Block-1

BPCC-133
PSYCHOLOGICAL DISORDERS
School of Social Sciences

Indira Gandhi National Open University
EXPERT COMMITTEE
Prof. Manjula M. Prof. Swati Patra Dr. Monika Misra
Additional Professor Discipline of Psychology Discipline of Psychology
NIMHANS, Bangalore SOSS, IGNOU, New Delhi SOSS, IGNOU, New Delhi
Prof. Anuradha Sovani Prof. Suhas Shetgovekar Dr. Smita Gupta
Dept. of Psychology Discipline of Psychology Discipline of Psychology
SNDT Women’s University SOSS, IGNOU, New Delhi SOSS, IGNOU, New Delhi
Mumbai
COURSE PREPARATION TEAM
Block & Unit Unit Writer / Editor ( Content, Format, Language)
Block 1 INTRODUCTON TO PSYCHOLOGICAL DISORDERS & DISORDERS OF ANXIETY AND

OBSESSIONS
Unit 1 What is a Psychological Disorder? Dr. Gulgoona Jamal, Assistant Professor, Zakhir Hussain
College, University of Delhi
Unit 2 Disorders of Anxiety, Panic, Fear and Dr. Gulgoona Jamal, Assistant Professor, Zakhir Hussain
Obsessions-I College, University of Delhi
Unit 3 Disorders of Anxiety, Panic, Fear and Dr. Gulgoona Jamal, Assistant Professor, Zakhir Hussain
Obsessions-II College, University of Delhi
Block 2 MOOD DISORDERS, PSYCHOTIC DISORDERS, SOMATIC SYMPTOMS AND EATING

DISORDERS
Unit 4 Mood Disorders and Suicide Dr, Itisha Nagar, Assistant Professor, Kamala Nehru
College, University of Delhi.
Unit 5 Schizophrenia Spectrum and Other Dr, Itisha Nagar, Assistant Professor, Kamala Nehru
Psychotic Disorders College, University of Delhi.
Unit 6 Somatic Symptoms and Related Disorders Dr, Itisha Nagar, Assistant Professor, Kamala Nehru
Unit 7 Eating disorders Dr, Itisha Nagar, Assistant Professor, Kamala Nehru
Block 3 DISORDERS OF PERSONALITY, PARAPHILIC AND SUBSTANCE-RELATED DISORDERS

Unit 8 Personality Disorders: Cluster A Ms. Vrushali Pathak, Assistant Professor (Ad-hoc), Jesus
and Mary College, University of Delhi.
Unit 9 Personality Disorders: Cluster B and Ms. Vrushali Pathak, Assistant Professor (Ad-hoc), Jesus
Cluster C and Mary College, University of Delhi.
Unit 10 Paraphilic Disorders and Sexual Ms. Vrushali Pathak, Assistant Professor (Ad-hoc), Jesus
Dysfunctions and Mary College, University of Delhi.
Unit 11 Substance-Related Disorders and Dr, Itisha Nagar, Assistant Professor, Kamala Nehru
Behavioral Addictions College, University of Delhi.
Block 4 DISORDERS OF CHILDHOOD AND ADOLESCENCE, TRAUMA AND STRESSOR

RELATED DISORDERS AND NEUROCOGNITIVE DISORDERS
Unit 12 Childhood and Neurodevelopmental Dr, Itisha Nagar, Assistant Professor, Kamala Nehru
Disorders-I College, University of Delhi.
Unit 13 Childhood and Neurodevelopmental Dr, Itisha Nagar, Assistant Professor, Kamala Nehru
Disorders-II College, University of Delhi.
Unit 14 Neurocognitive Disorders Ms. Vrushali Pathak, Assistant Professor (Ad-hoc), Jesus
Unit 15 Trauma and Stressor Related Disorders Ms. Vrushali Pathak, Assistant Professor (Ad-hoc), Jesus
subsection by a relatively smaller but bold typeface. Divisions within the
subsections are in relatively smaller bold typeface so as to make it easy for you
to understand.
Let us now discuss each section of a unit.
Learning Objectives
We begin each unit with the section Learning Objectives. It tells you briefly
what we expect from you once you complete working on the unit.
Introduction
In the section Introduction, we specify,

a) The relationship of the present unit to the previous unit.
b) The theme of the present unit
c) The order of presentation of all the sections in the unit from Introduction to
Summary
Summary
This section of each unit under the heading Summary, presents the whole unit
for the purpose of ready reference and recapitulation.
Box
Sometimes certain topics may deal with abstract ideas and related concepts, as
well as some case studies. Thus, it becomes necessary to explain these related
concepts in a separate enclosure, which is called Box, in our units. This is added
information which is necessary to comprehend the main text. These boxes may
include (i) explanatory notes regarding concepts, (ii) information about main
works of scientists/psychologists who have contributed to a particular topic, (iii)
certain case-studies that are related to the concepts being discussed, etc.
Illustration
There are several illustrations in each unit in the form of pictures, figures, diagrams
and images. The main purpose of these illustrations is to make the study
comprehensive and interesting.
Case Study
In many of the Units, disorders have been explained with the help of Case studies.
The case studies are integrated in the content and highlight the important features
of the disorders. With the case studies, you will become aware of how the disorders
affect one’s day to day functioning and the surroundings. Case studies will also
help you to understand that psychological disorders may occur in people across
diverse backgrounds.
Check Your Progress
We have given self-check exercises under the caption Check Your Progress at
the end of main sections. To answer the Check Your Progress questions, you
should,
a) Write your answers using the space given below each question
b) Label the diagrams in the space provided (if any).
You will be tempted to have a glance of the main text as soon as you come across
an exercise. But we do hope that you will resist this temptation and turn to the
main text only after completing the answers.
You should read each unit and note the important points in the margin provided
in the course material. This will help in your study. It will also help you to answer
the self-check exercises and the assignment questions, as well as help in revising
your course before appearing for your Term End Examination.
Key Words
Each unit has key words at the end of the unit, to explain the basic ideas, technical
terms and difficult words.
References and Further Reading
We have given a list of references at the end of each unit. This is a list of books
and articles used by the course writers to prepare the units. This reflects that
your course material is based on a wide spectrum of literature available on a
particular theme, related to your course. This also informs you of the wide
literature available in the particular area of study. If interested in widening your
knowledge, you may look for the mentioned references. Each reference mentions
the name of the author, year of publication, title of the book/article, name of
publisher and place of publication.
Further readings help you to increase your level of understanding of a particular

theme in each unit, though it is not a compulsory reading.
References for Images
The URL for the figures has been mentioned for the sources of images and pictures
in the unit. If interested, you may also look for the mentioned references.
Web Resources
We have given a list of online references, on various topics, in each unit. Apart
from the text material, if you are interested in learning more about the topic, then
you may access the website as mentioned, for a particular topic.
Review Questions
Besides Check Your Progress, we have given Review Questions after summary
section in each unit. You may practice these questions which will help you in
answering assignments and Term End Examination Question Paper, though the
pattern and style of questions asked may not be similar.
Audio and Video Aids
Some Units have been selected for the audio and video programmes to supplement
the printed material. This will help you to understand the units with greater clarity.
Preparation of Course Material
The syllabus of course material BPCC-133 is designed by an Expert Committee

(see page 2 of this course) and prepared by Course Preparation Team which
comprises the author(s) of units, content editor(s), language editor, and the course
coordinator. The expert committee selected the themes and sub-themes of the
blocks and units, keeping in view the prescribed syllabi of UGC (CBCS
model).The authors of units have provided their expertise in elaborating them in
the form of the main text of each unit. The content editor has carefully examined
the course contents and has made an attempt to make the material clear and
comprehendible.
For any query or feedback related to the course, you may contact the Course
Coordinator at,
Dr. Monika Misra

Room No.31, Block-F,
School of Social Sciences
IGNOU, New Delhi
E: monikamisra@ignou.ac.in
P: 011-29572781
Block 2 consists of four Units. Unit 4 focuses on mood disorders. The types of
unipolar and bipolar disorders are explained in this unit. Their causal factors,
prevalence and treatment are also discussed. The unit also covers suicide and
suicidal ideation.
Unit 5 gives a description on schizophrenia spectrum disorders. The unit presents

an overview of positive and negative symptoms, types of psychotic disorders,
biological, psychological and socio-cultural causes of the disorder. The unit also
briefly discusses the treatment of psychosis.
Unit 6 highlights somatic symptoms and related disorders.The clinical picture,

causal factors and treatment of illness anxiety disorder, factititious disorder and
conversion disorder are discussed. Distinction between conversion disorder,
factitious disorder, and malingering (faking) is also explained.
Unit 7 introduces eating disorders, namely bulimia nervosa, and anorexia nervosa.
Their clinical features, probable causes and treatment options are discussed.
Block 3 consists of four units. Unit 8 introduces you to an important group of

disorders, namely personality disorders. In this unit, Cluster A: schizoid, paranoid
and schizotypal personality disorders are discussed with their clinical features,
causes and treatment.
In a similar way, in Unit 9, Cluster B and C personality disorders are explained.

Unit 10 introduces to the paraphilic disorders and sexual dysfunctions. Concepts
like normal sexuality, gender differences in sexuality, and sexual response cycle
are explained. The sexual disorders and dysfunctions as mentioned in DSM-5
have been discussed. We then move to discuss their etiology and treatment
modalities. An overview of gender dysphoria and transsexualism is also presented.
Unit 11 explains substance use and related disorders. The changes in the
classification from DSM IV are also discussed. The unit explains the differences
between substance use, abuse and dependency. Explanation of etiology and the
physical and psychological effects of substance use disorders are addressed.
Gambling disorder, a recent entry in DSM-5, has also been discussed briefly.
Block 4 consists of four units. Unit 12 and Unit 13 give a description of childhood
and adolescent psychological disorders. Developmental psychopathology is
discussed in Unit 12. The main disorders described are childhood depression,
oppositional defiant disorder/conduct disorder and attention deficit/hyperactivity
disorders. Neurodevelopmental disorders like, intellectual disability, autism
spectrum disorder and specific learning disorders are discussed in Unit 13.
Unit 14 discusses the nature of neurocognitive disorders. Major neurocognitive

disorders, delirium, and amnestic disorders are explained. The unit also covers
the causal factors and treatment of neurocognitive disorders.
Lastly, Unit 15 will introduce you to trauma and stressor related disorders. The
unit will explain the concepts of stress, stressors, and association of stress to
mental and physical health. Disorders like adjustment disorder, acute stress
disorder and posttraumatic stress disorder will be discussed. The unit will also
highlight the significance and objectives of crisis intervention for trauma related
disorders.
BLOCK 1
INTRODUCTION TO PSYCHOLOGICAL
DISORDERS AND DISORDERS OF ANXIETY
AND OBSESSIONS
Introducton to Psychological
Disorders & Disorders of
Anxiety and Obsessions
14
What is a Psychological
UNIT 1 WHAT IS A PSYCHOLOGICAL Disorder?
DISORDER? *
Structure
1.0 Introduction
1.1 Definition and Criteria of Psychological Disorder
1.2 History of Psychological Disorders
1.3 Psychological Models
1.4 Classification of Psychological Disorders
1.5 Causes of Psychological Disorders
1.6 Assessment of Psychological Disorders
1.7 Types of Assessment
1.8 The Integration of Assessment Data
1.9 Ethical Issues in Assessment
1.10 Summary
1.11 Keywords
1.12 Review Questions
1.13 References and Further Reading
1.14 Web Resources
Learning Objectives
After reading this Unit, you will be able to:
Explain the meaning and nature of psychological disorders
Discuss the clinical presentation, causal factors, and treatment of
psychological disorders;
Summarize the classification of psychological disorders;
Explain the meaning of abnormal behaviour; and
Elucidate the methods and techniques used in assessment of psychological
disorders.
1.0 INTRODUCTION
Psychological disorders are fairly common. This should not surprise you. When
we speak about health, it encompasses both physical and mental health. However,
invariably, our attention is drawn primarily towards physical problems and
diseases. Psychological disorders or psychopathology, have certain symptoms,
etiology (how it occurs), the conditions in which it is maintained, and effect on
day-to -day functioning of the individual. Psychological disorder may develop
in anyone, irrespective of age, gender, ethnicity, region, and other such factors.
It affects the people surrounding the person who has a psychological disorder. At
times, people experience more than one disorder at the same time (comorbidity).
Psychological problems are on the rise not only in India, but across the world.
Observing the frequency, and widespread suffering that the disorder causes, it
* Dr. Gulgoona Jamal, Assistant Professor, Zakhir Hussain College, University of Delhi, New 15
delhi
Introducton to Psychological becomes pertinent to understand its nature. To start with this, in the present Unit,
history, classification, and criteria of psychological disorders will be discussed,
followed by the causal factors and assessment of psychological disorders.
1.1 WHAT IS A PSYCHOLOGICAL DISORDER?

According to Barlow and Durand (2008), psychological disorder is a
psychological dysfunction within an individual that is associated with distress
or impairment in functioning and a response that is not typical or culturally
expected. Let us examine the three criteria enlisted in this definition of a
psychological disorder:
Psychological dysfunction in the definition refers to breakdown in cognitive,
emotional, or behavioral functioning. For example, you are out in a market for
shopping, but instead of enjoying it, you experience severe fear all the time and
just want to rush back home, even though there is nothing to be afraid of, and
this happens every time when you go to the market. However, if there was a
bomb scare or a riot erupted in that market in the recent past, then it would not be
dysfunctional for you to be fearful and avoid that market for some time. Many
people may experience a mild version of a fearful reaction without meeting the
criteria for a disorder. To draw the line between normal and abnormal dysfunction
is often difficult. Hence, these problems are often considered to be on a continuum
or a dimension, rather than as categories that are either present or absent. Thus,
having a dysfunction is not enough to meet the criteria for a psychological disorder.
Distress or impairment in functioning seems to be an important and clearly
defined component. However, it is often quite normal to be distressed (e.g., death
of a loved one). There are certain disorders which do not lead to personal distress
e.g., mania, in which the patient feels elated and enjoys it so much that he/she
avoids treatment but nonetheless is still in a dysfunctional state.The concept of
impairment is useful though not entirely satisfactory, e.g., a person may consider
him/herself shy, but it does not mean he/she is abnormal unless they are unable
to interact with people and make friends. This again illustrates that most
psychological disorders are extreme expressions of normal emotions, behaviors,
and/or cognitive processes.
A typical or not culturally expected is an important but insufficient criterion to
determine abnormality. At times, things are considered abnormal because they
occur infrequently and deviates from the average. The greater the deviation, the
more abnormal it is. However, not all kinds of deviation can be considered as
disorders, e.g., artists usually deviate from normal, but instead of being identified
as disordered, they are called talented and with unusual thinking. Not only such
people are well paid, but they enjoy their careers as well. The society accepts
such unusual thinking.
In addition to the above, some other criteria are:

Violation of social norms is considered to be abnormal. This definition is very
useful in understanding the cultural differences in psychological disorders, e.g.,
to enter a trance state or to believe that one is possessed, reflects a psychological
disorder in western cultures but not in many other cultures where it is expected
and accepted (Sapolsky, 2002). However, violation of social norms as a criterion
has been misused, e.g., political dissidents are often committed to mental
16 institutions, for example, during dictatorship in former Soviet Union.
Statistical infrequency as defined by Davison, Neale and Kring (2004) is a What is a Psychological
Disorder?
criterion for abnormal behavior. The normal curve places most people in the
middle as far as any characteristic is concerned and very few people fall at either
extreme. Statistical infrequency is used explicitly in diagnosing intellectual
disabilities.
Wakefield (1992, 1999) proposed abnormal behavior as a harmful dysfunction.

This definition has two parts: harmful and dysfunction. Harmful is a value
judgement whereas dysfunction is an objective, scientific component. To judge
a behavior as harmful requires some standard which is likely to depend on
sociocultural values. Dysfunction occurs when an internal mechanism is unable
to perform the function for which it was designed by evolution. The problem
with Wakefield’s definition is that while in medicine, dysfunctions can be
identified in a rather straightforward manner, e.g., clogged arteries cause
cardiovascular disease. However, in case of mental disorders, mental or biological
mechanisms that are not functioning properly are largely unknown, e.g.,
schizophrenia is caused due to excessive secretion of dopamine or lack of
postsynaptic receptors is still being investigated.
Thus, no single criterion provides a satisfactory definition of abnormal behavior.

However, together the criteria provided a framework initially, to define
abnormality. Variants of these approaches are most often used in current diagnostic
practice and is outlined in DSM-5 (American Psychiatric Association, 2013).
DSM-5 defines psychological disorder as the behavioral, emotional, or cognitive
dysfunctions that are unexpected in their cultural context and associated with
personal distress or substantial impairment in functioning.
Check Your Progress 1

1) Define psychological disorder.
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2) What are the components of a psychological disorder?
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1.2 HISTORY OF PSYCHOLOGICAL DISORDERS

In this section, we highlight some views on psycological disorders from a
historical perspective
Ancient views of psychological disorders
Over the centuries, human efforts to explain abnormal behavior have ranged
from demonology, magic, theology, physiology to psychology. The earliest
evidence that attempts to understand abnormal behavior, comes from Egyptian
Papyri, sixteenth century BCE (Oshaka &Oshaka, 2000), which shows that the
brain was recognized as the site of mental functions. Diseases with unknown 17
Introducton to Psychological causes were treated with in cantations and magic. In ancient civilizations of China,
Greece, and Egypt, abnormal behavior was attributed to possession by God or
demons depending on the symptoms. If the behavior was religious, the person
was thought to be possessed by God, but if the behavior was aggressive, bizarre,
or overexcited then the person was thought to be possessed by demons. The
possessed individuals were treated through exorcism (driving out an evil spirit
from a person or a place).
Later in Greece, medical perspective was used to understand mental disorders

and their treatment under the leadership of Pericles (461-429 BCE). This period
also saw the rise of ‘Father of modern medicine’Hippocrates, the Greek
physician, who rejected demonology and instead suggested that just like physical
illnesses, mental illnesses are also caused by natural processes such as brain
pathology and require appropriate treatment. He saw brain as the central organ
of intellectual activity, identified the role of heredity, and head injuries as a cause
of mental and sensory disorders. He also gave the famous classification of mental
disorders into three categories: mania, melancholia, and phrenitis (brain fever).
He classified personalities based on four humors, blood, phlegm, black and yellow
bile, in the human beings (Maher & Maher, 1994).
Fig. 1.0: Hippocrates of Kos (Father of Medicine) Fig.1.1: Plato

Source: https://en.wikipedia.org/wiki/Hippocrates Source: https://en.wikipedia.org/wiki/
Plato
The Greek philosopher Plato (429–347 BCE) took a philosophical view of

mentally disturbed individuals and suggested that they are not responsible for
the criminal acts committed by them and hence should not be given punishment
like the common people. He suggested that mentally disturbed individuals should
be kept in hospitals run by society. His famous book, The Republic, underscores
the importance of individual differences in mental and physical abilities and role
of sociocultural factors in thinking and behavior. Though Plato had a modern
outlook, he believed that mental disorders are also partly caused by divine factors.
Aristotle (384-322 BCE) who was a disciple of Plato has written extensively
about mental disorders and consciousness. He rejected the psychological factors
like emotions and cognitions as causes of mental disorders and accepted
Hippocrates’ biological views on mental disorders. Hippocrates’ work was
supported by some of the later Greek and Roman physicians such as the most
18
influential Greek physician, Galen (130-200 CE). He did anatomical studies of What is a Psychological
Disorder?
the nervous system in animals (human autopsies were not allowed till then). He
also divided the causes of psychological disorders into physical and mental
categories.
Fig.1.2: Aristotle Fig. 1.3: Galen

Source:https://en.wikipedia.org/wiki/Aristotle Source:https://en.wikipedia.org/wiki/Galen
China was one of the earliest developed civilizations to provide medical attention
to mental disorders (Soong, 2006). Chinese medicine took a natural than a
supernatural view of mental disorders. It was based on the premise that mental
disorders occur because of disbalance of yin and yang (positive and negative
forces) and treatment involved restoring the balance between yin and yang (Tseng,
1973).
Ancient Indian texts give description about mental disorders. In Ayurveda (Science
of Life), personality types and temperament depend on the humor, systemic and
mental perspectives. There are three humors - vata (ether), pitta (bile), and kaph
(phlegm). Based on this classification, there are seven personality subtypes. There
are five other basic elemental subtypes and eight systemic subtypes of personality
that are the basis of all physical and mental disorders (Dwivedi, 2002). Atharveda
classifies mental disorders of both mild and severe in nature. Charaka Samhita
and Sushruta Samhita also give a detailed description about diseases that include
mental disorders.
Psychological disorders in the middle ages

