Abnormal Psychology Past Paper PDF

1 UNDERSTANDING ABNORMAL BEHAVIOR : CLINICAL ASSESSMENT AND DIAGNOSIS - I Unit Structure 1.0 Objectives 1.1 Introduction 1.2 What is Abnormal Behaviour 1.2.1 Defining Abnormality 1.2.2 Challenges Involved in characterizing abnormal behaviour.in 1.2.3 What cause...

1 UNDERSTANDING ABNORMAL BEHAVIOR : CLINICAL ASSESSMENT AND DIAGNOSIS - I Unit Structure 1.0 Objectives 1.1 Introduction 1.2 What is Abnormal Behaviour 1.2.1 Defining Abnormality 1.2.2 Challenges Involved in characterizing abnormal behaviour.in 1.2.3 What causes Abnormality 1.3 The Diagnostic and Statistical Manual of Mental Disorders es 1.3.1 How the DSM Developed 1.3.2 Controversial Issues Pertaining to the DSM ot 1.3.3 Definition of Mental Disorder 1.3.4 Assumptions of the DSM-IV-TR un 1.4 Classifying Abnormal Behavior 1.5 Historical View of Abnormal Behavior m 1.5.1 The Emergence of Contemporary views of Abnormal Behavior 1.6 Summary 1.7 Questions 1.8 References 1.0 OBJECTIVES After reading this unit you will be able to:  Understand what is meant by abnormality and the difficulties in defining it.  Discuss the factors involved in the development of abnormality.  Describe the development and use of the Diagnostic and Statistical Manual of Mental Disorders. 1 Abnormal Psychology 1.1 INTRODUCTION Efforts to understand, explain and control problematic behaviors can be traced back to several years. Abnormal Psychology is the systematic study of abnormal behavior. It is a branch of psychology that is concerned with the etiology, symptomatology, and the process of mental illnesses. In this chapter we will examine what is meant by deviant or ‘abnormal’ behavior? After defining abnormality, we will discuss the challenges involved in characterizing abnormal behavior as well as the causes of abnormality. Following this we will discuss the Diagnostic and Statistical Manual of Mental Disorders and related topics. The concept of psychological assessment, behavioral assessment, multicultural assessment, environmental assessment and physiological assessment would be discussed with relevant examples. 1.2 WHAT IS ABNORMAL BEHAVIOUR?.in Let’s consider the following case. Does anything about Raju seem strange to you? How would you feel if es you were to see someone like Raju walking in your neighborhood? You could be surprised or scared or may even laugh? You may think there is something abnormal about this person. On what basis is Raju judged to be ot abnormal? Is it because the way he is talking is odd? Or since he is making high claims? Or because one cannot anticipate how he may behave after a while? un Anything that deviates from the normal or differs from the usual or typical is called abnormal. However, there can be exceptions and certain very unusual behaviors may also be considered normal in the given m cultural/social context. E.g. a gifted child. So, on what we should decide what is normal and what is abnormal? To answer the above question, there are certain criteria that help us define abnormality and also distinguish between what is normal and abnormal. 1.2.1 Defining Abnormality The current diagnostic procedures used in the mental health community rely on four important ways in which abnormality can be defined. Impairment: According to this criterion, maladaptive behaviors that prevent an individual from functioning well in his/her daily life can be considered abnormal. Impairment refers to a reduction in a person’s ability to function at an optimal or average level. For example, when a woman consumes psychoactive substances (drugs), her cognitive and perceptual abilities get impaired, and she would be at risk if she drives in this state. In the case mentioned earlier, Raju spent all his savings to buy an expensive 2 camera thinking that he could set up a studio. This can be thought of as his Understanding Abnormal impaired judgment. Behavior : Clinical Assessment and Diagnosis- I In certain situations, the person may report feeling great and describe oneself in positive terms but those around may suggest that s/he is functioning inadequately in her/his personal or work life. E.g. an individual experiencing manic symptoms of Bipolar disorder. Distress: This criterion suggests that a particular behavior should be considered as abnormal if the individual suffers discomfort because of that behavior and wish to get rid of them. The experience of distress - emotional or physical pain - is common in life. However, in case of mental disorders the intensity of pain is so high that it interferes with the person’s daily living. For example, a victim of an extremely traumatic event may experience unrelenting pain or emotional turmoil and may not be able to cope in daily life. Risk to Self or Other People: When an individual’s actions pose a threat to one’s own life or to the life of others, the behavior is considered to be.in abnormal. A severely depressed individual is at risk for committing suicide and therefore the condition is referred to as abnormal. Similarly, a person suffering from Schizophrenia is out of touch with reality and may es put oneself and/ or others at risk. In some situations, a person’s thoughts and behaviors threaten the physical or psychological wellbeing of others and are therefore, considered abnormal such as the act of abusing children or exploiting others. ot Socially and Culturally Unacceptable Behaviour: Behaviours that are not in line with the social or cultural norms are considered abnormal. un Certain behaviours may be acceptable in some cultures but considered odd in certain others. For e.g., In India, the phenomenon of being possessed by God is a common practice during Navratri or other festivals, but the same behaviour would be considered abnormal in most of the other countries. m Thus, the social context needs to be taken into account while judging behaviour as normal or abnormal. 1.2.2 Challenges Involved in Characterizing Abnormal Behaviour Although there are clear criteria for defining abnormality, diagnosing abnormal conditions is not as straightforward as it may seem. In 1973, David Rosenhan conducted a classic study that threw light on the difficulties involved in this process - 8 sane individuals were able to trick the staff of 12 psychiatric hospitals across the United States. Each of them was gainfully employed and presented oneself at these hospital reporting hearing voices such as “Empty”, “Hollow,” and “Thud.” These kind of psychotic symptoms were chosen because they had never been reported in the history of psychiatric literature. Except their names and employment, none of their other details were changed and thus their history and present behaviour (except for the symptoms) could not be considered abnormal in any way. Interestingly, all 3 Abnormal Psychology the hospitals admitted these pseudopatients and although they stopped producing the symptoms immediately following the admission, none of the staff members noticed it. On the contrary, their ordinary actions were taken as additional evidence of their abnormality. What was most striking was the inhuman approach of the staff - the pseudopatients felt as if nobody from the staff was concerned about their needs. Also, the staff didn’t believe them when they tried to convince them that they were actually normal. The pseudopatients were released in 7 to 52 days and at the time of discharge, each of them had received a diagnosis of ‘schizophrenia in remission’, which meant that their symptoms were not present, at least during that time. Rosenhan (1973) concluded that what prevented the hospital staff from detecting the pseudopatient’s normality is the general bias to call a healthy person sick. Since this study involved deception of the mental health professionals, it was criticized for an ethical reason. Questions pertaining to why a control group was not used for comparison were raised. It was also said that since the symptoms reported (hallucinations) were of a.in serious nature, most clinicians would have done what the hospital staff did. Scribner (2001) found that Rosenhan’s controversial study had led to an es extreme change in the mental health field where now patients with diagnosable psychotic symptoms had difficulty receiving mental health services. He reported 7 cases with documented history of chronic ot Schizophrenia, 6 of which were not treated even while they were in the active phase of symptoms. un Lauren Slater (2004) attempted to replicate Rosenhan’s study. She went to several clinicians complaining hearing “thud” and no other symptom. She was denied admission everywhere and at the most, diagnosed with depression with psychotic symptoms, was prescribed some m medication and sent away. She also reported that as opposed to the pseudopatient’s experience in the Rosenhan study, she was treated very kindly by every mental health staff. Thus, in spite of the criticisms, Rosenhan’s study proved to be crucial in pointing out that the attitudes towards diagnosing and admitting individuals with psychological difficulties need to change. 