
(9) Anchoring on Erotic Zones of the Body
5. Delayed Ejaculation
1) Diagnostic Criteria
2) Treatment
6. Premature (Early) Ejaculation
1) Diagnostic Criteria
2) Treatment
7. Female Sexual Interest/Arousal Disorder
1) Diagnostic Criteria
2) Treatment
8. Female Orgasmic Disorder
1) Diagnostic Criteria
2) Treatment
9. Genito-Pelvic Pain/Penetration Disorder
1) Diagnostic Criteria
2) Treatment
10. Substance/Medication-Induced Sexual Dysfunction
1) Diagnostic Criteria
11. Treatment
12. Conclusion
15. Gender Dysphoria

1. Introduction
2. Gender Dysphoria (GD)
1) Diagnostic Criteria
(1) Gender Dysphoria in Children
(2) Gender Dysphoria in Adolescents and Adults
2) Treatment for Gender Dysphoria
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3) Treatment for Gender Dysphoria in Childhood

4) Reconciliation with the Anatomic Sex
5) Sex-Change to the Desired Gender
6) Treatment
7) Brief Examples of the Techniques
(1) Sensate Focus Technique
(2) Squeeze Technique
3. Treatment
1) Counselling
2) Psychological Treatments
4. Conclusion

16. Paraphilic Disorders

1. Introduction
2. Voyeuristic Disorder
1) Diagnostic Criteria
3. Exhibitionistic Disorder
1) Diagnostic Criteria
4. Frotteuristic Disorder
1) Diagnostic Criteria
5. Sexual Masochism Disorder
1) Diagnostic Criteria
6. Sexual Sadism Disorder
1) Diagnostic Criteria
7. Paedophilic Disorder
1) Diagnostic Criteria
8. Fetishistic Disorder
1) Diagnostic Criteria
9. Transvestic Disorder
1) Diagnostic Criteria
10. Causes of Paraphilias
11. Principles that Underlie Treatment for Paraphilias
12. Treatment
1) Victim Identification
2) Covert Conditioning
3) Orgasmic Reconditioning
4) Masturbatory Extinction
5) Masturbatory Satiation
6) Aversive Therapies
7) Group Therapy
8) Medications
13. Conclusion
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17. Disruptive, Impulse-Control, and Conduct Disorders

1. Introduction
2. Oppositional Defiant Disorder
1) Diagnostic Criteria
2) Treatment
3. Intermittent Explosive Disorder
1) Diagnostic Criteria
2) Treatment/Course and Prognosis
4. Conduct Disorder
1) Diagnostic Criteria
2) Treatment
5. Antisocial Personality Disorder
6. Pyromania
1) Diagnostic Criteria
2) Treatment
7. Kleptomania
1) Diagnostic Criteria
2) Treatment/Course and Prognosis
8. Treatment
9. Conclusion

18. Neurodevelopmental Disorders

1. Introduction
2. Intellectual Disabilities
1) Intellectual Disability (Intellectual Developmental Disorder) (Formerly
Known as Mental Retardation)
(1) Diagnostic Criteria
2) Global Developmental Delay
3) Treatment
3. Communication Disorders
1) Language Disorder
(1) Diagnostic Criteria
2) Speech Sound Disorder
(1) Diagnostic Criteria
3) Childhood-Onset Fluency Disorder (Stuttering)
(1) Diagnostic Criteria
4) Social (Pragmatic) Communication Disorder
(1) Diagnostic Criteria
5) Treatment
4. Autism Spectrum Disorder
1) Diagnostic Criteria
2) Treatment
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(1) Counselling
(2) Behaviour Therapy
(3) Other Interventions
5. Attention-Deficit/Hyperactivity Disorder
1) Attention-Deficit/Hyperactivity Disorder
(1) Diagnostic Criteria
2) Treatment
6. Specific Learning Disorder
1) Diagnostic Criteria
7. Motor Disorders
1) Developmental Coordination Disorder
(1) Diagnostic Criteria
2) Stereotypic Movement Disorder
(1) Diagnostic Criteria
(2) Treatment
3) Tic Disorders
(1) Diagnostic Criteria
(2) Treatment
8. Treatment for Neurodevelopmental Disorders
9. Conclusion

19. Neurocognitive Disorders

1. Introduction
2. Delirium
1) Diagnostic Criteria
2) Treatment
3. Major and Mild Neurocognitive Disorders
1) Major Neurocognitive Disorder
(1) Diagnostic Criteria
2) Mild Neurocognitive Disorder
(1) Diagnostic Criteria
4. Major Or Mild Neurocognitive Disorder due to Alzheimer’s Disease
1) Diagnostic Criteria
5. Major Or Mild Frontotemporal Neurocognitive Disorder
1) Diagnostic Criteria
6. Major Or Mild Neurocognitive Disorder with Lewy Bodies
1) Diagnostic Criteria
7. Major Or Mild Vascular Neurocognitive Disorder
1) Diagnostic Criteria
8. Treatment
9. Conclusion

20. Substance-Related and Addictive Disorders

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1. Introduction
2. Gambling Disorder
(1) Diagnostic Criteria
(2) Treatment
3. Therapy for Substance-Related and Addictive Disorders
1) Theoretical Model
(1) Problem Severity
(2) Motivation
(3) Factors Maintaining Current Drinking Pattern
2) Treatment Modalities
(1)Treatment of Alcohol Dependence
(2) Detoxification
(3) Biofeedback
(4) Abreaction
(5) Supportive Psychotherapy
(6) Couple Therapy
(7) Group Therapy
(8) Self-

Help Groups

4. Conclusion
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Preface
Counsellors, while dealing with the clients’ problems or issues, are at a
loss at times not knowing what counselling or psychotherapy to apply. First,
one should be aware of the type of mental illnesses that beset humans in the
clinical setup. Secondly, one should also know what will work for the client
with a particular issue. Keeping this in mind, I thought of presenting the
mental disorders according to the Diagnostic and Statistical Manual of Mental
Disorders – 5 (DSM - 5) of the American Psychiatric Association (APA) that is
in vogue in the clinical field. After speaking about the symptoms of each
illness, I am presenting the available counselling or psychotherapies that are
being used by counsellors in general. Thus, this book is meant to be a
handbook to make quick references to counselling and psychotherapy. This
will greatly assist counsellors and psychotherapists who are beginners; and
veterans too will find it convenient for easy reference.

One may make use of any counselling or psychotherapy for a particular

issue; yet by the experience of the people in the helping profession of
counselling and psychotherapy, we begin to understand that some specific
counselling and psychotherapy will directly address certain type of mental
illness. Therefore, I have endeavoured to list those counselling methods and
psychotherapies after the description of the each mental illness. For some of
the mental illnesses, we do not have adequate therapies. Of course,
counsellors are pursuing their research in finding out suitable therapies.
Some of them are still in their infancy state and counsellors make use of trial
and error methods to test their hypotheses. Certainly, they have also come
up with the happy conclusion of listing out some particular therapies for
certain kinds of psychological illnesses.

I would always welcome individuals to try various types of therapies

with clients. If one method does not work, one should immediately go to
other types of therapies. It is good to accept clients with a positive approach
thinking that you can really facilitate the clients to work out their problems.
In some way, you communicate your confidence to the clients. Clients non-
verbally pick up your confidence or diffidence. Of course, in the beginning, all
of us are nervous, but as days go by, one can learn to be comfortable with
the clients and their issues. Sit with the clients with the attitude that you
would certainly heal the clients. If you are determined, then your
determination and faith will facilitate the clients to heal themselves.

Above all, one needs to be genuine in one’s relationship and dealing

with the clients. Anything non-genuine will be counterproductive of your
efforts to facilitate the client. With this introductory note, I feel delighted to
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invite you to go through the pages of this book and add more therapies to
the given list by your own experience.

For the sake of simplicity, and unless otherwise stated, the use of
“man,” “he,” “him,” “his,” and “himself” will apply equally to both genders.
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1. Mental Status Examination

1. Introduction
The fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) introduces an integration of a dimensional approach to
diagnosis and classification, in contrast to the categorical approach of the
fourth edition. Previous editions of DSM used a strictly categorical model
requiring a clinician to determine that a disorder was present or absent. The
dimensional approach, which allows a clinician more latitude to assess the
severity of a condition and does not imply a concrete threshold between
“normality” and a disorder, is now incorporated via select diagnoses. Its
inclusion will also provide more utility in research contexts.

If one uses categorical approach of classifying mental disorders one

focuses on the kind of problem a person is experiencing but in dimensional
approach one focuses on the extent in which a person has a disorder.
Oftentimes many disorders, especially personality disorders, are simply
normal traits gone too far. The dimensional approach quantifies a person’s
symptoms or other characteristics of interest and represents them with
numerical values on one or more scales or continuums, rather than assigning
them to a mental disorder category.

The mental state examination is a description of all the areas of mental

functioning of the patient. Psychiatrists follow a structured format in recording
their findings. These descriptive data are then used to support the psychiatrists’
diagnostic conclusions.
2. General Description
1) Appearance
This includes the prominent physical features of an individual and they
highlight his unique aspects. They are facial features; hair colour, texture,
styling, and grooming; height; weight; body shape; cleanliness; neatness;
posture; bearing; clothing; jewellery; skin texture, scar formation, and tattoos;
level of eye contact; eye movements; facial expressions and mobility;
tearfulness; degrees of friendliness; and an estimate of how old the patient looks
compared with his chronological age.
2) Motor Behaviour
This includes the patient’s gait and freedom of movement, noting the
firmness and strength of handshake. The psychiatrist observes any involuntary
or abnormal movements such as tremors, tics, mannerisms, lip smacking,
akathisias, or repeated stereotyped movements. Comments on the
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purposefulness of movements and the degrees of agitation of the patient as

reflected in pacing and hand-wringing are noted.
3) Speech
The rate of speech, the spontaneity of verbalizations, the range of voice
intonation patterns, the volume in terms of loudness, defects with verbalizations
such as stammering or stuttering, and any aphasias are to be noted.
4) Attitudes
How the patient related to the interviewer, the general impression as
“friendly and cooperative,” and focus on any shifts or changes in attitude during
particular points in the interview are to be noted.
3. Emotions
1) Mood
Mood is the sustained feeling tone that prevails over time for a patient. At
times, the patient will verbalize this mood, and at other times, the psychiatrist
will have to enquire about it and even infer the patient’s mood from observations
of the patient’s nonverbal body language. When describing, it is necessary to
record how deeply it is felt, the length of time that it has prevailed, and how
much it fluctuates. Anxious, panicky, terrified, sad, depressed, angry, enraged,
euphoric, and guilty are the moods frequently described.
2) Affective Expression
Observations regarding the range of expression of feeling tones are recorded.
The predominant expression is described, which includes flat affect, in which
there is virtually no visible expression of feelings during the relating of
emotionally charged material. This mode of expression has been classically
associated with schizophrenia. The incongruity of the expressions with the
verbalizations is most striking in schizophrenia and other psychotic disorders.
Constricted affects are often seen with depression, lability (alternation between
euphoria and irritability) of mood may be associated with cognitive disorders,
and blunting of affects is often seen with dementia. The patient’s nonverbal
behaviours, such as facial mobility, voice intonation patterns, and body
movements are noted to assess affective expression.
3) Appropriateness
Here what is noted is whether the affective tone and the expression are
appropriate to the subject matter being discussed in the context of the patient’s
thinking. Disharmony between affective expression and thought content needs
to be explored.
4. Perceptual Disturbances
1) Hallucinations and Illusions
A hallucination is a perceptual distortion that a patient experiences for
which there is no external stimulus. These hallucinations may be auditory
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(hearing noises or voices that nobody else hears), visual (seeing objects that are
not present), tactile (feeling sensations when there is no stimulus for them), or
olfactory (smelling odours that are not present). Hallucinations during the
hypnagogic state (the drowsy state preceding sleep) and the hypnopompic state
(the semiconscious state preceding awakening) are experiences associated with
normal sleep and with narcolepsy. An illusion is a false impression that
results from a real stimulus. One perceiving a rope as a snake in the dark is
an example of illusion.
2) Depersonalisation and Derealisation
“Depersonalisation” describes the patients’ feelings that they are not
themselves, that they are strange, or that there is something different about
themselves that they cannot account for. The symptom is associated with a
variety of psychiatric disorders. “Derealisation” expresses the patients’ feeling
that the environment is somehow different or strange but they cannot account
for these changes. This perceptual distortion is frequently seen in
schizophrenic patients.
5. Thought Process
One notices how well a patient formulates, organizes, and expresses his
thoughts. Coherent thought is clear, easy to follow, and logical. A formal thought
disorder includes all disorders of thinking that affect language, communication of
thought, or thought content. This disorder is found in schizophrenic patients.
1) Stream of Thought
Here one notices the quantity and rate of the patient’s thoughts. One looks
for the two extremes, whether a paucity or a flooding of thoughts. Also one
needs to note whether there is retardation or slowing or whether there is
acceleration or racing. When thoughts are so sped up that one has difficulty
keeping up with the patient, it is termed as a “flight of ideas.” One notices the
goal-directedness and continuity of the patient’s thoughts. Disturbances include
circumstantiality, tangential thinking, blocking, loose associations, and
perseveration. “Circumstantiality” is a disorder of associations in which the
patient exhibits lack of goal directedness, incorporates tedious and
unnecessary details, and has difficulty in arriving at an end. “Tangentiality”
describes a thought process in which the patient digresses from the subject
under discussion and introduces thoughts that seem unrelated, oblique, and
irrelevant. “Blocking” is a sudden cessation in the middle of a sentence, at
which point a patient cannot recover what he has said or complete his thoughts.
“Loose association” refers to a jumping from one topic to another with no
apparent connection between the topics. “Perseveration” refers to the
patient’s repeating the same response to a variety of questions and topics, with
an inability to change his response or to change the topic.
Marked abnormalities of thought processes include neologisms, word salad,
clang associations, and echolalia. A “neologism” is a word that a patient makes
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up — often a condensation of several words that is unintelligible to another

person. “Word salad” is an incomprehensible mixing of meaningless words and
phrases. In “clang associations,” the connections between thoughts may be
tenuous, and the patient uses rhyming and punning. “Echolalia” describes a
patient’s irrelevant parroting of what another person has said.

2) Thought Content (Delusions, Obsessions, Compulsions,

Preoccupations, Phobias)
Thought content refers to what the patient talks about. There are specific
areas that the psychiatrist inquires about if they are not brought up by the
patient. One important area is whether the patient has suicidal thoughts. This is
particularly required in patients who signal feelings of helplessness,
hopelessness, worthlessness, or giving up.
Delusions are false fixed beliefs that have no rational basis in reality and are
deemed unacceptable by the patient’s culture. Delusions that cannot be
understood by other psychological processes are referred to as “primary
delusions.” Some examples for this are thought insertion, thought
broadcasting, and beliefs about world destruction. “Secondary delusions” are
based on other psychological experiences. These include delusions derived from
hallucinations, other delusions, and morbid affective states. These types of
delusions include those of persecution, of jealousy, of guilt, of love, of poverty,
and of nihilism. In addition to the description of delusions, one should also note
the degrees of organization of the delusion. One should also note if there are
ideas of reference and ideas of influence.
One notices any “obsessions” the patients may have. These are marked by
repetitive, unwelcome, irrational thoughts that impose themselves on the
patient’s consciousness and over which he has no apparent control. These
thoughts are accompanied by feelings of anxious dread and are ego-alien,
unacceptable, and undesirable. They are strongly resisted by the patient.
“Compulsion,” a closely parallel phenomenon, is repetitive, stereotyped
behaviour that the patient feels impelled to perform ritualistically, even though
he recognizes the irrationality and absurdity of the behaviour. Although no
pleasure is derived from performing such an act, there is a temporary sense of
relief of tension when it is completed. The degree of interference by obsession
and compulsion with the patient’s functioning has to be noted.
“Preoccupations” reflect the patient’s absorption with his own thoughts
to such a degree that the patient loses contact with external reality. Mild
forms of preoccupations are reflected in absentmindedness; severe form can
involve suicidal or homicidal ideation and the autistic thinking of the
schizophrenic patient.
“Phobias” are morbid fear that is reflected by morbid anxiety. Even if
they are not spontaneously conveyed in the interview, one should make specific
enquiries about their presence.
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3) Abstract Thinking
Abstract, or categorical thinking is formed late in the development of thought
and reflects the capacity to formulate concepts and to generalize. Several
methods are used to test this capacity. These include testing similarities,
differences, and the meaning of proverbs. The inability to abstract is
referred to as concreteness, which in turn reflects an earlier childhood
development of thought. Concreteness of responses on formal testing reflects
intellectual impoverishment, cultural deprivation, and cognitive disorders such as
dementia. Bizarre and inappropriate responses to proverbs reflect schizophrenic
thinking.
An example of testing for similarities in the patient would be like this:
Counsellor: How are a mango and a banana alike? Patient: They are both fruits.
The answer reflects the capacity to abstract. Patient: Pluck them from the trees.
It is a form of concreteness. A bizarre response would be: Mango market going
banana leaves. In the same way, one could test the patient for the meaning of a
proverb. Counsellor: Give the meaning of “All that glitters is not gold.” Patient:
Appearances are deceptive. The patient has the capacity to abstract. Patient:
Appearances, you know, you know. It is a concrete response. Patient:
Appearances appearances go and come back. It is an inappropriate response.
4) Education and Intelligence
Intelligence is best measured in the clinical interview by the patient’s use of
vocabulary. The expectations of levels of intelligence are influenced by the level
of education of the patient. If for example a patient who did only his primary
education exhibits an advanced vocabulary, the counsellor concludes that the
patient’s intelligence exceeds his scholastic achievement. Specific testing for
intelligence is used only when deficits are anticipated on the basis of the
interview.
5) Concentration
Concentration reflects the patient’s ability to focus and to maintain his
attention on a task. In the interview, troubles with concentration are reflected in
the patient’s inability to pay attention to the questions that he is being asked.
The patient may be distracted by external or internal stimuli. When the patient’s
concentration is impaired, the psychiatrist often has to repeat the questions.
Formal testing for concentration includes serial 7s, in which the patient is
asked to subtract 7 from 100 and keep subtracting 7 from each answer. Serial
3s or counting backward from 20 can be substituted if the patient has cognitive
difficulties performing serial 7s. The counsellor can devise other methods of
checking with numbers. Immediate recall and concentration abilities often
overlap. One way to test for immediate recall is to ask the patient to repeat
digits forward and backward.
The patient is instructed to repeat the numbers recited by the counsellor. The
counsellor recites a three-digit number 1 second apart and asks the patient to
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repeat them. The counsellor can go on like this, adding one digit at a time until
he is able to assess how many digits of number the patient can repeat. The
same exercise is conducted with repeating the digits backward. Thus, the
counsellor records how many numbers the patient can recite backward.
6. Orientation (Time, Place, Person, Situation)
Orientation reflects patients’ capacities to know who they are, where they
are, what date and time it is, and what their present circumstances are. Patients
who have deficits in these four spheres are commonly suffering from cognitive
disorders. 1) Testing for time includes asking the patient the month, the day of
the month, the year, the day of the week, and the time of day and the season of
the year. 2) Orientation to place includes the patient’s knowing the name of the
place where he is currently located and the name of the city and state. 3)
Orientation to person includes the patient’s knowing his own name and the
names and roles of persons in his immediate surroundings. 4) Orientation to
situation indicates the patient’s present circumstances and why he finds himself
in such circumstances.
This is often an important clue toward the competency of individuals to give
informed consent. In reversible cognitive disorders such as delirium, the
reorientation to person precedes that of place, and the last function recovered
is time. The counsellor could ask: Do you know what today date is? The month?
The year?
7. Memory
1) Remote Memory
Remote memory is the recollection of events earlier in life. The counsellor
tests for this function by asking where the patient grew up; where he went to
school, and what his first job was and inquires about significant people from the
past (e.g., naming of presidents, prime ministers) and significant events (e.g.,
World War I & II).
2) Recent Past Memory
Recent past memory refers to recalling verifiable events from the past few
days. To test this, the counsellor inquires about what the patient ate for
breakfast or what he read in the newspaper or asks for details about what the
patient watched on television the night before.
3) Recent Memory
Recent or short-term memory is gauged by the patient’s capacity to recount
what he was told 5 minutes after hearing and being coached to remember it.
The counsellor tests this capacity by asking the patient to repeat the names of
three unrelated objects, and then informing him that they will go on to
discuss other subjects and that in 5 minutes the patient will be asked to name
the three objects.
8. Impulse Control
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Impulse control is “the ability to control the expression of aggressive, hostile,

fearful, guilty, affectionate, or sexual impulses in situations where their
expression should be maladaptive.” Manifestations of this phenomenon are
verbal and/or behavioural. A loss of control can reflect a low frustration
tolerance (LFT).
9. Judgement
Judgement refers to the patient’s capacity to make appropriate decisions and
appropriately act on them in social situations. An assessment of this function is
best made in the course of obtaining the patient’s history. There is no
necessary correlation between intelligence and judgement. Formal testing
is rarely helpful. The counsellor could ask the patient like this: What would you
do if you saw a child drowning in a pond?
10. Insight
The capacity of the patient to be aware and to understand that he has a
problem or illness and to be able to review its probable causes and arrive at
tenable solutions is referred to as insight. Emotional insight refers to the
patient’s awareness of his motivations, and, in turn, his feelings, so that the
patient can change longstanding, ingrained patterns of behaviour. Self-
observation alone is insufficient for insight. Emotional insight must be
applied for change to occur.
11. Reliability
The counsellor, upon completion of an interview, assesses the reliability of
the information that has been obtained. Factors affecting reliability include the
patient’s intellectual endowment, his honesty and motivations, the presence of
psychosis or organic defects, and the patient’s tendency to magnify or
understate his problems.1
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2. PERSONALITY DISORDERS

1. Introduction

This chapter begins with a general definition of personality disorder that

applies to each of the 10 specific personality disorders. A personality disorder
is an enduring pattern of inner experience and behaviour that deviates
markedly from the expectations of the individual’s culture, is pervasive
and inflexible, has an onset in adolescence or early adulthood, is stable
over time, and leads to distress or impairment.

The personality disorders are grouped into three clusters based on descriptive
similarities. Cluster “A” includes paranoid, schizoid, and schizotypal personality
disorders. Individuals with these disorders often appear odd or eccentric.
Cluster “B” includes antisocial, borderline, histrionic, and narcissistic
personality disorders. They often appear dramatic, emotional, or erratic. Cluster
“C” includes avoidant, dependent, and obsessive-compulsive personality
disorders. They often appear anxious or fearful. It should be noted that this
clustering system, although useful in some research and educational situations,
has serious limitations and has not been consistently validated. Moreover,
individuals frequently present with co-occurring personality disorders from
different clusters.

There are four defining features of personality disorders. These are: 1)

Distorted thinking patterns, 2) Problematic emotional responses, 3)
Over- or under-regulated impulse control, and 4) Interpersonal
difficulties.

These four core features are common to all personality disorders. Before a
diagnosis is made, a person must demonstrate significant and enduring
difficulties in at least two of those four areas. Furthermore, personality
disorders are not usually diagnosed in children because of the requirement that
personality disorders represent enduring problems across time. These four key
features combine in various ways to form ten specific personality disorders
identified in DSM-5 (APA, 2013). Each disorder lists criteria reflecting observable
characteristics associated with that disorder. In order to be diagnosed with a
specific personality disorder, a person must meet the minimum number of
criteria established for that disorder. Furthermore, to meet the diagnostic
requirements for a psychiatric disorder, the symptoms must cause functional
impairment and/or subjective distress. This means the symptoms are
distressing to the person with the disorder and/or the symptoms make it difficult
for them to function well in society.

Oftentimes, a person can be diagnosed with more than just one personality
disorder. Research has shown that there is a tendency for personality disorders
within the same cluster to co-occur (Skodol, 2005).
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It is important to remember that everyone can exhibit some of these

personality traits from time to time. To meet the diagnostic requirement of a
personality disorder, these traits must be inflexible; i.e., they can be repeatedly
observed without regard to time, place, or circumstance. Furthermore, these
traits must cause functional impairment and/or subjective distress. Functional
impairment means these traits interfere with a person's ability to function well in
society. The symptoms cause problems with interpersonal relationships; or at
work, school, or home. Subjective distress means the person with a personality
disorder may experience his symptoms as unwanted, harmful, painful,
embarrassing, or otherwise cause him significant distress.

Personality disorders are a long-standing and deeply ingrained

pathology that permeates one’s entire being. He generally lacks flexibility
and resilience, especially under stress. When it is the question of change, he is
inflexible. He engages in various cycles of repetitive self-defeating behaviours.
Mostly he has trouble accepting responsibility for his difficulties and usually
blames others or himself too much. Certainly, he has poor coping mechanisms
and relationship skills. He has little insight and tends to externalise his
difficulties.

Formerly, personality disorders were explained almost exclusively from a

psychodynamic perspective, but now they are viewed as resulting from a
combination of biological and psychosocial factors. Although genetic factors
predispose a person to certain traits of temperament, yet what have a
favourable or unfavourable impact on the traits are environmental factors.
Psychosocial factors like family dysfunction, physical or sexual abuse in
childhood, an invalidating environment, adversity, attachment-related issues,
difficulties in early learning, and sociocultural predisposition have an influence
toward a personality disorder. Personality disorders are evident only by
adolescence or early adulthood and tend to continue throughout life. To make a
diagnosis of personality disorder under the age of 18, the individual should
manifest symptoms for at least one year. Only the antisocial personality disorder
cannot be diagnosed under the age of 18.2

2. General Personality Disorder

1) Diagnostic Criteria

A. An enduring pattern of inner experience and behaviour that deviates

markedly from the expectations of the individual’s culture. This pattern is
manifested in two (or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people,
and events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of
emotional response).
3. Interpersonal functioning.
4. Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of
personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
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D. The pattern is stable and of long duration, and its onset can be traced
back at least to adolescence or early adulthood.
E. The enduring pattern is not better explained as a manifestation or
consequence of another mental disorder.
F. The enduring pattern is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., head trauma).

2) Usefulness of Treatment3

N Personality Psychother Sociotherapie Pharmacot

o. Type apies s herapies
1. Paranoid No support No support Uncertain
support
2. Schizoid Modestly Modestly No Support
Helpful Helpful
3. Schizotypal No Support Uncertain Modestly
support Helpful
4. Antisocial No support Modestly No support
helpful
5. Borderline Modestly Significantly Modestly
helpful helpful helpful
6. Histrionic Significantly No support No support
helpful
7. Narcissistic Significantly No support No support
helpful
8. Avoidant Significantly Modestly Uncertain
helpful helpful support
9. Dependent Significantly Modestly No support
helpful helpful
1 Obsessive- Significantly No support No support
0. compulsive helpful

3) Treatment

Personality disorders consist of deeply ingrained attitudes and behaviour

patterns that consolidate during development and have endured since childhood
and therefore it is difficult to change them. The individuals themselves with the
personality disorders may not consider the disorders as undesirable and related
to his problems.

Psychoanalysts attempted to address the issue of treatment. Originally,

neurosis was considered a discrete set of symptoms related to a discrete
developmental phase or to discrete conflicts and this view was later replaced by
the idea that more enduring defensive styles and identification processes were
the building blocks of character traits. Thus came into existence the concept of
character analysis and defence analysis by Wilhelm Reich (1940) and others.
Side by side, a development in technique evolved from group therapy
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experience. Maxwell Jones (1953) emphasized the importance of confrontations

given within group settings in which peer pressure made it difficult for the
individuals to ignore feedback or to leave the group. This general principle was
adopted by other forms of sociotherapies.

The use of pharmacotherapy for personality disorders is in progress. Thus

impulsiveness and aggression may respond to serotonergic medications, mood
instability and lability may respond to serotonergic medications and to other
antidepressants, and psychotic-like experiences may respond to neuroleptics.

Recently cognitive-behavioural therapies are used more and more in treating

personality disorders. Cognitive strategies involve identifying specific internal
mental schemes by which patients typically misunderstand certain situations or
misrepresent themselves, and then learning how to modify those internal
schemes.

Initially, psychodynamic psychotherapy was the preferred approach to

treatment. Slowly, the literature focused increasingly on cognitive approaches,
as well as on variations of cognitive-behaviour therapy, such as dialectical
behaviour therapy and schema therapy. The counsellor’s ability to adapt his
interventions to the client’s in-session behaviour is a key to successful
treatment. Therefore, counselling will be multifaceted, with a psychodynamic or
cognitive basis to address the client’s core difficulties. Behaviour therapy is
useful especially when the client is reluctant to long-standing treatment, or who
has severely dysfunctional and self-destructive behaviour patterns that require
rapid modifications. Recently, dialectical behaviour therapy and mentalization-
based therapy have shown effectiveness to reduce suicide attempts and self-
harming behaviours. Family therapy and group therapy are useful adjuncts to
individual therapy. These need to be initiated only in conjunction with individual
therapy or only after some progress has been made in individual therapy. 4

CLUSTER “A” PERSONALITY DIORDERS:

Odd or Eccentric

Now let us look at how all four core features merge to create specific patterns
called personality disorders.

Cluster “A” is called the odd, eccentric cluster. It includes Paranoid

Personality Disorder, Schizoid Personality Disorder, and Schizotypal Personality
Disorder. The common features of the personality disorders in this cluster are
social awkwardness and social withdrawal. These disorders are dominated by
distorted thinking.

1. Paranoid Personality Disorder

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The Paranoid Personality Disorder is characterized by a pervasive distrust

and suspiciousness of other people. People with this disorder assume that
others are out to harm them, take advantage of them, or humiliate them in
some way. They put a lot of effort into protecting themselves and keeping their
distance from others. They are known to pre-emptively attack others whom they
feel threatened by. They tend to hold grudges, are litigious, and display
pathological jealousy. Distorted thinking is evident. Their perception of the
environment includes reading malevolent intentions into genuinely harmless,
innocuous comments or behaviour, and dwelling on past slights. For these
reasons, they do not confide in others and do not allow themselves to develop
close relationships. Their emotional life tends to be dominated by distrust and
hostility.

The person with paranoid personality disorder has elements of projection and
projective identification. He believes that others dislike him and treat him badly
and therefore, he takes a defensive attitude to interpersonal relations and starts
protecting himself by treating others badly. Naturally, when others respond with
disapproval and rejection, his belief that others dislike him is confirmed. It is
possible that he is likely to have grown up in an atmosphere charged with
criticism, blame, and hostility, and has identified with a critical parent. He is
overly concerned about the evaluation by others and tends to be vigilant in
scanning the environment for criticism and malicious intentions of others. He
tends to believe he is simultaneously special and not good enough. He may
appear chronically tense due to his constant vigilance. Brief psychotic symptoms
may even occur in his life.5

1) Diagnostic Criteria

A. A pervasive distrust and suspiciousness of others such that their motives

are interpreted as malevolent, beginning by early adulthood and present
in a variety of contexts, as indicated by four (or more) of the following:
1. Suspects, without sufficient basis, that others are exploiting, harming,
or deceiving him.
2. Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates.
3. Is reluctant to confide in others because of unwarranted fear that the
information will be used maliciously against him.
4. Reads hidden demeaning or threatening meanings into benign remarks
or events.
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or
slights).
6. Perceives attacks on his character or reputation that are not apparent
to others, and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of
spouse or sexual partner.
B. Does not occur exclusively during the course of schizophrenia, a bipolar
disorder or depressive disorder with psychotic features, or another
psychotic disorder, and is not attributable to the physiological effects of
another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add
“premorbid,” i.e., “paranoid personality disorder (premorbid).”
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2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Paranoid No support No support Uncertain
support

Because persons with Paranoid Personality Disorder mistrust others, they

usually avoid psychiatric treatment. When they approach treatment, they are to
be respected with straightforward and unintrusive style aimed at building trust.
It is better to offer a straightforward apology when found fault with rather than
respond evasively or defensively. Again, it is not necessary to maintain an overly
warm style, because excessive warmth and expression of interest can
exacerbate patient’s paranoid tendencies. A supportive psychotherapy that
incorporates the above-mentioned tips may be the best treatment for these
patients. Group treatment or cognitive-behavioural treatment aimed at anxiety
management and the development of social skills might be useful — which they
tend to resist due to suspiciousness and fear of losing control and being
criticized.

Individual therapy is ideal for him. His therapy should not emphasize either
interpretation or reflection of feelings since both are likely to be threatening to
him. A behavioural approach with the client’s control focusing on problem
solving, stress management, and development of assertiveness and other
interpersonal skills is helpful. Once a collaborative therapeutic relationship is
established with the therapist, cognitive therapy can be introduced. He may not
respond to group therapy and family therapy. Transient psychotic symptoms and
severe anxiety are sometimes noticed in him. An integrative approach to
treatment that combines a psychodynamic approach with cognitive-behaviour
therapy seems good for him. Relapses can be avoided by having occasional
follow-up sessions.6

2. Schizoid Personality Disorder

Schizoid Personality Disorder is characterized by a pervasive pattern of

social detachment and a restricted range of emotional expression. For
these reasons, people with this disorder tend to be socially isolated. They do not
seem to seek out or enjoy close relationships. They usually choose solitary
activities, and seem to take little pleasure in life. These "loners" often prefer
mechanical or abstract activities that involve little human interaction and appear
indifferent to both criticism and praise. Emotionally, they seem aloof, detached,
and cold. They may be oblivious to social nuances and social cues, thus causing
them to appear socially inept and superficial. Their restricted emotional range
and failure to reciprocate gestures or facial expressions (such as smiles or nods
of agreement) cause them to appear rather dull, bland, or inattentive. It is more
common among males than females. The Schizoid Personality Disorder
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appears to be rather rare. This disorder is not commonly seen in clinical

settings.

1) Diagnostic Criteria

A. A pervasive pattern of detachment from social relationships and a

restricted range of expression of emotions in interpersonal settings,
beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:
1. Neither desires nor enjoys close relationships, including being part of a
family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another
person.
4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar
disorder or depressive disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder and is not attributable to the
physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add
“premorbid,” i.e., “schizoid personality disorder (premorbid).”

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Schizoid Modestly Modestly Helpful No Support
Helpful

Individuals with schizoid personality disorder rarely seek treatment since they
do not perceive that any relationship including a therapeutic relationship as
potentially valuable or beneficial. Some patients may tolerate supportive therapy
aimed at the resolution of a crisis, others may respond to insight-oriented
psychotherapy aimed at effecting a basic shift in their comfort with intimacy and
affects. The therapist should avoid early interpretation or confrontation. They
may be coached to use inanimate bridges, such as writing and artistic
productions to develop therapy relationship. Use of cognitive-behavioural
therapies may be useful to encourage social involvement. Group therapies too
facilitate the development of social skills and relationships. Schema therapy
(QUOTE PAGE) based on cognitive therapy to address clients’ underlying
assumptions and dysfunctional thoughts by using imagery exercises, empathy,
limited reparenting, and homework assignments to modify maladaptive schemas
is found useful. The clients should not be overwhelmed by multifaceted
treatment nor should they be pushed into group or family therapy before they
are ready or where there is not enough empathy from the participating clients. 7
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3. Schizotypal Personality Disorder

Persons with Schizotypal Personality Disorder are characterized by a

pervasive pattern of social and interpersonal limitations. They experience acute
discomfort in social settings and have a reduced capacity for close relationships.
For these reasons, they tend to be socially isolated, reserved, and distant. Unlike
the Schizoid Personality Disorder, they also experience perceptual and cognitive
distortions and/or eccentric behaviour. These perceptual abnormalities may
include noticing flashes of light no one else can see, or seeing objects or
shadows in the corner of their eyes and then realizing that nothing is there.
People with Schizotypal Personality Disorder have odd beliefs, for instance, they
may believe they can read other people's thoughts, or that their own thoughts
have been stolen from their heads. These odd or superstitious beliefs and
fantasies are inconsistent with cultural norms. Schizotypal Personality Disorder
tends to be found more frequently in families where someone has been
diagnosed with Schizophrenia; a severe mental disorder with the defining
features of psychosis (the loss of reality testing). There is some indication that
these two distinct disorders share genetic commonalities (Coccaro & Siever,
2005)

They tend to be guarded, suspicious, and hypersensitive. They have hardly

any friends other than first-degree relatives. They manifest flat and
inappropriate affect, and are uncomfortable and awkward in social situations.
They have cognitive or perception distortions and eccentricities of behaviour that
is marked by ideas of reference, magical thinking, unusual beliefs or perception
experiences, prominent superstitions, eccentric actions or grooming, and
idiosyncratic speech patterns. Men are more affected by this disorder than
females. Men may have also co-occurring paranoid and narcissistic personality
disorders.8

1) Diagnostic Criteria

A. A pervasive pattern of social and interpersonal deficits marked by acute

discomfort with, and reduced capacity for, close relationships as well as
by cognitive or perceptual distortions and eccentricities of behaviour,
beginning by early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behaviour and is
inconsistent with subcultural norms (e.g., superstitiousness, belief in
clairvoyance, telepathy, or “sixth sense”; in children and adolescents,
bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical,
overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behaviour or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and
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tends to be associated with paranoid fears rather than negative

judgements about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar
disorder or depressive disorder with psychotic features, another psychotic
disorder, or autism spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add
“premorbid,” e.g., “schizotypal personality disorder (premorbid).”

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Schizoty No Support Uncertain Modestly
pal support Helpful

A supportive relationship that counters cognitive distortions and ego-

boundary problems may be useful. The therapist can involve an educational
approach that fosters the development of social situations, or encourage risk-
taking-behaviour in social situations. There is evidence to support the usefulness
of low-dose antipsychotic medications in the treatment of schizotypal personality
disorder.

An available, reliable, encouraging, warm, empathic, positive, and

nonintrusive stance of therapy, which is structured, seems to be helpful. It is
recommended that supportive, lengthy, and slow-paced therapies are used.
Therapies should start with supportive interventions, medication, and
subsequently making gentle use of cognitive and behavioural strategies to
promote self-awareness, self-esteem, reality testing, and more socially
acceptable behaviour. Therapies should focus on dealing with personal hygiene
and daily activities, seeking to prevent isolation and total dysfunction, and
establishing some independence and pleasure in the lives of the clients.
Cognitive therapies that gently challenge the clients to check if evidences are
available for suspicious and paranoid thoughts, ideas of reference, superstitious
and magical thoughts, and illusions will be helpful. Of course, behaviour therapy
can help improve speech patterns, personal hygiene, and social skills. 9

CLUSTER “B” PERSONALITY DISORDERS:

Dramatic, Emotional, or Erratic

Cluster “B” is called the dramatic, emotional, and erratic cluster. It includes
Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic
Personality Disorder, and Narcissistic Personality Disorder. Disorders in this
cluster share problems with impulse control and emotional regulation.

1. Antisocial Personality Disorder

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The Antisocial Personality Disorder is characterized by a pervasive pattern of

disregard for the rights of other people that often manifests as hostility
and/or aggression. Deceit and manipulation are also central features. In many
cases, hostile-aggressive and deceitful behaviours may first appear during
childhood. These children may hurt or torment animals or people. They may
engage in hostile acts such as bullying or intimidating others. They may have a
reckless disregard for property such as setting fires. They often engage in deceit,
theft, and other serious violations of standard rules of conduct. When this is the
case, Conduct Disorder (a juvenile form of Antisocial Personality Disorder) may
be an appropriate diagnosis. Conduct Disorder is often considered the
precursor to an Antisocial Personality Disorder.

In addition to reckless disregard for others, they often place themselves in

dangerous or risky situations. They frequently act on impulsive urges without
considering the consequences. This difficulty with impulse control results in loss
of employment, accidents, legal difficulties, and incarceration. Persons with
Antisocial Personality Disorder typically do not experience genuine
remorse for the harm they cause others. However, they can become quite
adept at feigning remorse when it is in their best interest to do so (such as when
standing before a judge). They take little to no responsibility for their actions. In
fact, they will often blame their victims for "causing" their wrong actions, or
deserving of their fate. The aggressive features of this personality disorder make
it stand out among other personality disorders as individuals with this disorder
take a unique toll on society.10

1) Diagnostic Criteria

A. A pervasive pattern of disregard for and violation of the rights of others,

occurring since age 15 years, as indicated by three (or more) of the
following:
1. Failure to conform to social norms with respect to lawful behaviours,
as indicated by repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or
conning others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicted by repeated physical fights
or assaults.
5. Reckless disregard for safety for self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behaviour or honour financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing
having hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behaviour is not exclusively during the course
of schizophrenia or bipolar disorder.

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

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ty Type apies
Antisocia No support Modestly helpful No support
l

It is recognized that Antisocial Personality Disorder cannot be successfully

treated by the usual psychiatric interventions. In confined settings, such as the
military or prisons, confrontation by peers may bring about changes in the
antisocial behaviours. With the passing of years, the prevalence of these
behaviours tends to decrease as these individuals become more aware of the
social and interpersonal maladaptiveness of their most noxious social
behaviours.11

A concrete, reality-based approach that addresses anger management,

substance use disorders, and provides adjunct treatment will be helpful.
Motivational interviewing which focuses on choice and helps clients to consider
the options that are available to them seems acceptable to these clients.
Residential therapeutic programmes for these people who have broken the law
focus on increasing their responsibility, their trust in themselves and others, and
their sense of mastery while making them aware of the consequences of their
behaviour. Such programmes remove clients from their former environments
where their antisocial behaviour might be reinforced by peers. Individual therapy
establishing first a collaborative therapeutic relationship and setting clear and
mutually agreed-on goals is essential for them. Behaviour therapy, reality
therapy, and cognitive therapy are other choices. Reality therapy can facilitate
clients to see the self-destructive nature of their actions, to recognize that their
behaviours are not helping them to meet their needs, and to make a
commitment to change. Behaviour therapy promotes positive change by
improving problem-solving and decision-making skills, anger management, and
impulse control.

Schema therapy that includes cognitive therapy with imagery, empathic

confrontations, homework assignments, and limited reparenting is considered
helpful. Since clients are less defensive talking about their past than the current
behaviour, that could serve as a bridge to discuss about the current behaviours.
Psychodynamic and insight-oriented therapies may not be helpful. Treating
coexisting substance-related disorders will reduce their urge to engage in
antisocial behaviour. Mentalization-based therapy (MBT) seeking to provide a
safe therapeutic environment in which the client can focus on anxiety-provoking
mental states can be used. Directive techniques persuading the clients to engage
in treatment with clear explanation of their disorder and setting explicit
guidelines and limits for their involvement in therapy is essential. 12

2. Borderline Personality Disorder (BPD)

Borderline Personality Disorder is one of the most widely studied personality

disorders. People with Borderline Personality Disorder tend to experience
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intense and unstable emotions and moods that can shift fairly quickly.
They generally have a hard time calming down once they have become upset. As
a result, they frequently have angry outbursts and engage in impulsive
behaviours such as substance abuse, risky sexual liaisons, self-injury,
overspending, or binge eating. These behaviours often function to soothe them
in the short-term, but harm them in the longer term.

People with Borderline Personality Disorder tend to see the world in polarized,
over-simplified, all-or-nothing terms. They apply their harsh either/or judgments
to others and to themselves and their perceptions of themselves and others may
quickly vacillate back and forth between "all good" and "all bad." This tendency
leads to an unstable sense of self, so that persons with this disorder tend to
have a hard time being consistent. They can frequently change careers,
relationships, life goals, or residences. Quite often, these radical changes occur
without any warning or advance preparation.

Their tendency to see the world in black-or-white (polarized) terms makes it

easy for them to misinterpret the actions and motives of others. These polarized
thoughts about their relationships with others lead them to experience intense
emotional reactions, which in turn interacts with their difficulties in regulating
these intense emotions. The result is that they will characteristically experience
great distress, which they cannot easily control and may subsequently engage in
self-destructive behaviours as they do their best to cope. The intensity of their
emotions, coupled with their difficulty regulating these emotions, leads them to
act impulsively.

To illustrate the way black-and-white thinking, emotional dysregulation, and

poor impulse regulation merge and culminate to create interpersonal conflict and
distress, let us use an example. Suppose the partner of a woman with Borderline
Personality Disorder fails to bring flowers for his wife when he returns from the
office. Black-and-white thinking causes her to conclude, "He does not love me
anymore,” and all-or-nothing thinking leads her to (falsely) conclude, "If he does
not love me, then he must hate me." Such thoughts would easily lead to some
pretty intense emotions, such as feeling rejected, abandoned, sad, and angry.
She has a hard time tolerating and dealing with these intense feelings and
consequently becomes highly upset and overwhelmed. The intensity of her
negative feelings seems unbearable. Next, she has a powerful impulse to "do
something" just so that these feelings will go away. She might angrily accuse
her partner of having an affair and she might plead with her partner not to leave
her.

Meanwhile her partner is baffled by this extreme reaction, particularly since

he is not having an affair, and he readily recalls all his other recent loving
gestures. Her partner might also become angry at these wild accusations of
infidelity and so the conflict escalates and things get more intense. Alone after
the fight, the woman feels overwhelming self-loathing or numbness and goes on
to intentionally injure herself (by cutting or burning herself) as a way to cope
with her numbness. When her partner learns about this self-harm behaviour, he
cannot understand it and concludes he is being manipulated. He expresses his
strong concern for her well-being but also his anger. In turn, she feels
misunderstood. Clearly, the Borderline Personality Disorder with its combination
of distorted thought patterns, intense and under-regulated emotions, and poor
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impulse control is practically designed to wreak havoc on any interpersonal

relationship.13

Major depressive disorder is a most common co-occurring disorder with BPD;

so also are panic disorder with agoraphobia, PTSD, somatoform, dissociative,
substance-related, and schizoaffective disorder. The clients have problems of
separation and individuation, which persists from childhood into adulthood. They
have little sense of themselves and an external locus of control. They seek to
avoid individuation by attaining a symbiotic relationship with another. This
disorder is particularly severe in late adolescence and early adulthood when
emotional dysregulation and self-identity are in a constant flux. 14

1) Diagnostic Criteria

A pervasive pattern of instability of interpersonal relationships, self-image,

and affects, and marked impulsivity, beginning by early adulthood and present
in a variety of contexts, as indicted by five or more of the following:
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not
include suicidal or self-mutilating behaviour covered in Criterion 5).
2. A pattern of unstable and intense interpersonal relationships characterized
by alternating between extremes of idealization and devaluation.
3. Identity disturbance: marked and persistently unstable self-image or
sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating). (Note: Do
not include suicidal or self-mutilating behaviour covered in Criterion 5.)
5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating
behaviour.
6. Affective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours and
only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms.

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Borderlin Modestly helpful Significantly Modestly
e helpful helpful

Therapists find extreme difficulties to deal with Borderline Personality

Disorder persons since they crave for the nurturing qualities and their rageful
accusations in response to the therapist’s perceived failures. Often therapists
develop intense negative counter-transference and reject them. Intensive
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exploratory psychotherapies directed at modifying their basic character structure

leading to the experience of developing a stable, trusting relationship with the
therapist, are found to be facilitative. Supportive psychotherapies or group
therapies also may bring about a significant change. Cognitive-behaviour
interventions do have salutary effect on them. Medications may diminish specific
problems such as impulsivity, affective lability, or intermittent cognitive and
perceptual disturbances as well as irritability and aggressive behaviour. 15

Dialectical behaviour therapy evolved from standard cognitive-behaviour

therapy as a treatment for borderline personality disorder, particularly the
chronically suicidal, severely dysfunctional individual, is found useful. The
theoretical orientation to treatment blends behaviour and crises intervention
theories with an emphasis on acceptance and tolerance drawn both from
Western contemplative and Eastern meditation practice. Balancing this emphasis
on acceptance with a corresponding emphasis on change is accomplished within
the framework of a dialectical position.

(1) Dialectical Behaviour Therapy (DBT)

Dialectics refers to the treatment approach or strategies used by the

therapist to effect change.

a. Dialectics as a World View

A dialectical worldview emphasizes wholeness, interrelatedness, and

process (change) as fundamental characteristics of reality. Dialectics asserts
that reality is nonreducible, that is, within each one thing or system, no matter
how small, there is polarity. In dialectics, the polar forces are called the thesis
and antithesis, the state of change that results is the synthesis of these forces.
It is the transactional tension between these forces within each system, positive
and negative, good and bad, children and parents, client and therapist, person
and environment and the like that produces change. The new state, following
change, also comprises polar forces and, thus, change is continuous and
constitutes the essential nature of life. A very important dialectical idea
is that all propositions contain within them their own oppositions.
Goldberg (1980) put this idea thus: I assume that truth is paradoxical, that each
article of wisdom contains within it its own contradictions that truths stand side
by side. Contradictory truths do not necessarily cancel each other out or
dominate each other, but stand side by side, inviting participation and
experimentation.16

Dialectical behaviour therapy (DBT) is a type of talking therapy. It was

originally developed by an American psychologist named Marsha Linehan. It is
based on cognitive behavioural therapy (CBT), but has been adapted to meet the
particular needs of people who experience emotions very intensely. It is mainly
used to treat problems associated with borderline personality disorder (BPD),
such as: repeated self-harming, attempting suicide, using alcohol or drugs to
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control emotions, eating problems, such as binge eating and purging, and
unstable relationships. The difference between CBT and DBT is: CBT focuses on
helping the client to change unhelpful ways of thinking and behaving. DBT also
helps the client to change unhelpful behaviours, but it differs from CBT in that it
also focuses on accepting who the client is at the same time. DBT places
particular importance on the relationship between the client and his therapist,
and this relationship is used to actively motivate the client to change.

b. Stages of Dialectical Behaviour Therapy

Stage I: Attaining Basic Capacities

The focus in this first stage is to attain a life pattern that is reasonably
functional and stable. Specific targets in order of importance are to reduce
suicidal behaviours, therapy-interfering behaviours, and to increase behavioural
skills. With severely dysfunctional and suicidal clients, significant progress on the
first stage targets can usually be expected to take up to 1 year or more.
Besides, the goal of increasing dialectical behaviours is universal to all modes of
treatment. Dialectical thinking encourages clients to see reality as
complex and multifaceted, to hold contradictory thoughts
simultaneously, and learn to integrate them, and to be comfortable with
inconsistency and contradictions. Dialectical behaviour encourages
clients to seek the middle path and avoid the extremes. Balance in
behaviour and openness of thought is advocated. For borderline individuals who
are extreme, rigid, and dichotomous in their thinking and behaviour, this is the
primary task. A dialectical emphasis applies equally to client patterns of
behaviour, as the client is encouraged to integrate and balance emotional and
overt behavioural responses. Dialectical tensions arise in the areas of skill
enhancement versus self-acceptance, problem solving versus problem
acceptance, and affect regulation versus affect tolerance. Behavioural extremes,
whether emotional, cognitive, or overt responses, are constantly confronted
while more balanced responses are taught. 17

Suicidal Behaviour

Keeping the client alive must be the first priority in any psychotherapy.
Reducing suicide crisis behaviour (any behaviours that place the client at high
and imminent risk for suicide or threaten to do so, including credible suicide
threats, planning, preparations, obtaining lethal means, and high suicide intent)
is the highest priority in DBT. Dealing with suicidal intent or attempts is the
priority and explicit goal in DBT since BPD clients are highly prone to such a
deed. In the same way, any acute, intentional self-injurious behaviours (i.e., all
instances of parasuicidal behaviours (Parasuicidal behaviour —
(Parasuicide [from Greek παρά, para-, "near" or "resembling" and suicide] is a
suicide attempt or gesture and self-harm where there is no resultant death. The
deliberate infliction of injury on oneself or the taking of a drug overdose as an
attempt at suicide, which may not be intended to be successful, is the single
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best predictor of subsequent suicide and to the inherent conflict between

ignoring self-injurious behaviour and a collaborative self-help pursuit such as
psychotherapy. DBT also targets suicide ideation and client expectations about
the value and long-term consequences of suicidal behaviour. 18

Therapy-Interfering Behaviours

Keeping clients and therapists working together collaboratively is the second

priority in DBT. The chronic nature of most borderline clients’ problems, clients’
high tendency to end therapy prematurely, and the likelihood of therapist
burnout and iatrogenic behaviours when treating BPD require explicit attention
with this population. Both client and therapist behaviours that threaten the
relationship or therapeutic progress are addressed in a direct manner
immediately, consistently, constantly, and, most important, before, rather than,
after, either the therapist or the client no longer wants to continue. Interfering
behaviours of the client, such as those that interfere with actually receiving the
therapy or with other clients benefiting from therapy (in group or milieu
settings) and that burn out or cross the personal limits of the therapist, are
treated within therapy session.19

Behavioural Skills

The third goal of the first stage is to achieve a reasonable capacity for skilful
behaviours in the areas of distress tolerance, emotion regulation, interpersonal
effectiveness, self-management, and the capacity to respond with awareness
without being judgemental (mindfulness skills). Mindfulness skills are central
in DBT. These are called “core” skills which represent behavioural translation of
meditation (including Zen) practice and include observing, describing,
spontaneous participating, a non-judgemental stance, focused awareness (one-
mindfulness), and focusing on effectiveness. (1) Distress tolerance skills
represent the ability to experience and observe one’s thoughts, emotions, and
behaviours without evaluation and without attempting to change or control
them. (2) Emotion regulation skills target the reduction of this emotional
distress through exposure to the primary emotion in a non-judgemental
atmosphere. They include affect identification and labelling, mindfulness to (i.e.,
experiencing non-judgementally) the current emotion, identifying obstacles to
changing emotions, increasing positive emotional events, and behavioural
expressiveness opposite to the emotion. (3) Interpersonal skills training
includes developing effectiveness for deciding on objectives within conflict
situations and the priority of those objectives vis-à-vis maintaining a positive
relationship and one’s self-respect and teaching strategies that maximize the
chances of obtaining those objectives without harming the relationship or
sacrificing self-respect. (4) Self-management skills include knowledge of the
fundamental principles of learning and behavioural change, the ability to set
realistic goals, the ability to conduct one’s own behavioural analysis, and the
ability to implement contingency management plans. 20
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Stage II: Post-Traumatic Stress Reduction

The first stage takes a very here-and-now approach to managing

dysfunctional behavioural and emotional patterns. The focus of the treatment is
distinctly on analyzing the relationship among current thoughts, feelings, and
behaviours and accepting and changing current patterns. The second stage of
therapy specifically targets the emotional processing of previous
traumatic events via reexposure to associated cues within the therapy
setting. This is to reduce post-traumatic stress. Psychodynamics will call the
first stage as containment phase and the second stage as uncovering phase.
Here four targets are important: (1) remembering and accepting the facts of
earlier traumatic events, (2) reducing stigmatization and self-blame commonly
associated with some types of trauma, (3) reducing the oscillating denial and
intrusive response syndromes common among those who suffered severe
trauma, and (4) resolving dialectical tensions regarding whom to blame for the
trauma. The targets of the second are not undertaken unless the first stage
targets are over.21

Stage III: Respect for Self

In this stage, one targets the client’s independent self-respect, as the

client is helped to value, believe in, trust, and validate himself. The
targets are the abilities to evaluate one’s own behaviour nondefensively, trust
one’s own responses, and hold on to self-evaluations independent of the
opinions of others. The client is to be encouraged to be independent in his
attempts at self-validation, self-care, and problem solving.

c. Dialectical Strategies

(a) Dialectics of the Relationship: Balancing Treatment Strategies

A dialectical therapeutic position is one of constant attention to combining

acceptance with change, flexibility with stability, nurturing with challenging, and
a focus on capabilities with a focus on limitations and deficiencies. The goal is to
bring out the opposites, both in therapy and in the client’s life, and to provide
conditions for synthesis. Change may be facilitated by emphasizing acceptance
and acceptance by emphasizing change. (Acceptance is emphasized by client-
centred therapy and change is emphasized by cognitive and behaviour
therapies.) DBT emphasizes both acceptance and change like Gestalt and
systems therapies.

(b) Teaching Dialectical Behaviour

Behavioural extremes and rigidity, whether cognitive, emotional, or overt,

are signals that synthesis has not been achieved and, thus, can be considered
nondialectical. A middle path is advocated. The client is assisted to move from
“either-or” to “both-and.” The point here is not to invalidate the first idea or
polarity when asserting the second.
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(c) Specific Dialectical Strategies (There Are Eight Strategies):

i. Entering the Paradox

The therapist presents the paradox without explaining it and highlights the
paradoxical contradictions within the behaviour, the therapeutic process, and
reality in general. An example: Clients are free to choose their own behaviour,
but they cannot stay in therapy if they do not work at changing their behaviour.
Another example: Clients are taught to achieve greater independence by
becoming more skilled at asking for help from others. Another: Clients are not
responsible for being the way they are, but they are responsible for what they
become.

ii. Metaphor: Parable, Myth, Analogy, and Story Telling

Metaphor provides an alternate means of teaching dialectical thinking.

Metaphors can aid understanding, suggest solutions to problems, and reframe
the problem of both the clients and the therapeutic process.

iii. Devil’s Advocate

In this strategy, the therapist presents a propositional statement that is an

extreme version of one of the client’s own dysfunctional beliefs and then plays
the role of devil’s advocate to counter the client’s attempts to disprove the
extreme statement or rule. An example will be when a client says that because
he did not get the first rank he will be better off dead. To this, the therapist can
say something like this: Because I never got not even once the first rank, I
would be better off dead. Another example of the therapist saying is that since
the therapy will be painful and difficult, it is not clear how making such a
commitment could possibly be a good idea. This might move the client to take
the opposite position in favour of therapeutic change.

iv. Extending

The term “extending” has been borrowed from “aikido,” a Japanese form of
self-defence. In this, extending is when the aikido practitioner waits for a
challenger’s movements to reach their natural completion and then extends his
end point slightly further than what would naturally occur, leaving the challenger
vulnerable and off balance. In DBT, extending is when the therapist takes the
severity or gravity of what the client is communicating more seriously than the
client intends. An example will be a person who wants to attend a one-month
course says that he needs four days’ holiday in between. The organizer says, “All
right. You can take not only four days’ holiday but also even more and you will
be an audit student.” The organizer did not want the customer take holidays but
he seemed to have gone to grant more than the student wanted and thus
thwarted the motive of the student.

v. Making Lemonade out of Lemons

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Here therapeutic problems are seen as opportunities for the therapist to help
the client. It involves taking something that is apparently problematic and
turning it into an asset. Problems become opportunities to practice skills.
Weaknesses become strengths.

vi. Core Strategies

Validation and problem-solving strategies, together with dialectical strategies,

make up the core of DBT and form the heart of the treatment. Validation
strategies are the most obvious acceptance strategies, while problem-solving
strategies are the change strategies.

vii. Validation

The therapist may focus on change in the client. It presupposes and confirms
the fears of the client that he is the problem and he cannot trust his own
reactions to events. Thus, the entire focus of change-based therapy can be
aversive since by necessity the focus contributes to and elicits self-invalidation.
Instead, the therapist must look for that part of the client’s response that is wise
and valid and reflect that validity or understandability. When validating, the
therapist communicates in a nonambiguous way that the client’s current and
past behaviour, thoughts, or emotions make sense and are understandable
within the context in which they occur. Cheerleading strategies are another
form of validation, which combats the feeling of hopelessness in the client. The
therapist communicates the belief that clients are doing their best and validates
the clients’ ability to eventually overcome their difficulties. He expresses a belief
in the therapy relationship, offers reassurance, and highlights any evidence of
improvement. Cheerleading strategies always remain an essential ingredient of a
strong therapeutic alliance.

viii. Problem Solving

Problem solving strategies are the core change strategies, designed to foster
an active problem-solving style. Problem solving is a two-stage process that
concentrates first on understanding and accepting a selected problem and then
on generating alternative solutions.

d. Behavioural Analysis

(a) Problem-Solving Procedures

DBT employs four problem-solving procedures taken directly from the

cognitive and behavioural treatment literature. These four — skills training,
contingency procedures, cognitive modification, and exposure — are viewed as
primary vehicles of change.

Skills Training: It is desired that the client actively engage in the acquisition
and practice of behavioural skills. The term “skills” is used synonymously with
“ability,” and includes in its broadest sense cognitive, emotional, and overt
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behavioural skills as well as their integration, which is necessary for effective

performance.

Contingency Procedures: Every response within an interpersonal interaction

is potentially a reinforcement, a punishment, or a withholding or removal of
reinforcement. Contingency management requires that therapists organize their
own behaviour so that behaviours that represent client progress are reinforced,
whereas unskilful or maladaptive behaviours are extinguished or lead to aversive
consequences.22

(b) Cognitive Modification

Cognitive modification therapy includes relieving one’s symptoms, helping

him recognize distorted automatic thoughts, teaching him logic and reason, and
helping him to modify long-held dysfunctional assumptions underlying major
concerns.

Cognitive Modification is also called Cognitive Restructuring. In this

therapy, Socratic questions (Socratic questioning is a form of
disciplined questioning that can be used to pursue thought in many directions
and for many purposes) are designed by the therapist to elucidate the clients’
cognitive distortions and encourage the testing of their validity, helping the
clients understand, normalize, and manage their fears. It is believed that
inordinate fears are maintained by mistaken or dysfunctional appraisals of
situations.

(c) Exposure (QUOTE PAGE)

3. Histrionic Personality Disorder

Persons with Histrionic Personality Disorder are characterized by a pattern of

excessive emotionality and attention seeking. Their lives are full of drama (so-
called "drama queens"). They are uncomfortable in situations where they are not
the centre of attention. People with this disorder are often quite flirtatious or
seductive, and like to dress in a manner that draws attention to them. They can
be flamboyant and theatrical, exhibiting an exaggerated degree of emotional
expression. Yet simultaneously, their emotional expression is vague, shallow,
and lacking in detail. This gives them the appearance of being disingenuous and
insincere. Moreover, the drama and exaggerated emotional expression often
embarrass friends and acquaintances as they may embrace even casual
acquaintances with excessive ardour, or may sob uncontrollably over some
minor sentimentality.

People with Histrionic Personality Disorder can appear flighty and fickle. Their
behavioural style often gets in the way of truly intimate relationships, but it is
also the case that they are uncomfortable being alone. They tend to feel
depressed when they are not the centre of attention. When they are in
relationships, they often imagine relationships to be more intimate in nature
than they actually are. People with Histrionic Personality Disorder tend to be
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suggestible; that is, they are easily influenced by other people's suggestions and
opinions.

They readily become impatient, jealous, manipulative, and volatile. They

typically grew up in families that were dramatic and chaotic. These families often
have a history of antisocial behaviour. Children in such families are approved
primarily for their attractiveness, talent, and charm. These children often have
experienced insufficiency, conflict, and disapproval in their early interactions.
Their exaggerated emotions can be seen as a way to attract, and maintain,
attention.23

1) Diagnostic Criteria

A pervasive pattern of excessive emotionality and attention seeking,

beginning by early adulthood and present in a variety of contexts, as indicted by
five (or more) of the following:
1. Is uncomfortable in situations in which he is not the centre of attention.
2. Interaction with others is often characterized by inappropriate sexually
seductive or provocative behaviour.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in
detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of
emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Histrionic Significantly No support No support
helpful

Individuals with histrionic personality disorder are treated better with

individual psychodynamic psychotherapy. This treatment is directed to
increasing the individuals’ awareness of how their self-esteem is maladaptively
tied to their ability to attract attention at the expense of developing other skills
and how their shallow relationships and emotional experience reflect
unconscious fears of real commitments. The increase of awareness occurs
through analysis of the here-and-now patient-therapist relationship (immediacy)
rather than through the reconstruction of the childhood experiences.

The therapist should maintain a professional relationship at all times. He

should never reinforce dramatic behaviour through attention. The clients may
respond to cognitive therapy. A sound therapeutic relationship, meaningful
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goals, and clear limits have to be established in the beginning itself. Therapy
should be systematic and goal-directed. Group therapy and family therapy are
found helpful.24

4. Narcissistic Personality Disorder

People with Narcissistic Personality Disorder have significant problems with

their sense of self-worth stemming from a powerful sense of
entitlement. This leads them to believe that they deserve special treatment,
and to assume that they have special powers, are uniquely talented, or that they
are especially brilliant or attractive. Their sense of entitlement can lead them to
act in ways that fundamentally disregard and disrespect the worth of those
around them.

People with Narcissistic Personality Disorder are preoccupied with fantasies of

unlimited success and power, so much so that they might end up getting lost in
their daydreams while they fantasize about their superior intelligence or
stunning beauty. These people can get so caught up in their fantasies that they
do not put any effort into their daily life and do not direct their energies toward
accomplishing their goals. They may believe that they are special and deserve
special treatment, and may display an attitude that is arrogant and haughty.
This can create a lot of conflict with other people who feel exploited and who
dislike being treated in a condescending fashion. People with Narcissistic
Personality Disorder often feel devastated when they realize that they have
normal, average human limitations; that they are not as special as they think, or
that others do not admire them as much as they would like. These realizations
are often accompanied by feelings of intense anger or shame that they
sometimes take out on other people. Their need to be powerful, and admired,
coupled with a lack of empathy for others, makes for conflictual relationships
that are often superficial and devoid of real intimacy and caring.

Status is very important to people with Narcissistic Personality Disorder.

Associating with famous and special people provides them a sense of
importance. These individuals can quickly shift from over-idealizing others to
devaluing them. However, the same is true of their self-judgments. They tend to
vacillate between feeling like they have unlimited abilities, and then feeling
deflated, worthless, and devastated when they encounter their normal, average
human limitations. Despite their bravado, people with Narcissistic Personality
Disorder require a lot of admiration from other people in order to bolster their
own fragile self-esteem. They can be manipulative in extracting the necessary
attention from those people around them.

They resist looking at their feelings of inferiority and tend to view the cause
of their distress as external, being unable to see how their own actions and
behaviour patterns may have contributed. Despite their apparent air of
superiority, they feel vulnerable and may react even to minor criticism with
depression. They tend to have hostile aggression and bullying behaviour. They
need to feel always powerful, in control, and superior to others, concealing their
real selves from others lest their fraudulence and failure be discovered. Certainly
they are troubled by an underlying feeling of emptiness. They are likely to
become contentious, arrogant, and demanding if they do not receive the
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treatment they believe they deserve. This disorder may develop out of parental
neglect and parental overvaluation in childhood. In the case of neglect,
narcissism develops as an attempt to overcompensate for feelings of low self-
worth by lack of empathy and feelings of entitlement. When overvalued without
the child having to work for approval, an inflated sense of self-worth develops. 25

1) Diagnostic Criteria

A pervasive pattern of grandiosity (in fantasy or behaviour), need for

admiration, and lack of empathy, beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates
achievements and talents, expects to be recognized as superior without
commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance,
beauty, or ideal love.
3. Believes that he is “special” and unique and can only be understood by, or
should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially
favourable treatment or automatic compliance with his expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve
his own ends.)
7. Lacks empathy: is unwilling to recognize or identify with the feelings and
needs of others.
8. Is often envious of others or believes that others are envious of him.
9. Shows arrogant, haughty behaviours or attitudes.

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Narcissis Significantly No support No support
tic helpful

Mostly individual psychodynamic psychotherapy, including psychoanalysis,

is used as treatment for Narcissistic Personality Disorder. In accordance with the
theory of Kohut, some therapists believe that the vulnerability to narcissistic
injury indicates that intervention should be directed at conveying empathy for
the patient’s sensitivities and disappointments. In this approach, it is allowed for
a positive idealized transference to develop which will later be disillusioned by
the inevitable frustrations encountered in therapy. In addition, that will clarify
the excessive nature of the patient’s reactions to frustrations and
disappointments. According to Kernberg (1974, 1975) the vulnerability should be
addressed earlier and more directly by interpretations and feedbacks by which
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these persons will come to recognize their grandiosity and its maladaptive
consequences.