During the Middle Ages (about 500 to 1500 CE), when Europe was immersed in
darkness and the scientific knowledge developed by Greek philosophers, was
pushed into oblivion, Islamic countries of West Asia protected Greek medicine
and furthered its research and knowledge. In Persia, Avicenna (980-1037 CE),
referred as the “Prince of Physicians” wrote the most widely referred work in the
world titled, “The Canon of Medicine”. In Baghdad in 792 CE, the first mental
hospital was established. In contrast to this progressive attitude, Europe was
devoid of scientific inquiry and humane treatment for the mentally ill people.
Supernatural explanations were given for abnormal behavior and mentally ill
were often accused of being possessed by devil, witchcraft and met with violent
deaths such as burnt at stake, drowned or beheaded. In 1486 CE, Pope Innocent
published a witch-hunting handbook, Malleus Maleficarum (Witch’s Hammer)
which describes ways of actively hunting out the suspected witches and punishing
them. 19
Introducton to Psychological By the end of the middle ages and with the advent of Renaissance, society began
taking a humane view of mental disorders. Swiss and German physicians,
Paracelsus (1490-1541 CE) and Johann Weyer (1515–1588CE) respectively,
criticized superstitious beliefs about mental disorders. Weyer in 1583 also wrote
a book, On the Deceits of the Demons which describes step by step rebuttal ofthe
Malleus Maleficarum.Weyer is considered as the founder of modern
psychopathology as he was the first specialist of mental disorders. Though he
faced protests from Church and his works were banned until the twentieth century.
The clergy themselves for example, St. Vincent de Paul (1576-1660 CE) began
questioning the prevalent inhuman practices for treating mentally ill. Strong
advocacy for scientific view of mental disorders led to the development of modern
clinical and experimental approaches. In sixteenth century, special institutions
for mentally ill, known as asylums were built but these did not serve the purpose
and soon these places were reduced to being referred as “Madhouses”. For
example, St. Mary of Bethlehem was soon named as St. Mary of Bedlam!
Asylums were also established in other countries like Austria, France, Mexico,
Russia and USA, but all of these were in a pathetic state and needed reforms.
Humanitarian treatment of people with psychological disorders and mental

hygiene movement
In France, Phillipe Pinel (1745-1826 CE) began the humanitarian treatment of
mentally ill patients. At the same time Tuke (1732-1822CE) in England also
established a retreat in York for mentally ill and provided them with humane
treatment. During this period, Benjamin Rush (1745-1813 CE) in Pennsylvania,
USA advocated moral management of patients with mental disorders. He is known
as the founder of the American psychiatry. He wrote the first systematic treatise
on psychiatry in America, Medical Inquiries and Observations upon Diseases of
the Mind (1812); and was the first American to organize a course in psychiatry
(Gentile & Miller, 2009). In the early nineteenth century, humanitarian treatment
was replaced by mental hygiene movement by Dorothea Dix (1802–1887 CE)
in USA. She fought for the cause of poor and forgotten people in mental hospitals
and jails. With her efforts, legislation was passed about state providing the mental
hospitals, other facilities and financial aid for the treatment of mentally ill people.
Fig. 1.4: Dorothea Lynde Dix (1802-1887)

Source: https://en.wikipedia.org/wiki/Dorothea_Dix
20
Contemporary Views about psychological disorders What is a Psychological
Disorder?
After the mental hygiene movement gained momentum in USA, technical
advances occurred in USA and in Europe that gave rise to contemporary views
of the mental disorders, its causes and treatment in the late nineteenth century.
These views spanned over the biological, psychological and experimental arenas
of inquiry. The biological field established the causation between brain pathology
and mental disorders, for example, Emil Kraepelin (1856-1926 CE) developed
the biological viewpoint by emphasizing the importance of brain pathology and
mental disorders. He also gave the classification system that became the precursor
of modern-day classification system like Diagnostic and Statistical Manual
(DSM).
Fig. 1.5: Emil Kraeplin (1856-1926)

Source: https://en.wikipedia.org/wiki/Emil_Kraepelin
Sigmund Freud (1856-1939 CE) introduced the psychological factors by

developing a theory of psychopathology that established a causal relationship
between mental disorders and inner psychological forces, like psychic energy,
unconscious motives, and psychosexual stages of development. Theories of
psychopathology were also developed through the experimental studies. The
first lab of psychology was established in Leipzig, Germany in 1879 by Wilhelm
Wundt who showed that psychological processes can be studied through
experimentation. Soon it was followed by Cattell (1860-1944 CE) who studied
individual differences in mental processing by adopting Wundtian methods. Other
important works in the tradition of experimental psychology were also carried
out that provided a new direction to the theory of psychopathology. For example,
Ivan Pavlov(1849-1936 CE) gave the principles of classical conditioning based
on his famous experiments with the dogs; John B. Watson (1878- 1958 CE)
through his experiments (Little Albert) established that all behavior (adaptive
and maladaptive) is learnt, and so unlearning of the maladaptive behavior can be
used as an effective treatment.
Thus, understanding the history of psychopathology helps us to appreciate the

struggles and efforts of various thinkers and researchers in the emergence of
abnormal psychology and that makes us to understand and treat mental disorders
in an efficient, scientific, and humane way.
21
Disorders & Disorders of Check Your Progress 2
1) How were disorders characterized in the middle ages?
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2) What are the contemporary views on psychological disorders?
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1.3 PSYCHOLOGICAL MODELS

There are various approaches to explain mental health disorders and problems.
It is not only the individual’s biological make-up, but also psychological factors,
like childhood experiences, learning, thinking, how one processes information,
and such other related factors that influence the development and maintenance
of psychological disorders. Thus, in this section the main psychological models,
namely, the psychodynamic model, the behavioural model, the cognitive model,
humanistic-existential model and socio-cultural model, will be discussed.
1) The Psychodynamic Model: The psychodynamic approach was posited by

Austrian neurologist Sigmund Freud. In his theory of psychoanalysis (first
of the‘talking therapies’), attempted to explain normal and abnormal
behaviour. Activities during childhood are driven by satisfying the needs of
id. How does one’s psychological mechanisms cope with anxiety and the
way in which memories are repressed that might cause conflict and stress,
are important in explaining normal and abnormal functioning. Psychological
health is maintained when there is a balance among id, ego and superego. If
these are in conflict, it will result in psychopathology. Conflict is reduced
by using defence mechanisms.
2) The Behavioural Model: The model is based on behaviouristic school of

psychology. The model puts forth that psychopathology is the result of
learned reactions to environmental experiences. ‘Faulty learning’ is the result
of either classical conditioning or operant conditioning.
3) The Cognitive Model: The approach was first introduced by Allbert Ellis
(1962) and Aaron Beck (1967). The model proposes psychopathology to be
the result of individual acquiring irrational beliefs, developing dysfunctional
ways of thinking and processing information in biased ways.
4) The Humanistic-Existentialist Model: The model proposes that ‘insight’ into

behavioural and emotional problems. People acquire psychological conflicts,
however, they have the ability to acquire self-awareness, values, sense of
meaning of life and pursue freedom of choice.
5) Socio-cultural Model: Social and cultural factors play an important in the

development and course of mental disorders. Individual’s culture and group
22
value system, play an important role. Daily life stressors may increase the What is a Psychological
Disorder?
vulnerability for mental disorders; however, studies also conclude that factors
like ethnic identity can buffer against the stressors and protect mental health
(Mossakowski, 2003).
1.4 CLASSIFICATION OF PSYCHOLOGICAL

DISORDERS
In our daily lives, we come across a lot of information in the form of objects,
elements, concepts, living beings etc. It is amazing that we can deal with so
much information. We do so by putting information into classes or categories
based on our observations of shared characteristics, for example, all four-legged
creatures are categorized as animals. Classification can be defined as making
generalizations based on our observations. Classification is a necessary step for
making sense of information in all formal fields of knowledge, such as sciences,
literature etc. Just like other fields of knowledge, abnormal psychology also makes
use of classification to deal with information about the various disorders, their
causes and treatments.
Carson, Butcher, and Mineka (2007) have defined classification in abnormal

psychology as an attempt to delineate meaningful sub-varieties of maladaptive
behavior. While diagnosis is assigning an individual to a category of a disorder
(e.g., phobia, depression etc.) based on symptoms, classification is assigning all
the possible categories to a system that will form the basis for diagnosis.
Need for classification in abnormal psychology (Carson, Butcher, & Mineka,

2007)
It differentiates among various types or categories of maladaptive behavior;
It brings order to the nature, causes, and treatment of such behavior;
It helps in meaningful communication about behavior (normal and abnormal);
It provides the basis for epidemiological data such as incidence and
prevalence of various disorders;
It provides the basis for formal diagnosis which is especially required by the
socio-legal system, e.g., insurance claims, court of law;
It also helps in identification of new type of disorders which require new
treatment techniques.
Approaches of Classification
1) Classical Categorical, 2) Dimensional, and 3) Prototypical
1) Classical Categorical approach originated in the work of Emil Kraepelin
(1856-1926 CE) and the biological tradition in the study of psychopathology.
According to Butcher, Mineka, Hooley, and Dwivedi (2016), classical
approach assumes the following:
a) All human behavior can be divided into the categories of healthy and
disordered;
b) Disorders are divided into discreet and non-overlapping classes;
c) Only one set of causal factors per disorder exist;
23
Introducton to Psychological d) There is only one set of defining criteria for each disorder, which must
be met for making a formal diagnosis.
Criticism: Psychological disorders are complex because psychological and
social factors interact with the biological factors to produce a disorder. The
mental health field, thus,did not adopt classical categorical model (Frances
&Widiger, 1986).
2) Dimensional approach as opposed to the classical categorical approach

assumes that:
a) A person’s behavior is defined in terms of different strengths along several
dimensions, for example, emotional stability, mood, aggression etc. which
can be rated on a Likert type of scale. Thus, a person’s behavior can be
defined on a scale of 0 to 10, as mildly anxious, (2) moderately depressed
(5), or mildly aggressive (2);
b) Same dimensions are to be used for defining behavior of everyone;
c) Difference in behavior would be based on the ratings on the established
dimensions that may range from low to high.
Criticism:Theorists have not reached a consensus on the number of

dimensions that can be used to define human behavior as some agree on one
dimension while others identify more than thirty-three dimensions (Millon,
1991).
3) Prototypical approach combines both categorical and dimensional

approaches. A prototype is a conceptual entity depicting an idealized
combination of characteristics that more or less regularly occur together in a
less than perfect or standard way at the level of actual observation (Butcher,
Mineka, Hooley, & Dwivedi, 2016). According to this approach, certain
essential characteristics are required to classify an entity, however, there are
some nonessential characteristics also that do not change the classification.
Criticism:The categories of disorders are not clearly defined as some symptoms

are shared by more than disorder. However, it has become the most favored
approach as it is user friendly and enlists many different features of the disorder,
out of which not all but some are required for the formal diagnosis.
How did we reach to the present system of classification?

Kring, Johnson, Davison, and Neale (2012) have enlisted the following efforts
in classification:
1886, USA:
1882, UK: Statistical
Association of
Committee of the
Medical 1913, USA: APA
Royal Medico- 1889, Paris:
Superintendents of accepted a new
Psychological Congress of Mental
American classification and
Association Science adopted a
Institutions for the incorporated some
produced a single classification-
Insane (a forerunner of Kraepelin’s ideas
classification but was never
of American but it lacked in
system. Revised widely used
Psychiatric consistency.
several times but
Association, APA)
was never adopted
adopted a revised
by its members.
British system
24
Development of ICD (World Health Organisation) and DSM (American What is a Psychological
Disorder?
Psychiatric Association) Systems
1939, WHO: Added mental disorders to the International list of Causes of Death
(ICD)
1948, WHO: International Statistical Classification of Diseases, Injuries, and
Causes of Death included classification of abnormal behavior, published the sixth
version, ICD-6
1952, APA: Diagnostic and Statistical Manual of Mental Disorders (DSM)
1968, APA: DSM-II, reliability was very low
1969, WHO: A new classification system
1980, APA: DSM-III
1987, APA: DSM-III-R (R stands for Revision)
1990, WHO: ICD-10 was endorsed
1994, APA: DSM-IV
2000, APA: DSM-IV-TR (TR stands for Text Revision)
2013, APA: DSM-5
2018, WHO: A version of ICD-11 was released
General Criticisms of Classification
1) Classification leads to loss of information: Classifying a person as
depressed or anxious results in loss of information about that person, reducing
his/her uniqueness. However, it is important to know whether the information
lost is relevant (Kring et al., 2012).
2) Labeling: Once labeled, an individual starts identifying him/herself with

the negative connotations associated with the label. It also leads to stigma
as mental disorders are viewed negatively by the society (Wahl &Harrman,
1989).
Kring et al (2012) draw attention to some specific criticisms of diagnosis by

DSM. They are as follows:
Discrete Entity vs. Continuum (Categorical vs. Dimensional classification):

The debate of discrete versus continuum has not been resolved and despite
criticism of categorical approach, DSM represents a categorical that is a yes-no
approach to classification.
Reliability: The extent to which a classification system or a test produces the

same scientific observation each time it is applied. Reliability of DSM-I and II
was not accepted. Though, later DSMs improved on the account of reliability
however, it still remains questionable.
Validity: The extent to which a classification system measures what it is supposed

to measure. The diagnoses of DSM are referred to as constructs because they
are inferred not proven, entities. Construct validity is determined by evaluating
the extent to which accurate statements and predictions can be made about a
category once it has been formed. So, DSM describes the constructs and not
facts.
25
Introducton to Psychological Nevertheless, classification systems like DSM help us in understanding the
various disorders, differences among them, their causes and to plan treatment.
According to Barlow and Durand (2005), DSM-III in 1980 was a landmark in
the history of nosology (classification) as it departed radically from its
predecessors, and three changes stood out:
First, atheoretical approach to diagnosis was attempted that used the precise
description of the disorder rather than theories of causal factors.
Second, specific, and detailed criteria for disorders helped to study their
reliability and validity.
Third, it introduced a “multiaxial system” that allowed clinicians to have a
detailed information about their patients through rating them on five different
dimensions, or axes. The details of multiaxial system are given below.
Axis I : The disorder itself, such as, schizophrenia or mood disorder
Axis II : More enduring (chronic) disorders of personality
Axis III : Physical disorders and conditions
Axis IV : Amount of psychosocial stress reported by the patient and rated
by the clinician in a dimensional fashion
Axis V : Current level of adaptive functioning
A revision of DSM-III called DSM-III-R was published in 1987, with further
improvement in reliability and validity.
Problems with DSM-III and III-R
Some of the diagnostic categories had low reliability.
Some criteria were whimsically rather than empirically established, e.g.,
one of the criteria for panic was four panic attacks in a four-week period. A
figure reached through an approximation rather than research.
Despite shortcomings, DSM-III and III-R had a substantial impact. It was
more popular and more clinicians used it than the ICD system.
ICD-10 was published in 1993 and to increase compatibility between DSM and
ICD-10, work on DSM-IV and ICD-10 was started simultaneously.
DSM-IV (1994) and DSM-IV-TR (2000)
According to Barlow and Durand (2005):
Scientific data was used to make changes in the diagnostic system;
Reanalysis of large set of data was done to increase its utility for DSM-IV;
Independent field trials examined the reliability and validity of alternative
sets of definitions or criteria, and, in some cases, the possibility of creating
a new diagnosis (Widiger et al., 1998);
The distinction between organically and psychologically based disorders
was eliminated;
The “multiaxial system” remains with some changes in the five axes. These
changes were as follows:
Axis I : Pervasive Developmental Disorders (PDD), Learning Disorders
(LD), motor skills disorders, and communication disorders,
26 previously coded on Axis II are now coded on Axis I
Axis II : Personality disorders and mental retardation What is a Psychological
Disorder?
Axis III : General medical conditions
Axis IV : Psychosocial and environmental problems (instead of
psychosocial stress in DSM-III & III-R)
Axis V : Current level of functioning using the GAF; Global Assessment
of Functioning (rating scale of 0-100) in life areas (social and
occupational relationships and use of leisure time).
Importance of Multiaxial system
Usually people consult a clinician for Axis I disorder
Axis II disorder may exist prior to Axis I disorder
Presence of Axis II along with Axis I condition indicates difficulty in
treatment
Axes III, IV, and V indicate the factors other than the symptoms that should
be considered in an assessment to understand the overall life situation, i.e.,
 Axis III indicates medical condition believed to be relevant to the present
disorder
 Axis IV indicates a proximal and a contributory cause
 Axis V indicates how much the person needs treatment based on GAF
ratings.
Other positive points of DSM-IV and DSM-IV-TR:
Extensive description of diagnostic categories: For each disorder there is a
description of essential features, associated features (lab findings and physical
examinations), research literature about age of onset, course, prevalence and sex
ratio, familial pattern, and differential diagnosis.
Social and Cultural Considerations: “Cultural formulation guidelines” is a plan

for integrating important social and cultural influences on diagnosis (Mezzich et
al., 1999), e.g., what is the primary social and cultural group of a patient (e.g.,
Chinese, Hispanic, etc.).‘Have the immigrants mastered the language of their
new country?Does the patient use term and descriptions from his or her “old”
country to describe the disorder?’These cultural considerations must not be
overlooked in making diagnosis and planning treatment, but yet, there is no
research supporting the utility of these cultural formulation guidelines (Alarcon
et al., 2002).
Overall, the reliability of DSM has improved due to increased explicitness of

the DSM criteria; use of standardized, reliably scored interviews for collecting
the information needed for a diagnosis.
According to Davison, Neale, and Kring (2004), following problems remained

in DSM-IV and DSM-IV-TR:
Discrete entity vs. continuum issue remains unresolved.
Arbitrariness in the rules for making diagnosis, e.g., diagnosis of mania is
given if the person shows at least three out of seven symptoms listed, or four
if their mood is irritable, but why require three and not two or five symptoms?
27
Introducton to Psychological The reliability of Axes I and II may not always be high in daily usage, for
clinicians may not adhere as precisely to the criteria as the researches.
The increased reliability may improve validity but it is not guaranteed, a

diagnosis may not reveal anything useful about a patient.
Subjective factors may still play a role in evaluations as well as cultural

factors may creep in.
Not all the DSM classification changes seem positive, e.g., should a problem
in learning or arithmetic, or reading be considered a psychiatric disorder?
Many childhood problems are made into psychiatric disorder, without good
justification for doing so, thereby causing a risk of labeling a child with a
disorder.
Continued efforts to improve DSM has led to DSM-5

The DSM-5 was published in 2013 after much debate and controversy. The key
aspects are as follows:
Multiaxial system has been abandoned in DSM-5.
It has used an operational approach to diagnosis, for example, diagnostic
criteria for Persistent Depressive Disorder (Dysthemia) are based on a
combination of diagnostic criteria from two diagnoses from DSM-IV: Chronic
Major Depression and Dysthymic Disorder. It has become more
comprehensive and differentiated through addition of newly diagnosed
disorders as well as by dividing the previous disorders into subcategories.
Gender differences have been accounted for diagnosis by providing the
differences in prevalence rates and symptoms between male and female
patients. For example, antisocial disorder (prevalence is higher in males)
and anorexia (higher prevalence in females) and symptoms of conduct
disorder are different in males and females (Butcher et al., 2016).
Appraisal of cultural background has also been done as nowadays clinicians
have to diagnose and treat many patients who come from cultural
backgrounds that are different from that of the client. Further, migrants are
likely to perform more poorly on diagnostic tests not because of a
psychological problem but because of unfamiliar language and its nuances
being used in the country to which they have migrated. Additionally, their
anxiety, depression or other disorders show more severe manifestations
because of the stress due to socio-cultural factors (Okazaki, Okazaki, &
Sue, 2009). Hence, the clinician must consider the clients’ background,
attitudes and social values while taking their case history and subsequent
therapy sessions.
The DSM-5contains a structured interview which has a sixteen item Cultural
Formulation Interview (CFI). The interview enquires about the patient’s
perspectives on their present problems, how they perceive the influence of
others in influencing their problems, ways in which their cultural background
can influence their adjustment and their experiences in seeking treatment
for their problems.
· Despite several improvements have been made in DSM-5, however, it
28 continues to suffer from the problem of labeling. Thus, when an individual
is labelled as suffering from schizophrenia, for example, the label does not What is a Psychological
Disorder?
provide any information about the patient as an individual, his/her strengths
and weaknesses other than disorder and the disorder itself. The individual
who is labeled also takes the role of the patient and expects him/herself to
behave in a certain way which is expected from a psychotic patient. Thus,
labeling has a negative effect on the patient as once labeled, the label sticks
to the patient for life and his/her other qualities are ignored. Nevertheless,
diagnosis is required to understand the causes and prognosis of a disorder,
as well as to decide its treatment. Hence, DSM-5 does play an important
role in diagnosis but practitioners must use it with caution to avoid labeling
of a person at the cost of his/her personhood.

