Psychopathology

Block-1 Introduction to Psychopathology [4]

Unit-1 Normal Human Experience

Unit-2 Introduction to DSM IV and Diagnostic Classification

Unit-3 Etiology of Psychopathology

Unit-4 Assessment of Psychopathology, Interview and Testing

Block-2 Childhood Psychopathology [4]

Unit-1 Child and Adolescent Disorder

Unit-2 Learning Disabilities

Unit-3 Mental Retardation

Unit-4 Pervasive Developmental Disorders

Block-3 Mild Mental Disorders [4]

Unit-1 Anxiety Disorder

Unit-2 Somatoform and Dissociative Disorders

Unit-3 Eating Disorders

Unit-4 Substance Use Disorder

Block-4 Severe Mental Disorders [4]

Unit-1 Schizophrenia and Other Psychotic Disorders

Unit-2 Personality Disorders

Unit-3 Paraphilias

Unit-4 Mood Disorders (Bipolar, Major Depression)

 Normal Human Experience
UNIT 1 NORMAL HUMAN EXPERIENCE

Structure
1.0 Introduction
1.1 Objectives
1.2 The Concept of Normality
1.3 Concepts of Abnormality
1.3.1 Statistical Infrequency
1.3.2 Violation of Social Norms
1.3.3 Maladaptive Behaviour
1.3.4 Personal Distress
1.3.5 Failure to Function Adequately
1.4 Other Models of Abnormality
1.5 History of Psychopathology
1.6 Let Us Sum Up
1.7 Unit End Questions
1.8 Glossary
1.9 Suggested Readings
1.10 Answers to Self Assessment Questions

1.0 INTRODUCTION
Psychopathology is the scientific study of abnormal behaviour. In the field of
mental health, clinicians are concerned with disturbed behaviour, its severity
and duration amongst patients, and look for indications of diagnosis, treatment
and follow up. At one extreme are the greatly and visibly disturbed people, once
called insane, mad or lunatic, and now called the psychotic. At the other end are
the unhappy people, unable to cope effectively with life demands, limited in
their ability to love, work or find meaning in their lives, either over long periods
or in brief, stress-related episodes. Against standards of mental health or normality
these are all described as forms of mental disorder or psychopathology. But what
defines psychological normality and abnormality? In this unit we will deal with
this issue.

This unit introduces a number of issues that are important to abnormal psychology.
It starts by defining what is meant by normality and abnormality. Next we will
describe the phenomena of psychopathology in terms of levels of dysfunctions.
Lastly we will study the history of psychopathology.

1.1 OBJECTIVES
After completing this unit, you will be able to:
• Define normality;
• Elucidate the concept of normality;
• Describe the criteria for abnormality; and
• Analyse the growth of the history of psychopathology. 5
Introduction to
Psychopathology 1.2 THE CONCEPT OF NORMALITY
Concept of normality is difficult to explain as over a period of time this concept
has been changing. Traditionally it was conceptualised as the person’s adjustment
to his environment. But now it is termed as ‘adaptability’. The concept of
normality focuses more on positive attributes such as individuality, creativity
and self-fulfilment. But most of us are unable to explore or realise our potentials
to the maximum and lead routine lives. Yet, we would not be considered abnormal
and maladjusted.

There is no clear consensus as to how normality is defined and which particular

types of disordered behaviour can be considered abnormal. Normality and
abnormality are viewed on a continuum with the characteristics and attributes
present in greater degree in normal people than in abnormal people.

Offer and Sabshin (1966) had surveyed the many meanings of normality which
have arisen in psychology, psychiatry, sociology and anthropology. Based on
their analysis normality is viewed as Health (meaning ‘not sick’), as an Ideal
state, as Average, as Socially acceptable and as Process (change over time).

Following are some of the norms used to define normality:

Psychological normality has most often been defined either as an average, an
ideal, or a level of adjustment. Normality as an average is a statistical definition
that identifies the typical or most common behaviours among a group of people
as being normal for that group. Have not we heard at time people saying to a
person behaving differently, that “why can’t you be like others?” This ‘others’
behaviour is the normal and those who differ from this are brought back into the
main stream.

Identifying some large middle percentage of a group of persons as showing normal

behaviour has the benefit of providing a precise criterion for deciding whom to
consider abnormal, namely those who fall outside this middle range. Attention
to typical patterns of behaviour also promotes cultural sensitivity and helps
clinicians avoid seeing psychopathology where none exists.

Cultural sensitivity in this regard consists of recognising that ‘normal’ for a person
depends in part on the attitudes and behaviour patterns that are valued in the
groups to which the person belongs. Being aware of normality in terms of
customs, traditions, and expectations, an abnormal behaviour in a person may
be even considered normal (for instance possession syndrome) in that person’s
sociocultural context. Such behaviours in another culture may be considered
abnormal and may require treatment.

Thus the cultural sensitivity to a great extent helps clinicians and psychologists
not to attribute psychopathology where it is not considered pathological but part
of a cultural behaviour. Psychological disturbance from seemingly strange
characteristics may be common in a subculture but others may not be familiar
with it because they are not part of that culture.

i) State of perfection as normality

Another way to define normality is to refer to a state of perfection that people
6 aspire to but seldom attain. This “nobody is perfect” assumes that all people
struggle with psychological limitations of one kind or another that prevent them Normal Human Experience
from being as happy and successful as they would like to be.

Regarding normality as an ideal way of being avoids statistical decisions that

label unusually intelligent, happy, or productive people as abnormal. Further
this approach calls attention to the potential for people to become more than
what they are, the ideal perspective on normality encourages striving toward self
improvement and the active pursuit of greater happiness and success.

On the other hand by implying that almost everyone is disturbed to some extent,
normality as an ideal is a difficult concept to apply.

ii) Level of adjustment as normality

Level of adjustment as a criterion for normality refers to whether people can
cope reasonably well with their experiences in life, particularly with respect to
being able to establish enjoyable interpersonal relationships and work
constructively toward self fulfilling goals. When normality is defined in these
terms, abnormality becomes a state of mind or way of acting that prevents people
from dealing adequately with the social and occupational demands of daily life.

iii) Reality testing as normality

Normal persons are able to perceive, interpret and react to what is going on in
the world around them in a realistic manner. They appraise themselves in a realistic
manner, neither overestimate nor underestimate themselves. They do not
misunderstand what others say and do and are able to analyse situations critically.

iv) Behaviour control as normality

Normal persons feel in control and are confident in themselves regarding
controlling and directing their behaviour. They are able to control their aggressive
and sexual impulses. Whenever there is a problem with conforming to social
norms, it is usually a well thought out and voluntary decision and not due to
uncontrollable impulses.

v) Self worth as normality

Normal individuals are able to appreciate their own self worth and feel accepted
by society. They are comfortable in their social relationships and are able to
accept and listen to differences of opinion and if they are convinced ready to
change their own views also.

vi) Self awareness as normality

Even if normal persons do not fully understand their feelings and behaviour yet
they do have some awareness of their feelings and motives. Important motives
and feelings may be suppressed or hidden from oneself and normal persons
would be aware of their feelings and emotions and know the motivation behind
their behaviour.

vii) Social relationships as normality

Normal individuals are able to form and maintain close, long term and healthy
relationships with other people. They do not manipulate or use relationships to
their own advantage and are also sensitive to the needs and feelings of others.
7
Introduction to They are able to reciprocate and provide comfort and affection to people close to
Psychopathology
them.

viii) Effective functioning

Normal people are enthusiastic about life and use their skills and abilities in
productive and creative manner. They are able to meet demands of daily life
without any need for external force or pressure.

1.3 CONCEPTS OF ABNORMALITY

If we define normality by the above said perspectives, then the opposite of these
should mean abnormality. However such statement could be only partly true.
Absence of these certainly leads to maladjustment with self and society and also
to certain psychological problems.

1.3.1 Statistical Infrequency

Under this definition, a person’s trait, thinking or behaviour is classified as
abnormal if it is rare or statistically unusual. With this definition it is necessary
to be clear about how rare a trait or behaviour needs to be before we class it as
abnormal.

For instance one may say that an individual who has an IQ below or above the
average level of IQ in society is abnormal (Figure 1.1 below normal distribution).

However this definition obviously has limitations, it fails to recognise the

desirability of the particular behaviour. Going back to the example, someone
who has an IQ level above average would not necessarily be seen as abnormal.
Rather they would be highly regarded for their intelligence.

This definition also implies that the presence of abnormal behaviour in people
should be rare or statistically unusual, which not the case. Instead, any specific
abnormal behaviour may be unusual, but it is not unusual for people to exhibit
some form of abnormal behaviour at some point in their lives.

The major limitation of this approach is that it fails to distinguish between

desirable and undesirable behaviour.

Statistically speaking, many very gifted individuals could be classified as

‘abnormal’ using this definition. The use of the term abnormal in this context
would not be appropriate.

Many rare behaviours or characteristics (e.g. left handedness) have no bearing

on normality or abnormality. Some characteristics are regarded as abnormal even
though they are quite frequent. Depression may affect 27% of elderly people
(NIMH, 2001). This would make it common but that does not mean it is not a
problem.

8
 Normal Human Experience

Fig.1.1: Normal distribution of IQ

1.3.2 Violation of Social Norms

Under this, a person’s thinking or behaviour is classified as abnormal if it violates
the (unwritten) rules about what is expected or acceptable behaviour in a particular
social group. Their behaviour may be confusing to others or make others feel
threatened or uncomfortable.

Social behaviour varies markedly when different cultures are compared. A

visitation by dead in many Asian cultures is considered normal but other societies
mark it as abnormal.

In another example, it is common in Southern Europe to stand much closer to

strangers than in India or even U.K.

Voice pitch and volume, touching, direction of gaze and acceptable subjects of
discussion have all been found to vary among cultures.

With this definition, it is necessary to consider the degree to which a norm is

violated, the importance of that norm and the value attached by the social group
to different sorts of violation. For example is the violation rude, eccentric,
abnormal or criminal?

The major limitation is that social norms change over time. Behaviour that was
once seen as abnormal may, given time, become acceptable and vice versa.

For example drunk driving was once considered acceptable but now seen as
unacceptable whereas homosexuality was once considered a psychological
disorder but now is considered acceptable.

Decade ago, most Indians would have been intolerant of women dressing in
minimum with bare arms and legs; they now tend to see this as a changing life
style rather than an abnormality.

So, the definition of abnormality needs to be more comprehensive than mere

social noncompliance.

9
Introduction to 1.3.3 Maladaptive Behaviour
Psychopathology
Maladaptive behaviours may be thought of as those that cause difficulties, or are
counterproductive, for the individual or for others. The repetitive hand washing
in obsessive compulsive disorder could be regarded as maladaptive, particularly
if it leads to sores or other skin damage. The self-starvation of a patient with
severe anorexia nervosa, which sometimes leads to death, would be a second
example. Yet would we consider the self-destructive behaviour of a cigarette
smoker evidence of mental illness? Clearly, no. as it is not an abnormality.

1.3.4 Personal Distress

Many patients with mental illness experience pronounced personal suffering.
For example, patients with severe depression often describe feelings of anguish
in addition to misery. Others express their distress in terms of physical complaints
and may even visit their doctor believing that they are physically unwell. However,
the subjective experience of the patient is not always a reliable indicator of illness,
as some do not themselves acknowledge that they are ill. For example, patients
with mania often say they feel ecstatic and euphoric, and in the early stages of
schizophrenia the individual may be indifferent to or unaware of their deteriorating
mental state.

1.3.5 Failure to Function Adequately

Under this definition, a person is considered abnormal if they are unable to cope
with the demands of everyday life. They may be unable to perform routine
activities of daily living e.g. self-care, hold down a job, interact meaningfully
with others, make themselves understood etc. Rosenhan & Seligman (1989)
suggest the following characteristics that define failure to function adequately:
• Suffering
• Maladaptiveness (danger to self)
• Vividness and unconventionality (stands out)
• Unpredictability and loss of control
• Irrationality/incomprehensibility
• Causes observer discomfort
• Violated moral/social standards
One limitation of this definition is that apparently abnormal behaviour may
actually be helpful, functional and adaptive for the individual. For example, a
person who has obsessive compulsive disorder of hand washing may find that
the behaviour makes him happy and better able to cope with his day.
Self Assessment Questions
1) Discuss the concept of abnormality.
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10
 Normal Human Experience
2) What is meant by statistical frequency.
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3) What are the various criteria for abnormality.
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1.4 OTHER MODELS OF ABNORMALITY

More complex models of abnormality in the context of mental health consider
abnormal behaviour to be a sign of a mental health problem when
• It is the result of distorted psychological processes.
• It causes or is the result of distress and/or is dysfunctional.
• It is an out-of-the-ordinary response to particular circumstances.
Another criterion is that the individual may place them self in danger as a result
of a distorted view of the world, although this is relatively infrequent even among
those who may be thought of as having a mental health problem. These criteria
can be summarised according to Comer as the ‘four Ds’:
• Deviance (from the norm)
• Distress
• Dysfunctional
• Dangerous.
Self Assessment Questions
1) Write how will you decide when any behaviour, such as social drinking
or even shopping or Internet use, crosses the line from “normal” to
“abnormal”?
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11
Introduction to
Psychopathology
2) Is there a set of your own personal criteria you use in all cases? How
does your criterion differ from the criteria specified in the unit?
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3) What are the various other models of abnormality?
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4) Why cultural diversity has to be considered while dealing with
pathology?
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5) Describe the various criteria used for abnormality and normality.
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1.5 HISTORY OF PSYCHOPATHOLOGY

Descriptions of abnormal behaviour can be found amongst the historical records
of the first civilisations and it is certain that the early Indians, Egyptians, Chinese,
Greeks, etc., were familiar with the features of disturbed behaviour that we may,
today, identify as mental illness.

Also for much of recorded history such people have found themselves
marginalised, shunned or ridiculed, with their symptoms variously attributed to
the processes of demonic possession, divine punishment, planetary influence or
12 witchcraft.
More than 2,000 years ago, the Greek philosophers Hippocrates and Plato argued Normal Human Experience
that mental illnesses had more commonplace causes. For instance Hippocrates
considered physiological dysfunction as the cause for mental illness. On the
other hand, Plato considered psychological conflict as the cause for mental
disorders. Charaka and Susruta, physician and surgeon par excellence from India,
who lived in 100 AD and 500 AD respectively, emphasised the importance of
emotions in the causation of mental illness.

For them peace and happiness were the outcome of positive mental health. They
too had put forth the theory of humoral disequilibrium brought about by one’s
improper lifestyle as the cause of illness.

Records for the next 1,500 years (of west) are very sketchy, although we know
that this period of European history (known as the Dark and Middle Ages) was
marked by a decline in rational scientific thinking and a return to religious
superstition.

The weak position of mentally ill individuals was illustrated in 1484, when the
Pope issued a decree reminding his emissaries that sudden loss of reason, amongst
other signs, should be regarded as one of the features of demonic possession, for
which the appropriate action was burning at the stake.

But outside Europe the story was not as bleak. In Arabia and parts of Asia there
was a revival of scientific interest. An asylum for the mentally ill was built in
Baghdad in 705 AD, providing humane treatment for its inmates. History records
that in Arabia and Asia mentally ill patients received a much more humane and
kind treatment than in Christian lands. The Muslim belief as stated by Prophet
that the insane were loved by God, underlay this sentiment.

In India the spread of Buddhism and Jainism and Hindu medicine, which
advocated humane treatment for the mentally ill, went a long way in making
humane treatment available to the sick. In spite of these few bright sparks the
period between 500 and 1000 AD was an age of mental and intellectual stagnation.

The idea that mentally deranged people might actually be ill first began to reappear
at the time of major population shifts from rural to urban dwelling. As cities got
larger, municipal authorities gave themselves powers to incarcerate people who
appeared to be mentally unwell.

Initially, specific provision for the mentally unwell was restricted to a handful of
institutions. For example, the Priory of Saint Mary of Bethlehem, founded in
1243, developed a facility for housing a small number of people with mental
illness, which somewhat later was handed over to the City of London as an
institution specifically for this purpose. Its name became corrupted and came to
be known as Bedlam. It developed a degree of notoriety as a sort of tourist
attraction, which people could visit to observe the behaviour of the inmates,
both male and female. (Astonishingly, this practice continued well into the 1800s.)

Moral Treatment
The French Revolution in the late 1700s brought about a marked change in the
methods of dealing with mentally ill people. The French physician Philippe Pinel
was shocked to see the conditions under which the inmates of asylums were
expected to live and, in the spirit of revolution, called for their unchaining. Pinel,
13
Introduction to with his enlightened approach, known as moral treatment, attracted the attention
Psychopathology
of other like-minded individuals and gradually a change in attitude towards how
best to manage mentally ill people spread through Western Europe.

For example, William Tuke, a Quaker, persuaded others from his religious group
to fund the building of a mental hospital, The York Retreat, was founded in
1796. Here, patients received care and treatments similar to those advocated by
Pinel.

Dorothea Dix (1802–1887), a Boston schoolteacher, travelled across the country

decrying the deplorable conditions in the jails and almshouses where mentally
disturbed people were placed. As a result of her efforts, 32 mental hospitals
devoted to treating people with psychological disorders were established
throughout the United States.

Institutional care of the mentally ill in India dates back to very old times which
were supported by contemporary rulers as shown by the Edicts of Asoka (BC
250) and others. A special hospital exclusively for the mentally ill patients was
established at Dhar, near Mandu in Madya Pradesh in the 15th century AD by
Mohammed Khilji. This was the first asylum in the country. This asylum provided
treatment according to the Ayurvedic and Unani systems of medicine.

Ironically, the success of moral treatment also contributed to its downfall in the
latter stages of the nineteenth century, as it became apparent that mental illness
was much more common than had previously been thought. (Tuke’s Retreat
could accommodate only thirty patients.)

As more people were recognised to be suffering from mental illness, major

building programmes were instigated both in Europe and the United States,
leading to the rapid growth in the number of state-run asylums for the mentally
ill. Over a relatively short period in Victorian England, several hundred hospitals
were built to accommodate many thousands of patients. The standards of care
that prevailed in York could not be extended to these new hospitals and moral
treatment fell out of favour.

The Modern Era: Brain or Mind

Despite the inevitable deterioration in provision for mentally ill people, by the
end of the century there was renewed interest in science and in the principle of
somatogenesis which had first been described by Hippocrates 2,000 years earlier.
It was against this background that the discipline of psychiatry began to emerge
and the work of Kraepelin and Bleuler came to prominence. At that time,
melancholia, mania and phrenitis, first described by Hippocrates, were identified
as mental disorders, and this list was expanded to include paranoia, catatonia
and hebephrenia, among many others.

Kraepelin’s best known contribution to psychopathology was his proposal that

mental illnesses can be divided into two broad syndromes: dementia praecox
and manic-depressive psychosis. He reached this conclusion on the basis of
detailed recording, over long periods of time, of the features (the signs and
symptoms) of illness displayed by his patients. Although Bleuler disagreed with
Kraepelin on matters of detail, he too adopted precise methods and his fascination
with the nature and causes of psychiatric symptoms was hallmark of his work.
14
Between them, Kraepelin and Bleuler shaped the direction that psychiatry has Normal Human Experience
subsequently taken and their contributions are still much in evidence today.
Kraepelin and Bleuler were convinced that mental illnesses had physical origins
(the somatogenic approach). However, others believed that there were
psychological (psychogenic) explanations of mental illness.

These ideas had originally been discussed by Plato and they began to receive
increasing attention once again. Mesmer (1734–1815) is often credited with
initiating the renewed interest in psychogenesis, having ‘invented’ a form of
hypnosis that came to be known as ‘mesmerism’. In the late nineteenth century
there was an explosion of interest in the role of psychological mechanisms in
illness.

Charcot, a prominent neurologist, demonstrated that symptoms characteristic of

nerve damage could arise for psychological reasons and could be influenced by
hypnotic suggestion. His colleague Breuer began using hypnosis as a treatment
and it became apparent to him that, if he talked with his clients about their
symptoms while they were under hypnosis, this often resulted in greater relief
from symptoms.

Breuer’s technique became known as catharsis and was for a time adopted by
another Viennese neurologist, Freud, who saw it as a potentially powerful means
of exploring the unconscious mind.

The Twentieth Century and Science

Our brief review has brought us to the beginning of the twentieth century. By
this time most of the main ideas that have continued to dominate and shape the
direction of modern psychopathology had already surfaced. During the past one
hundred years, the pendulum has continued to swing between somatogenic and
psychogenic explanations of disorder. Initially, the camps divided geographically,
with the Europeans favouring somatogenesis, while practitioners in the United
States preferred psychogenic explanations of mental illness.

The divide has, to some extent, fallen along occupational lines, with medically
trained psychiatrists resorting to somatogenic approaches and psychologists, not
surprisingly, tending to rely upon psychogenic explanations.

One of the main strengths of psychopathology over the past century has been a
willingness on the part of practitioners to rely on empirical evidence gathered
through scientific research. This approach has, for example, led to the demise of
unsupportable procedures such as insulin coma therapy (an early treatment for
schizophrenia).

On the other hand, it has established the advantages of equally controversial

procedures such as electro-convulsive therapy (ECT). Not all scientific discoveries
have favoured somatogenic approaches. For example, the value of biofeedback
training to help control anxiety and the adoption of a procedure known as cognitive
therapy in the treatment of depression, both tend to support psychogenic
arguments.

Gradually, research in psychopathology has made people aware that neither a

strictly somatogenic or psychogenic approach can fully explain how mental
illnesses arise. Indeed, evidence suggests that most occur as a result of a
15
Introduction to combination of factors, and a causal model known as the stress-diathesis model
Psychopathology
(Goldman 1992) has evolved to occupy this centre ground.

In simple terms, this model implies that mental illness is a reaction to life
experiences in individuals who are vulnerable or predisposed in some way to
that mental illness. One sort of predisposition may be genetic, but others may
involve early brain damage or even early experience. The causative factors will
inevitably vary, ranging from the effects of major and sudden life events such as
bereavement or unemployment, to the minor but more enduring tensions of family
life.
Self Assessment Questions
1) Trace the history of psychopathology in the medieval period.
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2) Trace the history of how mental illness was considered during the 17th
and 18th centuries?
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3) What are the developments that took place during the 20th century
regarding mental illness?
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Short questions
i) Write the names of the different perspectives in defining normality as
offered by Offer and Sabshin?
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16
 Normal Human Experience
ii) Write the names of the different criteria as offered by Comer to determine
that behaviour is abnormal?
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iii) How do views about abnormal behaviour vary across cultures?
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iv) How have views about abnormal behaviour changed over time?
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1.6 LET US SUM UP

The study of psychopathology is the search for the reasons people behave, think,
and feel in unexpected, sometimes bizarre, and self-defeating ways. A person
can be called normal if he is not sick, if he is average, if he confirms to social
norms, or if he approximates an ideally mature, healthy or fully functioning
personality. In addition to this he should be able to interpret correctly what is
going around him, has control over his behaviour, is aware of his feelings and
emotions, be able to establish close interpersonal relationships and finally lead a
productive life. In evaluating whether behaviour is abnormal, psychologists
consider several different characteristics: statistical infrequency, violation of
societal norms, personal distress, behavioural dysfunction and failure to function
adequately. Each characteristic tells something about what can be considered
abnormal, but none by itself provides a fully satisfactory definition.

The debate about whether mental illnesses have somatogenic or psychogenic

origins has dominated the history of psychopathology and can be traced back to
the ideas of Hippocrates and Plato. Only recently have people begun to realise
that mental disorders probably arise as a result of the combination of factors,
rather than being due to single causes. Currently, integrated models of causation,
like the stress-diathesis model, find the widest acceptance in psychopathology.
17
Introduction to
Psychopathology 1.7 UNIT END QUESTIONS
1) Describe in detail the different norms used by mental health professions in
defining normal behaviour?
2) Describe in detail the different criterion and models used by mental health
professions in defining abnormal behaviour?
3) Write how has the treatment of people with mental disorders changed over
time?

1.8 GLOSSARY
Incarceration : Incarceration is the detention of a person in jail,
typically as punishment for a crime. People are most
commonly incarcerated upon suspicion or conviction
of committing a crime, and different jurisdictions
have differing laws governing the function of
incarceration within a larger system of justice.
Incarceration serves four essential purposes with
regard to criminals:
1) to punish criminals for committing crimes
2) to isolate criminals to prevent them from
committing more crimes
3) to deter others from committing crimes
4) to rehabilitate criminals
Incarceration rates, when measured by the United
Nations, are considered distinct and separate from
the imprisonment of political prisoners and others
not charged with a specific crime. Historically, the
frequency of imprisonment, its duration, and severity
have varied considerably. There has also been much
debate about the motives for incarceration, its
effectiveness and fairness, as well as debate regarding
the related questions about the nature and etiology
of criminal behaviour.
Psychopathology : This is the study of the causes, processes, and
manifestations of mental disorders. It is the
behavioural manifestation of any mental disorder.
Somatogenic : Arising from physiological causes. That is thbe
mental disorder arises from physiological causes
rather than being psychogenic in origin;
“somatogenic theories of schizophrenia” . Here there
is involvement of the body as distinguished from
the mind or spirit.
Maladjustment : Psychol a failure to meet the demands of society,
such as coping with problems and social
relationships: usually reflected in emotional
instability. It is a faulty or bad adjustment.
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 Normal Human Experience
1.9 SUGGESTED READINGS
Carson, R. C., Butcher, J. N., & Mineka, S. 2003. Abnormal Psychology and
Modern Life. Pearson Education: New Delhi.
Comer, R.J. 2010. Abnormal Psychology, 7th edition. Worth Publishers. New
York.
Davison, G.C., Neale, J.M., Kring, A.M. Abnormal Psychology, 9th edition. Wiley
& Sons:USA.
Sharma, R., 2006. Abnormal Psychology. Atlantic Publishers & Distributors:
New Delhi.

19
Introduction to
Psychopathology UNIT 2 INTRODUCTION TO DSM IV AND
DIAGNOSTIC CLASSIFICATION

Structure
2.0 Introduction
2.1 Objectives
2.2 Classification in Psychopathology
2.2.1 Purpose of Classification
2.2.2 Types of Classification
2.2.3 Historical Perspective
2.3 Classification Systems
2.4 The DSM-IV
2.4.1 Features of DSM-IV
2.4.2 The DSM-IV Axes
2.4.3 The Major Diagnostic Categories
2.4.4 Problem of Labeling
2.5 Evaluating the DSM System
2.6 Advantages and Disadvantages of the DSM System
2.7 Let Us Sum Up
2.8 Unit End Questions
2.9 Glossary
2.10 Suggested Readings
2.11 Answers to Self Assessment Questions

2.0 INTRODUCTION
In the last unit, we had studied the meaning of normality and various alternative
views of normality, concept of mental health, mental illness and the phenomena
of psychopathology.

In this unit, we will describe how to classify mental disorders and teach you the
classification in terms of the Diagnostic and statistical manual of mental disorders
(DSM) which is a part of American Psychiatric Association. We will first discuss
the concept of classification, its purpose, historical background and types of
classification and then describe the major classification systems in use. Next,
the unit would describe the DSM-IV classification in detail, its features and the
multiaxial approach and we will also describe the major diagnostic categories
and the symptoms and factors relevant to particular disorders. Lastly, we would
evaluate the DSM classification and also discuss its major advantages and
disadvantages.

2.1 OBJECTIVES
After studying this unit, you will be able to:
• Understand the purpose of classification;
20
• Know the major classificatory systems used in abnormal psychology; Introduction to DSM IV and
Diagnostic Classification
• Describe in detail DSM-IV and its multiaxial classification system, including
its major diagnostic categories; and
• Analyse the advantages and disadvantages of the modern classification
system.

2.2 CLASSIFICATION IN PSYCHOPATHOLOGY

The structure of our language is based on classification. Every common noun
such as tree, chair, and cat indicates category of “things”. It is a natural human
tendency to identify and categorise a wide range of observable phenomena and
experiences with an aim to increase their understanding and their predictability.
Classification is an attempt to bring order out of a mass of chaotic information.
It is a process by which complex phenomenon are organised into categories,
classes or ranks so as to bring together those things that most resemble each
other, and to separate those that differ. This basic human tendency to categorise
things is reflected in defining the illnesses as well.

2.2.1 Purpose of Classification

There are three major purposes of classification, viz., (i) facilitate comprehension
(ii) enable communication (iii) help in prediction. Let us take each of these and
explain.
i) To facilitate Comprehension: In psychopathology, comprehension means
understanding the nature, causes and course of an illness and factors
influencing them. By knowing the common characteristics of a particular
group, details of its individual members are easily understood.
ii) To enable communication: Classification aids effective communication. The
system provides a language with which health professionals in different
parts of the world can communicate with each other. It serves as shorthand
for describing the objects contained in them. Diagnosis conveys a lot of
information in one or two words about the clinical picture with which a
particular patient presents. For example, a diagnosis of recurrent depressive
disorder would indicate that the patient has had at least two episodes of
depression, each lasted for a minimum of 2 weeks and the episodes were
separated by several months of normal mood state and the patient would
have symptoms such as low mood, loss of interest and enjoyment, reduced
energy and activity with disturbed sleep and appetite.
iii) Helps in prediction: Diagnosis helps to predict the prognosis. Many
psychological disorders are associated with distinctive course and outcome.
For example, the bipolar disorder is usually episodic and has good outcome
while the personality disorders have poor outcome.

Apart from these general purposes, classification also serves specific purposes
such as educational, clinical, administrative, legal, research, etc. Research helps
in generation of hypothesis and prediction of outcome.

21
Introduction to 2.2.2 Types of Classification
Psychopathology
Diseases may be classified in different ways, depending on the purpose they
serve. They may be classified based on (i) etiology (causes), (ii) course and (iii)
outcome and also (iv) based on symptoms.

Any classification of psychological disorders, like medical illnesses, should ideally

be based on etiology. But, for a large majority of psychological disorders, no
distinct cause is known at present, although there are many probabilities for
each of them.

Hence, the only rational way to classify at present is syndrome based. A syndrome
is defined as a group of symptoms and signs that often occur together, and which
describes a recognisable clinical condition. This approach of classifying
psychological disorders on the basis of their clinical signs and symptoms is very
similar to the historical approach to classifying medical illnesses, when etiology
of a majority of medical illnesses was still not known.

2.2.3 Historical Perspective

The earliest records on recognition and classification of mental disorders were
found in references to them in Egypt and India as early as BC 3000. By BC 1500
India had its own classification of mental illness as seen in ayurveda (meaning
the science of life), where spoiling of humors (vital bodily fluids or pith) and
demonic possessions were responsible for different types of mental illnesses. A
thousand years later Hippocrates (BC 460-337) described six types of mental
disorders. He classified abnormal behaviours according to his theory of humors
which states that illness occurs due to imbalance of humors in the body. Influenced
by Hippocrates the Greek physician Galen developed the system further and this
remained in use till the 18th century. In the early years of the 19th century, Philippe
Pinel adopted a descriptive system of classification in which he divided the mental
disorders into five groups: mania without delirium, mania with delirium,
melancholia, dementia and idiocy.

The present day classification used in most of the countries is rooted in a system
compiled by Emile Kraepelin (1855-1926). The table of contents of his textbook
of psychiatry formed the basis for the modern classification. He observed that
patients whose symptoms had a similar course suffered from the same disease.
Long term observation of patients in mental hospitals helped him to differentiate
illnesses depending on their course and outcome. By the end of the 19th century
an outline of the present day classification had been laid down.

2.3 CLASSIFICATION SYSTEMS

At present, there are two major classification systems in use worldwide, namely
ICD-10 (1992) and DSM-IV-TR (2000).

ICD-10 (The International Classification of Diseases, 10th Revision, 1992): is

WHO’s classification for all diseases and related health problems and not only
mental disorders. Chapter ‘F’ classifies mental disorders as Mental and
Behavioural Disorders (MBDs) and codes them on an alphanumeric system from
F00 to F99.

22
DSM-IV-TR (The Diagnostic and Statistical Manual of mental Disorders, IV Introduction to DSM IV and
Diagnostic Classification
Edition, Text Revision, 2000): is the APA’s (American Psychiatric Association’s)
classification of mental disorders. DSM-IV-TR is a text revision of the DSM-IV
published in 1994. The latest version of theses classifications resemble each other
in most of the details but differ in others. All the categories used in DSM-IV are
seen in ICD-10 but all categories of ICD-10 are not seen in the other.

DSM is primarily formulated for use in a single country (United States). ICD, on
the other hand is designed for international use and with variations in the official
classification in Europe and several countries. In India ICD-10 is the official
diagnostic system. Differences between the two classifications can be seen in
the table below.

The next editions of ICD (ICD-11) and DSM (DSM-V) are likely to be available
in the year 2011.

Table: ICD-10 and DSM-IV: Comparison

ICD-10 DSM-IV
1. International classification 1. National classification
2. Available in several versions 2. Single version
3. Available in different languages 3. English language only
4. Alphanumerical coding 4. Numerical coding
5. 10 major categories of disorders 5. 17 major categories
6. Single axis for chapter V (F) 6. Multiaxial classification

Self Assessment Questions

1) Write, in five lines, the contribution of Kraeplin towards classification?
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2) Write, in four lines, the main purposes of classification?
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23
Introduction to
Psychopathology 3) Write, in five lines, about the major classification systems widely used?
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2.4 THE DSM-IV

The 6th revision of the International Statistical Classification of Diseases was
widely criticised and failed to gain acceptance except in very few countries. As
an alternative to ICD-10 the American Psychiatric Association (APA) published
a Diagnostic Manual in 1952 called The Diagnostic and Statistical Manual. This
provided description for the categories of mental disorders which were listed.
In 1965 the second edition of DSM (DSM-II) was published which did not differ
much from DSM-I. However it contained a glossary with definitions of the various
disorders which the ICD-8 (published at the same time), lacked.
A third revision in an improved form was published in 1980 which was revised
again and brought out as DSM-IIIR in 1987.
DSM-IV was published in 1994 and is complementary to ICD-10 and the latest
version is a text revision called DSM-IV-TR published in 2000.

2.4.1 Features of DSM-IV

DSM-IV comprises of 17 major categories and over 300 specific disorders. The
major categories included in DSM IV are as given in the box below.
1) Disorders usually first diagnosed in infancy, childhood, or adolescence
2) Delirium, dementia, and amnestic and other cognitive disorders
3) Mental disorders due to a general medical condition not elsewhere
classified
4) Substance-related disorders
5) Schizophrenia and other psychotic disorders
6) Mood disorders
7) Anxiety disorders
8) Somatoform disorders
9) Factitious disorders
10) Dissociative disorders
11) Sexual and gender identity disorders
12) Eating disorders
13) Sleep disorders
14) Impulse-control disorders not elsewhere classified
15) Adjustment disorders
24 16) Personality disorders (Axis II)
Like ICD-10 the above is also a descriptive classification and is not etiologic. Introduction to DSM IV and
Diagnostic Classification
Specific diagnostic categories are provided for each mental disorder along with
other details of the disorder like epidemiology details, course of illness,
differential diagnosis, decision trees, etc. An important and distinct feature is the
scope for multiaxial evaluation. The classification has five axes and the patient
is simultaneously evaluated along several variables.
While Axis I provides information about clinical disorders, axis II provides
information about personality disorders and mental retardation. Axis III provides
information about any medical conditions that are presen, while Axis IV describes
psychosocial and environmental factors affecting the person. Axis V is a rating
scale called the Global Assessment of Functioning.(GAF)
The GAF goes from 0 to 100 and provides a way to summarise in a single number
just how well the person is functioning overall. (These axes are dealt with in
detail in the subsequent section)
In the DSM-IV, abnormal behaviour patterns are categorised according to the
features they share. For example, abnormal behaviour patterns chiefly
characterised by anxiety, such as panic disorder or generalised anxiety disorder,
are classified as anxiety disorders. Behaviours chiefly characterised by disruptions
in mood are categorised as mood disorders.

2.4.2 The DSM-IV Axes

Today, practitioners make use of a multiaxial classification system designed to
summarise the diverse information relevant to an individual case rather than to
provide a single label. Instead of merely assigning a case to a category (such as
schizophrenia), clinicians using a multiaxial system can describe an individual
in terms of a set of clinically important factors, or axes. DSM-IV provides
information about the context in which abnormal behaviour occurs as well as a
description of the behaviour. The axes of DSM-IV provide information about
the biological, psychological, and social aspects of a person’s condition.

The system contains the following axes:

Axis I: Main clinical problem or disorder
This axis includes a wide range of clinical syndromes, including anxiety disorders,
mood disorders, schizophrenia and other psychotic disorders, adjustment
disorders, and disorders usually first diagnosed during infancy, childhood, or
adolescence (except for mental retardation, which is coded on Axis II).

Axis II: Personality disorders and Mental Retardation

Personality disorders are enduring and rigid patterns of maladaptive behaviour
that typically impair relationships with others and social functioning. These
include antisocial, paranoid, narcissistic, and borderline personality disorders.
Mental retardation, which is also coded on Axis II, involves pervasive intellectual
impairment. People may be given either Axis I or Axis II diagnoses or a
combination of the two when both apply. For example, a person may receive a
diagnosis of an anxiety disorder (Axis I) and a second diagnosis of a personality
disorder (Axis II).

25
Introduction to Axis III: General Medical Conditions
Psychopathology
All medical conditions and diseases that may be important to the understanding
or treatment of an individual’s mental disorders are coded on Axis III. For example,
if hypothyroidism were a direct cause of an individual’s mood disorder (such as
major depression), it would be coded under Axis III. Medical conditions that
affect the understanding or treatment of a mental disorder (but that are not direct
causes of the disorder) are also listed on Axis III. For instance, the presence of a
heart condition may determine whether a particular course of drug therapy should
be used with a depressed person.

Axis IV: Psychosocial and Environmental Problems

The psychosocial and environmental problems that affect the diagnosis, treatment,
or outcome of a mental disorder are placed on Axis IV. These include job loss,
marital separation or divorce, homelessness or inadequate housing, lack of social
support, the death or loss of a friend, or exposure to war or other disasters. Some
positive life events, such as a job promotion, may also be listed on Axis IV, but
only when they create problems for the individual, such as difficulties adapting
to a new job.

Axis V: Global Assessment of Functioning (Level of functioning)

The clinician rates the client’s current level of psychological, social, and
occupational functioning using a scale similar to that shown in Table 1.2.4. The
clinician may also indicate the highest level of functioning achieved for at least
a few months during the preceding year. The level of current functioning indicates
the current need for treatment or intensity of care. The level of highest functioning
is suggestive of the level of functioning that might be restored.
An example of how this is recorded is given in the box below.
As an example, results of a DSM-IV multiaxial evaluation are recorded as:
Axis I Major depressive disorders, single episode in partial remission
Axis II Borderline personality disorder
Axis III Diabetes mellitus – type 1/insulin dependent
Axis IV Social Isolation
Axis V GAF 40

2.4.3 The Major Diagnostic Categories

Most research and treatment in psychopathology is targeted toward the Axis I
and Axis II disorders. We now provide a brief overview of several of these
disorders.

Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence

The DSM-IV lists ten major categories of childhood disorder, all of which, except
mental retardation, are coded on Axis I. These disorders are grouped together
primarily due to their time of onset rather than by their shared symptoms. In
general, they reflect problems with development and maturation. These include
disruptive behaviour, conduct disorder, Attention-deficit hyperactivity disorders,
learning disorders, etc.

26
Delirium, dementia, amnesia, etc. Introduction to DSM IV and
Diagnostic Classification
These disorders usually take us to the other end of the age-scale, and encompass
serious and often irreversible impairments of cognition and mental function.
They include Alzheimer’s disease and Huntington’s disease.

Substance-related disorders
Ingestion of one or more of a variety of substances (LSD, alcohol, etc.) is deemed
to have brought about the change in mental functioning. They include alcohol
use disorder, cocaine use disorder, etc.

Schizophrenia and other psychotic disorders

Marked to a greater or lesser extent by the presence of delusions (false beliefs),
hallucinations (false perceptions) and disordered thinking. The individual’s
behaviour signals loss of contact with reality, either intermittently or indefinitely.

Mood disorders
As the name implies, the primary disturbance for this set of disorders is to mood
(or affect). It encompasses various degrees of depression, mania, bipolar disorder
(otherwise known as manic-depressive illness) and seasonal affective disorder.

Anxiety disorders
DSM identifies ten different types, including phobias, obsessive-compulsive
disorder and post-traumatic stress disorder.

Somatoform and dissociative disorders

In the former, the individual repeatedly complains of physical symptoms which
have no basis in reality. In the latter, there are sudden inexplicable changes to
memory or consciousness (again, in the absence of any physical causes).

Sexua- and gender identity disorders

Sexual dysfunction disorders. The paraphilias, fetishism, pedophilia and
sadomasochism are amongst those listed.

Eating and sleeping disorders

The former identifies anorexia and bulimia; the latter encompasses a range of
sleep disorders including insomnia, narcolepsy and sleep apnea.

Factitious disorder
This rare diagnosis applies to people who deliberately induce physical or
psychological symptoms apparently in order to gain attention.

Adjustment disorders
This refers to the development of an emotional or behavioural disorder, clearly
related to some major life stressor, not meeting any other Axis 1 diagnosis.

Impulse control disorders

The name is self-defining. This controversial diagnostic category includes
kleptomania, pyromania and even pathological gambling.

27
Introduction to There are only two groups of Axis II disorders:
Psychopathology
i) Mental retardation
People with this disorder display significantly sub average intellectual functioning
and poor adaptive functioning by 18 years of age.

ii) Personality disorders

People with these disorders display a very rigid maladaptive pattern of inner
experience and outward behaviour that has continued for many years. People
with antisocial personality disorder, for example, persistently disregard and violate
the rights of others. People with dependent personality disorder are persistently
dependent on others, clinging, obedient, and very afraid of separation.

2.4.4 Problem of Labeling

A problem that occurs any time we categorise people is Labelling. Something in
human nature causes us to use a label, even one as superficial as skin colour, to
characterise the totality of an individual (“He’s brown….. He’s different from
me”). We see the same phenomenon among psychological disorders (“He’s a
schizo”). The very act of classifying people can lead to unintended results for
example many socio-cultural theorists believe that diagnostic labels can become
self fulfilling prophecies.
When people are diagnosed as mentally disturbed, they may be viewed and reacted
to correspondingly. If others see them as deficient and expect them to take on a
sick role, they may begin to consider themselves sick as well and act that way.
Furthermore, our society attaches a stigma to abnormality. People labelled
mentally ill may find it difficult to get a job, especially a position of responsibility,
or to be able to participate in social relationships. Once a label has been applied,
it may stick for a long time.
Because of these problems, some clinicians would like to do away with diagnoses.
Others disagree. They believe we must simply work to increase what is known
about psychological disorders and improve diagnostic techniques (Cunningham,
2000). They hold that classification and diagnosis are critical to understanding
and treating people in distress.

Self Assessment Questions

1) What is the importance of DSM IV?
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2) What is the difference between ICD 10 and DSM IV?
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28
 Introduction to DSM IV and
3) What is the multiaxial system of diagnosis? Diagnostic Classification

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4) Discuss the major diagnostic categories.
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2.5 EVALUATING THE DSM SYSTEM

To be useful, a diagnostic system such as the DSM must demonstrate reliability
and validity. The DSM can be considered reliable, or consistent, if
i) different evaluators using the system are likely to arrive at the same diagnoses
when they evaluate the same cases.
ii) if diagnostic judgments correspond with observed behaviour. For example,
people diagnosed with social phobia should show abnormal levels of anxiety
in social situations.
iii) Another form of validity is predictive validity, or ability to predict the course
the disorder is likely to follow or its response to treatment. For example,
people diagnosed with bipolar disorder typically respond to the drug lithium.
iv) Likewise, persons diagnosed with specific phobias (such as fear of heights)
tend to be highly responsive to behavioural techniques for reducing fears.

Overall, evidence supports the reliability and validity of many DSM categories,
including many anxiety and mood disorders, as well as alcohol and drug
dependence disorders (Grant et al., 2006; Hasin et al., 2006).

Yet questions about validity persist for some diagnostic classes, such as Axis II
personality disorders, as well as Axis V, Global Assessment of Functioning (Moos,
McCoy, & Moos, 2000; Widiger & Simonsen, 2005). Overall, it is fair to say
that the validity of the DSM remains a subject of ongoing debate and study.

Many observers have argued that the DSM should become more sensitive to
cultural and ethnic diversity. The behaviours included as diagnostic criteria in
the DSM are determined by consensus of mostly U.S. trained psychiatrists,
psychologists, and social workers.

29
Introduction to Had the American Psychiatric Association asked Asian trained or Latin American
Psychopathology
trained professionals to develop their diagnostic manual, for example, there might
have been some different diagnostic criteria or even different diagnostic
categories.

In fairness to the DSM, however, the latest edition does place greater emphasis
than did earlier editions on weighing cultural factors when assessing abnormal
behaviour. It recognises that clinicians unfamiliar with an individual’s cultural
background may incorrectly classify that individual’s behaviour as abnormal
when it in fact falls within the normal spectrum in his or her culture. The same
behaviour might be deemed normal in one culture but abnormal in another.

The DSM-IV-TR specifies that in order to make a diagnosis of a mental disorder,

the behaviour in question must not merely represent a culturally expectable and
sanctioned response to a particular event, even though it may seem odd in the
light of the examiner’s own cultural standards.

The DSM-IV-TR also recognises that abnormal behaviours may take different
forms in different cultures and that some abnormal behaviour patterns are
culturally specific.

All things considered, the current edition of the DSM, the DSM-IV-TR, is widely
recognised as an improvement over previous editions, even though questions
remain about the reliability and validity of certain diagnostic categories and about
the specific criteria used to reach certain diagnoses.

Self Assessment Questions

1) Evaluate the DSM IV.
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2) How does cultural factors play a role in diagnosis of a mental disorder?
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30
 Introduction to DSM IV and
3) Please list some of the behaviours which are considered appropriate Diagnostic Classification
and normal in your culture but might be seen as abnormal in different
cultures?
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2.6 ADVANTAGES AND DISADVANTAGES OF THE

DSM SYSTEM
The major advantage of the DSM may be its designation of specific diagnostic
criteria. The DSM permits the clinician to readily match a client’s complaints
and associated features with specific standards to see which diagnosis best fits
the case. For example, auditory hallucinations (“hearing voices”) and delusions
(fixed, but false beliefs, such as thinking that other people are devils) are
characteristic symptoms of schizophrenia.

The multiaxial system gives a comprehensive picture of clients by integrating

information concerning abnormal behaviours, medical conditions that affect
abnormal behaviours, psychosocial and environmental problems that may be
stressful to the individual, and level of functioning.

The possibility of multiple diagnoses is taken care of by making the clinicians to

consider presenting current problems (in Axis I) along with the relatively long-
standing personality problems (in Axis II) that may contribute to them.

Criticisms are also levelled against the DSM system. Critics challenge the utility
of certain conditions, like particular symptoms with particular syndromes or
specific diagnostic criteria, such as the requirement that major depression be
present for 2 weeks, be met before a diagnosis is reached (Faraone et al., 2006;
Zimmerman et al., 2006).

Others challenge the reliance on the medical model. In the DSM system, problem
behaviours are viewed as symptoms of underlying mental disorders in much the
same way that physical symptoms are signs of underlying physical disorders.
The very use of the term diagnosis presumes the medical model is an appropriate
basis for classifying abnormal behaviours.

But some clinicians feel that behaviour, abnormal or otherwise, is too complex
and meaningful to be treated as merely symptomatic. They assert that the medical
model focuses too much on what may happen within the individual and not
enough on external influences on behaviour, such as social factors (socio-
economic, socio-cultural, and ethnic) and physical environmental factors.

Another concern is that the medical model focuses on categorising psychological

(or mental) disorders rather than describing people’s behavioural strengths and
31
Introduction to weaknesses. Similarly, many investigators question whether the diagnostic model
Psychopathology
should retain its categorical structure (a disorder is either present or not).

Critics also complain that the DSM system might stigmatize people by labelling
them with psychiatric diagnoses. Our society is strongly biased against people
who are labelled as mentally ill. They are often shunned by others, including
even family members, and subjected to discrimination.

The DSM system, despite its critics, has become part and parcel of the everyday
practice of most U.S. mental health professionals. It may be the one reference
manual found on the bookshelves of nearly all professionals. Perhaps the DSM
is best considered a work in progress, not a final product.
Self Assessment Questions
1) Do we really need an authoritative diagnostic manual? Why or why
not?
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2) How can we fix the problems of negative, derogatory connotations of
diagnoses of mental disorders in our society?
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3) What are the advantages and disadvantages of the DSM system?
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4) What is the DSM? Use four lines for your answer.
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32
 5) Why DSM is considered a multiaxial system? Use five lines for your Introduction to DSM IV and
Diagnostic Classification
answer
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6) What are the major strengths and weaknesses of the DSM?
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2.7 LET US SUM UP

Classification is necessary in all branches of knowledge. In the area of personality
and abnormal behaviour, classification is based on assessment of what clients
say and how they behave. It also takes account of events they have experienced
in the present as well as their past histories. In abnormal psychology the
classification of a person is referred to as a diagnosis. The diagnosis places the
person’s disorder within an existing system or grouping of disorders.

The classification is a descriptive one in which different types of disorders are

described in detail. On the one hand, a descriptive classification system is valuable
for communication concerning treatment, in research, and for statistical purposes.
On the other hand, classification may result in labelling that creates stigmatization.
In classifying individuals, it is important to characterise their problems within
the context of their stresses as well as of their vulnerabilities, resiliency and
coping abilities.

A multiaxial diagnostic system is designed, not to provide a simple label, but to

summarise information about several aspects of the person’s history and
behaviour. Since 1980, the diagnostic system used for most purposes in the United
States, the Diagnostic and Statistical Manual of Mental Disorders (DSM), has
used a multiaxial system. DSM-IV has five axes: Axis I, the primary diagnosis;
Axis II, personality disorders and mental retardation; Axis III, relevant physical
conditions; Axis IV, recent stresses; Axis V, a global assessment of psychosocial
functioning, currently and in the past year.

Axis I includes groupings for developmental disorders, serious cognitive

disorders, substance-related disorders, sleep disorders, schizophrenia and other
psychotic disorders, mood disorders, anxiety disorders, somatoform disorders,
dissociative disorders, sexual disorders, factitious disorders, impulse control
33
Introduction to disorders not classified elsewhere, eating disorders, adjustment disorders and
Psychopathology
psychological factors that affect a physical condition. Axis II includes personality
disorders and mental retardation.

The DSM approach is to use highly specific, descriptive diagnostic criteria for
each category. This approach increases the reliability of diagnosis among
clinicians. DSM-IV is more comprehensive and includes many more disorders
and subdivisions of different disorders than previous editions. But more research
is needed to know whether these additional classifications are justified. Overall,
the changes in DSM-III, DSM-III-R, DSM-IV and DSM-IV R have added clarity
to the diagnostic process.

2.8 UNIT END QUESTIONS

1) Write about the meaning, purpose and history of classification of mental
disorders?
2) Write about the major differences between ICD-10 and DSM-IV?
3) Write in brief about the major diagnostic categories present in DSM-IV?
4) Critically evaluate the DSM system?

2.9 GLOSSARY
Syndrome : A cluster of symptoms that usually occur
together.
Classification System : A list of disorders, along with descriptions of
symptoms and guidelines for making
appropriate diagnoses.
Diagnosis : The process of attempting to determine the
identity of a possible disease or disorder and to
the opinion reached by this process.
Course : ‘usual’ pattern that disease takes.
Prognosis : Medical term to describe the likely outcome of
an illness.
Onset : Beginning or time when the signs or symptoms
first appear.
Reliability : In psychological assessment, the consistency of
a measure or diagnostic instrument or system.
Validity : The degree to which a test or diagnostic system
measures the traits or constructs it purports to
measure.

2.10 SUGGESTED READINGS

Bennett , Paul 2005. Abnormal and Clinical Psychology: An Introductory
Textbook, 2nd Edn. Open University Press, McGraw-Hill Education: England.
34
Carson, R. C., Butcher, J. N., & Mineka, S. 2002. Abnormal Psychology and Introduction to DSM IV and
Diagnostic Classification
Modern Life. Allyn & Bacon: New York.

Mangal, S.K. 2006. Abnormal Psychology. Sterling Publishers: New Delhi.

Sarason, I.G., Sarason, B.R.2005. Abnormal Psychology: The Problem of

Maladaptive Behaviour. Prentice-Hall of India: New Delhi.

35
Introduction to
Psychopathology UNIT 3 ETIOLOGY OF PSYCHOPATHOLOGY

Structure
3.0 Introduction
3.1 Objectives
3.2 Etiology of Abnormal Behaviour
3.3 Biological Factors
3.3.1 Neurotransmitter and Hormonal Imbalances in the Brain
3.3.2 Hormonal Imbalance
3.3.3 Genetics
3.3.4 Constitutional Liabilities
3.3.5 Brain Structure
3.3.6 Physical Deprivation or Disruption
3.4 Psychological Factors
3.4.1 Psychodynamics and the Parent- Child Relationship
3.4.2 Attachment and Security
3.4.3 Learned Behaviour
3.4.4 Distorted Thinking
3.4.5 Family Theories
3.5 Socio-Cultural Factors
3.5.1 Social-Economic Status
3.5.2 Gender
3.5.3 Age
3.5.4 Race and Ethnicity
3.5.5 Urban Environment
3.5.6 Social Networks
3.5.7 Migration
3.6 Integrative Models
3.6.1 The Diathesis-Stress Model
3.6.2 Developmental Psychopathology
3.7 Let Us Sum Up
3.8 Unit End Questions
3.9 Glossary
3.10 Suggested Readings

3.0 INTRODUCTION
In unit 2, we learned several aspects of the classification of mental disorders, the
DSM-IV and its major features and as well as its advantages and disadvantages.
In this unit we will try to understand the different causes of abnormal behaviour.

In this unit we will explore the causal factors and as well as study the viewpoints
which speak of the development and maintenance of abnormal behaviour. It is
important to have an understanding of these causes in prevention and treatment
of abnormal and maladaptive behaviour. For this purpose, we will examine

36
contemporary approaches to understanding abnormal behaviour from the Etiology of Psychopathology
biological, psychological and socio-cultural perspectives. Many scholars today
believe that abnormal behaviour patterns are complex phenomena that are best
understood by taking into account the different perspectives, rather than stressing
any one causal factor. For this reason current view of abnormal behaviour tends
to integrate several viewpoints. At the end of this unit we will describe the current
approach — the integrative perspective for explaining the etiology of
psychopathology.

3.1 OBJECTIVES
After studying this unit, you will be able to:
• Explain the causes of Abnormal Behaviour;
• Describe the biological factors contributing to abnormal behaviour;
• Explain the psychological factors causing abnormal behaviour;
• Analyse the Socio-Cultural Factors contributing to abnormal behaviour; and
• Describe the integrative models explaining abnormality.

3.2 ETIOLOGY OF ABNORMAL BEHAVIOUR

Knowledge of the causes of psychological disorders is important for two main
reasons. First, in everyday clinical work it helps the psychologist to understand
possible causes of an individual patient’s psychological disorder. Second, it adds
to the general understanding of mental disorders, which may contribute to
advances in diagnosis, treatment, or prognosis. In this unit we will only deal
with the first of these—the assessment of the causes of disorders.

When trying to understand the causes or etiology of abnormal behaviour there

are really no clear cut answers as we have for understanding physical illnesses.
Various viewpoints or models of the causes of abnormal behaviour have emerged
because no single approach could satisfactorily explain all abnormal behaviours.
Each approach focuses on important aspects of behaviour, although they fall
short of explaining the entire behaviour. Behaviour, whether normal or abnormal,
is determined by a multitude of factors. These factors can be grouped under
three categories, viz., biological, psychological and socio cultural. These factors
alone or in most cases jointly influence and give rise to the behaviour, that is
normal or abnormal. Biological model include causal factors from the fields of
genetics and neuroscience. Psychological model includes factors from
psychodynamic, behavioural and cognitive processes. Social influences contribute
in a variety of ways to psychopathology.

Irrespective of whichever viewpoint one follows, one should have an

understanding of some important terms that are used in psychopathology to have
clear understanding of the different types of causes and the role they play in the
etiology of maladaptive and abnormal behaviour.

A necessary cause is a condition that must be there for a disorder to occur. For
example, general paresis, a degenerative brain disorder cannot develop unless a
person had syphilis. A necessary cause is not always sufficient to cause a disorder
and therefore other factors may also be required.
37
Introduction to A sufficient cause is a condition that guarantees the occurrence of a disorder. For
Psychopathology
example, one theory says that hopelessness is a sufficient cause of depression
(Abramson et al 1995). According to this theory if you are hopeless enough
about your future then you will become depressed.

A contributory cause is one that increases the probability of developing a disorder.

For example, parental rejection could increase the probability that the child may
have problems in handling close relationships later.

When there are multiple causes it is useful to group them into predisposing,
precipitating, and perpetuating factors.

Predisposing factors determine the vulnerability to other causes that act close to
the time of the illness. Many predisposing factors act early in life, for example,
genetic endowment, the environment in utero, trauma at birth, and social and
psychological factors in infancy and childhood.

Precipitating factors are events that occur shortly before the onset of a disorder
and appear to have induced it. They may be physical, psychological, or social.
Physical precipitating factors include diseases such as cerebral tumour, traumatic
brain injury that is caused by accidents, and the effects of drugs taken for treatment
or used illegally.

As for psychological causes, there are many as for example a psychological cause
can be bereavement, losing a very near and dear person. This causes depression.
While moving home is a social cause, some causes may act in more than one
way; for example, a head injury may induce a psychological disorder through
physical changes in the brain and through psychological effects.

Perpetuating factors (or maintaining factors) prolong a disorder after it has

begun. Sometimes a feature of a disorder makes itself perpetuating (e.g. some
ways of thinking commonly prolong anxiety disorders). Social factors are also
important (e.g. overprotective attitudes of parents or care givers or relatives).
Awareness of perpetuating factors is particularly important in planning treatment
because they may be modifiable even when little can be done about predisposing
and precipitating factors.

3.3 BIOLOGICAL FACTORS

The biological viewpoint focuses on mental disorders as diseases whose primary
symptoms are behavioural or cognitive although their causes are biological or
physiological as against the physical illnesses where the cause and symptoms
are purely physical. According to this view, mental disorders are seen as disorders
of the central nervous system and thus are sometimes inherited or caused by
some medical factors like injuries or physical diseases. Psychological or
environmental factors are not considered to cause these disorders. We will discuss
‘five’ of the most important categories of biological factors that seem to be
responsible for maladaptive behaviour. These are given below:
• Neurotransmitter and Hormonal imbalances in the brain,
• Genetics,
• Constitutional liabilities,
38
• Brain structure, Etiology of Psychopathology

• Physical deprivation or disruption.

3.3.1 Neurotransmitter and Hormonal Imbalances in the Brain

Neurotransmitter Imbalances
The 100 billion neurons in the central nervous system (CNS) communicate by
chemical messengers called neurotransmitters. When these neurotransmitters
become imbalanced they give rise to many psychological problems. Biological
approaches to treatment focus mainly on medications that rectify neurotransmitter
imbalances.

Neurotransmitters (e.g., serotonin, dopamine, nor epinephrine, GABA) are

released into the synaptic cleft*. They regulate level of mood, anxiety, and
cognitive functioning.

Factors affecting neurotransmitter imbalance include:

1) Excessive production and release of the neurotransmitter substance into the
synapses, causing an excess in levels of that neurotransmitter.
2) Dysfunctions in the normal processes by which neurotransmitters are
deactivated after they are released into the synapse. This deactivation is
done in two ways. They are either deactivated by enzymes present in the
synapse or reabsorbed or sucked back into the presynaptic axon button, a
process called re-uptake. Dysfunctions can occur when the enzymes in the
synapse are deficient or there is slowing of the process of re-uptake.
3) Problems in the receptors in the postsynaptic neuron, which may either be
abnormally sensitive or insensitive.
Different disorders are thought to occur from different patterns of neurotransmitter
imbalances. Different types of drugs that are used to treat various disorders are
believed to work by correcting these imbalances. For example, the antidepressant
drug Prozac slows down the re-uptake process of the neurotransmitter serotonin.
Dopamine has been implicated in schizophrenia and GABA has been strongly
implicated in anxiety.

3.3.2 Hormonal Imbalance

Hormones are chemicals messengers secreted by the endocrine glands (e.g.,
pituitary). They play a role in the functioning of the nervous system and in the
regulation of behaviour (e.g., during adolescence, changes in the hypothalamic-
pituitary-adrenal axis are involved in the increase in cortisol, a stress-related
hormone). Malfunction of this system has been said to be responsible for various
forms of psychopathology. Hormonal influences are also responsible for the
differences in behaviour between men and women.

3.3.3 Genetics
Genes play an important role in determining risks for both psychotic and non
psychotic disorders. For example, the lifetime risk of schizophrenia is 1%, but
for the offspring of an affected person it becomes 10% and in bipolar disorder is
20%.

39
Introduction to For many years, twin studies served as the most direct way of determining whether
Psychopathology
or not a disorder has a genetic basis. In the classic twin study design, the similarity
of monozygotic (‘identical’) twins and disygotic (‘fraternal’) twins are compared.
Because monozygotic twins share all of their genes and disygotic twins share
only half their genes, greater similarity among monozygotic twins than among
disygotic twins implies a genetic component.

Another genetically informative design that has been used in psychopathology

research is the adoption design. In this design, the prevalence of psychopathology
in adopted children is examined as a result of psychopathology in their biological
parents and in their adoptive parents. If there is a significant association between
psychopathology in the adopted individuals and their biological parents, a genetic
influence is suggested; if there is a significant association between
psychopathology in the adopted individuals and their adoptive parents, a family
environment influence is suggested.

For most major mental disorders (e.g., schizophrenia, the major mood disorders,
anxiety disorders, alcohol-use disorders), twin and/or adoption studies have
demonstrated significant genetic effects. However, these studies also demonstrate
equally, if not more, important environmental effects. However, psychologists
often assume that ‘environment’ means the family or psychosocial environment
and this is not necessarily the case. Factors such as the prenatal environment
and viral infections are all part of the ‘environment’ in genetic terms.

Recent years have witnessed a revolution in molecular genetics. As a result, we

are no longer primarily interested in conducting twin or adoption studies to
determine whether or not a disorder has a genetic component. Today, and
increasingly in the future, we are more concerned with the discovery of the specific
genes that are inherited and how they act to produce mental disorders.

Using several different techniques to analyse DNA (the molecular basis of genes),
researchers are now in a position to correlate the presence of specific genes with
specific mental disorders. The task is complicated because existing research
suggests that most mental disorders are caused by multiple genes (polygenic),
making it very difficult to discover each individual gene that is associated with a
disorder.

Finally, there are so many genes that the thousands of analyses undertaken in a
single study can sometimes lead to false positive findings. Thus replication of
positive findings is crucial. Despite these problems, it seems highly likely that in
the next decade many genes associated with mental disorders will be identified.

3.3.4 Constitutional Liabilities

The term ‘constitutional’ is used to describe any characteristic that is either innate
or acquired early in life often at prenatal stage and in such strength that it is
functionally similar to a genetic characteristic. Physical handicaps and
temperament are some of the traits included in this category.

Embryonic abnormalities or environmental conditions operating before or after

birth may result in physical defects. The most common birth difficulty associated
with learning disabilities and behavioural and emotional disorders is low birth
weight. Prenatal conditions that can lead to premature birth and low birth weights
40
include nutritional deficiencies, disease, and exposure to radiation, drugs, severe Etiology of Psychopathology
emotional stress or mother’s excessive use of alcohol or tobacco. Socio-economic
status is also related to foetal and birth difficulties.

The temperament of an infant or young child has profound effects on a variety of

important developmental processes (Rothbart & Ahadi, 1994). For example, a
child with fearful temperament would become conditioned to ‘fear situations’ in
which fear is provoked. Later the child may learn to avoid entering these feared
situations and evidence suggests that they might be likely to learn to fear social
situations.

A child with a low threshold or low tolerance for distress may also learn to
regulate distress by keeping the level of stimulation low, whereas a child with a
high need for stimulation may do things to increase stimulation. Given these
effects on various developmental processes, it can be said that temperament might
also cause various forms of psychopathology in later life. For example, children
who are fearful in many situations might be at risk for developing anxiety disorders
later in childhood or in adulthood.

3.3.5 Brain Structure

Knowledge about brain structure has increased with the advances in computed
tomography (CT) scanning and magnetic resonance imaging (MRI). This has
lead to many notable observations. For instance, neuroimaging in some patients
with schizophrenia shows dilated cerebral ventricles and reduced frontal lobe
density. This evidence indicates that schizophrenia may be neurodevelopmental
in origin. Exposure to adverse conditions which can affect brain development
(in utero or in early life) may lead to changes in the frontal lobes that increase the
risk of schizophrenia. Neuroimaging also helps us to distinguish between different
types of dementia. Also, some older people experiencing severe depression for
the first time might have underlying cerebro-vascular disease.

3.3.6 Physical Deprivation or Disruption

The most basic human requirements are those of food, water, oxygen, sleep and
elimination of wastes. Insufficient rest, inadequate diet or working too hard when
ill, can all interfere with a person’s ability to cope and might predispose him or
her to a variety of problems. Experimental studies of volunteers who have gone
without sleep for 72 to 98 hours show psychological problems like disorientation
for time and place and feelings of depersonalisation. Prolonged food deprivation
also affects psychological health. Severe malnutrition in children not only impairs
physical development and lowers resistance to disease but it also stunts brain
growth, results in lowered intelligence and increases risk for disorders like
attention-deficit disorder.

Healthy mental development depends on a child’s receiving adequate stimulation

from the environment. In addition to the psychological problems which can result
by too little stimulation, the physical development of the brain is also affected
by an unstimulating environment.

Many animal studies have demonstrated that under conditions of special

stimulation, such as enriched and complex environments in which many different
activities can be engaged in, the animals were provided varying stimulation. It
41
Introduction to was found that there were positive changes in brain chemistry and structural
Psychopathology
changes in many parts of the brain (Diamond, 1988; Nelson & Blum, 1997). On
the other hand sensory overload can also impair adult functioning.

Critical thinking.....
Some severe psychiatric conditions such as Huntington’s disease in which
the individual develops increasing muscular spasticity and mental
deterioration leading to death in middle age can be predicted by genetic
testing. It cannot be prevented, but those who have the gene for the condition
may choose not to have children and pass the gene on to them. Would you
want to know as a young person whether you carry the gene?

3.4 PSYCHOLOGICAL FACTORS

Personality ‘traits’ are usually defined as those aspects of how one person relates
to others, reacts to interpersonal stimuli and evaluates themselves over time. For
all this, a person may laugh, cry, be angry, be thoughtful and act unkindly at
different times. This does not mean that their ‘personality’ is constantly changing
– it is the overall balance of thinking, feeling and behaviour that is important,
not how they react in any specific situation.

A key factor is flexibility. More ‘mature’ personalities have a wider range of

responses to cope with different circumstances. Those with a more limited range
may manage in predictable situations but not in more challenging ones. For
example, obsessional people may cope well with a highly predictable office job
but do poorly in a management type position where tasks are less clearly defined.

There are several causes of how personality develops. Most are based on close,
long term clinical observations and offer important insights into how people
think and feel.

3.4.1 Psychodynamics and the Parent-Child Relationship

Freud emphasised the role of the early parent–child relationship in the
development of mental illness. According to Freud, to the extent that the child
did not successfully negotiate the psychosexual stages, mental illness would
develop.

But Freud did not focus on what actually occurred in the parent–child relationship
(e.g. whether parents were actually poor caretakers). Instead, his focus was on
the unconscious internal desires and motivations of the child (e.g. sexual and
aggressive impulses) and how the child negotiated them as s/he progressed through
the early relationship with the child’s parents. For example, if an adult male
found himself unable to deal with authority figures, this might be interpreted as
unresolved aggressive impulses towards his father. Whether his father behaved
as a harsh authority figure or not would be considered less relevant. So, according
to Freud, mental illness is due to intra-psychic (i.e. within the mind) conflict.
This means a person may have very little insight into the ‘true’ causes of their
symptoms, as these are thought to be occurring at an unconscious level of
processing.

42
Many of Freud’s ideas have gone unsupported by research, but a number of them Etiology of Psychopathology
have proven to be fairly accurate. For example, there is ample evidence that
people experience and process things at an unconscious level (Westen, 1998)
and that early interpersonal experiences affect later outcomes. In fact, this latter
hypothesis became central to contemporary psychodynamic models of abnormal
behaviour.

Contemporary psychodynamic models (e.g., Kohut, 1977; Kernberg, 1976;

Mitchell, 1988) also suggest that the early parent child relationship is the original
source of mental illness, and that what goes on in the mind of the child (and the
adult) is important. But these models differ from Freud’s in that they focus more
on interpersonal relationships than on intra-psychic conflict. These later models
suggest that the early relationship between the child and the primary caregiver is
crucial to the development of the self-concept, concepts of others, and the quality
of relationships throughout life. The idea is that this early caregiver and child
relationship is internalised by children, so that they learn about themselves and
others from the manner in which the caregiver treats them. According to this
framework, the nature of this internalised relationship and its resulting impact
on the sense of self and the sense of others is what can create vulnerability to
psychological problems. Table below presents the different stages of evelopment
according to Psychoanalytical approach and the associated problems thereof that
can develop if the concerned stage of development is not passed through without
difficulty. If there had been conflicts and the child could not pass through the
stage without difficulties, certain problems can arise which are given below in
the table.

Table: Some adult personality characteristics associated with a failure to

progress through Freud’s development stages
Stage Associated Problems that may develop
Oral Depression, narcissism, dependence
Anal Obstinacy, obsessive-compulsive disorder, sadomasochism
Phallic Gender identity problems, antisocial personality
Latent Inadequate or excessive self-control
Genital Identity diffusion

3.4.2 Attachment and Security

The attachment model of psychopathology, developed by Bowlby (1969; 1973;
1980) resembles the contemporary psychodynamic models in that it also
emphasises the early parent child relationship and how the resulting models of
self and others guide development. However rather than being interested in
people’s perceptions of their early experience, Bowlby was interested in the actual
characteristics of the relationship. He relied on observational studies of parents
and children to build his theory, rather than on retrospective reports of adults.
The theory therefore has a strong empirical foundation.