A psychodynamic approach will succeed. Cognitive-behaviour therapy can

be used with success. Therapy should focus on rapport, cognitive reorientation,
reality testing, communication skills, and rehearsal of new behaviours. Group
therapy can help them develop a more realistic sense of themselves, deal with
others in less abrasive ways, and stabilize their functioning.26

CLUSTER “C” PERSONALITY DISORDERS:

Anxious or Fearful

Cluster “C” is called the anxious, fearful cluster. It includes the Avoidant,
Dependent, and Obsessive-Compulsive Personality Disorders. These three
personality disorders share a high level of anxiety.

1. Avoidant Personality Disorder

The Avoidant Personality Disorder is characterized by a pervasive pattern of

social inhibition, feelings of inadequacy, and a hypersensitivity to negative
evaluation. People with this disorder are intensely afraid that others will ridicule
them, reject them, or criticize them. This leads them to avoid social situations
and to avoid interactions with others. This further limits their ability to develop
social skills. People with Avoidant Personality Disorders often have a very limited
social world with a small circle of confidants. Their social life is otherwise rather
limited.

Their way of thinking about and interpreting the world revolves around the
thought that they are not good enough, and that others do not like them. They
think of themselves as unappealing and socially inept. These types of thoughts
create feelings of intense anxiety in social situations, along with a fear of being
ridiculed, criticized, and rejected. The intensity of this fearful anxiety, and the
discomfort it creates, compels them to avoid interpersonal situations. They
might avoid parties or social events, and may have difficulty giving presentations
at work or speaking up in meetings. Others might perceive them as distant or
shy. They likely come across as stiff and restricted. All this will likely interfere
with their ability to make friends, or to move ahead professionally.

Persons with this disorder view themselves as inferior and unattractive to

others but long for companionship and involvement in social activities. There is
emotional fragility, reluctance to become involved with others without
guarantees of acceptance, fear of doing something inappropriate and foolish in
public, and avoidance of new and challenging activities. They value and desire
relationship as children but simultaneously fear and avoid them. They may
experience a pre-occupied-fearful attachment style.27

1) Diagnostic Criteria
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A pervasive pattern of social inhibition, feelings of inadequacy, and

hypersensitivity to negative evaluation, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:
1. Avoids occupational activities that involve significant interpersonal contact
because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being
shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of
inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new
activities because they may prove embarrassing.

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Avoidant Significantly Modestly helpful Uncertain
helpful support

Since the persons with Avoidant Personality Disorder are experiencing

excessive fear of rejection and criticism and are reluctant to form relationships,
it is difficult to engage them in treatment. Therapists could use supportive
techniques, be sensitive to the patient’s hypersensitivity, and employ gentle
interpretation of the defensive use of avoidance. Slowly depending upon their
willingness, other forms of therapies could be used, including short-term, long-
term, and psychoanalytic approaches. Therapists’ counter-transference reactions
such as over-protectiveness, hesitancy to adequately challenge the patient, or
excessive expectations for change may sabotage the chance of change in the
patients. It is likely that assertiveness and social skills training will increase
patients’ confidence and willingness to take risks in social situations. Using
cognitive techniques, gentle challenges of the pathological assumptions about
their sense of ineptness may also be useful. Homogeneous supportive groups
may help them develop social skills. The patients may improve with treatment
with monoamine oxidase inhibitors or serotonin reuptake inhibitors. Anxiolytics
at times may help patients better manage severe anxiety caused by facing
previously avoided situations or trying new behaviours.

They respond to behavioural therapy starting with fairly safe relaxation

exercises and then progress to assertiveness and social skills, modelling, various
kinds of role playing and psychodrama, anxiety management, and graduated
exposure or desensitization using a hierarchy of feared situations. Cognitive
therapy can be employed after some behavioural change has been made.
Testing automatic thoughts and assumptions can help them become aware of
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and change negative self-talk and help them overcome cognitive and emotional
avoidance. Listing of evidences for and against automatic thoughts can promote
changes in self-critical cognitions. Schema therapy that incorporates cognitive,
experiential, and behavioural interventions, and therapeutic relationship itself,
can help clients identify and change maladaptive schemas. Group therapy can
help clients learn and practice new social skills in a safe context, receive
feedback and encouragement, and increase their comfort with others. 28

2. Dependent Personality Disorder

The core feature of the Dependent Personality Disorder is a strong need to

be taken care of by other people. This need to be taken care of and the
associated fear of losing the support of others, often leads people with
Dependent Personality Disorder to behave in a "clingy" manner; to submit to the
desires of other people. In order to avoid conflict, they may have great difficulty
standing up for themselves. The intense fear of losing a relationship makes them
vulnerable to manipulation and abuse. They find it difficult to express
disagreement or make independent decisions, and are challenged to begin a task
when nobody is available to assist them. Being alone is extremely hard for them.
When someone with Dependent Personality Disorder finds that a relationship
they depend on has ended, they will immediately seek another source of
support.

They have low self-esteem, low self-confidence, and a high need for
reassurance. They think that they have little to offer and so must assume a
secondary, even subservient position. They tend to inordinately tolerant of
destructive relationships and unreasonable requests. They may have a history of
having been overprotected. As children, they were understood as low in energy,
sad, and withdrawn; they were filled with self-doubt, avoided competitive
activities, and had peer relationships that were awkward, unattractive, and
incompetent. They experience little happiness and seem to have a pervasive
underlying pessimistic and dysphoric mood. They may appear rigid,
judgemental, and moralistic. 29

1) Diagnostic Criteria

A pervasive and excessive need to be taken care of that leads to submissive

and clinging behaviour and fears of separation, beginning by early adulthood and
present in a variety of contexts, as indicated by five (or more) of the following:
1. Has difficulty making everyday decisions without an excessive amount of
advice and reassurance from others.
2. Needs others to assume responsibility for most major areas of his life.
3. Has difficulty expressing disagreement with others because of fear of loss
of support or approval. (Note: Do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his own (because of a
lack of self-confidence in judgement or abilities rather than a lack of
motivation or energy).
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5. Goes to excessive lengths to obtain nurturance and support from others, to

the point of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears
of being unable to care for himself.
7. Urgently seeks another relationship as a source of care and support when
a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of
himself.

2) Treatment

Personali Psychotherapies Sociotherapies Pharmacother

ty Type apies
Depende Significantly Modestly helpful No support
nt helpful

Usually the persons with Dependent Personality Disorder enter therapy with
complaints of depression or anxiety that may be precipitated by the threatened
or actual loss of a dependent relationship. They are known to respond well to
various types of individual psychotherapy. It is found that treatment may be
particularly helpful if it explores patients’ fears of independence; uses the
transference to explore their dependency; and is directed towards increasing
patients’ self-esteem, sense of effectiveness, assertiveness, and independent
functioning. Group therapy and cognitive-behaviour therapy aimed at increasing
independent functioning, with assertiveness and social skills training are found
useful for some patients. If their dependence is found in relationship, then
couples or family therapy may be helpful.

Psychodynamic approach, in which the emergence of a dependent

transference is allowed and dealt with, can be utilized in growth promoting ways.
Encouragement and support can be used to promote autonomy and improved
communication and problem solving. Thus, they will have self-esteem, increase
their sense of autonomy and individuation, and teach them to manage their own
lives. Cognitive behaviour therapy is successful and it includes relaxation and
desensitization to help the client handle challenging interpersonal situations, and
provide training in assertiveness and communication skills to help the client
identify and express feelings and wants in more functional ways. Cognitive
therapy can challenge dichotomous and dysfunctional beliefs that limit clients’
autonomy and impair their self-esteem. Schema therapy can help them develop
new core cognitions. Family and group therapy are often found useful. 30

3. Obsessive-Compulsive Personality Disorder (OCPD)

Persons with Obsessive-Compulsive Personality Disorder are preoccupied with

rules, regulations, and orderliness. This preoccupation with perfectionism and
control is at the expense of flexibility, openness, and efficiency. They are great
makers of lists and schedules, and are often devoted to work to such an extent
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that they often neglect social relationships. They have perfectionist tendencies,
and are so driven in their work to "get it right" that they become unable to
complete projects or specific tasks because they get lost in the details, and fail
to see the "forest for the trees." Persons with Obsessive-Compulsive Personality
Disorder tend to be rigid and inflexible in their approach to things. It simply is
not an option for them to do a "sub-standard" job just to get something done.
Often, they are unable to delegate tasks for fear that another person will not
"get it right." Sometimes people with this disorder adopt a miserly style with
both themselves and others. Money is regarded as something that must be
rigidly controlled in order to ward off future catastrophe. People with this
disorder are often experienced as rigid, controlling, and stubborn.

They have typically experienced strict and punitive parenting. The home
environments have usually been rigid. They will almost inevitably have
interpersonal and social difficulties. Anxiety and depression frequently
accompany them. They use rules to insulate themselves from their emotions and
requiring others to conform to their rules as well. They are so overly involved
with rules that they become rigid and perfectionistic. 31

1) Diagnostic Criteria

A pervasive pattern of preoccupation with orderliness, perfectionism, and

mental and interpersonal control, at the expense of flexibility, openness, and
efficiency, beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following;
1. Is preoccupied with details, rules, lists, order, organization, or schedules to
the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to
complete a project because his own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure
activities and friendships (not accounted for by obvious economic
necessity).
4. Is overconscientious, scrupulous, and inflexible about matters of morality,
ethics, or values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have no
sentimental value.
6. Is reluctant to delegate tasks or to work with others unless they submit to
exactly his way of doing things.
7. Adopts a miserly spending style toward both self and other; money is
viewed as something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.

2) Treatment

Personalit Psychotherapi Sociotherapi Pharmacotherapies

y Type es es
Obsessive Significantly No support No support
- helpful
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compulsiv
e

The therapists may find it difficult to treat persons with Obsessive-

Compulsive Personality Disorder because of their excessive intellectualization
and difficulty in expressing emotions. All the same, these people seem to
respond well to psychoanalytic psychotherapy or psychoanalysis. The therapists
need to be active in therapy sessions and focus on the feelings and emotions,
which the patients avoid, instead of intellectualising with the patients. Defences
such as rationalization, isolation, undoing, and reaction formation need to be
addressed and clarified. In the therapy, there may be power struggles as a mark
of the patient’s excessive need for control. Sometimes cognitive techniques may
also be used to diminish the patient’s excessive need for control and perfection.
Dynamically oriented group therapies that focus on feelings may provide insight
and increase their comfort with exploring and expressing new affects. The
patients usually tend to avoid group therapies because of their need to control
and they are afraid that they will lose control of the group.

More present- and action-oriented approaches can be used to help them

establish more realistic expectations for themselves and others. Cognitive-
behaviour therapy is likely to be well received by them. Behavioural experiments
rather than direct disputation are used to change automatic thoughts such as
“All the significant persons should appreciate and love me.”32

OTHER PERSONALITY DISORDERS

1. Personality Change due to Another Medical Condition

1) Diagnostic Criteria

A. A persistent personality disturbance that represents a change from the

individual’s previous characteristic personality pattern.
Note: In children, the disturbance involves a marked deviation from
normal development or a significant change in the child’s usual behaviour
patterns, lasting at least 1 year.
B. There is evidence from the history, physical examination, or laboratory
finds that the disturbance is the direct pathophysiological consequence of
another medical condition.
C. The disturbance is not better explained by another mental disorder
(including another mental disorder due to another medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

2. Conclusion
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Since 1980, personality disorders were put on a separate axis in DSM-III.

From then onward, clinical interest and research in these disorders have grown
enormously. The subsequent period has brought to the fore specific treatment
strategies and a better understanding of the prognosis and aetiology of these
disorders. The challenges that face the research are an explication of the
boundaries between personality disorders and normalcy and secondly the
discovery of biogenetic bases for personality disorder classification. In all
likelihood, with the continued inquiry by clinical and basic-science investigators,
the classification system will continue to change so that it becomes even more
tightly linked to the aetiology and treatment of these disorders.

It is important to remember that everyone can exhibit some of these

personality traits from time to time. To meet the diagnostic requirement of a
personality disorder, these traits must be inflexible; i.e., they can be repeatedly
observed without regard to time, place, or circumstance. Furthermore, these
traits must cause functional impairment and/or subjective distress. Functional
impairment means these traits interfere with a person's ability to function well in
society. The symptoms cause problems with interpersonal relationships; or at
work, school, or home. Subjective distress means the person with a personality
disorder may experience his symptoms as unwanted, harmful, painful,
embarrassing, or otherwise cause him significant distress. 33

3. SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS

1. Introduction
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Schizophrenia spectrum and other psychotic disorders include schizophrenia,

other psychotic disorders, and schizotypal (personality) disorder. They are
defined by abnormalities in one or more of the following five domains: delusions,
hallucinations, disorganized thinking (speech), grossly disorganized or abnormal
motor behaviour (including catatonia), and negative symptoms.

2. Schizophrenia Symptoms and Diagnosis

Presently there is no physical or lab test that can diagnose schizophrenia

absolutely. The psychiatrist usually comes to the diagnosis based on clinical
symptoms. Some of the physical tests can rule out other conditions like seizure
disorders, metabolic disorders, thyroid dysfunction, brain tumour, and street
drugs use which may have similar symptoms.

Those who are with schizophrenia usually experience a combination

of positive symptoms (i.e. hallucinations, delusions, racing
thoughts), negative symptoms (i.e. apathy, lack of emotion, poor or
nonexistent social functioning), and cognitive symptoms (disorganized
thoughts, difficulty concentrating and/or following instructions, difficulty
completing tasks, memory problems).34

1) “Positive” Symptoms (Things That May Start to Manifest or Happen)

Some of the symptoms are called positive by the psychiatrist not because
they are good, but because they are added to the normal behaviour. The
changes in the patient are "add-ons" to normal behaviour.

(1) Delusions

Delusions are beliefs that seem strange to most of us and one can prove
that they are wrong. However, the person affected with delusion might think
that someone is trying to control his brain through TV or the police are out to get
him. He might believe that he is someone else, like a famous actor or the
president, or that he has superpowers.

Delusions are fixed beliefs that are not amenable to change in light
of conflicting evidence. Their content may include a variety of themes (e.g.,
persecutory, referential, somatic, religious, grandiose). Persecutory delusions
(i.e., belief that one is going to be harmed, harassed, and so forth by an
individual, organization, or other group) are most common. Referential
delusions (i.e., belief that certain gestures, comments, environmental cues,
and so forth are directed at oneself) are also common. Grandiose delusions
(i.e., when an individual believes that he has exceptional abilities, wealth, or
fame) and erotomanic delusions (i.e., when an individual believes falsely that
another person is in love with him) are also seen. Nihilistic delusions involve
the conviction that a major catastrophe will occur, and somatic delusions focus
on preoccupations regarding health and organ function.
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Delusions are deemed bizarre if they are clearly implausible and not
understandable to same-culture peers and do not derive from ordinary life
experiences.

Bizarre delusion — the belief that outside force has removed his internal
organs and replaced them with someone else’s organs without leaving any
wounds or scars. Delusions that express a loss of control over mind or
body are generally considered to be bizarre like that one’s thoughts have
been “removed” by some outside force (thought withdrawal), that alien
thoughts have been put into one’s mind (thought insertion), or that one’s body
or actions are being acted on or manipulated by some outside force (delusions
of control). Nonbizzare delusion — the belief that one is under surveillance
by the police, despite a lack of convincing evidence.

The distinction between a delusion and a strongly held idea is sometimes

difficult to make depending in part on the degree of conviction with which the
belief is held despite clear or reasonable contradictory evidence regarding its
veracity.

(2) Hallucinations

In hallucination, one hears, sees, smells, or feels things no one else does.
Oftentimes, one hears voices in his head. These might tell him what to do, warn
him of danger, or say mean things to him. Even these voices might talk to one
another.

Hallucinations are perception-like experiences that occur without an

external stimulus. They are vivid and clear, with the full force and impact of
normal perceptions, and not under voluntary control. They may occur in any
sensory modality, but auditory hallucinations are the most common in
schizophrenia and related disorders. Auditory hallucinations are usually
experienced as voices, whether familiar or unfamiliar, that is perceived as
distinct from the individual’s own thoughts. The hallucinations must occur in
the context of a clear sensorium; those that occur while falling asleep
(hypnagogic) or waking up (hypnopompic) are normal experiences.
Hallucinations may be a normal part of religious experience in certain cultural
contexts. In grief, when one is grieving, one may have hallucinations temporarily
and that is normal.

(3) Disorganized Thinking (Thought Disorders unusual or dysfunctional of

thinking) (Speech)

Disorganized thinking (formal thought disorder) is typically inferred from

the individual’s speech. The individual may switch from one topic to another
(derailment or loose associations). Answers to questions may be obliquely
related or completely unrelated (tangentiality). When speech is so severely
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disorganized and is incomprehensible and resembles receptive aphasia in its

linguistic disorganization then it is incoherence or “word salad”.

(4) Grossly Disorganized or Abnormal Motor Behaviour Movement

Disorders (Agitated Body Movements) (Including Catatonia)

Grossly disorganized or abnormal motor behaviour may manifest itself in a

variety of ways ranging from childlike “silliness” to unpredictable agitation.
Problems may be noted in any form of goal-directed behaviour, leading to
difficulties in performing activities of daily living.

Catatonic behaviour is a marked decrease in reactivity to the

environment. This ranges from resistance to instructions (negativism); to
maintaining a rigid, inappropriate or bizarre posture; to complete lack of verbal
and motor responses (mutism and stupor). It includes purposeless and
excessive motor activity without obvious cause (catatonic excitement),
repeated stereotyped movements, staring, grimacing, mutism, and echoing of
speech. Catatonic symptoms may occur in other mental disorders (e.g., bipolar
or depressive disorders with catatonia)

(5) Confused Thoughts and Speech 

A person with schizophrenia will have a hard time organizing his thoughts.
He might not be able to follow along when someone talks to him. Instead, it
would appear that he is zoning out or distracted. When he talks, his words can
come out jumbled and may not make sense.

(6) Trouble Concentrating 

The patient will not be able to follow a conversation or any programme on

the screen because he has difficulty in concentrating.

(7) Different Movements 

The patient can seem jumpy. At times, he will make the same movements
over and over again. However, sometimes, he might be perfectly still for hours
at a stretch which is termed as “catatonic.” Contrary to what is popularly
believed, they are not violent.

2) “Negative” Symptoms (Things That Stop Happening)

The patient loses interest in something or is not able to do them anymore as

he did formerly. He experiences a lack of interest in grooming and hygiene. This
need not be mistaken with the teens, because even healthy teens can have big
emotional swings between highs and lows. Likewise, depression too has some of
the same symptoms.
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Negative symptoms account for a substantial portion of the morbidity

associated with schizophrenia but are less prominent in other psychotic
disorders. In schizophrenia, there are two prominent negative symptoms:

(1) Diminished Emotional Expression

There are reductions in the expression of emotions in the face, eye

contact, intonation of speech (prosody), and movements of the hand, head, and
face that normally give an emotional emphasis to speech. The patient may not
talk much or show any feelings. When he talks, his voice can sound flat, like he
has no emotions, which is termed as “flat affect.”

(2) Avolition

There is decrease in motivated self-initiated purposeful activities. One

may sit for long periods of time and show little interest in participating in work
or social activities.

Other Negative Symptoms Are

(3) Anhedonia

There is a decreased ability to experience pleasure from positive stimuli or

degradation in the recollection of pleasure previously experienced.

(4) Asociality

There is an apparent lack of interest in social interactions and may be

associated with avolition.

(5) Withdrawal  

The patient stops making plans and will behave like a hermit. If one wants
any answer from him, one has to work hard to get a reply.

(6) Struggling with the Basics of Daily Life  

The patient stops bathing or taking care of himself.

(7) No Follow-Through

The patient has trouble staying on schedule or finishing what he starts. At

times, he cannot get started at all. He may find difficulty in beginning and
sustaining the activities.

3) “Cognitive” Symptoms (Thinking Problems)

Thinking problem will refer to how well one’s brain learns, stores, and uses
information. The patient will have a hard time with his “working memory” (the
ability to use information immediately after learning it). He may not be able to
keep track of different kinds of facts at the same time, like a phone number plus
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instructions. One experiences trouble focusing or paying attention. It can be

hard for him to organize his thoughts and make decisions. There is poor
“executive functioning” (the ability to understand information and use it to
make decisions).35

Part I

Schizophrenia

1. Schizophrenia

1) Diagnostic Criteria

A. Two (or more) of the following, each present for a significant portion
of time during a 1-month period (or less if successfully treated). At
least one of these must be (1), (2), or (3): 1. Delusions. 2.
Hallucinations. 3. Disorganized speech (e.g., frequent derailment or
incoherence). 4. Grossly disorganized or catatonic behaviour. 5.
Negative symptoms (i.e., diminished emotional expression or
avolition).
B. For a significant portion of the time since the onset of the
disturbance, the level of functioning in one or more major areas,
such as work, interpersonal relations, or self-care, is markedly below
the level achieved prior to the onset (or when the onset is in
childhood or adolescence, there is failure to achieve expected level of
interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months.
This 6-month period must include at least 1 month of symptoms (or
less if successfully treated) that meet Criterion A (i.e., active-phase
symptoms) and may include periods of prodromal or residual
symptoms. During these prodromal or residual periods, the signs of
the disturbance may be manifested by only negative symptoms or by
two or more symptoms listed in Criterion A present in an attenuated
form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either 1) no major
depressive or manic episodes have occurred concurrently with the
active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition.
F. If there is a history of autism spectrum disorder or a communication
disorder of childhood onset, the additional diagnosis of schizophrenia
is made only if prominent delusions or hallucinations, in addition to
the other required symptoms of schizophrenia, are also present for at
least 1 month (or less if successfully treated).
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2. Schizophreniform Disorder

1) Diagnostic Criteria

A. Two (or more) of the following, each present for a significant portion of
time during a 1-month period (or less if successfully treated). At least
one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3.
Disorganized speech (e.g., frequent derailment or incoherence). 4.
Grossly disorganized or catatonic behaviour. 5. Negative symptoms
(i.e., diminished emotional expression or avolition).
B. An episode of the disorder lasts at least 1 month but less than 6
months. When the diagnosis must be made without waiting for
recovery, it should be qualified as “provisional.”
C. Schizoaffective disorder and depressive or bipolar disorder with
psychotic features have been ruled out because either 1) no major
depressive or manic episodes have occurred concurrently with the
active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition.

3. Schizoaffective Disorder

In schizoaffective disorder, a major mood episode must be present for a

majority of the time the disorder has been present in the person. The APA says
this change in DSM 5 was made on “both conceptual and psychometric grounds.
It makes schizoaffective disorder a longitudinal instead of a cross-sectional
diagnosis — more comparable to schizophrenia, bipolar disorder, and major
depressive disorder, which are bridged by this condition. This change in DSM 5
was also made to improve the reliability, diagnostic stability, and validity of this
disorder, while recognizing that the characterization of patients with both
psychotic and mood symptoms, either concurrently or at different points in their
illness, has been a clinical challenge.”36

1) Diagnostic Criteria

A. An uninterrupted period of illness during which there is a major mood

episode (major depressive or manic) concurrent with Criterion A of
schizophrenia. Note: The major depressive episode must include
Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a
major mood episode (depressive or manic) during the lifetime duration
of the illness.
C. Symptoms that meet criteria for a major mood episode are present for
the majority of the total duration of the active and residual portions of
the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a
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drug of abuse, a medication) or another medical condition.

4. Brief Psychotic Disorder

1) Diagnostic Criteria

A. Presence of one (or more) of the following symptoms. At least one of

these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3.
Disorganized speech (e.g., frequent derailment or incoherence). 4.
Grossly disorganized or catatonic behaviour. Note: Do not include a
symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less
than 1 month, with eventual full return to premorbid level of
functioning.
C. The disturbance is not better explained by major depressive or bipolar
disorder with psychotic features or another psychotic disorder such as
schizophrenia or catatonia, and is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition.

5. Delusional Disorder

1) Diagnostic Criteria

A. The presence of one (or more) delusions with a duration of 1 month or

longer.
B. Criteria A for schizophrenia has never been met.
C. Apart from the impact of the delusion(s) or its ramifications, functioning
is not markedly impaired, and behaviour is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been
brief relative to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a
substance or another medical condition and is not better explained by
another mental disorder, such as body dysmorphic disorder or
obsessive-compulsive disorder.

6. Substance/Medication-Induced Psychotic Disorder

1) Diagnostic Criteria

A. Presence of one or both of the following symptoms: 1. Delusions. 2.

Hallucinations.
B. There is evidence from the history, physical examination, or laboratory
findings of both (1) and (2): 1. The symptoms in Criterion A developed
during or soon after substance intoxication or withdrawal or after
exposure to a medication. 2. The involved substance/medication is
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capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by a psychotic disorder that is
not substance/medication-induced. Such evidence of an independent
psychotic disorder could include the following: The symptoms preceded
the onset of the substance/medication use; the symptoms persist for a
substantial period of time (e.g., about 1 month) after the cessation of
acute withdrawal or severe intoxication; or there is other evidence of an
independent non-substance/medication-induced psychotic disorder (e.g.,
a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Note: This diagnosis should be made instead of a diagnosis of substance
intoxication or substance withdrawal only when the symptoms in Criterion A
predominate in the clinical picture and when they are sufficiently severe to
warrant clinical attention.

7. Psychotic Disorder due to Another Medical Condition

1) Diagnostic Criteria

A. Prominent hallucinations or delusions.

B. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is the direct pathophysiological
consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

Part II
CATATONIA

Catatonia can occur in the context of several disorders, including

neurodevelopmental, psychotic, bipolar, depressive disorders, and other medical
conditions (e.g., cerebral folate deficiency, rare autoimmune and paraneoplastic
disorders). DSM 5 does not treat catatonia as an independent class but
recognizes (a) catatonia associated with another mental disorder (i.e., a
neurodevelopmental, psychotic disorder, a bipolar disorder, a depressive
disorder, or other mental disorder), (b) catatonic disorder due to another
medical condition, and (c) unspecified catatonia.

1. Catatonia Associated with another Mental Disorder (Catatonia

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Specifier)

1) Diagnostic Criteria

A. The clinical picture is dominated by three (or more) of the following

symptoms:
1. Stupor (i.e., no psychomotor activity; not actively relating to
environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity)
3. Waxy flexibility (i.e., slight, even resistance to positioning by
examiner)
4. Mutism (i.e., no, or very little, verbal response [exclude if known
aphasia])
5. Negativism (i.e., opposition or no response to instructions or external
stimuli)
6. Posturing (i.e., spontaneous and active maintenance of a posture
against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed
movements).
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech)
12. Echopraxia (i.e., mimicking another’s movements).
Coding Note: indicate the name of the associated mental disorder when
recording the name of the condition (i.e., catatonia associated with major
depressive disorder).

2. Catatonic Disorder due to Another Medical Condition

1) Diagnostic Criteria

A. The clinical picture is dominated by three (or more) of the following

symptoms:
1. Stupor (i.e., no psychomotor activity; not actively relating to
environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity)
3. Waxy flexibility (i.e., slight, even resistance to positioning by
examiner)
4. Mutism (i.e., no, or very little, verbal response [exclude if known
aphasia])
5. Negativism (i.e., opposition or no response to instructions or external
stimuli)
6. Posturing (i.e., spontaneous and active maintenance of a posture
against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed
movements).
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9. Agitation, not influenced by external stimuli.

10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech)
12. Echopraxia (i.e., mimicking another’s movements).
13. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct
pathophysiological consequence of another medical condition.
14. The disturbance is not better explained by another mental
disorder (e.g., a manic episode).
15. The disturbance does not occur exclusively during the course of a
delirium.
16. The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
Coding note: Include the name of the medical condition in the name of
the mental disorder (e.g., catatonic disorder due to hepatic
encephalopathy).

Part III

1. Course of Schizophrenia

The course of schizophrenia can follow various patterns, although it is

typically viewed as a chronic disorder that begins in late adolescence and has a
poor long-term outcome. Its onset may be insidious or abrupt, although
generally begins with a prodromal phase characterized by social withdrawal and
other subtle changes in behaviour and emotional responsiveness. A patient may
be seen as remote, aloof, emotionally detached, or even odd or eccentric. The
onset of subtle thought disturbances and impaired attention may also occur at
this stage. The prodrome varies in length, but typically lasts from months to
years.

The prodrome is followed by an active phase in which psychotic symptoms

predominate. At this point, clinical disorder becomes evident, and a diagnosis of
schizophrenia can usually be made. This phase is characterized by florid
hallucinations and delusions. A residual phase follows the resolution of the active
phase and is similar to the prodrome. Psychotic symptoms may persist during
this phase, but at a lower level of intensity, and they may not be as troublesome
to the patient.

Active-phase symptoms may occur episodically (‘acute exacerbations’) with

variable levels of remission seen between episodes. The frequency and timing of
these episodes are unpredictable, although stressful situations may precede
these relapses or, in some instances, drug abuse. Through this process, patients
accrue increased levels of morbidity in the form of residual or persistent
symptoms and decrements in function from their premorbid status. Relatively
severe psychosis is continuous and unrelenting in some patients. There is a
tendency for the symptoms of schizophrenia to evolve. Patients may show a
preponderance of positive symptoms early in their illness, but gradually
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develop more negative or deficit symptoms. There is some evidence that

schizophrenia may plateau at about 5 years without further
deterioration.

Schizophrenia typically begins in early adulthood, but can develop at any age
including early childhood. One study indicated that the mean age at onset is
21.4 years for men and 26.8 years for women. Patients are more likely to
remain single and unmarried than are patients in other diagnostic groups.
Patients generally have a low social status. Research has long shown increased
mortality in patients with schizophrenia. They are at high risk for suicidal
behaviour. Unlike other psychiatric patients who commit suicide,
schizophrenic patients may fail to communicate their suicidal intentions
and may act impulsively. Recent studies show that schizophrenic patients and
other severe mental disorders exhibit relatively high rates of violent behaviour
and criminality. Summaries of individual family studies have shown siblings of
schizophrenic patients to have a near 10% lifetime risk of developing
schizophrenia, while children who have one parent with schizophrenia have a
5%-6% lifetime risk.37

2. Outcome of Schizophrenia38

In summary, outcome studies show that schizophrenia is a devastating

illness that affects every aspect of a patient’s life. All the same, many patients
with schizophrenia will have a relatively good outcome and will avoid the severe
deterioration.

Features Associated With Good and Poor Outcome in Schizophrenia

Feature Good Outcome Poor Outcome

Onset Acute Insidious

Duration Short Chronic

Psychiatric history Absent Present

Affective symptoms Present Absent

Sensorium Clouded Clear

Obsessions/compulsions Absent Present

Assaultiveness Absent Present

Premorbid functioning Good Poor

Marital history Married Never Married

Psychosexual functioning Good Poor

Neurological functioning Normal Soft signs present*

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Neuropsychological test results Normal Abnormal

Structural brain abnormalities None Present

Social class High Low

Family history of schizophrenia Negative Positive

*Neurological soft signs (NSS) comprise subtle deficits in sensory integration, motor coordination, and
sequencing of complex motor acts, which are typically observed in the majority of schizophrenia patients.

3. Treatment

1) Clinical Management

Antipsychotic medication has been the mainstay of treatment in both acute

and chronic schizophrenia since chlorpromazine was introduced in 1952. Many
conventional antipsychotic drugs are now available, each differing in potency and
side effects, but similar in mode of action and efficacy. With the exception of the
new atypicals, no conventional antipsychotic has been shown to be superior to
other. There is no evidence to support using a specific agent for a specific
subtype of schizophrenia, nor is there any benefit from prescribing more than a
single antipsychotic at a time. The majority of acutely psychotic schizophrenic
patients will respond to a daily dose between 10 and 15 mg of haloperidol (or its
equivalent) within several days or weeks. Higher dosages of conventional
antipsychotics may be needed in some patients but there is no evidence to
support an advantage to either rapid loading or sustained high dosages. Highly
agitated patients should be given frequent, equally spaced doses of an
antipsychotic drug. Patients benefiting from short-term treatment with
antipsychotic medications are candidates for long-term prophylactic treatment,
which has as its goal the sustained control of psychotic symptoms.

Emphasis in recent years has focused on maximizing benefits and minimizing

risks of medication by attempting to establish the minimum effective dosage
requirements for all phases of treatment and to provide alternative strategies for
individuals who fail to benefit from antipsychotic drug treatment. At present, all
approaches to the treatment-refractory patient remain experimental, and further
research in this area is of critical importance. Definite advances have been made
in exploring the impact of psychological and psychosocial treatments
administered in conjunction with various antipsychotic drug strategies. More
sophisticated and comprehensive assessment measures have been applied in
long-term treatment trials, enabling us to be more specific about treatment
goals and treatment evaluation. Although no major “breakthrough” has occurred
in the treatment of schizophrenia, incremental advances which can reduce rates
of relapse and rehospitalisation, improve the quality of adaptation, and reduce
the risk of significant adverse effects are of enormous importance to affected
individuals, their families, and society.
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2) Physical Treatment

(1) Electroconvulsive Therapy (ECT)

Although electroconvulsive therapy has been found primarily to benefit those

with mood disorders, it is still widely used in the treatment of schizophrenia. ECT
is effective in acute and subacute forms of schizophrenia, but rarely helpful in
chronic cases. Its primary usefulness is in the treatment of a few specific
syndromes and in patients not responding to antipsychotic medication. Catatonia
and depression secondary to schizophrenia have both been recognized as
indications for ECT, though this phenomenon has not been carefully studied.
Other physical treatments like insulin coma therapy, psychosurgery and
hemodialysis have failed to show any benefit to the patients.

3) Psychosocial and Programmatic Intervention

Like antipsychotic medication, psychosocial treatment should be tailored to fit

the schizophrenic patients’ needs. A greater emphasis is placed on outpatient
management and brief hospital stays. Hospitalisation is reserved for
schizophrenic patients who pose a danger to themselves or others. An active
ward milieu is superior to a custodial one in the hospital, especially if well
structured and not overly stimulating. The following characteristics have been
found optimal: small units, short stays, high staff to patient ratio, low staff
turnover, low percentage of psychotic patients, broad delegation of responsibility
with clear lines of authority, low perceived levels of anger and aggression, high
levels of support, and a practical problem-solving approach. Patients not needing
to be hospitalised may still benefit from the structure provided in day treatment
or partial hospital programmes, especially patients with substantial symptoms
who have not responded adequately to medication. These programmes generally
operate weekdays, with patients returning home on evenings and weekends.
Psychopharmacologic management is provided along with psychosocial
rehabilitation. With most programmes, the services provided and frequency of
attendance will be individualized to fit the needs of the patient.

Alcohol and other drug abuse is a significant problem for many schizophrenic
patients. Substance abuse or dependence aggravates the symptoms of
schizophrenia, leads to medication noncompliance, and undermines other
treatment interventions. Abstinence should be encouraged in all patients, and
some will need referral for drug detoxification and rehabilitation.

Psychosocial Rehabilitation

“Psychosocial rehabilitation” is a term used to describe services that aim to

restore the patient’s ability to function in the community. This may involve the
medical and psychosocial treatments and ways to foster social interaction, to
promote independent living, and to encourage vocational performance. Patients
are encouraged to become involved in developing and implementing their
rehabilitation plan, which has as its focus enhancing the patient’s talents and
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skills. The goal of psychosocial rehabilitation is to integrate the patient back into
his community, rather than segregating the patient in separate facilities. There
are also organizations that serve a variety of functions including providing job
training, social and leisure time activities, residential assistance, and skills
training. Appropriate and affordable housing should be provided for the patients.
The options may range from supervised shelters and group homes (“halfway
houses”) to boarding homes to supervised apartment living. Group homes
provide peer support and companionship, along with on-site staff supervision. Of
course, persons with greater levels of impairment may need round-the-clock
supervision in a nursing home.

Vocational Training

Vocational training and support can also be of enormous benefit to

schizophrenic patients in helping to mainstream them back into the community.
Vocational interventions can be effective in helping patients find and maintain
paid jobs. It may involve supported employment, competitive work in integrated
settings, and more formal job training programmes. A simple, repetitive job
environment offering both interpersonal distance and on-site supervision may be
the best initial setting, such as that found in a “sheltered workshop.” Though
some patients will not be employable in any setting because of apathy,
amotivation, or chronic psychosis, employment should be encouraged in able
patients. A job will serve to improve self-esteem, provide additional income, as
well as provide a social outlet for the patient. Gradually the patient may move
toward a more demanding work setting. Failure might diminish a patient’s
already shaky self-esteem and reinforce the “sick” role. In some countries
“assertive community treatment” (ACT) is available, which consists of the careful
monitoring of patients, the availability of mobile mental health teams, and
aggressive programming individually tailored to each patient. ACT involves
teaching patients basic living skills, helping patients work with community
agencies, and helping them develop a social support network.

4) Psychotherapies

Token economies in which patients are provided a high degree of ward

structure and are rewarded for desired behaviours seem to be effective in
controlling behaviour in the hospital, but this improvement often does not
generalize to situations outside the hospital. Group therapy is frequently used
with schizophrenic patients in the hospital to provide emotional support in a
setting where a patient can learn social skills, and where friendships can
develop. Inpatient groups that are most successful are highly structured and set
limited goals. Traditional group therapy approaches that encourage self-
exploration and the seeking of insight are generally countertherapeutic.
This is particularly true with psychotic or highly paranoid individuals who might
misinterpret situations that arise in group therapy.

(1) Cognitive Therapy Techniques

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a. Cognitive Rehabilitation

Cognitive rehabilitation has as its goal the remediation of abnormal thought

processes known to occur in schizophrenia and uses techniques pioneered in the
treatment of brain-injured persons. Here the focus is on improving information
processing skills such as attention, memory, vigilance, and conceptual abilities.
This may help improve on performance on specific tasks but whether
improvement on specific tasks can generalize to other situations needs further
study.

b. Cognitive Content

Content approaches focus on changing the schizophrenic patient’s abnormal

thoughts (e.g., delusions) or his response to them or to his abnormal
experiences (e.g., hallucinations). Patients learn various coping strategies such
as listening to music to mask auditory hallucinations or reality testing of
delusional beliefs. While these techniques appear promising as a way to reduce
residual psychotic symptoms, more research is needed to learn which techniques
are most effective.

c. Social Skills Training

Since social and interpersonal skills are generally deficient in schizophrenic

patients, social skills training aims to help the patient develop more appropriate
behaviour. This is accomplished by using modelling and social reinforcement and
by providing opportunities, both individual and group, to practice the new
behaviours. This could be as simple as helping the patient learn to maintain eye
contact or as complicated as helping the patient learn conversational skills.
Social skills training can significantly enhance social functioning, but probably
has little effect on risk of relapse. The best results appear to occur in early onset
schizophrenic patients whose social development would have been disrupted by
the emergence of illness and in persons who persist in a training programme for
more than 1 year.

Social skills training and cognitive remediation are psychological techniques

with considerable face validity for treatment of negative symptoms of
schizophrenia and their consequences. There was no clear evidence for any
benefits of social skills training on relapse rate, global adjustment, social
functioning, quality of life, or treatment compliance. Cognitive remediation had
no benefit on attention, verbal memory, visual memory, planning, cognitive
flexibility, or mental state. Therefore, social skills training and cognitive
remediation do not appear to confer reliable benefits for patients with
schizophrenia and cannot be recommended for clinical practice.

5) Psychosocial Treatment and Rehabilitation

Psychosocial treatment is an extremely important component of

comprehensive management. It includes six steps.
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(1) Psychoeducation of the client and especially the family/caregivers (with

patient’s consent) regarding the nature of illness, and its course and treatment.
It helps in establishing a good therapeutic relationship with the patient (and the
family). It also involves explaining the stress-vulnerability model of
schizophrenia to the client and caregivers.

(2) Group psychotherapy is aimed at teaching problem solving and

communication skills. This can be conducted in a format known as the social
skills training package.

(3) Family therapy in which the family members are also provided social
skills training enhances communication and helps decrease intrafamilial tensions.
It also aims at decreasing the expressed emotions of significant others in the
family. The family members are made aware regarding decreasing expectations
and avoiding critical remarks, emotional over-involvement, and hostility.

(4) Milieu therapy (or therapeutic community) includes treatment in a

living, learning, or working environment ranging from inpatient psychiatric unit
to day-care hospitals and halfway homes.

(5) Individual psychotherapy is usually supportive. The current

consensus does not recommend the use of psychoanalytic
psychotherapy in routine treatment of schizophrenia. Many recommend
the use of cognitive behaviour therapy (CBT).

(6) Psychosocial rehabilitation can go well with milieu therapy. It includes

activity therapy, to develop the work habit, training in a new vocation or
retraining in a previous skill, vocational guidance, independent job placement,
sheltered employment or self-employment, and occupational therapy. Above all,
antipsychotic drug treatment in the acute stages, as well as for
maintenance treatment, is the mainstay of managing schizophrenia.
Psychosocial treatment is an important adjunct to drug treatment, which
enhances its efficacy and leads to a more complete recovery and rehabilitation.
It may not be possible that psychosocial treatment in the absence of drug
treatment will be able to treat schizophrenia effectively.

6) Rehabilitation Centre

Joseph McDonald, a Capuchin in Toronto, Canada has a post-psychiatric

home and the Capuchins have a post-psychiatric drop-in centre in the heart of
the city of Toronto. The idea behind the post-psychiatric home is that the
psychiatric patients after their inpatient treatment when they return home have
nobody who cares for them. In fact, they do not belong to anybody and thus
they do not have a support group of family or friends. They are placed by the
Government in condominium where they are isolated and in a short while return
to the mental hospital. Joseph McDonald had an intuition as to why the post-
psychiatric patients relapse soon and return to the mental hospital. According to
him, they do not belong to anybody. Therefore, belonging to somebody is
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necessary for the patients. Secondly, they should be in touch with nature.
Thirdly, they should maintain certain transcendental relationship, not necessarily
an organized religion. Thus, he collected the post-psychiatric patients and placed
them in three houses where they lived as brothers and sisters under his and his
collaborators’ guidance.

Here, first they belonged to a certain community that cares for them.
Secondly, there was a garden in which they could freely move and take care of
the garden and the household chores as a family. Thirdly, there was worship
service both in the morning and evening. The morning worship was optional in
the sense that those who were able to attend it could do so and in the evening,
before the dinner, all were obliged to attend the worship.

Amazingly, the result was that the members of the post-psychiatric home
rarely relapsed compared to their counterparts who went to the condominium.
This is an alternative way of dealing with mental illnesses and relapses, which
are frequent among the post-psychiatric patients.

7) Treatment for Other Psychotic Disorders

Antipsychotics are the mainstay of treatment, and are used to control

agitation and psychotic features. Usually lower doses of antipsychotics are
needed. ECT may be needed in cases with marked agitation and emotional
turmoil, as well as in cases where there is a danger to self and/or others.
Psychotherapy and other psychological interventions may be needed in cases
with associated stress, as well as for psychoeducation for the patient and family.
Engagement with psychological treatment is usually after the acute
episode has been under control and the patient can communicate his
fears and anxieties.39

4. Conclusion

Indeed tremendous progress has been made during the last 40 years to
better understand schizophrenia. While the introduction of DSM-III criteria in
1980 narrowed the definition for schizophrenia and created a more
homogeneous group of subjects for research, some experts believed the
narrowing went too far. A reemphasis on negative symptoms of schizophrenia
(Bleuler’s “fundamental” symptoms*) in DSM-IV has added balance to the
perhaps too-rigid emphasis on Schneiderian symptoms** in the 1970s.
Advances in classification and epidemiology have allowed us to re-evaluate the
distribution of schizophrenia and its risk factors.

The development of brain-imaging techniques such as CT, MRI, SPECT, and

PET has enhanced our understanding of schizophrenia. This technology is
allowing us to explore the nature and pattern of brain deficits and examine the
possibility of symptom-localization in schizophrenia. The development of “brain
banks” as well as new techniques in histopathology has given renewed emphasis
to post-mortem research, permitting a more detailed investigation of
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abnormalities in neurotransmitter systems and in the neuropathology of

schizophrenia. While the nosologists and neuroscientists have been clarifying the
classification and pathologic mechanisms of schizophrenia, geneticists have been
amassing large family data sets and applying new methods such as gene
mapping that promise to enrich the study of genetic factors in schizophrenia.

While technological advances are helping us to explore the aetiology of

schizophrenia, knowledge about course and outcome has been enhanced
through long-term studies. Now it is understood that the best treatment
approach to schizophrenia combines pharmacological and psychosocial
measures. The pharmacological treatment of schizophrenia has unduly relied on
the well-worn dopamine theory, and investigators are now looking at other
neurotransmitter systems that may yield a more complex interactive model of
neurotransmission abnormalities that will result in new pharmacological
approaches. Now newer atypical antipsychotics have become available, helping
many patients formerly thought to be treatment-refractory to achieve better
functioning in the community. New research has highlighted the importance of
family interaction models in schizophrenia, leading to more specific psychosocial
interventions in the treatment of this disorder. During the 1990s, the “Decade of
the Brain,” the drive in psychiatry has been to develop a comprehensive
understanding of brain function at levels that range from mind to molecule and
to determine how aberrations in these normal functions lead to the development
of symptoms of mental illness. Let us hope that the progress in the coming years
will enhance our understanding of the pathophysiology and aetiology of
schizophrenia and help treat patients better and if possible prevent its
development.40

*(1) ‘Affect’: Inappropriate or flattened affect-emotions incongruent to

circumstances/situation; (2) ‘Autism’: social withdrawal — preferring to live in
a fantasy world rather than interact with social world appropriately; (3)
‘Ambivalence’ : holding of conflicting attitudes and emotions towards others
and self; lack of motivation and depersonalization; and (4) ‘Associations’ :
loosening of thought associations leading to word salad/ flight of ideas/ thought
disorder.

**(1) Auditory hallucinations: hearing thoughts spoken aloud, hearing voices

referring to himself, made in the third person, auditory hallucinations in the form
of a commentary; (2) Thought withdrawal, insertion and interruption; (3)
Thought broadcasting; (4) Somatic hallucinations; (5) Delusional perception;
and (6) Feelings or actions experienced as made or influenced by external
agent.
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4. BIPOLAR AND RELATED DISORDERS

1. Introduction

There are several types of bipolar disorder. Each type is identified by the
pattern of episodes of mania and depression. The treatment that is best for one
may differ depending on the type of bipolar disorder one has.
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1) Bipolar I Disorder (mania and depression) – Bipolar I disorder is the

classic form of the illness, as well as the most severe type of bipolar disorder. It
is characterized by at least one manic episode or mixed episode. The vast
majority of people with bipolar I disorder have also experienced at least one
episode of major depression, although this is not required for diagnosis.

2) Bipolar II Disorder (depression and hypomania) – Mania is not involved

in bipolar II disorder. Instead, the illness involves recurring episodes of major
depression and hypomania, a milder form of mania. In order to be diagnosed
with bipolar II disorder, one must have experienced at least one hypomanic
episode and one major depressive episode in his lifetime. If one ever has a
manic episode, the diagnosis would be changed to bipolar I disorder.

3) Cyclothymia (hypomania and mild depression) – Cyclothymia is a milder

form of bipolar disorder. Like bipolar disorder, cyclothymia consists of cyclical
mood swings. However, the highs and lows are not severe enough to qualify as
either mania or major depression. To be diagnosed with cyclothymia, one must
experience numerous periods of hypomania and mild depression over at least a
two-year time span. Because people with cyclothymia are at an increased risk
of developing full-blown bipolar disorder, it is a condition that should be
monitored and treated.

There are no laboratory tests, no brain scans, and no paper-and-pencil tests

that can tell you if one has got bipolar disorder. The diagnosis is made by an
experienced clinical provider who takes a careful history and makes interview
observations. People with bipolar disorder have ups and downs like anybody else
but their ups and downs go beyond the ups and downs that come with everyday
life.

4) Symptoms

(1) Depressive Symptoms

The downs consist of sad or blue moods, sometimes with a sense that things
are bad and will never get better. Often one stops feeling pleasure in his usual
activities; becomes unrealistically pessimistic, hopeless, or guilty; or even think
about ending his life. Sometimes there are physical changes as well like inability
to sleep and loss of appetite or eating too much.

(2) Manic and Hypomanic Symptoms

The ups are more variable. Many times the ups are happy and optimistic. At
other times, they make people feel irritable. Often the main feeling is one of
being “speedy” or “racing” as though a person has too much energy and cannot
turn his motor off. Their thoughts or words can race so quickly that they can
hardly keep up with them. Often they have so much energy that they do not feel
the need to sleep. They may take up more projects, involve in risky investments
or gambling, or take social risks like romance or sexual behaviour out of context.
One with depression will almost universally feel that “something is wrong here”
and it is not always the case with the person with manic symptoms. In
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hypomania, the same symptoms can occur as in mania but they are not as
severe as mania but still can cause many difficulties. Periods of manic or
depressive symptoms are called episodes, and they typically last for several
weeks but can sometimes last months or sometimes only a couple of days. 41

5) Is it Bipolar Disorder or Depression?

Bipolar disorder is commonly misdiagnosed as depression since most people

with bipolar disorder seek help when they are in the depressive stage of the
illness. When they are in the manic stage, they do not recognize the problem.
What is more, most people with bipolar disorder are depressed a much greater
duration of the time than they are manic or hypomanic. Bipolar disorder is easily
confused with depression because it can include depressive episodes. The main
difference between the two is that depression is unipolar, meaning that
there is no “up” period, but bipolar disorder includes symptoms of
mania. To meet the diagnostic criteria for major depressive disorder, there
should be no history of a manic episode or a hypomanic episode. The essential
feature of major depressive disorder is a period of two weeks during which there
is either depressed mood most of the day nearly every day or loss of interest or
pleasure in nearly all activities.

Being misdiagnosed with depression is a potentially dangerous problem

because the treatment for bipolar depression is different from for regular
depression. In fact, antidepressants can actually make bipolar disorder worse.
Mood-stabiliser medications are needed. Therefore, it is important to see a
psychiatrist who can help one figure out what is really going on. 42

6) Indication that One’s Depression is Bipolar Disorder

(1) One experienced repeated episodes of major depression, (2) One had his
first episode of major depression before age 25, (3) One has a first-degree
relative with bipolar disorder, (4) When one is not depressed, one’s mood and
energy levels are higher than most people’s, (5) When one is depressed, one
oversleeps and overeats, (6) One’s episodes of major depression are short (less
than 3 months), (7) One has lost contact with reality while depressed, (8) One
has had postpartum depression before, (9) One has developed mania or
hypomania while taking an antidepressant, (10) One’s antidepressant stopped
working after several months, and (11) One has tried 3 or more antidepressants
without success.43

Bipolar and related disorders are separated from the depressive disorders in
DSM-5 and placed between the chapters on “Schizophrenia Spectrum and Other
Psychotic Disorders” and “Depressive Disorders” in recognition of their place as a
bridge between the two diagnostic classes in terms of symptomatology, family
history, and genetics. The diagnoses included in this chapter are bipolar I
disorder, bipolar II disorder, cyclothymic disorder, substance/medication-induced
bipolar and related disorder, and bipolar and related disorder due to another
medical condition.
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2. Bipolar I Disorder

1) Diagnostic Criteria

For a diagnosis of bipolar I disorder, it is necessary to meet the

following criteria for a manic episode. The manic episode may have been
preceded by and may be followed by hypomanic or major depressive
episodes.

Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently increased goal-directed
activity or energy, lasting at least 1 week and present most of the day,
nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity,
three (or more) of the following symptoms (four if the mood is only
irritable) are present to a significant degree and represent a noticeable
change from usual behaviour:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation (i.e., purposeless non-goal-directed
activity).
7. Excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment
in social or occupational functioning or to necessitate hospitalization to
prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication, other treatment) or to another
medical condition.
Note: A full manic episode that emerges during antidepressant treatment
(e.g., medication, electroconvulsive therapy) but persists at a fully
syndromal level beyond the physiological effect of that treatment is
sufficient evidence for a manic episode and, therefore, a bipolar I
diagnosis.
Note: Criteria A-D constitute a manic episode. At least one lifetime manic
episode is required for the diagnosis of bipolar I disorder.

Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or

irritable mood and abnormally and persistently increased goal-directed
activity or energy, lasting at least 4 consecutive days and present most
of the day, nearly every day.
B. During the period of mood disturbance and increased energy or activity,
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three (or more) of the following symptoms (four if the mood is only
irritable) have persisted, represent a noticeable change from usual
behaviour and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation (i.e., purposeless non-goal-directed
activity).
7. Excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that
is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by
others.
E. The episode is not severe enough to cause marked impairment in social or
occupational functioning or to necessitate hospitalization. If there are
psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication, other treatment).

Note: A full hypomanic episode that emerges during antidepressant treatment

(e.g., medication, electroconvulsive therapy) but persists at a fully syndromal
level beyond the physiological effect of that treatment is sufficient evidence for a
hypomanic episode diagnosis. However, caution is indicated so that one or two
symptoms (particularly increased irritability, edginess, or agitation following
antidepressant use) are not taken as sufficient for diagnosis of a hypomanic
episode, nor necessarily indicative of a bipolar diathesis.
Note: Criteria A - F constitute a hypomanic episode. Hypomanic episodes are
common in bipolar I disorder but are not required for the diagnosis of bipolar I
disorder.

Major Depressive Episode

A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning; at least one of the symptoms is either (1) depressed mood
or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another
medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by
either subjective report (e.g., feels sad, empty, or hopeless) or
observation made by others (e.g., appears tearful). (Note: In
children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either
subjective account or observation).
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3. Significant weight loss when not dieting or weight gain (e.g., a

change of more than 5% of body weight in a month), or decrease
or increase in appetite nearly every day. (Note: In children,
consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable
by others; not merely subjective feelings of restlessness or being
slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day (not merely self-reproach or
guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a
substance or another medical condition.
Note: Criteria A – C constitute a major depressive episode. Major
depressive episodes are common in bipolar I disorder but are not
required for the diagnosis of bipolar I disorder.
Note: Responses to a significant loss (e.g., bereavement, financial
ruin, losses from a natural disaster, a serious medical illness or
disability) may include the feelings of intense sadness, rumination
about the loss, insomnia, poor appetite, and weight loss noted in
Criterion A, which may resemble a depressive episode. Although such
symptoms may be understandable or considered appropriate to the
loss, the presence of a major depressive episode in addition to the
normal response to a significant loss should also be carefully
considered. This decision inevitably requires the exercise of clinical
judgement based on the individual’s history and the cultural norms for
the expression of distress in the context of loss.

Bipolar I Disorder

A. Criteria have been met for at least one manic episode (Criteria A –
D under “Manic Episode” above).
B. The occurrence of the manic and major depressive episode(s) is not
better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.

3. Bipolar II Disorder

1) Diagnostic Criteria

For a diagnosis of bipolar II disorder, it is necessary to meet the

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following criteria for a current or past hypomanic episode and the following
criteria for a current or past major depressive episode:

Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or

irritable mood and abnormally and persistently increased goal-directed
activity or energy, lasting at least 4 consecutive days and present
most of the day, nearly every day.
B. During the period of mood disturbance and increased energy or
activity, three (or more) of the following symptoms (four if the mood is
only irritable) have persisted, represent a noticeable change from
usual behaviour and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
3. More talkative than usual or pressure to keep talking.
4. Fight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation (i.e., purposeless non-goal-directed
activity).
7. Excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees,
sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning
that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable
by others.
E. The episode is not severe enough to cause marked impairment in
social or occupational functioning or to necessitate hospitalization. If
there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication, other treatment).

Note: A full hypomanic episode that emerges during antidepressant

treatment (e.g., medication, electroconvulsive therapy) but persists at a
fully syndromal level beyond the physiological effect of that treatment is
sufficient evidence for a hypomanic episode diagnosis. However, caution is
indicated so that one or two symptoms (particularly increased irritability,
edginess, or agitation following antidepressant use) are not taken as
sufficient for diagnosis of a hypomanic episode, nor necessarily indicative
of a bipolar diathesis.

Major Depressive Episode

A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning; at least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure (anhedonia).
Note: Do not include symptoms that are clearly attributable to
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another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated
by either subjective report (e.g., feels sad, empty, or hopeless)
or observation made by others (e.g., appears tearful). (Note: In
children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by
either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a
change of more than 5% of body weight in a month), or
decrease or increase in appetite nearly every day. (Note: In
children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day
(observable by others; not merely subjective feelings of
restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt
(which may be delusional) nearly every day (not merely self-
reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or as observed
by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or
a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a
substance or another medical condition.
Note: Criteria A – C constitute a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial
ruin, losses from a natural disaster, a serious medical illness or
disability) may include the feelings of intense sadness, rumination
about the loss, insomnia, poor appetite, and weight loss noted in
Criterion A, which may resemble a depressive episode. Although such
symptoms may be understandable or considered appropriate to the
loss, the presence of a major depressive episode in addition to the
normal response to a significant loss should also be carefully
considered. This decision inevitably requires the exercise of clinical
judgement based on the individual’s history and the cultural norms for
the expression of distress in the context of loss.

Bipolar II Disorder

A. Criteria have been met for at least one hypomanic episode (Criteria
A – F under “Hypomanic Episode” above) and at least one major
depressive episode (Criteria A – C under “Major Depressive
Episode” above).
B. There has never been a manic episode.
C. The occurrence of the hypomanic episode(s) and major depressive
episode(s) is not better explained by schizoaffective disorder,
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schizophrenia, schizophreniform disorder, delusional disorder, or

other specified or unspecified schizophrenia spectrum and other
psychotic disorder.
D. The symptoms of depression or the unpredictability caused by
frequent alternation between periods of depression and hypomania
causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

4. Cyclothymic Disorder

1) Diagnostic Criteria

A. For at least 2 years (at least 1 year in children and adolescents) there
have been numerous periods with hypomanic symptoms that do not meet
criteria for a hypomanic episode and numerous periods with depressive
symptoms that do not meet criteria for a major depressive episode.
B. During the above 2-year period (1 year in children and adolescents), the
hypomanic and depressive periods have been present for at least half the
time and the individual has not been without the symptoms for more than
2 months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never
been met.
D. The symptoms in Criterion A are not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or
other specified or unspecified schizophrenia spectrum and other psychotic
disorder.
E. The symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (E.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

5. Substance/Medication-Induced Bipolar and Related Disorder

1) Diagnostic Criteria

A. A prominent and persistent disturbance in mood that predominates in the

clinical picture and is characterized by elevated, expansive, or irritable
mood, with or without depressed mood, or markedly diminished interest
or pleasure in all, or almost all, activities.
B. There is evidence from the history, physical examination, or laboratory
findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance
intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
C. The disturbance is not better explained by a bipolar or related disorder
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that is not substance/medication-induced. Such evidence of an

independent bipolar or related disorder could include the following:
The symptoms precede the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month)
after the cessation of acute withdrawal or severe intoxication; or there is
other evidence suggesting the existence of an independent non-
substance/medication-induced bipolar and related disorder (e.g., a history
of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, and other important areas of functioning.

6. Bipolar and Related Disorder due to Another Medical Condition

1. Diagnostic Criteria

A. Prominent and persistent period of abnormally elevated, expansive, or

irritable mood and abnormally increased activity or energy that
predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is the direct pathophysiological consequence
of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning, or
necessitates hospitalization to prevent harm to self or others, or there are
psychotic features.

7. Treatment

1) Medication Treatment for Bipolar Disorder

Medication is the cornerstone on bipolar disorder treatment. Taking a

mood-stabilizing medication can help minimize the highs and lows of bipolar
disorder and keep symptoms under control.

Most people with bipolar disorder need medication in order to keep their
symptoms under control. When medication is continued on a long-term basis, it
can reduce the frequency and severity of bipolar mood episodes, and sometimes
prevent them entirely.

If one has been diagnosed with bipolar disorder, he and his doctor will work
together to find the right drug or combination of drugs for his needs. Because
everyone responds to medication differently, one may have to try several
different medications before one finds one that relieves his symptoms.
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One Needs to Check in Frequently with One’s Doctor. It is important to

have regular blood tests to make sure that your medication levels are in the
therapeutic range. Getting the dose right is a delicate balancing act. Close
monitoring by one’s doctor will help keep one safe and symptom-free.

One Needs to Continue Taking One’s Medication, Even if One’s Mood Is

Stable. One should not stop taking one’s medication as soon as one starts to
feel better. Most people need to take medication long-term in order to avoid
relapse.

One Need not Expect Medication to Fix All the Problems. Bipolar disorder
medication can help reduce the symptoms of mania and depression, but in order
to feel one’s best, it is important to lead a lifestyle that supports wellness. This
includes surrounding oneself with supportive people, getting therapy, and
getting plenty of rest.

One Needs to Be Extremely Cautious with Antidepressants. Research

shows that antidepressants are not particularly effective in the treatment of
bipolar depression. Furthermore, they can trigger mania or cause rapid cycling
between depression and mania in people with bipolar disorder.

2) Psychotherapy

Therapy is essential for dealing with bipolar disorder and the problems it
has caused in one’s life. Working with a therapist, one can learn how to cope
with difficult or uncomfortable feelings, repair one’s relationships, manage
stress, and regulate one’s mood.

Research indicates that people who take medications for bipolar disorder are
more likely to get better, faster, and stay well if they also receive therapy.
Therapy can teach one how to deal with the problems that one’s symptoms are
causing, including relationship, work, and self-esteem issues. Therapy will also
address any other problems one is struggling with, such as substance abuse or
anxiety.

Psychotherapy is usually used as an add-on to medications rather than

instead of medications. Research evidence indicates that any of a variety of
psychotherapies may be helpful in bipolar disorder, and no one type is any
better than others are.

The Importance of Therapy for Bipolar Disorder

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Some patients, if their mood is stabilized, see the psychiatrist only every
month or two. However, more regular therapy, typically cognitive behavioural
therapy, which can help people get on a good schedule and understand and
interpret events and thoughts, is recommended. Cognitive theory suggests that
people have unrealistically negative beliefs about themselves and their world and
they produce depression. Behaviour therapy views that depression is a
mental giving-up when goals cannot be reached. It is also recommended
that one has interpersonal therapy, which can be helpful in maintaining stable
friendships, relationships, and family interaction — often, a problem with people
who are bipolar. Interpersonal theory proposes that depression develops most
often in the context of adverse events, particularly loss or conflict related to
important relationships. Physical stress like flu, surgery, sleep deprivation, and
seasonal changes can trigger or worsen episodes. For most people social stress
can trigger or worsen episodes. Even positive stresses like success at work or
school or new relationship can trigger symptoms.

Characteristics of an Effective Psychotherapy for Depression

Even though data from controlled studies of psychotherapy of depression

are limited, certain characteristics have repeatedly emerged as distinguishing
effective treatments, regardless of the technical details of the therapy.
Extended, unstructured psychotherapies may be useful for treating associated
problems such as personality disorders, but given the lack of data supporting the
use of these therapies as primary treatments for depression, more focused,
time-limited therapies seem appropriate, at least as initial approaches.

Effective psychotherapy for depression should have the following

characteristics: time-limited; explicit rationale for treatment shared by patient
and therapist; active and directive therapist; focus on current problems;
emphasis on changing current behaviour; self-monitoring of progress;
involvement of significant others; expression of cautious optimism; problems
divided into manageable units with short-term goals; and homework
assignments.

The increased acceptance of stress-vulnerability models of severe mental

disorders and of brief evidence-based psychological treatments in their
treatment has finally led to increased interest in the role of psychotherapies in
bipolar disorders. We review now the results from randomised controlled trials of
psychological therapies as an adjunct to standard medications. The evidence
suggests that the addition of a psychological therapy may significantly reduce
symptoms, enhance social adjustment and functioning, and reduce relapses and
hospitalisations in patients with bipolar disorder. However, the methodological
problems in the published randomised controlled trials and the heterogeneity in
the outcomes achieved (some therapies reduce manic relapses but not
depressive relapses, others have the opposite effect) suggest that further
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studies are required to fully establish the place of these approaches in day-to-
day practice.

(1) Cognitive Therapy (CT)

Cognitive therapy is based on the premise that the negative emotions of

depression are reactions to negative thinking derived from global dysfunctional
negative attitudes. The patient and the therapist work together to identify
automatic negative thoughts, correct the pervasive beliefs that generate these
thoughts, and develop more realistic basic assumptions. Treatment involves
systematically monitoring negative cognitions whenever the patient feels
depressed; recognizing the association between cognition, affect, and behaviour;
generating data that support or refute the negative cognition; generating
alternative hypotheses to explain the event that precipitated the negative
cognition; and identifying the negative schemata predisposing to the emergence
of global negative thinking; e.g., an all-or-nothing assumption. In the course of
examining dysfunctional attitudes, the patient learns to label and counteract
information-processing errors such as overgeneralization, excessive
personalization, all-or-nothing thinking, and generalizing from single negative
events.

An example of the cognitive therapy would be a man who feels depressed at

the thought “nobody loves me” when his friend did not greet him
enthusiastically. This thought might be seen to follow logically from the
assumption “If my friend is not always happy to see me, he does not love me.”
Two kinds of alternative hypotheses could be generated in considering this
cognition. First, the patient’s friend may have been preoccupied with something
else or may have been happy to see him but did not demonstrate it in exactly
the way he (the client) expected. Second, lack of enthusiasm at one particular
moment is not necessarily a sign of generalized lack of love. Eventually the
patient learns to correct the underlying all-or-nothing belief “People either are
completely devoted to me or they do not care at all.”

(2) Cognitive-Behaviour Therapy (CBT)

In cognitive-behavioural therapy (CBT), one examines how one’s thoughts

affect one’s emotions. One also learns how to change negative thinking patterns
and behaviours into more positive ways of responding. For bipolar disorder, the
focus is on managing symptoms, avoiding triggers for relapse, and problem-
solving.

Cognitive behavioural therapy is a common form of individual therapy for

bipolar disorder. The focus of cognitive behavioural therapy is identifying
unhealthy, negative beliefs and behaviours and replacing them with healthy,
positive ones. It can help identify what triggers one’s bipolar episodes. One also
learns effective strategies to manage stress and to cope with upsetting
situations.
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Cognitive and Behavioural Therapy: Cognitive and behavioural therapy tend

to be combined to one degree or another. While cognitive therapy works on
thought patterns that are disabling, behaviour therapy works on behaviour
patterns that cause problems in life.

(3) Behaviour Therapy (BT)

Therapies for depression derived from principles of classic and operant

conditioning, social learning theory, and learned helplessness include social
learning approaches, self-control therapy, social skills training, and structured
problem-solving therapy. Behaviour therapies utilize education, guided practice,
homework assignments, and social reinforcement of successive approximations
in a time-limited format, typically over 8-16 weeks. Depressive behaviours such
as self-blame, passivity, and negativism are ignored, whereas behaviours that
are inconsistent with depression, such as activity, experiencing pleasure, and
solving problems, are rewarded. Rewards can include anything that the patient
seems to seek out — from attention, to praise, to being permitted to withdraw or
complain, to money. Learned helplessness is combated by the therapist’s giving
patients small, discrete tasks that very gradually become more demanding. For
example, a person who is hopeless about finding a suitable job, is first of all
asked to buy a newspaper; then go through the newspaper and list all the
available jobs; then he is asked to choose one and make an application and the
like. Each positive experience reinforces a feeling of accomplishment that makes
the next task easier. Social skills training teaches self-reinforcement, assertive
behaviour, and the use of social reinforcers such as eye contact and
compliments.