1) What are the main psychological models that try to explain mental
disorders?
.............................................................................................................
.............................................................................................................
.............................................................................................................
2) Why do we need to classify psychological disorders?
.............................................................................................................
.............................................................................................................
.............................................................................................................
3) What are the methods of classifying abnormal behavior?
.............................................................................................................
.............................................................................................................
.............................................................................................................
4) State the importance of a multiaxial system of classification.
.............................................................................................................
.............................................................................................................
.............................................................................................................
1.5 CAUSES OF PSYCHOLOGICAL DISORDERS

In this section, we discuss the main causes of psycological disorders.
What causes abnormal behavior?
So far, the field of abnormal psychology has been unable to provide a single
direct answer to this question. Hence, many investigators prefer to talk in terms
of risk factors (variables correlated with an abnormal behavior) rather than causes
(Butcher, Hooley, Mineka, & Dwivedi, 2017). Nevertheless, understanding the
causes remains the ultimate goal. Causal factors can be analyzed by considering
the following:
29
Introducton to Psychological Distinction between necessary, sufficient, and contributory causes;
Anxiety and Obsessions The problem of feedback and circularity in abnormal behavior;
Concept of Diathesis-Stress model of abnormal behavior.
The above are explained as follows:

Necessary, sufficient, and contributory causes:
Necessary cause: a condition that must exist for a disorder to occur. It is not
always sufficient by itself to cause a disorder. Many mental disorders do not
seem to have a necessary cause and the search for such causes continues.
Sufficient Cause: a condition that guarantees the occurrence of a disorder. A
sufficient cause may not be a necessary cause. For example, hopelessness is a
sufficient cause of depression but it is not a necessary cause as there are other
causes of depression as well (Abramson, Alloy, and Metalsky, 1995).
Contributory Cause: a condition that increases the probability of developing a
disorder but is neither necessary nor sufficient for the disorder to occur, e.g.,
divorce might precipitate depression.
Time-frame under which different causes operate is also important (Butcher et
al., 2017):
Distal causal factors: causal factors that occur early in life and may not show
their effect for many years, but may contribute to a predisposition to develop a
disorder, e.g., death of a parent in early childhood may become a distal cause for
depression in adulthood.
Proximal causal factor: causal factor that operate shortly before the occurrence
of the symptoms of a disorder. It may be a condition that proves too much for a
person and may trigger a disorder. Sometimes it may seem to be trivial and only
distantly related to the more distal causes, proverbial for the “straw that breaks
the camel’s back”. For example, a minor argument between a couple may lead to
major difficulties in case of a couple who are already experiencing marital
problems.
Reinforcing cause: condition that tends to maintain maladaptive behavior that

is already occurring, e.g., pampering by parents may lead to maintenance of
illness in a child.
For many forms of psychopathology, we do not yet have a clear understanding

of whether there are necessary or sufficient causes; however, we do have a
good understanding of many of the contributory causes for most mental
disorders.
Further, what may be a proximal cause at one stage in life may become a distal
cause for a disorder later in life, e.g., loss of a parent in childhood may be a
proximal cause for the child’s grief reaction and may become a distal cause for
an anxiety disorder later in adulthood.
The problem of feedback and circularity in abnormal behavior

Abnormal behavior most often does not follow a simple linear model of cause
and effect, and sometimes it becomes difficult to distinguish between cause and
effect, e.g., whether excessive drinking in a spouse leads to rejection by the
30 other partner or rejection by the partner leads to excessive drinking.
Diathesis–Stress model What is a Psychological
Disorder?
The diathesis–stress model is a psychological theory that explains behavior as
both a result of biological and genetic factors (“nature”), and life experiences
(“nurture”). This model thus assumes that a disposition towards a certain disorder
may result from a combination of one’s genetics and early learning. Diathesis is
the predisposition toward developing a disorder. It can derive from biological,
psychosocial, and/or sociocultural causal factors. Stress is the response of an
individual to demands that he/she perceives as taxing or exceeding his/her personal
resources. According to the model, this predisposition, in combination with certain
kinds of environmental stress results in abnormal behavior. Diathesis-Stress
Models have been proposed by Meehl, 1962; Metalsky et al., 1982; Rosenthal,
1963; Zuckerman, 1999.
This theory is often used to describe the manifestation of mental disorders, like
schizophrenia that are produced by the interaction of a vulnerable hereditary
predisposition, with precipitating events in the environment. It was originally
introduced as a means to explain some of the causes of schizophrenia.
Vulnerability
In the diathesis–stress model, a biological or genetic vulnerability or
predisposition (diathesis) interacts with the environment and life events (stressors)
to trigger behaviors or psychological disorders. The greater the underlying
vulnerability, the less stress is needed to trigger the behavior or disorder.
Conversely, where there is a smaller genetic contribution greater life stress is
required to produce the particular result.
Nevertheless, it is a distal necessary or contributory cause, and is not sufficient

to cause a disorder, i.e., someone with a diathesis towards a disorder does not
necessarily mean they will ever develop the disorder. Both the diathesis and the
stress are required for this to happen.

1) What are the causes of abnormal behavior?
.............................................................................................................
.............................................................................................................
.............................................................................................................
2) Explain the diathesis-stress model.
.............................................................................................................
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1.6 ASSESSMENT OF PSYCHOLOGICAL

DISORDERS
Psychological assessment dates to Galton’s work (1879) and is one of the oldest
and most widely developed branches of contemporary psychology (Butcher,2010;
31
Introducton to Psychological Weiner & Greene, 2008). Butcher, Hooley, and Mineka (2014) have defined
psychological assessment as:
“Psychological assessment refers to a procedure by which clinicians, using
psychological tests, observation, and interviews, develop a summary of the client’s
symptoms and problems. Clinical diagnosis is the process through which a
clinician arrives at a general “summary classification” of the patient’s symptoms
by following a clearly defined system such as DSM-5 orICD-10 (International
Classification of Diseases), the latter published by the World Health
Organization.”
Clinical assessment may be defined as the collection, organization, and
interpretation of information about a person and his or her situation (Bootzin,
1997). According to Butcher et al. (2014), psychological assessment can be an
ongoing process that proceeds along with, rather than only preceding, treatment
efforts and may be important during treatment, e.g., to assess outcome. Pre-
treatment assessment has several functions, such as, it helps in establishing
baselines for various psychological functions so that the effects produced by
treatment can be measured; it can be used in court testimony; it helps in screening
candidates for various roles and occupations and usually the effort is to identify
people who seem to be unfit for a certain occupation.
The basic elements in assessment are as follows:
1) Diagnosis: presenting problem must be adequately classified for several
reasons:
Medico-legal cases may require it;
Helps in planning and managing the treatment;
Helps the administration to provide the facilities needed;
Taking a social history, that means a basic understanding of the
individual’s history, intellectual functioning, personality characteristics,
environmental pressures, and resources;
Helps in understanding the disorder that has brought the person to the
clinic.
2) Personality Factors: Such as long-term personality characteristics.
3) The Social Context: The environmental demands, the supports, and the social
stressors that exist in a person’s life.
The integration of the above information leads to a Dynamic Formulation which
describes the current situation and includes hypotheses about what is driving the
person to behave in maladaptive ways (Butcher et al., 2014).
Carson, Mineka, Butcher, and Hooley (2013) have enlisted the following factors
that influence the assessment process:
Clinician’s professional orientation, e.g., a psychiatrist will likely focus on
biological assessment methods;
Trust and rapport between the clinician and the client.
Reliability and Validity in Assessment
Reliability refers to consistency of measurement. Following are the types of
32 reliability:
Test-retest: the extent to which people being observed or tested twice score in What is a Psychological
Disorder?
the same way.
Alternate or Parallel Form: the extent to which scores on the two forms of the
test are consistent.
Inter rater: the degree to which two independent observers or judges agree.
Internal consistency: the extent to which items of a test are related to each other.
Validity refers to whether the measure fulfills its intended purpose. Following
are the types of validity:
Content validity: whether a measure adequately samples the domain of interest.
Criterion validity: whether a measure is associated in an expected way with
some other measure (criterion). It can be assessed by evaluating the ability of the
measure to predict some other variable in future, e.g., IQ tests are used as
predictors of later school achievement.
Concurrent validity: the extent to which a relationship exists between two
variables that are being measured at the same time, e.g., on a measure of distorted
thoughts, depressed people score higher than the non-depressed people.
Construct validity: whether a test is a measure of a characteristic or construct
(Cronbach & Meehl, 1955) A construct is an inferred attribute, such as,
anxiousness or distorted cognition.
1.7 TYPES OF ASSESSMENT

Clinical psychologists collect the data and evaluates the information from the
individual with regard to psychological disorder, to make diagnosis, plan the
treatment, and prognosis (predict the outcome). The following are the main types
of assessment for psychological disorders:
A. Biological Assessment
B. Psychological Assessment
Interview
Clinical Interview
Psychological Tests
Observing behaviour
C. Behavioral and Cognitive Assessment
A. Biological Assessment
Biological assessment includes:
1) Brain Imagery: Seeing the brain and how its structure and functioning
may be related to abnormal behavior. The following techniques are used for
brain imaging:
a) Computerized Axial Tomography Scan (CT or CAT)
This helps to assess structural brain abnormalities. A moving beam of
X-rays passes into a horizontal cross section of the patient’s brain,
scanning it through 360 degrees. The moving X-ray detector on the 33
Introducton to Psychological other side measures the amount of radioactivity that penetrates and
detects subtle differences in tissue density. A computer uses the
information to construct a two-dimensional, detailed image of the cross
section, giving it optimal contrasts. Then the patient’s head is moved
and the machine scans another cross section of the brain. This way any
structural abnormality, e.g., blood clots, tumors etc. can be detected.
b) Magnetic Resonance Imaging (MRI)
Superior to CT scan, MRI produces pictures of higher quality and does
not rely on even the small amount of radiation required by a CT scan.
In MRI, the person is placed inside a large, circular magnet, which
causes the hydrogen atoms in the body to move. The magnetic force is
turned off, the atoms return to their original position and produce an
electromagnetic signal. These signals are read by the computer and
translated into pictures of brain tissue. It has allowed brain surgeries of
such delicate parts of the brain which otherwise would have been
inoperable without clear pictures.
c) Functional MRI or fMRI
It allows to take pictures of brain at work. fMRI studies have found
less activation in the frontal lobes of patients with schizophrenia than
in the frontal lobes of normal people as they performed a cognitive
task (e.g., Yurgelon-Todd et al., 1996).
d) Positron Emission Tomography (PET)
This is an expensive and invasive procedure that allows measurement
of both brain structure and function. A substance used by the brain is
labeled with a short-lived radioactive isotope and injected into the blood
stream. The radioactive molecules of the substance emit a particle called
a positron, which quickly collides with an electron. A high-energy light
particle shoots out from the skull in opposite directions and are detected
by the scanner. The computer analyzes millions of such recordings and
converts them into a picture of the functioning brain. The images are
in color, fuzzy spots of lighter and warmer colors are areas in which
metabolic rates for the substance are higher. Visual images of the
working brain can indicate sites of epileptic seizures, brain cancers,
strokes etc., as well as the distribution of psychoactive drugs in the
brain.
2) Neurochemical Assessment
PET scanning allows an assessment of receptors for a given neurotransmitter.
In postmortem studies, the brains of deceased patients are removed and the
amount of specific neurotransmitter and receptors in brain areas can then
be directly measured. By analyzing the metabolites of neurotransmitters
that have been broken down by enzymes. Metabolite is typically an acid,
which is produced when a neurotransmitter is deactivated, e.g., Homovanillic
acid is the metabolite of dopamine, 5-hydroxyindoleacetic acid is the
metabolite of serotonin. Metabolites can be detected in urine, blood, and
cerebrospinal fluid. A high level of a particular metabolite indicates a high
level of a neuro transmitter.
34
3) Neuropsychological Assessment What is a Psychological
Disorder?
First let us see the difference between a neurologist and neuropsychologist.
A neurologist is a physician who specializes in medical diseases that affect
the nervous system, e.g., cerebral palsy. A neuropsychologist is a
psychologist who studies how dysfunctions of the brain affect the way, we
think, feel, and behave. They have developed tests called
neuropsychological tests. These tests assess behavioral disturbances caused
by brain dysfunctions.
Such tests are often used in conjunction with brain scanning

techniques.These are based on the idea that different psychological functions
(e.g., motor, speed, memory, language etc.) are localized in different areas
of the brain Eg., Halstead-Reitan Neuropsychological Battery (developed
by Halstead and then modified by Reitan; Reitan & Davison, 1974), and
Luria-Nebraska Neuropsychological Battery (Golden, Hammeke, &Purisch,
1980).
Halstead-Reitan Battery includes the following tests:
1) Tactile Performance Test-Time: performing the form board test while
blindfolded, first using the preferred hand and then the other, and finally
both. It is sensitive to damage in the right parietal lobe.
2) Tactile Performance Test-Memory: after completing the timed test,

patient is asked to draw the form board from memory, showing the
blocks in their right location.
3) Speech Sounds Perception Test: participants listen to a series of

nonsense words, each comprising two consonants with a long ‘e’ sound
in the middle. They then select the “word” they heard from a set of
alternatives. It measures left-hemisphere function, especially temporal
and parietal areas.
This battery can help in making diagnostic decisions, e.g., it helps to

discriminate between dementia due to depression and dementia due to a
degenerative brain disease (Reed & Reed, 1997).
Luria-Nebraska Neuro Psychological battery is based on the work of a

Russian psychologist, Alexander Luria (1902-1977). It has 269 items spread
out in 11 sections:
1) Basic and complex motor skills; Rhythm and pitch abilities; Tactile
and kinesthetic skills; Verbal and spatial skills; Receptive speech ability;
Expressive speech ability; Writing; Reading; Arithmetic skills;
Memory; Intellectual processes.
2) The pattern of scores is discriminating and indicative of overall
impairment, helps reveal damage to the frontal, temporal, sensorimotor,
or parietal-occipital area of right or left hemisphere.
3) It takes 2 ½ hours to administer it. Furthermore, it is believed to pick
up effects of brain damage that are not yet detectable by neurological
examination or imaging techniques.
35
Introducton to Psychological 4) It can control for educational level so that a less educated person will
not receive a lower score (Brickman et al., 1984). A version for children
ages 8-12 for diagnosing brain damage and in evaluating the educational
strengths and weaknesses of children (Golden, 1981; Sweet et al., 1986).
4) Psychophysiological Assessment
Psychophysiology is a field of study that is concerned with the bodily
changes that accompany psychological events or that are associated with a
person’s psychological characteristics (Grings & Dawson, 1978). Bodily
changes include heart rate, muscle tensions, blood flow in various parts of
the body, brain waves, etc.The activities of the autonomic nervous system
can be assessed by electrical and chemical measurements to understand the
nature of emotion, e.g.,
 Heart rate is one important measure which is measured by
electrocardiogram (ECG).
 Skin conductance or electrodermal responding; anxiety, fear, anger,
etc. increase activities in the sympathetic nervous system, which then
boosts sweat gland activity that in turn increases the electrical
conductance of skin.
 Brain activity is measured by electroencephalogram (EEG), helps in
detecting abnormal brain activity, e.g., epilepsy, brain lesions, etc.
 Portable devices are also being used to study blood presoure in vivo
(as people go about their daily business).
Critical evaluation of biological assessment
Many assessment techniques may not differentiate clearly among
emotional states such as, skin conductance which not only increases in
anxiety but in happiness also.
Usually, there is no one-to-one relationship between assessment and
psychological dysfunctions. Factors such as, duration of brain damage
(whether chronic or acute), coping strategies used by the patient, efforts
at special education should be taken into account.
A very important consideration is the abilities that the patient has
brought to the event of brain injury, i.e., the patient’s repertoire of
abilities before the brain damage should be taken into account.
B. Psychological Assessment: Interviewing, psychological tests and observing
behavior are the main methods to collect data about a psychological disorder.
Interview: The purpose of the interview determines the type of interview

to be conducted. The main types are as follows:
Intial intake or admission interview: The purpose of the initial intake
or admission interview is to understand the patient’s symptoms and
accordingly recommend the most appropriate treatment or intervention
plan. The interview can be conducted when the patient is in hospital
inpatient care, outpatient facility or any other mental health setting.
Mental Status Examination: This is conducted primarily to screen
the psychological functioning and mark out any absence or presence
36
of any abnormal mental phenomenon, such as, delirium, hallucination, What is a Psychological
Disorder?
etc. Insight, judgement, attention, memory, thought processes, etc. are
briefly evaluated.
Crisis interview: Such an interview is conducted in the middle of a
significant, or a traumatic or life-threatening crisis. Professional engaged
in suicide helplines, or a mental health clinic often conduct crisis
interview.
Diagnostic interview: The purpose of diagnostic interview is to make
a diagnosis after examining symptoms and problems. Diagnosis is
formulated by the clinician based on DSM-5 classification.
Unstructured interview: Clinicians operate from only the vaguest
outlines. The information is collected largely depends on the interviewer
and the responsiveness of the interviewee.Clinicians often rely on their
intuition and general experience, as a consequence reliability is probably
low, i.e., two interviewers may well reach different conclusions about
the same patient. Majority of clinical interviews are conducted within
confidential relationships. Hence, it has not been possible to establish
either their reliability or their validity through systematic research.
Structured Interview: Questions are set out in a prescribed fashion
for the interviewer. Developed by mental health professionals in order
to collect standardized information, particularly for making diagnostic
judgments based on the DSM-5, e.g., Structured Clinical Interview for
DSM-5 Disorders- Clinical Version (SCI-DSM-5 CV). It also contains
detailed instructions to the interviewer concerning when and how to
probe in detail and when to go on to questions about another diagnosis.
Use of structured interviews such as SCID has led to improvement of
diagnostic reliability.With adequate training, inter-rater reliability for
structured interviews is generally good (Blanchard & Brown, 1998).
Clinical Interview: Korchin (1986) has enlisted the following types of interviews:
Clinical Interview: conversation between a clinician and a patient it is aimed

at determining history, causes for problems, and possible treatment options.
Assessment Oriented Interview: typically occurs early in the patient’s contact

with the clinic; its major purpose is to clarify the clinician’s understanding
of the patient’s problems to plan further intervention.
Therapeutic Interview: facilitates the patient’s understanding of him/her

self so as to effect desirable changes in his feelings and behavior.
Characteristics of a clinical interview (Kring, Johnson, Davison, &

