MODULE 3: BEHAVIOUR CHANGE

The most basic form of behavior is that seen in unicellular organisms, in higher animals,
behavior is controlled by the endocrine system and the nervous system.

Human behaviour can be described as common, if it is a form of behaviour found in majority of

people in the community, It is said to be normal if, in that community it is within accepted
norms. Other words such as usual or unusual, acceptable, or unacceptable and abnormal are all Commented [yd1]: Abnormal behaviour broadly refers to
deviations from what is considered typical behaviour. This
used. deviation can be further be specified to qualitative
abnormality- deviation from culturally accepted standards or
THEORIES quantitive abnormal- behaviour that deviates from the
statistical average of a population.
Nature vs nurture

Aristotle-384-322 B.C. believed in sensory experience (what we perceive with our five senses)
as the source of knowledge that make us who we are- This has been referred as empiricism.

Plato (427-437 B.C.) on the other hand believed that Human beings enter the world with in-
born knowledge of reality- referred to as Nativism/ Nature, he went on to add that reasoning
provided access to this knowledge.

Ivan Pavlov (1849- 1936), the classical conditioning

B.F. Skinner (1904-1990) the operant conditioning.

- The study of nerve impulses by Herman von Helmholtz (1821-1894)

- The desription of Brain function research by Broca (1824- 1880)

Evolutionary theory- Darwin-( 1809-1882) and his cousin Sir Francis Galton- natural selection to
account for development of human abilities. With the survival of those with most highly
developed abilities.

Freud and Psychoanalysis

Sigmund Freud (1856- 1939) has a special place in mental health as the father of the modern
psychotherapy. Having started as a neurologist he moved on to become the founder of a new
discipline- psychoananlysis, with a heavy leaning towards environment as the basis of
psyhcological disorders or abnormal human behaviour.

According to the Psychoanalytical theory:

Early childhood experiences play an important role in the developement of personality, and
experiences and conflicts during the first five year form the basis of psychosexual development.
Freud theorised that abnormal behaviour as in psychological disorders developed as a result of
unresolved childhood conflicts and trauma.

He also described the 3 instances of the psyche:

 the id
 the ego
 the super ego

the three structure of the psyche:

 Conscious
 Subconscious
 Unconscious

Freud described the five stages of psychosexual development as:

 the oral stage
 the anal stage
 the phallic stage also referred to as the oedipal stage
 the latent stage
 the genital stage.
Another psychoanalyst- Erik Erikson went on to describe the 8 stages of Psychosocial
development

Humanistic Theories of Behaviour

Humanistic perspective- Abraham Maslow (1908-1970), theorised that human behaviour was
geared towards satisfaction of needs. He described the hierarchy of needs, starting with the
most basic to the highest as: Physical needs, Safety needs, Love needs, Aesthetic needs.
Carl Rogers (1902- 1987) on the other hand postulated that human beings have through free
will the capacity to overcome the influences of unconcious motive and environmental
experiences. Human beings have a natural tendency for self-actualisation (the attainment of
one‘s potential)

Social Learning- Social Influences

The social learning theory postulates that as we grow and develop in our lives, we also develop
social attitudes which strongly influence our behavior. Children internalize the values of their
parents attitudes of the society and cultural expectations about how to behave- socialization

Cognitive Behavioral Theories

In the Cognitive Perspective (Gardner 1985), the brain has an active role in organising
perceptions, in processing information, and in interpreting experiences.

Jean Piaget (1896-1980) described the cognitive development as an important basis of

behaviour.

Instincts, Basic Drives and Motives

Earlier attempts to explain human behaviour on the basis of instincts as in other animals was
replaced by the drives theory and motivation.

A Drive is described as a force originating from a natural need, like thirst or hunger. Such a
situation stimulates the organism to comply with the need.

This is complented by motivation corresponding to the state of an organism- to start or to

continue an act e.g. the type of food available or seen.

