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ABNORMAL PSYCHOLOGY

(PAPER II)

VI SEMESTER

CORE COURSE

B Sc COUNSELING PSYCHOLOGY

(2011 Admission)

UNIVERSITY OF CALICUT

SCHOOL OF DISTANCE EDUCATION

Calicut university P.O, Malappuram Kerala, India 673 635.

School of Distance Education

Abnormal Psychology 2

UNIVERSITY OF CALICUT

SCHOOL OF DISTANCE EDUCATIONSTUDY MATERIAL

Core Course

B Sc COUNSELLING PSYCHOLOGY

VI Semester

ABNORMAL PSYCHOLOGY (PAPER II)

Prepared by: Smt. Nisha. K,Asst. Professor,Dept. of Psychology,University of Calicut.

Scrutinized by: Dr. C. Jayan,Professor,Dept. of Psychology,University of Calicut.

Layout: Computer Section, SDE

©Reserved



MODULE CONTENTS PAGE No

I OTHER BEHAVIOR DISORDERS 4

II ASSESSMENT 27



MODULE 1

OTHER BEHAVIOR DISORDERS

The schizophrenia and delusional disorder

Introduction

Belgian Psychiatrist described the case of schizophrenia in1860.He usedthe term' Demence Precoce'.The Latin form of this term -dementia Precox-wasadopted by theGerman psychiatrist Emil kraeplin in late 19th century to refer toa group of conditions that all seemed to have the features of mental deteriorationbeginning early in the life. The term schizophrenia was used bythe SwissPsyhiatrist Eugen Bleuler in 1911, it means split mind.

Clinical picture of schizophrenia

There are two general symptom patterns or syndrome of schizophrenia-1]Positive and 2] Negative syndrome schizophrenia.

• Positive sign or syndrome: These syndromes are those in which somethinghas been added to a normal repertoire of behavior and experience. It alsoknown as type I schizophrenia.The symtoms are hallucination, delusion,derailment of association, bizarre behavior, minimal cognitive impairment,sudden onset, and variable course. The above symptoms plus goodresponse to drugs, limbic system abnormalities and normal brain ventricleare also present.

• Negative signs or syndrome refers to an absence of or deficit of behaviorsnormally present in an individual's repertoire.It is also known as Type IIschizophrenia.The symptoms are

• Emotional flattening

• Poverty of speech

• Lack of sociability

• Apathy

• Significant Cognitive impairment



• Insidious onset

• Chronic course

The above symptoms plus uncertain respond to drug, frontal lowabnormalities, and Enlarged brain ventricle are the features present in negativesyndrome.

Major symptoms of schizophrenia.

1. Disturbance of associative linking

Often referred to as formal thought disorder. Associative disturbance isusually considered as prime indicative of a schizophrenic disorder. Basically, anaffected person fails to make sense despite seeming to confirm to the semanticand syntactic rules governing verbal communication

2. Disturbance of thought content

Typically involve certain standard types of delusion or false belief.Prominent among these are beliefs that one’s thought, feelings or actions arebeing controlled by external agents, that one’s private thoughts are beingbroadcast indiscriminately to others and that thoughts are being inserted intoone's brain by alien forces etc

3. Disruption of perception

Unable to sort out and process the great mass of sensory information towhich all of us are constantly exposed. Hallucination (false perception) such asvoices that only the schizophrenic person can hear. Auditory hallucinations areoften seen, also visual and olfactory hallucination.

4. Emotional dysfunction.

This include the following features

1. Inappropriate emotions

2. Anhedonia-inability to, experience joy or pleasure

3. Emotional shallowness or blunting, lack of intensity or clear definition

4. May appear emotionless

5. Confused sense of self

1. May feel confused about their identity to the point of loss of subjectivesense of self



2. Dellusional assumption of a new identity including an identity likeJesus Christ etc

3. Persons may be confused about aspect of their own body includinggender,or may be uncertan about the boundaries separating the self from the restof the world.

6. Disrupted volition

Goal directed activity is almost universally disrupted in them. Theimpairment always occurs in areas of routine daily functioning such as work,social relation, self care etc

7. Retreat to an inner world

1. Ties to the external world are almost loosened in this disorder.

2. Withdrawal from reality and involve active disengagement from theenvironment and elaboration of an inner world in which the person developillogical and fantastic ideas

8. Disturbed motor behavior

1. Peculiarities of movements are observed

2. Most disturbance are ranged from an executed state of hyper activity to amarked decrease in movements

3. Rigid posturing, mutism, ritualistic mannerism

Subtype of schizophrenia

1. Undifferentiated Type

This is something of a waste basket category. They meet a criteria for usualdiagnosis of schizophrenia including hallucination, delusion disordered thoughtsand bizarre behavior.

But they do not clearly fit into one of the other type. Also they show indication ofperplexity ,confusion, emotional turmoil,delusions of reference, excitement,depression and fear etc.

2. Paranoid type of schizophrenia

They show histories of increased suspiciousness and difficulties ininterpersonal relations

They show absurd, illogical and often changing delusions.Persecutorydelusions are common.



They are highly suspicious of relatives and may complaint of being watched,followed, poisoned and talked about.

Grandiose delusions delusions are common.

These delusions are frequently accompanied by vivid auditory, visual andother hallucination

Impairment of critical judgment, unpredictable and occasionally dangerousbehavior

3. Catatonic type of schizophrenia

Pronounced motor signs, either of an excited or a stuporous type. Patients arehighly suggestible and will automatically obey command and or imitate theactions of others (ecoproxia) or mimic their phrases (Ecolalia).

• Tendency to remain motionless for hours or even days in a singleposition(catatonic stupor)

• The clinical picture may undergo an abrupt change,with excitement comingon suddenly and may becomeviolent,maytalk or shout,pace rapidly,openlyindulge in sexual activity, attempt suicide and impulsively attack and try tokick others.