Neale, 2012):
 Attention is paid to the way a respondent answers or does not answer

questions;
 The paradigm within which an interview operates influences the type

of information sought, how it is obtained, and how it is interpreted. It
does not follow one prescribed course but varies with the paradigm
adopted by the interviewer;
37
Introducton to Psychological  Establishing the rapport with the client and obtaining his/her trust is
very important because interviews are usually carried out with people
who are under considerable stress and sometimes are required to reveal
personal information;
 Clinician empathize with their clients in an effort to draw them out of
their anxieties;
 A simple summary statements of what the client has been saying is
helpful in sustaining the momentum of talk about painful and possibly
embarrassing events;
 Accepting attitude toward personal disclosures dispels the fear that
revealing secrets to another human being will have disastrous
consequences (London, 1964);
 Situational factors of the interview may exert strong influence; however,
clinicians often tend to overlook them.
Psychological Tests
‘Psychological tests are standardized sets of procedures or tasks for
obtaining samples of behavior’ (Butcher et al., 2014).The clinician compares
an individual’s responses on a given test with the test norms or test score
distributions and makes an evaluation about him/her based on those
comparisons. Nowadays, along with the manual or paper-pencil tests, their
computer-administered and computer-interpreted formats are also available.
In comparison to interviews and observational techniques, psychological

tests are more precise and reliable, however, these are not perfect as the
inferences drawn from such tests depend on competence of the clinician
who administers and interprets the tests (Butcher et al., 2014).
There are two main types of psychological tests, namely, intelligence

and personality tests.
Intelligence Tests: A wide range of intelligence tests are available today,
out of which the most widely used in the clinical practice to measure children’
intellectual abilities are the Wechsler Intelligence Scale for Children-Revised
(WISC-IV) (Weiss et al., 2006) and the Stanford-Binet Intelligence Scale
(Kamphaus &Kroncke, 2004) (Wasserman, 2003). Wechsler Adult
Intelligence Scale-Revised (WAIS-IV) is used to measure adult intelligence
(Benson et al., 2010; Lichtenberger & Kaufman, 2009). It consists of 15
subtests and measures both verbal and nonverbal intelligence. These tests
use extensive with exhaustive items to measure the intellectual abilities,
however, are culturally biased. Also, it takes 2 to 3 hours to administer,
score and interpret the individual’s performance on these tests, hence, these
are not time and cost effective. These tests are only used when it is absolutely
necessary to measure an individual’s intellectual abilities, for example,
intellectual impairment, organic brain damage.
Objective Personality Tests: These are the structured personality tests,

such as questionnaires, self-report inventories, or rating scales with carefully
phrased and precise items and alternative responses as choices (Butcher et
al., 2017). The structured format allows objective quantification of the
38
sample of behavior under study. The precision and quantification increase What is a Psychological
Disorder?
the reliability of such tests. Some of the widely used objective personality
tests are the NEO-PI (Neuroticism-Extroversion-Openness Personality
Inventory; Costa &Widiger, 2002) used for normal population, the Millon
Clinical Multiaxial Inventory (MCMI-III; see Choca, 2004) used for
clinical population. However, one of the most widely used personality
assessment instrument, is the Minnesota Multiphasic Personality
Inventory Revised (MMPI-2) used for adults (Butcher, 2011; Greene, 2011).
Starke Hathaway and J. C. McKinley introduced MMPI for general use in
1943. It was revised in 1989 and renamed as MMPI-2 and remains till today
the most widely used personality test for clinical and forensic court related
assessment and in psychopathology research in the United States (Archeret
al., 2006; Lally, 2003), as well as the most frequently taught assessment
tool in graduate clinical psychology programs (Piotrowski & Zalewski,
1993). The translated versions of the inventory are widely used
internationally (the original MMPI was translated over150 times and used
in over 46 countries; Butcher, 2010). Over 32 translations of MMPI-2 have
been made since its publication in 1989 (Butcher & Williams, 2009). It is a
self-report questionnaire, consists of 550 items which covers wide range of
topics from physical condition and psychological states to moral and social
attitudes. Though it is widely used as a diagnostic tool in clinical and forensic
setups, however, it has been criticized by psychodynamic as well as behavior
schools-oriented clinicians. While the psychodynamics-oriented clinicians
criticized it for being too superficial and inadequate for measuring the
complexities of human behavior, the behaviorally oriented clinicians felt it
measured unobservable “mentalistic” constructs such as traits (Butcher et
al., 2014). Nevertheless, it remains one of the most exhaustive objective
measure of personality.
Overall, the objective personality tests have advantages as well as
limitations. These are cost effective, highly reliable, and objective and can
be computer administered and interpreted. However, these have been
criticized for being too mechanistic and rely on the literacy ability of the
patients. Moreover, since the items or questions are direct so they may elicit
not the true but socially desirable answers from the respondents.
Projective Personality Tests: These tests are semi-structured or unstructured
and use ambiguous stimuli ranging from less ambiguous such as pictures,
incomplete sentence stems, to ambiguous stimuli such as inkblots. Some of
the semi-structured projective tests are Rosenzweig Picture-Frustration
test, Thematic Apperception Test, Rotter’s Incomplete Sentence Blank,
and unstructured projective tests are inkblot tests, such as Rorschach
Inkblot Test. Since these tests do not rely on explicit verbal questions, so
the person’s responses are not limited to the “true,” “false,” or “cannot say”
variety. The projective techniques assume that individuals “project” their
own problems, motives, and wishes onto the test material when they try to
make sense out of vague and unstructured stimuli. People reveal their
personal preoccupations,conflicts, motives, coping techniques, and other
personality characteristics through their interpretations of the ambiguous
materials.
Projective personality tests have their own advantages and limitations.
Though the test stimuli are standardized, however, interpretation of the item
39
Introducton to Psychological responses is subjective and unreliable. Projective tests are especially useful
in clinical settings to obtain a comprehensive picture of a person’s
psychodynamic functioning. However, it's strength is its weakness also, as
their interpretation is subjective, unreliable, and these are not time and cost
effective in terms of administration and interpretation.
Observing behavior: Behavioural observation involves observation of

symptoms and problems related to psychological disorders.
C. Behavioral and Cognitive Assessment

Behavioral and cognitive oriented clinicians are guided by the system that
leads them to assess four sets of variables, SORC (Kanfer& Philips, 1970);
S = Stimuli, the environmental situations that precede the problem. The
clinician may try to identify the stressors that tend to elicit a given
maladaptive behavior.
O = Organismic, referring to both physiological and psychological factors
assumed to be operating under the skin. Perhaps, the client’s fatigue is caused
in part by excessive use of alcohol or by a cognitive tendency toward self-
deprecation manifested in such statements, “I never do anything right, so
what is the point trying?”
R = Overt Responses. Clinicians determine what behavior is problematic,
as well as the behavior’s frequency, intensity, and form, e.g., a client might
say that he/she is not assertive. Does the person mean that he/she is not
assertive in all situations and with everybody or its specific to situations
and people?
C= Consequent variables, events that appear to be reinforcing or punishing
the behavior in question, e.g., when the client does not show assertiveness,
it pays by maintaining the status quo, thereby keeping the person from being
assertive.
 A behaviorally oriented clinician attempts to specify SORC factors for
a particular client.
 Followers of Skinner underplay the O variables and focus more on S,
R, and C.
 Cognitively-oriented behavior therapists pay less attention to C
variables because cognitive-behavior paradigm does not emphasize
reinforcement.
 The information about SORC is gathered by several methods such as
direct observation of behavior in real life as well as in contrived settings,
interviews, and self-report measures (Bellack & Hersen, 1998).
1.8 THE INTEGRATION OF ASSESSMENT DATA

Integration of the assessment data into a coherent working model that helps in
diagnosis, prognosis and treatment plan. Assessment data is integrated either by
the clinician or an interdisciplinary team of professionals, such as, psychologist,
psychiatrist, neurologist, psychiatric social worker, nurse, and physiotherapist,
and occupational therapists etc. It also helps in evaluating the outcome of therapy
and in comparing the effectiveness of different therapeutic and preventive
approaches (Butcher et al., 2017).
40
1.9 ETHICAL ISSUES IN ASSESSMENT Disorder?
According to Butcher et al. (2017), clinical assessment of an individual has far-

reaching implications for him/her, for example, a clinical interpretation may
implicate a person as a patient in need of treatment or as a criminal to be punished!
Since, it may affect a person’s personal as well as professional life, so sources of
biases should be kept in mind while making a clinical assessment of a person,
such as, a) potential cultural bias of the instrument; b) cultural bias or theoretical
orientation of the clinician; c) inadequate emphasis on the external factors; d)
insufficient validation of information about the client or his/her situation; and e)
insufficient data or premature evaluation.
By considering the strengths and weaknesses inherent in the procedure of clinical

assessment, a clinician or a team of mental health professionals can efficiently
use it to diagnose and treat the clients.

1) List the techniques of biological assessment.
.............................................................................................................
.............................................................................................................
.............................................................................................................
2) What are the ethical issues in assessment?
.............................................................................................................
.............................................................................................................
.............................................................................................................
3) Differentiate between subjective and objective measures of personality
assessment.
.............................................................................................................
.............................................................................................................
.............................................................................................................
1.10 SUMMARY
Now that we have come to the end of this unit, let us list all the major points that
we have already learnt.
Psychological disorder is a psychological dysfunction within an individual
that is associated with distress or impairment in functioning and a response
that is not typical or culturally expected.
The earliest evidence about attempts to understand abnormal behavior comes
from sixteenth century BC from Egyptian Papyri.
Humanitarian treatment of mentally ill patients began in France by Phillipe
Pinel.
41
Introducton to Psychological Ancient Indian texts, like, Atharveda, Ayurveda, Charaka Samhita and
Sushruta Samhita have discussed about diseases that include mental disorders
also.
Classification can be defined as making generalizations based on our
observations. Classification is a necessary step for making sense of
information in all formal fields of knowledge.
Classification differentiates among various types or categories of
maladaptive behavior and brings order to the nature, causes, and treatment
of such behavior
The DSM-5 was published in 2013 and has used an operational approach to
diagnosis.
Necessary, sufficient, and contributory causes are required to classify
abnormalities.
Psychological assessment refers to a procedure by which clinicians, using
psychological tests, observation, and interviews, develop a summary of the
client’s symptoms and problems.
There are three types of assessment: biological assessment, psychological
assessment and cogintive and behavioral assessment.
1.11 KEYWORDS
Psychological Dysfunction: Refers to breakdown in cognitive, emotional, or
behavioral functioning.
Distal causal factors: Causal factors that occur early in life and may not show
their effect for many years, but may contribute to a predisposition to develop a
disorder
Diathesis–Stress model: The diathesis–stress model is a psychological theory
that explains behavior as both a result of biological and genetic factors (“nature”),
and life experiences (“nurture”).
Brain Imagery: Seeing the brain and how its structure and functioning may be
related to abnormal behavior.
Neurochemical Assessment: Analyzing the metabolites of neurotransmitters
that have been broken down by enzymes
Neuropsychological Assessment: Assessing behavioral disturbances caused by
brain dysfunctions
Psychological tests: Standardized sets of procedures or tasks for obtaining
samples of behavior
Reliability: Refers to consistency of measurement.
Validity: Refers to whether the measure fulfills its intended purpose
1.12 REVIEW QUESTIONS

1) ______________, into a coherent working model helps in diagnosis,
prognosis and treatment plan.
42
2) ________ picks up effects of brain damage that are not detectable by What is a Psychological
Disorder?
neurological examination.
3) _________ assumes that a disposition towards a certain disorder may result
from a combination of one’s genetics and early learning.
4) The biological viewpoint emphasizing the importance of brain pathology
and mental disorders was posited by __________.
5) In ____________, people reveal their personal preoccupations, conflicts,
motives, coping techniques, and other personality characteristics through
their interpretations of the ambiguous materials.
6) What are the characteristics of a psychological disorder?
7) Discuss the various methods of classification.
8) How is DSM-5 different from DSM IV?
9) Explain the methods of biological assessment.
10) Elucidate the characteristics of clinical interviewing.
11) What is a psychological assessment?
12) Describe behavioral and cognitive assessment of psychological disorders.
1.13 REFERENCES AND FURTHER READING

Abramson, L., Alloy, L., &Metalsky, G. (1995). Hopelessness depression. In G.
Buchanan &M.Seligman (Eds.), Explanatory Style (pp. 113–34). Hillsdale, NJ:
Erlbaum.
Archer, R. P., Buffington-Vollum, J. K., Stredny, R. V.,& Handel, R. W. (2006).
A survey of psychologicaltest use patterns among forensic psychologists. Journal
of Personnel Assessment., 87, 84–94.
Barlow, D. H. &Durand, V. M. (2005). Abnormal Psychology: An Integrative
Approach (4th Ed.). Wadsworth Publishing.
Barlow, D. H. & Durand, V. M. (2005). Abnormal Psychology(5th Ed.). Wadsworth
Publishing.
Bellack, A. S.&Hersen, M. (1998). Behavioral assessment: A practical handbook
(4th ed.). Boston: Allyn & Bacon.
Bootzin, R.R. (1997). Examining the theory and clinical utility of writing about
emotional experiences. Psychological Science, 8, 167–169.
Brickman, A. S., McManus, M., Grapentine, W. L., & Alessi, N. (1984).
Neuropsychological assessment of seriously delinquent adolescents. Journal of
the American Academy of Child Psychiatry, 23, 453-457.
Butcher, J. N., & Williams, C. L. (2009). Personalityassessment with the MMPI-
2: Historical roots, internationaladaptations, and current challenges. Applied
Psychology: Health and Well-Being, 2, 105–35.
Butcher, J. N. (2010). Personality assessment from the19th to the early 21st
century: Past achievements andcontemporary challenges. Annual Review of
Clinical Psychology, 6, 1–20.
43
Lally, S. J. (2003). What tests are acceptable for usein forensic evaluations? A What is a Psychological
Disorder?
survey of experts. Prof.Psychol: Res. Pract., 34, 434–47.
Lichtenberger, E. O., & Kaufman, A. S. (2009). Essentials of WAIS-IV assessment.
New York: JohnWiley.
London,P.(1964). The modes and morals of psychotherapy. New York: Holt,
Rinehart & Winston.
Maher, B. A., & Maher, W. R. (1994). Personality andpsychopathology: A
historicalperspective. Journal of Abnormal Psychology, 103, 72–77.
Meehl, P. E. (1962). Schizotaxia, schizotypy, schizophrenia. American
Psychologist,17, 827–38.
Mezzich, J. E., Kirmayer, L. J., Kleinman, A., Fabrega,H., Parron, D. L., Good,
B. J.(1999). Theplace of culture in DSM-IV. Journal of Nervous Mental Disorders,
187,457–64.
Millon, T. (1991). Classification in psychopathology: Rationale, alternatives,
and standards. Journal of Abnormal Psychology, 100(3), 245-261.
Mossakowski KN. Coping with perceived discrimination: Does ethnic identity
protect mental health? Journal of Health and Social Behavior. 2003;44(3):318–
331. [PubMed] [Google Scholar]
Okazaki,S., Okazaki,M., &Sue,S. (2009). Clinical Personality Assessment with
AsianAmericans.InJ. N. Butcher (Ed.), Oxford handbook of personality
assessment. (pp. 377–395).
Okasha, A., &Okasha, T. (2000). Notes on mentaldisorders in Pharaonic Egypt.
History of Psychiatry,11, 413–24.
Piotrowski, C., &Zalewski, C. (1993). Training inpsychodiagnostic testing in
APA approved psyDandphD clinical psychology programs. Journal of Personality
Assessment, 61,394–405.
Reitan, R. M., &Davison, I. A. (1974). Clinical neuropsychology: Current status
and applications. Washington, DC: V. H. Winston.
Sapolsky, R. M. (2000). Glucocorticoids and hippocampalatrophy in
neuropsychiatric disorders. Archives of General Psychiatry, 57, 925–35.
Shaffer, D., Fisher, P., Lucas, C. P., et al. (2000). NIMH Diagnostic Interview for
Children Version IV (NIMH DISC-IV): Description, differences from previous
versions, and reliability of some common diagnoses. Journal of the American
Academy of Child & Adolescent Psychiatry, 39, 28-38.
Soong, W. T. (2006). Psychiatry in Taiwan: Past, presentand future. International
Medical Journal, 13,21–28.
Spitzer, R. L., Gibbon, M.,& Williams, J. B. W. (1996). Structured clinical
interview of DSM-IV Axis I disorders. New York: New York State Psychiatric
Institute, Biometrics Research Department.
Sweet, J. J., Carr, M. A., Rossini, E., & Kasper, C. (1986). Relationship between
the Luria-Nebraska Neuropsychological Battery and the WISC-R: Further
examination using Kaufman’s factors. International Journal of Clinical
Neuropsychology, 8, 177-180. 45
Introducton to Psychological Tseng, W. S. (1973). The development of psychiatricconcepts in traditional
Chinese medicine. Archives of General Psychiatry, 29(4), 569–75.
Wahl,O. F. &Harman, C. R. (1989). Family Views of Stigma. Schizophrenia
Bulletin, 15(1), 131–139.
Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between
biological facts and social values. American Psychologist, 47, 373-388.
Wakefield, J. C. (1999). Evolutionary versus prototype analyses of the concept
of disorder. Journal of Abnormal Psychology, 108, 3, 374-399.
Wasserman, J. D. (2003). Assessment of intellectualfunctioning. Handbook of
psychology (Vol. 10, pp.417–42). New York: John Wiley & Sons.
Weiner, I. B., & Greene, R. L. (2008). Handbook of personality assessment.
Hoboken, NJ: John Wiley &Sons.
Weiss, L. G., Saklofske, D. H., Prifitera, A., &Holdnack, J. A. (Eds.). (2006).
WISC-IV advancedclinical interpretation. Burlington, MA: ElsevierAcademic
Press.
Widiger, T. A., Frances, A. J., Pincus, H. A., Ross, R., First, M. B., Davis, W., &
Kline, M.(Eds.). (1998). DSM-IV sourcebook (Vol. 4). Washington, DC: American
Psychiatric Association.
Yurgelun-Todd, D. A., Waternaux, C. M., Cohen, B. M., Gruber, S. A., English,
C. D., & Renshaw, P. F. (1996). Functional magnetic resonance imaging of
schizophrenic patients and comparison subjects during word production. The
American Journal of Psychiatry, 153(2), 200-205.
1.14 WEB RESOURCES

To read about mental health and illness in India, visit;
https://thebanyan.org
To know about nutrition and mental health, watch the video (Dept. of
Neurophysiology, NIMHANS, Bangluru)
https://youtu.be/yuGbKFAkGjl
Watch American psychological drama film, One Flew Over The Cuckoo’s
Nest; Directed by Milos Torman (1975).
Answers to the Fill in the Blanks (1-5).
1) Integration of assessment data
2) Neuropsychological assessments
3) Diathesis-stress Model
4) Emil Kraepelin
5) Projective personality tests
46
UNIT 2 DISORDERS OF ANXIETY, FEAR, Disorder?
PANIC, AND OBSESSIONS-I*
Structure
2.0 Introduction
2.1 Difference Among Fear, Panic, and Anxiety
2.2 Clinical Features of Phobia
2.3 Why do Phobias Develop?
2.4 Treatment of Phobias
2.5 Clinical Features of Social Phobia
2.6 Causal Factors of Social Phobia
2.7 Treatment for Social Phobia
2.8 Clinical Aspects of Panic Disorder
2.9 Causal Factors for Panic Disorder
2.10 Treatment of Panic Disorder
2.11 Summary
2.12 Keywords
2.15 Web Resources
Learning Objectives
Differentiate between panic, fear, anxiety and obsession;
Describe the clinical aspects of anxiety disorders recognised in DSM-5;
Explain the causal factors of specific phobia and agoraphobia and their
treatment; and
Elucidate the causal factors of social anxiety disorder and panic disorder
and their treatment.
2.0 INTRODUCTION
We often become anxious in our day to day life situations, such as, when we
have to appear for an exam/job interview, or caught in a traffic jam while already
running late, trying to meet the deadlines etc. Our level of anxiety decreases
once we come out of such situations, However, it is important to look at certain
situations when the individual remains anxious irrespective of the situation and
is unable to cope with it.When this happens, the person is said to be suffering
from anxiety disorder/s. There are several anxiety disorders that have been
identified by DSM-5, like generalized anxiety disorder, specific phobia, social
phobia, panic disorder, and agoraphobia. In this Unit, you will learn the clinical
aspects, causal factors and treatment of specific phobia, social phobia, panic
Delhi
Introducton to Psychological disorder, and agoraphobia. You will learn about generalized anxiety disorder
and obsessive-compulsive disorders in the subsequent unit. But before we delve
further into these disorders, let us first understand about anxiety and other similar
conditions such as fear and panic.
2.1 DISTINCTION BETWEEN ANXIETY, FEAR,

AND PANIC
The most common way to distinguish fear and anxiety has been in the terms of
an actual external stimulus that is perceived as a real danger/threat by most people.
Fear is experienced in the presence of real danger/threat whereas anxiety is
experienced only in anticipation of danger/threat when such a danger/threat is
not present or cannot be specified. Several researchers have distinguished between
fear, panic, and anxiety in terms of cognitive/subjective, physiological, and
behavioral components (e.g., Barlow, 2002; Bouton, 2005; & Grillon, 2008).
These components are loosely associated, i.e., every individual may not
necessarily experience all the three components. Thus, someone having fear or
anxiety may experience cognitive and physiological component with greater
intensity than the behavioral component and vice versa (Carson, Butcher, Mineka,
& Holley, 2013).
Cognitive/Subjective: “I am afraid”
Physiological: Increased heart rate, fast and heavy

breathing
Behavioral: Strong urge to escape from the situation
Fig. 2.1 Components of fear
Panic, like fear has all the above three components. However, additionally, panic
attack is characterised by subjective feelings of impending doom, fear of dying,
going crazy and losing control. Anxiety on the other hand is a more diffused,
future-oriented state that comprises of a complex blend of cognitions and
emotions.
Cognitive/Subjective: negative mood, worry about possible future

danger/threat, self-preoccupation, inability to predict and/or
control the occurrence of future danger/threat
Physiological: chronic tension and over arousal, full-fledged fight

or flight response is not there as in fear but the person is primed for
fight or flight response for the anticipated danger
Behavioral: avoidance of anticipated dangerous/threatening

situations but there is no immediate urgency to escape as in fear.
Fig.2.2 Components of anxiety

48
Disorders of Anxiety, Panic
Check Your Progress 1 and Obsessions-I
1) Differentiate between panic, anxiety and fear.
.............................................................................................................
.............................................................................................................
.............................................................................................................
2) List the main components of anxiety.
.............................................................................................................
.............................................................................................................
.............................................................................................................
2.2 CLINICAL FEATURES OF PHOBIA