1.2.3 What causes Abnormality? There are various assumptions about the causes of abnormality. One being the biological approach which considers the abnormal behaviours to be caused by a biological factor such as genetic vulnerability to a disorder inherited from a parent, imbalance in neurotransmitters, brain injury, toxic substances etc. The psychological approach considers the abnormal behaviours to be caused by the early childhood experiences, traumatic experiences, maladaptive thought process, low self-concept etc. The social perspective considers the abnormal behaviours to be caused by the 4 disturbed interpersonal relationships, discrimination, or the negative social Understanding Abnormal environment in which an individual lives. Behavior : Clinical Assessment and Diagnosis- I There is long going debate whether abnormality is caused due to biological or environmental factor? This is referred to as the nature- nurture question wherein some consider the abnormality to be caused by something in the nature i.e. biological or due to nurture i.e. environmental factor. E.g. when a professional singer’s child also becomes a professional singer. So, was the singing ability passed genetically through birth or was it because of having father who is a professional singer and so the behavior learned through observation, countless hours of repetition and practice. So, now the forth approach is considered to be more acceptable. Social scientists are of the view that there is an interaction between biological, psychological and social factors. This approach is termed as ‘biopsychosocial’. On the similar line, the diathesis-stress model suggests that an individual is genetically predisposed (diathesis) i.e. they carry some genetic risk to a particular disorder to a particular disorder or.in have acquire vulnerability early in life due to some formative events such as birth complications, head injury, traumas, or malfunctioning or harsh family. This vulnerability placed them at higher risk of developing that disorder as they grow when they experience any kind of traumatic or es stressful situation or trigger. The can be due to psychological factors like a faulty personality trait, irrational thought process, low self-esteem or due to social factors like a history of abuse or poor interpersonal relations. ot The full-blown disorder can develop only when the vulnerability combines with the stress. Also, a feedback loop tends to develop, such that, changes un in one system lead to changes in the second and then the changes in the second system bring about changes in the first. For example, an increase in a certain neurotransmitter (biological factor) may make an individual angry and irritable (psychological factor). This may cause the person to m react angrily towards his friends, who may begin avoiding him (social factor) due to this behaviour. The rejection from friends (social factor) may make the person even more agitated, which may cause further changes in the neurotransmitters (biological factor). Although the theoretical approaches are discussed in detail in topic 2, let’s have a brief look at the biopsychosocial factors involved in the development of abnormality. Biological causes:  In understanding what causes abnormality from the biological perspective, mental health professionals focus on the processes in a person’s body, such as genetic inheritance, altering function of nervous system or physical disturbances.  Many disorders run in the family. For example, the chances of the son or daughter developing schizophrenia are greater if either of their 5 Abnormal Psychology parents is suffering from it as compared to children of parents who do not have the disorder.  Other factors such as medical conditions (thyroid), brain damage (head trauma), exposure to certain environmental stimuli (toxic substances, allergens), ingestion of certain medicines, illicit drugs, etc., can cause disturbances in the physical functioning that cause emotional or behavioural disturbances. Psychological causes:  Traumatic life experiences that have an impact on the individual’s thoughts, feelings, behavior or personality constitute the psychological factors in the development of abnormality. For example, an irrational fear of the marketplace may be caused due to a childhood experience of having been lost in the market.  Early interpersonal relationships may lead to distortions in perception and faulty thought processes. For example, a boy who is very upset because his girlfriend didn’t call back may realize that his reaction.in stems from his history of being disappointed by his unreliable parents and having internalized the idea that important people tend to disappoint. es  Unrealistic expectations, learned helplessness, focusing on the negative, blaming, dichotomous thinking (seeing things as black or white), catastrophizing (exaggerating) etc., can trigger psychological ot difficulties.  Low self-esteem, poor judgment, pessimistic thought process, low un self-confidence makes a person more vulnerable to the psychological difficulties Sociocultural causes: m  The term sociocultural refers to the sources of social influence in one’s life. The most immediate or inner circle that has an impact on a person comprises of the family members and friends. A troubled relationships can make one feel depressed. Similarly, a failed lover may become suicidal.  The next circle involves extended family, neighbours with whom there is less interaction. Nonetheless their behaviours, standards, attitudes, and expectations do influence individuals.  The next circle involves teachers, school, college, institution, workplace. What an individual learns from each of these places or the experiences that they get plays an important role in shaping ones thought and behavior.  The society plays a decisive role in most people’s lives. Political turmoil, even at the local level can leave one feeling anxious or fearful. Discrimination based on gender, caste, sexual orientation, disability 6  can have an impact on individuals. As seen earlier, social and cultural Understanding Abnormal norms determine what would be called abnormal, to a large extent. Behavior : Clinical Assessment and Diagnosis- I 1.3 THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS  Mental health professionals refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM) for standard terms and definitions of various forms of abnormality. It is a classification system that includes descriptions of all psychological disorders, which are also known as mental disorders.  The DSM, published by the American Psychiatric Association (APA), is periodically revised to incorporate the latest information related to psychological disorders. The DSM was first published in 1952 and since then has gone through several changes with its latest version being DSM-IV-TR (text revision).  To develop revised editions of the DSM, task forces are appointed.in which comprise of clinicians and researchers with expertise in specific disorders. Based on their research and case studies analysis, a list of several disorders ranging from mild adjustment problems to severe disorders has been listed. es  The DSM ensures standardized interpretation of the diagnostic labels and provides a common language and format for communication ot between clinicians and researchers. Its multiaxial format (explained later in the chapter) also allows thorough un evaluation of cases with attention to the mental disorders, general medical conditions, psychosocial problems, and the level of functioning, which might get ignored if the focus were on evaluating only the presenting complaints. m  The recent editions of the DSM follow an a theoretical approach, that is, they try to present psychological disorders in a manner that reflects observable phenomena rather than what caused it. For example, anxiety disorders are described in terms of the associated psychological and physical symptoms associated with no reference to what caused these symptoms.  The DSM classification system also helps in treatment planning. For example, a clinician would choose very different treatment plans for individuals with anxiety disorders as compared to those with psychotic illnesses. Also, every DSM-IV diagnosis has specific numerical code, which helps individuals acquire health insurance to manage the treatment cost.  The authors of the DSM have tried to develop a reliable and scientifically and clinically sound system such that anyone showing a specific set of symptoms receives the same diagnosis across clinicians, irrespective of their theoretical orientation. 7 Abnormal Psychology  Emphasis has also been on the ensuring its validity i.e. the extent to which the diagnostic criteria measure a specific disorder and how well the disorders can be distinguished from each other. For this, the experts have been required to consider the base rate of a disorder - that is, the frequency with which a disorder is found among the general population. Low base rate means fewer cases and therefore establishing the reliability of the disorder becomes difficult. 1.3.1 How the DSM Developed The DSM was the first official classification system that was developed exclusively for diagnosing mental disorders. Let’s look at the history of the DSM - the initial editions of this manual were not as precise and reliable as the recent ones.  The DSM-I, the first edition published in 1952, followed a theoretical approach where mental disorders were seen as a result of an individual’s ‘emotional reactions’ or their ‘emotional problems’.  