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SCHIZOPHRENIA AND OTHER
PSYCHOTIC DISORDERS - I
Unit Structure
1.0 Objectives
1.1 Introduction
1.2 Characteristics of Schizophrenia – positive, negative and other
Symptoms
1.3 Other Psychotic Disorders
1.4 Summary
1.5 Questions
1.6 References
1.0 OBJECTIVES After reading this unit, you will the able to know :
About one of the major psychotic disorder: schizophrenia.
About the positive, negative and other symptoms of schizophrenia.
The other psychotic diso rders related to schizophrenia –
schizophreniform disorder, brief psychotic disorder, schizoaffective
disorder, delusional disorder.
1.1 INTRODUCTION Schizophrenia is one of the most common psychotic disorders. It is a
puzzling disorder wherein sometime s patient thinks and communicates
clearly and is related with reality. And, sometimes the same individual’s
thinking and speech is disorganized and is not in touch with reality.
Process disrupted by schizophrenia include those that involve an
individual’s thought, perception, emotions, motor functions etc.
There is a strong evidence for a genetic transmission of this disorder.
Structure of brain, prenatal environment and birth complications may
result in this disorder. DSM recognizes two main symptoms of
schizophrenia - positive and negative. Type I symptoms (positive) include
unusual perceptions, thoughts and behaviours. Type II symptoms
(negative) represent loss or absence of behaviours.
1.2 CHARACTERISTICS OF SCHIZOPHRENIA The term psychotic has been used to characterize much unusual behaviour
where an individual seems to not be in touch with reality. Although in its
strictest sense it usually involves delusions (which involve irrational munotes.in
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Abnormal Psychology
2 beliefs) and / or hallucination (expe riencing things through the scenes in
the absence of any external events such as hearing voices). Schizophrenia
is just one of the disorders that involve psychotic behavior. This is a
disorder that affects a person’s thought, feeling, behavior, perception,
motor functioning, motivation, judgment, insight and overall intrapersonal
and interpersonal functioning. It is more common in men than women.
Psychologists in this field typically distinguish between what are called
positive and negative symptoms of sch izophrenia. Positive symptoms refer
to more active manifestations of abnormal behaviour or an excess of
distortion of normal behaviors. The positive symptoms include delusions,
hallucinations and disorganized thought, disorganized speech and
catatonic beha vior. Negative symptoms involve deficit in normal
behaviour or normal functioning. A negative symptom of schizophrenia
affects an individual’s speech, emotion and motivation. Examples of
negative symptoms are avolition, alogia, restricted affect etc.
In order to diagnose an individual with schizophrenia, an individual
should experience two or more of the positive symptoms and/or negative
symptoms for at least one month.
Positive S ymptoms of Schizophrenia :
a. Delusions :
Delusions are a misrepresentation of reality in an individual’s content of
thought. Delusions are difficult to believe. For example, an individual
might believe that squirrels are aliens sent to earth on a reconnaissance
mission. It is a fixed false belief that an individual holds. They will not
give upon their belief in spite they are been presented with the evidence
against their belief. Individual experiencing delusion are preoccupied with
them.
Common types of delusions are :
i. Persecutory Delusions: Individual suffering from these del usions
constantly feel that others intends to harm them or their loved ones.
They are being watched or tormented by people whom they know.
ii. Delusions Reference: Individual suffering from this type of delusion
believe that random events, comments pas sed by others are aimed at
them. People with delusion of reference may feel that a politician is
trying to harm him personally through speech.
iii. Grandiose Delusions: Individual suffering from this delusion feel
that they are special person and have m agic powers. They may think
that they are great historical characters.
iv. Delusion of Thought Insertions: Individual suffering from this
delusion feel that their thoughts are being controlled by outside forces
An intriguing view of delusion is that they may serve a purpose for people
with schizophrenia, who are otherwise quite upset by the changes, taking munotes.in
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3 Schizophrenia and Other Psychotic Disorders - I place within themselves. The delusions may serve as adaptive function for
delusional individuals is at present just a theory with little support, b ut it
may help us understand this phenomenon and the reactions to it expressed
by those experiencing the delusions.
b. Hallucinations :
The experience of sensory events without any input from surrounding
environment is called hallucination. Hallucination c an involve any of the
senses, although hearing things that are not there or auditory hallucination
in the most common form experienced by person with schizophrenia.
Types of Hallucinations :
i. Auditory Hallucinations: In auditory hallucinations individuals hear
heavy voices, music, different type of noises, in its absence.
ii. Visual Hallucinations: An individual suffering from this may see a
stimuli in its absence.
iii. Tactile Hallucinati ons: It involves a feeling that some odd is
happening to one’s body . E.g., insects are crawling all over the body.
iv. Somatic Hallucinations: It involves feeling that something is
happening inside one’s body and they are tickling him from within.
Rese arch on hallucinations suggests that people tend to experience
hallucination more frequently when they are unoccupied or restricted from
sensory input. By studying cerebral blood flow using single photon
emission computed tomographty (SPECT). scientists of London have
discovered that the part of the brain most active during hallucinations was
the area called Broca’s area. Broca’s area is involved in speech
production.
If hallucinations involves understanding the speech of others, you might
expect more acti vity in the area of the brain that involves language
comprehension, on area called Wernick’s area. Research establishes that
during hallucination Broca’s is more active than Wernick’s area. This
observation of brain activity during hallucinations supports a theory that
the people who are hallucinating are in fact not hearing the voices of
others but instead are listening to their own thoughts or voice and can not
recognise the difference.
c. Disorganized speech :
People with schizophrenia often lack ins ight that they have disease. They
experience associative splitting and cognitive slippage. DSM – IV has
used the term disorganised speech to describe these problems with
communications.
The most commonly found disorganized tendency is to slip from one top ic
to a totally unrelated topic. There is no association between topics
discussed by them. This is also known as derailment of thought. When the munotes.in
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4 person with schizophrenia is questioned then they may give a totally
unrelated reply.
At times, an individual with schizophrenia may use a word in a
conversation which has no meaning in any dictionary. It has meaning only
to them. This is known as neologisms. They also associate the words on
the basis of its sounds rather than meaning. Such associations are known
as clangs. e.g., dog may be called “spog” and cat as “meaw”.
Sometimes the person may repeat the same word again and again by
stressing on particular word. This is known as perseveration.
Men with schizophrenia show greater tendency of language deficit as
compared to women. Men have limited linguistic resources to overcome
their problems.
Grossly Disor ganised or Catatonic Behaviour:
People with schizophrenia engage in a number of other active behaviours
that might be considered positive symptoms.
People with schizophrenia are unpredictable and suddenly react in an
agitated manner. They may suddenly shout, swear and wander about up
and down the street alone. They may tend to engage in an embarrassing
behaviour by acting in a socially disapproved manne r, like publicly
masturbating. Their daily routines are disturbed, where they do not care
for themselves, showing carelerneres in eating, dressing, oral hygiene, etc.
Catatonic behaviour too can been seen in patients of schizophrenia.
Catatonia referred to as a group of disorganised behaviours that reflect an
extreme lack of responsiveness to the outside world. Catatonia involves a
spectrum of motor dysfunctions from wi ld agitation to immobility.
Catatonic excitement involves extreme uncontrollable agitation expressing
a number of delusions and hallucinations.
Negative Sym ptoms of Schizophrenia :
In contrast to the active presentations that characterize the positive
symp toms of schizophrenia, the negative symptoms usually refer to the
absence or insufficiency of normal behaviour and include emotional and
social withdrawal, blunted effect, apathy, and poverty of thought or
speech.
a. Flat Affect:
Approximately two third s of the people with schizophrenia exhibit what is
called as flat affect. They do not show emotions. They may stare at you
with vacant eyes, speak in a flat and toneless manner and seems to be
unaffected by things going on around them. This condition in al so known
as blunted affect. The person remains in a freeze condition most of the
time. They are extremely unresponsive to the events around them. The flat
affect in schizophrenia may represent the person’s difficulty with
expressing emotion and an inabilit y to feel the emotion. munotes.in
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5 Schizophrenia and Other Psychotic Disorders - I b. Avolition:
Avolition is an individual’s inability to initiate and persist in many
important activities. It is also referred to as apathy. Avolition is an
inability to be committed to a common goal directed activity. People with
this symptom show little interest in most of the basic day -to-day activities,
including personal hygiene. People with schizophrenia are unmotivated,
disorganized and careless in the task that they undertake.
c. Alogia:
It refers to as poverty of speech. It is relative absence in either the amount
or the content of speech. A person suffering with alogia may respond the
question with very brief replies that have little content and many appear
disinterested in the conversation. Or may not reply at all. Some times
alogia takes the form a delayed comments or slow response to the
questions. This deficiency in communication by some people with
schizophrenia is believed to reflect a negative thought disorder rather than
an in adequacy in communication skills.
Other Symp toms of Schizothrenia :
Some symptoms of schizophrenia are not prominently seen in all cases but
they do frequently occur in schizophrenic as follows -
a. Inappropriate Affect:
An individual with schizophrenia may react with an inappropriate
emot ion to a particular action, e.g., individual may cry when it is time to
laugh and vice -versa.
b. Anhedonia:
It is derived from the word bedonic, pertaining to pleasure. It refers to the
lack of pleasure experienced by people with schizophrenia. Individu als
with anhedonia report no interest in an activities that they would typically
be considered pleasurable, including eating, social relations, sexual
interactions, etc.
c. Impaired Social Skills :
Most of the schizophrenic patients show poor social ski lls, such as
difficulty in maintaning conversation, job and relationship.
Sub-Types of Schizophrenia :
DSM -IV-TR describes five major sub -types of Schizophernia - Paranoid
schizophrenia, Disorganised schizophrenia, Catatonic schizophrenia,
Undifferentiated schizophrenia and Residual schizophrenia.
Paranoid schizophrenia : wherein the prominent feature is delusion
and hallucination. The clinical picture is dominated by absurd and
illogical beliefs. munotes.in
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6 Disorganized schizophrenia : which is characterized by disorganized
speech, disorganized behavior, and flat or inappropriate affect
Catatonic schizophrenia : which involves pronounced motor signs
that reflect great excitement or stupor.
Undifferentiated schizophrenia : wherein an individual present the
symptoms of two or more subtypes of schizophrenia.
Residual schizophrenia : wherein individual experiences only
negative symptoms of schizophrenia and absence of positive
symptoms.
Unfortunately, research using the subtyping approach did not yielded
major insights into the etiology or treatment of the disorder. Reflecting
this, subtypes of schizophrenia are n o longer included in DSM -5.
Check Your Progress:
1. Discuss the positive symptoms of schizophrenia.
2. Explain the negative symptoms of schizophrenia.
3. What are the other symptoms of schizophrenia.
4. Explain the subtypes of schizophrenia
1.3 OTHER PSYCHOTIC DISORDERS (THE SCHIZOPHRENIA SRECTRUM DISORDERS) a. Brief Psychotic Disorder :
This disorder shows the sudden onset of one or more “positive” symptoms
such as delusions, hallucinations, or disorganised speech or behaviour for
the period of less than a month. The symptoms are not seen beyond one
month.
b. Schizophreniform Disor der:
Some people experience the psychotic symptoms similar to schizophrenia,
but for limited period, usually last from one month to six months. If the
symptom seen beyond s ix months then the diagnosis of schizophrenia is
given to that person. These symptoms disappear quickly, often for
unknown reasons, and the person can usually resume his or her life as
before. There are few studies on this disorder, therefore, data on impo rtant
aspects of it are sparse. It appears, however, that the lifetime prevalence is
approximately 0.2% (American Psychiatric Association, DSM – IV,
1994).
c. Schizoaffective Disorder :
The symptoms of schizophrenia coincides with symptoms of depression or
mania, but there is at least a two week period when only symptoms of munotes.in
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7 Schizophrenia and Other Psychotic Disorders - I schizophrenia are present with no signs or symptoms of depression or
mania.
d. Delusional Disorder :
The major feature of delusional disorder is a persistent delusion or belief
that is contrary to reality. These individual appears to be very normal until
the point they talk about their delusion. This persistent delusion is not the
result of an organic factor such as brain seizures or any severe psychotic
disorder. Individual with these delusions tend not to have most of the other
problems associated with schizophrenia. They may become socially
isolated because of their suspicion of others. The different types of
delusional disorder are –
i. Persecutory Delusion : False belief that they or their loved ones are
treated in a wrong or unkind manner.
ii. Grandiose Delusion : False belief that one has great, knowledge, or
talent.
iii. Jealous type of Delusion : False belief, without any strong reason,
that their partner is being unfaithful towards them.
iv. Erotomanic type of Delusion : False belief that another person is in
love with them.
v. Somatic Delusion : False belief that on e’s has some diseased or some
medical condition.
e. Shared Psychotic Disorder :
It is a name given to a condition in which an individual develops
delusions simply as a result of a close relationship with a delusional
individual. The content and nature of the delusion depends on the delusion
of the partner and can range from the relatively bizarre, such as believing
that enemies are sending gamma rays through your house to less bizarre,
such as believing that you are about to receive a major promotion.
Check Your Progrss :
1. Explain any two other Psychotic Disorders.
2. Discuss Schizophreniform Disorders.
3. Explain different types of delusions found in delusional disorder.
1.4 SUMMARY Schizophrenia is a type of psychosis which is very common. There ar e
mainly two types of clinical symptoms of this disorder – negative and
positive symptoms. Positive symptoms include delusions, hallucinations,
disorganised thought and speech, disorganised or catatonic behaviour. munotes.in
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Abnormal Psychology
8 Delusions are ideas that an individual be lieves are true but are highly
unlikely and often simply impossible. There are different types of
delusions – Persecutory delusions, delusions of reference, grandiose
delusions and delusions of thought insertion. Hallucination
Is the experience of sensory events without any input from surrounding
environment. The types of hallucination are visual, auditory, tactile and
somatic. The individual suffering from schizophrenia also have
disorganised speech and disorganized thought process due to which it
become difficult to have a smooth conversation with them. They also
display maladaptive behavior or catatonic behavior wherein they either
have excessive motor movements or no movements at all.
Negative symptoms of schizophrenia are affect flattening alogia and
avolition. Affect flattening is a severe reduction or absence of affective
responses to the environment. Alogia is reduction in speaking. Avolition is
an inability to persist at common, goal directed activities. Other symptoms
are inappropriate affect, anhe donia and impaired social skills.
The other psychotic disorders are brief psychotic disorder,
schizophreniform disorder, schizoaffective disorder, delusional disorder
and shared psychotic disorder which falls on the same continuum of
schizophrenia.
1.5 QUESTIONS 1. Discuss the various characteristics, positive and negative symptoms of
schizophrerina.
2. Discuss the different types of psychotic disorders.
3. Write notes on the following .
a. Hallucinations and its types.
b. Types of Delusions.
c. Subtypes of Schizophrenia
1.6 REFERENCES Oltmanns, T.F. & Emery, R. E. (2010). Abnormal Psychology, 6th
ed., New Jersery : Pearson Prentice Hall.
Bennet, P. (2003). Abnormal and Clinical Psychology : An
Introductory Textbook – Open University Press.
*****
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9 2
SCHIZOPHRENIA AND OTHER
PSYCHOTIC DISORDERS - II
Unit Structure
2.0 Objectives
2.1 Risk and Causal factors of Schizophrenia
2.2 Summary
2.3 Questions
2.4 References
2.0 OBJECTIVES After reading this unit, you will the able to know about various factors
contributing to development of schizophrenia and other psychotic
disorders.
2.1 RISK AND CASUAL FACTORS Despite enormous efforts by researchers, this question still defies a simpl e
answer. What is clear is that no one factor can fully explain why
schizophrenia develops. Psychiatric disorders are not the result of a single
genetic switch being flipped. Rather, a complex interplay between genetic
and environmental factors is responsi ble.
Genetic factors :
Genetic factors are clearly implicated in schizophrenia. It has long
been known that disorders of the schizophrenia type are “familial”
and tend to “run in families
Having a relative with the disorder significantly raises a per son’s risk
of developing schizophrenia. For example, the prevalence of
schizophrenia in the first -degree relatives (parents, siblings, and
offspring) of a patient with schizophrenia is about 10 percent. For
second -degree relatives who share only 25 percent of their genes with
the patient (e.g., half -siblings, aunts, uncles, nieces, nephews, and
grandchildren), the lifetime prevalence of schizophrenia is closer to 3
percent.
Study after study has shown a higher concordance for schizophrenia
among identic al, or monozygotic (MZ), twins than among people
related in any other way, including fraternal, or dizygotic (DZ), twins.
Concordance rates for schizophrenia are compared for the biological
and the adoptive relatives of people who have been adopted out of
their biological families at an early age (preferably at birth) and have
subsequently developed schizophrenia. If concor dance is greater munotes.in
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Abnormal Psychology
10 among the patients’ biological than adoptive relatives, a hereditary
influence is strongly suggested
Having high heritability, researchers are attempting to locate the
specific genes involved and to understand the factors that increase the
genet ically vulnerable a chances of developing the disorder.