“A phobia is a persistent and disproportionate fear of a specific object or situation
that presents little or no actual danger to a person” (Carson, Butcher, & Mineka,
2003). DSM-5 has identified three categories of phobias: specific phobia, social
phobia and agoraphobia.
According to DSM-5 Specific Phobia, previously known as simple phobia, has

five sub types: animals (e.g., snakes, spiders, dogs); natural environment (e.g.,
water, heights, storms); blood-injection-injury; situational (bridges, tunnels);
others (vomiting, choking, ‘space phobia’ where the person has a fear of falling
down if he/she is away from walls or support).
Social Phobia is a fear of social situations. A person is afraid of acting in a

humiliating or embarrassing way when he/she is exposed to the scrutiny of others.
Social phobia may be specific to a situation such as fear of public speaking or
generalised as in fear of many different social interactions.
Agoraphobia was traditionally thought to be a fear of “agora”, Greek word for

public places of assembly (Marks, 1987). It is a fear of crowded places such as
shopping malls, theaters etc. It can also be a fear of having a panic attack in
situations where escape might prove to be difficult or embarrassing.
Now, we will discuss the above mentioned phobias, separately.
Specific Phobias
Specific phobia is diagnosed when a person shows strong and persistent fear
which is triggered by a specific object or situation. On encountering a phobic
stimulus, the person with specific phobia show an immediate fear response that
resembles a panic attack except for the presence of a clear external trigger (APA,
2013). She/he experiences anxiety on anticipation of the phobic stimulus and go
to great lengths to avoid it. The person is fearful and avoids even the mere
representations (picture/model) of the phobic stimulus. Most often, the person
has an insight about one’s condition, that is, the person recognizes that the response
to a phobic stimulus is unreasonable or excessive.
49
Disorders & Disorders of Box 2.1: Criteria for Specific Phobia according to DSM-5 (APA, 2013)
A. Marked and persistent fear that is excessive or unreasonable, cued by
the presence or anticipation of a specific object or situation (e.g., flying,
heights, animals, receiving an injection, seeing blood).
B. Exposure to the phobic stimulus almost invariably provokes an
immediate anxiety response, which may take the form of a situationally
bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums,
freezing, or clinging.
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.
D. The phobic situation(s) is avoided or else is endured with intense anxiety
or distress.
E. The avoidance, anxious anticipation, or distress in the feared situation(s)
interferes significantly with the person’s normal routine, occupational
(or academic) functioning, or social activities or relationships, or there
is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The anxiety, panic attacks, or phobic avoidance associated with the
specific object or situation are not better accounted for by another mental
disorder, such as Obsessive-Compulsive Disorder (e.g., fear of dirt in
someone with an obsession about contamination), Posttraumatic Stress
Disorder (e.g., avoidance of stimuli associated with a severe stressor),
Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia
(e.g., avoidance of social situations because of fear of embarrassment),
Panic Disorder with Agoraphobia, or Agoraphobia without history of
Panic Disorder.
Types of Specific Phobias

DSM- 5 defines five types of specific phobias:
1) Animal Type: These include fears of animals such as dogs, cats, spiders,
bugs, mice, rats, birds,fish, and snakes.
2) Natural Environment Type: These include fears of heights, storms, and being
near water.
3) Blood-Injection-Injury Type: These include fears of seeing blood, receiving

a blood test or injection, watching medical procedures on television, and
for some individuals, even just talking about medical procedures.
4) Situational Type: These include fears of situations such as driving, flying,

elevators, and enclosed places.
5) Other Type: These include other specific fears, including fears of choking
or vomiting after eating certain foods, fears of balloons breaking or other
loud sounds, or fears of clowns.
50
Comorbidity: People who suffer from specific phobia are likely to suffer from Disorders of Anxiety, Panic
and Obsessions-I
other anxiety disorders also (Crum and Pratt,2001).
Prevalence, age of onset, and gender differences: Lifetime prevalence for

specific phobias is 12 percent which implies that these phobias are quite common
(Kessler, Chiru et al., 2005c). In India, however, prevalence rate has been reported
to be 4.2 percent which is significantly lower as compared to other countries
(Chandrashekhar & Reddy, 1998). Despite being very common, people with
specific phobias are less likely to seek treatment than people with other anxiety
disorders. The most common specific phobias are fears of spiders, snakes, and
heights. Phobias also depend on culture, e.g., in China, “Paleng” is a fear of
cold, in which the person fears that loss of body heat may be life threatening.
The age of onset for specific phobias varies depending on the fear. Animal phobias,
storm phobias, blood-injection-injury phobias and dental phobias typically begin
in early childhood. The average age of onset for height phobias is in the teens,
whereas specific phobias of enclosed places (claustrophobia) and driving phobia
often begin in adolescence and early adulthood (Barlow, 2002a).
Some specific phobias (e.g., spiders, storms) are much more common among
women than men, whereas others (e.g., blood phobias) are more equally found
in men and women. Lifetime prevalence is about 7 percent for men and 16 percent
for women (Kessler et al., 1994).
General Characteristics of People with phobias

People with phobias usually know that their fears are somewhat irrational,
but they cannot help themselves;
If they attempt to approach the phobic situation, they are overcome with
fear or anxiety, which may vary from mild feelings of apprehension and
distress to a full-fledged activation of the fight or flight response very similar
to panic attack;
Phobic behavior tends to be reinforced by the reduction in anxiety that occurs
each time a feared situation is avoided; and
Phobias may sometimes be maintained by secondary gains, such as, increased
attention, sympathy, and some control over the behavior of others. These
benefits are usually not in awareness of the sufferer.
2.3 WHY DO PHOBIAS DEVELOP?

The causes of specific phobias are complex, involving biological factors, a history
of negative experiences in the feared situation as well as other psychological
factors, and evolutionary factors.
Biological Perspective
Genetic Factors: The speed and strength of conditioning of fear is determined
by genetic and temperamental variables (Hettema, et al., 2003; Oehlberg &
Mineka, 2011). This means that phobias are acquired as a result of genetic makeup
or temperament and personality. People who are carriers of one of the two variants
on the serotonin-transporter gene which is linked to high neuroticism are more
likely to be conditioned to fear stimuli (Lonsdorf et al., 2009). Related to these
51
Introducton to Psychological findings, Kagan et al. (2001) reported that behaviorally inhibited (shy, timid)
toddlers showed a higher risk for the development of multiple specific phobias
at 7-8 years of age than were uninhibited toddlers. Studies have also indicated a
modest genetic contribution, for example, Fyer et al. (1995) reported an elevated
risk of specific phobias in first-degree relatives of those who had been diagnosed
with specific phobia. Twin studies on females and males found a higher
concordance rate for animal phobias in MZ than DZ twins (Kendler et al., 1999;
Hettema et al., 2005). The same studies have also reported the effect of the non
shared environment on the origin of specific phobias which implies the role of
other factors, such as psychological and socio-cultural in the acquisition of specific
phobias.
Psychological Perspective
Psychoanalytic Viewpoint: According to Freud, phobias represent a defense
against anxiety that stems from repressed impulses of the id. As it is too dangerous
to know the repressed id impulse, the anxiety is displaced (defense mechanism:
displacement) onto an external object or situation that has some symbolic
relationship to the feared object. Freud (1909) explained the development of
phobia with the case study of little Hans, a five-year old boy with a phobia of
horses. Freud suggested that Hans’s phobia was developed as a result of anxiety
due to Oedipus complex. Hans unconsciously hated his father and wanted to kill
him and possess his mother. This led to a fear in Hans that his father would kill
or castrate him for having such negative feelings. Since these unconscious
conflicting thoughts were not acceptable to the conscious mind, the anxiety created
was displaced onto horses as these symbolically represented his father. This
explanation was criticized as being far too speculative by many researchers and
an alternative explanation of Hans’ phobia in terms of the learning theory was
provided by behavioral theorists.
Behavioral Perspective: In the development of phobias, the behavioral theorists

focus on;
Learned Behavior: Wolpe and Rachman in 1960 suggested that Hans’ horse
phobia originated from an instance of traumatic classical conditioning. He
had witnessed an accident in which a horse was badly hurt. It upset him so
much that he started to avoid leaving the house so as not to encounter the
horses in the street. Several research studies by other theorists also supported
the role of classical conditioning principals in acquisition of phobias. An
individual learns to fear a previously neutral stimulus which is paired with
a noxious object or event. Once a phobia is acquired it gets generalized to
similar objects or events. In a survey conducted by Osr and Hugdahl (1981),
fifty eight percent of the respondents attributed their phobia to a traumatic
conditioning situation. Further, direct conditioning may be especially
common in the onset of dental phobia (Kent, 1997), claustrophobia
(Rachman, 1997), and accident phobia (Kuch, 1997).
Vicarious or Observational Learning: Phobias can be acquired by merely
observing another person who acts fearfully to a given object or situation
(Ost & Hugdahl, 1981). For example, lab reared rhesus monkeys who were
not initially afraid of snakes rapidly developed phobia of snakes after
observing their wild reared counterparts behaving fearfully with snakes
(Mineka & Cook, 1993). Similar observations were reported when lab reared
52 monkeys watched the videotape of wild reared monkeys behaving fearfully
with snakes. This implies that phobias can be developed through mass media Disorders of Anxiety, Panic
and Obsessions-I
also (Mineka & Sutton, 2006). This involves informational learning where
an individual learns to fear a particular object or situation by hearing or
reading that the situation is dangerous, for example, learning to fear flying
by hearing about plane crashes in the news, or learning to fear driving by
continually receiving warnings from others that driving is dangerous.
Cognitive Perspective: Cognitive factors, such as attention, memory,

cognitive biases help to maintain the phobias that have been acquired.
Generally, people with specific phobias tend to pay more attention to
threatening information that relates to their fear (Mineka, 1992). For
example, individuals with spider phobias are often the first people to spot a
spider if there is one in the room. People with phobias also tend to have
distortions in their memories for encounters with the objects and situations
they fear. For example, people with an animal phobia may remember the
animal that they have encountered as larger, faster, or more frightening than
it was. Further, people with specific phobias tend to hold beliefs and to
interpret situations in such a way as to maintain or increase their anxiety
(Ohman & Mineka, 1999). For example, people with a fear of height may
assume that they are more likely to fall. People who fear enclosed places,
such as elevators, may believe that they will run out of air, or that they will
be unable to escape. Lastly, avoidance of feared situations prevents people
with specific phobias from learning that the situations they fear are not as
“dangerous” as they feel. In addition, relying on “safety behaviors” (e.g.,
driving extra slowly to avoid an accident, always wearing shoes to prevent
insects from touching one’s feet) can also help to maintain a person’s fears.
Evolutionary Perspective
Our evolutionary history has affected which stimuli are likely to be feared,
e.g., snakes, water, heights, enclosed spaces are more likely to be objects of
fear than bicycles, knives, cars, even though the latter objects may be at
least as likely to be associated with trauma. Primates and humans have a
biological preparedness to rapidly associate certain kinds of objects- such
as snakes, spiders, water and enclosed spaces with aversive events. It has
been suggested that this preparedness may have been a selective advantage
(e.g., helped in survival) for our ancestors in the course of evolution (Mineka
& Ohman, 2002). Ohman (1996) has provided two lines of evidence to
support the preparedness theory of phobias. First, in case of human
participants, fear was conditioned more effectively to fear relevant stimuli
such as snakes and spiders than to fear irrelevant stimuli such as flowers
and vegetables. In case of primates, lab reared monkeys with no prior
experience to fear relevant stimuli also showed conditioning for fearing
relevant than irrelevant stimuli.
2.4 TREATMENT OF PHOBIA

The main treatment options for phobia are as follows:
Exposure Therapy:
The client is exposed to the feared object, animal, or place in a controlled
environment (Choy et al., 2007). There are various forms of the exposure therapy,
for example, systematic desensitization, flooding, virtual reality. Systematic 53
Introducton to Psychological desensitization is based on the premise that one cannot be anxious and relaxed at
the same time. It is conducted in several steps. Firstly, with the help of client, a
hierarchy of the fear eliciting situation is formed, beginning from the least fear
producing to the most fear producing situation, e.g., dog barking in the next lane
to the dog barking just in front of the client. Secondly, the client is taught relaxation
exercises, such as progressive muscle relaxation, deep breathing. Then the person
is asked to relax and imagine the fear producing situation in the ascending order
of the hierarchy, beginning from the least fear producing situation. Gradually,
the client learns to relax in the most fear producing situation, thereby extinguishing
phobia. An opposite of this technique is flooding, where the client is exposed to
the most fear producing situation and is taught that he/she can go through the
fear producing situation without being harmed contrary to his/her expectation of
getting hurt. Earlier therapists used the real situations or imagination (if the
situation was hazardous), whereas now therapists use virtual reality. In this type
of therapy, the therapists with the help of computers and other equipment simulate
the fear producing situation, e.g., heights, air travel and the client is exposed to
the simulation exercise. Through all these techniques, the client realizes the
irrationality of his/her fear and thus the fear gets extinct.
Modeling:
Based on Bandura’s (1977) vicarious learning theory, the client either observes
another person (sometimes the therapist) in real life or in a movie, acting fearlessly
in a situation that causes phobia in the client. By watching another person acting
fearlessly and calmly, the client also learns that the phobic situation or the stimulus
is harmless, which helps to treat phobia.
While the behavior therapies have been found to be effective in treating phobia,
medication and cognitive techniques, such as cognitive restructuring, have not
been found to be effective. According to the recent findings, a drug, called d-
cycloserine, when used in conjunction with exposure therapies like virtual reality,
has been found to increase the effectiveness of exposure therapies (Norberg et
al., 2008).

1) What are phobias?
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2) Explain modelling as the way to treat phobia.
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2.5 CLINICAL FEATURES OF SOCIAL ANXIETY

DISORDER (SOCIAL PHOBIA)
Social phobia is a persistent, irrational fear generally linked to the presence of
54 other people. It can be extremely debilitating.What is the difference between
Social Phobia and Social Anxiety Disorder?The difference between social phobia Disorders of Anxiety, Panic
and Obsessions-I
and social anxiety disorder (SAD) is largely chronological, in that social phobia
is the former term and SAD is the current term for the disorder. The official
psychiatric diagnosis of social phobia was introduced in the third edition of the
Diagnostic and Statistical Manual (DSM-III). Social phobia was described as a
fear of performance situations and did not include fears of less formal situations
such as casual conversations.
DSM-5 describes social anxiety disorder as “disabling fears of one or more

specific social situations (such as public speaking, urinating in a public bathroom,
or eating or writing in public) where the person fears of being exposed to the
scrutiny and potential negative evaluation of others or that he/she may act in an
embarrassing or humiliating manner”. Therefore, the person tries to avoid such
social situations or when avoidance is not possible endures them with great
distress. There are two subtypes of SAD according to DSM-5, one is specific to
performance situations, e.g., public speaking, and the other is general or in non-
performance situations, e.g., eating in public.
Box 2.2: Criteria for Social Anxiety Disorder according to DSM-5

(APA, 2013)
A. A marked or persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people or to
possible scrutiny by others. The individual fears that he or she will act
in a way (or show anxiety symptoms) that will be humiliating or
embarrassing.
Note: In children, there must be evidence of the capacity for age-
appropriate social relationships with familiar people and the anxiety
must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or situationally
predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums,
freezing, or shrinking from social situations with unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are
endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or
performance situation(s) interferes significantly with the person’s normal
routine, occupational (academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition and is not better accounted for by another mental disorder
(e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety
Disorder, Body Dysmorphic Disorder, a Pervasive Developmental
Disorder, or Schizoid Personality Disorder).
55
Disorders & Disorders of H. If a general medical condition or another mental disorder is present, the
Anxiety and Obsessions fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering,
trembling in Parkinson’s disease, or exhibiting abnormal eating
behaviour in Anorexia Nervosa or Bulimia Nervosa.
Comorbidity: People who suffer from SAD are also likely to suffer from one
or more anxiety disorders and depressive disorder (Ruscio et al., 2008).
Generalized SAD has been found to be comorbid with depression and alcohol
abuse (Wittchen, Stein, & Kessler, 1999). Specific SAD is comorbid with GAD,
specific phobias, panic disorder, avoidant personality disorder, mood disorders
and alcohol abuse (Crum & Pratt, 2001).
Prevalence, age of onset, gender differences and cultural factors: SAD is

common and found even in public celebrities, for example, Barbara Streisand
(American actor and singer). Its lifetime prevalence is 12 percent of a given
population (Ruscio et al., 2008). In India, prevalence rate of 12.8 percent has
been found in the adolescents (Mehatalia & Vankar, 2004). It is a persistent
disorder with spontaneous recovery shown by only 37 percent of the sufferers
over 12 years (Bruce et al., 2005).
SAD usually begins during early or middle adolescence or early adulthood (Ruscio
et al., 2008). SAD is more common among women than men as 60 percent of the
women have been reported to suffer from the disorder. SAD is also affected by
cultural factors. Example, in Japan, fear of giving offense to others is very
important, whereas in USA, fear of being negatively evaluated by others is a
source of social anxiety.
General Characteristics of People with SAD

The individual usually tries to avoid situations in which she /he might be
evaluated and reveal signs of anxiousness or behave in an embarrassing
way;
Fears concerning excessive sweating or blushing are common;
Speaking, performing in public, eating in public, using public lavatories,
etc. can elicit extreme anxiety; and
They often work in occupations or professions far below their talent or
intelligence because their extreme social sensitivity does not allow them to
work in situations which involve interactions with people.
2.6 CAUSAL FACTORS FOR SOCIAL ANXIETY

DISORDER
Let us understand the casual factors for social anxiety diorder.
Genetic and Temperamental Factors: Results from a very large study of female
twins suggests a variance of 30 percent due to genetic component in development
of SAD (Smoller et al., 2008). Family studies also show that first degree relatives
of probands were more than two to three times as likely to also share a diagnosis.
Further, infants easily distressed by unfamiliar stimuli are at an increased risk
for becoming fearful during childhood and by adolescence, show increased risk
56 of developing social phobia (Kagan, 1997).
Introducton to Psychological Further, even very brief presentations of the angry face that are not consciously
perceived are sufficient to activate the conditioned responses (Ohman, 1996).
2.7 TREATMENT OF SOCIAL PHOBIA

Main treatment options used by people for social phobia are:
Cognitive-Behavioral Therapy:
Cognitive restructuring along with behavioral techniques has been proved
to be more effective as compared to lone use of behavioral therapy (Barlow
et al., 2007). The distorted cognitions of client that lead to social phobia,
such as, “nobody likes me”; “people do not find me attractive” are identified
and the therapist helps the client to restructure such negative cognitions
through reanalysis. During the reanalysis, the client is educated about the
origin of cognitive distortions, the automatic negative thoughts and how
these affect the client’s social behavior and restructuring such thoughts by
cognitive techniques, for example, questioning the validity of such negative
thoughts, taking negative thoughts as hypotheses and logically testing those
hypotheses. The clients are also encouraged to do exercises where they are
taught to shift their focus from self to others and the situations. Videotaping
their social interactions has also been successfully used as a feedback
mechanism (Mörtberg et al., 2007).
Medications:
Research has also shown that medications such as antidepressants (e.g.,
Monoamine Oxidase Inhibitors, or MAOIs and Selective Serotonin Reuptake
Inhibitors, or SSRIs) have been proved to be effective treatment for social
phobia (Ipser et al., 2008). However, further comparative research in this
area has reported the cognitive-behavior therapy to be more effective than
the medications as it does not involve side effects and relapse rates are also
low (Stein & Stein, 2008). Lastly, researchers such as Guastella et al. (2008)
have reported that a medication, named D-cycloserine taken in conjunction
with cognitive-behavior therapy led to faster rates of successful treatment.