4. Disorganized type (hebephrenia)

• Represents a more severe disintegration of personality.

• Usually occurs at an early age, emotional distortion manifested asinappropriate laughter, stillness, peculiar mannerism etc.

• Emotional distortion and blunting typically are manifested in inappropriatelaughter and silliness,peculiar mannerisms etc.

• Speech become incoherent and include considerable baby talk, childishgiggling etc.

• Patients may invent new words[Neologism]

• Auditory hallucination are common

5. Residual type

This category used for people who have experienced episodes ofschizophrenia that they have recovered sufficiently as not to show prominentpsychotic symptom.

6. Schizophreniform disorder



Schizophrenia like psychosis of less than six month duration.

Causal factors of schizophrenia

Biological causal factors

• Genetic influences

• Schizophrenia tends to run in families. Evidence for higher expectedrates of schizophrenia among biological relatives.

• Strong correlation between closeness of blood relationship

• No specific genes identified

• Twins studies

Concordance rate for identical twins is found to be significantly higherthan those for fraternal twins.

• Adoption studies

True separation of hereditary from environmental influence by usingadoption strategy. Here concordance rate for schizophrenia is comparedfor the biological and adaptive relatives of persons who have beenadopted out of the biological family at an early age subsequently becameschizophrenic.

If the rate is greater among the patient's biological than adaptiverelatives, a hereditary influence is strongly suggested.

• Biochemical factors

This factor suggests that mental disoders are due to chemicalimbalances. Dopamine hypothesis suggest that schizophrenia is theproduct of an excess of dopamine activity at certain syntaptic sites. Thisis based on the observation that all of the early anti schizophrenic drugshad the common property of blocking dopamine mediated neurontransmission.

• Neurophysiological factors

Imbalance in various nerophysiological processes and inappropriateautonomic arousal. Abnormal brain reaction to stimulations, neurologicalabnormalities such as reflex hyper activity and deficit performance in nonpsychological testing are found.

• Neuroanatomical factors



• Early brain injury

• Obstetrical complications,such as premature birth is found as a factor.

• Abnormal enlargement of ventricles.[Ventricles are the hollow areas inbrain that is filled with cerebro spinal fluid]

• Hypofrontability--Low frontal lobe activation.

Psycho social causal factors

• Damaging parent-child and family interactions.

This involves the following factors.

• Schizophrenogenic parents: Parents were routinely assumed to havecaused their children's disorders through hostility, deliberate rejection etc. Theseparents are cruel and abusive.

• Destructive parental interactions: Study by Lidz and associate of 14families with schizophrenic offspring. They failed to find a single couple thatfunctioned as well. 8 out of the 14 family live in a state of severe chronic discordin which continuation of marriage was threatened. Six others achieve a state ofequilibrium in which the relationship was maintained at the expense of a basicdistortion in family relationship.

Faulty communication

Gregory Bateson identifies the conflicting and confusing nature ofcommunication among members of family experiencing a schizophrenic outcomes. In this pattern parents present the child about ideas, feeling and demandsthat are mutually incompatible. For e.g.; a mother may be verbally loving andaccepting but emotionally anxious and rejecting.

Socio cultural factors

Lower the socio economic status the higher prevalence of schizophrenia.

Treatment

1. Antipsychotic medication; major tranquilizer were introduced in the mid1950s.

2. Psycho social approaches in treating schizophrenia

Family therapy

Individual psycho therapy



It is effective in enhancing social adjustment and social role performance ofdischarged patients.

Social skills training and community treatment.

DELUSIONAL DISORDER

Formerly called paranoia or paranoid disorder. Diagnosis of delusionaldisorder is difficult because it is not always possible to determine the truth orfalsity of an idea. Definitions of delusional disorder in DSM IV usually specifiesthat an idea must be held as prepositions (complete contrary to the nature) bythe majority of a persons in community.

Types of delusional disorder

1. Persecutory type

The predominant delusional theme is that one or someone to whom oneclosely related is being subjected to some kind of malevolent treatment such asspying, spreading of false rumors of illegal or immoral behavior.

2. Jealous type

The predominant delusional theme is that one’s sexual partner is unfaithful.

3. Erotomanic type

The predominant delusional theme is that some person of higher status is inlove with or to start sexual liasion with the delusion person.

4. Somatic type

The predominant theme is that the affected person is having a anunshakable belief about having some physical illness.

5. Grandiose type

The predominant theme is that the affected person is having a belief that he isa person of extra ordinary status, power, ability, talent, duty etc.

6. Mixed type

The combination of the above when no single theme predominate.

Clinical pictures of delusional disorder

Individual feel singled out and taken advantage of mistreated, plotted against,ignored or mistreated by enemies.



Delusion mainly center around one major theme such as financial matters,job etc

Ideas of persecution is predominant

Apart from delusional system such an individual may appear perfectly normalinconventional emotionally and conduct.

Hallucination rarely found.

Projective thinking: individual selectively project the action of others to confirmsuspiciousness and blames others for their failures.

Hostility: anger and hostile

Paranoid illumination: the moment when everything ‘false into place’ theindividual finally understands the strange feelings and even being experienced.

Delusions: it influence and perception may be based on some grains of truth.

Causal factors of delusional disorder

They do not show a history of normal play with other children or goodsocialization in terms of warm affectionate relationship.

Their relatively unfriendly interpersonal style may make them unpopular withpeers

This misunderstanding ,suspiciousness or coldly rejecting persons frequentlybecame a target of actual discrimination and mistreatment

MOOD DISORDER

Mood: A temporary but relatively sustained and pervasive affective state with amore specific and short term emotion.

Mood disorder severe alterations in mood and for more prolonged periods of time.

2 key moods-The key moods that is present in mood disorder are mania &depression.

• Mania

• Depression

Mania:This is the phase that is characterised by excitement and euphoria.