Combination of neuroimaging and genomics of the siblings show
fMRI abnormalities less severe than those that appear in the brains of
affected indi (Gur & Gur, 2010)
At present, researcher s have identified at least 19 possible genes
discrete over chromosomes 1,2,5,6,8,11,13,14,19,22. Some of the
functions of these chromosomes involve the neurotransmitters
including dopamine and GABA, as well as serotonin and glutamate.
Other factors tha t have been implicated in the development of
schizophrenia include prenatal exposure to the influenza virus, early
nutritional deficiencies, rhesus incompatibility, maternal stress, and
perinatal birth complications.
Urban living, immigration, and can nabis use during adolescence have
also been shown to increase the risk of developing schizophrenia.
Current thinking about schizophrenia emphasizes the interplay
between genetic and environmental factors
Neurodevelopmental Perspective :
According t o neurodevelopmental perspective, schizophrenia is a
disorder of development that arises during the years of adolescence or
early adulthood due to alterations in the genetic control of brain
maturation.
Genetic vulnerability becomes evident if an indiv idual is exposed to
certain risks during early brain development.
These risks can occur during the prenatal period in the form of viral
infections, malnurition or exposure to toxins or during/shortly after
birth if they exposed to injuries or viral i nfections, or if their mothers
suffer birth complications.
Harm to their developing brains may show up early in life in the form
of decreased head size motor impairments in cognition and social
functioning
Support to the neurodevelopmental hypothesis also comes from the
fact that an individual having their first psychotic episodes have a
number of incomprehensible brain abnormalities as the result of the
illness. As their illness proceeds they may show con tinued harmful
changes through a process of “neuroprogression” in which the effects
of schi interact with brain changes caused by normal aging
munotes.in
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11 Schizophrenia and Other Psychotic Disorders - II Neurochemistry :
Based on the observation of the effect of drug to relax surgical
patients, French physicians began to experiment these drug to treat an
individual with psychotic disorders.
Chlorpromazine was found to be effective to deal the psychotic
symptoms. Chlorpromazine had its effect by blocking dopamine
receptors. This gave rise to the idea that dopam ine, more specifically,
the d2 receptor, plays a role in development schizophrenia
Gamma -aminobutyric acid (GABA) also appears to be involved in
development of schizophrenia.
Changes in the n -methyl -d-aspartate (NMDA) receptors also seem to
play a role in development of psychotic symptoms. NMDA help to
promote new learning in the brain by helping to build synapses. So,
alternations in NMDA may, in turn, be related to changes in the
neurons that make them less capable of supporting memory and
learni ng.
Symptoms of schizophrenia related to increase excitation, decreased
inhibition and altered cognitive functioning would thus correspond to
these changes in the neurotransmitters
Structural Abnormality :
One of the earliest discoveries from neur oimaging methods was that
the brain of an individual with schizophrenia have enlarged ventricles,
the cavities within the brain that hold cerebrospinal fluid. This
condition is called as Ventricular Enlargement, often occurs along
side cortical atrophy, i. e. a wasting away of brain tissue.
The loss of brain volume is particularly found in the prefrontal lobes,
which is an area responsible for planning, inhibiting thoughts and
behavior.
Over the course of the illness, the cortex shows marked thinning
throughout the brain, but particularly in the frontal lobes and temporal
lobes, parts of the brain that process auditory info
Psychological Theories :
Psychodynamic Perspective :
Sigmund F reud (1924) in his psychodynamic theory suggested that
negative childhood experiences may result in schizophrenia in a person.
Poor parenting may place additional strain on a vulnerable person already
at risk for schizophrenia. Freud said that when mother s behave extremely
harsh towards their child and when they do not express love to their child
then the child regresses and shows infantile tendencies while carrying out
the daily functioning. This becomes unhealthy for the Ego to discriminate
between re ality and unreality. munotes.in
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12 Freida Formm Reichmann (1948) pointed out that poor parenting can
affect the mental state of a child. Two contrasting situation were a mother
is over protective on one side and at the same time questioning the child
about his well -worth. This leads the child in state of confusion,
worthlessness and despair. It may lead to disturbed and illogical ego that
may result in tendencies of schizophrenia.
Behavioural and Cognitive Causes :
Belcher (1988) studied that schizophrenia can devel op through operant
conditioning under normal circumstances. In case of people with
schizophrenia, the basic training for operating over environment is
missing. Because of inadequate parenting or due to some unfortunate
circumstance they learn irrelevant, inappropriate and socially unacceptable
responses towards others around them.
According to Belcher (1988) if the family members ignore reacting to
illogical and inappropriate behaviour that the schizophrenic people show,
then he develops operant condition ing.
Cognitive theorists considered that schizophrenia in caused because of
lack of basic perceptual and intentional skills. Delusions are formed due to
irrelevant misinterpretation of the information attended and perceived in a
distorted manner. For exam ple, if a schizophrenic person report his
hallucination to which his family members may neglect or reject. This in
turn can, be misinterpreted by the patient that his family members have
teamed up with invisible force to harm him. This may give rise to
paranoid beliefs in the person with schizophrenia.
Psychosocial and Cultural Factors :
Disturbed pattern of communication in a child’s family environment
could precipitate factor for development of schizophrenia.
Researchers tried to study the modes o f communication and behavior
within families with schizophrenia member. Researchers attempted to
document deviant patterns of communication and inappropriate ways
that parents interacted with their children could be the factors playing
role in development of schizophrenia.
Clinicians thought these disturbances results in the development of
defective emotional responsiveness and cognitive distortions which
are fundamental to the psychological symptoms.
Contemporary researchers approached the issues by trying to predict
outcome or recovery in adults hospitalized for schizophrenia.
According to them, instead of disturbed family as the cause, they view
the family as a potential source of stress in the env ironment of the
person who is trying to recover from a schizophrenia episode
They explained the above with the help of an index which termed as
Index of expressed emotion (EE) i.e. stress that family members
create. This provides a measure of the degre e to which family munotes.in
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13 Schizophrenia and Other Psychotic Disorders - II members speak in ways that reflect criticism, hostile feelings and
emotional overinvolvement or overconcern
Researchers found that people living in families high in EE are more
likely to suffer a relapse, particularly if they are expo sed to high
levels of criticism
One fMRI study showed that people with schizophrenia experiences
higher activation of brain regions involved in self -reflection and
sensitivity to social situations when hearing speech high in EE
compared to neural speec h
EE could never employ an experimental design as a result researchers
can never draw casual links between EE and schizophrenia
It is also very likely that the presence of an individual with
schizophrenia creates stress within the family.
Broad er social factors such as social class and income can also
contribute to the development of schizophrenia.
In the first epidemiological study of mental illness in the US,
Hollinshead and Redlich (1958) observed that schizophrenia was far
more prevale nt in the lowest socio -economic classes. Number of
reserchers have since replicated this findings.
Possible interpretation could be the individual with schizophrenia may
be experiencing “downward drift”. That is their disorder drives them
into poverty, which interferes with their ability to work and earn a
living
Stress of living in isolation and poverty in urban areas contributes to
the risk of developing of schizophrenia.
Rates of schizophrenia is higher in individual who were born or raised
in urban areas, not just those who moved there as adults.
People living in other country - (i.e. Those who have “migrant”
status) have higher rates of schizophrenia. Those who mig rate to
lower -status jobs and urban areas are more likely to suffer from
schizophrenia.
Other risk factors in sociocultural background include adversity in
childhood including parental loss or separation, abuse and a target of
bullying. In adulthood th ey are more vulnerable to first or subsequent
episodes of psychosis.
Individual with high genetic risk who are exposed to environmental
stressors are more likely than others to develop schizophrenia.
Recognizing that the cause of schizophrenia is mu ltifaceted and
develop over time, Stilo and Murray (2010) proposed a munotes.in
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14 “developmental cascade” hypothesis that integrates genetic
vulnerabilities, damage occurring in the prenatal and early childhood
periods adversity and drug abuse as leading, ultimately to change in
dopamine expressed in psychosis
2.2 SUMMARY Schizophrenia is a disorder that is result of interaction between biological
factors, psychological factors and social factors, wherein biological factors
play an important role.
2.3 QUESTIONS Q.1 Discuss various risk and causal factors of schizophrenia.
2.4 REFERENCES Oltmanns, T.F. & Emery, R. E. (2010). Abnormal Psychology, 6th
ed., New Jersery : Pearson Prentice Hall.
Bennet, P. (2003). Abnormal and Clinical Psychology : An
Introductory Textbook – Open University Press.
*****
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15 3
MOOD DISORDER AND SUICIDE - I
Unit Structures
3.0 Objectives
3.1 Introduction
3.2 General Characteristics of Mood Disorder
3.3 Depressive Disorders
3.3.1 Major Depressive Disorder
3.3.2 Types of Depression
3.3.3 Dysthymic Disorder
3.4 Disorders Involving Alterations of Mood
3.4.1 Bipolar disorder
3.4.2 Cyclothymic disorder
3.5 Summary
3.6 Questions
3.7 References
3.0 OBJECTIVES After studying this unit you should :
Comprehend the general characteristics of mood disorder.
Know the various types of mood disorders.
3.1 INTRODUCTION We do feel happy and energetic and sometimes sad and depressed. These
are commonly experienced mood changes. The mood disorders explained
in this unit are more serious and disruptive in nature.
Mood disorder is one of the group of disorders involving seve re and
enduring disturbances in emotions ranging from elation to severe
depression. Mood disorder involves disturbances in person’s emotional
state or mood. People can experience extreme depression or alternate
between elation and depression.
3.2 THE GENERAL CHARACTERISTICS OF MOOD DISORDERS 1. Individual feels overwhelming sadness or dysphoria.
2. Some may have experiences that are opposite of depression, feelings
of happiness called as euphoria. munotes.in
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16 3. Mood disorder has a time limit period during which sp ecific
symptoms of disorders are seen. The time limited period of intense
symptoms of disorder is called as an episode. The episode of disorder
may be very lengthy extending up to 2 or 3 years .
4. Mood disorders are classified as mild, moderate and severe depending
on the severity of episode.
5. Every clinician documents whether the disorder is first occurance or
if there is recurrence of symptoms. If it is a recurrent episode,
clinician tries to find out if the client has fully recovered or not.
6. Some people may display even bizarre and unusual behaviors, such as
odd bodily postures or movements or excessive purposeless motor
activity.
7. The clinician also tries to determine if there is a postpartum disorder.
A disorder that is seen in women after givi ng birth to baby is called
postpartum disorder.
3.3 DEPRESSIVE DISORDERS The person experiencing depressive disorder, usually experiences feelings
that follow a tragic loss or grief. People do get back to day -to-day affairs
and come to terms with tragic loss and grief. Individuals suffering from
depression, continue to experience feelings of hopelessness, fatigue, and
worthlessness and show suicidal tendencies even when there is no
apparent cause.
3.3.1 Major Depressive Disorder :
i) The following are t he characteristic s of major depressive episodes:
1. It involves an intense dysphoric mood that is much more serious than
ordinary sad moments of day -to-day life. The dysphoria may be
found in the form of excessive dejection or sudden loss of internal in
the activities that were previously pleasurable.
2. If intense depression continues after death of loved one for more
than 2 months, then it is a major depressive disorder.
3. The depressive disorders may not always have a precipitating event.
Onset may be without any known cause.
4. Person experiences impairment at home and work due to depression.
5. The physical signs of depressive episode are manife sted as somatic
symptoms like :
a. Lethargy and listlessness.
b. Psychomotor retardation involving slowing down of body
moments. munotes.in
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17 Mood Disorder and Suicide - I c. Some people may show extreme psychomotor agitation. These
behaviors may be bizarre and extreme, sometimes may be even
categorised as catatonic.
6. Eating disturbances are more common. P eople may not have appetite
and may even avoid food. Some others may overeat, or overindulge in
sweet and carbohydrates.
7. Dramatic changes in sleep patterns are observed. People may show
insomnia or engage in excessive sleeping. The EEG sleep patterns
show that clients show disturbances in sleep continuity, intermittent
wakefulness and early morning awakening. Disturbances in REM
sleep are evident; there are more eye moments and increased duration
of REM sleep. Such major REM abnormalities are seen bef ore the
major depressive episode.
8. The cognitive symptoms are :
i. Intensely negative self –concept, low self -esteem followed by a
strong need to be punished.
ii. Intense guilt feelings and persistent and thinking about the past
mistakes is common.
iii. Difficulty in thinking, concentration and decision making.
9. Loss of interest in the activities that were considered as interesting in
the past. Person is overcome by feelings of negativity and
hopelessness and thinks that death is the only way of esc aping and
may actually commit suicide.
The symptoms of depression may continue from 2 weeks to period of two
months. If untreated, symptoms may continue for another six months. The
symptoms of major depressive episode occur gradually, they are not
shown o ver night.
3.3.2 Types of Depression :
A. Depressive episodes involving melancholic features.
B. Depressive episodes involving seasonal patterns.
A. Depressive episodes i nvolving melancholic features:
Persons loose interest in most of the activitie s. They find it difficult to
react to events that require pleasurable reactions. Morning is very
difficult for these people. They may wake up early in the morning and
continue the day with sad and gloomy feelings and other major symptoms
of depression.
B. Depressive episod es involving Seasonal Patterns:
People with seasonal patterns of depression develop disorder almost at the
same time each year or may be about 2 months during winter, but then, munotes.in
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18 they come back to normal life. During episode they lack energy, interest,
may sleep excessively, and overeat m ore carbohydrates. Some researchers
propose that seasonal depression is linked with changes in biological
rhythms. It is found that people with seasonal depression are found more
in states where there is less temperature.
The onset and the course of disor der:- The average age for major
depressive disorder is 30 years.(Hasin et al 2005) A study performed
Cross National Collaboration Group 1992, (Kessler at al 2003) showed
that incidence of depression and consequent suicide is steadily
increasing over th e years. The national morbidity study has shown that
increasing younger groups called as cohorts have higher prevalence rates
than older people. Individuals aged 18 -29 years are more likely to become
depressed at the earlier ages than the people in t he age group 30 -44 years.
In short, depression has started surfacing at an early age with greater
frequency.
The length of depressive episode is variable. Some episode may last for
two weeks and in more severe cases it may last for several years. If
untre ated the first episode of depression may last for 4 to 9 months (Eaton
et al 1997).
Some may attempt to reduce depression by resorting to drug or alcohol
addiction. Depressive episodes may be found in children and adolescents.
The typical age of onset ha s been estimated be early 20’s. D.N. Klein
Taylor Dickstein and Harding found the three characterstics of the onset of
disorder before 21.
1. It lasts longer
2. It shows relatively poor response for treatment.
3. The chances are stronger that the disor der may run in the family of
affected persons.
Study done by Kersler et al (2005) show that approximately 2.5 percent of
adult population develop this disorder in the course of their life. This
disorder reaches its peaks by 45 to 59 years. Adults usuall y report the
physical symptoms of depression. Finally, hospitalization is very rarely
required except in the cases where depression leads to suicidal attempts
3.3.3 Dysthymic Disorder :
Some people experience depression involving sadness, but sadness is n ot
so intense to be described as major depressive episode. But such
depression is very often long lasting. This does not refer to the mood
changes that we do experience in day -to-day life. People with dysthymic
disorder show the symptoms of major depressiv e disorder for at least 2
years (1 year for children and adolescence). These symptoms may include
appetite disorder, sleep disturbances, low energy, fatigue, low self esteem,
poor concentration, difficulty in decision making and feelings of
hopelessness. munotes.in
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19 Mood Disorder and Suicide - I Dysthymic disorder differ from major depressive episode only on the basis
of its course, i.e., chronic in nature and severity of the symptom. People
with dysthymic disorder are never symptom free for more than two
months. They may withdraw from social in teractions and react with anger
and irritability towards others. Many a times, dysthymic disorder may be
accompanied by other serious psychological disorder. In some instances
dysthymia may be accompanied by personality disorder, some of them
may even deve lop major depressive episode. Some of them may engage
into substances abuse. Hence, clinicians may diagnose wrongly, and
attempts may be done to reduce feelings of hopelessness and
worthlessness.
The Prevalence and Occurrence of the Disorder: - It is obse rved that 2.5
percent of adult population will develop this disorder in the course of life
and the disorder reaches its peak from 45 to 59 years (Kessler et al 2005).
In the older patients the disorder may take physical form rather than
psychological distu rbance.
3.4 DISORDERS INVOLVING ALTERATIONS OF MOOD There are two types of disorder involving mood alterations.
1) Bipolar disorder 2) Cyclothymic disorder
3.4.1 Bipolar disorder :
It involves an intense and disruptive experience of elations or euphoria
alternating with major depressive episode. Bipolar disorder may occur in
two forms. Individuals may experience manic episode or may experience
mixed episode.
Cyclothymic disorder in volves alteration between dysphoria and less
intense type of euphoria called hypomaniac disorder.
Manic episode : Any manic episode, even if it is not followed by
depressive episode, is described as bipolar disorder. Previously bipolar
disorders were des cribed as manic depressive disorder. The term
bipolar implies two poles or extremes, mania and depression.
People with bipolar disorder may not always show symptoms of
depression. It is assumed that people with bipolar disorder w ill experience
depression at some time in later months or years.
Person experiencing manic episode may appear to be outgoing, talkative,
creative, witty and self -confident. The expansiveness and feelings of
energy can cause serious problems in their day -to-day functioning. Self -
esteem of these individuals may be grossly inflated. Their thinking may be
grandiose and even may have psychotic quality.
