TYBA Abnormal Psychology - SEM VI PDF

T.Y.B.A. SEMESTER - VI (CBCS) PSYCHOLOGY PAPER - V ABNORMAL PSYCHOLOGY SUBJECT CODE : UAPS602  © UNIVERSITY OF MUMBAI Prof. (Dr.) D. T. Shirke Offg. Vice Chancellor...

T.Y.B.A. SEMESTER - VI (CBCS) PSYCHOLOGY PAPER - V ABNORMAL PSYCHOLOGY SUBJECT CODE : UAPS602  © UNIVERSITY OF MUMBAI Prof. (Dr.) D. T. Shirke Offg. Vice Chancellor University of Mumbai, Mumbai. Prin. Dr. Ajay Bhamare Prof. Prakash Mahanwar Offg. Pro Vice-Chancellor, Director University of Mumbai. IDOL, University of Mumbai. Programe Co-ordinator : Prof. Anil R. Bankar Head, Faculty of Humanities and Social Sciences, IDOL, University of Mumbai Course Co-ordinator : Dr. Naresh Tambe Assistant Professor (Psychology), IDOL, University of Mumbai. Editor: : Ms. Trupti Mohan Nawar Assistant Professor, Ramnarain Ruia College, Matunga, Mumbai-400019. Course Writer: : Dr. Vipan Kumar R.D. National College, Bandra West, Mumbai-400050. : Prof. Archana Ambore Mithibai College of Arts, Vile Parle West Mumbai-400056. : Dr. Babita Sinha SPDT College or Arts, Science and Commerce, Andheri East, Mumbai-400069. : Prof. Vimal Ambre Gonsalo Garsia College, Vasai, Dist. Thane. April 2023, Print I Published by Director ipin Enterprises Institute of Distance and Open Learning, University of Mumbai,Vidyanagari, Mumbai - 400 098. Tantia Jogani Industrial Estate, Unit No. 2, Ground Floor, Sitaram Mill Compound, DTP COMPOSED J.R. Boricha ANDMarg,PRINTED Mumbai -BY400 011 Mumbai University Press, Vidyanagari, Santacruz (E), Mumbai - 400098.  CONTENTS Unit No. Title Page No Module 1: Schizophrenia and other Psychotic Disorders 1. Schizophrenia and other Psychotic Disorders - I 1 2. Schizophrenia and other Psychotic Disorders - II 9 Module 2: Mood Disorders and Suicide 3. Mood Disorders and Suicide - I 15 4. Mood Disorders and Suicide - II 23 Module 3: Personality Disorders 5. Personality Disorders - I 36 6. Personality Disorders - II 42 Module 4: Sexual Variants, Abuse and Dysfunctions 7. Sexual Variants, Abuse and Dysfunctions - I 60 8. Sexual Variants, Abuse and Dysfunctions - II 68 *****  Choice Based Credit System (CBCS) T.Y.B.A. Abnormal Psychology Syllabus to be implemented from 2022-2023 Paper V: Abnormal Psychology Part II Code Sem Course Title Credits Marks UAPS602 6 Abnormal Psychology 4 100 Learning Objectives: 1) To have students build knowledge and understanding of the basic concepts in Abnormal Psychology and the theories of Abnormality. 2) To have students build knowledge and understanding of the different Psychological Disorder– their symptoms, diagnosis, causes and treatment. 3) To create awareness among students about Mental Health problems in society 4) To create a foundation in students for higher education and a professional career in Clinical Psychology. Semester 6 Abnormal Psychology Part II (Credits = 4) 4 lectures per week Unit 1: Schizophrenia and other Psychotic Disorders a) Clinical Picture and Subtypes of Schizophrenia. b) Other Psychotic Disorders: Schizoaffective Disorder, Schizophreniform Disorder, Delusional disorder and Brief Psychotic Disorder. c) Risk and Causal factors: Genetic Factors, Neurodevelopmental Perspective, Neurochemistry, Psychosocial and Cultural Factors. Unit 2: Mood Disorders and Suicide a) Unipolar Depressive Disorders: Dysthymia Disorder, Major Depressive Disorder. b) Causal Factors in Unipolar Mood Disorders - Biological Causal Factors, Psychological Causal Disorders c) Bipolar and Related Disorders: Cyclothymic Disorder, Bipolar Disorder (I and II) and Causal Factors in Bipolar Disorders: Biological and Psychological Causal Factors. d) Sociocultural Factors Affecting Unipolar and Bipolar Disorders, Treatment and Outcomes. e) Suicide: The Clinical Picture and the Causal Pattern. Unit 3: Personality Disorders a) Clinical features of Personality Disorders. b) Cluster A, Cluster B and Cluster C Personality Disorders. c) General Sociocultural Causal factors, Treatments for Personality Disorders. Unit 4: Sexual Variants, Abuse and Dysfunctions a) Sociocultural Influence on Sexual Practices and Standards. b) The Paraphilias: Causal Factors and Treatment for Paraphilias. c) Gender Dysphoria, Sexual Abuse. d) Sexual Dysfunctions: Forms and Treatment. Book for study:  Egan,G.& Reese,R.J. (2019).The Skilled Helper: A Problem- Management and Opportunity-Development Approach to Helping.(11th Edition) Cengage Learning.  Gladding,S. T. (2014). Counselling: A Comprehensive Profession. (7thEd.). Pearson Education. New Delhi: Indian subcontinent version by Dorling Kindersley India Books for reference:  Capuzzi, D., & Gross, D. R. (2007). Counselling and Psychotherapy: Theories and Interventions. (4th ed.). Pearson Prentice Hall. First Indian reprint 2008 by Dorling Kindersley India pvt ltd.  Capuzzi, D., & Gross, D. R. (2009). Introduction to the Counselling Profession.(5th ed.). New Jersey: Pearson Education  Corey, G. (2005). Theory and Practice of Counselling and th Psychotherapy (7 ed.). Stamford, CT: Brooks/Cole  Corey, G. (2008). Group Counselling. Brooks/Cole. First Indian reprint 2008 by Cengage Learning India  Corey ,G (2016). Theory and Practice of Counselling and Psychotherapy. Cengage Learning, India  Cormier, S. & Nurius, P.S. (2003). Interviewing and change strategies for helpers: Fundamental skills and cognitive behavioural interventions. Thomson Brooks/Cole  Dryden, W., & Reeves, A. (Eds). (2008). Key issues for Counselling in Action. 2nd ed. London: Sage publications  Gelso, C.J., & Fretz, B.R. (2001). Counselling Psychology: Practices, Issues, and Intervention. First Indian reprint 2009 by Cengage Learning India  Gibson, R.L., & Mitchell, M.H. (2008). Introduction to Counselling and Guidance.7th ed., Pearson Education, Dorling Kindersley India, New Delhi  Henderson,D.A. &Thompson C.L. (2015) Counselling Children.Cengage Learning  Heppner, P. P., Wampold, B. E., & Kivlighan, D. M. Jr. (2007). Counselling research.Brooks/ Cole, Indian reprint 2008 by Cengage Learning, New Delhi  Ivey,A.E., Ivey M.B.& Zalaquett ,C,P. (2018).Intentional Interviewing and Counselling: Facilitating Client Development in a Multicultural Society. Cengage, Boston M A  Jena, S.P.K. (2008). Behaviour Therapy: Techniques, research, and applications.Sage publications, New Delhi  Kinara, A. K. (2008). Guidance and Counselling. Pearson, New Delhi: Dorling Kindersley India pvt ltd.  McLeod, J. (2009). An Introduction to Counselling. (4th ed.). Open University Press/ McGraw-Hill Higher Education  Nelson-Jones, R. (2009). Introduction to Counselling Skills: Text and Activities. 3rd ed., London: Sage publications  Nelson-Jones, R. (2012). Basic Counselling Skills: A helper’s manual. 3nd ed., Sage South Asia edition  Nugent, F.A., & Jones, K.D. (2009). Introduction to the Profession of Counselling. (5th ed.). New Jersey: Pearson Education  Simmons, J. & Griffiths, R. (2009). CBT for Beginners. London: Sage publications *****  1 SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS - I Unit Structure 1.0 Objectives 1.1 Introduction 1.2 Characteristics of Schizophrenia – positive, negative and other Symptoms 1.3 Other Psychotic Disorders 1.4 Summary 1.5 Questions 1.6 References 1.0 OBJECTIVES After reading this unit, you will the able to know:  About one of the major psychotic disorder: schizophrenia.  About the positive, negative and other symptoms of schizophrenia.  The other psychotic disorders related to schizophrenia – schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, delusional disorder. 1.1 INTRODUCTION Schizophrenia is one of the most common psychotic disorders. It is a puzzling disorder wherein sometimes patient thinks and communicates clearly and is related with reality. And, sometimes the same individual’s thinking and speech is disorganized and is not in touch with reality. Process disrupted by schizophrenia include those that involve an individual’s thought, perception, emotions, motor functions etc. There is a strong evidence for a genetic transmission of this disorder. Structure of brain, prenatal environment and birth complications may result in this disorder. DSM recognizes two main symptoms of schizophrenia- positive and negative. Type I symptoms (positive) include unusual perceptions, thoughts and behaviours. Type II symptoms (negative) represent loss or absence of behaviours. 1.2 CHARACTERISTICS OF SCHIZOPHRENIA The term psychotic has been used to characterize much unusual behaviour where an individual seems to not be in touch with reality. Although in its strictest sense it usually involves delusions (which involve irrational 1 Abnormal Psychology beliefs) and / or hallucination (experiencing things through the scenes in the absence of any external events such as hearing voices). Schizophrenia is just one of the disorders that involve psychotic behavior. This is a disorder that affects a person’s thought, feeling, behavior, perception, motor functioning, motivation, judgment, insight and overall intrapersonal and interpersonal functioning. It is more common in men than women. Psychologists in this field typically distinguish between what are called positive and negative symptoms of schizophrenia. Positive symptoms refer to more active manifestations of abnormal behaviour or an excess of distortion of normal behaviors. The positive symptoms include delusions, hallucinations and disorganized thought, disorganized speech and catatonic behavior. Negative symptoms involve deficit in normal behaviour or normal functioning. A negative symptom of schizophrenia affects an individual’s speech, emotion and motivation. Examples of negative symptoms are avolition, alogia, restricted affect etc. In order to diagnose an individual with schizophrenia, an individual should experience two or more of the positive symptoms and/or negative symptoms for at least one month. Positive Symptoms of Schizophrenia: a. Delusions: Delusions are a misrepresentation of reality in an individual’s content of thought. Delusions are difficult to believe. For example, an