UNDERSTANDING PSYCHOLOGICAL DISORDER

UNIT 1
TOPIX - Introduction: Understanding abnormal behaviour classification:
DSM & ICD (Latest versions), Clinical assessment.

Abnormal psychology is the scientific study of troublesome feelings, thoughts,

and behaviours associated with mental disorders. This area of science is
designed to evaluate, understand, predict, and prevent mental disorders and help
those who are in distress. There is still no universal agreement about what is
meant by abnormality or disorder. This is not to say we do not have definitions;
we do. However, a truly satisfactory definition will probably why do the
definition of a mental disorder present so many challenges? A major problem is
that there is no one behavior that makes someone abnormal. However, there no
single indicator is sufficient to define or determine abnormality. Nonetheless,
the more that someone has difficulties in the following
1. Suffering: If people suffer or experience psychological pain, we are inclined
to consider this as indicative of abnormality. Depressed people clearly suffer, as
do people with anxiety disorders.
2. Maladaptive Ness: Maladaptive behavior is often an indicator of abnormality.
The person with depression may withdraw from friends and family and may be
unable to work for weeks or months. Maladaptive behavior interferes with our
wellbeing and with our ability to enjoy our work and our relationships.
However, not all disorders involve maladaptive behavior
3. Statistical Deviancy: The word abnormal literally means “away from the
normal.” But simply considering statistically rare behavior to be abnormal does
not provide us with a solution to our problem of defining abnormality. Genius is
statistically rare, as is perfect pitch. However, we do not consider people with
such uncommon talents to be abnormal in any way. Also, just because
something is statistically common
4. Violation of the Standards of Society: All cultures have rules. Some of these
are formalized as laws. Others form the norms and moral standards that we are
taught to follow. Although many social rules are arbitrary to some extent, when
people fail to follow the conventional social and moral rules of their cultural
group, we may consider their behavior abnormal. For example, wearing bikini is
considered abnormal in India but it is very common in Europe.
5. Social Discomfort: When someone violates a social rule, those around him or
her may experience a sense of discomfort or unease. how do you feel when
someone you met only 4 minutes ago begins to chat about her suicide attempt?
Unless you are a therapist you would probably consider this an example of
abnormal behavior.
6. Irrationality and Unpredictability: we expect people to behave in certain
ways. Although a little unconventionality may add some spice to life, there is a
point at which we are likely to consider a given unorthodox behavior abnormal.
If a person sitting next to you suddenly began to scream and yell obscenities at
nothing, you would probably regard that behavior as abnormal.of abnormal
behavior.
7 Dangerousness: It seems quite reasonable to think that someone who is a
danger to themselves or to another person must be psychologically abnormal.
Indeed, therapists are required to hospitalize suicidal clients or contact the
police if they have a client who makes an explicit threat to harm another person.
But, as with all of the other elements of abnormality, if we rely only on
dangerousness as our sole feature of abnormality, we will run into problems. Is a
soldier in combat mentally ill? He may be a danger to others. Yet we would not
consider him to be mentally ill. Why not? And why is someone who engages in
extreme sports or who has a dangerous hobby (such as free diving or race car
driving) not immediately regarded as mentally ill? Just because we may be a
danger to ourselves or to others does not mean we are mentally ill. Conversely,
we cannot assume that someone diagnosed with a mental disorder must be
dangerous. Although people with mental illness do commit serious crimes,
serious crimes are also committed every day by people who have no signs of
mental disorder. Indeed, research suggests that in people with mental illness,
dangerousness is more the exception than the rule.
CHARACTERISTICS OF ABNORMAL PERSON
According to kisker,” Human behavior and experiences which are strange,
unusual or different from ordinary are considered abnormal.” An abnormal
person is quite often the victim of mental deficiency or mental disease. In some
abnormal individuals the intellectual level is fairly high, but their balance is
quite disturbed. Emotional instability and inconsistency are more or less a
common trait in most abnormal individuals. Abnormal individuals, as a class,
are comprised of mentally diseased, juvenile delinquents, unsocial and anti-
social individuals.
1. Criminal and juvenile delinquents. The criminal or the juvenile delinquent is
in some measure abnormal, his mind an inferno of various kinds of conflicts
which sometime take destructive and heinous forms. He is self –centred and
vagrant, full of the feeling of vengeance, a composite of the unsociable,
irritable, quarrelsome, cruel, hypersexual, and destructive traits. he does not
hesitate to inflict much damage and pain on others where his own interest is
involved. His drives are very powerful, intense, but very momentary. His
practical life is anything but satisfactory, his ideals low, if any. The juvenile
delinquent indulges in many activities that do not benefit him in the least while
they do considerable damage to others.
2. Mentally Diseased. All mentally diseased individuals are considered
abnormal, usually, most abnormal people exhibit lack of love and sympathy,
sense of emotional insecurity and all kinds of emotional complexes. While the
balanced and normal individual manifests self-evaluation, adaptability, maturity,
regular life, lack of excess, satisfactory social adjustment, contentment with the
main occupation of his life, the unbalanced and abnormal individual exhibits an
absence of almost all these qualities. Such an individual does not understand his
own faults, and is more inclined to blame the world for them. Immaturity is
evident in his mental and emotional make up. His sexual life is not normal, and
he may also exhibit various kinds of sexual perversities
3. Unsocial and Anti-social. The abnormal individual is unsocial, incapable of
distinguishing between right and wrong and also of attaching any importance to
the socially accepted notions of them. it is not necessary that the abnormal
individual be accepted notions of them. it is not necessary that the abnormal
individual be also immoral, but the excessively and almost completely abnormal
individual is in some respect necessarily immoral. The abnormal individual is
not inclined to set much store by the social ethos and moral point of view. On
the one hand, he lives a secluded life and wants to have nothing to do with the
society at large. He has not the least hesitation in doing things that harm other
people.

The DSM-5 Definition of Mental Disorder

Behavioural or psychological syndrome (or pattern) that is present in an
individual and that reflects some kind of underlying psychobiological
dysfunction. Importantly, this behavioural syndrome should result in clinically
significant distress, disability, or impairment in key areas of functioning.
Predictable responses to common stressors or losses (such as death of a loved
one) are excluded. It is also important that this dysfunctional pattern of behavior
not stem from social deviance or conflicts that the person has with society as a
whole.
CRITERIA OF ABNORMALITY (4 D’S)
Most practitioners agree that mental disorders involve behavior or other
distressing symptoms that depart from the norm and that harm affected
individuals or others. The four major DS involved in judging psychopathology
are:
● DISTRESS: Distress can be defined as anguish or suffering and all of us
experience distress at different times in our lives. However, when a person with
a psychological disorder experiences distress, it is often out of proportion to a
situation. It is the degree of distress or the circumstances in which the distress
arises that mark a psychological disorder. Most people who seek the help of
therapists are experiencing psychological distress that affects social, emotional,
or physical functioning. In the social sphere, an individual may become
withdrawn and avoid interactions with others or may engage in inappropriate or
dangerous social interactions. In the emotional realm, distress might involve
extreme or prolonged reactions such as anxiety and depression. Distress also
surfaces physically in conditions such as asthma or hypertension or with
symptoms of fatigue, pain, or heart palpitations
● DEVIANCE: Deviance is a sociological term for individuals who violate the
norms of society (Dijken & Koomen, 2007). The violation can be informal like
dress and appearance of formal, like the rules that govern motoring. Abnormal
behaviours deviator represents a significant deviation from- social norms. Less
frequent or less probable behaviours are considered to be abnormal or
statistically deviant. Abnormal behavior, thoughts, and emotions are those that
differ markedly from a society’s ideas about proper functioning. Behavior,
thoughts, and emotions that break norms of psychological functioning are called
abnormal. All this depends on specific circumstances as well as cultural norms.
Some examples of unusual behavior include false perceptions of reality, an
intense preoccupation with repetitively washing one’s hands, or demonstrating
extreme panic in a social setting.
● DYSFUNCTION: Psychological dysfunction refers to a breakdown in
cognitive, emotional, or behavioural functioning. Abnormal behavior tends to be
dysfunctional, i.e., it interferes with daily functioning. It so upsets, distracts, or
confuses people that they cannot care for themselves properly, participate in
ordinary social interactions, or work productively. A person with a
psychological disorder may be impaired in functioning at school, at work, or in
relationships. It is the degree of impairment that indicates a psychological
disorder. The person is impaired to a greater degree than most people in a
similar situation. One way to assess dysfunction is to compare someone’s
performance with the role requirements. Dysfunction can also be assessed by
comparing a person’s performance with his or her potential.
● DANGER: Perhaps the ultimate in psychological dysfunction Ing is behavior
that becomes dangerous to oneself and others. Individuals whose behavior is
consistently careless, hostile, or confused may be placing themselves or those
around them at risk. Even though it is a statistical rarity for individuals who are
mentally ill to commit violent crimes, media coverage of national tragedies has
led the public to associate mental illness with violence. Drug and alcohol abuse
is much more likely to result in violent behavior than are other kinds of mental
disorders (Friedman & Michels, 2013). Therapists are required by law to take
appropriate action when a client is potentially homicidal or suicidal. Another
component that must be considered with the determination of abnormal
behavior and dangerousness is substance abuse. The potential for violence and
dangerousness is increased when a person is under the influence of drugs and/or
alcohol.
CAUSES OF ABNORMAL

You must now be interested to know as to what causes the problems discussed
above. The current views of abnormal behaviour tend to be an integration of
several paradigms. A paradigm is a set of basic assumptions that together define
how to conceptualize studies and interpret data. The choice of a paradigm has
some very important consequences in which abnormal behaviour is defined. Let
us study these paradigms:
1) Biological Paradigm: This view holds that mental disorders are caused
by biological or bodily processes. This paradigm is also called as the
medical model. Individuals working with this paradigm assume that
answers to abnormal behaviour lie within the body. Let us take an
example Both researches and theory support that anxiety disorders may
stem from a defect within the autonomic nervous system that causes a
person to be easily aroused or heredity probably predisposes an individual
to develop schizophrenia. For the past many years biological research has
made great progress in elucidating brain behaviour relationship but still it
 is not sufficient to say that the biological paradigm answers all the
questions of abnormal psychology.
2) The psychoanalytic Paradigm: Originally developed by Sigmund Freud
this paradigm assumes unconscious conflicts to be the reason of abnormal
behaviour. Freud particularly emphasized that intense anxiety can be
caused by forbidden impulses for sex or aggression. The Freudian view
also gives importance to guilt generated by superego in response to these
impulses. The ego is caught in between id and superego which forces a
person to adopt rigid defence mechanisms and inflexible behaviours
3) Behavioural Paradigm: The behavioural paradigm considers
maladaptive ~behaviour as the result of failure in learning required for
adaptive behaviour tend learning ineffective responses to those
behaviours
4) Cognitive Paradigm: This paradigm considers that the interpretations
made by people are central to the understanding of abnormal behaviour.
these interpretations are based on the type of underlying experiences tend
schemas which people have
CLASSIFICATION SYSTEM OF PSYCHOLOGY
According to American Psychological Association, classification refers to the
grouping of mental disorders on the basis of their characteristics or symptoms.
It is a procedure of constructing groups of categories and for assigning entities
(disorders or people) to these categories on the basis of their shared attributes or
relations (Million, 1991). It is the activity of ordering or arrangement of objects
into groups or sets on the basis of their relationships (Sokal, 1974). In other
words, it is the process of synthesizing categories out of the raw material of
sensory data. Classification is important as it helps to simplify thinking and
reduce complexity of any clinical or psychological phenomenon; to
communicate effectively; to understand the causal factors/ethology of any
disorder; and to decide the appropriate treatment. Such systems reduce the
cognitive load; enable the manipulation of objects by simplifying the
relationships among them; and generate hypotheses and predictions. The
Diagnostic and Statistical Manual of Mental Disorders (DSM) (APA, 1980) and
the International Classification of Disease (ICD) (WHO, 1992) are two
classification systems that list and describe criteria for diagnosing mental
disorders. Both systems have been revised with the goals of producing DSM-5
and ICD-11, respectively
DSM: The American Psychiatric Association was earlier called the Committee
on Statistics of the American Medico psychological Association. In 1917, DSM
(earlier called Statistical manual for the use of institutions for the insane) was
first published. It had 21 disorders which were psychotic in nature
DSM-I: After World War II, American psychiatry was embarrassed by the
chaotic state of classification in the United States. The APA decided to
overcome this situation by creating a classification that would be acceptable to
all members of its organization and that could unify the diagnostic terms of its
psychiatrists. The result was the DSM. The DSM-1 was published in 1952. It
contained 128 categories. Organizationally, the DSM-I had a hierarchical
system in which the initial node in the hierarchy was differentiating organic
brain syndromes from “functional” disorders which are physically undetectable.
The functional disorders were further subdivided into psychotic versus neurotic
versus character disorders. The descriptions of disorders were short, vague, and
subjective in nature. They mainly focused on the causes.

