Introduction

You must have come across people who are unhappy, troubled and dissatisfied. Their minds and hearts are filled with sorrow, unrest and tension and they feel that they are unable to move ahead in their lives; they feel life is a painful, uphill struggle, sometimes not worth living. Famous analytical psychologist Carl Jung has quite remarkably said, “How can I be substantial without casting a shadow? I must have a dark side, too, if I am to be whole and by becoming conscious of my shadow, I remember once more that I am a human being like any other”. At times, some of you may have felt nervous before an important examination, tense and concerned about your future career or anxious when someone close to you was unwell. All of us face major problems at some point of our lives. However, some people have an extreme reaction to the problems and stresses of life. In this chapter, we will try to understand what goes wrong when people develop psychological problems, what are the causes and factors which lead to abnormal behaviour, and what are the various signs and symptoms associated with different types of psychological disorders?

The study of psychological disorders has intrigued and mystified all cultures for more than 2,500 years. Psychological disorders or mental disorders (as they are commonly referred to), like anything unusual may make us uncomfortable and even a little frightened. Unhappiness, discomfort, anxiety, and unrealised potential are seen all over the world. These failures in living are mainly due to failures in adaptation to life challenges. As you must have studied in the previous chapters, adaptation refers to the person’s ability to modify her/his behaviour in response to changing environmental requirements. When the behaviour cannot be modified according to the needs of the situation, it is said to be maladaptive. Abnormal Psychology is the area within psychology that is focused on maladaptive behaviour - its causes, consequences, and treatment.

Concepts Of Abnormality And Psychological Disorders

Although many definitions of abnormality have been used over the years, none has won universal acceptance. Still, most definitions have certain common features, often called the ‘four Ds’: deviance, distress, dysfunction and danger. That is, psychological disorders are deviant (different, extreme, unusual, even bizarre), distressing (unpleasant and upsetting to the person and to others), dysfunctional (interfering with the person’s ability to carry out daily activities in a constructive way), and possibly dangerous (to the person or to others).

This definition is a useful starting point from which we can explore psychological abnormality. Since the word ‘abnormal’ literally means “away from the normal”, it implies deviation from some clearly defined norms or standards. In psychology, we have no ‘ideal model’ or even ’normal model’ of human behaviour to use as a base for comparison. Various approaches have been used in distinguishing between normal and abnormal behaviours. From these approaches, there emerge two basic and conflicting views:

The first approach views abnormal behaviour as a deviation from social norms. Many psychologists have stated that ‘abnormal’ is simply a label that is given to a behaviour which is deviant from social expectations. Abnormal behaviour, thoughts and emotions are those that differ markedly from a society’s ideas of proper functioning. Each society has norms, which are stated or unstated rules for proper conduct. Behaviours, thoughts and emotions that break societal norms are called abnormal. A society’s norms grow from its particular culture - its history, values, institutions, habits, skills, technology, and arts. Thus, a society whose culture values competition and assertiveness may accept aggressive behaviour, whereas one that emphasises cooperation and family values (such as in India) may consider aggressive behaviour as unacceptable or even abnormal. A society’s values may change over time, causing its views of what is psychologically abnormal to change as well. Serious questions have been raised about this definition. It is based on the assumption that socially accepted behaviour is not abnormal, and that normality is nothing more than conformity to social norms.

The second approach views abnormal behaviour as maladaptive. Many psychologists believe that the best criterion for determining the normality of behaviour is not whether society accepts it but whether it fosters the well-being of the individual and eventually of the group to which s/he belongs. Well-being is not simply maintenance and survival but also includes growth and fulfilment, i.e. the actualisation of potential, which you must have studied in Maslow’s need hierarchy theory. According to this criterion, conforming behaviour can be seen as abnormal if it is maladaptive, i.e. if it interferes with optimal functioning and growth. For example, a student in the class prefers to remain silent even when $\mathrm{s} /$ he has questions in her/his mind. Describing behaviour as maladaptive implies that a problem exists; it also suggests that vulnerability in the individual, inability to cope, or exceptional stress in the environment have led to problems in life.

If you talk to people around, you will see that they have vague ideas about psychological disorders that are characterised by superstition, ignorance and fear. Again it is commonly believed that psychological disorder is something to be ashamed of. The stigma attached to mental illness means that people are hesitant to consult a doctor or psychologist because they are ashamed of their problems. Actually, psychological disorder which indicates a failure in adaptation should be viewed as any other illness.

Activity 4.1
Talk to three people: one of your friends, a friend of your parents, and your neighbour.

Ask them if they have seen someone who is mentally ill or who has mental problems. Try to understand why they find this behaviour abnormal, what are the signs and symptoms shown by this person, what caused this behaviour and can this person be helped.

Share the information you elicited in class and see if there are some common features, which make us label others as ‘abnormal’.

Historical Background

To understand psychological disorders, we would require a brief historical account of how these disorders have been viewed over the ages. When we study the history of abnormal psychology, we find that certain theories have occurred over and over again.

One ancient theory that is still encountered today holds that abnormal behaviour can be explained by the operation of supernatural and magical forces such as evil spirits (bhoot-pret), or the devil (shaitan). Exorcism, i.e. removing the evil that resides in the individual through countermagic and prayer, is still commonly used. In many societies, the shaman, or medicine man (ojha) is a person who is believed to have contact with supernatural forces and is the medium through which spirits communicate with human beings. Through the shaman, an afflicted person can learn which spirits are responsible for her/his problems and what needs to be done to appease them.

A recurring theme in the history of abnormal psychology is the belief that individuals behave strangely because their bodies and their brains are not working properly. This is the biological or organic approach. In the modern era, there is evidence that body and brain processes have been linked to many types of maladaptive behaviour. For certain types of disorders, correcting these defective biological processes results in improved functioning.