Depression:This phase is characterised by the feelings of extra ordinary sadnessand dejections.



Manic episode” a mood episode lasting atleast one weak, characterized bycontinuously elevated expansive or irritable mood, sufficiently severe to causemarket impairment in social or occupational functioning.

Characteristics

• Inflated self esteem or grandiose ideas or actions, decreased need of sleep,increase talkativeness

• Flight of ideas

• Distractibility

• Increased psycho motor agitation

• Mood disorder can be classified into unipolar disorder and bipolar disorder.

UNIPOLAR DISORDER

Person experience only depressive episodes.The following are themain types of unipolar disorder.

• Dysthymia: for atleast the past two years, the person has been bothered formost of the day, for more days, by a depressed mood, and atleast two otherdepressive symptoms, but not of sufficient persistent or severity to meet thecriteria for major depression.

Symptoms of dysthymia

The person may experience atleast two of the following six symptomswhen depressed.

• Poor appetite or over eating

• Sleep disturbance or insomnia

• Low energy level

• Low self esteem

• Difficulties in concentration or decision making

• Feeling of hopelessness

• Adjustment disorder with depressed mood

The person reacts with a maladaptive depressed mood to some identifiablestressor occurring within the past 3 months, does not exceed 6 months.



• Major depressive disorder

The person has one or more major depressive episodes in the absence ofany manic or hypo manic episode.

Symptoms

• Prominent and persistent depressed mood

• Loss of pleasure for atleast two weeks, accompanied by four or moresymptoms such as poor appetite, insomnia, psycho motor retardation,fatigue, feeling of breathlessness or ill, inability to concentrate andthoughts of death and suicide.

BIPOLAR DISORDER

Person experience both manic and depressive episodes. The following arethe different types of bipolar disorder.

• Cyclothymia, depressed

At present or during the past two years, the person experienced episodes resemblingdysthymia but also had one or more periods of hypomania.

• Bipolar 1 disorder, depressed

The person experiences a major depressive episode and has had one or more manicepisodes.

• Bipolar II disorder, depressed

A major depressive episode and had one or more hypo manic episodes.

Subtypes of major depressive disorder

• Melancholic or endogenous depression.

In addition to meeting the criteria of major depressive disorder, a patient has eitherloss of interest or pleasure in almost al activities. He may experience atleast three ofthe following symptoms.

• Early morning awakening

• Depression being worse in the morning

• Marked psycho motor retardation

• Significant lows of appetite and weight



• Inappropriate or excessive guilt

Severe major depression disorder with psychotic features

Characterized by lows of contact with reality and including delusions (fallsbeliefs) or hallucinations may sometimes accompany the other symptoms ofmajor depression.

Mood congruent and mood incongruent

Delusions and hallucination present are mood congruent. If they are appropriateto serious depression. The mood incongruent means delusional thinking is incongruentmeans delusional thinking is inconsistent with the predominant mood.

Seasonal affective disorder

Mood disorder may show seasonal pattern that is atleast two episodes ofdepression in the past two years occurring at the same time of the year (winter) and fullremission of the same time of the year (spring).

Schizo affective disorder

A person must have a period of illness during which he or she needs the criteriafor both a major mood disorder (uni polar and bipolar) and atleast two major symptomsof schizophrenia (hallucination and delusion)

Causal factors in mood disorder

Biological Factors

Hereditary factors

Prevalence of mood disorder is higher among blood relatives of persons withclinically diagnosed mood disorder.

• Twin study also suggested that they may be a moderate geneticcontribution to unipolar depression

• 9% of first degree relatives of a persons with bipolar disorder can also beexpected to have bipolar disorder

• Concordance rates for these disorders are much higher for identical thanfraternal twins

Bio chemical factors

Studies revealed that depression may arise from disruption in the delegate balanceof neurotransmitter substances that regulates the brain functioning.



Three neurotransmitters were focused viz norepineprine, dopamines and serotoninbecause researchers observed that anti depressants seemed to have the effect ofincreasing the availability of these neurotransmitter at synaptic functions.This leadto monoamine hypothesis that depression was atleast sometimes due to an absoluteor relative depletion of one or all of these neuro transmitters. Later this hypothesiswas rejected.

Neuro endocrine and neuro physiological factors

Hormone cortisol is secreted by adrenal glands. Blood plasma level of cortisolknown to be elevated in form 50-60% of seriously depressed patients.A potentsuppressor of plasma cortisol in normal individuals, dexamethasone fails to suppresscortisol in about 45% of depressed patients.

Dexametharone suppression text (DST) was used to assess depressedindividuals. People with hypothyroidism often become depressed due to disturbance inhypothalamic pituitary-thyroid axis. Lesions of the left anterior or prefrontal cortex leadto depression.

Psycho social causal factors

Stressful life events

It is divided into five types

• Situations that tend to lower self esteem like being fired or failing in exams

• Thwarting of an important goal

• Developing a physical disease or abnormality that activates ideas of deathlike diagnosed as having cancer.

• Single stressors of overwhelming magnitude such as the death of the child ora parent

• Several stressors occurring in a series

Diathesis -stress model

• It explains how stress interacts with various types of vulnerability factors toreduce depression

• The idea that people who eventually develop a disorder differ in someunderlying way from those who do not and this difference is known asdiathesis(predisposition)

• It was assumed that the diathesis was biological in original and but latercognitive and social factors also contribute



Beck’s cognitive theory

The one of the most prominent theory of depression for over 30 years is that ofAaron Beck- a psychiatrist. Beck hypothesise that the cognitive symptoms ofdepression may often proceeds and cause the mood symptoms rather than viceversa. That is, if you are ugly, those thoughts will lead to a depressed mood.According to Beck’s it is these negative cognition that are central to depression.

Features of Beck’s theory

• They are underlying depressogenic schemas or dysfunctional belief,which are rigid, extreme and counterproductive. For eg: if everyonedoes not love me, then my life is worthless.