Attachment theory suggests that when parental behaviour fails to make children
feel safe, secure, and able to turn to and trust the parent in times of need, then
children will be unable to regulate their emotions and needs adaptively and will
develop negative, ‘insecure’ views of themselves and others. This would put
43
Introduction to children at risk for developing psychological disorders. Research supports this
Psychopathology
hypothesis, as ‘insecure’ children and adults who show more psychopathology
than ‘secure’ children and adults (see Dozier, Stovall & Albus, 1999; Greenberg,
1999).

3.4.3 Learned Behaviour

Behavioural models suggest that all behaviours, abnormal included, is a product
of learning, that is mainly learning by association. For example, according to
the classical conditioning model of learning (e.g. Pavlov, 1928), if a person
experiences chest pain which results in anxiety while shopping in a departmental
store, he may develop a fear of departmental stores and begin to avoid them
because he associates them with anxiety. There is nothing inherently frightening
about departmental stores, but this person fears them because of the association
that he has formed with his earlier anxiety about having a possible heart attack.

To cite another example which instead of classical conditioning approach uses

the operant model of learning (e.g. Skinner, 1953). Let us say a young normal
weight woman begins to lose weight and her friends and family praise her for
doing so, she may continue to lose weight, even if it means starving herself. Her
restricted eating behaviour will continue because she now associates a reduction
in her diet with the praise and acceptance of others.

There is a third type of learning, called as the observational learning. This does
not rely on personal experiences to establish associations. In observational learning
(modelling), behaviour is learned simply by watching someone else do something
and observing what happens to them (Bandura, 1969). For example, a young
boy may learn to be aggressive after watching his peers act aggressively.

Each of these learning models was built on a solid foundation of empirical

research, and there is a great deal of evidence that each of the three learning
processes plays an important role in abnormal behaviour.

Behavioural work with animals first led to the idea that repeated unpleasant
experiences, over which an individual has no control, might induce a state of
learned helplessness. Seligman (1974) subjected dogs to inescapable electric
shocks: at first they ran around in a distressed way, but then they seemed to give
up and passively accept the painful stimulation. Seligman was impressed by the
apparent similarity between their behaviour and the symptoms of depression.
Translating this work to the human situation would imply that some people learn
to expect that, no matter what they do, their efforts seem to end in failure. It is
this sense of helplessness and lack of control that leads to depression.

3.4.4 Distorted Thinking

Cognitive models of abnormal behaviour focus on the way people think about
themselves, others and the world (e.g. Beck et al., 1979). Distorted cognitive
processes – such as selectively attending to some information and ignoring other
information, exaggerating negative feelings, expecting the worst, or making
inaccurate attributions about events have been shown to play an important role
in various types of psychological disorders.

For example, suppose a woman has a bad day at work. If she says to herself, ‘Oh
well, tomorrow will be better’, she will probably feel fine. But if she says to
44
herself, ‘Oh, I’m just a horrible person with no future’ (i.e. if she exaggerates her Etiology of Psychopathology
negative feelings), she may become depressed. Or suppose a young man loses at
a game of carroms. If he thinks, ‘I sure had bad luck with the carroms today’, he
will feel fine. But if he thinks, ‘my rotten friends purposely cheated me!’ he may
become hostile and aggressive.

3.4.5 Family Theories

Some psychologists have suggested that psychosis is a way of thinking and
behaving acquired in childhood, usually as a result of the attitudes, communication
and behaviour of parents. Fromm-Reichmann (1948) coined the term
schizophrenogenic mother, to describe a parent who was cold, domineering and
manipulative, and who had a marked tendency to induce conflict in others around
her. According to Fromm-Reichmann, this combination of characteristics made
these mothers unable to show normal affection to their children. She considered
that this deficiency in mothering caused the child to develop a lifelong distrust
and resentfulness towards others and thereby to go on to develop schizophrenia.

Bateson et al. (1956) argued that schizophrenia develops as a result of repeated

exposure to a process called the double-bind. This term means communications
that are inherently contradictory or conflicting, and which put the child in a ‘no
win’ situation. For example, a child would be in a double-bind if he were told by
his parents to go outside and play outside in a muddy garden, but also that he
must not get his clothing dirty. The child would have no opportunity to please
his parents, as all of the actions open to him would be likely to lead to parental
disapproval. But there is little, if any, scientific support that shows mothers of
patients to be aloof, cold or rejecting, or that people with schizophrenia were
repeatedly exposed to double-binds as children.
Lidz et al. (1958) suggested that abnormalities in the relationships between the
parents of mentally ill patients were primarily responsible for their developing
psychological problems. They coined the terms skew and schism to describe
such relationships. Skew describes a marriage where one partner is dominant
and the other submissive, while schism describes the relationship in which parents
are emotionally distant from one another. He proposed that, over a period of
time, these dysfunctional patterns of interaction would be psychologically harmful
to the child, leading ultimately to their developing psychopathology.
According to Laing, abnormalities in relationships within the family, together
with abnormal communication between parent and child, undermine the child’s
sense of self.
Outright parental abuse (physical, sexual or both) of children has also been
associated with many negative effects on the development of children. Abused
children often have tendency to be overly aggressive both verbally and physically
and some even respond with anger and aggression to friendly overtures from
classmates. Researchers have also found that maltreated children have difficulties
in linguistic development and might also develop depression and anxiety.

3.5 SOCIO-CULTURAL FACTORS

In contrast to the psychological and biological perspectives proposed by
psychologists and psychiatrists, sociologists have long emphasised the influence
45
Introduction to of various socio-cultural factors on mental disorder. These factors are discussed
Psychopathology
below.

3.5.1 Social-Economic Status

Social class is one of the most important causal factors in mental illness. This
has been clearly and consistently demonstrated by studies related to mental
disorder. It was found that those from the lower economic classes are more likely
than those from other classes to be mentally ill. Although mental illness among
the low socio-economic classes is more likely to be reported to the authorities,
surveys on random samples of the population have consistently found a greater
percentage of lower class people suffering from psychological symptoms.

There are two conflicting explanations of this. One, called social causation,
suggest that lower economic class people are more prone to mental disorder
because they are more likely to experience social stress (e.g. unemployment,
separation), to suffer from psychic frailty, infectious diseases, neurological
impairments, and to lack good medical treatment, coping ability and social
support. Through an accumulation of these problems, and the stresses that result,
low social status becomes a cause of mental illness.

The other explanation emphasises social selection or drift. This suggests that
mentally ill people from higher social classes often drift downward into the lower
class areas, ( due to job loss, unemployment) helping to increase the rate of
mental illness in such neighbourhoods. This explanation suggests that being lower
economic class is a result of mental illness among formerly higher status
individuals. Both explanations may be true to some extent.

3.5.2 Gender
The next social factor associated with mental illness is gender. There are
conflicting findings as to which gender is more likely to become mentally ill. In
most studies women are found to have a higher rate of mental disorder, but some
others find men to be more predominant or no difference between the sexes.

These conflicting findings, however, refer to mental illness most generally. Studies
on specific types of disorders, however, do indicate gender differences. These
usually show that women predominate in depression and anxiety disorders, while
men more commonly have antisocial personalities, paranoia, drug and alcohol
abuse disorders. Most sociologists’ attribute this difference to differences in gender
roles.

The female role is relatively restrictive and oppressive, likely to confine the
woman to her inner self, such that she tends to keep her frustration and anger to
herself rather than aggressively pour it out on others. Hence women are more
likely to fall victim to depression and anxiety. Men, on the other hand, have a
more liberated role, and they are encouraged to be bold, assertive and aggressive
in social relations. If frustrated and angry, they are more likely to take it out on
others — behaving as antisocial and paranoid individuals.

3.5.3 Age
Another social factor that has been associated with mental disorder is age. Studies
conducted before the 1980’s suggested that older persons were more likely to
46
suffer from mental disorders. This was attributed to societal neglect of the elderly Etiology of Psychopathology
eventually resulting in institutionalisation, where the neglect can continue. Yet,
more recent studies in the 1980’s and 1990s show that the elderly are the least
likely among all age groups to become mentally ill.

The increasing prevalence of depression among younger people can be attributed

to changes in modern society, that is an increase in social stresses coupled with
a decrease in social resources for dealing with them. Most of these stresses come
from family problems (e.g. divorce, child abuse, or parental indifference). The
difficulty in coping comes largely from the loss of the extended family and close-
knit village-like community in modern society. Research has shown, for example,
that lack of parental love and affection, divorce, and other factors can significantly
contribute to the development of depression, anxiety, or other types of mental
disorder.

3.5.4 Race and Ethnicity

A third social factor in mental disorders is race and ethnicity. Like gender, these
have not been consistently found to be related to mental illness in general. While
many studies have shown higher rates of psychological stress among minorities,
the standard explanation has been that these groups experience more social stresses
stemming from discrimination, poverty and cultural conflict.

On the other hand, there are studies showing no significant difference in

psychological problems between minorities and whites in U.S. An explanation
for this finding could be: minority group identification, group solidarity, or social
networks which protect them against these social stresses, for example people
from India who have settled in west tend to form social groups, clubs or cultural
societies. The same explanation has been offered to account for the lower rate of
mental illness among British minorities.

More consistent data are available on the relationship between race or ethnicity
and specific forms of mental disorder. In the U.S., Puerto Ricans and African
Americans are more likely than Irish or Jewish Americans to have sociopathic
inclinations or paranoid tendencies. Jewish Americans, in contrast, tend more to
manifest depressive disorders. In addition, Americans of Korean ancestry, have
more depressive symptoms than whites.

3.5.5 Urban Environment

An important social factor implicated in mental illness is the urban environment
itself. Community surveys indicate higher rates of mental disorders in urban
areas, particularly the inner city, than in rural areas, including the suburbs and
small towns. It is argued that the urban environment produces a lot of mental
problems because it generates an abundance of physical and social stresses (e.g.
traffic congestion, noise, population density, tenuous social relations, loneliness
and lack of social support). Some community studies also reveal a link between
urban living and specific psychological problems (e.g. neurotic and personality
disorders).

In contrast, more serious psychotic conditions are more prevalent among rural
and small town residents. This could be explained by the argument that rural and
small-town residents find their lives too restrictive, and they are not able to express
47
Introduction to frustration and anger in the presence of others — who may easily find out who
Psychopathology
the troublemakers are. By suppressing their frustration, they may get deeper and
deeper into themselves until they become psychotic. In contrast, urban dwellers
can get away from family and friends, are freer to express frustration in the
midst of strangers, and tend more to tolerate unconventional behaviour. If they
persist in doing so, urbanites may become neurotics, who, unlike psychotics,
retain their grip on conventional reality. Otherwise, they may develop an antisocial
psychopathic personality, which is essentially an “acting out” disorder.

3.5.6 Social Networks

Having caring and close relationships strongly protects against most non psychotic
forms of mental illness. Supportive social networks, particularly family, are crucial
in times of crisis. Such networks extend beyond family and close friends, and in
many communities include religious groups. People with psychological illness
tend to have more impaired social networks than their peers.

3.5.7 Migration
Immigrants are not a homogenous group. Economic immigrants (those who chose
to migrate in search of a better life) often have better than average mental health.
In contrast, refugees from war and persecution have often suffered experiences
that affect their mental health adversely.

Sometimes first generation immigrants appear to have lower rates of mental

illness because of low rates of recognition. By contrast, the second generation
may have higher rates, partly due to conflict between the cultural norms of the
host society and the expectations of their parents. There may also be an effect of
time on presentation. One study of southern European women immigrants found
that they developed depression about fifteen years after arrival.

It was suggested that while initially they were busy helping their husbands and
children to settle (i.e. their children became fluent in English and their husbands
became established in their jobs) the women became increasingly isolated and
eventually lost their meaningful role.

Thinking about . . .

Most strategies for reducing the burden of mental health disorders have
focused on treatment once they have developed. The importance of social
and cultural factors points to another way of addressing the issue: to reduce
the social, economic and cultural factors that may contribute to poor mental
health. This could be done in a number of ways – anti-bullying campaigns
in schools, providing cheap or free crèches so that young single mothers
can access recreational facilities or have a break from child care, ensuring
economic security for people in old age – that on the surface have little to
do with mental health, but may actually have a significant impact on it

So, if you are given free rein, how would you change the society in which
we live to maximize the mental health of the general population?

48
 Etiology of Psychopathology
3.6 INTEGRATIVE MODELS
The models of abnormal behaviour described above are quite different from one
another, and each is more or less well suited to particular disorders. As most
disorders are quite complex, no single model can provide a full explanation of
their onset and course over time. Instead, each model can help us to understand
a different aspect of each disorder. This is where integrative models are useful.

You may have noticed that only some of the models above explicitly focus on
childhood factors that may contribute to the development of abnormal behaviour,
whereas the others only do so at an implicit level. For example, behavioural
models suggest that abnormal behaviour is the product of ‘earlier’ learning
experiences, but they don’t elaborate on exactly what those experiences are. By
contrast, developmental psychopathology provides a more rigorous framework
for understanding how psychopathology develops from childhood to adulthood.
It is also likely that mental illness results only when particular combinations of
factors are present. This notion is at the heart of the diathesis–stress model.

3.6.1 The Diathesis–Stress Model

Research in psychopathology has made people aware that neither a strictly
biological or psychological approach can fully explain how mental illnesses arise.
Evidence also suggests that most occur as a result of a combination of factors,
and a causal model known as the stress-diathesis model (Goldman 1992) has
evolved. In simple terms, this model implies that mental illness is a reaction to
life experiences in individuals who are vulnerable (a diathesis) or predisposed in
some way to that mental illness. One sort of predisposition may be genetic, but
others may involve early brain damage or even early experience. The causative
factors (stress) will vary, ranging from the effects of major and sudden life events
such as bereavement or unemployment, to the minor but more enduring tensions
of family life. This approach can also be called as biopsychosocial approach.

Diatheses and stressors can be defined broadly. For example, a genetic or

biological predisposition to mental illness might be the diathesis, and a troubled
parent–child relationship could be the stressor; or a dysfunctional pattern of
thinking about the world can be the diathesis, and a major life event the stressor.

3.6.2 Developmental Psychopathology

According to this model, psychopathology is best understood using a lifespan
development approach. It considers how the negotiation and attainment of earlier
developmental tasks affects people’s capacities to manage later tasks (e.g.
Cicchetti, Rogosch & Toth, 1994).

In other words, people may travel down one of many paths, their success or
failure at various junctures along the way determines the subsequent path that
they follow. So, earlier deficits in functioning may leave us unprepared to
successfully negotiate subsequent related situations, putting us at even greater
risk for psychopathology. For example, a young girl who is harshly and chronically
criticized by her parents may develop low self-esteem and the expectation that
people will not like her, which puts her at risk of becoming depressed.

49
Introduction to She may then have difficulty making friends in school because she is afraid of
Psychopathology
rejection. She may feel lonely and undesirable, her withdrawal leading to actual
rejection by her peers, continuing her risk for depression. But if this young girl
has a teacher who treats her with warmth and care and helps her learn how to
make friends, her risk for depression might be reduced.

This is because she is acquiring important skills that have the potential to change
the course of her subsequent development.
Self Assessment Questions
Exercise: 1
Multiple choices
1) .......................... theorists believe that severe problems in the relationships
between children and their caregivers may lead to abnormal development
and psychological difficulties.
a) Ego, b) Self, c) Behaviour, d) Object relations
2) .......................... are chemicals released into the bloodstream.
a) Genes, b) Synapses, c) Neurotransmitters, d) Hormones.
3) Behavioural therapists base their explanations and treatments of mental
abnormality on principles of
a) Relationships, b) ego development, c) dream analysis, d) learning
4) Which is an inaccurate statement about the role of genes in abnormal
behaviour?
a) Genes probably play a part in mood disorders.
b) Researchers are able to identify some specific genes that cause some
major mental disorders.
c) Researchers have not been able to identify any specific genes that
cause most mental disorders.
d) In most cases, many genes combine to help produce dysfunctional
behaviour.
5) A researcher who examines the physiological responses associated with
a psychological disorder is interested in which perspective?
a) Social, b) behavioural, c) biological, d) developmental
6) Much of our development and most of our behaviour, personality and
IQ are influenced by many genes, each contributing only a portion of
the overall effect. This type of influence is known as:
a) Integrative, b) polygenic, c) reciprocal, d) recessive
7) Which model states that individuals inherit tendencies to express certain
traits or behaviours, which may then be activated under conditions of
stress?
a) Developmental, b) stress management, c) diathesis-stress,
d) non genomic inheritance
8) Reuptake occurs when
a) A neurotransmitter is drawn back into the nerve cell from the synaptic
cleft
50
 Etiology of Psychopathology
b) Individuals with mental illness are moved against their will into
mental institutions.
c) A person experiences the same type of mental illness multiple times.
d) Nerve impulses travel from the sense organs to specific areas of the
brain.
9) In the diathesis-stress model, “diathesis” refers to
a) An inherited tendency or condition that makes a person susceptible
to developing a disorder.
b) The conditions in the environment that can trigger a disorder
depending upon how severe the stressors are
c) An inherited disorder
d) The inheritance of multiple disorders
10) People who have many social contacts and live their lives continually
interacting with others
a) Often suffer from psychological disorders such as dependency
b) Have not been found to differ on any health outcome
c) Live longer and healthier lives
d) Develop more infections and have poorer overall health.

3.7 LET US SUM UP

The causes of abnormal behaviour are complex and fascinating. We can say that
psychological disorders are caused by nature (biology) and by nurture
(psychosocial) and we would be both right and wrong.

To identify the causes of various psychological disorders, we must consider the

interaction of all relevant dimensions i.e. genetic contributions, the role of the
nervous system, behavioural and cognitive processes, emotional influences, social
and interpersonal influences, and developmental factors. Thus, we have arrived
at a multidimensional integrative approach to the causes of psychological
disorders.

The field of neuroscience promises much as we try to understand psychopathology.

Within the nervous system, levels of neurotransmitter and neuroendocrine activity
interact in very complex ways to modulate and regulate emotions and behaviour
and contribute to psychological disorders. Critical to our understanding of
psychopathology are the levels of neurotransmitter and hormones. Imbalances
in their levels could lead various types of psychological problems.

The genetic influence on much of our development and most of our behaviour,
personality and even our IQ is polygenic i.e. influenced by many genes. This is
assumed to be same for abnormal behaviour as well, although research is
beginning to identify specific small groups of genes that relate to some of the
major psychological disorders.

The psychodynamic, behavioural and cognitive models provide a valuable

perspective on how the parent-child relationship, type of learning and the way
we process information affect the adaptation each of us experience throughout 51
Introduction to life. Social and interpersonal influences profoundly affect both psychological
Psychopathology
disorders and biology.

In considering an integrative approach to psychopathology it is important to

understand the various paths to a particular outcome not just the results. In the
diathesis-stress model, individuals are assumed to inherit certain vulnerabilities
that make them susceptible to a disorder when the right kind of stressor comes
along. Psychopathology should also be understood in terms of the life span
developmental approach.

3.8 UNIT END QUESTIONS

1) What are the biological underpinnings of abnormal behaviour?
2) What are the major psychological factors of abnormal behaviour?
3) What is the basic idea underlying the socio-cultural perspective on abnormal
behaviour?
4) What is the diathesis-stress model?

3.9 GLOSSARY
Perspective : A view

Prognosis : Is a medical term to describe the likely outcome

of an illness.

Degenerative disease : is a disease in which the function or structure of

the affected tissues or organs and will
progressively deteriorate over time.

Implicated : Connected or involved with.

Neurotransmitters : Chemical substances that transmit messages from

one neuron to another.

Hormone : Chemical messenger produced by the endocrine

glands.

Neuron : Individual nerve cell, responsible for transmitting

information.

Synapse : The junction between one neuron and another

through which nerve impulses pass.

Synaptic cleft : The small gap between the axon of one and the
dendrites of the receiving or postsynaptic neuron.

Axon : Nerve cell branches that transmit outgoing

electrochemical impulses to other neurons.

Dendrite : Branched part of a cell that serves as receptor for

nerve impulses from the axons of other cells and
52
transmit them to cell body.
Central nervous system : The brain and spinal cord. Etiology of Psychopathology

Defence mechanisms : The reality-distorting strategies used by the ego to

shield the self from awareness of anxiety-
provoking materials.

Classical conditioning : A form of learning in which a response to one

stimulus can be made to occur to another stimulus
by pairing or associating the two stimuli.

Operant conditioning : A form of learning in which behaviour is acquired

and Strengthened when it is reinforced.

Diathesis : A vulnerability or predisposition to a particular

disorder.

Depersonalisation : Feelings of unreality or loss of personal identity.

3.10 SUGGESTED READINGS

Carson, R. C., Butcher, J. N., & Mineka, S. Abnormal Psychology and Modern
Life, 11TH edition. Pearson Education:New Delhi

Davison, G.C., Neale, J.M., Kring, A.M. Abnormal Psychology, 9th edition. Wiley
& Sons:USA.

Sarason, I.G., Sarason, B.R. 1998. Abnormal Psychology: The Problem of

Maladaptive Behaviour. Prentice-Hall of India: New Delhi.

53
Introduction to
Psychopathology UNIT 4 ASSESSMENT OF
PSYCHOPATHOLOGY, INTERVIEW
AND TESTING

Structure
4.0 Introduction
4.1 Objectives
4.2 Concept of Assessment
4.3 Basic Requirements of Assessment Measures
4.4 Methods of Assessment
4.4.1 The Clinical Interview
4.4.2 Format of Clinical Interview
4.4.3 Types of Clinical Interviews
4.4.4 Limitations of Clinical Interviews
4.5 Psychological Tests
4.5.1 Intelligence Tests
4.5.2 Personality Inventories
4.5.3 Rating Scales
4.5.4 Projective Tests
4.5.5 The Rorschach Test
4.5.6 The Thematic Apperception Test
4.5.7 Sentence Completion Test
4.5.8 Drawings
4.6 Neuropsychological Assessment
4.7 Clinical Observations
4.7.1 Naturalistic and Analogue Observation
4.7.2 Self-monitoring
4.8 Socio-cultural and Ethnic Factors in Assessment
4.9 Let Us Sum Up
4.10 Unit End Questions
4.11 Glossary
4.12 Suggested Readings and References

4.0 INTRODUCTION
From the last units we have now a fairly good idea about what abnormal behaviour
is and what are the different causes of this behaviour. Clinical practitioners apply
this general information in their work. To help a particular client overcome his
or her problems, a psychologist must have the fullest possible understanding of
that person and know the circumstances under which the problems arose. Only
after thoroughly examining the person can the therapist effectively apply relevant
information. When faced with a new client clinicians use the procedures of
assessment and diagnosis to gather individual information about a client. Then
they would be in a position to apply treatment.
54
Let us consider in this unit the various ways of assessing abnormal behaviour. Assessment of
Psychopathology, Interview
We will first begin by trying to understand the concept of assessment and the and Testing
basic requirements for methods of assessment—that they be standardised, reliable
and valid. Then we would be discussing in detail the types of assessment methods
like clinical interviews and psychological tests.

4.1 OBJECTIVES
After studying this unit, you will be able to:
• Define assessment;
• Indicate the basic requirements of assessment measures;
• Elucidate the methods of assessment;
• Define the Psychological Tests to be administered;
• Elucidate the Neuropsychological Assessment;
• Analyse the Clinical Observations; and
• Explain the Socio-cultural and Ethnic factors in Assessment.

4.2 CONCEPT OF ASSESSMENT

Assessment is simply the process of gathering relevant information in an effort
to reach a conclusion. It goes on in every aspect of life. We make assessments
when we decide what product to buy, what subject and which college to choose
or which candidate to vote for. College admissions officers, who have to select
the “best” of the students applying to their college, depend on academic records,
recommendations, entrance test scores, interviews, and application forms to help
them decide. Employers, who have to predict which applicants, are most likely
to be effective workers, collect information from résumés, interviews, references,
and perhaps on the job observations. This type of assessment is used for the
daily and routine activities, in order to choose the best which is reliable, long
lasting and effective. In contrast, the clinical assessment is done with a specific
target.

Clinical assessment is used to determine how and why a person is behaving

abnormally and how that person may be helped. It also helps clinicians to evaluate
people’s progress after they have been in treatment for a while and decide whether
the treatment should be changed.

There are hundreds of clinical assessment techniques and tools that have been
developed. These techniques fall into three categories: clinical interviews, tests,
and observations. To be useful, these tools must be standardised and have clear
reliability and validity.

4.3 BASIC REQUIREMENTS OF ASSESSMENT

MEASURES
In explaining the criteria of a good psychological test or any assessment, tools
have to be objective, standardised, reliable, and valid and should have norms.
This criterion could be followed here because crucial decisions are made on the
55
Introduction to basis of assessment. For example, recommendations for specific treatment
Psychopathology
techniques may vary according to our assessment of the problems client exhibits.
Therefore, methods of assessment must be standardised, reliable and valid.

To standardise a measure the technique used is to have common steps to be

followed whenever it is administered. Similarly, clinicians must standardise the
way they interpret the results of an assessment tool in order to be able to understand
what a particular score means. They may standardise the scores of a test, for
example, by first administering it to a group of subjects whose performance will
then serve as a common standard, or norm, against which later individual scores
can be measured. The group that initially takes the test is called the standardisation
sample. This sample must be typical or representative of the larger population
the test is intended for. For example, If a social support test meant for the public
at large were standardised on a group living on ship, for example, the resulting
“norm” might turn out to be misleading.

The reliability of a method of assessment refers to its consistency. A measure of

height would be unreliable if people looked taller or shorter at every measurement.
A reliable measure of abnormal behaviour must also yield the same results on
different occasions. Also, different people should be able to use the measure and
agree on the result. For example, two teachers may be asked to use a behavioural
rating scale to evaluate a child’s aggressiveness, hyperactivity, and sociability.
The scale would have good reliability if both teachers rated the same children in
similar ways.

Assessment techniques must also be valid; that is, instruments used in assessment
must measure what they intend to measure. Suppose a measure of depression
actually turned out to be measuring anxiety. Using such a measure may lead an
examiner to a wrong diagnosis.

4.4 METHODS OF ASSESSMENT

Psychologists use different methods of assessment to arrive at diagnoses, including
interviews, psychological testing, self-report questionnaires, behavioural
measures, and physiological measures. A careful assessment provides a wealth
of information about client’s personality and cognitive functioning. This
information helps clinicians develop a broader understanding of their clients’
problems and helps to recommend appropriate forms of treatment. In most cases,
the formal assessment involves one or more clinical interviews with the client,
leading to a diagnostic impression and a treatment plan.

In some cases, more formal psychological testing might be needed to probe the
client’s psychological problems relating to intellectual, personality, and
neuropsychological functioning. The various methods of assessment are discussed
below.

4.4.1 The Clinical Interview

The clinical interview is the most widely used means of assessment. The interview
is usually the client’s first face-to-face contact with a clinician. Clinicians often
begin by asking clients to describe the presenting complaint in their own words,
saying something like, “Can you describe to me the problems you’ve been having
56
lately?” (Therapists should learn not to ask, “What brings you here?” to avoid Assessment of
Psychopathology, Interview
receiving answers such as, “A car,” “A bus,” or “My parents.”). and Testing

The clinician will then usually probe different aspects of the presenting complaint,
such as behavioural abnormalities and feelings of discomfort, the circumstances
regarding the onset of the problem, history of past episodes, and how the problem
affects the client’s daily functioning. The clinician may explore possible
precipitating events, such as changes in life circumstances, social relationships,
employment, or schooling. The interviewer encourages the client to describe the
problem in her or his own words in order to understand it from the client’s
viewpoint.

4.4.2 Format of Clinical Interview

Although the format may vary, most interviews cover these topics:

i) Identifying data: Information regarding the client’s socio-demographic

characteristics like address and telephone number, marital status, age, gender,
racial/ethnic information, religion, employment, family composition, and
so on.
ii) Description of the presenting problem(s): How does the client perceive
the problem? What troubling behaviours, thoughts, or feelings are reported?
How do they affect the client’s functioning? When did they begin?
iii) Psychosocial history: Information describing the client’s developmental
history like educational, social, and occupational history; early family
relationships.
iv) Medical/psychiatric history: History of medical and psychiatric treatment
and hospitalisations: Is the present problem a recurrent episode of a previous
problem? How was the problem handled in the past? Was treatment
successful? Why or why not?
v) Medical problems/medication: Description of present medical problems
and present treatment, including medication. The clinician is alert to ways
in which medical problems may affect the presenting psychological problem.
For example, drugs for certain medical conditions can affect people’s moods
and general levels of arousal.
The interviewer should be attentive to the client’s nonverbal as well as verbal
behaviour, forming judgments about the appropriateness of the client’s attire
and grooming, apparent mood, and ability to focus attention. Clinicians should
also judge the clarity or soundness of clients’ thought and perceptual processes
and level of orientation, or awareness of themselves and their surroundings (who
they are, where they are, and what the present date is). These clinical judgments
form an important part of the initial assessment of the client’s mental state.

4.4.3 Types of Clinical Interviews

There are three general types of clinical interviews. The unstructured, semi-
structured and structured interviews:

In an unstructured interview, the clinician adopts his or her own style of

questioning rather than following a standard format. The major advantage of the
57
Introduction to unstructured interview is its spontaneity and conversational style. Because the
Psychopathology
interviewer is not bound to follow any specific set of questions, there is an active
give-and-take with the client. The major disadvantage is the lack of
standardisation. Also, the conversational flow of the interview may fail to touch
on important clinical information needed to form diagnostic information, such
as suicidal tendencies.

In a semi-structured interview, the clinician follows a general outline of questions

designed to gather essential information but is free to ask the questions in any
particular order and to branch off into other directions to follow up on important
information.

In a structured interview, the interview follows a preset series of questions in a

particular order. For example the mental status exam, in which a set of questions
and observations are used to systematically evaluate the client’s awareness,
orientation with regard to time and place, attention span, memory, judgment and
insight, thought content and processes, mood, and appearance. Structured
interviews (also called standardised interviews) provide the highest level of
reliability and consistency in reaching diagnostic judgments, which is why they
are used frequently in research settings.

4.4.4 Limitations of Clinical Interviews

Although interviews often produce valuable information about people, there are
limits to what they can accomplish. One problem is that they sometimes lack
validity, or accuracy. Individuals may intentionally mislead in order to present
themselves in a positive light or to avoid discussing embarrassing topics. Or
people may be unable to give an accurate report in their interview. Individuals
who suffer from depression, for example, take a pessimistic view of themselves
and may describe themselves as poor workers or inadequate parents when that
isn’t the case at all.

Clinicians too may make mistakes in judgments that slant the information they
gather. They usually rely too heavily on first impressions, for example, and give
too much weight to unfavourable information about a client (Meehl, 1996, 1960).
Interviewer biases, including gender, race, and age biases, may also influence
the interviewers’ interpretations of what a client says (Plante, 1999). Interviews,
particularly unstructured ones, may also lack reliability. People respond differently
to different interviewers, providing less information to a distant interviewer than
to a warm and supportive one. Similarly, a clinician’s race, sex, age, and
appearance may influence a client’s responses (Paurohit, Dowd, & Cottingham,
1982). Because different clinicians can obtain different answers and draw different
conclusions, even when they ask the same questions of the same person, some
researchers believe that interviewing should be discarded as a tool of clinical
assessment.

4.5 PSYCHOLOGICAL TESTS

A psychological test is a structured method of assessment used to evaluate
reasonably stable traits, such as intelligence and personality. Tests are usually
standardised on large numbers of subjects and provide norms that compare clients’
scores with the average. By comparing test results from samples of people who
58
are free of psychological disorders with those of people who have psychological Assessment of
Psychopathology, Interview
disorders, we may gain some insights into the types of response patterns that are and Testing
indicative of abnormal behaviour. Although we tend to think of medical tests as
a “gold standard” of testing, a recent analysis showed that many psychological
tests were on par with many medical tests in their ability to predict variables,
such as underlying conditions or future outcomes (Daw, 2001; Meyer et al., 2001).

Psychological testing is done primarily with four objectives:

1) To screen for certain traits or behaviours like psychoticism, extroversion,

neuroticism, poor coping resources etc. Emotionally unstable individuals
are more prone to develop emotional or behavioural disorders. Psychological
tests are used for screening individuals who are at risk for developing these
disorders.
2) To assess psychopathology and to help in making a diagnosis.
3) To elicit factors which are causative as well as maintaining maladaptive
disorders.
4) To plan rehabilitation programme for patients with psychological or
neurological disorders, handicaps and head injury patients.
Here we will examine major kinds of psychological tests: Intelligence tests,
Personality inventories, projective tests, neuropsychological, and psycho-
physiological tests.

4.5.1 Intelligence Tests

The assessment of abnormal behaviour often includes an evaluation of
intelligence. Formal intelligence tests are used to help diagnose mental retardation.
They evaluate the intellectual impairment that may be caused by other disorders,
such as organic mental disorders caused by damage to the brain. They also provide
a profile of the client’s intellectual strengths and weaknesses to help develop a
treatment plan suited to the client’s competencies. The general score derived
from intelligence tests is termed an intelligence quotient, or IQ, so called because
initially it represented the ratio of a person’s “mental” age to his or her
chronological” age, multiplied by 100.

There are now more than 100 intelligence tests available. The most widely used
are Wechsler Adult Intelligence Scale, Wechsler Intelligence Scale for Children,
and Stanford-Binet Intelligence Scale. Some of the tests are

Wechsler’s intelligence scales are the most widely used intelligence tests. Different
versions are used for different age groups. The Wechsler scales group questions
into subtests or subscales, with each subscale measuring a different intellectual
ability. The Wechsler scales are thus designed to offer insight into a person’s
relative strengths and weaknesses, and not simply yield an overall score.
Wechsler’s scales include both verbal and performance subtests to compute verbal
and performance IQs. Verbal subtests generally require knowledge of verbal
concepts; performance subtests rely more on spatial relations skills.

The Malin’s Intelligence Scale for Indian Children (MISIC) is an Indian adaptation
of the Wechsler’s Intelligence Scale for Children (WISC). The MISIC test is
used for children aged 6–15 years and consists of a questionnaire in Hindi/English.
59
Introduction to Like the original scale these tests also have two groups called verbal and
Psychopathology
performance which have different subtests. Malin’s adaptation omits one subtest
called the picture arrangement of the performance scale as it proved to be too
culturally biased. Based on the answers given by the patient the ‘raw scores’ are
calculated. The norms for different age groups, derived from an Indian population
are available along with the questionnaire. These norms give the weighted scores
for the corresponding raw scores in individuals of different age groups. Verbal,
performance and full scale IQ can be derived from the scale.

Bhatia’s Battery of performance test of intelligence, devised by Dr. C.M.Bhatia

in India, measures performance intelligence. The test consists of five sub-tests
that are loaded that are loaded with the general factor (G) and a specific factor
(S). The sub-tests are Kohs block design test, Alexander’s pass along test, Pattern
drawing test, immediate memory test and picture construction test.

Standard Progressive Matrices (SPM) was developed by Raven and has three
forms. Besides standard progressive matrices the other two are coloured and
advanced progressive matrices. The test has five sets of matrices with 12 patterns
in each set. This test is considered culture fair test as familiarity with any specific
language is not needed. Intelligence is expressed in terms of percentile ranks in
this test (see figure below).

Intelligence tests are among the most carefully produced of all clinical tests.
Because they have been standardised on large groups of subjects, clinicians have
a good idea how each individual’s score compares with the performance of the
population at large. These tests have also shown very high reliability: people
who repeat the same IQ test years later receive approximately the same score.
Finally, the major IQ tests appear to have fairly high validity: for example
children’s IQ scores often correlate with their performance in school.

Intelligence tests also have some key shortcomings. Factors that have nothing to
do with intelligence, such as low motivation and high anxiety, can greatly
influence a performance. In addition, IQ tests may contain cultural biases in
their language or tasks that place people of one background at an advantage over
those of another.

Fig. Object Assembly test in MISIC

Standard Progressive Matrices

60
4.5.2 Personality Inventories Assessment of
Psychopathology, Interview
Personality inventories are also called Objective tests. We consider these tests and Testing
objective because they limit the range of possible responses and so can be scored
objectively. They are also considered objective because they were developed
based on empirical evidence supporting their validity. Personality inventory
asks subjects a wide range of questions about their behaviour, beliefs, and feelings.
In a typical personality inventory, individuals indicate whether or not each of a
long list of statements applies to them. Psychologists then use the responses to
draw conclusions about the person’s personality and psychological functioning.
By far the most widely used personality inventory is the Minnesota Multiphasic
Personality Inventory (MMPI). Some of the tests are:

Minnesota Multiphasic Personality Inventory (MMPI): The MMPI contains

more than 500 true-false statements that assess interests, habits, family
relationships, physical (somatic) complaints, attitudes, beliefs, and behaviours
characteristic of psychological disorders. It is widely used as a test of personality
as well as to assist clinicians in diagnosing abnormal behaviour patterns. The
items in the MMPI make up 10 clinical scales:
1) Hypochondriasis (HS): Items showing abnormal concern with bodily
functions (“I have chest pains several times a week”).
2) Depression (D): Items showing extreme pessimism and hopelessness (“I
often feel hopeless about the future”).
3) Conversion hysteria (CH): Items suggesting that the person may use
physical or mental symptoms as a way of unconsciously avoiding conflicts
and responsibilities (“My heart frequently pounds so hard I can feel it”).
4) Psychopathic deviate (PD): Items showing a repeated and gross disregard
for social customs and an emotional shallowness (“My activities and interests
are often criticized by others”).
5) Masculinity femininity (MF): Items that are thought to distinguish male
and female respondents (“I like to arrange flowers”).
6) Paranoia (Pa) Items that show abnormal suspiciousness and delusions of
grandeur or persecution (“There are evil people trying to influence my
mind”).
7) Psychasthenia (Pt) Items that show obsessions, compulsions, abnormal
fears, and guilt and indecisiveness (“I save nearly everything I buy, even
after I have no use for it”).
8) Schizophrenia (Sc) Items that show bizarre or unusual thoughts or behaviour,
including extreme withdrawal, delusions, or hallucinations (“Things around
me do not seem real”).
9) Hypomania (Ma) Items that show emotional excitement, over activity, and
flight of ideas (“At times I feel very ‘high’ or very ‘low’ for no apparent
reason”).
10) Social Introversion (Si) These items asssess a person’s tendency to withdraw
from social contacts and responsibilities. ((“I am easily embarrassed”).

61
Introduction to Scores for each scale can range from 0 to 120. When people score above 70,
Psychopathology
their functioning on that scale is considered deviant. When the scores are
connected on a graph, a pattern called the profile takes shape, indicating the
person’s general personality and underlying emotional needs. In addition to such
clinical measures, questions have been built into the MMPI to detect whether
respondents are lying, defensive, or careless in their answers.

Eysenck’s Personality Questionnaire (EPQ): This questionnaire measures

only three dimensions of personality namely, introversion-extroversion,
neuroticism, psychoticism and has a lie score which provides validity to the
scores. This questionnaire consists of 86 items and has been commonly used in
research studies in India.

The MMPI and other personality inventories have several advantages over
projective tests. Because they are paper-and-pencil tests, they do not take much
time to administer, and they are objectively scored. Most of them are standardised,
so one person’s scores can be compared to those of many others. They often
show greater test retest reliability than projective tests. For example, people who
take the MMPI a second time after a period of less than two weeks receive
approximately the same scores. Personality inventories also appear to have greater
validity, or accuracy, than projective tests. However, they cannot be considered
highly valid. When clinicians have used these tests alone, they have not been
able to judge a person’s personality accurately.

One problem is that the personality traits that the tests seek to measure cannot be
examined directly. How can we fully know a person’s character, emotions, and
needs from self-report alone? Another problem is the frequent failure of the
tests to allow for cultural differences in people’s responses. Responses indicative
of a psychological disorder in one culture may be normal responses in another
(Butcher, 2000; Dana, 2000). Despite their limited validity, personality inventories
continue to be popular. Research indicates that they can help clinicians learn
about people’s personal styles and disorders as long as they are used in
combination with interviews or other assessment tools.

4.5.3 Rating Scales

To measure psychopathology objective rating scales can be used. Rating scales
enable the observer to indicate not only the presence or absence of a trait or
behaviour but also its prominence. The rating scales are generally of two types:
self rating scales and observer rating scales. Beck’s Depression rating scale and
Hamilton rating scales are commonly used to measure depression. Anxiety can
be measured on State and Trait Anxiety Scale and Hamilton Anxiety scale.
Brief psychiatric rating scale (BPRS) is one of the most widely used rating scale
for recording observations in clinical practice and in research. The BPRS provides
a structured format for rating clinical symptoms such as somatic concern, anxiety,
emotional withdrawal, hostility, guilt feelings, suspiciousness and unusual thought
patterns. It contains 18 scales that are scored from ratings made by clinician
following an interview with the patient.

4.5.4 Projective Tests

The word projective is used because these personality tests derive from the
psychodynamic belief that people impose, or “project,” their own psychological
62
needs, drives, and motives, much of which lie in the unconscious, onto their Assessment of
Psychopathology, Interview
interpretations of ambiguous stimuli. A projective test, unlike an objective test, and Testing
offers no clear, specified response options. Clients are presented with ambiguous
stimuli, such as inkblots, and asked to respond to them.

The psychodynamic model holds that potentially disturbing impulses and wishes,
often of a sexual or aggressive nature, are often hidden from consciousness by
our defence mechanisms. Indirect methods of assessment, however, such as
projective tests, may offer clues to unconscious processes. More behaviourally
oriented critics say that the results of projective tests are based more on clinicians’
subjective interpretations of test responses than on empirical evidence.

Many projective tests have been developed, including tests based on how people
fill in missing words to complete sentence fragments or how they draw human
figures and other objects. The two most prominent projective techniques are the
Rorschach Inkblot Test and the Thematic Apperception Test (TAT).

4.5.5 The Rorschach Test

The Rorschach test was developed by a Swiss psychiatrist, Hermann Rorschach
(1884–1922). He had experimented with the use of ink-blots in his clinical
practice. He noted that people saw different things in the same blot, and he
believed their “percepts” reflected their personalities as well as the stimulus
cues provided by the blot. He had selected 10 ink blots and published them in
1921 for use in assessment. Five of the inkblots are black and white, and the
other five have colour. Each inkblot is printed on a separate card, which is handed
to subjects in sequence. Subjects are asked to tell the examiner what the blot
might be or what it reminds them of. Then, they are asked to explain what features
of the blot (its colour, form, or texture) they used to form their perceptions.

Clinicians who use the Rorschach form their interpretations based on the content
and the form of the responses. For example, they may infer that people who use
the entire blot in their responses show an ability to integrate events in meaningful
ways. Those who focus on minor details of the blots may have obsessive–
compulsive tendencies, whereas clients who respond to the negative (white)
spaces may see things in their own idiosyncratic ways, suggesting underlying
negativism or stubbornness. A response consistent with the form or contours of
the blot is suggestive of adequate reality testing. People who see movement in
the blots may be revealing intelligence and creativity. Content analysis sheds
light on underlying conflicts. For example, adult clients who see animals but no
people may have problems relating to people. Clients who appear confused about
whether or not percept of people are male or female may, according to
psychodynamic theory, be in conflict over their own gender identity.

4.5.6 The Thematic Apperception Test (TAT)

The Thematic Apperception Test (TAT) was developed by psychologist Henry
Murray (1943) at Harvard University in the 1930s. Apperception is a French
word that can be translated as “interpreting (new ideas or impressions) on the
basis of existing ideas (cognitive structures) and past experience.” The TAT
consists of a series of cards, each depicting an ambiguous scene It is assumed
that clients’ responses to the cards will reflect their experiences and outlooks on
life—and, perhaps, shed light on their deep-seated needs and conflicts.
63
Introduction to Subjects are asked to describe what is happening in each scene, what led up to it,
Psychopathology
what the characters are thinking and feeling, and what will happen next.
Psychodynamic theorists believe that people will identify with the protagonists
in their stories and project underlying psychological needs and conflicts into
their responses. More superficially, the stories suggest how clients might interpret
or behave in similar situations in their own lives. TAT results may also suggest
clients’ attitudes toward others, particularly family members.

The Indian adaptation of this test is also available which had been developed by
Uma Choudary.

Fig.: An inkblot used in Rorschach

Fig. A picture used in TAT

4.5.7 Sentence Completion Test

The sentence-completion test, first developed in the 1920s (Payne, 1928), asks
people to complete a series of unfinished sentences, such as “I wish ________”
or “My father ________.” The test is considered a good springboard for discussion
and a quick and easy way to pinpoint topics to explore in treatment.

4.5.8 Drawings
On the assumption that a drawing tells us something about its creator, clinicians
often ask clients to draw human figures and talk about them. Evaluations of
these drawings are based on the details and shape of the drawing, solidity of the
pencil line, location of the drawing on the paper, size of the figures, features of
the figures, use of background, and comments made by the subject during the
drawing task. In the Draw-a-Person (DAP) Test, the most popular of the drawing
tests, subjects are first told to draw “a person,” and then are instructed to draw
another person of the opposite sex.

Until the 1950s, projective tests were the most common technique for assessing
personality. In recent years, however, clinicians and researchers have relied on
them largely to gain “supplementary” insights. One reason for this shift is that
practitioners who follow the newer models have less use for the tests than
psychodynamic clinicians do. Even more important, the tests have rarely
demonstrated much reliability or validity (Wood et al., 2002; Meyer, 2001).
64
 Assessment of
4.6 NEUROPSYCHOLOGICAL ASSESSMENT Psychopathology, Interview
and Testing
Neuropsychological assessment involves the use of tests to help determine
whether psychological problems reflect underlying neurological impairment or
brain damage. When neurological impairment is suspected, a neurological
evaluation may be requested from a neurologist—a medical doctor who
specialises in disorders of the nervous system.

A clinical neuropsychologist may also be consulted to administer

neuropsychological assessment techniques, such as behavioural observation and
psychological testing, to reveal signs of possible brain damage.
Neuropsychological testing may be used together with brain-imaging techniques
such as the MRI and CT to shed light on relationships between brain function
and underlying abnormalities. The results of neuropsychological testing may not
only suggest whether patients suffer from brain damage but also point to the
parts of the brain that may be affected.

The Bender Visual Motor Gestalt Test

One of the first neuropsychological tests to be developed and still one of the
most widely used neuropsychological tests is the Bender Visual Motor Gestalt
Test, now in a second edition, the Bender-Gestalt II. “The Bender” consists of
geometric figures that illustrate various Gestalt principles of perception. The
client is asked to copy geometric designs, and signs of possible brain damage
include rotation of the figures, distortions in shape, and incorrect sizing of the
figures in relation to one another. The examiner then asks the client to reproduce
the designs from memory, because neurological damage can impair memory
functioning. Although the Bender remains a convenient and economical means
of uncovering possible organic impairment, more sophisticated test batteries have
been developed for this purpose, including the widely used Halstead-Reitan
Neuropsychological Battery and Luria-Nebraska Battery.

The Halstead-Reitan Neuropsychological Battery

Psychologist Ralph Reitan developed the battery by adapting tests used by his
mentor, Ward Halstead, an experimental psychologist, to study brain–behaviour
relationships among organically impaired individuals. The battery contains tests
that measure perceptual, intellectual, and motor skills and performance. A battery
of tests permits the psychologist to observe patterns of results, and various patterns
of performance deficits would suggest certain kinds of brain defects, such as
those occurring following head trauma.

PGI Memory Scale

This scale has been standardised by Pershad for Indian population. It is used on
both literate and illiterate, adults and older persons. It has 10 subtests, namely -
remote memory, recent memory, mental balance, attention and concentration,
delayed recall, immediate recall, verbal retention for similar pairs, verbal retention
for dissimilar pairs, verbal retention and recognition (See Figure). This test has
objective scoring and norms according to age and sex.

Memory Questionnaires
For assessment of working memory simple assessment questionnaires can also
be used. The content of these questionnaires is related to historical facts, important 65
Introduction to life events, memory of specific situations on the basis of repeated experience
Psychopathology
with everyday memory tasks. Generally immediate, recent and remote memory
is assessed.

Fig.: Recognition tests in PGI Memory Scale

4.7 CLINICAL OBSEVATIONS

In addition to interviewing and testing people, clinicians may systematically
observe their behaviour. In one technique, called naturalistic observation,
clinicians observe clients in their everyday environments. In another, analogue
observation, they observe them in an artificial setting, such as a clinic or laboratory.
Another technique is self-monitoring wherein clients are instructed to observe
themselves.

4.7.1 Naturalistic and Analogue Observations

Naturalistic clinical observations usually take place in homes, schools, institutions
such as hospitals and prisons, or community settings. Most of them focus on
parent-child, sibling-child, or teacher-student interactions and on fearful,
aggressive, or disruptive behaviour.

Often such observations are made by participant observers, key persons in the
client’s environment, and reported to the clinician. When naturalistic observations
are not practical, clinicians may resort to analogue observations, often aided by
special equipment such as a videotape recorder or one-way mirror. Analogue
observations have often focused on children interacting with their parents, married
couples attempting to settle a disagreement, speech-anxious people giving a
speech, and fearful people approaching an object they find frightening.

Although much can be learned from actually witnessing behaviour, clinical

observations have certain disadvantages. For one thing, they are not always
reliable. It is possible for various clinicians who observe the same person to
66
focus on different aspects of behaviour, assess the person differently, and arrive Assessment of
Psychopathology, Interview
at different conclusions. and Testing

Another possible problem is observer bias—the observer’s judgments may be

influenced by information and expectations he or she already has about the person.

A client’s reactivity may also limit the validity of clinical observations; that is,
his or her behaviour may be affected by the very presence of the observer. If
clients are aware that someone is watching them, for example, they may change
their usual behaviour, perhaps in the hope of creating a good impression.

Finally, clinical observations may lack cross-situational, or external, validity. A

child who behaves aggressively in school is not necessarily aggressive at home
or with friends after school. Because behaviour is often specific to particular
situations, observations in one setting cannot always be applied to other settings
(Haynes, 2001; Simpson & Halpin, 1986).

4.7.2 Self-Monitoring
Training clients to record or monitor the problem behaviour in their daily lives is
another method of relating problem behaviour to the settings in which it occurs.
In self-monitoring, clients take up the responsibility for assessing the problem
behaviour in the settings in which it naturally occurs.
Behaviours that can be easily counted, such as food intake, cigarette smoking,
nail biting, hair pulling, study periods, or social activities, are well suited for
self-monitoring. Self-monitoring can produce highly accurate measurement,
because the behaviour is recorded as it occurs, not reconstructed from memory.
There are various devices for keeping track of the targeted behaviour. A
behavioural diary or log is an easy way to record calories ingested or cigarettes
smoked. Such logs can be organised in columns and rows to track the frequency
of occurrence of the problem behaviour and the situations in which it occurs
(time, setting, feeling state, etc.). In reviewing an eating diary with the clinician,
a client can identify problematic eating patterns, such as eating when feeling
bored or in response to TV food commercials, and devise better ways of handling
these cues.
Behavioural diaries can also help clients increase desirable but low-frequency
behaviours, such as assertive behaviour and dating behaviour. Unassertive clients
might track occasions that seem to warrant an assertive response and jot down
their actual responses to each occasion. Clients and clinicians then review the
log to highlight problematic situations and rehearse assertive responses.
Self-monitoring also has its disadvantages. Some clients are unreliable and do
not keep accurate records. They become forgetful or sloppy, or they underreport
undesirable behaviours, such as overeating or smoking, because of embarrassment
or fear of criticism.

4.8 SOCIO-CULTURAL AND ETHNIC FACTORS IN

ASSESSMENT
Researchers and clinicians must keep socio-cultural and ethnic factors in mind
when assessing personality traits and psychological disorders. When testing people
67
Introduction to from other cultures, careful translations are essential to capture the meanings of
Psychopathology
the original items. However, assessment techniques that are reliable and valid
within one culture may not be so in another, even when they are translated
accurately (Bolton, 2001; Cheung et al., 2003).

For example, the Chinese version of the Beck Depression Inventory (BDI), a
widely used inventory of depression in the United States, has shown good validity
in distinguishing people with depression from people without depression (Chan,
1991 Yeung et al., 2002).

However, other investigators found that Chinese people in both Hong Kong and
the People’s Republic of China showed high levels of disturbed behaviour when
tested with a Chinese version of the MMPI (Cheung, Song, & Butcher, 1991).
When a more careful analysis was done it suggested that their test responses
reflected cultural differences rather than greater psychopathology (Cheung, 1991;
Cheung & Ho, 1997).

In other words, researchers need to disentangle psychopathology from socio-

cultural factors. Translations of assessment instruments should not only translate
words, but also provide instructions that encourage examiners to address the
importance of cultural beliefs, norms, and values, so diagnosticians and
interviewers will consider the client’s background when making assessments of
abnormal behaviour patterns.

Self Assessment Questions

1) What are the basic requirements of assessment measures?

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2) What is a clinical interview?

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3) What are psychological tests?

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68
 Assessment of
4) What is a neuropsychological assessment? Psychopathology, Interview
and Testing
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5) Why is it important to take cultural or ethnic factors into account in

psychological assessment?
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4.9 LET US SUM UP

People’s psychological problems, which are no less complex than people
themselves, are assessed in many ways. Clients are asked to explain their problems
as best they can. Psychologists can draw on batteries of tests that assess
intelligence, personality, and neuropsychological integrity. Many psychologists
prefer to observe people’s behaviour directly. Modern technology has provided
several means of studying the structure and function of the brain. The methods
of assessment clinicians select reflect the problems of their clients, their theoretical
orientations, and their mastery of specialised technologies.

4.10 UNIT END QUESTIONS

1) What are the three major types of clinical interviews?
2) What are the major types of psychological tests?
3) What are some of the methods used in behaviour observation?

4.11 GLOSSARY
Assessment : The process of collecting and interpreting
relevant information about a client or subject.
Reliability : A measure of the consistency of test or
research results.
Validity : The accuracy of a test’s or study’s results;
that is, the extent to which the test or study
actually measures or shows what it
claims.
69
Introduction to Mental Status Examination : A set of interview questions and observations
Psychopathology
designed to reveal the degree and nature of a
client’s abnormal functioning
Battery : A series of tests, each of which produces a
different kind of data

4.12 SUGGESTED READINGS AND REFERENCES

Carson, R. C., Butcher, J. N., & Mineka, S. Abnormal Psychology and Modern
Life, 11TH edition. Pearson Education:New Delhi

Davison, G.C., Neale, J.M., Kring, A.M. Abnormal Psychology, 9th edition. Wiley
& Sons:USA.

Sarason, I.G., Sarason, B.R. 1998. Abnormal Psychology: The Problem of

Maladaptive Behaviour. Prentice-Hall of India: New Delhi.

References
Barlow, D.H., & Durand, V.M. 2007. Abnormal Psychology: An Integrative
Approach. Thomson Learning Inc., New Delhi.
Bennett, Paul. 2005. Abnormal and Clinical Psychology: An Introductory
Textbook, 2nd Ed. Open University Press, McGraw-Hill Education: England.
Carson, R. C., Butcher, J. N., & Mineka, S. 2003. Abnormal psychology and
modern life. Pearson Education: New Delhi.
Constantino, M. J., & Spofford, C.M. 2008 Encyclopedia of Counseling. Sage
Publications. (http://www.sage-ereference.com/counseling/Article_n182.html).
Halgin, R.P., & Whitbourne, S.K. 1997. Abnormal Psychology: The Human
Experience of Psychological Disorders. Brown & Benchmark Publishers:
London.
Hecker, J.E., & Thorpe, G.L. 2005. Introduction to Clinical Psychology: Science,
Practice, and Ethics. Pearson Education: New Delhi.
Kenneth, S., & Trull, T. 2007. The International Handbook of Psychology.
SAGE Publications. <http://www.sage-ereference.com/hdbk_intlpsych/
Article_n21.html>.
Korchin, S.J. 2004. Modern Clinical Psychology: principles of intervention in
the clinic and community. CBS Publishers: New Delhi.
Mangal, S.K. 2006. Abnormal Psychology. Sterling publishers: New Delhi.
Pichot, P. 2003. Encyclopedia of Psychological Assessment. Sage Publications.
(http://www.sage-ereference.com/psychassessment/Article_n71.html).
Sarason, I.G., & Sarason, B.R.2005. Abnormal Psychology: The problem of
maladaptive behaviour. Prentice-Hall of India: New Delhi.
Sharma, R., 2006. Abnormal Psychology. Atlantic Publishers & Distributors:
New Delhi.

70
 Child and Adolescent
UNIT 1 CHILD AND ADOLESCENT Disorder

DISORDER

Structure
1.0 Introduction
1.1 Objectives
1.2 Classification of Childhood Disorders
1.3 Attention-Deficit/Hyperactivity Disorder (ADHD)
1.3.1 Etiology of ADHD
1.3.2 Biological Causes
1.3.3 Psychological Causes
1.3.4 Treatment of ADHD
1.4 Conduct Disorder and Oppositional Defiant Disorder
1.4.1 Conduct Disorder
1.4.2 Oppositional Defiant Disorder (ODD)
1.4.3 Etiology of Conduct Disorder
1.4.4 Treatment and Outcomes
1.5 Anxiety Disorders of Childhood and Adolescence
1.5.1 School Phobia
1.5.2 Separation Anxiety
1.5.3 Fear of School
1.5.4 Social Phobia
1.6 Acute and Posttraumatic Stress Disorder (PTSD)
1.7 Treatment of Anxiety Disorders
1.7.1 Medications
1.7.2 Psychological Treatment
1.8 Childhood Depression
1.8.1 Etiology of Childhood Depression
1.8.2 Treatment of Depression
1.9 Let Us Sum Up
1.10 Unit End Questions
1.11 Glossary
1.12 Suggested Readings
1.13 Answers to Self Assessment Questions

1.0 INTRODUCTION
Although it is sometimes assumed that childhood and adolescence are times of
carefree bliss, as many as 20% of children and adolescents have one or more
diagnosable mental disorders. Most of these disorders may be viewed as
exaggerations or distortions of normal behaviours and emotions.
Like adults, children and adolescents vary in temperament. Some are shy and
reticent; others are socially exuberant. Some are methodical and cautious, and
others are impulsive and careless. Whether a child is behaving like a typical
5
Childhood Psychopathology child or has a disorder is determined by the presence of impairment and the
degree of distress related to the symptoms. For example, a 12-yr-old girl may be
frightened by the prospect of delivering a class report in front of her class. This
fear would be viewed as social phobia only if her fears were severe enough to
cause significant impairments and distress.
The mental disorders that children can develop are commonly divided into two
groups: disruptive or externalising behaviour disorders (e.g., attention-deficit
hyperactivity disorder, conduct problems) and emotional or internalising
behaviour disorders (e.g., anxiety, depression). In this unit we would focus on
types of internalising and externalising disorders in children. We will also discuss
in depth the etiology and treatment involved in these disorders.

1.1 OBJECTIVES
After reading this unit, you will be able to:
• Define emotional and behavioural disorders;
• Describe the different types of the emotional and behavioural disorders that
are most likely to arise in childhood and adolescence;
• Explain the etiology (causes) of these disorders; and
• Describe the different types of treatment for these disorders.

1.2 CLASSIFICATION OF CHILDHOOD

DISORDERS
An important perspective within which to understand children’s mental disorders
is developmental. By its nature, children’s behaviour fluctuates over time. One
of the biggest challenges for parents and psychologists is to distinguish between
normal developmental changes and the emergence of a disorder (atypical changes).
Development is also an important consideration in determining whether early
signs of a disorder will emerge as a full-blown disorder, develop into a different
disorder, or resolve into healthy functioning.
To classify abnormal behaviour in children, psychologists must first consider
what is normal for a particular age. The diagnosis for a child who lies on the
floor kicking and screaming when he or she does not get his or her way must
take into account whether the child is two years old or seven. The field of
developmental psychopathology studies disorders of childhood within the context
of normal life-span development, helping us to identify behaviours that are
appropriate at one stage but are considered disturbed at another.
Childhood disorders are often categorised into two broad groups, called
externalising and internalising disorders. Externalising disorders are characterised
by more outward- directed behaviours, such as aggressiveness, noncompliance,
over activity, and impulsiveness, and include disorders such as ADHD, conduct
disorder (CD), and oppositional defiant disorder (ODD). Internalising disorders
are characterised by more inward-focused experiences and behaviours such as
depression, social withdrawal, and anxiety, and include childhood anxiety and
mood disorders. Children and adolescents may exhibit symptoms from both
domains. Externalising behaviours are consistently found more often among boys
and internalising behaviours more often among girls, at least in adolescence,
6 across cultures.
 Child and Adolescent
1.3 ATTENTION DEFICIT/HYPERACTIVITY Disorder

DISORDER
Attention Deficit Hyperactivity Disorder (ADHD) belongs to the group of
externalising disorders of childhood. The term hyperactive is familiar to most
people, especially parents and teachers. The child who is constantly in motion,
tapping fingers, jiggling legs, poking others for no apparent reason, talking out
of turn, and fidgeting is often called hyperactive. These children also have
difficulty concentrating on the task at hand for an appropriate period of time.
To distinguish the normal range of hyperactive behaviours from a diagnosable
ADHD, the behaviours should be extreme for a particular developmental period,
persistent across different situations, and linked to significant impairments in
functioning. The ADHD diagnosis should not be applied to youngsters who are
rambunctious, active, or slightly distractible, children are often so in the early
school years. To use the label simply because a child is livelier and more difficult
to control than a parent or teacher would indicate a misuse of the term. The
diagnosis of ADHD is reserved for truly extreme and persistent cases.
Children with ADHD seem to have particular difficulty controlling their activity
in situations that call for sitting still, such as in the classroom or at mealtimes.
When required to be quiet, they appear unable to stop moving or talking. They
are disorganised, erratic, tactless, obstinate, and bossy. Their activities and
movements seem haphazard. They quickly wear out their shoes and clothing,
smash their toys, and exhaust their families and teachers. Many children with
ADHD have difficulty getting along with peers and establishing friendship,
perhaps because their behaviour is often aggressive and generally annoying and
intrusive to others. Although these children are usually friendly and talkative,
they often miss subtle social cues, such as noticing when playmates are tiring of
their constant jiggling. They also frequently misinterpret the wishes and intentions
of their peers and make inadvertent social mistakes, such as reacting aggressively
because they assume that a neutral action by a peer was meant to be aggressive.
DSM-IV-TR includes three subcategories of ADHD:
i) Predominantly inattentive type: Children whose problems are primarily those
of poor attention.
ii) Predominantly Hyperactive-Impulsive type: Children whose difficulties
result primarily from hyperactive-impulsive behaviour.
iii) Combined type: Children who have both sets of problems.

7
Childhood Psychopathology The combined type comprises the majority of ADHD children. The prevalence
of ADHD has been difficult to establish because of varied definitions of the
disorder over time and differences in the populations sampled. The consensus is
that about 3 to 7 percent of school-age children worldwide currently have ADHD
(DSM-IV-TR, 2000). Evidence indicates that ADHD is more common in boys
than in girls, but exact figures depend on whether the sample is taken from clinic
referrals or from the general population. Boys are more likely to be referred to
clinics because of a higher likelihood of aggressive and antisocial behaviour.

At one time it was thought that ADHD simply went away by adolescence.
However this belief has been contradicted by numerous longitudinal studies (e.g.,
Barkley et al., 1990; Biederman et al., 1996; Claude & Firestone, 1995; Weiss &
Hechtman, 1993). Although they do show reduced severity of symptoms in
adolescence, 65 to 80 percent of children with ADHD still meet criteria for the
disorder in adolescence and in adulthood. In addition to the fidgety, distractible,
impulsive behaviours, adolescents with ADHD are far more likely to drop out of
high school and develop antisocial behaviour than their peers. In adulthood,
although most are employed and financially independent, these individuals
generally reach only a lower socioe-conomic level and change jobs more
frequently than would normally be expected.

Case Example
Rohit is not doing well in school. His teacher is convinced that he is just not
trying. He doesn’t listen and he rarely completes work in class time. When
work is done, Rohit often misses important details. What is turned in is
often incomplete. Furthermore, he is constantly losing pencils and paper,
and his book is a mess. Rohit has many symptoms of ADHD, inattentive
type.

1.3.1 Etiology of ADHD

The cause of ADHD in children has been much debated. It still remains unclear
to what extent the disorder results from environmental or biological factors and
recent research point to both genetic and social environmental factors. Many
researchers believe that biological factors such as genetic inheritance will turn
out to be important precursors to the development of ADHD. But firm conclusions
about any biological or psychological basis for ADHD must await further research.

1.3.2 Biological Causes

i) Genetic Factors
Research suggests that a genetic predisposition toward ADHD may play an
important role. When parents have ADHD, half of their children are likely to
have the disorder. Adoption studies and numerous large-scale twin studies indicate
a genetic component to ADHD, with monozygotic concordance rates as high
as.70 to .80.

Exactly what is inherited is as yet unknown, but recent studies suggest that brain
function and structure differ in children with and without ADHD. Studies have
documented that the frontal lobes of children with ADHD are under responsive
to stimulation and cerebral blood flow is reduced (Sieg et al;, 1995). Moreover,
parts of the brains (frontal lobes, caudate nucleus, globus pallidus) of ADHD
8
children are smaller than those of normal children. Evidence shows poorer Child and Adolescent
Disorder
performance of children with ADHD on neuropsychological tests of frontal-
lobe functioning (such as inhibiting behavioural responses), which provides
further support for the theory that a basic deficit in this part of the brain may be
related to the disorder.

ii) Perinatal and Prenatal Factors

Other biological risk factors for ADHD include a number of perinatal and prenatal
complications. Low birth weight, for example is considered to be a specific
predictor of the development of ADHD. Other complications associated with
childbirth such as delayed birth cry are also predictive of ADHD symptoms.

iii) Environmental Toxins

Although evidence suggests that lead poisoning may be associated to a small
degree with symptoms of hyperactivity and attention problems, most children
with lead poisoning do not develop ADHD, and most children with ADHD do
not show elevated levels of lead in the blood.

Nicotine (especially maternal smoking) is an environmental toxin that plays an

important part in the development of ADHD. Milberger et al. (1996) reported
that 22 percent of mothers of children with ADHD reported smoking a pack of
cigarettes per day during pregnancy, compared with 8 percent of mothers whose
children did not develop ADHD. Animal studies indicate that chronic exposure
to nicotine increases dopamine release in the brain and causes hyperactivity. On
the basis of these data, Milberger and his associates hypothesise that maternal
smoking can affect the dopaminergic system of the developing foetus, resulting
in behavioural disinhibition and ADHD.

Can excessive early TV viewing be linked to ADHD?

Researchers have found that television exposure at ages 1 to 3 years is
associated with attention problems at age 7. In fact, they found that each
hour of daily viewing increased the risk of ADHD by almost 10% at age 7.
As a result, the authors suggest limiting exposure to television viewing in
the formative years of brain development (Christakis, Zimmerman,
DiGiuseppe, & Mc-Carty, 2004).

1.3.3 Psychological Causes

Bruno Bettelhmeim (1973), a child psychoanalyst, had proposed a diathesis-
stress theory of ADHD, suggesting that hyperactivity develops when a
predisposition to the disorder is coupled with authoritarian upbringing by parents.
If a child with a disposition toward over activity and moodiness is stressed by a
parent who is impatient and resentful, the child may be unable to cope up with
the parent’s demands for obedience. As the parent becomes more and more
negative and disapproving, the parent-child relationship ends up in a battleground.
When such a disruptive and disobedient pattern gets established, the child will
not be able to handle the demands of school, and his or her behaviour will often
be in conflict with the rules of the classroom.

Learning may also be responsible in causing ADHD as well. Hyperactivity could

be reinforced by the attention it elicits, thereby increasing in frequency or intensity.
Hyperactivity may also be modelled on the behaviour of parents and siblings.
9
Childhood Psychopathology However, such theories have not been supported by research. Neurological and
genetic factors have far greater support than psychological factors in the etiology
of ADHD.

1.3.4 Treatment of ADHD

ADHD is typically treated with medication and behavioural methods based on
operant conditioning.

Medications
Stimulant medications (like methylphenidate, or Ritalin) have been prescribed
for ADHD since the early 1960s. The prescription of these medications is
sometimes continued into adolescence and adulthood as accumulating evidence
suggests that the symptoms of ADHD do not usually disappear with the passage
of time.

The drugs used to treat ADHD reduce disruptive behaviour and improve ability
to concentrate. Numerous controlled studies comparing stimulants with placebos
in double blind designs have shown short term improvements in concentration,
goal-directed activity, classroom behaviour, and social interactions with parents,
teachers, and peers and reductions in aggressiveness and impulsivity in about 75
percent of ADHD children (Spencer et al., 1996; Swanson et al., 1995).

Despite the promising findings on the efficacy of stimulant medications for

ADHD, other research indicates that these drugs may not improve academic
achievement over the long haul. Further, stimulant medications have side effects.
In addition to transient loss of appetite and sleep problems a risky side effect of
the widespread prescription of stimulants has emerged. Newsweek magazine
reported in the mid-1990s that children had begun to use Ritalin and other
stimulants obtained from their siblings or friends as recreational drugs. Its use
has also spread among high school and college students not suffering from ADHD
as they find that snorting it like cocaine helps them focus better on their
schoolwork and ward off fatigue. While these misuses of Ritalin are indeed
troubling, it is nonetheless effective in the treatment of ADHD and should be
considered a critical component of treatment programs.

Psychological Treatment
Other than medications, the most promising treatments of ADHD children involve
parent training and changes in classroom management based on operant-
conditioning principles. These programs have demonstrated at least short-term
success in improving both social and academic behaviour. In this treatment,
children’s behaviour is monitored at home and in school, and they are reinforced
for behaving appropriately, for example, for remaining in their seats and working
on assignments. Point systems and star charts are typical components of these
programs. Youngsters earn points and younger children earn stars for behaving
in certain ways; the children can then spend their earnings for rewards. The
focus of these operant programs is on improving academic work, completing
household tasks, or learning specific social skills, rather than on reducing signs
of hyperactivity, such as running around and jiggling.

School interventions for children with ADHD include training teachers to

understand the unique needs of these children and to apply operant techniques in
10
the classroom, peer tutoring in academic skills, and having teachers provide Child and Adolescent
Disorder
daily reports to parents about in-school behaviour, which is followed up with
rewards and consequences at home. Research has demonstrated that certain
classroom structures can have a favourable impact on children with ADHD. For
example, in the ideal classroom environment teachers modify the presentation
format and materials used for tasks, keep assignments brief and provide immediate
feedback regarding accuracy, have an enthusiastic and task-focused style, provide
breaks for physical exercise, use computer-assisted drill programs, and schedule
academic work during the morning hours. Such environmental changes are
designed to accommodate the limitations imposed by this disorder rather than to
change the disorder itself.

