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ABNORMAL PSYCHOLOGY (PAPER II) B Sc COUNSELING PSYCHOLOGY VI SEMESTER

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ABNORMAL PSYCHOLOGY (PAPER II) B Sc COUNSELING PSYCHOLOGY VI SEMESTER
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
UNIVERSITY OF CALICUT
SCHOOL OF DISTANCE EDUCATION
STUDY 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
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MODULE
CONTENTS
PAGE No
I
OTHER BEHAVIOR DISORDERS
4
II
ASSESSMENT
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MODULE 1
OTHER BEHAVIOR DISORDERS
The schizophrenia and delusional disorder
Introduction
Belgian Psychiatrist described the case of schizophrenia in1860.He used
the term' Demence Precoce'.The Latin form of this term -dementia Precox-was
adopted by theGerman psychiatrist Emil kraeplin in late 19th century to refer to
a group of conditions that all seemed to have the features of mental deterioration
beginning early in the life. The term schizophrenia was used bythe Swiss
Psyhiatrist Eugen Bleuler in 1911, it means split mind.
Clinical picture of schizophrenia
There are two general symptom patterns or syndrome of schizophrenia1]Positive and 2] Negative syndrome schizophrenia.
•
Positive sign or syndrome: These syndromes are those in which something
has been added to a normal repertoire of behavior and experience. It also
known 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 good
response to drugs, limbic system abnormalities and normal brain ventricle
are also present.
•
Negative signs or syndrome refers to an absence of or deficit of behaviors
normally present in an individual's repertoire.It is also known as Type II
schizophrenia.The symptoms are
•
Emotional flattening
•
Poverty of speech
•
Lack of sociability
•
Apathy
•
Significant Cognitive impairment
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Insidious onset
•
Chronic course
The above symptoms plus uncertain respond to drug, frontal low
abnormalities, and Enlarged brain ventricle are the features present in negative
syndrome.
Major symptoms of schizophrenia.
1. Disturbance of associative linking
Often referred to as formal thought disorder. Associative disturbance is
usually considered as prime indicative of a schizophrenic disorder. Basically, an
affected person fails to make sense despite seeming to confirm to the semantic
and 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 are
being controlled by external agents, that one’s private thoughts are being
broadcast indiscriminately to others and that thoughts are being inserted into
one's brain by alien forces etc
3. Disruption of perception
Unable to sort out and process the great mass of sensory information to
which all of us are constantly exposed. Hallucination (false perception) such as
voices that only the schizophrenic person can hear. Auditory hallucinations are
often 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 subjective
sense of self
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2. Dellusional assumption of a new identity including an identity like
Jesus Christ etc
3. Persons may be confused about aspect of their own body including
gender,or may be uncertan about the boundaries separating the self from the rest
of the world.
6. Disrupted volition
Goal directed activity is almost universally disrupted in them. The
impairment 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 the
environment and elaboration of an inner world in which the person develop
illogical 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 a
marked 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 usual
diagnosis of schizophrenia including hallucination, delusion disordered thoughts
and bizarre behavior.
But they do not clearly fit into one of the other type. Also they show indication of
perplexity ,confusion, emotional turmoil,delusions of reference, excitement,
depression and fear etc.
2. Paranoid type of schizophrenia
They show histories of increased suspiciousness and difficulties in
interpersonal relations
They show absurd, illogical and often changing delusions.Persecutory
delusions are common.
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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 and
other hallucination
Impairment of critical judgment, unpredictable and occasionally dangerous
behavior
3. Catatonic type of schizophrenia
Pronounced motor signs, either of an excited or a stuporous type. Patients are
highly suggestible and will automatically obey command and or imitate the
actions of others (ecoproxia) or mimic their phrases (Ecolalia).
•
Tendency to remain motionless for hours or even days in a single
position(catatonic stupor)
•
The clinical picture may undergo an abrupt change,with excitement coming
on suddenly and may becomeviolent,maytalk or shout,pace rapidly,openly
indulge in sexual activity, attempt suicide and impulsively attack and try to
kick others.
4. Disorganized type (hebephrenia)
•
Represents a more severe disintegration of personality.
•
Usually occurs at an early age, emotional distortion manifested as
inappropriate laughter, stillness, peculiar mannerism etc.
•
Emotional distortion and blunting typically are manifested in inappropriate
laughter and silliness,peculiar mannerisms etc.
•
Speech become incoherent and include considerable baby talk, childish
giggling etc.
•
Patients may invent new words[Neologism]
•
Auditory hallucination are common
5. Residual type
This category used for people who have experienced episodes of
schizophrenia that they have recovered sufficiently as not to show prominent
psychotic symptom.