Another approach is the psychological approach. According to this point of view, psychological problems are caused by inadequacies in the way an individual thinks, feels, or perceives the world.

All three of these perspectives supernatural, biological or organic, and psychological - have recurred throughout the history of Western civilisation. In the ancient Western world, it was philosopherphysicians of ancient Greece such as Hippocrates, Socrates, and in particular Plato who developed the organismic approach and viewed disturbed behaviour as arising out of conflicts between emotion and reason. Galen elaborated on the role of the four humours in personal character and temperament. According to him, the material world was made up of four elements, viz. earth, air, fire, and water which combined to form four essential body fluids, viz. blood, black bile, yellow bile, and phlegm. Each of these fluids was seen to be responsible for a different temperament. Imbalances among the humours were believed to cause various disorders. This is similar to the Indian notion of the three doshas of vata, pitta and kapha which were mentioned in the Atharva Veda and Ayurvedic texts. You have already read about it in Chapter 2.

In the Middle Ages, demonology and superstition gained renewed importance in the explanation of abnormal behaviour. Demonology related to a belief that people with mental problems were evil and there are numerous instances of ‘witch-hunts’ during this period. During the early Middle Ages, the Christian spirit of charity prevailed and St. Augustine wrote extensively about feelings, mental anguish and conflict. This laid the groundwork for modern psychodynamic theories of abnormal behaviour.

The Renaissance Period was marked by increased humanism and curiosity about behaviour. Johann Weyer emphasised psychological conflict and disturbed interpersonal relationships as causes of psychological disorders. He also insisted that ‘witches’ were mentally disturbed and required medical, not theological, treatment.

The seventeenth and eighteenth centuries were known as the Age of Reason and Enlightenment, as the scientific method replaced faith and dogma as ways of understanding abnormal behaviour. The growth of a scientific attitude towards psychological disorders in the eighteenth century contributed to the Reform Movement and to increased compassion for people who suffered from these disorders. Reforms of asylums were initiated in both Europe and America. One aspect of the reform movement was the new inclination for deinstitutionalisation which placed emphasis on providing community care for recovered mentally ill individuals.

In recent years, there has been a convergence of these approaches, which has resulted in an interactional, or biopsycho-social approach. From this perspective, all three factors, i.e. biological, psychological and social play important roles in influencing the expression and outcome of psychological disorders.

Classification Of Psychological Disorders

In order to understand psychological disorders, we need to begin by classifying them. A classification of such disorders consists of a list of categories of specific psychological disorders grouped into various classes on the basis of some shared characteristics. Classifications are useful because they enable users like psychologists, psychiatrists and social workers to communicate with each other about the disorder and help in understanding the causes of psychological disorders and the processes involved in their development and maintenance.

The American Psychiatric Association (APA) has published an official manual describing and classifying various kinds of psychological disorders. The current version of it, the Diagnostic and Statistical Manual of Mental Disorders, $5^{\text {th }}$ Edition (DSM-5), presents discrete clinical criteria which indicate the presence or absence of disorders.

The classification scheme officially used in India and elsewhere is the tenth revision of the International Classification of Diseases (ICD-10), which is known as the ICD-10 Classification of Behavioural and Mental Disorders. It was prepared by the World Health Organisation (WHO). For each disorder, a description of the main clinical features or symptoms, and of other associated features including diagnostic guidelines is provided in this scheme.

Activity 4.2
Certain behaviours like eating sand would be considered abnormal. But not if it was done after being stranded on a beach in a plane crash.

Listed below are ‘abnormal’ behaviours followed by situations where the behaviours might be considered normal.

(i) talking to yourself - you are praying.

(ii) standing in the middle of the street waving your arms wildly - you are a traffic policeman.

Think about it and list similar examples.

Factors Underlying Abnormal Behaviour

In order to understand something as complex as abnormal behaviour, psychologists use different approaches. Each approach in use today emphasises a different aspect of human behaviour, and explains and treats abnormality in line with that aspect. These approaches also emphasise the role of different factors such as biological, psychological and interpersonal, and socio-cultural factors. We will examine some of the approaches which are currently being used to explain abnormal behaviour.

Biological factors influence all aspects of our behaviour. A wide range of biological factors such as faulty genes, endocrine imbalances, malnutrition, injuries and other conditions may interfere with normal development and functioning of the human body. These factors may be potential causes of abnormal behaviour. We have already come across the biological model. According to this model, abnormal behaviour has a biochemical or physiological basis. Biological researchers have found that psychological disorders are often related to problems in the transmission of messages from one neuron to another. You have studied in Class XI, that a tiny space called synapse separates one neuron from the next, and the message must move across that space. When an electrical impulse reaches a neuron’s ending, the nerve ending is stimulated to release a chemical, called a neuro-transmitter. Studies indicate that abnormal activity by certain neuro-transmitters can lead to specific psychological disorders. Anxiety disorders have been linked to low activity of the neurotransmitter gamma aminobutyric acid (GABA), schizophrenia to excess activity of dopamine, and depression to low activity of serotonin.

Genetic factors have been linked to bipolar and related disorders, schizophrenia, intellectual disability and other psychological disorders. Researchers have not, however, been able to identify the specific genes that are the culprits. It appears that in most cases, no single gene is responsible for a particular behaviour or a psychological disorder. Infact, many genes combine to help bring about our various behaviours and emotional reactions, both functional and dysfunctional. Although there is sound evidence to believe that genetic/ biochemical factors are involved in mental disorders as diverse as schizophrenia, depression, anxiety, etc. but biology alone cannot account for most mental disorders.