individual might believe that squirrels are aliens sent to earth on a reconnaissance mission. It is a fixed false belief that an individual holds. They will not give upon their belief in spite they are been presented with the evidence against their belief. Individual experiencing delusion are preoccupied with them. Common types of delusions are: i. Persecutory Delusions: Individual suffering from these delusions constantly feel that others intends to harm them or their loved ones. They are being watched or tormented by people whom they know. ii. Delusions Reference: Individual suffering from this type of delusion believe that random events, comments passed by others are aimed at them. People with delusion of reference may feel that a politician is trying to harm him personally through speech. iii. Grandiose Delusions: Individual suffering from this delusion feel that they are special person and have magic powers. They may think that they are great historical characters. iv. Delusion of Thought Insertions: Individual suffering from this delusion feel that their thoughts are being controlled by outside forces An intriguing view of delusion is that they may serve a purpose for people with schizophrenia, who are otherwise quite upset by the changes, taking 2 place within themselves. The delusions may serve as adaptive function for Schizophrenia and Other delusional individuals is at present just a theory with little support, but it Psychotic Disorders - I may help us understand this phenomenon and the reactions to it expressed by those experiencing the delusions. b. Hallucinations: The experience of sensory events without any input from surrounding environment is called hallucination. Hallucination can involve any of the senses, although hearing things that are not there or auditory hallucination in the most common form experienced by person with schizophrenia. Types of Hallucinations: i. Auditory Hallucinations: In auditory hallucinations individuals hear heavy voices, music, different type of noises, in its absence. ii. Visual Hallucinations: An individual suffering from this may see a stimuli in its absence. iii. Tactile Hallucinations: It involves a feeling that some odd is happening to one’s body. E.g., insects are crawling all over the body. iv. Somatic Hallucinations: It involves feeling that something is happening inside one’s body and they are tickling him from within. Research on hallucinations suggests that people tend to experience hallucination more frequently when they are unoccupied or restricted from sensory input. By studying cerebral blood flow using single photon emission computed tomographty (SPECT). scientists of London have discovered that the part of the brain most active during hallucinations was the area called Broca’s area. Broca’s area is involved in speech production. If hallucinations involves understanding the speech of others, you might expect more activity in the area of the brain that involves language comprehension, on area called Wernick’s area. Research establishes that during hallucination Broca’s is more active than Wernick’s area. This observation of brain activity during hallucinations supports a theory that the people who are hallucinating are in fact not hearing the voices of others but instead are listening to their own thoughts or voice and can not recognise the difference. c. Disorganized speech: People with schizophrenia often lack insight that they have disease. They experience associative splitting and cognitive slippage. DSM – IV has used the term disorganised speech to describe these problems with communications. The most commonly found disorganized tendency is to slip from one topic to a totally unrelated topic. There is no association between topics discussed by them. This is also known as derailment of thought. When the 3 Abnormal Psychology person with schizophrenia is questioned then they may give a totally unrelated reply. At times, an individual with schizophrenia may use a word in a conversation which has no meaning in any dictionary. It has meaning only to them. This is known as neologisms. They also associate the words on the basis of its sounds rather than meaning. Such associations are known as clangs. e.g., dog may be called “spog” and cat as “meaw”. Sometimes the person may repeat the same word again and again by stressing on particular word. This is known as perseveration. Men with schizophrenia show greater tendency of language deficit as compared to women. Men have limited linguistic resources to overcome their problems. Grossly Disorganised or Catatonic Behaviour: People with schizophrenia engage in a number of other active behaviours that might be considered positive symptoms. People with schizophrenia are unpredictable and suddenly react in an agitated manner. They may suddenly shout, swear and wander about up and down the street alone. They may tend to engage in an embarrassing behaviour by acting in a socially disapproved manner, like publicly masturbating. Their daily routines are disturbed, where they do not care for themselves, showing carelerneres in eating, dressing, oral hygiene, etc. Catatonic behaviour too can been seen in patients of schizophrenia. Catatonia referred to as a group of disorganised behaviours that reflect an extreme lack of responsiveness to the outside world. Catatonia involves a spectrum of motor dysfunctions from wild agitation to immobility. Catatonic excitement involves extreme uncontrollable agitation expressing a number of delusions and hallucinations. Negative Symptoms of Schizophrenia: In contrast to the active presentations that characterize the positive symptoms of schizophrenia, the negative symptoms usually refer to the absence or insufficiency of normal behaviour and include emotional and social withdrawal, blunted effect, apathy, and poverty of thought or speech. a. Flat Affect: Approximately two thirds of the people with schizophrenia exhibit what is called as flat affect. They do not show emotions. They may stare at you with vacant eyes, speak in a flat and toneless manner and seems to be unaffected by things going on around them. This condition in also known as blunted affect. The person remains in a freeze condition most of the time. They are extremely unresponsive to the events around them. The flat affect in schizophrenia may represent the person’s difficulty with expressing emotion and an inability to feel the emotion. 4 b. Avolition: Schizophrenia and Other Psychotic Disorders - I Avolition is an individual’s inability to initiate and persist in many important activities. It is also referred to as apathy. Avolition is an inability to be committed to a common goal directed activity. People with this symptom show little interest in most of the basic day-to-day activities, including personal hygiene. People with schizophrenia are unmotivated, disorganized and careless in the task that they undertake. c. Alogia: It refers to as poverty of speech. It is relative absence in either the amount or the content of speech. A person suffering with alogia may respond the question with very brief replies that have little content and many appear disinterested in the conversation. Or may not reply at all. Sometimes alogia takes the form a delayed comments or slow response to the questions. This deficiency in communication by some people with schizophrenia is believed to reflect a negative thought disorder rather than an in adequacy in communication skills. Other Symptoms of Schizothrenia: Some symptoms of schizophrenia are not prominently seen in all cases but they do frequently occur in schizophrenic as follows- a. Inappropriate Affect: An individual with schizophrenia may react with an inappropriate emotion to a particular action, e.g., individual may cry when it is time to laugh and vice-versa. b. Anhedonia: It is derived from the word bedonic, pertaining to pleasure. It refers to the lack of pleasure experienced by people with schizophrenia. Individuals with anhedonia report no interest in an activities that they would typically be considered pleasurable, including eating, social relations, sexual interactions, etc. c. Impaired Social Skills: Most of the schizophrenic patients show poor social skills, such as difficulty in maintaning conversation, job and relationship. Sub-Types of Schizophrenia: DSM-IV-TR describes five major sub-types of Schizophernia - Paranoid schizophrenia, Disorganised schizophrenia, Catatonic schizophrenia, Undifferentiated schizophrenia and Residual schizophrenia.  Paranoid schizophrenia: wherein the prominent feature is delusion and hallucination. The clinical picture is dominated by absurd and illogical beliefs. 5 Abnormal Psychology  Disorganized schizophrenia: which is characterized by disorganized speech, disorganized behavior, and flat or inappropriate affect  Catatonic schizophrenia: which involves pronounced motor signs that reflect great excitement or stupor.  Undifferentiated schizophrenia: wherein an individual present the symptoms of two or more subtypes of schizophrenia.  Residual schizophrenia: wherein individual experiences only negative symptoms of schizophrenia and absence of positive symptoms. Unfortunately, research using the subtyping approach did not yielded major insights into the etiology or treatment of the disorder. Reflecting this, subtypes of schizophrenia are no longer included in DSM-5. Check Your Progress: 1. Discuss the positive symptoms of schizophrenia. 2. Explain the negative symptoms of schizophrenia. 3. What are the other symptoms of schizophrenia. 