INDEX

TOPIC PAGE NO.

1. Normality and abnormality:

Concepts of mental illness and health

2. Attitudes towards mental illness and stigma

3. Personality formation in the family

4. Psychosocial aspects of suicide

5. Psychosocial aspects of old age

6. Impact of addictive behavior

7. Social class, gender, religion and mental illness

8. Cultural models of mental illness

9. Epidemiological studies and socio-demographic

correlates of mental illness in India

10. Impact of violence (domestic, sexual and ethnic violence)

11. The construct of healthy personality

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 12. Preventive aspects of mental illness

Normality and Abnormality: Concepts of Mental Health and Illness

Most of us would have labeled some or other behaviour as ‘abnormal’. But defining the
concept of normality or abnormality has been a riddle. Although many definitions have
been proposed over the years, none has won total acceptance. The World Health
Organization defines mental health as "a state of well-being in which the individual
realizes his or her own abilities, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to his or her community”.
There have been different understandings of what is normal and healthy. Definitions of
mental health are influenced by cultural and subjective considerations and different
professional theories. One of the major classifications of the concepts of normality was
given by Offer and Sabshin (1974). They synthesized various theoretical and main
clinical concepts of normality into four major perspectives:
1. Normality as Health: This is the traditional medical-psychiatric
approach to normality where normality is considered as health. This is the model that is
conventionally followed by biological psychiatrist and for him normality is freedom from
symptoms and pathology. So the therapist aims at reduction of symptoms and making the
‘patient’ symptom free. This would mean that the normal is not essentially working at
his/her optimal state. Thus, normality means lack of a disorder.
It is, thus, seen that normality and abnormality are relative terms. And thus, for the
definition of normality/health, definition of a disorder becomes important. The
Diagnostic and Statistical Manual of Mental Disorders has defined a mental disorder as:
“A mental disorder is a behavioral or psychological syndrome or pattern associated with
distress (e.g. a painful symptom) or with a significantly increased risk of suffering, death,
pain, disability or an important loss of freedom. In addition, the syndrome or pattern must
not be merely an expected and culturally sanctioned response to a particular event, such
as the death of a loved one.”
Thus this definition of normality looks at the distress and discomfort
experienced by the person. If he does not experience these emotions, he is considered
normal. The whole issue becomes more categorical in this context – a person is, either
normal or abnormal. The approach has, of course, been criticized. The homogeneity of
the so-called ‘normals’ can’t be concluded and it is more reasonable to assume that the
normal population is quite diverse (Buck, 1992). Many people who are categorized as
normal, exhibit behaviour that is undesirable. Also, are there cases of persons who do
activities which do not distress them, but causes distress to others, as in the case of some
personality disorders. There has also been contentions that normal is just not the absence

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of disorders and would include a state of well-being, adjustment to oneself and others and
experience of a wide range of positive emotions.
2. Normality as Utopia: conceives normality as that harmonious and
optimal blending of the diverse elements of mental apparatus that culminates in optimal
functioning or “self actualisation”. This approach can be traced back to Freud, who said:
“A normal ego is like normality in general, an ideal fiction”.
3. Normality as Average: This perspective is commonly used in the
normative studies of behaviour. This approach is based on the mathematical principle of
the bell-shaped curve and its applicability to physical, psychological and sociological
data. This perspective conceives of the middle range as normal and both extremes as
abnormal. This is the most popular perspective of normality in mental health. This
produces the trichotomy of three different “types” of humans: the abnormal insane and
delinquent, the gifted and genius and the normals who make up “the rest of us”.
4. Normality as a Process: This perspective asserts that normal
behaviour is the end result of interacting systems that change over time. In contrast to the
other three perspectives, the proponents of this perspective advocate that normality can
be seen from a point of view of temporal progression.
Conceptualizations of Mental Health: There have been different conceptualizations of
mental health. Mental health has been considered synonymous to normal. But this is too
simplistic a view. While normality may be viewed as the psychological characteristics
attributed to the majority of people in a population at a given time, mental health includes
absence of sickness/disease, the presence of wellness and the capacity to think rationally
and logically and to cope with life’s transitions, stresses, traumas, and losses in a way that
allows for emotional stability and growth. It involves the attempt to live meaningfully, in
a particular set of social and environmental circumstances, relying on a particular collect
of resources and supports.
Six empirical approaches of mental health have been proposed:
1. Mental Health as Above Normal: This is based on the traditional
medical approach of viewing those below average as abnormal. But mental health is not
just getting one to normal, but is above average. This model considers mental health as
the exception, not as the rule. Thus, mental health is a mental state that is objectively
achievable – as in Sigmund Freud’s definition of mental health as the capacity to love and
work.
2. Mental Health as Positive Psychology: This model conceives mental
health as the ‘best possible’. Health is not just the absence of negatives but is the
presence of positives. These positives include optimism, hope, happiness and other
similar constructs. Maslow has advocated the optimal utilization of one’s resources,
potentials and talents.
Positive psychologists have divided health into four components:
1) Talents are inborn and genetic and cannot be much changed. (E.g. I.Q.)

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 2) Enablers reflect social and environmental factors. (E.g. a good family)
3) Strengths are character traits that reflect facets of mental health like
openness and curiosity and can be changed.
4) Outcomes reflect variables dependant on strengths like quality of life, social
relationships, subjective well-being etc.
However, positive psychology has the danger of imposition of culturally insensitive
parochial virtues universally. It, involves enormous amount of value judgements. Thus,
happiness and its expression may vary from culture to culture and can’t be measured
similarly.
Also, some authors have contended that too much emphasis on optimism may hamper
accurate perception of reality. Freud, Marx and Darwin have viewed optimism as cultural
adolescence and not as mature mental health.
3) Mental Health as Maturity: This model takes a longitudinal view of
maturity. It depends on development of the brain as well as the evolution of social and
emotional intelligence through experience. Erikson has conceptualised his eight stages of
adult development as ‘criterion of mental health’. He considered such development as
leading to a widening of ‘social radius’. And for this the individual should be able to
master the tasks at each stage properly. Thus, an adolescent would be healthy if he could
establish his identity properly and for this he should have mastered the task of intimacy at
the previous stage. Thus, in such a model the social radius of each stage fits in the next.
However, in practical, healthy adult development nay not follow rigid rules. Some
individuals may master some tasks much later. The model is useful in understanding
where an individual stands in terms of these stages and would help in guiding individuals
through these stages of healthy development.
4) Mental Health as Socio-emotional Intelligence: All emotions are basically
useful to our survival. The capacity of identifying different emotions in ourselves and
others play an important role in mental health. Mental health involves accurate
identification and regulation of emotions, focussing these emotions for a desired goal and
skills in negotiating relationships with others. Neurophysiologists have understood
emotions as neurophysiological phenomena and have succeeded in identifying brain areas
in emotional processing and regulation. Measurement of emotional intelligence has also
seen advancements in the recent years.
The model has been used to impart skills in emotional regulation and negotiation in
school and helping executives, diplomats and others in handling relationships and conflict
resolution. The usefulness of the model lies in its preventive value so that it can be used
in preventing personal and interpersonal distress by imparting skills in emotional
processing and regulation.
5) Mental Health as Subjective Well Being: This model places utmost
importance on the person’s perception of his own life and mind. Subjective well-being
cannot be defined by any criteria formulated objectively any one; it rather depends on the

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person solely. The same situation may be viewed differently by different persons.
However, there are debates whether subjective well-being should include the social and
relational consequences. For example, tantrums, promiscuity, revenge etc. may make the
person subjectively happy, but may not be socially desirable or bring him happiness
which lasts long. Also, subjective distress can be healthy as negative emotions have been
proved to have survival and adaptive value.
6) Mental Health as Resilience: This model looks at mental health as the
capacity to adapt to different stresses in life in a constructive way and optimal adaptation
to such stressful situations. This may involve the use of ‘healthy defense mechanisms’
which help in maximisation of gratification and maintaining psychological homeostasis.
These mechanisms allow the individual to consciously experience feelings, ideas and
their consequences. Some of such ‘healthy defense mechanisms’ proposed are
Humour: Taking one’s life not too seriously.
Altruism: Giving away to other’s what one would like to receive.
Suppression: Minimising and postponing of gratification.
Anticipation: Bearing in mind the affective responses to a future event in
‘manageable doses’.
Sublimation: Channelizing energy from one’s conflicts into socially acceptable
ways.
Jahoda (1958) has given the following criteria for mental health:
• Realistic attitudes toward self
• Growth, development, self-actualization
• Integration of psychic forces
• Autonomy
• Adequate perception of reality
• Environmental mastery
Abnormality: Definitions and criteria
The word ‘ab’ stands for ‘away from’. Thus, ‘abnormal’ stands for ‘away from the rule or
standard’. Corresponding to the above perspectives of normality, there have been various
definitions of mental abnormality:
1. Abnormality as Deviance: Thus, abnormality is viewed as those
behaviours, emotions and thoughts that differ from a society’s social or statistical norms.
The majority’s views are accepted as normal. Thus, judgements of abnormality will vary
from culture to culture and situations to situations. Some have questioned the implicit

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assumption of the majority’s views being always desirable and being always in the best
interest of both the individual and the group.
The other view of abnormality is based on statistical norms – anything that is deviant
from the average is abnormal. The middle ranges in the well-known ‘normal curves’ are
normal and the both the extremes are considered abnormal. This is mostly applied in
some measurable constructs like intelligence. Thus, genius is as abnormal as the retarded.
2. Abnormality as Distress: - abnormality as intense feelings of
anxiety, depression, guilt or other forms of distress. The person would, of course, seek
ways to reduce the distress. But, again, those individuals who are pleasant in themselves
but create harm/distress to others are not abnormal by this criteria. Or else, those who do
not experience any distress in situations where it is expected may be considered normal.
3. Abnormality as Dysfunction: Abnormality is considered to be
equivalent to maladaptive behaviour where the individual is unable to cope with or adjust
to the environmental demands placed on him. Thus, the individual may not be able to
carry out his daily activities properly or may not be productive. This perspective is
commonly used in clinical assessments but, is essentially negative and does not look at
optimal utilisation of resources.
4. Abnormality as Danger: Here, abnormal behaviour is defined as
that which is dangerous to the individual or other people. However, some researchers
have contended that it is not always so. People with anxiety, depression or even bizarre
thinking do not pose any immediate danger to themselves or other people (Monahan,
2001).
5. Abnormality as Immaturity: Thus, the abnormal are immature.
This definition clearly rests on the cultural view of maturity and immaturity. It, of course,
is all the more difficult to define what is ‘appropriate’ or ‘mature’.
Conceptualisations of Mental Illness: ‘Ill’ is ‘not healthy’. Thus, the fuzziness and
perplexity in the definition of mental health is reflected in the definition of illness too.
Each civilisation defines its own illnesses. What is illness in one might be chromosomal
abnormality, crime, holiness, or sin in another.
There have been different interpretations and understandings of mental illness and
historically ranged from theories of supernatural possession to naturally occurring
biological causes. A short description of each of the prominent viewpoints is given below:
1) The Bio-medical Model: This model focuses on mental illness as
diseases, the symptoms of which are cognitive or behavioural. Thus, mental disorders are
viewed as disorders of central nervous system, autonomic nervous system or other similar
causes which are the result of genetic transmission or some pathological process. All
behaviour is seen as rooted in underlying physiological processes in the body. Therefore
cure is only possible by removing the root cause and returning the body to its “normal”
level of functioning.

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 2) The Psychodynamic Model: This model, developed by Freud,
emphasized on the role of unconscious motives and ego defense processes. Early
childhood experiences of individuals determined their later adjustment and
maladjustment. It suggested that abnormal mental phenomena were exaggerations of
normal ego-defense mechanisms and occurred as the person attempted to cope with
difficult problems.
3) The Behavioural Model: This model is concerned with the role of
learning in abnormal behaviour. The classical conditioning model is based on learning
principles in which involuntary responses to stimuli are learned through association
between stimuli and responses. Classical conditioning helps explain acquisition of
phobias, unusual sexual attractions, and other extreme emotional reactions. It, also, serves
as a basis for effective treatment techniques. The operant conditioning model views
maladaptive behaviours linked to environmental reinforces – the behaviours followed by
positive consequences are repeated while those followed by negative consequences are
not. The Observational Learning Model asserts that behaviours are acquired by watching
someone else perform those behaviours.
4) The Cognitive Model: These models assert that conscious thought
mediates or modifies a person’s emotional state and/or behavior in response to a stimulus.
Albert Ellis views psychological problems as being produced by irrational thought
patterns stemming from individual’s belief system. Irrational thinking operates from
dogmatic, absolutist “shoulds,” “musts,” and “oughts” that cause human misery as
“musturbatory activities.” Aaron Beck views automatic thoughts, which are rigid,
inflexible, and distorted interpretations of events that seem to happen by reflex, as
causing miseries for human life in a given situation.
5) The Humanistic/Existential Model: This model advocates that to
understand an individual’s thoughts and behaviours, one must understand his subjective
universe (i.e., his unique experiences and how he construes them). Society imposes
conditions of worth (via conditional positive regard) upon individuals, which influences
self-concept. Psychological distress arises due to incongruence between a person’s
inherent potential and his self-concept. Through authentic, caring, and accepting stance,
the therapist enables the client to explore attitudes, beliefs, and feelings more deeply and
thus, increase self-acceptance and accept greater responsibility for his/her behavior.
6) The Family Systems Model: This model emphasizes the family’s
influence on individual behaviour. It suggests that abnormal behavior is a reflection of
unhealthy family dynamics and poor communication and that therapist must focus on
family system, not just the individual.
7) The Socio-cultural Model: This model suggests that abnormalities can be
influenced by social experiences and cultural values. Abnormalities a result of a
dysfunctional system, not just an individual’s pathology. The model recognizes that
individual is part of social system and can be influenced by the same. Scholars like
Thomas Szasz have viewed mental illness as “troubling social labels” and that social
factors involve in how we define mental illness.

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 8) The Biopsychosocial Model: These models integrate biological,
psychological and social factors and suggest that abnormality is caused by the interaction
of these factors and that the relative importance of each of these factors depends on the
individual and the environment. This approach, thus, combines treatment methods and
makes it better tailored for the individual.
Conclusion: Though the concepts of normality and abnormality as well as health and
illness are extremely important in the field of mental health profession, professionals
have not been successful in defining these concepts properly. The definitions are biased
by norms, culture and other contextual factors. Also, different models put forth different
definitions. These models, of course, have helped us in understanding the concepts closer.
However, there has been no comprehensive definition. The attempts at integration of
different models like the Biopsychosocial model are positive in this direction. These
models have also highlighted the importance of interaction between various factors
contributing to illness and disorders which calls for comprehensive treatment approaches
and has important clinical implications.
Key References:
Buck, L.A. (1992). The Myth of Normality: Consequences for the Diagnosis of
Abnormality and Health. Social Behaviour and Personality. 20, 251-262.
Butcher, J.N., Carson, R.C., & Mineka, S. (2000). Abnormal Psychology and Modern
Life. New Delhi: Pearson Education.
Offer, D. & Sabshin, M. (1974). Normality: Theoretical and Clinical Concepts of Mental
Health. Oxford: Basic Books.
Page, J.D. (1947). Abnormal Psychology: A Clinical Approach to Psychological
Deviants. New York: Mc Graw Hill Book Company Inc.
Vaillant, G.E., & Vaillant, C.O. (2005). Normality and Mental Health. In Sadock, B.J., &
Sadock, V.A. (Eds.). Comprehensive Textbook of Psychiatry. Amsterdam: Lippincott
Williams & Wilkins.

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 NORMALITY AND ABNORMALITY
WHO famously defines health as:
... a state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity (WHO 2001).
Three ideas central to the improvement of health follow from this definition:

 mental health is an integral part of health

 mental health is more than the absence of illness
 mental health is intimately connected with physical health and behaviour.

However, just as age or wealth each have many different expressions across the world
and yet have a core common-sense universal meaning, so mental health can be
conceptualized without restricting its interpretation across cultures. WHO has recently
proposed that mental health is:

... a state of well-being in which the individual realizes his or her own abilities, can cope
with the normal stresses of life, can work productively and fruitfully, and is able to make
a contribution to his or her community (WHO 2001).
In this positive sense, mental health is the foundation for well-being and effective
functioning for an individual and for a community. Neither mental nor physical health
can exist alone. Mental, physical and social functioning are interdependent. Furthermore,
health and illness may co-exist. They are mutually exclusive only if health is defined in a
restrictive way as the absence of disease (Sartorius 1990). Recognizing health as a state
of balance including the self, others, and the environment helps communities and
individuals understand how to seek its improvement.
Mental health is more than the absence of mental illness
As already noted, mental health implies fitness rather than freedom from illness. As
Vaillant (2003) points out, this is a complex task. “Average mental health” is not the same
as “healthy”, for averaging always includes mixing in with the healthy the prevailing
amount of psychopathology. What is healthy sometimes depends on geography, culture,
and the historical moment. Whether one is discussing state or trait also needs to be clear –
is an athlete temporarily disabled with a fractured ankle healthy or the asymptomatic
person with a history of bipolar affective disorder healthy or unhealthy? There is also
“the two-fold danger of contamination by values” (Vaillant 2003, p. 1374) – a given
culture’s definition of mental health can be parochial and, even if mental health is

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“good”, what is it good for? The self or the society? For fitting in or for creativity? For
happiness or for survival? Even so, Vaillant advocates that common sense should prevail
and that certain elements have a universal importance to mental health; just as despite
every culture differing in its diet, the importance of vitamins and the four basic food
groups is universal
No health without mental health: mental health and behaviour
Mental health status is associated with behaviour at all stages of life. A body of evidence
indicates that the social factors associated with mental ill-health are also associated with
alcohol and drug use, crime, and dropout from school. The absence of the determinants of
health, and the presence of noxious factors, also appear to have a major role in other risk
behaviours such as unsafe sexual behaviour, road trauma, and physical inactivity.
Furthermore, there are complex interactions between these determinants, behaviours and
mental health. For example, a lack of meaningful employment may be associated with
depression, and alcohol and drug use. This may in turn result in road trauma, the
consequences of which are physical disability and loss of employment

The Social Construction of Mental Illness

There is little doubt that categories of psychopathology historically have been intertwined
with structures of power and with cultural norms. Drapetomania, the desire of slaves to
escape captivity, was in the early nineteenth century considered a mental illness
(Cartwright, 1851/1981; Szasz, 1971). Victorian physicians regularly performed
"therapeutic" clitoridectomies on masturbators, who also were thought to be pathological.
As recently as 1938, listed among the forty psychiatric disorders in a leading textbook
(Rosanoff, 1938), were moral deficiency, masturbation, misanthropy, and vagabondage.
Homosexuality, which had been universally regarded as a manifestation of mental illness
by Western psychiatry, was "officially" depathologised in 1973, after a contentious
political struggle, by a vote of the board of trustees of the American Psychiatric
Association (Kutchins and Kirk, 1997). Other conditions commonly regarded as
pathologies by many clinicians and researchers, e.g., Premenstrual Dysphoric Disorder
and Masochistic Personality Disorder, were denied official status as mental illnesses after
highly polemical and acrimonious conflicts among the parties who influenced the
fashioning of DSM-IV. Not so long ago psychiatrists in the former Soviet Union
performed an Orwellian manoeuvre of medicalising opposition to the state when they
employed the diagnosis "sluggish schizophrenia" to effect the incarceration of many
political dissidents (Bloch and Reddaway, 1977).

Writers of a social constructionist bent (Gergen and McNamee, 2000; Sarbin and
Mancuso, 1972) are inclined to conclude from the long lamentable catalogue of
psychiatric folly that psychopathology is pretty much a matter of what conduct and states
of mind are fashionable across history and culture. They hold that mental illness is
fundamentally about what a society values, as with musical tastes or standards of proper
attire. This position is often contrasted with the naturalist/biomedical view that mental
illnesses are universals, natural kinds (each of which is underpinned by an identical
biological deep structure) that are constant across culture and history. If the

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normativism/cultural relativism espoused by social constructionist writers were true, we
might expect, through historical or cultural research, to find societies where it was the
norm to be what we would today term pathological. This turns out not to be the case for
the major psychiatric disorders: the psychoses or the mood disorders. The prototypical
mental illness, schizophrenia, comes close to being universal and uniform across diverse
societies, although such incidentals as delusional content (e.g., thinking oneself to be Bill
Gates rather than Napoleon), of course, are variable.

It is not surprising that severe mental illness is not valued as a universal in any known
society. Psychotics and depressives cannot serve as the cornerstones of any society in
which energy, ingenuity, and cooperation are necessary for that society's survival. This is
not to say that within complex societies with excess resources there cannot be subgroups
where psychopathology is the norm. Nor is it the case that societies cannot prosper if
many or all of their members engage in conduct or have experiences that contemporary
Western psychiatry would regard to be indicative of mental illness, e.g., hearing voices
that do not emanate from living persons (Jaynes, 1976; Mezzich, Kleinman, Fabrega, and
Parron, 1996).

Culture accounts for significant variance in mental illness, just enough to refute the
biomedical view. There are many specific syndromes, such a Koro (the delusion that
one's penis is retracting into the abdominal cavity and that death will ensue) that are
unique to particular cultural contexts. Symptoms that indicate pathology in one society,
e.g., regularly hearing the voice of a dead relative, are normal and customary in others.
The epidemics of anorexia nervosa and bulimia in the contemporary West are
unprecedented, but are spreading to upper classes around the world, along with
Westernisation and its current aesthetic ideal of a slender female body (Ung and Lee,
1999). Writers such as Ian Hacking (1995, 1999) have argued persuasively that some
mental disorders, e.g., multiple personality disorder, are roles that are created by the
theories and practices of the mental health professions and subsequently enacted by
patients. On this view clinical theory and practice are not only mirrors of cultural norms
but shapers of those norms as well (Woolfolk, 1998).

If we count as mental illnesses those disorders that represent the extremes of various
personality types, e.g., narcissistic personality disorder, as DSM-IV does, the cultural
case becomes much stronger. Factors highly influenced by socialization; attitudes toward
self, intimacy, and authority, as well as patterns of emotional expression and interpersonal
relations, are the constituents of personality and also constitute the dimensions of those
highly variable cultural norms that are the diagnostic criteria in this controversial region
of psychopathology, the personality disorders.

The naturalistic conception of mental illness given by biological psychiatry inevitably

fails to take into account that psychiatry is not only a branch of knowledge but also a
social institution that fashions and adjusts what the sociologist Benjamin Nelson (1981)
termed directive structures, cognitive frameworks that channel and motivate behaviour
through the articulation of what is "valued" and "normal." Directive structures are
analogous to Parson's (1977) normative order: the norms and values instantiated in and

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disseminated by social institutions and that maintain social solidarity, regulate social
action, and control social deviance. Contemporary Western societies have tended to
medicalise, as opposed to criminalize, social deviance. The more societies choose to
medicalise social deviance, the more psychiatric disorders they will recognize and the
greater numbers of their citizens will be subject to the ministrations of mental health
professionals.

Normality and abnormality

The concept of abnormality changes with knowledge and the prevailing social attitudes,
therefore it is difficult to define an individuals' mental state or behaviour as abnormal.
The term Abnormal is defined in the 1985 edition of The Penguin Dictionary of
Psychology as "Any departure from the norm or the normal". It also defines Normal as
"Conforming to that which is characteristic and representative of a group; not deviating
markedly from the average or the typical.". Legally, normality is largely defined as the
ability to distinguish between right & wrong, and to control their own behaviour
(Roediger et al., 1986).

Psychology is a wide and eclectic discipline mainly concerned with ‘normal’ conduct and
experience, although concepts of abnormality are considered. Buss (1966) suggests that
psychologists have put forward four conceptions of normality/abnormality:
• The statistical concept;
• the concept of an ideal;
• the concept of specific behaviour; and
• the concept of distorted cognitions.
The statistical concept
The statistical view holds that frequently occurring behaviors in a population are normal,
and thus infrequently occurring behaviors are not normal. This is similar to ‘norms’ in
sociology. For example if we observe the speed at which a person walks – a certain pace
would be considered normal. Above this speed, a person might be considered to be
anxious, while below it the person might be considered depressed. Most people walk at a
rate between the upper and lower limits of this frequency distribution. However,
questions arise, such as who decides on the cut-off points at each end of the distribution
and how are such decisions made? Thus frequency of behaviour in itself does not inform
us when certain behaviour is to be judged abnormal, as value judgments have to be made
as to where the cut-off points should be between normality and abnormality. Further, a
statistical model may not be valid across cultures – even within the same country. For
example, walking slowly may be the norm in a country village, while walking quickly is
the norm in a busy city. In themselves statistical concepts do not inform us why some
deviations from the norm are only noted when they are apparent in one direction rather
than bi-directional. The example of walking refers to a bi-directional judgment: fast or
slow. However, regarding other concepts such as intelligence, negative judgements are

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only made when outside the norm in one direction. While being ‘bright’ is valued and
will not, without other considerations, lead to being put into the patient role, being ‘dim’
may well do so. The statistical approach within the field of abnormal psychology remains
influential. Psychologists are taught the parameters of normality and abnormality through
the statistical approach, which stresses that characteristics in any population follow a
normal distribution. The acceptance of a normal distribution implies that there are
underlying assumptions in psychological models of a continuous relationship between the
normal and abnormal. However the idea of continuity in one variable does not mean that
there is continuity between other variables. For example, in Eysenck’s personality theory
(Eysenck 1955), although both neurosis and psychosis follow a normal distribution curve,
they are considered to be separate from each other.
The ‘ideal’ concept of normality
Concepts regarding an ideal for human development are implicit in humanistic and
psychoanalytical models. In psychoanalysis, normality is defined when the individual’s
conscious characteristics dominate over unconscious characteristics (Kubie 1954). In the
humanistic model, the ideal person is one who fulfils their human potential or ‘self
actualizes’. Jahoda (1958) outlines six criteria for positive mental health:
1. Balance of psychic forces;
2. Self-actualization;
3. Resistance to stress;
4. Autonomy;
5. Competence;
6. Perception of reality.
Each of these criteria is problematic. The first two only have meaning within frames of
reference that concur with the humanistic and psychoanalytical models. The third,
resistance to stress, does not address issues such as its appropriateness. There are some
situations where anxiety is normal and adaptive. Further, lack of anxiety under high stress
conditions has been one of the defining characteristics of ‘primary psychopathy’ in the
psychiatric model. Similarly, people who tend to avoid human contact, or who are
extremely autonomous, may be classified as ‘schizoid’ or suffering from ‘simple
schizophrenia’. Competence is a highly variable characteristic, its norms differing
according to time and place. Perception of reality has the same problem of inconsistency
in definition. For example, in some cultures the ability to see visions and hear voices is
esteemed, whereas in other cultures such phenomena would be appraised negatively, and
taken as evidence that the person does not share accepted reality.
Specific behaviors
The development of psychology as a scientific academic discipline has been associated
with its focus on specific, objective aspects of conduct and on characteristics that are

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readily amenable to empirical measurement. Academic psychology separated from
philosophy, of which it originally formed a part, on the basis of these objective
considerations. The theory of behaviorism tried to restrict the area of concern of
psychology to behaviour, and so dismiss subjective experience as unsuitable for scientific
enquiry. Although this view no longer dominates psychology, it remains influential. Thus
psychologists have tried to operationalize in behavioral terms what is meant by
abnormality. Terms such as ‘maladaptive’, ‘unwanted’, ‘unacceptable’ behaviour are used
generally within most psychological models. The advantage of this perspective is that it is
explicit in defining abnormality. However, its weakness is that values and norms are left
implicit and rarely questioned. The concept of specific behaviour still does not answer
questions about who decides what is wanted or acceptable and what happens when some
people find certain behaviors desirable and acceptable and others do not. As we discuss
later when considering the socio-cultural model, many theorists point out that it is those
holding more influence or power in society who define what is acceptable reality. Hence,
what is deemed unwanted or maladaptive behaviour does not have the status of objective
fact but rather is socially negotiated. Conceptualizations of psychopathology are relative,
reflecting the value system and power relationships of a particular culture at a particular
time.
Defining normality
‘Normality’ has, at various times and by different people, been defined in a number of
ways.
Sociocultural normality
Every society has its own characteristic pattern of normal behaviour and beliefs. A
definition of sociocultural normality embraces the rules, or norms, governing what are
considered appropriate in a particular society. What is considered normal dress in a
Western society is not appropriate dress in a traditional Islamic society. In some cultures,
it is quite common to eat dog. In others, cannibalism is practiced. Neither of these foods
are part of a normal diet in contemporary Australia.
Functional normality
Psychologists and psychiatrists often use the term normality to describe an individual
who has a useful and satisfying life without causing harm to others or suffering from
personal distress. If a person can function within their society, they are considered to be
psychologically normal. This is called functional normality. Some people are unable to
cope with the everyday problems of living. Sometimes they exhibit behaviors that are
clearly harmful to themselves—for example, a woman loses her family and friends
because she is unable to control her consumption of alcohol. Or they may exhibit
behaviors that are harming others, such as various criminal acts. These behaviours may
be considered not functionally normal, and we will look further at this issue when
considering the definition of abnormality.

14
Historical normality
Historical normality refers to behaviour that used to be considered normal but is no
longer seen that way (or vice versa). During the Olympic Games in ancient Greece, the
competitors were all male. This was established by the custom of performing naked. In
the modern Olympics, there are almost as many female as male competitors and clothing
is required. Another example of historical normality concerned the practice of bathing
only once or twice a year in Europe in the seventeenth and eighteenth centuries. Today
we would label this ‘abnormal’.
Situational normality
Consider the following examples:
It may be acceptable to leave your rubbish on the table of a fast food restaurant when you
leave, but leaving your rubbish behind you when you leave a National Park will incur a
heavy fine. It may be acceptable to comment aloud on the acting style of a character in a
soap opera on TV, but it is abnormal to do so during live theatre. We may find it
acceptable for men to dress in very skimpy female clothing for the Gay Mardi Gras, but
we would probably be very upset to find our dentist in that attire when we visited him
with a toothache. These examples illustrate that what is normal in one situation is
unacceptable in another, even within the same society. This is called situational
normality.
Medical normality
The approach to physical illness used by the medical profession has been related to the
definition of normal and abnormal behaviour. According to this view, if a patient’s vital
signs (for example, blood pressure and heart rate) differ too far from the normal levels
found in most healthy people, then the patient is likely to be ill—for example, infected
with an influenza virus. It can also be argued that if a person’s behaviour departs too
much from the expected behaviour of a healthy individual in a particular situation, the
person is no longer normal, and is liable to be diagnosed with a mental illness. This
implies that there is an expected state of medical normality. If an individual departs from
the expected normal state, then the assumption is that this is due to some underlying,
physical cause.
Defining abnormality
To assess and treat abnormal behaviour, it is important to be able to clearly define normal
and abnormal behaviour and to have specific criteria for distinguishing one from the
other. The word abnormality literally means ‘away from the normal’, implying some
deviation from a clearly defined norm. In the case of physical illness, the norm is the
structural and functional integrity of the body, and the boundary between normal and
abnormal is usually clear. On the psychological level, however, there is no agreed model
of what normal functioning is. This leads to considerable disagreement about what is or is
not normal.

