CHAPTER ONE

INTRODUCTION AND BASIC ISSUES

Abnormal psychology is the application of the concepts and research tools of the science of psychology to the
study of behaviour disorders. It is a search for why people behave in unexpected, sometimes bizarre, and typically
self-defeating ways. The problems experienced by people whose behaviour may be termed abnormal are called
psychopathology (psyche = mind and pathology = disease; therefore pathology of the mind). There is
terminological confusion with respect to the basic concept of abnormal psychology. Early theorists defined
abnormal psychology as the study of mental illness but present day psychologists have objected to the term
mental illness because it reflects the disease model which is commonly used in medicine. Objection has also been
raised about the use of terms like insanity and lunacy which reflect the legal perspective of abnormal condition.
Other terms that have been used include mental disorder, behavioural disorder, behavioural pathology and
madness. However, the term madness is primarily a lay person word and not a technical or scientific term.
The term that is currently used is that which was adopted by the World Health Organisation (WHO) in 1992 in the
latest edition of its publication manual called ICD-10. The term is mental and behavioural disorders
Abnormal psychology - branch of psychology which involved the scientific studies of the causes, development,
maintenance, assessment and the treatment of mental and behavioural disorders.
In addition to these terms, the terms psychopathological behaviour or abnormal behaviour or abnormality or
psychopathology are also used as global descriptive terms for mental and behavioural disorders.
Most often used interchangeably with the term psychopathology.
Professionals who conduct research into the nature, causes, and development of such problems are called
psychopathologists. This term can apply to people with various types of professional training, including
psychiatrists, psychologists, and social workers. What unites them is their commitment to understanding the
causes as well as the manifestations of abnormal behaviour.
Defining Abnormal Behaviour
Defining abnormal behaviour has proved to be a difficult task for three reasons.
1. Abnormality is a construct – an abstraction – and, therefore, subject to various definitions.
2. Psychologists often disagree as to what constitute a specific instance of abnormal behaviour.
3. There are cultural differences in what can reasonably be considered abnormal behaviour.
Thus, no one has been able to provide a consistent definition of abnormal behaviour that easily accounts for all
situations in which the concept is invoked (Gorenstein, 1992).
Yet, the question of what is, and what is not, abnormal behaviour is an important one, because to a large extent
our society is based on such concepts. Drawing the line between the two is extremely difficult. Normal and
abnormal behaviour are not discrete categories. People and behaviour do not fit into perfect slots of healthy or
unhealthy, crazy or normal.

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Paradigms or Models of Abnormal Behaviour
The Paradigms or models of abnormal behaviour refer to the various ways of defining, characterising and
distinguishing what behaviour is abnormal from that which is normal. The models also refer to the theoretical
basis of conceptualising the content of abnormal psychology. The models essentially reflect the views and
perspective of different schools of thought in psychology or the different theoretical approaches of some
researchers even within the same school.
Against this background, the following are some of the often used models.
1. Statistical model
It states that behaviour is abnormal if it deviates from the behaviour of the majority of people in a given
population or if the behaviour does not represent the statistical average of the population. The problems with this
model are:
(a) It does not take into account the behaviour of those minority members of the population whose behaviour
might be positive consequently, both highly positive and highly negative patterns of behaviour one categorised
abnormal.
(b) The model tends to neglects excellence in behaviours
(c) The parameters for distinguishing normal from abnormal behaviour are arbitrarily.
2. Social conformity model
It states that an individual’s behaviour is abnormal if it does not conform to the established norms that prevail in
the individual’s culture or society. The problems with this model include:
(a) It does not take into account variation in culture, since abnormal behaviour in one culture may be normal
behaviour in another culture. Similarly, within the same culture, behaviour that is abnormal at one point in time
may be normal at another point.
(b) The model creates abnormal behaviour by inducing anxiety in non conformist.
(c) The model creates stumbling block for creative innovators whose value system are often at various with values
of most members of the society.
3. Medical model
An individual is judged to be abnormal if he or she can be assigned to any one of the many psychiatric categories
or if the individual has been exposed to some form of psychiatric treatment. The shortcomings of this model are:
(a) The fact that the diagnostic categories of most psychiatric classification manuals have
questionable validity tends to cast a doubt in the reliability of this model
(b) There have been cases of individuals admitted for psychiatric treatment even where their
behaviours did not appear to be abnormal. Similarly, there have been cases of individuals with

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 manifest abnormal patterns of behaviour that have not been considered for receiving psychiatric
treatment.
(c) A person regarded as manifesting abnormal behaviour at one point in time could be observed
manifesting normal behaviour at other times even without receiving psychiatric treatment.
4. Legal model
it states that an individual is judged to be insane or abnormal if evidences can be adduced in a court of law to
show that the individual is so impaired that he or she cannot judge right from wrong or if it can be shown that the
individual lacks competency and efficiency in taking care of his day to day activities. The short comings of this
model include:
(a) It emphasises only the cognitive dimension of behaviour. The psychomotor and affective
dimensions are neglected.
(b) It is difficult to accurately determine what determines competence and efficiency in behaviour

5. Ideal model
It states that normal behaviour is said to be that which approximates the ideal or perfect form of behaviour while
abnormal behaviour is said to be that which moves away from ideal. The deficiency with this model is that the
ideal behaviour may be so uncommon or sometimes non existent in a given population as a result of which most
forms of behaviour within the population may be said to be abnormal
6. Nuisance model
Behaviour is said to be abnormal to the extent to which it constitutes a nuisance to some members of the society.
The nuisance value is reckoned in terms of the extent to which the behaviour poses physical, political, economic
or social threat to members of the society. The shortcoming of this model is that the nuisance value may be more
imagined than real because those who label the behaviour as abnormal may be having erroneous expectations
from the individual being labelled.
7. Unpredictability model
It states that an individual’s behaviour is abnormal if it lacks consistency or it cannot be predicted. The flaw in
this model is that the behaviour may be so consistently unpredictable that it becomes the individual’s normal
pattern of behaviour and in that case, the talk of abnormality may not fit the individual
8. Personal Distress model
It is also called subjective evaluation model. It states that a person’s behaviour can be regarded as being
abnormal if the person so describes himself or herself. This model is predicated on the fact that individuals
understand themselves better than any other person and it is therefore valid for them to make subjective
evaluations about their feelings which are not subject to observation or quantification by other people.
This model has been criticised on the ground that it is not totally embracing because there are people who may not
claim to be having abnormal behaviour even though their overt behaviour indicate abnormality. In addition, an
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individual’s self report may be misleading or exaggerated especially if the behaviour is within the range of
acceptable behaviours in a given environment.
9. Objective Evaluation Model
It states that abnormal behaviour is that which has been distinguished from normal behaviour on the basis of the
results of standardized, valid and reliable psychological tests administered on a group of persons. The deficiency
in this model is that during the standardization of psychological tests, there is no objective way of selecting the
criterion group out of the population.
10. Theoretical Bias Model
It states that abnormal behaviour is a function of the theoretical perspective of researchers in the different schools
of psychology. Consequently, the views about abnormal behaviour vary among the psychoanalytic, behaviourist,
humanistic, existential, cognitive and other schools of psychology.

Defining Normality
Defining abnormality, as we have seen, is a difficult and tricky task. The alternative has been to try to
define normality, which is even more difficult. Offer & Sabsin (1966) came up with five alternative views that
researchers have used in attempts to define the concept.
Normality as health. Normality is simple seen as ‘not sick’. In other words, behaviour or a person is
normal if there is an absence of gross pathology. Health refers to a reasonable rather than an optimal state.
Normality as ideal. Normality is described in terms of a desirable, ideal, or optimal state rather than as a
reasonable level of functioning.
Normality as average. This, like the statistical approach to the definition of abnormality, is based on the
concept of the normal curve
Normality as the socially acceptable. The fact is that there is no behaviour that is abnormal in itself.
Behaviour must be judged in the context of particular social situation. If it conforms with the expectation of
society within that context, it is normal in one situation may not be in another. What is normal in one society may
not be in another. Using this criterion, therefore, normality is not universal.
Normality as a process. Some theorists have attempted to characterize normality in terms of processes
over time. They emphasize the evolutionary nature of biological or psychological systems and insist that the
evaluation of a particular behaviour may change depending on the phase of the life process. Erickson (1968)
views the epigenesist of personality development in terms of the successful mastery of successive stages of
development. This leads to adult functioning and normality. It is the temporal process that therefore defines
normality.

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CONCLUSION
These various models of abnormal behaviour have shown that no one model satisfactorily explains which
behaviour is normal and which is abnormal. The difficulty of not being able to explain the phenomenon
satisfactorily arises from the fact that normal and abnormal patterns of behaviour exist on a continuum without a
clear line of demarcation between where normal behaviour stops and where abnormal behaviour begins.

BRIEF HISTORY OF PSYCHOPATHOLOGY

The search for explanations of the causes of abnormal behaviour dates to ancient times. The Greeks, Egyptians,
Hebrews and other ancient cultures took the view that deviations from the norms of behaviour could be attributed
to good or bad spirits. Disturbed and abnormal behaviour were interpreted as being a sign of mystical or demonic
interventions. That is, abnormal behaviour was attributed to the disfavour of gods or the mischief of demons.
Some very unpleasant treatments such as trephing, flogging, flogging, starvation or prolonged chanting over the
afflicted person as they lay motionless were employed to drive out the evil spirits. This is still the case in some
cultures and belief systems today.
The physical explanation for abnormal behaviour began with the Greek philosopher Hippocrates (460 – 367 B.C.)
who argued that they should be regarded as signs of illness rather than a sign of possession. Hippocrates
hypothesized that abnormal behaviour was caused by an imbalance of one of four body fluids (he called humours)
– blood, phlegm, black bile, and yellow bile. According to this theory of humours different personality styles
resulted from an excess of each of the four respective fluids. An excess of blood results in a sanguine (cheerful)
personality. A phlegmatic (sluggish) personality is due to too much phlegm. Excess of black is responsible for a
melancholic (gloomy) personality, and a choleric (ill-tempered) personality resulted from too much yellow bile.
Consequently, a person’s symptoms show which type of body fluid was out of order, and therefore, suggested
which type of remedy would be most appropriate. The treatment recommended by Hippocrates consisted of drugs
and purgatives and also exercise to restore abnormal behaviour by using physical remedies. Although the specific
of Hippocrates theory is of little value today, his systematic attempt to uncover natural, biological explanations
for abnormal behaviour is a lasting contribution.
In the middle ages the emphasis on objectivity and careful observation in general and the physiological
explanation of abnormal behaviour faded in Europe. Religious explanation again became more popular and
common. This gave rise to the possession theory. However, systematic and naturalistic accounts of mental illness
were kept alive in the Arabic World (Deutsch, 1949). While the church was establishing itself across Europe the
general assumption was people who showed disturbed or abnormal behaviour had ‘troubled souls’, and prescribed
cures were the ‘laying of hands’ from a holy person. Later, however, possession by demons or the devil and
witchcraft became the usual explanation, and more punitive methods were used to drive out these evil spirits. The
torturing and burning of ‘witches’ became commonplace. However, Neugebauer (1979) fond records directly
attributing ‘lunacy’ (a medieval synonym for abnormal behaviour) in various cases to ‘a blow received on the
head’, ‘her husband’s death’, ‘a long incurable infirmity’, and ‘fear of his father’. Thus, Erhenreich & English
5
(1973) have argued that the demonology and witch hunting of medieval Europe was an attempt by the
increasingly influential medical profession to discredit folk (traditional herbal) medicine.
The European Renaissance (approximately 1300-1600 A.D.) reawakened the idea that people who acted strangely
were ‘mentally ill’. The Dutch physician Johann Weyer was among the first to suggest that many mental disorders
required treatments order than exorcism. In 1621 Robert Burton published the Anatomy of melancholy, which
attempted to describe the causes, symptoms, and cures of mental illness. In time institutions arose to care for those
with mental illness. One of these was St. Mary of Bethlehem (bedlam) established in 1547, which began to
specialize in the treatment of people who showed disturbed or abnormal behaviour. Treatment was still cruel
practices and the patients lived in dreadful conditions.
During the French revolution of 1793, Philip Pinel pioneered a new humanitarian approach to the running of these
institutions. Pinel called his techniques moral therapy and insisted that the patient should always be treated with
dignity irrespective or whether they needed to be treated firmly or gently. He considered the mentally ill as
normal people who had lost the power to reason properly owing to environmental stress. He also introduced
occupational therapy by giving patients simple work to do. Pinel’s approach is distinctive in that it represents
one of the first of the environmental stress explanations of disturbed behaviour. The success of his treatment is
also quite different from those of earlier theories. Explanations arising from physiological imbalances produced
confinement and restraint, as the disturbance was seen as largely inevitable. But explanation arising from
environmental stress resulted in a type of treatment, which seemed to be able to produce some very definite
improvements in he patients’ ability to cope.
Wilhelm Griesinger, who insisted that any diagnosis of mental disorder specify a physiological cause, revived the
physiological explanation of Hippocrates again in Europe in the 19th century. His follower, Emil Kraepelin
(1883) published a classification system that helped to establish the organic theory of mental illness. Another
event at this time was the discovery of general paresis – a severe mental disorder that has a deteriorating course
and eventually ends in death. At the time this search for somatogenic causes of abnormality was progressing
other scientists continued Pine’s psychogenic point of view which assumes that though the mentally ill’s body is
tact, the disturbance can be explained in psychological terms. For exampled, Jean Martin Charcot and his student
Pierre Janet believed that hysteria was due to subconscious thoughts that brook loose through a weakness of the
nervous system. Josef Breuer was at about the same time using hypnosis to treat the same problems. This was
later referred to as the cathartic method. In 1895, in collaboration with Sigmund Freud, he published Studies in
Hysteria. The somatogenic hypothesis led to the idea that somatic therapies – adjusting the state of the body with
drugs and/or other physical treatments – as the most appropriate for treating abnormal behaviour. On the other
hand, the psychogenic theorists, following the tradition of Freud insists on psychotherapy.

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 CHAPTER TWO
MODELS OF ABNORMAL PSYCHOLOGY
Over the years psychologists who study abnormal behaviour have developed several models, paradigms, or
perspectives to conceptualize and explain its causes. These are ways of thinking about the factors that may
underlie abnormal behaviour and how it can be treated or prevented. They are loose sets of general assumptions
about what should be studied, how to gather data, and how to think about such behaviour. We shall discuss four of
these.
The Medical Model
This is also referred to as the physiological, biological or disease model. It is the oldest and still the most widely
used model. It assumes that the origin of abnormal behaviour lies in some kind of malfunction in the body or
brain. It also assumes that different kinds of malfunctions will produce different types of ‘disorders’ or mental
illness. In other words, the medical model suggests that psychological abnormalities, like physical ones, can be
viewed as diseases. A disease is a pattern of symptoms that consistently occur together. Ideally, each
psychological disorder should also be characterized by a unique set of symptoms constituting a single disease.
The full development of the medical model began with the growing awareness of pathology and the new
discoveries of microscopy, which led to the discovery of viruses, germs and the like. It became apparent that
diseases had physical causes and could be treated on the physical level. This new knowledge led to a kind of
physiological determinism in which only physical causes were considered to be possible for any illness. The
medical model matured with the first widely accepted classification systems of mental illness. In the medical
context, a classification system to identify the different types of disorders is useful since it provides some clues as
to the possible cause(s) and treatment(s) for an illness. Nevertheless, it is accepted that all diseases are
disturbances of the body’s physiological processes. There is thus a growing body of knowledge dealing with the
physiological factors relevant in abnormal behaviour.

The Psychological Models

The different theories of personality, many of which were developed by psychologists engaged in clinical work,
produced different explanations of what is happening when someone develops abnormal behaviour and the best
ways to treat such deviant behaviour. For convenience we shall discuss these theories under three broad
categories: psychodynamic, behavioural and humanistic.
The Psychodynamic Model: Originally developed by Sigmund Freud (1856 – 1939), the psychoanalytic
perspective is widely employed by psychiatrists and psychologists. It assumes that abnormal behaviour results
from unconscious conflicts that originate primarily in childhood and produce a variety of symptoms. Present day
ego analysts who are part of the Freudian tradition place greater emphasis on conscious ego functions.
Nevertheless, the psychoanalytic paradigm has generally focused in searching the unconscious and early life of
the person for the causes of abnormality. Freud divided the mind (psyche) into three parts: the id, ego and

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superego. He also said that there are three levels of awareness – the conscious, preconscious and unconscious
aspects of the mind. Finally, Freud conceived of the personality apparatus as developing through a series of four
separate psychosexual stages: oral, anal, phallic and latency.
The Behavioural Model: The behaviourist viewpoint ignores any possible underlying causes of the disturbed
behaviour, which the individual is showing. Abnormal behaviour is presumed to have resulted from faulty or
inappropriate learning. The groundwork for behavioural theory of learning was based on Watson & Raynor’s
(1920) demonstration that phobia could be induced by conditioning principles. This showed that if phobia could
be learned other forms of abnormal behaviour could also be learned in the same way as most ‘normal’ behaviours
are learned. In 1950 Dollard & Miller showed how psychoanalytic principles could be reinterpreted in terms of
learning theory. Soon after, B.F. Skinner (1953) published Science and Human Behaviour, which argued that all
human behaviour could be explained in terms of conditioning principles. Finally, in 1958 Wolpe published the
first accounts of the application of systematic desensitization as a treatment for phobia. All these showed that
learning theory techniques could be used to induce and remove the symptoms of abnormal behaviour. Thus, the
behavioural or learning paradigms suggest that deviant behaviour develop through classical conditioning, operant
conditioning, modelling and particular cognitive sets.
The Humanistic Model: Humanistic theories were reactions to the mechanistic approach of the behaviourists and
the negative picture of man presented by psychoanalysis. The essence of their argument has to do with what
constitutes positive mental health. For the behaviourists, positive mental health consisted only of the absence of
pathological symptoms. For the psychoanalysts it considered of keeping a balance between unconscious pressures
and the demands of reality. Humanistic theorists believed that positive mental health involved psychological
growth and development. To them, behaviour is not determined but instead is a product of free will. Therefore,
abnormal behaviour is largely the result of failure to realize one’s potential and of difficulties in maintaining
accurate self-concept. Humanistic psychology is distinguished by its explicitly positive view of human nature,
which is assumed to be inherently good. Humanists therefore blame abnormal behaviour on society instead of on
the individual.

The Diathesis-Stress Model

The fundamental assumption here is that any health or illness outcome is a consequence of biological,
psychological and social factors. A predisposing influence or condition (diathesis) combines with current
environmental factors (stress) to produce a disorder. This model considers the often subtle interactions between
predisposition towards a disease and environmental, or life events, affecting the person. People are assumed
predisposed to react differently to environmental stress. The diathesis can be anything in the individual’s
background, such as his genetic predisposition or a history of physical abuse in childhood that predispose toward
certain disorders. However, it usually refers to a biological basis in the genetics and biochemistry of the
individual. Learning, stress, and other environmental factors may then interact with these predisposing
mechanisms to produce the actual symptoms. When both diathesis and stress are present, symptoms are likely to
appear. The diathesis-stress model is quite flexible. Many types of diathesis-stress modals have been proposed for
different kinds of abnormal behaviour. A diathesis is not necessarily biological in origin, and stress is not
8
necessarily a psychological factor. It is utility is that no single agent is seen as the ‘cause’ of abnormal behaviour.
Instead, a disorder is seen as resulting from several different factors all combined together.

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 CHPTER THREE
CLASSIFICATION OF ABNOMAL BEHAVIOUR
Formal classification systems of abnormal behaviour have been developed in order to facilitate communication,
research and treatment planning. A classification system is used to subdivide or organize a set of objects. It is
designed to group together objects having a common property and to ignore differences among objects that are
relevant to the purpose at hand. A classification system could be categorical or dimensional. A categorical
system assumes that distinctions between members of different categories are quantitative in nature. A
dimensional system describes objects in terms of continuous dimensions. Rather than assuming than an object
wither has or does not have particular property, it may be useful to focus on a specific characteristic and
determine how much of that characteristic the object exhibits.
Brief History of Classification Systems
The classification of abnormal behaviour is as old as civilization itself. The oldest written description of abnormal
behaviour has been traced to the Egyptians, Greeks and Romans. The Greeks devised a classification system that
contained a small number of broad categories but later added many specific disorders. Other civilizations
continued to add categories until the 18 th century when Philippe Pinel a comprehensive list of 2,400 mental
disorders.
Emil Kraepelin (1856-1926), a German psychiatrist, is generally regarded as the father of the categorical
classification system that currently prevails win psychopathology. He believed that mental illness could be
understood in terms of a finite number of specific disorders. Each of such disorders has its own identifiable set of
symptoms and a unique course, and is the product of some form or the other of a cerebral dysfunction (Berries &
Hauser, 1988). Kraepelin (1913) identifies five types of mental disorders; neurosis, personality disorders, organic
psychosis, functional psychosis, and mental retardation. Neurosis (now called anxiety disorders) is disorders that
involve excessive anxiety in ‘normal’ situations. Categories of neurosis included phobia, obsession, compulsion
and multiple personality. Personality disorders involve ways of thinking which are socially unusual or deviant. It
includes paranoia, obsessive personality, schizoid personality and psychopathy. Organic psychosis implies that
these disorders results from identifiable physical causes such as brain infection, brain tumours injuries to the
nervous system and so on. Functional psychoses are disorders in which the person s clearly disturbed and not in
touch with reality, but there is no organic cause of the problem. Kraepelin (1921) divided these major mental
disorders into two broad categories: dementia praecox (now called schizophrenia) and manic-depressive
psychosis (now called bipolar mood disorder). The distinction was based on age on onset, clinical symptoms, and
the course of the disorder (that is, its progression over time). Mental retardation is not actually a mental illness,
but Kraepelin classified it as such. It is worthy of note that despite the widespread acceptance and influence of
Kraepelin’s diagnostic system at that time, other psychiatrists of the era, most notably Adolf Meyer (1866-1950)
and Sigmund Freud (1856-1939) proposed alternative approaches.
Two major diagnostic systems were developed shortly after the Second World War (WWII). In 1948, the World
Health Organization (WHO) published the sixth edition of the International Classification of Diseases (ICD-6),
the first such classifications to have a section on mental illness. In 1952 the American Psychiatric Association

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(APA) published its own Diagnostic and Statistical manual of Mental Disorders (DSM-I). Since then both
classification systems have undergone regular revisions. Their current versions are ICD-10 (WHO, 1993) and
DSM-V (APA, 2013).

DSM-V AND ICD-10

Both classification systems have a lot of similarities. Committees of psychiatrists who collect information from
their professional colleagues usually review them. Of recent, clinical psychologists have been involved in such
committees. While, however, the ICD review committees is made up of professionals drawn from all over the
world including Nigeria, that of the DSM are always American psychiatrists and psychologists. Second, both are
based on clinical descriptions of psychopathology that have not been empirically validated. This method has led
to the elimination of some terms and categories that had been based on psychoanalytic concepts like neurosis and
hysteria. Other features include the introduction of multi-axial system and the production of specific, detailed
criterion sets for each disorder. Another feature of both manuals are the definition of each disorder by not only an
inclusion criteria (symptoms that must be present before a diagnosis is made) but many disorders are also
defined in terms of certain exclusion criteria. In other words, the diagnosis can be ruled out if certain conditions
prevail. It is apparent deliberate attempts were to coordinate the production of DSM-V and ICD-10. The two
manuals are quite similar in most respects (Kendall, 1991). Most of the categories listed in them are identical, and
the criteria for specific disorders are usually quite similar. However, there are some interesting differences
between DSM-V and ICD-10. There are, for example, differences in the ways in which they subdivide mood
disorders and personality disorders. The DSM-V also devotes more attention to eating disorders and sexual
disorders, which appear less prevalent in other cultures (Kendall, 1991). Due to the similarities of both manuals
noted above, only the DSM-V is discussed in detail here and will used in this course.

The DSM-V System

DSM-V’s definition of mental disorders places primary emphasis on the consequence of certain behavioural
syndromes (A group of symptoms that appear together and are assumed to represent a specific disorder is called a
syndrome). According to this definition, mental disorders are defined by clusters of persistent, maladaptive
behaviours that are associated with personal distress, such as anxiety or depression, or with impairment in social
functioning, such as job performance or personal relationships. The manual uses a multi-axial assessment and
classification system. That is, any given person’s presenting disorder is rated in terms of five general factors or
axes. These axes (see Table 3-1) directs the practitioner’s attention to different factors, so that they get a more
complete picture of the possible relevant influences, and can direct relevant treatment accordingly. Two of the
axes are concerned with diagnostic categories, and the other three provide for the collection of additional relevant
information.
More than 200 specific diagnostic categories are described in DSM –V. These are arranged under 18 primary
headings, most of which are listed in Table 3-2 below. The categories are based on descriptive similarities rather
than on presumed causes. They focus on features and include diagnostic features – symptoms that must be
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present before a person is diagnosed as suffering from a particular problem. In addition the manual includes
information on associated features and disorders – clinical features that are frequently associated with particular
disorders but are not considered essential to its diagnosis.
Table 3-1: The Major Axes in DSM-V

Axis Name Description

I Clinical Syndromes Major psychiatric disorders such as schizophrenia,

mood disorders, and anxiety disorders.

II Personality disorders and Concerned with stable, long-standing problems –

mental retardation maladaptive aspects of personality that exert powerful
effects on individual’s behaviour and lives.

III General Medical conditions General medical conditions related to each disorder.
Medical conditions that might influence the patient’s
behaviour.

IV Psychosocial and Considers psychosocial problems that might affect the

environmental problems diagnosis, treatment or prognosis of the various
disorders. That is, factors that could add to the
patient’s stress and so affect the problem.