(4) Interpersonal Therapy (IPT)

Interpersonal therapy is designed to improve depression by enhancing the

quality of the patient’s interpersonal world. The treatment begins with an
explanation of the diagnosis and treatment options, legitimising depression as a
medical illness. The acute course of treatment is conducted according to a
manualized protocol over 12-16 weeks. A protocol for maintenance interpersonal
therapy has also been developed. Through structured assignments, interpersonal
therapy helps the patient to work toward explicit goals related to whichever of
the four basic interpersonal problems (unresolved grief, role disputes, transitions
to new roles, and social skills deficits) is believed to be present. Role-playing is
used to help the patient acquire new interpersonal skills, and structured conjoint
meetings are used to help partners to clarify their expectations of each other.

(5) Interpersonal and Social Rhythm Therapy

a. Interpersonal therapy focuses on current relationship issues and helps one

improve the way he relates to the important people in one’s life. By addressing
and solving interpersonal problems, this type of therapy reduces stress in one’s
life. Since stress is a trigger for bipolar disorder, this relationship-oriented
approach can help reduce mood cycling.
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b. For bipolar disorder, interpersonal therapy is often combined with social

rhythm therapy. People with bipolar disorder are believed to have overly
sensitive biological clocks, the internal timekeepers that regulate circadian
rhythms. This clock is easily thrown off by disruptions in one’s daily pattern of
activity, also known as one’s “social rhythms.” Social rhythm therapy
focuses on stabilizing social rhythms such as sleeping, eating, and
exercising. When these rhythms are stable, the biological rhythms that
regulate mood remain stable too.

c. Interpersonal and Social Rhythms Therapy: Interpersonal and social

rhythms therapy is based on the observation that some people with bipolar
disorder often end up living isolated lives and that both their social and their
physical routines get disorganized, making the depression or even manic
symptoms worse. The focus in these therapies is to addressing social and
relationship issues (interpersonal) and regularizing sleep-wake routines
(rhythms) in order to stabilize mood.

(6) Family-Focused/Family Therapy

Living with a person who has bipolar disorder can be difficult, causing strain
in family and marital relationships. Family-focused therapy addresses these
issues and works to restore a healthy and supportive home environment.
Educating family members about the disorder and how to cope with its
symptoms is a major component of treatment. Working through problems in the
home and improving communication is also a focus of treatment.

This therapy involves seeing a psychologist or other mental health provider

along with one’s family members. Family therapy can help identify and reduce
stress within one’s family. It can help one’s family learn how to communicate
better, solve problems, and resolve conflicts.

(7) Psychodynamic Psychotherapy

At one time, extended and often unstructured psychodynamic psychotherapy

was the standard psychotherapy for depression, and some case reports seemed
to support its efficacy. With more experience, the utility of nondirective
“traditional” psychodynamic approaches as a treatment for depression (as
opposed to character pathology) was increasingly questioned. There are no
controlled studies of prolonged psychodynamic psychotherapy or psychoanalysis
in mood disorders. Brief dynamic psychotherapies have been applied to
depressive disorders, but they have not been studied as rigorously as cognitive
therapy and interpersonal therapy have been.

(8) Jungian Therapy

Jungian authors have likened the mania and depression of bipolar disorder to

the Jungian archetypes “puer” and “senex.” The puer archetype is defined by the
behaviours of spontaneity, impulsiveness, enthusiasm or mania and is
symbolized by characters such as Peter Pan or the Greek god Hermes. The senex
archetype is defined by behaviours of order, systematic thought, caution, and
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depression and is symbolized by characters such as the Roman god Saturn or

the Greek god Kronos. Jungians conceptualize the puer and senex as a
coexistent bipolarity appearing in human behaviour and imagination, but in
neurotic manifestations appears as extreme oscillations and as unipolar
manifestations. In the case of the split puer-senex bipolarity the therapeutic task
is to bring the puer and senex back into correlation by working with the
patient's mental imagery.

(9) Lifestyle Changes

By carefully regulating one’s lifestyle, one can keep symptoms and mood
episodes to a minimum. This involves maintaining a regular sleep schedule,
avoiding alcohol and drugs, following a consistent exercise programme,
minimizing stress, and keeping one’s sunlight exposure stable year round.

Sufficient Sleep

If sleeping is disturbed, the symptoms can occur. Sleep disruption may

actually exacerbate the mental illness state. Those who do not get enough sleep
at night, sleep late and wake up late, or go to sleep with some disturbance(e.g.
music or charging devices) have a greater chance of having the symptoms and,
in addition, depression. It is highly advised to not sleep too late and to get
enough sleep of high quality.

Self-Management & Self-Awareness

Understanding the symptoms, when they occur, and ways to control them
using appropriate medications and psychotherapy, has given many people
diagnosed with bipolar disorder a chance at a better life. Prodrome symptom
detection has been shown to be used effectively to anticipate onset of manic
episodes and requires high degree of understanding of one's illness. Because the
offset of the symptoms is often gradual, recognizing even subtle mood changes
and activity levels is important in avoiding a relapse. Maintaining a mood chart is
a specific method used by patients and therapists to identify mood,
environmental and activity triggers.

Stress Reduction

Forms of stress may include having too much to do, too much complexity and
conflicting demands among others. There are also stresses that come from the
absence of elements such as human contact, a sense of achievement,
constructive creative outlets, and occasions or circumstances that will naturally
elicit positive emotions. Stress reduction will involve reducing things that cause
anxiety and increasing those that generate happiness. It is not enough to just
reduce the anxiety.
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Co-Morbid Substance Misuse Disorder

Co-occurring substance misuse disorders, which are extremely common in

bipolar patients, can cause a significant worsening of bipolar symptomatology
and can cause the emergence of affective symptoms. The treatment options and
recommendations for substance use disorders are wide but may include certain
pharmacological and nonpharmacological treatment options.

Connect with Others

It is good to strike a balance in one’s social life. Overstimulation can be

stressful and trigger problems, but so can isolation.
People who are bipolar tend to have trouble maintaining relationships; they wear
out their friendships. Aiming for things that make one feel good is useful: a
hobby or sport, or volunteering for a cause that is important to one. This way
one is getting one’s mind off oneself and focusing it on something else, which
can be therapeutic.

Be Wary of Triggers

Stress, social isolation, sleep deprivation, and deviation from one’s normal
routine can trigger episodes of depression or mania. One needs to be cautious
during life-changes like starting a new job, going to college, or getting a divorce.
One can encounter problems even when it is not a major event. It does not have
to be a fight or a major disruption in one’s day. Anytime one is out of balance, it
can be a trigger.

Steer Clear of Drugs and Alcohol

About 50% of bipolar patients have a problem with substance abuse. This is
one of the biggest challenges to getting good treatment outcomes.
Although one might feel alcohol helps one cope with depression, it is actually
contributing to sleep disturbances and mood changes.
Patients who abuse drugs and alcohol have poor cognitive functioning and a
lower chance for a full recovery of mood symptoms.

Combat Weight Gain

Many of the medications used to treat bipolar disorder, including lithium and
antipsychotics, can trigger metabolic syndrome or weight gain in some patients.
It is recommended keeping track of one’s weight and talking with one’s doctor if
one notices a problem after starting a new drug. The impact is very
individualized; some people do not have this problem while others do. Eating
right and getting regular exercise can help control your weight.

(10) Complementary Treatments for Bipolar Disorder

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Most alternative treatments for bipolar disorder are complementary

treatments, meaning they should be used in conjunction with medication,
therapy, and lifestyle modification. Here are a few of the options that are
showing promise:

Light and Dark Therapy 

Like social rhythm therapy, light and dark therapy focuses on the sensitive
biological clock in people with bipolar disorder. This easily disrupted clock throws
off sleep-wake cycles, a disturbance that can trigger symptoms of mania and
depression. Light and dark therapy for bipolar disorder regulates these biological
rhythms — and thus reduces mood cycling — by carefully managing one’s
exposure to light. The major component of this therapy involves creating an
environment of regular darkness by restricting artificial light for ten hours every
night.

Mindfulness Meditation 

Research has shown that mindfulness-based cognitive therapy and

meditation help fight and prevent depression, anger, agitation, and anxiety. The
mindfulness approach uses meditation, yoga, and breathing exercises to focus
awareness on the present moment and break negative thinking patterns.

Acupuncture 

Acupuncture is currently being studied as a complementary treatment for

bipolar disorder. Some researchers believe that it may help people with bipolar
disorder by modulating their stress response. Studies on acupuncture for
depression have shown a reduction in symptoms, and there is increasing
evidence that acupuncture may relieve symptoms of mania also.

There are many things one can do to stabilize one’s mood and stay well.
Making healthy choices for oneself can make a huge difference in how one feels.

(11) Other Therapies 

Other therapies that have been studied with some evidence of success
include early identification and therapy for worsening symptoms (prodrome
detection) and therapy to identify and resolve problems with one’s daily routine
and interpersonal relationships (interpersonal and social rhythm therapy). One
can also ask one’s doctor if any of these options may be appropriate for him.

3) Combining Medications and Psychotherapy

Studies suggest that psychotherapies along with added antidepressants

during the acute phase of treatment, found only a trend favouring a modest
advantage for combined treatment. Until more informative data become
available about mild to moderate unipolar nonpsychotic depression, the
recommendation that such depressive episodes be treated initially either with
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antidepressants or with one of the focused psychotherapies for depression

seems reasonable. Some experts suggest that more severe major depressive
episodes be treated first with antidepressants alone. These experts recommend
combining medication and psychotherapy for patients with an inadequate
response to either modality, with multiple symptom clusters that might respond
differentially to psychotherapy and medication, or with a previously chronic
course.

Certain types of psychotherapy, used in combination with medication, may

provide some benefit in the treatment of bipolar disorders.  Psychoeducation has
been shown to be effective in improving patients' compliance with their lithium
treatment. Evidence of the efficacy of family therapy is not adequate to support
unrestricted recommendation of its use. There is "fair support" for the utility
of cognitive therapy. Evidence for the efficacy of other psychotherapies is absent
or weak, often not being performed under randomized and controlled conditions.
Well-designed studies have found interpersonal and social rhythm therapy to be
ineffective.

Although medication and psychotherapy cannot cure the illness, therapy can
often be valuable in helping to address the effects of disruptive manic or
depressive episodes that have hurt a patient's career, relationships, or self-
esteem. Therapy is available not only from psychiatrists but from social workers,
psychologists, and other licensed counsellors.

4) Comprehensive Treatment for Bipolar Disorder

A comprehensive treatment plan for bipolar disorder aims to relieve

symptoms, restore one’s ability to function, fix problems the illness has caused
at home and at work, and reduce the likelihood of recurrence. A complete
treatment plan involves:

Education 

Managing symptoms and preventing complications begin with a thorough

knowledge of one’s illness. The more one and one’s loved ones know about
bipolar disorder, the better able one will be to avoid problems and deal with
setbacks.

There is a variety of specific types of psychoeducation available for bipolar

disorder. Some are one-to-one with a care provider; others use groups. When
done individually, clients get more private attention, while groups allow mutual
learning and support. The more effective forms of education are less like a
lecture and more oriented to hands-on activities.

Counselling to help one learn about bipolar disorder (psychoeducation)

can help one and one’s loved ones understand bipolar disorder. Knowing what is
going on can help one get the best support and treatment, and help one and
one’s loved ones recognize warning signs of mood swings.

Support  
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Living with bipolar disorder can be challenging, and having a solid support

system in place can make all the difference in one’s outlook and motivation.
Participating in a bipolar disorder support group gives one the opportunity to
share one’s experiences and learn from others who know what one is going
through. The support of friends and family is also invaluable. Reaching out to
people who love one will not mean one is a burden to others.

Group Therapy 

Group therapy provides a forum to communicate with and learn from

others in a similar situation. It may also help build better relationship skills. 44

8. CONCLUSION

Mood disorders are not unitary illnesses but complex syndromes with distinct
aetiologies, courses, and treatment responses. Even the most complete
description of an affective episode at one point in time does not fully capture the
picture of a mood disorder as it evolves over time. Mood disorders are not static
but are dynamic conditions in which each new episode is a function of the
previous episodes.

The evolving course of mood disorders is the result of an incompletely

understood interaction of genetics, environmental factors, and cell biology. In
many cases, initial episodes appear in response to an external stress, usually a
loss or separation, or an event that evokes strong arousal or helplessness. Mood
in early episodes is often more reactive to the environment. The neurobiology of
an initial affective episode may be less complex, because a single treatment is
often effective, and the physiology as well as the psychology of abnormal mood
remits completely with treatment in the absence of substantial genetics loading
or overwhelming early adverse experience. If they are not too severe, early
depressive episodes respond, equally well to environmental manipulation,
psychotherapy, or medications.

With succeeding affective episodes, the psychobiology of mania or depression

becomes more deeply ingrained by processes such as kindling, resetting of
synaptic connections, and changes in gene expression induced by
neurotransmitter, receptor, and second messenger responses to abnormal
moods. At this state, dysregulated affect becomes part of the normal repertoire
of the synapse. At the same time, negative thinking, withdrawal, social
ineptitude, irritability, and other depressive behaviours elicit negative input from
others, which reinforces feelings of helplessness and solidifies the patient’s
identity as someone who is unfulfilled, overwhelmed, unpredictable, impulsive,
incompetent, or unreliable. As more time is spent in the neurobiology and the
psychology of abnormal mood, remissions are less complete and the new
recurrences develop with less provocation.

Later affective recurrences are more abrupt, more severe, and more
complex, as additional systems are recruited into an abnormal state.
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Environmental manipulation and structured psychotherapies become less

effective. It is easier to treat early episodes than it is to treat later episodes of
bipolar mood disorders. Complete treatment of early episodes and continuation
of effective therapy reduce the risk of later, more refractory episodes. Denial,
reluctance to acknowledge needing help because being helped feels like a sign of
weakness, and pressure from family members make it difficult for people in the
early stages of a mood disorder to recognize the seriousness of the illness. 45

5. DEPRESSIVE DISORDERS

1. Introduction

Depressive disorders include disruptive mood dysregulation disorder, major

depressive disorder (including major depressive episode), persistent depressive
disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-
induced depressive disorder, and depressive disorder due to another medical
condition. The common feature of all of these disorders is the presence of sad,
empty, or irritable mood, accompanied by somatic and cognitive
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changes that significantly affect the individual’s capacity to function. What differ
among them are issues of duration, timing, or presumed aetiology.

2. Disruptive Mood Dysregulation Disorder

1) Diagnostic Criteria

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal

rages) and/or behaviourally (e.g., physical aggression toward people or
property) that are grossly out of proportion in intensity or duration to the
situation or provocation.
B. The temper outbursts are inconsistent with one’s developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry
most of the day, nearly every day, and is observable by others (e.g.,
parents, teachers, peers).
E. Criteria A-D have been present for 12 or more months. Throughout that
time, the individual has not had a period lasting 3 or more consecutive
months without all of the symptoms in Criteria A-D.
F. Criteria A and D are present in at least two of three settings (i.e., at
home, at school, with peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or
after age 18 years.
H. By history or observation, the age at onset of Criteria A-E is before 10
years.
I. There has never been a distinct period lasting more than 1 day during
which the full symptom criteria, except duration, for a manic or
hypomanic episode have been met.
Note: Developmentally appropriate mood elevation, such as occurs in the
context of a highly positive event or its anticipation, should not be
considered as a symptom of mania or hypomania.
J. The behaviours do not occur exclusively during an episode of major
depressive disorder and are not better explained by another mental
disorder (e.g., autism spectrum disorder, posttraumatic stress disorder,
separation anxiety disorder, persistent depressive disorder [dysthymia]).
Note: This diagnosis cannot coexist with oppositional defiant disorder,
intermittent explosive disorder, or bipolar disorder, though it can coexist
with others, including major depressive disorder, attention-
deficit/hyperactivity disorder, conduct disorder, and substance use
disorders. Individuals whose symptoms meet criteria for both disruptive
mood dysregulation disorder and oppositional defiant disorder should
only be given the diagnosis of disruptive mood dysregulation disorder. If
an individual has ever experienced a manic or hypomanic episode, the
diagnosis of disruptive mood dysregulation disorder should not be
assigned.
K. The symptoms are not attributable to the physiological effects of a
substance or to another medical or neurological condition.

3. Major Depressive Disorder

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1) Diagnostic Criteria

A. Five (or more) of the following symptoms have been present during the
same 2-week period and represent a change from previous functioning;
at least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another
medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad, empty, or hopeless) or observation made
by others (e.g., appears tearful). (Note: In children and adolescents, can be
irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day (as indicated by either subjective account
or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in
appetite nearly every day. (Note: In children, consider failure to make
expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by
others; not merely subjective feelings of restlessness or being slowed
down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may
be delusional) nearly every day (not merely self-reproach or guilt about
being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide.
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a
substance or another medical condition.
Note: Criteria A – C constitute a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin,
losses from a natural disaster, a serious medical illness or disability) may
include the feelings of intense sadness, rumination about the loss, insomnia,
poor appetite, and weight loss noted in Criterion A, which may resemble a
depressive episode. Although such symptoms may be understandable or
considered appropriate to the loss, the presence of a major depressive
episode in addition to the normal response to a significant loss should also
be carefully considered. This decision inevitably requires the exercise of
clinical judgement based on the individual’s history and the cultural norms
for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better
explained by schizoaffective disorder, schizophrenia, schizophreniform
disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
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E. There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or
hypomanic-like episodes are substance-induced or are attributable to
the physiological effects of another medical condition.

4. Persistent Depressive Disorder (Dysthymia)

1) Diagnostic Criteria

This disorder represents a consolidation of DSM-IV-defined chronic major

depressive disorder and dysthymic disorder.

A. Depressed mood for most of the day, for more days than not, as
indicated by either subjective account or observation by others, for at
least 2 years.
Note: In children and adolescents, mood can be irritable and duration
must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the
disturbance, the individual has never been without the symptoms in
Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present
for 2 years.
E. There has never been a manic episode or a hypomanic episode, and
criteria have never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective
disorder, schizophrenia, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Note: Because the criteria for a major depressive episode include four
symptoms that are absent from the symptom list for persistent
depressive disorder (dysthmia), a very limited number of individuals will
have depressive symptoms that have persisted longer than 2 years but
will not meet criteria for persistent depressive disorder. If full criteria for
a major depressive episode have been met at some point during the
current episode of illness, they should be given a diagnosis of major
depressive disorder. Otherwise, a diagnosis of other specified depressive
disorder or unspecified depressive disorder is warranted.
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5. Premenstrual Dysphoric Disorder

1) Premenstrual Syndrome

Premenstrual syndrome or premenstrual tension (PMT — as it has been

commonly called) is characterized by a variety of physical, psychological, and
behavioural symptoms occurring in the second half of menstrual cycle. Typically,
the symptoms start after a few days of ovulation, reach a peak about 4-5 days
before menstruation and disappear usually around menstruation. The period
between menstruation and next ovulation is normal. 46

2) Diagnostic Criteria

A. In the majority of menstrual cycles, at least five symptoms must be

present in the final week before the onset of menses, start to improve
within a few days after the onset of menses, and become minimal or
absent in the week postmenses.
B. One or more of the following symptoms must be present:
1. Marked affective lability (e.g., mood swings; feeling suddenly sad or
tearful, or increased sensitivity to rejection).
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-deprecating
thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.
C. One (or more) of the following symptoms must additionally be present, to
reach a total of five symptoms when combined with symptoms from
Criterion B above.
1. Decreased interest in usual activities (e.g., work, school, friends,
hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating; or specific food cravings.
5. Hypersomnia or insomnia.
6. A sense of being overwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling, joint or
muscle pain, a sensation of “bloating,” or weight gain.
Note: The symptoms in Criteria A - C must have been met for most
menstrual cycles that occurred in the preceding year.
D. The symptoms are associated with clinically significant distress or
interference with work, school, usual social activities, or relationships with
others (e.g., avoidance of social activities; decreased productivity and
deficiency at work, school, or home).
E. The disturbance is not merely an exacerbation of the symptoms of
another disorder, such as major depressive disorder, panic disorder,
persistent depressive disorder (dysthymia), or a personality disorder
(although it may co-occur with any of these disorders).
F. Criterion A should be confirmed by prospective daily ratings during at
least two symptomatic cycles. (Note: The diagnosis may be made
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provisionally prior to this confirmation.)

G. The symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication, other treatment) or
another medical condition (e.g., hyperthyroidism).

3) Treatment

(1) The treatment for water retention can be by diuretics, and restricting
the fluid intake. (2) Psychotherapy may be helpful in some cases where conflicts
regarding menstruation and/or feminity are present. (3) Hormonal treatment
with oral or parenteral progesterone has been recommended by some, with good
results. (4) In resistant cases, other drugs such as lithium, bromocriptine,
antidepressants, and anti-anxiety agents have been used with varying success. 47

6. Substance/Medication-Induced Depressive Disorder

1) Diagnostic Criteria

A. A prominent and persistent disturbance in mood that predominates in the

clinical picture and is characterized by depressed mood or markedly
diminished interest or pleasure in all, or almost all, activities.
B. There is evidence from the history, physical examination, or laboratory
findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance
intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
C. The disturbance is not better explained by a depressive disorder that is
not substance/medication-induced. Such evidence of an independent
depressive disorder could include the following:
The symptoms precede the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month)
after the cessation of acute withdrawal or severe intoxication; or there is
other evidence suggesting the existence of an independent non-
substance/medication-induced depressive disorder (e.g., a history of
recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, and other important areas of functioning.
This diagnosis should be made instead of a diagnosis of substance
intoxication or substance withdrawal only when the symptoms in Criterion
A predominate in the clinical picture and when they are sufficiently severe
to warrant clinical attention.

7. Depressive Disorder due to Another Medical Condition

1) Diagnostic Disorder
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A. Prominent and persistent period of depressed mood or markedly

diminished interest or pleasure in all, or almost all, activities that
predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is the direct pathophysiological consequence
of another medical condition.
C. The disturbance is not better explained by another mental disorder (e.g.,
adjustment disorder, with depressed mood, in which the stressor is a
serious medical condition).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

8. Psychotherapies

1) Cognitive Therapy

(1) Theory of Cognitive Therapy

Depression is one of the most common presenting problems encountered by

mental health professionals. A variety of approaches has been applied to
treatment of depression, with growing emphasis on short-term psychotherapies:
behavioural therapy, interpersonal psychotherapy, brief psychodynamic therapy,
and cognitive therapy. Of all the cognitive-behavioural approaches to
depression, cognitive therapy has received the most empirical attention.
Despite the tremendous advances in psychotherapy for depression,
pharmacotherapy remains the standard against which other treatments
are compared. Initial research suggested that cognitive-behavioural therapy is
at least as effective as tricyclic antidepressants in the treatment of non-bipolar,
depressed outpatients. More recent studies show that cognitive therapy is more
effective than nothing at all, behaviour therapy or pharmacotherapy in the
treatment of clinical depression. The efficacy of the cognitive-behavioural
approach with depression is especially striking in light of a number of studies
showing that traditional psychotherapies are only slightly more effective than pill
placebos in reducing depressive symptomatology.

(2) Assumption of Cognitive Model

The cognitive model assumes that cognition, behaviour, and biochemistry are
all important components of depressive disorders. They are not competing
theories of depression but rather are different levels of analysis. Each has its
own “focus of convenience.” The pharmacotherapist intervenes at the
biochemical level; the cognitive therapist intervenes at the cognitive, affective,
and behavioural levels since from the cognition flows the feelings and from there
the behaviour. When we change depressive cognitions, we simultaneously
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change the characteristic mood, behaviour, and probably biochemistry of

depression.

(3) Cognitive Triad of Depression

Cognitive science research emphasizes the importance of information-

processing in depressive symptomatology. Negatively biased cognition is a
core process in depression. This process is reflected in the “cognitive triad of
depression”: Depressed patients typically have a negative view of
themselves, their environment, and the future. (1) They view themselves as
worthless, inadequate, unlovable, and deficient; (2) view the environment as
overwhelming, as presenting insuperable obstacles that cannot be overcome
and as continually resulting in failure or loss; (3) view the future as hopeless
and believe that their own efforts will be insufficient to change the unsatisfying
course of their life.

This negative view of the future often leads to suicidal ideation and actual
attempts. Depressed clients consistently distort their interpretations of events so
that they maintain negative views of (1) themselves, (2) the environment, and
(3) the future. These distortions represent deviations from the logical processes
of thinking used typically by people. Depressed clients have “arbitrary inference”
by which they reach a conclusion that is not justified by the available evidence.
For example, a depressed woman interprets her casually-talking husband with a
woman, as having sexual relationship. Other such distortions include all-or-
nothing thinking, overgeneralization, selective abstraction, and magnification.

(4) Cognitive Techniques

The cognitive therapist uses techniques for eliciting automatic thoughts,

testing automatic thoughts, reattribution, and identifying schemas to help both
the therapist and the patient understand the client’s construction of reality.

a. Eliciting Automatic Thoughts

Automatic thoughts are those thoughts that intervene between outside

events and the individual’s emotional reactions to them. They often go unnoticed
because they are part of a repetitive pattern of thinking and because they occur
so often and so quickly. One rarely stops to assess their validity because they
are so believable, familiar, and habitual. The cognitive therapist and the client
make a joint effort to discover the particular thoughts that precede such
emotions as anger, sadness, and anxiety. Therapists use questioning, imagery,
and role playing to identify the automatic thoughts. The therapist asks what
thoughts went through the mind in response to particular events. This
questioning provides clients with a model for introspective exploration.

Alternatively, when the patient is able to identify those external events and
situations that evoke a particular emotional response, the therapist may use
imagery by asking the client to picture the situation in detail. In this technique,
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the therapists ask the clients to relax, close their eyes, and imagine themselves
in the distressing situation. The clients describe in detail what is happening as
they relive the event. If the distressing event is an interpersonal one, the
therapist can utilize role-playing. The therapist plays the role of the other person
in the encounter, while the patients play themselves. The automatic thoughts
can usually be elicited when the clients become sufficiently engaged in the role-
play. Once the clients become familiar with the techniques for identifying
automatic thoughts, they are asked to keep a Daily Record of Dysfunctional
Thoughts.

b. Testing the Automatic Thoughts

Once a key automatic thought is identified, one approaches the thoughts with
a testable hypothesis. This scientific approach is fundamental to cognitive
therapy, where the client learns to think in a way that resembles the
investigative process. Through the procedures of gathering data, evaluating
evidence, and drawing conclusions, the client learns firsthand that one’s view of
reality can be quite different from what actually takes place. The therapist
approaches the testing of the automatic thoughts by asking the patients to list
evidence from their experience for and against the hypothesis. Sometimes, after
considering the evidence, the clients will immediately reject the automatic
thought, recognizing that it is either distorted or actually false.

In testing the automatic thoughts, it is sometimes necessary to define the

client’s use of a word. There are global labels such as “bad,” “stupid,” or
“selfish.” What is needed in this case is an operational definition of the word.

c. Reattribution

Reattribution is another useful technique for helping the client reject an

inappropriate, self-blaming thought. Reattribution can be used when the patient
unrealistically attributes adverse occurrences to a personal deficiency such as
lack of ability or effort. The therapist and the client review the relevant events
and apply logic to the available information to take a more realistic assignment
of responsibility. Another strategy involving reattribution is for the therapist to
demonstrate to clients that they use stricter criteria for assigning responsibility
to their own unsatisfactory behaviour than they use in evaluating the behaviour
of others.

d. Schemas

An important predisposing factor for many clients with depression is the

presence of early schemas. A schema is a (cognitive) structure for
screening, coding, and evaluating the stimuli that impinge on the
organism. Based on this matrix of schemas, the individual is able to orient
himself in relation to time and space and to categorize and interpret experiences
in a meaningful way. In the field of psychopathology, the term “schema”
has been applied to structures with a highly personalized idiosyncratic
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content that are activated during disorders such as depression, anxiety,

panic attacks, and obsessions, and become prepotent. Thus in clinical
depression, the negative schemas are in ascendency, resulting in a systematic
negative bias in the interpretation and recall of experiences as well as in short-
term and long-term predictions, whereas the positive schemas become less
accessible. It is easy for them to see the negative aspects of an event, but
difficult to see the positive. They can recall negative events much more readily
than positive ones. They weigh the probabilities of undesirable outcomes more
heavily than positive outcomes.

(a) Maladaptive Schemas

There is a subset of schemas (the deepest level of cognition), which is called

maladaptive schemas. Early maladaptive schemas refer to extremely stable and
enduring themes that develop during childhood and are elaborated upon
throughout the individual’s lifetime. For example, a child learns to construct
reality through his early experiences with the environment, especially with his
significant others. Sometimes these early experiences lead children to accept
attitudes and beliefs that will later prove maladaptive. For example, a child may
develop a schema that no matter what he does, he will never succeed.

(b) Characteristics of Maladaptive Schema

The early maladaptive schemas have several defining characteristics. They

are experienced as (1) a priori truths about oneself and the environment; (2)
self-perpetuating and resistant to change; (3) dysfunctional; (4) often triggered
by some environmental change (e.g., loss of a mate or a job); (5) tied to high
levels of affect when activated; and (6) usually result from an interaction of the
child’s innate temperament with dysfunctional developmental experiences with
family members or caretakers.

The focus of cognitive therapy is on changing depressive thinking. These

changes may be brought about in a variety of ways: through behavioural
experiments, logical discourse, examination of evidence, problem solving, role-
playing, and imagery restructuring and many more.

There is mounting evidence that cognitive therapy is an effective, short-term

treatment for adult outpatients with nonbipolar depressions. Cognitive therapy
teaches patients to elicit their automatic thoughts and early maladaptive
schemas. These cognitions are then put to the test by examining evidence,
setting up in vivo experiments, weighing advantages and disadvantages, trying
graded tasks, and employing other intervention strategies. Through this process,
clients begin to view themselves and their problems more realistically, feel
better, change their maladaptive behavioural patterns, and take steps to solve
real-life difficulties.

2) Behavioural Techniques
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Behaviour Therapy: In this are included the various short-term modalities

such as social skills training; problem solving techniques, assertive training, self-
control therapy, activity scheduling, and decision-making techniques. It can be
useful in mild cases of depression or as an adjunct to antidepressant in
moderate depression.

Behavioural techniques are especially necessary for those more severely

depressed patients who are passive, anhedonic, socially withdrawn, and unable
to concentrate for extended periods. By engaging the client’s attention and
interest, the cognitive therapist tries to induce the patient to counteract
withdrawal and become more involved in constructive activity. Behavioural
techniques are used to modify automatic thoughts. The severely depressed client
is caught in a vicious cycle in which a reduced activity level leads to negative
self-label, which, in turn, results in even further discouragement and consequent
inactivity. Intervention with behavioural techniques can enter and change this
self-destructive pattern.

The most commonly used behavioural techniques include scheduling activities

that include both mastery and pleasure exercises, cognitive rehearsal, self-
reliance training, role playing, role reversal, and diversion techniques.

The scheduling of activities is frequently used to counteract loss of

motivation, hopelessness, and excessive rumination. Activities are scheduled
hour by hour, day by day. This also helps clients obtain more pleasure and a
greater sense of accomplishment from activities on a daily basis. The clients rate
each completed activity (using a 0-10 scale) for both mastery and pleasure. The
ratings usually contradict clients’ beliefs that they cannot accomplish or enjoy
anything anymore.

Cognitive rehearsal entails asking the client to picture or imagine each step
involved in the accomplishment of a particular task.

With self-reliance training, clients learn to assume increased responsibility for

routine activities such as showering, making their bed, cleaning the house,
cooking their own meals, and shopping. Self-reliance involves gathering
increased control over emotional reactions.

Role-playing can be used to bring out automatic thoughts through the

enactment of particular interpersonal situations, such as an encounter with a
supervisor at work.

Role reversal, a variation of role-playing, can be used for helping clients test
how other people might view their behaviour.

The therapist may introduce various diversion techniques to assist the client
in learning to reduce the intensity of painful affects. The client learns to divert
negative thinking through physical activity, social contact, work, play, and visual
imagery.
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3) Psychosocial Techniques

Although somatic treatment appears to be the primary mode of management

in major mood disorders, psychosocial treatment is often helpful: (1) As an
adjunct to somatic treatment, (2) In mild to moderate cases of depression, and
(3) Certain selected cases.

Interpersonal Therapy (IPT): It attempts to recognize and explore

interpersonal stressors, role disputes and transitions, social isolation, or social
skills deficits, which act as precipitants for depression. It is useful in the
treatment of mild to moderate unipolar depression, with or without
antidepressants.

Psychoanalytic Psychotherapy: The short-term psychoanalytic

psychotherapies aim at changing the personality itself rather than just
ameliorating the symptoms. Its usefulness is uncertain in florid depressive or
manic episodes. It may be useful in the treatment of dysthymic disorder,
depression co-morbid with personality disorders, or depression with a history of
childhood loss/child abuse.

Group Therapy: It is useful in mild cases of depression. It is a useful

method of psychoeducation in both recurrent depressive disorder and bipolar
disorder.

Family and Marital Therapy: Family therapy has not been found useful in
treatment of mood disorders per se. These can help decrease the intrafamilial
and interpersonal difficulties, and to reduce or modify stressors, which may help
in a faster and more complete recovery. Their most common use is to ensure
continuity of treatment and adequate drug compliance.48

9. Conclusion

A depressive disorder is an illness that involves the body, mood, and

thoughts. It interferes with daily life, normal functioning, and causes pain for
both the person with the disorder and those who care about him. It is a
persistent feeling of sadness and worthlessness and a lack of desire to engage in
formerly pleasurable activities.

A depressive disorder is not the same as a passing blue mood. It is not a

sign of personal weakness or a condition that can be willed or wished away.
People with a depressive illness cannot merely "pull themselves together" and
get better. Without treatment, symptoms can last for weeks, months, or years.
Depression is a common but serious illness, and most people who experience it
need treatment to get better. Appropriate treatment, however, can help most
people who suffer from depression.
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6. ANXIETY DISORDERS

1. Introduction

Anxiety disorders include disorders that share features of excessive fear and
anxiety and related behavioural disturbances. Fear is the emotional response
to real or perceived imminent threat, whereas anxiety is anticipation of
future threat. Obviously, these two states overlap, but they also differ, with
fear more often associated with surges of autonomic arousal necessary for fight
or flight, thoughts of immediate danger, and escape behaviours, and anxiety
more often associated with muscle tension and vigilance in preparation for future
danger and cautious or avoidant behaviours. Sometimes the level of fear or
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anxiety is reduced by pervasive avoidance behaviours. Panic attacks feature

prominently within the anxiety disorders as a particular type of fear response.
Panic attacks are not limited to anxiety disorders but rather can be seen in other
mental disorders as well.

The anxiety disorders differ from one another in the types of objects or
situations that induce fear, anxiety, or avoidance behaviour, and the associated
cognitive ideation. Thus, while the anxiety disorders tend to be highly comorbid
with each other, they can be differentiated by close examination of the types of
situations that are feared or avoided and the content of the associated thoughts
or beliefs.

Anxiety is marked by both emotional and physiological symptoms. Fear and

apprehension are the primary emotional symptoms, which can be accompanied
by confusion, impaired concentration, selective attention, avoidance, and,
especially in children and adolescents, behavioural problems. Physiological
symptoms are dizziness, heart palpitations, changes in bowel and bladder
functioning, perspiration, muscle tension, restlessness, insomnia, irritability,
headaches, and queasiness. They are hypervigilant for signs of possible danger
thus having an “attentional bias for threat.” They consider themselves as
powerless and may view the world as a source of harm and threat. 49

2. Separation Anxiety Disorder

Separation anxiety disorder is one of the most common disorders found in

children. Approximately one third of the cases will persist into adulthood. It is
characterized by excessive distress upon separation from home or primary
attachment figures. This disorder is precipitated by a stressful event, such as a
significant loss, separation from loved ones, or exposure to danger, an insecure
attachment to the primary caregiver, and enmeshed family relationships.
Children with this disorder express fear of going to sleep, request someone stay
with them until they do, experience frequent nightmares, and attempt to sleep
in their parents’ bed.

1) Diagnostic Criteria

A. Developmentally inappropriate and excessive fear or anxiety concerning

separation from those to whom the individual is attached, as evidenced
by at least three of the following:
1. Recurrent excessive distress when anticipating or experiencing
separation from home or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures
or about possible harm to them, such as illness, injury, disasters, or
death.
3. Persistent and excessive worry about experiencing an untoward event
(e.g., getting lost, being kidnapped, having an accident, becoming ill)
that causes separation from a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school,
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to work, or elsewhere because of fear of separation.

5. Persistent and excessive fear of reluctance about being alone or
without major attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to
sleep without being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches,
stomach-aches, nausea, vomiting) when separation from major
attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in
children and adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in
social, academic, occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such
as refusing to leave home because of excessive resistance to change in
autism spectrum disorder; delusions or hallucinations concerning
separation in psychotic disorders; refusal to go outside without a trusted
companion in agoraphobia; worries about ill health or other harm
befalling significant others in generalized anxiety disorder; or concerns
about having an illness in illness anxiety disorder.

2) Treatment

Separation Anxiety Disorder can be a phobic response, usually

surrounding the fear of leaving the primary caregiver, but it may also be related
to fear of social and school situations. Phobias and fears are acquired
through classical conditioning. They can be unlearned with the behavioural
technique of exposure therapy. In exposure therapy, the child systematically
confronts the feared situation through graded exposure. Cognitive-
behavioural therapy is the treatment of choice for this disorder. There is
a treatment called Coping Cat Model, a multifaceted treatment programme
that involves education, parent and family, and cognitive, affective, sociological,
and behavioural elements. This cognitive-behaviour therapy builds on the
therapist-child relationship and provides psychoeducation on the physiological
signs of excessive anxiety, normal anxiety, self-talk associated with anxiety, the
use of relaxation to reduce anxiety, and behavioural skills. In this, the first half
of treatment is the educational and the second half is the exposure. If school
attendance is a problem of short duration, a return to school is sufficient. With
regard to long absenteeism from school, shaping attendance behaviours by
bringing the child to the school premises, to the front door, and finally to the
classroom and gradually extending the time that the child remains at school.
When there is enmeshment at home, family therapy is recommended. Parents
themselves may be dependent upon the children or immature. Family therapy
should address the issue of re-establishing appropriate hierarchies and
boundaries between the family subgroups. Relaxation techniques seem to be
successful in treating this disorder.50

3. Selective Mutism
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1) Diagnostic Criteria

Kronenberger and Meyer (2001) describe four subtypes of selective

mutism. (1) Children who are shy and fearful, with significant stranger anxiety,
(2) Children who are noncompliant and hostile, (3) Children whose mutism is
the result of a traumatic or upsetting event or experience, and (4) Children who
have a symbiotic relationship with the primary caregiver and who are
manipulative and controlling, although they sometimes seem shy. The onset of
this disorder is before the age 5. These symptoms occur only in social situations,
at school, or among strangers.

Selective mutism should be differentiated from shyness in normal

children, intellectual disabilities, pervasive developmental disorder, expressive
language disorder, and conversion disorder. Most cases improve with the
passage of time, though some children may require pharmacotherapy and/or
psychosocial management.

A. Consistent failure to speak in specific social situations in which there is

an expectation for speaking (e.g., at school) despite speaking in other
situations.
B. The disturbance interferes with educational or occupational achievement
or with social communication.
C. The duration of the disturbance is at least 1 month (not limited to the
first month of school).
D. The failure to speak is not attributable to a lack of knowledge of, or
comfort with, the spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder
(e.g., childhood-onset fluency disorder) and does not occur exclusively
during the course of autism spectrum disorder, schizophrenia, or another
psychotic disorder.

2) Treatment

For children with Selective Mutism, teaching the social and other skills can
help reduce the feelings of fear and shyness in the child and help learn to
express needs more directly. Later treatment will emphasize behaviour therapy
aimed at improving the child’s comfort level in social environments. There is a
method called “stimulus fading,” which is similar to systematic desensitization.
In this, a parent with whom the child does speak accompanies the child to the
site where the child is mute. The child is gradually introduced to the feared
situation while the parent withdraws. One can also reward the child for
increasing his communication and social interaction. These behaviours can be
generalized through shaping and reinforcement techniques. Play therapy by its
symbolic nature will allow the child a nonverbal modality in which to safely
process uncomfortable feelings and upsetting experiences that may be at the
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base of selective mutism. Cognitive-behavioural therapy helps children reduce

their anxious fears and develop positive thoughts. 51

Phobias in General

Phobias have two ingredients: a persistent, unwarranted, and

disproportionate fear of an actual or anticipated environmental stimulus and a
dysfunctional way of coping with that fear, with resulting impairment in social or
occupational functioning. Persons with phobias experience either limited-
symptom or full panic attacks when they face or expect to face the objects of
their fear. Persons with established phobias experience anticipatory anxiety and
may be associated with long-standing underlying apprehension and with
avoidance behaviour. They react with self-protective primal reactions (the 4 Fs:
fight, flight, freeze or faint). The median age of onset of specific phobia is 7
years. The symptoms experienced are: racing heart, muscle tension, the urge to
run, rapid breathing, an impending feeling of doom, feeling fidgety, shortness of
breath, cold hands or feet, trembling, and pounding in the chest. Genetics and
biology seem to influence phobias. Thus a low threshold for alarm reactions or
vasovagal responses interacts with the environmental influences and paves way
for the development of phobias. Therefore, the interaction of anxiety sensitivity
and expected anxiety leads to avoidant behaviour in order to reduce the fear.

Treatment in General

Exposure-based therapies seem to be successful. It can be done in vivo or

through imaginal desensitization, which includes visualization or pictures of the
feared object. Various types of pacing may be used like intensive, spaced, or
graduated. But all exposures should share the following five common features:
(1) Development of anxiety hierarchies, (2) Imaginal or in vivo systematic
desensitization, possibly through modelling, (3) cognitive restructuring, (4)
Encouragement of expressions of feeling, a sense of responsibility, and self-
confidence, and (5) Accompanying of a partner or significant other in
desensitization process and in communication skills training as in the treatment
of agoraphobia. To these one can also add relaxation training, breathing
retraining, and paradoxical intention. Most theories advocate exposing clients to
feared situations long enough for the fear to be aroused and reduced within a
single session.

Flooding: Flooding or implosion involves prolonged and intensive

exposure, usually 30 minutes to 8 hours, to the feared object until satiation and
anxiety reduction are achieved.

Graduated Exposure: Graduated exposure is done by having a person

face the object of a phobia for a very brief time and then increasing the duration
of exposure until the person can remain reasonably calm in the presence of the
feared object or situation for approximately one hour.
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Systematic Desensitization: Systematic desensitization therapy begins

by setting up an anxiety hierarchy, that is, a list of the client’s fears, organized
according to severity. The therapist begins with the least frightening
presentation of the feared object and uses relaxation techniques to help the
client become comfortable with that level of exposure. Relaxation is used since
anxiety and relaxation cannot coexist. Presentation of the feared object
gradually moves up the hierarchy with the client becoming acclimated to each
successive level. This process can be (1) imaginal, that is, conducted in
imagination, (2) in vivo (conducted in context), or (3) a combination of the two.
It may be good to start with the imaginal systematic desensitization.

Cognitive Restructuring: Cognitive restructuring can be an important

adjunct to exposure therapy. Socratic questions are designed by the therapist to
elucidate the clients’ cognitive distortions and encourage the testing of their
validity, helping clients understand, normalize, and manage their fears. It is
believed that inordinate fears are maintained by mistaken or dysfunctional
appraisals of situations.52

4. Specific Phobia

Anxiety in response to physical sensations may play a role in the

development of specific phobias, especially in the case of claustrophobia. When
people are anticipating or confronting feared objects or situations, they become
agitated and fearful and may experience physical symptoms of anxiety, such as
shortness of breath, fear of doom, desire to run, and heart palpitations.

1) Diagnostic Criteria

A. Marked fear or anxiety about a specific object or situation (e.g., flying,

heights, animals, receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying,
tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or
anxiety.
C. The phobic object or situation is actively avoided, or endured with
intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the
specific object or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
G. The disturbance is not better explained by the symptoms of another
mental disorder, including fear, anxiety, and avoidance of situations
associated with panic-like symptoms or other incapacitating symptoms
(as in agoraphobia); objects or situations related to obsessions (as in
obsessive-compulsive disorder); reminders of traumatic events (as in
posttraumatic stress disorder); separation from home or attachment
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figures (as in separation anxiety disorder); or social situations (as in

social anxiety disorder).

1) Treatment
Phobia is defined as an irrational fear of a specific object, situation or activity,
often leading to persistent avoidance of the feared object, situation or activity.
The common types of phobias are Agoraphobia, Social Phobia, and Specific
(Simple) phobia.

Most patients with phobic disorder rely on avoidance to manage their fears
and anxieties. As long as they find ways to limit their lives within the limitations
imposed by phobias, they experience little, if any, anxiety. When they are forced
to face the phobic situation, anxiety mounts and they then seek treatment. The
patients with more than one phobia and presence of panic symptoms often seek
treatment earliest. The treatment approach is usually multi-modal.

The treatment of choice for specific phobias is exposure. Exposure

treatment may be divided into two groups, depending on whether exposure to
the phobic object is in vivo or imaginal. In vivo exposure involves the patient
in real-life contact with the phobic stimulus. When imaginal techniques are used,
the phobic stimulus is confronted through the therapist’s descriptions and the
patient’s imagination.
The method of exposure in both the in vivo and imaginal techniques can be
graded or ungraded. Graded exposure uses a hierarchy of anxiety-provoking
events, varying from least to most stressful. The patient begins at the least
stressful level and gradually progresses up the hierarchy. Ungraded exposure
begins with the patients confronting the most stressful items in the hierarchy.
Most exposure techniques have been used in both individual and group
settings. In a group setting, both the example and the encouragement of other
members are often particularly helpful in persuading the patient to re-enter the
phobic situation. Techniques may include systematic desensitisation, imaginal
flooding, prolonged in vivo exposure, and participant modelling and reinforced
practice.
No medication has been shown to be effective in treating specific phobias.
The therapist plays an important role in modelling nonfearful behaviour.
However, observational learning is not enough to effect significant change; the
therapist needs to be supportive and optimistic about the outcome of treatment
and communicate acceptance and empathy while still encouraging people to
experience the frightening situation.
Actually specific phobias are the most treatable of all anxiety disorders.
Exposure, involving prolonged contact with feared objects or situations, is good.
Here, a list of feared objects is developed. Then a hierarchy is established for
each listed stimulus with the rating on a scale of 1 to 100 for the level of fear
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and the avoidance it provokes. In vivo or imaginal desensitization is used to

lessen the fear. What is crucial in this approach is that it involves relaxation and
exposure to one item at a time until the anxiety connected to that item is
reduced to a manageable level. It is good to keep in mind that most children are
not developmentally capable of benefiting from imaginal exposure.
Effective treatment usually combines exposure with encouragement to
develop a sense of mastery. Exposure can be combined with imaginal flooding
(used carefully), use of positive coping statements, paradoxical intention
(focusing on anticipatory anxiety), thought stopping, thought switching, success
rehearsal, assertiveness training, hypnosis, cognitive restructuring, increased
exposure to an awareness of internal cues of anxiety, modelling by the therapist
or another, reinforced practice, and supportive and family therapy. Cognitive
approach alone is not effective for the treatment of specific phobias. However,
exposure-based treatment combined with cognitive restructuring is effective.
Massed exposure seems to reduce fear.53
5. Social Anxiety Disorder (Social Phobia)

Social phobias often focus on specific situation like public speaking, eating
in public, taking tests, attending parties, interacting with authority figures, and
being interviewed. Situations involving evaluation are particularly threatening.
Actual or threatened exposure to such situations produces an immediate anxiety
response. If a person fears most social situations, he is known to have a
generalized type of social anxiety disorder. Children of this disorder are known to
exhibit selective mutism, school refusal, separation anxiety, and excessive
shyness.54

1) Diagnostic Criteria

A. Marked fear or anxiety about one or more social situations in which the
individual is exposed to possible scrutiny by others. Examples include
social interactions (e.g., having a conversation, meeting unfamiliar
people), being observed (e.g., eating or drinking), and performing in
front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just
during interactions with adults.
B. The individual fears that he will act in a way or show anxiety symptoms
that will be negatively evaluated (i.e., will be humiliating or
embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying,
tantrums, freezing, clinging, shrinking, or failing to speak in social
situations.
D. Social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the
social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
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G. The fear, anxiety, or avoidance causes clinically significant distress or

impairment in social, occupational, or other important areas of
functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms
of another mental disorder, such as panic disorder, body dysmorphic
disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity,
disfigurement from burns or injury) is present, the fear, anxiety, or
avoidance is clearly unrelated or is excessive.
Specify if: Performance Only: If the fear is restricted to speaking or
performing in public.

2) Treatment

The major cognitive-behaviour techniques are used in the treatment of social

phobia: exposure, cognitive restructuring, and social skills training.
Exposure treatment involves imaginal or in vivo exposure to specific feared
performance and social situations. Although patients with very high levels of
social anxiety may need to start out with imaginal exposure until a certain
degree of habituation is attained, therapeutic results are not gained until in vivo
exposure is done to the real-life feared situations.
Social skills training employs modelling, rehearsal, role-playing, and assigned
practice to help individuals learn appropriate behaviour and to decrease anxiety
in social situations. This type of training is more applicable to those who have
actual deficits in social interacting above and beyond their anxiety or avoidance
of social situations. Cognitive restructuring focuses on poor self-concepts, the
fear of negative evaluation by others, and the attribution of positive outcomes to
chance or circumstance and negative outcomes to one’s own shortcomings.
Cognitive-behaviour techniques lead to long-lasting gains and therefore may
be of particular importance in this disorder, which tends to have a chronic, often
lifetime, course. At this point, in vivo exposure is a critical component of the
treatment. The introduction of cognitive restructuring at some point in the
treatment contributes to further gains and to their long-term maintenance.
3) Psychotherapies
(1) Overview of Cognitive-Behaviour Group Therapy (CBGT)

a. Treatment Orientation Interview

Once the clinician has done enough assessment to determine the diagnosis
and the potential group members’ appropriateness for treatment, the treatment
orientation interview should be completed by one or both the therapists for the
group. This interview has four primary purposes. First, it allows the therapist to
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preview the nature of the group treatment for the client. Second, the therapist
teaches the client how to use the Subjective Units of Distress Scale (SUDS).
Third, a fear and avoidance hierarchy is constructed. Finally, the therapist(s)
and client develop an explicit treatment contract.

b. Treatment Preview

The potential group members need to be appraised of what treatment will

involve. The therapist should outline the cognitive-behavioural model of social
phobia in understandable terms and explain how confronting one’s fears is
essential to overcoming them. The practical benefits of the treatment must be
explained in detail to the clients.

c. SUDS Training

First, the therapist should explain that SUDS is a 1-100 scale with greater
numbers indicating greater distress. Anchor points are developed at 25 (mild
anxiety), 50 (moderate anxiety, beginning to have difficulty concentrating), 75
(worst anxiety he has experienced or can imagine experiencing) by asking the
client to report specific situations in which he experienced that level of anxiety.

d. Fear and Avoidance Hierarchy

Here an individualized fear and avoidance hierarchy is developed. A

completed hierarchy will have 10 rank-ordered situations rated for fear,
avoidance, and fear of negative evaluation by others. Simply, it will mean that
the client lists out 10 worst fear situations in order, according to the rating he
gives.

e. Treatment Contract

Social phobics often fear and avoid a variety of situations, usually more than
can be realistically addressed to in 12 weeks of treatment. It can be agreed that
two to three feared situations are taken at each session for the primary focus of
treatment. Reasonable goals are to be set, and treatment targets are to be
determined.

The whole thing is done as a role-play in a group setting. E.g., one is afraid
of initiating a talk or intervening in a group discussion. The therapist sets a
group in which the client is asked to intervene and talk; the client’s level of
anxiety is questioned every now and then during the process to assess the
improvement.

(2) Psychodynamic Therapy

Here below is a model of psychodynamic therapy. Flora is 35 years old and

complains of difficulties in meeting strangers. She is afraid and nervous to face any
newcomer.

COUNSELLOR: As you are narrating your fear what are you experiencing?
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Flora: I feel very much upset and perspiring. I am unable to face anybody and I feel nervous.
COUNSELLOR: Can you speak more on what you are experiencing?
Flora: Well it is a very choking experience. I feel that I am unnerved and not able to function
well. I can neither eat nor sleep. Actually, there is no danger in meeting a stranger. This I
can understand intellectually, but emotionally I am not able to digest.
COUNSELLOR: Can you give me an imagery of what you are experiencing?
Flora: It is like being smothered and attacked.
COUNSELLOR: So you feel smothered and attacked.
Flora: Yes, that is what I feel.
COUNSELLOR: Do you remember any incidence in your early childhood when you felt smothered
and attacked by others?
Flora:…Something comes to my mind. When I was four years old I was alone at home when my
parents had gone out. At that time, a bearded man came to our house to ask for my
father. Seeing that old man, I was frightened and I ran inside the house crying. I did not
come out until my mother arrived and consoled me. Now I find a connection between
meeting that bearded man and any stranger right now.
COUNSELLOR: Now close your eyes, be four years old, and relive that experience of meeting the
bearded man. When you have experienced that frightful meeting, you can come back
to the group and open your eyes.

(Flora closes her eyes and weeps remembering and reliving her facing the bearded man and finally
opens her eyes.)

COUNSELLOR: What are you experiencing right now, Flora?

Flora: I feel light and relaxed.
COUNSELLOR: What more do you experience?
Flora: I am feeling confident and trustful.
COUNSELLOR: All right. Now close your eyes and in fantasy take that little four year old girl and
console her the way you would want. Give all the necessary things — support,
comfort and consolation. You are doing it from the position of strength right now.
Flora: (after a while) Yes, I have done.

COUNSELLOR: Now look around and pick up anyone who may look like a stranger; go and
shake hands with him.
Flora: Arun looks like a stranger to me.
Counsellor: Go and shake hands with him.

(Flora goes to Arun, extends her hand, and shakes hands with him.)

Counsellor: Now what do you feel Flora?

Flora: I feel comfortable and I feel like hugging Arun.
Counsellor: That is great! What prevents you from hugging him, go ahead and hug him.

(Flora hugs Arun and reports that she is happy, relaxed, and comfortable.)

COUNSELLOR: Flora, a little homework for you. For three days you will carry your younger self
that is the four-year old girl that you were and carry her along with you wherever you
go, and sleep with her, comfort her when needed, and report to me at the end.
Flora: Yes, I shall do it.

(3) Visual-Kinaesthetic Dissociation (V.K. DISSOCIATION) OR TIME TRAVELLING

OR DOUBLE DISSOCIATION
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V.K. Dissociation therapy is meant to deal with traumatic and phobic

experiences. Let us take an example of a woman who, when she got up in the middle
of the night, met a thief walking on the corridor of her house. Let her imagine being
seated with you in a theatre and make sure that she has a vivid picture of the situation
of the theatre and the screen. Let her put a still picture of herself on the screen just
before the starting of the trauma; that is, before sighting the thief. Now let her float
out of her body along with you and go to the projection booth from where she is able
to see her body seated in the theatre and is able to view the still picture of herself on
the screen. Now hold her hand interlocked with your fingers and this forms a
resourceful state. She can squeeze your fingers when she is frightened and get the
necessary resources. When these things are ready, ask her to run the film on the
screen; she sees the thief who comes towards her and she runs to her room and locks
the door. The whole episode is seen and digested by her. This in short is the therapy
of V.K. Dissociation.
COUNSELLOR: Imagine that you and I are seated in the theatre.
COUNSELLEE: Yes, we are seated in the theatre.
COUNSELLOR: Of what is the seat made?
COUNSELLEE: It is made of synthetic fibre.
COUNSELLOR: Of what colour is the seat?
COUNSELLEE: It is maroon.
COUNSELLOR: How far is the screen?
COUNSELLEE: Some 35’ away.
COUNSELLOR: Put a still picture of you on the screen just before the starting of the original trauma,
that is, just before seeing the thief.
COUNSELLEE: Yes, I have put it.
COUNSELLOR: Now both of us are floating out of our bodies and we go to the projection booth.
COUNSELLEE: Yes, we are in the projection booth.
COUNSELLOR: Look down and see our bodies seated in the theatre and look at the screen and see the
still picture of yourself. Now start the film on the screen, see it from the beginning till
the end. When you feel frightened or anxious, you can squeeze my hand and be
assured of the resource. When you have seen the film you open your eyes and come
back.

(The client does it and opens the eyes at the end.)

COUNSELLOR: Now close your eyes and run the film backward from the end to the beginning and
open your eyes.
COUNSELLEE: …Yes, I have done.
COUNSELLOR: Now close your eyes and run the film all bleached out and open your eyes.
COUNSELLEE: …Yes, I have done.
COUNSELLOR: Now think of the incident and report to me what you are experiencing.
COUNSELLEE:…I feel fine.

(4) Pharmacology
Certain medication options are clearly efficacious in social phobia. Many
performing artists or public speakers find that –blockers, taken orally a few
hours before stage time, reduce palpitations, tremor, and the “butterfly feeling.”
Although a variety of –blockers are probably efficacious for performance
anxiety, the most common ones used are either propranolol (20mg) or atenolol
(50mg). –blockers are more effective in controlling stage fright, with minimal or
no side effects, than are benzodiazepines, which may decrease subjective
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anxiety but not optimise performance and may have an adverse effect on
“sharpness.” Monoamine oxidase inhibitors (MAOI) have proved to be the most
effective medications for treating generalized social phobia. Several recent
studies indicate that selective serotonin reuptake inhibitors (SSRIs) have
positive effects.
(5) Multifaceted Treatment

Although the use of behavioural interventions is the same for all phobic
disorders, the treatment plan for social phobia is typically multifaceted and is
aimed both at reducing fear and at improving socialization and social skills. Here,
cognitive interventions and behavioural ones are always integrated. All types of
cognitive-behaviour therapies such as exposure alone, cognitive restructuring
alone, exposure combined with cognitive restructuring, social skills training, and
applied relaxation produce moderate to good effect in reducing the symptom.
There are some forms of self-monitoring such as soliciting feedback from
others, role-playing, rehearsal with videotaping or audiotaping, self-ratings, and
ratings by others, posture, eye contact, and other aspects of socialization.
Relaxation techniques like abdominal breathing, visualization, and progressive
muscle relaxation will reduce anxiety. Cognitive-behavioural group therapy
seems to be effective. There are also other effective therapies like mindfulness,
attention training, self-efficacy interventions (as guided mastery), and
interpersonal therapy. Medication is not meant to treat social phobias. However,
it may be used with psychotherapy to reduce performance anxiety and to
facilitate one to participate in therapy.55

6. Panic Disorder

The Phenomenon of Panic: Panic attacks are discrete episodes of intense

dread or fear, accompanied by physical and cognitive symptoms. The panic
attack is discrete by virtue of its suddenness or abruptness, as opposed to the
gradually building anxious arousal.

Panic disorder is attacks of panic that are unexpected. A panic attack is a

circumscribed period of intense fear or discomfort that develops suddenly,
usually beginning with cardiac symptoms and difficulty breathing. There are
three types of panic attacks: (1) unexpected or uncued attacks with no apparent
trigger, (2) situationally bound or cued attacks in anticipation of specific stimuli
like hearing of an earthquake, and (3) situationally predisposed attacks usually
associated with specific fear-inducing triggers like actual experience of an
earthquake. Panic disorder can become chronic and debilitating. 56

1) Diagnostic Criteria

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of

intense fear or intense discomfort that reaches a peak within minutes,
and during which time four (or more) of the following symptoms occur:
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Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealisation (feelings of unreality) or depersonalization (being
detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness,
headache, uncontrollable screaming or crying) may be seen. Such
symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more of one
or both of the following:
1. Persistent concern or worry about additional panic attacks or their
consequences (e.g., losing control, having a heart attack, “going
crazy”).
2. A significant maladaptive change in behaviour related to the attacks
(e.g., behaviours designed to avoid having panic attacks, such as
avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g.,
the panic attacks do not occur only in response to feared social
situations, as in social anxiety disorder; in response to circumscribed
phobic objects or situations, as in specific phobia; in response to
obsessions, as in obsessive-compulsive disorder; in response to
reminders of traumatic event, as in posttraumatic stress disorder; or in
response to separation from attachment figures, as in separation anxiety
disorder).

7. Panic Attack Specifier

Note: Symptoms are presented for the purpose of identifying a

panic attack; however, panic attack is not a mental disorder and cannot
be coded. Panic attacks can occur in the context of any anxiety disorder
as well as other mental disorders (e.g., depressive disorders,
posttraumatic stress disorder, substance use disorders) and some
medical conditions (e.g., cardiac, respiratory, vestibular,
gastrointestinal). When the presence of a panic attack is identified, it
should be noted as a specifier (e.g., “posttraumatic stress disorder with
panic attacks”). For panic disorder, the presence of panic attack is
contained within the criteria for the disorder and panic attack is not used
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as a specifier.

1) Overview of the Treatment

The basic aim of the treatment protocol is to influence directly the cognitive-
misinterpretational aspect of panic attacks and anxiety, the hyperventilatory
response, conditioned reactions to physical cues, fear, and avoidance of
situations.

This is done first by providing of accurate information as to the nature of the

physiological aspects of the fight-flight response. Such information teaches
clients that they experience “sensations” and not “panics” and that these
sensations are normal and harmless.

Second, treatment aims at teaching specific techniques to help modify

cognitions, including identifying and challenging aberrant beliefs. Next, specific
information concerning the effects of hyperventilation and its role in panic
attacks is provided as well as extensive breathing retraining. Then, repeated
exposure to feared internal cues is conducted to decondition fear reactions and
allow structured application of cognitive and breathing strategies. In vivo
exposure to feared and avoided situations is then practiced to weaken
associations between certain situational contexts and the experience of anxiety
and panic.

(1) Cognitive Restructuring

Cognitive treatment focuses on correcting misappraisals of bodily sensations.

The cognitive strategies are conducted in conjunction with behavioural
techniques, although the effective mechanism of change is assumed to lie in the
cognitive realm.

(2) Breathing Retraining

Panic attacks are viewed as stress-induced respiratory changes that either

provoke fear because they are perceived as frightening or augment fear already
elicited by other phobic stimuli. The resultant hyperventilation is prevented or
dealt with breathing exercises.

(3) Relaxation

A form of relaxation known as applied relaxation has shown promising results

as a treatment for panic attacks. Applied relaxation entails training in
progressive muscle relaxation (PMR) until the client is skilled in the use of cue-
control procedures, at which point the relaxation skill is applied to practice of
items from a hierarchy of anxiety-provoking tasks.

(4) Interoceptive Exposure

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Interoceptive exposure is conducted through procedures that induce panic-

type sensations reliably, such as cardiovascular exercise, inhalation of carbon
dioxide (by breathing in and out in a paper bag), spinning in a chair, and
hyperventilation. The exposure is conducted using a graduated format. The
purpose of interoceptive exposure, as in the case of exposure to external phobic
stimuli, is to disrupt or weaken associations between specific bodily cues and
panic reactions. The reason for interoceptive exposure is one of fear extinction,
given the conceptualization of panic attacks as “conditioned” or learned alarm
reactions to salient bodily cues.

Cognitive-behaviour therapy seems to be effective. The cognitive

interventions seek to change clients’ catastrophic and distorted thinking, and
such behaviour techniques as distraction, comforting rituals, meditation, and
relaxation contribute to the physiological reduction of anxiety that contribute to
panic attacks.

Panic control therapy (PCT) is a multifaceted cognitive-behaviour

treatment for panic disorder. It addresses the mistaken beliefs clients have
about the meaning of physical sensations. It includes psychoeducation,
relaxation training, cognitive restructuring, and interoceptive exposure, which
involves progressive evocation of the somatic sensation of panic attacks.
Interoceptive exposure exercises simulate panic attacks like running very fast
until out of breath. Then the clients are made to recognize that these sensations
are not life-threatening, and help clients confront their mistaken beliefs about
the meaning of physical sensations in order to extinguish their fear.

Acceptance and commitment therapy (ACT) and sensation-focused intensive

treatment (SFIT) show promising results. Acceptance and commitment therapy
combines acceptance, compassion, and commitment to goals with interventions
drawn from cognitive-behaviour therapy. By this, clients learn to identify their
thoughts and feelings and practice mindful acceptance when fear arises.
Sensation-focused intensive treatment (SFIT) reduces panic symptoms. 57

8. AGORAPHOBIA

Agoraphobic avoidance refers to avoidance or endurance with dread of

situations from which escape might be difficult, or help unavailable in the event
of a panic attack, or in the event of developing symptoms that could be
incapacitating and embarrassing, such as loss of bowel control or vomiting.

Typical agoraphobic situations include going to shopping malls, waiting in

line, going to movie theatres, travelling by car or bus, entering crowded
restaurants, and being alone.

Agoraphobic avoidance is rated in terms of impairment in functioning,

ranging from mild to moderate to severe. Mild — hesitates to drive a long
distance alone but manages to drive to and from work, prefers to sit on the aisle
at movie theatres but still goes to movies, and feels uncomfortable in crowded
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places. Moderate — drives within a 5-mile radius of home but only if

accompanied, who shops at off-peak times and avoids large supermarkets, and
who avoids flying or travelling by train. Severe — one who is nearly
housebound.

Agoraphobia, especially in association with panic disorder, is the most

common phobia. Clients have anxiety about being in places or situations from
which escape might be difficult or embarrassing or in which help might not be
available in the event of having an unexpected or situationally predisposed panic
attack or panic-like symptom. They experience fear of losing control. They tend
to be anxious, apprehensive, low in self-esteem, socially uncomfortable, vigilant,
concerned about their health, and at times obsessive.58

1) Diagnostic Criteria

A. Marked fear or anxiety about two (or more) of the following five
situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships,
planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theatres, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that
escape might be difficult or help might not be available in the event of
developing panic-like symptoms or other incapacitating or embarrassing
symptoms (e.g., fear of falling in the elderly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of
a companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the
agoraphobic situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
H. If another medical condition (e.g., inflammatory bowel disease,
Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly
excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms
of another mental disorder – for example, the symptoms are not confined
to specific phobia, situational type; do not involve only social situations
(as in social anxiety disorder); and are not related exclusively to
obsessions (as in obsessive-compulsive disorder), perceived defects or
flaws in physical appearance (as in body dysmorphic disorder), reminders
of traumatic events (as in posttraumatic stress disorder), or fear of
separation (as in separation anxiety disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of panic
disorder. If an individual’s presentation meets criteria for panic disorder and
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agoraphobia, both diagnoses should be assigned.

2) Treatment

(1) Cognitive-Behaviour Therapy

The goal of psychotherapeutic intervention in agoraphobia is to encourage
patients to re-enter the phobic situation and demonstrate to themselves that
they will not have panic attacks while taking medication and therefore may give
up both the avoidance and the worry, or anticipatory anxiety, about having
attacks.
At the start of treatment, the therapist explains to the patient the three-stage
development of the illness and the fact that the medication will block the
spontaneous panics but may not alleviate anticipatory anxiety or the desire to
avoid. Once the frequency of spontaneous panics has abated, some patients will
begin to try out previously avoided situations on their own. Others will need
structured encouragement in the form of supportive psychotherapy.
Overall, focused behaviour therapies appear to be more effective for patients
with more severe or resistant agoraphobia; exposure techniques have been used
in conjunction with antipanic medication in the treatment of patients with
agoraphobia with panic attacks. A popular form of behaviour therapy is group in
vivo exposure, in which groups of agoraphobic patients (initially accompanied by
the therapist) travel together to restaurants, shopping malls, and other
locations. Self-help groups are also helpful for raising the morale and sharing
information among agoraphobic individuals. It appears that combination
treatments (medication and psychotherapy) are positive, at least for those
patients who are resistant to either form of treatment alone.
(2) Situational Exposure

In vivo situational exposure used to treat agoraphobia refers to repeated

confrontation with, or approach to, the object or situation that is avoided.
Usually these are typical agoraphobic situations such as malls, churches, or
other crowded places and public transportation or other situations from which
escape might be difficult in case of a panic attack.