• Negative automatic thoughts

Thoughts that often occur just below the surplus of the awareness and involveunpleasant pessimistic prediction. These pessimistic predictions tend to centreon three themes of what Beck calls the negative cognitive triad.

Negative cognitive traids

_Negative thoughts about self (for e.g.: I’m ugly)

_Negative thoughts about ones experience and the surrounding world (e.g.:no one loves me)

_ Negative thoughts about one’s future (it is hopeless because things willalways be this way)

Helplessness and hopelessness theory

Learned helplessness theory was proposed by Seligman. Learned helplessnessproduce three deficits. 1) Motivational deficit 2) cognitive deficit and 3) emotionaldeficit.

Hopelessness theory is a revision of helplessness theory by Abramson etall. They proposed that having a pessimistic attribution style in conjunction withone or more negative life events was not sufficient to produce depression unlessone first experiences a state of hopelessness.

Marriage and family life problem

Mood disorders are also caused by marital and family life problems

Socio-cultural causal factors

• There are cross cultural difference in depressive symptoms, nonwestern culture like China, the rate of depression are low.



• Demographic difference in United States. Poor socio economic classhave higher rate of major depression disorder but bipolar disorder aremore common in high socio economic classes.

Treatment and outcomes

• Pharmaco therapy & electro convulsive therapy( ECT)

Anti depressants, antipsychotic and antianxiety drugs are all used

Antidepressants are chosen from the selective serotonin uptake inhibitors.

Lithium therapy

It is used as a mood stabilizer in the treatment of depressionand mania. Mood stabilizer is often used to describe these drugs becausethey have both anti manic and anti depressant effects. But there are sideeffects for lithium like lethargy, decreased motor coordination and gastrointestinal difficulties, also kidney malfunctioning and damage.

ECT

ECT is often used with seriously depressed patients who may present animmediate and serious suicidal risk.

• Psycho therapy

Drugs and ECT are combined with individual or group psycho therapydirected at helping a patient develops a more stable long range adjustment.

• Cognitive behavioral therapy (CBT)

Two of the best known of depression_ specific psycho therapies forunipolar depression are the cognitive behavioral therapy of Beck and theinterpersonal therapy of Klerman,Weissman,colleagues. CBT consists of highlystructured, systematic attempts to teach with depression to evaluate theirvalues, believes and negative automatic thoughts systematically; IPT is mainlyused in marital relation.

• Family and marital therapy

Family and marital is also given when required.

SUBSTANCE ABUSE AND DEPENDENCE



Addictive behavior: behavior based on the pathological need for asubstance/activity, may involve the abuse of substances, such on nicotine,alcohol, cocaine, the excessive ingestion of high calorie food, resulting in externalobesity.

Psycho active drugs: Those drugs that affect mental functioning; alcohol,nicotine, barbiturates, minor tranquilizers, amphetamines, heroin andmarijuana.

Tolerance: the need for id amounts of a substance to active the desiredeffects results from bio chemical changes in the body that affect the rate ofmetabolism and eliminate alcohol from the body.

Withdrawal symptoms: physical symptoms such as sweating, tremors andtension that accompany disturbance from the drug.

Alcohol abuse and dependence

WHO no longer recommends the term alcoholism but prefer the termalcohol dependence syndrome- “a state, psychic and usually also physicalresulting from taking alcohol, characterized by behavioral and other responsesthat always include a compulsion to take alcohol on a continous/periodic basisinorder to experience its psychic affects, sometimes to avoid the discomfort of itsabsence, tolerance may/ may not be present.

History

People of ancient cultures (Egyptian, Greek and Roman) excessivelyused alcohol. Beer was developed by an Arabian chemist. First alcoholic onrecord is Cambyses, king of Persia in 6th century BC.

Prevalence, commodity and demographics of alcoholism

Alcoholism is a major problem in US. Life span of them is about 12 yearsshorter than that of the organized citizen. Alcohol use is the 3rd major cause ofdeath In US

Alcoholic; refers to a persons with a serious drinking problem whose drinkingimpairs his/her like real adjustment in terms of health personal relationshipsand occupational functioning.

Alcoholism: refers to a dependence on alcohol that serious and interacts withthe life adjustment.

Development of alcoholic dependence

Excessive drinking can be viewed as progressing insidiously from early to middle– to late – stage alcoholism, although some alcoholics do not follow thisprogressively developing pattern.Many studies shown that alcohol is a dangerous



systemic poison even in small amounts, other believe that in moderate amount itis not harmful to most people. Small amounts of red wine can even serve as aprotective factual in heart disease.For pregnant women, even moderate amountsare believed to be dangerous.

Physical effects of chronic alcohol use

Alcohol that is taken in must be assimilated by the body (05-10%eliminated through breath, urine & perspiration). The work of assimilation isdone by the liver, but when large amounts of alcohol are ingested, the liver maybe seriously overworked & eventually suffer irreversible damage. In fact, from 15-30% of heavy drinkers develop cirrhosis of the liver – a disorder involvingextensive stiffening of the blood vessels. Alcohol is also a high calorie deug. A pintof whisky provides about 1200 calories, which is approximately half the ordinarycaloric requirements for a day. This consumption of alcohol reduces a drinker’sappetite for other food – because alcohol has no nutritional value, the excessivedrinker often, suffer from malnutrition.

Psychological effects of Alcohol abuse and dependence

Chronic drinker suffers from chronic fatigue oversensitivity & depression.Excessive drinking results in lowered feelings of adequacy & worth, impairedreasoning & judgments & gradual personality deterioration.

Drinker assumes increasingly lesser responsibility, loses pride in personalappearance, neglects spouse & family, becomes irritable & unwilling to discussthe problem.

As judgment become impaired, an excessive drinker may be unable to holda job & generally becomes unqualified to cope with new demands.

Personality disorganization and deterioration is also seen among alcoholics.