V Global assessment of Provides for global ratings of adaptive functioning –

functioning how the person is actually functioning in his life.
Looks at positive aspects of functioning during past
year in tree areas: psychological, social and
occupational.

The manual also includes associated laboratory findings and physical examination signs. These are biological
factors associated with the disorder. Finally, the manual requires that information on age-relate, culture-related,
and gender related features (that is, variations in each disorder that may be related to age, cultural background
and gender) is considered before a diagnosis is made.
Table 3-2: Major Diagnostic Categories of DSM-V

Diagnostic Category Description Examples

Disorders first diagnosed in Begins before or during Attention deficit disorder Mental
infancy, childhood or adolescence retardation, Learning Disruptive
adolescence. behaviour.

Cognitive disorders Permanent or temporary Delirioum, Dementia, Amnesia,

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 Dysfunctions of the brain Disturbance of consciousness
due to disease, blows to the
head or chemicals.

Mental disorders due to Dysfunction due to other Delirium due to high fever
general medical condition illnesses or medical
condition

Substance related disorders Patterns of abnormal use Alcohol dependence, alcoholism,

and abuse of alcohol and caffeinism, marijuana-, cocaine- use
other drugs disorders, drug dependence

Schizophrenia and other Psychotic symptoms: Schizophrenia, delusional disorder.

psychotic disorders history of more than 6. Shared psychotic

Mood disorders Disturbed affect (emotion), Major depression, Dysthymia,

depression mania Bipolar disorder, Cyclothymia

Anxiety disorders Feelings of apprehension Generalized anxiety disorder panic

Tension, or fear; symptoms disorder, phobia, obsessive-
Heightened psychological compulsive disorder posttraumatic
arousal stress disorder.

Somatoform disorder Somatic (physical)a Somatization disorder, conversion

symptoms caused by disorder, hyponcondrasis, pain
psychological disorder

Factitious disorder Expression disorders not Intentional feigning of symptoms

real

Dissociative disorder Sudden loss of or change in Dissociative amnesia, dissociative

personal identity, memory fugue, dissociative identity disorder
and consciousness

Sexual and Gender identify Disorders of sexual Paraphilias, sexual desire sexual
disorders identity, sexual functioning, arousal disorders, Gender identity
sexual behaviour, or gender disorders
identity

Eating disorders Problems with intake of Anorexia nervosa, Bulimia nervosa

food

Sleep disorders Disturbances of the normal Primary insomnia, nightmare

sleep circle narcolepsy

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 Impulse control disorders not Lack of inhibition of Intermittent explosive disorder,
gambling elsewhere control over behaviour kleptomania, pathological
described.

Adjustment disorders Development of emotional School phobia, work stress,

or behavioural symptoms in adjustment disorder
response to an identifiable
stressor

Personality disorders Stable, long-standing Paranoid, schizoid, antisocial,

personality maladaptive modes of histrionic, avoidant disorders
thoughts, feelings and
reaction

Other conditions that may be Catchall category that Medication-induced disorder,

a focus of clinical attention. includes problems not in problems related to abuse or neglect
the categories above

EVALUATION OF CLASSIFICATION METHODS

It is important to note that classification systems are evolving documents. Critics have since the advents
classifications in psychopathology asserted that psychiatric system the diagnosis they produce are far from
perfect. Basic problems relate to the reliability and validity of the system, but some criticisms go beyond these
technical failings. The low reliability of diagnostic categories and the criticisms has led to constant revisions of
the available diagnostic manuals. These are aimed at many of the highlighted weaknesses and making diagnosis
more reliable.
One of the most vociferous critics of classification systems, Thomas Szasz (1961), asserted that the whole concept
of “mental illness” is misleading because it referred to things that are not mental illness at all. Other critics have
argued that diagnostic manuals have tended to deal with psychiatric problems as if they originated purely within
the individual, and have nothing to do with anything else that is going on in the person’s life. DSM-IV and ICD-
10 have tried to overcome some of these problems and criticism. Attention is now focused in strengths and the
revision of weaknesses as the process of development of diagnostic continues.
Problems of Reliability: The term reliability refers consistency of measurement, including diagnostic decisions.
If a diagnostic category is to be useful, it will have to be applied consistently. Earl studies showed that psychiatric
diagnosis can be quite unreliable. The developers of DSM-IV attempted to solve the reliability problem by
providing much moiré detailed, specific reported agreements as high as 87% among diagnosticians for such
disorders as phobias, obsessive-compulsive disorders, and trauma disorders. However, agreement is lower for
panic disorder and much more for generalized anxiety and personality disorders (DiNardo et al., 1993; Livesley &
Jackson, 1992; Watson et al., 1991).

14
Problems of Validity: The ultimate issue in the evaluation of a diagnostic category is whether the category is
useful. By knowing that a person fits into a particular group or class, do we learn anything meaningful about that
person? Studies have shown that labels given to patients on the basis of diagnosis are often not accurate
reflections of actual problems. Factor analytic studies on the different symptoms used to identify diagnostic
categories have shown that people sharing the same diagnostic category had widely different symptoms. For a
category to be meaningful and important, it must have aetiological, concurrent and predictive validities.

The Labeling Problem

Not only many psychiatric labels be inaccurate, they may have a variety of negative effects on the individual.
Being labeled schizophrenic, for example, may cause the person to treated differently by others even when his/her
behaviour is normal (Rosenhan, 1973). Furthermore, such labels can stigmatize the person, making it difficult for
him/her to get housing, job, loans and so on (Penn et al., 1994). The label can play a prominent role in impairing
the social and psychological functioning of the individual. Despite criticism of current systems, it would
probably be almost impossible for clinical psychology and psychiatry to function without them. As noted earlier,
formal classification systems have been developed in order to facilitate communication, research, and treatment
planning.

15
 CHAPTER FOUR
ASSESSMENT OF ABNORMAL BEHAVIOUR

Psychological assessment is the process of collecting and interpreting information that will be to understand
another person. All clinical assessment are more or less formal ways of finding out what is wrong with a person,
what may have caused his problem(s) in the past, and what steps may be taken to improve the individual’s
condition. In practice, the results of assessment procedures ends in a decision-making process called diagnosis.
Diagnosis is the process of deciding that a person fits into a particular category. That is, the person’s behaviour
meets the specific criteria for a particular type of disorder. This decision allows the clinician to use the general
base of knowledge for the disorder in question, including associated features, probable course, and treatments that
are likely to be effective. The formulation of a treatment plan depends on the diagnosis plus many other types of
information gather from the assessment procedures
Assumption about Behaviour
Assessment is governed by several import concepts and assumptions regarding the nature of human behaviour and
the ability of psychological science to measure and explain events.
The Consistency of Behaviour: Assessment involves the collection of specific samples of a person’s behaviour.
These samples may include what the person says during an interview, responses the person makes on a
psychological test, or things that the person does while being observed. None of these would be important if we
assume that they are isolated events. They are useful to the extent that they represent examples of the ways in
which they will feel of behave in other situations. Psychologists must therefore b concerned about the consistency
of behaviour across time and situations. They want to know if they can generalize, or draw inferences about the
person’s behaviour in the natural environment on the basis of the samples of behaviour that is obtained in their
assessment. Psychologists typically employ more than one source of information when conducting a formal
assessment. Because we are trying to compose a broad, integrated picture of a person’s adjustment, we must
collect information from several sources and attempt to integrate these data.
Levels of Analysis
The kind of information that is collected will on the way in which the clinician views the problem. Mental
disorders are embedded in multiple interacting systems that involve biological, psychological, and social factors.
At one level the distinction is between the individual on the one hand and the social system on the other. At
another level, the emphasis may be on psychological variables or on biological factors that might influence the
aetiology of the problem. The choice of the level of analysis will determine to a large extent the sorts of
instruments that will be employed in the assessment process.

16
ASSESSMENT PROCEDURES
An enormous array of assessment tools is available to psychologists. Many of these procedures are commonly
employed in clinical practice and in the process of research. In the following discussion the alternative assessment
procedures are organized according to the systems outlined above.
Assessment of Psychological Systems
Person variables – actions, feelings, speech, skills, abilities, cognitive functioning, social skills, and so on – that
is, questions about the individual person are of major concern in psychopathology. They can be addressed through
a number of procedures including interviews, observations, various types of self-report instruments and
psychological tests.
Clinical Interviews The best ways to find out about someone else is to talk with that person. We may
therefore define an interview as an interpersonal encounter, conversational style, in which one person (the
interviewer) uses language as the principal means of finding out about another (the interviewee). Interview is the
most commonly used procedure in psychological assessment because it provides an opportunity to ask the person
for his/her own description of the problem. Many symptoms of psychopathology are subjective in nature and an
interview can provide analysis of these problems. Interviews also allow the interviewer to observe important
features of a person’s appearance and nonverbal behaviour.
Interviews vary with regard to the amount of structure imposed by the interviewer. Some are relatively open-
ended or non-directive. In this type of interview the interviewer follows the train of thought of the interviewee.
The goal is to help the interviewee clarify his subject feelings and to provide emphatic support for whatever she
decide to do about her problems. The structured interview follows a more specific question-and-answer format.
The interviewer must ask each person a specific list of detailed questions. Several different structured interviews
have been developed for the purpose of making psychiatric diagnosis. Some of these are broadband instruments
designed for the assessment of different disorders. A good example is the Structured Clinical Interview for the
DSM (SCID, Spitzer et al., 1979). Other forms of structured interviews have been designed for the assessment of
specific problems such as personality disorders (Widiger & Francis, 1985), anxiety disorder (DiNardo et al.,
1988), behaviour problems of children (Edelbrock & Costello, 1984) and so on.
Clinical interviews usually begin with an overview of the presenting problem. The interviewer uses open-ended to
elicit a description of the problem. If the patient does not provide sufficient information, the interviewer might ask
for clarifications, and follow leads that are raised by the patient’s responses. After this opening phase the
interviewer begins to impose more and more structure as the interview progresses, the structures interview
schedule provides a series of question that will be necessary to arrive at diagnosis or a more complete description
of the presenting symptoms.
Structured interview schedules provide a systematic framework for the collection of important diagnostic
information, but do not eliminate the need for an experienced and skilled interviewer. If the interviewer is not able
to establish rapport with the patient, then he might not elicit most of the information required for a sound
diagnosis.

17
Advantages of Clinical Interviews
1. The interviewer can control the interaction and can probe further when necessary.
2. By observing the patient’s nonverbal behaviour, the interviewer can detect areas of resistance.
3. An interview can provide a lot information in a short period of time.
Disadvantages of Clinical Interviews
1. Some patients may be unable or unwilling to provide a rational account of their problems.
2. People may reluctant to admit experiences that are embarrassing or frightening. This can lead social
desirability responding.
3. Subject factors play an important role in the interpretation of interview data.
4. Information provided by a person is necessarily filtered through the person’s eyes (e.g., errors in
memory).
5. Interviewers can influence the patient’s responses by the ways they phrase their questions and respond to
the patient’s responses.
Observational Procedures
Direct observations of behaviour can be carried out either in the person’s natural environment or in a contrived
situation. It is difficult to observe most behaviour as they actually take place, and little control can be excised
however, where and when such behaviour may occur. For these reasons the therapist may contrive artificial
situations in the clinic or laboratory so that she can observe how a client acts under certain conditions.
Observational methods may be formal or informal in nature. Informal observations are primarily qualitative in
nature. The observer observes the person’s behaviour, the context and environment in which it occurs without
attempting to record the frequency or intensity or specific responses. All he does is a description of the behaviour
in an uninterrupted sequence of various parts using psychological terms. Formal observation may involve the use
of rating scales or behavioural coding systems. The use of rating scales involves the observer making judgements
that places the person somewhere along a dimension such as the extent to which the person exhibits behaviour.
Rating scales provides abstract descriptions of a person’s behaviour rather than what the person has done.
Behavioural coding systems focus on the frequency of specific behaviours or events (Foster & Cone, 1986). It
depends on recording of the person’s actual activities. Coding systems can be used in observations carried out in
natural settings as well as contrived environments. In some cases observations are made directly by therapists and,
at other times the information is provided by people who have better opportunities to see the patient’s behaviour
in the natural environment, including teachers, parents, spouses and peers.
Systematic observations are intended to provide a detailed record of the frequency of particular behaviours. This
information is based on selective observations that are made during a given time interval. The formal record
18
includes only those specific behaviours that have been identified as relevant. Efforts are also made to describe, as
specifically as possible, the situations in which the behaviours are observed. A good example of the behavioural
coding system is the Time-Saving Behaviour Checklist (TSBC; Paul & Lentz, 1977; Power, 1979). TSBS was
developed for use with hospitalized patients.
Advantages of Observation
1. Provides useful supplementary information to that collected during the interview procedure because it
relies on direct observation rather than the self-, subjective report of the patient (Foster & Cone, 1986).
2. Rating scales are primarily useful as an overall index of symptoms severity or functional impairment.
3. Behavioural coding systems detailed information about a person’s behaviour in a particular situation.
Limitations of Observation
1. It is time consuming and therefore expensive.
2. Raters require training.
3. Observer bias and errors might influence coding.
4. Problem of behaviour reactivity – people may intentionally or unintentionally alter their behaviour
because they are being watched.
5. Problem of consistency of behaviour across many situations.
6. Many aspects of psychopathology are subjective and thus cannot be observed by others (Jacobson, 1985).
Psychological Tests
Psychological tests are structured assessment procedures. The same test is administered on many people at
different times, and the responses collected are analyzed to indicate how certain kinds of people tend to respond to
the items (statements or questions on a psychological test are called items). Statistical norms for the test can
hereby be established as soon as the data collected is extensive enough. This process is called standardization.
The response of a particular person can then be compared to the statistical norms. Psychological tests are easier to
administer and interpret than interviews and observational. Several classes of psychological tests have been
developed, these include: personality inventories, self-report inventories, projective personality tests, tests of
organic brain damage and tests of intelligence.
Personality Inventories: These are also sometimes called objective tests because of their nature in presenting the
test taker with a number of specific items on paper. They are therefore also classed as paper-and-pencil tests.
Personality inventories typically consist of a large number of self-descriptive items to which it applies. Several
types of personality inventories are used widely. Examples include: Eysenck’s Personality Inventory (EPI),
Myers-Briggs Type Indicator (MBTI), the Sixteen Factor Personality Inventory (16PF), Minnesota Multiphasic
Personality Inventory (MMPI), the NEO Personality Inventory (NEO-PI), Cormrey personality Inventory (CPI),
Awaritefe Psychological Index (API) and many others. Some of these tests are designed to identify personality
19
traits in a normal population, and others focus more specifically on psychopathological problems. Although it is
rare for a personality test to lack reliability, the validity of some of them is suspect especially in Nigeria for
developed abroad.
Once a person has responded to the various items on the inventory, one or more scores can be calculated to
indicate where she stands on the personality variable(s) being measured. On this basis a distinction may be made
between normative and ipsative personality tests.
Normative tests are those that can be used to compare one individual with other people. They give results on
standard scales, which are compared with tables of statistical norms provided in the test manual to give the tester
an idea of how typical that person’s result is. A test’s manual usually provides information on why and how the
test was constructed, how to administer the test and how to interpret the scores. Standard personality inventories
like the API, EPI and 16PF are normative tests.
Ipsative tests are used to provide detailed information about a person’s own individual personality structure.
They do this by looking at which of that person’s characteristics are strongest or weakest within that person, but
not in that allows comparison with other people. For example, the NEO-PI may be used to assess a person on the
five robust factors of emotional stability, conscience, extraversion, agreeableness and openness. This would give a
result indicating which of these is the strongest and is the weakest quality in that particular person’s character.
However, in clinical practice, most personality inventories can be used for both normative and ipsative purposes.
Advantages of Personality Inventories
1. Personality inventories are seldom used by itself in clinical practice, but they serve as useful supplements
to other methods of assessments. When used in this way, the personality inventories provide information
about a person’s test-taking attitude, which alerts the clinician to the possibility that client, is careless,
defensive, or exaggerating his problems.
2. Most personality inventories cover a wide range of problems in a direct and efficient manner. It would a
clinician several hours to go over all of these topics using an interview format alone.
3. because personality inventories are scored objectively, the initial description of the client’s adjustment is
not influenced by the clinician’s subject impression of the client.
4. Personality inventories can be interpreted in an actuarial fashion using extensive banks of information
regarding people who respond to items in a particular way.

Limitation of Personality Inventories

1. Dues to changes in cultures over time and the fact of cultural variations, personality inventories need to
be upgraded and recalibrated regularly to make them relevant, reliable and valid.

20
 2. Most personality inventories are not particularly sensitive to certain forms of psychopathology. For
example, the MMPI does not contain items relevant to anxiety disorders, personality disorders and the
subtypes of mood disorders.
3. Personality inventories depend on a person’s ability to read and respond to write statements. Some cannot
complete the rather extensive list of questions. These include people who are acutely psychotic, the
intellectually impaired, and the poorly educated.
4. Specific data are not always available for a particular population.
5. Many clients’ test results do not meet the criteria for particular trait type with which extensive data are
associated. Therefore, actuarial interpretation is not really possible for some population.
Self-Report Inventories: Although al personality inventories are self-report scales, the term is sometimes
restricted to other questionnaires, scales, inventories and checklists that are used to collect information about
specific adjustment problems including subjective mood states such as depression, anxiety, patterns of obsessive
thinking and attitude about drinking alcohol, eating and social behaviour. examples include the Beck Depression
Inventory (BDI) for assessing a person’s level of depression; the Yale-Brown Obsessive-Compulsive Scale
(YBOCS) for obsessive-compulsive disorder; the Hopkins Symptoms Checklist (SCL-90) for anxiety; the Enugu
Somatisation Scale (ESS) for somatisation disorder and so on. The format of most self-report inventories is
similar to those employed with personality inventories. The primary difference is in the range of topics covered
by the types of instruments. Personality inventories are designed to measure several dimensions that are related to
abnormal behaviour, while self-report scales are aimed more specifically at focal topics, or at one aspect of a
person’s adjustment. Self-report inventories are usually not standardized on large samples of normal subjects prior
to their use in clinical settings.

Advantages of Self-Report Inventories

1. Self-report inventories provide information that supplements those collected during clinical interviews.
2. They are extremely efficient ways of gathering information regarding a wide range of topics.
3. They can also be score objectively and, therefore, provide a specific index that is frequently useful in
measuring changes from one period to the next – for example, before and after treatment.
Limitations of Self-Report Inventories
The limitations of the personality inventories all apply also to the self-report scales. In addition, several studies
have raised serious questions about the validity of self-report inventories when they are for diagnostic purposes.
Self-report scales sometimes fail to identify patients who are considered maladjusted on the basis of clinical
interviews. One reason for this discrepancy is the fact that some patients consider themselves to be less troubled
than they appear to a clinician when they are interviewed (Sawyer et al., 1993).

21
Projective Personality Tests: Projective tests present the test-taker with a set of standard, ambiguous, structured
stimuli that are vague enough to permit variations in responses. The Rorshach Inkblot Test (RIT; Rorschach,
1935) and the Thematic Apperception Test (TAT; Murray, 1938) are perhaps the best known of the projective
tests. In an inkblot test the person is shown a series of blots (the RIT consists of 10 blots – 5 contain various
shades of grey on a white background and 5 others contain elements of colour), one at a time and asked to tell
what figures or objects she sees in each of them. Similarly, in the TAT the examine is shown a series of pictures
(they are actually drawings) that depict human figures in various ambiguous situations. Most of the cards portray
more than one person. The examinee is asked to tell a story related to each of the picture cards.
Developers and users of projective tests assume that because the stimulus materials are unstructured, the
examinee’s responses will be determined primarily by unconscious processes and will reveal his attitudes,
motivations, and modes of behaviour. This assumption is referred to as the projective hypothesis, which is based
on the psychodynamic views about the nature of personality and psychopathology. The hypothesis emphasizes the
importance of unconscious motivation – conflicts and impulses of which the person is largely unaware. In other
words, a person being tested presumably project hidden desires and conflicts when he tries to describe or explain
the test cards. In so doing, they may reveal things about themselves of which they are not consciously aware or
that they might not be willing to admit if they were asked directly. Thus the tests can help the clinician by pas the
defence mechanisms and get to the basic causes of distress.
Although the projective testing procedures are relatively efficient, the procedures for scoring and interpreting the
responses pose severe problems. Examines usually provide a complex response to a complex stimulus, which is,
by design open to a fantastic range of interpretations. Original methods of scoring and interpretation place
considerable emphasis on the thematic content of the person’s response. This kind of interpretation, which
depends heavily on symbolism and clinical inference have very low reliability and validity (Shontz & Green,
1992). Examiners can, however, achieve satisfactory levels of agreement with extensive training in a particular
scoring system.
More recent approaches to the use of project tests view examinees’ descriptions of the cards as a sample their
perceptual and cognitive styles. For example, Exner (1986) and Kleiger (1992) have developed an objective
scoring procedure for the RIT that is based primarily on form rather than the content of the subject’s responses.
This interpretation depends on the ways in which the description takes into account the shapes and colours of the
cards. The reliability of this scoring system is better than would be achieved by the content scoring method. The
validity of the scores, however, remains open to question (Davis, 1978; Shontz & Green, 1992).

Advantages of Projective Tests

1. Projective tests are interesting to give and interpret and they sometimes provide a way of talking to people
who will otherwise find it difficult to discuss their problems.
2. Some people may feel more comfortable talking in an unstructured situation than they would if they
would if they were required to participate in a structured interview or to complete the lengthy MMPI.

22
 3. Projective tests can provide an interesting source of information regarding the person’s unique view of the
world.
4. Projective tests may provide information that cannot be obtained through direct interview or observational
methods in the area of interpersonal relationships that are governed by unconscious cognitive and
emotional events (Stricker & Healey, 1990).
Limitations of Projective Tests
1. Research studies have found little evidence to support the reliability and validity of the projective tests
(Dawes, 1994; Wiezbicki, 1993).
2. The lack of standard administration and scoring procedures are serious problems.
3. Little information is available to use as norms for either adults or children.
4. Some project tests procedures, for example the RIT, can be very time consuming, particularly if the
r4esponses are scored with a standardized procedure such as the Exner’s system.
5. The reliability of scoring and interpretation tend to be low.
6. Information regarding the validity of the projective tests is particularly negative (Dawes, 1994).
Tests for Organic Brain Dysfunction: Changes in physiological response systems are measured by neurological
tests and devices (see section on assessment of biological systems), however, many brain abnormalities involve
alterations in structures so subtle that they may elide direct physical measurement. Moreover, we still know very
little about how the brain works. Since the way the person functions is the problem – what she does, says, thinks
or feels – a number of tests for assessing behavioural disturbances that are caused by organic brain dysfunction
have been developed. Such instruments usually consists of a battery of tests each tapping different functions. For
example, the Reitsan-Halstead battery is made up of the following tests:
Tactual performance tests: The examinee tries to fit blocks into spaces wile blindfolded, using each hand in
turn. After finishing the task, the person tries to draw the board showing the blocks in their proper spaces.
Trial-making tests: On a board with several circled numbers and alphabets, the examinee is instructed to draw
lines connecting all the numbers and alphabets alternating numbers and alphabets while doing so.
Finger oscillation tests: in this procedure the examinee taps the index finger as fast as he can for five trials of 10
seconds each. The index finger of each hand is tested.
Aphasia screening tests: A number of language abilities are tested by asking the person to name digits, spell,
read, and write and so on. Performance on the tests is interpreted by drawing on knowledge of the relation
between certain structures and behaviour. Thus, a particular deficit may suggest that a problem exists in specific
area in one or the other hemisphere.
Advantages of Tests of organic Brain Dysfunction

23
 1. They have reliability and validity in the assessment of brain damage.
2. They provide efficient cost-effective ways of assessing the functioning of the brain.

Limitations of Tests of Organic Brain Dysfunction

1. Since they are indirect methods the examiner need an extensive knowledge of the anatomy and
physiology of the nervous system to be able to interpret their scores.
2. They of limited value in clinical practice since they are used for assessment of disorders that are not very
common.
Intelligence Tests: Psychological measures of intelligence are required for the diagnosis of mental retardation,
because sub average intellectual functioning is defined in terms of a score on an intelligence test. All intelligence
tests are based on the assumption that one sample from an individual’s current intellectual functioning can predict
how well he will perform in school. In fact, Alfred Binet, a French psychologist, originally constructed mental
tests to help Parisian school board predict which children would profit from schooling. Intelligence tests such as
the Wechsler, Standford-Binet, Ravens and so on, yield a score called intelligence quotient or IQ, measure of an
individual’s intellectual ability.
Earlier versions of intelligence tests derived an IQ by calculating the ratio of mental age to chronological age and
multiplying by 100. Contemporary tests are constructed on the theory that intellectual ability is normally
distributed in the population. Most people are assumed to be near average in intelligence, while a few people are
thought to be exceptionally low or exceptionally high in their intellectual ability. The individual’s IQ is
determined based on how the person scores on an intelligence test relative to the norms for his age group. Narrow
age ranges are used in creating norms for children because of their changing cognitive abilities and rapid
acquisition of knowledge. In contrast, all adults are treated as a part of the same age group.
Intelligence tests are standardized to have a mean of 100 and a standard deviation of 1.5. Thus, about two-thirds
of the population have a IQ within one standard deviation of the mean – between 85 and 115. The cut-off score
for mental retardation is approximately two standard deviations below the mean, which theoretically would
include two or three percent of the population with IQs of 70 and below.
Advantages of Intelligent Tests
1. IQ tests are widely used because they have demonstrated value for predicting academic performance.
2. IQ is a trait that is stable over time. IQ scores of school-aged children are good predictors of IQ scores
later in life. This is true for the mentally retarded as well as for those with IQs in the normal range
(Baroff, 1986).
Limitations of Intelligence Tests
1. IQ score distribution overestimate the observed prevalence rate of mental retardation in the population.