DSM-I: After World War II, American psychiatry was embarrassed by the
chaotic state of classification in the United States. The APA decided to
overcome this situation by creating a classification that would be acceptable to
all members of its organization and that could unify the diagnostic terms of its
psychiatrists. The result was the DSM. The DSM-1 was published in 1952. It
contained 128 categories. Organizationally, the DSM-I had a hierarchical
system in which the initial node in the hierarchy was differentiating organic
brain syndromes from “functional” disorders which are physically undetectable.
The functional disorders were further subdivided into psychotic versus neurotic
versus character disorders. The descriptions of disorders were short, vague, and
subjective in nature. They mainly focused on the causes.
DSM-II: The DSM-II was published in 1968. It had 182 disorders and the
symptoms were described as reflections of broad underlying conflicts or
maladaptive reactions to life problems rather than in observable behavioural
terms (Wilson, 1993). Unlike the DSM-I, many of the new categories added in
the DSM-II were categories of relevance to outpatient mental health efforts.
Anxiety disorders, depressive disorders, personality disorders (PDs), and
disorders of childhood/adolescence were larger subsets than they had been in
the DSM-I.
DSM-III: In the DSM-III, categorization was based on description rather than
assumptions about the causes of the disorder, and a more biomedical approach
replaced the psychodynamic perspective (Wilson, 1993). The DSM-III,
published in 1980, contained 265 diagnostic categories. It contained diagnostic
criteria to specify the meaning of the categories. Another innovation to the
DSM-III was that the system was multiaxial. Each patient was expected to be
diagnosed along five separate axes. Axis, I represented clinical disorders and
other disorders that may be a focus of clinical attention (any psychological
disorder other than personality disorders and mental retardation). Axis II dealt
with specific to personality disorders and developmental delays. Axis III dealt
with physiological mental disorders (general medical conditions). Axis IV
included psychosocial and environmental problems (educational, occupational
problems, etc.) Axis V represented global assessment of functioning scale (1-
100_ in which 100 represented superior functioning in a wide range of activities
and has no symptoms; 60 represented moderate difficulty in social and
occupational functioning; and 10 represented persistent danger of severely
hurting self or others, or persistent inability to maintain minimal personal
hygiene. The next version, the DSM-III-R (APA, 1987) included not only
revisions but also renaming, reorganization, and replacement of several
disorders, which yielded 292 diagnoses (Mayes & Horwitz, 2005).
DSM-IV: In 1994, DSM-IV listed 297 disorders. This revision emerged from
the work of a steering committee, consisting of work groups of experts who (a)
conducted an extensive literature review of the diagnoses, (b) obtained data
from researchers to determine which criteria to change, and (c) conducted
multicentre clinical trials (Schaffer, 1996). DSM-IV-TR (APA, 2000), a “text”
revision, was published in 2000 with most diagnostic criteria unaltered.
DSM-5: The DSM-5 (APA, 2013) includes 237 diagnoses and uses a
developmental approach to abnormal behavior. Also, DSM-5 emphasizes the
role of culture and gender in the expression of psychiatric disorders and, in
comparison to previous editions, uses more dimensional ratings to classify
symptom severity. The multiaxial system was completely removed. Axes I, II,
and III represented psychiatric and medical diagnoses. Axis IV contained
ethology or descriptions of disorders. Axis V was dropped altogether.
ICD: The World Health Organization’s (WHO) International classification of
diseases and related health problems (ICD) is well established as the global
standard for the diagnosis, treatment, research, and statistical reporting of all
human health conditions, including mental and behavioural disorders. Thus, it
represents a powerful clinical, administrative, scientific, and epidemiological
tool. The section on mental and behavioural disorders is one chapter (Chapter V
or F) within the ICD, which, in turn, is one component of the WHO family of
International Classifications.
During the latter half of the nineteenth century, European and American health
statisticians increasingly recognized the advantages of a common international
classification for tracking mortality statistics. While various medical
nomenclatures had existed for centuries, the first to gain international
acceptance was Jacques Bertillon’s International list of causes of death, adopted
in 1893 by the International Statistical Institute. This event marked the inception
of the ICD. The first revision of the ICD (ICD-1) was published in 1900, with
subsequent revisions occurring every 8-10 years until the publication of the
ICD-9 in 1975, after which point revisions became less frequent (Moriyama,
Loy, & Robb-Smith, 2011).
ICD-6: Early editions of the ICD were developed for the primary purpose of
classifying causes of death for statistical and public health purposes. However,
with the 1948 publication of ICD6, the scope of the ICD expanded to include
not only causes of death, for the calculation of mortality statistics, but also
health conditions, for the calculation of morbidity statistics (e.g., disease
prevalence and incidence). In 1948, the WHO took charge of the classification
system, which was expanded the following year to include coding for causes of
morbidity in addition to mortality. The system was rechristened the International
Classification of Disease system. There were three main sections under 26
categories in the chapter “Mental, Psychoneurotic, and Personality disorders”:
psychosis, psychoneurotic disorders, and disorders of character, behavior, and
intelligence. The ICD classification of mental disorders did not change from
ICD-6 to ICD-7 (1957), other than to amend errors and inconsistencies
ICD-8: ICD-8 was published in 1968. The section of psychosis was kept as it is.
The sections of neurosis, personality disorders, and non-psychotic mental
disorders were combined together. Another section was mental retardation.
Following the approval of ICD-8, WHO decided that additional guidance was
needed for meaningful application of its categories in clinical settings and
published a glossary of terms (WHO, 1974) that provided definitions for most
ICD-8 mental disorder categories as well as other key diagnostic concepts
ICD-9, ICD-10, and ICD-11: ICD-9 came in 1979. There were no major
changes as such. The glossary’s material was largely incorporated into the ICD-
9 chapter on mental disorders, which is the only ICD-9 chapter with operational
definitions for each category, and was readily adopted by nearly all WHO
member states. ICD-10 was published in 1994. The structure was removed.
Instead, the disorders were rearranged in accordance to the commonalities
between disorders rather than psychosis and neurosis. ICD-11 was published in
2019 and will come into effect in 2022
ADVANTAGES AND DISADVANTAGES OF CLASSIFICATION
SYSTEM
The classifications currently used in psychiatry and other mental health related
professions have advantages. The use of a common language to describe
observed clinical phenomena is critical to both clinical practice and research.
The common terms for symptoms and categories allow the new clinician to
develop a relatively accurate picture of the patient. Using diagnostic labels to
describe sets of symptoms helps clinicians and researchers communicate about
their patients. Deciding which diagnosis best fits a patient’s pattern of
symptoms also helps the clinician develop an appropriate treatment plan.
Classification makes it possible to communicate about particular clusters of
abnormal behavior in agreed-upon and relatively precise ways. For example, we
cannot conduct research on what might cause eating disorders unless we begin
with a more or less clear definition of the behavior under examination;
otherwise, we would be unable to select, for intensive study, persons whose
behavior displays the aberrant eating patterns we hope to understand.
Organizing information within a classification system also allows us to study
the different disorders that we classify and therefore to learn more about not
only what causes them but also how they might best be treated. Defining the
domain of what is considered to be pathological establishes the range of
problems that the mental health professional can address. As a consequence, on
a purely pragmatic level, it furthermore delineates which types of psychological
difficulties warrant insurance reimbursement and the extent of such
reimbursement
There are a number of disadvantages in the usage of a discrete classification
system. Classification, by its very nature, provides information in a shorthand
form. However, using any form of shorthand inevitably leads to a loss of
information. In other words, as we simplify through classification, we inevitably
lose an array of personal details about the actual person who has the disorder.
There can still be stigma associated with having a psychiatric diagnosis. There
is the fear that speaking candidly about having a psychological disorder will
result in unwanted social or occupational consequences or frank discrimination.
Related to stigma is the problem of stereotyping. Because we may have heard
about certain behaviours that can accompany mental disorders, we may
automatically and incorrectly infer that these behaviours will also be present in
any person we meet who has a psychiatric diagnosis. Finally, stigma can be
perpetuated by the problem of labelling. A person’s self-concept may be directly
affected by being given a diagnosis of schizophrenia, depression, or some other
form of mental illness. Furthermore, once a group of symptoms is given a name
and identified by means of a diagnosis, this diagnostic label can be hard to take
even if the person later makes a full recovery. Diagnostic classification systems
do not classify people. Rather, they classify the disorders that people have.
Clinical Assessment
The clinical assessment of any psychological problem involves a series of steps
designed to gather information (or data) about a person and his or her
environment in order to make decisions about the nature, status, and treatment
of psychological problems. Typically, clinical assessment begins with a set of
referral questions developed in response to a request for help. Usually, the
request comes from the patient or someone closely connected to that person,
such as a family member, teacher, or other health care professional.
GOALS OF ASSESSMENT
As part of the assessment process, the psychologist decides which procedures
and instruments to administer. The patient’s age, medical condition, and
description of his or her symptoms strongly influence the tools selected for
assessment, but the psychologist’s theoretical perspective also affects the scope
of the assessment. Once an assessment has been completed and all data have
been collected, the psychologist integrates the findings the process of
assessment sometimes has a therapeutic effect. Assessment can be useful even
before a referral is provided through the process of screening. Screenings can
help identify people who have problems but who may not be aware of them or
may be reluctant to mention them and/or those who may need further
evaluation.
PROPERTIES OF ASSESSMENT INSTRUMENTS
The potential value of an assessment instrument rests in part on its various
psychometric properties, which affect how confident we can be in the testing
results.
Standardization Standard ways of evaluating scores can involve normative or
self-referent comparisons (or both)
Normative comparisons require comparing a person’s score with the scores of a
sample of people who are representative of the entire population (with regard to
characteristics such as age, sex, ethnicity, education, and geographic region) or
with the scores of a subgroup who are similar to the patient being assessed.
Self-referent comparisons are those that equate responses on various
instruments with the patient’s own prior performance, and they are used most
often to examine the course of symptoms over time
Reliability The reliability of an instrument is its consistency, or how well the
measure produces the same result each time it is give Reliability is assessed in
many ways.
Validity A measure must not only be reliable but also valid. Validity refers to the
degree to which a test measures what it was intended to assess. The instrument’s
validity tells us how well we are assessing these complicated dimensions
ASSESSMENT INSTRUMENTS
Psychologists can select from a wide range of assessment instruments when
planning an evaluation. Choosing the best set of instruments depends on the
goals of the assessment, the properties of the instruments, and the nature of the
patient’s difficulties. Some instruments ask patients to evaluate their own.
symptoms (self-report measures); others require a clinician to rate the symptoms
(clinician rated measures). Some instruments assess subjective responses (what
the patient perceives) and others objective responses (what can be observed).
Some measures are structured (each patient receives the same set of questions),
and others are unstructured (the questions vary across patients)
CLINICAL INTERVIEWS
Clinical interviews consist of a conversation between an interviewer and a
patient, the purpose of which is to gather information and make judgments
related to the assessment goals. They also can be conducted in either an
unstructured or structured fashion. In an unstructured interview, the clinician
decides what questions to ask and how to ask them. Typically, the initial
interview is unstructured. In a structured interview, the clinician asks each
patient the same standard set of questions, usually with the goal of establishing
a diagnosis.
PSYCHOLOGICAL TESTS
Personality test is a psychological test that measures personality characteristics.
If the psychologist believes that personality characteristics are causes for
psychological disorder. The best-known personality test is the Minnesota
Multiphasic Personality Inventory
Intelligence Tests Although their results are often misinterpreted, intelligence
tests are some of the most frequently used tests among psychologists. Created to
predict success in school, these tests were designed to produce an intelligence
quotient, or IQ, score. Stanford Binet Intelligence Scale and the Weschler Adult
Intelligence Scale, another widely used intelligence test
Projective Tests Projective testing emerged from psychoanalytic theory. Two
widely used projective tests are the Rorschach Inkblot Test and the Thematic
Apperception Test.
Tests for Specific Symptoms In addition to tests of general psychological
functioning, we also need assessment tools that provide reliable and valid
measures of specific types of symptoms, such as depression and anxiety.
Depressive symptoms, for example, are commonly assessed by the Beck
Depression Inventory–II
BEHAVIORAL ASSESSMENT
This approach relies on applying the principles of learning to understand
behavior, and its ultimate goal is a functional analysis (Haynes et al., 2006).
When conducting a functional analysis (also known as behavioural analysis or
functional assessment), the clinician attempts to identify causal (or functional)
links between problem behaviours and contextual variables (e.g., environmental
and internal variables that affect the problem behavior). To identify antecedents
and consequences of behavior, a behavioural assessment often starts with a
behavioural interview. The interviewer asks very specific questions to discover
the full sequence of events and behaviours surrounding the patient’s primary
problems. self-monitoring, a process in which a patient observes and records his
or her own behavior as it happens self-monitoring requires patients to record
their symptoms when they occur, allowing real-time information about the
frequency, duration, and nature of the symptoms. Self-monitoring can also
create a record of how often problem behaviours are occurring before treatment
begins and how symptoms change over time. Self-monitoring can also create a
record of how often problem behaviours are occurring before treatment begins
and how symptoms change over time.

PSYCHOPHYSIOLOGICAL ASSESSMENT
Psycho-physiological assessment measures brain structure, brain function, and
nervous system activity. This type of assessment measures physiological
changes in the nervous system that reflect emotional or psychological events.
Different types of measurements assess a range of biochemical alterations in the
brain or physiological changes in other parts of the body. One of the oldest,
most common and least invasive types of psycho-physiological measurements is
electroencephalography (EEG).
CASE STUDY
One of the famous case studies in India that delves into abnormal psychology is
the story of Phoolan Devi, known as the "Bandit Queen." Her life was marked
by extreme hardship, trauma, and societal rejection, which led to behaviours
often viewed as abnormal by societal norms.
Phoolan Devi was born into a lower-caste family in rural Uttar Pradesh. Her life
took a drastic turn when she was kidnapped by a higher-caste gang and endured
brutal treatment, including rape. She eventually escaped and formed her gang,
seeking revenge against those who had wronged her.
Her actions, while driven by a quest for justice and retribution against her
oppressors, were seen as abnormal and criminal by society. However,
understanding her story from an abnormal psychology perspective can shed
light on the impact of severe trauma, societal marginalization, and the
development of extreme behaviours in response to such experiences.
The case of Phoolan Devi offers a lens to study abnormal psychology, exploring
the intricate interplay between traumatic experiences, societal factors, and the
manifestation of behaviours considered deviant or abnormal in a given context.

CONCLUSION
Defining mental disorders presents numerous challenges due to the intricate
nature of human behavior and the multifaceted factors contributing to
abnormality. The absence of a singular, definitive behavioural marker for
abnormality makes classification complex. The DSM-5's framework emphasizes
dysfunction, distress, deviance, and danger (the 4 D's) as criteria, but these
parameters are subjective and context-dependent, often differing across cultures
and contexts. Additionally, the causes of mental disorders are multifactorial,
involving biological, psychological, and social elements. Classification systems
in psychology aim to organize and guide diagnosis and treatment, yet they also
face criticism for potential stigmatization and oversimplification. Clinical
assessment, crucial in understanding and assisting those in distress, involves a
comprehensive evaluation of various factors. In conclusion, while classification
systems and criteria aid in understanding and addressing mental disorders, the
complexity of human behavior necessitates ongoing refinement and a nuanced
approach to effectively support individuals facing mental health challenges
UNIT 2
TOPIC - anxiety disorders (clinical picture & etiologic): a) Specific Phobias
& Social Anxiety Disorder, Panic Disorder, Generalized anxiety disorder.

Anxiety involves a general feeling of apprehension about possible future

danger, and fear is an alarm reaction that occurs in response to immediate
danger. Today the DSM has identified a group of disorders—known as the
anxiety disorders—that share obvious symptoms of clinically significant fear or
anxiety often produces tension, worry, and physiological reactivity. Anxiety is
frequently an anticipatory emotion—a sense of unease about a dreaded event or
situation from an evolutionary perspective, anxiety may be adaptive, producing
bodily reactions that prepare us for “fight or flight.” Thus, mild or moderate
anxiety prevents us from ignoring danger and allows us to cope with potentially
hazardous circumstances. Fears a more intense emotion experienced in response
to a threatening situation. In some cases, as we saw with Scott Stossel’s
reactions to various events in the opening vignette, fear and anxiety occur even
when no danger is present. Unfounded fear or anxiety that interferes with day-
to-day functioning and produces clinically significant distress or life impairment
is a sign of an anxiety disorder. Those who are affected by anxiety have plenty
of company. Anxiety disorders are the most common mental health condition in
the United States and affect about18 percent of adults—40 million people—in a
given year (R. C. Kessler, Chiu, Demler, & Walters, 2005). In a large survey of
adolescents, 31.9 percent had experienced an anxiety disorder (lifetime
prevalence), with 8.3 percent experiencing severe impairment (Meri kangas, He,
Burstein, Swanson, et al., 2011). The prevalence of anxiety disorders is quite
high when adolescents and adults are both considered (see Figure 5.1). Anxiety
disorders are responsible for a great deal of distress and dysfunction, especially
because they are often accompanied by depression or substance abuse (Barrera
& Norton, 2010). Anxiety reactions, such as a phobia, can significantly interfere
with a person’s quality of life, as you can see from the following case of a
young woman who developed a fear of dogs. That has not yet occurred.
To Freud, these neurotic disorders developed when intrapsychic conflict
produced significant anxiety. Anxiety was, in Freud’s formulation, a sign of an
inner battle or conflict between some primitive desire (from the id) and
prohibitions against its expression (from the ego and superego). Sometimes this
anxiety was overtly expressed (as in those disorders known today as the anxiety
disorders). In certain other neurotic disorders, however, he believed that the
anxiety might not be obvious, either to the person involved or to others, if
psychological defines mechanisms were able to deflect or mask it. The term
neurosis was dropped from the DSM in 1980. In addition, in DSM-III, some
disorders that did not involve obvious anxiety symptoms were reclassified as
either dissociative or somatoform disorders (some neurotic disorders were
absorbed into the mood disorders

