Paper-V-Abnormal-Psychology-English-Version-munotes

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UNDERSTANDING ABNORMAL
BEHAVIOR : CLINICAL ASSESSMENT
AND DIAGNOSIS - I
Unit Structure
1.0 Objectives
1.1 Introduction
1.2 What is Abnormal Behaviour
1.2.1 Defining Abnormality
1.2.2 Challenges Involved in characterizing abnormal behaviour
1.2.3 What cau ses Abnormality
1.3 The Diagnostic and Statistical Manual of Mental Disorders
1.3.1 How the DSM Developed
1.3.2 Controversial Issues Pertaining to the DSM
1.3.3 Definition of Mental Disorder
1.3.4 Assumptions of the DSM -IV-TR
1.4 Classifying Abnormal Behav ior
1.5 Historical View of Abnormal Behavior
1.5.1 The Emergence of Contemporary views of Abnormal Behavior
1.6 Summary
1.7 Questions
1.8 References
1.0 OBJECTIVES
After reading this unit you will be able to:
 Understand what is meant by abnormality an d the difficulties in
defining it.
 Discuss the factors involved in the development of abnormality.
 Describe the development and use of the Diagnostic and Statistical
Manual of Mental Disorders. munotes.in

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2 1.1 INTRODUCTION
Efforts to understand, explain and control p roblematic behaviors can be
traced back to several years. Abnormal Psychology is the systematic study
of abnormal behavior. It is a branch of psychology that is concerned with
the etiology, symptomatology, and the process of mental illnesses. In this
chap ter we will examine what is meant by deviant or ‘abnormal’
behavior?
After defining abnormality, we will discuss the challenges involved in
characterizing abnormal behavior as well as the causes of abnormality.
Following this we will discuss the Diagnostic and Statistical Manual of
Mental Disorders and related topics.
The concept of psychological assessment, behavioral assessment,
multicultural assessment, environmental assessment and physiological
assessment would be discussed with relevant examples.
1.2 WHAT IS ABNORMAL BEHAVIOUR?
Let’s consider the following case.
Does anything about Raju seem strange to you? How would you feel if
you were to see someone like Raju walking in your neighborhood? You
could be surprised or scared or may even laugh? You may th ink there is
something abnormal about this person. On what basis is Raju judged to be
abnormal? Is it because the way he is talking is odd? Or since he is
making high claims? Or because one cannot anticipate how he may
behave after a while?
Anything that d eviates from the normal or differs from the usual or typical
is called abnormal. However, there can be exceptions and certain very
unusual behaviors may also be considered normal in the given
cultural/social context. E.g. a gifted child. So, on what we sho uld decide
what is normal and what is abnormal?
To answer the above question, there are certain criteria that help us define
abnormality and also distinguish between what is normal and abnormal.
1.2.1 Defining Abnormality
The current diagnostic procedures used in the mental health community
rely on four important ways in which abnormality can be defined.
Impairment: According to this criterion, maladaptive behaviors that
prevent an individual from functioning well in his/her daily life can be
considered abn ormal. Impairment refers to a reduction in a person’s ability
to function at an optimal or average level. For example, when a woman
consumes psychoactive substances (drugs), her cognitive and perceptual
abilities get impaired, and she would be at risk if s he drives in this state. In
the case mentioned earlier, Raju spent all his savings to buy an expensive munotes.in

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3 camera thinking that he could set up a studio. This can be thought of as his
impaired judgment.
In certain situations, the person may report feeling grea t and describe
oneself in positive terms but those around may suggest that s/he is
functioning inadequately in her/his personal or work life. E.g. an
individual experiencing manic symptoms of Bipolar disorder.
Distress: This criterion suggests that a part icular behavior should be
considered as abnormal if the individual suffers discomfort because of that
behavior and wish to get rid of them.
The experience of distress - emotional or physical pain - is common in
life. However, in case of mental disorders t he intensity of pain is so high
that it interferes with the person’s daily living. For example, a victim of an
extremely traumatic event may experience unrelenting pain or emotional
turmoil and may not be able to cope in daily life.
Risk to Self or Other P eople: When an individual’s actions pose a threat
to one’s own life or to the life of others, the behavior is considered to be
abnormal. A severely depressed individual is at risk for committing
suicide and therefore the condition is referred to as abnorma l. Similarly, a
person suffering from Schizophrenia is out of touch with reality and may
put oneself and/ or others at risk. In some situations, a person’s thoughts
and behaviors threaten the physical or psychological wellbeing of others
and are therefore, considered abnormal such as the act of abusing children
or exploiting others.
Socially and Culturally Unacceptable Behaviour: Behaviours that are
not in line with the social or cultural norms are considered abnormal.
Certain behaviours may be acceptable in some cultures but considered odd
in certain others. For e.g., In India, the phenomenon of being possessed by
God is a common practice during Navratri or other festivals, but the same
behaviour would be considered abnormal in most of the other countries.
Thus, the social context needs to be taken into account while judging
behaviour as normal or abnormal.
1.2.2 Challenges Involved in Characterizing Abnormal Behaviour
Although there are clear criteria for defining abnormality, diagnosing
abnormal condition s is not as straightforward as it may seem. In 1973,
David Rosenhan conducted a classic study that threw light on the
difficulties involved in this process - 8 sane individuals were able to trick
the staff of 12 psychiatric hospitals across the United Stat es. Each of them
was gainfully employed and presented oneself at these hospital reporting
hearing voices such as “Empty”, “Hollow,” and “Thud.” These kind of
psychotic symptoms were chosen because they had never been reported in
the history of psychiatr ic literature.
Except their names and employment, none of their other details were
changed and thus their history and present behaviour (except for the
symptoms) could not be considered abnormal in any way. Interestingly, all munotes.in

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4 the hospitals admitted these p seudopatients and although they stopped
producing the symptoms immediately following the admission, none of
the staff members noticed it. On the contrary, their ordinary actions were
taken as additional evidence of their abnormality.
What was most striking was the inhuman approach of the staff - the
pseudopatients felt as if nobody from the staff was concerned about their
needs. Also, the staff didn’t believe them when they tried to convince
them that they were actually normal. The pseudopatients were rele ased in
7 to 52 days and at the time of discharge, each of them had received a
diagnosis of ‘schizophrenia in remission’, which meant that their
symptoms were not present, at least during that time.
Rosenhan (1973) concluded that what prevented the hospita l staff from
detecting the pseudopatient’s normality is the general bias to call a healthy
person sick. Since this study involved deception of the mental health
professionals, it was criticized for an ethical reason. Questions pertaining
to why a control g roup was not used for comparison were raised. It was
also said that since the symptoms reported (hallucinations) were of a
serious nature, most clinicians would have done what the hospital staff
did.
Scribner (2001) found that Rosenhan’s controversial st udy had led to an
extreme change in the mental health field where now patients with
diagnosable psychotic symptoms had difficulty receiving mental health
services. He reported 7 cases with documented history of chronic
Schizophrenia, 6 of which were not tr eated even while they were in the
active phase of symptoms.
Lauren Slater (2004) attempted to replicate Rosenhan’s study.
She went to several clinicians complaining hearing “thud” and no other
symptom. She was denied admission everywhere and at the most,
diagnosed with depression with psychotic symptoms, was prescribed some
medication and sent away. She also reported that as opposed to the
pseudopatient’s experience in the Rosenhan study, she was treated very
kindly by every mental health staff.
Thus, in sp ite of the criticisms, Rosenhan’s study proved to be crucial in
pointing out that the attitudes towards diagnosing and admitting
individuals with psychological difficulties need to change.
1.2.3 What causes Abnormality?
There are various assumptions about the causes of abnormality. One being
the biological approach which considers the abnormal behaviours to be
caused by a biological factor such as genetic vulnerability to a disorder
inherited from a parent, imbalance in neurotransmitters, brain injury, toxi c
substances etc. The psychological approach considers the abnormal
behaviours to be caused by the early childhood experiences, traumatic
experiences, maladaptive thought process, low self -concept etc. The social
perspective considers the abnormal behaviou rs to be caused by the munotes.in

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5 disturbed interpersonal relationships, discrimination, or the negative social
environment in which an individual lives.
There is long going debate whether abnormality is caused due to
biological or environmental factor? This is refe rred to as the nature -
nurture question wherein some consider the abnormality to be caused by
something in the nature i.e. biological or due to nurture i.e. environmental
factor. E.g. when a professional singer’s child also becomes a professional
singer. So , was the singing ability passed genetically through birth or was
it because of having father who is a professional singer and so the
behavior learned through observation, countless hours of repetition and
practice.
So, now the forth approach is considered to be more acceptable. Social
scientists are of the view that there is an interaction between biological,
psychological and social factors. This approach is termed as
‘biopsychosocial ’. On the similar line, the diathesis -stress model
suggests that an indi vidual is genetically predisposed (diathesis) i.e. they
carry some genetic risk to a particular disorder to a particular disorder or
have acquire vulnerability early in life due to some formative events such
as birth complications, head injury, traumas, or malfunctioning or harsh
family. This vulnerability placed them at higher risk of developing that
disorder as they grow when they experience any kind of traumatic or
stressful situation or trigger. The can be due to psychological factors like a
faulty pers onality trait, irrational thought process, low self -esteem or due
to social factors like a history of abuse or poor interpersonal relations.
The full -blown disorder can develop only when the vulnerability combines
with the stress. Also, a feedback loop te nds to develop, such that, changes
in one system lead to changes in the second and then the changes in the
second system bring about changes in the first. For example, an increase in
a certain neurotransmitter (biological factor) may make an individual
angry and irritable (psychological factor). This may cause the person to
react angrily towards his friends, who may begin avoiding him (social
factor) due to this behaviour. The rejection from friends (social factor)
may make the person even more agitated, which may cause further
changes in the neurotransmitters (biological factor).
Although the theoretical approaches are discussed in detail in topic 2, let’s
have a brief look at the biopsychosocial factors involved in the
development of abnormality.
Biolog ical causes :
 In understanding what causes abnormality from the biological
perspective, mental health professionals focus on the processes in a
person’s body, such as genetic inheritance, altering function of
nervous system or physical disturbances.
 Many di sorders run in the family. For example, the chances of the son
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6 parents is suffering from it as compared to children of parents who do
not have the disorder.
 Other factors such as medical c onditions (thyroid), brain damage (head
trauma), exposure to certain environmental stimuli (toxic substances,
allergens), ingestion of certain medicines, illicit drugs, etc., can cause
disturbances in the physical functioning that cause emotional or
behavi oural disturbances.
Psychological causes :
 Traumatic life experiences that have an impact on the individual’s
thoughts, feelings, behavior or personality constitute the psychological
factors in the development of abnormality. For example, an irrational
fear of the marketplace may be caused due to a childhood experience
of having been lost in the market.
 Early interpersonal relationships may lead to distortions in perception
and faulty thought processes. For example, a boy who is very upset
because his girlfr iend didn’t call back may realize that his reaction
stems from his history of being disappointed by his unreliable parents
and having internalized the idea that important people tend to
disappoint.
 Unrealistic expectations, learned helplessness, focusing o n the
negative, blaming, dichotomous thinking (seeing things as black or
white), catastrophizing (exaggerating) etc., can trigger psychological
difficulties.
 Low self -esteem, poor judgment, pessimistic thought process, low
self-confidence makes a person mo re vulnerable to the psychological
difficulties
Sociocultural causes :
 The term sociocultural refers to the sources of social influence in one’s
life. The most immediate or inner circle that has an impact on a person
comprises of the family members and fri ends. A troubled relationships
can make one feel depressed. Similarly, a failed lover may become
suicidal.
 The next circle involves extended family, neighbours with whom there
is less interaction. Nonetheless their behaviours, standards, attitudes,
and exp ectations do influence individuals.
 The next circle involves teachers, school, college, institution,
workplace. What an individual learns from each of these places or the
experiences that they get plays an important role in shaping ones
thought and behavi or.
 The society plays a decisive role in most people’s lives. Political
turmoil, even at the local level can leave one feeling anxious or fearful.
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7 can have an impact on individuals. As seen earlier, social and cultural
norms determine what would be called abnormal, to a large extent.
1.3 THE DIAGNOSTIC AND STATISTICAL MANUAL
OF MENTAL DISORDERS
 Mental health professionals refer to the Diagnostic and Statistical
Manual of Mental Disorder s (DSM) for standard terms and definitions
of various forms of abnormality. It is a classification system that
includes descriptions of all psychological disorders, which are also
known as mental disorders.
 The DSM, published by the American Psychiatric As sociation (APA),
is periodically revised to incorporate the latest information related to
psychological disorders. The DSM was first published in 1952 and
since then has gone through several changes with its latest version
being DSM -IV-TR (text revision).
 To develop revised editions of the DSM, task forces are appointed
which comprise of clinicians and researchers with expertise in specific
disorders. Based on their research and case studies analysis, a list of
several disorders ranging from mild adjustment problems to severe
disorders has been listed.
 The DSM ensures standardized interpretation of the diagnostic labels
and provides a common language and format for communication
between clinicians and researchers.
Its multiaxial format (explained later in th e chapter) also allows thorough
evaluation of cases with attention to the mental disorders, general medical
conditions, psychosocial problems, and the level of functioning, which
might get ignored if the focus were on evaluating only the presenting
complai nts.
 The recent editions of the DSM follow an a theoretical approach, that
is, they try to present psychological disorders in a manner that reflects
observable phenomena rather than what caused it. For example,
anxiety disorders are described in terms of t he associated
psychological and physical symptoms associated with no reference to
what caused these symptoms.
 The DSM classification system also helps in treatment planning. For
example, a clinician would choose very different treatment plans for
individua ls with anxiety disorders as compared to those with
psychotic illnesses. Also, every DSM -IV diagnosis has specific
numerical code, which helps individuals acquire health insurance to
manage the treatment cost.
 The authors of the DSM have tried to develop a reliable and
scientifically and clinically sound system such that anyone showing a
specific set of symptoms receives the same diagnosis across clinicians,
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8  Emphasis has also been on the ensuring its validity i.e. the extent to
which the diagnostic criteria measure a specific disorder and how well
the disorders can be distinguished from each other. For this, the
experts have been required to consider the base rate of a disorder - that
is, the frequency with whi ch a disorder is found among the general
population. Low base rate means fewer cases and therefore
establishing the reliability of the disorder becomes difficult.
1.3.1 How the DSM Developed
The DSM was the first official classification system that was dev eloped
exclusively for diagnosing mental disorders. Let’s look at the history of
the DSM - the initial editions of this manual were not as precise and
reliable as the recent ones.
 The DSM -I, the first edition published in 1952, followed a theoretical
appro ach where mental disorders were seen as a result of an
individual’s ‘emotional reactions’ or their ‘emotional problems’.
 The DSM -II which was published in 1968, tried to introduce explicit
definitions and diagnostic terms that would reduce reliance on
theoretical assumptions. However, the criteria to describe different was
not precisely explained and was mostly based on the concepts of
psychoanalytic theory.
 In 1974, the APA appointed a task force i.e. a team of scholars and
practitioners to develop a manua l that would be based on observable
phenomena and acceptable to clinicians irrespective of their theoretical
orientation. This led to the DSM -III, published in 1980.
 Although the DSM -III was a refined edition, it had instances in which
the diagnostic crite ria were not entirely clear. Due to this, the DSM -
III-R was published in 1987 as an interim manual till a more complete
edition was developed.
 Around the same time, the APA once again set up a task force that
worked towards improving the reliability and va lidity of the diagnoses,
in stages. In stage 1, its members reviewed the relevant research
published which was then carefully analyzed in stage 2. The next stage
involved field trials in which several thousand individuals with
diagnosed psychological disor ders were interviewed. Consistency in
diagnosis was assessed by having pairs of clinicians independently rate
clients through videotaped interviews. To establish the validity of the
diagnosis, clinicians evaluated individuals diagnosed with specific
psycho logical disorders, with the number and nature of symptoms
needed to diagnose specific conditions. These field trials helped to
empirically decide the specific kind and number of symptoms that
would make a diagnostic criteria. For example, to diagnose Majo r
Depressive Disorder, a person has to have atleast five out of the nine
listed symptoms which include lack of interest, sad mood, disturbed
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9  Thus, the DSM -IV was published in 1994. A major feature of this
version was that it included ‘the symptoms cause clinically significant
distress or impairment in social, occupational or other areas of
functioning’ as one criterion for almost half of all the disorders.
 The DSM -IV with updated information, known as DSM -IV-TR (text
revised) was published by 2013.
 And, then the latest been DSM -V was published in 2013. A lot of
changes have been made from DSM -IV-TR to DSM 5. One of the key
changes is the elimination of multi -axial system. Then, the task forces
of DSM 5 also considered getting away with the categorical model to
represent different disorders and adopt the dimensional model. But
they end up not doing so. However, Section 3 of DSM 5 provides
clinician the description of different disorder based on dimensi onal
model.
 The current organization of DSM 5 begins with neurodevelopmental
disorders, then next category is of “internalizing” disorders (wherein
anxiety, depressive, and somatic symptoms are more prominent) and
lastly “externalizing” disorders (wherei n impulsive, disruptive conduct
and substance use symptoms are more prominent).
1.3.2 Controversial Issues Pertaining to the DSM
 For many years, critics of the DSM have argued that it tends to
unfairly label people and is not a very reliable and valid too l. It is also
suggested that politics and culture have influenced the definitions of
disorders from time to time. For example, homosexuality was included
as a diagnostic category in the DSM -II and was removed following
protests from gay activists at the AP A annual conferences from 1970
to 1973.
 Also, pressure from the Vietnam War veterans forced the authors of
DSM -III to recognize that a group of symptoms experienced by
survivors of traumatic events represented a disorder and thus post -
traumatic stress dis order was introduced. This demonstrates the biased
processes involved in defining mental disorders.
 In addition to this, the DSM classification system is criticized for
being prejudiced against women, in that women are more likely to be
diagnosed with pers onality or mood disorders because feminine
personality characteristics are perceived as being pathological. As a
result of this, the authors of the DSM -IV have been particularly careful
about basing their decisions on fair interpretation of the research da ta
(Kirk & Kutchins, 1992; Kutchins & Kirk, 1997).
1.3.3 Definition of Mental Disorder
The concept of mental disorders is fundamental to the processes of
diagnoses and treatment. The authors of the DSM define a mental disorder
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10 pattern that occurs in an individual that is associated with present
distress (e.g., painful symptom) or disability (i.e., impairment in one
or more areas of functioning) or with a significantly increased risk of
suffering death, pain, disability, or an important loss of freedom and it is
not typical or culturally expected.”
Let’s understand this definition.
 A mental disorder is clinically significant - this implies that the
symptoms have to be present for a specified period of time and should
have a major effect on the person’s life. Thus, an occasional low mood
or strange behaviour or a sense of instability are common experiences
and do not represent a mental disorder. In order to be considered it as
significant it need to be persistent and severe in nature.
 A mental disorder is behavioral or psychological syndrome or
pattern - a syndrome is a collection of defined symptoms. A
behavioural or psychological syndrome indicates a set of observable
actions and the thoughts and feelings reported by the individual.
Accordingly a random thought or behaviour does not constitute a
mental disorder. A person has to experience a wide range of defined
thoughts, feelings and behaviours in order to be called as having a
psychological disorder.
 Further, it is associated with present distress, disability,
impairment or serious risk . This means that the syndrome
sufficiently interferes with the individual’s everyday functioning. For
example, a woman who compulsively washes han ds may be very
disturbed by her actions and may not be able to overcome the
behaviour. Her productivity at work and social life may also be
severely affected by this.
In certain mental disorders the person may not experience any distress
but there may be a serious risk to life. For example, a person in a
hyperexcited state of mania, having a good time, may believe he can
fly and is thus at risk.
 Finally, the disorder is not a culturally expected or sanctioned
pattern . For example, a woman feeling sad, havi ng difficulty eating,
sleeping, concentrating, etc., for few days, following the death of her
husband, will not be called as suffering from Major Depressive
Disorder because it is an expected reaction to this event.
1.3.4 Assumptions of the DSM -IV-TR
The D SM is based on some assumptions:
1. Medical Model : The DSM follows a medical model which means that
every physical and psychological disorder is regarded as a disease. In this
sense the DSM is similar to the ICD, the International Classification of
Disease s (ICD), developed by the World Health Organisation, and ensures
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11 According to this view, schizophrenia is a disease and the individual
suffering from it is referred to as patient . The use of the term mental
disord er is also in line with this view. Although the term mental disorder
implies a distinction between ‘mental’ disorders and ‘physical’ disorders,
it is important to recognize that there aren’t any fundamental differences
between mental disorders and general medical conditions. Mental
disorders tend to involve biological factors and similarly physical
disorders have psychological components.
2. A theoretical Orientation : The authors of the DSM have tried to
develop a descriptive rather than explanatory classif ication system, that is,
a psychological disorder is presented as an observable phenomenon rather
than in terms of what caused it.
The DSM is neutral with respect to the theories of causality. For example,
the DSM -IV-TR classifies social phobia as an anxie ty disorder in which
the person has persistent fear of social or performance situations, without
any reference to whether the anxiety is caused due to a childhood trauma
or an unconscious conflict or any other factor.
The early editions of the DSM were bas ed on the psychoanalytical
tradition in which mental disorders were seen as ‘neurosis’ or an
‘emotional reaction’ to one’s problems and were thought to be a result of
unconscious conflicts. The term neurosis is not a part of the DSM
anymore but is still c ommonly used to describe symptoms that are
distressing and do not have a physiological basis. The term is also used to
refer to excessive anxiety or worry and to distinguish the condition from
psychosis.
Psychosis involves the presence of hallucinations (f alse perceptions) and
delusions (false beliefs). It is a condition in which the person is not in
touch with reality and shows grossly disturbed and bizarre behaviour.
Psychosis is not a diagnostic category but used as a descriptive term in the
DSM -IV-TR.
3. Categorical Approach : The DSM -IV-TR classifies the disorders into
separate categories. For instance, conditions which involve excessive
anxiety or worry are categorized as anxiety disorders, those which affect
the mood are referred to as mood disorders .
Although systematic, this approach has a limitation - psychological
disorders cannot be very neatly separated from one another. For example,
it is difficult to distinguish between sad mood and clinical depression
(severe enough to receive a diagnosis of depression). Also, some cases
involve a mixed presentation such a person experiencing anxiety and sad
mood or mood symptoms with psychosis.
There are two issues related to the categorical approach. One is
comorbidity, that is, conditions in which a person has two or more
disorders that co -exist. For instance, negative emotional states are
common in anxiety disorders, mood disorders and some personality
disorders. The second is that of boundaries - some disorders have munotes.in

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12 overlapping symptoms, such as conduct d isorder, oppositional defiant
disorder and attention - deficit/hyperactivity disorder (Widiger & Samuel,
2005).
Due to this, a dimensional approach is being considered. That is, instead
of fitting an individual’s symptoms into some category s/he would recei ve
a numerical rating on his symptoms indicating the severity of each. The
dimensional model is thought to give a better picture of the individual’s
condition. And, the task force of DSM 5 is hoping to develop the next
edition using dimensional model.
4. M ultiaxial system : This system involves assessing five areas of an
individual’s functioning so that the treatment can be planned accordingly
and the course of the disorder can be predicted. The DSM comprises of
five axes:
Axis I: Clinical Disorders and Oth er Conditions That May Be a Focus
of Clinical Attention
This axis is used for listing the various forms of abnormality, that is, the
clinical syndromes or disorders with the exception of the Personality
Disorders and Intellectual Disability, such as Schizo phrenia, the different
types of Anxiety disorders, such as social phobia, specific phobia,
generalized anxiety disorder etc., the Obsessive and compulsive related
disorders like obsessive compulsive disorders, hoarding disorder, body
dysmorphic disorder, etc., Mood disorders such as major depressive
disorder, bipolar disorder, etc., Adjustment disorders, Cognitive disorders
like delirium, dementia, amnestic disorder, etc. If an individual has more
than one Axis I disorder, all should be reported with the primary reason
for the visit being listed first.
Axis II: Personality Disorders and Mental Retardation
All the Personality Disorders like Paranoid personality disorder, Schizoid
personality disorder, Schizotypal personality disorder, Antisocial
personalit y disorder, Narcissistic personality disorder, etc., and Intellectual
Disability are reported on Axis II. Maladaptive personality features or
excessive use of defense mechanisms can also be mentioned here. This
axis ensures that the unhealthy personality characteristics and mental
retardation will be taken into account while attending to the primary
complaint.
Axis III: General Medical Conditions
This axis is for reporting the general medical conditions that are important
in understanding an individual’s m ental disorder. General medical
conditions may be related to the mental disorders in several ways. In some
cases they may play a role in the development of an Axis I disorder, for
example, Hypothyroidism may lead to depressive symptoms in some or an
indivi dual may develop an Adjustment disorder as a reaction to the
diagnosis of Brain tumor. In certain cases medical conditions may
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13 heart disease may influence the clinician’s choice of me dicines for this
patient’s depression.
Axis IV: Psychosocial and Environmental Problems
The psychosocial and environmental problems that influence the
diagnosis, treatment and prognosis (future course) of mental disorders
listed on Axis I and/or II are rep orted on this axis. This includes a negative
life event, interpersonal stresses, lack of social support, etc. These
problems may influence the development or treatment of mental disorders
or may develop as a result of the Axis I/II condition.
Axis V: Globa l Assessment of Functioning
This axis is for reporting the clinician’s judgement of the individual’s
overall functioning, which is useful in treatment planning or predicting its
outcome. The Global Assessment of Functioning (GAF) scale is used by
clinician to rate the individual’s psychological, social and occupational
functioning. For example, score of 100 means superior functioning with
no symptoms while a score of 50 indicates serious symptoms.
91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.
81-90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).
71-80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work).
61-70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR
some difficulty in social occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.
51-60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co -workers).
41-50 Severe symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). munotes.in

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14 31-40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood ( e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger childre n, is defiant at home, and is failing at school).
21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends).
11-20 Some danger of hurting self or others (e.g., suicidal attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
1-10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.0 Inadequate information.

1.4 CLASSIFYING ABNORMAL BEHAVIOR
 Most sciences rely on classification (e.g., the periodic table in
chemistry and the classification of living organisms into kingdoms,
phyla, classes, and so on in biology).
 At the most fundamental level, classification systems provide us with a
nomenclature (a naming system) and enable us to structure
information in a more helpful manner.
 Organizing info rmation within a classification system also allows us to
study the different disorders that we classify and therefore to learn
more about not only what causes them but also how they might best be
treated.
 A final effect of classification system usage is s omewhat more
mundane.
 The classification of mental disorders has social and political
implications (see Blashfield & Livesley, 1999; Kirk & Kutchins,
1992). Simply put, defining the domain of what is considered to be
pathological establishes the range of problems that the mental health
profession can address. As a consequence, on a purely pragmatic level,
it furthermore delineates which types of psychological difficulties
warrant insurance reimbursement and the extent of such
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15 1.5 HISTORICAL VIEW OF ABNORMAL BEHAVIOR
The historical view of abnormal behavior has come a long way
considering the reason behind the abnormal behavior to be attributed to
supernatural forces or evil forces to the knowledge based on scientific
study. The course of thi s evolution has at times been matter of efforts of
many prominent experts and researchers.
Demonology, Gods and Magic
 As mentioned earlier, one of the earliest explanations to the abnormal
behavior was attributed to God or evil spirits.
 References to abno rmal behavior in early writings show that the
Chinese, Egyptians, Hebrews, and Greeks often attributed such
behavior to a demon or god who had taken possession of a person.
 Whether the “possession” was assumed to involve good spirits or evil
spirits usual ly depended on the affected individual’s symptoms. If a
person’s speech or behavior appeared to have a religious or mystical
significance, it was usually thought that he or she was possessed by a
good spirit or god. Such people were often treated with cons iderable
awe and respect, for people believed they had supernatural powers.
 Most possessions, however, were considered to be the work of an
angry god or an evil spirit, particularly when a person became excited
or overactive and engaged in behavior contra ry to religious teachings.
 Apparently they were punished and punishment involve withdrawal
from God’s protection and abandonment of the person to the forces of
evil.
 In such cases, every effort was made to rid the person of the evil spirit.
The primary t ype of treatment for demonic possession was exorcism ,
which is a physically and mentally painful form of torture carried out
by a shaman, priest,or medicine man.
 Archaeological evidence also showed the use of the procedure called
as trephining on the peopl e showing abnormal behavior. The
trephining is a process wherein a hole is drill on the skull of an
individual with the believe that the hole will pave way to remove the
evil spirit out of the body.
Hipoocrates’ Early Medical Concepts
 The Greek physician Hippocrates (460 –377 b.c.), often referred to as
the father of modern medicine, received his training and made
substantial contributions to the field.
 Hippocrates denied that deities and demons intervened in the
development of illnesses and instead insist ed that mental disorders,
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16  He believed that the brain was the central organ of intellectual activity
and that mental disorders were due to brain pathology. He also
emphasized the importanc e of heredity and predisposition and pointed
out that injuries to the head could cause sensory and motor disorders.
 Hippocrates classified all mental disorders into three general
categories —mania, melancholia, and phrenitis (brain fever) — and
gave detaile d clinical descriptions of the specific disorders included in
each category.
 He relied heavily on clinical observation, and his descriptions, which
were based on daily clinical records of his patients, were surprisingly
thorough.
 However, Hippocrates had little knowledge of physiology. He believed
that hysteria (the appearance of physical illness in the absence of
organic pathology) was restricted to women and was caused by the
uterus wandering to various parts of the body, pining for children. For
this “d isease,” Hippocrates recommended marriage as the best remedy
Early Philosophical Conceptions of Consciousness
Plato: -
 The Greek philosopher Plato (429 –347 b.c.) studied mentally disturbed
individuals who had committed criminal acts and how to deal with
them.
 He wrote that such persons were, in some “obvious” sense, not
responsible for their acts and should not receive punishment in the same
way as normal persons. He also made provision for mental cases to be
cared for in the community (Plato, n.d.).
 Plato viewed psychological phenomena as responses of the whole
organism, reflecting its internal state and natural appetites. Plato
emphasized the importance of individual differences in intellectual and
other abilities and took into account sociocultural influ ences in shaping
thinking and behavior.
 His ideas regarding treatment included a provision for “hospital” care
for individuals who developed beliefs that ran counter to those of the
broader social order. There they would be engaged periodically in
convers ations comparable to psychotherapy to promote the health of
their souls (Milns, 1986). Despite these modern ideas, however, Plato
shared the belief that mental disorders were in part divinely caused.
Aristotle
 The celebrated Greek philosopher Aristotle (3 84–322 B. C.), who was
a pupil of Plato, wrote extensively on mental disorders. Among his
most lasting contributions to psychology are his descriptions of
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17  He held the view that “thinking” as directed would eliminate pain and
help to attain pleasure.
 On the question of whether mental disorders could be caused by
psychological factors such as frustration and conflict, Aristotle
discussed the possibility and rejected it; his lead on this issue was
widely followed.
 Aristotle generally subscrib ed to the Hippocratic theory of
disturbances in the bile. For example, he thought that very hot bile
generated amorous desires, verbal fluency, and suicidal impulses.
Later Greek and Roman Thought
 Hippocrates’ work was continued by some of the later Gree k and
Roman physicians.
 One of the most influential Greek physicians was Galen (a.d. 130 –
200), who practiced in Rome. He made a number of original
contributions concerning the anatomy of the nervous system. (These
findings were based on dissections of ani mals; human autopsies were
still not allowed.)
 Galen also took a scientific approach to the field, dividing the causes
of psychological disorders into physical and mental categories. Among
the causes he named were injuries to the head, excessive use of
alcohol, shock, fear, adolescence, menstrual changes, economic
reversals, and disappointment in love.
 Roman medicine reflected the characteristic pragmatism of the Roman
people. Roman physicians wanted to make their patients comfortable
and thus used pleasa nt physical therapies such as warm baths and
massage.
 However, they also followed the principle of contrariis contrarius
(“opposite by opposite” ) —for example, having their patients drink
chilled wine while they were in a warm tub.
Early Views of Mental D isorders in China
 China was one of the earliest developed civilizations in which medicine
and attention to mental disorders were introduced (Soong, 2006).
 However, at this early date, Chinese medicine was based on a belief in
natural rather than supernatu ral causes for illnesses. For example,
according to them, the human body, like the cosmos, is divided into
positive and negative forces that both complement and contradict each
other. If the two forces are balanced, the result is physical and mental
health ; if they are not, illness results. Thus, treatments focused on
restoring balance.

