Unit 1

Introducing psychopathology:
- Concept of abnormal behaviour
Definition Behaviour that deviates significantly from societal norms or from what is considered typical or healthy. However,
determining what is "abnormal" can be complex because it varies across cultures, contexts, and historical periods.

Key characteristics Statistical Actions or mental processes that are statistically uncommon. However, rarity alone doesn’t
Rarity/deviancy: imply abnormality, they are also rare but not seen as undesirable.
→ Why can the
definition change… Violation of Social Violates societal expectations or cultural standards.
Norms:

Personal Distress Experiences significant distress or discomfort. Some conditions may not cause distress to
(suffering): the person, but might still be harmful to others.

Maladaptive Impairment in a person’s ability to function effectively in everyday life. This could include
Behavior: behaviours that hinder well-being or lead to harmful outcomes.

Social discomfort: People may be uncomfortable around the violator

Unexpectedness and Abnormal behaviour can be characterised by impulsive, unpredictable actions that are
Unpredictability: difficult to understand within a given context.

Dangerousness: People who make explicit threats to harm another person.

- Classification of abnormal behaviour: DSM and ICD (Latest Edition)

Course Symptoms → cluster → syndrome → predictable course → specific disorder
→ regular basis → disorder
 - Merits and demerits of classification
Provide - Agreed upon list → distinct categories → clear description & criteria
- Stats → Determines → incidence & prevalence rates
- Aetiology and treatment
- Insurance claims

Demerits - Shorthand → loss of info

- Stigma → comfort in disclosing
- Stereotype → automatic beliefs
- Labelling → self-concept affected

- Clinical Assessment
Clinical diagnosis and - Assessment data → pattern of symptoms the person presents → consistent with Diagnostic criteria in DSM
classification system & ICD
- Diagnosis only to aid the mental health professional → determining of prognosis, treatment plans and
outcomes (APA 2013)

- The evolution of DSM

1952 DSM - I 106 disorder → reaction

1968 DSM - II 182 → no term “reaction”, based on causality

1980-87 DSM - III Dropped psychodynamic perspective

Revised → genetic role considered (Emil Kraeplin)

- The DSM-5 definition of mental disorder.

Definition "A syndrome characterised by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour
that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental
disorders are usually associated with significant distress or disability in social, occupational, or other important activities."
 Key Clinically Significant Disturbance The symptoms or behaviours must be severe enough to cause noticeable impairment.
elements Everyday stress or minor deviations from the norm don’t constitute a disorder under the
DSM-5.

Disturbance in Cognition, Disorders can manifest in various ways, including irrational thought patterns, emotional
Emotion Regulation, or Behavior dysregulation (such as extreme mood swings), or behaviours that are outside of societal
norms or are harmful.

Reflecting Dysfunction in A mental disorder indicates an underlying dysfunction—whether psychological, biological,

Underlying Processes or developmental—that disrupts normal mental functioning.

Associated with Distress or For a behaviour or pattern to be classified as a mental disorder, it generally needs to cause
Disability significant personal distress (such as anxiety or depression) or impairment in critical areas
of functioning, such as social relationships, work, or self-care.

Exclusion of Socially Deviant The DSM-5 clarifies that socially deviant behaviour (e.g., political, religious, or sexual
Behaviour differences) and conflicts between the individual and society are not, by themselves,
mental disorders unless they result from dysfunction within the individual. This distinction
aims to avoid labelling behaviours that might simply deviate from cultural norms as
pathological.

The DSM-5’s definition helps clinicians standardise diagnoses, guiding research, treatment, and communication within mental health
care. However, the definition acknowledges that mental disorders are complex, multifaceted, and influenced by personal, cultural, and
situational factors, making diagnosis a nuanced process.

- DSM 5: Major changes in classification.

Disorder Code Description

Prolonged grief F43.8 A new diagnosis characterised by an intense, persistent grief response following the death of a loved one.
disorder Symptoms persist for at least 12 months (or 6 months in children), leading to significant functional
impairment. This includes emotional numbness, yearning, and difficulty in accepting the loss.

Unspecified Mood F39 This category is introduced for situations where mood symptoms cause significant impairment but do not meet
Disorder the full criteria for any specific mood disorder. This inclusion offers flexibility for diagnosing atypical mood
 disturbances.

Suicidal behaviour T14.91 This disorder is diagnosed when an individual has made a suicide attempt within the past 24 months. The
disorder attempt was not made solely for attention-seeking purposes, and there is a high risk of further suicidal
behaviour. It can be used as a stand-alone diagnosis or alongside other mental health conditions.

Non-Suicidal R45.88 This new inclusion defines repetitive, intentional self-inflicted harm (e.g., cutting, burning) without suicidal
Self-Injury (NSSI) intent. It causes distress or impairment and is not explained by other disorders (like borderline personality
disorder). This was previously listed under "Conditions for Further Study" in DSM-5 but is now included as a
formal diagnosis.

Stimulant-Induced F15.96 This disorder addresses cognitive impairment caused by prolonged stimulant use, particularly involving drugs
Mild Neurocognitive such as methamphetamine or cocaine. Symptoms include memory difficulties, attention issues, and executive
Disorder function deficits.

Other DSM-5-TR Updates - Gender Dysphoria: Language has been updated to be more gender-inclusive, reflecting a modern
understanding of gender identity. Terms such as "desired gender" are replaced with "experienced
gender."
- Substance Use Disorders: Some diagnostic criteria and descriptors have been updated for clarity and
to reflect the latest research in substance abuse and treatment approaches.
- Cultural Concepts of Distress: Expanded descriptions of how culture affects the presentation,
understanding, and treatment of various mental disorders.

The DSM-5-TR incorporates numerous updates and refinements to better align diagnostic criteria with current research and improve
clarity in diagnosing mental health disorders. Below are the significant changes:

Language Updates Gender Dysphoria: Terminology revised to be more inclusive and precise regarding gender diversity. For example,
for Inclusivity and terms like "desired gender" have been changed to "experienced gender" to better reflect the lived experience of
Precision individuals with gender dysphoria.

Enhanced clarity on gender-neutral language throughout diagnostic criteria for various disorders.

Cultural Concepts of Distress: Expanded descriptions of how cultural and social factors impact the expression and
understanding of mental health disorders.
Updates to Attention-Deficit/Hyperactivity Disorder (ADHD)
Diagnostic Criteria - Criterion A: Clarification on the examples provided for inattention and hyperactivity symptoms across age
for Specific Disorders groups, particularly in adults.

Major Depressive Disorder (MDD):

- Expanded to include more nuanced symptoms that may present in culturally diverse groups. More emphasis on
mood-congruent psychotic features in severe cases.

Persistent Depressive Disorder (Dysthymia): Criteria now better distinguish between chronic depression and
intermittent major depressive episodes.

New and Expanded Prolonged Grief Disorder:

Disorders - Newly included to better address the prolonged and debilitating grief experienced after the death of a loved one,
with diagnostic criteria focusing on functional impairment.

Unspecified Mood Disorder:

- Introduced for flexibility in diagnosing mood disturbances that don’t meet criteria for other specific mood
disorders.

Suicidal Behavior Disorder and Non-Suicidal Self-Injury:

- Moved from "Conditions for Further Study" in DSM-5 to full diagnoses in DSM-5-TR.

Refinement of Substance/Medication-Induced Disorders:

Substance Use - Greater clarity in the descriptions of disorders related to the use of specific substances, such as cannabis,
Disorders alcohol, and stimulants.

Stimulant-Induced Mild Neurocognitive Disorder:

- Newly added to capture cognitive impairments following prolonged stimulant use, such as methamphetamine or
cocaine.

