Psychological Disorders and Psychotherapy

Chapter 5

Psychological Disorders and Psychotherapy

I. Meaning of “Abnormal behaviour” - biological, psychological and socio - cultural

perspectives. Principles of classification of psychological disorders with reference
to DSM IV.
Common features of abnormal behaviour deviance, distress, dysfunction, danger.

Different views of "abnormal" behaviour - the statistical stand - the

biological/medical approach - the psychodynamic perspective - the sociocultural
dimension; why classification of disorders is necessary – an understanding of the
Diagnostic and Statistical Manual of Mental Disorders – IV (brief explanation of each
Axis).

(II) Characteristics of some psychological, behavioural, and developmental disorders:

Anxiety - generalised, phobic, obsessive-compulsive; Mood - bi-polar, depression.
Personality - anti-social, avoidant and dependent (causes and symptoms of all).

What is meant by anxiety - different forms of anxiety disorders: generalised (GAD),

phobias, obsession -compulsive disorders; Mood disorders- characteristics of severe
depression, manic-depressive or bipolar disorder; personality disorders - anti-social,
avoidant and dependent (causes and symptoms).

Neurodevelopmental and anxiety disorders in childhood: Neurodevelopmental

disorders - Attention Deficit Hyperactive Disorder (ADHD), Autism Spectrum
Disorder- Autism (definition and symptoms only). Anxiety- Separation Anxiety
Disorder in childhood (definitions and symptoms only).

(III) Schizophrenia – meaning and characteristics.

Basic nature of Schizophrenia: symptoms-positive and negative. Main types of
characteristics of Disorganized, Catatonic and Paranoid Schizophrenia (symptoms).

(IV) Psychotherapy - Psychoanalysis; Client-centred; Behavioural, Psychosocial

Rehabilitation.

What is meant by Psychotherapy - central features of psychodynamic therapies – free

association, dream analysis, resistance, transference and counter transference
(explain briefly). The principles on which client centred therapy has been developed.
Behavioural therapies based on classical conditioning (flooding and systematic
desensitisation) and operant conditioning (shaping and token economy) and
modelling (explain briefly). Psychosocial Rehabilitation. Cognitive Behaviour
Therapy, A.Ellis’ Rational Emotive Therapy (explain briefly)
 Psychological Disorders and Psychotherapy

Abnormal behaviour covers a wide range from behaviours that cause unhappiness for the
person involved to those that harm others. It is often a difficult judgement call to decide when
the line between abnormality and normality has been crossed. An understanding of the roles
of stress, personal vulnerabilities, and resilience is important in interpreting abnormal
behaviour.

Abnormal psychology is the area within psychology that is focused on maladaptive behaviour-
its causes, consequences, and treatment. The spectrum of differentness is wide, ranging from
reality defying delusions, and severe worries to behavioural oddities. This spectrum
encompasses problems related to the capacities to

• Think rationally and logically

• Cope effectively with stress and the challenges that arise in situations and throughout
the life course and
• Demonstrate emotional stability and growth

The term abnormal psychology refers to the scientific study of people who are atypical or
unusual, with the intent to be able to reliably predict, explain, diagnose, identify the causes of,
and treat maladaptive behaviour. A more sensitive and less stigmatizing term that is used to
refer to the scientific study of psychological disorders is psychopathology.

While the concept of mental or psychological disorders is difficult to define, and no definition
will ever be perfect, it is recognized as an extremely important concept and therefore
psychological disorders (aka mental disorders) have been defined as a psychological
dysfunction which causes distress or impaired functioning and deviates from typical or expected
behaviour according to societal or cultural standards.

FOUR D’S OF ABNORMALITY

Common features of abnormal behaviour

1. Dysfunction (interfering with the person’s ability to carry out daily activities in a
constructive) - It’s an inability to perform daily functioning or everyday activities. It
includes clinically significant disturbance in an individual’s cognition, behaviour and
thought. For instance, an individual experiencing delusion that he is an omnipotent
deity would have a breakdown in cognition because his thought processes are not
consistent with reality.