6. Schizophreniform disorder
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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 expected
rates 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 higher
than those for fraternal twins.
•
Adoption studies
True separation of hereditary from environmental influence by using
adoption strategy. Here concordance rate for schizophrenia is compared
for the biological and adaptive relatives of persons who have been
adopted out of the biological family at an early age subsequently became
schizophrenic.
If the rate is greater among the patient's biological than adaptive
relatives, a hereditary influence is strongly suggested.
•
Biochemical factors
This factor suggests that mental disoders are due to chemical
imbalances. Dopamine hypothesis suggest that schizophrenia is the
product of an excess of dopamine activity at certain syntaptic sites. This
is based on the observation that all of the early anti schizophrenic drugs
had the common property of blocking dopamine mediated neuron
transmission.
•
Neurophysiological factors
Imbalance in various nerophysiological processes and inappropriate
autonomic arousal. Abnormal brain reaction to stimulations, neurological
abnormalities such as reflex hyper activity and deficit performance in non
psychological testing are found.
•
Neuroanatomical factors
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•
Early brain injury
•
Obstetrical complications,such as premature birth is found as a factor.
•
Abnormal enlargement of ventricles.[Ventricles are the hollow areas in
brain 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 have
caused their children's disorders through hostility, deliberate rejection etc. These
parents are cruel and abusive.
•
Destructive parental interactions: Study by Lidz and associate of 14
families with schizophrenic offspring. They failed to find a single couple that
functioned as well. 8 out of the 14 family live in a state of severe chronic discord
in which continuation of marriage was threatened. Six others achieve a state of
equilibrium in which the relationship was maintained at the expense of a basic
distortion in family relationship.
Faulty communication
Gregory Bateson identifies the conflicting and confusing nature of
communication among members of family experiencing a schizophrenic out
comes. In this pattern parents present the child about ideas, feeling and demands
that are mutually incompatible. For e.g.; a mother may be verbally loving and
accepting 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 mid
1950s.
2. Psycho social approaches in treating schizophrenia
 Family therapy
 Individual psycho therapy
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It is effective in enhancing social adjustment and social role performance of
discharged patients.
 Social skills training and community treatment.
DELUSIONAL DISORDER
Formerly called paranoia or paranoid disorder. Diagnosis of delusional
disorder is difficult because it is not always possible to determine the truth or
falsity of an idea. Definitions of delusional disorder in DSM IV usually specifies
that an idea must be held as prepositions (complete contrary to the nature) by
the majority of a persons in community.
Types of delusional disorder
1. Persecutory type
The predominant delusional theme is that one or someone to whom one
closely related is being subjected to some kind of malevolent treatment such as
spying, 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 in
love with or to start sexual liasion with the delusion person.
4. Somatic type
The predominant
theme is that the affected person is having a
unshakable belief about having some physical illness.
an
5. Grandiose type
The predominant theme is that the affected person is having a belief that he is
a 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.
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 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 normal
inconventional emotionally and conduct.
 Hallucination rarely found.
Projective thinking: individual selectively project the action of others to confirm
suspiciousness and blames others for their failures.
Hostility: anger and hostile
Paranoid illumination: the moment when everything ‘false into place’ the
individual 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 good
socialization in terms of warm affectionate relationship.
 Their relatively unfriendly interpersonal style may make them unpopular with
peers
 This misunderstanding ,suspiciousness or coldly rejecting persons frequently
became a target of actual discrimination and mistreatment
MOOD DISORDER
Mood: A temporary but relatively sustained and pervasive affective state with a
more 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 sadness
and dejections.
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Manic episode” a mood episode lasting atleast one weak, characterized by
continuously elevated expansive or irritable mood, sufficiently severe to cause
market 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 the
main types of unipolar disorder.
•
Dysthymia: for atleast the past two years, the person has been bothered for
most of the day, for more days, by a depressed mood, and atleast two other
depressive symptoms, but not of sufficient persistent or severity to meet the
criteria for major depression.
Symptoms of dysthymia
The person may experience atleast two of the following six symptoms
when 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 identifiable
stressor occurring within the past 3 months, does not exceed 6 months.
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•
Major depressive disorder
The person has one or more major depressive episodes in the absence of
any manic or hypo manic episode.
Symptoms
•
Prominent and persistent depressed mood
•
Loss of pleasure for atleast two weeks, accompanied by four or more
symptoms such as poor appetite, insomnia, psycho motor retardation,
fatigue, feeling of breathlessness or ill, inability to concentrate and
thoughts of death and suicide.