The DSM-II which was published in 1968, tried to introduce explicit.in definitions and diagnostic terms that would reduce reliance on theoretical assumptions. However, the criteria to describe different was not precisely explained and was mostly based on the concepts of es psychoanalytic theory.  In 1974, the APA appointed a task force i.e. a team of scholars and practitioners to develop a manual that would be based on observable ot phenomena and acceptable to clinicians irrespective of their theoretical orientation. This led to the DSM-III, published in 1980. un  Although the DSM-III was a refined edition, it had instances in which the diagnostic criteria were not entirely clear. Due to this, the DSM- III-R was published in 1987 as an interim manual till a more complete edition was developed. m  Around the same time, the APA once again set up a task force that worked towards improving the reliability and validity of the diagnoses, in stages. In stage 1, its members reviewed the relevant research published which was then carefully analyzed in stage 2. The next stage involved field trials in which several thousand individuals with diagnosed psychological disorders were interviewed. Consistency in diagnosis was assessed by having pairs of clinicians independently rate clients through videotaped interviews. To establish the validity of the diagnosis, clinicians evaluated individuals diagnosed with specific psychological disorders, with the number and nature of symptoms needed to diagnose specific conditions. These field trials helped to empirically decide the specific kind and number of symptoms that would make a diagnostic criteria. For example, to diagnose Major Depressive Disorder, a person has to have atleast five out of the nine listed symptoms which include lack of interest, sad mood, disturbed sleep, disturbed appetite, feelings of worthlessness, etc. 8  Thus, the DSM-IV was published in 1994. A major feature of this Understanding Abnormal version was that it included ‘the symptoms cause clinically significant Behavior : Clinical distress or impairment in social, occupational or other areas of Assessment and Diagnosis- I functioning’ as one criterion for almost half of all the disorders.  The DSM-IV with updated information, known as DSM-IV-TR (text revised) was published by 2013.  And, then the latest been DSM-V was published in 2013. A lot of changes have been made from DSM-IV-TR to DSM 5. One of the key changes is the elimination of multi-axial system. Then, the task forces of DSM 5 also considered getting away with the categorical model to represent different disorders and adopt the dimensional model. But they end up not doing so. However, Section 3 of DSM 5 provides clinician the description of different disorder based on dimensional model.  The current organization of DSM 5 begins with neurodevelopmental disorders, then next category is of “internalizing” disorders (wherein.in anxiety, depressive, and somatic symptoms are more prominent) and lastly “externalizing” disorders (wherein impulsive, disruptive conduct and substance use symptoms are more prominent). es 1.3.2 Controversial Issues Pertaining to the DSM  For many years, critics of the DSM have argued that it tends to unfairly label people and is not a very reliable and valid tool. It is also ot suggested that politics and culture have influenced the definitions of disorders from time to time. For example, homosexuality was included as a diagnostic category in the DSM-II and was removed following un protests from gay activists at the APA annual conferences from 1970 to 1973.  Also, pressure from the Vietnam War veterans forced the authors of m DSM-III to recognize that a group of symptoms experienced by survivors of traumatic events represented a disorder and thus post- traumatic stress disorder was introduced. This demonstrates the biased processes involved in defining mental disorders.  In addition to this, the DSM classification system is criticized for being prejudiced against women, in that women are more likely to be diagnosed with personality or mood disorders because feminine personality characteristics are perceived as being pathological. As a result of this, the authors of the DSM-IV have been particularly careful about basing their decisions on fair interpretation of the research data (Kirk & Kutchins, 1992; Kutchins & Kirk, 1997). 1.3.3 Definition of Mental Disorder The concept of mental disorders is fundamental to the processes of diagnoses and treatment. The authors of the DSM define a mental disorder as “a clinically significant behavioral or psychological syndrome or 9 Abnormal Psychology pattern that occurs in an individual that is associated with present distress (e.g., painful symptom) or disability (i.e., impairment in one or more areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom and it is not typical or culturally expected.” Let’s understand this definition.  A mental disorder is clinically significant - this implies that the symptoms have to be present for a specified period of time and should have a major effect on the person’s life. Thus, an occasional low mood or strange behaviour or a sense of instability are common experiences and do not represent a mental disorder. In order to be considered it as significant it need to be persistent and severe in nature.  A mental disorder is behavioral or psychological syndrome or pattern - a syndrome is a collection of defined symptoms. A behavioural or psychological syndrome indicates a set of observable actions and the thoughts and feelings reported by the individual..in Accordingly a random thought or behaviour does not constitute a mental disorder. A person has to experience a wide range of defined thoughts, feelings and behaviours in order to be called as having a psychological disorder. es  Further, it is associated with present distress, disability, impairment or serious risk. This means that the syndrome sufficiently interferes with the individual’s everyday functioning. For ot example, a woman who compulsively washes hands may be very disturbed by her actions and may not be able to overcome the un behaviour. Her productivity at work and social life may also be severely affected by this. In certain mental disorders the person may not experience any distress but there may be a serious risk to life. For example, a person in a m hyperexcited state of mania, having a good time, may believe he can fly and is thus at risk.  Finally, the disorder is not a culturally expected or sanctioned pattern. For example, a woman feeling sad, having difficulty eating, sleeping, concentrating, etc., for few days, following the death of her husband, will not be called as suffering from Major Depressive Disorder because it is an expected reaction to this event. 1.3.4 Assumptions of the DSM-IV-TR The DSM is based on some assumptions: 1. Medical Model: The DSM follows a medical model which means that every physical and psychological disorder is regarded as a disease. In this sense the DSM is similar to the ICD, the International Classification of Diseases (ICD), developed by the World Health Organisation, and ensures uniformity in the usage of medical terms. 10 According to this view, schizophrenia is a disease and the individual Understanding Abnormal suffering from it is referred to as patient. The use of the term mental Behavior : Clinical disorder is also in line with this view. Although the term mental disorder Assessment and Diagnosis- I implies a distinction between ‘mental’ disorders and ‘physical’ disorders, it is important to recognize that there aren’t any fundamental differences between mental disorders and general medical conditions. Mental disorders tend to involve biological factors and similarly physical disorders have psychological components. 2. A theoretical Orientation: The authors of the DSM have tried to develop a descriptive rather than explanatory classification system, that is, a psychological disorder is presented as an observable phenomenon rather than in terms of what caused it. The DSM is neutral with respect to the theories of causality. For example, the DSM-IV-TR classifies social phobia as an anxiety disorder in which the person has persistent fear of social or performance situations, without any reference to whether the anxiety is caused due to a childhood trauma or an unconscious conflict or any other factor..in The early editions of the DSM were based on the psychoanalytical tradition in which mental disorders were seen as ‘neurosis’ or an ‘emotional reaction’ to one’s problems and were thought to be a result of es unconscious conflicts. The term neurosis is not a part of the DSM anymore but is still commonly used to describe symptoms that are distressing and do not have a physiological basis. The term is also used to ot refer to excessive anxiety or worry and to distinguish the condition from psychosis. un Psychosis involves the presence of hallucinations (false perceptions) and delusions (false beliefs). It is a condition in which the person is not in touch with reality and shows grossly disturbed and bizarre behaviour. Psychosis is not a diagnostic category but used as a descriptive term in the m DSM-IV-TR. 3. Categorical Approach: The DSM-IV-TR classifies the disorders into separate categories. For instance, conditions which involve excessive anxiety or worry are categorized as anxiety disorders, those which affect the mood are referred to as mood disorders. Although systematic, this approach has a limitation - psychological disorders cannot be very neatly separated from one another. For example, it is difficult to distinguish between sad mood and clinical depression (severe enough to receive a diagnosis of depression). Also, some cases involve a mixed presentation such a person experiencing anxiety and sad mood or mood symptoms with psychosis. There are two issues related to the categorical approach. One is comorbidity, that is, conditions in which a person has two or more disorders that co-exist. For instance, negative emotional states are common in anxiety disorders, mood disorders and some personality disorders. The second is that of boundaries - some disorders have 11 Abnormal Psychology overlapping symptoms, such as conduct disorder, oppositional defiant disorder and attention- deficit/hyperactivity disorder (Widiger & Samuel, 2005). Due to this, a dimensional approach is being considered. That is, instead of fitting an individual’s symptoms into some category s/he would receive a numerical rating on his symptoms indicating the severity of each. The dimensional model is thought to give a better picture of the individual’s condition. And, the task force of DSM 5 is hoping to develop the next edition using dimensional model. 