2. Distress (unpleasant and upsetting to the person and to others) refers to suffering.
Distress is when the individual showing any behaviour is extremely upset. It can take
the form of psychological or physical pain, or both concurrently. Abnormal behaviour
cannot be described by distress alone. For eg: The loss of a loved one would cause
even the most “normally” functioning individual pain and suffering. An athlete who
experiences a career-ending injury would display distress as well.
 Psychological Disorders and Psychotherapy

3. Deviance- (different, extreme, unusual, even bizarre). The word deviance indicates a
move away from what is normal, typical, or average. Deviance from culture norms mean
away from the normally accepted behaviours by a particular society. The behaviours
which violate social norms or expectations might be considered as abnormal.
However, Social norms varies a lot across cultures and ethnic groups. For instance, just
a few decades ago homosexuality was considered taboo in the U.S., and it was included
as a mental disorder in the first edition of the DSM; but today, it is generally accepted.

4. Danger (to the person or to others) - refers to when behaviour represents a threat to
the safety of the person or others. If an aggressive person tries to cut or harm himself
with a knife or attack someone else with it is also considered to be abnormal. However,
it is important to note that having a mental disorder does not automatically deem one
to be dangerous and most dangerous individuals are not mentally ill.

DIFFERENT VIEWS OF "ABNORMAL" BEHAVIOUR

The models of abnormality are frameworks that provide comprehensive accounts of how and
why mental disorders develop and how they can be treated. The viewing of mental disorder
involves several perspectives that should be viewed as complementary to one another.
Together these approaches provide a more accurate and complete picture of how such
disorders arise and how they can be treated than any single perspective does alone.

1. Statistical and Social Norm Deviance: one way to define normal and abnormal is to
use statistical definition. Frequently occurring behaviour would be considered normal,
and behaviour that is rare would be up normal.

For example, refusing to wear clothing in a society that does not permit nudity would
likely be rare and be seen as abnormal.

How much the behaviour is thinking deviates from the norms of the society also
matters.

2. The biological model, views abnormality as a symptom of an underlying disease that

requires a cure. It emphasizes the role of the nervous system in mental disorders.
This approach seeks to understand such disorders in terms of malfunctioning of
portions of the brain, imbalances in various neurotransmitters and genetic factors.

The biological approach attributes mental illness or abnormality to physical causes,

biochemical causes, and genetic causes. It is seen that many mental disorders show
a high degree of concordance among close relatives. If one family member develops
a disorder, then others are at increased risk for developing it too. The biological model
has become increasingly influential in recent years as advances in neuroscience have
revealed more and more about the role of various portions of the brain in many aspects
 Psychological Disorders and Psychotherapy

of behaviour, and as techniques for observing the functioning of the brain (e.g.
magnetic resonance imaging, PET scans) have improved

Hence, it attempts to treat these abnormalities using medically grounded procedures

- pharmacology or drug therapy, electrical voltage therapy, or psycho surgery (brain
surgery).

3. Psychological factors too can be important. The psychological perspective

emphasizes the role of basic psychological processes and interpersonal
relationships in the occurrence of mental disorders. For instance, many
psychologists believe that learning plays a key role in many disorders. An example:
phobias, or excessive fears of objects or situations.
a) Psychodynamic Approach (imp): see abnormality as caused by conflicts in the
unconscious produced by experience. The perspective holds that abnormal
behaviour stems from childhood conflicts over opposing wishes regarding sex
and aggression. Freud believed the children pass through a series of stages in
which sexual and aggressive impulses take different forms and produce conflict
that requires resolution- and if these childhood conflicts are not dealt with
successfully, they remain unresolved in the conscious and eventually bring
about abnormal behaviour. Freud believed that the interplay of id, ego and
superego is of crucial significance in determining behaviour. Often inner mental
conflicts arise because the three sub-systems are striving for different goals. If
unresolved, these intrapsychic conflicts lead to mental disorder.

According to this view a woman who has unacceptable thoughts of sleeping

with her brother-in-law might feel dirty and be compared to wash her hands
every time those thoughts threaten to become conscious ridding herself
symbolically of the dirty thoughts.

b) Behaviourism (cover briefly): The perspective that looks at the behaviour

itself as the problem. Behaviourists explain disordered behaviour as being
learned just like normal behaviour. To explain why abnormal behaviour occurs,
one must analyze how abnormal behaviour has been learned and observe the
circumstances in which it is displayed.