Review questions

Abnormal human behaviour can be described using all the following except

Qualitative deviation from cultural norms

Quantitative deviations from society norms
Behaviour characterized by socio-occupation dysfunction
 Behaviour based on different political opinion as the mainstream
Behaviour characterized by personal distress

The historical discourse on Nature vs Nurture refers to:

The argument for or against science

The argument for hereditary factors vs environment to explain human behaviour
The argument for religion vs science
The argument for modern Tradition medicine vs modern medicine
The argument for ethnocentrism vs universalism

Broca (1824-1880), the man who discovered the Broca area in the brain was, with reference to
the above discourse, a

Psychoanalyst
environmentalist
a behavioralist
existentialist
rationalist

Sigmund Freud (1856-1939) theorised that abnormal behaviour and psychological disorders
developed because of unresolved childhood conflicts and founded a field of
psychology/psychotherapy referred to as

Humanism
Behaviouralism
Psychoanalysis
Existentialism
Rationalism

Behavioral change theories

Behavioural change theories and models are attempts to explain the reasons behind
alterations in individuals' behavioural patterns.

Examples of behaviour change theories that are of particular relevance to health include:

a. Classical and Operant conditioning

 b. Social cognitive learning Theory

c. Theory of self-efficacy

d. Reasoned action theory

Classical conditioning

Operant conditioning

B F. Skinner (1904-1990) went further to describe how the consequences of behaviour can be
used to strengthen newly introduced or existing behaviour or abolish unwanted behaviour in a
series of experiments involving rats. He called this new type of learning operant conditioning
and the consequences of behaviour that influence behaviour, reinforcement either positive or
negative e.g where a rat is rewarded when it pushes a panel with food pellets. But may also be
punished with electric shock.

Social cognitive theory

Bandura (1986) described the basic reciprocal interactions between environmental, personal
and behavioural elements as key determinants of behavioural change.

Bandura went on to describe a more complex reciprocal interaction between thoughts,

behaviour, individual's characteristics and social environment.

Based on this theory there are three distinct components of interactions:

- An individual's thoughts affect their behaviour and an individual's characteristics elicit certain
responses from the social environment.

- Likewise, an individual's environment affects the development of personal characteristics as

well as the person's behaviour,

- Lastly an individual's behaviour may change their environment as well as the way the
individual thinks or feels.
 Theory of self-efficacy

One of the key concepts inherent in the Social cognitive theory is the Self-efficacy where Self-
efficacy refers to one’s confidence in the ability to take action and persist in action.

Self-efficacy determines other important elements of behaviour change like:

1. the choice of activities in which people engage

2. how much energy they will expend on such activities and
3. the degree of persistence they demonstrate in the face of failure and/or adversity

Theory of reasoned Action-(Ajzen 1985)

This theory has its basis in the humanistic theory of behaviour and starts off by making an
assumption that humans are rational and individuals consider the consequences of a behaviour
before performing the particular behaviour. As a result, intention is an important factor in
determining behaviour and behavioural change.

Secondly that intentions develop from an individual's perception of a behaviour as positive or

negative together with the individual's impression of the way their society perceives the same
behaviour.

Thus, personal attitude and social pressure shape intention, which is essential to performance
of a behaviour and consequently behavioural change

Trans theoretic/Stages of Change Model

The trans theoretic Model by Prochaska and DiClemente (1986) of change also called the stages
of change model is a model that has often been used to predict the changes that one is
expected to go through in recovery from an addiction.

Behavioural change under this model is a described as a five-step process between which
Individuals may oscillate up and down before achieving complete change.

Precontemplation stage- In addiction medicine there is the time during which the individual
doesn't acknowledge they have a problem or is in denial.

Contemplation stage- develops a desire to change

Preparation- shows intention to change the behaviour.

Action stage- begins to exhibit new behaviour consistently

Maintenance stage- exhibits the new behaviour consistently for over six months.

It is however important to note that behaviour change can only take place in the context of an
enabling or supportive environment. The relevant features of such a context include: social,
cultural, ethical and spiritual, legal and political features and resources.

2.4.2 The Health Belief Model

The Health Belief Model (HBM) attempts to explain health-behaviour in terms of individual
decision-making based on attitudes and beliefs of the individual.

The Key variables of HBM include

a) Perceived Threat: Consists of two parts-

1. Perceived Susceptibility: One's subjective perception of the risk of contracting a health
condition
2. Perceived Severity: Feelings concerning the seriousness of contracting an illness or of
leaving it untreated. While a youth may perceive getting rained on as a risk factor in
catching a cold, the seriousness of the illness may not be considered severe enough to
keep him from playing football in the rain.

b. Perceived Benefits: The believed effectiveness of strategies designed to reduce the

threat of illness.
c. Perceived Barriers: The potential negative consequences that may result from taking
particular health actions, including physical, psychological, and financial demands.
d. Cues to Action: Events, either bodily (e.g., physical symptoms of a health condition) or
environmental (e.g., media publicity)
e. Self efficacy: an individual's perceived ability to successfully carry out a "health"
strategy, such as using a condom consistently.

