ABNORMAL PSYCHOLOGY

MODULE 1: BASIC CONCEPTS

Mental disorder, classification, Historical views of abnormal behaviour, causal factors-
Biological, psychosocial and socio cultural

MODULE 2: STRESS DISORDERS AND ANXIETY DISORDERS

Stress and stressors- Coping strategies, stress disorders: Adjustment Disorder-Post traumatic
stress disorder; Anxiety disorder: specific phobia, social phobias, Generalized Anxiety
disorders, obsessive-compulsive disorder. Causal factors

MODULE 3: SOMATOFORM AND DISSOCIATIVE DISORDER

Somatic Symptom Disorders, Hypochondriasis, Somatization Disorder, Pain Disorder,
Conversion Disorder; Dissociative Disorders - Depersonalization/ Derealisation Disorder,
Dissociative Amnesia and Dissociative Fugue, Dissociative Identity Disorder (DID). causal
factors

MODULE 4: PERSONALITY DISORDERS

Cluster A Personality Disorders-Paranoid Personality Disorder, Schizoid Personality Disorder,
Schizotypal Personality Disorder.
Cluster B Personality Disorders- Histrionic Personality Disorder, Narcissistic Personality
Disorder, Antisocial Personality Disorder, Borderline Personality Disorder.
Cluster C Personality Disorders - Avoidant Personality Disorder, Dependent Personality
Disorder, Obsessive-Compulsive Personality Disorder. Causal Factors.
 MODULE 1: BASIC CONCEPTS
“Abnormal Psychology is a branch that deals with the scientific study of abnormal
behaviours to describe, predict, explain, treat and change abnormal patterns of
functioning”

WAYS OF DEFINING ABNORMAL PSYCHOLOGY

• Subjective discomfort – feelings of anxiety, depression or emotional distress
• Deviation from social and cultural norms – disobeying societal standards for normal
conduct, usually leads o destructive or self-destructive behavior
• Statistically deviant – having extreme scores on some dimension such as anxiety or
depression
STATISTICALLY DEVIANT OR ABNORMAL
Statistically infrequent behaviours are considered as abnormal. The
behaviours seen in most of the people which lies in the middle range
is considered as normal.
DEVIANCE
Rare/ infrequent behaviour that deviates from the average/majority =
ABNORMAL
Typical or Usual = NORMAL
The more infrequently a behaviour occurs, the more abnormal it is
considered.
THREE CRITERIA FOR ABNORMALITY
Behaviours Explanation
Maladaptive bhaviours Behaviours that make it difficult to function, to
adapt to environment and to meet everyday
demands.
e.g. Passive aggressiveness, Self-harm, OCD,
Anger
Significant impairment in social Loss of ability to control behaviours, feelings,
functioning communication and thoughts adequately
e.g. Mood disorders, Stress disorders, Anxiety
disorders, Psychotic disorders
Atypical behaviour Socially and culturally unacceptable behaviours.
e.g. Autism, Asperger’s syndrome
PSYCHOLOGICAL DISORDER
The four D’s –
1. DISFUNCTION – Causes disruption in social, occupational, day to day functioning.
2. DISTRESS – Unpleasant and Upsetting. Cause distress to individuals or to those around the
individual.
3. DEVIANCE – Different, Extreme, Unusual. (a) Statistical Deviance (b) Cultural Deviance
4. DANGER – Causes interference with life. Poses risk of Harm.

MENTAL DISORDER
DSM – 5: A mental disorder is a syndrome characterized by clinically significant disturbance in an
individual’s cognition, emotion, or behaviour that reflects a dysfunction in the psychological,
biological or developmental processes underlying mental functioning. Usually associated with
significant distress or disability in social, occupational and other important areas of functioning.
Socially deviated behaviour and conflicts between the individual and society are also not
considered mental disorders unless they result from a dysfunction in the individual.
CLASSIFICATION OF MENTAL DISORDERS
Classification also known as psychiatric nosology or psychiatric taxonomy, is a process by which
complex phenomena are reduced by rearranging into certain categories based on shared
characteristics. Also known as diagnostic classification – which is done based on some symptoms
and diagnostic criteria.
ADVANTAGES AND DISADVANTAGES OF CLASSIFICATION
Advantages Disadvantages
→ Organization of disorders into diagnostic → Helps to determine the epidemiology
classes. (incidence and prevalence of disorders)

→ To allow mental health practitioners and → Labelling can cause stigma which results
researchers to communicate more effectively in unwanted social and occupational
with each other consequences
→ To arrive at diagnosis that has important → Problems of stereotyping also occur-
predictive power others consider them with prejudice.
→ To distinguish and differentiate one diagnosis
from other
→ Give structure for teaching phenomenology
and differential diagnosis
→ Psychoeducation of patients and their families
→ Helps to determine the epidemiology
(incidence and prevalence of disorders)
TWO MAJOR APPROACHES TO CLASSIFICATION
CATEGORICAL
• It involves the assessment of whether an individual has a disorder on the basis of typical
symptoms and characteristics.
• Based on ‘all or none’ principle- consider illness as being present or absent-no in between
diagnosis.
• Used in DSM and ICD.
DIMENSIONAL
• Views that symptoms of disorders exist on a dimension which is a continuum from normal to
severely ill.
• Considers the degree to which a symptom is present.
• In the present DSM-5 and ICD-10 there is an integration of both approaches

MAJOR SYSTEMS OF CLASSIFICATION IN PSYCHIATRY

• ICD – International Classification of Diseases and related health problems proposed by World
Health Organization (WHO)- now its tenth revision (ICD-10)
• DSM – Diagnostic and Statistical Manual of mental disorders- by American Psychiatric
Association (APA)- now as DSM-5
• Chinese Classification of Mental Disorders (CCMD)
• Latin American Guide for Psychiatric Diagnosis

DSM 5
Officially convened in August 2007 with many changes and clearances. After many proposals
and reviews, approved in December 1, 2012 and released in 18th May 2013 (used Hindu rather
than Roman Numerals). Chairman – David Kupfer. 947 pages and 22 chapters.
Divided into three sections:
• Section I- DSM 5 basics (introduction, history, development, harmonization with ICD)
• Section II- diagnostic criterion and codes
• Section III- emerging measures and models and an appendix (assessment measures,
cultural formulations, conditions for further studies)
MAIN CHANGES IN DSM-5:
▪ Deletion of multiaxial system
▪ Changes in the structure and grouping of disorders
▪ Ex: removed PTSD and ASD from anxiety disorders & placed in a new chapter called trauma
and stress related disorders
▪ New chapter of Obsessive compulsive and other related disorders
▪ About 15 more disorders were added. Ex: social communication disorders, premenstrual
dysphoric disease etc.

GROUPING OF DIAGNOSTIC CATEGORIES

The DSM-5 groups are:
1. Neurodevelopmental disorders 10. Sleep Disorders
2. Schizophrenia and primary psychotic disorders 11. Disorders of Sexual Function
3. Bipolar and Related Disorders 12. Antisocial and Disruptive Disorders
4. Mood Disorders 13. Substance Abuse-Related Disorders
5. Anxiety Disorders 14. Neurocognitive Disorders
6. Disorders Related to Environmental Stress 15. Personality Disorders
7. Obsessive Compulsive Spectrum 16. Paraphilia
8. Somatic Symptom Disorder 17. Other Disorders
9. Feeding and Eating Disorder

DSM [REVISIONS AND PUBLICATIONS]

ICD
EVOLUTION OF ICD
• 1855 William Farr first medical statistician, submitted his report on nomenclature and statistical
classification of diseases
• 1893 Jacques Bertillon French physician, introduced Bertillon Classification of Causes of Death
• 1900 an international conference revised and formulated “International Classification of
Causes of Death”
• 1948, WHO assumed responsibility for ICD.
• 1949- the sixth revision, involved significant changes
• Title was changed to ‘International Statistical Classification of Diseases, Injuries, and Causes of
Death’ and it includes a section on mental disorders.
 • 1965 eighth revision
• 1975 Ninth revision- most important event was the inclusion of glossary and brief description of
the categories in the fifth chapter of mental disorders. It includes 17 sub chapters
• 1989 Tenth revision
• 1990 ICD-10 was endorsed by the 43rd World Health Assembly and came to use in WHO
member states as from 1994
• 2000 India adopted this classification

ICD 10
• 21 chapters
• Used alphanumeric coding system. (A00 –Z99)
• Enlarged the number of categories.
• Mental disorders are included in chapter V (F00-F99), in 11 blocks or categories
• Used multiaxial system: three axes
▪ Axis I- clinical syndromes (psychiatric disorders)
▪ Axis II- disabilities
▪ Axis III- environmental/circumstantial and personal lifestyle factors

MENTAL AND BEHAVIOURAL DISORDERS FROM ICD 10

Major Categories of Mental and Behavioral Disorders in ICD-10
─ F00-F09 Organic disorders
─ F10-F19 Psychoactive substance use disorders
─ F20-F29 Schizophrenia and other psychotic disorders
─ F30-F39 Mood [affective] disorders
─ F40-F49 Neurotic and stress-related disorders
─ F50-F59 Physiological function disorders
─ F60-F69 Adult personality disorders
─ F70-F79 Mental retardation
─ F80-F89 Psychological developmental disorders of childhood
─ F90-F99 Behavioral and emotional disorders of childhood and adolescence

MENTAL DISORDERS IN ICD-11

• Improved consistency and uniformity, considered more environmental and cultural factors
• Gave more importance to features or symptoms of a disorder
F00-F09 Organic, including symptomatic, mental
disorders Neurodevelopmental disorders
F10-F19 Mental and behavioral disorders due to
psychoactive substance use
F20-F29 Schizophrenia, schizotypal and delusional Schizophrenia or other primary psychotic disorders
disorders
F30-F39 Mood (affective) disorders Mood disorders
F40-F48 Neurotic, stress – related and somatoform Anxiety and fear related disorders
disorders
F50-F59 Behavioural syndromes associated with Obsessive – compulsive or related disorders
physiological disturbances and physical factors
F60-F69 Disorders of adult personality and Disorders specifically associated with stress
behavior
F70-F79 Mental retardation Dissociative disorders
F80-F89 Disorders of psychological development Bodily distress disorder
F90-F98 Behavioural and emotional disorders with
onset usually occurring in childhood and Feeding or eating disorders
adolescence
F99-F99 Unspecified mental disorder Elimination disorders
Disorders due to substance use or addictive
behaviors
Impulse control disorders
Disruptive behavior or dissocial disorders
Personality disorders and related traits
Paraphilic disorders
Factitious disorders
Neurocognitive disorders
Mental or behavioral disorders associated with
pregnancy, childbirth and the puerperium, not
elsewhere classified
Psychological or behavioural factors affecting
disorders or diseases classified elsewhere.

COMPARING ICD & DSM

ICD DSM
• Official world classification by WHO • National classification of US by APA
• Useful for the different health professionals • Focus on psychiatrists and psychologists
• Created with the idea of being useful for • Developed to fulfil the particular needs of the
different health systems around the world US health system
• Free of charge and open access • Property of APA
• Clinical descriptions • Operational criteria
• Multilingual and multicultural • US, Anglophone perspective
• Advantages for clinical use • Advantages for research
• Multiple versions and formats for multiple users • Different formats, one version

HISTORICAL & CONTEMPORARY VIEWS ON ABNORMAL BEHAVIOUR

PHASES IN HISTORY
● STONE AGE [Half a million years ago]
Trephination
Chipping or drilling away an area of the skull with crude stone instruments to make a hole letting
the evil spirit in the head to escape through it. People believed that abnormal behaviors are
caused by the action of evil spirit.
● DEMONOLOGY, GODS AND MAGIC
The Chinese, Egyptian, Hebrews and Greeks often attributed abnormal behaviour to a demon or
God who had possessions of a person. The decision as to whether the possession involved good
spirits or evil spirit usually depending upon the symptoms. If a person’s behaviour appeared to
have religious components, then he or she was possessed by good spirit else, he or she was
possessed by bad spirit.
People who believed to be possessed by god were often treated with considerable awe and
respect, and believed that they have supernatural powers Primary type of treatment for demonic
possessions: exorcism. It includes various techniques for casting an evil spirit out of an afflicted
person- by using magic, prayer, incantation, noise making, and the use of horrible tasting solutions
etc.
● EARLY GREEK THINKERS
▪ Hippocrates is the Father of modern medicine. He proposed a natural causation of
mental illness and discarded supernatural views. He said mental diseases are mainly caused by
biological abnormalities and gave importance to heredity and brain pathology. He also gave
importance to dreams in understanding the abnormal behaviours. Hippocrates classified mental
diseases into three categories: Mania, melancholia and phrenitis (brain fever).
 ▪ Galen followed Hippocrates. He had proposed a doctrine of four humors. Based on that
four temperaments: Sanguine, Melancholic, Phlegmatic and Choleric. The four elements of the
material world are: earth, air, fire and water, which had the attributes of moistness, dryness, heat
and cold. These elements combine to form four essential fluids or humors of the body; blood
(sanguis), yellow bile (choleric), black bile (melancholic) and phlegm (phlegmatic). These fluids
combined in different proportions in individuals, and a person’s temperament is determined by
the dominant humor in his body.
▪ Plato studied mentally ill people who committed criminal acts. Mentally ill people are not
responsible for criminal acts and should not receive punishment like normal criminals. He put
forward a more humanitarian approach. He proposed to provide hospital care for the mentally ill.
He also emphasized the importance of individual differences in intelligence, thinking and other
behaviours and also gave importance to sociocultural influences. He partly believed in divine
causation (supernatural powers).
▪ Aristotle made a long term contribution regarding consciousness. He wrote extensively on
mental disorders. He generally followed the views of Hippocrates.
● LATER GREEK THINKERS
Medical and therapeutic practices developed to a higher level in the temples dedicated to
Saturn – pleasant circumstances were prepared. Physicians used many techniques – dieting,
massage, hydrotherapy, education, gymnastics, music, travelling and dance. Some less desirable
practices such as bleeding, purging and mechanical restraints were also used.
Asclepiades: (124 -40 B C) developed a theory of disease based on the flow of atoms through
the pores in the body. Treatments include massage, diet, bathing, exercise, music, rest and quiet
to restore the body balance.
● MIDDLE AGES
▪ Middle East
Islamic countries of the middle east continued the scientific aspects of Greek tradition. The first
mental hospital was established in Bagdad, where individuals received humane treatment. An
outstanding person – Avicenna of Arabia – also known as the prince of physicians, wrote the book
‘Canon of Medicine’- most widely studied medical work ever written. In his writings, Avicenna
frequently referred to hysteria, manic reactions, epilepsy and melancholia.
─ Europe
Largely devoid of scientific thinking and humane treatment for the mentally disturbed.
Supernatural explanations of the causes of mental illness grew in popularity. Two events of the
▪ HUMOUR ▪ TEMPERAMENT ▪ ELEMENT ▪ QUALITIES ▪ CHARACTERISTIC/
▪ PERSONALITY

▪ BLOOD ▪ SANGUINE ▪ AIR ▪ HOT, ▪ COURAGEOUS,

MOIST HOPEFUL,
AMOROUS

▪ YELLOW ▪ CHOLERIC ▪ FIRE ▪ HOT, DRY ▪ SHORT TEMPERED,

BILE AMBITIOUS

▪ BLACK ▪ MELANCHOLY ▪ EARTH ▪ COLD, ▪ INTROSPECTIVE,

BILE DRY SENTIMENTAL

▪ PHLEGM ▪ PHLEGMATIC ▪ WATER ▪ COLD, ▪ CALM,

MOIST UNEMOTIONAL

times: Mass Madness and Exorcism

─ Mass madness: the widespread occurrence of behaviour disorders that were apparently
cases of hysteria. Whole large groups of people were affected simultaneously. The different
manifestations are –
 Dancing manias – epidemics of dancing, raving, jumping and convulsions were
reported as early as the 10th century. The dancing mania later spread to Germany and
to the rest of Europe where it was known as Saint Vitus’s dance.
 Tarantism – a disorder that included an uncontrollable impulse to dance that was
often attributed to the bite of the southern European tarantula or wolf spider.
 Lycanthropy – outbreaks seen in isolated areas, a condition in which people believed
themselves to be possessed by wolves and imitated their behaviour.
Mass madness had reached its peak during the 14th and 15th centuries- a period noted for social
oppression and epidemics. At this time Europe was ravaged by a plague known as the Black
Death which killed millions and severely disrupted social organization. This resulted in occurrence
of many mental illnesses including mass madness.
Mass hysteria: It usually mimics some type of physical disorder such as fainting spells or convulsive
movements that occurs to a group of people occurs today also occasionally. e.g.: 1983 – it
occurred among hundreds of Palestinian girls – later found to be occurred due to severe political
repercussions.
─ Exorcism and Witchcraft: Major treatment method for the management of mentally ill.
Monasteries served as the refuges and places of confinement for them. During the early part of
medieval period the mentally disturbed were treated with considerable kindness. Some
monasteries also used exorcisms. Exorcisms are symbolic acts that are performed to drive out the
devil from the persons believed to be possessed. Usually performed by the gentle “laying on of
hands”. Such methods were often joined with vaguely understood medical treatments, derived
mainly from Galen. It had long been thought that during the middle ages, many mentally
disturbed people were accused of being witches and thus were punished and often killed. But
several more recent interpretations have questioned the truthfulness of such accusations
● HUMANITARIAN APPROACHES
During the latter part of middle ages scientific questioning re-emerged and a movement
emphasizing the importance of human interests and concerns began – movement loosely
referred to as humanism. Superstitious beliefs began to be challenged. Therapeutic treatments
were used.
The major figures in Europe are follows:
─ Paracelsus [1490 – 1541]
Swiss physician, insisted that the dancing mania was not possession, but a form of disease that
should be treated as such. Formulated the idea of psychic causes for mental illness and
advocated treatment by ‘bodily magnetism’ later called hypnosis. Although he rejected
demonology, his view of abnormal behaviour caused by astral influences. Believed that the moon
excreted a supernatural influence on human brain (lunatic, lunacy).
─ Johann Weyer [1515 – 1588]
He was a German physician and writer. He was deeply disturbed by the imprisonment, torture and
burning of people accused with witchcraft and conducted a careful study of the entire problem
and concluded that most of the accused persons are mentally sick and need treatment
Weyer published ‘Deception of Demons’ which contains a step by step rebuttal of the witch
hunting handbook, and calls for humane consideration to the sick people who are accused for
witchcraft. He was one of the first physicians who specialized in mental disorders. He can be rightly
called the founder of modern psychopathology. Weyer was scorned by his peers and his works
were banned by the church until 20th century.
─ St. Vincent de Paul [1576 – 1660]
Same as Weyer he also declared “mental diseases are no different to bodily disease and
Christianity demands of the humane and powerful to protect, and the skillful to relieve the one as
well as the other”.

▪ ESTABLISHMENT OF EARLY ASYLUMS AND SHRINES

From the 16th century on, special institutions called asylums – sanctuaries or places of refuge
meant solely for the care of the mentally ill – were established in many countries. Early asylums are
called ‘madhouses’ were not pleasant places but primarily storage spaces for the insane. The
unfortunate residents lived and died amid conditions of filth and cruelty.
First asylum – 1409 in Spain. 1547 – monastery of St Mary of Bethlem in London made in to asylum
by Henry VII – called as “Bedlam”, widely known for its deplorable conditions and practices.
More violent patients were exhibited to the public for one penny a look, and harmless inmates
were forced to seek charity in streets.

▪ HUMANITARIAN REFORMS
─ Philippe Pinel [1745 – 1826]
By the 18th century, most mental hospitals in Europe and America were in a great need of reforms.
The humanitarian treatment of patients received great impetus from the work of Philippe Pinel in
France. Pinel’s experiment in 1792 had revolutionary effects on the betterment of patients.