Diagnostic criteria for Cannabis Use Disorder (F12.20) have been clarified to better distinguish between use and
dependence.

Clarifications on Autism Spectrum Disorder (ASD):

Neurodevelopmental - Clarified language regarding the onset of symptoms and impairment in social communication and restrictive,
Disorders repetitive behaviours.
 Specific Learning Disorder:
- Expanded to reflect more nuances in learning difficulties, particularly in mathematical reasoning and reading
comprehension.

Cultural Concepts of Expanded section on the impact of cultural factors on the presentation, diagnosis, and understanding of mental health
Distress conditions.

Greater emphasis on cultural sensitivity and how mental disorders are influenced by sociocultural contexts.

Disorders with Neurocognitive Disorders:

Age-Specific - Updates to better account for cognitive decline associated with ageing, including differentiating between mild
Considerations and major neurocognitive impairment.

Clarified criteria for mood disorders and anxiety disorders as they present in older adults.

Personality Disorders No major structural changes, but enhanced clarity in the definitions and criteria of personality disorders, especially
concerning comorbid conditions.

Emphasis on dimensional approaches to personality disorders, including more specific guidance on diagnosing
borderline and antisocial personality disorders.

Expanded Greater attention to racial and ethnic disparities in the diagnosis of mental health conditions, with updated guidance on
Consideration of how these factors influence the manifestation of symptoms
Race, Ethnicity, and
Trauma Trauma-Informed Diagnosis: More explicit references to trauma and stressor-related disorders and the impact of
adverse experiences on mental health.

- Prevalence and incidence of mental disorders.

Epidemiologist Study the distribution of diseases and disorders.

Aetiology Study the origin and causes.

Mortality The number of deaths in one period of time or one place.

Morbidity The condition of suffering from a disease or medical condition.

Incidence - No. of new cases that occur over a given period (1 year)
- They tend to be lower than prevalence figures because they exclude preexisting cases

Prevalence (%) Number of active cases in a population during any given time

Prevalence Lifetime Prevalence Point Prevalence

types:
Estimate the number of people who have had a Estimated proportion of actual, active disorder cases in
particular disorder at any time in their lives (even if a given population at a given time.
recovered)

Unit 2
Anxiety Disorders:
Generalised Anxiety Disorder
Intro - Unreasonable/irrational, chronic, excessive
- Formerly known as free-floating anxiety
- 6 months << , difficult to control
- Mst have 3/6 symptoms
- Chronic worry, tension
- Marked vigilance for possible signs of threat
- Procrastination, checking, calling a loved one

Criteria a. Excessive anxiety and worry

b. The individual finds it difficult to control the worry
c. The anxiety and worry are associated with 4-6 of the following symptoms
- Restlessness or on edge
- Easily fatigued
- Difficulty concentrating or a blank mind
- Irritability
- Muscle tension
- Sleep disturbance
d. Symptoms cause clinically significant distress or impairment in social, occupational or other important
 areas of functioning.
e. Should not attribute to physiological effects of a substance or other medical condition
f. Not be explained by any other mental disorder.

Comorbidity - Stress
- Major Depressive disorder
- Minimal Suicidal tendencies

Psychological - Results from an unconscious conflict between ego and id impulses that are not adequately dealt with
Causal factors because the person’s defence mechanisms have either broken down or have never developed.
- Freud → primarily sexual and aggressive impulses that had been either blocked from depression or
punished upon expression that led to GAD
- Defence mechanism → overwhelmed when a person experiences frequent and extreme levels of anxiety as
might happen if Id impulses are frequently blocked from expression
- Viewpoint is not testable and has therefore been largely abandoned among clinical researchers.

Biological Genetics There is evidence that GAD has a genetic component, with family studies showing that people
causal factor with a family history of anxiety disorders have a higher risk of developing GAD. Genetic
factors can affect neurotransmitter regulation, brain structure, and function, increasing
susceptibility.

Neurotransmitters Neurotransmitters such as serotonin, norepinephrine, gamma-aminobutyric acid (GABA), and

dopamine play essential roles in regulating mood and anxiety. People with GAD may have
imbalances in these neurotransmitters, leading to increased stress response, fear processing,
and difficulties in mood regulation.

Brain structure Studies using brain imaging have shown that individuals with GAD often have differences in
certain brain areas, particularly:
- Amygdala: Involved in fear and emotion processing, it can become overactive in
people with GAD, leading to heightened anxiety responses.
- Prefrontal Cortex: Responsible for decision-making and impulse control, it may be
underactive in GAD, reducing the ability to regulate emotional responses effectively.
- Anterior Cingulate Cortex: This area integrates emotional and cognitive information,
 and its dysfunction is also associated with anxiety.

Hormone The Hypothalamic-Pituitary-Adrenal (HPA) axis, which regulates the body’s response to
stress, may be overactive in individuals with GAD, leading to prolonged stress hormone
release (e.g., cortisol) and increased anxiety. Chronic high cortisol levels can have long-term
effects on brain areas like the hippocampus and amygdala.

Phobia, fear and anxiety

Aspect Phobia Fear Anxiety

Definition An intense, irrational fear of a An emotional response to a real, A vague, uneasy feeling about a
specific object, situation, or immediate threat. potential threat or future uncertainty.
activity, often leading to avoidance.

Duration Persistent and long-lasting unless Short-lived and ends once the Can be chronic, lingering for long
treated. threat is gone. periods.

Triggers Specific object or situation (e.g., Immediate, actual danger (e.g., a Often non-specific or related to future
spiders, heights). car approaching fast). events, situations, or uncertainties.

Intensity Often intense and disproportionate Proportionate to the level of threat. Varies from mild to severe, but often out
to the actual threat. of proportion to reality.

Anxiety Disorders
Specific Phobias Definition: Intense, irrational fear of a specific object, situation, or activity (e.g., animals, heights, flying).

Symptoms: Immediate anxiety or panic upon exposure, often leading to avoidance behaviour.

Impact: Can interfere with daily life if the feared object or situation is commonly encountered.
 Social Phobias Definition: Extreme fear of social or performance situations where one may be judged or embarrassed.

Symptoms: Sweating, trembling, blushing, nausea, and difficulty speaking in social settings

Impact: This can lead to avoidance of social interactions, impacting relationships, career, and quality of life.

Panic Disorder Definition: Recurrent, unexpected panic attacks (sudden periods of intense fear or discomfort).

Symptoms: Palpitations, shortness of breath, chest pain, dizziness, and feelings of loss of control or impending
doom.

Impact: Fear of future attacks often leads to avoidance behaviours, and can significantly affect daily
functioning.

Agoraphobia Definition: Anxiety about being in situations where escape may be difficult or help unavailable during a manic
episode.

Symptoms: Fear of crowds, open spaces, or situations like using public transportation, often leading to
avoidance.

Impact: Severe cases can lead to individuals becoming homebound, greatly limiting their mobility and
independence.

Psychosocial causal factors, Treatment and outcome.

Psychosocial Childhood Experiences: Traumatic or stressful events, such as abuse or neglect, can increase susceptibility.
Causal
Factors Parenting Styles: Overprotective or controlling parenting can foster anxiety in children.

Social Environment: Peer relationships, bullying, and cultural factors contribute to social anxiety.

Cognitive Patterns: Negative thought patterns, like catastrophic thinking and a heightened sense of threat, are
linked to anxiety.

Treatment Cognitive-Behavioural Therapy (CBT): Helps individuals identify and change distorted thought patterns and
 behaviours that fuel anxiety.

Exposure Therapy: Gradual, controlled exposure to anxiety triggers to reduce fear responses.