1.4 CONDUCT DISORDER AND OPPOSITIONAL

DEFIANT DISORDER
This group of externalising disorders involves a child’s or an adolescent’s
relationship to social norms and rules of conduct. In both oppositional defiant
disorder and conduct disorder, aggressive or antisocial behaviour is the focus.
These disorders are closely linked. However, it is important to distinguish between
persistent antisocial acts such as setting fires, where the rights of others are violated
and the less serious pranks often carried out by normal children and adolescents.
Also, oppositional defiant disorder and conduct disorder involve misdeeds that
may or may not be against the law; juvenile delinquency is the legal term used to
refer to violations of the law committed by minors.

1.4.1 Conduct Disorder(CD)

The DSM-IV-TR definition of conduct disorder focuses on behaviours that violate
the basic rights of others and major societal norms. Nearly all such behaviour is
also illegal. The types of behaviour considered typical of conduct disorder include
aggression and cruelty toward people or animals, damaging property, lying, and
stealing. Conduct disorder denotes a frequency and severity of acts that go beyond
the mischief and pranks common among children and adolescents. Often the
behaviour is marked by callousness, viciousness, and lack of remorse, making
conduct disorder precursor for adult antisocial personality disorder.

1.4.2 Oppositional Defiant Disorder (ODD)

A related but less well understood externalising category in the DSM is
oppositional defiant disorder (ODD). Oppositional defiant disorder is diagnosed
if a child does not meet the criteria for conduct disorder, especially, if extreme
physical aggressiveness is not met, but exhibits behaviours such as losing his or
her temper, arguing with adults, repeatedly refusing to comply with requests
from adults, deliberately doing things to annoy others, and being angry, spiteful,
touchy, or vindictive. The DSM also mentions that such children, most of them
boys, seldom see their conflicts with others as their fault; they justify their
oppositional behaviour by claiming that unreasonable demands are being placed
on them. In everyday talk these children are simply referred to as spoiled brats.

Population-based studies indicate that conduct disorder is fairly common. A

review of epidemiological studies reveals prevalence rates ranging from 4 to 16
percent for boys and 1.2 to 9 percent for girls.
11
Childhood Psychopathology Many children with conduct disorder display other problems as well. There is a
high degree of co morbidity between conduct disorder and ADHD. This is true
for boys, much less is known about comorbid conduct disorder and ADHD among
girls. Substance abuse also commonly co occurs with conduct problems. Anxiety
and depression, generally viewed as internalising problems, and these are common
among children with conduct disorder.

Important Distinction
While ODD is associated with overt and non destructive behaviours, CD is
linked with overt and covert behaviours which can be destructive and violate
the rights of others.

1.4.3 Etiology of Conduct Disorder

Different causes have been put forward for the etiology of conduct disorder,
including biological, Psychological (learning and cognitive) and sociological
factors.

Biological Factors
The evidence for genetic influences in conduct disorder is mixed, although
heritability may well play a part. For example, a study of over 3,000 twin pairs
indicated only modest genetic influence on childhood antisocial behaviour; family
environment influences were found to be more significant (Lyons et al., 1995).
However, a study of 2,600 twin pairs in Australia found a substantial genetic
influence and almost no family environment influences for childhood symptoms
of conduct disorder (Slutske et al., 1997). The authors of the latter study point
out that the differences in the samples may have accounted for the different
findings.
Evidence from twin studies indicates that aggressive behaviour (e.g., cruelty to
animals, fighting, destroying property) is clearly heritable, whereas other
delinquent behaviours (e.g., stealing, running away, truancy) may not be. Other
evidence suggests that the period when antisocial and aggressive behaviour
problems begin is related to heritability. For example, aggressive and antisocial
behaviour that begins in childhood is more heritable than similar behaviours
that begin in adolescence. What might be heritable in conduct disorder are
temperamental characteristics that interact with other biological difficulties (e.g.,
neuropsychological deficits) as well as with a whole set of environmental factors
(e.g., parenting, school performance, peer influences) to cause conduct disorder.
Neurological investigations have found less frontal lobe activity in the brains of
youth with conduct disorder (Moffit & Henry, 1989). Neuropsychological deficits
have been implicated in the childhood profiles of children with conduct disorder.
These deficits include poor verbal skills, difficulty with executive functioning
(the ability to anticipate, plan, use self-control, and problem solve), and problems
with memory. In addition, children who develop conduct disorder at an earlier
age have been shown to have an IQ score of one standard deviation below age-
matched peers without conduct disorder, and this IQ deficit is apparently not due
to lower socioeconomic status, race or school failure.

Psychological Factors
An important part of normal child development is the growth of moral awareness,
12 the acquisition of a sense of what is right and wrong and the ability, even desire,
to abide by rules and norms. Most people refrain from hurting others not only Child and Adolescent
Disorder
because it is illegal but because it would make them feel guilty to do otherwise.
Children with conduct disorder often seem to be deficient in this moral awareness,
lacking remorse for their wrongdoing and viewing antisocial acts as exciting
and rewarding, as central to their very self-concept.

According to learning theorists children can learn aggressiveness from parents

who behave aggressively. Indeed, children who are physically abused by parents
are likely to be aggressive when they grow up. Children may also imitate
aggressive acts seen from other sources, such as on television. Since aggression
is an effective, albeit unpleasant, means of achieving goals, it is likely to be
reinforced. Thus, once imitated, aggressive acts will probably be maintained.

In addition, parenting characteristics such as harsh and inconsistent discipline

and lack of monitoring are consistently associated with antisocial behaviour in
children. Perhaps children who do not experience negative consequences for
early signs of misbehaviour later develop more serious conduct problems. A
social cognitive perspective on aggressive behaviour comes from the work of
Kenneth Dodge and his associates. In one of his early studies, Dodge found that
the cognitive processes of aggressive children had a particular attribution bias;
these youngsters interpreted ambiguous acts, such as being bumped in line, as
evidence of hostile intent. Such perceptions lead these children to retaliate
aggressively for actions that may not have been intended as provocative.
Subsequently, their peers, remembering these aggressive behaviours, tend to be
aggressive more often against them, further angering the already aggressive
children and continuing a cycle of rejection and aggression. Dodge has constructed
a social-information processing theory of child behaviour that focuses on how
children process information about their world and how these cognitions markedly
affect their behaviour (Crick & Dodge, 1996).

Peer Influences
Investigations of how peers influence aggressive and antisocial behaviour in
children have focused on two broad areas: Acceptance or rejection by peers and
affiliation with deviant peers.

Being rejected by peers has been shown to be causally related to aggressive

behaviour, particular in combination with ADHD. Studies have shown that being
rejected by peers can predict later aggressive behaviour, even after controlling
for prior levels of aggressive behaviour. Associating with other delinquent peers
also increases the likelihood of delinquent behaviour (Patterson & Capaldi, 1991).
But it is not confirmed whether delinquent children choose to associate with
like-minded peers, thus continuing on their path of antisocial behaviour, or if
simply being around delinquent peers can influence the beginnings of antisocial
behaviour.

Sociological Factors
Social class and urban living are related to the incidence of delinquency. High
unemployment, poor educational facilities, disrupted family life, and a subculture
that finds delinquency acceptable have all been found to be contributing factors.
The combination of early antisocial behaviour in the child and socio-economic
disadvantage in the family predicts early criminal arrests.
13
Childhood Psychopathology 1.4.4 Treatments and Outcomes
The management of conduct disorder is one of the most important challenges to
society. We will discuss some of the psychological methods aimed at the
individuals and their families.

As mentioned earlier, conduct disorder is the precursor to psychopathy. And like

psychopaths, young people who commit violent and antisocial acts with little
remorse or emotional involvement are highly difficult to reach. Incarceration,
release, and recidivism is usually the pattern. One of society’s most pressing
problems is how to deal with people whose social conscience appears to be
grossly underdeveloped. Simply jailing juvenile delinquents will not reduce crime.
A longitudinal study demonstrated that punitive discipline, such as juvenile
incarceration, leads to lower job stability and more adult crime. Thus, harsh
discipline, whether imposed by the state or by the parents, appears to contribute
in a major way to further delinquency and criminal activity in adulthood.

Family Interventions
Some of the most promising approaches to treating conduct disorder involve
intervening with the parents or families of the child with conduct disorder. Gerald
Patterson and his colleagues have developed a behavioural program of parental
management training (PMT), in which parents are taught to modify their responses
to their children so that pro social rather than antisocial behaviour is consistently
rewarded. Parents are taught to use techniques such as positive reinforcement
when the child exhibits positive behaviours and time-out and loss of privileges
for aggressive or antisocial behaviours.

Multisystemic Treatment
A promising treatment for serious juvenile offenders is Henggeler’s multisystemic
treatment (MST). MST involves delivering intensive and comprehensive therapy
services in the community, targeting the adolescent, the family, the school, and
in some cases the peer group. The intervention views the conduct problem as
influenced by multiple contexts within the family and between the family and
other social systems.

The strategies used by MST therapists are varied, incorporating behavioural,

cognitive, family-systems, and case-management techniques. The therapy’s
uniqueness and effectiveness lies in emphasising individual and family strengths,
identifying the context for the conduct problems, using present-focused and
action-oriented interventions, and using interventions that require daily or weekly
efforts by family members. Treatment is provided in “ecologically valid” settings,
such as the home, school, or local recreational centre, to maximise generalisation
of therapeutic changes.

Cognitive Approaches
Although the above mentioned interventions with parents and families are a
critical component of success, such treatments are expensive and time-consuming.
Some families may not even be able or willing to become involved in it. Thus it
is important to know about other research which indicates that individual cognitive
therapy can improve children and their behaviour even without the involvement
of the family. For example, teaching children cognitive skills to control their
14
anger shows real potential in helping them reduce their aggressive behaviour. In
anger-control training, aggressive children are taught self-control in anger Child and Adolescent
Disorder
provoking situations. They learn to withstand verbal attacks without responding
aggressively by using distracting techniques such as humming a tune, saying
calming things to themselves, or turning away. The children then apply these
self-control methods while a peer provokes and insults them.

Another strategy involves focusing on the deficient moral development of children

with conduct disorder. Teaching moral-reasoning skills to groups of adolescents
with behaviour problems in school has achieved some degree of success. This
success is heartening, but other research cautions that behavioural changes
produced by altering cognitive patterns may yield only short-term gains—
improvements that maybe lost when the youngsters return to their familiar, “bad”
neighbourhoods. Environmental contingencies—the communities in which
people live –need to be considered when dealing with the complexities of
aggression.
Self Assessment Questions
Multiple Choices
1) What percentage of the school-aged population can be expected to have
ADHD?
a) 20%–25%
b) 12%–15%
c) 1%–2%
d) 3%–7%
2) Which of the following is a likely consequence of having the hyperactive/
impulsive type of ADHD as a teenager?
a) increased risk of car accidents as teenagers
b) increased risk of drop out before graduation
c) increased risk of having conduct problems
d) all of the above
3) Parents report that children who are diagnosed with ADHD demonstrated
all of the following in early childhood except:
a) excessive sleep
b) difficult temperament
c) irritability
d) establishing secure attachments with caregivers
4) Sam hits Joey because he thinks that Joey is going to hit him. Joey is
shocked because he just turned around to look at the clock on the wall
behind Sam. Sam’s behaviour is likely the result of:
a) relational aggression
b) hostile attribution bias
c) instrumental aggression
d) bullying
15
Childhood Psychopathology
5) Neurological investigations have found .......................................... in
aggressive youth.
a) increased frontal lobe activity
b) high levels of DBH
c) decreased frontal lobe activity
d) low levels of hormone testosterone

1.5 ANXIETY DISORDERS OF CHILDHOOD AND

ADOLESCENCE
Anxiety disorders are characterised by fear, worry, or dread that greatly impairs
the ability to function normally and that is disproportionate to the circumstances
at hand. Anxiety may also result in physical symptoms.

Some anxiety is a normal aspect of development, as in the following cases:

• Most toddlers become fearful when separated from their mother, especially
in unfamiliar surroundings.
• Fears of the dark, monsters, bugs, and spiders are common in 3 to 4 year
olds.
• Shy children may initially react to new situations with fear or withdrawal.
• Fears of injury and death are more common among older children.
• Older children and adolescents often become anxious when giving a book
report or talking in front of their classmates.
Such difficulties should not be viewed as evidence of a disorder. However, if
manifestations of anxiety become so exaggerated that they greatly impair
functioning or cause severe distress, an anxiety disorder should be considered.
At some point during childhood, about 10 to 15% of children experience an
anxiety disorder (e.g., social phobia, separation anxiety disorder, specific phobia,
panic disorder, acute and posttraumatic stress disorders), making these one of
the most common disorders of childhood. Although most unrealistic childhood
fears dissipate over time, it is also true that most of the adults suffering from
anxiety can trace their problems back to their childhood.

The seriousness of childhood anxiety problems should therefore not be

underestimated. Not only do they suffer, as adults do, from being anxious they
also lose out on mastering developmental tasks at various stages of their lives.
For example, a child who is painfully shy and who finds interacting with peers
intolerable is also unlikely to learn how to interact with other people. This deficit
will persist as the child grows into adolescence and later as an adult would lead
to social retardation. The most common types of anxiety disorders which children
usually suffer are mentioned below.

1.5.1 School Phobia

Social phobia, sometimes called school refusal, has serious academic and social
consequences for the child and can be extremely disabling. Two types of school
phobia have been identified. They are:
16
• Separation anxiety Child and Adolescent
Disorder
• Phobia or fear of school

1.5.2 Separation Anxiety

This is one of the most common types of anxiety disorder. In this disorder, children
worry constantly that some harm will befall their parents or themselves when
they are away from their parents and when at home they shadow one or both of
their parents. Although school refusal is the most common symptom of children
with separation anxiety disorder (75%), only one third of all children who refuse
to attend school do so because they have separation anxiety disorder.

Since the starting of school is usually the first circumstance that requires lengthy
and frequent separation of children from their parents, separation anxiety is often
a main cause of school phobia. One study found that 75 percent of children who
have school refusal caused by separation anxiety have mothers who also avoided
school during childhood. It has been hypothesised that the child’s reluctance to
go to school stems from some problem in the mother-child relationship. Perhaps
the mother communicates her own separation anxieties and unwittingly reinforces
the child’s dependent and avoidant behaviour.

1.5.3 Fear of School

The second major type of school refusal is that associated with a true phobia of
school i.e. either a fear specifically related to school or a more general social
phobia. Children with this type of phobia generally begin refusing to go to school
later in life and have more severe and pervasive avoidance of school. Their fear
is more likely to be related to specific aspects of school environment, such as
worries about academic failure or discomfort with peers.

Psychologists agree that if it is not treated, school phobia in childhood can have
long-term negative consequences as the person grows into adolescence and
adulthood. The child with a school phobia can grow up to be a seriously dependent
and fearful person.

1.5.4 Social Phobia

Most classrooms have at least one or two children who are extremely quiet and
shy. Often these children will play only with family members or familiar peers,
avoiding strangers both young and old. Their shyness may prevent them from
acquiring social skills and participating in a variety of activities enjoyed by most
of their age mates, for they avoid playgrounds and games played by neighbourhood
children. Although some children who are shy may simply be slow to warm up,
withdrawn children never do, even after prolonged exposure to new people.

Extremely shy children may refuse to speak at all in unfamiliar social

circumstances; this condition is called selective mutism. In crowded rooms they
cling and whisper to their parents, hide behind the furniture, cower in corners,
and may even have tantrums. At home they ask their parents endless questions
about situations that worry them. Withdrawn children usually have warm and
satisfying relationships with family members and family friends, and they show
a desire for affection and acceptance.

17
Childhood Psychopathology Theories of etiology of social phobia in children are generally similar to theories
of social phobia in adults. Research has shown that children with anxiety disorders
overestimate the danger in many situations and underestimate their ability to
cope with them. The anxiety created by these cognitions then interferes with
social interaction, causing the child to avoid social situations and thus does not
get much practice at social skills. Another reason could be that withdrawn children
may simply not have the social know how that facilitates interaction with same
age children. The finding that isolated children make fewer attempts to make
friends and are less imaginative in their play may indicate a deficiency in social
skills. Finally, isolated children may have become so because they have in the
past spent most of their time with adults; these children interact more freely with
adults than with other children.

1.6 ACUTE AND POSTTRAUMATIC STRESS

DISORDERS (PTSD)
Acute stress disorder (ASD) is a brief period (about 1 month) of intrusive
recollections (e.g., flashbacks and nightmares), dissociation, avoidance, and
anxiety occurring within 1 month of a traumatic incident.

Posttraumatic stress disorder (PTSD) causes recurring, intrusive recollections

of an overwhelming traumatic incident that persist more than one month, as
well as emotional numbing and hyper arousal.

Because vulnerability and temperament are different, not all children who are
exposed to a severe traumatic event develop a stress disorder. Traumatic events
commonly associated with these disorders include assaults, sexual assaults, abuse,
car accidents, dog attacks, and injuries (especially burns). In young children,
domestic violence is the most common cause of post traumatic stress disorder.

Acute stress disorder (ASD) and post traumatic stress disorder (PTSD) are closely
related and are distinguished primarily by duration of symptoms. ASD is
diagnosed within 1 month of the traumatic event, and PTSD is diagnosed only
after 1 month has passed and symptoms have persisted. In a few cases, onset of
PTSD symptoms may be delayed months or even years after the traumatic event.

Emotional numbing and hyper arousal are common. Emotional numbing includes
the following symptoms such as general lack of interest, social withdrawal, a
subjective sense of feeling numb, a foreshortened expectation of the future (e.g.,
thinking “I will not live to see 20)”. Hyper arousal symptoms include jitteriness,
exaggerated startle response, difficulty relaxing, and disrupted sleep sometimes
with frequent nightmares. Typically, children with acute stress disorder are in a
daze and may seem dissociated from everyday surroundings.

Children with posttraumatic stress disorder have intrusive recollections that cause
them to re-experience the traumatic event. The most dramatic kind of recollection
is a flashback. Flashbacks may be spontaneous but are most commonly triggered
by something associated with the original trauma. For example, the sight of a
dog may trigger a flashback in children who experienced a dog attack. During a
flashback, children may be in a terrified state and unaware of their current
surroundings while desperately searching for a way to hide or escape; they may
temporarily lose touch with reality and believe they are in grave danger. Some
18
children have nightmares. When children re-experience the event in other ways Child and Adolescent
Disorder
(e.g., in thoughts, mental images, or recollections), they remain aware of current
surroundings, although they may still be greatly distressed.

Diagnosis is based on a history of severely frightening and horrifying trauma

followed by re-experiencing, emotional numbing, and hyper-arousal. These
symptoms must be severe enough to cause impairment or distress.

Prognosis for children with acute stress disorder is much better than for those
with posttraumatic stress disorder, but both benefit from early treatment. Severity
of the trauma, physical injuries, and the underlying resiliency of children and
family members affect the final outcome.

Information
Parents who are overprotective or who are anxious themselves may act to
shield the child from perceived threat and thereby reduce the child’s
opportunity to develop adequate coping skills while reinforcing the child’s
avoidance tendencies. At least one study has demonstrated that children
who were anxiously attached as infants were twice as likely to develop an
anxiety disorder in adolescence compared to peers who were securely
attached.

1.7 TREATMENT OF ANXIETY DISORDERS

The anxiety disorders of childhood may continue into adolescence and young
adulthood, leading first to maladaptive avoidance behaviour and later to
increasingly idiosyncratic thinking and behaviour or an inability to “fit in” with
a peer group. Typically, however, this is not the case. As effected children grow
and have wider interactions in school and in activities with peers, they often
benefit from experiences such as making friends and succeeding at given tasks.
Teachers who are aware of the needs of overanxious, shy, and withdrawn children
are often able to ensure that they will have successful experiences that help
alleviate anxiety.

1.7.1 Medications
Psychopharmacological treatment of anxiety disorders in children and adolescents
is becoming more common today. Birmaher et al., (2003) evaluated the efficacy
of using fluoxetine in the treatment of a variety of anxiety based disorders and
found the medication useful. However, the cautious use of medication is advisable
as this might lead to dependence. Medications such as SSRIs often help in
PTSD to reduce emotional numbing and re-experiencing of symptoms but are
less effective for hyper arousal.

1.7.2 Psychological Treatment

Behaviour therapy procedures have proved to be useful with anxious children.
Such procedures include assertiveness training to provide help with mastering
essential competencies, and desensitisation to reduce anxious behaviour. Kendall
and his colleagues have reported the successful use of manual-based cognitive
behavioural treatment (well-defined procedures using positive reinforcement to
enhance coping strategies to deal with fears) for children with anxiety disorders.
Behavioural treatment approaches such as desensitisation must be explicitly 19
Childhood Psychopathology tailored to a child’s particular problem, and in vivo methods (using real-life
situations graded in terms of the anxiety they arouse) tend to be more effective
than having the child “imagine” situations.

1.8 CHILDHOOD DEPRESSION

Despite reports of childhood depression dating as far back as the 1930s, there
was early scepticism whether children were capable of experiencing depression.
In the 1960s it was thought that depression in children manifested as delinquent
behaviours whereas the 1970’s ushered in the belief that children could experience
depressed feelings, but only on a temporary basis (e.g., adjustment reaction).
Today, it is recognised that children can experience the entire gamut of depressed
feelings from depressed mood to depressed syndromes to depressive disorders;
although there is controversy whether children and adolescents express the same
symptoms as adults, and how to best categorise, assess, and treat the disorder in
children and youth.
Currently, childhood depression is classified according to essentially the same
DSM diagnostic criteria as are used for adults (American Psychiatric Association,
DSM-IV-TR, 2000). However, recent research on the neurobiological correlates
and treatment responses of children, adolescents, and adults has shown clear
differences in hormonal levels and in the response to treatment. One modification
used for diagnosing depression in children is that irritability is often found as a
major symptom and can be substituted for depressed mood. Childhood depression
includes behaviours such as withdrawal, crying, avoidance of eye contact, physical
complaints, poor appetite, and even aggressive behaviour and in some cases
suicide.
Depression in children and adolescents occurs with high frequency. The point
prevalence (the rate at the time of the assessment) of major depressive disorder
has been estimated to be between 0.4 and 2.5 percent for children and between
4.0 and 8.3 percent for adolescents. The lifetime prevalence for major depressive
disorders in adolescents is between 15 and 20 percent. Before adolescence, rates
of depression are somewhat higher in boys, but depression occurs at about twice
the rate for adolescent girls as for adolescent boys.

1.8.1 Etiology of Childhood Depression

As with adults, evidence suggests that biological and psychological factors
(learning) play a role in the development of depression in children.

Biological Factors
There appears to be an association between parental depression and mood
problems in children. According to a study, children of parents with major
depression were more impaired, received more psychological treatment, and had
more psychological diagnoses than children of parents with no psychological
disorders (Kramer, Warner, et. al. 1998). A controlled study of family history
and onset of depression found that children from mood-disordered families had
significantly higher rates of depression than those from non disordered families.
The suicide attempt rate has also been shown to be higher for children of depressed
parents (7.8 percent) than for the offspring of control parents (Weissman et. al.
1992). All these correlations suggest a potential genetic component to childhood
20 depression, but in each case, learning could also be the causal factor.
Other biological factors might also make children vulnerable to depression. These Child and Adolescent
Disorder
factors include biological changes in the neonate as a result of alcohol intake by
the mother during pregnancy. One recent study reported that prenatal exposure
to alcohol is related to depression in children. Intense or persistent sensitisation
of the central nervous system in response to severe stress might also induce
hyper reactivity and alteration of the neurotransmitter system, leaving children
vulnerable to later depression.

Psychological Factors
Learning of maladaptive behaviours appears to be important in childhood
depressive disorders. A number of studies have indicated that children’s exposure
to early traumatic events can increase their risk for the development of depression.
Children who have experienced past stressful events are susceptible to states of
depression that make them vulnerable to suicidal thinking under stress. Children
who are exposed to negative parental behaviour or negative emotional states
may develop depressed mood themselves. For example, childhood depression
has been found to be more common in divorced families.

One important area of research is focusing on the role of the mother-child

interaction in the transmission of depressed mood. Specifically, investigators
have been evaluating the possibility that mothers who are depressed transfer
their low mood to their infants through their interactions with them. Depression
among mothers is not uncommon and can result from several sources. Some
women become depressed during pregnancy or following the delivery of their
child, in part because of exhaustion and hormonal changes that can affect mood.
Several investigators have reported that marital problems, delivery complications,
and difficulties with the infant are also associated with depression in mothers.
Although most of the studies have implicated the mother- child relationship in
development of the disorder, depression in fathers has also been related to
depression in children.

Another important line of research in childhood depression involves the cognitive

behavioural perspective. Considerable evidence has shown that depressive
symptoms are positively correlated with the tendency to attribute positive events
to external, specific, and unstable causes and negative events to internal, global,
and stable causes; wth fatalistic thinking; and with feelings of helplessness. For
example, the child may respond to peer rejection or teasing by concluding that
he or she has some internal flaw. Hinshaw (1994) considers the tendency to
develop distorted mental representations an important cause of depression. In
addition, children who show symptoms of depression tend to underestimate their
self competence over time (Cole et al. 1998).
BOX: Characteristics Associated With Depression in Children and
Adolescents
Characteristics and signs that may be associated with child and adolescent
depression:
• Repeated complaints of vague physical symptoms (e.g., headaches,
stomachaches, leg pains, feeling tired, weary, dizzy, feeling sick to the
stomach); not feeling well.
• Frequent school absences without medical support; poor school
performance.
21
Childhood Psychopathology
• Extreme vulnerability to criticism; overly sensitive.
• Reckless and impulsive behaviour; heightened risk taking.
• Loss of interest in social contact; withdrawal from playing with friends.
• Frequent complaints of boredom.
• Irritable outbursts, angry provocations; hostility towards others.
• Unexplained crying; easily upset.
• Talk of running away from home.
• Substance or alcohol abuse.
• Repeated comments that no one cares about them; or no one loves them.
• Difficulty with relationships.
Source: Adapted from the NIMH Fact Sheet (2000) on depression.

1.8.2 Treatment of Depression

The view that childhood and adolescent depression is like adult depression has
prompted researchers to treat children displaying mood disorders – particularly
adolescents who are viewed as suicidal with medications that have worked with
adults. Research on the effectiveness of antidepressant medications with children
is both limited and contradictory at best, and some studies have found them to be
only moderately helpful. Some present studies using fluoxetine (Prozac) with
depressed adolescents have shown the drug to be more effective than a placebo,
and recent studies have shown fluoxetine to be effective in the treatment of
depression along with cognitive behavioural therapy although complete remission
of symptoms was seldom obtained.

Antidepressant medications may have some undesirable side effects (nausea,

headaches, nervousness, insomnia, and even seizures) in children and adolescents.
Attention is also being given to the increased risk of suicidal ideation and
behaviour in children and adolescents who are taking SSRIs for their depression.
However, the use of antidepressant medication for depressed adolescents has
increased from three to fivefold over the past 10 years.

An important aspect of psychological treatment with children is providing a

supportive emotional environment in which they can learn more adaptive coping
strategies and effective emotional expression. Older children and adolescents
can often benefit from a positive therapeutic relationship in which they can discuss
their feelings openly. Younger children and those with less developed verbal
skills can benefit from play therapy. Controlled studies of psychological treatment
with depressed adolescents have shown significantly reduced symptoms with
cognitive behavioural therapy (Brent, Holder, et. al. 1997) derived from Beck’s
cognitive behavioural approach. But over the past few years, the predominant
approach for treating depression in children and adolescents has been the
combined use of medication and psychotherapy.
Self Assessment Questions
Multiple choices
1) All of the following have been found to increase the risk for childhood
depression, except:
22
 Child and Adolescent
a) family conflict Disorder
b) increased attentional control
c) harsh parenting style
d) peer rejection
2) Children and youth who were raised by depressed mothers exhibit all
of the following except:
a) increased risk for developing insecure attachments
b) increased risk for depression themselves
c) increased emotional regulation
d) responses to having a mother who is less emotionally available
3) Anil’s mother is concerned because Anil is very fearful of monsters and
is afraid of the dark. You explain to Anil’s mother that at Anil’s age this
is a common fear. How old is Anil?
a) 7 years old
b) 9 years old
c) 6 years old
d) 4 years old.
4) Which of the following is not a common type of phobia?
a) fear of books
b) fear of heights
c) fear of thunder
d) fear of flying
5) Which of the following is FALSE regarding separation anxiety disorder
and school refusal?
a) 75% of children with separation anxiety disorder demonstrate
school refusal
b) only 10% of children who refuse to attend school have separation
anxiety disorder
c) school refusal can occur for many reasons, including school bullying
d) highly structured behavioural methods are the best intervention
for school refusal

1.9 LET US SUM UP

Mental health problems in children are relatively common. This is defined as a
disturbance in the areas of relationship, feelings, behaviour or development. These
disturbances must be of sufficient severity as to require professional intervention.
Many developmental, emotional and behavioural problems are short-lived. For
instance, fears in small children, temper tantrums in toddlers and periods of
defiance in adolescence are common; they may cause worry for a period without
ever needing any professional intervention. However, if a child is doing something
that is outside the range you would expect for his or her age and circumstances
23
Childhood Psychopathology and is either causing or experiencing distress (in the children themselves and all
those who care for them), then there is a problem which merits attention. Similarly,
if what he or she is doing is getting in the way of living a reasonable life, there is
a problem.
Childhood disorders are often organised in two broad categories, called
externalising and internalising disorders. Externalising disorders are characterised
by behaviours, such as aggressiveness, noncompliance, over activity, and
impulsiveness, and include the DSM IVTR categories of ADHD, conduct disorder
(CD), and oppositional defiant disorder (ODD). Internalising disorders are
characterised by more inward-focused experiences and behaviours such as
depression, social withdrawal, and anxiety, and include childhood anxiety and
mood disorders.
Attention Deficit Hyperactivity Disorder is one of the more common behaviour
problems of childhood. In this disorder, the child shows impulsive, overactive
behaviour that interferes with his or her ability to accomplish tasks. The major
approaches to treating hyperactive children have been medication and behaviour
therapy. Using medications with children is somewhat controversial. Behaviour
therapy, particularly cognitive behavioural methods, has shown a great deal of
promise in modifying the behaviour of hyperactive children.
In conduct disorder, a child engages in persistent aggressive or antisocial acts.
The possible causes of conduct disorder or delinquent behaviour include
biological factors, personal pathology, family patterns, and peer relationships.
Children who suffer from anxiety or depressive disorders typically do not cause
trouble for others through their aggressive conduct. Rather, they are fearful shy,
withdrawn, and insecure and have difficulty adapting to outside demands. The
anxiety disorders may be characterised by extreme anxiety, withdrawal, or
avoidance behaviour. A likely cause is early family relationships that generate
anxiety and prevent the child from developing more adaptive coping skills.

1.10 UNIT END QUESTIONS

1) Describe ADHD and its sub categories?
2) Discuss the etiology and treatment for ADHD?
3) Discuss the difference between conduct disorder and oppositional defiant
disorder?
4) Describe the causal factors implicated in conduct disorder and treatment of
conduct disorder?
5) Describe in detail the anxiety disorders in children and adolescents?
6) Discuss the etiology and treatment for depression in children and adolescents?

1.11 GLOSSARY
Disinhibition : A lack of restraint
Incarceration : Detention of a person in jail
Recidivism : The chronic tendency toward repetition of criminal
or anti social behaviour patterns or state of
24 returning habitually to crime.
 Child and Adolescent
1.12 SUGGESTED READINGS Disorder

Bennett , Paul 2005. Abnormal and Clinical Psychology: An Introductory

Textbook, 2nd Edn. Open University Press, McGraw-Hill Education: England.
Barlow, D.H., & Durand, V.M. 2007. Abnormal Psychology: An Integrative
Approach. Thomson Learning Inc., New Delhi.
Carson, R. C., Butcher, J. N., Mineka, S., Hooley, J.M. 2007. Abnormal
Psychology. Pearson Education: New Delhi.
Sarason, I.G., & Sarason, B.R.2005. Abnormal Psychology: The Problem of
Maladaptive Behaviour. Prentice-Hall of India: New Delhi.
Sharma, R., 2006. Abnormal Psychology. Atlantic Publishers & Distributors:
New Delhi.

1.13 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1

1) d, 2) d, 3) a, 4) b, 5) c

Self Assessment Questions 2

1) b, 2) c, 3) d, 4) a, 5) b

25
Childhood Psychopathology
UNIT 2 LEARNING DISABILITIES

Structure
2.0 Introduction
2.1 Objectives
2.2 Learning Disabilities
2.3 Types of Learning Disabilities
2.3.1 Learning Disorders
2.3.2 Reading Disorder
2.3.3 Disorders of Written Expression
2.3.4 Mathematics Disorder
2.3.5 Communication Disorder
2.3.6 Expressive Language Disorder
2.3.7 Mixed Receptive Expressive Language Disorder
2.3.8 Phonological Disorder
2.3.9 Motor Skills Disorder
2.4 Causes of Learning Disabilities
2.4.1 Errors in Foetal Brain Development
2.4.2 Other Factors that Affect Brain Development
2.4.3 Problems During Pregnancy and Delivery
2.4.4 Toxins in the Child’s Environment
2.5 Learning Disabilities: Related Problems and Issues
2.5.1 Social, Emotional and Behavioural Difficultires
2.5.2 Other Disorders that Make Learning Difficult
2.6 Diagnosis of Learning Disability
2.7 Intervention for Learning Disability
2.8 Let Us Sum Up
2.9 Unit End Questions
2.10 Glossary
2.11 Suggested Readings

2.0 INTRODUCTION
Academic achievement is highly valued in our society. It often causes parents to
invest a great deal of time and emotional energy to ensure their children’s academic
success, it can also be very upsetting when a child with no obvious intellectual
deficits does not achieve as expected. A learning disability is a neurological
disorder. In simple terms, it results from a difference in the way a person’s brain
is “wired.” People with learning disabilities are as smart as or smarter than their
peers, but they have difficulty reading, writing, spelling, reasoning, recalling
and/or organising information if left to figure things out by themselves or if
taught in conventional ways. This unit will focus on building an in depth
understanding of learning disabilities. We will describe the different types of
learning disabilities classified in DSM-IV-TR. The causes and the different types
of problems and issues associated with learning disabilities would be discussed.
We will also focus on diagnosis and intervention for learning disabilities.
26
 Learning Disabilities
2.1 OBJECTIVES
After reading this unit, you will be able to:
• Define learning disabilities;
• Describe the characteristics of learning disabilities;
• Explain the causes and types of learning disabilities;
• Analyse the various problems and issues related to learning disabilities; and
• Explain the process of diagnosis and intervention in learning disabilities.

2.2 LEARNING DISABILITIES

“He has the ability, if he just tried harder, he could do it. He chooses not to
do the work.”
“If she would just pay attention, she would get it.”
“After I give the instructions, he sits there and stares at his paper. He is not
motivated.”

Children with a learning disability cannot try harder, pay closer attention, or
improve motivation on their own; they need help to learn how to do those things.
Learning disabilities signify inadequate development in a specific area of
academic, language, speech, or motor skills. These disorders affect learning in
individuals who otherwise demonstrate at least average abilities essential for
thinking and/or reasoning.

A learning disability is a type of neurological disorder that affects the brain’s

ability to receive, process, store, and respond to information. Learning disabilities
can affect a child’s ability in the areas of listening, speaking, reading, writing,
and mathematics.

Fig. 2.1: Movie “Taare Zamein Par” dealt with issue of Learning disability

Children with learning disabilities are usually of average or above average

intelligence but have difficulty acquiring the basic academic skills that are essential
27
Childhood Psychopathology for success at school and work, and for coping with life in general. These children
show a distinct gap between the level of achievement that is expected and what
is actually being achieved. These disorders are not primarily due to hearing and/
or vision problems, mental retardation, autism, cultural or linguistic differences,
and lack of motivation or ineffective teaching.

Learning disabilities can be lifelong conditions that in some cases affect many
parts of a person’s life. In some people, many overlapping learning disabilities
may be apparent. Other people may have a single, isolated learning problem that
has little impact on other areas of their lives.

2.3 TYPES OF LEARNING DISABILITIES

“Learning disability” is not a diagnosis in the same sense as “chickenpox” or
“Flu”. Chickenpox and Flu imply a single, known cause with a predictable set of
symptoms. Rather, Learning disability is a broad term that covers a range of
possible causes, symptoms, treatments, and outcomes. Partly because learning
disabilities can show up in so many forms, it is difficult to diagnose or to pinpoint
the causes. And no one knows of a pill or remedy that will cure them.

Not all learning problems are necessarily learning disabilities. Many children
are simply slower in developing certain skills. Because children show natural
differences in their rate of development, sometimes what seems to be a learning
disability may simply be a delay in maturation. To be diagnosed as a learning
disability, specific criteria must be met. The term learning disabilities is not
used by DSM-IV-TR but is used by most health professionals to group together
three disorders that do appear in the DSM. Learning disabilities can be divided
into three broad categories:
• Learning disorders
• Communication disorders
• Motor Skills disorders
Any of these disorders may apply to a child who fails to develop to the degree
expected by his or her intellectual level in a specific academic, language or motor
skill area. Each of these categories includes a number of more specific disorders.
Table below presents the details.

Table: Specific Types of Learning Disabilities

Type of Learning Primary Area Affected Description of Difficulties

Dyscalculia Mathematics Problems understanding and using

math concepts and symbols, recalling
math facts and understanding concepts
such as time and money.

At its most basic level, problems may

exist in simple counting due to
problems with one to one
correspondence. Student may not be
able to count by 3s or 5s. Math word
problems are difficult because the
28
 Learning Disabilities
student does not have a sense of what
information is relevant and what is
irrelevant to solving the problem.

Dysgraphia Written Expression Handwriting can be illegible due to

poor letter formation and poor letter
spacing.

Academic problems may include

spelling and excessive time required to
execute written notes and assignments.
Often experience difficulty organising
information and in starting written
assignments.

Dyslexia Reading, Spelling Problems in recalling letter sequences

(“gril” for “girl”), sound to symbol
association (recall the sound that goes
with the letter b), and word forms (was
vs. saw).

Student may mix up letters within

words and words within sentences
while reading. Letter reversals (b and
d), inversions (p and d) are common,
and can also extend to numbers (9 for
6). Often there are problems with
directionality and spatial orientation
(left and right).

Dyspraxia Tasks requiring fine May demonstrate a specific disorder in

motor skills the area of motor skill development.
May experience problems planning and
completing fine motor tasks.
Approximately 2% of the general
population is afflicted and about 70%
are male.

Simple tasks such as buttoning a shirt

or more complex tasks such as using
scissors to cut straight lines or brushing
teeth may be a challenge.

Nonverbal Mathematics and Impaired functioning evident in non

Learning Spatial Awareness language areas, such as mathematics,
Disability visual/spatial organisation and motor
coordination.

Social skills are also impaired due to

problems with interpreting subtle social
cues.

Let us take learning disorders and deal with it.

29
Childhood Psychopathology 2.3.1 Learning Disorders
Students with learning disorders are often years behind their classmates in
developing reading, writing, or arithmetic skills. DSM-IV-TR divides learning
disorders into three categories:
• Reading disorder
• Disorder of written expression
• Mathematics disorder
None of these diagnoses is appropriate if the disability can be accounted for by a
sensory deficit, such as a visual or auditory problem.

Fig.2.2

Children with learning disorders find classroom a frustrating place when they
are unable to understand what they are reading or to follow directions.

Self Assessment Questions

1) Define Learning disability.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) What are the types of learning disabilities?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What are the subtypes of learning disabilities?
...............................................................................................................
...............................................................................................................
...............................................................................................................

30
...............................................................................................................
2.3.2 Reading Disorder Learning Disabilities

This type of disorder, also known as dyslexia, is quite widespread. In fact, reading
disabilities affect 5 to 10 percent of school-age children. Children with reading
disorder have significant difficulty with word recognition, reading comprehension
and written spelling. When reading out loud they omit, add, or distort the
pronunciation of words to an extent which is unusual for their age. In adulthood,
problems with reading, comprehension, and written spelling persist. But presence
of this disorder does not prevent the person from great achievements. For example,
Tom Cruise, well-known actor, has dyslexia.

Scientists have found that a significant number of people with dyslexia share an
inability to distinguish or separate the sounds in spoken words. A child with
dyslexia, for example, might have problem in identifying the word “bat” by
sounding out the individual letters, b-a-t. Other children with dyslexia may have
trouble with rhyming games, such as rhyming “cat” with “bat.” These skills are
fundamental to learning to read. Fortunately, remedial reading specialists have
developed techniques that can help many children with dyslexia acquire these
skills.

However, there is more to reading than recognising words. If the brain is unable
to form images or relate new ideas to those stored in memory, the reader can’t
understand or remember the new concepts. So other types of reading disabilities
can appear in the higher grades when the focus of reading shifts from word
identification to comprehension.

Remember
There is a common misperception that all people with dyslexia see words
backwards (e.g., was for saw). However, only about 30% of persons with
dyslexia have trouble with reversing letters and numbers.

2.3.3 Disorder of Written Expression

This disorder involves impairment in the ability to compose the written word i.e.
spelling errors, errors in grammar or punctuation, or very poor handwriting which
is serious enough to interfere significantly with academic achievement or activities
of daily living that require writing skills.

Writing involves several brain areas and functions. The brain networks for
vocabulary, grammar, hand movement, and memory must all be in good working
order. So a developmental writing disorder may result from problems in any of
these areas. For example, a child, who is unable to distinguish the sequence of
sounds in a word, has problems with spelling. A child with a writing disability
might be unable to compose complete, grammatical sentences.

2.3.4 Mathematics Disorder

Children with mathematics disorder may have difficulty rapidly and accurately
recalling arithmetic facts, counting objects correctly and quickly, or aligning
numbers in columns.

If you doubt that arithmetic is a complex process, think of the steps you take to
solve this simple problem: 25 divided by 3 equals?
31
Childhood Psychopathology Arithmetic involves recognising numbers and symbols, memorising facts such
as the multiplication table, aligning numbers, and understanding abstract concepts
like place value and fractions. Any of these may be difficult for children with
arithmetic disorder. Problems with numbers or basic concepts are likely to show
up early. Disabilities that appear in the later grades are more often tied to problems
in reasoning.

Many aspects of speaking, listening, reading, writing, and arithmetic overlap

and build on the same brain capabilities. So it’s not surprising that people can be
diagnosed as having more than one area of learning disability. For example, the
ability to understand language underlies learning to speak. Therefore, any disorder
that hinders the ability to understand language will also interfere with the
development of speech, which in turn hinders learning to read and write. A single
gap in the brain’s operation can disrupt many types of activity.

2.3.5 Communication Disorders

Speech and language problems are often the earliest indicators of a learning
disability. People with developmental speech and language disorders have
difficulty producing speech sounds, using spoken language to communicate, or
understanding what other people say. Depending on the problem, the specific
diagnosis may be:
• Expressive Language disorder
• Mixed Receptive-Expressive Language disorder
• Phonological disorder
• Stuttering

2.3.6 Expressive Language Disorder

In expressive language disorder, the child has difficulty expressing himself or
herself in speech. The child might look eager to communicate but would have
difficulty finding the right words. For example, he may be unable to come up
with the word bus when pointing to a bus on the road. By age four, such child
would be able to speak only in short phrases. Old words are easily forgotten
when new ones are learned and also the use of grammatical structures would be
below his age level.

Remember
According to the DSM, expressive language disorders may occur in
communication regardless of whether the communication is oral or sign
language.

2.3.7 Mixed Receptive Expressive Language Disorder

In addition to having expressive language problems, as mentioned above, children
in this category also experience receptive language difficulties (understanding
words, sentences, or types of words, e.g., spatial, quantity, and so forth). Some
people have trouble understanding certain aspects of speech. It’s as if their brains
are set to a different frequency and the reception is poor. For example, a toddler
who doesn’t respond to his name, a preschooler who hands you a bell when you
asked for a ball, or a worker who consistently can’t follow simple directions.
Their hearing is fine, but they can’t make sense of certain sounds, words, or
32
sentences they hear. They may even seem inattentive. Because using and Learning Disabilities
understanding speech are strongly related, many people with receptive language
problem also have an expressive language disability.

Of course, in preschoolers, some misuse of sounds, words, or grammar is a normal

part of learning to speak. It’s only when these problems persist that there is any
cause for concern.

2.3.8 Phonological Disorder

Children with phonological disorder are able to comprehend and use a substantial
vocabulary but their speech is not clear. Children with this disorder have trouble
controlling their rate of speech. Or they may lag behind playmates in learning to
make speech sounds. For example, a child at age 6 might still say “wabbit”
instead of “rabbit” and “thwim” for “swim.” They have not learned articulation
of the later-acquired speech sounds, such as r, sh, th, f, z, l, and ch. Developmental
articulation disorders are common. They appear in at least 10 percent of children
younger than age 8. Fortunately, articulation disorders can often be outgrown or
successfully treated with speech therapy.

Stuttering
This involves disturbance in verbal fluency that is characterised by one or more
of the following speech patterns:
• Frequent repetitions or prolongations of sounds (e.g., “C-c-c-c-can I go?”).
• Long pauses between words.
• Substituting easy words for those that are difficult to pronounce.
• Repeating whole words (e.g., saying “go-go-go-go” instead of just one “go”).
• Sometimes bodily twitching and eye blinking accompany the verbal
difficulties.
Stuttering can interfere with academic, social and occupational functioning and
can prevent a capable person from reaching his potential. It is worse when the
person gets nervous or anxious. This usually shows up at around age five and
almost always before the age of ten and is found three times more in males than
females. Recovery can be spontaneous.

2.3.9 Motor Skills Disorder

Motor skills disorder, also known as developmental coordination disorder,
involves impairment in the development of motor coordination that is not
explainable by mental retardation or a known physical disorder such as cerebral
palsy. Children having this disorder would have difficulty tying shoe laces and
buttoning shirts and, when older, with playing ball, printing or handwriting. This
diagnosis is made only if the impairment interferes significantly with academic
achievement or with activities of daily living.
Self Assessment Questions
1) What is reading disorder? Give examples.
...............................................................................................................
...............................................................................................................
33
Childhood Psychopathology
2) What is meant by disorders of writing expressions?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Define communication disorder and present the characteristics.
...............................................................................................................
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...............................................................................................................
...............................................................................................................
...............................................................................................................
4) What is phonological disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
5) Describe the motor skills disorder.
...............................................................................................................
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2.4 CAUSES OF LEARNING DISABILITIES

One of the first questions parents ask when they learn their child has a learning
disorder is “Why? What went wrong?”

Mental health professionals stress that since no one knows what causes learning
disabilities, it doesn’t help parents to look backward to search for possible reasons.
There are too many possibilities to pin down the cause of the disability with
certainty. It is far more important for the family to move forward in finding ways
to get help.

Scientists, however, do need to study causes in an effort to identify ways to

prevent learning disabilities. Once, scientists thought that all learning disabilities
34 were caused by a single neurological problem. But research has helped us see
that the causes are more diverse and complex. New evidence seems to show that Learning Disabilities
most learning disabilities do not stem from a single, specific area of the brain,
but from difficulties in bringing together information from various brain regions.

Today, a leading theory is that learning disabilities stem from subtle disturbances
in brain structures and functions. Some scientists believe that, in many cases, the
disturbance begins before birth.

2.4.1 Errors in Foetal Brain Development

Throughout pregnancy, the foetal brain develops from a few all-purpose cells
into a complex organ made of billions of specialised, interconnected nerve cells
called neurons. During this evolution, things can go wrong that may alter how
the neurons form or interconnect.

In the early stages of pregnancy, the brain stem forms. It controls basic life
functions such as breathing and digestion. Later, a deep ridge divides the
cerebrum—the thinking part of the brain—into two halves, a right and left
hemisphere. Finally, the areas involved with processing sight, sound, and other
senses develop, as well as the areas associated with attention, thinking, and
emotion. As new cells form, they move into place to create various brain structures.
Nerve cells rapidly grow to form networks with other parts of the brain. These
networks are what allow information to be shared among various regions of the
brain.

Throughout pregnancy, this brain development is vulnerable to disruptions. If

the disruption occurs early, the foetus may die, or the infant may be born with
widespread disabilities and possibly mental retardation. If the disruption occurs
later, when the cells are becoming specialised and moving into place, it may
leave errors in the cell makeup, location, or connections. Some scientists believe
that these errors may later show up as learning disorders.

2.4.2 Other Factors That Affect Brain Development

Through experiments with animals, scientists are trying to determine what disrupts
brain development. By studying the normal processes of brain development,
scientists can better understand what can go wrong. Some of these studies are
examining how genes, substance abuse, pregnancy problems, and toxins may
affect the developing brain.

Genetic Factors
The fact that learning disabilities tend to run in families indicates that there may
be a genetic link. For example, children who lack some of the skills needed for
reading, such as hearing the separate sounds of words, are likely to have a parent
with a related problem. However, a parent’s learning disability may take a slightly
different form in the child. A parent who has a writing disorder may have a child
with an expressive language disorder. For this reason, it seems unlikely that
specific learning disorders are inherited directly. Possibly, what is inherited is a
subtle brain dysfunction that can in turn lead to a learning disability.

There is also an alternative explanation for why learning disability might seem
to run in families. Some learning difficulties may actually stem from the family
environment. For example, parents who have expressive language disorders might
35
Childhood Psychopathology talk less to their children or the language they use may be distorted. In such
cases, the child lacks a good model for acquiring language and therefore, may
seem to be learning disabled.

Tobacco, Alcohol, and Other Drug Use

Many drugs taken by the mother pass directly to the foetus. Research shows that
a mother’s use of cigarettes, alcohol, or other drugs during pregnancy may have
damaging effects on the unborn child. Therefore, to prevent potential harm to
developing babies, efforts are being made by governments all over the world to
make people aware of the possible dangers of smoking, drinking, and using drugs.

Scientists have found that mothers who smoke during pregnancy may be more
likely to bear smaller babies. This is a concern because small newborns, usually
those weighing less than 5 pounds (or less than 2.5 kg), tend to be at risk for a
variety of problems, including learning disorders.

Alcohol is also dangerous to the foetus’ developing brain. It appears that alcohol
may distort the developing neurons. Heavy alcohol use during pregnancy has
been linked to foetal alcohol syndrome, a condition that can lead to low birth
weight, intellectual impairment, hyperactivity, and certain physical defects. Any
alcohol use during pregnancy, however, may influence the child’s development
and lead to problems with learning, attention, memory, or problem solving.
Because scientists have not yet identified “safe” levels, alcohol should not be
used by women who are pregnant or who may soon become pregnant.

Drugs such as cocaine-especially in its smoke able form known as crack-seem

to affect the normal development of brain receptors. These brain cell parts help
to transmit incoming signals from our skin, eyes, and ears, and help regulate our
physical response to the environment. Because children with certain learning
disabilities have difficulty understanding speech sounds or letters, some
researchers believe that learning disabilities, as well as ADHD, may be related
to faulty receptors. Current research points to drug abuse as a possible cause of
receptor damage.

2.4.3 Problems During Pregnancy and Delivery

Other possible causes of learning disabilities involve complications during
pregnancy. In some cases, the mother’s immune system reacts to the foetus and
attacks it as if it were an infection. This type of disruption seems to cause newly
formed brain cells to settle in the wrong part of the brain. Or during delivery, the
umbilical cord may become twisted around the neck and temporarily cut off
oxygen to the foetus. This, too, can impair brain functions and lead to Learning
disability.

2.4.4 Toxins in the Child’s Environment

New brain cells and neural networks continue to be produced for a year or so
after the child is born. These cells are vulnerable to certain disruptions, also.

Researchers are looking into environmental toxins that may lead to learning
disabilities, possibly by disrupting childhood brain development or brain
processes. Cadmium and lead, both prevalent in the environment, are becoming
a leading focus of neurological research. Cadmium, used in making some steel
36
products, can get into the soil, then into the foods we eat. Lead was once common Learning Disabilities
in paint and gasoline, and is still present in some water pipes. A study of animals
sponsored by the National Institutes of Health showed a connection between
exposure to lead and learning difficulties. In the study, rats exposed to lead
experienced changes in their brainwaves, slowing their ability to learn. The
learning problems lasted for weeks, long after the rats were no longer exposed to
lead.

In addition, there is growing evidence that learning problems may develop in

children with cancer who had been treated with chemotherapy or radiation at an
early age. This seems particularly true of children with brain tumours who received
radiation to the skull.

Self Assessment Questions

1) What are the causes of learning disabilities?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) What are the factors that affect brain development that lead to learning
disabilities?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Describe the problems during pregnancy and delivery that would affect
braing development.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) How does toxin in the child’s environment affect the child’s learning ?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
37
Childhood Psychopathology
2.5 LEARNING DISABILITIES: RELATED
PROBLEMS AND ISSUES
2.5.1 Social, Emotional and Behavioural Difficulties
When students have learning difficulties, sometimes secondary issues emerge.
Students can get anxious about school work or become depressed. Behaviours
can develop that are coping strategies to deal with frustration. While these
behaviours are not seen by others as effective, they may indeed serve an important
function to the student:
Work avoidance: avoids embarrassment – “it is better to not do work than to do
it and get a poor grade – it is better to be seen as forgetful than stupid”.
Denial of problems: “if I ignore the problem I feel better now”.
Acting out in class: “if I am silly in class my peers may value me. If I get kicked
out of class I won’t have to read aloud. It is better to be seen as bad than stupid”.
Drugs and Alcohol: “these help me feel better and hanging out with kids involved
with similar activities. It is at least a group that wants me”.
Social and emotional skills are an area where a parent can have a huge impact.
For all children, but especially those with learning disabilities, social and
emotional skills are the most consistent indicators of success, outweighing
everything else, including academic factors. Academic challenges may lead to
low self–esteem, withdrawal and behaviour problems, but these things can be
countered by creating a strong support system for the child and helping them
learn to express themselves, deal with frustration and work through challenges.
Focus should be on their growth as a person, and not just on academic
achievements which will help them learn good emotional habits and the right
tools for lifelong success.

2.5.2 Other Disorders that Make Learning Difficult

Difficulty in school doesn’t always stem from a learning disability. Anxiety,
depression, stressful events, emotional trauma, and other conditions affecting
concentration make learning more of a challenge.

ADHD – Attention Deficit Hyperactivity Disorder (ADHD), while not considered

a learning disability, can certainly disrupt learning. Children with ADHD often
have problems with sitting still, staying focused, following instructions, staying
organised, and completing homework.

Autism – Difficulty mastering certain academic skills can stem from Pervasive
Developmental Disorders such as autism and Asperger’s syndrome. Children
with an autism spectrum disorder may have trouble making friends, reading body
language, communicating, and making eye contact.

2.6 DIAGNOSIS OF LEARNING DISABILITY

Learning disability is defined as a significant gap between a person’s intelligence
and the skills the person has achieved at each age. This means that a severely
retarded 10-year-old who speaks like a 6-year-old probably doesn’t have a
38
language or speech disability. He has mastered language up to the limits of his Learning Disabilities
intelligence. On the other hand, a fifth grader with an IQ of 100 who can’t write
a simple sentence probably does have learning disability.

Learning disorders may be informally identified by observing significant delays

in the child’s skill development. A 2-year delay in the primary grades is usually
considered significant. So learning disabilities aren’t usually suspected unless
there is more than a 2-year delay. Actual diagnosis of learning disabilities,
however, is made using standardised tests that compare the child’s level of ability
to what is considered normal development for a person of that age and intelligence.

Factors that affect test outcomes include the child’s actual abilities, the reliability
of the test instrument, and his ability to understand the directions, questions, and
pay attention during the testing session. Learning disabilities are diagnosed in
different ways.
Vision and hearing are always tested to rule out sensory impairment and assure
that the person can see and hear clearly.
Academic skills disorders, reading, math, and writing are evaluated using
standardised tests. (e.g., Specific learning disability (SLD) battery)
Intelligence testing is completed by a psychologist.
Pronunciation, vocabulary, and grammar are compared to the developmental
abilities of same-age peers to diagnose speech and language disorders.
Medical doctors check for ear infections or throat and vocal cords problems.
Once all other possible factors that might have caused the learning problems are
eliminated, diagnosis of a learning disability might be made.

Important Distinction
As part of the differential diagnoses, the DSM–IV–TR (APA, 2000) notes
that a key defining feature in making a differential diagnosis between mental
retardation and a learning disorder is that in mental retardation, academic
achievement is low, but commensurate with expected IQ. However, in those
with a learning disorder, academic achievement is substantially below
measured intelligence.

2.7 INTERVENTION FOR LEARNING

DISABILITIES
Although obtaining a diagnosis is important, even more important is getting the
right help. Because learning disabilities can affect the child and family in so
many ways, help may be needed on a variety of fronts: educational, medical,
emotional, and practical.

In most ways, children with learning disabilities are no different from children
without these disabilities. At school, they eat together and share sports, games,
and after-school activities. But since children with learning disabilities do have
specific learning needs, schools should provide special programs. Schools should
typically provide special education programs either in a separate all-day classroom
or as a special education class that the student attends for several hours each
39
Childhood Psychopathology week. Parents can also hire trained tutors to work with their child after school. If
the problems are severe, parents can also choose to place their child in a special
school for the learning disabled.

Special education teachers identify the types of tasks the child can do and the
senses that function well. By using the senses that are intact and bypassing the
disabilities, many children can develop needed skills. These strengths offer
alternative ways the child can learn. After assessing the child’s strengths and
weaknesses, the special education teacher designs an Individualised Educational
Program (IEP). The IEP outlines the specific skills the child needs to develop as
well as appropriate learning activities that build on the child’s strengths. Many
effective learning activities engage several skills and senses. For example, in
learning to spell and recognise words, a student may be asked to see, say, write,
and spell each new word. The student may also write the words in sand, which
engages the sense of touch. Many experts believe that the more senses children
use in learning a skill, the more likely they are to retain it.

Researchers are also investigating nonstandard teaching methods. Some create

artificial learning conditions that may help the brain receive information in
nonstandard ways. For example, in some language disorders, the brain seems
abnormally slow to process verbal information. Scientists are testing whether
computers that talk can help teach children to process spoken sounds more quickly.
The computer starts slowly, pronouncing one sound at a time. As the child gets
better at recognising the sounds and hearing them as words, the sounds are
gradually speeded up to a normal rate of speech.

The effects of learning disabilities can ripple outward from the disabled child or
adult to family, friends, and peers at school or work. Children with learning
disabilities often absorb what others thoughtlessly say about them. They may
define themselves in light of their disabilities, as “behind,” “slow,” or “different.”

Specially designed computer games may help

Fig. 2.3: Children improve their language skills

Sometimes they don’t know how they’re different, but they know how awful
they feel. Their tension or shame can lead them to act out in various ways-from
withdrawal to belligerence. They may stop trying to learn and achieve and
eventually drop out of school. Or they may become isolated and depressed.

Children with learning disabilities and attention disorders may have trouble
making friends with peers. Some children with delays may be more comfortable
with younger children who play at their level. Social problems may also be a
product of their disability. Some people with learning disabilities seem unable to
interpret tone of voice or facial expressions. Misunderstanding the situation,
they act inappropriately, turning people away.
40
Without professional help, the situation can spiral out of control. The more that Learning Disabilities
children or teenagers fail, the more they may act out their frustration and damage
their self-esteem. The more they act out, the more trouble and punishment it
brings, further lowering their self-esteem. Having a child with a learning disability
may also be an emotional burden for the family. Parents often sweep through a
range of emotions: denial, guilt, blame, frustration, anger, and despair. Brothers
and sisters may be annoyed or embarrassed by their sibling, or jealous of all the
attention the child with learning disability gets.

Counselling can be very helpful to people with LD and their families. Counselling
can help affected children, teenagers, and adults develop greater self-control and
a more positive attitude toward their own abilities. Talking with a counsellor or
psychologist also allows family members to air their feelings as well as get support
and reassurance.

Science Talks
In one study, researchers found that Kindergarten children differed in their
ability to answer the question: “Which number is bigger—4 or 3?” Despite
controlling for student ability to count and produce simple calculations,
students with higher socio-economic status (SES) answered the question
correctly 96% of the time compared to only 18% accuracy for children
from lower SES backgrounds. The researchers suggest that number sense
development may be linked to informal learning in some home
environments and that early intervention (pre-K or K) may be beneficial
in allowing some students to catch up.

Many parents find that joining a support group also makes a difference. Support
groups can be a source of information, practical suggestions, and mutual
understanding. Self-help books written by educators and mental health
professionals can also be helpful.

Behaviour modification also seems to help many children with learning disability.
In behaviour modification, children receive immediate, tangible rewards when
they act appropriately. Receiving an immediate reward can help children learn to
control their own actions, both at home and in class. A school or private counsellor
can explain behaviour modification and help parents and teachers set up
appropriate rewards for the child.

Parents and teachers can help by structuring tasks and environments for the child
in ways that allow the child to succeed. They can find ways to help children
build on their strengths and work around their disabilities. For a teenager with a
language problem, it may mean providing pictures and diagrams for performing
a task. A counsellor or school psychologist can help identify practical solutions
that make it easier for the child and family to cope day by day.

Every child needs to grow up feeling competent and loved. When children have
learning disabilities, parents may need to work harder at developing their
children’s self-esteem and relationship-building skills. But self-esteem and good
relationships are as worth developing as any academic skill.

41
Childhood Psychopathology
Self Assessment Questions
Multiple Choices:
1) ....................... signify inadequate development in a specific area of
academic, language, speech, or motor skills that is not due to mental
retardation, autism, or deficient educational opportunities.
a) Psychological difficulties
b) Developmental disabilities
c) Learning disabilities
d) Physical disabilities
2) There are several categories of communication disorders including all
of the following EXCEPT ...........................
a) expressive language disorder
b) receptive speech disability
c) phonological disorder
d) Stuttering
3) Children with ........................ disorder have difficulty recalling arithmetic
facts, counting objects correctly and aligning numbers in columns.
a) Reading
b) Mathematics
c) Communication
d) Motor skills
4) Disorder of written expression is often associated with
a) Reading disorder
b) Mixed expressive-receptive language disorder
c) Developmental coordination disorder
d) Mathematics disorder
5) Manifestations of developmental coordination disorder include:
a) Delays in reaching motor milestones such as sitting and crawling
b) Avoidance of participation in sports activities with peers
c) Messy or illegible writing
d) All of the above
6) Children with expressive language disorder are distinguishable from
children with pervasive developmental disorders in that they___
a) Appropriately use gestures to communicate
b) Readily form meaningful and warm social relationships
c) Show significant frustration with the inability to communicate
verbally
d) All of the above
42
 Learning Disabilities
7) What is dyslexia?
a) Any impairment of language processing
b) Specific problems with reading
c) Inability to retrieve difficult vocabulary words, on command
d) A group of symptoms including stuttering and letter-reversal
8) A specific learning disability involves problems with motor skills is
referred to as:
a) dysgraphia
b) dyscalculia
c) dyspraxia
d) dystonia
9) Treatment for learning, communication, and motor skills disorders a
....................... approach designed by teachers, school psychologists,
specialised therapists, and parents.
a) Systemic
b) Multidisciplinary
c) CBT
d) None
10) The special education teacher designs an _____ program which outlines
the specific skills the child needs to develop as well as appropriate
learning activities that build on the child’s strengths.
a) Individualised Educational Program (IEP)
b) Computer
c) Training
d) Academic

2.8 LET US SUM UP

Learning disabilities involve delay or deficit in some area of functioning including
academic, language, speech, or motor skills that is not due to mental retardation,
autism, a demonstrable physical disorder, or deficient educational opportunities.
Children with these disorders are usually of average or above average intelligence
but have difficulty learning specific skills like arithmetic or reading. These
disorders can interfere with the child’s ability to make progress in school and in
social situations and, for adults, can interfere with occupational success and social
adjustment. These disorders are usually identified within the school system rather
than through mental health clinics.

Neurological impairments are thought to be at the root of these disorders. There

is mounting evidence that the learning disabilities have genetic and other
biological components as causal factors. Treatment for learning, communication,
and motor skills disorders occurs in the schools and involves a multi disciplinary
approach designed by teachers, school psychologists, specialised therapists, and
43
Childhood Psychopathology parents. One of the most important focus of treatment is to build on the child’s
strengths so he or she can feel a sense of self-esteem and accomplishment.

2.9 UNIT END QUESTIONS

1) What is learning disability? Define the seven learning disabilities in the
three groups?
2) What are the different causes of learning disabilities?
3) Mention the types of problems and issues associated with learning
disabilities?
4) Write about the ways in which learning disabilities are diagnosed?
5) Describe the types of approaches to learning disabilities?

2.10 GLOSSARY
Accounted : Explained by
Communication disorders : Problems in transmitting or conveying
information, including stuttering and expressive
language disorder.
Reading disorder : Reading performance significantly below age
norms.
Receptive language : Communicated material that is understood.
Stuttering : Disturbance in the fluency and time patterning
of speech (e.g., sound and syllable repetitions
or prolongations).

2.11 SUGGESTED READINGS

Barlow, D.H., & Durand, V.M. 2007. Abnormal Psychology: An Integrative
Approach. Thomson Learning Inc., New Delhi.

Davison, G.C., Neale, J.M., Kring, A.M. Abnormal Psychology, 9th edition. Wiley
& Sons:USA.

Wilmshurst, Linda. 2008. Abnormal Child Psychology: A Developmental

Perspective. Taylor & Francis Group: New York.

2.12 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions
1) (c), 2) (b), 3) (b), 4) (a), 5) (d), 6) (d), 7) (b), 8) (c), 9) (b), 10) (a)

44
 Learning Disabilities
UNIT 3 MENTAL RETARDATION

Structure
3.0 Introduction
3.1 Objectives
3.2 Mental Retardation
3.2.1 Criteria to Diagnose Mental Retardation
3.2.2 Intelligence Test Scores
3.2.3 Adaptive Functioning
3.2.4 Age of Onset
3.3 Classification of Mental Retardation
3.3.1 Mild Mental Retardation
3.3.2 Moderate Mental Retaration
3.3.3 Severe Mental Retardation
3.3.4 Profound Mental Retardation
3.4 Prevalence of Mental Retardation
3.5 Etiology of Mental Retardation
3.5.1 Genetic Conditions and Chromosomal Abnormalities
3.5.2 Environmental Factors
3.5.3 Psychosocial Factors
3.6 Prevention and Treatment of Mental Retardation
3.6.1 Behavioural Intervention
3.6.2 Cognitive Interventions
3.6.3 Computer Assisted Instructions
3.6.4 Parent Training Programmes
3.7 Let Us Sum Up
3.8 Unit End Questions
3.9 Suggested Readings

3.0 INTRODUCTION
Mental retardation is a developmental disability characterised by inadequate
adaptation to societal demands. This disability is typically diagnosed in early
childhood, when a discrepancy is recognised between a child’s level of intellectual
and adaptive functioning and that of children of the same chronological age. In
this unit we would be studying mental retardation, the criteria used to define
mental retardation. We discuss the various causal factors of mental retardation
and lastly we describe in detail the prevention and intervention approaches.

3.1 OBJECTIVES
After reading this unit, you will be able to:
• Define Mental Retardation;
• Describe the different levels of mental retardation;
• Explain the etiology of mental retardation; and
• Elucidate the measures of prevention and treatment of mental retardation. 45
Childhood Psychopathology
3.2 MENTAL RETARDATION
The American Association on Mental Retardation (AAMR) has served as the
premier authority on matters of definition and classification for mental retardation
since 1876. The Diagnostic and Statistical Manual of Mental Disorders (DSM),
published by the American Psychiatric Association (APA), incorporated the
AAMR definition beginning in 1968.

AAMR (2002) defines mental retardation as a “state of functioning beginning in

childhood that is characterised by limitations in intellectual and adaptive skills”.

3.2.1 Criteria to Diagnose Mental Retardation

The DSM-IV TR definition has three criteria that must be met for a diagnosis of
mental retardation:
• Significantly subnormal intellectual functioning,
• Impairments in adaptive functioning, and
• Onset before 18 years of age.

3.2.2 Intelligence-Test Scores

The first component of the DSM definition requires a judgement of intelligence.
According to the DSM, subnormal intellectual functioning is an IQ of
approximately 70 or less obtained on a standardised and well recognised
instrument that has been developed specifically to assess intelligence (e.g.,
Wechsler Intelligence Scale for Children, Stanford-Binet, etc.). Approximately 3
percent of the population falls into the criterion of “significant sub average general
intellectual functioning.”

The determination of IQ should be based on tests administered by a competent,

well trained professional. While Interpreting scores the clinician must take into
account cultural, linguistic and sensory or motor limitation that may affect
performance. For example, when testing a child with cerebral palsy who has
limited use of his or her hands, the examiner might select IQ tests that require
verbal responses or simple gesture responses, rather than the traditional intellectual
tests, which include a nonverbal or performance component requiring complex
and rapid motor movements. Similarly, a child who speaks Hindi at home and
English at school cannot be tested in a valid way using only English-language
measures (American Association of Mental Retardation [AAMR], 1992).

3.2.3 Adaptive Functioning

Adaptive functioning refers to mastering childhood skills such as toileting and
dressing; understanding the concepts of time and money; being able to use tools,
to shop, and to travel by public transportation; and becoming socially responsive.
An adolescent, for example, is expected to be able to apply academic skills,
reasoning, and judgement to daily living and to participate in group activities.
An adult is expected to be self-supporting and to assume social responsibilities.

Several tests have been constructed to assess adaptive behaviour. Best known
are the Adaptive Behaviour Scale, or ABS and the Vineland Adaptive behaviour
Scales (Sparrow, Ballo, & Cicchetti , 1984). One main problem with many
46 assessments of adaptive behaviour is that they fail to consider the environment
to which the person must adapt. A person who lives in a small rural community Mental Retardation
where everyone is acquainted may not need skills as complex as those needed by
someone who lives in New Delhi. Youngsters who are competent working at
farm chores, walking to school, and shopping at the local store may, when
transported to a city, be considered deficient in adaptive behaviour if they are not
able to ride the metro or take the subway to school or buy groceries at a store
where English is spoken. By the same token, city children may find themselves
at a loss with some of the activities expected of the youngsters living on a farm.
An effective and valid assessment of adaptive behaviour should therefore consider
the interaction between the child and the surroundings in which he or she must
function.