4. Explain the subtypes of schizophrenia 1.3 OTHER PSYCHOTIC DISORDERS (THE SCHIZOPHRENIA SRECTRUM DISORDERS) a. Brief Psychotic Disorder: This disorder shows the sudden onset of one or more “positive” symptoms such as delusions, hallucinations, or disorganised speech or behaviour for the period of less than a month. The symptoms are not seen beyond one month. b. Schizophreniform Disorder: Some people experience the psychotic symptoms similar to schizophrenia, but for limited period, usually last from one month to six months. If the symptom seen beyond six months then the diagnosis of schizophrenia is given to that person. These symptoms disappear quickly, often for unknown reasons, and the person can usually resume his or her life as before. There are few studies on this disorder, therefore, data on important aspects of it are sparse. It appears, however, that the lifetime prevalence is approximately 0.2% (American Psychiatric Association, DSM – IV, 1994). c. Schizoaffective Disorder: The symptoms of schizophrenia coincides with symptoms of depression or mania, but there is at least a two week period when only symptoms of 6 schizophrenia are present with no signs or symptoms of depression or Schizophrenia and Other mania. Psychotic Disorders - I d. Delusional Disorder: The major feature of delusional disorder is a persistent delusion or belief that is contrary to reality. These individual appears to be very normal until the point they talk about their delusion. This persistent delusion is not the result of an organic factor such as brain seizures or any severe psychotic disorder. Individual with these delusions tend not to have most of the other problems associated with schizophrenia. They may become socially isolated because of their suspicion of others. The different types of delusional disorder are – i. Persecutory Delusion: False belief that they or their loved ones are treated in a wrong or unkind manner. ii. Grandiose Delusion: False belief that one has great, knowledge, or talent. iii. Jealous type of Delusion: False belief, without any strong reason, that their partner is being unfaithful towards them. iv. Erotomanic type of Delusion: False belief that another person is in love with them. v. Somatic Delusion: False belief that one’s has some diseased or some medical condition. e. Shared Psychotic Disorder: It is a name given to a condition in which an individual develops delusions simply as a result of a close relationship with a delusional individual. The content and nature of the delusion depends on the delusion of the partner and can range from the relatively bizarre, such as believing that enemies are sending gamma rays through your house to less bizarre, such as believing that you are about to receive a major promotion. Check Your Progrss: 1. Explain any two other Psychotic Disorders. 2. Discuss Schizophreniform Disorders. 3. Explain different types of delusions found in delusional disorder. 1.4 SUMMARY Schizophrenia is a type of psychosis which is very common. There are mainly two types of clinical symptoms of this disorder – negative and positive symptoms. Positive symptoms include delusions, hallucinations, disorganised thought and speech, disorganised or catatonic behaviour. 7 Abnormal Psychology Delusions are ideas that an individual believes are true but are highly unlikely and often simply impossible. There are different types of delusions – Persecutory delusions, delusions of reference, grandiose delusions and delusions of thought insertion. Hallucination Is the experience of sensory events without any input from surrounding environment. The types of hallucination are visual, auditory, tactile and somatic. The individual suffering from schizophrenia also have disorganised speech and disorganized thought process due to which it become difficult to have a smooth conversation with them. They also display maladaptive behavior or catatonic behavior wherein they either have excessive motor movements or no movements at all. Negative symptoms of schizophrenia are affect flattening alogia and avolition. Affect flattening is a severe reduction or absence of affective responses to the environment. Alogia is reduction in speaking. Avolition is an inability to persist at common, goal directed activities. Other symptoms are inappropriate affect, anhedonia and impaired social skills. The other psychotic disorders are brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder and shared psychotic disorder which falls on the same continuum of schizophrenia. 1.5 QUESTIONS 1. Discuss the various characteristics, positive and negative symptoms of schizophrerina. 2. Discuss the different types of psychotic disorders. 3. Write notes on the following. a. Hallucinations and its types. b. Types of Delusions. c. Subtypes of Schizophrenia 1.6 REFERENCES  Oltmanns, T.F. & Emery, R. E. (2010). Abnormal Psychology, 6th ed., New Jersery : Pearson Prentice Hall.  Bennet, P. (2003). Abnormal and Clinical Psychology : An Introductory Textbook – Open University Press. ***** 8  2 SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS - II Unit Structure 2.0 Objectives 2.1 Risk and Causal factors of Schizophrenia 2.2 Summary 2.3 Questions 2.4 References 2.0 OBJECTIVES  After reading this unit, you will the able to know about various factors contributing to development of schizophrenia and other psychotic disorders. 2.1 RISK AND CASUAL FACTORS Despite enormous efforts by researchers, this question still defies a simple answer. What is clear is that no one factor can fully explain why schizophrenia develops. Psychiatric disorders are not the result of a single genetic switch being flipped. Rather, a complex interplay between genetic and environmental factors is responsible. Genetic factors:  Genetic factors are clearly implicated in schizophrenia. It has long been known that disorders of the schizophrenia type are “familial” and tend to “run in families  Having a relative with the disorder significantly raises a person’s risk of developing schizophrenia. For example, the prevalence of schizophrenia in the first-degree relatives (parents, siblings, and offspring) of a patient with schizophrenia is about 10 percent. For second-degree relatives who share only 25 percent of their genes with the patient (e.g., half-siblings, aunts, uncles, nieces, nephews, and grandchildren), the lifetime prevalence of schizophrenia is closer to 3 percent.  Study after study has shown a higher concordance for schizophrenia among identical, or monozygotic (MZ), twins than among people related in any other way, including fraternal, or dizygotic (DZ), twins.  Concordance rates for schizophrenia are compared for the biological and the adoptive relatives of people who have been adopted out of their biological families at an early age (preferably at birth) and have subsequently developed schizophrenia. If concordance is greater 9 Abnormal Psychology among the patients’ biological than adoptive relatives, a hereditary influence is strongly suggested  Having high heritability, researchers are attempting to locate the specific genes involved and to understand the factors that increase the genetically vulnerable a chances of developing the disorder. Combination of neuroimaging and genomics of the siblings show fMRI abnormalities less severe than those that appear in the brains of affected indi (Gur & Gur, 2010)  At present, researchers have identified at least 19 possible genes discrete over chromosomes 1,2,5,6,8,11,13,14,19,22. Some of the functions of these chromosomes involve the neurotransmitters including dopamine and GABA, as well as serotonin and glutamate.  Other factors that have been implicated in the development of schizophrenia include prenatal exposure to the influenza virus, early nutritional deficiencies, rhesus incompatibility, maternal stress, and perinatal birth complications.  Urban living, immigration, and cannabis use during adolescence have also been shown to increase the risk of developing schizophrenia.  Current thinking about schizophrenia emphasizes the interplay between genetic and environmental factors Neurodevelopmental Perspective:  According to neurodevelopmental perspective, schizophrenia is a disorder of development that arises during the years of adolescence or early adulthood due to alterations in the genetic control of brain maturation.  Genetic vulnerability becomes evident if an individual is exposed to certain risks during early brain development.  These risks can occur during the prenatal period in the form of viral infections, malnurition or exposure to toxins or during/shortly after birth if they exposed to injuries or viral infections, or if their mothers suffer birth complications.  Harm to their developing brains may show up early in life in the form of decreased head size motor impairments in cognition and social functioning  Support to the neurodevelopmental hypothesis also comes from the fact that an individual having their first psychotic episodes have a number of incomprehensible brain abnormalities as the result of the illness. As their illness proceeds they may show continued harmful changes through a process of “neuroprogression” in which the effects of schi interact with brain changes caused by normal aging 10 Neurochemistry: Schizophrenia and Other Psychotic Disorders - II  Based on the observation of the effect of drug to relax surgical patients, French physicians began to experiment these drug to treat an individual with psychotic disorders.  Chlorpromazine was found to be effective to deal the psychotic symptoms. Chlorpromazine had its effect by blocking dopamine receptors. This gave rise to the idea that dopamine, more specifically, the d2 receptor, plays a role in development schizophrenia  Gamma-aminobutyric acid (GABA) also appears to be involved in development of schizophrenia.  Changes in the n-methyl-d-aspartate (NMDA) receptors also seem to play a role in development of psychotic symptoms. NMDA help to promote new learning in the brain by helping to build synapses. So, alternations in NMDA may, in turn, be related to changes in the neurons that make them less capable of supporting memory and learning.  Symptoms of schizophrenia related to increase excitation, decreased inhibition and altered cognitive functioning would thus correspond to these changes in the neurotransmitters Structural Abnormality:  One of the earliest discoveries from neuroimaging methods was that the brain of an individual with schizophrenia have enlarged ventricles, the cavities within the brain that hold cerebrospinal fluid. This condition is called as Ventricular Enlargement, often occurs along side cortical atrophy, i.e. a wasting away of brain tissue.  