Anxiety is a natural response to stress or perceived threats. It's a feeling of

apprehension, worry, or unease that can range from mild to severe. In everyday
life, it's common to experience anxiety before a job interview, a test, or a major
life change. However, when anxiety becomes excessive, uncontrollable, and
interferes with daily life, it might be diagnosed as an anxiety disorder. Anxiety
disorders encompass a group of mental health conditions characterized by
intense, excessive, and persistent worry and fear about everyday situations.
Some common types include: Anxiety disorders are complex and can be
influenced by a combination of factors, including genetics, brain chemistry,
personality, and life events. They are highly treatable, often with a combination
of therapy, medication, lifestyle changes, and self-help strategies. It's essential
to differentiate between normal anxiety and anxiety disorders. While some level
of anxiety is a part of life, anxiety disorders can be debilitating and may require
professional help for management and treatment.
1. Generalized Anxiety Disorder (GAD): Persistent and excessive worry
about various aspects of life, even when there is little or no reason to worry.
Generalized Anxiety Disorder (GAD) is a state of chronic, excessive and
unreasonable worry about multiple life events or activities. Since anxiety is not
anchored to a specific object or situation as in phobias, it was earlier described
as free-floating anxiety (Butcher, Hooley, Mineka, & Dwivedi, 2017).
Individual with GAD is persistently anxious often about minor things, and
worry chronically (Davison, Neale, & Kring, 2004). People with GAD spend a
great deal of time worrying about a wide range of topics and describe their
worrying as uncontrollable (Ruscio, Borkovec, & Ruscio, 2001)
Comorbidity GAD is associated with functional impairment and increased risk
of adverse health outcomes, including cardiovascular disease and suicide
(Keller, 2002). It is also frequently found in conjunction with other psychiatric
conditions, including depression (Wells & Butler, 1997; Browned al., 2001),
panic disorder, posttraumatic stress disorder, and social phobia (Kessler &
Itchen, 2002).
Prevalence: GAD is common, with a prevalence rate of 3 percent for a period of
any1 given year and a lifetime prevalence of 5.7 percent (Kessler, Berglund,
Dealer, et al. 2005). Lifetime prevalence in India is 5.8 percent (Chandrashekar
& Reddy, 1998).
Age of onset: Nearly 60 to 80 percent people with GAD report that they have
been anxious for as long as they remember whereas many others have reported
a slow and insidious onset (Roemer et al., 2002). It is difficult to determine the
age of onset, but research has suggested that older adults often develop it and it
is the most common anxiety disorder for them (e.g., Mackenzie et al., 2011).
Course: GAD is a chronic disorder. A twelve-year follow-up study reported that
42 percent of the people diagnosed with GAD did not remit even after 13 years
and nearly 50 percent of those who remitted had a recurrence (Bruce et al.,
2005). Though it tends to disappear after age 50 for many people, it is usually
replaced by somatic symptoms disorder with physical health concerns (Rubio &
Lopez-Ibori, 2007). It is a common and a chronic disorder, however, in spite of
high levels of worry and perceived low well-being, most of the people with
GAD manage their lives though with some role impairment. As compared to
panic disorder or major depressive disorder which are more debilitating
disorders, people with GAD are less likely to avail the psychological treatment
facilities, because they usually visit physicians with physical complains like
muscle ache, gastrointestinal problems etc. (Hofmann et al., 2010).
Gender ratio: GAD is twice as common in women as in men (Rickels &
Schweizer, 1997).
General characteristics of people with GAD
● People suffering from GAD live in a relatively constant state of diffuse
uneasiness, tension, and worry.
● They are almost always in an anxious apprehension, defined as a future
oriented mood state in which a person constantly attempts to be ready to deal
with any upcoming negative events.
● There is chronic over arousal along with high levels of negative affect, and a
sense of uncontrollability (Barlow et al., 1996).
● Decision making is difficult as they have poor concentration and dread to
make mistakes.
● They often unsuccessfully attempt to avoid anxiety by procrastinating or
indulging in checking activities.
● They are hyper-vigilant for all possible signs of threat in their environment.
● There are frequent complaints of muscle tension and aches in the neck and
upper shoulder region.
● Sleep disturbances, such as insomnia, nightmares and sometimes
hypersomnia (excessive sleep) to escape from anxiety are often reported.
● Such people feel upset, uneasy, and discouraged due to constant worries.
● Family, finance cess, work, and personal illness were found to be the most
common life areas of worry (Roemen, Molina, & Borkovec, 1997)
. ● Decision making is difficult for them and they worry endlessly over possible
errors that they might have made while deciding.
● Real and imagined mistakes committed currently or in the past are often
reviewed after going to bed.
● All the possible future difficulties are anticipated by them
● They are unable to logically think that it is useless to trouble oneself with
future outcomes which are beyond one’s control.
● Failure to control their tendency to worry gives them a feeling of helplessness
CLINICAL PICTURE
Generalized Anxiety Disorder (GAD) is a mental health condition characterized
by excessive and persistent worry or anxiety about various aspects of life, even
when there is little or no apparent reason for concern. The Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) outlines specific criteria for
diagnosing GAD:
1. Excessive anxiety and worry: Individuals experience excessive anxiety and
worry about a variety of events or activities, such as work, health, family, or
other everyday issues. This worry is difficult to control and often
disproportionate to the actual likelihood or impact of the feared event.

2. Difficulty controlling worry: The worry is accompanied by difficulty in

controlling the worry itself. Individuals may feel overwhelmed by their anxious
thoughts, finding it challenging to stop or manage them effectively.

3. Symptoms duration: The excessive worry and anxiety persist for most days
for at least six months. This prolonged duration is a key factor in distinguishing
GAD from transient or situational anxiety.

4. Associated symptoms: In addition to excessive worry, GAD may involve

various physical, cognitive, and emotional symptoms, such as restlessness,
fatigue, irritability, muscle tension, difficulty concentrating, sleep disturbances
(difficulty falling asleep or staying asleep), and feeling on edge or easily
startled.

5. Significant impairment: The anxiety, worry, and associated symptoms

significantly interfere with daily life, including work, school, relationships, or
other important activities.

6. Not attributable to another condition: The symptoms are not better explained
by another mental health disorder, medical condition, substance use, or
medication side effects.

If an individual consistently experiences these symptoms and they significantly

impact their daily functioning, it's essential to seek professional evaluation and
support from mental health professionals such as psychologists or psychiatrists.
Treatment for GAD often involves a combination of therapy, medication, and
lifestyle changes to help manage symptoms and improve quality of life.
Causes of GAD
(1) Biological Perspective Genetic Factors: There is mixed evidence for
genetic factors, however, a modest genetic component for GAD has been
reported (Hatemi, Neale, & Kendler, 2000). Among the research studies
carried out so far, one of the largest and most recent twin studies has
reported a variance of 15 to 20 percent in liability to GAD due to genetic
component. In other words, there is higher concordance rate for GAD in
MZ than DZ twins. Further, strong evidence has been found for a
common underlying genetic predisposition for GAD and major
depressive disorder (MDD) (Kendler et al., 2007). Nevertheless, whether
a person with a genetic risk for GAD or MDD will develop the disorder/s
is determined by the environmental factors (nonshared environment). A
basic personality trait called neuroticism has been conceptualized as the
common underlying predisposition for developing GAD and MDD
(Kendler et al., 2007).

Neurochemical and Neurohormonal Factors: Neurobiological model is

based on the research conducted between 1950s and 1970s on the
operations of benzodiazepines, a group of drugs that are effective in the
treatment of anxiety. Researchers discovered a receptor in the brain for
benzodiazepines that is linked to the inhibitory neurotransmitter, Gamma
Amino Butyric Acid or GABA. In normal fear reactions, neurons
throughout the brain fire and create the experience of anxiety. This neural
firing also stimulates GABA system, which inhibits this activity and
reduces anxiety. GAD may result from some defect in the GABA system
so that anxiety is not brought under control. The benzodiazepines may
reduce anxiety by enhancing the release of GABA. GABA, serotonin and
norepinephrine have been suggested to play a role in anxiety (LeDoux,
2002), but their interaction remains largely unknown till date (Butcher et
al., 2017)

The Corticotropin Releasing Hormone (CRH): The CRH plays a role in

GAD as it is an anxiety producing hormone. When CRH is activated by
stress or perceived threat, it stimulates the pituitary gland which in turn
releases the adrenocorticotropic hormone (ACTH). The ACTH stimulates
the adrenal gland which in turn releases the stress hormone called
cortisol. The CRH is believed to play an important role in GAD as it has
been discovered to affect the bed nucleus of the extension of amygdala
which mediates generalized anxiety (Davis, 2006).
(2) Psychoanalytic Perspective Generalized anxiety is the result of a constant
unconscious struggle between id impulses and ego. Id impulses are
aggressive and sexual in nature, and struggle for expression whereas the
ego because of its unconscious fear of being punished, does not let id
express its desires. Since the source of anxiety is unconscious, person
does not know the reason for anxiety and as a result is always anxious
and apprehensive. The person cannot evade anxiety as he/she cannot
escape from id, for escape from id means that the person is no longer
alive. Furthermore, since anxiety is not displaced onto a specific object or
situation as it happens in the case of phobia, hence the person is anxious
nearly all the time. But due to lack of empirical verification, this
viewpoint is not clinically accepted.

Behavioural Perspective According to Wolpe (1958), the elicitors of

anxiety may be environmental factors, e.g., other people or social
situations. A person who spends most hours of his/her day with other
people may be anxious because of the people or the social situations and
not because of any internal factors, i.e., the person learns to associate
their anxiety with the presence of other people.

Cognitive-Behavioural Perspective The main underlying idea is that GAD

results from distorted cognitive processes. People with GAD often
misperceive benign events, such as crossing the street as involving
threats, and their cognitions focus on anticipated future disasters (Beck et
al., 1987). Their attention is easily drawn to threatening stimuli (Mogg,
Miller, & Bradley, 2000). Studies have shown that in contrast to non-
anxious people, generally anxious people tend to notice threat cues when
presented with a mixture of threat and non-threat cues (Mineka et al.,
1998). Furthermore, they are more inclined to interpret ambiguous stimuli
as threatening and to rate ominous events as more likely to occur to them
(Butler & Matthews, 1983). The heightened sensitivity to threatening
stimuli occurs even when the stimuli cannot be consciously perceived
(Bradley et al., 1995).

Uncontrollable and unpredictable aversive events are much more stressful

and hence more anxiety provoking than the controllable and predictable
events. People with GAD may have a history of experiencing many
important life events as unpredictable and uncontrollable (Mineka &
Finberg, 1998). Early experience with control and mastery can immunize
to some extent against the harmful effects of exposure to stressful
situations and may in turn immunize against GAD (Barlow et al., 1998).
 Borkovec et al. (1998) have proposed another cognitive view as they
focused on the various functions served by worry. Worry can be
negatively reinforcing; it may serve five positive functions for people
with GAD:
● Superstitious avoidance of catastrophe (worrying will lessen the
likelihood of a feared event);
● Actual avoidance of catastrophe (worrying helps to generate ways of
avoiding catastrophe)
; ● Avoidance of deeper emotional topics (worrying distracts from more
troublesome emotions);
● Coping and preparation; and
● Motivating device (helps in motivating oneself to work)
A subset of people with GAD believe that worry has positive functions, which
in turn helps in maintenance of high levels of anxiety (Dugas et al., 2007).
Worrying is self-sustaining as it does not produce much emotional arousal, e.g.,
it does not produce the physiological changes that usually accompany emotion,
and it blocks the processing of emotional stimuli. Despite its positive functions,
worry has some negative consequences as well (Newman & Liera, 2011). Worry
is not an enjoyable activity as it involves thinking about the negative
catastrophic outcomes and can lead to a greater sense of anxiety and danger.
According to Wells and Papageorge (1995), it may lead to more intrusive
thoughts as they found in a study that involved three groups watching a
gruesome movie in three conditions. After watching the movie, one group was
told to relax, the second group was told to imagine the events in the movie and
the third group was asked to verbally worry about the movie. It was found that
people in the third group had more intrusive thoughts as compared to the other
two groups after several days of watching the movie. Worrying also leads to
more intense negative emotions (Newman & Libera, 2011). Further, there is
evidence for paradoxical effect of worry also, that is, attempts to control worry
leads to more intrusive thoughts which lead to a feeling of uncontrollability.
This in turn leads to anxiety which further enhances worry. Thus, it leads to a
vicious cycle of worry, intrusive thoughts and anxiety (Mineka & Finberg,
2006).

CASE STUDY OF GAD

Michael, a 19-year-old college freshman, grappled with GAD, which became
apparent in his transition from high school to university life. He found it
challenging to adapt to the new environment, fearing social interactions and
academic performance. Michael often isolated himself in his dorm room,
avoiding social events and class presentations. His anxiety hindered forming
friendships, impacting his mental well-being and self-esteem. Therapy sessions
utilized a combination of cognitive restructuring and social skills training.
Gradually, Michael gained confidence through exposure to social settings,
learning effective communication strategies, and reframing negative thoughts.
As a result, he started engaging in campus activities, building connections, and
experiencing a significant reduction in anxiety levels.

2. panic disorder: Involves sudden and repeated episodes of intense fear

that trigger severe physical reactions when there is no real danger. These
panic attacks can be terrifying and can lead to a fear of future attacks.
Panic attack is an episode of intense fear or apprehension with a sudden onset.
Such symptoms develop abruptly and usually reach its peak within 10 - 15
minutes. During such attack the victim becomes completely overpowered by the
symptoms, many of which are physiological in nature. Panic attacks are
characterised by their unexpectedness. The DSM IV TR mandates that a person
would be diagnosed as suffering from panic disorder if she had experienced
recurrent unexpected attacks and is persistently concerned with having another
attack. This condition must go on for at least one month. Also, the person must
have at least four of the following thirteen symptoms during the attack:
l Palpitation or pounding heart
l Sweating
l Trembling or shaking
l Sensation of shortness of breath or being smothered
l Feeling of choking
l Chest pain or discomfort
l Nausea or abdominal distress
l Feeling dizzy, lightheaded or faint
l Derealisation or depersonalisation
l Fear of losing control or going crazy
l Fear of dying
l Paraesthesia’s
l Chill or hot flushes
The typical clinical description of panic attack is featured by intense terror, at
times in the form of fear of dying or going crazy. Nervousness, shaking and
stress are common. The person seems to have no control on oneself. Sometimes
one feels like the beginning of a heart attack, as difficulty in breathing (as if one
is not getting enough air), palpitation, hyperventilation, rapid heart bits, chest
pain and choking sensation along with profuse sweating predominate. Often
there is a dizziness, light-headedness, nausea and fainting. One feels dissociated
from reality – one almost seems to be detached from the immediate
surroundings and drawn in a whirlpool of odd sensations. Occasionally there are
hot flashes or sudden chills, burning sensation in facial and neck area, tingling
in fingers and toes (paraesthesia). Difficulty in vision is also observed in the
form of flashing vision and tunnel vision (loss of peripheral vision). The most
prominent underlying characteristic is of being out of control in all respects.
The reactions are usually those associated with activation of sympathetic
nervous system. You must know that panic attack is not dangerous, but it can be
truly frightening. There are numerous cases when the patient has been admitted
for emergency cardiac care, particularly because the symptoms are mostly
physiological and mimics cardiac symptoms.
CLINICAL PICTURE
Panic disorder is a type of anxiety disorder characterized by recurring and
unexpected panic attacks. According to the DSM-5 (Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition), here are the criteria for diagnosing
panic disorder:

1. Recurrent unexpected panic attacks: A panic attack is an abrupt surge of

intense fear or discomfort that reaches a peak within minutes. During an attack,
individuals may experience symptoms such as palpitations, sweating, trembling,
shortness of breath, chest pain, nausea, dizziness, chills, numbness, or a feeling
of losing control.

2. Concern or worry about future panic attacks or their consequences: After

experiencing panic attacks, individuals often worry about when the next attack
might occur or develop maladaptive behaviors to avoid situations that might
trigger an attack.
To meet the criteria for panic disorder, these panic attacks must occur
unexpectedly and be followed by at least one month of persistent concern about
having another attack, worry about the implications of the attack, or a
significant change in behavior related to the attacks.

Comorbidity Prevalence:
Panic disorder commonly coexists with other mental health conditions such as
other anxiety disorders (e.g., agoraphobia, generalized anxiety disorder), mood
disorders (e.g., depression), substance use disorders, and certain medical
conditions.

Age of Onset:
Panic disorder often begins in late adolescence or early adulthood, but it can
occur at any age. The typical age of onset is between late teens and the mid-30s.