Applications of behavioral change theories and models

While behaviour change models have been applied in many situations, three areas have
dominated:

a. Health
b. Education
c. Criminology

Review questions

Which one of the following is true of classical conditioning in Pavlov’s experiment

 Salivation to a bone only in the dog is a conditioned stimuli
A Bell is a an unconditioned reflex
A bell is an unconditioned stimuli
A bone is a conditioned reflex
A bone is a conditioned stimuli

Canning in schools is an education practice that is associated with

Classical conditioning
Health belief model
psychodynamic psychology
Permissive parenting
Operant conditioning

Which of the following is not associated with self-efficacy

Creativity
Persistence in an action
one’s confidence in the ability
Choice of activities
Amount of energy expended in an activity

Which one of these theories refers to the ancient Greek theory of Body types

Sheldon,s theory
Theory of Physiognomy
Kretchmer’ s theory
Somatotype theory
The Humoral theory

CONSTITUTIONAL FACTORS AND HUMAN BEHAVIOUR

The humoral theory of behavior

The greeks described 4 type s of personalities based on the then known body fluids:

1. Blood- with cheerful, pleasure-seeking and sociable or sanguine temperament

2. Phlegm- with calm relaxed and quiet with phlegmatic temperament
3. Black bile- with a depressed, introverted and thoughtful, or melancholic temperament
4. Yellow bile- with irritable, ambitious and leader-like choleric temperament

The theories of body and human behaviour

These include:

 Phrenology and Pysiognomy

 Ernst Kretchmer a German Psychiatrist (1888-1964), described four constitutional types:

a. The Pyknic
b. The Asthenic
c. The Athletic
d. The Displastic

 Sheldon’s Constitutional Theory of Personality- described 3 types of physiques which he

called somatotypes

a. Endomorphy
b. Mesomorphy
c. Ectomorphy

Review questions

Which one of these theories refers to the ancient Greek theory of Body types

Sheldon,s theory
Theory of Physiognomy
Kretchmer’ s theory
Somatotype theory
The Humoral theory

The sample group that Ernst Kretchmer used to develop his theory of physique Body build and
personality came from a population of

High school students

Mentally ill patients
 Ford factory workers
Photographs of young men
Randomly sampled adults

GENETIC INFLUENCE AND BEHAVIOUR

Human variation in behaviour and susceptibility to mental illness, risk taking and performance
on intelligence tests, and other traits can partly be answered by behavioural genetics..

A gene or even several genes cannot make you act in any particular way in day to day life
because behaviour is a manifestation of the play of genetics on the body's development and
physiology in response to the environment. We do inherit our genes, we do not inherit
behavior traits in any fixed sense. The effect of our inherited set of genes on our behavior is
entirely dependent upon the context of our life as it unfolds day to day.

The way genes relate to behavior is complex, indirect, and closely related to variable events like
internal environment and external environment Environment in genetic terms means all
influences other than inherited factors.

The External environment encompasses family and friends, home and workplace, and specific
experiences from everyday life.

The Internal environment comprises of factors belonging to the internal, biological world:
nutrients, hormones, viruses, bacteria, toxins, and other products that affect the body during
prenatal development and throughout life.

Gene/environment interaction is the complex exchange of reciprocating influence that goes

beyond nature vs nurture. The two act upon and with each other. The same genotype
(underlying genetic structure) in different environments may lead to similar or different
phenotypes (observable traits). The same environment operating upon different genotypes
may also lead to similar or different phenotypes.

It all depends upon interactions.

Sibling Differences in Behaviour

Biological siblings are half alike genetically, on average, and twins are fully alike genetically and
yet still turn out differently in many ways. Children growing up together may have a shared or
non shared environment. The shared environment e.g parents socioeconomic status may make
them similar while the non shared environment-illnesses, friends, teachers etc. may make them
different.