15
Although different in detail, the sociocultural, historical and situational definitions are
based around the idea that what is normal or abnormal depends very much on the context
in which the behaviour occurs. We will emphasize deviation from the norms of a
particular society as a method of defining abnormality. The functional and medical
definitions focus on the idea that behaviour is abnormal when it is maladaptive.
Abnormal behaviour as deviation from societal norms
One approach to defining abnormality is to adopt a culturally relativist position:
behaviour is abnormal only if it departs from the expectations of the particular culture.
This view was taken by Ullmann and Krasner (1975), who argued that the behaviour of a
Nazi concentration camp commander should be considered normal because he was
operating successfully within his social and cultural group. Although his behaviour may
be repulsive to us, this is only because we have judged him according to our own set of
values. We can therefore still call his behaviour ‘normal’.
If we accept the view that behaviour that is normal is the same thing as behaviour that is
socially acceptable, and that one set of values is as good as any other set of values, this
means that the role of psychotherapists would be simply to make people conform to the
norms and values of their own society. Many people feel that this approach is
unacceptable because some forms of behaviour are, in fact, better for us than others.
People who argue against the cultural relativist view say that it is possible to think of a
society as being sick, so that people conforming to the norms of that society would then
be considered abnormal.
Another problem with the culturally relativist position arises from the fact that many
contemporary societies are multicultural. While such societies frequently allow a wide
range of ideas and behaviors, it is difficult to imagine a society where extremely different
cultural groups could live together
Abnormal behaviour as functionally maladaptive behaviour
An approach that is generally accepted as a more satisfactory way of defining
abnormality takes the view that behaviour is abnormal if it operates against the wellbeing
of the person or group. Behaviour is abnormal if it is maladaptive, in the sense that it
interferes with the person’s functioning or growth, or causes the person extreme distress.
Most forms of mental illness have these features. Behaviour can also be considered
maladaptive if it operates against the long-term welfare of the whole group. Many forms
of criminal behaviour have no obvious adverse effects on the person carrying out the
behaviour, but do hurt other people.
As with most definitions, there are examples that do not fit the definition clearly. For
example, a very successful businessman sends all his competitors into bankruptcy and
poverty. We tend to accept this behaviour, provided that the businessman sticks to the
rules of the society. While the definition of abnormal behaviour as functionally
maladaptive is probably the best definition available, it does have its limitations. Because
there is no clear-cut way of defining health, as there often is with physical abnormality,

16
the society’s standards help determine the values we impose on people and how these are
applied in the definition of abnormal behaviour.
Personal Distress and Abnormality
In this criterion one would look at the person's subjective [internal] feelings rather than
their [external] behavior. They may feel unhappy, depressed and agitated. They may be
unable to concentrate or sleep. They may hide these feelings from others and their
behavior may appear normal. There may be the "Smiling Depression" where an
individual is very depressed but hides that depression from family and friends. Often the
first that his family know of the depression is when he attempts to kill himself.
Rosenhan and Seligman (1989) propose seven major features of abnormality that appear
in abnormal behaviour as opposed to normal behaviour. The more of these features that
are possessed by the individual, the more likely they are to be considered abnormal.

 Suffering: Most abnormal individuals (such as those suffering with anxiety

disorders) report that they are suffering. However normal people can suffer at
times in their lives and some abnormal individuals, such as those with personality
disorders, treat others badly but do not appear to suffer themselves
 Maladaptiveness: Maladaptive behaviour is behaviour that prevents an
individual from achieving major life goals; from having fulfilling relationships
with others or working effectively (for instance an agrophobic will not venture out
of the house due to fear).
 Vividness and unconventionality: Vivid and unconventional behaviour is
relatively unusual. It is behaviour that differs substantially from the way in which
you would expect normal people to behave in similar situations. However there
are many people who behave in this way that are not deemed to be abnormal.
 Unpredictability and loss of control: With most people, you normally predict
what they will do in known situations. In contrast, abnormal behaviour is often
highly unpredictable and uncontrolled and inappropriate for the situation.
 Irrationality and incomprehensibility: One of the characteristics of abnormal
behaviour is that there appears to be no good reason why the person should
choose to behave in that way.
 Observer discomfort: Our social behaviour is governed by a number of
unspoken rules about behaviour, such as the way we maintain eye contact or
personal space. When others break these rules we experience discomfort. But this
does not necessarily indicate abnormal behaviour, for instance different cultures
may well have different social rules about behaviour.
 Violation of moral and ideal standards: When moral standards are violated, this
behaviour may be judged to be abnormal

One of the problems with using the seven features of abnormality is that they rely on
subjective judgments and it can be quite difficult to decide which of the features are

17
actually present in a person’s behaviour. One family may try to commit an elderly relative
because of eccentric behaviour which other people may find harmless.
Continuity and Discontinuity in Conceptualizing Psychopathology
Normal and abnormal behavior can be regarded as either continuous or discontinuous
phenomena. From a continuity perspective, differences between disturbed and well-
adjusted persons are quantitative. A quantitative approach conceives normal and
abnormal behaviors as deriving from the same psychological dimensions or traits, with
maladjusted individuals having more or less than the optimum amount of these traits. For
example, a moderate amount of self-control contributes to good adjustment, whereas too
little self-control can lead to pathological impulsivity and too much self-control, to
pathological inhibition and rigidity. Similarly, a moderate capacity to reflect on yourself
and your experiences tends to promote good adjustment, whereas insufficient reflection
can lead to limited self-awareness, and excessive reflection can lead to paralyzing self-
consciousness.
From a continuity perspective, every aspect of a disturbed person’s behavior constitutes
an exaggeration of normal ways of thinking, feeling, or acting. Any normal person can be
expected on occasion to think, feel, or act the way disturbed people do, but the key
consideration is one of degree. Normal people show maladaptive exaggerations of
behavioral traits less frequently, to a lesser extent, and for shorter periods of time than
people who are psychologically disturbed. From a discontinuity perspective, by contrast,
differences between normal and abnormal behavior are considered qualitative, that is, as
differences in kind rather than degree. A qualitative approach emphasizes the study of
abnormal psychology in its own right, rather than as an extension of normal psychology,
to focus on the unique circumstances that give rise to psychological disturbance and on
the special kinds of care and treatment that disturbed persons require.
Both of these approaches to the relationship between psychological normality and
abnormality serve useful purposes. The continuity perspective helps mental health
professionals and the general public avoid regarding disturbed persons as “different”
from the rest of us. Being able to think of psychologically disordered people as having
more or less of certain characteristics that we all have, instead of being in an entirely
different dimension, fosters understanding of their problems and enlightened and
sympathetic efforts to help them overcome these problems. By contrast, the discontinuity
perspective has at times resulted in psychologically disturbed people being viewed as
alien and unfathomable, with the regrettable consequence of relegating them to places
where they are out of sight and out of mind and treating them with little regard for their
humanity. The continuity perspective on psychopathology also brings with it some
downside, however, particularly with respect to minimizing the implications of apparent
psychological disorder. In this regard, the discontinuity perspective can be very helpful
by virtue of its stress on the uniqueness of psychopathology. A qualitative approach has
the benefit of increasing the likelihood that disturbed people, their family and friends, and
mental health professionals who evaluate them will recognize and respond to their needs
for help.

18
Accordingly, the problems of psychologically disturbed persons are best viewed from
both continuity and discontinuity perspectives. To what extent can the adjustment
problems of these people be seen and understood as exaggerations (too much or too little)
of characteristics common to all people? At the same time, to what extent have these
tendencies to think, feel, and act in certain ways become sufficiently exaggerated to
warrant a diagnostic classification and a treatment recommendation, both of which
qualitatively distinguish these persons from most people?
References
Beutler, L. E., & Malik, M. L. (2002). Rethinking the DSM: A psychological perspective.
Washington, DC: American Psychological Association.
Blashfield, R. K., & Livesly, W. J. (1999). Classification. In T. Millon, P. H. Blaney, & R.
D. Davis (Eds.), Oxford textbook of psychopathology (pp. 3–28). New York: Oxford
University Press.
Offer, D., & Sabshin, J. (Eds.). (1991). The diversity of normal behavior. New York:
Basic Books

Woolfolk, R. (2001). The Concept of Mental Illness: An Analysis of Four Pivotal Issues.
The Journal of Mind and Behaviour, 22, 161-178

‘Personality Formation in the Family’

The influence of the family on the development of the individual personality cannot be
overemphasized. Almost every theoretical approach to conceptualizing the formation of
personality, from the psychodynamic to the humanistic-existential, have acknowledged
integral role of the family environment in the formation of personality. The following
essay will aim to touch on several of these theories of personality, focusing mainly on
their explanations for the influence of family factors on personality development. Some

19
of the more recent research relevant to these factors will also be highlighted and
reviewed.
THEORECTICAL FRAMEWORKS
The Psychodynamic Approach
The first systematic theoretical approach in psychology to attempt an explanation for the
formation of human personality is the Psychodynamic Approach, which is characterized
by the work of Freud, Jung, Adler, Horney etc. The Psychodynamic approach in general,
places much emphasis on the early years of an individual’s development as the defining
period in personality formation. According to Freud’s theory of the Structure of
Personality, the Ego is the first aspect of personality to be developed out of a child’s
interaction with his immediate environment (i.e. his primary care-givers or family).
Unlike the instinctual Id which is inborn, the remaining two structural components of
personality- the Ego as well as the Superego, are both born out of the interaction of the
individual with his environments (the first of which is the family).
The influence of the family on personality development, according to Freud, is not seen
merely at the level of the structure, but also in the manifestation and interaction of these
structures, as postulated in his theory of the Psychosexual stages of development. He
proposed that these personality structures are developed and manifested through
approximately the first twelve years of an individual’s life, and guided by the principle of
moving towards the pleasurable and away from the painful. In these stages, the family’s
excessively punitive or permissive reactions to the individual’s behaviour serve to fixate
development within a particular stage. Of particular note is the Oedipal Stage and its
resolution.
Another theorist with the same psychodynamic orientation but whose ideas differed
significantly from Freud’s, was Jung. Jung’s conceptualization of the formation of
personality is complex and focuses mainly on the role of the individual. However, central
to his theory is the concept of Individuation of the individual. This process of ‘self-
realization’, although intrapsychic in nature, cannot happen in a social vacuum. The
process requires the individual to interact with his environment, the most powerful part of
which is the family. The family plays a vital part in this path of Self-discovery by helping
shape some of the components of personality, such as the Archetypes, the Ego, as well as
interacting with the Attitudes of Introversion and Extraversion, to determine the level and
manifestation of the individual’s individuation.
Adler, in his Individual Psychological approach to personality, implicated the influence of
the family on the budding personality through his concept of the ‘Inferiority Complex’,
which he explained as the deep feeling of weakness, inadequacy and frustration
developed within a child as an inevitable result of his size and powerlessness in the face
of his environment in general, particularly his parents. Adler attributes virtually all
development and progress to this initial feeling of inferiority. An important aspect of this
development is the concept of Life Goals that are framed within each individual and
which provide a focus for achievement. These goals, though perhaps not consciously
chosen, are formed in childhood largely influenced by experiences, values and attitudes,

20
and therefore largely shaped by the family context. Other components of personality such
as the Self-concept, Self-ideal, Image of the world, and Ethical convictions that combine
to form an individual’s ‘Style of Life’, are also the result of experiences within the first
four or five years.
When discussing the role of the family in personality formation, one of the most relevant
theories to focus on would be that of Horney’s Feminine Psychology. Horney was one of
the first psychodynamic theorists to highlight the cultural factors involved in the
formation of personality. Initially her work focused on the female psyche and the forces
that shape the female personality. She proposed that the family was a key influence in the
shaping of the girl child and that the female’s entire personality and behaviour is
determined by this early shaping. However, Horney later moved away from her focus on
feminine psychology and developed more gender-neutral ideas involving the social and
cultural factors that she believed to mediate the formation of any personality, whether
male or female. This later theory proposed that ‘Basic Anxiety’, which was developed in
early childhood through the interactions between the child and the family, played a
central role in the adjustment of the individual as a whole.
A host of theories inspired by Horney’s early work on Feminine Psychology have now
come to be grouped together as the Feminist Approach to personality. And some of the
theorists most prominently associated with this approach are Jean Miller, Irene Stiver,
Judith Jordan and Janet Surrey. Over the years that the feminist approach has gained
momentum, these theorists have developed the Relational-Cultural theory to explain the
importance of relations in the development of the female personality. This theory
proposes that it is the relationships, especially the pattern of the early attempts to make
relationships that determine the nature of an individual’s personality and all future
interactions. This is proposed to be especially true of females, who are theorized to be
inherently oriented towards connectivity.
Most of the theories discussed so far were framed very early in the development of
psychology as a field and have been criticized as being obsolete. However, one of the
more recent theories to gain prominence within the psychodynamic approach is Erikson’s
Epigenetic Model of Human Development. The theory is based on the epigenetic
principle, which as explained by Erikson proposes that “anything the grows has a ground
plan, and that out of this ground plan the parts arise, each part having its time of special
ascendancy, until all parts have arisen to form a functioning whole.” Erikson proposed
eight stages through which the personality develops from infancy, each stage building on
the previous one. Each of these stages is also theorized to have a ‘Crisis’, or a critical
moment through which an individual’s skills are tested. The first four to five stages with
their respective crises form the foundations of an individual’s personality and are
mediated mainly by the influences of the family on the individual.
The Behaviouristic Approach
The Behaviouristic approach began with Watson, and was later popularized by theorists
such as Pavlov, Skinner, Mowrer and Bandura. The Behaviouristic approach as a whole
views an individual as essentially the sum of his behaviours. They emphasize the
malleability of these behaviours through the control of the stimuli that determine them.

21
This ‘black box’ approach was epitomized initially by Pavlov’s theory of Classical
Conditioning which proposed that repeatedly associating a neutral stimulus with one that
automatically elicits a response would result in the neutral stimulus also gaining the
power to elicit that same response. Pavlov proposed that this process of pairing stimuli
formed the basis of learning and that learning formed the basis of behaviour and
personality. A later theorist, Skinner proposed a similarly linear theory. He theorized that
any behaviour was strengthened or weakened based on the consequences resulting from
it. Therefore, he proposed that rewards or punishments determine behaviour, learning and
therefore, personality. Thus, both these theories do recognize that behaviour is shaped by
the environment and therefore, necessarily by the family at an early age. However, they
also propose that all behaviours are acquired throughout an individual’s lifetime and
therefore are changeable at any stage during the lifetime.
The theories of Pavlov and Skinner although providing the platform for the
popularization of Behaviourism, also faced significant criticism for their mechanistic
approach to understanding personality. Bandura’s theory brought a new focus to the
Behavioural school of thought. Bandura proposed that learning could be through
observation alone, rather than just first-hand experience or repeated practice. This implied
the mediation of cognition in behaviour. This theory of Observational Learning redefined
behaviourism and gave rise to the Cognitive approach.
The Cognitive Approach
Given impetus by Bandura’s theory, the Cognitive approach went a step further than the
observational learning theory, proposing that the key to understanding personality and
behaviour is the thoughts and beliefs acquired through the course of development. One of
the most prominent theorists connected to this approach is Beck. But before him, Piaget
and Vygotsky also proposed theories that redefined psychology. Piaget’s theory, although
more focused on tracing the cognitive development of an individual, does have
implications for the formation of a personality. He proposed that cognitive development
went through the following stages- Sensorimotor (birth-24months), Preoperational (2-7
yrs), Concrete Operational (6-11 yrs), and Formal Operational (11 yrs and above). Piaget
also put forward the concepts of cognitive Schemes and Structures, which play a part in
the process of Adaptation, in the form of assimilating aspects of the environment to one’s
schemes or accommodating one’s schemes to fit the environment. These schemes and the
resulting adaptation would be mediated mainly by the family environment.
The role of the family in personality development more directly addressed by the theory
put forward by Vygotsky. He proposed that any interpretation or organization of
experience is based on the utilization of shared socio-cultural symbols, and therefore
necessitated an inter-psychological space in which parents provide required cognitive
‘Scaffolding’. This Zone of Proximal Development involves the parent and the child and
would therefore determine personality formation.
One of the most influential theories within the Cognitive approach in recent times is the
theory proposed by Beck. Who proposed that the family environment, in combination
with early childhood experiences resulted in the development of certain patterns of
thinking (i.e. Schemas) that formed the foundations of personality. Thus, patterns of

22
reinforcements and punishment utilized by the family have a great impact on personality
genesis.
More recent theories that have risen to prominence include the Neo-Piagetian theories
such as that of Case, highlight the role of parental empathy in the development of
personality in children.
Attachment Theory
Growing out of the psychoanalytic emphasis placed on the log-term impact of the
mother-infant relationship, theorists like Bowlby and Ainsworth proposed that emotional
attachment between children and familiar care-givers mediated personal, social and
behavioural development of the child. They suggested that the early interactions between
these care-givers and the child determined the level of security internalized. It is this
initial internalization of security or the lack of it which determines later adjustment of the
individual.
Temperament
A concept that has gained increasing influence in the study of personality is
Temperament. Based on the work by Thomas and Chess, temperament can be understood
as the many sources of variation in affect, mood, and action influenced by the genetic
processes that emerge early in life. The extensive number of influences on brain and
nervous system development provide for a large variety in temperaments. There are
several approaches to the study of temperament itself out of which three of the most
influential are those proposed by Thomas & Chess, Rothbart, and Kagan.
Thomas & Chess proposed nine dimensions of temperament which include those related
to activity level, regularity of bodily functions, initial reaction to unfamiliarity etc.
Through these dimensions they suggested three types of temperaments- Easy, Slow-to-
warm-up, and Difficult. They later also introduced the concept of ‘Goodness of Fit’,
which was the match between the child’s temperament and the family ideal for the child.
Rothbart proposed that infants vary primarily on two temperamental dimensions- Ease of
arousal or reactivity (which include motor behaviour and physiologic responses) and
Self-regulation or mediation of this reactivity.
Kagan theorized that the differences in adjustment and achievement between shy
individuals and others in various domains, which have been consistently shown in several
studies, may be attributed to the temperamental categories of inhibited and uninhibited to
the unfamiliar. The first category is characterized by avoidance and suppression of
spontaneity to the unfamiliar, and the second by approach behaviour to the same
unfamiliar events.
RELEVANT RESEARCH
When reviewing the research so far one could categorise the studies in terms of the
variables analyzed. Research has studied the effect of the general family environment on
personality development, the effect of genetics on personality, studies have also focused

23
on Attachment theory, as well as Personality Disorders. Psychologists have also studied
the influence of rituals, rules and the effect of each parent on personality development of
the child.
General Studies
Lidz (1979) proposed that many of the most significant changes in concepts of
personality development and maldevelopment derive simply from belated appreciation
that the child grows up in a family; and that the child requires considerable positive input
from those who raise him to grow into a reasonably integrated person. It is of particular
importance to recognize that there is a very direct relationship between the family
transactions, the separation-individuation process, boundary formation, the attainment of
various degrees of object constancy, problems of splitting, superego directives, and what
can be conscious and what need be repressed into the unconscious. A study by
Aleksandrowicz, Aleksandrowicz (1975) described a girl who was studied by means of
the Brazelton Neonatal Behavioral Assessment Scale from her 1st until her 28th day of
life, observed at the age of 1 year, and, at the age of 1 1/2 years, was seen in a psychiatric
family interview. Carmel's continuous, inconsolable crying and lack of responsiveness led
to a family adjustment with the passive, somewhat disorganized mother moving into the
background and the anxious father taking over. He developed a way of keeping activity.
This physical stimulation, coupled with overprotection (the father's tendency to interpose
himself between the girl and other people) as well as controlling all frustration, resulted
in a precarious balance at the price of Carmel's reduced autonomy, delay in adaptive ego
functions, and severe stranger anxiety. The case illustrates the interaction between innate
characteristics and parental attitudes, and the need for preventive counselling based on
understanding a child's idiosyncratic behaviour patterns.
A study by Schill, Beyler, Morales, Ekstrom (1991) found that people scoring higher on
a scale of self-defeating personality perceived their family environments as lacking
cohesiveness. Men also perceived their family environments as discouraging open
expression of feelings, being unconcerned about school and work achievement, and
providing no ethical or religious values. Results were seen as lending validity to clinical
theories of masochism which relate lack of family support and lack of reinforcement for
assertive, efficacious behavior to the development of self-defeating behavior patterns.
And another study by Lazartigues, Morales, Planche (2005) showed how historical and
sociological approaches also allows us to examine some of the effects induced by
consensus and hedonism, the new familial parameters, on the child's life and
development. The modern family being classically founded upon duty (central value) and
the principle of authority to settle relationships between individuals, its main features are
opposed to those of the contemporary family. The latter, which started to emerge over the
sixties, is characterized by both the prevalence of parent-child relationships
symmetrization and the emergence of the search for immediate pleasure. The change
from parental authority to consensus as a principle ruling the relationships within families
leads to many consequences later noticed through changes in the construction of the
child's psyche along his development and in the relationships dynamics.

24
Genetic Studies
A study by Jang, Vernon and Livesley (2000) analysed the association between heredity
and antisocial personality traits, especially alcohol use. They found that heritable
personality factors that influence the childhood perception of the family environment
play a small role in the liability to alcohol misuse. Rather this liability to misuse alcohol
seems to be associated with genetic factors common to a specific subset of antisocial
personality traits describing conduct problems, stimulus-seeking and narcissistic
behaviours.
Kreuger, Markon and Bouchard (2003) in a study of retrospective accounts of family
rearing environments involving 180 reared-apart twins found that retrospective accounts
of family environments were partially heritable and all the heritable variance in
environmental measures could be accounted for by heritable variance in personality. In
addition, differences between twins in their accounts of their rearing environments
(nonshared environmental factors) were not significantly linked to differences between
twins in their personalities.

Attachment Studies
Using a sample of 304 adults Diehl, Elnick, Bourbeau & Labouvie-Vief (1998) examined
mean differences in family climate and personality variables on the basis of individuals'
attachment styles. Compared with adults with an insecure attachment style, persons with
a secure attachment style described their family of origin and their current family more
positively and scored higher on personality variables indicative of self-confidence,
psychological well-being, and functioning in the social world.
Brennan & Shaver (1998) used attachment theory to attempt to explain personality
disorders using a sample of 1407 non-clinical adolescents and adults. They found a large
degree of overlap between attachment patterns and personality disorders. However,
personality disorders akin to psychopathy seemed to have no significant association with
attachment patterns.

Personality Disorder Studies

In a study by Masiak, Gadamska, Gajewska-Zbiegień, Kobiałka, Kostrzewski,
Zmysłowska, (1983) a group of 50 patients were examined. In the clinical picture of
disturbances of the development of patients personality, the conduct disorders prevailed.
The suicidal and parasuicidal behaviour occurred in 1/3 of the patients. Also the
depressive and other neurotic symptoms took place. The intelligence level was average
and dull normal. The following personality features were established: emotional
instability, guilt proness , low self- sentiment , high ergic tension (both sexes); protension
( suspection jealous ), shrewdness (girls) and threat sensitive (boys). Patients attitudes
toward both parents were disturbed and unfavourable for normal personality
development. The declared mothers attitudes toward patients were also unfavourable for
development of mature personality.
In another study by Ernst, Klosinski (1989) a retrospective study of the patient histories
of 113 children and adolescents with the diagnosis "compulsive neurosis" were examined
in terms of the criteria personality development, family structure, frequency of certain
forms and contents of compulsory behavior, significance and symbolism of the

25
compulsive behavior within the family dynamics. Compulsive fears were most frequently
manifested in fears about the mother, followed by poisoning and hypochondriac fears.
Compulsive impulses were only found from prepuberty. In the girls they were always
directed to killing the mother. The analysis of personality development revealed that there
were indications of special features in the anal phase in only three cases. On the other
hand, special events of pathoplastic significance were found in half of the patients. In
about 33%, anancastic characteristics were present in the parents (eight parents were
manifestly subject to compulsive neurosis). Conflict avoidance and ambitious demands
on the children concerned were typical in the families. In contrast to the reference
population, the compulsively neurotic children and adolescents were of average
intelligence, frequently attended higher schools and belonged to a higher social class.
A study by Bonenberger, Klosinski, Zeitschrift (1988) on 103 pubertal patients with
anorexia nervosa found that symbiotically close mother-daughter relationship with
elements of aggression was found in about 75% of the subjects studied. In the fathers, the
autoritarian-dominant type predominated. Slightly less that 17% of the fathers could be
characterized as being weak and passive. Protestant patients were overrepresented in the
population studied, and brothers were underrepresented. Both the high percentage of
daughters who rejected their fathers in an aggressive way (33.3%) and the high
percentage with a pronounced oedipal problem with their fathers (44.5%) led us to
conclude that the father-daughter relationship has a significance which should not be
overlooked in the context of anorexia development and symptom-maintaining dynamic
features.
A study by Sameroff, Seifer, Zax, Barocas (1987) in which early indicators of
schizophrenic outcomes were sought in a group of children of chronically ill
schizophrenic women, a sample of pregnant women with varying degrees of mental
illness were examined during the perinatal period and recruited into a 4-year longitudinal
evaluation. It was found that found that a specific maternal diagnosis of schizophrenia
had the least impact. Neurotic-depressive mothers produced worse development in their
children than schizophrenic or personality-disordered mothers. Both social status and
severity/chronicity of illness showed a greater impact on development. Children of more
severely or chronically ill mothers and lower-SES black children performed most poorly.
These results do not support etiological models based on simple biological or
environmental transmission of schizophrenia. The role of social and family
environmental factors in predicting child cognitive and social-emotional competence was
further evaluated using a multiple risk index. Children with high multiple environmental
risk scores had much worse outcomes than children with low multiple risk scores.
And in a study by Klonsky, Oltmanns, Turkheimer, Fiedler (2000) on the relationships
between personality disorders and retrospective reports of family support and conflict
with parents involving 798 American Air Force recruits showed that in general, it does
not appear that individual personality disorders have unique relations with retrospective
reports of family adversity. Instead, the relation between personality disorders and family
adversity seems to depend on a component common to all personality disorders.
Studies on Rituals, Rules and Parents

26
In a study by Ford (1983), he proposed that rules provide the connection between family
process and individual behavior. They also constitute an integrated theory of families and
individual personality development.
Eaker and Walters(2002) conducted a study on 159 female undergraduates and found that
Family ritual satisfaction was positively related to late adolescent psychosocial
development and mediated the relation between family boundaries and psychosocial
development. Furthermore, the relation between personality (measured as
discontentedness, an aspect of neuroticism) and satisfaction with family rituals was found
to be mediated by family boundaries.
Tuttman (1986) raised the importance of the father’s role in the development of the male
child’s personality, especially in his capacity to mature and separate.

Criticisms and Future Directions

Not all research supports the importance of the effects of family environment on the
personality development of the individual. For example, Rowe (1990), in a review of
twin studies suggested that the individual differences between twins (both those reared
apart, as well as those reared together) may be due to factors other than family
environment. He found that non-intellectual traits were influenced mainly by genetic
influences as well as specific environmental influences that need not be parental or
familial. Intellectual traits showed modest family environmental influences, but these too
might decrease as the individual grows out of childhood.
Changes in family structure have also provided more recent areas of interest and research.
Single-parent families, as well as homosexual families are now increasingly common and
researchers have started to focus on these particular family situations, and their effects on
formation of personality. Agbayewa (1984) highlighted this issue in examining the case
of a six year old boy raised in a female homosexual family and its effect on the sex role
development. Although the results were inconclusive, the study did show that women
may function as fathers in a family.

References
Lidz, T (1979). Family studies and changing concepts of personality development
Canadian Journal of Psychiatry, 24, 621-623.
Aleksandrowicz MK, Aleksandrowicz DR (1975) The molding of personality: a
newborn's innate characteristics in interaction with parents' personalities. Child
Psychiatry and Human Development, 5, 231-241.
Schill T, Beyler J, Morales J, Ekstrom B (1991). Self-defeating personality and
perceptions of family environment. Psychological Reports, 69, 744-746.
Lazartigues A, Morales H, Planche P (2005). Consensus, hedonism: the characteristics of
new family and their consequences for the development of children. Encephale 31, 457-
465.

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Jang KL, Vernon PA, Livesley WJ (2000). Personality Disorder Traits, family
environment, and alcohol misuse: a multivariate behavioural genetic analysis. Addiction,
95, 873-888
Kreuger RF, Markon KE, and Bouchard TJ (2003). The Extended Genotype: The
heritability of personality accounts for the heritability of recalled family environments in
twins reared apart. Journal of Personality, 71, 809-833
Diehl M, Elnick AB, Bourbeau LS & Labouvie-Vief G (1998). Adult Attachment Styles:
Their relations to family context and personality. Journal of Personality and Social
Psychology, 74, 1656-1669
Brennan KA & Shaver PR (1998). Attachment styles and personality disorders: their
connections to each other, and to parental divorce, and to parental care-giving. Journal of
Personality, 66, 835-878.
Masiak M, Gadamska T, Gajewska-Zbiegień Z, Kobiałka E, Kostrzewski J, Zmysłowska
K (1983). Personality disorders in adolescents. , Problemy Medycyny Wieku
Rozwojowego, 12, 83-98.