Medications: SSRIs (Selective Serotonin Reuptake Inhibitors) and benzodiazepines are often prescribed to manage
symptoms.

Mindfulness and Relaxation Techniques: Meditation, deep breathing, and progressive muscle relaxation can help
reduce anxiety symptoms.

Outcomes Efficacy: Many people experience significant relief with treatment, particularly with CBT and medication.

Relapse: Some individuals may experience symptom recurrence, particularly if stress levels increase.

Long-Term Management: Learning coping strategies and maintaining a supportive social network can improve
long-term outcomes and quality of life.

Varied Response: Outcomes can differ widely; some may achieve full remission, while others manage symptoms
on a long-term basis.

Unit 3
- Mental Retardation
Intellectual disability - ICD significant limitation → intellectual functioning and adaptive behaviour >18 age

Intellectual Developmental deficits in general mental abilities and impairment in everyday adaptive functioning, compared to an
Disorder - DSM individual’s age, gender, and socioculturally matched peers.

Onset developmental period

diagnosis clinical assessment and standardised testing of intellectual and adaptive functions. diagnostic criteria
→ ADL = activity, daily living
 Symptoms Deficit in:
- Reasoning
- Abstraction
- Judgement
- Learning
- Adaptive functioning

provisional diagnosis 12-15 hours informant interaction → if SQ is(not) subpar it’s diagnosis can change.

→ level of severity → determined based on adaptive functioning, not IQ.

ICD DSM Levels/ IQ Clinical features of ID
specifiers

317 F70 Mild 50-55 to 70 → Cognitive deficits include a reduced ability to abstract and egocentric thinking
→ Children with milder intellectual disabilities may function academically at the high
elementary level and may acquire vocational skills sufficient to support themselves in
some cases
→ Social assimilation may be problematic
→ Communication deficits, poor self-esteem, and dependence may further contribute
to a relative lack of social spontaneity

318.0 F71 Moderate 35-40 to 50-55 → Communication skills develop more slowly, and social isolation may ensue in the
elementary school years.
→ Academic achievement is usually limited to the middle-elementary level
→ Children with moderate intellectual deficits benefit from individual attention
focused on the development of self-help skills
→ these children are aware of their deficits and often feel alienated from their peers
and frustrated by their limitations
→ they continue to require a relatively high level of supervision but can become
competent at occupational tasks in supportive settings
318.1 F72 Severe 20-25 to 35-40 → preschool years
→ affected children have minimal speech and impaired motor development
→ some language development may occur in school-age years
→ generally need extensive supervision

318.2 F73 Profound Below 20-25 → requires constant supervision and is severely limited in both communication and
motor skills
→ adulthood - some speech development, and simple self-help skills may be acquired
→ isolation
→ hyperactivity
→ low frustration tolerance
→ aggression
→ affective instability, repetitive and stereotypic motor behaviours, and self-injurious
behaviours.

Causes
Genetic factors Intellectual disabilities tend to run in families

Infection and - Infections - Viral encephalitis or genital herpes

toxic agents - Pregnant woman - syphilis or HIV-1 or German measles
- Carbon monoxide and lead → during foetal development or after birth
- Immunological → antitetanus serum or typhoid
- Teratogens → drugs and alcohol → congenital malformations

Trauma - Physical injury at birth

(physical injury) - Difficulties in labour due to malposition of the foetus or other complications may irreparably damage the
infant’s brain
- Bleeding within the brain is probably the most common result
- Hypoxia → lack of sufficient oxygen to the brain stemming from delayed breathing may damage the
brain.

Malnutrition & - Dietary deficiencies in protein and other essential nutrients during the early development of the foetus
other biological could do irreversible physical and mental damage
factors - A limited number of cases of intellectual disability are associated with organic brain pathology.

Down syndrome - Langdon Down → 1866

- Chromosomal disorder causes intellectual disability
- The prevalence of Down syndrome has been reported to be 5.9/10,000 of the general population
- Trisomy 21, not 46 but 47 chromosomes

Clinical causes Trisomy 21

- Cause: In about 95% of cases, Down syndrome is caused by Trisomy 21, where there are three copies of
chromosome 21 instead of the usual two.
- Mechanism: This occurs due to a random error in cell division called nondisjunction. This nondisjunction
can happen in the mother’s egg or, less commonly, in the father’s sperm, leading to an embryo with three
copies of chromosome 21.

Clinical features 1. Physical Features

(or) symptoms Distinctive Facial Appearance:
- Flat facial profile and nose bridge
- Almond-shaped eyes that slant upward
- Small ears and a small mouth, often with a protruding tongue
- Short neck with excess skin at the back of the neck
- Head and Body Structure:
- Small head and flattened back of the head
- Low muscle tone (hypotonia), which can lead to floppy movements in infancy
- Short stature and shorter limbs
- Small hands and feet with a single crease across the palm (palmar crease)
- Small pinky fingers that sometimes curve inward
Other Physical Traits:
- Loose joints and ligament laxity, leading to flexibility
- Brushfield spots (small white spots on the iris of the eyes)
2. Cognitive and Developmental Symptoms
 Intellectual Disability:
- Mild to moderate cognitive impairment, including challenges with attention, memory, and learning
Developmental Delays:
- Delayed speech and language development
- Slower progression in motor skills, such as walking, sitting, and crawling
Behavioural Traits:
- Social strengths but sometimes difficulty with expressive language
- Increased risk of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and
anxiety
3. Health Complications (Associated Conditions)
- Heart Defects: Nearly 50% of people with Down syndrome have congenital heart defects, which may
require surgery.
- Gastrointestinal (GI) Issues: Conditions like duodenal atresia, Hirschsprung’s disease, and other GI
obstructions are common.
- Hearing and Vision Problems: Increased risk of hearing loss, ear infections, and vision problems, such as
cataracts and strabismus.
- Endocrine Disorders: Higher risk of hypothyroidism (low thyroid hormone levels).
- Immune System Issues: Increased susceptibility to infections and certain autoimmune conditions, like
celiac disease.
- Blood Disorders: Higher incidence of leukaemia and other blood disorders.
- Sleep Apnea: Common due to anatomical features like a small mouth and large tongue.
Phenylketonuria
Cranial anomalies → alterations in head size and shape for which causal factors have not been established
macrocephaly - rare condition
- Large headedness
- The abnormal growth of glial cells, which form the supporting structure for brain tissue, increases the size
and weight of the brain, enlarges the skull, and causes visual impairment, convulsions, and other
neurological symptoms.

microcephaly - small headedness

- Circumference 17in (normal 22in)
Dwarfism - Developmental delays, including speech and movement
(skeletal - Difficulties with coordination and balance
dysplasia) - Intellectual delay

hydrocephalus - relatively rare

- Accumulation of abnormal amount of CSF in the cranium → damage to brain tissue and enlargement of the
skull.
- Congenital cases → head already enlarged at birth or slowly begins
- Can also arise in infancy → brain tumour, subdural hematoma, meningitis → blockage of the CSF pathway

Treatment and management of ID

Autism
Diagnostic Deficits in Social Challenges in social reciprocity (e.g., abnormal conversation flow, limited sharing of emotions
criteria: Communication or interests)
and Interaction
Issues with nonverbal communication (e.g., poor eye contact, atypical gestures, or lack of
facial expressions)

Difficulties in forming and maintaining relationships (e.g., struggles with adjusting behaviour,
limited imaginative play, or lack of interest in peers).

Restricted, Repetitive actions, speech, or play (e.g., lining up toys, echolalia).