Loss of employments of marital breakup is also common.

General health is also deteriorated.

Psychosis associated with alcoholism

Several acute psychotic reactions are also seen.

1) Alcohol withdrawal delirium

Alcohol withdrawal delirium usually happens following a prolonged drinkingspree when the person is in a state of withdrawal. Slight noises or sudden movingobjects may cause considerable excitement and agitation.

Symptoms of alcohol withdrawal delirium includes



_ Disorientation for time and place.

_ vivid hallucination

_ acute fear

_Extreme suggestively

_ Marked tremors of hands, tongue & lips.

2) Alcohol Ammestic disorder (korasakoff’s syndrome)

The person suffering from alcohol amnesic disorder may suffer frommemory deficit. They may not recognize pictures, faces, rooms and otherobject that they ‘ve just seen, although they may feel they are familiar. Theyare delusional and disoriented for time & place. They also suffer from vitaminB deliciency (thaiamine)

Casual factors

1) Biological factors

The development of an alcohol addiction is a complex processinvolving many elements – constitutional vulnerability & environmentalencouragement as well as the unique biochemical properties of certainpsychoactive substances can lead to addictive behavior.

Neurobiology of addiction

Drugs differ in terms of their biochemical properties as well ashow rapidly they enter the brain. There are several routes of administration –oral, nasal & intravenous. Alcohol is usually drunk which is the slowest route.Cocaine is often self administrated by injection or taken nasally. Central to theneuron chemical process underlying addiction is the role the drug plays inactivating the ‘pleasure pathway”- the meroscorticolimbic dopamine pathway(MCLP) – is the centre of psychoactive drug activation in the brain.

Craving & genetic vulnerability

Alcoholism clearly tends to run in families.A review of 39 studies of familiesof 6251 alcoholics & 4083 non alcoholics reported that 1/3 of alcoholoics hadatleast one parent with alcohol problem.

Study of children of alcoholics by cloninger & colleagues (1986) reported that,for males having one alcoholic parent increased the rate of alcoholism from11.4% to 29.5% & having 2 parents increased the rate to 41.27%. For femaleswith one alholic parent the rate is 9.01, two parents the rate is 25%.

Genetic influences and learning



Learning factors appear to play an important part in the development ofconstitutional reaction tendencies. The person must be exposed to thesubstance to a sufficient degree for the addictive behavior to appear. Peerpressures, parental example & advertising also influence addictive behavior.Living in an environment that promotes initial as well as continuing use of thesubstances.

2) Psycho social casual factors

Alcoholics develop a powerful psychological as well as social dependence.Thefollowing are the psychosocial causal factors.

Failures in parental guidance

Stable family relationship & parental guidance are extremely important moldinginfluences for children & this stability is often lacking in families of alcoholics.Children who have parents who are extensive alcohol or drug abusers arevulnerable to develop addiction. The experiences or lessons we learn fromimportant figures in our early years have a significance importance on us asaudits - parent substance use is associated with early adolescent drug use.Children who’re exposed to the negative role models in their liver & vulnerable.Negative socialization factors might influence alcohol use.

Psychological vulnerability

Many alcoholics tend to be emotionally immature, expect a great deal of theworld, requires praise & appreciation, react to failure with marked feelings ofhurt & inferiority, have low frustration tolerance. Persons of risk for developingalcoholism are significantly more impulsive & aggressive

Stress, tension reduction & reinforcement.

Typical alcoholic is discontented with his life & is unable or unwilling totolerate stress & tension. Also subjects drank to relax. Anyone who finds alcoholto be tension- reducing is in danger of becoming an alcoholic, even without anystressful life situation. According to Cox & Klinger describe a motivational modelof alcohol use, i.e. the final common pathway of alcohol is motivation.i.e, aperson decided consciously or unconsciously, whether to consume a particulardrink of alcohol – alcohol is consumed to bring about affective changes, such asmood – altering effects . In short, alcohol is consumed because it is reinforcing tothe individual.

Expectations of social success

Cognitive expectations play an important role both in the initiation ofdrinking and in the maintenance of drinking behavior once the person has begun



to use alcohol. Young asdolesence expect that alcohol use will lower tension andanxiety and increase sexual desire and pleasure in life- which is referred to as thereciprocal influence model.

Marital and other intimate relationships

Excessive drinking often begins during crisis periods in marital or otherpersonal relationships, particularly crsis that lead to hurt and self devaluation.This is considered as one of the cause of divorce in U.S.

Socio cultural factors

Culture has become dependent on alcohol as a social lubricant and a means ofreducing tensions.

Treatment

Alcoholism is difficult to treat because they refuse to admit that they havea problem and many leave before therapy is completed.

A multi disciplinary approach to the treatment of drinking problemsappears to be most effective because the problems are often complex, requiringflexibility and individualization of treatment procedures.

Use of medications in treating alcohols

Biological approaches include a variety of treatment measures such asmedicines to reduce craving, to ease the deterioration process and to treat cooccurring mental health problems.

1) Medications to block the desire to drinkDisulfiram – a drug that causes vilolet vomiting when followed by ingestion ofalcohol.

Naltrexone – help to reduce the craving for alcohol.

2) Medications to lower the side effects of alcohol withdrawalDrugs like Valium help to overcome motor exitement, nausea and vomiting.

Psychological treatment approaches

Treatment often followed by medical treatments including family counsiling andthe use of community resources relating to employment etc.

1) Group therapy

In the confrontational give and take of Group therapy, alcoholics oftenforcedto face their problems and their tendencies to deny or to minimize theirinvolvement in their troubles when they describe them to a knowing audience



of “peers”. It may be difficult for them to hide or deny drinking problems whenthey are confronted by persons who have had similar problems

Group therapy provide opportunity for them to see new possibilities for copingwith circumstances that have led to their difficulties.

