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INDIAN JOURNAL OF
CLINICAL PSYCHOLOGY
Editorial Board, Journal Committee, Executive Council & Secretariat i-ii
Instructions to Authors iii-v
Volume 41, Number - 2
Editorial
September, 2014 NEUROPSYCHOTHERAPY: The New Frontiers in Clinical Psychology 83-84
ISSN 0303-2582 K.S. Sengar
Research Articles 85-93
Divorce, Mental Illness & The Law: Role of Mental Health Personnel
Neha Sayeed and Sayeed Akhtar
Reducing Internalized Stigma of Mental Illness among Patients with 94-101
Schizophrenia Using Acceptance and Commitment Therapy
Minkesh Chowdhary and Masroor Jahan
Concurrency in Skill Enhancement and Problem Behavior Reduction 102-111
Following Customized Behavioural Interventions in Children with
Autism
Kadambari N and Venkatesan S
Efficacy of Wisconsin’s Card Sorting Test Retraining on Cognitive 112-119
Deficits in Patients with Schizophrenia: A Randomized Double Blind
Controlled Study
Sayali Mishra, K S Senger and B R Mishra
Migraine and Tension-type headache in Indian adolescents: Psychosocial 120-126
causes and its Psychosocial Correlates
Pragya Sharma, Manju Mehta and Rajesh Sagar
A Study on Parent-Child Relationship, Ego Identity and Expression of 127-133
Editor Aggression in Juvenile Delinquents
Sreetama Chatterjee and Tilottama Mukherjee
K.S. Sengar
Executive Functions in Patients with Obesity: Impact of Bariatric 134-139
Surgery
K Praveen Kumar, M Thomas Kishore and K S Lakshmi
Reasons for Smoking among College Students 140-145
L. N. Suman, R. M. Nagalakshmi and K.Thennarasu
Socio-demographic Correlates of Children Suffering from Juvenile 146-149
Deliquency
Shweta Sharma, J Mahto and Deapti Mishra
A Study of Socio-demographic Variables and Personality Profile of 150-155
Persons with Homicidal Behaviour in Clinical Settings
Samir Sarma, Kangkan Pathak and Maitreyee Dutta
Mental Health Clinics 156-160
Efficacy of Psychodrama in Individuals with Alcohol Dependence
Narendra Nath Samantaray, Priti Singh, Amool R Singh, K S Sengar and
Archana Singh
RNI RN 26039/74
Efficacy of Cognitive Behavior Therapy on Person with Obsessive 161-163
Official Publication of
Hoarding
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WISC-IVINDIA You knew the WISC had high clinical utility. Now it is also more relevant
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Use Wechsler Intelligence Scale for Children – Fourth Edition (India) to obtain a valid and
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Raven’s Progressive Matrices and Vocabulary Scales enjoy a long and famous history in the
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INDIAN JOURNAL OF CLINICAL PSYCHOLOGY
Volume 41 January 2014 No. 2
Editor : K. S. Sengar
Editorial Board Editorial Advisory Board

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Ashima N. Wadhawan (Delhi) Amool R Singh (Ranchi)

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V. C. George, Amool R Singh
Miraj RINPAS, Kanke, Ranchi–834006 (Jharkhand)
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Indian Journal of Clinical Psychology Copyright, 2014 Indian Association of
2014, Vol. 41, No. 2, 83-84 Clinical Psychologists (ISSN 0303-2582)
Editorial
NEUROPSYCHOTHERAPY: The New Frontiers in Clinical Psychology
K.S. Sengar
Since its beginning the field of Clinical 1999). The term “Neuropsychotherapy” has
Psychology advancing to understand the human emerged from different conceptual connotations.
behaviour. Since beginning the history the discipline This is basically out product of the use of various
of clinical psychology has been contributed measures of psychotherapeutic procedures in
by the professionals of various disciplines i.e., integrated pattern in the land of neuropsychological
Physiology, Biology, Orthopsychiatry, Paediatrics, knowledge and rehabilitation for the brain
Physics and most significantly by Neurology. The injured cases. Hence according to Judd (1999)
role of the Clinical Psychologist in the profession Neuropsychothterapy is needed when the person
of mental health is now not confined to only the with brain illness has significant behavioiurral
evaluation of intelligence, personality and other or emotional problems resulting from illness. 2)
diagnostic work rather now the management of The problem can not be managed or improved
the various mental health problems in children, adequately or efficiently in and by the person's
adolescents, and adults is inseparable professional setting. 3) Interventions is likely to reduce
responsibility which needs the regular these problems.Thus, the neuropsychotherapy is
advancement of the knowledge and skills in the the modality of treatment based on the various
profession. Today, the Clinical Psychologists neurological and psychological problem by jointly
are not only giving their professional services in use of advance methods of neuroscience, procedures
the traditional mental hospitals or other genral of neuropsychological rehabilitation, and
hospital set up rather they are advancing in the various psychotherapeutic procedures including
field of Juvenile Justice System, Criminal Justice behavioural, cognitive and psychoanalytic. The
System / Courts, Trauma Centers, in Rehabilitative central features of the Neuropsychotherapy is to
Services and center for Brain Injury where Clinical know pre illness personality, managing emotional
Psychologists functioning as other professionals to reaction to illness and organic changes in
help the patient to regain strength through certain emotion and behaviour through the use of various
scientific procedures based on specific scientific behaviour, cognitive procedures and electronic
knowledge and practice which help the patient device (biofeedback) in integrated manner.
on managing various cognitive, emotional and Though, the history of use of such procedure
personality deficits followed by brain injury or dates back in 1970s but most of the work in
also due to some psychological trauma. organized manner with new procedure and thinking
Neuropsychotherapy is a form of treatment was started by Barbara A Wilson in 1980s in the
based on recent advances in the domains of treatment of brain dysfunctional patients through
neuroscienc, neuropsychological rehabilitation, behavioural therapeutic approach together with
and models of psychotherapy. It can be considered neuropsychological knowledge (Wilson & Maffat,
an alliance between scientific, theoritical and 1984). Forther the work and writing of Luria,
clinical knowledge in these areas (Laaksonen, A R among the persons suffering from various
2007). In fact the neuropsychotherapy is the mood and personality problems after brain injury
use of neuropsychological knowledge in the and the role of neuropsychological rehabilitation
psychohterapy of persons with brain disorders, contributed significantly in understanding of
psychological balance and well being greatly neuropsychotherapy as advance modality of
depends on availablity of information and management of neuropsychological problems in
therapeutic support. Neuropsychotherapy is name brain injury and psychiatric cases (Laaksonen,
for interventions which we need for people who 1994).
suffer from emotional, behavioural and personality Fractured Mind (Odgen, 2005), emotional
problems after the brain injury or otherwise too trauma, shattered worlds, and grief reactions/
and also remediation of cognitive disorders and grieving and depression is not unknown for the
psychiatric patients's neurological dysfunctions persons working in the field of mental health and
as an essential part of neuropsychotherapy (Tedd, neurosciences. Since long the psychotherapeutic
83
K. S. Sengar
measures alone were not being considered a device result on enhancement of ability to access
potent measures for the management of such and maintains different state of physiological
problems in brain dysfunctional cases despite arousal and to navigate from high vigilance to
the phenomenological necessity. In present era rest. The neuropsychotherapy by reinforcing the
world is turning towards increasing number of equilibrium states successfully helps to produce
stroke, diabetes and multifocal lesions which the promising results in management of cases
are associated with frequently mood changes, with ADHD, depression and anxiety and also in
depression, anxiety, multiple behavioural normalization of pain thresholds, appetite and
problem i.e. anger, problem in social adjustment, various physical and biological problems. It is
individuality, and tolerability and many other world wide researched and established fact today
mental health problems. Earlier it was thought that that brain training can improve concentration,
all problems can be managed through medication coordination, creativity, happiness, immune
but it was observed that pharmacological treatment system, inner peace, mental clarity, mental energy,
and long duration of hospitalization is not helpful mental stability, physical energy, ability to read
to ameliorate the problem completely and make the and write, sleep quality, relaxation and memory
person fully functional as before the illness rather etc. and various modality of psychotherapy too,
problems related to psychological, behavioural specially neuropsychotherapy where brain training
and even biological continued for longer period has been proved to bring potential changes in the
even may be lifelong. Historically, the role of neuropsychopathology. Researches in this area
psychotherapeutic measures in post stroke care have further proved that various psychological
was to manage mood changes and various other procedures applied in the mangement of
emotional and personality problems are evident psychaitric problems and neuropsychological
in 1970s (Heinstein, 1970). His suggestion is to rehabilitation are not only evident in reporting
involve the step wise psychological approach significant changes in emotional area rather
involving structured procedures and active neurophysiological and structural changes also
participation of family members can help the takes place in brain.
person to regain their premorbid abilities rather than REFERENCES
medication. The neuropsychological recognition of Grawe, K (2007). Neuropsychotherapy: How the Nerurosciencess
deficits the rehabilitation procedures can help the Inform Effective Psychotherapy. Hahwah, New Jersy.
person to regain the previous ability for adaptation Pub by Lawrence Erlbaum Assoc.
and other premorbid functioning (i.e. personality, Judd (1999). Neuropsychotherpay annd Commuity
self-esteem, intelligence, and experiences) Integration: Brian , Illness. Emotion and
Behaviourcritical issues in Neuropsychotherepy.
The neuropsychotherapy uses the process of Heidelberg N Y Plenum Publishrs.
operant conditioning through the help of electronic Laaaksonen, R., & Ratna, M (2013). Introduction to
devices/ equipment that monitors and measures Neuropsychotherapy. Psychology Press, 27, Church
the electrical activity of the brain and TRAIN the Road, Hoves East, Sussex.
brain to be more available to life requirements Laaksonen, R. (1994). Cognitive Training Method in
Rehabilitation of Memory in A L Christensen B
(neuroregulation). The use of neuropsychotherapy Uzzel (Eds). Brain Injury and Neuropsychological
is variable as in seizure disorder the hyperactivity Rehabilitation, (Pp125-133). International Perspective
in the brain during the seizure is significantly Hillsdale N.J., Lawrence Frlbaum Assoc Pub
reduced and as result the seizures reduced Laaaksonen, R. (2007). Neuropsychotherapy as an Integrated
significantly (seizure reduced 66%). It is also Part of Neuropsychological Rehabilitation. Svensk,
evident that reduction in hyperactivity in brain Neurpsychology, N.R. 2-3, 8-11.
significantly enhanced the academic performance Odgen (2005). Fractured Mind. A Case Study Approach to
Clinical Neuropsychology, Oxford Univ Press, New York.
in school children by use of beta (12-15 Hz). It has
given the promising results on the cases of post Ritva, L,. & Marvi, R. (2013). Introduction of
Neuropsychotherapy. Psychology Press, 27, Church
traumatic disorder, addiction and management of Road, Hoves East, Sussex.
autistic children. Hence, the neuropsychotherapy Tedd (1999. Neuropsychotherapy and Community
has resulted evidence based procedure which is Integration. In Brian, Illness, Emotions and Behaviour.
visible/testable cross sectionally on electronic Kluwer Academic Press, Plenum Pub.
84
Review Article
Divorce, Mental Illness & The Law: Role of Mental Health
Personnel
Neha Sayeed 1 and Sayeed Akhtar 2
Abstract
Divorce rate in India are one of the lowest in the world, but it is increasing progressively
.Mental illness in one of the spouses are often alleged to be the ground of dissolution of
marriages. There is increasing cases of such kind in the family courts. The law of the land
pertaining to divorce on the ground of insanity, specially Hindu Marriage Act, 1955 has been
discussed. Annulment of marriage due to absence of competency at the time of marriage
and consent are important issue. Mental health professional may be called to authenticate
the certificate issued by him and may be examined and cross examined as expert witness.
An effort has been made to acquaint the mental health professional of the legal proceedings
followed by the court in such cases and the role of mental health professional with
reference to preparing reports has been delineated. Finally, court judgments which is often
cited in such cases has been included and recent judgments in the Supreme court of India and
various high courts has been reviewed.
Key Words: Divorce, Mental Illness, Dissolution, Marriage, Courts, Judgment.
INTRODUCTION (India Today, February 28, 2005). About 5-10

Stable and satisfying marriages contribute cases — both divorce and alimony — are being
to men's and women's improved physical and filed every day in the family court in Chennai
psychological health and longevity as well as (Dhanda, 2000). There were three prominent
their material wealth (Linda & Waite, 1995) causes firstly, personality related behaviours
and to better outcomes for children's wellbeing (24 per cent),secondly, material and monetary
(Silburn et al., 1996; Amato & Booth, 1997). gains through marriage (23 per cent), and finally,
However, these protective benefits of marriage incompatibility (21 per cent). (Jamwal,1998) .
for adults and children appear to apply only Major mental health disorders may be the cause
in marriages that are not beset with severe or effect of marital disharmony. Divorce-seeking
mental health problems in a spouse (Halford couples have a high psychiatric morbidity in
& Bouma, 1997). Divorce (or the dissolution comparison to well-adjusted couples with more
of marriage), on the other hand, is the final neurotic traits. According to Halford and Bouma
termination of matrimonial union and the legal (1997), "marital distress and psychological
duties and responsibilities of marriage. Divorce disorder reciprocally influence each other."
rate in India is one of the lowest, a little over Marital problems can generate or exacerbate
1 per cent, while the comparable figure for the some psychological disorders but individuals
USA is 54 per cent. The social stigma attached with psychiatric disorders are also less likely
to divorce is also diminishing. Divorce is no to develop satisfying marriages. In India, issues
longer a dirty word. There has been a 100% of marriage, nullity and divorce are governed
increase in divorce rates in the past five years in by personal laws i.e. laws enacted for different
India (Dummett, 2011). Whereas in 1995, 2055 religious groups. Broadly, there are four personal
couples filed for divorce in Mumbai, in 2004, laws viz., Hindu (including, Jains, Buddhists)
the number went up to 3400 in that city alone. Christian, Muslim and Parsi laws. Separate
.1. Assistant Professor, Department of Clinicall Psychology, CIP, Ranchi, 2. Consultant Psychhiatrist, Ranchi Jh (India)
Corresponding author Name : Neha Sayeed;
85
Neha Sayeed et al ... / Divorce, Mental Illness & The Law: Role of Mental Health Personnel
marriage law for Sikhs has been enacted the commencement of this Act, may, on a
recently. The Hindu Marriage Act, 1955 and the petition presented by either the husband or the
Special Marriage Act, 1954 consider insanity as wife, be dissolved by a decree of divorce on the
a ground for divorce. In fact, the language that ground that the other party: has been incurably
both the acts use is similar. According to the of unsound mind, or has been suffering
Dissolution of the Muslim Marriage Act (1939), continuously or intermittently from mental
a wife can file for a divorce if her husband has disorder of such a kind and to such an extent that
been insane for two years and he subjects his the petitioner cannot reasonably be expected to
wife to intense cruelty. live with the respondent.
DIVORCE & THE LAW The expression ‘mental disorder’
means mental illness, arrested or incomplete
Hindu Marriage Act, 1955 :
development of mind, psychopathic disorder
This is an Act to amend and codify the
or any other disorder or disability of mind
law relating to marriage among Hindus. This
and includes schizophrenia; the expression
enactment of 1955 has been subsequently
‘psychopathic disorder’ means a persistent
amended eight times from 1956 to 2003. This
disorder or disability of mind (whether or
Act requires that for marriage to be valid, neither
not including subnormality of intelligence)
party must be incapable of giving valid consent
which results in abnormally aggressive or
because of unsoundness of mind. The expression
seriously irresponsible conduct on the part of
‘unsoundness of mind’ has to be understood as
lack of a state of mind or capacity to understand the other party, and whether or not it requires
one's affairs or marital obligations; neither party or is susceptible to medical treatment. The
should be suffering from mental disorder of a expression ‘incurably’ of unsound mind cannot
type and to an extent as to render the party unfit be so widely interpreted as to cover feeble-
for marriage and the procreation of children. A minded persons or persons of dull intellect who
party would be unfit for procreation if the party understand the nature and consequences of the act
would not be able to look after or maintain the and are therefore able to control them and their
children from the marriage or the children would affairs, and their reaction in the normal way (A.S.
be likely to be suffering from the same mental Mehta versus Vasumathi (A.I.R. 1969) Guj–48;
disorder or defect. The court can nullify the Parvathi Mishra versus Jagadhanantha Mishra
marriage if either condition or both the conditions (1994) 78 CLT 561). When there was sufficient
contemplated exist. The unfitness for marriage evidence for the court to conclude that the slight
and procreation of children contemplated here mental disorder of the wife was not of such a kind
is one arising from mental disorder only, and not and to such an extent that the husband could not
on account of any other disorder. Infertility or
reasonably be expected to live with her, divorce
sterility as such is not a ground for annulment of
could not be granted (Rita Roy versus Sitesh
marriage under Section 12 or for divorce under
Section 13 the word ‘procreation’ includes the Chandra, A.I.R. 1982) CAL 138, 86 CWL 167
capacity to rear children besides the capacity to (Each case has to be considered on its own merits.
beget them. Lastly, neither party should have been A Division Bench of the Andhra Pradesh High
subject to recurrent attacks of insanity meaning Court held in Hema Reddy versus Rakesh Reddy
‘subject to an increase of the acuteness or severity (2003) that psychological depression by itself is
of unsoundness of mind recurring periodically in no ground for divorce under the Hindu Law.
its course’. A marriage in contravention of this
Dissolution of Marriage Under the Muslim Law:
condition is not void but voidable.
A Muslim marriage can be dissolved by
Divorce under Hindu Marriage Act: divorce by the parties without recourse to the
Under Section 13 (1) of this Act, any court and on certain grounds by recourse to the
marriage solemnized, whether before or after court.
86
The law as ordained by the Holy Quran The grounds for nullity of marriage as
is that talaq (divorce)must be for a reasonable per the I DA Section 19. Impotence, lunacy or
cause and that it must be preceded by an attempt idiocy are among the five causes for nullity.
at reconciliation between the husband and the Under Section 19 (3), it must be established that
wife by two arbiterators, one chosen by the wife the respondent was a lunatic or idiot at the time
from her family and the other by the husband of marriage
from his family. If their attempts fail then talaq Grounds for Divorce in the Parsi Marriage Act:
may be effective. According to the Muslim Any married person may seek divorce on
Marriage Act (1939) a woman married under the the following grounds: That the defendant at the
Muslim law shall be entitled to obtain a decree time of the marriage was of unsound mind and
for the dissolution of her marriage (based on has been habitually so up to the date of the suit;
mental health issues) on the following grounds: provided that divorce shall not be granted on this
a) That the husband has been insane for a ground, unless the plaintiff (i) was ignorant of
period of 2 years. the fact at the time of the marriage, and (ii) has
b) That husband subjected his wife to severe filed the suit within three years from the date of
cruelty. the marriage.
That the husband was impotent at the time Grounds of Annulment & Divorce Under
of marriage and continues to be so. Inability of Special Marriage Act:
the husband to consummate the marriage is one The Special Marriage Act was enacted
pattern of impotence. to provide a special form of marriage by any
person in India and all Indian nationals in foreign
Christian Law: countries irrespective of the religion either
On the demand of several Christian party to the marriage may profess. The Special
organizations, Section X of the Indian Divorce Marriage Act provides that for marriage to be
Act (1869), was amended by Act No. 51 of valid, neither party should be incapable of giving
2001. As per this amendment, the grounds for a valid consent to it as a result of unsoundness of
divorce are very much similar to those under the mind; or though capable of giving valid consent,
Special Marriage Act and the Hindu Marriage has been suffering from mental disorder of
Act. Unsoundness of mind is a ground for such a kind or to such an extent as to be unfit
divorce on two conditions: (i) the unsoundness for marriage and the procreation of children, or
of mind must be ‘incurable’ and medical has been subject to recurrent attacks of insanity.
evidence is required to prove it. (ii) It must According to the Marriage Laws (Amendment)
be present for at least two years immediately Act, 1976, recurrent epilepsy was also a
before the filing of the petition. It is submitted disqualification for marriage. Now that has been
that both the conditions must run together. If the removed by the Marriage Laws (Amendment)
respondent's unsoundness of mind was curable Act (No. 39 of 1999) with effect from December
in the beginning, but later on became incurable, 1999.
the period of two years will be counted from the Under the Act petition based on ground
date when the disease became incurable. of nullity of marriage has to be brought by
The Christian wife has some exclusive the aggrieved party to the Court at the earliest
grounds for divorce: The three exclusive opportunity and within a period of one year
grounds for divorce that a wife can file are (i) if possible. A sound mental condition is laid
rape, (ii) sodomy, and (iii) bestiality. Dissolution down as one of the essential qualifications to
of marriage by mutual consent is now possible be possessed by either party to a marriage and
for Christians under Section X A of the IDA decree of nullity of a marriage can be sought
(Amendment Act), 2001. even at a time when parties may not have
87
begotten children. The procreation of children, Consent for Marriage:

therefore, in marital relationship must mean not 'Consent' used in Section 12 (1) (c) of Hindu
merely giving birth to children, but capacity Marriage Act,1955, need not be the consent
to look after them as well. The use of the two given personally by the petitioner and without
expressions together i.e. 'unfit for marriage' intervention of any mediator or any agent. In
and 'procreation of children' permit such a the context of Hindu Marriages the 'consent'
wider interpretation to the latter expression as held by me includes a consent to marriage
used therein. A Hindu marriage, according to given by a spouse through his/her parents, elders
the customary law, is a sacrament and is also a in the family, other relations or friends. In the
contract which is now regulated by the Statute Calcutta case consent to the marriage given
i.e. the Act. A contract to marry is simple and by the husband, through his father, to whom
is a high degree of intelligence is not needed to all necessary disclosures regarding wife were
understand what it implies. Weakness of mind, made by her, was treated to be a good consent
disorder of character or personality apart from binding on the husband although the husband
associated mental illness are not sufficient to had not personally negotiated, for marriage.
invalidate a marriage contract. The presence of (Ruby Roy v. Sudarshan Roy, AIR 1988 Cal
mental disorder, which, at the time of marriage, 210. Under such circumstances, the disclosure
made the individual concerned unable to to the father was obviously disclosure to the son
comprehend the nature and implications of and consent of the father on such disclosure was
marriage, prevented him from fulfilling the consent of the son on such disclosure." It cannot
physical conditions of the marriage contract, be disputed that the fact of mental unfitness
or prevented him from taking care of himself and that she was taking mental treatment for
or his property, would render the marriage be it was material circumstance concerning the
declared null and void after application to the wife which ought to have been disclosed to the
divorce Court. Mental disorder developing after husband or his relations who had negotiated the
marriage does not per se entitle either partner to marriage on his behalf (Smt. Alka Sharma vs
Abhinesh Chandra Sharma, Madhya Pradesh
a divorce or judicial separation.
High Court) Equivalent citations: AIR 1991, MP
Impotence as Ground of Annulment: 205, I (1992) DMC 96, 1991 (MPLJ, 625).
Impotence means the incapacity to
perform sexual intercourse which is full and
MENTAL ILLNESS & DIVORCE: COURT
natural. Refusal to have sex is different from
PROCEEDINGS
impotence. Impotence is different from sterility.
The law presumes a person to be sane,
Consummation means full penetration, not
unless proved otherwise. Insanity has to be
attempt to penetrate. Based on impotence at the
proved. Preponderance of probabilities is the
time of marriage as per Section 19 (1) of the IDA
standard of proof. The burden of proving the
and as per Section 30 of the Parsi Marriage Act insanity of the respondent rests on the petitioner.
and as per Section 24 (ii) of the Special Marriage The court comes to a conclusion on the basis
Act (1954) and according to Section 12A of the of not only medical evidence, but also other
Hindu Marriage Law, the marriage becomes null pieces of evidences. It is the responsibility of
and void. the psychiatrist to keep the documents sound.
According to Section 2 (v) of the A certificate given by the psychiatrist is only an
Dissolution of Marriage Act, one of the grounds opinion, and it attains the status of evidence only
for dissolution of marriage is impotence. The when its author undergoes cross-examination.
institution of suit should be applied for within The law should not discourage persons from
one year for nullity and after one year for seeking treatment for mental disorders, rather
divorce. it should perform a promotive and facilitative
88
role. It is suggested that an express legislative facie case and there is sufficient material before
provision should be incorporated, which states the Court (Sharda vs Dharmpal on 28 March,
that a past history of mental illness will be no bar 2003, Equivalent citations: AIR 2003 SC 3450,
to marriage; failure to disclose such past history 2003 (3) ALT 41 SC). If despite the order of the
or the fact of treatment would not amount to court, the respondent refuses to submit himself
suppression of a material fact (Nambi, S., 2005). to medical examination, the court will be entitled
Most of the divorce cases are brought in the to draw an adverse inference against him.
Family Courts. Family Court was established
ROLE OF MENTAL HEALTH
under Family Courts Act,1984 with the view
PROFESSIONALS:
to promote conciliation in disputes concerning
If one is using ‘mental disorder’ as grounds
marriage and related disputes. Family courts
and mental health personnels both do not want for divorce, one must prove that his or her spouse
to promote the incidence of broken homes. The is suffering from a mental illness and it is of an
decision of the court either preserves or breaks incurable nature and it has become impossible
a family. The psychiatrist must be aware of to live with, and for seeking annulment on the
the legal provisions, in order to meet the legal grounds of mental disorder, it is imperative to
requirements show that the spouse was suffering from mental
disorder at the time of marriage and this very fact
In all cases of this nature, it is evident that
was not disclosed. When a case of divorce based
the Courts scrutinize evidence and documents
on mental disorder arises, the court scrutinizes
before passing a judgment. The Court dismisses
all evidence and documents provided before
arguments that are backed only by reckless
passing a judgment. All arguments that are
allegations unless they are supported and
simply reckless allegations are dismissed and
substantiated. For instance, merely proving
only those that can be supported with substantial
an individual to be suffering from a mental
disorder is not enough. While granting divorce, evidence are taken into consideration. For
the Court looks at the circumstances on which example, simply showing that a person is
divorce is being asked for and the degree and suffering from a mental disorder is not adequate.
nature of the mental disorder. The court believes The court looks into the nature of the disorder
that the disorder should be of such a degree and if it deems that the condition has reached
that it is becomes difficult to live with the such a degree that it is difficult to live with the
person. Prognosis of the disorder, i.e., whether person, then only does it pass judgment. Further,
it is curable and controllable or not; is another it delves into prognosis of the disorder, that
important aspect that is often considered by is, whether or not the disorder is curable and
the law. In cases of this nature, the opinion of a controllable. Usually in such cases, the court
medical expert is always sought. Where mental takes the opinion of a medical expert. If there
condition of a spouse is the controversial issue, is a controversial issue at hand, the Court may
the Court has the authority to issue a direction even ask for a medical examination to be taken.
for medical examination. The Court also looks The medical evidence regarding the
at other circumstances before passing any requisite degree of mental disorder is relevant,
judgment. though not conclusive (Sharada versus
A matrimonial court has the power to order Dharmapaul (2003), 4 SCC 493). In so far as
a person to undergo medical tests, including granting the relief of divorce under Section
undergoing examination of his/her mental 13 (1) (iii) of the Act is concerned, the nature
status, and it is not violation of the right to and degree of mental disorder which meets the
personal liberty under Article 21 of the Indian requirements has been clearly discussed and spelt
Constitution. However, the Court should exercise out in one of the important cases (Ramnarayan
such a power if the applicant has a strong prima Gupta vs Sreemathi Rajeshwari Gupta, Justice
89
Venkatachaliah [Supreme Court 1998]). ‘Each might say that someone exhibits borderline
case of mental illness or schizophrenia has to “traits” or narcissistic “traits,” if they even
be considered on its own merits.’ The judgment go that far. It is advised that the professional
is significant because it gives importance to the should have proper documentation. The content
effects and the impact rather that to the mere of this document should not be disclosed to the
labelling of mental illnesss. The mental health third party (Guidelines for Marriage & Mental,
professional who is treating the patient may be Health Issues in Women, preliminary Draft
summoned for Consensus, Speciality Section - Women’s
When a person is referred to a psychiatrist Mental Health, Indian Psychiatric Society)
or psychologist for examination and opinion, Based on the findings of the “history,
one must avoid shortcut method of issuing a clinical examination and diagnostic
four line certificate. One must give a detailed psychometry”, the psychiatrist may give
report. If the certificate does not bear the opinion that whether the patients suffers from
thumb impression or signature of the alleged “mental illness” or not; and if she suffers what
patient, it cannot be said with certainty that is the diagnosis, and the severity of illness.
the said certificate was issued after having The psychiatrist or the clinical psychologist
examined the defendant as have been observed may be called to witness box and they may be
by apex court in Ram Narain Gupta vs Smt. subjected to examination and cross examination.
Rameshwari Gupta. It must contain identifying In the cross examination, the questions may be
information including identifying marks and a irritating regarding qualification and experience.
photograph of the person examined, the source More often than not the lawyers come prepared
of information and relation with the person with printout of available literature on the
being examined and reliability of the informant. internet about the illness and may test your
The chronology of symptoms development and knowledge. They may ask about the different
the social, personal and occupational problems text books and psychological tests and their
caused by the illness may be clearly mentioned. validity. One should be prepared to answer these
History of past and family history of psychiatric questions. The vital question the court will like
illness and the diagnosis if available should be to know your opinion about the diagnosis of
mentioned. Thorough mental status examination the person examined and basis of your reaching
should be carried out to find whether the to this conclusion, the severity of illness, and
person has delusion, hallucination, signs of finally opinion whether the illness is curable?
affective illness, obsession, compulsion etc. The court may ask your opinion whether the
The treatment history and response to various person can reasonably be expected to live with
treatments should be obtained. The insight and the spouse. In allowing a petition for divorce on
judgment should be invariably mentioned .The the ground of unsoundness of mind, the expert
patient must undergo a detailed psychological opinion of mental health professional is an
diagnostic test and the test report may be important evidence. Medical evidence regarding
attached. Psychological evaluations can be a unsoundness of mind is not conclusive proof
double-edged sword. First and foremost, I would of such state but would be of great assistance
caution you that you should never expect an to court in arriving at proper determination of
outright diagnosis of a personality disorder from state of mind of person concerned."27(Parvathi
a court ordered psychological evaluation. This Ammal vs Kamalammal And Others, Equivalent
may be because the criteria for the diagnosis citations: 2003 (3) CTC 404, (2003) 3 MLJ
are not very well defined, and there’s also an 131. The court reaches to final conclusion
unstated presumption that people are always a by other evidences, documentary or verbal,
little crazy when they’re involved in that kind circumstantial or otherwise and on the merit of
of litigation. It is advisable that the evaluator individual cases.
90
IMPORTANT COURT JUDGEMENTS Vinod Kumari vs Major Surinder Mohan:

Pankaj Mahajan vs Dimple: There was an admission on the part of the
The Supreme Court granted divorce to lady that she used to lose temper and she used
the appellant-husband who came to know that to be given medicines. It was also established
the respondent-wife was suffering from acute that the wife was suffering from Schizophrenia.
mental depression coupled with schizophrenia She was aggressive and prone to abusing and
even prior to the marriage and was taking she used to curse her husband and neglected him
treatment for the same. The appellant-husband with food and she used to sleep separately at odd
hoping that the respondent-wife would become hours. She was under the impression that her
alright took her to various doctors, but her mental food had been mixed with poison. Divorce was
condition did not improve and she became more granted. Similarly, in Balwinder Singh's case, it
and more violent and aggressive. She insulted was proved that wife was suffering from mental
and humiliated the appellant-husband in front disorder even before the marriage and she was so
of his colleagues and relatives. The Apex court greatly excited that she tried to commit suicide.
ruled that “It is clear from the above that the (Balwinder Kaur vs Baldev Singh, 1985 (1)
respondent-wife was not of sound mind and she HLR 97).
did not look after the household work rather she
Asa Rani vs Raj Kumar:
used to give threats to commit suicide. She did
not even make, food for the appellant-husband In Asa Rani's case, the wife was a case
and he had to arrange the same from outside. of insanity and it was proved by oral and
Apart from this, she, used to embarrass the documentary evidence that the wife had been
appellant-husband before his landlord's family mentally sick and it was impossible for the
and because of her weird behavior and threats husband to live with her under those conditions
to commit suicide, the appellant-husband was and hence divorce petition was allowed.
forced to leave the rented accommodation. In the Ayyalasomayajula Satyanandam vs
case on hand, the appellant-husband has placed Ayyalasomayajula Ushadevi:
adequate materials to show that the respondent- A Division Bench of this Court in a case for
wife used to give repeated threats to commit divorce on the ground of unsound mind observed
suicide and once even tried to commit suicide that it is for the petitioner to establish either of
by jumping from the terrace. Cruelty postulates incurable unsoundness of the respondent or that
a treatment of a spouse with such cruelty as to the mental disorder is such a kind and to such an
create reasonable apprehension in his mind that extent that the other spouse cannot reasonably
it would be harmful or injurious for him to live be expected to live with the respondent.
with the other party. The acts of the respondent-
wife are of such quality or magnitude and Pronab Kumar Ghose vs Krishna Ghose:
consequence as to cause pain, agony and The standard of proof in matrimonial cases
suffering to the appellant-husband which is not such as is required in a criminal case, but the
amounted to cruelty in matrimonial law. The Court need only be satisfied on preponderance
court was satisfied that the appellant-husband of probabilities. The Division Bench of Calcutta
had placed ample evidence on record that the High Court, in the case of Pronab Kumar
respondent-wife is suffering from "mental Ghose's case (AIR 1975 Cal 109) granted a
disorder" and due to her acts and conduct, she decree in favour of the husband holding that "the
caused grave mental cruelty to him and it is not events which preceded, attended and followed
possible for the parties to live with each other, the marriage unmistakably go to show that at the
therefore, a decree of divorce deserves to be relevant time i.e. on the date of the marriage the
granted in favour of the appellant-husband. wife must have suffered from Schizophrenia".
91
Sharada vs Dharampal: non-entity and as a negative- unit in family or

The Supreme Court observed as under: society is law's concern also and is reflected, at
“The decisions rendered by various Courts of least partially, in the requirements of Section 13
this country lead to a conclusion that a decree (1) (iii). Apex Court cautioned that Sec. 13 (1)
for divorce in terms of Section 13 (1) (iii) of the (iii) of the Act does not make a mere existence
Act can be granted in the event the unsoundness of a mental disorder of any degree sufficient in
of mind is held to be not curable. A party may law to justify the dissolution of a marriage.
behave strangely or oddly inappropriate and
Kollam Padma Latha (Dr.) vs Kollam
progressive in deterioration in the level of work
Chandra Sekhar (Dr.)
may lead to a conclusion that he or she suffers
Hob’le Andhra High Court in 2006
from an illness of slow growing developing over
observed that husband cannot simply abandon his
years. The disease, however, must be of such a
wife because she is suffering from sickness. The
kind that the other spouse cannot reasonably be
expert witness stated that schizophrenia can be
expected to live with him or her. A few strong
put on par with the diseases like hypertension and
instances indicating a short temper and somewhat
diabetes on the question of treatability, thereby
erratic behavior on the part of the spouse may
meaning that constant medication is required, in
not amount to his/her suffering continuously or
which event, disease would be under control. In
intermittently from mental disorder.
this case, first of all, there is no positive material
Ram Narayan Gupta vs Smt. Rameshwari: to show that appellant was suffering from any
The Supreme Court observed that that kind of schizophrenia as already referred. No
"mere branding of a person as schizophrenic doubt, there is no dispute that she was suffering
will not be sufficient for purposes of Section from slight mental disorder like depression. For
13(1) (iii) of the Act, and “schizophrenia is that reason, respondent-husband cannot divorce
what schizophrenia does to a patient”. The appellant-wife. Can a husband divorce his
High Court referred to and relied upon the wife suffering from diabetes or hypertension?
decision of the Calcutta High Court in Smt. Certainly, not. No doubt, mental disorder cannot
Rita Roy v. Sitesh Chandra, AIR 1982 (Cal.) be equated with diabetes or hypertension. When
138. In; that case the Division Bench of the schizophrenia is not of such a serious nature and
Calcutta High Court observed: " each case of particularly when it is treatable, it cannot be a
schizophrenia has to be considered on its own ground for divorce under Section 13(1) (iii) of
merits and that “two elements are necessary to the Act.
get a decree (i) The party concerned must be of Samar Ghosh vs. Jaya Ghosh
unsound mind or intermittently suffering from In the decision reported in 2007 (3) CTC
schizophrenia or mental disorder and (ii) that 464, the Supreme Court observed on ‘Mental
disease must be of such a kind and of such an Cruelty' “The married life should be reviewed
extent that the other party cannot reasonably be as a whole and a few isolated instances over a
expected to live with her. Only one element of period of years will not amount to cruelty. The
that clause is insufficient to grant a decree. The ill-conduct must be persistent for a fairly lengthy
court observed that "Giving something a name period, where the relationship has deteriorated to
seems to have a deadening influence upon all an extent that because of the acts and behavior of
our relations to it". It brings matter to finality. a spouse, the wronged party finds it difficult to
Nothing further seems to need to be done. The live with the other party any longer, may amount
disease has been identified. The necessity for to mental cruelty. Unilateral decision of refusal
further understanding of it has ceased to exist." to have intercourse for considerable period
This medical-concern against too readily without there being any physical incapacity or
reducing a human being into a functional valid reason may amount to mental cruelty.
92
CONCLUSION http://indiankanoon.org/doc/932494/hindu Marriage

Divorce court cases are common. One India Today, February 28, 2005: ‘Split Seconds’, 62-70
must have knowledge of prevalent laws of land Jamwal, N.S (1998). Marital Discord : Modes of Settlement
and the different court proceedings. The role of with Special Reference to Family Courts in India. A
mental health professionals in such cases needs Doctoral Thesis submitted to the Department of Social
to be properly delinieated including ,proper Work, Jamia Millia Islamia
documentation, preparation of report for the Kollam Padma Latha (Dr.) vs Kollam Chandra Sekhar (Dr.) ,:
2007 (1) ALD 598, 2007 (1), ALT 177
court and certification. The judgements may be
important and may prove beneficial to mental Lawrence, D. (1996). Western Australian Child Health Survey:
Family and Community Health, Perth,
health professional when he or she deposes as
witness and undergoes cross examination in Linda, W. J., & Lillard, L.A. (1995). “Till Death Do Us Part:
Marital Disruption and Mortality.” American Journal of
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Silburn, S., Zubrick, S., Garton, A., Gurrin, L., Burton, P.,
Women’s Mental Health, Indian Psychiatric Society
Dalby, R., Carlton, J., Shepherd, C. & Lawrence,
Halford, K. & Bouma, R. (1997). 'Individual psychopathology D. (1996). Western Australian Child Health Survey:
and marital distress', in Halford, K. & Markham, H.
Family and Community Health, Perth, ABS Cat. No.
(eds) Clinical Handbook of Marriage and Couples
Interventions, John Wiley and Sons, Chichester, UK 4304.5, Canberra.
Hindustan Times (2008). Marriage on Trail, Hindustan times, Smt. Rita Roy v. Sitesh Chandra, AIR 1982 (Cal.) 138.
Feb 17, 12. Ten Divorce Cases Per Day in City’, Hindustan Times, July
http://chdslsa.gov.in/right_menu/act/pdf/family.pdf 29, 2008: 5.
http://chdslsa.gov.in/right_menu/act/pdf/muslim.pdf T. Hari Kumar Naidu vs Smt. Prameela on 8 September, 2000,
http://ibnlive.in.com/news/divorce-rates-are-skyrocketing-in- University Press, Cambridge.
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http://indiankanoon.org /doc /4234 /THE SPECIAL
MARRIAGE ACT, 1954, ACT NO. 43 of 1954
93
Research Article
Reducing Internalized Stigma of Mental Illness among Patients

with Schizophrenia Using Acceptance and Commitment Therapy
Minkesh Chowdhary1 and Masroor Jahan2
ABSTRACT
Schizophrenia is still considered to be a chronic and debilitating illness. Stigma refers to loss
of status and discrimination triggered by negative stereotypes about people labeled as having
mental illness. It produces more harmful consequences to the patient when it is internalized
and this internalized form of stigma is regarded as ‘internalized stigma’. Acceptance and
commitment therapy is a type of mindfulness therapy which aims to maximize human
potential for a rich, full and meaningful life through acceptance, defusion, mindfulness,
and values methods. Present study is aimed to reduce internalized stigma of mental illness
among patients with schizophrenia using acceptance and commitment therapy. 24 patients
diagnosed with schizophrenia according to ICD-10 DCR were chosen from different inpatient
departments of RINPAS, Kanke using the simple random sampling technique. After taking
informed consent from the patients, socio-demographic and clinical data sheet, PANSS,
BPRS and ISMI were administered and then they were randomly assigned to TAU+ACT
group and TAU group. Acceptance and commitment therapy was given to TAU+ACT group,
total 10-12 sessions of 45 minutes each with a frequency of twice a week. After completion
of the therapy sessions, post assessment was done and follow up assessment was done after
four months of post assessment. Data was analyzed with the help of Mann-Whitney U
test, Wilcoxon Sign Rank Test and Chi-square Test was used for statistical analysis. The
significant reduction was found in internalized stigma of the schizophrenic patients in the
post intervention phase which was maintained at follow up. Results have been discussed in
the light of supportive studies, limitations and future directions.
Key Words: Schizophrenia, Internalized Stigma, Acceptance and Commitment Therapy.
Introduction been studied in terms of mental illness. It refers

Schizophrenia and other psychotic to loss of status and discrimination triggered by
disorders are still chronic and debilitating negative stereotypes about people labeled as
conditions despite the advances in having mental illness (Link & Phelan, 2001).
pharmacological treatments (Pratt & Mueser, Stigma produces more harmful consequences
2002). Research suggests that between 25 to 60 to the patient when it is internalized and this
percent of the patients continue to experience internalized form of stigma is regarded as
psychotic symptoms even after satisfactory drug ‘internalized stigma’. Corrigan, Watson, and
adherence (Curson et al., 1988). Barr (2006) suggested that internalized stigma is
Apart from the psychotic features, patients the devaluation, shame, secrecy, and withdrawal
with schizophrenia and other psychotic disorder triggered by applying negative stereotypes to
have several other issues such as stigma, poor self oneself.
esteem and cognitive deficits etc. that contributes There are different interventions targeting
further, in worsening of symptoms, relapses and self stigma. These intervention strategies
poor outcome. Out of these adverse conditions are based on two approaches. First approach
“Stigma” is a widely studied construct that has focuses on changing the self stigmatizing
1. Junior Research Fellow (UGC), 2. Additional Professor,Department of Clinical Psychology. RINPAS, Kanke,
Ranchi (Jh) - 834006. Corresponding Author: Masroor Jahan, e-mail: masroorjahan@yahoo.com
94
Minkesh Chowdhary et al ... / Reducing Internalized Stigma of Mental Illness among Patients with...
beliefs and attitudes while the second approach Measures:

focus on encouraging the individuals to accept Socio-Demographic and Clinical Data Sheet:
the existence of stigmatizing stereotypes It will consist of all areas of socio-demographic
without challenging them and that enhance details like age, sex, domicile, education,
stigma coping skills through improvements in employment, marital status etc., and questions
self esteem, empowerment and help seeking related to nature of illness, substance
behavior (Mittal, Sullivan, Lakshminarayana, dependence, co-morbid psychiatric disorder, age
Elise, & Corrigan, 2012). Present study focuses of onset of illness, duration of illness, hearing &
on second type of intervention known as visual impairment and severe physical illness in
Acceptance and Commitment introduced by the near past.
Bach and Hayes (2002). This therapy utilized Brief Psychiatric Rating Scale (BPRS):
acceptance, defusion, mindfulness, and values The BPRS, one of the most widely used
methods in the treatment of psychiatric disorders psychiatric rating scales, is an 18-item semi-
and other ailments (Hayes et al., 2004). structured clinical interview used to assess
METHOD general psychopathology, positive and negative
symptoms, as well as disorganization and mood
Sample:
problems (Lukoff, et al., 1986; Overall &
In this study initially 24 schizophrenic
Gorham, 1962). The BPRS has been shown to
patients meeting various inclusion and exclusion
consist of four independent factors, and Thinking
criterions were selected from different inpatient
Disturbance (positive symptoms), Anergia
wards of RINPAS, Kanke, Ranchi, Jharkhand (negative symptoms), Affect (depression,
through simple random sampling. In due course anxiety, hostility), and Disorganization
of study four patients (2 from each group) drop subscales can be computed (Long & Brekke,
out from the study as two were prematurely 1999; Mueser et al., 1997). Furthermore, the
discharged from the hospital on care giver BPRS is a valid measure that is sensitive to
request and 2 did not turned up for follow up change in acute inpatient care settings (Varner
assessment. Hence, final analysis was done only et al., 2000). The median inter-rater reliability
for 20 patients. Both groups were comparable for the total psychopathology score has been
in socio-demographic characteristics and reported to be 0.85 and for different subscales
clinical variables. Hence, possible effects of ranging from 0.86 to 0.94.
these variables were controlled prior to the
The Positive and Negative Syndrome Scale
intervention. Patients were in the age range of
(PANSS) (Kay et al., 1987):
20 to 35 years. Most of them were educated
up to at least 9th std. To control confounding PANSS is a 30-item rating instrument
variable patients with history suggesting – evaluating the presence/absence and severity of
mental retardation, general medical conditions, positive, negative and general psychopathology
substance abuse and having acute medical of schizophrenia. This evaluates the patient,
condition or florid psychosis or other co-morbid based on the severity of positive, negative,
psychiatric condition at the time of selection and general psychopathological features. The
were excluded. scale was developed from the BPRS and the
Psychopathology Rating Scale. All 30 items are
Research Design: rated on a 7-point scale (1=absent; 7= extreme).
A Pre-test and post test with control group It takes 30-40 minutes to complete. Alpha
design was used in this study. Equal number of coefficient analysis indicated high internal
patients was randomly assigned to acceptance reliability and homogeneity among items with
and commitment therapy group (TAU + ACT) coefficient ranging from 0.73 to 0.83 for each
and treatment as usual group (TAU). of the scale.
95
Internalized Stigma of Mental Illness Scale administered to collect baseline data. After this
(Ritsher et al., 2003): they were randomly assigned to TAU+ACT
Internalized Stigma of Mental Illness Scale or TAU group. Patients in the TAU condition
was developed by Ritsher et al. (2003). In this received standard treatment on the unit, which
scale there are twenty-nine items grouped into includes psycho-educational, supportive therapy
five subscales reflecting, Alienation, Stereotype and pharmacotherapy. Patients in the TAU+ACT
endorsement, Perceived discrimination, condition received approximately 8-10 one
Social withdrawal, and Stigma resistance. The hour long sessions of individual ACT twice in
Alienation subscale, with six items, measures a week during their stay in the hospital. The
the subjective experience of being less than a full ACT protocol based on Bach and Hayes (2002)
member of society. The Stereotype Endorsement work was developed so that patients could
subscale, with seven items, measures the degree participant in treatment as their stay will dictate.
to which respondents agreed with common Specifically, each 1-hour session contained a core
stereotypes about people with a mental illness. set of components that allowed participants to
The Discrimination Experience subscale, with participate in the number of individual sessions
five items, measures respondents’ perceptions appropriate to their length of stay. Each session
of the way they tend to be treated by others. was started with an educational component that
The Social Withdrawal subscale, with six items, addressed psychotic symptoms. Next, goals and
measures aspects of social withdrawal such as; valued behaviours were elicited and the role
I don’t talk about myself much because I don’t of disturbing thoughts/emotions as barriers to
want to burden others with my mental illness. goal attainment was discussed. After this ACT
The Stigma Resistance Subscale, with five model was presented to provide a rationale for
items, measures a person’s ability to resist or be treatment. Various mindfulness and acceptance
unaffected by internalized stigma. All items are exercises were practiced to decrease avoidance
measured on a 4-point Likert-type agreement or struggle with internal experiences. Patients
scale (1 = strongly disagree to 4 = strongly agree). were taught to accept and experience symptoms
The 29-item ISMI had an internal consistency non-judgmentally without allowing them to
reliability coefficient was found 0.90 interfere with goal-directed behavior. Each
session was ended with a review and suggestions
(N=127). The test-retest reliability
for practice of exercises to be attempted between
coefficient was found 0.92. Further construct
sessions. A core set of mindfulness/acceptance
validity of this instrument was found ranging
exercises were rotated through sessions. Prior
from 0.35 to 0.59.
to discharge, participants were evaluated again
Procedure: on the same measures as it was on baseline. At
In this study patients diagnosed with a 4-month follow-up, participants were again
schizophrenia as per ICD-10 (DCR) and meeting evaluated on the same measures of this study
the inclusion and exclusion criterions were complete.
selected from different units of Ranchi Institute
Statistical Analysis:
of Neuro-Psychiatry and Allied Sciences.
As sample size in this study was small,
Potential and interested candidates were
hence obtained data was analyzed by using
approached. Once patients agreed to participate,
non-parametric statistics, namely, Chi-square
informed consent was taken and demographic
test, Mann Whitney U test (for between group
and clinical information was collected by
comparison) and Wilcoxon Sign Rank test (for
using socio-demographic and clinical data
within group comparison).
sheet. Immediately after obtaining consent and
collecting socio-demographic and clinical data, RESULTS
PANSS, BPRS (screening tools), and ISMI were Table 1 is showing the comparison between
96
patients with schizophrenia in treatment as Stereotype 12.20 16.80 6.55 14.45 10.50 2.99**
usual group and patients in treatment as usual endorsement ±2.97 ±1.93
plus acceptance and commitment therapy group Discrimination 10.90 14.40 7.60 13.40 21.50 2.21*
(TAU+ACT) at baseline, post and follow up Experience ±2.51 ±3.50
Social 11.60 16.20 6.60 14.40 11.00 2.96**
scores on internalized stigma of mental illness
withdrawal ±2.50 ±3.08
(ISMI). To compare both groups on baseline,
Stigma 10.40 15.60 6.10 14.90 6.00 3.34**
post and follow up assessment scores Mann Resistance ±1.83 ±2.91
Whitney ‘U’ test was calculated. p<0.05*, p<0.01**, p<0.01***
Table 1: Comparison between Treatment as usual By observing the first part of Table 1 it is
plus Acceptance and Commitment evident that there was no significant difference
Therapy Group (TAU+ACT) and between both the groups in terms of total scores
Treatment as usual Group (TAU) on on ISMI and its various domains. This suggests
Baseline Assessment, Post Assessment, that both groups were similar in terms of
and Follow up Assessment. total scores on ISMI and scores on its various
Baseline Assessment domains. Second part of the Table 1 shows
Variable Group Mean U Z the comparison between both groups on post
(Mean Rank assessment scores. From this part it is clear that
± SD) statistically significant difference was found
TAU+ TAU TAU+ TAU between both groups on total ISMI score (U =
ACT ACT
2.50, Z = 3.59, p<0.001) as well as on its various
Internalized 75.80 81.00 9.30 11.70 38.00 0.90
±15.11 ±14.22
domains i.e. alienation (U = 1.00, Z = 3.72,
Stigma Total
Alienation 15.20 17.60 8.70 12.30 32.00 1.37
p<0.001), stereotype endorsement (U = 4.00, Z
±3.85 ±3.30 = 3.48, p<0.001), discrimination experience (U
Stereotyped 17.40 18.90 9.45 11.55 39.50 0.79 = 12.50, Z = 2.86, p<0.01), social withdrawal (U
Endorsement ±4.19 ±3.41 = 15.50, Z = 2.62, p<0.01) and stigma resistance
Discrimination 13.60 14.30 9.75 11.25 42.50 0.57 (U = 12.50, Z = 2.85, p<0.01)).
Experience ±2.75 ±3.20
Looking at the provided mean value,
Social 15.80 17.00 9.50 11.50 40.00 .76
Withdrawal ±3.39 ±3.62
standard deviations, U value, Z valve and
Stigma 13.80 13.20 11.00 10.00 45.00 .380 significant level it is evident that patients in
Resistance ±2.65 ±3.36 acceptance and commitment therapy group
Post Assessment scored lower on all the domains of ISMI. It
Internalized 54.70 82.00 5.75 15.25 2.50 3.59*** indicates towards the significant effect of ACT
Stigma Total ±7.68 ±11.02 in reducing internalized stigma of mental illness
Alienation 10.50 16.70 8.70 12.30 1.00 3.72*** in patients with schizophrenia.
±1.77 ±2.98
Third part of the Table 1 shows the
Stereotyped 11.50 18.40 5.90 15.10 4.00 3.48***
Endorsement ±3.10 ±2.54 comparison between both groups on follow
Discrimination 10.80 15.90 9.75 11.25 12.50 2.86** up assessment in terms of total ISMI scores
Experience ±1.81 ±3.67 and its various domains. On this comparison
Social 11.50 16.30 7.05 13.95 15.50 2.62** statistically significant difference was found
Withdrawal ±2.71 ±4.00 between both groups on different measures of
Stigma 10.40 14.70 6.75 14.25 12.50 2.85** internalized stigma of mental illness scale i.e.
Resistance ±2.22 ±2.75
ISMI total score (U = 0.00, Z = 3.78, p<0.001),
Follow up Assessment
alienation (U=5.00, Z = 3.41, p<0.01), stereotype
Internalized 55.90 79.60 5.50 15.50 .000 3.78***
Stigma total ±7.66 ±7.41 endorsement (U = 10.50, Z = 2.99, p<0.01),
Alienation 10.80 16.60 6.00 15.00 5.00 3.41** discrimination experience (U = 21.50, Z = 2.21,
±2.04 ±3.23 p<0.05), social withdrawal (U = 11.00, Z = 2.96,
97
p<0.01), and stigma resistance (U = 6.00, Z = between pre and post scores of acceptance and
3.34, p<0.01). commitment therapy group. From the first part
Follow up assessment’s mean value, of the table it is evident that no statistically
standard deviation value, U value, Z value and significant difference was found between
significance level indicates that even on follow baseline assessment scores and post assessment
up, therapy group scored lower in comparison scores of TAU group which indicates that this
to non therapy group on all the domains of group did not improved significantly on the
internalized stigma scale. This proves that ACT measures of internalized stigma of mental illness
effect that was gained during post assessment rather showed slightly increased scores.
was maintained for longer durations. Second part of the Table 2 shows
the comparison between baseline and post
Table 2: Comparison Between Baseline and Post assessment scores of ACT group. Results of this
Scores across both Groups. table shows that significant difference was found
Variable Group Mean Rank Z between baseline assessment scores and post
(Mean + SD) assessment scores on total score of internalized
Baseline Post -ve +ve stigma of mental illness scale (Z = 2.80, p<0.01)
Ranks Rank
and on its various domains i.e. alienation (Z =
TAU+ACT Group
2.71, p<0.01), stereotyped endorsement (Z =
Internalized 75.80 54.70 5.50 00.00 2.80**
2.81, p<0.01), discrimination index (Z = 2.33,
stigma total ±15.41 ±7.68
p<0.05), social withdrawal (Z = 2.69, p<0.01),
Alienation 15.20 10.50 6.00 1.00 2.71**
±3.85 ±1.77 and stigma resistance (Z = 2.57, p<0.01).
Stereotyped 17.40 11.50 5.50 00.00 2.81** These findings suggests that after acceptance
endorsement ±4.19 ±3.10 and commitment therapy this group showed
Discrimination 13.60 10.80 6.00 1.50 2.33* significant reduction in internalized stigma of
Experience ±2.75 ±1.81 mental illness and in its various domains.
Social 15.80 11.50 5.00 00.00 2.69** Table 3 shows comparison between post
withdrawal ±3.39 ±2.71 and follow scores across both groups. For
Stigma 13.80 10.40 5.50 1.00 2.57** this comparison Wilcoxon Sign Rank test was
resistance ±2.65 ±2.22 calculated for both the groups.
TAU Group
Internalized 81.00 82.00 4.90 6.10 .307 Table 3: Comparison Between Post and Follow up
stigma total ±14.22 ±11.01 Scores across both Groups.
Alienation 17.60 16.70 5.42 4.17 1.19 Variable Group Mean Rank Z
±3.30 ±2.98 (Mean + SD)
Stereotyped 18.90 18.40 6.10 4.90 .308 Post Follow -ve +ve
endorsement ±3.41 ±2.54 up Ranks Rank
Discrimination 14.30 15.90 4.25 5.21 1.68 TAU+ACT Group
Experience ±3.19 ±3.66 Internalized 54.70 55.90 4.17 4.70 .772
Social 17.00 16.30 7.30 3.70 .926 stigma total ±7.68 ±7.66
withdrawal ±3.62 ±4.00 Alienation 10.50 10.80 3.70 6.63 .478
Stigma 13.20 14.70 3.00 7.17 1.60 ±1.77 ±2.04
resistance ±3.35 ±2.75 Stereotyped 11.50 12.20 5.75 4.79 1.32
p<0.05*, p<0.01** endorsement ±3.10 ±2.97
Discrimination 10.80 10.90 5.75 4.40 .060
Table 2 shows the comparison between Experience ±1.81 ±2.51
pre and post scores across both groups. First Social 11.50 11.60 5.50 5.50 .00
part of the table shows the comparison between withdrawal ±2.71 ±2.50
pre and post scores of treatment as usual group. Stigma 10.40 10.40 5.63 4.50 .00
Second part of the table shows the comparison resistance ±2.22 ±1.83
98
TAU Group Post-follow up differences