There are several psychological models which provide a psychological explanation of mental disorders. These models maintain that psychological and interpersonal factors have a significant role to play in abnormal behaviour. These factors include maternal deprivation (separation from the mother, or lack of warmth and stimulation during early years of life), faulty parent-child relationships (rejection, overprotection, over-permissiveness, faulty discipline, etc.), maladaptive family structures (inadequate or disturbed family), and severe stress.

The psychological models include the psychodynamic, behavioural, cognitive, and humanistic-existential models. The psychodynamic model is the oldest and most famous of the modern psychological models. You have already read about this model in Chapter 2 on Self and Personality. Psychodynamic theorists believe that behaviour, whether normal or abnormal, is determined by psychological forces within the person of which $\mathrm{s} /$ he is not consciously aware. These internal forces are considered dynamic, i.e. they interact with one another and their interaction gives shape to behaviour, thoughts and emotions. Abnormal symptoms are viewed as the result of conflicts between these forces. This model was first formulated by Freud who believed that three central forces shape personality - instinctual needs, drives and impulses (id), rational thinking (ego), and moral standards (superego). Freud stated that abnormal behaviour is a symbolic expression of unconscious mental conflicts that can be generally traced to early childhood or infancy.

Another model that emphasises the role of psychological factors is the behavioural model. This model states that both normal and abnormal behaviours are learned and psychological disorders are the result of learning maladaptive ways of behaving. The model concentrates on behaviours that are learned through conditioning and proposes that what has been learned can be unlearned. Learning can take place by classical conditioning (temporal association in which two events repeatedly occur close together in time), operant conditioning (behaviour is followed by a reward), and social learning (learning by imitating others’ behaviour). These three types of conditioning account for behaviour, whether adaptive or maladaptive.

Psychological factors are also emphasised by the cognitive model. This model states that abnormal functioning can result from cognitive problems. People may hold assumptions and attitudes about themselves that are irrational and inaccurate. People may also repeatedly think in illogical ways and make overgeneralisations, that is, they may draw broad, negative conclusions on the basis of a single insignificant event.

Another psychological model is the humanistic-existential model which focuses on broader aspects of human existence. Humanists believe that human beings are born with a natural tendency to be friendly, cooperative and constructive, and are driven to self-actualise, i.e. to fulfil this potential for goodness and growth. Existentialists believe that from birth we have total freedom to give meaning to our existence or to avoid that responsibility. Those who shirk from this responsibility would live empty, inauthentic, and dysfunctional lives.

In addition to the biological and psychosocial factors, socio-cultural factors such as war and violence, group prejudice and discrimination, economic and employment problems, and rapid social change, put stress on most of us and can also lead to psychological problems in some individuals. According to the socio-cultural model, abnormal behaviour is best understood in light of the social and cultural forces that influence an individual. As behaviour is shaped by societal forces, factors such as family structure and communication, social networks, societal conditions, and societal labels and roles become more important. It has been found that certain family systems are likely to produce abnormal functioning in individual members. Some families have an enmeshed structure in which the members are overinvolved in each other’s activities, thoughts, and feelings. Children from this kind of family may have difficulty in becoming independent in life. The broader social networks in which people operate include their social and professional relationships. Studies have shown that people who are isolated and lack social support, i.e. strong and fulfilling interpersonal relationships in their lives are likely to become more depressed and remain depressed longer than those who have good friendships. Socio-cultural theorists also believe that abnormal functioning is influenced by the societal labels and roles assigned to troubled people. When people break the norms of their society, they are called deviant and ‘mentally ill’. Such labels tend to stick so that the person may be viewed as ‘crazy’ and encouraged to act sick. The person gradually learns to accept and play the sick role, and functions in a disturbed manner.

In addition to these models, one of the most widely accepted explanations of abnormal behaviour has been provided by the diathesis-stress model. This model states that psychological disorders develop when a diathesis (biological predisposition to the disorder) is set off by a stressful situation. This model has three components. The first is the diathesis or the presence of some biological aberration which may be inherited. The second component is that the diathesis may carry a vulnerability to develop a psychological disorder. This means that the person is ‘at risk’ or ‘predisposed’ to develop the disorder. The third component is the presence of pathogenic stressors, i.e. factors/ stressors that may lead to psychopathology. If such “at risk” persons are exposed to these stressors, their predisposition may actually evolve into a disorder. This model has been applied to several disorders including anxiety, depression, and schizophrenia.

Major Psychological Disorders

Anxiety Disorders

One day while driving home, Deb felt his heart beating rapidly, he started sweating profusely, and even felt short of breath. He was so scared that he stopped the car and stepped out. In the next few months, these attacks increased and now he was hesitant to drive for fear of being caught in traffic during an attack. Deb started feeling that he had gone crazy and would die. Soon he remained indoors and refused to move out of the house.

We experience anxiety when we are waiting to take an examination, or to visit a dentist, or even to give a solo performance. This is normal and expected and even motivates us to do our task well. On the other hand, high levels of anxiety that are distressing and interfere with effective functioning indicate the presence of an anxiety disorder - the most common category of psychological disorders.

Everyone has worries and fears. The term anxiety is usually defined as a diffuse, vague, very unpleasant feeling of fear and apprehension. The anxious individual also shows combinations of the following symptoms: rapid heart rate, shortness of breath, diarrhoea, loss of appetite, fainting, dizziness, sweating, sleeplessness, frequent urination and tremors. There are many types of anxiety disorders (see Table 4.1). They include generalised anxiety disorder, which consists of prolonged, vague, unexplained and intense fears that are not attached to any particular object. The symptoms include worry and apprehensive feelings about the future; hypervigilance, which involves constantly scanning the environment for dangers. It is marked by motor tension, as a result of which the person is unable to relax, is restless, and visibly shaky and tense.