Course:
The course of panic disorder can vary among individuals. Some may experience
isolated episodes, while others may have recurrent or persistent symptoms. With
appropriate treatment, including therapy and sometimes medication, many
people with panic disorder can manage and reduce their symptoms effectively.

Early intervention and appropriate treatment methods can significantly improve

the prognosis and help individuals with panic disorder manage their symptoms
and lead fulfilling lives.
A Case Study of Panic Attack
Raj, a 21-year-old student in Delhi, faced a tough challenge during his exams.
Every time he sat down to study or take a test, he'd suddenly feel overwhelmed
by panic. His heart raced, he'd break into a sweat, and the room would start
spinning. This scared him a lot because he wanted to do well in his exams. But
this fear of failing made things worse. Instead of asking for help from teachers
or studying with friends, he avoided them. Sadly, this made his grades drop,
which stressed him out even more. It felt like a cycle where the pressure to do
well led to panic, which, in turn, made studying harder, making him even more
anxious about exams.
AETIOLOGY OF PANIC DISORDER
The aetiology of panic disorder may be divided in biological and psychosocial
factors. The biological factors include genetic factors and biochemical
abnormalities in the brain. The psychosocial factors are more concerned with
understanding the changes in the individual’s perception which triggers panic
attacks. They include learning factors and a number of cognitive variables that
may trigger or maintain panic attacks. In this section you will learn about these
factors in some detail.
 Biological Factors

1)Genetic factors: Family and twin studies indicate that

panic disorder runs in families. Identical twins seem to have
greater possibilities of panic disorder, while concordance is
less in fraternal twins. The specific genes responsible for
panic disorder are yet to be discovered. However, there
seems some evidence that panic disorder and phobia may
have some genetic commonness.

2) Brain and biochemical abnormalities: Attempts have been

made to associate panic attacks with biochemical
characteristics of the brain. It has been observed that
exposure to certain biochemicals generate panic attack in
those who are already suffering from panic disorder, while
this may not have any impact on others. Thus, there has been
a suggestion that there might be definite neurobiological
differences between the normal persons and those with panic
disorder. Some of such substances which may be considered
panic provocation agents are sodium lactate, carbon dioxide,
caffeine etc
However, the brain mechanisms associated with the action of these substances
are not identical and there have been suggestions that no single neurobiological
mechanism may be held responsible for all types of panic attacks
Some of the brain mechanisms implicated in panic attack are the increases
activity in the hippocampus and locus coeruleus, which are responsible for
monitoring external and internal stimuli and moderates’ brain’s reactions to
them. The amygdala is critically important in fear reaction, and is involved in
the ‘fear network’ of the brain. Abnormal sensitivity in this region may cause
repeated anxiety attacks. Increased noradrenergic activity simulates cardiac
problem by enhancing heart rate and breathing problems. It has also been
suggested that people with panic disorder may have abnormalities in their
benzodiazepine receptors which help in anxiety reduction. The role of GABA
neurotransmitter may be important in this respect.
 Psychological Factors
1) Learning factor: The learning theorists have tried to explain
panic attacks as learnt phenomena – specifically as responses to
conditioned stimuli. You already know how conditioning occurs
and how apparently neutral stimulus may acquire a significance to
elicit some response. Take the case of Maya as an instance. The
panic attack happened for her for the first time in the underground
train. Subsequently the situation of the train becomes the
conditioned stimulus, and Maya is afraid that the next panic attack
may also occur in the crowded vehicle. Thus, the initial learning is
reinforced and increases in vigour by reinforcements in cyclic
pattern. This explanation is also known as ‘fear of fear’.
Sometimes, an internal stimulus may act as the trigger to panic
attack. For example, an increased heart rate may be so associated
with panic attack experiences that if heart rate increases for any
reason, panic attack starts. Thus, oversensitivity to internal stimuli
can also be a cause of panic disorder.
2) Cognitive factors: The cognitive approach to panic attack
focuses on the interpretation of bodily sensations and external cues
that may trigger the attack. While the learning approach highlights
the oversensitivity to bodily cues, the cognitive approach further
affirms that a catastrophic meaning may be assigned to the bodily
sensation. For example, the racing of the heart may be attributed to
a serious malfunctioning of the cardiac system, rather than to the
medicine one has taken. If the person is not aware of this
catastrophic thought, it may fall within the arena of ‘automatic
thoughts’ that non-consciously result in the attack. You may note
that the role of interpretation is crucial here. This has been
highlighted by experiments where the heart rate has been increased
in panic disorder patients by using drugs. If the person knows
about the possible effects of the drug, panic attack does not take
place or occurs to a much milder degree panic disorder patients are
 also known to demonstrate cognitive bias toward certain
experiences and symbols. For example, they may be more prone to
words like ‘fainting’ or ‘shortness of breath’. There is however
controversy as to whether these biases have been generated after
repeated panic attacks or were already present before the first
attack. However, there seems to be accumulating evidence that a
special kind of cognitive orientation is present in some people,
which make them more amenable to consider certain stimuli as
triggers of panic attack more quickly than others.
3. Social Anxiety Disorder: Fear of being judged or embarrassed in social
situations. This can be so severe that it interferes with work, school, or
other ordinary activities.
Social anxiety disorder (SAD) is also called as social phobia which is a
persistent, irrational fear generally linked to the presence of other people and
can be extremely debilitating. However, the difference between social phobia
and social anxiety disorder is largely chronological, in that social phobia is the
former term and SAD is the current term for the disorder. The official
psychiatric diagnosis of social phobia was introduced in the third edition of the
Diagnostic and Statistical Manual (DSM-III). Social phobia was described as a
fear of performance situations and did not include fears of less formal situations
such as casual conversations.
DSM-5 describes social anxiety disorder as “disabling fears of one or more
specific social situations (such as public speaking, urinating in a public
bathroom, or eating or writing in public) where the person fears of being
exposed to the scrutiny and potential negative evaluation of others or that one
may act in an embarrassing or humiliating manner”. Therefore, the person tries
to avoid such social situations or when avoidance is not possible endures them
with great distress. There are two subtypes of SAD according to DSM-5, one is
specific to performance situations, e.g., public speaking, and the other is general
or in non-performance situations, e.g., eating in public.
Selective mutism can be considered as one variant of social anxiety disorder.
Mostly seen in children, selective mutism involves the inability of the child to
speak in specific situations whereas s/he is able to speak normally in other
situations. For example, while the child speaks well at home, she fails to
verbalize at school because of experiencing higher levels of social anxiety. They
fail to communicate in selective situations/contexts despite the ability to speak
in other situations
Comorbidity: People who suffer from SAD are also likely to suffer from one or
more anxiety disorders and depressive disorder (Ruscio et al., 2008).
Generalized SAD has been found to be comorbid with depression and alcohol
abuse (Wittchen, Stein, & Kessler, 1999). Specific SAD is comorbid with GAD,
specific phobias, panic disorder, avoidant personality disorder, mood disorders
and alcohol abuse (Crum & Pratt, 2001).
Prevalence, age of onset, gender differences and cultural factors: SAD is
common and found even in public celebrities, for example, Barbara Streisand
(American actor and singer). Its lifetime prevalence is 12 percent of a given
population (Ruscio et al., 2008). In India, prevalence rate of 12.8 percent has
been found in the adolescents (Mahakali & VanKirk, 2004). It is a persistent
disorder with spontaneous recovery shown by only 37 percent of the sufferers
over 12 years (Bruce et al., 2005).
SAD usually begins during early or middle adolescence or early adulthood
(Ruscio et al., 2008). SAD is more common among women than men as 60
percent of the women have been reported to suffer from the disorder. SAD is
also affected by cultural factors. Example, in Japan, fear of giving offense to
others is very important, whereas in USA, fear of being negatively evaluated by
others is a source of social anxiety
General characteristics of people with SAD
● The individual usually tries to avoid situations in which she /he might be
evaluated and reveal signs of anxiousness or behave in an embarrassing way;
● Fears concerning excessive sweating or blushing are common;
● Speaking, performing in public, eating in public, using public lavatories, etc.
can elicit extreme anxiety; and
● They often work in occupations or professions far below their talent or
intelligence because their extreme social sensitivity does not allow them to
work in situations which involve interactions with people

CLINICAL PICTURE

Social Anxiety Disorder (SAD), according to the DSM-5 criteria, involves

marked and persistent fear or anxiety about one or more social situations where
the individual is exposed to possible scrutiny by others. This fear is often
intense and can lead to avoidance of social situations or endured with intense
anxiety or distress. The anxiety or fear is typically out of proportion to the
actual threat posed by the social situation and can significantly interfere with
one's daily life, work, or relationships.

The DSM-5 criteria for Social Anxiety Disorder include:

1. Marked fear or anxiety about one or more social situations where the
individual is exposed to possible scrutiny by others. These situations often
provoke fear or anxiety.
2. The individual fears that they will act in a way or show anxiety symptoms
that will be negatively evaluated (e.g., be embarrassed, humiliated, or rejected)
in these social situations.
3. Social situations are avoided or endured with intense fear or anxiety.
4. The fear or anxiety is persistent and typically lasts for six months or more.
5. The fear, anxiety, or avoidance is significantly distressing or impairs social,
occupational, or other important areas of functioning.
6. The fear, anxiety, or avoidance is not attributable to the effects of a substance
(e.g., medication) or another medical condition and is not better explained by
another mental disorder.

Comorbidity prevalence: Social Anxiety Disorder commonly coexists with other

mental health conditions like depression, other anxiety disorders, substance use
disorders, and personality disorders.

Age of onset: Social Anxiety Disorder often begins in childhood or adolescence.

However, it can develop at any age, with symptoms typically emerging around
early to mid-adolescence.

Course: The course of Social Anxiety Disorder can vary widely among
individuals. Some people may experience fluctuations in symptoms over time,
with periods of remission and relapse. For others, symptoms may persist
consistently over the long term. Early intervention and treatment can
significantly impact the course of the disorder, potentially reducing its severity
and preventing long-term impairment.

Treatment for SAD often involves psychotherapy (such as cognitive-behavioral

therapy), medications (like selective serotonin reuptake inhibitors - SSRIs), or a
combination of both. Additionally, support groups and lifestyle changes can also
be beneficial in managing symptoms and improving overall well-being.
Causes of Social Anxiety Disorder
(1) Biological Perspective Genetic and Temperamental Factors: Results
from a very large study of female twins suggests a variance of 30 percent due to
genetic component in development of SAD (Smoller et al., 2008). Family
studies also show that first degree relatives of probands were more than two to
three times as likely to also share a diagnosis. Further, infants easily distressed
by unfamiliar stimuli are at an increased risk for becoming fearful during
childhood and by adolescence, show increased risk of developing social phobia
(Kagan, 1997).
(2) Psychological Perspective Behavioural Explanation: SAD in many
cases is a result of direct
or vicarious classical conditioning. In a study, 56 percent of people with
specific SAD and 44 percent with generalized SAD reported direct
traumatic conditioning experiences (Townsley et al., 1995). People with
generalized SAD may be especially likely to have grown up with parents
who were socially isolated or who devalued sociability, thus providing
ample opportunity for vicarious learning (Rosenbaum et al., 1994). Also,
many people with social phobia reported to develop it while having
problems in fitting in within their peer group (Harvey et al., 2005).
Cognitive Factors: Socially anxious people are more concerned about
evaluation than people who are not anxious (Goldfried, Padawer, &
Robins, 1984) and are more aware of the image they present to others
(Bates, 1990). They tend to view themselves negatively even when they
have actually performed well in social interactions (Wallace & Alden,
1997). In a study by Davison & Zighelboim (1987) which used
articulated thoughts in simulated situations, it was reported that people
with social phobia showed more negative articulated thoughts in a
stressful situation in comparison to people without social phobia.
Persistent and irrational fears actually occurs because fear is elicited
through early automatic processes that are not available to conscious
 awareness. After this initial processing the stimulus is avoided, so it is not
processed fully enough to allow the fear to extinguish (Amir, Foe, &
Coles, 1998)
Social Skills Deficit Model: According to this model, inappropriate
behaviour or a lack of social skills is the cause of social anxiety. The
individual has not learned how to behave so that he/she feels comfortable
with others. The person repeatedly commits faux pas (tactless mistake),
person is awkward and socially inept often criticized by social
companions. Support for this model comes from findings that socially
anxious people are indeed rated as being low in social skills (Twentyman
& McFall, 1975)
. Perception of Uncontrollability and Unpredictability: Submissive and
unassertive behaviour which is a characteristic feature of people with
social phobia is a result of uncontrollability and unpredictability in life
situations. People with social phobia have a diminished sense of personal
control over events in their lives (Cloister et al., 1992).
(3) Evolutionary perspective According to Ohman et al., 1985, social phobias
may have developed as a “by-product of dominance hierarchies”. Aggressive
encounters between members of a social group establish dominance hierarchies
where a defeated individual usually displays fear and submissive behavior but
rarely escapes from the situation. Thus, people with social phobia are more
likely to endure being in the feared situation than to run away. Perhaps, social
phobias develop mostly in adolescence and early adulthood when dominance
conflicts are most prominent.
Preparedness and Social Phobia: Ohman and colleagues (1985) have suggested
that we humans may have an evolutionary based predisposition to acquire fears
of social stimuli that signal dominance and aggression (e.g., anger or contempt)
from other humans. The researchers have reported that participants develop
stronger conditioned responses when slides of angry faces are paired with mild
electric shock than when happy or neutral faces are paired with the same
shocks. Further, even very brief presentations of the angry face that are not
consciously perceived are sufficient to activate the conditioned responses
(Ohman, 1996).
Case Study Social Anxiety Disorder
Sarah's journey with social anxiety during presentations was a profound
challenge despite her professional success. Her fear of public speaking cast a
shadow on her career advancement, despite her competence in other areas. The
physical manifestations of anxiety—racing heart, sweaty palms, and mental
blocks—severely impeded her ability to shine during presentations. Therapy
became her anchor, a safe space to confront the deep-rooted fears. Through
gradual exposure and tailored coping mechanisms, Sarah learned to navigate
her anxiety. With time and persistence, she cultivated a newfound confidence
that empowered her to manage her anxiety during presentations. This
transformation not only helped her professional growth but also instilled a
sense of personal triumph over a once-overwhelming obstacle.
4. Specific Phobias: Intense fear or anxiety about a particular object or
situation, such as heights, flying, or spiders. The word ‘Phobia’ derives from
the name of the Greek god ‘Phobos’ who used to frighten his enemies. A phobia
is an intense and irrational fear of some object, living being or situation. Do you
get notably disturbed if a cockroach flies around and falls on your body? Of
course, nobody would love to caress a cockroach, but some people get
completely panicky at the thought of touching it. Depending upon how severe it
is, this may be a phobic reaction.
DSM IV – TR specifies that to be diagnosed as suffering from phobic disorder,
one must have a persistent and disproportionate fear of some specific object,
social situation or crowded place that actually carries little danger. Exposure to
the phobic stimulus almost invariably produces intense anxiety response. The
patient usually knows that the fear is unreasonable, but she has no control on the
reaction. The phobic situation is usually avoided, or if forced to endured, may
be tolerated with great discomfort.
When forced to encounter the phobic stimulus, the reactions may be like panic
attack, or a little less severe than it. The attention of the person facing the
phobic object is directed completely toward it, the affect is intense fear and the
behavioural reaction is escape. As soon as the person can escape from the
presence of the phobic stimulus, the negative affect and accompanying
physiological reactions subside. Thus, the flight reaction is reinforced as it
provided relief from tension.
According to DSM IV – TR, phobias can be of three types: Specific Phobia,
Social Phobia and Agoraphobia. Specific phobias are the irrational fear of
specific objects, animals or situations. Some typical examples are: fear of closed
space or claustrophobia, fear of heights or acrophobia, fear of blood or
hemophobia, fear of snake or Ophidiophobia, fear of spider or arachnophobia,
fear of fire or pyrophobia and even fear of phobias or phobophobia. You can get
a list of the phobias on internet
The specific phobias can be divided in some subtypes like
l animal type - cued by animals or insects
l natural environment type - cued by objects in the environment, such as
storms, heights, or water
l blood-injection-injury type - cued by witnessing some invasive medical
procedure
l situational type - cued by a specific situation, such as public transportation,
tunnels, bridges, elevators, flying, driving, or enclosed spaces
l other type - cued by other stimuli than the above, such as of choking,
vomiting, or contracting an illness
Social phobias, as you may guess from its name, are persistent irrational fear
associated with presence of other people. Remember how we sometimes get
tongue tied at the interview boards? Social phobia is an extreme form of this
kind of discomfort. Often extreme feelings of shyness and self-consciousness
build into a powerful fear, so that it becomes difficult to participate in everyday
social situations. People with social phobia can usually interact easily with close
and familiar persons. But meeting new people, talking in a group, or speaking in
public can trigger the phobic reaction. Often situations where one might be
evaluated become the phobic situation. All of us may have occasional social
anxieties, especially under judgmental situation. But a person with diagnosable
social phobia often becomes incapable of normal social interaction

CLINICALPICTURE

Specific Phobia Disorder, as outlined in the Diagnostic and Statistical Manual of

Mental Disorders (DSM-5), involves an excessive or irrational fear of a specific
object or situation that leads to significant distress or avoidance. Here's a
breakdown according to DSM criteria:

Clinical Picture:
1. Marked Fear or Anxiety: The individual experiences intense fear or anxiety
when exposed to the specific object or situation.
2. Immediate Anxiety Response: This fear or anxiety response is immediate
upon encountering or even thinking about the phobic stimulus.
3. Avoidance Behavior: The person might go to great lengths to avoid the feared
object or situation, which can significantly interfere with their daily life.
4. Duration: The fear or anxiety typically persists for six months or longer.
5. Significant Distress: The fear or anxiety causes significant distress or
impairment in social, occupational, or other important areas of functioning.