(3) Massed Exposure

At its most intensive, exposure therapy may be conducted 3 to 4 hours a

day, 5 days a week. Long, continuous sessions are generally considered more
effective than shorter or interrupted sessions.

(4) Graduated Intense Exposure

In vivo exposure is conducted typically in a graduated format, progressing

from least to most difficult hierarchy items.
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(5) Controlled Escape

It is the in vivo exposure trial until anxiety reduces. Long-term fear reduction
depends on activation of fearful arousal plus within-session fear reduction.

(6) No Distraction

It is suggested that exposure is most functional when attention is directed

fully toward the phobic object and internal and external sources of distraction
are minimized.
(7) Pharmacotherapy
Antipanic medication is given to block the occurrence of panic attacks, and its
efficacy is well documented. However, medication alone is often not an adequate
treatment in patients with significant agoraphobic avoidance. Some means of
exposing agoraphobic patients to the feared situations is necessary for overall
improvement. Such exposure may be achieved by various nonspecific methods
such as psychoeducation, reassurance, and supportive therapy. Focused
cognitive-behaviour therapy (CBT) is more successful than nonspecific
techniques in reducing agoraphobic avoidance. Cognitive therapy has been
shown to decrease panic attacks but not agoraphobia, whereas
exposure reduces agoraphobia but not panic.
From the part of the therapist, encouragement and reinforcement can help
clients take risks. The therapist providing structure and contextual therapy is
important. Often agoraphobia is part of panic disorder. Therefore, if panic
disorder is treated, the problem of agoraphobia subsides. If agoraphobia is not
accompanied by panic attacks, then behavioural methods in combination with
cognitive therapy would be useful. There are other useful behaviour
interventions like training in relaxation and assertiveness, cognitive therapy
(using thought stopping, restructuring of negative thoughts), and training in
positive self-statements about coping abilities in combination with exposure. 59
9. Generalized Anxiety Disorder (GAD)

Clients with GAD have excessive anxiety and worry. The physiological
symptoms are edginess or restlessness, tiring easily, difficulty in concentrating,
irritability, muscle tension, and difficulty in sleeping. The most common affective
and somatic symptoms are inability to relax, tension, fright, jumpiness,
unsteadiness, apprehension, and uncontrollable worry. Some of the somatic
symptoms are dry mouth, intestinal discomfort, tension-related headache, and
cold hands. The common cognitive behavioural symptoms are difficulty in
concentrating, apprehension about losing control, fear of being rejected, inability
to control thinking, confusion, high negative affect, over-arousal, and tendency
to anticipate the worst. The central manifestation of GAD is anticipatory
anxiety.

1) Diagnostic Criteria
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A. Excessive anxiety and worry (apprehensive expectation), occurring more

days than not for at least 6 months, about a number of events or
activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms having been
present for more days than not for the past 6 months):
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless,
unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.
E. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g.,
anxiety or worry about having panic attacks in panic disorder, negative
evaluation in social anxiety disorder [social phobia], contamination or
other obsessions in obsessive-compulsive disorder, separation from
attachment figures in separation anxiety disorder, reminders of traumatic
events in posttraumatic stress disorder, gaining weight in anorexia
nervosa, physical complaints in somatic symptom disorder, perceived
appearance flaws in body dysmorphic disorder, having a serious illness in
illness anxiety disorder, or the content of delusional beliefs in
schizophrenia or delusional disorder).

2) Overview of Treatment

The treatment of anxiety disorders is usually multi-modal. The treatment

protocol for Generalized Anxiety Disorder (GAD) typically averages 12 to 15
hour-long sessions held weekly with the last two sessions held bi-weekly.
Treatment may be given either in a small group or individually. Treatment for
GAD has several components that address each of the three systems of anxiety:
(1) Physiological: Progressive Muscle Relaxation (PMR) training; (2)
Cognitive: Cognitive restructuring; and (3) Behavioural: worry behaviour
prevention, problem solving, and time management.

At the heart of the treatment for GAD is the element of worry exposure, in
which clients are directed to spend a specified period of time daily (usually 1 hr)
processing their worry content.

3) Process of Treatment
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(1) Relaxation Training and Techniques

The procedures begin with Progressive Muscle Relaxation (PMR) (16 muscle
groups) with discrimination training. Discrimination training entails teaching the
client to discriminate sensations of tension and relaxation in each muscle group
during the PMR exercise. This is done to increase the client’s ability to detect
sources and early signs of muscle tension, thereby facilitating the rapid
deployment of relaxation techniques to those areas. Now relaxation deepening
techniques are employed during the induction, including slow diaphragmatic
breathing, repeating the word relax on the exhale.

Relaxation techniques are very useful in patients with mild to moderate

anxiety. These techniques are used by the patient himself as a routine exercise
everyday and also whenever anxiety-provoking situation confronts him. They
include Jacobson’s progressive relaxation technique, yoga, pranayama, self-
hypnosis, and meditation.

(2) Cognitive Therapy

The client should be made clear that in the case of inappropriate anxiety,
it is a person’s interpretations of situations, rather than the situations
themselves, that are responsible for the negative affect experienced in response
to the situation. The client should be assisted to realize that he must be able to
identify the specific interpretations/predictions he is making in order to be in a
position to challenge these cognitions effectively. This will include for example,
questioning the client “What did you picture happening in that situation that
made you tense up?”; imagery — asking the client to imagine the situation in
detail as a means of providing additional cues for retrieving automatic thoughts
occurring in that situation; and role playing.

(3) Worry Exposure

Worry exposure entails the following procedures: (1) identifying and

recording the client’s anxiety-provoking worry; (2) practicing imagery training
by imagining pleasant scenes; (3) practicing vividly the worry sphere by having
the client concentrate on his anxious thoughts while trying to imagine the worst
possible feared outcome of that sphere of worry (e.g. that when the child does
not turn up on time after school imagining that somebody had kidnapped it);
(4) holding these thoughts and images clearly in mind for at least 25-30
minutes; and (5) having the client to generate as many alternatives as he can
to the worst possible outcome (e.g. extracurricular activities in the school would
have held the child longer after the school hour). The client is instructed that
when the exposure exercise no longer evokes more than a mild level of anxiety
(i.e., 2 or less on the 0-8 anxiety scale, despite several attempts of vividly
imagining that worry, he should move on to the next sphere of worry on the
hierarchy.

(4) Worry Behaviour Prevention

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Most of the GAD worries are associated with carrying through some
corrective, preventive, or ritualistic behaviour. As in the case with compulsions in
OCD, these “worry behaviours” are negatively reinforcing to the client as they
usually result in temporary anxiety reduction (e.g., frequent telephone calls to
the loved ones at work). The next move is to instruct the client to refrain from
engaging in the worry behaviour, perhaps engaging in a competing response in
its place (e.g., not telephoning to the loved ones frequently during work time).

(5) Problem Solving

Individuals often encounter two types of difficulties when problem solving:

(1) viewing the problem in general, vague, and catastrophic ways and (2)
failing to generate any possible solutions. The client is to be instructed to
conceptualize problems in specific terms and to break the problem into smaller,
more manageable segments. Then, the client is to be asked to brainstorm his
way through each manageable segment of the problem. After a host of potential
solutions have been generated, each one is evaluated to determine which are
the most practical, with the end-goal of selecting and acting on the best possible
solution.

(6) Time Management

Many GAD clients feel overwhelmed by obligations and deadlines, in addition

to everyday hassles and stressors. Because of the nature of GAD (e.g., anxious
apprehension), these clients are apt to magnify these daily hassles, augmenting
the impact of these minor stressors. Therefore, basic skills in time-management
and goal-setting are useful to do the task at hand rather than worrying about
accomplishing future tasks. Time-management strategies involve three basic
components: (1) delegating responsibility, (2) assertiveness (e.g., saying “no”),
and (3) adhering to agendas. Clients with perfectionistic tendencies may refrain
from allowing others to take on the task that they typically assume themselves.
They are also reluctant to refuse unexpected or unrealistic demands placed on
them by others, preventing them from completing planned activities. Agenda
adherence should begin with the examination of the client’s daily activities
(generated by at least 1 week of client self-monitoring). Next, the therapist can
assist the client in establishing an organized strategy for sticking to agendas and
structuring daily activities such that the client’s most important activities are
accomplished.

(7) Psychodynamic Psychotherapy

Psychodynamically oriented psychotherapy is not usually helpful in treatment

of phobias. Supportive psychotherapy is a helpful adjunct to behaviour therapy
and drug treatment. Cognitive Behaviour Therapy (CBT) can be used to break
the anxiety patterns in phobic disorder. It is good to combine CBT with
behavioural techniques.
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Psychoanalytic psychotherapy is not usually indicated, unless

characterological (personality) problems co-exist. Supportive psychotherapy is
used alone, when anxiety is mild, or in combination with drug therapy. The
establishment of a good therapist-patient relationship is often the first step.
Lately, there has been an increasing use of CBT in the management of anxiety
disorders, particularly panic disorders (with or without agoraphobia). CBT can be
used either alone or in conjunction with medication.

(8) Other Behaviour Therapies

Behaviour therapy is usually successful. Some of the techniques are: (1)

Flooding, (2) Systematic desensitization, (3) Exposure and response
prevention, and (4) Relaxation techniques, (5) Biofeedback, and (6)
Hyperventilation.

For GAD, the most frequently used therapy is cognitive-behavioural

therapy. The therapy targets excessive, uncontrollable worry and the persistent
over arousal that accompanies it.

Cognitive Therapy: It includes reliving one’s symptoms, helping the

client recognize distorted automatic thoughts, teaching him logic and reason,
and helping him to modify long-held dysfunctional assumptions underlying major
concerns.

Behaviour Therapy: Progressive muscle relaxation, autogenic training

(calming the body and mind), guided imagery, yoga, self-monitoring by keeping
logs of anxiety levels and self-calming activities, diaphragmatic breathing,
meditation, biofeedback, exercise, expressive therapy, and systematic
desensitization.

Affective Therapy: Accept Feelings (normalize, identify, and express

feelings); watch the anxiety (seek objectivity and distance by using diaries and
ratings to demonstrate that the anxiety is situation-limited, time-limited, and
controllable); act with the anxiety rather than fight it in dysfunctional ways
(Clients are encouraged to act against their inclinations by confronting fears
rather than avoiding them and to deliberately seek out anxiety-provoking
situations in order to inoculate themselves against anxiety); repeat the steps
(clients are taught that doing so will establish learning and facilitate the
process); and expect the best (clients are encouraged to maintain an optimistic
outlook).

Cognitive-Behavioural Therapy: Self-monitoring of mood levels,

analysis and modification of catastrophizing and other cognitive distortions,
relaxation training, including cue-controlled relaxation, problem-solving,
cognitive countering, and time-management.
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Stress Management Training: This training includes didactic education

about anxiety, relaxation, distraction, cognitive restructuring, and exposure.
Clients can also be encouraged to engage in pleasurable activities.

Acceptance and Commitment Therapy (ACT): ACT involves

psychoeducation about the purpose of anxiety, its benefits, and how it becomes
dysfunctional; evaluation of clients’ strategies for coping with anxiety; focus on
value-driven behaviour as an alternative to anxiety; in-session experiential
exposure exercises that encourage clients to practise mindful observation,
acceptance, and cognitive diffusion; and commitment to engage in actions that
are more consistent with clients’ values.60

10. Substance/Medication-Induced Anxiety Disorder

1) Diagnostic Criteria

A. Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory
findings, of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance
intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
C. The disturbance is not better explained by an anxiety disorder that is not
substance/medication-induced. Such evidence of an independent anxiety
disorder could include the following:
The symptoms precede the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month)
after the cessation of acute withdrawal or severe intoxication; or there is
other evidence suggesting the existence of an independent non-
substance/medication-induced anxiety disorder (e.g., a history of
recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, and other important areas of functioning.
Note: This diagnosis should be made instead of a diagnosis of substance
intoxication or substance withdrawal only when the symptoms in
Criterion A predominate in the clinical picture and they are sufficiently
severe to warrant clinical attention.

11. Anxiety Disorder due to Another Medical Condition

1) Diagnostic Criteria

A. Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory
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findings that the disturbance is the direct pathophysiological consequence

of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

12. Treatment
Psychodynamic therapy for phobias does not have encouraging results.
However, in those patients in whom underlying conflicts associated with phobic
anxiety and avoidance can be identified by the therapist and lend themselves to
insightful exploration, psychodynamic therapy may be beneficial. Furthermore, a
psychodynamic approach may be valuable in understanding and resolving the
secondary interpersonal ramifications in which phobic patients and their partners
are often caught up and that could serve as resistance to the successful
implementation of medication or behavioural treatments.
There are some common strategies that can be applicable to treatments for
most anxiety disorders: (1) Establishing of a strong therapeutic alliance to
ensure the client’s motivation and feeling of safety, (2) Assessment of the
manifestations of anxiety and of the stimuli for fears, (3) Referral for medical
evaluation to determine any contributing physical disorders, as well as the need
for medication, (4) Teaching relaxation skills like meditation, physical exercise,
mindfulness-based strategies, progressive muscle relaxation, visual imagery,
and breathing retraining, (5) Analysis of dysfunctional cognitions that contribute
to anxiety and replacing them with empowering, positive, more accurate
cognitions, (6) Exposure to feared objects by in vivo or imaginal desensitization,
eye movement desensitization and reprocessing (EMDR), and flooding, (7)
Homework to tract and increase one’s progress and to promote client’s
responsibility, and (8) solidification of efforts to cope with anxiety and prevent a
relapse.
Cognitive-Behavioural Therapy is the generic name given to the combination
of cognitive therapy with behaviour therapy. Some of them are like exposure-
based treatment and stress inoculation training (SIT). Exposure-based therapy
as developed by Wolpe (1958) is called systematic desensitization, which
teaches clients to relax while exposing them to the feared object or situation.
Stress inoculation training teaches clients learn muscle relaxation, thought
stopping, breath control, guided self-dialogue, covert modelling, and role-playing
to help them cope with anxiety.
Acceptance–Based Therapies in Eastern traditions help relieve overall
suffering. The following come under this category of therapy: mindful mediation,
dialectical behaviour therapy, and acceptance and commitment therapy. These
models help clients to integrate mindfulness into their daily lives. They are made
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to become aware of their metacognitions or “thinking about thinking,” and thus

change their dysfunctional thoughts and modify their behaviours as a result. 61

13. Conclusion

Anxiety disorders are highly prevalent, come in many forms and are often
chronic, with many patients requiring long-term maintenance therapy. Anxiety
and depression may also be comorbid in up to 50% of patients, leading to
problems during diagnosis and treatment. Despite their frequency, the
recognition and treatment of anxiety disorders is frequently suboptimal, with as
few as 15% of patients obtaining treatment consistent with evidence-based care
recommendations.

Current treatment guidelines for anxiety disorders include a range of

pharmacological and non-pharmacological approaches. However, the use of
these guidelines alone may not be sufficient to improve patient outcomes.
Optimal treatments for anxiety should be based on chronic disease management
and balance efficacy with long-term tolerability. Current first-line therapies
should include broad-spectrum agents that have proven efficacy in treating both
anxiety and depression and are effective across all treatment phases.
Combination therapy involving medication and psychological approaches, e.g.,
cognitive behavioural therapy, may also be helpful.

7. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

1. Introduction

Obsessive-compulsive and related disorders include obsessive-compulsive

disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania
(hair-pulling disorder), excoriation (skin-picking) disorder,
substance/medication-induced obsessive-compulsive and related disorder, and
obsessive-compulsive and related disorder due to another medical condition.

OCD is characterized by the presence of obsessions and/or compulsions.

Obsessions are recurrent and persistent thoughts, urges, or images that are
experienced as intrusive and unwanted, whereas compulsions are repetitive
behaviours or mental acts that an individual feels driven to perform in response
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to an obsession or according to rules that must be applied rigidly. Some other

obsessive-compulsive and related disorders are also characterized by
preoccupations and by repetitive behaviours or mental acts in response to the
preoccupations. Other obsessive-compulsive and related disorders are
characterized primarily by recurrent body-focused and repetitive behaviours
(e.g., hair pulling, skin picking) and repeated attempts to decrease or stop the
behaviours.

2. Obsessive-Compulsive Disorder (OCD)

In obsessive-compulsive disorder, there is obsession and

compulsion whereas in obsessive-compulsive personality disorder, there
is no obsession and compulsion but only a perfectionistic or compulsive
lifestyle is present. Obsessions in OCD have content that is unacceptable to
the client that they are immoral, illegal, disgusting, or embarrassing and create
considerable anxiety. Compulsion in OCD are behavioural or mental acts, often
ritualized to be carried out to prevent anxiety, discomfort, or unwanted thoughts
and events. There are four common patterns in OCD: (1) obsession focused on
contamination by excessive washing; (2) obsessive doubts leading to time-
consuming and ritualized counting, repeating, and checking; (3) obsession
without compulsions of a religious nature or of sexual or violent acts that are
horrifying to the person; and (4) a powerful need for symmetry or precision that
causes a person to perform routine activities with extreme slowness (eating and
dressing). Common compulsions are counting, hoarding, repeating, organizing,
asking for reassurance, and touching in some ritualistic fashion. 62

1) Diagnostic Criteria

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are
experienced, at some time during the disturbance, as intrusive and
unwanted, and that in most individuals cause marked anxiety or
distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or
images, or to neutralize them with some other thought or action (i.e.,
by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviours (e.g., hand washing, ordering, checking) or
mental acts (e.g., praying, counting, repeating words silently) that
the individual feels driven to perform in response to an obsession
or according to rules that must be applied rigidly.
2. The behaviours or mental acts are aimed at preventing or reducing
anxiety or distress, or preventing some dreaded event or situation;
however, these behaviours or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent,
or are clearly excessive.
Note: Young children may not be able to articulate the aims of
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these behaviours or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than
1 hour per day) or cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition.
D. The disturbance is not better explained by the symptoms of another
mental disorder (e.g., excessive worries, as in generalized anxiety
disorder; preoccupation with appearance, as in body dysmorphic
disorder; difficulty discarding or parting with possessions, as in hoarding
disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin
picking, as in excoriation [skin-picking] disorder; stereotypes, as in
stereotypic movement disorder; ritualized eating behaviour, as in eating
disorders; preoccupation with substances or gambling, as in substance-
related and addictive disorders; preoccupation with having an illness, as
in illness anxiety disorder; sexual urges or fantasies, as in paraphilic
disorders; impulses, as in disruptive, impulsive-control, and conduct
disorders; guilty ruminations, as in major depressive disorder; thought
insertion or delusional preoccupations, as in schizophrenia spectrum and
other psychotic disorders; or repetitive patterns of behaviour, as in
autism spectrum disorder).

3. Body Dysmorphic Disorder

1) Diagnostic Criteria

A. Preoccupation with one or more perceived defects or flaws in physical

appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has
performed repetitive behaviours (e.g., mirror checking, excessive
grooming, skin picking, reassurance seeking) or mental acts (e.g.,
comparing his appearance with that of others) in response to the
appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with
body fat or weight in an individual whose symptoms meet diagnostic
criteria for an eating disorder.

2) Treatment

Surgery has not been of great help. Promising results have been noted with
SSRIs at higher dosage levels as in obsessive-compulsive disorder. Behaviour
therapies and dynamic psychotherapies are known to be helpful.
For OCD, exposure and response prevention therapies are the first-line
treatment. Prolonged exposure to obsessional cues, and strict prevention of
rituals are found to be very effective. In exposure therapy, exposure is
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graduated, beginning with situations that evoke low anxiety and then moving on
to high levels of anxiety-provoking stimuli.63
4. Hoarding Disorder

1) Diagnostic Criteria

A. Persistent difficulty discarding or parting with possessions, regardless of

their actual value.
B. This difficulty is due to a perceived need to save the items and to distress
associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of
possessions that congest and clutter active living areas and substantially
compromises their intended use. If living areas are uncluttered, it is only
because of the interventions of third parties (e.g., family members,
cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning (including
maintaining a safe environment for self and others).
E. The hoarding is not attributable to another medical condition (e.g., brain
injury, cerebrovascular disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the symptoms of another mental
disorder (e.g., obsessive in obsessive-compulsive disorder, decreased
energy in major depressive disorder, delusions in schizophrenia or
another psychotic disorder, cognitive deficits in major neurocognitive
disorder, restricted interests in autism spectrum disorder).

5. Trichotillomania (Hair-Pulling Disorder)

1. Diagnostic Criteria

A. Recurrent pulling out of one’s hair, resulting in hair loss.

B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical
condition (e.g., a dermatological condition).
E. The hair pulling is not better explained by the symptoms of another
mental disorder (e.g., attempts to improve a perceived defect or flaw in
appearance in body dysmorphic disorder).

2) Treatment

There is no specific treatment for trichotillomania; but psychoanalytic,

behavioural, or pharmacological treatments may potentially decrease hair
pulling. Most cases of trichotillomania in young children resolve spontaneously.
It might represent a transient behaviour in response to a psychosocial stressor,
or it may represent a habit, without the presence of an obvious precipitant. If
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hair loss persists, psychiatric consultation needs to be had and inquiry into areas
of parent-child relationships or other areas of potentially conflict may illuminate
the problem.64

6. Excoriation (Skin-Picking) Disorder

1) Diagnostic Criteria

A. Recurrent skin picking resulting in skin lesions.

B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a
substance (e.g., cocaine) or another medical condition (e.g., scabies).
E. The skin picking is not better explained by symptoms of another mental
disorder (e.g., delusions or tactile hallucinations in a psychotic disorder,
attempts to improve a perceived defect or flaw in appearance in body
dysmorphic disorder, stereotypies in stereotypic movement disorder, or
intention to harm oneself in nonsuicidal self-injury).

7. Substance/Medication-Induced Obsessive-Compulsive and Related

Disorder

1) Diagnostic Criteria

A. Obsessions, compulsions, skin picking, hair pulling, other body-focused

repetitive behaviours, or other symptoms characteristic of the obsessive-
compulsive and related disorders predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory
findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after
substance intoxication or withdrawal or after exposure to a
medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
C. The Disturbance is not better explained by an obsessive-compulsive and
related disorder that is not substance/medication-induced. Such evidence
of an independent obsessive-compulsive and related disorder could
include the following:
The symptoms precede the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month)
after the cessation of acute withdrawal or severe intoxication; or there is
other evidence suggesting the existence of an independent non-
substance/medication-induced obsessive-compulsive and related disorder
(e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
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social, occupational, or other important areas of functioning.

Note: This diagnosis should be made in addition to a diagnosis of
substance intoxication or substance withdrawal only when the symptoms
in Criterion A predominate in the clinical picture and are sufficiently
severe to warrant clinical attention.

8. Obsessive-Compulsive and Related Disorder due to Another Medical

Condition

1) Diagnostic Criteria

A. Obsessions, compulsions, preoccupations with appearance, hoarding,

skin picking, hair pulling, other body-focused repetitive behaviours, or
other symptoms characteristic of obsessive-compulsive and related
disorder predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is the direct pathophysiological consequence
of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

9. Treatment
First, one can talk to one’s doctor about one’s symptoms. One’s doctor should
do an exam to make sure that another physical problem is not causing the
symptoms. The doctor may refer one to a mental health specialist.

What was previously thought to be a rare, psychodynamically laden, and

difficult-to-treat illness now appears to have a strong biological component and
to respond well to potent selective serotonin reuptake inhibitors.
OCD is generally treated with psychotherapy, medication, or both.

1) Psychotherapies

(1) Cognitive Behaviour Therapy (CBT)

Cognitive behavioural therapy (CBT) is especially useful for treating OCD. It

teaches a person different ways of thinking, behaving, and reacting to situations
that help him better manage obsessive thoughts, reduce compulsive behaviour,
and feel less anxious. One specific form of CBT, exposure and response
prevention has been shown to be helpful in reducing the intrusive thoughts and
behaviours associated with OCD.
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Initial Interview

The therapist must identify specific cues that cause the client distress (threat
cues), avoidance, rituals, and feared consequences.

External Fear Cues

Most obsessive compulsive fear is reaction to specific environmental cues

(objects, persons, or situations), but each patient will have his own idiosyncratic
threat cues. For example, one may fear contamination touching a stranger only
or another may fear contamination touching anybody. Identification of the
source of the fear is important. Confronting the source of the fear is essential for
successful behaviour treatment. The therapist should conduct a thorough
investigation of objects, situations, and places that evoke obsessional
distress for the patient at the time of presentation and at onset. Such
information will help identify the source of the distress. To understand the level
of distress, the Subjective Units of Distress (SUDs) ranging from 1 to 100 can be
introduced. The client is asked to rate each situation with respect to the level of
distress that they expect to experience upon exposure.

Internal Fear Cues

Anxiety and distress may also be generated by images, impulses, or abstract

thoughts that the individual finds disturbing, shameful, or disgusting, e.g.,
images of oneself engaging in sexual activity with religious figures. Certainly,
internal threat cues may be produced by external situation such as the sight of a
statue of a goddess triggering sexual intercourse.

Feared Consequences

Many obsessive compulsives are afraid that something terrible will happen if
they fail to perform their rituals, e.g., a washer fearing someone will die at home
if he does not wash his hands frequently.

Avoidance and rituals

In order to maximize treatment efficacy, all avoidance and ritualistic

behaviours, even seemingly minor ones, should be prevented. Therefore, it is
necessary to find out all passive avoidance and rituals like not entering public
rest rooms, not preparing meals, and not taking out the trash. There are also
subtle forms of avoidance such as wearing slip-on shoes to avoid touching laces,
and using drinking straws to avoid contact with a glass or a can. There are also
active rituals which may be explicit like prolonged washing, repeated checks of
the door, or subtle like wiping hands on pant legs.

Treatment for obsessive-compulsive disorder (OCD) depends on how

much the condition is affecting one’s daily life.

(2) Associative Splitting

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More recent behavioural work has focused on associative splitting. It is a

new technique aimed at reducing obsessive thoughts. The method draws upon
the “fan effect” of associative priming. The sprouting of new associations
diminishes the strength of existing ones. As OCD patients show marked biases or
restrictions in OCD-related semantic networks (e.g., cancer is only associated
with “illness” or “death,” fire is only associated with “danger” or
“destruction”), they are encouraged to imagine neutral or positive associations
to OCD-related cognitions (cancer = stars, fountains; fire = fireflies, fireworks,
candlelight-dinner). 

(3) Behaviour Therapy (BT)

A type of cognitive-behaviour therapy called exposure and response

prevention is considered the most effective for OCD. With exposure and
response prevention therapy, one repeatedly exposes oneself to an obsession,
such as something one fears is contaminated, and deny oneself the ritual
compulsive act, which in this case would be washing one’s hands. This therapy is
done with a therapist or on one’s own with direction from one’s therapist.

In the beginning of exposure and response prevention therapy, the therapist

may ask one to write a list of one’s obsessions, rituals (compulsions), and things
that one avoids and then have one rank the amount of anxiety each of the
obsessions causes from the highest to the lowest. One might begin exposing
oneself to an obsession that causes a moderate amount of anxiety and then
work one’s way up the list to the obsession that causes the most anxiety.
Therapists often combine exposure and response prevention therapy with
cognitive-behavioural therapy to help overcome the faulty beliefs (such as fear
of contamination) that lead to OCD behaviours.

Behavioural treatments of OCD involve two separate components: (1)

exposure procedures that aim to decrease the anxiety associated with
obsessions and (2) response prevention techniques that aim to decrease the
frequency of ritual or obsessive thoughts. Exposure techniques range from
systematic desensitisation with brief imaginal exposure, to flooding, in which
prolonged exposure to the real-life ritual-evoking stimuli causes profound
discomfort. Exposure techniques aim to ultimately decrease the discomfort
associated with the eliciting stimuli through habituation. In exposure therapy,
the patient is assigned homework exercises that must be carried out and the
patient may require assistance in achieving exposure at home through
therapists’ home visits or from family members.
Response prevention involves having patients face the feared stimuli (e.g.,
dirt, chemicals) without excessive hand washing or having them tolerate doubt
(e.g., doubt about whether the door is locked) without excessive checking.
Initial work may involve delaying performance of the ritual, but
ultimately the patient attempts to resist the compulsions fully. The
psychoeducation and support of family members can be pivotal to the success of
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the behaviour therapy, because family dysfunction is prevalent and the majority
of parents or spouses accommodate to or are involved in the patients’ rituals,
possibly as a way to reduce the anxiety or anger that patients may direct at their
family members. It is generally agreed that combined behavioural
techniques (i.e., exposure with response prevention) yield the greatest
improvement.

2) Medication

Doctors may also prescribe medication to help treat OCD. The most
commonly prescribed medications for OCD are antidepressants. Although
antidepressants are used to treat depression, they are also particularly helpful
for OCD. They may take several weeks — 10 to 12 weeks for some — to start
working. Some of these medications may cause side effects such as headache,
nausea, or difficulty sleeping. These side effects are usually not severe for most
people, especially if the dose starts low and is increased slowly over time. One
can talk to the doctor about any side effects one may have.

It is important to know that although antidepressants can be safe and

effective for many people, they may be risky for some, especially children,
teens, and young adults. A “black box” — the most serious type of warning that
a prescription drug can have — has been added to the labels of antidepressant
medications. These labels warn people that antidepressants may cause some
people to have suicidal thoughts or make suicide attempts. Anyone taking
antidepressants should be monitored closely, especially when they first start
treatment with medications.

In addition to prescribing antidepressants, doctors may prescribe other

medications such as benzodiazepines to address the anxiety and distress that
accompany OCD. Not all medications are effective for everyone. One needs to
talk to one’s doctor about the best treatment choice for one.

3) Combination

Behaviour modification is an effective mode of therapy, with a success rate as

high as 80%, especially for the compulsive acts. Recently CBT and BT are
combined in most centres. The techniques used are: (1) Thought-stopping (and
its modifications), (2) Response prevention, (3) Systematic desensitization, (4)
Modelling.

Some people with OCD do better with CBT, especially exposure and response
prevention. Others do better with medication. Still others do best with a
combination of the two. Many studies have shown that combining CBT with
medication is the best approach for treating OCD, particularly in children and
adolescents. One can talk to the doctor about the best treatment for one.

4) Other Therapies
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(1) Psychoanalytic Psychotherapy is used in certain selected patients, who

are psychologically oriented.

(2) Supportive Psychotherapy is an important adjunct to other modes of

treatment. Supportive psychotherapy is also needed by the family members.

(3) Thought Stopping

Thought Stopping: For the cognitive channel, thought stopping is

especially useful in breaking into the ruminative thoughts that characterize many
victims’ reactions. The client is asked to begin generating thoughts about the
feared stimuli and then those thoughts are interrupted, initially by having the
therapist yell “stop!” simultaneously clapping hands together loudly. Then the
client is asked to use the word stop subvocally or to devise his own covert
thought-stopping term or visualization. The client may also wear a rubber band
on his wrist and snap it to stop his thoughts. The rubber band snapping is the
cue to stop one’s obsessive thoughts. He then learns to use thought stopping
covertly and to substitute a relaxed state for the anxious state.

(4) Systematic Desensitization

Systematic desensitization therapy begins by setting up an anxiety

hierarchy, that is, a list of the client’s fears, organized according to severity. The
therapist begins with the least frightening presentation of the feared object and
uses relaxation techniques to help the client become comfortable with that level
of exposure. Presentation of the feared object gradually moves up the hierarchy
with the client becoming acclimated to each successive level. This process can
be imaginal, that is, conducted in imagination; in vivo conducted, in context; or
a combination of the two. It may be good to start with the imaginal systematic
desensitization.

(5) Modelling

We learn many things by imitating others. The person whom we

imitate is a model. We just copy or imitate a desired behaviour of that model. In
the modelling, the client learns new skills by imitating another person, such as a
parent or therapist, who performs the behaviour to be acquired. For example,
modelling may be used to promote the learning of simple skills such as self-
dressing for an intellectually disabled person, or more complex skills such as
being more effective in social situations for a withdrawn individual.

(6) Hypnotic Counselling (QUOTE PAGE)

(7) Swish
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To do swish therapy, we need to find out two submodalities. We shall

proceed to find out submodalities and choose two powerful submodalities from
among them to do the swish therapy.

Finding out Submodalities

NLP has developed a number of therapies to deal with various types of

problems of individuals. In all the therapies, submodalities are involved. It is by
manipulating the submodalities one brings about change in one’s behaviour.
Therefore, before we enter into the forms of therapies let us have an idea of
submodalities and how they are identified. It is presumed that we learn both
good and bad through submodalities. Submodalities are the finer components of
the modalities or modes or representational systems or simply the five
sensations. Take for example, the visual modality which can be broken down
into smaller chunks or units like brightness, colour, size, shape, framed or
unframed, location, associated or dissociated, multiple or single, distance,
simultaneous or sequential, still or moving, speed, focus, 3-dimensional or flat,
contrast, duration and perspective. In the same way auditory mode is broken
down into tempo, volume, pitch, rhythm, associated or dissociated, duration,
location, distance, mono or stereo, clarity, punctuation (staccato or legato)
resonance and echo. In addition, the kinaesthetic submodalities are
temperature, pressure, location, texture, movement, intensity, extent, shape,
frequency, number, balance, symmetry, weight, and distribution. For the
therapeutic purposes one needs to get two submodalities either from one mode
or from two modes.

For all practical purposes it is good to find out two submodalities in the visual
modality. This is done by asking the client to think of a pleasant experience with
his eyes closed and ask him to move the picture far and near to find out the
optimum level or threshold of distance; increase or decrease the brightness to
know the optimum level or threshold of brightness; increase or decrease the size
and likewise do with every submodality of the visual order. Among them those
that make a difference in feeling would be the powerful submodalities, which we
need for therapies. The threshold of the two powerful submodalities are to be
identified; for example, if you increase the size of the picture beyond a particular
point, the raise becomes uncomfortable and that point is the threshold or
optimum level.

A Model of Finding out Submodalities

COUNSELLOR: Close your eyes and think of a pleasant experience you had in
the recent past.
COUNSELLEE: Yes.

DISTANCE
COUNSELLOR: How far is the picture of the original experience?
COUNSELLEE: Twelve feet away.
COUNSELLOR: Bring it closer.
COUNSELLEE: Nine feet.
COUNSELLOR: What are you experiencing?
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COUNSELLEE: I like it very much.

COUNSELLOR: Bring it closer.
COUNSELLEE: Five feet.
COUNSELLOR: What are you experiencing?
COUNSELLEE: It is wonderful.
COUNSELLOR: Bring it closer.
COUNSELLEE: Three feet.
COUNSELLOR: What are you experiencing?
COUNSELLEE: I do not like it.
COUNSELLOR: Take it back to the original place of twelve feet and then take
it farther away.
COUNSELLEE: Fifteen feet.
COUNSELLOR: What are you experiencing?
COUNSELLEE: I do not like it.
COUNSELLOR: Bring it back to the original distance.
Here we have found out the threshold or optimum level of distance, which is
five feet.

SIZE
COUNSELLOR: How big is the picture?
COUNSELLEE: 5’/10’
COUNSELLOR: Make it bigger.
COUNSELLEE: 7’/12’
COUNSELLOR: What is happening within you?
COUNSELLEE: I am happy about it.
COUNSELLOR: Make it bigger.
COUNSELLEE: 10’/15’
COUNSELLOR: What are you experiencing within you?
COUNSELLEE: Super.
COUNSELLOR: Make it bigger.
COUNSELLEE: I do not like to make it bigger, because it is unpleasant.
COUNSELLOR: Bring it back to the original size and make it smaller.
COUNSELLEE: 3’/8’
COUNSELLOR: What is happening to you?
COUNSELLEE: I do not like it.
COUNSELLOR: Bring it back to the original size.
The optimum level or threshold of size is 10’/15.’

BRIGHTNESS
COUNSELLOR: Is the picture bright or dull?
COUNSELLEE: Bright.
COUNSELLOR: Make it brighter.
COUNSELLEE: Yes, it is brighter.
COUNSELLLOR: What is happening within you?
COUNSELLEE: I love it.
COUNSELLOR: Make it brighter.
COUNSELLEE: Yes, I did it.
COUNSELLOR: What are you experiencing within you?
COUNSELLEE: It is very lovely.
COUNSELLOR: Make it brighter.
COUNSELLEE: It is blurring and I do not like it.
COUNSELLOR: Bring it back to the original brightness and make it dim.
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COUNSELLEE: Yes, it is dim.

COUNSELLOR: What is happening to you?
COUNSELLEE: It does not look nice.
COUNSELLOR: Bring it back to the original brightness.
The client can remember the optimum level or threshold of brightness since
it cannot be put in measurement.

DEPTH PERCEPTION
COUNSELLOR: Is the picture flat (two-dimensional) or three-dimensional?
COUNSELLEE: It is flat.
COUNSELLOR: Make it three-dimensional.
COUNSELLEE: Yes, it is three-dimensional.
COUNSELLOR: What is happening within you?
COUNSELLEE: Looks enchanting.
COUNSELLOR: Make it two-dimensional.

Likewise we can check with the other visual submodalities (colour, size,
shape, framed or unframed, location, associated or dissociated, multiple or
single, distance, simultaneous or sequential, still or moving, speed, focus, 3-
dimensional or flat, contrast, duration and perspective) and pick up two powerful
submodalities to do the Swish therapy.

When a submodality can be increased to infinity it is called analogous (like

distance, size, and brightness) and when it can admit only two possibilities of
change (like flat or three-dimensional, colour or black and white, a sound either
mono or stereo) it is called digital.

Wanting Habit Control or Behaviour Change (SWISH)

In NLP, we have a generative pattern called swish which can be used on

almost any problem or growth. It works well with habit control. With the help of
submodalities, swish is devised to work on behaviour patterns. It is used for
changing behaviour and making good behaviour one’s own. Examples: nail
biting, any kind of mannerism, smoking, any compulsion like smelling a glass
before use, any response one does and does not want to do, overeating, getting
angry, hyper-ventilation, feeling of being intimidated by people, being jealous,
feeling not worthwhile, any addictive behaviour, any kind of fear and frustration.

Swish means sweeping away at a stroke. The swish works with two
distinctive traits of the brain, direction and speed. Using the swish you enable
the brain to have a new direction for the stimulus received. You also run the
swish very quickly because that is the way the brain works. Here below I furnish
the steps of the swish.

(1) What to Change

Know the behaviour that you want to change. It should be clearly defined
or described.

(2) Why Change

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Find out all the arguments why you should not change the present behaviour.
This is only to make sure that the client wants to change the behaviour by all
means.

(3) Secondary Gains

Take care of the positive by-products or secondary gains. Every behaviour,

however bad it is, has some positive gains; for example, smoking is considered
very injurious to health. However, smoking has its own secondary gains; for
example, people smoke to be accepted by the peer group, to feel great and
grown up, to keep company, to be relieved of the tension, to think, and the like.
The secondary gains are useful and one should not give up these secondary
gains. What is aimed at is the extinction of the habit of smoking, but not the
secondary gains.

(4) Trigger Stimulus

Know the trigger stimulus, which is the starting point of the unwanted
behaviour. The present state has to be connected to the desired state, and
hence it is essential to find out the trigger stimulus. Much depends upon finding
out and connecting it to the new state, which is desired. In the case of smoking
that which triggers off a compulsion to smoke will vary from person to person.
For one person the very sight of a shop will be sufficient to make him want to
smoke. For another it may be seeing a person smoking, for another the smell of
it, and for another it could be the lighting of the cigarette. Since the triggers
stimulus varies from person to person, we have to make sure as to which is the
exact trigger stimulus for a particular individual. To help the client find out the
trigger stimulus, ask him to go through a past experience.

(5) Attractive Desired State:

Desired state should be attractive. Just as the client was determined to get
rid of the old habit, he should be extremely eager to attain the desired state. For
that, help the client picture to himself the desired state as if he already has it
and make it more attractive by putting in whatever is needed. From the non-
verbal communication, especially calibration, you will be able to make out that
the desired state is enchanting.

(6) Present to Desired

The movement is from the present state to the desired state. For the
smoking man the present state is his smoking habit, and the desired state will
be being relaxed without the compulsion of smoking.

(7) Altered State after Swish

After every swish the client should have an altered state, that is, the client
should blank out the screen. If he kept his eyes closed, after every swish, he
should open them before starting once again.

(8)Two Submodalities

Find out two powerful submodalities from the visual model.

(9) Start at the Optimum

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Start at the optimum level (threshold) of the present state and immediately
gaze at the desired state, which is at the weakest.

(10) Rehearse

First, arrange the swish and ask the client to go through it slowly as a
practice, seeing the present state, for example, big and close, and immediately
looking at the desired state, small and far. As the client looks at the desired
state, the desired state will become bigger and closer (the optimum level), and
the present state will become smaller and farther.

(11) Swishing

Once practiced, then make the client to swish it a number of times, at least
five times, and it should be done very fast so that the whole process of a swish
takes only two seconds.

Let us take an example of a person who frequently washes his hands. The
trigger stimulus is the sight of a tap. Let us imagine that his submodalities are
size and colour. The desired state will be to be free in seeing a tap but not
washing. The present state of washing the hands with the trigger stimulus of
seeing the tap is set at 10 feet x 8 feet size (optimum level) and coloured, while
the desired state of being free from the compulsion of washing the hands will be
very tiny and black and white. The client looks at the present state and
immediately looks at the desired state, at which the present state becomes very
tiny and black and white while the desired state will become as big as 10’ x 8’
(the optimum level) and coloured. Then the client opens the eyes and then
starts once again, thus doing it very fast for a number of times.

(12) Future Pacing

Once swish has been done it should be checked. If for example, swish was
done for hand washing, then ask the client to see a tap and check if he still has a
compulsion to wash his hands.

(13) Rectification

If the swish has not worked, then put in whatever is needed and follow all
the steps all over again.65

10. Conclusion

Obsessive-Compulsive Disorders’ (OCD) symptoms vary from mild to

severe. They include obsessions (thoughts or feelings) that make one feel
distressed or anxious, and compulsions (actions) which one feels necessary to
perform to cancel out the obsession. It is most common to have both obsessions
and compulsions, but one can also have either alone. One may have more than
one obsession and/or compulsion. One may carry out compulsive behaviours to
counteract the anxiety caused by one’s obsessions. These may be obvious
actions, or just things one does in one’s mind.

People with OCD are usually, but not always, aware that their thoughts or
actions are unreasonable. It is common to feel guilty, disgusted, depressed, or
embarrassed about it. Compulsive behaviours can be very time-consuming,
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often getting in the way of normal work and family life.

If one has OCD one may also have depression. This may be due to the
emotional strain of dealing with obsessions, or because OCD and depression
involve similar chemical imbalances in the brain.
OCD has been linked to increased activity in certain parts of the brain and a
decreased level of a natural chemical called serotonin. This chemical is important
in the regulation of mood.

Getting professional help is the best way to deal with OCD. Treatment can
help one gain control over one’s obsessions and stop carrying out compulsions.
Treatment may include psychological treatments, medicines or a combination of
these.

8. TRAUMA- AND STRESSOR-RELATED DISORDERS

1. Introduction

Trauma- and stressor-related disorders include disorders in which exposure

to a traumatic or stressful event is listed explicitly as a diagnostic criterion.
These include acute stress disorder, posttraumatic stress disorder (PTSD),
reactive attachment disorder, disinhibited social engagement disorder, and
adjustment disorders.

Psychological distress following exposure to a traumatic or stressful event is

quite variable. In some cases, symptoms can be well understood within an
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anxiety- or fear-based context. It is clear, however, that many individuals who

have been exposed to a traumatic or stressful event exhibit a phenotype in
which, rather than anxiety- or fear-based symptoms, the most prominent clinical
characteristics are anhedonic and dysphoric symptoms, externalizing angry and
aggressive symptoms, or dissociative symptoms. Social neglect — that is, the
absence of adequate caregiving during childhood — is a diagnostic
requirement of both reactive attachment disorder and disinhibited social
engagement disorder. Although the two disorders share a common aetiology,
the former is expressed as an internalizing disorder with depressive symptoms
and withdrawn behaviour, while the latter is marked by disinhibition and
externalizing behaviour.

2. Acute Stress Disorder (ASD)

1) Diagnostic Criteria

A. Exposure to actual or threatened death, serious injury, or sexual violence

in one (or more) of the following ways:
1. Direct experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member
or close friend. Note: In cases of actual or threatened death of a family member
or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders collecting human remains; police
officers repeatedly exposed to details of child abuse).
Note: This does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work related.
B. Presence of nine (or more) of the following symptoms from any of the
five categories of intrusion, negative mood, dissociation, avoidance, and
arousal, beginning or worsening after the traumatic event(s) occurred:

Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
Note: In children, repetitive play may occur in which themes or
aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s). Note: In children there
may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels
or acts as if the traumatic event(s) were recurring. (Such reactions
may occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings.)
Note: In children, trauma-specific re-enactment may occur in play.
4. Intense or prolonged psychological distress or marked physiological
reactions in response to internal or external cues that symbolize or
resemble an aspect of the traumatic event(s).

Negative Mood
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5. Persistent inability to experience positive emotions (e.g., inability to

experience happiness, satisfaction, or loving feelings).

Dissociative Symptoms

6. An altered sense of the reality of one’s surroundings or oneself (e.g.,

seeing oneself from another’s perspective, being in a daze, time
slowing).
7. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as
head injury, alcohol, or drugs).

Avoidance Symptoms

8. Efforts to avoid distressing memories, thoughts, or feelings about or

closely associated with the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories,
thoughts, or feelings about or closely associated with the traumatic
event(s).

Arousal Symptoms

10. Sleep disturbance (e.g., difficulty falling or staying asleep or

restless sleep).
11. Irritable behaviour and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
towards people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.
C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1
month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma, but
persistence for at least 3 days and up to a month is needed to meet
disorder criteria.
D. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a
substance (e.g., medication, or alcohol) or another medical condition
(e.g., mild traumatic brain injury) and is not better explained by brief
psychotic disorder.

2) Description of ASD

In the weeks after a traumatic event, one may develop an anxiety disorder
called acute stress disorder (ASD). ASD typically occurs within one month of a
traumatic event. It lasts at least three days and up to one month. People with
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ASD have symptoms similar to those seen in post-traumatic stress disorder

(PTSD).

Approximately six to 33 percent of people who experience a traumatic event

develop ASD. Examples of traumatic events include, but are not limited to, rape,
physical assault, near-death experiences, witnessing a murder, combat, and
having a child in a neonatal intensive care unit.

Acute Stress Disorder, or ASD, is a psychiatric diagnosis that was introduced

into the DSM-IV in 1994. The current diagnostic criteria for ASD are similar to
the criteria for PTSD, although the criteria for ASD contain a greater emphasis
on dissociative symptoms and the diagnosis can only be given within the first
month after a traumatic event. The inclusion of ASD in the DSM-IV was not
accompanied by extensive research, and some debate exists regarding whether
the diagnostic criteria accurately reflect pathological reactions to trauma that
occur within the first month after a trauma. However, even though debate exists
about the empirical basis of the diagnosis, it has been found to be highly
predictive of subsequent PTSD.

3) Commonality of ASD

Studies of ASD have utilized a variety of measurement tools with varying

degrees of reliability and validity. The following rates should be interpreted with
some caution, and it is possible that the rates will change as measures for ASD
become more uniform among researchers.

Studies of motor vehicle accident (MVA) survivors have found rates of ASD
ranging from approximately 13% to 21%. A study of survivors of a typhoon
revealed an ASD rate of 7%, while a study of survivors of an industrial accident
revealed a rate of 6%. A rate of 19% was found in survivors of violent assault
while a rate of 13% was found in a mixed group consisting of survivors of
assaults, burns, and industrial accidents. A study of victims of robbery and
assault found that 25% met criteria for ASD, while a study of victims of a mass
shooting found that 33% met criteria.

A study that used PTSD criteria and evaluated rape survivors within the first
month of a trauma revealed a prevalence rate of 94%. This last study evaluated
PTSD diagnostic criteria during the first month after a trauma. Therefore, it did
not assess for the presence of dissociative symptoms that are specific to the
diagnosis of ASD (but not PTSD). However, the study is included here to give the
reader a sense of the level of posttraumatic sequelae that may be expected after
sexual assault.

4) Vulnerability to ASD Resulting from Trauma

While many studies have examined factors that place individuals at risk for
developing PTSD, only a handful of studies have examined risk factors for the
development of ASD. One retrospective study found that individuals with
exposure to prior trauma, individuals with prior PTSD, and individuals with more
psychiatric dysfunction were all more likely to develop ASD when confronted
with a new traumatic stressor. Bryant and Harvey report that in their sample of
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MVA survivors without head injuries, there were several strong predictors of ASD
severity: depression score, history of psychiatric treatment, history of PTSD, and
prior motor vehicle accidents. These predictors accounted for 61% of the
variance. There is also some evidence that individuals prone to experiencing
dissociation in the face of traumatic stressors may be more likely to develop
ASD.

5) Difference between ASD and PTSD

ASD and PTSD differ in two fundamental ways. The first difference is that the
diagnosis of ASD can be given only within the first month following a traumatic
event. If posttraumatic symptoms were to persist beyond a month, the clinician
would assess for the presence of PTSD. The ASD diagnosis would no longer
apply.

ASD also differs from PTSD in that it includes a greater emphasis on

dissociative symptoms. An ASD diagnosis requires that a person experience
three symptoms of dissociation (e.g., numbing, reduced awareness,
depersonalization, derealisation, or amnesia), while the PTSD diagnosis does not
include the dissociative symptom cluster.

6) ASD’s Predictive Validity for PTSD

A diagnosis of ASD, in the absence of treatment, appears to be an accurate

predictor of subsequent PTSD. Harvey and Bryant found that 78% of MVA
survivors who initially met criteria for ASD met criteria for PTSD six months
post-trauma. In a similar study of MVA survivors with mild traumatic brain
injury, 82% of those initially diagnosed with ASD met criteria for PTSD six
months post-trauma. Brewin et al. found that 83% of assault victims who
initially met criteria for ASD met criteria for PTSD at a 6-month follow-up.

Bryant and Harvey note that while ASD is highly predictive of subsequent
PTSD, subthreshold ASD (which is typically ASD without the dissociative
symptoms) is also a good predictor of PTSD. This suggests that the ASD criteria
do not adequately capture all individuals who are at risk for developing full-
blown PTSD. The reason for this appears to be that some individuals at risk for
PTSD do not develop acute dissociative symptoms and, therefore, do not ever
meet criteria for ASD. Research is currently underway regarding the different
trajectories that individuals follow in the development of PTSD.

7) Diagnosis of ASD

There are a few well-established and empirically-validated measures to

assess ASD. The tools with the strongest psychometric properties are described
below:

The Acute Stress Disorder Interview (ASDI) is the only structured clinical
interview that has been validated against DSM-IV criteria for ASD. It appears to
meet standard criteria for internal consistency, test-retest reliability, and
construct validity. The interview was validated by comparing it with independent
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diagnostic decisions made by clinicians with experience in diagnosing both ASD

and PTSD.

The Acute Stress Disorder Scale (ASDS) is a self-report measure of ASD

symptoms that correlates highly with symptom clusters on the ASDI. It has good
internal consistency, test-retest reliability, and construct validity. 66

8) Treatments for ASD

This disorder (ASD) may resolve itself with time or may develop into a more
severe disorder such as PTSD. However, results of Creamer, O'Donnell, and
Pattison's (2004) study of 363 patients suggest that a diagnosis of acute stress
disorder had only limited predictive validity for PTSD. Creamer et al. did find that
re-experiences of the traumatic event and arousal were better predictors of
PTSD. Medication can be used for a short duration (up to four weeks).

Studies have been conducted to assess the efficacy of counselling and

psychotherapy for people with ASD. Cognitive behavioural therapy, which
included exposure and cognitive restructuring, were found to be effective in
preventing PTSD in patients diagnosed with ASD with clinically significant results
at 6 months follow-up. A combination of relaxation, cognitive restructuring,
imaginal exposure, and in vivo exposure was superior to supportive counselling.

No treatment may be needed, as symptoms usually go once the stressful

event is over. Understanding the cause of symptoms, and talking things over
with a friend or family member, may help. However, some people have more
severe or prolonged symptoms.

(1) Cognitive Behavioural Interventions

At present, cognitive behavioural interventions during the acute aftermath of

trauma exposure have yielded the most consistently positive results in terms of
preventing subsequent posttraumatic psychopathology. Four out of five
randomized clinical trials (RCTs) related to early cognitive behavioural
interventions during the acute aftermath of trauma found that the Cognitive
Behavioural Therapy (CBT) group experienced a greater reduction of PTSD
symptoms than comparison groups.

Bryant and colleagues have conducted the only studies that specifically
assessed and treated ASD. They have shown that a brief cognitive behavioural
treatment may not only ameliorate ASD, but it may also prevent the subsequent
development of PTSD. Approximately 10 days after exposure to a MVA, industrial
accident, or nonsexual assault, Bryant and colleagues randomly assigned those
with ASD to five individual, 1.5-hour sessions of either a cognitive behavioural
treatment or a supportive counselling control condition. They found that fewer
CBT subjects met criteria for PTSD post-treatment at 6 months later.
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(2) Cognitive Behavioural Therapy (CBT)

Cognitive Behavioural Therapy (CBT) is a talking therapy and is based on the

idea that certain ways of thinking can trigger or fuel certain mental health
problems. The therapist helps you understand your current thought patterns, in
particular, to identify any harmful, unhelpful and false ideas or thoughts. The
aim is then to change your ways of thinking in order to avoid these ideas and
help your thought patterns to be more realistic and helpful. When it is used for
acute stress reactions it is known as trauma-focused CBT.

(3) Psychological Debriefing

Psychological debriefing is an early intervention that was originally developed

for rescue workers that has been more widely applied in the acute aftermath of
potentially traumatic events.

(4) Visual-Kinaesthetic Dissociation (VKD) (QUOTE PAGE)

(5) Counselling
This may be an option if symptoms are persistent or severe. Counselling
helps you explore ways of dealing with stress and stress symptoms. This may be
available locally but some charities also offer online resources and telephone
help lines that may be useful.67

3. Posttraumatic Stress Disorder (PTSD)

Both posttraumatic stress disorder and acute stress disorder imply a

reaction to an extreme traumatic stressor that has caused or threatened death
or severe injury. The difference between these two are time of onset and
duration. Acute stress disorder begins within four weeks of exposure to a
traumatic stressor and lasts at least three days but no longer than four weeks.
However, symptoms of PTSD last for more than one month. 68

1) Diagnostic Criteria for Adults

The following criteria apply to adults, adolescents, and children older than
6 years.

A. Exposure to actual or threatened death, serious injury, or sexual violence

in one (or more) of the following ways:
1. Direct experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family
member or close friend. In cases of actual or threatened death of a
family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of the
traumatic event(s) (e.g., first responders collecting human remains;
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police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic
media, television, movies, or pictures, unless this exposure is work
related.
B. Presence of one (or more) of the following intrusion symptoms associated
with the traumatic event(s), beginning after the traumatic event(s)
occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in
which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s).
Note: In children there may be frightening dreams without
recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels
or acts as if the traumatic event(s) were recurring. (Such reactions
may occur on a continuum, with the most extreme expression being a
complete loss of awareness of present surroundings.)
Note: In children, trauma-specific re-enactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic
event(s).
5. Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s),
beginning after the traumatic event(s) occurred, as evidenced by one or
both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or
feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse distressing
memories, thoughts, or feelings about or closely associated with the
traumatic event(s).
D. Negative alterations in cognitions and mood associated with the
traumatic event(s) beginning or worsening after the traumatic event(s)
occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s)
(typically due to dissociative amnesia and not to other factors such as
head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about
oneself, others, or the world (e.g., “I am bad,” “No one can be
trusted,” “The world is completely dangerous,” “My whole nervous
system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of
the traumatic event(s) that lead the individual to blame himself or
others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to
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experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred,
as evidenced by two (or more) of the following:
1. Irritable behaviour and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
towards people or objects.
2. Reckless or self-destructive behaviour.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1
month.
G. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the physiological effects of a
substance (e.g., medication, alcohol) or another medical condition.

2) Diagnostic Criteria for Children

The following criteria apply to children 6 years and younger.

A. In children 6 years and younger, exposure to actual or threatened death,

serious injury, or sexual violence in one (or more) of the following ways:
1. Direct experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others
especially primary caregivers.
Note: Witnessing does not include events that are witnessed only
in electronic media, television, movies, or pictures.
3. Learning that the traumatic event(s) occurred to a parent or care-
giving figure.
B. Presence of one(or more) of the following intrusion symptoms associated
with the traumatic event(s), beginning after the traumatic event(s)
occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the
traumatic event(s).
Note: Spontaneous and intrusive memories may not necessarily
appear distressing and may be expressed as play reenactment.
2. Recurrent distressing dreams in which the content and/or affect of
the dream are related to the traumatic event(s).
Note: It may not be possible to ascertain that the frightening content
is related to the traumatic event.
3. Dissociative reactions (e.g., flashbacks) in which the individual
feels or acts as if the traumatic event(s) were recurring. (Such
reactions may occur on a continuum, with the most extreme
expression being a complete loss of awareness of present
surroundings.) Such trauma-specific reenactment may occur in
play.
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4. Intense or prolonged psychological distress at exposure to internal

or external cues that symbolize or resemble an aspect of the
traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic
event(s).
C. One (or more) of the following symptoms, representing either persistent
avoidance of stimuli associated with the traumatic event(s) or negative
alterations in cognitions and mood associated with the traumatic
event(s), must be present, beginning after the event(s) or worsening
after the event(s):

Persistent Avoidance of Stimuli

1. Avoidance of or efforts to avoid activities, places, or physical
reminders that arouse recollections of the traumatic event(s).
2. Avoidance of or efforts to avoid people, conversations, or
interpersonal situations that arouse recollections of the traumatic
event(s).

Negative Alterations in Cognitions

3. Substantially increased frequency of negative emotional states
(e.g., fear, guilt, sadness, shame, confusion).
4. Markedly diminished interest or participation in significant
activities, including constriction of play.
5. Socially withdrawn behaviour.
6. Persistent reduction in expression of positive emotions.
D. Alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred,
as evidenced by two (or more) of the following:
1. Irritable behaviour and angry outbursts (with little or no
provocation) typically expressed as verbal or physical aggression
towards people or objects (including extreme temper tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
E. The duration of the disturbance is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in
relationships with parents, siblings, peers, or other caregivers or with
school behaviour.
G. The disturbance is not attributable to the physiological effects of a
substance (e.g., medication, or alcohol) or another medical condition.

3) Treatment

(1) Psychotherapy

It is generally believed that some form of psychotherapy is necessary in the

treatment of posttraumatic pathology. Crisis intervention shortly after the
traumatic event is effective in reducing immediate distress, possibly prevents
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chronic or delayed responses, and, if the pathological response is still tentative,

may allow for briefer interventions.
Brief dynamic psychotherapy has been advocated both as an immediate
treatment procedure and as a way of preventing chronic disorder. Embry (1990)
outlined seven major parameters for effective psychotherapy in war veterans
with chronic PTSD: (1) initial rapport building, (2) Limit-setting and supportive
confrontation, (3) affective modelling, (4) defocusing on stress and focusing on
current life events, (5) sensitivity to transference-countertransference issues,
(6) understanding of secondary gain, and (7) therapist’s maintenance of a
positive treatment attitude. Group therapy can also serve as an adjunctive
treatment, or as the central treatment mode. The identification, support, and
hopefulness of peer settings can facilitate therapeutic change.

a. V.K.D. (QUOTE PAGE)

b. Eye Movement Desensitization and Reprocessing (EMDR)

Francine Shapiro developed EMDR. It integrates a wide range of procedural elements

along with the use of rhythmic eye movements and other bilateral stimulation to treat traumatic
stress and memories of clients. It is a form of exposure therapy designed to assist clients in
dealing with traumatic memories. It is trauma that causes posttraumatic stress disorder (PTSD) in
people. Clients like children, couples, sexual abuse victims, combat veterans, victims of crime,
rape survivors, accident victims, and persons dealing with anxiety, panic, depression, grief,
addictions, and phobias can greatly benefit from EMDR.

EMDR integrates important aspects of many other types of therapy such as psychodynamic,
cognitive, behavioural, and interactional. It has an eight-phase approach. They are: (1) client
history and treatment planning, (2) preparation, (3) assessment, (4) desensitization, (5)
installation, (6) body scan, (7) closure, and (8) evaluation.

(a) Client History & Treatment Planning: First of all the history of the client with regard to the
problem has to be taken. It involves conceptualizing and defining the client’s problem and
identifying and evaluating specific outcome goals. Specific targets are selected such as
dysfunctional memories that set the groundwork for pathology, present situations that trigger the
disturbance, and specific skills and behaviour necessary for adaptive future action.

(b) Preparation Phase: This step involves establishing a therapeutic alliance. The EMDR
process and its effects are explained to the clients. Any concerns or expectations of the clients are
discussed. Relaxation procedures are initiated and a safe climate is created where the client is
able to engage in emotive imagery.

(c) Assessment Phase: Here the therapist identifies a traumatic memory that results in anxiety,
and the emotions and physical sensations associated with the traumatic event; he evaluates the
Subjective Units of Distress (SUD), identifies a negative cognition that is associated with the
disturbing event and finds an adaptive belief (or positive cognition) that would lessen the anxiety
surrounding the traumatic event. The client is asked to hold the disturbing event in mind and rate
it on the 0-10 SUD Scale, in which 0 is neutral or no disturbance, and 10 is the greatest
disturbance imaginable. How the client interprets the events to himself is to be determined. This
is done by asking the client to concentrate on a specific memory and say which words
automatically come to mind that describe his feelings about himself or his behaviour in the
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situation. Thus, one gets the negative self-beliefs or negative lessons the client learned about
himself from his trauma, as for example one would say “I am a worthless person.” The adaptive
belief or positive cognition that is needed has to be identified and measured. It is done on a
Validity of Cognition (VOC) Scale from 1-7 in which 1 means completely false and 7 means
completely true. The client will be asked to report how true his positive cognition (belief) feels
using the VOC Scale. After doing the EMDR therapy, of course, the client is asked to report an
increase in how true his positive cognition (belief) feels.

(d) Desensitization Phase: The client visualizes the traumatic image, verbalizes the maladaptive
belief (or negative cognition), and pays attention to the physical sensations. It is a limited
exposure and the client may have direct exposure to the most disturbing element for less than one
minute per session. During this process, the client is instructed to visually track the therapist’s
index finger as it is moved rapidly and rhythmically back and forth across the client’s line of
vision from 12 to 24 times with appropriate variations and changes of focus until the SUD level
of the client is reduced to 0 or, if appropriate, to 1 or 2. The movement of the index finger could
be done diagonally, horizontally or back and forth. Now the client is instructed to block out the
negative experience momentarily and breathe deeply and to report what he is imagining, feeling,
and thinking.

How the eye-movement works here for a cure of the traumatic event is a question that might
arise in one’s mind. So far, no answer has been found out. There are many theories proposed and
they still remain only theories. One of the theories speaks of Ivan Pavlov who in 1924
conjectured that there was an excitatory-inhibitory balance in the brain that maintained normal
functioning. If something caused an imbalance to occur (as when something caused over
excitation), a neural pathology resulted. The way to return to normal functioning and cure a
neurosis is to restore the balance between excitation and inhibition. Perhaps trauma causes an
over-excitation to the nervous system and the eye-movements cause an inhibitory (or relaxation)
effect that counterbalances it. When upsetting memories come up in dreams, rapid eye
movements (REM) bring about a relaxation effect to allow processing of the experiences. The
effect is due to reciprocal inhibition, the factor responsible for the anxiety relieving results of
systematic desensitization treatment.

Systematic desensitization consists of conditioning a client out of his fear by teaching him to
do deep muscle relaxation first in the presence of a mild version of his object of fear, then
progressively moving to more potent version, and arriving eventually at a full-strength version.
The reason why it is done is that deep muscle relaxation inhibits low-level anxiety, and as low
levels are treated, the whole hierarchy of fears drops down in intensity. Perhaps the eye-
movements in dreaming reciprocally inhibit the distress. If the client’s disturbance were mild
enough, the eye movements of sleep would offset them. That is the reason why when we go to
bed with mild upsets, we get up in the morning fresh because in REM sleep our mild upsets are
healed. If the disturbance is too severe, it offsets the effect of the eye-movements and we get up
with nightmares instead of completing them. Therefore, the same principle of REM sleep works
in EMDR therapy completing the severe upsets.

Another theory suggests that a reflex has developed through evolution that allows mammals
to observe danger. The resulting excitation causes the animal to fight or flee. The eye movement
in EMDR triggers an associated innate mechanism that inhibits that response. The result is a rapid
psychological reorientation that brings about a sense of safety.

Yet another theory suggests that the neuronal bursts of the rapid eye movements (like a low-
voltage current) could be causing an inhibitory effect in the place where the traumatic memory is
stored, thereby reversing the neural pathology. Perhaps this is what happens in REM (rapid eye
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movement) sleep.

(e) Installation Phase: This phase consists of installing and increasing the strength of the
positive cognition the client has identified as the replacement for the original negative cognition.
For example, a person who witnessed the drowning of a child in the river may have the negative
belief “I did not do enough to save the child.” Now he might say “Well, I did all that was
possible within my power at that moment.” How deeply the client feels his positive cognition is
then measured using the VOC Scale. The goal is for the client to accept the full truth of his
positive self-statement at the level of 7 (completely true).

(f) Body Scan Phase: At this juncture, the client is asked to visualize the traumatic event and the
positive cognition and to scan his body mentally from top to bottom and identify any bodily
tension states. Once the positive cognition has been installed and strengthened, the client is asked
to bring the original target event to mind and see if he notices any residual tension in his body. If
so, these physical sensations are targeted for reprocessing. The reason behind this procedure is a
physical resonance to unresolved thoughts. When a person is negatively affected by trauma,
information about the traumatic event is stored in motoric (or body systems) memory, rather than
in narrative memory and the person retains the negative emotions and physical sensations of the
original event. When the information is processed, it can move to narrative (or verbalizable)
memory, and the body sensations and negative feelings associated with it disappear. Therefore,
the EMDR treatment session is considered complete only when the client brings up the original
target image without feeling anybody tension.

(g) Closure Phase: Every session has to be brought to an adequate closure. The client is asked to
maintain a log or journal and record any disturbing material. The use of the log and relaxation or
visualization techniques are needed for client-stability between sessions.

(h) Re-evaluation Phase: The homework of the client is reviewed at the beginning of each
session. This phase comprises reconceptualising the client’s problems, establishing the work of
cognitive restructuring, continuing the self-monitoring process, and collaboratively evaluating the
outcome of treatment.
ILLUSTRATION: (A MODIFIED VERSION OF EMDR THERAPY)

Sam was a young man of 24 years. He was travelling at night and reached his
destination early in the morning around 2 o’clock. As he approached two men standing
near an auto-rickshaw to enquire about the address he had in hand they assaulted him,
beat him up, took away all his possession and left him bruised. This was a traumatic event
for Sam.