4. Multiaxial system: This system involves assessing five areas of an individual’s functioning so that the treatment can be planned accordingly and the course of the disorder can be predicted. The DSM comprises of five axes: Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention This axis is used for listing the various forms of abnormality, that is, the.in clinical syndromes or disorders with the exception of the Personality Disorders and Intellectual Disability, such as Schizophrenia, the different types of Anxiety disorders, such as social phobia, specific phobia, es generalized anxiety disorder etc., the Obsessive and compulsive related disorders like obsessive compulsive disorders, hoarding disorder, body dysmorphic disorder, etc., Mood disorders such as major depressive disorder, bipolar disorder, etc., Adjustment disorders, Cognitive disorders ot like delirium, dementia, amnestic disorder, etc. If an individual has more than one Axis I disorder, all should be reported with the primary reason un for the visit being listed first. Axis II: Personality Disorders and Mental Retardation All the Personality Disorders like Paranoid personality disorder, Schizoid m personality disorder, Schizotypal personality disorder, Antisocial personality disorder, Narcissistic personality disorder, etc., and Intellectual Disability are reported on Axis II. Maladaptive personality features or excessive use of defense mechanisms can also be mentioned here. This axis ensures that the unhealthy personality characteristics and mental retardation will be taken into account while attending to the primary complaint. Axis III: General Medical Conditions This axis is for reporting the general medical conditions that are important in understanding an individual’s mental disorder. General medical conditions may be related to the mental disorders in several ways. In some cases they may play a role in the development of an Axis I disorder, for example, Hypothyroidism may lead to depressive symptoms in some or an individual may develop an Adjustment disorder as a reaction to the diagnosis of Brain tumor. In certain cases medical conditions may influence the treatment of the Axis I disorder, for instance, a person’s 12 heart disease may influence the clinician’s choice of medicines for this Understanding Abnormal patient’s depression. Behavior : Clinical Assessment and Diagnosis- I Axis IV: Psychosocial and Environmental Problems The psychosocial and environmental problems that influence the diagnosis, treatment and prognosis (future course) of mental disorders listed on Axis I and/or II are reported on this axis. This includes a negative life event, interpersonal stresses, lack of social support, etc. These problems may influence the development or treatment of mental disorders or may develop as a result of the Axis I/II condition. Axis V: Global Assessment of Functioning This axis is for reporting the clinician’s judgement of the individual’s overall functioning, which is useful in treatment planning or predicting its outcome. The Global Assessment of Functioning (GAF) scale is used by clinician to rate the individual’s psychological, social and occupational functioning. For example, score of 100 means superior functioning with no symptoms while a score of 50 indicates serious symptoms..in 91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his es or her many positive qualities. No symptoms. 81-90 Absent or minimal symptoms (e.g., mild anxiety before an exam), ot good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument un with family members). 71-80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family m argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). 61-70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. 51-60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 41-50 Severe symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). 13 Abnormal Psychology 31-40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood ( e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). 21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). 11-20 Some danger of hurting self or others (e.g., suicidal attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute)..in 1-10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.0 Inadequate information. es 1.4 CLASSIFYING ABNORMAL BEHAVIOR ot  Most sciences rely on classification (e.g., the periodic table in chemistry and the classification of living organisms into kingdoms, un phyla, classes, and so on in biology).  At the most fundamental level, classification systems provide us with a nomenclature (a naming system) and enable us to structure m information in a more helpful manner.  Organizing information within a classification system also allows us to study the different disorders that we classify and therefore to learn more about not only what causes them but also how they might best be treated.  A final effect of classification system usage is somewhat more mundane.  The classification of mental disorders has social and political implications (see Blashfield & Livesley, 1999; Kirk & Kutchins, 1992). Simply put, defining the domain of what is considered to be pathological establishes the range of problems that the mental health profession can address. As a consequence, on a purely pragmatic level, it furthermore delineates which types of psychological difficulties warrant insurance reimbursement and the extent of such reimbursement. 14 1.5 HISTORICAL VIEW OF ABNORMAL BEHAVIOR Understanding Abnormal Behavior : Clinical The historical view of abnormal behavior has come a long way Assessment and Diagnosis- I considering the reason behind the abnormal behavior to be attributed to supernatural forces or evil forces to the knowledge based on scientific study. The course of this evolution has at times been matter of efforts of many prominent experts and researchers. Demonology, Gods and Magic  As mentioned earlier, one of the earliest explanations to the abnormal behavior was attributed to God or evil spirits.  References to abnormal behavior in early writings show that the Chinese, Egyptians, Hebrews, and Greeks often attributed such behavior to a demon or god who had taken possession of a person.  Whether the “possession” was assumed to involve good spirits or evil spirits usually depended on the affected individual’s symptoms. If a.in person’s speech or behavior appeared to have a religious or mystical significance, it was usually thought that he or she was possessed by a good spirit or god. Such people were often treated with considerable awe and respect, for people believed they had supernatural powers. es  Most possessions, however, were considered to be the work of an angry god or an evil spirit, particularly when a person became excited or overactive and engaged in behavior contrary to religious teachings. ot  Apparently they were punished and punishment involve withdrawal from God’s protection and abandonment of the person to the forces of un evil.  In such cases, every effort was made to rid the person of the evil spirit. The primary type of treatment for demonic possession was exorcism, m which is a physically and mentally painful form of torture carried out by a shaman, priest,or medicine man.  Archaeological evidence also showed the use of the procedure called as trephining on the people showing abnormal behavior. The trephining is a process wherein a hole is drill on the skull of an individual with the believe that the hole will pave way to remove the evil spirit out of the body. Hipoocrates’ Early Medical Concepts  The Greek physician Hippocrates (460–377 b.c.), often referred to as the father of modern medicine, received his training and made substantial contributions to the field.  Hippocrates denied that deities and demons intervened in the development of illnesses and instead insisted that mental disorders, like other diseases, had natural causes and appropriate treatments. 15 Abnormal Psychology  He believed that the brain was the central organ of intellectual activity and that mental disorders were due to brain pathology. He also emphasized the importance of heredity and predisposition and pointed out that injuries to the head could cause sensory and motor disorders.  