Most people in manic episode may have bizarre thoughts, They may show
unusual ideas and swings of unusual crea tivity. There is a rapid change in
thoughts and ideas; they may jump from one activity to another. They are munotes.in
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20 easily distracted and continually require stimulation. They may speak
rapidly to others with a such a speed that others find it difficult to
interpr et. People experiencing manic episode may seek out pleasurable
activities that may be impulsive in nature. He or she may engage in
ill-advised sexual relationships or spending sprees. Often person has grand
plans and goals which he pursues obsessiv ely.
Manic episode may appear and diminish suddenly. The depressive episode
may appear gradually and diminish with same speed. The duration of
manic episode depends on the treatment taken by the individual.
Types of Bipolar disorder :
Bipolar disorder I: Bipolar I disorder is diagnosed when individuals
experience one or more manic disorder, with the possibility of
experiencing one or more depressive disorder. But it is always not
necessary that person experience one or more depressive episode.
Bipolar dis order II : Bipolar II is a disorder in which major
depressive episode alternates with hypomania episode i.e., individual
has one or more major depressive episode and at least one hypomanic
episode.
Preval ence and course of the disorder :
It is relatively very rare for someone to develop bipolar disorder after the
age of 40. But once it appears it tends to be chronic, where manic and
depression keep on recurring indefinitely. Bipolar disorder is less
commonly seen as compared with major depressive disorder. The
incidence of bipolar disorder is equally found in both males and females
(Kessler of et al 1994). There are gender differences in the onset of the
disorder. The first episode for men is more likely to be major manic
episode and for women it is more li kely to be major depressive episode.
Bipolar disorder has been reported in psychiatric literature, it has been
found in children as young as 3 years. There is lack of consistency in the
diagnostic criteria and methods of assessment for young children.
Psychologically disturbed children display wide range of symptoms.
3.4.2 Cyclothymic disorder :
It is similar in many ways to dysthymic disorder in its severity and
duration of symptoms. People with cyclothymic disorder experience
alterations between dysphoric and hypomanic episode for over the span of
2 years (1 year for children and adolescene). Hy pomanic episodes are the
less intense and less disruptive euphoric state. They display unusually
dramatic and recurrent mood shifts. The elation may not be severe enough
to be diagnosed as manic episode and depression is never severe enough to
be diagnose d as depressive episode. It is the effects of the disorder that
disrupts the life of an individual. munotes.in
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21 Mood Disorder and Suicide - I Persons with cyclothymic disorder tend to be in one mood state or other
with relatively few periods of neutral mood. The behaviour is not severe
enough to require hospitalisation or immediate intervention.
The average onset of this disorder in between 19 to 22 years. This disorder
begins with minor mood changes or minor cyclothymic mood swings.
In many cases such people are only regarded as moody. Sometim es,
individual with this disorder is actually more likely to experience some
impairment in interpersonal dealings as people may consider them
unreliable because of their mood changes.
The problem of diagnosis becomes complicated among children because
the symptoms of bipolar disorder may co -exist with already present
disorders like conduct disorder, hyperactivity, attention deficit disorder
(Shapiro 2005). Lot of research needs to be done in area of diagnostics for
judging bipolar disorder in children.
Kindling is a phenomena indicating that individuals who have experienced
manic episode are at greater risks of experiencing another episode, even if
they are taking medicines for controlling it. Manic depressive episode may
occur just before or so on aft er major depressive episode. The frequency
of manic depressive episode is on an average 4 episodes within a span of
decade, for those who do not under go any treatment or medication. Not
more than 15% people experience four to eight episodes of mood disord er.
These individuals are described as rapid cyclers. Majority of women are
likely to become rapid cyclers, Hyperthyroidism, use of antidepressant
drugs increase the chances of reducing the time gap between episodes.
Most individuals with bipolar disorde r feel normal between the episodes.
But one forth of them may continue to feel depressed and have difficulty
in dealing with people at home or at work, problems are especially likely
for individuals who struggle with unpredictable mood changes that occur
in rapid cycles because other people consider them to be moody and
unreliable.
3.5 SUMMARY In this unit we had discussed the general characteristics of mood disorder.
Following this we had discussed the different types of mood disorders.
The characterist ics of major depressive episode and various types of
depression were discussed. One of the most common types of depression
is Dysthymic disorder, which was briefy explained. Two types of disorder
involving mood alteration was also discussed, which include d bipolar
disorder and cyclothymc disorder. Types of bipolar disorder, its
prevalence and course was also discussed.
3.6 QUESTIONS 1. Discuss the general characteristics of mood disorders.
2. Explain the various characteristics of major depressive epi sodes. munotes.in
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22 3. Discuss :
a. Depressive episodes involving melancholic features.
b. Depressive episodes involving seasonal patterns.
c. Dysthmic Disorder
4. Discuss Bipolar and Cyclothymic disorder.
3.7 REFERENCES Richard P. Halgin and Susan Krauss Whitbourne, (2010) Abnormal
Psychology, Clinical Perspectives or Psychological disorders. (6th
Ed).
V. Mark Durand and David -H-Barlow (2010, 2006, Essentials of
Abnormal Psychology. Wadsworth, Cengage learning.
*****
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23 4
MOOD DISORDER AND SUICIDE - II
Unit Structures
4.0 Objectives
4.1 Casual factors in Unipolar and Bipolar Disorders
4.1.1 Biological Perspectives
4.1.2 Psychological Perspectives
4.1.3 Behavioural and Cognitive Perspective
4.1.4 Socio Cultural and Interpersonal Perspectives
4.2 Treatment of Mood Disorders
4.2.1 Biological Treatment
4.2.2 Psychological Treatment
4.3 Suicide
4.3.1 Causes of Suicide
4.3.2 Assessment and Treatmen t
4.4 Summary
4.5 Questions
4.6 References
4.0 OBJECTIVES After studying this unit you should :
Understand the theories and treatment of Mood disorders.
Became aware about suicide its causes, assessment and treatment.
4.1 CAUSAL FACTORS IN UNIPOLAR AND BIPOLAR DISORDERS There are different perspectives towards mood disorders. They explain the
causes of mood disorders. Researchers have identified biological,
psychological and social factors that seem to play an importa nt role in the
etiology of mood disorders.
4.1.1 Biological Perspectives :
The Twin studies and family studies indicate the role of biological factors
in mood disorders.
Genetics:
Studies on genetics suggest that bipolar disorder is seen in families.
Research has shown that the first degree relatives of people with major
depression are twice likely to develop disorder as compared with munotes.in
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24 individuals from general population (Sullivan, Neak & Kender 2006) The
risk in higher for the first degree relatives of children of depressed
individuals (Lieb et al 2002) The studies of three generation of children,
parents and grandparents, show that this disorder tend to run in families. If
major depressive disorder is present in parents and grandparents, children
are more likely to show symptoms of psychopathology.
The five large scale studies observed inheritance patterns in families. They
found that the heritability of 31 to 42 percent, meaning among 100
individuals who have close relative who has disorder out of them
approximately 30 to 40 of them have a major likelihood of having major
depression (Sullivan, Neals & Kendler 2009).
National Institute of Mental Health carried out a major study or bipolar
disorder at 5 major research centers, They carried our genet ic linkage
analysis of 500 individuals diagnosed with bipolar disorder.(Faraone,
Glatt, Su & Tsuang, 2004) This is a largest study that offered evidence for
genetic linkage. The available evidence does not clearly indicate the role
of specific genes (De Paule 2004).
In the development of mood disorders, gender also plays an important
role. In a study of over 1000 pairs of opposite sex twins who were
interviewed 2 years apart, to study the effect of receiving social support on
the development of depressiv e symptoms. It was found that both men and
women of twin pairs had more chances of developing major depression
when social support is very low, as compared with men and women who
had more social support. The study indicated that even powerful genetic
risk factors can be influenced by environmental conditions.
Biochemical factors – The biological theories emphasise the altered
neurotransmitter functioning as a cause of mood disorder. It is not
possible to observe neurotransmitter substances in human brain.
Following are two explanations given that suggest the role of deficiency of
neurotransmitter substances.
1. Catecholamine hypothesis, suggests that, the shortage of
norepinephrine (a catecholamine) causes depression and excess
causes mania.
2. Indolemine hypothesis (Glassman, 1969) suggests that deficiency of
serotonin produces behavioural symptoms of depression.
The above two hypothesis regarding the role of deficient neurotransmitter
substances in mood disorder, is called as Monoamine Depletion Model.
All the antidepressants currently used attempt to increase the availability
of these neurotransmitter substance s. Studies have pointed out the
relationship between hormonal activity and depression. Researchers are
focusing on the role of Cortisol. It is a hormone that mobilises body’s
resources during stress. munotes.in
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25 Mood Disorder and Suicide - II The research findings in the area of genetics imply t he role of biological
factors in the causation and symptomatology of mood disorder.
4.1.2 Psychological Perspectives :
The review of genetic contribution to the causes of depression could be
attributed to psychological factors.
Psychodynamics Theor ies:
1. The earlier theories emphasised upon the loss and feelings of
rejection as a cause of mood disorders. The later psychodynamic
theories emphasised the inner psychic processes as the basis of mood
disorders.
2. British psychoanalyst, John Bowlby propo sed that people can become
depressed as adults, if they were raised by parents who failed to
provide them with secure and stable relationship.
Similar theory was proposed by Jules Bempoard (1985). He emphasised
the role of deficient parenting in mood di sorders. Children of such parents
become preoccupied by being loved by others. As adults they form
relationship where they overvalue the support of their partners. End of
such relationship may make depressed person experience feelings of
inadequacy and los s.
3. Psychoanalytic theory of personality suggests that mania is a
defensive response adopted by an individual to deal with feelings of
inadequacy and loss. People become hyperenergetic as a defense
against becoming gloomy and depressed.
4.1.3 Behavio ural and Cognitive Perspective :
1. Lazarus and Skinner (1968, 1953) proposed that depression is the
consequence of reduction of positive reinforcement. Depressed people
withdraw from life because they do not have an incentive to remain
active.
2. The contemporary perspective on depression is (Kanter et al 2004),
based on Lewinshon’s theory, maintaining that low rate of response
contingent positive reinforcement is the cause of depression.
Behavioural approaches have been integrated into cognitive appr oaches.
Cognitive approaches propose that serious mood changes can result from
events in our lives or from our perception of events.
Cognitive perspectives suggest that people experience depression as their
earlier experiences sensitise, them to react in certain ways to stressful
events. People react to stressful events, with a set of thoughts involving
negative view of self, world and future. Beck in 1967, described this
negative view of self world and future as cognitive triad, he further
proposed that if this view is activated once, it continues further in a
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26 Cyclical thinking is maintained by cognitive distortions. T hey are the
errors that depressed people make while drawing conclusions. The
cognitive distortions include applying illogical rules, jumping to
conclusions, over generalising and taking detail out of context. As a
consequence of this, depressed people gi ve negative meaning to past and
future events. They may have pessimistic expectations from future. Such
persons may not be even aware of such negativity in their thinking.
Beck proposes that depressed people feel sad because they are deprived of
somethin g that threatens their self esteem. It represents an individual’s
misguided attempts to adapt to psychological environment.
Harry Stack Sullivan proposed that abnormal behaviour is a consequence
of impaired interpersonal relationships, including deficienc ies in
communication.
Bowlby proposed that, a disturbed attachment pattern in the childhood in
the cause of depression is later years.
Interpersonal theory of depression connects this ideas and gives
behavioural and cognitively oriented theory of depress ion. It explains the
steps in the development of depression.
i. Failure to develop social skills in childhood. The skills required for
developing relationship.
ii. This leads to sense of despair and solution resulting in depression.
iii. Once depressi on in established it is further enhanced by poor social
skills and communication. This invites rejection from others. The
depression that develops in adulthood may arise when person
experiences a event like a death or loss of loved one. Depression
continue s because of a vicious cycle.
Poor communications skills keep people away; poor interactions make
person experience feelings of loneliness and worthlessness still more
intensely, Women are more exposed to stressful events as compared to
men. As a consequen ces women are more likely to experience depression.
These individuals are convinced of facture in their efforts. The positive
experience also may be distorted to fit in their negative framework. The
cognitive distortions make depressed individuals to expe rience low
feelings of well being, energy and desire to be with others and lack of
interest in the environment. For e.g., one may find them making
statements like …. “If a person like me contests for election, no one will
really vote for me because I kn ow people do not like me”.
4.1.4 Socio Cultural and Interpersonal Perspectives :
Interpe rsonal model of mood disorder: (Myrna Werssman, Gerald
Klerman & associates) – This model emphasises disturbed social
functioning. The interpersonal therapy (IPT) f ollows from this model. It is
a time limited form of therapy for treating depressed persons. This – munotes.in
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27 Mood Disorder and Suicide - II therapy assumes that individuals are genetically vulnerable to
interpersonal stress and hence they are more likely to experience
depressive episode. The int erpersonal therapy focuses on both poor social
skills and origin of depressed person’s problem.
Adolph Meyer (1957), An interpersonal theorist with psychobiological
approach to abnormal behaviour emphasised that, psychological problems
are diagnosed with depression. (Hammen 2005).
4.2 TREATMENT OF MOOD DISORDERS 4.2.1 Biological Treatment :
The most common treatment for mood disorder is antidepressants. People
with bipolar disorder are treated with lithium carbonate. The most
common medication used to treat depressions are:
i. Tricyclic Antidepressants. (TCAS)
ii. Monoamine Oxidase Inhibitor (MAOIS).
iii. Selective Serotonin Reputake Inhibitors (SSRIS).
Tricyclic antidepressants (TCAS) : these chemicals have three ring
structures. They are available in the market with trade names like Elavit,
Endep, Norpramin, Tofranil, Aventyl and Pamelor. These medications are
effective with people who have disturbed appetite and sleep. These
tricyclic antidepressant increase the excitatory effect of postsynaptic
neurons.
Monoamine Oxidase Inhibitions (MAOIS) : These drugs are available
with trade names Nard il and tranlcypromine (Parnate) – It is effective in
treatment of chronic depression.These chemicals function by prolonging
the effects of neurotransmitter substances. MAOIS are not frequently
prescribed as they can lead to serious complications. People ta king
MAOIS are not able to take allergy medications or not able to ingest food
containing tyramine, e.g., beer, Cheese and Chocolate. The combination of
this with MAOIS can rise blood pressure dramatically.
Selective Serotonin Reputake Inhibitors – (SSRIS ): It is generally used
as an alternative to tricylic and MAIOS. They block the uptake of
serotonin, so that more of serotonin in made available to action at receptor
sites. SSRIS are different from other antidepressants as they do not block
many receptor sites at a moment; that can cause sedation, weight gain,
constipation and rise in the blood pressure and dry mouth. The new SSRI
medications also have side effects such as feelings of nausea, agitation and
sexual dysfunction.
Studies during past two de cades suggest the effectiveness of SSRIS. The
result of these studies should be viewed with caution. These studies fail to
indicate the effectiveness of medication. Most studies done in this area
have not been published. munotes.in
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28 There are reports of higher s uicide risk with SSRI medication. But the
investigation during 1996 to 1998 showed that the rate of suicide is much
lower among people treated with SSRI as compared with other
antidepressants.
The higher suicide rate among SSRIS prescribed persons made clinicians
to focus attention on the number of related variables such as comorbid
psychological disorder, gender and geographic location and role of
psychotherapy. Antidepressants,are frequently prescribed to patients with
severe symptoms by nature. They are at the higher risk of suicide (Rosack
2005). Therefore, precaution has to be exercised by administering to
children and adolescents. Several studies have shown a link between
suicidal behaviour and antidepressants.
Antidepressants medications have ar e commonly used for relieving
symptoms. But many people are not eligible for this medication, especially
women of child bearing age.
Lithium carbonate in a common salt found in the natural environment. It is
used as an antidepressant, Dosage has to be car efully monitored to prevent
toxicity, and low thyroid functioning, which might intensify lack of energy
associated with depression. Lithium carbonate has side effects such as
mild central nervous system disturbances, gastrointestinal upsets or even
cardia c effects.
Lithium interferes with the high associated with the bipolar disorder.
Persons with bipolar disorder actually enjoy the pleasurable feelings
associated with mania. By the time full blown mania is developed,
individuals may not accept that they have any problem. If side effects are
considered, then person is at risk of developing another episode.
Therefore, therapists encourage the clients to remain on the maintance
dose of lithium.
The variable nature of bipolar disorder makes it necessary to have an
additional antidepressant along with lithium. Persons prone to mania may
develop mania after medication. Persons with psychotic symptoms, may
benefit from antipsychotic medications. Clin icians may also prescribe
ECT., for clients with mood disorders for whom medication may be
ineffective or slow in alleviating the symptoms. People have negative
attitude towards ECT, as it is more likely to be misused. This method has
been used for punish ment in the past rather than for treatment.