BIPOLAR DISORDER
Person experience both manic and depressive episodes. The following are
the different types of bipolar disorder.
•
Cyclothymia, depressed
At present or during the past two years, the person experienced episodes resembling
dysthymia 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 manic
episodes.
•
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 either
loss of interest or pleasure in almost al activities. He may experience atleast three of
the following symptoms.
•
Early morning awakening
•
Depression being worse in the morning
•
Marked psycho motor retardation
•
Significant lows of appetite and weight
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Inappropriate or excessive guilt
Severe major depression disorder with psychotic features
Characterized by lows of contact with reality and including delusions (falls
beliefs) or hallucinations may sometimes accompany the other symptoms of
major depression.
Mood congruent and mood incongruent
Delusions and hallucination present are mood congruent. If they are appropriate
to serious depression. The mood incongruent means delusional thinking is incongruent
means delusional thinking is inconsistent with the predominant mood.
Seasonal affective disorder
Mood disorder may show seasonal pattern that is atleast two episodes of
depression in the past two years occurring at the same time of the year (winter) and full
remission 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 criteria
for both a major mood disorder (uni polar and bipolar) and atleast two major symptoms
of schizophrenia (hallucination and delusion)
Causal factors in mood disorder
Biological Factors
Hereditary factors
Prevalence of mood disorder is higher among blood relatives of persons with
clinically diagnosed mood disorder.
•
Twin study also suggested that they may be a moderate genetic
contribution to unipolar depression
•
9% of first degree relatives of a persons with bipolar disorder can also be
expected to have bipolar disorder
•
Concordance rates for these disorders are much higher for identical than
fraternal twins
Bio chemical factors
Studies revealed that depression may arise from disruption in the delegate balance
of neurotransmitter substances that regulates the brain functioning.
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Three neurotransmitters were focused viz norepineprine, dopamines and serotonin
because researchers observed that anti depressants seemed to have the effect of
increasing the availability of these neurotransmitter at synaptic functions.This lead
to monoamine hypothesis that depression was atleast sometimes due to an absolute
or relative depletion of one or all of these neuro transmitters. Later this hypothesis
was rejected.
Neuro endocrine and neuro physiological factors
Hormone cortisol is secreted by adrenal glands. Blood plasma level of cortisol
known to be elevated in form 50-60% of seriously depressed patients.A potent
suppressor of plasma cortisol in normal individuals, dexamethasone fails to suppress
cortisol in about 45% of depressed patients.
Dexametharone suppression text (DST) was used to assess depressed
individuals. People with hypothyroidism often become depressed due to disturbance in
hypothalamic pituitary-thyroid axis. Lesions of the left anterior or prefrontal cortex lead
to 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 death
like diagnosed as having cancer.
•
Single stressors of overwhelming magnitude such as the death of the child or
a parent
•
Several stressors occurring in a series
 Diathesis -stress model
•
It explains how stress interacts with various types of vulnerability factors to
reduce depression
•
The idea that people who eventually develop a disorder differ in some
underlying way from those who do not and this difference is known as
diathesis(predisposition)
•
It was assumed that the diathesis was biological in original and but later
cognitive and social factors also contribute
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 Beck’s cognitive theory
The one of the most prominent theory of depression for over 30 years is that of
Aaron Beck- a psychiatrist. Beck hypothesise that the cognitive symptoms of
depression may often proceeds and cause the mood symptoms rather than vice
versa. 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 everyone
does not love me, then my life is worthless.
•
Negative automatic thoughts
Thoughts that often occur just below the surplus of the awareness and involve
unpleasant pessimistic prediction. These pessimistic predictions tend to centre
on 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 will
always be this way)
 Helplessness and hopelessness theory
Learned helplessness theory was proposed by Seligman. Learned helplessness
produce three deficits. 1) Motivational deficit 2) cognitive deficit and 3) emotional
deficit.
Hopelessness theory is a revision of helplessness theory by Abramson et
all. They proposed that having a pessimistic attribution style in conjunction with
one or more negative life events was not sufficient to produce depression unless
one 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, non
western culture like China, the rate of depression are low.
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•
Demographic difference in United States. Poor socio economic class
have higher rate of major depression disorder but bipolar disorder are
more 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 depression
and mania. Mood stabilizer is often used to describe these drugs because
they have both anti manic and anti depressant effects. But there are side
effects for lithium like lethargy, decreased motor coordination and gastro
intestinal difficulties, also kidney malfunctioning and damage.
ECT
ECT is often used with seriously depressed patients who may present an
immediate and serious suicidal risk.