The loss of brain volume is particularly found in the prefrontal lobes, which is an area responsible for planning, inhibiting thoughts and behavior.  Over the course of the illness, the cortex shows marked thinning throughout the brain, but particularly in the frontal lobes and temporal lobes, parts of the brain that process auditory info Psychological Theories: Psychodynamic Perspective: Sigmund Freud (1924) in his psychodynamic theory suggested that negative childhood experiences may result in schizophrenia in a person. Poor parenting may place additional strain on a vulnerable person already at risk for schizophrenia. Freud said that when mothers behave extremely harsh towards their child and when they do not express love to their child then the child regresses and shows infantile tendencies while carrying out the daily functioning. This becomes unhealthy for the Ego to discriminate between reality and unreality. 11 Abnormal Psychology Freida Formm Reichmann (1948) pointed out that poor parenting can affect the mental state of a child. Two contrasting situation were a mother is over protective on one side and at the same time questioning the child about his well-worth. This leads the child in state of confusion, worthlessness and despair. It may lead to disturbed and illogical ego that may result in tendencies of schizophrenia. Behavioural and Cognitive Causes: Belcher (1988) studied that schizophrenia can develop through operant conditioning under normal circumstances. In case of people with schizophrenia, the basic training for operating over environment is missing. Because of inadequate parenting or due to some unfortunate circumstance they learn irrelevant, inappropriate and socially unacceptable responses towards others around them. According to Belcher (1988) if the family members ignore reacting to illogical and inappropriate behaviour that the schizophrenic people show, then he develops operant conditioning. Cognitive theorists considered that schizophrenia in caused because of lack of basic perceptual and intentional skills. Delusions are formed due to irrelevant misinterpretation of the information attended and perceived in a distorted manner. For example, if a schizophrenic person report his hallucination to which his family members may neglect or reject. This in turn can, be misinterpreted by the patient that his family members have teamed up with invisible force to harm him. This may give rise to paranoid beliefs in the person with schizophrenia. Psychosocial and Cultural Factors:  Disturbed pattern of communication in a child’s family environment could precipitate factor for development of schizophrenia.  Researchers tried to study the modes of communication and behavior within families with schizophrenia member. Researchers attempted to document deviant patterns of communication and inappropriate ways that parents interacted with their children could be the factors playing role in development of schizophrenia.  Clinicians thought these disturbances results in the development of defective emotional responsiveness and cognitive distortions which are fundamental to the psychological symptoms.  Contemporary researchers approached the issues by trying to predict outcome or recovery in adults hospitalized for schizophrenia. According to them, instead of disturbed family as the cause, they view the family as a potential source of stress in the environment of the person who is trying to recover from a schizophrenia episode  They explained the above with the help of an index which termed as Index of expressed emotion (EE) i.e. stress that family members create. This provides a measure of the degree to which family 12  members speak in ways that reflect criticism, hostile feelings and Schizophrenia and Other emotional overinvolvement or overconcern Psychotic Disorders - II  Researchers found that people living in families high in EE are more likely to suffer a relapse, particularly if they are exposed to high levels of criticism  One fMRI study showed that people with schizophrenia experiences higher activation of brain regions involved in self-reflection and sensitivity to social situations when hearing speech high in EE compared to neural speech  EE could never employ an experimental design as a result researchers can never draw casual links between EE and schizophrenia  It is also very likely that the presence of an individual with schizophrenia creates stress within the family.  Broader social factors such as social class and income can also contribute to the development of schizophrenia.  In the first epidemiological study of mental illness in the US, Hollinshead and Redlich (1958) observed that schizophrenia was far more prevalent in the lowest socio-economic classes. Number of reserchers have since replicated this findings.  Possible interpretation could be the individual with schizophrenia may be experiencing “downward drift”. That is their disorder drives them into poverty, which interferes with their ability to work and earn a living  Stress of living in isolation and poverty in urban areas contributes to the risk of developing of schizophrenia.  Rates of schizophrenia is higher in individual who were born or raised in urban areas, not just those who moved there as adults.  People living in other country - (i.e. Those who have “migrant” status) have higher rates of schizophrenia. Those who migrate to lower-status jobs and urban areas are more likely to suffer from schizophrenia.  Other risk factors in sociocultural background include adversity in childhood including parental loss or separation, abuse and a target of bullying. In adulthood they are more vulnerable to first or subsequent episodes of psychosis.  Individual with high genetic risk who are exposed to environmental stressors are more likely than others to develop schizophrenia.  Recognizing that the cause of schizophrenia is multifaceted and develop over time, Stilo and Murray (2010) proposed a 13 Abnormal Psychology “developmental cascade” hypothesis that integrates genetic vulnerabilities, damage occurring in the prenatal and early childhood periods adversity and drug abuse as leading, ultimately to change in dopamine expressed in psychosis 2.2 SUMMARY Schizophrenia is a disorder that is result of interaction between biological factors, psychological factors and social factors, wherein biological factors play an important role. 2.3 QUESTIONS Q.1 Discuss various risk and causal factors of schizophrenia. 2.4 REFERENCES  Oltmanns, T.F. & Emery, R. E. (2010). Abnormal Psychology, 6th ed., New Jersery : Pearson Prentice Hall.  Bennet, P. (2003). Abnormal and Clinical Psychology : An Introductory Textbook – Open University Press. ***** 14  3 MOOD DISORDER AND SUICIDE - I Unit Structures 3.0 Objectives 3.1 Introduction 3.2 General Characteristics of Mood Disorder 3.3 Depressive Disorders 3.3.1 Major Depressive Disorder 3.3.2 Types of Depression 3.3.3 Dysthymic Disorder 3.4 Disorders Involving Alterations of Mood 3.4.1 Bipolar disorder 3.4.2 Cyclothymic disorder 3.5 Summary 3.6 Questions 3.7 References 3.0 OBJECTIVES After studying this unit you should:  Comprehend the general characteristics of mood disorder.  Know the various types of mood disorders. 3.1 INTRODUCTION We do feel happy and energetic and sometimes sad and depressed. These are commonly experienced mood changes. The mood disorders explained in this unit are more serious and disruptive in nature. Mood disorder is one of the group of disorders involving severe and enduring disturbances in emotions ranging from elation to severe depression. Mood disorder involves disturbances in person’s emotional state or mood. People can experience extreme depression or alternate between elation and depression. 3.2 THE GENERAL CHARACTERISTICS OF MOOD DISORDERS 1. Individual feels overwhelming sadness or dysphoria. 2. Some may have experiences that are opposite of depression, feelings of happiness called as euphoria. 15 Abnormal Psychology 3. Mood disorder has a time limit period during which specific symptoms of disorders are seen. The time limited period of intense symptoms of disorder is called as an episode. The episode of disorder may be very lengthy extending up to 2 or 3 years. 4. Mood disorders are classified as mild, moderate and severe depending on the severity of episode. 5. Every clinician documents whether the disorder is first occurance or if there is recurrence of symptoms. If it is a recurrent episode, clinician tries to find out if the client has fully recovered or not. 6. Some people may display even bizarre and unusual behaviors, such as odd bodily postures or movements or excessive purposeless motor activity. 7. The clinician also tries to determine if there is a postpartum disorder. A disorder that is seen in women after giving birth to baby is called postpartum disorder. 3.3 DEPRESSIVE DISORDERS The person experiencing depressive disorder, usually experiences feelings that follow a tragic loss or grief. People do get back to day-to-day affairs and come to terms with tragic loss and grief. Individuals suffering from depression, continue to experience feelings of hopelessness, fatigue, and worthlessness and show suicidal tendencies even when there is no apparent cause. 3.3.1 Major Depressive Disorder: i) The following are the characteristics of major depressive episodes: 1. It involves an intense dysphoric mood that is much more serious than ordinary sad moments of day-to-day life. The dysphoria may be found in the form of excessive dejection or sudden loss of internal in the activities that were previously pleasurable. 2. If intense depression continues after death of loved one for more than 2 months, then it is a major depressive disorder. 3. The depressive disorders may not always have a precipitating event. Onset may be without any known cause. 