2) Environmental intervention

Environmental support is an important ingredient to alleviate an alcoholicsaversive life situation.

They become separated from family and friends and either lose theirjobs.They are so lonely and live in impoverished neighbourhoods.

Simply helping alcohols learn more effective coping techniques may not beenough if their social environment remains hostile and threatening.

For alcoholics who have been hospitalized, halfway houses are designed toassist them in their return to family and community.

The relapses and continued deterioration that alcohols often experienceare often associated with their lack of close relationship with family as well asliving in a stressful event.

3) Behavior therapy

1. Aversive conditioning- presentation of a wide range of noxious stimuli withalcohol consumption in order to suppress drinking behavior.

2. Intramuscular injection of emetine hydrochlorid, an emetic – beforeexperiencing the nausea that results from the injection, a patient is givenalcohol, so that the sight, smell and taste of the beverage become associatedwith severe retching and vomiting. I.e. a conditional aversion to taste to smellof alcohol develops.

DRUG ABUSE

Effects of Morphine and Heroin

Introduced into the body by smoking, snorting (inhaling the powder),eating ;“skin popping” or “main lining”(introducing the drug via hypodermic injection)

skin popping – injecting the liquefied drug just beneath the skin andmaintaining- injecting the drug directly in to the blood stream.

The following are the effects of morphine and heroine:

Vomiting and nausea also known to be a part of immediate effects.



The rush is followed by pleasant feeling of relaxation euphoria etc last for 4 to6 phases.

Use for long period results in a physiological craving for the drug.

When people addicted to opiate do not get a dose of the drug withinapproximately 8 hours, they start to experience Withdrawal Symptoms(WS)

WS include symptoms of runny nose, fearing eyes, perspiration, restlessness,increased respiration rate and an intensified desire for the drug- a feelingchilliness alternate with motor disturbances of flushing and excessivesweating, vomiting, diarrhea, head ache, tremors, insomnia etc leads to agradual deterioration of well being.

Cocaine and Amphetamines

Cocaine- a plant product- high price may be injected by sniffing, swallowingor injection. Cocaine precipitates a euphoric state of 4 to 6 hours durationduring which they experience feelings of confidence and contentment followed byhead ache, dizziness and restlessness. When chronically abused, acute toxicpsychotic symptoms may occur like visual, auditory hallucination. Cocainestimulates the cortex of brain, including sleeplessness and excitement.

Amphetamines

Earliest amphetamine – Benzedrine or amphetanic sulfate was firstsynthesized in 1927.It was initially known as “wonder pills” that helped peoplestay alert or awake and function temporarily at a level beyond normal. There is atendency to suppress appetite. Today amphetamine is used medically for curb inthe appetite when weight reduction is desirable. Also used for alleviating mildfeeling of depression, relieving fatigue etc.

Barbiturates

Once widely used by physicians to calm patients and induce sleep.Barbiturates act as depressants to slow down the action of the central nervoussystem and significantly reduce performance on cognitive tasks. An individualexperiences a feeling of relaxation in which tensions seem to disappear. Strongdoses produce sleep immediately. Excess doses result in paralysis of the brain.Impaired decision making and problem solving, slow speech, sudden mood shiftsare common.

LSD and Related Drugs

Hallucinogens are drugs whose properties are thought to inducehallucination. However these preparations usually do not intact “create” sensoryimages but distort them, So that individual sees or hears things in different andunusual ways. These are often referred to as psychotics. The major drugs in thiscategory are LSD(Lysergic acid Diethylamide), mescaline and psilocybin.



LSD, the most potent of the hallucinogen, the orderless, colorless andtasteless drug can produce intoxication with an amount smaller than a grain ofsalt. After taking LSD a person typically goes through about 8 hours of changesin sensory perception, mood swings and feeling of depersonalization anddetachment. The LSD experience is not always pleasant. It can be extremelytraumatic and the distorted object and sounds, the illusory colors and the newthoughts can be terrifying. An interesting and unusual phenomenon that mayoccur following the use of LSD is a flash back, an involuntary recurrence ofperceptual distortions or hallucinations weeks or even months after taking thedrug.

Marijuana

Although marijuana is classified as a mild hallucinogen, there aresignificant differences in the nature, intensity and duration of its effects ascompared with those induced by LSD. Marijuana comes from the leaves andflowering tops of the hemp plant, cannabis sativa. In its prepared state,marijuana consists chiefly of the dried green leaves hence the colloquial namegrass. It is ordinarily smoked in the form of cigarettes or in pipes. Marijuana isrelated to a strong drug.

When marijuana is smoked and inhaled, a state of slight intoxicationresults. This state is one of the mild euphoria distinguished by increased feelingof wellbeing, heightened perceptual acuity & pleasure, relaxation oftenaccompanied by a sensation to drifting or floating away .sensory inputs areintensified- STM may be affected.

Psychological effects include immediate increase in heart rate, a slowing ofreaction time, a slight contraction of pupil size, a dry mouth and an increasedappetite.

Caffeine and nicotine

Although these do not represent the extensive and self destructive problemsfound in drug and alcohol disorders, they are important in causing physical andmental health problem in our society due to,

* These drugs are easy to abuse

* These drugs are readily available

* These drugs have addictive properties

* It is difficult to guilt using these drugs

* Difficulty in dealing with withdrawal symptoms

Caffeine



It is found in commonly available drinks and foods

* Problems can occur as a result excessive caffeine intake

* Negative effects include intoxication rather than withdrawal

* Withdrawal from caffeine does not produce severe symptoms of restlessness,nervousness excitement, insomnia and other gastro intestinal complaints.

Nicotine

It is the chief active ingredient in tobacco, it is found in such items ascigarettes, chewing tobacco and ligers. Nicotine dependency syndrome, whichalways begins during the adolescent years and may continue in the adult life as adifficulty to breathe and health endangering habits. The nicotine withdrawaldisorder results from reducing the intake of nicotine containing substances afteran individual has acquired physical dependence on them. The symptomincluding craving for nicotine, irritability, frustration or anger, anxiety, difficultyconcentrating, restlessness, decrease the heart rate etc.



