III SEM MSc Counselling Psychology

Core Theory: 60 hours

PAPER IV: PY9421

PSYCHOPATHOLOGY
II
Defining Mental Health

● MH as above normal
● MH as developmental maturity
● MH as positive or spiritual emotions
● MH as socio-emotional intelligence
● MH as subjective well-being
● MH as Resilience
What is abnormal ?
● Nail biting
● Math anxiety
● Talking to self
● Homosexuality
 4 D’s of
Abnormal Behaviour
Defining Psychopathology
“Psychopathology is the precise description, categorization and
definition of abnormal experiences as recounted by the patient
and observed in his behaviour. It relies on the method of
phenomenology by focusing on experienced phenomena in order
to establish their universal character”

[Sim’s Symptoms in the Mind- Oyebode, 2015]

Classification Systems of Psychological Disorders
DSM - Diagnostic and Statistical Manual of Mental Disorders
Currently in its 5th version [Text Revision]

ICD - International Classification of Diseases

Currently in its 11th version
PSYCHOPATHOLOGY II | SYLLABUS
Unit I Schizophrenia Spectrum and other Psychotic
Disorders 14 hours
Causes, types and clinical features of
- Schizotypal disorder
- Delusional disorder
- Brief psychotic disorder
- Schizophreniform disorder
- Schizophrenia
- Schizoaffective Disorder
Unit II Trauma and Stress related Disorders 10 hours

Causes, types and clinical features of

- Reactive attachment disorder
- Disinhibited social engagement disorder
- PTSD
- Acute Stress disorder
- Adjustment disorder
Unit III Substance related and Addictive Disorders 12 hours

Causes, types and clinical features of

- Substance related and addictive disorders
- Alcohol, caffeine, hallucinogens, inhalants, opioids, sedatives,
hypnotics, anxiolytics, stimulants, tobacco and other
substances
Unit IV Dissociative Disorders and Somatic Symptom and related
Disorders 12 hours

Causes, types and clinical features of

- Dissociative Identity disorder
- Dissociative Amnesia
- Depersonalization/ Derealization disorder
- Somatic Symptom Disorder
- Illness anxiety disorder
- Conversion disorder
- Factitious disorder
Unit V Personality disorders and Mental Health Issues in
Geriatric Populations 12 hours

Causes, types and clinical features of

- Personality disorders
Mental health issues in Geriatric population:
- Neurodegenerative disorders

- Late onset depression

- Late onset psychosis

Resources
● DSM-5
● ICD 10
● Kaplan and Saddock Synopsis of Psychiatry
● Ahuja Handbook of Psychiatry
● Barlow and Durand (2012, 2015) Abnormal Psychology: An
integrative approach
● Kring et al (2012) Abnormal Psychology
● Carson & Butcher (2007) Abnormal Psychology and Modern Life
Unit I
Schizophrenia
spectrum and other
Psychotic disorders
- Schizophrenia
- Schizophreniform disorder
- Schizoaffective Disorder
- Brief psychotic disorder
- Delusional disorder
- Schizotypal disorder
SCHIZOPHRENIA
● Signs and symptoms are variable and include changes in perception, emotion,
cognition, thinking, and behaviour
● The disorder usually begins before age 25 years, persists throughout life, and
affects persons of all social classes.
● Lifetime prevalence :1 percent
● Onset: Earlier in men [10-25] than in women [25-35]. Women display a bimodal
age distribution, with a second peak occurring in middle age [ 40+].
● Prognosis: Female schizophrenia patients’ treatment outcome is better than
that for male schizophrenia patients
SCHIZOPHRENIA
● Causal factors:
○ Season specific risk factors, such as a virus or a seasonal change in diet
○ Gestational and birth complications - exposure to influenza epidemics,
maternal starvation during pregnancy, Rhesus factor incompatibility
○ Genetic factors- incidence of schizophrenia in children of either one or
two parents with schizophrenia is twice
○ Paternal age [60+] and andropause*
○ Psychosocial factors- double bind communication, schisms or skewed
communication in families
 Historical
Perspectives
Emil Kraepelin Eugene Bleuler
Benedict Morel • Dementia Precox • Schizophrenia
• démence précoce • Early onset • Four As-
• Deteriorative disorder of • Associations
illness of cognition • Affect
adolescence • Hallucinations, • Autism
delusions
• Ambivalence
 Historical
Emil Kraepelin Perspectives
Eugene Bleuler
Benedict Morel • Dementia Precox • Schizophrenia
• démence précoce • Early onset • Four As-
• Deteriorative disorder of • Associations
illness of cognition • Affect
adolescence • Hallucinations, • Autism
delusions
• Ambivalence
Historical Perspectives