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18  Chinese medicine reached a relatively sophisticated level during the
second century, and Chung Ching, who has been called the Hippocrates
of China, wrote two well -known m edical works around a.d. 200. Like
Hippocrates, he based his views of physical and mental disorders on
clinical observations, and he implicated organ pathologies as primary
causes. However, he also believed that stressful psychological
conditions could cau se organ pathologies, and his treatments, like those
of Hippocrates, utilized both drugs and the regaining of emotional
balance through appropriate activities.
Views of Abnormality During the Middle Ages
 During the Middle Ages (about a.d. 500 to a.d. 150 0), the more
scientific aspects of Greek medicine survived in the Islamic countries
of the Middle East.
 The first mental hospital was established in Baghdad in A.D. 792. It
was soon followed by others in Damascus and Aleppo (Polvan, 1969).
In these hospit als, mentally disturbed individuals received humane
treatment.
Humanitarian Approaches
 During the latter part of the Middle Ages and the early Renaissance,
the superstitious beliefs that had hindered the understanding and
therapeutic treatment of mental di sorders began to be challenged.
Scientific questioning reemerged and a movement emphasizing the
importance of specifically human interests and concerns began —a
movement (still with us today) that can be referred to as humanitarian
approach.
 Paracelsus (14 90–1541), a Swiss physician, was an early critic of
superstitious beliefs about possession. He insisted that the dancing
mania was not a possession but a form of disease, and that it should be
treated as such. Although Paracelsus rejected demonology, his v iew of
abnormal behavior was colored by his belief in astral influences
(lunatic is derived from the Latin word luna, or “moon”). He was
convinced that the moon exerted a supernatural influence over the
brain —an idea, incidentally, that persists among some people today.
 Johann Weyer (1515 –1588), a German physician and writer was so
deeply disturbed by the imprisonment, torture, and burning of people
accused of witchcraft that he made a careful study of the entire
problem.
 About 1583 he published a book, O n the Deceits of the Demons, that
contains a step -by-step negation of the Malleus Maleficarum, a witch -
hunting handbook published in 1486 for use in recognizing and
dealing with those suspected of being witches. In his book, Weyer
argued that a considerabl e number, if not all, of those imprisoned,
tortured, and burned for witchcraft were really sick in mind or body
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19 innocent people. Weyer’s work enjoyed the approval of a few
outstanding physic ians and theologians of his time.
 Weyer was one of the first physicians to specialize in mental disorders,
and the founder of modern psychopathology. Unfortunately, however,
he was too far ahead of his time. He was scorned by his peers and his
works were banned by the Church and remained so until the twentieth
century.
 From the sixteenth century on, special institutions called asylums —
sanctuaries or places of refuge meant solely for the care of the
mentally ill —grew in number. The early asylums were begun as a way
of removing from society troublesome individuals who could not care
for themselves. Although most early asylums, often referred to as
“madhouses,” were not pleasant places or “hospitals” but primarily
residences or storage places for the insane. The unfortunate residents
lived and died amid conditions of incredible filth and cruelty.
 Later because of the efforts of some prominent professionals, the
situation started changing. In the United States, the Pennsylvania
Hospital in Philadelphia, comple ted under the guidance of Benjamin
Franklin in 1756, provided some cells or wards for mental patients.
The Public Hospital in Williamsburg, Virginia, constructed in 1773,
was the first hospital in the United States devoted exclusively to
mental patients. H owever, there too, the treatment techniques were
aggressive, aimed at restoring a “physical balance in the body and
brain.” They included powerful drugs, water treatments, bleeding and
blistering, electric shocks, and physical restraints. For example, a
violent patient might be plunged into ice water or a listless patient into
hot water.
 By the late eighteenth century, most mental hospitals in Europe and
America needed reform. The humanitarian treatment of patients
received great impetus from the work of Ph ilippe Pinel (1745 –1826) in
France. In this capacity, he received the grudging permission of the
Revolutionary Commune to remove the chains from some of the
inmates as an experiment to test his views that mental patients should
be treated with kindness and consideration —as sick people, not as
vicious beasts or criminals. Had his experiment proved a failure, Pinel
might have lost his head, but fortunately it was a great success. Chains
were removed; sunny rooms were provided; patients were permitted to
exerc ise on the hospital grounds; and kindness was extended to these
poor beings. The effect was almost miraculous. The previous noise,
filth, and abuse were replaced by order and peace.
 At about the same time that of Pinel, an English Quaker named
William Tuke (1732 –1822) established the York Retreat, a pleasant
country house where mental patients lived, worked, and rested in a
kindly, religious atmosphere (Narby, 1982). The Quakers believed in
treating all people, even the insane, with kindness and acceptance.
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20  Benjamin Rush (1745 –1813), the founder of American psychiatry and
also one of the signers of the Declaration of Independence was
associated with the Pennsylvania Hospital in 1783, Rush encouraged
more humane treatment of the mentally ill; wrote the firs t systematic
treatise on psychiatry in America, Medical Inquiries and Observations
upon Diseases of the Mind (1812); and was the first American to
organize a course in psychiatry (see Gentile & Miller, 2009).
 But even his principal remedies were bloodlett ing and purgatives. In
addition, he invented and used a device called “the tranquilizing
chair,” intended to reduce blood flow to the brain by binding the
patient’s head and limbs.
 Despite these limitations, we can consider Rush an important
transitional f igure between the old era and the new.
 During the early part of this period of humanitarian reform, the use of
moral management —a wide -ranging method of treatment that
focused on a patient’s social, individual, and occupational needs —
became relatively wide spread. This approach, which stemmed largely
from the work of Pinel and Tuke, began in Europe during the late
eighteenth century and in America during the early nineteenth
century.
 Despite its reported effectiveness in many cases, moral management
was nea rly abandoned by the latter part of the nineteenth century. The
reasons were many and varied. Among the more obvious ones were
overcrowding, lack of sufficient staff and limited hospital facilities.
Two other reasons are, in retrospect, truly ironic. One w as the rise of
the mental hygiene movement , which advocated a method of
treatment that focused almost exclusively on the physical well -being
of hospitalized mental patients. Although the patients’ comfort levels
improved under the mental hygienists, the pa tients received no help for
their mental problems and thus were subtly condemned to helplessness
and dependency. Secondly, advances in biomedical science also
contributed to the demise of moral management and the rise of the
mental hygiene movement.
 Benja min Franklin’s work with electricity was among the earliest
efforts to explore electric shock to treat mental illness, an insight he
gained accidentally. His proposals for using electricity to treat
melancholia (depression) grew out of his observations tha t a severe
shock he had experienced altered his memories.
 Dorothea Dix (1802 –1887) became an important driving force in
humane treatment for psychiatric patients. In 1841, she began to teach
in a women’s prison. Through this contact she became acquainted with
the deplorable conditions in jails, almshouses, and asylums. As a result
of what she had seen, Dix carried on a zealous campaign between
1841 and 1881 that aroused people and legislatures to do something
about the inhuman treatment accorded the mental ly ill. Through her
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21  Millions of dollars were raised to build suitable hospitals, and 20 states
responded directly to her appeals. She also directed the opening of two
large institutions in Canada and c ompletely reformed the asylum
system in Scotland and several other countries. She is credited with
establishing 32 mental hospitals.
 Later critics have claimed that establishing hospitals for the mentally
ill and increasing the number of people in them spa wned overcrowded
facilities and custodial care (Bockhoven, 1972; Dain, 1964). However,
her advocacy of the humane treatment of the mentally ill stood in stark
contrast to the cruel treatment common at the time.
Nineteenth -Century Views of the Causes and Tr eatment of Mental
Disorders
 In the early part of the nineteenth century, mental hospitals were
controlled essentially by laypersons because of the prominence of
moral management in the treatment.
 Effective treatments for mental disorders were unavailable, the only
measures being such procedures as drugging, bleeding, and purging,
which produced few objective results.
 However, during the latter part of the century, professionals gained
control of the insane asylums and incorporated the traditional moral
management therapy into their other rudimentary physical medical
procedures.
Changing Attitudes Toward Mental Health in the Early Twentieth
Century
 By the end of the nineteenth century, mental patients admitted to
mental hospital or asylum lived under relat ively harsh conditions
despite of moral management. Little was done by the resident
psychiatrists to educate the public or reduce the general fear and horror
of insanity. A principal reason for this silence, of course, was that
early psychiatrists had litt le actual information to impart and in some
cases employed procedures that were damaging to patients.
 Gradually, however, important strides were made toward changing the
general public’s attitude toward mental patients.
 The twentieth century began with a continued period of growth in
asylums for the mentally ill; however, the fate of mental patients
during that century was neither uniform nor entirely positive. The
movement to change the mental hospital environment was also
enhanced significantly by scien tific advances in the last half of the
twentieth century, particularly the development of effective
medications for many disorders —for example, the use of lithium in the
treatment of manic depressive disorders (Cade, 1949) and the
introduction of phenothia zines for the treatment of schizophrenia.
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22  During the latter decades of the twentieth century, our society had
seemingly reversed its position with respect to the means of providing
humane care for the mentally ill in the hospital environment. Vigorous
efforts were made to close down mental hospitals and return
psychiatrically disturbed people to the community. This movement,
referred to as deinstitutionalization , although motivated by
benevolent goals, has also created great difficulties for many
psychol ogically disturbed persons and for many communities as well.
 The original impetus behind the deinstitutionalization policy was that
it was considered more humane and cost effective. There was great
hope that new medications would promote a healthy readjust ment and
enable former patients to live more productive lives outside the
hospital.
 However, deinstitutionalization movement failed. The problems
caused by deinstitutionalization appear to be due, in no small part, to
the failure of society to develop way s to fill the gaps in mental health
services in the community (Grob, 1994).
 By the end of the twentieth century, inpatient mental hospitals had
been substantially replaced by community -based care, day treatment
hospitals, and outreach.
1.5.1 The Emergenc e of Contemporary Views of Abnormal Behavior
While the mental hygiene movement was gaining ground in the United
States during the latter years of the nineteenth century, great technological
discoveries occurred which led to the scientific, or experimentall y
oriented, view of abnormal behavior and the application of scientific
knowledge to the treatment of disturbed individuals. The four major
themes in abnormal psychology that spanned the nineteenth and twentieth
centuries and generated powerful influences on our contemporary
perspectives in abnormal behavior are (1) biological discoveries, (2) the
development of a classification system for mental disorders, (3) the
emergence of psychological causation views, and (4) experimental
psychological research devel opments.
1. Biological Discoveries:
Advances in the study of biological and anatomical factors as underlying
both physical and mental disorders developed in this period. A major
biomedical breakthrough, for example, came with the discovery of the
organic factors underlying general paresis —syphilis of the brain. One of
the most serious mental illnesses of the day, general paresis produced
paralysis and insanity and typically caused death within 2 to 5 years as a
result of brain deterioration. The discovery of a cure for general paresis
began in 1825, when the French physician A. L. J. Bayle differentiated
general paresis as a specific type of mental disorder.
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23 The field of abnormal psychology had come a long way —from
superstitious beliefs to scientific proo f of how brain pathology can cause a
specific disorder. This breakthrough raised great hopes in the medical
community that organic bases would be found for many other mental
disorders —perhaps for all of them.
With the emergence of modern experimental scie nce in the early part of
the eighteenth century, knowledge of anatomy, physiology, neurology,
chemistry, and general medicine increased rapidly. Scientists began to
focus on diseased body organs as the cause of physical ailments. It was the
next logical st ep for these researchers to assume that mental disorder was
an illness based on the pathology of an organ —in this case, the brain.
The first systematic presentation of this viewpoint, however, was made by
the German psychiatrist Wilhelm Griesinger (1817 –1868). In his textbook
The Pathology and Therapy of Psychic Disorders, published in 1845,
Griesinger insisted that all mental disorders could be explained in terms of
brain pathology.
In the 1920s through the 1940s, an American psychiatrist, Walter
Freeman , followed the strategies developed by Italian psychiatrist Egas
Moniz to treat severe mental disorders using surgical procedures called
lobotomies. These surgical efforts to treat mental disorder were considered
to be ineffective and inappropriate by many in the profession at the time
and were eventually discredited, although lobotomy is still used in some
rare cases.
2. Development of a Classification System
The most important contributions of Emil Kraepelin was his system of
classification of mental d isorders, which became the forerunner of today’s
DSM classification. Kraepelin noted that certain symptom patterns
occurred together regularly enough to be regarded as specific types of
mental disease. He then proceeded to describe and clarify these types of
mental disorders, working out a scheme of classification that is the basis
of our present system. Kraepelin saw each type of mental disorder as
distinct from the others and thought that the course of each was as
predetermined and predictable.
3. Develop ment of the Psychological Basis of Mental Disorder
Despite the emphasis on biological research, understanding of the
psychological factors in mental disorders was progressing as well. The
first major steps were taken by Sigmund Freud (1856 –1939), the most
frequently cited psychological theorist of the twentieth century (Street,
1994). During five decades of observation, treatment, and writing, Freud
developed a comprehensive theory of psychopathology that emphasized
the inner dynamics of unconscious motive s (often referred to as
psychodynamics) that are at the heart of the psychoanalytic perspective.
The methods he used to study and treat patients came to be called
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24 The Evolution of the Psychological Research Tradition: Experimental
Psycholo gy
The origins of much of the scientific thinking in contemporary psychology
lie in early rigorous efforts to study psychological processes objectively,
as demonstrated by Wilhelm Wundt (1832 –1920) and William James
(1842 –1910).
 The Early Psychology Labo ratories
In 1879, Wilhelm Wundt established the first experimental psychology
laboratory at the University of Leipzig. While studying the psychological
factors involved in memory and sensation, Wundt and his colleagues
devised many basic experimental meth ods and strategies. Wundt directly
influenced early contributors to the empirical study of abnormal behavior;
they followed his experimental methodology and applied some of his
research strategies to study clinical problems.
By the first decade of the twe ntieth century, psychological laboratories
and clinics were burgeoning, and a great deal of research was being
generated (Goodwin, 2011). This period saw the origin of many scientific
journals for the propagation of research and theoretical discoveries, an d as
the years have passed, the number of journals has grown. The American
Psychological Association now publishes 54 scientific journals, many of
which focus on research into abnormal behavior and personality
functioning
 The Behavioral Perspective
Althou gh psychoanalysis dominated the field of abnormal psychology at
the end of the nineteenth century and in the early twentieth century,
another school —behaviorism —emerged out of experimental psychology
to challenge its supremacy.
Behavioral psychologists b elieved that only the study of directly
observable behavior —and the stimuli and reinforcing conditions that
“control” it —could serve as a basis for formulating scientific principles of
human behavior. The behavioral perspective is organized around a centra l
theme: the role of learning in human behavior.
Although this perspective was initially developed through research in the
laboratory rather than through clinical practice with disturbed individuals,
its implications for explaining and treating maladaptiv e behavior soon
became evident.
Classical Conditioning :
 A form of learning in which a neutral stimulus is paired repeatedly
with an unconditioned stimulus that naturally elicits an unconditioned
behavior. After repeated pairings, the neutral stimulus bec omes a
conditioned stimulus that elicits a conditioned response.
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25  This work began with the discovery of the conditioned reflex by
Russian physiologist Ivan Pavlov (1849 –1936). Around the twentieth
century, Pavlov demonstrated that dogs would gradually beg in to
salivate in response to a nonfood stimulus such as a bell after the
stimulus had been regularly accompanied by food.
 Pavlov’s discoveries in classical conditioning excited a young
American psychologist, John B. Watson (1878 –1958), who was
searching for objective ways to study human behavior. Watson thus
changed the focus of psychology to the study of overt behavior rather
than the study of theoretical mentalistic constructs, an approach he
called behaviorism.
Operant Conditioning
 E. L. Thorndike (18 74–1949) and subsequently B. F. Skinner (1904 –
1990) were exploring a different kind of conditioning, one in which
the consequences of behavior influence behavior.
 Behavior that operates on the environment may be instrumental in
producing certain outcomes, and those outcomes, in turn, determine
the likelihood that the behavior will be repeated on similar occasions.
 For example, Thorndike studied how cats could learn a particular
response, such as pulling a chain, if that response was followed by
food reinf orcement. This type of learning came to be called
instrumental conditioning and was later renamed operant
conditioning by Skinner. Both terms are still used today.
1.6 SUMMARY
In this unit we had defined abnormality and discussed the four important
ways in which abnormality can be defined. Changes involved in
characterizing abnormal behaviour were also discussed. Following this we
had discussed the various causes of abnormality. The concept of
Diagnostic and Statistical Manual of Mental Disorders was als o discussed
along with various controversial issues pertaining to the DSM.
1.7 QUESTIONS
1. Discuss the various ways in which abnormality can be defined.
2. Discuss the Diagnostic and Statistical Manual of Mental Disorders.
3. Write short notes on –
a. Definition of Mental Disorder
b. Assumptions of DSM -IV-TR
c. Five Axis of DSM
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26 1. Write a note on the Classification of abnormal behavior
2. Write a detail note on Humanitarian Approaches
3. Write a detail note on the Emergence of Contemporary views of
Abnormal Behavior
1.7 REFERENCE S
Butcher, J.N; Hooley, J.M; Mineka, S; & Dwivedi, C.B. (2020). Abnormal
Psychology . (16th ed.). Pearson
Barlow David H and Durand M.V. Abnormal Psychology, (2005), New
Delhi.Halgin R.P. and Whitbourne S.K. (2010) Abnormal Psychology,
Clinical Perspectives on Psychological Disorders, (6th Ed.), McGraw Hill.

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27 2
UNDERSTANDING ABNORMAL
BEHAVIOR : CLINICAL ASSESSMENT
AND DIAGNOSIS II
Unit Structure
2.0 Objectives
2.1.1 Psychological Assessment
2.1.2 Physiological Assessment
2.3 Summary
2.4 Questions
2.5 References
2.0 OBJECTIVES
After reading this unit you wil l be able to:
 Explain how Psychological Assessment is carried out with the help of
Clinical interviews and Mental Status Examination.
 Understand Behavioural, Multicultural, Environmental and
Physiological assessment.
2.1 THE BASIC ELEMENTS IN ASSESSMENT
2.1.1 Psychosocial Assessment
Psychological assessment refers to gathering and integration of
psychological data for the purpose of a psychological evaluation through
the use of tests, interview, observation, etc. This kind of an assessment is
carried out i n order to arrive at a diagnosis for an individual with a mental
disorder, to determine the individual’s intellectual capacity, to predict
how suitable a person is for a job and to assess if a person is competent to
stand trial.
There are various techniq ues used in assessment. For e.g. clinical
interview, mental status examination, behavioral assessment, multicultural
assessment, neuropsychological assessment etc. Out of these many we will
be discussing the following two - the clinical interview and the m ental
status examination.