Ernst H, Klosinski G (1989). Development and family environment in compulsive

neurotic children and adolescents: a retrospective and comparative study. Praxis Der
Kinderpsychologie Und Kinderpsychiatrie, 38,256-263

Bonenberger R, Klosinski G, Zeitschrift Für (1988). Parent personality, family status and
family dynamics in anorexia nervosa patients with special reference to father-daughter
relations (a retrospective study). Kinder- Und Jugendpsychiatrie, 16, 186-195
Sameroff A, Seifer R, Zax M, Barocas R (1987). Early indicators of developmental risk:
Rochester Longitudinal Study. Schizophrenia Bulletin, 13, 383-394.
Klonsky ED, Oltmanns TF, Turkheimer E, Fiedler ER (2000). Recollections of conflict
with parents and family support in the personality disorders. Journal of Personality
Disorders, 14, 327-338.
Ford FR (1983). Rules: the invisible family. Family Process, 22, 135-145.
Eaker DG, and Walters LH (2002). Adolescent satisfaction in family rituals and
psychosocial development: A developmental systems theory perspective. Journal of
Family Psychology, 16, 406-414.
Tuttman S (1986). The father's role in the child's development of the capacity to cope
with separation and loss. The Journal of The American Academy Of Psychoanalysis, 14,
309-322.
Rowe DC (1990). As the twig is bent? The myth of child-rearing influences on
personality. Journal of Counseling & Development, 68, 606-611.
Agbayewa MO (1984). Fathers in the newer family forms: male or female? The
Canadian Journal of Psychiatry, 29, 402-406.

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Frager R, Fadiman J (2006). Personality and Personal Growth. 6 th Ed. Perason, New
Jersey.

PARENTING STYLE
INTRODUCTION :
Each individual’s development is the result of a wide range of unique influences- genes,
parental practices, the social environment and the individual’s own reaction to these.
Each individual’s life is an “experiment of one” in the sense that influences are applied to
a person’s life in a way that can never be duplicated for someone else. Personality
development refers to how parts of personality and their organization grow and change
throughout the life span. The study of personality development emphasizes personality’s
major parts and their configurations. The developmental perspective focuses on how
those major parts develop and change over time. To understand personality development,
one must take into account factors like biological influences like temperament which
forms the building blocks of later traits and behavior, social setting concerns such as birth
order and family size, social interactions such as friendship and larger groups such as
parents and peer groups. The family of an individual exerts profound influence on his or
her personality formation. As the infant grows, the parent’s roles come into play as they
set examples and control the child’s behavior and environment.
PARENTING STYLES :

29
Diana Baumrind distinguished between two fundamental dimensions of parenting :
nurturance and control. Nurturance concerned the degree to which the parents supported,
cared for, and provided love for the child. Control concerned the degree to which the
parents influenced the child, dictating what the child must do and administering rewards
and punishments. Depending on whether the parents were low on both the dimensions or
high on both or high on one or other, four parental types can be identified (Maccoby and
Martin, 1983). Parenting styles emerge as an interaction between parents and children,
with the parenting influencing the child and vice versa.
Authoritative parents are both nurturing and controlling. These parents express care for
their children at the same time guiding their behavior through gentle discipline and rule
setting. They raise children who are friendly with peers and co-operative with adults. The
tend to self-controlled, independent and more achievement motivated (Baumrind, 1973).
As they reach adolescence, they show greater academic performance, more prosocial
behavior and less involvement in substance abuse than others (Radziszewska et al.,
1996).
Authoritarian parents are also controlling but tend to exercise control through setting
rules and enforce them through discipline. These parents employ relatively little
explanation or justification for their goals and are lower in nurturance, more generally.
They use more aggression and violence for control. In turn, they raise children who
themselves are more violent, have poor peer relations and who are at risk for being
bullied (Pettit et al, 1996). The children of these parents also suffer from lower self-
esteem, low empathy for others, and poorer adjustment at school (Krevans and Gibbs,
1996).
Permissive or indulgent parents are highly nurturing but fail to set limits or exercise
control over their children. These children have a sense of relative lack of social
responsibility and lack of independence (Baumrind, 1973).
Uninvolved or neglectful parents neither express caring for their children nor set limits
or exercise discipline. Their children seem to be at greater risk of lower self-esteem,
lower levels of some cognitive capacities and at risk of higher levels of aggression,
maladjustment and drug abuse (Weiss and Schwartz, 1996).

NURTURANCE

Responsive, Rejecting
Child centered Parent centered

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 Demanding
High on control Authoritative Authoritarian

CONTROL

Undemanding
Low on control Permissive Uninvolved

Family size : An important aspect in the family context is the number of siblings. In
larger families, each child has available a smaller fraction of the over all family
resources. As a consequence, parents may more often be forced into non-optimal
parenting styles because of the greater demands on their time (Steelman et al, 2002).
Larger families in which there is greater spacing between siblings show less of the
negative impact of family size.
Birth order : In Frank Sulloway’s (1996) view, siblings complete among one another for
limited resources in the family. First born children, because they are on the scene earliest,
often identify more closely with their parents than with other siblings. As a consequence
such first borns may be more comfortable with parental power relative to later children.
As they grow, this comfort may lea them to become more conservative, to uphold society
as it stands and favour the status quo. Later borns on the other hand, question authority
and are open to alternative ideas and power structure. In Sulloway’s terms, such later-
borns are “born to rebel”.
THEORIES OF PERSONALITY :
SIGMUND FREUD :
Freud was the first psychological theorist to emphasize the developmental aspects of
personality. He felt personality was pretty well formed by the end of fifth year and
subsequent growth consisted of elaborating this basic structure. According to him
personality develops in response to four major source of tension

 Physiological growth process

 Frustrations
 Conflict
 Threats

As a consequence of tension emanating from thee sources, the person is forced to learn
new methods of reducing tension. This learning is what is meant by personality
development.

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Identification and displacement are two methods by which the individual learns to resolve
frustration, conflicts and anxieties.
Identification: method by which a person takes over the features of another person and
makes them a corporate part of his/her personality. One learns to reduce tension by
modeling one’s behaviour after that of someone else. This takes place unconsciously. One
can identify with animals, imagery character institutions, abstract ideas and inanimate
objects as well as with other human beings. If identification helps reduce tension the
quality is taken over; if it does not, it is discarded. It is also a method by which one may
regain an object that has lost children who have been rejected by their parents tend to
form strong identifications with them in the hope of regaining their love. One may also
identify with a person in order to avoid punishment and out of fear. This kind of
identification is the basis for the formation of the superego. The final personality
structure represents an accumulation of numerous identification made at various periods
of the person’s life, although the father and mother are probably the most important
identification figures in anyone’s life.
Displacement: it is the ability to form substitute object- cathexis and is the most powerful
mechanism for the development of personality. The direction displacement takes in
determined by two factors:
1) Resemblance of the substitute object to the original one.
2) The sanctions and prohibition imposed by society. A displacement that produces a
higher cultural achievement is called sublimation. The complex network of interests,
preferences, values, attitudes and attachments that characterize the personality of the
adult human being is characterized by displacement.
The defense mechanisms of the ego are the extreme measures the ego takes to relieve the
pressure of excessive anxiety. The principal defenses are repression, projection, reaction
formation, fixation and regression. They have two characteristics in common
1) They deny, falsify or distort reality and
2) They operate unconsciously so that the person is not aware of what is taking place.
Fixation and regression are ordinarily relative conditions: a person rarely fixates or
regresses completely. These two are responsible for the unevenness in personality
development.

Freud’s Stages of Psychosexual Development

Sigmund Freud (1856-1939) is probably the most well known theorist when it comes to
the development of personality. Freud’s Stages of Psychosexual Development are, like
other stage theories, completed in a predetermined sequence and can result in either
successful completion or a healthy personality or can result in failure, leading to an
unhealthy personality. This theory is probably the most well known as well as the most
controversial, as Freud believed that we develop through stages based upon a particular
erogenous zone. During each stage, an unsuccessful completion means that a child

32
becomes fixated on that particular erogenous zone and either over– or under-indulges
once he or she becomes an adult.

Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral
pleasures (sucking). Too much or too little gratification can result in an Oral Fixation or
Oral Personality which is evidenced by a preoccupation with oral activities. This type of
personality may have a stronger tendency to smoke, drink alcohol, over eat, or bite his or
her nails. Personality wise, these individuals may become overly dependent upon others,
gullible, and perpetual followers. On the other hand, they may also fight these urges and
develop pessimism and aggression toward others.

Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on
eliminating and retaining feces. Through society’s pressure, mainly via parents, the child
has to learn to control anal stimulation. In terms of personality, after effects of an anal
fixation during this stage can result in an obsession with cleanliness, perfection, and
control (anal retentive). On the opposite end of the spectrum, they may become messy
and disorganized (anal expulsive).

Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud
believed that during this stage boy develop unconscious sexual desires for their mother.
Because of this, he becomes rivals with his father and sees him as competition for the
mother’s affection. During this time, boys also develop a fear that their father will punish
them for these feelings, such as by castrating them. This group of feelings is known as
Oedipus Complex ( after the Greek Mythology figure who accidentally killed his father
and married his mother).

Later it was added that girls go through a similar situation, developing unconscious
sexual attraction to their father. Although Freud Strongly disagreed with this, it has been
termed the Electra Complex by more recent psychoanalysts.

According to Freud, out of fear of castration and due to the strong competition of his
father, boys eventually decide to identify with him rather than fight him. By identifying
with his father, the boy develops masculine characteristics and identifies himself as a
male, and represses his sexual feelings toward his mother. A fixation at this stage could
result in sexual deviancies (both overindulging and avoidance) and weak or confused
sexual identity according to psychoanalysts.

Latency Stage (age six to puberty). It’s during this stage that sexual urges remain
repressed and children interact and play mostly with same sex peers.

Genital Stage (puberty on). The final stage of psychosexual development begins at the
start of puberty when sexual urges are once again awakened. Through the lessons learned
during the previous stages, adolescents direct their sexual urges onto opposite sex peers,
with the primary focus of pleasure is the genitals.
CARL JUNG:

33
Jung place emphasis upon the forward going character of personality development. He
believed that humans are constantly progressing or attempting to progress from a less
complete stage of development to a more complete one. According to him, the ultimate
developmental goal toward which people strive is summed up by the term self realization.
Self realization means the fullest most complete differentiation and harmonious blending
of all aspects of a humans total personality.
Though not very specific he described four general developmental stages:
Childhood: the child’s life is determined by instinctual activities necessary for survival.
Behaviour during childhood also is governed by parental demands. The emotional
problems experienced by young children generally reflect disturbing influences in the
home”
Young Adulthood: Puberty serves as the psychic birth for the personality. Child becomes
differentiated from his or her parents. The adolescent grapphes with issues of sexuality as
well as power or insecurity
Middle Age: People start to find a purpose for their lives and a reason for their existence.
They change from an extraverted to an introverted attitude, and they move towards self
realization.
Old Age: was regarded as a period of relative unimportance, when the old person
gradually sinks into unconsciousness.
Progression and Regression:
Development may follow either a progressive, forward movement or a regressive,
backward movement.
Progression: means that the conscious ego is adjusting satisfactorily both to the demands
of the external environment and to the need of the consciousness. When forward
movement is frustrated by circumstances, the libido is prevented form being invested in
extraverted or environment oriented values. Then the libido makes a regression into the
unconsciousness and invests itself in introverted values.
Development is an unfolding of original undifferentiated wholeness with which humans
are born to the ultimate goal of realization of selfhood. To have a healthy, integrated
personality, every system must be permitted to reach the fullest degree of differentiation,
development and expression. This is referred to as the individualism.

ALFRED ADLER:
He gave the concept of “style of life”. Style of life is the system principle by which the
individual personality functions; it is the whole that commands the parts. It is the
principle that explains the uniqueness of the person. It is about how a person confronts
the three “life problems”:- social relations, occupation, love and marriage. Four styles of

34
life described are: a)the rolling type, b)the getting type, c)the avoiding type and d)the
socially useful type.
Childhood Experiences: he was interested in the early influences that predispose the child
to a faulty style of life. He discovered three important factors:-
(i) children with inferiorities
(ii) spoiled children
(iii) neglected children
Children with physical and mental infirmities bear a heavy burden and are likely to feel
inadequate in meeting the tasks of life. However if they have understanding and
encouraging parents they may compensate for their inferiorities and transforms their
weakness into strength.
He spoke about the evils of pampering as he considered that the greatest curse can be
visited upon the child. Pampered children do not develop social feeling. They become
despots who expects society to conform to their self centered wishes.
Neglect of child also has unfortunate consequences. Badly treated in childhood, as adults
they become enemies of society. Thus three conditions- organic infirmity, pampering and
rejection- produce enormous conceptions of the world and result in a pathologic style of
life.
KAREN HORNEY:
He believed in interrelationships among people and transformed Freud’s instinctual focus
into a cultural focus. For Horney, concerns over security and over intrapsychic and
intrapersonal alienation provide the primary motivating forces for personality. She
suggested that anything that disturbs the security of the child in relation to his or her
parents produces Basic anxiety.
The insecure, anxious child develops various strategies by which to cope with its feelings
of isolation and helplessness. It may become hostile and seek to avenge itself against
those who have rejected or mistreated it or may become overly submissive in order to
win back the love that it feels it has lost. It may develop an unrealistic, idealized picture
of itself in order to compensating for it sense of helplessness and exploiting other people.
Or the child becomes highly competitive in which winning is far more important than the
achievement.
These strategies may become a more or less permanent fixture in the personality. He
introduced a list of ten needs that are acquired as a consequence of trying to find
solutions for the problem of disturbed human relationships. These are called neurotic
needs. These ten inner needs are the sources from which inner conflict develops. These
needs are unsatiable for neurotic.
All of these conflicts are avoidable or resolvable if the child I raised in a home where is
security, trust, love, respect, tolerance and warmth.

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HARRY STACK SULLIVAN:
Sullivan spelled out the sequence of interpersonal situation to which the person is
exposed in passing from infancy to adulthood. He conceptualized ix stage of
development.1) infancy 2) childhood 3) juvenile era 4) preadolescence 5) early
adolescence and 6) late adolescence.
Nursing during the infancy period provides the baby with its first interpersonal
experience with talk about interpersonal interaction with in and outside the family & its
impart on the development of the personality.

ERIK ERIKSON :

Erik Erikson (1902-1994) was interested in how children socialize and how this affects
their sense of self. Erikson’s Theory of Psychosocial Development has eight distinct
stages, each with two possible outcomes. According to the theory, successful completion
of each stage results in a healthy personality and successful interactions with others.
Failure to successfully complete a stage can result in a reduced ability to complete further
stages and therefore a more unhealthy personality and sense of self.

Trust vs Mistrust. From birth to one year, children begin to learn the ability to trust
others based upon the consistency of their caregiver(s). If trust develops successfully, the
child gains confidence and security in the world around him and is able to feel secure
even when threatened. Unsuccessful completion of this stage can result in an inability to
trust, and therefore a sense of fear about the inconsistent world. It may result in anxiety,
heightened insecurities, and an over feeling of mistrust in the world around them.

Autonomy vs. Shame and Doubt. Between the ages of one and three, children begin to
assert their independence, by walking away from their mother, picking which toy to play
with, and making choices about what they like to wear, to eat, etc. If children in this stage
are encouraged and supported in their increased independence, they become more
confident and secure in their own ability to survive in the world. If children are criticized,
overly controlled, or not given the opportunity to assert themselves, they begin to feel
inadequate in their ability to survive, and may then become overly dependent upon
others, lack self-esteem, and feel a sense of shame or doubt in their own abilities.

Initiative vs. Guilt. Around age three and continuing to age six, children assert
themselves more frequently. They begin to plan activities, make up games, and initiate
activities with others. If given this opportunity, children develop a sense of initiative, and
feel secure in their ability to lead others and make decisions. Conversely, if this tendency
is squelched, either through criticism or control, children develop a sense of guilt. They
may feel like a nuisance to others and will therefore remain followers, lacking in self-
initiative.

Industry vs. Inferiority. From age six years to puberty, children begin to develop a
sense of pride in their accomplishments. They initiate projects, see them through to
completion, and feel good about what they have achieved. During this time, teachers play

36
an increased role in the child’s development. If children are encouraged and reinforced
for their initiative, they begin to feel industrious and feel confident in their ability to
achieve goals. If this initiative is not encouraged, if it is restricted by parents or teacher,
then the child begins to feel inferior, doubting his own abilities and therefore may not
reach his potential.

Identity vs. Role Confusion. During adolescence, the transition from childhood to
adulthood is most important. Children are becoming more independent, and begin to look
at the future in terms of career, relationships, families, housing, etc. During this period,
they explore possibilities and begin to form their own identity based upon the outcome of
their explorations. This sense of who they are can be hindered, which results in a sense of
confusion ("I don’t know what I want to be when I grow up") about themselves and their
role in the world.

Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more
intimately with others. We explore relationships leading toward longer term commitments
with someone other than a family member. Successful completion can lead to
comfortable relationships and a sense of commitment, safety, and care within a
relationship. Avoiding intimacy, fearing commitment and relationships can lead to
isolation, loneliness, and sometimes depression.

Generativity vs. Stagnation. During middle adulthood, we establish our careers, settle
down within a relationship, begin our own families and develop a sense of being a part of
the bigger picture. We give back to society through raising our children, being productive
at work, and becoming involved in community activities and organizations. By failing to
achieve these objectives, we become stagnant and feel unproductive.

Ego Integrity vs. Despair. As we grow older and become senior citizens, we tend to
slow down our productivity, and explore life as a retired person. It is during this time that
we contemplate our accomplishments and are able to develop integrity if we see
ourselves as leading a successful life. If we see our lives as unproductive, feel guilt about
our pasts, or feel that we did not accomplish our life goals, we become dissatisfied with
life and develop despair, often leading to depression and hopelessness.

ATTACHMENT THEORY AND DEVELOPMENTAL PERSONALITY STYLES

Bowlby (1969) suggested that there were distinct qualities of the caregiver- child bond
that come to regulate children’s emotional experience and behavior. According to Bowlby
(1969), infants are equipped at birth with a biologically based behavioral and
motivational system that has evolved with the purpose of promoting to a care giver. From
an evolutionary perspective, the formation of close relationships serves to provide safety
and protection, ultimately increasing the infant’s chances of survival. When an infant
either becomes separated from his or her care giver or the bond is threatened in some

37
way, activation of this innate behavioral system results in characteristic proximity seeking
behaviors ( ex., crying). The care giver’s responses to these behaviors become
systematically organized into a goal-directed partnership between care giver and child.
According to Bowlby (1969), it is the extent to which the care giver is consistently
accessible and responsive to the infant’s bids for comfort and security that determines the
quality and type of attachment the child will have for the care giver which is central to
the infant’s comfort and security. The child’s experience of a positive, responsive
relationship with a caregiver or important others is a necessary precursor for healthy
exploration and adjustment. Persistent threats to the balance of this goal-directed
partnership lead to less adaptive ways of the child relating within the child-care giver
relationship and ultimately in the way the child is able to relate to the outside world.
Mary Ainsworth and her colleagues’ (1978) research with the Strange Situation Protocol
helped to establish four commonly accepted child-care giver attachment patterns : secure,
anxious-ambivalent, avoidant and disorganized.
Securely attached infants explore their environment, looking back at their care giver
periodically. They show some distress when separated but are easily comforted upon
reunion. These infants seem to experience their attachment figure as available and
responsive. The child- caregiver relationship is characterized as a secure base to which
the child eels safe to return or comfort when exploration becomes particularly anxiety
provoking or uncomfortable.
Anxious- ambivalent infants typically do not explore their environment and instead
choose to cling to their care givers (Ainsworth, 1985). They display extreme agitation
upon separation. Upon reunion, these infants seek contact while arching away from the
care giver, resisting all efforts to be comforted. These infants seem to perceive the
attachment figure as either inconsistently available or unresponsive when needed.
Avoidant infants display a pervasive indifference before and after separation (Ainswoth,
1985). These children avoid their caregiver upon his or her return. In these relationships,
the infant’s bids for comfort and protection have presumably been rebuffed or rejected.
Main, Kaplan and Cassidy (1985) proposed a fourth attachment pattern, disorganized
attachment, to describe infants who displayed a pronounced mixture of ambivalent and
avoidant patterns of behavior.
Infants develop working models or cognitive expectations about the accessibility and
responsiveness of their caregiver as well as their own ability to elicit need-meeting
responses from their caregiver (Bowlby, 1973). A working model of self is an evolving
schema of how children view themselves based on their role in the attachment
relationship. One’s internal working model of self is a set of beliefs about one’s
worthiness and competence as an individual. Working models of others are believed to be
derived from the original working models of primary caregivers and are thought to
eventually generalize to a broader base of expectations about others and the world.
The confirmation of early working models in the form of later attachment experiences
contribute to the persistence of these models. Environmental pressures are due largely to

38
the fact that the family environment in which a child lives and grows tends to remain
relatively unchanged. This means that whatever family pressures led to the development
of a child to take the pathway he is now on are likely to persist and so to maintain
development on that same pathway.
A second source of continuity of attachment patterns is the way in which the personality
structure becomes self-confirmatory over time through the operation of assimilative,
feedforward mechanisms (Lyddon, 193; Mahoney, 1991). Feedforward processes actively
anticipate and constrain experiences to assimilate them into already held beliefs. Such
mechanisms serve to “fit” new experiences into existing cognitive constructions and are
relatively inflexible to new information.
Working models of secure individuals reflect a relative balance between feedforward
(assimilative) and feedback (accommodative) processes, and as a result, the secure self-
system is relatively flexible and open to change and new learning (Mikulincer, 1997).
The elf-systems of insecurely attached individuals, on the other hand, tend to be
relatively closed to new information and tend to operate primarily in an assimilative
mode and have often foreclosed around a few salient themes such as dependence,
mistrust or personal worthlessness.
Attachment researchers have extended their study of attachment to the developmental
periods of adolescence and adulthood. One of the more popular and widely researched
models of adult attachment is that developed by Bartholomew (1990) who proposed a
four category system of adult attachment that organizes a person’s working models along
two dimensions:
a) distinction between self and others
b) valence (positive versus negative)
The intersection of these dimensions lead to four protoypical styles of adult attachment :

 Secure ( positive view of self and others)

Secure individuals possess a sense of self-worth coupled with an expectation that
other people are generally trust worthy, accessible and responsive.

 Preoccupied (negative view of self and positive of others)

Those with preoccupied attachment style possess a sense of personal
unworthiness combined with a positive evaluation of others. These individuals
tend to be very eternally oriented in their self-definitions.

 Dismissing (positive view of self, negative view of others)

Those with a dismissing attachment style are characterized by a sense of self that
is worthy and positive combined with a low evaluation or mistrust of others.

 Fearful (negative view of self and others)

They exhibit a sense of personal unworthiness combined with an expectation that
other people will be rejecting and untrustworthy. These individuals trust neither
their own internal cognitions or feelings nor other people’s intentions.

39
Bartholomew(1990) specified that her model does not assume that all individuals are
expected to exhibit a single attachment style, rather it is more appropriate to view adult
attachment multidimensionally, with individuals exhibiting one or more dimensions as
predominant.
Attachment theory, as a developmentally based model of personality formation, also
lends itself to a developmental conceptualization of personality disorders.
The insecure dimensions of Bartholomew’s model provide an attachment theory
framework from which to understand the organizational features of the working models
associated with those who are diagnosed with personality disorders.
Preoccupied Attachment Dimension
This dimension is characterized by a sense of personal unworthiness and a positive
evaluation of others. Developmental personality styles that seem to exemplify this
dimension of attachment include dependent, obsessive-compulsive and histrionic.
Dependent personality style : People with dependent personality style usually lack
assertiveness and self-confidence. Their interpersonal behavior is usually clinging,
compliant, pleasing, and self-sacrificing. Developmentally, their family history is often
characterized by overprotective caregivers who relay a message to them that they are not
capable of accomplishing things on their own. Overtime, these individuals begin to
construct a view of themselves as personally inadequate, exemplified by the core belief
that others are in their life to take care of them.
Obsessive compulsive personality style : They typically demand perfectionism from
others as well as for themselves. Such behaviors can be traced developmentally to
parenting styles that demand achievement. Caregiver love is often contingent on such
achievement, and parent-child interactions tend to characterized by parental over-
involvement (Ivey, 1991). As a consequence, the child eventually internalizes extremely
high perfecitonistic standards and develops a view of self that is reliable, competent and
righteous (Ingram, 1982). However, the child also comes to believe that if something
goes wrong, he or she is responsible. Because the parental figures are often
perfectionistic as well, the individual’ views of others are grounded on that perfectionism.
However, these children are rarely able to live up to their parent’s expectations.
Therefore, they ultimately develop a view of themselves that is inherently negative
because, although they see themselves as reliable and competent, they continually fall
short in the eyes of the parental figure.
Histrionic personality style : This style is relevant to the preoccupied dimension of
attachment. Parenting styles experienced by these individuals are usually enmeshed and
engulfing and convey to the child the message that: ‘If you do what I want, I will give
you my attention’. Because atleast one of the child’s parents often exhibits histrionic
features as well, lability, eccentricity and superficiality, features of histrionic personality
style, are model for the child. These parental characteristics may also contribute to
minimal or inconsistent disciplining, forcing the child to use extreme measures to be

40
noticed. Failure to elicit need-meeting behaviors from parental figures tends to contribute
to a negative self-view.

Preoccupied and Fearful attachment dimensions:

Avoidant personality style: These individuals seem to incorporate both preoccupied and
fearful attachment dimensions. These individuals tend to have a self-view that is negative
and an other-view that vacillates between positive and negative. Their family history is
characterized by either an engulfing or avoidant parenting style (Sperry & Mosak, 1996).
With an engulfing parent, the child may feel overwhelmed by the responsibility of such a
high level of emotions within the relationship. The opportunity for autonomy diminishes.
As the child grows older, he or she desires closeness with others but fears that such
intimacy may become engulfing. As a response, such interactions are avoided. With an
avoidant parenting style, the child develops a fragile sense of self and ultimately fears the
same type of rejection from other people in their life. The assumption is that it is better to
avoid relationships than to risk being rejected again.
Fearful Attachment dimension
Paranoid personality style: Family histories of individuals with paranoid personality
style typically include some form of active rejection and persecution by cargivers coupled
with a critical and vigilant approach to parenting. Caregivers also tend to be
perfectionistic in their expectations. The core message they relay to the child is ‘You are
different, don’t make mistakes’ (Sperry and Mosak, 1996). Persecution and criticalness
that dominates the caregiver-child interaction results in negative working models of self
and others and a pervasive mistrust in other people (Thompson-Pope and Turkat, 1993).
Fearful and Dismissing Attachment dimensions :
Antisocial personality style: They distrust others and often exploit and manipulate others
for their own personal gain. The family history of individuals with this personality style
is often marked by parental hostility and probable abuse. These experiences convey the
message that ‘the end justifies the means’ (Sperry & Mosak, 1996). Much of their own
vindictive behavior is learned from their caregivers. Overall, there is little affection and
nurturance in the home and the child is forced to be self-reliant. The view of the self
wavers between negative which is likely the result of messages translated from abuse and
lack of nurturance in the home and alternatively a positive view of self that often
develops, possibly as a defense in reaction to this negative view and may lead to a sense
of personal entitlement. Initially created in the context of vindictive, abusive and
unloving interactions with their parents, the view of others is ultimately transferred to
others in general.
Narcissistic Personality style: Family histories of those with this personality style are
often characterized by parental over evaluation and indulgence (Sperry & Mosak, 1996),
with parental approval and affection often tied to personal accomplishments rather than
the self (Ivey & Ivey, 1998). In general, the parental injunction they receive is ‘You are
special, unique and entitled to extraordinary rights and privileges.’ Because of the

41
discrepancy between their inflated view of themselves and their diminished view of
others, they tend to have a negative and disdainful working model of others. Although
they may behave outwardly with overzealous confidence, this is often a mask for the
intense insecurity they often feel. Their care givers give them the message that others owe
them admiration and privilege. As this view collides with fragile view if self, defense
mechanisms that protect the fragile self-system are strengthened and their narcissistic
behavior becomes more apparent to others.
Schizotypal personality style : The parenting style typical of their developmental history
is cold and derogatory. Ineffective and easily misinterpreted parental communications are
common, typified by the message ‘ You are a strange bird’ (Sperry & Mosak, 1996). This
parenting style leaves the individual feeling different without a sense of self, empty,
estranged and depersonalized (Millon, 1981). These developmental antecedents
encourage the person to become independent on others while fearing that others have
negative intentions. As a result, their view of others is predominantly negative.
Dismissing Attachment dimension
Schizoid personality style: The developmental histories of these individuals tend to be
characterized by experiences with caregivers who are rigid, emotionally unresponsive,
and undersocialized in interpersonal skills (Thompson-Pope & Tirkat, 1993). Parental
behaviors and interactions tend to convey to the child the message ‘who are you, what do
you want?’ These interactions lead to a view of the self that reinforces this difference
from others while it decreases their immediate need for interaction with others. This rigid,
unresponsive developmental history helps to create the belief ‘others are indifferent and
the world is difficult, so why try to establish relationships?” These individuals are not
bothered by their lack of interpersonal relationships and therefore can be conceptualized
with a positive self-view.
Disorganized Attachment dimension :
Borderline personality disorder: Individuals with this personality style exhibit a unique,
unstable and dynamic personality structure that tends to shift among the various insecure
attachment dimensions creating a disorganized profile. Caregivers are often overprotective,
demanding, or inconsistent, providing the child with little or no sense of stability or structure
with which to regulate emotions. Furthermore, physical or sexual abuse or both, are often noted
and some researchers even speculate that because of the inconsistent availability of caregivers
during traumatic childhood events, the emotional neglect and absence of surrogate adult
attachment figures may be as powerful as the actual childhood traumatic event in the
development of the personality style (Sabo, 1997). These experiences translate into a self-other
view that is dominated by inconsistency and a general inability to define both themselves and
others as either positive or negative. The accompanying inconsistent behaviors they exhibit often
lead others to be either reactive or avoidant of them, which tends to further perpetuate their
disorganized self-other views.