1) What are the characteristics of social phobia?
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2) Why does social phobia develop?
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3) How does cognitive-behaviour therapy help in the treatment of social
phobia?
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58
2.8 CLINICAL ASPECTS OF PANIC DISORDER and Obsessions-I
DSM-5 defines a panic attack as a discrete period of intense fear or discomfort,

in which at least four from a list of 13 standard symptoms develop abruptly and
reach a peak within 10 minutes. Although the symptoms must peak within 10
minutes, the attacks often peak within a few seconds and the symptoms gradually
subside over a period lasting from a few minutes to about a half hour.
Box 2.3: Criteria for Social Phobia according to DSM-5

(APA, 2013)
A. Recurrent unexpected panic attacks. A panic attack is anabrupt surge of
intense fear or intense discomfort that reaches a peak within minutes,
and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
1) Palpitations, pounding heart, or accelerated heart rate.
2) Sweating.
3) Trembling or shaking.
4) Sensations of shortness of breath or smothering.
5) Feelings of choking.
6) Chest pain or discomfort.
7) Nausea or abdominal distress.
8) Feeling dizzy, unsteady, light-headed, or faint.
9) Chills or heat sensations.
10) Paresthesias (numbness or tingling sensations).
11) Derealization (feelings of unreality) or depersonalization (being
detached from oneself).
12) Fear of losing control or “going crazy.”
13) Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) may be seen. Such symptoms should
not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of
one or both of the following:
1) Persistent concern or worry about additional panic attacks or their
consequences (e.g., losing control, having a heart attack, “going crazy”).
2) A significant maladaptive change in behavior related to the attacks (e.g.,
behaviors designed to avoid having panic attacks, such as avoidance of
exercise or unfamiliar situations).
C) The disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hyperthyroidism, cardiopulmonary disorders).
59
Disorders & Disorders of D) The disturbance is not better explained by another mental disorder (e.g.,
Anxiety and Obsessions the panic attacks do not occur only in response to feared social situations,
as in social anxiety disorder; in response to circumscribed phobic objects
or situations, as inspecific phobia; in response to obsessions, as in
obsessive-compulsive disorder; in response to reminders of traumatic
events, as in posttraumatic stress disorder; or in response to separation
from attachment figures, as in separation anxiety disorder).
It is clear from the above list that out of 13, majority (1 to 10) of the symptoms
are physical whereas only last three are cognitive symptoms. In addition to these
symptoms, panic attacks may be accompanied by other symptoms as well (e.g.,
blurred vision).
Panic attacks are experienced across all the anxiety disorders, triggered by a
feared situation object/situation/thought/worry. Many people without an anxiety
disorder may experience panic attacks from time to time (e.g., when giving a
formal presentation or taking an exam, or upon encountering some other stressful
situation). Panic attacks occur frequently in the general population, with some
studies showing that up to a third of individuals experience a panic attack during
a given year. Unlike most panic attacks, which are typically triggered by stress,
worries, or feared situations, the panic attacks that occur in panic disorder often
occur out of the blue, without any obvious trigger or cause.
Table 2.1: Distinguishing features between Panic and Anxiety

Panic Attack Anxiety
Symptoms develop abruptly Does not have an abrupt onset
Usually reach peak intensity Symptoms are not as intense as
within 10 minutes subside in 20 in panic
to 30 minutes
Rarely last more than an hour It is long lasting
Types of Panic Attacks

Cued or situationally predisposed panic attacks: Panic attacks linked to specific
situations such as, driving a car. They are strongly associated with situational
triggers.
Uncued panic attacks: Attacks may occur in unexpected or benign states or in

the absence of any provocation, e.g., in sleep which is known as nocturnal panic.
In case of some people, panic disorder may lead to agoraphobia. In DSM-5 panic
disorder is diagnosed as with or without agoraphobia. The term agoraphobia
comes from the Greek word, agora which means market; hence it means a “fear
of the marketplace.” Though it implies a fear of open spaces, however, people
having agoraphobia are much more fearful of enclosed spaces, such as tunnels,
small rooms, and elevators. Some people with panic disorder develop a concern
that they will not be able to make an exit from a crowded place if they have a
panic attack. Hence, they avoid going to places where they believe that their
escape would be difficult in an emergency (i.e., panic attack) and it would cause
embarrassment to them. At first, people avoid those situations where they
developed agoraphobia but soon it gets generalized and they begin to avoid not
60
only places outside home, such as market, elevators, public transport but Disorders of Anxiety, Panic
and Obsessions-I
sometimes places within home also, e.g., attic, terrace which they believe would
be difficult to escape from. Most but not all, people with panic disorder develop
at least some degree of agoraphobia. In extreme cases, an individual with panic
disorder and agoraphobia may not leave the house at all. Usually people with
agoraphobia are able to leave the house, if someone they know accompanies
them whom they believe will be able to help them in making a safe exit in case of
a panic attack.
Comorbidity: Many people (83 percent approximately) suffering from panic
disorder with or without agoraphobia also have some other psychological disorder
such as GAD, specific phobia, social phobia, depression, substance use disorder
(such as smoking and alcohol consumption) and avoidant personality disorder
(Bernstein et al., 2006).
Prevalence, gender differences and age of onset: Lifetime prevalence for panic
disorder with or without agoraphobia has been reported to be 4.7 percent, but
panic disorder without agoraphobia is more prevalent. Prevalence varies cross-
culturally, e.g., in Africa; it was diagnosed in about 1percent of men and 6 percent
of women (Hollifield et al., 1990). In Taiwan, prevalence is quite low, perhaps
because of a stigma about reporting a mental problem (Weissman et al., 1997).
Among the Eskimo of west Greenland, e.g., Kayak Angst occurs in seal hunters
who are alone at sea. Attacks involve intense fear, disorientation, and concerns
about drowning.
Panic Disorder with and without agoraphobia is more prevalent in women than
in men with a prevalence of 5 percent and 2 percent, respectively (Kessler, Chiu,
et al., 2005c). About 80 to 90 percent of patients with agoraphobia are reported
to be women (White & Barlow, 2002). However, evidence has been found that
men with agoraphobia often indulge in self-medication with nicotine and alcohol
to endure panic attacks and often do not develop avoidance behavior as has been
found in agoraphobia (Starcevic et al., 2008). Panic disorder is a debilitating
disorder. Though its symptoms may increase or decrease at times however, it has
a chronic course. Recovery may take a long time (12 years as reported in a
longitudinal study) with recurrence in 58 percent of the patients (Bruce et al.,
2005).
The age of onset has been found to be 23 to 34 years on an average. For women
it usually starts in 30s or 40s (Kessler, Chiu, et al., 2006). Its onset is associated
with stressful life experiences (Pollard, Pollard, & Corn, 1989).
2.9 CAUSAL FACTORS FOR PANIC DISORDER

The causes of panic disorder involves the interplay of many factors.
Genetic Variables: Family and twin studies have pointed toward a genetic
component in the development of panic disorder. Kendler et al. (2001) reported
a variance of 33 to 43 percent due to genetic factors in a large twin study that
analyzed the factors for inheritability of panic disorder. Like other anxiety
disorders, people with neuroticism are more likely to develop panic disorder.
Recently, researchers have attempted to find specific genes that are responsible
for inheriting panic disorder. However, Strug et al., 2010; Klauke et al., 2010,
found no unequivocal results.
61
Introducton to Psychological Brain Activity: Earlier theories suggested the role of locus coeruleus (LC) in the
brain stem and norepinephrine, a neurotransmitter particularly involved in the
activity of LC in causing panic attacks. Stimulation of this area in the monkeys
causes a panic attack. Hence, it was suggested that naturally occurring attacks
might be due to over activation of norepinephrine in LC (Redmond, 1977).
Research with humans also found that Yohimbine, a drug that stimulates activity
in LC could elicit panic attack in patients with panic disorder (Charney et al.,
1987). However, more recent research is not consistent with this position, for
example, drugs that block firing in the LC were unable to treat patients with
panic disorder (McNally, 1994). Later research found that an overactive amygdala
rather than LC is implicated in panic disorder. Amygdala consisting of a group
of nuclei is located in front of the hippocampus in the limbic system and its role
in emotion of fear has been established through empirical research. Stimulation
of amygdala stimulates LC and other autonomic responses occurring during panic
attack (Gorman et al., 2000). Amygdala is said to be at the center of the “fear
network” and is connected to the lower brain areas like LC as well as higher
cortical areas like prefrontal cortex. Hence, panic attacks may occur either due
to stimulation of lower or higher areas of brain.
Dysfunctional Biochemistry: Klein (1981) and Sheehan (1982) hypothesized that

biochemical dysfunctions lead to panic attacks which are the alarm reactions.
For more than two decades this hypothesis was supported by several studies.
These studies showed that in comparison to normative group, when people with
panic disorder are exposed to panic provocation procedure, they are more likely
to suffer from panic attacks. The panic provocation procedure involves exposure
to biological challenges, such as inhaling air with higher than normal level of
carbon dioxide (Woods et al., 1987), taking large amounts of caffeine (Uhde,
1990), infusing sodium lactate into the body (Gorman et al., 1989), to induce
intense physical symptoms such as palpitations, high blood pressure and
hyperventilation that is likely to evoke a panic attack. The noradrenergic and
serotonergic systems are known to be involved in panic attacks (Graeff & Del-
Ben, 2008). The noradrenergic system gets activated due to stress and in turn
leads to cardiovascular symptoms which provoke panic attack. On the other hand,
serotonergic system’s activation decreases the noradrenergic activity. This has
been supported by the medication results, as drugs used for treatment of panic
disorder not only decrease the noradrenergic activity, but it also increases the
serotonergic activity. Another neurotransmitter, GABA, which has an inhibitory
effect on anxiety has also been found to be abnormally low in people with panic
disorder. Thus, such people suffer from anxiety in anticipation of suffering from
another panic attack.
Psychological Perspective
Behavioral Factors: Several researchers have suggested that a comprehensive
learning theory can account for the development of panic disorder (Bouton, 2005;
Mineka & Zinbarg, 2006). Goldstein and Chambless (1978) have studied the
effect of interoceptive (internal to body) and exteroceptive (external to body)
stimuli in conditioning of panic disorder. Through classical conditioning
interoceptive cues, like heart palpitations, stomach ache and exteroceptive cues
such as a place or presence of specific people that were present during the initial
panic attack gets associated with it and later on act as triggers for anxiety about
future panic attacks (Acheson et al., 2007). In simple words, people end up
developing a “panic” about a “panic attack”! This also explains the agoraphobic
62
avoidance of places like markets or shopping malls as these serve as exteroceptive Disorders of Anxiety, Panic
and Obsessions-I
cues for an oncoming panic attack. Inhibitory learning which is required for
extinction of a conditioned response has been suggested to be impaired in panic
disorder, thus people with panic disorder are unable to learn to discriminate the
conditioned stimulus as a safety cue (Lissek et al., 2009). However, panic attacks
sometimes seem to be uncued, i.e., no trigger, internal or external, seems to be
present before the panic attack. This is because panic attack in some cases result
from the internal cues that are unconsciously experienced by the individual. This
can be understood with an example of a person frightened of a racing heart and
who while feeling happy and excited gets a panic attack and is unable to
understand the reason of it as he/she was happy. The panic attack in this case
occurred because while feeling happy and excited the person’s heart raced which
served as a cue (though not in awareness of that person) for the panic attack
(Mineka & Zinbarg, 2006).
Cognitive factors: People with panic disorder have hypersensitivity for their bodily
sensations which are interpreted by them as a sign of an impending panic attack
(Beck & Emery, 1985; D. M. Clark, 1986, 1997). The tendency to interpret bodily
sensations as a sign of impending catastrophe such as a heart attack, tumors etc.
has been called catastrophizing by Clark.
Such frightening thoughts start the vicious cycle as it increases the already present
physical symptoms of anxiety which in turn increase the catastrophic thoughts
which in turn triggers the panic attack. It should be noted that the person may be
unaware about catastrophizing as these thoughts are out of consciousness (Rapee,
1996). Beck has called these thoughts as automatic thoughts which actually trigger
the panic attack. However, the cause of developing catastrophizing thoughts is
not known, nevertheless only those people who have a tendency for
catastrophizing develop panic disorder (e.g., Clark, 1997). Evidence has been
found in line with this theory, e.g., Clark (1997) and Teachman et al. (2007) have
reported that individuals with panic disorder have a greater tendency to
catastrophize their bodily sensations. This cognitive theory of panic disorder
also predicts that model also predicts that the panic can be reduced or prevented
by changing people’s cognitions about their bodily sensations. Further, likelihood
of panic attacks was significantly reduced when people suffering from panic
disorder were given a detailed explanation of what physical symptoms to expect
when injected with sodium lactase in a panic provocation study (Clark, 1997;
Schmidt et al., 2006).
Both learning and cognitive theories provide explanations about panic attack,
however the main difference between the two theories is the emphasis that the
cognitive theory puts on the meaning that people with panic disorder give to
their bodily sensations. Such interpretation of bodily sensations is not necessary
for conditioning as the interoceptive or exteroceptive stimuli could be outside
the realm of awareness (Bouton et al., 2001). In the light of this difference, learning
theory is better able to account for uncued panic attacks as well as panic attacks
while sleeping as both occur in the absence of automatic cognitions.
Anxiety Sensitivity and Perceived Control: Several explanations have been
provided that can find support in both learning and cognitive perspectives. For
example, McNally (2002) and Pagura et al. (2009) found that people with
hypersensitivity to anxiety are more likely to develop panic attacks and
subsequently panic disorder. Interestingly, some studies have also shown the
role of perceived control in reduction and even prevention of panic attacks, e.g., 63
Introducton to Psychological in a panic provocation study if a person has a control over inhalation of carbon-
dioxide (inhalation of CO2 is known to bring on panic), the possibility of suffering
from a panic attack is reduced significantly or even blocked (e.g., Sanderson et
al., 1989; Zvolensky et al., 1998, 1999). Further, Bentley et al. (2012) have shown
that anxiety sensitivity interacts with perceived control for the development of
panic attack, i.e., lower the perceived control, greater was the effect of anxiety
effect on panic disorder. Lastly, higher the perceived control over emotions and
threatening situations, lower was the agoraphobic avoidance as the person feels
in control of the situation (Suarez et al., 2009; White et al., 2006).
Safety Behaviors and the Persistence of Panic: Panic disorder once developed
is maintained despite contrary evidence. That is, someone who has always suffered
from a panic attack about having a heart attack on finding his/her heart racing
but never actually had a heart attack should understand that a racing heart does
not lead to a heart attack. But this logic does not prevent a panic attack because
each time the person was apprehending a heart attack he/she indulged in a “safety
behavior” like slow breathing and believed that this “safety behavior” prevented
the heart attack. Thus, the “safety behaviors” maintain the panic disorder. Thus,
people with panic disorder should be persuaded to abandon the “safety behaviors”
so that they could realize that their indulgence in safety behaviors does not prevent
the heart attack or any other impending fatality like fainting (Clark, 1997;
Salkovskis et al., 1996). Research suggests that dropping of safety behaviors by
people with panic disorder increased the effectiveness of the treatment (Rachman
et al., 2008).
Cognitive Biases and the Maintenance of Panic: People with panic disorder have
a tendency for processing the threating information in a biased manner. For
example, such people interpret the ambiguous bodily sensations as well as other
ambiguous situations as more threatening than the people in the control group
(Clark, 1997; Teachman et al., 2006). Also, such people have a biased attention
also as they focus more on the threatening information, such as words indicating
panic like palpitations, numbness, fainting etc. (Lim & Kim, 2005; Mathews &
MacLeod, 2005).). fMRI studies have shown greater activation of memory areas
that are involved in processing information about threatening stimuli in people
with panic disorder than the normative group (Maddock et al., 2003). However,
the role of biased information processing as a cause or as a symptom of panic
disorder remains unclear.
Overall, it can be concluded that both biological and psychosocial factors have
been found to play a role in the development of panic disorder and neither of the
two in isolation can explain its development.
2.10 TREATMENT OF PANIC DISORDER

The approches to treatment of panic disorder are as follows:
Exposure Therapy:
As explained in the above section on phobias, exposure therapy for agoraphobia

and panic involves exposing the client to the feared situation for a long period of
time often in the presence of the therapist or a family member. The underlying
idea is that the client on being exposed to the feared situation for a long time
without eliciting any harmful effects help him/her to realize the futility of his/her
64
agoraphobia with panic attacks. This exercise has been shown to be effective in Disorders of Anxiety, Panic
and Obsessions-I
treating 60 to 75 percent of people with agoraphobia and a maintenance rate of
2-4 years (Barlow et al., 2007). A limitation of this therapy was that it did not
deal with panic disorder specifically. Hence, another technique, known as
interceptive exposure was devised to deal with panic attacks in 1980s. This
technique involves causing internal bodily sensations such as spinning head,
nausea, breathlessness which are associated with panic attacks with the help of
activities like seating a client in a spinning or rocking chair. When the client
undergoes a prolonged exposure to such situations without getting a panic attack,
the association of the internal bodily cues to panic attacks gets extinct.
Integrative technique:
Cognitive restructuring integrated with exposure therapy used specifically to

treat panic disorder is known as panic control treatment. It involves educating
the client about the role of catastrophic automatic thoughts in causing and
maintaining the panic disorder. During the therapy, the client is taught to identify
the negative automatic thoughts and dispute those in a logical manner, using
techniques like hypotheses testing and humor. Then the client is exposed to the
panic eliciting situations (both internal bodily sensations and external cues) to
develop tolerance against the discomfort caused by such situations. This helps
the client to deal with panic causing situations efficiently. Research evidence
has shown the integrative technique to be more effective than using either the
exposure or cognitive restructuring technique alone (Arch & Craske, 2009). It
has proven to be effective in 70-90 percent of clients and maintenance rate of 1
to 2 years has also been reported (McCabe & Gifford, 2009).
Medications:
Medicines like anxiolytics (anti-anxiety drugs) and antidepressants have also
shown to be effective in treating agoraphobia and panic. Researches, however
conclude that both drugs have advantages and disadvantages also. Anxiolytics
which belong to the category of benzodiazepines include drugs like alprazolam
or clonazepam which have been shown to treat acute episodes of extreme anxiety
as these drugs work quickly (within 30-60 minutes). However, these also have
side effects such as drowsiness, sedation, impaired cognitive as well as motor
performance. Additionally, physiological dependence may also develop because
of prolonged use and lead to withdrawal symptoms like sleep disturbance,
dizziness and panic attacks. Relapse rate is also quite high (Pollack & Simon,
2009). Antidepressants including tricyclics, SSRIs and SNRIs (Serotonin-
Norepinephrine Reuptake Inhibitors) used for treating panic disorder and
agoraphobia also have advantages and disadvantages in comparison to anxiolytics.
Some advantages of antidepressants are that these treat the comorbid depression
and do not lead to physiological dependence (Pollack & Simon, 2009). However,
a disadvantage of antidepressants is that in comparison to anxiolytics, these take
longer time (approx. 4 weeks) to act, hence, cannot be used in acute cases of
panic disorder. Other side effects include, dry mouth, severe constipation, blurred
vision etc. Lastly, relapse rates are quite high when discontinued (Roy-Byrne &
Cowley, 2007).
Though a combination of cognitive-behavior therapy and medication therapy
has found to be slightly more effective (Barlow et al., 2007). However, it has
been found that once the medication is discontinued, relapse is common as perhaps
many of the clients attribute their treatment gains to medication (Mitte, 2005). 65
Introducton to Psychological Nevertheless, a drug named D-cyloserine used in combination of CBT has shown
promising results (Otto et al., 2009).
1) List the clinical features of a panic attack.
.............................................................................................................
.............................................................................................................
.............................................................................................................
2) Mention the cognitive factors that lead to development of panic attacks.
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
3) How does integrative technique help in the treatment of panic disorder?
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................
2.11 SUMMARY
The main anxiety disorders that have been identified by DSM-5, are
generalized anxiety disorder, specific phobia, social phobia, panic disorder,
and agoraphobia.
A phobia is a persistent and disproportionate fear of a specific object or
situation that presents little or no actual danger to a person.
According to DSM-5, Specific phobia, previously known as simple phobia,
has five sub types: animals (e.g., snakes, spiders, dogs); natural environment
(e.g., water, heights, storms); blood-injection-injury; situational (bridges,
tunnels); others (vomiting, choking, ‘space phobia’ where the person has a
fear of falling down if he/she is away from walls or support).
Phobias develop as a result of psychological, behavioural, biological,
evolutionary, or cognitive factors.
A social phobia is a persistent, irrational fear generally linked to the presence
of other people. It can be extremely debilitating.
The difference between social phobia and social anxiety disorder (SAD) is
largely chronological, in that social phobia is the former term and SAD is
the current term for the disorder.
Panic disorders are characterised by panic attack which are a discrete period
66
of intense fear or discomfort, in which at least four from a list of 13 standard Disorders of Anxiety, Panic
and Obsessions-I
symptoms develop abruptly and reach a peak within 10 minutes.
Panic attacks are experienced across all the anxiety disorders. Cognitive-
behaviour therapy and medication is found to be effective in the treatment
of panic disorder.
2.12 KEYWORDS
Anxiety: Feeling experienced only in anticipation of danger/threat when such a
danger/threat is not present or cannot be specified
Comorbidity: When two or more disorders or illnesses that occur in the same
person
Panic: Subjective feelings of impending doom, fear of dying, going crazy and
losing control.
Panic attack: Discrete period of intense fear or discomfort, in which at least
four from a list of 13 standard symptoms develop abruptly and reach a peak
within 10 minutes
Gamma Amino Butyric Acid or GABA: Inhibitory neurotransmitter that helps
to keep the feeling of anxiety away
Corticotropin Releasing Hormone (CRH): The CRH plays a role in GAD as it
is an anxiety producing hormone.
Phobia: A phobia is a persistent and disproportionate fear of a specific object or
situation that presents little or no actual danger to a person
Social phobia: A persistent, irrational fear generally linked to the presence of
other people. It can be extremely debilitating.
Agoraphobia: A fear of “agora”, Greek word for public places of assembly or
marketplace. It is a fear of crowded places.
2.13 REVIEW QUESTIONS