• Psycho therapy
Drugs and ECT are combined with individual or group psycho therapy
directed 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 for
unipolar depression are the cognitive behavioral therapy of Beck and the
interpersonal therapy of Klerman,Weissman,colleagues. CBT consists of highly
structured, systematic attempts to teach with depression to evaluate their
values, believes and negative automatic thoughts systematically; IPT is mainly
used in marital relation.
• Family and marital therapy
Family and marital is also given when required.
SUBSTANCE ABUSE AND DEPENDENCE
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Addictive behavior: behavior based on the pathological need for a
substance/activity, may involve the abuse of substances, such on nicotine,
alcohol, cocaine, the excessive ingestion of high calorie food, resulting in external
obesity.
Psycho active drugs: Those drugs that affect mental functioning; alcohol,
nicotine, barbiturates, minor tranquilizers, amphetamines, heroin and
marijuana.
Tolerance: the need for id amounts of a substance to active the desired
effects results from bio chemical changes in the body that affect the rate of
metabolism and eliminate alcohol from the body.
Withdrawal symptoms: physical symptoms such as sweating, tremors and
tension that accompany disturbance from the drug.
Alcohol abuse and dependence
WHO no longer recommends the term alcoholism but prefer the term
alcohol dependence syndrome- “a state, psychic and usually also physical
resulting from taking alcohol, characterized by behavioral and other responses
that always include a compulsion to take alcohol on a continous/periodic basis
inorder to experience its psychic affects, sometimes to avoid the discomfort of its
absence, tolerance may/ may not be present.
History
People of ancient cultures (Egyptian, Greek and Roman) excessively
used alcohol. Beer was developed by an Arabian chemist. First alcoholic on
record 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 years
shorter than that of the organized citizen. Alcohol use is the 3 rd major cause of
death In US
Alcoholic; refers to a persons with a serious drinking problem whose drinking
impairs his/her like real adjustment in terms of health personal relationships
and occupational functioning.
Alcoholism: refers to a dependence on alcohol that serious and interacts with
the 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 this
progressively developing pattern.Many studies shown that alcohol is a dangerous
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systemic poison even in small amounts, other believe that in moderate amount it
is not harmful to most people. Small amounts of red wine can even serve as a
protective factual in heart disease.For pregnant women, even moderate amounts
are 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 is
done by the liver, but when large amounts of alcohol are ingested, the liver may
be seriously overworked & eventually suffer irreversible damage. In fact, from 1530% of heavy drinkers develop cirrhosis of the liver – a disorder involving
extensive stiffening of the blood vessels. Alcohol is also a high calorie deug. A pint
of whisky provides about 1200 calories, which is approximately half the ordinary
caloric requirements for a day. This consumption of alcohol reduces a drinker’s
appetite for other food – because alcohol has no nutritional value, the excessive
drinker 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, impaired
reasoning & judgments & gradual personality deterioration.
Drinker assumes increasingly lesser responsibility, loses pride in personal
appearance, neglects spouse & family, becomes irritable & unwilling to discuss
the problem.
As judgment become impaired, an excessive drinker may be unable to hold
a 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 drinking
spree when the person is in a state of withdrawal. Slight noises or sudden moving
objects may cause considerable excitement and agitation.
Symptoms of alcohol withdrawal delirium includes
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_ 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 from
memory deficit. They may not recognize pictures, faces, rooms and other
object that they ‘ve just seen, although they may feel they are familiar. They
are delusional and disoriented for time & place. They also suffer from vitamin
B deliciency (thaiamine)
Casual factors
1) Biological factors
The development of an alcohol addiction is a complex process
involving many elements – constitutional vulnerability & environmental
encouragement as well as the unique biochemical properties of certain
psychoactive substances can lead to addictive behavior.
Neurobiology of addiction
Drugs differ in terms of their biochemical properties as well as
how 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 the
neuron chemical process underlying addiction is the role the drug plays in
activating 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 families
of 6251 alcoholics & 4083 non alcoholics reported that 1/3 of alcoholoics had
atleast 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 from
11.4% to 29.5% & having 2 parents increased the rate to 41.27%. For females
with one alholic parent the rate is 9.01, two parents the rate is 25%.
Genetic influences and learning
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Learning factors appear to play an important part in the development of
constitutional reaction tendencies. The person must be exposed to the
substance to a sufficient degree for the addictive behavior to appear. Peer
pressures, parental example & advertising also influence addictive behavior.
Living in an environment that promotes initial as well as continuing use of the
substances.
2) Psycho social casual factors
Alcoholics develop a powerful psychological as well as social dependence.The
following are the psychosocial causal factors.