3.2.4 Age of Onset

The final definition criterion is that mental retardation should manifest before
age eighteen, so that any deficits in intelligence and adaptive behaviour from
injury and illness occurring later in the life is not classified as mental retardation.
Children with severe impairments are often diagnosed during infancy. Most
Children considered mentally retarded, however, are not identified until they
enter school. These children have no obvious physiological, neurological, or
physical manifestations, and their problems become apparent only when they
are unable to keep up with their peers in school.

3.3 CLASSIFICATION OF MENTAL RETARDATION

The most consistent feature of mental retardation is that the person learns very
slowly. Other areas of difficulty are attention, short-term memory, planning, and
language. DSM-IV-TR describes four levels of severity of mental retardation
based on IQ levels as the criteria in distinguishing ranges of impairment. But IQ
ranges are not the sole basis of diagnosis; deficiencies in adaptive behaviour are
also a criterion of mental retardation. For example, if a person’s IQ falls in the
mildly retarded range but shows no deficits in adaptive functioning then he would
not be considered mentally retarded. In fact the IQ criterion should be applied
after deficits in adaptive functioning have been identified. The following is a
brief summary of characteristics of people at each level of mental retardation.

3.3.1 Mild Mental Retardation

Mild mental retardation (IQ range, 50-55 to 70) represents approximately 85
percent of persons with mental retardation. In general, children with mild mental
retardation are not identified until after first or second grade, when academic
demands increase. By late adolescence, they often acquire academic skills at
approximately a sixth grade level. Specific causes for the mental retardation are
often unidentified in this group. As adults they are likely to be able to maintain
themselves in unskilled jobs or in sheltered workshops, although they may need
help with social and financial problems. Many adults with mild mental retardation
can live independently with appropriate support and raise their own families.

3.3.2 Moderate Mental Retardation

Moderate mental retardation (IQ range, 35-40 to 50-55) represents about 10
percent of persons with mental retardation. Most children with moderate mental
retardation acquire language and can communicate adequately during early
47
Childhood Psychopathology childhood. They are challenged academically and often are not able to achieve
academically above a second to third grade level. During adolescence,
socialisation difficulties often set these persons apart, and a great deal of social
and vocational support is beneficial. Brain damage and other pathologies are
frequent. People with moderate mental retardation may have physical defects
and neurological dysfunctions that hinder fine motor skills, such as grasping and
colouring within lines, and gross motor skills, such as running and climbing. As
adults, persons with moderate mental retardation may be able to perform
semiskilled work under appropriate supervision.

3.3.3 Severe Mental Retardation

Severe mental retardation (IQ range, 20-25 to 35-40) comprises about 4 percent
of individuals with mental retardation. They typically demonstrate basic motor
and communication deficits during infancy. Many also show signs of neurological
dysfunction and have an increased risk for brain seizure disorder, or epilepsy. In
school, they may be able to string together only two or three words when speaking.
Individuals in this category usually require careful supervision, profit somewhat
from vocational training, and can perform only basic work tasks in structured
and sheltered settings. Their understanding of communication is usually better
than their speech. In adulthood, persons with severe mental retardation may adapt
well to supervised living situations, such as group homes, and may be able to
perform work-related tasks under supervision.

3.3.4 Profound Mental Retardation

Profound mental retardation (IQ range below 20-25) constitutes approximately
1 to 2 percent of persons with mental retardation. Most individuals with profound
mental retardation have identifiable causes for their condition. This level of
retardation is very noticeable at birth or early infancy. With training, people with
profound mental retardation may learn or improve basic skills such as walking,
some talking, and feeding themselves. They need a very structured environment,
with close supervision and considerable help, including a one-to-one relationship
with a caregiver, in order to develop to the fullest.

Severe and profound levels of mental retardation often appear as part of larger
syndromes that include severe physical handicaps. The physical problems are
often even more limiting than the individual’s low intellectual functioning and
in some cases can be fatal.
The four ranges of MR, according to the DSM-IV-TR (APA, 2000) are:
• Mild MR: 50–55 to approximately 70 IQ
• Moderate MR: 35–40 to 50–55
• Severe MR: 20–25 to 35–40
• Profound MR: Below IQ of 20–25

3.4 PREVALENCE OF MENTAL RETARDATION

The prevalence of mental retardation at any one time is estimated to range from
1 percent to 3 percent of the population. The incidence of mental retardation is
difficult to calculate because mild mental retardation sometimes goes
48
unrecognised until middle childhood. In some cases, even when intellectual
function is limited, good adaptive skills are not challenged until late childhood Mental Retardation
or early adolescence, and the diagnosis is not made until that time. The highest
incidence is in school-age children, with the peak at ages 10 to 14 years. Mental
retardation is about 1.5 times more common among men than among women. In
older persons, prevalence is lower; those with severe or profound mental
retardation have high mortality rates because of the complications of associated
physical disorders.
Remember
Terman’s idea of the intelligence quotient (IQ) allows for comparing the
mental functioning of children of different ages. The formula is to divide
mental age by chronological age (multiply by 100). For example, Sham is
8 years old (chronologically), but he functions like a 6 year old. His IQ
would be 6/8 × 100 = 75.

3.5 ETIOLOGY OF MENTAL RETARDATION

In only about 25 percent of population with mental retardation the primary cause
has been identified. The specific causes that are identified are typically biological.
The causes include:

3.5.1 Genetic Conditions and Chromosomal Abnormalities

Sometimes MR is caused by genetic defects that can be inherited from parents,
or result from chromosomal abnormalities when genes combine, or other genetic
reasons. Examples of genetic conditions are Down syndrome, Fragile X syndrome,
and phenylketonuria (PKU).

Down syndrome
Down syndrome (or Mongolism) is a chromosomal abnormality involving
chromosome 21 (trisomy or extra chromosome 21). There are variations within
the disorder and not all features are present in every one with Down syndrome.
Some of the more classic features include, short stature, short broad hands and
feet, round face, almond-shaped eyes (oblique eye fissures), flat facial features
(protruding tongue), and low muscle tone. Language and motor skills are the
most impaired in children with Down syndrome. Speech problems are common,
as are health problems, especially with the heart. The cardinal feature of Down
syndrome is a limitation in intellectual functioning. The average score for an
individual with Down syndrome is approximately an IQ of 50. Mental age in
individuals with Down syndrome is typically 8 years of age or lower. There is
increased risk for having a child with Down syndrome with increases in maternal
and paternal age. Although normally approximately 1 in 800 births will be a
Down syndrome infant, the risk for women over 45 years of age is 1 in 25 births.

Fig.3.1: Children with Down syndrome 49

Childhood Psychopathology Fragile X syndrome
This is the most common inherited cause after Down syndrome of mental
retardation, in which the X chromosome breaks into two. The symptoms of Fragile
X include intellectual deficits, and possible physical characteristics (longer ears,
faces, and jaws). There may also be challenging behaviours (fearfulness, anxiety)
and males may tend to be inattentive or aggressive, while females may appear
withdrawn and shy. Language problems are also often evident and children may
exhibit heightened sensitivity to sound, touch, and bright light. A number of
children with Fragile X will also have co morbid autism.

Phenylketonuria (PKU)
A number of disabilities can be caused by recessive genes. One of the most
commonly occurring recessive disorders that can cause serious mental retardation
is phenylketonuria, or PKU. Infants born with two recessive genes lack a necessary
enzyme which is responsible for converting one of the basic amino acids
(phenylalanine) into a product (tyrosine) that is essential to body functioning. If
the enzyme is not present, phenylalanine will continue to build, reaching toxic
levels that can damage the central nervous system (CNS). Unchecked, the infant
will develop progressive mental retardation and if not found prior to 1 year of
age, the infant will become permanently retarded. Detected early, parents of
children with PKU are advised to provide the infant a diet low in phenylalanine
so that they can develop normally and reach a normal level of intelligence.

3.5.2 Environmental Factors

Mental retardation can result when the foetus is exposed to environmental toxins
(called taratogens) that can cause damage to the unborn foetus when they cross
the placenta during pregnancy when vital organs and the nervous system are in
the process of being developed.

Maternal Substance Use/Abuse

Babies born to mothers who use cocaine can suffer a wide range of side effects
after birth, including physical defects and brain dysfunction in haemorrhages
and seizures. Mothers who are addicted to crack often give birth to infants who
suffer from low birth weight and damage to the CNS.

Foetal alcohol syndrome (FAS)

Approximately 33% of all babies born to mothers who are heavy consumers of
alcohol will be born with foetal alcohol syndrome (FAS). Clinical features of
FAS include central nervous system dysfunction (mental retardation, hyperactivity,
irritability); impaired motor coordination and over activity. Physically, these
children often evidence slow growth and unusual facial features, including
underdeveloped upper lip, flattened nose, or short and upturned widely spaced
eyes, and small head. Although facial features become less pronounced with
age, cognitive deficits remain. If a child has a milder set of symptoms, often
associated with less maternal alcohol consumption during pregnancy, the resulting
syndrome is referred to as foetal alcohol effects.

Exposure to Toxins
Environmental pollutants like mercury and lead can cause poisoning and mental
retardation. Mercury may be ingested by eating affected fish. Lead is found in
50
lead-based paints, smog, and the exhaust from automobiles that burn leaded Mental Retardation
fuel. Exposure to lead-based paint has been implicated in many complications
regarding pregnancy, birth, and infant/child outcomes. Lead-based paint can be
consumed by infants from paint chips that fall off the walls of older residences,
or pregnant women can be exposed to these conditions. Prenatal exposure to
lead-based paint has been linked to brain damage and a host of physical side
effects like kidney damage, anaemia, and seizures. A number of studies have
demonstrated the harmful effects of lead exposure to human and animals in
addition to IQ in areas of attention, learning, memory, school performance, and
behaviour.

Other proven or suspected environmental developmental neuro-toxicants include

PCB, dioxins, pesticides, tobacco smoke, maternal use of tobacco, marijuana,
and cocaine and thalidomide.

Infectious Diseases
When in utero the foetus is at increased risk of mental retardation resulting from
maternal infectious diseases such as rubella (German measles). The extent of
impairment of the unborn child depends upon when the mother is exposed to
rubella relative to foetal development. The greatest impairments in the foetus
occur if exposure coincides with the embryonic period (3 to 8 weeks gestation).
Mothers who contract rubella during this time frame expose the unborn embryo
to a 50% chance of impairments in the formation of eye, ear, heart, inner organs,
and mental capacity. As a result of exposure to rubella in utero, children born
with congenital rubella syndrome often have multiple handicaps including low
IQ, sensory impairments (vision, hearing loss), and demonstrate self-injurious
behaviours or aggression.

Cytomegalovirus, toxoplasmosis, rubella, herpes simplex, and syphilis are all

maternal infections that can cause both physical deformities and mental
retardation. The mother may experience slight or no symptoms from the infections,
but the on the developing foetus can be devastating. Pregnant women who go for
prenatal checks are given a blood test for syphilis. Women today can also have
their blood tested to determine whether they are immune to rubella and if not
they are advised to be vaccinated at least six months before becoming pregnant.

HIV infection has become a significant cause of mental retardation. When not
treated for HIV infection during pregnancy and delivery, an HIV positive woman
is more likely to pass on the virus to the developing foetus, and about half of
these infected infants develop mental retardation.

Infectious diseases can also affect a child’s developing brain after birth.
Encephalitis and meningococcal meningitis may cause irreversible brain damage
and even death if contracted in infancy and early childhood.

Birth Trauma and Problems at Birth

A lack of oxygen at birth (anoxia) can result due to several reasons including
having the cord wrapped around the babies’ neck, or the baby presenting in a
difficult position for birth (e.g., breech position requiring delivery to be feet
first). A lack of oxygen supply to the brain could result in higher risk for intellectual
deficits.
51
Childhood Psychopathology Prematurity
Prematurity (in particular, birth weight around or under 1000 g) is a well-known
risk factor. Survival rates for infants born prematurely in neonatal care centres
increase with each week of gestational age from 22 (0–21%) to 26 weeks (75–
93%). The majority of the survivors will be free of major disability, even though
about 20 per cent will later be diagnosed as having mental retardation and another
40–50 percent may have subtle neurodevelopmental or neuropsychiatric disabilities
in the school and teenage years. Even birth weights under about 3000 g can
cause increased risk for school identified disability including MR.

Traumatic brain injury increases the risk for MR as well as for a number of
adverse behavioural outcomes. Children exposed to violence, accidents (falls,
near drowning, and automobile accidents) often lead to traumatic brain injury
and mental retardation. Trauma-related psychological distress may also cause
significant reductions of IQ.

3.5.3 Psychosocial Factors

Psychosocial factors interact with environmental factors in a variety of ways to
produce a range of clinical presentations in the field of MR. Psychosocial
deprivation can lead to reduction in IQ. The effects can be transient in some
cases where the psychosocial environment is changed for the better at an early
stage. However, they can also be long-term, possibly permanent, in cases of
long-standing deprivation (including in children raised in extremely under-
stimulating orphanages or homes). In such cases, the effects on IQ are likely to
occur through permanently altered brain function. Psychosocial deprivation is
much more likely to account for an important proportion of MR variance in
underdeveloped countries, and in slums.
Self Assessment Questions
Multiple Choices
1) One of the definitional criterions of mental retardation is that it should
occur before age .........................................
a) 15
b) 18
c) 16
d) 21
2) According to the DSM–IV–TR, which of the following children would
be considered to have a moderate degree of MR?
a) Ram, who has an IQ of 48 and has three adaptive deficits
b) Om, who has an IQ of 56 and has two adaptive deficits
c) George, who has an IQ of 30 and has four adaptive deficits
d) Hari, who has an IQ of 34 and has three adaptive deficits
3) Given the moderate level of retardation, academic expectations would
be equivalent to:
a) Grade 6 level

52
 Mental Retardation
b) pre-academic skills
c) about a Grade 2 level
d) Grade 5 level.
4) Down syndrome was initially classified as:
a) Warren’s syndrome.
b) Mongolism.
c) Fragile X syndrome.
d) Moronic syndrome.
5) Which of the following is not an intelligence test?
a) Bayley Scales of Infant Development
b) Wechsler Intelligence Scale for Children
c) Vineland Adaptive Behaviour Scales
d) The Stanford –Binet
6) Which of the following is not a teratogen?
a) Alcohol
b) Anoxia
c) lead-based paint
d) PCB

3.6 PREVENTION AND TREATMENT OF MENTAL

RETARDATION
Prevention of mental retardation depends on understanding its causes. The
importance of prevention and early intervention cannot be overemphasised.
Prevention programs have to be launched at all levels of intervention from prenatal
awareness campaigns (Effects of drug abuse and alcohol; genetic counselling)
to early intervention programs targeting parenting skills and early stimulation
programs. The impact of early intervention programs within the first 5 years of
life has been documented in various studies in the prevention of cognitive declines.

Interventions for children with MR vary widely depending on the specific area
(behavioural or intellectual) targeted for improvement. The majority of
interventions focus on the reduction of behavioural/emotional issues, or increasing
social, educational, or adaptive functions.

3.6.1 Behavioural Interventions

Behavioural programs have been very successful in targeting and altering
problematic social, emotional, and behavioural concerns. The reason for the
success of the behavioural programs can be linked to their focus on breaking
down problem behaviours into component parts (simplicity) and to systematically
shape behaviours into more socially adaptive behaviours through contingency
management. There is a wealth of empirical support for the use of behavioural
methods with MR populations.
53
Childhood Psychopathology There are many different techniques that can be adapted to suit programs across
the developmental spectrum and can be applicable to a wide range of problem
behaviours (e.g., behaviour chaining, secondary rewards, token economies).

Applied Behaviour Analysis (also known as Intensive Behavioural Intervention

or IBI) is one of the more effective teaching strategies devised for helping mentally
retarded children to learn. The approach is based squarely on learning theory and
classical and instrumental learning approaches.

Applied behaviour analysis takes complex tasks ( such as eating) and breaks
them down into their most fundamental parts (pick up spoon, scoop food from
plate onto spoon, bring spoon to mouth, remove food with lips, chew and swallow
food). Skills are systematically introduced in small steps. As one small skill is
mastered, the next is introduced. Students learn by making simple associations
between causes and effects. They are presented with a stimulus (an object or a
signal) and given an instruction. If they respond appropriately, they are
immediately rewarded and inappropriate behaviours are ignored, redirected, or
discouraged. Applied behaviour analysis’s emphasis on providing immediate
rewards for correct behaviour is crucial to motivation.

Behavioural programs that use contingency management techniques (such as

consequences for good behaviour i.e. rewards; or consequences for inappropriate
behaviours, such as removal of privileges) can be developed to either decrease
inappropriate behaviours (aggression, noncompliance) or increase deficit
behaviours (compliance, social skills) at school and in the home.

3.6.2 Cognitive Interventions

Many children with mental retardation fail to use strategies in solving problems,
and when they do have strategies, they often do not apply them effectively. Self-
instructional training teaches these children to guide their problem-solving efforts
through speech. Meichenbaum and Goodman (1971) outlined a five-step
procedure.

• The teacher performs the task, speaking instructions aloud to himself or

herself while the child watches and listens.

• The child listens and performs the task while the teacher says instructions to
the child.

• The child repeats the task while giving himself /herself instructions aloud.

• The child repeats the task again while whispering the instructions.

• Finally, the child is ready to perform the task while uttering instructions
silently to her/him.

• Children with more severe retardation use signs rather than speech to guide
themselves trough the tasks.

Self-instructional training has been employed to teach retarded children self-

control and how to pay attention as well as how to master academic tasks. Children
with severe retardation can effectively master self-help skills through this
technique.
54
 Mental Retardation

3.6.3 Computer Assisted Instructions

Computer assisted instruction is increasingly found in educational settings of all
kinds. It might be especially helpful in the education of individuals with mental
retardation. The visual and auditory components of computers help maintain the
attention of distractible students. The level of the material can be made to suit
the level of the child and also the computer can meet the need for numerous
repetitions of material without getting bored or impatient as a human teacher
might.

Fig.3.3:Computer-assisted instruction is well suited for children with MR

3.6.4 Parent Training Programmes

Including parents in the intervention process (whether academic, behavioural,
or social) is extremely important. Research has demonstrated that parents can be
effective monitors of their child’s progress and improve overall success by helping
children to transferring skills from one situation to the next. There are many
ways that parents can increase their child’s success, such as helping in transferring
skills learned at school to the home environment or skills learned in leisure
activities to social activities. Transferring information across situations is one of
the more difficult tasks for children with mental retardation.
Self Assessment Questions
1) Define Mental Retardation?
...............................................................................................................
...............................................................................................................
...............................................................................................................
55
Childhood Psychopathology
2) Name the different levels of mental retardation?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What is Phenylketonuria (PKU)?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) Write about the environmental hazards in causing mental retardation?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
5) What is Applied Behaviour Analysis?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

3.7 LET US SUM UP

Since 1876, the American Association for Mental Retardation (AAMR) has been
instrumental in shaping how MR is defined and conceptualised. Mental retardation
is coded on Axis II, due to its lifelong nature. The three criteria for diagnosis
include: significantly subnormal intelligence (IQ 70 or less); impaired adaptive
functioning, and onset before age 18. The DSM recognises four levels of severity
of MR: Mild (IQ 50–55 to 70), Moderate (IQ 35–40 to 50–55), Severe (20–25 to
35–40), and Profound (IQ below 20–25). Contemporary view focuses more on
the strengths of the individual with mental retardation than on their placement to
56 a particular level of MR.
The more severe forms of mental retardation have a biological basis, such as the Mental Retardation
chromosomal trisomy that causes Down syndrome. Certain infectious diseases
in the pregnant mother, such as HIV, rubella, and syphilis, as well as illnesses
that affect the child directly, such as encephalitis, can effect cognitive and social
development, as can malnutrition, severe falls, and accidents that injure the brain.
Environmental factors are considered the principal causes of mild retardation.
Using operant conditioning, self-instructional training, and modelling, therapists
have been able to treat successfully many of the behavioural problems and to
improve their intellectual functioning.

3.8 UNIT END QUESTIONS

1) Explain the three traditional criteria used to define mental retardation?
2) Give a brief summary of the characteristics of people at each level of mental
retardation?
3) Describe in detail the genetic or chromosomal causes of mental retardation?
4) Explain how infectious diseases and birth trauma cause mental retardation?
5) Give an account of types of interventions used for mental retardation?

3.9 SUGGESTED READINGS

Barlow, D.H., & Durand, V.M. 2007. Abnormal Psychology: An Integrative
Approach. Thomson Learning Inc., New Delhi.

Carson, R. C., Butcher, J. N., Mineka, S., Hooley, J.M. 2007. Abnormal
Psychology. Pearson Education: New Delhi.

Sarason, I.G., & Sarason, B.R.2005. Abnormal Psychology: The Problem of

Maladaptive Behaviour. Prentice-Hall of India: New Delhi.

3.10 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Self Assessment Questions 1
1) b, 2) a, 3) c, 4) b, 5) c 6) b

Self Assessment Questions 2

According to DSM-IV TR, mental retardation is defined as significantly sub-
average intellectual functioning along with deficits in adaptive behaviour and
occurring prior to age eighteen.

The DSM recognises four levels of severity of MR: Mild (IQ 50–55 to 70),
Moderate (IQ 35–40 to 50–55), Severe (20–25 to 35–40), and Profound (IQ
below 20–25).

Phenylketonuria is one of the most commonly occurring recessive disorders. In

PKU the baby appears normal at birth but lacks an enzyme needed to break
down phenylalanine, an amino acid found in protein foods. When this condition
is undetected, the phenylalanine builds up in the blood and leads to brain damage
and MR. 57
Childhood Psychopathology Several environmental pollutants can cause MR. Toxic agents, such as carbon
monoxide and lead cause brain damage during foetal development or after birth.
In some instances certain drugs taken by the mother during pregnancy may lead
to congenital malformations, or an overdose of drugs administered to the infant
may result in toxicity and brain damage. Similarly intake of alcohol or smoking
by mother during pregnancy can also lead to mental retardation.

Applied behaviour analysis (ABA) is the science of applying experimentally

derived principles of behaviour to improve socially significant behaviour. It
involves the breakdown of all skills into small, discrete tasks, taught in a highly
structured and hierarchical manner. Central to the successful application of this
method is the art of differential reinforcement. That is, the therapist, parent, or
caregiver learns how to systematically reward or reinforce desired behaviour,
and ignore, redirect, or discourage inappropriate behaviours.

58
 Mental Retardation
UNIT 4 PERVASIVE DEVELOPMENTAL
DISORDERS

Structure
4.0 Introduction
4.1 Objectives
4.2 Pervasive Developmental Disorders
4.3 Characteristic Features of Pervasive Developmental Disorders
4.3.1 Impairment in Social Interaction
4.3.2 Communication Difficulties
4.3.3 Restricted and Repetitive Behaviours
4.3.4 Sensory Problems
4.4 Types of Pervasive Developmental Disorders
4.4.1 Autism Disorder
4.4.2 Asperger’s Disorder
4.4.3 Rett’s Disorder
4.4.4 Childhood Disintegrative Disorder
4.4.5 Pervasive Development Disorder Not Otherwise Specified
4.5 Autism
4.5.1 The Clinical Picture in Autism
4.5.2 Signs of Autism in Infancy, Childhood and Adoloscence
4.5.3 Causal Factors in Autism
4.6 Interventions
4.6.1 Behavioural Issues
4.6.2 Appropriate Educational Programme
4.6.3 Psychological Treatment
4.7 Let Us Sum Up
4.8 Unit End Questions
4.9 Glossary
4.10 Suggested Readings and References
4.11 Answers to Self Assessment Questions

4.0 INTRODUCTION
The pervasive developmental disorders are a group of severely disabling
conditions that are among the most difficult to understand and treat. Persons
with pervasive developmental disorders all experience problems with language,
socialisation, and cognition. The word pervasive means that these problems are
not minor, but significantly affect individuals throughout their lives. In this unit
we would study pervasive developmental disorders, their characteristic features
and different types. Included under pervasive developmental disorders are autistic
disorder (or autism), Asperger’s disorder, Rett’s disorder, childhood disintegrative
disorder, and pervasive developmental disorder-not otherwise specified.
Unfortunately, there is very little research on these categories except autism. In
addition there has been considerable disagreement concerning the validity of
59
Childhood Psychopathology childhood disintegrative disorder and whether it is distinct from autistic disorder.
It is also not clear if Asperger’s disorder differs qualitatively from autistic disorder
or if it differs only in severity. Because of these limitations, in this unit we will
illustrate the pervasive developmental disorders by focusing in detail on autistic
disorder by describing its clinical picture, causal factors and treatment.

4.1 OBJECTIVES
After completing this unit, you will be able to:
• Define Pervasive Developmental disorders;
• Describe their characteristic features;
• Describe various types of pervasive developmental disorders covered in
DSM-IV-TR;
• Define autism;
• Explain the clinical picture and causal factors of autism; and
• Analyse the different treatment methods for pervasive developmental
disorders.

4.2 PERVASIVE DEVELOPMENTAL DISORDERS

Not until the middle of the twentieth century was there a name for a disorder that
affects thousands of children, a disorder that causes disruption in families and
unfulfilled lives for many children. In 1943 Dr. Leo Kanner of the Johns Hopkins
Hospital studied a group of 11 children and introduced the label early infantile
autism into the English language. At the same time a German scientist, Dr. Hans
Asperger, described a milder form of the disorder that became known as Asperger
syndrome. Thus these two disorders are today listed in the Diagnostic and
Statistical Manual of Mental Disorders DSM-IV-TR (fourth edition, text revision)
as two of the five pervasive developmental disorders (PDDs), more often referred
to today as autism spectrum disorders (ASD).

Pervasive developmental disorders are a group of neurobiological disorders that

demonstrate deficits in
1) Social interaction,
2) Verbal and nonverbal communication, and
3) Repetitive behaviours or interests.
In addition, they will often have unusual responses to sensory experiences, such
as certain sounds or the way objects look, and stereotyped behaviours (e.g., hand
flapping, rocking, twirling). Cognitive deficits or uneven skill development are
often present. Each of these symptoms runs the gamut from mild to severe. These
are present in each individual child differently. For instance, a child may have
little trouble learning to read but exhibit extremely poor social interaction. Each
child will display communication, social, and behavioural patterns that are
individualistic but fit into the overall diagnosis of Pervasive developmental
disorders.

60
Children with Pervasive developmental disorders do not follow the typical Pervasive Developmental
Disorders
patterns of child development. In some children, hints of future problems may
be apparent from birth. In most cases, the problems in communication and social
skills become more noticeable as the child lags further behind other children of
the same age. Some other children start off well enough. Oftentimes it is between
12 and 36 months, the differences in the way they react to people and other
unusual behaviours become apparent. Some parents report the change as being
sudden, and that their children start to reject people, act strangely, and lose
language and social skills they had previously acquired. In other cases, there is a
“plateau,” or levelling, of progress so that the difference between the child with
autism and other children the same age becomes more noticeable.

Fig. 4.1: The communication deficits typical of autism often lead to social isolation

4.3 CHARACTERISTIC FEATURES OF

PERVASIVE DEVELOPMENTAL DISORDERS
Pervasive Developmental Disorder is defined by the combination of broad range
of symptoms in domains such as social interaction, play, language and
communication, restrictive and repetitive activities and interests etc. (see Table 4).
These behavioural characteristics are described below.

4.3.1 Impairment in Social Interaction

From the start, typically developing infants are social beings. Early in life, they
gaze at people, turn toward voices, grasp a finger, and even smile. In contrast,
most children with pervasive developmental disorders seem to have tremendous
difficulty learning to engage in the give-and-take of everyday human interaction.

Even in the first few months of life, many do not interact and they avoid eye
contact. They seem indifferent to other people, and often seem to prefer being
alone. They may resist attention or passively accept hugs and cuddling. Later,
they seldom seek comfort or respond to parents’ displays of anger or affection in
a typical way.

61
Childhood Psychopathology Research has suggested that although children with pervasive developmental
disorders are attached to their parents, their expression of this attachment is
unusual and difficult to “read.” To parents, it may seem as if their child is not
attached at all. Parents who looked forward to the joys of cuddling, teaching,
and playing with their child may feel crushed by this lack of the expected and
typical attachment behaviour.

Children with pervasive developmental disorders also are slower in learning to

interpret what others are thinking and feeling. Subtle social cues—whether a
smile, a wink, or a grimace—may have little meaning. To a child who misses
these cues, “Come here” always means the same thing, whether the speaker is
smiling and extending her arms for a hug or frowning and planting her fists on
her hips. Without the ability to interpret gestures and facial expressions, the
social world may seem bewildering.

To compound the problem, people with pervasive developmental disorders have

difficulty seeing things from another person’s perspective. Most 5-year-olds
understand that other people have different information, feelings, and goals than
they have. A child with pervasive developmental disorder may lack such
understanding. This inability leaves them unable to predict or understand other
people’s actions.

Although not universal, it is common for children with pervasive developmental

disorders also to have difficulty regulating their emotions. This can take the
form of “immature” behaviour such as crying in class or verbal outbursts that
seem inappropriate to those around them. The individual with Autism Spectrum
Disorder (ASD) might also be disruptive and physically aggressive at times,
making social relationships still more difficult. They have a tendency to “lose
control,” particularly when they are in a strange or overwhelming environment,
or when angry and frustrated. They may at times break things, attack others, or
hurt themselves. In their frustration, some bang their heads, pull their hair, or
bite their arms.

4.3.2 Communication Difficulties

By age 3, most children have passed predictable milestones on the path to learning
language; one of the earliest is babbling. By the first birthday, a typical toddler
says words, turns when he hears his name, points when he wants a toy, and when
offered something distasteful, makes it clear that the answer is “no.”

Some children diagnosed with pervasive developmental disorders remain mute

throughout their lives. Some infants who later show signs of pervasive
developmental disorders coo and babble during the first few months of life, but
they soon stop.

Others may be delayed, developing language as late as age 5 to 9. Some children

may learn to use communication systems such as pictures or sign language. Those
who do speak often use language in unusual ways. They seem unable to combine
words into meaningful sentences.

Some speak only single words, while others repeat the same phrase over and
over. Some children with pervasive developmental disorders parrot what they
hear, a condition called echolalia. Although many children with no pervasive
62
developmental disorders go through a stage where they repeat what they hear, it Pervasive Developmental
Disorders
normally passes by the time they are 3.

Some children only mildly affected may exhibit slight delays in language, or
even seem to have precocious language and unusually large vocabularies, but
have great difficulty in sustaining a conversation. The “give and take” of normal
conversation is hard for them, although they often carry on a monologue on a
favourite subject, giving no one else an opportunity to comment. Another difficulty
is often the inability to understand body language, tone of voice, or “phrases of
speech.” They might interpret a sarcastic expression such as “Oh, that’s just
great” as meaning it really IS great.

While it can be hard to understand what pervasive developmental disorders

children are saying, their body language is also difficult to understand. Facial
expressions, movements, and gestures rarely match what they are saying. Also,
their tone of voice fails to reflect their feelings. A high-pitched, sing-song, or
flat, robot-like voice is common.

Some children with relatively good language skills speak like little adults, failing
to pick up on the “kid-speak” that is common in their peers. Without meaningful
gestures or the language to ask for things, children with pervasive developmental
disorders are at a loss to let others know what they need.

As a result, they may simply scream or grab what they want. Until they are
taught better ways to express their needs, children with pervasive developmental
disorders do whatever they can to get through to others. As children with pervasive
developmental disorders grow up, they can become increasingly aware of their
difficulties in understanding others and in being understood. As a result they
may become anxious or depressed.

4.3.3 Restricted and Repetitive Behaviours

Although children with pervasive developmental disorders usually appear
physically normal and have good muscle control, odd repetitive motions sets
them off from other children. These behaviours might be extreme and highly
apparent or more subtle. Some children and older individuals spend a lot of time
repeatedly flapping their arms or walking on their toes. Some suddenly freeze in
position.

As children, they might spend hours lining up their cars and trains in a certain
way, rather than using them for pretend play. If someone accidentally moves one
of the toys, the child may be tremendously upset.

Children with pervasive developmental disorders need, and demand, absolute

consistency in their environment. A slight change in any routine—in mealtimes,
dressing, taking a bath, going to school at a certain time and by the same route—
can be extremely disturbing.

Perhaps order and sameness lend some stability in a world of confusion. Repetitive
behaviour sometimes takes the form of a persistent, intense preoccupation. For
example, the child might be obsessed with learning all about vacuum cleaners,
train schedules, or lighthouses. Often there is great interest in numbers, symbols,
or science topics.
63
Childhood Psychopathology
CASE STUDY
Sham was an active and busy child. But his parents were worried about
him. Compared with the other 3-year-olds they knew, Sham was different—
he wasn’t talking, and he didn’t seem to want or try to play with his sister.
At nursery school Sham wouldn’t join in with the other kids, but he really
enjoyed playing with water. He would splash and play at the sink for hours,
with a big smile on his face. After a year of expressing concern to their
paediatrician, Sham’s parents finally obtained a referral to a psychologist
who diagnosed Sham as having pervasive developmental disorder.

4.3.4 Sensory Problems

When children’s perceptions are accurate, they can learn from what they see,
feel, or hear. On the other hand, if sensory information is faulty, the child’s
experiences of the world can be confusing. Many children with pervasive
developmental disorders are highly attuned or even painfully sensitive to certain
sounds, textures, tastes, and smells.

Some children find the feel of clothes touching their skin almost unbearable.
Some sounds—a vacuum cleaner, cooker whistle, a ringing telephone, a sudden
storm, even the sound of waves lapping the shoreline—will cause these children
to cover their ears and scream.

In pervasive developmental disorders, the brain seems unable to balance the

senses appropriately. Some children with pervasive developmental disorder are
oblivious to extreme cold or pain. A child with pervasive developmental disorder
may fall and break an arm, yet never cry. Another may bash his head against a
wall and not wince, but a light touch may make the child scream with alarm.

Table: Symptom Categories in the Pervasive Developmental Disorders

Social Impairment of interpersonal relatedness, impaired
capacity for empathy, lack of interest in others
Communication Deficits in language, abnormalities of form, and/or
content of language, deficits in nonverbal
communication
Behaviour Stereotyped behaviour, need for constancy in the
environment, resistance to change

4.4 TYPES OF PERVASIVE DEVELOPMENTAL

DISORDERS
The term pervasive developmental disorders (PDDs) is a relatively new
classification which was first used in the 1980s to describe a class of childhood-
onset brain disorders that resulted in severe and pervasive impairments in
functioning. Disorders within this classification share common characteristics
of impairments in social interaction, imaginative activity, verbal and nonverbal
communication skills, and a limited number of interests and activities that tend
to be repetitive. The latest revision of the DSM–IV–TR (APA, 2000) recognises
five disorders under the category of Pervasive Developmental Disorders (see
table. for comparison of pervasive developmental disorders):
64
1) Autistic disorder Pervasive Developmental
Disorders
2) Asperger’s disorder or Asperger’s Syndrome (AS)
3) Rett’s disorder
4) Childhood Disintegrative Disorder (CDD)
5) Pervasive Developmental Disorder Not Otherwise Specified, or PDDNOS

4.4.1 Autistic Disorder

The best known of these disorders, is characterised by sustained impairment in
comprehending and responding to social cues, aberrant language development
and usage, and restricted, stereotypical behavioural patterns. Individuals with
Autism vary widely in symptom expression, cognitive level, and adaptive abilities.

4.4.2 Asperger’s Disorder

Asperger’s disorder is characterised by impairment and oddity of social interaction
and restricted interest and behaviour similar to those seen in autistic disorder. It
is regarded as a mild version of autism. Unlike autistic disorder, in Asperger’s
disorder no significant delays occur in language, cognitive development, or age-
appropriate self-help skills.

Asperger’s Disorder appears to have a somewhat later onset than Autistic Disorder,
or at least is recognised later. An individual with Asperger’s Disorder does not
possess a significant delay in language development; however, he or she may
have difficulty understanding the subtleties used in conversation, such as irony
and humour. Also, while many individuals with autism have mental retardation,
a person with Asperger’s possesses an average to above average intelligence.
Asperger’s is sometimes incorrectly referred to as “high-functioning autism.”

4.4.3 Rett’s Disorder

Rett’s syndrome is relatively rare, affecting almost exclusively females, one out
of 10,000 to 15,000. After a period of normal development, sometime between 6
and 18 months, autism-like symptoms begin to appear. The little girl’s mental
and social development regresses. Children with Rett’s Disorder follow an
apparently normal prenatal and perinatal period of development, with typical,
early psychomotor development and normal head circumference at birth.

This period of fairly typical development is followed by a gradual loss of speech

and purposeful hand use and the development of microcephaly (deceleration of
head growth) , seizures, autistic features, difficulties in coordinating gait or trunk
movements, and stereotypic hand movements (such as hand wringing, licking or
biting the fingers and tapping or slapping).

Interest in social engagement diminishes in the first few years following onset,
but may re-emerge later. Children with Rett’s Disorder have severe impairment
in language development, severe psychomotor retardation, and severe to profound
mental retardation. Some of the problems associated with Rett’s disorder can be
treated. Physical, occupational, and speech therapy can help with problems of
coordination, movement, and speech.

65
Childhood Psychopathology 4.4.4 Childhood Disintegrative Disorder
Childhood Disintegrative Disorder (CDD), also termed Heller’s syndrome, is
characterised by a marked regression in several areas of functioning following
normal development in the first 2 years of life.
Regression can occur any time after the first 2 years and before age 10, but onset
typically occurs before 4 years of age. After the deterioration, the children closely
resemble children with autistic disorder. The core features of the disorder include
loss of communication skills, marked regression of reciprocal interactions, and
the onset of stereotyped movements and compulsive behaviour.
Emotional symptoms are common, particularly anxiety and also is the regression
of self-help skills, such as bowel and bladder control. Very few children who
have pervasive developmental disorder diagnosis meet the criteria for childhood
disintegrative disorder (CDD).
An estimate based on four surveys of pervasive developmental disorders found
fewer than 2 children per 100,000 with pervasive developmental disorders could
be classified as having CDD. This suggests that CDD is a very rare form of
pervasive developmental disorders. It has a strong male dominance. The long
period of normal development before regression helps differentiate CDD from
Rett’s syndrome.

4.4.5 Pervasive Developmental Disorder Not Otherwise Specified

A diagnosis of Pervasive Developmental Disorder not otherwise specified
(PDDNOS) is given when there exists clinically significant impairments in social
interaction and/or communication, or restricted interests and behaviours, but
criteria for a specific pervasive developmental disorder are not met or do not
have the degree of impairment described in any of the above four pervasive
developmental disorders specific types This usually occurs in cases where
symptoms are present but are too few in number to meet criteria for a specific
diagnosis. The condition usually shows a better outcome than autistic disorder.
Table: Comparison of Pervasive Developmental Disorder Diagnoses
Features Autistic Asperger’s Rett’s Disorder Childhood
Disorder Disorder Disintegrative
Disorder
Age at Onset < 3 years, usually Typically > 3 Deceleration of 2–10 years; normal
in first year years; no delays in head growth, development prior
language and 6–18 months; to 2 years of age
cognitive loss of
development purposeful hand
skills, 6–30
months

Gender 4–5 times more At least 5 times Reported almost Occurs in slightly
likely in males more likely in exclusively in more males than
than in females males than in females females
females

Relationship Typically mild to None Severe to Severe MR

to mental profound MR; profound
retardation females likely to MR
(MR) exhibit more
severe MR
66
 Pervasive Developmental
Pervasive
Degenerative No No Yes In most children, Developmental
Disorders
Disorders
degeneration
stabilizes;
occasionally
some skills
regained

Seizures Occur in up to No Yes Increased risk of

25% of children Seizures
and adolescents;
more common in
adolescence

Examples of Fragile X Chromosomal Not applicable Metachromatic

associated syndrome; aberrations; leukodystrophy;
conditions tuberous obsessive Schilder’s disease
sclerosis; compulsive
neurofibromatosis; disorder;
chromosomal depression;
aberrations attention
deficit
hyperactivity
disorder

Self Assessment Questions

Multiple Choices
1) The term pervasive developmental disorder is a relatively new category
of classification. The term was first used in the:
a) 1960s
b) 1940s
c) 1980s
d) 1990s
2) The latest revision of the DSM–IV–TR (APA, 2000) recognises _____
disorders under the category of Pervasive Developmental Disorders.
a) Three
b) Five
c) Two
d) Four
3) Which of the following is not true regarding Rett’s disorder?
a) functional hand use is replaced by hand wringing movements
b) deceleration of head growth
c) onset of poor coordination, gait
d) loss of speech function

67
Childhood Psychopathology
4) Which of the following is false regarding prevalence rates for pervasive
developmental disorders?
a) The ratio of autism to Asperger’s disorder has been reported as 4
to 1
b) Males are more likely to be diagnosed with autism than females
c) Females have less severe forms of autism than males
d) Males are 5 times more likely to be diagnosed with Asperger’s
syndrome than females.
5) Which of the following is true regarding Rett’s disorder?
a) Males who have the mutated gene die shortly after birth
b) Males cannot inherit the disorder because it is on an X chromosome
c) Only females are affected by the mutated gene
d) Males are not susceptible to the genetic mutation.

4.5 AUTISM
Autism or autistic disorder or childhood autism, or Kanner’s autism is described
as one of the most common and most puzzling and disabling of the pervasive
developmental disorders. It is a developmental disorder that involves a range of
behaviours including deficits in language, and perceptual and motor development;
defective reality testing; and an inability to function in social situations.

Autism in infancy and childhood was first described by Kanner (1943). Autistic
disorder is believed to occur at a rate of about 8 cases per 10,000 children (0.08
percent). By definition, the onset of autistic disorder is before the age of 3 years,
although in some cases, it is not recognised until a child is much older.

Autistic disorder is four to five times more frequent in boys than in girls. Girls
with autistic disorder are more likely to have more severe mental retardation.
There is no clear relation to socio-economic status; the links with high
socio-economic status as suggested by early studies was probably due to referral
bias.

4.5.1 The Clinical Picture in Autism

The most important clinical manifestations of autistic disorder are markedly
abnormal development in social interaction and communication skills, and
patterns of restrictive, repetitive, and stereotyped behaviour and interests.

These manifestations are evident in the first 3 years of life but may present
differently at various developmental stages. Children and adolescents with autistic
disorder may be unable to understand that others have needs or may not be aware
of others’ feelings or distress.

They may treat others as objects, tools, or mechanical aids. In addition, children
and adolescents with autistic disorder may show impairment in their nonverbal
social behaviours (e.g., lack of eye-to-eye gaze, reciprocal smiling, and
affectionate contact) and in their inability engage in symbolic or imaginative
68 play.
In addition, a high prevalence of sleep problems has been reported for autistic Pervasive Developmental
Disorders
children. Failure to cooperate in toilet training and aversion to certain foods
creates added difficulty for parents of autistic children and may disrupt family
life.

Self-injurious behaviour (e.g., head banging, self-biting, hair pulling) can occur
in more severely affected children and adolescents. Some children and adolescents
with autistic disorder may have “islets of precocity” (i.e., highly developed skills
in very narrow and specific areas, such as the ability to decode numbers, list
things from memory, or draw or play music exceptionally well) that contrast
markedly with the level of their general cognitive functioning.

A Mothers Story
Ryan, always in a whirl of activity, has had many labels. He was diagnosed
with PDDNOS at age three and a half. When he went to preschool, his
label was “developmentally delayed.” Now he’s 8 years old, and his label
is “autistic.” He spends most of his time in a 2nd grade class. He’s doing
great, but he still needs lots of extra help—speech therapy, occupational
therapy, and physical therapy. He loves playing football with kids in his
class. His disability is only one part of who he is; he also has lots of strengths
and talents. Every day still has its challenges, but we love him. He’s not a
label—he’s Ryan.

4.5.2 Signs of Autism in Infancy, Childhood and Adolescence

Infancy
Infants with autistic disorder may show little interest in being held, or they may
not be comforted by physical closeness with their parents. They have significant
limitations in social smiling, eye contact, vocalisation, and social play. Infants
with autistic disorder display little interest in the human face.

Early Childhood
Children may not follow (shadow) their parents at home, preferring to be alone.
They may not show anxiety in being separated from their parents but may become
noticeably agitated in response to minor changes in their environment or routine.

They often display echolalia (stereotyped repetition of another person’s words

or phrases), repetitive motor behaviour, and unusual attachments to objects. As
they grow older they tend not to make friends and do not exhibit social or
emotional reciprocity.

Children commonly demonstrate delays in or total lack of development of spoken

language.

Middle Childhood
Children rarely share pleasure or excitement with others, and their social and
vocal expressions and interactions are limited.

Adolescence
Adolescents show significant deficits in understanding social expectations and
have few or no friendships. They may exhibit unusual affect and perseverative
(persistent and repetitive), ritualistic speech or behaviours. 69
Childhood Psychopathology 4.5.3 Causal Factors in Autism
Genetic Factors
Current evidence supports a genetic basis for the development of autistic disorder
in most cases, with a contribution of up to four or five genes. Family studies
have demonstrated a 50 to 200 times increase in the rate of autism in siblings of
a child with autistic disorder. Additionally, even when not affected with autism,
siblings are at increased risk for a variety of developmental disorders often related
to communication and social skills. The specific modes of inheritance are not
yet clear.

Current research has revealed promising leads on genes likely to cause the
development of autistic disorder. Linkage analyses have demonstrated that regions
of chromosomes 7, 2, 4, 15, and 19 are likely to contribute to the genetic basis of
autism. It now appears that multiple genes are involved in the development of
autism.

The results of the two of the largest twin studies show that the rate of autistic
disorder was 36 percent in monozygotic pairs versus 0 percent in dizygotic pairs
in one study and about 96 percent in monozygotic pairs versus about 27 percent
in dizygotic pairs in the second study. High rates of cognitive difficulties, even
in the non autistic twin in monozygotic twins with perinatal complications, suggest
that perinatal problems along with genetic vulnerability may lead to autistic
disorder.

Fragile X syndrome, a genetic disorder in which a portion of the X chromosome

fractures, appears to be associated with autistic disorder. Approximately 1 percent
of children with autistic disorder also have fragile X syndrome. Children with
fragile X syndrome tend to show gross motor and fine motor difficulties as well
as relatively poorer expressive language compared with children with autism
without fragile X syndrome.

Tuberous sclerosis is a rare genetic disorder that causes benign tumours to grow
in the brain as well as in other vital organs. It has a consistently strong association
with pervasive developmental disorders. One to 4 percent of people with pervasive
developmental disorders also have tuberous sclerosis.

Biological Factors
The high rate of mental retardation among children with autistic disorder and
the higher-than-expected rates of seizure disorders further support the biological
basis for autistic disorder. Approximately 70 percent of children with autistic
disorder have mental retardation. About one third of these children have mild to
moderate mental retardation, and close to half of these children are severely or
profoundly mentally retarded. Children with autistic disorder and mental
retardation typically show more marked deficits in abstract reasoning, social
understanding, and verbal tasks than in performance tasks, such as block design
and digit recall.

Of persons with autism, 4 to 32 percent have grand mal seizures at some time,
and about 20 to 25 percent show ventricular enlargement on computed
tomography (CT) scans. Various electroencephalogram (EEG) abnormalities are
found in 10 to 83 percent of autistic children, and although no EEG finding is
70
specific to autistic disorder, there is some indication of failed cerebral Pervasive Developmental
Disorders
lateralisation.

Perinatal Factors
A higher-than-expected incidence of perinatal complications seems to occur in
infants who are later diagnosed with autistic disorder. Maternal bleeding after
the first trimester and meconium in the amniotic fluid have been reported in the
histories of autistic children more often than in the general population. In the
neonatal period, autistic children have a high incidence of respiratory distress
syndrome and neonatal anaemia.

Autistic disorder is also associated with neurological conditions, notably

congenital rubella, phenylketonuria (PKU), and tuberous sclerosis. The finding
that autistic children have significantly more minor congenital physical anomalies
than expected suggests abnormal development within the first trimester of
pregnancy.

Males with autism, as a group, have been found to be the products of longer
gestational age and were heavier at birth than babies in the general population.
Females with autism are more likely to be the product of post-term pregnancies
than babies in the general population.

Socio-cultural Factors
At first, theorists thought that family dysfunction and social stress were the
primary causes of autism. When he first identified autism, for example, Kanner
argued that particular personality characteristics of the parents created an
unfavourable climate for development and contributed to the child’s disorder.
He saw these parents as very intelligent yet cold-”refrigerator parents.”

These claims had enormous influence on the public and on the self-image of the
parents themselves, but research has totally failed to support a picture of rigid,
cold, rejecting, or disturbed parents. Similarly, some clinical theorists have
proposed that a high degree of social and environmental stress is a factor in
autism. Once again, however, research has not supported this notion. Investigators
who have compared children with autism to children without the disorder have
found no differences in the rate of parental death, divorce, separation, financial
problems, or environmental stimulation.

Psychological Factors
According to certain theorists, people with autism have a central perceptual or
cognitive disturbance that makes normal communication and interactions
impossible. One influential explanation holds that individuals with the disorder
fail to develop a theory of mind i.e. an awareness that other people base their
behaviours on their own beliefs, intentions, and other mental states, not on
information that they have no way of knowing.

By 3 to 5 years of age, most children can interpret and understand from the
perspective of another person and use it to anticipate what the person will do. In
a way, they learn to read others’ minds. Let us say, for example, that we watch
Sunil place a marble in a container and then we observe Ram moves the marble
to a nearby basket while Sunil is playing elsewhere.
71
Childhood Psychopathology We know that later Sunil will search first in the container for the marble because
he is not aware that Ram moved it. We know that because we take Sunil’s
perspective into account. A normal child would also anticipate Sunil’s search
correctly. A person with autism would not. He or she would expect Sunil to look
in the nearby basket because that is where the marble actually is. Sunil’s own
mental processes would be unimportant to the person.

Studies show that people with autism do have this kind of “mind blindness,”
although they are not the only kinds of individuals with this limitation. They
thus have great difficulty taking part in make-believe play, using language in
ways that include the perspectives of others, developing relationships, or
participating in human interactions.

Children with autism who score above an IQ of 70 are referred to as having

high functioning autism (HFA). Within the diagnosis of autism, males are 9
times more likely than females to be labelled as HFA.

4.6 INTERVENTIONS
No one therapy or method will work for all individuals with Autistic Disorder or
pervasive developmental disorders. Many professionals and families will use a
range of treatments simultaneously, including behaviour modification, structured
educational approaches, medications, speech therapy, occupational therapy, and
counselling.

These treatments promote more typical social and communication behaviour

and minimise negative behaviours (e.g., hyperactivity, meaningless, repetitive
behaviour, self-injury, aggressiveness) that interfere with the child’s functioning
and learning. There has been an increasing focus on treating preschool children
with pervasive developmental disorders by working closely with family members
to help the children cope with the problems encountered at home before they
enter school. Many times, the earlier these children begin treatment, the better
the outcome.

4.6.1 Behavioural Issues

As children with pervasive developmental disorders struggle to make sense of
the many things that are confusing to them, they do best in an organised
environment where rules and expectations are clear and consistent. The child’s
environment needs to be very structured and predictable. Many times a behaviour
problem indicates that the child is trying to communicate something — confusion,
frustration or fear.

Think of the child’s behaviour problem as a message to be decoded. Try to

determine the possible cause of the behaviour. Has the child’s routine or schedule
changed recently? Has something new been introduced that may be distressing
or confusing the child? When a child’s communication skills improve, behaviour
problems often diminish—the child now has a means of expressing what is
bothering him or her, without resorting to negative behaviour. The use of positive
behavioural support strategies for these children has proved effective.

72
4.6.2 Appropriate Educational Programme Pervasive Developmental
Disorders
Education is the primary tool for treating pervasive developmental disorders.
Many children with pervasive developmental disorders experience the greatest
difficulty in school, where demands for attention and impulse control are virtual
requirements for success. Behavioural difficulties can prevent some children
from adapting to the classroom. However, with appropriate educational help, a
child with pervasive developmental disorders can succeed in school. The most
essential ingredient of a quality educational program is a knowledgeable teacher.
Other elements of a quality educational program include:
• structured, consistent, predictable classes with schedules and assignments
posted and clearly explained;
• information presented visually as well as verbally;
• opportunities to interact with non-disabled peers who model appropriate
language, social, and behavioural skills;
• a focus on improving a child’s communications skills using tools such as
communication devices;
• reduced class size and an appropriate seating arrangement to help the child
with pervasive developmental disorders avoid distraction;
• modified curriculum based on the particular child’s strengths and weaknesses;
• using a combination of positive behavioural supports and other educational
interventions; and
• frequent and adequate communication among teachers, parents, and the
clinician.

4.6.3 Psychological Treatment

Counselling may be helpful to families to help them adjust to raising a child
with a disability. If the child is already attending a school program, both parents
and teachers need to be told of the symptoms of pervasive developmental disorders
and how those symptoms may affect the child’s ability to function at home, in
the neighbourhood, in school, and in social situations.

Psychologists can also provide ongoing assessments, school consultation, case

management, and behaviour training. Some children also benefit from counselling
from an experienced practitioner who knows about pervasive developmental
disorders. Family teamwork can ease the burden on the primary home caregiver,
who needs a support system.
73
Childhood Psychopathology The Lovaas Method
This method (which is a type of Applied Behaviour Analysis [ABA]), developed
by psychologist Ivar Lovaas at UCLA, is an intensive intervention program
originally designed for preschool-aged children with autism. It uses behavioural
techniques such as modelling and reinforcement (rewarding desired behaviour,
and ignoring or discouraging undesirable actions) to achieve its goals. Generally,
this method consists of 30 to 40 hours a week of basic language skills, behaviour,
and academic training.

Therapy usually consists of 4 to 6 hours per day of one-on-one training, 5 to 7

days a week. Some research has shown remarkable progress in about 50% of the
children receiving this therapy. The Lovaas Method is getting wide attention,
but, as with other therapies, it needs more study.

Medical Treatment
There is no one specific medication that helps all children with pervasive
developmental disorders. Some medications have been found to be helpful, but
for many children with autism or pervasive developmental disorders, medication
levels need to be experimented with until the optimal combination and dosage
are found. Since this differs with each child, there is no set medical treatment for
children with pervasive developmental disorders but, rather, an individual
medication regimen for each.

Because of these complexities, in the eyes of many, medication therapy is viewed

as a treatment to be used only when other types of treatment have been
unsuccessful. The most commonly used medication for treating behaviour
problems in autistic children is haloperidol, an antipsychotic medication
frequently used in the treatment of schizophrenia.

This drug has been shown to reduce social withdrawal, stereotyped motor
behaviour, and maladaptive behaviour, such as self-mutilation and aggression.
But many children with autism do not respond positively to the drug. This drug
has also not shown any effect on the other aspects of autism, such as language
impairment and abnormal interpersonal relationships. Haloperidol also has
potentially serious side-effects.

The primary aim of medical treatment of children with pervasive developmental

disorders is to ensure physical and psychological health. A good preventive health
care program should include regular physical checkups to monitor growth, vision,
hearing, and blood pressure; immunisation according to schedule; and attention
to diet and hygiene.

Children with pervasive developmental disorders are not the only ones who need
extra help and support. Parenting a child with special needs is a demanding task.
Learning and accepting that a child has a disability is a very emotional process.
Initially, parents may feel alone and not know where to begin their search for
information, assistance, and support. Parent groups offer parents and families a
place to share information, give and receive emotional and practical support,
and work as a team to address common goals.

74
 Pervasive Developmental
Self Assessment Questions Disorders
1) What are pervasive developmental disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Describe the symptom categories in the pervasive developmental
disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Name the types of disorders covered in pervasive developmental
disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) What is childhood disintegrative disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
5) What is “islets of precocity?”
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

75
Childhood Psychopathology
4.7 LET US SUM UP
Pervasive developmental disorders (PDDs) are a group of neurobiological
disorders characterised by fundamental deficits in social interaction skills or
communication skills, or by the presence of stereotyped (purposeless and
repetitive) behaviours, interests, or activities. Common features include difficulty
with transitions or change, unusual sensory interests or sensitivities, an extremely
narrow and intense focus of interest, and stereotyped behaviours (e.g., hand
flapping, rocking, twirling). Cognitive deficits or uneven skill development are
often present. There are five different categories of Pervasive Developmental
Disorders that are currently recognised by the DSM–IV–TR (APA, 2000),
including: Rett’s disorder, childhood disintegration disorder, autism, Asperger’s
disorder, and PDDNOS.

Autistic disorder, the best known of these disorders, is characterised by sustained

impairment in comprehending and responding to social cues, aberrant language
development and usage, and restricted, stereotypical behavioural patterns.
Asperger’s disorder is a condition in which the child is markedly impaired in
social relatedness and shows repetitive and stereotyped patterns of behaviour
without a delay in language development. In Asperger’s disorder, a child’s
cognitive abilities and adaptive skills are normal. Rett’s disorder appears to occur
exclusively in girls; it is characterised by normal development for at least 6
months, stereotyped hand movements, a loss of purposeful motions, diminishing
social engagement, poor coordination, and decreasing language use. In childhood
disintegrative disorder, development progresses normally for the first 2 years,
after which the child shows a loss of previously acquired skills in two or more of
the following areas: language use, social responsiveness, play, motor skills, and
bladder or bowel control.

Autistic disorder was originally believed to be the result of coldness and aloofness
in parents and their rejection of their children, but research gives no credence to
such notions. A biological cause is suspected for a number of reasons: its early
onset; family and twin studies give compelling evidence of a genetic
predisposition; abnormalities have been found in the brains of autistic children.
The most promising treatments of autism and pervasive developmental disorders
are psychological in nature, involving modelling and operant conditioning
procedures. Although the progress for children with pervasive developmental
disorders remains poor in general, parental involvement may help children to
participate meaningfully in social interactions. Various drug treatments have been
used but have proved to be less effective than behavioural treatments.

4.8 UNIT END QUESTIONS

1) Describe in detail the main characteristic features of pervasive developmental
disorders?
2) What is autism and discuss the clinical picture in autistic disorder?
3) What are the biological factors in autism?
4) Discuss the psychological causes of autism?
5) Describe in depth the various interventions for pervasive developmental
disorders?
76
 Pervasive Developmental
4.9 GLOSSARY Disorders

Echolalia : Repetition or echoing of the speech of others, a

normal intermediate step in the development of
speech skills. Originally thought to be a unique
symptom of autism, it is now seen as evidence of
developmental delay involved in that disorder.

Fragile X syndrome : Pattern of abnormality caused by a defect in the

X chromosome resulting in mental retardation,
learning problems, and unusual physical
characteristics.
Microcephaly : Means “small headedness”. It involves impaired
development of the brain and a failure of the
cranium to attain normal size.

4.10 SUGGESTED READINGS AND REFERENCES

Carson, R. C., Butcher, J. N., & Mineka, S. 2003. Abnormal Psychology and
Modern Life. Pearson Education: New Delhi.

Sarason, I.G., & Sarason, B.R.2005. Abnormal Psychology: The Problem of

Maladaptive Behaviour. Prentice-Hall of India: New Delhi.

Davison, G.C., Neale, J.M., Kring, A.M. Abnormal Psychology, 9th edition. Wiley
& Sons:USA.

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adolescent outcome of hyperactive children diagnosed by research criteria: 1.
An 8 year perspective follow-up study. Journal of the American Academy of
Child and Adolescent Psychiatry, 32, 233–256.
Barlow, D.H., & Durand, V.M. 2007. Abnormal Psychology: An Integrative
Approach. Thomson Learning Inc., New Delhi.
Bennett, Paul. 2005. Abnormal and Clinical Psychology: An Introductory
Textbook, 2nd Ed. Open University Press, McGraw-Hill Education: England.
Bettelheim, B. (1973). Bringing up children. Ladies Home Journal, 90, 28.
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Childhood Psychopathology Brent, D.A., Holder, D., Kolko, D., Birmaher, B., Baugher, M., Roth, C., Iyengar,
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Carson, R. C., Butcher, J. N., & Mineka, S. 2003. Abnormal psychology and
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Christakis, S. A., Zimmerman, F. J., DiGiuseppe, D. L., & McCarty, C. A. (2004).

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Comer, R.J. 2010. Abnormal Psychology, 7th edition. Worth Publishers. New
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Crick, N. R., & Dodge, K. A. (1996). Social information–processing mechanisms

in reactive and proactive aggression. Child Development, 67, 993–1002.

Davison, G.C., Neale, J.M., Kring, A.M. Abnormal Psychology, 9th edition. Wiley
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Halgin, R.P., & Whitbourne, S.K. 1997. Abnormal Psychology: The Human
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Hinshaw, S.P. (1994). Conduct disorder in childhood: conceptualisation,

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Klin, A., Volkmar, F. R. 1997. Asperger’s syndrome. In Cohen DJ, Volkmar FR,
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Kramer, R.A., Warner, V., Olfson, M., & Weissman, M. M. (1998). General
medical problems among the offspring of depressed parents: A 10-year follow-
up. Journal of the American Academy of Child and Adolescent Psychiatry. 37(6),
602-11.

Lyons, M. J., True, W.S., Eisen, A., Meyer, J. M., et al. (1995). Differential
heritability of adult and juvenile antisocial traits. Archives of General Psychiatry.
52, 906-915.
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Mangal, S.K. 2006. Abnormal Psychology. Sterling publishers: New Delhi. Pervasive Developmental
Disorders
Milberger, S., Biederman, J., Faraone, S., & Chen, L. (1996). Is maternal smoking
during pregnancy a risk factor for ADHD in children? American Journal of
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Moffitt, T. E (1993). The neuropsychology of conduct disorder. Development

and Psychopathology, 5(1–2), 135–151.

Moffitt, T. E., & Henry, B. (1989). Neuropsychological assessment of executive

functions in self-reported delinquents. Development and Psychopathology, 1,105–
118.

National Institute of Mental Health (NIMH) Fact Sheet. (2000). Depression in

children and adolescents: A fact sheet for physicians. Retrieved from http://
www.mental-healthmatters.com/articles/article.php?artID=320

Patterson, G. R., Capaldi, D., & Bank, L. (1991). An early starter model for
predicting delinquency. In D. Pepler & K. H. Rubin (Eds.), The development
and treatment of childhood aggression (pp. 139–168). Hillsdale, NJ: Erlbaum.

Sarason, I.G., & Sarason, B.R.2005. Abnormal Psychology: The problem of

maladaptive behaviour. Prentice-Hall of India: New Delhi.

Sharma, R., 2006. Abnormal Psychology. Atlantic Publishers & Distributors:

New Delhi.

Sieg, K.G., Gaffney, G. R., Preston, D. F., & Hellings, J. A. (1995). SPECT brain
imaging abnormalities in attention deficit hyperactivity disorder. Clinical Nuclear
Medicine. 20, 55-60.

Slutske, W. S., Heath, A. C., Dinwiddie, S. H., & Martin, N. G. (1997). Modelling
genetic and environmental influences in the etiology of conduct disorder: A study
of 2,682 adult twin pairs. Journal of Abnormal Psychology. 106, 266-279.

Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vineland Adaptive

Behaviour Scales. Circle Pines, MN: American Guidance Service.

Spencer, T. J., Biederman, J., & Harding, M. (1996). Pharmacotherapy of attention

deficit-hyperactivity disorder across the life cycle. Journal of the American
Academy of Child and Adolescent Psychiatry, 35, 409–432.

Swanson, J., McBurnett, K., & Wigal, T. (1995). Stimulant medications and the
treatment of the children with ADHD. In T.H. Ollendick & R.J. Prinz (Eds.),
Advances in Clinical Child Psychology (Vol 17, pp. 265-322). New York: Plenum.

Weiss, G., & Hechtman, L. (1993). Hyperactive children grow up (2nd Ed.).
New York: Guilford.

Weissman, M. M., Fendrich, M., & Wickramaratne, P. (1992). Incidence of

psychiatric disorder in offspring at high and low risk for depression. Journal of
the American Academy of Child and Adolescent Psychiatry. 31, 640-48.

79
Childhood Psychopathology
4.11 ANSWERS TO SELF ASSESSMENT
QUESTIONS
Self Assessment Questions 1

1) c, 2) b, 3) d, 4) c, 5) A

Self Assessment Questions 2

Pervasive developmental disorders are a group of neurobiological disorders
characterised by fundamental deficits in social interaction skills, communication
skills, and by the presence of stereotyped (purposeless and repetitive) behaviours,
interests, or activities.

There are three symptom categories in pervasive developmental disorders. They

are social, communication and behaviour. Social category involves impairment
of interpersonal relatedness, impaired capacity for empathy, lack of interest in
others. Communication involves deficits in language, deficits in verbal and
nonverbal communication. Behaviour category involves stereotyped behaviour,
need for constancy in the environment and resistance to change.

There are five different categories of Pervasive Developmental Disorders that

are currently recognised by the DSM–IV–TR: Autism, Asperger’s disorder, Rett’s
disorder, childhood disintegration disorder, and pervasive developmental disorder
not otherwise specified.

Childhood disintegrative disorder is a rare condition wherein development

progresses normally for the first 2 years then the child shows marked regression
in multiple areas such as language use, social responsiveness, play, motor skills,
and bladder or bowel control.

One of the most fascinating cognitive phenomena in autistic disorder is the

presence of so-called “islets of precocity” or “splinter skills”. Approximately 10
percent of individuals with autism exhibit splinter skills—high performance on
a specific skill in the presence of mild or moderate mental retardation. This
phenomenon tends to occur among a narrow range of skills—memorising lists
or other trivial information, calculations, visual-spatial skills such as drawing,
musical skills such as perfect pitch or ability to memorise a piece of music after
hearing it once.

80
 Anxiety Disorder
UNIT 1 ANXIETY DISORDER

Structure
1.0 Introduction
1.1 Objectives
1.2 Anxiety Disorders
1.2.1 Common Symptoms of Anxiety Disorders
1.2.2 Category of Anxiety Disorders
1.2.3 Approaches to Intervention of Anxiety Disorders
1.3 Causes of Anxiety Disorders
1.3.1 Causes
1.4 Approaches to Intervention in Anxiety Disorders
1.4.1 Psychodynamic Perspective
1.4.2 Behavioural Perspective
1.4.3 Cognitive Perspective
1.4.4 Combination of Cognitive and Behavioural Approaches
1.4.5 Biological Perspective
1.5 Let Us Sum Up
1.6 Unit End Questions
1.7 Suggested Readings and References

1.0 INTRODUCTION
This unit focuses on anxiety disorders. It gives an introduction to anxiety disorders
and then go on to give the various categories of anxiety disorders. Discussing
the common symptoms of anxiety disorders, the unit mentions specifically about
the physiological and psychological symptoms. Anxiety up to a point is conducive
for performance and beyond a point where the anxiety becomes overwhelming;
the performance of the individual gets adversely affected. These are being
discussed in detail in this unit. The various causative factors of anxiety disorders
are presented and different approaches to intervention are discussed which
includes psychoanalytical, cognitive, behavioural and biological perspectives.

1.1 OBJECTIVES
After reading this unit, you will be able to:
• Define anxiety disorders;
• Enlist various types of anxiety disorders;
• Describe the Symptoms anxiety disorders;
• Explain the causes of anxiety disorders;
• Analyse the various approaches to treatment of anxiety disorders; and
• Describe the Interventional approaches for anxiety disorders.

5
Mild Mental Disorders
1.2 ANXIETY DISORDERS
In everyday life almost everybody gets anxious or feels nervous before a test, or
an important business meeting. Even rich or poor, famous or general public suffers
from this anxiety may be in the terms of worries and fears. The term ‘anxiety
disorders’ is a term that covers pathological fear and anxiety. These terms to an
extent became more popular in psychiatry at the very end of the 19th century.

One could state that anxiety disorders as a term had also started during Sigmund
Freud’s time. Freud and his disciples considered anxiety as a warning signal that
endangers or threatens the id impulses of undesirable nature which are also against
social norms and which were about to enter the conscious mind. Freud argued
that anxiety can be adaptive if the discomfort with it motivates people to learn
new ways of approaching life’s challenges.

It is normal to experience anxiety when faced with any stress or threatening

situations, but it becomes abnormal to feel strong, chronic anxiety in the absence
of a visible cause. There is a growing evidence of most of the people suffering
from anxiety disorders are overly sensitive to threat cues, they exhibit a heightened
sensitivity, vigilance or readiness to attend to potential threats.

Current psychiatric diagnostic criteria recognises a wide variety of anxiety

disorders. Vulnerability is the lack of “perceived control” over stressful life
circumstances. While the presence of environmental stressors may set the stage
for the development of an anxiety disorder, researchers have found it is not only
the actual presence of environmental stressors that create anxiety; but rather,
anxiety is greatly determined by a person’s perceived ability to control a potentially
stressful event. It is important to realise that this lack of control may, or may not
be accurate. Rather, it is the person’s perception about their degree of control
that is important.

It is believed that people’s perceptions of control are heavily influenced by

childhood experiences. When children repeatedly experience a “lack of control”
or a sense of unpredictability over the events in their lives, they may come to
view the world as unpredictable and dangerous. This world view may lead to
feelings of helplessness, and a tendency to expect negative outcomes, no matter
how they may try to prevent them.

Examples of early life experiences that may influence a person’s perception of

control include:
1) family dynamics such as parenting style (i.e., overprotective parenting style,
and its opposite, under-protective, low-care style),
2) significant life stressors such as loss of, or separation from, primary
caregivers, and
3) traumatic experiences such as childhood abuse (physical, emotional, and/or
sexual).
This is not to say that our psychological trajectory is fixed in childhood and that
nothing can be done to change it.

6
Instead, it simply means that early experiences may have contributed to this Anxiety Disorder
psychological vulnerability and explains, in part, why some people are more
prone to experience anxiety than others. The perceived lack of control extends
to a person’s experience of their anxiety disorder. People with anxiety disorders
often report they have no control over their symptoms and this lack of control is
highly distressing to them. This fact may explain why the often good intentioned
attempts by loved ones, to offer reassurance, are often met with doubt by the
person with an anxiety disorder.

The term anxiety is mainly defined as vague, diffuse and a very unpleasant feeling
of fear and apprehension. The individual shows combinations of the symptoms
like rapid heart rate, shortness of breath, diarrhea, fainting, dizziness, sweating,
sleeplessness, frequent urination and tremors. People who feel anxious are not
aware of the reasons for their fear. Thus even though fear and anxiety involve
similar reactions , the cause of worry is readily apparent.