1) Panic control treatment to treat panic disorder combines ____________.
2) Medications such as antidepressants (e.g., Monoamine Oxidase Inhibitors,
and Selective Serotonin Reuptake Inhibitors) have been proved to be effective
treatment for _____________.
3) Phobias represent a defense against anxiety that stems from repressed
impulses of the id. This is the ___________ perspective of phobia.
4) Fear of public speaking or generalized as in fear of many different social
interactions is known as _____________.
5) Agoraphobia refers to the fear of _______ and ____________.
6) Define anxiety and give the characteristics of anxiety disorders.
7) What is the DSM-5 criteria of a panic attack?
8) Discuss the causes of social anxiety disorder.
9) What are the different kinds of phobias?
10) Discuss the treatment of panic disorder. 67
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2.15 WEB RESOURCES

Watch the video on ' what is social Anxiety Disorder?' ( Health Matters,
University of california TV).
https://m.youtube.com/watch? v = 4truuD_xMPO
Answers to the Fill in the Blanks (1-5)

1) cognitive restructuring integrated with exposure therapy
2) social phobia
3) psychoanalytical
4) social phobia
5) enclosed spaces, such as tunnels, small rooms, and elevators.
78
UNIT 3 DISORDERS OF ANXIETY, FEAR, and Obsessions-I
PANIC, AND OBSESSIONS-II*
Structure
3.0 Introduction
3.1 Generalized Anxiety Disorder
3.2 Clinical Features of Generalized Anxiety Disorder
3.3 Causal Factors: Why Does GAD Develop?
3.4 Treatment of GAD
3.5 Obsessive-Compulsive Disorder
3.6 Clinical Aspects of OCD
3.7 Causal Factors of OCD
3.8 Treatment of OCD
3.9 Summary
3.10 Keywords
3.13 Web Resources
Learning Objectives
Describe the clinical features of generalised anxiety disorder;
Elucidate treatment of generalised anxiety disorder;
Identify the clinical features of obsessive-compulsive disorders; and
Explain the various treatment options for obsessive-compulsive disorders.
3.0 INTRODUCTION
As you learnt in the previous Unit, there are several anxiety disorders that have
been identified by DSM-5, like generalized anxiety disorder, specific phobia,
social phobia, panic disorder, and agoraphobia. The clinical aspects, causal factors
and treatment of specific phobia, social phobia, panic disorder, and agoraphobia
were covered in the previous unit. In this Unit, you will learn the clinical features,
causal factors and treatment of generalized anxiety disorder and obsessive-
compulsive disorders. Previous DSMs classified obsessive-compulsive disorder
(OCD) as an anxiety disorder. However, DSM-5 has listed it under a separate
category, named as obsessive-compulsive and related disorders. Let us learn about
these disorders in detail.
3.1 GENERALIZED ANXIETY DISORDER

Generalized Anxiety Disorder (GAD) is a state of chronic, excessive and
unreasonable worry about multiple life events or activities. Since anxiety is not
Delhi
Introducton to Psychological anchored to a specific object or situation as in phobias, it was earlier described
as free-floating anxiety (Butcher, Hooley, Mineka, & Dwivedi, 2017). Individual
with GAD is persistently anxious often about minor things, and worry chronically
(Davison, Neale, & Kring, 2004). People with GAD spend a great deal of time
worrying about a wide range of topics and describe their worrying as
uncontrollable (Ruscio, Borkovec, & Ruscio, 2001).
3.2 CLINICAL FEATURES OF GENERALIZED

ANXIETY DISORDER
The clinical features of GAD, according to DSM-5, have been explained in the
box (Box 3.1).
Box 3.1: DSM-5 Criteria for Generalized Anxiety Disorder

(APA, 2013)
A. Excessive anxiety and worry (apprehensive expectation), occurring more
days than not for a period of at least 6 months, about a number of events
or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms present for more
days than not for the past 6 months).
Note: Only one item is required in children.
1) restlessness or feeling keyed up or on edge
2) being easily fatigued
3) difficulty concentrating or mind going blank
4) irritability
5) muscle tension
6) sleep disturbances (difficulty falling or staying asleep, or restless
unsatisfying sleep)
D. The focus of the anxiety and worry is not confined to features of an
Axis I disorder, e.g., the anxiety or worry is not about having a Panic
Attack (as in Panic Disorder), being embarrassed in public (as in Social
Phobia), being contaminated (as in Obsessive-Compulsive Disorder),
gaining weight (as in Anorexia Nervosa), having multiple physical
complaints (as in Somatization Disorder), or having a serious illness
(as in Hypochondriasis), and the anxiety and worry do not occur
exclusively during Posttraumatic Stress Disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas
of functioning.
F. The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hyperthyroidism) and does not occur exclusively during
a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental
Disorder.
(Note: No changes were made from DSM-IV to DSM-5.)
80
Comorbidity Disorders of Anxiety, Panic
and Obsessions-II
GAD is associated with functional impairment and increased risk of adverse
health outcomes, including cardiovascular disease and suicide (Keller, 2002). It
is also frequently found in conjunction with other psychiatric conditions, including
depression (Wells & Butler, 1997; Brownet al., 2001), panic disorder,
posttraumatic stress disorder, and social phobia (Kessler & Wittchenn, 2002).
Prevalence: GAD is common, with a prevalence rate of 3 percent for a period of

any1 given year and a lifetime prevalence of 5.7 percent (Kessler, Berglund,
Dealer, et al. 2005). Lifetime prevalence in India is 5.8 percent (Chandrashekar
& Reddy, 1998).
Age of onset: Nearly 60 to 80 percent people with GAD report that they have
been anxious for as long as they remember whereas many others have reported a
slow and insidious onset (Roemer et al., 2002). It is difficult to determine the age
of onset, but research has suggested that older adults often develop it and it is the
most common anxiety disorder for them (e.g., Mackenzie et al., 2011).
Course: GAD is a chronic disorder. A twelve-year follow-up study reported that

42 percent of the people diagnosed with GAD did not remit even after 13 years
and nearly 50 percent of those who remitted had a recurrence (Bruce et al., 2005).
Though it tends to disappear after age 50 for many people, it is usually replaced
by somatic symptoms disorder with physical health concerns (Rubio & Lopez-
Ibor, 2007). It is a common and a chronic disorder, however, in spite of high
levels of worry and perceived low well-being, most of the people with GAD
manage their lives though with some role impairment. As compared to panic
disorder or major depressive disorder which are more debilitating disorders,
people with GAD are less likely to avail the psychological treatment facilities,
because they usually visit physicians with physical complains like muscle ache,
gastrointestinal problems etc. (Hofmann et al., 2010).
Gender ratio: GAD is twice as common in women as in men (Rickels &

Scheweizer, 1997).
General Characteristics of People with GAD

People suffering from GAD live in a relatively constant state of diffuse
uneasiness,tension, and worry;
They are almost always in an anxious apprehension, defined as a future
oriented mood state in which a person constantly attempts to be ready to
deal with any upcoming negative events;
There is chronic over arousal along with high levels of negative affect, and
a sense of uncontrollability (Barlow et al., 1996);
Decision making is difficult as they have poor concentration and dread to
make mistakes;
They often unsuccessfully attempt to avoid anxiety by procrastinating or
indulging in checking activities;
They are hyper-vigilant for all possible signs of threat in their environment;
There are frequent complaints of muscle tension and aches in the neck and
upper shoulder region; 81
Introducton to Psychological Sleep disturbances, such as insomnia, nightmares and sometimes
hypersomnia (excessive sleep) to escape from anxiety are often reported;
Such people feel upset, uneasy, and discouraged due to constant worries;
Family, finances, work, and personal illness were found to be the most
common life areas of worry (Roemen, Molina, & Borkovec, 1997);
Decision making is difficult for them and they worry endlessly over possible
errors that they might have made while deciding;
Real and imagined mistakes committed currently or in the past are often
reviewed after going to bed;
All the possible future difficulties are anticipated by them;
They are unable to logically think that it is useless to trouble oneself with
future outcomes which are beyond one’s control; and
Failure to control their tendency to worry gives them a feeling of helplessness.
3.3 CAUSAL FACTORS: WHY DOES GAD

DEVELOP?
There are many possibble causes of GAD to develop. They arre indicated as
follows:
Genetic Factors:There is mixed evidence for genetic factors, however, a modest
genetic component for GAD has been reported (Hettema, Neale, & Kendler,
2000). Among the research studies carried out so far, one of the largest and most
recent twin studies has reported a variance of 15 to 20 percent in liability to
GAD due to genetic component. In other words, there is higher concordance rate
for GAD in MZ than DZ twins. Further, strong evidence has been found for a
common underlying genetic predisposition for GAD and major depressive
disorder (MDD) (Kendler et al., 2007). Nevertheless, whether a person with a
genetic risk for GAD or MDD will develop the disorder/s is determined by the
environmental factors (nonshared environment). A basic personality trait called
neuroticism has been conceptualized as the common underlying predisposition
for developing GAD and MDD (Kendler et al., 2007).
Neurochemical and Neurohormonal Factors:Neurobiological model is based on
the research conducted between 1950s and 1970s on the operations of
benzodiazepines, a group of drugs that are effective in the treatment of anxiety.
Researchers discovered a receptor in the brain for benzodiazepines that is linked
to the inhibitory neurotransmitter, Gamma Amino Butyric Acid or GABA. In
normal fear reactions, neurons throughout the brain fire and create the experience
of anxiety. This neural firing also stimulates GABA system, which inhibits this
activity and reduces anxiety. GAD may result from some defect in the GABA
system so that anxiety is not brought under control. The benzodiazepines may
reduce anxiety by enhancing the release of GABA. GABA, serotonin and
norepinephrine have been suggested to play a role in anxiety (LeDous, 2002),
but their interaction remains largely unknown till date (Butcher et al., 2017).
The Corticotropin Releasing Hormone (CRH): The CRH plays a role in GAD as
it is an anxiety producing hormone. When CRH is activated by stress or perceived
82
threat, it stimulates the pituitary gland which in turn releases the Disorders of Anxiety, Panic
and Obsessions-II
adrenocorticotropic hormone (ACTH). The ACTH stimulates the adrenal gland
which in turn releases the stress hormone called cortisol. The CRH is believed to
play an important role in GAD as it has been discovered to affect the bed nucleus
of the extension of amygdala which mediates generalized anxiety (Davis, 2006).
Psychoanalytic Perspective
Generalized anxiety is the result of a constant unconscious struggle between id
impulses and ego. Id impulses are aggressive and sexual in nature, and struggle
for expression whereas the ego because of its unconscious fear of being punished,
does not let id express its desires. Since the source of anxiety is unconscious,
person does not know the reason for anxiety and as a result is always anxious
and apprehensive. The person cannot evade anxiety as he/she can not escape
from id, for escape from id means that the person is no longer alive. Furthermore,
since anxiety is not displaced onto a specific object or situation as it happens in
the case of phobia, hence the person is anxious nearly all the time. But due to
lack of empirical verification, this viewpoint is not clinically accepted.
Behavioural Perspective
According to Wolpe (1958), the elicitors of anxiety may be environmental factors,
e.g., other people or social situations. A person who spends most hours of his/her
day with other people may be anxious because of the people or the social situations
and not because of any internal factors, i.e., the person learns to associate their
anxiety with the presence of other people.
Cognitive-Behavioral Perspective
The main underlying idea is that GAD results from distorted cognitive processes.
People with GAD often misperceive benign events, such as crossing the street as
involving threats, and their cognitions focus on anticipated future disasters (Beck
et al., 1987). Their attention is easily drawn to threatening stimuli (Mogg, Miller,
& Bradley, 2000). Studies have shown that in contrast to non-anxious people,
generally anxious people tend to notice threat cues when presented with a mixture
of threat and non-threat cues (Mineka et al., 1998).Furthermore, they are more
inclined to interpret ambiguous stimuli as threatening and to rate ominous events
as more likely to occur to them (Butler & Matthews, 1983).The heightened
sensitivity to threatening stimuli occurs even when the stimuli cannot be
consciously perceived (Bradley et al., 1995).
Uncontrollable and unpredictable aversive events are much more stressful and
hence more anxiety provoking than the controllable and predictable events. People
with GAD may have a history of experiencing many important life events as
unpredictable and uncontrollable (Mineka & Zinbarg, 1998).Early experience
with control and mastery can immunize to some extent against the harmful effects
of exposure to stressful situations and may in turn immunize against GAD (Barlow
et al., 1998).
Borkovec et al. (1998) have proposed another cognitive view as they focused on
the various functions served by worry. Worry can be negatively reinforcing; it
may serve five positive functions for people with GAD:
Superstitious avoidance of catastrophe (worrying will lessen the likelihood
of a feared event);
83
Introducton to Psychological Actual avoidance of catastrophe (worrying helps to generate ways of avoiding
catastrophe);
Avoidance of deeper emotional topics (worrying distracts from more
troublesome emotions);
Coping and preparation; and
Motivating device (helps in motivating oneself to work).
A subset of people with GAD believe that worry has positive functions, which in
turn helps in maintenance of high levels of anxiety (Dugas et al., 2007). Worrying
is self-sustaining as it does not produce much emotional arousal, e.g., it does not
produce the physiological changes that usually accompany emotion, and it blocks
the processing of emotional stimuli. Despite its positive functions, worry has
some negative consequences as well (Newman & Liera, 2011). Worry is not an
enjoyable activity as it involves thinking about the negative catastrophic outcomes
and can lead to a greater sense of anxiety and danger. According to Wells and
Papageorgio (1995), it may lead to more intrusive thoughts as they found in a
study that involved three groups watching a gruesome movie in three conditions.
After watching the movie, one group was told to relax, the second group was
told to imagine the events in the movie and the third group was asked to verbally
worry about the movie. It was found that people in the third group had more
intrusive thoughts as compared to the other two groups after several days of
watching the movie. Worrying also leads to more intense negative emotions
(Newman & Libera, 2011). Further, there is evidence for paradoxical effect of
worry also, that is, attempts to control worry leads to more intrusive thoughts
which lead to a feeling of uncontrollability. This in turn leads to anxiety which
further enhances worry. Thus, it leads to a vicious cycle of worry, intrusive
thoughts and anxiety (Mineka & Zinbarg, 2006).
3.4 TREATMENT OF GAD

Psychological therapy and medication are used as treatment options for GAD.
Cognitive-Behavioral Therapy (CBT): As has been described in the above
sections, CBT uses a combination of behavioral techniques such as progressive
muscle relaxation exercises (to relieve the physiological symptoms, such as
breathlessness, muscle tension) and cognitive techniques, such as cognitive
restructuring (for dealing with the psychological symptoms, such as anxiety,
cognitive distortions, catastrophizing, etc), (Barlow, Allen, & Basden, 2007).
Though, GAD has been known as one of the most difficult among anxiety
disorders to treat, nevertheless, research review has found the CBT to successfully
alleviate the symptoms of GAD (Mitte, 2005). Interestingly, research has shown
CBT to be as effective as benzodiazepines and it has also helped to taper off long
usage of medication (Gosselin et al., 2006).
Medications: Often, people suffering from GAD consult general practitioners

(GPs) for somatic systems such as muscle aches, tingling sensations, numbness,
breathlessness etc. and are prescribed benzodiazepines or anxiolytics, such as
alprax, restryl (market names). These drugs lead to symptom relief, and are more
effective in alleviation of physiological rather than psychological symptoms.
But these drugs can lead to psychological and physiological dependence.
Buspirone is a new drug which is more effective in alleviating psychological
84 symptoms like anxiety and does not lead to sleepiness and psychological or
physiological dependence but it takes a longer time (2 -4 weeks) to show effect Disorders of Anxiety, Panic
and Obsessions-II
(Roy-Byrne & Cowley, 2007). Similarly, some antidepressants have also proved
to be beneficial in treating GAD, but these also take a long time (several weeks)
to show their effect (Goodman, 2004).

1) List the characteristics of GAD.
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.............................................................................................................
2) Explain the psychoanalytical perspective for the development of GAD.
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3) What are the treatment options for GAD?
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3.5 OBSESSIVE-COMPULSIVE DISORDER

Obsessive-compulsive disorder (OCD) is characterised by the occurrence of
unwanted, intrusive obsessive thoughts and distressing images which are usually
accompanied by compulsive behaviors. Compulsive behaviors are carried out
either to undo or neutralize the obsessions or to prevent the occurrence of some
dreadful event.
3.6 CLINICAL ASPECTS OF OCD

Obsessive-compulsive disorder (OCD) is now included in DSM-5 under the
category of obsessive-compulsive and related disorders. Other disorders
included are hoarding disorder, excoriation (skin picking) disorder, body
dysmorphic disorder and trichotillomania (compulsive hair-pulling). Many
of us may occasionally find ourselves indulging in repetitive or stereotypical
behavior such as checking locks or gas stove; however, it does not mean that we
suffer from OCD. Obsessive-compulsive disorder involves much more excessive,
persistent and distressing thoughts and the associated compulsive acts
that significantly interfere with everyday activities (See Box 3.2 for DSM-5
criteria).
85
Disorders & Disorders of Box 3.2: Criteria of Obsessive-Compulsive Disorder, DSM-5
Anxiety and Obsessions ( APA,2013)
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1) Recurrent and persistent thoughts, urges, or images that are
experienced, at some time during the disturbance, as intrusive and
unwanted, and that in most individuals cause marked anxiety or
distress.
2) The individual attempts to ignore or suppress such thoughts, urges,
or images, or to neutralize them with some other thought or action
(i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1) Repetitive behaviors (e.g., hand washing, ordering, checking) or
mental acts (e.g., praying, counting, repeating words silently) that
the individual feels driven to perform in response to an obsession
or according to rules that must be applied rigidly.
2) The behaviors or mental acts are aimed at preventing or reducing
anxiety or distress, or preventing some dreaded event or situation;
however, these behaviors or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent,
or are clearly excessive.
Note: Young children may not be able to articulate the aims of
these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more
than 1 hour per day) or cause clinically significant distressor impairment
in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition.
D. The disturbance is not better explained by the symptoms of another
mental disorder (e.g., excessive worries, as in generalized anxiety
disorder; preoccupation with appearance, as in body dysmorphic
disorder; difficulty discarding or parting with possessions, as in hoarding
disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin
picking, as in excoriation[skin-picking] disorder; ritualized eating
behavior, as in eating disorders; preoccupation with substances or
gambling, as in substance-related and addictive disorders; preoccupation
with having an illness, as in illness anxiety disorder; sexual urges or
fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-
control, and conduct disorders; guilty ruminations, as in major depressive
disorder; thought insertion or delusional preoccupations, as in
schizophrenia spectrum and other psychotic disorders; or repetitive
patterns of behaviour, as in autism spectrum disorder).
According to DSM-5, “obsessions involve persistent and recurrent intrusive

thoughts, images, or impulses that are experienced as disturbing, inappropriate,
86 and uncontrollable. People who have such obsessions actively try to resist or
suppress them or to neutralize them with some other thought or action. Disorders of Anxiety, Panic
and Obsessions-II
Compulsions can involve either overt repetitive behaviors that are performed as
lengthy rituals (such as hand washing, checking, putting things in order over and
over again). Compulsions may also involve more covert mental rituals (such as
counting, praying, or saying certain words silently over and over again). A person
with OCD usually feels driven to perform this compulsive, ritualistic behavior
in response to an obsession, and there are often very rigid rules regarding exactly
how the compulsive behavior should be performed. The compulsive behaviors
are performed with the goal of preventing or reducing distress or preventing
some dreaded event or situation”.
OCD lowers the quality of life and leads to significant functional impairment
and thus it is often considered to be one of the most disabling mental disorders
(Stein et al., 2009). Unlike schizophrenia (in which absence of insight is a
characteristic feature), the person suffering from OCD must recognize that the
obsessions and compulsions have not been imposed externally but are the product
of his or her own mind and are senseless and excessive. However, this insight
may be absent in a minority of cases (Ruscio et al., 2010). As mentioned above,
many of us may experience obsessions and compulsive behavior occasionally
but the diagnosis of OCD implies spending at least 1 hour in obsessional and
compulsive activities and most of the waking hours in severe cases. But research
has shown that normal and abnormal obsessions and compulsive behaviors are
placed on a continuum in terms of differing frequency, intensity, troublesomeness
and the degree of resisting the obsessions and compulsions (e.g., Steketee &
Barlow, 2002). More than 25 percent of people in the National Comorbidity
Study (NCR-R) were found to have experienced obsessions or compulsions at
some point in their lives by Ruscio et al. (2010).
Obsessive thoughts involve themes like fears of contamination, harming oneself

or others, pathological doubt, need for symmetry, religious, aggressive and/or
sexual obsessions. These themes have been reported to be consistent across
cultures and life span (Pallanti, 2009). Aggressive or violent themes often involve
thoughts of harming close family members such as poisoning a spouse or children
and though rarely acted on, such thoughts torment the person who has such
thoughts.
To deal with such tormenting thoughts, people with OCD are often compelled to
indulge in meaningless and sometimes absurd activities are known as
compulsions. There are 5 primary compulsive behaviors, cleaning (washing),
checking, ordering, arranging, and counting (Mathews, 2009). At a given time,
different kinds of compulsive behaviors may be shown by people. Some people
may show extreme slowness in performing daily chores while others may insist
on having things in a strictly symmetrical fashion (Mathews, 2009). Washing or
cleaning may range from washing hands for 15-20 minutes (with only water or
general soap) to several hours of washing hands with detergents or disinfectants.
This may lead to bleeding hands with scaling and peeling skin. Similarly, checking
rituals may range from mild (checking for lights, locks etc.) twice or thrice a day
to extreme checking where people would go back to their third-floor apartment
after reaching the basement parking and repeatedly indulge in the same behavior,
so that they are unable to perform the activity that they were supposed to do.
Since both cleaning and checking rituals are carried out a specific number of
times so these also involve repetitive counting. Although, performing the
compulsive acts lead to reduction in anxiety and a sense of control but the relief 87
Introducton to Psychological is short-lived and so the person has to keep on repeating the act (e.g., Purdon,
2009).
Comorbidity with Other Disorders