24
 2. Intelligence tests are not “culture fair” since they were developed for middle class Americans and
Europeans and, therefore, contain items that are not sensitive to cultural and linguistic diversity.
3. One very important controversy is how intelligence is measured among the mentally retarded. Many
mentally retarded children have sensory or physical handicaps that impede their performances on standard
IQ tests.
4. The most basic concern about intelligence tests is the most important one: What is intelligence? It must be
recognized that is much more than an IQ score – common sense, social sensitivity, and the so-called
“street smart” are also part of what most of us would consider as intelligence. Thus, the AAMR (1992)
include adaptive skills in its definition of mental retardation. Adaptive skills include both practical
intelligence and social intelligence. Practical intelligence refers to the ability to manage the ordinary
activities of daily living, while social intelligence indicates the ability to understand how to conduct
oneself in social situations.
5. It is apparent from the above that intelligence tests measure what a psychologist consider intelligence to
be.

Assessment of Social Systems

Psychologists are also interested in situational determinants of behaviour, that is, environmental conditions that
precede and follow certain responses. The assessment of social systems focuses on specifying conditions under
which behaviour does or does not occur. The same range of procedures that we discussed for the assessment of
person variables can also be used to examine situation variables. For example, clinical interviews can be used to
describe client’s family and social environment, both past and present. Clinicians have constructed structured as
well as informal interviews to assess the social an emotional climate within families. One example is the
Camberwell Family Interview (CFI; Hooley, 1986) a measure of expressed emotion. Questions on the CFI are
designed to elicit comments from the patient’s parents or spouse that reflects their own attitudes and feelings
about the patient’s behaviour.
Many self-report inventories, rating scales and behavioural coding systems have been designed for the
assessment of marital relationships and family and family systems. One popular self-report inventory is the
Family Environment Scale (FES; Moos 1974; 1981), which is composed of 90 true/false items designed to
measure social characteristics of families. The scale is composed of 10 subscales that are aimed at three
dimensions of the family: relationships (cohesion, expressiveness, and conflicts), personal growth (independence,
achievement orientation, intellectual-cultural orientation, active-recreational orientation, and moral-religious
emphasis), and system maintenance (organization and control).
Direct observations can also be used to assess the social climate within a family. The Family Interaction Coding
System (FICS; Jones, Reid & Patterson, 1975; Reid, 1978) can be used to observe interactions between parents
and children in their homes. However, a trained observer is required for such visits and every member of the

25
family must be present. The observer focuses on and describes the interaction of two members of the family
within a 5-minutes block of time, using the coding system.

Assessment of Biological Systems

We know that biological factors affect human behaviour, so clinicians have developed a number of techniques for
measuring the behavioural effects of biological systems. These techniques are seldom used in clinical practice (at
least for the diagnosis of psychopathology), but they are used extensively in research.
Psycho physiological Assessment: Changes in physiological response systems such as heart rate, respiration, and
skin conductance provide another important source of important regarding a person’s psychological adjustment.
For example, we know that the heart rate of most people will increase markedly under conditions of psychological
as well as physical stress. The autonomic nervous system is highly reactive to environmental events and can
provide useful information about a person’s internal states, such as emotion (Kozak & Miller, 1992). Recording
procedures have been developed to measure important psycho physiological responses as summarized in table 4,
as the person becomes aroused, measures do not act together. If several physiological responses are measured at
the same time, they may not all demonstrate the same strength, or even direction, of response. Anxiety disorders
has been employed (Turpin, 1991). As shown in Table 4-1, many of the body and so on can be assessed while the
clients are afraid, depressed, asleep, imagining, or solving problems. Special attention can also be paid to th
patterning of response such as when heart rate increases while skin conductance remains constant.
Advantages of Psycho physiological Assessment
1. Psycho physiological measuring procedures are relatively unobtrusive.
2. Psycho physiological recording procedures do not depend on self-report and, therefore, may be less
subject to voluntary control. People may be less likely to make the assessment show what they want it to
show.
3. Some of the measures can be obtained while the person is engaged in other activities.
4. They are apparent objective measurement devices and measures.
Limitations of Psycho physiological Assessment
1. They require relatively sophisticated equipment and a technician who is trained in their use. Therefore
they are costly to acquire, run and maintain.
2. Many psycho physiological measures do not differentiate clearly among different emotional states. Heart
rate, for example, increases with a variety of emotions, not only anxiety.
3. They require special settings for taking of measurements so that the data will be meaningful.
4. The recording equipment and electrodes may be frightening or intimidating to some people.

26
 5. There are generally low correlations between different response systems. It is not wise to arbitrarily select
one specific physiological measure, such as heart rate and assume that it is a direct index of arousal.
6. Physiological reactivity and the stability of physiological response system vary from one person to
person. The measures may be informative for some people but not for others.
7. Physiological responses can influence by many other factors such as age and medication, as well as
psychological factors such as being self-conscious or fearing loss of control.

Table 4-1: Physiological Systems and Their measurements

Response Psycho physiological Basis of Response

System Response

Cardiovas- Electrocardiogram (EKG) Action potential of cardiac muscle during contraction

cular
Systolic: force of blood leaving the heart. Diastolic:
residual pressure in the vascular.
Blood pressure (BP)

Electroder Skin resistance level (SRL), Source of signal is uncertain, current theories favour sweat
mal gland activity
and response (SRR),
Skin conductance level
(SCL), and response (SCR)

Central Electroencrphalogram (EEG) Electrical activity of cortical

Nervous
Average evoked response Same as EEG but in response to specific stimulus.
System
(AER)
Same as EEG, appears during preparatory responses.
and event-related potential
(ERP)
Contingent negative
Variation

Specialize Sexual (Plethysmograph) Engorgement of genital tissue with blood.

d
Inhalation and exhalation of air.
Responses
Respiration rate Latency to onset of patterns as associated with dreaming.
Rapid eye movement (REM) Visual tracking of an oscillating pendulum-like stimulus
sleep latency

27
 Smooth pursuit of eye
movements (SPEM)

Brain imaging techniques: Recent decades have witnessed a tremendous explosion information and technology
in the neurosciences. One of these is invention of sophisticated methods of creating images of the living human
brain. Some of these procedures provide static images of various brain structures at rest, just as an x-ray provides
photographic images of a bone or some other organs of the body. The computerized tomographic (CT) scanning
and the magnetic resonance imaging (MRI) technique can be used to provide static pictures of specific brain
structures. Even more sophisticated machinery are available for creating dynamic images of the brain while the
person is performing other tasks. Examples include the measurement of regional cerebral blood flow (rCBF) and
the position emission tomography (PET) scanning, which can provide useful images of dynamic brain functions,
indicating areas that are possibly defective.
Advantages of Imaging Techniques
In addition to those already noted for psycho physiological assessment, brain imaging provide detailed
information regarding the structure of brain areas and activity levels in the brain that are associated with the
performance of particular tasks.
Limitations of Imaging Techniques
Apart from those already mentioned for psycho physiological assessment, brain imaging also have the following
draw backs:
1. They are primarily research tools and have little clinical importance outside of the assessment and
treatment of such disorders as Alzheimer’s disease.
2. Norms have not yet been established for any of these measures. It is not possible to use brain-imaging
procedures for diagnostic purposes.
3. These procedures (at least some of them) expose patients to radioactive substances.

28
 CHAPTER FIVE
THE RESEARCH METHODS OF ABNORMAL PSYCHOLOGY
The progress of as a science has taken place by means of diverse investigating strategies. The research procedures
prescribe rules to be followed in formulating and evaluating hypotheses that directs the collection and
interpretation of data. Four basic methods frequently applied in the study of abnormal behaviour are discussed in
this chapter.
SINGLE-SUBJECT RESEARCH
Sometimes the researcher is faced with unusual or rare problems, which involve just one or a few individuals.
Single-subject or small-N designs are used in such cases. There are two major procedures for conducting such
research: the case study and the single-subject experiment.
The Case Study: Case studies (histories) involve the collection of historical and biographical data on a single
person. Such data are then used to provide a detailed description and analysis of the problems experienced by that
particular person. Case studies are used to:
1. Demonstrate important, often novel, methods or procedures of interviewing, diagnosis and treatment.
2. Provide a detailed clinical descriptions of disorders especially those that have not previously received
much attention in the literature or for problems that are relatively rare or unusual;
3. Disconfirm allegedly universal aspects of a particular theoretical proposition; and
4. Generate hypotheses that can be tested through controlled research.
Elaborate case studies can provide an exhaustive catalogue of the symptoms that the person displayed, the manner
in which these symptoms developed, the developmental and family history that preceded the onset of the disorder,
as well as whatever response the person may have shown to treatment efforts.
Advantages of the Case Study
1. Case studies provide important insights about the nature of mental disorders, especially when special
circumstances happen to prevail in combination with the appearance of a disorder.
2. Case studies can provide especially telling instances that negate an assumed universal relationships or
laws.
3. Case studies often provide important hypotheses which experiments can later subject to controlled
investigation.
Limitations of the Case Study
1. The finding of case studies usually lack the degree of control and objectivity of research done by other
methods.

29
 2. In the presentation of a case history, the control for confirming one hypothesis and ruling out alternative
hypotheses are usually absent. That is, the results can viewed from many different perspectives.
3. It is risky to draw general conclusions about a disorder from a single example. How can we know that this
individual is representative of the people with this disorder?
4. Due to these shortcomings the case study is weak internal and external validity.
Single-Subject Experimental Designs: The experimental method can also be applied in studies involving one or
a few persons. The basic strategy in such studies is to compare/manipulate a variable or variables within the same
individual over some time. Thus, the individual serves as is own control. The time (usually days, weeks or
months) is divided into several segments as outlined below:
Baseline phase (A): A selected variable is observed and recorded for a specific period of time. Scales or properly
calibrated instruments can be used to measure this target variable during this phase.
Treatment phase (A): The targeted behaviour is actively manipulated. The manipulation can be the introduction
of therapy or the withdrawal of certain privileges. Whatever is chosen must be that which have an effect on
(cause) the target behaviour. The behaviour is also measured and recorded by the same instruments during this
phase.
Reversal phase (B): Attempt to reinstate conditions that prevailed in the baseline phase (A) by withdrawing the
manipulation variable. Target behaviour is also measured with the same instruments.
Treatment phase (B) A reintroduction of the experimental manipulation as obtained in treatment phase (A). The
same instruments also measure the behaviour.
If the behaviour in the experimental periods (treatment phase A & B) is different from that in the control period
(baseline A and rehearsal B), there would be little doubt that the manipulation, rather than chance factors
produced the change. This can of course be verified statistically using the same statistics as for other experimental
designs.
To illustrate let us consider a method reducing a self-injurious behaviour. Deji has a serious rivalry. Anything
times his carries and cuddles his younger sister he is extremely jealous and start to bang his head on the wall or
the floor. Deji is also very fond of his father; in fact any time the father is around he prefers to play with rather the
mother or any other person. This affection for the father was used as the experimental variable. The study ran for
twenty days in first five days the frequency of Deji’s head banging was recorded. Then for another five days the
father was told to withdraw his love for by refusing to play with him or even talk with him any time Deji A
banged was also recorded in this block of five days and so on.
The procedure described above is called the reversal or ABAB design. The technique cannot always be applied
for several reasons. First the initial state of the subject may not be recoverable as when treatment cause
irreversible change. Second reinstating the original conditions, especially in therapeutic procedures may be
unethical. When the reversal technique does not apply, the multiple baseline procedure, wherein two or more

30
behaviours are chosen for study, is the method of choice. The strategy is essentially the same except that at the
reversal phase, attention switches to the second behaviour instead of a return to baseline.

One advantage of the single-subject experiment is that the inclusion of the control periods and the careful
measurement of some aspects of behaviour improve the internal validity of the technique. However, even though
the single-subject experiment demonstrate experimental effect, no generalization may be possible. The fact that a
particular treatment works for single person does no necessarily imply that the treatment will be universally
effective.

31
 CHAPTER SIX
ANXIETY DISORDERS
Anxiety – a vague feeling of dread, a fear with no specific objects that is accompanied by increased arousal – is
an emotion that everyone experiences at times. When such feelings become very intense and persist for long
periods of time, however they can produce harmful effects and be the basis for a number of psychological
disorders. Since the most prominent defining feature of anxiety is fear, it is necessary to distinguish between the
two. Fear is experienced in the face of real, immediate danger. It usually builds up quickly in intensity and helps
to organize the person’s behavioural responses to threats from the environment (escaping of fighting). Anxiety,
on the other hand, involves a more general or diffuse emotional reaction – beyond simple fear – that it out
proportion to threats from the environment (Roth & Argyle, 1988). Rather than being directed towards the
person’s present circumstances, anxiety is typically with the anticipation of future problems.
Anxiety can be adaptive at low levels, because it serves as a signal that the person must prepare for an upcoming
event (Costello, 1970). When you think about your final exams, for example, you can become somewhat anxious.
That emotional response may help to initiate and sustain your efforts to study. In contrast, high levels of anxiety
can become so incapacitating that concentration and study are disrupted. Such pervasive anxiety is characterized
by pessimistic thoughts and feelings, which focuses attention inwards in the form of negative emotions and self-
evaluations. This is maladaptive anxiety that consists of: (1) high levels of diffuse negative emotion, (2) a sense of
uncontrollability, and (3) a shift of attention to a primary self-focus or a state of self-preoccupation (Barlow,
1991). Worrying is one prominent cognitive activity that is associated with anxiety.
Worry can be defined as a relatively uncontrollable sequence of negative, emotional thoughts and images that are
concerned with possible future threats or danger (Pruzinsky & Borkovec, 1990). Research evidence suggests that
the crucial features of pathological worrying may lack of control and negative affect rather than simply the
anticipation of future events (Craske et al., 1989). We noted above that anxiety could be a partial basis for a
number of psychological disorders, among these are anxiety disorders, somatoform disorders and dissociative
disorders (see Table 6-1). The last two will be discussed in Chapter 7.
Classification of Anxiety Disorders
Anxiety disorders are characterized by high levels of anxiety accompanied by patterns of ineffective,
maladaptive behaviour (Walley et al., 1994). They are also referred to as neuroses, although the term is no longer
used in most classification manuals such as DSM-IV and ICD-10.
Table 6-1: Categories Listed as Anxiety Disorder in DSM-IV

Panic Disorder: Without Agoraphobia

Panic disorder: With Agoraphobia
Agoraphobia: Without a History of Panic Disorder
Specific Phobia

32
 Specific type: Animal type/Nature-Environment type/Blood-injection-injury type/situational type/other
type.
Social Phobia
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Generalized Anxiety Disorder
Anxiety Disorder due to ……………………………………………………….
(indicate the General Medication Condition)
Substance-Induced Anxiety Disorder
(refer to Substance related disorders for Substance specific codes)
Anxiety Disorder NOS.

People with anxiety disorders feel threatened and insecure and are typically uncertain of their ability to function in
the real world. They will do whatever is necessary, including defensive engaging win maladaptive behaviour, to
avoid anxiety-provoking situations. Such individuals also experience a variety of physical symptoms ranging
from chest pain and rapid heartbeat of muscle tension, sweating, “butterflies” in the stomach, diarrhea and
headache. In many cases, these symptoms are so severe that the person cannot function effectively. Included
among the anxiety disorders are generalized anxiety disorder (GAD), panic attack disorder (PAD), obsessive-
compulsive disorder (OCD), and phobic disorders (see Table 6-1)
Generalized Anxiety Disorder (GAD): A GAD is one in which the person feels anxious and apprehensive, have
a sense of impending disaster, and believes he falling apart or loosing control. Much of the anxiety is free-
floating – anxiety that cannot be attributed to any specific current event. The person will also experience fatigue,
nightmares, and periodic attack of intense anxiety that may last for a few minutes to several hours.
Panic Attack Disorder (PAD): PAD is an extreme anxiety reaction, in which the heart beats faster, thinking
becomes disordered and the person becomes unable to make decisions. The person is unable to function
effectively for a long period of time that can lasts for minutes or hours. Panic disorder is diagnosed when a person
experience at least three separate episodes within a 3-week with evidence of at least four of the 13 symptoms
listed in Table 6-2 (Okasha et al., 1994). The number and combinations of these symptoms vary from one person
to the next, and they may also change over time within the same person.

33
Table 6-2: The Symptoms of Panic Attack in DSM-IV

Physiological Cognitive

Palpitation, pounding heart, Inability to make decisions

or accelerated heart rate,
sweating

Trembling or shaking Fear of dying

Sensation of short breath or Derealization (feelings of unreality)

smothering

Chest pain or discomfort Depersonalization (being detached from oneself)

Nausea or abdominal distress Fear of loosing control or going crazy

Feeling dizzy, unsteady light

headed, or faint

Chills (cold sweat) or hot

flushes

Phobic Disorders: A phobia is an irrational, excessive fear of some object or situation that is accompanied of
phobia. A fear is not considered phobic unless the definition of phobia. A fear is not considered phobic unless the
person either avoids contact with the source of her fear or experience intense anxiety in the presence of the
stimulus. Her anxiety about encountering the object or situation triggers her fear, which actually interferes with
her ability to carry on with a normal life. Phobias have traditionally been named according to the Greek words for
the feared object or situation (see Table 6-3). Some phobias are relatively straightforward, involving fear of
specific objects or situations, such are called simple phobia. Others (usually referred to as complex phobia) have
broad implications for the sufferer’s behaviour and life style.
Table 6-3: Some Common Phobias

Name Short Description

Acrophobia Irrational fear of heights

Ailurophobia Irrational fear of cats
Agoraphobia Irrational fear of open spaces
Arachnophobia Irrational fear of spiders
Apiphobia Irrational fear of bees
Austraphobia Irrational fear of lightning

34
 Claustrophobia Irrational fear of enclosed spaces
Cynophobia Irrational fear of dogs
Ergosiophobia Irrational fear of work
Helminphobia Irrational fear of worms
Hemaphobia Irrational fear of blood
Hippophobia Irrational fear of horses
Hydrophobia Irrational fear of water
Keraunophobia Irrational fear of thunder
Musophobia Irrational fear of mice
Necrophobia Irrational fear of death
Nycrophobia Irrational fear of the dark
Ochlophobia Irrational fear of crowds
Oneirophobia Irrational fear of dreams
Phasmophobia Irrational fear of ghosts
Pheniphobia Irrational fear of daylight
Pyrophobia Irrational fear of fire
Sciophobia Irrational fear of shadows
Spermophobia Irrational fear of germs
Tachophobia Irrational fear of speed
Xenophobia Irrational fear of strangers
Zoophobia Irrational fear of small animals.

Agoraphobia (literally meaning fear of the market place or places of assembly) is fear of being alone win public
places without access to help. It is sometimes accompanied by panic disorder and sometimes not. The
agoraphobic’s fear usually becomes more intense as the distance between the person and his familiar surroundings
increases or as avenues for escape is closed off. Much of the fear is that of being separated from signals associated
with safety. Thus, he develops a sense of helplessness in many situations and frequently experiences anxiety of
panic attacks as a result of the overwhelming fear that he will be psychologically abandoned. So severe is the

35
anxiety that many agoraphobics are literally household and many avoid going outside even when doing so is
important.

Social Phobia is another complex and incapacitating form of phobic disorder. It involves high levels of anxiety
associated with possibility that others will react negatively to one’s behaviour (Woody et al., 1997). People with
social phobia experience marked fear when they are forced to engage in such activities as public speaking,
initiating conversation, eating in a restaurant, and using public toilets, which might involve being observed or
evaluated by other people (Liebowtiz et al., 1985). Attempts to avoid these feared situations cause serious
impairment in the person’s social and occupational activities.

Obsessive-Compulsive Disorder (OCD) Obsessions are repetitive, unwanted, intrusive cognitive events that
may take the form of thought or images or impulses. They intrude suddenly into consciousness and lead to an
increase in subjective anxiety. Obsessions are unwelcome (unwanted) thoughts, and they are nonsensical; they
seem silly or “crazy”. Obsessive thoughts of pathological proportions differ from common obsessions in that they
are more persistent, less rational and tend to interfere with ongoing behaviour. The most common obsessive
thoughts are concerned with germs, dirt, and disasters such as death or injury. Compulsions are repetitive
behaviours that are considered by the person who performs them to be senseless or irrational. The person to resist
but cannot. Compulsions reduce anxiety, but they do not produce pleasure. This distinguishes them from the so-
called compulsive behaviours like drug addiction and gambling. Common compulsions include such things as
hand washing, stepping over craks on the sidewalk, and excessive cleanliness (Valleri-Basile et al., 1994).

OCD is characterized by persistent, uncontrollable, ritualistic acts that accomplish no practical end (Pigot et al.,
1994). The person typically looses voluntary control over aspects of his thoughts and actions. The most common
OCD is compulsive checking which frequently represents and attempt to ensure the person’s safety or the safety
and health of friends or family members. The person will check things over and over again in an attempt to
prevent the occurrence of imagined, unpleasant, or disastrous event (for example, accident or sickness).

Co-morbidity of Anxiety Disorders

Within the field of psychopathology, the simultaneous manifestation of a disorder (for example, GAD) and other
syndromes is referred to as co-morbidity. The various symptoms of anxiety disorders overlap considerably.
Many people who experience panic attacks develop phobic avoidance, and many people with obsessive thoughts
would also be considered generally anxious. Brown & Barlow (1992) found that 50% of people who meet the
criteria for at least on anxiety disorder also met the criteria for at least on other form of anxiety disorder.
Considerable overlap also exists between the emotion symptoms of anxiety and depression. People with a
diagnosis of major depression (see Topic 9) are 19 times more likely to experience a panic disorder and 15 times

36
more likely to develop agoraphobia than are non-depressed people (Weissman, 1988). What this means is that
anxiety and depression frequently appear together. Someone with a diagnosis of clinical depression is also likely
to exhibit symptoms of anxiety disorder and vice versa. Substance dependence is another common complication
associated with anxiety disorders. Chambless (1987) found that 40% of alcoholic patients would have met
diagnostic criteria for at least one anxiety disorder at some point during their lives.
Epidemiology of Anxiety Disorders
Epidemiology is the scientific study of the frequency and distribution of disorders within a population. The
prevalence of anxiety disorder in Nigeria is unknown. In the USA, the Epideminological Catchments Area (ECA;
Robbins & Regier, 1991) study found that anxiety disorders are more common than other forms of psychological
disorders. Phobic disorder with a prevalence of about 90% of the adult population is the most common, followed
by GAD (4%), OCD (2%), and PAD (1%) in any given year (see Table 6-4). The ECA and other studied
confirmed gender differences in several types of anxiety disorders as shown in Table 6-4 below.
Table 6-4: gender Differences in the frequency of Anxiety Disorders

Lifetime Risk (%)

Disorder Men Women

Specific Phobia 14.45 7.75

Agoraphobia 7.89 3.18

Social Phobia 2.91 2.53

Obsessive-Compulsive Disorder 3.04 2.03

Panic Disorder 2.10 0.98

Women are about twice as likely as men to experience simple phobias, agoraphobia panic disorder, and
generalized anxiety disorder. There appear to be no significant gender differences in the experience of obsessive-
compulsive disorder (Karno & Golding, 1991). -Anxiety disorders have been observed in many cultures both in
developed and developing countries. However, the focus of typical anxiety complaints can vary dramatically
across cultural boundaries. People in Western societies often experience anxiety in relation to their work
performance, whereas people in other societies may be more concerned with family issues and religious
experiences. In the Yoruba culture, for example anxiety is frequently associated with fertility and the health of
family members.
Aetiology of Anxiety Disorders
Both psychoanalysis and attachment theories emphasize the importance of parent-child relationships in the
aetiology of anxiety disorders. Freud's theory of signal anxiety focused primarily on the importance of mental
conflicts and innate biological impulses (primarily sexual and aggressive instincts). The notion is that a person's
ego can experience a small amount of anxiety as a signal indicating that an instinctual impulse that has previously
37
been associated with punishment and disappointment is about to be acted upon. This signal triggers the
engagement of ego defences, which can inhibit the expression of the act. When, however, the traumatic events or
circumstances are extreme they can overwhelm the system leading to high levels of free-floating anxiety. The
specific form of overt symptoms is determined by the defence mechanisms that are employed by the ego.

Attachment theory (Ainsworth, 1984; Bowlby. 1973) went further to suggest that individual differences in
attachment styles, presumably rooted in early childhood social relationships, and may set the stage for the
development of future anxiety reactions.
Classical conditioning principles have most often been used to explain the development of phobic disorders.
According to the version of this model, the CS could be any neutral stimulus that happened to be present when an
immense fear reaction was provoked. Through the process of association, the CS would consequently elicit a CR,
which was similar in quality to the original UCR. A modified version of this model, the preparedness theory
(Seligman, 1971), recognises that there are biological constraints on the kinds of associations members of a
species are able to make, and these constraints presumably develop throughout the long process of evolution. That
is human beings maybe prepared to develop intense, persistent fears only to a select set of objects or situations. In
this sense certain fears are adaptive. However, people can learn to (through modelling or vicariously) 10 avoid
certain stimuli if they observe other people showing a strong fear response to those stimuli.
Cognitive theorists (Clark, 1986; Costello, 1992; McNally, 1990) have argued that panic disorder is caused by
the catastrophic misinterpretation of bodily sensations or perceived threat and perceived control of events in the
environment. The negative emotion associated with perception of lack of control can trigger a related cognitive
process that most of us call worrying, which Mathews (1990) defined as " La special state of the cognitive system
adapted to anticipate possible future danger. Worrying is unproductive and self-defeating in large part because it
is associated with a focus on self-evaluation (fear of failure) and negative emotional responses rather than on
external aspects of the problem and on active coping behaviours. The struggle to control these thoughts often lead
to a thought suppression process - an attempt to stop thinking about something. OCD may be a consequence of
this process (Barlow, 1988).
Family and twin studies support the hypothesis that genetic factors are involved in the transmission of anxiety
disorders (see Tables 6-5 and 6-6) that these disorders may share a common genetic predisposition. It seems
reasonable to conclude that some people inherit
Table 6-5: Frequency of Anxiety disorders in First-Degree Relatives of Three Types of Subjects

Proband with: Percent of relatives with:

PAD GAD Specific Phobia

Panic Attack Disorder 14.9 5.4 1.7

Generalized Anxiety Disorder 4.1 19.5 1.6

38
 No Psychiatric Diagnosis 3.5 3.5 1.8

Table 6-6: Twin Concordance Rates for Specific Anxiety Disorders

Disorder Study ercent (# twins)

Concordan DZ
MZ
PAD Torgerson(1983) .31 .00
GAD Torgerson (1983) .00 .05
GAD Kendler et al (1992a) .28 .17
Agoraphobia Kendler et al (1992b) .23 .15
Social phobia Kendler et al (1992b) .24 .14
Animal phobia Kendler et al (1992b) .26 .11
Phobia (all) Carey & Gottesman (1981) .88 .31
OCD Carey & Gottesman (1981) .87 .47
a predisposition that makes them especially vulnerable to the development of anxiety disorder. The specific form
of this predisposition is however currently unknown.