Pinel’s experiment: He received a grudging permission to remove the chains of some of the
inmates and to treat them with kindness and consideration – as sick people, not as beasts or
criminals. His experiment was great success, chains were removed, sunny rooms were provided,
patients were permitted to exercise in hospital grounds, the effect was miraculous. Previous noise,
filth and abuse were replaced by order and peace. It was extended to other hospitals as well.
─ William Tuke [1732 – 1822]
Established the York Retreat in England. It is a pleasant country house whether mental patients
lived, worked and rested in a kindly, religious atmosphere. This retreat represented the culmination
of noble battle against the brutality, ignorance and indifference to patients.
▪ RUSH AND MORAL MANAGEMENT IN AMERICA
─ Benjamin Rush [1745 – 1813]
The founder of American Psychiatry, also one of the signers of the declaration of independence,
encourages more humane treatment of the mentally ill.
Moral Management: A wide ranging method of treatment that focused on a patient’s social,
individual and occupational needs. Emphasized the moral and spiritual development and
rehabilitation. Antipsychotics are unavailable that time, still this movement of rehabilitation proved
to be very effective method of treatment.
▪ BENJAMIN FRANKLIN – EARLY DISCOVERY OF THE ELECTRIC SHOCK
His proposals for using electricity to treat mental problems come from his own experience with
severe shock he received accidentally that has altered his memories.
▪ DOROTHEA DIX [1802 – 1887] – MENTAL HYGIENE MOVEMENT
Starting in the 1840’s, Dorothea advocated a method of treatment that focused almost
exclusively on the physical wellbeing of hospitalized mental patients. She is credited with
establishing 32 mental hospitals, directed the opening of two large institutions in Canada, and
completely reformed the asylum system in Scotland and many other countries.
● MENTAL HOSPITAL CARE BY 20TH CENTURY
In the first half of 20th century, hospital care for the mentally ill (institutionalization) afforded very
little in the way of effective treatment. In 1946, Mary Jane Ward published a very influential book,
‘The Snake Pit’. This work called the attention to the plight of mental patients and helped to
create concern to provide mental health care in the community.
 Deinstitutionalization movement – an international movement included vigorous efforts to close
down overcrowded mental hospitals and return mentally ill people to the community, as a means
of providing more integrated and humane treatment than that was available in the ‘isolated’
environment in the hospitals.

● CONTEMPORARY VIEWS
▪ Biological discoveries
The disciplines of anatomy, physiology, neurology and general medicine advanced the
knowledge which led to the identification of biological or organic pathology underlying many
physical and psychological ailments.
▪ The development of a psychiatric classificatory system
Kreapelin paid a dominant role in the development of the biological viewpoint. His works helped
to establish the importance of brain pathology in mental disorders.
▪ Development of psychological basis of mental disorders
The first major step in understanding the psychological causation were taken by Sigmund Freud.
His Psychoanalysis emphasized the inner dynamics of unconscious motives and the role of
conflicts in developing mental disorders. He used hypnosis, free association and dream analysis to
treat patients.
Mesmerism: - Franz Anton Mesmer followed Paracelsus views about the influence of planets in the
human body. He believed that human body contains a universal magnetic fluid and planets
affects its balance. He developed a treatment called mesmerism, like hypnotism, where patients
were seated in a special tub full of chemicals and iron rods protruded to patients affected body
parts and Mesmer touch the rods with his wand in a special manner accompanying with music.
Also referred to as animal magnetism.
▪ The evolution of psychological research tradition: experimental psychology
─ Wilhelm Wundt: In 1879, he established the first psychological laboratory helps to study
the empirical causes of abnormal behaviour.
─ Lightner Witmer: founder of clinical psychology.
─ William James: pioneer in experimental psychology. Other important parallel
perspective is behaviourism, which explained the abnormal behaviours and treatment
methods using learning principles.

GENERAL RISK FACTORS

ETIOLOGY
Refers to the study and scientific investigation
into the root causes of a psychological disorder
so that it might be resolved.

CAUSES
NECESSARY SUFFICIENT CONTRIBUTORY
A condition that must exist for a A condition that guarantees the It is neither necessary not
disorder to occur. occurrence of a disorder sufficient, but these causes
contribute to the development
• If disorder Y occurs, the cause • If causes X occurs, then
of a disorder
X must have preceded it. disorder Y will also occur
• e.g. • e.g.
• If causes X occurs, the
- trisomy 21 must be - hopelessness is a
probability of Y increases
present for developing sufficient cause of
• e.g.
Downs syndrome. depression
parental rejection or abuse
may increase the probability
 - Severe stress must of adjustment or relationship
precede before problems later in child's life.
developing PTSD.
• Most mental disorders do not
have necessary cause.

FEEDBACK AND BIDIRECTIONALITY OF ABNORMAL BEHAVIOUR

Abnormal behaviors follow a causal and effect relationship. The relationship is bidirectional –
causal factors contribute to the development of disorder (effect) and the disorder or symptoms in
turn influence or maintain the cause. Most disorders are caused by more than one cause- thus
developing a causal pattern. e.g. causes such as divorce, job loss etc. leads to depression and
depression affect ones sleep and lifestyle causing insomnia, anhedonia etc. These effects in turn
negatively affect the lifestyle, i.e.; they do not search for further job or relation.
DIATHESIS – STRESS MODEL
• Diathesis – Predisposition or “vulnerability” (derived
from biological, psychological, and socio – cultural causal
factors) towards developing a disorder.
• Stress – Response of an individual to demands that are
perceived as exceeding personal resources.
• Mental Disorders/Addictions – Develop as a result of a
combination of psychosocial stressors operating on a person
who has had childhood trauma – that developed into a
diathesis for the disorder.

DIATHESIS – STRESS INTERACTION – 2 MODELS

1. Additive model: HIGH
Diathesis and stress sum together to develop a disorder.
If a person has no diathesis and still experience severe
stress can develop a disorder. If a person has high level
of diathesis and severe stress are most vulnerable to
develop mental disorder. So either diathesis or stress or
LOW
both may contribute to the development of disorder.
LOW HIGH
HIGH
High level of Diathesis
Medium level of Diathesis
No Diathesis

LOW 2. Interactive model:

LOW HIGH

High level of Diathesis

Medium level of Diathesis
No Diathesis
 Some amount of diathesis must be present before stress will have any effect in developing a
disorder. If a person has no diathesis and experience severe stress, they will not develop a
mental disorder. So both diathesis or stress together interact and contribute to the
development of disorder.

CAUSAL FACTORS AND VIEW POINTS OF ABNORMAL BEHAVIOUR

1. BIOLOGICAL VIEWPOINTS AND CAUSAL FACTORS
Mental disorders are viewed as a disorder of bodily systems; mainly nervous and endocrine system
– which may either have inherited or is caused by some organic pathology.
Mainly focused on four categories of biological factors –
1. NEUROTRANSMITTER & HORMONAL IMBALANCES IN THE BRAIN AND OTHER PARTS OF CNS
(a) NEUROTRANSMITTERS: Chemical substances that are released as a response to nerve
impulse in synapses (junction between pre and post synaptic neurons); which either excite or
inhibit the post synaptic neuron. The brain sends and process the signals through the functioning
of neurotransmitters. Imbalances in the neurotransmitters cause the development of mental
disorders. They form a chemical circuit for the normal functioning of brain.
e.g. depression is caused by the decreased functioning of serotonin – thus medicines that
prevents the reuptake of serotonin from synapse are used to treat it. Thus serotonin will be
available in synapse for long time.
The imbalances include:
• Excessive production and release of neurotransmitters in the synapse leads to functional
excess – over activation.
• Dysfunction in the deactivation of used neurotransmitters – problems in the reuptake or
degradation of used neurotransmitters.
• Problems in the receptors in post synaptic neurons- they may be abnormally sensitive or
insensitive.
Five major neurotransmitters that are involved in psychopathology
• Norepinephrine: involved in emergency and stress reactions; related to attention,
concentration, orientation and basic motives. Role in stress and anxiety disorders
• Dopamine: creates pleasure and role in cognitive processing. It has a role in schizophrenia,
depression, and addictive disorders
• Serotonin: involved in thinking and information processing. Role in affective disorders-
depression, suicide and anxiety
• Other important ones are glutamate and gamma amino butyric acid (GABA): involved in
the development of many symptoms
 (b) HORMONES: Chemical messengers produced by endocrine glands and release
directly into bloodstream then travel to target cells to produce the effect. Nervous and endocrine
systems are closely connected and referred as neuroendocrine system. e.g. pituitary gland
(master gland) which regulates the other glands through its hormones; is controlled by
hypothalamus.
Three important axes involved in psychopathology
• HPA AXIS (Hypothalamic-Pituitary-Adrenal axis):
Active during stressful situations. Hypothalamus releases corticotrophin releasing hormone(CRH)
which activate pituitary and release adrenocorticotrophic hormone (ACTH) which activate
adrenal gland to produce adrenaline and cortisol (stress hormones)- mobilize the body to deal
with stress. After action cortisol, deactivate hypothalamus through negative feedback.
Abnormalities in the negative feedback result in excessive production of cortisol and
epinephrine – leads to anxiety, depression and stress disorders.
• HPG AXIS (Hypothalamic – Pituitary – Gonadal):
Imbalances in the sex hormones leads to maladaptive sexual behaviours, sexual dysfunctions and
other behaviour problems.
• HPT AXIS (Hypothalamic – Pituitary – Thyroid): Imbalances in the thyroid hormones leads to
many maladaptive symptoms and disorders such as depression, anxiety, stress, adjustment
problems etc.

2. GENETIC VULNERABILITIES
Most mental disorders show at least some genetic influence. These are inherited though our
genes, which are placed in chromosomes we get from our parents- 23 pairs: 22 pair autosomes
and one pair sex chromosomes. Research in developmental genetics proved that abnormalities in
the structure and number of chromosomes leads to the development of a disorder. e.g. trisomy 21
– Downs syndrome. Most mental disorders have polygenic effect- their occurrence are influenced
by the interactive or additive action of multiple genes. Also caused by polymorphisms: - naturally
occurring variations in genes. A Genetically vulnerable person usually has large number of
inherited abnormalities/ polymorphic genes that operate together in additive or interactive
fashion which leads to the structural abnormalities in nervous and endocrine system.
(a) GENOTYPE – ENVIRONMET INTERACTIONS: In most disorders, genetic factors are contributory
to the disorder. They contribute to the vulnerability or diathesis which is then combine with
significant stressor in life leads to the development of a disorder. e.g.: genetic risk for depression
(inherited genes or polymorphism) + severe stress → depression. Explained by Diathesis –Stress
model of abnormal behavior.
• GENOTYPE – a person’s total genetic endowment
• PHENOTYPE – observed structural and functional characteristics results from the interaction
of genotype and environment.

(b) GENOTYPE – ENVIRONMENT CORRELATIONS: Sometimes genotype shapes the environmental

experience a child has, known as genotype environment correlations.
A child’s genotype has 3 types of effects:
▪ Passive effect: - genotype has passive effect on the environment. Ex: highly intelligent
parents (genes) provide highly stimulating environment for child. Thus both are positively
correlated
▪ Evocative effect: - child’s genotype may evoke particular kinds of reactions from others.
e.g. positive and happy babies evoke more positive response from others.
▪ Active effects: - child’s genotype may play a role in shaping the environment. e.g. an
extrovert child always seeks and finds many companies and friends in any conditions.
Methods of studying genetic influences
─ BEHAVIOUR GENETICS:
This field focus on studying the heritability of mental disorders, normal and abnormal behaviours.
Many methods are using for this studies:
• Family history/ pedigree method: investigator observes the first and second degree
relatives of proband (subject or carrier of disorder)- to find out the rate of occurrence of
disorder among family and also compare it with general population (incidence).
• Twin method: find out the concordance rate – percentage of twins sharing the disorder.
Studies monozygotic and dizygotic twins- who reared apart and reared together
• Adoption methods: compare the biological parents of adopted children who have
disorder and biological parents of normal adopted children. Compare the biological
parents who have the disorder with others who don’t have the disorder.
• Linkage Analysis and Association Studies: Attempt to determine the actual location of
genes responsible for mental disorders. Linkage analysis: tries to analyze is there any
linkage or close association between genes causing mental disorders and some known
physical characteristics (genetic markers). Ex: trace the relation between eye color and
schizophrenia- find out whether a specific eye colored persons has schizophrenia in a
population. If it occurs like this, we can prove that genes for schizophrenia are closely
associated with genes for eye color.
Findings: →Bipolar disorder – genes in chromosome 2
→Schizophrenia- chromosomes 22, 6, 8 and 1
Association studies are also similar to these in which investigators compare two large groups; one
with disorder and other without disorders – to find out the relation between genetic markers and
mental disorders.
3. TEMPERAMENT
Refers to a child’s characteristic ways of reactivity and self-regulation. Strongly influenced by
genetic factors, pre and post-natal experiences.
Early temperament (2 to 3 months of age): largely inherited/ genetical.
Mainly 5 dimensions:
i. Fearfulness, irritability and frustration
ii. Positive and happy effect
iii. Activity level- high or low
iv. Attentional persistence
v. Effortful control
There are 3 dimensions of adult personality related to Childs
i. Neuroticism or negative emotionality
ii. Extraversion or positive emotionality
iii. Constraint (conscientiousness and agreeableness)
Relationship between early temperament and adult psychopathology
• Behaviourally inhibited children: - fearful, shameful and hyper vigilant children have
increased chance for developing stress, anxiety disorders and depression. These traits are
highly heritable
• Behaviourally uninhibited children: - fearless, easy going extroverts who obeys no rules and
regulations- later develops conduct disorder by age 13 and may progress into antisocial
personality disorder in adult life.
4. BRAIN DYSFUNCTION AND NEURAL PLASTICITY
(a) SPECIFIC BRAIN LESIONS AND DAMAGE TO NERVE TISSUES CAUSES MENTAL DISORDERS: These
studies are doing with the help of neuroimaging or scanning techniques.
(b) NEURAL PLASTICITY: Flexibility of the brain in making changes in organization and function in
response to pre and post-natal experience, stress, diet, disease, drugs and maturation.
Existing neural circuit can be modified and new neural circuits can be generated (either
 beneficial or detrimental). Neural plasticity is somewhat lifelong and highly applicable in
humans also.
(c) POSITIVE EFFECT OF PRENATAL EXPERIENCE: an experiment was conducted by providing highly
enriched environment for pregnant rats and later found that the offspring of those rats
were less negatively affected by brain injuries than that of other group with no such
settings. Post-natal experience: formation of new neural connections are affected by
experiences an organism has e.g.: rats brought up in enriched environment shows
heavier and thicker brain cell development and more synaptic connections.
(d) NEGATIVE EFFECT: pregnant monkeys were exposed to loud sounds and later found that
their offspring had neurochemical abnormalities.
Developmental system approach
Gene activity influence one’s neural activity which in turn influence one’s behavior and behavior
influence the environment. These effects are bidirectional. Environment influences one’s behavior
and it in turn influence or modify the neural activity and it influence (suppress or exaggerate) the
gene expression.

2. PSYCHOLOGICAL VIEWPOINTS AND CAUSAL FACTORS

PSYCHOLOGICAL VIEWPOINTS
Factors that make people vulnerable to disorder. These factors alone or interact with each other
and also with genetic environmental factors which gives rise to psychopathology. Explains the
major viewpoints or perspectives in explaining human behaviour
1. PSYCHODYNAMIC PERSPECTIVES:
(a) SIGMUND FREUD’S PSYCHOANALYTIC THEORY
Key concepts:
Unconscious repressed materials has the main role in developing
psychopathology, which always seeks expression and emerges
in fantasies, dreams, slips of tongue, and as maladaptive
behaviours.
Intrapsychic conflict between id, ego and super ego due to
different goals creates anxiety, plays a key role in the
development of abnormal behaviours.
Anxiety are of 3 types: -
Reality or objective anxiety, which is conscious and can deal by
the ego.
Neurotic and moral anxiety, which are mainly unconscious and
cannot be dealt by the ego using rational ways. So ego uses
irrational protective measures – defence mechanisms.

Types of defence mechanisms

PATHOLOGICAL/ NARCISSISTIC IMMATURE DEFENSES
─ Denial ─ Acting Out
─ Distortion ─ Blocking
─ Projection ─ Hypochondriasis
─ Introjection
─ Passive – aggressive behaviour
─ Regression
─ Schizoid Fantasy
─ Somatization
 Freud’s Defence Mechanisms
DEFENSE MECHANISMS DESCRIPTION EXAMPLE
REPRESSION Unknowingly placing an unpleasant Not remembering a traumatic
memory or thought in the incident in which you witnessed
unconscious. crime.
REGRESSION Reverting back to immature Throwing temper tantrums as an
behaviour from an earlier stage of adult when you don’t get your way.
development.
DISPLACEMENT Redirecting unacceptable feelings
Taking your anger towards your boss
from the original source to a safer,
out on your spouse or children by
substitute target. yelling at them and not your boss.
SUBLIMATION Replacing socially unacceptable
Channelling aggressive drives into
impulses with socially acceptable
playing football or inappropriate
behaviour. sexual desires into art.
REACTION FORMATION Acting in exactly the opposite way
Being overprotective of and
to one’s unacceptable impulses.
lavishing attention on an unwanted
child.
PROJECTION Attributing one’s own unacceptable Accusing your boyfriend of cheating
feelings and thoughts to others and on you because you have felt like
not yourself. cheating on him.
RATIONALIZATION Creating false excuses for one’s Justifying cheating on an exam by
unacceptable feelings, thoughts or saying that everyone else cheats.
behaviour.
NEWER PSYCHODYNAMIC PERSPECTIVES

STAGE AGE TASK PROBLEMATIC TRAITS

ORAL Birth to 18 months Establishment of trust, Excessive dependency, envy and
comfortable expression, and jealousy, narcissism, pessimism,
gratification of oral needs. excessive optimism.
ANAL 18 months to 3 years Learning independence and Orderliness, obstinacy, frugality,
control. heightened, ambivalence,
messiness, defiance, rage,
obsessive compulsive,
sadomasochism.
PHALLIC/ 3 to 6 years Identification with same – sex Sexual identity issues, castration in
OEDIPAL parent, development of males, penis envy in females,
sexual identity. excessive guilt.
LATENCY 6 to 12 years Sexuality sublimated, Inability to sublimate energies to
emphasis on same – sex learn, excessive inner control,
peers. obsessive traits.
GENITAL 13 to 20 years Establishment of separation Reworking all the previous
from parents and mature no developmental issues,
incestuous relationships with establishing a life not dependent
others on parents.

NEWER PSYCHODYNAMIC PERSPECTIVES

• Ego Psychology – Anna Freud
Mainly concentrated on ego and defence mechanisms. Psychopathology occurs when ego isn’t
able to do its executive functioning properly and can’t use adequate defence mechanisms
properly. Can’t control ones’ delay gratification.
• Object relations theory – Melanie Klein, Mahler, Fairburn et al
▪ Object – symbolic representation of another person in a child’s environment: parent. Focus on
the individuals’ interactions and relationships with real (external objects) and imagined
(internal objects).
▪ Introjection – process through which a child incorporates the characteristics and traits of
objects into his/her own personality.
▪ Internalization of image of a punishing father creates a stubborn, harsh or self-critical
personality in later life.
▪ Conflict arises when these different images start to split off from the central ego and tries to
seek independent existence. An individual experience such splitting among internalized
objects is ‘the servant of many masters’ and lead a disintegrated abnormal life
▪ Otto Kernberg proposed that people with borderline personality disorder (unstable character,
feelings and relations, sudden mood swings and not having a full sense of self identity); are
unable to integrate and reconcile many pathological internalized objects.
Interpersonal Perspective
•
Focus on the social determinants of behaviour and relationship with others; defects in these
causes psychopathology
▪ Alfred Adler: social beings motivated by desire to belong and participate in group. When
these needs are blocked, maladaptive behaviours occurs
▪ Karen Horney: psychopathology results from the insecure attachment to parents during
childhood, which creates neurotic anxiety leads to development of maladaptive traits
▪ Erikson: proposed a stage concept of life span, and each stage has different function. Conflict
in proper development leads to psychopathology. e.g. conflict in oral stage leads to the
development of mistrust
▪ John Bowlby: early attachment relationships influence later personality development.

2. BEHAVIOURAL PERSPECTIVES
A movement against psychoanalysis; rejected the importance of subjective experiences,
unconscious motives and conflicts. Mainly concentrate on directly observable behavior. Central
theme – learning (a relatively permanent change in behavior as a result of experience). Most
behaviors- both normal and abnormal are learned ones and that can be unlearn through
learning principles. John Watson – founder of behaviorism.
─ BEHAVIORIST APPROACH(A01)
• Classical Conditioning: Is about the association between a stimulus and a response ~
Pavlov. e.g. phobias arise from stimulus – response associations.
Fear of flying → a person enters the airport (stimulus) they feel hot, sweaty and nauseous
(response) the association between the two causes the phobia.