MODULE 2

ASSESSMENT

The relationship between assessment and diagnosis

It is often important to have an adequate classification of the presentingproblem for a number of reasons in any case, a formal diagnosis is necessarybefore insurance. Claims can be field, clinically; knowledge of a person’s type ofdisorder can help in planning and maintaining the appropriate treatment.Administratively, it is essential to know the range of diagnostic problems that arerepresented among the patient or client population and for which treatmentfacilities need to be available.

Taking a client history

For most clinical purposes, a formal diagnostic classification per second ismuch less important than having a basic understanding of the individualshistory, intellectual functioning, Personality characteristics and environmentalresources and pressures. That is an adequate assessment includes much morethan the diagnostic label.

Personality factors

In addition, assessment needs to include a description of any relevant longterm personality characteristics.

The social context

It is also important to assess the social context in which the individualoperates. What kinds of environmental demands all typically placed on theperson, and what supports or special stressors exist in his or her life situation.

Assessment of the physical organism



In some situations of with certain psychological problems, a medicalevaluation is necessary to rule out physical abnormalities that may be causing orcontributing to the problems. The medical evaluation may include both a generalphysical and special examinations aimed at assessing the structural andfunctional integrity of the brain as the behaviorally significant physical system.

1. The general physical examination

The physical examination consists of the kinds of procedures most of ushave experience in getting a “medical checkup”. Typically, a medical history isobtained and the major systems of the body are checked. This part of theassessment procedures is of obvious import for disorders that entail physicalproblems, such as somatoform, addictive and organic brain syndromes. Inadditions a variety of organic conditions, including various hormonalirregularities, can produce in some people behavioral symptoms that closelymimic those of mental disorders usually, considered to have predominantlypsycho social origins.

2. The neurological examination

Because brain pathology is sometimes involved or suspected to underlinesome mental disorders, a specialized neurological examination can be given inaddition to the general medical examination. This may involve getting anelectroencephalograph (EEG) to assess the brain wave patterns in awake andsleeping stages.

Anatomical brain scans

1. CAT ( Computerised Axial Tomography )

Anatomical brain scans, radiological technology, such as computerizedaxial tomography, known In brief as the CAT scan reveals images of parts of thebrain that might be diseased.

2. MRI

Magnetic resonance imaging (MRI) is the technique of choices in detectingstructured anatomical anomalies in the central nervous system, particularly thebrain.

3. PET scans (position emission tomography)

PET scan allows for an appraisal of how an organ is functioning bymeasuring metabolic processes. The PET scan provides metabolic portraits bytracking natural compounds like glucose as they are metabolized by the brain orother organs.

The neuropsychological examination



The techniques described so far are fairly accurate in identifyingabnormalities in the brains physical properties. Such abnormalities are veryoften accompanied by gross impairment in behavior and varied psychologicaldeficits. Although the nature of the latter may not be accurately predicted evenafter the precisely localizing these psychological impairments due to organicbrain abnormalities may become manifest before any organic brain lesion isdetectable by scanning or other means.

This need is met by a growing care of psychologists specializing inneuropsychological assessment, which involves the use of an expanding array oftesting devices to measure a person’s cognitive, perceptual and motorperformance as clues to the extent and location of brain damage.

In many instances of knowledge of suspected organic brain involvement aclinical neuropsychologist will administer a test battery to a patient. The person’sperformance on standardized tasks, particularly perceptual motor ones, can givevaluable clues about any cognitive and intellectual impairment following braindamage.

Many neurophysiologists prefer to select a highly individualized array oftests to administer, depending on a patients case history and other availableinformation.

Psychological assessment

Psychological assessment attempts to provide a realistic picture of anindividual in interaction with his or her social environment. This picture includesrelevant information concerning the individual’s personality make up and presentlevel of functioning, as well as information about the stressors and resources inhis or her life situation. For example, early in the process, clinicians may act likepuzzle solves, absorbing as much as information about the client as possible.Present feelings, attitudes, memories, demographic facts and so on and trying tofit the pieces together into a meaningful pattern.

1. Assessment interviews

An assessment interview often considered the central dimension of theassessment process, usually involves a face to face interaction in which aclinician obtains information about various aspects of a patients situations,behavior from a simple set of questions or prompts, to a more extended anddetailed format. It may be relatively open in character with an interviewer makingmoment to moment decisions about his or her next question based on responsesto prior ones, or it may be more tightly controlled and structured so as to ensurethat a particular set of questions is covered. In the later case the interviewer maychoose from a member of highly structured, standardized interview formatswhose reliability has been established in prior research. As used reliability meanssimply that two or more interviewers asserting the same client will generate



highly similar conclusions about the client, a type of consensus that researchshows can by no means be taken for granted.

Structured and unstructured interview

Although we know of few clinicians who express enthusiasm for the morecontrolled and structured type of assessment interview (preferring the freedom toexplore as they feel responses merit).the research data show it to yield far morereliable results. in general, than the more flexible format.

On the other hand, every rule has its exceptions, and we have seenbrilliantly conducted assessment Interviews where each question was fashionedon the spur of the moment. In most instances, however an assessor would bewise to conduct an interview that is carefully structured in terms of goals,comprehensive symptom review, other content to be explored, and the type ofrelationship the interviewer attempts to establish with the person.