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28 1. Clinical Interview
This is the most common method used to assess the client, his presenting
problem, and history and future goals. The interview involves asking
questions in a face -to-face interaction. The clinician may audio tape or
videotape the details or note them down during or after the interview with
the due consent from the client. There are two kinds of clinical interviews:
Unstructured Interview :
 In this type of an interview, the client is asked open -ended questions
related to his or her presenting problem, the family background and life
history.
 The term ‘unstructured’ is used to indicate that the interviewer is free
to ask questions in any order and frames them in a manner that he
prefers. The client’s response to th e previous question and nonverbal
cues such eye -contact, posture, tone of voice, etc., guide the
interviewer in this process.
 The interviewer’s approach is influenced by the purpose of the
interview. A clinician who wants to arrive at a diagnosis would ask
questions related to the client’s symptoms, such as changes in mood,
sleep pattern, disturbance in appetite, nature of thoughts, etc., their
onset, duration and progress, medical or psychiatric history if any, etc.
 Some clients seek help for personal issu es such as disturbed
relationships and may not have a diagnosable psychological disorder.
In such cases the interviewer would try to enquire about the reasons
for the client’s distress.
 A significant part of an unstructured interview is history taking, whi ch
involves asking questions related to personal history such as major life
events since childhood, academic interest and performance, number of
friends and leisure activities, work life, marriage, habits, etc., and
family history such as numbers of family members, close relatives and
relationships with them, atmosphere at home, history of illnesses in the
family, etc.
 This gives the clinician a picture of the client’s world and may also
help draw connections between the client’s current problem and a
traum atic event in early life.
Structured and Semistructured Interviews :
 The structured interview gives less freedom to the clinician as it
involves asking a set of predetermined questions in a fixed order. The
semistructured interview also has a standardised s et of questions but
the interviewer can ask follow up questions to clarify the client’s
responses, if needed.
 The advantage of structured and semistructured interviews is that they
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29 wide ra nge of psychological disorders while others are meant to
diagnose specific conditions such as a Schizophrenia or Mood or
Anxiety disorder. Secondly, one gets lots of information of the client
in short period of the time. Thirdly, can be very well used by t he
practitioner who is new in the field and serve helpful to come down to
appropriate diagnosis.
 The Anxiety Disorders Interview Schedule for DSM -IV (ADIS -IV) is
a commonly used structured interview while the Structured Clinical
Interview for DSM -IV-TR Axi s I disorders (SCID -I) and the
Structured Clinical Interview for DSM -IV Personality disorders
(SCID -II) are examples of semistructured interviews (despite the word
structured).
 The World Health Organisation (WHO) and the U.S. Alcohol, Drug
and Mental Heal th Administration (ADAMHA) have developed the
Composite International Diagnostic Interview (CIDI), which is an
assessment tool that has been translated in many languages and can be
used with people from different cultures.
2. Mental Status Examination
The mental status means what and how the client thinks, speaks and
behaves. The mental status examination or the MSE is used to assess the
client’s thoughts, feelings and behaviour and identify symptoms. The
MSE report is based on the client’s responses and th e clinician’s objective
observations of the client’s appearance, speech and behaviour. One of the
examples of a structured MSE is the mini -mental status examination
(MMSE) which is very useful in assessing patients with cognitive
disorders such as dementia . Following are the components of the MSE:
1) Appearance and Behaviour: The clinician carefully looks for any
peculiarities in the client’s appearance and overall behaviour as this can
give an insight into her/her mental state. Anxious patients tend to fid get or
pace around while some others tend to move about in a sluggish manner.
Clinicians asses client’s motor behaviour, that is, the movements. Eg.
hyperactivity which refers to increased physical activity and quick
movements or psychomotor agitation whic h is characterized by agitation
and excessive motor and cognitive activity. Some patients show
psychomotor retardation , that is, visible slowing of thoughts, speech and
movements. Strange mannerisms, stereotyped movements and vocal or
motor tics (involunta ry muscular movements) are seen in some others.
In extreme cases, motor abnormalities may manifest as catatonia which is
seen in psychotic patients. Some of these patients constantly maintain an
immobile position (catalepsy) or assume bizarre postures or c an be
moulded into a position that is then maintained (waxy flexibility).
Some may experience Compulsion which is a form of motor disturbance
in which there is an uncontrollable impulse to perform an act repeatedly.
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30 answering every question, chanting a particular mantra every few minutes,
etc.
2) Orientation: This refers to one’s awareness of time, place and person.
In some disorders, the patient’s sense of themselves and the surrounding is
disturbed. Assessing orientation is very important in diagnosing cognitive
disorders such as Delirium, Dementia, Amnesia and also psychotic
disorders like Schizophrenia.
3) Content of Thought: Disturbances in the thought process occurs in
various forms. Som e patients may have an obsession , which means an
intrusive, repetitive, thought, image or impulse which causes distress. For
example, thoughts of being unclean or contaminated, that is often
accompanied by the compulsion of washing hands.
Another form of disturbance in thought content is delusions . These are
unshakable, false beliefs which cannot be corrected through logical
reasoning. For example, a man may believe that he is a messenger of God
who has been sent on Earth for a special mission. Delusions can be of
different types:
 Grandeur : A person’s exaggerated conception of one’s importance,
power, beauty or identity. Above is the example of Grandeur type of
delusion.
 Control : False thinking that a person’s will, thoughts or feelings are
being controlle d by external forces. One form of this delusion is
thought broadcasting in which the person believes that his/her
thoughts can be heard by others as if they were being broadcast over
the air. Likewise, thought insertion is a delusional belief that others
are implanting thoughts in a person’s mind.
 Reference : False belief that other’s actions refer to oneself or that
others are talking about him/her. E.g. when someone watches a web
series and believes that the conversation between the two protagonist
is me ant specifically for them.
 Persecution : False belief that the person him/herself or a loved one is
being harassed, cheated or mistreated by someone. E.g, My colleague
break into my cabin at night and steal my important files.
 Self-blame : False feeling of r egret or guilt in which the person holds
him/her responsible for some wrongdoing. E.g., a person might think
that he/she is responsible for the covid pandemic.
 Somatic : False belief involving body functions such the belief that the
brain is rotting or mel ting.
 Infidelity : False belief associated with pathological jealousy about a
person’s lover being unfaithful.
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31 There are overvalued ideas which refer to unusual thoughts of a bizarre
nature but they are not as rigid as delusions. For example, a man who
believes that his credit card number should end with the digit 6 and refuses
to accept a new credit card with a different last number. Magical thinking
involves seeing a connection between two events which would seem
unrelated to most people. For example, a woman may believe that every
time she buys things from a particular shop her husband loses a contract.
Overvalued ideas and magical thinking do not indicate that the person has
a mental disorder but suggests some psychological decline. Violent
thoughts suc h suicidal ideas or thoughts of harming or killing another
person also need to be assessed.
4) Thinking Style and Language: An individual’s style of thinking is
manifested through his or her speech. For example, speaking to person
with Schizophrenia or oth er forms of psychosis can be difficult because
their language may be illogical. Examples of thought disorder:
 Incoherence : The speech is not clear and understandable. For
example, “the ice -cream threw the poodle that is not here.”
 Loosening of associations : Ideas expressed are unrelated. For
example, “Suma is nice person but there is lot of poverty in the world
and I am going to cut my hair tomorrow.”
 Illogical thinking : Thoughts that has wrong conclusions. For example,
a person who likes milk thinks she mu st be a cat.
 Neologisms : New words created, often by combining syllables of
other words. For example, “I saw some “snarks” today that were
“boredomly bad.”
 Blocking : Sudden interruption in the train of thought before the idea is
finished.
 Circumstantiality : Indirect speech that is delayed in reaching the
point by bringing in lot of irrelevant details.
 Tangentiality : Going off on a different point without coming to the
original idea.
 Clanging : Association of words similar in sound but not in meaning.
For exa mple, “That is Ross, there is so much moss, the coin will toss.”
 Confabulatio n: Making up ideas to fill in gaps in memory. This is not
an attempt to lie but to give the most possible answer. For example,
when one is not very sure if he has had breakfast an d is asked what he
had eaten, he may give an elaborate account of a typical breakfast.
 Echolalia : Pathological repeating of words or phrases of one person
by another.
 Flight of ideas : Rapid, continuous shifting from one idea to another in
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32  Pressure of speech : Rapid speech as if the person feels forced to
speak continuously.
 Perseveration : Continuing with a response to a previous question or
stimulus after a new question or stimulus is presented.
5) Affect and Mood : Emotion i s a complex feeling state with somatic,
cognitive and behavioural components. Affect refers to an observed
expression of emotion. While assessing the affect, the clinician checks if it
is appropriate (condition in which emotional tone is in harmony with th e
accompanying idea) or inappropriate (disharmony between the feeling
tone and the thought or idea accompanying it).
The intensity of affect, that is, its strength is also noted. The affect is
described as blunted affect when there is a severe reduction in the
intensity of externalized feeling tone and as flat affect when signs of
affective expression are absent or nearly absent, the face is immobile and
voice is monotonous. On the other hand, exaggerated or heightened or
overdramatic affect is reported whe n the emotional expression is very
strong. The range of affect in terms of the variety of emotional expressions
noted is also taken into account.
Mood is a pervasive and sustained state of emotion that one feels inside.
Mood may be described as dysphoric (unpleasant feelings such as sadness
or irritability), euphoric (very cheerful with feelings of grandeur),
euthymic (normal range of mood; absence of depressed or elevated
mood), angry, anxious, etc.
6) Perceptual Experiences: Some psychological disorders a re
characterized by disturbances in perception. The clinician enquires about
these by asking whether the patient hears voices or sees things that others
are unaware of. Hallucinations are false sensory perceptions in the absence
of real external stimuli. T hese are different from illusions in which there is
distortion of a real stimulus such misperceiving a rope as a snake.
Hallucinations can involve any of the five senses:
 Auditory hallucinations are the most common and involve hearing
sounds or voices (usu ally insulting comments such as “you are dumb”)
or conversations. Command hallucinations are those in which one
hears instruction to act in a certain way.
 Visual hallucinations involve seeing images of objects or persons. For
example, a person may claim t o see God or one’s spouse who has
passed away.
 Olfactory hallucinations are uncommon and refer to false perception
of smells such as unpleasant odours.
 Gustatory hallucinations are false perceptions of taste usually
unpleasant in nature.
 Somatic hallucinat ions involve false sensations pertaining to the body,
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33 7) Sense of Self: Some psychological disorders affect the person’s identity
or the sense of ‘who am I.’ Depersonalisation is a phenomenon in which
the person feels he is unreal, strange or unfamiliar with himself. For
example, one may feel that his mind and body are not connected. One may
also experience identity confusion which involve a lack of clear sense of
who one is, what one’s role i s, etc.
8) Motivation: In some psychological disorders, the patients lose interest
in all activities to the extent that even ordinary tasks such as having a bath
or dressing may seem difficult. Some may not be willing to put in any
effort to change and mi ght find their familiar state of distress better than
the uncertainty of facing new challenges.
9) Cognitive Functioning: During the MSE, the clinician attempts to
judge the client’s general intellectual capacity from the answers given by
the client, on qu estions related to attention and concentration, memory,
ability to think in an abstract manner, etc. For instance, in case a client’s
memory is severely impaired, the clinician might suspect a neurological
condition such Alzheimer’s disease. Here, the clin ician doesn’t administer
an IQ test but rather gets a general idea about the client’s cognitive
abilities.
10) Insight and Judgement: The clinician is also interested in seeing
whether the client understands one’s own difficulties. Insight refers to a
person’s ability to understand the true cause and meaning of a situation.
For example, a person who has paranoid delusions may be very defensive
and unable to see things objectively, showing poor insight.
Judgment is the ability to assess a situation correctly and to act
appropriately in the situation. Clients who are severely impaired may not
be in a position to make correct decisions and this may result in harm to
self or others. Thus, checking the client’s judgment gives the clinician an
idea of protective m easures that may have to be initiated.
3. Behavioural Assessment
Behavioural assessment involves systematic recording of an individual’s
behaviour in order to identify problem behaviours, the factors that help
maintain these behaviours and decide techniqu es to modify the
undesirable behaviours. Clinicians use various methods such as behavioral
interviews, observational methods - naturalistic observation/ controlled
observation, self -monitoring, role -playing, inventories, checklists, etc., of
which behaviou ral self - report and observation are most common.
Behavioural Self -Report :
 This is a method in which the client provides information about how
frequently certain behaviours occur, either through an interview or by
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34  The advantage of self -report is that it helps obtain critical information
about the client’s behaviours which others would not have access to.
 Behavioural interviews involve a detailed enquiry into what happens
before, during and after the behaviour in question. In understanding the
‘before’ factors, the clinician may ask questions such as when and
where does the behaviour occur, does the behaviour occur in presence
of any particular person or stimulus, etc.
 Particulars of the ‘during’ phase may be found out with the help of
questions such as how many times and for how long does the problem
behaviour occur, what happens first, what follows that, etc.
 The client is also asked about the consequence of the behav iour in
terms of what effect does it have or how does it benefit him or her. For
example, in case of a client who wants to give up smoking, the clinician
may be interested in knowing how frequently the person smokes in a
day, any specific time and place at which he smokes, does he smoke in
the company of certain people, what triggers the smoking behaviour,
what the client thinks and feels after smoking, etc.
 Thus, the extensive information obtained helps set realistic goals and
devise strategies to change t he undesirable behaviour.
 Another behavioural self -report technique is self -monitoring, which
involves keeping a record of the frequency of the problem behaviour
such as, number of cigarettes or calories consumed, number of times
the client bit her nails o r had unwanted thoughts or got angry.
 The client is trained to note the time, place and relevant information
pertaining to the target behaviour. Self -monitoring is a very useful
technique because it may lead to important insights, for example, a
woman may realise that she tends to eat more while watching the
television or when she is distracted.
 Behavioural checklists or inventories help to find whether certain
events or experiences have occurred. For example, the Conners Ratings
Scales -Revised uses self and observer ratings to assess attention deficit
hyperactivity disorder and determine the number and nature of
undesirable behaviours present. Checklists and inventories are quite
commonly used in the clinical set up because they are easy to use and
econom ical.
Behavioural Observation :
 In this method, the clinician observes and records the frequency of the
behaviour in question, including any other relevant situational
variables. For example, a nurse may be asked to observe the number of
times a patient was hes her hands and also her reactions when she is
prevented from doing that. Or a trained observer may record the
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35  In observing the clients, the clinician first selects the problem behavior
or the target behavior on the basis of an interview, direct observation
or using behavioural checklists or inventories. The problem behaviour
is then broken down into behavioural terms, that is, it is defined. For
example, temper tantrum would be defined in te rms of crying and
shouting.
 Selecting vague target behaviours is inappropriate in behavioural
observation because it makes measurement difficult. For example,
violent behaviour cannot be measured unless specified as breaking
things around or whichever is t he behaviour exhibited.
 It is best to observe the target behaviour in the natural setting and this
kind of behavioural observation is known as in vivo observation. In
assessing a child with attention deficit hyperactivity disorder, a
clinician is likely to get an accurate picture of the child’s problem
behaviours if he is observed in the classroom or at home rather than in
the lab or clinic.
 While using this method the clinician has to be careful about the
client’s reactivity - the knowledge of being observ ed can influence the
target behaviours. In order to avoid these problems, the client may be
observed through a one -way mirror. In some situations, others may be
included and the client’s interaction with them may be observed with
focus on the target behavi ours.
4. Multicultural Assessment
In the process of assessment, the clinician needs to be sensitive to the
cultural, racial and ethnic background of the client. There is a growing
emphasis on developing culture fair tests and being careful while
administe ring and interpreting psychological tests as the background from
which the client comes can seriously influence the test performance. For
example, while assessing a client whose mother -tongue is not English, the
clinician needs to ensure that the instructi ons are followed and that the
client’s scores are interpreted on the basis of norms developed for that
specific group. Also, certain phrases or behaviours may have multiple
meanings and are likely to be misunderstood by the clients. Thus, the
clinicians ar e required to have to sufficient knowledge of the client’s
cultural background and critically evaluate the tests to see if they are
designed for use with the specific group to which the client belongs.
5. Environmental Assessment
As seen earlier, the envi ronment that surrounds a person has a tremendous
impact on his/her life. Psychologist Rudolf Moos has developed
Environmental assessment scales in which individuals provide ratings on
aspects of the environment that are thought to influence behaviour. This
includes the various circles of social influence in one’s life such as the
family, the neighbourhood, the school and the society at large. For
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36 members. Nature of relations, such as cohesiveness and identification with
family members, expression of emotions, etc; the activities that the family
engages such as what do the members do for recreation or how are
respons ibilities shared, attitudes / beliefs of the family members, etc.
Another example is the Global Family Environment Scale, a cross -cultural
tool that measures factors such as the extent to which the family provides
good physical and emotional care, secure a ttachments, consistency and
discipline.
These scales can be used to assess the home environment of
children/adolescents with behavioural disorders, excessive anxiety, etc.,
and thus help clinicians get insight into the family dynamics of the client
and und erstand its impact on the client’s condition.
6. Neuropsychological Assessment
 Neuropsychological assessment involves assessing brain functioning
from how an individual performs on certain psychological tests.
 Two best known test batteries that are used fo r neuropsychological
evaluation are the Halstead -Reitan Battery and the Luria -Nebraska
Neuropsychological Battery.
 The Halstead -Reitan is used to differentiate between the brain
damaged individuals and the neurologically intact and comprises of
subtests such as category test, tactual performance test, rhythm test,
speech -sounds perception test, time sense test, aphasia screening test,
finger -oscillation test, etc. This may often be combined with the
MMPI -2 to get a measure of the individual’s personality and the
WAIS -III to assess cognitive functioning.
 The Luria -Nebraska test assesses a wide range of cognitive functions
such as memory; motor functions; rhythm; tactile, auditory and visual
functions; receptive and expressive speech; writing; spelling; rea ding
and arithmetic.
 This test is extremely sensitive for identifying specific types of
problems such as dyslexia and dyscalculia rather giving global
impressions of brain dysfunction. Also as compared to the Halstead -
Reitan battery, this test is admin istered faster and is more
standardised.
 The Neuropsychological Assessment Battery (NAB) is another
instrument that can be administered within 4 hours and includes
modules on attention, language, memory, spatial functions, executive
functions, etc.
The re liability and validity of neuropsychological tests may be affected by
mood states (anxiety and depression), motivation and also effects of
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37 2.1.2 Physiological Assessment
As discussed earlier that biological factor plays an important role in
various psychological disorder. It is important to understand the biological
basis of behaviour. Due to this physiological assessment becomes a part of
the evaluative process.
Psycho -physiological Assessment
 Psycho -physiological assessment involves the use of instrumentation
to monitor psycho -0physiological processes, based on the idea that
psychological experiences are associated with definite physiological
components such as changes in heart functioning, muscles, skin, brain,
etc.
 The electroencephalogra m (ECG) is used to monitor whether the
heart is functioning normally. A measure of the blood pressure gives
an estimate of any excessive or damaging pressure of the blood against
the walls of the blood vessels. This helps to assess the risk for
developi ng any stress -related heart conditions.
 The electromyography (EMG) is an instrument which is used to
measure muscle tensing/contraction associated with stress and to rule
out conditions such as headaches.
 Individuals tend to sweat excessively when they ar e tensed - this
leads to changes in the electrical properties of the skin and can be
measured with the help of the galvanic skin response (GSR).
Brain Imaging Techniques
Various techniques that construct pictures of the structure and function of
the brain have been developed since the 1970s:
The Electroencephalogram (EEG):
 The EEG measures the electrical activity in the brain that indicates
one’s level of arousal, that is, whether one is alert, resting, sleeping or
dreaming.
 The procedure involves attachin g the electrodes onto the scalp with an
electricity -conducting gel. The machine picks up the brain activity and
a device called the galvanometer, which has an ink pen attached to it,
writes continuously creating wave -like patterns on moving paper strip.
 The EEG shows a distinct pattern of brain waves depending on the
mental activity one engages in. Thus, the EEG recording helps in
assessing conditions such as epilepsy in which convulsions are caused
by disturbed neural activity, sleep disorders, brain tumor s, etc.
 An abnormality in the EEG patterns is used as a basis for further
investigations. In recent years computerised interpretations of the EEG
have made objective evaluation possible. The computer can convert
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38  For example, low amplitude areas are shown in black or blue while
high amplitude areas are highlighted in yellow and red. These
colourful images help understand the patterns of electrical activity
throughout the surface of the brain and are useful for diagnosis.
Computerized Axial Tomography (CAT CT scans):
 This is a technique in which one lies down with the head in a large X -
ray tube. Highly focused beam of X -rays is then passed through the
brain from many different angles. Differing densities of the d ifferent
brain regions result in different deflections (bending) of the X -rays.
 The deflection is greater in case of dense tissue such as bones and it is
least in case of fluid. The X -ray detectors gather the readings taken
from multiple angles and a compu terised program constructs an image
of the brain in the form of slices (tomo means ‘slice’ in Greek).
 This method helps obtain a cross sectional slice of the brain from a
specific angle or level. For example, CT scans can provide images such
as the fluid f illed ventricles in the brain, showing differences in the
brains of people with and without Schizophrenia.
Magnetic Resonance Imaging (MRI):
 This technique uses magnetic fields and radio waves to produce high
quality two or three dimensional images, based in the water content of
the different tissues. The person undergoing an MRI lies inside a
tunnel -like structure that surrounds the person with a strong magnetic
field.
 The activity of the electromagnetic energy from several angles,
through a computer progr am is converted into a high resolution image
of the scanned region. The MRI images are quite detailed and can
detect tiny changes of structures within the body.
 Using the MRI, trauma to the brain can be seen as bleeding or
swelling. Sometimes tumors that g o undetected in CT scans can be
seen in MRI. It is also used in identifying brain dysfunction in specific
disorders.
 For example, one study compared the MRIs of women with Major
Depressive Disorder (MDD) and controls on a task in which they had
to learn ob jects paired with faces displaying six emotions. It was seen
that women with MDD had difficulty learning the pairs and also
showed larger amygdala (part of the limbic system that is involved in
emotional responsiveness). However, when both the above factor s
were taken together, only women with MDD and larger amygdala
were found to do poorly on the learning task. This suggests that the
memory deficit may have resulted from changes in the brain triggered
by MDD (Weniger, Lange & Irle, 2006).
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39 Functional Magne tic Resonance Imaging (fMRI):
 This is a new technique and a specialized MRI which relies on the idea
that when an area of the brain becomes active due to mental processing,
the blood flow to that region increases.
 This scan is called ‘functional’ MRI becau se it shows the brain as it is
functioning while performing a mental task and is therefore very useful
in psychological assessment.
 The fMRI produces images of the active brain regions when one
processes information. This is done by showing regions with in creased
activity in different colours reflecting high and low levels of blood
flow. The advantage of this technique is that it shows the brain in action
rather than just its physical structures.
Positron Emission Tomography (PET), Singe Photon Emission
Com puted Tomography (SPECT):
 This is another brain imaging technique that involves injecting a
radioactively labelled compound into the person’s veins which binds
itself to the oxygen in the blood.
 This compound travels to the brain through the blood and emit s
positively charged electrons (positrons), which are detected by the
scanner. A computer program then converts this into images showing
the structure and function of organs and tissue.
 Bright colours like red indicate greater activity in the brain while
colours likes blue -green -violet suggest lower activity. Thus, any kind
of mental activity will result in lighting up a region of the brain.
2.3 SUMMARY
In this unit the concept of psychological assessment was discussed. The
important instruments of psychol ogical assessment, i.e., clinical interview
as well as mental status examination were discussed. Various types of
assessment such as multicultural assessment, environmental assessment,
physiological assessment were also discussed.
2.4 QUESTIONS
1. Explain Cl inical Interview and its types.
2. Write a detailed note on Mental Status Examination.
3. Write short notes on the following.
a. Behavioural Assessment
b. Multicultural Assessment
c. Environmental Assessment
d. Neuropsychological Assessment
4. Discuss the different types of Ph ysiological Assessment.
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40 2.5 REFERENCES
Butcher, J.N; Hooley, J.M; Mineka, S; & Dwivedi, C.B. (2020). Abnormal
Psychology . (16th ed.). Pearson
Barlow David H and Durand M.V. Abnormal Psychology, (2005), New
Delhi.Halgin R.P. and Whitbourne S.K. (2010) Abnormal Psychology,
Clinical Perspectives on Psychological Disorders, (6th Ed.), McGraw Hill.