Another type of anxiety disorder is panic disorder, which consists of recurrent anxiety attacks in which the person experiences intense terror. A panic attack denotes an abrupt surge of intense anxiety rising to a peak when thoughts of a particular stimuli are present. Such thoughts occur in an unpredictable manner. The clinical features include shortness of breath, dizziness, trembling, palpitations, choking, nausea, chest pain or discomfort, fear of going crazy, losing control or dying.

You might have met or heard of someone who was afraid to travel in a lift or climb to the tenth floor of a building, or refused to enter a room if $s /$ he saw a lizard. You may have also felt it yourself or seen a friend unable to speak a word of a well-memorised and rehearsed speech before an audience. These kinds of fears are termed as phobias. People who have phobias have irrational fears related to specific objects, people, or situations. Phobias often develop gradually or begin with a generalised anxiety disorder. Phobias can be grouped into three main types, i.e. specific phobias, social phobias, and agoraphobia.

Specific phobias are the most commonly occurring type of phobia. This group includes irrational fears such as intense fear of a certain type of animal, or of being in an enclosed space. Intense and incapacitating fear and embarrassment when dealing with others characterises social anxiety disorder (social phobia). Agoraphobia is the term used when people develop a fear of entering unfamiliar situations. Many people with agoraphobia are afraid of leaving their home. So their ability to carry out normal life activities is severely limited.

Separation anxiety disorder (SAD) is another type of anxiety disorder. Individuals with separation anxiety disorder are fearful and anxious about separation from attachment figures to an extent that is developmentally not appropriate. Children with SAD may have difficulty being in a room by themselves,

Activity 4.3
Recall how you felt before your Class X Board examination. How did you feel when the examinations were drawing near (one month before the examinations; one week before the examinations; on the day of the examination, and when you were entering the examination hall)? Also try to recollect what you felt when you were awaiting your results. Write down your experiences in terms of bodily symptoms (e.g. ‘butterflies in the stomach’, clammy hands, excessive perspiration, etc.) as well as mental experiences (e.g. tension, worry, pressure, etc.). Compare your symptoms with those of your classmates and classify them as Mild, Moderate, or Severe.

going to school alone, are fearful of entering new situations, and cling to and shadow their parents’ every move. To avoid separation, children with SAD may fuss, scream, throw severe tantrums, or make suicidal gestures.

Obsessive-Compulsive and Related Disorders

Have you ever noticed someone washing their hands everytime they touch something, or washing even things like coins, or stepping only within the patterns on the floor or road while walking? People affected by obsessivecompulsive disorder are unable to control their preoccupation with specific ideas or are unable to prevent themselves from repeatedly carrying out a particular act or series of acts that affect their ability to carry out normal activities. Obsessive behaviour is the inability to stop thinking about a particular idea or topic. The person involved, often finds these thoughts to be unpleasant and shameful. Compulsive behaviour is the need to perform certain behaviours over and over again. Many compulsions deal with counting, ordering, checking, touching and washing. Other disorders in this category include hoarding

Table 4.1 : Major Anxiety Disorders and their Symptoms

1. Generalised Anxiety Disorder : prolonged, vague, unexplained and intense fears that have no object, accompanied by hypervigilance and motor tension.

2. Panic Disorder : frequent anxiety attacks characterised by feelings of intense terror and dread; unpredictable ‘panic attacks’ along with physiological symptoms like breathlessness, palpitations, trembling, dizziness, and a sense of loosing control or even dying.

3. Specific Phobia : irrational fears related to specific objects, interactions with others, and unfamiliar situations.

4. Separation Anxiety Disorder : extreme distress when expecting or going through separation from home or other significant people to whom the individual is immensely attached to.

5. Other disorders included under this category are Selective Mutism, Substance/MedicationInduced Anxiety Disorder, Anxiety Disorder Due to Another Medical condition, etc. disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder etc.

Trauma- and Stressor-Related Disorders

Very often people who have been caught in a natural disaster (such as tsunami) or have been victims of bomb blasts by terrorists, or been in a serious accident or in a war-related situation, experience post-traumatic stress disorder (PTSD). PTSD symptoms vary widely but may include recurrent dreams, flashbacks, impaired concentration, and emotional numbing. Adjustment Disorders and Acute Stress Disorder are also included under this category.

Somatic Symptom and Related Disorders

These are conditions in which there are physical symptoms in the absence of a physical disease. In these disorders, the individual has psychological difficulties and complains of physical symptoms, for which there is no biological cause. These include conversion disorders, somatic symptom disorder, and illness anxiety disorder among others.

Somatic symptom disorder involves a person having persistent body-related symptoms which may or may not be related to any serious medical condition. People with this disorder tend to be overly preoccupied with their symptoms and they continually worry about their health and make frequent visits to doctors. As a result, they experience significant distress and disturbances in their daily life.

Illness anxiety disorder involves persistent preoccupation about developing a serious illness and constantly worrying about this possibility. This is accompanied by anxiety about one’s health. Individuals with illness anxiety disorder are overly concerned about undiagnosed disease, negative diagnostic results, do not respond to assurance by doctors, and are easily alarmed about illness such as on hearing about someone else’s ill-health or some such news.

In general, both somatic symptom disorder and illness anxiety disorder are concerned with medical illnesses. But, the difference lies in the way this concern is expressed. In the case of somatic symptom disorder, this expression is in terms of physical complaints while in case of illness anxiety disorder, as the name suggests, it is the anxiety which is the main concern.

The symptoms of conversion disorders are the reported loss of part or all of some basic body functions. Paralysis, blindness, deafness and difficulty in walking are generally among the symptoms reported. These symptoms often occur after a stressful experience and may be quite sudden.