Attachment Dimensions Personality styles

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Preoccupied Dependent
Obsessive compulsive
Histrionic

Preoccupied and fearful Avoidant

Fearful Paranoid

Fearful and Dismissing Antisocial

Narcissistic
Schizotypal

Dismissing Schizoid

Disorganized Borderline

Psychopathology and Family:

Eating disorders:
Eating disorder symptoms have been thought to reflect adaptations to problematic family
interaction patterns. Anorexia nervosa is construed as the individual’s adaptation to
familial over protectiveness and intrusions, conceptualizing food refusal as a child’s
means of self-assertion, in the face of excessive familial controls or emotional
investment. Palazolli (1978) emphasizes familial problems around interpersonal

43
boundaries and difficulties with separation and autonomy that draw the anorexic into
feeling excessively responsibility for her parents’ happiness or guilt around the demands
her needs create. Minuchin et al., (1978) addresses familial enmeshment, over
protectiveness, rigidity and problems around conflict resolution. Such processes are
conceived to cause children to deny their needs or to resort to over controlled eating to
express frustrations and assert self-control in the family environments that otherwise do
not allow autonomous expression. Models of Bulimia nervosa convey a view of child’s
frantic struggles to satisfy needs in disengaged or neglectful families. Humphrey (1991)
formulated bulimic syndrome in terms of family-wide deficits in nurturance and tension
regulation and systems that ensnare members in mutually destructive, hostile projections
(or blaming). The bulimic eating pattern is conceived to play a role in self and mood-
regulatory function.
Anxiety
A number of studies have indicated that maternal anxiety may contribute to the
development of anxiety symptoms in the child (Hayward and Wilson, 2004). Maternal
stress and parental irritability were significant predictors of child behavior problems
(Holden and Richie, 1991).
Schizophrenia
The family influences the outcome of the disorder through negative comments and
nonverbal actions. These particular interactions between family members that are dealing
with a patient with a psychological disorder are stressful on the recovering patient. The
stress from the family for the patient to recover and end certain behaviors causes the
person a relapse in their illness (Vaughn & Leff, 1976). Factors such as communication
deviance, expressed emotion an affective style have shown to affect the course of the
illness.
Parenting and Behavior Problems :
Children from violent families were reported to have more internalizing behavior
problems, more difficult temperaments and tend to be more aggressive than the
comparison children (Holden and Richie, 1991).
Psychological development in a child was closely related to proximal environmental
variables uch as stimulating child-rearing practices rather than macro-environmental
factors such as residence, parental education and income (Kapur, Girimaji, Prabhu,
Reddy and Kaliaperumal, 1994).
Aggressive adolescents were more likely to come from homes with increased marital
conflicts and negative parenting such as hard punishments, rejection, intimidation as well
as physical and verbal abuse (Talwar, 1998)

44
 CHARU GUPTA
SUBMITETD TO: DR M P SHARMA

PSYCHO-SOCIAL ASPECTS OF OLD AGE

During the 20th century life expectancy has increased dramatically in developed as well as
developing countries with people all over the world enjoying a longer life expectancy
than their predecessors. Census trends show that India is entering the ‘age of the aged’. It
is estimated that within the next 50 years, approximately 30% of the world population
will be aged 65 years or aged; more importantly by the year 2025, 70% of world’s aged
population will be living in developing countries (Indian Council of Medical Research,
2008). Three-forth of India’s elderly are ‘young old’ (between 60-70) and the remaining
‘old old’ (over 70) (Venkoba Rao, 1993).

In common practice, developmental psychology refers to the differentiation of the

organism up to the age of physical maturity, and ageing refers to changes or
differentiation after the age of physical maturity. In simple terms, Aging refers to the
biological, social, economic and cultural changes that take place along with passage of
time in an individual. The study of aging in all of its aspects including biological,
psychological and sociological is known as science of Gerontology.

In developing countries those aged 60 years and above are considered as the aged or
elderly, while in the developed countries all those aged 65 years and above come in this
category (Reddy, 1992).

It is difficult to define normal aging, since many changes observed in older adults and
previously perceived as concomitants of normal aging are now recognized as effects of
disease in later life. The behavioral science view allows for incremental as well as
decremental changes with aging.

Handler (1960) has defined aging as “the deterioration of a mature organism resulting
from time-dependent, essentially irreversible changes intrinsic to all members of a
species, such that, with the passage of time they become increasingly unable to cope with
the stresses of the environment, thereby increasing the probability of death”

There have been different viewpoints on ageing.

Biological Aging: From the biological viewpoint, aging is the progressive loss of
functional capacity after an organism has reached maturity. Decline in functioning can be
separated into:

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Primary aging (Senescence): A biological phenomenon the cause of which is rooted in
heredity. The inborn causes of age changes produce inevitable decremental changes that
are time related but are etiologically relatively independent of stress, trauma or disease.
Senescence is not always equated with aging; it is viewed as the increasing vulnerability
or decreasing capacity of an organism to maintain homeostasis as it progresses through its
life span. According to Comfort (1956) senescence is a change in the behavior of an
organism with age, which leads to decreased power of survival and adjustment.
Secondary aging: It refers to defects and disabilities whose first cause comes from hostile
factors in the environment, particularly trauma or disease (Busse and Blazer, 1980)

Biological Characteristics of Aging:

There is evidence supporting at least 5 common characteristics of aging in mammals:

1. Increased mortality with age after maturation.

2. Changes in biochemical composition in tissues with age.
3. Progressive decrease in physiological capacity with age.
4. Reduced ability to respond adaptively to environmental stimuli with age.
5. Increased susceptibility and vulnerability to disease.

Psychological Age: According to Birren and Renner (1977) the psychological age refers
to “the adaptive capacities of individuals, that is, how well they can adapt to changing
environmental demands in comparison with the average.” It is influenced by the key
organ systems like the brain and the cardiovascular system, but it also involves the study
of memory, learning, intelligence, skills, feeling, motivation and emotions.

Functional Age: The concept of functional age is closely related to the psychological
age. It is an individual’s level of capacities relative to others of his age for functioning in
a given human society.
Social Age: Social age refers to “the roles and social habits of an individual with respect
to other members of a society” (Birren and Renner, 1977).

Indigenous concepts of aging in India

Maharishi Manu (100 BCE – 100 CE) has described the ideal framework of organizing
life in terms of age and class specific duties (‘varnasrama dharma’) in one of the Hindu
Dharmashastras called “Manusmriti”. The four stages of life (Asrama) were identified as
follows:

 Bhramacharya: Student life or the life of a celibate

 Grhastha: The life of a householder

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  Vanaprastha: The life of a hermit
 Samnyasa: The life of a wandering ascetic (Yati)

Manu considered human life span to be of one hundred years, with each stage consisting
of a duration of 25 years.
According to Tilak (1997), the stage of life model suggests the epistemological,
emotional and ethical developments in the human being during the entire life span. This
model sees later years of life as an integrative period continuous with early years in some
ways and yet distinct. The task of meaningfully integrating and relating one’s life as it has
been lived and find acceptance of death is specific concerns of later existence. In terms of
goals of life one strives for, youth and middle age are for fulfilling the worldly ends and
old age is for spiritual liberation (Moksa)
Ayurvedic View of Old Age and Death: Ayurveda considers ‘Jara’ or old age as normal
and natural (Svabhavika). The word ‘Jara’ itself is derived from roots meaning ‘running
out of the years of a person’ and ‘changes occurring with the passage of time’. Two of the
ancient Indian physicians, Caraka and Susruta considered aging as a disease. The stages
involved in the aging process were accumulation of the humor of wind; vitiation with
abnormal increase in its proportion; diffusion-spreading of the deranged humor to all
parts of the body; localization – undermining the entire organs; manifestation – process of
aging becoming visible; rupture – aging process mediating between life and death and
culminatind in death. Several factors such as force of time, inherent tendency,
imprudence, volitional transgressions are considered responsible for aging.
One of the branches of Ayurveda as given in Caraka Samhita is “Rasayana Chikitsa” –
rejuvenation. This is a branch dealing with gerontological treatment.
Theories of aging
There is no composite theory of ageing, but numerous theories have been proposed and
advanced to explain how and why living organisms age and die.
As already noted, aging involves phenomena of varied nature from physiological to
psychological changes as well social problems involving interaction between different
age groups (Shock, 1977).

Biological Theories

Biological theories of aging can be classified on the basis of predisposing factors as

intrinsic (primary aging) or extrinsic to the organism (secondary aging). The former are
the developmental genetic theories, while the latter are called stochastic theories.

47
Developmental-Genetic Theories

Developmental-genetic theories consider the process of aging to be part of the genetically

programmed and controlled continuum of development and maturation. Although this is
an attractive notion, the diverse expression of aging effects is in sharp contrast to the
tightly controlled and very precise processes of development. This class of theories is
supported by the observation that the maximum lifespan is highly species specific.

The Genetic Theory: The premise of the genetic theory is that genes are categorized as
juvenescent or senescent. Juvenescent genes promote and maintain growth and vigor
through the adult years, while senescent genes become active in middle adult and later
years and initiate a process of decline and deterioration. Empirical evidence to support
the theory of this “aging gene” is lacking.

The Biological Clock Theory (Schneider and Rowe, 1990) suggests that an organism’s
development and subsequent decline are regulated by some programmed internal genetic
clock. This internal clock runs down over a predetermined length of time. Supporters of
this theory point to certain normal physiological changes in humans that appear to be
correlated with time, such as graying hair and menopause, etc. One limitation of the
theory is its inability to generalize in vitro and in vivo studies. Second, the theory does
not explain what factors trigger the end of the cellular replication and the beginning of
cellular degeneration. It also does not explain extreme cases of longevity

Neuro-endocrine Theory: The neuroendocrine theory proposes that functional

decrements in neurons and their associated hormones are central to the aging process. An
important version of this theory holds that the hypothalamic-pituitary-adrenal (HPA) axis
is the master regulator of aging in an organism. Because the neuroendocrine system
regulates early development, growth, puberty, control of the reproductive system,
metabolism, and many other aspects of normal physiology, functional changes in this
system could exert effects throughout the organism. The decline in female reproductive
capacity is an obvious neuroendocrine age-related change. Many human studies
demonstrate gradually decreasing levels of peripheral hormones accompanied by normal
levels of trophic hormones. This suggests either increased response to the peripheral
hormones by the HPA axis or inappropriately low expression of the stimulating hormone.
However, many organisms with aging phenotypes similar to those of higher vertebrates
lack complex neuroendocrine systems. The changes that occur in the neuroendocrine
system may be due to fundamental age-related changes in all cells and may therefore be
secondary manifestations of the aging phenotype.

Immunologic Theory: The immunologic theory of aging is based upon two main
observations: (a) the functional capacity of the immune system (antibody production)
declines with age, as evidenced by a decreased response of T cells to mitogens and
reduced resistance to infectious disease; and (b) autoimmune phenomena increase with
age, such as an increase in serum autoantibodies. The result is that the body’s ability to
differentiate between normal and abnormal or foreign substances fails. This response is
sometimes seen in cases of tissue rejection in organ transplantation.

48
Although the immune system obviously plays a central role in health maintenance and
survival, similar criticism can be directed at the immunologic theory as has been directed
at the neuroendocrine theory. Complex immune systems are not present in organisms that
share aspects of aging with higher organisms. In addition, the inability to distinguish
between fundamental changes occurring in many types of cells and tissues, not just those
of the immune system, and the secondary effects mediated by the aging-altered immune
system, make interpretation of this theory difficult.

Stochastic Theories

Error-Catastrophe: Error Theory (Hayflick, 1985): It explains the development of

harmful genes that interfere with biological processes such as protein synthesis. Damage
to biological synthesis results in the development of damaged cells that interfere with
normal biological functions. The proliferation of cancerous cells is an example of a
process in which normal cells become aberrant through some error process.

Cross Linkage Theory: Collagen tissue, as important component of connective tissue

that maintains the structure of cells, tissues, and organs, undergoes changes with aging.
Collagen provides elasticity necessary in many types of tissue such as cardiac and
muscle. With age, the combination of chemical changes and external stimuli cause the
formation of molecular bonds in collagen called cross-links, which tend to stabilize the
collagen fibers resulting in rigid, fragile tissue. Scientists do not understand the
mechanism that triggers the formation of cross-links, but it is believed that the most
active period of cross-link development is between 30-50 years of age.

Cross-links also form in elastin in connective tissue. Elastin is similar to collagen in that
maintains tissue flexibility and permeability. The effects of cross-linking in elastic fibres
are most pronounced in the changes in facial skin with aging. Skin becomes brittle, dry,
saggy, and appears translucent. The formation of cross-links in probably not the sole
cause of aging, but structural and functional changes associated with aging are impacted
by collagen alterations at the cellular level.

Free Radical Theory: Biologists theorize that some environmental stimuli such as
radiation, ozone, and certain chemicals interfere with cellular activity, resulting in the
production of free radicals, which are compounds produced in cells as a result of
environmental stimuli. They may interact with various cellular structures, causing
damage to normal cellular function. Free radicals are also formed during the normal
process of cellular oxygenation when the cell removes waste products. Although the cell
is capable of neutralizing and removing such by-products, it is theorized that over time
the cell loses its capacity to eliminate waste and repair itself. Researchers are continuing
to study potential effectiveness of antioxidants, such as vitamin A, C, and E, in protecting
cellular structures (Packer and Glazer, 1990)

Somatic Mutation and DNA Repair: Stochastic theories propose that aging is caused by
random damage to vital molecules. The damage eventually accumulates to a level
sufficient to result in the physiological decline associated with aging. The most prominent

49
example is the somatic mutation theory of aging, which states that genetic damage from
background radiation produces mutations that lead to functional failure and, ultimately,
death. Exposure to ionizing radiation does shorten lifespan.

The DNA repair theory is a more specific example of the somatic mutation theory. The
ability to repair ultraviolet-radiation-induced DNA damage in cell cultures derived from
species with a variety of different life spans correlates directly with the Maximum Life
Span Potential (MLSP). Unfortunately, there is not enough experimental support to
conclude that these differences between species are a causative factor in aging. The
cumulative evidence indicates that overall DNA repair capacity does not appear to change
with age, although the site-specific repair of select regions of DNA appears to be
important in several types of terminally differentiated cells.

Protein Modification: In addition to age-related changes in the steady-state levels of

proteins, qualitative alterations leading to changes in function occur. Aging is
accompanied by decreased specific activity in many enzymes, altered heat stability, and
increased carbonyl content of proteins. These changes can be caused by direct oxidation
of amino acid residues, metal-catalyzed oxidation, modification by lipid oxidation
products, and glycation. Kohn and Bjorksten hypothesized that the accumulation of post-
translationally altered proteins could impair cellular, and ultimately, organ function.

Sociological Theories of Aging

Disengagement Theory

It was the first sociologic theory developed by social gerontologists beginning with an
exploratory study by Henry and Cumming (1961) of 275 healthy financially
stable person between the age of 50 and 95 living in Kansas City. They theorized
that a process of mutual withdrawal naturally occurs between the aging
individual and society which is inevitable and universal in its occurrence. The
retirement process is an example of this disengagement.

The theory can be summarized as follows:

 It refers to an inevitable process in which many of the relationships between a

person and other members of society are severed & those remaining are altered in
quality.
 Withdrawal may be initiated by the aging person or by society, and may be partial
or total.
 It was observed that older people are less involved with life than they were as
younger adults.
 As people age they experience greater distance from society & they develop new
types of relationships with society.

50
In developed countries there is evidence that society forces withdrawal on older people
whether or not they want it.

The theory has been criticized on its presumed universality and on the fact that it does not
allow for biologic or personality differences between individuals. The effect of on the
elderly person (regardless of the initiator – individual or society) may be positive or
negative depending on the degree of preparedness and acceptance by the individual.

Havighurst, Neugarten and Tobin (1968) found that individual personality traits and past
experiences influence how an individual and society adapts to aging (for example, a
withdrawn person will continue to withdraw after aging). They also state that society at
times makes efforts to engage the elderly such as part time or consultant jobs for the
retired.

Continuity Theory

The continuity theory developed out of Havighurst’s reformulation of the disengagement

theory. It’s basic premise is that people adapt best when they are allowed to be who they
are and that, with aging, people become “more like themselves”, that is, as one ages, he
or she attempts to maintain continuity and consistency of habits, beliefs, norms, values
and other aspects of personality. The theory states that older adults try to preserve and
maintain internal and external structures by using strategies that maintain continuity.
Thus, older people may seek to use familiar strategies in familiar areas of life. They tend
to use continuity as an adaptive strategy to deal with changes that occur during normal
aging.

Continuity theory has excellent potential for explaining how people adapt to their own
aging. It allows for individual differences in the aging process, and theorizes that each
individual’s personality contains a self-maintaining component, meaning that one’s long
standing behavior patterns enhance coping and adjustments to new situations across the
life span (Atchley, 1989)

Activity Theory

Activity theory emphasizes the importance of ongoing social activity and states that an
active lifestyle and social roles offset the negative effects of aging. The theory suggests
that a person's self-concept is related to the roles held by that person i.e. retiring may not
be so harmful if the person actively maintains other roles, such as familial roles,
recreational roles, volunteer & community roles. To maintain a positive sense of self the
person must substitute new roles for those that are lost because of age. And studies show
that the type of activity does matter, just as it does with younger people. By retaining a
high level of participation in one’s socio-environment, elderly individuals would report
higher level of overall life satisfaction and a more positive self concept.

Four propositions were initially identified in the conceptualization of the activity theory
(Lemon et al, 1972):

51
  The greater the loss in social roles (both formal and informal), the less the activity
participation.
 The more activity maintained, the greater the social role support for the older
person.
 Maintaining stability of social roles supports one’s positive self concept.
 The more positive the person’s self concept, the greater the degree of life
satisfaction experienced.

Wider acceptance of the activity theory is hindered by the lack of empirical evidence to
support these postulates. The importance, type, and availability of a particular activity as
perceived by the elderly person is an important consideration affecting self concept and
life satisfaction. The activity theory may apply to those elderly who enjoy and have
opportunity to participate in meaningful activities and social interactions.

Psychological Theories of Aging

Life Stage Theories

Several life stage theories have been advanced over the past several years. These theories
divide the life span into a series of sequential transitions linked with the achievement of
an age appropriate developmental task at each stage.

Levinson’s life stage theory of human development focused on an individual’s shift from
one stage to another being guided by a mentor who was usually at least 10 years older
than the individual. The mentor may be anyone significant to an individual, no
necessarily a blood relative. Levinson’s theory is limited in its application to the elderly,
as the last shift described is that of ages 35 to 45 years. Levinson described this shift as
comprising midlife crises and the end of youthful dreams.

Carl Jung’s life stage theory (1971) was based on psychoanalytic theory that states that as
one goes through life, he or she develops inner exploratory abilities that add meaning to
life. He also postulated that personality differences between males and females become
less distinct as people age. The final life stage deals with maintaining a balance between
wisdom and senility in old age. The elderly person who is successful in life does not
attempt to compete with youth, but rather is able to deal with age changes.

A Summary of Major Theorists’ Views on the Developmental Tasks of Aging

Erikson (1986) termed the crisis of the last epoch of life integrity vs. despair and
believed that successful resolution of this crisis involved a process of life review and
achievement of a sense of peace and wisdom through coming to terms with how one’s
life was lived.

 trust vs. mistrust

 autonomy vs. shame

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  initiative vs. guilt
 industry vs. inferiority
 identity vs. confusion
 intimacy vs. isolation
 generativity vs. stagnation
 ego integrity vs. despair

Peck identified the following three tasks faced in old age:

1. ego differentiation vs. work-role preoccupation – to develop satisfactions from

one’s self as a person rather than through the work role
2. body transcendence vs. body preoccupation – to find psychological pleasures
rather than becoming absorbed with the health problems or physical limitations
imposed by aging.
3. ego transcendence vs ego preoccupation – to feel pleasure through reflecting on
one’s life rather than dwelling on the limited number of years left to live

Havighurst described tasks of aging individuals to include the following:

 adjusting to decreased strength and health status

 maintaining involvement with friends and society
 establishing satisfactory living arrangements
 readjusting one’s lifestyle to reduced income and retirement
 coping with the death of one’s spouse

Butler and Lewis viewed the major tasks of late life as follows:

1. adjusting to one’s infirmities

2. developing a sense of satisfaction with the life that has been lived
3. preparing for death

Overall, the developmental tasks of Late Adulthood can be summarized as:

 To maintain the body image and physical integrity

 To conduct a life review
 To maintain sexual interests and activities
 To deal with the death of significant loved ones
 To accept the implications of retirement
 To accept the genetically programmed failure of organ systems

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  To divest oneself of the attachment to possessions
 To accept changes in relationship with grandchildren

Human Motivation and Development Theory

Maslow’s motivation and development theory (1962) is widely viewed as a valuable

framework to understand human needs and values from a holistic point of reference.
Maslow’s theoretic construct is described as a hierarchy of needs and is diagrammed in
the form of a pyramid. Five levels of needs are identified, the most basic representing the
base of the pyramid. From the most basic (1) to the highest level (5), these needs include
the following:

1. biological and physiological

2. safety and security

3. affiliation or sense of belonging

4. self esteem; and

5. self-actualization

Ebersole and Hess (1994) have conceptualized Maslow’s hierarchy of needs and applied
his theory to identification of special needs of the elderly at each level. They also
identified some of the specific needs of the older adult and potential strategies to meet
those needs. (Refer Table 1 below)

Table 1: Special needs of the elderly according to Maslow’s Hierarchy of Needs

Maslow’s Needs
Needs of the elderly Strategy to meet needs
Hierarchy
Finding meaning in life and Identify value and contributions
death Self-actualization of the individual
Encourage continuity of
participation in the decision
Transcendence over aging making process
processes
Reminisce about past in relation
to present and future
Creativity and Mastery

Responsible roles Maintain aspects of roles

Self esteem important to the individual
Facilitate socialization

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Social supports Promote physical appearance
Locus of control Facilitate decision making
Cognitive awareness

Relationships Identify impact of loss on

Belonging individual
Intimacy
Support needs for intimacy and
sexuality
Affiliations Facilitate changes in life style

Sensory awareness Obtain necessary equipment or

Safety and security supplies for home independence
Environmental safety Assist with obtaining legal or
financial help
Legal and economic issues
Educate the elderly person and
family regarding home safety
Biologic needs Provide for physical comfort
Biological integrity
Comfort needs Provide for nutritional needs

Adaptation Theory

The adaptation theory as described by Vaillant (1977) is more of a conceptual model that
categorizes the changes brought about by aging. Vaillant identified a series of shifts and
tradeoffs that occur during the aging process. What is critical to successful adaptation is
the ability of the individual to let go of parts of the past, while pursuing quality of life
components. For example, the elderly person often experiences sensory losses, especially
in the areas of vision and hearing and adapts to such losses by facilitating the quality of
the remaining sensory perceptions. For instance, the use of large print books, direct
lighting, or hearing aids would enhance the older person’s remaining sight and hearing.
Encouraging the use of other sensory perceptual systems such as touch or taste would be
another way for the older individual to gather pertinent information from the
environment.

Life Structure Theory

Lowenthal (Lowenthal and Chiriboga, 1973) described a human development theory

based on organizational life cycles and transitions. His theory is based on clinical
observations of the ability of individuals to cope with transitions such college, marriage,
and retirement. Transitions may be categorized as occupational, familial, economic, and
life cycle (e.g. infancy, childhood, adolescence). Each transition may bring on a period of
stress, depending on the degree of preparation, type of transition, and the individual’s
coping mechanisms. Although life structure transitions may be gradual, others may be
sudden or unexpected, resulting in severe role reversals in some cases.

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Psychoanalytic Model

Gould (1977) developed and described a model of human development that was based on
his psychoanalytic practice, that combined some basic premises of psychoanalysis with
Maslow’s hierarchy of needs. Gould believed that human development begins as an
internal process of reflection. One must give up lower level needs, such as biological and
safety, to achieve self actualization during mature adulthood. He believed that old age
should be period of individuality and continued self-development through such means as
recreational or creative activities.

Psychosocial Factors in Aging

Factors affecting good aging appear to be multidimensional.

George Valliant followed up a group of Harvard freshmen into old age. He found that
having been close to brothers and sisters during college correlated with emotional well
being; undergoing early traumatic life experiences, such as the death of a parent or
parental divorce, did not correlate with poor adaptation in old age; being depressed at
some point between ages 21 and 50 predicted emotional problems at age 65; and
possessing the personality traits of pragmatism and dependability as a young adult was
associated with a sense of well being at age 65.

Palmore (1980) points out the following social factors which significantly contribute in
aging: modernization, dependence, ageism and other prejudices, uselessness, poverty,
employment, segregation, discrimination, socio-economic status, loss of role and status,
bereavement, isolation through disability, leisure activities, religious institutions,
community disintegration, health care activities, social security and other social support
systems.

Ageism and stereotyping the elderly

Ageism, a term coined by Robert Butler, refers to discrimination towards old persons and
to the negative stereotypes about old age that are often held by younger adults. Old
persons may themselves resent and fear other old persons and discriminate against them.
In Butler’s scheme person’s often associate old age with loneliness, poor health, senility,
and general weakness or infirmity. The experience of older persons, however, does not
consistently support this attitude. For example, although 50% of young adults expect poor
health to be a problem for those over 65 years old, 75% of persons 65 to 74 years of age
describe their health as good. Two thirds of persons 75 and older feel the same way.

Ageism often leads to stereotyping that may result in discriminative behaviors towards
the elderly. It may be expressed in daily language, for example, adjectives such as
crotchety, grumpy, old fashioned, feebleminded, etc. are frequently used to describe the
appearance, behaviors and demeanor of the elderly. This terminology is demoralizing to
elderly persons, and may result in the elderly believing and behaving according to these
terms.

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Some myths associated with aging are:

 Elderly people are all the same as a group

 Chronologic, biologic, and psychosocial aging occurs at the same rate

 Old age is a period of ongoing losses

 Senility and old age are synonymous

 Elderly cannot learn new skills

 Elderly are generally more depressed.

Retirement

One of the first adjustments facing the elderly is retirement. About 33% of retirees have
difficulty adjusting to certain aspects of retirement, such as reduced income and altered
social roles and prestige within the community. Many individuals base their sense of
identity on the position they hold in the work force. Friendships and social relationships
often include those who share a common work experience. Occupational identity is
largely responsible for a person’s social position and for the social role attached to that
position.

In addition to major economic and status considerations, sheer availability of time is also
one of the major consequence of retirement. Thus the problem of use of leisure time
arises during this phase. During the working years, leisure is a small segment of one’s
total available time, and therefore activities may be chosen merely to contrast with or to
escape from the working activities. This sort of leisure activity may prove to be
unsatisfactory when it occupies the major portion of one’s life.

Retirement may include the reestablishment and renegotiation of roles between spouses.
Each spouse, whether working outside the home or not, has had a daily routine that
provided a sense of identity and accomplishment. Retirement requires significant
adjustments for both partners. Preparing for retirement is a preventive intervention that
helps the individuals plan for transitions and maximizes the potential for health and well
being in old age.

Bereavement

According to Feifel (1965), “the adaptation of the older person to dyeing and death may
well be a crucial aspect of the ageing process”. The Ageing person’s awareness of death,
its personal meaning to him, and the effects of these on behavior all become important
factors on understanding and managing the problems of later life. Losses experienced
during the aging process vary from the loss of significant others to the loss of social
status. Older women outnumber older men and the morality rate for women has declined

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rapidly over the past 40 years. The mortality rate is related to the adjustment of men and
women to the loss of a spouse or significant other.

Men’s and women’s responses to the loss of significant relationships differ. In the two
year period following the death of a spouse, men tend to have a higher mortality rate than
women. In the first 3 months following the death of a spouse, the mortality rate increases
48% in men over the age of 65 and 22% in women over the age of 65.

Widowhood, the death of friends, and the recognition of declining functions make the
older persons more aware of the reality of their own death. Contemplating one’s mortality
and working through the process of grief assists individuals to find meaning in the life
that still remains for them. Cultural values, personal characteristics, health beliefs, health
practices and social support systems play an important role in achieving optimal
functioning and quality of life in this age group.

Spikes (1980) has outlined the following factors related with death anxiety or fear of
death and adaptation to death among the elderly: personality factors, the general state of
physical health; the state of cognitive function; the cause and course of death; the socio-
cultural climate; and the age of the person.

Discussing the past is therapeutic and necessary for the elderly to feel their life has had
meaning. Through the life review, unresolved guilt, unachieved aspirations, perceived
failures, and other aspects of unfinished business can be better understood and resolved.
Feifel’s reports and others have confirmed that for many older persons a belief in life
after death or trust in religious support serves as a bolster against threat of death.

Relocation

Giving up one’s home and moving into a nursing home or a long-term care facility is one
of the transitions often experienced in later life. The probability of nursing home
placement within a person’s lifetime is closely related to age. Maxwell (1979) found that
institutionalized elderly people frequently encounter social isolation and under-
stimulation.

Moving to a nursing home is often seen as relinquishing independence and assuming a

dependent role. Older adults faced with the loss of loved ones, multiple health problems,
and decreasing ability to care for themselves need to have the support of hope. Sources of
hope include religious symbols, relationships with others and activities. A well designed
environment can influence feelings of hopefulness; elderly clients should be encouraged
to choose or plan their new environments as much as possible.

Individuals who see themselves as hardy, that is, committed, in control, and challenged
are less likely to experience depression upon institutionalization in a nursing home.
Therefore, care planning in the nursing home must involve clients in the planning
process. An older person faced with an unscheduled life event which may be permanent,
needs all possible resources to cope with stress and avoid depression.

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By participating in decisions related to relocation, the elderly client will retain a sense of
control in an event that otherwise may seem out of control. Methods of assisting
individuals to maintain control include planning for social, spiritual and physical care
needs.

Adult children of the elderly are often faced taking decisions about nursing home
placement. They may experience guilt and fears about abandoning their parents. The set
of circumstances surrounding placement in a nursing home are complex and unique to
each family. Pre-placement education and support groups can lessen the stress involved
in the same.

Marital and Sexual Aspects of Old Age

Several studies indicate that conjugal satisfaction of elderly people is associated with
their health, at the psychological and physical levels, as well as to their general
satisfaction with life (e.g. Atchley & Miller, 1983; Levenson et al., 1993). At the
psychological level, conjugal distress could be one of the major sources of anxiety and
depression in a person’s life (Stuart, 1980). It is generally agreed that elderly people who
still have sexual relations benefit from an important source of reinforcement and
pleasure, which helps to preserve a psychological and physical well-being and which
indirectly contributes to reduce various physical and mental health problems.

There is a belief, in the general public and even among professionals, according to which
sexuality is among the first functions to diminish with age. This belief is a myth because
sexuality is rather one of the last faculties to decline. According to Kaplan (1974, 1990),
sexual potential and erotic pleasure wear out only with death. However, it is clear that age
affects the intensity, the frequency and the quality of the sexual response. According to
Kinsey et al. (1948, 1953) and Masters and Johnson (1966), the sexual reactions and
sexual capacity of men peak at 17± 18 years of age, only to diminish gradually thereafter.
In women, sex sensations reach a peak in the late thirties and early forties. However, the
feminine curve reaches a less pronounced peak in women of that age than in men in late
adolescence. Afterwards the curve diminishes, although in a slower manner than in men.
As discussed earlier, mortality in men is higher than in women, a sizeable portion of
women will spend the major portion of their old age in widowhood without a sexual
partner.