COUNSELLOR: How would you rate the intensity of your experience in the SUD Scale 0 - 10?
SAM: It would be perhaps 8.
COUNSELLOR: As you visualize the assault, what emotions do you experience?
SAM: Fear.
COUNSELLOR: What physical sensations do you have right now?
SAM:…A tightness at the back.
COUNSELLOR: What words come to you automatically as you are visualizing the assault?
SAM: I am helpless and desperate.
COUNSELLOR: What thought, if you had any, would have decreased the intensity of your feeling?
SAM: May be a thought like “I am powerful and able.”
COUNSELLOR: How would you rate that positive belief on the Validity of Cognition Scale 1-7?
That is, to what extent is that positive belief true in your case?
SAM: May be 3.
COUNSELLOR: Now, SAM, just visualize the assault and verbalize the negative belief that you are
helpless and desperate and pay attention to the physical sensation. As you do this,
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visually track my index finger as I am moving it rapidly and rhythmically back and
forth. Then block out the negative experience momentarily and breathe deeply and
report to me what you are imagining, feeling and thinking.
……………………………..
……………………………..
SAM: I feel relieved.
COUNSELLOR: Now think about your positive belief and how will you rate it in the VOC Scale?
SAM: I would put it at 6.
COUNSELLOR: Just scan your body from top to bottom and report to me if there is any bodily
tension.
SAM: Still a bit of tightness at my back.
COUNSELLOR: You could continue your relaxation exercise and keep a log of what you are
experiencing till the next session. Next time we shall take it up to complete the work.
SAM: Thank you very much, sir.

This therapy includes an exposure-based therapy (with multiple brief,

interrupted exposures to traumatic material), eye movement, and recall and
verbalization of traumatic memories of an event or events.

It has demonstrated efficacy similar to other forms of cognitive and

behaviour therapy.

c. Psychodynamic Psychotherapy

Psychodynamic psychotherapy focuses on the meaning of the trauma for the

individual in terms of prior psychological conflicts and developmental experience
and relationships.

It focuses on the effect of the traumatic experience on the individual’s prior

self-object experiences, self-esteem, altered experience of safety, and loss of
self-cohesiveness, and self-observing functions.

d. Psychoeducation and Support

Psychoeducation and support both appear to be helpful as early interventions

to reduce the psychological sequelae of exposure to mass violence or disaster.

When access to expert care is limited by environmental conditions or reduced

availability of medical resources, rapid dissemination of educational materials
may help many persons to deal effectively with subsyndromal manifestations of
traumatic exposure.

Early supportive interventions, psychoeducation, and case management

appear to be helpful in acutely traumatized individuals as they promote
engagement in ongoing care and may facilitate entry into evidence-based
psychotherapeutic and psychopharmacologic treatments.
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Encouraging acutely traumatized persons to first rely on their inherent

strengths, their existing support networks, and their own judgment may reduce
the need for further intervention.

Stress inoculation, imagery rehearsal, and prolonged exposure techniques

may be helpful for treatment of PTSD and PTSD-associated symptoms such as
anxiety and avoidance.

Present-centred and trauma-focused group therapies may reduce PTSD

symptom severity.

e. Reframing

Sometimes certain incidents are made traumatic by the culture and

subsequent treatment of the same incident. A woman when she was a small
child went to a teacher for tuition. That teacher caressed her, touched her
genitals, and played with her. Since it happened to her as a child, she did not
worry about it. Later when she grew up, from the discourses of others, she
understood it as something traumatic. She went and spoke to three counsellors
and came to the fourth counsellor finally by chance. Having listened to her, the
fourth counsellor said that it happened when she was a child and she knew
hardly anything about sex. “It might have been a playful and pleasurable
experience for you as a child. You were not responsible for the act and therefore
you need not feel guilty about it.” The woman, who was all in tears while
narrating the incident suddenly stopped crying, wiped her tears and appeared
cheerful. Here it is a question of reframing. Firstly, the people around her made
her feel guilty by their reframing an innocent act from the part of the child.
Secondly, three counsellors had reinforced her negative belief by their own
incompetence. Finally, the fourth one did the reframing but in the opposite
direction. Here the point is that certain theories and cultural beliefs can
unnecessarily cripple people and may create trauma where there had never been
a trauma. If everyone around the client feels that a certain act is horrible, then
the client tends to feel the same. However, at the same time if the people
around the client take it as a matter of fact, then the client also feels all right.

f. Cognitive and Behaviour Therapies

Cognitive and behaviour therapies target the distorted threat appraisal

process (e.g., through repeated exposure or through techniques focusing on
information processing without repeated exposure) in an effort to desensitize the
patient to trauma-related triggers.

When therapy is given over a few sessions (beginning 2 to 3 weeks after

trauma exposure) it may speed up the recovery and prevent PTSD.

g. Behaviour Therapies
A variety of behavioural techniques has been applied. People involved in
traumatic events such as accidents frequently develop phobias or phobic anxiety
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related to or associated with these situations. Systematic desensitisation or

graded exposure has been found to be effective in cases of phobia or phobic
anxiety associated with PTSD. This technique is based on the principle that when
patients are gradually exposed to a phobic or anxiety-provoking stimulus, they
will become habituated or deconditioned to the stimulus. Variations of this
treatment include using imaginal techniques (i.e., imaginal desensitisation) and
exposure to real-life situation (i.e., in vivo desensitisation). Prolonged exposure
(i.e., flooding), if tolerated by patients, can be useful and has been reported to
be successful.
Relaxation techniques produce the beneficial physiological result of reducing
motor tension and lowering the activity of the autonomic nervous system.
Progressive muscle relaxation (PMR) involves contracting and relaxing various
muscle groups beginning from head to feet to introduce the relaxation response.
This technique is useful for symptoms of autonomic arousal such as somatic
symptoms, anxiety, and insomnia. Hypnosis has also been used to induce the
relaxation response.
Cognitive therapy and thought-stopping have been used to treat unwanted
mental activity in PTSD.
The treatment consists of the following measures:

(a) Prevention

Anticipation of disasters in the high risk areas, with the training of

personnel in disaster management.

(b) Disaster Management

Here the speed of providing practical help is of paramount importance.

This is also a preventive measure.

(c) Supportive Psychotherapy

The aim of supportive psychotherapy is achieved by a conglomeration of

techniques which include guidance, suggestion, environmental manipulation,
reassurance, persuasion, development of a doctor-patient relationship,
diversion, and even hospitalisation and medication. This is a highly skilled
method of psychotherapy, which can provide excellent results when used
judiciously.

(d) Cognitive Behaviour Therapy (CBT)

Cognitive behavioural therapy is based on the principle that the way one
feels is partly dependent on the way one thinks about things. CBT helps one
realise that one’s problems are often created by one’s mindset. It is not the
situation itself that is making one unhappy, but how one thinks about it and
reacts to it. The CBT therapist can help one identify any unhelpful or unrealistic
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thoughts that may be contributing to one’s problem — for example, one’s self-
esteem (the way one feels about oneself). The CBT therapist will be able to help
one adopt more realistic and helpful thoughts about these issues.

h. Stress Inoculation Training (SIT)

It is meant at giving the client a sense of mastery over his fears by

teaching a variety of coping skills. SIT is approached in phases. The first
phase is preparation for treatment and includes an educational element to
provide an explanatory or conceptual framework from which the client can
understand the nature and origin of his fear and anxiety and make sense of the
assault and its aftermath. In SIT, a social learning theory explanation is used.
Along with this, fear and anxiety reactions are explained as occurring along three
channels, namely (1) the physical or autonomic channel, (2) the behavioural or
motoric channel, and (3) the cognitive channel. Specific examples are given for
each and the client identifies his own reactions within each channel.

The second phase of SIT is the training of coping skills. At least two coping
skills from each channel are taught. The client first selects three target fears he
would like to reduce. He is asked to complete an “emotional thermometer” on
which he rates his level of fear and his level of happiness three times a day. In
addition, he keeps a daily record of the number of thoughts he has regarding
each target-fear during each morning, afternoon, and evening. The general
format for training of coping skills is the same for all the six skills taught as
listed out below:

Physical Channel

Skills taught most often for coping with fear in the physical channel are
muscle relaxation and breathing control.

Muscle relaxation: For this, the Jacobsonian tension-relaxation contrast

method is used most frequently. Total relaxation of all major muscle groups is
included during the training session.

Breath Control: Deep diaphragmatic breathing is taught using

psychocybernetics exercises.

Behaviour Channel

For the behaviour channel, covert modelling and role-playing are the coping
skills usually taught.

Covert Modelling: The client is taught to visualize a fear or anxiety-

provoking situating and to imagine himself confronting it successfully. This skill
is practiced until proficiency is obtained.

Role-playing: The client and the therapist act out successful coping in
anxiety-producing scenes with which the client expects to be confronted. In a
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group, the other members may be used in the role-playing. The client may then
be asked to role-play scenes with family members or friends.

Cognitive Channel

Thought Stopping: For the cognitive channel, thought stopping is especially

useful in breaking into the ruminative thoughts that characterize many victims’
reactions. The client is asked to begin generating thoughts about the feared
stimuli and then those thoughts are interrupted, initially by having the therapist
yell “stop!” simultaneously clapping hands together loudly. Then the client is
asked to use the word stop subvocally or to devise his own covert thought-
stopping term or visualization. He then learns to use thought stopping covertly
and to substitute a relaxed state for the anxious state.

Guided Self-Dialogue: The client is taught to focus on his internal dialogue

and trained to label negative irrational and maladaptive self-statements. He is
then taught to substitute more adaptive self-verbalizations. Self-dialogue is
taught in five categories: (1) preparation, (2) confrontation, (3) management,
(4) coping with feelings of being overwhelmed, and (5) reinforcement. For each
of these categories, a series of questions and/or statements is generated that
encourage the client to assess the actual probability of the negative event’s
happening, to manage the overwhelming fear and avoidance behaviour, to
control self-criticism and self-devaluation, to engage in the feared behaviour,
and finally to reinforce himself for making the attempt and following the steps.

i. Prolonged Exposure

It is a cognitive-behavioural treatment approach specifically for rape-related

PTSD. Treatment requires activation of the fear memory and incorporation of
new information incompatible with the current fear structure, so that new
memories are formed. The memory is activated through exposure techniques
similar to those used with victims of other types of trauma. Specifically, the
victim is asked to recall the assault in detail and helped to process the memory
until it is no longer intensely painful. This is combined with in vivo exposure to
feared (but objectively safe) stimuli. The treatment is usually conducted
individually in nine biweekly 90-minute sessions.

j. Cognitive Processing Therapy (CPT)

Cognitive processing therapy is a therapy model developed to treat the

specific symptoms of post-traumatic stress disorder in victims of sexual assault.
It combines the main ingredient of exposure-based therapies with the cognitive
restructuring components found in most cognitively based therapies. The content
of the cognitive portion of the therapy challenges specific cognitions that are
most likely to have been disrupted as a result of the trauma.

k. Prolonged Exposure Therapy

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It is a behavioural intervention that involves exposure to the feared

stimuli until the person’s anxiety is extinguished. It can be to the trauma
memory itself. Flooding, or prolonged exposure involves the client recalling or
imagining the feared situation in vivo, through visual imagery, or with the
assistance of virtual reality. Then a fear hierarchy can be created of major
stimuli that are feared and avoided, and the client focuses on feared cues for 45
minutes daily. The client should begin with a moderately feared stimulus in the
hierarchical list. The client should describe the trauma scene in the present
tense. The client proceeds until the fear is extinguished. This is done to activate
the fear memory and to provide new information that is incompatible with the
fear so that new learning can take place. The client can also visit the feared
locations in the presence of the therapist.

l. Cognitive Processing Therapy

This therapy is a combination of elements of exposure therapy, anxiety

management training, and cognitive restructuring. Here, exposure is combined
with cognitive restructuring to change the client’s disrupted cognitions. Exposure
is done through information about the trauma, recollection of responses, and
discussion of the trauma’s meaning. Appropriate processing of the traumatic
memories involves development of coping skills, changes in maladaptive beliefs,
and identification of a safe setting.

m. Anxiety Management Training (AMT)

AMT combines prolonged activation of traumatic memories with strategies like

relaxation, cognitive restructuring, and bio-feedback that are meant to modify
these memories and the associated fears. There are other therapies like Eye
Movement Desensitization and Reprocessing, group and family therapy, and
stress inoculation training (education and training in six coping skills – muscle
relaxation, thought stopping, breath control, guided self-dialogue, covert
modelling, and role-playing).

n. Hypnosis

Illustration (For Traumatic Experience)

1) Induction

(Dave Elman’s Induction Modified) “Just begin to make yourself

comfortable. Let your feet rest on the floor and your hands on your lap, or by
either side. Let your head drop forward slightly as you roll your eyes up and back
as though you were looking toward a point in your forehead. It may strain a little
but keep it up. Now inhale deeply which fills your lungs to the full. You continue
looking up and back. By now you allow your eyelids to grow heavy and close
down. You can exhale slowly and patiently. Now runs a deep relaxation from the
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top of your head to the tip of your toes. Let all the muscles of your body become
loose and limp and you are wonderfully relaxed.

“It is time for you to bring your awareness again to your eyes. Your eyes
are already comfortably closed; imagine that they are closing down all over again
becoming even more heavy and lazy. Just relax those muscles of the eyes so
that they will not work anymore. Since you have done it well, you can just test
and find them shut and unable to open. Since your eyelids are tightly shut, it is a
clear indication that you are relaxed. Let the wave of relaxation run down from the
top of your head to the tip of your toe.”

2) Relaxation

(Breath Based) “As you sit comfortably and symmetrically in your

chair you can hold yourself upright with a minimum of muscular effort. As
you have gently drawn your eyelids on the eyes, just begin to relax and be
aware of your breathing. Take a deep breath and let it out making your
breathing slower and deeper. If you feel your attention is wandering, gently
bring it back to focus on your breathing. As you are more relaxed, you
might notice certain pleasant sensations and things that you normally
overlook. You might feel the flow of cool air on your upper lip as you
breathe in and the warm air as you breathe out. You may allow your
attention to follow each in-breath a little bit deeper down each time;
continue to allow this way as you feel deep down inside. Allow yourself to
remain there for a while enjoying the relaxation you have achieved. You
may pause as long as you like and then slowly return.”

3) Deepening

“In a moment you will start counting down backwards from 100.
Fine….. When you pronounce every number you will say “Deeper relaxed
and deeper relaxed.” When you do each counting you double your mental
relaxation. Thus you will be very relaxed as you proceed and the numbers
will escape your mind. You will allow your mind to relax so deeply that the
numbers will just fade away. If you understand what I say, you can just
nod your head. Well done….. Now you can start counting …let the
numbers fade away. Push them out of your mind. Are they gone?… Fine,
go deeper now. (If the subject counts more than ten numbers you can ask
him to stop saying) ‘Well done, that is good enough; stop counting and
relax deeper.’”

4) Trance

“By now you have reached a trance state. It is the deepest level of
hypnosis you have reached. It is so good to feel the way you right now are
feeling. It is marvellously engrossing you in complete and total relaxation
and depth of sleep. You would very much desire to be in this state
because it is so very enchanting to you. It satisfies all your senses and
takes you to deeper realm of consciousness that is beyond your imagining.
Allow yourself to remain here in this state for a while. It is so beneficial to
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experience this marvellous state of the depth of consciousness.”

5) Suggestions

“Looks like you are overwhelmed by the traumatic experience. Now

you have the possibility and freedom to turn down the dial of your own
sensation to a trauma-free level you want so that you feel really
comfortable and relaxed. Your trauma experience is gone and you feel
healthy and whole; even if you want, you do not feel the pain.”

6) Post-Hypnotic Suggestion and Trigger

“When you encounter any component of the trauma experience, it will

automatically turn into a physical comfort.”

Trigger

“Whenever you experience elements of trauma experience you just

say “Gone are the trauma” and you immediately feel a physical relief and
comfort.”

6) Trance Termination

“In a moment, I will count from 1 to 5. At the count of 5 you will open your
eyes feeling fully alert and refreshed. You will realize that you had a long period
of deep, restful sleep, and awaken to your greatest potential. Look back and
check if you need to take any experience to wakeful state. If there is anything you
want to leave behind, you do so. Number 1: You are coming up and emerging
from your deep sleep. Number 2: Your body and mind are fully coordinated into a
harmonious integrity. Number 3: You are experiencing a great self-confidence in
all your abilities. Number 4: You have come almost to the brink of the threshold of
your awareness, taking a deep breath, wiggling your fingers and toes. Number 5:
You open your eyes…Welcome back here, to the here and now, wide awake and
refreshed. You may stretch yourself if you like.”

(2) Pharmacotherapy
A variety of different psychopharmacological agents has been used in the
treatment of PTSD by clinicians and reported in the literature as case reports,
open clinical trials, and controlled studies. Thus, Adrenergic blockers, Tricyclics,
Monoamine oxidase inhibitors, Lithium, Anticonvulsants, Serotonin reuptake
inhibitors and Buspirone are used.

Treatment for acute stress disorder and PTSD should begin immediately
after the trauma. It should access and process the trauma, the expression of
feelings, increased coping with and control over memories (to dilute pain),
reduction of cognitive distortions and self-blame, and restoration of self-concept
and previous level of functioning.69
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4. Reactive Attachment Disorder (RAD)

According to Bowlby, attachment theory is a way of conceptualizing the

propensity of human beings to make strong affectional bonds to particular others
and of explaining the many forms of emotional distress and personality
disturbance, including anxiety, anger, depression, and emotional detachment, to
which unwilling separation and loss give rise. Against this attachment theory,
one needs to understand reactive attachment disorder. Attachment is the
emotional bond that exists between the child and the caregiver. It is essential
for the early attachment bonds. Development of the ability to modulate
emotional arousal and self-soothe is dependent on having had a safe base or
secure attachment with a primary caregiver. This disorder starts before the age
of 5, in which children manifest severe disturbance in social relatedness. If the
children have experienced extremely poor care involving persistent disregard of
their basic emotional or physical needs or disruptions in primary caregivers, then
this pathogenic carer causes disturbance in social functioning.

The inhibited type children are extremely withdrawn, unresponsive, or

hyper vigilant. The disinhibited type children demonstrate no preferential
attachment to any caregiver but instead are excessively social and seek comfort
indiscriminately. The disinhibited type children are found in institutions and
foster homes and they were mostly maltreated.70

1) Diagnostic Criteria

A. A consistent pattern of inhibited, emotionally withdrawn behaviour

towards adult caregivers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.
B. A persistent social and emotional disturbance characterized by at least
two of the following:
1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are
evident even during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as
evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having
basic emotional needs for comfort, stimulation, and affection met by
caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to
form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form
selective attachments (e.g., institutions with high child-to-caregiver
ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed
behaviour in Criterion A (e.g., the disturbances in Criterion A began
following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
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F. The disturbance is evident before age 5 years.

G. The child has a developmental age of at least 9 months.
Specify if: The disorder has been present for more than 12 months.

2) Treatment

Assessing the child's safety is an essential first step that determines whether
future intervention can take place in the family unit or whether the child should
be removed to a safe situation. Interventions may include psychosocial support
services for the family unit (including financial or domestic aid, housing and
social work support), psychotherapeutic interventions (including treating parents
for mental illness, family therapy, individual therapy), education (including
training in basic parenting skills and child development), and monitoring of the
child's safety within the family environment.

In 2005, the American Academy of Child and Adolescent Psychiatry laid down
guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published
parameters for the diagnosis and treatment of RAD. Recommendations in the
guidelines include the following:

(1) The most important intervention for young children diagnosed with
reactive attachment disorder and who lack an attachment to a discriminated
caregiver is for the clinician to advocate for providing the child with an
emotionally available attachment figure. (2) Although the diagnosis of reactive
attachment disorder is based on symptoms displayed by the child, assessing the
caregiver's attitudes toward and perceptions about the child is important for
treatment selection. (3) Children with reactive attachment disorder are
presumed to have grossly disturbed internal models for relating to others. After
ensuring that the child is in a safe and stable placement, effective attachment
treatment must focus on creating positive interactions with caregivers. (4)
Children who meet criteria for reactive attachment disorder and who display
aggressive and oppositional behaviour require adjunctive (additional)
treatments.

Mainstream prevention programmes and treatment approaches for

attachment difficulties or disorders for infants and younger children are based on
attachment theory and concentrate on increasing the responsiveness and
sensitivity of the caregiver, or if that is not possible, placing the child with a
different caregiver. These approaches are mostly in the process of being
evaluated. The programmes invariably include a detailed assessment of the
attachment status or caregiving responses of the adult caregiver as attachment
is a two-way process involving attachment behaviour and caregiver response.
Some of these treatment or prevention programmes are specifically aimed at
foster carers rather than parents, as the attachment behaviours of infants or
children with attachment difficulties often do not elicit appropriate caregiver
responses. Approaches include "Watch, wait and wonder," manipulation of
sensitive responsiveness, modified "Interaction Guidance," "Clinician-Assisted
Video feedback Exposure Sessions (CAVES)," "Preschool Parent
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Psychotherapy," "Circle of Security," "Attachment and Biobehavioural Catch-up"

(ABC), the New Orleans Intervention, and parent–child psychotherapy. Other
treatment methods include Developmental, Individual-difference, and
Relationship-based therapy ([Developmental Individual Difference Relationship]
DIR, also referred to as Floor Time) by Stanley Greenspan, although DIR is
primarily directed to treatment of pervasive developmental disorders.

The relevance of these approaches to intervention with fostered and adopted

children with RAD or older children with significant histories of maltreatment is
unclear.

3) Alternative Treatment

Outside the mainstream programmes is a form of treatment generally

known as attachment therapy, a subset of techniques (and accompanying
diagnosis) for supposed attachment disorders including RAD. In general, these
therapies are aimed at adopted or fostered children with a view to creating
attachment in these children to their new caregivers. The theoretical base is
broadly a combination of regression and catharsis, accompanied by parenting
methods, which emphasize obedience and parental control. There is considerable
criticism of this form of treatment and diagnosis as it is largely invalidated and
has developed outside the scientific mainstream. There is little or no evidence
base and techniques vary from non-coercive therapeutic work to more extreme
forms of physical, confrontational and coercive techniques, of which the best
known are holding therapy, rebirthing, rage-reduction and the Evergreen model.
These forms of the therapy may well involve physical restraint, the deliberate
provocation of rage and anger in the child by physical and verbal means
including deep tissue massage, aversive tickling, enforced eye contact and
verbal confrontation, and being pushed to revisit earlier trauma. Critics maintain
that these therapies are not within the attachment paradigm, are potentially
abusive, and are antithetical to attachment theory. 

The American Professional Society on the Abuse of Children

(APSAC) Taskforce Report of 2006 notes that many of these therapies
concentrate on changing the child rather than the caregiver. Children may be
described as "RADs," "Radkids" or "Radishes" and dire predictions may be made
as to their supposedly violent futures if they are not treated with attachment
therapy. The Mayo Clinic, a well known U.S. non-profit medical practice and
medical research group, cautions against consulting with mental health providers
who promote these types of methods and offer evidence to support their
techniques; to date, this evidence base is not published within reputable medical
or mental health journals.

The goal of treatment is to improve the relationship between the child and
the primary caregiver. One should ensure that the child has a caregiver who is
emotionally available, sensitive, ad responsive, and to whom attachment can
develop. Then the therapist should address those behaviours that interfere with
the development of adequate and secure attachments. Psychoeducation can be
accompanied by parent-child dyad therapy, in which the therapist models
positive interactions and facilitates parent-child play.71
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5. Disinhibited Social Engagement Disorder

1) Diagnostic Criteria

A. A pattern of behaviour in which a child actively approaches and interacts

with unfamiliar adults and exhibits at least two of the following:
1. Reduced or absent reticence in approaching and interacting with
unfamiliar adults.
2. Overly familiar verbal or physical behaviour (that is not consistent
with culturally sanctioned and with age-appropriate social
boundaries).
3. Diminished or absent checking back with adult caregiver after
venturing away, even in unfamiliar settings.
4. Willingness to go off with an unfamiliar adult with minimal or no
hesitation.
B. The behaviours in Criterion A are not limited to impulsivity (as in
attention-deficit/hyperactivity disorder) but include socially disinhibited
behaviour.
C. The child has experienced a pattern of extremes of insufficient care as
evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having
basic emotional needs for comfort, simulation, and affection met by
caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to
form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form
selective attachments (e.g., institutions with high child-to-caregiver
ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed
behaviour in Criterion A (e.g., the disturbances in Criterion A began
following the pathogenic care in Criterion C).
E. The child has a developmental age of at least 9 months.
Specify if: The disorder has been present for more than 12 months.

2) Treatment

An integrative approach to psychotherapy is the most effective way to treat

disinhibited social engagement disorder. The therapy must facilitate multisensory
experiences, communication, social skills, emotional awareness and self-
exploration (Malchiodi & Crenshaw, 2013). Establishing rapport between child
and therapist is typically easy because, according to the DSM-5, overfriendliness
and trust is a key feature of disinhibited social engagement disorder (American
Psychiatric Association, 2013). Establishing a relationship, however, is more
challenging because children with disinhibited social engagement disorder only
develop shallow, superficial attachments. Play therapy and creative arts therapy
are two effective approaches to treating disinhibited social engagement disorder
(Malchiodi & Crenshaw, 2013)
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Because children naturally develop attachments through play, play therapy

offers an opportunity to create attachments that did not occur during early
infancy. In many cases, the primary caregiver is invited to join the play therapy
sessions, so that the new attachment can extend beyond the therapist. Creative
arts therapy is another effective approach to treating disinhibited social
engagement disorder. Creative arts therapy uses painting, drawing, dance,
music, and theatrical activities as a means of carrying out psychotherapy. Like
play therapy, creative arts therapy is interactive and experiential (Malchiodi &
Crenshaw, 2013).

Infants develop healthy attachments to parents and primary caregivers

through their five senses. Being held, fed, and talked to, for example, are
important components of attachment development. These needs do not
disappear with age. Children, teens, and adults experience relationships through
hugging, touching, story-telling, and eating together. Both play therapy and
creative arts therapy provide sensory experiences. Both approaches also
normalize experiences for children with disinhibited social engagement disorder,
because children in all cultures enjoy play and artistic expression. Another
benefit to both play therapy and creative arts therapy is that both approaches
can be done non-verbally. This is important because young children are not
always able to verbally discuss trauma, thoughts, and feelings (Malchiodi &
Crenshaw, 2013).72

6. Adjustment Disorders

A variety of stressors can precipitate an adjustment disorder. Stressors

can be a single event, or multiple events; they can be circumscribed events like
relapse of an illness or continuous circumstances like the death of a spouse.
Adjustment disorder is indicated by the reaction to the stressor, rather than the
presence of the stressor itself. There are six types of adjustment disorders: (1)
adjustment disorder with depressed mood, (2) with anxiety, (3) with mixed
anxiety and depressed mood, (4) with disturbance of conduct, (5) with mixed
disturbance of emotions and conduct, or (6) unspecified. The rate of suicide
among persons with adjustment disorder is similar to that for depression,
schizophrenia and other more chronic disorders. Persons who have not learned
to regulate their emotions or who do not have supportive families or other
outlets for their stress, often turn to alcohol or drugs, acting out behaviours, or
self-harm. If symptoms persist beyond 6 months, the diagnosis must be
changed.73

1) Diagnostic Criteria

A. The development of emotional or behavioural symptoms in response to

an identifiable stressor(s) occurring within 3 months of the onset of the
stressor(s).
B. These symptoms or behaviours are clinically significant, as evidenced by
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one or both of the following:

1. Marked distress that is out of proportion to the severity or intensity of
the stressor, taking into account the external context and the cultural
factors that might influence symptom severity and presentation.
2. Significant impairment in social, occupational, or other important
areas of functioning.
C. The stress-related disturbance does not meet the criteria for another
mental disorder and is not merely an exacerbation of a preexisting
mental disorder.
D. The symptoms do not represent normal bereavement.
E. Once the stressor or its consequences have terminated, the symptoms do
not persist for more than an additional 6 months.

2) Treatment

(1) Psychosocial Treatment

Most adjustment disorders improve spontaneously without even treatment

if the stressors are removed, or accommodated, but therapy can facilitate
recovery. Clients can be helped by problem-solving techniques to reduce or
remove the stressor; to provide psychoeducation to help him cognitively reframe
when the stressor cannot be removed; or to alter response to the stressor
through the use of relaxation and mindfulness-based techniques. A flexible
crisis-intervention model of therapy focuses both on relieving the acute
symptoms and on promoting his adaptation to and ability to cope with the
stressors.

Crisis Intervention Therapy

Crisis intervention therapy follows five typical steps: (1) Clarifying and
promoting understanding of the problem, (2) Identifying and reinforcing the
client’s strength and coping skills and teaching new coping skills if needed, (3)
Collaborating with the client to develop a plan of action that will mobilize and
empower the client, (4) Providing information and support to promote
affective, cognitive, and behavioural improvement in the client, and (5)
Terminating treatment, making appropriate referrals, and following up.

Stress Inoculation Training (SIT)

Stress inoculation training (SIT), which is a form of cognitive-behavioural

approach proposes three overlapping phases: 1) Conceptualization:
developing a warm, collaborative relationship through which the problem can be
assessed and reconceptualised, 2) Skills acquisition and rehearsal:
developing coping strategies like relaxation, communication skills, and decision
making, and 3) Application and follow-through: applying coping strategies to
current problems and taking steps to prevent relapse. Recently along with stress
inoculation training, gradual exposure to increasing stress as a method to
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enhance the person’s problem-solving capacity in relation to the work

environment is found successful.

Psychodynamic Therapy

One can also use brief psychodynamic psychotherapy that is supportive,

active, flexible, and goal-directed, working in a time-limited context.

Solution Focused Therapy

There is another method called solution-focused therapy as developed by

Shazer (1991) that emphasizes health, positive reframing, and rapid resolution
of problems. He used to ask the clients a miracle question that if by a miracle
your problem is solved overnight by a therapy, how will you know that and in
what way you will be different. This question will assist people focus on goals
that are likely to lead to the resolution of the precipitants of the problem and to
improvement in coping and feelings of empowerments.

Dialectical Behaviour Therapy

Dialectical Behaviour Therapy that teaches clients how to regulate the

stress and the emotional distress that result from significant life changes is
another option. By this method, clients become more mindful of their feelings,
able to express both positive and negative emotions in an appropriate manner,
and tolerate their emotions. The therapist can help clients proactively work
through their anger.

Acute Stress Reaction

The treatment consists of removal of the patient from the stressful

environment and helping the patient to “pass through” the stressful experience.

(2) Supportive Psychotherapy

Psychotherapy is the treatment of choice for any adjustment disorder, since

the disorder is seen as usually a quite normal reaction to a specific situational
event. The form and type of psychotherapy will vary upon the clinician, but as
with all psychotherapy, it should occur within a supportive, non-judgmental
environment that encourages the client's growth through exploration of new
behaviours and ideas. This therapy often takes the form of solution-focused to
help the individual deal more effectively with the specific life problem. Often the
therapist acts as a partner in therapy, helping guide the client toward finding
these new coping mechanisms, or finding a better understanding of issues in
their lives. Crisis intervention is useful in some patients, by helping to quickly
resolve the stressful life situation, which has led to the onset of adjustment
disorder.

Adjustment disorder, by definition, is a short-term difficulty that rarely goes

beyond 6 months. Lingering feelings may occur beyond that time, but those are
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natural and likely not to be severe enough to require additional attention or

treatment. It often helps treatment progress (and is required in many agencies)
to put together a firm but realistic treatment plan, so the patient can also see
the short-term nature of the therapy.

The exact content and type of therapy used will vary widely. Treatment will
often emphasize the importance of social support within the client's life,
alternative activities to explore or to find meaning in, increasing a person's
range and effectiveness of coping skills, learning better ways of dealing with
stress, and the like. If stress is an issue, therapy may also offer relaxation
training and techniques and examine methods for reducing stress.

Family therapy may be appropriate for certain individuals, especially if the

presenting person is an adolescent. This type of therapy also is appropriate
when the family is "scapegoating" a particular family member, or there is a clear
"identified patient," when the actual problem is family-systems related.
Education related to the disorder is sometimes needed, and the family can be
reassured as to the nature and seriousness of the disorder, as well as its
prognosis. Couples therapy is appropriate when the disorder is additionally
negatively affecting the romantic relationship.

It is imperative that a thorough initial evaluation be conducted to ensure

that the individual is suffering from only an adjustment disorder and not a more
serious mental disorder. This evaluation should also be used to determine the
best modality of treatment to ensure timely treatment effectiveness.

Basic Principles

Adjustment Disorder (by definition) lasts less than 6 months, thus supportive
psychotherapy is usually all that is necessary. This supportive psychotherapy
should emphasize that full recovery usually occurs within a few months, and that
this natural recovery is hastened by a psychotherapy, which focuses on stress-
reduction. Thus, the problem triggering the Adjustment Disorder should be
clarified, and alternative solutions explored. Finally, some plan for stress-
reduction should be agreed upon. It is important that the therapist not dictate
what changes the patient must make.Brief environmental change may be
helpful; however, simplistic advice such as "take a few days of vacation" is
usually insufficient.

For the Anxious and Depressed Patient

Psychotherapy should fight against the patient's attempts to withdraw and

"just give up.” The patient should be encouraged, perhaps by "prescription," to
increase contact with others. Likewise, the family should adopt a kind but firm
pressure aimed at overcoming the patient's desire to withdraw and "give up.”

Other, more serious mental disorders are frequently misdiagnosed as

"Adjustment Disorders.” Thus, if long-term therapy is needed, the patient
probably has something else (e.g., Major Depressive Disorder, or Generalized
Anxiety Disorder).
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For the Irresponsible or Aggressive Patient

If the patient's socially unacceptable behaviour has caused trouble with the
law, authorities, or school, the therapist should caution the family against
"rescuing" the patient from the consequences of this behaviour. Too often, such
"rescuing" only reinforces the patient's socially unacceptable behaviour and
prevents any subsequent emotional growth.

For the Adolescent Patient

The therapy of an adolescent with an Adjustment Disorder should usually

involve the family. Adolescents in conflict are actively asking for help, although
their pleas may be misunderstood because of their aggressive behaviour.

(3) Individual Psychotherapy

Formal psychotherapy is seldom necessary in the isolated stress response or

Adjustment Disorder. Supportive psychotherapy, with an emphasis on the here
and now, is usually sufficient. Usually all that is required is crisis intervention,
brief counselling, and education.

(4) Family Therapy

While much of treatment usually is individual psychotherapy, family members

can benefit from a family session after the start of individual psychotherapy.
During the family session, the therapist should reassure the family that the
Adjustment Disorder usually is short-lived and should respond to their
understanding and support.

(5) Behaviour Therapy

Behaviour therapy usually focuses on having the patient to keep a daily log of
what triggers the stress, how the patient responds to the stress, and what helps
reduce the stress. Techniques for general tension reduction are also helpful in
reducing the reaction to stressful events.

(6) Group Therapy

Many patients with Adjustment Disorder (e.g., following a diagnosis of cancer

or AIDS, or breakup of a relationship) often benefit from attending support
groups with others who have also experienced the same stressor. Within the
group, members exchange advice, share coping strategies, and provide support
and encouragement. Some support groups also provide new social networks to
replace those lost through events such as death or divorce.

(7) Self-Help

Self-help methods for the treatment of this disorder are often overlooked by
the medical profession because very few professionals are involved in them.
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Often people with this disorder will gain the most help from attending a group
related to their specific problem. This could be anything, ranging from someone
who just got divorced, to someone who was just diagnosed with cancer, to
dealing with job loss, and the like. One can join a support group. This allows for
the sharing of information and experiences which can be vital in the road to
recovery. Social support is also a vital component of a self-help group and
increased social support. It usually leads to better and quicker recovery.

As an adjunct to regular psychotherapy, people can also be encouraged to

use a support group to try out new coping skills and express their feelings to
others who have gone through similar experiences. This is usually very
rewarding and helpful.

3) Medications

Medications are generally not appropriate for an adjustment

disorder, unless it is complicated by another mental disorder diagnosis.
Physicians should be especially careful of over-prescribing medications for
diagnosis of anxiety or depression, unless the individual better meets the criteria
for those diagnoses.74

7. Conclusion

Trauma is a type of damage to the psyche that occurs because of a

severely distressing event. Trauma is often the result of an overwhelming
amount of stress that exceeds one’s ability to cope or integrate the emotions
involved with that experience. A traumatic event can involve one experience or
repeated events or experiences over time.

Traumatizing, stressful events can have a long-term impact on mental and

physical health. Situations where an individual is exposed to a severely stressful
experience involving threat of death, injury, or sexual violence can result in the
development of post-traumatic stress disorder (PTSD). With this disorder, the
trauma experienced is severe enough to cause stress responses for months or
even years after the initial incident. The trauma overwhelms the victim’s ability
to cope psychologically, and memories of the event trigger anxiety and physical
stress responses, including the release of cortisol. People with PTSD may
experience flashbacks, panic attacks and anxiety, and hypervigilance (extreme
attunement to stimuli that remind them of the initial incident).

A number of psychotherapies have demonstrated usefulness in the

treatment of PTSD and other trauma-related problems. Basic counselling
practices common to many treatment responses for PTSD include education
about the condition and provision of safety and support. The psychotherapy
programmes with the strongest demonstrated efficacy include cognitive
behavioural therapy (CBT), variants of exposure therapy, stress inoculation
training (SIT), variants of cognitive therapy (CT), eye movement desensitization
and reprocessing (EMDR), visual and kinaesthetic dissociation (VKD), and many
combinations of these procedures.
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9. DISSOCIATIVE DISORDERS

1. Introduction

Dissociative disorders are characterized by a disruption of and/or

discontinuity in the normal integration of consciousness, memory, identity,
emotion, perception, body representation, motor control, and behaviour.
Dissociative symptoms can potentially disrupt every area of psychological
functioning.

Dissociative symptoms are experienced as (1) unbidden intrusions into

awareness and behaviour, with accompanying losses of continuity in subjective
experience (i.e., “positive” dissociative symptoms such as fragmentation of
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identity, depersonalization, and derealisation) and/or (2) inability to access

information or to control mental functions that normally are readily amenable to
access or control (i.e., “negative” dissociative symptoms such as amnesia).

The dissociative disorders are frequently found in the aftermath of trauma,

and many of the symptoms, including embarrassment and confusion about the
symptoms or a desire to hide them, are influenced by the proximity to trauma.

2. Dissociative Identity Disorder (DID)

1) Diagnostic Criteria

A. Disruption of identity characterized by two or more distinct personality

states, which may be described in some cultures as an experience of
possession. The disruption in identity involves marked discontinuity in
sense of self and sense of agency, accompanied by related alterations in
affect, behaviour, consciousness, memory, perception, cognition, and/or
sensory-motor functioning. These signs and symptoms may be observed
by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal
information, and/or traumatic events that are inconsistent with ordinary
forgetting.
C. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or
religious practice.
Note: In children, the symptoms are not better explained by imaginary
playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a
substance (e.g., blackouts or chaotic behaviour during alcohol
intoxication) or another medical condition (e.g., complex partial
seizures).

2) Treatment

While there is no "cure" for dissociative identity disorder, long-term

treatment can be helpful, if the patient stays committed. Effective treatment
includes talk therapy or psychotherapy, hypnotherapy, and adjunctive therapies
such as art or movement therapy. There are no established medication
treatments for dissociative identity disorder, making psychologically-
based approaches the mainstay of therapy.

(1) Psychotherapy

a. Therapeutic Direction (Integration of Disparate Elements)

The fundamental psychotherapeutic stance should involve meeting patients

halfway in the sense of acknowledging that they experience themselves as
fragmented, yet the reality is that the fundamental problem is a failure of
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integration of disparate memories and aspects of the self. Therefore, the goal in
therapy is to facilitate integration of disparate elements. This can be achieved in
a variety of ways.

Secrets are frequently a problem with the patients who attempt to use the
therapist to reinforce a dissociative strategy that withholds relevant information
from certain personality states. Such patients often like to confide plans or
stories to the therapist with the idea that the information is to be kept from the
other parts of the self. It is wise to clarify explicitly that the therapist will not
become involved in secret collusion. For example, if a patient’s new alter wants
to arrange for an apparently accidental death, the therapist should inform the
patient that he has to share this information with the other personalities.

b. Hypnosis

First, the simple structure of hypnotic induction may elicit dissociative

phenomena. The capacity to elicit such symptoms on command provides the first
hint of the ability to control these symptoms. Most of these patients have the
experience of being unable to stop dissociative symptoms but are often intrigued
by the possibility of starting them. This carries with it the potential for changing
or stopping the symptoms as well.

Hypnosis can be helpful in facilitating access to dissociated personalities. The

personalities simply occur spontaneously during hypnotic induction. An
alternative strategy is to hypnotize the patient and use age regression to help
the patient reorient to a time when a different personality state was manifest. An
instruction later to change times back to the present tense usually elicits a
return to the other personality state. This then becomes an alternative means of
teaching the patient control over the dissociation.

Alternatively, entering the state of hypnosis may make it possible to simply

“call up” different identities or personality states. Patients can be taught a simple
self-hypnosis exercise. The patient can be taught to count to himself from one to
three: On 1, do one thing; look up. On 2, do two things: slowly close your eyes
and take a deep breath. On 3, do three things: let the breath out, let your eyes
relax but keep them closed, and let your body float. Then let one hand float up
in the air like a balloon. Develop a pleasant sense of floating throughout your
body. After some formal exercises such as this, it is often possible to simply ask
to speak with a given alter personality, without the formal use of hypnosis.
Merely asking to talk with a given identity usually suffices after a while.
c. Memory Retrieval

The therapy becomes an integrating experience of information sharing among

disparate personality elements. In conceptualising DID as a chronic PTSD, the
psychotherapeutic strategy involves a focus on working through traumatic
memories in addition to controlling the dissociation. Controlled access to
memories greatly facilitates psychotherapy. As in the treatment of patients with
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dissociative amnesia, a variety of strategies can be employed here too to break

down amnestic barriers. Using hypnosis to go to that place in imagination and
asking one or more such parts of the self to interact can be helpful. Once these
memories of earlier traumatic experience have been brought into consciousness,
it is crucial to help the patient work through the painful affect, inappropriate self-
blame, and other reactions to these memories. It may be useful to have the
patient visualize the memories rather than relive them as a way of making their
intensity more manageable. It also can be useful to have the patient divide the
memories onto two sides of an imaginary screen; as for example, picturing on
one side what the abuser did, and on the other side, how the patient tried to
protect himself from the abuser.

These approaches help the individuals work through traumatic memories,

enabling them to debar the memories from consciousness and therefore
reducing the need for dissociation as a means of keeping such memories out of
the consciousness. The information retrieved from memory in these ways should
be reviewed, traumatic memories put into perspective, and emotional expression
encouraged and worked through, with the goal of sharing the information as
widely as possible among the various parts of the patient’s personality structure.
Instructions to other alter personalities to “listen” while a given alter is talking,
and reviewing previously dissociated material uncovered, can be helpful. The
therapist conveys his desire to disseminate the information.

d. The ‘Rule of Thirds’

The rule of thirds involves that the therapist spends the first third of the
psychotherapy session assessing the patient’s current mental state and life
problems and defining a problem area that might benefit from retrievals into
conscious memory and working through; spends the second third of the
session assessing and working through this memory; and finally allows the third
period for helping the patient assimilate the information, regulate and modulate
emotional responses, and discuss any responses to the therapist and plans for
the immediate future. It is good to use this final third period of the session for
debriefing and helping the patient to reorient, to attempt to integrate the new
material, to transmit information across personalities, and to prepare to
terminate the session. There may be resistance on the part of the patient to
sharing of information across personalities. Appropriate limits must be made
about self-destructive or threatening behaviour, and agreements made
regarding physical safety and treatment compliance. Other matters must be
presented to the patient in such a way that dissociative ignorance is not an
acceptable explanation for failure to live up to the agreements.

e. Traumatic Transference

Here we speak about patients who have been physically and sexually abused.
Their presumed caretakers have acted in an exploitative and sometimes sadistic
fashion. The patients may expect the same from the therapist. It is good to keep
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these issues in mind and make them frequent topics of discussion. Attention to
these issues can diffuse, but not eliminate, such traumatic transference
distortions of the therapeutic relationship.

f. Integration

The ultimate goal of psychotherapy is integration of the disparate states.

There can be considerable resistance from the part of the client to this attempt.
Early in therapy, the patient views the dissociation as tremendous protection.
The patient may experience efforts of integration as an attempt on the part of
the therapist to destroy the personalities. These fears must be worked through
and the patient shown how to control the degree of integration, giving the
patient a sense of gradually being able to control his dissociative processes in
the service of working through traumatic memories. The goal of
psychotherapy is mastery over the dissociative process, controlled
access to dissociative states, integration of warded-off painful memories
and material, and a more integrated continuum of identity, memory, and
consciousness.

(2) Psychopharmacology

There is not enough evidence to indicate that medication of any type has a
direct therapeutic effect on the dissociative process manifested by DID patients.
Actually, most dissociative symptoms seem relatively resistant to
pharmacological intervention. Therefore, pharmacological treatment has been
limited to the control of signs and symptoms affecting DID patients or comorbid
conditions rather than the treatment of dissociation per se.

Though benzodiazepines have been employed to facilitate recall through

controlling secondary anxiety associated with retrieval of traumatic memories,
the result is not encouraging. In fact, sudden mental state transitions induced by
medications may increase rather than decrease amnesic barriers. Thus, inducing
state changes pharmacologically could in theory add to difficulty in retrieval.
Antidepressants are the most useful class of psychotropic agents for patients
with DID. Such patients frequently have dysthymic disorder or major depression
as well, and when these disorders are present, especially with somatic signs and
suicidal ideation, antidepressant medication can be helpful. However, its use
should be limited to the treatment of DID patients who experience symptoms of
major depression.
The newer selective serotonin reuptake inhibitors (SSRIs) are effective at
reducing comorbid depressive symptoms and have the advantage of far less
lethality in overdose compared with tricyclics and monoamine oxidase inhibitors
(MAOIs). Antipsychotics are rarely useful in reducing dissociative symptoms.
Anticonvulsants have been used to treat seizure disorders, which have a high
rate of comorbidity with DID, comorbid mood disorder, and the impulsiveness
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associated with personality disorders. These agents are rarely definitively helpful
and they do have high incidence of serious side effects. 75
3. Dissociative Amnesia

1) Diagnostic Criteria

A. An inability to recall important autobiographical information, usually of a

traumatic or stressful nature, that is inconsistent with ordinary
forgetting.
Note: Dissociative amnesia most often consists of localized or selective
amnesia for a specific event or events; or generalized amnesia for
identity and life history.
B. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a
substance (e.g., alcohol or other drug of abuse, a medication) or a
neurological or other medical condition (e.g., partial complex seizures,
transient global amnesia, sequelae of a closed head injury/traumatic
brain injury, other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder,
posttraumatic stress disorder, acute stress disorder, somatic symptom
disorder, or major or mild neurocognitive disorder.

2) Treatment

The first goal of treatment is to relieve the symptoms and control any
problem behaviour. Treatment then aims to help the person safely express and
process his painful memories, develop new coping and life skills, restore
functioning, and improve relationships. The best treatment approach depends on
the individual and the severity of his symptoms. Treatments may include the
following:

(1) Psychotherapy

The psychotherapy of dissociative amnesia involves assessing the dissociated

memories, working through affectively loaded aspects of these memories, and
supporting the patient through the process of integrating these memories into
consciousness.

This kind of therapy for mental and emotional disorders uses psychological
techniques designed to encourage communication of conflicts and increase the
insight into problems.

a. Clinical Hypnosis

This is a treatment method that uses intense relaxation, concentration, and

focused attention to achieve an altered state of consciousness (awareness),
allowing people to explore thoughts, feelings, and memories they may have
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hidden from their conscious minds. The use of hypnosis for fixing dissociative
disorders is controversial due to the risk of creating false memories.

Most patients are highly hypnotizable on formal testing and therefore are
easily able to make use of hypnosis — such as age regression. Patients are
hypnotized and instructed to experience a time before the onset of the amnesia
as though it were the present. Then the patients are reoriented in hypnosis to
experience events during the amnesic time. Hypnosis can enable such patients
to reorient temporarily and therefore to achieve access to otherwise dissociated
memories. If there is traumatic content to the warded-off memory, patients may
abreact (i.e., express strong emotion) as these memories are elicited, and they
will need psychotherapeutic help in integrating these memories and the
associated affect into consciousness.

b. Screen Technique

There is something called “screen technique” by which such memories can

be brought into consciousness while modulating the affective response to them.
In this approach, patients are taught, by using hypnosis, to relive the traumatic
event as if they were watching it on an imaginary movie or television screen.
This technique is often helpful for individuals who are unable to relive the event
as if it were occurring in the present tense, either because that process is too
emotionally taxing or because they are not sufficiently hypnotizable to be able to
engage in hypnotic age regression. This technique also helps dissociate between
the psychological and somatic aspects of the memory retrieval. Patients can be
put into self-hypnosis and instructed to get their bodies into a state of floating
comfort and safety. They are reminded that no matter what they see on the
screen their bodies will be safe and comfortable.

c. Cognitive Therapy

Cognitive therapy focuses on changing the dysfunctional thinking patterns

and the resulting feelings and behaviours.

d. Family Therapy

Family therapy helps to teach the family about the disorder and its causes, as
well as to help family members recognize symptoms of a recurrence.

e. Creative Therapies (art therapy, music therapy)

Creative therapies allow the patient to explore and express his thoughts and
feelings in a safe and creative way.

(2) Medication
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There are no established pharmacological treatments except for the use of

benzodiazepines or barbiturates for drug-assisted interviews. Most cases of
dissociative amnesia revert spontaneously, especially when the individuals are
removed from their stressful or threatening situations, when they feel physically
and psychologically safe, and/or when they are exposed to cues from the past
(i.e., family members).

There is no medication to treat the dissociative disorders themselves.

However, a person with a dissociative disorder who also suffers from depression
or anxiety might benefit from treatment with an antidepressant or anti-anxiety
medicine.76

4. Depersonalization/Derealisation Disorder

1) Diagnostic Criteria

A. The presence of persistent or recurrent experiences of depersonalization,

derealisation, or both:
1. Depersonalization: Experiences of unreality, detachment, or being an
outside observer with respect to one’s thoughts, feelings, sensations,
body, or actions (e.g., perceptual alterations, distorted sense of time,
unreal or absent self, emotional and/or physical numbing).
2. Derealisation: Experiences of unreality or detachment with respect to
surroundings (e.g., individuals or objects are experienced as unreal,
dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealisation experiences, reality testing
remains intact.
C. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, medication) or another medical
condition (e.g., seizures).
E. The disturbance is not better explained by another mental disorder, such
as schizophrenia, panic disorder, major depressive disorder, acute stress
disorder, posttraumatic stress disorder, or another dissociative disorder.

2) Treatment

The treatment is usually not very successful though comorbid symptoms of

anxiety and depression can often be treated. The various methods, which can be
tried, include (1) Supportive psychotherapy. (2) Drug therapy with
antidepressants; rarely anti-psychotics may also be tried.

Depersonalisation is most often transient and may remit without formal

treatment. Recurrent or persistent depersonalisation should be thought of both
as a symptom in and of itself and as a component of other syndromes requiring
treatment, such as anxiety disorders and schizophrenia.
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The symptom itself may respond to self-hypnosis training. Often, hypnotic

induction will induce transient depersonalisation symptoms in patients. This is a
useful exercise because by having a structure for inducing the symptoms, one
provides patients with a context and confidence for understanding and
controlling them. The symptoms are presented as a spontaneous form of
hypnotic dissociation that can be modified. Individuals for whom this approach is
effective can be taught to induce a pleasant sense of floating lightness or
heaviness in place of the anxiety-related somatic detachment. Often, the use of
an imaginary screen to picture problems in a way that detaches them from the
typical somatic response is also helpful.

Other treatment modalities employed include behavioural techniques, such as

a paradoxical intention, record keeping, and positive reward; flooding;
psychotherapy, especially psychodynamic; and psychoeducation. It is also
suggested that one could use psychotropic medications, including
psychostimulants, antidepressants, antipsychotics, anticonvulsants, and
benzodiazepnes. Some have suggested electroconvulsive therapy. 77

5. Dissociative Fugue Disorder

The dissociative fugue is, essentially, the active state of amnesia

wherein a person is doing things he will later forget. A person in a
dissociative fugue will suddenly, and uncharacteristically, travel from home or
work with a purpose in mind but without memory of some or of all of one's
past. The definition of a dissociative fugue indicates the person is not
confused or dazed, but rather he or she seems to be running away from
something from which they are not aware. Another symptom of a dissociative
fugue is confusion over one's identity or, possibly, even taking on a new
identity. A person in a dissociative fugue may be violent and homicidal but is
not generally suicidal.

1) Treatment

Hypnosis can be helpful in accessing otherwise unavailable components of

memory and identity. The approach used is similar to that for dissociative
amnesia. Hypnotic age regression can be used as the framework for assessing
information available at a previous time. Demonstrating to patients that such
information can be made available to consciousness enhances their sense of
control over the material and facilitates the therapeutic working through of
emotionally laden aspects of it.

Once reorientation is established and the overt aspects of the fugue have
been resolved, it is important to work through interpersonal or intrapsychic
issues that underlie the dissociative defences. Patients are often relatively
unaware of their reactions to stress because they so effectively can dissociate
them. Thus, effective psychotherapy is also anticipatory, helping patients to
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recognize and modify their tendencies to set aside their own feelings in favour of
those of others.

Patients may be helped with a psychotherapeutic approach that facilitates

conscious integration of dissociated memories and motivations for behaviour
previously experienced as automatic and unwilled. It is good to address current
psychosocial stressors. To the extent that current psychosocial stress triggers
fugue, resolutions of that stress can help resolve the fugue state and reduce the
likelihood of recurrence. Highly hypnotizable individuals are prone to these
extreme dissociative symptoms. Psychotherapy can be effective in helping
such individuals recognize and modify their tendency toward unthinking
compliance with others and toward extreme sensitivity to rejection and
disapproval.78

6. Dissociative Trance Disorder

This condition is characterized by an acute narrowing or complete loss

of awareness of immediate surroundings that manifests as profound
unresponsiveness or insensitivity to environmental stimuli. The
unresponsiveness may be accompanied by stereotyped behaviours (e.g.,
finger movements) of which the individual is unaware and/or that he cannot
control, as well as transient paralysis or loss of consciousness. The
dissociative trance is not a normal part of a broadly accepted collective
cultural or religious practice.

1) Treatment

The dissociative disorders constitute a challenging component of psychiatric

illness. The failure of integration of memory, identity, perception, and
consciousness seen in these disorders results in symptomatology that illustrates
fundamental problems in the organization of mental processes. Dissociative
phenomena often occur during and after physical trauma but also may represent
transient or chronic defensive patterns. Dissociative disorders are generally
treatable and constitute a domain in which psychotherapy is a primary modality,
although pharmacological treatment of comorbid conditions such as depression
can be quite helpful. The dissociative disorders are ubiquitous around the world,
although they take a variety of forms. They represent a fascinating window into
the processing of identity, memory, perception, and consciousness, and they
pose a variety of diagnostic, therapeutic, and research challenges.
Treatment varies from culture to culture. Most syndromes occur within the
context of acute social stress and thus serve the purpose of recruiting help from
the family and other support systems or removing the subject from the
immediate danger or threat. Ceremonies to remove or appease the invading
spirit are commonly used. The role of psychiatry should be focused on ruling out
any possible organic cause for the symptoms displayed, treating comorbid
psychiatric conditions (if any are present), avoiding excess medication,
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understanding the social context and role of the syndrome, and facilitating a
favourable outcome.79

7. Treatments and Drugs for Dissociative Disorders

The effectiveness of treatments for dissociative disorders has not been

studied. Treatment options are based on case studies, not research. Treatment
may take many years. Options may include:
A safe environment — doctors will try to get the person to feel safe and
relaxed, which is enough to trigger memory recall in some people with
dissociative disorders. Psychiatric drugs — such as barbiturates. Hypnosis —
may help to recover repressed memories, although this form of treatment for
dissociative disorders is considered controversial. Psychotherapy — also known
as “talk therapy” or counselling, which is usually needed for the long term.
Examples include cognitive therapy and psychoanalysis. Stress management
— since stress can trigger symptoms. Treatment for other disorders —
typically, a person with a dissociative disorder may have other mental health
problems such as depression or anxiety. Treatment may include antidepressants
or anti-anxiety medications to try to improve the symptoms of the dissociative
disorder.

1) Psychotherapy

Psychotherapy is the primary treatment for dissociative disorders. This form

of therapy, also known as talk therapy, counselling or psychosocial therapy,
involves talking about one’s disorder and related issues with a mental health
provider. The therapist will work to help one understand the cause of one’s
condition and to form new ways of coping with stressful circumstances. Over
time, one’s therapist may help one talk more about the trauma one experienced,
but generally only when one has the coping skills and relationship with one’s
therapist to safely have these conversations.

Children who are physically, emotionally, or sexually abused are at increased

risk of developing mental health disorders, such as dissociative disorders. If
stress or other personal issues are affecting the way one treats one’s child, it is
good to seek help. If one’s child has been abused or has experienced another
traumatic event, it is recommended that one see a doctor immediately. The
doctor can refer one to mental health providers who can help the child recover
and adopt healthy coping skills.

It is good to talk to a trusted person such as a friend, the doctor, or a

leader in one’s faith community. Asking for help and locating resources such as
parenting support groups and family therapists are useful. Many charitable
institutions and community education programmes offer parenting classes that
also may help one learn a healthier parenting style.

Psychotherapy is the treatment of choice for individuals suffering

from any type of dissociative disorder. Approaches vary widely, but
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generally take an individual modality (as opposed to family, group or couples

therapy) and emphasize the integration of the various personality states into
one, cohesive whole personality.

It should be noted that while it is convenient to talk of people who suffer

from this disorder as having "multiple personalities," this is just a theoretical
construct. People who suffer from this disorder believe they have multiple
personalities, which then take on a life of their own within the individual
(perhaps reinforced by the belief). The term DID for this disorder in the DSM
more accurately reflects the problem the individual suffers from dissociative
identities. Their personality is the sum of these identities, which have been split
off at some point in the past. The split is usually due to some individual or
multiple traumatic events.

(1) Self-Help

In a growing trend, people with this disorder are starting to come together to
form mutual self-help support groups within larger communities and virtually,
through online communities. There are no overt reasons why a support group for
this disorder would not be beneficial to individuals.

Patients who are survivors of extensive childhood abuse frequently present

complicated clinical dilemmas. Dissociative episodes, flashbacks, and self-
destructive and suicidal impulses are common difficulties encountered by such
patients. Once the diagnosis of abuse has been made, the initial task of therapy
is to detoxify the patient's environment by stopping all forms of abuse.
Treatment must be geared toward trust issues, toleration of affect with the
patient's understanding of himself, and enabling the patient to function as
effectively as possible.

(2) Encouraging Healthy Coping Behaviours

The primary focus is to help patients learn to control and contain their
symptoms. Patients must learn to deal with dissociation, flashbacks, and intense
affects (feelings) such as rage, terror, and despair. Embarking on a treatment
plan can be dangerous if the patient has not developed ways to tolerate the
emotional turmoil that arises when uncovering traumatic memories. Until the
patient can learn healthy alternatives to tolerate feelings and control behaviours,
he cannot adequately or safely undertake the exploratory work involved in
uncovering and processing the memories of abuse.

Control is a major issue for survivors of abuse, and by learning new ways to
control and contain their symptoms, patients no longer view themselves as
victims of the past. The emphasis is to have patients reconnect with their sense
of power. Encouraging patients to design and choose which technique to use and
when to use it contributes to their sense of being in charge of themselves;
patients can begin to deal correctly with feelings of helplessness.

(3) Logging and Monitoring Emotions

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Many patients who experience loss of time through dissociation or flashbacks

describe the events as being abruptly triggered. These symptoms sometimes
become so severe that patients can no longer function in their usual way.

One way to help patients begin to work with their sense of unpredictability is
to have them keep a log of their emotions. The patients must first identify
emotions. Once they have developed the ability to identify feelings, they can
monitor the intensity of each feeling. Patients usually report a cluster of
recurrent emotions such as anxiety, sadness, or rage. Quite frequently, these
symptoms precede dissociation, flashbacks, self-destructive impulses, and
suicidal impulses. Patients should be coached on how to intervene long before
anxiety rises to a critical level.

(4) Developing a Crisis Plan

Identifying the cause of the anxiety is also important. Teaching patients to

develop a list that ranges from simple to complex activities is helpful. Once
patients become engaged in the activities, the intensity of emotions usually
decreases. In addition, patients feel more in control. This reconnects them to
personal strengths and the choices that can be exercised. Most patients require
time to learn new and effective coping skills. It is good to emphasize that
patients must practise new skills and techniques until they develop a sense of
mastery.

If the difficulties experienced by patients with histories of abuse are directly

related to the abuse experiences, definitive treatment cannot seemingly be
successful without acknowledgment of these experiences. Clinicians treating
such patients may collude with them in their beliefs about themselves if unaware
of the existence of the traumatic aetiologies of the current disturbance.

(5) Behaviour Therapy

Since the patients with dissociative disorders can be attention-seeking and
their symptoms increase with focus of attention, the symptoms should not be
unduly focused on. These patients should be treated as normal, and not
encouraged to stay in a sick-role. Any improvement in symptomatology should
be actively encouraged. Since these patients are also very suggestible, they
respond quickly to the above-stated methods, with a consistently firm but
empathic attitude. When there is a sudden, acute symptom, its prompt removal
may prevent habituation and future disability. This may be achieved by one of
the following methods: (1) Strong suggestion for a return to normalcy, (2)
Aversion therapy (liquor ammonia, aversive electric stimulus, pressure just
above eyeballs or tragus of ear, closing the nose and mouth) are occasionally
employed carefully in resistant cases.
However, the use of aversion therapy has been decried as it: (1) Tends to
get over-used, (2) May harm the patient, (3) Violates the basic human rights of
the patient, and (4) Can lend a wrong mental picture of the patient in the
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physician’s mind, i.e., of a “manipulator’” needing punishment! The current

status is that aversion therapy is not a preferred treatment choice.
(6) Amplification of Suggestion with hypnosis, free-association, intravenous
amytal or thiopentone, or intravenous diazepam.
(7) Abreaction
Abreaction is bringing to the conscious awareness, thoughts, affects and
memories for the first time. This may be achieved by: (1) hypnosis, (2) free
association, (3) Intravenous thiopentone or diazepam: the aim of abreaction
with thiopentone is, both, to make the conflicts conscious and to make the
patient more suggestible to therapist’s advice. Once the conflicts have become
conscious and their affects (emotions) have been released, the conversion or
dissociative symptom disappears.
(8) Supportive Psychotherapy
Supportive psychotherapy is needed especially when the conflicts (and the
current problems) have become conscious and have to be faced in routine life. It
is an important adjunct to treatment.
(9) Psychoanalysis
This mode of treatment is chosen not on the basis of conversion/dissociative
symptoms but on the total personality structure of the patient. Several patients
respond remarkably well. The total length of therapy in classical psychoanalysis
is usually five years or more.

2) Medications

Although there are no medications that specifically treat dissociative

disorders, one’s doctor may prescribe antidepressants, anti-anxiety medications
or antipsychotic medications to help control the mental health symptoms
associated with dissociative disorders. The use of medication, except for the
treatment of acute, specific concurrent mental disorders, is not recommended.
Maintenance and effective use of prescriptions (given the multiple personality
states) is difficult to attain. If medication is prescribed, it should be carefully
monitored.

8. Conclusion

Dissociative disorders are a range of conditions that involve the

involuntary separation of feelings, thoughts, and awareness from the dominant
state of consciousness. These can be seen as an adaptive response to trauma,
which is highly effective in protecting one’s psychological integrity at the time
but which thereafter can become an embedded and problematic structure of the
mind, which can be very disruptive.

It requires psychotherapy, which demands a high level of theoretical

knowledge both in order to assess and recognise the extent of a patient’s
dissociative states and to treat these appropriately. Mild traumas may result in
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the very common phenomena of separated self-states, of which a patient is not

consciously aware until they emerge in the therapeutic relationship. Severe
trauma, particularly childhood abuse, can manifest as extreme dissociative
states in which the core ego appears to disappear as sub-personalities come to
the fore.

The symptoms of a dissociative disorder usually first develop as a

response to a traumatic event, such as abuse or military combat, to keep those
memories under control. Stressful situations can worsen symptoms and cause
problems with functioning in everyday activities. However, the symptoms a
person experiences will depend on the type of dissociative disorder that a person
has.

Treatment for dissociative disorders often involves psychotherapy and

medication. Though finding an effective treatment plan can be difficult, many
people are able to live healthy and productive lives.

10. SOMATIC SYMPTOM AND RELATED DISORDERS

1. Introduction

Somatic symptom disorder and other disorders with prominent somatic

symptoms constitute a new category. This chapter includes the diagnoses of
somatic symptom disorder, illness anxiety disorder, conversion disorder
(functional neurological symptom disorder), psychological factors affecting other
medical conditions, and factitious disorder. All of the disorders in this chapter
share a common feature: the prominence of somatic symptoms associated
with significant distress and impairment. (“Somatic Symptom Disorder” was
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formerly known by two names “Somatisation Disorder” and “Somatoform

Disorder.”)

2. Somatic Symptom Disorder

1) Diagnostic Criteria

A. One or more somatic symptoms that are distressing or result in

significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviours related to the somatic
symptoms or associated health concerns as manifested by at least one of
the following:
1. Disproportionate and persistent thoughts about the seriousness of
one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health
concerns.
C. Although any one somatic symptom may not be continuously present,
the state of being symptomatic is persistent (typically more than 6
months).

2) Treatment
There appears to be no single superior treatment approach for Somatic
Symptom Disorder. Mostly primary care physicians can manage these patients
with consultation of a psychiatrist when needed. An eclectic approach comports
well with this disorder. The eclectic approach consists of three principles: (1)
establish a firm therapeutic alliance with the patient, (2) educate the patient
regarding the manifestations of somatic symptom disorder, and (3) provide
consistent reassurance.
Firstly, therapeutic alliance is important to acknowledge the patient’s pain
and suffering to communicate that the physician is caring, compassionate, and
interested in providing help. Secondly, educating the patient on the diagnosis
and describing the various facets of somatic symptom disorder in a positive light
is important. Telling the patient that the person is suffering from a medically
recognized illness and that the condition will not lead to chronic mental or
physical deterioration or death is important. Thirdly, there should be consistent
reassurance. Usually patients think that the physician is not doing what he
should and so they want to go “doctor shopping.” Since patients frequently
complain of anxiety and depressive symptoms, prescription medications for
these complaints should be held to a minimum and carefully monitored. The goal
of treatment is to help one learn to control one’s symptoms.
Having a supportive relationship with a health care provider is the most
important part of treatment. One should have only one primary care provider, to
avoid having too many tests and procedures. Scheduling regular appointments
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to review one’s symptoms and how one is coping are needed. The health care
provider should explain any test results.

Finding a mental health provider who has experience treating somatic

symptom disorders with talk therapy (psychotherapy) can be helpful. Cognitive
behavioural therapy (CBT) can help one deal with one’s pain. During therapy,
one will learn: To recognize what seems to make the pain worse; to develop
methods of coping with the symptoms; and to keep oneself more active, even if
one still has pain. If one has depression or an anxiety disorder, it may respond
to antidepressant medications.

The client should not be told that his symptoms are imaginary. Many
health care providers now recognize that real physical symptoms can result from
psychological stress. People with somatic symptom disorder may find it difficult
to accept a referral to a mental health professional or to accept that medical
evaluation and treatment cannot relieve the symptoms. They are particularly
sensitive to the stigma associated with mental disorders. In addition, they
sometimes are dismissed by a subset of physicians who do not see their
symptoms as a legitimate cause for concern.