Internalized 82.00 79.60 7.20 3.80 .869 Internalized -1.20 2.40 9.30 11.70 38.00 .91
stigma total ±11.01 ±7.41 stigma total ±5.99 ±7.58
Alienation 16.70 16.60 5.70 5.30 .102 Alienation -0.30 0.10 10.05 10.95 45.50 .34
±2.98 ±3.23 ±2.31 ±3.87
Stereotyped 18.40 16.80 4.71 6.00 1.257 Stereotype -0.70 1.60 8.05 12.95 25.50 1.87
Endorsement ±1.70 ±3.09
endorsement ±2.54 ±1.93
Discrimination -0.10 1.50 8.90 12.10 34.00 1.24
Discrimination 15.90 14.40 5.25 6.50 1.514
±2.80 ±2.91
Experience ±3.66 ±3.50
Social -0.10 0.10 10.35 10.65 48.50 .12
Social 16.30 16.20 7.13 4.42 .103
Stigma 0.00 .90 11.60 9.40 39.00 .841
Stigma 14.70 15.60 5.50 5.50 1.129 resistance ±2.40 ±2.88
resistance ±2.75 ±2.91
p<0.01**, p<0.01***
Results of both parts of Table 3 indicates
that no significant difference was found between Results of first part of Table 4 revealed
the post and follow up scores across both that ACT group showed significantly higher
groups and none of the groups showed further difference on the measures of internalized stigma
improvement or worsening of internalized of mental illness in comparison to TAU group. It
stigma on follow up in comparison of post indicates that ACT group observed significant
assessment. Further both group maintained changes in internalized stigma of mental illness
their previous position in terms of severity of after therapy i.e. on post assessment. Contrary
internalized stigma. While ACT group showed to this TAU group showed consistency in their
stability in improvement or gains previously internalized stigma of mental illness on post
achieved due to acceptance and commitment assessment. Both group differed significantly in
therapy, TAU group showed stability in term of terms of changes in internalized stigma of mental
further deterioration. illness scale scores from baseline assessment
Table 4: Comparison between TAU Group and to post assessment. Significant difference was
TAU Plus ACT Group on Difference found between both groups in terms of total
Scores on Baseline – Post Assessment and internalized stigma of mental illness scale score
Post-Follow up Assessment. (U = 3.00, Z = 3.55, p<0.001) and on its various
domains i.e. alienation (U = 14.50, Z = 2.70,
Group Mean Rank
Variable (Difference U Z p<0.01), stereotyped endorsement (U = 10.00, Z
Mean ± SD) = 3.03, p<0.01), discrimination experience (U =
TAU TAU TAU TAU 12.50, Z = 2.87, p<0.01), social withdrawal (U =
+ACT +ACT
17.50, Z = 2.48, p<0.01), and stigma resistance
Baseline-post differences
(U = 8.50, Z = 3.16, p<0.01).
Internalized 21.10 1.00 15.20 5.80 3.00 3.55***
Stigma Total ±9.40 ±8.47 Second part of the Table 4 revealed that
changes from post to follow up scores in both
Alienation 4.70 0.90 14.05 6.95 14.50 2.70**
±2.94 ±2.33 groups were not significant which means that
after post assessment both grouped did not
Stereotyped 5.90 0.50 14.50 6.50 10.00 3.03**
endorsement ±2.18 ±4.11 changed much in comparison to each other and
Discrimination 2.80 1.60 14.25 6.75 12.50 2.87**
that their follow up assessment scores were more
Experience ±2.78 ±2.71 or less same as they were on post assessment.
Social 4.30 0.70 13.75 7.25 17.50 2.48** DISCUSSION
Present study was conducted to evaluate
Stigma 3.40 1.50 14.65 6.35 8.50 3.16** the significance of Acceptance and commitment
resistance ±2.71 ±2.54
therapy in reducing internalized stigma of mental
99
illness among patients with schizophrenia. techniques and acceptance and commitment
In this study it was found that ACT group therapy e.g. psycho-education, and cognitive
improved significantly on all the domains of behavior therapy. McCay et al. (2010) found
internalized stigma of mental illness i.e. alienation, that psycho-educational programs are effective
stereotype endorsement, discrimination, social in reducing or minimize self-stigmatizing
withdrawal, stigma resistance and total score of attitudes, develop hope, and helps the individual
internalized stigma of mental illness scale after to interpret the illness and in pursuing life goals.
completion of therapy at post assessment. They Similarly in ACT focused is paid in eliciting
showed significant improvement on all of these life goals and attempts are made towards their
measures. This proves that ACT is effective in achievement. Lumo et al. (2008) evaluated the
reducing internalized stigma of mental illness. effect of ACT in reducing the self stigma in
Significant difference was found between both substance abuse patients and found it effective
groups on all the domains of internalized stigma in reducing stigma. Findings of the present study
at post assessment where, ACT group score are consistent with these findings. ACT also
significantly lower in comparison to TAU group. shares some elements with cognitive behavior
This finding again supports the significance of therapy though its orientation is different to
see the psychopathology. Empowering the
ACT in reducing internalized stigma.
individual is primary focus of ACT and it was
Comparison between both groups on found that empowering is inversely related
follow up assessment revealed that on follow to self-stigma (Brohan et al., 2010). Similar
up also ACT group scored significantly lower findings were reported by Masuda et al. (2007)
on all the domains of internalized stigma in who reported effectiveness of ACT in reducing
comparison to TAU group. This finding suggests stigma in people with psychological disorders
that ACT was effective in reducing stigma. and suggested that acceptance and commitment
Comparison between both groups on therapy is an important avenue of exploration
difference (base line – post) scores suggests for stigma researchers.
that on post assessment ACT group showed Findings of present study supports the
significantly sharp decline in internalized stigma use of acceptance and commitment therapy and
as compared to TAU group. Further no significant new avenue in reducing the internalized stigma
difference was found between both groups on of mental illness in schizophrenia patients,
difference scores of post – follow assessment. however, the study has certain limitations. The
This finding indicates that none of the group sample size wassmall due to which parametric
showed significant changes in internalized analysis was not done despite randomized
stigma and previous position was maintained control design and only male patients were
in both the groups. The reason seems to be that selected which limits its generalization for
after post assessment both group maintained female group. Further research is required on
more or less same status as it was on post larger sample using double-blind procedure on
assessment. ACT group though did not improve various sub-groups of schizophrenia.
further but maintained the therapeutic gains that
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101
Research Article
Concurrency in Skill Enhancement and Problem Behavior
Reduction Following Customized Behavioural Interventions in
Children with Autism
Kadambari N1 and Venkatesan S2
ABSTRACT
Concurrency is simultaneous occurrence of two or more events at the same time or in the
same location. Most behavior change programs attempted on children with autism have
been carried out separately for reducing problem behavior followed by enhancement of
skill behavior or vice versa. Even as there are admitted challenges in identifying problem
behaviours as distinct from skill behaviours, this study examines the feasibility, efficacy
and benefits of a customised, time-bound and synchronized intervention in ameliorating the
behavioural repertoire in eight children on autism spectrum. The targeted sample underwent
a randomly blinded baseline assessment on two standardized behavior assessment scales,
viz., ‘Problem Behavior Survey Schedule’ and ‘Activity Checklist for Preschool Children
with Developmental Disabilities’ before being subjected to the 8-week long interventions
spread over 12-one hour one-to-one and small group based sessions in home as well as
therapy settings. The interventions used procedures derived from applied behavior analysis,
environmental manipulation, direct instruction on identified individual skill deficits,
structured teaching and parent guidance covering play, receptive-expressive communication,
sensory-motor, pre-academics and self help activities. Even though there was observable-
measurable changes in skill and problem behaviours as reflected by their test scores
following the behavior interventions, the overall results were statistically insignificant (p:
>0.05). A next level domain analysis showed that only ’sensory’ items under skill behaviours
were maximally gained as under problem behaviours, ‘temper tantrums’, ‘hyperactivity’ and
‘rebellious behavior’ reduced most (p: <0.01) over all other behavioural domains in children
with autism. There are indications to show that greater skill behavior scores are inversely
correlated to their problem behavior scores, both, in terms of intensity as well as frequency.
The results are presented and discussed in the light of a growing need or value for concurrent
use of customised behavioural interventions in skill enhancement and problem behaviour
reduction to optimise benefits for children with autism.
Key Words: Concurrency, Behavioural Intervention, Skill behavior, Problem behavior
iNTRODUCTION preschool and kindergartens (Eikeseth,

The efficacy of individualised behavioural Klintwall, Jahr & Karlsson, 2012; Eikeseth,
interventions in facilitating clinically significant Smith, Jahr & Eldevik, 2002) to community-
gains in intellectual, language, social, emotional based settings (Stahmer, Collings & Palinkas,
and adaptive functioning of children with autism 2005). Studies have explored the viability of
has been severally demonstrated against matched using parents as co-therapists (McConachie
control-groups receiving other interventions & Diggle, 2007; Smith, Buch & Gamby,
(Cohen, Amerine-Dickens, & Smith, 2006; 2000; Holmes, Hemsley, Rickitt & Likierman,
Howard et al. 2005; Beadle-Brown, Dorey & 1982; McClannahan, Krantz & McGee,
Murphy, 2004; Anderson & Romanczyki, 1999). 1982).
The location of these interventions have varied Behavioural interventions applied on
from homes (Anderson et al., 1987), mainstream children with autism cover two aspects: (a)
1. Research Scholar, Department of P G Studies in Psychology, University of Mysore, 2. Professor in Clinical
Psychology, AIISH, Mysore: 570 006. Correponding Author: Kadambari.N, Email: psyconindia@gmail.com
102
Kadambari N et al... / Concurrency in Skill Enhancement and Problem Behavior Reduction
acquisition, maintenance or enhancement of for the child with autism, there are marked holes
positive asset driven skill behaviours; and, in our knowledge largely due to methodological
(b) reduction, elimination or extinguishing considerations (Matson et al, 2012a). A recent
of negative problem behaviours. Whereas study argued that the 20-40 hours per week
‘behaviours’ are defined as ‘observable and prescribed for behavioural interventions is
measurable actions’, they are assumed to be much more than what is described in most ABA
learned due to environmental contingencies studies or that the children treated are typically
by which they get elicited and maintained. By between 2-3 years which is much younger than
the same school of thought, every behavior the samples of most ABA studies (Matson et al.,
is understood to serve immediate functional- 2012 b). Hence, there is little wonder that results
utilitarian purpose for the organism, which of such interventions are generally reported as
when analysed become the basis for engineering positive.
behavior change programs. There are antecedent Ideally, there is need to combine,
driven and/or consequence controlled behaviours
integrate and develop a holistic approach
whose precise manipulations is the essence of
to behavioural interventions. Remediation
‘Applied Behavior Analysis’ (ABA) programs
must target decrement of problem behaviours
that have been tried successfully on children
with simultaneous increment in scores of skill
with autism (Matson et al, 2012; 1996). Ideally,
behaviours for individual or groups of children.
behavioural interventions come from research-
Against the background of this need, rationale
based organizations and are implemented by
and justification, it was the aim of this study to
certified experts. A few reasons why such
examine the feasibility, efficacy and benefits
programs may fail could be that the treatment
of a customised, time bound and synchronized
is not sufficiently intensive and the intervention
behavioural intervention in ameliorating the
period is too brief or even that it does not
behavioural repertoire on a treatment group of
meet the standard in terms of program quality
(Reichow, 2012; Humphrey & Parkinson, 2006; children on the autism spectrum. The specific
Gresham & MacMillan, 1998; 1997). objectives of this study were:
Despite the apparently overwhelming •• To identify, list and record a baseline on
evidence favouring behavioural interventions, the different types and specific instances
critical methodological issues related to research of problem behaviours as distinct from
design, randomization, heterogeneity of sample deficits in their skill behaviours in children
populations, case controls, recovery indices, diagnosed as autism;
measurement issues, generalization, and outcome •• To evolve and implement an individualized
evaluation involved in such studies have been and/or small group based interventions
raised (Kuppens & Onghena, 2012; Dawson et on the target behaviours in children with
al., 2009; Matson & Smith, 2008; Matson, 2007; autism for specified time frame and/or
Hume, Bellini & Pratt, 2005). Issues related to across envisaged sessions in home or
cost-benefits in terms of behavior intervention school settings;
services, its implementation and teacher or •• To undertake a final evaluation of the
therapist training, how to integrate it with intervention effects upon different types
other treatments and how best to fill the gaps and specific instances of skill and problem
between research and practice have also been behaviours in home or school settings
posited (Jacobson & Mulick, 2000). There are for the identified children diagnosed as
controversies regarding who responds best and autism; and,
to what degree. Despite the widespread notion •• To establish the reliability and validity
that these programs result in long term benefits indices of the measured indices.
103
METHOD cases in this study. They were drawn on the

The study uses 2-group pre test post test basis of convenience sampling from special/
comparative intervention-cum-correlation mainstream schools located in Mysore,
research design covering the period of data Karnataka.
collection between June-July, 2013. The key Tools:
terms used in this enquiry are: ‘Concurrency’, Behavior assessment protocols typically
‘Behavioural Intervention’ and targeted variables use of psychometrically valid and standard
are: ‘skill behavior’ and ‘problem behavior’ as tools to appraise, both, skill/positive as well
applied on a clinical sample of children with as negative/problem behaviours. Some well
autism known western and Indian tools for assessment
Operational Definitions of problem behaviours are listed in a related
publication (Ganesh & Venkatesan, 2012). Most
(a) Concurrency:
of them use parent/teacher ratings or estimations
Concurrency, as used in this study, is
of problem behaviours in children with an
simply the co-occurrence of two or more events
acceptable measure of congruence between
or variables simultaneously at the same time, in
such respondents (Glaser, Kronsnoble &
the same location or in the same children with
Forkner, 1997; Peshawaria, Venkatesan
respect to their ‘skill behavior’ and ‘problem
& Menon, 1990; 1988). Among the
behavior’.
standardized behavior assessment scales
Skill & Problem Behaviours: developed in our country, the two most
Skills or adaptive behavior contrasts relevant tools opted for use in this study are:
maladaptive, dysfunctional, non-productive Activity Checklist for Preschool Children
problem behaviours. It is age appropriate with Developmental Disabilities (ACPC-
behavior necessary for an individual to function DD; Venkatesan, 2004) and Problem Behavior
safely and independently in daily life. Problem Survey Schedule (PBSS; Venkatesan, 2013).
behaviours, on the other hand, are negative, The ACPC-DD is a standardized behavior
undesirable, maladaptive, or challenging assessment device to elicit systematic and
although observable-measurable actions of comprehensive information on current level of
people which may be deemed as not being age or skill behaviours in preschool aged children (0-72
situation appropriate, unproductive, interfering months) with developmental disabilities. The tool
in their learning of new behaviours, harmful to consists of 400 items distributed evenly across 8
self or others, occurring in magnitude sufficient behavioural domains relevant to daily activities
to cause stress to others (Venkatesan, 2004). of such infants, toddlers and preschoolers,
Typical categories of such behaviours are: viz., Sensory, Gross-Motor, Fine-Motor,
‘violent and destructive’, ‘self injurious’, ‘odd’ Communication, Play, Self-Help Activities,
‘antisocial’, ‘repetitive’, ‘temper tantrums’,
Cognitive Activities and Pre-academics. The
‘misbehaviour with others’, ‘anxieties or fears’,
specific number of items under each domain is
‘hyperactivity and rebellion’ (Peshawaria &
intentionally fixed at 50. As per the procedure
Venkatesan, 1992 b).
laid down for administration of ACPC-DD, each
Sample: child is assessed and a behavioural profile of
The study covered 8 children (Age Range: assets/deficits (i.e., behaviours s/he “could” and/
3-6 years; Mean: 4.97; SD: 0.98) diagnosed as or “could not” perform) are enlisted as baseline.
autism without any co-morbid conditions. The The items are scored on 0-5 and maximum score
ICD-10 official criteria (WHO, 2012) were can be 250 under each domain and 2000 on the
followed in classification or categorization of whole for any given child.
104
The PBSS consists of 100 items grouped each child was recorded during every follow up
under 11 domains. The scoring of each child on along with information on items not achieved or
PBSS is carried out on two counts: ‘Frequency those marked as “ongoing” activities for further
Count Score’ (FCS) based on presence or absence training.
of given problem behaviours; and ‘Intensity/ The scores on the two checklists were
Severity Count Score’ (I/SCS) of problem compiled into discrete or meaningful categories
behavior for a given child. The former is marked during data analysis and statistical treatment. To
as ‘present’ (score: one) or ‘absent’ (score: zero). determine covariance between acquisitions of
The latter is calculated on a 3-point rating scale: skills as reflected on ACPC-DD and decrement
‘never’ (score: zero), ‘occasionally’ (score: of problem behaviours as measured on PBSS,
one), and ‘frequently’ (score: two). Thus, the correlation coefficients were calculated. By
maximum possible FCS on PBSS is 100 and I/ consensus, based on content and directionality,
SCS is 200 for a given child. Additionally, PBSS the classification, categorization and cataloguing
facilitates for each child another ‘Directionality of raw data on reported behavior changes vis-
Score’ (DS) in terms of ‘internalizing’ and/or à-vis children with autism was carried out by 3
‘externalizing’ patterns of problem behavior. independent mutually blinded raters including
The inter-rater reliability coefficient for PBSS
the parent, teacher and therapist. The inter-rater
is reported as 0.91 (p: <0.001) and 3-week test-
reliability exercises measured range of 95.6-97.2
retest reliability is 0.89 (p: <0.001). across the three respondents. All analysis was
Procedure: done on SPSS/PC (George & Mallery, 2003).
Each child included in this study
Behavioural Interventions:
underwent baseline (BL) assessment on ACPC- This intervening variable in this study
DD and PBSS before a short list of 5-10 involved strategies that enable children to
behavioural objectives simultaneously covering, acquire certain behaviours to cover deficits and/
both, skill and problem behaviours (if any) was or tone down excesses in a typically contrived
identified for intervention on a clinic and home environment before such changes are generalized.
based intervention module. Supporting verbal The emphasis was on analysis of here-and-now
and written guidelines on how to train the child antecedents and/or consequences, which when
on the chosen target behaviour or managing identified and manipulated was used to alter
problem behavior, simple or pragmatic record any given behavior. Key elements in effective
keeping procedures, behavioural techniques to behavioural interventions typically included
be implemented, bibliotherapeutic materials, involvement of parents, peers and significant
reward or incentive systems to be used, were others as co-teachers or co-therapists, adoption
also given to each enlisted caregivers. Teaching of certain characteristic teaching methods,
aids/materials relevant to the chosen behavioural covering the particular curriculum spread
objectives were exemplified. Written instructions across different environments, multiple settings,
accompanied the verbal explanations such that levels and variety of skills, and simultaneously
record keeping was simple, pragmatic, direct addressing reduction of aberrant behaviours.
and immediate during home training. The The ground techniques involved use of rewards,
standardized “toy-kit” to go with ACPC_DD careful selection of instructional materials and
(Venkatesan, 2012; 2010) was also used as part procedures like environmental manipulation,
of this program. There was at least one follow up operant techniques like shaping, chaining,
in 4 weeks ranging for a period of two months. prompting or fading, contingency contracting,
The entire intervention was implemented across token economy, time out, extinction, etc. The
12 structured sessions including 4 sessions of stress was on customised or individualized
group work. The behavioural achievements of instruction. Thereafter, the children as well
105
as the caregivers wee continuously shadowed identification of functions underlying specific

across real-life settings like school, home or problem behaviours, recommending them to
community to achieve transfer of learning and desist against use of ad hoc, arbitrary or counter-
generalization, integration and mainstreaming. productive techniques like false inducements,
Broadly, the 8-week long customised nagging, pleading, begging or bargaining with
behavioural intervention spread over 12-one children. Counselling focused on assuaging doubts
hour sessions in home, school and therapy and elimination of felt or reported sense of guilt in
settings comprised of one-to-one as well as small few parents to use certain behavioural techniques
group based sessions using procedures derived (Humphrey & Parkinson, 2006; Gresham &
from ABA, environmental manipulation, direct MacMillan, 1998; 1997; Peshawaria & Venkatesan,
instruction on identified individual skill deficits, 1992b; Lovaas, 1987).
structured teaching and parent guidance covering
RESULTS & DISCUSSION
play, receptive-expressive communication,
The results are presented and discussed
sensory-motor, pre-academics and self help
sequentially under the following heads:
activities. An exclusive and simultaneous focus
was laid on identification and management Comparative Pre and Post-treatment Scores
of problem behaviours wherever present in on Skill & Problem Behaviour
each child. This was carried out by listing the A comparative pre to post-treatment scores
observed or reported problem behaviours, (Table 1) and their percentage gain (or increment)
prioritizing, analysing their antecedents and in skill behavior scores and/or concurrent
consequences, mapping their perceived ‘causes’ percentage decrement of scores for problem
and/or ongoing ‘handling’ strategies, eliciting behaviours as reported across informants (Table
the constraints involved in implementation of - 2) is given with graph (Figure - 1).
home based programs etc. The overall long
Skill Behaviours Problem Behaviours Intensity Score
term objective of the intervention program was Score Baseline Final Baseline Final
to enable the targeted children to internalize (N: 8) P T Th P T Th
what is being trained or remedied and thereby Total 8192 8878 321 391 371 246 255 247
Mean 1024 1109.8 40.1 48.9 46.4 30.8 31.9 30.9
reach a level of sufficient independent mastery. SD 142.9 147.6 16.9 14.2 12.7 16.0 9.2 8.8
Similarly, the locus of control was not to be p-value T: 1.18; df: 14; X2: 2.21; Df: 2; p: 0.3312
an external parent, school, teacher, parent or p: 0.26
therapist driven initiative, but more of internally Problem Behaviours Frequency Score
self-driven behaviours in the caregiver as well Score Baseline Final
as the child. (N: 8)
P T Th P T Th
The specific skill training procedures or Total 225 246 236 200 214 208
techniques used in this study included activity Mean 28.1 30.8 29.5 25 26.8 26
scheduling, task analysis, prompting, shaping, SD 8.7 7.7 6.3 10.4 6.2 5.7
chaining, fading, reinforcement, contingency p-value X2: 0.03; Df: 2; p: 0.9851
contracting, token economy, modelling, etc. (P: Parent; T: Teacher; Th.: Therapist)
The individualised remediation techniques The BL mean for overall sample (N: 8)
implemented after functional analysis of on ACPC-DD is 1024 (51.2%; SD: 142.87) out
each problem behavior included extinction, of maximum possible score of 2000 for any
differential reinforcement, time out, physical given child assessed on this tool (Table 1).This
restraint, restitution or overcorrection, conveying improved following behavioural intervention to
displeasure, etc. Additional guidelines 1110 (55.5%; SD: 147.55) by a clear margin of
given to parents on home based program 86 points (4.3 %). Concurrently, out of maximum
applications included resolving disagreements possible score of 200, there is decrement on pre-
between caregivers, enabling them on correct to-post intervention mean Problem Behavior
106
Intensity Scores (PBIS) of 40.12 (20.06%; SD: Table 2: Concurrent Percentage Increment/
16.94) to 30.75 (15.38%; SD: 16.03) measuring Decrements for Skill & Problem
decrease by 9.37 points (4.69%) for parents; Behavior Scores across Informants
48.87 (24.44%; SD: 14.15) to 31.87 (15.94%; SD: SB PBIS-P PBIS-T PBIS-Th PBFS-P PBFS-T PBFS-Th
9.20) showing decrease by 17 points (8.5%) for BL 51.2 20.06 24.44 23.16 28.13 30.75 29.50
teachers; and from 46.37 (23.16 %; SD: 12.73) to
FL 55.5 15.38 15.94 15.44 25.00 26.75 26.0
30.87 (15.44%; SD: 8.82) with decrease by 15.5
points (7.72 %) for therapists respectively. (Note: Values as converted to common
In terms of Problem Behavior Frequency point of reference as percentage gain or loss);
Score (PBFS), based on presence or absence of
given problem behaviours, out of maximum
possible score of 100, there is decrement between
pre-to-post intervention from 28.13 (SD: 8.71)
to 25 (SD: 10.42) by 3.13 points (3.13%) for
parents; 30.8 (SD: 7.70) to 26.8 (SD: 6.20) by
4 points (4%) for teachers; and from 29.5 (SD:
6.32) to 26.8 (SD: 5.73) by 3.5 points (3.5%) for
therapists respectively. Thus, the trend of reported BL: Base Line; FL: Final; SB: Skill Behavior; PBFS/
decrements for, both, PBIS and PBFS is highest Th/T/P: Problem Behavior Frequency Score as given
in teachers, followed by therapists and least by by Therapist/Teacher/Parent; PBIS/Th/T/P: Problem
parents of the children although none of the gains Behavior Intensity Score as given by Therapist/
are statistically significant (p: >0.05)(Table 2). Teacher/Parent)
Domain Wise Distribution of Pre & Post-treatment Scores on Skill Behaviour:
Table 3 : Domain Wise Distribution of Pre & Post-treatment Scores on Skill Behaviour
Domain® Sensory Gross Motor Fine Motor Communication Play Self-Help Cognitive Pre Academic
Score¯ BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL
Total 1654 1512 1338 1418 1215 1271 913 986 650 735 1269 1386 380 444 773 927
Mean 206.8 213.8 167.3 177.3 151.9 158.9 114.1 123.3 81.3 91.9 158.6 173.3 47.5 55.5 96.6 115.9
SD 5.3 5.5 11.5 10.4 18.5 16.0 37.4 40.4 13.7 14.0 30.3 28.0 23.6 30.0 29.8 7.1
T-value; Df 2.59; 14 0.24; 14 0.81; 14 0.47; 14 1.53; 14 1.01; 14 0.59; 14 1.78; 14
p-value 0.02; S 0.81; ns 0.43; ns 0.64; ns 0.15; ns 0.33; ns 0.56; ns 0.10; ns
(BL:Baseline; FL:Final) (Cronbachs Alpha: -0.30770439; Split-Half (odd-even) r: -0.078935; Spearman Brown Prophecy:-
0.17140028;KR20: 1.168543238)
Even though there was overt changes between pre-test (Mean: 206.8; SD: 5.3) to post
in skill behaviours as reflected by increased treatment (Mean: 213.8; SD: 5.5) scores (t: 2.59;
test scores in the studied sample of children df: 14; p: <0.02). Probably, the program focus,
following behavior interventions, the overall content, and/or even the demand of behavior
results did not throw up statistically significant change agents were on sensory issues in the
gains (p: >0.05). There are also forward moving
studied children with autism. In a related study,
skill behavior scores in all the measured
it has been shown that sensory-motor efficacy of
domains of ACPC-DD. A further and deeper
probe undertaken across the eight skill behavior children with autism can be improved through
domains (Table 3) reveal statistically significant tailor-made interventions (Baranek, 2002;
gains only in area of ‘sensory’ behaviours Dawson & Watling, 2000).
107
Domain Wise Distribution of Pre & Post-T treatment Scores on Problem Behaviour:
Table 4 A: Domain Wise Distribution of Pre & Post-treatment Intensity Scores on Problem Behaviour
Domain V&D TT MO SIB Rep. B OB H Reb. B. ASB F Oth
Name¯ BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL
Total 50 37 33 18 33 25 29 24 53 35 65 39 53 31 27 13 0 0 13 12 14 13
Mean 6.4 4.6 4.1 2.3 4.1 3.1 3.6 3 6.6 4.4 8.1 4.9 6.6 3.9 3.4 1.6 0 0 1.6 1.5 1.8 1.6
SD 3.5 2.3 1.6 1.0 2.4 2.1 2.8 2.9 2.6 2.2 2.7 1.7 0.9 0.6 1.4 1.2 0 0 1.8 1.8 2.2 2.0
t-value 1.22; 14 2.70; 14 0.95; 14 0.421; 14 1.83; 14 2.84; 14 7.06; 14 2.76; 14 0.111; 14 0.162; 14
P 0.24; ns 0.01; s 0.36; ns 0.68; ns 0.09; ns 0.01; ns 0.001; s 0.01; s 0.91; ns 0.874; ns
(BL: Baseline; FL: Final)(V&D: Violent Destructive Behavior; TT: Temper Tantrums; MO: Misbehavior with
Others; SIB: Self Injurious Behavior; Rep. B.: Repetitive Behavior; OB: Odd Behavior; H: Hyperactivity; Reb.
B.: Rebellious Behavior; ASB: Anti-Social Behavior; F: Fears; Oth. Others)
Table 4 B: Domain Wise Distribution of Pre & Post-treatment Frequency Scores on Problem Behaviour
Domain®Name¯ V&D TT MO SIB Rep. B OB H Reb. B. ASB F Oth
BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL BL FL
Total 39 34 20 17 24 20 19 18 30 26 37 34 31 30 17 11 0 0 11 10 8 8
Mean 4.9 4.3 2.5 2.1 3 2.5 2.4 2.3 3.8 3.3 4.6 4.3 3.9 3.8 2.1 1.4 0 0 1.4 1.3 1 1
SD 2.5 2.0 0.9 0.8 1.4 1.5 1.8 1.8 1.2 1.5 1.6 1.5 0.4 0.5 0.8 1.1 0 0 1.3 1.3 1.2 1.2
T-value; df 0.53; 14 0.94; 14 0.69; 14 0.11; 14 0.74; 14 0.39; 14 0.44; 14 1.46; 14 0.15; 14 0.00; 14
p-value 0.60; ns 0.36; ns 0.50; ns 0.91; ns 0.47; ns 0.71; ns 0.67; ns 0.17; ns 0.88; ns 1.00; ns
(BL: Baseline; FL: Final) (V&D: Violent Destructive Behavior; TT: Temper Tantrums; MO: Misbehavior with
Others; SIB: Self Injurious Behavior; Rep. B.: Repetitive Behavior; OB: Odd Behavior; H: Hyperactivity; Reb.
B.: Rebellious Behavior; ASB: Anti-Social Behavior; F: Fears; Oth. Others)
In above table there are no statistically Intensity Score (PBIS) and the Problem
significant differences elicited in respect to Behavior Frequency Score (PBFS).
Problem Behavior Frequency Score (PBFS)
(Table 4B), such differences emerge only with Table 4A; as in case of ‘temper tantrums’ (BL
respect to certain domains only in relation to Mean: 4.1; BL SD: 1.6; FL Mean:2.3; FL SD:1.0),
Problem Behavior Intensity Score (PBIS). ‘hyperactivity’ (BL Mean: 6.6; BL SD: 0.9; FL
Mean:3.9; FL SD:0.6) and ‘rebellious behavior’
As with scores on overall skill behavior
changes, the same trend is seen even with regard (BL Mean: 3.4; BL SD: 1.4; FL Mean:1.6;
to improvements in their problem behaviours FL SD:1.2)(P: <0.01). The score gains are
without statistically significant (p: > 0.05). The insignificant for all the other problem behavior
PBSS covers ten sub-categories of behavior domains. Interestingly, ‘anti-social behaviours’
problems. This gives an opportunity As with are not reported at all in children with autism.
scores on overall skill behavior changes, This implies that the behavioural intervention
the same trend is seen even with regard to program has been probably successful only
improvements in their problem behaviours to the extent of reducing the intensity (not so
without statistically significant (p: > 0.05). The much the frequency) of the problem behaviour
PBSS covers ten sub-categories of behavior in this sample of children with autism. problem
problems. This gives an opportunity for behaviour in this sample of children with autism.
undertaking a concurrent domain analysis on
intensity and frequency of problem behaviours Reliability & Validity:
in this sample of children with autism across Inter observer reliability between
two dimensions, viz., Problem Behavior teachers, parents and therapists involved in
108
planning, implementation and reporting of gains problem behaviour reduction simultaneously.