Repetitive
Patterns of Inflexible adherence to routines (e.g., distress with changes, rigid thinking).
Behavior,
Interests, or Highly fixated, intense interests.
Activities
Atypical sensory responses (e.g., sensitivity to sounds, fascination with lights).

Developmental Symptoms begin in early development, though may not be fully apparent until social demands
Onset: increase.

Significant Impact Symptoms must lead to noticeable difficulties in social, occupational, or other functional areas.
 Not Due to Other The symptoms should not be better explained by other intellectual or developmental disorders.
Conditions

Prevalence - 1% and 2% of the population, with similar estimates in child and adult samples.
- Internationally prevalence is close to 1% (0.62% median) with minimal variation across regions, ethnicities,
or age groups.
- Globally, ASD is diagnosed more in males than females, with a male-to-female ratio of 3:1, though there are
concerns about under-recognition in women and girls.

Comorbidity - Intellectual disabilities, language disorders, and learning challenges, including difficulties in literacy,
numeracy, and coordination.
- Psychiatric conditions commonly co-occur with ASD, with about 70% of individuals having at least one
additional mental disorder, such as anxiety, depression, or ADHD.
- Restricted eating patterns are also frequent.
- In nonverbal individuals, changes in sleep, eating, or behaviour may indicate anxiety, depression, or pain
from undiagnosed medical issues.
- Common medical conditions with ASD include epilepsy and constipation.

Levels
Level 3: Requiring Social Communication: Severe verbal and nonverbal deficits; minimal initiation or response to social
Very Substantial interactions.
Support
Restricted/Repetitive Behaviours: Extreme inflexibility; significant distress with changes, impacting all
areas of functioning.

Level 2: Requiring Social Communication: Marked deficits in communication despite support; limited interactions focused on
Substantial specific interests.
Support
Restricted/Repetitive Behaviours: Inflexible behaviour is observable, causing distress and functional
interference across contexts.

Level 1: Requiring Social Communication: Noticeable communication difficulties without support; trouble with initiating and
Support maintaining social interactions.

Restricted/Repetitive Behaviours: Inflexibility impacts functioning in specific areas; difficulty switching

tasks and managing organisation.

- ADHD
Definition - Categorised by a pattern of diminished sustained attention and increased impulsivity or hyperactivity.
- Significant impairment in academic functioning as well as in social and interpersonal situations.
- Often associated with comorbid depressive disorders, including LD, Anxiety disorders, mood disorders
and disruptive behaviour disorders

History - The early 1900s → hyperactive children (damage from encephalitis) → hyperactivity syndrome
- 1960’s → heterogenous group → poor coordination, LD & emotional liability but without specific Neuro
Disorder

Epidemiology - 7-8% of pre-pubertal (6-10) elementary school children

- 5% of youth (children and adolescence
- 2.5% of adults
- More prevalent in boys (2:1, high as 9:1)
- First-degree biological → high risk developing ADHD + disruptive behaviour disorders, anxiety disorder
and depressive disorders

Symptoms - Hysteric
- Tiptoeing
- Sensitive to loud noises
- Delayed speech development
- Ignoring dangers
- Rejecting cuddles
- Build toys in one line
- Avoiding eye contact
- Playing alone
Clinical - Hyperactivity
features - Attention deficient (short attention span, distractibility, preservation, failure to finish tasks, inattention,
poor concentration)
- Impulsivity (action before thought, abrupt shifts, lack of organisation, jumping)
- Memory and thinking deficits
- SLD
- Speech and hearing deficits

Associated - Perceptual-motor impairment

features - Emotional lability
- Developmental coordination disorder
- Behavioural symptoms of aggression and defiance
- School difficulties, both learning and behavioural

Comorbidity - Communication disorders & learning disorders → hamper acquisition and retention
- Display of knowledge complicates the course of ADHD

Diagnosis
(Synopsis of DSM-5 ICD-10
psychiatry)
Name - Attention-deficit/hyperactivity disorder Hyperkinetic disorder, disturbance of
activity and attention

Duration ≥ 6 months Usually occur before the age of 5

Present before the age of 12

Symptoms Inattention Cannot engage in activities requiring

- Poor attention to detail/frequent mistakes prolonged attention
- Hard to maintain attention/focus Disorganised about completing tasks
- When spoken to, they appear not to listen Excess activity
- Poor follow-through on tasks May have:
- Poor organisational skills - Impulsivity
- Procrastinates from tasks that require attention - Recklessness
 - Losing things - Social disinhibition
- Distractible
- Forgetfulness
hyperactivity/impulsivity
- fidgety/restless
- Cannot stay seated
- runs/climbs inappropriately
- Cannot do things quietly
- Cannot keep still
- Inappropriately talkative
- Inappropriately blurts out answers
- Cannot wait for his turn
- Interrupts others

No. of ≥ 6 of each category (≥ 5 for ≥ 17)

symptoms Symptoms occur in >1 setting

Symptoms - Combined presentation

specifiers - predominantly inattentive presentation
- predominantly hyperactive/impulsive presentation

Course In partial remission: last months. Symptoms continue but are less than required for diagnosis.
specifiers

Severity Mild (at risk)

specifiers - Minimal symptoms are required for diagnosis
- Minor functional impairment
Moderate (risk)
- Immediate symptoms and impairment
Severe (developed)
- Severe symptoms
- Marked impairment
Aetiology Genetic factors
- 2-8 times for siblings as well as parents of an ADHD child
- Clinically one sibling may have impulsivity/hyperactivity predominantly and others may have
predominantly inattentive symptoms
- 70% of children meet the criteria for a comorbid psychiatric disorder, including learning disorders, anxiety
disorders, mood disorders, conduct disorders and substance use disorders
Neurochemical factors
Neurophysiological factors
Neuroanatomical aspects (superior and temporal cortices with focusing attention, external parietal and corpus
striatal regions with motor executive functions
Developmental factors
Psychosocial factors (severe, chronic abuse, maltreatment and neglect)

- Learning Disabilities Common disorders

SLD - A neurodevelopmental disorder that impacts the brain’s ability to receive, process, store and respond
to information.
- It primarily affects academic skills such as reading, writing and mathematics despite having average
or above-average intelligence.
- Can not be below 70 IQ

DSM-5 - Reading disorder, mathematics disorder, disorder of written expression and learning disorder →
DSM4
- In DSM5 they are designated using specifiers (impairment in; reading, written expression,
mathematics) (mild. Moderate, severe)

Diagnostic criteria (Table 2-18 454-6 Synopsis of psychiatry)

Dyslexia - Specific learning disorder with impairment in reading

- 75%of children and adolescents with SLD
 - Difficulty with reading, decoding and understanding written language
→ Symptoms:
- mixes up words and sounds “beddy tear” for “teddy bear”
- struggles to find rhyming words
- They find it hard to say the alphabet in the right order
- Challenges with word recognition, decoding and spelling
- Problems with reading fluency and comprehension
→ when the child is a bit older
- Difficulty spelling simple words
- Reluctant to read aloud in class
- Confusing letters with similar shapes
- Mixing up the position of sounds in a word.