Failures in parental guidance
Stable family relationship & parental guidance are extremely important molding
influences for children & this stability is often lacking in families of alcoholics.
Children who have parents who are extensive alcohol or drug abusers are
vulnerable to develop addiction. The experiences or lessons we learn from
important figures in our early years have a significance importance on us as
audits - 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 the
world, requires praise & appreciation, react to failure with marked feelings of
hurt & inferiority, have low frustration tolerance. Persons of risk for developing
alcoholism are significantly more impulsive & aggressive
Stress, tension reduction & reinforcement.
Typical alcoholic is discontented with his life & is unable or unwilling to
tolerate stress & tension. Also subjects drank to relax. Anyone who finds alcohol
to be tension- reducing is in danger of becoming an alcoholic, even without any
stressful life situation. According to Cox & Klinger describe a motivational model
of alcohol use, i.e. the final common pathway of alcohol is motivation.i.e, a
person decided consciously or unconsciously, whether to consume a particular
drink of alcohol – alcohol is consumed to bring about affective changes, such as
mood – altering effects . In short, alcohol is consumed because it is reinforcing to
the individual.
Expectations of social success
Cognitive expectations play an important role both in the initiation of
drinking and in the maintenance of drinking behavior once the person has begun
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to use alcohol. Young asdolesence expect that alcohol use will lower tension and
anxiety and increase sexual desire and pleasure in life- which is referred to as the
reciprocal influence model.
Marital and other intimate relationships
Excessive drinking often begins during crisis periods in marital or other
personal 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 of
reducing tensions.
Treatment
Alcoholism is difficult to treat because they refuse to admit that they have
a problem and many leave before therapy is completed.
A multi disciplinary approach to the treatment of drinking problems
appears to be most effective because the problems are often complex, requiring
flexibility and individualization of treatment procedures.
Use of medications in treating alcohols
Biological approaches include a variety of treatment measures such as
medicines to reduce craving, to ease the deterioration process and to treat co
occurring mental health problems.
1) Medications to block the desire to drink
Disulfiram – a drug that causes vilolet vomiting when followed by ingestion of
alcohol.
Naltrexone – help to reduce the craving for alcohol.
2) Medications to lower the side effects of alcohol withdrawal
Drugs like Valium help to overcome motor exitement, nausea and vomiting.

Psychological treatment approaches
Treatment often followed by medical treatments including family counsiling and
the use of community resources relating to employment etc.
1) Group therapy
In the confrontational give and take of Group therapy, alcoholics oftenforced
to face their problems and their tendencies to deny or to
minimize their
involvement in their troubles when they describe them to a knowing audience
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of “peers”. It may be difficult for them to hide or deny drinking problems when
they are confronted by persons who have had similar problems
Group therapy provide opportunity for them to see new possibilities for coping
with circumstances that have led to their difficulties.
2) Environmental intervention
Environmental support is an important ingredient to alleviate an alcoholics
aversive life situation.
They become separated from family and friends and either lose their
jobs.They are so lonely and live in impoverished neighbourhoods.
Simply helping alcohols learn more effective coping techniques may not be
enough if their social environment remains hostile and threatening.
For alcoholics who have been hospitalized, halfway houses are designed to
assist them in their return to family and community.
The relapses and continued deterioration that alcohols often experience
are often associated with their lack of close relationship with family as well as
living in a stressful event.
3) Behavior therapy
1. Aversive conditioning- presentation of a wide range of noxious stimuli with
alcohol consumption in order to suppress drinking behavior.
2. Intramuscular injection of emetine hydrochlorid, an emetic – before
experiencing the nausea that results from the injection, a patient is given
alcohol, so that the sight, smell and taste of the beverage become associated
with severe retching and vomiting. I.e. a conditional aversion to taste to smell
of 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 and
maintaining- 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.
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
The rush is followed by pleasant feeling of relaxation euphoria etc last for 4 to
6 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 within
approximately 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 feeling
chilliness alternate with motor disturbances of flushing and excessive
sweating, vomiting, diarrhea, head ache, tremors, insomnia etc leads to a
gradual deterioration of well being.
Cocaine and Amphetamines
Cocaine- a plant product- high price may be injected by sniffing, swallowing
or injection. Cocaine precipitates a euphoric state of 4 to 6 hours duration
during which they experience feelings of confidence and contentment followed by
head ache, dizziness and restlessness. When chronically abused, acute toxic
psychotic symptoms may occur like visual, auditory hallucination. Cocaine
stimulates the cortex of brain, including sleeplessness and excitement.