Family studies in behavioural genetics

In a family study there is the key subject- the proband who posses of the trait to be studied

The trait is sought in:

 First degree relatives- parents, siblings, and children

 Second-degree relatives- aunts, uncles, grandchildren, grandparents, and nephews or
nieces.

Some of the most important contributions in our understanding of behavioural genetics

have come from twin studies.

 Concordance rates: If Data from many twin pairs are collected and the rates of similarity
for MZ and DZ pairs compared- for discrete traits (traits that are either present or
absent, such as a disease) we say that concordance rates are - the proportion of the
twin pairs that both have the trait under study.
 Co-relation coefficient: If Data from many twin pairs are collected and the rates of
similarity for MZ and DZ pairs compared continuous traits ( traits that are documented
as a range like, height, weight, intelligence etc), we do statistical calculations for co-
relation coefficient.

Review Questions

Environmental influence on Behaviour normally refers to influence from one of the following:
Genetic endowment
Climatic conditions
Physiognomy
Life events
Hereditary factors

Which of the following statements is not true of behavioural genetics?

A proband is the person who has the traits you want to study
A first degree relative is the mother, the father and siblings
Monozygotic twins share the same genome
Study of dizygotic twins reared together is a good source of shared environment
Study of monozygotic twins reared apart is a good source of shared environment

GENETIC INFLUENCE ON INTELLIGENCE AND PSYCHOLOGICAL DISORDERS

5.3 Intelligence and behavioural genetics

Intelligence is a complex general capacity of the Brain- the ability to reason, to think abstractly,
to draw conclusions, to solve problems, to learn from experience, and to remember what has
been learned.

A theory of multiple intelligences proposed (Howard Gardner in 1983) holds that humans have
eight forms of intelligence:

 Linguistic,
 Logical-Mathematical,
 Spatial,
 Kinesthetic,
 Musical,
 Intrapersonal,
 Interpersonal
 Naturalist

Simple single gene defects

Listed here is a group of Single gene defect disorders with added implications on mental well
being:

1. Cystic fibrosis- Chromosome 7

2. Huntington's disease- Chromosome 4
3. PKU- phenylalanine hydroxylase Chromosome 12
4. Fragile X syndrome is an X- linked disorder that expressed in Boys with Autism and
learning disability

Examples of a polygenic disorders, related to impaired neurotransmitter production and

functions are schizophrenia and bipolar mood disorders. NB: The concordance rate of
schizophrenia are higher in MZ as in DZ twins.

Review Questions

The following are true about the etiology of schizophrenia except

Schizophrenia is a polygenic disorders related to impaired neurotransmitter production and

functions
The 1st degree relatives of schizophrenia have 10 times greater risk of schizophrenia as the
general population
The concordance rate of schizophrenia is higher in MZ as in DZ twins
 The concordance rate of schizophrenia is higher in DZ as in MZ twins
Intrauterine and perinatal viral infections are thought to be important environmental
factors

Which of the following is true of psychiatric disorders in childhood and adolescence?

The prevalence of psychological disorders is higher in girls as compared to boys

There is a higher prevalence of learning disabilities in girls
There is an excess of boys among children with emotional disorders
Girls are more likely to display truancy as compared to boys

SEX AND GENDER DIFFERENCES IN ABNORMAL BEHAVIOUR

There are gender differences in normal behaviour like mate selection as in what women look
for in a mate and what do men look for in a mate. Other difference include, mating strategies
as in commitment, variation in number of partners, desire for monogamy. There are also
gender differences in career choice.

Abnormal behaviour refers to deviations from what is considered typical behaviour and this
can be either:

 Qualitative abnormality- deviation from culturally accepted standards

 Quantitive abnormal- behaviour that deviates from the statistical average

Abnormal behaviour however is not always an indicator of psychological disorder.

In psychological disorders, Abnormality is only one of the 3 basic elements that comprises
psychological disorders. Abnormality here refers to:

 Pattern of moods
 Thoughts
 Perception
 Behaviour

The other two criteria are:

maladaptiveness- behaviour that seriously disrupts your social occupational functioning.