Fear and stress reactions are essential for human survival. They enable people to
pursue important goals and to respond appropriately to danger. In a healthy
individual, the stress response (fight, fright, or flight) is provoked by a genuine
threat or challenge and is used as a spur for appropriate action.

An anxiety disorder, however, involves an excessive or inappropriate state of

arousal characterised by feelings of apprehension, uncertainty, or fear. The word
is derived from the Latin, angere, which means to choke or strangle. The anxiety
response is often not triggered by a real threat. Nevertheless it can still paralyze
the individual into inaction or withdrawal. An anxiety disorder persists, while an
appropriate response to a threat resolves, once the threat is removed.

Anxiety disorders involve a state of distressing chronic but fluctuating

nervousness that is inappropriately severe for the person’s circumstances.

Anxiety disorders can make people sweat, feel short of breath or dizzy, have a
rapid heartbeat, tremble, and avoid certain situations.

These disorders are usually diagnosed using specific established criteria.

Drugs, psychotherapy, or both can substantially help most people.

Anxiety is a normal response to an actual or perceived threat or to psychological
stress and is experienced occasionally by everyone. Normal anxiety has its roots
in fear and serves an important survival function. When someone is faced with a
dangerous situation, anxiety induces the fight or flight response. With this
response, a variety of physical changes, such as increased blood flow to the heart
and muscles, provide the body with the necessary energy and strength to deal
with life-threatening situations, such as running from an aggressive animal or
fighting off an attacker.

However, when anxiety occurs at inappropriate times, occurs frequently, or is so

intense and long-lasting that it interferes with a person’s normal activities, it is
considered a disorder.

Anxiety disorders are more common than any other category of mental health
disorder and are believed to affect about 15% of adults in the United States.
However, anxiety disorders often are not recognised by people who have them
7
Mild Mental Disorders or by health care practitioners and consequently are seldom treated. The graph
below presents the detail.

Anxiety and Performance

Anxiety affects performance up to a point anxiety enhances the performance but
beyond a point that is when anxiety is overwhelming, the performance goes
down considerably. This is illustrated in the graph given below.

How Anxiety Affects Performance

Optimal Level
High
Performance
Efficiency

Unable to
cope

Low
Anxiety
Low High
Level

The effects of anxiety on performance can be shown on a curve. As the level of

anxiety increases, performance efficiency increases proportionately, but only up
to a point. As anxiety increases further, performance efficiency decreases. Before
the peak of the curve, anxiety is considered adaptive; because it helps people
prepare for a crisis and improve their functioning. Beyond the peak of the curve,
anxiety is considered maladaptive, because it produces distress and impairs
functioning.

1.2.1 Common Symptoms of Anxiety Disorders

All types of anxiety disorders have one common feature. This causes a general
problem with the persons ability to have a normal everyday routine and normal
life. All of the anxiety disorders lead to a pessimistic outlook on life and a feeling
of a loss of control over an upcoming bad situation.

The symptoms of anxiety are:

• Nervousness
• Vigilance
• Sleeplessness
• Breathlessness
• Feeling faint
• Lack of concentration
• Worry or apprehension
8
• Trembling Anxiety Disorder

• Sweating
• Feeling tired
• Frequency of urination
• Palpitation almost pounding of heart
• Muscle tension
• Headaches
• Insomnia
• Restlessness
• Irritability
• Hot flashes or chills
• Hyperventilation
• Nausea or stomach cramps etc.

Thus on the whole even though the symptoms have been separately mentioned,
they are interrelated and affect the daily living of the individual. Despite no clear
definition has been yet formulated for anxiety disorder, most psychologists have
made distinction between normal anxiety and neurotic anxiety or anxiety
disorders.

Normal anxiety occurs when people react appropriately to the anxiety causing
situation. In contrast anxiety disorders are disproportionately intense in which
real danger is little or only posed by either situation. This stimulates intense
feelings of anxiety that can affect or derail a persons’ desires or obligations.
Self Assessment Questions
1) How would you define anxiety disorders?
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2) Write up the major symptoms of anxiety disorders.
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9
Mild Mental Disorders
3) How are anxiety disorders identified?
...............................................................................................................
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1.2.2 Category of Anxiety Disorders

According to a standard manual for mental health clinicians the Diagnostic and
Statistical Manual of Mental Disorders (Fourth Edition text revised of DSM IV
TR) categorises anxiety disorders under the following headings:
i) Generalised Anxiety Disorders: This consists of more prolonged ,vague,
unexplained but intense fears that do not seem to be attached to any particular
object. It resembles normal fears but no actual danger is present in most of
the cases. A person who has experienced six month or more persistent and
excessive worry is diagnosed with generalised anxiety disorder. The
symptoms of this disorder are of four types, which may be experienced
individually or in combination. They are:
• Motor Tension
• Apprehensive feelings about the future
• Automatic reactivity
• Hyper vigilance
ii) Panic Disorder: Panic Disorders may come about with no warning signs.
The indicators are mostly similar to generalised anxiety disorders except
that they are magnified and usually have a sudden onset. Panic attacks also
have shortness of breath, increased heart rate, dizziness and a feeling of
helplessness. The victims fear that they will die, or go crazy or do something
uncontrolled and they report a variety of unusual psycho sensory symptoms.
These attacks mainly ranges in length from a few seconds to many hours
and even days. They also differ in severity and in the degree of incapacitation.
Symptoms of Panic Attacks
1) Dizziness, unsteadiness or faintness
2) Trembling, shaking or sweating
3) Heart palpitations or high heart rate
4) Chest pain or discomfort
5) Numbness or tingling
6) Fear of death or losing control
This disorder also affect women more than men and younger age groups
more than the elderly. Compared to other anxiety disorders panic attacks
appear to be more distressing and sometimes severe panic states are followed
by periods of psychotic disorganisation in which there is a reduced capacity
to test reality.
10
iii) Obsessive Compulsive Disorder: According to DSMIV(TR) either Anxiety Disorder
obsessions or compulsions need to be present. But most people who have
obsessive compulsive disorder demonstrate both. This illness is very much
what it sounds like. This disorder mainly conveys the driven quality of the
thoughts and rituals seen in people with this condition. Obsessions are
recurring thoughts, impulses or images that the person tries to eliminate or
resist but either cannot or has extreme difficulty in doing so.

The Person does not have the control on their obsessions which leads to
increase anxiety and to the method generally used to try to control the
obsessions. People usually involve in doubt, hesitation, fear of contamination
or fear of ones own aggression. Compulsions are thought or action that
provide relief are generally used to suppress the obsession.

The compulsions are not connected realistically with the obsessions they
are excessive in their nature. The exact incidence of obsessive compulsive
disorder is hard to determine. The victims tend to be secretive about their
pre occupations and frequently are able to work effectively in spite of their
problems.
Symptoms of Obsessive Compulsive disorder:
1) Obsessivness to check the door locks
2) Obsessive of sexual thoughts
3) Obsession of counting
4) Washing the hands continuously.
5) Lots of doubt
6) Brushing the teeth continuously under compulsion
Thus obsessive compulsive disorder causes marked distress and takes
considerable time to overcome the problem.

iv) Phobias: Phobia is a term derived from the Greek word “Phobos”. It is an
intense irrational and persistent fear of certain situations, activities, things
etc. People with this disorder know exactly for what they are afraid of,
except for their fears of specific objects, phobic situations, individuals etc.
Physically there does not seem to be anything wrong with them, but their
fears are out of proportion with reality seem to be inexplicable and are beyond
their voluntary control. Phobics do not need the actual presence of the feared
object or situation to experience intense tension and discomfort. It tends to
grow progressively broader. Phobias may begin with a generalised anxiety
attack but that anxiety in course of time gets crystallised around a particular
object or situation.

One study on phobic patients showed that their fears fell into five categories,
viz., (i) separation, (ii) animals, (iii) bodily mutilation, (iv) social situation
and (v) nature. Phobias like other forms of maladaptive behaviour do not
come in isolation. They are usually intertwined with a host of other problems.
In consequence it is difficult to estimate their frequency accurately. Mild
phobias are common, though phobias which are serious enough to be
clinically diagnosed and recommended for treatment etc., occur infrequently.
11
Mild Mental Disorders It has been experienced by the psychologists that phobias were obtained
more commonly among women in all age groups, and these were found to
be the second most common illness among men older than 25 years of age.
Classification of Phobias
Phobias are many and are classified according to the feared object. For
instance a person having phobia for heights will be considered as having
phobia called “Acora phobia” that is fear of heights. Then we have fear of
opens spaces, closed spaces and so on and these are presented below:
i) Agora phobia: Fear of open places
ii) Claustro phobia: Fear of closed spaces
iii) Xeno phobia: Fear of strangers
iv) Ochlo phobia: Fear of crowd
v) Hemo phobia: Fear of blood
vi) Somni phobia: Fear of sleep
vii) Phasmo phobia: Fear of ghosts
viii) Myso phobia: Fear of dirt
ix) Algophobia: Fear of pain
x) Andro phobia: Fear of men
xi) Aqua phobia: Fear of water
xii) Hydro phobia (commonly used terms); Fear of water
xiii) Arachno phobia: Fear of spiders
xiv) Social phobia: Fear and embarrassment in dealing with others.
Symptoms of Phobia
There are typical characteristic symptoms of phobias and these include the
following:
• Intense and disabling fear, panic and anxiety
• Fear becomes too much excessive and unreasonable
• Avoiding certain places and situation for fear
• Avoidance becomes prominent and affects the normal life
• Obsessive thinking
• Fleeing from the situation
• Persistent worry
• Shaking and palpitation
Thus phobias have been seen more prevalent than generalised anxiety
disorder and have no specific known cause for happening.

v) Post Traumatic Stress Disorder: This is a disorder that develops after a

person experiences a traumatic or terrifying event. For example physical or
sexual assault, unexpected death of loved ones, natural disasters causing
heavy damage and death and destruction, etc. Longtime after the event had
12
 occurred the person mentally remains occupied along with the same feelings Anxiety Disorder
of anxiety that the original event had produced.

According to DSMIV (TR) (Diagnostic Statistical Manual) the symptoms

like persistent re experiencing of event, avoidance or emotional numbing
remain for more than one month .It causes significant impairment in social,
occupational or in other areas of functioning. Mainly in the occurrence of
post traumatic disorder the physical and psychological trauma comes in
combination and affect the life of the individual. It has been said by the
Psychologist atkinetal (2000) that posttraumatic stress disorder is cause by
physical or psychological trauma caused by human such as by rape, war or
terror attack. Sometimes possible sources also come from childhood, assault,
drug-addiction, illness, medical complications or employment in occupations
exposed to war or disaster. Sometimes heredity brain functioning also affects
the human being life.
Symptoms of Post Traumatic Stress Disorder
i) Anger and irritability
ii) Flashbacks
iii) Feelings of intense distress
iv) Depression and hopelessness
v) Feeling jumpy and easily startled
vi) Rapid breathing nausea and muscle tension
vii) Suicidal thoughts
viii) Feelings of alienated
ix) Chest pain
Thus post traumatic stress disorder is gradual and ongoing process. Individual
need to be confident and strong to overcome from this disorder otherwise it
leads to worsening the situation.
vi) Acute Stress Disorder: It is a psychological condition arising in response
to a terrifying or traumatic event. Disorder is similar to posttraumatic stress
disorder but experienced immediately after the traumatic event. The onset
of a stress response is associated with specific physiological actions in the
sympathetic nervous system. Both directly and indirectly through the release
of epinephrine from the medulla of the adrenal glands.
Symptoms of Acute Stress Disorder
i) Numbing
ii) Detachment
iii) Derealisation
iv) Depersonalisation
v) Dissaociative amnesia
vi) Flashbacks
vii) Avoidance of any stimulation

13
Mild Mental Disorders The acute stress disorder and posttraumatic stress disorder are more or less is
some if this disorder persists longer than one month the diagnosis is changed to
posttraumatic stress disorder.

Self Assessment Questions

1) Describe some of the important features of anxiety disorders as given
in DSM IVTR.
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2) List out types of anxiety disorders. Categorise them as per by DSM IV
TR.
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3) What is the assessment of the overlap between posttraumatic stress
disorder and acute stress disorder?
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4) What is the difference between Panic attacks and phobia?
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14
 Anxiety Disorder
1.3 CAUSES OF ANXIETY DISORDER
The causes of anxiety disorders are not fully known, but both physical and
psychological factors are involved. Because anxiety disorders are prevalent in
some families, heredity probably plays a role. Anxiety is viewed at a psychological
level as a response to environmental stresses, such as the breakup of a significant
relationship or exposure to a life threatening disaster.

When a person’s response to stresses is inappropriate or a person is overwhelmed

by events, an anxiety disorder can arise. For example, some people find speaking
before a group exhilarating. But others dread it, becoming anxious with symptoms
such as sweating, fear, rapid heart rate, and in some cases also tremors.

Such people may avoid speaking even in a small group. Anxiety disorders may
also be caused by a physical disorder or the use of a drug. For example, an
overactive thyroid or adrenal gland can cause anxiety, as can a tumor called a
pheochromocytoma. Drugs that can cause anxiety include corticosteroids, cocaine,
amphetamines, ephedrine, and sometimes caffeine if too much is consumed.
Withdrawal from alcohol or certain sedatives can also cause symptoms of an
anxiety disorder. In older people, dementia may be the most common cause of
anxiety. Although the exact cause of these anxiety disorders are not fully
understood.

1.3.1 Causes
The causative factors include the following:
• Genetics
• Substance Abuse
• Stressful Life
• Mental or physical abuse
• Changes in living situation
• Illness
• Death of a loved one
• Faulty relationship
• Brain chemistry
• Changing of jobs or school
• Migration
• Traumatic experience
• Fixation with objects, situations
• Witnessing bad experience
• Embarrassment
• Torture
• Natural disaster
Thus with the high prevalence of these anxiety disorders the necessary thing is
need to be quite cautious regarding the said disorders and public awareness. The
15
Mild Mental Disorders social stigma associated with it may decrease and encourage those who suffer
from it to seek professional help.
Self Assessment Questions
1) List out some causes of anxiety disorders.
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2) What type of relationship can lead towards anxiety disorders and how.
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3) How migration can affect the daily life of the individuals and causes
anxiety disorder. Cite one example.
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1.4 APPROACHES TO INTERVENTION IN

ANXIETY DISORDERS
Whether specific or general but anxiety disorder is a major component of this
unit. It needs to be dealt with by various approaches to manage the suffering
individuals.

1.4.1 Psychodynamic Perspective

This perspective believes in that the major determinant of anxiety disorders is
intra-psychic events and unconscious motivation. It is being accepted that anxiety
is an alarm reaction that appears when person is threatened. It is normal to
experience some overt anxiety, the amount of anxiety and the nature of the threat
that determine whether an instance of anxiety is normal or pathological. The
theorists in this approach targets the causes of anxiety that reaches clinical
proportions like perceptions of oneself as helplessness in coping with surrounding
pressure, privation, loss of emotional support or dangerous impulses which comes
close to breaking into consciousness.
16
This approach views that anxiety disorder stems from the psychological conflict Anxiety Disorder
and unconscious mental processes. Any situation or object has symbolic
significance and can be regarded as a stand in for something else that one is
frightened of something that is completely beyond ones awareness. It represents
an unresolved psychological conflict. Obsessive ideas and compulsive activity
comes from significant distressing unconscious thoughts.

Psychoanalysts believe that these thoughts involve aggression and rage that may
have first been aroused in the battle for autonomy between the growing child
and the mother or the care giver. Sigmund Freud father of psychoanalysis
emphasised the roles of several defense mechanisms in the development of various
anxiety disorders. These include isolation, undoing and reaction formation.
Psychotherapy is proved to be the focus clinical tool of the psycho dynamically
oriented clinician. It deals with the psychodynamic roots of the maladaptive
behaviour. Most specialists believe that such behaviour occur when a person
becomes preoccupied with relieving anxiety.

These specialists use catharsis technique which targets in ventilating the repressed
thoughts of the person. These all can only get success through free association
method between the therapist and the patient. It is believe to be the way of
squeezing out all the hidden unresolved issues disturbing the individuals.

1.4.2 Behavioural Perspective

Behaviour therapists have challenged the approaches of psychotherapists.
Psychotherapists believe that in order to change abnormal behaviour one must
remove or reduce the conflict underlying the behaviour .According to
behaviourists anxiety which reaches clinical proportions is a learned or acquired
response a symptom that has been created by environmental conditions.

B.F Skinner the leading behaviourist preferred exclusively on observable stimulus

and response variable. In this approach the new learning for eliminating anxiety
is associated with conditioning, reinforcement and extinction. Behaviour therapy
has been directed at discovering the variables that help defuse highly emotional
responses.

Expose therapy introduced by the behaviourists has been used in treating phobias,
obsessive compulsive disorders and other anxiety disorders. It motivates the client
or patient to maintain contact with the actual noxious stimuli or with their
imagined presence until he or she becomes used to them. In association to this
technique three other types of therapy also can be used like systematic
desensitisation, implosive therapy and vivo exposure.

In systematic desensitisation the treatment of strong fears is based on

conditioning principles. The patient or client is taught to relax and then is presented
with a series of stimuli that are graded from low to high according to their capacity
to evoke anxiety. Usually the process in reduction of the level of any emotional
response to particular stimulus is gradually.

Implosive therapy is based on the belief that many conditions including anxiety
disorders are outgrowth of painful of prior experiences. Therapists ask their clients
to imagine scenes related to particular personal conflicts and to recreate the anxiety
felt in those scenes. The target of the therapist is to strive to heighten the realism
17
Mild Mental Disorders of the recreation and to help the patient extinguish the anxiety that was created
by the original aversive conditions client is also helped to adapt the more mature
forms of behaviour.

In Vivo exposure is carried out in a real life setting not simply in the imaginations
of the client and the therapist as they sit in the therapist clinic. Sometimes in this
therapy someone relieves their specific fear in three sessions only.

Modelling is used often to anxiety provoking stimuli. Therapists models a

response and then provides corrective feedback as the patient performs the same
behaviour. Modelling play a vital role in guided mastery in which therapists guide
the client toward mastery over frightening situations and maladaptive behaviour.

1.4.3 Cognitive Perspective

Cognitive therapy is highly effective in reducing anxiety, regardless of client
feels relaxed or anxious during their exposure. It seeks to help the patient
overcome the difficulties by identifying and changing dysfunctional thinking,
behaviour and emotional responses.

Modeling proves to be an important cognitive element from overcoming intense

fear and acquire self confidence. Sometimes the way people think about certain
things changes when they acquire new response capacities. According to cognitive
theorists thinking disturbances that occur only in certain places or in relation to
specific problems are the sources of anxiety. These types of thoughts include
unrealistic appraisals of situations and consistent overestimation of their
dangerous aspects. The therapist tries to highlight the distortions and encourages
the patient to change his or her attitudes. The different techniques used to effect
change using cognitive therapy are:

Rationale Emotive Therapy

It is based on the belief that for any individual most of the problems originate in
irrational thought. The principle of this therapy is the relationships between
thinking, feelings and action. It is an analysis model which deals with what is
going on. It has its own self control procedures. This helps in becoming able to
easily influence the situation and also help in gaining insight in new ways of
thinking.

Cognitive Restructuring
This motivates the patient or client attention to the unrealistic thoughts that serve
as cues for his or her maladaptive behaviour. It is the responsibility of the client
or patient to review their irrational beliefs and expectations to develop more
rational ways of life.

Thought Stopping
It is one of the techniques in cognitive perspective which works on the assumption
that a sudden distracting stimulus can serve to terminate obsessional thoughts
successfully.

Cognitive Rehearsal
It is an approach where patient can mentally rehearse adaptive approaches to
problematic situations. This is particularly useful for problems that cannot be
18
conveniently stimulated in a clinical setting. If someone suffering from a social Anxiety Disorder
phobia can imagine being in a group and can mentally rehearse behaviour and
internal statements designed to improve his or her interpersonal relationships, it
would go a long way in making the person give up the fear being in a group or
social situation.

1.4.4 Combination of Cognitive and Behavioural Approaches

These two approaches in combination aim to solve issues concerning
dysfunctional emotions, behaviours and cognitions through a goal oriented
systematic procedure. The cognitive behavioural technique is effective for the
treatment of a variety of problems including mood, anxiety, personality, eating,
substance abuse and psychotic disorders. The program has been used in a series
of clinical studies with social phobia and generalised anxiety disorder patients.
Thus this therapy involves in helping patients on the overall aspects. It supports
in modifying beliefs, identifying distorted thinking, changing behaviour etc.

1.4.5 Biological Perspective

It has been seen by the psychologists that different reactions are caused by an
individual’s biological state. It is an accepted fact that people whose nervous
system is particularly sensitive to stimulation appear more likely to experience
severe anxiety. Heredity has shown a strong influence on such characteristics as
timidity, fearfulness and aggressiveness. A study found that children of people
treated for anxiety disorders were more anxious and fearful and showed more
school difficulties, worries and had greater number of problems as compared to
children of normal parents. Psychologists have also supported the effect of
more genetic factor and a statistically significant and weaker effect for a family
environment factor.

Drug Therapies
Drugs in the form of medications have also proved effective in treating specific
anxiety disorders. Benzodiazepines the tranquilising drugs are the most commonly
used somatic therapy in the treatment of anxiety. Anti depressants is also one of
drugs to treat anxiety disorders and group of disorders.

From this unit which has dealt with anxiety disorders, types, symptoms, causes
and treatment it is clear that all categories are overlapping. The symptoms are
more or less the same, with too being similar and having in all cases certain core
cause for all but only need to have vigilance over the activities of the individual
without shyness and social stigma.

If the awareness is spread out in the society then problem can be diagnosed at the
initial stage.
Self Assessment Questions
1) Psychodynamic Approach states ...........................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
19
Mild Mental Disorders
2) Systematic Desensitisation is ................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

3) Cognitive restructuring focuses .............................................................

...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

1.5 LET US SUM UP

Let us sum up this unit that anxiety disorders are often debilitating chronic
conditions which come from an early age or suddenly can be triggered in life of
an individual. These disorders are often co morbid with other mental disorders
particularly clinical depression which is less disturbing in the daily life than
anxiety disorders. As a student of abnormal psychology, in this unit, you have
studied anxiety disorders which you know are integral part of our life whether or
not we recognise their effect in our behaviour.

1.6 UNIT END QUESTIONS

1) Describe anxiety disorders.
2) Define the types of anxiety disorders.
3) Explain the common signs and symptoms of anxiety disorders. With
examples.
4) Describe the causes of anxiety disorders.
5) How common are anxiety disorders.

1.7 SUGGESTED READINGS AND REFERENCES

Barlow.H.David(2008) Abnormal Psychology :An Integrative Approach, Canada,
Wadsworth Cenanage Learning(Pub).

Barlow &Durand(2005) Essentials of Abnormal Psychology,New York, Thomson

Wadsworth(Pub).

Davison C .Gerald (2005) Abnormal Psychology, John Wiley&Sons(Pub).

20
References Anxiety Disorder

Abramowitz, J. S., Franklin, M. E., & Foa, E. B. (2002). Empirical status of

cognitive-behavioural therapy for obsessive-compulsive disorder: A meta-analytic
review. Romanian Journal of Cognitive and Behavioural Psychotherapies, 2,
89-104.
Altrocchi John(1985).Abnormal Behaviour,New York,Harcourt Brace
Jovanovich.
American Psychiatric Association. (2000). Diagnostic and statistical manual of
mental disorders (Revised 4th Ed.). Washington, DC: Author.
Baer, L., & Jenike, M. A. (1992). Personality disorders in obsessive compulsive
disorder. Psychiatric Clinics of North America, 15, 803-812.
Barlow, D. H., Craske, M. G., Cerny, J. A., & Klosko, J. S. (1989). Behavioural
treatment of panic disorder. Behaviour Therapy, 20, 261-282.
Barlow, D. H. (2000). Unraveling the mysteries of anxiety and its disorders from
the perspective of emotion theory. American Psychologist, 1247-1263.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of
anxiety and panic (2nd ed.). New York: Guilford Press.
Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of
anxiety and panic (2nd ed.). New York: Guilford Press.
Hales RE, Yudofsky SC, Talbott JA(1999) eds. APA Textbook of Psychiatry. 3rd
ed. Washington, DC: American Psychiatric Press; .
Huppert, J. D. (2009). Anxiety disorders and depression comorbidity. In: Oxford
handbook of anxiety and related disorders (pp. 576-586). Antony, Martin M.
(Ed.); Stein, Murray B. (Ed.); New York, NY, US: Oxford University Press.
Lazarus, R. S. (1977). Cognitive and coping processes in emotion. In A.Monat
& R. S. Lazarus (Eds.) Stress and coping: An anthology (pp 145-158). New
York, NY: Columbia University Press.
Lazarus, R. S. & Folkman, S. (1984). Stress, appraisal, and coping. New York,
NY: Springer Publishing Company.
Ledley, D. R., Marx, B. P., & Heimberg, R.G. (2005). Making cognitive-
behavioural therapy work: Clinical process for new practitioners. New York,
NY: The Guilford Press.
McLaughlin, K. A., & Hatzenbuehler. M. L. (2009). Stressful life events, anxiety
sensitivity, and internalising symptoms in adolescents. Journal of Abnormal
Psychology, 118(3), 659-669.
National Institute of mental health (2008). The numbers count: Mental disorders
in America
Neziroglu, F., Bubrick, J., & Yaryura-Tobias, J. (2004). Overcoming compulsive
hoarding: Why you save & how you can stop. Oakland, CA: New Harbinger
Publications.
Norton, P. J., & Price, E. C. (2007). A meta-analytic review of adult cognitive-
behavioural treatment outcome across the anxiety disorders. The Journal of
21
Mild Mental Disorders Nervous and Mental Disease, 195, 521-531.
Pfeiffer PN, Ganoczy D, Ilgen M, Zivin K, Valenstein M. (2009) Comorbid
anxiety as a suicide risk factor among depressed veterans.
Pollack MH, Simon NM, Worthington JJ, et al. Combined paroxetine and
clonazepam treatment strategies compared to paroxetine monotherapy for panic
disorder. J Psychopharmacol. Sep 2003.
Sarson & Sarson(1993) Abnormal Psychology: The problem of Maladaptive
Behaviour (seventh ed) ,New Jersey: Prentice Hall.
Johnston, J. E. (2006). The complete idiot’s guide to controlling anxiety. New
York: Penguin Group.

Websites
Anxiety disorders Association of America
Association for Behavioural and Cognitive Therapies
National Institute of Mental Health

22
 Anxiety Disorder
UNIT 2 SOMATOFORM AND DISSOCIATIVE
DISORDERS

Structure
2.0 Introduction
2.1 Objectives
2.2 Definition and Concept
2.2.1 Characteristics of the Disorder
2.3 Types of Somatoform Disorders
2.4 Causes of Somatoform Disorders
2.5 Interventions
2.5.1 Relationship with the Primary Care Practitioner
2.5.2 Psychotherapy
2.5.3 Cognitive Behaviour Therapy
2.5.4 Alternate Treatment
2.5.5 Psycho Education Technique
2.5.6 Medications
2.6 Dissociative Disorders
2.6.1 Dissociative Amnesia
2.6.2 Dissociative Identity Disorder
2.6.3 Dissociative Fugue
2.6.4 Depersonalisation Disorder
2.6.5 Symptoms of Dissociative Disorder
2.6.6 Causes of Dissociative Disorder
2.7 Treatment
2.8 Let Us Sum Up
2.9 Unit End Question
2.10 Suggested Readings and References

2.0 INTRODUCTION
This unit deals with the somatoform disorders and dissociative disorders. The
unit commences with a definition and conceptualisation of the disorders and
presents the characteristic features of somatoform disorder. This is followed by
types of somatoform disorder and causes of this disorder. The type of treatment
interventions are then taken up and the various treatment interventions such as
psychotherapy, cognitive behaviour therapy etc. are discussed. This is followed
by detailed presentation of dissociative disorders and the types of these disorders,
the causes and the various treatment interventions.

2.1 OBJECTIVES
After completing this unit, you will be able to:
• Define and conceptualise somatoform and somatisation disorders;
• Explain the characteristic features of this disorder;
23
Mild Mental Disorders • Delineate the types of somatoform disorders;
• Describe the treatment interventions in regard to the somatoform disorder;
• Define and conceptualise dissociative disorders;
• Describe the symptoms of dissociative disorders;
• Explain the causative factors leading to dissociative disorders; and
• Describe the treatment interventions for the dissociative disorders.

2.2 DEFINITION AND CONCEPT

Somatoform disorders are a category or a group of psychiatric disorders which
are characterised by conversion of emotional distress into physical symptoms.
These symptoms of physical illness have no actual organic cause but people do
suffer and complain about the problem. In one sense it may be stated that people
suffering from these disorders are preoccupied with a slight or non existent issues
in the sense that eventhough the symptoms are physical, like paralysis of the
limbs etc., there is no real identificable physical cause. All efforts to find the
physical cause through various pathological tests prove nil and thus the person is
referred to a psychologist or psychiatrist for further investigations and diagnosis.
This somatoform disorder is also called as psychosomatic disorders. People with
this disorder do not fake illness but they are commitedly believe that they have
a serious physical problem.

It has been long discussed by the experts that how mind and body interact and
influence health of the individual. Sometimes social and mental stress can
aggravate many physical disorders like diabetes mellitus, coronary artery disease
and asthma. Such stress can trigger, worsen or prolong physical symptoms.

Physical symptoms can evolve from stress or mental symptoms in anyone,

including people who do not have a serious underlying mental health disorders.
Such physical symptoms are often mild and transient. They sometimes become
difficult for a doctor to diagnose. Mental factors can also influence the course of
a disorder. Conversely a physical disorder can also influence or lead to a mental
condition. For example, people with a life threatening, recurring or chronic
physical disorder may become depressed. The depression in turn may worsen
the effects of the physical disorder.

2.2.1 Characteristics of the Disorder

The disorder which is characterised by psychosomatic or somatisation process
may be considered to lie in a continuum from those in which symptoms develop
consciously and volitionally to development of symptoms at an unconscious
level.

The continuum includes somatoform disorders, factious disorders and

malingering. Somatoform disorders are more physically oriented which are not
fully explained by another disorder physical or mental. These are distressing and
often impair social, occupational , academic, or some other aspects of functioning.

Factious disorder involve the conscious and volitional feigning of symptoms

without any external causes.
24
Patients gain gratification from assuming the sick role through the simulation, Somatoform and
Dissociative Disorders
exaggeration or aggravation of symptoms and signs. Malingering is intentional
feigning of physical or mental symptoms motivated by an external incentive.
Thus after clustering the three continuums it can only be said that patients suffers
which can be worse but without any external causes.

Somatoform disorders are commonly found more in women than in men and it
can be evidenced in the ineffective role performance and disturbed body image.
It includes chronic syndrome of multiple somatic symptoms that cannot be
explained medically but are associated with psychosocial stress, but these mental
problems are not characterised by physical disease.

As a group the disorders are difficult to recognise and treat because patients
often have long histories of medical or surgical treatment with several different
doctors. In addition the physical symptoms are not under the patient’s conscious
control so that he or she is not intentionally trying to confuse the doctor or
complicate the process of diagnosis. Somatoform disorders are however a
significant problem for the health care system because patients with these
disturbances overuse medical services. It is clear that many of the bodily
complaints that physicians are asked to treat suggest physical pathology, but no
actual impairment can be found.

Although failure to diagnose a case medically might be due to the doctors lack
of knowledge of psychiatric syndromes or to a faulty laboratory test. In a large
number of cases the symptoms may be due to psychological rather than
physiological factors. Though psychological it does not mean that the symptoms
are consciously produced but actually unconsciously felt by the patients.

Somatoform disorders are also known as Briquets syndrome (named after Paul
Briquet ) or Brissaual Marie syndrome (named after Edward Brissaul and Pierro
Marie). This disorder is characterised by physical symptom that mimic physical
disease or injury for which there does not exist any identifiable physical cause.
People with somatoform medical tests results are either normal or do not explain
the person’s symptoms. People who have this disorder may undergo several
medical evaluations and tests to be sure that they do not have an illness related to
a physical cause or some major lesion.

Patients become often very worried about their health because the doctors are
unable to find a cause for their health problems. Their symptoms are similar to
the symptoms of physical illness and lasts for several years. No treatment helps
and finally they are referred to psychiatrists or psychologists.

In brief, it may stated that Somatoform is defined by DSM IV (Diagnostic

Statistical Manual 4th Ed) as being characterised by physical symptoms that
cannot be explained by any medical condition. As stated in DSM IV these are
inclusive characteristics that result in mental or emotional stress. It is a recognition
of the connection between a person’s mind and body. It is a condition in which a
person feels pain in the joints, back and pelvic region and often accompanied by
frequent headaches.

25
Mild Mental Disorders
Self Assessment Questions
1) Define and elucidate the concept of somatoform disorders.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) What are the typical features of this disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What is Briquet syndrome?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) Define somatoform disorder in terms of DSM IV criteria.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

2.3 TYPES OF SOMATOFORM DISORDERS

The somatoform disorders recognised by DSM IV TR are:
• Conversion disorders
• Hypochondriasis
• Somatisation disorders
• Body dysmorphic disorders
• Pain disorders

26
Thus somatoform disorders are classified in various categories with typical signs Somatoform and
Dissociative Disorders
and symptoms. They represent a group of disorders. Let us take up one by one
these disorders and discuss:

i) Conversion Disorders: It is a condition where patients present with

neurological symptoms like numbness, blindness, paralysis or fits. The term
conversion comes from the origin in that anxiety is converted into physical
symptoms. The old term for conversion disorders was hysteria. Physicians
in ancient Greece believed that hysteria only occurred in females and it was
caused by the uterus wandering in the body. The term conversion came into
being used in the twentieth century. It was derived by Freud who believed
that in times of extreme emotional stress, painful feelings or conflicts are
repressed and are converted into physical symptoms to relieve anxiety.

This disorder is from the family of somatoform disorders, the defining

characteristic being that of having no evidence of medical causes but the
symptoms are present in intense form. It is believed that the many
psychological problems are converted into physical symptoms and thus the
disorder gets its name conversion disorder. The DSM IV (TR) classifies
conversion disorder as one of the somatoform disorders which includes
pseudo neurological syndrome, hysterical neurosis and psychogenic disorder.

It has been estimated that 25-72% of patients who visit with these types of
disorders suffer from conversion disorder wherein patients are believed to
convert their emotional problems into physical symptoms. Research has
shown that such patients spend nine times more for health care as compared
to people who do not have somatisation disorder or who do not convert
their emotional problems into physical disorder. Of persons who suffer from
somatisation disorder, 82% of adults stop working because they feel that
they suffer from some major problem.

In fact the problem faced by them is somewhat complicated and generally

results from psychological trauma. Conversion disorder is also referred to
as hysteria which is thought to be caused by stress and conflict, in which
people experience physical problems in the form of conversion. It tends to
develop during late childhood or early adulthood, or at any age. This disorder
is more common in women than in men. DSM IV TR (2000) specifies six
criteria for conversion disorders. With this specification, it has also been
seen that conversion occurs with some motor and sensory symptoms or
convulsions and sometimes with mixed presentations.

According to psychodynamic theory the symptoms of conversion develop

to defend against unacceptable impulses. Conversion symptom is to bind
anxiety and keep the conflict internal, that is within the self at an unconscious
level. The symptom has a symbolic value that is a representation and partial
solution of a deep seated psychological conflict to avoid running away from
the situation.

While psychodynamic explanation nis coversion of psychological conflict

into physical symptoms, according to learning theory conversion symptoms
are a learned maladaptive response to stress. Patients try to achieve secondary
gain by avoiding activities that are particularly offensive to them and gain
support from family. 27
Mild Mental Disorders Common symptoms of conversion disorder
• Poor coordination or balance
• Paralysis in an arm or a leg
• Lump in throat
• Inability to speak
• Impaired vision
• Loss of balance
• Hallucinations
• Difficulty in walking
Some categorised specific symptoms
Sensory symptoms: It includes anesthesia, loss of pain, tingling or crawling
sensations.
Motor symptoms: In this all body muscles become disorganised or immobile.
Visceral symptoms: This includes trouble in swallowing, frequent belching,
coughing or vomiting all carried to an extreme.
ii) Hypochondriasis: It is similar in many ways to undifferentiated somatoform
disorder. The patient shows an unrealistic fear of disease in spite of
reassurance that his or her social or occupational functioning is not impaired.
Patient is convinced that the physical symptoms they are experiencing are
the signs of a major illness with obsessive pre occupations.

Patients are concerned over the condition of their bodily organs and
continually worry about their health. Hypochondriasis is more organ specific.
Generally patients tend to misunderstand the nature of the significance of
psychological activity and exaggerate the symptoms when they occur. It
was earlier known as hypochondriacal disorder. It is generally considered a
disorder in young adults but is now increasingly recognised in children and
adolescents. It also develops in elderly people with previous history of health
related fears accounting equally among men and women. Hypochondriasis
may persist over a number of years but usually occurs in a series of episodes
rather than continuous treatment seeking. The flare ups of the disorder are
often correlated with stressful events in the patient’s life. This also results
in part from the patient’s unconscious imitation of their parents behaviour.
Common symptoms of hypochondriasis
• Poor co-ordination or balance
• Headaches
• Sweating
• Many symptoms of physical illnesses
iii) Somatisation disorder: It was formerly called Briquet’s syndrome, named
after the French physician. It is a pattern of symptoms in different parts of
the patient’s body that cannot be accounted for by medical illness. It begins
before the age of 30 and is more common in women. Patients with
somatisation disorder believe that they are sick and they generally provide
28
 long and detailed histories in support of their belief, with large quantities of Somatoform and
Dissociative Disorders
medicines. These individuals almost share many common features of
histrionic personality disorders including a self centered attitude and
exaggerated expression of emotions. Anxiety and depression are common
features as is manipulativeness which may take the form of suicide threats
and attempts. It has been described that generally somatisers are considered
as immature and overly excitable persons. It is not uncommon for a family
to have more than one somatiser. People who are classified as having a
somatising disorder tend to be suggestible thereby causing many other family
members too develop such symptoms. Thus the high prevalence of the
disorder in certain families may reflect the influence of a somatising parent
rather than heredity.

Symptoms
i) Pain in the body
ii) Gastro-intestinal symptoms
iii) Sexual symptoms
iv) Pseudo-neurological symptoms
iv) Body dysmorphic disorder: This is another category of somatoform
disorder. It is generally described as a preoccupation with an imagined or
exaggerated defect in appearance. Most of the cases involve features on the
patient’s face and head but especially those associated with sexual attraction,
are the focus of concern in this disorder.

It is regarded as a chronic condition that begins in the patient’s late teens

and fluctuates over the course of time. Generally patients in this disorder
misconceptualise their body and show more inclination towards the
procedure to repair or treat the defect through plastic surgery. It affects both
the sex equally.
Symptoms
i) Imaginary physical flaws
ii) Acne
iii) Scarring
iv) Facial lines
v) Marks
vi) Pale skin
vii) Thinning of hair
v) Pain disorder: It is marked by the presence of severe pain. Patient’s pain
appears to be largely due to psychological factors but in other cases the pain
is derived from a medical condition as well as the patient’s mental problems.
It is relatively common in the general population especially among older
adults nearly equal among both the sexes. Sometimes pain is often so severe
that it disables the patient from proper functioning which can last from a
few days in the short spell to many years in the long run. It is especially
defined by APA (2000) that this disorder may begin at any age and is observed
29
Mild Mental Disorders more among women than in men. This also often occurs after an accident or
an illness that may have caused genuine pain.
Symptoms
i) Chronic headaches
ii) Back problem
iii) Arthritis
iv) Cramps
v) Muscle aches and
vi) Pelvic pain

Self Assessment Questions

1) What are the major types of somatoform disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Enlist the symptoms of conversion disorders.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) How does somatisation disorder differ from pain disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

2.4 CAUSES OF SOMATOFORM DISORDERS

Somatoform disorders have been categorised and diagnosed for more than a
century. It has been studied from current explanations that there is a concept of
misconnection between mind and body. Different theories state that the mind
has a finite capacity to cope with stress and strain. The increasing social and
emotional stresses beyond a certain point can be experienced as physical
symptoms principally affecting the digestive, nervous and reproductive systems.
30
Presently researchers have found a connection between the brain immune system Somatoform and
Dissociative Disorders
and the digestive system which could be the reason why somatoform affects
these systems of the patient. The major causes are as follows:
• Defence against psychological distress
• Heightened sensitivity to physical sensations
• Catastrophic thoughts
• Discomfort or pain in the body
• Family stress
• Parental modeling
• Cultural influence
• Genetic factors
Thus this group of disorders come without any medical explanations by the doctors
making the patient fearful. Anxiety causes the focal point even more intensely
on their symptoms turn the individual more disabling causing hypothetical
suffering.
Self Assessment Questions
1) What are the causes of somatoform disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Write down causes of hypochondriasis
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) How does psychological feeling make an individual sick without any
actual bodily symptoms, clarify.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
31
Mild Mental Disorders
2.5 INTERVENTIONS
Accurate diagnosis with proper intervention is required for somatoform disorders.
This can protect the individuals from unnecessary surgery, laboratory tests or
other treatments or procedures.
The interventions required are:

2.5.1 Relationship with the Primary Care Practitioner

Due to long term medical history of these patients safeguard relationship with
the practitioner is needed. This can able the person to avoid unnecessary treatment.
Many practitioners prefer to schedule brief appointments on a regular basis with
the patients.

2.5.2 Psychotherapy
Patients with these types of disorders are considered only for insight oriented
psycho therapy. Generally they are benefitted from supportive approaches to
treatment that is aimed at symptom reduction and stabilisation of the patient’s
personality. Sometimes patients with pain disorders benefit from group therapy
or supports group therapy. Family therapy is also recommended for children or
adolescents with somatoform disorders.

2.5.3 Cognitive Behavioural Therapy

This has been proven effective. In a study of 54 body dysmorphic disorder patients
who were assigned to cognitive behavioural therapy intervention were found to
have had decreased symptoms in 82% cases in comparison to other techniques.

2.5.4 Alternative Treatment

Patients with these disorders are helped by a variety of alternative techniques
like hydrotherapy, massage, meditation, homeopathic treatment. They have often
got relief from pain and physical stress. This also facilitates emotional as well as
spiritual well being.

2.5.5 Psycho Education Technique

This is a technique initiated by psychologists. It is useful in explaining stress or
any emotional distress. Relaxation, stress management etc. It is of great help in
decreasing the emotional and bodily arousals.

2.5.6 Medications
Sometimes in extreme cases patients are also given anti anxiety drugs or anti
depressant drugs. In general it is better to avoid medication because patient may
become drug dependent and they should be encouraged to try other therapies.

Thus, in brief one may state that somatoform disorder is a group of problems
which are characterised by persistent physical symptoms which can be indicative
of a medical disorder, a problem without any demonstrative basis.

The origin of this disorder to the human body is still unknown, but some studies
have shown that primary somatoform disorders is related to the occurrence of
heightened awareness of the normal bodily sensations of a person. Many
32
psychological interventions are now incorporated to address these disorders. Somatoform and
Dissociative Disorders
Psychological theorists believed that by encouraging people can be a way in
articulating their emotions and using the alternate medical techniques.
Self Assessment Questions
1) What are the treatment techniques for somatoform disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Describe anyone of the technique.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Describe the importance of relationship between patient and doctor
during treatment.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

2.6 DISSOCIATIVE DISORDERS

These disorders are defined as conditions that involve breakdown of memory,
identity, awareness, perception etc. It interferes in person’s general functioning.

Dissociative disorders are a group of psychiatric syndromes. The APA and DSM
IV(TR) include one category for atypical dissociative disorders. The person’s
identity may be temporarily forgotten or a new identity assumed or there may be
a feeling that one’s sense of reality is lost.

Maladaptive behaviour arises from dissociative disorders. They provide a striking

contrast to those that arise from post traumatic stress disorder and adjustment
disorders. People with dissociative disorders use a variety of dramatic maneuvers
to escape from the anxiety and conflicts aroused by stress.

Their behaviour involves sudden and temporary alterations of consciousness

which serve to reduce the individual’s painful experiences.
33
Mild Mental Disorders Sometimes these disorders appear to begin and end abruptly and are precipitated
by stressful experiences. Disorders mostly occurs in childhood but there is a
history of serious family turmoil.

According to DSM IV (TR) and APA the four major dissociative categories are.
(i) Dissociative amnesia (ii) Dissociative Identity disorder (iii) Dissociative fugue
(iv) Depersonalisation disorder. Let us take up these and deal with them in detail.

2.6.1 Dissociative Amnesia (earlier known as psychogenic

amnesia)
It is a feature of temporary or permanent loss of a part or all of their memory.
Person becomes incapable of recalling important personal information that
becomes more extensive than explained by normal forgetfulness. It also happens
due to extreme psychosocial stress. This stress can get related with catastrophic
events. Different types of memory loss have been identified in person with
dissociative amnesia and they are:

Localised amnesia: This happens for a particular event. The disease renders the
afflicted unable to recall the details of an usually traumatic event such as violent
incestual rape. This is generally experienced in battle or situations of torture.

Selective amnesia: It is as the name says that individual becomes selective in the
manner to recall or remember. Often person remembers certain general
occurrences of a trauma situation and not the specific parts which make it so.

Continuous amnesia: It occurs when patients have no money of events up to and

including the present time. It means patients are alert and aware but not able to
remember.

2.6.2 Dissociative Identity Disorder (Earlier Known as Multiple

Disorders)
It is the most dramatic among all disorders. A women who had been physically
and sexually abused by her father throughout her childhood and adolescence
exhibit four personalities as an adult. Each personality was of a different age,
representing the phases of the woman’s experience like fearful child, rebellious
teenager, protective which the women was consciously aware. In addition to
these experienced harsh trauma individuals seem prone to go into spontaneous
hypnotic trances.

2.6.3 Dissociative Fugue (Earlier Known as Psychogenic Fugue)

It has its own exceptional feature of unexpected travel away from home and
customary workplace. The travel and behaviour seen in a person in fugue are
more purposeful than any wandering that may also take place in amnesia often
they suffer from post-traumatic stress.

2.6.4 Depersonalisation Disorder

It generally leads to observable distress in the affected individual often occurs in
individual who are also affected by some other psychological non-dissociative
disorder who suffers from sleep deprivation at the onset of depersonalisation
disorder.
34
 Somatoform and
Self Assessment Questions Dissociative Disorders
1) What is dissociative disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Describe major types of dissociative disorders.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Define identity disorder.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) What is dissociative fugue? Explain.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

2.6.5 Symptoms of Dissociative Disorder

i) Low speech
ii) Anxious mood
iii) Limited concentration
iv) Impaired memory
v) Lack of insight
vi) Irritability
vii) Poor long term memory
viii) Frequently off orientation
ix) Un-relatedness 35
Mild Mental Disorders 2.6.6 Causes of Dissociative Disorder
i) Stressful Life events
ii) Traumatic experiences
iii) Natural disorder
iv) Personalised stress
v) Shocking death of loved ones
vi) Unbearable pressure
vii) Horrifying past
viii) Sexual or emotional abuse
ix) Childhood trauma
x) Disparate self concepts
Thus dissociative disorders are difficult to explain. More or less all types of
dissociative disorders are same and have similar etiology. Often it is unclear
whether a given case involves association or is some sort of psychotic
manifestations.
Self Assessment Questions
1) What are the major causes of dissociative disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Write down the various symptom.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What are the types of amnesia?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
36
 Somatoform and
2.7 TREATMENT Dissociative Disorders

Relaxation technique
Relaxation technique (also known as relaxation training) is a method, process,
procedure, or activity that helps a person to relax. It helps the individual to attain
a state of increased calmness, or reduce levels of anxiety, stress and anger.
Relaxation techniques are often employed to decrease muscle tension, lower the
blood pressure and slow down heart and breathing rates, among other health
benefits. It includes deep breathing, visualisation, progressive muscle relaxation,
meditation, and yoga. All these can help the individual activate his or her
relaxation response. When practiced regularly, these activities lead to a reduction
in the person’s everyday stress levels and a boost in the person’s feelings of joy
and serenity.

Cognitive behavioural technique

It is in combination of cognitive and behavioural approaches, based on the idea
that thoughts cause the feelings and behaviour but not the external things. There
are several approaches to cognitive behavioural therapy, including Rational
Emotive Behaviour Therapy, Rational Behaviour Therapy, Rational Living
Therapy, Cognitive Therapy, and Dialectic Behaviour Therapy. Thus the therapist
uses approaches and interventions that would maximally benefit the client or
patient by changing their maladaptive behaviours and developing positive
relationship between the therapist and the client. Therapist also believes that
clients change their behaviour because they learn to think differently and they
act on that learning. The therapist also focuses on teaching the client rational self
counseling. The therapist’ s role is to facilitate client to achieve goals and in this
process, the client learns many new methods to get over his stress and anxiety.
He then implements whatever he has learnt whenever he faces a conflict or a
problem or a symptom.

Psychological interventions
It is also useful like the attention training, using distraction tools, hypnosis or
environmental manipulation. These techniques reduce the person’s preoccupation
or overattention to the body part and the awareness of physiological disturbances
(Looper, 2002). Patients with Somatisation disorder usually refuse to undergo
psychotherapy because they already have clearly set in their mind that the physical
symptoms that they have is in fact an illness.

In Conversion disorder, behaviour therapy is very useful. Stress management

counseling is used to prevent the recurrence of the abnormal gait, which was
understood as a maladaptive response to stress.

Hypnosis can also be used in this disorder. Other treatments such as the use of
electromyography biofeedback, behavioural reinforcement combined with
strategic “double bind” therapy, hypnosis combined with lorazepam and
amobarbital interviewing.

In Hypochondriasis disorder, the physician should answer all the questions given
by the patient. In this way the patient might reduce his anxiety through the
physician’s explanations (or explanatory therapy).
37
Mild Mental Disorders Psychosocial interventions
It is specific to somatoform disorders In somatisation disorder, patients may
resist suggestions for individual or group psychotherapy because they view their
illness as a medical problem. Patients who accept psychotherapy may be able to
reduce health care utilisation. Psychosocial interventions that focus on maintaining
social and occupational function despite chronic medical symptoms may be
helpful.

Conversion disorder: Limited studies about specific psychotherapy exist for

conversion disorder. Behaviour therapy or hypnosis may be effective. Symptoms
often resolve spontaneously.

Hypochondrias: Hypochondrias is physicians should attempt to answer questions

and reduce the patient’s fear of a specific illness. Group psychotherapy may
provide social support and reduce anxiety. Cognitive therapy strategies may help
by focusing on distorted disease related cognitions. Individual insight oriented
psychotherapy has not been proven effective.

Pain disorder: Behaviour therapy, including biofeedback can be helpful. Hypnosis

also may be considered for chronic pain syndromes. Some outcome data supports
the effectiveness of individual psychotherapy. Exploration of interpersonal effects
of chronic pain may reduce social complications of pain.

2.8 LET US SUM UP

Thus individuals with somatoform and dissociative disorders all have
interpersonal, biological and interpersonal factors which contribute in its
development. This tend to differ from on to another. Many prior experience with
real physical problems usually among other family members tend to influence
the later choice of specifics dissociative and somatic symptoms that patient tend
to adopt symptoms with which they are familiar. These symptoms are the part of
a larger constellation of psychopathology. Individuals may have a marked
biological vulnerability to develop the disorder when under stress with biological
process. For the countless some other cases however biological contributing
factors seem to be less important than the overriding influence of interpersonal
factors.

2.9 UNIT END QUESTIONS

1) Discuss the somatoform disorders.
2) What are the characteristics of somatoform disorders?
3) Define various somatoform disorders with their types .And also cite
examples.
4) Difference between Somatoform Disorders and dissociative disorders.
5) Define the similarity and differences between dissociative disorder and
dissociative identity disorder. Elaborate with examples.
6) What are the causal factors of dissociative disorders.

38
 Somatoform and
2.10 SUGGESTED READINGS AND REFERENCES Dissociative Disorders

American Psychiatric Association. 2000. Diagnostic and Statistical Manual of

Mental Disorders. ed., text revision. Washington, DC: American 4th Psychiatric
Association.

Butcher, James, N. and Mineka, Susan & Hooley, Jill, M. (2006). Abnormal
Psychology My Psych Lab, MI.

Coleman, J.C. (2000). Abnormal Psychology And Modern Life. Allyn & Bacon,
NJ

Sharpe, M., and A. C. D. C. Williams. 2002. Treating patients with somatoform

pain disorder and hypochondriasis. In Psychological Approaches to Pain
Management: A Practitioner’s Handbook, edited by D. C. Turk and R. J. Gatchel.
New York: Guilford Press.

References
Arnow, B. A., E. M. Hunkeler, C. M. Blasey, J. Lee, M. J. Constantino, B. Fireman,
et al. 2006. Comorbid depression, chronic pain, and disability in primary care.
Psychosomatic Medicine 68: 262-268.

Becker, N., A. Bondegaard Thomsen, A. K. Olsen, P. Sjogren, P. Bech, and J.

Eriksen. 1997. Pain epidemiology and health related quality of life in chronic
non-malignant pain patients referred to a Danish multidisciplinary pain center.
Pain 73: 393-400.

Brinkhaus, B., C. M. Witt, S. Jena, K. Linde, A. Streng, S. Wagenpfeil, et al.

2006. Acupuncture in patients with chronic low back pain: A randomized
controlled trial. Archives of Internal Medicine 166: 450-457.

Clark, D. M., P. M. Salkovskis, A. Hackmann, A. Wells, M. Fennell, J. Ludgate,

et al. 1998. Two psychological treatments for hypochondriasis. British Journal
of Psychiatry 173: 218-225.

Dahl, J., and T. Lundgren. 2006. Living Beyond Your Pain: Using Acceptance
and Commitment Therapy to Ease Chronic Pain. Oakland, CA: New Harbinger
Publications.

Elliott, A. M., B. H. Smith, K. I. Penny, W. C. Smith, and W. A. Chambers. 1999.

The epidemiology of chronic pain in the community. Lancet 354: 1248-1252.

Fallon, B. A. 2004. Pharmacotherapy of somatoform disorders. Journal of

Psychosomatic Research 56: 455-460.

Fink, P., M. S. Hansen, and M.-L. Oxhoj. 2004. The prevalence of somatoform
disorders among internal medical inpatients. Journal of Psychosomatic Research
56: 413-418.

Fishbain, D. A., M. Goldbery, T. M. Khalil, S. S. Asfour, E. Abdel-Moty, R.

Meagher, et al. 1988. The utility of electromyographic biofeedback in the
treatment of conversion paralysis. American Journal of Psychiatry 145: 1572-
1575.
39
Mild Mental Disorders Grabe, H. J., C. Meyer, U. Hapke, H.-J. Rumpf, H. J. Freyberger, H. Dilling, et
al. 2003. Specific somatoform disorder in the general population. Psychosomatics:
Journal of Consultation Liaison Psychiatry 44: 304-311.
Hiller, W., M. M. Fichter, and W. Rief. 2003. A controlled treatment study of
somatoform disorders including analysis of healthcare utilisation and cost-
effectiveness. Journal of Psychosomatic Research 54: 369-380.
Kabat-Zinn, J., L. Lipworth, and R. Burney. 1985. The clinical use of mindfulness
meditation for the self-regulation of chronic pain. Journal of Behavioural
Medicine 8: 163-190.
Kabat-Zinn, J., L. Lipworth, R. Burney, and W. Sellers. 1987. Four-year follow-
up of a meditation-based program for the self-regulation of chronic pain:
Treatment outcomes and compliance. Clinical Journal of Pain 2: 159-173.
Kashner, T. M., K. Rost, B. Cohen, M. Anderson, and G. R. Smith. 1995.
Enhancing the health of somatisation disorder patients: Effectiveness of short-
term group therapy. Psychosomatics 36: 462-470.
Lidbeck, J. 1997. Group therapy for somatisation disorders in general practice:
Effectiveness of a short cognitive-behavioural treatment model. Acta Psychiatrica
Scandinavica 96: 14-24.
Liddle, S. D., G. D. Baxter, and J. H. Gracey. 2004. Exercise and chronic low
back pain: What works? Pain 107: 176-190.
Looper, K. J., and L. J. Kirmayer. 2002. Behavioural medicine approaches to
somatoform disorders. Journal of Consulting and Clinical Psychology 70: 810-
827.
Manheimer, E., A. White, B. Berman, K. Forys, and E. Ernst. 2005. Meta-analysis:
Acupuncture for low back pain. Annals of Internal Medicine 142: 651-663.
Marcus, D. A. 2002. Pharmacoeconomics of opioid therapy for chronic non-
malignant pain. Expert Opinion on Pharmacotherapy 3: 229-235.
Masheb, R. M., and R. D. Kerns. 2000. Pain disorder. In Effective Brief Therapies:
A Clinician’s Guide, edited by M. Hersen and M. Biaggio. San Diego, CA:
Academic Press.
Moene, F. C., K. E. L. Hoogduin, and R. Van Dyck. 1998. The inpatient treatment
of patients suffering from (motor) conversion symptoms: A description of eight
cases. International Journal of Clinical and Experimental Hypnosis 46: 171-190.
Newton-John, T. R., S. H. Spence, and D. Schotte. 1995. Cognitive-behavioural
therapy versus EMG biofeedback in the treatment of chronic low back pain.
Behaviour Research and Therapy 33: 691-697.
Nicholas, M. K., A. R. Molloy, and C. Brooker. 2006. Using opioids with
persisting noncancer pain: A biopsychosocial perspective. Clinical Journal of
Pain 22: 137-146.
Patterson, D. R. 2004. Treating pain with hypnosis. Current Directions in
Psychological Science 13: 252-255.
Patterson, D. R., and M. P. Jensen. 2003. Hypnosis and clinical pain. Psychological
40 Bulletin 129: 495-521.
Rooijmans. 1995. Cognitive behavioural therapy for medically unexplained Somatoform and
Dissociative Disorders
physical symptoms: A randomised controlled trial. British Medical Journal 311:
1328-1332.
Scharff, L. 1997. Recurrent abdominal pain in children: A review of psychological
factors and treatment. Clinical Psychology Review 17: 145-166.
Skapinakis, P., G. Lewis, and V. Mavreas. 2003. Cross-cultural differences in the
epidemiology of unexplained fatigue syndromes in primary care. British Journal
of Psychiatry 184: 205-209.
Smith, B. H., A. M. Elliott, W. A. Chambers, W. C. Smith, P. C. Hannaford, and
K. Penny. 2001. The impact of chronic pain in the community. Family Practice
18: 292-299.
Speckens, A. E. M., A. M. van Hemert, P. Spinhoven, K. E. Hawton, J. H. Bolk,
and H. G. M.
Speed, J. 1996. Behavioural management of conversion disorder: Retrospective
study. Archives of Physical Medicine and Rehabilitation 77: 147-154.
Stewart, W. F., R. B. Lipton, D. D. Celentano, and M. L. Reed. 1992. Prevalence
of migraine headache in the United States. Relation to age, income, race, and
other sociodemographic factors. Journal of the American Medical Association
267: 64-69.
Thomas, K. J., H. MacPherson, J. Ratcliffe, L. Thorpe, J. Brazier, M. Campbell,
et al. 2005. Longer term clinical and economic benefits of offering acupuncture
care to patients with chronic low back pain. Health Technology Assessment 9:
iii-iv, ix-x, 1-109.
Turk, D. C. 1994. Perspectives on chronic pain: The role of psychological factors.
Current Directions in Psychological Science 3: 45-48.
Volz, H. P., H. Murck, S. Kasper, and H. J. Moller. 2002. St. John’s wort extract
(LI 160) in somatoform disorders: Results of a placebo-controlled trial.
Psychopharmacology 164: 294-300.
Wallis, C. 2005. The right (and wrong) way to treat pain. Time, Feb. 28, 47-57.
Warwick, H. M., D. M. Clark, M. Cobb, and P. M. Salkovskis. 1996. A controlled
trial of cognitive-behavioural treatment of hypochondriasis. British Journal of
Psychiatry 169: 189-195.
Waxman, R., A. Tennant, and P. Helliwell. 2000. A prospective follow-up study
of low back pain in the community. Spine 25: 2085-2090.

41
Mild Mental Disorders
UNIT 3 EATING DISORDERS

Structure
3.0 Introduction
3.1 Objectives
3.2 Definition and Concept
3.2.1 Definition of Eating Disorder
3.2.2 Characteristics of Eating Disorder
3.3 Types of Eating Disorders
3.3.1 Anorexia Nervosa
3.3.2 Bulimia Nervosa
3.3.3 Binge Eating Disorder
3.4 Let Us Sum Up
3.5 Unit End Questions
3.6 Suggested Readings and References

3.0 INTRODUCTION
In this unit we will be dealing with different types of eating disorders, their
causes, symptoms and treatment. The unit begins with defining eating disorders
and elucidating its characteristic features. This is followed by presenting different
types of eating disorders scuch as anorexia nervosa, bulimia nervosa and the
binge eating disorders. The causes are then given in detail for each of these
disorders followed by treatment interventions which include psychotherapy,
cognitive therapies and medications.

3.1 OBJECTIVES
After completing this unit, you will be able to:
• Define eating disorders;
• Elucidate the characteristics of eating disorders;
• Describe the various types of eating disorders;
• Elucidate the Symptoms of eating disorders;
• Explain the causes of eating disorders; and
• Describe the treatment interventions for each of the eating disorders.

3.2 DEFINITION AND CONCEPT

Eating disorders have been one of the increasing disorders in the developed and
developing countries. The drive for thinness not only affects the actress but the
young , middle aged and older adults. This disorder generally refers to a group of
conditions characterised by abnormal eating habits which may involve insufficient
or excessive food intake in the body of the individual.

42
The disorder afflicts millions of people, thousands of whom may die from them Eating Disorders
yearly. The history of eating disorders has been in existence even from the ancient
Roman times. The ancient Romans were known for many accomplishments as
well as decadences and one of these was the overindulgence or known as ‘orgy’.
Romans were the first orgy who used to eat more .

It is well known that in this disorder, particularly in serious conditions, one finds
that individuals are preoccupied with are food and weight. There is no specific
reason for this disorder to come about, however it can involve many environmental
and familial conditions and situations. Studies have shown that females have
greater chance of developing eating disorders as compared to males especially
in the adolescent years. It is often marked by extremes and manifests itself in the
form of severe disturbances in eating behaviour, like extreme reduction of food
intake or overeating or feelings of extreme distress or concern about body weight
or shape etc. Person starts with eating small or large amount of food than usual
but at the same time urge to eat less or more spirals out of control. It is very
complex and despite different scientific research the illness remains elusive in
terms of understanding the psychodynamics underlying the problem.

It frequently appears during adolescence or young adulthood but some reports

indicate that they can also develop during childhood or in later adulthood. People
with eating disorders suffer from a number of physical problems like heart or
kidney failure and many other severe gastro intestinal or cardio vascular disorders
which may eventually lead to death. This disorder coexists with other psychiatric
disorders, and clearly with the potentially life threatening conditions it has become
a growing, intricate and complex problem.

Despite the collective label, these disorders are not about food. It is a way of
coping with a deeper problem that a person finds too difficult or painful to deal
with directly. These are the complex conditions that signal difficulties with
identity, self concept and self esteem. Eating disorders are cross cultural, and
have racial and socio economic boundaries which affect men and women almost
equally.

Eating disorder is a serious psychological condition in which the sufferer is

obsessed with food, diet and often body image to the point where their quality of
life suffers and their health is at extreme risk from long term poor or inadequate
diet. This disorder is not a sign of a person mentally ill etc., but the problem is of
intake of food and the disorder is actually only the symptom of some underlying
problem in that person’s life.

In addition there are many cases of abnormal eating that have the same features
of eating disorders which have been diagnosed. Obesity is classified as a general
medical condition and not as an eating disorder because it is not consistently
associated with psychological or behavioural problems. Thus millions of people
suffer from this eating disorder which starts mainly from the age of twenty or
even adolescent years and continues. This condition as illness is often hidden so
sometimes it becomes difficult to diagnose. This typically affects young women
than men with a pattern of eating less or over eating. Obviously the amount of
fat deposited is related to the energy absorbed from the food and by the hormonal
changes which generally occur in the young age.

43
Mild Mental Disorders 3.2.1 Definition of Eating Disorder
Eating disorder is defined as a psychological disorder centering on the avoidance,
excessive consumption or purging of food. It is also said regarding eating disorder
that it is a type of dependency. Eating becomes the object of dependency and
disturbs the balance of daily life. Others define eating disorders as an illness that
causes a person to adapt harmful eating habits. These disorders are more common
amongst teenage girls and young women. Eating disorder is defined by
psychologists as a psychological disorder that impairs normal eating behaviour.
Over eating, anorexia and bulimia are examples of eating disorders.

3.2.2 Characteristics of Eating Disorder

This disorder is marked by extremes. It is present when a person experiences a
severe disturbance in eating behaviour such as extreme distress or concern about
body weight or shape. Unlike hysteria eating disorder does not so much mimic a
physical illness but manipulates food intake and becomes obsessive about one’s
own body’s shape and weight. It has been also found that eating disorder is a
personality disorder.

When a patient has a personality disorder and an eating disorder, the therapist
would do well to first tackle the eating disorder. Personality disorders are intricate
and intractable. They are rarely curable (though certain aspects, like obsessive-
compulsive behaviours, or depression can be ameliorated with medication or
modified). The treatment of personality disorders requires enormous, persistent
and continuous investment of resources of every kind by everyone involved.

From the patient’s point of view, the treatment of her personality disorder is not
an efficient allocation of scarce mental resources. Neither are personality disorders
the real threat. An eating disorder is both a signal of distress (“I wish to die, I feel
so bad, somebody help me”) . This is where we can and should begin to help the
patient by letting her regain control of her life. The family or other supporting
figures must think what they can do to make the patient feel that she is in control,
that she is managing things her own way, that she is contributing, has her own
schedules, her own agenda, and that she, her needs, preferences, and choices
matter.

Further problems about accepting a psychological explanation for the eating

disorder are first that many women have found after careful testing to have a
normal personality and second the personality scores of normal people and those
who suffer from eating disorder overlap considerably. Psychological explanations
have been suggested one of which is the concept that some obese women use
eating as a substitute for love. A person who feels lonely, empty and unloved
unless she has constant company may eat to compensate. From this it follows
that psychological factors may be involved in explaining why individuals who
have an eating disorder persist with their eating disorder.
Self Assessment Questions
1) Discuss the concept of eating disorder.
...............................................................................................................
...............................................................................................................
...............................................................................................................
44
 Eating Disorders
2) Define in your own words eating disorder and cite a few examples.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What are the typical characteristics of eating disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

3.3 TYPES OF EATING DISORDERS

Eating disorders are basically of three types and these are presented below:
• Anorexia nervosa
• Binge eating disorders
• Bulimia nervosa
Let us deal with each of these in detail.

3.3.1 Anorexia Nervosa

This term has been in use since 1700 especially for a condition in which a person
refused to maintain a healthy body weight. Much later, as per medical opinion
anorexia nervosa was considered to be the result of an endocrine disturbance,
which possibility remains even today and it is said that this condition is due to a
disorder of the hypothalamus. The term anorexia nervosa literally means “nervous
lack of appetite”, in which people with anorexia lack in appetite and battle with
hunger every day.

Person suffers from the fear of becoming fat is an anorectic’s faulty perception
of her body. In reality anorectics self esteem is clearly tied to this distorted view
of her body. Continued weight loss is considered by anorectics to be a sign of
achievement and self discipline while any weight gain even if it brings them
close to a healthy body weight is considered a sign of weakness of lack of self
control. It can cause menstruation to stop and often leads to bone loss, loss of
skin integrity etc. The risk of death is greatly increased in the individual with
this disease.

It is a variety of external and internal conflicts like stress, anxiety, unhappiness

and feelings of life being out of control. Not eating or anorexia is a negative way
to cope with emotions, feel happy and satisfied. Problems range from frequent
infections and general poor health to life threatening conditions. Research suggests
that anorexia nervosa has the highest death rate of any psychiatric disorder. 45
Mild Mental Disorders Generally people with this disorder are characterised by an irrational dread of
becoming fat coupled with a relentless pursuit of thinness. Even though they do
not eat and starve, they appear to have excessive energy to go on working in the
usual manner. These persons not only maintain a dangerously low body weight
but also carry on their work as if there is nothing wrong with them.

It also attempts to deal with perfectionism and desire to control things by strictly
regulating food and weight. Mainly young women and more so in industrialised
countries appear to be afflicted by this disorder where cultural expectations
encourage women to be thin.
The key symptoms are:
i) Refusal to sustain a minimal normal body weight
ii) Intense fear of gaining weight
iii) Distorted view of one’s body or weight
iv) Severe starvation
v) Obsession in regard to Food and weight
vi) Intense and overwhelming fear of gaining weight
vii) Thinning of hair
viii) Dry skin
ix) Low blood pressure
x) Fatigue and exhaustion
xi) Loss of memory to an extent.
xii) Obsessive Compulsive behaviour
xiii) Depression
xiv) Osteoporosis
xv) Fast heart rhythms
xvi) Anxiety
xvii) Low self esteem
Thus people with anorexia continue to think that they are over weight even after
they become extremely thin, and are very ill and near death condition. Although
idealisation of thinness in a certain culture plays a vital role in the development
of anorexia, there are other contributing factors like genetics, personality traits
and family environment which all contribute to the development of this disorder.

Causes
1) Biological causes: It has been suggested by psychologists that genetic
predisposition to anorexia plays a major role. If a young girl has a sibling
with anorexia she is 10 to 20 times more likely than the general population
to develop anorexia. People with anorexia have high levels of cortisol, brain
hormone most related to stress, decreased levels of neurotransmitters such
as serotonin and norepinephrine which are associated with feelings of well
being.