Amphetamines
Earliest amphetamine – Benzedrine or amphetanic sulfate was first
synthesized in 1927.It was initially known as “wonder pills” that helped people
stay alert or awake and function temporarily at a level beyond normal. There is a
tendency to suppress appetite. Today amphetamine is used medically for curb in
the appetite when weight reduction is desirable. Also used for alleviating mild
feeling 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 nervous
system and significantly reduce performance on cognitive tasks. An individual
experiences a feeling of relaxation in which tensions seem to disappear. Strong
doses produce sleep immediately. Excess doses result in paralysis of the brain.
Impaired decision making and problem solving, slow speech, sudden mood shifts
are common.
LSD and Related Drugs
Hallucinogens are drugs whose properties are thought to induce
hallucination. However these preparations usually do not intact “create” sensory
images but distort them, So that individual sees or hears things in different and
unusual ways. These are often referred to as psychotics. The major drugs in this
category are LSD(Lysergic acid Diethylamide), mescaline and psilocybin.
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LSD, the most potent of the hallucinogen, the orderless, colorless and
tasteless drug can produce intoxication with an amount smaller than a grain of
salt. After taking LSD a person typically goes through about 8 hours of changes
in sensory perception, mood
swings and feeling of depersonalization and
detachment. The LSD experience is not always pleasant. It can be extremely
traumatic and the distorted object and sounds, the illusory colors and the new
thoughts can be terrifying. An interesting and unusual phenomenon that may
occur following the use of LSD is a flash back, an involuntary recurrence of
perceptual distortions or hallucinations weeks or even months after taking the
drug.
Marijuana
Although marijuana is classified as a mild hallucinogen, there are
significant differences in the nature, intensity and duration of its effects as
compared with those induced by LSD. Marijuana comes from the leaves and
flowering tops of the hemp plant, cannabis sativa. In its prepared state,
marijuana consists chiefly of the dried green leaves hence the colloquial name
grass. It is ordinarily smoked in the form of cigarettes or in pipes. Marijuana is
related to a strong drug.
When marijuana is smoked and inhaled, a state of slight intoxication
results. This state is one of the mild euphoria distinguished by increased feeling
of wellbeing, heightened perceptual acuity & pleasure, relaxation often
accompanied by a sensation to drifting or floating away .sensory inputs are
intensified- STM may be affected.
Psychological effects include immediate increase in heart rate, a slowing of
reaction time, a slight contraction of pupil size, a dry mouth and an increased
appetite.
Caffeine and nicotine
Although these do not represent the extensive and self destructive problems
found in drug and alcohol disorders, they are important in causing physical and
mental 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
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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 as
cigarettes, chewing tobacco and ligers. Nicotine dependency syndrome, which
always begins during the adolescent years and may continue in the adult life as a
difficulty to breathe and health endangering habits. The nicotine withdrawal
disorder results from reducing the intake of nicotine containing substances after
an individual has acquired physical dependence on them. The symptom
including craving for nicotine, irritability, frustration or anger, anxiety, difficulty
concentrating, restlessness, decrease the heart rate etc.
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MODULE 2
ASSESSMENT
The relationship between assessment and diagnosis
It is often important to have an adequate classification of the presenting
problem for a number of reasons in any case, a formal diagnosis is necessary
before insurance. Claims can be field, clinically; knowledge of a person’s type of
disorder can help in planning and maintaining the appropriate treatment.
Administratively, it is essential to know the range of diagnostic problems that are
represented among the patient or client population and for which treatment
facilities need to be available.
Taking a client history
For most clinical purposes, a formal diagnostic classification per second is
much less important than having a basic understanding of the individuals
history, intellectual functioning, Personality characteristics and environmental
resources and pressures. That is an adequate assessment includes much more
than the diagnostic label.
Personality factors
In addition, assessment needs to include a description of any relevant long
term personality characteristics.
The social context
It is also important to assess the social context in which the individual
operates. What kinds of environmental demands all typically placed on the
person, and what supports or special stressors exist in his or her life situation.
Assessment of the physical organism
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In some situations of with certain psychological problems, a medical
evaluation is necessary to rule out physical abnormalities that may be causing or
contributing to the problems. The medical evaluation may include both a general
physical and special examinations aimed at assessing the structural and
functional 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 us
have experience in getting a “medical checkup”. Typically, a medical history is
obtained and the major systems of the body are checked. This part of the
assessment procedures is of obvious import for disorders that entail physical
problems, such as somatoform, addictive and organic brain syndromes. In
additions a variety of organic conditions, including various hormonal
irregularities, can produce in some people behavioral symptoms that closely
mimic those of mental disorders usually, considered to have predominantly
psycho social origins.
2.