accrued with behavioural intervention against In sum, the results of this study has
its baseline was undertaken by calculating demonstrated the feasibility for identifying,
Pearson’s Correlation Coefficients and drawing listing and recording a baseline on the different
the matrix between ratings given by the three types and specific instances of problem
independent mutually blind respondents. The behaviours as distinct from deficits in their skill
inter-rater reliability coefficients for overall behaviours in children diagnosed as autism.
ratings on skill and problem behaviours are It has shown that it is possible to evolve or
found to be in upper range of r: 0.85 to r: 1.00 (p: carry out case-by-case topological mapping
<0.001). Cronbachs alpha-internal consistency of situations, triggers, antecedents, functions,
coefficients of reliability is measured as maintaining aspects and consequences of the
0.73, split half (odd-even) reliability is 0.81, identified or observed problem behaviours
Spearman-Brown Prophecy is 0.89 and K R 20 for the identified children autism before
is 0.82 respectively. Similarly, for domain wise undertaking strategic individualized and/or
distribution of pre to post-treatment scores on small group based behavioural interventions
skill behaviour, Cronbachs alpha coefficients within specified time frame and/or across
of reliability is found to be -0.31, Split-Half envisaged sessions in home or school settings.
(odd-even) r: -0.08, Spearman Brown Prophecy The results indicate increments in post
is -0.17 and KR 20 is 0.69. The negative signs intervention scores measuring skill behavior
are indicating that the mean of all inter-item acquisition and concurrent decrease in scores
correlations is negative. Is this a reflection of measuring problem behaviours as reported
measurement error? Or is it suggestive that the independently by parents, teachers as well as
sample size is too small? Or is it an indication therapists following individualized and/or small
that the respondents have underplayed all skill group based behaviours interventions on the
behavior areas except ‘sensory’ domain, which targeted children with autism for a specified time
is characteristically read and/or more frequently frame and/or across envisaged sessions in home
attributed for children with autism? Similarly, or school settings. Further, related reliability and
with regard to problem behavior intensity and validity indices of the measured variables are
frequency, while correlation coefficients of the
also calculated and found to be high. However,
three raters (parents, teachers and therapists)
admittedly, there may be issues related to
cluster consistently above or higher than r:
treatment fidelity in home-based interventions,
0.90 for baseline to final evaluation; for skill
compliance, difficulties in accurately measuring
behaviours, they are low (r: <0.35) before
the extent of interventional inputs especially in
and after treatment. Are these indications that
naturalistic and parent-based interventions and
greater the skill behavior scores of children,
the need for their independent monitoring that
lower are their problem behavior scores in terms
may all require more in-depth and systematic
of intensity as well as frequency? While no
explorations in near future.
definite conclusions may be drawn until more
research is undertaken exclusively along these ACKNOWLEDGEMENTS
lines, the indications, if any, appear to be so. The authors seek to place on record the
Although not in the ambit of this investigation, gratitude and credits due to participants in the
another post-interventional terminal evaluation study and Director, AIISH, Mysore, for the
reflected significant quantitative and qualitative permission granted. This work is part of the
gains which were also maintained after a 4-week doctoral dissertation being undertaken by the
follow thereby testifying the value of customised first author under the guidance of the second
behavioural techniques in skill enhancement and author.
109
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111
2014, Vol. 41, No. 2,112-119 Clinical Psychologists (ISSN 0303-2582)
Research Article
Efficacy of Wisconsin’s Card Sorting Test Retraining on Cognitive
Deficits in Patients with Schizophrenia: A Randomized Double
Blind Controlled Study
Sayali Mishra1, K S Senger2 and B R Mishra3
Abstract
Schizophrenia is an illness which causes multiple deficits in the area of social, personal,
occupational and more importantly in cognition. The present study aimed to evaluate the
efficacy of WCST retraining on the domains of attention, vigilance, working memory in
the persons with schizophrenia. The present study aimed to evaluate the efficacy of WCST
retraining on the domains of attention, vigilance and working memory in patients with
schizophrenia. A prospective, hospital-based, randomized, double blind controlled study
was conducted on 34 patients with Schizophrenia having at least 5 years of formal education.
divided in two groups (study group and Control group) by block randomization technique,
were evaluated on PANSS, ESDST, and N-Back (Verbal) test (1- back and 2- back), to
measure the baseline deficits in attention, vigilance and working memory respectively. The
experimental group was given WCST retraining for Cognitive remediation and the control
group was kept wait listed without any intervention. WCST retraining was done in the
patients of the experimental group by the didactic method. Following the intervention,the
attention, vigilance and working memory were reevaluated. Results reveals that there were
no significant differences between the groups in ESDST scores. In the N-back test (1-back),
at baseline itself, there was highly significant difference between the two groups in the Hits
score (p= 0.001), and this difference was maintained between the groups (p=0.000), even
after WCST training. In N-back test (2-back) there was no significant between the group
difference in the total error score at baseline but following WCST training statistically
significant difference (p=0.048) was observed in the total error score between the two
groups. The didactic method of WCST retraining in patients with schizophrenia was found
to produce statistically significant improvement in verbal working memory but not on the
measures of attention and vigilance.
Key Words: Wisconsin’s Card Sorting Test (WCST), Positive and Negative Syndrome
Scale of Schizophrenia (PANSS), Eysenck’s Series of Digit Span Test (ESDST), Number
Back Test (N-Back Test), Cognitive Remidiation, Cognitive Deficits
Introduction of neuropsychological tools in patients with

Schizophrenia is commonly considered schizophrenia have revealed wide-ranging
to be among the most intractable of mental neurocognitive deficits involving working
illnesses with a chronic course and relatively memory, attention/vigilance, verbal learning and
stable neurocognitive deficits. Cognitive memory, visual learning and memory, reasoning
deficits are highly prevalent in schizophrenia, and problem solving, speed of processing, and
with estimates that as many as 98% of social cognitions (Green, Kern, Braff & Mintz,
schizophrenia patients demonstrate impairment 2000). The degree of impairment has been
relative to their premorbid cognitive functions reported to be one and a half to two standard
Harrison and Weinberger (2005). The use deviations below healthy controls on several
1.Ph. D. Scholor, RINPAS, 2. Additional Professor, Deptt. of Clinical Psychology, RINPAS, Kanke, Ranchi, India 3. Assistant
Professor of Psychiatry, AIIMS, Bhubaneswar, Orissa, India. Corresponding Author: Sayali Mishra, saipsyche@rediffmail.com
112
Sayali Mishra et al... / Efficacy of Wisconsin’s Card Sorting Test Retraining on Cognitive Deficits...
key dimensions of neurocognitive functions. of attention, vigilance and working memory in

(Heinrichs & Zakzanis, 1998). The findings of the patients with schizophrenia.
meta-analyses of the various neuropsychological
METHOD and MATERIAL
tests have found that, the executive functions
This was a prospective, hospital-based,
and working memory are typically affected in
randomized, double blind controlled study
patients with schizophrenia (effect sizes ranging
conducted at RINPAS, Ranchi, India, over a
from 0.61 to 1.18) (Dickinson, Ramsey & Gold,
period of 15 months. Patients with the diagnosis
2007). The findings of the MATRICS project
again suggests maximum deficits in the domains of Schizophrenia according to ICD-10 DCR
of vigilance, more marked deficits in verbal (WHO, 1992), aged between 20-50 years, having
learning than retention or recall (Green, Kern, at least 5 years of formal education and giving
Braff & Mintz, 2000). informed consent, were included in the study.
Patients with co-morbid mental retardation,
The neurocognitive deficits have an impact
substance use, any medical or neurological
on functional outcome as they are correlated
illness, having received electroconvulsive
with poor functional abilities including skills
therapy in the past, were excluded from the
acquisition, problem solving and community
study. The study sample involved 34 patients
living. The advent of atypical antipsychotics has
with schizophrenia (n=34). The relevant socio-
made it possible to reduce psychotic symptoms,
demographic and clinical data were collected.
but their impact on cognitive or functional
Positive and negative symptom scale (PANSS)
impairments have not been encouraging (Harvey
was administered to evaluate the severity of
& Keefe, 2001). In view of the limited efficacy of
antipsychotics, remediation of cognitive deficits positive and negative symptoms. The patients
through cognitive retraining by psychological were initially administered ESDST (Eysenck’s
methods has shown promising results (Brenner Series of Digit Span Test), and N-Back (Verbal)
et al.,1992; Hodel et al., 1997 ). test (1- back and 2- back), to measure the baseline
deficits in attention, vigilance and working
WCST (Wisconsin Card Sorting Test)
memory respectively. The selected 34 patients
is a complex problem-solving task, which
were divided into 2 equal groups (17 patients in
requires multiple cognitive processes including
experimental and 17 in control group) by block
memory, auditory and visual attention, motor
randomization. Four patients dropped out of
skills, learning, abstraction, categorization
the study. The experimental group was given
and executive control (Banno et al., 2012).
WCST retraining for cognitive remediation by
Many studies have focused that the deficits
a clinical psychologist, till they were error free.
in WCST could be improved by providing
The control group was kept wait listed without
the subjects various training strategies such
giving any intervention. In order to prevent bias,
as Didactic Instructional Training (Kern et
al., 1996). Instructional and Learning-based the interventional psychologist was blind to the
Techniques (Young, et al., 1995) and Enhanced nature of randomization.
strategy formation (Spaulding, Reed, Sullivan, WCST retraining was done in the patients
Richardson, & Weiler,1999). WCST training in of the experimental group, by administering the
subjects has been found to produce generalization 128-card version of WCST. The test required the
effect and improve performance in other non- patients to match a series of cards beneath four
trained neuropsychological tasks involving reference cards according to shape, color, and
executive functions (Bellack, Blanchard, Murphy number of geometric shapes and infer the sorting
& Podell,1996; Goldberg & Weinberger, 1994). rule from feedback to their responses. The results
The present study was designed to evaluate the were scored using the WCST: Computer Version
efficacy of WCST retraining on the domains 3: Research Edition (WCST: CV-3). The Didactic
113
method was used for the purpose of WCST 2-Back), and the changes in scores (Post-WCST
retraining (Goldberg & Weinberger, 1994). administration) were done using Mann-Whitney
U test. Pearson’ correlation was done to see any
Didactic Method of WCST Retraining :
correlation between various socio-demographic,
The retraining was conducted on cards 1
clinical variables and performance in the various
to 5 and repeated for cards 32 to 37 adjusting
for the correct sorting rule, so participants Cognitive function tests.
received 2 sets of training per 64-card deck. If ResultS
the participant did not understand the concept In present study, the experimental group
even after training, the examiner was allowed consisted of 15 patients with a mean age of 35.60
to provide the following corrective steps: (a) (SD 9.68) years and the control group consisted
explain the concept of number, (b) rephrase of 15 patients with a mean age of 32.13 (SD
by explaining that only one principle is correct 9.63) years. The mean year of formal education
at a time, (c) explain that choosing the correct was 11.80 (SD 2.56) years for the experimental
category again would be correct, and (d) explain group and 9.93 (SD 2.68) years for the control
that if the response is “Wrong”, it is probably group, with a trend towards significant difference
true that it will continue to be wrong and he/she between the two groups (p= 0.062). In the
should try either shape or number. However, if experimental group, all the patients were male,
after two sets of training (cards 1 to 5 and 32 to whereas, in the control group, 3 out of the 15
37) the participant was still unable to correctly patients were female. No statistically significant
respond, the test was discontinued ((Goldberg & between group differences were observed in any
Weinberger, 1994)). socio-demographic variables.
Following cognitive remediation with In the experimental group, with regard to
WCST in the experimental group and nil the initial WCST trial administered, the median
intervention in the waitlisted control group, total number of trials administered was 128 (Q1-
PANSS, ESDST and N-Back (Verbal) test were 121, Q3-128), with the total number of correct
again administered to observe the changes in responses being 74 (Q1-7, Q3-80), Perseverative
the scores. In order to minimize bias, the rater errors were 29 (Q1-25, Q3-39) and Non-
remained blind to the nature of intervention Perseverative errors being 19 (Q1-14, Q3-21).
provided to the subjects. Throughout the study The conceptual responses were 60 (Q1-52, Q3-
the subjects received the pharmacological
70) and the number of categories completed was
treatment as decided by the treating team.
2 (Q1-1, Q3-6), whereas, the number of failures
Statistical Analysis: to maintain set was 3 (Q1-2, Q3-3). The subjects
The data was analyzed using the computer were WCST retrained by didactic method, till
software program, SPSS-20.0 for Windows®, they were error free.
with different parametric and nonparametric
Table 1:
Descriptive Statistics (Median and
tests. The level of significance was taken as p
Percentiles) of the Various Parameters of
< 0.05 (two tailed). The description of sample
the First WCST Trial Administered in the
characteristics was done with descriptive
Experimental Group
statistics: percentage, mean and standard
deviation. Group differences for sample Total
Total
Persev
Non-
Concep Cat.
Fail.
WCST correct Persev. Main.
characteristics were examined with independent trials
respon.
errors
errors
Respon Comp.
Set
t-test, chi-square test and Fischer’s exact test
Median 128 74 29 19 60 2 3
wherever applicable. Group differences in
25 121 70 25 14 52 1 2
baseline scores (Pre-WCST administration)
Percentile 75 128 80 39 21 70 6 3
of PANSS, ESDST, and N-Back test (1- and
114
Legend: Total correct respon.- Total correct Table 3: Comparison of N-Back (1-Back) Test
responses; Persev.- Perseverative; Concep Scores Between the Experimental and
Respon- Conceptual responses; Cat. Comp.- Control Group at Baseline and after
Categories completed; Fail. Main. Set- Failure WCST Training:
WCST Non-
to maintain set . (n= 15) WCST (n=
Mann-
Variable Whitney Z P
With regard to the severity of Mean 15) Mean
U
Rank rank
psychopathology, at baseline itself, there
Pre- Hits 20.80 10.20 33.000 -3.424 .001**
was significant between group difference in WCST
Err. Omis. (O) 14.40 16.60 96.000 -.700 .484
PANSS Positive scale score (p= .058*), and
Err. Commis (C) 14.00 17.00 90.000 -1.175 .240
this difference was maintained between the
Total Error O+C) 13.83 17.17 87.500 -1.058 .290
two groups after WCST training (p= .050*).
Post- Hits 20.77 10.23 33.500 -3.750 .000**
However, there was no significant difference WCST
Err. Omis. (O) 13.40 17.60 81.000 -1.397 .162
between the two groups in PANSS Negative Err. Commis.(C) 14.00 17.00 90.000 -1.795 .073
scale score, General Psychopathology scale Total Error (O+C) 13.00 18.00 75.000 -1.645 .100
score and total score, both before and after Legend: (O) - Errors of Omission, (C) - Errors of
WCST retraining. The findings suggest the lack Commission, (O+C) - Total Error Score
of any therapeutic effects of WCST retraining **Significance at p<.001, *Significance at p<.05 (2-tailed)
on the severity of psychopathology measures in
In the N-back test (1-back), at baseline
patients with schizophrenia.
itself, there was highly significant difference
Table 2:
Comparison of Digit Span Test between the two groups in the Hits score (p=
Scores between the Experimental 0.001), and this difference was maintained
and Control Group at Baseline and between the groups (p=0.000), even after WCST
After WCST Training training in the experimental group. However,
there was no significant between the group
WCST
(n= 15)
Non- WCST Mann- differences in the Error of Omission, Error of
Variable (n= 15) Whitney Z p
Mean
Mean Rank U
Commission and Total error score at baseline
Rank
and post WCST rating.
DF 15.47 15.53 112.000 -.022 .982 Table 4: Comparison of N-Back (2-Back) test scores
Pre-WCST
DB 16.37 14.63 99.500 -.616 .538 between the Experimental and Control
Group at Baseline and After WCST Training:
DF 17.70 13.30 79.500 -1.441 .149
Post-WCST WCST Non-
Mann-
DB 15.97 15.03 105.500 -.313 .754 (n= 15) WCST (n=
Variable Whitney Z P
Mean 15)
U
Rank Mean rank
Legend: DF-Digit forward, DB- Digit
Pre- Hits 16.83 14.17 92.500 -.848 .397
backward; P= Not significant
WCST
Err. Omis. (O) 14.73 16.27 101.000 -.490 .624
In ESDST (Eysenck’s Series of Digit Err. Commis.(C) 14.30 16.70 94.500 -.850 .396
Span Test) for measurement of attention and
Total Error (O+C) 14.57 16.43 98.500 -.594 .553
vigilance, there were no significant differences
Post- Hits 16.67 14.33 95.000 -.753 .452
between the groups in DF and DB scores at WCST
Err. Omis. (O) 14.67 16.33 100.000 -.539 .590
baseline. Even after WCST training of patients
Err. Commis. (C) 13.47 17.53 82.000 -1.477 .140
in the experimental group, no significant
between group differences were observed in DF Total Error 12.40 18.60 66.000 -1.981 .048*
and DB scores. *Significance at p<.05 (2-tailed)
115
In N-back test (2-back), at baseline, there of errors (Errors of omission and commission)
was no significant between group difference (r=0.543, p=0.036) in the N-Back test. Similarly,
in the total error score, but following WCST family history of psychiatric illness was found
training in the experimental group, a statistically to positively correlated with the total number of
significant difference (p=0.048) was observed errors (r=0.538, p=0.039) in the N-Back test.
in the total error score between the two groups. Regression analysis was done to observe
This reflects the therapeutic benefits of WCST the effect of education (in years) on the various
retraining in the domain of working memory WCST trial parameters. A significant relationship
deficits in patients with schizophrenia. was observed between the covariate duration of
Pearson correlation coefficients between education (in years) and the various WCST trial
the various socio-demographic, clinical parameters (β= 1.872; P= 0.014), suggesting the
variables and performance in Cognitive function influence of education (in years) on WCST trial
tests in the study sample at baseline (before performance. The Cox & Snell R Square value
WCST training), reflect the possible influences (= 0.544) and Nagelkerke R Square (=1.000)
of the various socio-demographic and clinical were suggestive of the appropriateness of the
variables on the performance in Cognitive model.
function assessment tests. With regard to the Discussion
WCST trial parameters, in the experimental The sample of our study comprised of
group, the years of education was found to 34 patients with schizophrenia, out of which
have a negative correlation with the number 4 patients dropped out, and finally 30 patients
of perseverative errors (r= -.519, p= .047). were recruited, which is comparable to previous
However, the years of education was found to studies on other methods of WCST retraining
have positive correlation with the number of in schizophrenic patients (Young, Freyslinger
conceptual responses (r=0.515, p= 0.049) and & Scaffolded, 1995; Choi, & Kurtz 2009).
the number of categories completed (r=0.709, The dropout rate was 11.8 %, which is less as
p=0.003). compared to the above mentioned studies, the
In the experimental group, age of the reason being non-cooperation to carry out the
patient was found to have positive correlation retraining procedures. In the experimental group,
with the score obtained or performance in DF all the patients were male, whereas, in the control
test (r=0.558, p=0.031). Similarly, the years group, 3 out of the 15 patients were female. The
of education was positively correlated with rest 30 patients cooperated to be retrained on
the score obtained or performance in DB test WCST by didactic method, till they were error
(r=0.611, p=0.015). However, past history free. Initial PANSS and the neuropsychological
of psychiatric illness was found to have tests such as ESDST, and N-Back (Verbal) test
negative correlation with the score obtained (1- test and 2- test), could be administered at
or performance in both DF test (r=-0.732, baseline and following intervention in all the
p=0.002) and DB test (r=-0.601, p=0.018). The patients.
history of significant head injury in the past was The mean age of patients in the
found to negatively correlate with the errors of experimental group was 35.60 (SD 9.68) years
commission in N-Back test (r= -.535, p=.040). and 32.13 (SD 9.63) years in the control group,
In the control group, history of significant which is similar to the previous studies involving
head injury was found to have negative WCST retraining (15, 16). The mean years of
correlation with the number of hits (r=-0.524, formal education was 11.80 (SD 2.56) years for
p=0.45), but, positive correlation with the errors the experimental group and 9.93 (SD 2.68) years
of omission (r=0.533, p=0.041) and total number for the control group, which is consistent with
116
the previous studies involving other methods as Error of Omission/Commission and Total
of WCST retraining:10.89 (SD1.96) years Error Score, both at baseline and post WCST
(Didactic retraining method), 11.31 (SD 2.35) rating. However, in the N2-Back Test, there was
years (Self-monitoring method)] (Bell, Bryson, no significant between the group difference in
Greig, Corcoran & Wexler, 2008). the total error score at baseline, but following
In relation to the performance in the initial WCST training in the experimental group, a
WCST administration in the experimental group, statistically significant difference (p=0.048)
the parameters were similar to the previous was observed in the total error score between
studies involving WCST performance in the two groups. The result suggests that WCST
schizophrenic patients, the findings suggesting retraining improved the verbal working memory
greater perseverative errors, perseverative measure in patients with schizophrenia. Since,
responses, trials to succeed at the first category, sustained attention or concentration is again
and lower conceptual level responses in patients influenced by working memory (Lewis &
with schizophrenia (Bromley, 2007). An Lieberman, 2000), and there was improvement
attractive hypothesis proposed to explain these in verbal working memory with WCST
deficits is that the patients with schizophrenia retraining, the beneficial effect of WCST
show a diminished capacity to generate or retraining on attention and concentration could
apply cognitive inhibition, which manifests as be possible, which was statistically not reflected
cognitive control deficits and frequent distraction in our study. Previous studies involving other
by non-pertinent stimuli (Young & Freyslinger, methods of WCST retraining have consistently
1995; Bromley, 2007). reported generalization of improvement to
The changes in the PANSS score following psychomotor speed, performance in divided
WCST retraining in the experimental group were attention tasks, tests of proverb interpretation
statistically insignificant, suggesting towards the and other untrained test of executive function
lack of therapeutic efficacy of WCST retraining (Bellack et al,.1996; Choi et al., 2009). In present
on the severity of psychopathology measures. study the improvement observed in the verbal
ESDST is a measure of attention & concentration working memory, and the indirect beneficial
and indirectly reflects the influence of working evidence on attention and vigilance, is possibly
memory. In the present study, no significant the generalization of improvement effect, which
between group differences were observed in the could be the resultant of the repeated didactic
Digit Span test scores between the experimental method of WCST retraining.
and control group, both at baseline and after The findings of correlation tests and
WCST training, indicating the lack of therapeutic regression analysis suggested that with
gains of WCST retraining on attention and greater years of education in patients with
vigilance in patients with schizophrenia. schizophrenia, during the performance on
N-Back Test (verbal) is a measure of verbal WCST, the number of conceptual responses and
working memory and comprises of ‘1 Back’ categories completed increased, while, there
and ‘2 Back’ task (Gazzaniga, Ivry, Richard, was decrease in the number of perseverative
Mangun, & George, 2009). In the N1-Back Test, errors. The performance on WCST depends
at baseline itself, there was highly significant on various cognitive skills including memory,
difference between the two groups in the learning, abstraction, categorization and
Hits score (p= 0.001), and this difference was executive control, which are again influenced
maintained between the groups (p=0.000), even by the years of education ((Banno et al., 2012).
after WCST training in the experimental group. The correlation coefficients again suggested
There was lack of significant between group that with increase in age and years of education,
differences in the other parameter scores such there was improvement of performance in
117
Digit span test in patients with schizophrenia. be completely negated. The finding suggests
Like in WCST, the performance on Digit that enhanced task instruction on the WCST by
span test depends on attention & immediate didactic method could possibly result in longer
memory, which have been reported to improve and generalization of the improvement effects
with age and years of education (Banno et al., to other cognitive test performance. Again, the
2012). History of psychiatric illness probably study provides clues that neuropsychological
has a negative influence on immediate or approaches to cognitive remediation could
working memory, which is reflected in the poor be potentially useful as a therapeutic tool for
performance on Digit Span Test in the study cognitive deficits in schizophrenia.
population (Braff, 1999). In the control group,
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119
Research Article
Migraine and Tension-type headache in Indian adolescents:
Psychosocial causes and its Psychosocial Correlates.
Pragya Sharma1, Manju Mehta2 and Rajesh Sagar3
Abstract
The present study aimed to explore the psychosocial causes of migraine and tension-
type headache in Indian adolescents and its impact on their daily living. Data on
headache was gathered from 10 participants by in-depth interviews about headache
history, headache impact test (HIT) and the maintenance of headache diary. Youth
Self Report was used to assess behavioural and emotional problems by measuring the
intensity and frequency of externalizing, internalizing, social, thought, and attention
problems. It was found that stress is one of the major triggering factors of migraine
and tension-type headache. Headache diary showed that more stress occurs prior to
a headache. Other causes were found to be peer and parental pressure; performance,
social and stage anxiety; conflicts with peers, parents and in romantic relationships; and
stressful family environment. Headache was found to lead to impairment in physical
wellbeing (somatic complaints), psychological well-being (anxiety, depression, and
emotional inhibition), daily functioning (school absence and social dysfunction), and
the global evaluation of health and of happiness. Thus it’s important to come up with
an intervention module that will address its causes and bring about an improvement.
Transdiagnostic Cognitive behavior therapy is a field new to Indian therapeutic context.
However, looking at its advantages, it’s beneficial to bring about these changes in the
existing therapeutic module.
Key Words: Adolescents, Migraine, Tension Type Headache, Psychosocial Causes
INTRODUCTION are further divided into specific headache types.