Comorbidity - Language disorder

- Disability with written expression
- ADHD
- Dyscalculia

course and prognosis - 15-21 days medications

aetiology/Etiology - data from cognitive, neuroimaging and genetic studies suggest that reading impairment is a
neurobiological disorder with a significant genetic contribution
- It reflects a deficiency in processing sounds of speech sounds, and thus, spoken language
- As it is related to language deficit, the left brain is the anatomical site of this dysfunction
- The planum temporale is [the cortical area just posterior to the auditory cortex(heschl’s gyrus)] in
the left brain and shows less symmetry than the same site in the right brain in children with both
language disorders and SLD
- Cell analysis studies suggest that in reading-impaired individuals, the visual magnocellular system
(which typically contains large cells) contains more disorganised and smaller cell bodies than
expected.
- Studies indicate that 35-40% of the first-degree relatives of children with reading deficits also have
reading disability.
- Ability to identify single words mapped to chromosome 15
 - Chromosome 6 maps to phonological awareness
- Locus on chromosome 18 has a strong influence on single-word reading and phoneme awareness

cognitive factors diverse hypotheses exist for underlying cognitive deficits in reading disorders
→ phonological theory
- Left hemisphere perisylvian
- Double-deficit → phonological + naming speed
- Triple-deficit → “ + orthographic (recalling written words)
→ Rapid auditory processing theory
- perform poorly on auditory tasks
- Exhibit abnormal neurophysiological responses to various auditory stimuli
- Perceptual deficits → acoustic structure → level of the syllable - rhythm detection
- Detection of modulation of the speech waveform
→ Cerebellar theory
→ Visual/magnocellular theory

Dysgraphia Challenges with handwriting, spelling and written expression

- Identifiable by 7 years of age
- Mild → 10 years

Symptoms Poor handwriting

Poor fine motor skill
Inconsistent spacing
Letter sizing and formation
Difficulty in the construction of coherent written sentences
Avoid dot joining

Aetiology Neurological Factors: Often linked to abnormal brain areas related to language and motor skills (e.g., left
parietal lobe, cerebellum). It may also have a genetic component.

Developmental Factors: Common in childhood and often associated with developmental coordination
disorder (DCD).
 Cognitive and Perceptual Factors: Includes visual-perceptual challenges and working memory deficits
that affect writing accuracy.

Motor Coordination Problems: Difficulties with fine motor and hand-eye coordination make writing
challenging.

Psychological and Environmental Factors: Stress or lack of classroom support can worsen symptoms.
Acquired dysgraphia may result from brain injury or stroke.

Treatment Occupational Therapy: Strengthening fine motor skills and improving handwriting techniques.

Educational Interventions: Individualised support plans (IEP/504), multisensory teaching, and assistive
technology.

Cognitive and Behavioural Strategies: Working memory training and self-regulation skills.

Physical Exercises: Activities that enhance overall motor skills and repetitive handwriting practice.

Accommodations: Using technology, reducing writing load, and alternative assessments.

Psychological Support: Counselling and support groups for emotional well-being.

Parent and Teacher Education: Training for consistent support at school and home.

Monitoring: Ongoing assessments to adapt interventions as needed.

Dyscalculia - Trouble with understanding and manipulating numbers and mathematical concepts
- Impairment in mathematics

Symptoms - Difficulty with number sense, memorisation of arithmetic facts and performing calculations
- Problems with mathematical reasoning and problem-solving
- Trouble with concepts like time, measurement and spatial reasoning

Aetiology Neurological Factors: Linked to abnormal development in brain areas for numerical processing (e.g., intraparietal
 sulcus, left angular gyrus).

Genetics: Has a hereditary component, often running in families.

Cognitive Deficits: Includes issues with working memory, spatial processing, and understanding numerical concepts.

Developmental and Environmental Influences: May co-occur with other disorders (e.g., ADHD, dyslexia);
inadequate maths education and socioeconomic factors can worsen symptoms.

Psychological Factors: Maths anxiety and low self-esteem can further impact learning.

Treatment Educational Interventions: Includes individualised education plans (IEPs), specialised maths instruction, and
tutoring.

Cognitive and Behavioural Strategies: Cognitive-behavioural therapy (CBT) and metacognitive techniques for
managing anxiety and enhancing problem-solving.

Assistive Technology: Tools such as maths software, calculators, and speech-to-text support.

Occupational Therapy: Aims to improve fine motor skills for writing numbers and using maths tools.

Environmental Modifications: Classroom adjustments like visual aids and manipulatives.

Psychological Support: Counselling and support groups address emotional challenges.

Parental and Teacher Support: Training and collaboration for consistent support and progress monitoring.

Attention deficit hyperactivity disorder (ADHD)

Definition - Categorised by a pattern of diminished sustained attention and increased impulsivity or hyperactivity.
- Significant impairment in academic functioning as well as in social and interpersonal situations.
- Often associated with comorbid depressive disorders, including LD, Anxiety disorders, mood disorders
and disruptive behaviour disorders

History - The early 1900s → hyperactive children (damage from encephalitis) → hyperactivity syndrome
 - 1960’s → heterogenous group → poor coordination, LD & emotional liability but without specific Neuro
Disorder

Epidemiology - 7-8% of pre-pubertal (6-10) elementary school children

- 5% of youth (children and adolescence
- 2.5% of adults
- More prevalent in boys (2:1, high as 9:1)
- First-degree biological → high risk developing ADHD + disruptive behaviour disorders, anxiety disorder
and depressive disorders

Symptoms - Hysteric
- Tiptoeing
- Sensitive to loud noises
- Delayed speech development
- Ignoring dangers
- Rejecting cuddles
- Build toys in one line
- Avoiding eye contact
- Playing alone

Clinical - Hyperactivity
features - Attention deficient (short attention span, distractibility, preservation, failure to finish tasks, inattention,
poor concentration)
- Impulsivity (action before thought, abrupt shifts, lack of organisation, jumping)
- Memory and thinking deficits
- SLD
- Speech and hearing deficits

Associated - Perceptual-motor impairment

features - Emotional lability
- Developmental coordination disorder
- Behavioural symptoms of aggression and defiance
- School difficulties, both learning and behavioural
Comorbidity - Communication disorders & learning disorders → hamper acquisition and retention
- Display of knowledge complicates the course of ADHD

Diagnosis
(Synopsis of DSM-5 ICD-10
psychiatry)
Name - Attention-deficit/hyperactivity disorder Hyperkinetic disorder, disturbance of
activity and attention

Duration ≥ 6 months Usually occur before the age of 5

Present before the age of 12

Symptoms Inattention Cannot engage in activities requiring

- Poor attention to detail/frequent mistakes prolonged attention
- Hard to maintain attention/focus Disorganised about completing tasks
- When spoken to, they appear not to listen Excess activity
- Poor follow-through on tasks May have:
- Poor organisational skills - Impulsivity
- Procrastinates from tasks that require attention - Recklessness
- Losing things - Social disinhibition
- Distractible
- Forgetfulness
hyperactivity/impulsivity
- fidgety/restless
- Cannot stay seated
- runs/climbs inappropriately
- Cannot do things quietly
- Cannot keep still
- Inappropriately talkative
- Inappropriately blurts out answers
- Cannot wait for his turn
- Interrupts others
 No. of ≥ 6 of each category (≥ 5 for ≥ 17)
symptoms Symptoms occur in >1 setting

Symptoms - Combined presentation

specifiers - predominantly inattentive presentation
- predominantly hyperactive/impulsive presentation

Course In partial remission: last months. Symptoms continue but are less than required for diagnosis.
specifiers

Severity Mild (at risk)

specifiers - Minimal symptoms are required for diagnosis
- Minor functional impairment
Moderate (risk)
- Immediate symptoms and impairment
Severe (developed)
- Severe symptoms
- Marked impairment