Personal distress-subjective feeling of anxiety, depression or other unpleasant emotions. and

personal distress.
The biopsychosocial model is an important key to understanding gender differences in
abnormal behaviour:

o Bio- Biological differences particularly hormonal

o Psycho- Differences in psychological development
o Social-Gender differences due to environmental influences

1. Disorders in children and Adolescence

o Boys are often more disturbed than girls at a ration of 2:1 or even 2.5:1
o Boys tend to display aggressive behaviour while girls tend to more emotional disorders.
o There is a higher prevalence of developmental disorders (Mental retardation, learning
disabilities etc) in boys.
o There is an excess of boys among children with conduct disorders that cannot be
accounted for solely by the higher frequency of developmental disorders in boys.

2. Substance related disorders

Substance abuse is commoner in males than females

Misuse and dependence on sedatives and tranquilizers has been found to be commoner in
middle aged women

There has been an increase in prevalence of alcohol abuse in women as women enter and work
more in the male environment out of the family circles

Alcohol dependency in women develops faster and on lower quantities of alcohol.

3. Anxiety disorders

Have been shown to be slightly more commoner in women than men this is particularly so for
Generalized Anxiety Disorders and phobias

4. Somatoform disorders

Among common somatoform disorders are: Somatization characterized by multiple physical

complaints and found more commonly in women and Conversion disorder, previously referred
to as "hysteria" which is 2-10 times more common in women than men

5. Affective disorders
The prevalence of depression is twice as high in women as in men-independent of culture and
ethnicity while The M:F ratio in Bipolar disorders (also referred to as Manic Depressive
Psychosis) is 1:1.

The rate of suicide in depressive illness which has been est. At 10- 15% is higher in males than
females. The rate of para-suicide on the other hand(attempted suicide) is higher in females.
Males tend to use more violent methods of suicide than females.

6. Schizophrenia

Schizophrenia which is one of the most devastating psychiatric disorders affects about 1% of
general population globally in the the male: female ration of 1:1.

7. Eating disorders

Anorexia- and bulimia nervosa occur almost predominantly in young white women and rarely
in males.

8. Sleep disorders

Are Commoner in women and elderly going by the increased use of sedatives in women.

9. Sexual disorders

Gender difference in sexual disorders are related to the different anatomical and physiological
functions of biological males and females and are therefore predominantly gender specific
disorders.

While men complain predominantly of erectile failure and premature ejaculation women
complain more of arousal and orgasmic problems.

10. Impulse disorders Impulse control disorder.

Refer to is a group of psychiatric disorders characterized by impulsivity - failure to resist a

temptation, urge or impulse that may harm oneself or others.

a. Intermittent explosive disorder, characterized by recurrent, significant outbursts of

aggression is commoner in men than women
b. Kleptomania characterized by repetitive, uncontrollable stealing of items not needed
for personal use has been found to be commoner in women.
 c. Pyromania characterized by repetitive purposeful fire setting and fascination with fire,
and pathological gambling repetitive by persistent and recurrent maladaptive patterns
of gambling behavior has been found to be commoner in men

11. Personality disorders

Gender differences in Personality disorders are closely related to the specific types of disorders.
Antisocial personality (previously referred to as Psychopathy) is commoner in men.

Review Questions

Which of the following is true of psychiatric disorders in childhood and adolescence?

The prevalence of psychological disorders is higher in girls as compared to boys

There is a higher prevalence of learning disabilities in girls
There is an excess of boys among children with emotional disorders
Girls are more likely to display truancy as compared to boys

The following are factors that contribute significantly to gender differences in Psychiatric
disorders except

Differences in Socio-economic status

Differences in Physiognomy
Differences in psychological development
Biological differences particularly hormonal

Which of the following statements is true about gender variation in behaviour?

Boys are often more disturbed than girls at a ration of 5:1

Boys tend to display more withdrawn behaviour in early childhood as compared to
adolescence girls
Girls tend to display more emotional disorders than boys
Mental retardation and learning disabilities are commoner in girls in early childhood
Aggressive behaviour in girls is rare

SOCIAL ATTITUDES AND BEHAVIOUR

Attitude is defined as a predisposition to classify objects and events and to react to them with
some degree of evaluative consistency. Attitudes can also be said to be Beliefs and feelings
about others or about events and the inclination to act.
Our expressed attitude does not always predict behaviour because both our attitudes and our
behaviour are subject to other external influences

Attitude- We sometimes say what we think others want to hear

Behaviour- we sometimes do what others expect us to do

The effects of attitude on behaviour becomes more reliable when one considers behaviour over
a long period of time

Minimising on external influences will increase prediction of behaviour from attitude

Attitude predicts behaviour when the attitude is more pertinent to behaviour- eg. A belief that
running is a good way to increase fittness has better predictability for jogging as opposed to
general concept of ‚healthy living‘

Action to Attitude theories

Social psychologists explain the effect of actions on attitude using 3 main theories:

1. Self-presentation theories- assumes that we express attitudes that make us appear

consistent
2. Cognitive disonance theory assumes that to reduce discomfort we justify our actions to
ourselves.
3. Self perception theory assumes that our actions are self revealing- we look at our
actions/ behaviour and explain our feelings and beliefs on this basis the same way we do
for other people.