According to behaviourists learning can occur through association,

reinforcement, and punishments or by observing others. For example, when
Emma was a small child, a spider dropped onto her leg causing her to scream
and react with fear. Her mother made a big fuss over her giving her lots of
attention. Each time Emma sees a spider after this she screamed again, drawing
attention to herself. Behaviour would say that Emma’s fear of a spider was
classically conditioned, and screaming reaction was positively reinforced by all
the attention.
 Psychological Disorders and Psychotherapy

c) Cognitive Perspective (cover briefly): rather than considering external

behaviour, cognitive psychologists assumes that cognitions that include
thoughts and beliefs are central to a person’s abnormal behaviour.

A cognitive psychologist might explain the fear of spiders as distorted thinking

that all spiders are vicious and will bite me and I will die. This thinking pattern
puts the individual at a higher risk of depression and anxiety than those of a
person who thinks more logically. Hence, a primary goal of treatment in
cognitive approach is to teach new, more adaptive ways of thinking.

4. Socio cultural perspective states that people's behaviour - both normal and abnormal-
is shaped by the kind of family, group, society, and culture in which they live.
Psychologists and other mental health professionals point to the important role of such
social variables as poverty, unemployment, inferior education, and prejudice as
potential causes of at least some mental disorders. In other words, the socio-cultural
perspective emphasizes the fact that external factors such as negative environments, a
disadvantaged position in society, and cultural traditions can play a role in mental
disorders.

CLASSIFICATION OF MENTAL DISORDERS

A classification of such disorders consists of a list of categories of specific psychological

disorders grouped into various classes based on some shared characteristics.

Importance of Classification

1. Having a common set of terms in systematic way of describing psychological disorders

in behavioural symptoms is vital to not only correct identification and diagnosis but
also in communication among mental health care providers.
2. Diagnosis and classification reduces the complexity of clinical phenomena leading to
better treatment planning.
3. It facilitates communication between clinicians by providing a structured set of
symptoms causes and treatments.
4. The likely course and outcome of clinical conditions can be confidently predicted.
The DSM helps provide clues about the condition’s causes.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

A manual design to help all mental health practitioners to recognize and correctly diagnose
specific disorders and is widely used in America and India. The APA published the first
diagnostic and statistical manual of mental disorders in 1952 since that time it is revised
regularly.

The DSM uses a multiaxial approach - a system or method of evaluation grounded in

biopsychosocial model to arrive at a comprehensive and more accurate diagnosis.
 Psychological Disorders and Psychotherapy

The Five Axes of DSM IV: As has been the case since the advent of DSM-III in 1980, DSMIV
evaluates an individual according to
five foci, or ‘axes.’ The first three axes
assess an individual’s present clinical
status or condition.

• Axis I: The clinical syndromes or

other conditions that may be a focus
of clinical attention. This would
include schizophrenia, generalized
anxiety disorder, major depression and
substance dependence. Axis I
conditions are roughly analogous to
the various illness and disease
recognized in general medicine.

• Axis II: Personality disorders and

Mental retardation

A very broad group of disorders, that encompasses a variety of problematic ways of relating
to the world, such as histrionic personality disorder, paranoid personality disorder, or antisocial
personality disorder. The last of these, for example, refers to an early – developing, persistent
and pervasive pattern of disregard for accepted standards of conduct, including legal ones.
Mental retardation is also diagnosed as an Axis II condition.

• Axis III: General medical conditions.

Listed here are any general medical conditions potentially relevant to understanding or
management of the case. Axis III of DSI-IV may be used in conjunction with an Axis I diagnosis
qualified by the phrase, “Due’ to [a specifically designated]” general medical condition – for
example, where a major depressive disorder is conceived as resulting from unremitting pain
associated with some chronic medical disease.

On any of these first three axes where the pertinent criteria are met more than one diagnosis
is permissible. The last two DSM-IV axes are used to assess broader aspects of an individual’s
situation.

• Axis IV: Psychological and environmental problems.

This group deals with the stressors that may have contributed to the current disorder,
particularly those that have been present during the prior year. The diagnostician is invited to
use a checklist approach for various categories of impinging life problems – family, economic,
occupational, legal, etc. For example, the phrase “Problems with Primary Support Group”, may
be included where a family disruption is judged to have contributed to the disorder.

• Axis V: Global assessment of functioning.

This is where clinicians note how well the individual is coping at the present time. A 100-point
rating scale, the Global Assessment of Functioning (GAF) Scale, is provided for the examiner
 Psychological Disorders and Psychotherapy

to assign a number summarizing a patient’s overall functional ability. Higher the score the
better the functioning.