Computerized interview

Computer programs with highly sophisticated branching subroutines areavailable to ”Tailor make” a diagnostic interview for a patient .For example,described a program called the computerized diagnostic interview for childrenthat can conduct a standard psychiatric interview

The clinical observation of behavior

One of the traditional and most useful assessment tools that a clinicianhas available is direct observation of a patient’s characteristics behavior. Themain purpose of direct observation s t learn more about the person’spsychological functioning through the objective description of appearance andbehavior in various contexts. Clinical observation refers to the clinician’sobjective description of the person’s appearance and behavior –his or herpersonal hygiene, emotional responses, any depression, anxiety, aggression,hallucination or delusions he or she may manifest. Ideally, clinical observationtakes place in the natural environment (such as classroom or home) but it ismore likely to take place upon admission to a clinic or hospital

In addition to making their own observation, many clinicians enlist theirpatient’s help by providing instruction in self-monitoring-self observation andobjective reporting of behavior, thoughts and feeling as they occur in variousnatural setting

Rating scale

As in the case of interview, the use of rating scale in clinical observationand in self reports helps not only to organize information but also to encouragereliability and objectivity. That is, the formal structure of a scale is likely to keepthe observer’s inferences to a minimum. The most useful rating scale commonly



used are those that enable a rater to indicate not only the presence or absence ofa trait or behavior but also its prominence.

One of the rating scales most widely used for recoding observations inclinical practice and in psychiatric research is the Brief Psychiatric Rating Scale(BPRS). The BPRS provides a structured and quantifiable format for ratingclinical symptoms, such as somatic concern, anxiety, emotional withdrawal, guiltfeelings, hostility, suspiciousness, and unusual thought patterns.

A similar but more specifically targeted instrument, the Hamilton RatingScale for Depression (HRSD) has become almost the standard in this respect forselecting clinically depressed research subject.

Psychological tests

Interview and behavioral observation are relatively direct attempts todetermine a person’s beliefs, attitudes, and problems. Psychological tests, on theother hand, are more indirect means of assessing psychological test(as opposedto the recreational ones sometimes appearing in newspaper and magazines) arestandardized sets of procedures or tasks for obtaining samples of behavior; asubject’s responses to the standardized stimuli are compared with those of otherpeople having comparable demographic characteristics, usually throughestablished test norms or test score distributions Two general categories ofpsychological tests for use in clinical practice are intelligence test and personalitytests

Intelligence Tests

A clinician can choose from a wide range of intelligence tests. TheWechsler intelligence scale for children-revised (WISC-3) and the current editionof the Stanford–binet intelligence scale are widely used in clinical settings formeasuring the intellectual abilities of children. Probably the most commonly usedtest for measuring adult intelligence is the Wechsler adult intelligence scale-revised (WAIS-3).It includes both verbal and performance material and consists of11 subjects. A brief description of two of the subjects will serve to illustrate thetype of functions the WAIS-3 measures.

Vocabulary (verbal): this subtest consists of a list of words to define thatare presented orally to the individual. This task is designed to evaluate theindividual vocabulary. This has been shown to be highly related to generalintelligence.

Digit span (performance): this subtest, a test of short term memory,consists of having a sequence of numbers administrated orally. The individual isasked to repeat the digits in the order administrated. Another task in this subtestinvolves remembering the numbers, holding them in memory, and revealing theorder sequence- the individual is instructed to say them backward.



Projective personality test

There are a great many tests designed to measure personalcharacteristics other than intellectual facility. It is customary to group thesepersonality tests into projective and objective tests. Projective tests areunstructured in that they rely on various ambiguous stimuli, such as inkblots orpictures, rather than explicit verbal questions, and the persons responses are notlimited to the true, false or cannot say correctly.

1.Rorschach Inkblot Test

The Rorschach, the Rorschach test is named after the Swiss psychiatristHerman Rorschach, who initiated experimental use of inkblots in personalityassessment in 1991.

Use of the Rorschach in clinical assessment is complicated and requiresconsiderable training. Methods of administrating the test vary, and someapproaches can take several hours and hence must complete for time with otheressential clinical service.

2. The Thematic Apperception Test (TAT)

TAT was introduced in 1935 by C.D Morgan and Henry Murray of theHarvard Psychological clinic. It still is widely used in clinical practice today. TheTAT uses a series of simple pictures, some highly representational and othersquite abstract about which a subject is instructed to make up stories. Thecontext of the pictures much of it depicting people in various contexts is highlyambiguous as to action and motives that subjects tend to reject their conflict andworries into it.

Objective Personality Test

Objective personality tests are structured that is they typically usequestionnaires, self inventories or Rating scales in which questions or items arecarefully phrased and alternative response are specified as choice

1.MMPI

The MMPI is one of the major structured inventories for personalityassessment.MMPI is the Minnesota multiphasic personality inventory (MMPI)now called the MMPI-2 after a revision in 1989 .We focus on it here because inmany ways it is the prototype and the standard of this class of instrument.

Clinical scales in MMPI



Scale 1 Hypochondriasis (HS) Measures excessive somatic concern andphysical

Scale 2 Depression (D) Measures symptomatic depression

Scale 3 Hysteria (HY) Measures hysteroid personality features

Scale 4 Psychopathic deviate (pd) Measures antisocial tendencies

Scale 5 Masculinity feminity (mf) Measures gender role reversal

Scale 6 Paranoia (pa) Measures suspicious paranoid ideations

Scale 7 Psychasthenia (pt) Measures anxiety and obsessive worryingbehaviour

Scale 8 Schizophrenia (sc) Measures pecularities in thinking feelingand social behavior

Scale 9 Hypomania(ma) Measures unrealistically elated moodstate and tendencies to yield to impulses.

Scale 10 Social introversion(si) Measures social anxiety withdrawal andover worrying

REFERENCES

1.Carson,RC,Butcher,N,Mineka,S(1996).Abnormal Psychology and Modern Life,(10th.ed)Harper Collins Inc,New York

2. Hurlock.E.B (1976) Personality Development,(IMH Ed).New York.Mc Graw HillInc.

3.Sarason,IG.,&Sarason,BR.,(1998)Abnormal Psychology: The Problem ofMaladaptive Behaviour,New Delhi: prentice Hall of India.

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