DSM-5 Criteria for Specific Phobia:

The diagnosis requires the following:
- The presence of a specific phobia, which causes marked fear or anxiety.
- The phobic object or situation almost always provokes immediate fear or
anxiety.
- The phobic object or situation is actively avoided or endured with intense fear
or anxiety.
- The fear or anxiety is disproportionate to the actual danger posed by the
specific object or situation.
- The fear, anxiety, or avoidance is persistent, typically lasting for six months or
more.
- The fear, anxiety, or avoidance causes significant distress or impairment in
various areas of functioning.

Comorbidity Prevalence:
Specific Phobia Disorder can often co-occur with other anxiety disorders, such
as generalized anxiety disorder, panic disorder, or social anxiety disorder. It
might also be associated with other mental health conditions like depression.

Age of Onset:
Phobias can develop at any age, but they often begin in childhood or
adolescence. Some individuals might have specific phobias that persist into
adulthood if left untreated.

Course:
The course of specific phobia disorder can vary. Some individuals may
experience spontaneous remissions, where their fear diminishes over time
without intervention. However, without treatment, the avoidance behavior and
fear response can persist for years.

Treatment options include therapy approaches like cognitive-behavioral therapy

(CBT), exposure therapy, and sometimes medication (especially in severe cases
or when anxiety symptoms are prominent).

Remember, these criteria are just a general guide. A mental health professional
should evaluate and diagnose specific phobia disorder based on a
comprehensive assessment of the individual's symptoms and their impact on
daily life.
A Case Study of Specific Phobia
Priya, a bright 25-year-old architecture student, once dreamed of designing
breathtaking skyscrapers that touched the sky. However, a haunting childhood
incident on a towering building's rooftop changed her trajectory. Since that
distressing experience, Priya grapples with an all-consuming fear of heights.
The mere thought of ascending to elevated spaces sends shivers down her spine,
triggering overwhelming panic and paralysing anxiety. This fear has become a
formidable barrier in her academic pursuit, hindering her ability to attend site
visits or engage fully in her field of study. Her aspirations to create awe-
inspiring structures now seem eclipsed by her phobia, impeding not just her
academic progress but also casting a shadow on her professional aspirations.
Avoiding elevated spaces has become a coping mechanism, but it's
inadvertently limiting her growth and opportunities in the very field she once
felt passionate about, leaving her feeling trapped between her ambitions and
her fear.
AETIOLOGY OF PHOBIC DISORDER
 Biological Factors
Biological factors are of less importance in phobias than in panic
disorders. The genetic basis of phobias has been suggested by some
studies, but it has not been well established.

At best the impact of genetic factors is modest. It has been suggested

however, that temperament plays a significant role in developing phobia.
 Some children are temperamentally jumpy or easily aroused. This
lability-stability dimension is a function of the predisposition of the
autonomic activity. Those who are easily aroused may have greater
chance of developing anxiety disorders in later life.

There have been some attempts to provide evolutionary biological

explanation of phobic disorders. People are more likely to develop fear of
snakes or heights than of books or cups. Thus, there seems to be a
‘preparedness’ to consider some objects as more phobic than others. This
preparedness has been retained by nature because the primates who
identified these danger signals quickly had a survival advantage.
However, for the normal person, the reality of the danger is judged, while
for the phobic person the reaction is exaggerated

 Psychological Factors
1) Psychoanalytical theory: You already know that
psychoanalytical approach emphasises the role of unconscious
needs and conflicts. Freud, in his description of fear of horses in
little Hans proposed that phobias are the ego’s way of dealing
with childhood conflict. For example, Hans could not resolve
his oedipal conflict properly and his fear of father was displaced
onto horses. Other psychoanalytical models attribute phobias
not to id drives, but to disastrous interpersonal experiences. The
mistrust and generalised fear of environment seems to be
displaced on the phobic object or situation. You may note that
social phobia may be particularly well explained by this latter
view.

The psychoanalytical model has been criticized by learning

theorists as they state that many phobias develop as result of
association with a fear eliciting object, and we need not go to
the deeper id impulses for explaining them.

2) Learning theories: When you learnt about classical

conditioning, you came across the experiments of Watson and
Rayner, who conditioned little Albert to fear furry objects by
associating a rat with a loud bang. The learning theory
explanation of phobia takes this experiment on avoidance
conditioning as the model of phobic reactions. It is believed that
 phobia is the end result of a process of a neutral stimulus being
turned into a phobic object due to unwarranted association in
time with a feared object. Initially the association creates the
fear of the neutral stimulus, and then escape or avoidance of the
stimulus results in relaxation. This relaxation in turn acts as a
reinforcer and maintains the phobia.
Another process emphasised within the learning approach is
modelling of phobias. While learning about Bandura’s social
learning theory, you have come across the concept of vicarious
learning. It refers to the fact that a child models behaviours, but
also attitudes and emotions. If a child repeatedly sees her
mother being afraid of something, the same would be observed
in the child also. The modelling theory proposes that phobias
are learnt via observational learning processes.

While learning theory justifies the origin of a number of

phobias in some cases, not all phobias can be explained by this
theory. Particularly, the role of preparedness that you have
learnt earlier in connection with biological factors remains a
significant issue. It may be stated that learning may play a role
in phobia, but it cannot be the whole story

3) Cognitive theories: Cognitive approach to phobias indicates a

greater selective attention toward the phobic object. There is
often an underlying core belief that negative things are going to
happen. Particularly in case of social phobia, but also in other
specific phobias, catastrophic outcomes are believed to be
inevitable, thus distorting the reality for the person.

Cognitive theory also admits that the core belief may remain at
a non-conscious level, thus making it difficult to modify.
However, if the person is taught to look into her own erroneous
assumptions and cognitive biases, the distortion in thought
process may be identified. Figure Diagram explaining
psychoanalytical, behavioural and cognitive explanation of
phobia
 UNIT 3
TOPIC - Feeding and Eating Disorders (Anorexia Nervosa, Bulimia
Nervosa and Binge-eating disorder), b) Gender Dysphoria.
Eating disorders are relatively recent additions to psychiatric classification
systems. The vast majority – more than 90% of those affected with eating
disorders are adolescents and young adult women. The reason for women being
vulnerable to eating disorders is their tendency to go on strict diets to achieve an
“ideal” figure
Eating disorders are sometimes symptoms of a physical ailment, but they might
also be external manifestations of mental disorder. The social causes of mental
disorder, the interchange between people and society, and the influence that
culture has on our perceptions of reality are probably most clearly demonstrated
in the mental disorder’s anorexia nervosa and bulimia nervosa.
Many newspapers and magazines feature glamorous celebrities who devised a
special diet and shed pounds to become new, healthy, more confident people.
Many psychological and social theorists believe that the influx of media images
of thin women, many directed at the young, is a prime cause of the massive
increase in eating disorders in the western world. In this unit we are going to
deal with eating disorders. First, we start with definition and description of
eating disorders. This is followed by sociocultural comparison of eating
disorders within different parts of America and then follow it up with other
countries including India. Then we present different types of eating disorders
such as anorexia nervosa, bulimia nervosa, binge eating etc. Then we deal with
causes of eating disorders in which we present biological, cultural, family and
other theories. This is followed by treatment of eating disorders and the
different types of treatment.
“Eating disorder” is when a person eats, or refuses to eat, in order to satisfy a
psychic need and not a physical need. The person does not listen to bodily
signals or perhaps is not even aware of them. A normal person eats when hungry
and stops eating when the body doesn’t need more, when he feels the signal of
satisfaction.
Eating disorders are usually classified as anorexia nervosa, bulimia nervosa and
binge eating disorders, in accordance with the symptoms. However, a person
may have an eating disorder without belonging exactly to any of these
categories.
Those who lose weight because of illness, e.g., cancer, are not considered to
have an eating disorder.
Eating disorders do not seem to manifest as Anorexia Nervosa and Bulimia in
non-Western cultures like India, but occur infrequently in milder forms with
fewer symptoms, In the absence of the major disorders, standard questionnaires
such as the Eating Attitudes Test appropriate for detecting severe disorders, may
not be useful in identifying low prevalence milder disorders.
Culture has been identified as one of the etiological factors leading to the
development of eating disorders. Rates of these disorders appear to vary among
different cultures and to change across time as cultures evolve. Additionally,
eating disorders appear to be more widespread among contemporary cultural
groups than was previously believed.
Anorexia nervosa has been recognised as a medical disorder since the late 19th
century, and there is evidence that rates of eating disorder this disorder have
increased significantly over the last few decades. Bulimia nervosa was only first
identified in 1979, and there has been some speculation that it may represent a
new disorder rather than one that was previously overlooked (Russell, 1997).
However, historical accounts suggest that eating disorders may have existed for
centuries, with wide variations in rates. Long before the 19th century, for
example, various forms of self-starvation have been described (Bemoras, 1996).
The exact forms of these disorders and apparent motivations behind the
abnormal eating behaviours have varied. The fact that disordered eating
behaviours have been documented throughout most of history calls into
question the assertion that eating disorders are a product of current social
pressures. Scrutiny of historical patterns has led to the suggestion that these
behaviours have flourished during affluent periods in more egalitarian societies
(Bemoras, 1997). It seems likely that the sociocultural factors that have
occurred across time and across different contemporary societies play a role in
the development of these disorders.
TYPES OF EATING DISORDERS
Although there are several different types of eating disorders, psychiatrists and
psychologists generally tend to divide them into two broad categories –
anorexia nervosa, bulimia nervosa and binge eating.
Anorexia nervosa is a condition characterised by a refusal to maintain a minimal
normal body weight, voluntary self-starvation and an intense fear of becoming
fat. These individuals achieve abnormally low weight by severely dieting
fasting and often by exercising compulsively. Most cases are female coming
from the upper or middle class.
Bulimia nervosa is characterised by recurrent episodes of binge eating while
experiencing a subjective sense of lack of control over the eating, the regular
use of extreme weight compensatory methods (for example, self-induced
vomiting, laxative abuse, diuretic abuse, excessive fasting and compulsive
exercise) and dysfunctional beliefs about weight and shape that unduly
influence self-evaluation or self-worth. 90 per cent of the cases happen to be
women. Bulimia nervosa is likely to result from a combination of genetic,
familial, psychological, and sociocultural factors
Binge eating disorder is characterised by recurrent episodes of binge eating but,
unlike bulimia nervosa, no extreme weight control behaviours are present. A
decreasing weight goal, increasing criticism of the body, increasing social
isolation, disruption of menstruation, reports of purging in the context of dieting
are some of the warning signals for parents. Parents are largely responsible for
shaping a child’s body image and eating lifestyle. It is believed that parents who
are themselves preoccupied with body image and weight increase the ranks of
childhood anorexics. Parents should communicate with their children and try to
maintain a healthy lifestyle at home for the sake of their children.
Depression, stress and genetics are important factors when it comes to eating
disorders. It has been observed that those who suffer from anorexia nervosa are
usually sensitive, intelligent people who have a tendency to turn into control
freaks. On the other hand, Anorexia bulimia is associated with those who are
very emotional They then alternate between periods of overeating and then a
self-inflicted punishment in the form of starvation.
Since, eating disorders usually begin in teens, parents can play an important role
in curbing them. Eating disorders in children can often be a result of unhealthy
eating habits at home. Parents should realise that children unconsciously follow
most of their dietary habits. For this reason, parents have to be careful about
their own diet and make sure that they are setting a healthy example for their
kids. Second, meal time should be fun. Painful or stressful topics should be kept
away from the dinner table. This is not a time to discuss your child’s bad
performance in exams. Instead, make it a family bonding time. Keep conflicts
away from meal time. Parents should also try to make a healthy diet palatable.
Incorporate interesting recipes so that eating becomes an enjoyable activity.
A balanced diet consists of adequate amount of carbohydrates, proteins, fats and
vitamins. An average Indian meal consisting of chapatis, dal, green vegetables
and curd forms an ideal diet. Deviating greatly from this for more than three
weeks would be considered as a disorder. There can be several reasons for this
First, there is tremendous peer pressure on young people to look good. Girls
compete with one another to fit into a smaller size as thin is in. The pressure to
look attractive is so great that they cut down blindly on the first thing that
happens to be in their control, which is their food. In the absence of proper
guidance, they blindly follow crash diets. Some even deprive themselves of all
food. There are others, who only go by calorie count, skip healthy meals and
binge on junk foods. In their mind they are not doing anything wrong as long as
they do not exceed the calorie count. This lack of information about a balanced
diet can lead to severe consequences.
Parents in such a situation should not coerce or nag their children. They, instead
have to lead by example. If kids see a healthy and an active lifestyle at home,
they will automatically emulate it. Do not sermonise, subtle guidance is the
need of the hour.
Sometimes eating disorders are a result of severe emotional stress r depression.
Parents have to understand their children and ensure that their emotional needs
are being fulfilled. These situations have to be tackled sensitively. In case, you
are not able to diagnose the cause, medical help should be considered.
In reality it is difficult to differentiate between the two since there is a lot of
overlap in the behavioural characteristics and psychological process of each.
Many theorists suggest that people’s eating habits and their perception of their
own body image lie on a continuum- along a scale that extends from extremely
distorted eating habits and an unrealistic body image at one end to no
psychological or behavioural distortions at all at the other. Every one stands
somewhere within in this range.
Sometimes, we see people who think they are fat and sometimes starve
themselves, or who are on permanent diets. This does not necessarily mean that
they have an eating disorder, but it does show how anorexia and bulimia might
be extreme versions of common occurrences.
Anorexia Nervosa
Anorexia nervosa literally means “nervous loss of appetite” yet people with
anorexia do not lose their appetites but are often hungry and preoccupied with
food. They want to eat but seem to be starving themselves. Anorexics might
even love to cook for others. They might read recipe books, prepare meals, shop
for food, and even work in restaurants, but they always avoid eating any caloric
rich food themselves. They usually have a distorted body image and think they
are fat when, in fact, they are wasting away and many anorexic people try to
hide their bodies in oversized clothes
Diagnosis of Anorexia Nervosa
People are diagnosed as anorexic if they weigh less than 85 per cent of the
expected weight for their age and height in the normal circumstances. They
might look extremely thin and feeble because of their significant weight loss,
and they often have other health problems, including low blood pressure,
constipation, dehydration, and low body temperature.
Diagnostic Criteria for Anorexia Nervosa (DSM-IV)
• Refusal to keep body weight or above 85% of the generally recognised normal
level for age and height.
• Intense fear of gaining weight or becoming fat, even when underweight.
• Disturbance in experience of body weight or shape, undue influence of these
factors on self-esteem or denial of the seriousness of the health risks of the
current low body weight.
• If menstruation has begun, the absence of three consecutive menstrual cycles.
Two types of anorexia are recognised:
1) The restricting type in which the main focus is on restricting food
intake and
2) The binge – eating/purging type in which there is regular binge eating
followed by purging by vomiting, laxatives, etc;
Prevalence of Anorexia Nervosa
Anorexia nervosa occurs mainly in women. For every male sufferer there are 15
females who have the disorder. However, there is evidence that the number of
men with eating disorders is rapidly increasing, Anorexia usually starts at
between 14 and 16 years, although two researchers from Great Ormond Street
Children’s Hospital in London, England, have reported cases of anorexia in
children as young as eight-year-old. It is estimated that between 5 and 15
percent of people with anorexia die from it or from related disorders
CLINICAL PICTURE
Anorexia nervosa is a serious eating disorder characterized by an intense fear of
gaining weight, a distorted body image, and severe restriction of food intake,
leading to dangerously low body weight. The Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) outlines the criteria for anorexia nervosa:

1. Restriction of energy intake relative to requirements, leading to significantly

low body weight for one's age, sex, developmental trajectory, and physical
health. This is often accompanied by intense fear of gaining weight or becoming
fat, even though the person is underweight.