Hippocrates classified all mental disorders into three general categories—mania, melancholia, and phrenitis (brain fever)— and gave detailed clinical descriptions of the specific disorders included in each category.  He relied heavily on clinical observation, and his descriptions, which were based on daily clinical records of his patients, were surprisingly thorough.  However, Hippocrates had little knowledge of physiology. He believed that hysteria (the appearance of physical illness in the absence of organic pathology) was restricted to women and was caused by the uterus wandering to various parts of the body, pining for children. For this “disease,” Hippocrates recommended marriage as the best remedy.in Early Philosophical Conceptions of Consciousness Plato:- es  The Greek philosopher Plato (429–347 b.c.) studied mentally disturbed individuals who had committed criminal acts and how to deal with them. ot  He wrote that such persons were, in some “obvious” sense, not responsible for their acts and should not receive punishment in the same un way as normal persons. He also made provision for mental cases to be cared for in the community (Plato, n.d.).  Plato viewed psychological phenomena as responses of the whole m organism, reflecting its internal state and natural appetites. Plato emphasized the importance of individual differences in intellectual and other abilities and took into account sociocultural influences in shaping thinking and behavior.  His ideas regarding treatment included a provision for “hospital” care for individuals who developed beliefs that ran counter to those of the broader social order. There they would be engaged periodically in conversations comparable to psychotherapy to promote the health of their souls (Milns, 1986). Despite these modern ideas, however, Plato shared the belief that mental disorders were in part divinely caused. Aristotle  The celebrated Greek philosopher Aristotle (384–322 B. C.), who was a pupil of Plato, wrote extensively on mental disorders. Among his most lasting contributions to psychology are his descriptions of consciousness. 16  He held the view that “thinking” as directed would eliminate pain and Understanding Abnormal help to attain pleasure. Behavior : Clinical Assessment and Diagnosis- I  On the question of whether mental disorders could be caused by psychological factors such as frustration and conflict, Aristotle discussed the possibility and rejected it; his lead on this issue was widely followed.  Aristotle generally subscribed to the Hippocratic theory of disturbances in the bile. For example, he thought that very hot bile generated amorous desires, verbal fluency, and suicidal impulses. Later Greek and Roman Thought  Hippocrates’ work was continued by some of the later Greek and Roman physicians.  One of the most influential Greek physicians was Galen (a.d. 130– 200), who practiced in Rome. He made a number of original contributions concerning the anatomy of the nervous system. (These.in findings were based on dissections of animals; human autopsies were still not allowed.)  Galen also took a scientific approach to the field, dividing the causes es of psychological disorders into physical and mental categories. Among the causes he named were injuries to the head, excessive use of alcohol, shock, fear, adolescence, menstrual changes, economic ot reversals, and disappointment in love.  Roman medicine reflected the characteristic pragmatism of the Roman un people. Roman physicians wanted to make their patients comfortable and thus used pleasant physical therapies such as warm baths and massage. m  However, they also followed the principle of contrariis contrarius (“opposite by opposite” )—for example, having their patients drink chilled wine while they were in a warm tub. Early Views of Mental Disorders in China  China was one of the earliest developed civilizations in which medicine and attention to mental disorders were introduced (Soong, 2006).  However, at this early date, Chinese medicine was based on a belief in natural rather than supernatural causes for illnesses. For example, according to them, the human body, like the cosmos, is divided into positive and negative forces that both complement and contradict each other. If the two forces are balanced, the result is physical and mental health; if they are not, illness results. Thus, treatments focused on restoring balance. 17 Abnormal Psychology  Chinese medicine reached a relatively sophisticated level during the second century, and Chung Ching, who has been called the Hippocrates of China, wrote two well-known medical works around a.d. 200. Like Hippocrates, he based his views of physical and mental disorders on clinical observations, and he implicated organ pathologies as primary causes. However, he also believed that stressful psychological conditions could cause organ pathologies, and his treatments, like those of Hippocrates, utilized both drugs and the regaining of emotional balance through appropriate activities. Views of Abnormality During the Middle Ages  During the Middle Ages (about a.d. 500 to a.d. 1500), the more scientific aspects of Greek medicine survived in the Islamic countries of the Middle East.  The first mental hospital was established in Baghdad in A.D. 792. It was soon followed by others in Damascus and Aleppo (Polvan, 1969). In these hospitals, mentally disturbed individuals received humane.in treatment. Humanitarian Approaches es  During the latter part of the Middle Ages and the early Renaissance, the superstitious beliefs that had hindered the understanding and therapeutic treatment of mental disorders began to be challenged. Scientific questioning reemerged and a movement emphasizing the ot importance of specifically human interests and concerns began—a movement (still with us today) that can be referred to as humanitarian approach. un  Paracelsus (1490–1541), a Swiss physician, was an early critic of superstitious beliefs about possession. He insisted that the dancing mania was not a possession but a form of disease, and that it should be m treated as such. Although Paracelsus rejected demonology, his view of abnormal behavior was colored by his belief in astral influences (lunatic is derived from the Latin word luna, or “moon”). He was convinced that the moon exerted a supernatural influence over the brain—an idea, incidentally, that persists among some people today.  Johann Weyer (1515–1588), a German physician and writer was so deeply disturbed by the imprisonment, torture, and burning of people accused of witchcraft that he made a careful study of the entire problem.  About 1583 he published a book, On the Deceits of the Demons, that contains a step-by-step negation of the Malleus Maleficarum, a witch- hunting handbook published in 1486 for use in recognizing and dealing with those suspected of being witches. In his book, Weyer argued that a considerable number, if not all, of those imprisoned, tortured, and burned for witchcraft were really sick in mind or body and that, consequently, great wrongs were being committed against 18  innocent people. Weyer’s work enjoyed the approval of a few Understanding Abnormal outstanding physicians and theologians of his time. Behavior : Clinical Assessment and Diagnosis- I  Weyer was one of the first physicians to specialize in mental disorders, and the founder of modern psychopathology. Unfortunately, however, he was too far ahead of his time. He was scorned by his peers and his works were banned by the Church and remained so until the twentieth century.  From the sixteenth century on, special institutions called asylums— sanctuaries or places of refuge meant solely for the care of the mentally ill—grew in number. The early asylums were begun as a way of removing from society troublesome individuals who could not care for themselves. Although most early asylums, often referred to as “madhouses,” were not pleasant places or “hospitals” but primarily residences or storage places for the insane. The unfortunate residents lived and died amid conditions of incredible filth and cruelty.  Later because of the efforts of some prominent professionals, the.in situation started changing. In the United States, the Pennsylvania Hospital in Philadelphia, completed under the guidance of Benjamin Franklin in 1756, provided some cells or wards for mental patients. The Public Hospital in Williamsburg, Virginia, constructed in 1773, es was the first hospital in the United States devoted exclusively to mental patients. However, there too, the treatment techniques were aggressive, aimed at restoring a “physical balance in the body and ot brain.” They included powerful drugs, water treatments, bleeding and blistering, electric shocks, and physical restraints. For example, a violent patient might be plunged into ice water or a listless patient into un hot water.  