The neurological examination
Because brain pathology is sometimes involved or suspected to underline
some mental disorders, a specialized neurological examination can be given in
addition to the general medical examination. This may involve getting an
electroencephalograph (EEG) to assess the brain wave patterns in awake and
sleeping stages.
Anatomical brain scans
1.
CAT
( Computerised Axial Tomography )
Anatomical brain scans, radiological technology, such as computerized
axial tomography, known In brief as the CAT scan reveals images of parts of the
brain that might be diseased.
2.
MRI
Magnetic resonance imaging (MRI) is the technique of choices in detecting
structured anatomical anomalies in the central nervous system, particularly the
brain.
3. PET scans (position emission tomography)
PET scan allows for an appraisal of how an organ is functioning by
measuring metabolic processes. The PET scan provides metabolic portraits by
tracking natural compounds like glucose as they are metabolized by the brain or
other organs.
The neuropsychological examination
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The techniques described so far are fairly accurate in identifying
abnormalities in the brains physical properties. Such abnormalities are very
often accompanied by gross impairment in behavior and varied psychological
deficits. Although the nature of the latter may not be accurately predicted even
after the precisely localizing these psychological impairments due to organic
brain abnormalities may become manifest before any organic brain lesion is
detectable by scanning or other means.
This need is met by a growing care of psychologists specializing in
neuropsychological assessment, which involves the use of an expanding array of
testing devices to measure a person’s cognitive, perceptual and motor
performance as clues to the extent and location of brain damage.
In many instances of knowledge of suspected organic brain involvement a
clinical neuropsychologist will administer a test battery to a patient. The person’s
performance on standardized tasks, particularly perceptual motor ones, can give
valuable clues about any cognitive and intellectual impairment following brain
damage.
Many neurophysiologists prefer to select a highly individualized array of
tests to administer, depending on a patients case history and other available
information.
Psychological assessment
Psychological assessment attempts to provide a realistic picture of an
individual in interaction with his or her social environment. This picture includes
relevant information concerning the individual’s personality make up and present
level of functioning, as well as information about the stressors and resources in
his or her life situation. For example, early in the process, clinicians may act like
puzzle solves, absorbing as much as information about the client as possible.
Present feelings, attitudes, memories, demographic facts and so on and trying to
fit the pieces together into a meaningful pattern.
1. Assessment interviews
An assessment interview often considered the central dimension of the
assessment process, usually involves a face to face interaction in which a
clinician obtains information about various aspects of a patients situations,
behavior from a simple set of questions or prompts, to a more extended and
detailed format. It may be relatively open in character with an interviewer making
moment to moment decisions about his or her next question based on responses
to prior ones, or it may be more tightly controlled and structured so as to ensure
that a particular set of questions is covered. In the later case the interviewer may
choose from a member of highly structured, standardized interview formats
whose reliability has been established in prior research. As used reliability means
simply that two or more interviewers asserting the same client will generate
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highly similar conclusions about the client, a type of consensus that research
shows can by no means be taken for granted.
Structured and unstructured interview
Although we know of few clinicians who express enthusiasm for the more
controlled and structured type of assessment interview (preferring the freedom to
explore as they feel responses merit).the research data show it to yield far more
reliable results. in general, than the more flexible format.
On the other hand, every rule has its exceptions, and we have seen
brilliantly conducted assessment Interviews where each question was fashioned
on the spur of the moment. In most instances, however an assessor would be
wise to conduct an interview that is carefully structured in terms of goals,
comprehensive symptom review, other content to be explored, and the type of
relationship the interviewer attempts to establish with the person.
Computerized interview
Computer programs with highly sophisticated branching subroutines are
available to ”Tailor make” a diagnostic interview for a patient .For example,
described a program called the computerized diagnostic interview for children
that can conduct a standard psychiatric interview
The clinical observation of behavior
One of the traditional and most useful assessment tools that a clinician
has available is direct observation of a patient’s characteristics behavior. The
main purpose of direct observation s t learn more about the person’s
psychological functioning through the objective description of appearance and
behavior in various contexts. Clinical observation refers to the clinician’s
objective description of the person’s appearance and behavior –his or her
personal hygiene, emotional responses, any depression, anxiety, aggression,
hallucination or delusions he or she may manifest. Ideally, clinical observation
takes place in the natural environment (such as classroom or home) but it is
more likely to take place upon admission to a clinic or hospital
In addition to making their own observation, many clinicians enlist their
patient’s help by providing instruction in self-monitoring-self observation and
objective reporting of behavior, thoughts and feeling as they occur in various
natural setting
Rating scale
As in the case of interview, the use of rating scale in clinical observation
and in self reports helps not only to organize information but also to encourage
reliability and objectivity. That is, the formal structure of a scale is likely to keep
the observer’s inferences to a minimum. The most useful rating scale commonly
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used are those that enable a rater to indicate not only the presence or absence of
a trait or behavior but also its prominence.