• Operant Conditioning: Is when we learn to behave in certain ways due to positive and
negative reinforcement ~ Skinner. Abnormal behaviour can result from reinforcement. e.g.
The early stages of drug abuse can be encouraged by positive reinforcement because of
the pleasure or comfort associated with drug use.
Anxiety → a person is rewarded when they are anxious by concern and attention from
others so they will repeat the behaviour.
 Eating disorders → a person will avoid the negative emotions associated with eating such
as weight gain.
• Social Learning Theory: Behaviour is shaped by observing and imitating the behaviour of
other ~ Bandura.
Aggression → imitating role models being rewarded for that anti – social behaviour.
Phobia → a child will imitate the fear of a role model who receives attention and
concern from others.
Apply classical conditioning, operant conditioning and social learning theory to the explanation
of abnormal behaviour.
- How can we apply Classical Conditioning to the explanation of Phobias?
Fear of heights: If a person climbs to the top of a high building (stimulus), looks down and
feels nausea and dizziness (response), the association between the two, and the response
will cause the phobia.
- Operant Conditioning can explain some psychological disorders such as antisocial
personality disorder – how?
If childhood aggression is reinforced, then the behaviour is likely to be repeated. Also,
anxiety or depression might receive reward in the form of attention and concern, also
making the behaviour be repeated.
- How can Social Learning Theory best explain some other phobias and disorders?
Antisocial behaviour can also be explained by SLT if a child observes a model who is
rewarded. This can lead to imitation. Also some phobias develop due to observing how a
model responds to a stimulus.

3. COGNITIVE- BEHAVIOURAL PERSPECTIVES

Individuals who suffer from mental disorders have distorted and irrational thinking styles –
which may cause maladaptive behaviour. It is usually the way you think about the problem rather
than the problem itself which causes the psychological problems. Individuals can overcome
mental disorders by learning to use more appropriate cognitions (thought processes).
─ AARON BECK
▪ Cognitive Model of Development: Early childhood experiences lead to basic beliefs
about oneself and one’s world.
▪ Automatic Thoughts: It is a significant role in perceived distress.
▪ Cognitive Schemas: How individuals think about their world. Schemas develop early
in life from personal experience and interaction with others.
─ BECKS COGNITIVE TRIAD OF DEPRESSION AND COGNITIVE ERRORS

─ ATTRIBUTION THEORY
PSYCHOLOGICAL CAUSAL FACTORS
Mainly four categories:
1. EARLY DEPRIVATION OR TRAUMA:
Inadequate resources (food, shelter, love and caring) leads to deprivation and creates irreversible
psychological issues. Common in abandoned or orphans in foster homes. These institutionalized
children lack physical contact and social stimulation also which causes behavioral, emotional
and learning problems.
(a) PARENTAL DEPRIVATION: Children who deprived of parental love, warmth and caring shows
many behavioral, adjustment and relationship problems. Different views are:
• Freud: it causes fixation in the oral stage
• Erickson: interfere with the development of basic trust. The child will be distrustful and
suspicious.
• Skinner: retard the social and personal skill development due to lack of stimulation and
reinforcement
• Beck: develop dysfunctional schemas about relationships (untrustful and unstable)

(b) INSTITUTIONALIZATION: Less warmth and physical stimulation, which negatively affect the
intellectual, emotional and social skills. Disturbed attachment relationships and psychopathology.
Delayed maturation and skill development.
• NEGLECT AND ABUSE IN HOME:
• Parental neglect: physical avoidance, denied of love and affection, lack of interest in
child’s activities or achievements, failure to spend time with children etc.
• Parental abuse: cruel treatments, emotional, physical or sexual abuse.
• Separation: Prolonged separation from parents’ cause despair, insecurity, increased
vulnerability to stressors, anxiety etc. and also shows detachment upon reunion with
parents.
Effects:
→ Children become aggressive, bullying and develop a disorganized or disoriented style
of attachment (insecure, inconsistent and unstable behaviors with caregivers).
→ Difficulties in language and communication skill development.
→ May be depressed, anxious, shows relationship problems, and drug abuse.

2. INADEQUATE PARENTING STYLES:

Deviations in the parenting also affect child’s mental health, because parent-child relation is a
continuing bidirectional relationship.
─ PARENTAL PSYCHOPATHOLOGY: High risk for children in developing difficulties. Some mental
disorders have very high genetic component; especially depression, drug abuse,
schizophrenia, antisocial personality disorder. e.g.: children of alcoholic parent have increased
risk for developing delinquent, antisocial traits and increased risk to become a drug addict.
─ PARENTING STYLES: Attitudes and values that are expressed towards a child across situations.
Four types of parenting styles//varies in degree of two dimensions
▪ Parental warmth: support, affection & encouragement Vs rejection, hostility & shame.
▪ Parental control: extent of discipline & monitoring Vs leaving unsupervised; it includes
behavioral control (by giving reward or punishment) and psychological control
(expression of approval or guilt induction)
Four types:
• Authoritative: High on warmth and moderate on control
They are very loving, attentive and caring at the same time set clear standards and
limits on certain behaviors while allowing freedom with in those limits. Their children have
positive early social development, energetic, friendly and good relations. Secure
attachment style, good resilience ability, good school performance and less likely to
have emotional and behavioral disorders.
• Authoritarian: low on warmth and high on control
Parents are cold, demanding and use punishment methods or overdisciplined. The
children become conflictual, irritable and moody. At adolescence they show lower
competence; boys tend to have increased risk for substance abuse and delinquency.
• Permissive or Indulgent: high on warmth and low on control
Overly indulged and protective but never sets limitations of any kind. Children become
impulsive, aggressive, selfish, demanding, inconsiderate and generally called as spoiled.
At adolescent age they show more antisocial behaviour and adjustment problems.
• Neglectful or Uninvolved: low both on warmth and control
The child develops disruptive attachment style, low self-esteem, moody and anxious.
Problems in interpersonal relations, academics and occupation.

3. MARITAL DISCORD AND DIVORCE:

Disturbed family structures will increase the vulnerability to disorders.
(a) MARITAL DISCORD: Frustrating, hurtful and damaging effects on both adults and children.
Children tend to be aggressive both to parents and peers. During adulthood, they show conflict in
their own romantic relations, and their own marriages likely to marked by discord, because they
learned negative interaction style from parents.
(b) DOMESTIC VIOLENCE: Refers to the use of unprovoked force to cause damage of any
type physical, emotional, sexual or financial- by a family member or spouse. Major cause of
physical and mental ill health of victims.
Includes:
• Physical violence (beating, kicking, slapping, attempts to kill etc.) – 96% cases
• Overburdening with work – 65%
• Forced abortion – 82%
• Withholding love and care – 53%
• Threats to end relationships – 83 %
• Spouse cruelty, rape, kidnap, dowry, psychiatric morbidities and sexual harassment also
included
Victims shows high levels of mental health problems, depression, psychosomatic issues, suicide
etc.
DIVORCED FAMILIES: In western countries half of the families are divorced and children
live in single parent families. In India also divorce rate is increasing. It has detrimental effect in
mental health. But divorce is beneficial for highly stressful and abusive marriages. Effect of divorce
on children:
→ Feelings of insecurity and rejection
→ Conflicted loyalties
→ Overindulgence of one parent creates conflict
 → Delinquency, anxiety, depression and maladaptive behaviors
→ Abuse from step parents
→ Conflicted relationships in adulthood

4. MALADAPTIVE PEER RELATIONSHIPS:

Peers mainly influences in preschool and adolescent years.
─ BULLYING causes severe stress and aggression in children and adolescence.
─ CYBER BULLYING (sending offensive, harassing or intimidating messages over the internet,
spreading ugly rumors and very personal information through internet sites) creates anxiety, school
phobia, lower self-esteem, and suicidal ideation among victims.
Sources of popularity vs rejection:
Two types of popular children and adolescence; the prosocial and antisocial types.
• Prosocial: communicate with peers in friendly, assertive and cooperative manner.
• Antisocial: usually boys, called “tough boys”- aggressive and defiant of peers and
authority.
─ REJECTED CHILDREN: two types – those who are too aggressive or those who are too
withdrawn
• Aggressive children: excessively demanding and aggressive approach when interacting
with peers. Offensive and attribute hostile intent to peers teasing. They are more punitive
and less forgiving. Poor ability to understands peers’ emotions. Mainly caused by the
maltreatment from home.
• Withdrawn children: highly unassertive and submissive toward peers. Often victims of
bullying and rejection.
In any of these case the children have risk for a variety of negative outcomes including
dropout, delinquency, anxiety, depression, suicidal ideation etc.

3. SOCIOCULTURAL VIEWPOINTS AND CAUSAL FACTORS

SOCIOCULTURAL VIEWPOINTS
Describe about the relationship between various socio cultural factors and mental disorders.
Impact of culture and other features of social environment (family, friends, institutions, norms,
values and standards) in developing mental disorders.
1. UNIVERSAL & CULTURE SPECIFIC SYMPTOMS AND DISORDERS
Many psychological disturbances are universal: seen in all cultures but studying is not easy
because of the absence of universally accepted tests. Occurrence of disorders in cultures; some
findings are-
• Schizophrenia has most favorable course in developing countries than in developed
countries.
• Depression is more in western countries due to lack of support system

2. CULTURE AND OVER CONTROLLED &/ UNDER CONTROLLED BEHAVIOUR

Under controlled behaviours: - aggression, disobedience and disrespectful acts
Over controlled behaviours: - shyness, anxiety and depression
In some cultures, such as that of Thailand, adults are highly intolerant to under controlled
behaviors, children are taught to be polite and inhibit anger. They are more tolerate to over
controlled behaviors compared to us. So among Thai children problems related to over controlled
behaviors are common; eg: anxiety and emotional disorders. Among us children problems related
to under controlled behaviors are common; such as adjustment, relationship problems, bullying,
aggression etc.
 COMMON CULTURE – BOUND SYNDROMES
Syndrome Region/ Population affected Description
AMOK Malaysia Dissociative episode characterized by a
period of brooding followed by an
outburst of violent, aggressive or
homicidal behaviour.
ARCTIC HYSTERIA Alaska Natives Abrupt dissociative episode
accompanied by extreme excitement
and frequently followed by convulsive
seizures and coma.
ATAQUE DE NERVIOS Latin America Symptoms include uncontrollable
shouting, attacks of crying, trembling,
heat in the chest rising to the head and
verbal or physical aggression.
BRAIN FAG West Africa Symptoms include difficulties in
concentrating, remembering and
thinking.
KORO Malaysia Sudden anxiety that the penis will
recede into the body and possibly
cause death.
MAL DE OJO (EVIL Spain A common idiom to describe disease,
EYE) Latin America misfortune and social disruption.
WINDIGO Native Americans Morbid state of anxiety with fears of
Central & N.E Canada becoming a cannibal.

SOCIOCULTURAL CAUSAL FACTORS

1. LOW SOCIOECONOMIC STATUS & UNEMPLOYMENT
Many studies proved that lower the SES, higher the incidence of many mental and physical
disorders. e.g.: antisocial personality disorders occur 3 times greater in low SES population.
Depressive disorders are 1.5 times greater in them.
Reasons:
→ Prejudice and stigma towards them
→ Unable to get proper help and treatment
→ Poverty: most severe stress. There is a strong relationship between parent’s poverty and
lower IQ’s in children up to age 5.
→ Some people (even in higher SES) slide down to lower range because of their maladaptive
behaviours
Unemployment
Economic recessions created millions of unemployment. The resulting financial hardship and
uncertainty causes great emotional distress and enhanced vulnerability to psychopathology.
Common problems are; depression, marital problems, somatic complaints, anxiety etc.
2. PREJUDICE & DISCRIMINATION IN RACE, GENDER AND ETHNICITY
Demoralizing stereotypes are present in all areas such as employment, education and housing. Ex:
in most campuses, many students socialize informally only with members of their own cultures
Prejudice and discrimination against minority groups are very common, which decreases their self-
esteem and increase the prevalence of depression. e.g. African American racial discrimination.
Prejudice against Muslim community after the attack on World trade center.
Discrimination against women; In work place: - two primary types
1. Access discrimination: positions where in women are not hired
2. Treatment discrimination: women paid less and get fewer opportunities
Sexual harassment, multiple social roles (full time mother, homemaker, employee). These all
creates higher stress which in turn causes anxiety, depression and marital dissatisfaction.
3. SOCIAL CHANGE AND UNCERTAINITY
Sudden drastic social changes that occurs due to wars, terrorist attacks, unemployment etc.
results in increased stress and related problems. Peoples in war areas are always in a state of
uncertainty which creates many psychological issues. Migration from countries also results in very
pathetic mental conditions. e.g.: terrorist attack in 2001- many Americans shows increased
anxiety, emotional and health problems after that. Israel Palestine war.
4. URBAN STRESSORS: VIOLENCE AND HOMELESSNESS
Rapid urban growth in less developed countries results in growing number of unemployed, poor,
homeless and people engaged in illicit activities such as criminals, drug dealers, prostitutes etc.
These are the important causal factors in developing mental disorders. Urban violence and
domestic violence specially against women and children creates increased rate of anxiety,
depression, suicide, PTSD, somatic illnesses among victims. Homelessness also creates a feelings of
insecurity which is detrimental to mental health. These all occur in both developed and less
developed countries.
**
CAUSAL FACTORS
● BIOLOGICAL FACTORS – Genetic defects, inheritance, pre and post – natal complications,
head injuries, exposure to toxins, chronic physical illness/disability.
● PSYCHOLOGICAL FACTORS – Troubling life experiences
▪ Intrapsychic – distorted thoughts, feelings and perceptions, stress & trauma
▪ Interpersonal – arguments and problems between people
● SOCIO CULTURAL FACTORS – Immediate circle (family)- parental factors (immature, mentally ill,
abusive or criminals), marital problems. Extended circle (friends, schoolmates, relatives &
Other peoples in our environment). Poverty, homelessness, overcrowding, stressful living
conditions, discrimination and prejudice.
BIOPSYCHOSOCIAL PERSPECTIVE OF ABNORMALITY
Abnormal behaviours are caused by the combined effects of biological, psychological and
sociocultural factors.
Diathesis – stress model
The proposal that people are born with a predisposition (diathesis) that places them at risk for
developing psychological disorders, if exposed to certain extremely stressful life experiences

KEY TERMS
• Syndrome – Cluster of symptoms that can result from different disease processes
• Disease – A definite pathological process having a characteristic set of signs and symptoms
• Diagnosis – Simply the opinion expert that a given disorder is present or absent in a patient.
• Diagnostic classification – Listing of different diagnosis grouped by their relatedness. Ex: anxiety
disorders (phobia, GAD, OCD, panic disorder).
• Diagnostic criteria – Rules that need to be followed by making a diagnosis.
 MODULE 2: STRESS DISORDERS AND ANXIETY
DISORDERS
STRESS
“Experiencing events that are perceived as endangering one’s physical or psychological
wellbeing”
Stress is a state of psychological and physical tension produced when
an individual perceives that they are unable to cope with the
demands imposed on them by a stressor. The consequent state of
tension can be adaptive (eustress) or maladaptive (distress).
A bodily or mental tension resulting from factors that tend to alter an
existent equilibrium. The definition has several elements:
─ There is a tension (force pulling on the system)
─ The tension is a threat to the normal equilibrium of the system
─ There is some compensation to reduce harm on the system
─ Bodily or mental tensions:
• Physical stressors: Ones that pose a direct threat to our physical well – being. e.g. cold,
heat, infection, toxic substances.
• Psychological stressors: Events that challenge our safety, not because they are
physically dangerous, but because our thoughts, perceptions and interpretations. e.g.
failing a test, sound of footsteps on a dark street.
STRESSORS: The events that cause the stress (e.g. car accidents, wars, exams, etc.)
• Acute Stressor – Only last for a short time
• Chronic Stressor – Last for an extended period of time
STRESS RESPONSE: People’s reactions to the stressors.
BEHAVIORAL MEDICINE: The study of how stress and other social, psychological and biological
factors come together to contribute to illness.
- Environmental stimulus
“I have a high stress job”
- Physical response
“My heart races when I feel a lot of stress”
- Interaction between environment and person
“I feel stressed when I have to make financial decisions at work, but other types of decisions don’t
stress me”
TYPES OF STRESS
● Eustress (good stress) – Motivates you to move into action to get things accomplished.
Happens in fun and exciting situations.
● Distress (bad stress) – Most common form of stress. Something we all go through in our daily
lives and often we don’t even notice it happening.
Benefits of Eustress
Performance Health
Increased arousal Cardiovascular efficiency
Bursts of physical strength Balance in the nervous system
Full engagement Enhanced focus in an emergency
Costs of Distress
Individual Organizational
Psychological disorders Participation problems
Medical illnesses Performance decrements
Behavioural problems Compensation awards
CATEGORIES OF STRESSFUL EVENTS
• Traumatic events
Situations of extreme danger that are outside the range of usual human experiences. e.g.
disasters, man-made disasters, catastrophic accidents, physical assault.
• Uncontrollable or unpredictable events
Controllability: The degree to which we can stop an event or bring it about influences our
perception of stressfulness. Perception plays an important role in controllability.
The less controllable an event, more likely it is to be stressful.
Predictability: The degree to which we know if and when an event will occur. Ability to predict the
occurrence of event reduces the severity of stress. People perceive predictable shocks as less
aversive than unpredictable ones.
• Major changes in life circumstances
Any life change that requires numerous readjustments can be perceived as stressful. Negative
events have a much greater impact on physical and psychological health than positive events.
Life Events Scale measures the impact of life changes, ranks events from most stressful to least
stressful.
• Internal conflicts
Unresolved issues that may either be conscious or unconscious. Conflict occurs when a person
must choose between incompatible, or mutually exclusive, goals or actions. Conflict may rise
when two inner needs or motives are in opposition:
- Independence vs. dependence
- Intimacy vs. isolation
- Cooperation vs. competition
- Expression of impulses vs. moral standards
SYMPTOMS OF STRESS
PHYSICAL SYMPTOMS BEHAVIOURAL SYMPTOMS
o Poor performance o Increased use of alcohol or drugs
o Increased sickness o Difficult relationships
o Cold and sweaty palms o Reduced social contact
o Headache/backache o Poor judgement/ indecision
o Jaw pain o Loss of appetite
o Heartburn o Irritability
o Diarrhoea o Tearfulness

STRESS RESPONSES
MAIN THEORIES OF STRESS
5. CANON’S FIGHT OR FLIGHT THEORY
Studied how stressors affect the sympathetic nervous system (SNS). “fight or flight” response
(Physiological response to stress):
Perception of stress

Activation of the SNS

Body prepared for intense motor activity for attack, defence, or escape

Psychological reactions to stress (Activation of SNS)

- Increased respiration rate
- Increased heart rate
- Higher blood pressure
- Increased metabolic rate
- Dilation of pupils
- Tensing of muscles
- Secretion of endorphins an ACTH
- Release of extra sugar from the liver

Fight or Flight response

Occurs through two routes
1. Adrenomedullary axis
Sympathetic nervous system

Adrenal Medulla

Catecholamine
(containing epinephrine and norepinephrine)

Cardiovascular, digestive, respiratory

2. Hypothalamic pituitary adrenal axis

Hypothalamus

CRH

Anterior pituitary

ACTH

Adrenal Cortex

Glucocorticoids (cortisol)

6. SELYE’S GENERAL ADAPTATION SYNDROME

Our innate response to stress was the same whether it is a tiger on a tree, getting cut off in traffic,
having to sit for an exam or having an argument with your spouse. Stress always triggers the same
innate survival mechanism.
Stressor (stimulus) – Any event or situation that triggers coping adjustments
Stress (response) – The process by which we perceive and respond to events that are perceived
as harmful, threatening or challenging.
The General Adaptation Syndrome (GAS)
A model of how the body defends itself in stressful situations.
• Alarm reaction: Body’s defences against a stressor are mobilized through activation of SNS
(preparing for fight or flight).
• Resistance: The organism adapts to the stressor (HPA axis activation).
• Exhaustion: Organism’s ability to resist is depleted and a breakdown results (diseases of
adaptation).