Dissociative Disorders

Dissociation can be viewed as severance of the connections between ideas and emotions. Dissociation involves feelings of unreality, estrangement, depersonalisation, and sometimes a loss or shift of identity. Sudden temporary alterations of consciousness that blot out painful experiences are a defining characteristic of dissociative disorders. Conditions included in this are Dissociative Amnesia, Dissociative Identity Disorder, and Depersonalisation/Derealisation Disorder. Salient features of somatic symptom and related disorders and dissociative disorders are given in Box 4.1.

Dissociative amnesia is characterised by extensive but selective memory loss that has no known organic cause (e.g., head injury). Some people cannot remember

Box 4.1
Salient Features of Somatic Symptom and Related Disorders and Dissociative Disorders

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Somatic Symptom and Related Disorders	$\qquad$ Dissociative Disorders
Somatic Symptom Disorder : The person experiences body-related symptoms in the absence of any medical condition (or even if medical condition is present, it is not as serious as the symptoms presented).	Dissociative amnesia : The person is unable to recall important, personal information often related to a stressful and traumatic report. The extent of forgetting is beyond normal.
Illness Anxiety Disorder : The person experiences worry about the possibility of developing a serious medical condition.	Depersonalisation/Derealisation Disorder : The person experiences a change in the person’s sense of reality and perception of self.
Conversion: The person suffers from a loss or impairment of motor or sensory function (e.g., paralysis, blindness, etc.) that has no physical cause but may be a response to stress and psychological problems.	Dissociative identity (multiple personality) Disorder: The person exhibits two or more separate and contrasting personalities, generally associated with a history of abuse.

anything about their past. Others can no longer recall specific events, people, places, or objects, while their memory for other events remains intact. A part of dissociative amnesia is dissociative fugue. Essential feature of this could be an unexpected travel away from home and workplace, the assumption of a new identity, and the inability to recall the previous identity. The fugue usually ends when the person suddenly ‘wakes up’ with no memory of the events that occurred during the fugue. This disorder is often associated with an overwhelming stress.

Dissociative identity disorder, often referred to as multiple personality, is the most dramatic of the dissociative disorders. It is often associated with traumatic experiences in childhood. In this disorder, the person assumes alternate personalities that may or may not be aware of each other.

Depersonalisation/Derealisation disorder involves a dreamlike state in which the person has a sense of being separated both from self and from reality. In depersonalisation, there is a change of self-perception, and the person’s sense of reality is temporarily lost or changed.

Depressive Disorders

One of the most widely prevalent and recognised of all mental disorders is depression. Depression covers a variety of negative moods and behavioural changes. Depression can refer to a symptom or a disorder. In day-to-day life, we often use the term depression to refer to normal feelings after a significant loss, such as the break-up of a relationship, or the failure to attain a significant goal. Major depressive disorder is defined as a period of depressed mood and/or loss of interest or pleasure in most activities, together with other symptoms which may include change in body weight, constant sleep problems, tiredness, inability to think clearly, agitation, greatly slowed behaviour, and thoughts of death and suicide. Other symptoms include excessive guilt or feelings of worthlessness.

Factors Predisposing towards Depression: Genetic make-up, or heredity is an important risk factor for major depression and other depressive disorders. Age is also a risk factor. For instance, women are particularly at risk during young adulthood, while for men the risk is highest in early middle age. Similarly gender also plays a great role in this differential risk addition. For example, women in comparison to men are more likely to report a depressive disorder. Other risk factors are experiencing negative life events and lack of social support.

Bipolar and Related Disorders

Bipolar I disorder involves both mania and depression, which are alternately present and sometimes interrupted by periods of normal mood. Manic episodes rarely appear by themselves; they usually alternate with depression. Bipolar mood disorders were earlier referred to as manic-depressive disorders.

Some examples of types of bipolar and related disorders include Bipolar I Disorder, Bipolar II disorder and Cyclothymic Disorder.

Every suicide is a misfortune. Suicide takes place throughout the lifespan. Suicide is a result of complex interface of biological, genetic, psychological, sociological, cultural and environmental factors.

Some other risk factors are having mental disorders (especially depression and alcohol use disorders), going through natural disasters, experiencing violence, abuse or loss and isolation at any stage of life. Previous suicidal attempt is the strongest risk factor.

Activity 4.4
You may have got some bad news in the family (for example, death of a close relative) or watched your favourite character dying in a film or got less marks than you hoped for or lost your pet. This may have made you sad and depressed and hopeless about the future. Try and recall such incidents in your life. List the situations that led to this reaction. Compare your list and reactions with those of others in class.

Often, suicidal behavior indicates difficulties in problem-solving, stress management, and emotional expression. Suicidal thoughts lead to suicidal action only when acting on these thoughts seems to be the only way out of a person’s difficulties. These thoughts are heightened under acute emotional and other distress. The ramifications of suicide on social circle and communities tend to be devastating and long-lasting.

The stigma surrounding suicide continues despite recent advances in research in this field. Due to this, many people who are contemplating or even attempting suicide do not seek help thus, preventing timely help from reaching them. Therefore improving identification, referral, and management of behaviour are crucial for preventing suicide. Therefore we need to identify vulnerability; comprehend the circumstances leading to such behaviour and accordingly plan interventions.

Suicides are preventable. There is a need for comprehensive multi-sectoral approach where the government, media and civil society all play important role as stakeholders. Some measures suggested by WHO include:

• limiting access to the means of suicide;
• reporting of suicide by media in a responsible way;
• bringing in alcohol-related policies;
• early identification, treatment and care of people at risk;
• training health workers in assessing and managing for suicide;
• care for people who attempted suicide and providing community support.