39
 CHAPTER SEVEN
SOMATOFORM AND DISSOCIATIVE DISORDERS
Previously categorised as hysteria - a type of neurosis, both somatoform and dissociative disorders are traceable to
unconscious processes. Thus even the descriptive approach to classification has separated them into discrete
diagnostic categories, they are often discussed together because of their historical relationship.
SOAMTOFORM DISODERS
All somatoform disorder involve physical complaints and symptoms that are similar to medical conditions but
have no underlying organic cause. That is, there is nothing physically wrong with the patient. The symptoms are
not feigned, however, as the physical problem exist in the mind of the person. The symptoms are not under
conscious or voluntary control (Kirmayer, et al, 1994). We should not confuse somatoform disorders with
psychosomatic (psychophysiological) disorders. The latter are true physical disorders like ulcer and heart disease,
in which stress may be a contributing factor. In contrast, psychosomatic disorders, the symptoms of somatoform
disorders cannot be explained by an underlying organic impairment. Still, may patients with these purely
psychological problems seek medical cure and receive unnecessary medical treatments. In fact, significant
proportions of patients first seen in hospital emergency rooms have no serious physical problems and are
eventually diagnosed with somatoform disorders (Farewell et al, 1997). There are no demonstrable physical
causes for the physical symptoms of somatoform disorders. They are somatic in form only - thus their name. The
physical symptoms can take a number of different forms. In some dramatic cases, the symptoms are substantial
impairments of a somatic system, particularly a sensory or muscular system. The patient will be unable to see, for
example, or will report a paralysis of one arm. In other types of somatoform disorder, patients experience multiple
physical symptoms rather than single, substantial impairment. In these cases, patients usually have numerous,
constantly evolving complaints about such problems as chronic pain, upset stomach, and dizziness. Finally some
types of somatoform disorders are defined by a preoccupation with a particular part of the body or with fears
about a particular illness. The patient may constantly worry that she has contracted a deadly disease, for example,
and the anxiety persists despite negative medical tests and clear reassurance by a physician.
Classification of Somatoform Disorders
DSM-IV lists five major subcategories of somatoform disorders: body dimorphic disorder, hypochondriasis,
somatization disorder, pain disorder, and conversion disorder. Body Dimorphic Disorder The distinguishing
feature of body dimorphic disorder is a preoccupation with some imagined defect in appearance. This
preoccupation typically focuses on some facial feature such as the nose or mouth, the preoccupation far exceeds
the normal worries and cause significant distress, which in the extreme may interfere with work or social
relationships. This disorder is diagnosed more frequently in some European and Asian countries. For example, in
Japan and Korea, it is classified as type of social phobia.
Hypochondriasis This is perhaps the best known of the somatoform disorders it is characterised by a fear or
belief that one is suffering from a physical illness. The person will be excessively concerned about his health and
worry constantly that he has a major physical disease (Barsky et al, 1994). The preoccupation with fears of
disease extends over long periods of time. The worries must last at least 6 months to meet DSM-IV diagnostic
40
criteria. A thorough medical examination will not convince the person, he will still worry that the illness has been
overlooked or that the tests were not properly done. He will constantly interprete minor irregularities in body
functioning as indicative of serious underlying disorder.
Somatization Disorder Somatization disorder is characterised by a history of multiple somatic complaints with
apparent psychological origin. The complaints involve multiple somatic system, including symptoms of pain
(backache, headache, abdominal pain), gastrointestinal symptoms (nausea, diarrhoea), sexual problems (sexual
dysfunction, menstrual difficulties), and pseudo neurologic symptoms (double vision, numbness, amnesia).
Because of the extent of health concerns shown by such patients DSM-IV recommends that the person must
complain of at least 8 symptoms (see Table 7-1) to meet the criteria for somatization disorder.
Patients with somatization disorder sometimes present their symptoms in histrionic manner - a vague but
dramatic, self-centred, and seductive style. Patients also sometimes exhibit la belle indifference (beautiful
indifference) a flippant lack of concern about the physical symptoms. Somatization disorder often begins in
childhood or adolescence and is more common in women. The problem is sometimes referred to as Briquette's
syndrome after the French physician Pierre Briquette.
Table 7-1: Diagnostic Criteria for Somatization Disorder

A. A history of many physical complaints beginning before age 30 that occur over a period of several
years and result in treatment being sought or significant impairment in social, occupational, or other
important area of functioning.
B. Each of the following criteria must have been met, with individual symptom occurring at any time
during the course of the disturbance
1. Four pain symptoms. A history of pain related to at least four different sites or functions (for
example, head, abdomen, joints, extremities, chest, rectum, during sexual intercourse, during menstruation, or
during urination)
2. Two gastrointestinal symptoms. A history of at least two gastrointestinal symptoms other than pain
(for example, nausea, diarrhoea, bloating, vomiting other than during pregnancy, or intolerance of several
different foods)
3. One sexual symptom. A history of at least one sexual or reproductive symptom other than pain (for
example, sexual indifference, erectile or ejaculation dysfunction, irregular menses, excessive menstrual
bleeding, vomiting throughout pregnancy)
4. One pseudo neurologic symptom. A history of symptom or deficit suggesting a neurological disorder
not limited to pain (conversion symptoms such as dizziness, double vision, deafness, loss of touch or
pain sensation, hallucination, aphonia, impaired coordination or balance, paralysis or localised
weakness, difficulty swallowing or lump in throat, difficulty breathing, urinary retention, seizure)

41
Conversion Disorder Patients with conversion disorder exhibit lose or impairment of physical functions
involving either the sensory or motor systems. The symptoms of the disorder often mimic those found in
neurological diseases, and they can be dramatic. Examples include "hysterical" blindness and "hysterical"
paralysis. Although conversion disorder frequently resembles neurological impairments, some can be
distinguished from these diseases because they make no anatomical sense. The patient may complain about
anaesthesia (or pain) in a way that does not correspond with the innervations of the body part. The term
conversion disorder implies that psychological conflicts are converted into physical symptoms. Other symptoms
of the disorder include glove anaesthesia, deafness, paraesthesia (a tingling sensation), and paresis mild, partial
paralysis. These often appear suddenly under conditions of high stress.
Pain Disorder Pain disorder is characterised by a preoccupation with pain, ft is diagnosed when persistent,
significant pain occurs in the absence of medical pathology that would explain its duration and magnitude. The
pain appears to be psychological in origin and is therefore sometimes called psychogenic pain. Although there is
no objective ways to evaluate pain, the complaints of patients with psychogenic pain seem excessive and
apparently motivated, at least in part, by psychological factors. Nevertheless, the experience of pain is very real
and can disrupt social and occupational functioning. Also, people who experience chronic pain are at particular
risk for developing dependence on minor tranquillisers or painkillers.
Epidemiology of Somatoform Disorders
True somatoform disorders are rare, although complaints about somatic symptoms that do not have an organic are
common and represent a significant proportion of medical care. Epidemiological research has not been conducted
on some somatoform disorders anywhere in the world. These include hypochondrias, body dimorphic disorder,
and pain disorder. Apart from hypochondrias, which is equally common among men and women, all forms of
somatoform disorders are more common in women. This is particularly true of somatization disorder, which is 10
times more common among females than males (Swartz, et al. 1990). The prevalence of somatization disorder is
also influenced by culture and socio-economic status. For example, it is relatively common Nigeria. In America it
is four times as common among African-Americans as among Americans of European heritage.
Co-morbidity of Somatoform Disorders
The considerable overlap between somatoform and other psychological disorders makes their differential
diagnosis difficult. People who suffer from somatoform disorders, particularly somatization and hypochondriasis,
also frequently suffer from depression (Bridges &Goldberg, 1988; Swartz et al., 1990). Some patients express
depression indirectly through their somatic complaints (Dipowski, 1988). Increased anxiety also is associated with
hypochondriasis and somatization disorder; this is particularly true of African patients who frequently explain
their psychological problems in physical terms. Somatization is said to be very common in Nigeria because their
anxiety and many other psychological problems in somatic terms.
Aetiology of Somatoform Disorders
The aetiology of somatoform disorders has not been the subject of much research. Biological concerns include the
misdiagnosis of incipient neurological disorders as somatoform disorders. Thus, the identification of somatoform
disorder involves a process called diagnosis by exclusion - somatoform disorders are diagnosed only when various
42
known organic causes of the physical symptoms are excluded or ruled out. Psychodynamic theories assume that
the symptoms of somatoform disorders are, in part, a way of reducing anxiety and depression by channelling these
negative feelings into the body. The secondary gain theory assumes that learning the sick role helps the patient
to avoid work or responsibility or to gain attention and sympathy. The positive reinforcement (extra attention) or
negative reinforcement (avoidance of work) and modelling strengthens the sick role (Lipowski, 1988).
Social and cultural theorists assume that patients with somatoform disorders are experiencing some sort of
underlying psychological distress. However, the patients describe their problems in as physical symptoms, and to
some extent experience them that way, because of limited insight into their emotional distress and/or the lack
social tolerance of psychological complaints. That is, people with somatoform disorders are really fearful, sad, or
uncertain about their life, but they experience or at least express, these emotional concerns in physical terms.
Prevalence data of the disorders seems to support this assumption. Somatoform disorders are more common in
non-industrialized countries, and they are more common among less educated people in industrialized countries
(Kirmeyer, 1984; Mechanic. 1986). This may be true, for as Maslow argued, people have time for introspection
only after meeting the more basic of survival and safety.
DISSOCIATIVE DISORDERS
The defining feature of dissociative disorders is dissociation, the disruption of mental processes involved in
memory or consciousness that are normally integrated (Spiegel & Cardena, 1991). The individual with
dissociation experience a profound and lengthy loss of identity or memory. Extreme cases of dissociation involve
a split in the functioning of the individual's sense of self. Trauma often plays a role in dissociation and
dissociative disorders. In some cases the dissociation is precipitated by sudden and recent traumatic events. In
other cases, the onset of dissociation is more gradual and is not linked with present trauma; nevertheless, the
problem can still be traced to a trauma in the past.
Classification of Dissociative Disorders
The DSM-1V distinguishes four major subtypes of dissociative disorders: fugue, amnesia, depersonalisation
disorder and dissociative identity disorder.
Fugue Dissociative fugue is a form of amnesia in which the person not only forgets who he is but actually moves
to a new area and establishes a new identity. It characterised by sudden and unexpected travel away from home,
an inability to recall the past, and confusion about identity. Some portion of memory is split off
dissociated from consciousness. This is precipitated by present or longstanding trauma and recovery of
psychological functioning is typically rapid and full without reoccurrence.
Amnesia Dissociative amnesia, sometime called psychogenic amnesia, is a temporary loss of memory about one's
personal characteristics and past history. The memory loss is typically selective rather than complete (Keamere?
al., 1997). The person may forget his own identity, family, and address but not how to do his job, drive a car or
perform other learned tasks. Like fugue, it is characterised by a sudden onset in response to trauma or extreme
stress, and by an equally sudden recovery of memory. Amnesia may take many forms, including retrograde
amnesia - a loss of memory for events before the trauma; posttraumatic amnesia - loss of memory for events after
the trauma; anterograde amnesia; and selective amnesia - which is described above is the most common
43
Depersonalisation: Depersonalisation disorder is characterised by severe and persistent feelings of being
detached from oneself. The experiences include such sensations as feelings of floating above one's body and
observing oneself act. The feelings are persistent or recurrent, and they cause marked distress. The onset of
depersonalisation disorder commonly follows a new or disturbing event such as drug use. The
dissociation/splitting between conscious and unconscious mental processes are limited and no memory loss occurs
(Spiegel & Cardena, 1991).
Dissociative Identity Disorder Perhaps the most dramatic of the dissociative disorders is dissociative identity
disorder, a condition labelled multiple personality disorder in earlier classification systems. In this rare disorder, a
single person seems to possess two, three or even many personalities. Some of these personalities are dominant,
and alternately take control of the person's behaviour. In addition, persons suffering from the disorder report
selective amnesia. Information retained by one of the personalities is not necessarily available to the others. The
original personality is especially likely to have amnesia for subsequent personalities, which may or may not be
aware of the "alternates" (Aldridge-Morris, 1989).
The different personalities have quite different characteristics, and the person switches among frequently. Because
of it's for criminal justice, dissociative identity disorder has received much public attention in Western countries.
The question has been whether such individuals are faking or not. This question has not been satisfactorily
answered. But people showing the disorder sometimes demonstrate distinctive patterns of brain activity when
each of the supposedly separate personalities appears. Similarly, each personality often scores differently on
standardized personality tests (Kaplan & Sadock, 1991). Even the need for eyeglasses, or being right- or left-
handed may vary among the different personalities. Nevertheless, the controversy about the reality of the disorder
continues. Some professionals argue that dissociative identity disorder is not more than role-playing; others assert
that it is very real and common.
Epidemiology of Dissociative disorders
The prevalence of Dissociative disorders is difficult to establish. The conditions have been considered
exceptionally rare. This may be because patients truly suffering from dissociative disorders are misdiagnosed as
having schizophrenia, borderline personality disorder, depression, panic disorder and substance abuse (Ross,
Norton & Wozney, 1989). Despite the scepticism about the prevalence of dissociative disorders, American
professionals diagnose the disorders more often than Europeans or Japanese, perhaps reflecting a North American
diagnostic "fad" (Mersky, 1992).
Aetiology of Dissociative Disorders
Little systematic research has been conducted on the aetiology of dissociative disorders. One exception is the
widely held view that the disorders are often precipitated by trauma, which is beginning to find some empirical
support. Trauma may contribute to dissociative disorder but it clearly not a sufficient cause. Some researchers
have theorized that disturbances of the temporal lobe of the brain, including seizure disorders, play a role in
dissociative identity disorder (Mesulam, 1981). Evidence that biological factors can produce dissociatve
symptoms suggests the existence of dissociation in cognitive processes.

44
Many case histories suggest that multiple personalities develop in response to trauma, particularly the trauma of
child abuse. One theory suggests that such trauma overwhelms children's usual intra-psychic defences, and
dissociation is used as a more dramatic alternative. Another invokes the concept of state-dependent learning.
Learning that occurs in one state of affect or consciousness is best recalled in the same state of affect or
consciousness (Bower, 1990). Through the repeated experience of trauma, dissociation, and such state-dependent
learning more and more complete and autonomous memories develop over time.

45
 CHAPTER EIGHT
SCHIZOPHRENIC DISORDERS
Schizophrenia is a pervasive and sometimes chronic form of psychological disorder that encompasses what many
of us know as madness. The name schizophrenia ("split mind") refers to a split between the mind and reality; the
idea is that the individual has retreated from reality into a private world, which might include hallucinations,
delusions or irrational perceptions of real events. Most psychological disorders cause distress to the persons who
experience them. Yet for the most part these persons can continue with their lives though they general suffer and
struggle somehow. In contrast, individuals afflicted with schizophrenia are so disturbed that they usually cannot
live ordinary lives. The symptoms of schizophrenia follow different patterns over time. Some recover very
quickly whereas others deteriorate progressively after the initial onset of symptoms. The most common symptoms
include changes in the way the person feels, thinks and relate to other people and the environment. It is a disorder
of "multiple handicaps".
The onset of schizophrenia occurs during adolescence and early adulthood. The period of risk for the development
of a first episode is considered to be between the ages of 15 and
35 years (Gottesman, 1991). The subsequent course of the disorder can follow many different patterns. The
problems of most patients can be divided into three phases of variable and unpredictable duration (see Table 8-1).
Table 8-1: The Phases of Schizophrenic Problems

Phase Description

Prodromal Precedes active phase. Obvious deterioration in role functioning. Apparent change in
personality. Signs and symptoms include peculiar behaviours, blunted affect, unusual
patterns of speech, and unusual perceptual experiences.

Active Characterised by psychotic symptoms and motor behaviour, hallucinations, delusions

and disorganised speech.

Residual Follows active phase. Same signs and symptoms as in prodromal phase. The
psychotic symptoms have improved, but the person continues to be impaired in
various ways

After the onset of schizophrenia, many people do not return to expected levels of social and occupational
functioning. Thus, schizophrenia is not a transient disorder, which is why the definition of schizophrenia that is
presented in DSM-IV requires that a person exhibit symptoms of the disorder for a period of at least six months
before s/he is considered to meet the diagnostic criteria.
TYPICAL SYMPTOMS OF SCHIZOPHRENIA
Schizophrenia involves severe disruptions in virtually all aspects of psychological functioning including
disturbances in five major areas: thought and language, perception, motor behaviour, affect (emotion), and social
interaction. These symptoms are sometimes divided into two types: negative and positive symptoms.

46
Negative symptoms are those that presumably reflect the absence of normal functioning - symptoms such as
deficits in emotional responding, lack of initiative, and social withdrawal.
Positive symptoms are assumed to indicate the presence of abnormal functioning - such as hallucinations,
delusions and disorganised speech. These symptoms can fluctuate in severity over time. Some patients exhibit
persistent psychotic symptoms. Others experience symptoms during active episodes and relatively adjusted
between such episodes.
Disturbances of Thought and Language
Schizophrenia is primarily a thought disorder - impairment in the ability to reason and communicate. Specific
symptoms of thought disorder include disorganised speech, delusions and alogia.
Disorganised speech includes loose association - thoughts and ideas shift rapidly from one subject to another
without apparent logical or meaningful association between the sequential thoughts. Because of this there is the
tendency of patients to say things that don't make sense to listeners. That is, their speech appear incoherent to
listeners. In addition, some patients use words in peculiar ways including clanging, neologisms, word salad,
tagentiality, and preservation. Clanging refers to the juxtaposition of words that are unrelated to each other.
Neologisms are words coined by the person or words used in a unique fashion. Word salad refers to using a series
of apparently disconnected words and phrases that seem to have no relationships. Tagentiality is replying to
questions with irrelevant responses. Preservation is the tendency to repeat the same word or phrase over and over
again.
Delusions are basically false or incorrect beliefs that have no basis in reality but that are rigidly held in spite of
their preposterous nature. Delusions are characterised by conviction and preoccupation and an inability to
consider the perspective of other people. Delusions take many forms. These include delusions of persecution - the
belief that one is being slotted against, spied on, threatened, or otherwise mistreated or victimised; delusions of
grandeur - the belief that one is extremely famous, important, or powerful; delusions of control - the belief that
other people, evil forces, or other mysterious external forces are in control of one's life; and delusions of thought
insertion - the belief that thoughts are being inserted into the patient's head.
Alogia, which literally means speechlessness, occur in either of two forms. In one known as poverty of speech,
patients show remarkable reduction in amount of speech. In the other, referred to poverty of content of speech,
patients speak without conveying any meaningful information.
Disturbances of Perception
The most obvious perceptual symptoms of schizophrenia are hallucinations or vivid sensory experiences that are
not caused by actual external stimuli. Although hallucinations can occur in any of the senses, those experienced
by schizophrenics are most often auditory in nature. Many patients hear voices that comment on their behaviour
or that give them instructions. Others hear voices that seem to argue with one another. Hallucinations are
persistent over time. Patients who experience auditory hallucinations often hear the voice(s) speaking to them
throughout the day for many days at a time. Other perceptual symptoms include disreality - things may look,
sound taste and/or smell different to the schizophrenic; disorientation in time, place and person - the patient is
47
unable to accurately judge the passage of time, is confused about where he is, and cannot accurately recall his
personal characteristics; attention deficit - a breakdown in selective attention; and deficits in social perception -
patients' ability to recognise the emotions of others when interacting with them is serious impaired.
Disturbances of Motor Behaviour
There are two kinds of motor disturbances in schizophrenia: catatonic stupor and catatonic excitement. Patients in
catatonic stupor engage in a variety of o unusual body movements, including bizarre gestures and facial
expressions. There is immobility and muscular rigidity. On the other hand some patients are excited and
hyperactive. This is catatonic excitement. Patients in this condition walk very fast, swinging their arms wildly
and walking at rapid pace, or very slowly, as if they were in a slow motion video.
Many catatonic patients exhibit reduced or awkward spontaneous movements. In more extreme forms the person
may assume unusual postures or remain in rigid standing or sitting positions for long periods of time. Such
catatonic posturing is often associated with a stuporous state.
Disturbances of Affect
Schizophrenic patients display emotional changes of various kinds. One of the most characteristic phenomena
involves a flattening or restriction of the person's nonverbal display of emotional responses that has been referred
to as blunted affect. Such patients fail to exhibit signs of emotion or feelings. Another type of emotional deficit is
called anhedonia, which refers to an inability to experience pleasure. Whereas blunted affect refers to the lack of
outward expression, anhedonia is a lack of positive subject feelings. Some patients exhibit affective responses that
obviously inconsistent with the situation. Inappropriate affect is characterised by an incongruity and lack of
adaptability in emotional expression.
Disturbances of Social Functioning
One of the most important and seriously debilitating aspects of schizophrenia is a malfunctioning of interpersonal
relationships (Meehl. 1993). Many people with scizophrenia withdraw from social relationships. This social
isolation may precede the onset of the active phase of the disorder. The withdrawal seen among many
schizophrenic patients is accompanied by indecisiveness, ambivalence and loss of will power. That is why the
symptom is known as avolition (lack of volition or will).
CLASSIFICATION OF SCHIZOPHRENIA
Schizophrenia was originally defined by Emil Kraepelin (1913) who emphasized the progressive course of the
disorder in distinguishing it from manic-depressive psychosis. Eugene Bleuler (1857-1939) coined the term
schizophrenia, proposing that disturbances of speech and emotion are the fundamental symptoms of the disorder.
The scope of its clinical definition has fluctuated over the course of the twentieth century. The .negative
symptoms of schizophrenia have been given increased emphasis in DSM-IV. The manual requires evidence of a
decline in the person's social and occupational functioning over a continuous period of at least six months. It also
recognises several subtypes of schizophrenia based on prominent symptoms.

48
Disorganised Type was formerly kwon as hebephrenlc schizophrenia because it is characterised by disorganised
speech, disorganised behaviour and flat or inappropriate affect. Disorganised patients exhibit marked social
impairment and incoherent speech. When delusions and hallucinations occur, their content are not well organised.
Catatonic Type is characterised by motor immobility (including rigidity and posturing) or extreme excitement
and hyperactivity (excessive and purposeless motor activity). The classic symptom of catatonia is a prolonged
period of unresponsive stupor, during which the patient may maintain unusual postures for hours or exhibit waxy
flexibility during which the patient's body (or parts thereof) can be placed in a variety of postures and the patient
maintains such postures or positions for long periods.
Paranoid Type is characterised by systematic delusions with persecutory or grandiose contents. It is also
associated with frequent preoccupation with auditory hallucinations.
Undifferentiated Type is diagnosed when the patient shows a mixture of symptoms that do not fit any other type
described above. That is, the patient displays prominent psychotic symptoms, which may meet the criteria for
several subtypes.
Residual Type includes patients who had previously experienced at least one episode of schizophrenia, but is
presently showing no clear signs of the disorder. That is, the patient no longer meets the criteria for active-phase
symptoms but nevertheless demonstrates continued signs of negative symptoms or attenuated forms of delusions,
hallucinations or disorganised speech.

The utility of these traditional subtypes has been seriously questioned. Evidence of their validity is mixed, some
investigators find the subtypes unstable (Deister & Marneros, 1993), and others however find them to be valid
(McGlasher & Fenon, 1991). Although some patients fit traditional descriptions of schizophrenic subtypes, many
others do not. Investigators who do not fond the traditional subtypes useful have proposed a variety of
alternatives. One approach differentiates between process schizophrenia - a disorder with gradual onset - and
reactive schizophrenia - a disorder with rapid onset. The process schizophrenic has very poor prognosis or
outlook and will often have the disorder for the rest of her life, while the reactive has a much better prognosis.
Traditional subtypes do not appear to able to predict the course of the disorder or response to treatment.
EPIDEMIOLOGY OF SCHIZOPHRENIA
The lifetime prevalence of schizophrenia is approximately one or two percent in virtually all areas of the world. In
other words, approximately one out of every 100 people will experience schizophrenic symptoms at some point
during their lives. Most first admissions occur between the ages of 15 and 45 years. The number of new cases
drops slowly after that, with very few people experiencing an initial episode after the age of 55 years (Gottesman,
1991). At least 60 % of all schizophrenics will have repeated episodes of the disorder. Of the reminder about 30%
will be symptom free for five years and 10% will be permanently disabled (Tschacher et al, 1997).
Men and women are equally likely to be affected. There are, however, interesting differences between the
genders with regards to patterns of onset and course of the disorder (see Table 8-2).