By the late eighteenth century, most mental hospitals in Europe and America needed reform. The humanitarian treatment of patients m received great impetus from the work of Philippe Pinel (1745–1826) in France. In this capacity, he received the grudging permission of the Revolutionary Commune to remove the chains from some of the inmates as an experiment to test his views that mental patients should be treated with kindness and consideration—as sick people, not as vicious beasts or criminals. Had his experiment proved a failure, Pinel might have lost his head, but fortunately it was a great success. Chains were removed; sunny rooms were provided; patients were permitted to exercise on the hospital grounds; and kindness was extended to these poor beings. The effect was almost miraculous. The previous noise, filth, and abuse were replaced by order and peace.  At about the same time that of Pinel, an English Quaker named William Tuke (1732–1822) established the York Retreat, a pleasant country house where mental patients lived, worked, and rested in a kindly, religious atmosphere (Narby, 1982). The Quakers believed in treating all people, even the insane, with kindness and acceptance. 19 Abnormal Psychology  Benjamin Rush (1745–1813), the founder of American psychiatry and also one of the signers of the Declaration of Independence was associated with the Pennsylvania Hospital in 1783, Rush encouraged more humane treatment of the mentally ill; 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 (see Gentile & Miller, 2009).  But even his principal remedies were bloodletting and purgatives. In addition, he invented and used a device called “the tranquilizing chair,” intended to reduce blood flow to the brain by binding the patient’s head and limbs.  Despite these limitations, we can consider Rush an important transitional figure between the old era and the new.  During the early part of this period of humanitarian reform, the use of moral management—a wide-ranging method of treatment that focused on a patient’s social, individual, and occupational needs—.in became relatively widespread. This approach, which stemmed largely from the work of Pinel and Tuke, began in Europe during the late eighteenth century and in America during the early nineteenth century. es  Despite its reported effectiveness in many cases, moral management was nearly abandoned by the latter part of the nineteenth century. The reasons were many and varied. Among the more obvious ones were ot overcrowding, lack of sufficient staff and limited hospital facilities. Two other reasons are, in retrospect, truly ironic. One was the rise of un the mental hygiene movement, which advocated a method of treatment that focused almost exclusively on the physical well-being of hospitalized mental patients. Although the patients’ comfort levels improved under the mental hygienists, the patients received no help for m their mental problems and thus were subtly condemned to helplessness and dependency. Secondly, advances in biomedical science also contributed to the demise of moral management and the rise of the mental hygiene movement.  Benjamin Franklin’s work with electricity was among the earliest efforts to explore electric shock to treat mental illness, an insight he gained accidentally. His proposals for using electricity to treat melancholia (depression) grew out of his observations that a severe shock he had experienced altered his memories.  Dorothea Dix (1802–1887) became an important driving force in humane treatment for psychiatric patients. In 1841, she began to teach in a women’s prison. Through this contact she became acquainted with the deplorable conditions in jails, almshouses, and asylums. As a result of what she had seen, Dix carried on a zealous campaign between 1841 and 1881 that aroused people and legislatures to do something about the inhuman treatment accorded the mentally ill. Through her efforts, the mental hygiene movement grew in America. 20  Millions of dollars were raised to build suitable hospitals, and 20 states Understanding Abnormal responded directly to her appeals. She also directed the opening of two Behavior : Clinical large institutions in Canada and completely reformed the asylum Assessment and Diagnosis- I system in Scotland and several other countries. She is credited with establishing 32 mental hospitals.  Later critics have claimed that establishing hospitals for the mentally ill and increasing the number of people in them spawned overcrowded facilities and custodial care (Bockhoven, 1972; Dain, 1964). However, her advocacy of the humane treatment of the mentally ill stood in stark contrast to the cruel treatment common at the time. Nineteenth-Century Views of the Causes and Treatment of Mental Disorders  In the early part of the nineteenth century, mental hospitals were controlled essentially by laypersons because of the prominence of moral management in the treatment.  Effective treatments for mental disorders were unavailable, the only.in measures being such procedures as drugging, bleeding, and purging, which produced few objective results. es  However, during the latter part of the century, professionals gained control of the insane asylums and incorporated the traditional moral management therapy into their other rudimentary physical medical procedures. ot Changing Attitudes Toward Mental Health in the Early Twentieth Century un  By the end of the nineteenth century, mental patients admitted to mental hospital or asylum lived under relatively harsh conditions despite of moral management. Little was done by the resident m psychiatrists to educate the public or reduce the general fear and horror of insanity. A principal reason for this silence, of course, was that early psychiatrists had little actual information to impart and in some cases employed procedures that were damaging to patients.  Gradually, however, important strides were made toward changing the general public’s attitude toward mental patients.  The twentieth century began with a continued period of growth in asylums for the mentally ill; however, the fate of mental patients during that century was neither uniform nor entirely positive. The movement to change the mental hospital environment was also enhanced significantly by scientific advances in the last half of the twentieth century, particularly the development of effective medications for many disorders—for example, the use of lithium in the treatment of manic depressive disorders (Cade, 1949) and the introduction of phenothiazines for the treatment of schizophrenia. 21 Abnormal Psychology  During the latter decades of the twentieth century, our society had seemingly reversed its position with respect to the means of providing humane care for the mentally ill in the hospital environment. Vigorous efforts were made to close down mental hospitals and return psychiatrically disturbed people to the community. This movement, referred to as deinstitutionalization, although motivated by benevolent goals, has also created great difficulties for many psychologically disturbed persons and for many communities as well.  The original impetus behind the deinstitutionalization policy was that it was considered more humane and cost effective. There was great hope that new medications would promote a healthy readjustment and enable former patients to live more productive lives outside the hospital.  However, deinstitutionalization movement failed. The problems caused by deinstitutionalization appear to be due, in no small part, to the failure of society to develop ways to fill the gaps in mental health services in the community (Grob, 1994)..in  By the end of the twentieth century, inpatient mental hospitals had been substantially replaced by community-based care, day treatment hospitals, and outreach. es 1.5.1 The Emergence of Contemporary Views of Abnormal Behavior While the mental hygiene movement was gaining ground in the United ot States during the latter years of the nineteenth century, great technological discoveries occurred which led to the scientific, or experimentally oriented, view of abnormal behavior and the application of scientific un knowledge to the treatment of disturbed individuals. The four major themes in abnormal psychology that spanned the nineteenth and twentieth centuries and generated powerful influences on our contemporary perspectives in abnormal behavior are (1) biological discoveries, (2) the m development of a classification system for mental disorders, (3) the emergence of psychological causation views, and (4) experimental psychological research developments. 1. Biological Discoveries: Advances in the study of biological and anatomical factors as underlying both physical and mental disorders developed in this period. A major biomedical breakthrough, for example, came with the discovery of the organic factors underlying general paresis—syphilis of the brain. One of the most serious mental illnesses of the day, general paresis produced paralysis and insanity and typically caused death within 2 to 5 years as a result of brain deterioration. The discovery of a cure for general paresis began in 1825, when the French physician A. L. J. Bayle differentiated general paresis as a specific type of mental disorder. 