Mood and anxiety disorders (e.g., social phobia, panic disorder, GAD, and PTSD)
often co-occur with OCD (Mathews, 2009). Several research studies have reported
that 25 to 50 percent of people with OCD are likely to experience major depression
at some point in their lives. Further, significant depressive symptoms are likely
to be found in approximately 80 percent of people with OCD (Torres et al., 2006).
One plausible reason suggested for co-occurrence of depression is that it could
be a patient’s response to the chronic and debilitating nature of OCD. Further,
the dependent and avoidant personality disorders can also co-occur with OCD.
Body dysmorphic disorder (BDD) has also been found to co-occur frequently
with OCD, e.g., a study found body dysmorphic disorder in 12 percent of patients
with OCD. In fact, researchers have suggested a close relationship between OCD
and BDD (e.g., Phillips et al., 2007, 2010; Veale & Neziroglu, 2004).
Prevalence, Age of Onset, and Gender Differences

The prevalence rate of OCD was 1.2 percent, and the lifetime prevalence was
2.3 percent in the National Comorbidity Survey-Replication study (Ruscio et
al., 2010). However, some studies have reported a lifetime prevalence of 3 percent
(Kessler et al., 2009). Both obsessions and compulsions are experienced by 90
percent of the patients with OCD (Franklin & Foa, 2007). Obsessive-compulsive
disorder leads to disturbed interpersonal and occupational relationships which
might be a reason for an overrepresentation of divorced and/or separated and
unemployed people among the patients with OCD (Torres et al., 2006). Unlike
other anxiety disorders where more females suffer than males, no significant
gender difference has been reported. The onset age is usually late adolescence
or early adulthood when prevalence is also the highest. However, OCD can be
found in children also with symptoms like adults (Poulton et al., 2009) with
higher prevalence, heritability, and severity among boys than in girls (Lomax et
al., 2009). Often the onset is gradual, and it tends to be chronic once the symptoms
become severe (e.g., Mataix-Cols et al., 2002).
3.7 CAUSAL FACTORS OF OCD

The main causal factors of OCD are as follows:
Biological Factors
Genetic Component: In a twin study, concordance rates of 68 percent and 31
percent were found for eighty pairs of monozygotic and 29 pairs of dizygotic
twins, respectively which indicates a moderate heritability of OCD (van
Grootheest et al., 2007). In family studies, prevalence rate of OCD in first degree
relatives of probands has been found to be 3 to 12 times higher than the normal
population (Grabe et al., 2006). Further, genetic component is significantly
stronger in the early onset of OCD than in the later onset of OCD (Grisham et al.,
2008). Also, tic-related OCD in childhood which is linked to Tourette’s syndrome
has also been found to have a significant genetic component (Lochner & Stein,
2003), for example, OCD was found in 23 percent of first-degree relatives of
patients with Tourette’s syndrome (Pauls et al., 1995). Lastly, the field of molecular
genetics has found specific genes for OCD that are different from Tourette’s
88 syndrome (Grisham et al., 2008; Stewart et al., 2007).
Structural and Functional Abnormalities of Brain: Brain imaging of OCD patients Disorders of Anxiety, Panic
and Obsessions-II
has shown abnormalities in cortical and subcortical regions such as the basal
ganglia. PET scans have also shown higher levels of activity in orbitofrontal
cortex and cingulate gyrus. In turn, all these structures are connected to the
amygdala, thalamus, and the limbic system. This brain circuitry is responsible
for the activation of primitive behaviors such as hygiene, aggression, and sex.
Symptoms of OCD lead to increased activation of this brain circuitry (Evans,
Lewis, & Lobst, 2004). Successful treatment of OCD shows some normalization
of this brain circuitry (Saxena et al., 2002). The central themes for obsessions,
such as sex, aggression, danger, and hygiene originate in the orbital frontal cortex
(Baxter et al., 1991). The cortico-basal-ganglionic-thalamic circuit allows only
the strongest of the primary urges to pass through and reach the thalamus which
is the relay station. All sensory input is received by the thalamus, which then
passes that sensory input back to the cerebral cortex. Baxter et al. (1991, 2000)
have proposed that abnormal functioning of the cortico-basal-ganglionic-thalamic
circuit due to overactivation of orbitofrontal and cingulate cortical regions does
not allow the controlled passage of information with the result that all the
messages, even subtle ones, regarding hygiene, aggressions etc. pass through.
This leads to inappropriate behaviors, such as repetitive behaviors in response to
concerns like aggression, hygiene etc. thereby leading to obsessional and
compulsive behavioral pattern. Research evidence (e.g., Szeszko et al., 2004;
Yoo et al., 2007) has suggested that one possible reason for abnormal circuitry
can be the abnormalities in white matter in the brain areas that form this circuit.
Neurochemistry of Brain: Indirect evidence for the involvement of serotonergic

system in OCD came from the pharmacological studies, e.g., in 1970s a tricyclic
antidepressant called clomipramine was found to be an effective treatment for
OCD. Although other tricyclic antidepressants are also available, but
clomipramine has been found to be most effective as it has significantly greater
effects on serotonin (Dougherty et al., 2007; Stewart et al., 2009). Also, selective
serotonin reuptake inhibitors (SSRIs) have also proved to be effective in treatment
of OCD (Dougherty, Rauch, et al., 2002, 2007). Interestingly, increased
serotonergic activity leads to OCD symptoms then how these antidepressants
which lead to an increase in the serotonin level could treat OCD? The
antidepressants such as tricyclics and SSRIs in a short term use increase the
serotonin levels but when taken for longer duration (6 to 12 weeks) leads to
down-regulation of serotonin receptors, causing a functional decrease in the
serotonin levels, which helps in controlling the symptoms of OCD (Dolberg et
al., 1996). GABA, glutamate and dopaminergic systems are also suggested to be
involved in OCD; however, their exact role is yet to be established (Stewart et
al., 2009).
It can be concluded that biological factors such as genetic components, structural,

and neurochemical abnormalities of brain have been found to be involved as
causes in OCD, however, the exact nature and contribution of these factors in
OCD are yet to be established.
Psychological Factors
Learning Theory: Mowrer (1947) has explained the obsessive-compulsive
disorder through his two-process theory of avoidance learning. In the first step,
through classical conditioning, the neutral stimuli get associated with frightening
thoughts and elicit anxiety, for example, a person associates behaviors like,
89
Introducton to Psychological touching a door handle or brushing of clothes against the wall/floor with infection
and so develops fear of contamination. In the second step, the person tries to
prevent infection by washing hands or clothes which also reduces the fear of
contamination. Thus, the person learns that washing behavior is effective in
anxiety reduction thereby reinforcing the washing response. In future, the person
would indulge in washing behavior whenever he/she feels anxious about
contamination (Rachman & Shafran, 1998). Since such behaviors reduce anxiety
hence these are extremely resistant to extinction (Mineka & Zinbarg, 2006).
Animals and humans have been reported to indulge in avoidance behavior
frequently when they face stressful and anxiety provoking events (e.g., Cromer
et al., 2007). In support of this theory, Rachman and Hodgson (1980) conducted
several studies. They purported that although an anxiety eliciting situation may
provoke many of us but people with OCD are forced to perform some action
repeatedly to reduce anxiety caused by an obsession. Despite realizing the futility
of his /her obsessions and related compulsive behaviors, the person is unable to
control such compulsive behaviors because these lead to reduction in anxiety
caused by the obsessions.
Thus, this model suggests that exposure to the anxiety provoking situation without
allowing the person suffering from OCD to indulge in an anxiety reducing
compulsive act will help in treatment. The underlying reasoning is that when the
person will find their anxiety subsiding on its own without indulging in any
compulsive act, it will help them realize the futility of their compulsions (Rachman
& Shafran, 1998). This model helps us to understand the maintenance of the
obsessive-compulsive behavior however, it is silent on the causal factors.
Cognitive Perspective: The ‘paradoxical effect of thought suppression’ helps us

to understand the cause of OCD. It has been shown experimentally that attempts
at suppressing of thoughts in normal people often leads to increase in those
thoughts later (Abramowitz et al., 2001; Wegner, 1994). People with OCD differ
from normal people with respect to the degree of thought suppression, i.e., people
with OCD find it more difficult to suppress their thoughts and failure at thought
suppression leads to negative mood. In a study, people with OCD were asked to
maintain a diary about their obsessive thoughts under two conditions. In one
condition, they were asked to suppress their thoughts and in the other condition
no such instructions were given. It was found that they reported more thoughts
when instructed for thought suppression (Salkovskis & Kirk, 1997). Researchers
have also found that obsessive-compulsive symptoms increase in general because
of thought suppression and such people spend a lot of time and effort in thought
suppression but remain unsuccessful in doing so (Purdon, 2004).
Several researchers like Salkovskis (e.g., 1989), Rachman (1997) have suggested
that rather than the obsessive thought itself, it is the appraisal of that thought in
terms of negative and catastrophic automatic thoughts that produces disturbances
and subsequent compulsive behavior. Thought-action-fusion has also been
suggested to explain OCD fusion (Berle & Starcevic, 2005; Rachman et al.,2006;
Shafran & Rachman, 2004). According to this explanation, people with OCD
have an exaggerated sense of responsibility and they interpret having a negative
thought as equivalent to acting on it. For example, if a person with OCD has a
thought of harming ones parent(s) they would appraise it as morally equal to
actually harming their parent(s), that is, ones thoughts and actions have been
fused together. To decrease the anxiety associated with this thought-action-fusion,
90 the person may indulge in compulsive behaviors.
People with OCD also show cognitive biases and cognitive distortions, for Disorders of Anxiety, Panic
and Obsessions-II
example, research studies have shown that just like people suffering from other
anxiety disorders, their attention is also focused on disturbing events that are
part of their obsessions (Mineka et al., 2003). Further, they lack confidence in
their short-term memory and hence indulge in ritualistic behavior repeatedly
that increases their compulsive behavior (Dar et al., 2000). According to
researchers (e.g., Morein-Zamir et al., 2010; Bannon et al., 2008), such people
also fail to inhibit motor responses and irrelevant information.
Evolutionary Factors
According to the evolutionary theorists, OCD has a role in our survival, for
example, thoughts about contamination and subsequent actions to prevent it helps
us to protect ourselves from potential infections and thus are valuable to our
lives (Mineka & Zinbarg, 1996, 2006). Also, displacement activities shown by
many animals in stressful situations resemble compulsive actions of OCD, such
as birds preening feathers in threatening situations (Craske, 1999).
3.8 TREATMENT OF OCD

The treatment options for OCD are as follows:
Behavioral Therapy: A combination of exposure therapy and response prevention

has been found to be effective in treating OCD (Stein et al., 2009). In this
treatment, the therapist along with the client prepares a hierarchy of distressing
stimuli, which is rated by the client on a 0 to 100 scale in terms of the severity of
distress or anxiety caused to the client. Then the client is asked to expose him/
herself to stimuli given in the hierarchy (in ascending order of anxiety) that cause
obsessive-compulsive responses, such as touching the doorknob. This is followed
by response prevention where the client is asked not to engage in any ritual like,
washing hands to deal with the anxiety provoked by the obsession. The response
prevention is important as the client can see that even when he/she did not engage
in a ritual to reduce anxiety and obsessional thought, no catastrophe occurred,
and the anxiety also reduced by itself. This observation helps the client to
understand the futility of his/her obsessive-compulsive responses, thereby
extinguishing them completely. Though some clients may not comply with this
treatment but many who do, show a symptom reduction of 50 to 70 percent
(Abramowitz et al., 2009).
Cognitive-Behavior Therapy: Though cognitive-behavior techniques, such as

cognitive restructuring has been found to be effective in treating OCD, however,
these have not been found to be superior to behavior therapy (Abramowitz et al.,
2009).
Medications: Antidepressants, specifically those that affect the functioning of

the neurotransmitter, serotonin have been reported to reduce symptoms by 25-
35 percent in 40 to 60 percent of the patients with OCD (Dougherty, et al., 2007).
In some cases of OCD which do not respond to the antidepressants, antipsychotic
medications in small amounts have been found to significantly reduce symptoms
(Bloch et al., 2006). However, a limitation of medication is that, relapse occurs
in 50 to 90 percent of patients on discontinuation of it (Dougherty et al., 2007).
In severe cases of OCD, where the patient suffers from the disorder for at least 5
years and does not respond to any treatment (psychotherapy or drug therapy),
91
Introducton to Psychological neurosurgical techniques have been suggested. However, these have been used
sparingly because of adverse side effects (Mindus, Rasmussen, & Rück et al.,
2008). Lastly, evidence has been found that lesser number of exposure and
response prevention sessions are required when the drug, d-cycloserine is also
prescribed to the patients of OCD (Wilhelm et al., 2009).

1) Differentiate between obsessions and compulsions.
.............................................................................................................
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2) What are the causal factors in the development of OCD?
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3) Explain behaviour therapy as a treatment option for OCD.
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3.9 SUMMARY
Generalized Anxiety Disorder is a state of chronic, excessive and
unreasonable worry about multiple life events or activities and is caused
due to genetic, psychological, chemical, behavioural or cognitive causes.
The Corticotropin Releasing Hormone plays a role in GAD as it is an anxiety
producing hormone.
CBT uses a combination of behavioral techniques such as progressive muscle
relaxation exercises to relieve the physiological symptoms, such as
breathlessness, muscle tension and cognitive techniques, in the treatment
of GAD.
Obsessive-compulsive disorder (OCD) is characterized by the occurrence
of unwanted, intrusive obsessive thoughts and distressing images which
are usually accompanied by compulsive behaviors.
OCD lowers the quality of life and leads to significant functional impairment
and thus it is often considered to be one of the most disabling mental
disorders.
Behaviour therapy is considered essential in the treatment of OCD, though
medication is also used.
92
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panic disorders, phobiasand generalized anxiety disorders. In P. E. Nathan &J.
M. Gorman (Eds.), A guide to treatments that work(2nd ed., pp. 301–36). New
York: Oxford UniversityPress.
Baxter, L. R., Jr., Schwartz, J. M., &Guze, B. H.(1991). Brain imaging: Toward
aneuroanatomy ofOCD. In J. Zohar, T. Insel, & S. Rasmussen (Eds.),The
psychobiology of obsessive-compulsive disorder. NewYork: Springer.
Beck, A., Emery, G., & Greenberg, R. (1985). Anxiety Disorders and Phobias. A
Cognitive Perspective (pp. 300-368). New York: Basic Books.
Beck, A. T., Brown, G., Steer, R. A., Eidelson, J. I., &Riskind, J. H. (1987).
Differentiating anxiety and depression: A test of the cognitive content-specificity
hypothesis. Journal of Abnormal Psychology, 96(3), 179-183.
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3.13 WEB RESOURCES

Watch the movie 'As Good As It Gets'; Directed by James L. Brooks (1997)
Answers to the Fill in the Blanks (1-5)
1) Free floating anxiety
2) Obsessive Compulsive Disorder
3) Pituitary gland; adrenocorticotropic hormone
4) Conflict between id impulses and ego
5) Obsessive Compulsive Disorder
104

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BPCC-133

School of Social Sciences

Block 1 INTRODUCTON TO PSYCHOLOGICAL DISORDERS & DISORDERS OF ANXIETY AND

Block 2 MOOD DISORDERS, PSYCHOTIC DISORDERS, SOMATIC SYMPTOMS AND EATING

Block 3 DISORDERS OF PERSONALITY, PARAPHILIC AND SUBSTANCE-RELATED DISORDERS

Block 4 DISORDERS OF CHILDHOOD AND ADOLESCENCE, TRAUMA AND STRESSOR

Let us now discuss each section of a unit.

In the section Introduction, we specify,

Check Your Progress

References and Further Reading

Further readings help you to increase your level of understanding of a particular

References for Images

Audio and Video Aids

The syllabus of course material BPCC-133 is designed by an Expert Committee

Dr. Monika Misra

Unit 5 gives a description on schizophrenia spectrum disorders. The unit presents

Unit 6 highlights somatic symptoms and related disorders.The clinical picture,

Block 3 consists of four units. Unit 8 introduces you to an important group of

In a similar way, in Unit 9, Cluster B and C personality disorders are explained.

Unit 14 discusses the nature of neurocognitive disorders. Major neurocognitive

1.1 WHAT IS A PSYCHOLOGICAL DISORDER?

In addition to the above, some other criteria are:

Wakefield (1992, 1999) proposed abnormal behavior as a harmful dysfunction.

Thus, no single criterion provides a satisfactory definition of abnormal behavior.

Check Your Progress 1

1.2 HISTORY OF PSYCHOLOGICAL DISORDERS

Later in Greece, medical perspective was used to understand mental disorders

Fig. 1.0: Hippocrates of Kos (Father of Medicine) Fig.1.1: Plato

The Greek philosopher Plato (429–347 BCE) took a philosophical view of

Fig.1.2: Aristotle Fig. 1.3: Galen

Psychological disorders in the middle ages

Humanitarian treatment of people with psychological disorders and mental

Fig. 1.4: Dorothea Lynde Dix (1802-1887)

Fig. 1.5: Emil Kraeplin (1856-1926)

Sigmund Freud (1856-1939 CE) introduced the psychological factors by

Thus, understanding the history of psychopathology helps us to appreciate the

1.3 PSYCHOLOGICAL MODELS

1) The Psychodynamic Model: The psychodynamic approach was posited by

2) The Behavioural Model: The model is based on behaviouristic school of

4) The Humanistic-Existentialist Model: The model proposes that ‘insight’ into

5) Socio-cultural Model: Social and cultural factors play an important in the

1.4 CLASSIFICATION OF PSYCHOLOGICAL

Carson, Butcher, and Mineka (2007) have defined classification in abnormal

Need for classification in abnormal psychology (Carson, Butcher, & Mineka,

2) Dimensional approach as opposed to the classical categorical approach

Criticism:Theorists have not reached a consensus on the number of

3) Prototypical approach combines both categorical and dimensional

Criticism:The categories of disorders are not clearly defined as some symptoms

How did we reach to the present system of classification?

2) Labeling: Once labeled, an individual starts identifying him/herself with

Kring et al (2012) draw attention to some specific criticisms of diagnosis by

Discrete Entity vs. Continuum (Categorical vs. Dimensional classification):

Reliability: The extent to which a classification system or a test produces the

Validity: The extent to which a classification system measures what it is supposed

Social and Cultural Considerations: “Cultural formulation guidelines” is a plan

Overall, the reliability of DSM has improved due to increased explicitness of

According to Davison, Neale, and Kring (2004), following problems remained

The increased reliability may improve validity but it is not guaranteed, a

Subjective factors may still play a role in evaluations as well as cultural

Continued efforts to improve DSM has led to DSM-5