49
Table 8-2: Prototypical Gender Differences in Schizophrenia

Variable Men Women

Onset Age Earlier (20s) Early Typical Later (30s)

First Hospital Admission
Symptoms
Premorbid Social
Competence Course
Withdrawn, passive Negative Late
Pooi-More often chronic
A typical, Affective, active
Positive
Good. Less than Chronic

For example, males show schizophrenic symptoms at earlier ages, about four to five years, than the average ages
for women (Keith, Regier & Rae, 1991; Riecher et al., 1991). Two large cross-cultural studies conducted under
the auspices of WHO (the International pilot Study of Schizophrenia - IPSS and the Determination of Outcome of
Severe Mental Disorders - DOS) found patients who exhibited characteristic signs and symptoms in all of the
study sites including Nigeria. Although comparison of patients across study centres revealed more similarities
than differences in clinical symptoms, there were some interesting variations. One interesting difference is with
regards to symptom patterns. The proportion of patients who fit the catatonic subtype was substantially larger
among patients in developing countries (India, Columbia, and Nigeria). Clinical and social outcomes were better
for patients in developed countries (England, Russia and USA; Leif et al., 1992; Jabenskv et al., 1992).
AETIOLOGY OF SCHIZOPHRENIA
A number of biological and environmental factors have been implicated in schizophrenia. According to
psychodynamic theories, schizophrenia is the result of regression — going back to an earlier state of
development - caused by intense anxiety over unconscious impulses. The regression process cause the person to
loose touch with reality, display a disorganisation of" thought processes, and adopt the passive attitude of the
infant. A variation to the psychodynamic approach is the idea that a schizophrenogenic mother (one who causes
schizophrenia) neglects her child's emotional needs, using him instead to satisfy her own needs. Bateson et al's.,
(1956) double-bind hypothesis suggests that parents induce schizophrenia in their children by putting them
through a series of conflicts in, which they (the parents) provide opposite messages. The social learning
approach says that people learn schizophrenic behaviour by imitating parents and other key figures in their
environment (Watt et al., 1982). The parent may display behaviours central to schizophrenia - inattention to the
external world, misinterpretation of reality, unusual motor behaviours, and somewhat disorganised thought
patterns - which the child then imitates (Rudd, 1994). Even if the parent is not actually schizophrenic, the child
may later integrate a number of these modelled behaviours into a pattern that can be diagnosed schizophrenic.
The sociogenic hypothesis of Hollingsheed & Redlich (1958) suggests that poor education and poor economic
conditions contribute to schizophrenia. Supportive evidence indicates that conditions of deprivation may indeed
be involved (Castee et al., 1993).

50
Genetic Factors in Schizophrenia
Schizophrenia like several other psychological disorders tends to run in families. Family studies indicate that the
closer the family relationship between two individuals, the higher the likelihood that if one develop schizophrenia,
the other will show signs of the disorder too. That is, as the degree of genetic similarity increases between an
individual and a schizophrenic patient, the risk to that individual increases. The risk for developing the disorder is
between 10 to 15 percent among first-degree relatives (children, siblings, DZ twins and parents) of schizophrenic
patients. Twin studies show that concordance rates are approximately 50% in MZ-twin compared to only 15% in
DZ-twin pairs. Adoption studies have found that approximately 15% of the offspring of schizophrenic parents
will eventually develop the disorder themselves, even if they are separated from their biological parents at an
early age and are raised by adoptive families. Furthermore, there are significantly higher rates of schizophrenia
among the biological relatives of the index adoptee than among the biological relatives of the adoptee of non-
schizophrenic parents (Kety, 1987).
Results from twin and adoption studies also indicate that the relatives of schizophrenic patients may develop
several types of psychotic disorder and personality disorders that resemble schizophrenia one way or another.
These disorders sometimes called the schizophrenia spectrum include schizoaffective disorder, delusional
disorder and schizotypal personality disorder. In other words, genetically predisposed vulnerability to
schizophrenia is sometimes expressed as schizophrenia-like personality traits and other types of psychological
disorders. The combined results from family, twin and adoption studies indicate that genetic factors are involved
in the transmission of schizophrenia (Gottsman, 1991; Kendler & Diehl, 1993). They do not, however, the whole
story. Some individuals apparently inherit a predisposition to schizophrenia, but the mode of transmission has not
been identified.
Biochemical Factors in Schizophrenia
The discovery of antipsychotic medication stimulated interest in the role of neurochemical factors in the aetiology
of schizophrenia. The dopamine hypothesis suggests that schizophrenia may stem, at least in part, from excess
activity in those parts of the brain that use dopamine as a neurotransmitter. The dopamine hypothesis grew out- of
attempts to understand how antipsychotic drugs improve the adjustment of many schizophrenic patients. However
evidence in support of the hypothesis have been inconsistent. Current neurochemical hypotheses focus on a broad
array of neurotransmitters. Including GABA, acetylcholine, serotonin, and neuropeptides. Special interest has
been focused on serotonin pathways since the introduction of a new class of antipsychotic drugs such as clozapine
(clozaril) that have beneficial effects on both positive and negative symptoms of schizophrenia and are useful in
treating patients who are resistant to traditional antipsychotic drugs.
Brain Structure and Schizophrenia
Growing evidence suggests hat schizophrenia may also stem from subtle but important damage to various
portions of the brain. Although advances in brain-imaging technology have allowed extensive study of structural
and functional brain abnormalities in schizophrenia, a specific brain lesion has not been identified, it is unlikely
that a disorder as complex as schizophrenia will be traced to a single site in the brain. Nonetheless, structural
images of schizophrenics' brains reveal enlarged ventricles as well as decreased size for parts of the limbic

51
system. Studies of brain metabolism and blood flow have identified functional changes in the frontal lobes,
temporal lobes and basal ganglia in many persons with schizophrenia. Current evidence points towards a subtle
and diffuse type of neuropathy in schizophrenia.
Family Factors in Schizophrenia
Disturbed patterns of family communication have been presumed to related to the aetiology of schizophrenia for
many years. Arieti (1974) and Lindz (1975) distinguished between two types of schizophrenic families. The first
of these is the schismatic family in which members are exposed either to high levels of conflict between the
parents. The children become caught as pawns in the power game between the two parents. The conflicting
demands arising from the two sides can mean that the child suffers intolerable psychological pressure as a result.
The second is the skewed family in which all power rest with one parent and calm prevails for this reason. The
dominant parent imposes his/her will or views on the whole family ignoring the emotional needs of other family
members but imposing on their day-to-day lives. Also expressed emotion (EE) studies indicated that families
with a greater than expected incidence of schizophrenia are ones in which patterns of communication are
confusing and upsetting to children. Several studies indicate that families of schizophrenics express high levels of
criticism and emotional over involvement toward members (Miklowit et al., 1989).
Social Factors in Schizophrenia
The evidence supporting the inverse relationship between social class and schizophrenia is rather substantial. This
relationship has been explained in two ways. The social causation hypothesis hold that harmful event associated
with membership in the lowest social classes, which might include many factors ranging from stress and social
isolation to poor nutrition play a causal role in the development of the disorder. The social selection hypothesis
holds that regardless of the social class of schizophrenic patient's family of origin, they gradually drift into the
lowest social classes. That is, in some cases low levels of socio-economic achievement represent a consequence
of the disorder. Several kinds of research have found that social factor appear to make a causal
contribution to schizophrenia.
The Diathesis-Stress Model of Schizophrenia: Rather than taking one of the five possibilities discussed above
as being 'the cause' of schizophrenia, modern theorists argue that it is the interaction between them that is
significant. The diathesis-stress model suggests that what is inherited with respect to schizophrenia is not the
disorder itself, but rather a predisposition (a diathesis] to develop it under conditions of high environmental stress.
According to Meehl (1967; 1990; 1993), all individuals who are predisposed to schizophrenia inherit a subtle
neurological defect of unknown form, which he referred to as schizotaxia. As a result of interaction between this
defect and inevitable learning experiences, schizotaxic individuals develop odd or eccentric behaviours, which are
called schizotypic signs. Most prominent among these behaviours are 'associative loosening' and 'aversive drift'.
Thus, in the diathesis-stress model no single agent is seen as the cause of schizophrenia. Instead, schizophrenia is
seen as resulting from several different factors all combining together.

52
 CHAPTER NINE
MOOD DISORDER
Severe emotional disturbances are called mood disorders. Since psychologists have several terms to describe
feelings it is necessary to distinguish between them. Emotion refers subjective feeling states, which are often
accompanied by physiological changes such as heart and respiration rates. Examples include sadness, anger and
disgust. Affect refers to the patterns of observable behaviours that are associated with these subjective feelings.
People express affect through changes in their facial expressions, the pitch of their voices, and their hand and
body movements. Mood refers to a pervasive and sustained emotional response that, in its extreme form, can
colour the person's perception of the world (APA, 1994). Mood disorders are primarily associated with two
specific moods: depression and elation.
Depression is both a mood and a clinical syndrome. A depressed mood is often characterised by sadness,
disappointment and despair. Clinical depression is combination of emotional, cognitive and behavioural
symptoms. Abnormal psychology is concerned with the clinical syndrome rather than the mood. Euphoria or
elation defines the opposite state from a depressed mood. This condition is characterised by an exaggerated
feeling of physical and emotional well-being (APA, 1994). Mania is the clinical syndrome of this mood. The
symptoms cluster of mania is also emotional, cognitive and behavioural.
Typical Symptoms of Mood Disorders
As noted above, mood disorders are defined in terms of emotional, cognitive and somatic symptoms.
Emotional Symptoms Dysphonic (unpleasant) mood characterised by feelings of gloom, dejection, despondency
and despair, and extreme sadness is the most common and obvious symptom of depression. There is no clear-cut
line dividing normal sadness from a depressed mood that is associated with clinical depression. Clinicians use
several features to help guide against this diagnostic distinction, including the severity, the quality, and the
pervasive impact of the depressed mood (see Table 9-1). In contrast, manic patients experience periods of
inexplicable and unbounded joy known as euphoria. The state is characterised by optimism, cheerfulness and
enthusiasm.
Cognitive Symptoms There is a slowing of thought, inability to make decisions, trouble concentrating and
distractibility in depression. Guilt and worthlessness are common
preoccupations of the depressed.
Table 9-1: Features that Distinguish Clinical Depression from normal Sadness

Feature Short Description

Intensity The mood change pervades all aspects of the person and impairs social and
occupational functions.
Absence of The mood may arise in the absence of any discernable precipitant or may
be precipitants grossly out of proportion to those precipitants.

53
 Quality The mood change is different from that experienced in normal sadness.
Associated The change in mood is accompanied by a cluster of signs and symptoms,
features including cognitive and somatic features.

History The mood change may be preceded by a history of past episodes of elation and hyper
activity.

In contrast, manic patients have racing thoughts - ideas flash through their minds faster than they can articulate
their thoughts. Inflated self-esteem, and distractibility and poor judgement are common and important symptoms
of mania.
Somatic Symptoms these are related to basic physiological or bodily functions. Psychomotor retardation -
slowed movement, fatigue, aches and pains, and serious changes in appetite and sleep patterns are characteristic
of depression. In marked contrast, manic patients are typically gregarious and energetic. They also experience
rapid and pressured speech.
Classification of Mood Disorders
DSM-IV has two major categories of mood disorders; unipolar and bipolar. In unipolar mood disorder the
patient experiences only episodes of depression. There are two types of unipolar disorder: major depressive
disorder and dysthymia. People with bipolar mood disorder experience episodes of mania, which are often
interspersed with episodes of depression. There are three types of bipolar disorder: bipolar I disorder, bipolar II
disorder and cyclothymia. We shall discuss only major depressive disorder and bipolar disorder. Table 9-2
presents a summary of the symptoms and features of both disorders.
Major Depressive Disorder Major depressive disorder is diagnosed when there is persistent, negative mod
state the includes profound sadness accompanied by feelings of hopelessness, dejection, despair, loneliness and
boredom, crying spells are common, and the person reports a feeling of demoralization, resulting in part
from a sense of incompetence.
Table 9-2: Characteristics of Unipolar and Bipolar Depression

Area Unipolar Bipolar

Affect Sad, hopeless, gloomy, Sad when depressed; elated, euphoric, impatient, very
(emotion) withdrawn sociable when manic.

Cognition Thought processes slow, Similar to unipolar when depressed, racing thoughts,
feelings of self-inadequacy, impulsive, delusions of grandeur, when manic.
self-blame, guilt, unable to
make decision

Motor Retarded motor functions Retarded when depressed; agitated when manic
activity

54
 Sleep No difficulty sleeping Increases when depressed; decreases when manic.
patterns

Gender Much more common in About equal in men and women, usually begins before
women age 30

Age of Any time, but commonly age

Onset 35-45

Family Substantial risk in first-degree Even higher risk in biological relatives of bipolars.
history relatives of depressives.

Personal Usually a history of low self- Usually a history of normal personality functioning
History esteem, dependence and
minor depressive Episodes
before onset

SES More common in lower levels More common in higher levels

Lifetime About 135 in men, 21% in About 0.4%-1.6% in men and women
women.

Other symptoms include poor appetite, insomnia or hypersomnia, lack of energy, inability to concentrate,
recurrent thoughts of death (suicide), and a reduction in pleasure derived from common activities. Somatic
complaints, especially pain, are common. Major depressive disorder may occur as a single episode but it is more
likely that there will be multiple episodes and that the disorder will be chronic (Alpert et al, 1994; Goodyear et
a/.1997).
Bipolar Disorder Bipolar disorder involves both depressive and manic episodes. A manic episode is a distinct
period of time during which the individual's mood become elated and expansive. The person is hyperactive and
may alternate between excessive cheerfulness and heightened irritability. She is often quite sociable, but in an
intrusive and demanding way. In typical cases, an initial manic episode is followed by an alternating series of
depressive and manic states, with intervening periods of relative normality. Patients with such mood swings who
exhibit less severe symptoms are diagnosed with cyclothymic disorder. Bipolar disorder like unipolar disorder
occur in cycles, with patients moving either from depressed to normal affect then back to depression, or from
depression to manic, on to normal and back again.
Co-morbidity of mood Disorders
Many people with mood disorders suffer from additional clinical problems. Alcoholism and depression are clearly
related phenomena. Many people who are depressed also drink heavily, and many people who are dependent on
alcohol eventually become depressed. There is also an association between these disorders within families.
Eating disorders and anxiety disorders are also more common among first-degree relatives of depressed patients
than among people in the general population.

55
Epidemiology of Mood Disorders
Depression is one of the most common forms of psychopathology. Estimates of the prevalence of mood disorders
range from 5% to 20% (Smith & Weissman, 1992). Unipolar disorders are much more common than bipolar
disorders. The ratio of unipolar disorder to bipolar disorder is at least 5:1. Major depressive disorder is far more
common in women, among younger people, and relatives of depressive patients (Lewinshon et al., 1993). Risk of
developing mood disorders also varies with race with higher rates in Caucasians (Americans and Europeans) than
in blacks (African Americans and Sub-Saharan Africans). Bipolar disorder is more prevalent in higher socio-
economic classes while major depressive disorder is more common among lower levels.
Aetiology of Mood Disorders
The aetiology of mood disorders can be traced to the combined effects of social, psychological and biological
factors.
Social Factors in Mood Disorders Depression often follows stressful events (Bron et al, 1991). The influence of
stressful life events, especially severe loses that is associated with significant people or significant roles (Monroe
& Simon, 1991). and other fate events beyond the individual's control (Shront et al, 1993), contribute to the onset
of depression. However, it is not the specific events itself that causes depression so much as the individual's
interpretation of the events. In particular, depression is more likely to occur when the person interprets a negative
event as beyond her control or when she sees herself as responsible for it. Research has shown that lack of life
satisfaction and loneliness, both potentially stressful, are also important in the development of depression (Green
et al., 1992). Psychodynamic theories emphasize the central role played by interpersonal relationships and loss
of significant others in setting the stage for depression as well as in brining about a depressive episode.
Psychological Factors in Mood Disorders Severe events are clearly related to the onset of depression, but do not
provide a complete account of who will become depressed. Several psychological factors may contribute to a
person's vulnerability to stressful events. These may be classified into: cognitive responses to failure and
disappointment, and interpersonal factors and social skills. Cognitive theories assume that the ways in which
people think about and perceive the world have important influence on the way they feel. In particular, Beck's
Cognitive model (Beck, 1967; 1974; 1984) describes a "depressive triad" of negative, demeaning thoughts of the
self, the world, and the future that is central to the understanding of mood disorders.
People suffering from depression possess negative self-schemas (self-schemas are cognitive frameworks that
serve to organize information about the self) - negative conceptions of their own characteristics, abilities, and
behaviour. As a result of the negative self-schemas, such persons tend to interpret event in ways that minimize
positive achievements, magnify problems, and over generalize from small numbers of isolated negative events
(Beck et al., 1993). This in turn leads them excessively to seek positive evaluations and reassurance of affection
from others, when these backfire (as they usually do) they reinforce the patient's negative self-evaluation.
Another cognitive view suggests that depression results from learned helplessness, a perceived lack of control
over life events (Seligman. 1975). The person has an accumulation of experiences in which his actions seem to
56
have had no effect or negative effect on life outcomes. He, therefore, learns to feel helpless and quickly gives up
whenever faced with a new challenge. He concludes that nothing he does really matters and that no actions on his
part will change the outcome an important addition to the learned helplessness view concerns the person's
attributions about the causes behind such lack of control (Abramson, Seligman & Teasdale, 1978; Alloy et ai,
1988). According to this modified theory, sometimes known as the hopelessness model, depression is relate not
simply to the belief that one cannot influence one's outcomes, but also the tendency to attribute unfavourable
events to stable internal causes. In other words, when negative events happen to depressed individuals, they take
the blame for the occurrence; they attribute the events to their own lasting shortcomings, such as lack of
intelligence, laziness, poor judgement and so on. (Seligman et al, 1988).
Interpersonal theories focus on the ways in which individuals respond to people and events in their
environment. Lewinshon (1974) and Coyne (1976) proposed that depressed people behave in ways that have a
negative impart on other people. In this way, they contribute to the stressful nature of their social environment.
Such "'depressed behaviours" may be initially reinforced by other people in their attempts to provide comfort and
support. By making these social contact contingent upon the expression of a depressed mood, significant other
may unintentionally increase the frequency and stability if their friend's depression. However, the continued
manipulation of depressed behaviours has an aversive impact on other people who will eventually be driven away.
Additionally, depressed persons, may actually behave in ways that have a genuinely negative effect on other
people, thus alienating themselves from friends and family members. When this occurs, depressed people may
come to see their self-critical comments as an accurate perception of the fact that they are not well liked by
others.
Biological Factors in Mood Disorders
Studies have confirmed that genetic factors are involved in the transmission of mood disorders.
Family studies show a 15% risk for mood disorders in first-degree relatives of major depressives (Permis, 1992)
and a 19% risk in the first-degree relatives of bipolar patients (Katz & McGuffin, 1993), much greater than for the
general population. Twin studies have found that identical twins of major depressives are at least twice as likely
to develop the disorder, as are fraternal twins. In one study, the concordance rate for bipolar disorder in MZ twins
and DZ twins were 59% and 19% respectively. For unipolar disorder concordance rates for MZ and DZ twins
were 54% and 24% respectively. The fact that the concordance rates for were significantly higher for MZ than for
DZ twins indicates that genetic factors are involved in the predisposition to mood disorders.
Adoption studies show that the risk of mood disorder is eight times as high in the biological relatives of unipolar
patients as in their foster relatives (Wender et al, 1986). Some other studies show that 31 % of the biological
parents and only two percent of the foster parents of bipolar patients are at risk. Overall, empirical evidence
suggest that habitability is about 40% for unipolar disorder and 80% for bipolar disorder (Kendley et al, 1992;
Torrey, 1994).
Genes may contribute to the development of mood disorders through an effect on the CNS. Many investigators
suspect that the genetic factors implicated in mood disorders operate by affecting brain neurochemistry (Potter,
1997). In the attempts to explain this relationship two theories have been dominant. One suggests that depression

57
occurs when levels of norepinephrine are abnormally low and that mania results when they are abnormally high
(Gottierry et al, 1997). The second theory implicates serotonin and proposes that the level of this neurotransmitter
is low in mood disorders, allowing fluctuations in other neurotransmitter substances.

CHAPTER TEN
PERSONALITY DISORDERS
Personality is the combination of traits or characteristics that air relatively enduring patterns of perceiving,
relating to and thinking about the environment and oneself, which are exhibited in a wide range of important
social and personal contexts (APA. 1994). When these traits bring the person into repeated conflicts with others,
an individual’s personality may be considered disordered.
Personality disorders are defined in terms of rigid, inflexible, maladaptive ways of perceiving and responding to
myself and one's environment that lead to social or occupational or personal distress. Like other categories of
psychological disorders, personality disorders do not involve high levels of anxiety, physical problems, and
reduced contact with reality or bizarre patterns of behaviour. Rather they are pervasive long-term behaviour
patterns influence most: areas of life. Personality disorders usually begin in childhood or early adolescence. And
they are exhibited consistently over an extended period of time. This stable long standing nature of personality
disorders is one of the most characteristic features that distinguish them from other forms of abnormal behaviour,
which are characteristically episodic in nature (Hirschfield, 1993). Most other forms of psychological disorders,
such is anxiety disorders and mood disorders, are ego-dystonic (that is. people with these disorders are distressed
by their symptoms and uncomfortable with their situation).
Personality of orders are usually ego-systonic - the ideas and impulses with which they are associated are
acceptable to the person. People with personality disorders frequently do not see themselves as being disturbed.
We might also say that they do not have insight into the nature of their problems.
Classification of Personality Disorders
Personality disorders are difficult to identify reliably, their aetiology are poorly understood, and there is relatively
little evidence that they can be treated successfully. There are, for example, important discrepancies between
DSM-IV and ICD-10 in their descriptions of these problems. Two types of personality in DSM-IV - borderline
and schizotypal - are not included in ICD-10. Personality disorders are considered separately from other forms of
psychopathology in DSM-IV. Most clinical disorders are listed in Axis 1, whereas personality disorders are listed
in Axis II (see Table 2-1). In DSM-IV. The 10 specific forms of personality disorders are organised into three
clusters on the basis of broadly defined characteristics (see Table 10-1).

Table 10-1: Personality Disorders Listed in DSM-IV

Personality Disorder Short Description

58
 Cluster A: Asocial Is suspicious and distrustful of others: always on
the guard for perceived attacks.
Paranoid
Discomfort with close relationships, cognitive and
Schizoid Schizotypal
perceptual distortions; eccentricities of behaviours.
Detachment from social relationships and restricted
range of expression of emotions. Has unusually
thought patterns and perceptions, problems in
social communication.
Lack of moral and ethical concerns, unable to learn
from
experience, manipulates others.

Cluster B: Instability of interpersonal relationships; self-

Flamboyant image, emotions, control over impulses, and
chronically bored.
Antisocial
Excessive emotionality and attention seeking.
Borderline Histrionic
Over-concerned with attractiveness, has temper
Narcissistic outburst.
Grandiosity, need for admiration, and lack
empathy.

Cluster C: Anxious Social inhibition, feelings of inadequacy and

hypersensitivity to negative evaluation.
Avoidant
excessive need to be taken care of, leading In
Dependent
submissive and clinging behaviour. Indecisive
Obsessive-compulsive
Preoccupation with orderliness and neatness and
perfectionism at the expense of flexibility.