ECT - (Electro Convulsive Therapy) : Lisanby (2007) has demonstrated
that ECT is life saving treatment for severely depressed people. Clients are
usually given anasthesia to reduce discomfort, and are given mus cle
relaxing drugs to prevent breaking of bones from convulsions during
seizures. Electric shock is directly administered through the brain for less
than a second. This produces seizures and brief convulsions. In current
practice ECT is administered 6 to 8 times, once every other day, until the
person’s mood returns to normal. The side effects are few. Person has
short term memory loss and confusion that disappears within one or two
weeks. Some clients may show long term memory problems. It is not clear munotes.in
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29 Mood Disorder and Suicide - II as to why ECT works. One explanation is that induces changes in
neurotransmitter receptors and body’s neural opiates.
TMS : Transcranial Magnetic Stimulation (TMS) in an alternative to
traditional ECT. TMS combined with medications have been found to be
more effective with persons who do not respond to medications.
Light therapy is another treatment offered for seasonal depression.
Depressed individuals are especially exposed to special light during
winter season. Another less well known method of the tre atment is sleep
deprivation. Both the methods are effective when combined with
medication.
4.2.2 Psychological Treatment :
Cognitive Behavioural approach and interpersonal psychotherapy are the
most commonly adopted approaches for treatment of depression.
Behavioural Approach :
The major features of this approach in dealing with depression are :
1. Careful assessment of frequency, quality and range of activities and
social interactions in client’s life.
2. Helping client change his or her social environm ent along with
teaching of social skills.
3. Encouraging clients to seek activities that restore mood balance,
helping clients to seek reinforcement in activities.
4. Educating client in settling realistic goals because depressed clients
often set unreal istic goals for themselves. Therapist may give
homework to clients in this area.
5. Therapist focuses on self -reinforcement procedures such as self
congratulations like rewarding one self with some pleasurable
activity.
6. If these procedures do not succee d then therapist may engage in more
extensive programme like instructions. Modeling and coaching, role
playing, rehearsals at real world trials, etc.
Cognitive based approach :
Short time structured approach - It focuses our negative thoughts and it
includes activities that will improve client’s daily life.
1. Clients are taught to examine carefully their thought processes while
they are depressed. They are made to recognise depressive errors in
thinking.
2. Client in taught that errors in thinking can directly cause depression. munotes.in
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30 3. It involves correcting cognitive errors and substituting more realistic
thoughts and appraisals.
4. Later in therapy underlying negative cognitive schemes (characteristic
ways of viewing the world) that trigger the cognitive e rrors are
targeted.
5. Therapist makes it clear to the client that both of them together will be
working as a team to uncover faulty thinking patterns.
To summarize, cognitive approach incorporates didactic work, i.e.,
cognitive restructuring and behavioural techniques. It involves explaining
theory to client, teaching the client how depression results from faulty
thinking and cognitive restructuring. Cl ients are instructed to monitor their
thought processes carefully, especially in situations where client might
feel depressed. Client is required to plan activity for a week, it may
involve graded task assignment. It may involve pleasure prediction
experim ents like how much pleasure will be produced by a given activity
and how much pleasure is produced in reality. This pleasure production
experiments help therapist in demonstrating to client how gloomy
predictions are inaccurate. Client is asked to rate th e pleasure of each
activity. If patient is inactive, then activities are planned on the hour by
hour basis. Thus, helping clients to experience success of accomplishing
something.
Cognitive behavioural therapy is a short term method. It requires general ly
10 to 12 sessions. People with chronic major depressive disorder may
require long term cognitive behaviour therapy.
Psychodynamic approaches involve short terms focused treatment
combined with medication. Clinicians treating bipolar disorder, begin wit h
medication, incorporated by psychological intervention.
Interpersonal Psychotherapy :
It is observed that problems in personal relationships, absence of
relationship, etc is a major stressful event, and it can lead to relapse of the
bipolar disorder.
Interpersonal and social rhythm therapy (IPSRT) :
This therapy is especially seem to be effective to deal with relapse episode
of Bipolar disorder. According to this model mood, episodes are likely to
emerge from:
a. Non adherence to medication
b. Stress ful life events
c. Disruption in social rhythms.
Clinicians, who follow IPSRT model, focus on educating clients, about
medication adherence, helping them to understand their feelings about the
disorder and how it has changed their lives. munotes.in
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31 Mood Disorder and Suicide - II
Clinicians empha sise the reduction of interpersonal stress in client’s life,
especially one who is suffering from bipolar disorder for following
reasons.
1. Stressful life events affect circadian rhythm, i.e., sleep wake cycles,
appetite energy levels.
2. Stressful life events change the daily routine.
3. This may affect person’s mood and may bring about changes in
social, rhythms. (Frank 2007).
Researchers have found this programme to be very effective in improving
relationships.
Socio cultural and interpersonal therapy :
The family members of the client are involved in treatment. They can
understand the experiences of the person with mood disorder and help
him or her in dealing with the symptoms. Interpersonal therapy may last
from 12 to 16 weeks. This theory is divided into three broad phases.
1. Assessing the nature of depression by using quantities measurement.
Interviews are carried and to determine exactly what triggered the
present episode.
2. Therapist and patient toget her formulate a treatment plan focusing on
primary problems like grief, interpersonal disputes and problems
faced due to inadequate social sketch.
3. Third phase treatment plans are carried out depending on the nature of
client’s problem.
4.3 SUICIDE Suicide is one of the most common causes of death among youngsters and
elderly members of society. Suicide in often associated with depression, it
is a way a escaping from hard realities of life. There seem to be 4 phases
of suicide: Suicidal Ideation, Suic ide Planning, Suicide Attempt and
Suicide.
American studies and statistics shows that men are likely to commit
suicide than women. Women may attempt suicide but their attempts may
not be completed as compared to men. Generally 90% adults who commit
suici de have some diagnosable psychological disorder. Disorders like
alcohol abuse, dependence or Schizophrenia are associated with suicide.
(Duberstein & Conwell 2000). Similarly, people with borderline
personality disorder also make suicide attempts.
The statistics of suicide in India in different. According to WHO, India has
a highest suicide rates in the world. The country’s health ministry munotes.in
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32 estimates that 1,20,000 people kill themselves every year and among these
40% of them are below 30 years.
South India in considered as world’s suicide capital. Kerala, has highest
suicide rate, 32 people commit suicide almost every day. In India it is
observed that women are more likely to commit suicide then men. The
study found that suicide rate for women in the age group of 19 -29 years in
148 per 1,00,000 and for men it is 58 per 1,00,000.
There are international variations in suicide rates. The highest rates of
suicide are found in Eastern Europe and lowest in Latin America. (WHO
2004).
4.3.1 Causes of Suici de:
i. Biological perspective :
In one the largest investigations of family patterns of suicide, 250 relatives
of 25 people who committed suicide were compared with 171 relatives of
men who did not commit or attempt suicide. The results of the study
showed that relatives of suicide completers had 10 times more chances of
committing suicide.
Baud (2005) showed that tendency to commit suicide is associated with
genetic vulnerability involving serotonin related genes. Thus, vulnerability
leads to certain personality traits which interact with life events, thus
making a person more prone to committing suicide. Similarly, low alcohol
tolerance combined with genetic vulnerability increases the risks of
committing suicide (Marusie 2005).
ii. Psychological perspective :
If one of the family member commits suicide then there is an increased
risks that someone else in the family will also follow. Brent and
colleagues observed a six fold increased risk of suicide attempts in the
offspring of the family members who had attempted suicide compared to
the offspring of persons who had not attempted suicide. If sibling was a
suicide attempter, then the risk increased even more (Brent et a l 2003).
The question is people who kill themselves, do they simply adopt a
solution that in familiar to them? or is it impulsivity that is inherited as a
family trait that is responsible?
Studies show that early onset of mood disorder, as well as aggressive and
impulsive traits, make such persons succeptible to su icidal behaviour
(Mann et al 2005).
Existing psychological disorders such as mood disorder may become a
precipitating cause of suicidal behaviour. Many people who commit
suicide do have mood disorders.
Similarly, alcohol use and abuse in also associated with suicides,
particularly in adolescent suicides. Combination of disorders such as
substance abuse and mood disorder in adults and mood disorder and munotes.in
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33 Mood Disorder and Suicide - II conduct disorder in children seem to create a stronger vulnerability, then
any one disorder alone. Hawto n & Colleagues (2003) found that
prevalence of previous attempts and repeated attempts doubled if a
combination of disorder in present. Esposito and Clum (2003) also noted
that presence of anxiety and mood disorder predicated suicide attempts in
adolescent s. J. Cooper and Colleagues (2005) followed almost 8,000
individuals who were treated in emergency room for deliberate self harm
for 4 years. Sixty of these people killed themselves, a 30 fold increase in
risk compared to population statistics.
The impor tant risks factor in suicidal behaviour is stressful life event
which are experienced as shameful or humiliating, such as failure that
may be real or imagined. The stress and disruption of national disasters
increase the likelihood of suicide.
The psy chological factors that predispose individuals to committing
suicide are explained by Edwin Shneidman (1984). He suggests that act of
taking one’s life is an attempt of interpersonal communication. Through
suicidal attempts people try to communicate frustr ated psychological
needs to significant people in life.
Beck explains suicide from cognitive perspective. He suggests that suicide
is an expression of feelings of hopelessness triggered by preception that
stress is beyond control. Beck (1996) has used the concept of suicidal
mode to describe the frame of mind of person who has made multiple
suicidal attempts.
Impaired decision making and altered Serotonin pathways in the parts of
the brain involved in making complex choices also predisposes an
individual towards suicidal behaviour.
iii. Socio cultural perspective :
Emile Durkheim, a French sociologist, suggest that a feeling of alienation
from society can become a cause of suicidal behaviour, Media also plays
an important role in propogating suicide, especially among teenagers.
Media accounts often describe in detail the methods used for suicide, thus
they provide guidelines to potential victims.
There are racial and age related differences in suicide. Whites are more
likely to commit suicide followe d by African Americans. The age at which
a member of a given race will commit suicide also varies e.g., for blacks
suicide may occur at an average age of 32 whereas for whites it may be 44
years.
4.3.2 Assessment and Treatment :
Clinicians can assess suic idal intent in the client. The suicidal intent
refers to how person in committed to dying. Secondly, the suicidal
lethality in also judged. The suicidal lethality refers to the dangerousness
of the method adopted for dying. Suicidal intent and lethalit y are always
connected. munotes.in
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34 Many people are willing to discuss their suicidal intentions. Many people
may prefer avoiding warning signs of suicide, by thinking that asking
about intention may provoke a person. Even a trained clinician may find it
difficult to judge the suicidal inten tions of person. Client may deny the
suicidal thought, but his behaviour may give clue about the suicidal
intention, Changes in mood, declining grades, recklessness, substance
abuse, giving up of former interests, stormy relationships are considered as
suicidal signs. The potential factors involved in suicide may differ from
individual to individual.
Suicidability is assessed through hotlines, hospital emergency rooms,
mental health clinic and inpatient psychiatric departments.
Professionals help the p erson with suicidal intention, by providing support
and by regaining sense of control in the life of the individual.
The clinician can have a two way agreement, where client promises to
contact clinician when he experiences such ideas and clinician promis es
client that he will be available whenever the crisis is experienced.
Therapist may use cognitive techniques and help an individual to get
control over the suicidal intentions by thinking about alternative ways of
dealing with the problem.
Brent (200 1) suggested a comprehensive model of treatme nt for
adolescence that include :
1. Treatment of psychopathology.
2. Reduction of cognitive distortion.
3. Work improvement of social skills.
4. Encouragement of problem solving.
5. Regulation of affect and f amily intervention.
4.4 SUMMARY In this unit we had discussed the various causes of mood disorders such as
biological perspective, psychological perspective, psychodynamic
theories, behavioral and cognitive perspective, etc.
Various treatments of mood disorder was also discussed. Towards the end
of the unit the concept of suicide, its cause, assessment and treatment were
discussed.
4.5 QUESTIONS 1. Discuss the various causal factors or theories of mood disorders.
2. Explain the various treatments of mood disorder.
3. Explain Suicide its causes, assessment and treatment. munotes.in
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35 Mood Disorder and Suicide - II 4.6 REFERENCES Richard P. Halgin and Susan Krauss Whitbourne, (2010) Abnormal
Psychology, Clinical Perspectives or Psychological disorders. (6 th
Ed).
V. Mark Durand and David -H-Barlow (2010, 2006, Essentials of
Abnormal Psychology. Wadsworth, Cengage learning.
*****
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36 5
PERSONALITY DISORDERS - I
Unit Structure
5.0 Objectives
5.1 Introduction
5.2 Nature or Clinical Feature of Personality Disorder
5.3 Classification of Personality Disorders:
5.3.1 Paranoid Personality Disorder
5.3.2 Schizoid Personality Disorder
5.3.3 Schizotypal Personality Disorder
5.4 Summary
5.5 Questions
5.6 References
5.0 OBJECTIVES After studying this unit you should be able to:
Understand the nature, definition and features of Personality
disorder s.
Know the classification of Personality Disorders.
Comprehend the characteristics as well as theories and treatment of
Paranoid Personality Disorder, Schizoid Personality Disorder,
Schizotypal Personality Disorder.
5.1 INTRODUCTION In this unit we will first define personality disorder and discuss its nature,
characteristics as well as classification of personality disorders.
Personality Disorder, initially called as character disorders, is defined as
"those characteristics that are inflexible and maladaptive and cause either
significant functional impairment or subjective distress”. Personality
disorders are classified into 10 different types and classifies understand 3
clusters: Cluster A, Cluster B and Cluster C. We will discuss t he
characteristic features, theories as well as treatment of the various
personality disorder listed in DSM 5.
Towards the end of this unit we will discuss the biopsychosocial
perspective. This perspective, as discussed in an earlier chapter, takes in to
account the biological, psychological and social factors in the
development of a given disorder. According to this perspective any
disorder is a combination of and integration of many causes and no one
cause can explain the causation of a given disorder munotes.in
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37 Personality Disorders - I 5.2 NATURE OF PERSONALITY DISORDERS Individuals who have maladaptive personality traits can be called as
having personality disorders. A personality trait can be defined as an
enduring pattern of perceiving, relating to and thinking about the
environmen t and others, a pattern that is ingrained in the matrix of the
individual’s psychological makeup. So, when an individual have
maladaptive way of perceiving, relating to and thinking about the
environment and others then he/she is said to be having personal ity
disorder.
Personality Disorders are patterns of behavior that are deeply ingrained
and are manifested primarily as exaggerations. The category of Personality
Disorder was introduced by the American Psychiatric Association's
Classification in its first Diagnostic and Statistical Manual (DSM -I)
(1952). Before the publication of this manual, personality disorders were
largely termed as "Character Disorders".
DSM defined Personality Disorder as "those characteristics that are
inflexible and maladaptive an d cause either significant functional
impairment or subjective distress”. It is a heterogeneous group of deeply
ingrained, usually life -long, maladaptive patterns of behavior in which
there was an absence of true neurotic or psychotic symptoms. Generally,
these are life -long patterns often recognizable by the time of adolescence
or earlier. Although these persons cause themselves and others much
unhappiness, their behavior is usually Egosyntonic and there is little
motivation for change (Arkem 1981).
Perso nality disorders involves a long -lasting maladaptive pattern of inner
experience and behaviour dating back to adolescence or young adulthood
that is manifested in atleast two of the following areas: (i) Cognition, (ii)
Affectivity, (iii) Interpersonal func tioning, (iv) Impulse control. Some
important features of personality disorders are as follows:
1. The have an inflexible pattern of interaction with others that causes
considerable distress and impairment either to themselves or to others.
2. Their prob lems involve excessive dependency, overwhelming fear of
intimacy, intense worry, exploitative behaviour or uncontrollable
rage. These individuals are usually unhappy and maladjusted.
3. It is the most challenging of the psychological disorders to treat.
4. The lifetime prevalence of personality disorders in the population
ranges from 1 -3 Percent, with higher prevalence seen in people with
clinical settings. Estimates of prevalence vary according to age and
socio -demographic factors.
5. Personality disorders are most commonly diagnosed among younger
individuals, students and unemployed homemakers. munotes.in
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38 6. The prevalence of personality disorders is higher among individuals
who have alcohol and drug abuse disorders.
7. Diagnosis of personality disorders is difficult because many
personality disorders have similar features.
In conclusion, we can say that Personality Disorders are learned life -long
consistent patterns of characteristic behavior which impair an individual's
occupational, interpersonal and social func tioning, and which lead to
problematic behavior both for the individual and for those around him.
5.3 CLASSIFICATION OF PERSONALITY DISORDERS: DSM – IV – TR has classified personality disorders in to three categories
covering a total of 10 personality disorders which are listed in the
following table.
We will discuss each of these Clusters in detail.
Cluster A :
Cluster A of personality disorder is characterized as having odd and
eccentric behavior. Paranoid Personality Disorder, Schizoid Personality
Disorder and Schizotypal Personality Disorder are the Cluster A disorder.
An individual having any of the disorder from this Cluster seem to be
having a very strange and unusual personality trait. People around them
might perceive this individual odd, usual and peculiar.
5.3.1 Paranoid Personality Disorder :
Individuals with paranoid personality disorder are extremely suspicious of
others and are always on the guard against potential danger or harm. Their
world v iew is very narrow and they are always on the look for
confirmation that others are taking advantage of them.