46
 Studies of twins have shown a higher rate of eating disorders when they are Eating Disorders
identical. Samples of DNA, substance inside cells that carry genetic
information, have all shown in research studies that there are abnormalities
in the structure or activity of the hypothalamus, causing the concerned
problem. a brain structure becomes responsible for irregular eating behaviour.
Abnormal neuro transmitter levels have been shown to exist in people with
anorexia.

ii) Psychological causes: People with anorexia are emotionally driven not only
in weight loss but also in other areas of their life like career, school work or
fitness. It includes the psychological disturbances like:
• Low self esteem
• Depression
• Anxiety
• Irritability
• Mood swings
People appear to have it all together on the surface inside they feel helpless,
inadequate and worthless. Generally anorexics feel harshly critical and have
no confidence thus some of the traits that occur in anorexics may be a result
rather than a cause of the disorder.

iii) Family and social pressure: Anorexia develops as a struggle for

independence and individuality. It is likely to surface in adolescence when
new demands for independence occur. Sometime family and other members
become responsible for a member to become anorexic by showing attitudes
towards the person the following:
i) Overprotection
ii) Rigid
iii) Extreme closeness
iv) Criticizing the child’s weight
v) Sexually abusive
vi) Overvaluing appearance
All these negative stressful life events trigger anorexia and the disorder
develops as a struggle for independence and individuality.
iv) Cultural pressure: Standards of beauty for women in societies and
bombarded messages from the media push women to diet for meeting the
standards. This idealised ultra thin body shape is almost impossible for most
women to achieve since it does not fit with the biological and inherited
factors that determine natural body weight. Certain occupations like
modeling, sports, running etc. pressurise the individual to maintain specific
body weight.

Life transitions
This also triggers anorexia in those who are already vulnerable because of the
factors like
47
Mild Mental Disorders i) Beginning of adolescence
ii) Beginning or failing in school
iii) Breakup of a relationship
iv) Death of a loved ones
These factors make it more difficult to stop from and makes individual obsessive
in continuing their anorexic thoughts.

Treatment:
The types of treatments are being used as follows:

i) Individual psychotherapy
It is the major step especially for people who are beyond adolescence. In this
cognitive behavioural approach helps in developing healthy ways of thinking
and pattern of behaviour and reenter in new relationship.

ii) Family therapy

It is important for family members who also push the individual towards the
tendency of anorexic. This approach can assess the impact of the disorder on the
family help members in overcoming from certain guilt and inferiority. This helps
the individual to develop practical strategies for overcoming.

iii) Group therapy

This is important in the hospital or in intensive day treatment. Some groups are
task oriented and may focus on eating food, body image, etc. The other group
may aim at understanding the psychological factors that may lead to the
development.

iv) Medication
In comparison to other interventions medication can prove effective. Depression
and other emotional problems are often a result of starvation, it is best to focus
on weight gain rather than medication.

v) Support group
It is generally led by non professionals which can be useful in different
circumstances. This provides support to people with anorexia and their families
with mutual support and advice about how to cope with disorders.

3.3.2 Bulimia Nervosa

It is an overeating characterised by retaining of food intake. This results in feelings
of guilt and low self esteem.

This term is appropriate on many levels as bulimia is a repeated cycle of binge

eating and purging. Binge eating is the abnormal over intake of large amount of
food that she or he has eaten by either making herself to vomit, taking an excessive
amount of laxatives, diuretics or engaging in fasting and or excessive exercise.
People with bulimia known as bulimica engage in such behaviour at least two
times a week for a period of six months or more.

48
It is generally associated with depression and other psychiatric disorders. Eating Disorders
Sometimes the symptom may also be associated with anorexia nervosa. Many
people with bulimia can maintain a normal weight and be able to keep their
condition a secret for years. Bulimics are usually ashamed of their behaviour
and attempt to hide their illness from others. If it is not treated bulimia can lead
to nutritional deficiencies and may have fatal complications.
Symptoms of Bulimia include the following:
i) Binge eating of high carbohydrate foods
ii) Eating until painfully full
iii) Dehydration
iv) Constipation, nausea, abdominal pain
v) Bad breath
vi) Sore throat
vii) Depression
viii) Excessive exercising
ix) Alternative eating
x) Using laxatives
xi) Frequent mood fluctuations
xii) Lack of energy
xiii) Bloating or fullness
xiv) Feelings of Guilt
xv) Suicidal tendencies
Currently with these symptoms no particular or specific known cause has been
found. Usually individual suffering from bulimia have low self esteem, feelings
of helplessness etc.

Causes
i) Culture: Culture does play a role in determining whether or not someone
will develop bulimia. For example, women in the different countries and
in different advertisements are bombarded with images of the “ideal” or
“perfect” woman, and these women are always thin. Seeing this often enough
can make it difficult for an ordinary woman to ever see herself as beautiful.
Men are even starting to suffer from the same sort of self image problems as
women.
ii) Low self-esteem: This is a major factor when it comes to developing bulimia
and is one of the causes of bulimia. It is not surprising that people who see
themselves as worthless and unattractive are at high risk. Growing up and
living in an environment conducive to abuse, criticism, pushing for perfection
and depression can contribute to people becoming bulimic.
iii) Dieting: Dieting can actually be one of the causes of bulimia. This happens
because dieting too much can lead to developing an eating disorder. Drastic
dieting can bring about the deprivation that may be a trigger to binge eating.
Once this happens binge and purge cycle will start and continue.
49
Mild Mental Disorders iv) Genetic involvement: Many people who are bulimic have mothers or sisters
who also have bulimia. Someone with parents who over value looks and
judge the ways their children look are more likely to develop bulimia or
some other eating disorder. These types of parents definitely belong on the
list of causes of bulimia. There is also research that shows low levels of
serotonin may play a part.

v) Major life changes: Major life changes such as going to a hostel for higher
studies or taking up a modeling job etc., have been found to be one of the
causes of bulimia. Episodes can be triggered by stressful situations such as
relocating or the end of a relationship. The binge and purge cycle can be a
way to try to handle the stresses these events bring. Traumatic events such
as rape can also be a trigger. People who are in professions or activities
that require an attractive appearance may become bulimic. Professions
such as ballet dancers, gymnasts, models, actors, wrestlers, or runners are at
high risk of developing bulimia.

Treatment
i) Breaking the binge and purge cycle
This is the phase of treatment which focuses on stopping the vicious cycle of
bingeing and purging and restoring normal eating patterns. The person learns to
monitor his or her eating habits, avoid situations that trigger binges, cope with
stress in ways that do not involve food, eat regularly to reduce food cravings,
and fight the urge to purge.

ii) Changing unhealthy thoughts and patterns

The second phase of bulimia treatment focuses on identifying and changing the
dysfunctional beliefs about weight, dieting, and body shape. The person is helped
to explore attitudes about eating, and rethink the idea that self worth is based on
weight.

iii) Solving emotional issues

The final phase of bulimia treatment involves targeting emotional issues that
caused the eating disorder in the first place. Therapy may focus on relationship
issues, underlying anxiety and depression, low self-esteem, and feelings of
isolation and loneliness.

3.3.3 Binge Eating Disorder

Binge eating is a pattern of disorder which consists of episodes of uncontrollable
eating. In such binges, a person rapidly consumes an excessive amount of food.
Most people who have eating binges try to hide this behaviour from others, and
often feel ashamed about being overweight or depressed about their overeating.

Eating binges can be followed by the so called compensatory behaviour, that is

acts by which the person tries to compensate for the effects of overeating. Although
people who do not have any eating disorder may occasionally experience episodes
of overeating, frequent binge eating is often a symptom of an eating disorder.

Binge eating is a central feature of bulimia nervosa and binge eating disorder. It
is also practiced by some people with an eating disorder not otherwise specified
or anorexia nervosa. Binge eating symptoms are also present in bulimia nervosa.
50
Additionally, bulimics are typically of normal weight, are underweight but have Eating Disorders
been overweight before, or are slightly overweight. Those with binge eating
disorder are more likely to be overweight or obese.

Binge eating disorder is similar to, but distinct from, compulsive overeating.
Those with Binge eating disorder do not have a compulsion to overeat and do
not spend a great deal of time fantasizing about food.

On the contrary, some people with binge eating disorder have very negative
feelings about food. As with other eating disorders, binge eating is an “expressive
disorder”, a disorder that is an expression of deeper psychological problems.

Some researchers believe that Binge eating disorder is a milder form or subset of
bulimia nervosa, while others argue that it is its own distinct disorder. Currently,
the DSM-IV categorises it under Eating disorder not otherwise specified
(EDNOS), an indication that more research is needed.

Symptoms
i) The person does not have control over consumption of food.
ii) Eats an unusually large amount of food at one time, far more than a normal
person would eat in the same amount of time.
iii) Eats much more quickly during binge episodes than during normal eating
times.
iv) Eats until physically uncomfortable and nauseated due to the amount of
food just consumed.
v) Eats when depressed or bored.
vi) Eats large amounts of food even when not really hungry.
vii) Usually eats alone during binge eating episodes, in order to avoid discovery
of the disorder.
viii) Often eats alone during periods of normal eating, owing to feelings of
embarrassment about food.
ix) Feels disgusted, depressed, or guilty after binge eating.
x) Rapid weight gain, and/or sudden onset of obesity.
Causes
i) Developmental aspect
It is the belief that pressure to look a certain way and fit in through being thin is
greatest during the period of adolescence. Girls are more affected by inner turmoil
at this time low self esteem, anxiety and being self conscious. This approach
suggests that boys usually find forming an identity somewhat easier than girls.
Society also recognises continually changing in terms of expectations of the
female role.

ii) Cognitive aspect

It is all about identifying and challenging negative behaviours, feelings and
thoughts and beliefs about oneself. Emphasis comes on learning to interrupt
destructive behaviour or thought patterns which serve to keep the vicious cycle.
This includes misusing laxatives, diet pills and diuretics.
51
Mild Mental Disorders iii) Genetic aspect
Genetic element associated with the mental health conditions. Some individuals
develop bulimia even due to genetic risk and responsible for triggering the
conditions. With these factors family systems, socio cultural models and individual
factor also play a major role in developing bulimia disorders.

Treatment
People who suffer from bulimia are less likely to end up in hospitals as in patients.
They can all be treated as outpatients with the help of medications and
pharmacology. They are generally invidually treated which in turn gives the patient
positive outcome and a healthy balanced life.

Other methods of psychological treatment include psychotherapy, cognitive

therapy etc.

i) Psychotherapy
Psychotherapy and cognitive behavioural technique prove to be more effective
for modifying thoughts and engaging in behavioural changes. In CBT, records
are maintained as to how much food they eat and periods of vomiting etc. Thesen
records help in identifying and avoiding emotional fluctuations that bring on
episodes of bilumia on regular basis.

ii) Nutritional Counseling

This focuses on health rather than weight. A nutritionist or dietician can help
those with eating disorders to understand adequate nutritional needs and to change
eating behaviours. Dietary counseling may involve having the person keep a
food diary to facilitate a return to normal dietary intake or to become aware of
triggers for bingeing.

iii) Medical Treatment

This involves careful monitoring of the person with an eating disorder, such as
weight, fluid and electrolyte balance, cardiac status, growth and development
(such as bone growth) and vital signs. It may involve injecting intravenous fluids
or in very serious cases, feeding against the will of the person.

iv) Pharmacology
It is especially for those with eating disorders. This consists of antidepressants
medication and with vitamins and mineral supplements.
Self Assessment Questions
1) What are the major types of eating disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

52
 Eating Disorders
2) Discuss the causes underlying the various eating disorders.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) Differentiate and show the similarity of bulimia and binge eating
disorder.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
4) What are the main causes in binge eating disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
5) What treatment interventions are available for these disorders?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

Thus the approach of the therapist or psychologist is to offer encouragement,

support throughout the treatment process and help in overcoming it fast.
Other common types of eating disorders are:
i) Binge eating disorder (Bulimia)
ii) Obesity
iii) Childhood obesity
With the overall study it is clear that researchers are using tools to better understand
eating disorders. New studies currently underway however are aiming to remedy
the lack of information available about treatment. Severe imbalances in eating
behaviours, such as severe and unhealthy decrease of food intake or extreme
53
Mild Mental Disorders overeating, in addition to these the feelings of depression, distress, or extreme
concern over body shape and weight.

An eating disorder can in general be expressed as a condition where a person’s

nutrition is not managed correctly, which can cause severe harm to the body. The
types of eating disorders develop in adolescence or in early stages of adulthood.
However in rare cases, it develops in childhood or at later stages of adulthood.

Females are more likely than males to develop an eating disorder. Only about
5% to 15% are male anorexics or bulimics and 35% are binge eaters.

3.4 LET US SUM UP

Eating disorders are one of the most difficult mental illnesses to diagnose and
cure. There appears to be a connection between all the major types of eating
disorders and this is depression. Furthermore all these disorders are marked by
extremes in behaviour. Also, this person experiences severe disturbances in eating
behaviour such as extreme reduction of food intake or extreme overeating or
feeling of extreme distress or concern about body shape. It is all interrelated and
focuses on some factual cause but still remains elusive for all.

Whatever the source of the psychological needs, control and comfort are the two
words that probably best sum up the needs that are filled by eating disorders.
Trauma a big upset or long term turbulence in life, can also influence a person to
do whatever they can to bring control to life, and food and weight can be easy
targets for control. Under eating and overeating have been shown to activate
calming brain chemicals, which may be why those experiencing emotional pain
turn to these eating patterns.

Furthermore, “Mastery” is also an important aspect of eating disorder psychology.

This is the sense that one can reach an achievement that others can not even if
that “achievement” is a too strict a diet.

Personalities: According to psychologists at the National Institute of Mental

Health, most people with eating disorders share these personality characteristics
such as low self-esteem, perfectionism, feelings of helplessness, and anxiety.
They have overly high expectations and have “all-or-nothing” thinking patterns.
One can see how these traits connect to over control eating. The problem is,
disordered eating patterns aren’t triggered by these characteristics, but they may
make it more difficult to recover.

Emotional causes: Anger and other emotions that are not expressed easily can
feed a disorder. In fact, therapists believe that eating disorders are more about
trying to relieve uncomfortable feelings and solving life problems than they are
about food. The person often is afraid to express these emotions verbally and
directly, so he or she does it indirectly through disordered eating patterns. For
some, a strong emotion will trigger an eating binge. Others may overeat to mask
and numb out difficult emotions. Non eaters are able to feel something, even if
it’s physical pain, which may be easier to deal with than their actual emotions.

54
 Eating Disorders
3.5 UNIT END QUESTIONS
1) Describe the overall concept of eating disorder.
2) Discuss anorexia nervosa with its symptoms and causes.
3) Elaborately write important treatment tips for eating disorder patients.
4) Whether anorexia nervosa disorder can be controlled– Explain.
5) What is bulimia nervosa? Put forward the characteristic features of the same.
6) What are the various treatment interventions to overcome bulimia?
7) What is binge eating? Elucidate.

3.6 SUGGESTED READINGS AND REFERENCES

Coleman, J.C. (200). Abnormal Psychology and Modern Life. Allyn & Bacon ,
New Delhi.

Barlow, David H. and Durand, Mark V. (2002). Abnormal Psychology An

Intergative Approach Wadsworth Cengage publisher. NY

Cave, Susan, (2005). Classification and Diagnosis of Psychological Abnormality.

Rutledge , NY.

References
American Psychiatric Association. Diagnostic and Statistical Manual for Mental
Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric
Press, 1994.
American Psychiatric Association (APA). Let’s Talk Facts About Eating
Disorders. 2005.
American Psychiatric Association Work Group on Eating Disorders. Practice
guideline for the treatment of patients with eating disorders (revision). American
Journal of Psychiatry, 2000; 157(1 Suppl): 1-39.
Andersen AE. Eating disorders in males. In: Brownell KD, Fairburn CG, eds.
Eating disorders and obesity: a comprehensive handbook. New York: Guilford
Press, 1995; 177-187.
Anderson AE. Eating disorders in males: Critical questions. In R Lemberg (ed),
Controlling Eating Disorders with Facts, Advice and Resources. Phoenix, AZ:
Oryx Press, 1992, pp.20-28.
Arnold LM, McElroy SL, Hudson JI, Wegele JA, Bennet AJ, Kreck PE Jr. A
placebo-controlled randomized trial of fluoxetine in the treatment of binge-eating
disorder. Journal of Clinical Psychiatry, 2002; 63:1028-1033.
Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating Disorders. New
England Journal of Medicine, 1999; 340(14): 1092-1098.
Birmingham CL, Su J, Hlynsky JA, Goldner EM, Gao M. The mortality rate of
anorexia nervosa. International Journal of Eating Disorders. 2005 Sep;
38(2):143-146.

55
Mild Mental Disorders Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L,
Brent DA. Clinical response and risk for reported suicidal ideation and suicide
attempts in pediatric antidepressant treatment, a meta-analysis of randomized
controlled trials. Journal of the American Medical Association, 2007; 297(15):
1683-1696.

Bryant-Waugh R, Lask B. Childhood-onset eating disorders. In CG Fairburn,

KD Brownell (eds.), Eating disorders and obesity: A comprehensive handbook,
2nd ed. New York: Guilford Press, 2002, pp. 210-214.

Bulik CM, Sullivan PF, Kendler KS. Medical and psychiatric comorbidity in
obese women with and without binge eating disorder. International Journal of
Eating Disorders, 2002; 32: 72-78.

Eisler I, Dare C, Hodes M, Russel G, Dodge, and Le Grange D. Family therapy

for adolescent anorexia nervosa: The results of a controlled comparison of two
family interventions. Journal of Child Psychology and Psychiatry, 2000; 1: 727-
736.

Fitzgerald KD, Welsh RC, Gehring WJ, Abelson JL, Himle JA, Liberzon I, Taylor
SF. Error-related hyperactivity of the anterior cingulated cortex in obsessive-
compulsive disorder. Biological Psychiatry, February 1, 2005; 57 (3): 287-294.

Halmi CA, Agras WS, Crow S, Mitchell J, Wilson GT, Bryson S, Kraemer HC.
Predictors of treatment acceptance and completion in anorexia nervosa:
implications for future study designs. Archives of General Psychiatry; 2005; 62:
776-781.

Insel TR and Quirion R. Psychiatry as a clinical neuroscience discipline. Journal

of the American Medical Association, November 2, 2005; 294 (17): 2221-2224.

Lasater L, Mehler P. Medical complications of bulimia nervosa. Eating Behaviour,

2001; 2:279-292.

Lock J, Agras WS, Bryson S, Kraemer, HC. A comparison of short-and long-

term family therapy for adolescent anorexia nervosa, Journal of the American
Academy of Child and Adolescent Psychiatry, 2005; 44: 632-639.

Lock J, Couturier J, Agras WS. Comparison of long-term outcomes in adolescents

with anorexia nervosa treated with family therapy. Journal of the American
Academy of Child and Adolescent Psychiatry, 2006; 45: 666-672.

Lock J, Le Grange D, Agras WS, Dare C. Treatment Manual for Anorexia

Nervosa: A Family-based Approach. New York: Guilford Press, 2001.

McIntosh VW, Jordan J, Carter FA, Luty SE, et al. Three psychotherapies for
anorexia nervosa: a randomized controlled trial. The American Journal of
Psychiatry, Apr. 2005; 162: 741-747.

Meyer-Lindenberg AS, Olsen RK, Kohn PD, Brown T, Egan MF, Weinberger
DR, et al. Regionally specific disturbance of dorsolateral prefrontal-hippocampal
functional connectivity in schizophrenia. Archives of General Psychiatry, April
2005; 62(4).

56
National Institute for Clinical Excellence (NICE). Core interventions in the Eating Disorders
treatment and management of anorexia nervosa, bulimia nervosa, and binge eating
disorder, 2004: London: British Psychological Society.

Pezawas L, Meyer-Lindenberg A, Drabant EM, Verchinski BA, Munoz KE,

Kolachana BS, et al. 5-HTTLPR polymorphism impacts human cingulated-
amygdala interactions: a genetic susceptibility mechanism for depression. Nature
Neuroscience, June 2005; 8 (6): 828-834.

Pope HG, Gruber AJ, Choi P, Olivardi R, Phillips KA. Muscle dysmorphia: an
underrecognised form of body dysmorphic disorder. Psychosomatics, 1997; 38:
548-557.

Romano SJ, Halmi KJ, Sarkar NP, Koke SC, Lee JS. A placebo-controlled study
of fluoxetine in continued treatment of bulimia nervosa after successful acute
fluoxetine treatment. American Journal of Psychiatry, Jan. 2002; 151(9): 96-
102.

Russell GF, Szmuckler GI, Dare C, Eisler I. An evaluation of family therapy in

anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 1987;
44: 1047-1056.

Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard A, Devlin

M, Mitchell J, Hasin D, Horne RL. Binge eating disorder: its further validation
in a multisite study. International Journal of Eating Disorders, 1993; 13(2):
137-153.

Steiner H, Lock J. Anorexia nervosa and bulimia nervosa in children and

adolescents: a review of the past ten years. Journal of the American Academy of
Child and Adolescent Psychiatry, 1998; 37: 352-359.

Streigel-Moore RH, Franko DL. Epidemiology of Binge Eating Disorder.

International Journal of Eating Disorders, 2003; 21: 11-27.

Taylor CB, Bryson S, Luce KH, Cunning D, Doyle AC, Abascal LB, Rockwell
R, Dev P, Winzelberg AJ, Wilfley DE. Prevention of Eating Disorders in At-risk
College-age Women. Archives of General Psychiatry; 2006 Aug; 63(8):881-888.

Walsh et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized

controlled trial. Journal of the American Medical Association. 2006 Jun 14;
295(22): 2605-2612.

Wilson GT and Shafran R. Eating disorders guidelines from NICE. Lancet, 2005;
365: 79-81.

Wonderlich SA, Lilenfield LR, Riso LP, Engel S, Mitchell JE. Personality and
anorexia nervosa. International Journal of Eating Disorders, 2005; 37: S68-
S71

57
Mild Mental Disorders
UNIT 4 SUBSTANCE USE DISORDER

Structure
4.0 Introduction
4.1 Objectives
4.2 Definition and Concept of Substance Use Disorder
4.2.1 Drug Addiction
4.2.2 Alcohol Related Disorder
4.2.3 Amphetamine Related Disorder
4.2.4 Caffeine Addiction Related Disorders
4.2.5 Cannabis Addiction
4.2.6 Cocaine Addiction
4.2.7 Hallucinogens Addiction
4.2.8 Addiction to Inhalents
4.2.9 Nicotine Substance Abuse Disorder
4.2.10 Phencyclidine Addiction
4.2.11 Sedative, Hypnotic, Anxiolytic Related Disorders
4.2.12 Polysubstance Use Disorder
4.3 Let Us Sum Up
4.4 Unit End Questions
4.5 Suggested Readings and References

4.0 INTRODUCTION
This unit deals with substance use and abuse disorders. It starts with definition
and Concept of Substance Use disorders. Within this we discuss disorders Drug
addiction, Alcohol related disorder, Amphetamine related disorder, Caffeine
addiction related disorders, Cannabis addiction, Cocaine addiction, Hallucinogens
addiction, Addiction to Inhalents., Nicotine substance abuse disorder,
Phencyclidine addiction, Sedative, Hypnotic, Anxiolytic related disorders, and
Polysubstance use disorder. Each disorder is discussed in terms of the symptoms,
causes, and treatment interventions.

4.1 OBJECTIVES
On completing this unit, you will be able to:
• Define substance use disorder;
• Elucidate the various types of substance use disorders;
• Explain the symptoms various substance use disorders;
• Analyse the various causes of substance abuse disorders; and
• Describe the Treatment for the substance use disorders.

58
 Substance Use Disorder
4.2 DEFINITION AND CONCEPT OF SUBSTANCE
USE DISORDER
Substance use related disorders are those which are related to intoxication, drug
dependence, drug abuse, withdrawal syndromes of substance abuse etc., caused
by different substances legal or illegal. This is an umbrella term used for describing
all major substance use and associated disorders. This disorder is obtained when
an individual persists in use of alcohol or other drugs despite problems related to
the use of the substance. Such cases are diagnosed as , substance abuse or use or
substance dependence disorder.

Generally youngsters during pre adolescence and adolescence stages try these
on an experimental curiosity basis. The disorder ranges from none to minor to
life threatening severity. Sometimes the occasional use can also put adolescents
at risk of very significant harm which includes over dose, motor vehicle collisions,
consequences of sexual contact and violent behaviour.

Substance dependence can be diagnosed with physiological symptoms in which

one finds the person developing increased tolerance for the existing dosage and
increasing the frequency and the strength of the concerned drug. For instance, if
a person was taking 25 mg of the drug, now he will require 50 mg of the drug to
obtain the same effect of intoxication. Similarly if he has been using the drug
twice a day, now he may use it four times a day. Withdrawal symptoms may also
increase in such cases. That is when the person does not take the drug for a while
or misses a dose or takes lesser dose, it produces many painful and undesirable
symptoms such as pain in the body, vomiting etc.

According to DSM IV (TR) substance related disorders can be sub categorised

into substance use disorder and substance induced disorder. Both can be
differentiated on the basis of their conditions in attributing the use of substance.

Substance induced disorders include intoxication, l substance induced withdrawal

psychosis and substance induced mood disorders. Second substance use disorder
includes substance abuse and substance dependence. Combining the two in DSM
V the conditions are called the substance use disorders.

Mostly youth and Adolescents engage in these behaviours and are always at a
higher risk of harm to themselves. Parental attitudes, societal provocation etc.,
also play important role in this type of dependence.

As per DSM IV, the above mentioned substance use or substance dependence is
characterised by continued use of substance even after the user has experienced
serious substance use related problems such as giddiness, nausea, discomfort
etc. Drug dependent persons desire for that particular drug when ever their bodily
system craves for it and they need more of the same substance to achieve the
effect that a lesser amount of the substance induced in the past. The continued
use of a substance for a long period of time, get the person hooked on to the drug
and the individual concerned is unable to continue even his routine work. Their
relationship with their own people and friends gets adversely affected. Such a
person prefers the company of other drug users or may take the drug in isolation.

59
Mild Mental Disorders When the disorder becomes severe, the person may develop delusions and
manifest hallucinations. For instance, Substance induced psychotic disorder is
categorised based on delusions or hallucinations. Delusions are fixed false beliefs
and hallucinations are false perception, that is false hearing, false seeing, false
taste or smell of things that are not present.

The DSM IV TR has put forward certain subcategories of substance use disorders
and these are discussed below:
i) Addiction
ii) Alcohol related disorder
iii) Amphetamine related disorder
iv) Caffeine related disorder
v) Cannabis related disorder
vi) Cocaine related disorder
vii) Hallucinogen related disorder
viii) Inhalant related disorder
ix) Nicotine related disorder
x) Opioid related disorder
xi) Phenycyclidine related disorder
xii) Sedative, hypnotic or anxiolytic related disorder
xiii) Polysubstance disorder
Let us take each of the above and discuss in detail.

4.2.1 Drug Addiction

It has been defined as a physical and psychological dependence on psycho active
substances. Addiction is a continued involvement with the concerned substance.
It is a primary chronic disease having memory problems and related circuitry. It
is an impairment in behavioural control and results in disability or premature
death.

In addition it includes drug addiction, substance dependence and behavioural

addiction. Addiction is a compulsive and repetitive use of the concerned drug
which ultimately results in impairment of many cognitive and behavioural
functions. It is an illness that requires treatment. People often assume that those
with addictions should be able to quit simply by making up their mind. However
it is not easy to give up the drug and even if they have been deaddicted or detoxified
of a certain drug, yet after sometime there can be a relapse and the person may
go back to that drug and become all the more addicted to it. Addiction is possible
for a wide range of chemical and other related substances.
Symptoms of drug addiction
i) Withdrawal symptoms related to that drug
ii) Ulcer
iii) Suicidal thoughts
60
iv) Stress and anxiety Substance Use Disorder

v) Reduced social contacts

vi) Destructive tendencies
No single criteria is indicative of the so called addiction, but in reality drug
becomes more addictive after a pattern of behaviour takes place over time.

Causes
The following are the causes involved in developing addictions:
i) Genetics
ii) Environment
iii) Pattern of drug Abuse
iv) Emotional disorder
v) Low frustration tolerance
Treatment:
i) Medication: The forms of treatment include replacement drugs such as
methadone, suboxone/subutex both generically known as buprenorphine,
are all used as substitutes for illicit opiate drugs.

Although these drugs are themselves addictive, the goal of opiate

maintenance is to provide a clinically supervised, stable dose of a particular
opioid in order to provide a measure of control to both pain and cravings.
This provides a chance for the addict to function normally and to reduce the
negative consequences associated with obtaining sufficient quantities of
controlled substances illicitly, by both reducing opioid cravings and also
the withdrawal symptoms.

ii) Behavioural therapy: Cognitive behaviour therapy is based on the idea

that feelings and behaviours are caused by a person’s thoughts. That is,
people may not be able to change their circumstances, but they can change
how they think about themselves and therefore change how they feel and
behave.

In the treatment for alcohol and drug dependence, the goal is to teach the
person to recognise situations in which they are most likely to drink or use
drugs, avoid these circumstances if possible, and cope with other problems
and behaviours which may lead to their substance abuse

iii) Counseling: Counselor tries to understand the client’s internal frustration,

repressed wishes and the various conflicts which all provoke the client
towards addiction. The nature of counseling generally is empathetic which
can facilitate the client with understanding and motivate him towards the
goal of giving up the drug habit.

4.2.2 Alcohol Related Disorder

More alcohol seeking or excess consumption of alcohol is defined by American
Psychiatric association (APA) as “alcoholism” or alcohol dependence. It is a
complex disorder that includes social and inter personal issues. Long term and
61
Mild Mental Disorders uncontrollable harmful consumption can cause alcohol related disorders. It is
contained in beer, wine and hard liquor and is a chemical compound known as
ethyl alcohol or ethanol.

Alcohol acts on the central nervous system as a blocker of messages transmitted

from one nerve cell to the next. The APA recognises alcohol disorder as alcohol
abuse. It is similar to dependence in that the use of alcohol impairs the affected
person’s ability to achieve goals and fulfill his personal and social responsibilities.
It also affects his or her interpersonal relationships to a great extent. This disorder
affects the person’s metabolism, gastrointestinal tract, nervous system, bone
marrow and endocrine system.

Symptoms of alcohol addiction

The various symptoms manifested by the person who is addicted to alcohol include
the following:
i) Tolerance
ii) Withdrawal
iii) Disorientation to time, place and person
iv) Hallucinations, visual, auditory and tactile
v) Delusions of suspicion, paranoid feelings, delusions of grandeur.
vi) Preoccupation with obtaining alcohol by any means.
vii) Disordered perception
viii) Overnight abstinence
ix) Irritability
x) Nausea and vomiting.
This disorder occurs twice as often in males than in females. It develops in people
of all races and socio economic classes. The alcohol abuse depends upon the
following causes

Behaviourally it relates to internal and external motivation. Internal state person

experiences personally certain pleasurable feelings after consumption of alcohol
and thus is induced to go for such pleasures again and again. As for the external
aspect, the alcohol consuming behaviour is learned from others (friends etc.) in
the society and gets reinforced also by them.

Biologically repeated or continued use of alcohol can impair brain levels of a

pleasure neurotransmitter called dopamine. Neurotransmitters are the chemicals
in the brain which pass impulses from one nerve cell to the next.

Genetic studies have shown more susceptibility to alcohol. Sons of alcoholics

are four times more likely to be alcoholic than are sons of non alcoholics. Genetic
predisposition to alcohol is growing and it is now widely accepted by researchers.

Psychodynamical aspect describes the typical addict who develops an alcohol

problem as an oral dependent personality. This approach believes that the person’s
basic need for oral gratification was not satisfied early in the person’s life. This
lack of satisfaction drives the individual towards oral satisfaction and personality
62 becomes dependent on alcohol.
Treatment Substance Use Disorder

i) Detoxification: It is the goal to get rid of the toxic effects of alcohol. For
this, the person is injected certain drugs which induce vomiting as and when
the person takes or even smells alcohol. It is because a person’s body has
become accustomed to alcohol, whenever the person does not take alcohol,
the body is deprived of alcohol and the whole system craves for alcohol and
develops certain symptoms such as twitching, cramps etc. in the absence of
alcohol. The moment the body receives alcohol, all the withdrawal symptoms
such as cramps etc., disappear and the person feels comfortable. Whenever
the doctor keeps the person off alcohol, the painful withdrawal symptoms
are common and the individual if has to be helped should also be supported
as he or she goes through withdrawal. Withdrawal symptoms and their
intensity differ from one person to another depending upon the severity of
the alcoholism as measured by the quantity of intake.

This phase of detoxification is usually over in about three to five days. Patients
going through mild withdrawal are simply monitored carefully to make sure
that more severe symptoms do not develop. No medications are necessary.
However in the case of severe withdrawal symptoms, the patient needs to
be monitored carefully and when necessary have to be administered substitute
drugs to reduce the severity of the withdrawal symptoms.

ii) Rehabilitation: After the patient has been detoxified, and sent back home
after three or four weeks of stay in the hospital, the possibility of the person
getting back to the drug is very high unless there is a very close monitoring
of his movements and behaviours. Generally the earlier friends tempt
the patient to try a little along with them and this temptation of little
drinking extends to heavy drinking and the patient is back on to his drug
habit. Such relapse can be avoided if the patient is put through intensive
counseling and psychotherapy including where necessary cognitive behaviour
therapy, family therapy, couple therapy and so on. A comprehensive
rehabilitation programme is required and the patient as well as their family
members can be given therapy to make them learn the process of support
mechanism.

iii) Medications: It affects the metabolism of alcohol and cause unpleasant

effects in patients who consume alcohol while taking the medicines. People
with alcohol dependence with other disorders like depression can work with
their physician to determine if medication might be a feasible treatment for
them.

iv) Additional treatment: There is also a need to relieve stress apart from
symptomatic treatment through medications. Alcoholics can be given
massage, meditation and hypno therapy. The mal nutrition of long term
alcohol use, is addressed by nutritionists or dieticians to make patients
healthy. Acupuncture is also believed to be one of the methods for decreasing
the symptoms.

4.2.3 Amphetamine Related Disorder

This is a highly addictive drug which dramatically affect the central nervous
system. Several amphetamines like dextroamphetamine (Dexedrine)
63
Mild Mental Disorders methamphetamine (desoxyn) and methylphenidate (Ritalin) etc., are generally
used. Though it is initially used for medicinal purposes in course of time with
continous usage, it becomes addictive. When the patients are given this to ingest,
they may fall asleep at all odd times, and cannot remain normal. Amphetamines
are administered to patients suffering from Attention Deficit Hyperactivity
Disorder, obesity and depression. This amphetamine is prescribed also to chronic
or episodic binges and also refers to serious maladaptive behavioural or
psychological changes that develop due to substance abuse.

Symptoms of amphetamine addiction

i) Paranoid behaviour
ii) Schizophrenia
iii) Hallucinations
iv) Delusions
v) Aggression
vi) High feeling of euphoria
vii) Repetitive behaviour
viii) Grandiosity
ix) Impaired judgment
x) Stroke.
Causes of amphetamine addiction
i) Amphetamine intoxication
ii) Binge pattern use of the substance
iii) Co morbid psychiatric disorders
iv) Abuse of other substances like alcohol or illicit drugs
v) Dehydration
vi) Potential for serotonin syndrome in those prescribed serotonin re uptake
inhibitors.
Treatment
The offending substance may be eliminated by means of acidification of the
urine. Psychotropic medication can be used to stabilise an agitated patient also
manifesting psychosis. Apart from all other activities patients can consult
neurologist, or an internal medicine specialist and or psychiatrist who can help
reduce the effects of amphetamine produced symptom.

4.2.4 Caffeine Addiction Related Disorders

It is a white bitter crystalline alkaloid which is derived from coffee and tea. It is
classified together with amphetamines and cocaine as an analeptic or central
nervous system stimulant. Tea, cocoa, coffee are an abundant source of caffeine.
These are less likely to produce the same degree of physical or psychological
dependence as other drugs of abuse. Symptoms are more common with anxiety
disorders difficult to differentiate.

64
Symptoms Substance Use Disorder

i) Restlessness
ii) Nervousness
iii) Excitement
iv) Insomnia
v) Gastro intestinal disturbance
vi) Muscle twitching
vii) Tachycardia
viii) Periods of inexhaustibility
ix) Psychomotor agitation
Causes
The immediate cause of caffeine intoxication and other related disorders is
consumption of an amount of caffeine sufficient to produce the symptoms
depending upon the tolerance of the body.

Caffeine tastes bitter and serves to limit the intake of caffeine products which
are responsible for causing inclinations towards continuing to ingest caffeine
related substances. Some of these substances include the following: Brewed
coffee, instant coffee, powdered cappuccino beverage, Snapple iced tea, mountain
dew, diet colas, coffee yoghurt, dark chocolate, Excedrin are all some of the
substances that may cause addiction if taken over a long period of time.

Treatment
It generally involves lowering the consumption from beverages containing
caffeine. Consumption has the advantage of having social reinforcement by which
a person can become caffeinated or non caffeinated. Thus physical dependence
on caffeine is less complicated by social factors that reinforce nicotine and other
drug habits. People also recover from caffeine intoxication without difficulty.

4.2.5 Cannabis Addiction

It is commonly called as marijuana, which consists of dried leaves and flower
tops of the cannabis plant. This cannabis refers to the several varieties of cannabis
sativa or Indian hemp plant that contains the psychoactive drug ‘delta-
tetrahydracannabinol’ (THC). The solidified resin called ‘hashish’ can be used
to produce psychoactive effects. This has been used since thousands of years and
described as early as the fifth century B.C when the Greek historian Herodotus
told of a tribe of nomads who after inhaling the smoke of roasted hemp seeds,
went into a kind of insensibility experiences. Cannabis is the abbreviation for
the Latin name of the hemp plant “cannabis sativa”

All parts of this plant contain psychoactive substances with THC making up the
highest percentage. There are more than 200 slang terms for marijuana. Including
pot, herb, weed, marijuana, gross, tea, and ganja. It is usually chopped and rolled
into a cigarette or in smoke pipe. By the year 2000 the debate for proving marijuana
as a medicine continued. THC is known to successfully treat nausea in cancer
treatment, acquire immune deficiency syndrome or glaucoma.
65
Mild Mental Disorders For addiction marijuana is generally taken by either eating or smoking parts of
the cannabis plant. When the smoke is inhaled it is spread across the surface of
the lungs quickly absorbed into the bloodstream and carried to the brain in a few
seconds. Marijuana suppresses the production of male hormones, decreases the
size and weight of the prostrate gland and testes and inhibits sperm production,
although these effects appear to be reversible. It also impairs short term memory
and slows down learning ability. This disorder includes cannabis dependence,
cannabis abuse and cannabis intoxication.
Symptoms of cannabis addiction:
i) Social withdrawal
ii) Respiratory disorder
iii) Cough and phlegm
iv) Chronic bronchitis
v) Frequent chest cold
vi) Slow heart rate
vii) Impaired learning
viii) Slow memory
ix) Distraction of attention
x) Accident in motor function
xi) Slow performance in work, school etc.
xii) Lethargy
xiii) Inappropriate laughter
xiv) Feeling of grandiosity
xv) Depression.
Causes of cannabis addiction
The causes for cannabis addiction is almost similar or the same that of the causes
of other addictive substances. The initial desire for a high combine with held
perception that cannabis use is not dangerous leads to experimentation in the
teen. Long term use leads to changes in the brain and makes the person prone
towards ingesting these addictive substances. The greater availability, higher
potency and lower price for cannabis in recent years all are responsible for the
cannabis addiction.

Treatment of cannabis addiction

The goal of cannabis treatment is abstinence. It starts from in patient department
in hospital with detoxification, and followed up with rehabilitation programme
in rehabilitation centre and includes intensive counseling sessions with the patient,
his family members and others. Cognitive behaviour therapy seems to work in
these cases but the relapse rate is also quite high once the patient goes back to
the society from the rehab centers as he is drawn into smoking marihuana by his
erstwhile friends and fellow addicts. Patients are also given anti-anxiety drugs,
and antidepressant medications depending on the symptoms manifested by them.
They need to be taken up on a comprehensive psychological treatment.
66
4.2.6 Cocaine Addiction Substance Use Disorder

The main active drug is in the leaves of the coca bush that grows on the eastern
slopes of the Andes Mountain in South America. The Indians of Peru and Bolivia
have used its leaves for centuries to increase endurance and decrease hunger so
that they can cope better with the rigors of their economically marginal high
altitude existence.

Cocaine is extracted from the coca plant which grows in central and South
America. It is dangerously addictive and users of the drug experience a high
feeling of euphoria or happiness along with hyper vigilance, increased sensitivity,
etc. In powder form cocaine named as coke, blow, cornflake, snow and toot, is
commonly inhaled or snorted. It is either injected or dissolved in water and taken.

DSM IV TR categorised cocaine related disorders in cocaine use disorder and

cocaine induced disorders.
Cocaine use disorder is classified as:
• Cocaine dependence
• Cocaine abuse
Cocaine induced disorder is classified as:
i) Cocaine intoxication
ii) Cocaine withdrawal
iii) Cocaine induced psychotic disorder with delirium
iv) Cocaine induced psychotic disorder with hallucinations
v) Cocaine induced mood disorder
vi) Cocaine induced anxiety disorder
vii) Cocaine induced sexual dysfunction
viii) Cocaine induced sleep disorder
ix) Cocaine related disorder not otherwise specified.

Symptoms of cocaine addiction

i) Elevated heart rate
ii) Elevated blood pressure
iii) Panic attacks
iv) Low self esteem
v) Diminished appetite
vi) Low of contact from reality
vii) Depressed mood
viii) Irritability
ix) Difficulty sleeping
x) Hypervigilance.

67
Mild Mental Disorders Causes of cocaine addiction
i) Physiological
ii) Reinforcement
Treatment of cocaine addiction
First and foremost thing for cocaine is that the cocaine dependent person must
become convinced that treatment is necessary. Sometimes addicts are induced to
come in for treatment only by pressure from family members, employers or the
law. Cocaine users also join mutual help group which encourage them to decrease
the intake of cocaine and thereby reduce addiction. Members admit their
powerlessness to control their drug use so they are being given psychotherapy,
CBT which can facilitate addicts in coping with the withdrawal syndromes
following non intake of cocaine. These persons also benefit from cocaine addiction
support group therapy as well as alternative therapy such as brief psychotherapy,
cognitive therapies, meditation, yoga etc.

4.2.7 Hallucinogens Addiction

Hallucinogens are chemically diverse group of drugs that cause changes in a
person’s thought process, perception of the physical world and sense of time
passing. These are also called as psychedelic drugs. Hallucinogenes are as old as
civilisation. Shamans in Siberia were known to eat the hallucinogenic mushroom
amanitamuscaria.

Peyota a spineless cactus native to the South Western United States and Mexico
was used by native people. The best known hallucinogens are lysergic acid
diethylmide (LSD), mescaline, and psilocybin which all produce visual
hallucination.

Hallucinogens like other drugs have similar physical and psychological effects
and they are a diverse group of compounds. Hallucinogens compound binds
with serotonin receptors, and serotonin is blocked from those receptor sites and
the nerve transmitter is altered. In hallucinogen intoxicated person is unconscious
or dissociated.
Symptoms of Hallucinogen addiction
i) Distortion of sight, sound
ii) Confusion of the senses
iii) Delusions of physical invulnerability
iv) Anxiety attacks
v) Reduced inhibitions
vi) Increased empathy
vii) Long term
viii) Increased blood pressure
ix) Increased heart rate
x) Sweating
xi) Diarrheoa
68 xii) Restlessness
Causes of hallucinogen addiction Substance Use Disorder

The origin of the disorder are not clearly known but it is believed that this may
be caused by the destruction of inhibitory neurons that regulate and filter the
sensory information. Still it is a rare disorder but depends much on the situational
factors and sometimes due to psychiatric disorder also it develops.

Treatment of hallucinogen addiction

Acute treatment is aimed at preventing the patient from harming himself or
anyone. Drugs like lorazepam are given for anxiety. Complication in treatment
occurs when the hallucinogen has been contaminated with other street drugs or
chemicals. But for more effect long term psychotherapy may prove more
successful. In continuation with this, we may also offer support group and
alternative therapy such as relaxation exercises, meditation, yoga etc.

4.2.8 Addiction to Inhalents

Inhalent abuse disorders are a heterogenous group of illness caused by the abuse
of solvents, glues, paint, fuels or other volatile substances. The resurgence of
this new found phenomena is believed to be due to a number of variables like
peer influence, rapid mood elevating quality, etc., which have made its potentially
fatal activity popular among many young people today. The inhalants share a
common route of administration that is they are all drawn into the body by
breathing. They are usually taken either by breathing in the vapors directly from
a container by inhaling fumes of the substances placed in a bag or by inhaling
the substances from a cloth soaked with the substance.

DSM IV TR lists inhalants dependence and inhalant abuse as substance use

disorders:
Symptoms of inhalents abuse disorder
i) Tolerance
ii) Loss of control
iii) Inability to stop
iv) Interference with activities
v) Harm to self
vi) Interference with role fulfillment
vii) Legal problems
viii) Lethargy
ix) Fatigue
x) Psychomotor retardation
xi) Blurred vision
xii) Weak muscle
Causes of inhalant abuse disorder
i) Poverty
ii) History of childhood abuse
69
Mild Mental Disorders iii) Poor grades in schools
iv) Dropping out of school
v) Peer influence
vi) Group settings where inhalants are used.

4.2.9 Nicotine Substance Abuse Disorder

This is a main psychoactive ingredient in tobacco. It is physically and
psychologically addictive drug. Pure nicotine is a colorless liquid that turns brown
and smells like tobacco when exposed to air. Nicotine can be absorbed through
skin lining of the mouth and nose, moist tissues lining the lungs.

Cigarettes are the most efficient nicotine delivery system, which is inhaled and
reaches the brain in less than 15 seconds. Nicotine in chewing tobacco and snuff
is absorbed through the mucous membranes lining the mouth and nasal passages.
Symptoms of nicotine abuse disorder
i) Irritability
ii) Sleep disturbances
iii) Increased anger
iv) Depression
v) Anxiety
vi) Constant thoughts about smoking
vii) Decreased heart rate
viii) Coughing
ix) Withdrawal
x) Mood disorder.
Causes nicotine abuse disorder
i) Peer pressure
ii) Inadequate coping skills
iii) Emotional resources
iv) Relieving tension
v) Abolishing loneliness
vi) Stress.

4.2.10 Phencyclidine (PCP) Addiction

It is best known as a street drug and is popularly known as angel dust. This
causes physiological changes to the nervous and circulatory system and causes
disturbances in thinking and behaviour. This drug was first synthesized by a
pharmaceutical company in the 1950s. It has side effects including agitated
behaviour and hallucinations. It is easy to manufacture and is inexpensive .The
effect of (PCP) is manifested in both behavioural and physiological symptoms.
According to DSM IV TR, PCP can induce mood disorder and psychotic disorder.

70
Symptoms of Phencyclidine abuse disorder Substance Use Disorder

i) Involuntary rapid movements of the eye

ii) High blood pressure
iii) Drooling from the mouth
iv) Racing heart rate
v) Lack of muscle coordination
vi) Coma
vii) Death
Causes of Phencyclidine abuse disorder
i) Easy availability
ii) Inexpressible
iii) Readily soluble
iv) Easily eaten ,smoked or injected.

4.2.11 Sedative, Hypnotic or Anxiolytic Related Disorder

These are types of tranquillisers which can be abused to produce an overly
clamming effect. At high doses or when they are abused, these drugs can cause
unconsciousness and even death. These are used in anesthesia to produce and
maintain unconsciousness. Many hypnotic drugs are habit forming and due to a
large number of factors they are known to disturb the human sleep pattern. Elderly
people are more sensitive to the side effects of these drugs and a meta analysis
showed that the risks generally outweigh any marginal benefits of hypnotic in
the elderly.
Symptoms of Sedative, hypnotic abuse disorder
i) Withdrawal
ii) Depersonalisation
iii) Illusions
iv) Insomnia
v) Symptom reemergence
vi) Cardiovascular disorder
Causes of Sedative, hypnotic abuse disorder
i) Psychological addiction
ii) Tolerance for the drugs
iii) Sedative dependence
iv) Physical addiction
v) Hostility
vi) Aggression
vii) Mood swings
viii) Slurred speech
ix) Anxiety 71
Mild Mental Disorders Treatment of Sedative, hypnotic abuse disorder
Physiological treatment
The successful treatment of sedative dependence is based on the idea of gradually
decreasing the amount of drug the patient uses in order to keep withdrawal
symptoms to a manageable level. This is called a drug taper. The rate of taper
depends on the dependency dose of the drug, the length of time the drug has
been taken, a person’s individual mental and physical response to drug withdrawal,
and any complicating factors such as other substance abuse or other physical or
mental illness.

For people dependent on a low dose of sedatives, the current level of use is
determined, and then the amount of drug is then reduced by 10 to 25 percent. If
withdrawal symptoms are manageable, reduction is continued on a weekly basis.
If withdrawal symptoms are too severe, the patient is stabilised at the lowest
dose with manageable symptoms until tapering can be re started. This gradual
reduction of use may take weeks, and the rate must be adjusted to the response
of each patient individually. The tapering process begins, but more gradually
than with low dose dependency. Often other drugs are given to combat some of
the withdrawal symptoms.

Psychological treatment
Cognitive behavioural therapy may be used in conjunction with drug tapering.
This type of therapy has basically two aims (i) to educate patients to recognise
and cope with the symptoms of anxiety associated with withdrawal, and (ii) to
help patients change their behaviour in ways that promote coping with stress.
Patients are also taught to mentally talk their way through their anxiety and stress.
Some people find support groups and journal keeping to be helpful in their
recovery.

Medications
This is to initially treat a patient who has taken an overdose of sedative hypnotics
like any other patient with drug intoxication. These medicines help in the
following ways:
• Provide an adequate airway and ventilation.
• Stabilise and maintain the hemodynamic status.
Once initial measures have been carried out, consider inducing emesis (vomiting),
performing lavage (washing out of body organ) and administering activated
charcoal to a patient who has orally ingested the drug, depending on the time of
ingestion and level of consciousness.
Emesis, lavage, and/or activated charcoal prevent absorption of the drug into the
system and absorption of the drug or active metabolites through enterohepatic
recirculation.
Laxatives may be used to induce catharsis.

4.2.12 Polysubstance Use Disorder

This refers to a type of substance dependence disorder in which an individual
uses at least three different classes of substances indiscriminately and does not
72 have a favourite drug that qualifies for dependence on its own.
According to DSM-IV-TR when an individual meets criteria for dependence on Substance Use Disorder
a group of substances (at least three different types used in the same 12 month
period) he or she is given the diagnosis of polysubstance dependence. For
example, an individual may use cocaine, sedatives, and hallucinogens
indiscriminately (i.e., no single drug predominated; there was no “drug of choice”)
for a year or more. The individual may not meet criteria for cocaine dependence,
sedative dependence, or hallucinogen dependence, but may meet criteria for
substance dependence when all three drugs are considered as a group.
Symptoms of Polysubstance use Disorder
• Tolerance (needing to use increasingly larger amounts of the drugs to get
the same effect).
• Withdrawal (experiencing withdrawal symptoms when discontinuing use
of the drugs).
• Loss of Control (using more drugs than planned, or using drugs longer or
more often than planned).
• Inability to Stop Using (unsuccessfully attempting to stop using drugs) the
drug.
• Time (spending a significant amount of time obtaining or using drugs) spent
in obtaining the drug.
• Interference with daily routine previously enjoyed activities (giving up
previously enjoyed activities to use drugs).
• Causing self injury or harm to Self (continuing to use drugs despite the fact
that they cause physical or psychological harm).
Causes of Polysubstance use Disorder
i) Depression
ii) Sleep disorder
iii) Cognitive impairment
iv) Withdrawal
v) Social commitment
Treatment
The polysubstance abuse dependence can be treated in outpatient and inpatient
departments. The cognitive behavioural technique is proved to be the more
appropriate because it facilitates the patient with changing thoughts, concept
and expose patients with new learning.
Self Assessment Questions
1) What are the common substance use disorders?
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73
Mild Mental Disorders
2) What are the symptoms of cocaine addiction?
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3) What are the symptoms of hallucinogen addiction? How do you treat
this disorder?
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4) What is cannabis addiction, what are the causes underklying this
addiction?
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5) Write the most common symptoms in all substance use disorders.
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6) How can alcoholism be treated.?
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74
 Substance Use Disorder
7) What are the various treatment available to treat sedative, hypnotic abuse
disorder?
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8) What is meant by polusubstance use disorder? How is this disorder
treated? What are its characteristic features?
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4.3 LET US SUM UP

Thus the mission for learning the substance use disorder is to improve outcomes
for families affected by this disorder. To accomplish the goal it is needed to have
effective practice of the various treatment models. These models could be adopted
by community and the agencies in the society. It is the responsibility of society
to eradicate this disorder so that adolescents, youth and older adults especially
the children in school can live a healthy life. Thus the knowledge for research
gaps in challenges in substance abuse disorder are needed to be discussed so as
to meet and deal with challenges effectively.

Priority should be given to substance abuse as it not only affects individuals, that
too youngsters in their prime age, psychologically but leads the individual towards
ill health and makes the person totally unproductive and helpless. Such youngsters
become a liability on the society.

There is a need to spread this knowledgein the society about the harmful effects
of drugs and how to make them inaccessible and unavailable and how to use the
legal system to prevent such drug sellers and drug pushers from hooking
youngsters on to the drug etc. A concerted and countrywide campaign is required
to prevent the drug use and abuse.

It is necessary to ensure that wellness promotion for chronic disease prevention

is needed. The link with primary health care would facilitate the rural people to
get rid of these problems. The psychologists, social workers, health care
professionals etc., can play a significant role in discouraging use of drugs by all
sections of society especially the youngsters.
75
Mild Mental Disorders
4.4 UNIT END QUESTIONS
1) Define DSMIV category substance use disorders with their symptoms.
2) How do addiction and alcoholism disorders differ? Discuss with examples.
3) Describe cocaine and nicotine disorders symptoms and their causes. Cite
examples.
4) Cognitive behavioural technique is the most effective for the substance use
disorder. Elaborate on this.
5) What are polysubstance disorder? How we can eradicate it from society.
Explain with your own understanding.

4.5 SUGGESTED READINGS AND REFERENCES

Coleman, J.C. (2000). Abnormal Psychology and Modern Life. Allyn & Bacon ,
London.

Bennett, Paul.(2003). Abnormal & Clinical Psychology : An Introductory Text

Book. Open University publisher, NY.

David H Barlow &V Mark Durand by Abnormal Psychology An Intergative

Approach (Wadsworth Cengage publisher).

Charles E Dodgan & W .Michael Shea (2000). Substance use Disorders:

Assessment & Treatment Academic Press, London.

American Psychiatric Association.(2000). Diagnostic and Statistical Manual of

Mental Disorders. 4th edition, text revised. Washington, DC: American
Psychiatric Association, Washington.

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Kandel DB, Yamaguchi K, Chen K: Stages of progression in drug involvement

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Oetting ER, Beauvais F: Adolescent drug use: findings of national and local
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Maisto SA, McKay JR: Diagnosis, in Assessing Alcohol Problems: A Guide for
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National Household Survey on Drug Abuse: Population Estimates 1994: DHHS

Publication 94-3063. Rockville, Md, Department of Health and Human Services,
1994

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Caetano R: Two versions of dependence: DSM-III and the alcohol dependence

syndrome. Drug Alcohol Depend 1985; 15:81–103

Grant BF, Towle LH: A comparison of diagnostic criteria: DSM-III-R, proposed

DSM-IV, and proposed ICD-10. Alcohol Health Res World 1991; 15:284–292

Grant BF, Chou SP, Pickering RP, Hasin DS: Empirical subtypes of DSM-III-R
alcohol dependence: United States, 1988. Drug Alcohol Depend 1992; 30:75–
84

Martin CS, Kaczynski NA, Maisto SA, Bukstein OM, Moss HB: Patterns of
DSM-IV alcohol abuse and dependence symptoms in adolescent drinkers. J Stud
Alcohol 1995; 56:672–680

Rounsaville BJ, Spitzer RL, Williams JBW: Proposed changes in DSM-III

substance use disorders: description and rationale. Am J Psychiatry 1986;
143:463–468

Harrison PA, Fulkerson JA, Beebe TJ: Multiple substance use among adolescent
physical and sexual abuse victims. Child Abuse Negl 1997; 21:529–539

77
Mild Mental Disorders Widiger TA, Trull TJ: Diagnosis and clinical assessment. Annu Rev Psychol
1991; 42:109–133

Winters K, Stinchfield R, Fulkerson J, Henly G: Measuring alcohol and cannabis

use disorders in an adolescent clinical sample. Psychol of Addictive Behaviours
1993; 7:185–196

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DSM-IV alcohol symptoms in adolescents: survival/hazard analyses. J Stud
Alcohol 1996; 57:549–558

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Microfilms number 9117615). Dissertation Abstracts International 1991; 52(1-
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Assoc J 1990; 143:1060–1069

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syndrome. Br J Addict 1976; 1:1058–1061.

78
 Schizophrenia and Other
UNIT 1 SCHIZOPHRENIA AND OTHER Psychotic Disorders

PSYCHOTIC DISORDERS

Structure
1.0 Introduction
1.1 Objectives
1.2 Concept and Definition of Schizophrenia
1.2.1 The Course of Schizophrenia
1.2.2 Suicide Risk in Schizophrenia
1.2.3 Schizophrenia and Violence
1.2.4 Schizophrenia and Jail
1.2.5 The First Signs of Schizophrenia
1.2.6 Historical Perspective of Schizophrenia
1.3 Symptoms of Schizophrenia
1.3.1 Positive Symptoms
1.3.2 Negative Symptoms
1.3.3 Cognitive Symptoms
1.3.4 Affective Symptoms
1.3.5 Suicidal Thoughts
1.3.6 Common Symptoms
1.4 Types of Schizophrenia
1.4.1 Paranoid Schizophrenia
1.4.2 Disorganised Schizophrenia (Hebephrenic)
1.4.3 Catatonic Schizophrenia
1.4.4 Undifferentiated Schizophrenia
1.4.5 Residual Type Schizophrenia
1.5 Causes of Schizophrenia
1.5.1 Genetics
1.5.2 Prenatal Obstetric Complications
1.5.3 Fetal Growth
1.5.4 Hypoxia
1.5.5 Infections
1.5.6 Other Factors
1.6 Treatment
1.6.1 Psychosocial Treatment for Schizophrenia
1.6.2 Supportive Therapy
1.6.3 Illness Management
1.6.4 Coping with Symptoms
1.6.5 Rehabilitation
1.6.6 Family Education and Support
1.6.7 Antipsychotic Drugs
1.6.8 Antidepressant Drugs
1.7 Let Us Sum Up
1.8 Unit End Questions
1.9 Suggested Readings and References
5
Severe Mental Disorders
1.0 INTRODUCTION
This unit deals with schizophrenia, a severe mental disorder which has relatively
poorer prognosis. The unit starts with concept and definition of schizophrenia,
the common symptoms of schizophrenia such as the negative and positive
symptoms, the cognitive and affective symptoms etc. Then the unit presents the
various types of schizophrenia, their symptoms, causes and treatment. The
common symptoms of schizophrenia are then discussed and the causes thereof.
Amongst the various treatment interventions, apart from medicines, the unit
presents the psychosocial treatment of schizophrenia. The rehabilitation of
schizophrenics and education to the family as to how to look after these patients
are presented in detail.

1.1 OBJECTIVES
On completing this unit, you will be able to:
• Define schizophrenic disorders;
• Describe various types of schizophrenia;
• Elucidate the symptoms of schizophrenia;
• Explain the causes of schizophrenia; and
• Delineate the treatment approaches for schizophrenia.

1.2 CONCEPT AND DEFINITION OF

SCHIZOPHRENIA
Schizophrenia also sometimes called as split personality disorder. It is a chronic,
severe, debilitating mental illness which affects about two percent of the
population. It is one of the psychotic mental disorders and is characterised by
behavioural and social abnormalities.

The individual with this disorder also develop disorganised speech, disorganised
rigid or lax behaviour, significantly decreased appropriate behaviours or feelings
as well as development of delusions. Delusions are false beliefs which for example
believe someone is out to kill him while actually there is no such person who has
any intention to kill the person. It is thus a false belief. The person however
believed in it as such a reality that he is unable to distinguish between what is
real and unreal. Thus based on the delusions his behaviour becomes highly bizarre.
Sometimes such persons may attack another without reason based on his
delusions.

Most cases of schizophrenia appear in the late teens or early adulthood. This is a
disease of the brain and one of the most disabling and emotionally devastating
illness and for a long time has not been properly diagnosed and quite often
misjudged and misunderstood.

Persons with this illness are stigmatized and are generally avoided by everyone.
In severe condition they are sent to hospitals for mental diseases. Like cancer
and diabetes, schizophrenia has a biological basis. It is relatively a common
disease affecting one to two percent of the population.
6
The Prevalance Rate for schizophrenia is approximately 1.1% of the population Schizophrenia and Other
Psychotic Disorders
over the age of 18 (source: NIMH) or, in other words, at any one time as many as
51 million people worldwide suffer from schizophrenia, including;
6 to 12 million people in China (a rough estimate based on the population)
4.3 to 8.7 million people in India (a rough estimate based on the population)
2.2 million people in USA
285,000 people in Australia
Over 280,000 people in Canada
Over 250,000 diagnosed cases in Britain
According to Robin Murray, Rates of schizophrenia are generally similar from
country to country—about 0.5% to 1 percent of the population.

Another way to express the prevalence of schizophrenia at any give time is the
number of individuals affected per 1,000 total population. In the United States
that figure is 7.2 per 1,000. This means that a city of 3 million people will have
over 21,000 individuals suffering from schizophrenia.

Incidence: The number of people who will be diagnosed as having schizophrenia

in a year is about one in 4,000. So about 1.5 million people will be diagnosed
with schizophrenia this year, worldwide. About 100,000 people in the United
States will be diagnosed with schizophrenia this year.

Note: The term ‘prevalence’ of Schizophrenia usually refers to the estimated

population of people who are living with Schizophrenia at any given time.

The term ‘incidence’ of Schizophrenia refers to the annual diagnosis rate, or the
number of new cases of Schizophrenia diagnosed each year.

1.2.1 The Course of Schizophrenia

Early intervention and early use of new medications lead to better medical
outcomes for the individual.
The earlier someone with schizophrenia is diagnosed and stabilised on treatment,
the better the long-term prognosis for their illness.
Teen suicide is a growing problem — and teens with schizophrenia have
approximately a 50% risk of attempted suicide.
In rare instances, children as young as five can develop schizophrenia.
According to National Institute of Mental Health (NIMH) Anti-psychotic
medications are the generally recommended treatment for schizophrenia. If
medication for schizophrenia is discontinued, the relapse rate is about 80 percent
within 2 years. With continued drug treatment, only about 40 percent of recovered
patients will suffer relapses.

Wide variation occurs in the course of schizophrenia. Some people have psychotic
episodes of illness lasting weeks or months with full remission of their symptoms
between each episode; others have a fluctuating course in which symptoms are
continuous but rise and fall in intensity. Others have relatively little variation in
7
Severe Mental Disorders the symptoms of their illness over time. At one end of the spectrum, the person
has a single psychotic episode of schizophrenia followed by complete recovery.
At the other end of the spectrum is a course in which the illness never abates and
debilitating effects increase. Recent research increasingly shows that the disease
process of schizophrenia gradually and significantly damages the brain of the
person, and that earlier treatments (medications and other therapies) seem to
result in less damage over time.
After 10 years, of the people diagnosed with schizophrenia:
25% Completely Recover
25% Much Improved, relatively independent
25% Improved, but require extensive support network
15% Hospitalised, unimproved
10% Dead (Mostly Suicide)

After 30 years, of the people diagnosed with schizophrenia:

25% Completely Recover
35% Much Improved, relatively independent
15% Improved, but require extensive support network
10% Hospitalised, unimproved
15% Dead (Mostly Suicide)
6% are homeless or live in shelters
6% live in jails or prisons
5% to 6% live in Hospitals
10% live in Nursing homes
25% live with a family member
28% are living independently
20% live in Supervised Housing (group homes, etc.)

1.2.2 Suicide Risk in Schizophrenia

People with the schizophrenia condition have a 50 times higher risk of attempting
suicide than the general population. The risk of suicide is very serious in people
with schizophrenia. Suicide is the number one cause of premature death among
people with schizophrenia, with an estimated 10 percent to 13 percent killing
themselves and approximately 40% attempting suicide at least once (and as much
as 60% of males attempting suicide). The extreme depression and psychoses
that can result due to lack of treatment are the usual causes. These suicide rates
can be compared to the general population, which is somewhere around 0.01%.

1.2.3 Schizophrenia and Violence

People with schizophrenia are far more likely to harm themselves than be violent
toward the public. Violence is not a symptom of schizophrenia.

Most people with schizophrenia, however, are not violent toward others but are
withdrawn and prefer to be left alone. Drug or alcohol abuse raises the risk of
violence in people with schizophrenia, particularly if the illness is untreated, but
8 also in people who have no mental illness.
1.2.4 Schizophrenia and Jail Schizophrenia and Other
Psychotic Disorders
The vast majority of people with schizophrenia who are in jail have been charged
with misdemeanors such as trespassing.

As many as one in five (20%) of the 2.1 million Americans in jail and prison are
seriously mentally ill, far outnumbering the number of mentally ill who are in
mental hospitals. The American Psychiatric Association estimated in 2000 that
one in five prisoners were seriously mentally ill, with up to 5 percent actively
psychotic at any given moment.

Many individuals with schizophrenia revolve between hospitals, jails and shelters.
In Illinois 30% of patients discharged from state psychiatric hospitals are
rehospitalised within 30 days. In New York 60% of discharged patients are
rehospitalised within a year.

Although it affects both the sexes equally in frequency and often appears earlier
in men usually in the late teens or early twenties, but women are affected in
between twenties to early thirties. It is found all over the world. The severity of
the symptoms and long lasting pattern of schizophrenia often cause a high degree
of disability. Medications and other treatments for schizophrenia when used
regularly and as prescribed can reduce and control the distressing symptoms of
the illness. Even it has been seen that treatment is effective with persisting
consequences of the illness like lost opportunities, stigma, residual symptoms
and medication side effects which may be very troubling.

1.2.5 The First Signs of Schizophrenia

The first signs of schizophrenia appear as confusing or even shocking changes
in behaviour. The activity of chemical messengers at certain nerve endings in the
brain is unusual and may be a clue to the cause of the disorder. When it is severe
this can lead to intense panic, anger, depression, elation or other activity. This
can be treated giving the majority of people chance to live an ordinary life.
Schizophrenia is a group of psychotic disorder that interferes with thinking and
mental or emotional responsiveness, which disintegrates the entire personality.

This disorder has important symptoms such as auditory hallucinations, paranoid

or bizarre delusions or disorganised speech and thinking, and it is accompanied
by significant social or occupational dysfunction. The onset of symptoms typically
occurs in young adulthood with a global lifetime prevalence.

Genetic, early environment, neurobiology, psychological and social process appear

to be important contributory factors in the development of the disorder. Although
no common cause of schizophrenia has been identified in all individuals and
diagnosed with the condition. In the recent days the researchers and clinicians
believe it results from a combination of both brain vulnerabilities and life events.

1.2.6 Historical Perspective of Schizophrenia

The history of schizophrenia begins with the name of Emile Krapelin (1856-
1926) a German Psychiatrist who adopted the term dementia praecox to classify
a group of disorders that had as their common feature intellectual and cognitive
deterioration early in life.

9
Severe Mental Disorders Dementia refers to severe intellectual deterioration while praecox refers to the
early onset of this disorder. Kraeplin stated that this disorder involves deterioration
of cognitive functions overtime and these are not alike other disorders such as
unipolar depression etc.

Eugene Bleuler was another person who worked on schizophrenia and coined
the term schizophrenia. This term schizophrenia is derived from the Greek words
‘schizo’ (split) and ‘phrene’ (mind) and thus was coined by Eugene Bleuler to
refer to the lack of interaction between thought processes and perception. Bleuler
changed the name from Dementia Praecox to schizophrenia as it was obvious
that Krapelin’s name was misleading.

The word “praecox” implied precocious or early onset, hence premature dementia,
as opposed to senile dementia from old age. Bleuler realised the illness was not
a dementia (it did not always lead to mental deterioration) and could sometimes
occur late as well as early in life and was therefore misnamed.

With the name ‘schizophrenia’ Bleuler tried to capture the separation of function
between personality, thinking, memory, and perception. However, it is commonly
misunderstood to mean that affected persons have a ‘split personality’.
Schizophrenia is commonly, although incorrectly, confused with multiple
personality disorder (now called ‘dissociative identity disorder’).

Although people diagnosed with schizophrenia may ‘hear voices’ and may
experience the voices as distinct personalities, schizophrenia does not involve a
person changing between distinct multiple personalities. The confusion perhaps
arises in part due to the meaning of Blueler’s term ‘schizophrenia’ (literally ‘split
mind’). Interestingly, the first known misuse of this word schizophrenia to mean
‘split personality’

Eugen Bleuler worked with Sigmund Freud and used the term Schizophenia. He
then used the term which refers to splitting of mental associations. Schizophrenic
disorders are known by the diagnostic criteria being given by DSM IV TR (2000).

Schizophrenia is defined as any of several psychotic disorders characterised by

distortions of reality and disturbances of thought and language and withdrawal
from social contact.

Schizophrenia is also defined as a mental disorder characterised by a disintegration

of the process of thinking and of emotional responsiveness. Diagnosis is based
on the patient’s self reported ‘split’ phren- ‘mind’). Schizophrenia does not imply
a “split mind” and it is not the same as dissociative identity disorder. It is not
“multiple personality disorder” or “split personality” a condition with which it is
often confused in public perception.

1.3 SYMPTOMS OF SCHIZOPHRENIA

The diagnostic criteria of DSM IV (TR) include negative symptoms. These
symptoms are as a rule, do not respond well to treatment and to many medications.
Behaviour or functions that are deficient or absent in a schizophrenic individual’s
behaviour and thus refer to a loss or reduction of normal functions. The
schizophrenic with negative symptoms has also a deficit or a lack in these
10 behaviours and are considered as deteriorated.
But the positive symptoms on the other hand come with individuals normal Schizophrenia and Other
Psychotic Disorders
behavioural repertoire and include delusions and hallucinations as well as
psychomotor agitation, bizarre behaviour and minimal cognitive impairment. It
also includes Type I and Type II Schizophrenia. These also include positive and
negative symptoms and respectively include with more emphasis on biology
and on medication efficacy. Type I schizophrenics respond well to antipsychotic
medications and have normal sized brain ventricles but the other one Type II
does not respond well to medications and may have enlarged ventricles and
abnormalities in their frontal lobe.