7. LAZARUS’ COGNITIVE APPRAISAL MODEL

The first psychological model of stress. Interpretation of the stressful event is more important than
the event itself. The individual’s perception of the psychological situation is the critical factor.
Appraising Events
• Primary appraisal – Determination of an event’s meaning, it’s effects their well-being.
• Secondary appraisal – Evaluation of one’s ability to control or cope with the event.
• Cognitive reappraisal – Process by which events are constantly re-evaluated.
Appraisals to assess situations
▪ Primary Appraisal – Determination of an event’s meaning, its effects on their well-being
(positive, negative or neutral).
─ Stressful appraisal: Event is seen as harmful, threatening or challenging
▪ Harm: When we lose/ expect to lose something of value to us (damage that has
already been done)
▪ Threat: Believing an event is demanding and will put us at risk for damage
(anticipation of harm)
▪ Challenge: Believing that we will grow from the event; we a person’s
confidence in overcoming difficult demands.
▪ Secondary Appraisal – Evaluation of one’s ability to control or cope with harm, threat or
challenge. 3 questions asked:
─ What options are available to me?
─ What is the likelihood that I can successfully apply the necessary strategies to reduce
the stress?
─ Will this process work, will it alleviate my stress?
▪ Cognitive Re – appraisal – Process by which events are constantly re-evaluated.
Event

Primary Appraisal
Harm (damage)
Threat (Future damage)
Challenge (slight positive)

Secondary Appraisal
Are my responses sufficient?

Yes No

No/Low stress High Stress

STRESS DISORDERS
(1) ADJUSTMENT DISORDER
(a) PTSD
(2) ANXIETY DISORDERS
(a) Specific Phobia
(b) Social Phobia
(c) Generalized Anxiety Disorder (GAD)
(d) Obsessive Compulsive Disorder (OCD)
(3) OTHER TRAUMA & STRESS DISORDERS
(a) Acute Stress Disorder (ASD)
(b) Reactive Attachment Disorder
(c) Disinhibited Social Engagement Disorder

1. ADJUSTMENT DISORDERS
“An adjustment disorder is a condition of emotional distress triggered by significant subjective
events in an individual’s life.”
According to ICD -10, It is defined as “a state of subjective distress and emotional disturbance,
usually interfering with social functioning and performance, arising in the period of adaptation to
a significant life change or stressful event.” Adjustment disorders are classified in the DSM -5 as a
range of stress response syndromes. This differs from the DSM – IV, in which adjustment disorders
were part of a residual category for individuals experiencing clinically significant distress that did
not fit diagnostic criteria for other psychiatric disorders. Diagnostic specifiers for the adjustment
disorders include with depressed mood, with anxiety, with mixed anxiety and depressed mood,
with disturbance of conduct, with mixed disturbance of emotions and conduct, and unspecified.
ADJUSTMENT DISORDERS IN DSM – 5
• CRITERION A – The development of emotional or behavioural symptoms in response to an
identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
• CRITERION B – These symptoms or behaviours are clinically significant, as evidenced by one
or both of the following:
8. Distress is out of proportion to the severity or intensity of the stressor
▪ External context
▪ Cultural factors
9. Significant impairment in social, occupational or other important areas of functioning.
• CRITERION C – The stress – related disturbance does not meet the criteria for another
mental disorder and is not merely an exacerbation of a pre-existing mental disorder.
• CRITERION D – The symptoms do not represent normal bereavement.
10. Conditions for further study – persistent complex bereavement disorder
• CRITERION E – Once the stressor or its consequences have terminated, the symptoms do
not persist for more than an additional 6 months.
Types of Adjustment disorders and their symptoms
• With depressed mood: Symptoms of sadness, tearfulness, hopelessness, or depression that
do not meet criteria for an episode of major depressive disorder or bereavement.
• With anxious mood: Symptoms of nervousness, fearfulness or anxiety that do not meet
criteria for an anxiety disorder.
• With mixed anxiety and depressed mood: Symptoms of both depression and anxiety, often
most common in older adults.
• With disturbance of conduct: Symptoms predominantly behavioural and often involving
acting out, fighting and disregarding the rights of others.
• With mixed disturbance of emotions and conduct: Symptoms including anxiety, depression
and behavioural problems.
• Not otherwise specified: Symptoms including maladaptive symptoms or behaviours related
to the stressor that are not included in the other subtypes.
Common symptoms
• Hopelessness
• Frequent crying
• Depressed mood
• Trembling or twitching
• Palpitations
• Health problems
• Withdrawal
• Anxiety or tension
• Acting rebellious or impulsive
• Acting anxious
• Withdrawn attitude
• Feeling sad and hopeless
• Suicidal thoughts
• Loss of self esteem
• Crying
Stressor does not have to be severe or outside the
“normal” human experience.
Prevalence
• Very common disorder
• In a study conducted in US, 10% had AD
• Male to female ratio is 1:2
• Outcome of depression international network (ODIN) study (18) found a prevalence of only
1% for AD in 5 European countries.
• Studies have also found a higher rate of AD among persons exhibiting suicidal behaviour,
mainly adolescents and young adults.
• AD has been reported to be almost three times as common as major depressions.
• Studies of soldiers psychiatrically evacuated from Iraq over a three-year period found that
AD wad the most common diagnosis made in 40% of evacuees.
Etiology
• Intrinsic factors – Age, sex; intellectual, emotional and ego development; coping skills;
temperament; past experiences.
• Extrinsic factors – Parents and support systems; expectations, understanding, skills, maturity
and support available from the child’s larger environment.
• Family conflict/ parental separation
• School problems/ changing schools
• Sexuality issues
• Death/illness/trauma in the family
• Responses may be familial(genetic/learned) and situational
• Death of family member or friend
• Relationship issues or divorce
• Major life changes
• Illness or health issue
• Moving to a new house or place
• Sudden disasters
• Money troubles or fears
Causes in children and teenagers
• Family fights or problems
• Problems in school
• Anxiety over sexuality
Management/Treatment
• It is conceptualized as a transitory diagnosis; brief therapies may be most appropriate
• There is no single treatment intervention approach for the heterogeneous clinical
manifestation of the disorder.
• The primary goals of treatment are to relieve symptoms and the achievement of a level of
adaptive functioning that is comparable to, or in some situations better than, the level of
premorbid functioning.
 • Supportive psychological approaches and cognitive – behavioural and psychodynamic
interventions.
• Relaxation techniques can reduce symptoms of anxiety.
• In persons who engage in deliberate self – harm, assistance in finding alternative responses
that do not involve self – destruction may be of benefit and to date Dialectical Behaviour
Therapy (DBT) has the best evidence base.
• Practical measures may be useful to assist the person in managing the stressful situation.
• The basic pharmacological management of adjustment disorder consists of symptomatic
treatment of insomnia, anxiety and panic attacks.
• Agents commonly used: benzodiazepines and antidepressants.
• A pilot study of cancer patients with anxious and depressed mood found trazodone superior
to a benzodiazepine.
• Nguyen in 2006 explores the differences in treating adjustment disorder with anxiety with
etifoxine and lorazepam.

(a) POST – TRAUMATIC STRESS DISORDER (PTSD)

Individuals who have been exposed to a traumatic event in which one person experienced
witnessed or was confronted with actual or threatened death or serious injury or the threat to the
physical integrity of self or other are said to possess PTSD. Stressor is a traumatic event.
Eponyms
• Civil War – Irritable heart
• World War I – Shell shock/ Effort syndrome
• World War II – Combat Stress Syndrome
• Vietnam War – Brought the concept of PTSD
• Gulf War syndrome
• PTSD entered the DSM III in 1980
Factors for PTSD
• Women are at greater risk than males
• Previous traumatic experiences, especially in early life
• Family history of PTSD or depression
• History of physical or sexual abuse
• History of substance abuse
• History of depression, anxiety or another mental illness
• High level of stress in everyday life
• Lack of support after the trauma
• Lack of coping skills
Signs and Symptoms
• Symptoms of PTSD: Re – experiencing the traumatic event
─ Intrusive, upsetting memories of the event
─ Flashbacks
─ Nightmares
─ Feelings of intense distress when reminded of the trauma
─ Intense physical reactions to reminders of the event
• Symptoms of PTSD: Avoidance and numbing
─ Avoiding activities, places, thoughts or feelings that remind the trauma
─ Inability to remember important aspects of the trauma
─ Loss of interest in activities and life in general
─ Feeling detached from others and emotionally numb
─ Sense of a limited future (you don’t expect to live a normal life span, get married,
have a career)
• Symptoms of PTSD: Increased anxiety and emotional arousal
─ Difficulty falling or staying asleep
─ Irritability or outbursts of anger
 ─ Difficulty concentrating
─ Hyper vigilance
─ Feeling jumpy and easily startled
• Symptoms of PTSD – Children and Adolescents
─ Fear of being separated from parent
─ Losing previously – acquired skills (such as toilet training)
─ Sleep problems and nightmare without recognizable content
─ Compulsive play in which themes or aspects of the trauma re repeated
─ New phobias and anxieties that seem unrelated to the trauma
─ Acting out the trauma through play, stories or drawings
─ Aches and pains with no apparent cause
─ Irritability and aggression
• Other common symptoms
─ Anger and irritability
─ Guilt, shame or self – blame
─ Substance abuse
─ Feelings of mistrust
─ Depression and hopelessness
─ Suicidal thought and feelings
─ Feeling alienated and alone
─ Physical aches and pains.
Screening patients for PTSD
Mnemonic
Detachment
Re – experiencing the event
Event had emotional events
Avoidance
Month in duration
Sympathetic hyperactivity or hypervigilance
A. The person has been exposed to a traumatic event in which both of the following were present:
(i) The person experienced, witnessed or was confronted with an event or events
that involved actual or threatened death or serious injury.
(ii) The person’s response involved intense fear, helplessness or horror
B. The traumatic event is persistently re – experienced in one (or more) of the following ways:
(i) Recollections of the event including images, thoughts or perceptions
(ii) Dreams of the event
(iii) Acting or feeling as the traumatic event were recurring (includes a sense of
reliving the experience, illusions, hallucinations, and dissociative flashback
episodes)
(iv) Intense psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event.
(v) Physiological reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma) as indicated by three (or more) of the
following:
(i) Efforts to avoid thoughts, feelings or conversations associated with the trauma
(ii) Efforts to avoid activities, places or people that arouse recollections of the trauma
(iii) Inability to recall an important aspect of the trauma
(iv) Markedly diminished interest or participation in significant activities
(v) Feeling of detachment
 (vi) Restricted range of affect (e.g. unable to have loving feelings)
(vii) Sense of a foreshortened future (e.g. does not expect to have a career, marriage,
children, or normal life span)
D. Persistent symptoms of increase arousal (not present before the trauma) as indicated by two or
more of the following:
(i) Difficulty falling or staying asleep
(ii) Irritability or outbursts of anger
(iii) Difficulty concentrating
(iv) Hypervigilance
(v) Exaggerated startle response
E. Duration of the disturbance (symptoms in criteria B, C and D) is more than 1 month
F. Impairment in social, occupational or other important areas of functioning

Comorbidity
• Depressive disorders
• Substance – related disorders
• Anxiety disorders
• Bipolar disorders

2. ANXIETY DISORDERS
(a) SPECIFIC PHOBIAS
Specific phobia or simple phobia, is an intense, unreasonable, and persistent fear caused by the
presence or anticipation of a specific object or situation. It provokes an immediate anxiety
response that can sometimes take the form of a panic attack. This intense fear often leads to
avoidance, and causes severe distress when the situation can’t be avoided.
According to DSM -5,
A. Marked fear or anxiety about a specific object or situation (e.g. flying, heights, animals,
receiving an injection, seeing blood). Note: In children, the fear or anxiety may be
expressed by crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or
situation and to the socio – cultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
Subtypes
Phobias are classified into different subtypes
• Situational type: Concerns a specific situation, such
as the fear of flying, bridges, elevators, driving etc.
• Blood – injection – injury type: Includes any invasive
medical procedure. This kind of phobia is often
associated with a fear of seeing blood or wounds,
having injection and other medical procedures.
• Natural environment type: Fear of storms, heights, the
dark, water etc.
• Animal type: Fear of insects, dogs, snakes, rodents, spiders, etc.
• Other type: Phobias can be caused by a wide variety objects or situations that don’t fit the
categories listed above. These include a fear of choking, loud noises, contracting an illness,
vomiting etc.
Animal phobia is very common during childhood, while blood – injury phobias are more common
in adolescents.
 Age of Onset
The usual age of onset is childhood to adolescence. Symptoms usually peak between 10 and 13
years of age. The onset of phobias differed between groups: hardly any phobias of animals had
started after age 5, while most phobias of the other varieties started after age 10.
ICD – 10 DSM – 5
• F40 Phobic anxiety disorders • Anxiety disorders
F40.2 Specific (isolated) phobias 300.29 Specific phobia
• Anxiety restricted to highly specific situations • Marked fear or anxiety about a specific object
or objects like animals, thunder, heights, or situation.
disease. • Actively avoided
• Autonomic symptoms as primary • Fear is out of proportion to the actual danger.
manifestation. • 6 months or more.
• Phobic situation is actively avoided. • Significant distress in important areas of
functioning.
Epidemiology
• Lifetime prevalence: 6 – 23%
• Females are more frequently affected than males
• Usually develops in early childhood
• Can develop after a traumatic event
• Chronic course with restriction of ADL
• Can spontaneously remit
Differential diagnosis
• Agoraphobia
• Social phobia
• OCD
• Hypochondriasis
• Delusional disorder
• PTSD
Comorbidity
• Panic attack
• Depression
• Substance – related disorders

PHOBIAS FROM A – Z
ACROPHOBIA: Fear of heights GAMOPHOBIA: Fear of marriage OPHIDIOPHOBIA: Fear of snakes

AGORAPHOBIA: Fear of being in GEPHRYOPHOBIA: Fear of PATHOPHOBIA: Fear of disease

a public place crossing a bridge
AILUROPHOBIA: Fear of cats GYMNOPHOBIA: Fear of seeing PEDIOPHOBIA: Fear of children
a naked person or dolls

ANDROPHOBIA: Fear of men GYNOPHOBIA: Fear of women PHOBOPHOBIA: Fear of phobias

ANTHROPOPHOBIA: Fear of HEDONOPHOBIA: Fear of PSYCHROPHOBIA: Fear of the
human companionship pleasure cold

ARACHNOPHOBIA: Fear of HYPENGYOPHOBIA: Fear of SCOPOPHOBIA: Fear of being

spiders responsibility stared at

BATHOPHOBIA: Fear of deep HYPNOPHOBIA: Fear of sleep SPECTROPHOBIA: Fear of mirrors

places
CLAUSTROPHOBIA: Fear of ICHTHYOPHOBIA: Fear of fish TOCOPHOBIA: Fear of childbirth
enclosed places
CYNOPHOBIA: Fear of dogs MYSOPHOBIA: Fear of dirt THEOPHOBIA: Fear of God
ENTOMOPHOBIA: Fear of insects NOSTOPHOBIA: Fear of returning TRISKAIDEKEPHOBIA: Fear of the
home number thirteen
EREUTHOPHOBIA: Fear of NYCTOPHOBIA: Fear of night or ZOOPHOBIA: Fear of animals
blushing darkness
Treatment
• Both psychotherapy and pharmacotherapy are useful in treating social phobias.
• Effective drugs for the treatment of social phobia include:
▪ Selective serotonin reuptake inhibitors (SSRIs)
▪ The benzodiazepines
▪ Venlafaxine
▪ Buspirone
• The benzodiazepines, alprazolam and clonazepam are also efficacious.
• Cognitive, behavioural and exposure techniques are also useful in performance situations.
• Psychotherapy for the generalized type of social phobias usually involves a combination of
behavioural and cognitive methods.
• Relaxation training.

(b) SOCIAL PHOBIAS

Social anxiety disorder is also known as social phobia. A social phobia is a strong, persisting fear of
situations in which embarrassment can occur.
Marked and persistent fear of one or more social or performance situations in which the person is
concerned about negative evaluation or scrutiny by others, for example: Public speaking, writing,
eating or drinking in public, initiating or maintaining conversations.
Fears humiliation or embarrassment, perhaps by manifesting anxiety symptoms (e.g. blushing or
sweating). Feared social or performance situations are avoided or endured with intense anxiety or
distress. They may be particularly bordered and unable to urinate in public lavatory or have
frequent urge to micturate, with fear of incontinence. Some may fear they may vomit in public
places. Alcohol misuse and depression are common co – morbidities.
Epidemiology
This disorder affects around 13.3% of the population and seems to affect women more often than
men at a ratio of 1:5:1. It can be hereditary and may subsequently result in depression or
alcoholism, particularly if it goes undiagnosed. Social anxiety disorder generally appears in
adolescence, but can occur at a younger age. The most common form of the disorder is a fear of
public speaking.
Clinical features
• Psychological arousal
─ Fearful anticipation
─ Irritability
─ Sensitivity to noise
─ Restlessness
─ Poor concentration
─ Worrying thought
• Gastrointestinal
─ Dry mouth
─ Difficulty in swallowing
─ Epigastric discomfort
─ Excessive wind
─ Frequent or loose motions
• Respiratory
 ─ Constriction in the chest
─ Difficulty inhaling
• Cardiovascular
─ Palpitations
─ Discomfort in chest
─ Awareness of missed beats
• Genitourinary
─ Frequent or urgent micturition
─ Failure of erection
─ Menstrual discomfort
─ Amenorrhea
• Muscle tension
─ Tremors
─ Headache
─ Aching muscles
• Hyperventilation
─ Dizziness
─ Tingling in the extremities
─ Feeling of breathlessness
• Sleep disturbance
─ Insomnia
─ Night terror

DSM – 5
A Marked gear of one or more situations where the individual is exposed to scrutiny by
others. May include interaction, observation or performance situations.

B Individual fears will act in a way or show anxiety that will lead to being negatively
evaluated.

C The social situations almost always provoke anxiety.

D The social situations are avoided or endured with intense fear or anxiety.

E The fear/anxiety is out of proportion to actual threat.

F The fear/anxiety/avoidance has lasted 6 months.

G The fear/threat/avoidance leads to significant distress or functional impairment.

H The fear/threat/avoidance is not due to a medical condition/drug.

I The fear/threat/avoidance is not due to another mental disorder.

J The fear/threat/avoidance is either unrelated to, or excessive considering existing medical

conditions.

Specifier: Performance only: fear restricted to speaking or performing in public.