The studies of older people’s sexual behavior seem to show that sexual activity is
influenced by a complex combination of physical, psychological and social factors. These
factors are physical health, social taboos, conjugal status, and knowledge about sexuality,
self-esteem and attitudes towards sexuality. Thus, sexuality does not inevitably vanish
with age, but is more dependent on these factors (Rienzo, 1985).

Conjugal Satisfaction and Retirement

According to the theory of socio-emotional selectivity of Carstensen (1991), people

reduce their social contacts when aging and establish close ties with a limited number of

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individuals, especially the other conjugal partner. Thus, aged individuals have a tendency
to spend most of their time with their partners (Atchley & Miller, 1983). In retired
people, the partner is the main source of social support (Troll et al., 1979). Conjugal life
thus holds a central place in the life of retired people, because of the reduction in
professional activities, children leaving home and the reduction of the social network.
Aged partners have more time to spare to practice hobbies together and to invest in their
conjugal relationship. In this sense, retirement may constitute an especially enriching
period for the couple, but this is not always the case. Studies in this area are few and
relatively contradictory, but they suggest that retirement could have greatly varied effects.
If some couples see an increase in conjugal satisfaction following retirement, enjoying
what is known as a `second honeymoon’, several people live this period with more
difficulty (Atchley, 1992; Atchley & Miller, 1983; Lee & Shehan, 1989). Even if the link
between retirement and conjugal distress is not clearly established in the literature,
several data suggest that it is a stressful transition period for the couple.

According to a study concerned with the elderly’ s activities, the fact of being married
presents a powerful protection against the decline in productivity in that group (Glass et
al., 1995). Hence, married elderly people are significantly less at risk of experiencing a
decrease in their productivity level than their unmarried counterparts.

Elder Abuse

Elder abuse is defined as any action on the part of a caregiver to take advantage of an
older person, his/her emotional well being, or property (Minakar and Frishman, 1995).
Elder abuse can appear in various forms such as:

1. Exploitation – Improper use of a person for one’s own profit. E.g. theft of
objects, use of legal power assigned by the older adult for own gain, etc.
2. Neglect – Refusing to meet basic physical and mental needs such as depriving
food, clothing, shelter, hygiene, corrective and remedial devices, refusing to
interact, etc.

3. Physical abuse such as beating, whipping, scalding, etc.

4. Psychological abuse – such as name calling, verbal assaults, humiliation,

social isolation, etc.

5. Violation of rights - refusal to allow the exercise of individual rights such as

right to consent for medical treatment, use personal financial resources, etc.

The victims of elder abuse are divided into two broad categories: (1) those in which the
elder has physical or mental impairment and depends on the family for daily care needs
and (2) those in which care needs are minimal or overshadowed by the pathological
behavior of the caregiver.

Mental abilities and wisdom

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In the field of cognitive ageing, the prevailing finding is one of age-related declines in
levels of functioning (e.g. Lindenberger & Baltes, 1994; Salthouse, 1991). Such findings
seem in contrast to the efficiency with which middle-aged and old adults manage their
lives and also govern societies. Consequently, researchers set out to identify areas of
intellectual functioning which do not show decline but rather demonstrate stability or
even growth across the lifespan (e.g. Baltes, Dittmann-Kohli, & Dixon, 1984; Commons,
Sinnot, Richards, & Armon, 1989). Among others, knowledge and judgement in difficult
and uncertain matters of life have been identified as one such area and the highest level of
functioning in that domain has been conceptualised as one psychological approach to
wisdom (Baltes, Smith, & Staudinger, 1992). Wisdom as far as emotional maturity is
concerned does come with age, researchers have found.
Researcher at the University of Alberta and scientists from Duke University have
identified brain patterns that help healthy older people regulate and control emotion better
than their younger counterparts.

Cultural Impact

Cultural beliefs also influence one’s attitude toward the elderly. Culture influences the
responses of the elderly to health, illness and treatment. Various cultures hold different
beliefs regarding aging. Since ancient times, the contributions of the elderly to a society
affect the status of the aged within a particular cultural group. For example, Far Eastern
cultures value the wisdom of elders and thus hold the aged in high esteem. In contrast,
some primitive cultures may have considered the elderly a burden, unable to hunt and
provide for the tribe. Such cultures have been known to banish the elderly from the tribe.
For example, in European American culture, Growing old is generally feared . Elderly are
not often respected nor revered . Nuclear families do not include the elderly. Ageism at
times is practiced and Elderly are often seen as sick, senile, and useless. Very similar to
Asian families, Hispanics also function within strong family units. They also have
devotion to extended family. Elderly have tremendous influence over family decisions.
However, African-American have different family dynamics. Grandparents often raise
their grandchildren. The extended family often includes church members.

Mental Health Problems of Older Adults

In India, study of mental health problems in the aged among the population has not
attracted much attention as to make it a sub-specialty (Venkoba Rao, 1987). The
prevalence rate of mental morbidity among the aged (60+) was found to be 89/1000
population (Venkoba Rao and Madhavan, 1983).Affective disorders, particularly
depression, late paraphrenia, and organic psychiatric syndromes constitute the bulk of the
total psychiatric morbidity. Geriatric depression is common with a prevalence of 60/1000
in the population (Venkoba Rao and Madhavan, 1983). Mania formed 16% of psychiatric
diagnosis and dementia contributed to 20% of the mental disorders among 150 aged
hospitalized subjects (Venkoba Rao, 1987). The rate of completed suicide is around
12/100,000 higher than the national rate of 7/100,000 (Government of India, 1977-86).
Psychiatric morbidity is seldom an ‘isolated’ event in the aged. A co-morbidity of two or
three diagnosis is a rule for the aged. There is also with it a physical health problem

61
and/or disability or handicap. In the order of frequency are ophthalmological, hearing,
urinary and neuro-plastic disorders (Venkoba Rao, 1990). In India an expression of
physical well being and contentment varies from 22.1 to 52.1% among the aged (Grover,
1986)

Conclusion:

In the times of advancement in medical sciences, by increasing the life expectancy of

people, the quantity of life has decreased. At the same time with the flux of values in the
changing societies, quality of life of elderly has been severely compromised.
Psychosocial aspects of old age helps the mental health professionals to be aware of the
difficulties and strengths of this phase of life and thus helps them in better management
of the elderly.

ANN X CHOOLAKAL
SUBMITTED TO: DR. SEEMA MEHROTRA
PSYCHOSOCIAL ASPECTS OF SUICIDE
There is but one truly serious philosophical problem, and that is suicide. Judging
whether life is or is not worth living amounts to answering the fundamental question of
philosophy. All the rest and whether or not the world has three dimensions, whether the
mind has nine or twelve categories—comes afterwards (Albert Camus, 1955).
Death is an aspect which has a great influence in the human history. For some death
evokes fear; for others its intriguing. People have tried to conquer death, to escape from
it, to embrace it. There are different views on death as there is on life. In the United States
and Canada suicide is defined (by a medical examiner or coroner) as one of the four
possible modes of death. An acronym for the four modes of death is NASH: natural,
accidental, suicidal, and homicidal.
Briefly defined, suicide is the human act of self-inflicted, self-intentioned cessation
(Shneidman, 1973). Suicide is not a disease (although there are many who think so); it is
not a biological anomaly (although biological factors may play a role in some suicides); it
is not an immorality (although it has often been treated as such); and it is not a crime in
most countries around the world (although it was so for centuries).
History of Suicide
Even from the Greek classical era suicide was a topic of discussion. According to
Pythagoras, suicide would upset the spiritual mathematics of all things. Plato and
Aristotle were in agreement with Pythagoras and viewed suicide as a crime or an act of a
coward trying to escape the challenges of the world. But coming to the Roman era, life
was held rather cheap and suicide was viewed rather neutrally or by some positively.
Seneca and Zeno even supported suicide in their writings. And Zeno went to the extent of
‘killing himself’.

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The Renaissance era writers and philosophers again differed in their opinions about
suicide. Shakespeare in his plays explains around 52 suicides and glorifies suicide to an
extent. Rene Descartes had the opposite view. Jean-Jacques Rousseau attempted to free
the suicide from evil. David Hume was another pioneer who viewed suicide as the right.
Immanuel Kant, however had a different view and for him life was sacred. Albert Camus
takes a neutral stand in this topic but has a positive view about life.
The Old Testament does not directly forbid suicide, but in Jewish law suicide is wrong.
Life had value. In the Old Testament one finds only six cases of suicide: Abimelech,
Samson, Saul, Saul’s armor-bearer, Ahithapel, and Zimni. The New Testament, like the
Old, did not directly forbid suicide. During the early Christian years, in fact, there was
excessive martyrdom and tendency towards suicide, resulting in considerable concern on
the part of the Church Fathers. Suicide by
these early martyrs was seen as redemption and thus, to stop the suicides, the Fathers
began increasingly to associate sin and suicide. In the fourth century, suicide was
categorically rejected by St Augustine (354–430). Suicide was considered sin because it
precluded the possibility of repentance and because it violated the Sixth Commandment,
“thou shall not kill”. St. Thomas of Aquinas again was opposed to suicide and depicted
suicide as unnatural and antisocial. Till date church views suicide as a sin.
Indian epics like Ramayana and Mahabharata have recorded multiple instances of
suicide. When lord Sri Rama died there was an epidemic of suicide in Ayodhya. During
the Vedic and upanishadic times, apart from ‘sati’, self- destruction for incurable
diseases- ‘mahaprasthan’ was allowed. But Brahmanical view was that anyone who tries
to kill oneself but fails should fast for a stipulated time period as part of punishment.
Bhagwat Gita is against self- torture and self- killing. Islam asks man to wait for his
destiny rather than snatching it from the hands of God.
Definitions of Suicide
There is no universally accepted definition of suicide today. Varah (1978) has collated a
variety of definitions, some are:
Erwin Ringel (Austria): Suicide is the intentional tendency to take one’s own life.
Charles Bagg (United Kingdom): Suicide is the intentional act of taking one’s life either
as a result of mental illness (these illnesses frequently though not always causing distress
to the individual carrying out the act) or as a result of various motivations which are not
necessarily part of any designated mental illness but which outweigh the instinct to
continue to live.
Walter Hurst (New Zealand): The decision to commit suicide is more often prompted by a
desire to stop living than by a wish to die. Suicide is a determined alternative to facing a
problem that seems to be too big to handle alone.
Sarah Dastoor (India):
I vengeful, killer, hate—inspired—so I die

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I guilty, sinner, trapped—escaping life
I hoping rebirth, forgiveness divine—live again
Tadeusz Kielanowski (Poland): Suicide is the most tragic decision of a man who found
nobody to hold out a hand to him.
Beck et al defines suicide as willful self inflicted life threatening act which results in
death. Shneidman’s revised definition says suicide is a conscious act of self induced
annihilation, best understood as a multi dimensional malaise in a needful person, who
defines an issue for which suicide is the best solution. WHO (1968) defined suicidal act,
as the injury with, varying degrees of lethal intent and suicide is defined as act with fatal
outcome.
Classifications in Suicide
Emil Durkheim’s Classification:
Durkheim has divided suicide into 3 types depending on the sociological approach. The
three types are as follows:
1. Egoistic Suicide: occurs when the society fails to offer a set of standard guidelines
for the conduct of individual.
2. Anomic suicide: occurs when society neglects to integrate the individual into its
fold effectively
3. Altruistic Suicide: occurs when there is over integration of an individual with the
society
Hendin’s Classification:
He classified suicide in five types based on how death is viewed:
1. Retaliatory Abandonment: death is viewed as an act of leaving or abandonment in
retaliation. This concept is derived during childhood. Children who have lost their
parents react as though they have been abandoned
2. Retroflexed Murder: suicide is considered as murderous rage which is turning in
and not repressed.
3. Reunion : death is viewed as pleasurable act and is incorporated into fantasy of
reunion with parental figures or loved ones who have already died and gone.
4. Self punishment: occurs in men over failure at work or fulfilling their duty or in
some females who have inability to love and look after their children at times
develop self hatred with consequent need of punishment
5. Seeing oneself as already dead: the equivalent of emotional dying is manifested as
strong feelings of detachment, repressed aggression and affectivity which has
gone into a frozen state and is perceived by some as their emotional death

Schneidman- Farebrow’s Classification:

They classified into 4 types as follows:

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 1. Those who conceive suicide as means of better life
2. Those who commit suicide as a result of psychosis with associated delusions
and hallucinations.
3. Those who commit suicide out of revenge against beloved person
4. Those who are old and infirm, suicide is said to be the release for them

Theories of suicide
Psychoanalytic
Sigmund Freud first formulated the psychoanalytic perspective early in the twentieth
century. According to him suicide is motivated by unconscious intentions. Even if the
person communicates that he or she has consciously planned suicide, the focus of the
action is in the unconscious. The root cause of suicide is the experience of loss and
rejection of a significant highly cathected object (i.e., a person)—the person, in fact, is
singly preoccupied with this loss/rejection. The suicidal person feels quite ambivalent.
He/she is both affectionate and hostile towards a lost/rejecting person. The suicidal
person is, in some direct or indirect fashion, identifying with a rejecting or lost person.
Attachment, based upon an important emotional tie,
is the meaning of identification. The suicidal person exhibits an overly regressive
attachment—“narcissistic identification”—with the object. He/she behaves as if he/she
were reacting to another person. The suicidal person is angry at the object although the
feelings and/or ideas of vengefulness and aggression are directed towards him/her. The
suicidal person turns back upon him/herself murderous wishes/impulses/needs that had
been directed against the object. Suicide is a fulfillment of punishment; i.e., self-
punishment. The suicidal person experiences a sense of guilt or self-criticism. The person
develops prohibitions of extraordinary harshness and severity towards him/herself. The
suicidal person’s organization of experiences is impaired. He/she is no longer capable of
any coherent synthesis of his/her experience.
Karl Meninger described three components of hostility in suicide as the ‘wish to kill’,
‘the wish to be killed’ and ‘the wish to die’ which is known as the Meninger’s triad.
Melanie Klein and her followers considered suicide as a psychotic action resulting from
the defense mechanisms that are responding from the person’s anxiety.
Cognitive-Behavioral
The cognitive-behavioral perspective is most widely associated with Aaron
T. Beck and his colleagues. According to them suicide is associated with depression and
the critical link between depression and suicidal intent is hopelessness. Hopelessness,
defined operationally in terms of negative expectations, appears to be the critical factor in
the suicide. The suicidal person views suicide as the only possible solution to his/her

65
desperate and hopelessly unsolvable problem (situation). The suicidal person views the
future as negative, often unrealistically. He/she anticipates more suffering, more hardship,
more frustration, more deprivation, etc. The suicidal person’s view of him/herself is
negative, often unrealistically.
He/she views him/herself as incurable, incompetent, and helpless, often with self-
criticism, self-blame, and reproaches against the self (with expressions of guilt and
regret) accompanying this low self-evaluation The suicidal person views him/herself as
deprived, often unrealistically.
Thoughts of being alone, unwanted, unloved, and perhaps materially deprived are
possible examples of such deprivation. Although the suicidal person’s thoughts
(interpretations) are arbitrary, he/she considers no alternative, accepting the validity
(accuracy) of the cognitions. The suicidal person’s thoughts, which are often automatic
and involuntary, are characterized by a number of possible errors, some so gross as to
constitute distortion; e.g., preservation, overgeneralization, magnification/minimization,
inexact labeling, selective abstraction, negative bias. Their affective reaction is
proportional to the labeling of the traumatic situation, regardless of the actual intensity of
the event. Irrespective of whether the affect is sadness, anger, anxiety, or euphoria, the
more intense the affect the greater the perceived plausibility of the associated cognitions.
The suicidal person, being hopeless and not wanting to tolerate the pain (suffering),
desires to escape. Death is thought of as more desirable than life.

Social Learning
The social learning view has been summarized by Lester (1987): Albert Bandura and
psychologists in the classical (Pavlov) and operant (Skinner) traditions are the best-
known theorists in this view. Suicide is a learned behavior. Childhood experiences and
forces in the environment shape the suicidal person and precipitate the act. Child-rearing
practices are critical, especially the child’s experiences of punishment. Specifically, the
suicidal person has learned to inhibit the expression of aggression outward and
simultaneously learned to turn it inward upon him/herself. The suicide can be predicted
based on the basic laws of learning. Suicide is shaped behavior—the behavior was and is
reinforced in his/her environment. The suicidal person’s thoughts provide the stimuli;
suicide (response) is imagined. Cognitions (such as self-praise) can be reinforcers for the
act. The suicidal person’s expectancies play a critical role in the suicide—he/she expects
reinforcement (reward) by the act. Depression, especially the cognitive components, is
strongly associated with the suicide. Depression goes far towards explaining suicide. For
example, depression maybe caused by a lack of reinforcement, learned helplessness,
and/or rewarded. Suicide can be a manipulative act. Others reinforce this. Suicide is not
eliminated by means of punishment. The suicidal person is non-socialized. He/she has not
been sufficiently socialized into traditional culture. The suicidal person has failed to learn
the normal cultural values, especially towards life and death. The suicide can be
reinforced by a number of environmental factors, for example, sub cultural norms,
suggestions on television, gender preferences for specific methods, suicide in significant
others (modeling), a network of family and friends, cultural patterns.

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Multidimensional
The psychologist who has consistently argued for a multidimensional view is Shneidman.
According to him, the suicidal person is in unbearable psychological pain. The person is
focused almost entirely on this unbearable emotion (pain), and especially one specific
(an arbitrarily selected) way to escape from it. The suicidal person experienced a situation
that is traumatic (e.g., poor health, rejection the spouse, being married to a non-
supportive spouse). What is implied is that some needs are unfulfilled, thwarted, or
frustrated. For the suicidal person, the idea of cessation (death, stopping, or eternal sleep)
provides the solution. It permits him/her to resolve the unbearable state of self-
destructiveness, disturbance, and isolation. By the suicide, the person wishes to end all
conscious experience. The goal of suicide is cessation of consciousness and the person
behaves in order to achieve this end. The suicidal person is in a state of heightened
disturbance (perturbation), e.g. he/she feels boxed in, rejected, harassed, unsuccessful,
and especially hopeless and helpless. The suicidal person’s internal attitude is
ambivalence. The suicidal person experiences complications, concomitant contradictory
feelings, attitudes and/or thrusts (not only towards him/herself and other people but
towards the act itself). The suicidal person’s cognitive state is constriction (tunnel vision,
a narrowing of the mind’s eye). He/she is figuratively intoxicated or drugged by his/her
overpowering emotions and constricted logic and perception. The suicidal person needs
or wishes to egress. He/she wants to leave (the scene), to exit, to get out, to get away, to
be gone, not to be around, to be “elsewhere”. . . not to be. There is a serial pattern to the
suicide. The suicidal person exhibits patterns of behavior that diminish or truncate his/her
life, which subtract from its length or reduce its scope. The person’s suicide has
unconscious psychodynamic implications.

Brain and socio-emotional factors

Rourke et al. (1989) have shown that one possible adolescent and adult outcome of
childhood central processing deficiencies is suicidal behavior as well as other socio-
emotional problems.
They report three major subgroups. The first group has a right brain dysfunction, and
such people are prone to learning problems with non-verbal, visual information. They
may show the following socio-emotional problems: not paying attention to visual objects
including other people; rarely expressing emotions appropriately in their facial
expressions; having a voice that can be expressionless; being very talkative; talking to
self; having flow problems in their speech; and being awkward socially. The second
group has a left brain dysfunction, and such people are prone to learning problems with
verbal information. They may show the following socio-emotional problems: rarely
initiating conversations; having problems paying attention, for example, in conversation;
being brief and often concrete in their remarks; often stating “I don’t know” to questions;

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and some are very impulsive, not thinking before they act. The third group has both left
and right brain dysfunction and exhibit a conglomerate of symptoms.
Other more specific cerebral deficits render people at risk for other specific
They have suggested that it is especially the first pattern associated with right brain
dysfunction that predisposes those afflicted to adolescent and adult suicide risk.

Physical Disabilities and Illness:

A physical illness is a major contributing factor in 11%-51% of suicide. 50% of males
with cancer do s within a year of diagnosis. Cancer in breast and genitals form 70% of all
cancer suicide victims in females.
Psychiatric Conditions:
It has been found that 94% of the suicides attempters had a psychiatric disorder. 45% had
mood disorders and 23% had substance use. Depression is the most common psychiatric
condition associated with suicide. Studies generally showed 30%-60% of depressed
patients commit suicide. Followed by depression schizophrenia is the next common
psychiatric condition with high suicide risk. Up to 10% of schizophrenia patients commit
suicide. In alcohol use a life time risk of 2.2%- 3.4% was estimated. Co morbidity like
depression play a major role here. Borderline personality disorder is another category of
psychiatric condition where the suicide risk is high. Almost 95% of personality disorder
patients have an Axis I diagnosis of depression/ alcohol use. Almost 30% of victims have
a Axis II diagnosis of personality disorder. 20% have cluster B, 10% have cluster C and
1% have cluster A personality disorder. In panic disorder there is 7% of individuals with
suicide phobia who is at an increased risk. Other co morbid conditions can also be
present.
Psychological Characteristics:
Hopelessness: it has been correlated with suicidal intent, suicide reattempt and suicidal
completion. Hopelessness is also the main dimension in Beck’s theory.
Impulsivity: it’s been found as a common characteristic in adolescent attempters.
Impulsivity in the face of chronic stress is the source of increased risk.
Hostility and aggression: interpersonal hostility, history of assaultive behavior and
impulsive aggressive personality disorders which may be related to inability to modulate
intense affect and aggression.
Socio-Cultural Factors:
Culturally also suicide has a very different perspective. In Japan, for example, suicide is
considered as a right of the defeated warrior to avert the shame of defeat in a battle-
Hara-kiri. They also culturally believe suicide as the way to reach their forefathers or

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reaching heaven. The aboriginal tribe of North America also is another sect of people
who support suicide. For them it is to keep their honor and pride.
Socio-Demographic Factors:
Age: suicide rates increase with age. In males, suicide rates peak after 45 while in
females it peaks after 55. Elderly people attempt less often but are more successful.
Sex: males to female ratio is said to be 2:1 to 7:1. Males use more violent methods like
hanging or shooting while females use methods like overdose or drowning
Race: ethnic and minority groups tend to be more cohesive and have less suicide rates.
Suicide rates among immigrants is more than natives
Marital status: suicide rates for single person are twice as high than a married personand
that of widowed, separated is 4-5 times higher.
Employment: unemployment has higher suicide rates, probably due to interactions of the
socio-cultural circumstances, psychological vulnerability and stressful life events
Occupation: physicians especially psychiatrists are at a higher risk of suicide followed by
ophthalmologists and anesthetist. Others are musicians, dentists, law officers, insurance
agents.
Other Factors:
Proximal risk factors: these are the circumstances surrounding a suicide attempt and
mainly involve recent life changes, particularly interpersonal stress. 4 particular events
are:
Serious arguments with spouse, having a new person at home, serious illness of a family
member, serious personal physical illness etc. 75% of adolescent attempters report
difficulty with one or both the parents
Family Factors: families of attempters and completers have increased risk of psychiatric
disorders , assaultive behaviors and attempts. Family pathology in the form of discord,
physical and sexual abuse, exposure to family violence and unsupportive interactions can
also be the causes of suicide.
Availability of Lethal Agents: availability of lethal drugs or fire arm can increase the risk
of suicide.
Many factors contribute or lead to the decision of ending one’s life. This decision is right
or wrong still continues to be a major philosophical question. The ways and reasons of
committing suicide have reached a higher proportion than in earlier years. Economical
problems and debt has driven the farmers of rural Karnataka and Kerala into mass
suicide, which extended to familicide in many cases. Suicide can also be seen as a cry for
help. Prevention of suicide should be taken up as a strategy to deal with future attempts
and thus extending a helping hand for the needy.

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 SHALINI JOHN
SUBMITTED TO: DR. SEEMA MEHROTRA
PSYCHOSOCIAL ASPECTS OF SUICIDE

“. . . the many at one moment shun death as the greatest of all

evils, and another yearn for it as a respite from the evils of life.”
Epicurus (341–270 BC)
Life and death seem to represent two sides of the same coin. Since years, men have
celebrated the new beginnings of life and have grappled with the issues of death. Death is
not easy to understand. And the nature of it becomes even more perplexing when the
form of death is – Suicide.

INTRODUCTION: DEFINITION AND HISTORY OF SUICIDE

There can be four modes of death: natural, accidental, suicidal, and homicidal (Leenaars,
2004) and understanding any of these forms of death is a complex endeavor. The current
essay seeks to understand aspects of one of the modes of death- Suicide.
The term ‘suicide’ comes from two Latin words ‘Sui’-of oneself and ‘Caedre’ - to kill. In
lay sense ‘Suicide’ refers to voluntary act of taking away of one’s life. According to The
Oxford English Dictionary, the word was used in 1651 by Walter Charleton when he said:
“To vindicate one’s self from…. inevitable calamity, by Sui-cide is not….a Crime.”
However, the exact date of its first use is open to some question. Some claim that it was
first used by Sir Thomas Browne in his book, Religio Medici, published in 1642. Edward
Philips, in his 1662 edition of his dictionary, A New World of Words, claimed to have
invented the word. Before the introduction of the word, other terms, of course, were used
to describe “the act”— among them self-destruction, self-killing, self-murder, and self-
slaughter. (as cited in Leenaars, 2006)

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WHO (1968) defines suicide as suicidal act as “the injury with varying degrees of lethal
intent” and suicide is defined as “a suicidal act with fatal outcome”. The most
comprehensive and popular definition has been given by Shneidman (1985) who
considers suicide as a “conscious act of self-induced annihilation, best understood as a
multidimensional malaise in a needful individual who defines an issue for which the
suicide is perceived as the best solution”.
Bush and Paragmant (1995) assert that suicidal behavior may be conceived as existing on
a continuum which includes behavior ranging from suicidal ideation, suicidal plan,
suicide attempt and complete suicide. Non Fatal Suicide Behavior (NFSB) includes all
behavior except complete suicide.
Suicide can be categorized in a number of ways. Durkheim’s (1951) typology is the most
popular in highlighting the types of suicide. According to him there are four basic types
of completed suicide: (1) Egoistic suicide, which results from apathy and the man no
longer finding a need for existence in life; (2) Altruistic suicide, which occurs when basis
of existence seems situated beyond life, in the duty or search for nirvana; (3) Anomic
suicide, which arises out of irritation, anger, weariness and unregulated emotions or
abrupt social change; (4) Fatalistic suicide, which arises due to excessive regulation of
ones life.
Karl Menninger (1938) writes of different types (1) chronic suicide—including
asceticism, martyrdom, neurotic invalidism, alcohol addiction, antisocial behavior, and
psychosis; (2) focal suicide— focusing on a limited part of the body—including self-
mutilation, multiple surgery, purposive accidents, impotence, and frigidity; and (3)
organic suicide—focusing on the psychological factors in organic disease, especially the
self-punishing aggressive and erotic components.
Another way of categorizing suicide based on the completion of the task is:
 Attempted suicide, is a potentially self injurious action with a non-fatal outcome for
which there is evidence, either explicit or implicit that individual intended to kill himself
or herself.
 Complete suicide, is an act in which the person, with the intention to end his life, dies

The “attempter”—now often referred to as the parasuicide— and the “completer” as two
sets of overlapping populations: (1) a group of those who attempt suicide, a few of whom
go on to commit it, and (2) a group of those who commit suicide, many of whom
previously attempted it.
The ratio between suicide attempts and completions is about 4:1 to about 10:1—one
committed suicide for every 4–10 attempts; however, in young people, some reports have
the ratio at 50:1, or even 100:1. The ratio appears to vary significantly between nations
and across risk groups, sex, and age.
Suicide is an important public health problem in many countries and leading cause of
death among teenagers and young adults. Worldwide, suicide ranks among the three

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leading causes of death among those aged 15-44 years. There are concentrated efforts that
are being put in order to understand the phenomena of suicide. ‘Suicidology’ is the study
of suicide and its prevention. It is a multidisciplinary enterprise studies psychological,
biological, cultural, sociological, interpersonal, intrapsychic, logical, conscious and
unconscious and philosophical elements in the suicidal event.
INDIAN SCENARIO
India is second only to China in the ranking of nations by total number of suicides (Khan,
2002) with the highest rates of suicides occurring in the age groups of 20–30 years (Rao,
1984). It is estimated that in India over 1, 00,000 people die due to suicide every year
contributing to more than 10% of suicides in the world. Suicide rates increased 67% in
2006, from 1980. Majority of suicides occur among men and younger age group. In India
more married women as compared to single or divorced women attempt suicide
(Ponnudurai & Jeyakar, 1980, as cited in Tanuj and Jena, 2006). The main factors linked
to higher numbers of suicides include early marriage and motherhood, infertility or not
giving birth to male children, lack of autonomy in selecting one’s life partner, economic
dependence, and marital and family conflict, especially with in-laws (Khan & Reza,
1998). Some of the highest suicide rates in India are reported from Pondicherry, Tamil
Nadu, and Karnataka. There are some reports of high rates of suicide in the teenage girls
(15-19 years) in some parts of Tamil Nadu and farmers in some areas of Andhra Pradesh
(Ahuja, 2006). Despite the gravity of the situation, information about the causes and risk
factors is insufficient (National Crime Bureau Report, 2006).
Some of the commonest modes of committing suicide are ingestion of poison (38.4%),
hanging (29.4%), burning (11%), drowning (about 9 %), and jumping in front of a
moving vehicle (about 3 %). In 2003, there were about 2400 dowry deaths. Men often
tend to use more violent methods for suicide than women.
Suicide is also an alarming problem in adolescents in many parts of the world, especially
for older boys. It is young adults (i.e., 18–25) and the elderly (i.e., above 55 or 60) who
are most at risk. One study in India by Kumar et al. (2000) found males outnumbered
females as far as attempted suicide were concerned. Singh et al. (1971) found Sikh
community to be over-represented in completed suicides in general population. Gupta et
al. (1981) in a study of suicide attempters reaching the hospital, had found that 75% of
the attempters belonged to the Hindu community. Older age group (15-18 years), female
sex and Hindu religion were found to be significant risk factors for NFSB (Tanuj and
Jena, 2006).
Medico- Legal aspects: As per Indian law, suicide and attempted suicide were punishable
offenses till very recently. According to Section 309 of Indian Penal Code, "whoever
attempts to commit suicide or any act towards the commission of such offence shall be
punished with simple imprisonment for a term which may extend to one year or fine or
both. The section was declared void in 1994 as it ………..however in 1996 it was
reinstated and held attempted suicide as an offence. This Supreme Court judgment is not
well received by mental health professionals who view suicide or attempted suicide as a
sign of psychological distress or psychiatric disorder. The Mc Naughten’s rule (Section
84 of Indian Penal Code), specifies that, "Nothing is an offence which is done by a person

72
who at the time of doing it, by reason of unsoundness of mind , is incapable of knowing
the nature of the act, or that he is doing what is either wrong or contrary to Law.”
Therefore attempted suicide is not an offence if the person at the time of committing it,
by reason of mental illness, did not know what he was doing or what he was doing was
either wrong or contrary to Law” (Yadwad & Gouda, 2005)
MODELS OF SUICIDE
Primary investigation into the etiology of suicide is associated with disciplines of
sociology and psychology, especially works of Emile Durkheim and Sigmund Freud.
There are various theories that have been put forth to understand suicide. Most of them
can be broadly grouped into either psychological theories or socio-cultural theories.
1. Psychoanalytic theory of suicide:
Contemporary understanding of suicide has been greatly influenced by the early
investigations of Sigmund Freud who suggested the experience of loss or rejection of a
significant and highly cathected object and the consequent anger towards this love object
which gets directed inwards. The anger is deflected towards the internal representation
(introjects) in the self, in the absence of external object. In people who attempt/commit
suicide there is often history of ambivalent feelings that the individual experiences
towards the object. The suicidal person is, in some direct or indirect fashion, identifying
with a rejecting or lost person. Attachment, based upon an important emotional tie, is the
meaning of identification. The individual experiences regressive attachment in the form
of ‘narcissistic identification’ towards the object. In an attempt of being angry at oneself,
the suicidal person is directing his vengeful feelings and anger towards the external
object. Suicide then can be thought of as fulfillment of punishment; i.e., self-punishment.
The suicidal person experiences a sense of guilt or self-criticism. The person develops
prohibitions of extraordinary harshness and severity towards him/herself. The suicidal
person’s organization of experiences is impaired. He/she is no longer capable of any
coherent synthesis of his/her experience.
Freud’s conceptualization has influenced a number of later psychoanalysts like Karl
Menninger who described three components of hostility in suicide as the ‘wish to kill’,
‘the wish to be killed’ and ‘the wish to die’; and Melanie Klein who highlighted suicide
as means of dealing with anxiety.