They may accuse a partner or spouse of being unfaithful, even when there
is no evidence for the same. They are hostile to those who criticize them.
They misconstrue innocent comments and minor events as having
threatening contents. They draw wrong inferences. Their emotional life is
constrained and i solated. Individuals having this disorder have
problematic relationships. They generally keep other people at a distance
because of irrational fears that others will harm them. They are
particularly sensitive to people in position of power. They have a fea rful
attachment style. They think and behave in ways that are unrelated to their
environment. They refuse to seek professional help as they don’t
acknowledge the nature of their problems.
According to Psychodynamic theorists, individuals having paranoid
personality disorder heavily uses defense mechanisms of projection. They
consider that other people rather than they themselves have negative or
damaging motives. munotes.in
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39 Personality Disorders - I According to Cognitive Behavioural theorists, such as Beck (2004)
individuals with paranoid personality disorder suffers from mistaken
assumptions about the world. They attribute personal problems and
mistakes to others. According to Cognitive Behavioural theorists three
basic mistaken assumptions that individuals with this disorder have are as
follows:
People are malevolent and deceptive
They will attack you if they get the chance
You can be OK only if you stay on your toes
The treatment of Paranoid Personality Disorder is the most difficult one.
These individuals are highly resistant to change, as they cannot form any
trusting relationship even with a therapist. The dropout rate, for such
disorder, in treatment is very high and the prognosis for this disorder is
poor. Some recent research has suggested that cognitive therapy to
overcome an individual’s mistaken assumptions is of considerable help.
The cognitive behavioural therapist attempts to increase the client’s
feelings of self -efficacy, so that t he client feels able to handle situations
without resorting to a defensive and vi gilant stance. It should be
remembered that direct c onfrontation with the paranoid client usually
backfires, because the client is likely to construe this as yet another attack.
5.3.2 Schizoid Personality Disorder :
Schizoid personality disorder is chara cterized by an indifference to social
and sexual relationships, as well as a very limited range of emotional
experience and expressions. Individuals with this disorder prefer to be
with themselves rather than with others. They lack desire to be accepted or
loved even by their family members. They are not interested in sex. They
are basically insensitive to feelings and thoughts of others. They are cold,
reserved, withdrawn and seclusive. They seek out situations in which there
is minimal interaction with others. They have problems in employment
and they do not retain jobs for a long period of time. They generally do not
seek psychotherapy.
According to some experts nutritional deficiency during the prenatal
period is one of the risk factors leading to dev elopment of schizoid
personality disorder by age 18 years.
Treating people with schizoid personality disorder is extremely difficult
because they lack the normal patterns of emotional responsiveness that
play a role in human communication. Individuals with this disorder do
not on their own seek treatment except when they are facing a crisis
situation. Therapeutic efforts, with this disorder consist in teaching them
the following skills:
i. Importance of social relationship as well as developing and or
maintaining good social relationships.
ii. Teaching them ce rtain skills of empathy. munotes.in
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Abnormal Psychology
40 iii. Developing social skills in them.
iv. Therapist should teach certain skills to these individuals through role -
playing.
The prognosis of this disorder is not good as like with other personality
disorder even they do not acknow ledge that they are having any problem.
5.3.3 Schizotypal Personality Disorder :
Individuals having schizotypal personality disorder are peculiar eccentric
and oddly bizarre in the way they think, behave and relate to others, even
in how they dress. Their peculiar ideas include magical thinking and belief
in psychic phenomenon such as clairvoyance and telepathy. They have
unusual perceptual experiences in the form of illusions. Their speech is
coherent, but the contents of speech are strange to others. Th eir affect is
constricted and inappropriate. They are often suspicious of other people
and may have ideas of reference. They are unable to experience pleasure
and their lives are characterized by blandness that robs them of the
capacity for enthusiasm. Th ese individuals find it difficult to form close
relationships with others.
The most important characteristics of these individuals include social
isolation, eccentricity, peculiar communication and poor social adaptation.
The symptoms of schizotypal pers onality disorder represent a latent form
of schizophrenia. People with schizotypal personality disorder are
vulnerable to developing a full blown psychosis .if exp osed to difficult
circumstances that challenge their ability to maintain contact with reali ty
Very few controlled studies concerning the treatment of this disorder is
available. Medical treatment of this disorder is very similar to that of
schizophrenia. The most commonly used drug in the treatment of this
disorder is Haloperidol. Individuals, when put on this drug show
improvement with ideas of reference, odd communication and social
isolation. The psychosocial treatment consists of teaching these
individuals social skills to help them and reduce their isolation from
others.
Cluster A pers onality disorder, particularly, Schizoid personality disorder
and Schizotypal personality disorder are consider to be falling on the
continuum of schizophrenia wherein schizophrenia is the extreme
condition. Individuals with this disorder tend not to impro ve over time and
some move on to develop schizophrenia.
5.4 SUMMARY Personality disorder is a separate group of disorders. In DSM IV these
disorders are coded on a separate Axis II. They are regarded as being
different enough from the standard psychiat ric syndromes to warrant
separate classification. Personality Disorders are learned life -long
consistent patterns of characteristic behavior which impair an individual's
occupational, interpersonal and social functioning, and which lead to munotes.in
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41 Personality Disorders - I problematic beha vior both for the individual and for those around him.
After defining personality disorders, some important features of this group
of disorders were discussed in brief.
5.5 QUESTIONS 1) Define Personality Disorders and discuss the various features of
Personality Disorders.
2) Discuss the Classification of Personality Disorders.
3) Write short notes on the following:
a) Paranoid Personality Disorder
b) Schizoid Personality Disorder
c) Schizotypal Personality Disorder
5.6 REFERENCES 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.
***** munotes.in
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42 6
PERSONALITY DISORDERS - II
Unit Structure
6.0 Objectives
6.1 Cluster B Disorders
6.1.1 Antisocial Personality Disorder
6.1.2 Borderline Personality Disorder
6.1.3 Histrionic Personality Disorder
6.1.4 Narcissistic Personality Disorder
6.2 Cluster C Disorder
6.2.1 Avoidant Personality Disorder
6.2.2 Dependent Personality Disorder
6.2.3 Obsessive -Compulsive Personality Disorder
6.3 Personality Disorder: The Bio -psychosocial Perspective
6.4 Summary
6.5 Questions
6.6 References
6.0 OBJECTIVES After studying this unit you should be able to comprehend the
characteristics as well as theories and treatment of Antisocial Personality
Disorder, Borderline Personality Disorder, Histrionic and Narcissistic
Personality disorders, Avoidant Personality Disorder, Dependent
Personality Disorder and Obsessive Compulsive Personality Disorder.
6.1 CLUSTER B DISORDERS Individuals having this cluster of disorders have in common a tendency to
be dramatic, emotional and erratic. Antisocial personality disorder,
Borderline personality disorder, Narcissistic personality disorder and
Histronic personality disorder are Cluster B disorders. Individual having a
disorder from this Cluster tend to be very much unpredictable and
unreliable.
6.1.1 Antisocial Personality Disorder :
Antisocial personality disorder has been known since a long time, but
different labels were used to refer to this disorder like sociopaths or
psychopaths. This is relatively one of the most studied and researched
disorders. In this disorder, the rights of others are violated. Individuals
with this disorder find themselves in confrontation with the laws and
norms of society.
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43 Personality Disorders - II Characteristics of Antisocial Personality Disorder:
This disorder was first recognized by Philippe Pinel as a form of madness
in which individuals exhibited impulsiveness and destructive behaviour
disorder while maintaining rational thought. Some important
characteristics of this disorder are as follows:
1. People with this disorder wreak havoc in society and for this reason
they have been the focus of great deal of research.
2. The lifetime prevalence of this disorder is 4.5 percent of the adult
males and 0.8 percent of the adult females (Robins and Regier, 1991).
3. Hervey Cleckley (1941) in his work “The Mask of Sanity”, made th e
first scientific attempt to list and categorise the behaviour of
“psychopathic” personality. Cleckley developed a set of criteria for
Psychopathy (which is today called as antisocial personality
disoreder). He identified more than a dozen criteria which constitutes
the core of antisocial personality disorder. Harvey Cleckly identified
16 traits that he found was common in these individuals. These are as
follows:
i. Inadequate motivated antisocial behavior.
ii. Unreliability.
iii. Untruthfulness and insi ncerity.
iv. Superficial charm of good intelligence
v. Absence of “Nervousness” or Psychoneurotic manifestations.
vi. Lack of remorse or shame.
vii. Poor judgment and failure to learn from experiences.
viii. Pathological egocentricity and incapacity for l ove.
ix. Specific loss of insight.
x. Unresponsiveness in general interpersonal relations.
xi. Sex life impersonal, trivial and poorly integrated.
xii. Failure to follow any life plan.
4. Cleckley used the term Semantic Dementia to capture the
psychopath’s inability to react appropriately to expressions of
emotionality. Cleckley’s notion of psychopathy remains a key concept
in descriptions of antisocial personality disorder.
5. Building on Cleckley’s work Canadian psychologist Robert D Hare
(1997) developed an assessment instrument known as the
Psychopathy Checklist – Revised (PCL – R) which has two factors: a)
Core Psychopathic Personality Traits and b) Antisocial Lifestyle. The munotes.in
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Abnormal Psychology
44 core per sonality traits include glibness and superficial charm, a
grandiose sense of self -wroth, a tendency towards pathological lying,
a lack of empathy for others, a lack of remorse and unwillingness to
accept responsibility for one’s action. The antisocial life style traits
revolve around impulsivity, a characteristic that can lead to
behaviours expressed in an unstable lifestyle, juvenile delinquency,
early behavioural problems, lack of realistic long - term goals and a
need for constant stimulation. Robert Hare et al (1989), elaborated
on the work of Cleckly and developed a 20 -item checklist that serves
as an assessment tool. Six of the criteria that Hare (1991) included in
his Revised Psychopathy checklist are as follows:
Grandiose sense of self -worth
Lack of remorse
Glibness/superficial charm
Proneness to boredom/need for stimulation
Pathological lying
Conning/manipulative
6. The DSM diagnostic criteria for this disorder also include behavioural
aspects of the disorder such as disreputable or man ipulative
behaviours. There is a difference between the DSM -IV criteria of
antisocial personality disorder and the Cleckley/Hare criteria. While
the former focuses on observable behavior the latter focuses primarily
on the underlying personality traits.
7. Individual having antisocial personality disorder show a pervasive
disregard for the rights of others as shown by such behaviours as
lawlessness, deceitfulness, and impulsivity. They do not show any
signs of remorse when they behave impulsively, recklessl y and
aggressively. Occasionally they may demonstrate feign remorse with
the intention of coming out of the difficult situation.
8. These individuals are smooth talkers who can get what they want by
presenting themselves in a favourable light.
9. It should be remembered that not all individuals having antisocial
personality disorder are criminals. The term criminal is a legal
connotation. Many qualities of the antisocial personality disorder are
reflected in acts that would not be considered as violations o f the law,
such as job problem, promiscuity and aggressiveness.
10. Research studies have shown that under controlled young children
i.e., children who are impulsive, restless and distractible are more
likely to meet the diagnostic criteria for antisocial personality disorder
and to be involved in crime as adults. munotes.in
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45 Personality Disorders - II 11. Though, today we have a good understanding of the predisposing
factors that lead to antisocial personality disorder, we have less
knowledge about the long -term prospects of individuals having
antisocial personality disorder.
12. Personality disorder, especially antisocial personality disorder reduces
as one reaches middle adulthood years and beyond. This is called a
maturation hypothesis, which means that individuals having this
disorder are be tter able to manage their behaivours as they age.
Theories and Treatment of Antisocial Personality Disorder:
Wide varieties of t heories have been developed to explain the causation of
Antisocial Personality Disorder. Some of the most important theorie s are
discussed below.
Biological Perspectives:
Biological perspectives emphasis on the role of brain pathology, genetic
factors and related cause. Brief descriptions of biological causes are as
follows:
Brain abnormalities:
Individuals having antisocial personality disorder have certain b rain
abnormalities. MRI studies have revealed that they have difficulty
processing conceptually abstract verbal information (Kiehl et al
2004).They also show deficits in emotional processing during juvenile
years. It ha s also been observed (Goethals et al 2005) that individuals
having antisocial personality disorder have deficits in prefrontal lobes of
the cerebral cortex – an area of the brain involved in planning future
activities and in considering the moral implicat ions of one’s actions.
Individuals having antisocial personality disorder also show amygdala
dysfunction as well as have dysfunction in the hippocampus regions.
Genetic Causes:
Genetic influences have been found to play an important role in the
developme nt of this disorder. Family, twin, and adoption studies all
suggest a genetic influence on both Antisocial Personality Disorder and
criminality. A comparison of the adopted children of Felons along with the
adoptive children of normal parents, carried out by Crowe (1974) revealed
that adopted off spring of felons had significantly higher rates of arrests,
conviction and Antisocial Personality than did the adoptive offspring of
normal mothers. This suggests that in the development of Antisocial
Personality D isorder and criminality genetic influences play a dominant
role. Crowe (1974) also pointed out that genetic influence is more likely to
act when certain type of environment is available. Though genetic factors
provide vulnerability, actual development of c riminality will depend upon
a particular type of environment. munotes.in
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46 In a similar study Cadoret et al (1995) found that if the children’s
biological parents had a history of Antisocial Personality Disorder and
their adoptive families exposed them to chronic stress through marital,
legal or psychiatric problems, the children were at greater risk for conduct
problems.
Twin studies also strongly support the view that genetic influence plays an
important role in the development of criminality. Eysenck and Eysenck
(1978) found that the average concordance rate for criminality am ong
Monozygotic (MZ) twins was 55%, whereas, among Dizygotic it was only
13 %.
Strong evidence in favour of inheritance of antisocial personality disorder
comes from a study of more than 3200 male twin pairs (Lyons et al, 1995).
Recently Button et al (200 5) have pointed out that those individuals who
are genetically predisposed to antisocial personality disorder may be
particularly vulnerable to family dysfunction, supporting the noriton of
gene -environment interaction.
Psychological Perspectives:
Accord ing to this perspective Antisocial personality disorder is a result of
neuropsychological deficits reflected in abnormal patterns of learning and
attention. According to David Lykken (1957), psychopathic individuals
failed to show the normal response of anxiety whey they are subjected to
aversive stimuli. Psychopathic individuals are unable to feel fear or
anxiety.
Deficient emotional arousal:
Research evidence indicates that a primary reaction tendency typically
found in antisocial individuals is a def icient emotional arousal; this
condition presumably renders them less prone to fear and anxiety in
stressful situations and less prone to normal conscience development and
socialization. In an early study, for example, Lykken (1957) concluded
that anti -social individuals have fewer inhibitions about committing
antisocial acts because they suffer little anxiety.
Response Modulation Hypothesis:
This hypothesis proposes that psychopaths are not able to process any
information that is nor relevant to their pri mary goals. Individuals having
antisocial personality are unable to think about someone else’s needs when
focused on one’s personal needs. The "response modulation" hypothesis,
postulates that psychopaths have difficulty shifting their attention from the
performance of a behavior to an evaluation of its consequences
Social Cognitive theory is another psychological perspective which
emphasizes that low self esteem is a causal factor in antisocial personality
disorder.
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47 Personality Disorders - II Socio -cultural Perspectives:
Social cu ltural factors emphasizes on the role of family, early
environment and socialization experiences that lead individuals to develop
psychopathic lifestyle. Anti -social personality is thought to be more
common in lower socioeconomic groups. Lee Robins (1966) found that
children of divorce generally develop antisocial personality disorder.
Research studies have revealed that disharmony between parents lead to
development of antisocial personality disorder. Poor child rearing
practices and inconsistent discipli ne also contribute to development of
antisocial personality disorder. Luntz and Wisdom (1994) found that
abused and neglected children often develop antisocial personality
disorder when they grow up. These individuals have 50 % more arrests for
violent cri mes as compared to control group individuals. Strangely
research studies have also found that malnutrition in early life may serve
as another risk factor for the development of antisocial personality
disorder. Children who between the ages of 03 years and 17 years
experienced poor nutrition showed more aggressiveness and motor activity
as they grew up.
Treatment of Antisocial Personality Disorder:
Antisocial behavior is difficult to treat. People with this disorder do not
change easily. They are unlikely to seek professional help voluntarily,
because they see no reason to change. If they do see a clinician, it is often
because treatment is mandated by a court order. The prognosis of this
disorder is highly poor.
This disorder can be prevented during chil dhood if cer tain steps are taken.
One such step is Parent Training. In this type of training parents are taught
to recognize behavior problems early and how to use praise and privileges
to reduce problem behavior and encourage prosocial behavior. A good
parenting skill is one of the prerequisites for effectively retarding the
development of antisocial personality disorder.
The client should be taught to feel remorse and guild for their behavio ur,
when they learn these, they start showing change in beha viour.