Aetiology Genetic factors

- 2-8 times for siblings as well as parents of an ADHD child
- Clinically one sibling may have impulsivity/hyperactivity predominantly and others may have
predominantly inattentive symptoms
- 70% of children meet the criteria for a comorbid psychiatric disorder, including learning disorders, anxiety
disorders, mood disorders, conduct disorders and substance use disorders
Neurochemical factors
Neurophysiological factors
Neuroanatomical aspects (superior and temporal cortices with focusing attention, external parietal and corpus
striatal regions with motor executive functions
Developmental factors
Psychosocial factors (severe, chronic abuse, maltreatment and neglect)
Unit 4
Somatic, Dissociative and Stress disorders: Somatic symptoms and related disorders-
- Somatic symptom disorder
Diagnostic Somatic Symptom Disorder involves distressing physical symptoms that disrupt daily life and are accompanied by
criteria excessive thoughts, feelings, or behaviours related to these symptoms. Key diagnostic criteria include:
- Somatic Symptoms: Persistent physical symptoms, often lasting more than six months, with or without
continuous presence.
Excessive Reactions: At least 1/3
- Disproportionate worry about symptom severity.
- High anxiety about health or symptoms.
- Significant time/energy devoted to health concerns.
Specifiers: With Predominant Pain: When pain is the main symptom.
Severity Levels:
- Mild: Only one excessive reaction.
- Moderate: Two or more excessive reactions.
- Severe: Multiple somatic complaints or one severe symptom, along with two or more excessive reactions.

Prevalence General Population: Approximately 4-6% of adults are affected, based on studies in Europe and North America.

Primary Care Settings: Prevalence is higher, estimated at 10-20% over 12 months, with even higher rates (40-60%)
in clinics specialising in psychosomatic or functional disorders.

Gender Differences: Women are more likely to experience and report somatic symptoms than men, leading to
higher prevalence among women.

Comorbidity - Anxiety and depression are common, each affecting up to 50% of cases and significantly worsening
functional impairment and quality of life.
- PTSD, OCD, and, in men, sexual dysfunction are also linked.
- In individuals with medical conditions, somatic symptom disorder amplifies impairment, reduces
treatment adherence, and worsens health outcomes, leading to higher healthcare use and lower quality of
life.
Illness anxiety disorder
Diagnostic A. Preoccupation with having or acquiring a serious illness.
Criteria B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is
present or there is a high risk of developing a medical condition (e.g., a strong family history is present), the
preoccupation is excessive or disproportionate.
C. There is a high level of health anxiety, and the individual is easily alarmed about their personal health status.
D. The individual performs excessive health-related behaviours (e.g., repeatedly checks his or her body for
signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may
change over that period.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic
symptom disorder, panic disorder, generalised anxiety disorder, body dysmorphic disorder,
obsessive-compulsive disorder, or delusional disorder, somatic type.
Specify whether:
- Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently
used.
- Care-avoidant type: Medical care is rarely used.

Prevalence - based on health anxiety or hypochondriasis prevalence data, affects 1.3% to 10% of the general population
in high-income countries,
- with 6-month to 1-year rates in medical settings ranging from 2.2% to 8%.
- Speciality clinics report higher rates, with about 20% of patients experiencing illness anxiety.
- Prevalence is similar between men and women.

Comorbidity Illness Anxiety Disorder commonly co-occurs with

- anxiety disorders (especially generalised anxiety disorder and panic disorder),
- OCD
- Depressive disorders
Around ⅔ of those with the disorder have at least one other major mental health condition, and they may also have
an increased risk of personality disorders.

Conversion disorder (Functional neurological symptom disorder)

 Diagnostics Conversion Disorder involves symptoms of altered voluntary motor or sensory function, with evidence
criteria indicating these symptoms are inconsistent with any recognized neurological or medical conditions.
The symptoms cannot be better explained by other medical or mental disorders and cause significant distress
or impairment in daily functioning. Types of symptoms include weakness, abnormal movement, speech or
swallowing issues, seizures, sensory loss, and disturbances in special senses (e.g., vision or hearing). The
disorder can be specified by duration (acute or persistent) and the presence of a psychological stressor.

Comorbidity - Anxiety disorders, especially panic disorder, and depressive disorders

- Personality disorders
- Neurological or other medical conditions

Factitious Disorder
Factitious Disorder A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease,
Imposed on Self associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behaviour is evident even in the absence of obvious external rewards.
D. The behaviour is not better explained by another mental disorder, such as delusional disorder or
another psychotic disorder.
Specify:
- Single episode
- Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

Factitious Disorder A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in
Imposed on another, associated with identified deception.
Another B. The individual presents another individual (victim) to others as ill, impaired, or injured.
(Previously C. The deceptive behaviour is evident even in the absence of obvious external rewards.
Factitious Disorder D. The behaviour is not better explained by another mental disorder, such as delusional disorder or
by Proxy) another psychotic disorder.
Note: The perpetrator, not the victim, receives this diagnosis.
Specify:
Single episode
- Recurrent episodes (two or more events of falsification of illness and/or induction of injury)
Dissociative disorders-Depersonalization/Derealization disorder

Diagnostic criteria A. Disruption of identity is characterised by two or more distinct personality states, which may be
described in some cultures as an experience of possession. The disruption in identity involves marked
discontinuity in the sense of self and sense of agency, accompanied by related alterations in affect,
behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These
signs and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic
events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or
chaotic behaviour during alcohol intoxication) or another medical condition (e.g., complex partial
seizures).

Dissociative Amnesia and Dissociative fugue

Diagnostic A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature,
criteria that is inconsistent with ordinary forgetting.
Note: Dissociative amnesia most often consists of localised or selective amnesia for a specific event or events; or
generalised amnesia for identity and life history.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of
abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient
global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder,
acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
Coding note: The code for dissociative amnesia without dissociative fugue is F44.0. The code for dissociative
 amnesia with dissociative fugue is F44.1.
Specify if: F44.1 With dissociative fugue: Purposeful travel or bewildered wandering that is associated with
amnesia for identity or other important autobiographical information.

Dissociative Identity disorder

Diagnostic A. Disruption of identity is characterised by two or more distinct personality states, which may be described in
criteria some cultures as an experience of possession. The disruption in identity involves marked discontinuity in
the sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness,
memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be
observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that
are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic
behaviour during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Biological Genetic Predisposition: Although no specific gene has been linked to DID, there may be a hereditary component,
causal factors as individuals with DID often have close relatives with other mental health conditions, such as mood disorders or
PTSD.

Neurobiological Differences:
- Brain Structure: Research suggests that individuals with DID may have structural differences in areas of the
brain involved in memory, emotional regulation, and self-awareness, such as the hippocampus, amygdala,
and prefrontal cortex.
- Brain Function: Functional brain imaging studies show variations in brain activity patterns when different
identities or "alters" are present. Differences have been observed in the areas linked to emotional processing
and stress response.

Stress Response and Cortisol Levels: Chronic trauma, often a precursor to DID, may alter the body's stress
 response system. People with DID sometimes show irregularities in cortisol production and response, which could
contribute to dissociative states and identity fragmentation.

Neurodevelopmental Factors: Early childhood trauma or neglect can interfere with normal neurodevelopment,
potentially leading to issues with emotional regulation, memory, and the development of a cohesive sense of self.
This may increase the likelihood of dissociation as a coping mechanism, leading to DID in those predisposed to the
disorder.

Abnormal Integration of Consciousness: There may be a biological susceptibility that impairs the integration of
consciousness, memory, and identity under stress. This can result in fragmented identities or personalities,
especially in response to trauma during early development.

Psychological Severe Childhood DID is often linked to chronic and severe trauma, particularly in early childhood, such as
Causal factors Trauma: physical, sexual, or emotional abuse. This can lead to dissociation as a coping mechanism,
where the mind creates separate identities to "compartmentalise" traumatic memories and
emotions.