Headache is a common complain among Primary headache disorders are not associated
adolescents (Perquin et al. 2000, Petersen et with an underlying pathology and include
al., 2003; Roth-Isigkeit et al., 2004). World migraine, tension-type and cluster headache.
Health Organization has given migraine the Primary headaches are the most commonly
disability score of 0.7 and referred to it as one of occurring in children and adolescents, especially
the most debilitating illnesses (Leonardi et al., migraine, tension type headache and chronic
2005). Headache leads to significant disruption daily headache. Secondary headache disorders
of adolescent’s normal daily activities at home, are attributed to an underlying pathological
school and social settings. It may also result in condition and can be due to various organic
emotional changes like anxiety or sadness. These etiologies or drug induced origin.
disruptions create significant disability thus
affecting the quality of life of the adolescent. Primary headaches are among the first 20
Early recognition and management of headache major causes of disability as per World Health
can improve their quality of life and normalize Organization (Pini, 2006). An increase has also
their daily activities. been seen in tension type headache in children
The International Classification of and adolescents (Just et al., 2003).
Headache Disorders – 2 (2004) categorizes The prevalence rate of headache ranged
headache as either primary or secondary which from 37 to 51 percent in those who were at least
1. Clinical Psychologist, 2. Professor of Clinical Psychology, 3. Associate Professor of psychiatry, Department of

Psychiatry, AIIMS, New Delhi - 110 029. Corresponding Auhor: manjumehta@gmail.com.
120
Pragya Sharma et al... / Migraine and Tension-type headache in Indian adolescents: Psychosocial...
seven years of age and gradually rose to 57 to absence and frequent somatic complaints due to
82 percent by age 15. Frequent episodic tension- frequent headache or migraine may lead to what
type headache was the most common (25.9%) Breslau et al. (1982) describe as "perceived role
headache followed by migraine (14.5%) (Karli restriction" in the parents. They define perceived
et al., 2006). In tension-type headache, the role restriction as "The extent to which a person
prevalence rates in adolescents have varied feels unable to pursue one's own personal
from 10% to 25%, being higher in girls than in interests due to the responsibilities involved with
boys (Zwart et al., 2004; Laurell et al., 2004). raising a child with a chronic physical condition".
In a twin study by Russell et al. (2006), the Perceived role restriction is related to the extent
prevalence of adolescent tension-type headache to which the child's family perceives social
has been shown to be as high as 81-91% among support from their social network. Therefore,
girls, and 79% among boys. though severe tension headache and migraine
In India, Gupta et al. (2009) found 57.5% are not regarded as disabling physical diseases,
adolescents to be suffering from recurrent these disorders may lead to a perceived role
headaches. Tension type headache was found to restriction in the family to the same degree as
be most common (51%) followed by migraine a disabling disease. As such, it can be expected
(Malik et al., 2012). Average age of headache that the quality of life related to the young
onset was 11 years. In a questionnaire based headache patients' role functioning in his or her
survey done on undergraduate dental students family will be decreased.
by Nandha et al. (2013) headache prevalence METHOD
of 64% was seen – higher in females (74%) as The present study aimed to explore the
compared to males (33%). psychosocial causes of migraine and tension-
Causal Factors in Primary Headache: type headache in Indian adolescents and its
Stress is the most common triggering impact on their daily functioning.
factor in tension type headache and migraine. Sample:
Prospective studies have shown that more The sample comprised of 10 adolescents
stress occurs the day before a migraine attack aged 10-19 year old (4 males and 6 females)
(Passchier et al., 1993). School-related stress who met current primary diagnosis of primary
including problems with peers, teachers and headache (tension type headache and migraine)
cognitive demands are a potent source of strain as per International Headache Society (IHS)
for adolescents (Hjern et al., 2008). Family criteria (minimum duration 6 months), having
conflict also emerges as a stressor and correlate average Intellectual Ability (above 90 MISIC)
of headache (Kashikar-Zuck et al., 2011). Lack and basic reading and writing ability with no
of sleep and missed meals are other causal significant change in medication regime since
factors of migraine in adolescents. past four weeks.
Impact: Those with a history of head injury,
Migraine or chronic headache is associated epilepsy, history suggestive of organic disorder
with impairment in physical wellbeing (somatic or concurrent primary diagnosis of any major
complaints), psychological well-being (anxiety, psychotic disorders, eating disorders, conduct
depression, and emotional inhibition), daily disorder, pervasive developmental disorders,
functioning (school absence and social substance abuse and mental retardation were
dysfunction), and the global evaluation of health excluded from the study.
and of happiness (Passchier and Knippenberg, Procedure:
1991). The research proposal was approved by
Caring for a child with a physical disease the ethics committee of the institute (All India
puts a strain on the child's family. School Institute of Medical Sciences, New Delhi).
121
Sample was chosen by purposive sampling and in social situations. It is useful for screnning and
assessments were carried out. monitoring change in headache impact. It has a
high reliability with internal consistency ranging
Measures:
from 0.82-0.92.
Socio-demographic and Clinical Data Sheet:
This data sheet was developed for the present RESULTS
study by the researcher to obtain socio- Headache history revealed various common
demographic details of the participants. A brief predisposing factors/ triggers and aggravating
clinical history with reference to the onset of factors. These were found to be conflicts
the problem, nature of the problem, treatment within home, with peers, in school/ romantic
history, family history, past history, personal relationships; stress related to examination; peer
history was assessed. and parental pressure; performance, social and
Malin's Intelligence Scale for Indian Children stage anxiety; and stressful family environment.
(MISIC) (Malin, 1971): Table 1: Results on Youth Self Report
It is an adaptation of Wechsler Syndrome Scale % of adolescents (n=10)
Intelligence Scale for Children (WISC) used to Anxious 80%
assess the cognitive abilities of the child. There Withdrawn/depressed 30%
are 11 sub-tests which generate a verbal IQ, Somatic complaints 40%
performance IQ and a total IQ score. Social problems 30%
Thought problems 10%
Youth Self Report (YSR) (Achenbach &
Attention problems 40%
Rescorla, 2001):
Rule-breaking behaviour 10%
It is used to measure behavioural and Aggressive behaviour 10%
emotional functioning of adolescents between
Headache diary revealed that the preceding
the ages of 12 and 18. It has two sub-areas: (a)
event was either stressful (like exam/homework
20 competence items and (b) 112 items that
related or personal, peer and family stressors) or
measure eight sub-scale symptoms: withdrawn,
threatening (self or social image). These findings
somatic complaints, anxiety and depression,
corroborate with those on headache history.
social problems, thought problems, attention
problems, aggressive behavior, and delinquent Table 2: Results on Headache Impact Test
behaviours. Scores on HIT % of adolescents (n=10)
Headache History (Steiner et al., 2007): 60 and above 40%
56 - 59 40%
It consisted of questions about headache types,
50 - 55 20%
time, character, cause and response of headache; 49 or less 0%
and health state.
For 40% of the adolescents, headache had
Headache Diary: a severe impact on their lives disrupting daily
It is used to record frequency, duration activities. For another 40%, headache had a
and intensity of headache - Whether they had substantial impact on their lives while in case of
headache attacks (yes/no), Intensity (Visual 20% adolescents, some impact of headache on
Analogue Scale: 0- 10; 0 – no pain; 10 -strong their lives was seen.
pain), Duration of the attack (in hours).
DISCUSSION
Headache Impact Test (HIT) (Kosinski et al., Prevalence of headache is common
2003): in childhood and increases in frequency in
It is a composite measure consisting adolescence. Stress is one of the major triggering
of six items used to measure the impact headache factors of migraine and tension-type headache
have on ability to function at school, home and in adolescents. It also leads to aggravation
122
of symptoms. Headache diary kept by the between adolescent headache, psychological

adolescents revealed that the event immediately stress and internalizing problems (Anttila et al.,
preceding headache was in most situations, 2004; Bag et al., 2005; Just et al., 2003; Mazzone
stressful. Bjorling (2009) in his study of 31 et al., 2006) such as withdrawal, anxiety,
female adolescents found a strong correlation depression, inhibition, passiveness and fear of
between perceived stress and headache. disease. A few studies (Mazzone et al.,2006;
Some possible triggers identified during Santalahti et al., 2005; Virtanen et al., 2004)
history taking were conflicts within home, also focus on the relation between headache
with peers, in school/ romantic relationships; and externalizing behaviours (environmental
stress related to examination; peer and parental conflict, impulsiveness, anger and antisocial
pressure; performance, social and stage anxiety; behavior).
and stressful family environment. A change in Research studies show that adolescents
section or school, birth of a new sibling, being with frequent headaches also suffered from
bullied, lack of friends, being overweight, anxiety, depression, somatic and attention
learning difficulties, change in residence and problems (Egger et al., 1998; Karwautz et al.,
death of a family member were some other 1999; Hunfeld et al., 2001). They were found to
triggers and aggravating factors that came up report more psychosocial problems and higher
during the headache history taking. These causes levels of psychiatric disorders (such as anxiety
were reiterated by the headache diary managed and depression) as compared to those who did
by the adolescents. Economic hardship (Holstein not suffer from headache (Boz et al., 2004;
et al., 2009), parental separation (Bugdayci et Mazzone et al., 2006). As far as the cause of
al., 2005), poor family environment (Juang et these disorders is concerned, few researches
al., 2004), abuse (Fuh et al., 2010; Zafar et al., consider chronic pain to be causing or being a
2012) and bullying (Luntamo et al., 2012) have consequence of emotional distress while others
been seen to have a positive association with indicate stress, environmental or genetic factors
headache. trigger a poor regulation of neurochemicals
YSR answers were scored on two profiles. which leads to the disorder (Bag et al., 2005;
The competence profile composed of three Boz et al., 2004; Venable et al., 2001; Rhee,
scales (Activities, Social, and Academic) was 2000).
found to be low in 80% of the adolescents Adolescents suffering from headache often
indicating poor functioning in academic, social report unpleasant social relations (Karwautz
and extracurricular activities. On the syndrome et al., 1999; Martin & Soon, 1993; Martin &
scale, 80% of the adolescents were seen to Theunissen, 1993) and strong reactions to stress.
have anxiety, 40% had somatic complaints and They also report high stress related to scholastic
attention problems each, 30% scored high on achievement caused by truancy and tiredness
withdrawn/ depressed scale and social problems (Sarioglu et al., 2003).
scale while 10% each had thought problems, On Headache Impact Test, for 40%
rule-breaking behavior and aggressive behavior. adolescents, headache had a severe impact on
Overall, the adolescents were seen to score higher their lives disrupting daily activities while for
on internalizing syndrome (Anxious, Depressed, another 40%, headache had a substantial impact
Somatic Complaints) than externalizing on their lives and in case of 20% adolescents,
syndrome (Rule Breaking Behavior, Aggressive some impact of headache on their lives was
Behavior scales). They scored high on mixed seen. These daily activities included household
scales of social problems, thought problems and chores, school or social activities. Further,
attention problems scales. headache had an impact on adolescent’s energy
Several researches show an association level and concentration, reducing both. It also
123
led to feelings of irritation and frustration. up with an intervention module that will address
Adolescent headache has been found to lead to headache causes and bring about an improvement.
impaired psychosocial functioning in various Transdiagnostic Cognitive behavior therapy is
areas of life (family, productivity at school and a field new to Indian therapeutic context, has
leisure time activities) (Wober et al., 2000) and certain advantages and may prove beneficial
seen to frequently lead to anxiety and depression in the treatment of adolescent headache and
in adulthood (Guidetti et al., 1998). Headache is comorbid disorders.
the third topmost reason for school absenteeism
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126
Research Article
A Study on Parent-Child Relationship, Ego Identity and
Expression of Aggression in Juvenile Delinquents
Sreetama Chatterjee1 and Tilottama Mukherjee2
Abstract
The alarming escalation in youth crime has become a major impediment to the well being
of society. Though, literature reveals importance of bio-psycho-social factors, yet specific
studies comparing juvenile delinquents’ varied psychopathology with that of normal
children is still scarce in Indian context. Hence, to probe further, the present study was done
by following a matched group design. Purposive sampling was used to take a sample of
thirty (15 juvenile delinquents and 15 normal controls without any OTHER behavioUral
problems) between 9 to 13 years of age . A specially designed Socio demographic data
sheet was given to both groups, Child Behaviour Questionnaire (CBQ) was used as a
screening tool for selection of control group, children’s perception of parents was assessed
by using Parent Child Relationship Scale (PCRS), ego-identity was assessed by Ego-
identity Scale and lastly aggression was evaluated by Rosenzweig Picture Frustration
Test. The mean values, standard deviation and students-t test was used. Results indicated
that the juvenile delinquents perceived their parents more negatively than control group.
Although no significant difference was found between the two groups in dimension of ego-
identity, however mean scores of normal children were comparatively higher. Also, they had
significantly low ego-defense and impunitiveness but significantly higher need persistence.
This indicates that low ego defense and impunitiveness, high need-persistence, coupled with
poor ego-identity and negative perception of parents, might predispose juvenile delinquents
act more impulsively on their needs and commit acts against law.
Key Words: Juvenile delinquents, Perception of Parents, Ego-identity, Aggression
INTRODUCTION personality, social class, parenting and shows

The juvenile delinquent or the juvenile in future –risk, since it refers to someone who
conflict with law has quite become the demon deviates seriously from the norms of his culture
of the twenty-first century. He has always been or society. Therefore what may start as a simple
considered a source of “threat or trouble”, but designation of law-breaking may end up as
it was not until the previous century that he has wide ranging attribution of complex difficulties
been thrust to the forefront of social concern. which warrant disproportionate intervention. In
Usually, a delinquent is referred to as a person India, for legally labeling an individual in the
who breaks the law habitually or persistently and age-group seven to eighteen as a delinquent, he
their activities involve violation of the law of the must be convicted by the court for violating the
land, committing offences like thefts, gambling, provisions of the Children’s Acts, the IPC and
cheating, pick-pocketing, murder, robbery, the CPC. The matter of concern, however is that
dacoity, destruction of property, violence the phenomenon of delinquency is definitely on
and assault, intoxication, vagrancy, begging, the rise (Farrington, 2001). Like other social
kidnapping, abduction and sexual offences. behaviour, delinquency also has complex roots
Apart from that it also connotes other deviations which cannot be explained so simply. Since it
in areas such as motivation, moral development, is an acknowledged fact that parents have an
1. Clinical Psychologist, Department of Clinical Psychology, Institute of Psychiatry, A Centre of Excellence, Kolkata
2. Asst.Professor, Department of Psychology, University of Calcutta.
Corresponding author, Email: tilottamamukherjee3@gmail.com
127
Sreetama Chatterjee et al... / A Study on Parent-Child Relationship, Ego Identity and Expression...
unrivalled significance in the life of a child, clear. Lastly another question that has intrigued
hence naturally the question arises whether researchers studying this phenomenon for quite
poor parent-child relationship might give rise long is why and how the aggression exhibited
to increased occurrence of delinquency. This by these delinquents is different from that shown
is considered important since some researchers by normal children. Mostly in psychology, as
believe that significance of intense relationship well as other social and behavioural sciences,
between parents and children directly affects aggression refers to behavior exhibited between
pro-social behavior and that most of us refrain members of the same species that is intended
from anti-social act, not because of the direct to cause pain or harm. Some other researchers
consequences but also because they are likely stated that in order to be classified as aggression,
to upset people who are significant to us. For actions must involve the intention of harm or
example, (Hawkins et al., 1998) had found injury to others and not simply the delivery of
harsh, non-supportive and non-responsive such consequences.
parenting has been identified as a risk factor for Hence coming back to the fact that the
developing early anti-social behavior, though phenomenon of juvenile delinquency is on a
this was earlier proposed by (Coleman, 1976) disproportionate rise, and keeping in view all the
that parental rejection tends to foster low self- aforesaid points, it appeared convenient to probe
esteem, feelings of insecurity and inadequacy, further into these domains and delineate factors
increased aggression and inability to give and such as quality of parent-child interactions,
receive love . Related to this, another pertinent development of ego-identity and finally assess
question that might arise in this domain is, whether their way of showing aggression is any
whether a person’s "identity” is in any way different and if how. Thus, the present study
related to the activities that he does. By identity aimed to assess the parent child relationship, ego
here one refers to the idiosyncratic things that identity and expression of aggression among
make a person unique or as Erikson described the juvenile delinquents with the following
“a sense of what we are and what we stand for.” objectives:
On some readings of Erikson, it is mentioned, 1. To ascertain whether there exists any
that the development of a strong ego identity, significant difference between the 2 groups
along with the proper integration into a stable of children, namely juvenile delinquents
society and culture, leads to a stronger sense of and normal children with respect to the
identity in general. Conversely, a deficiency in perception of their parents.
either of these factors may increase the chance 2. To ascertain whether there exists any
of an identity crisis or confusion resulting significant difference between the 2 groups
in a profound sense of futility, personal of children, namely the juvenile delinquents
disorganisation and aimlessness (Cote & Levin, and normal children with respect to their
1983). Gulfem and Gul (2004) had studied the ego-identity.
relationship between the identity-formation of 3. To ascertain whether there exists any
Turkish adolescents with familial variables and significant difference between the 2 groups,
family interaction, and found it to be significantly namely the juvenile delinquents and normal
influential in identity formation of adolescents. children with respect to their direction and
These results supported the psychodynamic and type of aggression.
cognitive theories and empirical studies that
disturbances in self representations and ego METHOD
identity are related to many different mental Sample:
disorders. Unfortunately still, after more than 30 The study comprised of two groups,
years of research on identity, the links between namely juvenile delinquents charged with theft
identity and disruptive behaviours are not (N=15) and normal control children (N=15)
128
thus making the total sample size 30 (N=30). nature of relationship of the individual in the
The evaluation of the juvenile delinquents was family through points like- kind of emotional
carried out in a Juvenile Delinquency Home load with family members, average number of
called Dhrubashram in Aryadaha, West Bengal, hours spent with family members.
after being approved by The West Bengal Social
Welfare Society. The approval was obtained only 2. Child Behaviour Questionnaire (CBQ,
after the researcher had agreed to abide strictly Performa-B, Rutter, 1967):
to regulations of Section 21 of the J.J Act (Care This scale was used as screening instrument
and Protection of Children ) Act,2000 read with to identify children having psychological
amendment of J.J. Act;2006. A cross-sectional disturbance. It has high degree of test-retest
design was used, where male children between reliability (0.89) and inter-rater reliability of
9 to 14 years of age and currently residents of 0.72 to discriminate between children of any
Dhrubashram were screened. After that only 15
psychiatric clinic and children in the general
such individuals, convicted under Section 378
population and to differentiate between many
and 380-382, that is for theft and those giving
consent were included. For the control group, types of psychiatric disorder was found. (Rutter,
15 children matched on age and sex with the 1967; Rutter et al., 1975). A score of 9 and
study group, and with a score of 9 or below the above was used as the cut-off for delineating the
cut-off of 9 on Child Behaviour Questionnaire control group.
were selected. The participants were tested 3. Parent Child Relationship Scale (Rao, 1989):
individually. Efforts were made to keep the
It was administered to children of each
testing conditions constant for both the groups.
groups for assessing perception of both their
Inclusion Criteria: parents. This particular tool contains 100
•• For both the groups the age- range was kept items categorized into ten dimensions namely,
strictly between 9 to fourteen years of age. protecting, symbolic punishment, rejecting,
•• All the subjects chosen were males only. object punishment, demanding, indifferent,
•• Gave consent for data collection. symbolic reward, loving, object reward, and
•• For the juvenile delinquent group, only neglecting. Each respondent score the tool for
those implicated under the charge of both father and mother separately. The scale is
theft who were currently residing in the scored separately for each of the parent meaning
rehabilitation home during the time of data every respondent obtains ten scores for ‘father
collection were taken. form’ and ten scores for ‘mother form’ on the ten
Exclusion Criteria: dimensions of the scales.
Presence of any psychiatric illness, chronic 4. Ego-Identity Scale (Tan et al, 1977):
physical illness, organic illnesses, mental This scale was administered to measure
retardation and those from families having a the ego identity of both groups. The EIS is a 12-
history of divorced parents were excluded from item scale that measures Erik Erikson’s concept
the sample. of ego identity and is defined as acceptance of
Tools : self and a sense of direction. Conversely identity
diffusion implies doubts about one’s self, lack
Information Schedule:
of sense and continuity over time, and inability
An information blank was administered to
to make decisions and commitments. The EIS
both groups that elicited information regarding
has fair internal consistency, with a split-half
socio-demographic details like name, age,
reliability coefficient of .68.
sex, religion, education, number of siblings,
father’s education and occupation, mother’s 5. Rosenzweig Picture Frustration Study (Indian
education and occupation, family history, socio- Adaptation- Children Form by Pareek, 1959):
demographic status and lastly also about the It is a controlled projective technique,
129
primarily intended to measure reactions to PCRS - Father Sample Mean S.D t-value
frustrating situations which was administered Loving JD 29.73 8.53
3.05**
on the children of both the groups to assess NC 39.00 8.19
direction of aggression and reaction to Object Reward JD 22.86 9.65
3.338**
NC 33.06 6.85
frustrating situations. The inter-scorer reliability
Neglect JD 22.93 6.68
of the P-F study is reportedly in the range of NC 19.06 6.57
1.598
.80 to .85 .However, the test-retest stability of
* Significant at 0.05 level, ** Significant at 0.01 level
the instrument is somewhere between fair and
marginal ( Rosenzweig & Adelman,1977). Under Results of the study indicated a significant
the category of direction of aggression, fall 3 types, mean difference between the perceptions of two
namely extrapunitiveness, intropunitiveness and groups with respect to their father’s protective
impunitiveness. Under type of reaction obstacle- function, symbolic and object punishment,
dominance, ego-defence and need-persistence rejection, symbolic and objective reward and
form the three types. loving function. That is, the father of juvenile
delinquents were perceived as more symbolically
Statistical Analysis: as well as objectively punishing, and rejecting,
1. Descriptive statistics (Mean and SD) were while they were perceived to be less rewarding
done to analyse the data.
(in a symbolical as well as objectively) and less
2. Students t-test was done to assess loving as well.
significant difference if any between the
groups and the alpha level of p<.01 and Table 2: Table Showing Mean, S.D and
p<.05 were considered significant. t-value of Variables of Parent-Child
Relationship Scale in Both Groups
RESULTS
(Relating to Perception of Mother).
Section I: Perception of Parents : PCRS – Mother Sample Mean S.D t-value
The first section has been divided into PROTECTING (PRO) JD 39.53 5.86
two parts for convenience. The first part shows 2.75*
NC 44.93 4.81
perception of children in case of their father and SYMBOLIC PUNISHMENT JD 28.46 3.81
.634
the second part shows perception of children in (SP) NC 27.13 7.18
case of their mother. REJECTION (REJ) JD 21.00 7.09
1.814
NC 16.93 5.00
Table 1: Table Showing Mean, S.D and OBJECT PUNISHMENT JD 20.33 5.48
1.207
t-value of Vvariables of Parent-Child (OP) NC 18.06 4.77
Relationship Scale in Both Groups DEMANDING (DEM) JD 32.60 4.03
.224
NC 32.06 8.30
(Relating to Perception of Father) INDIFFERENT (IND) JD 23.06 7.25
PCRS - Father Sample Mean S.D t-value .472
NC 24.13 4.88
Protecting JD 32.53 10.10 SYMBOLIC REWARD (SR) JD 32.06 8.55
2.940** 3.096**
NC 40.80 4.05 NC 40.20 5.50
Symbolic Punishment JD 30.73 4.46 LOVING (LOV) JD 33.06 7.47
2.652* 4.401**
NC 25.66 5.90 NC 43.13 4.74
Rejection JD 25.20 8.25 OBJECT REWARD (OR) JD 23.46 6.49
3.339** 5.312**
NC 17.26 4.06 NC 35.80 6.22
Object Punishment JD 23.26 7.08 NEGLECT (NEG) JD 19.93 5.35
2.510* 2.558*
NC 17.26 5.95 NC 15.66 3.61
Demanding JD 33.60 4.43 * Significant at 0.05 level, ** Significant at 0.01 level
.953
NC 31.73 6.15
Indifferent JD 23.26 5.48 Results revealed that delinquents tend to
1.219
NC 25.53 4.67 perceive their mother as less protective, less
Symbolic Reward JD 29.60 8.44
2.943** rewarding (both symbolically and objectively), less
NC 38.33 7.78 loving, and more neglecting than normal children.
130
Section II: Ego-identity DISCUSSION
Table 3: Table Showing Mean, S.D and t-value of Keeping in mind the absolute necessity
Ego-Identity in Both Groups of probing deeper into the phenomenon of
Sample Mean S.D t-value juvenile delinquency, the present study aimed to
JD 7.00 1.51 understand whether there exists any significant
Ego identity 1.447
NC 8.2 2.83 difference between juvenile delinquents and
* Significant at 0.05 level, ** Significant at 0.01 level normal children with respect to the perception
Though no significant difference has of parents, ego-identity and expression of
been found among the juvenile delinquents aggression. The results have been discussed
and normal children in the dimension of ego- under the following sections:
identity, however the relatively higher mean
Section I: Perception of Parents :
scores of normal children as compared with
mean scores of the juvenile delinquents indicate Results interestingly indicated a significant
that the normal children have a strong sense of mean difference between the perceptions of two
who they are and what they stand for. It might groups with respect to their father’s protective
also indicate that they have been able to develop function, symbolic and object punishment,
a strong sense of ego-identity in general along rejection, symbolic and objective reward and
with integration into a stable society or culture. loving function. That is, the father of the study
However in the case of juvenile delinquents group were perceived as less protective, less
their non-acceptance by the society might have symbolically and objectively rewarding, and
led them to have an identity-crisis or confusion. also less loving. They were also perceived
Section III: Nature and as more symbolically as well as objectively
direction of aggression punishing, and rejecting. These finding are
Table 4: Table Showing Mean, S.D and t-Value of in corroboration with the findings that harsh,
Dimensions of Aggression in Both Groups. non-supportive and non-responsive parenting
might be a risk factor for developing early anti-
RPFS Sample Mean S.D t-value
social behaviour (Hawkins et al., 1998). Hence
OBSTACLE- JD 15.27 4.69 it can be assumed, that the delinquent group’s
.446
DOMINANCE (O-D) NC 14.57 3.85
negative perception of father might result in a
EGO-DEFENCE (E-D) JD 39.85 9.14
NC 48.05 9.75
2.373* poor attachment and poor identification with the
father, and interfere with adequate development
NEED-PERSISTENCE JD 44.85 8.51
(N-P) NC 37.35 9.19
2.318* of their super-ego. This might consequently
predispose them to adopt deviant models of
EXTRA-PUNITIVENESS JD 43.60 11.45
1.122 social interaction and prompt them to act in a
(E) NC 38.19 14.78
INTRO-PUNITIVENESS JD 24.83 5.53 delinquent manner. Another credible explanation
1.686 could be that when the father is perceived as less
(I) NC 21.38 5.64
IMPUNITIVENESS (M) JD 31.52 10.58 loving and less protective then it can also result
2.053*
NC 40.41 13.00 in aggression towards the father-figures. To add
* Significant at 0.05 level, ** Significant at 0.01 level to this, their sense of inadequacy might make
With respect to the nature and direction them perceive fathers as a superior and stronger
of aggression it was found that the juvenile opponent, and culminate in anger that might
delinquents showed less ego-defense and more later be generalized to others.
need persistence than the normal children. In Another significant finding that deserves
contrast, the control group showed significantly explanation is how their perception of father
more impunitive responses than juvenile as less objectively rewarding might affect their
delinquents. behavior. It is generally assumed, that whether
131
parents respond reliably and contingently to delinquents showed less ego-defense and more
the infant will affect his trust, security of his need persistence than the normal children,
attachment, and shall later get manifested in a meaning they have difficulty in evading their
range of behavior; that is whether the parents pressing needs. So it is likely that when they
reinforce aggressive or friendly behaviour are faced with situations that block their need
will influence the children’s future as well. So gratification, then they might act out aggressively
naturally when parents tend to focus more on without bothering to adhere to the sanctions
the child’s negative and oversees the positive of the society or law. In contrast, the control
behaviour then the child may become vulnerable group has shown significantly more impunitive
to develop delinquency as a conduct. responses indicating they might harbor more
The next important finding, that the patience to evade a frustrating situation. The
delinquents perceive their mother as less present findings are consistent with study
protective, less rewarding (both symbolically and conducted by Kundu and Basu (1991).
objectively), less loving, and more neglecting CONCLUSION
than normal children is consistent with the In general, the results showed a trend that
homeostasis model of adjustment (Miller et al., the juvenile delinquents perceive both their
1990). The aforementioned study also attributed parents as exhibiting lesser positive behaviour
children’s maladaptive behaviour to be the towards them, like showing lesser affection,
outcome of their inappropriate adaptation to love or rewarding them for appropriate conduct.
a distorted family atmosphere. The observed Instead they perceived that their parents are more
inconsistency in parenting by mother could be rejecting, punishing and neglectful. Though no
thus instrumental in developing and maintain a significant difference was found between the
tendency to acting out by these children. two groups with respect to their ego-identity,
Section II: Ego-identity yet the control group showed a relatively higher
Although the findings show no significant score. Lastly a significant difference emerged
difference between the two groups in dimension between the scores of juvenile delinquents
of ego-identity, however the relatively higher and normal children with respect to the nature
mean scores of normal children in comparison and direction of aggression, where the former
to that of the juvenile delinquents indicate showed lesser ego-defense and more need
that the normal children have a stronger sense persistence than latter. Interestingly enough,
of who they are and what they stand for. This on the other hand, the normal children showed
indicates that they have been able to develop a significantly more impunitive responses than
stronger sense of ego-identity in general along the juvenile delinquents.
with integration into a stable society or culture. In sum, from the findings of the study, it
However in the case of delinquent group, their has been suggested that low ego defense, high
non-acceptance by the society might have need-persistence and low tendency to evade the
further led them to have an identity-crisis or source of frustration and gloss over, coupled
confusion, a finding consistent with previous with a negative perception towards their parents
findings (Erikson, 1963). and low ego-identity of the juvenile delinquents
Section III: Nature and might make them more intolerant to the tensions
direction of aggression caused by frustrating situations. This could
Lastly the finding showed a significant probably result in the acting out behavior by
difference between juvenile delinquents and these children, thus rendering them to become a
normal children with respect to the nature and juvenile delinquent.
direction of aggression. That is, the juvenile The findings derived from this study can
132
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Attainment and adjustment in geographic areas-
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Coleman, J.C. (1976). Abnormal Psychology and Tan, A.L., Kendis, R.J., Fine, J.T. & Porac, J. (1977). A
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133
Research Article
Executive Functions in Patients with Obesity: Impact of

Bariatric Surgery
K Praveen Kumar1, M Thomas Kishore2 and K S Lakshmi3
Abstract
Obesity is associated with various kinds of cognitive impairments among which executive
dysfunctions are very prominent. Alternatively, weight reduction through structured program
is known to improve cognitive functions. Bariatric surgery is reported to improve cognitive
functions. But no studies are in Indian context in this regard. Therefore, this preliminary
study examined the impact of bariatric surgery on executive functions in Indian setting.
Twenty patients with morbid obesity who opted for bariatric surgery and 20 patients with
morbid obesity who were advised but did not opt for bariatric surgery were recruited through
convenient sampling. Both groups were matched for age, gender, years of education and
comorbid conditions. Each participant was individually assessed with Modified Wisconsin
Card Sorting Test (M-WCST), Digit Span Test (DST) and Comprehensive Trail Making
Test (TMT) both at baseline and again after 40 days from the initial assessment. At baseline,
a large number of participants from both the groups showed abnormal executive functioning.
But after the intervention period, significant improvement was noted on all the selected
cognitive variables. Weight reduction due to bariatric surgery will have positive impact on
executive functions. The findings have implications for neurocognitive evaluations in pre-
surgery and post-Surgery conditions.
Key Words: Bariatric surgery, Cognition, Executive Functions, Obesity
Introduction the cognitive functions executive functions