Treatment
• Both psychotherapy and pharmacotherapy are useful in treating social phobias.
• Effective drugs for the treatment of social phobia include:
▪ Selective serotonin reuptake inhibitors (SSRIs)
▪ The benzodiazepines
▪ Venlafaxine
▪ Buspirone
 • The benzodiazepines, alprazolam and clonazepam are also efficacious.
• Cognitive, behavioural and exposure techniques are also useful in performance situations.
• Psychotherapy for the generalized type of social phobias usually involves a combination of
behavioural and cognitive methods.
• Relaxation training.
Course and Prognosis
→ Social phobia tends to have its onset in late childhood or early adolescence.
→ Social phobia tends to be a chronic disorder.
→ The disorder can profoundly disrupt the life of an individual over many years.
→ This can include disruption in school or academic achievement and interference with job
performance and social development.
GLOSSOPHOBIA
Fear of Public Speaking. If nervousness about speaking interferes with you regular life, you may
have social phobia. Informally referred to as stage fright. It is a very common phobia i.e. around
85% of the people experience anxiety when they speak in public. Considered to be a Social
Anxiety Disorder (SAD)
e.g. A glossophobic might make a conscious effort to avoid situations in which he or she may
have to engage in public speaking, thus limiting his or her life and career choices.
Symptoms of speech anxiety can be categorised into three:
• Physical
o Autonomic Nervous system
▪ Fight or flight reaction
─ Acute hearing
─ Increased heart rate
─ Increased blood pressure
─ Dilated pupils
─ Sweating
─ Heavy breathing
─ Stiff muscles
─ Dry mouth
• Verbal
▪ Tense voice
▪ Quivering voice
▪ Repitition of “umms” and “ahhs”
• Non – verbal
▪ Tone of voice
▪ Facial expressions
▪ Body movement

(c) GENERALIZED ANXIETY DISORDER (GAD)

An anxiety disorder that is characterised by excessive uncontrollable and irrational worry about
everyday things. A common chronic disorder characterised by long lasting anxiety that is not
focused on any one objects or situation.
It is a part of a spectrum of disorders known as anxiety disorders. It can be mistaken with other
anxiety disorders. It differs from other types in that it is persistent, invasive and uncontrollable
anxiety or worry towards any issue or situation.
Etiology
No single cause exists. However, GAD has been associated with:
• GENDER
Females are twice as likely to be diagnosed with GAD as men.
• PRESENCE OF PHYSICAL OR EMOTIONAL TRAUMA
Bullying is associated with increased risk.
• GENETIC FACTORS
A significant number of patients and their first degree relatives develop GAD. Polymorphisms on
chromosome 8.
• NEUROTRANSMITTERS
Variations in benzodiazepines, serotonin, N – methyl – D – aspartate, cholecystokinin.
Challenging Parenting is found to reduce risk of GAD
Epidemiology
The usual age of onset is variable – from childhood to late adulthood, with the median age of
onset approximately 31 years. Women are 2 – 3 times more likely to suffer from GAD than men.
GAD is very common in the elderly population.
Difference between Normal Worry and GAD
NORMAL WORRY GAD
→ Your worrying doesn’t get in the way of → Your worrying significantly disrupts your job,
your daily activities and responsibilities. activities or social life.
→ You’re able to control your worrying. → Your worrying is uncontrollable.
→ Your worries, while unpleasant, don’t cause → Your worries are extremely upsetting and
significant distress. stressful.
→ Your worries are limited to a specific, small → You worry about all sorts of things, and tend
number of realistic concerns to expect the worst.
→ Your bouts of worrying last for only a short → You’ve been worrying almost every day for
period of time at least 6 months.
Signs and Symptoms
The symptoms of GAD fluctuate. You may notice better and worse times of the day. Not everyone
with GAD has the same symptoms. Most people with GAD experience a combination of a
number of the following emotional, behavioural and physical symptoms.
• Emotional Symptoms
─ Constant worries running through your head.
─ Feeling like your anxiety is uncontrollable; there is nothing you can do to stop the
worrying.
─ Intrusive thoughts about things that make you anxious; you try to avoid thinking
about them, but you can’t.
─ An inability to tolerate uncertainty; you need to know what’s going to happen in the
future.
─ A pervasive feeling of apprehension or dread.
• Behavioural Symptoms
─ Inability to relax, enjoy quiet time, or be by yourself.
─ Difficulty concentrating or focussing on things.
─ Putting things off because you feel overwhelmed.
─ Avoiding situations that make you anxious.
• Physical Symptoms
─ Feeling tense; having muscle tightness or body aches.
─ Having trouble feeling asleep or staying asleep because your mind won’t quit.
─ Feeling restless, edgy or jumpy.
─ Stomach problems, nausea, diarrhoea.
Diagnostic Criteria
A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a
number of events or activities.
B. The individual finds it difficult to control the worry.
C. The anxiety and worry:
(i) Restlessness or feeling keyed up or on edge.
(ii) Being easily fatigued.
 (iii) Difficulty concentrating or mind going blank.
(iv) Irritability
(v) Muscle tension
(vi) Sleep disturbance
D. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in
social occupational.
E. The disturbance is not attributable to the physiological effects of a substance.
F. The disturbance is not better explained by another mental disorder.
Treatment
Focusses on managing symptoms. Classified into:
• Psychotherapy: Also known as talk therapy conducted in therapy sessions. 75% of patients
to receive psychotherapy benefit from it. It is shown to improve emotional health,
behaviour and brain & body function. Types:
─ Cognitive Behavioural Therapy (CBT)
─ Interpersonal Therapy (IPT)
─ Dialectical Behaviour Disorder Therapy
─ Support Therapy
• Medications: Based on the belief that mental illness come from chemical imbalances in the
brain. Types:
─ Antipsychotics:
▪ Typical: haloperidol, loxapine, chlorpromazine etc.
▪ Atypical: clozapine, risperidone, aripiprazole etc.
Side effects: Drowsiness, upset stomach, increased appetite, weight gain and seizures.
─ Antidepressants:
▪ Atypical antidepressants: Bupropion, Nefazodone, Trazodone etc.
Side effects: Insomnia, constipation, tremors, dry mouth.
─ Mood Stabilizers:
▪ Commonly prescribed: Lithium, Valproic acid, Carbamazepine etc.
Side effects: Weight gain, dizziness, blurred vision, confusion, stomach problems.
Famous Examples of GAD
Some famous people who dealt with and/or still with GAD include:
• Vincent Van Gogh – artist (alcoholic; disorder stressed him out; committed suicide eventually).
• Brian Wilson – Beach Boys artist (diagnosed due to abusive, traumatic childhood experiences;
has coped with it and still performs).
• Abraham Lincoln – famous president (loss of loved ones as a kid and a parent lead him to
anxiety; coped with it well, well enough to return to presidency and do well, obviously...)

(d) OBSESSIVE COMPULSIVE DISORDER (OCD)

An anxiety disorder characterised by intrusive, obsessive
thoughts that produce uneasiness, apprehension, fear or
worry, by repetitive behaviours aimed at reducing the
associated anxiety or by a combination of such obsessions
and compulsions. Secondary to both depressive illness and
Gilles se la Tourette syndrome.
DSM – IV – TR describes OCD as recurrent obsessions or
compulsions that are severe enough to be time
consuming or to cause marked distress or significant
impairment.
Obsession:
Repetitive, intrusive thoughts, ideas or impulses that are recognised as a foreign or repugnant to
the individual. They are involuntary, seemingly uncontrollable thoughts, images or impulses that
occur over and over again in the mind.
Common Obsessions:
OBSESSION % OF SAMPLE (N – 200)
Dirt and contamination 45
Pathological doubt 42
Need for symmetry 31
Somatic 36
Sexual content 26
Others 13
Multiple obsessions 60
Hoarding
Superstitious fears
Compulsion:
Repetitive, stereotyped behaviours that are senseless and are not connected in a realistic way
with what they are meant to produce or prevent. The individuals usually recognize the
senselessness of the behaviours, although they do relieve tension.

Common compulsions:
COMPULSION % OF SAMPLE (N – 200)
Checking 63
Washing and cleaning 50
Counting 36
Need to ask and confess 31
Symmetry and precision 28
Hoarding 18
Multiple compulsions 48

Categories of OCD patients

• Washers: afraid of contamination
• Checkers: repeatedly check things associated with harm or danger
• Doubters or sinners: everything isn’t perfect or done just right something terrible will happen
or they will be punished
• Counters and arrangers: Obsessed with order and symmetry
• Hoarders: something bad will happen if they throw anything away
OBSESSIONS COMPULSIONS

Fear of contamination Cleaning or washing rituals

Pathological doubt Repetitive checking

Sexual or Violent intrusive Repetitive undoing thoughts

thoughts
Fear of causing harm Repeated checking

Need for symmetry and Ordering or arranging things

exactness
Religious obsessions Religious rituals e.g. excessive praying

Superstitious obsessions Superstitious rituals e.g. repeating activities a certain number of times
LINKING OBSESSIONS AND COMPULSIONS

Epidemiology
• Prevalence – 2 to 3%
• Children and adolescents = Adults
• Men and women equally affected
• Adolescence – Boys > Girls
• Mean age of onset – 20 years
Co morbidities
• Depression • Eating disorders
• Social phobia • PTSD
• Specific phobia • Anxiety disorders
• Panic disorder • Personality disorders
• Alcohol – use disorders • Schizophrenia

Etiological factors
• Psychoanalytical theory: OCD patients have:
→ weak, underdeveloped egos (reasons: unsatisfactory parent – child relationship,
conditional love etc.)
→ Regression to the pre – oedipal anal – sadistic phase, combined with use of specific ego
defence mechanisms (isolation, undoing displacement, reaction formation), produces
the clinical symptoms of obsessions and compulsions.
• Learning theory: It explains OCD patients as:
→ Conditioned response to a traumatic event.
→ Traumatic event produces anxiety and discomfort
→ Passive avoidance (staying away from the source)
→ Active avoidance (staying with the source)
• Biological aspects:
─ Biochemical Factors: The neurotransmitter serotonin as ENERGY CONSUMPTION IN OCD
influential in the etiology of obsessive – compulsive behaviours.
Drugs that have been used successfully in alleviating the symptoms
of OCD are clomipramine and the selective serotonin reuptake
inhibitors (SSRIs), all of which are believed to block the neuronal
reuptake of serotonin, thereby potentiating serotoninergic activity in
the CNS.
─ Neuroanatomy: Neuroimaging techniques have
shown abnormal metabolic rates in the basal ganglia and orbital
frontal cortex of individuals with the disorder.
Brain imaging studies
 ▪PET scan – Increased activity in frontal lobes, basal ganglia and cingulum.
▪ CT and MRI studies – Decreased sizes of caudate bilaterally.
▪ EEG abnormality marked over temporal lobes
─ Physiology

Behavioural factors
Obsessions considered as conditioned stimuli. When a relatively
neutral stimulus is coupled with an anxiety – provoking stimulus,
through conditioning, it will produce anxiety even when presented
alone. Compulsions are learnt as a way to reduce anxiety. Once
relief of anxiety is produced, the relief serves as reinforce to the
compulsion, which are then being repeated by the patient.
Treatment
Only completely curable rare cases. Most people have some
symptom relief with treatment. Treatment choices depend on the
problem and patient’s preferences.
• Behavioural Therapy:
→ Effective mode of therapy, with success rate as high as 80%.
→ Exposure and responsive prevention (ERP): Widely practiced behavioural therapy for OCD.
Two components –
▪ Exposure Treatment
▪ Response Prevention Treatment: The ritual behaviours that people with OCD engage in to
reduce anxiety. Patients learn to resist the compulsion to perform rituals and are
eventually able to stop engaging in these behaviours.
Treatment starts with exposure to situations that cause the least anxiety. As the patient overcomes
these, they move on to situations that cause more anxiety.
→ Desensitization
→ Thought stopping
→ Flooding
→ Implosion therapy
→ Patients must be truly committed to improvement
→ Psychotherapy
▪ Attention of family members through provision of emotional support, reassurance,
explanation and advice on how to manage and respond to patient.
 ▪ Family therapy can build a treatment alliance as well as help in the resistance of
compulsions.
▪ Group therapy.

• Cognitive Therapy
→ Cognitive: change the way they think to deal with their fears.
→ Behavioural: change the way they react to “anxiety – provoking” situations.
→ Exposure and Response prevention
▪ Slowly learning to tolerate anxiety associated with not performing ritual behaviour.
→ Psychotherapy
▪ Talking with therapist to discover what causes anxiety and how to deal with symptoms.
→ Systematic Desensitization
▪ Learning cognitive methods to deal with anxiety then gradual exposure to feared object.
→ Should be done when people are ready for it.
→ Must be customised for each person’s specific form of OCD and their needs.
→ No side effects except increased anxiety with exposure to fear.
→ Often lasts about 12 weeks.
→ Positive effects off CBT last longer than those of medication.
→ If OCD returns can successfully treat again with same therapy.
→ Best treatment approach for most is CBT combined with medication.
• Medication/Pharmacotherapy:
→ Clomipramine – TCA
→ SSRI’s –
▪ Fluoxetine
▪ Fluvoxamine
▪ Paroxetine
▪ Sertraline
▪ Citalopram
→ Anti – psychotics, busiprone, clonidine, MAO inhibitors
• Electroconvulsive therapy – Severe depression with OCD.
• Psychosurgery, followed by intensive behaviour therapy aimed at rehabilitation.

3. OTHER STRESS DISORDERS

(a) ACUTE STRESS DISORDER (ASD)
A mental disorder that can occur in the first month following a trauma. The symptoms that define
ASD overlap with those for PTSD. One difference, though, is that a PTSD diagnosis cannot be given
until symptoms last for one month. Also, compared to PTSD, ASD is more likely to involve feelings
such as not knowing where you are or feeling as if you are outside your body.
Risks:
• Having gone through other traumatic events
• Having had PTSD in the past
• Having had prior mental health problems
Diagnostic Criteria
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of
the following ways:
(i) Directly experiencing the traumatic event(s).
(ii) Witnessing, in person, the event(s) as it occurred to others.
(iii) Learning that the traumatic event(s) occurred to a close family member or close
friend. Note: In cases of actual or threatened death of a family member or friend, the
event(s) must have been violent or accidental.
 (iv) Experiencing repeated or extreme exposure to aversive details of the traumatic
event(s) (e.g. first responders collecting human remains; police officers repeatedly
exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television movies, or
pictures, unless this exposure is work related.
B. Presence of nine (or more) of the following symptoms from any of the five categories of
intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after
the traumatic event(s) occurred:
• Intrusion Symptoms
─ Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children, repetitive play may occur in which themes or aspects of the traumatic
event(s) are expressed.
• Negative mood
Persistent inability to experience positive emotions
• Dissociative symptoms
─ An altered sense of the reality of one’s surroundings or oneself
─ Inability to remember an important aspect of the traumatic event(s)
• Avoidance symptoms
─ Efforts to avoid distressing memories, thoughts, or feelings about or closely
associated with the traumatic event(s).
─ Efforts to avoid external reminders that arouse distressing memories, thoughts, or
feelings about or closely associated with the traumatic event(s).
• Arousal symptoms
─ Sleep disturbance
─ Irritable behaviour and angry outbursts (with little or no provocation), typically
expressed as verbal or physical aggression toward people or objects.
─ Hypervigilance
─ Problems with concentration
C. Duration of the disturbance (symptoms in criterion B) is 3 days to 1-month trauma exposure.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g. medication
or alcohol) or another medical condition (e.g. mild traumatic brain injury) and is not better
explained by brief psychotic disorder.

Etiology
• STRESSOR
→ Prime causative factor
→ Stressors of human design – rape and violent assault, are usually more pathogenic.
→ Sudden, unexpected, and life threatening events
→ Disasters related
Risk factors for being exposed to trauma
- Less than a college education
- Being male
- History of childhood conduct problems
- Family history of psychiatric illness
- Extroverted
- More neurotic
Risk factors for PTSD among those exposed to trauma
- Female, neuroticism
- Lower social support
 - Lower IQ
- Pre – existing psychiatric illness
- Family history of mood, anxiety, or substance abuse disorders
• GENETICS
→ 1/3rd of variance in symptoms is genetic.
→ Trauma exposure – little or no effect on measures of IQ & neurocognitive functioning.
→ Similarity in the test scores between co – twins implies genetic influence on cognitive
performance.
→ Above average cognitive ability – protect
• PSYCHODYNAMIC FACTORS
→ Trauma has reactivated a previously quiescent, yet unresolved psychological conflict
→ The subjective meaning of a stressor may determine its traumatogenicity
→ Traumatic events can resonate with childhood traumas
→ Inability to regulate affect can result from trauma.
→ Somatization and alexithymia may be among the after effects of trauma.
→ Common defences – denial, minimization, splitting, projective, dissociation, and guilt.
• COGNITIVE FACTORS
→ Affected people cannot process or rationalize the trauma that precipitated the disorder
→ They continue to experience the stress and attempt to avoid experience the stress and
attempt to avoid experiencing it by avoidance techniques
→ Less decline in vividness, emotional intensity, and accuracy of traumatic memories.
→ Exhibit difficulty retrieving specific memories
→ Difficulties of attentional control.
• EMOTIONAL STROOP PARADIGM
Delayed naming of the word’s colour. Heightened stroop interference for trauma words in PTSD.
• NORADREGENERGIC SYSTEM
→ Nervousness, increased blood pressure and heart rate, palpitations, sweating, flushing, and
tremors – symptoms of adrenergic drugs.
→ Increased 24 – hour urine epinephrine concentrations in veterans.
→ Increased urine catecholamine concentrations in sexually abused girls.
→ Platelet alpha2 and lymphocyte beta 2 adrenergic receptors are down regulated.
• HPA AXIS
→ Low plasma and urinary free cortisol.
→ CRF challenge yields a blunted ACTH response.
→ DMST – enhanced suppression of cortisol.
→ Indicates hyper – regulation of HPA axis.
• GULF WAR SYNDROME
→ Began in 1990 and ended in 1991.
→ Irritability, chronic fatigue, shortness of breath, muscle and joint pain, migraine headaches.
→ Digestive disturbances, rash, hair loss, forgetfulness and difficulty concentrating.
→ Amyotrophic Lateral Sclerosis (ALS).
• 11/09
→ Terrorist activity destroyed the world trade centre in New York city and damaged the
pentagon in Washington.
→ Survey found a prevalence rate of 11.4 % for depression in US citizens 1 month after 11/09.
• TSUNAMI
→ December 26, 2004.
→ Many survivors continue to live in fear and show signs of PTSD.
→ Fishermen fear venturing out to sea.
→ Children fear playing at beaches they once enjoyed.
→ Trouble sleeping in fear of another tsunami
 MODULE 3: SOMATOFORM AND DISSOCIATIVE
DISORDER
SOMATOFORM
A group of disorders in which people experience significant physical symptoms for which there is
no apparent organic cause. Symptoms are often inconsistent with possible physiological
processes. People do not consciously produce or control the symptoms but truly experience the
symptoms. Symptoms pass only when the psychological factors that led to the symptoms are
resolved.
When a physical ailment has no apparent medical cause, physicians may suspect a somatoform
disorder. People with a somatoform disorder do not consciously want, or purposely produce, their
symptoms. They believe their problems are genuinely medical. There are two main types of
somatoform disorders:
• Hysterical somatoform disorders
• Preoccupation somatoform disorders

TYPES
CONVERSION DISORDER Loss of functioning in some part of the body
for psychological rather than physical
reasons.
SOMATIZATION DISORDER History of complaints about physical
symptoms, affecting many different areas
of the body, for which medical attention
has been sought but no physical cause
found.
PAIN DISORDER History of complaints about pain, for which
medical attention has been sought but
that appears to have no physical cause.
HYPOCHONDRIASIS Chronic worry that one has a physical
disease in the absence of evidence that
one does; frequently seek medical
attention.
 BODY DYSMORPHIC DISORDER Excessive preoccupation with some part of
the body the person believes is defective.
SOMATOFORM AND PAIN DISORDERS Subjective experience of many physical
symptoms, with no organic causes.
PSYCHOSOMATIC DISORDERS Actual physical illness present and
psychological factors seem to be
contributing to the illness.
MALINGERING Deliberate faking of physical symptoms to
avoid an unpleasant situation, such as
military duty.
FACTITIOUS DISORDERS Deliberate faking of physical illness to gain
medical attention.

Diagnostic Criteria
A. One or more somatic symptoms that are distressing or result in significant disruption of
daily life.
B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms or
associated health concerns as manifested by at least one of the following:
(i) Disproportionate and persistent thoughts about the seriousness of one’s symptoms
(ii) Persistently high level of anxiety about health or symptoms.
(iii) Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being
symptomatic is persistent (typically more than 6 months).
Specify if:
With predominant pain (previously pain disorder): This specifier is for individuals whose somatic
symptoms predominantly involve pain.
Specify if:
Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long
duration (more than 6 months).
HYPOCHONDRIASIS
A somatoform disorder in which a person
interprets normal physical sensations as
symptoms of a disease or serious illness.
Hypochondriasis is an excessive concern about
disease and preoccupation with one’s health.
Hypochondriasis is an unrealistic interpretation
of physical symptoms and sensations; leading to
preoccupation with the fear or belief that one
has a serious disease. This fear or conviction of
disease is disabling and persists despite
appropriate medical reassurance. Also called
Illness Anxiety Disorder.
Hypochondriasis is characterized by 6 months or
more of a general and non-delusional
preoccupation with fear of having, or the idea
that one has, a serious disease based on the
person’s misinterpretation of bodily symptoms.
This preoccupation causes significant distress
and impairment in one’s life; it is not accounted for by another psychiatric or medical disorder;
and a subset of individuals with hypochondriasis has poor insight about the presence of this
disorder. The term hypochondriasis is derived from the old medical term hypochondrium and
reflects the common abdominal complaints of many patients with the disorder but they may
occur in any part of the body.
Epidemiology
One recent study reported a 6 – month prevalence of hypochondriasis of 4 to 6% in a general
medical clinic population, but it may be as high as 15%. Men and women are equally affected by
hypochondriasis. Although the onset of symptoms can occur at any age, the disorder most
commonly appears in persons 20 to 30 years of age. Some evidence indicates that the diagnosis
is more common among blacks than among whites, but social position, education level, and
marital status do not appear to affect the diagnosis. Hypochondriacal complaints reportedly
occur in about 3% of medical students, usually in the first 2 years, but they are generally transient.
DSM-IV-TR Diagnostic Criteria
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the
person's misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type)
and is not restricted to a circumscribed concern about appearance (as in body dysmorphic
disorder).
D. The preoccupation causes clinically significant distress or impairment in social occupational, or
other important areas of functioning.
E. The duration of the disturbance is at least 6 months F. The preoccupation is not better
accounted for by generalized anxiety disorder, OCD, panic disorder, a major depressive
episode, separation anxiety, or another somatoform disorder.
On examination
• Details Physical examination to rule our somatic causes.
• Mental State Examination (MSE)
→ Appropriate attitude and behaviour demonstrates a preoccupation with physical
symptoms and complaints.
→ Mood: mildly anxious and depressed
→ No thought disorder; thoughts are limited to issues around physical symptoms
→ Insight/judgement; insight appears limited in that nonmedical causes of symptoms are not
considered. Judgement appears unimpaired.
Etiology
• Hypochondriasis results from the augmentation of normal bodily sensations.
• The patient learns the sick role that is reinforced through social gratification. The sick role then
becomes a mean of receiving attention from others.
• Hypochondriasis, represents an underlying depressive disorder, GAD or OCD.
• Psychodynamic theory
→ According to this theory, aggressive and hostile wishes toward others are transferred into
physical complaints.
→ Hypochondriasis is also viewed as a defense against guilt, a sense of innate badness, an
expression of low self – esteem, and a sign of excessive self-concern.
• Learning theory
→ Sick role made by a person facing seemingly insolvable problems.
→ The sick role offers an escape that allows a patient to avoid obligations, to postpone
unwelcome challenges, and to be excused from usual duties.
Treatment
• Treat any comorbid psychiatric condition, such as OCD, panic disorder and depressive
disorder.
• High doses of SSRI show promising results
• Cognitive Behavioural therapy is very useful to change the patient’s cognitive style.
• Group psychotherapy
Treatment and Management – IAD
• Establish a firm therapeutic alliance with the patient.
• Educate the patient regarding the manifestations of hypochondriasis.
• Offer consistent reassurance.
• Optimize the patient's ability to cope with the symptoms, rather than trying to eliminate the
symptoms.
• Avoid performing high-risk, low-yield invasive procedures Close collaboration among all
clinician to prevent investigative duplication.
• RCT indicates that cognitive-behavioural therapy (CBT) is efficacious in the treatment of
hypochondriasis.
• In clinical settings, both the availability of CBT and treatment adherence of patients with
hypochondriasis to psychotherapy in general are major barriers to successful outcomes.