2. Cognitive Behavioral Model

Major contribution from this perspective can be attributed to Aaron Beck. Other theorists
who have contributed to understanding suicide include George Kelly, Albert Ellis, and
Don Meichenbaum. The popular understanding of suicide is associated with the
following deductions from cognitive theories. Suicide is associated with depression. And
hopelessness is the single best predictor of depression. Hopelessness, defined
operationally in terms of negative expectations, appears to be the critical factor in the
suicide. The suicidal person views suicide as the only possible solution to his/her
desperate and hopelessly unsolvable problem. S/he evaluates the future negatively and
anticipates suffering, hardships. The view of oneself is also negative, often involving self-

73
criticism, self-blame, and reproaches against the self. Although the suicidal person’s
thoughts (interpretations) are arbitrary, he/she considers no alternative, accepting the
accuracy of the cognitions. The suicidal person’s thoughts, which are often automatic and
involuntary, are characterized by a number of possible errors, some so gross as to
constitute distortion; e.g., preservation, overgeneralization, magnification/minimization,
inexact labeling, selective abstraction, negative bias.
3. Social Learning Model:
The primary proponent contribution in the filed of social learning is Albert Bandura, with
classic contribution made by Pavlov and Skinner. Lester (1987) summarized the major
factors associated with suicide. According to this viewpoint suicide is a learned behavior.
The early experiences and environmental factors of the person shape the suicidal person
and precipitate the act. Child-rearing practices are critical, especially the child’s
experiences of punishment. Specifically, the suicidal person has learned to inhibit the
expression of aggression outward and simultaneously learned to turn it inward upon
him/herself. The suicide can be predicted based on the basic laws of learning. The
suicidal person’s thoughts provide the stimuli; suicide (response) is imagined. Cognitions
(such as self-praise) can be reinforcers for the act. The suicidal person’s expectancies
play a critical role in the suicide—he/she expects reinforcement (reward) by the act.
Depression, especially the cognitive components, is strongly associated with the suicide.
Depression goes far towards explaining suicide. For example, depression may be caused
by a lack of reinforcement, learned helplessness, and/or rewarded. Suicide can be a
manipulative act. Others reinforce this. Suicide is not eliminated by means of
punishment. The suicidal person is non-socialized. He/she has not been sufficiently
socialized into traditional culture. The suicidal person has failed to learn the normal
cultural values, especially towards life and death. The suicide can be reinforced by a
number of environmental factors, for example, subcultural norms, suggestions on
television, gender preferences for specific methods, suicide in significant others
(modeling), a network of family and friends, cultural patterns.

4. Shneidman’s Psychological Model:

Shneidman (1987) proposed a model based on his 10 commonalities of suicide. His cubic
model conceptualized a cube made of 125 cublets with 25 cubes on the plane and 5 in
each row and each column. These three faces of the cube are the three corresponding
components of the model as explained below.

 Pain – Represented on the front of the cube it represents psychological

pain resulting from thwarted psychological needs. The left most column represent little
most or no pain increasing steadily towards the right to intolerable pain.
 Perturbation – this component is the ‘state of being’ is on the side plane
and is ranked on 5 point rating scale increasing upwards. This includes (1) perceptual
constriction, (2) penchant for precipitator self harm or inimical action.
 Press – Borrowed from Murray (1938), this component refers to those
aspects of the inner and outer world or environment that impinge on the individual and
make a difference. It is both positive and negative; it can be either actual or imagined.

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The cublet number 5-5-5 is crucial. Not everyone in this cublet commits suicide but no
one commits suicide except those in this cublet. The implication of therapy, therefore is,
reduce one dimension (preferably all 3) and the risk of suicide is eliminated.
5. Durkheim’s theory of suicide
Consistent with his theory of society, Durkheim (1951) interprets suicide as a result of
social causes. While individual factors do account for some suicides, they don’t explain
the social suicide rate. Beginning with the most particularistic social cause, one proceeds
to the common denominator of all suicides. Durkheim using statistical data posits that
extrasocial factors such as insanity, race, heredity, imitation etc show ‘no significance’
associations with suicide rates. He then compounds the lower level generalizations of the
‘greater then’ variety from his statistics which are 23 in number. After these level our
hypothesis, he gives 3 second level generalizations

 Suicide varies inversely with the degree of religious society

 Suicide varies inversely with the degree of domestic society
 Suicide varies inversely with the degree of integration of political society
Finally on the third level, he posits a grand hypothesis as - Suicide varies inversely with
the degree of integration of the social groups of which the individual forms a part.
In effect, Durkheim suggests that any disturbance in the collective order can lead to
increased suicide rate.
Maris’s study on evaluating the relevance of Durkheim’s theory (1969) has indicated
some drawbacks. The findings have not replicated Durkheim’s findings. The data was
found to be related to SES inversely, social mobility, social position, age, sex roles, as
against what was postulated. There is overgeneralization in Durkheim’s theory that is not
accounted for in the data. There are ecological errors in his methodology and the
rudimentary multivariate analysis results in gross misrepresentations of data.
6. Status Integration Theory of Suicide
Gibbs and Martin (1958) recognized these drawbacks in Durkheim’s theory and
attempted to operationalize his concept of ‘social integration’ as the ‘stability and
durability of social relationships’. They theorize that when people’s role configurations
are filled with conflict they try to leave it, when they can’t do that they leave life. Thus
the degree of trouble a person may have in maintaining status integration, the more
determining it’ll be of his intend to commit suicide.
7. Powell’s Status and Anomic theory of suicide
Powell (1958) also drew from Durkheim’s theory to propound his theory which assumes
that individuals kill themselves when they cannot validate their ‘selves’ through the
normally approved form of status activity. This is essentially a form of the frustration-
leads-to-suicide theoretical assumption.

His scheme can be represented as follows:

Social Institutional Conceptual system (esp. work roles)

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status system

1. Dissociation from conceptual framework Anomic

2. Envelopment of self by cultural norms

 Self cannot act (impotence of self)

 No validation of self ( ‘unlived life’)
 Suicide (?high suicide probability)

8. Ecological theories of suicide

Lorbaugh’s (1928) study of the ‘dweller in furnished room’ was one of the first studies to
relate suicide to physical aspects of the city, to types of social relations caused by
physical and population factors of the city.
Schmid (1933) emphasized the suicidogenic effects of the core areas of the city and tried
to show that the risk and rate steadily decreases as one moves out towards the suburbs.
Most other sociologist adopting the ecological perspective emphasized the population
variable as dominant causes for social disorganization assumed to cause suicide. The
most important causes of disorganization are variables of mobility, social anonymity and
rate of social relations contact.
However, this viewpoint doe not have evidence supporting their thesis.
Later work on ecological understanding of suicide was done by Sainsbury (1955) who
gave the multi factorial approach. Apart from social disorganization he also emphasized
the over all effects of the characteristics properties of populations and also ‘neighborhood
factors’. He studied variables of ‘social status’ like unemployment, poverty, n loss of
status etc in relation to suicide. However, even his analysis was merely an attempt at
weighting potential correlates of suicide.
Cavan (1928) had already delineated the most important crises to be:
1. Unidentified craving that is frustrated
2. Recognized wish that is frustrated
3. Specified wish that is frustrated
4. Mental conflicts
5. Broken life organizations
Ecological theories suffered from many drawbacks. None of them developed ideas about
the relations of specific social and individual meaning to suicide. None of them were very
clear of the problems involved and none of them attempted self to suicide.

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 9. Status change theories of suicide
Along the lines of Sainsbury’s use of the concept of ‘status change’ other theorists have
propounded explanations of suicide as an outcome of change specifically loss of social
status.
(1) Gibb’s & Porterfield’s theory (1951): they identify significant variables which are:

 Long term status change

 Relative lack of strong social ties
 Personal crisis
Crisis is the fundamental variable of their theory but they provide no definition of this
variable.
Biological Factors

Mobility Tension
up

Social Structure Lack of support p (Suicide)

Mobility Frustration Crisis p (Suicide)

down of social
expectations

10. Breed’s status change theory

Breed (1963): emphatically argued the loss of status as he only major cause among many
‘complex phenomena’. He implicitly assumed that suicides are deviant behavior,
ultimately a product of structured strain and caused by difference between a standard and
ego actions.
(1) Social structure of Social situation the evaluation of individuals’
values & roles person is in role performance
(2) Individual factors Individual role Individuals’
evaluations
performance
(1) + (2) Strain Increased probability

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 of suicide in individuals

While Breed’s theory has better empirical evidence, it is still very restricted in ways
intended to support the statistical hypothesis.
11. Halbwach’s subcultural theory of suicide
Halbwach (1930) believed that relations between rural-urban residence suicide rates were
the most important empirical relations to be obtained. He proposed that “way of life” a
concept similar to ‘culture’ is the determining factor for the degree of differentiation of
social life. He then argued that this social differentiation/ complexity in greater degree,
cause greater rate of suicide because it causes certain situations that are more conducive
to social conflicts. These conflicts cause a tendency to depression which may lead to
suicide. Halbwach has stated the fundamental importance of meaning situated motives of
individuals in causation of suicide.
Way of life of a Degree of differentiation of their
group of individuals social life

Situations of individuals

Sentiments and moments

of the individual

Suicide tendency of individual which sums

up to a suicide rate for the group

12. Henry and Short theory of suicide (1954)

They consider suicide as a form of aggression and therefore look at it with the framework
of the frustration-aggression theory. They through a series of hypothesis infer that
frustration leads to increase in homicide or suicide. In stating so, they assume that an
increase in general economic gain will lead to decreased frustration and consequently
decreased aggression and an increase in the same will lead to an increase in frustration &
aggression. Additionally, an individual will express or direct his aggression against the
objects to which he imputes generalized responsibility of his frustrations. The direction of
imputation of responsibility is determined by the degree of external restraints on the
action, such that a high degree of external restrain will lead to imputation to alter and a
low degree of the same will lead to imputation of the ego.

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Since this degree of general restraint is determined by social strata, the lower classes tend
to see themselves as hopeless victims of forces beyond their control & the upper middle
class tend to regard themselves as the masters of their own fates. Thus the upper class
people will have to accept personal blame for responsibilities of economic, social
failures. In extreme cases, such self blame can lead to suicide.
The limitations of this theory are manifold. Among other, one criticism is that it does not
achieve a synthesis of psychological & sociological variables. Rather it is another
multifactor approach to suicide.
13. Gold’s theory of suicide
Martin Gold’s (1958) socio-psychological theory extends Durkheim’s work. It posits that
socialization of aggression is the fundamental determinant for preference of suicide or
homicide. The type of socialization normally associated with outward expression of
aggression found mostly in lower classes and the type of socialization normally
associated with aggression is more frequently seen in upper classes. Gold does not
attempt to show that social position of the individual has any causal effect on their
socialization practices. But it is possible that an individual with a tendency to express
aggression outwardly and to socialize their children outwardly are lower class because of
this tendency rather than social class being causative in outward expression.
This theory has been criticized because there is no clear differentiation between
psychological individual factors and sociological factors. There is little evidence of the
fact that socialization of normal aggression has anything to do with rare actions like
suicide.
CULTURAL DIFFERENCES IN SUICIDE
Culture is an important lens through which one needs to explore and understand suicide.
In order to make forays into interventions, one needs to understand the significance and
import of culture in influencing suicide. Suicide differs across various cultures. There is
prevalence of 25 per 100,000 suicide rate among some northern European countries and
Japan. Japan, though not welcomed, has accepted suicide. An example of a specific form
of suicide is ‘Seppuku’. It is a form of Japanese ritual suicide by disembowelment. Part
of the samurai honor code, seppuku was used voluntarily by samurai to die with honor
rather than fall into the hands of their enemies, as a form of capital punishment for
samurai who have committed serious offenses, and for reasons that shamed them. The
most famous form of seppuku is also known as hara-kiri, which is a colloquial version of
seppuku. Suicide rate is also influenced by religious diktat. In countries like Ireland and
Greece, which has strong religious prohibitions against suicide, the rates are as low as 6
per 100, 000.
GENDER DIFFERENCES
The basic sex difference in suicide is that males kill themselves more than females,
although this is not evident in China (Pritchard, 1996 as cited in Leenaars, 2006). In
contrast, females attempt suicide more often than males, and this sex difference has been

79
found in almost all nations (Lester, 1992). The generally accepted male–female ratio of
completed suicides is 3–4 males to 1 female, but there is great variation around the world.
Gender differences are evident in the methods employed for suicide as women use less
lethal means than men (Leenaars, 2006).
MYTHS AND FACTS ABOUT SUICIDE
There are many misconceptions around suicide (Shneidman & Mandelkorn, 1967 as cited
in Leenaars, 2004).
1. Fable: People who talk about suicide don’t commit suicide.
Fact: Of any 10 persons who kill themselves, 8 have given definite warnings of their
suicidal intentions.
2. Fable: Suicide happens without warning.
Fact: Studies reveal that the suicidal person gives many clues and warnings regarding
suicidal intentions.
3. Fable: Suicidal people are fully intent on dying.
Fact: Most suicidal people are undecided about living or dying, and they “gamble with
death”, leaving it to others to save them. Almost no one commits suicide without letting
others know how they are feeling.
4. Fable: Once a person is suicidal he or she is suicidal forever.
Fact: Individuals who wish to kill themselves are suicidal only for a limited period of
time.
5. Fable: Improvement following a suicidal crisis means that the suicidal risk is over.
Fact: Most suicides occur within about three months following the beginning of
“improvement”, when the individual has the energy to put his or her morbid thoughts and
feelings into effect.
6. Fable: Suicide strikes much more often among the rich—or, conversely, it occurs most
exclusively among the poor.
Fact: Suicide is neither the rich person’s disease nor the poor person’s curse.
Suicide is very “democratic” and is represented proportionately among all levels of
society.
7. Fable: Suicide is inherited.
Fact: Suicide is not inherited. It is an individual pattern.
8. Fable: All suicidal individuals are mentally ill, and suicide always is the act of a
psychotic person.

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Fact: Studies of hundreds of genuine suicide notes indicate that although the suicidal
person is extremely unhappy, he or she is not necessarily mentally ill.
RISK FACTORS FOR SUICIDE
Psychiatric illness: Suicide is a model of psychiatric emergencies and is also the
commonest cause of death among the psychiatric patients. At least 90 percent of people
who kill themselves have diagnosable and treatable psychiatric illnesses -- such as major
depression, bipolar depression, or some other depressive illness, including schizophrenia
alcohol or drug abuse, personality disorders especially borderline or antisocial.
Depression is the most common underlying disorder among people who attempt suicide
and Beck (1995) states that hopelessness is the single best clinical predictor of suicide in
depressed clients. Genetic factors and biochemical factors are also found to be
contributing to risk of suicide. A clear relationship has been demonstrated between low
concentrations of the serotonin metabolite 5-hydroxyindoleactic acid (5-HIAA) in
cerebrospinal fluid and an increased incidence of attempted and completed suicide in
psychiatric patients.
Past attempts: Between 20 and 50 percent of people who kill themselves had previously
attempted suicide. Those who have made serious suicide attempts are at a much higher
risk for actually taking their lives.
Verbal, behavioral, cognitive clues: As many as 75-80% of all people who committed
suicide gave pre-suicidal clues. Sudden preoccupation with death, engaging in life
threatening behavior, sense of being emotionally overwhelmed due to anger, anxiety,
emptiness, loneliness, loss, and sadness. Reporting to feel hopelessness or helplessness
and stating to meaninglessness of life and ones desire to end it, are all clues about
potential suicidal behavior.
Family history of suicide: The risk to suicide increases if there is history of suicide in the
family.
Illness and Disabilities: Patients with incurable or debilitating physical disorders like
cancer, AIDS, often commit suicide (22.5 % of all suicides, NCRB, 2003). Currently
research suggests that some physical illnesses are associated with suicidal behaviour,
including anorexia, bulimia, diabetes, epilepsy, traumatic brain injury, and muscular
dystrophy (Barraclough, 1986).
Environmental stressors: Psychosocial factors like failure in examination, love loss,
marital difficulties, family dispute, financial difficulties, occupational concerns; all
increase the chances of emotional distress which in turn puts one at a risk for suicide.
Research on interpersonal factors shows that family risk factors for youth suicidal
behavior has been linked with negative parent-child relationship (e.g. high conflict, low
closeness), child maltreatment, residing with less than two biological parents, and family
history of affective and antisocial disorders Parental separation and family history of
alcohol abuse are more strongly associated with completed suicide than with other
suicidal symptoms and insecure parent-child attachments are more consistently

81
associated with nonfatal suicidal symptoms than completed suicide (Martin, Catherine,
2003)
Age, Race, Sex: Most studies done in American European setups reflect that 70% of
suicide completers are white male. Elderly Caucasian males have the highest suicide
rates. Males are three to five times more likely to commit suicide than females.
In a study by Tanuj and Jena (2006), the risk factors found in Indian adolescent boys
included- Hindu religion, female sex, older adolescent, physical abuse by parents, feeling
neglected by parents, history of running away from school, history of suicide by a friend,
death wish and deliberate self harm were found to be significant risk factors for NFSB.
BEHAVIORAL SIGNS/ PREDICTORS OF SUICIDE
Behavioral changes: Sudden crying spells, withdrawal, or engaging in life threatening
behavior could indicate distress which can be preliminary behavioral indications of
potential suicide attempt.

Suicide notes: Suicide notes are important clues. Notes are very rarely written by
children, but are somewhat more frequent among adolescents. About 18–37% of adults
leave notes (samples have varied greatly).
Untimely wills: Preparation of untimely will, giving away of prized possessions are all
signs of preparation or awareness of impending death. This could indicate towards plan
related to attempting suicide.
Although there has been an increase in the number of reported cases of suicide in the
past, it is speculated that there are equal, if not more, number of cases that go unreported
and unnoticed. Whether a person commits suicide or decides to live despite the pain, the
study of factors which potentially influences the decision becomes very important. This
perhaps will help us fathom the otherwise mysterious and sometimes incomprehensible
aspect of – Suicide.
KEY REFERENCES
Ahuja, N. (2006). A Short Textbook of Psychiatry. 6h ed.: Jaypee Brothers Medical
Publishers. New Delhi
Leenaars, A (2004). Psychotherapy with suicidal People: A person centered approach.
John Wiley & Sons, Ltd.
Sidharth, T. & Jena, S. (2006). Suicidal Behaviors in Adolescents. Indian Journal of
Pediatrics, Volume 73—September

Yadawd, B.S. & Gauda, H.S (2005). Is attempted suicide an offence? JIAFM, 27
(2). ISSN 0971-0973

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 UTTARA CHARI
SUBMITTED TO: DR. ANISHA SHAH
Social Class, Gender, Religion, and Mental Illness
The culture-bound syndromes are testament to the fact the socio-cultural factors
play a significant role in the expression of human distress. Even illnesses considered
universal such as depression and psychoses manifest differently across age, gender, social
class, nationalities etc. It is for reasons of this variability that trans-cultural/multicultural
psychology has emerged as a fourth force within the field (Smith, 2004).
Pedersen (2004) asserts that cultural encapsulation influences the defining of
normal and abnormal behaviours. Cultural encapsulation refers tendency to believe what
is present within the cocoon of one’s existence as the ideal/norm (Pedersen, 2004). The
etic perspective, embedded within this notion, assumes human condition and experience
to be universal, and culture to have a marginal pathoplastic effect in its expression.
Modern classification systems, for instance the Diagnostic and Statistical Manual of
Mental Disorders (DSM) are prey to this bias. Despite the accommodation of the etic
perspective through the inclusion of culture-bound syndromes, the debates regarding
cross-cultural applicability are paramount. As Thakker and Ward (1998) assert, “the
cultural additions in the DSM-IV demonstrate a move toward a general acceptance of
differences in psychopathology across cultures….this move is undermined by the
assumption that disorders included in the main text are essentially universal” (p. 503).
Thus, there is clearly a need to incorporate cultural factors in the understanding of human
behaviours, more so with deviancies as it is primed to affect their management.
Culture may be defined as “the characteristic values, behaviours, products, and
worldviews of a group of people with a distinct sociohistorical context” (Smith, 2004, p.
329). The term is broad, comprising of many variables. For instance, the assessment
framework developed by Pamela Hays involves the following (Smith, 2004):

83
A: Age and generational themes
DD: Developmental and acquired disabilities
R: Religion and spiritual orientation
E: Ethnicity and race
S: Socioeconomic status
S: Sexual orientation
I: Indigenous heritage
N: National origin
G: Gender
Thus the list of cultural variables is exhaustive yet comprehensive. India, in
maintaining its unity in diversity is home to some of the most distinctive religions and
social classes. Essentially a patriarchal country, gender related concerns are also
significant in the day-to-day lives of its citizens. Thus, it would seem most viable to
examine the association between these variables and mental illness in the country.
Hwang, Myers, Abe-Kim, Ting (2008) in proposing the Cultural Influences on
Mental Health Model (CIMH) suggest that culture influences the prevalence,
phenomenology, etiology and course, assessment and diagnosis, treatment of mental
illnesses, in addition to the coping styles and help-seeking behaviours of people.
Research has spanned all facets of influence and considerable knowledge has been
gained. However, the starting point in understanding any illness pattern is its prevalence.
Thus it seems most beneficial to examine this facet within the Indian and international
context.
The ensuing discussion shall explore the influence of social class, gender, and
religion on mental illness, with a focus on prevalence rates. Theories highlighting the
association between these variable and mental illness will be examined.
Social Class:
Every society has marked distributions based on economic and social resources.
The common sense notion of social class is that it is “the relative standing of an
individual in his or her larger society with regards to education, social networks,
employment, and economic power and potential” (Smith, 2004, p. 336). This stratified
approach to understanding social class assumes an etic perspective in that individuals
from a designated social class are deemed similar and suffer equivalent consequences.
There have been attempts to incorporate elements of the etic perspective. One such
attempt is the Social Class Worldview Model (SCWM) proposed by Liu (Smith, 2004).
According to this model, social class is “the inequalities that arise between people when
individuals understand the economic expectations of their environment and behave to
meet these demands” (Smith, 2004, p. 296). This model adopts an interactional

84
perspective, incorporating subjective interpretations of social class and societal demands.
Belonging to a particular class in itself is not damaging, and there are mechanisms that
contribute to either healthy or unhealthy consequences (Masten, 2001).
Studies have frequently found higher prevalence of psychiatric disorders among
persons belonging to the lower social classes (Murali & Oyebode, 2004). Among this
group, unemployment was to be a confounding factor, significantly increasing the
percentage of mental illnesses. In evaluating the findings of Office of Population
Censuses and Surveys (OPCS) study, Murali & Oyebode, 2004 find that unemployment
“significantly increased the odds ratio of psychiatric disorders” (p. 217). It was found to
quadruple the odds for substance dependence, triple the odds for phobia and functional
psychoses, and double the odds for depression and other neurotic disorders (Murali &
Oyebode, 2004).
Indian studies examining the relationship between social class and mental illness
have reported equivocal results, possibly due to differences in study methodology. The
biggest point of difference arises in comparisons of rural and urban populations. When
exclusively considering the urban population, findings have been similar to international
studies. Patel, Araya, de Lima, Ludermir, Todd (1999) in their study carried out in Goa
found lower social classes to have higher rates of Common Mental Disorders. Varma,
Wigg, Murthy, Misra (1980) found affective psychoses to be more prevalent among
individuals from lower social classes. The International Pilot Study on Schizophrenia
(IPSS) found the prognosis of schizophrenia to be better in developing countries than in
developed countries (Murray, Jones, Susser, Van Os, & Cannon, 2003). The sample from
Agra in India showed the best prognosis with reduced rates of remission (Murray et al.,
2003).
Miech, Caspi, Moffitt, Wright, and Silva (1999) reported differential influence of
social class across the four categories of anxiety, depression, antisocial, and attention-
deficit disorders. Social class was associated with all four disorder categories but varied
in their impact as a causal or consequent factor. Lower social class was found to be a
causal factor for anxiety and antisocial disorders. Lower social class was also a
consequence for antisocial and attention-deficit disorders. There was no significant
directional pattern for depression.
The debate regarding social class being a causal or consequence variable in the
epidemiology of mental illness has contributed to the development of breeder versus drift
hypothesis. The social causation (breeder) and social selection (drift) theories prompted
by research into schizophrenia, have often been applied to other categories of disorders.
The social causation theory postulates that greater socio-economic adversity
experienced by individuals from lower social classes’ precipitates psychosis in vulnerable
individuals (Murali & Oyebode, 2004). Alternatively, social selection theory asserts that
individuals with a mental illness move downwards towards the lower socioeconomic
strata due to being unable to function at the upper strata of society (Murali & Oyebode,
2004). Thus belonging to lower social class becomes the consequence of having a mental
illness.
A theory that possibly considers both facets of causation and consequence is the
Anomie theory put forward in 1957 by Merton (Michener, DeLamater, & Myers, 2004).
According to this theory, socially deviant behaviour arises when people have inadequate
resources to achieve socially valued goals, for example wealth. Thus belonging to a lower

85
social class is a causal factor. When lacking in resources, individuals reach a state anomie
– a state that reduces commitment to norms or pursuit of goals. In the background of this
state, individuals respond in one of four ways: ritualism – reject goals, but continue to
conform to social norms; retreatism – reject goals/means and withdraw from active
participation in society; innovation – remain committed to goals however use
inappropriate ways to achieve them; rebellion – overthrow the system and create different
goals/means. Individuals have a propensity of developing any of the mental illnesses
based on the response to the state of anomie. Also in the face of maladaptive responses,
the individual may be unable to function adequately due to use poor coping resulting in a
drift towards lower social classes.
A less popular theory is the social reaction hypothesis that suggests that
individuals from middle and upper classes tend to rate a person from a lower class as
being more disordered than themselves (Gove, 1972). This theory brings to light the etic
perspective where the behaviour of an individual from a lower social class is considered
deviant if it does not fit in with the norms of the middle and upper classes.
Thus, an examination of the association of social class with mental illness
suggests higher prevalence of disorders among persons from lower social classes.
However, being only correlational, the cause-effect relationship cannot be deduced. Thus,
there is a requirement to further explore the mechanisms and direction of influence
between social class and mental illness.
Gender

The terms sex and gender are often used synonymously. Sex relates to the
biological/anatomical aspects of being male or female, whereas gender refers to the social
aspects. This also however is not an absolute distinction. Modern thought conceptualizes
sex also to be a socially constructed term wherein the finer physiological aspects of being
male or female are determined by the society/culture. Simultaneously in discussing
gender, the social aspects are often coloured by the physiological aspects. For instance, a
society where one of the male’s roles is to carry out hard physical labour is influenced by
the fact that they are physically resistant possibly due to higher testosterone levels. Thus,
current conceptualizations of gender and sex overlap and hence mental health research
focusing on either factor is equally relevant. The World Health Organization (2002)
asserts:

“socially constructed differences between women and men in roles and

responsibilities, status and power, interact with biological differences between the sexes
to contribute to differences in the nature of mental health problems suffered, health
seeking behaviour of those affected and responses of the health sector and society” (p. 1).

Historically men have been deemed as being “rational” whereas women as

“emotional” along with men being perceived as wrong “doers” and women as
“disordered” (Wild, 2005). Although findings of both Indian and international studies
have been equivocal, there is consensus that women have higher rates of mental illness
(Davar, 1999; Gove, 1972; Gove & Tudor, 1973). Within the Indian context, prevalence

86
rates for mental illness for men and women are around 10.48% and 14.45% respectively
(Davar, 1999). There have been attempts to study socio-demographic aspects of this
distribution such as, single versus married persons. Indian studies have found that
irrespective of socio-demographic category, “more women show up with symptoms than
men” (Davar, 1999). This is in contrast to international studies that have reported
equivalent prevalence rates for mental illness among single men and women (Gove,
1972; Gove & Tudor, 1973). International findings for married persons have been similar
to Indian studies (Gove, 1972; Gove & Tudor, 1973).
In reporting prevalence rates, Davar (1999) differentiates between severe mental
disorders (schizophrenia, bipolar disorder) and common mental disorders (depression,
obsessive-compulsive disorder, anxiety, phobia, and somatisation). Indian studies have
not found any significant gender distribution for severe mental disorders (Davar, 1999).
However when common mental disorders are compared, there is a found to be a higher
prevalence for women than men with rates of around 10.35% & 6.8% respectively
(Davar, 1999). Alcohol dependence and violence are more common in men (Davar,
1999). International studies have reported similar results. The World Health Organization
(2002) found no consistent gender distribution for severe mental disorders, although men
had an earlier age of onset for schizophrenia and women to had more severe forms of
bipolar disorder. Depression and anxiety were more common in women, while substance
use disorders and antisocial behaviours were common in men. (World Health
Organization, 2002).