Obesity is a state of excess adipose tissue and received much attention as they are related to
presents a risk to both physical and psychological goal directed behaviours. Commonly studied
health. It may also affect the cognitive functions executive functions are: behavioural planning,
independent of the level of intelligence, monitoring, response inhibition, motivation,
associated conditions, environmental factors judgment, flexibility and decision making. But
and personal characteristics such as age and there are some contradictory findings with regard
gender (Anstey, Cherbuin, Budge, & Young, to the role of obesity in cognitive impairment.
2010; Boeka, & Lokken, 2008; Cournot et al., Some studies suggest that obese individuals
2006; Gunstad et al., 2008; Lokken, Boeka, are at fourfold risk for cognitive impairments
Yellumahanthi, Wesley, & Clements, 2010; (Verdejo et al., 2010) though it is argued that
Smith, Hay, Campbell, & Trollor 2011; Verdejo- the effect sizes are too modest to accept the
García et al., 2010). Among the cognitive relationship between obesity on cognitive
functions, impairments related to attention, impairment (Roberts, Demetriou, Treasure, &
memory, language and executive functions were Chanturia, 2007). Further, a few studies indicate
reported (Cserjesi, Molnar, Luminet, & Lenard, that obesity is not a risk factor for cognitive
2007; Gallucci et al., 2013; Gunstad et al., 2007; impairment (Singh et al., 2012) and rather
Fergenbaum et al., 2009; Khodapanah, Moradi, people with obesity perform well on executive
Vosough, & Khodapanah, 2010). Among functioning tests related to working memory,
1. MSc (Health Psychology), 2. Associate Professor of Health Psychology, Centre for Health Psychology, University
of Hyderabad, 3. Sr. Consultant, Global Hospitals, Hyderabad 500 004, India.
Corresponding Author: M. Thomas Kishore; mtkpsy@gmail.com
134
K Praveen Kumar et al... / Executive Functions in Patients with Obesity: Impact of Bariatric Surgery
planning and analogical reasoning (Gallucci et males and 10 females, matched for age, years of
al., 2013). Despite these conflicting evidences, it education and comorbid conditions. Those with
is generally accepted that obesity is a risk factor a Body Mass Index
for cognitive impairment. A pertinent issue in BMI of 35 Kg/M2 and above were included
this context is whether management of obesity in the study. History of neurological disorder,
leads to restoration of cognitive functions. head injury, major psychiatric illnesses, alcohol
Indeed there are few important studies in this or substance abuse, developmental disabilities
regard, which indicate that weight reduction
and impaired sensory-motor functions were the
through bariatric surgery leads to improvement
exclusion criteria.
in cognitive functions (Gunstad et al., 2011).
Bariatric surgery includes two common Tools:
procedures namely, sleeve gastrectomy and Wisconsin Card Sorting Test (M-WCST;
gastric bypass procedure. Sleeve gastrectomy Schretlen, 2010), Digit Span Test (DST;
is a surgical weight-loss procedure in which the Wechsler, 2008) and Comprehensive Trail
stomach is reduced to about 25% of its original Making Test (TMT; Reynolds, 2002) were used
size, by surgical removal of a large portion of the as measures of executive functions. M-WCST
stomach. Whereas the gastric bypass procedures yields several indices of executive functions
first divide the stomach into a small upper among which the following were selected:
pouch and a much larger lower pouch and then number of categories, number of preservative
re-arrange the small intestine to connect to the errors, and number of total errors and percent
proximal pouch. Both the procedures alter the of preservative errors were taken. High scores
functional volume of the stomach and thereby on all indices except the ‘number of categories’
alter the physiological and physical response to indicate greater impairment of executive
food. Studies from the West indicate that weight functions. Low DST scores indicate impairment
reduction due to bariatric surgery has positive in attention and working memory. Though TMT
impact on cognition (Dhabuwala, Cannan, & has five sub-tests, only the first and last sub-
Stubbs, 2000; Frigg, Peterli, Peters, Ackermann, test was used as they reportedly yield the same
& Tondelli, 2004; Gunstad et al., 2011; Siervo results as the full TMT. Time taken to complete
et al., 2012; Stanek & Gunstad, 2012). As the the trails is the measure, with lesser time
prevalence of obesity is increasing in India indicating better cognitive performance.
along with the number of people from this group
opting for bariatric surgery, this preliminary Procedure:
study was designed to understand the impact The authors contacted the prospective
of bariatric surgery on executive functions in participants by the surgeons when they came for
Indian setting by case-control method. consultations. Informed consent was obtained
after explaining the purpose of the study. Relevant
METHOD socio-demographic variables were collected
Participants: by direct interviewing. Minimal demographic
The sample consisted of 20 patients opting data, clinical details such as the medical
for bariatric surgery (hereafter, surgical group) diagnosis, BMI, associated comorbidities, type
and 20 obese patients not opting for surgery of surgery were collected from the hospital
(hereafter, control group) in the age group of 18 records. Executive functions were assessed
to 50 years. These patients came from all over the by administering the tools individually in a
country, with nearly 50% of them from the city convenient environment. The pre-test was done
where the authors are based. They were recruited two days prior to the surgery and the post-test
from two local, private hospitals through was done 40 days after surgery, that is, during
purposive sampling. Each group consisted of 10 the first follow-up after surgery. Same procedure
135
was followed with the control group where there the groups did not differ significantly with
was an interval of 40 days between assessment reference to the comorbidities (χ²= .12; p =.95).
and reassessment. Thus both the groups were These results indicate that the groups were well
assessed at equivalent time points. matched for age, education, BMI and comorbid
Statistical Analysis: conditions.
The data was analyzed using Statistical Table 3: Summary of Executive Functioning
Package for Social Sciences for Windows- (Baseline) in Surgical and Control Groups.
Version 20.0 (SPSS). Descriptive statistics
Executive Surgical group Control group
(Mean, SD, percentages) an inferential statistics Functions p
(ANCOVA) were applied as per their basic
Borderline n (%)
Borderline n (%)
Abnormal n (%)
Abnormal in (%)
Normal n (%)
Normal n (%)
assumptions. ANCOVA was calculated using
χ2 (df=1)
the pre-test score as a covariate and post-test
score as an independent variable to measure
the difference between the two groups and
Executive 14 1 (5) 5 (25) 10 7 (35) 3 (15) 5.67 .056
their status after intervention where the group Functions (70) (50)
affiliation was kept constant. Chi-square was Composite
used to see the improvement in the categorical Number of 12 3 (15) 5 (25) 10 3 (15) 7 (35) 0.52 .773
variables, as applicable. Categories (60) (50)
RESULTS Number of 9 (45) 6 (30) 5 (25) 5 (25) 9 (45) 6 (30) 0.52 .222
Perseverative
Descriptive data indicates that 18 had Errors
opted for sleeve gasterectomy and the remaining
Number of 10 5 (25) 5 (25) 9 (45) 8 (40) 3 (15) 1.25 .780
for gastric bypass. Total Errors (50)
Table 1: Group Differences in Age, BMI and Percentage of 7 (35) 6 (30) 7 (35) 2 (10) 12 6 (30) 4.86 .088
Education Perseverative (60)
Errors
Surgical group Control group t p Time Taken for 8 (40) 0 12 12 0 (0) 8 (40) 1.60 .206
M±SD M±SD (df=38) TMT Trail 1 (60) (60)
Age (in years) 32.25 ±8.10 33.20 ±8.88 .32 .75 Time Taken for 14 0 6 (30) 14 0 (0) 6 (30) .00 1.0
TMT Trail 5 (70) (70)
BMI 43.34±5.86 40.12±6.16 1.69 .09
Results of baseline assessment presented
Education (in 13.90 ±2.17 13.20±2.96 1.85 .40
years)
in table 3 shows that there were no significant
difference between the surgical and control
Table 1 indicates that there were no
groups on executive functioning tests; and a
significant differences between the groups in age
substantial proportion of participants from
(t= .32; df= 38; p = .75), BMI (t= 1.69; df= 38;
both groups were in the abnormal category as
p = .09) and education (t=1.85; df= 38; p = .40).
far as the executive functions were concerned.
Table 2 : Group Differences in Comorbid Specific results are as following: executive
Hypertension
function composite (χ²= 5.67; df=2; p = .056),
Comorbid Surgical group Control group χ2 p number of categories (χ²= .52; df=2; p =.77),
condition
n(%) n(%) (df=2) number of perseverative errors (χ²= 3.01; df=2;
None 14 (70) 15 (75) .12 .95 p =.22), number of total errors (χ²= .49; df=2;
Present 6 (30) 5 (25) p =.78), percentage of perseverative errors (χ²=
Table 2 indicates that 30% of the surgical 4.86; df=2; p =.09), time taken for TMT trail
group and 25% of the control group had 1 (χ²= 1.60; df=2; p =.21) and time taken for
comorbid hypertension, which indicates that TMT trail 5 (χ²= .00; df=2; p =1.00).
136
Table 4 : Summary of Executive Functioning in Number of Non- 6.60 4.01 8.40 4.28 54.31 .000
Surgical and Control Groups after the Perseverative surgical
Errors
Intervention Period Surgical 7.30 5.01 4.50 3.26
Executive Surgical Control Number of Non- 21.35 9.25 22.50 9.42 55.05 .000
functions p Total Errors surgical
Worsened
Worsened
Surgical 20.55 11.56 15.40 9.48
Improved
Improved
χ² (df = 2)
Percentage Non- 28.80 11.31 37.75 10.76 16.12 .000
Static
Static
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
of surgical
Executive 13 7 (35) 0 (0) 0 (0) 12 8 (40) 23.32 .000 Perseverative Surgical 33.20 17.33 23.20 14.53
Function (65) (60) Errors
Composite Time taken Non- 57.90 22.20 59.45 22.74 33.76 .000
Number of 10 10 0 (0) 1 (5) 15 4 (20) 12.36 .002 on TMT Trail 1 surgical
Categories (50) (50) (75) Surgical 50.75 26.16 41.5 17.07
Number of 9 (45) 10 1 (5) 2 4 (20) 14 18.29 .000
Time taken Non- 103.85 51.9 106.90 71.10 25.39 .000
Perseverative (50) (10) (70)
on TMT Trail 5 surgical
Errors
Number of 14 6 (30) 0 (0) 3 9 (45) 8 (40) 15.71 .000 Surgical 90.75 52.11 52.09 34.29
Total Errors (70) (15) Digit Forward Non- 8.25 2.31 7.60 2.23 50.67 .003
Percentage of 9 (45) 8 (40) 3 (15) 2 7 (35) 11 9.09 .011 surgical
Perseverative (10) (55) Surgical 9.30 2.05 10.45 1.79
Errors Digit Non- 5.10 2.31 4.95 2.25 15.47 .000
Time Taken 9 (45) 11 0 (0) 1 (5) 16 3 (15) 10.33 .006 Backward surgical
for TMT Trail 1 (55) (80) Surgical 6.50 2.39 7.40 2.32
Time Taken 11 8 (40) 1 (5) 1 (5) 17 2 (10) 11.91 .001
Digit Span Non- 13.30 4.07 12.40 4.12 31.91 .000
for TMT Trail 5 (55) (85)
surgical
Table 4 indicates the status of improvement Surgical 15.08 4.12 17.85 3.78
in the cognitive status after the intervention Table 5 shows the results of ANCOVA, which
period. The results indicate that the surgical indicate that there was improvement in all
patients significantly improved on all dimensions domains of executive functioning after bariatric
of executive functioning than their counterparts. surgery viz. number of categories (F = 13.93;
Results of specific indices are as following: df=1,37; p = 001), number of perseverative
executive function composite (χ²= 23.32; df=2; p errors (F = 54.31; df=1,37; p <.000), number
=.000), number of categories (χ²= of total errors (F = 55.06; df=1,37; p <.000),
12.36; df=2; p =.002), number of percentage of perseverative errors (F = 16.12;
perseverative errors (χ²= 18.29; df=2; p =.000), df=1,37; p <.000), time taken for TMT trail 1
number of total errors (χ²= 15.71; df=2; p =.000), (F = 33.77; df=1,37; p <.000), time taken for
percentage of perseverative errors (χ²= 9.09; df=2; TMT trail 5 (F = 25.39; df=1,37; p <.000), digit
p =011), time taken for TMT trail 1 (χ²= 10.33; forward (F = 50.68; df=1,37; p <.000), digit
df=2; p =.006) and time taken for TMT trail 5 (χ²= backward (F = 9.94; df=1,37; p = .003) and digit
11.91; df=2; p =.001). span (F = 31.92; df=1,37; p <.000).
Table 5: Results of ANCOVA Comparing Pre-test DISCUSSION
and Post-test Scores of Executive Functions Current understanding is that obesity is a
between Burgical and Control Groups risk factor for many cognitive disorders (Boeka
(N=40). & Lokken, 2008; Cournot et al., 2006; Cserjesi
Executive Group Pre-test Post-test F p et al., 2007; Gunstad et al., 2010). But weight
Functions scores scores (df- reduction through bariatric surgery would show
1,37)
M SD M SD cognitive gains (Siervo et al., 2012; Gunstad,
Number of Non- 3.25 1.74 3.30 1.68 13.93 .001 Mueller, Stanek, & Spitznagel, 2012). In this
Categories surgical context the present study was designed as a
Surgical 3.20 1.98 3.95 1.60 preliminary effort to understand the cognitive
137
outcome of bariatric surgery in Indian context. that pre-surgical patients experience serious
This study indicates that both the groups were cognitive impairments but they significantly
statistically similar on baseline assessment of improve after bariatric surgery when compared
executive functions except for complex visuo- to the controls (Alosco et al., 2013). The finding
motor speed besides sustained attention measured are significant in the backdrop that Alosco et al.
by TMT Trail 5. Baseline performance on TMT (2013) have reported cognitive gains after three
Trail 1 indicates that 40% of surgical group months of intervention and are maintained up to
and 60% of control group showed abnormality 24 months. This study establishes that cognitive
on tasks related to attention. Similarly baseline gains could be noticed from around one and
performance on M-WCST and TMT indicate half month after surgery. Though, present study
that executive functions and visuo-motor speed provides evidence for cognitive gains after
is affected in morbid obesity. High perseverative bariatric surgery, it cannot be conclusively
errors indicate poor mental flexibility in obesity. stated that all gains are due to surgery alone
These findings are consistent with recent studies because of small sample size. Present study
suggesting that morbid obesity is strongly from India adds to the existing knowledge that
associated with impaired executive functions, neuropsychological evaluations should be part
visuo-spatial functions and attention (Boeka & of evaluation and outcome measures of obesity
Lokken, 2008; Cserjesi, Luminet, Poncelet, & and bariatric surgery.
Lenard, 2009).
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Research Article
Reasons for Smoking among College Students
L. N. Suman1 R. M. Nagalakshmi2 and K.Thennarasu3
Abstract
The aim of the study was to examine reasons for smoking among college students as well
as reasons that may make them consider quitting smoking. The sample consisted of 66
undergraduate students identified as smokers in a survey of 1000 undergraduate students
(488 boys and 512 girls) in the age range of 17 to 21 years studying in thirteen colleges in
Bangalore City. The survey used the Susceptibility to Smoking Scale (Pierce, et al, 1998)to
detect smokers. A semi-structured interview schedule was used to examine four domains of
smoking related issues: (i) Pathways to Smoking (ii) Smoking Expectancies (iii) Negative
Smoking Consequences (iv) Motivation to Quit Smoking. Results revealed that peer
influence, academic stress and problems in the family context were important reasons for
initiating smoking. Positive expectancies such as beliefs that smoking reduces tension and
gives pleasure, maintained the smoking behaviour. Two thirds of the sample was unaware of
the adverse consequences of smoking while one third had contemplated quitting smoking.
The findings have implications for planning early interventions for smoking among college
students.
Key Words: Smoking, College Students, Smoking Expectancies; Smoking Consequences,
Quitting Smoking
Introduction Tobacco is consumed primarily through smoking

Smoking and other forms of tobacco use in urban areas while chewing tobacco in addition
have been linked to a number of serious diseases to smoking tobacco is more widespread in rural
which places an enormous burden not only on areas. In the National Sample Survey of 1998-
the individual sufferer but also on the health 1999, the all India figures for youth aged above
care system. Tobacco smoke when inhaled 10 years were: 45.3% for male rural tobacco
severely damages the internal organs and other users; 29.9% for male urban tobacco users;
parts of the human body. The consequences 11.8% for female rural tobacco users and 5.1%
range from gum diseases, loss of sense of smell, for female urban tobacco users (Reddy & Gupta,
premature ageing, pneumonia and osteoporosis 2004). Agrawal and Agrawal (2011) analysed a
to cardiovascular diseases and cancers. Smoking cross sectional data of 1,11,077 adolescents aged
heightens the risk of heart attacks and stroke; 10-19 years who had been included in India’s
lung cancer and oral cancers; cancer of the liver second National Family Health Survey (NFHS-
and kidneys; cancer of stomach, pancreas and 2, 1998-99). They found that the prevalence
colon (Ryu, et al., 2001; Vineis, et al., 2004). of tobacco chewing, smoking and drinking
Health professionals have repeatedly noted that among adolescents was 3.3%, 1.2% and 0.9%
it will not be possible to reduce tobacco-related respectively. They opined that comprehensive
deaths over the next 30-50 years, unless adult prevention and control programs, especially
smokers are encouraged to quit. community based interventions, are required in
India is the world’s second highest tobacco India for addressing the risk-taking behaviour
growing and tobacco consuming country. among adolescents.
1. Professor, Department of Clinical Psychology, 2. Research Officer, Department of Psychiatry, 3. Professor,

Department of Biostatistics, NIMHANS, Bangalore 560 029
Corresponding Author L N Suman • E-mail: elenes@nimhans.kar.nic.in or ln_suman@rediffmail.com
140
L. N. Suman et al... / Reasons for Smoking among College Students
Sharma, Singh, Ingle, and Jiloha (2006) manliness, relieved boredom and eased tension.
examined reasons for smoking among 800 male Affordability and accessibility were also cited as
college students. They observed that lifetime factors related to smoking. 40% reported that they
stress score was significantly higher among had been influenced by advertisements, which
smokers than nonsmokers. The mean lifetime promoted tobacco products. The authors note
stress score of heavy smokers was significantly that in order to develop culturally appropriate
higher than low to moderate smokers. The prevention and cessation interventions for
findings of the study indicated the need to youth, data is required on trajectories of
counsel male college students so as to deter tobacco use and non-use, changes in the age
them from taking up smoking as a mechanism of initiation, and transition points to increased
against stress. Siziya, et al. (2008) carried out use. More recently, Shaniya and Sharma (2012)
a study on reasons for smoking among 2014 in a college student study of 76 smokers and 76
school going children in Punjab. They found that non-smokers in the age range of 16 to 19 years
the following factors were positively associated found that tobacco users had low self- esteem
with smoking: presence of smokers in the and low life satisfaction in comparison to non-
family, friends who smoked,positive attributions users. The authors noted that the findings have
to smoking and enough pocket money to buy implications in tobacco cessation programs and
tobacco products. The authors recommend community level tobacco prevention programs
public health interventions aimed at reducing for adolescents.
adolescent cigarette smoking.
Considering the paucity of research on
The problem of tobacco use among reasons for smoking among adolescents in India,
youngsters has been noted in Karnataka also. the aim of the study was to examine reasons
Gururaj and Girish (2007) carried out the Global for smoking among college students as well as
Youth Tobacco Survey in Karnataka (GYTS-K) reasons that may make them consider quitting
among children aged 13 to 15 years. In a sample smoking.
of 4110 students, the prevalence of tobacco use
was 4.90% (Males: 8% and Females: 2.10%). Method
In a cross sectional study in Karnataka by Sample:
Hemagiri, Vinay and Muralidhar (2011),1536 The sample consisted of 66 established
adolescents between the ages of 10-19 years were smokers (51 boys and 15 girls) who gave written
interviewed about tobacco use. It was found that informed consent for a personal interview related
prevalence of tobacco use was 11.13%. Further, to their smoking behavior. They were identified
prevalence increased from 14.81% in the age as smokers in a survey of 1000 undergraduate
group of 14-15 years to 68.42% among the students (488 boys and 512 girls) in the age range
age group of 18-19 years. Results revealed that of 17 to 21 years studying in thirteen colleges
adolescents perceived their parents, relatives in Bangalore City. The colleges were selected
and friends as important factors for their tobacco by stratified cluster random sampling method.
use. The authors recommend tobacco education The survey used the Susceptibility to Smoking
to be initiated in schools and colleges to prevent Scale (Pierce, et al, 1998)to detect established
and control tobacco use among adolescents. smokers. A total of 306 students (30.60%) were
Reasons for tobacco use among 1587 male identified as established smokers, of whom 178
college youth in Karnataka were examined by (58.17%) were boys and 128 (41.83%) were
Nichter, et al (2004). Results indicated that forty- girls. Out of the 306 students, 240 students
five percent of college students surveyed had (78.43%) did not give consent for the interview
used tobacco products. In interviews, students and the 66 students who gave consent (21.57%)
reported that smoking a cigarette enhanced one’s were interviewed.
141
Inclusion Criterion: Interviews were carried out in individual

Subjects who gave written informed settings in classrooms provided by the colleges.
consent for a personal interview Subjects were assured that confidentiality would
Exclusion Criterion: be maintained. Results were analyzed using
Subjects who had undergone any tobacco qualitative analysis and descriptive statistics
cessation or smoking related programs such as percentages.
Measures: RESULTS
Pathways to smoking behaviours are given
i) Socio-demographic Data Sheet:
in Table 1.
This was developed by the investigator
to obtain details regarding the subject’s age, Table 1: Pathways to Smoking#
gender, education and family details. It was also Sl. No Pathway Total Percentage
used to obtain information about smoking by the 1 Peer Pressure to Smoke 49 74.24%
subject’s family members and peers. 2 To Cope with Family Problems 37 56.06%
3 To Cope with Academic Stress 31 46.97%
ii) Susceptibility to Smoking Scale:
4 Modeling Smoking Behaviours 21 31.82%
The scale developed by Pierce, et al (1998), of Family Members
helps in putting adolescents into exclusive 5 For Enjoyment 20 30.30%
categories: non-susceptible never smokers,
# Students reported more than one pathway
susceptible never smokers, experimenters, and
for initiating smoking
established smokers. An established smoker
is defined as an adolescent giving a positive Results indicate that peers who are smokers
response to the question, “Have you smoked at have a tremendous influence on their friends
least 100 cigarettes in your life?”The scale was with regard to initiation of smoking behaviours.
used in the present study to screen for established Peer acceptance and peer approval are important
determinants for cigarette smoking as they
smokers among college students.
provide group support and group identity. Tension
iii) Semi-structured Interview Schedule: reduction by using nicotine to induce relaxation is
This was developed by the researchers another important reason for smoking. Smoking
to examine four domains of smoking related to cope with family problems and academic
issues: (i) Pathways to Smoking (ii) Smoking stress indicates poor problem solving and stress
Expectancies (iii) Negative Smoking management. In line with social learning theory,
Consequences (iv) Motivation to Quit Smoking. it was found that modelling smoking behaviours
Within each domain, open-ended questions of family members constitutes a risk for nicotine
dependence along with smoking to experience its
were used to encourage the subjects to freely
pleasurable effects.
express their answers. The interview is meant
for students who have initiated smoking. It takes Students had significant positive smoking
expectancies which maintained the behaviour.
about 20 minutes to complete. All interviews
These are listed in Table 2 which indicates that
were conducted in individual sessions.
smoking is perceived to be beneficial in many
Procedure: ways. Smoking was experienced as providing
Ethical clearance for the study was quick relief from stress and leading to a calm
obtained from the Institutional Ethics state. It was also experienced as pleasurable and
Committee. Permission to contact the students enjoyable, especially in the company of friends
was obtained from the college managements. during recreational breaks. These expectancies
Written informed consent was obtained from all and perceived benefits contribute to high risk
the participating subjects who met the inclusion for both current smoking practices and the
and exclusion criteria laid down for the study. possibility of continued future smoking.
142
Table 2: Smoking Expectancies Table 4: Reasons for Motivation to Quit#
Sl. No Expectancy Total Percentage Sl. No Motive to Quit Total Percentage
1 Relief from Tension 56 84.84% 1 Against society’s norms 21 31.82%

2 Pleasure and Enjoyment 45 68.18% 2 Hazardous to health 20 30.30%
3 Increased Alertness 20 30.30% 3 Parental criticism of smoking 13 19.70%
4 Spoils Future and 11 16.67%
4 Feeling Superior 19 28.79% Relationships at Work
5 Impressing Others 10 15.15% 5 Loss of Social Prestige 9 13.64%
# Students reported more than one Smoking Expectancy #Students reported more than one Reason for
It can be seen from Table 3 that only about Motivation to Quit.
one third of the students were aware of the health One third of the students had contemplated
hazards from smoking. The same one third of quitting smoking as it violated societal and
the students elaborated on various risks from family norms and could harm relationships
smoking such as problems related to appetite, with others. They were embarrassed to be
weight and conflicts with parents. They were seen openly smoking and were worried about
unaware of serious diseases related to smoking their social image. They were also worried
tobacco such as cancer and heart disease. More about the reactions of their parents if they were
than 60% were completely unaware of negative caught smoking or if their smoking behaviour
consequences of smoking and downplayed the became known to their parents and other family
risks involved. Health warnings on cigarette elders. Negative consequences for health were
packets did not matter significantly to them and also acknowledged as one of the reasons for
smoking was perceived to be a harmless pastime. considering quitting smoking.
Table 3: Negative Smoking Consequences# DISCUSSION

The finding of 30.60% smokers among
Sl. No Consequence Total Percentage
college students in the present study is lower
1 Harmful to Health 37 56.06% when compared to the figures reported by Nichter
2 Decreases Appetite 28 42.42% et al. (2004) who had found in their study that
3 Causes Weight Problems 10 15.15% 45% of college students surveyed had used
4 Causes Relationship 7 10.61% tobacco products. However, the figures of the
Problems at Home present study are higher than those reported by
5 Pollutes the Environment 6 9.09% the Global Youth Tobacco Survey (Sinha et al,
2008) and the findings of Gururaj and Girish
# Students reported more than one Negative Smoking (2007). This may be due to the fact that their
Consequence surveys consisted mainly of school students while
As can be seen from Table 4, two thirds of the current study was on a sample of college
the students were not motivated to quit as they students. This indicates that prevalence and risk
did not perceive smoking to be a problem. They for smoking increases with age. The figures found
were unconcerned about the potential harm in the present study are closer to those reported
from smoking and felt that since they were still by Otten et al. (2007) who found that out of 7426
young, the adverse effects would not be a matter adolescents, 65.70% had not experimented with
of concern. This indicates that these adolescents smoking while 28% had tried smoking.
are at risk for health problems if they continue The finding of significant peer influence
to smoke. This subgroup would require focused on smoking is similar to results obtained in
interventions to motivate them to quit smoking previous studies by Robinson et al. (1997) and
and enable them to remain abstinent. McVicar (2011). Another important pathway
143
to smoking, that is, to reduce tension, which to smoking and also failed to recognize
indicates negative reinforcement from smoking, substance use as harmful to physical health. Other
may also be the reason why students try to negative consequences reported by the students
cope with family problems by smoking. This in the current study, such as smoking reduces
finding is similar to that reported by Carvajal, appetite, and causes weight problems, are also of
et al (2006) that adolescents with lower parental a fairly mild nature of consequences. Although
relatedness were more likely to initiate smoking. health risks were acknowledged, students in the
Similarly, Gau et al. (2009) had also noted that present study were not very aware of the nature
college smokers, compared to nonsmokers, of health risks or the seriousness of potential
reported that their fathers showed less affection health problems due to smoking. This indicates
and care and mothers less overprotection toward that programs such as those proposed by Sun. et
them. Family cohesion was also perceived to be al. (2007) who developed an effective classroom-
lower in the smokers than in the nonsmokers. based curriculum for tobacco use prevention and
These results indicate the need to probe into cessation programs, are also required for Indian
family circumstances that might be related to students.
adolescent smoking. Further, smoking to cope The dominance of social and family
with academic stress indicates the need to teach reasons for considering quitting smoking
healthier coping strategies to college students. indicates the powerful influence of sociocultural
Most of the smoking related expectancies factors in regulating health behaviours. This
reported in the present study are similar to may also be one of the reasons for more than
those reported by adolescents in other countries three fourths of the smokers refusing to take
(Guo 2007; Kassel et al., 2007). As Correia, part in the interview. It is possible that stigma
et al (2006) noted, daily smokers reported attached to adolescent smoking may have made
more positive consequences than occasional them wary of giving consent in spite of the
smokers, who in turn reported more positive assurance of confidentiality. As recommended
consequences than former and non-smokers. by Stephens et al. (2009), targeting normative
Health messages in prevention programs must beliefs about smoking and attitudes to smoking,
hence emphasize the point that smoking has as well as targeting intention to smoke among
little or no positive consequences. Ramsay and adolescents, can be effective approaches to
Hoffman (2004) developed a peer-led smoking prevent smoking and reduce harm from smoking.
cessation program for undergraduate students Further, as suggested by Huver et al. (2006),
consisting of both individual and group sessions. interventions aimed at prevention of smoking
Each session provided education and training should encourage those anti-smoking parenting
in stress management, nutrition and exercise practices that influence adolescent smoking-
habits,managing environmental smoking related cognitions in a favorable manner.
triggers, and coping in social situations. They CONCLUSION
recommended that college administrators and The study highlights the importance of
health educators should develop integrated screening college students for tobacco use. Early
tobacco management strategies on college detection of established smokers can lead to early
campuses. interventions and reduce harm from tobacco use.
Negative consequences from smoking Novice smokers or occasional users will also
were perceived to be not only lesser but also as benefit from indicated prevention programs or
not directly affecting the individual smoker (eg, early intervention. Early interventions are most
smoking pollutes the environment and causes effective in motivating occasional smokers to
relationship problems). This is strikingly similar quit tobacco use completely. Efforts must also
to findings reported by Gau et al. (2009) who be made to examine if there are other problems
found that smokers perceived fewer objections affecting the students and an appropriate
144
professional should address those problems. Otten, R; Engels, R.C.M.E; Van de Ven, M.O.M & Bricker,
This will reduce maintaining factors such as J.B (2007). Parental smoking and adolescent
emotional distress and academic stress and smoking stages: The role of parents’ current and
former smoking, and family structure. Journal of
enable better chances of quitting smoking. Behavioural Medicine, 30: 143-154.
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among college students.Addictive Behaviours, 31, adolescent smoking in a biracial sample.Journal of
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145
Research Article
Socio-demographic Correlates of Children Suffering from
Juvenile Deliquency
Shweta Sharma1, J Mahto2 and Deapti Mishra3
Abstract
The criminal behaviour is most often advocated as result of cirtain social, psychological
atrocities. Present study aimed to know socio demographic variables, which are
responsible for criminal behavior because criminals are not born they are made, and if
we as a society can make them then we as a society also have the power to cure them.
A Juvenile Delinquent, a person who is under age (below 18), who is found to have committed
a crime in states which have declared by law that a minor lacks responsibility and thus may
not be sentenced as an adult. The sample of the present study form 50 male delinquents
children from “Bal-Sampreshan Grah”,Manacamp, Raipur (C.G.) were purposively selected
for the study. These juvenile delinquents sometimes have mental disorders/behavioural
issues such as post traumatic stress disorder or bipolar disorder, and are sometimes
diagnosed with conduct disorder partially as a result of their delinquent behaviours. Many
factors like schools, neighbourhood, Family, Society, Situations are equally responsible for
the degradation or fall of a child. Hence, instead of labelling them as one we must try and
find ways, rectify the errors in their lives which led them to behave in this manner. Children
can be easily rehabilitated and psychological rehabilitation can be helpful to take them back
in society.
Key Words: Juvenile Delinquent, Behavioural Issues, Conduct Disorder, Anti Social
Elements and Criminals.
Introduction errors in their lives which led them to behave