Ideally, if a primary care physician and mental health professional work

together, the person's physical symptoms can be evaluated while he also gets
help managing the frustration of not having a clear diagnosis or treatment plan.
However, mental health treatment can sometimes reduce symptoms or improve
quality of life.

There is some preliminary evidence that cognitive behavioural therapy (CBT)

can help reduce symptoms or address any accompanying anxiety or depression.
Sometimes, an antidepressant medication or other psychiatric medication can
provide relief from the physical symptoms that stem from somatic symptom
disorder (especially if the person also has an anxiety or mood disorder).
Treatment is often aimed at managing conflict at home or coping with secondary
problems, such as problems with work and social functioning.

Psychotherapy can help the person deal with or manage chronic physical
discomfort. Stress management (for example, relaxation techniques) may be
useful. Some cognitive behaviour therapists teach patients to identify the
thoughts and feelings that are associated with changes in physical symptoms.
They may help an individual reduce the tendency toward "body scanning," or the
constant monitoring of body sensations.80

(1) Doctor-Patient Relationship

Patients who experience unexplained physical symptoms often cling to the

belief that their symptoms have an underlying physical cause, despite evidence
to the contrary. Patients may also dismiss any suggestion that psychiatric factors
are playing a role in their symptoms. A strong doctor-patient relationship is a
key to getting help with somatic symptom disorders. Seeing a single health care
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provider with experience managing somatic symptom disorders can help cut
down on unnecessary tests and treatments.

The focus of treatment is on improving daily functioning, not on managing

symptoms. Stress reduction is often an important part of getting better.
Counselling for family and friends may also be useful. Cognitive behavioural
therapy may also help relieve symptoms associated with somatic symptom
disorders. The therapy focuses on correcting: distorted thoughts, unrealistic
beliefs, and behaviours that prompt health anxiety.

(2) Psychosocial Interventions (Primary Care Management)

Randomized trials have demonstrated the value of physician education in the

management of the patient with somatic symptom disorder.  Cognitive-
behavioural psychotherapy strategies may be specifically helpful in reducing
distress and high medical use. Psychosocial interventions directed by physicians
form the basis for successful treatment. A strong relationship between the
patient and the primary care physician can assist in long-term management.
Psychoeducation can be helpful by letting the patient know that physical
symptoms may be exacerbated by anxiety or other emotional problems.
However, one needs to be careful because patients are likely to resist
suggestions that their condition is due to emotional rather than physical
problems.

The primary care physician should inform the patient that the symptoms do
not appear to be due to a life-threatening, disabling, medical condition and
should schedule regular visits for reassessment and reinforcement of the lacking
severity of ongoing symptoms. The patient also may be told that some patients
with similar symptoms have had spontaneous improvement, implying that
spontaneous improvement may occur. However, the physician should accept the
patient's physical symptoms and not pursue a goal of symptom resolution.

Indeed, regular, noninvasive, medical assessment reduces anxiety and limits

health care–seeking behaviour; this may be facilitated by regularly scheduled
visits with the patient's primary care physician. The therapist needs to
encourage patients to remain active and limit the effect of target symptoms on
the quality of life and daily functioning. Family members should not become
preoccupied with the patient’s physical symptoms or medical care. Family
members should direct the patient to report symptoms to their primary care
physician.

(3) Cognitive-Behavioural Therapy 

Approaches derived from cognitive behaviour therapy have been shown to

reduce the intensity and frequency of somatic complaints and to improve
functioning in many somatising patients:

This type of treatment starts with the mutual agreement that whatever the
patient has been thinking and doing about the condition has not been successful.
It then begins to challenge the patient's beliefs and maladaptive behaviours in a
caring manner. Short course intervention therapy (eight to 16 sessions)
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specifically for treatment of somatising patients has been shown to be

remarkably effective in improving function and reducing distress.

The sessions combine general guidance such as stress management,

problem-solving and training in social skills, with specific interventions targeted
at the amplification and need-to-be-sick features of somatisation. Recent studies
have shown that cognitive-behavioural therapy reduces depressive symptoms in
people with somatic diseases. In particular, this type of therapy is especially
effective for patients who fit the criteria for a depressive disorder. Cognitive-
behavioural therapy was superior to control conditions, with even greater effects
to groups restricted to participants with depressive disorder.

Patients, even those who have a satisfactory relationship with a primary

physician, are commonly referred to a psychiatrist. Pharmacologic treatment of
concurrent mental disorders (e.g., depression) may help; however, the primary
intervention is psychotherapy, particularly cognitive-behavioural therapy.
Patients also benefit from having a supportive relationship with a primary care
physician, who coordinates all of their health care, offers symptomatic relief,
sees them regularly, and protects them from unnecessary tests and procedures.

To date, cognitive behaviour therapy (CBT) is the best established treatment

for a variety of somatic symptom disorders. CBT aims to help patients realize
their ailments are not catastrophic and to enable them to gradually return to
activities they previously engaged in, without fear of “worsening their
symptoms.” Consultation and collaboration with the primary care physician also
demonstrated some effectiveness. The use of  antidepressants is preliminary but
does not yet show conclusive evidence. Electroconvulsive shock therapy (ECT)
has been used in treating somatic symptom disorder among the elderly;
however, the results are still debatable with some concerns around the side
effects of using ECT. 

(4) Supportive Psychotherapy

The treatment of choice is usually supportive psychotherapy. The first step

is to enlist the patient in the therapeutic alliance by establishing a rapport. It is
useful to demonstrate the link between psychosocial conflicts and somatic
symptoms, if it is apparent. In chronic cases, symptom reduction rather than
complete cure might be a reasonable goal.

(5) Behaviour Modification

After rapport is established, attempts at modifying behaviour are made,

for example, not focusing on the symptoms per se, and positively reinforcing
normal functioning.

(6) Relaxation Therapy with Graded Physical Exercises

The procedures begin with Progressive Muscle Relaxation (PMR) (16

muscle groups) with discrimination training. Discrimination training entails
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teaching the client to discriminate sensations of tension and relaxation in each

muscle group during the PMR exercise. This is done to increase the client’s
ability to detect sources and early signs of muscle tension, thereby facilitating
the rapid deployment of relaxation techniques to those areas. Now relaxation
deepening techniques are employed during the induction, including slow
diaphragmatic breathing, repeating the word relax on the exhale.

Relaxation techniques are very useful in patients with mild to moderate

anxiety. These techniques are used by the patient himself as a routine exercise
everyday and also whenever anxiety-provoking situation confronts him. They
include Jacobson’s progressive relaxation technique, yoga, pranayama, self-
hypnosis, and meditation.81

3. Illness Anxiety Disorder (Formerly Called Hypochondriasis)

1) Diagnostic Criteria

A. Preoccupation with having or acquiring a serious illness.

B. Somatic symptoms are not present or, if present, are only mild in
intensity. If another medical condition is present or there is a high risk
for developing a medical condition (e.g., strong family history is present),
the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily
alarmed about personal health status.
D. The individual performs excessive health-related behaviours (e.g.,
repeatedly checks his body for signs of illness) or exhibits maladaptive
avoidance (e.g., avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the
specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another
mental disorder, such as somatic symptom disorder, panic disorder,
generalized anxiety disorder, body dysmorphic disorder, obsessive-
compulsive disorder, or delusional disorder, somatic type.

2) Treatment

Until recently, illness anxiety disorder as a primary condition was not seen to
be responsive to known psychopharmacological drugs. However, illness anxiety
disorder symptoms secondary to depressive and anxiety disorders may improve
with successful treatment of the primary disorder. The selective serotonin
reuptake inhibitors (SSRIs) seem to give good result in treating illness anxiety
disorder symptoms. Supportive, rational, ventilative (cathartic or emotive), and
educative psychotherapies are being used. It is advisable that the patient
receives consistent treatment, generally by the same primary physician, with
supportive, regularly scheduled office visits, not based on the evaluation of
symptoms. As far as possible, it is good to avoid hospitalisation, medical tests,
and medications with addictive potential. The patient’s attention should be
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shifted from symptoms to social or interpersonal problems. In any case,

treatment should prevent adoption of the sick role and chronic
invalidism.
The treatment of illness anxiety disorder is often difficult. It basically consists
of: (1) Supportive psychotherapy and (2) Treatment of associated or underlying
depression and/or anxiety, if present.

(1) Relaxation Techniques

Jacobson’s progressive muscular relaxation, autohypnosis or hypnosis,

yoga, transcendental meditation (TM), and/or biofeedback.

(2) Teaching Relaxed Breathing Techniques

Breathing techniques include: (1) Breathing more from the abdomen,

thus avoiding the use of accessory muscles of expiration. (2) Slow inspiration
with passive expiration, without muscular effort, (3) A short rest cycle to be
voluntarily introduced after each respiratory cycle.

(3) Treatment of Underlying Anxiety or Depression

If anxiety or depression is present, they are to be dealt with

antidepressants and/or short-term benzodiazepines.

(4) Breathing-In-Bag Technique

The aim of this technique is to have the patient re-breathe the expired air.
This prevents the decrease in pCO2 which causes physical symptoms, or causes
an increase in pCO2, where physical symptoms have already developed. Re-
breathing in a paper bag, which is carried by the patient, quickly reverts the
symptoms. It is important to emphasise the safe use of the bag, to prevent the
possibility of suffocation. There is some recent evidence doubting the efficacy of
this approach.
Therapy includes the following: (1) Exploration of the client’s attitudes
toward illness. (2) Presentation of information on the client’s medical condition.
(3) Perceptual retraining to help the client focus more on external information
and less on internal cues. (4) Suggestion that the symptoms will be reduced.
(5) Encouragement of self-talk and internal dialogue to reduce stress and
anxiety.82

4. Conversion Disorder (Also called Functional Neurological Symptom

Disorder)

1) Diagnostic Criteria

A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the
symptom and recognized neurological or medical conditions.
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C. The symptom or deficit is not better explained by another medical or

mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning or
warrants medical evaluation.

2) Treatment
Usually, the initial aim in treating patients with conversion disorder is the
removal of the symptom. If the patient is not in particular discomfort and the
need to regain function is not great, direct attention may not be necessary.
Under all circumstances, direct confrontation is not recommended since such a
communication may cause a patient to feel even more isolated. A conservative
approach of reassurance and relaxation is effective. Once physical illness
is excluded, prognosis for conversion symptoms is good.
If an immediate need for symptom resolution is required, a number of
techniques, including narcoanalysis (e.g., amobarbital interview), hypnosis, and
behaviour therapy may be used. It is good to go for prompt resolution of
symptoms since duration is associated with greater risk of recurrence and
chronic disability.
In narcoanalysis, amobarbital or another sedative-hypnotic medication such
as larazepam is given to the patient intravenously to the point of drowsiness.
Sometimes this is followed by administration of a stimulant medication such as
methamphetamine. At this point, the patient is encouraged to discuss stressors
and conflicts. More chronic symptoms may not respond to such a technique. In
hypnotic therapy, symptoms may be removed during a hypnotic state, with the
suggestion that the symptoms will gradually improve post-hypnotically.
Information regarding stressors and conflicts may be explored as well. Behaviour
therapies like relaxation training and aversion therapy could be of use.
In fact, it is not the particular technique rather than the influence of
suggestion that is important. Therefore, various rituals such as exorcism
and other religious ceremonies undoubtedly have led to immediate
cures. Suggestion seems to play a big part in cases of mass hysteria in which
for example, individuals exposed to a toxin develop similar symptoms that do
not appear to have any organic basis. Often, the epidemic can be contained if
affected individuals are segregated. Simple announcements that no toxin is
present and that symptoms have been linked to mass hysteria will be effective.
All these techniques are meant for symptom removal.
Long-term approaches involve a pragmatic, conservative approach that
entails support for and exploration of various areas of conflict, particularly
interpersonal relationships. Ford (1995) has suggested a treatment strategy
based on “three Ps,” whereby predisposing factors, precipitating
stressors, and perpetuating factors are identified and addressed. A certain
degree of insight may be attained, at least in terms of appreciating relationships
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between various conflicts and stressors and the development of symptoms.

Long-term, intensive insight-oriented psychotherapy like psychodynamic would
be effective.83
5. Psychological Factors Affecting Other Medical Conditions

1) Diagnostic Criteria

A. A medical symptom or condition (other than a mental disorder) is

present.
B. Psychological or behavioural factors adversely affect the medical
condition in one of the following ways
1. The factors have influenced the course of the medical condition as
shown by a close temporal association between the psychological
factors and the development or exacerbation of, or delayed recovery
from, the medical condition.
2. The factors interfere with the treatment of the medical condition (e.g.,
poor adherence).
3. The factors constitute additional well-established health risks for the
individual.
4. The factors influence the underlying pathophysiology, precipitating or
exacerbating symptoms or necessitating medical attention.
C. The psychological and behavioural factors in Criterion B are not better
explained by another mental disorder (e.g., panic disorder, major
depressive disorder, posttraumatic stress disorder).

6. Factitious Disorder

The essential feature of factitious disorder is the falsification of medical or

psychological signs and symptoms in oneself or others that are associated with
the identified deception. Individuals can also seek treatment for themselves or
another following induction of injury or disease. The diagnosis requires
demonstrating that the individual is taking surreptitious actions to misrepresent,
simulate, or cause signs or symptoms of illness or injury in the absence of
obvious external rewards. Methods of illness falsification can include
exaggeration, fabrication, simulation, and induction.

1) Diagnostic Criteria

(1) Factitious Disorder Imposed on Self

A. Falsification of physical or psychological signs or symptoms, or induction

of injury or disease, associated with identified deception.
B. The individual presents himself to others as ill, impaired, or injured.
C. The deceptive behaviour is evident even in the absence of obvious
external rewards.
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D. The behaviour is not better explained by another mental disorder, such

as delusional disorder or another psychotic disorder.

(2) Factitious Disorder Imposed on Another (Previously Factitious

Disorder by Proxy)

A. Falsification of physical or psychological signs or symptoms, or induction

of injury or disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill,
impaired, or injured.
C. The deceptive behaviour is evident even in the absence of obvious
external rewards.
D. The behaviour is not better explained by another mental disorder, such
as delusional disorder or another psychotic disorder.

For persons with factitious disorder, personality reconstruction through

therapy is unlikely. However, improvement in coping skills, reduction in self-
injurious behaviour and dangerous medical procedures and symptom reduction
are to be undertaken for those with Factitious Disorder Imposed on Self. For the
Factitious Disorder Imposed on Another, early detection is essential to prevent
injury or death of the child or other target of the harmful behaviour. 84

7. Irritable Bowel Syndrome (IBS)

IBS is a common syndrome, often known by a large variety of names,
such as spastic colitis, irritable colon syndrome, nervous diarrhoea, mucus
colitis, and colon neurosis. The principal abnormality in IBS is a disturbance of
bowel mobility, which is modified by psychosocial factors. The patients usually
present with one or more of the following symptoms: (1) Abdominal pain,
discomfort or cramps. (2) Alteration of bowel habits (diarrhoea or constipation).
(3) A sensation of incomplete evacuation (incomplete voiding).
1) Treatment
(1) A stable and trustful doctor-patient relationship; (2) Supportive
psychotherapy best carried out in a medical or gastroenterology (GE) clinic by
the treating physician; (3) Identification of current life stressors, environmental
manipulation, and learning of coping skills aimed at dealing with stressors are
very helpful; and (4) Anti-anxiety and antidepressant medication may be helpful
at times. At other times, they just act like placebos.
A team approach to treatment of somatic symptom and related disorders
is welcome with the physician and the therapist working together. While the
physician focuses on the medical aspects of those complaints, the therapist can
be presented as a consultant who will help alleviate the impact of stress on the
client’s physical complaints. What is troublesome is not the severity of the
symptoms but the client’s dramatic and persistent complaints about them. The
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overall goal should be to focus on improving functioning rather than on reducing

physical symptoms. When functioning is improved, the symptoms will
spontaneously decrease.
Somatically focused anxiety is a common characteristic. It should be
understood as a cognitive distortion. Cognitive-behaviour therapy will reduce
amplification as well as the withdrawal from relationships and activities. Therapy
should focus on the present and seek to increase skills in stress management
and coping, facilitate verbal expression of feelings, promote empowerment, and
encourage healthy cognitions as well as increased activity and socialization.
Medical complaints should be de-emphasized. Since the clients genuinely believe
that their symptoms are real, the therapist should treat them gently.
The following three-stage treatment is helpful: (1) Therapy begins with a
concrete focus on physical symptoms, teaching clients strategies for reducing
them. Biofeedback and relaxation training are useful. (2) Supportive discussion
on symptoms and lifestyle helps the client make connections between the two,
raising awareness of difficulties that may be experienced in the interpersonal,
occupational, and leisure areas as well as in self-expression. (3) Employing
cognitive and emotive approaches, enabling people to gain deeper awareness of
their cognitive distortions, become better able to identify and express their
emotions and make changes in thoughts, feelings, behaviours, relationships, and
lifestyle.85

8. Conclusion
Somatic symptom disorders are disorders with prominent somatic or bodily
symptoms. They are common in healthcare settings and with varied features.
Many presentations can be confirmed by available investigations, many are not.
The variability adds to the vagueness and variety of the presentations, which
make these disorders a challenge in the psychiatric practice. Somatic
presentations are non-specific; however, but prominent somatic presentations
are more often noted in somatic symptom disorders.

Classifying somatic symptom disorders is likely to remain a challenge, as

much as understanding the mechanisms, which underlie these disorders. The
confusing and misleading “medically unexplained symptom” disorders need a
fresh and appropriate replacement. The classificatory systems are undergoing
revisions, and we hope a progress in the classification of somatic symptom
disorders.

11. FEEDING AND EATING DISORDERS

1. Introduction

The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
(DSM-5) has made a number of changes to the feeding and eating disorders —
such as anorexia, bulimia, and binge eating.
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2. Anorexia Nervosa (AN)

1) Diagnostic Criteria

A. Restriction of energy intake relative to requirements, leading to a

significantly low body weight in the context of age, sex, developmental
trajectory, and physical health. Significantly low weight is defined as a
weight that is less than minimally normal or, for children and
adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat or persistent behaviour
that interferes with weight gain, even though at a significantly low
weight.
C. Disturbance in the way in which one’s body weight or shape is
experienced, undue influence of body weight or shape on self-evaluation,
or persistent lack of recognition of the seriousness of the current low
body weight.

2) Treatment

A multifaceted treatment programme would be ideal in dealing with anorexia

nervosa. The treatment should aim at restoring the patient’s nutritional state to
normal. The most effective form of behavioural therapy is the operant
conditioning paradigm. Positive reinforcements are used and consist of increased
physical activity, visiting privileges, and social activities contingent on weight
gain. Behaviour therapy could be used to stop vomiting. A response-prevention
technique is used when bingeing and purging patients are required to stay in an
observed dayroom area for 2-3 hours after every meal. Cognitive therapies could
be used with the assessment of cognition as the first step. The patients could be
asked to write down their thoughts to find out systematic distortions in the
processing and interpretation of events. Cognitive techniques include
operationalizing beliefs, decentring, using the “what if” technique, evaluating
automatic thoughts, testing prospective hypotheses, reinterpreting body image
misperception, examining underlying assumptions, and modifying basic
assumptions.

The treatment of anorexia nervosa can be considered in two phases, which

often merge into each other. Short-term treatment, to encourage weight gain
and correct nutritional deficiencies, if any. Long-term treatment, aimed at
maintaining the near normal weight achieved in short-term treatment and
preventing relapses. The various treatment modalities used can include:

(1) Behaviour Therapy (BT)

Behavioural treatments are based on providing positive reinforcements

(and at times, negative reinforcements) contingent on weight gain by the
patient. A too rapid weight gain is not desirable or safe. The weight gain should
not exceed 1.5 to 2 kg in a fortnight. As patients are usually unable to eat a
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large meal, especially in the initial part of treatment, it is advisable to suggest

more number of meals (about six per day). Occasionally, forceful Ryle’s tube
feeding may be needed initially, in resistant patients.

(2) Individual Psychotherapy

Individual therapy is often helpful in addition to supportive physical

treatment. This could involve psychotherapy with a focus on cognitive behaviour
therapy, psychodynamic principles, or supportive measures.

(3) Hospitalisation

Hospitalisation with adequate nursing care for food intake and weight gain
can be helpful in short-term treatment as well as prevention and/or treatment of
complications. However, hospitalization does not necessarily ensure long-term
improvement. It is important to keep a close eye on water and electrolyte
balance, need for supplementation with vitamins and minerals, and prevent
osteoporosis.

(4) Group Therapy and Family Therapy

Group/family therapy can be helpful in psychoeducation for the patient

and caregivers/family about nature of anorexia nervosa and its treatment.
Psychoeducation may also include discussion of current social norms of slimming
and fitness, since there is evidence to suggest that anorexia nervosa is far more
common in countries with social pressures for slimming. The prognosis is
generally better if diagnosis is made early, absence of previous hospitalizations,
and absence of bulimic episodes. Weight gain and improvement in mental
outlook often precede return to menstrual function. 86

3. Bulimia Nervosa (BN)

1) Diagnostic Criteria

A. Recurrent episodes of binge eating. An episode of binge eating is

characterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than what most individuals
would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how much one
is eating).
B. Recurrent inappropriate compensatory behaviours in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives, diuretics,
or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviours both occur,
on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia
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nervosa.

2) Treatment

(1) Cognitive-Behaviour Therapy (CBT)

Cognitive-Behaviour Therapy (CBT) gives encouraging results for people

with Bulimia Nervosa (BN). The now widespread use of Cognitive-Behaviour
Therapy (CBT) in North America, Europe, and Australia derives directly from
Fairburn’s first formulation of this approach in the early 1980s. CBT consists of
19 sessions of individual treatment spanning roughly 20 weeks. Treatment is
problem-oriented and focused primarily on the present and future. It has three
stages.

The first stage involves education about bulimia nervosa and orientation
to its treatment with CBT. The cognitive view of the maintenance and
modification of the disorder is explained, and its relevance to the patient’s
current problems is made clear. Information about nutrition and weight
regulation, and how they are critical to cure the eating disorders, is explained.
Core behavioural techniques are introduced. Self-monitoring is initiated for
tracking eating habits and for assessing situations that trigger binge eating and
purging. Other self-regulatory strategies for reducing the frequency of binge
eating and normalizing eating patterns, such as stimulus control, are also
explained. The aim at this stage is to return the client to eating three meals a
day with the provision for healthy snacks.

The second stage has an increasingly cognitive focus. The techniques

from the first stage are supplemented with a variety of procedures for reducing
dietary restraint and developing cognitive and behavioural coping skills for
resisting binge eating. This approach is similar to the cognitive therapy for
depression. Clients are taught to identify and alter the dysfunctional thoughts
and attitudes regarding shape, weight, and eating. Cognitive change is achieved
by prompting clients to engage in behavioural experiments designed to challenge
their dysfunctional assumptions.

The third stage focuses on the use of relapse-prevention strategies to

ensure the maintenance of change following treatment.

To conclude, bulimia nervosa and binge eating in obese patients can be

effectively treated. Taking into account the available evidence from controlled
outcome studies as a whole, CBT appears to be the most effective form of
treatment. All the same, it is often insufficient. Given the limitations of CBT,
alternative methods for treating nonresponders need to be developed. An
intensive form of psychological treatment such as CBT is not always necessary.
Some individuals with bulimia nervosa respond favourably to a structured,
educational approach conducted in a group setting. This type of cost-efficient
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programme seems well suited to high-functioning individuals with no

complicating psychopathology.

Behaviour therapy, cognitive therapy, psychodynamic therapy, and

psychoeducation therapy are being used with success. Cognitive restructuring is
the basis of all the cognitive-behaviour therapy. Behaviour therapy is used to
specifically to stop the binge-eating/purging behaviours. Antidepressant
medications have consistently shown some efficacy in the treatment of bulimia
nervosa.

(2) Behaviour Therapy

Behaviour therapy is based on providing positive reinforcements (and at

times negative reinforcements) contingent on the control of binge eating by the
patient.

(3) Individual Psychotherapy

Individual therapy is a talking therapy in which the client speaks out his
problem to the therapist. The therapist assists the client by his expertise making
use of any method that suits the client’s problem.

(4) Group Therapy and Family Therapy

Group therapy and family therapy are used for psychoeducation of the
patient and caregivers/family about the nature of bulimia nervosa and its
treatment.87

4. Binge-Eating Disorder (BED)

1) Diagnostic Criteria

A. Recurrent episodes of binge eating. An episode of binge eating is

characterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour
period), an amount of food that is definitely larger than what most
individuals would eat in a similar period of time under similar
circumstances.
2. A sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how much
one is eating).
B. The binge-eating episodes are associated with three (or more) of the
following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is
eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
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D. The binge eating occurs, on average, at least once a week for 3

months.
E. The binge eating is not associated with the recurrent use of
inappropriate compensatory behaviour as in bulimia nervosa and does
not occur exclusively during the course of bulimia nervosa or anorexia
nervosa.

2) Treatment

Treatment for Binge-Eating Disorder (BED) involves the following: (1) The
first and most important step is correct diagnosis and exclusion of other physical
and/or psychiatric causes; (2) Identification of psychosocial stressor; (3)
Environmental manipulation and encouragement of coping strategies to deal
with stress; and (4) Psychotherapy of either cognitive behavioural or
psychodynamic nature.88

5. Pica

1) Diagnostic Criteria

A. Persistent eating of non-nutritive, non-food substances over a period of

at least 1 month.
B. The eating of non-nutritive, non-food substances is inappropriate to the
developmental level of the individual.
C. The eating behaviour is not part of a culturally supported or socially
normative practice.
D. If the eating behaviour occurs in the context of another mental disorder
(e.g., intellectual disability [intellectual developmental disorder], autism
spectrum disorder, schizophrenia) or medical condition (including
pregnancy), it is sufficiently severe to warrant additional clinical
attention.

2) Treatment

Behavioural therapy seems to be fitting for children and mentally retarded

persons with pica. They are rewarding appropriate eating, teaching the
differentiation of edible foods, over-correction (immediate enforcement of oral
hygiene), and negative reinforcement (time-outs, physical restraint) especially
meant for mentally retarded individuals. Psychosocial interventions include
promotion of maternal supervision and stimulation, improvement of play
opportunities (new toys), and placement in day care. It is good to supplement
the therapy with concomitant medical treatments. 89

6. Rumination Disorder

The onset of rumination disorder is at 3 to 12 months. This disorder is

also found in older children and adults with intellectual disabilities (mental
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retardation). This disorder develops after a period of normal eating and digesting
and is not due to a general medical condition. They exhibit straining postures
and sucking movements that facilitate the regurgitation. They seem to derive
satisfaction from this activity. Most children recover spontaneously. This disorder
has two subtypes. The first one is psychogenic, which shows no evidence of
intellectual disabilities. It may be due to negative interactions between infants
and caregivers, especially around feeding issue. The other is self-stimulating
type to be found in children with intellectual disabilities. This disorder can be
diagnosed when a child persistently fails to eat adequately and has not gained
age-appropriate weight or has lost a significant amount of weight over a period
of at least one month.90

1) Diagnostic Criteria

A. Repeated regurgitation of food over a period of at least 1 month.

Regurgitated food may be re-chewed, re-swallowed, or spit out.
B. The repeated regurgitation is not attributable to an associated
gastrointestinal or other medical condition (e.g., gastroesophageal reflux,
pyloric stenosis).
C. The eating disturbance does not occur exclusively during the course of
anorexia nervosa, bulimia nervosa, binge-eating disorder, or
avoidant/restrictive food intake disorder.
D. If the symptoms occur in the context of another mental disorder (e.g.,
intellectual disability [intellectual developmental disorder] or another
neurodevelopmental disorder), they are sufficiently severe to warrant
additional clinical attention.

2) Treatment

Since there is no established treatment for this disorder, various forms of

behavioural therapy, parental guidance, and medication (antispasmodics and
tranquillisers) have been tried. Some of the behavioural techniques are cuddling
and playing with the child before, during, and after mealtime to reduce social
deprivation and behavioural withdrawal. Aversive conditioning (e.g., putting hot
pepper sauce or lemon on the infant’s tongue) may be helpful. Negative
attention alone like shouting or slapping the child may reinforce the behaviour,
especially if other forms of reinforcement and attention are lacking or ineffective.
May be one could try a combination of a negative reinforcement (a scolding and
putting the child down for 2 minutes) with a reward for nonrumination (parental
attention and social interaction, like being cleaned and played with) are
successful. Temporary hospitalisation may separate the child from the primary
caregiver and provide an alternative feeding environment.
Cognitive-behavioural and educational approaches are useful in
addressing this disorder. Parents should be informed of children’s developmental
and eating patterns. It is also suggested to provide the child with a parent
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substitute who can give a warm, nurturing feeding environment while the
parents receive counselling.91

7. Avoidant/Restrictive Food Intake Disorder (ARFID)

ARFID pertains to specific subtypes of feeding disorders that occur in

infancy, early childhood, adolescents, and even persisting into adulthood. The
implications of these disorders can affect physical health, emotional well being,
as well as psychosocial development. Individuals who suffer with ARFID struggle
with an inability to consume adequate caloric intake to sustain nourishment that
is needed for proper growth or maintenance.

1) Diagnostic Criteria

A. An eating or feeding disturbance (e.g., apparent lack of interest in eating

or food; avoidance based on the sensory characteristics of food; concern
about aversive consequences of eating) as manifested by persistent
failure to meet appropriate nutritional and/or energy needs associated
with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or
faltering growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an
associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of
anorexia nervosa or bulimia nervosa, and there is no evidence of a
disturbance in the way in which one’s body weight or shape is
experienced.
D. The eating disturbance is not attributable to a concurrent medical
condition or not better explained by another mental disorder. When the
eating disturbance occurs in the context of another condition or disorder,
the severity of the eating disturbance exceeds that routinely associated
with the condition or disorder and warrants additional clinical attention.

2) Treatment

There are therapies that can help with exposure, anxiety, and thought
processes that surround the Avoidant/Restrictive Food Intake Disorder. Often
therapists will work on a hierarchy of fear foods from least fearful to most
anxiety provoking. From that, the therapist and the client will work on being able
to expose the client to foods moving up the hierarchy category slowly. This type
of work includes mental visualization, writing and verbally talking through steps
to exposure, practicing distress coping skills and cognitive behavioural therapy
to address negative thoughts, and life practice sessions to sensitize clients to
various situations and foods.
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Other therapies that work to help with ARFID are Cognitive Behavioural

Therapy and Dialectical Behavioural therapy. In conjunction with exposure and
anxiety therapy, individuals will work with their treatment team to address any
unhealthy or negative thoughts and behaviours that are treatment-interfering.
With Dialectical Behavioural Therapy a person learns mindfulness within the
moment, distress tolerance skills to manage high anxiety-provoking situations,
as well as emotional identification. With these tools, a person is able to
understand better what their body is trying to say to them, versus such anxiety.

Often a food may remind them of being “forced” to eat certain foods when
young and having an adversative reaction, or having a highly adverse event,
such as becoming car sick or choking on food when young. These situations can
lead to avoidance of that food as well as similar foods and go from picky eating
to ARFID.

Other effective treatments include group therapy and group meals to work on
sensory issues within a supportive setting. Many times groups will go out into
the community and eat in a public place. There are various levels of treatment
for an individual struggling with ARFID. One is a residential therapy which allows
for the person to live in with 24-hour support and treatment. This level usually
involves several aspects of individual therapy, family therapy, nutritional
support, group therapy, and skills-based groups.

Another level is Intensive Outpatient Programming which the individual

attends 3-7 days a week for three hours at a time. This level is usually a group
format only, with a supportive meal and therapeutic sessions outside of the
group setting. Outpatient therapy is the last level of support where a person can
come up to 3-4 days a week of individual sessions for support.

8. Obesity

Obesity is a medical condition in which excess body fat has accumulated to

the extent that it may have a negative effect on health. People are generally
considered obese when their body mass index (BMI), a measurement obtained
by dividing a person's weight (in kilograms) by the square of the person's
height (in metres), is over 30 kg/m, with the range 25–30 kg/m defined
as overweight. Some East Asian countries use lower values. Obesity increases
the likelihood of various diseases and conditions, particularly cardiovascular
diseases, type 2 diabetes, obstructive sleep apnoea, certain types
of cancer, osteoarthritis and depression. Obesity is most commonly caused by a
combination of excessive food intake, lack of physical activity, and genetic
susceptibility. A few cases are caused primarily by genes, endocrine
disorders, medications, or mental disorder. The view that obese people eat little
yet gain weight due to a slow metabolism is not generally supported. On
average, obese people have greater energy expenditure than their normal
counterparts due to the energy required to maintain an increased body mass.

From both a public health perspective and for the individuals affected, obesity
is a major problem. Obesity carries substantial risk for serious disease. In
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overweight individuals, risk is elevated for hypertension, diabetes, cardio-

vascular disease, and some cancers.92

1) Conceptual Model for Assessment and Treatment of Obesity

Obesity is not a psychological disorder. It is not included as a psychiatric

disorder. Obesity in and of itself does not signify the presence of accompanying
psychological distress. Neither is obesity behaviour. However, behaviour change
is an absolute necessity if the condition of obesity is to be managed. An obese
person attempting to lower his weight must initiate and maintain changes in the
behaviours that influence nutrient intake and caloric expenditure which is
complex and individualistic. It is now recognized that the goal of treatment is
management rather than cure, and that this goal requires long-term
intervention. Intervention requires tailoring treatment to individual client
characteristics and circumstances.

(1) Focus on Lifestyle Change

It is necessary to make effort to effect life-style change, that is, to develop

long-standing, routine patterns of behaviour that will support attainment and
maintenance of a lower weight in the face of genetic, interpersonal, and
environmental influences to the contrary. This approach is different in important
ways from dieting. It makes explicit the necessity of long-term change, moves
emphasis from weight loss to weight maintenance, and shifts the client’s
attention from the unpredictability of weight change to the more controllable
target of behaviour change. There are several ways to present this life-style
approach to the client. There is the acronym LEARN meaning Life-Style,
Exercise, Attitudes, Relationships, and Nutrition. There is another mnemonic
which is ABCDS meaning Activity increase, Behavioural change, Cognitive
restructuring, Dietary modification, Social support. Many possible approaches
are available for matching individuals to treatments, yet none has been validated
by experimental studies.

To conclude, obesity is a complex disorder with multiple aetiologies, medical

and psychological effects, and avenues for treatment. There are many
approaches available for the person attempting to lose weight. Fundamental to
any programme are alterations in food intake and physical activity. This is to be
distinguished from the means chosen to accomplish these alterations. Thus,
several conceptual factors are important. First, a life-style change philosophy is
needed in which reasonable changes in eating and exercise are encouraged, and
where the emphasis is on weaving these changes into day-to-day patterns of
living. Second, setting reasonable goals and working toward large changes by
making small, incremental, and manageable changes. Third, it is to focus on the
maintenance of behaviour change.

Clients with eating disorders are very sensitive to disapproval or interpersonal

rejection. There are some clinician attributes that contribute to effective
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treatment: sustaining empathy, practicing patience and a long-term perspective,

limiting battles for control, making behavioural agreements and contracts,
challenging cognitive distortions, and balancing nurturing with authoritativeness.

(2) Multidisciplinary Approach

The treatment team consists of a physician, a nutritionist, and a mental

health professional to monitor the impact of the disorder of the client’s health.
Exposure and response prevention are important for people who binge and
purge.

(3) Cognitive-Behaviour Therapy

This therapy includes three phases: (1) psychoeducation about the eating
disorder and expectations for treatment, including homework, self-monitoring;
(2) the use of cognitive restructuring to identify, challenge, and change
maladaptive thinking; (3) relapse prevention and problem-solving skills to help
clients cope with stress and apply their newly found skills to other areas of their
lives.

(4) Dialectical Behaviour Therapy

This therapy is meant for clients with chronic eating disorders who are
resistant to treatment and those who also have borderline features, such as
nonsuicidal self-injurious behaviours and dissociative episodes. This therapy
aims at reducing negative emotions and improving emotion-regulation skills. It
may be especially helpful for those with high negative affect, impulsivity, and
those who use eating to help them regulate their emotions.

(5) Manualized Treatment

It is a form of cognitive-behaviour approach. There are three stages to it:

(1) Information about the treatment approach, on eating disorders, and on
nutrition. Self-monitoring is begun, and techniques to modify behaviour are
taught. (2) Cognitive interventions are had, and clients are helped to identify
and modify their dysfunctional thoughts about eating, weight, and body size. (3)
Maintenance of gains and the prevention of relapses. Manuals cover a spectrum
of treatment options like in-patient treatment, self-help, family-based,
individual, and adolescent body image distortion.

(6) Hospitalization

The primary goal for the severely underweight person with anorexia is to
implement refeeding and weight gain. For those who binge or bulimia, it may be
necessary to establish control over excessive bingeing and purging. 93

9. Treatment for Feeding Disorder

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For treatment for Feeding Disorder of Infancy or Early Childhood, it is found

useful to employ the services of a multidisciplinary team, preferably in a hospital
setting, for evaluating (assessment of body growth as well as observations of
the mother-child interactions in general and in particular feeding) and initiating
treatment.

(1) Psychotherapy

Individual and/or group psychotherapy sessions help many women with

eating disorders to better understand their disease process, and experience a
decrease in their symptoms. A psychologist, therapist, social worker,
psychiatrist, or eating disorder specialist may conduct individual and group
therapy for eating disorders.

(2) Family Counselling

Eating disorders not only affect the sufferer, but also impact her entire
family. Family therapy may also help the family to engage in their own recovery
process and to better support their loved one in her recovery.

(3) Dietary Consultation

A registered dietician experienced in developing meal plans for eating

disorder patients may be able to help the sufferer overcome their apprehensions
about food. Turning over nutrition, exercise, and dietary needs to the help of a
nutritionist can provide the sufferer with a sense of trust and surrender needed
to end reliance on eating disorder symptoms.

(4) Peer Support Groups

Unlike therapeutic groups run by professionals, peer-led support groups can

help eating disorder sufferers learn to verbalize feelings about food, share their
unique stories, and reduce the shame associated with the diseases. The 12 step
mutual support groups with focus on eating disorder recovery include Overeaters
Anonymous, Anorexics and Bulimics Anonymous, and Eating Disorders
Anonymous.

(5) Residential Treatment Centres

For women with more advanced eating disorders, residential treatment offers
the opportunity to step back from the triggers and stresses of daily life to focus
on healing and recovery. Residential treatment centres for eating disorders
provide 24-hour medical and clinical support in a fully-integrated therapeutic
environment that can rapidly accelerate the recovery process. Residential
treatment for eating disorders may make particular sense for the persons who
also suffer with co-occurring addictions or other psychiatric disorders.
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(6) Outpatient Treatment Programmes

Some hospitals and independent organizations offer structured programmes

that provide outpatient treatment for eating disorders. For persons who are able
to tolerate emotions and avoid symptoms at home, these programmes can be a
viable alternative to inpatient hospitalizations or residential eating disorder
treatment.

(7) Inpatient Hospitalization

For women with advanced eating disorders that result in serious health
consequences, inpatient hospital treatment may be the only way to stabilize her
medical symptoms and allow her to participate actively in treatment.
Hospitalization may be required when a woman refuses all food and must receive
nutrition through a feeding tube in order to survive. Hospital stays may last
anywhere from a few days to several months, and patients are usually
discharged to an intensive outpatient programme or to a residential eating
disorder treatment centre.

Few studies guide the treatment of individuals with Other Specified Feeding
and Eating Disorders (OSFED). However, cognitive behaviour therapy (CBT),
which focuses on the interplay between thoughts, feelings, and behaviours, has
been shown to be the leading evidence-based treatment for the eating disorders
of Bulimia Nervosa (BN) and Binge-Eating Disorder (BED). For OSFED, a new
cognitive behavioural treatment can be used called enhanced CBT (CBT-E),
which was recently designed to treat all forms of eating disorders. This method
focuses not only what is thought to be the central cognitive disturbance in eating
disorders (i.e. over-evaluation of eating, shape, and weight), but also on
modifying the mechanisms that sustain eating disorder psychopathology, such
as perfectionism, core low self-esteem, mood intolerance, and interpersonal
difficulties. CBT-E showed effectiveness in two studies (total N = 219) and well
maintained over 60-week follow-up periods. CBT-E is not specific to individual
types of eating disorders but is based on the concept that common mechanisms
are involved in the persistence of atypical eating disorders, Anorexia Nervosa
(AN), and Bulima Nervosa (BN).94

A wide range of psychological therapies have been used to treat patients

with binge eating and bulimia nervosa, including Cognitive-Behaviour Therapy
(CBT), behaviour therapy, psychodynamic therapy, family therapy, experiential
therapy, and the 12-Step approach based on an addiction model of the disorder.
In addition, a variety of pharmacological treatments has been used, including
antidepressants, anti-convulsants, and opiate antagonists.

(8) Medication
Studies have found that certain women with eating disorders, and especially
those suffering with co-occurring disorders, can benefit from prescription
medication. Medication may make it easier for sufferers to participate more fully
in treatment and take greater ownership of their recovery. Medication for eating
disorders and co-occurring disorders should only be prescribed by an
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experienced psychiatrist or medical doctor specializing in eating disorders and/or

addiction medicine.95

10. Conclusion

Food is one of the many mediums through which our emotions and
distress can be expressed, so one may have a very difficult relationship with
food which impacts on one’s mental health, but does not fit into any of the
current categories of diagnosis. It is also possible to experience more than one
eating disorder, or to experience some symptoms from each disorder.

A multidisciplinary approach is highly recommended so that the client is

addressed from different angles by a physician, a nutritionist, and a mental
health professional. This in a way is better than one approach since the issue is
complex.

12. ELIMINATION DISORDERS

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1. Introduction

Elimination disorders involve the inappropriate elimination of urine or

faeces and are usually first diagnosed in childhood or adolescence. This group of
disorders includes enuresis, the repeated voiding of urine into inappropriate
places; and encopresis, the repeated passage of faeces into inappropriate
places. Subtypes are provided to differentiate nocturnal from diurnal (i.e., during
waking hours) voiding for enuresis and the presence or absence of constipation
and overflow incontinence for encopresis. Although there are minimum age
requirements for diagnosis of both disorders, these are based on developmental
age and not solely on chronological age. Both disorders may be voluntary or
involuntary. Although these disorders typically occur separately, co-occurrence
may also be observed.

2. Enuresis

Diurnal enuresis happens during the daytime and is considered to be

related to poor toilet training, social anxiety or preoccupation with other
activities. What is common is nocturnal enuresis. It generally occurs during the
first one third of the night, and occasionally during the REM stage of sleep, and
may occur during deep sleep that prevents awareness of the need to urinate.
They may also experience episodes of sleepwalking, encopresis, and nightmares
and may report dreams about urinating. Early nocturnal enuresis is often the
result of the child’s sleeping deeply, having a small bladder, and the child will
outgrow. However, middle and later childhood nocturnal enuresis will trigger
emotional disorders. Secondary enuresis, which follows a period of appropriate
bladder control, is likely to develop between the ages of 5 and 8. 96

1) Diagnostic Criteria

A. Repeated voiding of urine into bed or clothes, whether involuntary or

intentional.
B. The behaviour is clinically significant as manifested by either a frequency
of at least twice a week for at least 3 consecutive months or the
presence of clinically significant distress or impairment in social,
academic (occupational), or other important areas of functioning.
C. Chronological age is at least 5 years (or equivalent developmental level).
D. The behaviour is not attributable to the physiological effects of a
substance (e.g., a diuretic, an antipsychotic medication) or another
medical condition (e.g., diabetes, spina bifida, a seizure disorder).

2) Treatment

Behavioural techniques are useful in treating nocturnal enuresis. They are

restriction of pre-bedtime fluid intake, planned midsleep awakenings for voiding
in toilet, and rewards for successful nights. There are also some pharmacological
interventions for enuresis.
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The management consists of one or more of the following measures:

(1) Restriction of fluid intake after 8 PM, in nocturnal enuresis; (2)

Bladder training during daytime, aimed at increasing the holding-time of
bladder. This is carried out in a step-by-step manner using positive
reinforcements; (3) Interruption of sleep before the expected time of bed
wetting. The child should be fully woken up and made aware of passing of urine;
(4) Conditioning devices, which cause an alarm to sound as soon as the voided
urine touches the bed sheet. It is important to check the child’s hearing before
starting treatment. The alarm causes inhibition of further micturition and the
child awakens. If properly used, it is an effective method of therapy; (5)
Supportive psychotherapy for the child, parents, and the whole family is often
needed; and (6) Pharmacotherapy: Drug treatment is usually not a preferred
option for the treatment of enuresis.

The therapist should establish a good rapport with the child and the
family. Knowledge about enuresis and its treatment can diminish anxieties.
Children can keep a voiding diary in which they log both daytime and night-time
urination patterns for one week. The popular enuresis alarm involves an alarm
worn on the body. A sensor is attached to a pad that is placed inside the child’s
pants, and the alarm is placed on the child’s wrist or in a pocket. When the pad
becomes wet, a sensor in the pad triggers the alarm and the child will get up to
urinate. There is a dry-bed training which may be useful in which the child is
taught to hold his urine for as long as possible during daytime hours. 97

3. Encopresis

Generally, children are developmentally, cognitively, and psychologically

ready to achieve toilet training between 24 to 30 months of age. There are
encopresis with constipation and overflow incontinence and encopresis without
these symptoms. Encopresis with constipation occurs after a severe constipation
resulting from an illness or a change in the diet. The resulting impaction of faecal
material can cause painful bowel movements, and anal fissures or irritations.
The child may develop fear response and withhold faeces in order to avoid
painful bowel movements. Parents insist on evacuating but the child resists and
thus child-parent conflicts ensue. Encopresis without constipation is the result of
operant conditioning, in which the child receives reinforcement of increased
attention from the parents for soiling.98

1) Diagnostic Criteria

A. Repeated passage of faeces into inappropriate places (e.g., clothing,

floor), whether involuntary or intentional.
B. At least one such event occurs each month for at least 3 months.
C. Chronological age is at least 4 years (or equivalent developmental level).
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D. The behaviour is not attributable to the physiological effects of a

substance (e.g., laxatives) or another medical condition except through a
mechanism involving constipation.

2) Treatment

Some of the techniques of treatment are bowel cleansing (laxatives, enemas,

daily maintenance on mineral oil), counselling (education, reducing interpersonal
struggles and negative affects, and rewards) and follow-up. Usually, residual
encopresis in adolescence and adulthood is associated with psychopathology. In
cases of stiff resistance, the focus of treatment must shift from the encopresis to
a more general treatment of associated psychopathological disorders.

The best treatment of encopresis is preventive. The toilet training period

should be made as consistent and smooth as possible. The family environment
should be warm and understanding. The emotional disturbances of the child
should not be ignored and should be dealt with at the earliest. The
communication between the family members should be direct. After encopresis
has developed, the treatment of choice is behaviour therapy, using
reinforcements (both positive and negative).

For a successful training, collaboration among parents, the child, the

therapist, and the physician is needed. There is an enhanced toilet training,
which combines behavioural treatment consisting of reinforcements, instructions
and modelling and parent education with medical management. This method
seems to be promising. Some children are resistant to treatment on account of
the co-occurring aggression, oppositional behaviour or temper tantrums. In this
case, psychodynamic play therapy will be useful. Persistent elimination problems
may indicate the child’s power struggles with the parents or a history of
toileting-associated trauma that may need intervention.99

4. Treatment and Prognosis

Most children outgrow their elimination disorders successfully by the time

they are teens, with the exception of those children, whose elimination disorders
are symptoms of other psychiatric disturbances.

Encopresis is treated with stool softeners or laxatives and by instituting

regular bowel evacuation practice. Enuresis is treated by behaviour
modification including changing night-time toileting habits. The most effective
method is by having the child sleep on a special pad that sets off an alarm when
the pad becomes wet. This wakes up the child and allows him to finish relieving
in the toilet. Eventually he awakes without assistance before wetting. Drugs can
also help in the treatment of enuresis, although relapse is common after they
are stopped. Secondary enuresis caused by stress is treated by resolving the
stress. Psychotherapy is usually not needed, although it may be helpful to
children who develop feelings of shame associated with their elimination
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disorders. Adults can help children avoid shame and embarrassment by treating
elimination accidents as a mater-of-fact and kindly.

Children with voluntary elimination disorders are treated for the diagnosed
psychiatric problem associated with the elimination disorder using behaviour
modification, drugs, and other psychiatric interventions. 100

5. Conclusion

Elimination disorders centre on the elimination of faeces or urine from the

body, usually involuntarily. The causes of elimination disorders range from
physical to mental, but treatment with psychotherapy is recommended for
treatment in either case.

Elimination disorders may be caused by a physical condition, a side effect of

a drug, or a psychiatric disorder. It is much more common for elimination
disorders to be caused by medical conditions than psychiatric ones. In most
cases in which the cause is medical, the soiling is unintentional. When the
causes are psychiatric, the soiling may be intentional, but it is not always so.

Most children outgrow their elimination disorders successfully by the time

they are teens, with the exception of those children, whose elimination disorders
are symptoms of other psychiatric disturbances. Adults can help children avoid
shame and embarrassment by treating elimination accidents as a mater-of-fact
and kindly.

Children with voluntary elimination disorders are treated for the diagnosed
psychiatric problem associated with the elimination disorder using behaviour
modification, drugs, and other psychiatric interventions.

13. SLEEP-WAKE DISORDERS

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1. Introduction

Unlike most of the other disorders, sleep disorders provide no secondary

gains and rewards and so clients want to get rid of the problem. The problem is
reflected by disturbances in the restorativeness and continuity of sleep, and
involves too much sleep, too little sleep, or dysfunctional sleep.

Nearly one third of human life is spent in sleep, a reversible state of relative
unresponsiveness and serenity that occurs more or less regularly and
repetitively each day. The EEG recordings show typical features of sleep, which
is divided into two broadly different phases.

Two Phases of Sleep

1) D-Sleep (desynchronized or dreaming sleep), also called as REM-sleep (rapid

eye movement sleep), active sleep, or paradoxical sleep.

2) S-sleep (synchronized sleep), also called as NREM-sleep (non-REM sleep),

quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four
stages, ranging from stages 1 to 4. As the person falls asleep, the person first
passes through these stages of NREM-sleep.

The EEG Recording

The EEG recording during the waking state shows alpha waves of 8-12
cycles/sec. frequency. The onset of sleep is characterized by a disappearance of
the alpha-activity.

Stage 1, NREM-sleep is the first and the lightest stage of sleep characterized
by an absence of alpha-waves, and low voltage, predominantly theta activity.

Stage 2, NREM-sleep follows the stage 1 within a few minutes and is

characterized by two typical EEG changes:

i) Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec.

frequency, lasting 0.5-2.0 seconds, with a characteristic waxing and waning
amplitude.

ii) K-complexes: High voltage spikes are present intermittently. αμV, δ-

Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of

0.5-3.0 cycles/sec.

Stage 4, NREM-sleep shows predominant δ-activity in EEG.

NREM-sleep is followed by REM-sleep, which is a light phase of sleep. The

EEG is characterized by a return of α-waves (α-sleep); other changes are similar
to stage 1 NREM-sleep. One of the most characteristic features of REM-sleep is
presence of REM or rapid (conjugate) eye movements. The other features
include generalized muscular atony, penile erection, autonomic hyperactivity
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(increase in pulse rate, respiratory rate and blood pressure), and movements of
small muscle groups, occurring intermittently. Although it is a light stage of
sleep, arousal is difficult.

These stages occur regularly throughout the whole duration of sleep. The first
REM period occurs typically after 90 minutes of the onset of sleep, although it
can start as early as 7 minutes after going-off to sleep, e.g., in narcolepsy, in
major depression, and after sleep deprivation.

Health Consequences and the Importance of Sleep

When a person does not get a good night’s sleep, it has a plethora of health
and cognitive consequences:

The most obvious concerns are fatigue and cognitive focus, but mood can be
greatly affected, too. A sleep disorder not only is a risk factor for subsequent
development of certain mental conditions but a potential warning sign for serious
mental or medical issues. For example, sleep disturbances can signal the
presence of medical and neurological problems such as congestive heart failure,
osteoarthritis, and Parkinson’s disease.

Sleep disorders range from insomnia disorder to narcolepsy and breathing-

related disorders to “restless legs syndrome.” They are diagnosed through
comprehensive assessment, which may entail a detailed patient history, physical
exam, questionnaires and sleep diaries, and clinical testing. They often are
addressed in similarly comprehensive ways involving behavioural, pharmacologic
and other treatments in combination with medical care.101

The classification of sleep-wake disorders is intended for use by general

mental health and medical clinician (those caring for adult, geriatric, and
paediatric patients). Sleep-wake disorders encompass 10 disorders: (1)
insomnia disorder, (2) hypersomnolence disorder, (3) narcolepsy, (4)
breathing-related sleep disorders, (5) circadian rhythm sleep-wake disorders,
(6) non-rapid eye movement (NREM) sleep arousal disorders, (7) nightmare
disorder, (8) rapid eye movement (REM) sleep behaviour disorder, (9) restless
legs syndrome, and (10) substance/medication-induced sleep disorder.
Individuals with these disorders complain of dissatisfaction regarding the quality,
timing, and amount of sleep. Resulting daytime distress and impairment are the
core features shared by all of these sleep-wake disorders.

2. Insomnia Disorder

1) Diagnostic Criteria

A. A predominant complaint of dissatisfaction with sleep quantity or quality,

associated with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty
initiating sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or
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problems returning to sleep after awakenings. (In children, this may

manifest as difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment
in social, occupational, educational, academic, behavioural, or other
important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively
during the course of another sleep-wake disorder (e.g., narcolepsy, a
breathing-related sleep disorder, a circadian rhythm sleep-wake disorder,
a parasomnia).
G. The insomnia is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication).
H. Coexisting mental disorders and medical conditions do not adequately
explain the predominant complaint of insomnia.

2) Treatment

Persons with Insomnia Disorder could be educated about normal sleep and
counselled around habits for promoting good sleep hygiene. One can also use
various relaxation therapies like hypnosis, meditation, deep breathing, and
progressive muscle relaxation. Eliminating environmental cues associated with
arousal can be done by stimulus control behaviour modification. In this
technique, the patients are instructed to use their bed only for sleep and
intimacy, to go to bed only when sleepy, to remove clocks from sight, and to
adhere to a stable sleep-wake schedule. This is to reduce the amount of wake
time spent in bed, thereby reestablishing the association between the bed and
sleep.102

3. Hypersomnolence Disorder

1) Diagnostic Criteria

A. Self-reported excessive sleepiness (hypersomnolence) despite a main

sleep period lasting at least 7 hours, with at least one of the following
symptoms:
1. Recurrent periods of sleep or lapses into sleep within the same day.
2. A prolonged main sleep episode of more than 9 hours per day that is
nonrestorative (i.e., unrefreshing).
3. Difficulty being fully awake after abrupt awakening.
B. The hypersomnolence occurs at least three times per week, for at least 3
months.
C. The hypersomnolence is accompanied by significant distress or
impairment in cognitive, social, occupational, or other important areas of
functioning.
D. The hypersomnolence is not better explained by and does not occur
exclusively during the course of another sleep disorder (e.g., narcolepsy,
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breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or

a parasomnia).
E. The hypersomnolence is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication.
F. Coexisting mental and medical disorders do not adequately explain the
predominant complaint of hypersomnolence.

2) Treatment

Hypersomnolence, also known as hypersomnia, involves repeated

or prolonged bouts of sleep or sleepiness at inappropriate times, such as during
the daytime or morning hours when the person is required to be awake.

The ideal treatment for hypersomnolence is based upon the symptoms

experienced. Stimulant medications, such as dose-controlled amphetamines,
most often prescribed for ADHD, can be used to sustain alertness in individuals
with hypersomnolence. Several examples include d-
amphetamine, methylphenidate (an ingredient in brand names, Ritalin and
Concerta) and modafinil. Other drugs used to treat hypersomnolence include
clonidine, levodopa, bromocriptine, activating antidepressants, and monoamine
oxidase inhibitors.

Behavioural techniques can also be helpful for regulating one’s sleep schedule
in ways that promote optimal day-to-day functioning. For example, avoiding
late-night work and social activities prevent delayed bedtime (one cause of
excessive daytime sleepiness). Patients should also avoid ingesting alcohol and
caffeine in the hours close to bedtime.103

4. Narcolepsy

1) Diagnostic Criteria

A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or

napping occurring within the same day. These must have been occurring
at least three times per week over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a
few times per month:
a. In individuals with long-standing disease, brief (seconds to
minutes) episodes of sudden bilateral loss of muscle tone with
maintained consciousness that are precipitated by laughter or
joking.
b. In children or in individuals within 6 months of onset, spontaneous
grimaces or jaw-opening episodes with tongue thrusting or a global
hypotonia, without any obvious emotional triggers.
2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF)
hypocretin-1 immunoreactivity values (less than or equal to one-third of
values obtained in healthy subjects tested using the same assay, or less than
or equal to 110 pg/mL). Low CSF levels of hypocretin-1 must not be
observed in the context of acute brain injury, inflammation, or infection.
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3. Nocturnal sleep polysomnography showing rapid eye movement (REM)

sleep latency less than or equal to 15 minutes, or a multiple sleep latency
test showing a mean sleep latency less than or equal to 8 minutes and
two or more sleep-onset REM periods.

2) Treatment

Treatment of narcolepsy has both nonpharmacologic and pharmacologic

components. Sleep hygiene is important. Most patients improve if they maintain
a regular sleep schedule, usually 7.5-8 hours of sleep per night. Scheduled naps
during the day also may help. 

Pharmacologic treatment of narcolepsy involves the use of central nervous

system (CNS) stimulants such as methylphenidate, modafinil,
dextroamphetamine sulfate, methamphetamine, and amphetamine. These
medications help reduce daytime sleepiness, improving the symptom in 65-85%
of patients. In patients for whom stimulant treatment is problematic, subjective
benefit from treatment with codeine has been reported. 104

5. Breathing-Related Sleep Disorders

The breathing-related sleep disorders category encompasses three

relatively distinct disorders: obstructive sleep apnoea hypopnoea, central sleep
apnoea, and sleep-related hypo-ventilation.

1) Obstructive Sleep Apnoea Hypopnoea

(1) Diagnostic Criteria

A. Either (1) or (2)

1. Evidence by polysomnography of at least five obstructive apnoeas or
hypopnoea per hour of sleep and either of the following sleep
symptoms:
a. Nocturnal breathing disturbances: snoring, snorting/gasping, or
breathing pauses during sleep.
b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient
opportunities to sleep that is not better explained by another
mental disorder (including a sleep disorder) and is not attributable
to another medical condition.
2. Evidence by polysomnography of 15 or more obstructive apnoeas
and/or hypopnoea per hour of sleep regardless of accompanying
symptoms.

2) Central Sleep Apnoea

(1) Diagnostic Criteria

A. Evidence by polysomnography of five or more central apnoeas per hour of

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sleep.
B. The disorder is not better explained by another current sleep disorder.

3) Sleep-Related Hypoventilation

(1) Diagnostic Criteria

A. Polysomnograpy demonstrates episodes of decreased respiration

associated with elevated CO2 levels. (Note: In the absence of objective
measurement of CO2, persistent low levels of hemoglobin oxygen
saturation unassociated with apneic/hypopneic events may indicate
hypoventilation.)
B. The disturbance is not better explained by another current sleep disorder.

4) Treatment for Breathing-Related Sleep Disorders

For the treatment of Breathing-Related Sleep Disorders, there are a few

behavioural approaches, which include weight loss, abstinence from sedative-
hypnotics, and sleep-position training (which helps the patient avoid the supine
position during sleep). Mechanical approaches include use of tongue-retaining
devices, orthodontic appliances that advance the mandible and thus regulate the
nasal continuous positive airway pressure. Some patients benefit from surgical
techniques.

(1) Conservative Treatments — In mild cases of obstructive sleep apnoea,

conservative therapy may be all that is needed. Overweight persons can benefit
from losing weight. Even a 10 percent weight loss can reduce the number of
apnoeic events for most patients. However, losing weight can be difficult to
attain with untreated obstructive sleep apnoea due to increased appetite and
metabolism changes that can occur with obstructive sleep apnoea. Individuals
with obstructive sleep apnoea should avoid the use of alcohol and
certain sleeping pills, which make the airway more likely to collapse during sleep
and prolong the apnoeic periods. In some patients with mild obstructive sleep
apnoea, breathing pauses occur only when they sleep on their backs. In such
cases, using pillows and other devices that help them sleep in a side position
may be helpful. People with sinus problems or nasal congestion should use nasal
sprays or breathing strips to reduce snoring and improve airflow for more
comfortable night-time breathing. Avoiding sleep deprivation is important for all
patients with sleep disorders.

(2) Mechanical Therapy — Positive Airway Pressure (PAP) therapy is the

preferred initial treatment for most people with obstructive sleep apnoea. With
PAP therapy, patients wear a mask over their nose and/or mouth. An air blower
gently forces air through the nose and/or mouth. The air pressure is adjusted so
that it is just enough to prevent the upper airway tissues from collapsing during
sleep. PAP therapy prevents airway closure while in use, but apnoea episodes
return when PAP is stopped or if it is used improperly. There are several styles,
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and types of positive airway pressure devices depending on specific needs of

patients.

(3) CPAP (Continuous Positive Airway Pressure) is the most widely used of
the PAP devices. The machine is set at one single pressure.

(4) Bi-Level PAP uses one pressure during inspiration, and a lower pressure
during expiration.

(5) Auto CPAP or Auto Bi-Level PAP uses a range of pressures that self-
regulates during use depending on pressure requirements detected by the
machine.

(6) Adaptive Servo-Ventilation (ASV) is a type of non-invasive ventilation

that is used for patients with central sleep apnoea, which acts to keep the airway
open and delivers a mandatory breath when needed.

(7) Mandibular Advancement Devices — These are devices for patients with
mild to moderate obstructive sleep apnoea. Dental appliances or oral mandibular
advancement devices that help prevent the tongue from blocking the throat
and/or advance the lower jaw forward can be made. These devices help keep the
airway open during sleep. A sleep specialist and dentist (with expertise in oral
appliances for this purpose) should jointly determine if this treatment is best for
the client.

(8) Nasal Expiratory Positive Airway Pressure — The device is worn over
both nostrils with the mouth closed to cause an increase in the airway calibre by
increasing expiratory resistance.

(9) Oral Pressure Therapy — The device is worn in the mouth with the patient
breathing through the nose. A vacuum pump with negative pressure pulls the
soft palate forward to open the airway.

(10) Hypoglossal Nerve Stimulator — A stimulator is implanted under the

skin on the right side of the chest with electrodes tunnelled under the skin to the
hypoglossal nerve in the neck and to intercostal muscles in the chest. When the
hypoglossal nerve is stimulated, the tongue moves forward out of the airway and
the airway is opened.

(11) Surgery — Surgical procedures may help people with obstructive sleep

apnoea and others who snore but do not have sleep apnoea. There are many
types of surgical procedures, some of which are performed as outpatient
procedures. Surgery is reserved for people who have excessive or malformed
tissue obstructing airflow through the nose or throat, such as a deviated nasal
septum, markedly enlarged tonsils, or small lower jaw with an overbite that
causes the throat to be abnormally narrow. These procedures are typically
performed after sleep apnoea has failed to respond to conservative measures
and a trial of CPAP. Types of surgery include:

a. Somnoplasty is a minimally invasive procedure that uses radiofrequency

energy to reduce the soft tissue in the upper airway.
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b. Tonsillectomy is a procedure that removes the tonsillar tissue in the back of

the throat which is a common cause of obstruction in children with sleep apnoea.

c. Uvulopalatopharyngoplasty (UPPP) is a procedure that removes soft

tissue on the back of the throat and palate, increasing the width of the airway at
the throat opening.

d. Mandibular/Maxillary Advancement Surgery is a surgical correction of

certain facial abnormalities or throat obstructions that contribute to obstructive
sleep apnoea. This is an invasive procedure that is reserved for patients with
severe obstructive sleep apnoea with head-face abnormalities.

e. Nasal surgery includes correction of nasal obstructions, such as a deviated

septum.105

6. Circadian Rhythm Sleep-Wake Disorders

1) Diagnostic Criteria

A. A persistent or recurrent pattern of sleep disruption that is primarily due

to an alteration of the circadian system or to a misalignment between the
endogenous circadian rhythm and the sleep-wake schedule required by an
individual’s physical environment or social or professional schedule.
B. The sleep disruption leads to excessive sleepiness or insomnia, or both.
C. The sleep disturbance causes clinically significant distress or impairment
in social, occupational, and other important areas of functioning.

2) Treatment

For people with Circadian Rhythm Sleep-Wake Disorder, the overall treatment
approach is to promote good sleep hygiene, with the goal of properly aligning
the patients’ circadian system with their sleep-wake schedule. Phototherapy is
known to help people with circadian rhythm sleep disorder. Exposure to light at
2,000 lux or more can shift circadian rhythms. Patients are instructed to sit 3
feet in front of a bright light source of at least 2,500 lux intensity. Patients may
require between 30 minutes and 2 hours of exposure, depending on therapeutic
response. The timing of exposure depends on the direction in which patients
wish to shift their sleep-wake schedule. Morning or evening exposure will phase-
advance or phase-delay the sleep-wake schedule, respectively. Melatonin is used
primarily for its apparent ability to phase-shift the endogenous circadian rhythm.
Ingestion of melatonin in the early evening causes the endogenous melatonin
release to occur earlier and produces an enhanced propensity for an earlier sleep
onset.106

7. Parasomnias

Parasomnias are disorders characterized by abnormal behavioural,

experiential, or physiological events occurring in association with sleep, specific
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sleep stages, or sleep-wake transitions. The most common parasomnias — non-

rapid eye movement (NREM) sleep arousal disorders and rapid eye movement
(REM) sleep behaviour disorder — represent admixtures of wakefulness and
NREM sleep and wakefulness and REM sleep, respectively. These conditions
serve as a reminder that sleep and wakefulness are not mutually exclusive and
that sleep is not necessarily a global, whole-brain phenomenon.

1) Non-Rapid Eye Movement Sleep Arousal Disorders

(1) Diagnostic Criteria

A. Recurrent episodes of incomplete awakening from sleep, usually occurring

during the first third of the major sleep episode, accompanied by either
one of the following:
1. Sleepwalking: Repeated episodes of rising from bed during sleep and
walking about. While sleepwalking, the individual has a blank, staring
face; is relatively unresponsive to the efforts of others to communicate
with him; and can be awakened only with great difficulty.
2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep,
usually beginning with a panicky scream. There is intense fear and
signs of autonomic arousal, such as mydriasis, tachycardia, rapid
breathing, and sweating, during each episode. There is relative
unresponsiveness to efforts of others to comfort the individual during
the episodes.
B. No or little (e.g., only a single visual scene) dream imagery is recalled.
C. Amnesia for the episodes is present.
D. The episodes cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a
substance e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not explain the episodes of
sleepwalking or sleep terrors.

(2) Treatment

If no violent behaviour is observed, initial treatment for Non-Rapid Eye

Movement Sleep Arousal Disorders focuses on reassuring and educating the
patient and his family about the fact that these arousal disorders are typically
benign and tend to dissipate over time.

Good sleep health practices, such as getting enough sleep and avoiding
alcohol use, should be discussed. For some of these conditions, such as sleep-
walking, the environment can be made safer by removing harmful objects from
the bedroom and locking doors and windows to prevent the patient from injuring
himself.