Psychotherapy for people with Antisocial Personality Disorder should
focus on helping the individual understand the nature and consequences of
his disorder so he can be helped to control his behavior. Exploratory or
insight -oriented forms of psychot herapy are generally not helpful to
people with Antisocial Personality Disorder
6.1.2 Borderline Personality Disorder :
Borderline personality disorder is characterized by a pervasive pattern of
instability, most evident in relationships, mood and sense o f identity. The
term borderline has been in use in the psychiatric literature since a long
time, but it was only with the DSM –III that this term received official
recognition for the first time. Stern (1938) used it as a catchall term to
refer to treatmen t-resistant clients. Knight (1953) regarded such
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48 psychosis, on the edge of schizophrenia. Many scholars regard it as a
variant of schizophrenia or mood disorder or possibly a hybrid.
Characteristics of Borderline Personality Disorder:
Some important characteristic features of Borderline Personality Disorder
are as follows:
i. Individuals with borderline personalities are frequently impulsive and
unpredictable, angry, empty, and uns table.
ii. Individuals with this disorder often experience a distinct kind of
depression that is characterized by feeling of emptiness. They often
vacillate between extreme emotional states, one day feeling on the top
of the world and the next moment fee ling depressed, anxious or
irritable.
iii. People with this disorder suddenly form intense demanding
relationships with others and to perceive other people as being all
good or all bad – a phenomenon called as splitting.
iv. The inappropriate intensity of their relationship results in recurrent
experiences of distress and rage. People with this disorder experience
anger and hostility. Their interpersonal relationships are always
disturbed and unstable. They commonly have a history of intense but
stormy rela tionship, typically involving over idealization of friends or
lovers that later end in bitter disillusionment and disappointment
(Gunderson & Singer, 1986). They often explode in rage when they
experience neglect and abandonment by their lover or some imp ortant
person in their life.
v. They also experience identity problems. They are often confused
about their identity as to who they are. They are unsure of what they
want out of life and lack a firm grasp of their sense of self. Their
uncertainty about who they are may be expressed in sudden shifts in
life choices such as career plans, values, goals and types of friends.
vi. They have chronic feeling of boredom and a low tolerance for
frustration. The chronic feelings of boredom make them seek
stimulation. In order to overcome boredom they may indulge in
impulsive behaviour such as promiscuity, careless spending, reckless
driving, binge eating, substance abuse, shoplifting, etc.
vii. They often indulge in suicidal thinking and self -injurious behaviour.
They indulge in suicide behaviour only to get attention from others –
a phenomenon called parasuicide. self - mutilation is one of the most
discriminating signs for borderline personality (Widiger et al, 1986).
viii. They typically display intense anger outburs ts with little provocation,
and they may show disturbance in basic identity that preoccupy them
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49 Personality Disorders - II ix. People with borderline personality disorder suddenly move from
anger to deep depression. They are also character ized by impulsivity,
which can be seen in their drug abuse and self mutilitation.
x. They are highly sensitive to stress and often break down displaying
brief psychotic reactions in the presence of intense stressful situations.
Although they are usually a ware of their circumstances, and
surroundings, borderline personalities may have short episodes in
which they appear to be out of contact with reality and experience
delusions or other psychotic -like symptoms, such as recurrent
illusions, magical thinking , and paranoid beliefs (O'Connell et al,
1989).
Mood disorder is common among individuals having borderline
personality disorder, about 24% to 74 % of the individual having this
disorder also has major depression and about 4 % to 20 % have bipolar
disorde r. About 25% of the bulimics also has this disorder.
Theories and Treatment of Borderline Personality Disorder:
This is one of the most challenging disorders as individuals suffering from
it create chaos in their lives as well as those of others with wh om they
interact. This disorder evolves as a result of combination of vulnerable
temperament, traumatic early experiences in early childhood and certain
triggering events in early adulthood
Biologic al Perspectives: Most theories regarding causation of this
disorder is psychological in nature, though psychologists have attempted
to identify biological correlates of psychological factors thought to be
involved in the development of this disorder. One set of biological factors
involved in the causation of this disorder is neurotransmitter
dysregulation. For Example sexual abuse in the childhood influences the
noradrenergic (sympathetic nervous system) pathways and makes them
hypersensitive, so that an individual is primed to overreact to experiences
of any kind later in childhood. This altered sympathetic system
functioning predisposes an individual towards impulsivity, due to
abnormalities in the serotonergic receptors in the brain.
MRI studies (Driessen at al 2000) comparing the brains of women having
Borderline Personality Disorder with control subjects have revealed that
the hippocampus was 16 percent smaller and amygdala was 08 percent
smaller among women suffering from Borderline Personality Disorder as
compared to normal healthy control subjects.
Psychological Perspectives:
These people somehow fail to complete the process of achieving an
articulated self -identity and hence do not really become individual. This
lack of individualisation leads to complication in interpersonal
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50 Clinic al observation of people whose behaviour meets the criteria of
borderline personality disorder points strongly to a problem of achieving a
coherent sense of self as a key predisposing causal factor
Most adults with Borderline Personality Disorder show a family history of
extreme negative experiences within the family. Three important factors
that have emerged as important in the development of Borderline
Personality Disorder are as follows:
a. Disturbed childhood family environment
b. Parental psychopathology
c. Child abuse
It has been observed that child sexual abuse is the most important
significant predictor of Borderline symptomatology. Early child abuse
experiences cause children to expect th at others will harm them. Zanarini
et al (1997) found that people with Borderline Personality Disorder
reported that their caretakers withdrew from them emotionally, treated
them inconsistently, denied the validity of their thoughts and feelings and
did no t carry out their roles as parents in terms of providing them with
protection from abuse. It has also been found that individuals with
Borderline Personality Disorder experience:
a. Deficits in the formation of self
b. Have a mother who is uninvolved w ith her child and inconsistent in
her emotional responsiveness.
c. Parents do not bolster the child’s independent sense of self.
d. As children such individual perceive other people in a distorted way
and builds a false self that is fused with distorted pe rceptions of the
self.
Beck and other cognitive theorists have observed that people having
Borderline Personality Disorder have a tendency to dictomise their
thinking about themselves and other people, they think in terms of “all or
nothing”. Such type of thinking leads to shift in moods. For example,
individuals with Borderline Personality Disorder display “splitting”, which
means that if individuals with this disorder originally perceive someone as
all good, and that person fails to follow through on a promise, the person
immediately is perceived as all bad.
People with Borderline Personality Disorder are not realistic while
evaluating themselves. Even on minor ground their entire self -evaluation
becomes negative. A low sense of self -efficacy related to their weak
identity causes a lack of confidence in their decisions, low motivation and
an inability to seek long -term goals.
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51 Personality Disorders - II Socio -cultural Per spectives:
According to Millon and Davis (1996) pressures of the contemporary
society have placed a strain on families and individuals which in turn has
exacerbated the deficient parenting that has given rise to this disorder.
Individuals with Borderline Personality Disorder are highly vulnerable to
reduced cohesion in society that is a result of urbanization and
modernization in the contemporary society. Their lack of psychic cohesion
is a reflection of instability within society and lack of clearly defined
cultural norms and cohesion. According to Goldman et al, 1993, family
difficulties, including depression, substance abuse and antisocial
behaviour lead to development of this disorder. According to Stone (1990)
an adult with Borderline Personality Disorder who was abused as a child,
passes on this pattern of parenting to the next generation, who then
become vu lnerable to developing this disorder.
Treatment of Borderline Personality Disorder:
Treatment of Borderline Personality Disorder poses number of challenges
to the clinicians. Some of the important points to be noted with respect to
the treatment of this disorder are as follows:
1. The treatment of this disorder is highly difficult as, according to
Million, (2000) these individuals “often appear to be more healthy at
first glance than they really are”.
2. These individuals do not remain in therapy for a long time and they
often drop out of therapy due to their volatility, inconsistency and
intensity.
3. Individuals with this disorder commonly become pathologically
dependent upon their therapist, as a result they may feel
uncontrollably enraged when the therapist fails to live up to their
idealization.
4. According to Goin (2001) in the treatment of the clients with this
disorder it is important to establish clear treatment framework by
discussing and clarifying treatment goals as well as the roles that the
clients and therapists are expected to play.
5. Therapist must also determine the extent to which these patients
need support and confrontation
One of the most systematically developed therapeutic approach to treat
individuals having this disorder is the Dialectical Behaviour Therapy
developed by Marsha Linehan. This approach integrates supportive and
cognitive behavioural treatments to reduce the frequency of self
destructive acts and to improve the client’s ability to handle disturbing
emotions, such as anger and dependency. The term dialectic al refers to
systematically combining opposed ideas with the goal of reconciling them.
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52 are and confronting their disturbing behaviour to help them to change.
Some specific aim of this therapy includes:
i. Regulating emotions
ii. Developing interpersonal effectiveness
iii. Learning to tolerate emotional distress
iv. Developing self -management skills
One technique used by therapists practicing Dialectical Behaviour
Therapy is call ed as core mindfulness in which the clients are taught to
balance emotions, reason and intuition in their approach to life’s problems.
Another approach to treat individuals having Borderline Personality
Disorder is called as Transference Focused Psychot herapy. In this
approach the therapist deals with dominant affect laden themes that
emerge in relationship between the client and therapist. In this approach
the therapist us es techniques of clarification, confrontation and
interpretations of the transfe rence in the here and now of the therapeutic
relationship
Medication is often used as an adjunct to therapy. Some medication has
been found to be effective in treating specific symptoms. Wide ranges of
medications have been used and these include: antidep ressants,
antipsychotics, anticonvulsants, lithium and minor tranquilizers. When
ever these medications are used, they should be prescribed with careful
assessment of specific symptoms.
In severe cases of Borderline Personality Disorder, effective treatm ent can
only be given in an inpatient or partial hospitalization setting. This
approach is more appropriate when the patient displays: sucidial
behaviour, attempts or threats, psychotic like episodes, threat or harm to
others, etc.
6.1.3 Histrionic Perso nality Disorder :
The term histrionic is derived from the latin word meaning “actor”. People
with this disorder display theatrical qualities in their everyday behaviour.
One important characteristic that differentiates individuals with this
disorder from th ose who show appropriate emotionality is the fleeting
nature of their emotional states and their use of excessive emotions to
manipulate others rather than to express their genuine feelings.
This disorder is more commonly diagnosed among women.
Some impor tant characteristics of this disorder are as follows:
1. Individuals with this disorder enjoy being the centre of attention and
behave in whatever way necessary to ensure that this happens.
2. They are very much concerned with their physical appearances, often
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53 Personality Disorders - II 3. These individuals are likely to be seen as flirtatious and seductive,
demanding the reassurance, praise and approval of others and they
become furious if they do not get it.
4. These individuals seek immediate gratification of their wishes and
overreact to minor provocations, usually in exaggerated ways, such as
weeping or fainting.
5. Their relationships are superficial. They are easily influenced by
others, lack analytical a bility and often see the world in broad
impressionistic ways.
6. People who are in relationships with individuals having this disorder
often feel frustrated and unsatisfied.
7. Individuals having this disorder have an insecure attachment type
style.
8. These individuals often exhibit dependence and helplessness and are
quite gullible. Their sexual adjustment is usually poor and
interpersonal relationships are stormy. In their interpersonal
relationships they are over concerned about approval from others.
9. Their cognitive style is impressionistic. They view situations in a very
global, black and white term.
Not much research has been done with respect to causes or treatment of
histrionic personality disorder. This disorder co - occurs with antisocial
personality disorder. This association has led to the suggestion that
Histrionic Personality Disorder and Antisocial Personality Disorder may
be sex typed alternative expressions of the same unidentified underlying
conditions.
Not much work has been done wit h respect to the treatment of this
disorder. It has been pointed out that modifying attention - seeking
behavior will help to reduce this disorder. A large part of therapy for these
individuals usually focuses on the problematic interpersonal relationships.
These individuals need to be taught how the short term gains derived from
their faulty interaction can create problems for them.
6.1.4 Narcissistic Personality Disorder :
Sigmund Freud described narcissistic individuals as one who shows an
exaggerated sense of self - importance and a preoccupation with receiving
attention. It has been pointed out that grandiosity was the most stable and
generalizable orientation for diagnosing narcissistic patterns. The
narcissistic personality disorder is more frequentl y observed in men than
in women.
People with this disorder expect others to compliment them and gratify all
their wishes and demands. They lack sensitivity to the needs of others.
They are preoccupied with and driven to achieve their own goals, even to
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54 doubt inspite of grandiosity. Million and his colleagues (2000) identified
four subtypes of this disorder:
Elitist Narcissistic: These individuals feel privileged and empowered
and tend to flaunt their status and achievements. They are upwardly
mobile, they engage in self -promotion and tries to cultivate special
status and any opportunity to be recognized.
Amorous Narcissistic: These individuals are sexually seductive, but
they a void real intimacy. Such individuals are especially drawn to
tempting, naïve and emotionally needy people.
Unprincipled Narcissistic: These individuals are very much like
antisocial individuals. They are unscrupulous, deceptive, arrogant and
exploitative .
Compensatory Narcissistic: These individuals tend to be
negativistic. They often create an illusions of being superior and
exceptional.
The traditional psychoanalytic approach regards narcissism as failure to
progress beyond the early stages of psycho sexual development. Object
relations approach views this disorder to be a result of disturbances in
parent -child relationships. Disturbed parent -child relationship leads to
faulty development of sense of self. Every child needs parents to provide
reassura nce and positive response to accomplishments. In the absence of
these, the child becomes insecure and this insecurity is expressed,
paradoxically as an inflated sense of self -importance that can be
understood as an individual’s attempt to makeup for wha t was missing
early in life. Narcissistic personality disorder is viewed as the adult’s
expression of childhood insecurity and the need for attention.
6.2 CLUSTER C DISORDER Cluster C is characterized as anxious and fearful. Avoidant personality
disord er, Dependent personality disorder and Obsessive Compulsive
personality disorder are Cluster C disorders.
6.2.1 Avoidant Personality Disorder :
Individuals having avoidant personality disorder refrain form social
encounters, especially avoiding situations in which there is a potential for
personal harm or embarrassment. Individuals with this disorder are
extremely sensitive to the opinion of other s and therefore avoid them.
Some important characteristic features of individuals having this disorder
are as follows:
These individuals are hypersensitive to rejection and apprehension of
any sign of social derogation. Their sensitivity to rejection causes
them to misinterpret even neutral and positive remarks in a different
manner. munotes.in
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55 Personality Disorders - II Individuals having this disorder readily see ridicule or disparagement
where none was intended.
These individuals are too fearful of criticism. They view even a slig ht
remark or personal comment as a form of extreme criticism.
Their self -esteem is very low and their fear of social rejection makes
them less friendly to others.
This disorder shares some characteristics with schizoid personality
disorder. In both diso rders, the person tends to stay away from intimate
relationships. However persons with avoidant personality disorder truly
desires closeness and feels a great deal of emotional pain about the
seeming inability to make connections with others. According t o some
scholars avoidant personality disorder is a more severe form of social
phobia
Millon (1981) has pointed out one psychosocial theory of the development
of this disorder. According to him, individuals with this disorder may be
born with a difficult t emperament or personality characteristic, as a result
their parent’s may reject them or at least not provide them with enough
early uncritical love. This rejection in turn, may result in low self -esteem
and social alienation.
Another group of researcher found that individuals having this disorder
had parents who were more rejecting, more guilt engendering and less
affectionate than the control group. According to psychodynamic writers
individuals having this disorder have a fear of attachment in relatio nships.
Cognitive behavioural approaches regard this disorder as hypersensitive to
rejection due to childhood experiences of extreme parental criticism.
These individuals have dysfunctional attitudes that they are unworthy of
other people’s regard. As a result of this attitude they view themselves as
unworthy and they expect that other people will not like them and as a
result they avoid getting close to other people.
Treatment:
As compared to other personality disorders, there are a number of well -
controlled studies on approaches to therapy for people with this disorder.
Behavioral intervention techniques for anxiety and social skills problems
have had some success. Since the problems experienced by people with
avoidant personality disorder resemble tho se of people with social Phobia,
many of the same treatments are used for both the groups. It has also been
found that systematic desensitization as well as behavioral rehearsal
works better with this group of individuals. The prognosis for this disorder
is generally poor. Therapist treating this personality disorder must have
considerable patience and attempt to build a strong therapeutic
relationship.
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56 6.2.2 Dependent Personality Disorder :
These individuals are highly dependent on others even for making
ordinary day -to-day decisions. Individuals having this disorder are
perceived to be “clingy”
Some important characteristic features of this disorder are as follows:
These individuals show extreme dependence on other people and
acute discomfort on being a lone. Without others near them they feel
abandoned and despondent. They often have the fear that close ones
will leave them.
In their interpersonal relationship they are timid, submissive and
passive.
These individuals usually build their lives around other people and
subordinate their own needs to keep these people involved with them.
They lack self -confidence and feel helpless even when they have
actually developed good work or other competencies.
These individuals typically appear selfless and bland, since they
usually feel they have no rights to express even mild individuality.
Individuals with this disorder are very much similar to those having
avoidant personality disorder with respect to their feelings of
inadequacy, sensitivity to criticism and need for reassurance.
Their extreme dependence upon others causes them to urgently seek
another relationship, when one breaks, to fill the void.
Early socializing experiences and child rearing practices contribute
towards the development of this disorder. According to psychodynamic
writers individuals with this personality disorder have regressed to or have
become fixated at oral stage of development because of parental
overindulgence or neglec t of dependency needs. According to Object
Relations theorists such individuals are insecurely attached and constantly
fear abandonment. According to them, individuals having this personality
disorder have low self esteem and rely on others for guidance a nd support.