Review Questions

Assessment of knowledge attitudes and practice

Refers to anthropological studies in traditional communities
Is an academic exercise that has little relevance in practice
Has no relevance in modern health practices
Is can be good indicator of how communities are reacting to health messages
Can only have relevance in literate communities
Attitudes

Can never be used to predict behaviour

Are internalized before the age 2years
Can easily be measured through school performance
Influence how people perceive and interpret events
 Are a good indicator of success in life

Predictability of behaviour from attitude

Can be increased by minimizing on external influences
Can be increased by increasing internal influences
Can be enhanced through a cross sectional survey
Corresponds to religious beliefs
Cannot be improved

Self presentation theories:

Assume that people justify their behaviour to reduce internal discomfort.
Assume that we express attitudes that make us appear consistent
Assume that we look at our behaviour from outside ourselves
Assume that people justify their actions to continue doing them
Assume that people are strictly speaking not responsible for their actions

LIFE EVENTS AND ABNORMAL BEHAVIOUR

Life events

The life span of human beings is characterised by milestones also referred to as life events.
These are events that have a major impact on the individual. Life events are external
environmental influences that have an impact on Human beings and which may be experienced
as negative (divorce) or positive (marriage).

Below is a list of some major life events as experienced by people worldwide

a. Entry into school

b. Birth of a sibling

c. Exams

d. Moving house or migration

e. Adolescent crisis

f. Initiation*(in traditional societies)

g. Adolescent pregnancy
h. Divorce, separation or death of parent(s) or siblings and other significant relatives

i. Marriage

j. Birth of a child

k. Loss of job

l. Change of job

m. homelessness

n. Separation, Divorce, or loss of spouse

o. A significant change in health (self or spouse)

p. retirement

Major life events across the lifespan

These include:

 Early life events

 Life Events in adolescence and early adulthood
 Life events in Middle and late adulthood

Early life events revolve around separation and loss and include separation from
mother/mothering person for reasons like - illness and admission to hospital of either child or
mother. The birth of a sibling may be perceived as loss of previous position as mother‘s baby
and expressed as sibling rivalry. The beginning of school may be perceived both as separation
from mothering person and familiar surrounding. Moving house or migration is similarly
experienced as loss of familiar environment and friends.

Symptoms may range from regression, depressive symptoms, withdrawal, aggression, conduct
disorders in older children and school refusal.

Life Events in adolescence and early adulthood-The Normal stressful changes of adolescence
make adolescents particularly vulnerable to negative life events. Stressful events include-
school change and entry into boarding schools, separation/abandonment, bereavement,
rejection by contemporaries and failure at school, loss of physical health that impair the
adolescent from active participation in activities.
One of the most important events in the life of an adolescent is the initiation of sex. This may
be complicated by unpreparedness, ignorance, coercion, orientation confusion and socio-
cultural and religious factors with associated guilt and shame. Sexual initiation may also result
in premature pregnancy and abortion, which in our country may be unsafe with serious to
severe medical implications.

Reactions to life events during adolescence include: depression, anxiety, avoidance disorders,
obsessive - compulsive disorders and phobias, school refusal and truancy. Conduct disorders
are common in boys and manifest as delinquency (crimes of violence, serious vandalism and
criminality linked to drug abuse, truancy and vagrancy).

Substance use and abuse is a common reaction to stress in adolescence, but may also result in
major life events- like severe punishment, expulsion from school or home etc.

Eating disorders are more common in girls. Anorexia nervosa is still relatively rare in our
communities but a common disorder of young white females. Others in include bulimia
nervosa, adiposity (obesity) not so uncommon in modern Kenya. Sleep disorders are also
common.