4. Person experiences impairment at home and work due to depression. 5. The physical signs of depressive episode are manifested as somatic symptoms like: a. Lethargy and listlessness. b. Psychomotor retardation involving slowing down of body moments. 16 c. Some people may show extreme psychomotor agitation. These Mood Disorder and behaviors may be bizarre and extreme, sometimes may be even Suicide - I categorised as catatonic. 6. Eating disturbances are more common. People may not have appetite and may even avoid food. Some others may overeat, or overindulge in sweet and carbohydrates. 7. Dramatic changes in sleep patterns are observed. People may show insomnia or engage in excessive sleeping. The EEG sleep patterns show that clients show disturbances in sleep continuity, intermittent wakefulness and early morning awakening. Disturbances in REM sleep are evident; there are more eye moments and increased duration of REM sleep. Such major REM abnormalities are seen before the major depressive episode. 8. The cognitive symptoms are: i. Intensely negative self –concept, low self-esteem followed by a strong need to be punished. ii. Intense guilt feelings and persistent and thinking about the past mistakes is common. iii. Difficulty in thinking, concentration and decision making. 9. Loss of interest in the activities that were considered as interesting in the past. Person is overcome by feelings of negativity and hopelessness and thinks that death is the only way of escaping and may actually commit suicide. The symptoms of depression may continue from 2 weeks to period of two months. If untreated, symptoms may continue for another six months. The symptoms of major depressive episode occur gradually, they are not shown over night. 3.3.2 Types of Depression: A. Depressive episodes involving melancholic features. B. Depressive episodes involving seasonal patterns. A. Depressive episodes involving melancholic features: Persons loose interest in most of the activities. They find it difficult to react to events that require pleasurable reactions. Morning is very difficult for these people. They may wake up early in the morning and continue the day with sad and gloomy feelings and other major symptoms of depression. B. Depressive episodes involving Seasonal Patterns: People with seasonal patterns of depression develop disorder almost at the same time each year or may be about 2 months during winter, but then, 17 Abnormal Psychology they come back to normal life. During episode they lack energy, interest, may sleep excessively, and overeat more carbohydrates. Some researchers propose that seasonal depression is linked with changes in biological rhythms. It is found that people with seasonal depression are found more in states where there is less temperature. The onset and the course of disorder:- The average age for major depressive disorder is 30 years.(Hasin et al 2005) A study performed Cross National Collaboration Group 1992, (Kessler at al 2003) showed that incidence of depression and consequent suicide is steadily increasing over the years. The national morbidity study has shown that increasing younger groups called as cohorts have higher prevalence rates than older people. Individuals aged 18-29 years are more likely to become depressed at the earlier ages than the people in the age group 30-44 years. In short, depression has started surfacing at an early age with greater frequency. The length of depressive episode is variable. Some episode may last for two weeks and in more severe cases it may last for several years. If untreated the first episode of depression may last for 4 to 9 months (Eaton et al 1997). Some may attempt to reduce depression by resorting to drug or alcohol addiction. Depressive episodes may be found in children and adolescents. The typical age of onset has been estimated be early 20’s. D.N. Klein Taylor Dickstein and Harding found the three characterstics of the onset of disorder before 21. 1. It lasts longer 2. It shows relatively poor response for treatment. 3. The chances are stronger that the disorder may run in the family of affected persons. Study done by Kersler et al (2005) show that approximately 2.5 percent of adult population develop this disorder in the course of their life. This disorder reaches its peaks by 45 to 59 years. Adults usually report the physical symptoms of depression. Finally, hospitalization is very rarely required except in the cases where depression leads to suicidal attempts 3.3.3 Dysthymic Disorder: Some people experience depression involving sadness, but sadness is not so intense to be described as major depressive episode. But such depression is very often long lasting. This does not refer to the mood changes that we do experience in day-to-day life. People with dysthymic disorder show the symptoms of major depressive disorder for at least 2 years (1 year for children and adolescence). These symptoms may include appetite disorder, sleep disturbances, low energy, fatigue, low self esteem, poor concentration, difficulty in decision making and feelings of hopelessness. 18 Dysthymic disorder differ from major depressive episode only on the basis Mood Disorder and of its course, i.e., chronic in nature and severity of the symptom. People Suicide - I with dysthymic disorder are never symptom free for more than two months. They may withdraw from social interactions and react with anger and irritability towards others. Many a times, dysthymic disorder may be accompanied by other serious psychological disorder. In some instances dysthymia may be accompanied by personality disorder, some of them may even develop major depressive episode. Some of them may engage into substances abuse. Hence, clinicians may diagnose wrongly, and attempts may be done to reduce feelings of hopelessness and worthlessness. The Prevalence and Occurrence of the Disorder:- It is observed that 2.5 percent of adult population will develop this disorder in the course of life and the disorder reaches its peak from 45 to 59 years (Kessler et al 2005). In the older patients the disorder may take physical form rather than psychological disturbance. 3.4 DISORDERS INVOLVING ALTERATIONS OF MOOD There are two types of disorder involving mood alterations. 1) Bipolar disorder 2) Cyclothymic disorder 3.4.1 Bipolar disorder: It involves an intense and disruptive experience of elations or euphoria alternating with major depressive episode. Bipolar disorder may occur in two forms. Individuals may experience manic episode or may experience mixed episode. Cyclothymic disorder involves alteration between dysphoria and less intense type of euphoria called hypomaniac disorder. Manic episode: Any manic episode, even if it is not followed by depressive episode, is described as bipolar disorder. Previously bipolar disorders were described as manic depressive disorder. The term bipolar implies two poles or extremes, mania and depression. People with bipolar disorder may not always show symptoms of depression. It is assumed that people with bipolar disorder will experience depression at some time in later months or years. Person experiencing manic episode may appear to be outgoing, talkative, creative, witty and self-confident. The expansiveness and feelings of energy can cause serious problems in their day-to-day functioning. Self- esteem of these individuals may be grossly inflated. Their thinking may be grandiose and even may have psychotic quality. Most people in manic episode may have bizarre thoughts, They may show unusual ideas and swings of unusual creativity. There is a rapid change in thoughts and ideas; they may jump from one activity to another. They are 19 Abnormal Psychology easily distracted and continually require stimulation. They may speak rapidly to others with a such a speed that others find it difficult to interpret. People experiencing manic episode may seek out pleasurable activities that may be impulsive in nature. He or she may engage in ill-advised sexual relationships or spending sprees. Often person has grand plans and goals which he pursues obsessively. Manic episode may appear and diminish suddenly. The depressive episode may appear gradually and diminish with same speed. The duration of manic episode depends on the treatment taken by the individual. Types of Bipolar disorder:  Bipolar disorder I: Bipolar I disorder is diagnosed when individuals experience one or more manic disorder, with the possibility of experiencing one or more depressive disorder. But it is always not necessary that person experience one or more depressive episode.  Bipolar disorder II: Bipolar II is a disorder in which major depressive episode alternates with hypomania episode i.e., individual has one or more major depressive episode and at least one hypomanic episode. Prevalence and course of the disorder: It is relatively very rare for someone to develop bipolar disorder after the age of 40. But once it appears it tends to be chronic, where manic and depression keep on recurring indefinitely. Bipolar disorder is less commonly seen as compared with major depressive disorder. The incidence of bipolar disorder is equally found in both males and females (Kessler of et al 1994). There are gender differences in the onset of the disorder. The first episode for men is more likely to be major manic episode and for women it is more likely to be major depressive episode. Bipolar disorder has been reported in psychiatric literature, it has been found in children as young as 3 years. There is lack of consistency in the diagnostic criteria and methods of assessment for young children. Psychologically disturbed children display wide range of symptoms. 