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41 3
CAUSAL FACTORS AND VIEWPOINTS - I
Unit Structure
3.0 Objectives
3.1 Introduction
3.2 The Purpose of Theoretical Perspectives in Abnormal Psychology
3.3 Causes and Risk factors for Abnormal Behavior
3.4 Viewpoints for Understanding the Causes of Abnormal Behaviour:
Biological Perspective
3.5 Summary
3.6 Questions
3.7 References
3.0 OBJECTIVES
After reading this topic you will be able to:
 Explain how theoretical orientation of the clinicians and researchers
determines the way they perceive abnormal behavio ur.
 Critically evaluate the biological, psychodynamic, humanistic,
sociocultural, behavioural and cognitively based perspectives of
Abnormal Psychology.
 Understand the integrative biopsychosocial approach to the theories
and treatment of psychological diso rders.
3.1 INTRODUCTION
Many different theoretical perspectives have been developed to
conceptualize and explain the various causes of abnormal behavior. In this
unit we will discuss the most prominent theoretical perspectives. The
chapter begins with the discussion on the purpose of theoretical
perspectives. Then we will discuss Biological perspectives include the
nervous system and its role in the development of abnormal behavior.
Under this we will discuss the role of genetics, models of genetic
transmis sion and the treatments based on biological perspectives such as
Psychosurgery, Electroconvulsive therapy, TMS, DBS, Medication, etc.
All these, including evaluation of biological perspective, would be
discussed.
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42 Then we will study different psychologica l perspective such as important
concepts of psychodynamic perspectives, post Freudian theories and
evaluation the psychodynamic perspective. After that we will study
humanistic perspective which was developed in 1950s out of works of
Carl Rogers, Abraham M aslow and others. Person centered and self -
actualization theories as well as treatment based on it would be examined
and evaluated. Then behavioral and cognitively based perspectives are
discussed. An important theoretical view point expressed in writings of
Ivan P. Pavlov in his classical conditioning, B.F. Skinner in his operant
conditioning, etc is discussed. Social learning and social cognition
developed late in 1960s and grew out of behavioral perspective. It was
developed by Albert Bandura. Cognitive based theory developed out of
the work of Aaron Beck and Albert Ellis. Treatment approaches based on
cognitive perspective include conditioning techniques, contingency
management techniques, modeling and self -efficacy training and cognitive
therapies are discussed.
After psychological theory we will study Socio -cultural factors that are
important to understand and assess abnormal behaviour. Among the socio -
cultural perspectives, family perspective on psychopathology would be
discussed. Similarly, Social di scrimination and Social influences and
historical events would be studied. Treatment based on socio -cultural
perspective such as family therapy, group therapy, multicultural approach,
milieu therapy would also be briefly discussed. Following this socio -
cultural perspective will be evaluated.
Towards the end of this unit we will discuss the biopsychological
perspective on theories and treatment.
3.2 THE PURPOSE OF THEORETICAL PERSPECTIVES IN
ABNORMAL PSYCHOLOGY
This chapter focuses on what causes abnormality . There are different
schools of thought that vary in their beliefs and assumptions about what
leads to abnormal behaviours and how they can be treated. The theoretical
orientation of the clinicians and researchers determine how they perceive
abnormal beha viour. In practice, most experienced clinicians follow an
eclectic approach, that is, they put together concepts and techniques from
several theoretical perspectives.
Following are some of the most prominent theories that are important to
know while tryin g to understand various mental disorders.
3.3 CAUSES AND RISK FACTORS:
Central to the field of abnormal psychology are questions about what
causes people to experience mental distress and to behave maladaptively.
If one knew the causes for given disorders, one might be able to prevent
conditions that lead to them and perhaps reverse those that maintain them.
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43 Necessary, Sufficient, and Contributory Causes
 A necessary cause (e.g., cause X) is a condition that must exist for a
disorder (e.g., disorder Y) to occur. For example, general paresis
(Y)—a degenerative brain disorder —cannot develop unless a person
has previously contracted syphilis (X). Or more generally, if Y occurs,
then X must have preceded it. To date, most mental disorders have not
been found to have necessary causes, although there continues to be a
search for such causes.
 A sufficient cause (e.g., cause X) of a disorder is a condition that
guarantees the occurrence of a disorder (e.g., disorder Y). For
example, one current theory hypothesizes that hopelessness (X) is a
sufficient cause of depression (Y) (Abramson et al., 1995; Abramson
et al., 1989). Or, more generally, if X occurs, then Y will also occur.
However, a sufficient cause may not be a necessary cause; there are
other causes of depre ssion as well.
 A contributory cause (e.g., cause X) is one that increases the
probability of a disorder (e.g., disorder Y) developing but is neither
necessary nor sufficient for the disorder to occur. Or, more generally,
if X occurs, then the probability of Y occurring increases. For
example, parental rejection could increase the probability that a child
will later have difficulty in handling close personal relationships. We
say here that parental rejection is a contributory cause for the person’s
later di fficulties, but it is neither necessary nor sufficient (Abramson
et al., 1989, 1995).
 In addition to distinguishing among necessary, sufficient, and
contributory causes of abnormal behavior, we must also consider the
time frame under which the different c auses operate. Some causal
factors occurring relatively early in life may not show their effects for
many years; these would be considered distal causal factors that may
contribute to a predisposition to develop a disorder. For example, loss
of a parent ea rly in life, or having abusive or neglectful parents as a
child or adolescent, may serve as a distal contributory cause
predisposing a person to depression or antisocial behaviors later in
life.
 By contrast, other causal factors operate shortly before the occurrence
of the symptoms of a disorder; these would be considered proximal
causal factors . A severe difficulties with a school friend or a marital
partner are examples of more proximal causal factors that could lead to
depression.
 In other cases, proxi mal factors might involve biological changes such
as damage to certain parts of the left hemisphere of the brain, which
can lead to depression.
 A reinforcing contributory cause is a condition that tends to
maintain maladaptive behavior that is already occ urring. An example
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44 responsibility that may come when a person is ill; these pleasant
experiences may unintentionally discourage recovery.
 For many forms of psychopathology, we do not yet have a cl ear
understanding of whether there are necessary or sufficient causes,
although answering this question remains the goal of much current
research. We do, however, have a good understanding of many of the
contributory causes for most forms of psychopatholog y. Some of the
distal contributory causes set up vulnerability during childhood to
some disorder later in life. Other more proximal contributory causes
appear to bring on a disorder directly, and still others may contribute
to maintenance of a disorder. Th is complex causal picture is further
complicated by the fact that what may be a proximal cause for a
problem at one stage in life may also serve as a distal contributory
cause that sets up a predisposition for another disorder later in life. For
example, t he death of a parent can be a proximal cause of a child’s
subsequent grief reaction, which might last a few months or a year;
however, the parent’s death may also serve as a distal contributory
factor that increases the probability that when the child grow s up he or
she will become depressed in response to certain stressors
Feedback and Bidirectionality in Abnormal Behavior
 Traditionally, the task of determining cause -and-effect relationships
has focused on isolating the condition X (cause) that can be
demonstrated to lead to condition Y (effect). For example, when the
alcohol content of the blood reaches a certain level, alcoholic
intoxication occurs.
 When more than one causal factor is involved, as is often the case, the
term causal pattern is used. Here , conditions A, B, C, and so on lead
to condition Y. In either case, this concept of cause follows a simple
linear model in which a given variable or set of variables leads to a
result either immediately or later.
 In the behavioral sciences, however, not only do we usually deal with
a multitude of interacting causes but we also often have difficulty
distinguishing between what is cause and what is effect because effects
can serve as feedback that can in turn influence the causes. In other
words, the effect s of feedback and the existence of mutual, two -way
(bidirectional) influences must be taken into account. Consider the
following example, which illustrates that our concepts of causal
relationships must take into account the complex factors of
bidirectiona lity of feedback
 Perceived Hostility A boy with a history of disturbed interactions
with his parents routinely misinterprets the intentions of his peers as
being hostile. He develops defensive strategies to counteract the
supposed hostility of those around him such as rejecting the efforts of
others to be friendly, which he misinterprets as patronizing.
Confronted by the boy’s prickly behavior, those around him become
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45 boy’s distorted e xpectations. In this manner, each opportunity for new
experience and new learning is in fact subverted and becomes yet
another encounter with a social environment that seems perversely and
persistently hostile —exactly in line with the boy’s expectations
Diathesis -Stress Models
 A predisposition toward developing a disorder is termed a diathesis.
 It can derive from biological, psychological, or sociocultural causal
factors.
 Many mental disorders are believed to develop when some kind of
stressor operates on a person who has a diathesis or vulnerability for
that disorder.
 The diathesis or vulnerability results from one or more relatively distal
necessary or contributory causes, but is generally not sufficient to
cause the disorder. Instead, there generally mu st be a more proximal
undesirable event or situation (the stressor), which may also be
contributory or necessary but is generally not sufficient by itself to
cause the disorder except in someone with the diathesis.
 Researchers have proposed several differ ent ways that a diathesis and
stress may combine to produce a disorder (Ingram & Luxton, 2005;
Monroe & Simons, 1991).
 In what is called the additive model , individuals who have a high
level of a diathesis may need only a small amount of stress before a
disorder develops, but those who have a very low level of a diathesis
may need to experience a large amount of stress for a disorder to
develop. In other words, the diathesis and the stress sum together, and
when one is high the other can be low, and vice v ersa; thus, a person
with no diathesis or a very low level of diathesis could still develop a
disorder when faced with truly severe stress.
 In what is called an interactive model , some amount of diathesis must
be present before stress will have any effect . Thus, in the interactive
model, someone with no diathesis will never develop the disorder, no
matter how much stress he or she experiences, whereas someone with
the diathesis will show increasing likelihood of developing the
disorder with increasing leve ls of stress.
 More complex models are also possible because diatheses often exist
on a continuum, ranging from zero to high levels.
 Since the late 1980s, attention has been focused on the concept of
protective factors , which are influences that modify a person’s
response to environmental stressors, making it less likely that the
person will experience the adverse consequences of the stressors
(Cicchetti & Garmezy, 1993; Masten et al., 2004; Rutter, 2006a,
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46  One important protective factor in childho od is having a family
environment in which at least one parent is warm and supportive,
allowing the development of a good attachment relationship between
the child and parent that can protect against the harmful effects of an
abusive parent (Masten & Coats worth, 1998).
 Ordinarily, protective factors operate only to help resist against the
effects of a risk factor rather than to provide any benefits to people
without risk factors (Rutter, 2006a).
 Protective factors are not necessarily positive experiences. Indeed,
sometimes exposure to stressful experiences that are dealt with
successfully can promote a sense of self -confidence or self -esteem and
thereby serve as a protective factor; thus some stressors paradoxically
promote coping. This “steeling” or “inoc ulation” effect is more likely
to occur with moderate stressors than with mild or extreme stressors
(Barlow, 2002; Hetherington, 1991; Rutter, 1987).
 And some protective factors have nothing to do with experiences at all
but are simply some quality or att ribute of a person. For example,
some protective attributes include an easygoing temperament, high
self-esteem, high intelligence, and school achievement, all of which
can help protect against a variety of stressors (Masten, 2001; Rutter,
1987; Sapienza & Masten, 2011).
 Protective factors most often, but not always, lead to resilience —the
ability to adapt successfully to even very difficult circumstances. An
example is the child who perseveres and does well in school despite
his or her parent’s drug addict ion or physical abuse (Garmezy, 1993;
Luthar, 2003; Sapienza & Masten, 2011). More generally, the term
resilience has been used to describe the phenomenon that “some
individuals have a relatively good outcome despite suffering risk
experiences that would b e expected to bring about serious sequelae”
(Rutter, 2007, p. 205).
3.4 VIEWPOINTS FOR UNDERSTANDING THE
CAUSES OF ABNORMAL BEHAVIOUR:
BIOLOGICAL VIEWPOINT:
The biological perspective focuses on how certain abnormalities in the
activities of the brain and the nervous system affect behavioural, cognitive
and emotional functioning of an individual.
The Nervous System and Behaviour
The nervous system is a complex structure that regulates our thoughts,
behaviours and emotions. The central nervous system’s fun ction is to
transmit messages from different parts of the body to the higher decision
making centre and then send their messages back to body. These messages
are relayed by the neurons, which are specialized cells for receiving,
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47 Neurons, Synapses and Neurotransmitters:
 There are over 100 billion neurons in the human body which carry
messages between the brain and the body. These neurons form an
interconnected pathway and pass the messages through neural
transmission and synaptic transmission.
 In neural transmission the information within the neuron moves in the
form of an electrochemical impulse and is called an action potential,
while synaptic transmission is the process by which information is
transmitted from one neur on to another neuron.
 Neurons are arranged in the form of chains but they do not touch each
other. The space between the axon of one neuron and the dendrite of
another is a gap called the synapse.
 When the neuron is stimulated, the resting potential chang es and
activates an action potential which travels along the axon to its tip, that
is, the synaptic knobs which have tiny vessels called synaptic vesicles
that contain neurotransmitters.
 Neurotransmitters are chemical substances which carry information
across the synapse and can have two effects on the receiving neuron -
inhibitory (turn off) or excitatory (turn on).
 If the effect is excitatory in nature then there is a change in the resting
potential of the receiving neuron and the process of neural
trans mission occurs in this neuron. On the other hand, if the effect of
the neurotransmitter is inhibitory, no action potential is generated in
the receiving neuron and the message is not transmitted.
 For some neurotransmitters there is a reuptake – the neurotr ansmitters
are reabsorbed by the synaptic terminals from which they were
released. Reuptake prevents the action of the neurotransmitter and the
further production of the chemical.
 Whether a neuron will generate an action potential and pass the
message to o ther neurons in its pathway depends on the balance
between the excitatory and inhibitory synapses. Thus, the neuron
integrates all the signals it receives and responds to the stronger signal.
 Scientists have found several types of neurotransmitters which operate
in the brain and carry out different functions. So, any imbalance in the
level of these neurotransmitter has a tendency to develop various
symptoms of mental disorders. Synaptic transmission in the brain can
be altered through the use of drugs th at increase or decrease the
effectiveness of the neurotransmitter.
 Serotonin plays a crucial role in the regulation of mood, appetite and
sleep. Low levels of serotonin are associated with depression.
Antidepressants work by inhibiting the reuptake of sero tonin that
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48  Norepinephrine is an excitatory neurotransmitter and influences mood
states. It is a stress hormones and prepares the body during the fight
and flight response. Drugs like cocaine/amphetamines have their
psychological effects by prolonging the action of norepinephrine and
slowing its reuptake. Its insufficiency causes depression.
 Dopamine when released in the brain produces intense feelings of
pleasure. An excess of dopamine is thought to cause Schi zophrenia
while its deficit leads to Parkinson’s disease.
 Gamma -aminobutyric acid (GABA) is a major inhibitory
neurotransmitter. It slowdowns the functioning of the other
neurotransmitter. Antianxiety drugs work by activating the action of
GABA, which slow s down the nervous system.
 Acetylcholine (ACh) usually has an excitatory effect, is present mainly
in the hippocampus and plays an important role in the formation of
new memories. Less amount of ACh caused by the degeneration of the
neurons that produce it is associated with Alzheimer’s disease.
 Glutamate is primarily the excitatory neurotransmitter which plays a
very important role in normal brain functioning. It sends signals to the
cells in the central nervous system.
Genetic Influences on Behaviour
Gene tics or heredity is biologically what one gets from one’s parents.
Basic concepts in Genetics
 The basic unit of genetics is the genome which is the complete set of
instructions for the development of every cell in the body. The human
genome is present in t he nucleus of the trillions of cells in one’s body
and consists of long molecules of deoxyribonucleic acid (DNA).
Phenotype refers to the expression of the genes as a result of their
interaction with the environment.
 Strands of the DNA have the information needed by the cells to
produce the protein which the primary component of all organisms. An
important function of the DNA is to replicate itself before cell division
begins so that every new cell has a copy of the instructions required
for manufacturing t he protein.
 There are 32000 thousand genes in the human body, which are
functional units of the DNA and carry the precise instructions for
manufacturing a specific protein. Genes are microscopic bags of
chemicals found on the chromosomes.
 Human beings have 23 pairs of chromosomes, one in each set from
each of the parents. Of the 23 single chromosomes in each cell, 22 are
called autosomes and carry non -sex-related information. The 23rd one
is the X or Y sex chromosome. In normal females the combination of
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49  The arrangement of genes on the chromosomes has no logical reason -
a gene that determines the eye colour may be next to the gene that
influences the height.
 Genes go through mutations, that is, alterations or changes caused
from incorrect copying of instructions during cell replication and this
may be inherited or acquired. Inherited mutations are caused due to
mutations in the DNA of the reproductive cells (sperm and ovum) -
when these mutated cells get pas sed to the child, the mutations would
be found in all the cells in the child’s body. Acquired mutations are
changes in the DNA that occur throughout one’s life due to sunlight or
carcinogens. Inherited mutations play a role in diseases such as cystic
fibro sis and sickle anemia and may predispose a person to cancer,
mental illnesses, etc. However, our cells have the ability to repair
many of these mutations. If the cells fail to do so, the mutations are
passed to the future copies of the affected cell.
Models of Genetic Transmission
 The chromosomes operate in pairs and each set has the same genes on
it but in different combinations called alleles. Alleles refer to whether
the combination of genes is dominant or recessive. The hair colour,
texture, eye colo ur, etc., are decided by the combination of alleles
inherited by the individual. A dominant allele always shows its effect
irrespective of what the other allele in the pair is whereas a recessive
allele expresses its effect only if it paired with another allele of its
own kind.
 Genetic disorders have a dominant -recessive pattern of transmission.
In dominant pattern of disease inheritance, if the person has a normal
allele and a disease allele, he is likely to develop the disease because
the disease all ele is dominant. Since, this person carries a normal and a
disease allele, his/her child has a 50 percent chance of inheriting the
disease allele and thus a 50 percent chance of having the disease.
 In recessive pattern of disease inheritance where both p arents carry
one normal allele (N) and one disease allele (D), neither of them have
the disease but both are carriers of it. The combination of alleles that
they are likely to pass on to their children are NN, ND, DN or DD.
Thus, their children has 1/4th chances of being normal (NN), 1/4th
chances of developed the disease (DD) and 2/4th chances of being
carriers of the disease (ND, DN).
 Disease inheritance sometimes is much complex and cannot be
explained through the dominant -recessive pattern of transmissi on. In
such cases the pattern is likely to be polygenic, that is, multiple genes
may play a role in the expression of a characteristic. Diabetes,
coronary heart disease, epilepsy, etc., are a result of such polygenic
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50  It is suggested that genetic factors are involved in the manifestation of
several traits such as subjective wellbeing, political views, job
satisfaction, religiosity etc. (Plomin & Caspi, 1999).
Genes, Environment and Psychological Disorders
 Researchers believe that an important aspe ct of genetic transmission is
that what are inherited are only the predisposition and not the inevitability
of the disorder. It is the mutual influences of nature (biology) and the
nurture (environment) on each other that determine most psychological
disor ders.
For instance, the trait of extraversion is thought to be partially inherited
(Loehlin, McCrae, Costa & John, 1998).
A child born with extraversion genes may generate positive reactions in
people in her environment, which further strengthen this perso nality trait.
It is also suggested that people tend to select environments that are
consistent with their inherited interests and capabilities and these
environments in turn facilitate the expression of these characteristics.
 The diathesis -stress model su ggests that a person must carry some risk
to the disorder in order to develop it. This vulnerability can be biological -
inheriting disordered genes, it may be psychological - a faulty personality
trait, or social - a history of abuse or poor interpersonal relations. In
addition to this, for the disorder to develop, one must experience some
kind of stress or trigger. This stress could be biological - an accident or
illness that changes the neurotransmitter balance, psychological -
perceived loss of control , or social - a traumatic event. The full - blown
disorder can develop only when the vulnerability combines with the
stress.
A large study which demonstrates the diathesis -stress model involved
biological parents with and without psychiatric disorders an d their
children. They were interviewed and ratings were obtained to determine
the child’s chances of developing psychiatric disorders (Johnson et al.,
2001). A significant factor here was the presence of maladaptive parental
behaviour. It was found that children who developed psychiatric disorders
tended to come from homes with maladaptive parental behaviours,
irrespective of whether their parents had psychiatric disorders or not.
Similarly, children of parents who had psychiatric disorders were found to
develop the disorders only when there was a history of disturbed parental
behaviour. Thus, the diathesis of parental psychiatric disorders produced a
full blown illness only when combined with the stress of living with
parents having maladaptive behaviour s.
Thus, a genome may not always express itself in the phenotype. A
phenomenon called incomplete penetrance occurs when the genotype that
predisposes a person to a disorder doesn’t get manifested.
 According to the multifactorial polygenic threshold sever al genes of
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51 characteristic. The specific combination of inherited genes decides
whether the vulnerability or risk is high, low or moderate. The symptoms
of the disorder are thought to deve lop when the combined effect of genetic
and environmental factors exceeds a certain threshold (Moldin &
Gottesman, 1997). This model is more popular than the single -gene
explanations of genetic transmission.
Treatment
Biological therapies work on reducing symptoms of a disorder by focusing
on the physiological abnormalities.
Psychosurgery: This is a surgical intervention on the brain and typically
involves cutting off the frontal lobe from the rest of the brain. This
technique was developed by Egas Moniz t o treat people with severe
psychosis in 1935 and won the Nobel Prize in 1949 for the same. The
negative effects of this technique included loss of motivation and
emotional dullness. Psychosurgery is not used anymore but yet
recommended by some to manage so me forms of obsessive compulsive
disorder (Woerdeman et al., 2006).
Electroconvulsive Therapy (ECT): The ECT was developed by Ugo
Cerletti in 1937 as a treatment for psychosis based on his observation that
dogs that underwent convulsions induced through el ectric shocks appeared
much calmer later.
The procedure for ECT involves giving the patients anesthesia so that they
aren’t conscious and muscle relaxants so that their muscle don’t jerk
violently. Metal electrodes are then taped to the head and a current of 70 -
130 volts is passed through one or both sides of the brain for about half a
second. As a result the patient goes into a convulsion which lasts for about
few seconds.
ECTs seemed to be effective in dealing with many types of severe
psychological diso rders, especially those who are showing resistance to
medication. Example, ECT are often given to depressive patients who
haven’t responded to medication. However, how exactly the technique
helps is not clearly known.
ECTs are controversial for several rea sons. First, there were reports about
it being inappropriately used to punish patients who seemed out of control.
Second, ECT can result in memory loss and difficulties in learning new
material. Third, though it is very effective in relieving depression, t he
relapse rate is 85 percent. And finally, the idea of passing electric current
through a person’s body is very frightening and seems like a very
primitive form of treatment.
Transcranial Magnetic Stimulation (TMS): This method involves
placing an electro magnet on the scalp and passing electric current through
the cortex to increase or decrease the excitability of neurons in a given
region. The effect is not restricted only to the cortex but spreads to the
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52 ECT as a treatment for depression (Couturier, 2005) and is quite effective
when given in combination with medication (Rumi et al., 2005).
Deep Brain Stimulation (DBS): In DBS an electrical conductor is
planted in the brain, whi ch provides continuous low electrical stimulation
to a small area of the brain. The procedure involves inserting a thin
insulated wire in the brain and connecting it through an extension of the
insulated wire passed under the skin of the head, neck and sh oulder to a
neurostimulator (battery) which is placed under the skin near the collar
bone. The DBS was developed with the aim of increasing activity in
certain brain regions, for instance, the basal ganglia which is less active
in patients with Parkins on’s disease. The technique is also being
considered for treating obsessive compulsive disorder and depression.
Medication: This is the most commonly used form of biological
treatment. Medications work by altering the activity and amount of
neurotransmitte rs.
 Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and
setraline, block the reuptake of serotonin thus increasing the amount of
this neurotransmitter in the synapse. SSRIs are effective in treating
several disorders such as depression, obsessive compulsive disorder,
eating disorders, borderline personality disorder, etc.
 Tricyclic Antidepressants such as clomipramine and desipramine,
work by blocking the reuptake of norepinephrine and serotonin and are
used in treating depression and obsessive compulsive disorder.
 Benzodiazepines like clonazepam and diazepam are antianxiety drugs
which increase the activity of GABA and thus inhibit the brain regions
that produce anxiety and panic.
 Atypical Antipsychotics such as clozapine and olanzapine block the
serotonin and dopamine receptors in the limbic system and are
effective in treating Schizophrenia and Alzheimer’s disease.
 Mood stabilisers such as lithium and valproate work by decreasing
levels of catecholamines and increasing release of GABA t o manage
Mania and Bipolar disorder.
 Neuroleptics like chlorpromazine and haloperidol are antipsychotic
medicines that block the dopamine receptors and are effective in
treating Schizophrenia and Alzheimer’s disease.
Biofeedback: Biofeedback involves the u se of instrumentation to monitor
psychophysiological processes, combined with behavioural principles to
bring these functions under voluntary control. The technique is based on
the idea that autonomic functions such as heart rate, blood pressure,
galvanic skin response, etc., can be voluntarily altered through the use of
reinforcement. It is suggested that some physiological symptoms are
caused due misinterpretation of bodily cues (Miller & Dworkin, 1977). In
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53 sophisticated instruments and then are encouraged to change these
functions by providing a reward. For instance, one may learn to recognise
muscle tension followed by techniques to relax them. When the person is
able to reduc e muscle tension through relaxation then some lights or music
is put on which acts as reinforcement. This is often combined with shaping
in such a way that the initial goals are within the person’s reach and then
are gradually made difficult.
Evaluation of the Biological Perspective
 It is important to understand the biological basis of behaviour as all
psychological problems are manifested in the body. Also there is a
reciprocal relationship between biological and psychological factors
explained as the con cept of feedback loop in the earlier chapter. For
instance, exam anxiety raises the heart beat, sweating, etc. and these
bodily sensations interfere with the ability to concentrate. The thought
that one is not able to focus makes one even more anxious w hich
further leads to physical changes.
 In the development of some psychological disorders such as
Schizophrenia and Depression, biological factors like genetic
involvement play a crucial role and accordingly biological therapy,
that is, medication becomes the primary treatment.
 Researchers have also found that the experience of traumatic events or
chronic stress affects the brain’s structure and functions. It is
suggested that with each traumatic incident the neurotransmitter
systems become more easily dys regulated - the first episode may take
a strong stressor to cause the dysregulation but later mild stressors can
also initiate the dysregulation.
 Finally, the biological perspective helps understand genetic
contributions to psychological disorders and tra its, and the patterns of
genetic transmission. The advancements in genetic technology provide
improved solutions for genetically based disorders.
3.5 SUMMARY
In this unit we have discussed the various theoretical perspectives. In this
we had discussed the biological perspective and concepts related to it such
as neurons, synapse, neurotransmitters, basic concepts of genetics, models
of genetic transmission, etc. Treatment based on biological perspectives
were also discussed.
3.6 QUESTIONS
1. Write short n otes on the following.
a. Necessary, Sufficient, and Contributory Causes
b. Feedback and Bidirectionality in Abnormal Behavior
c. Diathesis -Stress Models
2. Discuss the biological treatment approaches. munotes.in

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54 3.7 REFERENCES
Butcher, J.N; Hooley, J.M; Mineka, S; & Dwiv edi, C.B. (2020). Abnormal
Psychology . (16th ed.). Pearson
Halgin R. P. and Whitbourne S.K. (2010) Abnormal Psychology :
Clinical Perspectives on Psychological Disorders, (6th Ed.), McGraw
Hill.
Nolen – Hoeksema S. (2008) Abnormal Psychology ( 4th Ed.), New York
McGraw Hill.


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Unit Structure
4.0 Objectives
4.1 Introduction
4.2 Psychodynamic viewpoints
4.3 Humanistic Perspective
4.4 Behavioural and Cognitively Based Perspectives
4.5 Sociocultural viewpoints
4.6 Biopsychosocial Perspective on T heories and Treatment : An
Integrative Approach
4.7 Summary
4.8 Questions
4.9 References
4.0 OBJECTIVES:
After reading this topic you will be able to:
 Explain how theoretical orientation of the clinicians and researchers
determines the way they perceive a bnormal behaviour.
 Critically evaluate the biological, psychodynamic, humanistic,
sociocultural, behavioural and cognitively based perspectives of
Abnormal Psychology.
 Understand the integrative biopsychosocial approach to the theories and
treatment of psy chological disorders.
4.1 INTRODUCTION
Under this we will discuss different psychological perspective such as
important concepts of psychodynamic perspectives, post Freudian theories
and evaluation the psychodynamic perspective. After that we will study
humanistic perspective which was developed in 1950s out of works of
Carl Rogers, Abraham Maslow and others. Person centered and self -
actualization theories as well as treatment based on it would be examined
and evaluated. Then behavioral and cognitively bas ed perspectives are
discussed. An important theoretical view point expressed in writings of
Ivan P. Pavlov in his classical conditioning, B.F. Skinner in his operant
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56 developed late in 196 0s and grew out of behavioral perspective. It was
developed by Albert Bandura. Cognitive based theory developed out of
the work of Aaron Beck and Albert Ellis. Treatment approaches based on
cognitive perspective include conditioning techniques, contingency
management techniques, modeling and self -efficacy training and cognitive
therapies are discussed.
After psychological theory we will study Socio -cultural factors that are
important to understand and assess abnormal behaviour. Among the socio -
cultural pers pectives, family perspective on psychopathology would be
discussed. Similarly, Social discrimination and Social influences and
historical events would be studied. Treatment based on socio -cultural
perspective such as family therapy, group therapy, multicul tural approach,
milieu therapy would also be briefly discussed. Following this socio -
cultural perspective will be evaluated.
Towards the end of this unit we will discuss the biopsychological
perspective on theories and treatment.
4.2 PSYCHODYNAMIC PERSPECT IVE
The psychodynamic view emphasizes on the idea that behaviour is
primarily influenced by unconscious factors. The term ‘psychoanalytical’
is used to refer to Freud’s ideas while the term ‘psychodynamic’ covers a
broader perspective that focuses on unco nscious processes as well as
various other factors that are thought to influence behaviour.
Freud’s Psychoanalytic theory
 Freud was a neurologist from Vienna who became interested in
unconscious processes while working with Jean Charcot. Freud’s
theory was controversial because he wrote extensively about the role
of sexual instincts during a period when sex was not discussed openly.
 He was of the opinion that early childhood experiences are the most
influential in determining one’s personality. He believed that events
that occur in childhood deeply impact the unconscious mind and these
experiences continue to influence an individual in his adulthood.
 This idea was based on Freud’s analysis of his own dreams, thoughts
and early childhood memories. He also rea lized that by recollecting
the memory of his traumatic train ride at the age of 4, he was relieved
from some very disturbing symptoms.
 Being a medical student he was convinced that disorders of the mind
could be studied scientifically and that they are cau sed by
physiological processes.
Structure of Personality: Id, Ego and Superego
According to Freud, the psyche or the mind comprises of three structures -
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57 that our behaviour is the res ult of a complex interaction between these
structures.
Id: The id is the most primitive part of the unconscious mind and contains
sexual and aggressive instincts. It is based on the ‘pleasure principle’ and
needs immediate satisfaction of its desires.
 Id w orks on the ‘pleasure principle’ An unfulfilled desire or impulse
creates tension and only when it is satisfied that one experiences
pleasure. The id tries to achieve pleasure from the actual gratification
of needs as well as wishful thinking.
 Freud uses t he term primary process thinking to indicate id’s attempts
to satisfy needs by forming wish -fulfilling mental images of the
desired objects. In other words, primary process thinking satisfies
motives in imagination rather than reality. Fantasizing about yo ur
enemy, being beaten up or having your favourite desert is an instance
of primary process thinking.
Ego: This part of the personality has conscious awareness and enables the
individual to perceive, use judgment, memory and make decisions
necessary to ada pt to the environment.
 It also helps to transform the wishes and fantasies of the id into reality.
It works on the ‘reality principle’ which makes the individual face the
constraints and difficulties of the external world.
 The ego engages in secondary pro cess thinking, a more logical and
rational way of solving problems. For example, suppose a man has an
argument with his wife and as a result gets delayed and misses his bus.
In this case primary process thinking would probably make him curse
wife whereas s econdary process thinking would help him look for a
solution such as finding an alternate way of reaching his destination.
 According to Freud, the ego doesn’t have a motivating force and draws
its energy from id’s energy that is the libido. He also believe d that
although the ego reflects conscious awareness, one is unaware of
certain aspects of the ego. This includes, memories of events in which
one has been self -centered or cruel or aggressive or behaved in
sexually unacceptable ways.
Superego: This refer s to one’s conscience and is the part of the psyche
that guides the ego’s efforts of gratifying the impulses and desires of the
id.
 The superego represents the do’s and don’ts of the society that one has
internalized. It focuses on what is right and what is wrong. An
individual’s whose superego is very high seems to be very moralist
and righteous. And an individual’s whose superego is very low seems
to be very anti -social and irresponsible
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58  So, Freud was of the opinion that if it weren’t for the superego, man
would have tried to seek inappropriate and unacceptable forms of
pleasure such as rape, murder, etc.
 Ego acts as a mediator between Id and Superego. As mentioned
earlier, Ego tries to satisfy Id but consider the judgment of Superego
and finding a mid -way between the two. Eg. Meena is in attending a
class and craves for food (Id), but she knows that it is wrong to eat
food during class and she needs to concentrate on what the teacher is
teaching (superego). So, to pacify her craving she tells herself tha t she
will have a lunch immediate after the lecture and now she needs to
concentrate in the class (ego).
Defense Mechanisms: Defenses are strategies to protect oneself from
unpleasant and disturbing emotions. They are used to protect one’s ego.
For examp le, if one is feeling guilty about getting poor marks in the exam,
blaming the teacher for being partial may make him feel better. Defense
mechanism can be healthy if used in moderation. The problem arises when
they are used rigidly and in excess, so much so that it can give rise to
psychological disorders.
Adaptive Defenses: These are healthy ways of coping with stress. Some
of the healthy and adaptive defenses include the following.
a. Humor : Focusing on the funny/lighter aspects of a situation.
Example: Moh an joked about how he slipped and fell down during the
conference.
b. Self-assertion : Dealing with distress by expressing one’s thoughts,
feelings directly. Example: Asha told her husband that she was let down
when he cancelled their dinner plan at the last m oment.
c.) Suppression : A conscious attempt to avoid unpleasant or disturbing
thoughts or ideas. Example: Sheena decided to avoid thinking about her
recent break up so that she could concentrate on her studies.
d.) Sublimation : Channelizing one’s energies in socially desirable ways.
Example: Betrayed in love, Mona decided to do her PhD on the dynamics
of romantic relationships.
Mental Inhibition: These are unconscious strategies to keep unwanted
thoughts, feelings, memories, desires, out of conscious awaren ess.
a.) Displacement : Transferring an unpleasant emotion onto a non -
threatening stimulus. Example: Being scolded by her mom, Rita slaps her
doll.
b. Dissociation : Withdrawing or distancing oneself from the
unpleasant memories, aspects of self or the environ ment. Example: While
being shouted at by the teacher, Gopal withdrew into his fantasy world
thinking about his favourite dinner being cooked at home.
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59 c.) Intellectualisation : Excessive emphasis on external reality or
irrelevant details to avoid expression or experience of emotion. Example:
Sumit who is getting divorced talks excessively about the validity of
marriage as a social institution.
d.) Reaction formation : Changing an unacceptable feeling or desire into
the opposite. Example: Roma who feels jealou s of her younger brother
showers him with lot of gifts.
e.) Repression : An unconscious attempt to push disturbing thoughts or
ideas out of awareness. Example: As an individual has a phobia of
injection missed his appointment for vaccination. Or a child suf fers abuse
by parent, represses the memories and becomes completely unaware of
them as he grow but has difficulty in forming relationship.
Minor Image -Distorting Defenses: These are tactics in which an
individual derives his self -esteem by altering or misr epresenting the image
of self, the body or others.
a. Devaluation : Dealing with distress by assigning negative
characteristics to oneself or others. Example: Roshan feels that she
doesn’t get good marks because of low intelligence and lack of proper
guidance.
b. Idealisation : Seeing others in unrealistically positive light. Example:
Sita ignores her husband’s dominance by thinking that he is a man of high
self-belief.
c. Omnipotence : Dealing with stress by thinking that one is superior to
others. Example : Prakash be haves arrogantly with others especially
during exams.
Major Image -Distorting Defenses:
a. Denial : Refusing to accept disturbing aspects of reality. An
unconscious attempt to ignore the reality of the situation or not able to
acknowledge the reality or consequ ences of the reality. Example: Reema
refused to acknowledge the news of her brother’s accidental death.
b. Splitting : Disintegrating the positives and negatives feelings or
aspects of self and others. Seeing things as all or none. Example: Mr.
Ramesh was Sneh a’s favourite uncle whom she idealized. But ever since
he spoke against her, she began viewing him as mean and evil.
c. Disavowal : Here, the individual disclaims responsibility in an attempt
to keep unpleasant thoughts, feelings, desires, and impulses out of
conscious awareness
d. Projection : Seeing one’s own unacceptable characteristics or
thoughts, feelings, impulses as someone else’s. Example: Satish is
attracted to other women and accuses his wife for being interested in other
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60
c.) Rationalisation : Givin g logical but false explanations to cover up
one’s real thoughts/ideas. Example: Rekha who’s upset because her friend
didn’t invite her to a party said that she wasn’t interested in it in the first
place.
Defenses Involving Action: These are strategies in which an individual
deals with the stress by acting or withdrawing from it.
a. Acting out : Dealing with distress with actions instead of thoughts or
feelings. Example: Children throw temper tantrums when they are
annoyed.
b. Passive aggression : Expressing anger, disappointment or opposition
indirectly. Example: Nita stops talking to her husband when she is angry
about something he has done.
c.) Regression : Dealing with distress by reverting to an earlier age level.
Generally an individual behave childlike during difficult time. Example:
Tushar began thumb sucking after the birth of his younger sibling.
Defenses Involving Breaks with Reality: These are coping techniques
that involve the use of bizarre thoughts or behaviour.
a. Delusional Projection : Delusionally seein g one’s own unacceptable
characteristics or thoughts, feelings, impulses as someone else’s.
Example: Karan who’s attracted to other women thinks that his wife is
interested in other men and is convinced that she is having an affair with
someone.
b. Psychotic distortion : Dealing with distress by delusional
misrepresentation of reality. Example: Geeta developed the belief that she
is an adopted child because her father scolded her for overspending.
Psychosexual Development : Freud’s theory of personality is a
developmental theory. He believed that our personality is formed as we
pass through a series of stages from infancy to adulthood and that the
events which occur during these stages are especially significant. He put
forth the idea that every stage is chara cterized by a body part that is
found pleasurable (erogenous zone) and how the child learns to satisfy the
sexual desire associated with each stage is crucial in determining the
personality.
Freud developed this theory on the basis of the reports of his own patients.
He was convinced that their problems were caused by repressed sexual
desires of early life. He spoke of two forms of disturbances, regression , in
which a person reverts back to a previous level, and fixation , in which the
person remains, st uck or fixed at a particular psychosexual stage.
1.) Oral stage: In this stage which lasts from birth to 18 months, the
mouth and the lips are the primary source of pleasure for the infant. This
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61 gains pleasure from nursing or eating, and the oral -aggressive phase in
which the child enjoys chewing, spitting and tries to bite anything that is
around. In Freud’s view, regression or fixation at the oral passive phase
would result in a n adult who depends excessively on oral gratification
such as overeating, cigarette smoking, etc. Those who are regressed or
fixated at the oral -aggressive phase tend to be unfriendly and critical of
others.
2.) Anal stage: In this stage the toddler (18 m onths to 3 years) derives
pleasure from holding on to and expelling feces. Fixation at this stage
may result in an anal retentive personality, that is, an adult who is a
control freak and obsessed about hoarding things. On the other hand,
fixation at thi s stage may also result in an anal expulsive character, that
is, an adult who is sloppy, disorganised and uncontrolled.
3.) Phallic stage: According to Freud, the child faces a significant crisis in
this stage of development (3 to 5 years) in which the e rogenous zone is the
genitals. Here, the child develops sexual attraction towards the opposite
sex parent (Freud referred to this as the Oedipus complex in boys and
Electra complex in girls, based on Greek mythology).
Oedipus complex is wherein the young boy wishes to unconsciously kill
his father and sexually possess the mother. However, he fears that the
father will punish him by cutting off his genitals (castration anxiety) for
having sexual feelings for the mother. This crisis is resolved when the
child represses his feelings for his mother and identifies with the father.
Electra complex is wherein the girl discovers that she doesn’t possess a
penis and comes to blame her mother for the same. She also hopes to share
her father’s penis and becomes sexu ally and emotionally attracted towards
him. This crisis gets resolved when the girl identifies with the mother and
incorporates her values.
Thus, in this stage the children’s superego begins to develop and prepares
them for dealing with unacceptable sexu al urges. Freud believed that
neurosis results from an inability to resolve the Oedipus/Electra complex.
4.) Latency stage: This is the phase (5 to 12 years) in which the sexual
energies take a backstage. During this phase, children channelize their
energi es into school work and play. They interact and imitate parents and
others of the same sex.
5.) Genital stage: In this stage (12 onwards), there is renewed interest in
deriving sexual pleasure through the genitals. Masturbation begins and
since parents are ruled out as sex objects through the resolution of the
phallic stage, one starts looking out for opposite sex partners. Any
unresolved issues from the earlier stages interfere with one’s ability to
successfully pass through this stage.
Post-Freudian Psych odynamic Views : The post -Freudian theorists
believed in the unconscious aspects of personality but criticized Freud for
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62 socio -cultural influences such as interpersonal and social needs to also
play an important role in shaping one’s personality.
 Carl Jung (1875 -1961) felt that Freud took a one -sided view of the
human condition. Jung believed that although the unconscious mind
contained selfish and hostile forces, it also contained positive, even
spiritual motives. He put forth the concept of ‘archetypes’, that is, certain
images which are commonly held by all human beings. For example, the
good or evil, self, hero, etc. Jung believed that characters like superman
are popular because they evo ke the hero archetype.
His original and lasting contribution is the idea of introversion
extroversion. He modified Freud’s view of the unconscious and said that
we have a personal unconscious that consists of our unknown impulses,
desires, thoughts, etc., and a collective unconscious, whose contents are
the same for all humans.
He also said that healthy personality development involves harmony
between the conscious and unconscious elements of the personality and
imbalance between these results in psychologi cal disorders.
 Alfred Adler (1870 -1937) and Karen Horney (1885 -1952) have both
focused on the ego and self -concept. They put forth the idea that we all
wish to see ourselves in positive light and use defenses in order to
maintain this positive image.
They asserted that neurosis develops in people who see themselves as
inferior and these feelings emerge in childhood. Adler believed that as
children we are small and dependent on adults for protection, due to which
we begin life with feelings of inferiority. Healthy personality development
depends on outgrowing the inferiority of childhood and seeing ourselves
as competent adults.
Karen Horney believed that conflicts don’t develop as a result of inborn
motives but because of inadequate child -rearing experience s. If a child
feels loved and secure no conflict will develop and positive aspects of
personality will dominate.
Both of them also emphasised on the role of social and interpersonal
factors in shaping the personality and believed that close relationships are
very satisfying in themselves and are not sought to fulfill sexual or
aggressive desires.
 Erik Erikson (1902 -1994) formulated a theory of human development
that covers the entire life span. He described eight stages of the life cycle.
At each stage individuals face some crisis that increases their
vulnerability. When they successfully master a particular stage, they gain
strength and move on to the next stage.
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63 Stage Approximate
age Positive
Outcomes Negative
Outcomes
1.Trust versus
mistrust Birth –
1.5 years. Feelings of trust
from others’
support. Fear and
concern
regarding
others.
2. Autonomy
versus shame
and doubt 1.5 – 3 years. Self-sufficiency if
exploration is
encouraged. Doubts about
self; lack of
independence.
3.Initiative
versus guilt 3 – 6 years. Discovery of
ways to initiate
action. Guilt from
actions and
thoughts.
4.Industry
versus
inferiority 6 – 12 years. Development of
sense of
competence. Feelings of
inferiority;
little sense of
mastery.
5.Identity
versus
identity
confusion Adole scence Awareness of
uniqueness of
self; knowledge
of roles. Inability to
identify
appropriate
roles in life.
6.Intimacy
versus
isolation Early
adulthood Development of
loving, sexual
relationships and
close friendships. Fear of
relationships
with others.
7.Generativity
versus
stagnation
Middle
adulthood Sense of
contribution to
continuity of life. Trivialisation
of one’s
activities.
8.Ego -
integrity
versus despair Late
adulthood Sense of unity in
life’s
accomplishments. Regret over
lost
opportunities.