Trauma can overwhelm a child's ability to process experiences cohesively, causing

fragmentation of identity and memory.

Attachment Issues Children who lack a stable, secure attachment with caregivers may develop dissociative
and Insecure tendencies. When primary caregivers are neglectful, abusive, or inconsistent, children may be
Attachment: unable to form a cohesive sense of self.

Dissociation can serve as a protective mechanism, helping children detach from frightening or
harmful situations by creating separate identities.

Fantasy Proneness Some individuals with DID have a high tendency toward fantasy and imagination. This trait,
and Suggestibility: along with suggestibility (an increased likelihood of being influenced by external cues), may
make it easier for the mind to create alternate identities.

Individuals with a high capacity for fantasy may find it easier to dissociate as a way to cope
with trauma, creating separate personas that can handle different aspects of reality.
 Disrupted Early trauma interferes with the normal development of self-identity. In healthy development,
Development of children integrate various aspects of their personality over time. However, trauma can
Self-Identity: interrupt this process, leading to a fractured sense of self.

Dissociation may act as a defence mechanism, with different identities emerging to handle
specific emotions, memories, or social roles, ultimately resulting in DID.

Emotion People with DID often have trouble regulating intense emotions due to disrupted
Regulation development. Dissociation allows them to "escape" from overwhelming emotions, creating
Difficulties: alters that can experience or hold emotions the individual feels they cannot handle as a single
identity.

Over time, these fragmented parts may solidify into separate identities as a way to
compartmentalise unmanageable emotions.

Repetitive Repeated dissociation during trauma can reinforce the habit of dissociating when stressed,
Reinforcement: eventually leading to identity fragmentation. In severe cases, separate identities become
established as a coping strategy, triggered not only by traumatic events but by other stressors
as well.

Unit 5
Obsessive-compulsive and related disorders
Obsessive-compulsive disorder
Obsessive Compulsive Disorder:
DSM Persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing, inappropriate and
uncontrollable
People → actively try to resist or suppress them or to neutralise them with some other thought or action.
Over repetitive behaviour → lengthy rituals
More covert mental rituals
The diagnosis requires that obsessions and compulsions must take at least 1 hour a day.
Severe cases → Most of a person’s waking hours
Prevalence - 90% of people with OCD who seek treatment have obs & comp
- Divorced & unemployed people → overrepresented among people with OCD
- Little or no gender difference in adults
- Early adolescent → more common in boys → ↑ severity, ↑ heritability
- Gradual onset → once serious → tends to be chronic → severity → wax and wane over time

Comorbidity - Depression → 25-50% → 80% may show symptoms

- Social phobia, panic disorder, GAD, PTSD
- Personality disorders → dependant & avoidant
- Body dysmorphic disorder → 15 years extensively

Diagnostic A. Presence of obsessions, compulsions, or both:

criteria → Obsessions are defined by (1) and (2):
- Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the
disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralise them with
some other thought or action (i.e., by performing a compulsion).
→ Compulsions are defined by (1) and (2):
- Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting,
repeating words silently) that the individual feels driven to perform in response to an obsession or according
to rules that must be applied rigidly.
- The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing
some dreaded event or situation; however, these behaviours or mental acts are not connected realistically
with what they are designed to neutralise or prevent, or are excessive.
Note: Young children may not be able to articulate the aims of these behaviours or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder

Psychological Maladaptive Overestimation of threat: Believing that bad things are more likely to happen and have severe
causes Thought Patterns consequences.
 and Beliefs Inflated responsibility: Feeling overly responsible for preventing harm or bad events.

Intolerance of uncertainty: Experiencing extreme discomfort with doubt or uncertainty leading

to compulsive behaviours aimed at achieving a (false) sense of certainty.

Perfectionism: A need for things to feel "just right," which can drive repetitive behaviours

Cognitive Catastrophizing: Assuming the worst possible outcome will occur if a ritual or compulsion is
Distortions not performed.

Thought-action fusion: Believing that simply having a thought about something (e.g.,
harming someone) is equivalent to acting on it or increasing the likelihood it will happen.

Magical thinking: The belief that certain thoughts, words, or actions can influence outcomes
in unrealistic ways, leading to superstitious or ritualistic behaviours.

Biological Genetical OCD tends to run in families, suggesting a genetic component. Studies indicate that people
causes with a first-degree relative with OCD are at a higher risk of developing the disorder. Specific
genes related to serotonin, glutamate, and dopamine pathways are thought to increase
susceptibility to OCD, although the exact genetic mechanisms are complex and not fully
understood.

Neurotransmitters Serotonin: Low levels of serotonin, a neurotransmitter associated with mood regulation, are
strongly implicated in OCD. This link is supported by the effectiveness of selective serotonin
reuptake inhibitors (SSRIs) in reducing OCD symptoms.

Glutamate: High levels of glutamate, an excitatory neurotransmitter, have also been associated
with OCD. Excessive glutamate activity may contribute to the overactivity of certain brain
circuits seen in OCD.

Dopamine: Dysregulation of dopamine, which plays a role in reward and motivation, is also
thought to contribute to the disorder, especially in compulsive behaviours.

Brain structure Cortico-Striato-Thalamo-Cortical (CSTC) Circuit: The CSTC loop, involving the
 orbitofrontal cortex, striatum, and thalamus, is hyperactive in individuals with OCD. This
circuit is responsible for regulating thoughts, emotions, and behaviours, and its overactivity is
associated with obsessive thoughts and compulsive behaviours.

Orbitofrontal Cortex: This region, which is involved in decision-making and evaluating

rewards and risks, tends to be overactive in people with OCD, contributing to repetitive and
persistent thoughts.

Anterior Cingulate Cortex (ACC): The ACC is involved in error detection and conflict
monitoring. Overactivity in the ACC can contribute to heightened feelings of doubt and
anxiety, potentially triggering compulsive behaviours as a way to reduce perceived errors.

Basal Ganglia: This structure, especially the caudate nucleus, plays a role in habit formation
and procedural learning. Dysregulation in the basal ganglia is linked to repetitive, ritualistic
behaviours, which are characteristic of OCD

Body dysmorphic disorder (F45.22)

Diagnostic A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or
criteria appear slight to others.
B. At some point during the disorder, the individual has performed repetitive behaviours (e.g., mirror checking,
excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance
with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual
whose symptoms meet diagnostic criteria for an eating disorder.
Specify if:
- With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small
or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas,
which is often the case.
Specify if:
- Indicate the degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I look
 deformed”).
- With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely
or probably not true or that they may or may not be true.
- With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.
- With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic
disorder beliefs are true.

Prevalence Adults in the US are 2.4% (2.5% in women and 2.2% in men).
Germany shows similar prevalence rates of 1.7%–2.9%, with a similar gender distribution.
Globally
- 11%–13% of dermatology patients
- 13%–15% of general cosmetic surgery patients
- 20% of rhinoplasty patients
- 11% of adult jaw correction surgery patients
- 5%–10% in adult orthodontia or cosmetic dentistry patients.
Among adolescents and college students, prevalence rates are notably higher in girls and young women than in boys
and young men.

Comorbidity Major depressive disorder → onset usually after that of body dysmorphic disorder. Comorbid social anxiety disorder,
OCD, and substance-related disorders (including the use of anabolic-androgenic steroids in the muscle dysmorphia
form of body dysmorphic disorder) are also common.