Emil Kraepelin Eugene Bleuler

Benedict Morel • Dementia Precox • Schizophrenia
• démence précoce • Early onset • Four As-
• Deteriorative disorder of • Associations
illness of cognition • Affect
adolescence • Hallucinations, • Autism
delusions
• Ambivalence
SCHIZOPHRENIA

Eugene Bleuler. Four A’s of dementia precox

Kurt Schneider. First rank symptoms of Schizophrenia

SCHIZOPHRENIA Clinical Picture
Thought and Speech Disorders
- Autistic Thinking – private and illogical connections
- Loosening of associations – disjoint or incoherent speech
- Thought blocking/ withdrawal
- Thought insertion
- Thought broadcasting
- Neologisms
- Mutism – no speech production
- Poverty of speech – decreased speech production / Over inclusion
- Echolalia – repeating or echoing words or phrases of examiner
- Perseveration – persistent repetition of words beyond relevance
- Verbigeration – senseless repetition of words or phrases
SCHIZOPHRENIA Clinical Picture
Thought and Speech Disorders

● Delusions - false unshakable beliefs which are not corresponding with

patient’s socio-cultural and educational background.

Delusions of persecution (being persecuted against, e.g. ‘people are against me’)
Delusions of reference (being referred to by others; e.g. ‘people are talking about me’)
Delusions of grandeur (exaggerated self-importance; e.g. ‘I am God almighty’)
Delusions of control (being controlled by an external force, known or unknown;
e.g. “My neighbour is controlling me”).
Somatic (or hypochondriacal) delusions (e.g.‘there are insects crawling in my scalp’).
SCHIZOPHRENIA Clinical Picture
Disorders of Perception

- Hallucinations – perceptions without a stimuli

- Elementary auditory hallucinations (i.e. hearing simple sounds
rather than voices)
- ‘ Thought echo’ (‘ audible thoughts’)
- ‘Third person hallucinations’ (‘voices heard arguing’, discussing
the patient in third person)
- ‘Voices commenting on one’s action’.
Visual hallucinations can also occur, usually along with auditory
hallucinations. The tactile, gustatory and olfactory types are less common.
SCHIZOPHRENIA Clinical Picture
Disorders of Affect
● apathy, emotional blunting, emotional shallowness, anhedonia
(inability to experience pleasure) and inappropriate emotional
response (emotional response inappropriate to thought)