Evaluation of DSM- Refer to Baron Pg-473, (cover briefly)

• Higher reliability than earlier versions

• Makes no attempt to explain psychological disorders
• Since it attaches specific label to people, it may actives stereotypes
• Gender biased
• Critics argue mental disorders occur on a continuum, not in discrete categories.

ANXIETY DISORDER

Anxiety refers to increased arousal accompanied by generalized feeling of fear or

apprehension. Anxiety can take different forms – specific form like fear of dog or phobias or
generalized emotions.

Anxiety disorders of psychological disorders that takes several different forms, but the primary
symptom is excessive or unrealistic anxiety.

GENERALIZED ANXIETY DISORDER

Excessive anxiety and worry, occurring more days than not for at least 6 months about several
events or activities (such as work or school performance). It is like a free-floating anxiety. The
person finds it difficult to control worry. The anxiety and worry are associated with at least
three (or more) of the following six symptoms:

• Restlessness or feeling keyed up or on edge

• Being easily fatigued
• Difficulty concentrating or mind going blank
• Vigilance is evidenced by irritability
• Muscle tension manifested in shakiness, restlessness, and headaches.
• Sleep disturbance (difficulty falling or staying asleep or restless, unsatisfying sleep)
• Hyperactivity is manifested by shortness of breath, excessive sweating, palpitations
and even stomach ailments like chronic diarrhoea

The focus of the anxiety and worry is not confined to features of an Axis I disorder,

• The anxiety, worry or physical symptoms cause clinically significant distress or

impairment in social, occupational, or other important areas of functioning.
• The disturbance is not due to the direct psychological effects of a substance (example
drugs of abuse [or] medication) or a general medical condition (e.g. hyperthyroidism),
and does not occur exclusively during a mood disorder, psychotic disorder, or a
pervasive developmental disorder.
 Psychological Disorders and Psychotherapy

PHOBIAS

Phobia refers to an irrational, persistent fear of an object, situation, or social activity. For
example, many people would feel fear if they suddenly came upon a live snake as they were
walking advert if steps to avoid the snake.
Now, a person with a phobia of snakes would avoid even a picture of a snake in a book.
Avoiding a live snake is rational, however avoiding a picture of a snake is not.
The major difference between phobias and generalised anxiety disorder is that in a phobia
people are aware exactly of the object or the situation that they are afraid of.
Three types of phobias identified by DSM-IV are discussed below.

1. Social phobia is the fear of interacting with others or being in social situations that might
need to a negative evaluation.
People with social anxiety disorder are afraid of being evaluated in some negative way
by others so they tend to avoid situations that could lead to something embarrassing
or humiliating. They become very self-conscious as a result.
Common types of social phobia are stage fright, fear of public speaking, fear of
urinating in public restroom.

The DSM-IV-TR Criteria for social anxiety disorder is as follows:

a) A marked in persistent fear of one or more social situations where individual is

exposed to unfamiliar people or to possible scrutiny by others (or show anxiety
symptoms) that will be humiliating or embarrassing.
b) Fear situations almost invariably provoke anxiety, which may take the form of a
panic attack
c) the person recognises that the fear is excessive or unreasonable.

Not surprisingly, people with social forebears often have a history of being shy as
children.

2. Specific Phobias: a specific phobia is an irritable fear of some object or specific situation,
such as a fear of dogs or a fear of being in small, enclosed spaces (claustrophobia).
The DSM-IV-TR Criteria for specific phobia is as follows:
• persistent excessive fear cued by the presence or anticipation of an object or
event
• exposure to the object event brings about immediate significant anxiety or
panic
• recognition that the fear is excessive
• the feared object or event is avoided or endured with great difficulty

Some specific phobias include trypanophobia (a fear of injections close for emphasis,
ablutophobia (fear of dental work), hematophobia (fear of blood) , ablutophobia
(fear of washing and bathing), and acrophobia (fear of heights).
 Psychological Disorders and Psychotherapy

3. Agoraphobia: agoraphobia is a Greek name that literally means fear of the

marketplace.
It is the fear of being in a place or situation from which escape is difficult or impossible
is something should go wrong as defined by the American Psychiatric Association.
The anxiety is present in more than one situation. Someone is diagnosed with
agoraphobia if they feel anxiety in at least two of five possible situations such as
• using public transportation like a bus or plane,
• being out in an open space such as on a bridge or in a parking lot,
• being in an enclosed space such as a grocery store or movie theatre,
• standing in line or being in a crowd like at a concert, or
• being out of the home alone.