Identifying students in distress : Any unexpected or striking change affecting the adolescent’s performance, attendance or behaviour should be taken seriously, such as:

• lack of interest in common activities
• declining grades
• decreasing effort
• misbehavior in the classroom
• mysterious or repeated absence
• smoking or drinking, or drug misuse

Strengthening students’ self-esteem : Having a positive self-esteem is important in face of distress and helps in coping adequately. In order to foster positive selfesteem in children the following approaches can be useful:

• accentuating positive life experiences to develop positive identity. This increases confidence in self.
• providing opportunities for development of physical, social and vocational skills.
• establishing a trustful communication.
• goals for the students should be specific, measurable, achievable, relevant, to be completed within a relevant time frame.

Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia is the descriptive term for a group of psychotic disorders in which personal, social and occupational functioning deteriorate as a result of disturbed thought processes, strange perceptions, unusual emotional states, and motor abnormalities. It is a debilitating disorder. The social and psychological costs of schizophrenia are tremendous, both to patients as well as to their families and society.

Symptoms of Schizophrenia

The symptoms of schizophrenia can be grouped into three categories, viz. positive symptoms (i.e. excesses of thought, emotion, and behaviour), negative symptoms (i.e. deficits of thought, emotion, and behaviour), and psychomotor symptoms.

Positive symptoms are ‘pathological excesses’ or ‘bizarre additions’ to a person’s behaviour. Delusions, disorganised thinking and speech, heightened perception and hallucinations, and inappropriate affect are the ones most often found in schizophrenia.

Many people with schizophrenia develop delusions. A delusion is a false belief that is firmly held on inadequate grounds. It is not affected by rational argument, and has no basis in reality. Delusions of persecution are the most common in schizophrenia. People with this delusion believe that they are being plotted against, spied on, slandered,

Activity 4.5
Can you list some characters in films you have seen or books you have read who suffered from any of the disorders we have studied here like depression or schizophrenia showing some of these delusions?

Can you identify which kind of delusion each of these is?

1. A person who believes that s/he is going to be the next President of India.

2. One who believes that the intelligence agencies/police are conspiring to trap her/him in a spy scandal.

3. One who believes that $\mathrm{s} /$ he is the incarnation of God and can make things happen.

4. One who believes that the tsunami occurred to prevent her/him from enjoying her/his holidays.

5. One who believes that her/his actions are controlled by the satellite through a chip implanted in her/his brain by some extraterrestrial beings.

threatened, attacked or deliberately victimised. People with schizophrenia may also experience delusions of reference in which they attach special and personal meaning to the actions of others or to objects and events. In delusions of grandeur, people believe themselves to be specially empowered persons and in delusions of control, they believe that their feelings, thoughts and actions are controlled by others.

People with schizophrenia may not be able to think logically and may speak in peculiar ways. These formal thought disorders can make communication extremely difficult. These include rapidly shifting from one topic to another so that the normal structure of thinking is muddled and becomes illogical (loosening of associations, derailment), inventing new words or phrases (neologisms), and persistent and inappropriate repetition of the same thoughts (perseveration).

People with schizophrenia may have hallucinations, i.e. perceptions that occur in the absence of external stimuli. Auditory hallucinations are most common in schizophrenia. Patients hear sounds or voices that speak words, phrases and sentences directly to the patient (second-person hallucination) or talk to one another referring to the patient as s/he (third-person hallucination). Hallucinations can also involve the other senses. These include tactile hallucinations (i.e. forms of tingling, burning), somatic hallucinations (i.e. something happening inside the body such as a snake crawling inside one’s stomach), visual hallucinations (i.e. vague perceptions of colour or distinct visions of people or objects), gustatory hallucinations (i.e. food or drink taste strange), and olfactory hallucinations (i.e. smell of poison or smoke).

People with schizophrenia also show inappropriate affect, i.e. emotions that are unsuited to the situation.

Negative symptoms are ‘pathological deficits’ and include poverty of speech, blunted and flat affect, loss of volition, and social withdrawal. People with schizophrenia show alogia or poverty of speech, i.e. a reduction in speech and speech content. Many people with schizophrenia show less anger, sadness, joy, and other feelings than most people do. Thus they have blunted affect. Some show no emotions at all, a condition known as flat affect. Also patients with schizophrenia experience avolition, or apathy and an inability to start or complete a course of action. People with this disorder may withdraw socially and become totally focused on their own ideas and fantasies.

People with schizophrenia also show psychomotor symptoms. They move less spontaneously or make odd grimaces and gestures. These symptoms may take extreme forms known as catatonia. People in a catatonic stupor remain motionless and silent for long stretches of time. Some show catatonic rigidity, i.e. maintaining a rigid, upright posture for hours. Others exhibit catatonic posturing, i.e. assuming awkward, bizarre positions for long periods of time.

Neurodevelopmental Disorders

A common feature of the neurodevelopmental disorders is that they manifest in the early stage of development. Often the symptoms appear before the child enters school or during the early stage of schooling. These disorders result in hampering personal, social, academic and occupational functioning. These get characterised as deficits or excesses in a particular behaviour or delays in achieving a particular age-appropriate behaviour.

We will now discuss several disorders like Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder, Intellectual Disability, and Specific Learning Disorder. These disorders, if not attended, can lead to more serious and chronic disorders as the child moves into adulthood.

The two main features of ADHD are inattention and hyperactivityimpulsivity. Children who are inattentive find it difficult to sustain mental effort during work or play. They have a hard time keeping their minds on any one thing or in following instructions. Common complaints are that the child does not listen, cannot concentrate, does not follow instructions, is disorganised, easily distracted, forgetful, does not finish assignments, and is quick to lose interest in boring activities. Children who are impulsive seem unable to control their immediate reactions or to think before they act. They find it difficult to wait or take turns, have difficulty resisting immediate temptations or delaying gratification. Minor mishaps such as knocking things over are common whereas more serious accidents and injuries can also occur. Hyperactivity also takes many forms. Children with ADHD are in constant motion. Sitting still through a lesson is impossible for them. The child may fidget, squirm, climb and run around the room aimlessly. Parents and teachers describe them as ‘driven by a motor’, always on the go, and talk incessantly.