2. Disturbance in the way one's body weight or shape is experienced, undue

influence of body weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.

Anorexia nervosa commonly presents with various physical, emotional, and

behavioural symptoms. Physically, individuals may exhibit extreme weight loss,
fatigue, dizziness, fainting, thinning of the hair, and brittle nails. They may also
have irregular menstrual cycles or lose their menstruation altogether
(amenorrhea). Psychological symptoms can include obsessive thoughts about
food, preoccupation with weight and body shape, anxiety, depression, and social
withdrawal.

Comorbidity prevalence among individuals with anorexia nervosa is relatively

high. They often experience other psychiatric disorders such as depression,
anxiety disorders (like generalized anxiety disorder or obsessive-compulsive
disorder), substance abuse, and personality disorders.

The age of onset for anorexia nervosa can vary, but it commonly begins in
adolescence or young adulthood, typically between the ages of 15 and 25.
However, it can also occur in childhood or later in adulthood.
The course of anorexia nervosa can be chronic and challenging. It can follow a
fluctuating pattern with periods of improvement or exacerbation. Recovery rates
vary, with some individuals experiencing full recovery, while others may
struggle with the disorder for years.

Treatment often involves a multidisciplinary approach including psychotherapy

(such as cognitive-behavioral therapy), nutritional counseling, medical
monitoring, and sometimes medication (like antidepressants). Early intervention
is crucial for better outcomes in managing anorexia nervosa.
CASE STUDY
Mia, a 17-year-old high school student, excelled academically and in athletics.
She was known for her perfectionist tendencies and often felt immense pressure
to meet high expectations. Mia started dieting after hearing comments about
her body during a gymnastics competition. Over time, her weight dropped
significantly, and she became obsessed with calorie counting, rigid exercise
routines, and food restriction. Despite her family's concern and interventions
from healthcare professionals, Mia continued to see herself as overweight and
remained terrified of gaining any weight. She struggled with severe anxiety and
depression, experiencing physical complications due to malnutrition. With
therapy and family support, Mia began to address her distorted body image and
gradually regained a healthier relationship with food and her body
Bulimia Nervosa
Bulimia nervosa is characterised by sporadic episodes of compulsive binge
eating. People with bulimia rapidly eat lots of carbohydrate-rich foods in a
seemingly uncontrolled way. They eat more than just a load of cookies – they
could eat a whole of pizza, a whole tub of ice-cream, several giant packs of
potato chips, a whole creamy desert, a whole quiche, or lots of fizzy or milky
drinks. They usually choose foods that are soft and easy to eat. The binge
usually ends with stomach pains or some kind of purging-either self-induced
vomiting or defecating as a result of taking laxatives
Some people begin their binges by eating coloured marker food so they will be
able to tell when they have thrown up all the food, they took in. Although many
people describe themselves as binge eaters, it is the severity and frequency of
the binge eating in bulimia that makes it such a severe disorder. In mild cases a
person might binge two or three times a week. In more extreme cases it might
occur 30 times a week.
Diagnostic Criteria for Bulimia Nervosa
(DSM IV) Frequently occurring episodes of binge eating that are characterised
by both
a) eating an amount of food that is definitely larger than most people would eat
within a specific period of time and in similar circumstances; and
b) a sense of lack of control over eating during the overeating episode.
• Recurrent behaviour to compensate for the overeating and prevent weight
gain, including vomiting, laxatives, fasting or excessive exercise.
• The occurrence of both the binge eating and the compensatory behaviours at
least twice a week for at least a 3 – month period.
• Self – evaluation that is over influenced by weight and body shape
• Bulimic behaviour that does not occur only during episodes of anorexia
nervosa. Two types of bulimia nervosa are recognised:
1) the purging type, in which vomiting or doses of laxatives are used
during the current episode; and
2) the no purging type in which fasting or excessive exercise, but not
purging is used to prevent weight again.
Impact of Bulimia
The process of bingeing and purging can have all sorts of side effects on the rest
of the body. Bulimia sufferers often have puffy cheeks, a bit like those of a
chipmunk. That is because vomiting swells the parotid glands in the lower jaw.
Their tooth enamel can often decay because of the acid that they bring up when
vomiting. You might also notice little calluses on the back of their hands, caused
by the rubbing against the upper teeth while sticking their fingers down their
throats to make themselves sick. Bulimia sufferers also have problems with
their digestive tract, dehydration, and nutritional balances, and anxiety,
depression, and sleep disturbance

CLINICAL PICTURE
Bulimia nervosa is a serious eating disorder characterized by a cycle of binge
eating followed by compensatory behaviors to prevent weight gain, such as self-
induced vomiting, misuse of laxatives, diuretics, fasting, or excessive exercise.
According to the DSM-5 (Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition) criteria, bulimia nervosa includes the following:

1. Recurrent episodes of binge eating: Eating, in a discrete period of time, an

amount of food that is definitely larger than what most individuals would eat
under similar circumstances.
2. A sense of lack of control over eating during the binge episode.
3. Recurrent inappropriate compensatory behaviors to prevent weight gain:
Regularly engaging in behaviors such as self-induced vomiting, misuse of
laxatives, diuretics, fasting, or excessive exercise.
4. The binge eating and inappropriate compensatory behaviors both occur, on
average, at least once a week for three months.
5. Self-evaluation is unduly influenced by body shape and weight.

Comorbidity prevalence with bulimia nervosa can include other mental health
conditions such as depression, anxiety disorders, substance abuse disorders,
personality disorders (especially borderline personality disorder), and self-harm
behaviours.

The age of onset for bulimia nervosa is typically in late adolescence or early
adulthood, often between the ages of 15 and 25, although it can manifest at
other ages as well.

The course of bulimia nervosa can vary significantly among individuals. Some
people may experience fluctuating patterns of symptoms, while others may have
a chronic course with ongoing struggles. Early intervention and effective
treatment can greatly improve the prognosis and help manage the disorder.

Treatment often involves a combination of therapies, including psychotherapy

(such as cognitive-behavioral therapy), nutritional counseling, and sometimes
medication. Support from a multidisciplinary team including therapists,
nutritionists, and medical professionals is crucial for managing bulimia nervosa
effectively.
CASE STUDY
Alex, a 25-year-old college graduate, led a seemingly normal life as a social
and outgoing individual. However, behind the facade, Alex struggled with
bulimia nervosa. Initially, Alex's binge-eating episodes began as a coping
mechanism for stress during university exams. This evolved into a pattern of
consuming large amounts of food, followed by purging behaviours through
self-induced vomiting and excessive exercise. Alex felt trapped in a cycle of
secrecy, shame, and guilt, often bingeing and purging multiple times a day.
The physical toll of bulimia began to manifest in dental issues and
electrolyte imbalances, impacting Alex's overall health and well-being. After
seeking therapy and support groups, Alex started to develop healthier
coping mechanisms and gradually reduced the frequency of binge-purge
episodes.

Binge Eating
It is characterised by episodes of bingeing without the use of compensatory
behaviours such as purging that are seen in bulimia nervosa. Two common
patterns characterise binge eating – compulsively snacking over long intervals
(such as all day at work or all evening in front of the computer or television) or
a consumption of large amounts of food at one time beyond the requirements to
satisfy normal hunger. Binge eating disorder often leads to problems with
weight regulation and sometime obesity. In clinical practice, it is difficult to
distinguish between a binge eating disorder and no purging bulimia nervosa.
Some studies found that binge eating women experienced more negative affect
(depression and anxiety). This suggests that treatment approaches should focus
on helping binge eaters learn to cope more adaptively with poor mood. In
addition to mood, situational and cognitive factors often play important roles in
binge eating
Triggers of Binge Eating
• Particular stressful situations
• Particular upsetting thoughts
• Feeling guilt about something one has done
• Feeling socially isolated or excluded 73
• Worries about responsibilities, problems or the future
• Boredom
CAUSES OF EATING DISORDERS
There is no single theory that can explain why people experience anorexia and
bulimia. There are many biological, psychodynamic, family and socio-cultural
theories that, when combined, can provide some understanding of what is
happening. The theories can lay the foundation for the types of treatment the
person might receive, but as yet there is no scientific explanation of why people
suffer from eating disorders.
CLINICAL PICTURE
Binge eating disorder (BED) is a serious mental health condition characterized
by recurrent episodes of eating large quantities of food in a discrete period while
feeling a lack of control over eating. According to the DSM-5 criteria, to
diagnose BED, an individual must exhibit:

1. Recurrent episodes of binge eating: Eating, in a discrete period of time (e.g.,

within any 2-hour period), an amount of food that is definitely larger than what
most individuals would eat in a similar period.

2. Lack of control over eating during the episode: Feeling a sense of lack of
control over eating during the episode, such as a feeling that one cannot stop
eating or control what or how much one is eating.

Additionally, the binge eating episodes are associated with three or more of the
following:
- Eating more rapidly than normal.
- Eating until feeling uncomfortably full.
- Eating large amounts of food when not physically hungry.
- Eating alone because of embarrassment about the quantity of food being eaten.
- Feeling disgusted with oneself, depressed, or very guilty afterward.

Some aspects related to BED:

Comorbidity Prevalence: BED often coexists with other mental health disorders
such as depression, anxiety, substance abuse, and other eating disorders like
bulimia nervosa. It can also be linked with various medical conditions such as
obesity, diabetes, and hypertension.

Age of Onset: Binge eating disorder can develop at any age but often starts in
the late teens or early 20s. However, it can also emerge in adulthood.

Course: The course of BED can vary. For some individuals, it may be episodic
with periods of remission and relapse, while for others, it may be more chronic.
Treatment options, including therapy and sometimes medications, can help
manage symptoms and improve quality of life for those with BED.

It's crucial to seek professional help if someone is experiencing symptoms of

binge eating disorder as early intervention and proper treatment can make a
significant difference in managing the condition. Therapy, particularly
cognitive-behavioral therapy (CBT), has shown effectiveness in treating BED.

CASE STUDY
Sarah, a 30-year-old marketing professional, had struggled with her weight and
emotional eating since her teenage years. She experienced episodes of
consuming large quantities of food in a short period, feeling distressed and
unable to control her eating behavior. Sarah used food as a way to cope with
stress, anxiety, and emotional turmoil in her personal and professional life.
These episodes led to weight gain and negative self-image, affecting Sarah's
confidence and relationships. Seeking therapy specializing in binge-eating
disorder helped Sarah understand the triggers for her overeating and develop
strategies to manage her emotions without turning to food. Gradually, she
began to regain control over her eating habits and foster a healthier
relationship with food and her body.

Gender Dysphoria
The disorders of sexual arousal, if they cause distress or impairment to the
individual, or cause personal harm, or the risk of harm to others are called
paraphilic disorders. It is important to note that DSM-5 does not consider a
paraphilia a disorder unless it is associated with distress and impairment or
harm or the threat of harm to others. Thus, unusual patterns of sexual attraction
are not considered to be sufficient to meet criteria for a disorder
In DSM-5 Gender Dysphoria has replaced gender identity disorder. “Gender
dysphoria” is
discomfort with one’s sex-relevant physical characteristics or with one’s
assigned gender.
The change in terminology is both usefully descriptive and theoretically neutral.
That is,
individuals who have been previously diagnosed with gender identity disorder
certainly experience
gender dysphoria, but whether or not this is always due to atypical gender
identity development is
less clear.
Gender dysphoria also is consistent with a dimensional approach (the degree of
dysphoria can
vary) and may fluctuate over time within the same individual (Cohen-Ketenes
& Pfaffian, 2010).
Gender dysphoria can be diagnosed at two different life stages, either
during adolescence or
adulthood (i.e., gender dysphoria in adolescents and adults) or childhood
(gender dysphoria in
children)
In DSM-5 Gender Dysphoria has replaced gender identity disorder. “Gender
dysphoria” is
discomfort with one’s sex-relevant physical characteristics or with one’s
assigned gender.
The change in terminology is both usefully descriptive and theoretically
neutral. That is,
individuals who have been previously diagnosed with gender identity disorder
certainly experience
gender dysphoria, but whether or not this is always due to atypical gender
identity development is
less clear.
Gender dysphoria also is consistent with a dimensional approach (the degree
of dysphoria can
vary) and may fluctuate over time within the same individual (Cohen-Kettenis
& Pfafflin, 2010).
Gender dysphoria can be diagnosed at two different life stages, either during
adolescence or
adulthood (i.e., gender dysphoria in adolescents and adults) or childhood
(gender dysphoria in
children)
In DSM-5 Gender Dysphoria has replaced gender identity disorder.
“Gender dysphoria” is
discomfort with one’s sex-relevant physical characteristics or with one’s
assigned gender.
The change in terminology is both usefully descriptive and theoretically
neutral. That is,
individuals who have been previously diagnosed with gender identity disorder
certainly experience
gender dysphoria, but whether or not this is always due to atypical gender
identity development is
less clear.
Gender dysphoria also is consistent with a dimensional approach (the degree
of dysphoria can
vary) and may fluctuate over time within the same individual (Cohen-Kettenis
& Pfaffian, 2010).
Gender dysphoria can be diagnosed at two different life stages, either
during adolescence or
adulthood (i.e., gender dysphoria in adolescents and adults) or childhood
(gender dysphoria in
children)