3.4.2 Cyclothymic disorder: It is similar in many ways to dysthymic disorder in its severity and duration of symptoms. People with cyclothymic disorder experience alterations between dysphoric and hypomanic episode for over the span of 2 years (1 year for children and adolescene). Hypomanic episodes are the less intense and less disruptive euphoric state. They display unusually dramatic and recurrent mood shifts. The elation may not be severe enough to be diagnosed as manic episode and depression is never severe enough to be diagnosed as depressive episode. It is the effects of the disorder that disrupts the life of an individual. 20 Persons with cyclothymic disorder tend to be in one mood state or other Mood Disorder and with relatively few periods of neutral mood. The behaviour is not severe Suicide - I enough to require hospitalisation or immediate intervention. The average onset of this disorder in between 19 to 22 years. This disorder begins with minor mood changes or minor cyclothymic mood swings. In many cases such people are only regarded as moody. Sometimes, individual with this disorder is actually more likely to experience some impairment in interpersonal dealings as people may consider them unreliable because of their mood changes. The problem of diagnosis becomes complicated among children because the symptoms of bipolar disorder may co-exist with already present disorders like conduct disorder, hyperactivity, attention deficit disorder (Shapiro 2005). Lot of research needs to be done in area of diagnostics for judging bipolar disorder in children. Kindling is a phenomena indicating that individuals who have experienced manic episode are at greater risks of experiencing another episode, even if they are taking medicines for controlling it. Manic depressive episode may occur just before or so on after major depressive episode. The frequency of manic depressive episode is on an average 4 episodes within a span of decade, for those who do not under go any treatment or medication. Not more than 15% people experience four to eight episodes of mood disorder. These individuals are described as rapid cyclers. Majority of women are likely to become rapid cyclers, Hyperthyroidism, use of antidepressant drugs increase the chances of reducing the time gap between episodes. Most individuals with bipolar disorder feel normal between the episodes. But one forth of them may continue to feel depressed and have difficulty in dealing with people at home or at work, problems are especially likely for individuals who struggle with unpredictable mood changes that occur in rapid cycles because other people consider them to be moody and unreliable. 3.5 SUMMARY In this unit we had discussed the general characteristics of mood disorder. Following this we had discussed the different types of mood disorders. The characteristics of major depressive episode and various types of depression were discussed. One of the most common types of depression is Dysthymic disorder, which was briefy explained. Two types of disorder involving mood alteration was also discussed, which included bipolar disorder and cyclothymc disorder. Types of bipolar disorder, its prevalence and course was also discussed. 3.6 QUESTIONS 1. Discuss the general characteristics of mood disorders. 2. Explain the various characteristics of major depressive episodes. 21 Abnormal Psychology 3. Discuss : a. Depressive episodes involving melancholic features. b. Depressive episodes involving seasonal patterns. c. Dysthmic Disorder 4. Discuss Bipolar and Cyclothymic disorder. 3.7 REFERENCES  Richard P. Halgin and Susan Krauss Whitbourne, (2010) Abnormal Psychology, Clinical Perspectives or Psychological disorders. (6th Ed).  V. Mark Durand and David-H-Barlow (2010, 2006, Essentials of Abnormal Psychology. Wadsworth, Cengage learning. ***** 22  4 MOOD DISORDER AND SUICIDE - II Unit Structures 4.0 Objectives 4.1 Casual factors in Unipolar and Bipolar Disorders 4.1.1 Biological Perspectives 4.1.2 Psychological Perspectives 4.1.3 Behavioural and Cognitive Perspective 4.1.4 Socio Cultural and Interpersonal Perspectives 4.2 Treatment of Mood Disorders 4.2.1 Biological Treatment 4.2.2 Psychological Treatment 4.3 Suicide 4.3.1 Causes of Suicide 4.3.2 Assessment and Treatment 4.4 Summary 4.5 Questions 4.6 References 4.0 OBJECTIVES After studying this unit you should:  Understand the theories and treatment of Mood disorders.  Became aware about suicide its causes, assessment and treatment. 4.1 CAUSAL FACTORS IN UNIPOLAR AND BIPOLAR DISORDERS There are different perspectives towards mood disorders. They explain the causes of mood disorders. Researchers have identified biological, psychological and social factors that seem to play an important role in the etiology of mood disorders. 4.1.1 Biological Perspectives: The Twin studies and family studies indicate the role of biological factors in mood disorders. Genetics: Studies on genetics suggest that bipolar disorder is seen in families. Research has shown that the first degree relatives of people with major depression are twice likely to develop disorder as compared with 23 Abnormal Psychology individuals from general population (Sullivan, Neak & Kender 2006) The risk in higher for the first degree relatives of children of depressed individuals (Lieb et al 2002) The studies of three generation of children, parents and grandparents, show that this disorder tend to run in families. If major depressive disorder is present in parents and grandparents, children are more likely to show symptoms of psychopathology. The five large scale studies observed inheritance patterns in families. They found that the heritability of 31 to 42 percent, meaning among 100 individuals who have close relative who has disorder out of them approximately 30 to 40 of them have a major likelihood of having major depression (Sullivan, Neals & Kendler 2009). National Institute of Mental Health carried out a major study or bipolar disorder at 5 major research centers, They carried our genetic linkage analysis of 500 individuals diagnosed with bipolar disorder.(Faraone, Glatt, Su & Tsuang, 2004) This is a largest study that offered evidence for genetic linkage. The available evidence does not clearly indicate the role of specific genes (De Paule 2004). In the development of mood disorders, gender also plays an important role. In a study of over 1000 pairs of opposite sex twins who were interviewed 2 years apart, to study the effect of receiving social support on the development of depressive symptoms. It was found that both men and women of twin pairs had more chances of developing major depression when social support is very low, as compared with men and women who had more social support. The study indicated that even powerful genetic risk factors can be influenced by environmental conditions. Biochemical factors – The biological theories emphasise the altered neurotransmitter functioning as a cause of mood disorder. It is not possible to observe neurotransmitter substances in human brain. Following are two explanations given that suggest the role of deficiency of neurotransmitter substances. 1. Catecholamine hypothesis, suggests that, the shortage of norepinephrine (a catecholamine) causes depression and excess causes mania. 2. Indolemine hypothesis (Glassman, 1969) suggests that deficiency of serotonin produces behavioural symptoms of depression. The above two hypothesis regarding the role of deficient neurotransmitter substances in mood disorder, is called as Monoamine Depletion Model. All the antidepressants currently used attempt to increase the availability of these neurotransmitter substances. Studies have pointed out the relationship between hormonal activity and depression. Researchers are focusing on the role of Cortisol. It is a hormone that mobilises body’s resources during stress. 24 The research findings in the area of genetics imply the role of biological Mood Disorder and factors in the causation and symptomatology of mood disorder. Suicide - II 4.1.2 Psychological Perspectives: The review of genetic contribution to the causes of depression could be attributed to psychological factors. Psychodynamics Theories: 1. The earlier theories emphasised upon the loss and feelings of rejection as a cause of mood disorders. The later psychodynamic theories emphasised the inner psychic processes as the basis of mood disorders. 2. British psychoanalyst, John Bowlby proposed that people can become depressed as adults, if they were raised by parents who failed to provide them with secure and stable relationship. Similar theory was proposed by Jules Bempoard (1985). He emphasised the role of deficient parenting in mood disorders. Children of such parents become preoccupied by being loved by others. As adults they form relationship where they overvalue the support of their partners. End of such relationship may make depressed person experience feelings of inadequacy and loss. 3. Psychoanalytic theory of personality suggests that mania is a defensive response adopted by an individual to deal with feelings of inadequacy and loss. People become hyperenergetic as a defense against becoming gloomy and depressed. 4.1.3 Behavioural and Cognitive Perspective: 1. Lazarus and Skinner (1968, 1953) proposed that depression is the consequence of reduction of positive reinforcement. Depressed people withdraw from life because they do not have an incentive to remain active. 2. The contemporary perspective on depression is (Kanter et al 2004), based on Lewinshon’s theory, maintaining that low rate of response contingent positive reinforcement is the cause of depression. Behavioural approaches have been integrated into cognitive approaches. Cognitive approaches propose that serious mood changes can result from events in our lives or from our perception of events. Cognitive perspectives suggest that people experience depression as their earlier experiences sensitise, them to react in certain ways to stressful events. People react to stressful events, with a set of thoughts involving negative view of self, world and future. Beck in 1967, described this negative view of self world and future as cognitive triad, he further proposed that if this view is activated once, it continues further in a cyclical manner. 