Very little research is available as to whether a particular treatment is
effective or not. A therapist should take care to see to it that the patient
does not become overly dependent on him or her. Unlike most other
personality disorder, the prognosis of this disorder is more optimistic and
hopeful. Most people with this condition are motivated to change.
Structured approach and guidance to become more independent has been
found to be beneficial. Clients must be taught to identify skill defic its and
work on improving those skills.
6.2.3 Obsessive -Compulsive Personality Disorder : munotes.in
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57 Personality Disorders - II Individuals with obsessive - compulsive personality disorder are too
preoccupied with concern about neatness and to be perfect. These
individuals show the following o ther features:
They are intensely perfectionists and inflexible
They have an inordinate concern with neatness and detail, often to the
point of losing perspective on what is important and what is not. And
so they are unable to take decisions.
People with this disorder have a poor ability to express emotions and
they have few intimate emotions.
They have a preoccupation with details and perfection that very often
interferes with their normal functioning. So they are often
unproductive and their p ursuit of perfection becomes self -defeating
rather than constructive.
These individuals have a fixation on things being done “the right
way”. They are very moralistic. Individuals with obsessive -
compulsive personality disorder show excessive concern for rules,
orders, efficiency and work, coupled with an insistence that everyone
do things their ways.
Such individuals tend to be over inhibited, over conscious, over
dutiful and rigid and to have difficulty relaxing or doing anything
just for fun.
They are usually preoccupied with trivial details and poor allocation
of time.
Obsessive -compulsive personalities have whole lifestyles characterized by
obstinacy and compulsive orderliness. Although they may be anxious
about getting all their work done in keeping with their exacting standards,
they are not anxious about their compulsive self. This is commonly found
among men than women.
Some researchers have pointed out that there may be a weak genetic
contribution to this disorder. Freud believed that the obsessive -compulsive
style represented fixation at or regression to the anal stage of psychosexual
development. According to cognitive behavioural therapy people with this
disorder have unrealistic expectations about being perfect and avoiding
mistakes . Their feelings of self worth depend on their behaving in ways
that conform to an abstract ideal of perfectionism. If they fail to achieve
that ideal they regard themselves as worthless.
Not much information is available with respect to the treatment o f this
disorder. Behavioral techniques including systematic desensitization and
behavioral rehearsal and some conditioning reinforcement techniques
work better with them. Therapists must help these individuals to relax or
use distraction techniques to redi rect their compulsive thoughts. Some
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58 stopping – instructing the client to reduce the amount of time spent in
ruminative worry.
6.3 PERSONALITY DISORDER: THE BIOPSYCHOSOCIAL PERSPECTIVE This perspective views a given disorder to be a combination of biological,
psychological and social perspective. People who have a borderline
personality disorder require a combination of treatmen t approaches which
includes biological, psychological and social interventions.
Biopsychosocial perspective views personality disorder to evolve over a
period of adulthood and tend to remain challenging for clinicians and
researchers. In the understanding and treatment of personality disorders
integrative view combining the various perspectives must be taken in to
consideration.
6.4 SUMMARY DSM V TR has classified personality disorders in to three categories
covering a total of 10 personality disorders wh ich were discussed in detail.
After discussing the characteristics symptoms, theories and treatment it
can be concluded that the prognosis of most of these disorders is difficult
as personality traits are very much ingrained in the person and most them
do not acknowledge that they are having defective personality traits.
6.5 QUESTIONS 1. Explain the Characteristic features of Antisocial Personality Disorder
2. Discuss the various Theories and Treatment of Antisocial Personality
Disorder
3. Discuss the ch aracteristic features of Borderline Personality Disorder
4. Discuss the various Theories and Treatment of Borderline Personality
Disorder
5. Write short notes on the following:
a) Histrionic Personality Disorder
b) Narcissistic Personality Disorder
c) Avoi dant Personality Disorder
d) Dependent Personality Disorder
e) Obsessive -Compulsive Personality Disorder
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59 Personality Disorders - II 6.6 REFERENCES 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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60 7
SEXUAL VARIANTS, ABUSE AND
DYSFUNCTIONS - I
Unit Structure
7.0 Objectives
7.1 Introduction
7.2 Abnormal Sexual Behaviour
7.3 Sociocultural Influence on Sexual Practices and Standards
7.4 Sexual Abuse
7.5 Paraphilias
7.5.1 Causes of Paraphilias
7.5.2 Treatment of Paraphilias
7.6 Summary
7.7 Questions
7.8 References
7.0 OBJECTIVES After reading this unit you will be able to know :
• About abnormal sexual behaviours.
• What are the different types of paraphilias, its causes and treatment.
• About gender identity disorder, its causes and treatment.
7.1 INTRODUCTION The inability to enjoy sexual relationship and experience distress and
difficulty while engaging in sexual acts is referred to as sexual disorder. In
this unit we will discuss about the concept of sexual disorder, its types and
treatments. First one is par aphilias or sexual deviation, second is sexual
dysfunction and third is gender identity disorder. There are different
theories of the causes of these disorders. Different treatments such as
biological therapies, psychological approaches and cognitive thera pies,
etc., are successful to great extent to help the people suffering from these
disorders.
7.2 ABNORMAL SEXUAL BEHAVIOUR Normal sexual response cycle has five stages – sexual desire, arousal,
plateau, orgasm and resolution state. But inability to en joy sexual
relationship and experiencing difficulty at any stage is considered sexual
disorder. For example, complete lack of sexual desire, active avoidance of munotes.in
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61 Sexual Variants, Abuse and Dysfunctions - I sexual activity, inability to be aroused or maintaining erections or absence
of orgasm are few sexual disorders.
Paraphilias are disorders that involve non -human objects, non -consenting
adults, children, etc.
Gender Identity disorder is wrong perception of one’s own gender
resulting in transsexual or transgender individuals. Sexual sadism,
pedop hlia, etc., include inflicting pain to sexual partners.
7.3 SOCIOCULTURAL INFLUENCE ON SEXUAL PRACTICES AND STANDARD Although some aspects of sexuality and mating, such as men’s greater
emphasis on their partner’s attractiveness, are cross culturally universal
(Buss, 1989, 2012), others are quite variable. For example, all known
cultures have taboos against sex between close relatives, but attitudes
toward premarital sex have varied considerably across history and around
the world.
Ideas about accept able sexual behavior also change over time. Less than
100 years ago, for example, sexual modesty in Western cultures was such
that women’s arms and legs were always hidden in public. Although this
is by no means the case in Western cultures today, it remai ns true in many
Muslim countries.
Despite the substantial variability in sexual attitudes and behavior in
different times and places, people typically behave as though the sexual
standards of their own time and place are obviously correct, and they tend
to be intolerant of sexual nonconformity. Sexual nonconformists are often
considered evil or sick. We do not mean to suggest that such judgments
are always arbitrary. There has probably never existed a society in which
Jeffrey Dahmer, who was sexually arou sed by killing men, having sex
with them, storing their corpses, and sometimes eating them, would be
considered psychologically normal. Nevertheless, it is useful to be aware
of historical and cultural influences on sexuality. When the expression or
the ac ceptance of a certain behavior varies considerably across eras and
cultures, we should at least pause to consider the possibility that our own
stance is not the only appropriate one.
7.4 SEXUAL ABUSE Sexual abuse is sexual contact that involves physica l or psychological
coercion or at least one individual who cannot reasonably consent to the
contact (e.g., a child). Such abuse includes pedophilia, incest, and rape,
and it concerns society much more than any other sexual problem. It is
somewhat ironic, t hen, that of these three forms of abuse, only pedophilia
is included in DSM -5. This partly reflects the seriousness with which the
society views these offenses and its preference for treating coercive sex
offenders as criminals rather than as having a ment al disorder (although
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62 Childhood Sexual Abuse :
The past few decades have seen intense concern about childhood sexual
abuse, with an accompanying increase in relevant research. There are at
least three r easons for including some discussion of this here. First, there
are possible links between childhood sexual abuse and some mental
disorders, so such abuse may be important in the etiology of some
disorders. Second, much evidence suggests that, broadly def ined,
childhood sexual abuse is more common than was once assumed, and it is
important to understand some of its causes. Third, some dramatic and
well-publicized cases involving allegations of childhood sexual abuse
have raised very controversial issues su ch as the validity of children’s
testimony and the accuracy of recovered memories of sexual abuse.
The prevalence of childhood sexual abuse depends on its definition, which
has varied substantially across studies. For example, different studies use
diffe rent definitions of “childhood,” with the upper age limit ranging from
12 to as high as 19 years. Some studies have counted any kind of sexual
interaction, even that which does not include physical contact (e.g.,
exhibitionism); others have counted only ph ysical contact; others have
counted only genital contact; and still others have counted consensual
sexual contact with a minor. A recent review of data from 22 countries
estimated that 7.9 percent of men and 19.7 percent of women had suffered
sexual abuse prior to age 18. The highest rates were from African
countries, and the lowest rates were from Europe; U.S. figures were
intermediate. Obviously “prior to age 18” comprises a wide range of ages,
and, for example, age 17 is not always viewed as part of chil dhood.
Consequences of Childhood Sexual Abuse :
Childhood sexual abuse may have both short -term and long -term
consequences. The most common short -term consequences are fears,
posttraumatic stress disorder (PTSD), sexual inappropriateness (e.g.,
touching others’ genitals or talking about sexual acts), an d poor self -
esteem, but approximately one -third of sexually abused children show no
symptoms (e.g., Kendall -Tackett et al., 1993; McConaghy, 1998).
Associations between reports of childhood sexual abuse and adult
psychopathology have been commonly report ed (Maniglio, 2009).
Specific examples include borderline personality disorder (Bandelow et
al., 2005; Battle et al., 2004), somatization disorder with dissociative
symptoms (Sar et al., 2004), and dissociative identity disorder (Maldonado
& Spiegel, 2007; Ross, 1999). A wide variety of sexual symptoms have
also been alleged to result from early sexual abuse (e.g., Leonard &
Follette, 2002; Loeb et al., 2002; see review in Maniglio, 2009), ranging,
for example, from sexual aversion to sexual promiscuity.
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63 Sexual Variants, Abuse and Dysfunctions - I 7.5 PARAPHILIAS 1. Pedophilia and Incest :
The most tragic deviant pattern of arousal is a sexual attraction to children
called pedophilia. The criteria for pedophilia are -
a. Intense sexually arousing fantasies, sexual urges with a child or
children (o ver a period of at least 6 months).
b. The person is alteast 16 years and at least 5 years older than the child
or children.
c. Sexual encounters between pedophilic and their child victims are
often brief but they may reoccur frequently.
d. The contact oft en consists of the pedophilic exposing and touching the
child’s genitals or perform fellatio (oral stimulation of the penis) or
cunnilingus (oral stimulation of the female genitals) on children.
e. Some pedophilic penetrates children’s vagina, mouth, or an us with
their fingers, foreign objects or their penis. Pedophilics often threaten
children, harm them physically, restrain them or tell them that they
will punish them or their loved one’s if the children do not obey the
pedophilics order. But most of th em are not physically abusive
because there is no harm or threats from their victims. Children may
participate in the molestation without seeming to protest, yet, they
may be scared and unwilling without expressing it. Most Pedophilics
are family members o r acquaintances of the children. Some develop
elaborate plans for gaining access to the children, such as winning the
trust of their mothers, marrying their mothers, or in rare cases
abducting children or adopting children from other countries. If the
children are from pedophilics own family, such as daughters or son,
then it is called incest. Victims of insects tend to be daughters who are
beginning to mature physically. Incestors relation may have more to
do with availability and other inter personal ongo ing issues in the
family.
2. Fetishism :
Fetishism involves the use of inanimate objects as the preferred source of
sexual arousal or gratification. There are different types of fetishism. The
most popular are women’s under garment. Fetishistic arousal can be
associated with different classes of objects or activities.
a. An inanimate object.
b. A source of specific tactile stimulation such as rubber, etc.
c. Part of the body such as toe, buttocks, etc.
Soft fetishes are soft, furry, lacy or frilly panties, stocking, etc., Hard
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64 3. Transvestic Disorder:
An elaborate form of fetishism is Transvestism, also referred as cross -
dressing, in which hetro sexual men dress in women’s clothing as their
primary means of becoming sexually aroused. Some use only one garment
such as women’s panty, under their business suits. The complete cross
dresser, fully clothes himself in women’s garm ents, applies make up and a
wig, etc. Few engage cross dressing alone, others participate in groups.
4. Sexua l Sadism and Sexual Masochism :
Sexual sadism and sexual masochism are two separate diagnoses, although
sadistic and masochism sexual practices are considered together as a
pattern of sadomasochism. Both are associated with either inflicting pain
or humiliation (Sadism) or being made to suffer pain or humiliation
(masochism). Some people occasionally engage in modestly sadistic or
masochistic beh aviours during sex or stimulate such behaviours without
actually inflicting pain or suffering.
They follow the rituals of practising of bondage and domination. One
partner is bound, gagged and immobilised and is subjected to sexual acts
of other partner. Apart from sexual, acts, beating, whippings, electrical
shock, burning, cutting, stabbing, strangulation, torture or even death.
Different props such as feather garments, chains, shackles, whips, ropes,
etc. are used by the sadistic partner to inflict pain on the other partner. Few
other partners can find it exciting, many give their consent to please their
partner, few do because they are paid for it and few are unconsenting
victims. They get excited to see fear and disgust on the partner’s face.
Sometimes the activities can go out of control, for example, Autoerotic
asphyxiation. In this activity, sexual arousal in gained by oxygen
deprivation caused by hanging or chest compression.
5. Frotteurism :
It is another paraphilia wherein an individual gains sexual pleasure by
rubbing against and fondling parts of the body of a non -consenting person.
They engage in this behaviour in public places such as on a bus, subway,
market place, etc., Most of the frotteurists are young males between 15
and 25 years of a ge.
6. Voyeurism and Exhibitionism :
Voyeurism refers to the practice of observing an unsuspecting person
undressing or naked in order to experience sexual aorousal. This type of
paraphilia involves secretly watching another individuals nude, bathing in
sexual positions. Most pedophilics are hetrosexual males abusing young
girls. Homosexual pedophilics typically abuse young boys. Women can be
pedophilics but it is rare.
7. Exhibitionism:
It refers to sexual arousal and gratification associated with ex posing one’s
genitals to unsuspecting strangers. A vast majority of cases, the munotes.in
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65 Sexual Variants, Abuse and Dysfunctions - I exhibitionists are men who bares all to surprise women at public places
such as parks, roads, etc. His behaviour is impulsive and compulsive. He
experiences excitement, fear, re stlessness and sexual arousal and feels
compelled to get relief by masturbating himself. Because of the public
nature of their behavior, they get caught but they are likely to continue
their behaviour after having been caught. The danger of being caught
increases their arousal. The element of risk or thrill seems to be important
part of this sexual disorder. The fear and disgust on victims face gives
them sexual pleasure. Exhibitionisms in same way is the mirror image of
voyeurism.
7.5.1 Causes of Paraphil ias Biological Causes:
Most of the paraphilics are male (over 90 percent). This may be because
paraphilic behaviour often involves hostile or aggressive impulses, which
may be more common in males than in females. Some studies have found
links between en docrine abnormalities and paraphilia. Some studies
suggest a relationship between testosterone abnormalities and sexually
aggressive paraphilias.
Alcohol and other drug abuse is common in paraphilias because these
substances, may disinhibit the paraphilic and so he acts out his fantasy.
Psychological Causes :
a. Psychodynamic Theory:
Freud viewed paraphilias as a result of arrested psychological
development or regression to childhood forms of sexual arousal. Robert
Stoller (1975) argued that the paraphilias are symbolic re -enactments of
childhood traumas in which the paraphilies is unconsciously taking
reverge on adults who inflicted harm on him as a child.
b. Behavioural Theory:
Behavioural theories view them as the result of chance classical
conditioning. An adolescent male might be masturbating and notice a
panty kept on the chair in the room. He thinks of the panty and becomes
more aroused . Next time he masturbates, he might be more drawn to the
panty because it aroused him a day before. If this fantasy becomes
strongly associated with sexual arousal for him, he may develop a fetish
for panties.
Paraphilias may be developed by social lear ning. Children whose parents
engaged in aggressive, sexual behaviours with them learn to engage in
impulsive, aggressive, sexualised acts towards others.
Many pedophilics have poor interpersonal skills and feel intimidated when
interacting sexually with adults. Others have strong hostility toward
women and carry out this hostile antisocial acts towards children.
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66 Cognitive Causes :
Cognitive theories says that a number of distortions and assumptions that
paraphilics have about their behaviours and the beh aviours of their
victims. These distortions may have been learned from parent’s deviant
messages about sexuality.
7.5.2 Treatment of Paraphilias :
Biological Treatment :
a. Certain drugs are sometimes used to treat paraphilias, the most
popular drug is an ant i- androgen drug called, Medroxy proqesterone
acetate. This drug eliminates the person’s sexual desire and fantasy by
reducing his testoterone levels. But fantasies and arousal soon returns
as soon as the drug is removed. This drug is useful for dangrous
sexual offenders who do not respond to alternative treatments.
b. Drastic biological interventions for pedophilics and men who commit
rape have been tried. These includes surgery on the centers of the
brain. Castration lowers sexual rates of paraphilias w ho have
committed sexual crimes.