Disorders of Motor Behaviour

● decrease (decreased spontaneity,inertia, stupor) or an increase in
psychomotor activity (excitement, aggressiveness, restlessness,
agitation)
● Mannerisms, grimacing, stereotypies (repetitive strange behaviour),
decreased self-care, and poor grooming are common features.
SCHIZOPHRENIA Clinical Picture
Negative Symptoms
● affective flattening or blunting, attentional impairment, avolition-apathy
(lack of initiative associated with psychomotor slowing), anhedonia,
asociality (social withdrawal), and alogia (lack of speech output)
SCHIZOPHRENIA Clinical Picture
Other symptoms
● Decreased functioning and self-care, as compared to the earlier levels achieved by the
individual.
● Loss of ego boundaries (feeling of blurring of boundaries of self with the environment;
uncertainty and perplexity regarding own identity and meaning of existence).
● Multiple somatic symptoms, especially in the early stages of illness.
● Insight (into the illness) is absent and social judgement is usually poor.
● There is usually no clinically significant disturbance of consciousness, orientation,
attention,memory and intelligence.
● There is usually variability in symptomatology over time which in some cases can be
marked.
● There is no obvious underlying organic cause that can explain the causation of the
symptoms.
● There is no prominent mood disorder of depressive or manic type.
DSM Criteria_Schizophrenia
Types of Schizophrenia (based on DSM IV-TR)
● Paranoid Schizophrenia
● Disorganised (or Hebephrenic) Schizophrenia
● Catatonic Schizophrenia
● Residual and Latent Schizophrenia
● Undifferentiated Schizophrenia
● Simple Schizophrenia
● Post-Schizophrenic Depression
Types of Schizophrenia (based on DSM IV-TR)
● Paranoid Schizophrenia
○ Well systemised (thematically connected delusions of persecution,
reference, grandeur (or ‘grandiosity’), control, or infidelity (or ‘jealousy’);
○ Hallucinations usually have a persecutory or grandiose content;
○ No prominent disturbances of affect, volition, speech, and/or motor
behaviour.
○ Less personality deterioration, functional capability may be only slightly
impaired
○ Course is usually progressive and complete recovery usually does not
occur. There may be frequent remissions and relapses.
Types of Schizophrenia (based on DSM IV-TR)
● Disorganised (or Hebephrenic) Schizophrenia
○ Marked thought disorder, incoherence and severe loosening of
associations. Delusions and hallucinations are fragmentary and
changeable
○ Emotional disturbances (inappropriate affect, blunted affect, or senseless
giggling), mannerisms, ‘ mirror-gazing’ (for long periods of time),
disinhibited behaviour, poor self-care and hygiene, markedly impaired
social and occupational functioning, extreme social withdrawal and other
oddities of behaviour
○ course is progressive and downhill. The recovery from the episode is
classically poor- one of the worst prognoses among schizophrenia
subtypes
Types of Schizophrenia (based on DSM IV-TR)
● Catatonic Schizophrenia
○ marked disturbance of motor behaviour, in addition to the general
guidelines of schizophrenia
○ can present in three clinical forms: excited catatonia, stuporous
catatonia, and catatonia alternating between excitement and
stupor.
○ course is often episodic and recovery from the episode is usually
complete.
Types of Schizophrenia (based on DSM IV-TR)
● Residual and Latent Schizophrenia
○prominent negative symptoms, with absence or marked reduction
of florid psychotic symptoms such as delusions and hallucination
○ marked social withdrawal, shallow emotional response, with loss
of initiative and drive
● Uundifferentiated Schizophrenia
○ When features of no subtype are fully present, or 2. When
features of more than one subtype are exhibited, and the general
criteria for diagnosis of schizophrenia are met
Types of Schizophrenia (based on DSM IV-TR)
● Simple Schizophrenia
○ most difficult to diagnose and poor prognosis with very insidious
and progressive course,
○ presence of characteristic ‘negative symptoms’ of residual
schizophrenia (such as marked social withdrawal, shallow
emotional response, with loss of initiative and drive), vague
hypochondriacal features, a drift down the social ladder, and living
shabbily and wandering aimlessly.
○ Delusions and hallucinations are usually absent, and if present
they are short lasting and poorly systematised
Types of Schizophrenia (based on DSM IV-TR)
● Post Schizophrenic depression
○ depressive features within 12 months of an acute episode of
schizophrenia.
○ to be distinguished from negative symptoms of schizophrenia and
extrapyramidal side-effects of antipsychotic medication
Interesting sub-types
● Pseudo-neurotic Schizophrenia
● Oneiroid Schizophrenia
● Van Gogh Syndrome
● Late Paraphrenia
● Pfropf Schizophrenia
● Type I and Type II Schizophrenia
Schizophreniform Disorder