25 Abnormal Psychology Cyclical thinking is maintained by cognitive distortions. They are the errors that depressed people make while drawing conclusions. The cognitive distortions include applying illogical rules, jumping to conclusions, over generalising and taking detail out of context. As a consequence of this, depressed people give negative meaning to past and future events. They may have pessimistic expectations from future. Such persons may not be even aware of such negativity in their thinking. Beck proposes that depressed people feel sad because they are deprived of something that threatens their self esteem. It represents an individual’s misguided attempts to adapt to psychological environment. Harry Stack Sullivan proposed that abnormal behaviour is a consequence of impaired interpersonal relationships, including deficiencies in communication. Bowlby proposed that, a disturbed attachment pattern in the childhood in the cause of depression is later years. Interpersonal theory of depression connects this ideas and gives behavioural and cognitively oriented theory of depression. It explains the steps in the development of depression. i. Failure to develop social skills in childhood. The skills required for developing relationship. ii. This leads to sense of despair and solution resulting in depression. iii. Once depression in established it is further enhanced by poor social skills and communication. This invites rejection from others. The depression that develops in adulthood may arise when person experiences a event like a death or loss of loved one. Depression continues because of a vicious cycle. Poor communications skills keep people away; poor interactions make person experience feelings of loneliness and worthlessness still more intensely, Women are more exposed to stressful events as compared to men. As a consequences women are more likely to experience depression. These individuals are convinced of facture in their efforts. The positive experience also may be distorted to fit in their negative framework. The cognitive distortions make depressed individuals to experience low feelings of well being, energy and desire to be with others and lack of interest in the environment. For e.g., one may find them making statements like …. “If a person like me contests for election, no one will really vote for me because I know people do not like me”. 4.1.4 Socio Cultural and Interpersonal Perspectives: Interpersonal model of mood disorder: (Myrna Werssman, Gerald Klerman & associates) – This model emphasises disturbed social functioning. The interpersonal therapy (IPT) follows from this model. It is a time limited form of therapy for treating depressed persons. This – 26 therapy assumes that individuals are genetically vulnerable to Mood Disorder and interpersonal stress and hence they are more likely to experience Suicide - II depressive episode. The interpersonal therapy focuses on both poor social skills and origin of depressed person’s problem. Adolph Meyer (1957), An interpersonal theorist with psychobiological approach to abnormal behaviour emphasised that, psychological problems are diagnosed with depression. (Hammen 2005). 4.2 TREATMENT OF MOOD DISORDERS 4.2.1 Biological Treatment: The most common treatment for mood disorder is antidepressants. People with bipolar disorder are treated with lithium carbonate. The most common medication used to treat depressions are: i. Tricyclic Antidepressants. (TCAS) ii. Monoamine Oxidase Inhibitor (MAOIS). iii. Selective Serotonin Reputake Inhibitors (SSRIS). Tricyclic antidepressants (TCAS): these chemicals have three ring structures. They are available in the market with trade names like Elavit, Endep, Norpramin, Tofranil, Aventyl and Pamelor. These medications are effective with people who have disturbed appetite and sleep. These tricyclic antidepressant increase the excitatory effect of postsynaptic neurons. Monoamine Oxidase Inhibitions (MAOIS): These drugs are available with trade names Nardil and tranlcypromine (Parnate) – It is effective in treatment of chronic depression.These chemicals function by prolonging the effects of neurotransmitter substances. MAOIS are not frequently prescribed as they can lead to serious complications. People taking MAOIS are not able to take allergy medications or not able to ingest food containing tyramine, e.g., beer, Cheese and Chocolate. The combination of this with MAOIS can rise blood pressure dramatically. Selective Serotonin Reputake Inhibitors – (SSRIS): It is generally used as an alternative to tricylic and MAIOS. They block the uptake of serotonin, so that more of serotonin in made available to action at receptor sites. SSRIS are different from other antidepressants as they do not block many receptor sites at a moment; that can cause sedation, weight gain, constipation and rise in the blood pressure and dry mouth. The new SSRI medications also have side effects such as feelings of nausea, agitation and sexual dysfunction. Studies during past two decades suggest the effectiveness of SSRIS. The result of these studies should be viewed with caution. These studies fail to indicate the effectiveness of medication. Most studies done in this area have not been published. 27 Abnormal Psychology There are reports of higher suicide risk with SSRI medication. But the investigation during 1996 to 1998 showed that the rate of suicide is much lower among people treated with SSRI as compared with other antidepressants. The higher suicide rate among SSRIS prescribed persons made clinicians to focus attention on the number of related variables such as comorbid psychological disorder, gender and geographic location and role of psychotherapy. Antidepressants,are frequently prescribed to patients with severe symptoms by nature. They are at the higher risk of suicide (Rosack 2005). Therefore, precaution has to be exercised by administering to children and adolescents. Several studies have shown a link between suicidal behaviour and antidepressants. Antidepressants medications have are commonly used for relieving symptoms. But many people are not eligible for this medication, especially women of child bearing age. Lithium carbonate in a common salt found in the natural environment. It is used as an antidepressant, Dosage has to be carefully monitored to prevent toxicity, and low thyroid functioning, which might intensify lack of energy associated with depression. Lithium carbonate has side effects such as mild central nervous system disturbances, gastrointestinal upsets or even cardiac effects. Lithium interferes with the high associated with the bipolar disorder. Persons with bipolar disorder actually enjoy the pleasurable feelings associated with mania. By the time full blown mania is developed, individuals may not accept that they have any problem. If side effects are considered, then person is at risk of developing another episode. Therefore, therapists encourage the clients to remain on the maintance dose of lithium. The variable nature of bipolar disorder makes it necessary to have an additional antidepressant along with lithium. Persons prone to mania may develop mania after medication. Persons with psychotic symptoms, may benefit from antipsychotic medications. Clinicians may also prescribe ECT., for clients with mood disorders for whom medication may be ineffective or slow in alleviating the symptoms. People have negative attitude towards ECT, as it is more likely to be misused. This method has been used for punishment in the past rather than for treatment. ECT - (Electro Convulsive Therapy): Lisanby (2007) has demonstrated that ECT is life saving treatment for severely depressed people. Clients are usually given anasthesia to reduce discomfort, and are given muscle relaxing drugs to prevent breaking of bones from convulsions during seizures. Electric shock is directly administered through the brain for less than a second. This produces seizures and brief convulsions. In current practice ECT is administered 6 to 8 times, once every other day, until the person’s mood returns to normal. The side effects are few. Person has short term memory loss and confusion that disappears within one or two weeks. Some clients may show long term memory problems. It is not clear 28 as to why ECT works. One explanation is that induces changes in Mood Disorder and neurotransmitter receptors and body’s neural opiates. Suicide - II TMS: Transcranial Magnetic Stimulation (TMS) in an alternative to traditional ECT. TMS combined with medications have been found to be more effective with persons who do not respond to medications. Light therapy is another treatment offered for seasonal depression. Depressed individuals are especially exposed to special light during winter season. Another less well known method of the treatment is sleep deprivation. Both the methods are effective when combined with medication. 4.2.2 Psychological Treatment: Cognitive Behavioural approach and interpersonal psychotherapy are the most commonly adopted approaches for treatment of depression. Behavioural Approach: The major features of this approach in dealing with depression are : 1. Careful assessment of frequency, quality and range of activities and social interactions in client’s life. 2. Helping client change his or her social environment along with teaching of social skills. 3. Encouraging clients to seek activities that restore mood balance, helping clients to seek reinforcement in activities. 4. Educating client in settling realistic goals because depressed clients often set unrealistic goals for themselves. Therapist may give homework to clients in this area. 5. Therapist focuses on self-reinforcement procedures such as self congratulations like rewarding one self with some pleasurable activity. 