─ Identify and challenge illness related misinterpretation of bodily sensation.

─ Show the patient how the symptom can be created by sensate focusing.
─ Reassurance and education regarding the source of symptom and its potential for harm.

SOMATIZATION DISORDER
Somatization disorder is an illness of multiple somatic complaints in multiple organ systems that
occurs over a period of several years and results in significant impairment or treatment seeking, or
both.
History
• Recognized since the time of ancient Egypt.
• An early name for somatization disorder was hysteria, a condition incorrectly thought to
affect only women. (The word hysteria is derived from the Greek word for uterus, hysteria)
• In the 17th century, Thomas Sydenham recognized that psychological factors, which he
called antecedent sorrows, were involved in the pathogenesis of the symptoms.
• In 1859, Paul Briquet, a French physician observed the multiplicity of the symptoms and the
affected organ systems and commented on the usually chronic course of the disorder.
• The disorder was called Briquet’s syndrome for a time, although the term somatization
disorder became the standard in the US when the third edition of DSM (DSM III) was
introduced in 1980.
Epidemiology
• Prevalence – 0.2% to 2% among women and is less than 0.2% in men.
• Usually begins in the teenage and young adulthood years.
• Onset after 30 years is extremely rare.
• More common in less educated and lower socioeconomic groups.
• Observed in 10% to 20% of female first degree relatives.
• Male relatives of women with somatization disorder have an increased risk of antisocial
personality, substance abuse disorders and somatization disorder.
Diagnosis
• A history of many physical complaints beginning before age 30 that occur over a period of
several years and result in treatment being sought or significant impairment in social,
occupational or other important area of functioning.
• Each of the following criteria must have been met, with individual symptoms occurring at
any time during the course of the disturbance:
─ Four pain symptoms: a history of pain related to at least four different sites or functions
─ Two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other
than pain
─ One sexual symptom: a history of at least one sexual or reproductive symptom other
than pain.
 ─ One pseudo neurological symptom: a history of at least one symptom or deficit
suggesting a neurological condition not limited to pain (conversion symptoms such as
impaired coordination or balance, paralysis or localized weakness, urinary retention,
hallucinations, blindness, deafness, seizures; dissociative symptoms)
C.(i) Symptoms in Criteria b cannot be fully explained by a known GMC or
(ii) When a GMC does exist, the symptoms in Criterion B are in excess of what would be
expected based on medical facts.
D. Symptoms not intentionally produced
Generalized symptoms Gastrointestinal symptoms Genitourinary symptoms
• Abdominal pain that is vague • Chronic bloating • Erectile dysfunction, ejaculatory
and nonfocal • Constipation Diarrhoea disturbance, and impotence
• Arthralgia • Food intolerance to • Decreased libido
• Backache multiple foods • Dyspareunia
• Chest pain that is nonspecific • Nausea • Dysuria
• Chronic tiredness • Rectal pain Vomiting • Menses that is painful irregular,
• Headache and heavy
• Vomiting that is prolonged or
frequent during pregnancy

Clinical Features
→ Patients with somatization disorder have many somatic complaints with long, complicated
medical histories.
Nausea and vomiting, difficulty swallowing, pain in the arms and legs, shortness of breath
unrelated to exertion, amnesia, and complications of pregnancy and menstruation are
among the most common symptoms.
→ Patients frequently believe that they have been sickly most of their lives.
→ Psychological distress and interpersonal problems are prominent; anxiety and depression are
the most prevalent psychiatric conditions.
→ Suicide threats are common, but actual suicide is rare.
→ Somatization disorder is commonly associated with other mental disorders including major
depressive disorder, personality disorders, GAD and phobias. The combination of these
disorders and the chronic symptoms results in an increased incidence of marital, occupational
and social problems.
Course and Prognosis
→ Somatization disorder is a chronic and relapsing disorder that rarely remits completely.
→ It is unusual for the individual with somatization disorder to be free of symptoms for greater than
1 year, during which time they may see a doctor several times.
→ Research has indicated that a person diagnosed with somatization disorder has approximately
an 80% chance of being diagnosed with this disorder 5 year later.
Etiology
• Psychological Factors
→ The cause is unknown
→ Interpretations of the symptoms as social communication whose result is to avoid
obligations to express emotions or to symbolize a feeling or a belief.
• Biological Factors
→ Patients have characteristic attention and cognitive impairments that result in the faulty
perception and assessment of somatosensory inputs.
• Genetics
→ Occurs in 10 to 20% of the first degree female, first degree male relatives are susceptible to
substance abuse and antisocial personality disorder.
→ 29% in monozygotic twins and 10% in dizygotic twins.
• Cytokines
 → Cytokines are messenger molecules that the immune system uses to communicate within
itself and with the nervous system, including the brain.
→ The abnormal regulation of the cytokine system may result in some of the symptoms seen in
somatoform disorders.
Therapy and Prognosis
The major importance for successful management:
• Trusting relationship between the patient and one primary care physician.
• Frequent changes of doctors ae frustrating and counter therapeutic.
• Regularly scheduled visits every 4 or 6 weeks.
• Brief outpatient visits – performance of at least partial physical examination during each visit
directed at the organ system of complaint.
• Explain to the patient and family relationship between psych and somatic
• Empathic attitude
• Avoid more diagnostic tests, laboratory evaluations and operative procedures unless clearly
indicated.
• Treatment of underlying depression and anxiety
• Potentially addicting medications should be avoided.
• Psychotherapy both group and individual decreases personal health care expenditures.
• Decreasing their rates of hospitalization
• Helped to cope with their symptoms
• To express underlying emotions
• To develop alternative strategies for expressing their feelings.
Behavioural Techniques
Increased activity involvement
→ Combats stress
→ Improves overall mood
→ Provides distraction from somatic symptoms
→ Pain perception has a subjective component – improved mood and distraction reduce the
experience of pain
→ Exercise has physiological effects that combat somatization and stress
Relaxation Techniques
→ Directly acts on physical symptoms, given its effects on breathing, heart rate, muscle
tension etc.
→ Patients report benefit soon upon learning the technique.
→ Helps with stress management
→ Includes diaphragmatic breathing, progressive muscle relaxation, biofeedback.
Cognitive Strategies
→ Much like CBT for depression
→ Use somatic symptoms as anchors for examining thoughts
→ Look for variations in adaptability of thoughts and discuss their effect
→ Patients are likely to have difficulty identifying thoughts/emotions

PAIN DISORDER
Pain disorder is one of the several somatoform disorders. It is classified as a mental disorder
because psychological factors play an important role in the onset, severity, worsening or
maintenance of pain. A pain disorder is characterized by the presence of, and focus on, pain in
one or more body sites and is sufficiently severe to come to clinical attention.
Patients feel chronic pain in one or more areas of the body. This pain is caused by psychological
stress and/or the over exaggeration of an injury. Pain disorder is part of the category of
somatoform disorders. Somatoform means that pain and symptoms are caused by psychological
factors. This pain can cause more problems such as distress and/ or impairment.
Diagnosis
• Pain in one or more anatomical sites is the predominant focus of the clinical presentation
and is of sufficient severity to warrant clinical attention.
• The pain causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
• Psychological factors are judged to have an important role in the onset, severity,
exacerbation or maintenance of the pain.
• The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or
malingering).
• The pain is not better accounted for by a mood, anxiety or psychotic disorder and does
not meet criteria for dyspareunia.
The DSM-IV-TR diagnostic criteria
• Pain in one or more anatomical sites is the predominant focus of the clinical presentation
and is of sufficient severity to warrant clinical attention.
• The pain causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
• Psychological factors are judged to have an important role in the onset, severity,
exacerbation, or maintenance of the pain.
• The symptom or deficit is not intentionally produced or
feigned (as in factitious disorder or malingering).
• The pain is not better accounted for by a mood, anxiety, or
psychotic disorder and does not meet criteria for
dyspareunia.
Clinical Features
• Low back pain, headache, atypical facial pain, chronic
pelvic pain, and other kinds of pain.
• Patients with pain disorder often have long histories of
medical and surgical care.
• Patients often deny any other sources of emotional dysphoria
and insist that their lives are blissful except for their pain.
• Their clinical picture can be complicated by substance related disorders, because these
patients attempt to reduce the pain through the use of alcohol and other substances.
Course and Prognosis
• The pain in pain disorder generally begins abruptly and increases in severity for a few weeks
or months.
• The prognosis varies, although pain disorder can often be chronic, distressful, and
completely disabling.
Epidemiology
• The prevalence of pain disorder appears to be common.
• Recent work indicates that the 6 – month and lifetime prevalence is approximately 5% and
12%, respectively.
• Psychodynamic factors
Patients who experience bodily aches and pains without identifiable and adequate physical
causes may be symbolically expressing an intra psychic conflict through the body.
• Biological factors
Serotonin and endorphins play a role in pain disorders.
• Behavioural factors
Pain behaviours are reinforced when rewarded and are inhibited when ignored or punished.
• Interpersonal factors
Means for manipulation and gaining advantage in interpersonal relationships. Such secondary
gain is most important to patients with pain disorder.
Treatment
• Medicine
• Therapy – behavioural, physical, hypnosis, and/or occupational
• The treatment may change according to the severity of the pain
• Acute pain – goal is to relieve pain with medicine
• Chronic pain – combination of medicine and therapy
• Pharmacotherapy – Analgesic medications do not generally benefit most patients with
pain disorder. Sedatives and antianxiety agents are not especially beneficial and are also
subject to abuse, misuse and adverse effects. Antidepressants, such as tricycles and SSRIs,
are the most effective pharmacological agents.
• Psychotherapy – Some outcome data indicate that psychodynamic psychotherapy
benefits patients with pain disorder.

BODY DYSMORPHIC DISORDER

Body dysmorphic disorder is characterized by a preoccupation with an imagined defect in
appearance that causes clinically significant distress or impairment in important areas of
functioning.
Etiology
• The cause of body dysmorphic disorder unknown.
• Some patients, the pathophysiology of the disorder may involve serotonin and may be
related to other mental disorders.
• Stereotyped concepts of beauty emphasized in certain families and within the culture at
large may significantly affect patients with body dysmorphic disorder.
Clinical features
• The most common concerns involve facial flaws, particularly those involving specific parts.
• Common associated symptoms include ideas of delusions of reference, either excessive
mirror checking or avoidance of reflective surfaces, and attempts to hide the presumed
deformity (with makeup or clothing), suicide.
• The effects on a person’s life can be significant; almost all affected patients avoid social
and occupational exposure.
• As many as one third of the patients may be housebound because of worry about being
ridiculed for the alleged deformities and approximately 1/5th attempt suicide.
Diagnosis
• Preoccupation with an imagined defect in appearance. If a slight physical anomaly is
present, the person’s concern is markedly excessive.
• The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
• The preoccupation is not better accounted for by another mental disorder (e.g.
dissatisfaction with body shape and size in anorexia nervosa).
Treatment
• Surgical, dental and other medical procedures to address the alleged defects is almost
invariably unsuccessful.

CONVERSION DISORDER
This used to be called “hysteria” when Freud was researching. Patient will lose control of bodily
functions such as: becoming blind, deaf or paralyzed. This happens without any physical damage
to affected organs or their neural connections. Anxiety will bring on these symptoms.
An illness of symptoms or deficits affecting voluntary motor or sensory functions, suggesting
another medical condition, but judges due to psychological factors because of preceding
conflicts or other stressors.
History
 • Clinical descriptions of conversion disorder date to almost 4000 years ago; the Egyptians
attributed symptoms to a wandering uterus.
• In the 19th century, Paul Briquet described the disorder as a dysfunction of the CNS.
• Sigmund Freud introduced the term conversion and hypothesized that the symptoms of
conversion reflect unconscious conflict.

Epidemiology
• Some symptoms, but not severe enough to warrant diagnosis in 1/3 of general population
at some time.
• Lifetime risk by some studies of 33% for either transient or longer term disorder.
• Range in general population of 11 – 300/100,000
• 25 – 30% of admissions to hospitals
• Onset at any age, but most common in late childhood to early adulthood (rare before 10
years of age, or after 35, but reported as late as the ninth decade of life)
• Ratio of women to men
• Range of 2/1 to 10/1 in adults
• Increased female predominance in children
• Symptoms in women more common on left side of body
• Women with conversion symptoms more likely to subsequently develop somatization
disorder.
• Association in men between conversion disorder and antisocial personality disorder.
• Men with conversion disorder often involved in occupation or military accidents.
• Psychoanalytic factors
→ Repression of unconscious intrapsychic conflict.
→ Conversion of anxiety into a physical symptom.
• Learning factors
→ Conversion disorder considered as piece of classically conditioned learned behaviour.
→ Symptoms of illness, learned in childhood, are called forth as a means of coping with an
otherwise impossible situation.
Clinical Features
• Sensory symptoms
→ Anaesthesia and paraesthesia common, especially in extremities.
→ Distribution of the neurological deficit inconsistent with either central or peripheral
neurological disease (e.g. stocking and glove anaesthesia, hemi anaesthesia beginning
precisely along the midline)
→ Possible involvement of organs of special sense (deafness, blindness, tunnel vision)
→ Classic dermatomes in patients with numbness usually are not followed.
• Motor Symptoms
→ Abnormal movements (gait disturbance, weakness/paralysis)
→ Movements generally worsen with calling of attention
→ Possible gross rhythmical tremors, chorea, tics and jerks.
→ Astasia – abasia (wildly ataxic/ staggering gait, gross irregular/ jerky truncal movements,
thrashing/ waving of arms – rare falls w/o injury)
→ Paralysis/ paresis involving one, two or all four limbs (w/o conformation to neural pathways)
→ Reflexes remain normal
→ No fasciculation/ muscle atrophy
→ Normal electromyography
• Seizure Symptoms
▪ Pseudo seizures
→ Differentiation from true seizure difficult by clinical observation alone.
→ 1/3 of those with pseudo seizures have coexisting epileptic disorder.
 → Tongue biting, urinary incontinence and injuries after falling can occur.
→ Pupillary and gag reflexes retained.
DSM – V diagnostic criteria
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and
recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social,
occupational or other important areas of functioning or warrants medical evaluation.