● Sudden onset and benign course associated with mood symptoms and
clouding of consciousness
● Acute psychotic disorder
● Experience functional impairment at the time of an episode, they are
unlikely to report a progressive decline in social and occupational
functioning
● Two or more psychotic symptoms (hallucinations, delusions,
disorganized speech and behavior, or negative symptoms) must be
present.
● Symptoms last for at least 1 month but less than 6 months
● Often have a family history of mood disorders
Schizophreniform Disorder
Lifetime Prevalence:
● 0.11 percent
● most common in adolescents and young adults and is less
than half as common as schizophrenia
Gender Differences:
● More common in women than in men
Prognosis:
Return to their baseline level of functioning after the disorder
has resolved.
DSM Criteria_Schizophreniform Disorder
Case_Schizophreniform Disorder
Mr. C, a 28-year-old accountant, was brought to the emergency department by the
police in handcuffs. He was disheveled, and shouted and struggled with the
police oɽcers. It was apparent that he was hearing voices because he would
respond to them with shouts such as, “Shut up! I told you I won’t do it!”
However, when confronted about the voices, he denied hearing anything. Mr. C
had a hypervigilant stare and jumped at the slightest noise. He stated that he must
run away quickly because he knew he would be killed shortly otherwise.His
beliefs were confirmed by a voice that would mock him. The voice told him time
and again that he should quit his job, relocate to another city, and forget about his
ex-girlfriend, but Mr. C refused, believing it would give them “more satisfaction
than they deserved.” He continued working, albeit cautiously, all the while
fearing for his life
[Caplan & Saddock]
Schizoaffective Disorder
● Features of both schizophrenia and mood disorders
(1) patients with schizophrenia who have mood symptoms,
(2) patients with mood disorder who have symptoms of schizophrenia,
(3) patients with both mood disorder and schizophrenia,
(4) patients with a third psychosis unrelated to schizophrenia and mood
disorder,
(5) patients whose disorder is on a continuum between schizophrenia and
mood disorder, and
(6) patients with some combination of the above
Schizoaffective Disorder
Lifetime Prevalence:
● 0.5 to 0.8 percent
Gender Differences:
● depressive type of schizoaffective disorder may be more common in
women
● age of onset for women is later than that for men, as in schizophrenia
● Men are likely to exhibit antisocial behavior and to have a markedly flat or
inappropriate affect
Prognosis:
● Better prognosis than patients with schizophrenia and a worse prognosis
than patients with mood disorders
DSM Criteria_
Schizoaffective Disorder
Case_Schizoaffective Disorder
Mrs. P is a 47-year-old, divorced, unemployed woman who lived alone and who experienced
chronic psychotic symptoms despite treatment with olanzapine 20 mg per day and citalopram
(Celexa) 20 mg per day. She believed that she was getting messages from God and the police
department to go on a mission to fight against drugs. She also believed that an organized crime
group was trying to stop her in this pursuit. The onset of her illness began at age 20 years when
she experienced the first of several depressive episodes. She also described periods when she felt
more energetic and talkative; had a decreased need for sleep; and was more active, sometimes
cleaning her house throughout the night. About 4 years after the onset of her symptoms, she
began to hear “voices” that became stronger when she was depressed but were still present and
disturbed her even when her mood was euthymic. About 10 years after her illness began, she
developed the belief that policemen were everywhere and that the neighbors were spying on her.
She was hospitalized voluntarily. Two years later, she had another depressive episode, and the
auditory hallucinations told her she could not live in her apartment. She was tried on lithium,
antidepressants, and antipsychotic medications but continued to be chronically symptomatic with
mood symptoms as well as psychosis.
[Caplan & Saddock]
Brief Psychotic Disorder
● Psychotic condition that involves the sudden onset of psychotic
symptoms, which lasts 1 day or more but less than 1 month
(1) the presence of a stressor,
(2) the absence of a stressor, and
(3) a postpartum onset
● Include at least one major symptom of psychosis, such as hallucinations,
delusions, and disorganized thoughts, usually with an abrupt onset, but
do not always include the entire symptom pattern seen in schizophrenia
● Acute and transient psychotic syndrome
Brief Psychotic Disorder
Lifetime Prevalence:
● generally considered uncommon
Gender Differences:
● more common in women than in men
Prognosis:
● Remission is full, and the individual returns to the premorbid level of
functioning