The disorders in each of the clusters were put together because they seem to be similar. Little empirical evidence
exists to support these groupings (Francis, 1 - 1! 5). The first cluster includes asocial people - those who tend to be
odd or eccentric. The Tree disorders in this cluster are share some symptoms with schizophrenia (see Topic 8).
The second cluster includes flamboyant people who appear to be excessively dramatic emotional and erratic. The
four disorders are all associated with marked difficulties in sustaining interpersonal relationships. The third cluster
59
includes anxious people who appeal' to be fearful. The common element to the three disorders in this cluster is
anxiety or fearfulness. All these personality disorders are based on exaggerated personality traits hat are
frequently annoying or disturbing to other people. They are extreme personality variations associated with failure
to achieve universal tasks establishing personal identity, forming attachment to others, experiencing intimacy with
them, and seeking affiliation (Livesley, et al, 1994).
Paranoid Personality Disorder People with paranoid personality disorder tend to be inappropriately suspicious
of other people's motive and behaviours therefore, they are constantly on guard since they expect that other people
are trying to harm them. They take extraordinary precautions to avoid being exploited or injured. Relationships
with friends and family members are difficult to maintain because the patient does not trust anyone. They
perceive hidden, threatening meanings to ordinary remarks and bear strong grudges for imaginary slights or
injuries.
Schizoid Personality Disorder This disorder is defined in terms of a pervasive of indifference to other people,
coupled with a diminished range of emotional experience and expression. Schizoid personalities are loners, they
prefer social isolation to interaction with friends, family members or any other kind of intimate contact. In short,
contact with other people is of little interest to them and they often tend to perceive the people around them as
mere nuisances. Other people see them as being cold and aloof. They do not experience strong subjective
emotions, such as sadness, anger or happiness. They are indifferent to praise or criticism and often show coldness
and detachment.
Schizotypal Personality Disorder
Schizotypal personality disorder centre around peculiar patterns of behaviour, many of which are in the
form of perceptual and cognitive disturbances. People with the disorder may report bizarre fantasies, and unusual
perceptual experiences. Their speech may be slightly difficult to follow because they use words in an odd way or
because they express themselves in a vague and disjointed manner. Their affective expression may be constricted
in range or they may be silly or inappropriate.
Antisocial Personality Disorder
This is also known as psychopathy. Persons with this disorder show persistent pattern of irresponsible and
antisocial behaviour. They show an almost total disregard for the rights and well-being of others. In fact, the
DSM-IV definition is based on the features that - beginning from childhood - indicate a pervasive pattern of
disregard for, and violation of the rights of others. In addition, they demonstrate several characteristics that make
them dangerous to others. They exhibit persistent failure to perform responsibilities that are associated with
occupational or family roles. Rules and regulations are not made for them, so they often have a history of a
antisocial behaviour, delinquency, theft, vandalism, lying, drug abuse, conflict with others including physical
fights. They are irritable and aggressive, highly deceitful - they will lie to anyone, anytime, if they perceive this as
advantageous. And after performing actions that harm others they show no remorse.
Borderline Personality Disorder this is a rather diffuse category whose essential feature is a pervasive pattern of
instability in mood and interpersonal relationships. Borderline personalities, find it very difficult to be alone. They
form intense, unstable relationship with other people and are often seen by other as being, manipulative. Their
60
opinions of significant others frequently vacillate between unrealistically positive (idealization) and negative
(devaluation) extremes. The)' also exhibit emotional instability. Their mood may shift rapidly and inexplicably
from depression to anger to anxiety over a pattern of several hours. Intense anger is common, and may be
accompanied by temper tantrums, physical assault, or suicidal threats and gestures. The prominent diagnostic
feature is identity disturbance - great difficult)' in maintaining an integrated image of oneself that incorporates
both positive and negative components.
Histrionic Personality Disorder Histrionic personalities have a pervasive pattern of excessive emotionality and
attention-seeking behaviour. They thrive or being the centre' of attention. They are self-centred, vain, and
demanding, and they constantly seek approx al from other people. Their emotions tend to be shallow and may
vacillate erratically. They frequently react to situations with inappropriate exaggeration.
Narcissistic Personality Disorder The essential feature of this disorder is a pervasive pattern of grandiosity.
Narcissistic people have greatly exaggerated sense of their own importance and are preoccupied with fantasies of
unlimited success, brilliance or beauty. They are preoccupied with their own achievements and abilities. Because
they consider themselves to be very special, they cannot empathise with the feelings of other people. So theirs is
grandiosity in fantasy and behaviour, coupled with need for admiration.
Avoidant Personality Disorder People with avoidant personality are socially inhibited, feels inadequate,
timorous and are hypersensitive to negative evaluation. They tend to be socially isolated when outside their own
family circles because they an afraid of criticism. They want to be liked by others, but are easily hurt by even
minimal signs of disapproval from other people. Thus, they avoid social and occupational activities that require
significant contact with other people. They are unwilling to get involved with people in new interpersonal
situations.
Dependent Personality Disorder Dependent personalities have excessive need to betaken care of, leading to
submissive and clinging behaviour and fears of separation. They are exceedingly dependent on others for advice
and reassurance. Of en unable to make everyday decisions on their own, they feel anxious and helpless when they
are alone. They are easily hurt by criticism and are extremely sensitive to disapproval and have difficult}
expressing disagreement with others.
Obsessive-Compulsive Personality Disorder This disorder is defined by perfectionism and inflexibility. People
with the disorder set ambitious standards for their own performance that frequently are so high as to unattainable.
They are pa occupied with rules and efficiency. They favour intellectual activities over feelings and emotional
experience. An obsessive-compulsive person also procrastinates. S/he is excessively conscientious. moralistic,
and judgemental, and they tend to be intolerant of affective behaviour in other people.
Epidemiology of Personality Disorder The prevalence rates of the personality disorders vary across settings,
according to diagnostic criteria, culture and gender. Results of studies of community samples reveal overall
lifetime prevalence of between 10% and 14% (Weissmat, 1993). Evidence regarding the prevalence of specific
types of personality disorders n two countries is summarized in Table 10-2.

61
Table 10-2: Summary of Epidemiogical Data on Personality Disorders

Subtype Germany U.S.

Paranoid 1.8 0.4
Schizoid 0.4 0.7
Schizotypal 0.7 3.0
Antisocial 0.2 3.0
Borderline 1.1 1.7
Histrionic 1.3 3.0
Narcissistic 0.0 0.0
Avoidant 1.1 1.3
Dependent 1.5 1.7
Obsessive Compulsive - 2.2 1.7
The results of these studies indicate that borderline; dependent and obsessive-compulsive personality disorders are
more common but that rates vary between countries. The same vtuialiun is apparent in studies comparing general
population samples < nd patient samples. In general, the prevalence of personality disorders is much higher
among people who are being treated for another psychological disorder. Prevalence of artisocial personalit}
disorder is particularly high in prison populations, with estimates from 30% to 70% depending on the sample and
diagnostic criteria.
The overall prevalence of personality disorders is approximately equal in men and women (Weissman, 1993).
There are, however, consistent gender differences with regard to some specific disorders, especially antisocial
personality disordered which is much more common among men than women with a ratio of 6:1 (Robins. Tipp &
Przybeck, 1991).
Co-morbidity of Personality Disorders
There is considerable overlap between categories in the personality disorders. Most who people meet the
diagnostic criteria for one personality disorder in DSM-IV also meets the criteria for another personality disorder
(Widiger & Rogers. 1989). I-or example, almost half the people who meet criteria the criteria for histrionic
personality disorder. Also meet the criteria for borderline personality disorder. Obsessive-compulsive personality
disorder, on the other hand, tends to have little overlap with any of the other categories.
Aetiology of Personality Disorders
Psychologists have studied aetiological factors for antisocial personality disorder extensively than any of the other
personality disorders. Therefore, antisocial personality disorder is used here as an illustration of the explanations
of the a uses of personality disorders. The literature suggests that antisocial personality disorder results from a
combination of biological and psychological factors. People with this disorder have dysfunctions of the frontal
lobe (Gorenstein. 1982: Meyers et a!., 1992]. commonly display abnormalities in EEG recordings (Salley et al.
1980), and have ANS at function at lower levels of arousal than those of normal people (Hare. 1982).

62
There is a so of serotonin and nueroendcrine abnormalities (Fishbein et a!., 1992; Smith et al, 199!), and both
twin and adoptee studies have produced evidence of modest inheritability (Nigg Goldsmith. 1992; Sucker at al.
1991). It has been suggested that that this hereditary factor may result in deficiencies in behavioural inhibition
system - this hypothetical neural system that mediates learning to respond to certain cues with anxiety and
learning to inhibit responses to cues signalling punishment (Fowles & Missel, 1994). The defficiency may lead to
the low anxiety of the psychopath and his failure to learn from experience. In addition, the behavioural
motivation system - the neural system that mediates responses to cues for rewards (positive reinforcement) - is
normal or overactive. partial!} explaining why such people are found of obtaining rewards.
Among the psychological explanations, psychodynamic theories suggest the problem is a weak superego. Freud
described the superego as the personality structure that serves as the conscience, a guide to moral action. When it
fails to develop adequately, the individual will have a weak moral structure, little conscience, and therefore,
minimal guilt or anxiety over committing immoral acts. From the behavioural perspective such persons may learn
as children, through experience to violent models, impulsive, aggressive behaviour is appropriate. Such modelling
influences can exert powerful affects on their adult behaviour.

63
 CHAPTER ELEVEN
POSTTRAUMATIC STRESS DISORDER
Stress can be defined as an event that creates physiological or psychological strain for the individual. Stressors
may include minor daily events like the frustration of power failure, being trapped in traffic, jam, and other
hassles and bustles of daily living. Stress is an inevitable, and in some cases a desirable fact of daily life. Some
stressors, however, are so catastrophic and horrifying that they can cause psychological harm to those who
experience them.
Traumatic stress involves exposure to such events that involves Actual or threatened death or serious injury to
self or others and creates intense fear, helplessness or horror. Examples of traumatic stressors include rapes,
bombings, airline dishes, earthquakes, major fires, devastating automobile wrecks and so on. Both survive s and
witnesses to traumatic stressors are expected to be greatly distressed as part of their normal response. For some
victims the trauma continues long after the event itself has ended. The horrifying experience lead to general
increases in anxiety and arousal, and avoidance of emotionally charge situations, and the frequent reliving of the
traumatic event. When these symptoms persist fro more than a month, this condition is referred to as
posttraumatic stress disorder (PTSD).
Typical Symptoms and Associated Features of PTSD
Posttraumatic disorder is characterised by three broad clusters of symptoms:
Re-experiencing of the Trauma Some people exposed to severe traumatic events persistently re-experience such
events in their thoughts or dreams frequently in the form of repeated and intrusive flashbacks or memories. In
rare cases the re-experience occurs as a dissociative slate whose alteration from memory and consciousness
resembles the symptoms of dissociative disorder (see Topic 7). However, the duration of such dissociative states
are of short duration.
Numbed Responsiveness and Avoidance the diminished responsiveness of people with PTSD has been referred
to as "psychic numbing" or "emotional anaesthesia" which aptly summarises their complaints of dampened or
non-existent feelings. PTSD patients also persistently avoid stimuli (places, people, thoughts) linked with the
trauma. This emotional avoidance leads to withdrawal from close relationships, and situations that evoke
memories of the trauma.
Increased Autonomic Arousal PTSD patients also persistently expene ice symptoms of increased arousal such
as difficulty falling asleep, irritability, or difficulty concentrating. Table 11-1 lists the specific DSM-1V criteria
for the three symptom clusters.
Table 11-1: The Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD)
A. The person has been exposed to a traumatic event in which both of the following were
present

64
1. The experienced, witnessed, or was confronted with an event or event that involved actual or threatened
death or serious injury, or a threat to the physical integrity of self or others.
2. The person's response involved intense fear, helplessness, or terror.
B. The traumatic event is persistently experienced in one (or mon) of the followingways
1. Recurrent and intrusive distressing recollection of the event including images, thoughts or perceptions.
2. Recurrent distressing dreams of the event.
3. Acting or feeling as if the traumatic event were recurring
4. intense psychological distress at exposure to internal or external cues that symbolize or resemble any
aspect of the traumatic event.
5. Physiologic reactivity upon exposure to internal or external cues that symbolise or resemble an aspect of
the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness as indicate by three (or more) of the following
1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma.
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma.
3. Inability to recall important aspects of the trauma.
4. Markedly diminished interest or participation in significant activities.
5. Feeling of detachment or estrangement from others.
6. Restricted range of affect.
7. Sense of foreshortened future.
D. Persistent symptoms of increased arousal, as indicated by two (or more) of the following
1. Difficulty falling or staying asleep.
2. Irritability or bursts of anger.
3. Difficulty concentrating.
4. 1 lyper vigilance
5. Exaggerated startle response.
E. Duration of the disorder is more than one month.
Classification of PTSD
The major issue in the classification of PTSD concern.-, the nature of the traumatic stressors that is responsible
for the onset of the disorder. Research has so lire focused of three categories of traumatic stressors: delayed
reaction to combat, exposure to natural and man made disasters, and victimization. Another issue of differential
diagnosis is to distinguish PTSD from acute stress disorder.
Acute stress disorder (ASD) is a similar but somewhat less intense reaction to trauma that lasts or more than two
days and less than four weeks. Co-morbidity is another issue, many people suffering from PTSD also meet the
diagnostic criteria for another mental disorder particular!} depression and substance abuse (Breslau, et al., 1991).
Epidemiology of PTSD
There are some data on the prevalence of PTSD but the figures must be interpreted with caution due to small size
of samples. Nevertheless, one stud} involving a random sample of 1,200 adults in a city in USA showed that 25%
of those who reported exposure to traumatic stressors later developed PTSD (Breslau et al. 1991). This study also
Miggests that trauma was more likely to be experienced by men by those with less education, and by people who
65
were more neurotic or extraverted: had a history of conduit problems during childhood, and had a family history
of mental disorder.
Aetiology of PTSD
Trauma is a necessary but not a sufficient cause of PTSD. Thus, although by definition the experience of trauma
is central to PTSD, other factors appear to be important in its aetiology. The systems approach requires that
biological, psychological and social factors be examined as to their contribution to the aetiology of PTSD.
Biological Factors in PTSD biological factors contribute indirectly to the development of PTSD by contributing
development of premorbid personality (Jones & Barlow, 1999). Premorbid personality may constitute a diathesis
that creates PTSD when combined with the stress of trauma. Several different psychological characteristics have
been suggested to form a diathesis for PTSD. These include antisocial behaviour (Helzer. Robins & McFlvov.
1987), depression (Frank et al, 1981), and neuroticism (McFarlane, 1989). Other research has focused on the
biological consequences of exposure to trauma and how these consequences play a role in the development of
PTSD (Watson, Hoffman & Wilson. 1981). The theory suggests that trauma increases the production of the
neurotransmitter, norepinephrine in the brain. This excess norepinephrine in turn causes the increased arousal and
aggression that are symptoms of the disorder. A related hypothesis suggests that traumatic stressors increase the
productions of endogenous opiods, which causes the numbing, that characterise PTSD (Van der kolk et. al. 1984).
Psychological Factors in PTSD Psychodynamic theories emphasize the role of defence mechanisms in
protecting the individual against me anxiety created by trauma regression is suggested to play a role in numbing
and withdrawal which are attempts to cope with the trauma. A break down of the regression process is said to
result in re-experiencing (Oei. Lim & Hennessey, 1990). Learning theorists proposed a two-factor theory that
involves the combination of classical conditioning and operant conditioning. The pairing of the terror inherent in
trauma with a variety of cues that are associated with the traumatic event is hypothesized to create a number of
fears as a result of classical conditioning. The avoidance of the fear producing situations is argued to maintain
these fears as a result of operant conditioning. Specifically, the negative reinforcement associated with the
reduction of aversive anxiety (Keane. Zimerring & Cadell. 1985: Foa, Stakette & Rothbaum. 1989).
Cognitive behavioural models suggests that higher cognitive processes like self-blame experience of further
trauma, and the development of fear structures are important in the aetiology of PTSD (Jones & Barlow, 1990).
Social Factors in PTSD Researchers have found that the more intense and life threatening traumatic events are
the more likely they to result in PYSD. For example, people wounded in war/conflict, caused the death of others
and or witnessed atrocities are more likely to develop the disorder (Oei, Lim & Hennessey. 1 990).

66
 CHAPTER TWELVE
SEXUAL DISORDERS
A discussion of sexual disorders requires that we have some knowledge of normal human sexuality. In a seminal
work. Masters and Johnson (1970) described the human sexual response cycle in terms of a sequence of over-
lapping phases: excitement, plateau, orgasm and resolution. Analogous phases occur in both men and women, but
the timing may differ. There are, of course, individual differences in virtually all aspects of the cycle. Variations
from the most common pattern may not indicate a problem unless the person is concerned about the response.
Sexual excitement increases continuous from the point of initial stimulation and may last anywhere from a few
minutes to several hours. Among the physiological changes during this phase are those associated with
vasocongestion - engorgement of the blood vessels various organs, especially the genitals. The male and female
genitalia become swollen, reddened and warmed. Sexual excitement also produces an increase in muscular
tension, heart rate, and respiration rate. These physiological responses are accompanied by subjective feelings
of arousal, especially are advanced stages of excitement that constitute the plateau phase, in which the body
prepares for orgasm.
The experience of orgasm is usually quite distinct from the gradual build-up of sexual excitement that precedes it.
This sudden release of tension is almost always experienced as being intensely pleasurable, but the specific nature
of the experience varies from one individual to another (Geer, Heiman & Leitenberg, 1994). The female orgasm
occur in three stages beginning with a "sensation of suspension" or "stoppage" which is associated with strong
genital sensations. The second stage involves a feeling of warmth spreading throughout the pelvic area. The third
stage is characterised by sensations of throbbing or pulsating, which are tied to rhythmic contractions of the
virginal. This is represented graphically below in Figure 12-1.
The male orgasm occurs in two stages, beginning with a sensation of ejaculatory inevitability. This is triggered by
the movement of seminal fluid toward the urethra. In the second stage, regular contractions propel the semen
through the urethra, and it is expelled through the urinary opening. During the resolution or after-effects phase,
which may last 30 minutes or longer the person's body returns to its resting state Men are typically unresponsive
to further sexual stimulation for a variable of time alter reaching orgasm. This is known as the refractory period
(see Figure 12-1). Women, on the other hand, may be able to respond to further stimulation almost immediately.
Sexual dysfunction can involve a disruption of any phase of the human sexual response cycle.
Figure 12.1:

67
Classification of Sexual Disorders
The classification of sexual disorders has changed dramatically over the centuries. In part, this has reflected
religious doctrines, social beliefs and cultural values. For example, throughout the 18 th and 19th centuries,
masturbation was considered to be responsible for causing various physical and mental disorders (Bullough,
1976). Early efforts to develop a classification system for sexual problems were primarily concerned with the
definition of "normal" behaviour and with a description of sexual pervasions. For example, Kaft-Ebing's (1840-
1902) classification of what he called the "'sexual neuroses" made only a brief mention of sexual dysfunctions, in
particular, erectile impairment and ejaculatory control. The vast majority of his manual was devoted to the so-
called pervasions, especially sadism, masochism, fetishism and homosexuality. However, in the 20 th century, there
began a trend toward greater tolerance of sexual variation among consenting adults and toward increased concern
about impairments in sexual performance and experience. This was due to the works of several scientists like
Freud (8156-1939), Ellis (1859-1939), and Kinsey( 1894-1956).
The early description of sexual disorder in the first and second editions of DSM (APA, 1952; 1968) was more-
influenced by psychodynamic theory than scientific data. Both maintained that homosexuality was, by definition
a form of mental disorder. DSM-II1 (APA, 1980) moved sexual disorder to a separate section of it own. Specific
types of sexual dysfunctions were listed in terms of interruptions of sexual response cycle, DSM-IV considers
sexual behaviour abnormal when it results in personal distress or when it involves non-consenting partners. It
includes three principal forms of sexual disorders: sexual dysfunctions, the paraphillias, and gender identity
disorder.
SEXUAL DYSFUNCTIONS
Inhibitions of sexual desire and interference with the physiological responses leading to orgasm are called sexual
dysfunctions. They can arise anywhere from the earliest stages of interest and desire through the climatic release
of orgasm. In some cases these problems take the form of inhibitions of sexual response of diminished pleasure.
Some people also experience pain in association with sexual intercourse. In order to meet the DSM-IV diagnostic
criteria, all categories of sexual dysfunctions must be (i) disturbance that causes marked distress or interpersonal
difficulty, and (ii) sexual dysfunction that is not better accounted for by another Axis I disorder (such as major
depression) and is not due to direct physiological effects of a chemical substance such as alcohol) or a general
medical condition.

68
Each of the specific types of sexual dysfunction can be characterised in terms of its pattern of onset and context of
occurrence. With regard to the pattern of onset, the problem can be either lifelong, meaning that the problem has
been present since the person's first sexual activity; or it can be acquired, meaning that the problem developed
after a period of normal functioning. With regard to the context of occurrence the problem can either be
generalized or situational. A generalized sexual dysfunction is not limited to certain partners or situations.
Situational problems are limited to certain partner or situations.
Hypoactive Sexual Desire Disorders Sexual desire set the stage for sexual arousal and precedes the phases of the
sexual response cycle. It is the person's willingness to approach or engage in those experiences that will lead to
sexual arousal.
Inhibited sexual desire may be defined in terms of subjective experiences such as lack of sexual fantasies and
lack of interest in sexual experience. The absence of interest in sex must be both persistent pervasive to be
considered a clinical problem. The central issue in inhibited sexual desire is interest - actively seeking out sexual
experience- rather than participation. We must note that a person's level of sexual desire is affected by age, gender
marital status and many other factors

Sexual Aversion Disorder Some people an active aversion to sexual stimuli and begin to avoid these situations
altogether. Some people avoid only certain aspect of sexual behaviour such as kissing, intercourse or oral sex,
fear of sexual encounters can occasionally reach intense proportions. This problem might be viewed as a form of
panic disorder (see Chapter six) because it extend beyond anxiety regarding sexual performance
Male Erectile Disorder Many men experience difficulties either obtaining an erection that is sufficient to
accomplish intercourse or maintaining an erection lone enough to satisfy themselves and their partners during
intercourse. Both problems are examples of erectile dysfunction. Men with this problem may feeling subjectively
aroused but the vascular reflex mechanism fails, and sufficient blood is not pumped to the penis to make it erect.
These difficulties can occur any time before orgasm. Some have trouble achieving an erection during foreplay,
whereas others have their erection and lose it around the time of insertion or during intercourse. This phenomenon
used to be called impotence, but the term has been dropped because of its negative implications. Erectile
dysfunctions can be relatively transient or the} 1 ma}1 be chronic. When they persist and become a serious source
of distress they can lead to serious marital and other health problems.
Female Sexual Arousal Disorder Sexual arousal can also be impaired in women, but it is somewhat more
difficult to describe and identify than erectile dysfunction in men. Put simply, a woman is said to experience
inhibited sexual arousal if she cannot either achieve or maintain genital responses such as lubrication and
swelling, that is necessary to complete intercourse. The desire is there, but the physiological responses that
characterise sexual excitement are inhibited.
Premature Ejaculation Some men experience problems with the control of ejaculation. They are unable to
control voluntarily the period of sexual excitement or plateau for a period of time sufficient to complete
intercourse. Unce they become intensely sexually aroused, they reach orgasm very quickly. Note that there is a
great variability in the duration of sexual intercourse. Some men are able to prolong sexual intercourse for hours;
69
others are satisfied with relatively brief encounters of sexeral minutes duration. Thus there are no widely accepted
quantitative or temporal criteria for defining premature ejaculation. For some clinicians, if a man ejaculates
before or immediately upon insertion. or after only three or four thrusts (intromi»ionsi. then such a person's sexual
behaviour is identified as premature ejaculation (McCarth}. 1989). Other clinicians place emphasis on the
couple's satisfaction. For example, if the man is unable to delay ejaculation until his partner reach orgasm at least
50% of the tune (Masters & Johnson. 1970) or the subjective perception of control (Kaplan, 1974).
Female Orgasmic Disorder Some women are unable to reach orgasm even though they apparently experience
uninhibited sexual arousal. Women who experience orgasmic difficulties may have a strong desire to engage in
sexual relation, they may find great pleasure in sexual foreplay, and they show all the signs of sexual; arousal,
nevertheless, they cannot reach the peak erotic experience of orgasm. In the generalised form such women have
never experienced orgasm by am means. In the situational form the woman is able to reach orgasm in some
situations but not others.
Pain During Sex Some people experience genital pain during or after sexual intercourse - a condition known as
dyspareunia. The problem can occur in either men or women, though it is considered to be much more common
in women (Qucvillon, 1993). The severity of the discomfort can range from mild irritation following sexual
activities to searing pain during the insertion of penis or during intercourse (Lazarus. 1989). The pains may be
sharp and intense, or the}' ma}' take the form of a dull, aching sensation: they may be experienced as coming
from a superficial area near the barrel of the vagina or as being located deep in the lower abdominal area: the}
may be intermittent or persistent.
Access to vagina is controlled by the muscle;- surrounding its entrance. Some women find that whenever
penetration of the vagina is attempted, these muscles snap tightly shot, preventing insertion of any object. This
involuntary muscular spasm, known as vaginisnus. prevents sexual intercourse as well as vaginal examination
and insertion of tampons. Women with vaginismus may be completely sexually responsive in other respects, fully
capable of arousal and orgasm through manual stimulation of the clitoris. Many women with dyspareunia or
vaginismus develop a lack of interest in, or an aversion toward sexual activity. In the extreme, they may become
afraid of sexual intercourse and vaginal penetration (Beck, 1993).

Co-morbidity of Sexual Dysfunctions

Disturbed relationship with other people, and other form of psychopathology, such as depression and anxiety, are
frequently associated with sexual problems. Problems in interpersonal relationships and subjective feelings of
intimacy represent important problems for men and women (Tiefer, 1988). Strong negative emotions such as fear,
anger and resentment are often associated with sexual problems. In some cases, these emotional problems appear
before the onset of the sexual dysfunction and sometimes they develop later. Given the connection that our
cultures make between virile sexual performance and "manhood'", it is not surprising that men with erectile
difficulties are often embarrassed and ashamed. Their humiliation can lead to secondary problems such as anxiety
and depression.