Hoarding disorder
Diagnostic A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
criteria B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
C. The difficulty of discarding possessions results in the accumulation of possessions that congest and clutter
active living areas and substantially compromise their intended use. If living areas are uncluttered, it is only
because of the interventions of third parties (e.g., family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning (including maintaining a safe environment for self and others).
E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease,
Prader-Willi syndrome).
 F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in
obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or
another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism
spectrum disorder).
Specify if:
- With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of
items that are not needed or for which there is no available space.
Specify if:
- With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviours (about
difficulty discarding items, clutter, or excessive acquisition) are problematic.
- With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviours (about
difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the
contrary.
- With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs
and behaviours (about difficulty discarding items, clutter, or excessive acquisition) are not problematic
despite evidence to the contrary.

Prevalence - 1.5% to 6% in the U.S. and Europe, with a meta-analysis indicating a prevalence of 2.5% across high-income
countries.
- symptoms are nearly three times more common in adults over 65 compared to younger adults (ages 30–40).

Comorbidity - Approximately 75% of mood or anxiety disorders.

- Major depressive disorder (30%–50%), social anxiety disorder, and generalised anxiety disorder.
- Approximately 20% of OCD.

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

Prevalence - 1% to 2%. Women are more frequently affected

- ratio estimated at 10:1 or greater
- gender ratio may be closer to 2:1 in community samples
- 10,000 adults ages 18–69 years
- 1.7% identified as having current trichotillomania and that rates did not differ significantly based on gender
(1.8% of men and 1.7% of women).

Comorbidity - Major depressive disorder and excoriation (skin-picking) disorder.

- Repetitive body-focused symptoms other than hair pulling or skin picking (e.g., nail biting)
- additional diagnosis of other specified obsessive-compulsive and related disorders (i.e., other body-focused
repetitive behaviour disorder).

Biological Genetic factors OCD and related disorders often run in families, suggesting a hereditary component. Twin studies show a
causal factors moderate genetic influence, especially in childhood-onset OCD

Certain gene variations related to serotonin and glutamate regulation may contribute to OCD risk.

Brain Structure Neuroimaging studies have found abnormalities in brain circuits involving the orbitofrontal cortex, anterior
and Function: cingulate cortex, and basal ganglia.

These areas are associated with habit formation, error detection, and emotional regulation.

Increased activity in these regions is often observed in individuals with OCD, with symptoms often
improving alongside the normalisation of these brain patterns after successful treatment.

Neurotransmitter Dysfunctional serotonin pathways play a key role in OCD, as well as potential dysregulation of dopamine
Imbalance: and glutamate systems.
 SSRIs (selective serotonin reuptake inhibitors), which increase serotonin levels, are often effective in
reducing OCD symptoms, supporting the role of neurotransmitter imbalances.

Psychological Cognitive People with OCD may have maladaptive thought patterns, such as an inflated sense of responsibility,
causal factors Factors intolerance of uncertainty, and a heightened need for control

These beliefs often lead to compulsive behaviours to prevent or "undo" perceived threats, reinforcing the
OCD cycle.

Behavioural Compulsions and rituals are reinforced through a cycle of relief from anxiety, which strengthens the
Factors: behaviour over time (negative reinforcement).

Avoidance behaviours reduce immediate distress but prevent individuals from learning that their fears are
irrational, maintaining the disorder.

Stress and Stressful life events or trauma may trigger the onset of OCD symptoms, particularly in individuals with a
Trauma: genetic predisposition.

Childhood experiences, such as overprotective or controlling parenting, may contribute to OCD's

development by reinforcing obsessive thought patterns and behaviours.

Treatment Pharmacological SSRIs: These are the first line of treatment and are effective for many individuals with OCD and related
and Outcome Treatments: disorders, helping to reduce symptoms.

Antipsychotics: In cases where SSRIs are ineffective, low doses of antipsychotic medications may be added
to target symptoms resistant to SSRIs alone.

Glutamate Modulators: Research is exploring medications that influence glutamate to target specific
neurochemical dysfunctions in OCD.

Psychotherapy: Cognitive Behavioral Therapy (CBT): CBT, particularly Exposure and Response Prevention (ERP), is
highly effective for OCD. ERP helps individuals face their fears without engaging in compulsive
behaviours, gradually reducing anxiety.
 Cognitive Therapy: Focuses on challenging maladaptive beliefs and cognitive distortions, which helps to
reduce compulsive responses to obsessive thoughts.

Acceptance and Commitment Therapy (ACT): Used in conjunction with CBT, ACT helps individuals accept
distressing thoughts without reacting compulsively.

Lifestyle and Family Therapy: Helps families support individuals with OCD without enabling their compulsions, reducing
Supportive conflict and stress.
Therapies:
Support Groups and Education: Group therapy and psychoeducation help individuals feel less isolated and
provide additional coping strategies.

Outcomes While many patients experience significant symptom reduction with treatment, complete remission is rare.
Treatment effectiveness varies, with about 40-60% of individuals responding well to CBT and/or
medication.

For treatment-resistant OCD, deep brain stimulation or transcranial magnetic stimulation are sometimes
considered.

Unit 6
Types of personality disorders-
A- Paranoid, Schizoid and Schizotypal personality disorders;
Details Paranoid Schizoid Schizotypal

Specifics - Long-standing suspiciousness - Lifelong pattern of social - Strikingly odd or strange

and mistrust withdrawal - Magical thinging
- Refuse responsibility for their - Eccentric, isolated, lonely - Peculiar notions
feelings and assign - Discomfort with human - Ideas of reference
responsibilities interaction - Illusions
- Often hostile, irritable, angry - Introversion, their bland - Derealization and
constricted affect commonplace
 Symptom - Does not want or enjoy close - Difficulty trusting
relationships. - Being hostile or argumentative
- Has an apparent indifference - Believing the world is
to praise or criticism by threatening
others. - Trouble coping with criticism
- Rarely experiences or - Assuming talking are talking
expresses strong emotions behind your back
- Has little or no sexual desires
- Hobbies solitary in nature

B- Histrionic, Narcissistic, Antisocial, Borderline Personality disorder;

Details Histrionic Narcissistic Antisocial Borderline

Pervasive & excessive Exaggerated sense of Violate and show disregard Pattern of instability of
emotionality & self-importance, for the rights of others interpersonal relationships,
attention-seeking preoccupational with being through deceitful, aggressive, self-image, affects, marked
behaviour. admired, and a lack of or antisocial behaviour, impulsivity
Early adulthood → variety empathy for the feelings of typically without remorse.
of context others Inability to conform to the
social norms that ordinarily
govern many aspects of a
person’s adolescent and adult
behaviour.

- Hostile towards
others
- Impulsive
- Disregard for rules
- Feeling of superior
- Manipulating others
- Not accepting
responsibilities.
C- Avoidant, Dependent and Obsessive-Compulsive Personality Disorder.
Domains Avoidant OCPD Dependent

- Extreme sensitivity to rejection - Emotionally constricted

- Socially withdrawn lives - Orderly
- Not social - Preservative
- Arent looking for - Stubborn
companionship - Indecisive
- Need strong guarantees of Pattern of perfectionism and
uncritical acceptance inflexibiliity
(inferiority complex)

Symptoms - Choosing isolation over social - Excessive doubt and - Trouble making decisions
- Fear of emnarrasment indecisiveness without reassurance
- Hyper sesenstive - Being unwilling to - Fear that they cant take care of
compromise themselves
- Being unwilling to throw out - Trouble expressing
broken or worthless object disagreement
- Perfectionism that interferes - Difficulty being alone
with completing tasks
- Becoming overly fixated on
a single task or belief
- Difficulty coping with
criticism

Sexual Variants and Sexual Abuse - The Paraphilias, Gender dysphoria, Sexual abuse - Childhood sexual abuse, Pedophilic disorder.