22 The field of abnormal psychology had come a long way—from Understanding Abnormal superstitious beliefs to scientific proof of how brain pathology can cause a Behavior : Clinical specific disorder. This breakthrough raised great hopes in the medical Assessment and Diagnosis- I community that organic bases would be found for many other mental disorders—perhaps for all of them. With the emergence of modern experimental science in the early part of the eighteenth century, knowledge of anatomy, physiology, neurology, chemistry, and general medicine increased rapidly. Scientists began to focus on diseased body organs as the cause of physical ailments. It was the next logical step for these researchers to assume that mental disorder was an illness based on the pathology of an organ—in this case, the brain. The first systematic presentation of this viewpoint, however, was made by the German psychiatrist Wilhelm Griesinger (1817–1868). In his textbook The Pathology and Therapy of Psychic Disorders, published in 1845, Griesinger insisted that all mental disorders could be explained in terms of brain pathology..in In the 1920s through the 1940s, an American psychiatrist, Walter Freeman, followed the strategies developed by Italian psychiatrist Egas Moniz to treat severe mental disorders using surgical procedures called lobotomies. These surgical efforts to treat mental disorder were considered es to be ineffective and inappropriate by many in the profession at the time and were eventually discredited, although lobotomy is still used in some rare cases. ot 2. Development of a Classification System The most important contributions of Emil Kraepelin was his system of un classification of mental disorders, which became the forerunner of today’s DSM classification. Kraepelin noted that certain symptom patterns occurred together regularly enough to be regarded as specific types of mental disease. He then proceeded to describe and clarify these types of m mental disorders, working out a scheme of classification that is the basis of our present system. Kraepelin saw each type of mental disorder as distinct from the others and thought that the course of each was as predetermined and predictable. 3. Development of the Psychological Basis of Mental Disorder Despite the emphasis on biological research, understanding of the psychological factors in mental disorders was progressing as well. The first major steps were taken by Sigmund Freud (1856–1939), the most frequently cited psychological theorist of the twentieth century (Street, 1994). During five decades of observation, treatment, and writing, Freud developed a comprehensive theory of psychopathology that emphasized the inner dynamics of unconscious motives (often referred to as psychodynamics) that are at the heart of the psychoanalytic perspective. The methods he used to study and treat patients came to be called psychoanalysis. 23 Abnormal Psychology The Evolution of the Psychological Research Tradition: Experimental Psychology The origins of much of the scientific thinking in contemporary psychology lie in early rigorous efforts to study psychological processes objectively, as demonstrated by Wilhelm Wundt (1832–1920) and William James (1842–1910).  The Early Psychology Laboratories In 1879, Wilhelm Wundt established the first experimental psychology laboratory at the University of Leipzig. While studying the psychological factors involved in memory and sensation, Wundt and his colleagues devised many basic experimental methods and strategies. Wundt directly influenced early contributors to the empirical study of abnormal behavior; they followed his experimental methodology and applied some of his research strategies to study clinical problems. By the first decade of the twentieth century, psychological laboratories and clinics were burgeoning, and a great deal of research was being.in generated (Goodwin, 2011). This period saw the origin of many scientific journals for the propagation of research and theoretical discoveries, and as the years have passed, the number of journals has grown. The American es Psychological Association now publishes 54 scientific journals, many of which focus on research into abnormal behavior and personality functioning ot  The Behavioral Perspective Although psychoanalysis dominated the field of abnormal psychology at un the end of the nineteenth century and in the early twentieth century, another school—behaviorism—emerged out of experimental psychology to challenge its supremacy. m Behavioral psychologists believed that only the study of directly observable behavior—and the stimuli and reinforcing conditions that “control” it—could serve as a basis for formulating scientific principles of human behavior. The behavioral perspective is organized around a central theme: the role of learning in human behavior. Although this perspective was initially developed through research in the laboratory rather than through clinical practice with disturbed individuals, its implications for explaining and treating maladaptive behavior soon became evident. Classical Conditioning:  A form of learning in which a neutral stimulus is paired repeatedly with an unconditioned stimulus that naturally elicits an unconditioned behavior. After repeated pairings, the neutral stimulus becomes a conditioned stimulus that elicits a conditioned response. 24  This work began with the discovery of the conditioned reflex by Understanding Abnormal Russian physiologist Ivan Pavlov (1849–1936). Around the twentieth Behavior : Clinical century, Pavlov demonstrated that dogs would gradually begin to Assessment and Diagnosis- I salivate in response to a nonfood stimulus such as a bell after the stimulus had been regularly accompanied by food.  Pavlov’s discoveries in classical conditioning excited a young American psychologist, John B. Watson (1878–1958), who was searching for objective ways to study human behavior. Watson thus changed the focus of psychology to the study of overt behavior rather than the study of theoretical mentalistic constructs, an approach he called behaviorism. Operant Conditioning  E. L. Thorndike (1874–1949) and subsequently B. F. Skinner (1904– 1990) were exploring a different kind of conditioning, one in which the consequences of behavior influence behavior.  Behavior that operates on the environment may be instrumental in.in producing certain outcomes, and those outcomes, in turn, determine the likelihood that the behavior will be repeated on similar occasions. es  For example, Thorndike studied how cats could learn a particular response, such as pulling a chain, if that response was followed by food reinforcement. This type of learning came to be called instrumental conditioning and was later renamed operant ot conditioning by Skinner. Both terms are still used today. 1.6 SUMMARY un In this unit we had defined abnormality and discussed the four important ways in which abnormality can be defined. Changes involved in characterizing abnormal behaviour were also discussed. Following this we m had discussed the various causes of abnormality. The concept of Diagnostic and Statistical Manual of Mental Disorders was also discussed along with various controversial issues pertaining to the DSM. 1.7 QUESTIONS 1. Discuss the various ways in which abnormality can be defined. 2. Discuss the Diagnostic and Statistical Manual of Mental Disorders. 3. Write short notes on – a. Definition of Mental Disorder b. Assumptions of DSM-IV-TR c. Five Axis of DSM 25 Abnormal Psychology 1. Write a note on the Classification of abnormal behavior 2. Write a detail note on Humanitarian Approaches 3. Write a detail note on the Emergence of Contemporary views of Abnormal Behavior 1.7 REFERENCES Butcher, J.N; Hooley, J.M; Mineka, S; & Dwivedi, C.B. (2020). Abnormal Psychology. (16th ed.). Pearson Barlow David H and Durand M.V. Abnormal Psychology, (2005), New Delhi.Halgin R.P. and Whitbourne S.K. (2010) Abnormal Psychology, Clinical Perspectives on Psychological Disorders, (6th Ed.), McGraw Hill. .in es ot un m 26  2 UNDERSTANDING ABNORMAL BEHAVIOR : CLINICAL ASSESSMENT AND DIAGNOSIS II Unit Structure 2.0 Objectives 2.1.1 Psychological Assessment 2.1.2 Physiological Assessment 2.3 Summary 2.4 Questions.in 2.5 References 2.0 OBJECTIVES es After reading this unit you will be able to:  Explain how Psychological Assessment is carried out with the help of ot Clinical interviews and Mental Status Examination.  Understand Behavioural, Multicultural, Environmental and un Physiological assessment. 2.1 THE BASIC ELEMENTS IN ASSESSMENT m 2.1.1 Psychosocial Assessment Psychological assessment refers to gathering and integration of psychological data for the purpose of a psychological evaluation through the use of tests, interview, observation, etc. This kind of an assessment is carried out in order to arrive at a diagnosis for an individual with a mental disorder, to determine the individual’s intellectual capacity, to predict how suitable a person is for a job and to assess if a person is competent to stand trial. There are various techniques used in assessment. For e.g. clinical interview, mental status examination, behavioral assessment, multicultural assessment, neuropsychological assessment etc. Out of these many we will be discussing the following two - the clinical interview and the mental status examination. 27 Abnormal Psychology 1. Clinical Interview This is the most common method used to assess the client, his presenting problem, and history and future goals. The interview involves asking questions in a face-to-face interaction. The clinician may audiotape or videotape the details or note them down during or after the interview with the due consent from the client. There are two kinds of clinical interviews: Unstructured Interview:  In this type of an interview, the client is asked open-ended questions related to his or her presenting problem, the family background and life history.  