70
Epidemiology of Sexual Dysfunctions
People are reluctant to discuss such an intimate aspect of the lives as their sexual behaviour. Thus, prevalence
data on sexual disorders are difficult to gather, where available they are sparse and most come from clinical case
reports. Surveys conducted among people in the general population indicate that various forms of sexual
dysfunctions are relatively common (see Table 12-1). Prematureejaculation may be the most frequent form of
sexual dysfunction, affecting nearly 1 in 3 adult men. Research studies among those people who seek professional
treatment indicate-that orgasmic and erectile dysfunctions have become more frequent: there is a decrease in
premature ejaculation; an increase in desire disorders; and males complain about sexual problems than females
(Specto & Carey, 1990). Orgasmic disorders, arousal disorders and inhibited sexual desire are more common
among women (Nathan. 1986).
Sexual behaviour changes with age (Masters and Johnson. 1970). As men get older they tend to achieve erection
more slowly in response erotic stimulation, but they can often maintain for longer periods of time. Older men find
it difficult to regain erection if it is lost before orgasm. As women get older, vaginal lubrication may occur at
slower rate, but the response of the clitoris remain essentially unchanged. The intensity of the subjective
experience of orgasm is decreased in older men and women. For both sexes, healthy sexual responsiveness is
most likely to be maintained among those who have been sexually active as younger adults.
Table 12-1; Prevalence of Sexual Dysfunctions In the general Population

Dysfunction Men Women

Desire disorders 1-15% 1-35%

Arousal disorders 4-9% 11-48%
Orgasmic disorders 3-4% 5-fI5%
Premature ejaculation 36-38%

Aetiology of Sexual Dysfunctions

At each stage of the sexual response cycle a person's behaviour is the determined by the interaction of many
biological and psychological factors; ranging from vasocongestion in the genitals to complex cognitive events
involving the perception of stimuli and the interpretation of sexual meanings. Interference with this system at any
point can result in serious problems.
Sexual desire A person's appetite for sexual experience is based on many ingredients. These include the
spontaneous appearance of sexual thoughts and fantasies, the inclination to seek out sexually arousing stimuli, and
the capacity to respond positively to sexual advances from a partner. Almost everyone recognises that sexual
desire fluctuates over, sometimes dramatically and frequently, for reasons not yet clearly understood (Levine.
1987). There is some evidence to suggest that biological factors are involved in the experience of sexual desire.
Among males, sexual desire is influenced by sex hormones, especially testosterone (Davidson, 1990). Men with
71
inadequate levels of hormones show an inhibited response to sexual fantasies, but they are able to have erections
in response to viewing erotic films (Bancroft et a/., 1983). In other words, sexual appetite is impaired if the level
of testosterone falls below a certain level. This level has however not been empirically determined. Although
sexual desire is strongly influenced by biological factors, psychological and social variables such as mental
scripts (Gagnon & Simon. 1973) also play an important role. Mental scripts are social meanings of events
learned in childhood and adolescence that are of paramount importance in releasing the biological processes of
sexual arousal.
Beliefs and attitudes toward sexuality as well as the quality of interpersonal relationship have an important
influence on the development of low sexual desire, especially among women. People who suffer from low levels
of sexual desire frequently experience other forms of mental disorders. Perhaps as many as 85% of males and
75% of females seeking treatment for hypoactive sexual desire report other forms of sexual dysfunctions
(Donahay & Carroll. 1993).
Sexual arousal in men Recent evidence indicate that erectile dysfunction is more often biologically based.
Clinical reports suggest that more than half of cases treated at sex clinics could be attributed to vascular,
neurological, or hormonal impairment (Melman. Tiefer & Pederson. 1988). Erection is the direct result of a
threefold increase in blood flow to the penis. It therefore not surprising that vascular diseases which may affect
the amount of blood flow reaching penis are likely to result in erectile difficulties. Neurological diseases such as
epilepsy and multiple sclerosis, can also produce erectile difficulties because erection depends on spinal reflexes
(Wincze & Carey, 1991). Many other factors can influence a man's erectile response, including various drugs.
One interesting finding indicate that men who smoke cigarettes are more likely to experience erectile difficulties
than are men in the general population (Mohr & Bentler, 1990). Many other drugs, including alcohol, marijuana,
drugs for treating hypertension, and antipsychotic and antidepressant drugs may have negative effects on sexual
arousal.
Masters and Johnson (1970) who gave primary emphasis to performance anxiety or fear of failure, claimed that
95% of erectile dysfunction is caused by psychological rather than biological factors. Men who have experience
or one or two occasions may be likely to have further problem to the degree that these difficulties make them self-
conscious and apprehensive regarding their ability to become aroused in future sexual encounters. Therapists that
sexual arousal and anxiety are incompatible emotional states (Kaplan. 1974). Some even propose that sexual
arousal problem may be mediated by a negative feedback loop in which unpleasant feelings lead to self distraction
and avoidance of erotic stimuli (Barlow, 1986; Cuebas & Barlow, 1990).
Sexual arousal in women Many biological factors and psychological diseases and impair a woman ability to
become sexually aroused. Various types of neurological disorders, pelvic diseases, and hormonal dysfunction can
interfere with the process of virginal swelling and lubrication. A previous history of sexual abuse can lead to
sexual aversion and it can interfere with a woman's ability to become sexually aroused (Becker, 1989). Failure to
engage in effective behaviours during foreplay – inadequate stimulation, poor timing, and poor communication -
are also contributing factors (Kaplan, 1974; Wineze & Carey, 1991) Culturally determined values can have a
dramatic impact on women attitude toward sexual dealings and behaviour (Heiman, 1983).

72
Inhibited orgasm Inhibited orgasm, in both men and women is sometimes caused by the abuse of alcohol and
other drugs. It can also be associated with use of some forms of prescribed medication (Segraves, 1998; Zajecks
et al., 1991). As noted earlier cultural values play an important role in sexual experience. Public attitude toward
female sexuality and especially the expectation that women can and should experience orgasm as an important
part of a sexual relationship, have changed progressively over the past several decades. Thus, more women now
complain of orgasmic difficulties.
PARAPHILLIAS
Paraphillias (also spelt paraphyllias) is also referred to as disorders of sexual preference (ICD-10; WHO, 1990)
or unconventional sexual behaviours. These terms are used to describe people who are sexually aroused by
unusual objects and situations, such as inanimate objects, sexual contacts with children, exhibiting their genitals
to strangers, and inflicting pain to another person. Paraphillias (from the Greek para, meaning "amiss" phillia,
meaning "love", and therefore, love beyond the usual) may be said to be an extreme form of unusual sexual
behahaviour in which sexual arousal is associated with a typical stimuli, and the person is preoccupied with, or
consumed by these activities According to DSM-IV, the central features of all paraphillias are persistent urges and
fantasies that are associated with (1) nonhuman objects, (2) suffering or humiliation of oneself or one’s partner, or
(3) children or other nonconscenting person.
Typical Symptoms and Associated Features of Paraphillias
People are capable of associating sexual arousal with a wide range of stimuli and activities. Some are quite
common, while others are unusual and perhaps startling. For some people, unusual erotic intentions remain
limited to fantasies. Others act on them. Problems of sexual appetite arise when a pattern develops involving a
long-standing unusual erotic preoccupation that is highly arousing, coupled with a pressure to act on the erotic
fantasy. The diagnosis of paraphillias is made only if the person has acted on the urges or is distressed by them.
Some people are able to become sexually aroused only by paraphillic fantasies or stimuli. Others find that they are
usually able to respond to sexually "normal".
Premature ejaculation Several factors can contribute to the development of premature ejaculation. Some men
simply reach orgasm more quickly than others. Such can bring about relationship difficulties and personal
distress. Premature ejaculation may be normal early stage in male sexual development (McCarthy. 1989).
Inhibited orgasm Inhibited orgasm, in both men and women is sometimes caused by the abuse of alcohol and
other drugs. It can also be associated with use of some forms of prescribed medication (Segraves, 1998; Zajecks
et «/., 1991). As noted earlier cultural values play an important role in sexual experience. Public attitude lovvmd
female sexuality and especially the expectation that women can and should experience orgasm as an important
part of a sexual relationship, have changed progressively over the past several decades. Thus, more women now
complain of orgasmic difficulties.
PARAPHILLIAS
Paraphillias (also spelt paraphyllias) is also referred to as disorder, of sexual preference (ICD-IO; WHO, 1990) or
unconventional sexual behaviours. These terms are used to describe people who are sexually aroused by unusual
73
objects and situations, such as inanimate objects, sexual contacts with children, exhibiting their genitals to
strangers, and inflicting pain to another person. Paraphillias (from the Greek para, meaning “amiss” and phillia,
and therefore, love beyond the usual) may be said to be an extreme form of unusual sexual behaviour in which
sexual arousal is associated with atypical stimuli, and the person is preoccupied with, or consumed by these
activities. According to DSM-V, the Central features of all paraphillias are persistent urges and fantasies that are
associated with (1) nonhuman objects, (2) suffering or humiliation of onself or one’s partner, or (3) children or
other nonconsenting persons.
Typical Symptoms and Associated Features of Paraphillias
People are capable of associating sexual arousal with range of stimuli and activities. Some are quite common,
while others are unusual and perhaps startling. For some people, unusual erotic intention remain limited to
fantasies. Others act on them. Problems of sexual appetite arise when a pattern develops involving a long-standing
unusual erotic preoccupation that is highly arousing, coupled with a pressure to act on the erotic fantasy. The
diagnosis of paraplllllias is made only if the person has acted on the urges or is distressed by them. some people
are able to become sexually aroused only be paraphillic fantasies or stimuli. Others find that they are usually able
to respond to sexually “normal” stimuli and their paraphillic preferences only intermittently, such as during
periods of stress.
The central problem is that sexual arousal is dependent on images that are detached from reciprocal; loving
relationships with another adult (Levine, Risen & Allhof, 1990). Themes of aggression, violence, hostility and
revenge are common in paraphillic fantasies, as impulses involving strangers or unwilling partners. For example,
a man might become sexually by images of displaying his penis to unsuspecting women, making obscene phone
call rubbing his genitals against women in a crowded bus, or fondling small children.
Compulsion and lack of flexibility are also important features of paraphillic behaviours. Paraphillias may occupy
a large amount of time and consume much of the person's energy. In that sense, they are similar to addictions.
People with paraphillic disorders feel compelled to engage in certain acts that may be personally degrading or
harmful to others, in spite of the fact that these actions are often repulsive to others and sometimes illegal. Many
people with paraphillias experience sexual dysfunction involving desire, arousal, or orgasm during conventional
sexual behaviour (Levine, Resin & Althof, 1990). Researchers have also noted that men with paraphillias can be
described as timid, low in self-esteem, and lacking in social skills (Blair & Lanyon. 1981).
Classification of Paraphillias
The range of objects, situations and behaviours that can become sexually arousing are virtually infinite (Stoller,
1975). Money (1994) suggests that there are at least 30 different types of paraphillias, including sexual arousing
association with stimuli ranging from animals (zoophillia). enemas, diapers, and tattoos to self-strangulation and
having sex with children (paedophilia), amputees, and people old enough to be one's parents or grandparents. In
actual practice, only a few prominent forms of paraphillias appear in DSM-IV. These types are the most common
and the ones that frequently lead to the person being arrested.
Exhibitionism A recurrent or persistent tendency to expose one's genitalia to strangers (particularly of the
opposite sex) or to people in public places, without inviting or intending closer contact. There is usually, buy not
74
invariably, sexual excitement at the time of the exposure and the act is commonly followed by masturbation. This
tendency may be manifest by overt behaviour only at times of emotional stress or crisis, interspersed with bng
periods without such behaviour. This disorder is virtually limited to heterosexual males who expose to female,
adults or adolescents, usually cotifnmtmfe from a safe distance in some public place. For some, exhibitionism is
the only sexual outlet, but others continue me habit simultaneously with active “normal” sex life.
Fetishism is the reliance on some non-living object as a stimulus for sexual arousal and sexual gratification.
Many fetishes are extensions of the human body such as articles of clothing e.g., female undergarments) and
footwear. Other common examples are characterized by some particular texture such as rubber, plastic or
leather. Fetish objects vary in their importance to the individual. In some cases they only serve to enhance sexual
excitement achieved in ordinary ways (e. G., having one's partner wear a particular garment). In rare and unusual
cases, fetish objects can involve human waste, dirt, animals or even dead bodies (necrophilia).
Fetishistic Transvestism (Transvestic Fetishism) is the wearing of the clothes of the opposite sex principally to
obtain sexual arousal and excitement. This disorder is found only in males.
Frotteurism is touching and rubbing one's genitalia against a non-consenting person for sexual stimulation in
crowded places, such as a crowded bus. The touching, not the coercive nature of the act, is what persons with this
disorder fond arousing.
Paedophitia is having sexual urges and fantasies involving sexual activity with children. Generally ones younger
than 13 or of pre-pubertal or early pubertal age. Some paedophiles are attracted only to girls; others only to boys
and others again are interested in both sexes. Paedophilia is rarely identified in women. Men who molest their
own pre-pubertal children occasionally approach other children as well.
Sado-masochism is a preference for sexual activity, which involves the infliction of pain, humiliation or
bondage. If the person prefers to be the recipient of such stimulation, it is called masochism, if the provider,
sadism. That is. sexual masochists like being beaten humiliated, bound or otherwise made to suffer to obtain
sexual mollification. On the other hand, sexual sadists get same from the psychological and physical suffering
(including humiliation) of their victim.
Voyeurism is a recurrent or persistent tendency to look at people engaging in sexual or intimate behaviour, such
as undressing. The act involves observing an unsuspecting person who is naked, disrobing, or engaging in sexual
activity. This usually leads to sexual excitement and masturbation and is carried out without the observed person
being unaware.
Epidemiology of Parapillias
There is very little evidence regarding the prevalence of the various types of paraphillias. With the exception of
masochism, paraphillias are almost always male behaviours. Some 95% of people who seek treatment for
paraphillic disorders are men (Levine, Risen & Althof. 1989). In case study of 48 patients. Chalkley & Powell
(1989) found only one woman complaining of fetishism. Masochism appears equally common in both men and
women. Paraphillias are usually not isolated phenomena. People who exhibit one type of paraphillia often exhibit
others. This pattern has been called crossing of paraphillic behaviours.
75
Aetiology of Paraphillias
Attempts at explaining the origins of paraphillias have benefited from the ways substance dependence disorders.
The development of addiction follows a sequence of stages: initiation, transition to abuse, and the
development of tolerance. Most of the theories discussed below tried to follow this sequence. Wilson's (1987)
imprinting theory explains the development of fetishes in terms of biologically prepared learning. It assumes
that the male brain is programmed to associate particular types of visual stimuli with sexual arousal. These
associations are typically developed early in life. The associations may become misprogrammed and sexual
arousal may become paired with objects that are related, through visual or other sensory cues to the mother's
body.
The courtship disorders hypothesis of Freund and Blanehard (1986) suggests a breakdown in the
usual sexual behaviour sequence of steps that include the location and appraisal of a potential partner; exchange
of signals in which partners communicate mutual interests; and tactile interaction that set the stage for-sexual
intercourse. That is people with paraphillias have somehow failed to learn more adaptive forms of courtship.
GENER IDENTITY DISORDERS
A person's sense of being either male of female, known as gender identity is almost always consistent with
his/her physical anatomy. Gender identity is usually fixed by the age of two or three years (Serbin & Sprafkin.
1987), by this age a toddler with a penis learns he is a boy and the one with a vagina learn she is a girl. In some
rare cases, a person develops a strong and persistent identification with the other gender as well as discomfort
with his/her own assigned gender. For example, a person might insist that, in spite of his genitalia, he is more like
a woman than a man. This phenomenon is called gender identity disorder.
We must distinguish gender identity from sex roles. Sex roles are characteristics, behaviours and skills that are
defined within a specific culture as being either masculine or feminine. Behaviours and appearances ascribed to
males are masculine and those ascribed to females is feminine. Nowadays, though, these have change
considerably. Thus, there is now an overlap in masculine and feminine sex roles.
Typical Symptoms and Associated Features of gender Identity Disorders
Some people are, often from an early age, convinced that they are living in the wrong body they are displeased
with their own bodies. Males feel strongly that they are women trapped in a man's body and females have the
opposite feeling. They desire to live and be accepted as a member of the opposite sex. They often have a sense of
discomfort with or inappropriateness of their anatomic sex and wish, often from an early childhood, to have
medical treatment (usually hormonal and surgical) to make their bodies as congruent as possible with the
preferred sex. This condition is called gender identity disorder in DSM-IV. It has also been known as
transsexualism (ICD-1 0), or gender dysphoria (Blanchard, 1989). Transsexuals feel that, with the exception of
their physical anatom), they are more like the opposite gender.
Epidemiology of Gender Identity Disorders

76
Gender identity disorders are quite rare. Male-to-female transsexuals are apparently more common than female-
to-male transsexuals, at least based on clinical data.
Aetiology of Gender Identity Disorders
Gender identity seems to be strongly influenced by sex hormones, especially during the prenatal period (Hoeing,
1985). Evidence has come from a condition called pseudohermaphrodism, in which individuals are born
genetically male, but are unable to produce a hormone that is responsible for shaping the penis and scrotum in the
foetus. Therefore, the child is born with external genitalia that are ambiguous in appearance. Many of such
children are raised as girls by their families. When they reach puberty a sudden increase in testosterone-leads to
dramatic appearance of the adolescent's genitals and the development of secondary sex characteristics, such a
child quickly begins to consider himself to be a man (Imperato-McGinley et al, 1974). The speed and apparent
ease with which people with these conditions adopt a masculine gender identity suggests that their brain had been
prenatally programmed for this alternative (Hoeing. 1985).

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 CHAPTER THIRTEEN
DISORDERS OF CHILDHOOD AND ADOLESCENCE
Apart from the disorders already discussed that are found, among adults, there are psychological problems
commonly found among infant children and adolescents. DSM-IV call such “Disorders. Usually first Diagnosed
in Infancy, Childhood, or Adolescence", while ICD-10 refer to them as "Behavioural and Emotional Disorders
With Onset Specific to Childhood and Adolescence”. Although children and adolescent suffer from most of the
adult disorders such as anxiety disorders and mood disorders, the same diagnostic criteria may not apply among
children and among adults. Also there are some disorders that are unique to childhood.
Assessment of Childhood Disorders
Identifying abnormal behaviour among children can be very difficult and often a subject task. This is due to many
unique problems posed by childhood disorders. When dealing with the psychological problems of childhood, it is
especially important to take a developmental psychopathology perspective. This implies considering
developmental problems when deciding whether children's behaviour is normal or abnormal. A given behaviour
may be normal at one age, but the same behaviour may constitute a psychological problem at a different age. For
example, it is normal for a 2-year-old to throw temper tantrums (to lie down on the floor, kick, scream and cry) if
she does not get what she want or get her way. Such behaviour is hardly expected of a 12-year-old. In fact, it will
be considered abnormal for her to behave in such a way. Thus, psychologists only become concerned when a
child's behaviour deviates substantially from developmental norms. It is course common knowledge that
developmental norms change rapidly during infancy, childhood and adolescence.
A unique complication in the assessment of childhood disorders stems from the fact that very few children and
adolescents identify themselves as needing psychological help. Instead some adult – parent, teacher, legal
authority, or mental health professional – typical decides that a child is emotionally disturbed. This fact creates
special problems for assessment. One more problem is that the evaluation of the child is potentially biased. This
means that in practice and research, child clinical psychologists must continually attempt to discern how much of
a problem reported by an adult is real and how much exists only in the eye of the beholder.
Difficulties in evaluating children’s inner thoughts and feelings constitute another core problem of assessment.
Due to this adults (at a least two – usually a parent and a teacher) are used to rate the child’s behaviour. This leads
to the problem of reconciling adults differing evaluation of the same child. Treatment often begins with an
attempt to get the adults to agree as to what the problem may really is. Very often, the child's pathology may
reflect conflict within the family or among adults caring for the child. Because such possibilities, many
psychologists prefer to see children in the context of the family therapy rather than treating children alone.
Classification of Childhood Disorder
Until recent years diagnosticians assumed that children suffered the same psychological disorders as adult. This
arose in part because there are some continuity between the psychological disorder of childhood and those of
adult life. Antisocial behaviour often continues into adult life. Evidence also indicates that depressed children are
at risk for experiencing depression during adult life (Harrington, 1990). The continuity is not necessarily
78
isomorphic or identical in form. Rather transformations can occur in the way an underlying characteristic is
expressed across the course of development. For example, a shy child does not simply become a shy adult.
The beginning of child psychology as a discipline can be traced to 1896 when Lightner Witmer (1867-1956)
established the first psychological clinic for children in the USA. This was due to the forces at work at that time,
one, the new science of psychology has just been recognised as a discipline of its own. Second, there was a
massive swing in attitude toward children, with childhood now recognised as a stage of development requiring
special social protection and nurturance. Despite these advances, however, childhood continued to be over
looked in the formal classification of mental disorders. For example, DSM-II (1968) listed only seven childhood
disorders.
Table 13-1: DSM-IV disorders usually First Diagnosed in Infancy, Childhood or Adolescence
Attention-Deficit and Disruptive Behaviour Disorders

 Attention-deficit/hyperactivity disorder
 Combined type
 Predominantly inattentive
 Predominantly hyperactive-impulsive type
o Conduct disorder
 Oppositional defiant disorder
Learning Disorders

 Reading disorder
 Mathematics disorder
 Disorder of written expression
Motor Skills Disorder
Developmental coordination disorder
Communication Disorders

 Expressive language disorder

 Mixed receptive-expressive language disorder
 Phonological disorder
 Stuttering
Feeding and Eating Disorders of Infancy and Childhood

o Pica
 Rumination disorder
 Feeding disorder of Infancy or early childhood
Tic Disorders

79
 o Tourette’s disorder
o Chronic motor or vocal tic disorder
o Transient tic disorder
Elimination Disorders

 Encompresis
 With constipation and overflow incontinence
 Without constipation and overflow incontinence
 Enuresis
Other Disorders of Indancy, Childhood and Adolescence

o Separation anxiety disorder

o Selective mutism
o Reactive attachment disorder of infancy or early children
o Stereotypic movement disorder
Due to the efforts of the Group for the Advancement of Psychiatry (GAP: 1966) and the WHO (Rutter. Shaeffer
A: Shepherd. 1975). the DSM-III (1980) ballooned the number of childhood disorders to 40.
Despite numerous changes, DSM-IV is still regarded as having too long a list of childhood disorders. This has
resulted in the manual receiving some critical reviews. Psychologists argued that the manual contain some
disorders that are so rare that they found only on the pages of the manual. Whereas there other childhood disorder
that are reltively common that are mentioned at all. This is the over inclusiveness – under incluiveness
controversy. The reason some of the disorders listed in Table 13-1 may seem unfamiliar is the questionable nature
of their status as mental disorders.
“Developmental coordination disorder” is perhaps the most obvious example of over the most obvious example
of over inclusiveness in DSM-IV. The manual defines it as “performance in daily activities that require motor
coordination is substantially below that expected given the persons chronological age and measured intelligence”.
The “lerning disorders” and the communication disorders” are even more controversial examples of possible over
inclusion in the manual. Educationists call the childhood problems learning disabilities and speech and learning
problems respectively. Both are common problems and serious difficulties experienced by children, but
psychologists question their status as mental disorders. They are viewed as being more of educational than mental
health concerns. On the issue of under inclusion, psychologists argue that DSM-IV is inconsistent with the issue
of under inclusion, psychologists argue that DSM-IV is inconsistent with empirical evidence derived from the
psychometric approach to classifying childhood disorders. A glaring example is the non-inclusion of internalizing
disorders.
The psychometric approach is the classification of diagnostic categories based on statistical analysis of
behaviour problem checklists completed by parents and teachers. The most significant contribution of the method
is its identification of two broad categories of childhood behaviour problems - the externalizing and internalizing
dimension. These dimensions have been empirically derived with great consistency and their reliability and

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validity have well established (Achenbach. 1985; Achenbach et al., 19888). Thus, the absence of externalising
category in DSM-IX surprising since the authors claim to have based their classification on empirical findings.
Externalising disorders are behaviour problems of childhood that are directed toward the external world. It can
be equated with the broad category of attention-deficit and disruptive behaviour disorders in DSM-IV (see Table
13-1). There are two prominent things about externalizing disorders: (1) these disorder are characterised by
children's failure to control their behaviour according to the expectations of others, particularly their parents and
teachers; and (2) externalizing disorders are, by far, the most commonly diagnosed psychological problems
among children.
Violations of age appropriate social rules may include disobedience, aggression, and perhaps legal violations
(particularly during adolescence). Several factors influence how these rule violations are evaluated by adults.
These include frequency, intensity, duration and cross-situational consistency. That is, such behaviours are of far
greater concern when they are frequent, intense, lasting and pervasive, when they are a part of syndrome or a
cluster of problems, than when it is a symptom that occurs in isolation.
Internalising disorders are psychological problems of childhood that are directed inward toward the child rather
than outward toward the world. Excessive anxiety, sadness and somatic complaints are the major internalising
disorders. As noted above, SDM-IV does not list internalising problems as a unique disorder of childhood, but
notes that children can qualify for the "adult" diagnosis for anxiety and mood disorders. Children do not interpret
events or express emotions in the same manner as adults. Thus, the same diagnostic criteria may not apply to
those disorders among children. DSM-IV seems to recognize this by giving some allowance when, for example,
diagnosing major depression – “irritable mood” replaces the "depressed mood" criterion of the adult version.
A major problem in evaluating children's internalising symptoms is that the course of children’s normal emotional
development is not well charted. One reason for this is that it is more difficult to assess children's inner experience
than it is to observe their behaviour. Children, in turn, often are not reliable or valid informants about their own
internal life, children's capacity to recognise emotions in themselves and in other emerges slowly over the course
of development, as does their ability to express – and – mask their own feelings (Lewis & Michalson. 1983).

Table 13-2: DSM-IV Diagnostic Criteria for Attention-Deficit/hyperactivity Disorder

A. Either (I) or (II):
(I) Inattention: Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a
degree that is maladaptive and inconsistent with developmental level.
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
activities.
2. Often have difficulty sustaining attention in tasks or play acitivities.
3. Often does not seem to listen when spoken to directly.

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4. Often does not follow through on instructions and fails to finish school work, chores, or duties in the
work place.
5. Often have difficulty organizing tasks and activities
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.
7. Often loses things necessary for tasks or activities.
8. Is often easily distracted by extraneous stimuli.
9. Is often forgetful of daily activities.
(II) Hyperactivity and Impulsivity. Six (or more) of the following symptom of hyperactivity-impulsivity
have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.
Hyperactivity
1. Often fidgets with hands or feet or squirms on seat.
2. Often leaves seat in classroom or in other situations in which remaining seated is expected.
3. Often runs about or climbs excessively in situations in which it is inappropriate.
4. Often have difficulty playing or engaging in leisure activities quietly.
5. Is often “on the go” or often acts as if "driven by a motor".
6. Often talks excessively.
Impulsivity
7. Often blurts out answers before questions have been completed.
8. Often have difficulty awaiting turn.
9. Often interrupts or intrudes on others.
B. Some hyperactive-impulsive or inattentive symptoms that caused impairments were present before age 7
years.
C. Some impairment from the symptoms is present in two or more settings.
D. There must be a clear evidence of clinically significant impairment in social, academic, or occupational
functioning
Coded based on type
Combined type Criteria for I and II are met for past 6 months.