Common Characteristics
SYMPTOM DISTINGUISHING FEATURES AND PRESENTATION
Blindness The patient has a recent onset of blindness, but does not sustain injury while
moving around the room, and doesn’t have any expected bruises or
scrapes. The pupillary reflex is present, showing that the optic nerve, chiasm,
tract, lateral geniculate body, and mesencephalon are intact.
Deafness The blink reflex to a loud and unexpected sound is present, showing the
brain stem is intact.
Psychogenic non Patients with psychogenic non epileptic seizures generally do not respond
epileptic seizures to antiepileptic drugs or seizures increase. There is no history of injury or loss
of control of bladder/ bowel during seizures.
Tremor When weights are added to the affected limb, the tremor tends to become
stronger but in those organic tremors, the tremor tends to diminish.
Paralysis The patient loses the use of half of his/her body or of a single limb. The
paralysis does not follow anatomical patterns and is often inconsistent upon
repeat examination.
Anaesthesia Loss of feeling and pain sensation may occur anywhere, but is most
common on the extremities. A typical “glove and stocking” distribution will
have a very precise and sharp boundary, often at a joint, unlike the glove
and stocking symptoms in polyneuropathy.
Course and Prognosis
• Initial symptoms resolve within a few days to < a month 90 to 100% (95% remit
spontaneously, usually by 2 weeks)
• 75% have no further episodes with 20 – 25% recurring within a year during periods of stress.
• 25 to 50% present later with neurological disorders or non-psychiatric medical conditions
affecting the nervous system.
Management
No well-established treatment regimens for conversion disorder. Neurologic examination may help
if the neurological examination is equivocal.
• Acute cases
─ Reassurance/ appropriate rehabilitation
─ Psychotherapy
• Conversion disorder clients seek help from physicians and resent referrals to psychotherapists
─ Psychoanalytic therapy is not effective for conversion disorder
─ The cognitive behavioural approach involves pointing out selective attention to physical
sensations and discouraging the client from seeking medical assistance
Treatment
There is little evidence based treatment of conversion disorder. Treatment may include:
• Physiotherapy were appropriate.
• Occupational therapy to maintain autonomy in activities of daily living.
• Treatment of comorbid depression or anxiety if present.
• Other treatments such as cognitive behavioural therapy, hypnosis, EMDR and
psychodynamic psychotherapy, EEG brain biofeedback need further.
DISSOCIATIVE DISORDERS
Dissociation means a period when we feel disconnected from the environment and/or from
ourselves. We all have these moments of disconnection from time to time – daydreaming while
driving, or switching off and missing part of a conversation, for example, these moments of ‘not
being with it’ normally pass quickly. Someone with a dissociative disorder has persistent, repeated
episodes of dissociation that are extreme enough to severely affect everyday life.
Dissociation is a mental process where a person disconnects from their thoughts, feelings,
memories or sense of identity. Dissociative disorders include dissociative amnesia, dissociative
fugue, depersonalisation disorder and dissociative identity disorder. People who experience a
traumatic event will often have some degree of dissociation during the event itself or in the
following hours, days, or weeks. For example, the event seems unreal or the person feels
detached from what’s going on around them as if watching the events on television.
Common symptoms
• Feeling disconnected from yourself
• Problems with handling intense emotions
• Sudden and unexpected shifts in mood – for example, feeling very sad for no reason
• Depression or anxiety, or both
• Feeling as though the world is distorted or not real (called derealisation)
• Memory problems that aren’t linked to physical injury or medical conditions
• Other cognitive problems such as concentration problems
• Significant memory lapses such as forgetting important personal information
• Feeling compelled to behave in a certain way
• Identity confusion – for example, behaving in a way that the person would normally find
offensive or abhorrent.
Epidemiology
Dissociative disorders are prevalent around the world and often occur with other psychiatric
disorders such as depression, PTSD, substance use disorders, and borderline personality. 6%
percent of the general population suffers from high levels of dissociative symptoms. Empirical data
support the relation between trauma and dissociation, particularly adult and childhood trauma
stemming from sexual and physical abuse.
Biological Factors
There is growing evidence of the role of trauma on intricate neurobiological and
neuroanatomical structures in dissociative disorders. Early childhood trauma, witnessing or
exposure to traumatic or violent incidents, apparently has the potential to produce enduring
alterations on brain chemistry, neuroendocrine process and memory.
Neurocircuitry System
There is strong clinical evidence that indicates that the amygdala is a central structure in the brain
neurocircuitry and plays a pivotal role in conditioned or fear responding. Dysregulation of the
amygdala or the hippocampus, or both, results in poor contextual stimulus discrimination and
leads to overgeneralization of fear responding cues.
Causes
Dissociative disorders usually develop as a mechanism for coping with trauma. The disorders most
often form in children subjected to chronic physical, sexual or emotional abuse or less frequently a
home environment that is otherwise frightening or highly unpredictable. Personal identity is still
forming during childhood and during these malleable years a child is more able than is an adult to
step outside herself or himself and observe trauma as though it’s happening to a different person.
A child who learns to dissociate in order to endure an extended period of his or her youth may
reflexively use this coping mechanism in response to stressful situations throughout life. Rarely,
adults may develop dissociative disorders in response to severe trauma.
The role family dynamics
The role family dynamics in the dissociative process is highly potent for the child experiencing
trauma such as physical or sexual abuse. Personality development in the child is fostered by the
family and is initially concentrated in the mother – child interaction.
In an incestuous family, little if any protection or soothing occurs. The members of the family
experiencing incest are usually closed, not only to each other but also to the outside world. A
child may react to her incestuous family by defensively detaching the abandoning parent.
Incestuous families often deny they have problems. Family dynamics around the abused child
leave her with a rigid perception of interpersonal roles.
Cultural considerations
Trance states of amnesia, emotional lability and loss of identity, though not necessarily perceived
as normal, may be generally accepted as part of socio – cultural context and religious practice.
Major dissociative disorders
● DISSOCIATIVE AMNESIA
Inability to remember significant events – everything of traumatic nature, that is too extensive to
be explained by normal forgetfulness. This disturbance can be based on neurobiological changes
in the brain caused by traumatic stress.
Epidemiology
• Approximately 6% of the general population
• Reported in late adolescence and adulthood
• No known difference is seen in incidence between men and women
• Increase incidence during times of war and natural disasters
Clinical Features
• Overt, Florid, dramatic clinical disturbance brought quickly to medical attention
• Experienced extreme acute trauma
• Depression and suicidal ideation
• Histories of prior adult or childhood abuse or trauma
• In the context of profound intrapsychic conflict or emotional stress
• Present with intercurrent somatoform or conversion symptoms, alterations in consciousness,
depersonalization, derealisation, trance states, spontaneous age regression and even
ongoing anterograde dissociative amnesia
• No single personality profile or antecedent history is consistently reported.
DSM IV – TR diagnostic criteria
A. The predominant disturbance is one or more episodes of inability to recall important personal
information, usually of a traumatic or stressful nature, that is too extensive to be explained by
ordinary forgetfulness.
B. The disturbance does not occur exclusively during the course of dissociative identity disorder,
dissociative fugue, PTSD, acute stress disorder or somatization disorder and is not due to the
direct physiological effects of a substance or a neurological or other general medicine
condition.
C. The symptoms cause clinically significant distress or impairment in social, occupational or other
important areas of functioning.
Symptoms
• Depression, mood swings, substance abuse, sleep disturbances, somatoform symptoms,
anxiety and panic, suicidal or self-mutilating impulses and acts, violent outbursts, eating
problems and interpersonal problems.
• Self-mutilation and violent behaviour in these patients may also be accompanied by
amnesia.
• Amnesia may also occur for flashbacks or behavioural re-experiencing episodes related to
trauma.
Types
• Localized: Inability to recall events related to a limited period of time.
 • Selective: Ability to recall some but not all of the events occurring during a circumscribed
period of time.
• Generalized: Failure to recall one’s entire life.
• Continuous: Failure to recall successive events as they occur.
• Systemized: Amnesia for certain categories of memory, such as all memories relating to one’s
family or to a particular person.
Etiology
• Amnesia and Extreme intrapsychic conflict
→ Patient experiencing intolerable emotions of shame, guilt, despair, rage and depression.
→ Result from conflicts over unacceptable urges or impulses, such as intense sexual, suicidal, or
violent compulsions.
• Betrayal trauma
→ Betrayal trauma attempts to explain amnesia by the intensity of trauma and by the extent
that a negative event represents a betrayal by a trusted, needed other.
→ This betrayal is thought to influence the way in which the vent is processed and remembered.
Course and prognosis
• Acute dissociative amnesia frequently spontaneously resolves once the person is removed
to safety from traumatic or overwhelming circumstances.
• Some patients do develop chronic forms of generalized, continuous or severe localized
amnesia and are profoundly disabled and require high levels of social support, such as
nursing home placement or intensive family caretaking.
Treatment
• Cognitive therapy – Identifying the specific cognitive distortions that are based in the
trauma.
• Hypnosis – Contain, modulate and titrate the intensity of symptoms. Facilitate controlled
recall of dissociated memories; to provide support and ego strengthening for the patient;
and finally to promote working through and integration of dissociated material. Self-hypnosis
apply containment and calming techniques in his or her everyday life.
• Somatic therapies – Pharmacologically facilitated interviews use sodium amobarbital,
thiopental, oral benzodiazepines, and amphetamines
• Group psychotherapy – Time limited and longer term group psychotherapies.

● DISSOCIATIVE FUGUE
Sudden, unexpected travel away from home or one’s customary place of daily activities, with
inability to recall some or all of one’s past. This is accompanying by confusion about personal
identity or even the assumption of a new identity. Precipitated by intolerable stressors. After
“waking up” the person has no memory of events during fugue. Patients may appear normal
during fugue; they are brought to experts due to amnesia of recent or lack of awareness of
personal identity.
DSM Criteria
A. The predominant disturbance is sudden, unexpected travel away from home or one’s
customary place of work, with inability to recall one’s past.
B. Confusion about personal identity or assumption of new identity.
C. The disturbance does not occur exclusively during the course of dissociative identity disorder
& is not due to direct physiological influence of substance or general medical condition.
D. The symptoms cause clinically significant distress or impairment in social, occupational or
other important areas of functioning.
Diagnosis and Clinical Features
Some patients report multiple fugues. After the termination of a fugue, the patient may
experience perplexity, confusion, trance like behaviours, depersonalization, derealisation and
conversion symptoms, in addition to amnesia. Some patients may terminate a fugue with an
episode of generalized dissociative amnesia.
Etiology
Traumatic circumstances, leading to an altered state of consciousness dominated by a wish to
flee, are the underlying cause of most fugue episodes.
Epidemiology
The disorder is thought to be more common during natural disasters, wartime, or times of major
social dislocation and violence, although no systematic data exist on this point. No adequate
data exist to demonstrate a gender bias to this disorder; however, most cases describe men,
primarily in the military. Dissociative fugue is usually described in adults.
Course and Prognosis
Most fugues are relatively brief, lasting from hours to days. Most individuals appear to recover,
although refractory dissociative amnesia may persist in rare cases. Some studies have described
recurrent fugues in most individuals presenting with an episode of dissociative fugue. No
systematic modern data exist that attempt to differentiate dissociative fugue from dissociative
identity disorder with recurrent fugues.
Treatment
Dissociative fugue is usually treated with an eclectic, psycho dynamically oriented psychotherapy
that focuses on helping the patient recover memory for identity and recent experience.
Hypnotherapy and pharmacologically facilitated interviews are frequently necessary adjunctive
techniques to assist with memory recovery. Patients may need medical treatment for injuries
sustained during the fugue, food and sleep.
● DISSOCIATIVE IDENTITY DISORDERS
According to DSM – IV- TR, dissociative identity disorder (DID), formerly called multiple personality
disorder (MPD), is a dramatic dissociative disorder in which a patient manifest two or more distinct
identifies that alternate in some way in taking control of behaviour. People with DID are of above
intelligence, and highly creative. There is also an inability to recall important personal information
that cannot be explained by ordinary forgetting. Each identity may appear to have a different
personal history, self – image and name, although there are some identities that are only partially
distinct and independent from other identities. Four times as many women are diagnosed as men.
In most cases the one identity that is most frequently encountered and carries the person’s real
name is the host identity. In most cases the host is not the original identity, and it may or may not
be the best adjusted identity.
The alter identities may differ in striking ways involving gender, age, handedness, handwriting,
sexual orientation, perception for eye glasses, predominant affect, foreign languages spoken,
and general knowledge. Alter identities take control at different points in time and the switches
typically occur very quickly although, more gradual switches can also occur.
Every alter knows to some degree what each alter and the host personality are doing or thinking.
History
The first case was identified almost 4 centuries ago. Formerly known as Multiple Personality Disorder
(MPD). The APA accepted MPD as a diagnostic category in 1980.
DSM IV – TR Criteria
A. The presence of two or more distinct identities or personality states enduring pattern of
perceiving, relating to, and thinking about the environment and self.
B. At least two of these identities or personality states recurrently take control of the person’s
behaviour.
C. Inability to recall important personal information that is too extensive to be explained by
ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of substance (e.g. blackouts or
chaotic behaviour during alcohol intoxication) or general medical condition (e.g. complex
partial seizures)
Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.
Comorbidity
• Affective disorders
• Psychotic disorders
• Anxiety disorders
• Posttraumatic stress disorder
• Personality disorders
• Cognitive disorders
Epidemiology
Few systematic epidemiological data exist for dissociative identity disorder. Clinical studies report
female to male ratios between 5 to 1 and 9 to 1 for diagnosed cases.
Causes
• Dissociative Identity disorder is strongly linked to severe experiences of early childhood
trauma, usually maltreatment.
• The rates of reported severe childhood trauma for child and adult patients with dissociative
identity disorder range from 85 to 97 percent of cases.
• Physical and sexual abuse are the most frequently reports sources of childhood trauma.
• The contribution of genetic factors is only now being systematically assessed, but preliminary
studies have not found evidence of a significant genetic contribution.
• The psychodynamic view
→ DID is thought to result from a lifetime of excessive repression.
→ Psychodynamic theorists believe that continuous use of repression is motivated by
traumatic childhood events, particularly abusive parenting.
→ According to psychodynamic theorists, children who experience such traumas may come
to dear the dangerous world they live in and take flight from it by pretending to be
another person who is looking on safely from afar.
→ Abused children may also come to fear the impulses that they believe are the reasons for
their excessive punishments.
→ Whenever they experience “bad” thoughts or impulses, they unconsciously try to disown
and deny them by assigning them to other personalities.
Symptoms
• In addition to the altering personalities, DID patients experience a wide variety of symptoms.
• DID patients may satisfy the DSM criteria at one a time and not at the others. This appearing
and disappearing of symptoms is similar to bipolar depression.
─ Often, symptoms will be admitted to in one portion of an interview and denied in
another.
─ Symptoms may appear in a “window of diagnosibility”.
• One of the most important symptoms is the presence of multiple personalities.
─ The average number of alters is 13 and the mode is 6. However, there have been cases
of patients with over 100 alters.
─ Each personality will have different sets of thoughts, memories, feelings and behaviours.
─ They can also have different handwriting, genders, sexual orientations, ages, clothing
tastes and even allergies.
• The host personality is the dominant personality, or the one in control the majority of the time.
It is the “original” personality.
─ 68% of DID patient’ host personalities were unaware of their alters.
─ The host, although often unaware of his alters may sense that something is wrong.
• An alter is any other personality existing in a DID patient.
• Amnesia is the second constant, symptom of DID
─ Both the original(host) personality and the alters are aware of lost period of time.
 ─ Often, memories of the trauma which caused DID are not recovered until well into the
therapy process
• Other variable symptoms include
─ Substance abuse
─ Suicidal tendencies
─ Dissociative disorders apart from DID
• Feeling like more than one person
• Encountering people with whom one is unfamiliar but who seem to know them sometimes as
someone else.
• Being called names that are unlike their own name
• Having memory lapses that are indicative of dissociation (significant life events, like birthdays,
birth of a child)
• Having blackouts
• Finding items that are clearly theirs but not recalling the ownership and now the items were
acquired.
• Hearing voices, other than their own, inside their head
• Not recognizing themselves in the mirror
• Feeling unreal
• Feeling like they are watching themselves move through life rather than living their own life.
How does DID work
─ Relationship between the alters usually follow one of the three patterns:
▪ They are mutually aware of each other
▪ They are mutually unaware of each other
▪ One is aware of the other, but the awareness id not reciprocated.
─ In its simplest form, two personalities alternate with each other, each unaware of the other.
─ Another pattern involves two or more dominant personalities and one or more subordinates.
─ 60% of DID patients weren’t aware of their alters
─ 86% had personalities that claimed to be aware of all alters.
─ The majority of DID patients are unaware of their alter personalities, though they may sense
something isn’t right.
A DID patient, ‘Gina” didn’t like the chocolate but began finding mugs with left over hot
chocolate in the sink. This made her aware of something wrong.
─ A DID patient forms alters in order to cope with trauma or disturbing experiences.
─ Different alters seem to handle different problems of the patient.
─ Personalities are often polar opposites, which in extreme cases may represent the conflict
between restraint and self – indulgence that all humans experience to some degree.
Treatments
• Psychotherapy
• Cognitive therapy
• Hypnosis
• Psychopharmacological interventions
• Electro convulsive therapy
• Group therapy
• Family therapy
→ Most people with multiple personality disorder are diagnosed between the ages of 20 and 40.
→ The most common treatment for MPS is long term psychotherapy twice a week.
→ The host and alters are encouraged to communicate with each other in order to integrate or
come together.
→ The treatment of MPD lasts an average of four years.
→ Psychotherapy with hypnosis – the therapist seeks to make contact with as many alters as
possible and to understand their roles and functions in the patient’s life.
 → Drug therapy – Relieve some specific coexisting symptoms, such as anxiety or depression.
Includes antidepressants, depressants, stimulants, antipsychotic medication, anxiety
medication.
→ Several periods of psychiatric hospitalization may be necessary to help the person through
difficult times.
→ Mutual self – help support groups within larger communities.
● DEPERSONALIZATION DISORDER
Sense of being cut off or detached from one’s self. Depersonalization is conceptualized as a
psychological numbing reaction that is evoked during times of extreme stress, representing an
adaptive mechanism when experienced during discrete episodes. It is an experience that does
not necessarily mean you have a psychological disorder. 50 – 70% of people would say that they
have experienced depersonalization at some point of their lives. It is estimated to occur in about
2% of the population.
▪ Feeling detached from yourself.
▪ Asking for yourself “am I real?”
▪ Dreamlike state where you feel robotic
▪ May last from hours to months
▪ Feeling unreal like an observer
▪ Feeling out of your body
▪ Constantly checking in to deep up your thoughts.
▪ Existential thoughts
▪ Spending lots of time with your
DISSOCIATIVE DISORDER NOT OTHERWISE SPECIFIED
Dissociative symptoms, not meet criteria of any specific disorder
Classification
DSM – 5 ICD 10
• Dissociative amnesia • Dissociative amnesia
• Dissociative identity disorder • Dissociative fugue
• Depersonalization disorder • Dissociative stupor
• Other specified dissociative disorder • Trance and possession disorder
• Unspecified dissociative disorder • Dissociative disorders of movement and sensation
• Mixed dissociative disorders (i.e. Ganser’s syndrome, multiple
personality disorder, transient dissociative disorder etc.)
Treatment
• Pharmacologic Interventions
─ Anxiolytic (benzodiazepines PRN and maintenance dose)
─ Antidepressant
─ Neuroleptics (atypical antipsychotics)
• Psychosocial interventions
─ Intensive psychotherapy
─ Hypnosis
• Client Grounding Techniques
─ Safe place
─ Ice in hands
─ Wrapping self in blanket
─ Counting backward or forward
• Client Education
─ Relapse prevention
─ Journaling
Therapeutic Management
• Psychotherapy is the primary treatment for dissociative disorders. This form of therapy, also
known as talk therapy, counselling or psychosocial therapy, involves talking about the
disorder and related issues with a mental health professional. It triggered the dissociative
symptoms. The course of psychotherapy may be long and painful, but this treatment
approach often is very effective in treating dissociative disorders.
• Creative Art Therapy is a type of therapy which uses the creative process to help people
who might have difficulty expressing their thoughts and feelings. Creative arts can help
increase self – awareness, cope with symptoms and traumatic experiences, and foster
positive changes. Creative art therapy includes art, dance and movement, drama, music
and poetry.
• Cognitive Therapy is a type of talk therapy helps identify unhealthy, negative beliefs and
behaviours and replace them with healthy, positive ones. It’s based on the idea that the
person’s own thoughts – not other people or situations – determine how they behave. Even
if an unwanted situation has not changed. It can change the way they think and behave in
a positive way.
• Medication – although there are no medications that specifically treat dissociative disorders,
the doctor may prescribe antidepressant, anti – anxiety medications or tranquilizers to help
control the mental health symptoms associated with dissociative disorders.
 MODULE 4: PERSONALITY DISORDERS
Personality is a relatively stable and enduring set of characteristic cognitive, behavioural and
emotional traits. Over time, a person will interact with others in a reasonably predictable way.
Personality changes with experience, maturity, and external demands in a way that promotes
adaptation to the environment. It is affected by genetic and psychosocial factors.
A personality disorder is an extreme set of characteristics that goes beyond the range found in
most people. Personality disorders are defined as an enduring pattern of inner experience and
behaviour that deviates markedly from the expectations of the individual’s culture. It is pervasive
and inflexible. It has an onset in adolescence or early adulthood. It is stable over time. It leads to
distress or impairment of functioning. It cannot be diagnosed before the age of 18. The pattern is
manifested in two (or more) of the following areas:
• Cognition
• Affectivity
• Interpersonal functioning
• Impulse control
Personality disorders occur in 10 – 20 percent of the general population. Approximately 50% of all
psychiatric patients have a personality disorder, which is frequently comorbid with other clinical
syndromes. Personality disorder is also a predisposing factor for other psychiatric disorders (e.g.
substance use, suicide, eating disorders, anxiety disorders, impulse control disorders, affective
disorders). In general, personality disorder symptoms are ego syntonic (i.e. acceptance to the
ego, as opposed to ego dystonic) and alloplastic (i.e. alter the external environment rather than
themselves).
COMMON FEATURES
→ Being overwhelmed by negative feelings such as distress, anxiety, worthlessness or anger.
→ Avoiding other people and feeling empty and emotionally disconnected.
→ Difficulty managing negative feelings without self – harming or, in rare cases, threatening
other people.
→ Odd behaviour
→ Difficulty maintaining stable and close relationships, especially with partners, children and
professional care givers.
→ Sometimes, periods of losing contact with reality.