 Object relations theorists such as Melanie Klein (1882 -1960),
Margaret Mahler (1897 -1985), D.W.Winnicott (1896 -1971) and Heinz
Kohut (1913 -1981) suggested that we create images or representations of
ourselves and others, on the basis of our early relation ships, and these are
carried throughout adulthood and influence subsequent relationships. They
suggested that self concept develops in 4 stages:
i. Undifferentiated stage : In this stage there is no sense of self
ii. Symbiosis : Here, the newborn doesn’t distingui sh between self and
others but has images of good self / bad self and good others/bad
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64 iii. Separation -individuation : In this stage, the child begins to
distinguish between self and other s but the images of good me -bad me
and good other -bad other are not integrated. For example, a child who
is annoyed with a parent, sees only the bad image of the parent and
says ‘I hate you’ with all his heart.
iv. Integration stage : By this stage the child understands complex
representations that include both good and bad aspects of self and
others. For example, the child who is annoyed with a parent now might
say ‘I am mad at you but I still love you.
 Mary Salter Ainsworth (1913 -1999) and others developed
characterizations of infants depending on the way they relate to the
caregiver. They described four attachment styles:
a.) Fearful , in which the child desires emotional closeness but is
uncomfortable becoming close due to lack of trust or the fear of gettin g
hurt.
b.) Preoccupied , in which the child wants to be emotionally close and
uncomfortable without close relationships. The child is dependent and
believes that others don’t value him as much as he does.
c.) Dismissing , in which the child is self -sufficie nt and prefers not be
emotionally close to anyone or have others depend on him.
d.) Secure , in which the child is comfortable depending on others and
letting others depend on him. The child also doesn’t worry about being left
alone or rejected.
Treatment
 According to Freud, the goal of psychoanalytical treatment is to
become consciously aware of the repressed material. This is achieved
through techniques like free association , in which the client is
encouraged to feel free and speak about anything that come s to his
mind, and dream analysis , in which the client relates details of a
dream and freely associates them while the psychoanalyst gives
meaning to the dreams on the basis of its content and the associations.
 The essence of psychoanalysis is the systemat ic analysis of
transference and resistance . Transference is the process in which,
while interacting with the therapist, the client relives conflictual
relationships shared with one’s parents and transfers them onto the
therapist. Often clients resist or ho ld back in therapy which blocks the
process. Dealing with unconscious fears and conflicts is painful and as
a result the client might forget (unconsciously block) important
information, may not be able to freely associate, postpone
appointments or disconti nue therapy altogether.
 The therapist uses interpretation , a technique in which client’s
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65 conflictual issues by resolving them in a healthy manner as compared
to what had occurred in th e childhood.
 The post -Freudian therapists developed new theories of personality
and methods of treatment but the reliance on Freudian concepts to
explore the unconscious continued.
Evaluation of Psychodynamic Theories
 Freud is credited for developing the f irst extensive theory of
psychology and an organized approach to therapy. Although the role
of instincts and the unconscious continues to be debated on, the idea
that early childhood is crucial in shaping one’s personality and that the
therapist plays a si gnificant role in facilitating the process of change,
are popular among clinicians irrespective of their theoretical
orientation.
 There is lot of evidence in support of the idea of the importance of
early life and that attachment styles are related to psy chological
disorders. For example, one study found that adolescents with an
insecure attachment style are more likely to develop anxiety disorders
as compared to those with a secure attachment style (Warren et al.,
1997). Another study found that those wit h an insecure style receive
higher scores on depression and experience depressive symptoms. It is
suggested these individuals selectively focus on the negative
information and hold themselves responsible for the negative events
(Shaver, Schachner, & Mkulin cer, 2005; Reis & Grenyer, 2004).
One study also showed that infant attachment style can predict relationship
with one’s romantic partner - those with a secure attachment style
comfortably relate to others and enjoy close relationships and
interdependence; ambivalent or preoccupied individuals want and seek
emotionally close relationships but worry that others won’t value them as
much; those with fearful style experience conflicts because they feel
others will reject or be disloyal to them; while those with a dismissive
style are self -sufficient and not very interested in close relationships.
 Freud’s theory did change the conceptualisation of psychological
disorders, but a major criticism in this regard is that Freudian concepts
such as the unconscious mater ial, repression, dreams, etc., cannot be
empirically tested. However, the concept of unconscious does find
wide acceptance in other areas of Psychology, for example, implicit
memory, where the person may not remember details of an event but
the performance clearly seems to be influenced by it is an instance of
an unconscious process.
 Interestingly certain aspects of Freud’s theory cannot be adequately
tested and challenged. For example, if one refutes the idea that the
defense mechanisms are used to protect oneself from anxiety aroused
by unconscious sexual impulses, Freud would suggest that it is one’s
anxiety about coming to terms with this fact that prevents him
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66 Feminist have criticised Freud for being biased against women and
emphasisin g on male development. Karen Horney rejected his concept of
penis envy as the central factor that determines their personality. She
suggested that women don’t envy the penis or masculinity per se but the
power and privileges they enjoy in society.
 Traditi onal psychoanalysis is criticised for being lengthy. However,
there are newer brief forms of therapy that use transference -based
interpretations and focus on the current problems of the client. Brief
psychodynamic therapy (BPT), developed by McCullough and
associates (2003) is based on the idea that the client’s problem stems
from the excessive use of dysfunctional defense mechanisms. BPT
involves increasing the clients’ awareness of their defenses and
encouraging them to drop the defenses and experience the unpleasant
emotions. The therapists then help the clients come to terms with these
distressing thoughts and impulses and develop healthy ways of
expressing them. Finally, the clients, especially those with personality
disorders are helped to build a po sitive self image and rewarding
relationships with others.
4.3 HUMANISTIC PERSPECTIVE
The humanistic perspective emerged as the ‘third force’ in psychology to
emphasize on the ‘human’ behind the cognitions, behaviours and feelings,
which seemed to be larg ely ignored by psychoanalysis and behaviourism.
According to this psychological view, human beings possess an innate
tendency to improve and to determine their lives by the decisions they
make.
Existential views have also influenced the humanistic perspect ive.
Existentialists believe that human beings try to seek the meaning of their
existence and those who appreciate each moment and live as fully as
possible in each moment are mentally healthy. The important founders of
humanistic psychology include Carl Rogers and Abraham Maslow.
Person -Centered Theory
 The person -centered or client -centered theory has been developed by
Carl Rogers, who considered every human being as unique. He
believed that individuals naturally move towards self -actualisation,
that is, fulfillment of their potential for love, creativity and meaning.
The term ‘client -centered’ suggests the idea that the focus is on the
client and not on the therapist or therapeutic techniques.
 The concepts of ‘self’ and ‘self -concept’, one’s subjective pe rception
of who one is and what one is like are central to Rogers’s theory. He
said there is the self – the person one thinks he is and the ideal self -
the person one wishes to be. For example, I am an average student
(self) but I would like to get a di stinction in my exams (ideal self).
 According to Rogers, a person is said to be fully functional or well -
adjusted when there is a match between the real and ideal self and munotes.in

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67 between one’s self -image and his experiences. The term ‘fully’
implies that the ind ividual is utilising his psychological resources
effectively. Thus, a psychological disorder results from an inability to
use one’s full potential that leads to an inconsistency between how one
perceives oneself and reality.
 Due to stress from parents an d the society, individuals develop rigid,
distorted perspectives of self and lose touch with their values and
needs. Consider the case of Sohan, who believes he is unpopular when
in fact most of his classmates are fond of him. This creates a
mismatch betw een reality and Sohan’s perception of it. Others may try
to interact with him but his ignorance would cause him to avoid them.
According to Rogers, this leads to emotional distress, unhealthy
behaviours and in extreme cases, psychosis.
 Rogers viewed a full y functioning individual as steadily moving
towards his own growth. He also suggested that psychological
problems result in children who have critical and harsh parents.
Messages such as ‘you are a good boy only if you listen to me’ create
‘conditions of w orth’ which make the child insecure and anxious that
he might do something that would disappoint his parents. Conditional
love on part of the parents is responsible for the child’s low self -
esteem and the difficulties that follow.
Self-Actualisation Theo ry
 Abraham Maslow, best known for his hierarchy of needs suggested
that the source of motivation is certain needs. He proposed five types
of needs - at the base of the hierarchy are the basic biological needs for
hunger, thirst, etc., followed by the safet y needs, the need for
belongingness, esteem needs and at the top of the hierarchy is the need
for self -actualisation.
 Maslow defined self -actualisation as the inner directed drive in human
beings to reach their highest potential. He described self -actualis ed
people as those who are more concerned about the welfare of others
than themselves, they usually work for some cause or task than for
fame or money, they enjoy the company of their friends but are not
dependent on their approval, they have an accurate view of life and
are yet positive about life etc.
 Maslow was of the opinion that there are very few self - actualising
individuals in this world and that many are partially actualised who get
to experience self -actualisation in what he referred to as the ‘ peak
experience’ - intensely moving experiences in which one is completely
immersed and feels a sense of unity with the world.
 He also said that behaviour is dominated and determined by needs that
are unfulfilled. When an individual attempts to satisfy his needs he
does it very systematically by beginning with the most basic needs and
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68  Both Maslow and Rogers were of the view that psychological
disorders are caused by a movement away from the ideal state and had
simila r ideas about the conditions that hinder self - actualisation.
Treatment
 Rogers firmly believed that the focus on therapy should be the client
and his needs. The clinician’s role is to help the client realise that he is
innately good and enhance his underst anding of himself.
 To deal with the difficulties caused by the conditions of worth, Rogers
suggested that the therapist provides the client with what he called as
the core conditions necessary for therapeutic change - positive regards,
empathy and genui neness. He believed it is important for the therapist
to have unconditional positive regard for the client, that is, a non -
judgmental acceptance of what the client thinks, feels and says. He
defined empathy as the therapist’s ability to enter the client’s
phenomenal world - to experience the client’s world as if it were your
own without ever losing the ‘as if’ quality. The term genuineness
refers to being honest and suggests that the therapist behaves in ways
that are congruent with his self - concept and t hus consistent across
time.
 Therapists following the Rogerian approach use the techniques of
reflection and clarification. Reflection involves rephrasing and
mirroring back what the client has just said. For example, a client
might say, “I feel terrible about having fought with mom.” The
therapist’s reflection of this statement could be, “So you feel very bad
when you have a fight with your mom.” Clarification involves
throwing light on or making clear a vague statement made by the client
about how he fee ls. For example, if the client says, “I am mad at my
friend for not returning my call”, to which the therapist might say,
“And may be slightly hurt as well.”
 Rogers also said that the therapist needs to avoid making suggestions
to the client as this lowers the dignity of the client and his capacity to
be self -directing.
 Maslow did not put forth a model of therapy to treat psychological
disorders but rather provided theoretical guidelines for the most
favourable form of human development.
 In recent times, theorists have come up with techniques like
motivational interviewing (MI) which involves using the core
therapeutic conditions suggested by Rogers in an attempt to encourage
changes from within and make the client independent.
Evaluation of Humanistic Th eories
 One criticism against the humanistic theories is that its concepts
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69 effectiveness of this approach but the measurement was based on self -
report techniques rather than objective eva luation.
 The humanistic theories are not very useful in explaining
psychological disorders. Nonetheless, Maslow’s principles are very
popular and widely used in industry to enhance employee motivation.
4.4 BEHAVIOURAL AND COGNITIVELY BASED
PERSPECTIVES
According to the behavioural and cognitively based perspectives,
abnormality results from faulty ways of thinking which are learned, and
lead to maladaptive behaviours.
Classical Conditioning
Classical conditioning is a type of learning which was studied
experimentally by Ivan Pavlov. It refers to the formation of an association
between a conditioned stimulus and response through repeated
presentation of the conditioned stimulus with the unconditioned stimulus
that originally produced the response.
For exampl e: Sharda feels sad every time she sees the sari gifted by her
husband, who passed away recently. Here, sari is initially a neutral
stimulus because it doesn’t evoke any response by itself. But after
becoming associated with her husband (a naturally evok ing stimulus)
seeing the sari (now, a conditioned stimulus) evokes the emotion of
sadness (conditioned response) .
Some crucial elements in classical conditioning:
 The stimulus which naturally evokes a reflex -like response is called the
unconditioned stimu lus.
 The reflex -like response produced by the unconditioned stimulus is
called the unconditioned response.
 The stimulus which is neutral in the beginning and begins evoking a
response after being paired with unconditioned stimulus is called the
condition ed stimulus.
 The response produced by the conditioned stimulus after pairing it with
the unconditioned stimulus is called the conditioned response.
 In stimulus generalisation, an individual responds in the same way
to different stimuli that have common pr operties.
 In stimulus discrimination, an organism learns to differentiate among
different stimuli and restricts its responding to one stimulus rather than
the other.
 The gradual reduction in the frequency of the conditioned response
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70  Spontaneous recovery refers to the reappearance of a previously
extinguished response after sometime has gone without exposure to the
conditioned stimulus.
John Watson (1878 -1958) demonstrated how conditioned fear developed
through an experiment conducted on an 11 month old infant ‘Little
Albert’. In the experiment, Albert was playing with white rats when
Watson with his associate exposed him to a loud noise. Following this
incident Albert developed a fear for rats. This proce ss is called aversive
conditioning in which an aversive/painful stimulus (noise) becomes
associated with a neutral stimulus (rats). Through stimulus generalisation,
Albert began fearing other white objects too. Although experiments of this
sort are not con ducted anymore due to ethical restrictions, Watson’s work
helped explain the development of phobias (irrational fears).
Counterconditioning, a process of eliminating the classically conditioned
response by pairing the conditioned stimulus with an unconditi oned
stimulus to elicit a response that is stronger than the conditioned response
and that cannot occur at the same time as the conditioned response, is
used to treat phobias.
Operant Conditioning
 Operant or Instrumental conditioning is a type of learnin g in which a
voluntary response is strengthened or weakened depending on its
positive or negative consequences. Skinner, the father of operant
conditioning, was influenced by Thorndike’s law of effect which
states that responses that satisfy some motive are repeated.
 Operant conditioning is based on the concept of reinforcement, a
process by which a stimulus increases the probability that an earlier
behaviour will be repeated. Reinforcers are of several kinds: a primary
reinforcer satisfies some biolog ical need and work naturally without
any prior experience. For example, food and water are primary
reinforcers.
 A secondary reinforcer is a stimulus that becomes reinforcing because
of its association with a primary reinforcer. Money is a secondary
reinfor cer because it helps obtain primary reinforcers. Attention,
recognition and praise are secondary reinforcers and often play a role
in the maintenance of psychological symptoms. For example, the
aches and pains reported individuals with somatoform disorde rs are
often reinforced due to the attention they get from family members.
 Reinforcement can be positive or negative. In positive reinforcement,
behaviour is repeating because of the reward that follows. In negative
reinforcement, the behaviour is repea ted because it removes
something unpleasant from the environment.
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71 punishment involves an unpleasant or painful stimulus that decreases
the probability that an earlier behaviour will be repeated.
 For example, a mischievous child may be told that he wont be allowed
to go out to play in the evening if he misbehaves. This is an instance
of negative reinforcement because with drawing the pleasant stimulus
(play) would encourage the child to behave (increase in frequency). On
the other hand, beating the child for misbehaving is an instance of
punishment because that is expected to reduce his disobedience
(decrease in frequency) .
 Shaping is a technique based on the principles of reinforcement in
which every step towards the desired goal is reinforced. For example,
while teaching a child to write alphabets, they are first encouraged to
draw a standing line, a sleeping line, then a slanting line and then
finally an A.
This is a very commonly used behavioural technique. For example, a shy
person who has difficulty communicating may be encouraged to look at
others and smile, then the next step would involve greeting them, still late r
speaking one line, then holding a conversation for two minutes and so on.
Social Learning and Social Cognition
 The social learning view is given by Albert Bandura who argued that
people also learn by observing the behaviour of other people.
Modeling is t he process in which people acquire new behaviours by
imitating the behaviour of important people in their lives.
 Social learning theorists study the influence of modeling and one’s
relationships with others on the development of psychological
disorders. They are also interested in social cognition, that is, the
manner in which we interpret, analyse, remember and use information
about the social world.
 Bandura said that observational learning (vicarious reinforcement)
takes place when a person observes the rewards and punishments that
another person receives for his behaviours and behaves accordingly.
 He also put forth the concept of self -efficacy, that is, the belief that
one can successfully execute behaviours necessary to control desired
outcome (‘I thi nk I can’). Self -efficacy is found to be related to
motivation, self -esteem, interpersonal relationships, health
behaviours, addictions, etc. (Bandura et al., 2004).
Cognitively Based Theory
 The cognitively based theories believe that cognitions, that i s, thoughts
or beliefs, shape behaviours. Aaron Beck and Albert Ellis are two
well-known cognitive theorists who have contributed to the
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72  Beck spoke about automatic thoughts - ideas t hat are so deep - rooted
that the individual is often not aware of them, which come to mind
spontaneously and cannot be neglected. For example, if one slips and
fall one might think “how stupid am I,” “others must be thinking I am
so dumb,” etc. These aut omatic thoughts are usually of a self -defeating
nature and are followed by the experience of negative emotions.
 Automatic thoughts arise from faulty attitudes. These attitudes make a
person interpret situations in a biased manner as shown below:
Dysfunctio nal Attitude
I need to at my best at all times.
↓
Experience
I happen to slip and fall.
↓
Automatic Thought
I am so dumb / People must be thinking I’m stupid.
↓
Negative Emotion
I feel useless and angry.
 Albert Ellis gave the A -B-C model which suggests tha t how one feels
is determined by the way one thinks about the events in his life. A
refers to the ‘activating event’, B to the ‘beliefs’ and C is the
‘consequences’. According to him, irrational beliefs, that is,
unrealistic and exaggerated views abou t self and the world are the
cause of several psychological disorders. Conforming rigidly to these
irrational beliefs using ‘should/must/ought’ makes one feel miserable
and results in emotional disturbances.
 David Barlow gave a model that explains the impact of a combination
of physiological, cognitive and behavioural factors on the development
of anxiety disorders. For example, a panic attack may be triggered
when a person who hyperventilates (physiological factor) after
climbing up stairs, misinterpre ts (cognitive factor) the physiological
signs as an indication of an impending heart attack and forms
associations between some stimuli and the experience of panic,
consequently avoiding that situation (behavioural factor).
Treatment
The behavioural and co gnitively based approach asserts that abnormality
results from faulty thought processes which are learned and can be
unlearned.
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73 Conditioning Techniques
 Using principles of classical conditioning and operant conditioning
such as positive and negative reinf orcement, counterconditioning,
aversive conditioning, extinction, etc behaviour therapists help client
change faulty behavioural patterns and substitute them with healthy
behaviours.
 Joseph Wolpe used counterconditioning to treat phobias or irrational
fears. For example, he taught cats who were classically conditioned
to experience anxiety in a room in which they were administered
shocks, to associate the room with eating, which reduced their anxiety.
 Counterconditioning is effective when the new stimulus used is able to
evoke a response that is stronger and cannot exist at the same time as
the conditioned response. For example, to help little Albert get rid of
his fear of white rats, one needs to pair white rats with a stimulus such
as chocolates or his favourite toy. Fear (evoked by the rats) and joy
(evoked by the chocolate/toy) being contradictory states cannot co -
exist and repeated pairing of this nature would gradually help to
reduce his fear.
 Another form of counterconditioning is systematic dese nsitisation in
which the therapist attempts to reduce the client’s anxiety by
combining relaxation techniques and progressive or graded exposure
to the phobic stimulus. For example, to treat a client with dog phobia,
the therapist may gradually expose him to the concept of dog in a
hierarchical order. The first step would involve helping the client enter
a relaxed state following which the therapist would speak about the
feared stimulus (the dog), the next step would involve watching
pictures of a dog, nex t watching a live dog outside from the window
and so on till the client is comfortable with the idea of being close to a
dog without anxiety.
 Also often used is the technique of flooding, which is the opposite of
systematic desensitisation and involves intensely exposing the client to
the feared object. For example, instead of gradually desensitising a
person who has bat phobia he may be exposed to a bunch of bats in
entirety.
 Wolpe developed one more form of counterconditioning -
assertiveness training, which involves expressing oneself and
satisfying one’s own needs and feeling good about it without hurting
others in the process. In this technique, the aim is to learn to
communicate the desired emotion (anger) effectively so that the
opposing emotion ( anxiety) gets weakened. As a result the client is
able to express one’s needs and deal with the challenging situation
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74 Contingency Management Techniques
 These set of techniques are based on the idea that any behaviour that is
followed by a po sitive consequence (reward) is repeated and
undesirable behaviours can be unlearned by taking away the rewards.
Accordingly, contingency management involves helping a client
connect the outcome of the behaviour with the behaviour itself. This
technique is effective in reducing disruptive behaviours such as
temper tantrums, in disciplining children, developing good habits,
reducing smoking, weight management, etc.
 Token economy is a form of contingency management in which clients
earn tokens or points sh owing desirable behaviour which can be later
exchanged for some concrete reward. For example: In 1970s, at a
mental health centre in Illinois, researchers designed an environment
for Schizophrenia inpatients that encouraged appropriate socialisation,
participation in group activities, self -care such as bed -making, and
discouraging violent behaviours. They then set up a token economy in
which patient could earn small luxuries such as buy cigarettes with the
tokens earned for keeping the room clean or be fin ed (lose tokens) for
behaving inappropriately. This technique can also be used to mange
behavioural disorders in children.
Modeling and Self -Efficacy Training
 Bandura believed in observational learning (vicarious reinforcement)
and used this understanding in treating phobias by showing clients
video -tapes or real -life model. For example, a boy who has developed
the fear of white rats may be shown a video in which a boy is enjoying
playing with a rat. This helps the boys to understand that rats need
not be dangerous and dealing with them can be fun.
 Another form of this technique is participant modeling, in which the
therapist first demonstrates the desired behaviour to the client and then
helps him do the same. For instance, in the earlier example, the
therapist might first play with the rat and then support the client in
doing so.
 Bandura is also credited for his theory of self -efficacy. According to
this theory, people’s beliefs about their capacities are better predictors
of their accomplishments tha n their actual skills. He said that fears
develop because the person believes that he doesn’t have the resources
needed to deal with the phobic stimulus and thus by improving self -
efficacy, the fear can be eliminated. Bandura describes four ways of
improvi ng self - efficacy:
1.) Performance attainment: The best way to enhance self - efficacy is to
successfully carry out the desired task.
2.) Vicarious experience: By observing someone similar overcome a
problem, one is likely to believe or have greater confi dence that one can
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75 3.) Verbal persuasion: Encouragement by saying ‘you can do it’ can
increase confidence and reassure a person of his capabilities.
4.) Physiological state: one is not likely to feel confident about doing w ell
when one is sweating excessively. By learning to relax and consciously
changing the physiological arousal one can reduce stress and improve self -
efficacy.
Thus, self -efficacy training can be useful in overcoming problems such as
smoking, obesity, und esirable health habits, etc.
Cognitive Therapies
 According to the cognitive and cognitive -behavioural therapies, the
way we think determines the way we feel. Based on this principle is
the technique of cognitive restructuring in which the therapist helps t he
client change the way he thinks about himself, others and the future.
The therapist does this by encouraging the client to identify
maladaptive attitudes and irrational beliefs, challenge them and replace
them with ideas that can be checked in real lif e.
 Panic control therapy (PCT) is a form of cognitive -behavioural therapy
that is used to treat panic disorder which is a type of anxiety disorder
in which the person experiences recurrent and unexpected panic
attacks. PCT combines cognitive restructuring, exposing the client to
the bodily sensations associated with panic attacks and breathing
retraining. Here, the client is taught to identify how faulty cognitive
judgments are contributing to the experience of anxiety, examine
their reactions and change them with appropriate breathing techniques
and recognise places, persons and behaviours that make them feel safe.
 Acceptance and Commitment Therapy (ACT) is also a cognitively
based form of therapy in which the client is encouraged to
acknowledge and acce pt all the distressing thoughts, feelings and
behaviours and thereby gain a sense of control that helps them in their
commitment to overcome them.
Evaluation of Behavioural and Cognitively Based Perspective
 The cognitive - behavioural perspective is credit ed for its simple
approach that emphasises on the use of objective/empirical procedures.
 According to the humanists, the behavioural perspective limits the
scope of Psychology because it doesn’t take into account the active
choices that individuals make ( free will) in dealing with the
environment.
 The Psychoanalysts have criticised the behaviourists for ignoring the
fascinating unconscious influences on behaviour.
 However, the cognitive theories acknowledge that thought processes
need to be studied and that implicit ideas about the self do influence
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76  Behavioural and cognitive theories have a wide application and are
useful in explaining and treating a variety of disorders including
anxiety disorders, mood disorders, eating disorders, sexual
dysfunctions, etc.
4.5 SOCIOCULTURAL PERSPECTIVE
This perspective focuses on how social and cultural agents or external
factors such as other people, social institutions and events in the social
context, influence the individual. The term sociocultural ref ers to all the
circles of social influence that surround the individual that is the family,
neighbourhood and society.
Family Perspective of Psychopathology
According to the family perspective, psychopathology or dysfunction in an
individual reflects psych opathology or dysfunction in the family members.
There are four approaches under this perspective:
1.) Intergenerational, given by Murray Bowen, suggests that how parents
interact with their children is influenced by how they were treated as
children.
2.) Salvador Minuchin gave the Structural approach which puts forth the
idea that in normal families every individual has specific functions and
the relationship boundaries are fixed and that troubles occur if family
members are too close or too distant.
3.) In the Strategic approach, proposed by Jay Haley, the therapist
influences the client with direct instructions about how to resolve issues
within the family, especially power relationships.
4.) In the Experiential approach, Carl Whitaker suggests that the family
dysfunctions are caused by obstacles in one’s personal development.
Virginia Satir’s sculpting techniques involves making clients role -play
difficulties in interaction. John Gottman found that characteristics such as
contempt, criticism, defens iveness and stonewalling are related to
difficulties in a marriage.
Family theorists have provided insights that help explain and treat
psychological disorders. For example, Eating disorders may be found in
families with disturbed relationships and starv ing oneself is seen as an
adolescent’s attempt to demonstrate one’s control over one’s body and
life.
Social Discrimination
 Sociocultural theorists suggest that discrimination on the grounds of
gender, race, religion, social class, age, sexual orientation , etc., can
also cause psychological disorders.
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77 difficulties are commonly found among those from the lower socio -
economic strata.
 In addition to this, the rates of crime and substance abuse are high and
poor physical and mental health often results in premature death
(Khaw et al., 2008). Age and gender bias can cause tremendous
frustration and emotional difficulties giving r ise to psychological
symptoms, especially since these characteristics are fixed.
Social Influences and Historical Events
 Theodore Millon (1988), a personality psychologist suggested that
changing societal values has led to a rise in psychological disorders in
the West. Social instability makes children perceive the world as
threatening and unpredictable and thus increase the risk of developing
disorders later in life.
 The rates of mental disorders are higher in societies that go through
significant social change. Reorganisation in the society, such as
industrialisation, changing people’s roles and relationships to the
society from a worker to an unemployed person or in a situation like
India -Pakistan partition, from a majority culture to a minority or
multi cultural society.
 Traumatic events of historical or political significance or natural
disasters such as the earthquakes, floods, famines also adversely affect
mental health. American psychologists, studying the effects of war
have found that it negativel y affects psychological functioning. Also,
the possibility of developing serious anxiety disorders is greater
among those who have been disturbed by terrorist attacks,
harassment, imprisonment or experienced war.
Treatment
Therapists play a significant role in helping individuals cope with the
stresses within the family, immediate environment or the society at large,
especially since the world cannot be changed.
Family Therapy
 Family therapy focuses on helping the family members relate to each
other and communicate in healthy ways. The therapist often spends
time talking to every family member so as to build rapport, especially
with those who seem to resist therapy.
 To improve communication, the therapist may initiate a conversation,
observe the dynamic s of their relationship and then guide the two
members as they proceed. Sometimes these sessions are videotaped or
held in rooms with one -way mirrors.
 Family therapy is different from individual psychotherapy, that is, here
the therapist works on disturbe d relationship patterns in the family as a
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78  Also, family therapists believe that harmonious relationships among
family members are more beneficial to treatment than the client -
therapist relationshi p.
 Various techniques are used by family therapists, for example, an
intergenerational therapist may use a genogram, which is a
diagrammatic representation of all relatives in the recent past. This
information gives the therapist an idea of the nature of r elationships
shared by the family members, which is then used to bring about
desirable changes.
Strategic family therapists work on finding solutions to issues within the
family by making the members role -play conflicting views; while an
experiential famil y therapist focuses on helping the family members
develop a better understanding of their relationships.
Group Therapy
 In this method people having similar problems share their experiences
with each other. Irvin Yalom (1995) suggested that this technique i s
effective for various reasons - it relieves the individuals and gives
them hope as they realise that their problems are not exceptional; they
receive useful information and suggestions from others who share
how they dealt with their issues and the fee ling of being of help to
someone makes them feel better about themselves.
 The evidence for the effectiveness of group therapy comes from
Alcoholics Anonymous, in which individuals with alcohol -related
problems and their families share their stories and the techniques they
successfully used to stay away from it.
 Group therapy also helps individuals with pedophilias, who have
sexually abused children, to drop their defenses by providing a very
supportive environment to share their concerns (Berlin, 1998).
 Studies have shown that group therapy is effective for individuals
with depression, especially when combined with individual therapy or
medication (Kasters et al., 2006).
Multicultural Approach
 The therapists need to be sensitive to the cultural background of the
clients. When dealing with clients from different backgrounds,
treatment should incorporate three components: awareness, knowledge
and skills.
 Awareness refers to the idea that the therapist needs to be familiar with
how the cultural context influe nces the client’s experience or the way
he relates to others.
 Knowledge relates to taking the responsibility of finding out about the
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79  Skills refer to expertise in the spec ific therapy techniques that would
work with the clients of a particular culture.
Milieu Therapy
 The term milieu implies the surrounding or the environment. This
form of therapy involves scientific structuring of the environment by
the staff - therapist, nurse or the paramedical professional, and clients
as a team, to enhance the client’s functioning.
 It focuses on improving social interaction, the physical structure of the
setting and scheduling activities such as group therapy session,
occupational ther apy, physiotherapy, etc.
 The goal of milieu therapy is to provide a supportive environment that
encourages socially desirable behaviour and to keep as many links as
possible to the client’s life, beyond the family.
Evaluation of Sociocultural Perspectiv e
 Clinicians acknowledge the role of the environment in causing or
maintaining psychological symptoms, with the understanding that not
much can be changed in the surrounding. For example, discrimination
has adverse effects on one’s mental health but putt ing a stop to it is
difficult. Similarly, the client’s family may have a clear role in his
psychological problems but the family members may be uncooperative
or unavailable.
 Though group therapy can be very effective, several clients are shy or
ashamed of sharing their concerns in front of others who are seen as
strangers. These issues can be dealt with in individual therapy by
focusing on how the cultural background of the client influences the
way he relates to others.
 In certain cases biological theories provide better explanations of
disorders than the sociocultutral ones. For example, Schizophrenia
cannot be accounted for by dysfunctional family patterns. However,
disturbed communication within the family is known to increase the
severity of Schizophr enia or cause relapse.
 Thus, though the sociocultural perspective throws light on the
psychological disorders, they are better explained when the biological
and psychological perspectives are combined with it.
4.6 BIOPSYCHOSOCIAL PERSPECTIVE ON
THEORIES AN D TREATMENT: AN INTEGRATIVE
APPROACH
There are five major schools of thought discussed in this chapter. In actual
practice, most clinicians prefer an eclectic approach that integrates
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80 There are three ways in which clini cians combine the different therapeutic
models (Goldfried & Norcross, 1995): technical eclecticism, theoretical
integration and the common factors approach. Those who follow technical
eclecticism acknowledge that particular techniques across theoretical
perspectives are effective in treating a particular problem, irrespective of
their own theoretical orientation. For example, a psychoanalyst may value
the use of graded exposure in treating a patient with phobia.
Theoretical integration comprises of develo ping one’s own theory about
the patient’s presenting problem by incorporating principles from different
theoretical models. For instance, a therapist may believe that maladaptive
family system and faulty cognitions have contributed to the client’s
condit ion and accordingly develop an intervention plan by combining
these two approaches.
The common factors approach involves using the core principles shared by
the different theoretical models and those which have been proven to
effective in clinical practic e such as the counselor -client relationship
(O’Leary & Murphy, 2006). Some clinicians follow a mixed model of
integration which combines aspects of all the three integrative approaches.
In understanding the psychological disorders in the following chapters it is
important to take into account the various biological, psychological and
social factors that may contribute to its development and treatment.