The prevalence of suicide and attempted suicide also increases in adolescence. In school
systems where exams start early like in KCPE- the level of stress may become unbearable
leading to psychiatric symptoms- depression, somatization, psychosomatic disorders, anxiety
disorders like- panic attacks, generalised anxiety disorders, conversion disorders.

Poor performance in exams may even lead to attempted suicide and suicide.

Events in early adulthood revolve around intimate relationships, leaving home, job marriage
and childbirth and not necessarily in that order. Among these, childbirth is probably one of the
most significant for women so that most women are able to say that life is never the same
again.

While the birth of a child is often a joyous event for women, Pregnancy and childbirth can
however be associated with biological changes and psychosocial stressors that predispose to
psychiatric disorders.

Women who are unable cope with childbirth for various reasons may suffer maternal blues,
post-natal depression and post-partum psychosis.

Common Stress factors in child birth include:

 Lack of social support

 Young motherhood
 Unplanned pregnancy
 Single motherhood etc.
  Physiological changes
 Marital disharmony

Changes in employment life can also be a stressful event.

Stressors include:

 Adjusting to a new job, and new working colleagues

 Climbing up the ladder may come with new challenges, conflicts and group dynamics

Reactions to major life events include: Depression, anxiety disorders, somatic disorders and
substance abuse, conduct disorders in children and relapses or worsening of previously
diagnosed mental disorders.

8.4.3 Life events in Middle and late adulthood

Menopause and Midlife crisis constitute major changes in middle adulthood. Menopause is
closely related to other major life events creating the midlife crisis. Events related to midlife
crisis include - loss of gainful employment through retirement, loss of own parents, loss of
children to the world (empty nest syndrome), diminishing physical health and physical
attractiveness.

Middle adulthood progresses to late adulthood and retirement which may be experienced as a
negative event to the individual because:

a) It represents major losses in income and in social status, purpose and role

b) It is a period characterized by monotony, boredom, and decline.

Retirement may be accompanied by depression and anxiety and even suicide

Late adulthood is a time of many losses-parents, friends, and spouse. It is also the time of
increasing physical disabilities and may even culminate in the loss of mobility. It is however the
loss of a long term spouse that has been found to be most striking.

Losses across the lifespan

The following are factors that determine reaction to death include:

 Sudden death

 Traumatic death
  Strong attachment to a particular person

 Close relationship with the bereaved

 Multiple bereavements

Major traumatic Life events

These include- severe road traffic accidents, personal violence, wars and other conflicts, and
natural catastrophes.

The reactions may be any form of psychiatric disorder- particularly major depressive and
anxiety disorders and substance use disorder, however reaction to trauma may warrant a
special diagnosis of „Acute stress disorder" or “Post Traumatic Stress Disorder" - syndromes
characterised by pathological reactions to a specific or multiple traumatic experiences.

Review Questions

Assessment of knowledge attitudes and practice

Refers to anthropological studies in traditional communities

Is an academic exercise that has little relevance in practice
Has no relevance in modern health practices
Is can be good indicator of how communities are reacting to health messages
Can only have relevance in literate communities

Attitudes

Can never be used to predict behaviour

Are internalized before the age 2years
Can easily be measured through school performance
Influence how people perceive and interpret events
Are a good indicator of success in life

Predictability of behaviour from attitude

Can be increased by minimizing on external influences

Can be increased by increasing internal influences
Can be enhanced through a cross sectional survey
 Corresponds to religious beliefs
Cannot be improved

Self presentation theories.

Assume that people justify their behaviour to reduce internal discomfort.

Assume that we express attitudes that make us appear consistent
Assume that we look at our behaviour from outside ourselves
Assume that people justify their actions to continue doing them
Assume that people are strictly speaking not responsible for their actions

IATROGENIC DISORDERS AND BEHAVIOUR

Iatrogenic disorders

Iatrogenic disorders are disorders caused by doctors and other health workers or health care
system and are present in all branches of medicine. Iatrogenic disorders arise as the result of
the health worker:

1. Making Incorrect or incomplete clinical assessment (physical , behavioral, psychosocial

and psychological)
2. Making Inappropriate diagnostic and treatment interventions
3. Making False attribution to the etiology of the problems
4. Failing to recognize and reinforcing dysfunctional behavior
5. Failing to promote function and effective return to work

Misdiagnosis in Psychiatry

Conversion disorders are often misdiagnosed as epilepsy and patients treated for years on
antiepileptics- sudden withdrawal of which causing seizures.