Thus, both international and Indian studies report higher prevalence of mental illnesses
among women. Disorders conventionally thought to be falling into the neurotic category
are more common in women, while disorders characterized by addictive and acting out
behaviours are more prevalent in men.

Women have been suggested to have a biological predisposition for mental illnesses. It
was postulated that “hormonal changes occurring during different stages of the
reproductive cycle” dispose women developing mental illnesses (Davar, 1999). This
theory however was disputed due to its failure to account for the fact that not all women
develop mental illnesses. It was also disapproved by feminists who expressed that the
theory degrades female physiology, which in turn is likely to affect the self-concept of
women (Davar, 1999).

Gove (1972, 1973) proposed a theory based on the roles occupied among men and
women to explain the differing rates of mental illnesses. He began with the proposition
that married women have a “fragile structural base” as they usually tend to occupy one
major role of being a home-maker, in contrast to men who occupy two roles, i.e., of a
household head and worker. Having two roles is beneficial as one is likely to gain
gratification from both roles and also have a backup in case of failure in one role. This is
unfortunately not the case with married women. Given this background, Gove (1972,
1973), compiling various studies proposed the following factors to explain the higher
prevalence of mental illnesses among women:

87
  Household chores are not very challenging and hence may be demotivating and
lowering of “prestige” for women. The chores also permit time for contemplating
and brooding, leading to greater distress.

 Even when employed, women are often discriminated against and compelled to
occupy positions that do not commiserate with their skill and/or educational
background. Their income is likely to be considered as ancillary. They are also
simultaneously engaged in taking care of the household. All these factors together
or individually are likely to contribute to higher levels of distress.

 Expectations confronting women from society are unclear and diffuse. This lack
of specificity, uncertainty, and lack of control over life can be frustrating.

 Women tend to have more problems in dealing with their children and that they
more frequently feel inadequate as a parent.
Gove (1972, 1973) reported that both single men and women have only one major
societal role, that of jobholder. Thus, the demands on both are likely to be similar,
resulting in similar prevalence rates for both genders internationally. However, the higher
rates reported for single women in Indian may be due to factors such as discrimination,
taboo about working, economic hardship forcing women to work, all of which are still
prevalent in Indian societies. The strength of Gove’s theory is that it took into account
cultural factors. However, it is to be seen whether the theory still holds true in today’s
where the attitudes, values, and norms have considerably changed.
In summary, women are found to have greater prevalence of mental illnesses.
Theories examining this association have been few, possibly due to the vast societal
differences in the conceptualization of gender and its roles. This is especially important,
as mental illnesses have been found to vary across cultures.
Religion
Religion has always played a dominant role in the understanding and expression
of mental illness. Historically mental illnesses were considered to be due to evil/demonic
factors. Subsequently treatment of mental illness included practices such as exorcism,
atonement, purification, and so forth. Over the years, religion has also found to play a
protective role in preventing mental illnesses. The association between religion and
mental illness has a long and wide past, which is likely to continue into the future.
There is considerable debate over defining and conceptualizing religion. Clark
(1958) offers a comprehensive definition of religion as the “inner experience of the
individual when he senses a Beyond, especially as evidenced by the effect of this
experience on his behaviour when he actively attempts to harmonize life with the
Beyond” (p. 22). This definition asserts three components of religion, namely subjective
(inner experience), supernatural (Beyond), and behavioural (harmonize life). Deviances
in the behavioural component are likely to find expression as psychopathology.
Religious behaviour may primary, secondary, or tertiary (Clark, 1958). Primary
religious behaviour refers to authentic inner experiences of the divine combined with the

88
efforts made to harmonize his life with the divine. Secondary religious experience refers
to certain behaviours/habits carried out without an intense subjective experience, more as
a function of the primary behaviour. Tertiary religious behaviour refers to routine or
convention accepted on the authority of someone else. An example from
psychopathology including all three behaviours would be behaviours of the trance
possession syndrome (primary), carrying out rituals consequent to trance possession
(secondary), and seeking assistance of faith healers due to the insistence from significant
authority figures (tertiary). As illustrated in this example, the association between religion
and mental illness goes beyond subjective experiences to the inclusion of interpretations
of these experiences by others and subsequent treatment.
Studies that have examined the relationship between religion and mental illness
have found religion to play a role in affective disorders and paranoid schizophrenia
(Clark, 1958). The relationship between religion and suicide is unequivocal. Studies
report that factors such as personality and social resources/class have an interaction effect
with religiosity in deterring individuals from suicide (Morphew, 1968 cited from Clark,
1975). Religiosity is found to have an inhibitory effect on impulse control/addictive
behaviours such as in drinking and sexual acts (Clark, 1958). However, parental
religiosity is found to be associated with greater drinking in the children (e.g., Walters,
1957; Wittman, 1939 cited in Clark, 1975).
Koenig (2001) posits four reasons for religiosity being associated with better
coping, seen in the reduced rates of suicide and addictive behaviours. Firstly, religious
beliefs facilitate the inculcation of a meaning and purpose for life. Secondly, religious
beliefs and practices evoke positive emotions. Thirdly, religious rituals sanctify major life
transitions such as during puberty/adolescence, which promote better community support
during such periods. Finally, religious beliefs provide guidance on acceptable and
normative behaviours. Taken together, these four factors buffer an individual against
maladjustment and psychopathology. With specific reference of increased alcohol
consumption among children from religious homes, it has been postulated that in the face
increased religiosity, children take on a “rebellious” stance and have make a choice of
either heavy drinking or abstinence, frequently the former (Straus & Bacon, 1953;
Skolnick, 1958 cited in Clark, 1958).
In explaining the psychopathy manifested across affective and psychotic illnesses,
differential learning, exposure, and cultural milieu are postulated to be influence
symptom expression (Hamilton, 1961 cited in Argyle & Beit-Hallahmi, 1975).
Boisen (n.d., cited from Clark, 1958) considers the catatonic state of withdrawal
to be due to “wrestling” with personal problems. When these problems revolve around
great concerns of life, they become religious in nature. Any messianic delusion
(grandiose delusion) accompanying this state is reflective of the acceptance and practice
of social responsibility by the individual. This delusion keeps the individual grounded in
reality as he/she becomes aware of social responsibilities; thus sometimes offering greater
stability than before. However, if the problem “breaks” the individual forcing him to give
up, it is leads to states of simple/paranoid/hebephrenic schizophrenia. This theory seems
plausible until the extent of stating that an individual in a catatonic state withdraws as
he/she deals with the issues of concern, possibly of a philosophical nature. However, the

89
account of a messianic delusion being grounded in reality is difficult to accept, as the
defining feature of a delusion is morbidity in origin. Nevertheless, this theory facilitated
substantial research into the religiosity as psychopathy and those exhibited by
mystics/ascetics. An examination into this facet is especially beneficial for the Indian
context as it is steeped in religious sentiment and fervour, and home to many religious
heads/mystics/ascetics.
Clark (1958) discusses two factors that religious geniuses (mystics) share with
individuals with a psychotic illness. These are: (1) a tendency to withdraw and isolate self
from others, and (2) tendency to act out on central impulses with less than normal
inhibition. The author suggests one strategy to differentiate between the two experiences,
namely morale-building, not of self but of others, society at large. It is proposed that a
religious genius’ touch with reality allows him/her to actually accomplish this task.
Argyle and Beit-Hallahmi (1975) propose to differentiate between the two groups across
three areas; personality structure, sociological climate, and historical aspects. They
suggest that a religious genius of yesteryears may possibly be regarded an individual with
a psychotic illness currently as the sociological climes would have changed. There are
also differences in the personality structure of both groups of individuals in that the
religious genius would have to be more organized and socially adept in
communicating/relating to others. These theories of Clark (1958) and Argyle & Beit-
Hallahmi (1975) taken together have significant implications for the psychologist as it
lies in his/her hands to differentiate between the two groups of individuals on the criteria
provided. Concurrently, the psychologist also needs to be alert to his/her own religious
beliefs and sentiments while assessing another. Thus, possibly no other cultural variable
holds as much significance as religion, emphasizing the need to further explore this
domain.
References
Argyle, M., Beit-Hallahmi, B. (1975). The social psychology of religion. London:
Routledge
Clark, W.H. (1958). The psychology of religion. NewYork: McMillan
Davar, B.V. (1999). Mental health of Indian women: A feminist agenda. New Delhi: Sage
Publications
Gove, W.R. & Tudor, J.F. (1973). Adult sex roles and mental illness. The American
Journal of Sociology, 78, 812-835.
Hwang, W., Myers, H.F., Abe-Kim, J. & Ting, J.Y. (2008). A conceptual paradigm for
understanding culture's impact on mental health: The cultural influences on mental health
(CIMH) model. Clinical Psychology Review, 28, 211–227.

Koenig, H.G. (2001). Religion and medicine II: Religion, mental health, and related
behaviours. International Journal of Psychiatry in Medicine, 31, 97-109.
Masten, A.S. (2001). Ordinary magic: Resilience process in development. American
Psychologist, 56, 227-238.

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Miech, R.A., Caspi, A., Moffitt, T.E., Wright, B.R.E., Silva, P.A. (1999). Low
socioeconomic status and mental disorders: A longitudinal study of selection and
causation during young adulthood. The American Journal of Sociology, 104, 1096-1131.
Michener, H.A., DeLamater, J.D., Myers, D.J. (2004). Social psychology (5th ed.). New
York: Wadsworth Publishing
Murali, V. & Oyebode, F. (2004). Poverty, social inequality and mental health. Advances
in Psychiatric Treatment, 10, 216-224. Retrieved on February 21, 2009, from
http://apt.rcpsych.org/cgi/content/full/10/3/216
Murray, R.M., Jones, P.B., Susser, E., Van Os, J., Cannon, M. (Eds.) (2003). The
epidemiology of schizophrenia. Cambridge: Cambridge University Press. Retrieved
February 21, 2009, from Google Book Search database.
Patel, V., Araya, R., de Lima, M., Ludermir, A., & Todd, C. (1999). Women, poverty and
common mental disorders in four restructuring societies. Social Science and
Medicine, 49, 1461-1471.
Smith, T.B. (Ed.). (2004). Practicing Multiculturalism: Affirming diversity in counselling
and psychology. Boston: Pearson Education, Inc.
Thakker, J. & Ward, T. (1998). Culture and classification: The cross-cultural application
of the
DSM-IV. Clinical Psychology Review, 18, 501–529.
The World Health Organization (2002). Gender and mental health. Geneva, Switzerland:
Author
Varma, V.K., Wig, N.N., Murthy, R.S., Misra, A.K. (1980). Socio-demographic correlates
of schizophrenia, affective psychoses, and neuroses in a clinic in India. Acta Psychiatrica
Scandinavica, 61, 404-412.
Wild, L. (2005). The sociology of mental illness. Document posted in University of Bath
website http://people.bath.ac.uk/ssxlw/The%20Sociology%20of%20Mental
%20Illness.ppt

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 HESI S HERBERT

SUBMITTED TO: DR. AHALYA RAGURAM

CULTURAL MODELS OF MENTAL ILLNESS

Culture has a complex and multifaceted relationship with manifestations of

psychopathology. Culturally- determined variations on the symptoms of major psychiatric
disorders constitute the most well-recognized aspect of such interface.The
phenomenology, course and outcome of mental disorders may be dependent to a great
extent on socio-cultural factors. Therefore analysis of the transcultural differences in
these may be helpful in separating out the culturally- generated features from others.
While the differences across Acultures may be related to the interaction of the illness with
the socio- cultural variables, the similarities, ‘the universals’ of the illness may reflect the
core and basic nature of illness. Although culture evolves as a group solution to the
problems of human existence and should be something positive and beneficial to
mankind, it has often been viewed as constraining and limiting human beings; as having a
generally undesirable and deleterious effect.

Social factors : this includes a multiplicity of events in the human environmental

sphere such as, social status, economic status, institutional affiliation, age, sex, race,
class, nature of ecological stress. Social, however also implies the prevailing social
structure, the degree of autonomy, mobility, and legitimate power in it. The central
question about the ways in which the social conditions make it significantly more likely
for the occurrence of psychopathology. The literature seems to suggest quite clearly that
neither race nor socioeconomic issues serve to explain adequately the higher frequency of
one class more than another among the mentall ill. A holistic social view is necessary.

Culture: it summarises a multivariate entity, from child-rearing practices to

kinship systems. It is the total way of life of a group of human beings, primarily the
shared patterns of values, beliefs, and feelings which are characterized by a distinct world
view, codes of conduct, definition of reality to satisfy biological and psychological needs.

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Culture guides values which serve as its major premise and foundation. The central
concern with regard to culture and psychopathology is how behaviour is structured,
organized, and influenced by underlying cultural rules or the extent to which cultural
reality creates conditions of vulnerability, making the advent of mental illness more likely
for individuals, group, the culture as a whole.

Socio-cultural factors

Social Class: it has been studies in relation to many aspects of psychopathology, but one
finding of particular interest is its association with schizophrenia. A relationship between
low social class and increase and prevalence of schizophrenia has been found. This
association is attributable either to social drift (schizophrenics do not achieve the
educational and occupational levels of their parents) or to the presumed effects of social
class.

Labelling: it seems more likely that the major impact of labelling is on the course of
disorder not as the original cause of disorder. The labelling effect may be increased by
other socio cultural factors such as high unemployment rates or cultural belief systems
that mitigate against the ex-psychiatric patient being employed, getting married, or
otherwise being accepted in the society as others are.

Social Supports: a major sociocultural factor influencing psychopathology is availability

of social supports. As suggested earlier, such supports may help buffer the individuals
against personal crises. They have an impact in childhood and adolescence, influencing
the development of self-esteem or coping capacities. Probably they also operate after
onset of disorder, to provide some limit on what the person is required to manage and
some solace and companionship in his attempt to do so.

Culture and Personality

The cross –cultural differences in personality configurations can be summed up as those

relating to as follows:

a) Fulfilment of biological needs: all human beings are born with certain undeniable and
unalterable biological needs. Such biological needs include the nutritional, eliminative
and sexual. Societies differ from each other in the handling of these. Rather than frank
acceptance of these needs the society in general may engage in the denial of it.

b) Social relationships and needs: the interrelationships between individuals in a society

may be characterized by more or less interdependence. This can be understood in a
dependence autonomy continuum. The dependent person has a greater need to seek for,
and capacity to accept, support. Greater autonomy involves greater responsibility.
Personal vs. Group identity and delimitation of ego-boundaries may be related to
dependence and autonomy. The dependent individual is more likely to identify with and
depend heavily on his primary group. The autonomous individual makes clearer
distinctions between him and others, is more conscious of his rights and prerogatives as

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well as responsibilities, and is more orderly, competitive and achievement- oriented on an
individual basis.

c) Cosmic, existential and religious values and needs: Some concept of cosmology is one
of the universals of human societies. Some concept of the nature and meaning of one’s
existence also permeates most societies, and individuals try to transcend their own
existence, admittedly with limited success. Man also likes to share, with some
Supernatural being, responsibility for his success, failure and fate. Further man’s
narcissism does not permit him to view his own life as limited and finite, and he needs to
invoke some concept of continuity of life. Finally the concept of God may represent
varying degrees of abstraction.

d) Cognitive styles: cultures differ from each other in cognitive style, ranging from
‘analytical’ to ‘synthetic’. The analytical mind tries to understand things by dividing it
into parts, whereas the synthetic sees things in their totality and sees the relationships
between things or phenomena. It is possible that analytical thinking has been conducive
to scientific and technological advancement. On the other hand, the synthetic approach
may be more applicable in primary-group oriented societies with high dependence and
loose ego-boundaries giving rise to a richer network of interpersonal relationships.

e) Linguistic competence: Cultures may differ in placing emphasis upon the experiencing
of an event as opposed to recording and chronicling it by translating it into words.

National character/ Modal Personality

National character refers to relatively enduring personality characteristics and pattern that
are modal among the adult member of a society.

i) Dependency vs. Autonomy

It has been pointed out that the Indian person is more dependent upon each other
than is the case, for example, in the Western setting. As children, we depend upon our
parents. As we grow older, there is dependence upon peer group and spouse. When we
grow old, the tables are turned, we come full circle, and we start depending upon our
children. In this there is a beautiful system of inter-dependence with everybody leaning
on everybody else. Many manifestations of this inter-dependence in social intercourse,
and colloquial language and idioms and folklore have been pointed out by Varma. Most
of the folklores as also popular literature and art-forms are centred around giving and
receiving, a sense of piety, sacrifice, submission and gratitude, and idioms give references
to oral activities.

A related concept, most developed by Marriott is that of ego- boundaries. A sense of

personal identity requires that the person is able to distinguish between himself and
others ‘me’ vs. ‘not me’. This is my corpus and everything that lies outside is not-me. As
Marriott has pointed out, on contrast to the generally closed, homogenous and enduring
mental integrations attributable to the adult persons in the West, the Hindu adults are
posited as persons ‘ who are open, composed of exogenous elements, substantially fluid,

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and thus necessarily changing and interchanging in their nature. Given the vulnerability
of open Hindu persons to a cosmos of interpersonal flow, persons as wholes cannot be
thought of enduring or bounded ‘egos’ in any Western sense.

ii) Social ethos and communal responsibility:

In certain ways, there seems to be a selfish outlook as far as the Indian person is
concerned. To illustrate, although personal cleanliness is highly valued, eg.taking bath
once or several times a day, washing, etc., one does not bother much as to where the
pollute water goes and how it may affect others adversely.

iii) Omnipotence and narcissm

A sense of narcissm prevails to different degrees in all cultures and can be said to
have psychological survival value. As Popper has pointed out, the clear sky above (which
reminds him of the universe) and his own intellect (which helps him comprehend and
transcend the universe) are the two most important aspects of human existence. The same
sense of omnipotence betrays itself in epics and folklore.

iv) Obsessionality
One thing that strikes the Westerner in India is the lack of compulsivity in
performing a job. The predominant approach towards work seems to be to do it as
casually as you can get by with. There seems to be a lack of pride in doing a job well.
“Chalta hai” (will do) seems to be the prototype of one’s responsibilities. The Western
work ethic and compulsivity, meticulousness and thoroughness are generally at a low
premium.

v) Duality in value systems

In- built contradictions in moral and social values abound in virtually all cultures.
The contradiction between free-will vs. determinism prevails, more or less, in all cultures.
Your fate is pre-ordained, but you must do things to improve it, though even your wisdom
is pre-determined.

vi) Preoccupation with peace and fear of aggression

The Indian society, one is struck by a great deal of preoccupation with peace. The
religious functions begin and end with incantations for peace. Such an over-
preoccupation with peace may indicate a decadent rather than a developing society.
vii) Tradition –orientation
Indian mind is highly tradition oriented. In a way, such traditionalism makes for a
certain stability in the social structure. Progress in the present sense of technological
progress, much not be viewed simply as a matter of moving forwards or upwards. There
are many forces which restrict, retard or undo such progress. In this matter, we Indians
can be said to differ from several small nations with traditions not going so far back in
history and which are more easily swayed by every passing external influence.

Western personality traits can be summarized as consisting of the following.

1. Concern with lack of control over oneself.

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2. Righteous indignation, punitive super-ego.
3. Compulsivity, pride in doing a job well, activity and work are highly valued.
4. Reference in colloquial language about messing, dirtying
5. High guilt- proneness
6. Acquisitiveness
7. Insecurity, lack of permanency, competitiveness
8. Abhorrence of dependence
9. Contradictions in social values
10. Belief in equality of all, Humanitarian and egalitarian mores.
11. Belief in individual freedom.

The Indian mind thus lacks certain attributes of the Western Personality. The
concern with lack of control over oneself is not so great or so anxiety- or guilt-
provoking. The responsibilities are shared. The punitive super-ego and righteous
indignation of the Western, Puritanical, Calvinist society are difficult for an averge Indian
to understand. Finally, as opposed to the Westerner, the Indian is better able to extend
support to and accept it from his fellow human beings.

HOW SOCIOCULTURAL FACTORS PLAY ROLE FOR VARIATION IN ILLNESS

The cultural differences can be considered with regard to incidence, types,

manifestations, natural history, course, outcome and treatment of mental illness.

Schizophrenia
Schizophrenia is universal and about equally prevalent in all societies. Certain
studies have however pointed out cross-cultural differences in it. Observers from both
Africa and India agree that paranoid formations in schizophrenic patients under their care
are less systematized than in Euro- Americans. Wittkower and Dubreuil (1971) comment
on the paucity of delusional content in these patients. While chronic schizophrenic
catatonic states have become rare in Europe and America, they are common in India and
other Asiatic countries. The intense emotional anxiety of the West is seldom seen in the
East where confusion and perplexity predominate in early schizophrenics. The highly
systematized, bizarre and idiosyncratic delusions of the West are less well seen in the
East. The IPSS has documented a more favourable course and outcome of schizophrenia
in the developing countries. It may be that, in the developed countries, the illness has a
greater tendency to get more deeply entrenched and hence, less amenable to therapeutic
change.
Depression
Till only decades ago, it was widely believed that depression did not occur in the
non- Western, developing world. Ideas of sin and unworthiness were thought to be almost
non-existent. Ideas of sin and guilt are not uncommon in the East, although often these
may be assigned to karma or to the deeds of a previous birth in groups subscribing to
such beliefs. The tendency to somatise seems to be more common in the East. This may
be related to the tendency to convert the anxiety from the psychic to the somatic.

Mania

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 The classical effusiveness and frank grandiosity seen in the West is seldom
encountered in India. What is usually seen is some sort of dysphoria, irritability,
impatience and hostility.

Neurosis
The definition and diagnosis of neurosis is influenced to a considerable degree by
the subject’s perception of illness which may vary to a sizable extent across socio-cultural
groups. To illustrate, if a person comes complaining of a subjective sense of anxiety or
sadness which he considers out of proportion to the external situation and which he views
as an illness, to a very large extent, we also shall diagnose him to be suffering from the
respective neurosis. Most of the cross-cultural differences in the incidence of mental
illness, therefore, no wonder pertain to the area of neuroses.

Acute/ reactive psychosis

Briefer psychotic illness is more common in the non-western countries. It is
possible that the incidence of such psychotic illnesses represents a greater vulnerability of
the basic personality to break down and to use psychotic rather than neurotic or normal
defense mechanisms in the face of stress. The WHO ‘outcome’ study has given some
credence that such psychotic conditions represent non-schizophrenic, functional
psychoses in certain cultures. It is possible that, partly, as these illness run a more benign
and circumscribed course, the course and outcome of schizophrenia from the cultures rich
in reactive psychoses has been reported to be more favourable.

Personality disorders and sexual deviation

These conditions are reported much less frequently from the developing countries.
It is not clear, if the true incidence of these is lower in the general population in these
countries. However, possibly these are not perceived as illness, and hence, not brought to
the attention of the mental professional. These, as also drug dependence, may be viewed
more as ‘habit’ or ‘nature’ rather than illness.

DESCRIPTION OF CULTURE BOUND SYNDROME

The designation ‘culture-bound reactive syndromes’ refers to psychopathological

entities that i) are not seen in the West, ii) are not mere variants of well- recognized
psychiatric disorders iii) have geographically defined prevalence, and iv) are largely
determined, at least in their symptomatology, by beliefs and assumptions prevalent in the
native culture. Following are four such syndromes

1. Dhat syndrome
This is a disorder affecting young and sexually inexperienced men. The majority
of these so afflicted live in rural areas and belong to families with extremely conservative
attitudes towards sex. The symptomatology includes various manifestations of anxiety
and multiple hypochondriacal complaints. The patient attributes his distress to an
excessive loss of semen via night emissions. The patient remains tense and preoccupied,
cannot sleep well, and loses weight. It can be understood only in its cultural context. In

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India, attitudes towards semen and its loss constitute an organized, deep-seated belief
system that can be traced back to the scriptures of the land. Semen is considered to be the
elixir of life, in both a physical and mystical sense.

2. Possession Syndrome
Symptoms of spirit possession occur in association with schizophrenic and manic
states, as well as independently. In the former instance, the symptoms of possession, that
is referred to as Possession Syndrome. The condition occurs almost exclusively among
women, and generally in the lower levels of literacy and socioeconomic class. Such
behaviour focuses the attention of the family on the individual; valuable time is gained;
and the resulting structural realignment of forces within the family often improves the
precipitating conditions.

3. Bhang Psychosis
European psychiatrists working in India when the country was still under British
rule were impressed with the frequency of psychotic reactions associated with chronic
Bhang abuse. Ewens(1904) felt that 20% of all psychiatric disorders in India were due to
cannabis intoxication. Dhunjibhoy (1930), an Indian psychiatrist provided the first
detailed description of what he called ‘ Indian Hemp Insanity’, a paranoid psychosis
difficult to distinguish from schizophrenia. From all these descriptions, it is hard to
determine whether Bhang Psychosis was an entity in itself or simply a schizophrenic
reaction unmasked in a susceptible individual by the use of cannabis. Two recent reports
again assert the independent existence of such a disorder on the grounds that the
paranoid-visual hallucinatory clinical picture occurs only in chronic Bhang users and
remits when the intoxicant is discontinued.

4. Keemam Dependence
Keemam is an indigenous product of India. It is a black substance of semi-solid
consistency, generally taken along with betel leaves and lime. The three substances are
chewed and their paste is kept in the mouth and sucked. Vahia and Sheth (1970) have
observed that while while keemam gives a feeling of high, it also produces psychic
dependence and its discontinuation may be associated with mild withdrawal symptoms.
These investigators subjected Keemam to pharmacological analysis and found, contrary
to the general belief that Keemam is a type of tobacco, that it contains in addition to
nicotine a substance pharmacologically like morphine as well as other unidentifiable
indigenous intoxicants. They propose that Keemam dependence is a pharmacologically
attenuated and culturally sanctioned form of drug dependence.

HOW CULTURAL AND SOCIAL FACTORS INFLUENCE HELP SEEKING

BEHAVIOUR

Takeuchi, Uehara, and Maramba (1999) state that “cultural factors are critical to
understand access to mental health services, the proper screening and diagnoses that lead
to treatment, and the actual effectiveness of treatment, but many of the relevant policy

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decisions will be based on the assumptions made about services and models for service
delivery.” They continue by reiterating the importance of documentation and research of
cultural factors for changes in policy and services. Unfortunately, few studies have
specifically tested whether cultural factors actually are linked to help seeking. Mental
health utilization rates of Asian Americans have been reported to be lower than those of
Whites (Chin, 1998).
Chin found various factors that have affected help seeking resulting in the
underutilization of services by Asian Americans. These include:
1. A holistic emphasis concerning the inseparability of the mind and body (i.e.,
somatization of emotional distress and emphasis on medication)
2. A view of the therapist as an authority
3. An unfamiliarity and unacceptability of psychotherapy, especially for immigrants
and refugees who seek solutions through lay and spiritual leaders.
4. Shame and stigma associated with mental illness.
However, utilization according to Sue and Morishima (1982) is a poor indicator of
the degree of mental distress. They suggest that some other factors may also contribute
to this underutilization of services. These include “use and availability of alternative
resources (e.g., general practitioners and medical clinics, counselling over psychiatric
services, herbalist, and or family) cost considerations, location and knowledge of
facilities, hours of operation, belief systems about mental health, and responsiveness of
services,” (Chin, 1998). Language barriers may also contribute to the underutilization of
mental health services by Asian Americans (Leong, 1986), not only in the form of
language itself but also the communication of illness.
 The family appears to be an important factor in shaping fundamental values and
beliefs, and influencing attitudes to help-seeking (Nobles & Sciarra, 2000). The
decision to seek help for psychological problems is determined and predominately
made by males in the immediate family, or elders in the extended family.
 Religious leaders and institutions have retained durable and strong affiliations in
their community and assume an influential role in the welfare and mental-health
care of their people. The possible cause of underutilization of services may be a
dependence on religious institutions for providing support, and religious leaders
for spiritual guidance, in times of psychological discomfort.
It is likely that cultural beliefs, shame, stigma, fear of being misunderstood, traditional
family structures, traditional support systems, and lack of trust of external providers may
all influence mental-health-care utilization. It would be highly desirable to support
religious leaders with educational programmes on mental-health issues enabling them to
enhance the scope, knowledge, and methods of supporting those with mental-health
problems. This would empower religious leaders to effectively advise and refer to the
most appropriate mental-health services. Reassuring and educating families will likely
facilitate the support they provide and treatment adherence. Community awareness of the
availability of mental-health services needs to be more widely promoted to allow ethnic
minorities greater access to services.

REFERENCES

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Akhtar, S. (1988). Four culture-bound psychiatric syndromes in India. International
Journal of Social Psychiatry 34(1), 70-74.

King L. M. (1978). Social and cultural influences on Psychopathology. Annual Review

Psychology. 29, 405- 33.

Strauss, J. S. (1979). Social and cultural influences on Psychopathology. Annual Review

Psychology 30, 397-415.

Varma, V. K. (1986). Cultural psychodynamics in health and illness. Indian Journal of

Psychiatry, 28(1), 13-34

Varma, V. K. (1988). Culture, personality and psychotherapy. International Journal of

Social Psychiatry 34 (2), 142-149.

Youssef, J., & Deane, F. P. (2006). Factors influencing mental-health help-seeking in

Arabic-speaking communities in Sydney, Australia. Mental Health, Religion &
Culture. 9(1) 43–66

MANPREET KAUR
SUBMITTED TO: DR. SEEMA MEHRAOTRA

EPIDEMIOLOGICAL STUDIES AND SOCIO DEMOGRAPHIC CORRELATES

OF MENTAL ILLNESS IN INDIA
EPIDEMIOLOGY is defined as ‘the study of the distribution and determinants of health
related states or events in specified populations, and the application of this study to the
control of health problems’.
In simple terms, it answers basic questions
 How many people are suffering from a given disorder at any point of time
 How a disease of interest is distributed in terms of several socio demographic
variables like age, sex, education, occupation, income and residence
 What are the causes for a given mental disorder in terms of social, biological,
environmental, psychological and cultural factors
 The changing patterns of a given disease in a population
 The natural history of a given illness in terms of relapse, remission or recovery
 The syndrome wise distribution
 The conceptual construction of diagnosis and classification through the
development of culture specific and standardized instruments and approaches
 The evaluation of possible interventions in terms of outcome and effect at
individual and community levels &
 The evaluation of organization and functioning of mental health services.