Personality disorders tend to fall into three groups according to their emotional flavour:
1. CLUSTER A: Odd or Eccentric
2. CLUSTER B: Dramatic, Emotional or Erratic
3. CLUSTER C: Anxious and Fearful
CLUSTER A: ODD OR ECCENTRIC
1. PARANOID PERSONALITY DISORDER (PPD)
A mental disorder characterized by paranoia and a pervasive,
long – standing suspiciousness and generalized mistrust of others.
Symptoms
• May be hypersensitive, easily feel slighted, and habitually
relate to the world by vigilant scanning of the environment
for clues or suggestions that may validate their fears or
biases.
• They think they are in danger and look for signs and threats of that danger.
• Tend to be guarded and suspicious and have quite constricted emotional lives.
• They may or may not have a tendency to bear grudges, suspiciousness, tendency to
interpret.
Specifiers
• Individuals think that people intend to harm, exploit, or deceive them
• Lost trust
• Misinterpretation of good motives
• Reluctant to relationships
• Hidden messages
• Unwillingness for forgiveness
• Counterattacks
• Pattologically jealous
Associated Features
• Overt argumentativeness
• “cold” with no tender feelings
• Self – sufficiency
• Autonomy
• Control
• Litigious
• Negative stereotypes
• Fanatical worldviews
Prevalence
• 0.5% - 2.25%
• 10% - 30%
• 2% - 10%
Course
• Early adulthood
• Chronic
Cultural Prevalence & Features
• Minority groups
• Economic/political refugees
• Unfamiliarity
Causes
A genetic contribution to paranoid traits and a possible genetic link between this personality
disorder and schizophrenia exist. Psychosocial theories implicate projection of negative internal
feelings and parental modelling. Cognitive theorists believe the disorder to be a result of an
underlying belief that other people are deceptive/malevolent in combination with a lack in self –
confidence.
Treatment
Because of reduced levels of trust, there can be challenges in treating PPD. However,
psychotherapy, antidepressants, antipsychotics and anti – anxiety medications can play a role
when an individual is receptive to intervention.
 2. SCHIZOID PERSONALITY DISORDER
It is a personality disorder characterized by a lack of interest in social relationships, a tendency
towards a solitary lifestyle, secretiveness, emotional coldness, and apathy.
Symptoms
• Often aloof, cold and indifferent
• Have trouble establishing personal relationships
• May remain passive in the face of unfavourable situations
• When the individual’s personal space is violated, they feel suffocated and feel the need to
free themselves
• It is not people as such that they want to avoid, but emotions both negative and positive,
emotional intimacy, and self-disclosure
Specifiers
• Distant relationships
• Solitary activities
• No sexual desires
• Rare pleasure
• Lack of network
• Indifference
• Emotional Detachment
Associated Features
• Difficulty to express emotions
• Difficulty to respond to significant life events
• Single lifestyle
• Isolated occupations are a good fit
• Brief psychotic episodes
Prevalence
• Individuals with schizophrenia
• Individuals with Schizotypal Personality disorder
• More males
• Impairment to males
Course
• Early adulthood
• variety of contexts
Causes
There is some evidence to suggest that there is an increased prevalence of schizoid personality
disorder in relatives of people with schizophrenia or schizotypal personality disorder. To Sula Wolff,
who did extensive research and clinical work with children and teenagers with schizoid symptoms,
“schizoid personality has a constitutional, probably genetic basis. Other researchers had
hypothesized that unloving, neglectful or excessively perfectionist parenting could play a role.
Twin studies with schizoid personality disorder traits, low sociability and low warmth, suggest these
traits are inherited. Because of this, there is indirect evidence linking the heritability of schizoid
personality disorder.
Treatment
• Medication
• Psychotherapy
• Modalifinil
• Socializations groups

3. SCHIZOTYPAL PERSONALITY DISORDER

It is a personality disorder characterized by a need for social isolation, anxiety in social situations,
odd behaviour and thinking, and often unconventional beliefs. A pervasive pattern of social and
interpersonal deficits marked by acute discomfort with, and reduced capacity for, close
relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour.
Symptoms
• Feel extreme discomfort with maintaining close relationships with people, so they avoid
forming them
 • Peculiar speech mannerisms and odd modes of dress
• May react oddly in conversations, not respond or talk to themselves
• Frequently misinterpret situations as being strange or having unusual meaning for them
Specifiers
• Misinterpretations
• “Magical thinking”
• Illusions
• Odd thinking and speech
• Suspiciousness
• Eccentric behaviour and appearance
• Lack of confidants
• Excessive social anxiety
Associated Features
• Mistreatment
• Psychotic episodes
Associated Disorders
• Brief Psychotic Disorder
• Schizophreniform Disorder
• Delusional
• Schizophrenia
Prevalence
• 3% of the general population
• First degree relatives with Schizophrenia
• More common in males
Course
• Early adulthood
• Stable course
• Variety of contexts
Causes
• Biological Genetics
• Social and Environmental Factors
Treatment
• Pharmacological
In order to decide which type of medication should be used, Paul Markowitz distinguishes two
basic groups of schizotypal patients:
Schizotypal patients who appear to be almost schizophrenic in their beliefs and behaviours – they
are usually treated with low doses of antipsychotic medications, e.g. thiothixine. However, it must
be mentioned that long – term efficiency of neuroleptics is doubtful
Schizotypal patients who are more obsessive – compulsive in their beliefs and behaviors – in this
case SSRIs e.g. Sertraline appear to be more effective.

CLUSTER B: DRAMATIC, IMPULSIVE AND ERRATIC

1. ANTISOCIAL PERSONALITY DISORDER
It is an inability to conform to the social norms that ordinarily govern
many aspects of a person’s adolescent and adult behaviour.
Sex ratio
3 : 1 males : females
Epidemiology
• The 12-month prevalence rates are between 0.2 and 3%
according to DSM 5.
• It is more common in poor urban areas and among mobile residents of these areas
• The highest prevalence is found among the most severe samples of men with alcohol use
disorder (over 70%) and in prison populations, where the prevalence is 75%.
• The onset of the disorder is before the age of 15 years.
• Girls usually have symptoms before puberty and boys even earlier.
Clinical Criteria
• The hallmarks of antisocial PD are pervasive disregard for and violation of rights of others
occurring since the age of 15 years and continuing into adulthood.
• A person has to be 18 years or older, and there has to be evidence of conduct disorder
before the age of 15.
• Indicated by three or more of the following:
1. Failure to conform to social norms
2. Deceitfulness, including lying and conning others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, including repeated physical fights or assaults
5. Reckless disregard for safety of self of others
6. Irresponsibility, indicated by the failure to honour financial obligations or to sustain
consistent work behaviour
7. Lack of remorse, indicated by indifference or rationalizing having hurt, mistreated or
stolen from others
Associated Features
• Promiscuity and inability to sustain a monogamous relationship
• Inflated and arrogant self – appraisal
• Lying, truancy, running away from home, thefts, fights, substance abuse, and illegeal
activities
• They often impress opposite sex clinicians
• Exhibit no anxiety or depression although suicide threats and somatic preoccupations may
be common
• Have good verbal intelligence
• They are extremely manipulative and can frequently talk others into participating in
schemes for easy ways to make money
• Those with this disorder do not tell the truth and cannot be trusted to carry out any task
• Promiscuity, spousal abuse, child abuse, and drunk driving are common events in their lives
Course
• After the age of 30, both the most flagrant antisocial behaviours (promiscuity, crime) and
the less severe behaviours and substance use tend to decrease.
• Even after tge severe antisocial behaviour “burns out”, people diagnosed with antisocial PD
usually continue to be irritable, impulsive, and detatched.
Causes
• Biological factors
• Genetic factors
• Environment factors
Treatment
• Medications
• Long term structured residential settings
• Psychotherapy along with behaviour modification techniques
• Self help groups or pro – social reform organizations

2. BORDERLINE PERSONALITY DISORDER

Alternate names
• Emotional Regulation Disorder (ERD)
• Emotional Dysregualtion Disorder
• Emotional Intensity Disorder (EID)
• Emotional Unstable Personality Disorder (EUPD)
• Emotion Impulse Regulation Disorder (EIRD)
• Impulsive Personality Disorder (IPD)
Borderline between neurosis and psychosis. Extraordinarily unstable. Affect, Mood, Behaviour,
Relations and Self – image.
Sex ratio
According to DSM 5, this disorder is more commonly diagnosed in females (75% of diagnosed
cases are females)
Epidemiology
• Prevalence rates of about 2% in the general population
• 10% of psychiatric outpatients
• 20% for psychiatric inpatients
• 30 – 60% among patients with PDs
• The diagnosis is more common in younger than in older samples
Clinical Criteria
• The hallmarks of Borderline PD are pervasive and excessive instability of affects, self – image,
and interpersonal relationships as well as marked impulsively.
• Diagnostic features also include at least five of the following:
1. Frantic efforts to avoid real or imagined abandonment
2. Unstable and intense interpersonal relationships, with alternating between
idealization and devaluation
3. Markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two potentially self-damaging areas (spending, sex, substance
abuse, binge eating, reckless driving)
5. Recurrent suicidal behaviour, gestures, threats or self-mutilating behaviours
6. Instability of affect due to marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriately intense anger or difficulty controlling anger
9. Stress related, transient paranoid ideation or dissociative symptoms
Associated Features
• Tendency to undermine self when close to realizing a goal
• Feeling more secure with nonhuman objects (pets, inanimate objects) than in interpersonal
relationships
• Mood Swings are common
• Patients can have short-lived psychotic episodes (so-called miscropsychotic episodes)
rather than full-blown psychotic breaks, and the psychotic symptoms of these patients are
almost always fleeting or doubtful.
• Their achievements are rarely at the level of their abilities
• Patients with borderline personality disorder cannot tolerate being alone, and they prefer a
frantic search for companionship
• Some clinicians use the concepts of panphobia, pananxiet, panambivalence and chaotic
sexuality to delineate these patients’ characteristics
Projective Identification
Otto Kemberg described the defense mechanism of projective identification that occurs in
patients with borderline personality disorder. It consists of 3 steps:
1. An aspect of the self is projected onto someone else
2. The projected then tries to coerce the other person into identifying with what has been
projected
3. Finally, the recipient of the projection and the projector feel a sense of oneness or union
Splitting
In splitting, persons toward whom patients’ feelings are, or have been,a mbivalent are divided
into good and bad.
For example, in an inpatient setting, a patient may idealize some staff members and uniformly
disparage others.
Course
• Variable. Most commonly follows a pattern of chronic instability in early adulthood, with
episodes of serious affective and impulsive dyscontrol
• The impairment and the risk of suicide are the greatest at the young adult years and
gradually wane with advancing age
• In the fourth and fifth decades, these individuals tend to attain greater stability in their
relationships and functioning
Causes
• Biological factors
• Genetic factors
 • Environment factors
Treatment
• Counseling and therapy
• Medicines
• Healthy habits
• Partial hospitalization

3. NARCISSISTIC PERSONALITY DISORDER

Heightened sense of self importance, lack of empathy and grandiose feeling. However,
underneath their self esteem is fragile and vulnerable to minor criticism. It is chronic and is difficult
to treat.
Sex ratio
This disorder is more commonly diagnosed in males (50 - 70% of diagnosed cases are males)
Epidemiology
• Prevalence rates of about 2-16% in the clinical population
• Less than 1% in the general population
Clinical Criteria
• The hallmarks of Narcissistic PD are pervasive sense of grandiosity (in fantasy or in
behaviour), need for admiration, lack of empathy, and chronic intense envy.
• Diagnostic features also include at least five of the following:
1. Grandiose sense of self-importance and specialness
2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty or ideal love
3. Sense of entitlement (having a right to do something)
4. Regards self as “special” and unique
5. Interpersonal exploitativeness such as taking advantage of others to achieve own needs
6. Lack of empathy
7. Excessive need for admiration and acclaims
8. Intensive and chronic envy (jealous)
9. Arrogant and haughty (superior, lack of respect) attitude
Associated Features
• Fragile self-esteem (which exclusively depends on external admiration) with hypersensitivity
to criticism
• High achievements more frequent than in any other PD
• Strong feelings of shame and humiliation
• Exhibitionism (behaviour motivated by the pleasure of being looked at)
• Fear of having their “hidden” imperfections and flaws revealed
Course
• Chronic
• However, narcissistic symptoms tend to diminish after the age of 40, when pessimism usually
develops
Causes
Cause of the disorder is unknown, however listed below are following factors to be identified
possibilities:
• An oversensitive temperament (personality traits) at birth
• Excessive admiration that is never balanced with realistic feedback
• Excessive praise for good behaviours or excessive criticism for bad behaviours in childhood
• Overindulgence and overvaluation by parents, other family members or peers
• Being praised for perceived exceptional looks or abilitied by adults
• Severe emotional abuse in childhood
• Learning manipulative behaviours from parents to peers
• Valued by parents as a means to regulate their own self esteem
Treatment
• Psychotherapy
A form of therapy developed by Jeffrey Young that integrates several therapeutic approaches
(psychodynamic, cognitive, behavioural etc) also offers an approach for the treatment of NPD.
Pattern change strategies, over a long period of time, are for narcissists to work on increasing their
ability to become more empathetic in everyday relationships.
Psychoanalytic psychotherapy has a higher success rate. Therapists must recognize the patient’s
traits and use caution in tearing down narcissistic defenses too quickly.

4. HISTRIONIC PERSONALITY DISORDER

• Excitable and emotional
• Attention seeking
• Exaggeate their thoughts and feelings
• Colourful, Dramatic and extrovert
• Flamboyant but inability to maintain deep, long lasting attachments
Sex ratio
This disorder occurs far more frequently among women. According to DSM 6, the disorder might
be equally frequent among men and women
Epidemiology
• Prevalence rates of about 2 in the general population
• 10-15% for psychiatric inpatients and outpatients
Are reported in DSM-IV-TR and DSM 5
Clinical Criteria
• The hallmarks of Histrionic PD are pervasive and excessive self-dramatization, excessive
emotionality, and attention seeking
• Diagnostic features also include at least five of the following:
1. Inappropriate sexual seductiveness or provocativeness
2. Excessive need to be in the center of attention
3. Rapidly shifting and shallow expression of emotions
4. Suggestibility
5. Physical appearance used for attention seeking purposes
6. Impressionistic speech lacking detail
7. Self-dramatization, theatricality, exaggerated expression of emotions
8. Relationships considered more intimate than they really are
Associated Features
• Difficulties achieving emotional intimacy in romantic or sexual relationships
• Promiscuity
• Seductive behaviour is common in both sexes. Sexual fantasies about people with whom
patients are involved
• In fact, histrionic patients may have a psychosexual dysfunction, women may be
anorgasmic and men may be impotent
• Their need for reassurance is endless
• They may act on their sexual impulses to reassure themselves that they are attractive to the
other sex
Course
With age, people with histrionic personality disorder show fewer symptoms, but because they lack
the enrgy of earlier years, the difference in number of symptoms may be more apparent than
real. People with ths disorder are sensation seekers, and they may get into trouble with the law,
abuse substances and act promiscuously

CLUSTER C: ANXIOUS AND FEARFUL

1. AVOIDANT PERSONALITY DISORDER
The patient with avoidant personality is essentially a shy, inhibited
person who has feelings of inadequacy and low self esteem.
These patients are hypersensitive to perceived criticism, but have
the capacity to develop appropriate relationships if they feel safe
and accepted. They may lead socially withdrawn lives. These
people are commonly describes as having an inferiority complex.
Diagnosis I
• Social inhibition
 • Feelings of inadequacy
• Extreme sensitivity to negative evaluation
• Avoidance of social interaction
Diagnosis II
Requires at least four:
1. Avoids occupational activities that involve significant social contact, due to fears of
disapproval or rejection.
2. Unwilling to deal with people unless sure of being liked.
3. Restraint within intimate relationships due to fear of being shamed or ridiculed.
4. Preoccupied with being criticized or rejected in social situations.
5. Inhibited in new social situations because of feelings of inadequacy.
6. View themselves as socially inept, personally unappealung,, or inferior to others.
7. Unusually reluctant to take risks or to engage in new activities because they may prove
embarrassing.
Epidemiology
• Prevalence rates of 2-3% in the general population
• 10% for psychiatric outpatients
• This disorder is equally frequent in males and females
• Infants classified as having a timid temperament is more susceptible to the disorder
Complications
Social phobia
Comorbidity
• These patients are at increased risk for mood and anxiety disorders (especially social
phobia, generalized type).
• About 25-50% have panic disorder
• 10-25% have Generalized Anxiety Disorder
• 20-25% have an Eating Disorder
• More than 33% have Body Dismorphic Disorder
• The most common co – occuring disorders are Schizotypal, Schizoid, Paranoid, Dependent
and Borderline
Impairment
Can be severe, tupically includes occupational and social difficulties
Course & Prognosis
• Many people with avoidant PD are able to function in a protected environment
• Some live their lives surrounded only by family members
• If their support system fails, they are subject to depression, anxiety and anger
• Phobic avoidance is common
• Patients with avoidant PD give histories of social phobia or incur social phobia in the course
of their illness
• Avoidant PD have chronic and persistent course
Treatment
• Psychotherapy: There have actually been a couple of studies that have examined the
effects of psychotherapy for avoidant PD. Social Skills Training and Exposure Therapy are
helpful.
One found that 20 sessions of Cognitive Behavioural Therapy (CBT) brought some
improvement in symptoms, and was superior to 20 sessions of Psychodynamic
Psychotherapy (PP).
Another study found that 40 sessions of CBT was equally effective to 40 sessions of PP.
• Pharmacotherapy: Used to manage anxiety and depression associated with disorder.
Some patients are helped by Beta adrenergic receptor antagorists (Atenolol) to manage
autonomic nervous system hyperactivity.
2. DEPENDANT PERSONALITY DISORDER
People with Dependent Personality Disorder subordinate their own needs to those of other. They
get others to assume responsibility for major areas of their lives. They have difficulty making
everyday decisions without an excessive amount of advice and reassurance from others. They
lack self confidence and experience intense discomfort when alone for more than a brief period.
Diagnosis I
• Excessive and pervasive need to be tajen care of
• Submissive
• Clinging, needy behaviour due to fear of abandonment
Appears in adolescence and young adulthood
Diagnosis II
Requires at least 5:
1. Needs excessive reassurance and advice to make everyday decisions
2. Need others to take responsibility for areas of their lives
3. Difficult to disagree with others out of fear of disapproval
4. Difficult to initiate projects or do things on their own
5. Excessively seeks nurturance and support from others, even by offering to do unpleasant
things
6. Feels stressed or helpless when alone due to exaggerated fears of being unable to care for
themselves
7. Urgently seeks another source of care when a close relationship ends
8. Preoccupied with fears of being left to take care of himself or herself
Epidemiology
• Prevalence rates of 0.6-3% in the general population
• Female > Male
• More common in younger children than in oldre ones
• People with chronic physical illness in childhood may be most susceptible to the disorder
Complications
• Mood disorders
• Anxiety disorders
• Adjustment disorders
• Social phobia
• Low socioeconomic status
• Poor family and marital functioing
Comorbidity
• Eating disorders
• Anxiety disorders
• Somatoform disorders
• Other personality disorders
• About 30% of these individuals can be diagnosed with depression
• Over 10% of these individuals can be diagnosed with bipolar disorder
• About 7% have dysthymia
Impairment
Frequently only mild, typically includes interpersonal relationships and occupational functioning if
independence is required.
Course & Prognosis
• Little is known about the course of Dependent PD
• Occupational functioning tends to be impaired because the person can’t act
independently and without close supervision
• Social relationships are limited to those on whom they can depend
• Risk of Major Depressive Disorder if they lose the person on whom they depend
• With treatment the prognosis is favourable
Treatment
• Psychotherapy: Insight – oriented therapies enable patients to understand the antecedents
of their behaviour, become more independent, assertive and self – reliant.
Behavioural therapy, assertiveness training, family therapy and group therapy have been
used with successful outcomes in many cases.
• Pharmacotherapy: Medications would not be expected to help very much for the core
symptoms of Dependent Personality Disorder, but will often be used to treat any associated
psychiatric conditions.
 3. OBSESSIVE COMPULSIVE PERSONALITY DISORDER
Characterised by orderliness, perfectionism, excessive attention to details, mental and
interpersonal control, a need for control over one’s environment, at the expense of flexibility,
openness to experience and efficiency.
Diagnosis I
Preoccupation with orderliness, perfectionism, details, mental and social control, and power over
one’s environment. At the expense of flexibility, openness and efficiency.
Requires at least 4:
Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major
point of the activity is lost shows perfectionism that interferes with task completion (e.g. is unable
to complete a project because his or her own overly strict standards are not met) is excessively
devoted to work and productivity to the exclusion of leisure activities and friendships (not
accounted for by obvious economic necessity) is over conscientious, scrupulous, and inflexible
about matter of morality, ethics, or values (not accounted for by cultural or religious identification)
is unable to discard worn – out or worthless objects even when they have no sentimental value is
reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of
doing things adopts a miserly spending style towards both self and others; money is viewed as
something to be hoarded for future catastrophes shows rigidity and stubbornness.
Diagnosis II
Requires at least 4:
1. Preoccupied with details, such that the point of the activity is lost
2. Perfectionism that interferes with task completion
3. Too devoted to productivity to the exclusion of friends and leisure activities
4. Inflexible about morality (Apart from religion)
5. Unable to discard worthless objects even with no sentimental value
6. Reluctant to delegate tasks or to work with others unless they submit to their way of doing
things
7. Miserly, money hoarded for future crisis
8. Rigid and stubborn
Epidemiology
• Prevalence rates of 2-8% in the general population
• 8-9% of psychiatric outpatients
• Female : male = 1 : 2
• Most often in oldest siblings
Complications
Distress and difficulties when confronted with new situations that require flexibility and compromise
Comorbidity
• These patients are at increased risk for major depression and anxiety disorder.
• There is equivocal evidence for an increased risk of OCD
Impairment
Frequently severe, typically includes occupational and social difficulties
Course & Prognosis
• Course is variable and unpredictable
• Some adolescents with OCPD evolve into warm, open and loving adults
• The disorder can be the harbinger of Schizophrenia or MDD
• Individuals with OCPD often experience a moderate level of professional success but they
are vulnerable to unexpected changes and their personal live may remain barren
• Late onset Depressive disorder is common
Treatment
• Psychotherapy: Insight oriented psychodynamic techniques and cognitive behavioural
therapy are helpful. Specific breathing and relaxation techniques can help decrease the
sense of stress and urgency.
• Pharmacotherapy: SSRIs appear to help the OCPD patients with their rigidity and
compulsiveness.