Failure to recognise the side effects of drugs and either withdraw or reduce dosage of
medication. This is particularly common with Phenothiazines and Antidepressants. A commonly
hidden side effect is sexual dysfunction which the patients may not report.

Misdiagnosis in Clinical Medicine/Surgery and related

Misdiagnosis in medicine of life threatening conditions may create psychiatric conditions

particularly Anxiety disorders and Depression. Common misdiagnosis includes:
  Misdiagnosis with cancer, or hiv/aids etc- may lead to stress depression and even
suicide
 Patients correctly diagnosed with life threatening conditions may develop adjustment
disorders due to poor counselling skills among clinicians

Medicalization of psychological disorders

Many Psychological disorders present with physical symptoms, failure of a clinician to take a
comprehensive history, examination and investigations may lead to medicalization.
Invocation of a medical diagnosis to explain physical discomfort that is not caused by organic
disease and application of a medical intervention to treat it as in:

 Manchausen‘s syndrome
 Anxiety disorders
 pain disorders
 Body dysmorphic syndrome
 Conversion disorders

Reinforcing and medicalization of deviant behaviour

Reinforcing deviant behaviour- Certain forms of deviant behaviour which do not require
medical intervention are reinforced through misdiagnosis or clinicians conviction that they
should be treated using medication.

Deviation from the cultural norms of a society is not necessarily a medical or psychiatric
condition. Medicalization and labelling of deviant behaviour of political dissidents as mentally ill
deserving treatment has a long history propagated by political systems in collusion with doctors
in various parts of the world.

Hypochondriasis and Autistic Spectrum disorders

Hypochondriasis is a well recognized condition in psychiatry, a condition in which the patient

believes they suffer from a major life threatening disorder and seek help from various doctors.
Failure to make a quick diagnosis and continuous investigation of such patients reinforces the
patients belief that they are suffering from a terminal illness.

Increased tendency to medicalise deviant behaviour and providing treatment- has particularly
affected children. Children who do not fit into the school system are quickly inappropriately
diagnosed and treated for disorders ranging from ADHD to autism. This has created a global
controversy particularly with highly gifted children. Some have argued that pharmaceutical
companies have a role in this trend

Labelling
Labelling of deviant behaviour- assigning the behaviour a medical or psychiatric diagnosis is a
major cause of stigma worldwide. Psychosociological theories also claim that people/society
reacts differently to labelled people this may cause the labelled individual to behave in the
manner expected of his label. Children and people of lower intelligence are particularly prone
to adapt labels.

Controversial diagnosis in Psychiatry

Some disorders are so controversial in psychiatry that diagnosis and inclusion in diagnostic
criteria has often been labelled as creating iatrogenic disorders. Among these are the
dissociative disorders particularly- Multiple personality disorder, which is more commonly
found in fictional literature than in textbooks and Borderline personality disorder.

Institutionalisation

Prolonged admission of patients into psychiatric institutions creates a dependency on care and
institutions that makes it difficult for the patient to reintegrate into society. The situation may
be exacerbated by a failure promote function and effective return to work. Patients suffering
from schizophrenia are particularly prone to this problem. Institutionalisation is usually
supported by the family and the community who wish to rid themselves of the responsibility of
the care of the patient and abandonment is common.

Review Questions

Iatrogenic disorders are

Disorders unique to Psychiatry

Are disorders which are found in urban settings
Are caused by health professionals
Are anxiety disorders
Are caused by neglectful relatives

Iatrogenic Substance use dependency is

Is a problem commonly associated with Antidepressants

Is related to prolonged prescriptions of benzodiazepines
Is associated with self diagnosis and treatment
Is associated with minor ailments
Is related to prolonged use of paracetamol
A patient is most likely to present to a medical doctor with a conviction of a terminal illness if
he/she has

Generalised Anxiety disorder

Major depressive disorder
Schizophrenia
Hypochondriasis
Body dysmorphic disorder

An iatrogenic disorder can arise from all the following except

Living with a spouse who is mentally ill.

Being misdiagnosed with HIV
Being admitted for a long time in a psychiatric ward
Being misdiagnosed for cancer
Being given a two month prescription for Diazepam