OBSESSIVE COMPULSIVE DISORDER :

An anxiety disorder in which individuals have recurrent, disturbing thoughts (obsessions) they
cannot prevent unless they engage in specific behaviours (compulsions). The Symptoms of
OCD – contamination, pathological doubt, intrusive thoughts, symmetry, religious obsession,
and compulsive hoardings

Obsessions are defined by the following:

1. Recurrent and persistent thoughts, impulses or images that are experienced at some
time during the disturbances as intrusive and inappropriate and cause marked anxiety
or distress.
2. The thoughts, impulses or images are not simply excessive worries about real life
problems.
3. The person attempts to ignore or suppress such thoughts, impulses, or images or to
neutralise them with some other thought or action.
4. The person recognises that the obsessional thoughts, impulses or images are a product
of his or her own mind (not imposed from
without as in thought insertion).

Compulsions are defined by the following:

1. Repetitive behaviours (e.g. hand-

washing, ordering, checking) or mental acts (e.g.
praying, counting, repeating words silently) that
the person feels driven to perform in response to
an obsession, or according to rules that must be
applied rigidly.
2. The behaviours or mental acts are aimed
at preventing or reducing distress or preventing
some dreaded event or situation; however, these
behaviours or mental acts either are not
connected in a realistic way with what they are designed to neutralize or prevent or are
clearly excessive.
 Psychological Disorders and Psychotherapy

B. At some point during the disorder, the person has recognized that the obsessions or
compulsions are excessive or unreasonable. However, this does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than
one hour a day) or significantly interfere with the persons normal routine, occupational (or
academic) functioning, or usual social activities or relationships.

Causes of anxiety disorders

1. Biological factors several disorders, including generalised anxiety disorder, panic

disorders, phobias, and OCD, tend to run in families, pointing to a genetic basis for
these disorders.
Functional neuroimaging studies have revealed that the amygdala, and area of the
limbic system, is more active in phobic people responding to a picture of spiders than
in non-phobic people. Studies show that a person's characteristic level of anxiety
related to a specific gene that is involved in the production of neurotransmitter -
serotonin.

2. Psychological factors
a) Psychodynamic Model: according to this model anxiety is a signal to the body that
the repressed urges are threatening to surface.
A phobia is a kind of displacement in which the phobic object is symbolic of whatever
the person has buried in the unconscious mind – the true source of the fear. For
example, of fear of axe might mean a fear of one's own aggressive tendencies, or a fear
of heights might mean a suicidal desire to jump.

b) Behavioural Model: takes a different approach and emphasis on environmental

factors. They consider anxiety to be learned response to stress.
For e.g. A young girl is bitten by a dog. when she next sees a dog, she is frightened
and runs away - a behaviour that they leave her anxiety and thereby reinforces
avoidance behaviour. after repeated encounters with dogs in which she is reinforced
for her avoidance behaviour, she develops a full-fledged phobia regarding dogs.

c) Cognitive Model: cognitive psychologists view anxiety disorders as an outgrowth of

illogical, irrational thought processes about circumstances in the person’s world. For
example, a person with anxiety disorder might view any friendly puppy as ferocious or
might see air disaster looming whenever he or she is in the vicinity of an airplane.
according to the cognitive perspective, people's maladaptive thoughts about the world
are the root cause of anxiety disorders.
Some common irrational thoughts or belief system (do it briefly)
• One way in which people with anxiety disorders show irrational thinking is through
magnification, or the tendency to make mountains out of molehills by interpreting
situations as being far more harmful, dangerous, or embarrassing then they are. For
example, in panic disorders a person might interpreter racing heartbeat as a sign
of heart attack instead of just a moment area rousing.
 Psychological Disorders and Psychotherapy

• all-or-nothing thinking, in which a person believes that his or her performance

must be perfect or the result will be a total failure.
• Over generalization is the distortion of thinking in which a person draws sweeping
conclusions based on only one incident or event and applies those conclusions to
events that are unrelated to the originally. It is the tendency to interpret a single
negative event as a never ending pattern of defeat and failure.
• Minimization is a distortion of thinking in which a person blows a negative event
out of proportion to its importance (magnification) while ignoring relative positive
events (minimization). In other words minimisation is giving little or no emphasis to
ones successes or positive events in traits.