Treatment may be required if the Non-Rapid Eye Movement (NREM) Sleep

Arousal Disorders are dangerous or distressing to the individual (i.e. violent). In
this case, non-pharmacological therapies for long-term management include
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psychotherapy, progressive relaxation, and hypnosis. Pharmacotherapy with

benzodiazepines (typically clonazepam), tricyclic antidepressants (typically
imipramine), or SSRIs (typically paroxetine) may provide temporary relief for
those who experience NREM Sleep Arousal Disorders. Any underlying conditions
that impact the Non-REM Sleep Arousal Disorders should also be addressed. 107

2) Rapid Eye Movement Sleep Behaviour Disorder (RBD)

(1) Diagnostic Criteria

A. Repeated episodes of arousal during sleep associated with vocalization

and/or complex motor behaviours.
B. These behaviours arise during rapid eye movement (REM) sleep and
therefore usually occur more than 90 minutes after sleep onset, are more
frequent during the later portions of the sleep period, and uncommonly
occur during daytime naps.
C. Upon awakening from these episodes, the individual is completely awake,
alert, and not confused or disoriented.
D. Either of the following:
1. REM sleep without atonia on polysomnographic recording.
2. A history suggestive of REM sleep behaviour disorder and an
established synucleinopathy diagnosis (e.g., Parkinson’s disease,
multiple system atrophy).
E. The behaviours cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning (which may include
injury to self or the bed partner).
F. The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition.
G. Coexisting mental and medical disorders do not explain the episodes.

(2) Treatment

RBD tends to respond to treatment with medications. Clonazepam is often

used. However, treatment also requires the following: Bedroom safety
precautions; Move objects away from the patient’s bedside (This includes night
stands, lamps, or other objects that could cause injury); Move the bed away
from the window; Place a large object such as a dresser in front of the window;
Maintain a normal total sleep time. Sleep deprivation will increase RBD. Monitor
for any sleepiness; Avoid certain medications and alcohol (They can cause or
increase RBD); Treat any and all other sleep disorders that will disrupt one’s
sleep and increase RBD; and undergo regular monitoring for any neurologic
symptoms. This includes tremor or other Parkinson symptoms. 108

3) Nightmare Disorder

(1) Diagnostic Criteria

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A. Repeated occurrences of extended, extremely dysphoric, and well-

remembered dreams that usually involve efforts to avoid threats to
survival, security, or physical integrity and that generally occur during the
second half of the major sleep episode.
B. On awakening from the dysphoric dreams, the individual rapidly becomes
oriented and alert.
C. The sleep disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects
of a substance (e.g., a drug of abuse, a medication).
E. Coexisting mental and medical disorders do not adequately explain the
predominant complaint of dysphoric dreams.

(2) Treatment

Reassurance and conservative management is the only treatment required

for sporadic nightmares. Daytime stressors should be identified and resolution
attempted. Bedtime should become a safe and comfortable time when parents
read to and talk with the child. Parents should monitor media exposure, as this
influences dream content. Television viewing should be avoided for about 2 hours
prior to bedtime. The most common strategies reported by children for handling
their nightmares include ignoring/distraction, talking to parents, or hugging soft
toys.  Several different cognitive-behavioural methods have been reported to be
effective in treating nightmares in children.  Hypnosis has been reported to be
effective in treating nightmares and other parasomnias in children and adults.  If
the nightmare is recurrent, discussing dream content and rescripting may
help.109

4) Restless Legs Syndrome (RLS)

(1) Diagnostic Criteria

A. An urge to move the legs, usually accompanied by or in response to

uncomfortable and unpleasant sensations in the legs, characterized by all
of the following:
1. The urge to move the legs begins or worsens during periods of rest or
inactivity.
2. The urge to move the leg is partially or totally relieved by movement.
3. The urge to move the legs is worse in the evening or at night than
during the day, or occurs only in the evening or at night.
B. The symptoms in Criterion A occur at least three times per week and have
persisted for at least 3 months.
C. The symptoms in Criterion A are accompanied by significant distress or
impairment in social, occupational, educational, academic, behavioural, or
other important areas of functioning.
D. The symptoms in Criterion A are not attributable to another mental
disorder or medical condition (e.g., arthritis, leg edema, peripheral
ischemia, leg cramps) and are not better explained by a behavioural
condition (e.g., positional discomfort, habitual foot tapping).
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E. The symptoms are not attributable to the physiological effects of a drug of

abuse or medication (e.g., akathisia).

(2) Treatment

There are no cures for primary restless legs syndrome, or RLS, although

various treatments often can help relieve symptoms. Treatment for
secondary restless legs syndrome (RLS caused by another medical problem)
involves treating the underlying cause.

The first line of defence against restless legs syndrome is to avoid

substances or foods that may be causing or worsening the problem. Stay away
from alcohol, caffeine, and nicotine. This may help relieve one’s symptoms. In
addition, review all medications one is taking with one’s doctor to determine if any
of these drugs could be causing the problem.
Any underlying medical conditions, such as anaemia, diabetes, nutritional
deficiencies, kidney disease, thyroid disease, varicose veins, or Parkinson's
disease, should be treated. Dietary supplements to correct vitamin or mineral
deficiency may be recommended. For some people, these treatments are all that
is needed to relieve RLS symptoms.

One may also benefit from physical therapy and self-care treatments, such

as stretching, taking hot or cold baths, whirlpool baths, applying hot or cold packs
to the affected area, limb massage, or vibratory or electrical stimulation of the
feet and toes before bedtime. Exercise and relaxation techniques also may be
helpful.110
5) Substance/Medication-Induced Sleep Disorder

1) Diagnostic Criteria

A. A prominent and severe disturbance in sleep.

B. There is evidence from the history, physical examination, or laboratory
findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance
intoxication or after withdrawal from or exposure to a medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
C. The disturbance is not better explained by a sleep disorder that is not
substance/medication-induced. Such evidence of an independent sleep
disorder could include the following:
The symptoms precede the onset of the substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month)
after the cessation of acute withdrawal or severe intoxication; or there is
other evidence suggesting the existence of an independent non-
substance/medication-induced sleep disorder (e.g., a history of recurrent
non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
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2) Treatment

Treatment for Substance/Medication-Induced Sleep Disorder consists in

avoiding the substance or medication that causes the disorder.

8. Treatment for Sleep Disorders

In treating sleep disorders, the therapist needs to make sure that the
client has a sleeping environment conducive to restful sleep, and to ensure good
sleep hygiene. The sleep pattern is to be established eliminating naps and
caffeine and establishing healthy patterns of eating, drinking, and exercising.
People with sleep disorders can be treated through behaviour therapy. Stimulus
control therapy and progressive muscle relaxation (PMR) have proven to be
helpful. There are also other effective treatments like sleep restriction, CBT,
followed by multi-component therapy without DBT, biofeedback, paradoxical
intention requiring the person to stay awake, and limiting the time available to
sleep. If it is a question of circadian rhythm problem, bright light therapy can be
helpful. Stimulus control therapy consists of a set of instructions to be followed
at bedtime to reduce behaviours that are incompatible with sleep and to address
circadian factors.

The instructions are (1) Go to bed when tired. (2) Use the bedroom only
for sleep-related activity and sex. Do not eat, watch television, work, or read in
the bedroom during the day or night. (3) Do not take a nap during the day. (4)
If unable to sleep after trying for 15 to 20 minutes, get up and go to another
room. Return to bed only when tired again. (5) Wake up in the morning at the
same time regardless of the amount of sleep the night before.

Relaxation therapy like progressive muscle relaxation, biofeedback, and

cognitive thought-stopping techniques are helpful. Sleep hygiene education
includes health-related practices such as diet, exercise, and control of substance
use, and helps clients regulate their environment (light, noise, and temperature)
so that it is conducive to sleep. Cognitive-behaviour therapy addresses the
maladaptive cognitions that tend to perpetuate insomnia. Not having sleep
causes worry about not sleeping, and the worry in turn exacerbates the difficulty
in sleeping. It is important to break the cycle to reduce the symptoms.

Sedative-hypnotic medications are used for insomnia. Circadian rhythm

sleep disorder, jet lag type, and shift work type are treated through lifestyle
modification that stabilizes sleep patterns. There is also another therapy called
chronotherapy or resetting of the biological clock. Phototherapy (light therapy),
stress management, relaxation, avoidance of alcohol and caffeine, and improved
sleep habits are all different types of treatment. Clients also benefit from
education and attention to any underlying conflicts or sources of excessive
arousal.111
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9. Conclusion

There are several different types of sleep-wake disorders. All involve

problems falling asleep or staying awake at desired or socially appropriate times.
Diagnosis of sleep-wake disorders is based on the type of sleep problems
present and the timing and setting in which they occur.

Sleep-wake disorders occur when the body’s internal clock does not work
properly or is uncoordinated with the surrounding environment. The body has an
internal timing system called the circadian system that regulates daily behaviour
and bodily functions through cycles called circadian rhythms. Circadian rhythms
influence things such as sleeping and eating patterns, body temperature, and
the production of certain hormones. These rhythms repeat approximately every
24 hours. (circa = about, approximately; dies = a day; circadian rhythms are
rhythms that repeat once a day, or in 24 hours)

A particular part of the brain called the suprachiasmatic nucleus generates

circadian rhythms. Exposure to light also affects the timing of the rhythms.
Normally, circadian rhythms are coordinated with the surrounding environment,
which helps people stay awake during the daytime and fall asleep at night.
Circadian rhythm sleep-wake disorders occur when the synchronization between
circadian rhythms and the external environment is lost or when the circadian
system itself is dysfunctional.

The specific treatment of sleep-wake disorders depends on the type of sleep-

wake disorder. In general, strategically timed exposure to light and following a
sleep schedule are behavioural changes that may be helpful. Melatonin is a
hormone produced by the body that regulates sleep-wake cycles, and melatonin
supplements may be used in some situations to help align the body’s circadian
rhythms with the outside environment. Other medications may also be used,
depending on the scenario, to either promote wakefulness or facilitate sleep.

14. SEXUAL DYSFUNCTIONS

1. Introduction
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Most sexual dysfunctions begin in early adulthood; however, male erectile

disorder tends to begin later. The course of the sexual dysfunctions is quite
variable. Some are due to the situations precipitated by stress or relationship
problems, and remit spontaneously once the situation changes. Others are
chronic or progressive, worsening as anxiety about the symptom increases. The
problems have many possible determinants including lifestyle factors such as
obesity, smoking, and lack of exercise, relationship factors, substances and
medical conditions, cultural and family background, knowledge about sexuality,
sexual and relationship history, potential history of sexual abuse, self-image,
coexisting mental disorder, negative attitudes towards sex on the part of clients
and their parents, clients’ dissatisfaction with and instability in their intimate
relationships, clients’ discomfort with their sexual identities, fear of rejection and
abandonment, difficulty sharing control and trusting others, poor communication
skills, anger and hostility, guilt about sexual thoughts and behaviours, impaired
self-esteem, anxiety about sexual performance, depression, and inaccurate
information about sexual functioning.112

2. Normal Human Sexual Response Cycle113

A normal human sexual response cycle can be divided into five

phases. Problems can arise in any of the five phases. The phases are:

1. Appetitive Phase: The phase before the actual sexual response cycle.
This consists of sexual fantasies and a desire to have sexual activity.

2. Excitement Phase: The first true phase of the cycle, which starts with
physical stimulation and/or by appetitive phase. The major changes
during this phase are:

Males: Penile erection, due to vasocongestion of corpus cavernosa;

elevation of testes with scrotal sac.

Females: Lubrication of vagina by a transudate; erection of nipples (in

most women); erection of clitoris; thickening of labia minora.
The duration of this phase is highly variable and may last for several
minutes (or longer).

3. Plateau Phase: The intermediate phase just before actual orgasm, at

the height of excitement. It is often difficult to differentiate the plateau
phase from the excitement phase. The following important changes
occur during this phase:

Males: Sexual flush (inconsistent); autonomic hyperactivity (increase in

pulse rate, respiratory rate and blood pressure); erection and
engorgement of penis to full size; elevation and enlargement of testes;
dew drops on glans penis (2-3 drops of mucoid fluid with spermatozoa).

Females: Sexual flush (inconsistent): Autonomic hyperactivity; retraction

of clitoris behind the prepuce; development of orgasmic platform in the
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lower 1/3rd of vagina, with lengthening and ballooning of vagina;

enlargement of breasts and labia minora; increased vaginal transudate.

The duration of this phase may last from half to several minutes.

4. Orgasmic Phase: the phase with peak of sexual excitement followed by

release of sexual tension, and rhythmic contractions of pelvic
reproductive organs. The important changes are as follows:

Males: 4-10 contractions of penile urethra, prostate, vas, and seminal

vesicles; at about 0.8 sec intervals; autonomic excitement becomes
marked in this phase. Doubling of pulse rate and respiratory rate, and 10-
40 mm increase in systolic and diastolic BP occur; ejaculatory inevitability
precedes orgasm; Ejaculatory spurt (30-60 cm; decreases with age);
contractions of external and internal sphincters.

Females: 3-15 contractions of lower 1/3 rd of vagina, cervix and uterus; at

about 0.8 sec intervals. No contractions occur in clitoris; autonomic
excitement becomes marked in this phase. Doubling of pulse rate and
respiratory rate, and 10-40 mm increase in systolic and diastolic BP occur;
contractions of external and internal sphincters.

The duration of this phase may last from 3-15 seconds.

5. Resolution Phase: This phase is characterized by the following common

features in both sexes: A general sense of relaxation and well-being,
after the slight clouding of consciousness during the orgasmic phase;
disappearance of sexual flush followed by fine perspiration; gradual
decrease in vasocongestion from sexual organs and rest of the body;
refractory period for further orgasm in males varies from a few
minutes to many hours; there is usually no refractory period in
females.

Sexual dysfunctions are a heterogeneous group of disorders that are

typically characterized by a clinically significant disturbance in a person’s ability
to respond sexually or to experience sexual pleasure. An individual may have
several sexual dysfunctions at the same time. In such cases, all of the
dysfunctions should be diagnosed.

3. Male Hypoactive Sexual Desire Disorder

1) Diagnostic Criteria

A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or

fantasies and desire for sexual activity. The judgement of deficiency is
made by the clinician, taking into account factors that affect sexual
functioning, such as age and general and socio-cultural contexts of the
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individual’s life.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress or other
significant stressors and is not attributable to the effects of a
substance/medication or another medical condition.

2) Treatment
Hypoactive sexual desire disorder has been the most difficult of all the
dysfunctions to treat. Testosterone has been used (in both men and women);
however, masculinising side effects make its use problematic in women. There is
no consistent evidence that it is useful for both men and women. The most
effective treatments involve a combination of cognitive therapy to deal with
maladaptive beliefs (e.g., that partners must always want sex at the same
time), behavioural treatment (e.g., exercises to enhance sexual pleasure and
communication), and marital therapy (e.g., to deal with the individual’s use of
sex to control the relationship).114
4. Erectile Disorder

1) Diagnostic Criteria

A. At least one of the three following symptoms must be experienced on

almost all or all (approximately 75%-100%) occasions of sexual activity
(in identified situational contexts or, if generalized, in all contexts):
1. Marked difficulty in obtaining an erection during sexual activity,.
2. Marked difficulty in maintaining an erection until the completion of
sexual activity.
3. Marked decrease in erectile rigidity.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress or other
significant stressors and is not attributable to the effects of a
substance/medication or another medical condition.

2) Treatment

If the patient has a willing sexual partner to participate in therapy, it is easier

to treat the erectile problems. It is also possible to treat someone without a
partner’s attendance. The main task of treatment is the use of behavioural
assignments to gradually decrease performance anxiety. Sensate focus
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exercises are helpful in which the patient engages in nongenital, nondemand

caressing with a partner and concentrates on pleasurable, genital sexual
activities (e.g., touch, oral contact) with no penetration permitted until anxiety
has been decreased sufficiently to permit full erectile function. One could also
employ group therapy, hypnotherapy, and systematic desensitisation by
reducing anxiety associated with being sexual. Psychodynamic interventions
could be useful in alleviating intrapsychic conflicts contributing to performance
anxiety. Couple therapy too can be beneficial.

Somatic treatments can be sufficiently helpful. Testosterone is administered

in cases of erectile problems due to hypogonadism. Vasoactive injections into
the corpora cavernosa can be successfully used. It is noted that the combination
of traditional sex therapy techniques and these injections may be helpful even in
cases of purely psychogenic erectile dysfunction.

Topical medications directly relax arterial smooth muscle in the penis. Oral
medications such as yohimbine is found to be useful. A major noninvasive,
nonpharmacological treatment is an external vacuum device. The device has a
plastic cylinder with one end open and the other end connected to a vacuum
pump. A vacuum is created that draws blood into the penis. A tension ring is
then slipped from the cylinder to the base of the penis for up to 30 minutes. For
individuals with pure organic or combination organic-psychogenic impotence who
do not respond to other treatment measures, penile prostheses (either bendable
silicone implant or an inflatable implant) can be used.

(1) Psychological Treatments

If conditions such as anxiety or depression are causing one’s erectile

dysfunction, one may benefit from counselling (a talking therapy).

(2) Psychosexual Counselling

Psychosexual counselling is a form of relationship therapy where the client

and his partner can discuss any sexual or emotional issues that may be
contributing to his erectile dysfunction. By talking about the issues, the client
may be able to reduce any anxiety that he has and overcome his erectile
dysfunction. The counsellor can also provide him with some practical advice
about sex, such as how to make effective use of other treatments for erectile
dysfunction to improve his sex life. Psychosexual counselling may take time to
work and the results achieved have been mixed.

(3) Cognitive Behavioural Therapy (CBT)

Cognitive behavioural therapy (CBT) is another form of counselling that

may be useful if one has erectile dysfunction. CBT is based on the principle that
the way one feels is partly dependent on the way one thinks about things. CBT
helps one realise that one’s problems are often created by one’s mindset. It is
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not the situation itself that is making one unhappy, but how one thinks about it
and reacts to it. The CBT therapist can help one to identify any unhelpful or
unrealistic thoughts that may be contributing to one’s erectile dysfunction — for
example, to do with: One’s self-esteem (the way one feels about oneself); one’s
sexuality; and one’s personal relationships. The CBT therapist will be able to
help one to adopt more realistic and helpful thoughts about these issues.

(4) Sensate Focus/Sexual Skills Training

If one’s erectile dysfunction has an underlying psychological cause then one

may benefit from a type of treatment called sensate focus.

Focus on Sensations

Sensate focus was developed by Masters and Johnson (1970). What is

aimed at by this process is to develop a heightened awareness of, and focus on,
sensations rather than performance — hence, “sensate focus.” By this, a person
or couple reduces anxiety by striving toward something that is immediately
achievable (i.e., emotional comfort and physical pleasure) rather than
simply trying to get an erection. An erection may not be achievable and may
increase the risk of “failure” and embarrassment. This is a gradual approach to
change. Clients discontinue intercourse early in therapy so that they can relearn
the “basics” of being affectionate and receiving pleasure. For some clients,
intercourse will not be reintroduced into their sexual repertoire for weeks or
even months. Sensate focus therapy and home exercises need to be conducted
in a shared and nonthreatening environment. The procedures for sensate focus
involve encouraging a couple to approach intimate physical and emotional
involvement with each other in a gradual, nonthreatening manner.

First Step

The first step of sensate focus typically includes nongenital touching (i.e.,
pleasuring) while both partners are dressed in comfortable clothing. The least
threatening behaviours may include back rubs or holding hands. The couple
should begin their physical involvement at a level that is acceptable to both
participants. Sensate focus is a type of sex therapy that the client and his
partner complete together. It starts with both agreeing not to have sex for a
number of weeks or months. During this time, they can still touch each other,
but not in the genital area (or a woman’s breasts). The idea is to explore one’s
bodies knowing that one will not have sex.

Second Step

The second step involves genital pleasuring. In this phase, partners are
encouraged to extend gentle touching to the genital and breast regions. Partners
are encouraged to caress each other, in turn, in a way that is pleasurable. The
couple is discouraged from focusing on performance-related goals (e.g., erection
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and orgasm). One can also begin to use one’s mouth to touch one’s partner, for
example, licking or kissing, them. This can build up to include penetrative sex.

Third Step

Once a couple becomes comfortable with genital touching and is ready to

resume sexual intercourse, it is necessary to emphasize that even sexual
intercourse can be broken down into several behaviours. Some may be
encouraged to engage in “containment without thrusting.” It will mean that
the receptive partner permits penetration and controls all aspects of this
exercise, like for example, the depth of penetration, and the amount of time
spent on penetration, which can be varied. The couple is to be encouraged
flexibility and variation in order to remove pressure associated with a couple’s
tendency to think in all-or-none terms.

(5) Avoiding Hurry, Worry, Fear, and Anxiety

Hurry, worry, fear, and anxiety will dampen one’s performance of sex.
Doing sex in a mighty hurry will not give enough satisfaction for the partner and
besides, the individual has to exert to perform the act. If there is a constant
worry, that might prevent one’s performance. Likewise, fear and anxiety too
come in the way of satisfying sex. Therefore, one needs to be relaxed in order to
be aroused sufficiently and engage peacefully and with ardent desire in the
sexual activity. Those who have the problem of anxiety disorder are likely to
meet with failure in the presence of hurry, worry, fear, and anxiety. There
should be a peaceful atmosphere without being interrupted by outside forces and
internal disturbance of hurry, worry, fear, and anxiety for the optimum level of
functioning of sexual activity.

(6) Education

Information can help to correct myths and to reverse misunderstandings that

impair sexual functioning; for example the belief that a real man performs in
sex. Myths create expectations that cannot be fulfilled most of the time and
inevitably lead to disappointment, guilt, and blame.

(7) Stimulus Control

Stimulus control refers to efforts to establish a pleasant, relaxing

environment that is conducive to sexual expression, thereby minimizing
interfering circumstances. The couple is to be encouraged to schedule a time for
sex, and to plan for it with as much effort as they might for any other special
event in their life. It is good to remember that anticipation fuels desire.

(8) Cognitive Restructuring

There are two kinds of cognitive restructuring. One is challenging negative

attitudes and the other is reducing interfering thoughts. One of the differences
between a myth and a negative attitude is that the latter is held onto tenaciously
despite compelling data to the contrary. A negative thought could be the
thinking that a lack of the partner’s passion is an indication of unfaithfulness.
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Most cases of erectile disorder are exacerbated and maintained by interfering

thoughts that precede and occur during sexual relations. In non-dysfunctional
men, thoughts preceding and occurring during sexual relations usually focus on
their partner’s or their own body parts, seductive behaviours, and anticipation of
arousal and pleasure. On the contrary, the dysfunctional male is preoccupied
with worries regarding the firmness of his erection, images of his partner being
disappointed, angry, or ridiculing, and distinct feelings of anxiety and
depression.

To help the client with interfering thoughts, the therapist must first help the
client to identify the presence of such thoughts. It is often helpful to give the
client alternative thoughts on which to focus during sexual activity. For example,
focusing on body parts or a sequence of sexual activities is usually more
conducive to arousal. Another strategy is to make him focus his thinking on
more positive thoughts by recalling his thought content during past satisfying
sexual experiences. It is also good to ask the partner what she thinks is the
cause of the erectile problem. This might give you a clue to the cause of the
problem.

(9) Anchoring on Erotic Zones of the Body

Anchor is a tool to keep the ship steady in a particular place. An anchor in

Neuro-Linguistic Programming (NLP) is any stimulus that evokes a consistent
response pattern from an individual. When a person is reliving a past
emotionally charged experience, we deliberately insert a specific stimulus like a
sound, a touch, a specific sight, a smell, or a taste. The stimulus then becomes
associated with the relived experience and will become its anchor. Later when
the associated stimulus is introduced, it will automatically produce the original
experience in the way it was experienced.

For example, you have had a nice experience of swimming. Now you recall
that event reliving it with all the experiences of the senses that were involved in
the original event, like the sight, touch, especially the feeling of coolness or
warmth, the sunshine, the feeling of the water all over the body, the smell of the
herbs of the pond and that of the water, the taste of water entering the mouth
and the sound of the splashing of the water as you swim. When you are fully
experiencing, I touch your forearm just below the wrist and apply a slight
pressure, which is sufficient enough to be felt, being neither too strong nor too
light. Then the touch anchors the experience. Later at any time when I touch
you in the same place with the same pressure, you will experience the original
event in its intensity. This is anchoring. Anchoring can be done with any one
stimulus from any of the five senses or modalities.

Anchoring resembles the conditioned stimulus of Ivan Pavlov. However, there

is a difference. In the experiment of the conditioned stimulus response of Pavlov,
the exercise of presenting a new stimulus to the old response has to be done
repeatedly over a long time for the response to become conditioned. But here in
anchoring one trial of conditioning is enough to produce the desired result. But
for this, certain conditions are required; they are as follows:

(1) Uniqueness
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Uniqueness refers to the place of anchoring. If the place of the body on which
anchoring is done is to be frequently manipulated or touched, then that place
will not differentiate one stimulus from the other. For that sake, we choose a
place that will not normally be used at other times. Anchors are usually done
just below the wrist, on both the knees, and on the palm of the client with your
palm and the fingers clasping his hand. These three places are usually employed
for the therapeutic purpose of anchoring, (though in theory anchoring can be
done on any part of the body).

(2) Timing

When a client is reliving an experience, there comes a moment during the

reliving that he reaches the climax of it and then it declines in its intensity. Here
timing refers to anchoring at the time of the climax, neither earlier nor later.
Otherwise, the anchoring will be weak and will not be forceful enough. Practically
I ask the client to indicate to me when he reaches the climax by raising a finger
of the other hand, and I observe the calibration (changes in skin colour, facial
muscle, breathing rate, and location) of the client, which should confirm the
indication given by the client.

(3) Intensity

The reliving of the original experience to be anchored should be an intense

experience. If the original experience itself is weak and the reliving of it is still
weaker, then you can expect only a weak anchor, which will not be sufficient for
the therapeutic purpose. When intense experiencing is anchored, then you have
a powerful anchor.

(4) Purity

First and foremost, purity refers to the fact that the stimulus you are
introducing for anchoring should not evoke any other experience anchored
previously by chance. For example, if a tone of voice which I use to anchor a
person for a pleasant experience is already understood by the person as a
stimulus evoking a strong negative feeling, then the anchor will not take place
for want of purity. Secondly, when anchoring a pleasant experience, there
should not be any other emotion already present in the client. For example, I
want to anchor a resourceful state of the client. As I am anchoring, if the client
is having a feeling of hatred, then that feeling of hatred will not permit a
resourceful state being anchored.

(5) Associated in the Experience

There are two ways in which we remember a past experience. When I picture
to my mind a past experience, I may be dissociated, which means now when I
look at the picture, though I am there in the picture, I do not have the original
feeling of sight, touch, smell, sound, and taste. I merely become a spectator.
The second way to recall a past experience is, when I picture to myself a past
experience, I feel I am actually experiencing all that I experienced through the
five senses at the original event. Here I am associated. For an anchor to take
place, one should be associated in the experience.

(6) Testing of Anchor

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To make sure, if the anchor has taken place, it needs to be checked. After
anchoring, take the hand with which you anchored and ask the person to come
back to the present situation slowly and engage him with conversation to
distract him so that he has a fully conscious wakeful state. After a while, you
touch the way you anchored him and see if the person experiences the anchored
event. If he experiences the original event then the anchor has taken place,
otherwise you repeat the whole process again.

Once one knows the method of anchoring, one can anchor an erotic
feeling on any body part that is not frequently touched or used ordinarily. For
example, one could anchor a pleasant erotic feeling on the earlobe or neck, or
any part of the body that is not touched normally in day-to-day living and thus
those parts will elicit the desired erotic feeling when retouched (once anchoring
has been done on them earlier).115

5. Delayed Ejaculation

1) Diagnostic Criteria

A. Either of the following symptoms must be experienced on almost all or all

occasions (approximately 75%-100%) of partnered sexual activity (in
identified situational context or, if generalized, in all contexts), and
without the individual desiring delay:
1. Marked delay in ejaculation.
2. Marked infrequency or absence of ejaculation.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress or other
significant stressors and is not attributable to the effects of a
substance/medication or another medical condition.

2) Treatment

Usually the treatment for Delayed Ejaculation is the same as the one used
for the female counterparts. The patient is told to masturbate as quickly as
possible to ejaculation while fantasying that his penis is inside his partner’s
vagina and ejaculating. The patient and his partner could also be taught sensate
focus exercises. If the person masturbates in the presence of his partner, his
partner could be instructed to place her hand over his to know how much of
touching and what pressure is required. Then perhaps he could place over hers,
while she masturbates him to ejaculation. At last, she should sit astride him and
stimulate him, eventually putting his penis in her vagina when he reaches the
point of ejaculatory inevitability. If the individual is not comfortable to ejaculate
in the presence of his partner, then he is given systematic desensitisation. 116

6. Premature (Early) Ejaculation

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1) Diagnostic Criteria

A. A persistent or recurrent pattern of ejaculation occurring during

partnered sexual activity within approximately 1 minute following vaginal
penetration and before the individual wishes it.
Note: Although the diagnosis of premature (early) ejaculation may be
applied to individuals engaged in nonvaginal sexual activities, specific
duration criteria have not been established for these activities.
B. The symptom in Criterion A must have been present for at least 6
months and must be experienced on almost all or all (approximately
75%-100%) occasions of sexual activity (in identified situational contexts
or, if generalized, in all contexts).
C. The symptom in Criterion A causes clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress or other
significant stressors and is not attributable to the effects of a
substance/medication or another medical condition.

2) Treatment

The treatment for Premature Ejaculation requires that the patient tolerate high
levels of excitement without ejaculating, and reducing anxiety associated with
sexual arousal. There are two successful techniques, namely start-stop
technique and squeeze technique. In start-stop technique, the patient lies
on his back while his partner strokes his penis. The patient focuses on the
pleasurable feelings resulting from the penile stimulation. When he feels that he
is about to ejaculate, he signals his partner to stop stimulation. Likewise, this
exercise is done at least four times before letting oneself to ejaculate. The
squeeze technique can be done along with the start-stop technique. In this,
the partner is taught to place her thumb on the frenulum of the penis and her
first and second fingers on the opposite side of the head of the penis. When he is
about to ejaculate the partner squeezes for up to 5 seconds and then releases
the penis for up to 30 seconds. This can be continued until the patient is no
longer on the verge of ejaculating. Then the partner resumes penile stimulation.
Somatic treatments too are prescribed which include intracavernous injection of
papaverine and phentolamine and oral medications such as clomipramine.

7. Female Sexual Interest/Arousal Disorder

1) Diagnostic Criteria

A. Lack of, or significantly reduced, sexual interest/arousal, as manifested

by at least three of the following:
1. Absent/reduced interest in sexual activity.
2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically unreceptive to a
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partner’s attempts to initiate.

4. Absent/reduced sexual excitement/pleasure during sexual activity in
almost all or all (approximately 75%-100%) sexual encounters (in
identified situational contexts or, if generalized, in all contexts).
5. Absent/reduced sexual interest/arousal in response to any internal or
external sexual/erotic cues (e.g., written, verbal, visual).
6. Absent/reduced genital or nongenital sensations during sexual activity
in almost all or all (approximately 75%-100%) sexual encounters (in
identified situational contexts or, if generalized, in all contexts).
B. The symptoms in Criterion A have persisted for a minimum duration
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress (e.g.,
partner violence) or other significant stressors and is not attributable to
the effects of a substance/medication or another medical condition.

2) Treatment

Treatment for persons with Female Sexual Interest/Arousal Disorder

involves reduction of anxiety associated with sexual activity. Behaviour
techniques such as those involving sensate focus most often seem to be
effective.117

8. Female Orgasmic Disorder

1) Diagnostic Criteria

A. Presence of either of the following symptoms and experienced on almost

all or all (approximately 75%-100%) occasions of sexual activity (in
identified situational contexts or, if generalized, in all contexts):
1. Marked delay in, marked infrequency of, or absence of orgasm.
2. Markedly reduced intensity of orgasmic sensations.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress (e.g.,
partner violence) or other significant stressors and is not attributable to
the effects of a substance/medication or another medical condition.

2) Treatment
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Treatment for Female Orgasmic Disorder involves the following: Through a

programme of directed masturbation a woman with anorgasmia (i.e., never
having had an orgasm) can become orgasmic. First of all any discomfort the
individual may feel about exploring her own body should be discussed. Secondly,
instructions should be given in a systematic programme for exercising the
pubococcygeus muscle, a muscle involved in orgasms. Then follows a
masturbatory programme that begins with a gradual visual and tactile
exploration of her body and moves toward focused genital touching. The patient
is also taught to combine sexual fantasies with stimulation. If the woman is
unable to have an orgasm while doing these, then a vibrator can be used while
engaging in focused genital touching. Now when the woman is able to have an
orgasm through self-stimulation, she can very well teach her sexual partner
(using sensate focus exercises) the type of genital stimulation she enjoys to
have an orgasm.

If a woman suffers from situational anorgasmia, it is good to explore the

relationship and involve her partner in treatment. Many women complain that
they do not experience an orgasm through penile-vaginal intercourse. This may
be due to lack of adequate stimulation both before and during intercourse, or not
using various sexual positions that allow stimulation of the clitoris by the patient
or her partner. When it is the question of letting go, then systematic
desensitisation is helpful. Sometimes psychodynamic conflicts, religious
concerns, and personal beliefs regarding intercourse and sexual pleasure may
interfere with obtaining orgasm.

Some prefer masturbation to stimulation by a partner. Even if there is a

partner available and willing, the person prefers to masturbate in the presence
of the partner. Even while engaging in bilaternal sexual activity, one will stop
stimulation by a partner but would like to complete the act by masturbating by
self. It is because one is anchored to repeated times of masturbation and only
the individual knows how to hold the genitalia, from which angle, with what
pressure, and at what speed that would make the person experience orgasm.
Such persons may not very much desire to be stimulated by the partner to
orgasm.118 I have met a number of women complaining that their husbands are
masturbating in bed while they, their female partners, are available

9. Genito-Pelvic Pain/Penetration Disorder

1) Diagnostic Criteria

A. Persistent or recurrent difficulties with one (or more) of the following:

1. Vaginal penetration during intercourse
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or
penetration attempts.
3. Marked fear or anxiety about vulvovaginal or pelvic pain in
anticipation of, during, or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during
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attempted vaginal penetration.

B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of a severe relationship distress (e.g., partner
violence) or other significant stressors and is not attributable to the effects
of a substance/medication or another medical condition..

2) Treatment

In the first place, persons with Genito-Pelvic Pain/Penetration Disorder, have

a comprehensive physical and gynaecological or urological examination. If there
is no organic pathology, the individual’s fear and anxiety underlying sexual
functioning need to be investigated. Some women respond favourably to
systematic desensitisation.

Treatment for Vaginismus (Recurrent or persistent involuntary spasm of

the musculature of the outer third of the vagina that interferes with sexual
intercourse.)

Vaginismus can be diagnosed with certainty only through a gynaecological

examination. There are some women who are anxious about sex and may
experience muscular tightening and some pain during penetration and this is not
considered vaginismus. It is good to start with desensitisation. There is another
procedure of inserting dilators of graduated sizes. The individual or the partner
can gradually insert a tampon or fingers until penile penetration can be effected.
It is good that the patient gently stroke her genitals and clitoris during the
insertion procedure. Penile penetration could be effected with the partner lying
on his back and the patient controlling the actual insertion and subsequent
movement during intercourse.119

10. Substance/Medication-Induced Sexual Dysfunction

1) Diagnostic Criteria

A. A clinically significant disturbance in sexual function is predominant in the

clinical picture.
B. There is evidence from the history, physical examination, or laboratory
findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after
substance intoxication or withdrawal or after exposure to a
medication.
2. The involved substance/medication is capable of producing the
symptoms in Criterion A.
C. The disturbance is not better explained by a sexual dysfunction that is
not substance/medication-induced. Such evidence of an independent
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sexual dysfunction could include the following:

The symptoms precede the onset of the substance/medication use;
the symptoms persist for a substantial period of time (e.g., about 1
month) after the cessation of acute withdrawal or severe intoxication:
or there is other evidence suggesting the existence of an independent
non-substance/medication-induced sexual dysfunction (e.g., a history
of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a
delirium.
E. The disturbance causes clinically significant distress in the individual.

11. Treatment

Treatment for sexual dysfunctions is mostly behavioural. All the same,

cognitive and psychodynamic interventions can also be useful in modifying self-
damaging thoughts and resolving long–standing problems such as abuse, family
dysfunction, and mistrust.

(1) Psychoeducation

Inadequate or incorrect information about the process of sexual arousal

and about what is considered normal sexual functioning causes sexual
dysfunctions. Therefore, educating clients about sexuality and sexual functioning
can help dispel their self-blame and modify their unrealistic expectations.

(2) Couple Therapy

Sexual dysfunctions arise from interpersonal relationship and affect the

relationship. Therefore, enquiring about the difficulty in relationship can help
understand the problem. There is something called “spectatoring” — the
process of watching and monitoring their own sexual performance as well as
their partners’ responses during sexual relations. Relaxation and comfortable
involvement in sexual behaviours can be prevented by self-monitoring and it
might worsen the symptom leading to a vicious cycle in which sexual dysfunction
promotes spectatoring, and spectatoring increases the severity of sexual
dysfunction. Therefore, clients are to be taught non-threatening relaxation
techniques like progressive relaxation or nonsexual massage and asked to
refrain temporarily from overt sexual activity. Slowly increasing the focus on
pleasure can help clients gradually resume a more rewarding sexual relationship.

To reduce pressure and demands, sensate focusing can be used to help

the couple enjoy closeness and intimacy without intercourse. One can also use
systematic desensitization masturbation for women with inhibited orgasm,
bridging that is making the transition from masturbation or manual stimulation
to intercourse, the squeeze technique for men with premature ejaculation, and
imagery and fantasy to enhance sexual arousal.
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For an effective therapy, the following guidelines will be useful: (1)

sensate focus — experiential/sensory awareness exercises, (2) stimulus control
and scheduling, (3) cognitive restructuring, to increase flexibility in attitudes
and promote commitment to change, and (4) communication skills training to
address interpersonal concerns as well as promote education on healthy
sexuality.

Therapeutic outcomes are enhanced by five factors: (1) quality of the

couple’s relationship, (2) motivation especially of the male partner, (3) absence
of severe mental disorders, (4) physical attraction between partners, and (5)
early compliance with assigned homework.

(3) Group Therapy

Group therapy supplies support, education, role models and reduction of

guilt and anxiety. It is mostly helpful for women with orgasmic disorder and men
with erectile disorders.120

12. Conclusion

Sexual dysfunction refers to a problem occurring during any phase of

the sexual response cycle that prevents the individual or couple from
experiencing satisfaction from the sexual activity. The sexual response cycle
traditionally includes excitement, plateau, orgasm, and resolution. Desire and
arousal are both part of the excitement phase of the sexual response. Research
suggests that sexual dysfunction is common (43 percent of women and 31
percent of men report some degree of difficulty).

A thorough sexual history and assessment of general health and other

sexual problems (if any) are very important. Assessing
performance anxiety, guilt, stress, and worry are integral to the optimal
management of sexual dysfunction. Many of the sexual dysfunctions that are
defined are based on the human sexual response cycle. As treatment is available
for sexual dysfunctions, it is recommended that one seek help from the
professionals.

15. GENDER DYSPHORIA

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1. Introduction

The area of sex and gender is highly controversial and has led to a
proliferation of terms whose meanings vary over time and within and between
disciplines. An additional source of confusion is that in English “sex” connotes
both male/female and sexuality. In this chapter, “sex” and “sexual” refer to the
biological indicators of male and female (understood in the context of
reproductive capacity), such as in sex chromosomes, gonads, sex hormones,
and nonambiguous internal and external genitalia. Disorders of sex development
denote conditions of inborn somatic deviations of the reproductive tract from the
norm and/or discrepancies among the biological indicators of male and female.
Cross-sex hormone treatment denotes the use of feminizing hormones in an
individual assigned male at birth based on traditional biological indicators or the
use of masculinising hormones in an individual assigned female at birth.

Gender dysphoria (GD) is a controversial diagnosis and like

homosexuality, it may be removed from the category of mental disorders and
viewed as an uncommon but not unhealthy pattern. There are two theories to
explain GD. Some believe that it has a biological basis that has not yet been
identified. Others view GD as a conditioned response. GD people prefer
activities, occupations, and dress associated with the gender other than their
biologically assigned gender. GD develops before the emergence of sexual
orientation just like the rest of the population. People with GD are emotionally
healthy and they only have a strong belief that they are in the wrong-gendered
body. They do not show greater psychopathology than the population at large. 121

2. Gender Dysphoria (GD)

1) Diagnostic Criteria

(1) Gender Dysphoria in Children

A. A marked incongruence between one’s experience/expressed gender and

assigned gender, of at least 6 months’ duration, as manifested by at least
six of the following (one of which must be Criterion A1):
1. A strong desire to be of the other gender or an insistence that one is
the other gender (or some alternative gender different from one’s
assigned gender).
2. In boys (assigned gender), a strong preference for cross-dressing or
simulating female attire; or in girls (assigned gender), a strong
preference for wearing only typical masculine clothing and a strong
resistance to the wearing of typical feminine clothing.
3. A strong preference for cross-gender roles in make-believe play or
fantasy play.
4. A strong preference for the toys, games, or activities stereotypically
used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys (assigned gender), a strong rejection of typically masculine
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toys, games, and activities and a strong avoidance of rough-and-

tumble play; or in girls (assigned gender), a strong rejection of
typically feminine toys, games, and activities.
7. A strong dislike of one’s sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics
that match one’s experienced gender.
B. The condition is associated with clinically significant distress or
impairment in social, school, or other important areas of functioning.

(2) Gender Dysphoria in Adolescents and Adults

A. A marked incongruence between one’s experienced/expressed gender and

assigned gender, of at least 6 months’ duration, as manifested by at least
two of the following:
1. A marked incongruence between one’s experienced/expressed gender
and primary and/or secondary sex characteristics (or in young
adolescents, the anticipated secondary sex characteristics).
2. A strong desire to be rid of one’s primary and/or secondary sex
characteristics because of a marked incongruence with one’s
experienced/expressed gender (or in young adolescents, a desire to
prevent the development of the anticipated secondary sex
characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of
the other gender.
4. A strong desire to be of the other gender (or some alternative gender
different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative
gender different from one’s assigned gender).
6. A strong conviction that one has the typical feelings and reactions of
the other gender (or some alternative gender different from one’s
assigned gender).
B. The condition is associated with clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.

2) Treatment for Gender Dysphoria

Most gender dysphoric individuals have adamant requests for sex

reassignment and they will not be satisfied anything less than surgical change.
The individuals are not amenable to counselling and psychotherapy. There are
complications in surgery, especially medical. Psychotherapy after surgery is
indicated to help the patient adjust to the surgical changes and discuss sexual
functioning and satisfaction.

3) Treatment for Gender Dysphoria of Childhood

Behaviour therapy as done to adults is helpful for children as well reinforcing

appropriate behaviours with tokens. Analytically oriented treatment deals with
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the family dynamics (e.g., a powerful, masculine-devaluing mother; an

ineffective, emotionally absent father) and individual dynamics (e.g., castration
anxiety following surgery) of the child. An eclectic approach to treatment has
been advocated that involves the development of a close trusting relationship
between a male therapist and the boy; stopping parental encouragement of
feminine behaviours; interrupting the excessively close relationship between
mother and son; enhancing the role of father and son; and reinforcing male
behaviours.

The treatment can aim at two opposite ends by either making the person
reconcile with the anatomic sex, or arrange sex-change to the desired gender.

4) Reconciliation with the Anatomic Sex

There are only occasional reports of achieving this purpose in primary

transsexuals. However, in secondary transsexuals, this method may be more
effective and should be employed first if possible though this decision is best
made by the client. The method helpful is behaviour therapy.

5) Sex-Change to the Desired Gender

This procedure is known as sex reassignment surgery (SRS). The procedures

include hormonal treatment, phaloplasty, castration, mastectomy, and
hysterectomy with salpingo-ophorectomy, which have been used in different
combinations. The procedure is performed more often in primary transsexuals.

As SRS is an almost irreversible process, the following steps are taken before
assigning a patient to surgery: (1) The diagnosis of primary, stable, long-
standing transsexualism is confirmed. (2) A possibility of stress-induced
transsexualism is considered and eliminated. (3) The client has to undergo
psychotherapy for at least 3-6 months preoperatively. (4) Experimental trial in
the new gender role pre-operatively, to assess patient’s ability to adjust in the
“new” role. (5) The limitations of SRS should be explained, e.g., infertility,
nonfunctional testes, etc. The success rate in carefully planned SRS can be up to
80-90%. Postoperative psychotherapy is of utmost importance in prevention of
psychiatric morbidity.122

6) Treatment

The treatment usually consists of one or more of the following methods:

1) Treatment of the underlying physical or psychiatric disorder; if

present.

2) Psychoanalysis: This is indicated when the dysfunction is more pervasive

and involves personality difficulties. The goal is not symptoms removal but is
resolution of the underlying unconscious conflicts.
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3) Hypnosis: Hypnosis can be used either alone or in conjunction with other

therapies aiming at symptom removal. However, only suggestible patients can
be hypnotized.

4) Group psychotherapy: Patients of same sex with different sexual

problems or of both sexes with similar sexual problems can be treated in group
therapy sessions. The focus is usually on providing education regarding normal
sexuality and to remove anxiety or guilt by sharing viewpoints in a group
setting.

5) Behaviour therapy: The methods commonly employed include the

following: (1) relaxation training, e.g., Jacobson’s progressive relaxation
technique. (2) Assertiveness training. (3) Systematic desensitization, aimed at
reducing the phobic anxiety related to the sexual act, e.g., in sexual aversion
disorder. (4) Biofeedback, using a penile plethysmograph.

6) Masters’ and Johnson’s technique: The patient is not treated alone,

but both the partners are treated together. This is called as dual-sex therapy,
where both the sexual partners are treated by a team of therapists (one male
and one female), although later modifications of this technique use only one
therapist. The goal of the treatment is symptom removal, using simple
behavioural techniques. The couple is usually seen on a weekly basis; however,
the sessions can be more frequent if the couple is encountering particular
difficulties during treatment.

Some common steps before starting therapy include: (1) detailed history
taking (sexual history) from each partner separately. (2) Round-table
discussions aiming at: (a) education about normal sexuality, (b) understanding
of the couple’s current sexual problems, (c) enhancing communication between
the partners regarding sexual matters, (3) Behaviour modification steps,
depending on the type of psychosexual dysfunction.

7) Brief Examples of the Techniques Used

(1) Sensate Focus Technique: This is used for treatment of impotence,

although it is also useful in management of other dysfunctions as well. The aim
is to discover on body (excluding genital area) sensate focuses (body areas
where manipulation leads to sexual arousal). This is usually a general exercise
before any therapy.

(2) Squeeze Technique (Seman’s Technique): This is meant for

premature ejaculation. The female partner is asked to manually stimulate the
penis causing erection. When the male partner experiences ejaculatory
inevitability, the female partner squeezes the penis on the coronal ridge thus
delaying ejaculation. There are similar simple techniques (such as orgasmic
conditioning, desensitization) for treatment of other psychosexual
dysfunctions.123
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3. Treatment

For the treatment of Gender Dysphora, the following consideration is helpful.

Gender identity is learned in the cultural context. Once a certain identity as to
who one is fixed, then it is difficult to reverse this attitude. Therefore, right from
the very beginning it is necessary to bring up children with clear concept of
who they are sexually. A wholesome attitude towards sex will go a long way in
forming favourable attitude about themselves with regard to their gender
identity.

1) Counselling

If one has been wondering if one might be transgender and whether gender
transition or gender reassignment surgery might be appropriate for one, the first
thing to do is to seek out more information and look for appropriate help. A
specialist gender-identity counsellor will have done additional training in
transgender and gender and sexuality diversity issues. Living in your true gender
will take courage and a fair degree of experimentation — finding a congruent
look, exploring ways to present your body that will be more easily read as
relating to your true gender. Exploring exactly what you want to communicate in
terms of gender identity takes time and patience.

Many people successfully live in a gender other than ascribed at birth —

some of whom have had surgical and hormonal intervention, some of whom who
have only had partial surgery or hormonal intervention, and some who live
successfully in their true gender without any medical intervention at all. The
important thing is that one takes time to work out what suits one best; and that
is where a skilled and experienced therapist can help.

2) Psychological Treatments

Until the 1970s, psychotherapy was the primary treatment for Gender
Dysphoria (GD), and generally was directed to helping the person adjust to the
gender of the physical characteristics present at birth. Psychotherapy is any
therapeutic interaction that aims to treat a psychological problem. Though some
clinicians still use only psychotherapy to treat GD, it is now typically used in
addition to biological interventions as treatment for GD. Psychotherapeutic
treatment of GD involves helping the patient to adapt. Attempts to "cure" GD by
changing the patient's gender identity to reflect birth characteristics have been
ineffective.

Persons with GD focus on making the body correspond to the self-image

they have in their brains rather than the reverse. Therefore, they are not
interested in changing their feelings about their gender. It is useful to relieve
any depression and anxiety and explore options than focusing treatment on
changing the gender dysphoria.
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Whether children with GD can be treated is a controversial issue. Some

suggest early intervention in the hope of changing GD behaviour. However,
others believe that gender identification is determined by the age of 2 or 3 and
has an underlying biological component. Therefore, instead of focusing on the
gender issues, the therapist should focus on treating the symptoms of
depression, anxiety, impaired self-esteem, and social discomfort that frequently
result from social ostracism.

We are not yet sure, how GD continues into adolescence and adulthood. If
they had received treatment in childhood, they do not continue with GD.
However, as they pass onto adolescence and adulthood, most boys develop a
clear preference for homosexuality and so the researchers conclude that there
may be a link between early cross-gender behaviour and homosexuality. If GD
continues to manifest in adolescence and adulthood, the likelihood of changing
gender-related attitudes and identifications is low. Therefore, it is useful to focus
on choosing ways to improve adjustment and life satisfaction. The goal for them
would be to promote adjustment or help them take decisions about biological
treatment rather than eliminating the symptoms of GD.

In their adjustment, lifestyle and relationship changes are to be taken into

consideration. Another option is hormone therapy and gender-reassignment
surgery. If they take hormone therapy, biological males take estrogen, and
biological females take testosterone. This effects biological changes that are
gratifying to some people with GD and improves their sense of well-being. The
option of gender reassignment is a controversial, complex, and multifaceted
process that includes hormone treatments, trial cross-gender living, and
eventual surgery.124

4. Conclusion

Gender dysphoria (GD), or gender identity disorder (GID), is the distress a

person experiences because of the sex and gender he is assigned at birth. In this
case, the assigned sex and gender do not match the person's gender identity,
and the person is transgender. There is evidence suggesting that twins who
identify with a gender different from their assigned sex may do so not only due
to psychological or behavioural causes, but also biological ones related to their
genetics or exposure to hormones before birth

Treatment for a person diagnosed with GD may include psychotherapy or to

support the individual's preferred gender through hormone therapy, gender
expression and role, or surgery. This may include psychological counselling,
resulting in lifestyle changes, or physical changes, resulting from medical
interventions such as hormonal treatment, genital surgery, electrolysis or laser
hair removal, chest/breast surgery, or other reconstructive surgeries. The goal
of treatment may simply be to reduce problems resulting from the person's
transgender status; for example, counselling the patient in order to reduce guilt
associated with cross-dressing, or counselling a spouse to help them adjust to
the patient's situation. Hormone treatment or surgery for gender dysphoria is
somewhat controversial because of the irreversibility of certain physical changes.
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16. PARAPHILIC DISORDERS

1. Introduction

The term paraphilia denotes any intense and persistent sexual interest other
than sexual interest in genital stimulation or preparatory fondling with
phenotypically normal, physically mature, consenting human partners. Some
paraphilias primarily concern the individual’s erotic activities like intense and
persistent interests in spanking, whipping, cutting, binding, or strangulating
another person, or an interest in these activities that equal or exceeds the
individual’s interest in copulation or equivalent interaction with another person;
and others primarily concern the individual’s erotic targets like intense or
preferential sexual interest in children, corpses, or amputees (as a class), as well
as intense or preferential interest in nonhuman animals, such as horses or dogs,
or in inanimate objects, such as shoes or articles made of rubber.

Disorders related to paraphilias include compulsive masturbation,

telephone sex, dependence on pornography, cybersex, and protracted
promiscuity. These may co-occur with other disorders like substance abuse,
anxiety or mood disorders, and disorders of impulse control. Mild versions
include only disturbing fantasies accompanied by masturbation. Severe cases
may use threats or force, injury to others, victimization of children, or even
murder. Tension builds in the client until it is relieved by a paraphilic act. 125

2. Voyeuristic Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from observing an unsuspecting person who is naked, in the process of
disrobing, or engaging in sexual activity, as manifested by fantasies,
urges, or behaviours.
B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.
C. The individual experiencing the arousal and/or acting on the urges is at
least 18 years of age.

3. Exhibitionistic Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from the exposure of one’s genitals to an unsuspecting person, as
manifested by fantasies, urges, or behaviours.
B. The individual has acted on these sexual urges with a nonconsenting
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person, or the sexual urges or fantasies cause clinically significant distress

or impairment in social, occupational, or other important areas of
functioning.

4. Frotteuristic Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from touching or rubbing against a nonsonsenting person, as manifested
by fantasies, urges, or behaviours.
B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant distress
or impairment in social, occupational, or other important areas of
functioning.

5. Sexual Masochism Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from the act of being humiliated, beaten, bound, or otherwise made to
suffer, as manifested by fantasies, urges, or behaviours.
B. The fantasies, sexual urges, or behaviours cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.

6. Sexual Sadism Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from the physical or psychological suffering of another person, as
manifested by fantasies, urges, or behaviours.
B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant distress
or impairment in social, occupational, or other important areas of
functioning.

7. Paedophilic Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent, intense sexually arousing

fantasies, sexual urges, or behaviours involving sexual activity with a
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prepubescent child or children (generally age 13 years or younger).

B. The individual has acted on these sexual urges, or the sexual urges or
fantasies cause marked distress or interpersonal difficulty.
C. The individual is at least age 16 years and at least 5 years older than the
child or children in Criterion A.
Note: Do not include an individual in late adolescence involved in an
ongoing sexual relationship with a 12- or 13-year-old.

8. Fetishistic Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from either the use of nonliving objects or a highly specific focus on
nongenital body part(s), as manifested by fantasies, urges, or behaviours.
B. The fantasies, sexual urges, or behaviours cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.
C. The fetish objects are not limited to articles of clothing used in cross-
dressing (as in transvestic disorder) or devices specifically designed for
the purpose of tactile genital stimulation (e.g., vibrator).

9. Transvestic Disorder

1) Diagnostic Criteria

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from cross-dressing, as manifested by fantasies, urges, or behaviours.
B. The fantasies, sexual urges, or behaviours cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.

10. Causes of Paraphilias

Most paraphilias emerge during adolescence although there is usually a

connection with events or relationships in early childhood. Once established,
they tend to be chronic, although some research has indicated that the
behaviours will reduce as the individual ages. Most individuals with paraphilias
are men. Although biological factors play a role in some paraphilias, researchers
have yet to identify a specific biological or biochemical cause. Instead,
psychological factors seem to be central. In most cases, one or more events
occurred during childhood that led the individual to associate sexual pleasure
with that event (or object) thus resulting in the development of a paraphilia.
Thus in therapy, it may be helpful to explore early sexual experiences and
fantasies.
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11. Principles that Underlie Treatment for Paraphilias

Psychodynamic or insight-oriented treatment does not seem to be

effective and so also cognitive-behavioural therapy. All the same, there are
some principles that underlie all the paraphilias. They are: (1) Identification of
triggers and substitution of alternative responses and behaviours, (2) Stress
reduction, (3) Aversion therapy that pairs paraphilic urges and fantasies with
negative experiences, such as undesirable images, electric shocks, or noxious
odours, (4) Covert sensitization, which uses negative images like images of
imprisonment or humiliation to discourage paraphlic behaviour, (5) Covert
extinction, in which the paraphilic behaviour is imagined, but without the
anticipated reinforcement or positive feeling, (6) Orgasmic reconditioning, (7)
Thought stopping, (8) Cognitive restructuring, (9) Encouragement of empathy
for the victim, and (10) Overall improvement of coping skills and lifestyle.126

12. Treatment

Let us consider the treatment for persons with Paraphilic Disorders.

Treatment depends on the nature of the paraphilia and may include a biological
component (such as medication), a psychological component (such as
psychotherapy), and a sociocultural component (such as group or family
therapy). Psychoanalysis and psychodynamic therapies are useful in some cases.
Early conflicts, trauma, and humiliations are to be identified and resolved to
remove the individual’s anxiety towards appropriate partners and enable one to
give up the paraphilic fantasies. Various forms of aversive conditioning methods
(e.g., noxious odours) and covert sensitisation method could be used. In covert
sensitisation method, the individual pairs his inappropriate sexual fantasies
with aversive, anxiety-provoking scenes, under the guidance of a therapist.
There is a technique called satiation in which the individual uses his deviant
fantasies postorgasm in a repetitive manner to the point of satiating himself with
the deviant stimuli, in essence making the fantasies and behaviour boring. In
behavioural treatments, skills training and cognitive restructuring are used to
change the individual’s maladaptive beliefs. It seems treatment programmes
that use comprehensive cognitive behavioural interventions, along with
antiandrogens and psychological treatment are the most effective. 127

1) Victim Identification

Victim identification may be a useful treatment intervention for

individuals with exhibitionism, frotteurism, paedophilia, sexual sadism, and
voyeurism. This type of treatment involves the therapist helping the client to
realize that the person they are doing the behaviour to (i.e., exposing
themselves, exhibiting sadist-type behaviours) is a victim. Additionally, the client
may be encouraged to identify the harm they cause to the person they are
exposing themselves to. Exercises such as role-reversal may be used and the
client may be asked how the victim might feel both during and after the
victimizing act. The goal of this therapeutic approach is for the client to develop
empathy towards their victims. If the client is able to develop sufficient empathy
toward their victims, they may reduce or discontinue the behaviour because it is
less pleasurable. However, it is important to note that many sex offenders may
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also have a personality disorder called Anti-Social Personality Disorder. This

disorder is characterized by a lack of empathy. Thus, treatments which depend
upon increasing empathy may have limited effectiveness for certain people.

2) Covert Conditioning

Covert conditioning is a behavioural method in which undesirable

behaviour becomes less desirable and is eventually eliminated. In the case of
paraphilias, the client is asked to imagine feeling shame when friends or family
members observe him engaging in the behaviour associated with the paraphilia.
This type of intervention can be used with nearly all of the paraphilias and can
help the client not engage in the behaviour or to find the behaviour less
pleasurable.

3) Orgasmic Reconditioning

In orgasmic reconditioning, the principles of learning are applied and the

client is first asked to identify a fantasy that involves the paraphilia in question.
Next, they are encouraged to engage in masturbation at home with specific
instructions to become aroused by the fantasy associated with their paraphilia,
but to complete the masturbation exercise (orgasm) while looking at an
appropriate object (i.e., a picture of an adult partner). Finally, the client is
instructed not to incorporate the fantasy at all. This type of treatment may be
particularly helpful for individuals who have a fetish. The client with a fetish is
asked to identify his fetishistic object. They are then sent home with instructions
to become aroused with/by the fetishistic object and to masturbate. Prior to
reaching orgasm, they are encouraged to look at a picture of an adult partner
and to orgasm/ejaculate while doing so. The idea behind this treatment is
simple: they are redirecting their arousal pattern and providing themselves
positive reinforcement (orgasm) while looking at an "appropriate" object.

4) Masturbatory Extinction

Masturbatory Extinction also includes the instruction to masturbate.

However, in this treatment clients are encouraged to masturbate and orgasm to
an appropriate fantasy. Then after orgasm (i.e., ejaculation) they are
encouraged to continue masturbating but to the deviant sexual fantasy. This
causes the appropriate fantasy to be reinforced with an orgasm but the
inappropriate fantasy to not be reinforced (Plaud, 2007).

5) Masturbatory Satiation

In masturbatory satiation, the client is encouraged to masturbate with the

deviant fantasy in mind. When the client reaches orgasm, he must continue to
masturbate to the deviant fantasy for one hour. Since this activity does not end
in a reinforcing ejaculation, the client may eventually lose interest in such
fantasies.

6) Aversive Therapies
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Aversive therapies include pairing arousal to the deviant fantasy with

either mild electric shock or unpleasant smells. In this type of treatment, the
client is encouraged to become aroused by the deviant fantasies and is
immediately bombarded with an unpleasant smell or electric shock. The pairing
of deviant fantasies with unpleasant sensations is thought to decrease both
fantasies and behaviours.

7) Group Therapy 

Group therapy may also be useful in the treatment of paraphilias. The focus
may be on taking responsibility for actions, victim impact and empathy,
establishing family support, building relationship and social skills, and cognitive
restructuring. With at least some of the paraphilias, the individual may lack
social skills and have difficulty establishing relationships with others. Thus,
treatment that focuses on building social skills may be helpful. This may include
some of the tactics we have already discussed (i.e., victim identification) and
may also help the client to develop a new way of looking at things.

8)  Medications

Biological treatments have been traditionally used to correct paedophilia or

exhibitionism. Since androgens play a major role in maintaining sexual arousal,
treatments have focused on blocking or decreasing the level of circulating
androgens. Antiandrogenic medications are used to treat sex offenders. The
ones most used are the progestin derivatives medroxyprogesterone acetate
(MPA) and cyproterone acetate (CPA). These only decrease libido and thus break
the individual’s pattern of compulsive deviant sexual behaviour and do not
change the direction of sexual drive toward appropriate adult partners.
Fluoxetine is administered to treat patients who have sexual obsessions,
addictions, and paraphilias.

The use of certain medications may be helpful in decreasing paraphilic

behaviour. In fact, reducing the amount of testosterone in the body in effect
lowers sex drive. When sex drive is lower, sexual behaviour is likely to decrease.
When sex drive is effectively lowered, the frequency in which an individual
engages in sexual behaviours also decreases. While decreasing sex drive by
lowering testosterone levels may help, it is important to note that this may not
"cure" the paraphilia. Therefore, medication should be combined with some type
of cognitive-behavioural treatments as well.

The treatment of paraphilias and related disorders has been challenging for
patients and clinicians. In the past, surgical castration was advocated as a
therapy for men with paedophilia, but has been abandoned for the time being
because most governments consider it a cruel punishment where the express-
willingness and consent of the patient is not objectively indicated.
Psychotherapy, self-help groups, and pharmacotherapy (including anti-androgen
hormone therapy sometimes referred to as "chemical castration") have all been
used. Other drug treatments for these disorders do exist.
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Antiandrogens such as cyproterone acetate and medroxyprogesterone

acetate have been widely used as therapy in these men to reduce sex drive.
However, their efficacy is limited and they have many side effects, including
breast growth, headaches, weight gain, and reduction in bone density. Even if
compliance is good, only 60 to 80 percent of men benefit from this type of drug.
Long-acting gonadotropin-releasing hormones, such as Triptorelin (Trelstar)
which reduces the release of gonadotropin hormones, are also used. This drug is
a synthetic hormone, which may also lead to reduced sex drive.

Psychostimulants have been used recently to augment the effects

of serotonergic drugs in paraphilic. In theory, the prescription of a
psychostimulant without pretreatment with an SSRI might further disinhibit
sexual behaviour, but when taken together, the psychostimulant may actually
reduce impulsive tendencies. Methylphenidate (Ritalin) is a substituted
phenethylamine stimulant used primarily to manage the symptoms of attention
deficit hyperactivity disorder (ADHD). Recent studies imply that methylphenidate
may also act on serotonergic systems. Amphetamine is also used medically as
an adjunct to antidepressants in refractory cases of depression.

13. Conclusion

There are many paraphilias. The focus of the paraphilia may be objects,
situations, animals, or people (such as children or nonconsenting adults). Sexual
arousal may depend on the use or presence of this focus. Once these arousal
patterns are established, usually in late childhood or near puberty, they are
often lifelong.

Some degree of variety in sexual activity is very common in healthy adult

sexual relationships and fantasies. When people mutually agree to engage in
them, unusual sexual behaviours that cause no harm may be part of a loving
and caring relationship. However, when sexual behaviours cause distress or
harm or interfere with a person's ability to function in daily activities, they are
considered a paraphilic disorder. The distress may result from other people's
reactions or from the person's guilt about doing something socially unacceptable.

Paraphilic disorders can seriously impair the capacity for affectionate,

reciprocal sexual activity. Partners of people with a paraphilic disorder may feel
like an object or as if they are unimportant or unnecessary in the sexual
relationship.
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17. DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS

1. Introduction

Disruptive, impulse-control, and conduct disorders include conditions

involving problems in the self-control of emotions. These disorders are unique in
that these problems are manifested in behaviours that violate the rights of
others (e.g., aggression, destruction of property) and/or that bring the individual
into significant conflict with societal norms or authority figures. The underlying
cause of the problems in the self-control of emotions and behaviours can vary
greatly across the disorders and among the individuals within a given diagnostic
category.

Every impulse-control disorder is characterized by repeated failure to

resist an impulse to perform a behaviour that is harmful. In this, it is
characterized by increasing tension or arousal before the harmful behaviour is
performed and by feelings of release or pleasure after the act has been
completed. Though the client may feel guilt and remorse, the behaviour itself is
usually ego-syntonic (the behaviours, values, and feelings that are in harmony
with and acceptable to the needs and goals of the ego). Most of the cases of
impulse control disorders follow a chronic course mostly associated with
comorbid diagnoses of OCD, substance-related disorders, and mood disorders.
These disorders seem to have a common underlying dynamic or cause. It is
believed that there is a biological cause (neurological predisposition) combined
with psychosocial causes (dysfunctional role models), exacerbated by
environmental stress.128

2. Oppositional Defiant Disorder

Oppositional defiant disorder manifests in a pattern of negativistic,

defiant, disobedient, and hostile behaviour toward authority figures. At younger
age, children manifest this disorder through temper tantrums, kicking, power
struggles with parents, disobedience, spitefulness, and low frustration tolerance.
Mostly they argue, threaten, show disrespect for adults, destroy property in a
rage, refuse to cooperate, and are stubborn.129

1) Diagnostic Criteria

A. A pattern of angry/irritable mood, argumentative/defiant behaviour, or

vindictiveness lasting at least 6 months as evidenced by at least four
symptoms from any of the following categories, and exhibited during
interaction with at least one individual who is not a sibling.
Angry/Irritable Mood
1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.
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Argumentative/Defiant Behaviour
4. Often argues with authority figures or, for children and adolescents,
with adults.
5. Often actively defies or refuses to comply with requests from
authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his mistakes or misbehaviour.
Vindictiveness
8. Has been spiteful or vindictive at least twice within the past 6 months.
Note: The persistence and frequency of these behaviours should be
used to distinguish a behaviour that is within normal limits from a
behaviour that is symptomatic. For children younger than 5 years, the
behaviour should occur on most days for a period of at least 6 months
unless otherwise noted (Criterion A8). For individuals 5 years or older,
the behaviour should occur at least once per week for at least 6
months, unless otherwise noted (Criterion A8). While these frequency
criteria provide guidance on a minimal level of frequency to define
symptoms, other factors should also be considered, such as whether
the frequency and intensity of the behaviours are outside a range that
is normative for the individual’s developmental level, gender, and
culture.
B. The disturbance in behaviour is associated with distress in the individual
or others in his immediate social context (e.g., family, peer group, work
colleagues), or it impacts negatively on social, educational, occupational,
or other important areas of functioning.
C. The behaviours do not occur exclusively during the course of a psychotic,
substance use, depressive, or bipolar disorder. Also, the criteria are not
met for disruptive mood dysregulation disorder.