Signs and symptoms of schizophrenia generally are divided into three categories
— positive, negative and cognitive.

1.3.1 Positive Symptoms

In schizophrenia, positive symptoms reflect an excess or distortion of normal
functions. These active, abnormal symptoms may include:

Delusions: Delusions are false beliefs. These beliefs are not based in reality and
usually involve misinterpretation of perception or experience. They are the most
common of schizophrenic symptoms.

Hallucination: These usually involve seeing or hearing things that do not exist,
although hallucinations can be in any of the senses. Hearing voices is the most
common hallucination among people with schizophrenia. These are called
auditory hallucinations.

Thought disorder: Difficulty speaking and organising thoughts may result in

stopping speech midsentence or putting together meaningless words, sometimes
known as “word salad.”

Disorganised behaviour: This may show in a number of ways, ranging from

child like silliness to unpredictable agitation.

1.3.2 Negative Symptoms

Negative symptoms refer to a diminishment or absence of characteristics of normal
function. They may appear months or years before positive symptoms. They
include:
• Loss of interest in everyday activities
• Appearing to lack emotion
• Reduced ability to plan or carry out activities
• Neglect of personal hygiene
• Social withdrawal
• Loss of motivation

1.3.3 Cognitive Symptoms

Cognitive symptoms involve problems with thought processes. These symptoms
may be the most disabling in schizophrenia, because they interfere with the ability
to perform routine daily tasks. A person with schizophrenia may be born with
these symptoms, but they may worsen when the disorder starts. They include:
11
Severe Mental Disorders • Problems with making sense of information
• Difficulty paying attention
• Memory problems

1.3.4 Affective Symptoms

Schizophrenia also can affect mood, causing depression or mood swings. In
addition, people with schizophrenia often seem inappropriate and odd in regard
to their moods, causing others to avoid them, which leads to social isolation.

People with schizophrenia often lack awareness that their difficulties stem from
a mental illness that requires medical attention. So it usually falls to family or
friends to get them help.

1.3.5 Suicidal Thoughts

Suicidal thoughts and behaviour are common among people with schizophrenia.
If you suspect or know that your loved one is considering suicide, seek immediate
help. Contact a doctor, mental health provider or other health care professional.

1.3.6 Common Symptoms

• Social withdrawal
• Flat ,expressionless gaze
• Inapropriate laughter or crying
• Depression
• Insomnia or oversleeping
• Delusions
– Delusions of persecution
– Delusions of reference
– Delusions of grandeur
– Delusions of control
• Hallucinations
– Auditory hallucinations
– Visual hallucinations in some cases
• Disorganised speech
• Disorganised behaviour
• Clumsy in motor functions
• Rigidity, tremor, jerking arm movements, or involuntary movements of the limbs
• Awakard Walking
• Unusual gestures and postures
• Inability to experience joy or pleasure from activities (called anhedonia)
• Appearing desireless or seeking nothing
• Feeling indifferent to important events
• Low motivation or No motivation
• Suicidal thoughts in some cases
• Rapidly changing mood.
12
 Schizophrenia and Other
Self Assessment Questions Psychotic Disorders
1) What is schizophrenia?
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2) What are negative and positive symptoms of schizophrenia?
...............................................................................................................
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3) What are the cognitive symptoms of schizophrenia?
...............................................................................................................
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4) Enlist the common symptoms of schizophrenia.
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1.4 TYPES OF SCHIZOPHRENIA

The nature of symptoms taken into account while determining the disease of
schizophrenia varies greatly with the progression of the disease. There are 5
types of schizophrenia, the subtypes are defined in accordance with the most
prominent characteristics. The same person maybe analysed with different types
of schizophrenia as the illness proceeds. The types of schizophrenia are:
i) Paranoid schizophrenia
ii) Disorganised schizophrenia (hebephrenia)
iii) Catatonic schizophrenia
13
Severe Mental Disorders iv) Undifferentiated schizophrenia
v) Residual type schizophrenia.
These are being discussed below in detail.

1.4.1 Paranoid Schizophrenia

The paranoid type of schizophrenia is marked by thoughts of conspiracy or
persecution and in some cases also auditory hallucinations. The patients however
are more capable of working and are better at relationships than those having the
other types of schizophrenia. The life is much more normal, especially if they
can manage the disease. Though the reason is unknown, it could probably be
leading from the fact that those suffering from this schizophrenic type begin to
show their symptoms during the later part of life, and have thus already managed
to grasp better functioning before the illness could settle.

The patients may be hesitant in discussing their illness, and need not categorically
look unusual or odd. Their delusions and hallucinations circle around particular
themes which do not change frequently. In schizophrenia paranoid type the overall
behaviour and temperament depends on the nature of their thoughts. For instance,
somebody who imagines to be unjustly persecuted could become hostile easily
or short tempered. These indications are generally understood by professionals
when extra stress triggers the symptoms. It is precisely in such situations that the
patient might realise the requirement for help. They may take such steps that
might attract attention.

However, as the features are barely visible, it becomes important for the patient
to discuss their thought reflections openly. This could be difficult where paranoia
or suspicions are high. There can be variations over the same time period, in
regard to its severity and nature. The thought process may get disorganised when
the condition is on the path of worsening or exacerbation.

During such phases, the patient may find it tougher to remember even the recent
events, or might speak incoherently, behaving in an irrational or in a disorganised
pattern. Since these are features prominently characteristic to other subtypes,
based on the state of their illness, the given symptoms may vary in several degrees
in paranoid subtype patients. Family and friends should be supportive,
encouraging the patient to seek help from a professional.

Signs and Symptoms

• Delusions of persecution, reference, exalted birth, special mission, bodily
change, or jealousy.
• Hallucinatory voices that threaten the patient or give commands, or auditory
hallucinations without verbal form, such as whistling, humming, or laughing.
• Hallucinations of smell or taste, or of sexual or other bodily sensations.
• Visual hallucinations may occur but are rarely predominant.
• Incoherent speech
• Marked loosening of associations
• Flat or grossly inappropriate affect

14
Causes Schizophrenia and Other
Psychotic Disorders
• Family history of schizophrenia
• Exposure to viruses while in the womb
• Poor nutrition while in the womb
• Stressful life events
• Older paternal age
• Addiction of psychoactive drugs during adolescence

Treatment
• The main treatments for paranoid schizophrenia are:
• Medications
• Psychotherapy
• Hospitalisation
• Electroconvulsive therapy (ECT)
• Vocational skills training

1.4.2 Disorganised Schizophrenia (Hebephrenic)

As evident from its very name, this type of schizophrenia is marked by
disorganised thought patterns, with less of delusion and hallucination difficulties.
The ability to normal functioning of regular living might get seriously impaired,
and might include trouble in performing routine activities such as brushing,
bathing, etc.

This is one of those sub types of schizophrenia where emotional impairment

may be observed. For instance, the patient’s emotions may fluctuate greatly, or
might be unjustified in a given circumstance, with unordinary responses of
emotions (flat or blunted effect). The patient is unusually giddy or jocular, like
one who chuckles at a solemn occasion like funeral.

The communication ability might get impaired, with a practically incomprehensible

speech, owing to disorganised thought patterns. It is important to look out for
speech which is marked with difficulties in forming of sentences with correct
word ordering than difficulties arising form articulation or enunciation.

Symptoms
• Delusions of persecution
• Delusion of reference, exalted birth, special mission, bodily change, or
jealousy;
• Hallucinatory voices that threaten the patient or give commands, or auditory
hallucinations without verbal form, such as whistling, humming, or laughing;
• Hallucinations of smell or taste, or of sexual or other bodily sensations;
visual hallucinations may occur but are rarely predominant.
Causes
The exact cause of paranoid schizophrenia is unknown. A genetic and enviornment
cause have been suggested, more common in families with psychotic mood
disorders, most notably paranoid schizophrenia and delusional disorders.
15
Severe Mental Disorders Biochemical factors and childhood experience have also been suggested as
possible causes.

Treatment
The main treatments for paranoid schizophrenia are:
• Medications
• Psychotherapy
• Hospitalisation

1.4.3 Catatonic Schizophrenia

Catatonic disorders are a group of symptoms characterised by disturbances in
motor (muscular movement) behaviour that may have either a psychological or
a physiological basis. The best known of these symptoms is immobility, which
is a rigid positioning of the body held for a considerable length of time. Patients
diagnosed with a catatonic disorder may maintain their body position for hours,
days, weeks or even months at a time.

Alternately, catatonic symptoms may look like agitated, purposeless movements

that are seemingly unrelated to the person’s environment. The condition itself is
called catatonia . A less extreme symptom of catatonic disorder is slowed-down
motor activity. Often, the body position or posture of a catatonic person is unusual
or inappropriate; in addition, he or she may hold a position if placed in it by
someone else.

Symptoms
These symptoms include:
• Catalepsy, or motionlessness maintained over a long period of time.
• Catatonic excitement, marked by agitation and seemingly pointless
movement.
• Catatonic stupor, with markedly slowed motor activity, often to the point of
immobility and seeming unawareness of the environment.
• Catatonic rigidity, in which the person assumes a rigid position and holds it
against all efforts to move him or her.
• Catatonic posturing, in which the person assumes a bizarre or inappropriate
posture and maintains it over a long period of time.
• Waxy flexibility, in which the limb or other body part of a catatonic person
can be moved into another position that is then maintained. The body part
feels to an observer as if it were made of wax.
• Akinesia, or absence of physical movement.
Causes
• Brain, including the limbic system, the frontal cortex, and the basal ganglia.
• Irregularities in production of neurotransmitters within the brain.
• Numerous medical conditions
Treatment
• Medications

16
• Psychotherapy Schizophrenia and Other
Psychotic Disorders
• Family education
• Hospitalisation

1.4.4 Undifferentiated Schizophrenia

Patients with undifferentiated schizophrenia do not experience the Paranoia
associated with paranoid schizophrenia. The catatonic state seen in patients with
catatonic schizophrenia, or the disorganised thought and expression observed in
patients with disorganised schizophrenia are not obtained here. However, they
do experience psychosis and a variety of other symptoms associated with
schizophrenia, including behavioural changes which may be noticeable to family
and friends.

This mental disorder is challenging to diagnose, and it can take weeks or months
to confirm a diagnosis of schizophrenia. During this process, other causes for
the symptoms are ruled out, and the patient is observed to collect information
about changes in the patient’s personality, modes of expression, and mood. Family
members and friends may also be interviewed and asked for information with a
goal of painting a more complete picture of what is going on inside the patient’s
mind.

In this schizophrenia type, the patient’s symptoms may fluctuate, or might stay
excessively stable, causing a doubt in placing it under any other sub type. The
best schizophrenia type’s definition for this type of schizophrenia is ‘mixed
clinical condition’.

Symptoms
This disorder does not have any specific symptoms and mostly similar to main
symptoms of Schizophrenia, which are as follows:
• Delusions
• Hallucinations
• Disorganised speech
• Grossly disorganised or catatonic behaviour
• Negative symptoms
Causes
• Genetic
• Migration
• Virus
• Family environment
Other Causes
Sometimes individuals born in cold and urban environments are more likely to
develop undifferentiated schizophrenia. Those infected with influenza, poliovirus,
CNS, respiratory diseases have a 10 to 50 percent higher chance of developing
schizophrenia. During the prenatal stage, those children subjected to famine,
separated from mother/parents/family, depression, bereavement and total damage
of everything during flood etc., are all more likely to develop schizophrenia
17
Severe Mental Disorders Treatment
• Psychotherapy
• Pharmacotherapy
There are a number of treatment options available for undifferentiated
schizophrenia. Patients can discuss treatment options with their physicians,
although it is important to be aware that it can take time for treatment to be
effective. Once patients start experiencing a change, they may require periodic
adjustments to their medications and treatment regimen to respond to changes
they experience over time. Undifferentiated schizophrenia cannot be cured, but
it can be managed with a cooperative effort.

1.4.5 Residual Type Schizophrenia

The symptoms are less severe as compared to the undifferentiated schizophrenia
or the disorganised schizophrenia. They do manifest idiosyncratic behaviours,
delusions or hallucinations and they appear less prominent as they were in the
worst days of illness. Just like varying types of schizophrenia, the ramifications
are highly varying too.

Different impairments affect different people in different degrees. While some

need custodial care, others may have a fairly normal career and family life. Though
generally patients do not stand at either of the two extreme points, they generally
have to opt for waning and waxing treatments marked with hospitalisation visits,
requiring outside support etc. On the other hand, a weaker prognosis is marked
by sinister and gradual onsets, starting from adolescence or childhood. They
cause abnormalities in the brain structure which can be revealed by imaging
studies often causing permanent damages after severe incidents.

Symptoms
• Social withdrawal
• Depersonalisation (intense anxiety and a feeling of being unreal)
• Loss of appetite
• Loss of hygiene
• Delusions
Hallucinations (distorted perception that is for example, hearing things when
there is none talking, seeing thing swhen there is none present)

The sense of being controlled by outside forces

Causes
• Genetic cause
• Enviornmental cause
Treatment
• Psychotherapy
• Pharmacotherapy

18
 Schizophrenia and Other
Self Assessment Questions Psychotic Disorders
1) What is Catatonic schizophrenia?
...............................................................................................................
...............................................................................................................
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2) Discuss the symptoms of disorganised schizophrenia and also the causes
of hebephrenia.
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3) What do you understand by undifferentiated schizophrenia? Put forward
the symptoms, causes and course of the illness?
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4) What is residual type schizophrenia?
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1.5 CAUSES OF SCHIZOPHRENIA

There are many factors that may cause schizophrenia. Scientists are still working
on this aspect, trying to identify all of them. The most common causes are:

1.5.1 Genetics
The genetic vulnerability and environmental factors can act in combination so
as to result in diagnosis of schizophrenia. Research suggests that genetic
vulnerability to schizophrenia is multi factorial, caused by interactions of several
genes. 19
Severe Mental Disorders Both individual and twin studies and meta-analyses of twin studies estimate the
heritability of risk for schizophrenia to be approximately 80% (this refers to the
proportion of variation between individuals in a population that is influenced by
genetic factors, not the degree of genetic determination of individual risk).

Concordance rates between monozygotic twins was close to 50%; whereas

dizygotic twins was 17%. Adoption studies have also indicated a somewhat
increased risk in those with a parent with schizophrenia even when raised apart.

Studies suggest that the phenotype is genetically influenced but not genetically
determined. The variants in genes are generally within the range of normal human
variation and have low risk associated with them each individually, and that
some interact with each other and with environmental risk factors. These may
not necessarily be specific to schizophrenia

Some twin studies have found rates as low as 11.0% to 13.8% among monozygotic
twins, and 1.8% to 4.1% among dizygotic twins. Tyronne Cannon reviewed the
situation, stating: “Previous twin studies have reported estimates of broad
heritability ranging from 0.41 to 0.87”Yet, in the “Pairs of Veteran Twins” study,
for example, 338 pairs were schizophrenic with only 26 pairs concordant, and it
was concluded in one report: “the role of the suggested genetic factor appears to
be a limited one; 85 percent of the affected monozygotic pairs in the sample
were discordant for schizophrenia”. In addition, some scientists criticize the
methodology of the twin studies, and have argued that the genetic basis of
schizophrenia is still largely unknown or open to different interpretations.

1.5.2 Prenatal Obstetric Complications

This occurs in approximately 25 to 30% of the general population and the vast
majority do not develop schizophrenia, and likewise the majority of individuals
with schizophrenia have not had a detectable obstetric event. Nevertheless, the
increased average risk is well-replicated, and such events may moderate the effects
of genetic or other environmental risk factors. The specific complications or
events most linked to schizophrenia, and the mechanisms of their effects, are
still under examination.One epidemiological finding is that people diagnosed
with schizophrenia are more likely to have been born in winter or spring.

1.5.3 Fetal Growth

Lower than average birth weight has been one of the most consistent findings,
indicating slowed fetal growth possibly mediated by genetic effects. Almost any
factor adversely affecting the fetus will affect growth rate, however, so the
association has been described as not particularly informative regarding causation.

1.5.4 Hypoxia
Hypoxia has been recently described as one of the most important of the external
factors that influence susceptibility, although studies have been mainly
epidemiological. Such studies place a high degree of importance on hypoxic
influence, but because of familial pattern of the illness in some families, propose
a genetic factor also; stopping short of concluding hypoxia to be the sole cause.
Fetal hypoxia, in the presence of certain unidentified genes, has been correlated
with reduced volume of the hippocampus, which is in turn correlated with
schizophrenia..
20
1.5.5 Infections Schizophrenia and Other
Psychotic Disorders
Numerous viral infections, in utero or in childhood, have been associated with
an increased risk of later developing schizophrenia. Schizophrenia is somewhat
more common in those born in winter to early spring, when infections are more
common.Influenza has long been studied as a possible factor. A 1988 study found
that individuals who were exposed to the Asian flu as second trimester fetuses
were at increased risk of eventually developing schizophrenia.

1.5.6 Other Factors

Childhood antecedents: The antecedents of schizophrenia are subtle. Average
group differences from the norm may be in the direction of superior as well as
inferior performance. Overall, birth cohort studies have indicated subtle
nonspecific behavioural features, some evidence for psychotic-like experiences
(particularly hallucinations), and various cognitive antecedents. There have been
some inconsistencies in the particular domains of functioning identified and
whether they continue through childhood and whether they are specific to
schizophrenia. A prospective study found average differences across a range of
developmental domains, including reaching milestones of motor development
at a later age, having more speech problems, lower educational test results, solitary
play preferences at ages four and six, and being more socially anxious at age 13.
Lower ratings of the mother’s skills and understanding of the child at age 4 were
also related.

Substance Use: The relationship between schizophrenia and drug use is complex,
meaning that a clear causal connection between drug use and schizophrenia has
been difficult to tease apart. There is strong evidence that using certain drugs can
trigger either the onset or relapse of schizophrenia in some people. It may also
be the case, however, that people with schizophrenia use drugs to overcome
negative feelings associated with both the commonly prescribed antipsychotic
medication and the condition itself, where negative emotion, paranoia and
anhedonia are all considered to be core features. The rate of substance use is
known to be particularly high in this group. In a recent study, 60% of people
with schizophrenia were found to use substances and 37% would be diagnosable
with a substance use disorder.

Social adversity: It has been seen that chance of developing schizophrenia has
been found to increase with the number of adverse social factors present in
childhood Stressful life events generally precede the onset of schizophrenia. A
personal or recent family history of migration is a considerable risk factor for
schizophrenia, which has been linked to psychosocial adversity, social defeat
from being an outsider, racial discrimination, family dysfunction, unemployment
and poor housing conditions. Childhood experiences of abuse or trauma are risk
factors for a diagnosis of schizophrenia later in life. Recent large-scale general
population studies indicate the relationship is a causal one, with an increasing
risk with additional experiences of maltreatment although a critical review
suggests conceptual and methodological issues require further research. .

Urbanicity: The association between living in an urban environment and the

development of schizophrenia, even after factors such as drug use, ethnic group
and size of social group have been controlled for. A recent study of 4.4 million
men and women in Sweden found a 68%–77% increased risk of diagnosed
21
Severe Mental Disorders psychosis for people living in the most urbanised environments, a significant
proportion of which is likely to be described as schizophrenia.

The effect does not appear to be due to a higher incidence of obstetric

complications in urban environments. He risk increases with the number of years
and degree of urban living in childhood and adolescence, suggesting that constant,
cumulative, or repeated exposures during upbringing occurring more frequently
in urbanised areas are responsible for the association.

Various possible explanations for the effect have been judged unlikely based on
the nature of the findings, including infectious causes or a generic stress effect.
It is thought to interact with genetic dispositions and, since there appears to be
nonrandom variation even across different neighborhoods, and an independent
association with social isolation, it has been proposed that the degree of “social
capital” (e.g. degree of mutual trust, bonding and safety in neighbourhoods) can
exert a developmental impact on children growing up in these environments

1.6 TREATMENT
1.6.1 Psychosocial Treatment for Schizophrenia
While medication is almost always a necessary component of schizophrenia
treatment, it does not offer a complete solution. People with schizophrenia also
need psychosocial treatments to help them cope with their illness, obtain services,
and become more independent. People who receive psychosocial treatment for
schizophrenia are more likely to take their medication regularly and avoid relapse
and hospitalisation.

1.6.2 Supportive Therapy

The goal of supportive therapy for schizophrenia is to help people adjust to their
illness and navigate the challenges of daily living. Individual and group therapy
provide the much needed emotional support for people with schizophrenia, while
simultaneously teaching them how to solve problems in their daily lives, improve
their relationships, and participate in their own recovery.

1.6.3 Illness Management

A primary focus of supportive therapy is patient education. Patients learn about
common schizophrenia symptoms and problems, treatment options, and the
importance of medication. This knowledge helps them take an active role in
treatment and better manage their illness. People with schizophrenia can learn to
monitor their progress, watch for signs of relapse, take their medication regularly,
and deal with side effects.

1.6.4 Coping with Symptoms

Supportive therapy can also teach people how to cope with symptoms of
schizophrenia that persist despite medication and treatment. Using cognitive-
behavioural techniques, patients learn to challenge delusional beliefs, ignore the
voices in their heads, or motivate themselves.

22
1.6.5 Rehabilitation Schizophrenia and Other
Psychotic Disorders
Vocational and social rehabilitation teaches basic life skills to people with
schizophrenia so they can function in their families or communities. There are
many different types of rehabilitation programs, but the shared focus is on helping
patients take care of themselves and make the most of their capabilities. Depending
on the individual’s personal goals and degree of illness, rehabilitation may include
training in handling finances, using public transportation, communicating with
others, and finding living arrangements. For those who want to work, vocational
rehabilitation includes work assessment, job skills training, and assistance finding
full or part-time employment.

1.6.6 Family Education and Support

Family support makes a difference in the outlook for people with schizophrenia.
When family members are involved in treatment, patients are more likely to
avoid relapse and achieve a higher level of functioning. If you have a family
member with schizophrenia, educating yourself about the illness will give you a
clearer understanding of your loved one and the challenges of treatment and
recovery.

1.6.7 Antipsychotic Drugs

The most common medical treatment for schizophrenia is the use of antipsychotic
medication. 70% of people using medications for schizophrenia improve, and
medicine can also cut the relapse rate for the disorder by half, reducing it to
40%. Classic schizophrenia medication includes Thorazine, Fluanxol, and
Haloperidol. These medications are effective in treating the positive symptoms
of schizophrenia. Newer “atypical” medications include Risperdal, Clozaril, and
Aripiprazole. These medications are recommended for first-line treatment and
are excellent at reducing negative symptoms.

1.6.8 Antidepressant Drugs

Antidepressants are recommended for those suffering from schizoaffective
disorder. Antidepressants can successfully reduce the symptoms of depression
in these patients.
Self Assessment Questions
1) What are the causes of schizophrenia?
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2) How can schizophrenia be treated?
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23
Severe Mental Disorders
3) What is psychotherapy?
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1.7 LET US SUM UP

In this unit we discussed the definition and description of schizophrenia. We
took up the symptoms of schizophrenia and focused on both positive and negative
symptoms and how they affect the disorder. Then we took up the various types
of schizophrenia such as the hebephrenic, paranoid, catatonic, undifferentiated
etc., and discussed each of their symptoms, causes and treatment of the same. In
regard to the causes of schizophrenia, general causes were discussed and
supporting twin studies for genetic factors were also discussed. Thus the family
study, twin study and adoption study all show a major contributor for
schizophrenia. It is a lifetime risk and correlates quite well with the proportion
of genes shared with an affected family member. The socio-economic role is
also important and lower group are always at the risk of the disorder. By and
large all the symptoms of schizophrenia, the causes or the etiological factors and
the various available treatment for the disorder have been presented in this unit.

1.8 UNIT END QUESTIONS

1) Describe Schizophrenia with its symptoms.
2) What are negative, positive and cognitive symptoms of schizophrenia?
Explain in detail
3) Describe the different types of schizophrenia and present the causes and
treatment for each type of schizophrenia
4) What is hebephrenia? Describe its causes and symptoms?
5) What are the treatment interventions available for treating schizophrenia?

1.9 SUGGESTED READINGS AND REFERENCES

Green, Michael, Foster. (2003). Schizophrenia Revealed: From Neurons to Social
Interaction. Skylane Publishing, NY
Keefe, Richard S.E. & Harvey, Phillip D. (2005). Understanding Schizophrenia:
A Guide to the New Research on Causes and Treatment , NAMI, Texas.
Torrey, Fuller,E. (2005). Surviving Schizophrenia: A Manual for Families,
Patients, and Providers . Robert W. Wance, NY
Sadock BJ, Sadock VA (2007). Schizophrenia. In Kaplan and Sadock’s Synopsis
of Psychiatry. 10th ed., pp. 467-497. Philadelphia: Lippincott Williams and
Wilkins.
24
References Schizophrenia and Other
Psychotic Disorders
Ho BC, et al. (2003). Schizophrenia and other Psychotic disorders. In R E Hales,
SC Yudofsky, eds., Textbook of Clinical Psychiatry, 4th ed., pp. 379-438.
Washington, DC: American Psychiatric Publishing.
Buchanan RW, Carpenter WT Jr (2005). Schizophrenia. In BJ Sadock, VA Sadock,
eds., Kaplan and Sadock’s Textbook of General Psychiatry, 8th ed., vol. 1, pp.
1329-1558. Philadelphia: Lippincott Williams and Wilkins.
Sørensen HJ, et al. (2003). Do hypertension and diuretic treatment in pregnancy
increase the risk of schizophrenia in offspring? American Journal of Psychiatry,
160(3): 464-468.
American Psychiatric Association (2000). Schizophrenia section of Schizophrenia
and other psychotic disorders. In Diagnostic and Statistical Manual of Mental
Disorders, 4th ed., text rev., pp. 287-313. Washington, DC: American Psychiatric
Association.
Bustillo JR, et al. (2001). The psychosocial treatment of schizophrenia: An update.
American Journal of Psychiatry, 158(2): 163-175.
Lehman AF, et al. (2004). Practice guideline for the treatment of patients with
schizophrenia, second edition. American Journal of Psychiatry, 161(2, Suppl):
1-56.
Drake RE, et al. (2000). Evidence-based treatment of schizophrenia. Current
Psychiatry Reports, 2(5): 393-397.
Buchner DM (2008). Physical activity. In L Goldman, D Ausiello, eds., Cecil
Textbook of Medicine, 23rd ed., pp. 64-67. Philadelphia: Saunders. Tamminga
CA, Holcomb HH. Phenotype of schizophrenia: a review and formulation. Mol
Psych 2005;10:27–39.
Picchioni MM, Murray RM. Schizophrenia. BMJ 2007;335:91–95.
Kane JM, Honigfeld G, Singer J, et al. Clozapine for the treatment-resistant
schizophrenic. Arch Gen Psychiatry 1988;45:789–796.
McGrath JJ. Variations in the incidence of schizophrenia: data versus dogma.
Schizophr Bull. 2006;32:195–197.
Aleman A, Kahn RS, Selten JP. Sex differences in the risk of schizophrenia.
Evidence from meta-analysis. Arch Gen Psychiatry 2003;60:565–571.
Hegarty JD, Baldessarini RJ, Tohen M, et al. One hundred years of schizophrenia:
a meta-analysis of the outcome literature. Am J Psychiatry 1994;151:1409–1416.
Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations,
incidence and course in different cultures. A World Health Organisation ten-
country study. Psychol Med Monogr Suppl 1992; 20:1–97.
Johnstone EC. Schizophrenia: problems in clinical practice. Lancet
1993;341:536–538.
Thornley B, Adams C. Content and quality of 2000 controlled trials in
schizophrenia over 50 years. BMJ 1998;317:1181–1184. Search date 1997;
primary sources hand searches of conference proceedings, Biological Abstracts,
Cinahl, The Cochrane Library, Embase, Lilacs, Psychlit, Psyindex, Medline, and
Sociofile.

25
Severe Mental Disorders
UNIT 2 PERSONALITY DISORDERS

Structure
2.0 Introduction
2.1 Objectives
2.2 Concept and Definition of Personality Disorders
2.2.1 Cluster A Personality Disorders
2.2.2 Cluster B Personality Disorders
2.2.3 Cluster C Personality Disorders
2.2.4 Historical Perspective
2.3 Definition of Personality Disorders
2.3.1 General Symptoms of Personality Disorders
2.4 Types of Personality Disorders Cluster A
2.4.1 Paranoida Personality Disorder
2.4.2 Schizoid Personality Disorder
2.4.3 Schizotypal Personality Disorder
2.5 Types of Personality Disorders Cluster B
2.5.1 Antisocial Personality Disorder
2.5.2 Borderline Personality Disorder
2.5.3 Histrionic Personality Disorder
2.5.4 Narcissistic Personality Disorder
2.6 Types of Personality Disorders Cluster C
2.6.1 Avoidant Personality Disorder
2.6.2 Dependent Personality Disorder
2.6.3 Obsessive Compulsive Personality Disorder
2.7 Let Us Sum Up
2.8 Unit End Questions
2.9 Suggested Readings and References

2.0 INTRODUCTION
In this unit we will be dealing with concept and definition of personality disorders.
In this we will deal with cluster A, B, and C personality disorders. This will be
followed by historical development of personality disorders, and definition and
concept of personality disorders. Then we will take up types of personality
disorders which will include paranoid, schizophrenic and schizotypal personality
disorders. After cluster A, we will take up personality disorders under cluster B
which will consist of antisocial personality disorder, borderline personality
disorder, histrionic and narcissistic personality disorders. This will be followed
by the cluster C personality disorders which will consist of avoidant personality
disorders, dependent personality disorder and the obsessive compulsive
personality disorder. In all these disorders the symptomatology, causes and
treatments of these disorders will be discussed.

26
 Personality Disorders
2.1 OBJECTIVES
On completing this unit, you will be able to:
• Define personality disorders;
• Describe the characteristic features of personality disorders;
• Explain various types of personality disorders;
• Elucidate the Symptoms of personality disorders;
• Analyse the causes of personality disorders; and
• Explain the various Treatment approaches for personality disorders.

2.2 CONCEPT AND DEFINITION OF

PERSONALITY DISORDERS
A person characteristics ways of responding are referred to his or her personality.
Personality styles can be maladaptive if an individual is unable to modify the
behaviour when the environment changes. This inability to change is referred to
as disorder. Personality disorder is a longstanding, maladaptive and inflexible
ways of relating to the enviiornment. These disorders sometimes may be noticed
in childhood or latest by early adolescence. These disorders cause problems for
the persons who suffer from it and also to people who are significant in the
individual’s life.

People with psychological personality disorders have traits that cause them to
feel and behave in socially distressing ways. Depending on the specific disorder,
these personalities are generally described in negative terms such as hostile,
detached, needy, antisocial or obsessive (Dobbert 2007).

Classification of Personality Disorders

Personality disorders are classified by DSM IV (TR) into three clusters of
disorders.
There are currently 10 conditions that are considered personality disorders, some
of which have very little in common. Mental health professionals group those
personality disorders that share characteristics into one of three clusters:

2.2.1 Cluster A Personality Disorders

These are considered to be marked by odd, eccentric behaviour. Paranoid, Schizoid
and Schizotypal Personality Disorders are in this category.

i) Paranoid Personality Disorder (PPD)

PPD is a type of psychological personality disorder characterised by an extreme
level of distrust and suspiciousness of others. Paranoid personalities are generally
difficult to get along with, and their combative and distrustful nature often elicits
hostility in others. The negative social interactions that result from their behaviour
reinforces their original pessimistic expectations.
Persons with PPD are unlikely to form many close relationships and are typically
perceived as cold and distant. They are quick to challenge the loyalty of friends
and loved ones and tend to carry long grudges (Dobbert 2007) 27
Severe Mental Disorders ii) Schizoid Personality Disorder
Individuals with schizoid personality are characteristically detached from social
relationships and show a restricted range of expressed emotions. Their social
skills, as would be expected, are weak, and they do not typically express a need
for attention or approval. They may be perceived by others as somber and of,
and often are referred to as “loners.”

iii) Schizotypal Personality Disorder

Schizotypal personalities are characterised by odd forms of thought, perception
and beliefs. They may have bizarre mannerisms, an eccentric appearance, and
speech that is excessively elabourate and difficult to follow. However, these
cognitive distortions and eccentricities are only considered to be a disorder when
the behaviours become persistent and very disabling or distressing.

In social interactions, schizotypals may react inappropriately, or not react at all,

or talk to themselves. They may believe that they have extra sensory powers or
that they are connected to unrelated events in some important way. However,
they tend to avoid intimacy and typically have few close friends. Although
schizotypals may marry and hold down jobs, they are prone to feel nervous around
strangers (Dobbert 2007).

2.2.2 Cluster B Personality Disorders

These are evidenced by dramatic, erratic behaviours and include Histrionic,
Narcissistic, Antisocial and Borderline Personality Disorders.

There are four Cluster B personality disorders: antisocial, borderline, narcissistic,

and histrionic. The DSM-IV views these as a subset of personality disorders that
are characterised by dramatic, emotional or erratic behaviour. Let us take up
antisocial personality disorders.

i) Antisocial Personality Disorder (APD)

According to DSM-IV, antisocial personality disorder is a “pervasive pattern of
disregard for, and violation of, the rights of others that begins in early childhood
or early adolescence and continues into adulthood.” People with antisocial
personality disorder have been described as lacking empathy and may often be
deceitful or break the law.They never feel bad or regret their wrong actions.
Despite being punished or jailed in certain cases, they continue to indulge in
wrong and deviant activities. Antisocial personality disorder is also associated
with impulsive behaviour, aggression (such as repeated physical assaults),
disregard for their own or other’s safety, irresponsible behaviour, and lack of
remorse.

ii) Borderline Personality Disorder (BPD)

BPD is associated with specific problems in interpersonal relationships, self-
image, emotions, behaviours, and thinking. People with BPD tend to have intense
relationships characterised by a lot of conflict, arguments and break-ups. They
also have difficulties related to the stability of their identity or sense of self.
They report many “ups and downs” in how they feel about themselves. Individuals
with BPD may say that they feel as if they are on an emotional roller coaster,
with very quick shifts in mood (for example, going from feeling OK to feeling
28 extremely down or blue within a few minutes).
BPD is associated with a tendency to engage in risky behaviours, such as going Personality Disorders
on shopping sprees, drinking excessive amounts of alcohol or abusing drugs,
engaging in promiscuous sex, binge eating, or self-harming.

iii) Narcissistic Personality Disorder

The next disorder in group B is the Narcissistic personality disorder, which is
characterised by an inflated sense of self-importance. People with narcissistic
personality disorder often believe that they are “special,” require excessive
attention, take advantage of others, lack empathy, and are described by others as
arrogant.

iv) Histrionic Personality Disorder

The next disorder in this group B is the histrionic personality disorder. The central
features of histrionic personality disorder are intense expressions of emotion
and excessive attention seeking behaviour. People with histrionic personality
disorder often seek out attention and are uncomfortable when others are receiving
attention. They may often engage in seductive or sexually promiscuous behaviour,
or use their physical appearance to draw attention to themselves. They also may
demonstrate rapidly shifting emotions and express emotion in a very dramatic
fashion.

2.2.3 Cluster C Personality Disorders

These are distinguished by anxious, fearful behaviour commonly seen in
Obsessive-Compulsive, Avoidant and Dependent Personality Disorders.

Let us deal with each of the disorders in each of the clusters. First taking up
Cluster A Personality Disorders, in which we have paranoid, schizoid and
schizotypal personality disorders.

In this group we have obsessive compulsive personality disorder, avoidant

personality disorder and dependent personality disorder. Let us take up the
Obsessive compulsive personality disorder.

i) Obsessive-Compulsive Personality Disorder

People suffering from OCPD, also called Anankastic Personality Disorder, are
so focused on order and perfection that their lack of flexibility interferes their
ability to get things done, and to enjoy life in general. Little is accomplished
because, whatever the task, for the obsessive-compulsive, it is never good enough.
These individuals become involved and overwhelmed in detail and are often
unable to see the big picture.

ii) Avoidant Personality Disorder (AvPD)

Those with AvPD experience an intense level of social anxiety. Extremely self-
conscious, they tend to avoid social situations and gravitate to jobs that involve
little interpersonal contact. Avoidants often feel inadequate or inferior to others
and are hypersensitive to rejection. Unlike individuals with schizoid personality
disorder, those with AvPD do crave social relationships but feel that social
acceptance is unattainable (Dobbert 2007).

29
Severe Mental Disorders iii) Dependent Personality Disorder (DPD)
DPD is a psychological personality disorder in which the individuals are
dependent on others to an extreme extent. They want to be taken care of, cling to
those they depend on, and often rely on others to make decisions for them. They
have a strong fear of rejection and may become suicidal when faced with a
disintegrating relationship. Those with DPD require excessive reassurance and
advice, and are commonly over-sensitive to criticism or disapproval.

All these disorders are dealt with in detail at a later section in this unit.

2.2.4 Historical Perspective

Three hundred years ago, in 1801 the French psychiatrist Pinel spoke of maniac
sans delire that is mania without delirium. Pinel defined what might now be
called Dissocial Personality Disorder and believed that it was characterised by
unexplained outbursts of rage and violence in the absence of impaired intellectual
function or delusion. At that time delusions were regarded as the central factor
of mental illness and Gelder et al (1989) presumed that this group also included
those mentally ill patients who were not deluded as for example those suffering
from mania or mood disorder.

In 1835, a doctor at Bristol Infirmary, Pritchard, formulated a new term, Moral

Insanity, defined as a morbid perversion of the natural feelings, affection,
inclination, temper, habits, moral dispositions and natural impulses. This referred
to both personality and mood disorders.

Further classifications were suggested through out the 19th century including
Monel’s cognitive delusions in 1852, followed by Degenerative Deviation, Moral
Imbecility, Constitutional Inferiority and Moral Delinquency. Later in the century,
a recognition of mentally ill without delusions occurred, and distinctions were
drawn between schizophrenia and affective or mood disorders. The concept of
moral insanity was consequently modified.

In 1872, Lombroso spoke of the unborn criminal and in 1884 Henry Maudsley
wrote” it is not our business to explain psychologically the origins and nature of
this depraved instincts, it is sufficient to establish their existence as facts of
observation.” This concept of “no capacity for true moral feeling” became the
forerunner to psychopathic states. In 1891 a German Doctor Koch, introduced
the term psychopathic inferiority. Kraepelin in 1905 replaced inferiority with
personality. He defined the psychopathic personality as falling into 7 types:
excitable, unstable, eccentric, liars, swindlers, antisocial, quarrelsome.

N 1923, Schneider, a German psychiatrist extended classification of psychiatry

to include 10 sub classifications incorporating not only those who caused suffering
to others but also those causing suffering to themselves.

In 1941, Cleckley coined the phrase, the “Mask of Insanity” and Sir David
Henderson defined psychopaths as people who through out thjeir lives have
exhibited disorders of conduct of an antisocial or asocial in nature, recurrent or
episodic. Henderson included three groups of psychopaths, aggressive, inadequate
and creative. This classification included those prone to suicide, drug and alcohol
abuse, pathological lying, hypochondriasis, instability and insensitivity.
30
Thus historically the Personality disorders have gone through considerable Personality Disorders
modifications. These disorder were earlier known as character disorders. The
term implies to a diagnostic category of psychiatric disorders characterised by
chronic, inflexible and maladaptive pattern of behaviour which is evident in the
way a person thinks, feels and behaves. A person with an untreated personality
disorder is rarely able to enjoy sustained, meaningful, and rewarding relationships
with others, and any relationships they do form are often fraught with problems
and difficulties.

2.3 DEFINITION OF PERSONALITY DISORDERS

American Psychiatric Association (APA) defines personality disorders as “an
enduring pattern of inner experience and behaviour that deviates markedly from
the expectations of the culture of the individual who exhibits it”. The different
behavioural patterns in personality disorders are typically associated with severe
disturbances in the behavioural tendencies of an individual, usually involving
several areas of the personality, and are nearly always associated with considerable
personal and social disruption.

The onset of these patterns of behaviour can typically be traced back to late
adolescence and the beginning of adulthood and, in rarer instances, childhood. It
is therefore unlikely that a diagnosis of personality disorder will be appropriate
before the age of 16 or 17 years.

Personality disorders are long term patterns of thoughts and behaviours that cause
serious problems with relationships and work. People with personality disorders
have difficulty dealing with everyday stresses and problems.

2.3.1 General Symptoms of Personality Disorders

These are given below:
• Frequent mood swings
• Stormy relationships
• Social isolation
• Angry outbursts
• Suspicion and mistrust of others
• Difficulty making friends
• A need for instant gratification
• Poor impulse control
• Alcohol or substance abuse
As per American Psychiatric Association definition, a personality disorder is an
enduring pattern of inner experience and behaviour that deviates markedly from
the expectations of the individual’s culture. It is pervasive and inflexible and has
an onset in adolescence or early adulthood. It is stable over time, and leads to
distress or impairment.

Some defines personality disorder as “ disorders of character and patterns of

perceiving and relating to the environment and oneself, marked by inflexible
31
Severe Mental Disorders traits that cause subjective (personal) distress and/or impairment in occupational
or social functioning.”

Thus Personality disorders are patterns of perceiving, reacting, and relating to

other people and events that are relatively inflexible and that impair a person’s
ability to function socially. Everyone has characteristic patterns of perceiving
and relating to other people and events (personality traits). That is, people tend
to cope with stresses in an individual but consistent way.

Self Assessment Questions

1) What is a personality disorder?
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2) Trace historically the emergence of personality disorders as an entity.
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3) Discuss common symptoms of personality disorders.
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4) How is personality disorders defined?
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Types of Personality Disorders Personality Disorders

The DSM-IV lists ten personality disorders, which are grouped into three clusters:
• Cluster A (odd or eccentric disorders)
– Paranoid personality disorder
– Schizoid personality disorder
– Schizotypal personality disorder

• Cluster B (dramatic, emotional, or erratic disorders)

– Antisocial personality disorder
– Borderline personality disorder
– Histrionic personality disorder
– Narcissistic personality disorder

• Cluster C (anxious or fearful disorders)

– Avoidant personality disorder
– Dependent personality disorder
– Obsessive-compulsive personality disorder (not the same as Obsessive-
compulsive disorder)

The DSM-IV also contains a category for behavioural patterns that do not match
these ten disorders, but nevertheless have the characteristics of a personality
disorder. This category is labelled Personality Disorder NOS (Not Otherwise
Specified).

2.4 TYPE OF PERSONALITY DISORDERS

CLUSTER A
2.4.1 Paranoid Personality Disorder
People with paranoid personality disorder (PPD) have long-term, widespread
and unwarranted suspicions which make them hostile, threatening or demeaning.
These beliefs are steadfastly maintained in the absence of any real supporting
evidence. The disorder, whose name comes from the Greek word for “madness”.

They suspect strangers, and even people they know, of planning to harm or exploit
them when there is no good evidence to support this belief. As a result of their
constant concern about the lack of trustworthiness of others, patients with this
disorder often have few intimate friends or close human contacts.

They do not fit in and they do not make good “team players.” Interactions with
others are characterised by wariness and not infrequently by hostility. If they
marry or become otherwise attached to someone, the relationship is often
characterised by pathological jealousy and attempts to control their partner. They
often assume their sexual partner is “cheating” on them.

People suffering from PPD are very difficult to deal with. They never seem to let
down their defenses. They are always looking for and finding evidence that others
are against them. Their fear, and the threats they perceive in the innocent
33
Severe Mental Disorders statements and actions of others, often contributes to frequent complaining or
unfriendly withdrawal or aloofness. They can be confrontational, aggressive and
disputatious. It is not unusual for them to sue people they feel have wronged
them. In addition, patients with this disorder are known for their tendency to
become violent.

Symptoms
• Suspiciousness and distrust of others
• Questioning hidden motives in others
• Feelings of certainty, without justification or proof, that others are intent on
harming or exploiting them
• Social isolation
• Aggressiveness and hostility
• Little or no sense of humor
Causes
The prevalence of Paranoid Personality Disorder is about 0.5% to 2.5% of the
general population. It is seen in 2% to 10% of psychiatric outpatients. This disorder
occurs more commonly in males. No one knows what causes paranoid personality
disorder, although there are hints that familial factors may influence the
development of the disorder in some cases.

There seem to be more cases of paranoid personality disorder in families that

have one or more members who suffer from such psychotic disorders as
schizophrenia or delusional disorder . This disorder is more common among
first degree biological relatives of those with Schizophrenia and Delusional
Disorder, Persecutory Type.

Other possible interpersonal causes have been proposed. For example, some
therapists believe that the behaviour that characterises PPD might be learned.
They suggest that such behaviour might be traced back to childhood experiences.
According to this view, children who are exposed to adult anger and rage with
no way to predict the outbursts and no way to escape or control them develop
paranoid ways of thinking in an effort to cope with the stress. PPD would emerge
when this type of thinking becomes part of the individual’s personality as
adulthood approaches.

Studies of identical (or monozygotic) and fraternal (or dizygotic) twins suggest
that genetic factors may also play an important role in causing the disorder. Twin
studies indicate that genes contribute to the development of childhood personality
disorders, and paranoid personality disorders.

Treatments
Because they are suspicious and untrusting, patients with this disorder are not
likely to seek therapy on their own. A particularly disturbing development or life
crisis may prompt them to get help. More often, however, the legal system or the
patient’s relatives order or encourage him or her to seek professional treatment.

Psychotherapy: The primary approach to treatment for such personality disorders

is psychotherapy . The problem is that patients with paranoid personality disorders
34
do not readily offer therapists the trust that is needed for successful treatment. Personality Disorders
As a result, it has been difficult to gather data that would indicate what kind of
psychotherapy would work best. Therapists face the challenge of developing
rapport with someone who is, by the nature of his personality disorder, distrustful
and suspicious.

Medications: With individual supportive psychotherapy is the treatment of choice

for this disorder, medications are sometimes used on a limited basis to treat the
symptoms In addition, during periods of extreme agitation and high stress that
produce delusional states, the patient may be given low doses of antipsychotic
medications.

2.4.2 Schizoid Personality Disorder

Schizoid personality disorder is one of a group of conditions called eccentric
personality disorders. People with these disorders often appear odd or peculiar.
People with schizoid personality disorder also tend to be distant, detached, and
indifferent to social relationships. They generally are loners who prefer solitary
activities and rarely express strong emotion. Although the names sound alike
and they might have some similar symptoms, schizoid personality disorder is
not the same thing as schizophrenia. Many people with schizoid personality
disorder can function fairly well. They tend to choose jobs that allow them to
work alone, such as night security officers and library or labouratory workers.

Symptoms
• Detachment from other people.
• Little or no desire to form close relationships with others.
• Rarely participates in activities for fun or pleasure.
• A sense of indifference to praise and affirmation, as well as to criticism or
rejection.
• Often described as cold, uninterested, withdrawn, and aloof
• Difficulty in relating with others
• Don’t desire any close relationship even with family members
• Aloof from any emotion
• Suffering from daydream and create vivid fantasies of complex inner lives.
Causes
The schizoid personality disorder has its roots in the family of the affected person.
These families are typically emotionally reserved, have a high degree of formality,
and have a communication style that is aloof and impersonal. Parents usually
express inadequate amounts of affection to the child and provide insufficient
amounts of emotional stimulus. This lack of stimulus during the first year of life
is thought to be largely responsible for the person’s disinterest in forming close,
meaningful relationships later in life.
People with schizoid personality disorder have learned to imitate the style of
interpersonal relationships modeled in their families. In this environment, affected
people fail to learn basic communication skills that would enable them to develop
relationships and interact effectively with others. Their communication is often
vague and fragmented, which others find confusing. 35
Severe Mental Disorders Treatments
i) Psychodynamically oriented therapies
A psychodynamic approach would typically not be the first choice of treatment
due to the patient’s poor ability to explore his or her thoughts, emotions, and
behaviour. When this treatment is used, it usually centers around building a
therapeutic relationship with the patient that can act as a model for use in other
relationships.

ii) Cognitive behavioural therapy

Attempting to cognitively restructure the patient’s thoughts can enhance self-
insight. Constructive ways of accomplishing this would include concrete
assignments such as keeping daily records of problematic behaviours or thoughts.

iii) Group therapy

Group therapy may provide the patient with a socialising experience that exposes
them to feedback from others in a safe, controlled environment. It can also provide
a means of learning and practicing social skills in which they are deficient.

iv) Family and marital therapy

It is unlikely that a person with schizoid personality disorder will seek this
therapy.Many people with this disorder do not marry and end up living with and
are dependent upon first-degree family members.

v) Medications
Some patients with this disorder show signs of anxiety and depression which
may prompt the use of medication to counteract these symptoms. In general,
there is to date no definitive medication that is used to treat schizoid symptoms.

2.4.3 Schizotypal Personality Disorder

People with classic schizotypal personalities are apt to be loners. They feel
extremely anxious in social situations, but they’re likely to blame their social
failings on others. They view themselves as alien or outcast, and this isolation
causes pain as they avoid relationships and the outside world. People with
schizotypal personalities may ramble oddly and endlessly during a conversation.
They may dress in peculiar ways and have very strange ways of viewing the
world around them. Often they believe in unusual ideas, such as the powers of
ESP or a sixth sense. At times, they believe they can magically influence people’s
thoughts, actions and emotions. In adolescence, signs of a schizotypal personality
may begin as an increased interest in solitary activities or a high level of social
anxiety.

Symptoms
• Incorrect interpretation of events, including feeling that external events have
personal meaning
• Indifferent thinking, beliefs or behaviour
• Belief in special powers, such as telepathy
• Perceptual alterations, in some cases bodily illusions, including phantom
pains or other distortions in the sense of touch
36
• Idiosyncratic speech, such as loose or vague patterns of speaking or tendency Personality Disorders
to go off on tangents
• Suspicious or paranoid ideas
• Flat emotions or inappropriate emotional responses
• Lack of close friends outside of the immediate family
• Persistent and excessive social anxiety that doesn’t abate with time.
Schizotypal personality disorder can easily be confused with schizophrenia, a
severe mental illness in which affected people lose all contact with reality
(psychosis), While people with schizotypal personalities may experience brief
psychotic episodes with delusions or hallucinations.

Causes
The schizoid personality disorder has its roots in the family of the affected person.
These families are typically emotionally reserved, have a high degree of formality,
and have a communication style that is aloof and impersonal. Parents usually
express inadequate amounts of affection to the child and provide insufficient
amounts of emotional stimulus. This lack of stimulus during the first year of life
is thought to be largely responsible for the person’s disinterest in forming close,
meaningful relationships later in life.

People with schizoid personality disorder have learned to imitate the style of
interpersonal relationships modeled in their families. In this environment, affected
people fail to learn basic communication skills that would enable them to develop
relationships and interact effectively with others.They often communicate vaguely
and fragmented which generally confuse others and so they are being
misunderstood.

Treatments
i) Psychodynamically oriented therapies
A psychodynamic approach would typically seek to build a therapeutically trusting
relationship that attempts to counter the mistrust most people with this disorder
intrinsically hold. More highly functioning schizotypals who have some capacity
for empathy and emotional warmth tend to have better outcomes in
psychodynamic approaches to treatment.

ii) Cognitive-behavioural therapy

Cognitive approaches will most likely focus on attempting to identify and alter
the content of the schizotypal’s thoughts. Distortions that occur in both perception
and thought processes would be addressed.. This would relax some of the social
anxiety felt in most interpersonal relationships and allow for some exploration
of the thought processes.

iii) Interpersonal therapy

Treatment using an interpersonal approach would allow the individual with
schizotypal personality disorder to remain relationally distant while he or she
“warms up” to the therapist. Gradually the therapist would hope to engage the
patient after becoming “safe” through lack of coercion.

37
Severe Mental Disorders iv) Group therapy
It provide the patient with a socialising experience that exposes them to feedback
from others in a safe, controlled environment. It is typically recommended only
for schizotypals who do not display severe eccentric or paranoid behaviour.

v) Family and marital therapy

It is unlikely that a person with schizoid personality disorder will seek family or
marital therapy. Many schizoid types do not marry and end up living with and
being dependent upon first-degree family members. If they do marry they often
have problems centered on insensitivity to their partner’s feelings or behaviour.

vi) Medications
There is considerable research on the use of medications for the treatment of
schizotypal personality disorder due to its close symptomatic relationship with
schizophrenia. Among otherslike Amoxapine fluoxetine have also been used
successfully to reduce symptoms of anxiety, paranoid thinking, and depression.

2.5 TYPE OF PERSONALITY DISORDERS

CLUSTER B
2.5.1 Antisocial Personality Disorder
Antisocial personality disorder is a type of chronic mental illness in which a
person’s ways of thinking, perceiving situations and relating to others are abnormal
and destructive.
People with antisocial personality disorder typically have no regard for right and
wrong. They may often violate the law and the rights of others, landing in frequent
trouble or conflict. They may lie, behave violently, and have drug and alcohol
problems. And people with antisocial personality disorder may not be able to
fulfill responsibilities to family, work or school.
Antisocial personality disorder is sometimes known as sociopathic personality
disorder. A sociopath is a particularly severe form of antisocial personality disorder.
On the other hand about 80-85% of incarcerated criminals have Antisocial
Personality Disorder. However, only about 20% of these criminals would qualify
for a diagnosis of being a psychopath. Most psychopaths meet the criteria for
Antisocial Personality Disorder, but most individuals with Antisocial Personality
Disorder are not psychopaths. Psychopaths account for 50 percent of all the most
serious crimes committed, including half of all serial killers and repeat rapists.

Symptoms
• They lack of conforming to laws and repeatedly commit crimes
• Repeatedly deceitful in relationships
• Failure to think or plan ahead
• Tendency of irritability, anger and aggression
• Disregard for personal safety or safety for others.
• Persistant lack of taking responsibility
• Lack of guilt for any wrong activity
38
Causes Personality Disorders

Studies of adopted children indicate that both genetic and environmental factors
influence the development of this disorder. Both biological and adopted children
of people diagnosed with the disorder have an increased risk of developing it.
Children born to parents diagnosed with antisocial personality but adopted into
other families resemble their biological more than their adoptive parents. The
environment of the adoptive home, however, may lower the child’s risk of
developing the mentioned disorder.

Researchers have linked antisocial personality disorder to childhood physical or

sexual abuse,some undiagnosed neurological disorders and low IQ. But, as with
other personality disorders, no one has identified any specific cause or causes of
antisocial personality disorder. Persons diagnosed with antisocial personality
also have an increased incidence of somatisation and substance-related disorders.

Treatment
Antisocial personality disorder is highly unresponsive to any form of treatment,
in part because persons with antisocial personality disorder rarely seek treatment
voluntarily. There are medications that are effective in treating some of the
symptoms of the disorder, noncompliance with medication regimens or abuse of
the drugs prevents the widespread use of these medications. The most successful
treatment programs for this personality disorders are long-term structured
residential settings in which the patient systematically earns privileges as he or
she modifies behaviour. It is unlikely, however, that they would maintain good
behaviour if they left the disciplined environment. Unfortunately, these approaches
are rarely if ever effective. Many persons with this disorder use therapy sessions
to learn how to turn “the system” to their advantage.

2.5.2 Borderline Personality Disorder

Borderline personality disorder is a personality disorder described as a prolonged
disturbance of personality function in a person, characterised by depth and
variability of moods. The disorder typically involves unusual levels of instability
in mood; black and white thinking, or splitting; the disorder often manifests
itself in idealisation and devaluation episodes, as well as chaotic and unstable
interpersonal relationships, self-image, identity, and behaviour; as well as a
disturbance in the individual’s sense of self. In extreme cases, this disturbance in
the sense of self can lead to periods of dissociation.

This disorder splitting includes a switch between idealising and demonising

others. This, combined with mood disturbances, can undermine relationships
with family, friends, and co-workers. This disorder disturbances also may include
self-harm. Without treatment, symptoms may worsen, leading (in extreme cases)
to suicide attempts.

Symptoms
• Frantic efforts to avoid real or imagined abandonment
• A pattern of unstable and intense interpersonal relationships
• Identity disturbance,
• Impulsivity in at least two areas that are potentially self-damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating) 39
Severe Mental Disorders • Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour
• Emotional instability due to significant reactivity of mood Chronic feelings
of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights)
• Stress-related paranoid thoughts or severe dissociative symptoms
• Distortions in cognition.
Causes
It has been seen that borderline personality disorder develops as a result of
biological, genetic and environmental factors. There is strong evidence to support
a link between distressing childhood experiences, particularly involving
caregivers, and borderline personality disorder. The types of experiences that
may be associated with this disorder include, but are not limited to, physical and
sexual abuse, early separation from caregivers, emotional or physical neglect,
emotional abuse, and parental insensitivity.

In particular, studies have shown that a variation in a gene which controls the
way the brain uses serotonin (a natural chemical in the brain) may be related to
borderline personality disorder. It appears that individuals who have this specific
variation of the serotonin gene may be more likely to develop this disorder if
they also experience difficult childhood events (e.g., separation from supportive
caregivers). In addition, a number of studies have shown that people with this
disorder have differences in both the structure of their brain and in brain function.
Borderline personality disorder has been associated with excessive activity in
parts of the brain that control the experience and expression of emotion.

Treatment
i) Schema Focused Therapy: Schema focused therapy for this focuses on
confronting maladaptive beliefs that are developed as a result of early life
events.
ii) Mentalisation Based Therapy: Mentalisation based therapy for the disorder
focuses on helping the client to recognise mental states, such as thoughts,
feelings, and wishes, in themselves and in others.
iii) Transference Focused Psychotherapy: Transference focused psychotherapy
uses elements of the relationship between the client and the therapist to
help reduce the symptoms.
iv) Medications: Some of the most commonly prescribed medications for the
disorder include antidepressants, antipsychotics, anxiolytics (anti-anxiety),
and mood stabilisers/anticonvulsants. Other potential treatments, such as
omega-3-fatty acids, are also being explored.
v) Hospitalisation: BPD is associated with very intense emotional experiences.
As a result, people with BPD may need intensive BPD treatment.

2.5.3 Histrionic Personality Disorder

Histrionic personality disorder, often abbreviated as (HPD), is a type of personality
disorder in which the affected individual displays an enduring pattern of attention-
40
seeking and excessively dramatic behaviours beginning in early adulthood and Personality Disorders
present across a broad range of situations. Individuals with HPD are highly
emotional, charming, energetic, manipulative, seductive, impulsive, erratic, and
demanding.

It has a unique position among the personality disorders in that it is the only
personality disorder explicitly connected to a patient’s physical appearance.. Some
research has suggested that the connection between histrionic personality disorder
and physical appearance holds for women rather than for men. Both women and
men express a strong need to be the center of attention. Individuals with the
disorder exaggerate, throw temper tantrums, and cry if they are not the center of
attention. Cognitive style can be defined as a way in which an individual works
with and solves cognitive tasks such as reasoning, learning, thinking,
understanding, making decisions, and using memory.

Symptoms
• Center of attention
• Sexually seductive
• Shifting emotions
• Physical appearance.
• Speech style
• Dramatic behaviours
• Suggestibility
• Overestimation of intimacy
Causes
This disorder is not definitively known, it is thought that HPD may be caused by
biological, developmental, cognitive, and social factors. Neurotransmitters are
chemicals that communicate impulses from one nerve cell to another in the brain
and these impulses dictate behaviour.

The tendency towards an excessively emotional reaction to rejection, common

among patients with HPD, Most psychoanalysts agree that a traumatic childhood
contributes towards the development of HPD. Bio social issues also contribute
to the development of personality.

Socio cultural and personal variables have found some connections between the
age of individuals with HPD and the behaviour displayed by these individuals.
The symptoms of HPD are long-lasting; however, histrionic character traits that
are exhibited may change with age.

Treatment
i) Psychodynamic therapy
Like other personality disorders, may require several years of therapy and may
affect individuals throughout their lives. Some professionals believe that
psychoanalytic therapy is a treatment of choice for this disorder because it assists
patients to become aware of their own feelings. Long-term psychodynamic therapy
needs to target the underlying conflicts of individuals with HPD and to assist
patients in decreasing their emotional reactivity. 41
Severe Mental Disorders ii) Cognitive-behavioural therapy
Cognitive therapy is a treatment directed at reducing the dysfunctional thoughts
of individuals with this disorder. Such thoughts include themes about not being
able to take care of oneself. Cognitive-behavioural training in relaxation for an
individual with HPD emphasises challenging automatic thoughts about inferiority
and not being able to handle one’s life.

iii) Group therapy

Group therapy is suggested to assist individuals with HPD to work on
interpersonal relationships. Psychodrama techniques or group role play can assist
individuals with HPD.

iv) Family therapy

Family therapy can support family members to meet their own needs without
supporting the histrionic behaviour of the individual with HPD who uses dramatic
crises to keep the family closely connected.

v) Medications
Pharmacotherapy is not a treatment of choice for individuals with HPD unless
HPD occurs with another disorder.

vi) Alternative therapies

Meditation has been used to assist extroverted patients with this disorder to relax
and to focus on their own inner feelings. Some therapists employ hypnosis to
assist individuals with HPD to relax.

2.5.4 Narcissistic Personality Disorder

Narcissistic personality disorder is a condition characterised by an inflated sense
of self-importance, need for admiration, extreme self-involvement, and lack of
empathy for others. Individuals with this disorder are usually arrogantly self-
assured and confident. They expect to be noticed as superior. Many highly
successful individuals might be considered narcissistic. However, this disorder
is only diagnosed when these behaviours become persistent and very disabling
or distressing. The word “narcissism” comes from a Greek myth in which a
handsome young man named Narcissus sees his reflection in a pool of water and
falls in love with it.

Narcissistic personality disorder is one of a group of conditions called dramatic

People with these disorders have intense, unstable emotions and a distorted self-
image. Narcissistic personality disorder is further characterised by an abnormal
love of self, an exaggerated sense of superiority and importance, and a
preoccupation with success and power.

Symptoms
• Self centered and boastful
• Seek constant attention and admiration
• Considering ownselves better than others
• Exaggerate own talents and achievements
42 • Believing for own special treatments
• Setting unrealistic goal Personality Disorders

• Believing that you’re better than others

• Fantasizing about power, success and attractiveness
• Exaggerating your achievements or talents
• Expecting constant praise and admiration
• Failing to recognise other people’s emotions and feelings
• Expecting others to go along with your ideas and plans
• Taking advantage of others.
Causes
According to Freud concept that the root of narcissim lies from the childhood
itself. It starts with the problem in parent child relationship. Child grows out of
primary narcissism through opportunities to be mirrored by (i.e., gain approval
from) his or her parents and to idealise them, acquiring a more realistic sense of
self and a set of personal ideals and values through these two processes. On the
other hand, if the parents fail to provide appropriate opportunities for idealisation
and mirroring, the child remains “stuck” at a developmental stage in which his
or her sense of self remains grandiose and unrealistic while at the same time he
or she remains dependent on approval from others for self-esteem.

This also views that the disorder roots in the child’s defense against a cold and
unempathetic parent, usually the mother. Emotionally hungry and angry at the
depriving parents, the child withdraws into a part of the self that the parents
value, whether looks, intellectual ability, or some other skill or talent. This part
of the self becomes hyperinflated and grandiose. Any perceived weaknesses are
“split off” into a hidden part of the self. Splitting gives rise to a lifelong tendency
to swing between extremes of grandiosity and feelings of emptiness and
worthlessness. On the other dimension of disorder also count due to social and
historical context.

Treatment
i) Hospitalisation
The hospitalisation of patients with severe Narcissistic Personality occurs
frequently. For some, such as those who are quite impulsive or self-destructive,
or who have poor reality-testing, r. Hospitalisations should be brief, and the
treatment specific to the particular symptom involved.

ii) Psychosocial Treatment

i) Individual Psychotherapy: Most psychiatrists will, as a practical matter, treat
most of their severely narcissistic patients for symptoms related to crises
and relatively external. Positive transference and therapeutic alliance should
not be relied upon, since the patient may not be able to acknowledge the
real humanness of the therapist but may have to see him/her as either
superhuman or devalued
ii) Group Therapy: The goals are to help the patient develop a healthy
individuality (rather than a resilient narcissism) so that he or she can
acknowledge others as separate persons, and to decrease the need for self-
defeating coping mechanisms. 43
Severe Mental Disorders
2.6 TYPES OF PERSONALITY DISORDERS
CLUSTER C
2.6.1 Avoidant Personality Disorder
Anxious (Avoidant) Personality Disorder is a condition characterised by extreme
shyness, feelings of inadequacy, and sensitivity to rejection. These individuals
feel inferior to others. This disorder is only diagnosed when these behaviours
become persistent and very disabling or distressing. This diagnosis should be
used with great caution in children and adolescents for whom shy and avoidant
behaviour may be appropriate (e.g., new immigrants).

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition, Text Revision (DSM-IV-TR), avoidant personality disorder (APD) is
characterised by a pervasive pattern of social inhibition, feelings of inadequacy,
and hypersensitivity to negative evaluation. Individuals who meet the criteria for
avoidant personality disorder are often described as being extremely shy, inhibited
in new situations, and fearful of disapproval and social rejection.

Similar to other personality disorders, avoidant personality disorder becomes a

major component of a person’s overall character and a central theme in an
individual’s pattern of relating to others. Also similar to other personality
disorders, the diagnosis is rarely made in individuals younger than 18 years,
even if the criteria are met. The literature regarding childhood avoidant personality
disorder is extremely limited.

Symptoms
• Extreme shyness
• Sensitivity to criticism and rejection
• Low self-esteem and feelings of inadequacy
• A desire for closeness with others but difficulty forming relationships with
people outside of immediate family.
• Avoidance of social situations, including those related to school or work.
• Person avoids occupational activities
• Person is reluctant to participate in any social involvement.
• Person is preoccupied with criticized or rejected.
Causes
The cause of avoidant personality disorder is not clearly defined, and may be
influenced by a combination of social, genetic, and biological factors. Avoidant
personality traits typically appear in childhood, with signs of excessive shyness
and fear when the child confronts new people and situations.

These characteristics are also developmentally appropriate emotions for children,

however, and do not necessarily mean that a pattern of avoidant personality
disorder will continue into adulthood. Many persons diagnosed with avoidant
personality disorder have had painful early experiences of chronic parental
criticism and rejection.
44
The need to bond with the rejecting parents makes the avoidant person hungry Personality Disorders
for relationships but their longing gradually develops into a defensive shell of
self-protection against repeated parental criticisms.

Treatment
i) Psychodynamically oriented therapies: These approaches are usually
supportive; the therapist empathizes with the patient’s strong sense of shame
and inadequacy in order to create a relationship of trust. Therapy usually
moves slowly at first because persons with avoidant personality disorder
are mistrustful of others.
ii) Cognitive-behavioural therapy: Cognitive-behavioural therapy (CBT) may
be helpful in treating individuals with avoidant personality disorder. This
approach assumes that faulty thinking patterns underlie the personality
disorder, and therefore focuses on changing distorted cognitive patterns by
examining the validity of the assumptions behind them.
iii) Group therapy: It may provide patients with avoidant personality disorder
with social experiences that expose them to feedback from others in a safe,
controlled environment. They may, however, be reluctant to enter group
therapy due to their fear of social rejection.
iv) Family and marital therapy: Family or couple therapy can be helpful for a
patient who wants to break out of a family pattern that reinforces the avoidant
behaviour..
v) Medications: The use of monoamine oxidase inhibitors (MAOIs) has proven
useful in helping patients with avoidant personality disorder to control
symptoms of social unease and experience initial success.

2.6.2 Dependent Personality Disorder

Dependent personality disorder is one of a group of conditions called anxious
personality disorders, which are marked by feelings of nervousness and fear.
DPD also is marked by helplessness, submissiveness, a need to be taken care of
and for constant reassurance, and an inability to make decisions. This is one of
the most frequently diagnosed personality disorders. It appears to occur equally
in men and women, and usually appears in early to middle adulthood. It was
formerly known as asthenic personality disorder, is a personality disorder that is
characterised by a pervasive psychological dependence on other people. The
difference between a ‘dependent personality’ and a ‘dependent personality
disorder’ is somewhat subjective, which makes a diagnosis sensitive to cultural
influences such as gender role expectations.

Symptoms
• Chronic and pervasive pattern of dependent, submissive, and needy behaviour
• Seek out excessive advice, approval, and encouragement
• Sensitivity to criticism or rejection
• Low self-confidence and self-esteem.
• An inability to make decisions without direction from others
• Feelings of helplessness when alone
45
Severe Mental Disorders • An inability to disagree with others
• Extreme devastation when close relationships end and a need to immediately
begin a new relationship
• Difficulty in making everyday decisions.
Causes
It is commonly thought that the development of dependence in these individuals
is a result of over-involvement and intrusive behaviour by their primary caretakers.
Families of those with dependent personality disorder are often do not express
their emotions and are controlling; they demonstrate poorly defined relational
roles within the family unit.

Individuals with dependent personality disorder often have been socially

humiliated by others in their developmental years. They may carry significant
doubts about their abilities to perform tasks, take on new responsibilities, and
generally function independently of others. This reinforces their suspicions that
they are incapable of living autonomously.

Treatment
i) Psychodynamically oriented therapies
The preferred approach is a time-limited treatment plan consisting of a
predetermined number of sessions. This has been proved to facilitate the
exploration process of dependency issues more effectively than long-term therapy
in most patients.

ii) Cognitive-behavioural therapy

Cognitive-behavioural approaches attempt to increase the affected person’s ability
to act independently of others, improve their self-esteem, and enhance the quality
of their interpersonal relationships.

iii) Interpersonal therapy

Treatment using an interpersonal approach can be useful because the individual
is usually receptive to treatment and seeks help with interpersonal relationships.
The therapist would help the patient explore their long-standing patterns of
interacting with others, and understand how these have contributed to dependency
issues.

iv) Family and marital therapy

Individuals with dependent personality disorder are usually brought to therapy
by their parents. They are often young adults who are struggling with neurotic or
psychotic symptoms. Marital therapy can be productive in helping couples reduce
the anxiety of both partners who seek and meet dependency needs that arise in
the relationship.

v) Medications
Individuals with dependent personality disorder can experience anxiety and
depressive disorders as well. In these cases, it may occasionally prove useful to
use antidepressants or anti-anxiety agents.