The term ‘unstructured’ is used to indicate that the interviewer is free to ask questions in any order and frames them in a manner that he prefers. The client’s response to the previous question and nonverbal cues such eye-contact, posture, tone of voice, etc., guide the interviewer in this process..in  The interviewer’s approach is influenced by the purpose of the interview. A clinician who wants to arrive at a diagnosis would ask questions related to the client’s symptoms, such as changes in mood, es sleep pattern, disturbance in appetite, nature of thoughts, etc., their onset, duration and progress, medical or psychiatric history if any, etc.  Some clients seek help for personal issues such as disturbed ot relationships and may not have a diagnosable psychological disorder. In such cases the interviewer would try to enquire about the reasons for the client’s distress. un  A significant part of an unstructured interview is history taking, which involves asking questions related to personal history such as major life events since childhood, academic interest and performance, number of m friends and leisure activities, work life, marriage, habits, etc., and family history such as numbers of family members, close relatives and relationships with them, atmosphere at home, history of illnesses in the family, etc.  This gives the clinician a picture of the client’s world and may also help draw connections between the client’s current problem and a traumatic event in early life. Structured and Semistructured Interviews:  The structured interview gives less freedom to the clinician as it involves asking a set of predetermined questions in a fixed order. The semistructured interview also has a standardised set of questions but the interviewer can ask follow up questions to clarify the client’s responses, if needed.  The advantage of structured and semistructured interviews is that they help make accurate diagnosis. Some of these are designed to cover a 28  wide range of psychological disorders while others are meant to Understanding Abnormal diagnose specific conditions such as a Schizophrenia or Mood or Behavior : Clinical Anxiety disorder. Secondly, one gets lots of information of the client Assessment and in short period of the time. Thirdly, can be very well used by the Diagnosis- II practitioner who is new in the field and serve helpful to come down to appropriate diagnosis.  The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) is a commonly used structured interview while the Structured Clinical Interview for DSM-IV-TR Axis I disorders (SCID-I) and the Structured Clinical Interview for DSM-IV Personality disorders (SCID-II) are examples of semistructured interviews (despite the word structured).  The World Health Organisation (WHO) and the U.S. Alcohol, Drug and Mental Health Administration (ADAMHA) have developed the Composite International Diagnostic Interview (CIDI), which is an assessment tool that has been translated in many languages and can be used with people from different cultures..in 2. Mental Status Examination The mental status means what and how the client thinks, speaks and es behaves. The mental status examination or the MSE is used to assess the client’s thoughts, feelings and behaviour and identify symptoms. The MSE report is based on the client’s responses and the clinician’s objective observations of the client’s appearance, speech and behaviour. One of the ot examples of a structured MSE is the mini-mental status examination (MMSE) which is very useful in assessing patients with cognitive un disorders such as dementia. Following are the components of the MSE: 1) Appearance and Behaviour: The clinician carefully looks for any peculiarities in the client’s appearance and overall behaviour as this can give an insight into her/her mental state. Anxious patients tend to fidget or m pace around while some others tend to move about in a sluggish manner. Clinicians asses client’s motor behaviour, that is, the movements. Eg. hyperactivity which refers to increased physical activity and quick movements or psychomotor agitation which is characterized by agitation and excessive motor and cognitive activity. Some patients show psychomotor retardation, that is, visible slowing of thoughts, speech and movements. Strange mannerisms, stereotyped movements and vocal or motor tics (involuntary muscular movements) are seen in some others. In extreme cases, motor abnormalities may manifest as catatonia which is seen in psychotic patients. Some of these patients constantly maintain an immobile position (catalepsy) or assume bizarre postures or can be moulded into a position that is then maintained (waxy flexibility). Some may experience Compulsion which is a form of motor disturbance in which there is an uncontrollable impulse to perform an act repeatedly. For example, counting the fingers or scratching one’s nose before 29 Abnormal Psychology answering every question, chanting a particular mantra every few minutes, etc. 2) Orientation: This refers to one’s awareness of time, place and person. In some disorders, the patient’s sense of themselves and the surrounding is disturbed. Assessing orientation is very important in diagnosing cognitive disorders such as Delirium, Dementia, Amnesia and also psychotic disorders like Schizophrenia. 3) Content of Thought: Disturbances in the thought process occurs in various forms. Some patients may have an obsession, which means an intrusive, repetitive, thought, image or impulse which causes distress. For example, thoughts of being unclean or contaminated, that is often accompanied by the compulsion of washing hands. Another form of disturbance in thought content is delusions. These are unshakable, false beliefs which cannot be corrected through logical reasoning. For example, a man may believe that he is a messenger of God who has been sent on Earth for a special mission. Delusions can be of.in different types:  Grandeur: A person’s exaggerated conception of one’s importance, power, beauty or identity. Above is the example of Grandeur type of es delusion.  Control: False thinking that a person’s will, thoughts or feelings are being controlled by external forces. One form of this delusion is ot thought broadcasting in which the person believes that his/her thoughts can be heard by others as if they were being broadcast over the air. Likewise, thought insertion is a delusional belief that others un are implanting thoughts in a person’s mind.  Reference: False belief that other’s actions refer to oneself or that others are talking about him/her. E.g. when someone watches a web m series and believes that the conversation between the two protagonist is meant specifically for them.  Persecution: False belief that the person him/herself or a loved one is being harassed, cheated or mistreated by someone. E.g, My colleague break into my cabin at night and steal my important files.  Self-blame: False feeling of regret or guilt in which the person holds him/her responsible for some wrongdoing. E.g., a person might think that he/she is responsible for the covid pandemic.  Somatic: False belief involving body functions such the belief that the brain is rotting or melting.  Infidelity: False belief associated with pathological jealousy about a person’s lover being unfaithful. 30 There are overvalued ideas which refer to unusual thoughts of a bizarre Understanding Abnormal nature but they are not as rigid as delusions. For example, a man who Behavior : Clinical believes that his credit card number should end with the digit 6 and refuses Assessment and to accept a new credit card with a different last number. Magical thinking Diagnosis- II involves seeing a connection between two events which would seem unrelated to most people. For example, a woman may believe that every time she buys things from a particular shop her husband loses a contract. Overvalued ideas and magical thinking do not indicate that the person has a mental disorder but suggests some psychological decline. Violent thoughts such suicidal ideas or thoughts of harming or killing another person also need to be assessed. 4) Thinking Style and Language: An individual’s style of thinking is manifested through his or her speech. For example, speaking to person with Schizophrenia or other forms of psychosis can be difficult because their language may be illogical. Examples of thought disorder:  Incoherence: The speech is not clear and understandable. For example, “the ice-cream threw the poodle that is not here.”.in  Loosening of associations: Ideas expressed are unrelated. For example, “Suma is nice person but there is lot of poverty in the world and I am going to cut my hair tomorrow.” es  Illogical thinking: Thoughts that has wrong conclusions. For example, a person who likes milk thinks she must be a cat. ot  Neologisms: New words created, often by combining syllables of other words. For example, “I saw some “snarks” today that were “boredomly bad.” un  Blocking: Sudden interruption in the train of thought before the idea is finished. m  Circumstantiality: Indirect speech that is delayed in reaching the point by bringing in lot of irrelevant details.  Tangentiality: Going off on a different point without coming to the original idea.  Clanging: Association of words similar