May be seen most frequently in patients from low socioeconomic classes and in
those who have experienced disasters or major cultural changes (e.g., immigrants)
DSM Criteria_
Brief Psychotic Disorder
Case_Brief Psychotic Disorder
A 20-year-old man was admitted to the psychiatric ward of a hospital shortly after
starting military duty. During the first week after his arrival to the military base, he
thought the other recruits looked at him in a strange way. He watched the people around
him to see whether they were out “to get” him. He heard voices calling his name several
times. He became increasingly suspicious and after another week had to be admitted for
psychiatric evaluation. There he was guarded, scowling, skeptical, and depressed. He gave
the impression of being very shy and inhibited. His psychotic symptoms disappeared
rapidly when he was treated with an antipsychotic drug. However, he had diɽculties in
adjusting to hospital light. Transfer to a long-term medical hospital was considered, but
after 3 months, a decision was made to discharge him to his home.The patient was the
eldest of five siblings. His father was an intemperate drinker who became angry and
brutal when drunk. The family was poor, and there were constant fights between the
parents. As a child, the patient was inhibited and fearful and often ran into the woods
when troubled. He had academic difficulties.
[Caplan & Saddock]
Delusional Disorder
● Person exhibits non bizarre delusions (often) of at least 1 month’s duration
that cannot be attributed to other psychiatric disorders
● Mental status examination shows them to be quite normal except for a
markedly abnormal delusional system
● Types: Erotomanic, Grandiose, Jealous, Prosecutory, Somatic, Mixed,
Unspecified
Delusional Disorder
Lifetime Prevalence:
● 0.2 to 0.3 percent
Gender Differences:
● More common in women than in men
● Men are more likely to develop paranoid delusions
● Women are more likely to develop delusions of erotomania
Prognosis:
● Stable
DSM Criteria_
Delusional Disorder
Case_Delusional Disorder
A 51-year-old man was arrested for disturbing the peace. Police had been called to a local park to
stop him from carving his initials and those of a recently formed religious cult into various trees
surrounding a pond in the park. When confronted, he had scornfully argued that having been
chosen to begin a new town-wide religious revival, it was necessary for him to publicize his intent in
a permanent fashion. The police were unsuccessful in preventing the man from cutting another
tree and arrested him. Psychiatric examination was ordered at the state hospital, and the patient
was observed there for several weeks. He denied any emotional diɽculty and had never received
psychiatric treatment. He had no history of euphoria or mood swings. The patient was angry about
being hospitalized and only gradually permitted the doctor to interview him. In a few days,
however, he was busy preaching to his fellow patients and letting them know that he had been
given a special mandate from God to bring in new converts through his ability to heal. Eventually,
his preoccupation with special powers diminished, and no other evidence of psychopathology was
observed. The patient was discharged, having received no medication at all. Two months later he
was arrested at a local theater, this time for disrupting the showing of a ɹlm that depicted subjects
he believed to be satanic.
[Caplan & Saddock]
Schizotypal Disorder
● Categorised under Personality disorders
● Strikingly odd or strange behaviours, magical thinking, peculiar notions,
ideas of reference, illusions, and derealization
● Exhibit disturbed thinking and communicating
● These patients may be superstitious or claim powers of clairvoyance and
may believe that they have other special powers of thought and insight.
Their inner world may be ɹlled with vivid imaginary relationships and
child-like fears and fantasies.
Schizotypal Disorder
Lifetime Prevalence:
● 3 percent
Gender Differences:
● Slightly more common in males
● Frequently diagnosed in females with fragile X syndrome
Prognosis:
● schizotype considered as the premorbid personality of the patient with
schizophrenia
● 10 percent of those with schizotypal personality disorder eventually
committed suicide
DSM Criteria_
Schizotypal Disorder
Case_Schizotypal Disorder
Tyler is a 15 year old male who is currently living at home with his mother
and younger sister. His mother describes Tyler as “always being an odd child”
who had significant difficulty relating to his peers. As a child he would spend
a great deal of time alone involved in role playing. She said that social
situations always provoke great anxiety in Tyler and he is extremely socially
inept. Tyler spends several hours a day on the Internet playing online games
and interacting with others in chat rooms. Tyler reports having one close
real-life friend but it is not clear when he sees this person.Since childhood
Tyler has been interested in paranormal experiences. His mother reports
that his interest goes beyond mere curiosity that would be “normal for
someone of his age. Tyler says that since the age of eight he has been
hearing a voice that says his name at night. This happens a couple of times a
year and Tyler said that he finds these experiences frightening. Occasionally
Treatment for Schizophrenia and other Psychotic Spectrum Disorders

1. Somatic treatment
a. Pharmacological treatment
b. Electroconvulsive therapy (ECT)
c. Miscellaneous treatments - microsurgeries, megavitamin therapy etc

1. Psychosocial treatment and rehabilitation

a. Psychoeducation
b. Group psychotherapy
c. Supportive individual psychotherapy
d. Family therapy
e. Therapeutic communities (Milieu therapy)
f. Psychosocial rehabilitation
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