46
2.6.3 Obsessive Compulsive Personality Disorder Personality Disorders

Obsessive-compulsive personality disorder (OCPD) is a type of personality

disorder marked by rigidity, control, perfectionism, and an overconcern with
work at the expense of close interpersonal relationships. Persons with this disorder
often have trouble relaxing because they are preoccupied with details, rules, and
productivity. They are often perceived by others as stubborn, stingy, self-righteous,
and uncooperative.

Symptoms
• Preoccupation with details, rules, lists, order, organisation, or schedules to
the point at which the major goal of the activity is lost.
• Excessive concern for perfection in small details that interferes with the
completion of projects.
• Dedication to work and productivity that shuts out friendships and leisure-
time activities, when the long hours of work cannot be explained by financial
necessity.
• Excessive moral rigidity and inflexibility in matters of ethics and values
that cannot be accounted for by the standards of the person’s religion or
culture.
Causes
Faulty parenting has been viewed as a major factor in the development of
personality disorders. Current studies have tended to support the importance of
early life experiences, finding that healthy emotional development largely depends
on two important variables: parental warmth and appropriate responsiveness to
the child’s needs. When these qualities are present, the child feels secure and
appropriately valued.

By contrast, many people with personality disorders did not have parents who
were emotionally warm toward them. Patients with OCPD often recall their
parents as being emotionally withholding and either overprotective or
overcontrolling. Children with this type of upbringing are also likely to choke
down the anger they feel toward their parents; they may be outwardly obedient
and polite to authority figures, but at the same time treat younger children or
those they regard as their inferiors harshly.

Genetic contributions to OCPD have not been well documented. Cultural

influences may, however, play a part in the development of OCPD.

Self Assessment Questions

1) What is antisocial personality disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
47
Severe Mental Disorders
2) Define antisocial personality disorder.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What is avoidant personality disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

2.7 LET US SUM UP

Thus personality disorder does not mean that some one’s personality is fatally
flawed or represent some freak behaviours, but in fact these disorders are not
very uncommon and deeply troubling and painful. Personality disorders cannot
be understood independently from healthy personalities. Everyone has a
personality and personality disorders reflect a variant form of normal healthy
personality. Thus personality disorder exists as a special case of a normal healthy
personality in much the same way as a square is a special case of the more general
construct of a rectangle. Recently many psychologists and psychiatrists felt that
sometimes treatment did not help people with a personality disorder, but specific
types of talk therapy have experienced more beneficial for improvement.

In this unit we discussed about the different personality disorders in terms of the
three clusters, viz., A, B, C, and each of these disorders were taken up and dealt
with in detail, in regard to symptomatology, causes and treatment of the disorders.

2.8 UNIT END QUESTIONS

1) Discuss personality disorders with its common symptoms.
2) Differentiate between antisocial and borderline personality disorder.
3) Discuss narcissist personality disorder with its symptoms and causes.
4) What are the general treatments necessary for personality disorders? Discuss.

2.9 SUGGESTED READINGS AND REFERENCES

Millon, Theodore and Seth, Grossman. (2002). Personality Disorders In Modern
Life ,John Wiley and Sons, NY

Dobbert, Duanne (2004). Understanding Personality Disorders: An Introduction

Praeger publisher Westport.
48
References Personality Disorders

Allen, J.G., Fonagy, P. (Eds.). (2006). The Handbook of Mentalisation Based

Treatment. Chicester: Wiley and Sons.

Alden, L. E., Laposa, J.M., Taylor, C.T., Ryder, A.G. (2002). Avoidant Personality
Disorder: Current Status and Future Directions. Journal of Personality Disorders,
16(1):1-29.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of

Mental Disorders (4th ed., Text Revision). Washington, DC: Author.

Bartz, J., Kaplan, A., Hollander, E. (2007). Obesessive Compulsive Personality

Disorder. In O’Donohue, W.T., Fowler, K.A., Lilienfeld, S.O. (Eds.). Personality
Disorders: Toward the DSM V. Thousand Oaks: Sage Publications.

49
Severe Mental Disorders
UNIT 3 PARAPHILIAS

Structure
3.0 Introduction
3.1 Objectives
3.2 Concept and Types of Paraphilias
3.2.1 Definition of Paraphilias
3.2.2 Types of Paraphilias
3.2.3 Causes of Paraphilias
3.2.4 Treatment for Paraphilias
3.3 Types of Paraphilias
3.3.1 Fetishism
3.3.2 Transvestism
3.3.3 Voyeurism
3.3.4 Exhibitionism
3.3.5 Sexual Sadism
3.3.6 Sexual Masochism
3.3.7 Pedophilia
3.3.8 Frotteurism
3.4 Let Us Sum Up
3.5 Unit End Questions
3.6 Suggested Readings and References

3.0 INTRODUCTION
Paraphilias are sometimes referred to as sexual deviations or perversions.
Paraphilias include fantasies, behaviours, or sexual urges focusing on unusual
objects, activities, or situations. Paraphilias include sexual urges or sexual
fantasies with non-human objects. It also involves humiliation or suffering of
oneself or another person. This rare disorder classified by DSM IV TR and
characterised by six month period of recurrent, intense, sexually arousing fantasies
or sexual urges involving a specific act depending on the paraphilia. The act is
commonly followed by arousal and orgasm usually achieved by masturbation
and fantasy. These are not very much recognised and often are difficult to treat
for several reasons. People who have these disorders conceal them; experience
guilt and shame have financial or legal problems and are generally uncooperative.
In this unit we will be discussing the paraphilias that is sexual deviations as an
abnormality and present the definitions and concepts of paraphilias. We will
then present the different types of paraphilias and how these are caused and what
types of treatment are available for the same.

3.1 OBJECTIVES
By the end of this unit, you will be able to:
• Define paraphilia;
• Enlist various types of paraphilia;
50
• Symptoms and causes of paraphilia; and Paraphilias

• Treatment approaches of paraphilia.

3.2 CONCEPT AND TYPES OF PARAPHILIAS

The paraphilias are a group of persistence sexual behaviour patterns in which
unusual objects, rituals or situations are required for full sexual satisfaction. The
difference between the normal and paraphilic persons is that sexuality focuses
on the acts or objects in question, without which orgasm is impossible.

Paraphilias have a compulsive quality, of orgasmic release 4 to 10 times a day.

They generally do not change their sexual preferences.

3.2.1 Definition of Paraphilias

Paraphilia (in Greek para ðáñÜ = beside and -philia öéëßá = friendship, having
the meaning of love) is a biomedical term used to describe sexual arousal to
objects, situations, or individuals that are not part of normative stimulation and
that may cause distress or serious problems for the paraphiliac or persons
associated with him or her. A paraphilia involves sexual arousal and gratification
towards sexual behaviour that is atypical and extremeNon-human objects.

The view of paraphilias as disorders is not universal. Some groups seeking greater
understanding and acceptance of sexual diversity have lobbied for changes to
the legal and medical status of unusual sexual interests and practices. In the
current version of the DSM (DSM-IV-TR), a paraphilia is not diagnosable as a
psychiatric disorder unless it causes distress to the individual or harm to others.

The DSM-5 draft adds a terminology distinction between the two cases, stating
that “paraphilias are not ipso facto psychiatric disorders”, and defining paraphilic
disorder as “a paraphilia that causes distress or impairment to the individual or
harm to others”.

Paraphilias are sexual feelings or behaviours that may involve sexual partners
that are not human, not consenting, or that involve suffering by one or both
partners.

According to the Diagnostic and Statistical Manual of Mental Disorders (known

as the DSM) fourth edition text revised ( DSM-IV-TR ), the manual used by
mental health professionals to diagnose mental disorders, it is not uncommon
for an individual to have more than one paraphilia.

3.2.2 Types of Paraphilias

The DSM-IV-TR lists the following paraphilias. The DSM-IV-TR also includes a
category for paraphilia not otherwise specified, which is the category for the less
common paraphilias, including necrophilia, zoophilia, and others.
The 8 different types of paraphilias are given below:
• Fetishism
• Transvestic fetishism
• Voyeurism
51
Severe Mental Disorders • Exhibitionism
• Sexual sadism
• Sexual masochism
• Pedophilia
• Fotteurism

3.2.3 Causes of Paraphilias

Almost all paraphilias are males.
Male vulnerability to paraphilias is linked to their greater dependency on visual
sexual imagery.
People with paraphilias have generally more than one paraphilia.
3.2.4 Treatment for Paraphilias
Treatment combining cognitive and behavioural elements appear relatively more
successful in treating this condition.

Aversion therapy is another treatment technique that seems to work effectively

for this condition. That is, aversive conditioning to deviant sexual fantasies.

Assisted covert sensitisation: This therapy involves having the patient imagine a
deviant sexual arousal scene. At the point where arousal is high, the patient
imagines aversive consequences and a foul odour is introduce via an open vial to
help condition a real aversion to these deviant ones.

3.3 TYPES OF PARAPHILIAS

As mentioned earlier there eight different types of paraphilias. Let us deal with
these one by one.

3.3.1 Fetishism
Sexual paraphilia, or sexual fetishism this is where Sexual arousal or pleasure is
derived from being robbed, conned, cheated, blackmailed or otherwise forced to
loose out fiscally by a partner or complete stranger.

The strong emotions of frustration, annoyance, rage, fear or submission are

subconsciously drawn upon by the person with Chremastistophilia and focused
into sexual arousal/gratification. This is seen as Edge play as it can be genuinely
life threatening to seek out a stranger to rob oneself purely for sexual release. In
recent years the genera of fetish websites focused at such people has grown
dramatically. It has been stated that financial dominants, chat with their ‘financial
submissives’ and talk about what the dominant will do with money ‘taken’ from
the submissive, etc., generally stir the strong emotions that fuel this paraphilia.

Symptoms
• Sexual arousal gained from wearing clothes of the opposite gender
• Sexual pleasure associated with wearing clothes of the opposite gender
• Recurring intense sexual fantasies involving wearing clothes of the opposite
gender
52
• Recurring intense sexual urges involving wearing clothes of the opposite Paraphilias
gender
• Recurring intense sexual behaviours involving wearing clothes of the
opposite gender

3.3.2 Transvestism
This is a practice of wearing the clothes of the opposite sex (cross-dressing),
generally to derive some kind of sexual pleasure. It is often mistakenly associated
with homosexuality; in fact, however, transvestites may be either heterosexual
or homosexual, and the practice of cross-dressing is sometimes even ridiculed
among homosexuals. The transvestite must also be distinguished from the
transsexual, who desires to become a functioning member of the opposite sex;
most transvestites are men who comfortably fill male roles in society and are
satisfied with their biological sex. Transsexuals, both male and female, are
uncomfortable with their sex .

Symptoms
Symptoms of transvestic fetishism mostly involve touching or wearing items of
clothing that are considered typically feminine. This initial interest may progress
to wearing undergarments or other items that can be hidden from the view of
others while providing arousal to the wearer.

Over time, the extent of dressing in women’s clothing expands, sometimes to

the point of dressing as a woman on a regular basis. A developed transvestic
fetish often involves feminine hair styling and the use of women’s cosmetics
and accessories.

In some persons diagnosed with transvestic fetishism, the motivation for cross-
dressing may change over time from a search for sexual excitement to simple
relief from stress, depression, or anxiety.

Causes
The basis for a transvestic fetish is obtaining sexual gratification by dressing in
clothing appropriate for the opposite sex. The cause may be adolescent curiosity.
A person with a transvestic fetish may not be aware of its roots. Transvestic
fetishism sometimes begins when a young boy dresses up in the clothes of an
older sister or his mother. The activity is continued because it is enjoyable but
the reasons for the enjoyment remain unconscious. In other cases a boy’s mother
may initiate the cross-dressing by dressing him as if he were a girl. This behaviour
is sometimes related to the mother’s anger at men or to a preference for having
daughters rather than sons.

Persons with transvestic fetishes should not be assumed to be homosexual.

According to DSM-IV-TR, most men who practice cross-dressing are basically
heterosexual in their orientation. Some, however, have occasional sexual
encounters with other men.

Treatment
In the earliest period of behaviour therapy, transvestic fetishes were narrowly
viewed as inappropriate behaviour that was confined to a limited range of
situations, and were sometimes treated with aversion therapy. This approach
53
Severe Mental Disorders was largely unsuccessful. Persons with fetishes have also been treated by using
a form of behavioural therapy known as orgasmic reorientation, which attempts
to help people learn to respond sexually to culturally appropriate stimuli. This
treatment also has had limited success.

Most persons who have a transvestic fetish never seek treatment from
professionals. Most are capable of achieving sexual gratification in culturally
appropriate situations. Their preoccupation with cross-dressing is viewed as
essentially harmless to other persons, since transvestism is not associated with
criminal activities or forcing one’s sexual preferences on others. As of 2002,
American society has developed tolerance for transvestites, thus further reducing
the demand for professional treatment.

3.3.3 Voyeurism
This comes from a French term voyeur, “one who looks”) can take several forms,
but its principal characteristic is that the voyeur does not normally relate directly
with the subject of their interest, who is often unaware of being observed.
Voyeurism is a psychosexual disorder in which a person derives sexual pleasure
and gratification from looking at the naked bodies and genital organs or observing
the sexual acts of others. The voyeur is usually hidden from view of others.
Voyeurism is a form of paraphilia.

A variant form of voyeurism involves listening to erotic conversations. This is

commonly referred to as telephone sex, although it is usually considered
voyeurism primarily in the instance of listening to unsuspecting persons.

The object of voyeurism is to observe unsuspecting individuals who are naked,

in the process of undressing or engaging in sexual acts. The person being observed
is usually a stranger to the observer. The act of looking or peeping is undertaken
for the purpose of achieving sexual excitement. The observer generally does not
seek to have sexual contact or activity with the person being observed.

Frequently, a voyeur may have a fantasy of engaging in sexual activity with the
person being observed. In reality, this fantasy is rarely consummated.

Symptoms
• Recurrent, intense or sexually arousing fantasies, sexual urges, or behaviours
• Fantasies, urges, or behaviours that cause significant distress to an individual
or are disruptive of his or her everyday functioning.
• Over a period of at least 6 months, recurrent, intense sexually arousing
fantasies, sexual urges, or behaviours involving the act of observing an
unsuspecting person who is naked, in the process of disrobing, or engaging
in sexual activity.
• The fantasies, sexual urges, or behaviours cause clinically significant distress
or impairment in social, occupational, or other important areas of functioning.
Causes
There is no scientific consensus concerning the basis for voyeurism. Most experts
attribute the behaviour to an initially random or accidental observation of an
unsuspecting person who is naked, in the process of disrobing, or engaging in
54
sexual activity. Successive repetitions of the act tend to reinforce and perpetuate Paraphilias
the voyeuristic behaviour.

Treatment
For treatment to be successful, a voyeur must want to modify existing patterns
of behaviour. This initial step is difficult for most voyeurs to admit and then
take. Most must be compelled to accept treatment. This may often be the result
of a court order.

Behavioural therapy is commonly used to try to treat voyeurism. The voyeur

must learn to control the impulse to watch non-consenting victims, and just as
importanly to acquire more acceptable means of sexual gratification. Outcomes
of behavioural therapy are not known. There are no direct drug treatments for
voyeurism.

Voyeurism is a criminal act in many jurisdictions. It is usually classified as a

misdemeanor. As a result, legal penalties are often minor. The possibility of
exposure and embarrassment may deter some voyeurs. It is also not easy to
prosecute voyeurs as intent to watch is difficult to prove. In their defense
statements, they usually claim that the observation was accidental.

3.3.4 Exhibitionism
Exhibitionism, colloquially referred to flashing, is behaviour by a person that
involves the exposure of private parts of his or her body to another person in a
situation when they would not normally be exposed, such as in a public place,
with a tendency toward an extravagant.

Exhibitionism is described in the DSM-IV-TR as the exposure of one’s genitals

to a stranger, usually with no intention of further sexual activity with the other
person. For this reason, the term exhibitionism is sometimes grouped together
with expression, “voyeurism,” (“peeping,” or watching an unsuspecting person
or people, usually strangers, undressing or engaging in sexual activity) as a “hands-
off” paraphilia.

This contrasts with the “hands on disorders” which involve physical contact
with other persons. The act may be at least partially sexual or intended to attract
the attention of another or others, or to shock. Some people have a psychological
compulsion to sexually expose themselves.

The condition is sometimes called apodysophilia. In some situations exposing in

public is a crime of indecent exposure or public nuisance. Though the offense is
not often prosecuted, it is considered serious when the flasher is a man. Public
exhibitionism by women has been recorded since classical times, often in the
context of women shaming groups of men into committing, or inciting them to
commit, some public action.

In some cases, the exhibitionist masturbates while exposing himself (or while
fantasizing that he is exposing himself) to the other person.

Some exhibitionists are aware of a conscious desire to shock or upset their target;
while others fantasize that the target will become sexually aroused by their display.

55
Severe Mental Disorders Types of exposure
i) Anasyrma: The lifting of the skirt when not wearing underwear, to expose
genitals.
ii) Flashing: Chiefly the momentary display of bare female breasts by a woman
with an up-and-down lifting of the shirt and/or bra. It can also involve the
exposure of a man’s or woman’s genitalia.
iii) Martymachlia: A paraphilia which involves sexual attraction to having
others watch the execution of a sexual act.
iv) Mooning: The display of bare buttocks by pulling down of trousers and
underwear. There tends to be a gendered double standard here: with males,
the act is most often done for the sake of humor, disparagement, and/or
mockery than for sexual excitement, whereas with females, the reverse tends
to be true, and sexual arousal (or at least sexual attention) of those mooned
is the intent.
v) Streaking: The act of running nude through a public place.
vi) Candaulism: When a person exposes their partner in a sexually explicit
manner.
Symptoms
These symptoms can be mild, moderate or severe or catastrophic and these are
explained below.
i) Mild: The person has recurrent fantasies of exposing himself, but has rarely
or never acted on them.
ii) Moderate: The person has occasionally exposed himself (three targets or
fewer) and has difficulty controlling urges to do so.
iii) Severe: The person has exposed himself to more than three people and has
serious problems with control.
A fourth level of severity, catastrophic, would not be found in exhibitionists
without other paraphilias. This level denotes the presence of sadistic fantasies
which, if acted upon, would result in severe injury or death to the victim.

Because exhibitionism is a hands-off paraphilia, it rarely rises above the level of

moderate severity in the absence of other paraphilias.

Causes
i) Biological theories: These generally hold that testosterone, the hormone
that influences the sexual drive in both men and women, increases the
susceptibility of males to develop deviant sexual behaviours. Some
medications used to treat exhibitionists are given to lower the patients’
testosterone levels.
ii) Learning theories: Several studies have shown that emotional abuse in
childhood and family dysfunction are both significant risk factors in the
development of exhibitionism.
iii) Psychoanalytical theories: These are based on the assumption that male
gender identity requires the male child’s separation from his mother
psychologically so that he does not identify with her as a member of the
56
 same sex, the way a girl does. It is thought that exhibitionists regard their Paraphilias
mothers as rejecting them on the basis of their different genitals. Therefore,
they grow up with the desire to force women to accept them by making
women look at their genitals.
iv) Head trauma: There are a small number of documented cases of men
becoming exhibitionists following traumatic injury (TBI) without previous
histories of alcohol abuse or sexual offenses.
A childhood history of attention-deficit/hyperactivity disorder (ADHD). The
reason for the connection is not yet known, but researchers at Harvard have
discovered that patients with multiple paraphilias have a much greater likelihood
of having had ADHD as children than men with only one paraphilia.

Treatments
Psychotherapy
Several different types of psychotherapy have been found helpful in treating
exhibitionism:
Cognitive-behavioural therapy (CBT): This approach is generally regarded as
the most effective form of psychotherapy for exhibitionism. Patients are
encouraged to recognise the irrational justifications that they offer for their
behaviour, and to alter other distorted thinking patterns.
Orgasmic reconditioning: In this technique, the patient is conditioned to replace
fantasies of exposing himself with fantasies of more acceptable sexual behaviour
while masturbating.
Group therapy
Couples therapy
Medications
Selective serotonin reuptake inhibitors (SSRIs). The SSRIs show promise in
treating the paraphilias, as well as depression and other mood disorders. It has
been found that decreased levels of serotonin in the brain result in an increased
sex drive.
The SSRIs are appropriate for patients with mild- or moderate-level paraphilias;
these patients include the majority of exhibitionists.
Female hormones. Estrogens have been used to treat sexual offenders since the
1940s. Medroxyprogesterone acetate, or MPA, is the most widely used hormonal
medication in the U.S. for the treatment of people with exhibitionism..

3.3.5 Sexual Sadism

The essential feature of sexual sadism is a feeling of sexual excitement resulting
from administering pain, suffering, or humiliation to another person. The pain,
suffering, or humiliation inflicted on the other is real; it is not imagined and may
be either physical or psychological in nature. A person with this disorder is also
called as a sadist.
The name of the disorder is derived from the proper name of the Marquis Donatien
de Sade (1740-1814), a French aristocrat who became notorious for writing novels
around the theme of inflicting pain as a source of sexual pleasure.
57
Severe Mental Disorders Symptoms
Individuals with sexual sadism derive sexual excitement from physically or
psychologically administering pain, suffering, and/or humiliation to another
person, who may or may not be a consenting partner.

A description of symptoms related to Sexual Masochism and Sadism, recurrent,

intense sexually arousing fantasies, sexual urges, or behaviours involving the
act (real, not simulated) of being humiliated, beaten, bound, or otherwise made
to suffer.

Difficulty with sleep, such as difficulty falling asleep, restless, broken sleep, a
need for more sleep or, over sleeping.

A change in appetite either eating more or eating less.

The disorder is characterised by either intense sexually arousing fantasies, urges,

or behaviours in which the individual is sexually aroused by causing humiliation
or physical suffering of another person.

Causes
There is no such cause or theory explaining the origin of sexual sadism, or of
sadomasochism. Some researchers attempt to explain the presence of sexual
paraphilias in general as the result of biological factors. Evidence for this
viewpoint comes from abnormal findings from neuropsychological and
neurological tests of sex offenders.

It is also believed that brain injury, schizophrenia or any other mental disorders
often lead to sexual disorders. Another theory about paraphilias is derived from
learning theory. It suggests that paraphilias develop because the person is required
to suppress, or squelch the inappropriate sexual fantasies.

Because the fantasies are not acted out initially, the urge to carry them out
increases. When the person finally acts upon the fantasies, they are in a state of
considerable distress and/or arousal.

Rather than suppressing fantasies, most people who are eventually arrested for
crimes involving sexual sadism begin with milder forms of acting on them and
progressing to more harmful ways of acting out. In other words, the severity of
sadistic acts tends to increase over time.

Treatment
i) Behaviour therapy
This is mostly used to treat paraphilias. This approach to treatment includes the
management and conditioning of arousal patterns and masturbation. Therapies
involve cognitive restructuring, social skill training.

ii) Medication
This may be used to reduce fantasies and behaviour relating to paraphilias. This
form of treatment is especially recommended for people who exhibit sadistic
behaviours that are dangerous to others. The medications that may be used include
female hormones (most commonly medroxyprogesterone acetate, or MPA), which
58
speed up the clearance of testosterone from the bloodstream. Also, antiandrogen Paraphilias
medications, which block the body’s uptake of testosterone. and the selective
serotonin reuptake inhibitors, or SSRIs.

Treatment of sexual sadism may also be complicated by health problems related

to sexual behaviour. Sexually transmitted diseases and other medical problems
may be present, especially when the sadistic behaviour involves the release of
blood or other body fluids.

3.3.6 Sexual Masochism

The essential feature of sexual masochism is the feeling of sexual arousal or
excitement resulting from receiving pain, suffering, or humiliation. The pain,
suffering, or humiliation is real and not imagined and can be physical or
psychological in nature. A person with sexual masochism is sometimes called a
masochist. Sexual masochism falls under the psychiatric sexual disorders category
of paraphilias, meaning “abnormal or unnatural attraction.”

Sexual masochism refers to engaging in or frequently fantasizing about being

beaten, bound, or otherwise made to suffer, resulting in sexual satisfaction.
Blindfolding, spanking and humiliation in the form of defecation, urination, etc.
are methods used by these patients. Masochists may inflict their own pain through
shocking, pricking or choking.

Approximately 30 percent of paraphilic patients also participate in sadistic

behaviour.

One particularly dangerous method is called hypoxyphilia (near-asphyxiation)

caused by reducing oxygen level in the brain. This results in the accidental death
of one or two per million people per year. To achieve near-asphyxiation,
masochists might place a noose around their necks, chest compression, put airtight
bags over their heads or use amyl nitrates (“poppers”).

Symptoms
Individuals with sexual masochism experience sexual excitement from physically
or psychologically receiving pain, suffering, and/or humiliation. They may be
receiving the pain, suffering, or humiliation at the hands of another person, who
may or may not be a sadist, or they may be administering the pain, suffering, or
humiliation themselves.

They experience distressed or impaired functioning because of the masochistic

behaviours, urges, and fantasies.

Causes
There is no such accepted cause or theory explaining the origin of sexual
masochism, or sadomasochism in general. However, there are some theories
that attempt to explain the presence of sexual paraphilias in general. One theory
is based on learning theory that paraphilias originate because inappropriate sexual
fantasies are suppressed. Because they are not acted upon initially, the urge to
carry out the fantasies increases and when they are finally acted upon, a person is
in a state of considerable distress and/or arousal. In the case of sexual masochism,
masochistic behaviour becomes associated with and inextricably linked to sexual
behaviour.
59
Severe Mental Disorders There is also a belief that masochistic individuals truly want to be in the
dominating role.

This causes them to become conflicted and thus submissive to others.

Another theory suggests that people seek out sadomasochistic behaviour as a

means of escape.

They get to act out fantasies and become new and different people.

Treatments
i) Behaviour therapy
This is often used to treat paraphilias. This can include management and
conditioning of arousal patterns and masturbation. Therapies involving cognitive
restructuring etc.

ii) Medication
This is also used to reduce fantasies and behaviour relating to paraphilias. This
is especially true of people who exhibit severely dangerous masochistic
behaviours.

Treatment can also be complicated by health problems relating to sexual

behaviour. Sexually transmitted diseases and other medical problems, especially
when the sadomasochistic behaviour involves the release of blood, can be present.
Also, people participating in hypoxyphilia and other dangerous behaviours can
suffer extreme pain and even death.

3.3.7 Pedophilia
It is typically defined as a psychiatric disorder in adults or late adolescents (persons
age 16 and older). It is characterised by a primary or exclusive sexual interest in
prepubescent children (generally age 13 years or younger, though onset of puberty
may vary).

The child must be at least five years younger in the case of adolescent pedophiles.
The word comes from the Greek: ðá?ò (paîs), meaning “child,” and öéëßá (philía),
“friendly love” or “friendship”.

Though this literal meaning has been altered toward sexual attraction in modern
times, under the titles “child love” or “child lover”, by pedophiles who use
symbols and codes to identify their preferences.

The International Classification of Diseases (ICD) defines pedophilia as a

“disorder of adult personality and behaviour” in which there is a sexual preference
for children of prepubertal or early pubertal age.

The term has a range of definitions as found in psychiatry, psychology, the

vernacular, and law enforcement.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM),

pedophilia is a paraphilia in which a person has intense and recurrent sexual
urges towards and fantasies about prepubescent children and on which feelings
they have either acted or which cause distress or interpersonal difficulty.
60
The current DSM-5 draft proposes to add hebephilia to the diagnostic criteria, Paraphilias
and consequently to rename it to pedohebephilic disorder. Although most
pedophiles are men, there are also women who exhibit the disorder. In popular
usage, pedophilia means any sexual interest in children or the act of child sexual
abuse, often termed “pedophilic behaviour”.

Pedophilia was first formally recognised and named in the late 19th century. A
significant amount of research in the area has taken place since the 1980s. At
present, the exact causes of pedophilia have not been conclusively established.
Research suggests that pedophilia may be correlated with several different
neurological abnormalities, and often co-exists with other personality disorders
and psychological pathologies. In the contexts of forensic psychology and law
enforcement, a variety of typologies have been suggested to categorize pedophiles
according to behaviour and motivations.

Symptoms
A pedophile is often very attractive to the children who are potential victims.
Potential pedophiles may volunteer their services to athletic teams, Scout troops,
or religious or civic organisations that serve youth. In some cases, pedophiles
who are attracted to children within their extended family may offer to baby-sit
for their relatives. They often have good interpersonal skills with children and
can easily gain the children’s trust.

Some pedophiles offer rationalisations or excuses that enable them to avoid

assuming responsibility for their actions. They may blame the children for being
too attractive or sexually provocative. They may also maintain that they are
“teaching” the child about “the facts of life” or “love”; this rationalisation is
frequently offered by pedophiles who have molested children related to them.
All these rationalisations may be found in pornography with pedophilic themes.

Causes
A variety of different theories exist as to the causes of pedophilia. A few
researchers attribute pedophilia along with the other paraphilias to biology. They
hold that testosterone, one of the male sex hormones, predisposes men to develop
deviant sexual behaviours. As far as genetic factors are concerned, as of 2002 no
researchers have claimed to have discovered or mapped a gene for pedophilia.

Some regard pedophilia as the result of a distorted need to dominate a sexual

partner. Since children are smaller and usually weaker than adults, they may be
regarded as nonthreatening potential partners. This drive for domination is
sometimes thought to explain why most pedophiles are males.

Treatments
In the earliest stages of behaviour modification therapy, pedophiles may be
narrowly viewed as being attracted to inappropriate persons. Such aversive stimuli
as electric shocks have been administered to persons undergoing therapy for
pedophilia. This approach has not been very successful.

In 2002, the most common form of treatment for pedophilia was psychotherapy.
It does not have a high rate of success in inducing pedophiles to change their
behaviour.
61
Severe Mental Disorders Pedophilia may also be treated with medications. The three classes of medications
most often used to treat pedophilia (and other paraphilias) are: female hormones,
particularly medroxyprogesterone acetate, or MPA; luteinising hormone-releasing
hormone (LHRH) agonists, which include such drugs as triptorelin (Trelstar),
leuprolide acetate, and goserelin acetate; and anti-androgens, which block the
uptake and metabolism of testosterone as well as reducing blood levels of this
hormone.

Most clinical studies of these drugs have been done in Germany, where the legal
system has allowed their use in treating repeat sexual offenders since the 1970s.
The anti-androgens in particular have been shown to be effective in reducing the
rate of recidivism.

3.3.8 Frotteurism
It refers to a paraphilic interest in rubbing, usually one’s pelvis or erect penis,
against a non consenting person for sexual gratification. It may involve touching
any part of the body including the genital area.

A person who practices frotteurism is known as a frotteur. The majority of frotteurs

are male and the majority of victims are female, although female on male, female
on female, and male on male frotteurs exist. Adult on child frotteurism can be an
early stage in child sexual abuse.

This activity is often done in circumstances where the victim cannot easily
respond, in a public place such as a crowded train or concert.

Usually, such nonconsensual sexual contact is viewed as a criminal offense: a

form of sexual assault albeit often classified as a misdemeanor with minor legal
penalties. Conviction may result in a sentence or psychiatric treatment.

Symptoms
The primary focus of frotteurism is touching or rubbing one’s genitals against
the clothing or body of a nonconsenting person. This behaviour most often occurs
in situations that allow rapid escape. Frottage (the act of rubbing against the
other person) is most commonly practiced in crowded places such as malls,
elevators, on busy sidewalks, and on public transportation vehicles.

The most commonly practiced form of frotteurism is rubbing one’s genitals against
the victim’s thighs or buttocks. A common alternative is to rub one’s hands over
the victim’s genitals or breasts.

Most people who engage in frottage (sometimes called frotteurs) usually fantasize
that they have an exclusive and caring relationship with their victims during the
moment of contact. However, once contact is made and broken, the frotteur
realises that escape is important to avoid prosecution.

Recurrent, intense, or sexually arousing fantasies, sexual urges, or behaviours

that involve touching and rubbing against a nonconsenting person.

The person has acted on these sexual urges, or the fantasies or urges cause
significant distress to the individual or are disruptive to his everyday functioning.

62
Causes Paraphilias

There is no scientific consensus concerning the cause of frotteurism. Most experts

attribute the behaviour to an initially random or accidental touching of another’s
genitals that the person finds sexually exciting. Successive repetitions of the act
tend to reinforce and perpetuate the behaviour.

Treatments
For treatment to be successful, the frotteur must modify existing patterns of
behaviour. This initial step is difficult for most people with this disorder to take.

Behaviour therapy is commonly used to try to treat frotteurism. The frotteur must
learn to control the impulse to touch nonconsenting victims. Medroxyprogesterone,
a female hormone, is sometimes prescribed to decrease sexual desire.

Frotteurism is a criminal act in many jurisdictions. It is usually classified as a

misdemeanor. As a result, legal penalties are often minor. It is also not easy to
prosecute frotteurs as intent to touch is difficult to prove. In their defense
statements, the accused often claim that the contact was accidental.

Self Assessment Questions

1) What is paraphilia?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Enlist major types of paraphilia
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What is exhibitionsim?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
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63
Severe Mental Disorders
4) Describe in detail the eight types of paraphilias.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
5) Discuss the causes, symptoms and treatment for pedophilia and
frotteurism.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

3.4 LET US SUM UP

In this unit we have defined paraphilias and discussed the eight types of
paraphilias. We have presented the symptoms for each paraphilia, along with
causes and treatment for the same. Most paraphilias seem to be treated more by
behaviour modification and cognitive behaviour therapy. Generally it has been
found that they do not come for treatment on their own, but sometimes being
forced by the court or by the law or by their relatives or neighbours who would
have been a victim. As for the causes of paraphilias in general, one has to
understand the sexual preferences as well as it has been noited that basically the
problem is biological in nature. The biological perspectives receives the most
attention and focuses as a main cause for deviation. Each of the perspectives
have something to offer understanding the paraphilias. It is because many of the
paraphilic types behaviour are being carried out in private areas and come to
public attention. Conventional psychotherapy is ineffective but biological
treatments involve female hormonal treatment which have been used with benefits
on a long term basis. In some cases, desensitisation has proved useful for the
cases.

3.5 UNIT END QUESTIONS

1) What are paraphilias? Why does it occur?
2) What are the various symptoms of paraphilias?
3) What are the different types of paraphilias?
4) Enumerate the causes, symptoms and treatment of fetishism and voyeurism.
5) What are the symptoms, causes and treatment of transvestism and pedophilia?
6) Why it is psychotherapy is not effective in most of the paraphilia cases?
64 Discuss.
 Paraphilias
3.6 SUGGESTED READINGS AND REFERENCES
Hickey , Eric, W. (2005). Sex Crimes and Paraphilia Sage Publicartion, NY.

Holmes, R.M. (2007). Sex Crimes and Paraphilia. Prentice Hall, London.

Medline World Health Organisation. The International Statistical Classification

of Diseases and Health Related Problems, Tenth Revision. 2nd ed. World Health
Organisation; 2004.

References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric
Association; 2000:566 - 576.

Sartorius A, Ruf M, Kief C, Demirakca T, Bailer J, Ende G. Abnormal amygdala

activation profile in pedophilia. Eur Arch Psychiatry Clin
Neurosci. Aug 2008;258(5):271-7.

Andersen ML, Poyares D, Alves RS, Skomro R, Tufik S. Sexsomnia: abnormal

sexual behaviour during sleep. Brain Res Rev. Dec 2007;56(2):271-82.

Cowell DD. Autoerotic asphyxiation: secret pleasure—lethal

outcome?. Pediatrics. Nov 2009;124(5):1319-24.

Abdo CH, Hounie A, de Tubino Scanavino M, Miguel EC. OCD and transvestism:
is there a relationship?. Acta Psychiatr Scand. Jun 2001;103(6):471-3; discussion
473.

Abouesh A, Clayton A. Compulsive voyeurism and exhibitionism: a clinical

response to paroxetine. Arch Sex Behav. Feb 1999;28(1):23-30.

Allgeier AR, Allgeier ER. Atypical sexual activity. In: Miller J, Brooks CL,
Rachlin H, O’Dea M, Michaels T, Roll M. Sexual Interactions. 2 nd
ed. Canada: D.C. Heath & Company; 1988:619-641/ 21.

Allnutt SH, Bradford JM, Greenberg DM, Curry S. Co-morbidity of alcoholism

and the paraphilias. J Forensic Sci. Mar 1996.

65
Severe Mental Disorders
UNIT 4 MOOD DISORDERS (BIPOLAR,
MAJOR DEPRESSION)

Structure
4.0 Introduction
4.1 Objectives
4.2 Concept and Definition of Mood Disorders
4.3 Major Depression
4.3.1 Biological Factors
4.3.2 Atypical Depression
4.3.3 Melancholic Depression
4.3.4 Psychotic Major Depression
4.3.5 Catatonic Depression
4.3.6 Postpartum Depression
4.3.7 Seasonal Affective Disorder
4.3.8 Symptoms of Depression
4.4 Causes of Depression
4.4.1 Genetic Risk Factor for Depression
4.4.2 Psychosocial and Environmental Risk Factor for Depression
4.4.3 Age and Depression Risk
4.4.4 Gender and Depression Risk
4.4.5 Race and Class and Depression Risk
4.4.6 Anxiety
4.4.7 Medical Illness
4.5 Treatment
4.6 Dysthymic Disorder
4.6.1 Symptoms
4.6.2 Causes
4.6.3 Treatment
4.7 Bipolar Disorder I
4.7.1 Symptoms of Bipolar Disorder I
4.7.2 Causes of Bipolar Disorder I
4.7.3 Treatment of Bipolar Disorder I
4.8 Bipolar Disorder II
4.8.1 Symptoms of Bipolar Disorder II
4.8.2 Causes of Bipolar Disorder II
4.8.3 Treatment of Bipolar Disorder II
4.9 Cyclothymic Disorder
4.9.1 Symptoms
4.9.2 Hypomanic Phase of Cyclothymic Disorder
4.9.3 Depressive Phase of Cyclothymic Disorder
4.9.4 Treatment of Cyclothymic Disorder
4.10 Substance Induced Mood Disorder
4.10.l Causes of Substance Induced Mood Disorder
4.10.2 Treatment of Substance Induced Mood Disorder
66
4.11 Mood Disorder of General Medical Condition Mood Disorders (Bipolar,
Major Depression)
4.11.1 Symptoms
4.11.2 Causes
4.11.3 Treatment
4.12 Let Us Sum Up
4.13 Unit End Questions
4.14 Suggested Readings and References

4.0 INTRODUCTION
Mood disorders are characterised by a disturbance in the regulation of mood,
behaviour, and affect. Mood disorders are subdivided into (1) depressive disorders,
(2) bipolar disorders, and (3) depression in association with medical illness or
alcohol and substance abuse. All disorders are differentiated from bipolar disorders
by the absence of a manic or hypomanic episode. The World Health Organisation,
(WHO) specified that, unipolar major depression ranked fourth among all diseases
in terms of disability adjusted life years and was projected to rank second by
year 2020.
Mood disorders, also called affective disorders, are a group of illnesses that have
as their distinguishing characteristic, an experience of mood that is unusual for
the circumstances. Most mood disorders are at least somewhat treatable with
drugs and psychotherapy.
In many cases, the root cause of the disorder may be some type of chemical
imbalance that is affecting the function of the thyroid or causing the brain to not
produce the correct ratio of different neurotransmitters. Mood disorders with
this type of origin can often be corrected with the use of medication, sometimes
coupled with nutritional supplements.
In this unit we will be dealing with mood disorders, their definition, their types,
symptoms and causes. For each of the mood disorders, the treatment will also be
presented.

4.1 OBJECTIVES
On completing this unit, you will be able to:
• Define mood disorders;
• Elucidate various types of mood disorders;
• Describe the Symptoms of various mood disorders;
• Elucidate the causes of mood disorders; and
• Analyse the Interventional approaches used in mood disorders.

4.2 CONCEPT AND DEFINITION OF MOOD

DISORDERS
Mood disorders are defined as a group of mental disorders involving a disturbance
of mood along with either a full or partial excessively happy or extremely sad
syndrome not caused by any other physical or mental disorder. It refers to a
prolonged emotion. 67
Severe Mental Disorders Thus it can be said that mood disorders are combination of sometimes happiness
and sadness. It is the emotional outbursts of the individuals.

The American Heritage dictionary called any of a group of psychiatric disorders

including depression and bipolar disorder, characterised by a pervasive disturbance
of mood that is not caused by an organic abnormality. Also this syndrome is
called affective disorder. This definition clarifies that mood disorders are merely
caused by disturbances in life.

Thus a variety of conditions characterised by a disturbances in mood which may

be mild to severe and contains signs of major depressive disorder or dysthymic
reaction or a symptoms of bipolar disorder. It is termed by DSM IV (R) as mood
disorder. It is the most common diagnoses in psychiatry and is persistently
emotional .

The best available evidence suggests that mood disorders lie on a continuum
with normal mood. Although mania and depression are often viewed as opposite
ends of the mood spectrum, they can occur simultaneously in a single individual
within a brief period, giving rise to the concept of mixed mood states.

As per Diagnostic and Statistical Manual of Mental Disorders, 4th edition, The
major categories of mood disorders are:
• Unipolar Mood Disorders
• Major depressive disorders
• Dysthymic disorder
• Bipolar mood disorders
• Bipolar I disorder,
• Bipolar II disorder
• Cyclothymic disorder
• Substance Induced Mood Disorder
• Mood Disorder of General Medical Condition
Thus the essential feature of disorders in this category is that all of them reflect
a disturbances in mood or emotional reaction that is not due to any other physical
or mental disorder. When an individual suffers from a mood disorder, their ability
to function and lead a productive and full life may suffer. Some emotional shifts
are normal, especially as a reaction to current events, such as the death of a loved
one. However, if the individual experiences depression that lingers with no
obvious cause or elation that seems out of balance with her life, she may have a
mood disorder.
Self Assessment Questions
1) Define mood disorder
...............................................................................................................
...............................................................................................................
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68
 Mood Disorders (Bipolar,
2) What are the characteristic features of mood disorders? Major Depression)
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What are the symptoms of mood disorders?
...............................................................................................................
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...............................................................................................................
...............................................................................................................
4) What are the major categories of mood disorders?
...............................................................................................................
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...............................................................................................................

4.3 MAJOR DEPRESSION

It also known as recurrent depressive disorder, clinical depression, major
depression, or unipolar disorder. This mental disorder is characterised by an all
low mood accompanied by low self esteem, and by loss of interest or pleasure in
normally enjoyable activities. The term “depression” is ambiguous. Major
depressive disorder is a disabling condition which adversely affects a person’s
family, work or school life, sleeping and eating habits, and general health.

The understanding of the nature and causes of depression has evolved over the
centuries, though this understanding is incomplete and has left many aspects of
depression as the subject of discussion and research. Proposed causes include
psychological, psycho-social, hereditary, evolutionary and biological factors.

Certain types of long-term drug use can both cause and worsen depressive
symptoms. Psychological treatments are based on theories of personality,
interpersonal communication, and learning.

4.3.1 Biological Factors

Most biological theories focus on the monoamine chemicals serotonin,
norepinephrine and dopamine, which are naturally present in the brain and assist
communication between nerve cells. This disorder may begin at any age, with an
average age at onset in the mid-20s. 69
Severe Mental Disorders Some individuals have isolated episodes that are separated by many years without
any depressive symptoms, whereas others have clusters of episodes, and still
others have increasingly frequent episodes as they grow older. After the first
episode of this disorder, there is a 60% chance of having a second episode. After
the second episode, there is a 70% chance of having a third, and after the third
episode, there is a 90% chance of having a fourth.
About 5%-10% of individuals with this disorder subsequently develop Bipolar I
Disorder. The acute onset of severe depression, especially with psychotic features
and psychomotor retardation, in a young person without prepubertal
psychopathology is more likely to predict a bipolar course.
A family history of Bipolar Disorder may also be suggestive of subsequent
development of Bipolar Disorder. In two-thirds of cases, the Major Depressive
Episode ends with complete recovery. For individuals that have only a partial
recovery, there is a greater likelihood of developing additional episodes of this
disorder and of continuing the pattern of partial interepisode recovery.
Individuals who have pre existing Dysthymic Disorder prior to the onset of this
disorder are more likely to have additional Major Depressive Episodes, have
poorer inter episode recovery, and also face more difficulty to treat Major
Depressive Episodes.
One year after the diagnosis of this disorder, 40% have no mood disorder; 20%
are partially recovered, and 40% still have symptoms that are sufficiently severe
to meet the criteria for a full Major Depressive Episode. The severity of the
initial Major Depressive Episode appears to predict persistence. Chronic general
medical conditions are also a risk factor for more persistent episodes. Among
those with an onset of depression in later life; there is evidence of subcortical
white matter hyper intensities associated with cerebro vascular disease. These
vascular depressions are associated with greater neuropsychological impairments
and poorer responses to standard therapies.
Episodes of this disorder often follow a severe psychosocial stressor, such as the
death of a loved one or divorce. Stressors may play a more significant role in the
precipitation of the first or second episode of this disorder and play less of a role
in the onset of subsequent episodes. Chronic medical conditions and Substance
Dependence (particularly Alcohol or Cocaine Dependence) may contribute to
the onset or exacerbation of this disorder.
According to the Diagnosticians there are several subtypes of depressive disorder
and these are given below.

4.3.2 Atypical Depression

It is characterised by mood reactivity (paradoxical anhedonia) and positivity,
significant weight gain, excessive sleep or somnolence (hypersomnia), a sensation
of heaviness in limbs known as leaden paralysis, and significant social impairment
as a consequence of hypersensitivity to perceived interpersonal rejection.

4.3.3 Melancholic Depression

Melancholic depression is have loss of pleasure (anhedonia) in most or all
activities, a failure of reactivity to pleasurable stimuli, a quality of depressed
mood more pronounced than that of grief or loss, a worsening of symptoms in
70
the morning hours, early morning waking, psychomotor retardation, excessive Mood Disorders (Bipolar,
Major Depression)
weight loss (not to be confused with anorexia nervosa), or excessive guilt.

4.3.4 Psychotic Major Depression (PMD)

PMD or simply psychotic depression is the term for a major depressive episode,
particularly of melancholic nature, where the patient experiences psychotic
symptoms such as delusions or, less commonly, hallucinations. These are most
commonly mood-congruent (content coincident with depressive themes).

4.3.5 Catatonic Depression (CD)

CD is a rare and severe form of major depression involving disturbances of
motor behaviour and other symptoms. Here the person is mute and almost
stuporose, and either immobile or exhibits purposeless or even bizarre
movements. Catatonic symptoms can also occur in schizophrenia, a manic
episode, or be due to neuroleptic malignant syndrome.

4.3.6 Postpartum Depression (PPD)

PPD refers to the intense, sustained and sometimes disabling depression
experienced by women after giving birth. Postpartum depression, which has
incidence rate of 10–15%, typically sets in within three months of labour, and
lasts for long. However, postpartum depression is different because it can cause
significant hardship and impaired functioning at home, work, or school as well
as possibly difficulty in relationships with family members, spouses, friends, or
even problems bonding with the newborn.

4.3.7 Seasonal Affective Disorder (SAD)

SAD also known as “winter depression” or “winter blues”, is a specifier. Some
people have a seasonal pattern, with depressive episodes coming on in the autumn
or winter, and resolving in spring. The diagnosis is made if at least two episodes
have occurred in colder months with none at other times over a two-year period
or longer.SAD is also more prevalent in people who are younger and typically
affects more females than males.

4.3.8 Symptoms of Depression

• Exhibits a very low mood
• Inability to experience pleasure
• inappropriate guilt or regret, helplessness
• Hopelessness, and self-hatred
• withdrawal from social situations and activities
• Reduced sex drive
• Thoughts of death or suicide
• Hyposomania or insomnia
• Thoughts and feelings of worthlessness
• Inappropriate guilt or regret
• Helplessness, hopelessness
• self-hatred
• Agitated or lethargic. 71
Severe Mental Disorders
4.4 CAUSES OF DEPRESSION
The cause of major depressive disorder is a combination of anxiety, medical
illness, brain chemistry, family history, and psychosocial environment. This is
not certain which of these factors dominates, but abnormal levels of the
neurotransmitters norepinephrine, serotonin, and dopamine are closely linked
with depression. Thus, the cause of depression is often attributed to a “chemical
imbalance.” These neurotransmitters play important roles in how we experience
pleasure and moods.

4.4.1 Genetic Risk Factors for Depression

The statistics shows that children of parents who suffer from depression are
more likely to develop the disorder themselves. A person has a 27% chance of
inheriting a mood disorder from one parent, and this chance doubles if both
parents are affected. Studies of the occurrence of depression in twins show a
70% chance for both identical twins to suffer from depression, which is twice
the rate of occurrence in fraternal twins.

4.4.2 Psychosocial and Environmental Risk Factors for

Depression
Depression is more common in people who have a history of trauma, sexual
abuse, physical abuse, physical disability, bereavement at a young age, alcoholism,
and insufficient family structure. In adults, the loss of a spouse is the most common
cause of a depressive episode. Women are at increased risk for depression during
and within the first few months after pregnancy (called postpartum depression).
Chronic depression may be more common in areas afflicted with war, natural
disasters, poverty, or neglect.
The following cognitive factors (which affect judgment and perception) are
associated with depression:
• Chronic low self-esteem
• Distorted perception of others’ views
• Distorted sense of life experience
• Inability to acknowledge personal accomplishment
• Negative idea of self
• Pessimistic outlook
• Quick and exaggerated temper.

4.4.3 Age and Depression Risk

It is known that depression can occur at any age, its onset is typically between
the ages 24 and 44. Later onset may correlate with the absence of a family history
of depression. Fifty percent of people with major depressive disorder experience
their first episode of depression at about age 40, but this may be shifting to the
30s. Studies find that the rate of incidence is higher among middle aged people.
Teenagers are more at risk for depression. The evidence is in teen suicide rates,
which are increasing yearly. Problems with self esteem may result from failure
or disinterest in meeting these expectations. Low self esteem can lead to a negative
72 perspective of life and depression.
4.4.4 Gender and Depression Risk Mood Disorders (Bipolar,
Major Depression)
Gender wise it has been seen that 10% of men and 20% of women are affected.
Hormonal differences may put women at a higher risk for depression. Hormone
levels are influenced by pregnancy, and many women experience depression
after delivery. The disparity between rates of depression in men and women may
reflect behaviours based on learned gender roles. Learned helplessness and socio-
economic stressors may result in depression in women.

4.4.5 Race and Class and Depression Risk

The race and class of the individuals are also affected by depression. The socio-
economic background is the major factor for predisposing the depressive
behaviour.

4.4.6 Anxiety
Anxiety in a person with major depression leads to a poorer response to treatment,
poorer social and work function, greater likelihood of chronicity and an increased
risk of suicidal behaviour. 80 to 90% of individuals with depressive disorder
invariably also have anxiety symptoms.

4.4.7 Medical Illness

It has been found that about 5% of individuals initially diagnosed as having
Major Depressive Disorder subsequently are found to have another medical illness
which was the cause of their depression. 25% of individuals with severe, chronic
medical illness (e.g., diabetes, myocardial infarction, carcinomas, stroke etc.)
develop depression. Medical conditions often causing depression are: Endocrine
disorders such as hypothyroidism, hyperparathyroidism, Cushing’s disease, and
diabetes mellitus.

4.5 TREATMENT
Psychotherapy can be used both at individual and group levels, by mental health
professionals, including psychotherapists, psychiatrists, psychologists, clinical
social workers, counselors, and suitably trained psychiatric nurses.

Medication should only be offered in conjunction with a psychological therapy,

such as CBT, interpersonal therapy, or family therapy. Psychotherapy has been
shown to be effective in older people. The most studied form of psychotherapy
for depression is CBT, which teaches clients to challenge self defeating, but
enduring ways of thinking (cognitions) and change counter productive behaviours.

Antidepressants are given in smaller dosage to those with mild or moderate

depression but a heavy dosage is given tothose with very severe depression. The
effects of antidepressants are somewhat superior to those of psychotherapy,
especially in cases of chronic major depression, although in short term trials
more patients, especially those with less serious forms of depression stop
medication than stop psychotherapy, most likely due to adverse effects from the
medication and to patients’ preferences for psychological therapies over
pharmacological treatments. Antidepressant medication treatment and even up
to one year of continuation is recommended.

73
Severe Mental Disorders
4.6 DYSTHYMIC DISORDER
Dysthymia is a low grade depression. It comes from the Greek word dysthymia
means bad state of mind. It presents with a chronic feeling of ill being and lack
in interest in any enjoyable activities. Unlike in major depression individuals are
unable to work but in dysthymic are able to work and function at a less than peak
performance. It has been seen that 50% of patients with dysthymic disorder recover
soon than any other depression.

4.6.1 Symptoms
• poor appetite or overeating
• insomnia or hypersomnia
• low energy or fatigue
• low self-esteem
• poor concentration or difficulty making decisions
• feelings of hopelessness low energy,
• sleep disturbances,
• appetite disturbances,
• irritable or angered easily,
• low self-esteem are usually part of the clinical picture as well.
• inability to concentrate,
• feelings of worthlessness,
• sad mood

4.6.2 Causes
i) Biochemical: The significance of these changes is still uncertain, but they
may eventually help pinpoint causes. The naturally occurring brain chemicals
called neurotransmitters, which are linked to mood, also may play a role in
causing dysthymia.
ii) Genes: In dysthymia there is also biological condition that appears to be the
most common amongst people who suffer from this disorder.
iii) Environment: Environment contributes to dysthymia. Environmental causes
are situations in your life that are difficult to cope with, such as the loss of a
loved one, financial problems and a high level stress.
iv) Physical Causes of Dysthymia: Physical causes of dysthymia include
biochemical changes, genetic factors, medical illness and medications and
changes in physiological brain activity. Research studies undertaken on twins
have identified that there exists a genetic link to depression as when one
identical twin suffers from the illness the other has around a 70% chance of
also being affected by depression.
v) Medical illness: This includes heart attack and those who are prone to heart
attacks are 40% more likely to suffer from depression due to also certain
medications such as steroids etc. This may also lead to episodes of the
74 condition.
vi) Psychosocial Causes of Dysthymia: Difficulty in family relationships, poor Mood Disorders (Bipolar,
Major Depression)
coping skills and lack of social support increase the likelihood of depression.
In addition tragedy, bereavement, loss, trauma and abuse may lead to
dysthymia. This is more common among children and adolescents who are
more vulnerable and also lack positive relationships.

4.6.3 Treatment
Only one in five who have dysthymia or other forms of depression needs help.
Dysthymia is a very treatable disorder. With the right kind of treatment, nearly
every patient can experience significant relief in 12 to 14 weeks. Untreated,
many dysthymics eventually develop major depression.

Often, psychotherapy is recommended first for three months, followed by

antidepressants if therapy alone is not effective. Sometimes, a combination of
psychotherapy and antidepressants is used early on.

Other forms of therapy used are:

• Cognitive-behavioural therapy, which shows patients how to change self-
defeating and disturbed thought patterns into more positive and productive
ways of thinking. Interpersonal therapy, which focuses on developing better
relationships.
• Cultural analysis, which points out unrealistic societal messages that
contribute to low self-esteem and a sense of powerlessness, especially for
women .
• Group therapy and self-help, which provide a source of emotional support
and vital social connections.
BIPOLAR DISORDERS
Bipolar disorder is of two types: Bipolar I and Bipolar II. Let us take up Bipolar
disorder I.

4.7 BIPOLAR DISORDER I

Bipolar disorder or manic depressive disorder, which is also referred to as bipolar
affective disorder or manic depression. It is a psychiatric diagnosis that describes
a category of mood disorders defined by the presence of one or more episodes of
abnormally elevated energy levels, cognition, and mood with or without one or
more depressive episodes.

The elevated moods are clinically referred to as mania or, if milder, hypomania.
Individuals who experience manic episodes also commonly experience depressive
episodes, or symptoms, or mixed episodes in which features of both mania and
depression are present at the same time. These episodes are usually separated by
periods of “normal” mood; but, in some individuals, depression and mania may
rapidly alternate, which is known as rapid cycling.

Diagnosis is based on the person’s self-reported experiences, as well as observed

behaviour, which includes distress, disruption and risk of suicide. The term
“bipolar disorder” origins and refers to the cycling between high and low episodes
(poles).
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Severe Mental Disorders A relationship between mania and melancholia had long been observed, although
the basis of the current conceptualisation can be traced back to French psychiatrists
in the 1850s. The term “manic-depressive illness” or psychosis was coined by
German psychiatrist Emil Kraepelin in the late nineteenth century, originally
referring to all kinds of mood disorder.

German psychiatrist Karl Leonhard split the classification again in 1957,

employing the terms unipolar disorder (major depressive disorder) and bipolar
disorder.

4.7.1 Symptoms of Bipolar Disorder I

• Feeling unusually “high” and optimistic or irritibality
• Unrealistic, grandiose beliefs about one’s abilities or powers
• Sleeping very little, but feeling extremely energetic
• Talking so rapidly that others can’t keep up
• Racing thoughts; jumping quickly from one idea to the next
• Highly distractible, unable to concentrate
• Impaired judgment and impulsiveness.

4.7.2 Causes of Bipolar Disorder I

i) Genetic Factors
When talking about biological causes, the first issue is whether bipolar disorder
can be inherited. This question has been researched through multiple family,
adoption and twin studies. In families of persons with bipolar disorder, first-
degree relatives (parents, children, siblings) are more likely to have a mood
disorder than the relatives of those who do not have bipolar disorder (3). Studies
of twins indicate that if one twin has a mood disorder, an identical twin is about
three times more likely than a fraternal twin .

ii) Neurochemical Factors in Bipolar Disorder

Bipolar disorder is primarily a biological disorder that occurs in a specific area
of the brain and is due to the dysfunction of certain neurotransmitters, or chemical
messengers, in the brain.

iii) Environmental Factors in Bipolar Disorder

An life event can trigger a mood episode in individuals with a genetic disposition
for this kind of disorder. The bipolar disorder appears at increasingly early age.
life event may trigger a mood episode in a person with a genetic disposition for
bipolar disorder.

4.7.3 Treatment of Bipolar Disorder I

i) Medications
There is a wide variety of medications that are used in treatment. Each group of
medications treats a particular set of symptoms. Side effects are common: some
may cause a patient to discontinue the medication, others may go away with
time or be tolerable or treatable.

76
ii) Psychological Therapy Mood Disorders (Bipolar,
Major Depression)
Psychiatrists, psychologists, therapists and counselors. Primary physicians,
psychiatric nurses, social workers and psychopharmacologists.

iii) Psychiatric Hospitalisation

Sometimes it is necessary to get 24-hour monitoring and treatment.the hospital
can only provide control and proper care.

4.8 BIPOLAR DISORDER II

According to the definition in the Diagnostic and Statistical Manual of Mental
Disorders (DSM IV), bipolar II disorder is characterised by one or more major
depressive episodes accompanied by at least one hypomanic episode.

The key difference between bipolar 1 and bipolar 2 is that bipolar 2 has hypomanic
but not manic episodes. However, in bipolar II disorder, the “up” moods never
reach full during the mani episodes.

The less intense elevated moods in bipolar II disorder are called hypomanic
episodes, or hypomania. A person affected by bipolar II disorder has had at least
one hypomanic episode in life. Most people with bipolar II disorder also suffer
from episodes of depression.

This is where the term “manic depression” comes from. In between episodes of
hypomania and depression, many people with bipolar II disorder live normal
lives.

4.8.1 Symptoms of Bipolar Disorder II

• Decreased energy
• Weight loss or gain
• Despair
• Irritability
• Uncontrollable crying

Symptoms and characteristics of hypomania include:

• Grandiosity
• Decreased need for sleep
• Pressured speech
• Racing thoughts
• Distractibility
• Tendency to engage in behaviour that could have serious consequences, such
as spending recklessly or inappropriate sexual encounters
• Excess energy

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Severe Mental Disorders 4.8.2 Causes of Bipolar Disorder II
i) Genetic Factors
The first issue in bipolar disorder is of inheritence. In families of persons with
bipolar disorder, first degree relatives (parents, children, siblings) are more likely
to have a mood disorder than the relatives of those who do not have bipolar
disorder. Studies of twins indicate that if one twin has a mood disorder, an identical
twin is about three times more likely than a fraternal twin to have a mood disorder
as well.

ii) Neurotransmitters
The neurotransmitter system has received a great deal of attention as a cause of
bipolar disorder. Some studies suggest that a low or high level of a specific
neurotransmitter such as serotonin, norepinephrine or dopamine is the cause.

iii) StressTriggers
For mental, emotional and environmental issues, stressful life events are thought
to be the main element in the development of bipolar disorder. These can range
from a death in the family to the loss of a job, from the birth of a child to a move.

4.8.3 Treatment of Bipolar Disorder II

i) Mood stabilising medications
These are usually the first choice to treat bipolar disorder. In general, people
with bipolar disorder continue treatment with mood stabilisers for years. Except
for lithium, many of these medications are anticonvulsants. Anticonvulsant
medications are usually used to treat seizures, but they also help control moods.
These medications are commonly used as mood stabilisers in bipolar disorder:

ii) Antidepressant medications

These medicines are sometimes used to treat symptoms of depression in bipolar
disorder. People with bipolar disorder who take antidepressants often take a mood
stabiliser too.

Some psychotherapy treatments used to treat bipolar disorder include the

following:

iii) Cognitive behavioural therapy (CBT)

This helps people with bipolar disorder learn to change harmful or negative
thought patterns and behaviours.

iv) Family focused therapy

This includes family members. It helps enhance family coping strategies, such
as recognising new episodes early and helping their loved one. This therapy also
improves communication and problem solving.

v) Interpersonal and social rhythm therapy

This therapy helps people with bipolar disorder improve their relationships with
others and manage their daily routines. Regular daily routines and sleep schedules
may help protect against manic episodes.
78
vi) Psychoeducation Mood Disorders (Bipolar,
Major Depression)
This aims to teach people with bipolar disorder about the illness and its treatment.
This treatment helps people recognise signs of relapse so they can seek treatment
early, before a full blown episode occurs. Usually done in a group,
psychoeducation may also be helpful for family members and caregivers.

4.9 CYCLOTHYMIC DISORDER

Cyclothymia is a mood disorder that causes hypomanic and mild depressive
episodes. A single episode of hypomania is sufficient to diagnose cyclothymic
disorder. However, most individuals also have dysthymic periods. The diagnosis
of cyclothymic disorder is not made when there is a history of mania or major
depressive episode or mixed episode.

The lifetime prevalence of cyclothymic disorder is 0.4 to 1%. The rate appears
equal in men and women, though women more often seek treatment. Cyclothymia
is similar to bipolar II disorder in that it presents itself in typical hypomanic
episodes. Because hypomania is often associated with exceptionally creative,
outgoing, and high-functioning behaviour, both conditions are often undiagnosed.
As with most of the disorders in the bipolar spectrum, it is the depressive phase
that leads most sufferers to get help.

4.9.1 Symptoms
i) Dysthymic phase
Symptoms of the dysthymic phase include difficulty making decisions, problems
concentrating, poor memory recall, guilt, self-criticism, low self-esteem,
pessimism, self-destructive thinking, continuously feeling sad, apathy etc.

ii) Euphoric phase

Symptoms of the euphoric phase include unusually good mood or cheerfulness
(euphoria), extreme optimism, inflated self-esteem, poor judgment, rapid speech,
racing thoughts, aggressive or hostile behaviour, being inconsiderate of others,
agitation, increased physical activity, risky behaviour, spending sprees.

4.9.2 Hypomanic Phase of Cyclothymic Disorder

1) Unusually good mood or cheerfulness (euphoria)
2) Extreme optimism
3) Inflated self-esteem
4) Poor judgment
5) Rapid speech

4.9.3 Depressive Phase of Cyclothymic Disorder

1) Sadness
2) Hopelessness
3) Suicidal thoughts or behaviour
4) Anxiety

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Severe Mental Disorders 5) Guilt
6) Sleep problems
The cause of cyclothymic disorder is unknown. Although the changes in mood
are irregular and abrupt, the severity of the mood swings is far less extreme than
that seen with bipolar disorder (manic depressive illness). Unlike in bipolar
disorder, periods of hypomania in cyclothymic disorder do not progress into
actual mania.

4.9.4 Treatment of Cyclothymic Disorder

i) Antidepressant Medication for Cyclothymia
A trial of lithium carbonate is often tried, especially if the mood swings seem to
be similar to those found in bipolar disorder. Prescription of such a medication
though should be dependent upon a thorough clinical examination and history
of the patient.

ii) Psychotherapy for Cyclothymia

Psychological treatment often focuses on the life adjustment problems that
develop because of the Cyclothymia, and in helping the individual recognise the
onset of a Cyclothymia and take corrective action. Treatment often takes the
form of individual psychotherapy, although group treatment can also be helpful
for this disorder.

iii) Self Help for Cyclothymia

Lifestyle improvements always have a positive impact, however can take more
effort to actually do as the depression becomes more severe. Self-help methods
for the treatment of this disorder are often overlooked by the medical profession
because very few professionals are involved in them

4.10 SUBSTANCE INDUCED MOOD DISORDER

A substance induced mood disorder is characterised by depressions or manic
episodes which develop during a time when the person is taking a medication
which causes depression or the manic symptoms a time when the person is
intoxicated by a drug or a time when the person is withdrawing from an
intoxicating drug.

The symptoms of substance induced mood disorder are the same as during other
types of depression, that is it has symptoms of sadness, emptiness, loss of interest
and pleasure, irritability and anger, changes in appetite, sleep problems,
restlessness, slow movement and thinking, fatigue, worthlessness and guilt, poor
concentration, thoughts about death and suicide.

The manic symptoms are the same as those experienced during other manic
episodes...elation, confidence, delusional thinking, high level of energy, increased
activity, productivity, loud and rapid speech, racing thoughts, risky behaviour,
impulsive behaviour, increased sexual behaviour, over spending, fast reckless
driving, wild business schemes, overeating, drinking too much, irritability, anger,
and agitation.

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4.10.1 Causes of Substance Induced Mood Disorder Mood Disorders (Bipolar,
Major Depression)
Medications and drugs which can cause substance induced mood disorder include
the following:
• Antihypertensives such as reserpine, methyldopa, clonidine, guanethidine,
hydralazine, and prazosin hydrodhloride
• Gastrointestinal medications such as cimetidine
• Anticonvulsant medications such as clonazepam
• Steroids
• Oral contraceptives such as progesterone
• Anti-inflammatory medications such as indomethacin
• L-dopa
• Antipsychotic medications
• All sedatives including barbiturates such as phenobarbital, benzodiazepines
such as diazepam, meprobamate, methaqualone, gultethimide, elhchlorvynol,
chloral hydrate, and ethanol
• Amphetamines (stimulates)
• Methadone
• Heroin
• Cocaine

4.10.2 Treatment of Substance Induced Mood Disorder

i) Medical Care
If the substance induced mood disorder symptoms are severe or cause significant
risk of harm to the patient or others, inpatient psychiatric care needs to be
considered. Specific indications for inpatient care include
1) serious suicidal ideation, which may include a plan,
2) homicidal ideation,
3) severe impairments in judgment leading to a moderate or high risk for danger
to self or others, or
4) an inability to care for oneself safely. If unsure about the diagnosis, a prompt
evaluation by the local emergency mental health system or a local emergency
department is indicated.
Regular assessment of suicide risk is mandatory in any patient with depression
or mania. Other risk factors for suicide include agitation, psychosis, past suicide
attempts, a family history of suicide, or recent psychiatric admission.

If the mood symptoms do not subside within 4 weeks, consider other etiologies
for the depression.

ii) Consultations
If the patient is suicidal, psychosis or mania is suspected, or depressive symptoms
are severe, consult a mental health professional. Patients may need intensive
81
Severe Mental Disorders outpatient or inpatient mental health care until the severity of the symptoms
decline.

4.11 MOOD DISORDER OF GENERAL MEDICAL

CONDITION
Mood disorder due to a general medical condition is characterised by depression
or manic episodes which are caused by a medical condition.

The symptoms of mood disorder due to a general medical condition are the same
as during other types of depressions, such as sadness, emptiness, loss of interest
and pleasure, irritability and anger, changes in appetite, sleep problems,
restlessness, slow movement and thinking, fatigue, worthlessness and guilt, poor
concentration, thoughts about death and suicide.

4.11.1 Symptoms
• Poor appetite or overeating.
• Insomnia or hypersomnia.
• Low energy or fatigue.
• Low self-esteem.
• Poor concentration or difficulty making decisions.
• Feelings of hopelessness.
• Psychomotor agitation or retardation nearly every day.

4.11.2 Causes
• Cardiovascular conditions such as myocardial infarction (heart attack)
• Gastrointestinal conditions
• Neurological disorders such as Huntington’s Disease, Alzheimer’s Disease,
and brain tumors
• diseases of the pancreas
• Thyroid abnormalities
• Addison’s Disease
• Cushing’s Disease
• Pheumatoid Arthritis
• Infectious diseases such as Mononucleosis
• Cancer
• Malnutrition
• Electrolyte disturbances

4.11.3 Treatment
Treatment for mood disorder due to a general medical condition must include
treatment of the medical condition causing the depression or manic disorder.

82
i) Psychiatric and psychological treatment Mood Disorders (Bipolar,
Major Depression)
This treatment intervention of the mood disorder is also often needed. Psychiatric
treatment will include medication to reduce the depressive or manic symptoms.
Psychological treatment will provide the person with emotional support and help
him develop coping skills.

Self Assessment Questions

1) What is major depressive disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
2) Enlist the causes of depression.
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
3) What are the causes of bipolar I disorder?
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................

4.12 LET US SUM UP

Thus mood disorders reflects a disturbance in mood or emotional response that
is not only due to physical but also due to some emotional distortions. All these
disorders type are more or less similar to one another and have a greater risk to
women than men. On thing is confirmed that bipolar depression are much higher
than that for any other general depression.

4.13 UNIT END QUESTIONS

1) Discuss the types and symptoms of unipolar disorders.
2) What is a Bipolar II disorder? Discuss with symptoms and its causes.
3) What are the major risk factors in depression?

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Severe Mental Disorders
4.14 SUGGESTED READINGS AND REFERENCES
Miller, Laura J. (2008). Post Partum Mood Disorder. American Psychiatry Press

Parker, Gordon, Straton,David (2007). Dealing with Depression. Mc Phersons

Printing Group

Sloman, Leon (2002). Subordination and Defeat: An Evolutionary Approach to

Mood Disorders and Their Therapy. Lawrence Erlbaum Associates

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