4.7 SUMMARY
In this unit we have discussed the various theoretical perspectives. The
first perspective wa s the psychodynamic perspective developed by
Sigmund Freud. We discussed the structure of personality and the concept
of defense mechanism. We also discussed the psychosexual stages of
development. Post Freudian Psychodynamic writers were also discussed.
Psychodynamic theory was evaluated. The next perspective that we
discussed was the Humanistic perspective. The person - centered theory as
well as self -actualisation theory was discussed.
Sociocultural perspective was the next perspective which we discu ssed.
We discussed the family perspective of psychopathology, social
discrimination and related concepts. Family therapy, group theory, milieu
therapy was also discussed.
Behavioural and cognitive based perspective is one of the most dominant
current per spectives. The behavioural perspective includes classical
conditioning, operant conditioning as well as social learning. Cognitive
based theories as well as treatment based on cognitive and behavioural
approaches were also discussed. These treatment app roaches include
conditioning techniques, contingency management techniques, modeling
and self -efficacy training, etc.
Towards the end of the unit we had discussed the concept of
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81 4.8 QUESTIONS
1. Discuss the concepts of Id, Ego an d Superego as given by Sigmund
Freud.
2. Discuss the various Adaptive Defenses.
3. Explain the psychosexual stages of development as outlined by
Sigmund Freud.
4. Write notes on the following
a. Person centered theory
b. Self actualisation theory
5. Discuss the sociocultur al perspective in detail.
6. Discuss the behavioural and cognitive perspective.
7. Write short notes on the following.
a. Conditioning Techniques
b. Contingency Management Techniques
4.9 REFERENCES
Butcher, J.N; Hooley, J.M; Mineka, S; & Dwivedi, C.B. (2020). Abnormal
Psychology . (16th ed.). Pearson
Halgin R. P. and Whitbourne S.K. (2010) Abnormal Psychology :
Clinical Perspectives on Psychological Disorders, (6th Ed.), McGraw
Hill.
Nolen – Hoeksema S. (2008) Abnormal Psychology (4th Ed.), New York
McGraw Hill.


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PANIC, ANXIETY, OBSESSIONS AND
THEIR DISORDERS - I
Unit Structure
5.0 Objectives
5.1 Obsessive Compulsive Disorder
5.2 Post -Traumatic Stress Disorder
5.3 The Bio psychosocial Perspective of Anxiety Disorder
5.4 Summary
5.5 Questions
5.6 References
5.0 OBJECTIVES:
After reading this unit you will get to know
 About symptoms, causes and treatments of OCD and PTSD.
 What is the bio -psychosocial perspective of anxiety disorders.
5.1 OBSESSIVE COMPULSIVE DISORDER (OCD) :
OCD is a type of anxiety disorder but di ffers from other anxiety disorders.
The person shows either obsessions and/or compulsion, which are
excessive and unreasonable.
Obsessions
They are recurrent and persistent thoughts, impulses, or images that are
experienced as intrusive and inappropriate a nd that cause anxiety or
distress.
Compulsions
They are repetitive behaviours (such as hand washing, checking, etc.) or
mental acts (such as praying, repeating words, etc.) that the person feels
driven to perform in response to an obsession or according to rules that
must be applied rigidly.
People with obsessive compulsive disorder experience anxiety when they
have an obsessions and when they cannot carry out their compulsions.
They try to ignore or suppress their obsessive thoughts. For them these
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83 some other thoughts or some compulsive behavior. For e.g. hand washing.
Some without any obsessive thought tend to engage in the ritualistic,
compulsive behavior. E.g. counting 10 after ever y 20 steps of walking. An
individual suffering from OCD experiences significant distress and
impairment in their personal, social and occupational functioning.
Common obsessions one focuses on are contamination, checking, need to
put things in order etc. Common compulsion are repetitive behavior,
putting things inn order, cleaning, checking etc.
BIOLOGICAL PERSPECTIVE –
Biological theories: Biological theories of OCD speculate that areas of
the brain involved a in the execution of primitive patterns of be haviour,
such as washing rituals, may be impaired in people with OCD.
Researchers have found abnormalities in the basal ganglia area of the
brain which plays an important role in motor movements. They also found
abnormal functioning of prefrontal cortex w hich plays an important role
iin inhibiting unwanted thoughts, images or urges.
Biological treatment: The drugs that regulates serotonin have proven
helpful in treating OCD. The most effective drug therapies for OCD are
the antidepressant known as selecti ve – serotonin reuptake inhibitors
(SSRI). In an extreme cases wherein drugs are not proving effective
enough to deal with the symptoms of OCD then patients is treated with
psychiatric surgery.
PSYCHOLOGICAL PERSPECTIVE –
Psychodynamic theories: Psychody namic theory of OCD suggest that
the obsessions and compulsions symbolizes unconscious conflict or
impulses. According to psychodynamic theorist, fixation in anal stage of
psychosexual development is associated with OCD.
Psychodyanamic treatment: The thera py for OCD involves uncovering
these unconscious thoughts.
Cognitive behavioral theories suggest that people with OCD are
chronically distressed, think in rigid and moralistic ways, judge negative
thoughts as more acceptable than other people do, and feel more
responsible for their thoughts and behaviours. This makes them unable to
turn off the negative, intrusive thoughts that most people have
occasionally. Compulsive behaviours develop through operant
conditioning, people are reinforced for compulsive beh aviours by the fact
that they reduce anxiety.
Cognitive Behavioural Therapy (CBT): CBT have also proven helpful
for OCD. These therapies expose OCD client to the content of their
obsessions while preventing compulsive behaviour, the anxiety over the
obsessions and the compulsions to do the behaviours are extinguished.
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84 Unfortunately neither the drug therapies nor the cognitive. behavioural
therapies tend to eliminate the obsessions and compulsions completely.
The relapse rate with the drug therapies is hi gh once the drugs are
discontinued. Cognitive behavioural therapies help prevent relapse.
5.2 POSTTRAUMATIC STRESS DISORDER (PTSD):
PTSD is an anxiety disorder which occurs after a person experiences a
severe trauma. It is a set of symptoms including hyper vigilance, re -
experiencing of the trauma, emotional numbing experienced by trauma
survivors.
People who experience severe and long lasting traumas, who have lower
levels of social support, who experience socially stigmatizing traumas,
who were already dep ressed or anxious before the trauma, or who have
maladaptive coping styles may be at increased risk for PTSD.
When the distress persists for few days to a month after the traumatic
event then the diagnosis of Acute stress disorder is assigned to that
individual. However, when the symptom persists beyond one month then
the diagnosis of PTSD is given.
The three main categories of symptoms of PTSD are –
1. Re – experiencing of the traumatic event –
Frequent nightmares, flashbacks of the event, other stimulus rem ind the
event, etc.
2. Emotional numbing and detachment -
Avoidance of anything which reminds of the event, restricted emotional
responses, no reaction to any kind of emotional provocation, sometimes
unable to remember certain aspects of the event, etc.
3. Hyper vigilance and chronic arousal -
Constantly alertness for the traumatic event, panic and flight, chronically
over aroused, easily startled, quick to anger, etc.
Four types of events are seen to result in PTSD –
1. Natural disasters – Floods, earthquakes, fire s, tornadoes, etc.
2. Abuse – Physical abuse like beating, sexual abuse like rape, emotional
abuse like critical parents, etc.
3. Combat and War related traumas - War prisoners witnessing
deaths, war zone stress etc.
4. Common traumatic events - Accidents, sudden d eath of loved ones,
drowning, heart break, etc.
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85 BIOLOGICAL PERSPECTIVE
Biological Theories – Researchers have found that lower level of the
hormone cortisol can result in PTSD, as it prolongs the activity of the
sympathetic nervous system. PTSD people sho w increased blood flow in
the amygdala area of the brain.
Twin and family studies shows that PTSD can be inherited, it runs in the
family
Biological Treatment – Serotonin reuptake inhibitors (SSRI) and
Benzodiazepines are helpful in treating PTSD symptoms.
PSYCHOLOGICAL PERSPECTIVE
Psychological Perspective - Human beings live with many assumptions
about themselves and others, this keeps the person’s faith and trust intact.
But an individual may experience PTSD if these assumptions get shattered
because of any kind of trauma.
People already suffering from depression and anxiety are more vulnerable
to develop PTSD.
The onset of PTSD also depends on the person’s coping styles and
adjustments. People using self -destructive styles such as taking alcohol,
drugs, isolation are more vulnerable to PTSD.
Cognitive Treatment - Systematic desensitization helps the patient to
identify the stimulus and rank the fear ascendingly. Positive imagery
training helps the victims of rape to recover from PTSD. Stress
management m ethods helps to develop skills to overcome stressful issues.
SOCIOCULTURAL PERSPECTIVE
Sociocultural Theories - People with strong social and supportive social
group are less likely to develop PTSD after a trauma.
Sociocultural Treatment - Community level i nterventions helps the
people with PTSD caused by natural disasters, etc.
Check Your Progress –
1. What are the causes of PTSD?
2. What are the treatments of PTSD?
5.3 BIOPSYCHOSOCIAL PERSPECTIVE OF ANXIETY
DISORDERS:
Biology is clearly involved in the experienc e of anxiety disorders.
Evolution has prepared our bodies to respond to threatening situations
with physiological changes that make it easier for a person to flee or fight
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86 actively or poorly regulated arousal. These people are more prone to
severe anxiety reactions to threatening stimuli and to the anxiety disorders.
Social perspective focus on differences between groups in the rates and
expression of anxiety disorders. Women have h igher rates of almost all the
anxiety disorders than do men. Women may have more genetic
vulnerability to anxiety disorders because of changes in their hormonal
levels.
Culture may differ in their expression of this disorder. Psychological
perspective focu s on the upbringing of an individual e.g., specific
traumatic experiences that some have suffered.
5.4 SUMMARY:
PTSD focuses on avoiding thoughts or images of past traumatic
experiences.
OCD disorder focuses on repulsive intrusive thoughts and the use of
ritualistic behaviours.
5.5 QUESTIONS :
1. Define Obsessive Compulsive Disorder. Discuss its theories and
treatment.
2. Define Post Traumatic Disorders and discuss its causes and treatment.
3. Write a note on Biopsychosocial perspective of Anxiety Disorders.
5.6 RE FERENCES
Abnormal psychology by David H. Barlow & V. Mark Durand, 1995,
2005, New Delhi.
Dhanda, Amrta (2000) Legal order and mental disorder, New Delhi. Sage
Publications Pvt Ltd.

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PANIC, ANXIETY, OBSESSIONS AND
THEIR DISORDERS - II
Unit Structure
6.0 Objectives
6.1 Introduction
6.3 Anxiety Disorders
6.4 Panic Disorder
6.4 Phobia (Agoraphobia, Specific Phobia, Social Phobia)
6.5 Generalized Anxiety Disorder
6.6 Summary
6.7 Questions
6.8 References
6.0 OBJECTIVES:
After reading this unit you will get to know
 About the nature of anxiety disorder.
 About the causes and treatments of panic disorder and phobias.
 About symptoms, causes and treatments of GAD.
6.1 INTRODUCTION:
Anxiety is a body’s natural response to stress. It is an emotion wherein,
while facing any stressful situation, an individual experiences fear, worry
and apprehension. In case of anxiety disorder, these feelings of fear, worry
and apprehension are extreme and are out of proportion.
Anxiety disorder is ch aracterized as a feeling of worry or fear that is so
strong that it interferes with the normal functioning of an individual and
causes distress and impairment. Many a time an individual experience
somatic symptoms. For e.g., heart palpitation, sweating, mu scle tension
etc. when a person is in stress.
There is no single cause of excessive emotional reactions such as anxiety
or panic. It seems that there is strong evidence of anxiety to be genetic in
nature. Though a very well and empirically sound explanati on is also
provided by Behaviorists theorist and Cognitive behavior theorist and the
treatment proposed by these approaches were found to be very effective in
dealing with the disorder. Different anxiety disorders such as GAD, OCD,
PTSD, Phobias, etc., can be treated by different approaches such as
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88 The Fear and Anxiety Response Patterns
 There has never been complete agreement about how distinct the two
emotions of fear and anxiety are from ea ch other. Historically, the
most common way of distinguishing between the fear and anxiety
response patterns has been whether there is a clear and obvious source
of danger that would be regarded as real by most people. When the
source of danger is obvious, the experienced emotion has been called
fear (e.g., “I’m afraid of snakes”). With anxiety, however, we
frequently cannot specify clearly what the danger is (e.g., “I’m anxious
about my parents’ health”)
 In recent years, however, many prominent researchers have proposed a
more fundamental distinction between the fear and anxiety response
patterns (e.g., Barlow, 1988, 2002; Bouton, 2005; Grillon, 2008;
McNaughton, 2008). According to these theorists, fear is a basic
emotion (shared by many animals) that invo lves activation of the
“fight -or-flight” response of the autonomic nervous system. Its
adaptive value as a primitive alarm response to imminent danger is
that it allows us to escape.
 Anxiety response pattern, in contrast, is a complex blend of unpleasant
emotions and cognitions that is both more oriented to the future and
much more diffuse than fear (Barlow, 1988, 2002). But like fear, it has
not only cognitive/subjective components but also physiological and
behavioral components.
 At the cognitive/subjec tive level, anxiety involves negative mood,
worry about possible future threats or danger, self -preoccupation, and
a sense of being unable to predict the future threat or to control it if it
occurs.
 At a physiological level, anxiety often creates a state o f tension and
chronic overarousal, which may reflect risk assessment and readiness
for dealing with danger should it occur (“Something awful may
happen, and I had better be ready for it if it does”). Although there is
no activation of the fight -or-flight r esponse as there is with fear,
anxiety does prepare or prime a person for the fight -or-flight response
should the anticipated danger occur.
 At a behavioral level, anxiety may create a strong tendency to avoid
situations where danger might be encountered, but there is not the
immediate behavioral urge to flee with anxiety as there is with fear
(Barlow, 1988, 2002).
 The adaptive value of anxiety may be that it helps us plan and prepare
for possible threat. In mild to moderate degrees, anxiety enhances
learn ing and performance. For example, a mild amount of anxiety
about how you are going to do on your next exam, or in your next
tennis match, can be helpful.
 But anxiety is maladaptive when it becomes chronic and severe, as we
see in people diagnosed with anx iety disorders. Although there are
many threatening situations that provoke fear or anxiety
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89 6.2 ANXIETY DISORDERS:
Most of the people tend to have some childhood fears or adulthood fears
which are mild, short -term, or reasonable. However, the fears experienced
by people with anxiety disorder are so severe and chronic that it interferes
with their functioning and negatively affects their quality of lives. As
mentioned earlier, their fears are out of proportion to dangers that they
truly face. The emotion response could be related to real fearful stimuli or
perceived threat. Once an individual experiences the anxiety, it tends to
feed on itself so that it might not stop even if the particular l ife stressor has
long since passed.
Four types of symptoms determine the presence of anxiety -
1. Somatic symptoms – muscle tension, heart palpitation, stomach pain
etc.
2. Emotional symptoms – restlessness, fearfulness, irritability and
constant watchfulness.
3. Cognitive symptoms – problems in taking decisions and concentration,
fear of dying, losing control, etc.
4. Behavioural symptoms – escapism in behaviour,
aggressiveness, avoidance, etc.
There are different types of disorders where the main cause is anxiety and
panic. Anxieties are consciously expressed or take some maladaptive
forms like phobia, GAD, PTSD, etc.
6.3 PANIC DISORDER AND PHOBIAS
Symptoms of Panic Attacks
Panic disorder is a disorder wherein an individual experiences panic attack
on recurrent basis o r there is constant worry of experiencing another panic
attack for least a month. Panic attacks, are short but intense periods in
which individual experiences intense fear and physical symptoms such as
heart palpitations, trembling, a feeling of choking, d izziness, intense
dread, losing ones control, going crazy, or even dying. In order to
diagnosis a person with panic disorder he/she must experience a panic
attack more than once. They tend to engage in maladaptive behavior such
as avoiding the place where they had the first panic attack.
Panic attacks may occur in the absence of any environmental triggers. For
some people panic attacks are situationally predisposed. The person is
more likely to have them in certain situation but does not always have
them w hen in those situations. In all cases, however, the panic attack is a
terrifying experience, causing a person intense fear or discomfort.
Some people with panic disorder have many attacks in a short period of
time. Less frequently, people who have panic d isorder often fear that
they have life – threatening illnesses. E.g., thyroid disorders, or with a
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90 people will develop panic disorder at some time in their lives. Most people
who develop panic disorder usually do so sometime between late
adolescence and their mid thirties. Many people with panic disorder also
suffer from chronic generalised anxiety, depression, and alcohol abuse.
Biological Perspective
According to biological theor y, an individual with panic disorder have
over reactive autonomic nervous systems, which put them into a full
flight -or-fight suspense with little provocation. This may be the result of
imbalances in norepinephrine or serotonin or due to hypersensitivity to
feelings of suffocation. There are also some evidence that panic disorder
may be transmitted genetically.
Antidepressants and benzodiazepines have been effective in reducing
panic attack and agoraphobic behaviour, but people tend to relapse into
these disorders when they discontinue these drugs.
Psychological Perspective
Psychological theories suggest that people who suffer from panic disorder
pay very close attention to their bodily sensations, misinterpret bodily
sensations in a negative way, and enga ge in snowballing, catastrophic
thinking. This thinking then increases physiological activation, and a full
panic attack starts.
Cognitive –behavioural therapy (CBT) seems to be an effective treatment
to deal with panic disorders. Clients are taught relaxat ion exercises and
then they learn to identify and challenge their catastrophic styles of
thinking, often while having panic attacks induced in the therapy sessions.
6.4 PHOBIAS
Agoraphobia :-
The term agoraphobia is from the Greek word meaning “fear of the ma rket
place”. However, the agoraphobia as a disorder is just not limited to
market place but it is a condition in which an individual has a fear of any
place that they think they might have trouble escaping or getting help in an
emergency. E.g., fear of not receiving any help if they experience a panic
attack, when they are watching movie in the threatre. Here, the basic fear
is not of the place (stimuli) but of not able to receive any help. Which
make this different from all other type of phobias. People wi th
agoraphobia fear of not receiving any help if needed in crowded places,
bustling places, such as the market place or the shopping mall. They also
fear enclosed space, such as buses, subways, or elevators. Finally, they
fear wide open spaces, such as ope n fields, particularly if they are alone.
This fear is so much in some individuals are they refrain from leaving
their home.
According to DSM 5, the symptom must persist over the period and
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91 agoraphobia begins within one year after a person begins experiencing
frequent anxiety symptoms.
In DSM -IV-TR, agoraphobia was not considered as a separate diagnosis
from panic disorder. So, people used to get the diagnosis of panic disorder
with or without agoraphia. But in DSM 5, based on considerable body of
research and ICD system, agoraphobia is consider as a separate diagnosis
in DSM 5.
Agoraphobia strikes people in their youth. In one large study, more than
70 percent of the people who develo ped agoraphobia did so before the
age of 25, and 50 percent developed the disorder before the age of 15
(Bourden et al. 1988).
Phobias
Specific Phobias: -
Phobias are intense and extreme fear of a particular object or situation.
When people with these phob ias encounter their feared objects or
situation, their anxiety is immediate and intense, and some may even have
full blown panic attacks. They go to any length to avoid encountering the
fearful object or situation. And most importantly they experience
significant distress and impairment.
Most phobias develop during childhood. Adults with phobias recognize
that their anxieties are illogical and unreasonable but they can’t control
their anxiety, however children may not have this insight. Although as
many as 4 in 10 people seem to have specific phobia some point in the
lifetime, making it one of the most common disorders.
Specific phobias fall into one of four categories, (APA, 2000) animal type,
natural environment type, situational type, and blood – injectio n – injury
type.
a. Animals type phobias is having extreme fear of a specific animal or
insets, such as dogs, cats, snakes, or spiders. A snake phobia
appears to be the most common type of animal phobia in the
United States.
b. Natural environment type phobia are intense fear of a specific
events or situations in the natural environment, such as storms, heights,
fire or water.
c. Situational type phobias usually involve fear of public transportation,
tunnels, bridges, elevators, flying, and driving. Claustrophobia , or fear of
enclosed spaces, is common situational phobia. People with situational
phobias believe they might have panic attacks in their phobic situations.
d. Blood -injection -injury type phobias , was first recognized in DSM
IV. People with this type of phob ia, fear seeing blood or an injury,
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92 e. Miscellaneous type phobia include the objects or situations, an
individual is intensely anxious of, which cannot be categorized in any of
the above fou r category.
Social Phobia
People with social phobia has an extreme fear of the social situation
wherein they think others will scrutinized them. They are intensely afraid
of getting embarrassed in front of other people. Social phobia creates
severe disrup tion in a person’s daily life. People with social phobia may
avoid eating or drinking in public. They fear that they might embarrassed
themselves with the noise while they eat or drop food, or otherwise
embarrass themselves. They may avoid writing in publ ic, including
signing their names, for fear that others see their hands tremble.
People with social phobia tend to fall into three groups (Eng et al 2000).
Some people with social phobia fear only public speaking. Others have
moderate anxiety about a va riety of social situations. Finally, who have
severe fear of many social situations, from speaking in public to just
having a conversation with another person, are said to have a generalised
type of social phobia.
Social phobia is relatively common, with a bout 8 percent of the U.S. adult
population qualifying for the diagnosis in a 12 month period and one in
eight people experiencing the disorder at some time in their lines (Kessley
et. al., 1998, Schnier el. al, 1992) Women are somewhat more likely than
men to develop this disorder.
Once it develops, social phobia tends to be a chronic problem if untreated.
Most people with a social phobia do not seek treatment for their
symptoms.
6.5 GENERALISED ANXIETY DISORDER (GAD)
People with GAD worry about many thing s in their lives. E.g., worry
about their performance on the job, about how their relationships are
going, and about their own health. The focus of their worries is not limited
to one issue or a particular situation or object but they tend to worry about
many different things. Their concern may shift frequently. Their worry is
accompanied by many of the physiological symptoms of anxiety,
including muscle tension, sleep disturbances, and a chronic sense of
restlessness.
GAD is a relatively common type of a nxiety disorder, with about 4
percent of the U.S. population experiencing it in any six - month period.
The majority of people with GAD also develop another anxiety disorder,
such as phobias or panic disorder and many experience depression as well.
Theorie s of Generalised Anxiety Disorder
1. Psychodynamic Theories : - munotes.in

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93 Freud (1917) developed the first psychological theory of generalised
anxiety. He distinguished among three kinds of anxiety : realistic,
neurotic, and moral. Realistic anxiety occurs when we face a real danger
or threat, such as an oncoming tornado. Neurotic anxiety occurs when we
are repeatedly prevented from expressing our id impulses, it causes
anxiety. Moral anxiety occurs when we have been punished for expressing
our id impulses, and w e come to associate those impulses with
punishment, causing anxiety. Generalised anxiety occurs when our
defense mechanisms can no longer contain either the id impulses or the
neurotic or moral anxiety that arises from these impulses.
More recent psychod ynamic theories attribute generalised anxiety disorder
to poor upbringing, which results in fragile and conflicted images of the
self and others. Children whose parents were not sufficiently warm and
nurturing, and many have been overly strict or critical, may develop
images of the self as vulnerable and images of others as hostile. As adults,
their lives are filled with frantic attempts to overcome or hide their
vulnerability, but stressors often overwhelm their coping capacities,
causing frequent bouts of anxiety.
2. Humanistic and Existential Theories : -
Carl Roger’s humanistic explanation of generalised anxiety suggests that
children who do not receive unconditional positive regard from significant
others become overly critical of themselves and develop con ditions of
worth, harsh self -standards they feel they must meet in order to be
acceptable. Throughout their lives, these people, then, strive to meet these
conditions of worth by denying their true selves and remaining constantly
vigilant for the approval of others. They typically fail to meet their self -
standards, causing them to feel chronically anxious or depressed.
Existential theorists attribute generalised anxiety disorder to existential
anxiety, a universal human fear of the limits and responsibili ties of one’s
existence. Existential anxiety arises when we face the finality of death, the
fact that we may unintentionally hurt someone, or the prospect that our
lives have has no meaning. We can avoid existential anxiety by accepting
our limits and str iving to make our lives meaningful, or we can try to
silence that anxiety by avoiding responsibility or by conforming to other’s
rules. Failing to confront life’s existential issues only leaves the anxiety in
place, however, and leads us to “inauthentic lives”.
3. Cognitive Theories : -
Cognitive theories of GAD suggest that the cognitions of people with
GAD are focused on threat, at both the conscious and non conscious
levels. At the conscious level, people with GAD have a number of
maladaptive assumptions t hat set them up for anxiety, such as “I must be
loved or approved of by everyone,” “It’s always best to expect the worst,
“People with GAD believe that worrying can prevent bad events from
happening. These beliefs are often superstitions, but people with GAD
also believe that worrying motivates them and facilitates their problem
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94 Indeed, they actively avoid visual images of what they worry about,
perhaps as a way of avoiding the negative emo tion associated with those
images.
Their maladaptive assumptions lead people with GAD to responds to
situations with automatic thoughts, which directly stir up anxiety, cause
them to be hyper vigilant, and lead them to overreact to situations.
Check Your Progress: -
1. What do you mean by GAD?
2. Discuss the different theories of GAD?
6.6 SUMMARY
Anxiety disorders are complex and most common form of mental disorder.
Anxiety is a future oriented state where a person focuses on the possibility
of experiencing danger. Panic and anxiety create different anxiety
disorders.
In phobia, the person avoids situations that produce severe anxiety or
panic disorders. Specific genetic vulnerability seems to put person at risk
for anxiety disorder. Psychological and social causes can result in anxiety
disorders. Psychological, social and biological treatments helps a patient
with anxiety disorder.
6.7 QUESTIONS
1. Define Anxiety and Panic Disorders and discuss their symptoms.
2. Write notes on the following.
a. Agoraphobia
b. Specific Phobia
c. Social Phobia
3. What is Generalised Anxiety Disorder. Discuss the various theories of
Generdised Anxiety Disorder.
6.8 REFERENCES
Abnormal psychology by David H. Barlow & V. Mark Durand, 1995,
2005, New Delhi.
Dhanda, Amrta (2000) Legal order and mental disorder, New Delhi. Sage
Publications Pvt Ltd.