Psychosocial Treatments :
a. Actually touching objects that arouses them.
b. De- Aversion Therapy :
During this therapy paraphilics might receive painful but harmless electric
shocks while viewing photographs of what arouse them or while
Sensitisation
This therapy helps to reduce the anxiety of the paraphilics about getting
involved in normal sexual acti vities with other normal adults. Relaxation
exercises overcomes their faulty association regarding sexual behaviour.
c. Cognitive Therapy :
This therapy encourages the paraphilics to identify and challenge thought
and situations that arouses them sexual ly. They are not asked to justify d.
Empathy training makes paraphilics to think about their victims
condition and understand their situations when they are attacked.
e. Role play and Group therapy :
These two therapy helps parapilic to interact, share and gain insight about
their own behaviours.
Check Your Progress :
1. What are the different types of paraphilias?
2. What are the different causes and treatments of paraphilias?
3. Write a Short Note on Sociocultural influence on Se xual practices and
standards. munotes.in
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67 Sexual Variants, Abuse and Dysfunctions - I 7.6 SUMMARY Three types of sexual disorders are gender identity disorder , sexual
dysfunction and paraphilias. GID is dissatisfactions with one’s biological
sex. Sexual dysfunctions such as disorders of sexual desire, arousal,
orgasmic disorder, inadequate penile erec tion, etc., are related to different
stages of normal sexual cycle. Paraphilias is sexual attractions to
inappropriate people such as children, or objects such as clothes, etc.
The causes are socially transmitted negative attitudes towards sex,
biological and psychological causes.
Treatments for sexual disorders include biological and psychosocial
approaches. Treatments for paraphilias are highly successful but available
only in specialised clinics. Treatments for sexual dysfunctions is
successful but not readily available.
7.7 QUESTIONS Q1. Discuss the different types of paraphilias.
Q2. Explain the various causes and treatment of paraphilias.
7.8 REFERENCES Oltmanns, T.F., Emery, R.E. (2010). Abnormal Psychology 6th ed.,
New Jersy : Pearson Prentice Hall
Nolen – Hoeksema, S. (2008). Abnormal Psychology. 4th ed. New
York : McGraw – Hill
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68 8
SEXUAL VARIANTS, ABUSE AND
DYSFUNCTIONS - II
Unit Structure
8.0 Objectives
8.1 Sexual Dysfunctions
8.1.1 Sexual Desire Disorders
8.1.2 Sexual Arousal Disorders
8.1.3 Orgasmic Disorders
8.1.4 Sexual Pain Disorders
8.1.5 Causes of Sexual Dysfunction
8.1.6 Treatments Suggested for Sexual Dysfunctions
8.2 Gender Dysphoria / Gender Identity Disorder
8.2.1 Symptoms
8.2.2 Causes of GID
8.2.3 Treatment of GID
8.3 Sexual Disorders: The Bio psychosocial Perspective
8.4 Summa ry
8.5 Questions
8.6 References
8.0 OBJECTIVES After reading this unit you will be able to know :
What are the types, causes of sexual dysfunctions.
The different perspectives of sexual disorders.
About gender identity disorder, its causes and treatment.
8.1 SEXUAL DYSFUNCTIONS Three stages of sexuality - desire, arousal and orgasm – each associated
with specific dysfunctions. A sexual dysfunction is an impairment is one
of these stages. In ad dition, pain can become associated with sexual
functioning, leading to additional sexual dysfunctions. Following are the
sexual dysfunctional disorders:
8.1.1 Sexual Desire Disorders :
a. Hypoactive Sexual Desire Disorder :
The person seems to have no int erest in any type of sexual activity. It is
absence of sexual fantasies and thought. This can be a lifelong problem or
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69 Sexual Variants, Abuse and Dysfunctions - II b. Sexual Aversion Disorder :
In this, the individual not only have no interest in sex, but even the thought
of sex or a brief touch, such as someone’s taking the person’s hand to
assist him or her in getting out of a car may evoke fear, panic or disgust. In
some cases of sexual aversion disorder, the principal problem might
actually be panic disorder , when the fear or alarm response has become
associated with the physical sensation of sex.
8.1.2 Sexual Arousal Disorders :
Disorders of arousal refers to male erectile disorder and female sexual
arousal disorder. Individuals with arousal disorders have frequent sexual
urgers and fantasies and strong desire to have sex. The individual having
erectile disorder have difficulty becoming aroused, that is, a male has
difficulty achieving maintaining an erection and a female cannot achieve
or maintain adequate lubrication.
Arousal disorders can be either lifelong or acquired. Lifelong refers to a
chronic condition that in present during a person’s entire sexual life.
Acquired arousal disorder being at a specific time before which sexual
activity was relatively normal. In addition arousal disorders can either be
generalised, in which case they occur every time individual attempts sex
or they can be situational, occurring only with some partners or at certain
times, but not with other partners or at other times.
8.1.3 Orgasmic Disorders :
a. Inhibited Orgasm (Female Orgasmic Disorder and Male Orgasmic
Disorder) :
It is inability to achieve an orgasm despite adequate sexual desire and
arousal, commonly seen in women but rarely seen in men. Five to ten
percent of the females may experience female orgasmic disorder in which
they never or almost never reach orgasm (Win cze & Carey, 1991).
b. Premature Ejaculation :
A far more common disorder of orgasm experienced by males is
premature ejaculation, which refers to ejaculation occurring well before
the partner wishes it to.
8.1.4 Sexual Pain Disorders :
In sexual pain diso rders marked pain in associated with sexual intercourse.
Two subtypes have been identified -
a. Dyspareunia :
For some males and females sexual desire is present and arousal and
orgasm are easily attained, but the pain of intercourse in so severe that
sexual behaviour is disrupted. This disorder is named dispareunia which,
in its original Greek, means “unhappily mated as bedfellows” (Wince &
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70 It may also be experienced by an indivi dual before or after the intercourse.
The disorder may occur both in male as well as a female.
b. Vaginismus :
More common than dyspareunia is vaginismus. In this condition,
occurring in women, the pelvic muscles located in the outer third of the
vagina un der go involuntary spasms where intercourse is attempted.
Women report sensation of “ripping, burning or tearing during attempted
intercourse”. In some females, even the thought of vaginal insertion may
result in muscle spasm.
8.1.5 Causes of Sexual Dysfu nction :
1. Biological Causes :
a. Disease : Diabetes has been linked to sexual dysfunction. Diabetes can
lower the sexual drive, arousal, pleasure and satisfaction, especially in
men. Cardiovascular disease, multiple sclerosis, renal failure, vascular
disease , spinal chord injury and injury to automatic neurons system
due to surgery or radiation have also been linked to causes of sexual
dysfunction. Males are more prone to get affected.
b. Hormones : Low level of androgen hormones in men, especially.
Testoster one, and high/level of estrogen and prolactin hormone have
been linked to cause sexual dysfunction. Menopausal women have
low sexual desire and arousal because of no estrogen secretion in the
body. Ovarian cancer, vaginal surgery and sexual self image prob lem
can bring sexual dysfunction among women.
c. Prescribed Drugs : Antihypertensive drugs (for high blood pressure),
antipsychotic drugs, anti depressants, tranquillisers, etc, are medical
drugs that cause sexual dysfunction.
Marijuana, cocaine, amphetamine and nicotine can impair sexual
functioning. Alcohol intake too is linked to sexual dysfunctioning.
2. Psychological Causes :
a. Psychological disorder : Depression is one such cause of sexual
dysfunction. Besides this, the i ndividual suffering from anxiety
disorder, panic disorder, obsessive compulsive disorder,
schizophrenia too have reported no or little desire for having sex.
They lack feelings of sexual arousal and have problems in sexual
functioning
b. Attitude and Cog nition about Sex : Attitudes and cognition about
sex – some people have negative attitudes about sex. They may
consider it dirty, sinful and disgusting and may avoid involving
themselves in any kind of sexual activity.
c. Performance anxiety : This is yet a nother blockade for people to
enjoy sex. There in so much worry and apprehension about their munotes.in
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71 Sexual Variants, Abuse and Dysfunctions - II sexual performance that it psychologically hinders the pleasure of
sexual acts among individuals.
3. Social and Inter personal Causes :
a. Problems in Relationship : People suffering from sexual dysfunction
are also seen to be struggling with maintaining intimate relationship.
Differences in opinion about conducting sexual activities may be the
main reason for conflicts between couples. Lack of communication
about sexua l preferences and arousal to each other trigger more
interpersonal conflicts. Besides this, the male arousal pattern differs
from female patterns. Non assertiveness in communicating one’s
sexual desires and stimulation to the partner can cause dissatisfact ion
in sexual life leading to frustration. Behaviour conflicts also
influences sexual relationship. Disrespect towards one’s partner,
bitterness, anger, frustration among couples block sexual desire and
healthy sexual functioning.
b. Trauma : Death of love d one, job loss, diagnosis of a serious disease
unemployment in men, etc., leads to lower self esteem and distorts the
self concept. Trauma also leads to depression and reduces desire for
sex.
4. Sexual Problems across life span :
As age declines, the biological changes occurring in the body influences
one’s sexual functioning. Adequate level of testosterone are essential for
proper sexual arousal in both men and women. Testosterone levels start
declining around age of fifty in men. Inadequate erections and sexual
dysfunction increases with age.
8.1.6 Treatments Suggested for Sexual Dysfunctions :
1. Biological Therapy :
Certain medical conditions like diabetes automatically lead to sexual
dysfunctionality. Regulating dosage of drugs helps in regulating/curing
sexual dysfunction.
Special drugs too are available that can treat sexual dysfunction. Viagra is
one such drug. Some drugs are also injected in the penis to gain penile
erections. Hormone therapy too in administered among men a nd women,
who are suffering from sexual dysfunctions.
2. Sex Therapy :
Sex therapy is recommended to couples. The major focus of therapy is on
training the couples on various sexual practices that can be beneficial to
keep them aroused and complement each ot her sexual preferences.
3. Couple Therapy :
Many times couples do not give enough attention to foreplay and
seduction prior to sexual intercourse. They just rush to experience the munotes.in
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72 sexual pleasure through the sexual act. This can be problematic for couple
later in life, when the biological level of testosterone and estrogen starts
diminishing it result in inadequate arousal and displeasurable experience
while having sex.
4. Individual Psychotherapy :
Cognitive behaviour therapy is conducted to reshape sexual attitudes and
script between couples (Rosen and Leiblum 1995). The reasoning behind
sexual fears are confronted to form fresh perspective and positive
cognitions. Psychodynamic therapies too are used to find clues from the
past to the current sexual probl ems.
5. Approach towards Homosexual and Bisexual Issues :
Gay, lesbians and bisexuals too experience sexual dysfunctions similar to
heterosexuals. Societal attitude towards gay, lesbians and bisexuals is the
most important factor negatively influencing t heir sexual problems.
8.2 GENDER DYSPHORIA / GENDER IDENTITY DISORDER (GID) Gender identity is the perception of a person about themselves as male or
female. It is a fundamental component of their self -concept.
Gender identity disorder is diagnosed when a person believes that they are
born with the wrong sex’s genitals and are fundamentally person of the
opposite sex. Person feels that they are trapped in the body of the opposite
gender.
DSM 5 renamed the diagno stic label of gender identity disorder to Gender
Dysphoria to remove the stigma associated with the term disorder.
8.2.1 Symptoms :
1. Strong and persistent identification with the other sex :
I. In children, this is manifested by repeatedly stated desire to be or
insistence that he or she is the other sex.
II. In boys, preference for cross dressing or stimulating female dress. In
girls, insistence on wearing only masculine clothing.
III. Strong and persistant preference for cross sex roles in play and in
fantasies.
IV. Strong preference for playmates of the other sex.
V. In adolescents or adults, identification with the other sex is seen by
symptoms such as desire to be with the other sex, desire to live or to
be treated as the other sex, conviction that h e/she has the typical
feeling or reactions of the other sex.
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73 Sexual Variants, Abuse and Dysfunctions - II 2. Discomfort :
Persistent discomfort with his/her sex and sense of in appropriateness in
the gender role of that sex.
3. Disinterest in Opposite Sex :
He/she is not interested in sexual relation w ith opposite sex. They
experience distress or problem in sexual interaction with the opposite sex,
if forced.
4. Disturbed Mental State :
To relieve themselves from the tension and confusion, some go for alcohol
and drugs. Because of rejection from others th ey experience frustration,
low self -esteem and distress.
8.2.2 Causes of GID :
1. Biological Causes :
a. Biological theories have emphasised the effects of prenatal hormones
on brain development. The excessive exposure to unusual levels of
hormones affects the hypothalamus and other important brain
structures that controls sexual identity and sexual orientation. But
these theories are not well investigated.
b. Few studies focus on a cluster of cells in the hypothalamus called the
“bed nucleus of stria termin alis”. It plays an important role in sexual
behaviour. The size of this cell cluster plays an important role in GID.
This cell cluster are found to be half of the size in transsexual as
compared to non - transsexuals.
c. Another study suggested that prenata l hormones play an important
role in GID. In an experiment, girls were exposed to elevated levels of
testosterone in utero. Most of these girls were born with some degree
of masculisation of their genitalia and have more masculine behaviour
than other girl s.
2. Psychological Causes :
a. Psychological theories focuses on the prenatal nurturing dimension.
How the parents share the child’s gender related norms will decide the
vulnerability of the child to develop GID later as adult. Usually
parents encourage their children to show gender appropriate
behaviour, for example, girls playing with dolls, boy acting as fathers,
etc. Boys showing feminine tendencies had mothers who desired girls
rather than boys, so pampering their sons with dolls, frocks, kitchen
set, etc., Absence of father figu re at home and overprotection of
mother also leads to feminine tendencies in boys.
b. Parental psychopathology also determines the development of GID in
individuals. It is seen that parents of GID individuals had history of
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74 of environment may create anxiety and confusion in children. It
makes the child unsure about him or herself. A child may adopt a
cross gendered identity as a way of pleasing the parent and reducing
his/her own anxiet y.
8.2.3 Treatment of GID :
a. The therapist tries to help these individuals to clarify their gender
identity and sexual orientation.
b. Some individuals undergo gender reassignment procedures by taking
hormone therapy through sex change operation. Befo re surgery they
are asked to groom themselves by cross dressing and interact in
society for one or two years. They are given life time hormone
therapy in which estrogen is given to a male to develop female
secondary sexual trait (breast, etc.,) and testost erone is given to
females to develop male secondary sexual trait (beard, etc.). Artificial
genitals are created, person can get sexual pleasure but reaching
orgasm is not possible. The change and adaptation may cause stress
which is managed by the help of counselors and therapists.
Check Your Progress :
1. What are the symptoms of gender identity disorder?
2. How an individual with gender identity disorder can be helped out?
3. What are the biological and psychological causes of gender identity
disorder?
8.3 SEXUAL DISORDER S: BIOPSYCHOSOCIAL PERSPECTIVE Patterns of sexual behaviour vary widely across different cultures around
the world. Although most individuals around the world, especially in
western cultures, practice safe sex, approximately 20% of individuals
engage in sex with multiple partners. Studies show that no gender
differences are apparent in attitudes about sexual satisfaction,
masturbation or homosexuality. In western cultures premarital sex is
common as compared to Sweden where attitudes , are more permissive.
What is normal sexual behaviour in one culture may not necessarily be
normal in another culture. Report says that homosexuality runs in families.
The environment and experience play very powerful role in sexual
behaviour. Sometimes n egative attitudes or experiences associated with
sexual interactions may contribute to sexual determination. Cultures with
very restrictive attitudes towards sex can influence sexual behaviour. For
example. Vaginismns is rare in North America but is most c ommon in
Ireland.
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75 Sexual Variants, Abuse and Dysfunctions - II 8.4 SUMMARY Three types of sexual disorders are gender identity disorder , sexual
dysfunction and paraphilias. GID is dissatisfactions with one’s biological
sex. Sexual dysfunctions such as disorders of sexual desire, arousal,
orgasmic disorder, inadequate penile erec tion, etc., are related to different
stages of normal sexual cycle. Paraphilias is sexual attractions to
inappropriate people such as children, or objects such as clothes, etc.
The causes are socially transmitted negative attitudes towards sex,
biological and psychological causes.
Treatments for sexual disorders include biological and psychosocial
approaches. Treatments for paraphilias are highly successful but available
only in specialised clinics. Treatments for sexual dysfunctions is
successful but not readily available.
8.5 QUESTIONS Q1. Write a note on Gender Identity Disorder.
Q2. Discuss the different types of sexual dysfunction and its causes.
Q3. Discuss various treatment options for sexual dysfunctions.
8.6 REFERENCES Oltmanns, T.F., Eme ry, R.E. (2010). Abnormal Psychology 6th ed.,
New Jersy : Pearson Prentice Hall
Nolen – Hoeksema, S. (2008). Abnormal Psychology. 4th ed. New
York : McGraw – Hill
***** munotes.in