Gender dysphoria, as defined in DSM-5, represents discomfort with one’s sex-

relevant physical characteristics or the assigned gender. The shift in terminology
from 'gender identity disorder' to 'Gender Dysphoria' aims to offer a more
descriptive and neutral framework. Individuals previously diagnosed with
gender identity disorder often experience gender dysphoria, yet whether this
always arises solely from atypical gender identity development remains less
certain. Moreover, gender dysphoria aligns with a dimensional approach,
acknowledging that the intensity of dysphoria can vary and may fluctuate within
the same individual over time (Cohen-Ketenes & Pfaffian, 2010). The diagnosis
of gender dysphoria can occur at two distinct life stages: during adolescence or
adulthood (referred to as 'gender dysphoria in adolescents and adults') and in
childhood ('gender dysphoria in children'
Gender identity, a basic feature of personality, refers to an individual’s feeling
of being male or female. Children become aware that they are male or female at
an early age and once it is formed, their gender identity is highly resistant to
change. Gender identity disorder (GID), is a condition in which a person has
been assigned one gender (usually at birth), but identifies as belonging to
another gender, or does not conform with the gender role their respective
society prescribes to them.
It is a psychiatric term for what is widely known by other terms such as
transsexuality, transgender, transvestism or cross-dressing. This disorder is
different from transvestism or transvestic fetishism where cross dressing occurs
for sexual pleasure, but the transvestite does not identify with the other sex.
Transsexualism should also not be confused with the behaviour of drag queens
and drag kings. Also, transvestic fetishism usually has little, if anything, to do
with transsexualism. As a general rule, transsexual people tend to dress and
behave in a manner consistent with the gender with which they identify
ORIGIN OF GENDER IDENTITY DISORDER
During the 1950’s and 60’s, psychologists began studying gender development
in young children, partially in an effort to understand the origins of
homosexuality which was viewed as a mental disorder at the time.
Psychoanalyst Robert Stoller is credited with introducing the term gender
identity and behavioural psychologist John Money was also instrumental in the
development of early theories of gender identity. His work popularized an
interactionist theory of gender identity, suggesting that, up to a certain age,
gender identity is relatively fluid and subject to constant negotiation.
Sigmund Freud also had a unique theory for the development of gender identity.
He believed it was developed during the phallic stage of development. During
this time, young boys develop an Oedipus complex and young girls an Electra
complex. Freud believed that during this time, the child has an unconscious
sexual desire for the parent of the opposite sex and jealousy or hatred for the
same sex parent. That jealousy eventually turns into emulating and the child
wants to be like that parent, eventually identifying with it.
The notion of gender identity appeared in the Diagnostic and Statistical Manual
of Mental Disorders in its third edition, DSM-III (1980), in the form of two
psychiatric diagnoses of gender dysphoria – gender identity disorder of
childhood (GIDC), and transsexualism (for adolescents and adults). The 1987
revision of the manual, the DSM-III-R added a third diagnosis – gender identity
disorder of adolescence and adulthood, non-transsexual type. This later
diagnosis was removed in the subsequent revision, DSM-IV (1994), which also
collapsed the GIDC and transsexualism in a new diagnosis of gender identity
disorder.
COMPONENTS OF GENDER IDENTITY DISORDER
People with gender identity disorder frequently report their feelings as “having
always been there”, and the disorder can be evident in early childhood. Most
people know whether they have a gender identity problem by the time they
reach adolescence, although in some cases it seems to appear in adulthood.

Gender identity disorder is a diagnosis given to persons who meet a certain

number of clinical criteria related to feelings of discontent regarding one’s
biologicals, and identification with the opposite biological sex. The individual
may identify to the point of believing that they are, in fact, a member of the
other sex who is trapped in the wrong body. There are two components of
gender identity disorder, both of which must be present to make the diagnosis.
i) There must be evidence of a strong and persistent gross-gender
identification, which is the desire to be, or the insistence that one is, of
the other sex. This cross-gender identification must not merely be a
desire for any perceived cultural advantages of being the other sex.
ii) ii) There must also be evidence of persistent discomfort about one’s
assigned sex or a sense of inappropriateness in the gender role of that
sex.
Gender identity disorder can affect children, adolescents, and adults.
Individuals with gender identity disorder have strong cross-gender
identification. They believe that they are, or should be, the opposite sex.
They are uncomfortable with their sexual role and organs and may express a
desire to alter their bodies. While not all persons with gender identity
disorder are labelled as transsexuals, there are those who are determined to
undergo sex change procedures or have done so, and, therefore, are classified
as transsexual.
Adults with gender identity disorder sometimes live their lives as members
of the opposite sex. They tend to be uncomfortable living in the world as a
member of their own biologic or genetic sex. They often cross-dress and
prefer to be seen in public as a member of the other sex. Some people with
the disorder request sex change surgery.

CRITERIA FOR GENDER IDENTITY DISORDER

According to the American Psychiatric Association and the Diagnostic and
Statistical Manual of Mental Disorders IV (DSM-IV) the following criteria
must be met before a person can be given the official diagnosis of gender
identity disorder:
• There must be evidence of strong and persistent cross-gender identification.
This cross-gender identification must not merely be a desire for any
perceived cultural advantages of being the other sex.
• There must also be evidence of persistent discomfort about one’s assigned
sex or a sense of inappropriateness in the gender role of that sex.
• The individual must not have a concurrent physical intersex condition (e.g.,
androgen insensitivity syndrome or congenital adrenal hyperplasia).
• There must be evidence of clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
The DSM-IV also provides diagnostic criteria for gender disorders that do
not meet the criteria for the general gender identity disorder diagnosis. The
following criteria are sufficient for a diagnosis of gender identity disorder in
Children as well as for Gender Identity Disorder Not Otherwise Specified
(GIDNOS). For the former diagnosis, criteria must be identified before a
person is 18 years of age.

CLINICAL PICTURE

Gender dysphoria is a condition characterized by distress or discomfort that

occurs when an individual's assigned gender at birth is not congruent with
the gender with which they identify. The Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) outlines criteria for diagnosing gender
dysphoria:

1. A marked incongruence between one's experienced/expressed gender and

assigned gender, lasting at least six months.
2. The individual must have a strong desire to be rid of their primary and/or
secondary sex characteristics or a strong desire for the primary and/or
secondary sex characteristics of the other gender.
3. The individual's desire to be of another gender must be accompanied by
clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
Comorbidity prevalence:
- Individuals with gender dysphoria may experience comorbid mental health
conditions such as depression, anxiety, substance abuse, and other mood
disorders. These conditions can arise due to the distress associated with the
incongruence between one's gender identity and assigned gender.

Age of onset:
- Gender dysphoria can manifest at different ages. Some individuals may
express discomfort with their assigned gender as early as childhood, while
others may not experience significant distress until adolescence or
adulthood. The age of onset varies widely among individuals.

Course:
- The course of gender dysphoria can also vary significantly. For some
individuals, their gender dysphoria may persist throughout their lives, while
for others, it might change or fluctuate over time. Some individuals may find
relief through social or medical gender transition, while others may manage
their dysphoria through therapy or other coping strategies.

Treatment and support for individuals with gender dysphoria often involve a
multidisciplinary approach, including mental health support, gender-
affirming therapy, hormone therapy, and, in some cases, gender-affirming
surgeries. It's important to note that not all individuals with gender dysphoria
will pursue medical interventions, as treatment choices vary based on
individual preferences and circumstances.

If you or someone you know is experiencing distress related to gender

identity, seeking support from mental health professionals or support groups
specializing in gender identity issues can be beneficial.
CAUSES OF GENDER IDENTITY DISORDER
John Money has coined a useful term “gender maps” to describe the
phenomenon of gender identity. He defined gender map as the entity,
template, or schema within the mind and brain that codes masculinity and
femininity and androgyny. This map or coding imprint is established very
early in life through an interaction of nature and nurture. Because gender
map development is highly influenced by hormones emanating from the
developing foetus, sex and gender identification are generally closely
matched. But like most aspects of being human, there are no guarantees. As a
result, an individual may, as early as the age of four, find themselves aware
of being caught between having the anatomy of one sex but being equipped
with a gender map much more typical of an individual of the opposite sex. It
is also apparently possible for an individual to have no clear sense of gender
whatsoever.
There is no clearly understood cause for gender identity disorder.
The biological theory is based on evidence that high levels of the male
hormone testosterone are associated with high levels of aggression in boys
and tomboyishness in girls. Social learning theory proposes that gender
typing is the result of a combination of observational learning and
differential reinforcement.
Cognitive-Developmental theory, states that gender understanding follows a
prescribed time line. The pattern put forth is that children recognise that they
are either boys or girls by the age of two or three, followed shortly by
recognition that gender is stable over time. By the age of six or seven
children understand that gender is also stable across situations.
No matter what theory one adopts, for most children, whose sex and gender
map are congruent, this insight typically goes unnoticed. However, if there is
sex/ gender map incongruence, the child is left perplexed about his or her
gender status and begins a lifelong, often compulsive search for resolution of
the discrepancy
All children naturally comply with the demands of their internal sense of
gender. Boys generally express male behaviour and girls generally express
female behaviour even when raised in closely monitored gender neutral
conditions. If there is any confusion in the child, he or she quickly learns
from adults and peers that certain gender expression behaviours are
inappropriate for that individual. This is true even of gender dysphoric
children. Some gender dysphoric children internalise their dilemma and
make heroic efforts to display the gender behaviour expected of them, while
expressing their internal sense of gender through secret play, cross-dressing,
and cross-gender fantasies. Others may continue to struggle by insisting that
they be allowed to openly express maleness or femaleness irrespective of
their assigned sex. Either way, the problem becomes subsumed into the
child’s personality
The arrival of adolescence increases the difficulties for people who are
gender dysphonic. Without fail, the subsequent development of secondary
sex characteristics counter to the individual’s desires increases anxiety.
Often, frustration sets in, and determination to finally resolve the problem
becomes the individual’s driving force in life. This is especially true for
gender dysphoric males. Since the obvious first effort is to accept the
physical evidence of their genitalia as reality, it is very common to see many
of these people push through these early years of adulthood by engaging in
stereotypical, even supermale activities. Since outward behaviour has no
permanent influence on internal gender understanding, these activities serve
only to complicate the individual’s social involvement, resulting in anxiety
about expressing his true felt gender.
This anxiety state is characterised by feelings of confusion, shame, guilt, and
fear. These individuals are confused over an inability to handle their gender
identity problem in the same way they readily handle other problems in life.
They feel shame over an inability to control what they believe society
considers to be sexually perverse activities. Even though cross dressing and
cross gender fantasies provide much needed temporary relief, these activities
often leave the individual profoundly ashamed of what she or he has done
Closely associated with shame is guilt over being dishonest by hiding secret
gender identity disorder needs and desires from family, friends, and society.
For example, people commonly get married and have children without
telling their spouse of their gender dysphoria before making the
commitment. Typically, it is kept secret because they have the mistaken
conviction that participation in marriage and parenting will in itself erase
their gender dysphoria. All of this then leads to fear of being discovered.
With some justification, gender dysphoric people fear being called sick,
uncaring, selfish and even being left alone by the people they love the most.
The psychological diagnosis of gender identity disorder (GID) is used to
describe a male or female who feels a strong identification with the opposite
sex and experiences considerable distress because of his or her actual sex.
Thus, Gender identity disorder can affect children, adolescents and adults.
Individuals with gender identity disorder have strong cross-gender
identification.
 They believe that they are, or should be, the opposite sex. They are
uncomfortable with their sexual role and organs and may express a desire to
alter their bodies. While not all persons with GID are labelled as
transsexuals, some are determined to undergo sex change procedures or to
pass socially as the opposite sex. Transsexuals alter their physical
appearance cosmetically and hormonally, and may eventually undergo a sex
change operation.
CASE STUDY
Max, a 20-year-old college student, had always felt discomfort with the gender
assigned at birth. From an early age, Max expressed a strong identification
with the male gender, which conflicted with the societal expectations associated
with the assigned female identity. Max experienced distress, anxiety, and
discomfort with physical characteristics and social roles that didn't align with
his true gender identity. This led to challenges in relationships and mental
health struggles. After seeking counselling and support from LGBTQ+
organizations, Max decided to undergo gender-affirming therapy and
transition. With the support of friends and family, Max began the process of
transitioning to live authentically as a male, leading to a significant
improvement in mental well-being and self-acceptance.