Autism Spectrum Disorder is characterised by widespread impairments in social interaction and communication skills, and stereotyped patterns of behaviours, interests and activities. Children with autism spectrum disorder have marked difficulties in social interaction and communication across different contexts, a restricted range of interests, and strong desire for routine. About 70 per cent of children with autism spectrum disorder have intellectual disabilities.

Children with autism spectrum disorder experience profound difficulties in relating to other people. They are unable to initiate social behaviour and seem unresponsive to other people’s feelings. They are unable to share experiences or emotions with others. They also show serious abnormalities in communication and language that persist over time. Many of them never develop speech and those who do, have repetitive and deviant speech patterns. Such children often show narrow patterns of interests and repetitive behaviours such as lining up objects or stereotyped body movements such as rocking. These motor movements may be self-stimulatory such as hand flapping or self-injurious such as banging their head against the wall. Due to the nature of these difficulties in terms of verbal and non-verbal communication, individuals with autism spectrum disorder tend to experience difficulties in starting, maintaining and even understanding relationships.

You have already read about variations in intelligence in Chapter 1. Intellectual disability refers to below average intellectual functioning (with an IQ of approximately 70 or below), and deficits or impairments in adaptive behaviour (i.e. in the areas of communication, self-care, home living, social/interpersonal skills, functional academic skills, work, etc.) which are manifested before the age of 18 years. Table 4.2 describes characteristics of the intellectually disabled persons.

In case of specific learning disorder, the individual experiences difficulty in perceiving or processing information efficiently and accurately. These get manifested during early school years and the individual encounters problems in basic skills in reading, writing and/or mathematics. The affected child tends to perform below average for her/his age. However, individuals may be able to reach acceptable performance levels with additional inputs and efforts. Specific learning disorder is likely to impair functioning and performance in activities/ occupations dependent on the related skills.

Disruptive, Impulse-Control and Conduct Disorders

The disorders included under this category are Oppositional Defiant Disorder, Conduct Disorder and others. Children with Oppositional Defiant Disorder (ODD) display age-inappropriate amounts of stubbornness, are irritable, defiant, disobedient, and behave in a hostile manner. Individuals with ODD do not see themselves as angry, oppositional, or defiant and often justify their behaviour as reaction to circumstances/demands. Thus, the symptoms of the disorder become entangled with the problematic interactions with others. The terms conduct disorder and antisocial behaviour refer to age-inappropriate actions and attitudes that violate family expectations, societal norms, and the personal or property rights of others. The behaviours typical of conduct disorder include aggressive actions that cause or threaten harm to people or animals, nonaggressive conduct that causes property damage, major deceitfulness or theft, and serious rule violations. Children show many different types of aggressive behaviour, such as verbal aggression (i.e. name-calling, swearing), physical aggression (i.e. hitting, fighting), hostile aggression (i.e. directed at inflicting injury to others), and proactive aggression (i.e. dominating and bullying others without provocation).

Feeding and Eating Disorders

Another group of disorders which are of special interest to young people are eating disorders. These include anorexia nervosa, bulimia nervosa, and binge eating .

In anorexia nervosa, the individual has a distorted body image that leads her/ him to see herself/himself as overweight. Often refusing to eat, exercising compulsively and developing unusual habits such as refusing to eat in front of others, the person with anorexia may lose large amounts of weight and even starve herself/himself to death. In bulimia nervosa, the individual may eat excessive amounts of food, then purge her/his body of food by using medicines such as laxatives or diuretics or by vomiting. The person often feels disgusted and ashamed when s/he binges and is relieved of tension and negative emotions after purging. In binge eating, there are frequent episodes of out-of-control eating. The individual tends to eat at a higher speed than normal and continues eating till s/he feels uncomfortably full. In fact, large amount of food may be eaten even when the individual is not feeling hungry.

Substance-Related and Addictive Disorders

Addictive behaviour, whether it involves excessive intake of high calorie food resulting in extreme obesity or involving the abuse of substances such as alcohol or cocaine, is one of the most severe problems being faced by society today.

Disorders relating to maladaptive behaviours resulting from regular and

Table 4.2 : Characteristics of Individuals with Different Levels of Intellectual Disability

consistent use of the substance involved are included under substance related and addictive disorders. These disorders include problems associated with the use and abuse of alcohol, cocaine, tobacco and opiods among others, which alter the way people think, feel and behave. While there are many disorders listed under this category, few frequently used substances are discussed below:

Alcohol

People who abuse alcohol drink large amounts regularly and rely on it to help them face difficult situations. Eventually the drinking interferes with their social behaviour and ability to think and work. Their bodies then build up a tolerance for alcohol and they need to drink even greater amounts to feel its effects. They also experience withdrawal responses when they stop drinking. Alcoholism destroys millions of families, social relationships and careers. Intoxicated drivers are responsible for many road accidents. It also has serious effects on the children of persons with this disorder. These children have higher rates of psychological problems, particularly anxiety, depression, phobias and substance-related disorders. Excessive drinking can seriously damage physical health. Some of the ill-effects of alcohol on health and psychological functioning are presented in Box 4.2 .