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SOMATIC SYMPTOMS AND
DISSOCIATIVE DISORDERS - I
Unit Structure
7.0 Objectives
7.1 Introduction
7.2 Dissociative Disorders
7.2.1 Depersonalization Disorder:
7.2.2. Dissociative Amnesia:
7.2.3. Dissociative Fugue:
7.2.4 Dissociative Identity Disorder (D ID):
7.3 Somatoform Disorders, Psychological Factors Affecting Medical
Conditions and Dissociative Disorders: The Biopsychosocial
Perspective
7.4 Summary
7.5 Questions
7.6 Reference
7.0 OBJECTIVES
After studying this unit you should be able to:
 Understand the concept of Dissociative Disorders
 Know the details about various types of Dissociative Disorder
 Know the biopsychsocial perspective of various Somatoform Disorder,
Psychological Factors Affecting Medical Conditions and Dissociative
Disorders.
7.1 INTRODU CTION
Dissociative disorders are an extreme form of psychological disturbance
involving anxiety and conflict in which part of an individual’s personality
actually separates from the rest of his or her conscious functioning. One
type of dissociative disorde r is the Dissociative Identity Disorder.
Characteristics of Dissociative Identity Disorder as well as its theories
and treatment would be discussed in brief. Some other dissociative
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96 and its variants, Dissociative Fugue, Depersonalisation Disorder. Theories
and treatment of these various dissociative disorders will be discussed.
Towards the end of the unit we will discuss the biopsychsocial perspective
of various Somatoform Disorder, Psy chological Factors Affecting Medical
Conditions and Dissociative Disorders.
7.2 DISSOCIATIVE DISORDERS
Dissociative disorders are one of the disorders that have received
considerable media attention. Dr. Sigmund Freud and Morton Prince
carried out some pio neering studies on this disorder. The dissociative
disorder refers to a group of related disorders in which there is certain
altered states of consciousness. The dissociative disorder are described as
sudden temporary alterations in the normally integrativ e functioning of
consciousness, identity or motor behavior. Dissociative disorders are
characterised by alterations in perceptions: a sense of detachment from
one’s self from the world or from memories.
Dissociative disorders are an extreme form of psycho logical disturbance
involving anxiety and conflict in which part of an individual’s personality
actually separates from the rest of his or her conscious functioning. An
individual with dissociative disorder experiences a temporary alteration in
consciousne ss involving a loss of personal identity, decreased awareness
of immediate surroundings and odd bodily movements. Once the
dissociation has occurred, the content of the dissociated part becomes
inaccessible to the rest of the client’s conscious mind.
Some of the most common types of dissociative disorders include:
Depersonalization Disorder, Dissociative Amnesia, Dissociative Fugue,
Dissociative Indentity Disorder, etc. We would discuss the different
variants of dissociative disorders.
7.2.1 Depersonaliz ation Disorder:
It is a dissociative disorder, usually occurring in adolescence, in which
individuals lose their sense of self and feel unreal or displaced to a
different location. Depersonalization involves a sense of thing or
experiences as being “unr eal” and a feeling of estrangement from oneself
or one’s surrounding, both feelings have an unpleasant quality and are
experienced as a distinct change from one’s usual mode of functioning. In
this disorder an individual feels that he is out of his body an d the body is
distorted. Sometimes, people also report that they were dead and floating
above the body.
Individuals with this disorder feel that they are, all of a sudden, different.
For example, that their bodies have drastically changed and hence, becom e
very much different. Individuals with this disorder have an out -of-body
experience in which they feel that they are, for time, floating above their
physical bodies and observing what is going on below. The phenomenon
of depersonalization includes alterations of mind -body perception,
ranging from detachment from one’s experiences to the feeling that one
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97 Depersonalization experiences also occur in normal people when they are
placed under great stress or when they use mind -altering drugs, such as
marijuana or LSD. In depersonalization disorder, however, distortions of
mind -body perceptions happen repeatedly without provocation by drugs.
Periods of extreme stress, such as the time immediately following an
accident can also p recipitate an episode of Depersonalization in a
vulnerable individual .
This disorder is often precipitated by acute stress resulting from an
infectious illness, an accident, or some other traumatic event. Individuals
who experience depersonalized state are usually able to function entirely
normally between episodes. Depersonalization is a psychological
mechanism whereby one “dissociates” from reality. Depersonalization is
often a part of a serious set of conditions where reality experience and
even one’s id entity seem to disintegrate.
This disorder is episodic by nature and lasts for few minutes or hours. This
is the most frequent disorder of dissociative type, so it is thought that it
must be mildest form of dissociation and must be more easily curable. I t is
assumed that depersonalization must be an attempt to escape from a
stressful situation. However, the data about the disorder is not very clear.
Most experts agree that dissociative disorders are the end product of
intensely traumatic experiences dur ing childhood, especially those
involving abuse or other forms of emotional maltreatment. Other forms of
traumatic experiences, which can be transient or long lasting may also lead
to dissociative disorders. Current views with regard to causation of
dissoc iative disorder is largely based on psychological perspectives. Our
knowledge of biological factors involved in causation of these conditions
is highly limited.
7.2.2. Dissociative Amnesia:
Dissociative Amnesic was earlier called as psychogenic amnesia. I n this
disorder an individual is unable to remember important personal details
and experiences usually associated with traumatic or very stressful events.
This memory loss is not attributable to brain dysfunction, brain disorder
or drugs. In this disorder an individual forgets his personal information in
totality or is unable to remember some specific personal details.
Dissociative Amnesia is common during the time of war or similar
stressful events. It should be remembered that in most cases of
Disso ciative Amnesia, the forgetting is very selective for traumatic events
or memories rather than generalized. Dissociative Amnesia is found to be
common during war. There are four forms of dissociative amnesia, each
associated with the nature of a person’s m emory loss. The four forms of
dissociative amnesia are as follows:
i. Generalized Amnesia : In this type of amnesia an individual is unable
to remember personal information, including one’s identity. The
duration of this disorder may range from being a life long or may last
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98 ii. Localized or Selective Amnesia : In this type of amnesia there is a
failure to recall specific events. These specific events, which are
difficult to remember, are related to specific period of time. This
amnesi a is more common as compared to generalized amnesia.
iii. Selective Amnesia: The individual fails to recall some, but not all
details of events that have occurred during a given period of time. For
example, the survivor of fire may remember the ambulance ride t o the
hospital, but not having been rescued from the burning house.
iv. Continuous Amnesia : It involves a failure to recall events from a
particular date up to and including the present time. For example a
soldier may remember his childhood and youth until th e time he entered
the armed services, but he may have forgotten everything that took
place after his first tour of combat duty.
Dissociative Amnesia is very difficult for clinicians to diagnose, because
there are so many possible causes of memory loss. Amn esia can also result
from physical dysfunction due to brain injury, epilepsy, substance abuse,
etc. Some individuals also fake symptoms of dissociative amnesia to gain
certain benefits or advantages. For example, a man who has committed a
serious crime m ay claim that he remembers nothing of the incident or even
who is.
7.2.3. Dissociative Fugue:
It was formerly called as psychogenic fugue. The term Fugue means flight
and this disorder is very much similar to dissociative amnesia. In this
disorder, an ind ividual take off from one place and move to another place
without their conscious awareness and may be further confused, on
gaining awareness, as to how they arrived at this new place. In this
disorder a person is completely forgets their own identity or is confused
about personal identity suddenly and unexpectedly travels to another
place.
People in a fugue state are unable to recall their history or identity and a
few may even assume a new identity. A fugue is rare and usually passes
quickly. The di sorder is more likely to occur at certain times, such as
during a war or following a natural disaster. Personal crises or extreme
stress, such as financial problems the desire to escape punishment or the
experience of a trauma can also precipitate fugue states. Some other
important features of this disorder are as follows:
 This disorder usually occurs in adulthood and never before
adolescence. It rarely occurs after the person has crossed the age of 50.
 Dissociative Fugue is such a rare disorder that vir tually no controlled
 Fugue state end rather abruptly and the individual returns home
recalling most if not all of what happened. In this disorder, the
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99 atleast some disintegration of identity if n ot the complete adaptation of a
new role.
 One type of distinct dissociative disorder not found among western
cultures is “Amok”, which is very similar to the term “running amok”.
In this state an individual is in a trance like state and often brutally
assaults and sometimes kills persons or animals and acquires a
mysterious source of energy, runs or flees for a long time, etc. This
disorder is most common among males
 A still another type of dissociative disorder found among the native
people of Aartic whic h is similar to “Amok” is called “Pivloktoq” and
the same disorder amongst the Navajo tribe is called “Frenzy
Witchcraft”.
Generally individuals who experience dissociative amnesia or a fugue
state usually get better on his or her own and remember what th ey have
forgotten. The therapy focuses on recalling what happened during the
amnesia or fugue states, often with help of friends or family who know
what happened, so patients can confront the information and integrate it
into their conscious experience.
7.2.4 Dissociative Identity Disorder (DID):
It is the most interesting and dramatic of all the dissociative disorder and
was earlier called as multiple personality disorder. In Dissociative Identity
Disorder, a person develops more than one self or personali ty. These
personalities are referred to as alerts, in contrast to the core personality,
the host.
In this disorder, more than 1 personality or fragments of personality
coexist within one body and mind. In some cases the identities are
complete, each with its own behavior, tone of voice and physical gestures.
In other cases, only a few characteristics are distinct, because the identities
are only partially independent.
The disorder was made famous in novels and movies, such as “Sybil” and
“The Three Faces o f Eve”. In Dissociative Indentity Disorder, each alter is
understood to be a consistent and enduring pattern of perceiving, relating
to and thinking about the environment and the self.
Characteristics of Dissociative Identity Disorder:
The major character istics of this disorder are as follows:
i. Amnesia is the most important characteristic feature of this disorder. In
amnesia, an individual have gaps in their memory about some aspects
of their personal history.
ii. The identity of this disorder is fragmented.
iii. Many personalities live inside one body. These can be anywhere from 3
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100 iv. Certain important aspects of person’s identity are
dissociated.
A person who comes for treatment with a DID is called as a host
personality. The host personality tend s to hold many different identities
together. The transition from one personality to another is called as a
“switch”. During a switch, physical transformation may occur. Posture,
facial expressions, pattern of facial wrinkling and even physical
disabilitie s may occur. One of the most important debatable issue is
whether the DID can be faked or whether it is real. Some important points
with respect to this disorder are as follows:
 Individuals with DID are very suggestible and the alternative
personalities th at these individuals manifest are actually created as a
reaction to leading questions suggested by therapists
during psychotherapy or in a state of hypnosis. Generally it is found that
the core personality is submissive and passive. And the alter
personali ty gets developed as a reaction to the alter personality.
 Objective tests suggest that many people with fragmented identities
are not consciously and voluntarily simulating
 The prevalence rate of this disorder has been found to be between 3%
to 6 %.
 DID i s more common among females. The ratio of females to males is
as
 The onset of this disorder is always in childhood, often as young as 4
years of age, although it is usually identified approximately at the age
of 7 years.
 It has also been noted that there i s a high degree of comorbidity of
DID with other disorders. It has also been found that large percentage
of DID patients may have substance abuse, depression, somatisation
disorder, borderline personality disorder, panic attacks and eating
disorders.
 DID i s often misdiagnosed as a psychotic disorder.
 DID occur in a variety of cultures across the world.
 Some investigators have studied the ability of individuals to fake
dissociative experiences. According to them, it is possible to stimulate
dissociative diso rder. Various experiments conducted by Spanos et al
(1994) have suggested that the symptoms of DID could be faked. They
found that in one experiment 80 percent of the individuals could
successfully fake an alternative personality.
Richard Kluft (2005) has done considerable research in this area. Putnam
et al (1986) have noted that, in the 50 years prior to 1970s, only a handful
of cases had been reported, but since 1970s, the number of reports
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101 disorder were reported during one 05 – year period in the 1980s than had
been documented in the preceding two centuries.
Causes of Dissociative Identity Disorder (DID): Some important causes
of DID are as follows:
i. Childhood Traumatic Events: Many surveys have reported that DID
is a result of traumatic life events. Putnam et al (1986) examined 100
cases and found that 97 % of the patients had experienced significant
trauma, usually sexual or physical abuse and 68 % had reported
incest. Similarly, R oss et al (1990) had reported that, of the 97 % of
the cases, 95 percent reported physical or sexual abuse. Often the
abuse is bizarre and sadistic. Traumatised individuals fail to develop
an integrated and continuous sense of self
ii. Lack of Social Support : It has also been found that a lack of social
support during or after the abuse also seems implicated. A recent study
of 428 adolescent twins has demonstrated that in 33% to 50% of the
cases dissociative disorder could be attributed to chaotic,
nonsuppor tive family environment.
iii. Sociocognitive Model of DID: This model was presented by
Lilienfeld et al (1999). According to this model, clients enact the roles
that they feel (consciously or unconsciously) are demanded by the
situation. Social attention to t he condition of DID, along with
unintentional prompting by therapist, can lead to the development of
this disorder in vulnerable individuals. According to Sociocognitive
Model, these individuals may in fact have suffered abuse as children,
but many other factors, socially determined, operate to create the
dissociative symptoms in adulthood
iv. Biological Contributions: Some researchers have implicated
biological contributions in the development of DID. It has been
reported that individuals with certain neu rological disorders,
particularly seizure disorders, experience many dissociative symptoms.
Devinsky et al (1989) reported that approximately 6 % of the patients
with temporal lobe epilepsy reported “out of body” experiences.
Similarly, another groups of r esearchers (Schenk and Bear, 1981) have
found that about 50 % of the patients with temporal lobe epilepsy
displayed some kinds of dissociative symptoms.
Treatment of Dissociative Disorder: Some important points with respect
to the treatment of this disorde r are as follows:
i. The treatment of DID is much more difficult as compared to other
dissociative disorders. Not much controlled research has been done on
the effects of treatment, though there are many documented successes
of attempts to reintegrate identit ies through long -term psychotherapy.
ii. The strategies that therapist use today in treating DID are based on
accumulated clinical wisdom as well as procedures that have been
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102 iii. The major goal in treating DID is to identify cues or triggers that
provoke memories of trauma and/or dissociation and to neutralize
them. Most important in the treatment process is that the patient is
taught to confront and relieve the early trauma and gain control over
the horrible events, at least as they recur in the patient’s mind
iv. In the treatment of DID hypnosis is often used to gain access to
unconscious memories and bring various alters into awareness.
v. Treatment of dissociative disorders involves helping the patient re -
experience the traumatic events in a controlled therapeutic manner in
order to develop better coping skills. In the case of dissociative
identity disorder, therapy is often long term, and may include
antidepressant drugs. Particularly essential with this disorder is a
sense of trust between therapist and patient.
vi. Sopme clinicians have used cognitive -behavioural techniques in the
treatment of DID instead of or in addition to hypnotherapy in an effort
to change the client’s dysfunctional; attitudes. These attitudes a rise
from the client’s history of abuse and includes the following core
beliefs:
 That it is wrong to show anger or defiance
 That one cannot handle painful memories
 That one unconsciously hates the parents or experiences conflicting
attitudes towards one o r both the parents
 That one must be punished
 That one cannot be trusted, etc.
According to Ross (1997) these core beliefs needs to be changed. Kluft
(1989) has used cognitive -behavioural techniques to bolster an
individual’s sense of self -efficacy through a process called temporizing,
in which the client controls the way that the alters make their appearance.
This may be accomplished through hypnosis in an effort to help the client
develop coping skills that can be used when dealing with stress.
1. Dissociat ive Identity Disorder and the Legal System: Forensic
psychologists and other legal experts have been concerned with the legal
aspects of DID. Legal Defendants have used this diagnostic category as a
defense for their offences. Forensic psychologists and o ther members of
the judicial system are faced with the difficult task of differentiating a
true dissociative disorder from instances of malingering. Kenneth Bianchi,
a serial murdrer also known as the Hillside Strangler, faked multiple
personality disorde r defense. Individuals who seek to explain their crimes
as products of alter personalities typically invoke an insanity defense or
claim that they are not competent to stand trial (Slovenko, 1993). Accused
undertake the defense that they have committed the crime under the
control of an alter personality. They may further claim that the offense
was committed in a state of dissociation and that they have no recall of
what happened. Steinberg et al (2001) developed criteria for assessing
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103 forensic evaluations. They recommended the use of Structued Clinical
Intervies for DSM IV Dissociative Disorders – Revised (SCID – D – R).
7.3 SOMATOFORM DISORDERS, PSYCHOLOGICAL
FACTORS AFFECTING MEDICA L CONDITIONS
AND DISSOCIATIVE DISORDERS: THE
BIOPSYCHOSOCIAL PERSPECTIVE
Historically these disorders were regarded as neurosis rather than
psychosis. People with these disorders have experienced conflict or trauma
during their lives and circumstances have created strong emotional
reactions that they could not integrate in to their memory, personality and
self-concept. The symptoms seen in somatisation disorder and dissociative
states represent not a loss of contact with reality but a translation of
vario us emotions in to terms that are less painful to acknowledge than is
the original conflict or trauma.
Stressful events in many individuals trigger maladaptive responses in
physical functioning, ranging from variety of physical conditions to sleep
dysfuncti ons and various somatic complaints which are often vague.
Currently the most prevalent view is that stress related factors and not
repressed sexuality is central to understanding somatoform disorders.
Besides stress, learning seems to play a strong role, e specially in cases
where individuals have developed secondary gains from their symptoms.
With regard to dissociative disorders, researchers believe that, actual,
rather than imagined trauma is the source of such symptoms as amnesia,
fugue and multiple iden tities.
Cognitive behavioural therapists have also offered their perspective on this
group of disorders. According to them low feelings of self -efficacy, lack
of assertiveness and faulty ideas about the self can all be contributing
factors to somatoform and dissociative disorders. For example believing
that one must be sick to be worthy of attention is a dysfunctional attitude
that underlie the development of somatoform disorders. Similarly faulty
beliefs about the self and the role of the self in past ex periences of trauma
seem to be important cognitive factors that may contribute to an
individual’s vulnerability to developing these maladaptive thoughts or
susceptibility to trauma.
7.4 SUMMARY
In this unit we have discussed the concept of Dissociative di sorders. We
have attempted to understand as to how these group of disorders are an
extreme form of psychological disturbance involving anxiety and conflict
in which part of an individual’s personality actually separates from the rest
of his or her con scious functioning. One type of dissociative that we
discussed in detail was the Dissociative Identity Disorder (DID). The
various characteristics of Dissociative Identity Disorders as well as its
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104 Many different typ es of dissociative disorders that we would discuss in
brief include Dissociateive Amnesia and its variants, Dissociative Fugue,
Depersonalisation Disorder. Theories and treatment of these various
dissociative disorders were also briefly discussed. Towards the end of the
unit we have discussed the biopsychsocial perspective of various
Somatoform Disorder, Psychological Factors Affecting Medical
Conditions and Dissociative Disorders.
7.5 QUESTIONS
Q1. What are Dissociative disorders? Discuss Dissociative Indentity
Disorder (DID), its Characteristics, Causes and treatment.
Q2. Write a note on Dissociative Identity Disorder and the Legal System.
Q3. Discuss Dissociative Amnesia, Dissociative Fugue and
Depersonalization Disorder.
Q4. Write a note on The Biopsycho social Perspective of Somatoform
Disorders, Psychological Factors Affecting Medical Conditions and
Dissociative Disorders.
7.6 REFERENCE
Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology: Clinical
Perspectives on Psychological Disorders. (6th ed.). McGraw -Hill.
Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M. (2007).
Abnormal Psychology . (13th ed.). Indian reprint 2009 by Dorling
Kindersley, New Delhi.
Nolen -Hoeksema, S. (2008). Abnormal Psychology . (4th ed.). New York:
McGraw -Hill.