UNIT 4
TOPIC - Schizophrenia : Schizophrenia: clinical picture and aetiology
Schizophrenia is a severe, psychotic disorder. People who have it may hear
voices, see things that are not there or believe that others are reading or
controlling their minds. In men, symptoms usually start in the late teens and
early 20s. They include hallucinations, such as visual hallucinations ( seeing
things which are not there), and auditory hallucinations (hearing things
which are not present), and delusions such as false beliefs that others are
plotting or conspiring against them while actually there is no such thing.
Incidence of Schizophrenia
The incidence of schizophrenia is estimated to be one percent to one and a
half percent of the U.S. population being diagnosed with it over the course of
their lives. In India, according to NIMH, it is estimated that 4.3 to 8.7
million people (a rough estimate based on the population) suffer from
schizophrenia. According to Barua et al (2006), the prevalence rate of
schizophrenia in India is 1%.
Characteristics of Schizophrenia
While there is no known cure for schizophrenia, it is a treatable disorder.
Most of those afflicted by schizophrenia respond to drug therapy, and many
are able to lead productive and fulfilling lives. It is characterised by a
constellation of distinctive and predictable symptoms. The symptoms that
are most commonly associated with the disease are called positive
symptoms, that denote the presence of grossly abnormal behaviour. These
include thought disorder, delusions, and hallucinations.
Thought disorder is the diminished ability to think clearly and logically.
Often it is manifested by disconnected and nonsensical language that renders
the person with schizophrenia incapable of participating in conversation,
contributing to the person’s alienation from his family, friends, and society
. Delusions are common among individuals with schizophrenia. An affected
person may believe that he is being conspired against (called “paranoid
delusion”). Broadcasting, describes a type of delusion in which the
individual with this illness believes that his thoughts can be heard by others.
Hallucinations are perceptual disorder, in which one could suffer from
auditory hallucination, visual hallucination and tactile hallucination.
Sometime the voices that the schizophrenic hears may describe the person’s
actions, warn him of danger or tell him what to do. At times the individual
may hear several voices carrying on a conversation. Less obvious than the
“positive symptoms” but equally serious are the deficit or negative
symptoms that represent the absence of normal behaviour. These include flat
or blunted affect (i.e., lack of emotional expression), apathy, and social
withdrawal). Schizophrenia is a mental disorder characterised by a
disintegration of thought processes and of emotional responsiveness. It most
commonly manifests as auditory hallucinations, paranoid or bizarre
delusions, or disorganised speech and thinking, and it is accompanied by
significant social or occupational dysfunction.
Onset of Schizophrenia
It can affect anyone at any point in life, it is somewhat more common in
those persons who are genetically predisposed to the disorder. The first
psychotic episode generally occurs in late adolescence or early adulthood.
The probability of developing schizophrenia as the offspring of two parents,
neither of whom has the disease, is 1 percent. The probability of developing
schizophrenia as the offspring of one parent with the disease is
approximately 13 percent. The probability of developing schizophrenia as
the offspring of both parents with the disease is approximately 35%. Persons
with schizophrenia develop the disease between 16 and 25 years of age.
This disorder has its onset around adolescent years to 20s to early 30s. This
disorder makes the person behave in the weirdest manner that persons with
this disorder are also stigmatized. As generally thought to be, schizophrenia
is not a split personality, it is a rare and very different disorder. Like cancer
and diabetes, schizophrenia has a biological basis. It is not caused by bad
parenting or personal weaknesses.
Onset is uncommon after age 30, and rare after age 40. In the 16–25-year-old
age group, schizophrenia affects more men than women. In the 25–30-year-
old group, the incidence is higher in women than in men. The onset of
symptoms typically occurs in young adulthood, with a global lifetime
prevalence of about 0.3–0.7%. Diagnosis is based on observed behaviour
and the patient’s reported experiences
ETIOLOGY OF SCHIZOPHRENIA
The causes of schizophrenia have been the subject of much debate, with
various factors proposed and discounted or modified. The language of
schizophrenia research under the medical model is scientific. Such studies
suggest that genetics, prenatal development, early environment,
neurobiology and psychological and social processes are important
contributory factors.
Current psychiatric research into the development of the disorder is often
based on a neurodevelopmental model (proponents of which see
schizophrenia as a syndrome. However, schizophrenia is diagnosed on the
basis of symptom profiles. Neural correlates do not provide sufficiently
useful criteria “Current research into schizophrenia has remained highly
fragmented, much like the clinical presentation of the disease itself”
Genetics
Genetic vulnerability and environmental factors can act in combination to
result in diagnosis of schizophrenia. Research suggests that genetic
vulnerability to schizophrenia is multi factorial, caused by interactions of
several genes. Both individual twin studies and meta-analyses of twin studies
estimate the heritability of risk for schizophrenia to be approximately 80%.
Concordance rates between monozygotic twins was close to 50%, whereas
dizygotic twins were 17%. Adoption studies have also indicated a somewhat
increased risk in those with a parent with schizophrenia even when raised
apart. Studies suggest that the phenotype is genetically influenced but not
genetically determined. Also, the variants in genes are generally within the
range of normal human variation and have low risk associated with them
each individually. Some interact with each other and with environmental risk
factors and that they may not be specific to schizophrenia
Prenatal
It is well established that obstetric complications or events are associated
with an increased chance of the child later developing schizophrenia,
although overall they constitute a nonspecific risk factor with a relatively
small effect Obstetric complications occur in approximately 25 to 30% of the
general population and the vast majority do not develop schizophrenia, and
likewise the majority of individuals with schizophrenia have not had a
detectable obstetric event. Nevertheless, the increased average risk is well
replicated, and such events may moderate the effects of genetic or other
environmental risk factors. The specific complications or events most linked
to schizophrenia, and the mechanisms of their effects, are still under
examination. One epidemiological finding is that people diagnosed with
schizophrenia are more likely to have been born in winter or spring.
However, the effect is not large. Explanations have included a greater
prevalence of viral infections at that time, or a greater likelihood of vitamin
D deficiency. A similar effect (increased likelihood of being born in winter
and spring) has also been found with other, healthy populations, such as
chess players
Fatal Growth
Lower than average birth weight has been one of the most consistent
findings, indicating slowed fatal growth possibly mediated by genetic
effects. Almost any factor adversely affecting the foetus will affect growth
rate, however, so the association has been described as not particularly
informative regarding causation. In addition, the majority of birth cohort
studies have failed to find a link between schizophrenia and low birth weight
or other signs of growth retardation
Hypoxia
It has been hypothesized since the 1970s that brain hypoxia (low oxygen
levels) before, at or immediately after birth may be a risk factor for the
development of schizophrenia. Hypoxia is now being demonstrated as
relevant to schizophrenia in animal models, molecular biology and
epidemiology studies. One study in Molecular Psychiatry was able to
differentiate 90% of schizophrenics from controls based on hypoxia and
metabolism. Hypoxia has been recently described as one of the most
important of the external factors that influence susceptibility, although
studies have been mainly epidemiological. Such studies place a high degree
of importance on hypoxic influence. Fatal hypoxia, in the presence of certain
unidentified genes, has been correlated with reduced volume of the
hippocampus, which is in turn correlated with schizophrenia. Although most
studies have interpreted hypoxia as causing some form of neuronal
dysfunction or even subtle damage, it has been suggested that the
physiological hypoxia that prevails in normal embryonic and fatal
development, or pathological hypoxia or ischemia, may exert an effect by
regulating or deregulating genes involved in neurodevelopment
Other Factors
There is an emerging literature on a wide range of prenatal risk factors, such
as prenatal stress, intrauterine (in the womb) malnutrition, and prenatal
infection. Increased paternal age has been linked to schizophrenia, possibly
due to “chromosomal aberrations and mutations of the aging germline.”
Maternal-fatal rhesus or genotype incompatibility has also been linked, via
increasing the risk of an adverse prenatal environment. Also, in mothers with
schizophrenia, an increased risk has been identified via a complex
interaction between maternal genotype, maternal behaviour, prenatal
environment and possibly medication and socio-economic factors. There
may be an association between celiac disease (gluten intolerance) and
schizophrenia in a small proportion of patients, though large randomized
controlled trials and epidemiological studies will be needed before such an
association can be confirmed. Withdrawal of gluten from the diet is an
inexpensive measure which may improve the symptoms in a small (£3%)
number of schizophrenic patients.
Childhood Antecedents
In general, the antecedents of schizophrenia are subtle and those who will go
on to develop schizophrenia do not form a readily identifiable subgroup,
which would lead to identification of a specific cause. Average group
differences from the norm may be in the direction of superior as well as
inferior performance. Overall, birth cohort studies have indicated subtle
nonspecific behavioural features, some evidence for psychotic like
experiences (particularly hallucinations), and various cognitive antecedents.
There have been some inconsistencies in the particular domains of
functioning identified and whether they continue through childhood and
whether they are specific to schizophrenia. A prospective study found
 average differences across a range of developmental domains, including
reaching milestones of motor development at a later age, having more speech
problems, lower educational test results, solitary play preferences at ages
four and six, and being more socially anxious at age 13.
SUBSTANCE USE
The relationship between schizophrenia and drug use is complex, meaning
that a clear causal connection between drug use and schizophrenia has not
been found. There is strong evidence that using certain drugs can trigger
either the onset or relapse of schizophrenia in some people. It may also be
the case, however, that people with schizophrenia use drugs to overcome
negative feelings associated with both the commonly prescribed
antipsychotic medication and the condition itself, where negative emotion,
paranoia and anhedonia are all considered to be core features. 1 3 The rate of
substance use is known to be particularly high in this group. In a recent
study, 60% of people with schizophrenia were found to use substances and
37% would be diagnosable with a substance use disorder.
CASE STUDY
James, a 28-year-old aspiring musician, began experiencing subtle changes
in his late teens. Initially, he noticed mild social withdrawal and growing
suspicion toward his friends' intentions. As time passed, James became
increasingly preoccupied with unusual beliefs, convinced that he was
receiving special messages through songs on the radio and television
broadcasts. He started isolating himself, feeling that others were plotting
against him. James also reported hearing indistinct voices commenting on
his actions and conspiring to harm him. His once vibrant and passionate
demeanour turned into a withdrawn and perplexed state. His family,
noticing these alarming changes, sought psychiatric help. James was
diagnosed with paranoid schizophrenia, and with a combination of
antipsychotic medication and therapy, he gradually regained a sense of
reality and stability, allowing him to pursue his passion for music once
again.
Suicide Risk in Schizophrenia
People with the schizophrenia condition have a 50 times higher risk of
attempting suicide than the general population. The risk of suicide is very
serious in people with schizophrenia. Suicide is the number one cause of
premature death among people with schizophrenia, with an estimated 10 percent
to 13 percent killing themselves and approximately 40% attempting suicide at
least once (and as much as 60% of males attempting suicide). The extreme
depression and psychoses that can result due to lack of treatment are the usual
causes. These suicide rates can be compared to the general population, which is
somewhere around 0.01%.
SYMPTOMS OF SCHIZOPHRENIA
The diagnostic criteria of DSM IV (TR) include negative symptoms. These
symptoms are as a rule, do not respond well to treatment and to many
medications. Behaviour or functions that are deficient or absent in a
schizophrenic individual’s behaviour and thus refer to a loss or reduction of
normal functions. The schizophrenic with negative symptoms has also a deficit
or a lack in these behaviours and are considered as deteriorated.
But the positive symptoms on the other hand come with individual’s normal
behavioural repertoire and include delusions and hallucinations as well as
psychomotor agitation, bizarre behaviour and minimal cognitive impairment. It
also includes Type I and Type II Schizophrenia. These also include positive and
negative symptoms and respectively include with more emphasis on biology
and on medication efficacy. Type I schizophrenics respond well to antipsychotic
medications and have normal sized brain ventricles but the other one Type II
does not respond well to medications and may have enlarged ventricles and
abnormalities in their frontal lobe.
Signs and symptoms of schizophrenia generally are divided into three categories
— positive, negative and cognitive
Negative Symptoms
Negative symptoms refer to a diminishment or absence of characteristics of
normal function. They may appear months or years before positive symptoms.
They include:
• Loss of interest in everyday activities
• Appearing to lack emotion
• Reduced ability to plan or carry out activities
• Neglect of personal hygiene
• Social withdrawal
• Loss of motivation
Cognitive Symptoms
Cognitive symptoms involve problems with thought processes. These symptoms
may be the most disabling in schizophrenia, because they interfere with the
ability to perform routine daily tasks. A person with schizophrenia may be born
with these symptoms, but they may worsen when the disorder starts. They
include
• Problems with making sense of information
• Difficulty paying attention
• Memory problems
Affective Symptoms
Schizophrenia also can affect mood, causing depression or mood swings. In
addition, people with schizophrenia often seem inappropriate and odd in regard
to their moods, causing others to avoid them, which leads to social isolation.
People with schizophrenia often lack awareness that their difficulties stem from
a mental illness that requires medical attention. So, it usually falls to family or
friends to get them help.
Suicidal Thoughts
Suicidal thoughts and behaviour are common among people with schizophrenia.
If you suspect or know that your loved one is considering suicide, seek
immediate help. Contact a doctor, mental health provider or other health care
professional.
Common Symptoms
• Social withdrawal
• Flat ,expressionless gaze
• Inappropriate laughter or crying
• Depression
• Insomnia or oversleeping
• Delusions
– Delusions of persecution
– Delusions of reference – Delusions of grandeur
– Delusions of control
• Hallucinations
– Auditory hallucinations
– Visual hallucinations in some cases
• Disorganised speech
• Disorganised behaviour
• Clumsy in motor functions
• Rigidity, tremor, jerking arm movements, or involuntary movements of the
limbs
• Awaked Walking
• Unusual gestures and postures
• Inability to experience joy or pleasure from activities (called anhedonia)
• Appearing desireless or seeking nothing
• Feeling indifferent to important events
• Low motivation or No motivation
• Suicidal thoughts in some cases
• Rapidly changing mood.

TYPES OF SCHIZOPHRENIA
The nature of symptoms taken into account while determining the disease of
schizophrenia varies greatly with the progression of the disease. There are 5
types of schizophrenia, the subtypes are defined in accordance with the most
prominent characteristics. The same person may be analysed with different
types of schizophrenia as the illness proceeds. The types of schizophrenia are:
I) Paranoid schizophrenia - Characterized by delusions and auditory
hallucinations, individuals with paranoid schizophrenia often have exaggerated
or false beliefs of persecution or conspiracy. They may believe that others are
spying on them, plotting against them, or attempting to harm them. Despite
these beliefs, their cognitive functions might remain intact, and they might not
exhibit significant disorganization of thoughts or behaviours.
ii) Disorganised schizophrenia (hebephrenia) - Disorganized schizophrenia is
marked by disorganized speech, behavior, and flattened or inappropriate affect.
Individuals might exhibit fragmented thoughts, nonsensical speech, and erratic
behavior. Their emotions can be inappropriate or dulled, making it difficult for
them to function in daily life.
iii)Catatonic schizophrenia - This type involves disturbances in movement.
People with catatonic schizophrenia might display immobility, rigidity, or
excessive, purposeless movement. They might also show symptoms such as
echolalia (repeating others' words) or echopraxia (imitating movements).
iv) Undifferentiated schizophrenia - When a person doesn't fit neatly into one
specific subtype of schizophrenia, they may receive a diagnosis of
undifferentiated schizophrenia. Their symptoms might not align strongly with
paranoid, disorganized, or catatonic patterns but still present with significant
psychotic features.
v) Residual type schizophrenia - Residual schizophrenia refers to individuals
who have previously experienced a major schizophrenic episode but are
currently not exhibiting prominent positive symptoms like hallucinations or
delusions. However, they might still display mild negative symptoms, such as
social withdrawal, flat affect, or odd behaviours.

CLINICAL PICTURE
Absolutely, let's delve deeper into the clinical picture, criteria, comorbidity
prevalence, and course of schizophrenia.

Clinical Picture and DSM Criteria:

Positive Symptoms:
- Delusions: These are fixed false beliefs that aren't based on reality. They can
include beliefs of being controlled, having special powers, or being persecuted.
- Hallucinations: Often auditory, hearing voices that others don't hear. Visual or
tactile hallucinations can also occur.
- Disorganized thinking and speech: Difficulty organizing thoughts and
expressing them coherently.

Negative Symptoms:
- Affective flattening: Reduced range or intensity of emotional expression.
- Alogia: Reduced speech output.
- Avolition: Reduced motivation to initiate and complete activities.

Cognitive Symptoms:
- Impaired working memory: Difficulty in holding and manipulating
information to reason and solve problems.
- Difficulty in attention: Trouble focusing or sustaining attention.

DSM Criteria for Diagnosis:

- Two or more symptoms present for a significant portion of time during a one-
month period.
- Functional impairment: Significant social or occupational dysfunction.
- Continuous signs of the disturbance persist for at least six months.

Comorbidity Prevalence:

Substance Use Disorders:

- Individuals with schizophrenia have a higher risk of substance abuse (alcohol,
cannabis, etc.). This can complicate treatment and exacerbate symptoms.

Depression and Anxiety Disorders:

- Schizophrenia often coexists with depressive disorders or anxiety disorders.
Symptoms of these disorders can worsen the overall clinical picture.

Cognitive Impairments:
- Difficulty in cognitive functions like memory, attention, and executive
functioning often accompanies schizophrenia, impacting daily functioning.
Physical Health Conditions:
- People with schizophrenia might have increased rates of physical health issues
such as obesity, diabetes, and cardiovascular diseases due to lifestyle factors,
medication side effects, or shared biological factors.

Course:

Acute Phase:
- Exacerbation of Symptoms: Intense positive symptoms (delusions,
hallucinations) and potentially disruptive behavior.

Residual Phase:
- Symptoms Reside: Some symptoms may persist, albeit at a reduced intensity,
leading to functional impairment.

Stabilization and Recovery:

- Management with Treatment: Medication, therapy, and social support aim to
stabilize symptoms and improve functionality.
- Potential for Relapse: Periods of exacerbation can occur, but with proper
management, relapses can be minimized.

Long-term Outlook:
- Varied Course: Some individuals experience periods of remission while others
may have persistent symptoms.
- Management is Key: Early intervention and ongoing treatment significantly
improve outcomes.
- Holistic Approach: Combining medication, therapy, and social support is
crucial for long-term management.

Understanding schizophrenia involves acknowledging its complexity and the

individual variations in symptoms, comorbidities, and course. A comprehensive
approach involving healthcare professionals, family, and social support systems
is vital in managing this condition effectively.

CASE STUDY
John is a 34-year-old man who had been leading a relatively normal life,
working as a software engineer at a reputable company. However, over the past
few months, his behavior began to change noticeably. He started withdrawing
from social interactions and spending extended periods alone in his apartment.
His colleagues noticed a decline in his work performance, as he became
increasingly preoccupied and struggled to concentrate during meetings.
John's family observed peculiar changes in his behavior at home. He became
distrustful of his family members, often claiming they were plotting against him.
He began talking to himself, responding to unseen entities, and expressed an
intense belief that his thoughts were being controlled by an external force. John
reported experiencing auditory hallucinations, hearing voices that criticized
and threatened him.
As his condition worsened, John's personal hygiene deteriorated, and he
neglected his daily routines, often forgetting to eat or sleep properly. Concerned
about his well-being, John's family sought psychiatric help. After a thorough
evaluation and assessment, he was diagnosed with schizophrenia.
John began treatment that involved a combination of antipsychotic medication
and therapy. Through therapy sessions, he worked on managing his symptoms
and learning coping strategies to differentiate between reality and his
hallucinations. Over time, with consistent support from his family and
healthcare professionals, John showed gradual improvement. He became more
aware of his condition and, with ongoing treatment, made strides toward
regaining aspects of his daily life and social functioning.
This case study of John illustrates how schizophrenia can impact an
individual's perception of reality, leading to disruptions in social, occupational,
and personal functioning. Effective treatment and support from mental health
professionals and loved ones play a crucial role in managing symptoms and
aiding recovery in individuals with schizophrenia.