One of the rating scales most widely used for recoding observations in
clinical practice and in psychiatric research is the Brief Psychiatric Rating Scale
(BPRS). The BPRS provides a structured and quantifiable format for rating
clinical symptoms, such as somatic concern, anxiety, emotional withdrawal, guilt
feelings, hostility, suspiciousness, and unusual thought patterns.
A similar but more specifically targeted instrument, the Hamilton Rating
Scale for Depression (HRSD) has become almost the standard in this respect for
selecting clinically depressed research subject.
Psychological tests
Interview and behavioral observation are relatively direct attempts to
determine a person’s beliefs, attitudes, and problems. Psychological tests, on the
other hand, are more indirect means of assessing psychological test(as opposed
to the recreational ones sometimes appearing in newspaper and magazines) are
standardized sets of procedures or tasks for obtaining samples of behavior; a
subject’s responses to the standardized stimuli are compared with those of other
people having comparable demographic characteristics, usually through
established test norms or test score distributions Two general categories of
psychological tests for use in clinical practice are intelligence test and personality
tests
Intelligence Tests
A clinician can choose from a wide range of intelligence tests. The
Wechsler intelligence scale for children-revised (WISC-3) and the current edition
of the Stanford–binet intelligence scale are widely used in clinical settings for
measuring the intellectual abilities of children. Probably the most commonly used
test for measuring adult intelligence is the Wechsler adult intelligence scalerevised (WAIS-3).It includes both verbal and performance material and consists of
11 subjects. A brief description of two of the subjects will serve to illustrate the
type of functions the WAIS-3 measures.

Vocabulary (verbal): this subtest consists of a list of words to define that
are presented orally to the individual. This task is designed to evaluate the
individual vocabulary. This has been shown to be highly related to general
intelligence.

Digit span (performance): this subtest, a test of short term memory,
consists of having a sequence of numbers administrated orally. The individual is
asked to repeat the digits in the order administrated. Another task in this subtest
involves remembering the numbers, holding them in memory, and revealing the
order sequence- the individual is instructed to say them backward.
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Projective personality test
There are a great many tests designed to measure personal
characteristics other than intellectual facility. It is customary to group these
personality tests into projective and objective tests. Projective tests are
unstructured in that they rely on various ambiguous stimuli, such as inkblots or
pictures, rather than explicit verbal questions, and the persons responses are not
limited to the true, false or cannot say correctly.
1.Rorschach Inkblot Test
The Rorschach, the Rorschach test is named after the Swiss psychiatrist
Herman Rorschach, who initiated experimental use of inkblots in personality
assessment in 1991.
Use of the Rorschach in clinical assessment is complicated and requires
considerable training. Methods of administrating the test vary, and some
approaches can take several hours and hence must complete for time with other
essential clinical service.
2. The Thematic Apperception Test (TAT)
TAT was introduced in 1935 by C.D Morgan and Henry Murray of the
Harvard Psychological clinic. It still is widely used in clinical practice today. The
TAT uses a series of simple pictures, some highly representational and others
quite abstract about which a subject is instructed to make up stories. The
context of the pictures much of it depicting people in various contexts is highly
ambiguous as to action and motives that subjects tend to reject their conflict and
worries into it.
Objective Personality Test
Objective personality tests are structured that is they typically use
questionnaires, self inventories or Rating scales in which questions or items are
carefully phrased and alternative response are specified as choice
1.MMPI
The MMPI is one of the major structured inventories for personality
assessment.MMPI is the Minnesota multiphasic personality inventory (MMPI)
now called the MMPI-2 after a revision in 1989 .We focus on it here because in
many ways it is the prototype and the standard of this class of instrument.
Clinical scales in MMPI
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Scale 1
Hypochondriasis (HS)
Measures excessive somatic concern and
physical
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 worrying
behaviour
Scale 8
Schizophrenia (sc)
Measures pecularities in thinking feeling
and social behavior
Scale 9
Hypomania(ma)
Measures unrealistically elated mood
state and tendencies to yield to impulses.
Scale 10 Social introversion(si)
Measures social anxiety withdrawal and
over 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 Hill
Inc.
3.Sarason,IG.,&Sarason,BR.,(1998)Abnormal Psychology:
Maladaptive Behaviour,New Delhi: prentice Hall of India.
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