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 
Anthony et al. observed that
First generation studies applied administrative treatment statistics to study the
association of socio demographic variables with specific mental disorders.
Second generation studies use of census method and surveys of the general population
Third generation studies use of field survey approaches with a specific on individual
disorders
PSYCHIATRIC EPIDEMIOLOGY IN INDIA
Dr. M.V. Govindaswamy was the first person to consider psychiatric epidemiology in
India. However, it failed to make any significant impact due to methodological errors.
The first major survey on psychiatric problems in India was undertaken by Prof. K.C.
Dube in Agra 1961.
SCHIZOPHRENIA
Following the first epidemiological study by Dr. Govindaswamy in 1957 several
researchers have examined the prevalence and socio demographic correlates of
schizophrenia. The Indian studies have examined population of varying sizes ranging
from 327 to 1, 01,229. The reported rates for schizophrenia vary from 0.9 to 7.2 per
1,000. The Bangalore study conducted, on a population of 32,498 and incorporating
significant methodological improvements, found the prevalence to be 3.09/1000. The
largest of these studies was done on a population of 1, 01, 229 near Chennai, recorded a
lower prevalence (2.49/1, 000).
A Meta analysis by Reddy and Chandrasekhar estimates the prevalence of
Schizophrenia to be 2.7 (2.2-3.3/1000) populations. Ganguli identified the prevalence to
be 2.5/1000 (urban 2.5 and rural 3.6) from a review of 13 studies. Even with a rate of 2.5-
2.7/1000 it is estimated that India has nearly 2.5 million schizophrenics needing care at
any point of time.
Studies on the incidence of schizophrenia have also been undertaken by Indian
researchers. The estimate of schizophrenia incidence was 0.38/1000 in urban and
0.44/1000 in rural parts of Chandigarh. In West Bengal the incidence was 0.93/1,000
population. The ICMR-SOFPUC study established the incidence to be 0.35/1,000.
The recent longitudinal study of functional psychosis in urban community slums by
ICMR (Indian Council of Medical Research), Chennai covered a population of 1,01, 229.
The Indian Psychiatric Survey Schedule (IPSS) and Present State Examination (PSE)
were used among the screening purposes and ICD-9 criteria for diagnostic classification
purposes. Incidence rates were arrived from a population of 25, 661 and the over all
incidence was 0.35/1,000 with an age adjusted incidence rate of 3.87/1, 000. The study
also revealed that nearly one third of patients had received no psychiatric care during
illness. Some of the specific observations on Schizophrenia in India are: a higher
incidence of the condition in India; increasing rates among men when compared to

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women; better course and outcome. The last could be perhaps due to several factors such
as low expressed emotions among relatives, greater tolerance, better quality of social
support and lower expectations from patients.
COMMON MENTAL DISORDERS
Common mental disorders (CMDs) are a term used for a range of conditions, with
depression recently gaining importance being the commonest studied by Indian
researchers. Patel in a recent review of CMDs in India, reports prevalence figures
ranging from 2% to 57%. The prevalence in general/primary healthcare settings varies
from 20% to 45%. In a review of utilization patterns of services in extension services of
NIMHANS, neurotic and psychiatric disorders constituted 24%. Ganguli summarizing
the findings from 15 studies observed the prevalence of depression to be 34/1000 of the
population. For psychotic depression and neurotic depression the rates were found to be
7.8/1000 and 22.8/1000 respectively. Reddy and Chandrasekhar noticed the prevalence
rates to be 13.9 in rural areas and 35.7/1000 in urban areas. The factors associated with
the occurrence of CMDs were female gender, poverty, unemployment, lower levels of
literacy which inturn are linked to a wide variety of social, economic and cultural issues.
CMDs are also linked to significant disability and impaired quality of life. It has been
observed that work loss due to illness can affect the quality of life and that families face
an increased financial burden in addition to the disruption of family and leisure activities.
With prevalence rates ranging from 30-35 per 1,000 it can be estimated that nearly 30-35
million people in India require mental health services.
MENTAL REATRDATION
A review of Indian studies on MR by Prabhu et al. revealed that the prevalence rates
varied from 0.22 to 32.7 per 1000 of the population. Madhavan in a collective review
noticed that the rates varied from 3.4/1000 to 30/1000. Using a two step procedure of
screening and confirmation by a psychiatrist, Gupta and Sethi from Uttar Pradesh in a
population based survey of 500 rural and 100 urban households reported a prevalence of
2.1%. Those with severe MR in the study were observed to be 1.5%. Other studies have
documented the prevalence of MR to vary from 8.6 and 8.3/1000 in Kolkata and Vellore
respectively. Specific surveys in school-going children have shown prevalence rate of 3.7
and 9/1000 respectively. Srinath and Girimaji in a recent review of child and adolescent
mental health problems in India concluded that 2% and 0.5% of children in India suffers
from mild and severe forms of MR respectively.
Few studies have examined the causes in the Indian region. Narayan in a study of severe
MR in 10,700 individuals identified the possible causes in 47 % of MR cases. The major
contributors were: obstetric factors- 24%, chromosomal disorders-10% and mutant genes-
13%. A variety of factors infections, malnutrition and birth damage account for the
greater extent of MR in India. In a multi center study of MR to identify causes it was
noticed that chromosomal disorders (24%), metabolic factors (5%), genetic syndromes
(12%) and prenatal causes (30%) were the commonest causes. It is commonly known that
goitre in India is one of the principal causes of MR in the sub Himalayan region of India.
CHILD AND ADOLESCENT MENTAL HEALTH PROBLEMS

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Prabhu in a review of child and adolescent mental health research in India identified
three periods: the past (1950-1965), the eclipse (1965-1980) and the turning point (1980
onwards) of growth in this area. The prevalence rates recorded in another study in
different populations varied from 7 to 172 per 1000 children. In a review of studies by
Kapur on mental health problems in children, it was observed that community surveys
identified only severe problems like enuresis, stuttering, sleep disorders, MR and
epilepsy. Further, school going children have higher psychological disturbances; urban
children report more problems than rural children; boys have a higher preponderance than
girls and scholastic backwardness is a major problem in the Indian region.
Srinath and Girimaji in a recent review on childhood psychiatric and emotional
problems reported the prevalence to vary from 25 to 356 per 1000 in field studies. The
ICMR undertook a study in Bangalore and Lucknow in 1997 by adopting a two stage
survey and using standardized instruments for different age groups (Child behaviour
checklists, Rutter’s teacher’s questionnaires, diagnostic interview schedules for parents
and teachers, parents’ interview schedule, children’s global assessment scales,
intelligence assessment, assessment of felt treatment needs and physical examination),
the prevalence of child and adolescent disorders in this study was observed to be 12.8%
in 1-16 year old children. With the recent figures from ICMR to be 128/1000 nearly five
million children (under 15 years) would require mental health care in India.
ALCOHOL RELATED MENTAL HEALTH PROBLEMS
In the last two decades alcohol related psychiatric problems have been studied through
psychiatric morbidity surveys in general population and also through studies in specific
populations. Surya et al. reported a prevalence rate of 3.6/1000 for alcoholism while
Gopinath observed rates of 2.4/1000 in Bangalore. The prevalence of alcoholism in
Vellore, Agra, Hoogly district, was observed to be 4.8/1000, 1.4/1000 and 13/1000
respectively for alcoholism, habitual use of alcohol and alcohol addiction. More recently,
Premarajan et al. reported rates of 34.1/1000 in Pondicherry for alcohol dependence
syndrome. Varma et al. in a survey of adults in urban and rural populations near
Chandigarh observed that 23.7% reported regular use of alcohol. Sethi and Trivedi
reported 50% of men above the age 15 in rural areas were found to consume alcohol.
More recently, Ponnudurai et al. in Chennai noticed a prevalence rate of 16.7% among
men, using Michigan Alcoholism Screening Test. Similarly, other studies from Tamil
Nadu by Chakravarthy and Mathrubootham observed rates 17% and 33 % among
men. In an interesting survey by Bang and Bang in 104 villages of the Ghadchiroli
district of Maharashtra, it was observed that nearly 1,00, 000 men consumed alcohol, of
which one fifth were addicts. From a head of the household survey in New Delhi by
Mohan et al. It was noticed that 26% of the residents in urban slums were substance
abusers, the majority involving alcohol. In a recent survey of 32,400 people in and
around Bangalore, 1.2% of men were found to suffer from alcohol dependence syndrome.
The Meta analysis by Reddy and Chandrasekhar revealed an overall prevalence of
6.9/1000 for India with urban and rural rates of 5.8 and 7.3/1000 of the population. The
rates among men and women were 11.9 and 1.7 respectively.
Surveys of alcohol use in specific populations have also been carried out in India. These
populations include school students, industrial workers and medical personnel. Mohan

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reported that 10-15% of college students were regular alcohol users. Among medical
personnel, the problem was severe, with 40-60% reporting alcohol use. Nearly 10-60% of
industrial workers were also found to be regular alcohol users as per the data available
from Delhi, Punjab and Chennai. Several studies indicate that nearly 20-30% of hospital
admissions are due to alcohol related problems in mental care settings.
On the basis of these rough estimates nearly 30% of men are current alcohol users, with
30% of them being alcohol dependant; it would appear that nearly 30 million require
some form of mental health care. Further, long term alcohol consumption is linked to a
wide variety of social (family disruption, marital disharmony, impact on children,
deprivation of family, work absenteeism, growing crime and violence, etc.) and health
(Cirrhosis of liver, road traffic injuries, suicides, etc) problems. Based on these
observations, it is estimated that nearly 9-10 million people would require interventional
support for alcoholism.

SUICIDES
Suicides are one of the acute emergencies resulting in death, depending on the mode of
the attempt as decided by nature, intent and lethality and the availability of healthcare.
Suicides have recorded an increase from nearly 40,000 in 1980 to 1, 10,000 persons
committed suicides in India in 1999 with an annual incidence of 11/ 1, 00,000. Several
studies undertaken in India have revealed the incidence of suicides to vary from 8 to 43
per 1, 00,000 of the population.
It is estimated that attempted suicides are 10-20 times this number and those with suicidal
thoughts, 50-100 times this figure. The male to female distribution has varied from 1:1.2
to 1:1.7 in different regions. Significant regional variations have been noticed with
Pondicherry, Kerala, West Bengal and Maharashtra registering high numbers.
Interestingly, nearly 60% of suicides occur in the 20-40 years age group all over India.
Further, the majority of suicides took place by hanging and poisoning, with self
immolation occurring more in women. A number of social, economic, cultural, mental
health and general health conditions have been incriminated in causation of suicides.
Among the various mental health problems depression, alcoholism, affective disorders
and even schizophrenia have been identified for suicides.
In a recent case control study from Chennai the presence of depression axis I disorder,
family history of psychopathology and stressful life events carried a high risk of suicides.
In an ongoing case control study in Bangalore the lack of coping skills, absence of social
support, dissatisfaction in life and alcoholism in the family, have emerged as major risk
factors.
DEMENTIA
Dementia defined as the ‘global deterioration of the individual’s intellectual, emotional
and cognitive faculties in a state of impaired consciousness. It is estimated that it will
increase from 6% in 2001 to 8.5% by 2025 thus resulting in nearly 90 million older

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people (65+) with dementia in the Indian region. Alzheimer’s disease contributes to 60%
of all dementias, affecting people over the age of 60 years.
Geriatric psychiatric epidemiological studies have been few and limited in India.
Venkoba Rao in a study of problem of the aged seeking psychiatric help in Madurai,
identified dementia in 30 while an earlier (20%) of the 150 consecutive cases among 60+
individuals. Study reported a prevalence of 23.6% for depression in subjects aged 50+ in
South India, Venkoba Rao and Madhavan noticed 6% of the elderly (60+ years) to be
depressed. Chandra et al. In their study in Ballabgarh, found the prevalence of
Dementia to be 1.36% in the 65+ age group. Old age was significantly associated with a
higher prevalence of Alzheimer’s disease and all dementia, but gender and literacy did
not have an influence. Dementia prevalence from other parts of India is found to be 2.7%
in urban Chennai, 3.5% in rural Thiroporur, and 3.4% in Thiruvanniyoor, Kerala.

FUTURE DIRECTIONS
Large scale multi centric studies on representative populations by developing
epidemiological databases in defined populations is a crucial activity to be
promoted in the years to come.
 Psychiatric epidemiology needs to expand into the areas of operational research to
study the utilization patterns of services, thereby making care available to those in
need.
 Epidemiological principles and methods should be adapted to answer system
related questions for requirements in drug availability, manpower development,
medical curricula, removal of stigma and others
 At the national level, there is a need to prioritize mental health problems for better
research and service.
 Psychiatric epidemiology especially needs trained and skilled manpower.
REFERENCES
Venkataswamy, R.M., & Chandrashekar, C.R.(1998). Prevalence of Mental and
Behavioural Disorders in India: A Meta Analysis. Indian Journal of Psychiatry, 40 (2),
149-157.
Ganguli, H.C. (2000). Epidemiological findings on the Prevalence of Mental disorders in
India. Indian Journal of Psychiatry, 42(1), 14-20.
Book: S P Agarwal, Mental Health an Indian Perspective (1946-2003)

Probability sampling
• Simple Random Sampling

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 • Systematic Random Sampling
• Stratified Random Sampling
• Cluster Sampling
• Multistage Sampling

Nonprobability Sampling
• Voluntary Sampling
• Convenience Sampling
• Judgement or Purposive Sampling
• Quota Sampling
• Snowball sampling

Advantages of Probability Sampling

The following are the basic advantages of probability sampling methods:

•Probability sampling does not depend upon the existence of detailed information about
the universe for its effectiveness.
•Probability sampling provides estimates which are essentially unbiased and have
measurable precision.
•It is possible to evaluate the relative efficiency various sample designs only when
probability sampling is used

PROBABILITY SAMPLING METHODS

Simple or Unrestricted Random Sampling

Simple random sampling refers to that sampling technique in which each and every unit
of the population has an equal opportunity of being selected in the sample. In simple
random sampling with items get selected in the sample is just a matter of chance—
personal bias of the investigator does not influence the selection. It should be noted that
the word 'random' does not mean "haphazard' or "hit-or-miss'—it rather means that the
selection process is such that chance only determines which items shall be included in the
sample. As pointed out by Chou, when a sample of size n is drawn from a population
with N elements, the sample is a 'simple random sample' if any of the following is true.
And, if any Of the following is true, so are the other two:

•All n items of the sample are selected independently of one another and all N items in
the population have the same chance of being included in the sample. By independence
of selection we mean that he selection of a particular item in one draw has no influence
on the probabilities of selection in any other draw.

•At each selection, all remaining items in the population have the same chance of being
drawn. If sampling is made with replacement, ie., when each unit drawn from the

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population is returned prior to drawing the next unit, each item has a probability of 1/N of
being drawn at each selection. If sampling is without replacement, i.e., when each unit
drawn from the population is not returned prior to drawing the next unit, the probability
of selection of each item remaining in the population at the first draw is 1/N, at the
second draw is 1/(N-1), at the third draw is l/(N-2), and so on. It should be noted that
sampling with replacement has very limited and special use in statistics—we are mostly
concerned with sampling without replacement.

• All the possible samples of a given size n are equally likely to be selected. To ensure
randomness of selection one may adopt either the Lottery Method or consult table of
random numbers.

Lottery Method: This is a very popular method of taking a random sample. Under this
method, all items of the universe are numbered or named on separate slips of paper of
identical size and shape. These slips are then folded and mixed up in a container or drum.
A blindfold selection is then made of the number of slips required to constitute the
desired sample size. The selection of items thus depends entirely on chance. The method
would be quite clear with the help of an example. If we want to take a sample of 10
persons out of a population of 100, the procedure is to write the names of the 100 persons
on separate slips of paper, fold these slips-mix them thoroughly and then make a
blindfold selection of 10 slips.
The above method is very popular in lottery draws where a decision about prizes is to be
made. However, while adopting lottery method it B absolutely essential to see that the
slips are of identical size, shape any colour, otherwise there is a lot of possibility of
personal prejudice an° bias affecting the results.

Table of Random Numbers: The lottery method discussed above become quite
cumbersome as the size of population increases. An alternative method of random
selection is that of using the table of random number
The random numbers are generally obtained by some mechanism which, when repeated
a large number of times, ensures approximately equal frequencies for the numbers
from 0 to 9 and also proper frequencies for various combinations of
number(such as 00,01,….999, etc) that could be expected in a random sequence of the
digits0 to 9.
Several standard tables of random numbers are available, among which the following
may be specially mentioned, as they have been tested extensively for randomness:
* Tippett's (1927) random number tables consisting of 41,600 random digits grouped
into 10,400 sets of four-digit random numbers; .

Tippett's table of random numbers is most popularly used in practice.

Merits Simple random sampling method has the following advantages:

•Since the selection of items in the sample depends entirely on chance there is no
possibility of personal bias affecting the results.

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•As compared to judgment sampling a random sample represents the universe in a
better way. As the size of the sample increases, it becomes increasingly
representative of the population.
•The analyst can easily assess the accuracy of this estimate because sampling errors
follow the principles of chance. The theory of random sampling is further developed than
that of any other type of sampling which enables the analyst to provide the most reliable
information at the least cost.

Limitations This method is however associated with following limitations:

•The use of simple random sampling necessitates a completely catalogued
universe from which to draw the sample. But it is often difficult for the investigator to
have up-to-date lists of all the items of the population to be sampled. This restricts the
use of this method in economic and business data where very often we have to employ
restricted random sampling designs.
•The size of the sample required to ensure statistical reliability is usually
larger under random sampling than stratified sampling.
•From the point of view of field survey it has been claimed that cases selected by
random sampling tend to be too widely dispersed Geographically and that
the time and cost of collecting data become.

• Random sampling may produce the most non-random looking results. For example,
thirteen cards from a well-shuffled pack of playing cards may consist of one suit. But the
probability of this type of occurrence is very, very low.

1. Stratified Sampling Stratified random sampling or simply stratified sampling is one of

the random methods which, by using the available information concerning the
population, attempts to design a more efficient sample than obtained by the simple
random procedure.
While applying stratified random sampling technique, the procedure followed is given
below:
(a) The universe to be sampled is sub-divided (or stratified) into groups which are
mutually exclusive and include all items in the universe.
(b) A simple random sample is then chosen independently from each group.

This sampling procedure differs from simple random sampling in that in the latter the
sample items are chosen at random from the entire universe. In stratified random
sampling the sampling is designed so that a designated number of items is chosen from
each stratum. In simple random sampling the distribution of the sample among strata is
left entirely to chance.

How to Select Stratified Random Sample?

Some of the issues involved in setting up a stratified random sample are :

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(i) Base of Stratification What characteristic should be used to sub divide the universe
into different strata? As a general rule, strata are created on the basis of a variable known
to be correlated with the variable of interest and for which information on each universe
element is known. Strata should be constructed in a way which will minimize differences
among sampling units within strata, and maximize difference among strata.
For example, if we are interested in studying the consumption pattern °f the people of
Delhi, the city of Delhi may be divided into various parts (such as zones or wards) and
from each part a sample may be taken at random. Before deciding on stratification we
must have knowledge of the traits of the population. Such knowledge may be based upon
expert Judgment, past data, preliminary observations from pilot studies, etc.
The purpose of stratification is to increase the efficiency of sampling by dividing a
heterogeneous universe in such a way that Q there is as great a homogeneity as possible
within each stratum, and (ii) a marked difference is possible between the strata.

(ii) Number of Strata. How many strata should be constructed? The Practical
considerations limit the number of strata that is feasible, costs of adding more strata may
soon outrun benefits. As a generalization more than six strata may be undesirable.

(iii) Sample size within Strata How many observations should be taken from each
stratum? When deciding this question we can use either a proportional or a
disproportional allocation. In proportional allocation, one samples each stratum in
proportion to its relative weight. In disproportional allocation this is not the case. It may
be pointed out that proportional allocation approach is simple and if all one knows about
each stratum is the number of items in that stratum, it is generally also the preferred
procedure. In disproportional sampling, the different strata are sampled at different rates.
As a general rule when variability among observations within a stratum is high, one
samples that stratum at a higher rate than for strata with less internal variation.

Proportional and Disproportional Stratified Sample

In a proportional stratified sampling plan, the number of items drawn from each strata is
proportional to the size of the strata. For example, if the population is divided into five
groups, their respective sizes being 10, 15, 20, 30 and 25 per cent of the population and a
sample of 5,000 is drawn, the desired proportional sample may be obtained in the
following manner:
From stratum one 5,000 (0.10) = 500 items
From stratum two 5,000(0.15) = 750 items
From stratum three 5,000 (0.20) = 1,000 items
From stratum four 5,000 (0.30) = 1,500 items
From stratum five 5,000(0.25) = 1,250 items
Total = 5,000 items

Proportional stratification yields a sample that represents the universe with respect to the
proportion in each stratum in the population. This procedure is satisfactory if there is no
great difference in dispersion from stratum to stratum. But it is certainly not the most
efficient procedure, especially when there is considerable variation in different strata.

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This indicates that in order to obtain maximum efficiency in stratification,, we should
assign greater representation to a stratum with a large dispersion and smaller
representation to one with small variation.
In disproportional stratified sampling an equal number of cases is taken from each
stratum regardless of how the stratum is represented in the universe. Thus, in the above
example, an equal number of items (1,000) from each stratum may be drawn. In practice
disproportional sampling is common when sampling forms a highly variable universe,,
wherein the variation of the measurements differs greatly from stratum to stratum.

Merits Stratified sampling methods have the following advantages:

• More representative. Since the population is first divided into various strata and
then a sample is drawn from each stratum there is a little possibility of any essential
group of the population being completely excluded. A more representative sample
is thus secured. C.J. Grohmann has rightly pointed out that this type of
sampling balances the uncertainty of random sampling against the bias of
deliberate selection.
• Greater accuracy. Stratified sampling ensures greater accuracy. The accuracy is
maximum if each stratum is so formed that it consists of uniform or homogeneous items.
• Greater geographical concentration. As compared with random sample, stratified
samples can be more concentrated geographically, i.e., the units from the different
strata may be selected in such a way that all of them are localised in one geographical
area. This would greatly reduce the time and expenses of interviewing.

Limitations The limitations of this method are:

• Utmost care must be exercised in dividing the population into various strata. Each
stratum must contain, as far as possible, homogeneous items as otherwise the
results may not be reliable. If proper stratification of the population is not done, the
sample may have the effect of bias.
• The items from each stratum should be selected at random. But this may be
difficult to achieve in the absence of skilled sampling supervisors and a random selection
within each stratum may not be ensured.
• Because of the likelihood that a stratified sample will be more widely distributed
geographically than a simple random sample cost per observation may be quite
high.

2. Systematic Sampling: A systematic sample is formed by selecting one unit at random

and then selecting additional units at evenly spaced intervals until the sample has been
formed. This method is popularly used in those cases where a complete list of the
population from which sample is to be drawn is available. The list may be prepared in
alphabetical, geographical, numerical or some other order. The items are serially
numbered. The first item is selected at random generally by following the Lottery
method. Subsequent items are selected by taking every kth item from the list where 'k

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refers to the sampling interval or sampling ratio, i.e., the ratio of population size to the
size of the sample. Symbolically:
N
k
n
where k = Sampling interval, N = Universe size, and n = Sample size.
While calculating k, it is possible that we get a fractional value. In such a case we should
use approximation procedure, le., if the fraction is less than 0.5 it should be omitted and if
it is more than 0.5 it should be taken as 1. If it is exactly 0.5 it should be omitted, if the
number is even and should be taken as 1, if the number is odd. This is based on the
principle that the number after approximation should preferably be even. For example, if
the number of students is respectively 1,020, 1,150 and 1,100 and we want to take a
sample of 200, k shall be:
1020
(i) k   5.1or 5
200
1150
(ii) k   5.75or 6
200
1100
(iii) k   5.5or 6
200

Merits : The systematic sampling design is simple and convenient to adopt.

The time and work involved in sampling by this method are "relatively less.
The results obtained are also found to be generally satisfactory provided
care is taken to see that there are no periodic features associated with
the sampling interval. If populations are sufficiently large, systematic
sampling can often be expected to yield -suits similar to those obtained by
proportional stratified sampling.

Limitations: The main limitation of the method is that it become less representative if we
are dealing with populations having “hidden periodicities”. Also if the population is order
in a systematic way with respect to the characteristics the investigator is interested in ,
then it is possible that only certain types of item will be included in the population, or at
least more of certain types than others. For instance, in a study of worker’ wages the list
may be such that every tenth worker on the list gets wages above Rs. 750per month.

3. Multi-stage Sampling or Cluster Sampling: Under this method the random selection is
made of primary, intermediate and final ( or the ultimate) units from a given population
or stratum. There are several stages in which the sampling process is carried out. At first,
he first stage units are sampled by some suitable method, such as sample random
sampling. Then, a sample of second stage units is selected from each of the selected first
stage units, again by some suitable method which may be the same as or different from
the method employed for the first stage units. Further stages may be added as required.
Merits Multi-stage sampling introduces flexibility in the sampling method which is
lacking in the other methods. It enables existing divisions and sub-divisions of the
population to be used as units at and permits the field work to be concentrated and yet

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large area to be covered. Another advantage of the method is that subdivision into second
stage units (i.e., the construction of the second stage frame) need be carried out
for only those first stage units which are included in the sample. It is, therefore,
particularly valuable in surveys of underdeveloped areas where no frame is
generally sufficiently detailed and accurate for subdivision of the material into
reasonably small sampling units.

Limitations: However, a multi-stage sample is in general less than a sample containing

the same number of final stage units which have been selected by some single stage
process.

We have discussed above the various random procedures in independent

designs. In practice we often combine two or more of these methods into a single design.

NON-PROBABILITY SAMPLING METHODS

Judgment Sampling

In this method of sampling the choice of sample items depends exclusively on the
judgment of the investigator. In other words, the investigator exercises his judgment in
the choice and includes those items in the sample, which he thinks are most typical of the
universe with regard to the characteristics under investigation. For example, if sample of
ten students is to be selected from a class of sixty for analysing the spending habits of
students, the investigator would select 10 students who, in his opinion, are representative
of the class.

Merits: Though the principles of sampling theory are not applicable to judgment
sampling, the method is sometimes used in solving many types of economic and business
problems. The use of judgment sampling is, justified under a variety of circumstances:

(i) When only a small number of sampling units are in the universe, simple
random selection may miss the more important elements, whereas judgment selection
would certainly include them in the sample.

(ii) When we want to study some unknown traits of a population, some of whose
characteristics are known, we may then stratify the population according to these known
properties and select sampling units from each stratum on the basis of judgment. This
method is used to obtain a more representative sample.

(iii) In solving everyday business problems and making public policy decisions,
executives and public officials are often pressed for time and cannot wait for probability
sample designs. Judgment sampling is then the only practical method to arrive at
solutions to their urgent problems.

Limitations Judgment sampling method is however associated with the allowing

limitations:

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(i) This method is not scientific because the population units to be sampled may be
affected by the personal prejudice or bias of the investigator. Thus, judgment sampling
involves the risk that the investigator may establish foregone conclusions by including
those items in the sample which conform to his preconceived notions. For example, if an
investigator holds the view that the wages of workers in a certain establishment are very
low, and if he adopts the judgment sampling method, he may include only those workers
in the sample whose wages are low and thereby establish his point of view which may be
far from the truth. Since an element of subjectiveness is possible, this method cannot be
recommended for general use.

(ii) There is no objective way of evaluating the reliability of sample results. The success
of this method depends upon the excellence in judgment. If the individual making
decisions is knowledgeable about the population and has good judgment, then the
resulting sample may be representative, otherwise the inferences based on the sample
may be erroneous. It may be noted that even if a judgment sample is reasonably
representative, there is no objective method for determining the size or likelihood of
sampling error. This is a big defect of the method.

Quota Sampling
Quota sampling is a type of judgment sampling and is perhaps the most commonly used
sampling technique in non-probability category. In a quota sample, quotas are set up
according to some specified characteristics such as so many in each of several income
groups, so, many in each age, so many with certain political or religious affiliations, and
so on. Each interviewer is then told to interview a certain number of persons which
constitute his quota. Within the quota, the selection of sample items depends on personal
judgment. For example, in a radio listening survey, the interviewers may be told to
interview 500 people living in a certain area and that out of every 100 persons
interviewed 60 are to be housewives, 25 farmers and 15 children under the age of 15.
Within these quotas the interviewer is free to select the people to be interviewed. The cost
per person interviewed may be relatively small for a quota sample but there are numerous
opportunities for bias which may invalidate the results. For example,
interviewers may miss farmers working in the fields or talk with those housewives who
are at home. If a person refuses to respond, the interviewer simply selects someone else.
Because of the risk of personal prejudice and bias entering the process of selection, the
quota sampling is not widely used in practical work.

Quota sampling and stratified random sampling are similar in as much as in both methods
the universe is divided into parts and the total sample is allocated among the parts.
However, the two procedures diverge radically. In stratified random sampling the sample
with each stratum is chosen at random. In quota sampling, the sampling within each cell
is not done at random, the field representatives are given wide latitude in the selection of
respondents to meet their quotas.

Quota sampling is often used in public opinion studies. It occasionally provides

satisfactory results if the interviewers are carefully trained and if they follow their

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instructions closely. It is often found that since the choice of respondents within a cell is
left to the field representatives, the more accessible and articulate people within a cell
will usually be the ones who are interviewed. Slight negligence on the part of
interviewers may lead to interviewing ineligible respondents. Even with alert and
conscientious field representatives it is often difficult to determine such control category
as age, income, educational qualifications, etc.

Convenience Sampling

A convenience sample is obtained by selecting 'convenient' population units. The method

of convenience sampling is also called the chunk A chunk refers to that fraction of the
population being investigated which is selected neither by probability nor by judgment
but by convenience. A sample obtained from readily available lists such as automobile
registrations; telephone directories, etc., is a convenience sample and not a random
sample even if the sample is drawn at random from the lists. If a person is to submit a
project report on labour-management relations in textile industry and he takes a textile
mill close to his office and interviews some people over there, he is following the
convenience sampling method. Convenience samples are prone to bias by their very
nature-selecting population elements which are convenient to choose almost always make
them special or different form the best of the elements in the population in some way.

Hence the result obtained by following convenience sampling method can hardly be
representative of the population—they are generally biased and unsatisfactory.
However, convenience sampling is often used for making pilot studies. Questions may
be tested and preliminary information may be obtained by the chunk before the
final sampling design is decided upon.

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