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105 8
SOMATIC SYMPTOMS AND
DISSOCIATIVE DISORDERS - II
Unit Structure
8.0 Objectives
8.1 Introduction
8.2 Somatic Symptoms and Related Disorders
8.3 Psychological Factors Affecting Medical Conditions
8.3.1 Theories and Treatment of Psychological Factors Affecting
Medi cal Conditions:
8.4 Summary
8.5 Questions
8.6 Reference
8.0 OBJECTIVES
After studying this unit, you should:
 Know the concept of somatoform disorders.
 Understand conversion disorder.
 Comprehend somatization disorder and related conditions.
 Know body dysmorphic disord er and hypochondriasis.
 Understand conditions related to somatoform disorders.
 Know theories and treatment of somatoform disorders.
 Understand Psychological Factors Affecting Medical Conditions and
associated topics such as coping, stress and the immune s ystem, etc.
8.1 INTRODUCTION
In this unit we will discuss the concept of somatoform disorders. The
concept of conversion disorder, somatisation disorder and related
conditions, dysmorphic disorder as well as hypocondriasis will also be
discussed. Following this we will discuss the various conditions related
to somatoform disorders, such as malingering, factitious disorder and
Munchausen’s syndrome. Theories and treatment of somatoform disorder
would also be discussed.
Many medical conditions are influenc ed by psychological factors. DSM
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106 includes situations in which psychological or behavioural factors have an
adverse effect on a medical conditions. Theories and treatment of these
conditio ns would also be discussed.
8.2 SOMATIC SYMPTOMS AND RELATED
DISORDERS
Somatoform disorders are those disorders in which an individual
complains of bodily symptoms but for which there is no clear -cut
identifiable physical cause. Somatoform disorders inclu de a variety of
conditions in which conflict becomes translated in to physical problems or
complaints that cause distress or impairment in a person’s life.
Psychologists have known Somatoform disorders since a long time. The
term “soma” refers to body an d somatoform disorders are those bodily
disorders for which there is no biological basis for physical complaints
and the cause is largely a result of psychological factors. Somatoform
disorders can be defined as an anxiety based pattern in which an individ ual
complains of bodily symptoms that suggest the presence of a physical
problem, but for which no organic basis can be found. Health
professionals find it difficult distinguishing between a physical cause and
a psychological cause when it comes to unders tanding bodily symptoms.
DSM -IV has identified many different forms of somatoform disorders.
These include: Conversion disorder, Somatisation disorder and related
conditions, Body dysmorphic disorder, Hypochondriasis, etc.
1. Hypochondriasis (Illness Anxiety Disorder): An individual who is
suffering from hypochondriasis believe or fear that they have a serious
illness, when in fact they are merely experiencing normal bodily reations.
It is one type of somatoform disorder, which is characterized by multiple
complaints about possible physical illness where no evidence for such
illness can be found. DSM 5 has relabel this diagnosis as ‘Illness Anxiety
Disorder’
In hypochondriasis, anxiety is a result because an individual misinterprets
the bodily symptoms as in dicative of illness or disease. For e.g., if a
person is having a headache then he might think that he is having brain
tumor. They have an unrealistic interpretation of relatively common
physical complaint. Their complaints are not restricted to any logica l
symptoms. They have trouble in giving precise description of their
symptoms.
They read a lot on medical topics and feel certain that they are suffering
from every new disease they read or hear about. They believe that they
are seriously ill and cannot recover. Besides, they also keep themselves
well informed about the latest medical treatments by reading popular
newspaper and magazines.
These patients are so preoccupied with their health, that many of them
keep detailed information about diet, fu nctioning of body, etc. Since the
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107 individual with this disorder is likely to visit a family physician. As their
symptoms have no physical causes, no treatment is possible. Inspite o f
best efforts by the doctors to convince the individual that nothing is
medically wrong with him and the disorder is more psychological in
nature; the patient is not able to understand this. Hence, they keep on
changing their physician until the physic ian treats the disease, which does
not exist at all. The problem of hypochondriasis come to the attention of
mental health experts only when all relevant medical conditions concerned
with the presenting physical complaints are ruled out.
Hypocondriasis dif fers from somatisation disorder on the following
grounds.
a. It occurs after the age of 30 years.
b. The abnormal concerns of hypocondriacal individuals are vague,
general, and do not focus on particular set of symptoms.
c. Hypocondriacal persons have a belief tha t they have a serious
illness, which is unique.
Research studies indicate that hypochondriasis shares many features with
anxiety disorders, particularly panic disorders. These two disorders are
frequently comorbid i.e. individuals with a hypochondriacal d isorder have
an additional diagnosis of anxiety disorder.
Patients having hypochondriasis are distinguished from those having
illness Phobia. Illness Phobia is future oriented, i.e. individuals who fear
developing a disease is said to have illness Phobia. On the other hand
hypochondriasis is a current anxiety about a presumed illness. In other
words, individuals who mistakenly believe they currently have a disease
are diagnosed as having hypochondriasis.
The prevalence of hypochondriasis in general popul ation is not well
known. It is estimated that anywhere between 1% to 14% of the medical
patients has hypochondriasis. The sex ratio of this disorder is 50 -50. Once
it was believed that hypochondriasis was most common among elderly
population. However, this is not so. It is estimated that hypochondriasis
can develop at any time of life, with peak age period found in adolescence,
middle age (40s and 50s) and ages 60 years.
Hypochandriasis is a culture specific disorder. Its manifestation is
considerably influ enced by sociocultural factors. Two important culture
specific syndromes are as follows:
a. Koro
b. Dhat
Koro: This syndrome is generally found among Chinese males, though it
is also found among western women to a lesser extent. In this syndrome
there is a belie f accompanied by severe anxiety and sometimes panic that
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108 because of the central importance given to sexual functioning among
Chinese males. In this syndrome an individual feels guilty about excessive
masturbation, unsatisfactory intercourse or promiscuity. These events
generally predispose men to focus their attention on their sexual organs,
which generally increases anxiety and arousal leading to hypochondrical
symptoms.
Dhat: This i s another culture specific syndrome, most common among
Indians. It is an anxious concern about loosing one’s semen. The loss of
semen is associated with a vague mix of physical symptoms including
dizziness, weakness and fatigue that are not so specific a s in Koro.
The various somatic symptoms present in hypochondriasis poses
diagnostic problem for a clinician and hence the clinician must remember
the following points:
a. First, the clinician must be accurately aware of the specific culture or
subculture of a patient in order to understand the cultural manifestation of
this disorder.
b. A clinician must rule out the physical cause of somatic complaints
before referring the patient to a mental health professional.
c. The mental health professional must determine th e nature of somatic
complaints in order to know whether they are associated with a
somatoform or are a part of other psychopathological syndrome such as
panic attack.
Causes of Hypochondriasis: Some important causes of hypochondriasis
are as follows:
 Diso rder of Cognition and Perception: Hypochondriasis is a
disorder of cognition and perception with strong emotional
contributions. Individuals with hypochondriasis pay undue attention to
physical sensations that are common to all normal individuals. They
quickly focus their attention on these sensations. The very fact of
focusing attention of their self increases their arousal and makes
physical sensations seem more intense than they actually are. For e.g. a
minor headache may be interpreted as a sign of br ain tumor.
 Increased Perceptual Sensitivity: Experiments using the stroop test
has revealed that individuals having hypochondriasis show enhanced
perceptual sensitivity to illness cues. They also tend to interpret
ambiguous stimuli as threatening.
 Integrat ed Approach: It should be remembered that no single
biological or psychological cause can be implicated in this disorder.
Researchers have pointed out that the fundamental causes of
hypochondriasis are similar to those implicated in the anxiety disorder .
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109 According to Cote et al (1996) three important factors related to the
etiology process of this disorder are as follows:
i.Hypochondriasis seems to develop in the context of stressful life
events. Such events often involve death or illness.
ii.People who develop hypochondriasis tend to have had a
disproportionate incidence of disease in their family when they
were children.
iii.Important interpersonal and social influence also plays an important
role in the development of hypochondriasis. For
e.g. some people who com e from families where illness is a major issue
seem to have learned that an ill person is often paid increased attention.
Hence, they develop illness.
Treatment: Some important points related to treatment of this disorder
are as follows:
i. Our knowledge abou t the treatment of this disorder is limited.
Scientifically controlled studies are very rare.
ii. Treatment of this disorder consists of identifying and challenging
illness related misinterpretation of physical sensations and on showing the
patient how to crea te “symptoms” by focusing attention on certain body
areas.
iii. Psychoanalysis has been found to be less effective with this type of
diorder. Ladee (1966) found that only four out of the 23 patients with this
type of treatment improved.
iv. Kellner (1992) found tha t reassurance seems to be effective in some
cases, especially when it is given by a medically trained person such as a
family physician.
v. Participation in support groups (i.e. group therapy or counselling) can
also be of considerable benefit for such patien ts.
2. Somatisation Disorder and Related Conditions: Somatisation
disorder involves the expression of psychological issues through bodily
problems that cannot be explained by any known medical condition or as
being due to the effects of a substance. They tend to complain of having
some or other physical problems like weakness, double vision, or
headache, allergies, nausea, stomach problem, and menstrual and sexual
difficulties.
The difference between somatization disorder and conversion disorder is
that somati sation disorder involves various physical symptoms whereas in
conversion disorder an individual complaints of voluntary motor or
sensory deficits that suggest a neurologic or medical condition. In
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110 symptoms rather than a single physical complaint. Such people experience
pain and sickness in exaggerated manner.
This condition generally, which is relatively rare, first appears before the
age of 30 years and leads to problems in the areas of social, occupational
and interpersonal functioning. Individuals suffering from this disorder
generally tend to be from lower socioeconomic classes.
This disorder was earlier called as Briquet’s Syndrome, after the famous
French physician, Pierre Briquet who in 1859 described patients who has
multiple somatic complaints for which he could not find any medical
cause. Somatisation disorder was known as Briquet’s syndrome for more
than 100 years and was called as somatisation disorder for the first time
only in 1980s in the DSM - III. In this disorder there are repeated and
multiple vague somatic complaints for which there is no physiological
cause. This is a very rare disorder and occurs on a continuum.
The prevalence shows that majority of the individuals with somatisation
disorder tend to be women, unmarried and from lower socioeconomic
groups. In addition to a variety of somatic complaints, individuals may
also have psychological complaints, usually anxiety or mood disorders.
Biological Theory - According to biological theorist, genetic factors plays
an important role in somatization disorder. Early studies of possible
genetic contributions have had shown mixed results. For e.g. Torgerson
(1986) found no increased prevalence of somatisation disorder in
mono zygotic pairs. However, most recent studies have found that this
disorder run in families and may have a heritable basis. It has also been
observed that Somatisation Disorder is strongly linked in family and
genetic studies to Antisocial Personality Disord er.
Jeffrey Gray and his associates (1985) have implicated neurophysiological
factors in the development of somatisation disorder. A variety of
neurophysiological evidence suggests a dysfunction in the brain circuit in
somatisation disorder.
Psychological Theory – According to behavioral theory, somatisation
disorder is a learned disorder. Individuals learn from significant others,
and through role modeling, significant somatic symptoms that are
characteristic of these disorders.
Sociocultual Theory - Accor ding to Widom (1984) and Colninger (1987)
in the occurrence of somatisation disorder, social and cultural factors too
play an important role. Gender roles encourage development of
somatisation disorder in women in many cultures.
Treatment: Treatment of som atisation disorder is exceedingly difficult
and there are no treatments with proven effectiveness that seem to cure the
syndrome. Barlow et al (1992) have pointed out that somatisation disorder
can be better managed by providing patients with the following :
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111  Providing reassurance.
 Reducing stress.
 Reducing the frequency of help -seeking behavior.
People with somatisation disorder do not voluntarily seek psychotherapy.
They seek psychotherapy only on the insistence from their physician. The
prognosis of this disorder is generally poor.
3. Pain Disorder: It is one variant of somatisation disorder in which
instead of the multiple somatic complaints, individual demonstrates only
one symptom, i.e. pain. The pain causes intense personal distress or
impairment. The c lient is not faking pain. But the pain pertaining any of
the bodily area do not have any medical base to it. In some cases of pain
disorder there may be a diagnosable medical condition but the reported
experience of pain is more than what can be normally s een. In such cases,
there may have been a clear physical reason for pain at least initially, but
psychological factors play a role in maintaining it.
An important feature of pain disorder is that the pain is real and it hurts
regardless of the cause. Sin ce it is a new and a separate category more
research on it is needed to increase our understanding of this disorder.
People with pain disorder are likely to become dependent on substances,
either illicit drugs or prescription medications, in their effort t o alleviate
their discomfort.
4. Conversion Disorder: Conversion disorder involves a translation of
unacceptable drives or troubling conflicts in to bodily motor or
sensory symptoms that suggest neurological or other kinds of
medical conditions. According to Barlow and Durand (2000),
conversion disorder can be defined as physical malfunctionng such
as blindness or paralysis suggesting neurological impairment but
with no organic pathology to account for it.
The essential feature of this disorder is an involunt ary loss or alteration of
a bodily function due to psychological conflict or need, causing the
individual to feel seriously distressed or to be impaired in social,
occupational or other important areas of life. It should be remembered
that the person is not intentionally producing the symptoms. Clinicians
cannot establish a medical basis for the symptoms and it appears that the
person is converting the psychological conflict or need in to a physical
problem.
This disorder was earlier called as hysteria an d it involves a neurotic
pattern in which symptoms of some physical malfunctioning or loss of
control appear without any underlying organic pathology. In 1850s a
French physician Paul Briquet systematically described and categorized
various symptoms of h ysteria based on his review of about 400 patients.
Jean Martin Charcot used the technique of hypnosis to show that
psychological factors played a role in the physical symptoms of hysteria.
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112 hysteria and enhanced the understanding about it. Sigmund Freud
developed a radically different theory of hysteria. He called it as hysterical
neurosis.
The symptoms of conversion disorder are multiple. All these symptoms of
conversion disorder can be grou ped into three broad categories. These are
as follows:
A. Sensory Symptoms: Some of the sensory symptoms involved in
conversion disorder are as follows:
 Anesthesia: loss of sensitivity.
 Analgesia: loss of sensitivity to pain.
 Hypesthesia: partial loss of sens itivity.
 Hyperaesthesia: excessive sensitivity.
Ironside and Bachelor (1945) found the following sensory symptoms
among conversion disorders. These are blurred vision, photophobia,
double vision, night blindness, jumping of print during attempts to read,
etc. These researchers also found that the symptoms of each airman
(whom they studied) were closely related to his performance duties. Night
fliers were more subject to night blindness, while day fliers more often
developed failing day vision.
B. Motor Symptom s: Some common motor symptoms seen in conversion
disorder are as follows:
i. Paralysis: Such a behavior is usually confined to
only one arm or leg and the loss of function is usually
selective for e.g. writer’s cramp, ticks (localized
muscular twitches).
ii. Cont ractors: Such a behavior involves flexing a finger and toes or
rigidity of the larger joints such as elbows and knees. Paralysis and
contractors frequently lead to walking disturbances.
iii.Aphonia: is a most common speech disturbance. In this disorder an
individual is able to talk only in whispers and mutism.
iv. Convulsion: This is an occasional motor symptom. However, people
with hysterical convulsion show features or the usual characteristics of
true epileptics.
C. Visceral Symptoms: Visceral conversion reaction s also cover a wide
range of symptoms, including headaches “lump in the throat” (formerly
known as globus hystericus) and choking sensations, coughing spells,
difficulty in breathing, cold and clammy extremities, bleaching, nausea,
vomiting, and so on. Oc casionally, persistent hiccoughing or sneezing
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113 Accurate diagnosis of conversion disorder is a difficult task because
conversion disorder can stimulate every known disease. Conversion
disorder can be distinguished from organic disorder on the basis of the
following points.
1. La Belle Indifference: This means that those who have conversion
disorder are unconcerned about the long -range effects of their
disabilities. Individuals with organic disorder are very much concerned
about the long -range effect of their symptoms.
2. Selective nature of the dysfunctioning: Individuals who have
conversion disorder are highly selective with respect to symptom
pathology. For example, in conversion blindness, an individual does
not usually bump into people or objects; “par alyzed”, muscles can be
used for some activities but not others; and controlled contractors
usually disappear during sleep.
3. Under hypnosis or narcosis: The interesting fact that under
hypnosis or narcosis (a sleep like state induced by drugs) the
symptom s can usually be removed, shifted, or reinduced by the
suggestion of the therapist. Similarly, if the individual is suddenly
awakened from a sound sleep, he or she may be tricked into using a
“paralyzed ” limb.
In the development of a conversion disorder, t he following chain of events
typically occurs:
a. A desire to escape from some unpleasant situation.
b. A feeling or a wish to be sick in order to avoid the situation (this wish,
however is suppressed as unfeasible or unworthy); and under additional or
continued stress.
c. The appearance of the symptoms of some physical ailment. The
individual sees no relation between the symptoms and the stress situation.
The particular symptoms that occur are usually those of a previous illness
or are copied from other sources, su ch as symptoms observed among
relatives, seen on television, or read about in magazines.
Conversion disorders seem to stem from feelings of guilt and the necessity
for self -punishment. Those who suffer from conversion disorder also
suffer from a dissociat ive disorder. It is difficult to diagnose conversion
disorder. Individuals suspected of conversion disorder must be given a
thorough neurological examination in addition to follow up to determine
whether a client’s symptoms represent an underlying medical condition.
Conversion disorders were once relatively common in civilian and
especially in military life. In World War I, conversion disorders were the
most frequently diagnosed psychiatric syndrome among soldiers. It was
also relatively common during World War II. Conversion disorders
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114 men who would ordinarily be considered stable. These disorders are
common among soldiers exposed to combat.
Statistical details reveal that conversion d isorder may occur in
conjunction with other disorder particularly Somatization disorder.
Conversion disorder is a rare phenomenon affecting about 1 to 3 % of
those referred for mental health care. The disorder often runs in families. It
generally appears between the ages of 10 and 35 Years and is more
frequently observed among women and in people with less education.
5. Body Dysmorphic Disorder: This is an imaginative disorder. This
disorder is also called as “imagined ugliness” (Phillips, 1991). It is a
somatoform disorder in which there is an excessive preoccupation with
some imagined defect in appearance by some one who actually looks
reasonably normal.
Individuals having this disorder have distorted negative concerns about
their own body or some part of their body. They are preoccupied, almost
to the point of being delusional, with the idea that a part of their body is
ugly or defective. They are so preoccupied with this thought that
experience intense distress and impairment in their personal, work a nd
social life. They may be abnormally worried about the texture of their
skin, too little facial hair, or they feel that there is deformity in the shape
of their nose, mouth, jaw or eyebrow. Individuals with this disorder
become fixated on mirrors. They o ften view themselves in a mirror to
check as if any change is taking place in them. These individual may
approach doctor for having corrective surgery and may undergo multiple
cosmetic surgery. Preliminary research suggests that as many as 2% of all
the pa tients who request plastic surgery may have this disorder. It has also
been noted that surgery on people with Body Dysmorphic Disorder
seldom produced the desired results and these people return for additional
surgery on the same defect, or concentrate on some new defect. Recent
research (1993) has revealed that preoccupation with imagined ugliness
actually increased in people who had plastic surgery, dental procedures or
special skin treatments for their perceived problems.
They may have “ideas of refer ence”, i.e. when a two people are engrossed
in their own conversation, a person with body dysmorphic disorder may
think that they are gossiping or laughing about the defect. In a very severe
case, individuals might have suicidal ideation as well as suicida l attempt
and even actual suicide.
The prevalence of this disorder is hard to estimate since by its very nature
it tends to be kept a secret. This disorder is more commonly found among
females; however, in Japan more males experience this disorder. This
disorder occurs in adolescence and peaks at the age of 18 or 19 years.
Causes: The etiology of this disorder is not well known. There is no data
available to indicate whether this disorder run in families or whether there
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115 The pattern of comorbidity with other disorders does give us some
indication about the etiology of this disorder. This disorder co - occurs with
hypochondriasis, however it does not co -occur with other somatoform
disorders, nor does it occur in family members of patients with other
disorders. A disorder that has been frequently found to co -occur with
Body Dysmorphic Disorder is the Obsessive Compulsive Disorder.
Body Dysmorphic Disorder has considerable degree of similarity wit h
Obsessive Compulsive Disorder. Some important points are as follows:
i.Individuals with Body Dysmorphic Disorder often complain of
persistent, intrusive and horrible thoughts about their appearances,
and they engage in such compulsive behaviours as repeate dly
looking in mirrors to check their physical features.
ii.Body Dysmorphic Disorder and Obsessive Compulsive Disorder also
have approximately the same age of onset and run the same course.
iii.The treatment of these two disorders is also the same. Medically the
drug that block the reuptake of serotonin, such as Clomipramine
(Anafranil) and fluoxetine (Prozac) are useful in both these
disorders. Similarly, exposure and response prevention, the type of
cognitive behavior therapy that is effective with Obsessive
Com pulsive Disorder, has also been successful with Body
Dysmorphic Disorder.
Treatment: Biological treatment includes use of SSRI to reduce the
symptoms associated with depression and anxiety due to body dysmorphic
disorder and other symptoms of BDD like dist ress, bodily preoccupation
and compulsion.
Psychological treatment of this disorder consists of bringing about a
cognitive change in the individual. CBT is used to challenge their
irrational thought process about their body and making them understand
that appearance is just one aspect of their total identity.
6. Conditions Related to Somatoform Disorders: Some important
conditions related to somatoform disorders that we will discuss in
this section are as follows:
i. Malingering (Faking) : It involves deliberatel y feigning the
symptoms of physical illness or psychological disorder for an
ulterior motive. A person may feign physical problem to either
obtain financial gain, avoid punishment or to fulfill some other
motive.
It is difficult to distinguish between malingering and any other type of
somatoform disorders. In the former the person is consciously aware that
he is faking a disorder, whereas, in conversion disorder the individual is
not aware, it occurs unconsciously. Three important points that can hel p
one to distinguish between other type of somatoform disorder and
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116  An individual with somatoform disorder is indifferent to the symptoms
as compared to other disorders, i.e., they show “la belle indifference”.
 Somatoform disorde rs are often precipitated by marked stress.
 Individuals with any type of somatoform disorders can usually
function normally and that they seem to be really unaware either of
this ability or of sensory input.
Psychologists have developed psychological instr uments to determine
whether a patient is malingering or not. One type of scale is the validity
scales found in the MMPI or EPQ. Another instrument is the Validity
Indicator Profile (Frederick, 1998) which consists of verbal and nonverbal
tasks designed t o determine whether a subject is responding legitimately
or is trying to look impaired.
ii. Factitious Disorder: Factitious disorder falls between malingering
and somatoform disorders. It refers deliberately faking to non -existent
physical or psychological di sorder for no apparent gain except possibly
sympathy and attention. People fake symptoms or disorders, not for the
purpose of any particular gain but because of an inner need top maintain a
sick role. The symptoms may be either physical or psychological or they
may be a combination of both. These individuals relish the notion of being
ill and may go to great lengths either to appear ill or to make themselves
ill
Munchausen’s Syndrome: It is a type of factitious disorder (also known
as factitious disorde r imposed on self), named after Baron von
Munchausen, a retired German cavalry officer known for his tall tales.
Munchausen’s Syndrome involves chronic cases in which the individual’s
whole life revolves with the pursuit of medical care. Munchausen
syndrom e is a type of factitious disorder, or mental illness, in which a
person repeatedly acts as if he or she has a physical or mental disorder
when, in truth, he or she has caused the symptoms. They are even willing
to undergo painful or risky tests and operations in order to get the
sympathy and special attention given to people who are truly ill.
Munchausen syndrome is a mental illness associated with severe
emotional difficulties.
Persons with Munchausen syndrome intentionally cause signs and
symptoms of a n illness or injury by inflicting medical harm to their body,
often to the point of having to be hospitalized. Like some will secretively
injure themselves to cause signs like blood in the urine or cyanosis of a
limb. These persons are sometimes eager to undergo invasive medical
interventions. They are also known to move from doctor to doctor,
hospital to hospital, or town to town to find a new audience once they
have exhausted the workup and treatment options available in a given
medical setting. Pers ons with Munchausen syndrome may also make false
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117 Munchausen by proxy syndrome: A related condition, called
Munchausen by proxy syndrome (factitious disorder imposed on anoth er),
refers to a caregiver who fakes symptoms by causing injury to someone
else, often a child, and then wants to be with that person in a hospital or
similar medical setting.
The exact cause of Munchausen syndrome is not known, but researchers
believe bo th biological and psychological factors play a role in the
development of this syndrome. Some theories suggest that a history of
abuse or neglect as a child, or a history of frequent illnesses requiring
hospitalization, might be factors associated with the development of this
syndrome. Researchers also are studying the possible link with personality
disorders, which are common in individuals with Munchausen syndrome.
Distinguishing Somatization, Pain, and Conversion Disorders from
Malingering and Factitious Disorder
Earlier we mentioned that the DSM distinguishes between malingering
and factitious disorder on the basis of the feigning person’s apparent goals.
It is sometimes possible to distinguish between a conversion (or other
somatic symptom) disorder and malingering, or factitiously “sick -role-
playing,” with a fair degree of confidence, but in other cases it is more
difficult to make the correct diagnosis. Persons engaged in malingering
(for which there are no formal diagnostic criteria) and those who hav e
factitious disorder are consciously perpetrating frauds by faking the
symptoms of diseases or disabilities, and this fact is often reflected in their
demeanor. In contrast, individuals with conversion disorders (as well as
with other somatic symptom diso rders) are not consciously producing
their symptoms, feel themselves to be the “victims of their symptoms,”
and are very willing to discuss them, often in excruciating detail
(Maldonado & Spiegel, 2001, p. 109). When inconsistencies in their
behaviors are pointed out, they are usually unperturbed. Any secondary
gains they experience are byproducts of the conversion symptoms
themselves and are not involved in motivating the symptoms. On the other
hand, persons who are feigning symptoms are inclined to be def ensive,
evasive, and suspicious when asked about them; they are usually reluctant
to be examined and slow to talk about their symptoms lest the pretense be
discovered. Should inconsistencies in their behaviors be pointed out,
deliberate deceivers as a rule immediately become more defensive. Thus
conversion disorder and deliberate faking of illness are considered distinct
patterns.
7. Theories and Treatment of Somatoform Disorder: Causes and
treatment of each of the somatoform disorder has been discussed ab ove.
However it is important to understand as to what motivates people to
appear sick. Psychologists explain motives with the help of primary gain
and secondary gain. Primary gain is avoidance of burdensome
responsibilities because one is “disabled”. Seco ndary gain is the sympathy
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118 Somatoform disorders can best be explained as interplay of biological
factors, learning experiences, emotional factors and faulty cognitions.
According to this integrati ve approach, childhood events set the stage for
the later development of symptoms.
Most contemporary approaches to treating somatoform disorders involve
exploring a person’s need to play the sick role, evaluating the contribution
of stress in the person’s life and providing clients with cognitive
behavioural techniques to control their symptoms. Medication can also be
used in certain cases. For some patients with somatisation disorder,
antidepressant medications can serve an important role in treatment.
8.3 PSYCHOLOGICAL FACTORS AFFECTING
MEDICAL CONDITIONS
Bodily conditions can be adversely affected by psychological factors. For
example, intense emotional stress can increase one’s vulnerability to
getting sick and can seem to slow down recovery from an ail ment.
Psychological factors can influence physical health either indirectly, by
changing behaviors that affect your health, such as eating, sleeping and
socializing, or directly, by producing changes in your hormones and/or
heart rate. Additionally, the mind can interact with the benefits of a
medicine, reducing the effectiveness of a certain drug or worsening the
negative symptoms associated with certain medical conditions. Therefore,
you should monitor your thoughts towards your health and psychologic al
well-being when coping with any medical condition.
The diagnosis of “Psychological Factors Affecting Medical Conditions”,
is given to those individuals who suffer from a recognized medical
condition that is adversely affected by emotional factors that influence
the course of the medical condition or interfere with treatment, create
additional health risk or aggravate its symptoms. Emotional and
psychological factors can aggravate any physical problem.
8.3.1 Theories and Treatment of Psychological Fac tors Affecting
Medical Conditions:
Researchers who study the mind body relationship attempt to determine
why some people develop physiological or medical problems, when their
lives become busy, complicated or filled with pleasant events. Some
important fa ctors worth noting are as follows:
1. Stress: Stress refers to unpleasant emotional reaction a person has
when he or she perceives an event as threatening. The emotional reaction
to stress may include heightened physiological arousal due to increased
reactivi ty of the sympathetic nervous system. The term stressor is used to
refer to any event that leads to stress. Holmes and Rahe (1967) developed
the Social Readjustment Rating Scale to assess life stress in terms of life
change units. They identified individua ls who are prone to stress and
likely to develop physical problems and illnesses as a result of constant
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119 forward which emphasizes the fact that it is not the event itself but the
ways in which it is interpreted that determines its impact.
2. Coping: Another important factor that is related to Psychological
Factors Affecting Medical Conditions is coping mechanisms that is used
by an individual. Coping can be defined as active efforts to master,
reduce or tolerate the demands created by stress. Coping is the process of
managing taxing circumstance, expending effort to solve personal and
interpersonal problems, and seeking to master, minimize, reduce, or
tolerate stress. Coping can be d efined as facing and finding effective
means of overcoming problems and difficulties.
Coping consists of efforts, both action - oriented and intrapsychic, to
manage (i.e. master, tolerate, reduce, minimize) environmental and
internal demands and conflicts among them”. Coping strategies are also
defined as actions that people take to master, tolerate, reduce or minimize
the effects of stressors and they can include both behavioural and
psychological strategies. Coping efforts can be either adaptive or ef fective
(healthy) or unadaptive and ineffective (unhealthy). Effective methods of
coping with stress help to remove the source of stress or control our
reactions to it. Ineffective coping techniques are those techniques that can
come in the way of our a daptation or that can create more problems for us
in the long run.
There are two types of coping:
Problem Focused Coping: It is a type of coping that is basically
concerned with alleviating the problem, trying to change the situation so
that the problem is eliminated or to avoid the occurrence of the same or
similar problem in the future. Problem focused coping is concerned with
direct efforts to deal with, understand and overcome current causes of
stress. Problem focused coping is generally superior i n reducing the
adverse effects of stress.
Emotion Focused Coping : It is a form of coping an individual makes
attempt to manage and deal with negative emotions and feelings that may
develop due to the stressful situation. Emotion focused coping also
involv es learning to handle one's emotions in an appropriate manner so
that we can face and adjust to situations where we find the problem to be
uncontrollable. Emotion focused coping centers around efforts to reduce
or manage the emotional distress resulting fr om stress and often involves
strategies such as refusing to recognize painful realities concluding oneself
that things could be worse, masking the stress with alcohol or other drugs.
3. Stress and the Immune System: Immune system is an important
system of our body that consists of cells, organs and chemicals in the body
that responds to attacks on the body from diseases and injuries. Immune
system protects us from onslaught. Immune system is the body's means of
identifying and eliminating any foreign materials (e.g. bacteria, parasites
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120 A new subject which studies how stress influences an individual’s body
immune system is called as Psychoneuroimmunology. It is more
specifically defined as the study of t he effects of psychological factors
such as stress, emotions, thoughts and behaviour on the immune system.
The field of psychoneuroimmunology focuses on the relationship between
psychological influences (such as stress), the nervous system, and the
immune system.
Stress appears to depress immune function in two main ways. First, when
people experience stress, they more often engage in behaviors that have
adverse effects on their health: cigarette smoking, using more alcohol or
drugs, sleeping less, exercis ing less, and eating poorly. In addition, stress
may alter the immune system directly through hormonal changes.
Research indicates that glucocorticoids —hormones that are secreted by
the adrenal glands during the stress response —actively suppress the
body’s immune system.
Two important points with respect to immune system and stress that are
worth noting:
 Stress triggers the same response in the immune system that infection
triggers.
 Positive effects of stress on the immune system only seem to work
when the stress is not continuous and a chronic condition. Prolonged
stress has detrimental effect on our immune system functioning.
A large number of research studies have revealed that stress considerably
influences the immune system's abilities to defend the bo dy. A large
number of studies, both laboratory as well as field, have been carried out
to demonstrate how immune system functioning is influenced by stress
and related variables.
4. Emotional Expression : When emotional expression is
inhibited, health problems arise. Research studies have
demonstrated that expressing emotions is beneficial to one’s
physical health and mental well -being. Inability to express one’s
emotions appropriately – either emotional outburst or its
suppression is unhealthy and can lead to w ide variety of problems
– both physical as well as psychological. Research studies by
James Pennebaker (1997) have observed that actively
confronting emotions that arise from an upsetting or a traumatic
event can have long -term health benefits. Fo r example writing
about a distressing experience facilitates coping and contributes
to physical health.
5. Personality Style : One’s personality style is also closely associated
with development of physical and mental health problems. One type of
personality style that has been extensively studied is the “Type A”
personality pattern. Type A people who are impatient, irritable, and
aggressive and are always in a pressure to get something done is more
prone to develop cardiovascular disorders such as heart atta cks. Type munotes.in

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121 A individuals react explosively to stressful situations. The
sympathetic system of Type A individual is always alert and at its
peak. Type A individuals with high levels of hostility, commonly
engage in unhealthy behaviours, such as smoking an d consuming large
amounts of alcohol.
A new personality type that has been identified by some researchers (Sher,
2005, Pedersen and Denollet, 2003) is the “Type D” (Distressed)
personality. These individual are at increased risk for heart disease due to
their tendency to experience negative emotions while inhibiting the
expression of these emotions when they are in social situations. These
individual also have a reduced quality of life and they benefit less from
medical treatment.
Sociocultural factors: Sociocultural factors play an important role in
causing and aggravating stress -related disorders. Living in a harsh social
environment threatens a person’s safety, interferes with the establishment
of social relationships and involves a high level of con flict, abuse and
violence. Chronic exposure to stressful environment can lead to higher
cortisol levels resulting in disturbances in the immune system.
Treatment: Treatment of problems associated with the condition called
“Psychological factors affecting m edical conditions” requires a
multidimensional approach. Medical treatment alone is insufficient.
People must be taught to change their lifestyle, develop certain behaviours
and changes in attitude that can go a long way in altering their lifestyle
and consequently gain control over their health and problems. One
interdisciplinary approach that has been developed is called as
behavioural medicine , which makes use of behavioural techniques and
learning approaches. In this approach they are taught to lear n about
unhealthy bodily processes and to take action to avoid or modify
circumstances in which they are likely to become sick. Individuals learn to
monitor early signs of mounting tension and to initiate steps to avert the
further development of pain.
8.4 SUMMARY
In this unit we have discussed the concept of somatoform disorders and
the various types of somatoform disorders which include conversion
disorder, Somatisation disorder and related conditions, Pain disorder,
Body dysmorphic disorder and Hypocho ndriasis. Clinical symptoms,
causes and treatment of each of these disorders were briefly explained.
Three conditions related to Somatoform Disorders were discussed in brief.
These include: Malingering (Faking) , Factitious Disorder and
Munchausen’s Syndr ome. Theories and Treatment of somatoform
disorders were also discussed in brief.
Psychological Factors Affecting Medical Conditions as well as its
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122 8.5 QUESTIONS
Q1. What are somatoform disorders.
Q2. Write short not es on the following:
a. Conversion disorder
b. Somatisation Disorder and Related Conditions
c. Pain Disorder Body Dysmorphic Disorder:
d. Hypochondriasis:
e. Conditions Related to Somatoform Disorders
f. Distinguishing Somatic Disorders from Malingering and Factitious
Disor der
g. Theories and Treatment of Somatoform Disorder
Q3. Discuss the Theories and Treatment of Psychological Factors
Affecting Medical Conditions:
8.6 REFERENCES
Halgin, R. P., & Whitbourne, S.K. (2010). Abnormal Psychology: Clinical
Perspectives on Psychologica l Disorders. (6th ed.). McGraw -Hill.
Carson, R. C., Butcher, J. N., Mineka, S., & Hooley, J. M. (2007).
Abnormal Psychology . (13th ed.). Indian reprint 2009 by Dorling
Kindersley, New Delhi.
Nolen -Hoeksema, S. (2008). Abnormal Psychology . (4th ed.). New Yo rk:
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