Reports in various researches and surveys in this manner. Children needs to be taken for
show an increase in delinquent behaviour of reforms/ rehabilitation an proper guidance
the students aged 14-20 years[World youth for corrective measures where they may learn
report,2003] not only in developed countries some skills and positive behaviour. In this
but also in developing countries like India. study efforts have been made to know the
Juvenile Delinquent is a person who is under
socio-demographic variables playing measure
age (usually below 18), who is found to have
role in the development the behaviour which is
committed a crime in states which have declared
by law that a minor lacks responsibility and thus in conflict with law.
may not be sentenced as an adult (Welbush, Methodology
2008). These juvenile delinquents sometimes The present study was aimed to find
suffers mental disorders/behavioural issues out socio-demographic variables of children
such as post traumatic stress disorder or bipolar suffering from juvenile delinquency.
disorder, and are sometimes diagnosed with
conduct disorder. Many factors like schools, Sample:
neighbourhood, family, society, situations are The Sample consisted of 50 male
equally responsible for the degradation or fall delinquent children from “Bal- Sampreshan
of a child. Hence instead of labelling them Grah”, Manacamp, Raipur was collected by
as one we must try and find ways, rectify the following inclusion adn exclusion criteria.
1. Clinical Psychologist 2. Former Head 3. Associate Prof., Department of Clinical Psychology,P. G. Institute of
Behavioural & Medical Sciences, Raipur [C.G.]. Corresponding Author: kshwetasharma@gmail.com
146
Shweta Sharma... / Socio-demographic Correlates of Children Suffering from Juvenile Delinquency
Inclusion Criteria: Number of Freinds 2 8 16

• Diagnosed children of Delinquency. 2 to 6 26 52
• 12 to 18 years of age.
More than 6 11 22
Exclusion Criteria:
No Freinds 5 10
• Below 12 years and above 18 years of age. With Whom They Share Their Parents 7 14
• For whom consent was not given. Secretes Freinfs 26 52
• Whose detailed information was not
Brother 14 28
available.
Sister 3 6
3. Tools:
Social Environment of Juvenile Good 15 30
Socio-demographic data sheet, especially Delinquents Poor 35 70
designed for this study was used to collect the
demographic information of the sample. Crime Record of Juvenile Murder 16 32
Delinquents Murder Attempt 2
Results
Rape 4 6
Table 1: Socio-demographic Characteristics
Stealing 23 46
of Juvenile Delinquents (JD)
Variable Group = JD (N-50) Drug Traffickingle 1 2
F % Kidnaper 1 2
Rural 14 28 Arms Act 3 6
Urban 13 26
Currency duplicacy 1 2
Slum-urban 23 46
Age at the time Crime was 10yrs 2 4
H/o Studies Variables (N-50] f % Committed 11yrs 1 2
of Juvenile Performance in Average in studies 10 20 12yrs 6 12
Delinquents Study Poor in studies 29 58 13yrs 2 4
Breakdown in Yes 32 64 14yrs 7 14
Study No 7 14 15yrs 12 24
Types of the Family, N-50 Nuclear 36 72 16yrs 12 24
Joint 14 8 17yrs 7 14
Family Situations of Juvenile Broken Home 9 18 18yrs 1 2
Delinquents Parental Rejection 3 6 Family History of Criminal Act Yes 6 12
N-50 No 44 88
Faulty discipline 7 14
Well Adjusted 31 62 Occupation / Work H/o Juvenile Below 8 Years 2 4
Delinquents 9-12 Yrs 13 26
Parental Status of Working N-50 Single 32 64
(Age at tehtime of Starting 13-16 Years 21 42
Both 17 34
Work) 16-18 Years 2 4
Time Spent by Father &/or Time None 19 38
Mother with the Delinquents Spent By 2-4 Hours Nature of work Waiter 3 6
19 38
N-50 Father Labour 11 22
5-8 Hours 9 18
Farmer 3 6
More than 8 2 4
Shop Keepr 18 36
Hours
Driver 3 6
Time spend by Father &/or Time None 14 28
Mother with the Delinquents Spent By 2-4 Hours Student 12 24
13 26
N-50 Mother Monthly Income 1000-2000 16 32
5-8 Hours 14 28
3000-5000 17 34
More than 8 8 16
Hours 5000 & Above 5 10
147
Frequency and Physical abuse 6 12.0 DISCUSSION

Percentage of Type of Sexual abuse 0 00.0 Juvenile delinquents were mostly in
History of Abuse Abuse
in Juvenile Abused by Relative 3 6.0
the age group of 15 to 17 year with a rapid
Delinquents
Neighbours/Others 2 4.0 decline in 18 years of age. Majority belonged
Someone unknown 1 2.0 to slum urban background followed by rural
Age at the Below 8 yrs. 3 6.0 and urban areas. They were mostly educated
Time of 13 to 16 yrs. 2 4.0
Abuse up to primary level,were poor in studies,had
16 to 18 yrs. 1 2.0
left studies due to lack of interest or financial
Frequency of Once 1 2.0
Abuse Repaeted 5 10.0 problems and wanted to resume their studies.
Socio-economic Upper High 2 4.0 Majority belonged to nuclear family. Parents
Status of high 1 2.0 had little time to spent with them and had poor
Families of
Juvenile
Upper Middle 6 12.0 social environment though they had average
Lower Middle 27 54.0
Delinquents 2 to 6 friends and could share their secrets
Lower 10 20.0
with their friends. Majority of them had lower
BPL 4 8.0
middle to poor socio- economic status and
fewer physically abused in their childhood
The results presented on table 1 shows that
frequently. Majority of then involved in stealing
nearlhalf of the population of present study was
followed by murder and rape. These findings
from urban slum area and 26 were belonging
are consistent with earlier findings too.
to urban and 28% from rural area. results in
Warr (1933) who stated that delinquency
table reveals majority were from nuclear famiy
escalates rapidly as individuals enter their ten
(72%) and interestingly 62% were reported
years and then declines almost as rapidly as
from well adjusted fmily. Another interesting
they enter their late teens and early twenties.
findings in table 2 is that majority (64%) of
Poverty and poor living condition is associated
children in conflict law were having single
with juvenile delinquency (William,1999).
parent by any reason but it is evident that
Socio-economic status and family status
parental vacume of either can leads to very
have been reported to make both joint
serious consequences to children may be srious and independent contributions to deviant
crime like murder etc. Table furhter indicaate behavior,may be because these children are
that the children in conflict with lawof them unable to get proper education due to poverty
majority reported that their either parents were and they have to do some work for income
not giving the proper time to share or discuss and their childhood is snatched from him.
the issues related to them or giving very less Matherne and Thomas (2001) also viewed that
time and subsequently tmajority (52%) were children/youth from non-traditional families
not having more nuber of freinds rather their (single parent, reconstituted) have a far greater
social circe was also very restricted. resuts of chance of engaging in delinquent behavior than
the tabe further indicate that such children children/youth from traditional families. One
were involved iin various antisocial activities of the reason why children from joint family
including serious crime like murder but most may be less likely to engage in delinquency
of them (46%) were found involved in stealing. is the presence of family resources (Matherne
Majoriy were form lower socio economic & Thomas, 2002). Parents who are poor in
conditions and haing the h/o abuse. communication skills,unable to establish
148
strong emotional ties and/or provide little to no unwholesome environment congenial for the
support for children risk seeing them engage in development of his faculties in conformity with
delinquent behavior (Keller, et al, 2002).Type social expectations.
of society and neighbourhood also marks an
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seriousness to find an effective remedy for the
problem of juvenile delinquency. The public World Youth Report. (2003)."Juvenile Delinquency."
attitude towards Juvenile delinquents must also http://www.un.org/esa/socdev/unyin/docu-
change. A juvenile delinquent is a product of ments/ch07.pdf.
149
Research Article
A Study of Socio-demographic Variables and Personality Profile of

Persons with Homicidal Behaviour in Clinical Settings
Samir Sarma1, Kangkan Pathak2 and Maitreyee Dutta 3
Abstract
Mentally ill patients with history of homicidal act or attempt are often encountered in
psychiatric practice. Multiple factors interact in shaping such behaviour. In this study
we attempted to find out the various socio – demographic characteristics and personality
profile of mentally ill persons with history of homicidal behaviour. The sample (N = 30)
was selected from inpatient ward of LGBRIMH – Tezpur (Assam), using random sampling
technique. After collecting relevant history and socio – demographic data, personality profile
was assessed using MCMI – III and impulsivity was assessed using BIS – 11 scales. BPRS
(18 item) score of 41 was taken as a cut – off prior to evaluations, above which personality
assessments were not carried out. Majority of the subjects were male (93.3%), mean age was
35.13 yrs. In majority of cases, the victim was a family member (70%). 80% of the subjects
had a primary clinical diagnosis of psychosis. MCMI – III results showed that 70% of the
subjects had at least one personality disorder. DSM – IV cluster – A personality disorders
(43.3%) were the most prevalent. Scores on BIS – 11 revealed that 53.3% have pathological
levels of impulsivity, especially in the domain of non – planning impulsivity (93.3%). The
study also found significant negative correlation between age and impulsivity. Impulsivity
was higher among cluster – B and lower among cluster – C personalities. Cluster – B
disorders were more among younger age group.
INTRODUCTION in examining factors that influence behaviour– or

Violence, including homicide is common which increase the risk of committing or being a
in society and is also frequently encountered in victim of violence – by dividing them into four
psychiatric practice. levels. These 4 levels are-
World Health Organization in the year 2002 1. Individual factors,
published the “World report on violence and 2. Relationship factors,
health”. This report was the first comprehensive 3. Community contexts &
summary of the problem of violence including
suicide, homicide & various war related violence 4. Societal factors.
on a global scale. It advocated a public health Several studies have reported unique
approach to violence in a more comprehensive characteristics of persons with homicidal
and holistic manner. behaviour. However, the number of previous
studies on persons with homicidal behaviour is
In the year 2000, an estimated 1.6 million
few in this part of the country.
people worldwide lost their lives to violence – a
rate of nearly 28.8 per 100,000. Around half of We, at LGB Regional Institute of Mental
these deaths were suicides, nearly one-third were Health – Tezpur (Assam), often get to see
homicides, and about one-fifth were casualties mentally ill patients, with history of homicidal
of armed conflict (W.H.O., 2002). act or attempt, both as inpatient as well as
The World report on violence and health outpatient. Therefore, we have selected this
used an ecological model to understand the group of patients as the subject of our study,
multifaceted nature of violence. The model assists and tried to assess their socio – demographic
1. Senior Resident, 2. Associate Professor, Department of Psychiatry, 3. Assistant Professor, Department of

Clinical Psychology, LGB Regional Institute of Mental Health, Tezpur (Assam)
Corresponding Author’s: Samir sarma , samir123xyz@gmail.com
150
Samir Sarma et al ... / A Study of Socio-demographic Variables and Personality Profile of Persons.........
characteristics, psychopathology and personality statistical analysis. Pearson’s correlation

profile. coefficient & Pearson’s chi-square values
were calculated to find out any significant
METHOD
correlations or associations among the different
The study was carried out during a 1
study variables. Fisher’s exact test was used,
year period starting from August – 2011. Cases
where ever Pearson’s chi-square test could
with history of homicide (act or attempt) were
not be applied due to smaller (< 5) expected
collected from LGBRIMH- Tezpur in-patients.
frequencies in > 20% of the cells on 2×2 tables.
Consecutive sampling technique was employed.
Significance level was taken at p (Probability)
All the indoor patients, with history of homicidal
value less than 0.05.
act or attempt that the investigator came across
during the study period were selected, until the RESULTS
predetermined number of 30 valid samples was Table 1: Showing Socio demographic Characteristics
reached. Persons with mental retardation and
Frequency
severe cognitive impairment were excluded (%)
from the study sample. AGE GROUPS
18 – 29 Yrs 9 (30.0%)
Written informed consent was taken from (Mean Age = 35.13 yrs)
all the participants & they were free to withdraw 30 – 39 Yrs 12 (40.0%)
it at any time. Relevant history was collected 40 – 49 Yrs 6 (20.0%)
from persons concerned & also from family 50 – 59 Yrs 3 (10.0%)
members. Data regarding socio-demographic 60 Yrs & Above 0 (0.0%)
variables were collected. Thorough mental 28 (93.3%)
GENDER Male
status examinations were carried out. Brief
Female 2 (6.7%)
Psychiatric Rating Scale (BPRS) (18-item)
was administered to rule out acute psychotic MARITAL STATUS Married 17 (56.7%)
exacerbations. Evaluation was not carried out Unmarried 10 (33.3%)
during acute phase of psychosis. A score of > Separated 3 (10.0%)
or = 41 on BPRS (18-item) was taken as the cut RELIGION Hindu 21 (70.0%)
off for exclusion. This cut off score has been Muslim 6 (20.0%)
selected as BPRS score = 41 correspond to CGI Christian 3 (10.0%)
(Clinical Global Impression) score = 4, which Others 0 (0.0%)
indicates “moderately severe” illness (Leucht, S.
MOTHER TONGUE Assamese 14 (46.7%)
et al., 2005).
Hindi 1 (3.3%)
Thereafter, personality assessment was
Bodo 1 (3.3%)
done using Millon Clinical Multiaxial Inventory-
Nepali 2 (6.7%)
III (MCMI-III) and impulsivity was assessed
using Barratt Impulsiveness Scale (BIS – 11). Bengali 7 (23.3%)
Naga 2 (6.7%)
Data was then statistically analysed to find
out any significance of the observed findings. Tea-tribe
3 (10.0%)
languages
A total of 32 individuals were interviewed
during this period, of which 2 persons, who gave Illiterate 1 (3.3%)
invalid & inconsistent responses on personality Primary School 10 (33.3%)
assessments were excluded from the study. EDUCATIONAL STATUS
Secondary School 18 (60.0%)
Graduate 1 (3.3%)
Statistical Analysis
Statistical Program for Social Sciences Postgraduate &
0 (0.0%)
Higher
(SPSS - Version 20) was used for all the
151
OCCUPATION Unemployed 8 (26.7%) Interpersonal 6 (20.0%)

Govt. Job 0 (0.0%) problems
Private Job 1 (3.3%) Association with 2 (6.7%)
REASON FOR drugs/alcohol
Agriculture 14 (46.7%) HOMICIDE
Psychotic process 22 (73.3%)
Daily Labour 5 (16.7%)
Others 2 (6.7%) Others 0 (0.0%)
DOMICILE Rural 28 (93.3%) Schizophrenia 21 (70.0%)
Urban 2 (6.7%) Other Psychosis 3 (10.0%)
MONTHLY FAMILY < 10,000 INR 23 (76.7%) PRIMARY CLINICAL Mood disorder 2 (6.7%)
INCOME > 10,000 INR 7 (23.3%) DIAGNOSIS Substance use 2 (6.7%)
RELATION WITH THE Family Member 21 (70.0%) disorders
VICTIM Known person, other 9 (30.0%) Personality Disorder 1 (3.3%)
than family member OCD Spectrum 1 (3.3%)
Stranger 0 (0.0%) Disorder
MCMI-III: Data from MCMI-III yielded the following results.
Table 2: Distribution of MCMI-III Personality Patterns in the Study Sample
LEVEL OF PERSONALITY PATHOLOGY
1 2 3 4 Total 3+4
MCMI-III Codes
(Score=0-59) (Score=60-74) (Score= 75-84) (Score= N (%) (Score=75-115)

Insignificant Personality Clinically 85-115) Clinically Significant
N (%) Features Significant Personality Personality Pathology
N(%) Personality Trait Disorder (Trait/Disorder) N(%)
N(%) N(%)
1 Schizoid 5 (16.7%) 15 (50.0%) 2 (6.7%) 8 (26.7%) 30 (100%) 10 (33.33%)
2A Avoidant 9 (30.0%) 7 (23.3%) 6 (20.0%) 8 (26.7%) 30 (100%) 14 (46.67%)
2B Depressive 10 (33.3%) 11 (36.7%) 7 (23.3%) 2 (6.7%) 30 (100%) 9 (30.00%)
3 Dependent 9 (30.0%) 15 (50.0%) 4 (13.3%) 2 (6.7%) 30 (100%) 6 (20.00%)
4 Histrionic 24 (80.0%) 5 (16.7%) 1 (3.3%) 0 (0.0%) 30 (100%) 1 (3.33%)
5 Narcissistic 15 (50.0%) 10 (33.3%) 0 (0.0%) 5 (16.7%) 30 (100%) 5 (16.67%)
CLINICAL PERSONALITY PATTERNS
6A Antisocial 12 (40.0%) 14 (46.7%) 2 (6.7%) 2 (6.7%) 30 (100%) 4 (13.33%)

Sadistic
6B 4 (13.3%) 23 (76.7%) 2 (6.7%) 1 (3.3%) 30 (100%) 3 (10.00%)
(Aggressive)
7 Compulsive 11 (36.7%) 15 (50.0%) 2 (6.7%) 2 (6.7%) 30 (100%) 4 (13.33%)
Negativistic
8A (Passive- 1 (3.3%) 17 (56.7%) 10 (33.3%) 2 (6.7%) 30 (100%) 12 (40.00%)
Aggressive)
Masochistic
8B (Self- 5 (16.7%) 14 (46.7%) 9 (30.0%) 2 (6.7%) 30 (100%) 11 (36.67%)
Defeating)
S Schizotypal 4 (13.3%) 19 (63.3%) 3 (10%) 4 (13.3%) 30 (100%) 7 (23.33%)
PERSONALITY
PATHOLOGY
C Borderline 7 (23.3%) 17 (56.7%) 4 (13.3%) 2 (6.7%) 30 (100%) 6 (20.00%)

SEVERE
P
Paranoid 3 (10.0%) 7 (23.3%) 11 (36.7%) 9 (30.0%) 30 (100%) 20 (66.67%)
Table - 2 Shows the frequency distribution of various MCMI-III personality features (Score=60-74)
/ traits (Score=75-84) / disorders (Score=85-115) in the study sample. The prevalence of DSM-IV
personality disorder clusters in the study sample is presented in table -3
152
Table 3: Prevalence of Personality Disorders (MCMI- Table 5: BIS – 11 Sub-scales Scores

III Score = 85 -115) in the study Sample BIS – 11 Sub-scales Level of Frequency
Personality Cluster-A Personality Personality Personality Impulsivity (%)
Disorder Personality Disorde Disorder Disorder - Attentional Impulsiveness Low 12 (40%)
(MCMI-III) Disorder (DSM-IV (DSM-IV NOS [Factors: Attention & Cognitive
(DSM-IV) Cluster-B )r Cluster-C) (DSM-IV ) Instability] High 18 (60%)
Present 21 (70.0%) 13 (43.3%) 7 (23.3%) 10 (33.3%) 6 (20.0%) Motor Impulsiveness Low 13 (43.3%)
Absent 9 (30.0%) 17 (56.7%) 23 (76.7%) 20 (66.7%) 24 (80.0%) [Factors: Motor & Perseverance] High 17 (56.7%)
Total 30 (100.0%) 30 (100.0%) 30 (100.0%) 30 (100.0%) 30 (100.0%)
Non-Planning Impulsiveness Low 2 (6.7%)
[Factors: Self-Control & Cognitive
BIS-11: Complexity] High 28 (93.3%)
Barratt (Barratt et al. 2005) has suggested
that a total score of 70 or higher indicates DISCUSSION
pathological impulsivity. Computing the This study observed several important
observed data at this level shows that 53.3% findings. Significant male preponderance has
(N=16) of the study subjects has impulsivity at been seen among mentally ill persons with
pathological level. homicidal behaviour. 28 out of 30 (93.3%) of
the study sample were male. Mean age of the
Table 4: Level of Pathological Impulsivity in the sample was 35.13 years with a range of 22–55
Study Sample years and a standard deviation of 9.6 years. Both
BIS-11 total Level of Impulsivity Frequency Percentage of these findings are in accordance with several
score (N) (%) well documented previous studies. Studies done
0 - 69 Non-pathological 14 46.7% by Shaw et al. (2006) in England and Wales,
70 - 120 Pathological 16 53.3% Simpson et al. (2004) in New Zealand, Koh et
Total 30 100% al. (2006) in Singapore, Fazel and Grann (2009)
BIS – 11 has 3 sub-scales (Attentional in Sweden, Ogungbemi and Ahmed (1993)
Impulsiveness, Motor Impulsiveness, and Non- in Nigeria, Yarvis R. M.(1995) in California,
Planning Impulsiveness) with 6 factors: Kishore et al. (1970) in Amritsar, India, all these
1. Attention: “focusing on a task at hand”. studies have previously demonstrated male
predominance among homicide perpetrators.
2. Motor impulsiveness: “acting on the spur of
the moment”. Most of the subjects in the current study
3. Self-control: “planning and thinking carefully”. were married (56.7%), 70% were Hindus,
4. Cognitive complexity: “enjoying challenging majority (46.7%) were Assamese speaking, 60%
mental tasks”. of them received education up to secondary
5. Perseverance: “a consistent life style”. school level, majority (46.7%) were cultivators,
6. Cognitive instability: “thought insertion and 76.7% had a family income less than 10,000
INR per month and vast majority were from
racing thoughts”.
rural background (93.3%). These observations
Among the 3 BIS-11 subscales, 60% are understandable considering the population
(N=18) of the subjects has higher scores on from which the sample has been selected.
attentional impulsiveness sub-scale [Factors:
One important observation of this study
Attention & Cognitive Instability], 56.7% is that the victims were always either a family
(N=17) has higher score on motor impulsivity member (70%) or other known person (30%). In
sub-scale [Factors: Motor & Perseverance] none of the cases strangers were involved. This
& 93.3% (N=28) has higher scores on non- is not in accordance to several previous studies.
planning impulsivity sub-scale [Factors: Self- Study by Yarvis R.M. (1980-1988) found that
Control & Cognitive Complexity]. 32% of the offenders killed a stranger. Shaw et
Results on non-planning impulsivity sub- al. (2006) found that 25% of the subjects in their
scale has been found to be statistically significant national clinical survey of homicide in England
on chi-square (goodness of fit) test (p < 0.01). and Wales killed a stranger.
153
In present study, majority committed the Age and impulsivity had significant negative
homicidal act under a psychotic process (73.3%) correlation. It means that younger subjects have
and significant majority of the subjects had the higher impulsivity and level of impulsivity
primary clinical diagnosis of psychosis (70% decreases with age. Literature does support
had schizophrenia and another 10% had other findings of present study. Steady decline in
psychotic disorders). These observations are impulsiveness with age (Eysenck,1985) and
understandable considering the institutional found age differences in impulsivity reported by,
setting from which the sample is selected. (Steinberg et al., 2008) which follows a linear
Personality assessment using MCMI – III pattern, with impulsivity declining steadily from
revealed that 70% (n=21) of the study subjects age 10 onwards.
have at least one personality disorder. Among Pathological impulsivity was found to
the various DSM-IV personality disorder be significantly higher among persons with
clusters, Cluster - A is found to be most prevalent DSM-IV cluster-B personality disorders,
43.3% (n=13). High prevalence of personality whereas cluster C and cluster A personalities
disorders and especially, Cluster – B disorders were associated with low impulsivity. In a
among homicide perpetrators has been well study by Steel and Blaszczynski (1998) on
documented in literature. Increased prevalence pathological gamblers, positive correlation
of Cluster – A personality in the our study was found between impulsivity and their
sample can probably be explained considering impulsivist-antisocial personality construct
the high number of psychotic patients and, (which included DSM-III-R cluster-B
also the mental hospital inpatient setting from disorders of antisocial, narcissistic, borderline,
where the sample was selected. This explanation histrionic personality and some cluster-C
is supported by a recent literature review by disorders including dependent, avoidant and
Adam et al. (2013) which states that many passive-aggressive personality). They also
patients who later develop schizophrenia or found negative correlation of impulsivity and
delusional disorder have a premorbid cluster – A DSM-III-R obsessive-compulsive personality
personality. Regarding impulsivity, 53.3% of the disorder. In another study Blackburn R. (1969)
subjects had pathological levels of impulsivity, found association between sensation seeking,
especially in the domain of non – planning impulsivity and psychopathic personality traits.
impulsivity (93.3%), suggesting impairment in The relationship between age and various
factors ‘self – control’ (planning and thinking MCMI-III personality scores. Results showed
carefully) and ‘cognitive complexity’ (enjoying significant negative correlations (p < 0.05) of age
challenging mental tasks). with sadistic [aggressive], negativistic [passive-
Several previous studies have reported aggressive] and borderline personality scores,
high level of impulsivity and low planning indicating that these personality characteristics
among psychotic murderers. Rath and Dash were commoner among subjects of younger
(1990) found that insanity related homicide as age group. Significant association was also
compared to non – psychotic homicide were found between DSM – IV cluster C personality
characterized by absence of malice aforethought, disorders and higher age group.
application of excessive violence, presence Although, it is widely believed that
of high impulsivity and lack of meticulous personality remains stable over a person’s life-
planning. Homicides committed by psychopathic time, several previous studies have yielded
offenders were significantly more instrumental some interesting findings. Amad A. et al. (2012),
(i.e. premeditation) in nature, whereas in a review of literature, on personality and
homicides committed by non-psychopaths often personality disorders in the elderly, found that
were “crimes of passion” associated with a high personality is not fixed and can change across the
level of impulsivity, reactivity and emotionality life-time including in the elderly. Longitudinal
(Woodworth & Porter, 2002). Several significant observations generally supported that the
correlations and associations were observed “immature” personality disorders (cluster B)
following statistical analysis of the results. show improvement over time, while the more
154
“mature” (clusters A and C) personality disorders Ogungbemi, K., & Ahmed M H (1993). Psychosocial
are characterized by a more chronic course. Aspects of Murder in Nigeria. Forensic Science
Many patients with late onset schizophrenia or Institute, 59 (2), 157-162
delusional disorder have a premorbid cluster Overall, J E., & Gorham, D R (1988). The Brief Psychiatric
Rating Scale (BPRS): recent developments in
A personality. Specht, Schmukle and Egloff
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features show age related decrease and increase. Amos, T., Kapur, N., & Appleby, L. (2006). Rates of
Mental Disorder in People Convicted of Homicide
In conclusion, we would like to highlight : National Clinical Survey. British Journal of
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2014, Vol. 41, No. 2,156-160 Clinical Psychologists (ISSN 0303-2582)
Case Report
Efficacy of Psychodrama in Individuals with Alcohol Dependence
Narendra Nath Samantaray1, Priti Singh2, Amool R Singh3, K S Sengar4 and Archana Singh5
ABSTRACT
Alcohol is an illness known as illness of family and whole family face the consequences of the
alcoholism. The problem of alcohol addiction / dependence has becomes a major source of stress for
whole family and relatives due to recurrent nature of the problem and its increasing cost in the form
of monetary loss, treatment, unemployment or non working condition of the individual. Studies have
indicated the importance of psychodramatic procedures in management of Alcohol dependent patients.
The present case report is a demonstration to bring an observational and phenomenological analysis
of the applicability of psychodrama in the management of conflict and manifestation of assertive
behavior in alcohol dependent patients. Mr B, 30 years old, male, graduate hails from middle socio
economic family of urban area of Ranchi, Jharkhand was admitted at RINPAS on 5.09.12 for alcohol
dependence syndrome. Assessment and Intervention involved 16 sessions. Post therapy and follow up
report indicated improvement.
Key Words: Psychodrama, Alcohol dependence, Conflict Management, Assertive Training, Case report
INTRODUCTION Research and therapeutic works has