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Predominantly inattentive type Criteria for I are met but criteria fro II are not met for past 6 months.
Predominantly Hyperactive-impulsive Type Criteria for II are met but criteria for I are not met for the past 6
moths

Typical Symptoms and Associated Features of Childhood Disorders

A thorough consideration of the symptoms of all the psychological problems of childhood would require looking
at the disorders listed in DSM-IV one by one. However, due to the over inclusion noted above, learning disorders,
motor skills disorder and communication disorders will not be discussed. The only exception is the
communication disorder – stuttering because or its relative commonality.
Attention-Deficit and Disruptive Behaviour Disorders
As noted above, this category equates with the psychometric classification of externalizing disorder- and is
broadly subdivided into three major subtypes: attention- deficit/hyperactivity disorder, conduct disorder and
oppositional defiant disorder. These disorder were once believed to stem from temperament and other biological
causes - such as brain damage specifically minimal brain Damage (MBD). That is brain damage too slight to be
detected except in the child's behaviour (Ehrenfest, 1926), however, this hypothesis has so far not been supported
by empirical evidence.
Attention-Deficit/Hyperactivity Disorders is characterised by three distinct symptoms: (1) hyperactivity,
(2) inattention, and (3) impulsitivity. See Table 13-2 for a full list of the DSM-IV diagnostic criteria.
Hyperactivity (overactivity), because of its disruptive nature, is the aspect that is more obvious to adults.
Overactivity implies excessive , especially in situations requiring relative calm. It may, depending upon the
situation, involve running and jumping around; or getting up from a seat when supposed to remain seated or
excessive talkativeness and noisiness, or fidgeting and wriggling while still.
Children’s hyperactivity is found across situations, even during sleep, but it much more notable in structured
setting than in unstructured ones (Barkley, 1988: 1990). For example, Adults notice hyperactive behaviour much
more readily in the classroom than in the playground. In fact, this is one reason why hyperactivity is typically
diagnosed for the first time during the early school years. Situational influences complicate the diagnosis of
attention-deficit/hyperactivity disorder because children who are extremely active in the may be relatively
controlled in a strange environment like the doctor or psychologist's office. Consequently reports from teachers
are critical in identifying the disorder.
Inattention (prematurely breaking off from tasks and leaving activities unfinished) is the second basic symptom
of attention-deficit/hyperactivity disorder. A particular attentional problem is “staying on the task” or what has
been termed sustained attention (Douglas 7 Peters, 1979). Sustained attention is usually tested in the laboratory
using the continuous performance test that requires children to monitor and respond to numbers and letters
presented on a computer screen. The performance of hyperactive children quickly deteriorates on this task - an
indication of their difficulties in sustaining attention (Douglas, 1986). Some children have problems that are

83
primarily hyperactive while others have problems with inattention as is evident from Table 15-2. Thus,
hyperactivity is not merely a consequence of inattention.
Impulsitivity is the flouting of social rules (as shown by intruding on or interrupting other’s activities or
prematurely blurting out answers to questions before they have been completed, or difficulty in waiting turns).
Teachers and parents frequently describe impulsive children as “acting before they think”. Such children often
find themselves in disciplinary problems because of unthinking breaches of rules rather than deliberate defiance.
Their relationship with adults are often socially disinhibited, with lack of normal caution and reserve; with other
children they are unpopular and may become isolated.
Conduct Disorder is defined primarily by forms of behaviour like stealing or assault that are illegal as well as
antisocial. There is repetitive and persistent pattern of dissocial, aggressive and defiant conduct. In the extreme
these may amount to major violations of age-appropriate social expectations. These are the sought of behaviour
that may be equate with juvenile delinquency. Juvenile delinquency is a legal classification, however, not a
mental health term. Technically youths are not classified as delinquent until they are found to be so be a judge.
Still, we can view conduct disorder as roughly comparable to law-Breaking among the young. Also some of the
DSM-IY diagnostic criteria for conduct disorder (see Table 13-3) are comparable to status offence – acts that are
illegal only because of the youth's status as a minor. Examples include running away from home and truancy from
school.

Table 13-3: DSM-IV Diagnostic Criteria for Conduct Disorder

A. A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-
appropriate societal norms or rules are violated, as manifested by three (or more) of following criteria in the past
12 months, with at least one criterion present in the past 6 months.
Aggression to people or animal
1 . Often bullies, threatens, or intimidates others.
2. Often initiates physical fights,
5. Has used a weapon that can cause serious physical harm to other
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim.
7. Has forced someone into sexual activity.
Destruction of property
8. Was deliberately engaged in fire setting with the intention of causing serious damage.
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9. Has deliberately destroyed others’ property.
Deceitfulness or theft
10. Has broken into someone else’s house, building or car.
11. Often lies to obtain goods or favours or to avoid punishment.
12, Has stolen items of none trivial value without confronting a victim.
Serious Violation of rules
13. Often stays out at night despite parental prohibition, beginning before age 13 years.
14. Has run away from home overnight at least twice while leaving in parental or surrogate’s home.
15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational
functioning.
Subtypes based on age of onset
Childhood-onset type Onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years.
Adolescence -onset type Absence of any criteria characteristic of Conduct Disorder prior to age 10 years.
Oppositional Defiant Disorder involves minor transgressions such as refusing to obey adult requests, arguing,
and acting angry. See Table 13-4 for the other symptoms and associated features. A basic controversy has been
whether oppositional defiant disorder is distinct from conduct disorder. In fact. ICD-10 lists it as a type of
conduct disorders that is characteristic of children below nine or ten years. It is therefore necessary for us to note
three important differences between the two. First, the diagnoses are distinguished primarily by the seriousness of
the rule violation listed in the diagnostic criteria (Tables 13-3 & 13-4). Second, the two are developmentally
related. Oppositional defiant disorder occurs primarily among school-aged children. It may develop into conduct
disorder, a more serious problem fond more commonly among preadolescent and teenagers (Loeber, Lahey &
Thomas, 1991).
Table 13-4: DSM-IV Diagnostic Criteria for Oppositional Defiant Disorder
A. A pattern of negativistic, hostile and defiant behaviour lasting at least 6 months, during which four (or
more) of the following are present.
1. Often loses temper.
2. Often argues with adults.
3. Often actively defies or refuses to comply with adults' requests on rules.
4. Often deliberately annoys people.
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5. Often blames other for his or her mistakes or misbehaviour.
6. Is often touchy or easily annoyed by others.
7. Is often angry or and resentful.
8. Is often spiteful and vindictive.
B. The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational
functioning.
Another controversy has been whether oppositional defiant disorder and attention-deficit/hyperactivity
disorder can be differentially reliable. That is, are the two conditions different psychological problems? The
current consensus is that the two are best conceived of as separate but overlapping problems (Barkley. 1990;
Hinshaw, 1987). They are highly co-morbid conditions – children with one condition also have the other problem.
A closer examination of the symptoms of oppositional defiant disorder may suggest a how it differs from the
other two. The disorder is defined by the presence of markedly defiant, disobedient provocative behaviour and
the absence of more severe antisocial and aggressive acts that violate the law and rights of others.
Communication Disorders – As stated above only stuttering is discussed in this category.
Stuttering (stammering) refers to speech that is characterised by frequent repetition or prolongation of
sounds or syllables or words; or, alternately by frequent hesitations or pauses that disrupt the rhythmic flow of
speech. Stuttering is quite common as transient phase in early childhood, or as a minor but persistent speech
feature in later childhood and adult life. It is classified a disorder only if its severity is such as to markedly impair
the fluency of speech.
Feeding and Eating, Disorders Of Infancy or Early Childhood
Pica is the persistent eating of non-nutritive substances such as paint or dirt. Many infant and toddlers put
non-nutritive substances in their mouths, but feeding disorder pica is rarely diagnosed except among mentally
retarded children.
Rumination disorder involves the repeated regurgitation and chewing of food. This is an infrequent or
rare feeding disorder found primarily among infants. It can be a very serious problem that causes\en low body
weight gain and can even lead to death.
Feeding disorder of infancy or early childhood Minor difficulties in eating is common in infancy and
early childhood (in the form of faddiness, supposed under eating or supposed over eating). A feeling disorder
generally involves food refusal and extreme faddiness in the presence of an adequate food supply, a reasonably
competent caregiver, and the absence of organic disease.
TIC DISORDER A tic is an involuntary, rapid, recurrent, non-rhythmic motor movement (usually involving
circumscribed muscle groups) or vocal productions that is of sudden onset and which serves no apparent purpose.
Tics tend to be experienced as irresistible but usually can be suppressed for varying periods of time,

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Tourette's disorder is a rate (4 to 5 ceases per 10,000 children) that is characterized by motor and vocal tics. The
tics can voluntarily suppressed only from brief periods of time, and they can interfere substantially with life
functioning. Each motor and verbal tic may be classified as either simple or complex; however, the boundaries are
not well defined. Common simple motor tics include eye blinking, neck jerking, shoulder shrugging and facial
grimacing. Common simple vocal tics include throat clearing, barking, sniffing and hissing. Common complex
motor tics include hitting oneself, jumping and hopping. Common complex verbal tic include repetitions of
particular words, and sometimes the use of socially unacceptable (often obscene) words (coprolalia), and the
repetition of one's own sounds and words (palilalia).
Chronic motor or vocal tic disorder This classification reflects the fact that a child may develop motor
or vocal tics in isolation. The vocal tics are often multiple with explosive vocalizations, throat clearing and
grunting. Sometimes there is an associated gesture. Motor tics are also multiple. Almost always the onset of tics is
in childhood or adolescence, the symptoms frequently worsen during adolescence and it is common for the
disorders to persist well into adult life.
Transient tic disorder Tics are often transient – that is, they last or only a brief period of time - not
longer than 12 months. This is the commonest form of tic, it is the most frequent at about the age of four or five
years, and usually take the form of blinking, facial grimacing or head jerking. In some cases the tics occur as a
single episode but in other cases there are remissions and relapses over a period of months.
Elimination Disorders are problems with voiding of body wastes or inappropriately controlled detection
and urination. Both are relatively common, especially enuresis (bedwetting), which is found approximately in
5% of 5-year-olds. 2-3% of 10-year-olds and 1% of 18-year-olds.
Enuresis (Bedwetting) is a disorder characterized by involuntary voiding of urine, by day and/or by night, that is
abnormal in relation to the child’s mental age; and which is not a consequence of a lack of bladder control due to
any neurological disorder or to epileptic attacks or to any structural abnormality of the urinary tract. The enuresis
may have been present from birth (i.e., an abnormal extension of the normal infantile incontinence) or may arise
following a period of acquired bladder control. The later onset (or secondary) variety usually begins at about the
age of 5 to 7 years. A lot of distress and stigma are associated with enuresis. These may lead to other secondary
psychological problems such as shyness and social anxiety. Enuresis is usually not diagnosed in children under
the age of 5 years or those with a mental age of 4 years.
Encopresis (soiling) is repeated, voluntary or involuntary passage of faeces, usually of normal or near-normal
consistency; into places not appropriate for the purpose in the child’s own socio-cultural setting. The problem
may represent an abnormal continuation of normal infantile incontinence, it may involve loss of continence
following the acquisition of bowel control.
OTHER DISORDERS OF INFANCY, CHIDHOOD AND ADOLESCENCE
This rubric comprises a heterogeneous group of disorders that share the characteristic of an onset in
childhood but otherwise differ in many respects. Some of the conditions represent well-defined syndromes
but others are no more than symptom complexes for which psychiatrists are yet to agree on appropriate
classification.
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Separation anxiety is a normal fear that typically develops in the month before a baby’s first birthday. At this
age it is not a psychological problem – in fact it is healthy response that indicates that an infant has a secure
attachment to his/her caretakers (Ainsworth et al., 1973). That is, it is normal for babies to show a degree of
anxiety over real or threatened separation from people to whom they are attached. However, excessive separation
anxiety can become a serious problem. DSM-IV list separation anxiety as a psychological problem
characterised by symptoms such as persistent and excessive worry for the safety of an attachment figure (usually
parents and other family members), fears of getting lost or being kidnapped, nightmares with separation themes,
and refusal to be alone. In other to meet the criteria for the disorder at least three of such symptoms must persist
for at least four weeks.
It is normal experience even very strong separation fears, thus DSM-1Y indicates that the anxiety must also
interfere with the child's functioning. Many situations that involve separation also involve other potential stressors
or sources of anxiety. Separation anxiety clearly is the problem in such cases. Particularly when it interferes with
school attendance. School refusal, also known as school phobia, is characterized by an extreme reluctance to go
to school, and is accompanied by various symptoms of anxiety, such as stomachaches and headaches. Some
children re literally phobic about aspects of attending school, but in many cases, school refusal can be traced to
separation anxiety disorder (Last & Strauss, 1990). Whatever its origin school refusal is a serious problem that has
been reported to account for more than two-thirds of referrals to psychological clinics.
Selective (Elective) mutism is characterized by a marked, emotionally determined, selectivity in speaking. The
child demonstrates his/her language competence in some situations but fails to speak in other (definable)
situations. Most frequently the disorder is first manifest in early childhood; it occurs with approximately the same
frequency in the two sexes; and it is usual for the mutism to be associated with marked personality features
involving social anxiety. Withdrawal, sensitivity, or resistance. Typically the child speaks at home or with close
friends, but is mute at school or with strangers, however other patterns including the converse may occur.
Reactive attachment disorder of childhood This disorder occurring in infants and young children is chracterised
by persistent abnormalities in the child’s pattern of social relationships that are associate with emotional
disturbances and that are reactive to changes in environmental circumstances. Fearfulness and hypervigilance that
does not respond to comforting are characteristic. Poor social interaction with peers is typical. Aggression to the
self and other is frequent. Misery is usual and growth failure occurs in some cases. The syndrome probably occurs
as a direct result of severe parental neglect, abuse or serious mishandling. The children show strongly
contradictory or ambivalent social responses that may be more evident at times of partings and reunions.
Epidemiology of Childhood Disorders
The available worldwide data on childhood disorders conclude that about 12% of children suffer from
psychological problems of one form or the other (US National Academy of Science, 1989; Idehen & Awaritefe.
1993). Clearly children’s mental is a major social problem in many countries. Several factors consistently
correlate with increase risk for psychological problems among children. Gender is one such risk factor. Clinical
studies show that more boys are treated for psychological problem than girls. Epidemiological studies find that
boys have far externalizing disorder than girls, and externalising problems are more likely to bring children into
contact with mental health professionals (Rutter, 1989). From 3 – 5% of children arc estimated to have attention-
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deficit/hyperactivity disorder, and anywhere from 5 to 15% of youths may have oppositional defiant disorder
and/or conduct disorder.
These problems arc from 2 to 10 times more common among boys than among girls. Gender differences in
externalizing disorders are related to biology and to socialization. Evidence from animal studies indicates that
exposure to the male sex hormones testosterone increases aggression. At the same time it is clear that boys and
girls are socialized into very different gender roles (Huston, 1983; Maccoby & Jacklin, 1974). Societies
encourage and accept more aggressive behaviour among boys than among girls. Except for normative increase,
the prevalence of externalizing behaviour declines with age. In contrast, the prevalence of internalizing problems
incrases with age.
Apart from gender and age. the prevalence of psychological disorders among children is also related to several
family variables. According to Rutter (1978; 1989) family adversity is an important risk factor. His family
adversity index includes six family predictors of behaviour problems in children: (1) low income; (2) crowding
in the home: (3) maternal depression; (4) paternal antisocial behaviour; (5) conflicts between parents; and (6)
removal of child from the home. Other epidiologic finding underscore the relationship between children’s
psychological problems and social disadvantage. For example, psychological disorders occur among 20% of
children living in urban inner-city neighbourhoods (US National Academy of Science, 1989; and are associated
with divorce and single parenting (Idehen & Awaritefe, 1993).
Aetiology of Childhood Disorders
The vast amount of data on the aetiology of psychological problems of children is on externalising disorders.
Thus our discussion will focus mainly on externalising problems.
Psychological factors in childhood disorders
Although there are multiplicities of theories that have tried to explain the origins of child psychological problems,
we shall discuss only three. The attachment theory of Bowlby & Ainsworth (1969: 1973; 1980) present a set
of proposals about the importance to psychologicsal development of close relationships, beginning with the
relationship between infants and their caregivers. They proposed that psychopathology is caused by troubled
attachment, especially when (1) no selective attachment is formed; (2) an insecure attachment is formed: or (3)
there are multiple and prolonged separations from (or the permanent loss of) an attachment figure. Extreme
parental neglect deprives infants of the opportunity to form selective attachment. Such neglect can cause reactive
attachment disorder or what attachment researchers call “anaclitic depression” – the lack of social responsiveness
found among infants who do not have a consistent attachment figure (Sroufe & Fleeson, 1986).
Parenting style theorists (Baumrind, 1971; Maccoby & Martin, 1983) assert that parenting styles can lead to
disruptions in attachment, and therefore cause psychological problems in children.
Parenting can be classified into four styles by combining the tow dimension of warmth and control (see Figure
13-1) Authoritative parents are the most effective because they provide the parental warmth and emotional
responsivieness that facilitates children’s socialization.

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Figure 13.1: A classification of Parenting Styles

Accepting, responsive Child- Rejecting, unresponsive

centred Parent-centred

Demanding, controlling Authoritative Ambivalent

Undemanding, low in Indulgent Neglectful

control attempts

Authoritative parents are both loving and firm in disciplining their children. In contrast to authoritative parents,
authoritarian parents lack warmth, and while the discipline is strict, it is often harsh and undemocratic.
Children of authoritarian parents are generally compliant, but they also may be anxious. Indulgent parents are
the opposite of authoritarian parents; they are affectionate but lax in their discipline. The children of indulgent
parents are impulsive and non-complaint, but they are not extremely antisocial. Finally, neglectful parents are
unconcerned either with their children’s emotional needs or with their needs for discipline. Children with serious
conduct problems often have neglectful parents.
Social learning theorists (for example, Patterson 1982) introduced the concept of coercion to explain
situations when unwitting parents positive reinforce children’s misbehaviour by giving in to their demands. The
children, in turn, negatively reinforce their parents by ending their obnoxious behaviour as soon as their parents
capitulate. Coercion describes a system of interaction in which parents and children reciprocally influence each
other's behaviour. Because both parties are reinforced, the coercive interaction is predicted to continue over time.
Biological Factors in Childhood Disorder
Biological factors that have been hypothesized to contribute to the development of psychological problems in
children include genetics, neurological abnormalities, and dietary factors. Researchers have found a 53%
concordance rate for attention-deficit/hyperactivity disorder among MZ twins, compared with a 335 concordance
rate for DZ pairs (Goodman & Stevenson, 1989). This suggests that genes contribute to this disorder, but non-
genetic factors are involved as well. Hyper activity or inattention may be directly heritable but oppositional
behaviour is not. One factor that has been hypothesized to cause oppositional defiant disorder and conduct
disorder might be genetically mediated: chronic under arousal of the autonomic nervous system. That is, children
with externalizing problems may be less emotionally reactive than other children, as a result they may be more
likely to engage in stimulation seeking and less likely to learn from punishment (Quay, 1965).
Some soft signs, such as delays in fine motor coordination, neurological disease/brain damage have been
found with greater frequency among children with attention-deficit/hyperactivity disorder, however, no clear
marker of biological vulnerability has been identified. Research has so far followed two directions: (1) the search
for selective dopamine deficits, and (2) the possibility that impairments are localised in the prefrontal region of
the right celebral hemisphere, an area of the brain that may underlie attentional abilities and behavioural inhibition
(Barkley, 1990). Researchers have failed to identify a specific biological aetiology perhaps because of problems

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of classification. The comorbidity of attention-deficit/hyperactivity disorder and oppositional defiant disorder
make it difficult to interpret past research, both problems are heterogeneous disorders that may require further
sub-classification.

Social Factors in Childhood Disorders

A lot of social factors have been associated with psychological problems in children. These include
growing up in poor urban inner-city neighbourhoods, poverty, inadequate schooling and violence. Cross-cultural
evidence points to societal influences of violence that is continually modeled on television, films and even the
print media.
EATING DISORDERS
Eating disorders were once considered to psychological problems of childhood, but DSM-IV lists them in their
separate diagnostic category. They are discussed here because they typically develop during adolescence. Eating
disorders are characterized by severe disturbances in eating behaviour. They include anorexia nervosa – a disorder
defined by dramatically restricted eating and extreme emaciation – and bulimia nervosa a disorder distinguished
by frequent binge eating followed by intentional purging. Anorexia is derived from the Greek word for “loss of
Appetite” and bulimia from the Greek word for “ox appetite” These problems often begin with normal diet that
goes awry. For example, a teenage girl of normal weight may attempt to lose a few pounds perhaps with the
encouragement of friends and family members, but the successful diet does not end when she reaches this goal.
The young woman remains on her diet, continually trying to lose a few more pounds. Family members and
friends become distressed by her increasingly emaciated appearance, but the teenager may insist that her
appearance is fine or even a bit too “fat”. The young woman with anorexia nervosa is not likely to be worried
about her thinness. In fact, shy may not recognise it.
Typical Symptoms and Associated Feature of Fating Disorders
Binging and purging are typical of bulimia nervosa. Binges are characterized by the rapid eating of a large
quantity of food. The food is often high in calories and is easily purged. Vomiting is the most common way of
purging the body of food to prevent weight gain after binging. Other compensatory behaviours include the misuse
of laxatives, diuretics, or enemas; long periods of fasting and intense exercise. People with bulima nervosa plan to
purge after binging. Nevertheless, they out of control in their behaviour. their actions are secretive and a source of
shame.
In contrast, people with anorexia nervosa take great pride in their self-control. Their eating is extremely restricted,
and although the disorder may be punctuated by occasional binging and purging, they feel like masters of control.
Thus, both eating disorders are characterized by a struggle for control. Bulimia nervosa is a failure of control and
a constant struggle to regain it. Anorexia nervosa is a dubious success in the striving for control. Anorexics
literarily starve themselves to the point where they are extremely emaciated, yet they steadfastly deny problems

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with their weigh. Rather than being ashamed, they feel proud. People with eating disorders are obsessed with
food and their body image, and they follow detailed rituals about eating and diet. In fact, some evidence links
anorexia nervosa to compulsive-obsessive disorder (Kasikis et al., 1986).
Classification of Eating Disorders
The term anorexia nervosa was coined in 1874 by a British physician, Sir William Gull (1816-1890).
Nevertheless, reference to eating disorders was rare in the literature until the 1960s and the disorders have
received scientific attention only in recent decades. The diagnosis first appeared in the DSM-II (1980), which
listed it as a subtype of the psychological disorders of childhood. DSM-IV created a separate category for eating
disorders, listing only two subtypes: anorexia nervosa and bulima nervosa.
Anorexia nervosa is defined by four symptoms: (1) a refusal to maintain weight at or above minimally normal
weight for age and height; (2) an intense fear of gaining weight; (3) a disturbance in the way weight or body shape
is experienced, undue influence of weight or body shape on self-evaluation, or denial of the consequences of low
body weight; and (4) amenorrhoea, the absence of menstruation, in post-menarcheal females. Buiimia nervosa is
denned by five symptoms; (1) recurrent episodes of binge eating that involve both large amount of food and a
feeling of lack of control over eating; (2) recurrent inappropriate compensator}' behaviour, especially purging; (3)
a frequency of at least two episodes per Jay with a duration of at least three months; (4) undue influence of weight
and body shape on self-evaluation; and five the disturbance does not occur solely during episodes of anorexia
nervosa.
Epidemiology of Eating Disorders
The prevalence of eating disorders has increased dramatically in recent years. The DSM-IV indicates that
anorexia nervosa is found among 0.5 to 1.0% and bulima nervosa occurs among 1 to 3% of female adolescents
and young adults. The disorders are 10 times more common among women than among women than among
men. Eating disorders are more prevalent in industrialised societies (Europeans, North Americans and
Japanese), higher socio-economic classes, and women working in professions in which slimness is valued.
Aetiology of Eating Disorders
The adolescent onset of eating disorders has provoked speculations that certain characteristics of
adolescence might cause the disorder. These include hormonal changes (Garfield & Garner, 1982), autonomy
struggles (Minuchin, Rosman, & Baker, 1978), and problems with sexuality (Coovert et al., 1989). Consistent
with the gender-roles interpretation of aetiology, other theorists have noted that the young adolescent girl is the
most idealized cultural image of beauty (Hsu, 1990). Contemporary images of women in Europe, America and
Japan (and to a lesser extent in some other parts of the world) place a premium on slimness and suggest that
women should be judge by their appearance. Adolescent girls are at risk for developing eating disorders in part
because teenagers attempt to shape themselves literally to fit their idealized image of woman. For them physical
attractiveness predicts self-esteem, whereas physical competence does the same for boys (Lerner, et al., 1986).
Troubled family relationships have been speculated to be a contributory factor to the development of eating
disorders. Families of girls with eating disorders have been found to be less emotional and nurturing and more
resistant to adolescent autonomy in comparison with other families (Humphrey, 1987). Other evidence indicates
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that families of anorexic girls may be enmeshed and overprotective whereas families of bulimic girls may be more
angry and rejecting (Yates, 1989).
The striving for control theory posits that girls with eating disorders are conforming and eager to please. Thus,
in attempting to please others they give up on the struggle for autonomy, as compensation the) seek control some
aspects of their lives. Such young women may also attempt to control their own emotions-excessively and
therefore have difficulty identifying their own feelings (Lcon et al., 1994).

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