6. If these procedures do not succeed then therapist may engage in more extensive programme like instructions. Modeling and coaching, role playing, rehearsals at real world trials, etc. Cognitive based approach: Short time structured approach- It focuses our negative thoughts and it includes activities that will improve client’s daily life. 1. Clients are taught to examine carefully their thought processes while they are depressed. They are made to recognise depressive errors in thinking. 2. Client in taught that errors in thinking can directly cause depression. 29 Abnormal Psychology 3. It involves correcting cognitive errors and substituting more realistic thoughts and appraisals. 4. Later in therapy underlying negative cognitive schemes (characteristic ways of viewing the world) that trigger the cognitive errors are targeted. 5. Therapist makes it clear to the client that both of them together will be working as a team to uncover faulty thinking patterns. To summarize, cognitive approach incorporates didactic work, i.e., cognitive restructuring and behavioural techniques. It involves explaining theory to client, teaching the client how depression results from faulty thinking and cognitive restructuring. Clients are instructed to monitor their thought processes carefully, especially in situations where client might feel depressed. Client is required to plan activity for a week, it may involve graded task assignment. It may involve pleasure prediction experiments like how much pleasure will be produced by a given activity and how much pleasure is produced in reality. This pleasure production experiments help therapist in demonstrating to client how gloomy predictions are inaccurate. Client is asked to rate the pleasure of each activity. If patient is inactive, then activities are planned on the hour by hour basis. Thus, helping clients to experience success of accomplishing something. Cognitive behavioural therapy is a short term method. It requires generally 10 to 12 sessions. People with chronic major depressive disorder may require long term cognitive behaviour therapy. Psychodynamic approaches involve short terms focused treatment combined with medication. Clinicians treating bipolar disorder, begin with medication, incorporated by psychological intervention. Interpersonal Psychotherapy: It is observed that problems in personal relationships, absence of relationship, etc is a major stressful event, and it can lead to relapse of the bipolar disorder. Interpersonal and social rhythm therapy (IPSRT): This therapy is especially seem to be effective to deal with relapse episode of Bipolar disorder. According to this model mood, episodes are likely to emerge from: a. Non adherence to medication b. Stressful life events c. Disruption in social rhythms. Clinicians, who follow IPSRT model, focus on educating clients, about medication adherence, helping them to understand their feelings about the disorder and how it has changed their lives. 30  Mood Disorder and Suicide - II Clinicians emphasise the reduction of interpersonal stress in client’s life, especially one who is suffering from bipolar disorder for following reasons. 1. Stressful life events affect circadian rhythm, i.e., sleep wake cycles, appetite energy levels. 2. Stressful life events change the daily routine. 3. This may affect person’s mood and may bring about changes in social, rhythms. (Frank 2007). Researchers have found this programme to be very effective in improving relationships. Socio cultural and interpersonal therapy: The family members of the client are involved in treatment. They can understand the experiences of the person with mood disorder and help him or her in dealing with the symptoms. Interpersonal therapy may last from 12 to 16 weeks. This theory is divided into three broad phases. 1. Assessing the nature of depression by using quantities measurement. Interviews are carried and to determine exactly what triggered the present episode. 2. Therapist and patient together formulate a treatment plan focusing on primary problems like grief, interpersonal disputes and problems faced due to inadequate social sketch. 3. Third phase treatment plans are carried out depending on the nature of client’s problem. 4.3 SUICIDE Suicide is one of the most common causes of death among youngsters and elderly members of society. Suicide in often associated with depression, it is a way a escaping from hard realities of life. There seem to be 4 phases of suicide: Suicidal Ideation, Suicide Planning, Suicide Attempt and Suicide. American studies and statistics shows that men are likely to commit suicide than women. Women may attempt suicide but their attempts may not be completed as compared to men. Generally 90% adults who commit suicide have some diagnosable psychological disorder. Disorders like alcohol abuse, dependence or Schizophrenia are associated with suicide. (Duberstein & Conwell 2000). Similarly, people with borderline personality disorder also make suicide attempts. The statistics of suicide in India in different. According to WHO, India has a highest suicide rates in the world. The country’s health ministry 31 Abnormal Psychology estimates that 1,20,000 people kill themselves every year and among these 40% of them are below 30 years. South India in considered as world’s suicide capital. Kerala, has highest suicide rate, 32 people commit suicide almost every day. In India it is observed that women are more likely to commit suicide then men. The study found that suicide rate for women in the age group of 19-29 years in 148 per 1,00,000 and for men it is 58 per 1,00,000. There are international variations in suicide rates. The highest rates of suicide are found in Eastern Europe and lowest in Latin America. (WHO 2004). 4.3.1 Causes of Suicide: i. Biological perspective: In one the largest investigations of family patterns of suicide, 250 relatives of 25 people who committed suicide were compared with 171 relatives of men who did not commit or attempt suicide. The results of the study showed that relatives of suicide completers had 10 times more chances of committing suicide. Baud (2005) showed that tendency to commit suicide is associated with genetic vulnerability involving serotonin related genes. Thus, vulnerability leads to certain personality traits which interact with life events, thus making a person more prone to committing suicide. Similarly, low alcohol tolerance combined with genetic vulnerability increases the risks of committing suicide (Marusie 2005). ii. Psychological perspective: If one of the family member commits suicide then there is an increased risks that someone else in the family will also follow. Brent and colleagues observed a six fold increased risk of suicide attempts in the offspring of the family members who had attempted suicide compared to the offspring of persons who had not attempted suicide. If sibling was a suicide attempter, then the risk increased even more (Brent et al 2003). The question is people who kill themselves, do they simply adopt a solution that in familiar to them? or is it impulsivity that is inherited as a family trait that is responsible? Studies show that early onset of mood disorder, as well as aggressive and impulsive traits, make such persons succeptible to suicidal behaviour (Mann et al 2005). Existing psychological disorders such as mood disorder may become a precipitating cause of suicidal behaviour. Many people who commit suicide do have mood disorders. Similarly, alcohol use and abuse in also associated with suicides, particularly in adolescent suicides. Combination of disorders such as substance abuse and mood disorder in adults and mood disorder and 32 conduct disorder in children seem to create a stronger vulnerability, then Mood Disorder and any one disorder alone. Hawton & Colleagues (2003) found that Suicide - II prevalence of previous attempts and repeated attempts doubled if a combination of disorder in present. Esposito and Clum (2003) also noted that presence of anxiety and mood disorder predicated suicide attempts in adolescents. J. Cooper and Colleagues (2005) followed almost 8,000 individuals who were treated in emergency room for deliberate self harm for 4 years. Sixty of these people killed themselves, a 30 fold increase in risk compared to population statistics. The important risks factor in suicidal behaviour is stressful life event which are experienced as shameful or humiliating, such as failure that may be real or imagined. The stress and disruption of national disasters increase the likelihood of suicide. The psychological factors that predispose individuals to committing suicide are explained by Edwin Shneidman (1984). He suggests that act of taking one’s life is an attempt of interpersonal communication. Through suicidal attempts people try to communicate frustrated psychological needs to significant people in life. Beck explains suicide from cognitive perspective. He suggests that suicide is an expression of feelings of hopelessness triggered by preception that stress is beyond control. Beck (1996) has used the concept of suicidal mode to describe the frame of mind of person who has made multiple suicidal attempts. Impaired decision making and altered Serotonin pathways in the parts of the brain involved in making complex choices also predisposes an individual towards suicidal behaviour. iii. Socio cultural perspective: Emile Durkheim, a French sociologist, suggest that a feeling of alienation from society can become a cause of suicidal behaviour, Media also plays an important role in propogating suicide, especially among teenagers. Media accounts often describe in detail the methods used for suicide, thus they provide guidelines to potential victims. There are racial and age related differences in suicide. Whites are more likely to commit suicide followed by African Americans. The age at which a member of a given race will commit suicide also varies e.g., for blacks suicide may occur at an average age of 32 whereas for whites it may be 44 years. 4.3.2 Assessment and Treatment: Clinicians can assess suicidal intent in the client. The suicidal intent refers to how person in committed to dying. Secondly, the suicidal lethality in also judged. The