Moreno defined “psychodrama” (1946) as indicated the effectiveness of psychodramatic
the science which explores the truth by dramatic procedures and other form of action oriented
action”. Psychodrama was further refined and therapies incorporating of various social skills and
defined by Kipper, (1997) as “a method that management of conflicts with individuals with
uses dramatizations of personal experiences substance dependence.
through role-playing enactments under a variety Dayton (2000) discussed efficacy of
of simulated conditions as a means for activating psychodrama who were dealing with addiction and
psychological processes”. trauma. Marayam (2012) examined the effectiveness
In psychodrama the process that takes place of dramatic procedures in improving social skills
in a group or in individualized session is a way of like refusal training. Greenwald et al. (1980) found
looking at one's life as it moves. It is a intrinsic effectiveness of action oriented therapy for alcohol
symbolic of looking at what happened and what addicted individuals in the development of adaptive
didn't happen in a given situation. All scenes refusal and social skills. Loughlin (1992) his study
take place in the present, even though a person aimed to investigate the perceived effectiveness of
may want to enact something from the past or dramatic procedures in the treatment of women with
something in the future. It imbibes a person to be alcohol problems mostly by resolving of conflicts.
more constructively spontaneous. The objectives Dushman (1991) found psychodrama to be effective
of insight and cathartic release play their part in in addicts as a means of catharsis which can be too
unblocking the person's, perception and ability to used for social skill training necessary for relapse
deal with change (Costa, 1992). prevention and abstinence.
Psychodrama therapy as promotes an The present case report is an illustration
environment in which addicted clients can openly of the effectiveness of psychodrama on alcohol
express emotions, explore a drug-free future, dependence individual in management of conflict
develop communication skills and make personal and improving assertive skills.
connections. Clients are urged not to rationalize
or deny addiction; rather, through the dramatic BRIEF CLINICAL HISTORY
process, they are challenged to face their issues Mr B, 30 years old, male, graduate, at present
directly and truthfully. unemployed, unmarried, hindu, hails from middle
1 & 2. Ph. D. Scholar, 3. Professor & Head, 4. Additional Professor, Department of Clinical Psychology, 5. Psychiatric Social
Worker, Deptt. of PSW, RINPAS, Kanke, Ranchi, India. Corresponding Author: Narendra Nath Samant Ray
156
Narendra Nath Samantaray... / Efficacy of Psychodrama in Individuals with Alcohol Dependence
socio economic family of urban area of Ranchi, greater effort when he required it the most. After his
Jharkhand was admitted at RINPAS on 5.09.12 for graduation he joined his family business of running
alcohol dependence syndrome. He has been taking private hostel but after six months he was given
alcohol for last 8 years. The first exposure of alcohol responsibility to run a “small” hostel in the sub urban
was with his friends circle. Initially the amount used area of Ranchi, but the land on which they had hostel
to be taken was 200-400ml approx/day, varying was in court litigation which caused further he has
twice or thrice in a month. But after two years, the to bear a loss of three lakh rupee. At this his father
frequency reached to twice in a week. The amount became very critical and always commented that he
during that time too increased at each time varied should never have been given charge. After that he
from approx. 200-400ml /day and during outing was never given a chance to run another separate
and parties with friends its quantity increased. business. After the loss and frequent criticism
Approximately, three years later, the alcohol was he always made to be felt ridiculous in home, he
taken nearly every day due to combined factors of considered himself very guilty and become an easy
family conflicts and friends influence, which are ally to alcohol. His addiction further intensified the
briefly discussed later. During that time, the amount severity of cold war between his father, he rarely
taken varies from 500-600 ml daily and occasionally talks him, he is so scared, dysphoric and hurt that
in every week it increases up to 5-6 quarters he hesitated for making a simple request or help
(approx. 800-900ml /day). The period of abstinence to either of his father or elder brother. Though he
during these periods were limited to a few days, at remained in home but his dysphoric, guilty and
best two three days. He spent all his saved money critic feelings become a fiery unbreakable fence
on alcohol an started borrowing from brother, confining him into untouchable territory. The more
friend and other relatives. Not only due to his he tried to analyze the others attitude the more
cravings but also it was fuelled by poor coping skill, gloomy reflection of others doomed him. In verse of
misguiding of his friends, provocation from them painful seclusion in home he found his friends and
and the family’s conflict. The history is suggestive alcohol a more inseparable more inevitable support.
of further deterioration in relationship with parents
In quest of solace, he glued with his friends
and siblings due to his alcohol addiction.
than before. Though he knew these solace from
FAMILY DYNAMICS, FRIENDS friends and alcohol were temporary in nature, but
CONFLICTS AND ADDICTION: he thought himself more week and become more
He is second to his elder brother and has two passive to immediate gratification of temporary
younger sisters. His family, father and elder brother pleasure. This fueled as more clear inroads to
now, runs a private hostel for male students at his habit of addiction and when it became a part
Ranchi. His married elder brother, other than him, and parcel the rest evil hall mark came from
takes alcohol in his family but occasionally. His physiological dependence. After the wrath of
relationship with his father is strained. He could physiological withdrawal he was left with no
never communicate his needs, desires and wishes to choice but to accept the slavery of alcohol.
his father properly. He believes father is too much The same trajectory of poor self control,
favours his elder brother. He always hesitates to ask criticism of father, poor communication, poor
any major help. And whenever he minimally tried assertiveness coupled with poor ego strength
his father was negative and apprehensive on his continued even after the first discharge from de
demands. The relationship with his father became
addiction centre. The intensity and severity of
understandably more strained following his severe
alcohol dependence for last 3 years. Relationship despondency were at zenith after the playback of
with his brother, before alcohol dependence, was his father’s cold war with him after his return from
marked with mixed feelings. He perceives his Patna. The more he tried to assimilate strength by
brother as a hardworking and responsible member, staying in his family the more he interpreted every
but he thinks he limits his responsibility to his move as silent satire to him. Slowly but steadily he
wife, father and elder sister. He “actually” never again repetitively tried his old solace from friends
really understood him and never extended a much circle and trapped again with alcohol with more ease.
157
ASSESSMENT taken for granted which brought an aura of tension

A base line data for conflict was taken with and pleaded him that to discuss every matter that
the help of Sack’s Sentence Completion test and is concerning him and not to assume any negative
for assertiveness the self prepared Assertiveness thoughts rather to clarify.
Checklist were administered. Qualitatively severe After the session a subjective report is taken,
level of conflict was found regarding the “attitude here he admits that actually he always assumed that
towards father” a sub domain of Family area. And his father would never understand him and hence, he
on assertiveness checklist, score of 5 suggesting, was very reluctant to discuss as here he discussed.
poor assertive level. He wished as he could have done the same thing in
past and then he hoped that at this his father could
THERAPEUTIC PROCESS (Participant Obser- have given a second thought but the same time he
vant and Phenomenological approach) was afraid that his father may not have behaved
Mr B’s after being finalized as a participant as he just enacted now. However, he felt relax and
his management was started with a more inquisitive more assertive after discussing about his brother’s
in depth history about structure, interaction, problem. The director instructed him to write his
aspiration and dynamics about his family and experience and learning in his note book so that he
himself who is presented above in his case record can utilize this when he goes back to his home.
section which constitutes initial three sessions. 7th to 9th session: Simple Enactment and Later
Initial sessions focused on more development Role Reversal:
of therapeutic alliance. In 4th sessions, the actual The protagonist here is said temporarily
psychodramatic procedure began. The warm up was
to become his father by adopting the position,
done first so that the Protagonist, Mr B, can learn
something about the other group members and to characteristics and behavior of the father. The
allow a room to approach the problem gradually. auxiliary performing occupies the part of the
The techniques of verbal warm up was used in two protagonist role as Mr B ( Here the auxiliary is
sessions are “Ball Toss” and “Introduction” methods. played by the director for first fifteen minutes then
In ball toss methods he along with the other was when the audience understood one of them played
allowed to ask questions to other, with whom the ball Mr B in later part). A situation was given to him, as
was in hand, as they wished and in “Introduction” his father has to discuss about Mr B with his elder
method he opted to act as his own mother and brother. In instruction the director, (researcher),
introduced about the son, Mr B, to audience. instructed that no matter any how the father has to
Empty Chair Technique and Catharsis (5th to 6th Sessions) give rational about his behavior towards his son.
It involved an individual session, where he Then enactment unfolded, it involved interaction
was allowed to talk with his assumed father who with the father with Mr B who tries him to explain
was sitting to the next kept empty chair whatever what he felt about him and how much pressure
he wants, the director instructed him to think of their family went through due to his loss. How
anything any topic that he wished to discuss with has his negligence caused harm to her sister’s
his father but could never. Here during enactment, reputation and what pain he is going through?
he initially hesitated but later in second session he Here the protagonist by playing his role of father
discussed with his father regarding his wish and enables him to see the world from the perspective
fear regarding his brother, he discussed that he of the father, his mind was expanded to seek really
always felt cold towards both of them and never
understand what it is like to be other person.
discussed his problem as he felt that would more
hamper his relationships. He elaborated to his Subjective Report after the Session by the Protagonist:
father that he felt he would be angrier, so through The subject here admits that it was not an
catharsis he pent upped the fears regarding his easy to be his father, though he earlier understands
brother and urged him to give his a chance to the difficulty and responsibility his father has but
overcome his mistake. While playing the other role still he thought the fathers should have given more
of father he too explained that it is his actuality time and thought and moreover, few more chance
158
with him. But he in the act tries to empathize with or a visit to a bar or any scene related to it. Then
his father and he explains that if “I won’t be serious he has to enact it in a role play, for the others role
about my life and my earnings then what my father he may select any member from group or audience
can do! But all I wanted that he should have more with whom he felt comfortable. While the group
understood me and this time when I go back I need member or the auxiliaries will try their best to
to discuss a lot with him with ease mind”. “ I also
pursue him to become ally to their demands but he
understand my father’s fear in giving me more
responsibility, he fears that my further loss will has to strongly resist by adopting novice way to
effect my family status but also my sister wedding oppose them using his creativity and spontaneity,
which is round the corner” and the methods have to be practical.
Techniques Used:
Application of Meta Role: (Used in 5th and 7th
Session along with Simple Enactment and Empty Role playing, Coaching, Meta Role, Mirror
Chair Sessions. and Replay Technique.
When the protagonist in empty chair (second He was challenged to use his spontaneity and
session of empty chair) was progressing he was creativity to generate new but practical authentic
becoming deviant, the director has to cut the scene and ways to deny such lure during scene enactment.
“froze”. Initially director discussed as his instruction Initially two trials he was not being interfered and
was to discuss with his father about his wishes and fears the director let his inner skill flourish as much
he otherwise avoids to discuss, rather he was discussing as possible, but after it the director noted the
trivial, he was made to have an insight to think when one changes and mole in his attitude with guidelines
does the role and to evaluate at the same time that what and modifications without much tampering his
he does is actually helpful or all in vain. Also how to originality. The guidelines were given with the
make apologies rather focusing only on rationalization help of psychodramatic techniques noted above.
was too aimed in meta role. However, not a particular technique is mostly
involved the integration of techniques keeping
Application of Double Technique:
the view of best interest of required skills.
As the director (researcher) knew the history and Wherever, he was found that what he is doing in
dynamics of the Protagonist, he became his double in order to avoid or refuse, it could be done in much
empty chair technique and also in simple enactment assertive manner and effective manner, the scene
play in 7th session. As the Protagonist, initially, was not was frozed, and he was made to pause and ponder
coming with his wish and fears while talking with his to think better rational and more effective ways
father, Director as a double to him gave voice over and than earlier, this too checks his flow of emotion.
raised the fear and uncomfortable tongue tiredness he He was repeatedly being realized that the present
has with his brother, upon a minor stimulation he later psychodrama sessions were the opportunities to
elaborated and it gave him the ignition or initiation that learn how inculcate these actions in real life, so
he wanted but was hesitating. Same was happening that at other times in his life when he is in a tight
when he was praising too much initially about his father situations, he can imagine that he is in psychodrama
in simple enactment rather coming to the actual feelings. and mentally step back and rethink the situation the
Also how to make apologies rather focusing only on way he was doing that in drama.
rationalization was too aimed in double.
Aside Technique and Doubling technique
by the director, where he felt the need to be used.
10th Session: Catharsis of Integration: In same manner refining and enriching his skills
Focusing on self explanation of what he learnt from are done by the help of director playing the double
his mistakes and loss in business and unhealthy friend circle when he felt the protagonist is becoming weak.
Working on Assertive Behavior (11th to 16th Session): He was hesitant but the double helped him to
Scenes and Instruction given to the strengthen his ego and effort in refusing others in
protagonist, he was told to think of a real situation a very firm, clear but in a very acceptable manner.
or event in past where he has failed to be assertive Upon the initial hesitant in later attempts the
mostly relating to where he could not refuse his protagonist successfully and confidently faced the
friend for alcohol, for the evening outing with them others lure.
159
Post Test Measure: realm. Psychodrama can provide the context for
It includes interviewing regarding conflict dealing with guilt and practicing making amends. In
scales, after the end of 16th session, the Sack’s addition to providing the opportunity for emotional
Sentence Completion Test (SSCT) and the release, as we have seen this case. Psychodrama
Assertiveness questionnaire was re administered, can be used to facilitate discharge planning and
but while qualitative assessment of SSCT special preparation for life outside of the treatment.
importance is given on those items where conflict Psychodrama role-playing teaches empathy skills
is found earlier like “attitude towards father” a par excellence. During dramatization through empty
sub domain of Family area. The post assessment chair, role reversal and double, Mr B quite literally
highlights the progress towards resolution is in put themselves in the place of the other person and
process in case of attitude towards his family. effort was there to experience the world from their
On Assertiveness Scale both on quantitative point of view. The psychodramatic approach can
measure he scored 10 which indicate of change be readily integrated with many other approaches
attitude towards assertive behavior. Behavioural to psychotherapy. As here we have assimilated
observation during the progress of dramatic certain behavioural techniques in psychodramatic
procedures noticed changes in assertive behavior mould mostly in case of teaching of assertive
skills. Individuals like here can be challenged and
as compared to follow up (after one month)
nourished to hone their spontaneity and creativity
PROGRESS REPORT AFTER ONE MONTH to generate novice items. Hence, Psychodrama can
OF FOLLOW UP give a significant advantage in changing behavior
After one month on follow up when he was both through exploratory, healing role play and role
interviewed how he progressed, he was content training or practicing more functional behaviours.
with his progress. He replied that he has already It offers a living laboratory in which a one can
view and experience their own life, comparing and
discussed in details with his father regarding his
contrasting differing sets of behaviours, separating
future plan, and father too was ready for lending
the past from the present and making conscious
him money by the help of bank, which he has to choices as to what may work best for them as move
pay back. Earlier his father was not ready for any towards recovery.
kind of monetary help but he expressed that this
time he has conveyed and showed a lot promise REFERENCES
Costa, J., & Walsh, S. (1992). A psychodrama group for health
in his words and deeds and for this reason he was workers. Nursing Stand. 6 (34), 30-3.
convinced. Telephonic interview with his father Dayton, T. (2000). Trauma and Addiction: Ending the Cycle of
revealed that he is happy to see improvement/ Pain Through Emotional Literacy, Deerfield Beach, FL:
change in his son. Regarding his friends, he Heart Communications, Inc.
expressed that actually none of his friends has Dushman, Rene. (1991). Psychodrama in an Adolescent
Chemical Dependency Treatment Program, Individual
forced him for alcohol, and few relatives in social Psychology: The Journal of Adlerian Theory, Research,
gathering offered him for alcohol he refused it 47 (4), 515 - 521.
firmly. But says that some time he develops wish Greenberg, L., Elliott, R., & Lietaer, G. (1994). Research on
to drink but he has not allowed it he feels that he Experiential Psychotherapy. In Bergin A
has overcome on the problem. E, Garfield S L (Ed.), Handbook of Psychotherapy and
Behavior Change, 509-539. Wiley & Sons, New York.
TREATMENT IMPLICATIONS OF CASE Loughlin, N. (1992). A trial of the use of psychodrama for women
A significant implication of this study from with alcohol problems. Nursing Practice, 5 (3), 14-19.
a clinical perspective involves the applicability Kipper, D. A. (1997). Classical and contemporary psychodrama:
A multifaceted, action-oriented psychotherapy.
of psychodrama in the conflict management and
International Journal of Action Methods, 50 (3), 99-107.
assertive skill developing of alcohol dependent
Maryam, K. (2012). Effectiveness of Psychodrama in Improving
patients. As in this case, psychodrama can be used Social Skills, Iranian Journal of Psychiatry and Clinical
to address a wide variety of issues including those in Psychology. 17 (4), 279-88.
the past, present, and even future possibility, of those Moreno, J. L (1946). Psychodrama. volume, 1. (pp. 177-216).
that involve the internal conflict or interpersonal New York, NY, US: Beacon House, 428 pp.
160
Case Report
Efficacy of Cognitive Behavior Therapy on Person with Obsessive
Hoarding
Mamta Bahetra1, Ranbir Singh Yakhmi2, and Seema Rani3
Abstract
OCD is a debilitating manifaceted mental health problem with variable symptomatology
which leads to significant impairment in personal, social and occupational impairment
and needs multimodal therapeutic process for the management. The individual may face
different type of symptoms OCD e.g. checking, washing hoarding etc. Hoarding is one of
the rare entity may be because its nature of confinement to the individual. One may give very
logical justification in case of hoarding and also it has no impact on others as sufferer feels.
Management of the OCD specially as hoarding is challenge for mental health professionals.
Nevertheless cognitive behaviour therapy and some especially tailored procedure of
behaviour therapy has shown promising results in the management of such problem
Key Words: Hoarding, OCD, Cognitive Behavior Therapy, Management
Introduction: actions give way to increase the intensity and

Obsessive – Compulsive Disorder is the frequency of obsession.
most distressing disorders among the anxiety Typically persons of OCD fall into one of
disorders as the sufferer has full knowledge the four main categories.
of his symptoms and in spite of having full
Checking
insights is unable to control it. There is
increasing evidence that OCD is a heterogenous Contamination
condition, where a person experiences frequent Hoarding
intrusive and unwelcomed obsessional thoughts, Ruminations
impulses, and images which often are followed
by repetitive compulsions, avoidance and Paradoxical hoarding behavior has from
assurances. In fact it can be so debilitating and an historical perspective, been documented with
disabling that WHO has ranked OCD in the top various psychiatric disorders as OCD, OCDP,
10 of most disabling illnesses of any kind in dementia, schizophrenia and depression. Frost
terms of lost earnings and quality of life. and Gross (1993) defined it as the repetitive
acquisition of large quantities of useless or
OCD sufferers experiences obsessions
poorly usable possession with failure to discard.
which take the form of persistent and
Frost and Hartl (1996) have conceptualized
uncontrollable thoughts, images, worries,
compulsive as multifaceted stemming from
impulses, fears or doubts. They are often
intrusive, undesired, disturbing and significantly information processing deficits, difficulties in
interfere with socio-occupational functioning. forming emotional attachment, behavioural
When the person gets too much distressed with avoidance and faulty beliefs about the nature of
unwanted thoughts he is compelled to indulged saving and possessions.
in many mental thoughts, rituals or actions Hoarding compulsions may be a result
in order to relieve in fact the repetition of the of specific hoarding obsession or may be a
1. Assistant Professor of Clinical Psychology, 2. M.D Psychiatry, Deptt. of Psychiatry, Guru Gobind Singh Med. Coll. & Hosp.,
Faridkot, 3. M.Sc. (nursing) University Coll. of Nursing, BFUHS, Faridkot
Corresponding Author: Mamta Bahetra, E-mail- dr.mamtabahetra@gmail.com
161
Mamta Bahetra et al... / Efficacy of Cognitive Behavior Therapy on Person with Obsessive Hoarding
consequence of a range of preceding symptoms in his profession was maintained.

including contamination, aggressive or Daily functioning: Besides his own daily
symmetry obsessions (Matsunaga, Hayashida, functioning he handed over his daily obligations
Kiriike, Nagata, & Stein, 2010)
to his wife e.g. counting money, depositing in
CASE HISTORY banks etc.
Mr. X a 43 year old married male, Insight: He was fully aware of his problem.
BAMS running his private clinic of approx. He wants his dispensary to be spic and span as
80-100 OPD. His wife was a pharmacist, had he was aware how his behavior and cluttering
one daughter and a son 18 and 11 years old affecting his life.
respectively. He was presented with OCD Support system: Support from his family
symptoms of repeated checking of papers, was very good. His wife visited at all sessions of
documents, getting reassurance from significant psychotherapy. Even his wife asked her father to
others. Hoarding necessary/unnecessary papers, shift his clinic to some other place.
keeping his documents, currency in unorganized
manner. Unable to discard prescription, leafs, TREATMENT PLAN
pamphlets,bus/railway tickets, bills etc. He was put on pharmacological treatment
Decreased social interaction, sleep and appetite. Tab Fluxetine 60mg, fluvoxamine 100mg
He was also dependent on three tablets orthodex. and Clomipramine75mg along with 8 weekly
Precipitating factor was shifting of ayurvedic sessions of Cognitive-Behaviour Therapy 45
clinic by his father in law in the same street. minutes each. CBT was designed with psycho-
Amount of Clutter: educational intervention, Jacobson Progressive
Muscular Relaxation, Behavioural Analysis,
The diagnosis of hoarding was confirmed
graded exposure and response prevention as
by some photographs of his drawers, tables and
well cognitive restructuring.
cupboards. There was a huge pile of papers.
Drawers of tables and his pockets were full of First two sessions were designed to relax
currency notes, tickets. him. Further sessions were meant for exposure
and response prevention (ERP) by emptying
Belief about Possession:
his pockets, categorizing currency, bills, bus
He expressed that he was unable to throw tickets useful papers, useless papers, then in
any of these documents with the belief that just graded way throwing useless papers, bills and
in case the item is ever needed or throwing it tickets. The anxiety graph was noted in the form
may cause any major harm or loss. The other of palpitation, sweating, uneasiness. He was
reason he has given the lack of confidence and instructed for relaxation. Home assignment was
energy. He wants to earn more and more money given for one week. Next week ERP done for
but managing them is a big problem to him. another pocket with same procedure. Anxiety
Information processing deficits:- Because graph was decreased. Rest of the session done
of anxiety of making any mistake and difficulty by categorizing his cupboards, drawers, table
in making any decision. He also found difficulty items in graded way, currency was organized, his
in categorizing his possession because every useful items papers, documents were organized
item was unique for him. in different office files having labels and tags on
Avoidance behavior: With the fear of them.
discarding any item he prefers to put them in RESULTS AND DISCUSSION
box, cupboard and in drawers. After 8 sessions of CBT his hoarding
Social and occupational functions: he obsession decreased significantly and he did
avoids visiting his relatives, friends but interest not show any anxiety symptom except that he
162
Mamta Bahetra et al... / Efficacy of Cognitive Behavior Therapy on Person with Obsessive Hoarding
could not reduce his tab orthodox upto 1 tab/ REFERENCES

day. Therefore combining CBT with medication Abramowitz, J S., Franklinm M E., Schwartz, S A.,
is optimal treatment for compulsive hoarding & Furr. J M. (2003). Symptom presentation
as with the other symptoms of OCD. Saxena & and outcome of cognitive behavior therapy for
Karron (2004); Mataix, et al. (2002) Abramowitz, J obsessive compulsive therapy for obsessive
S., Franklin et al. (2003) have shown benefits of compulsive disorder. Journal of Consulting and
CBT for compulsive hoarding although with Clinical Psychology, 71 (6), 1049-57.
poorer response and higher rates than non Frost, R., & Gross, R.. (1993). The hoarding of
hoarding OCD patients. Exposure and response possessions. Behavioural Research & Therapies,
prevention focuses on preventing further 31, 367-81.
hoarding, discarding, organizing and response Frost, R., & Hartl, T. (1996). A cognitive behavioural
prevention. Cognitive restructuring is done on model of compulsive hoarding. Behavioural
focusing information processing, obsessional Research Therapies,34, 341-50.
anxiety associated with hoarding then with Mataix, Cols D., Marksm I M., Greis, J M., Kobak, K A.,
discarding and avoidance decision. Patient was & Baer, L. (2002). Obsessive compulsive symptom
asked to have a daily log of everyday item they dimension as predictors of compliance with and
acquire or buy to build his awareness of what response to behavior therapy: results from clinical
triggers his behaviours. For desensitization trial. Psychotherapy & Psychosomatic. 71 (5),
repeated exposure with anxiety, anger while 255-62.
discarding item and making decision done. He
Matsunaga, H., Hayashida, K., Kiriikem, N,. Nagatam
was motivated to provoke anxiety, anger by
T., & Stein, D J. (2010). Clinical features and
discarding then keeping only necessary items. treatment characteristics of compulsive hoarding
His erroneous belief of discarding valuable in Japanese patients with obsessive compulsive
thing was restructured that he has to challenge disorder. C N S Spectrum 15 (4) , 285-365.
dire consequences of discarding them. In order
Sanjaya Saxena & Karron M. Maidment. (2004).
to maintain his progress and reduce relapse
Treatment of compulsive Hoarding. Journal of
risk the patient was taught to create a realistic
Clinical Psychology, 60 (11), 1143-54.
schedule that would include time for himself, his
work, his family, recreation etc.
163
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A study on parent-child relationship, ego identity and expression of

Article in Indian Journal of Clinical Psychology · January 2021

Sreetama Chatterjee Tilottama Mukherjee

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Identification of learning disability in primary school children in Kolkata View project

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Pearson Clinical and Talent Assessment

Editorial Board Editorial Advisory Board

Ashima N. Wadhawan (Delhi) Amool R Singh (Ranchi)

L. S. S. Manickam (Mysore) Distinguished Former Editors

N. G. Desai (Delhi) D. K. Menon (1990 – 1991)

Immediate Past Hon. Gen. Secretary Treasurer

West Zone North Zone

Results: f. Entire Issue or Special Section of Journal

INTRODUCTION (India Today, February 28, 2005). About 5-10

begotten children. The procreation of children, Consent for Marriage:

IMPORTANT COURT JUDGEMENTS Vinod Kumari vs Major Surinder Mohan:

Sharada vs Dharampal: non-entity and as a negative- unit in family or

CONCLUSION http://indiankanoon.org/doc/932494/hindu Marriage

Reducing Internalized Stigma of Mental Illness among Patients

Introduction been studied in terms of mental illness. It refers

beliefs and attitudes while the second approach Measures:

TAU Group Post-follow up differences

iNTRODUCTION preschool and kindergartens (Eikeseth,

METHOD cases in this study. They were drawn on the

as the caregivers wee continuously shadowed identification of functions underlying specific

planning, implementation and reporting of gains problem behaviour reduction simultaneously.

with Autism Spectrum Disorders. Research in Consumer demand of services by parents of

Introduction of neuropsychological tools in patients with

key dimensions of neurocognitive functions. of attention, vigilance and working memory in

and DB scores. *Significance at p<.05 (2-tailed)

INTRODUCTION are further divided into specific headache types.

1. Clinical Psychologist, 2. Professor of Clinical Psychology, 3. Associate Professor of psychiatry, Department of

of symptoms. Headache diary kept by the between adolescent headache, psychological

INTRODUCTION personality, social class, parenting and shows

Executive Functions in Patients with Obesity: Impact of

Introduction the cognitive functions executive functions

Introduction Tobacco is consumed primarily through smoking

1. Professor, Department of Clinical Psychology, 2. Research Officer, Department of Psychiatry, 3. Professor,

Inclusion Criterion: Interviews were carried out in individual

1 Relief from Tension 56 84.84% 1 Against society’s norms 21 31.82%

Table 3: Negative Smoking Consequences# DISCUSSION

Introduction errors in their lives which led them to behave

Inclusion Criteria: Number of Freinds 2 8 16

Frequency and Physical abuse 6 12.0 DISCUSSION

A Study of Socio-demographic Variables and Personality Profile of

INTRODUCTION in examining factors that influence behaviour– or

1. Senior Resident, 2. Associate Professor, Department of Psychiatry, 3. Assistant Professor, Department of

characteristics, psychopathology and personality statistical analysis. Pearson’s correlation

OCCUPATION Unemployed 8 (26.7%) Interpersonal 6 (20.0%)

(Score=0-59) (Score=60-74) (Score= 75-84) (Score= N (%) (Score=75-115)

6A Antisocial 12 (40.0%) 14 (46.7%) 2 (6.7%) 2 (6.7%) 30 (100%) 4 (13.33%)

7 Compulsive 11 (36.7%) 15 (50.0%) 2 (6.7%) 2 (6.7%) 30 (100%) 4 (13.33%)

C Borderline 7 (23.3%) 17 (56.7%) 4 (13.3%) 2 (6.7%) 30 (100%) 6 (20.00%)

Table 3: Prevalence of Personality Disorders (MCMI- Table 5: BIS – 11 Sub-scales Scores

INTRODUCTION Research and therapeutic works has