Heroin

Box 4.2
Effects of Alcohol : Some Facts

• All alcohol beverages contain ethyl alcohol.
• This chemical is absorbed into the blood and carried into the central nervous system (brain and spinal cord) where it depresses or slows down functioning.
• Ethyl alcohol depresses those areas in the brain that control judgment and inhibition; people become more talkative and friendly, and they feel more confident and happy.
• As alcohol is absorbed, it affects other areas of the brain. For example, drinkers are unable to make sound judgments, speech becomes less careful and less clear, and memory falters; many people become emotional, loud and aggressive.
• Motor difficulties increase. For example, people become unsteady when they walk and clumsy in performing simple activities; vision becomes blurred and they have trouble in hearing; they have difficulty in driving or in solving simple problems.

Heroin intake significantly interferes with social and occupational functioning. Most abusers further develop a dependence on heroin, revolving their lives around the substance, building up a tolerance for it, and experiencing a withdrawal reaction when they stop taking it. The most direct danger of heroin abuse is an overdose, which slows down the respiratory centres in the brain, almost paralysing breathing, and in many cases causing death.

Cocaine

Regular use of cocaine may lead to a pattern of abuse in which the person may be intoxicated throughout the day and function poorly in social relationships and at work. It may also cause problems in short-term memory and attention. Dependence may develop, so that cocaine dominates the person’s life, more of the drug is needed to get the desired effects, and stopping it results in feelings of depression, fatigue, sleep problems, irritability and anxiety. Cocaine poses serious dangers. It has dangerous effects on psychological functioning and physical well-being.

Some of the commonly abused substances are given in Box 4.3.

Box 4.3
Commonly Abused Substances (Following the DSM-5 Classification)

• Alcohol
• Stimulants: dextroamphetamines, metaamphetamines, cocaine
• Caffeine: coffee, tea, caffeinated soda, analgesics, chocolate, cocoa
• Cannabis: marijuana or ‘bhang’
• Hallucinogens: LSD, mescaline
• Inhalants: gasoline, glue, paint thinners, spray paints, typewriter correction fluid, sprays
• Tobacco: cigarettes, bidi
• Opioid: morphine, heroin, cough syrup, painkillers (analgesics, anaesthetics)
• Sedatives, Hypnotics or Anxiolytics : sleeping pills, anti-anxiety medication

Key Terms

Abnormal psychology, Antisocial behaviour, Anxiety, Autism spectrum disorder, Bipolar and related disorders, Deinstitutionalisation, Delusions, Depressive disorders, Diathesis-stress model, Feeding and eating disorders, Genetics, Hallucinations, Hyperactivity, Intellectual disability, Neurodevelopmental disorders, Neurotransmitters, Norms, Obsessive-compulsive disorders, Phobias, Schizophrenia, Somatic symptom and related disorders, Substance related and addictive disorders.

Summary

• Abnormal behaviour is behaviour that is deviant, distressing, dysfunctional, and dangerous. Those behaviours are seen as abnormal which represent a deviation from social norms and which interfere with optimal functioning and growth.
• In the history of abnormal behaviour, the three perspectives are, i.e. the supernatural, the biological or organic, and the psychological. In interactional or bio-psycho-social approach, all three factors, viz. biological, psychological and social play important roles in psychological disorders.
• Classification of psychological disorders has been done by the WHO (ICD-1O) and the American Psychiatric Association (DSM-5).
• A variety of models have been used to explain abnormal behaviour. These are the biological, psychodynamic, behavioural, cognitive, humanistic-existential, diathesisstress systems, and socio-cultural approaches.
• The major psychological disorders include anxiety, obsessive-compulsive and related, trauma-and stressor-related, somatic symptom and related, dissociative, depressive, bipolar and related, schizophrenia spectrum and other psychotic, neurodevelopmental, disruptive, impulse-control and conduct, feeding and eating, and substance related and addictive disorders.

Review Questions

1. Identify the symptoms associated with depression and mania

2. Describe the characteristics of children with hyperactivity.

3. What are the consequences of alcohol substance addiction?

4. Can a distorted body image lead to eating disorders? Classify the various forms of it.

5. “Physicians make diagnosis looking at a person’s physical symptoms”. How are psychological disorders diagnosed?

6. Distinguish between obsessions and compulsions.

7. Can a long-standing pattern of deviant behaviour be considered abnormal? Elaborate.

8. While speaking in public the patient changes topics frequently, is this a positive or a negative symptom of schizophrenia? Describe the other symptoms of schizophrenia.

9. What do you understand by the term ‘dissociation’? Discuss its various forms.

10. What are phobias? If someone had an intense fear of snakes, could this simple phobia be a result of faulty learning? Analyse how this phobia could have developed.

11. Anxiety has been called the “butterflies in the stomach feeling”. At what stage does anxiety become a disorder? Discuss its types.

Project Ideas

1. All of us have changes in mood or mood swings all day. Keep a small diary or notebook with you and jot down your emotional experiences over 3-4 days. As you go through the day (for instance, when you wake up, go to school/college, meet your friends, return home), you will observe that there are many highs and lows, ups and downs in your moods. Note down when you felt happy or unhappy, felt joy or sadness, felt anger, irritation and other commonly experienced emotions. Also note down the situations which elicited these various emotions. After collecting this information, you will have a better understanding of your own moods and how they fluctuate through the day.

2. Studies have shown that current standards of physical attractiveness have contributed to eating disorders. Thinness is valued in fashion models, actors, and dancers. To study this, observe the people around you. Select at least 10 people (they may include your family, friends and other acquaintances), and rate them in terms of Large, Average and Thin. Then pick up any fashion or film magazine. Look at the pictures of models, winners of beauty competitions, and film stars. Write a paragraph or two describing the magazine’s message to its readers about the normal or acceptable male or female body. Does this view match what you see as normal body types in the general population?

3. Make a list of movies, TV shows, or plays you have seen where a particular psychological disorder has been highlighted. Match the symptoms shown to the ones you have read. Prepare a report.