2) Treatment

Behavioural techniques can modify oppositional behaviour. Psychoanalytic

psychotherapy may be also effective.130

3. Intermittent Explosive Disorder

1) Diagnostic Criteria

A. Recurrent behavioural outbursts representing a failure to control

aggressive impulses as manifested by either of the following:
1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments
or fights) or physical aggression toward property, animals, or other
individuals, occurring twice weekly, on average, for a period of 3
months. The physical aggression does not result in damage or
destruction of property and does not result in physical injury to
animals or other individuals.
2. Three behavioural outbursts involving damage or destruction of
property and/or physical assault involving physical injury against
animals or other individuals occurring within a 12-month period.
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B. The magnitude of aggressiveness expressed during the recurrent

outbursts is grossly out of proportion to the provocation or to any
precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premeditated (i.e., they are
impulsive and/or anger-based) and are not committed to achieve some
tangible objective (e.g., money, power, intimidation).
D. The recurrent aggressive outbursts cause either marked distress in the
individual or impairment in occupational or interpersonal functioning, or
are associated with financial or legal consequences.
E. Chronological age is at least 6 years (or equivalent developmental level).
F. The recurrent aggressive outbursts are not better explained by another
mental disorder (e.g., major depressive disorder, bipolar disorder,
disruptive mood dysregulation disorder, a psychotic disorder, antisocial
personality disorder, borderline personality disorder) and are not
attributable to another medical condition (e.g., head trauma, Alzheimer’s
disease) or to the physiological effects of a substance (e.g., a drug of
abuse, a medication). For children ages 6-18 years, aggressive behaviour
that occurs as part of an adjustment disorder should not be considered
for this diagnosis.
Note: This diagnosis can be made in addition to the diagnosis of attention-
deficit/hyperactivity disorder, conduct disorder, oppositional defiant
disorder, or autism spectrum disorder when recurrent impulsive aggressive
outbursts are in excess of those usually seen in these disorders and warrant
independent clinical attention.

2) Treatment/Course and Prognosis

Episodic violent behaviour is quite common in the general population, but

strictly diagnosed intermittent explosive disorder is quite rare. The development
of a treatment plan for a patient who has long-standing, episodic aggressive
behaviour is complicated and involves the assessment and amelioration of
multiple factors, such as temperament, sensory cues, neuroanatomy,
neurochemistry, neuroendocrine function, stress, and social condition. Right
now, we do not have any drug specifically for the treatment of aggression. All
the same, numerous pharmacological agents and long-term psychotherapy are
effective in diminishing violent behaviour in some individuals. The treatment of a
patient, who becomes acutely violent, regardless of the underlying aetiology,
commonly involves physical restraint, seclusion, and sedation.131

4. Conduct Disorder

Child temperament, parenting factors, socioeconomic factors, prenatal

complications, exposure to violence, and association with antisocial peers are
factors that contribute to conduct disorder. Noncompliant behaviour, which is
disregard for adults, is the main aspect for the development of severe conduct
problems at home, at school, and with peers.132

1) Diagnostic Disorder
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A. A repetitive and persistent pattern of behaviour in which the basic rights

of others or major age-appropriate societal norms or rules are violated, as
manifested by the presence of at least three of the following 15 criteria in
the past 12 months from any of the categories below, with at least one
criterion present in the past 6 months:
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others
(e.g., a bat, brick, broken bottle, knife, and gun).
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
7. Has forced someone into sexual activity.
Destruction of Property
8. Has deliberately engaged in fire setting with the intention of causing
serious damage.
9. Has deliberately destroyed others’ property (other than by fire
setting).
Deceitfulness or Theft
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods or favours or to avoid obligations (i.e.,
“cons” others).
12. Has stolen items of nontrivial value without confronting a victim
(e.g., shoplifting, but without breaking and entering; forgery).
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions, beginning
before age 13 years.
14. Has run away from home overnight at least twice while living in the
parental or parental surrogate home, or once without returning for a
lengthy period.
15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behaviour causes clinically significant impairment in
social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial
personality disorder.

2) Treatment

The treatment of conduct disorder is usually difficult. The most frequent

mode of management is placement in corrective institutions, often after the child
has had legal difficulties. Behavioural, educational, and psychotherapeutic
measures are usually employed for the behaviour modification. Drug treatment
may be needed in presence of epilepsy (anticonvulsants), hyperactivity
(stimulant medication), impulse control disorder and episodic aggressive
behaviour, and psychotic symptoms (antipsychotics).
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Because of the diversity of presentations and severities of conduct disorder,

treatment can move in several directions like legal sanctions, family
interventions, social support, psychotherapeutic treatment of individual or family
psychopathology, or neuromedical treatment. From the beginning until the end,
the quick establishment of a containment structure and an expectation of
effective limit-setting to provide both safety and a holding environment for
treatment are essential.

Cognitive-behaviour therapy will help in developing skills for managing anger,

controlling impulsivity, and communicating. Training in problem-solving skills
may be useful.

Early interventions are more effective, easier, and have a protective element.
Commonalities of symptoms across diagnoses have prompted the use of
transdiagnostic treatment approaches that alleviate one, or a cluster, of
symptoms. Commonalities of such behaviour will include emotion disregulation,
impulsivity, anger management, learning deficits, and deficits in social skills.
Parent management training is a cognitive-behavioural approach that teaches
skills to monitor children’s behaviour, maintaining discipline, and providing
rewards. Problem-solving skills training decreases aggressive behaviours.
Functional family therapy identifies faulty or dysfunctional interactions in the
family and replace them with more functional responses and behaviours.
Multisystemic therapy helps deal with adolescents with substance misuse, sexual
disorders, chronic antisocial behaviour, serious mental health issues, and family
dysfunction. Individual and group therapy will always benefit a young person.
Reality therapy will provide a framework for challenging the distorted
environmental perceptions often held by adolescents. 133

5. Antisocial Personality Disorder

Criteria and text for antisocial personality disorder can be found in the
chapter “Personality Disorders.” Because this disorder is closely connected to the
spectrum of “externalizing” conduct disorders, it is mentioned here but dealt
with in the chapter “Personality Disorders.”

6. Pyromania

1) Diagnostic Criteria

A. Deliberate and purposeful fire-setting on more than one occasion.

B. Tension or affective arousal before the act.
C. Fascination with, interest in, curiosity about, or attraction to fire and its
situational contexts (e.g., paraphernalia, uses, consequences).
D. Pleasure, gratification, or relief when setting fires or when witnessing or
participating in their aftermath.
E. The fire-setting is not done for monetary gain, as an expression of
sociopolitical ideology, to conceal criminal activity, to express anger or
vengeance, to improve one’s living circumstances, in response to a
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delusion or hallucination, or as a result of impaired judgement (e.g., in

major neurocognitive disorder, intellectual disability [intellectual
developmental disorder], substance intoxication).
F. The fire-setting is not better explained by conduct disorder, a manic
episode, or antisocial personality disorder.

2) Treatment

Treatment for fire-setters has been traditionally problematic due to the

frequent refusal to take responsibility for the act, the use of denial, the existence
of alcoholism, and the lack of insight. Many psychotherapists use psychoanalytic
approach. Many behavioural researchers use aversive therapy and some others
use positive reinforcement with threats of punishment, stimulus satiation, and
operant structured fantasies with positive reinforcement. The pyromaniac
impulse is episodic and often self-limited and frequently appears during a
developmental or situational crisis. Fire-setting associated with mental
retardation, alcoholism, or a ritualistic pattern indicates a poor prognosis. Of
course, a better prognosis exists if the patient can verbalize and work through
frustrations in therapy.134

7. Kleptomania

1) Diagnostic Criteria

A. Recurrent failure to resist impulses to steal objects that are not needed
for personal use or for their monetary value.
B. Increasing sense of tension immediately before committing the theft.
C. Pleasure, gratification, or relief at the time of committing the theft.
D. The stealing is not committed to express anger or vengeance and is not in
response to a delusion or a hallucination.
E. The stealing is not better explained by conduct disorder, a manic episode,
or antisocial personality disorder.

2) Treatment/Course and Prognosis

No systematic study has been done for the treatment of Kleptomania.

Available information on treatment is limited to a number of case reports that
use a broad range of therapeutic interventions and all of them with little success.
The psychoanalytic view suggests that kleptomania is a symptom of an
underlying conflict. Some have used insight-oriented and supportive
psychotherapy. Some have used behaviour therapy with the use of covert
sensitisation in the treatment. Some have used desensitisation to reduce the
anxiety that had prompted the stealing behaviour. Some have used somatic
therapies like electroconvulsive therapy (ECT) alone and others in combination
with antidepressants.135
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8. Treatment

Children with ADHD and disruptive behaviour disorders often benefit from
special behavioural techniques that can be implemented at home and at school.
These approaches typically include methods for training the child to become
more aware of his own anger cues, use these cues as signals to initiate various
coping strategies (“Take five deep breaths and think about the three best
choices for how to respond before lashing out at a teacher.”), and provide
himself with positive reinforcement (telling himself, “Good job, you caught the
signal and used your strategies!”) for successful self-control. The parent and the
child’s teachers, meanwhile, can learn to better manage ODD or CD-type
behaviour through negotiating, compromising, problem-solving with the child,
anticipating and avoiding potentially explosive situations, and prioritizing goals
so that less important problems are ignored until more pressing issues have
been successfully addressed. These highly specific techniques can be taught by
professional behaviour therapists or other mental health professionals
recommended by the child’s paediatrician or school psychologist, or other
professionals involved with one’s family.

If the child has a diagnosis of coexisting Oppositional Defiant Disorder (ODD)

or Conduct Disorder (CD), and well-planned classroom behavioural techniques in
his mainstream classroom have been ineffective, this may lead to a decision to
place him in a special classroom at school that is set up for more intensive
behaviour management. However, schools are mandated to educate the child in
a mainstream classroom if possible, and to regularly review the child’s education
plan and reassess the appropriateness of his placement.

There is growing evidence that the same stimulant medications that improve
the core ADHD symptoms may also help coexisting ODD and CD. Stimulants
have been shown to help decrease verbal and physical aggression, negative peer
interactions, stealing, and vandalism. Although stimulant medications do not
teach children new skills, such as helping them identify and respond
appropriately to others’ social signals, they may decrease the aggression that
stands in the way of forming relationships with others their age. For this reason,
stimulants are usually the first choice in a medication treatment approach for
children with ADHD and a coexisting disruptive behaviour disorder.

The earlier the stimulants are introduced to treat the coexisting ODD or CD,
the better. A child with a disruptive behaviour disorder whose aggressive
behaviour continues untreated may start to identify himself with others who
experience discipline problems. By adolescence, he may resist treatment that
could help him change his behaviour and make him less popular among these
friends. He will have grown accustomed to his defiant “self” and feel
uncomfortable and “unreal” when stimulants help check his reckless, authority-
flaunting style. By treating these behaviours in elementary school or even
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earlier, one may have a better chance of preventing the child from creating a
negative self-identity.

If the child has been treated with 2 or more types of stimulants and his
aggressive symptoms are the same or worse, his paediatrician may choose to
reevaluate the situation and replace the stimulant with other medications. If
stimulant medication alone led to some but not enough improvement, his
paediatrician may continue to prescribe stimulants in combination with other
agent(s).

No clear-cut treatment is available for many of the impulse-control disorders.

There are some tentative ones. Behaviour techniques like stress management,
distraction, relaxation training, systematic desensitization, contingency
contracting, habit reversal training, and aversive conditioning are found to be
helpful. Some therapists use overcorrection through public confession and
restitution. It is good to find out better ways to meet the needs that had been
addressed by the impulsive behaviour. Since these disorders worsen under
stress, raising awareness of stressful triggers is important. Reinforcement with
praise and tangible rewards also can help modify behaviour. When an impulsive
behaviour reaches addictive proportions, the client may experience symptoms of
withdrawal after its cessation. The withdrawal symptoms need to be
addressed.136

9. Conclusion

For now, the only consensus is that physical, biological, psychological,

emotional, and even cultural factors may all play a role in causing disruptive,
impulse-control, and conduct disorders.

Treatments are often attempted through both cognitive behavioural therapy

and psychotropic medication regimens, though the pharmaceutical options have
shown limited success. Therapy aids in helping the patient recognize the
impulses in hopes of achieving a level of awareness and control of the outbursts,
along with treating the emotional stress that accompanies these episodes.

Cognitive-behavioural therapy (CBT) is the only treatment that can

be used for all types of impulse-control disorders. This may include
training to become aware of behavioural triggers and strategies to control them.
Older children who are disruptive at school may require intensive behaviour
management. Other than CBT, finding successful treatment options is a work in
progress. For example, experts disagree about using medication as treatment,
and there are no approved drugs for these disorders. Fluoxetine (Prozac) has
shown some benefit for intermittent explosive disorder. Other selective serotonin
reuptake inhibitors have had mixed results in kleptomania and pyromania.
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18. NEURODEVELOPMENTAL DISORDERS

1. Introduction

The neurodevelopmental disorders are a group of conditions with onset in the

developmental period. The disorders typically manifest early in development,
often before the child enters grade school, and are characterized by
developmental deficits that produce impairments of personal, social, academic,
or occupational functioning. The range of developmental deficits varies from very
specific limitations of learning or control of executive functions to global
impairments of social skills or intelligence. The neurodevelopmental disorders
frequently co-occur; for example, individuals with autism spectrum disorder
often have intellectual disability (intellectual developmental disorder), and many
children with attention-deficit/hyperactivity disorder (ADHD) have a specific
learning disorder. For some disorders, the clinical presentation includes
symptoms of excess as well as deficits and delays in achieving expected
milestones. For example, autism spectrum disorder is diagnosed only when the
characteristic deficits of social communication are accompanied by excessively
repetitive behaviours, restricted interests, and insistence on sameness.

2. Intellectual Disabilities

1) Intellectual Disability (Intellectual Developmental Disorder)

(Formerly Known as Mental Retardation)

Children of mild intellectual disabilities may not exhibit atypical behaviours

in all environments except when they are placed in situations where they require
higher reasoning skills. Children with moderate intellectual disabilities may not
be able to achieve complete independence. Children with severe intellectual
disabilities will exhibit significant motor deficiencies and cognitive impairment.
Profound intellectual disabilities are rare.137

(1) Diagnostic Criteria

Intellectual disability (intellectual developmental disorder) is a disorder

with onset during the developmental period that includes both intellectual and
adaptive functioning deficits in conceptual, social, and practical domains. The
following three criteria must be met:

A. Deficits in intellectual functions, such as reasoning, problem solving,

planning, abstract thinking, judgement, academic learning, and learning from
experience, confirmed by both clinical assessment and individualized,
standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental

and socio-cultural standards for personal independence and social
responsibility. Without ongoing support, the adaptive deficits limit functioning
in one or more activities of daily life, such as communication, social
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participation, and independent living, across multiple environments, such as

home, school, work, and community.

C. Onset of intellectual and adaptive deficits is during the developmental

period.

2) Global Developmental Delay

This diagnosis is reserved for individuals under the age of 5 years

when the clinical severity level cannot be reliably assessed during early
childhood. This category is diagnosed when an individual fails to meet
expected developmental milestones in several areas of intellectual
functioning, and applies to individuals who are unable to undergo systematic
assessments in intellectual functioning, including children who are too young
to participate in standardized testing. This category requires reassessment
after a period of time.

3) Treatment

Early intervention for Intellectual Disability is essential. Special education,

home health care, language stimulation, and social skills training at an early age
can have a great impact on treatment outcomes. A developmental approach of
taking into account the child’s cognitive age rather than chronological age and
setting goals based on individual abilities and needs, is a necessity to working
with these children. Mild and moderate cases of children will benefit from parent
training, community-based treatment, and individual psychotherapy promoting
the child’s positive self-regard and improving his social and occupational skills.
Severe cases of children need to reside in institutions where the therapists will
contribute to the quality of life by helping them develop recreational interests
and interpersonal relationships. Behaviour modification is especially helpful in
decreasing self-injurious behaviours. If the treatment meets the specific needs
of the clients, then that is efficacious. 138

3. Communication Disorders

1) Language Disorder

(1) Diagnostic Criteria

A. Persistent difficulties in the acquisition and use of language across

modalities (i.e., spoken , written, sign language, or other) due to deficits
in comprehension or production that include the following:
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1. Reduced vocabulary (word knowledge and use).

2. Limited sentence structure (ability to put words and word endings together
to form sentences based on the rules of grammar and morphology).
3. Impairments in discourse (ability to use vocabulary and connect sentences
to explain or describe a topic or series of events or have conversation).

B. Language abilities are substantially and quantifiably below those expected

for age, resulting in functional limitations in effective communication, social
participation, academic achievements, or occupational performance,
individually or in any combination.

C. Onset of symptoms is in the early developmental period.

D. The difficulties are not attributable to hearing or other sensory

impairment, motor dysfunction, or another medical or neurological condition
and are not better explained by intellectual disability (intellectual
developmental disorder) or global developmental delay.

2) Speech Sound Disorder

(1) Diagnostic Criteria

A. Persistent difficulty with speech sound production that interferes with

speech intelligibility or prevents verbal communication of messages.

B. The disturbance causes limitations in effective communication that

interfere with social participation, academic achievement, or occupational
performance, individually or in any combination.

C. Onset of symptoms is in the early developmental period.

D. The difficulties are not attributable to congenital or acquired conditions,

such as cerebral palsy, cleft palate, deafness or hearing loss, traumatic brain
injury, or other medical or neurological conditions.

3) Childhood-Onset Fluency Disorder (Stuttering)

(1) Diagnostic Criteria

A. Disturbances in the normal fluency and time patterning of speech that are
inappropriate for the individual’s age and language skills, persist over time,
and are characterized by frequent and marked occurrences of one (or more)
of the following:

1. Sound and syllable repetitions.

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2. Sound prolongations of consonants as well as vowels.

3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetition (e.g., “I-I-I-I see him”)

B. The disturbance causes anxiety about speaking or limitations in effective

communication, social participation, or academic or occupational
performance, individually or in any combination.

C. The onset of symptoms is in the early developmental period. (Note: Late-

onset cases are diagnosed as adult-onset fluency disorder.)

D. The disturbance is not attributable to a speech-motor or sensory deficit,

dysfluency associated with neurological insult (e.g., stroke, tumour, trauma),
or another medical condition and is not better explained by another mental
disorder.

4) Social (Pragmatic) Communication Disorder

(1) Diagnostic Criteria

A. Persistent difficulties in the social use of verbal and nonverbal

communication as manifested by all of the following:

1. Deficits in using communication for social purposes, such as greeting and

sharing information, in a manner that is appropriate for the social context.
2. Impairment of the ability to change communication to match context or
the needs of the listener, such as speaking differently in a classroom than on
a playground, talking differently to a child than to an adult, and avoiding use
of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as taking
turns in conversation, rephrasing when misunderstood, and knowing how to
use verbal and nonverbal signals to regulate interaction.
4. Difficulties understanding what is not explicitly stated (e.g., making
inferences) and nonliteral or ambiguous meanings of language (e.g., idioms,
humour, metaphors, multiple meanings that depend on the context for
interpretation).

B. The deficits result in functional limitations in effective communication,

social participation, social relationships, academic achievement, or
occupational performance, individually or in combination.

C. The onset of the symptoms is in the early developmental period (but

deficits may not become fully manifest until social communication demands
exceed limited capacities).

D. The symptoms are not attributable to another medical or neurological

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condition or to low abilities in the domains of word structure and grammar,

and are not better explained by autism spectrum disorder, intellectual
disability (intellectual developmental disorder), global developmental delay,
or another mental disorder.

5) Treatment

The treatment for Communication Disorders is by behaviour modification

techniques such as desensitization, biofeedback and stammer suppresser; and
by techniques to diminish anxiety like relaxation therapy, drug therapy, or
individual or group psychotherapy.139

4. Autism Spectrum Disorder

Children with autistic disorder have significant deficit in socialization,

communication, and behaviour. They suffer from motivational impairments that
inhibit their response to social and environmental input. They rarely engage in
make-believe play that mimics human activity. Their play more often exhibits
repetitive, stereotyped interactions with inanimate objects. The onset of autistic
disorder is before the age 3. As young children they have deficits in pointing
ability, reluctance to look at others, and inability to orient to their names. 140

1) Diagnostic Criteria

A. Persistent deficits in social communication and social interaction across

multiple contexts, as manifested by the following, currently or by history:

1. Deficit in social-emotional reciprocity, ranging, for example, from abnormal

social approach and failure of normal back-and-forth conversation; to
reduced sharing of interests, emotions, or affect; to failure to initiate or
respond to social interactions.
2. Deficits in nonverbal communicative behaviours used for social interaction,
ranging, for example, from poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact and body language or deficits
in understanding and use of gestures; to a total lack of facial expressions and
nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships,
ranging, for example, from difficulties adjusting behaviour to suit various
social contexts; to difficulties in sharing imaginative play or in making
friends; to absence of interest in peers.

B. Restricted, repetitive patterns of behaviour, interests, or activities, as

manifested by at least two of the following, currently or by history (examples
are illustrative, not exhaustive):

1. Stereotyped or repetitive motor movements, use of objects, or speech

(e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia,
idiosyncratic phrases).
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2. Insistence on sameness, inflexible adherence to routines, or ritualized

patterns of verbal or nonverbal behaviour (e.g., extreme distress at small
changes, difficulties with transitions, rigid thinking patterns, greeting rituals,
need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus
(e.g., strong attachment to or preoccupation with unusual objects,
excessively circumscribed or perseverative interests). (Perseveration:
Persistence at tasks or in particular way of doing things long after the
behaviour has ceased to be functional or effective; continuance of the same
behaviour despite repeated failures or clear reasons for stopping).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory
aspects of the environment (e.g., apparent indifference to pain/temperature,
adverse response to specific sounds or textures, excessive smelling or
touching of objects, visual fascination with lights or movement).

Specify current severity: Severity is based on social communication

impairments and restricted, repetitive patterns of behaviour.

C. Symptoms must be present in the early developmental period (but may

not become fully manifest until social demands exceed limited capacities, or
may be masked by learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational,

or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability

(intellectual developmental disorder) or global developmental delay.
Intellectual disability and autism spectrum disorder frequently co-occur; to
make comorbid diagnoses of autism spectrum disorder and intellectual
disability, social communication should be below that expected for general
developmental level.

Specify if:
With or without accompanying intellectual impairment
With or without accompanying language impairment
Associated with a known medical or genetic condition or environmental factor
Associated with another neurodevelopmental, mental, or behavioural disorder
With catatonia

2) Treatment

(1) Development of a regular routine with as few changes as possible;

(2) Structured class room training, aiming at learning new material and
maintenance of acquired learning; (3) Positive reinforcements to teach self-care
skills; (4) Speech therapy and/or sign language teaching; and (5) Behavioural
techniques to encourage interpersonal interactions.

The treatment for Autism Spectrum Disorders consists mainly of three

modes of intervention that are often used together.
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(1) Counselling

Parental counselling and supportive psychotherapy can be very useful in

allaying parental anxiety and guilt, and helping their active involvement in
therapy. However, overstimulation of child should be avoided during treatment.

(2) Behaviour Therapy

Behavioural therapies are found to be helpful in controlling unwanted

symptoms, promoting social interactions, increasing self-reliance, and facilitating
exploration (i.e., novelty-seeking behaviour). Assertiveness training,
educational, vocational training, teaching of adaptive skills and support in
managing major life events are effective. Environmental management, especially
predictable or programmed structure, is of particular value. There is no drug
treatment of autistic disorder itself, but psychotropic medications can be used to
target particular symptoms, symptom clusters, and comorbid disorders in
patients. Thus, though no single medication is generally indicated, a variety of
different agents can provide symptomatic benefit.

(3) Other Interventions

The most effective treatment for autistic children is structured and based
on the child’s interests. Therapists can teach tasks as a series of simple steps,
engage their attention, and provide positive reinforcement for behaviour.
Parental involvement makes a significant positive improvement in treatment
outcomes. Early and intensive behavioural interventions programme that
provides one-to-one behaviour modification improving communication and
academic skills, teaching self-help skills, improving motor skills, and engaging in
play is helpful. This is proposed before the child enters the school. Once in
school, what is needed is individualized educational plan to address not only
academic concerns but also the social and emotional challenges. 141

5. Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) cannot be prevented and

currently there is no cure. It is primarily predominantly hyperactive-impulsive
type, predominantly inattentive type, and combined type. This disorder
negatively affects the functioning of the brain’s neural circuits, which are
instrumental in attention, cognitive control, and decision-making. It is
understood that irregular metabolism of brain chemistry contributes directly to
ADHD behavioural patterns. Premotor and superior prefrontal lobe regions of the
brain, areas that are responsible for executive functioning and impulse control
are less active in them. This disorder has a strong genetic component. The onset
of this disorder is prior to age 7.142

1) Attention-Deficit/Hyperactivity Disorder

(1) Diagnostic Criteria

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A. A persistent pattern of inattention and/or hyperactivity-impulsivity that

interferes with functioning or development, as characterized by (1) and/or
(2):

1. Inattention: Six (or more) of the following symptoms have persisted for at
least 6 months to a degree that is inconsistent with developmental level
and that negatively impacts directly on social and academic/occupational
activities:
Note: The symptoms are not solely a manifestation of oppositional
behaviour, defiance, hostility, or a failure to understand tasks or
instructions. For older adolescents and adults (age 17 and older), at least
five symptoms are required.

a. Often fails to give close attention to details or makes careless mistakes

in schoolwork, at work, or during other activities (e.g., overlooks or
misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g.,
has difficulty remaining focused during lectures, conversations, or lengthy
reading).
c. Often does not seem to listen when spoken to directly (e.g., mind
seems elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks but
quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and belongings in
order; messy, disorganized work; has poor time management; fails to
meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports, completing forms, reviewing
lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school
materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses,
mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents
and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands;
for older adolescents and adults, returning calls, paying bills, keeping
appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms

have persisted for at least 6 months to a degree that is inconstant with
developmental level and that negatively impacts directly on social and
academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional
behaviour, defiance, hostility, or a failure to understand tasks or
instructions. For older adolescents and adults (age 17 and older), at least
five symptoms are required.

a. Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected
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(e.g., leaves his place in the classroom, in the office or other

workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate.
(Note: In adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to
be or uncomfortable being still for extended time, as in restaurants,
meetings; may be experienced by others as being restless or difficult
to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed
(e.g., completes people’s sentences; cannot wait for turn in
conversation).
h. Often has difficulty waiting his turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations,
games, or activities; may start using other people’s things without
asking or receiving permission; for adolescents and adults, may
intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior

to age 12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two

or more settings (e.g., at home, school, or work; with friends or relatives; in
other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the
quality of, social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia

or another psychotic disorder and are not better explained by another mental
disorder (e.g., mood disorder, anxiety disorder, dissociative disorder,
personality disorder, substance intoxication or withdrawal).

Specify whether:
Combined presentation
Predominantly inattentive presentation
Predominantly hyperactive/impulsive presentation

Specify if: In partial remission

Specify current severity: Mild, Moderate, Severe

2) Treatment

For the treatment of ADHD, the therapist has to be calm and patient in
order to avoid escalating the excitable behaviours of the client. Many
transference and counter transference issues may come up because of the
volatility of the client. It requires a multimodal treatment strategy that combines
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stimulant therapy (medication), parent training and counselling, and

behavioural-targeted classroom interventions. Family counselling, individual
counselling focusing on social skills training or other specific needs, and support
groups for parents are helpful. Negative behaviour traits found in the child can
disrupt the entire family system. Therefore, treatment should include a parent
management-training. Parent training reduces parental stress, increases
parental sense of control and self-esteem. In order to reinforce desirable
behaviour in multiple settings, consistent and regular communication among
parents, teachers, school counsellors, and therapists is essential. Individual
therapy will help the child cope with academic, social, and family stressors.
Behaviour modification and counselling are very important in the successful
management of ADD and can be used along with drug therapy. 143

6. Specific Learning Disorder

1) Diagnostic Criteria

A. Difficulties learning and using academic skills, as indicated by the presence

of at least one of the following symptoms that have persisted for at least 6
months, despite the provision of interventions that target those difficulties:

1. Inaccurate or slow and effortful word reading (e.g., reads single words
aloud incorrectly or slowly and hesitantly, frequently guesses words, has
difficulty sounding out words).
2. Difficulty understanding the meaning of what is read (e.g., may read text
accurately but not understand the sequence, relationships, inferences, or
deeper meanings of what is read).
3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or
consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or
punctuation errors within sentences; employs poor paragraph organization;
written expressions of ideas lacks clarity).
5. Difficulties mastering number sense, number facts, or calculation (e.g.,
has poor understanding of numbers, their magnitude, and relationships;
counts on fingers to add single-digit numbers instead of recalling the math
fact as peers do; gets lost in the midst of arithmetic computation and may
switch procedures).
6. Difficulties with mathematical reasoning (e.g., has severe difficulty
applying mathematical concepts, facts, or procedures to solve quantitative
problems).

B. The affected academic skills are substantially and quantifiably below those
expected for the individual’s chronological age, and cause significant
interference with academic or occupational performance, or with activities of
daily living, as confirmed by individually administered standardized
achievement measures and comprehensive clinical assessment. For
individuals age 17 years and older, a documented history of impairing
learning difficulties may be substituted for the standardized assessment.

C. The learning difficulties begin during school-age years but may not
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become fully manifest until the demands for those affected academic skills
exceed the individual’s limited capacities (e.g., as in timed tests, reading or
writing lengthy complex reports for a tight deadline, excessively heavy
academic loads).

D. The learning difficulties are not better accounted for by intellectual

disabilities, uncorrected visual or auditory acuity, other mental or
neurological disorders, psychosocial adversity, lack of proficiency in the
language of academic instruction, or inadequate educational instruction.

Note: The four diagnostic criteria are to be met based on a clinical synthesis
of the individual’s history (developmental, medical, family, educational),
school reports, and psychoeducational assessment.

7. Motor Disorders

1) Developmental Coordination Disorder

(1) Diagnostic Criteria

A. The acquisition and execution of coordinated motor skills is substantially

below that expected given the individual’s chronological age and
opportunity for skill learning and use. Difficulties are manifested as
clumsiness (e.g., dropping or bumping into objects) as well as slowness
and inaccuracy of performance of motor skills (e.g., catching an object,
using scissors or cutlery, handwriting, riding a bike, or participating in
sports).

B. The motor skills deficit in Criterion A significantly and persistently

interferes with activities of daily living appropriate to chronological age
(e.g., self-care and self-maintenance) and impacts academic/school
productivity, prevocational and vocational activities, leisure, and play.

C. Onset of symptoms is in the early developmental period.

D. The motor skills deficits are not better explained by intellectual disability
(intellectual developmental disorder) or visual impairment and are not
attributable to a neurological condition affecting movement (E.g., cerebral
palsy, muscular dystrophy, degenerative disorder).

2) Stereotypic Movement Disorder

The repetitive behaviours of the children of stereotypic movement

disorder are voluntary even though the children report that they cannot stop
them. Children with inadequate social stimulation may have this disorder and
may start after a stressful event. Comorbidity with intellectual disability and
pervasive developmental disorder is common.144

(1) Diagnostic Criteria

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A. Repetitive, seemingly driven, and apparently purposeless motor behaviour

(e.g., hand shaking or waving, body rocking, head banging, self-biting,
hitting own body).
B. The repetitive motor behaviour interferes with social, academic, or other
activities and may result in self-injury.
C. Onset is in the early developmental period.
D. The repetitive motor behaviour is not attributable to the physiological
effects of a substance or neurological condition and is not better explained
by another neurodevelopmental or mental disorder (e.g., trichotillomania
[hair-pulling disorder], obsessive-compulsive disorder).

(2) Treatment

Treatment for stereotypic movement disorder is similar to those for

autism, tic disorders, and obsessive compulsive disorder. Classical conditioning
pairs the stereotypic behaviour with some aversive stimulus or competing
behaviour. This type of aversion or competition is meant to decrease the
frequency of the targeted behaviour. For example, pasting a tape on the thumb
will prevent the child from thumb sucking. Operant conditioning will use both
positive and negative reinforcers to change targeted behaviours. The child may
be rewarded for the time he did not have stereotypic movement. 145

3) Tic Disorders

Tic disorders worsen under stress and are less noticeable during sleep, or
when involved in an engrossing activity. Simple motor tics are eye blinking, neck
jerking, facial grimacing, shrugging, or coughing. Simple vocal tics are clearing
one’s throat, grunting, sniffing, or barking. Complex motor and vocal tics include
complete actions or words that are repeated involuntarily and in a rapid,
staccato fashion. Complex motor tics involve jumping, grooming, or smelling an
object.146

(1) Diagnostic Criteria

Note: A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or

vocalization.

Tourette’s Disorder

A. Both multiple motor and one or more vocal tics have been present at
some time during the illness, although not necessarily concurrently.
B. The tics may wax and wane in frequency but have persisted for more than
1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., cocaine) or another medical condition (e.g., Huntington’s
disease, postviral encephalitis).
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Persistent (Chronic) Motor or Vocal Tic Disorder

A. Single or multiple motor or vocal tics have been present during the illness,
but not both motor and vocal.
B. The tics may wax and wane in frequency but have persisted for more than
1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., cocaine) or another medical condition (e.g., Huntington’s
disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.

Provisional Tic Disorder

A. Single or multiple motor and /or vocal tics.

B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a
substance (e.g., cocaine) or another medical condition (e.g., Huntington’s
disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder or persistent
(chronic) motor or vocal tic disorder.

(2) Treatment

The treatments for tic disorders are habit reversal behavioural training,
stress reduction techniques, psychoeducation of children and families about the
disorder, advocacy with education professionals, and medication management
when needed. The first step is to educate the child and the parents about the
nature of the disorder and the influence that stress, anxiety, and fatigue can
have on symptoms. Behavioural techniques are used to diminish tic-related
behaviours. Self-monitoring involves the child in recording the occurrence and
frequency of tics. This will indicate the progress the child has made. Progressive
relaxation techniques, deep breathing, or imagery before or during episodes of
tics are beneficial. Habit reversal training is suggested. By this method, the child
uses reinforcement and other behavioural techniques to recognize premonitory
urges, become aware of the presence of tics, monitor their own behaviours
during stress-inducing situations, use relaxation techniques, and perform
competing behaviours that are incompatible with the tic-related behaviour.

Pharmacotherapy is usually the preferred mode of treatment though there

is lack of clear evidence of efficacy. Antipsychotics are often helpful in small
doses and several other drugs have been tried. 147

8. Treatment for Neurodevelopmental Disorders

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The treatment of specific developmental disorders is based on the learning

theory principles and is behavioural in approach. It involves use of special
remedial teaching, focusing on the underlying deficit (for example, perceptual
motor training in motor skills disorder). The treatment of common co-morbid
emotional problems is often necessary. Parental education and counselling are
important components of good management.148

9. Conclusion

Neurodevelopmental disorders are disabilities associated primarily with the

functioning of the neurological system and brain. Examples of
neurodevelopmental disorders in children include attention-deficit/hyperactivity
disorder (ADHD), autism, learning disabilities, intellectual disability (also known
as mental retardation), conduct disorders, cerebral palsy, and impairments in
vision and hearing. Children with neurodevelopmental disorders can experience
difficulties with language and speech, motor skills, behaviour, memory, learning,
or other neurological functions. While the symptoms and behaviours of
neurodevelopmental disabilities often change or evolve as a child grows older,
some disabilities are permanent. Diagnosis and treatment of these disorders can
be difficult; treatment often involves a combination of professional therapy,
pharmaceuticals, and home- and school-based programmes.

Genetics can play an important role in many neurodevelopmental disorders,

and some cases of certain conditions such as intellectual disability are associated
with specific genes. However, most neurodevelopmental disorders have complex
and multiple contributors rather than any one clear cause. These disorders likely
result from a combination of genetic, biological, psychosocial, and environmental
risk factors. A broad range of environmental risk factors may affect
neurodevelopment, including (but not limited to) maternal use of alcohol,
tobacco, or illicit drugs during pregnancy; lower socioeconomic status; preterm
birth; low birth weight; the physical environment; and prenatal or childhood
exposure to certain environmental contaminants.

There is a need for early interventions and further education on new

morbidities. Strategies should include further professional training on
neurodevelopmental disorders for teachers, psychosocial interventions,
psychoeducation and training programmes for parents, and the implementation
of an optimized cooperation between families and institutional settings.
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19. NEUROCOGNITIVE DISORDERS

1. Introduction

The neurocognitive disorders (NCDs) (referred to in DSM-IV as “Dementia,

Delirium, Amnestic, and Other Cognitive Disorders”) begin with delirium,
followed by the syndromes of major NCD, mild NCD, and their aetiological
subtypes.

2. Delirium

1) Diagnostic Criteria

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain,

and shift attention) and awareness (reduced orientation to the
environment).
B. The disturbance develops over a short period of time (usually hours to a
few days), represents a change from baseline attention and awareness,
and tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g., memory deficit,
disorientation, language, visuospatial ability, or perception).
D. The disturbance in Criteria A and C are not better explained by another
preexisting, established, or evolving neurocognitive disorder and do not
occur in the context of a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal (i.e., due
to a drug of abuse or to a medication), or exposure to a toxin, or is due
to multiple aetiologies.

2) Treatment

There are two things to be managed in treatment. First of all the

underlying medical condition causing the delirium should be found out.
Secondly the inappropriate behaviours that endanger medical care should be
treated. Though medication is used, there is no consensus concerning whether
delirium should be treated pharmacologically. Of course, psychosocial support is
very much needed. Environmental interventions are sometimes helpful like
placing a clock, calendar, familiar objects in the room and thus reorient the
patient to date and surroundings.149

3. Major and Mild Neurocognitive Disorders

1) Major Neurocognitive Disorder

(1) Diagnostic Criteria

A. Evidence of significant cognitive decline from a previous level of

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performance in one or more cognitive domains (complex attention,

executive function, learning and memory, language, perceptual-motor, or
social cognition) based on:
1. Concern of the individual, a knowledgeable informant, or the clinician
that there has been a significant decline in cognitive function; and
2. A substantial impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in its
absence, another quantified clinical assessment.
B. The cognitive deficits interfere with independence in everyday activities
(i.e., at a minimum, requiring assistance with complex instrumental
activities of daily living such as paying bills or managing medications).
C. The cognitive deficits do not occur exclusively in the context of a
delirium.
D. The cognitive deficits are not better explained by another mental disorder
(e.g., major depressive disorder, schizophrenia).

2) Mild Neurocognitive Disorder

(1) Diagnostic Criteria

A. Evidence of modest cognitive decline from a previous level of

performance in one or more cognitive domains (complex attention,
executive function, learning and memory, language, perceptual motor, or
social cognition) based on:
1. Concern of the individual, a knowledgeable informant, or the clinician
that there has been a mild decline in cognitive function: and
2. A modest impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in its
absence, another quantified clinical assessment.
B. The cognitive deficits do not interfere with capacity for independence in
everyday activities (i.e., complex instrumental activities of daily living
such as paying bills or managing medications are preserved, but greater
effort, compensatory strategies, or accommodation may be required).
C. The cognitive deficits do not occur exclusively in the context of a
delirium.
D. The cognitive deficits are not better explained by another mental disorder
(e.g., major depressive disorder, schizophrenia).

4. Major or Mild Neurocognitive Disorder due to Alzheimer’s disease

1) Diagnostic Criteria

A. The criteria are met for major or mild neurocognitive disorder.

B. There is insidious onset and gradual progression of impairment in one or
more cognitive domains (for major neurocognitive disorder, at least two
domains must be impaired).
C. Criteria are met for either probable or possible Alzheimer’s disease as
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follows:
For Major Neurocognitive Disorder:
Probable Alzheimer’s disease is diagnosed if either of the following is
present; otherwise, possible Alzheimer’s disease should be diagnosed.
1. Evidence of a causative Alzheimer’s disease genetic mutation from
family history or genetic testing.
2. All three of the following are present:
a. Clear evidence of decline in memory and learning and at least one
other cognitive domain based on detailed history or serial
neuropsychological testing).
b. Steadily progressive, gradual decline in cognition, without
extended plateaus.
c. No evidence of mixed aetiology (i.e., absence of other
neurodegenerative or cerebrovascular disease, or another
neurological, mental, or systemic disease or condition likely
contributing to cognitive decline).
For Mild Neurocognitive Disorder:
Probable Alzheimer’s disease is diagnosed if there is evidence
of a causative Alzheimer’s disease genetic mutation from either
genetic testing or family history.
Possible Alzheimer’s disease is diagnosed if there is no
evidence of a causative Alzheimer’s disease genetic mutation from
either genetic testing or family history, and all three of the
following are present:
1. Clear evidence of decline in memory and learning.
2. Steadily progressive, gradual decline in cognition, without
extended plateaus.
3. No evidence of mixed aetiology (i.e., absence of other
neurodegenerative or cerebrovascular disease, or another
neurological or systemic disease or condition likely contributing
to cognitive decline).
D. The disturbance is not better explained by cerebrovascular disease,
another neurodegenerative disease, the effects of a substance, or
another mental, neurological, or systemic disorder.

5. Major or Mild Frontotemporal Neurocognitive Disorder

(1) Diagnostic Criteria

A. The criteria are met for major or mild neurocognitive disorder.

B. The disturbance has insidious onset and gradual progression.
C. Either (1) or (2):
1. Behaviour variant:
a. Three or more of the following behavioural symptoms:
i. Behavioural disinhibition.
ii. Apathy or inertia.
iii. Loss of sympathy or empathy.
iv. Perseverative, stereotyped or compulsive/ritualistic behaviour.
v. Hyperorality and dietary changes.
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b. Prominent decline in social cognition and/or executive abilities.

2. Language variant:
a. Prominent decline in language ability, in the form of speech
production, word finding, object naming, grammar, or word
comprehension.
D. Relative sparing of learning and memory and perceptual-motor function.
E. The disturbance is not better explained by cerebrovascular disease,
another neurodegenerative disease, the effects of a substance, or
another mental, neurological, or systemic disorder.

Probable frontotemporal neurocognitive disorder is diagnosed if

either of the following is present; otherwise, possible frontotemporal
neurocognitive disorder should be diagnosed:
1. Evidence of a causative frontotemporal neurocognitive disorder
genetic mutation, from either family history or genetic testing.
2. Evidence of disproportionate frontal and/or temporal lobe involvement
from neuroimaging.
Possible frontotemporal neurocognitive disorder is diagnosed if
there is no evidence of a genetic mutation, and neuroimaging has not been
performed.

6. Major or Mild Neurocognitive Disorder with Lewy Bodies

(1) Diagnostic Criteria

A. The criteria are met for major or mild neurocognitive disorder.

B. The disorder has an insidious onset and gradual progression.
C. The disorder meets a combination of core diagnostic features and
suggestive diagnostic features for either probable or possible
neurocognitive disorder with Lewy bodies.

For probable major or mild neurocognitive disorder with Lewy

bodies, the individual has two core features, or one suggestive feature
with one or more core features.

For possible major or mild neurocognitive disorder with Lewy

bodies, the individual has only one core feature, or one or more
suggestive features.

1. Core diagnostic features:

a. Fluctuating cognition with pronounced variations in attention and
alertness.
b. Recurrent visual hallucinations that are well formed and detailed.
c. Spontaneous features of Parkinsonism, with onset subsequent to
the development of cognitive decline.

2. Suggestive diagnostic features:

a. Meets criteria for rapid eye movement sleep behaviour disorder.
b. Severe neuroleptic sensitivity.
D. The disturbance is not better explained by cerebrovascular disease,
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another neurodegenerative disease, the effects of a substance, or

another mental, neurological, or systemic disorder.

7. Major or Mild Vascular Neurocognitive Disorder

(1) Diagnostic Criteria

A. The criteria are met for major or mild neurocognitive disorder.

B. The clinical features are consistent with a vascular aetiology, as
suggested by either of the following:
1. Onset of the cognitive deficits is temporally related to one or more
cerebrovascular events.
2. Evidence for decline is prominent in complex attention (including
processing speed) and frontal-executive function.
C. There is evidence of the presence of cerebrovascular disease from
history, physical examination, and/or neuroimaging considered sufficient
to account for the neurocognitive deficits.
D. The symptoms are not better explained by another brain disease or
systemic disorder.

Probable vascular neurocognitive disorder is diagnosed if one of the

following is present; otherwise possible vascular neurocognitive disorder
should be diagnosed:
1. Clinical criteria are supported by neuroimaging evidence of significant
parenchymal injury attributed to cerebrovascular disease (neuroimaging-
supported).
2. The neurocognitive syndrome is temporally related to one or more
documented cerebrovascular events.
3. Both clinical and genetic (e.g., cerebral autosomal dominant arteriopathy
with subcortical infarcts and leukoencephalopathy) evidence of
cerebrovascular disease is present.
Possible vascular neurocognitive disorder is diagnosed if the clinical
criteria are met but neuroimaging is not available and the temporal
relationship of the neurocognitive syndrome with one or more
cerebrovascular events is not established.

8. Treatment

Whenever a primary systemic or cerebral disorder is causally tied to the

amnestic syndrome, initial treatment (with thiamine, antiviral medication,
aspirin) must be directed towards the underlying pathological process. Presently
there are no known, definitively effective treatments for amnestic disorder that
are specifically aimed at reversing apparent memory deficits. Patients require
supervised living situations to ensure appropriate feeding and care. 150

9. Conclusion
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There is a steady increase in the number of individuals with symptoms of

delirium, dementia, amnesia and other cognitive disorders. These cognitive
disorders occur commonly and are particularly prevalent in geriatric patients.
Delirium is the most common psychiatric syndrome seen in a general medical
hospital. Dementia is a rapidly growing major health problem. Amnestic
disorders, although seen somewhat less frequently, commonly occur after severe
head trauma, strokes, alcohol abuse, and other disorders. Clinical comfort in the
diagnosis, management, and treatment of these disorders is essential for a
psychiatrist.151
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20. SUBSTANCE-RELALTED AND ADDICTIVE DISORDERS

1. Introduction

Psychoactive substance use disorders are major public health problems that
are frequently underdiagnosed and undertreated. Increased public awareness is
leading to promising efforts at locating high-risk populations, providing early
treatment, designing effective social policies aimed at prevention, and improving
differential therapeutics. However, the scenario will continue to plague
humankind, as it existed from the beginning of civilization. It is the question of
how best are we going to safeguard the wellbeing of humankind.
The substance-related disorders encompass 10 separate classes of drugs: (1)
alcohol; (2) caffeine; (3) cannabis; (4) hallucinogens (with separate categories
for phencyclidine [or similarly acting arylcyclohexylamines] and other
hallucinogens); (5) inhalants; (6) opioids; (7) sedatives, hypnotics, and
anxiolytics; (8) stimulants (amphetamine-type substance, cocaine, and other
stimulants); (9) tobacco; and (10) other (or unknown) substances. These 10
classes are not fully distinct. All drugs that are taken in excess have in
common direct activation of the brain reward system, which is involved
in the reinforcement of behaviours and the production of memories.
They produce such an intense activation of the reward system that
normal activities may be neglected. Instead of achieving reward system
activation through adaptive behaviours, drugs of abuse directly activate
the reward pathways. The pharmacological mechanisms by which each class
of drugs produces reward are different, but the drugs typically activate the
system and produce feelings of pleasure, often referred to as a “high.”
Furthermore, individuals with lower levels of self-control, which may reflect
impairments of brain inhibitory mechanisms, may be particularly predisposed to
develop substance use disorders, suggesting that the roots of substance use
disorders for some persons can be seen in behaviours long before the onset of
actual substance use itself.152

This chapter also includes gambling disorder, reflecting evidence that

gambling behaviours activate reward systems similar to those activated by drugs
of abuse and produce some behavioural symptoms that appear comparable to
those produced by the substance use disorders.

Since the substance-related and addictive disorders concern medical persons

I have not gone into the details of the substance use disorders and substance-
induced disorders. Suffice to mention the names of the substances. Of course, I
have dealt with the treatment. The names of the disorders are: (1) Substance-
Related Disorders, (2) Alcohol-related disorders, (3) Caffeine-Related Disorders,
(4) Cannabis-Related Disorders, (5) Hallucinogen-Related Disorders, (6)
Inhalant-Related Disorders, (7) Opioid-Related Disorders, (8) Sedative-,
Hypnotic-, or Anxiolytic-Related Disorders, (9) Stimulant-Related Disorders,
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(10) Tobacco-Related Disorders, (11) Other (Or Unknown) Substance-Related

Disorders, and (12) Non-Substance-Related Disorders

2. Gambling Disorder

1) Diagnostic Criteria

A. Persistent and recurrent problematic gambling behaviour leading to

clinically significant impairment or distress, as indicated by the individual
exhibiting four (or more) of the following in a 12-month period:
1. Needs to gamble with increasing amounts of money in order to
achieve the desired excitement.
2. Is restless or irritable when attempting to cut down or stop gambling.
3. Has made repeated unsuccessful efforts to control, cut back, or stop
gambling.
4. Is often preoccupied with gambling (e.g., having persistent thoughts
of reliving past gambling experiences, handicapping or planning the
next venture, thinking of ways to get money with which to gamble).
5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious,
depressed).
6. After losing money gambling, often returns another day to get even
(“chasing” one’s losses).
7. Lies to conceal the extent of involvement with gambling.
8. Has jeopardized or lost a significant relationship, job, or educational
or career opportunity because of gambling.
9. Relies on others to provide money to relieve desperate financial
situations caused by gambling.
B. The gambling behaviour is not better explained by a manic episode.

2) Treatment

There are a number of treatments meant for compulsive gambling like

psychoanalysis, behaviour therapy, cognitive therapy, medications, and ECT.
The high incidence of major affective disorders among pathological gamblers
leads one to question the relationship between these disorders. In some
gamblers the affective disorder may promote the gambling, whereas in other
gamblers it seems likely that the depletion of resources (e.g., emotional, family,
friends, financial) is responsible for the affective state of the gambler when one
enters treatment. There may be a subgroup of compulsive gamblers who remain
depressed in spite of abstinence.

Behavioural treatments, particularly aversive therapy, have been used to

treat compulsive gamblers with disappointing results. Now there is a trend away
from the use of single limited procedures such as aversion therapy towards a
multimodal approach. Psychoanalytic treatment seemed effective when the
gambler is admitted to an inpatient psychiatric treatment centre, particularly
when there is a risk of suicide, emotional decompensation, or exhaustion. The
initial assessment must include the compulsive gambler’s areas of high risk;
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marital problems, large debts, demands or threats from creditors, loss of

employment, legal problems, and isolation from friends and relatives. The
treatment plan is then designed to treat problems identified during the intake
process. Besides all these, group therapy with other compulsive gamblers and
involvement of the compulsive gambler with Gamblers Anonymous will be highly
beneficial.

There are supportive groups like Gamblers Anonymous and its sister groups
Gam-Anon (for families and spouses of compulsive gamblers) and Gam-a-Teen
(for adolescent children of compulsive gamblers) are important resources for
treatment. The only requirement for membership in Gamblers Anonymous is an
expressed desire to stop gambling. Unfortunately, many of the treatments meet
with failures.153

3. Therapy for Substance-Related and Addictive Disorders

Therapies for Substance-Related and Addictive Disorders should deal with (1)
Patient education, (2) Cognitive behavioural therapy, (3) Behavioural therapies,
(4) Group therapies, (5) Self-help groups and 12 step programs.

If patient is discharged from inpatient hospitalization, patient needs to be

seen in an outpatient setting, intensive outpatient setting or partial
hospitalization by a behavioural health provider within 7 calendar days. 154

1) THEORETICAL MODEL

The model for treatment planning considers three major dimensions: extent
and severity of problems, motivation, and an analysis of factors maintaining the
current drinking pattern.

(1) Problem Severity

The consideration of the extent and severity of problems is important in

decision making about the types of treatments to be offered. Clients who have
characteristics of antisocial personality and those with different levels of severity
of psychiatric problems will respond differently to different types of treatment
approaches.

(2) Motivation

Clients vary in the degree to which they recognize their drinking as

problematic and in their personal readiness to change. Motivation of the client
can be seen on a continuum. The continuum ranges from the stage of
precontemplation, in which a person does not recognize a behaviour as
problematic, to contemplation, where the person begins to consider that a
behavioural pattern might be problematic, to the action stage, in which a person
is ready to change his behaviour to deal with a problem.

(3) Factors Maintaining Current Drinking Pattern

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The treatment model assumes that drinking can best be treated by

examining current factors that maintain drinking, rather than historical
factors. Factors that maintain drinking may be individual or related to
environmental circumstances or interpersonal relationships. To understand this,
there is a SORC model: Environmental Stimuli (S), which occur antecedent to
drinking, elicit cognitive, affective, and physiological Organismic (O) reactions.
The drinking Response (R) follows, and is believed to be maintained by the
positive consequences (C) of drinking.

2) Treatment Modalities

Before starting any treatment, it is important to follow these steps: (1)

Ruling out (or diagnosing) any physical disorder. (2) Ruing out (or diagnosing)
any psychiatric disorder and /or co-morbid substance use disorder. (3)
Assessment of motivation for treatment. (4) Assessment of social support
system. (5) Assessment of personality characteristics of the patient. (6)
Assessment of current and past social, interpersonal, and occupational
functioning.

The treatment can be broadly divided into two categories that are often
interlinked. These are detoxification and treatment of alcohol dependence.
Besides, there are other therapies/techniques.

(1) Treatment of Alcohol Dependence

After detoxification, the counsellor adapts several methods. Some of these

important methods include: (1) Behaviour Therapy: The most commonly used
behaviour therapy in the past has been aversion therapy, using either a
subthreshold electric shock or an emetic such as apomorphine. Many other
methods (covert sensitisation, relaxation techniques, assertiveness training, self-
control skills, and positive reinforcement) have been used alone or in
combination with aversion therapy. Currently many practitioners consider
aversion therapy as unethical for the treatment of alcohol dependence. (2)
Psychotherapy: Both individual and group psychotherapy have been used. The
client should be educated about the risks of continuing alcohol use, asked to
resume personal responsibility for change and be given a choice of option for
change. Motivational enhancement therapy with or without cognitive behaviour
therapy and life-style modification is often useful. (3) Deterrent Agents: It is
also called alcohol sensitizing drugs. It is a medical treatment using disulfiram.
There is a variety of other medicines acting as deterrent agents.

(2) Detoxification

If a client is physically dependent on alcohol, he will experience alcohol

withdrawal symptoms when decreasing or stopping drinking. There are a number
of signs that a client may be physically dependent on alcohol. Daily drinking,
drinking regularly or intermittently throughout the day, and morning drinking all
suggest physical dependence. Awaking during the night with fears, trembling, or
nausea, or experiencing such symptoms on first wakening, is also suggestive of
dependence.
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In a physically dependent client, cessation of or a substantial decrease in

drinking will result in the appearance of minor withdrawal symptoms, such as
tremulousness, nausea, vomiting, difficulty sleeping, irritability, anxiety, and
elevations in pulse, blood pressure, and temperature. Such symptoms usually
begin within 5-12 hr of the cessation of drinking. More severe withdrawal
symptoms, such as seizure, delirium, or hallucinations, may also occur, usually
within 24-72 hr of the cessation of drinking. If the client has not consumed
alcohol for several days prior to initial contact, one need not worry about
withdrawal symptoms. If the client stopped drinking within the last 3 days, it is
good to enquire about and observe for signs of withdrawal.

Detoxification is the treatment of alcohol withdrawal symptoms, i.e.,

symptoms produced by the removal of the “toxin” (alcohol). The best way to
stop alcohol (or any other drug of dependence) is to stop it suddenly unless the
risks of acute discontinuation are felt to be high by the treating team. The
decision is often based on several factors including chronicity of alcohol
dependence, daily amount consumed, past history of alcohol withdrawal
complications, level of general health and the patient’s wishes.

The usual duration of uncomplicated withdrawal syndrome is 7-14 days. The

aim of detoxification is symptomatic management of emergent withdrawal
symptoms.

In addition to drugs for detoxification, vitamins should also be administered

according to the need of the client. The medical staff should take care of
hydration.

Although detoxification can be achieved on an outpatient basis, some

patients with the following symptoms do require hospitalisation. They are: (1)
Signs of impending delirium tremens (tremor, autonomic hyperactivity,
disorientation, or perceptual abnormalities), or (2) Psychiatric symptoms
(psychotic disorder, mood disorder, suicidal ideation or attempts, alcohol-
induced neuropsychiatric disorders), or (3) Physical illness (caused by chronic
alcohol use or incidentally present), or (4) Inability to stop alcohol in the home
setting. Detoxification is the first step in the treatment of alcohol dependence.

(3) Biofeedback

Biofeedback (introduced for the first time in 1969) is the use of an instrument
(usually electronic), which provides immediate feedback to the patient regarding
his physiological activities normally not available to the conscious mind, such as
ECG, EEG, pulse rate, blood pressure, EMG, and galvanic skin response (GSR).

The feedback helps the patient, apparently to control these responses.

Relaxation is easily achieved by this method. A simpler form (relaxometer) uses
only one parameter, the GSR. The other uses of biofeedback include treatment
of enuresis, migraine headaches, tension headache, idiopathic hypertension,
incontinence, cardiac arrhythmias, uncontrolled generalised tonic clonic seizures,
and also for neuromuscular rehabilitation.

(4) Abreaction
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Abreaction is an important procedure which brings to conscious awareness,

for the first time, unconscious conflicts and associated emotions. The release of
emotions is therapeutic. Although abreaction is an integral part of
psychoanalysis and hypnosis, it can be used independently also. Abreaction can
be done with or without the use of medication.

(5) Supportive Psychotherapy

This is a very directive method of psychotherapy, with the focus clearly on

existing symptoms and/or current life situations. The aims of the therapy are:

(1) Correction of the situation problem, (2) Symptom rectification, (3)

Restoring or strengthening defences, (4) Prevention of emotional breakdown,
and (5) Teaching new coping skills.

The aim is achieved by a conglomeration of techniques which include

guidance, suggestion, environmental manipulation, reassurance, persuasion,
development of a doctor-patient relationship, diversion, and even hospitalisation
and medication. This is a highly skilled method of psychotherapy, which can
provide excellent results when used judiciously.

(6) Couple Therapy

Involving the spouse in alcoholism treatment will increase the probability of a

positive treatment outcome. Couple therapy is most appropriate for clients who
have a stable relationship in which the partner is willing to be involved in
treatment and can function in a supportive manner. Treatment to partners of
alcoholics separate from treatment for the drinker is also available.

To conclude, providing treatment to individuals with drinking problems is a

complex process. The clinician is faced with complex decisions about matching
each client to the appropriate level of care, setting for treatment, treatment
modalities, and techniques. Diagnostic skills to identify concomitant medical,
psychological, psychiatric, and cognitive problems are challenged by each client.
Treatment ranges from the briefest, one-session treatments to motivate heavy
drinkers to reduce their drinking to the complex and longer treatment provided
to the chronic alcoholic.

(7) Group Therapy

There is a strong belief that group therapy is preferable to individual therapy.

Interaction among group members provides opportunities for modelling,
feedback, and behavioural rehearsal that are less available in the individual
setting. Joining AA (Alcoholics Anonymous), a voluntary self-help group is very
helpful. Although the approach is partly religious in nature, many patients derive
benefits from the group meetings that are non-professional in nature.

(8) Self-Help Groups

Alcoholics Anonymous (AA) is the most commonly utilized self-help group.

AA offers a specific approach to recovery, rooted in the view that alcoholism is a
physical, emotional, and spiritual disease and that there is no cure for alcoholism
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but the disease can be arrested. Recovery is viewed as a lifelong process that
involves working the 12 steps of AA and abstaining from the use of alcohol.

Much of the success of the AA Programme depends on the fact that an

alcoholic who no longer drinks has an exceptional capacity for reaching out and
facilitating an uncontrolled addict. When a recovered alcoholic narrates his own
problem of drinking, how he became sober, and invites the newcomer to join the
informal fellowship, it resonates with the addict and he is inclined to follow the
example of the former addict.

The newcomers are not asked to accept and follow the twelve steps in their
entirely if they are not willing or unable. The following will be pointed out to
them: (1) it is they themselves who have to determine whether they are in fact
alcoholics; (2) all available medical testimony indicates that alcoholism is a
progressive illness; (3) alcoholism cannot be cured in the ordinary sense of the
term; and (4) alcoholism can be arrested through total abstinence from alcohol
in any form.

The essence of the programme of personal recovery is contained in the

Twelve Steps describing the experience of the earliest members of the
fellowship. The twelve steps are:

(1) We admitted we were powerless over alcohol — that our lives had
become unmanageable; (2) Came to believe that a Power greater than
ourselves could restore us to sanity; (3) Made a decision to turn our will and
our lives over to the care of God as we understood Him; (4) Made a searching
and fearless moral inventory of ourselves; (5) Admitted to God, to ourselves
and to another human being the exact nature of our wrongs; (6) Were entirely
ready to have God remove all these defects of character; (7) Humbly asked
Him to remove our shortcomings; (8) Made a list of all persons we had harmed,
and became willing to make amends to them all; (9) Made direct amends to
such people wherever possible, except when to do so would injure them or
others; (10) Continued to take personal inventory and when we were wrong
promptly admitted it; (11) Sought through prayer and meditation to improve
our conscious contact with God as we understood Him, praying only for
knowledge of His will for us and the power to carry that out; and (12) Having
had a spiritual awakening as the result of these steps, we tried to carry this
message to alcoholics and to practice these principles in all our affairs. 155

4. Conclusion

People rely on substances for many reasons: for fun, to be social with
friends, to deal with stressful situations, or to escape from other things going on
in their lives.

Misuse of substances such as alcohol and drugs puts one at risk of

physical and psychological harm, both short-term and long-term. Addictions are
not limited to alcohol and drugs; they include gambling, smoking, shopping,
gaming, and sex, among other things. With all addictive disorders, one can
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develop strong cravings, find it hard to cut down, or experience withdrawal when
one does. Substance and other addictions can put one at risk of developing
mental health conditions, or make existing mental health conditions much
worse.

The first thing to do is to take note of how much one is using and when.
Creating a recovery plan with help from a family member, friend or support
service can be useful. This plan may include online self-help programmes,
advice, and support from other organisations or local community services.
Treating any underlying mental health conditions is crucial, and may include
counselling, cognitive behaviour therapy, or medication.

Partners, families, and friends can play an active role in recovery by

learning about the addiction, encouraging better habits, and being supportive.
This can make all the difference in overcoming the problem. Accepting that there
may be a relapse on the road to recovery from addictive disorders is also
important. 
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1.12.17
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syndrome-treatment 1.12.17
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and Linda McBride. Overcoming Bipolar Disorder. Oakland: New Harbinger
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Anugraha Publications, 2006.
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 1

ENDNOTES

(Key to Understand the Endnotes: The websites and the books consulted
are serially numbered in the bibliography. In the endnotes, after every note you will
find a number/s which refer/s to the serial number/s of the website/s or books. Thus
for example, if you take the second endnote, you will find the numbers 50, 51,
80.348-349 which means that the numbers 50 and 51 refer to the website according
to the serial numbers of the bibliography and the number 80 refers to the book with
 its pages 348-349.)

79. 42-49.
2
50; 51; 80.348-349 .
3
79.57
4
79.56-57; 80.352-354.
5
50; 80.354-35.
6
79.61; 80.356-357.
7
50; 79; 64; 80.360.
8
80.361-362.
9
50; 80.361-364;79.68.

10
51.
11
79.71.
12
51; 79.71; 80.366-369.

13
51.
14
80.370-372.
15
79.74.
16
77.400.
17
77.404.
18
77.404-405.
19
77.405.
20
77.405-406.
21
77.406.
22
77.405,412-419.
23
80.378; 51.
24
79.77; 80.380-381.
25
51;80.382-383.
26
79.80;80.384-385.
27
51; 80.385-386.
28
79.83;80.388-389.
29
51; 80.390-391.
30
79.86; 80.392-393.
31
51; 80.394-395.
32
79.89; 80.396.

33
51.
34
68.
35
69.
36
54.
37
79.138-140.
38
79.139-140
39
2; 79.140-144;1;76.67-68,87.
40
79.144-145.
41
78.7-9.
42
4.
43
4.
44
69.64-65; 4; 8; 9; 10; 3; 78.23-24,64-65; 4; 6; 79. 202-205.
45
79.206-207.
46
76.108.
47
76.108.
 48
77.240-242, 249-268, 275; 76.79-80
49
80.189,193.
50
80.96-100.
51
80.101-102; 76.171.
52
80.202-206.
53
80.211-212; 79.230-231.
54
80.213-214.
55
77.111-112.; 80.215-216; 79.230-231
56
80.197-198; 77.1.
57
80.200; 77.16-19, 22.
58
80.206-207; 77.3.
59
80.208-209; 77.19-22; 79.230-231
60
80.232-233; 76.91-92; 79.154-166; 77.154-166.
61
79.232-233; 80.195-196.
62
80.217.
63
80.219-220; 79.329.
64
79.308.
65
76.98; 100; 14; 13; 12; 11;79.241-242; 77.202-235.
66
13; 17
67
22; 21; 18; 20.
68
80.221-222.
69
80.226-227; 77.57-59; 76.112; 79.248-250; 19.
70
80.103-104
71
80.105; 15.
72
16.
73
80.128-130.
74
24; 23; 24; 76.112; 80.132-135.
75
79.277-281; 26.
76
79.271-272.
77
79.282-283; 76.110.
78
79.274-275.
79
79.289.
80
37; 35; 79.315.
81
76.105; 36; 34; 33; 31; 32.
82
80.333; 76.106-107 ; 79.326.
83
79.320-322.
84
80.338-339.
85
80.329-330; 76.107-108.
86
76.143-144; 79.397.
87
76.144; 79.399; 77.313, 287-288.
88
76.145.
89
79.464-465.
90
80.85.
91
80.86; 79.466.
92
77.318.
93
80.281-283; 77.324-325, 358-359.
94
38; 39.
95
77.280.
96
80.93-94.
97
80.94-95; 76.169; 79.474.
98
80.91-92.
99
80.92-93; 76.170; 79.473.
100
40.
101
76.133; 80.308; 62.
102
79.337.
103
70.
104
71.
105
79.342; 72.
106
79.344.
107
73.
108
74.
109
74.
110
75.
111
80.313-314.
112
80.287
113
72.127
114
79.363.
115
77.462-467; 41; 79.367.
116
79.371.
117
79.365.
118
79.369.
119
79.373-375.
120
80.289-291.
121
80.296-297
122
79.391-392;76.122.
123
76.130-131.
124
42;.43;.80.298-299.
125
80.293-294.
126
44; 45; 80.295.
127
79.386-387.
128
80.300.
129
80.73-74.
130
79.463.
131
79.296.
132
80.75.
133
80.80-82;.79.461;.76.167-168.
134
79.300-301.
135
79.298.
136
46; 80.305.
137
80.50-51.
138
80.51-52.
139
76.170.
140
80.56-57.
141
76.163-164; 79.449; 80.62.
142
80.64-65.
143
80.68-70; 76.166-167.
144
80.107.
145
80.107-108.
146
80.87.
147
76.168; 80.89-90.
148
76.163.
149
79.416.
150
79.430.
151
79.430.
152
79.516; 48.
153
79.305-306.
154
49
155
77.365-368, 393; 68.370-372; 76.40-42, 216-219.